Imaging Iron in MS using Susceptibility Weighted Imaging ... Iron in MS... · SWI is a technique...
Transcript of Imaging Iron in MS using Susceptibility Weighted Imaging ... Iron in MS... · SWI is a technique...
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Imaging Iron in MS using Susceptibility Imaging Iron in MS using Susceptibility Weighted Imaging (SWI):Weighted Imaging (SWI):
““Is the basic etiology ofIs the basic etiology of multiple multiple sclerosissclerosis vascular in origin?vascular in origin?””
E. Mark HaackeE. Mark HaackeWayne State UniversityWayne State UniversityDetroit, Michigan 48201 and Detroit, Michigan 48201 and The MRI Institute for Biomedical ResearchThe MRI Institute for Biomedical ResearchDetroit, Michigan 48202Detroit, Michigan 48202
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OutlineNormal iron content in the brainLocal iron increases in MSProving it is iron we are seeingIron in MS lesionsIron in vessel wallSWIM and deoxyhemoglobinReduced perfusion in MSIron increases in the central venous drainage systemThe link to chronic cerebrospinal venous insufficiency
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Imaging Iron in Healthy Tissue
Under normal circumstances iron will appear as ferritin or heme-iron in the form of deoxyhemoglobin
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Iron can be visualized with SWIIron can be visualized with SWI
Demonstration of ferritiniron distribution in the brain.
The difference between white matter, gray matter and CSF creates a new type of iron related contrast with SWI.
Note the highest iron concentration in the motor cortex.
motor cortex
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Red Nucleus
Substantia Nigra
Pars compacta
Pars reticulata
Crus Cerebri
Medial Geniculate
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Imaging Iron in Diseased Tissue
Local iron increases seen in the basal ganglia and thalamus for multiple sclerososIt is likely to be either ferritin or hemosiderin
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Iron in Multiple SclerosisIron in Multiple Sclerosis
Figure A is from 10-10-2006 Figure B is from 3-25-2008
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Iron in Iron in pulvinarpulvinar thalamusthalamus
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Blue areas represent region II: the high iron content region
CN
GP
Put
PT
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SWI putative iron content as measured with high pass filtered phase data shows a clear iron increase in younger subjects compared to age matched normals.
Iron- Phase-RII-PT
R2 = 0.1433
R2 = 0.1202
0
20
40
60
80
100
120
15 20 25 30 35 40 45 50 55 60 65 70 75age
iron
con
tent
(μg
)
Average iron- Phase-RII-PT
R2 = 0.1483
R2 = 0.1623
90
110
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150
170
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15 20 25 30 35 40 45 50 55 60 65 70 75
age
iron
con
tent
(S
iem
ens
phas
e un
ites)
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SWI putative iron content as measured with high pass filtered phase data shows a clear iron increase in younger subjects compared to age matched normals.
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Iron in the globus pallidus bilaterally. Far above normal levels. Is the great vein of
Galen also showing an increase in deoxyhemoglobin?
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Iron in lesions
We see iron not only in the basal ganglia and thalamus but also in the lesions as well.
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This is a classic example of a Dawson finger with this ovoid This is a classic example of a Dawson finger with this ovoid lesion containing rather lesion containing rather unifromunifrom iron content.iron content.
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Central iron surrounded by another iron ring structure
T1 Post T2 SWI Pre Magnitude SWI Pre Phase
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Validating that the SWI filtered phase really does represent local
iron content
We use SR-XRF or synchrotron radiation x-ray fluoresence to compare to SWI phase but one can also use a Perl’s stain to find iron.
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SWISWI--0.5x0.50.5x0.5x0.5 mmx0.5 mm33
TR=29msTR=29msTE=7.02msTE=7.02msFA=12FA=12oo
BW=50Hz/pixBW=50Hz/pix
Two MS lesions seen within the slab using 3D SWI.
phase
Collaborative research with SWI and XRF with Helen Nichol from the University of Saskatchewan in Saskatoon.
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SWI and XRF scanning
susceptibility weighted imaging: 500μ resolution
x-ray fluorescence imaging: 50μ resolution
images courtesy of: Helen Nichol and Richard McCrea
Dept of Anatomy and Cell Biology, University of Saskatchewan.
XRF
phasemagnitude
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Panel A, intra and extra-cellular iron deposits (ID) encircle a dilated vein (V) in a cerebral MS plaque, Perls’ method150 x.
Panel B, intra and extra-cellular iron deposits (ID) encircle a dilated vein (V) in venous ulcer bed, Perls’ method 80 x
P. Zamboni, The Big Idea: Iron-dependent inflammation in venous disease and proposed parallels in multiple sclerosis.
J. Royal Society of Medicine, V99, Nov 2006 pages 589-593.
Perhaps the iron seen with SWI in MS is hemosiderin?
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Imaging Vessel Wall
Abnormal fluid dynamics leads to an inflammatory response and atherosclerosis or a breakdown of the vessel wall for CVD.
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vessel wall is diamagnetic in SWI
V
A A
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SWI transverse vessel wall
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vessel wall imaging with SWI
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A 25 year old female with carotid arteritis, the lumen of the carotid almost disappeared, and the centre dark area
in the phase images could be the thrombosis.
note the details even in the area where the bifurcation is occurring
the internal carotid seems to have plaque build up on both sides
note the detail inside the right carotid and see the other slides too
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Imaging Heme Iron or Deoxyhemoglobin
From this perspective SWI might be called an enhanced resting state BOLD (blood oxygen level dependent) method.
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4T SWI4T SWI0.5 x 0.5 x 1.0 mm0.5 x 0.5 x 1.0 mm33
image from WSUimage from WSU
Image courtesy of Image courtesy of Georges Georges SalomanSaloman
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SWI is a technique that SWI is a technique that is sensitive to local iron is sensitive to local iron
content. content.
SWI at 3T projected over SWI at 3T projected over roughly 16 mm to show roughly 16 mm to show the the pialpial and and medullarymedullary
veins in the brain. veins in the brain. SWI is very sensitive to SWI is very sensitive to
iron in the form of iron in the form of deoxyhemoglobindeoxyhemoglobin, ,
ferritinferritin and and hemosiderinhemosiderin. .
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7Tin vivo
visualization of the venules
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SWI Venography
A1 A2
B1 B2
C1 C2
Discussion: From PET data it is known that there is less oxygen utilization by white matter under MS stress. This seems to match what we see in SWI venographywith the vessels most likely not showing because of the decreased levels of deoxyhemoglobin.
Do vessels degrade because flow is shunted away from them?
Slide courtesy of Yulin Ge, NYU
normal control (A) and two MS patients (B, C) demonstrate a significantly reduced number of veins in perviventricular NAWM in patients compared to controls. MS patient with more lesions (C) has less venous structures depicted on SWI mIP image than MS patient with fewer lesions (B).
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Imaging Cerebral Hemodynamics
Cerebral blood volume and blood flow and oxygen saturation are key to understanding local vascular changes.
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mIP (2) Phase FLAIR PWI
CBF CBV FWHM MTT
PWI shows loss of CBV in chronic lesion
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Nulling different tissues
Similarity Map: nulling veins nulling lesions FLAIR
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Imaging Oxygen Saturation
Finding the oxygen saturation is key to understanding local hemodynamics. We use SWIM to quantify deoxyhemoglobin.
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Removing dipole artifacts
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SWIM puts the magnetic field response back into the source
Usual phase showing dipole field from 0.5 mm isotropic 3D data set
SWIM susceptibility map of the same region MIPped over several slices
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SWIM from three different echo times.
TE = 11ms
TE = 19msTE = 15ms
TE = 19ms mIPover phase
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SWIM full brain analysis: a first attempt to quantify oxygen saturation
of the veins in the brain
TE = 19msSWIM
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Applications of SWIM
StrokeMultiple sclerosisTumor responsefMRIVenous thrombosis
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The Link Between Veins and Iron in Neurodegenerative Disease
Poor venous circulation can lead to vessel wall damage and microbleeding that increases over time. Iron = hemosiderin
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Caudate veins Caudate veins and the and the
thalamostriatethalamostriatevenous venous
drainage drainage system as system as
seen with SWI seen with SWI at 7Tat 7T
caudate nucleus
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Understanding iron build-up in
the brain
Draining vein from the putamen may explain a long term puzzle about the pattern of iron build up in the putamen
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Caudate and Globus Pallidus
First insight: Could this change in phase be caused by blood vessels? Is it related to changes in iron content with age? Could it explain inter-subject variability?
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CADASIL case for 50+ year old CADASIL case for 50+ year old versus normal young volunteerversus normal young volunteer
CADASILCADASIL Young healthy subjectYoung healthy subject
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Iron in Multiple SclerosisIron in Multiple Sclerosis
Figure A is from 10-10-2006 Figure B is from 3-25-2008
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DVA: 39 year old woman presenting with recurring migraines –deep medullary veins draining into subependymal veins
Developmental venous anomaly similar to what we see in Sturge Weber disease:
Courtesy of Masahiro Ida
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Case 13
Thalamostriate System Basal Ganglia
Midbrain
Thalamostriate system - mIP
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Case 5
Thalamostriate System Basal Ganglia
Midbrain
Thalamostriate system - mIP
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Case 6
Thalamostriate System Basal Ganglia
Midbrain
Thalamostriate system - mIP
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Case 7
Thalamostriate System Basal Ganglia
Midbrain
Thalamostriate system - mIP
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Case 11
Thalamostriate System Basal Ganglia
Midbrain
Thalamostriate system - mIP
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High Iron Region (RII) - Total
RII ‐ Total Iron
PATIENT CN GP PUT PT RN SN THA Total
1 √ 1
2 √ √ 2
3 0
4 √ √ √ √ √ 5
5 √ √ √ √ 4
6 √ 1
7 0
8 √ √ 2
9 √ √ √ 3
10 √ √ 2
11 0
12 0
13 0
14 √ √ 2
Total 3 2 3 6 1 6 1 9 out of 14
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Inclusion of all regions
High Iron Region – TotalHigh Iron Region – Average
High Iron Region – AreaWhole Structure – Total
Whole Structure – Average
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All Measures
Iron that appears above average age matched values for any measure
PATIENT CN GP PUT PT RN SN THA Total
1 √ √ √ 3
2 √ √ √ 3
3 √ √ √ √ 4
4 √ √ √ √ √ √ 6
5 √ √ √ √ √ √ 6
6 √ √ √ √ 4
7 √ √ 2
8 √ √ √ √ 4
9 √ √ √ √ 4
10 √ √ √ √ 4
11 √ √ 2
12 0
13 0
14 √ √ √ 3
Total 6 6 5 7 6 8 7 12 out of 14
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All Measures
Iron that appears above average age matched values for any measure
PATIENT CN GP PUT PT RN SN THA Total
1 2 5 1 8
2 2 5 1 8
3 1 1 1 1 4
4 5 5 5 5 3 2 25
5 1 5 1 5 4 4 1 21
6 1 1 1 3 4
7 2 3 5
8 3 1 4 1 9
9 4 2 1 4 11
10 4 1 3 1 9
11 1 1 2
12 0
13 0
14 1 1 2 4
Total 6 6 5 7 6 8 7 12 out of 14
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Paolo Zamboni and his team’s proof
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Paolo Zamboni and his team’s proof
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Our first caseOur first case
Magnitude Phase Flow vertically
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MS patient Normal control
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Example MRV data showing a tight stenosis in a young MS patient
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3D MRV of narrowed vein
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Abnormal signal in the sagittal sinus
Normal signal in the sagittal
sinus
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Implications of iron in mutliple sclerosis
Ferritin in healthy tissue:Nanomolars measured with SWI
Heme-iron for visualizing veins
Quantification of hemodynamicsAbormal iron content in MS
Vessel wall breakdown leads to microhemorrhage.Iron acts as an inflammatory agent exacerbating other
effects of loss of vessel wall shear stress.Further breakdown of the microvascular system follows
creating a pathology opposite to flow (just like Fog saw).Ischemic areas lose cerebral blood volume also from
shunting of blood and atrophy of vessels.
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Future DirectionsFuture Directions
Can SWI iron content be used as a biomarker for venous vascular Can SWI iron content be used as a biomarker for venous vascular changes particularly in young patients?changes particularly in young patients?
Does more iron indicate more severe tissue damage?Does more iron indicate more severe tissue damage?
Should we treat with antiShould we treat with anti--inflammatory and iron chelating agents? inflammatory and iron chelating agents?
Does reperfusion put the vessels with now normal Does reperfusion put the vessels with now normal hemodynamicshemodynamics at at risk because of vessel wall weakening? risk because of vessel wall weakening?
Can oxygen saturation and SWI measurements help demarcate the Can oxygen saturation and SWI measurements help demarcate the condition of local condition of local hemodynamicshemodynamics in the brain? in the brain?
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ConclusionsConclusions
MRI is a powerful means to collect 3D angiographic (both MRI is a powerful means to collect 3D angiographic (both anatomical and functional) information and vessel wall informatianatomical and functional) information and vessel wall information.on.
SWI can be used for detecting SWI can be used for detecting deoxyhemoglobindeoxyhemoglobin as well as iron as well as iron content in the form of content in the form of hemosiderinhemosiderin or or ferritinferritin..
MS patients have an increased amount of iron in the basal gangliMS patients have an increased amount of iron in the basal ganglia, a, and other basal ganglia structures. and other basal ganglia structures.
This may be from vascular damage to the veins in the form of This may be from vascular damage to the veins in the form of hemosiderinhemosiderin or from or from ferritinferritin from from oligodendrocytesoligodendrocytes..
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We propose a simple first pass protocol to include the following three tests:
Post contrast time resolved MRA: to find the stenoses
SWI: to find the iron and venous damage
Flow quantification: to find the abnormal fluid dynamics
Please visit our site www.nice-mri.com to review the database concept we are proposing and more importantly for MS
updates starting Monday visit www.ms-mri.com
ADDENDA
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Short term future directions:
We are trying to collect as many cases as we can in the next few weeks in an open study so that I can take a
proposal to some MS groups around the world to join us in this venture and share their data for a fixed protocol. This
work will be continued for the next few months to collect as many cases as possible.
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Long term goals:
Create a continuing database with a single international protocol for a blinded study in MS for patients with 10 years
or less MS indications. Collect hundreds of cases from sites around the world.
Research protocols could easily be tacked on to this such as 4D flow measurements, higher resolution SWI, etc but the baselines should stay the same for now. This would
make all the work we do far more valuable to the medical community at large.