Innovative minimally invasive options to treat drug-resistant epilepsies.

Despite the regular discovery of new molecules, one-third of epileptic patients are resistant to antiepileptic drugs. Only a few can benefit from resective surgery, the current gold standard. Although effective in 50-70% of cases, this therapy remains risky, costly, and can be associated with long-term cognitive or neurological side effects. In addition, patients are increasingly reluctant to have a craniotomy, emphasizing the need for new less invasive therapies for focal drug-resistant epilepsies. Here, we review different minimally invasive approaches already in use in the clinic or under preclinical development to treat drug-resistant epilepsies. Localized thermolesion of the epileptogenic zone has been developed in the clinic using high-frequency thermo-coagulations or magnetic resonance imaging-guided laser or ultrasounds. Although less invasive, they have not yet significantly improved the outcomes when compared with resective surgery. Radiosurgery techniques have been used in the clinic for the last 20years and have proven efficiency. However, their efficacy is not better than resective surgery, and various side effects have been reported as well as the potential risk of sudden unexpected death associated with epilepsy. Recently, a new strategy of radiosurgery has emerged using synchrotron-generated X-ray microbeams: microbeam radiation therapy (MRT). The low divergence and high-flux of the synchrotron beams and the unique tolerance to MRT by healthy brain tissues, allows a precise targeting of specific brain regions with minimal invasiveness and limited behavioral or functional consequences in animals. Antiepileptic effects over several months have been recorded in animal models, and histological and synaptic tracing analysis suggest a reduction of neuronal connectivity as a mechanism of action. The possibility of transferring this approach to epileptic patients is discussed in this review.

Artificial intelligence to predict clinical disability in patients with multiple sclerosis using FLAIR MRI.

PURPOSE: The purpose of this study was to create an algorithm that combines multiple machine-learning techniques to predict the expanded disability status scale (EDSS) score of patients with multiple sclerosis at two years solely based on age, sex and fluid attenuated inversion recovery (FLAIR) MRI data. MATERIALS AND METHODS: Our algorithm combined several complementary predictors: a pure deep learning predictor based on a convolutional neural network (CNN) that learns from the images, as well as classical machine-learning predictors based on random forest regressors and manifold learning trained using the location of lesion load with respect to white matter tracts. The aggregation of the predictors was done through a weighted average taking into account prediction errors for different EDSS ranges. The training dataset consisted of 971 multiple sclerosis patients from the "Observatoire français de la sclérose en plaques" (OFSEP) cohort with initial FLAIR MRI and corresponding EDSS score at two years. A test dataset (475 subjects) was provided without an EDSS score. Ten percent of the training dataset was used for validation. RESULTS: Our algorithm predicted EDSS score in patients with multiple sclerosis and achieved a MSE=2.2 with the validation dataset and a MSE=3 (mean EDSS error=1.7) with the test dataset. CONCLUSION: Our method predicts two-year clinical disability in patients with multiple sclerosis with a mean EDSS score error of 1.7, using FLAIR sequence and basic patient demographics. This supports the use of our model to predict EDSS score progression. These promising results should be further validated on an external validation cohort.

Brain networks of rats under anesthesia using resting-state fMRI: comparison with dead rats, random noise and generative models of networks.

OBJECTIVE: Connectivity networks are crucial to understand the brain resting-state activity using functional magnetic resonance imaging (rs-fMRI). Alterations of these brain networks may highlight important findings concerning the resilience of the brain to different disorders. The focus of this paper is to evaluate the robustness of brain network estimations, discriminate them under anesthesia and compare them to generative models. APPROACH: The extraction of brain functional connectivity (FC) networks is difficult and biased due to the properties of the data: low signal to noise ratio, high dimension low sample size. We propose to use wavelet correlations to assess FC between brain areas under anesthesia using four anesthetics (isoflurane, etomidate, medetomidine, urethane). The networks are then deduced from the functional connectivity matrices by applying statistical thresholds computed using the number of samples at a given scale of wavelet decomposition. Graph measures are extracted and extensive comparisons with generative models of structured networks are conducted. MAIN RESULTS: The sample size and filtering are critical to obtain significant correlations values and thereby detect connections between regions. This is necessary to construct networks different from random ones as shown using rs-fMRI brain networks of dead rats. Brain networks under anesthesia on rats have topological features that are mixing small-world, scale-free and random networks. Betweenness centrality indicates that hubs are present in brain networks obtained from anesthetized rats but locations of these hubs are altered by anesthesia. SIGNIFICANCE: Understanding the effects of anesthesia on brain areas is of particular importance in the context of animal research since animal models are commonly used to explore functions, evaluate lesions or illnesses, and test new drugs. More generally, results indicate that the use of correlations in the context of fMRI signals is robust but must be treated with caution. Solutions are proposed in order to control spurious correlations by setting them to zero.

Brain lateralization probed by water diffusion at the atomic to micrometric scale.

Combined neutron scattering and diffusion nuclear magnetic resonance experiments have been used to reveal significant interregional asymmetries (lateralization) in bovine brain hemispheres in terms of myelin arrangement and water dynamics at micron to atomic scales. Thicker myelin sheaths were found in the left hemisphere using neutron diffraction. 4.7 T dMRI and quasi-elastic neutron experiments highlighted significant differences in the properties of water dynamics in the two hemispheres. The results were interpreted in terms of hemisphere-dependent cellular composition (number of neurons, cell distribution, etc.) as well as specificity of neurological functions (such as preferential networking).

Anomalous water dynamics in brain: a combined diffusion magnetic resonance imaging and neutron scattering investigation.

Water diffusion is an optimal tool for investigating the architecture of brain tissue on which modern medical diagnostic imaging techniques rely. However, intrinsic tissue heterogeneity causes systematic deviations from pure free-water diffusion behaviour. To date, numerous theoretical and empirical approaches have been proposed to explain the non-Gaussian profile of this process. The aim of this work is to shed light on the physics piloting water diffusion in brain tissue at the micrometre-to-atomic scale. Combined diffusion magnetic resonance imaging and first pioneering neutron scattering experiments on bovine brain tissue have been performed in order to probe diffusion distances up to macromolecular separation. The coexistence of free-like and confined water populations in brain tissue extracted from a bovine right hemisphere has been revealed at the micrometre and atomic scale. The results are relevant for improving the modelling of the physics driving intra- and extracellular water diffusion in brain, with evident benefit for the diffusion magnetic resonance imaging technique, nowadays widely used to diagnose, at the micrometre scale, brain diseases such as ischemia and tumours.

Mapping of brain tissue hematocrit in glioma and acute stroke using a dual autoradiography approach.

Hematocrit (Hct) determines the ability of blood to carry oxygen. While changes in systemic Hct are known to impact stroke or tumor control, changes in local (tissue) Hct (tHct) induced by these diseases have however received little attention. In this study, we evaluate tHct in acute stroke and in glioma models using a new approach to map tHct across the brain, a dual isotope autoradiography, based on injections of 125I-labeled albumin and 99mTc-lalbeled red blood cells in the same animal. For validation purpose, tHct was mapped in the rat brain (i) under physiological conditions, (ii) following erythropoietin injection, and (iii) following hemodilution. Then, tHct was then mapped in stroke (middle cerebral artery occlusion) and tumor models (9LGS and C6). The mean tHct values observed in healthy brains (tHct = 29 ± 1.3%), were modified as expected by erythropoietin (tHct = 36.7 ± 2.6%) and hemodilution (tHct = 24.2 ± 2.4%). Using the proposed method, we observed a local reduction, spatially heterogeneous, in tHct following acute stroke (tHct = 19.5 ± 2.5%) and in both glioma models (9LGS: tHct = 18.5 ± 2.3%, C6: tHct = 16.1 ± 1.2%). This reduction and this heterogeneity in tHct observed in stroke and glioma raises methodological issues in perfusion imaging techniques where tHct is generally overlooked and could impact therapeutic strategies.

Hypertonic sodium lactate reverses brain oxygenation and metabolism dysfunction after traumatic brain injury.

BACKGROUND: The mechanisms by which hypertonic sodium lactate (HSL) solution act in injured brain are unclear. We investigated the effects of HSL on brain metabolism, oxygenation, and perfusion in a rodent model of diffuse traumatic brain injury (TBI). METHODS: Thirty minutes after trauma, anaesthetised adult rats were randomly assigned to receive a 3 h infusion of either a saline solution (TBI-saline group) or HSL (TBI-HSL group). The sham-saline and sham-HSL groups received no insult. Three series of experiments were conducted up to 4 h after TBI (or equivalent) to investigate: 1) brain oedema using diffusion-weighted magnetic resonance imaging and brain metabolism using localized 1H-magnetic resonance spectroscopy (n = 10 rats per group). The respiratory control ratio was then determined using oxygraphic analysis of extracted mitochondria, 2) brain oxygenation and perfusion using quantitative blood-oxygenation-level-dependent magnetic resonance approach (n = 10 rats per group), and 3) mitochondrial ultrastructural changes (n = 1 rat per group). RESULTS: Compared with the TBI-saline group, the TBI-HSL and the sham-operated groups had reduced brain oedema. Concomitantly, the TBI-HSL group had lower intracellular lactate/creatine ratio [0.049 (0.047-0.098) vs 0.097 (0.079-0.157); P < 0.05], higher mitochondrial respiratory control ratio, higher tissue oxygen saturation [77% (71-79) vs 66% (55-73); P < 0.05], and reduced mitochondrial cristae thickness in astrocytes [27.5 (22.5-38.4) nm vs 38.4 (31.0-47.5) nm; P < 0.01] compared with the TBI-saline group. Serum sodium and lactate concentrations and serum osmolality were higher in the TBI-HSL than in the TBI-saline group. CONCLUSIONS: These findings indicate that the hypertonic sodium lactate solution can reverse brain oxygenation and metabolism dysfunction after traumatic brain injury through vasodilatory, mitochondrial, and anti-oedema effects.

MR Vascular Fingerprinting in Stroke and Brain Tumors Models.

In this study, we evaluated an MRI fingerprinting approach (MRvF) designed to provide high-resolution parametric maps of the microvascular architecture (i.e., blood volume fraction, vessel diameter) and function (blood oxygenation) simultaneously. The method was tested in rats (n = 115), divided in 3 models: brain tumors (9 L, C6, F98), permanent stroke, and a control group of healthy animals. We showed that fingerprinting can robustly distinguish between healthy and pathological brain tissues with different behaviors in tumor and stroke models. In particular, fingerprinting revealed that C6 and F98 glioma models have similar signatures while 9 L present a distinct evolution. We also showed that it is possible to improve the results of MRvF and obtain supplemental information by changing the numerical representation of the vascular network. Finally, good agreement was found between MRvF and conventional MR approaches in healthy tissues and in the C6, F98, and permanent stroke models. For the 9 L glioma model, fingerprinting showed blood oxygenation measurements that contradict results obtained with a quantitative BOLD approach. In conclusion, MR vascular fingerprinting seems to be an efficient technique to study microvascular properties in vivo. Multiple technical improvements are feasible and might improve diagnosis and management of brain diseases.

Cell-based therapy for traumatic brain injury.

Traumatic brain injury is a major economic burden to hospitals in terms of emergency department visits, hospitalizations, and utilization of intensive care units. Current guidelines for the management of severe traumatic brain injuries are primarily supportive, with an emphasis on surveillance (i.e. intracranial pressure) and preventive measures to reduce morbidity and mortality. There are no direct effective therapies available. Over the last fifteen years, pre-clinical studies in regenerative medicine utilizing cell-based therapy have generated enthusiasm as a possible treatment option for traumatic brain injury. In these studies, stem cells and progenitor cells were shown to migrate into the injured brain and proliferate, exerting protective effects through possible cell replacement, gene and protein transfer, and release of anti-inflammatory and growth factors. In this work, we reviewed the pathophysiological mechanisms of traumatic brain injury, the biological rationale for using stem cells and progenitor cells, and the results of clinical trials using cell-based therapy for traumatic brain injury. Although the benefits of cell-based therapy have been clearly demonstrated in pre-clinical studies, some questions remain regarding the biological mechanisms of repair and safety, dose, route and timing of cell delivery, which ultimately will determine its optimal clinical use.

T2-*weighted perfusion MRI.

T2*-weighted perfusion MRI is based on the so-called "first passage" approach: the modifications in the T2-weighted MRI signal are followed during the first passage of a bolus of contrast agent. The pixel-by-pixel analysis of the curves is used to obtain parametric maps (time of arrival, time of the peak, mean transit time, relative volume and blood flow). Further analysis, with deconvolution by arterial input function (concentration of contrast agent in the blood), helps improve the quantification. It is possible to pre-inject a small dose of contrast agent to limit the impact of the extravasation of the contrast agent.

Manganese enhanced MRI in rat hippocampus: a correlative study with synchrotron X-ray microprobe.

Manganese enhanced MRI (MEMRI) offers many possibilities such as tract tracing and functional imaging in vivo. Mn is however neurotoxic and may induce symptoms similar to those associated with Parkinson's disease (manganism). The mechanisms of Mn-induced neurotoxicity are not clear. In this study, we combine synchrotron X-ray fluorescence microprobe (SR-XRF) and MEMRI techniques to investigate spatial distribution of Mn within the rat hippocampus and how Mn interacts with Ca, Fe and Zn at a cellular level. Images were acquired in the rat hippocampus (n=23) and using two injection routes: intra-cerebral (MnCl(2): 50 mM, 10 µL) and intra-peritoneal (MnCl(2): 100 mM, 30 mg/kg). For both injection routes, Mn is found in dentate gyrus and in CA3: control: 2.5 ± 1.6, intra-peritoneal: 5.0 ± 2.4, and intra-cerebral: 25.1 ± 9.2 µg/g. Mn follows Zn distribution and has a negative impact on the total amount of Zn and Fe. The Mn-enhanced MRI contrast is well correlated with the total Mn amount measured with SR-XRF (R(2)=0.93; p<0.002). After intra-cerebral injection, the hippocampal fissure is found to accumulate a large amount of Mn and yields a hypointense MRI signal, which may be ascribed to a reduction in T2. This study shows that SR-XRF is well suited to investigate Mn distribution at a mesoscale and that MRI is sensitive to low Mn concentrations. As perturbations in metal homeostasis may alter brain function, the injected dose of Mn in MEMRI studies needs to be carefully adjusted to obtain reliable functional information.

Monochromatic minibeam radiotherapy: theoretical and experimental dosimetry for preclinical treatment plans.

Monochromatic x-ray minibeam radiotherapy is a new radiosurgery approach based on arrays of submillimetric interlaced planar x-ray beams. The aim of this study was to characterize the dose distributions obtained with this new modality when being used for preclinical trials. Monte Carlo simulations were performed in water phantoms. Percentage depth-dose curves and dose profiles were computed for single incidences and interleaved incidences of 80 keV planar x-ray minibeam (0.6 × 5 mm) arrays. Peak to valley dose ratios were also computed at various depths for an increasing number of minibeams. 3D experimental polymer gel (nPAG) dosimetry measurements were performed using MRI devices designed for small animal imaging. These very high spatial resolution (50 µm) dose maps were compared to the simulations. Preclinical minibeams dose distributions were fully characterized. Experimental dosimetry correlated well with Monte Carlo calculations (Student t-tests: p > 0.1). F98 tumor-bearing rats were also irradiated with interleaved minibeams (80 keV, prescribed dose: 25 Gy). This associated preclinical trial serves as a proof of principle of the technique. The mean survival time of irradiated glioma-bearing rats increased significantly, when compared to the untreated animals (59.6 ± 2.8 days versus 28.25 ± 0.75 days, p < 0.001).

Perfusion imaging using dynamic arterial spin labeling (DASL).

Recently, a technique based on arterial spin labeling, called dynamic arterial spin labeling (DASL (Magn Reson Med 1999;41:299-308)), has been introduced to measure simultaneously the transit time of the labeled blood from the labeling plane to the exchange site, the longitudinal relaxation time of the tissue, and the perfusion of the tissue. This technique relies on the measurement of the tissue magnetization response to a time varying labeling function. The analysis of the characteristics of the tissue magnetization response (transit time, filling time constant, and perfusion) allows for quantification of the tissue perfusion and for transit time map computations. In the present work, the DASL scheme is used in conjunction with echo planar imaging at 4.7 T to produce brain maps of perfusion and transit time in the anesthetized rat, under graded hypercapnia. The data obtained show the variation of perfusion and transit time as a function of arterial pCO2. Based on the data, CO2 reactivity maps are computed. Published 2001 Wiley-Liss, Inc.

Methodology of brain perfusion imaging.

Numerous techniques have been proposed in the last 15 years to measure various perfusion-related parameters in the brain. In particular, two approaches have proven extremely successful: injection of paramagnetic contrast agents for measuring cerebral blood volumes (CBV) and arterial spin labeling (ASL) for measuring cerebral blood flows (CBF). This review presents the methodology of the different magnetic resonance imaging (MRI) techniques in use for CBV and CBF measurements and briefly discusses their limitations and potentials.

A model of the dual effect of gadopentetate dimeglumine on dynamic brain MR images.

An optimized dynamic gradient echo sequence with two echoes is used to obtain data that can be analyzed with indicator dilution theory as well as with pharmacokinetic theory. Taking advantage of the simultaneity of T(*)(2) and T(1) information, both theories can be employed and merged to interpret consistently the observed effects of the redistribution of a contrast agent (gadopentetate dimeglumine) into the tissue from first pass onward. The regional cerebral blood volume (rCBV) and the exchange rate of the contrast agent between the vascular and the interstitial space through the blood-brain barrier are analyzed for each pixel in a two-step algorithm. Two values for rCBV are obtained with different weighting for the microvascular fraction of the blood volume. Because the analysis, called PELEAKAN, is capable of separating effects related to perfusion (through intravascular blood volume) and to leakage in places where the blood-brain barrier is damaged, it is an appropriate tool for evaluating these parameters in brain tumors, and we show clinical examples of this analysis in brain tumor patients.

Perfusion analysis using dynamic arterial spin labeling (DASL).

A variety of magnetic resonance (MR) techniques have proved useful to quantify perfusion using endogenous water as a blood flow tracer. Assuming that water is a freely diffusable tracer, the model used for these techniques predicts that the quantitation of perfusion is based on three parameters, all of which can depend on blood flow. These are the longitudinal tissue relaxation time, the transit time from point of labeling to tissue, and the difference in tissue MR signal between an appropriate control and the labeled state. To measure these three parameters in parallel, a dynamic arterial spin labeling (DASL) technique is introduced based on the analysis of the tissue response to a periodic time varying degree of arterial spin labeling, called here the labeling function (LF). The LF frequency can be modulated to overdetermine parameters necessary to define the system. MR schemes are proposed to measure the tissue response to different LF frequencies efficiently. Sprague-Dawley rats were studied by DASL, using various frequencies for the LF and various arterial pCO2 levels. During data processing, the periodic behavior of the tissue response to the LF allowed for frequency filtering of periodic changes in signal intensity unrelated to perfusion and arterial spin labeling. Measures of transit time, tissue longitudinal relaxation time, and perfusion agreed well over a range of LF frequencies and with previous results. DASL shows potential for more accurately quantifying perfusion as well as measuring transit times associated with arterial spin labeling techniques.

Radial echo-planar imaging.

A new ultrafast magnetic resonance imaging pulse sequence named radial echo-planar imaging (rEPI) is introduced. The sequence is based on a modification of the echo-planar imaging (EPI) sequence to scan k-space radially, in an attempt to combine the speed of EPI with the benefits of radial sampling. Like in EPI, all the desired lines in k-space are scanned consecutively in opposite directions. The unique feature of this new sequence, however, is that the orientation of the readout gradient is incrementally rotated, so that all the echoes are refocused through the center of k-space. Therefore, rEPI data are acquired in a polar grid, and image reconstruction can be done either by means of filtered back-projection or by regridding the data to a Cartesian matrix followed by 2D Fourier transform. First results show that rEPI images can be acquired with the same speed and signal-to-noise ratio of EPI images. rEPI images are also shown to be less sensitive to off-resonance effects than EPI images. Further studies are underway to investigate the usefulness of rEPI for spectroscopic imaging and applications affected by motion.

Simultaneous glutamate and perfusion fMRI responses to regional brain stimulation.

Functional magnetic resonance imaging (fMRI) rests on the assumption that regional brain activity is closely coupled to regional cerebral blood flow (rCBF) in vivo. To test the degree of coupling, cortical brain activity was locally stimulated in rats by reversed microdialysis infusion of picrotoxinin, alphagamma-aminobutyric acid-A antagonist. Before and during the first 30 minutes of infusion, simultaneous fMRI (rCBF) and neurochemical (interstitial glutamate concentration) measures of brain activity were highly correlated (r = 0.83). After 30 minutes of picrotoxinin-induced stimulation, glutamate levels decreased but rCBF remained elevated, suggesting that additional factors modulate the relationship between neuronal neurotransmitters and hemodynamics at these later stages.