Crossed cerebellar diaschisis: insights into oxygen challenge MRI.

Hyperoxia during T2*-weighted magnetic resonance imaging (oxygen challenge imaging (OCI)) causes T2*-weighted signal change that is dependent on cerebral blood volume (CBV) and oxygen extraction fraction (OEF). Crossed cerebellar diaschisis (CCD), where CBV is reduced but OEF is maintained, may be used to understand the relative contributions of OEF and CBV to OCI results. In subjects with large hemispheric strokes, OCI showed reduced signal change in the contralesional cerebellum (P=0.027, n=12). This was associated with reduced CBV in contralesional cerebellum (P=0.039, n=9). CCD may be a useful model to determine the relative contribution of CBV to signal change measured by OCI.

Early life socioeconomic status, chronic physiological stress and hippocampal N-acetyl aspartate concentrations.

OBJECTIVE: Early life socioeconomic deprivation has been associated with cognitive and behavioural changes that persist through towards adulthood. In this study, we investigated whether early life socioeconomic status is associated with changes in the hippocampus N-acetyl aspartate (NAA), using the non-invasive technique of magnetic resonance spectroscopy (MRS). METHODS: We performed proton magnetic resonance spectroscopy ((1)H-MRS) of the hippocampus at 3T in 30 adult males, selected from the PSOBID cohort. We conducted multiple regression analysis to examine the relationship between early socioeconomic status (SES) and concentration of N-acetyl-aspartate in the hippocampus. We also examined whether the relationship between these variables was mediated by markers of chronic physiological stress. RESULTS: Greater socioeconomic deprivation was associated with lower hippocampal NAA concentrations bilaterally. The relationship between early life SES and hippocampal NAA concentrations was mediated by allostatic load index - a marker of chronic physiological stress. CONCLUSIONS: Greater early life socioeconomic deprivation was associated with lower concentrations of NAA reflecting lesser neuronal integrity. This relationship was mediated by greater physiological stress. Further work, to better understand the biological processes underlying the effects of poverty, physiological stress on hippocampal metabolites is necessary.

Biodistribution and dosimetry of ¹²³I-mZIENT: a novel ligand for imaging serotonin transporters.

PURPOSE: 123I-labelled mZIENT (2ß-carbomethoxy-3ß-(3'-((Z)-2-iodoethenyl)phenyl)nortropane) has been developed as a radioligand for the serotonin transporter. The aim of this preliminary study was to assess its whole-body biodistribution in humans and estimate dosimetry. METHODS: Three healthy controls and three patients receiving selective serotonin reuptake inhibitor (SSRI) therapy for depression were included (two men, four women, age range 41-56 years). Whole-body imaging, brain SPECT imaging and blood and urine sampling were performed. Whole-body images were analysed using regions of interest (ROIs), time-activity curves were derived using compartmental analysis and dosimetry estimated using OLINDA software. Brain ROI analysis was performed to obtain specific-to-nonspecific binding ratios in the midbrain, thalamus and striatum. RESULTS: Initial high uptake in the lungs decreased in later images. Lower uptake was seen in the brain, liver and intestines. Excretion was primarily through the urinary system. The effective dose was estimated to be of the order of 0.03 mSv/MBq. The organ receiving the highest absorbed dose was the lower large intestine wall. Uptake in the brain was consistent with the known SERT distribution with higher specific-to-nonspecific binding in the midbrain, thalamus and striatum in healthy controls compared with patients receiving SSRI therapy. CONCLUSION: ¹²³I-mZIENT may be a promising radioligand for imaging the serotonin transporters in humans with acceptable dosimetry.

Atypical adult medulloblastoma.

Medulloblastomas are malignant primitive neuro-ectodermal neoplasms of childhood. In adults, clinical manifestations, imaging and prognosis can be different from that observed in children. Three adult patients with confirmed diagnoses of medulloblastoma are discussed in this report. They presented with unusually prolonged clinical courses and with imaging more suggestive of L'hermitte-Duclos disease. Medulloblastoma should be considered in all adults with posterior fossa masses despite having clinical and radiological features suggestive of a low-grade tumour. Definitive diagnosis requires histological confirmation in all cases.

T2*-weighted magnetic resonance imaging with hyperoxia in acute ischemic stroke.

OBJECTIVE: We describe the first clinical application of transient hyperoxia ("oxygen challenge") during T2*-weighted magnetic resonance imaging (MRI), to detect differences in vascular deoxyhemoglobin between tissue compartments following stroke. METHODS: Subjects with acute ischemic stroke were scanned with T2*-weighted MRI and oxygen challenge. For regions defined as infarct core (diffusion-weighted imaging lesion) and presumed penumbra (perfusion-diffusion mismatch [threshold = T(max) > or =4 seconds], or regions exhibiting diffusion lesion expansion at day 3), T2*-weighted signal intensity-time curves corresponding to the duration of oxygen challenge were generated. From these, the area under the curve, gradient of incline of the signal increase, time to maximum signal, and percentage signal change after oxygen challenge were measured. RESULTS: We identified 25 subjects with stroke lesions >1ml. Eighteen subjects with good quality T2*-weighted signal intensity-time curves in the contralateral hemisphere were analyzed. Curves from the diffusion lesion had a smaller area under the curve, percentage signal change, and gradient of incline, and longer time to maximum signal (p < 0.05, n = 17) compared to normal tissue, which consistently showed signal increase during oxygen challenge. Curves in the presumed penumbral regions (n = 8) showed varied morphology, but at hyperacute time points (<8 hours) showed a tendency to greater percentage signal change. INTERPRETATION: Differences in T2*-weighted signal intensity-time curves during oxygen challenge in brain regions with different pathophysiological states after stroke are likely to reflect differences in deoxyhemoglobin concentration, and therefore differences in metabolic activity. Despite its underlying complexities, this technique offers a possible novel mode of metabolic imaging in acute stroke.

Functional Magnetic Resonance Imaging (fMRI) reproducibility and variance components across visits and scanning sites with a finger tapping task.

Multicentre MRI studies offer great potential to increase study power and flexibility, but it is not yet clear how reproducible the results from multiple centres may be. Here we present results from the multicentre study 'CaliBrain', examining the reproducibility of fMRI data within and between three sites. Fourteen subjects were scanned twice on three 1.5 T GE scanners using an identical scanning protocol. We present data from a motor task with three conditions, sequential and random finger tapping and rest. Similar activation maps were obtained for each site and visit; brain areas consistently activated during the task included the premotor, primary motor and supplementary motor areas, the striatum and cerebellum. Reproducibility was evaluated within and between sites by comparing the extent and spatial agreement of activation maps at both the subject and group levels. The results were within the range previously reported for similar tasks on single scanners and both measures were found to be comparable within and between sites, with between site reproducibility similar to the within site measures. A variance components analysis was used to examine the effects of site, subject and visit. The contributions of site and visit were small and reproducibility was similar between and within sites, whereas the variance between subjects, and unexplained variance was large. These findings suggest that we can have confidence in combined results from multicentre fMRI studies, at least when a consistent protocol is followed on similar machines in all participating scanning sites and care is taken to select homogeneous subject groups.

Accuracy of Parkinson's disease diagnosis in 610 general practice patients in the West of Scotland.

UK-based community studies have found high rates of misdiagnosis in Parkinson's disease (PD). Searches of prescription databases and case records identified 610 patients taking antiparkinson therapy for a PD diagnosis in 92 West of Scotland General Practices. Patients with no documented progression of parkinsonism and/or no increase in antiparkinson medication for 3 years were assessed by two movement disorder specialists. FP-CIT SPECT scanning was performed in clinically uncertain cases. Those considered unlikely to have PD had antiparkinson drugs tapered then stopped, with a minimum of 6 months follow-up. Age, sex and disease duration matched controls were also assessed. 64 of 89 (71.9%) patients meeting selection criteria were assessed, of whom 36 (56.3%) were appropriate for therapy withdrawal. Thirty three of those 36 patients (91.7%) and 3 of 64 (4.7%) controls stopped antiparkinson therapy without deterioration giving an overall total of 36 of 610 (5.9%). The revised diagnoses in this group were mainly essential tremor (ET) (n = 14) and vascular parkinsonism (VP) (n = 10). Patients managed in Primary Care were significantly more likely to complete therapy withdrawal than those attending a specialist clinic (15.3% vs. 2.6%, P < 0.0001). The total annual cost of antiparkinson medication for these 36 patients was 13,400 pounds; the mean duration of diagnosis was 6.8 years (SD 5.6). At least 1 in every 20 patients taking medication for PD is misdiagnosed. Nearly all of these patients can be identified by simple screening of prescription databases and case records in Primary Care, followed by clinical review, which allows withdrawal of unnecessary medication.

Parkinson's disease is overdiagnosed clinically at baseline in diagnostically uncertain cases: a 3-year European multicenter study with repeat [123I]FP-CIT SPECT.

Overdiagnosis of Parkinson's disease (PD) is suggested by specialist review of community diagnosis, and in postmortem studies. In specialist centers 4 to 15% of patients entered into clinical trials as early PD do not have functional imaging support for a PD diagnosis. In a European multicenter, prospective, longitudinal study, we compared clinical diagnosis with functional SPECT imaging using [123I]FP-CIT (DaTSCAN, GE Healthcare). Repeat observations were performed over 3 years in patients with tremor and/or parkinsonism in whom there was initial diagnostic uncertainty between degenerative parkinsonism and nondegenerative tremor disorders. Video-recording of clinical features was scored independently of functional imaging results by two blinded clinicians at 36 months (= gold standard clinical diagnosis). Three readers, unaware of the clinical diagnosis, classified the images as normal or abnormal by visual inspection. The main endpoint was the sensitivity and specificity of SPECT imaging at baseline compared with the gold standard. In 99 patients completing the three serial assessments, on-site clinical diagnosis overdiagnosed degenerative parkinsonism at baseline in diagnostically uncertain cases compared with the gold standard clinical diagnosis (at 36 months), the latter giving a sensitivity of 93% and specificity of 46%. The corresponding baseline [123I]FP-CIT SPECT results showed a mean sensitivity of 78% and a specificity of 97%. Inter-reader agreement for rating scans as normal or abnormal was high (Cohen's kappa = 0.94-0.97).

Potential use of oxygen as a metabolic biosensor in combination with T2*-weighted MRI to define the ischemic penumbra.

We describe a novel magnetic resonance imaging technique for detecting metabolism indirectly through changes in oxyhemoglobin:deoxyhemoglobin ratios and T2(*) signal change during 'oxygen challenge' (OC, 5 mins 100% O(2)). During OC, T2(*) increase reflects O(2) binding to deoxyhemoglobin, which is formed when metabolizing tissues take up oxygen. Here OC has been applied to identify tissue metabolism within the ischemic brain. Permanent middle cerebral artery occlusion was induced in rats. In series 1 scanning (n=5), diffusion-weighted imaging (DWI) was performed, followed by echo-planar T2(*) acquired during OC and perfusion-weighted imaging (PWI, arterial spin labeling). Oxygen challenge induced a T2(*) signal increase of 1.8%, 3.7%, and 0.24% in the contralateral cortex, ipsilateral cortex within the PWI/DWI mismatch zone, and ischemic core, respectively. T2(*) and apparent diffusion coefficient (ADC) map coregistration revealed that the T2(*) signal increase extended into the ADC lesion (3.4%). In series 2 (n=5), FLASH T2(*) and ADC maps coregistered with histology revealed a T2(*) signal increase of 4.9% in the histologically defined border zone (55% normal neuronal morphology, located within the ADC lesion boundary) compared with a 0.7% increase in the cortical ischemic core (92% neuronal ischemic cell change, core ADC lesion). Oxygen challenge has potential clinical utility and, by distinguishing metabolically active and inactive tissues within hypoperfused regions, could provide a more precise assessment of penumbra.

Classification images reveal the information sensitivity of brain voxels in fMRI.

Reverse correlation methods have been widely used in neuroscience for many years and have recently been applied to study the sensitivity of human brain signals (EEG, MEG) to complex visual stimuli. Here we employ one such method, Bubbles (Gosselin, F., Schyns, P.G., 2001. Bubbles: A technique to reveal the use of information in recognition tasks. Vis. Res. 41, 2261-2271), in conjunction with fMRI in the context of a 3AFC facial expression categorization task. We highlight the regions of the brain showing significant sensitivity with respect to the critical visual information required to perform the categorization judgments. Moreover, we reveal the actual subset of visual information which modulates BOLD sensitivity within each such brain region. Finally, we show the potential which lies within analyzing brain function in terms of the information states of different brain regions. Thus, we can now analyse human brain function in terms of the specific visual information different brain regions process.

Serial postmortem relaxometry in the normal rat brain and following stroke.

PURPOSE: To investigate MRI for noninvasive autopsy by means of measurements of serial changes in relaxation parameters of the rat brain during the postmortem interval. MATERIALS AND METHODS: Postmortem relaxometry measurements were performed before and hourly after death for 24 h on five control rats and five rats that underwent middle cerebral artery occlusion. Analyses were performed on representative regions of gray, white, and mixed gray/white matter structures. RESULTS: Significant decreases in both T(1) and T(2) values were measured in all areas in the control group within 24 h of death. In the stroke animals, T(2) differences between normal and ischemic striatal tissue decreased by 11 +/- 4% (P < 0.01), with a complete convergence of T(2) values observed between ischemic striatal tissue and nonischemic cortical tissue. CONCLUSION: Lesion conspicuity and the ability to differentiate between different tissue compartments are significantly affected by postmortem interval, and alterations to pulse timing parameters will be necessary if the sensitivity of MRI to detect central nervous system diseases in postmortem tissue is to be maintained. Indeed in the case of stroke at least, convergence of T(2) values with normal tissue post mortem indicates that T(1)-weighted images may be more sensitive to the presence of such lesions.

Successful antiparkinsonian medication withdrawal in patients with Parkinsonism and normal FP-CIT SPECT.

Between 4% and 14% of patients diagnosed with Parkinson's disease and entering clinical trials have normal presynaptic dopaminergic imaging. The effects of antiparkinsonian therapy have varied in these studies, and the consequences of stopping treatment are not reported. We present 11 patients who initially fulfilled diagnostic criteria and were treated for Parkinson's disease but in whom emerging diagnostic doubts led to antiparkinsonian therapy withdrawal, which was achieved without deterioration. Such cases represent a nondegenerative form of Parkinsonism, which does not benefit from dopaminergic therapy. Prospective vigilance regarding this category is of importance in clinical practice and clinical trials.

Two-year follow-up in 150 consecutive cases with normal dopamine transporter imaging.

BACKGROUND AND AIMS: Functional pre-synaptic dopamine brain imaging is generally abnormal when parkinsonism is degenerative (such as in idiopathic Parkinson's disease) and normal in patients with non-degenerative movement disorder (such as essential tremor). However, some patients diagnosed as early Parkinson's disease have normal presynaptic dopamine imaging. Follow-up of patients with normal imaging should help determine whether such patients truly have degenerative parkinsonism (and therefore represent false negative imaging results), or emerge as cases of non-degenerative parkinsonism (and therefore represent initial clinical over-diagnosis of Parkinson's disease). METHODS AND RESULTS: One hundred and fifty cases with normal I-FP-CIT SPECT undertaken during routine care over a 3-year period were reviewed 2.4 years (interquartile range, 2.2-3.1 years) after SPECT. Diagnosis after follow-up was non-degenerative parkinsonism or tremor in 146 (97%), who did not progress clinically, and degenerative parkinsonism in four (3%), in whom clinical progression was noted. Anti-Parkinson therapy was used in 36, and withdrawn in 27 with no deterioration in 25. Patients strictly fulfilling Brain Bank criteria (part 1) were more likely to undergo a trial of anti-Parkinson therapy (P < 0.05) but were no more likely to maintain or respond to anti-Parkinson therapy than those not fulfilling criteria. CONCLUSION: The clinical profile and therapy response during follow-up of patients with normal presynaptic dopamine imaging supports the diagnosis of a non-degenerative movement disorder in nearly all cases.

Assessment of 123I-FIAU imaging of herpes simplex viral gene expression in the treatment of glioma.

BACKGROUND: Herpes simplex virus 1716 (HSV1716), a selectively replication competent mutant of HSV1, is under investigation as an oncolytic viral therapy in human malignant glioma. As with similar therapies, a technique for measurement of viral replication and distribution over time following virus administration is required. Imaging expression of the HSV-thymidine kinase (HSV-tk) gene offers an opportunity for non-invasive assessment of viral distribution in living subjects. This is the first study to explore the use of HSV-tk as a reporter gene and radiolabelled thymidine analogue 5-[(123)I]iodo-1-(2-deoxy-2-fluoro-beta-D-arabinofuranosyl) uracil ((123)I-FIAU) as a marker substrate to non-invasively monitor HSV1716 replication in humans during treatment of high-grade glioma. METHODS: I-FIAU brain SPECT imaging was undertaken in eight patients receiving intra-tumoural injection of HSV1716, before and after administration of the virus. Baseline images were acquired 3 days prior to virus administration and between 1 and 5 days following virus administration. Region of interest analysis was used to investigate whether there was an increase in (123)I-FIAU concentration following virus administration due to HSV-tk expression. RESULT: Increased (123)I-FIAU accumulation due to HSV-tk expression was not detected in this study. The possible explanations for this finding are explored and design options for future studies are discussed.

Measurement of tumor "size" in recurrent malignant glioma: 1D, 2D, or 3D?

BACKGROUND AND PURPOSE: Tumor "size" is used internationally as a surrogate marker for overall survival when following current response assessment protocols (World Health Organization and Response Evaluation Criteria in Solid Tumors). With little evidence of a relationship between tumor "size" and survival in intrinsic brain tumors, this study was undertaken to investigate the predictive value of MR imaging-defined tumor size for survival in patients with recurrent malignant glioma and to compare the different measures of tumor size used in these current response assessment protocols. METHODS: Volumetric, bidimensional, and unidimensional measurements of tumor size were made using baseline contrast-enhanced T1-weighted images of 70 patients with recurrent malignant glioma receiving intravenous chemotherapy. Cox's proportional hazards model was used to investigate the prognostic importance of tumor size using survival as the end point. Further statistical analysis was undertaken to investigate the relationship between the different measurement techniques. RESULTS: Only the volumetric measurement of tumor size was found to be predictive of survival in recurrent malignant glioma on both univariate and multivariate analysis. Furthermore, analysis demonstrated that the unidimensional and bidimensional measures of tumor were not comparable with the more accurate and direct volumetric measurement. CONCLUSION: Indirect unidimensional and bidimensional measurement techniques do not have a significant association with overall survival or adequately assess tumor size in recurrent malignant glioma. These findings have serious implications about the validity of using current response assessment protocols in therapy trials for recurrent malignant glioma.

Perfusion SPECT in cochlear implantation and promontory stimulation.

BACKGROUND: Recent studies of profoundly deaf patients with cochlear implants have demonstrated that these patients are able to process sound in the auditory cortex in a similar way to normal subjects. However, there are large variations in outcome. Various clinical criteria are used for subject selection and the decision as to which ear is to be implanted involves electrical stimulation of the promontory which is used to confirm the persistence of auditory neurones and fibres that can be utilized by the cochlear implant. In this study we have used SPECT with Tc-HMPAO to investigate activation of the auditory cortex in cochlear implantees post-surgery. In addition we also investigated whether electrical stimulation of the promontory does produce change in blood flow in the auditory cortex in pre-surgery candidates, which would indicate viable auditory networks that can be utilized by a cochlear implant device. METHODS AND RESULTS: Image analysis was performed with SPM99. Results of a simple subtraction paradigm indicated bilateral activation of auditory cortex and Wernicke's area in the post-implant group during auditory stimulus (speech) and bilateral activation of the ventral lateral posterior thalamus and bilateral auditory association cortex BA21/22/42, in the pre-implant group during electrical stimulus but no activation of the primary auditory cortex. A conjunction analysis used to investigate the common areas of activation across both groups during the stimulus condition showed that there was a common bilateral activation of the primary auditory cortex in both groups (BA22/41/42). In addition, analysis of a subset of the seven post-implant subjects who did not comprehend the speech in our study showed an activation (Pu<0.05, where Pu is the peak voxel threshold, uncorrected for multiple comparisons) in the left auditory cortex that extended into area BA22 synonymous with Wernicke's area. This supports the theory that this region has a sensory role.

Prospective study of presynaptic dopaminergic imaging in patients with mild parkinsonism and tremor disorders: part 1. Baseline and 3-month observations.

To record prospectively, from early presentation, the clinical features of parkinsonism and tremor disorders, in relation to evidence of dopaminergic deficit shown with [(123)I]-FP-CIT (DaTSCAN, Amersham Health) single photon emission computerised tomography (SPECT). Clinical signs were recorded in 62 patients, of whom 24 failed standard Parkinson's disease (PD) and essential tremor criteria, and 38 fulfilled UK Brain Bank step 1 PD criteria. Striatal radioligand uptake was graded visually as normal or abnormal, and specific:nonspecific ratios were calculated. Bradykinesia and rigidity showed significant overall association with abnormal scans (P < or = 0.003), but rest tremor did not (P = NS). In the 24 patients not fulfilling specific criteria (mean age 63 [SD 9] years, disease duration 3 [SD 4] years), 10 (42%) had abnormal visual SPECT assessment and 14 (58%) had normal scans. Of 38 patients with early PD by clinical criteria (mean age 60 [SD 9] years, disease duration 3 [SD 1.7] years), 33 (87%) were visually abnormal. Baseline clinical diagnosis corresponded with SPECT imaging results in 51 of 62 cases (82%), which increased to 56 of 62 cases (90%) with amendment of seven clinical diagnoses at 3 months (blind to SPECT results). Akinetic-rigid cardinal diagnostic features of parkinsonism associate well with dopaminergic deficit in patients with early and mild clinical features. When these clinical features are uncertain, or the patient fails clinical diagnostic criteria, testing for dopaminergic deficit with [(123)I]-FP-CIT SPECT may assist the diagnostic process.

MR findings in intralabyrinthine schwannomas.

AIM: Intralabyrinthine schwannomas (ILS) are rare benign tumours. They are not always recognized on routine magnetic resonance imaging (MRI). We aimed to study the clinical presentation and MRI findings in our patients with ILS. MATERIALS AND METHODS: Retrospective analysis of patients with vestibular schwannomas treated at this center. RESULTS: Of 144 vestibular schwannomas studied at this centre, three patients had an ILS. The most common presenting symptoms were unilateral hearing loss, tinnitus and vertigo. Two patients demonstrated a progressive sensorineural hearing loss (SNHL). The third patient had a severe SNHL at presentation. MRI enhanced with contrast medium was positive in the two patients with progressive SNHL and negative in the patient with the severe SNHL. CONCLUSION: This series demonstrates the ability of MRI to identify schwannomas filling the labyrinth, and also its inability to identify extremely small ILS. It underlines the importance of sending the cristae of patients undergoing labyrinthectomy for presumed Ménière's disease for histological examination.