The effects of hemodynamic lag on functional connectivity and behavior after stroke

Stroke disrupts the brain's vascular supply, not only within but also outside areas of infarction. We investigated temporal delays (lag) in resting state functional magnetic resonance imaging signals in 130 stroke patients scanned two weeks, three months and 12 months post stroke onset. Thirty controls were scanned twice at an interval of three months. Hemodynamic lag was determined using cross-correlation with the global gray matter signal. Behavioral performance in multiple domains was assessed in all patients. Regional cerebral blood flow and carotid patency were assessed in subsets of the cohort using arterial spin labeling and carotid Doppler ultrasonography. Significant hemodynamic lag was observed in 30% of stroke patients sub-acutely. Approximately 10% of patients showed lag at one-year post-stroke. Hemodynamic lag corresponded to gross aberrancy in functional connectivity measures, performance deficits in multiple domains and local and global perfusion deficits. Correcting for lag partially normalized abnormalities in measured functional connectivity. Yet post-stroke FC-behavior relationships in the motor and attention systems persisted even after hemodynamic delays were corrected. Resting state fMRI can reliably identify areas of hemodynamic delay following stroke. Our data reveal that hemodynamic delay is common sub-acutely, alters functional connectivity, and may be of clinical importance

A dual-center validation of the PIRAMD scoring system for assessing the severity of ischemic Moyamoya disease

Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD) is a recently proposed imaging-based scoring system that incorporates the severity of disease and its impact on parenchymal hemodynamics in order to better support clinical management and evaluate response to intervention. In particular, PIRAMD may have merit in identifying symptomatic patients that may benefit most from revascularization. Our aim was to validate the PIRAMD scoring system

The longitudinal changes of BOLD response and cerebral hemodynamics from acute to subacute stroke. A fMRI and TCD study

<p>Abstract</p> <p>Background</p> <p>By mapping the dynamics of brain reorganization, functional magnetic resonance imaging MRI (fMRI) has allowed for significant progress in understanding cerebral plasticity phenomena after a stroke. However, cerebro-vascular diseases can affect blood oxygen level dependent (BOLD) signal. Cerebral autoregulation is a primary function of cerebral hemodynamics, which allows to maintain a relatively constant blood flow despite changes in arterial blood pressure and perfusion pressure. Cerebral autoregulation is reported to become less effective in the early phases post-stroke.</p> <p>This study investigated whether any impairment of cerebral hemodynamics that occurs during the acute and the subacute phases of ischemic stroke is related to changes in BOLD response.</p> <p>We enrolled six aphasic patients affected by acute stroke. All patients underwent a Transcranial Doppler to assess cerebral autoregulation (Mx index) and fMRI to evaluate the amplitude and the peak latency (time to peak-TTP) of BOLD response in the acute (i.e., within four days of stroke occurrence) and the subacute (i.e., between five and twelve days after stroke onset) stroke phases.</p> <p>Results</p> <p>As patients advanced from the acute to subacute stroke phase, the affected hemisphere presented a BOLD TTP increase (p = 0.04) and a deterioration of cerebral autoregulation (Mx index increase, p = 0.046). A similar but not significant trend was observed also in the unaffected hemisphere. When the two hemispheres were grouped together, BOLD TTP delay was significantly related to worsening cerebral autoregulation (Mx index increase) (Spearman's rho = 0.734; p = 0.01).</p> <p>Conclusions</p> <p>The hemodynamic response function subtending BOLD signal may present a delay in peak latency that arises as patients advance from the acute to the subacute stroke phase. This delay is related to the deterioration of cerebral hemodynamics. These findings suggest that remodeling the fMRI hemodynamic response function in the different phases of stroke may optimize the detection of BOLD signal changes.</p

Modulation of BOLD and Arterial Spin Labeling (ASL-CBF) Response in Patients with Transient Visual Impairment after Posterior Circulation Stroke*

Background and Purpose:: Blood oxygenation level-dependent (BOLD) signal and arterial spin labeling cerebral blood flow (ASL-CBF) changes, as detected by functional magnetic resonance imaging (fMRI) are closely related to neural activity. The aim of this case series study was to investigate modulations of the BOLD and ASL-CBF response in the primary visual cortex after posterior circulation stroke with transient visual impairment. Methods:: BOLD activity, resting CBF and task-related ASL-CBF response have been investigated 24-48 h after onset of transient visual symptoms in two patients who were treated conservatively, two patients who received thrombolysis after posterior circulation stroke, and five healthy controls with checkerboard stimulation and visual evoked potentials (VEPs). Results:: After normalization of transient visual symptoms the BOLD response and VEPs showed no hemispheric differences between patients and controls. The relative blood flow in the posterior cerebral arteries and the relative ASL-CBF response to checkerboard stimulation were reduced in three patients, compared to controls. In one patient who received intraarterial thrombolytic therapy, improvement of the relative CBF and ASL-CBF responses was observed, indicating early reperfusion. Conclusion:: In this case series of four patients, different CBF responses to conservative and thrombolytic therapy were observed, and early reperfusion after intraarterial thrombolysis was detected. Functional imaging, which makes use of the ASL-CBF technique, is feasible to measure early poststroke vascular changes, which are hardly detectable with BOLD-fMR

Flow-augmentation STA-MCA bypass for acute and subacute ischemic stroke due to internal carotid artery occlusion and the role of advanced neuroimaging with hemodynamic and flow-measurement in the decision-making: preliminary data

Symptomatic patients with ischemic stroke due to internal carotid artery (ICA) occlusion often present with compromised brain hemodynamic status involving substantially larger parts of the affected vascular territory than the ischemic core itself (1-3). Despite the fact that the “Extracranial-Intracranial” (EC-IC) Bypass Study Group and the “Carotid Occlusion Surgery Study” (COSS) failed to demonstrate a benefit of bypass in comparison to medical therapy (4,5), several studies showed a significant improvement in hemodynamic parameters after superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery was performed in carefully selected patients (6-9) and even a reduction in stroke recurrence (6). Analysis showed that the failure of the COSS trial (5) to show a benefit regarding ipsilateral 2-year stroke recurrence in patients undergoing cerebral bypass revascularization was likely caused by a failure of the semiquantitative, hemispheric oxygen extraction fraction (OEF) ratio method used in the trial than by the selection of the patients for bypass based on hemodynamic compromise (10). Therefore, alternative and especially quantitative imaging techniques are needed to assess hemodynamic status in patients with ischemic stroke due to ICA occlusion

Pathophysiological Interference with Neurovascular Coupling – When Imaging Based on Hemoglobin Might Go Blind

Assessing neuronal activity by non-invasive functional brain imaging techniques which are based on the hemodynamic response depends totally on the physiological cascade of metabolism and blood flow. At present, functional brain imaging with near infrared spectroscopy (NIRS) or BOLD-fMRI is widely used in cognitive neuroscience in healthy subjects where neurovascular coupling and cerebrovascular reactivity can be assumed to be intact. Local activation studies as well as studies investigating functional connectivity between brain regions of the resting brain provide a rapidly increasing body of knowledge on brain function in humans and animals. Furthermore, functional NIRS and MRI techniques are increasingly being used in patients with severe brain diseases and this use might gain more and more importance for establishing their use in the clinical routine. However, more and more experimental evidence shows that changes in baseline physiological parameters, pharmacological interventions, or disease-related vascular changes may significantly alter the normal response of blood flow and blood oxygenation and thus may lead to misinterpretation of neuronal activity. In this article we present examples of recent experimental findings on pathophysiological changes of neurovascular coupling parameters in animals and discuss their potential implications for functional imaging based on hemodynamic signals such as fNIRS or BOLD-fMRI. To enable correct interpretation of neuronal activity by vascular signals, future research needs to deepen our understanding of the basic mechanisms of neurovascular coupling and the specific characteristics of disturbed neurovascular coupling in the diseased brain

Functional MRI and Diffusion Tensor Imaging of Brain Reorganization After Experimental Stroke

The potential of the adult brain to reorganize after ischemic injury is critical for functional recovery and provides a significant target for therapeutic strategies to promote brain repair. Despite the accumulating evidence of brain plasticity, the interaction and significance of morphological and physiological modifications in post-stroke brain tissue remain mostly unclear. Neuroimaging techniques such as functional MRI (fMRI) and diffusion tensor imaging (DTI) enable in vivo assessment of the spatial and temporal pattern of functional and structural changes inside and outside ischemic lesion areas. This can contribute to the elucidation of critical aspects in post-stroke brain remodeling. Task/stimulus-related fMRI, resting-state fMRI, or pharmacological MRI enables direct or indirect measurement of neuronal activation, functional connectivity, or neurotransmitter system responses, respectively. DTI allows estimation of the structural integrity and connectivity of white matter tracts. Together, these MRI methods provide an unprecedented means to (a) measure longitudinal changes in tissue structure and function close by and remote from ischemic lesion areas, (b) evaluate the organizational profile of neural networks after stroke, and (c) identify degenerative and restorative processes that affect post-stroke functional outcome. Besides, the availability of MRI in clinical institutions as well as research laboratories provides an optimal basis for translational research on stroke recovery. This review gives an overview of the current status and perspectives of fMRI and DTI applications to study brain reorganization in experimental stroke models

Evaluation of the cerebrovascular reactivity in patients with Moyamoya Angiopathy by use of breath-hold fMRI: investigation of voxel-wise hemodynamic delay correction in comparison to [15^{15}O]water PET

PURPOSE: Patients with Moyamoya Angiopathy (MMA) require hemodynamic assessment to evaluate the risk of stroke. Hemodynamic evaluation by use of breath-hold-triggered fMRI (bh-fMRI) was proposed as a readily available alternative to the diagnostic standard [$^{15}$O]water PET. Recent studies suggest voxel-wise hemodynamic delay correction in hypercapnia-triggered fMRI. The aim of this study was to evaluate the effect of delay correction of bh-fMRI in patients with MMA and to compare the results with [$^{15}$O]water PET. METHODS: bh-fMRI data sets of 22 patients with MMA were evaluated without and with voxel-wise delay correction within different shift ranges and compared to the corresponding [$^{15}$O]water PET data sets. The effects were evaluated combined and in subgroups of data sets with most severely impaired CVR (apparent steal phenomenon), data sets with territorial time delay, and data sets with neither steal phenomenon nor delay between vascular territories. RESULTS: The study revealed a high mean cross-correlation (r = 0.79, p < 0.001) between bh-fMRI and [$^{15}$O]water PET. The correlation was strongly dependent on the choice of the shift range. Overall, no shift range revealed a significantly improved correlation between bh-fMRI and [$^{15}$O]water PET compared to the correlation without delay correction. Delay correction within shift ranges with positive high high cutoff revealed a lower agreement between bh-fMRI and PET overall and in all subgroups. CONCLUSION: Voxel-wise delay correction, in particular with shift ranges with high cutoff, should be used critically as it can lead to false-negative results in regions with impaired CVR and a lower correlation to the diagnostic standard [$^{15}$O]water PET

Understanding Stroke in the Connected Human Brain

Although structural damage from stroke is focal, remote dysfunction can occur in regions of the brain distant from the area of damage. Lesions in both gray and white matter can disrupt the flow of information in areas connected to or by the area of infarct. This is because the brain is not an assortment of specialized parts but an assembly of distributed networks that interact to support cognitive function. Functional connectivity analyses using resting functional magnetic resonance imaging (fMRI) have shown us that the cortex is organized into distributed brain networks. The primary goal of this work is to characterize the effects of stroke on distributed brain systems and to use this information to better understand neural correlates of deficit and recovery following stroke. We measured resting functional connectivity, lesion topography, and behavior in multiple domains (attention, visual memory, verbal memory, language, motor, and visual) in a cohort of 132 stroke patients. Patients were followed longitudinally with full behavioral and imaging batteries acquired at 2 weeks, 3 months, and 1 year post-stroke. Thirty age- and demographic- matched controls were scanned twice at an interval of three months. In chapter 1, we explore a central question motivating this work: how is behavior represented in the brain? We review progressing prospective – from basic functional localization to newer theories connecting inter-related brain networks to cognitive operations. In so doing, we attempt to build a foundation that motivates the hypotheses and experimental approaches explored in this work. Chapters 2 and 3 serve primarily to validate approaches and considerations for using resting fMRI to measure functional connectivity in stroke patients. In chapter 2, we investigate hemodynamic lags after stroke. ‘Hemodynamic lag’ is a local delay in the blood oxygen level dependent (BOLD) response to neural activity, measured using cross-correlation of local fMRI signal with some reference brain signal. This work tests assumptions of the BOLD response to neural activity after stroke, but also provides novel and clinically relevant insight into perilesional disruption to hemodynamics. Significant lags are observed in 30% of stroke patients sub-acutely and 10% of patients at one-year. Hemodynamic lag corresponds to gross aberrancy in functional connectivity measures, performance deficits and local and global perfusion deficits. Yet, relationships between functional connectivity and behavior reviewed in chapter 1 persist after hemodynamic delays is corrected for. Chapter 3 provides a more extended discussion of approaches and considerations for using resting fMRI to measure functional connectivity in stroke patients. Like chapter 1, the goal is to motivate experimental approaches taken in later chapters. But here, more technical challenges relating to brain co-registration, neurovascular coupling, and clinical population selection are considered. In chapter 4, we uncover the relationships between local damage, network wide functional disconnection, and neurological deficit. We find that visual memory and verbal memory are better predicted by connectivity, whereas visual and motor deficits are better predicted by lesion topography. Attention and language deficits are well predicted by both. We identify a general pattern of physiological network dysfunction consisting of decrease of inter-hemispheric integration and decrease in intra-hemispheric segregation, which strongly related to behavioral impairment in multiple domains. In chapter 5, we explore a case study of abulia – severe apathy. This work ties together principles of local damage, network disruption, and network-related deficit and demonstrates how they can be useful in understanding and developing targeted treatments (such as transcranial magnetic stimulation) for individual stroke patients. In chapter 6, we explore longitudinal changes in functional connectivity that parallel recovery. We find that the topology and boundaries of cortical regions remains unchanged across recovery, empirically validating our parcel-wise connectivity approach. In contrast, we find that the modularity of brain systems i.e. the degree of integration within and segregation between networks, is significantly reduced after a stroke, but partially recovered over time. Importantly, the return of modular network structure parallels recovery of language and attention, but not motor function. This work establishes the importance of normalization of large-scale modular brain systems in stroke recovery. In chapter 7, we discuss some fundamental revisions of past lesion-deficit frameworks necessitated by recent findings. Firstly, anatomical priors of structural and functional connections are needed to explain why certain lesions across distant locations should share behavioral consequences. Secondly, functional priors of connectomics are needed to explain how local injury can produce widespread disruption to brain connectivity and behavior that have been observed