Decoding cerebro-spinal signatures of human behavior: Application to motor sequence learning.

Mapping the neural patterns that drive human behavior is a key challenge in neuroscience. Even the simplest of our everyday actions stem from the dynamic and complex interplay of multiple neural structures across the central nervous system (CNS). Yet, most neuroimaging research has focused on investigating cerebral mechanisms, while the way the spinal cord accompanies the brain in shaping human behavior has been largely overlooked. Although the recent advent of functional magnetic resonance imaging (fMRI) sequences that can simultaneously target the brain and spinal cord has opened up new avenues for studying these mechanisms at multiple levels of the CNS, research to date has been limited to inferential univariate techniques that cannot fully unveil the intricacies of the underlying neural states. To address this, we propose to go beyond traditional analyses and instead use a data-driven multivariate approach leveraging the dynamic content of cerebro-spinal signals using innovation-driven coactivation patterns (iCAPs). We demonstrate the relevance of this approach in a simultaneous brain-spinal cord fMRI dataset acquired during motor sequence learning (MSL), to highlight how large-scale CNS plasticity underpins rapid improvements in early skill acquisition and slower consolidation after extended practice. Specifically, we uncovered cortical, subcortical and spinal functional networks, which were used to decode the different stages of learning with a high accuracy and, thus, delineate meaningful cerebro-spinal signatures of learning progression. Our results provide compelling evidence that the dynamics of neural signals, paired with a data-driven approach, can be used to disentangle the modular organization of the CNS. While we outline the potential of this framework to probe the neural correlates of motor learning, its versatility makes it broadly applicable to explore the functioning of cerebro-spinal networks in other experimental or pathological conditions.

Quantitative T2' imaging in patients with clinically isolated syndrome.

OBJECTIVE: The T2' imaging has been shown to be sensitive to oxygen saturation changes in normal appearing white and grey matter (NAWM, NAGM) in patients with relapsing-remitting multiple sclerosis (RRMS). We aimed to explore the presence and extent of T2' changes in patients with a clinically isolated syndrome (CIS) and a possible association of T2' with conventional magnetic resonance imaging and clinical outcomes. MATERIAL AND METHODS: Quantitative T2- and T2*-weighted images were acquired in 32 treatment-naive patients with a CIS within 3 months of presentation and 15 age-matched healthy controls (HC). Quantitative T2' values were determined in six regions of interest (ROIs). RESULTS: The T2' values in CIS did not differ significantly from those in HC. Among patients, T2' values correlated positively with the T2 lesion volume (T2LV, r = 0.34, P < 0.05). T2' values of the frontal NAWM correlated with the T2LV (r = 0.35, P < 0.05) and T2 lesion count (r = 0.4, P = 0.02). CONCLUSION: As opposed to RRMS, patients with CIS did not show T2' alterations compared to HC. However, the association between the T2LV and higher T2' values suggests that T2' reflects disease evolution. In CIS metabolic changes might be masked by compensatory mechanisms and become overt when disease progresses as has been shown for RRMS patients.

Interactions between brain and spinal cord mediate value effects in nocebo hyperalgesia.

Value information about a drug, such as the price tag, can strongly affect its therapeutic effect. We discovered that value information influences adverse treatment outcomes in humans even in the absence of an active substance. Labeling an inert treatment as expensive medication led to stronger nocebo hyperalgesia than labeling it as cheap medication. This effect was mediated by neural interactions between cortex, brainstem, and spinal cord. In particular, activity in the prefrontal cortex mediated the effect of value on nocebo hyperalgesia. Value furthermore modulated coupling between prefrontal areas, brainstem, and spinal cord, which might represent a flexible mechanism through which higher-cognitive representations, such as value, can modulate early pain processing.

Diffusion Tensor Imaging of the Normal Cervical and Thoracic Pediatric Spinal Cord.

BACKGROUND AND PURPOSE: DTI data of the normal healthy spinal cord in children are limited compared with adults and are typically focused on the cervical spinal cord. The purpose of this study was the following: to investigate the feasibility of obtaining repeatable DTI parameters along the entire cervical and thoracic spinal cord as a function of age in typically developing pediatric subjects; to analyze the DTI parameters among different transverse levels of the cervical and thoracic spinal cord; and to examine the sex differences in DTI parameters along the cervical and thoracic spinal cord. MATERIALS AND METHODS: Twenty-two subjects underwent 2 identical scans by using a 3T MR imaging scanner. Axial diffusion tensor images were acquired by using 2 overlapping slabs to cover the cervical and thoracic spinal cord. After postprocessing, DTI parameters were calculated by using ROIs drawn on the whole cord along the entire spinal cord for both scans. RESULTS: An increase in fractional anisotropy and a decrease in mean diffusivity, axial diffusivity, and radial diffusivity were observed with age along the entire spinal cord. Significantly lower fractional anisotropy and higher mean diffusivity values were observed in the lower cervical cord compared with the upper cervical cord. Axial diffusivity values in the cervical cord were higher compared with the thoracic cord. No statistically significant sex differences were observed for all DTI parameters. There was a moderate-to-strong repeatability for all DTI parameters. CONCLUSIONS: This study provides an initial understanding of DTI values of the spinal cord relevant to age and sex and shows that obtaining repeatable DTI values of the entire cord in children is feasible.

Gradient-echo line scan imaging using 2D-selective RF excitation.

A gradient-echo line scan imaging technique was developed which employs two-dimensional spatially selective radiofrequency (2DRF) pulses for consecutively exciting individual columns of transverse magnetization, i.e., image lines. Although a variety of trajectories are possible for 2DRF excitation, the current implementation involved a blipped-planar trajectory in conjunction with additional saturation RF pulses to suppress side excitations above and below the desired image section, i.e., along the blip direction of the 2DRF pulse. Human brain imaging at 2.0 T (Siemens Vision, Erlangen, Germany) resulted in measuring times of 5.2 s for a 5-mm section at 1.0 x 1.0 mm in-plane resolution. Functional neuroimaging of the motor cortex at 1.2 s temporal resolution and 0.78 x 1.56 mm in-plane resolution exploited the capability of imaging inner volumes (here a 25-mm strip) without signal aliasing.

Single-shot line scan imaging using stimulated echoes.

A new high-speed MRI method is described for single-shot line scan imaging (LSI) based on stimulated echoes (STE). To allow for multislice imaging, the technique comprises a series of slice-selective preparation pulses (each corresponding to the first RF pulse of a STE sequence), a slab-selective refocusing pulse (second RF pulse), and multiple line-selective read pulses (third RF pulses). An alternative version employs packages of two slice-selective pulses followed by multiple line-selective read pulses. Experimental applications deal with human brain imaging on a clinical MRI system at 2.0 T. The technique offers user-selectable trade-offs between volume coverage (1-15 sections) and in-plane spatial resolution (1-5 mm linear pixel dimension) within total acquisition times of less than 500 ms. Although LSI yields a lower signal-to-noise ratio than Fourier imaging, single-shot LSI with STEs is free from resonance offset effects (e.g., magnetic field inhomogeneities and susceptibility differences) that are typical for echo-planar imaging. Moreover, the technique exhibits considerable robustness against motion and provides access to arbitrary fields-of-view, i.e., localized imaging of inner volumes without aliasing artifacts due to phase wrapping.

Reducing inhomogeneity artifacts in functional MRI of human brain activation-thin sections vs gradient compensation.

We evaluated two methods for correcting inhomogeneity-induced signal losses in magnetic resonance gradient-echo imaging that either use gradient compensation or simply acquire thin sections. The strategies were tested in the human brain in terms of achievable quality of T2*-weighted images at the level of the hippocampus and of functional activation maps of the visual cortex. Experiments were performed at 2.0 T and based on single-shot echo-planar imaging at 2. 0 x 2.0 mm(2) resolution, 4 mm section thickness, and 2.0 s temporal resolution. Gradient compensation involved a sequential 16-step variation of the refocusing lobe of the slice-selection gradient (TR/TE = 125/53 ms, flip angle 15 degrees ), whereas thin sections divided the 4-mm target plane into either four 1-mm or eight 0.5-mm interleaved multislice acquisitions (TR/TE = 2000/54 ms, flip angle 70 degrees ). Both approaches were capable of alleviating the inhomogeneity problem for structures in the base of the brain. When compared to standard 4-mm EPI, functional mapping in the visual cortex was partially compromised because of a lower signal-to-noise ratio of inhomogeneity-corrected images by either method. Relative to each other, consistently better results were obtained with the use of contiguous thin sections, in particular for a thickness of 1 mm. Multislice acquisitions of thin sections require minimal technical adjustments.

Diffusion tensor imaging of the normal pediatric spinal cord using an inner field of view echo-planar imaging sequence.

BACKGROUND AND PURPOSE: DTI in the brain has been well established, but its application in the spinal cord, especially in pediatrics, poses several challenges. The small cord size has inherent low SNR of the diffusion signal intensity, respiratory and cardiac movements induce artifacts, and EPI sequences used for obtaining diffusion indices cause eddy-current distortions. The purpose of this study was to 1) evaluate the accuracy of cervical spinal cord DTI in children using a newly developed iFOV sequence with spatially selective 2D-RF excitations, and 2) examine reproducibility of the DTI measures. MATERIALS AND METHODS: Twenty-five typically developing subjects were imaged twice using a 3T scanner. Axial DTI images of the cervical spinal cord were acquired with this sequence. After motion correction, DTI indices were calculated using regions of interest manually drawn at every axial section location along the cervical spinal cord for both acquisitions. Various DTI indices were calculated: FA, AD, RD, MD, RA, and VR. Geometric diffusion measures were also calculated: Cp, Cl, and Cs. RESULTS: The following average values for each index were obtained: FA = 0.50 ± 0.11; AD = 0.97 ± 0.20 × 10(-3)mm(2)/s; RD = 0.41 ± 0.13 × 10(-3)mm(2)/s; MD = 0.59 ± 0.15 × 10(-3)mm(2)/s; RA = 0.35 ± 0.08; VR = 0.03 ± 0.00; Cp = 0.13 ± 0.07; Cl = 0.29 ± 0.09; and Cs = 0.58 ± 0.11. The reproducibility tests showed moderate to strong ICC in all subjects for all DTI parameters (ICC>0.72). CONCLUSIONS: This study showed that accurate and reproducible DTI parameters can be estimated in the pediatric cervical spinal cord using an iFOV EPI sequence.

T2' imaging indicates decreased tissue metabolism in frontal white matter of MS patients.

BACKGROUND AND PURPOSE: T2'-Magnetic resonance imaging (MRI) allows estimation of oxygen metabolism in normal appearing white and gray matter (NAWM and NAGM) and is sensitive to local iron deposition. We hypothesized that T2' imaging is feasible in routine use and reveals differences between MS patients and healthy subjects. METHODS: T2- and T2*-weighted images were acquired in 23 MS patients (Mean age: 36.8, range: 23-58 years) and 23 age-matched healthy subjects. Quantitative T2- and T2*-values were determined in six regions of interest (ROIs). RESULTS: The T2' values in thalamus and caudate nucleus were significantly lower in MS patients than in healthy subjects (139 ms vs 157 ms, P < 0.001 and 97 ms vs 115 ms, P < 0.01). The NAWM in the frontal lobe revealed significant higher T2' values than in healthy subjects (217 ms vs 170 ms, P < 0.001). The subcortical NAWM revealed significant lower T2' values than in healthy subjects (174 ms vs 187 ms, P < 0.028). CONCLUSION: T2' values differed significantly between MS patients and healthy subjects. The reduced T2' values in the basal ganglia are presumably related to higher iron concentration whereas the increased T2' in frontal NAWM most probably reflects reduced tissue metabolism. T2' imaging is feasible for routine-use and promising for monitoring therapy effects.

Age-dependent normal values of T2* and T2' in brain parenchyma.

BACKGROUND AND PURPOSE: Physiologic age-related T2* and T2' values are required as reference for comparison with disease-related deviations. In our study, T2* and T2' values (T2 values as control) were determined with MR imaging in healthy subjects to determine standard values and investigate age-related changes. MATERIALS AND METHODS: Data of 50 patients without intraparenchymal pathology and 10 acute stroke patients who underwent MR imaging including a T2 and T2* sequence with 3 echotimes were included. After calculation of T2*, T2', and T2 maps, the values of gray matter (GM) and white matter (WM) for each hemisphere were measured in 6 distinct regions of interest (ROIs). RESULTS: There was a negative correlation between age and T2* values in the caudate nucleus (r = -0.34 Pearson correlation; P = .001) and lentiform nucleus (r = -0.67; P = .001) and a positive correlation in the occipital (r = 0.41; P = .001) and subcortical (r = 0.45; P = .001) WM. An age dependency for T2' values was only found for the caudate (r = -0.35; P = .001) and lentiform nucleus (r = -0.69; P = .001). T2' values in acute stroke were lower than normal in all patients with stroke. CONCLUSION: Decrease in T2' and T2* values in GM and increase of T2* values in WM correlate with the progress of brain aging. Explanations for decreasing T2' and T2* values include iron deposition in the caudate and lentiform nucleus. In contrast to T2* values, there is no association of T2' values with the degree of leukoaraiosis. These age-dependent values can be used as a reference in neurovascular diseases and for the discussion of functional MR imaging data.

Diffusion tensor mapping of the human brain using single-shot line scan imaging.

A recently developed single-shot line scan imaging technique for diffusion measurements (Finsterbusch and Frahm, Magn Reson Med 1999;42:772-778) was extended to full diffusion tensor mapping of the human brain. Because the sequence acquires stimulated echoes from individual columns of magnetization ("lines"), the approach is affected neither by spatial aliasing when studying inner volumes nor by resonance offset effects or T2* dephasing as in diffusion-weighted echoplanar imaging. Experiments on healthy subjects were performed at 2.0 T using 31 single-shot images (5b values, 6 orientations, 520 msec each) at 1.5 x 1.5 mm2resolution (interpolated) and 6.0 mm section thickness. Apart from calculated images with isotropic diffusion weighting, the results include maps of the six independent diffusion tensor components, the apparent diffusion coefficient, the relative anisotropy, and the main diffusion direction. The achievable signal-to-noise ratio and resolution allow the identification of differently oriented nerve fibers in the brain stem. J. Magn. Reson. Imaging 2000;12:388-394.

Diffusion-weighted single-shot line scan imaging of the human brain.

Single-shot line scan imaging (LSI) was adapted to diffusion-weighted (DW) MRI by replacing the initial 90 degrees radiofrequency pulse of the underlying high-speed stimulated echo sequence by a DW spin-echo preparation period. Implementation on a 2. 0 T whole-body MRI system yielded DW images of the human brain with b factors of 750 s mm(-2) and total imaging times of about 500 ms either for a single slice at 1.5 x 3.0 x 6 mm(3) resolution or simultaneously for up to seven slices at 3.75 x 3.75 x 8 mm(3) resolution. Isotropic DW images and maps of the trace of the diffusion tensor were calculated from four scans with different combinations of three orthogonal diffusion gradients. DW LSI combines high speed with robustness against image artifacts caused by motion (no phase ghosting) and tissue susceptibility differences (no signal losses, no geometric distortions). Because the latter is an important advantage over echo-planar imaging, DW LSI may find useful applications despite a limited signal-to-noise ratio. Magn Reson Med 42:772-778, 1999.

Rapid isotropic diffusion mapping without susceptibility artifacts: whole brain studies using diffusion-weighted single-shot STEAM MR imaging.

A subsecond magnetic resonance imaging (MRI) technique for isotropic diffusion mapping is described which, in contrast to echo-planar imaging (EPI), is insensitive to resonance offsets, i.e., tissue susceptibility differences, magnetic field inhomogeneities, and chemical shifts. It combines a diffusion-weighted (DW) spin-echo preparation period and a high-speed stimulated echo acquisition mode (STEAM) MRI sequence and yields single-shot images within measuring times of 559 msec (80 echoes). Here, diffusion encoding involved one scan without DW, three DW scans with b = 490 sec mm(-2), and three DW scans with b = 1000 sec mm(-2) (orthogonal gradient orientations). An automated on-line evaluation resulted in isotropic DW images as well as ADC maps (trace of the diffusion tensor). Experiments at 2.0 T covered the brain of healthy subjects in 20 contiguous sections of 6 mm thickness and 2.0 x 2.0 mm(2) in-plane resolution within a total measuring time of 78 sec. High-resolution studies at 1.0 x 1.0 mm(2) (interpolated from 2.0 x 1.0 mm(2) acquisitions) were obtained within 5 min 13 sec using four averages. In comparison with EPI, DW single-shot STEAM MRI exhibits only about half the SNR, but completely avoids regional signal losses, high intensity artifacts, and geometric distortions.

Stroke-like pattern in DTI and MRS of childhood mitochondrial leukoencephalopathy.

In a 13-month-old boy with recurrent motor deterioration provoked by fever MRI and proton MRS detected a leukoencephalopathy with reduced cerebral metabolites and elevated lactate. At follow-up 6 and 16 months later these abnormalities improved gradually. Serial diffusion tensor imaging revealed a stroke-like pattern with an initial strong reduction of the apparent diffusion coefficient followed by elevated values 6 months later. The relative diffusion anisotropy remained reduced. Muscle biopsy confirmed a mitochondrial encephalomyopathy.

Diffusion tensor imaging for long-term follow-up of corticospinal tract degeneration in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a predominantly clinical and electromyographic diagnosis. Conventional MRI reveals atrophy of the motor system, particularly the pyramidal tract, in the advanced stages but does not provide a sensitive measure of disease progression. Three patients with different principal symptoms of ALS, i.e., with predominant involvement of the upper (UMN) or lower (UMN) motor neurons, or bulbar disease, respectively, underwent serial clinical examination including lung function tests, conventional MRI, and diffusion tensor imaging (DTI). MRI demonstrated changes in of the pyramidal tract without measurable variation on follow-up. The patient with UMN involvement showed remarkable progressive loss of diffusion anisotropy in the pyramidal tract. DTI might be useful, together with clinical follow-up, as an objective morphological marker in therapeutic trials.

Megalencephalic leukoencephalopathy with subcortical cysts in an adult: quantitative proton MR spectroscopy and diffusion tensor MRI.

A 37-year-old macrocephalic woman was investigated for increasing gait disturbance due to longstanding spasticity and ataxia. MRI showed widespread bilateral increase in signal from cerebral white matter on T2-weighted images. Numerous subcortical cysts were visible in anterior-temporal and parietal regions. These clinical and neuroradiological features are those of megalencephalic leukoencephalopathy with subcortical cysts (MLC), a recently delineated white-matter disease with onset in childhood. Quantitative localised proton MR spectroscopy of white matter revealed marked reduction of N-acetylaspartate, creatine, and choline with normal values for myo-inositol, consistent with axonal loss and astrocytic proliferation. Diffusion tensor imaging showed an increased apparent diffusion coefficient and reduced anisotropy in affected white matter pointing to reduced cell density with an increased extracellular space. These findings are in line with histological changes alterations known to occur in MLC.

Comparative EPR and redox studies of three prokaryotic enzymes of the xanthine oxidase family: quinoline 2-oxidoreductase, quinaldine 4-oxidase, and isoquinoline 1-oxidoreductase.

For three prokaryotic enzymes of the xanthine oxidase family, namely quinoline 2-oxidoreductase, quinaldine 4-oxidase, and isoquinoline 1-oxidoreductase, the electron transfer centers were investigated by electron paramagnetic resonance. The enzymes are containing a molybdenum-molybdopterin cytosine dinucleotide cofactor, two distinct [2Fe-2S] clusters and, apart from isoquinoline 1-oxidoreductase, a flavin adenine dinucleotide. The latter cofactor yields two different organic radical signals in quinoline 2-oxidoreductase and quinaldine 4-oxidase, typical for the neutral and anionic form, respectively. A "rapid" Mo(V) species is present in all enzymes with small differences in magnetic parameters. From spectra simulation of 95Mo-substituted quinoline 2-oxidoreductase, a deviation of 25 degrees between the maximal g and 95Mo-hyperfine tensor component was derived. The very rapid Mo(V) species was detected in small amounts upon reduction with substrates in quinoline 2-oxidoreductase and quinaldine 4-oxidase, but showed a different kinetic behavior with considerable EPR intensities in isoquinoline 1-oxidoreductase. The FeSI and FeSII centers produced different signals in all three enzymes and, in case of isoquinoline 1-oxidoreductase, revealed a dipolar interaction, from which a maximum distance of 15 A between FeSI and FeSII was estimated. The midpoint potentials of the FeS centers were surprisingly different and determined for FeSI/FeSII with -155/-195 mV in quinoline 2-oxidoreductase, -250/-70 mV in quinaldine 4-oxidase, and +65/+10 mV in isoquinoline 1-oxidoreductase. The slopes of the fitting curves for the Nernst equation are indicative for nonideal behavior. Only in quinoline 2-oxidoreductase, an averaged midpoint potential of the molybdenum redox pairs of about -390 mV could be determined. Both of the other enzymes did not produce Mo(V) signals in redox titration experiments, probably because of direct reduction of Mo(VI) to Mo(IV) in the presence of dithionite.

Distortion-free diffusion tensor imaging of cranial nerves and of inferior temporal and orbitofrontal white matter.

The main impact of functional neuroimaging has been its ability to locate neuronal activity either directly (EEG, MEG) or through the hemodynamic response caused by neuronal activity (PET, fMRI). In the past decade functional neuroimaging has been extended to investigate how brain regions interact, using the concepts of functional and effective connectivity. These concepts are further strengthened by estimates of anatomical connectivity of the same subject. A tool to determine anatomical connectivity in vivo may be provided by diffusion tensor imaging (DTI) methods. These can be used to determine the orientation of fiber bundles in white matter on the basis of the diffusion characteristics of water. Commonly, DTI data are acquired using echo planar imaging which suffers from susceptibility artifacts in orbitofrontal and inferior temporal cortex. Here we demonstrate the use of an alternative pulse sequence, diffusion-weighted single-shot STEAM, for assessing fiber orientation in orbitofrontal cortex and the cranial nerves. The scope of DTI needs to be extended to these structures to investigate psychiatric disorders in which orbitofrontal pathology or temporo-frontal disconnection have been postulated.

[PACS: from project to reality. Report of experiences on full digitalisation of the radiology department of a major hospital]. / PACS: Vom Projekt zur Realität. Erfahrungsbericht über die vollständige Digitalisierung der Radiologischen Abteilung eines Schwerpunktkrankenhauses.

OBJECTIVE: To assess the time needed and the resulting effects of a complete digitalisation of a radiological department of a major hospital (856 beds, 28,000 in-patients, 35,000 out-patients/year) a pilot study was performed. This had to be done without interrupting routine services. RESULTS: After intensive preparations were performed and the hospital-network was completed, within a two year period all radiological functions (mammography excluded), reporting stations and archives were changed to a complete digital workflow. All modalities (provided by 3 different companies) are now connected by DICOM-work lists. The picture-files (4 GB/day) are automatically routed to the work-stations (n = 10), where the reporting and file shows are performed, to the digital archive and to the peripheral viewing-stations (n = 44). The distribution of the digital pictures takes place all over the hospital including the ORs and special units. We accomplished, to connect electronically the report and the image data. The clinical file shows are also performed completely digitally. The access to the data of the deep archive is possible by the dept. of radiology without any manual interaction. The film consumption was reduced to an amount of less than 10%, as compared to the prior PACS situation. Since PACS has been introduced the radiological productivity increased by more than 15% and throughput-time was clearly reduced. CONCLUSIONS: The complete digitalisation increases productivity and attractiveness of a hospital-radiology and helps to shorten diagnostic and therapeutic decision-making. The transfer from a conventional to a digital workflow is possible without interrupting the clinical services. Extensive preparations and ongoing assistance of such projects though are clearly needed.

Quantitative proton magnetic resonance spectroscopy of children with adrenoleukodystrophy before and after hematopoietic stem cell transplantation.

About 35-40 % of boys with X-linked adrenoleukodystrophy (ALD) develop a rapidly progressive cerebral form which leads to severe neurologic disability and death within 3-5 years after onset of clinical symptoms. Because previous proton magnetic resonance spectroscopy (MRS) studies of ALD identified metabolite patterns characteristic of demyelination, gliosis, and neuroaxonal loss, this work tested the hypothesis that MRS--apart from indicating disease progression--provides criteria for the outcome after hematopoietic stem cell transplantation (HSCT) which has been promising at an early stage of the active disease. Follow-up quantitative proton MRS was performed in frontal and occipital white matter of ALD patients (n = 12) before and up to 5 years after HSCT. The observed metabolite alterations were retrospectively correlated with the clinical outcome representing either a stable condition (n = 5), a further deterioration (n = 5), or death (n = 2). While disease progression of patients before HSCT was mainly characterized by a further increase of elevated choline-containing compounds (Cho) as an indicator of active demyelination, a positive outcome after HSCT was correlated with high N-acetylaspartate (tNAA) levels in affected white matter before HSCT yielding positive and negative predictive values for tNAA of 80 %. Although to be confirmed in a larger cohort of patients, the present findings suggest the preservation of neuroaxonal integrity as a prerequisite for an arrested course. Conversely, the combination of increased Cho with markedly reduced tNAA before HSCT apparently reflects a degree of tissue degeneration which precludes a successful therapeutic intervention.