Barriers to integrating portable Magnetic Resonance Imaging systems in emergency medical service ambulances for stroke care.

This study examines the barriers to integrating portable Magnetic Resonance Imaging (MRI) systems into ambulance services to enable effective triaging of patients to the appropriate hospitals for timely stroke care and potentially reduce door-to-needle time for thrombolytic administration. The study employs a qualitative methodology using a digital twin of the patient handling process developed and demonstrated through semi-structured interviews with 18 participants, including 11 paramedics from an Emergency Medical Services system and seven neurologists from a tertiary stroke care centre. The interview transcripts were thematically analysed to determine the barriers based on the Systems Engineering Initiative for Patient Safety framework. Key barriers include the need for MRI operation skills, procedural complexities in patient handling, space constraints, and the need for training and policy development. Potential solutions are suggested to mitigate these barriers. The findings can facilitate implementing MRI systems in ambulances to expedite stroke treatment.

This study investigates the challenges of integrating portable MRI systems into ambulances for faster stroke care. It identifies key barriers such as operational skills, procedural complexities, space constraints, and policy development needs, and offers a few solutions to improve emergency stroke treatment.

The Use of Portable, Very Low-field (0.064T) MRI to Image Cochlear Implants: Metallic Image Artifact in Comparison to Traditional, Stationary 3T MRI.

Objective: To assess image artifact when imaging a cochlear implant (CI) with a conventional 3T MRI machine compared with a very low-field (0.064T) MRI. Patients: None. Intervention: Diagnostic study. Main Outcome Measure: Image artifact size associated with the CI affixed to an MRI phantom at very low-field 0.064T MRI versus 3T MRI. Results: The longest diameter of the image artifact was 125 mm for the 3T MRI and 86 mm for the 0.064T MRI, representing 45% longer image artifact generated in the 3T MRI. The actual volume of the imaging phantom was 1371 cm3. The volume of the image artifact was measured as 379 cm3 in the 3T MRI, representing a loss of 27.6% of the actual volume of the imaging phantom. The volume of image artifact was measured as 170 cm3 in the 0.064T MRI, representing a loss of 12.4% of the phantom volume. Conclusions: 3T MRI had better image quality. This result was not surprising given that larger magnetic field strength is known to provide higher resolution. There was 15% less image artifact generated in the very low-field MRI machine compared with a conventional 3T device. And there was also subjectively increased distortion of the imaging phantom at 3T MRI compared with the 0.064T MRI. With minimized safety concerns and a much lower cost than conventional 3T machines, very low-field scanners may find expanded clinical uses. This preclinical study explores the potential utility of very low-field MRI in scanning CI recipients.

Mobile point-of-care MRI demonstration of a normal volunteer in a telemedicine-equipped ambulance.

OBJECTIVE: Several centers have implemented ambulances equipped with CT scanners and telemedicine capabilities, known as mobile stroke units (MSU), to expedite acute stroke care delivery in the pre-hospital setting. While MSUs have been shown to improve outcomes compared with standard emergency medical management, there are limitations to incorporating CT, including radiation exposure to emergency medical services personnel. Recently, a portable, low-field strength MRI (Swoop®, Hyperfine, Inc., Guilford, CT) received FDA clearance for in-hospital use. Here, as proof-of-concept, we explore the possibility of performing MRI in a telemedicine-equipped ambulance during active transport. MATERIALS AND METHODS: In this initial technical demonstration, we imaged an MR phantom and a normal human volunteer using a standard stroke protocol during active ambulance transport. RESULTS: Images of the MR phantom and volunteer were successfully obtained and were immediately available for viewing in the hospital PACS system. The images were deemed of diagnostic quality by the radiologist. Active motion correction maintained superior image quality despite vehicle and scanner motion. In-plane, low contrast resolution of greater than 4 × 4 mm was achieved. Average transmit speeds were calculated to be 3.54 Megabits/second and upload data rates varied while in transit ranging from 8.54 to 4.13 Megabits/second. CONCLUSION: While MRI is not yet ready for clinical use in the MSU setting, our initial experience suggests potential technological feasible of this approach following future technical and MRI sequence development. Additional studies, incorporating patients, would be required to determine clinical feasibility.

Modulation of vestibular input by short-term head-down bed rest affects somatosensory perception: implications for space missions.

Introduction: On Earth, self-produced somatosensory stimuli are typically perceived as less intense than externally generated stimuli of the same intensity, a phenomenon referred to as somatosensory attenuation (SA). Although this phenomenon arises from the integration of multisensory signals, the specific contribution of the vestibular system and the sense of gravity to somatosensory cognition underlying distinction between self-generated and externally generated sensations remains largely unknown. Here, we investigated whether temporary modulation of the gravitational input by head-down tilt bed rest (HDBR)-a well-known Earth-based analog of microgravity-might significantly affect somatosensory perception of self- and externally generated stimuli. Methods: In this study, 40 healthy participants were tested using short-term HDBR. Participants received a total of 40 non-painful self- and others generated electrical stimuli (20 self- and 20 other-generated stimuli) in an upright and HDBR position while blindfolded. After each stimulus, they were asked to rate the perceived intensity of the stimulation on a Likert scale. Results: Somatosensory stimulations were perceived as significantly less intense during HDBR compared to upright position, regardless of the agent administering the stimulus. In addition, the magnitude of SA in upright position was negatively correlated with the participants' somatosensory threshold. Based on the direction of SA in the upright position, participants were divided in two subgroups. In the subgroup experiencing SA, the intensity rating of stimulations generated by others decreased significantly during HDBR, leading to the disappearance of the phenomenon of SA. In the second subgroup, on the other hand, reversed SA was not affected by HDBR. Conclusion: Modulation of the gravitational input by HDBR produced underestimation of somatosensory stimuli. Furthermore, in participants experiencing SA, the reduction of vestibular inputs by HDBR led to the disappearance of the SA phenomenon. These findings provide new insights into the role of the gravitational input in somatosensory perception and have important implications for astronauts who are exposed to weightlessness during space missions.

The effect of prolonged spaceflight on cerebrospinal fluid and perivascular spaces of astronauts and cosmonauts.

Long-duration spaceflight induces changes to the brain and cerebrospinal fluid compartments and visual acuity problems known as spaceflight-associated neuro-ocular syndrome (SANS). The clinical relevance of these changes and whether they equally affect crews of different space agencies remain unknown. We used MRI to analyze the alterations occurring in the perivascular spaces (PVS) in NASA and European Space Agency astronauts and Roscosmos cosmonauts after a 6-mo spaceflight on the International Space Station (ISS). We found increased volume of basal ganglia PVS and white matter PVS (WM-PVS) after spaceflight, which was more prominent in the NASA crew than the Roscosmos crew. Moreover, both crews demonstrated a similar degree of lateral ventricle enlargement and decreased subarachnoid space at the vertex, which was correlated with WM-PVS enlargement. As all crews experienced the same environment aboard the ISS, the differences in WM-PVS enlargement may have been due to, among other factors, differences in the use of countermeasures and high-resistive exercise regimes, which can influence brain fluid redistribution. Moreover, NASA astronauts who developed SANS had greater pre- and postflight WM-PVS volumes than those unaffected. These results provide evidence for a potential link between WM-PVS fluid and SANS.

Comparison of Dural Venous Sinus Volumes Before and After Flight in Astronauts With and Without Spaceflight-Associated Neuro-Ocular Syndrome.

Importance: Spaceflight-associated neuro-ocular syndrome (SANS) occurs in 40% to 60% of National Aeronautics and Space Administration (NASA) International Space Station (ISS) astronauts who present postflight with ophthalmological findings and elevated intracranial pressure. The etiology of SANS is unknown; it is hypothesized that venous outflow congestion from the head and neck occurs because of microgravity, which is supported by the finding of internal jugular vein stagnant flow and thrombosis in some astronauts, but the impact on intracranial dural venous sinus structures remains unknown. Objectives: To clarify the potential risk of retrograde extension of clot intracranially among astronauts with internal jugular venous thrombosis by evaluating intracranial venous structures following spaceflight and to assess for any association between intracranial venous congestion and SANS. Design, Setting, and Participants: This retrospective cohort study of all NASA astronauts who had undergone magnetic resonance (MR) venography at the time of the study included quantitative and qualitative assessments of the intracranial venous system on preflight and postflight MR venograms. Data were collected a mean (SD) of 525.8 (187.5) days before spaceflight and 2.0 (1.5) days after return to Earth. A semiautomated segmentation of the venogram images was used, which was then compared with a neuroradiologist's assessment. Exposures: A mean (SD) 184.3 (66.0) days of ISS spaceflight missions. Main Outcomes and Measures: Dural venous sinus volumes before and after spaceflight. Results: A total of 12 astronauts (2 [16.67%] women; 10 [83.33%] men), with a mean (SD) age of 47.8 (5.8) years, were included. Overall, 4 astronauts (33.33%) met the diagnostic criteria for SANS. No dural venous sinus thrombosis was detected for any astronaut. Astronauts with SANS had significantly greater median (range) preflight to postflight increases in volume vs astronauts without SANS for all 3 venous sinus structures: superior sagittal sinus (13.40% [8.70% to 17.47%] vs -2.66% [-15.84% to 5.31%,]; P = .004), right transverse/sigmoid sinus (17.15% [7.63% to 30.08%] vs 0.77% [-14.98% to 15.12%]; P = .02), and left transverse/sigmoid sinus (9.40% [5.20% to 15.50%] vs -1.40% [-14.20% to 12.50%]; P = .03). There was a positive correlation between the neuroradiologist's evaluation and the semiautomated method for the superior sagittal sinus (rpb = 0.64; P = .02) and the right transverse/sigmoid sinus (rpb = 0.58; P = .050). Conclusions and Relevance: These findings, in conjunction with the growing body of evidence of abnormal blood flow dynamics during spaceflight, suggest an association between intracranial venous congestion and SANS. Thus, there is an implication that individuals with increased venous sinus compliance may be at increased risk of developing SANS. These findings should be confirmed in a larger astronaut population and may contribute to understanding disorders of intracranial venous outflow on Earth.

Zero gravity induced by parabolic flight enhances automatic capture and weakens voluntary maintenance of visuospatial attention.

Orienting attention in the space around us is a fundamental prerequisite for willed actions. On Earth, at 1 g, orienting attention requires the integration of vestibular signals and vision, although the specific vestibular contribution to voluntary and automatic components of visuospatial attention remains largely unknown. Here, we show that unweighting of the otolith organ in zero gravity during parabolic flight, selectively enhances stimulus-driven capture of automatic visuospatial attention, while weakening voluntary maintenance of covert attention. These findings, besides advancing our comprehension of the basic influence of the vestibular function on voluntary and automatic components of visuospatial attention, may have operational implications for the identification of effective countermeasures to be applied in forthcoming human deep space exploration and habitation, and on Earth, for patients' rehabilitation.

Altered cerebral perfusion in response to chronic mild hypercapnia and head-down tilt Bed rest as an analog for Spaceflight.

PURPOSE: Following prolonged stays on the International Space Station (ISS), some astronauts exhibit visual acuity changes, ophthalmological findings, and mildly elevated intracranial pressures as part of a novel process called spaceflight-associated neuro-ocular syndrome (SANS). To determine the pathophysiology of SANS, NASA conducted a multi-investigator study in which 11 healthy participants underwent head-down tilt bed rest, mimicking microgravity-induced cephalad fluid shifts, combined with elevated ambient CO2 levels similar to those on the ISS (HDT+CO2). As part of that study, we examined the effects of HDT+CO2 on cerebral perfusion. METHODS: Using arterial spin labeling, we compared cerebral perfusion before, during, and after HDT+CO2 in participants who developed SANS (n = 5) with those who did not (n = 6). RESULTS: All participants demonstrated a decrease in perfusion during HDT+CO2 (mean decrease of 25.1% at HDT7 and 16.2% at HDT29); however, the timing and degree of change varied between the groups. At day 7 of HDT+CO2, the SANS group experienced a greater reduction in perfusion than the non-SANS group (p =.05, 95% CI:-0.19 to 16.11, d=.94, large effect). Conversely, by day 29 of HDT+CO2, the SANS group had significantly higher perfusion (approaching their baseline) than the non-SANS group (p = .04, 95% CI:0.33 to 13.07, d=1.01, large effect). CONCLUSION: Compared with baseline and recovery, HDT+CO2 resulted in reduced cerebral perfusion which varied based on SANS status. Further studies are needed to unravel the relative role of HDT vs hypercapnia, to determine if these perfusion changes are clinically relevant, and whether perfusion changes contribute to the development of SANS during spaceflight.

Longitudinal change in ventricular volume is accelerated in astronauts undergoing long-duration spaceflight.

An 11-25% increase in total ventricular volume has been documented in astronauts following spaceflight on the ISS. Given the approximately 2-year time interval between pre- and post-flight MRI, it is unknown if ventricular enlargement simply reflects normal aging or is unique to spaceflight exposure. Therefore, we compared percent ventricular volume change per year (PVVC/yr) documented on pre- to post-flight MRI in a group of NASA ISS astronauts (n = 18, 16.7% women, mean age (SD) 48.43 (4.35) years) with two groups who underwent longitudinal MRI: (1.) healthy age- and sex-matched adults (n = 18, 16.7% women, mean age (SD) 51.26 (3.88) years), and (2.) healthy older adults (n = 79, 16.5% women, mean age (SD) 73.26 (5.34) years). The astronauts, who underwent a mean (SD) 173.4 (51.3) days in spaceflight, showed a greater increase in PVVC/yr than the control (6.86 vs 2.23%, respectively, p < .001) and older adult (4.18%, p = 0.04) groups. These results highlight that on top of physiologically ventricular volume changes due to normal aging, NASA astronauts undergoing ISS missions experience an additional 4.63% PVVC/yr and underscore the need to perform post-flight follow-up scans to determine the time course of PVVC in astronauts over time back on Earth along with monitoring to determine if the PVVC is ultimately clinically relevant. One sentence summary: NASA astronauts who were exposed to prolonged spaceflight experienced an annual rate of ventricular expansion more than three times that expected from normal aging.

Brain stimulation in zero gravity: transcranial magnetic stimulation (TMS) motor threshold decreases during zero gravity induced by parabolic flight.

We are just beginning to understand how spaceflight may impact brain function. As NASA proceeds with plans to send astronauts to the Moon and commercial space travel interest increases, it is critical to understand how the human brain and peripheral nervous system respond to zero gravity. Here, we developed and refined head-worn transcranial magnetic stimulation (TMS) systems capable of reliably and quickly determining the amount of electromagnetism each individual needs to detect electromyographic (EMG) threshold levels in the thumb (called the resting motor threshold (rMT)). We then collected rMTs in 10 healthy adult participants in the laboratory at baseline, and subsequently at three time points onboard an airplane: (T1) pre-flight at Earth gravity, (T2) during zero gravity periods induced by parabolic flight and (T3) post-flight at Earth gravity. Overall, the subjects required 12.6% less electromagnetism applied to the brain to cause thumb muscle activation during weightlessness compared to Earth gravity, suggesting neurophysiological changes occur during brief periods of zero gravity. We discuss several candidate explanations for this finding, including upward shift of the brain within the skull, acute increases in cortical excitability, changes in intracranial pressure, and diffuse spinal or neuromuscular system effects. All of these possible explanations warrant further study. In summary, we documented neurophysiological changes during brief episodes of zero gravity and thus highlighting the need for further studies of human brain function in altered gravity conditions to optimally prepare for prolonged microgravity exposure during spaceflight.

Spaceflight-Associated Changes in the Opacification of the Paranasal Sinuses and Mastoid Air Cells in Astronauts.

Importance: Head congestion is one of the most common somatic symptoms experienced by astronauts during spaceflight; however, changes in the opacification of the paranasal sinuses or mastoid air cells in astronauts have not been adequately studied. Objectives: To quantify preflight to postflight changes in the opacification of the paranasal sinuses and mastoid air cells in Space Shuttle astronauts and International Space Station (ISS) astronauts and to assess whether there are differences between the 2 groups of astronauts. Design, Setting, and Participants: This cohort study examined preflight and postflight head magnetic resonance images (MRIs) of 35 astronauts who had participated in either a short-duration (≤30 days) Space Shuttle mission or a long-duration (>30 days) ISS mission and had undergone both preflight and postflight MRI. Images were obtained before and after spaceflight. Images were evaluated by 2 neuroradiologists blinded to which mission each astronaut had flown and to which images were preflight or postflight images. Exposure: Spaceflight on the Space Shuttle or the ISS. Main Outcomes and Measures: Measured outcomes included preflight to postflight changes in Lund-Mackay scores for the paranasal sinuses and in scores grading mastoid effusions. Results: Most astronauts in both the Space Shuttle group (n = 17; 15 men; mean [SD] age at launch, 47.7 [3.1] years) and the ISS group (n = 18; 14 men; mean [SD] age at launch, 48.6 [4.7] years) exhibited either no change or a reduction in paranasal sinus opacification as seen on postflight MRI scans (Space Shuttle group: 6 [35.3%] had no sinus opacification before or after spaceflight, 5 [29.4%] had less sinus opacification after spaceflight, 3 [17.6%] had the same amount of sinus opacification before and after spaceflight, and 3 [17.6%] had increased paranasal sinus opacification after spaceflight; ISS group: 8 [44.4%] had no sinus opacification before or after spaceflight, 4 [22.2%] had less sinus opacification after spaceflight, 1 (5.6%) had the same amount of sinus opacification before and after spaceflight, and 5 [27.8%] had scores consistent with increased paranasal sinus opacification after spaceflight). Long-duration spaceflight (ISS group) was associated with an increased risk of mastoid effusion relative to short-duration spaceflight (relative risk, 4.72; 95% CI, 1.2-18.5). Images were obtained a mean (SD) 287.5 (208.6) days (range, 18-627 days) prior to and 6.8 (5.8) days (range, 1-20 days) after spaceflight. Astronauts had undergone either a mean (SD) of 13.6 (1.6) days of spaceflight on the Space Shuttle (17 astronauts) or 164.8 (18.9) days on the ISS (18 astronauts). Conclusions and Relevance: This study found that exposure to spaceflight conditions on the ISS is associated with an increased likelihood for the formation of mastoid effusions. There was no association between exposure to spaceflight conditions and changes in paranasal sinus opacification. The limitations of this study include lack of information concerning medical history and mission-specific operational experience for individual astronauts. Further studies are indicated to determine the cause and composition of the mastoid effusions.

Dose Finding Study of Gadopiclenol, a New Macrocyclic Contrast Agent, in MRI of Central Nervous System.

OBJECTIVES: The aim of this study was to determine a safe and effective dose of gadopiclenol, a new high relaxivity macrocyclic gadolinium-based contrast agent. Based on the contrast-to-noise ratio (CNR) as primary criterion, this new agent was compared with gadobenate dimeglumine in patients with contrast-enhancing central nervous system lesions. METHODS AND MATERIALS: This phase IIb international, multicenter, double-blind, randomized, controlled, parallel dose groups, and cross-over study included adult patients with known or highly suspected lesions with disrupted blood-brain barrier. Patients were randomized to 1 of 4 doses of gadopiclenol (0.025, 0.05, 0.1, 0.2 mmol/kg) and to 1 series of 2 magnetic resonance imaging scans: gadopiclenol then gadobenate dimeglumine at 0.1 mmol/kg or vice versa. The qualitative and quantitative efficacy evaluations were performed by 3 independent off-site blinded readers. Adverse events were monitored up to 1 day after second magnetic resonance imaging. RESULTS: The study population included 272 patients (58.5% females) with a mean (SD) age of 53.8 (13.6) years. The superiority of gadopiclenol over gadobenate dimeglumine was statistically demonstrated at 0.2 and 0.1 mmol/kg for all readers with an increase in CNR of more than 30% (P ≤ 0.0007). At 0.05 mmol/kg, gadopiclenol showed a CNR of similar magnitude as gadobenate dimeglumine at 0.1 mmol/kg, with no statistically significant difference. Similar results were obtained for lesion-to-brain ratio and contrast enhancement percentage, as secondary criteria. The relationship between CNR and dose of gadopiclenol was linear for all readers. Mean scores for lesion visualization variables, particularly lesion contrast enhancement, tended to be higher with gadopiclenol at 0.1 and 0.2 mmol/kg compared with gadobenate dimeglumine. All 3 readers mainly expressed an overall diagnostic preference for images with gadopiclenol at 0.1 mmol/kg (45.3%, 50.9%, or 86.8% of images) or expressed no preference (49.1%, 49.1%, or 9.4%, respectively), whereas preference for images with gadobenate dimeglumine was reported by 2 readers for 3.8% and 5.7% of the images. Predominantly, no preference was expressed when comparing images with gadopiclenol at 0.05 mmol/kg to those with gadobenate dimeglumine.Rates of adverse reactions were comparable for gadopiclenol (11.7%) and gadobenate dimeglumine (12.1%). Changes from baseline of more than 25% in serum creatinine and estimated glomerular filtration rate occurred in less than 2% of patients equally for gadopiclenol and gadobenate dimeglumine. Changes from baseline for the values of blood urea nitrogen and cystatin C were also similar between gadopiclenol and gadobenate dimeglumine. No safety concerns were detected on centralized electrocardiography readings. CONCLUSIONS: Between the doses of 0.025 and 0.2 mmol/kg of gadopiclenol, the increase in CNR is linear. Compared with gadobenate dimeglumine at 0.1 mmol/kg, the doses of 0.05 and 0.1 mmol/kg of gadopiclenol gave similar or significantly greater contrast enhancement, respectively, and thus both doses can be considered for future phase III studies.