P.S. Jones

The relationship between motor deficit and hemisphere activation balance after stroke: A 3T fMRI study.

Functional imaging during movement of the hand affected by a stroke has shown excess activation of the contralesional motor network, implying less physiological hemisphere activation balance. Although this may be adaptive, the relationship between the severity of motor deficit and the hemisphere activation balance for the four major cortical motor areas has not been systematically studied. We prospectively studied 19 right-handed patients with first-ever stroke (age range 61+/-10 years) in the stable phase of recovery (>3 months after onset), using auditory-paced index-thumb (IT) tapping of the affected hand at 1.25 Hz as the fMRI paradigm. The hemisphere activation balance for the primary motor (M1), primary somatosensory (S1), supplementary motor (SMA) and dorsal premotor (PMd) areas was measured by a modified weighted laterality index (wLI), and correlations with motor performance (assessed by the affected/unaffected ratio of maximum IT taps in 15 s, termed IT-R) were computed. There were statistically significant negative correlations between IT-R and the wLI for M1 and S1, such that the more the hemispheric balance shifted contralesionally, the worse the performance. Furthermore, worse performance was related to a greater amount of contralesional, but not ipsilesional, activation. No significant correlation between IT-R and the wLI was obtained for the SMA and PMd, which functionally have stronger bilateral organization. These findings suggest that the degree of recovery of fine finger motion after stroke is determined by the extent to which activation balance in the primary sensory motor areas--where most corticospinal fibers originate--departs from normality. This observation may have implications for therapy.

Does healthy aging affect the hemispheric activation balance during paced index-to-thumb opposition task? An fMRI study

Normal aging is generally associated with declining performance in cognitive and fine motor tasks. Previous functional imaging studies have been inconsistent regarding the effect of aging on primary motor cortex (M1) activation during finger movement, showing increased, unchanged or decreased activation contralaterally, and more consistently increased activation ipsilaterally. Furthermore, no study has addressed the effect of age on M1 hemispheric activation balance. We studied 18 optimally healthy right-handed subjects, age range 18-79 years (mean +/- SD: 47 +/- 17) using 3 T fMRI and right index finger-thumb tapping auditory-paced at 1.25 Hz. The weighted Laterality Index (wLI) for M1 was obtained according to Fernandez et al. (2001) [Fernandez, G., de Greiff, A., von Oertzen, J., Reuber, M., Lun, S., Klaver, P., et al. 2001. Language mapping in less than 15 min: real-time functional MRI during routine clinical investigation. Neuroimage 14 585-594], with some modifications. The wLI, as well as the total activation on each side, were assessed against age using non-parametric correlation. There was a highly significant negative correlation between age and wLI such that the older the subjects, the lower the wLI. Furthermore, there was a highly significant positive correlation between total activation for ipsilateral M1 and age, and a nearly significant trend for contralateral M1. This study documents that during execution of a simple paced motor task, the older the subject the less lateralized the M1 activation balance as a result of increasing amount of activation on both sides, more significantly so ipsilaterally. Thus, in aging, enhanced M1 recruitment bilaterally is required to produce the same motor performance, suggesting a compensatory process. These findings are in line with cognitive studies indicating a tendency for the aging brain to reduce its functional lateralization, perhaps from less efficient transcallosal connections.

Mapping the involvement of BA 4a and 4p during Motor Imagery

Motor Imagery (MI) is an attractive but intriguing means to access the motor network. There are marked inconsistencies in the functional imaging literature regarding the degree, extent and distribution of the primary motor cortex (BA 4) involvement during MI as compared to Executed Movement (EM), which may in part be related to the diverse role of BA 4 and its two subdivisions (i.e., 4a and 4p) in motor processes as well as to methodological issues. Here we used fMRI with monitoring of compliance to show that in healthy volunteers optimally screened for their ability to perform MI the contralateral BA 4 is involved during MI of a finger opposition sequence (2, 3, 4, 5; paced at 1 Hz), albeit less than during EM of the same sequence, and in a location sparing the hand area. Furthermore, both 4a and 4p subdivisions were found to be involved in MI, but the relative involvement of BA 4p appeared more robust and closer to that seen with EM. We suggest that during MI the role of BA 4 and its subdivisions may be non-executive, perhaps related to spatial encoding, though clearly further studies are needed. Finally, we report a similar hemispheric activation balance within BA 4 with both tasks, which extends the commonalities between EM and MI.

Selective neuronal loss in rescued penumbra relates to initial hypoperfusion

Selective neuronal loss (SNL) in the rescued penumbra could account for suboptimal clinical recovery despite effective early reperfusion. Previous studies of SNL used single-photon emission tomography (SPECT), did not account for potential volume loss secondary to collapse of the infarct cavity, and failed to show a relationship with initial hypoperfusion. Here, we obtained acute-stage computerized tomography (CT) perfusion and follow-up quantitative (11)C-flumazenil (FMZ)-PET to map SNL in the non-infarcted tissue and assess its relationship with acute-stage hypoperfusion. We prospectively recruited seven patients with evidence of (i) acute (<6 h) extensive middle cerebral artery territory ischaemia based on clinical deficit (National Institutes of Health stroke scale, NIHSS score range: 8-23) and CT Perfusion (CTp) findings and (ii) early recanalization (spontaneous or following thrombolysis) based on spectacular clinical recovery (DeltaNIHSS > or =6 at 24 h), good clinical outcome (NIHSS < or =5) and small final infarct (6/7 subcortical) on late-stage MRI. Ten age-matched controls were also studied. FMZ image analysis took into account potential post-stroke volume loss. Across patients, clusters of significantly reduced FMZ binding were more prevalent and extensive in the non-infarcted middle cerebral artery cortical areas than in the non-affected hemisphere (P = 0.028, Wilcoxon sign rank test). Voxel-based between-group comparisons revealed several large clusters of significantly reduced FMZ binding in the affected peri-insular, superior temporal and prefrontal cortices (FDR P < 0.05), as compared with no cluster on the unaffected side. Finally, comparing CTp and PET data revealed a significant negative correlation between FMZ binding and initial hypoperfusion. Applying correction for volume loss did not substantially alter the significance of these results. Although based on a small patient sample sometimes studied late after the index stroke, and as such preliminary, our results establish the presence and distribution of FMZ binding loss in ultimately non-infarcted brain areas after stroke. In addition, the data suggest that this binding loss is proportional to initial hypoperfusion, in keeping with the hypothesis that the rescued penumbra is affected by SNL. Although its clinical counterparts remain uncertain, it is tempting to speculate that peri-infarct SNL could represent a new therapeutic target.

How affected is oxygen metabolism in DWI lesions? A combined acute stroke PET-MR study

Objective: To use back-to-back diffusion-weighted imaging (DWI) and PET to obtain quantitative measures of the cerebral metabolic rate of oxygen (CMRO2) within DWI lesions, and to assess the perfusion-metabolism coupling status by measuring the cerebral blood flow and the oxygen extraction fraction within DWI lesions. Methods: Six prospectively recruited acute carotid-territory stroke patients completed the imaging protocol, which was commenced 7 to 21 hours from onset and combined DWI derived from state-of-the-art diffusion tensor imaging sequencing using a 3-T magnet and fully quantitative 15O-PET. The PET variables were obtained in individual DWI lesions in each patient. Results: Across patients, the CMRO2 was reduced in the DWI lesion relative to mirror (mean reduction 39.5%; p = 0.028). Examining individual DWI lesions, however, revealed considerable variability in the extent of this CMRO2 reduction. The flow–metabolism coupling pattern underlying the DWI lesion was also variable, including ongoing ischemia, mild oligemia, and partial or complete reperfusion. Discussion: Diffusion-weighted imaging (DWI) lesions generally reflect substantial disruption of energy metabolism. However, the degree of metabolic disruption is variable, indicating DWI lesions may not always represent irreversibly damaged tissue. Finally, because DWI lesions can persist despite reperfusion, assessment of perfusion is necessary for interpretation of DWI changes in acute stroke.

The Diffusion-Weighted Lesion in Acute Stroke: Heterogeneous Patterns of Flow/Metabolism Uncoupling as Assessed by Quantitative Positron Emission Tomography

Background: To investigate what the hyperintense lesion in diffusion-weighted imaging (DWI) of acute ischaemic stroke represents metabolically, we prospectively imaged acute carotid-territory stroke patients with DWI along with fully quantitative positron emission tomography (PET), which gives physiological maps of cerebral blood flow (CBF), the cerebral metabolic rate of oxygen (CMRO2) and the oxygen extraction fraction (OEF). Method: Of 10 patients who consented, 5 (3 males, 2 females, 53–84 years, NIHSS 6–16) completed the imaging protocol of back-to-back DWI and PET within 21 (mean 15.7, range 7–21) h of stroke onset. All images were co-registered with the DWI lesion forming a region of interest (ROI) that was transferred to the PET parametric maps (OEF, CBF, CMRO2). Patterns of blood flow and metabolism were assessed within the DWI ROI. Results: Within the DWI lesions, the following patterns were observed: very low CBF and CMRO2/variable OEF; low CBF/high OEF, and high CBF/low OEF. There was a heterogeneity of patterns between and within DWI lesions. In addition, areas of hyperperfusion (with low OEF) and areas of hypoperfusion (with high OEF) were seen outside the DWI lesions. Conclusion: The DWI lesion does not have a single flow/metabolism counterpart, suggesting that it reflects various stages of the ischaemic process.

18F-AV-1451 positron emission tomography in Alzheimer's disease and progressive supranuclear palsy.

The extent to which the tau tracer [18F]AV-1451 can differentiate between tauopathies is unknown. By comparing patients with Alzheimer’s disease and progressive supranuclear palsy (PSP), Passamonti et al. show that [18F]AV-1451 displays greater specificity for Alzheimer-related tau pathology than PSP-related pathology. A machine learning algorithm correctly diagnosed 94% of cases.

Mapping selective neuronal loss and microglial activation in the salvaged neocortical penumbra in the rat

Rescuing the ischemic penumbra from infarction is the mainstay of acute stroke therapy. However, the rescued penumbra may be affected by selective neuronal loss (SNL) and microglial activation (MA), which may hinder functional recovery and hence represent potential new therapeutic targets. Imaging them in vivo is currently attracting considerable interest, but relevant rat models are needed to underpin methods development and validation. Although striatal SNL/MA is well described following proximal MCA occlusion (MCAo), neocortical SNL/MA is still poorly characterized, yet has greater clinical relevance. This study aimed to assess the distribution and intensity of neocortical SNL and MA in a distal clip MCAo model known to cause severe neocortical ischemia. Spontaneously hypertensive rats were subjected to 45 min distal MCAo with ipsilateral common carotid artery occlusion. At day 14, post mortem SNL and MA were mapped using NeuN and OX42 immunohistochemistry, respectively. In a separate group, cerebral blood flow (CBF) was mapped during MCAo using (14)C-iodoantipyrine autoradiography. Values for SNL, MA, and CBF were obtained in the same set of anatomical ROIs covering the cortical MCA territory. Extensive SNL and MA affected the non-infarcted MCA cortex, adopting a well-defined regional distribution and a striking patchy/pseudo-columnar pattern. Regional intensities of SNL and MA were strongly inter-correlated, and also strikingly related to occlusion CBF, showing sharp rises for CBF <40%, i.e. the penumbra threshold. This rat model may be useful in providing in vitro reference for studies aiming to validate novel imaging tracers of SNL and MA in vivo.

Cocaine dependence: a fast-track for brain ageing?

Cocaine-dependent individuals anecdotally appear aged and their mortality rates are estimated up to eight times higher than in the healthy population.1 Psychological and physiological changes typically associated with old age such as cognitive decline, brain atrophy, or immunodeficiency are also seen in middle-aged cocaine-dependent individuals.2,3 These observations raise the question of whether cocaine abuse might accelerate the process of normal ageing. Although this is a little-studied area, there are several reasons for assuming that chronic cocaine exposure interferes with the processes of brain ageing. We compared the effects of age on gray matter volume in 120 individuals aged 18–50 years (Supplementary Information). Half of the sample met the standard diagnostic criteria for cocaine dependence of the DSM-IV-TR;4 whereas the other half had no history of substance misuse disorders or major psychiatric disorders. The two groups were matched for age (t118=−0.12, P=0.905), gender (χ2=2.8, P=0.148), and verbal IQ (t115=−0.36, P=0.716), as described elsewhere.5 All participants underwent a structural MRI brain scan, which was analyzed using voxel-based morphometry5 to produce whole-brain maps of age-related change in gray matter volume. All participants showed a reduction of gray matter volume in cortical and subcortical regions as a linear function of increasing calendar age (Figures 1a and b). However, the annual rate of global gray matter volume loss in cocaine-dependent individuals was almost twice the rate of healthy volunteers (that is, 3.08 ml per year (standard error (s.e.): 0.49 ml) versus 1.69 ml per year (s.e.: 0.41 ml)). Consequently, the rate of age-related gray matter volume loss in cocaine-dependent individuals was significantly greater than in healthy volunteers (F1,116=4.7, P=0.031); this interaction remained significant after excluding 16 individuals with comorbid alcohol dependence (F1,100=6.4, P=0.013). Accelerated ageing in cocaine-dependent individuals was also demonstrated by a significant age-by-group interaction on gray matter volume of the regions affected by age (P<0.001, see Figure 1c). Cocaine-dependent individuals showed a significantly greater-than-normal age-related decline in gray matter in prefrontal and temporal regions compared with healthy controls. By contrast, parts of the striatum appeared resistant to age-related volume decline in the cocaine-using group. Enlarged striatal volume has frequently been reported in stimulant-dependent individuals,5,6 possibly reflecting a marker of reduced dopamine neurotransmission in this dopamine-rich brain region where drugs like cocaine work. Decline in striatal dopamine receptor density has been associated with normal age-related cognitive decline.7 The relative absence of age-related changes in the striatum of cocaine-dependent people may thus reflect another feature of an abnormal brain ageing process. Figure 1 Age-related changes in gray matter volume in 60 healthy volunteers and 60 cocaine-dependent individuals. The brain maps show regions of age-related gray matter volume loss separately in healthy volunteers (a) and cocaine-dependent individuals (b); the ... Abnormal ageing in chronic cocaine users is an emerging public health concern, which has received little attention. Approximately 1% (ref. 8) of the 21 million users of cocaine wordwide,9 are considered to develop cocaine dependence. These individuals may potentially be at risk of premature brain ageing. Young people taking cocaine today need to be educated about the long-term risk of ageing prematurely, specifically at a time when many developed economies are facing the demographic challenge of an ageing population. Our findings also draw attention to the increasing number of older drug users seeking treatment for drug abuse.10 Drug-treatment services, however, mainly target drug use in young people, focusing on prevention and harm reduction; the needs of older drug users are not so well catered for. As the psychological and physiological challenges of ageing may have also accelerated in individuals with long-term drug dependence,11 the effects of cocaine on the process of ageing should be recognized in order to design and administer age-appropriate treatments for older drug users.

The relationship between motor deficit and primary motor cortex hemispheric activation balance after stroke: longitudinal fMRI study

Background In the chronic stage of stroke, previous work has shown that the worse the hand motor deficit, the greater the shift of primary motor cortex (M1) activation towards the contralesional hemisphere (ie, unphysiological) balance. Whether the same relationship applies at earlier stages of recovery in serially studied patients is not known. Methods fMRI of fixed-rate auditory-cued affected index-thumb tapping was obtained at two time points (mean 36 and 147 days poststroke) in a cohort of nine patients with ischaemic stroke (age: 56±9 years; three women/six men; seven subcortical, one medullary and one cortical). On each fMRI day, the unaffected/affected ratio of maximal index tapping rate (IT-R) was obtained. To assess the M1 hemispheric activation balance, the authors computed the classic Laterality Index (LI). The correlation between LI and IT-R was computed for each time point separately. Results The expected correlation between LI-M1 and IT-R, that is, motor performance worse with more unphysiological LI, prevailed at both time points (Kendall p=0.008 and 0.058, respectively), with no statistically significant difference between the two regressions. The same analysis for the dorsal premotor cortex and the supplementary motor area showed no significant correlation at either time-point. Conclusion These results from a small cohort of longitudinally assessed patients suggest that the relationship between M1 laterality index and hand motor performance appears independent of time since onset of stroke. This in turn may suggest that attempting to restore the hemispheric balance by enhancing ipsilesional M1 and/or constraining contralesional M1 activity may have consistent efficacy throughout recovery.