Alessandra Bertoldo

Microglial activity in people at ultra high risk of psychosis and in schizophrenia; an [11C]PBR28 PET brain imaging study

OBJECTIVE The purpose of this study was to determine whether microglial activity, measured using translocator-protein positron emission tomography (PET) imaging, is increased in unmedicated persons presenting with subclinical symptoms indicating that they are at ultra high risk of psychosis and to determine whether microglial activity is elevated in schizophrenia after controlling for a translocator-specific genetic polymorphism. METHOD The authors used the second-generation radioligand [(11)C]PBR28 and PET to image microglial activity in the brains of participants at ultra high risk for psychosis. Participants were recruited from early intervention centers. The authors also imaged a cohort of patients with schizophrenia and matched healthy subjects for comparison. In total, 50 individuals completed the study. At screening, participants were genotyped to account for the rs6971 polymorphism in the gene encoding the 18Kd translocator protein. The main outcome measure was total gray matter [(11)C]PBR28 binding ratio, representing microglial activity. RESULTS [(11)C]PBR28 binding ratio in gray matter was elevated in ultra-high-risk participants compared with matched comparison subjects (Cohens d >1.2) and was positively correlated with symptom severity (r=0.730). Patients with schizophrenia also demonstrated elevated microglial activity relative to matched comparison subjects (Cohens d >1.7). CONCLUSIONS Microglial activity is elevated in patients with schizophrenia and in persons with subclinical symptoms who are at ultra high risk of psychosis and is related to at-risk symptom severity. These findings suggest that neuroinflammation is linked to the risk of psychosis and related disorders, as well as the expression of subclinical symptoms.

The methodology of TSPO imaging with positron emission tomography

The 18-kDA translocator protein (TSPO) is consistently elevated in activated microglia of the central nervous system (CNS) in response to a variety of insults as well as neurodegenerative and psychiatric conditions. It is therefore a target of interest for molecular strategies aimed at imaging neuroinflammation in vivo. For more than 20 years, positron emission tomography (PET) has allowed the imaging of TSPO density in brain using [11C]-(R)-PK11195, a radiolabelled-specific antagonist of the TSPO that has demonstrated microglial activation in a large number pathological cohorts. The significant clinical interest in brain immunity as a primary or comorbid factor in illness has sparked great interest in the TSPO as a biomarker and a surprising number of second generation TSPO radiotracers have been developed aimed at improving the quality of TSPO imaging through novel radioligands with higher affinity. However, such major investment has not yet resulted in the expected improvement in image quality. We here review the main methodological aspects of TSPO PET imaging with particular attention to TSPO genetics, cellular heterogeneity of TSPO in brain tissue and TSPO distribution in blood and plasma that need to be considered in the quantification of PET data to avoid spurious results as well as ineffective development and use of these radiotracers.

Novel Reference Region Model Reveals Increased Microglial and Reduced Vascular Binding of 11C-(R)-PK11195 in Patients with Alzheimer's Disease

11C-(R)-PK11195 is a PET radiotracer for the quantification of peripheral benzodiazepine binding sites (PBBSs). The PBBS is a consistent marker of activated microglia, and 11C-(R)-PK11195 has been used to image microglial activity in the diseased brain and in neoplasia. However, the PBBS is also expressed in the brain vasculature (endothelium and smooth muscles), and no evidence, to our knowledge, exists of a change in the vascular PBBS in pathologic brains or of such a change having an effect on the quantification of 11C-(R)-PK11195 binding. To investigate this issue, we have used a modified reference-tissue model (SRTMV) that accounts for tracer vascular activity both in reference and target tissues and applied it for the estimation of binding potential (BP) in a cohort of patients with Alzheimers disease (AD). Methods: A total of 10 patients with AD and 10 age-matched healthy subjects who underwent a 11C-(R)-PK11195 scan were considered in the analysis. The time–activity curves of 11 regions of interest were extracted using the Hammersmith maximum probability atlas. BPs were first estimated using the standard simplified reference-tissue model (SRTM) with the reference tissue computed with a supervised selection algorithm. Subsequently, we applied an SRTMV that models PBBS vascular activity using an additional linear term for both target (VbT) and reference (VbR) regions accounting for vascular tracer activity (CB), whereas CB was extracted directly from the images. VbR was fixed to 5%, and R1, k2, BP, and VbT were estimated. PBBS density in the vasculature was also assessed by immunocytochemistry on a separate cohort of young and elderly controls and 3 AD postmortem brains. Results: The inclusion of a vascular component in the SRTM increased BPs in all subjects, but the amount of the increase was different (about 11.9% in controls and 16.8% in patients with AD). In addition, average VbT values derived using the SRTMV were 4.22% for controls but only 2.87% in patients with AD. Immunochemistry showed reduced PBBS expression in AD due to vascular fibrosis. Conclusion: The reduction of VbT in AD can be interpreted as a consequence of 2 independent but concurring phenomena. The vascular fibrosis in the AD brain causes the well-documented decrease of the size of lumens and the reduction of blood volume. At the same time, the fibrotic process determines the loss of vascular PBBS, particularly in smooth muscles, as here documented by immunochemistry. The inclusion of the additional vascular component in the SRTM effectively models these 2 concurrent processes and amplifies the BP in AD more than in controls because of the decrease in tracer binding to the vasculature in the disease cohort.

Evaluation of compartmental and spectral analysis models of [/sup 18/F]FDG kinetics for heart and brain studies with PET

Various models have been proposed to quantitate from [/sup 18/F]-Fluoro-Deoxy-Glucose ([/sup 18/F]FDG) positron emission tomography (PET) data glucose regional metabolic rate. The authors evaluate here four models, a three-rate constants (3 K) model, a four-rate constants (4 K) model, an heterogeneous model (TH) and a spectral analysis (SA) model. The data base consists of [/sup 18/F]FDG dynamic data obtained in the myocardium and brain gray and white matter. All models were identified by nonlinear weighted least squares with weights chosen optimally. The authors show that: 1) 3 K and 4 K models are indistinguishable in terms of parsimony criteria and choice should be made on parameter precision and physiological plausibility; in the gray matter a more complex model than the 3 K one is resolvable; 2) the TH model is resolvable in the gray but not in the white matter; 3) the classic SA approach has some unnecessary hypotheses built in and can be in principle misleading; the authors propose here a new SA model which is more theoretically sound; 4) this new SA approach supports the use of a 3 K model in the heart with a 60 min experimental period; it also indicates that heterogeneity in the brain is modest in the white matter; 5) [/sup 18/F]FDG fractional uptake estimates of the four models are very close in the heart, but not in the brain; 6) a higher than 60 min experimental time is preferable for brain studies.

Cortical diffusion-tensor imaging abnormalities in multiple sclerosis: a 3-year longitudinal study.

PURPOSE To evaluate whether diffusion-tensor imaging can be combined with double inversion recovery to improve the detection of structural changes occurring in the cortex of patients with multiple sclerosis (MS). MATERIALS AND METHODS Once local ethics committee approval and informed consent were obtained, 168 patients with relapsing-remitting MS and 45 sex- and age-matched control subjects were included in a 3-year longitudinal study. Expanded Disability Status Scale (EDSS) and magnetic resonance (MR) imaging examinations were performed at study entry and after 3 years. Number and volume of cortical lesions, T2 white matter lesion volume (WMLV), and fractional anisotropy (FA) and mean diffusivity (MD) of normal-appearing gray matter (NAGM) and cortical lesions were analyzed. Between-group differences in terms of NAGM-FA and NAGM-MD were assessed with analysis of variance followed by Tukey test correction. RESULTS At baseline, NAGM-FA was higher in patients (mean ± standard deviation, 0.149 ± 0.011) than in control subjects (0.125 ± 0.008; P < .001) and higher in patients with cortical lesions (0.154 ± 0.011) than in those without (0.138 ± 0.010; P < .001). Moreover, FA was higher in cortical lesions than in NAGM (P < .001). After 3 years, NAGM-FA was unchanged in control subjects and increased in patients (0.154 ± 0.012; P < .001), especially in patients with worsened EDSS score (0.170 ± 0.011; P < .001). The same behavior was observed for NAGM-MD. At baseline, NAGM-FA significantly correlated with EDSS score (r = 0.75; P < .001) and cortical lesion volume (r = 0.850; P < .001). Multivariate analysis identified NAGM-FA (B = 0.654; P < .001) and T2 WMLV (B = 0.310; P < .001) as independent predictors of EDSS score, while NAGM-FA change (B = 0.523; P < .001) and disease duration (B = 0.342; P < .001) were independent predictors of EDSS change. CONCLUSION Compared with control subjects, patients with RRMS had an increase in FA of NAGM that strongly correlated with cortical lesion volume and clinical disability.

Kinetic modeling without accounting for the vascular component impairs the quantification of [11C]PBR28 brain PET data

The positron emission tomography radioligand [11C]PBR28 targets translocator protein (18 kDa) (TSPO) and is a potential marker of neuroinflammation. [11C]PBR28 binding is commonly quantified using a two-tissue compartment model and an arterial input function. Previous studies with [11C]HRJ-PK11195 demonstrated a slow irreversible binding component to the TSPO proteins localized in the endothelium of brain vessels, such as venous sinuses and arteries. However, the impact of this component on the quantification of [11C]PBR28 data has never been investigated. In this work we propose a novel kinetic model for [11C]PBR28. This model hypothesizes the existence of an additional irreversible component from the blood to the endothelium. The model was tested on a data set of 19 healthy subjects. A simulation was also performed to quantify the error generated by the standard two-tissue compartmental model when the presence of the irreversible component is not taken into account. Our results show that when the vascular component is included in the model the estimates that include the vascular component (2TCM-1K) are more than three-fold smaller, have a higher time stability and are better correlated to brain mRNA TSPO expression than those that do not include the model (2TCM).

Interactions Between Delivery, Transport, and Phosphorylation of Glucose in Governing Uptake Into Human Skeletal Muscle

Skeletal muscle accounts for a large proportion of insulin-stimulated glucose utilization. It is generally regarded that much of the control over rates of uptake is posited within the proximal steps of delivery, transport, and phosphorylation of glucose, with glucose transport as the main locus of control. Whether insulin modulates the distribution of control across these steps and in what manner remains uncertain. The current study addressed this in vivo using dynamic positron emission tomography (PET) imaging of human muscle with sequential injections of three tracers ([15O]H2O, [11C]3-O-methyl glucose [3-OMG], and [18F]fluoro-deoxy glucose [FDG]) that enabled quantitative determinations of glucose delivery, transport, and its phosphorylation, respectively. Lean, healthy, research volunteers were studied during fasting conditions (n = 8) or during a euglycemic insulin infusion at 30 mU/min per m2 (n = 8). PET images were coregistered with magnetic resonance imaging to contrast glucose kinetics in soleus, a highly oxidative muscle, with tibialis anterior, a less oxidative muscle. During fasting conditions, uptake of [11C]3-OMG was similar in soleus and tibialis anterior muscles, despite higher delivery to soleus (by 35%; P < 0.01). Uptake of [18F]FDG was also similar between muscle during fasting, and glucose transport was found to be the dominant locus of control (90%) for glucose uptake under this condition. Insulin increased uptake of [11C]3-OMG substantially and strongly stimulated the kinetics of bidirectional glucose transport. Uptake of [11C]3-OMG was higher in soleus than tibialis anterior muscle (by 22%; P < 0.01), a difference partially due to higher delivery, which was again found to be 35% higher to soleus (P < 0.01). The uptake of [18F]FDG was 65% greater in soleus compared with tibialis anterior muscle, a larger difference than for [11C]3-OMG (P < 0.01), indicating an added importance of glucose phosphorylation in defining insulin sensitivity. Analysis of the distribution of control during insulin-stimulated conditions revealed that most of the control was posited at delivery and transport and was equally divided between these steps. Thus, insulin evokes a broader distribution of control than during fasting conditions in governing glucose uptake into skeletal muscle. This redistribution of control is triggered by the robust stimulation of glucose transport, which in turn unmasks a greater dependence upon delivery and glucose phosphorylation.

Integrating EEG and fMRI in epilepsy.

Integrating electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) studies enables to non-invasively investigate human brain function and to find the direct correlation of these two important measures of brain activity. Presurgical evaluation of patients with epilepsy is one of the areas where EEG and fMRI integration has considerable clinical relevance for localizing the brain regions generating interictal epileptiform activity. The conventional analysis of EEG-fMRI data is based on the visual identification of the interictal epileptiform discharges (IEDs) on scalp EEG. The convolution of these EEG events, represented as stick functions, with a model of the fMRI response, i.e. the hemodynamic response function, provides the regressor for general linear model (GLM) analysis of fMRI data. However, the conventional analysis is not automatic and suffers of some subjectivity in IEDs classification. Here, we present an easy-to-use and automatic approach for combined EEG-fMRI analysis able to improve IEDs identification based on Independent Component Analysis and wavelet analysis. EEG signal due to IED is reconstructed and its wavelet power is used as a regressor in GLM. The method was validated on simulated data and then applied on real data set consisting of 2 normal subjects and 5 patients with partial epilepsy. In all continuous EEG-fMRI recording sessions a good quality EEG was obtained allowing the detection of spontaneous IEDs and the analysis of the related BOLD activation. The main clinical finding in EEG-fMRI studies of patients with partial epilepsy is that focal interictal slow-wave activity was invariably associated with increased focal BOLD responses in a spatially related brain area. Our study extends current knowledge on epileptic foci localization and confirms previous reports suggesting that BOLD activation associated with slow activity might have a role in localizing the epileptogenic region even in the absence of clear interictal spikes.

Estimation of Component and Parameter Distributions in Spectral Analysis

A method is presented for estimating the distributions of the components and parameters determined with spectral analysis when it is applied to a single data set. The method uses bootstrap resampling to simulate the effect of noise on the computed spectrum and to correct for possible bias in the estimates. A number of bootstrap procedures are reviewed, and one is selected for application to the kinetic analysis of positron emission tomography dynamic studies. The technique is shown to require minimal assumptions about noise in the measurements, and its small sample properties are established through Monte-Carlo simulations. The advantages and limitations of spectral analysis with bootstrap resampling for deriving inferences for tracer kinetic modeling are illustrated through sample analyses of time-activity curves for [18F]fluorodeoxyglucose and [15O]-labeled water.

Nonlinear Stochastic Regularization to Characterize Tissue Residue Function in Bolus-Tracking MRI: Assessment and Comparison With SVD, Block-Circulant SVD, and Tikhonov

An accurate characterization of tissue residue function R(t) in bolus-tracking magnetic resonance imaging is of crucial importance to quantify cerebral hemodynamics. R(t) estimation requires to solve a deconvolution problem. The most popular deconvolution method is singular value decomposition (SVD). However, SVD is known to bear some limitations, e.g., R(t) profiles exhibit nonphysiological oscillations and take on negative values. In addition, SVD estimates are biased in presence of bolus delay and dispersion. Recently, other deconvolution methods have been proposed, in particular block-circulant SVD (cSVD) and Tikhonov regularization (TIKH). Here we propose a new method based on nonlinear stochastic regularization (NSR). NSR is tested on simulated data and compared with SVD, cSVD, and TIKH in presence and absence of bolus dispersion. A clinical case in one patient has also been considered. NSR is shown to perform better than SVD, cSVD, and TIKH in reconstructing both the peak and the residue function, in particular when bolus dispersion is considered. In addition, differently from SVD, cSVD, and TIKH, NSR always provides positive and smooth R(t).