RPS 1411 - Neuroimaging in white matter disease

Author Block: E. Middlebrooks, V. Patel, X. Zhou, S. Straub, L. Okromelidze, V. Gupta, S. J. Singh Sandhu, S. Tao; Jacksonville, FL/US
Purpose: Detection of infratentorial demyelinating lesions in multiple sclerosis (MS) presents a challenge in MRI. The goal of this study is to assess the efficacy of a novel MRI approach, lesion-attenuated MPRAGE acquisition (LAMA) in detection of demyelinating lesion within the posterior fossa and upper cervical spine in patients with MS on 7T MRI.
Methods or Background: A retrospective cross-sectional study of 42 patients with MS who had 7T brain imaging with LAMA, 3D DIR and 2D T2-weighted turbo spin echo sequences was performed. Three neuroradiologists assessed lesion count in the brainstem, cerebellum, and upper cervical spinal cord using both DIR and T2-weighted images in one session, and LAMA in a separate one. Additionally, contrast-to-noise ratio (CNR) between LAMA and the conventional sequences was compared.
Results or Findings: LAMA identified more lesions than DIR+T2 (6.4 versus 3.0; p<0.001), exhibited better interrater agreement (ICC = 0.75 [95% CI = 0.41 – 0.88] versus 0.61 [95% CI = 0.35 – 0.78]), and higher contrast-to-noise ratio (3.7 ± 0.9) versus that of DIR (1.94 ± 0.7) and T2 (1.2 ± 0.7) (all p < 0.001). In cases with no lesions detected using DIR+T2, at least one lesion was identified in 83.3% with LAMA. Across all analysed brain regions, LAMA consistently detected more lesions than DIR+T2.
Conclusion: LAMA has demonstrated improved detection of infratentorial demyelinating lesions in patients with MS compared to traditional methods at 7T through high spatial resolution, robust lesion contrast, and resilience against prevalent 7T MRI artefacts such as B1+transmit heterogeneity. Integrating LAMA with standard MP2RAGE provides an additional tool for accurate characterisation of the extent of MS.
Limitations: AMA is limited to 7T. Further investigation is needed to assess its comparative advantage over other sequences at the reduced field strength.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This retrospective study was approved by Mayo Clinic Institutional Review Board.

Author Block: A. Di Gioia, F. Colarieti, P. Badini, C. Santobuono, I. Antonio, S. Martino, F. Bruno, A. Splendiani, E. Di Cesare; L'Aquila/IT
Purpose: The aim of this study was to compare the characteristics, results and experience by using three commercially available software programmes for segmentation and counting of multiple sclerosis lesions and measurement of dementia brain volume assessment.
Methods or Background: Brain MRI with standard imaging protocol and including volumetric FLAIR and T1 sequences were performed in 28 patients (11 famales and 17 males) affected by multiple sclerosis (13 patients) and dementia (15 patients). MRI scans were segmented twice in each software package by two investigators. Intra-rater, inter-rater and between-software agreement was compared.
Results or Findings: The main differences were found in the segmentation of white matter lesions, in particular the recognition of hypointense lesions in T1 that were evidenced from each of the three software used. Furthermore differences were found in both total lesion volume and number of lesions, with a median difference mostly shown in the evaluation and recognition of periventricular lesions (-0.39ml; 95% CI from -1.745 to 1.0). Concerning volume calculation, the inter-software and interobserver analysis shows the main difference being in the evaluation of the frontal (-49.3ml; 95% CI from -60.9 to -37.8) and parietal region volume (-46.8; 95% CI from -51.2 to 42.4).
Conclusion: The use of artificial intelligence software is becoming an essential part of clinical evaluation in medicine, and in our specific case in the evaluation of multiple sclerosis lesions and measurement of dementia brain volume assessment. Despite technological progress, according to our clinical study, there doesn’t yet seem to be a high level of agreement within and between the software in terms of intra-rater, inter-rater and intra-software programme differences. Therefore, users should be aware of the lack of interchangeability between these software programmes when they are applied in clinical practice.
Limitations: The low study sample and the fact this this was a retrospective analysis were identified as limitations.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki.

Author Block: S. Peters¹, G. Kellermann², J. Watkinson¹, M. Huhndorf¹, K. Stürner¹, O. Jansen¹, N. Larsen¹; ¹Kiel/DE, ²Hamburg/DE
Purpose: Evaluation of MR images of patients with multiple sclerosis (MS) is part of daily clinical routine. Consequently, a growing number of companies offer software for automated lesion detection. The aim of this study was to evaluate the effect of such software on the radiological reporting.
Methods or Background: Four radiologists retrospectively evaluated MRI examinations of 50 MS patients and counted the lesions in FLAIR images separated by the locations periventricular, cortical/juxtacortical, infratentorial and unspecific. After six weeks they repeated the evaluation, this time additionally using the AI based software mdbrain. In both settings the required time for lesion detection was documented. Furthermore, the four radiologists evaluated follow-up MRIs of 50 MS patients concerning new and enlarging lesions in the same manner.
Results or Findings: To determine the lesion-load the average reporting time decreased from 286.85 seconds to 196.34 seconds (p>0.001). For the evaluation of the follow-up images the average reporting time dropped from 196.17 seconds to 120.87 seconds (p<0.001). The interrater reliabilities showed no remarkable change. The interclass correlation coefficient (ICC) was 0.83 for the determination of the lesion-load without software support and 0.84 with software support. For the follow-up evaluation, the ICC was 0.92 without software support and 0.82 with software support.
Conclusion: Increasing workload is a growing problem in daily clinical routine. Usage of AI based support for image-interpretation can be helpful in clinical routine and significantly lowers reporting times in a system with already limited resources. The interrater reliability was not remarkably affected be the usage of the software, probably because of the already high agreement without software support.
Limitations: With these results, a direct conclusion regarding the effect on the reporting quality cannot be made.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the ethics committee of the medical faculty of the Christian-Albrechts-University (CAU) Kiel.

Author Block: O. A. Kargin, S. Arslan, U. Uygunoglu, B. C. Poyraz, B. Korkmazer, E. Seyahi, O. Kizilkilic; Istanbul/TR
Purpose: Behcet's syndrome (BS) is a chronic, recurrent, multisystemic vasculitis of unknown aetiology. Neuroaxonal damage in its neurological involvement, known as Neuro-Behcet's syndrome (NBS), can lead to declines in neurocognitive functions, contributing to disease-related morbidity. Our study aims to evaluate the microstructural integrity of cerebral white matter tracts in patients with NBS and BS without neurological involvement via DTI, correlate DTI data with neurocognitive functions, and explore clinical-anatomical relationships to identify potential neuroimaging biomarkers.
Methods or Background: The study comprised 34 NBS patients and 32 BS patients without neurological involvement, identified based on the Behcet's Syndrome International Study Group (ISG) and the International Consensus Recommendation (ICR) criteria. Additionally, 33 age- and educational status-matched healthy individuals were included as controls. All participants underwent DTI, as well as standardised neuropsychological tests assessing various cognitive domains, including attention, memory, verbal fluency, abstraction, executive control, visuospatial skills, and sensorimotor performance. DTI data were analysed using tract-based spatial statistics (TBSS) and automated probabilistic tractography to investigate intergroup differences. Subsequently, the correlations between DTI parameters of white matter tracts and neuropsychological test scores were examined.
Results or Findings: DTI revealed decreased fractional anisotropy and increased radial diffusivity, mean diffusivity, and axial diffusivity in both supratentorial and infratentorial white matter in NBS patients, indicating widespread loss of microstructural integrity. Moreover, this loss of integrity was also observed in BS patients without overt neurological involvement, albeit to a more limited extent. In NBS patients, specific white matter tracts, including superior thalamic radiation, cingulum, and fornix, were associated with poor cognitive performance across multiple domains.
Conclusion: Our results suggest that DTI findings can potentially serve as biomarkers to assess neurocognitive impairment associated with central nervous system involvement in BS.
Limitations: This is a cross-sectional study without longitudinal follow-up.
Funding for this study: Funding was provided by the Scientific Research Projects Coordination Unit of Istanbul University-Cerrahpasa. Project number TTU-2022-36692.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by Istanbul University-Cerrahpasa Clinical Research Ethics Committee (reference number 162).

Author Block: M. Sobański¹, M. Gajowczyk¹, P. Rygiel², A. Korbecki¹, J. Korbecka¹, M. Sobańska¹, A. Sebastian¹, J. Bladowska¹; ¹Wroclaw/PL, ²Enschede/NL
Purpose: Primary Sjögren's syndrome (pSS) is an autoimmune disease in which central nervous system (CNS) involvement may occur. Incidence and pathogenesis of changes related to CNS in pSS is not well understood. Diffusion tensor imaging (DTI) can be used to demonstrate impaired integrity of cerebral white matter (CWM), especially by quantitative values such as fractional anisotropy (FA).
Methods or Background: A study group containing 33 patients with primary Sjögren's syndrome and a control group containing 26 healthy patients were studied by performing DTI on a 3T MRI scanner. Data was reprocessed by automatic TractSeg algorithm, which is a fully convolutional neural network (FCNN), resulting in a segmentation of 72 white matter (WM) tracts per patient, as well as a value of FA for each tract.
Results or Findings: Reduction in FA in the study group relative to the control group was found in multiple CWM areas. Previously unreported involvement of the cerebellar WM tracts and optic radiations were found. There were also numerous correlations between reduced FA values in white matter tracts and rheumatological factors.
Conclusion: DTI examination is a sensitive advanced MRI technique for detecting impaired integrity of cerebral WM tracts in patients with pSS. The greatest reduction in FA in the study group was found in the cerebellar peduncles, which is also a novel observation. Other WM tracts also showed reduction in FA. Numerous associations between neuroradiological findings and rheumatological factors have been demonstrated. The utility of automated methods of collecting measurements in the DTI, such as TractSeg's FCNN, allows for a rapid and reproducible collection of qualitative and quantitative data.
Limitations: Identified limitations were the (1) small study group, and (2) lack of DTI study at the moment of diagnosis of pSS.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study received institutional review board approval and written informed consent was obtained from all participants. Opinion number of the Bioethics Committee at the Medical University of Wroclaw - KB - 578/2020.

Author Block: R. Akdoğan¹, M. A. Tezcan², Z. Tüzün¹, S. A. Atalay¹, K. Kaşali¹, G. Polat¹, M. Alkan Melikoğlu¹; ¹Erzurum/TR, ²Malatya/TR
Purpose: In our study, we aimed to determine the diagnostic value of measuring the lesion-cortex signal ratio (LCSR) in the FLAIR sequence for distinguishing T2 hyperintense white matter lesions related to SLE from non-specific T2 hyperintensities, with the intention of providing guidance to clinicians in the diagnosis and treatment process of the disease.
Methods or Background: A total of 30 SLE patients with white matter hyperintensities and without additional conditions were included in the study. A control group of 30 patients with non-specific hyperintensities in the white matter in the FLAIR sequence was selected. LCSR measurements were performed twice at different times by two radiologists. The data are presented as mean and standard deviation, and the Mann-Whitney U test was used to compare LCSR means between SLE patients and the control group. ROC analysis was conducted to assess whether LCSR measurement can be used to differentiate SLE white matter lesions from non-specific hyperintensities.
Results or Findings: The Cronbach's alpha value between the measurements of the two observers at two different time points was found to be 0.971 and 0.946, respectively, with a highly significant agreement value of 0.959 between them. The LCSR value for SLE patients was measured as 1.30±0.12, while it was significantly higher at 1.13±0.10 for the control group (p<0.001). In the ROC analysis conducted to determine whether LCSR measurement can be used to differentiate SLE white matter lesions from non-specific hyperintensities, the area under the curve was calculated as 0.872±0.043, and it was found to be statistically significant (p<0.001). Consequently, the LCSR cut-off value was determined as 1.1939, with a sensitivity of 0.836 and a specificity of 0.833.
Conclusion: Measurement of LCSR in the FLAIR sequence allows for a high-precision differentiation between white matter lesions associated with SLE and non-specific T2 hyperintense lesions. Furthermore, the excellent interobserver agreement in LCSR measurements attests to its reproducibility.
Limitations: The retrospective design of this study was an identified limitation.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study received ethics committee approval.

Author Block: B. Atasoy Badur, N. Atila, P. Soysal, O. Ipar, A. Kaya, S. Balsak, A. Alkan; Istanbul/TR
Purpose: Malnutrition is described as the clinical condition of decreased nutrient intake and/or inadequate nutrient absorption. It may result in adverse effects in geriatrics. The aim of this study is to investigate whether the nutritional status in the geriatric population is associated with the integrity of white matter tracts by using DTI.
Methods or Background: This is a retrospective cross-sectional study with a total of 224 geriatric patients. Mini-nutritional assessment (MNA) was utilised to detect malnutrition risk. Routine brain MRI protocol and DTI were performed for all patients. 18 different white matter tracts in both cerebral hemispheres were evaluated by ROI-based approach. The MD, FA, AD and RD values were recorded.
Results or Findings: According to the MNA: 86 patients have normal nutritional status, 107 patients are with malnutrition risk and 31 patients are diagnosed with malnutrition. There is a significant difference between these three groups in terms of age and lab values of folate. There is no statistically significant difference between the groups in terms of gender, co-morbid disease and laboratory values of vitamin B12, vitamin D or thyroid function tests. Regarding the DTI values, the most affected white matter tracts are cingulum (CG), genu of corpus callosum, forceps minor, anterior limb of internal capsul, superior (SCP) and middle cerebellar peduncle. After adjusting for the folate and age on the effect of DTI parameters, CG and SCP are still affected.
Conclusion: The findings indicate that malnutrition in geriatric patients may be associated with deteriorated DTI values of white matter tracts, especially in cingulum and superior cerebellar peduncle, which might be considered as an indicator of impaired white matter integrity.
Limitations: The ROI-based approach is operator-dependent.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the local ethics committee.

Author Block: C. Péter, B. Szilveszter, M. Vecsey-Nagy, S. Borzsák, G. Gyebnár, Z. Mihály, Z. Czinege, P. Sótonyi, A. Varga; Budapest/HU
Purpose: Diffusion tensor imaging (DTI) metric changes were assessed in a prospective cohort of asymptomatic carotid endarterectomy (CEA) patients in correlation with patient characteristics, and vascular anatomy (4-axis; circle of Willis [CW] scores).
Methods or Background: Prospectively enrolled patients (54, males 54%, age 69.7±7 years) had DTI pre-CEA (mean 2, range 0-31 days) and post-CEA (mean 2, range 0-5 days). DTI metrics (FA–fractional anisotropy, axial, mean, radial diffusivities – AD, MD, RD) were calculated for 16 white matter (WM) regions (8-8 regions of index and contralateral hemispheres) pre-CEA and post-CEA and compared using the repeated measure Wilcoxon signed rank test (p<0.0125, Bonferroni corrected). Preoperative supraaortic plus intracranial CTA was performed to create the 4-axis score (range 0-15,mthe lower the worse) and CW score (0–5, 0 if both the anterior plus ispilateral posterior semicircles towards the operated internal carotid artery are incomplete). Univariate and multivariate linear regression analyses were used to correlate main demographic, comorbidity data, vascular scores (p<0.05).
Results or Findings: Significantly decreased FA in 1/8 index WM region (p=0.007), singificantly increased AD in 7/8 index, 4/8 contralateral WM regions (p<0.0001-0.0120), significantly increased MD in 6/8 index, 4/8 contralateral WM regions (p<0.0001-0.005), significantly increased RD in 5/8 index, 3/8 contralateral WM regions (p<0.0001-0.011) was found. In 19/26 regions with significant DTI metric changes from pre-to-post-CEA, the 4-axis score was a significant predictor using univariate regression analysis (p<0.001-0.038), remaining significant with multivariate regression analysis in the index temporal, contralateral frontal, parietal WM regions (p=0.006-0.012) for MD, and in the index insular (p= 0.042) and temporal WM regions (p=0.039) for RD.
Conclusion: DTI metric changes suggesting microstructural deterioration were found from pre-CEA to post-CEA, more pronounced on the index side, with the weighted 4-axis score as a significant predictor.
Limitations: Identified limitations were (1) the small cohort and (2) the lack of correlation with surgical/anaesthesiology data.
Funding for this study: Funding was received from the National Research, Development and Innovation Office – NKFIH, K 129277.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the institutional ethical committee with approval code: IV/667-1/2022/EKU.