Gadolinium DTPA Enhancement Characteristics of the Rat Sciatic Nerve after Crush Injury at 4.7T.

BACKGROUND AND PURPOSE: Traumatic peripheral nerve injury is common and results in loss of function and/or neuropathic pain. MR neurography is a well-established technique for evaluating peripheral nerve anatomy and pathology. However, the Gd-DTPA enhancement characteristics of acutely injured peripheral nerves have not been fully examined. This study was performed to determine whether acutely crushed rat sciatic nerves demonstrate Gd-DTPA enhancement and, if so, to evaluate whether enhancement is affected by crush severity. MATERIALS AND METHODS: In 26 rats, the sciatic nerve was crushed with either surgical forceps (6- to 20-N compressive force) or a microvascular/microaneurysm clip (0.1-0.6 N). Animals were longitudinally imaged at 4.7T for up to 30 days after injury. T1WI, T2WI, and T1WI with Gd-DTPA were performed. RESULTS: Forceps crush injury caused robust enhancement between days 3 and 21, while clip crush injury resulted in minimal-to-no enhancement. Enhancement after forceps injury peaked at 7 days and was seen a few millimeters proximal to, in the region of, and several centimeters distal to the site of crush injury. Enhancement after forceps injury was statistically significant compared with clip injury between days 3 and 7 (P < .04). CONCLUSIONS: Gd-DTPA enhancement of peripheral nerves may only occur above a certain crush-severity threshold. This phenomenon may explain the intermittent observation of Gd-DTPA enhancement of peripheral nerves after traumatic injury. The observation of enhancement may be useful in judging the severity of injury after nerve trauma.

Quantitative analysis of the effects of physiologic brain motion on point-resolved spectroscopy.

BACKGROUND AND PURPOSE: Although single-voxel proton MR spectroscopy is a noninvasive method that enables measurement of brain metabolite concentrations, it has been shown that physiologic brain motion causes inaccuracies in measurement of metabolite concentrations and increases the overall SD of the measurements when the stimulated echo acquisition mode (STEAM) is used. We tested the hypothesis that the point-resolved spectroscopy (PRESS) technique is less sensitive to physiologic brain motion than the STEAM technique. METHODS: In 10 healthy subjects, spectra were obtained from a voxel located in the left basal ganglia by using the PRESS sequence with cardiac gating and without water suppression to assess global phase change as a function of physiologic brain motion. This was accomplished by acquiring data at various time delays from the R wave throughout the cardiac cycle. Subsequently, spectra were obtained in 10 healthy subjects by using PRESS both without and with cardiac gating, and with water suppression, to determine whether brain motion resulted in a statistically significant difference in mean and SD of measured metabolite concentration. RESULTS: At various time delays from the R wave throughout the cardiac cycle, no significant global phase difference was noted in water signal intensity. In addition, when PRESS data were obtained both without and with cardiac gating (by using an optimal delay obtained from previously published data by using STEAM), no significant difference was seen in measured metabolite concentrations and SDs. CONCLUSION: The PRESS technique is relatively insensitive to physiologic brain motion.

Contrast-enhanced MR angiography of spinal vessels.

Compared to routine spin-echo images, contrast-enhanced MR angiography provides improved characterization of the spinal vasculature. This technique can help narrow the differential diagnosis and guide further treatment in patients with radiculopathy or myelophathy. The most useful application to date has been in screening for spinal dural fistulae. The fast, three-dimensional method offers the possibility of distinguishing the largest spinal arteries and veins, although additional technical improvements and clinical experience are needed to accomplish this goal.

MR imaging and localized proton spectroscopy of the precentral gyrus in amyotrophic lateral sclerosis.

BACKGROUND AND PURPOSE: In the search for a diagnostic test for amyotrophic lateral sclerosis (ALS), especially upper motor neuron (UMN) involvement, MR imaging and proton spectroscopy techniques have each received attention, but their findings have not been correlated. The purpose of this study was to identify relationships among the results of current techniques, taking into account the severity of clinical UMN disease, so that objective measures of the pathogenesis of ALS may be established. METHODS: Eighteen subjects with clinically diagnosed ALS and 12 healthy volunteers underwent MR imaging of the brain and localized proton MR spectroscopy. Water-suppressed spectra from the left precentral gyrus and from the left cuneus gyrus were analyzed with the LCModel method, yielding concentrations for N-acetyl (NA), total creatine (Cr), choline (Cho), glutamate (Glu), glutamine (Gin), and myo-inositol (Ins) metabolic substrates. Signal intensities of the precentral gyrus on T2-weighted images were assessed qualitatively in a blinded fashion. RESULTS: For the precentral gyrus, mean Cho (1.3 mM) and Ins (3.25 mM) for the ALS group were significantly increased. After adjustment for Cr covariance, mean Glu (5.08 mM) and NA (6.31 mM) were decreased. For the cuneus gyrus, no difference in metabolite concentrations between groups was observed. Trend analysis of the precentral gyrus metabolite concentrations revealed significant increases in Cho and Ins and decreases in NA and Glu with respect to the severity of clinical UMN signs. Metabolic changes were greater in the subset of ALS patients with precentral gyrus signal changes on imaging, and significantly increased Ins was associated with cortical hypointensity on fast spin-echo images. CONCLUSION: Mean metabolite concentrations determined from precentral gyrus spectra reflect clinical and pathologic changes that occur in ALS. Imaging findings, while related to the spectral and clinical results, are not specific to ALS.

1H-magnetic resonance spectroscopy in amyotrophic lateral sclerosis.

1H-magnetic resonance spectroscopy (MRS) is potentially a powerful tool for the investigation of the chemicals of the brain in vivo in health and disease. Levels of N-acetyl-aspartate (NAA) in the motor cortex and brainstem of patients with amyotrophic lateral sclerosis (ALS) have been reported to be reduced by up to 68%, and in one report the level of glutamate in the brainstem was increased by 58%. We studied levels of metabolites in the cerebral cortex and brainstem of 20 ALS patients and 14 age-matched controls with a 1.5 Tesla Picker magnet using MRS. We used the same spectra for determining both the area of the metabolite peaks expressed as a ratio of the area of the creatine (Cr) peak, and the absolute concentrations using the Provencher LC model. These produced different results. With the LC model, the NAA content of the motor cortex of ALS patients was reduced by 7.7% (P=0.015), and that of the brainstem was reduced by 21.5% (P=0.035), compared with controls. The degree of reduction of NAA was related to the severity of upper motor neuron abnormalities. No effect of treatment with anti-glutamate agents on NAA concentration could be detected. Concentrations of other metabolites were not affected in ALS. It appears that MRS is a technique that is still in development, and that further refinement is required before it can be used to understand disease mechanisms and investigate treatment in ALS.

Diffusion-weighted MR imaging in a rat model of syringomyelia after excitotoxic spinal cord injury.

BACKGROUND AND PURPOSE: Recent experimental data have shown that an increase of excitatory amino acids and the initiation of inflammatory responses within the injured spinal cord may play a role in post-traumatic syringomyelia. The purpose of this study was to determine whether diffusion-weighted MR imaging with apparent diffusion coefficient (ADC) maps could provide earlier evidence of spinal cord cavitation in a rat model of syringomyelia than available with conventional MR imaging. METHODS: The spinal cord gray matter of four rats was injected with the alpha-amino-3 hydroxy-5 methyl-4 isoxazole propionic acid/metabotropic receptor agonist quisqualic acid. Animals were sacrificed at 1, 4, or 8 weeks after injection, and the spinal cords were fixed in formalin for 1 week and imaged with T1-, T2-, and diffusion-weighted sequences. One control specimen was also imaged. ADC maps were constructed from the diffusion-weighted data. Histopathologic analyses of sections stained with cresyl violet were compared with the MR images. RESULTS: By 1 week after injection, ADC maps at the level of injection showed areas within the gray matter of increased intensity and increased ADC values as compared with the control specimen. These bright areas corresponded to cysts or cavities within the cord parenchyma on the histopathologic sections. The ADC values within affected gray matter areas progressively increased at 4 and 8 weeks, also corresponding to cyst formation. Conventional T1- and T2-weighted images showed corresponding lesions with cystic characteristics at 4 and 8 weeks, but not at 1 week. CONCLUSION: In an animal model of syringomyelia, diffusion-weighted imaging with ADC maps detected cystic lesions within spinal cord gray matter before they were seen on conventional T1- and T2-weighted images.

Vascular anatomy and disorders of the lumbar spine and spinal cord.

The design and interpretation of MR imaging studies of patients with suspected spinal vascular disease are based on a knowledge of arterial and venous anatomy. This article describes the major intradural vessels and their appearance on spin-echo MR images and gadolinium-enhanced MR angiography. Current gadolinium-enhanced MR techniques primarily detect veins, which may be increased in apparent number, size, or tortuosity in the pathological conditions discussed. These characteristics of abnormal veins have yet to be quantified, and differentiation between normal and abnormal is sometimes difficult. Familiarity with the appearance of normal veins on MR angiography facilitates recognition of abnormal vessels and thus the formulation of a more accurate differential diagnosis in the patient with a conus or cauda equina lesion. In the future, gadolinium-enhanced 3D MR angiography may achieve adequate spatial and temporal resolution to differentiate spinal arteries from spinal veins. This differentiation could further simplify the diagnosis of vascular lesions, depending or the complexity of the vascular pattern observed. Also, the combination of MR angiography and diffusion imaging of the cord may finally provide the information needed for characterization by MR imaging of clinically suspected arterial infarction.

Fatigue-induced changes in bioprosthetic heart valve three-dimensional geometry and the relation to tissue damage.

BACKGROUND AND AIM OF THE STUDY: In a previous study, we used magnetic resonance (MR) imaging to reconstruct, three-dimensionally, porcine bioprosthetic heart valve (PBHV) cusp geometry. Initial results using three valves indicated that accelerated testing induced changes in cuspal shape, including focal regions of high curvature. Since for thin-walled shell structures, such as the PBHV cusp, curvature changes can affect the stress distribution independently from changes to mechanical properties, shape changes might have adverse effects on PBHV durability. METHODS: The MR technique was applied to an expanded valve database to explore more fully shape change with fatigue. The spatial curvature distribution was compared across valves subjected to a range of accelerated test times. RESULTS: Results confirmed our initial findings that PBHV cusps undergo a continuous, non-recoverable deformation with accelerated testing. This deformation resulted in an increase in the portion of cuspal surface exhibiting high curvature values. In one cusp we mapped structural information obtained by small-angle light scattering back to the three-dimensional cuspal surface using an interpolation technique. Results from the mapped cusp demonstrated a strong spatial correlation between elevated curvatures and structural damage. CONCLUSIONS: The observed changes in cuspal shape accelerate PBHV damage due to an increase in flexural strains induced by an increase in curvature reversal during operation, rather than an increase in tension during closure.

Diffusion-weighted magnetic resonance imaging confirms marked neuroprotective efficacy of albumin therapy in focal cerebral ischemia.

BACKGROUND AND PURPOSE: We have recently shown high-dose human serum albumin therapy to confer marked histological protection in experimental middle cerebral artery occlusion (MCAo). We have now used diffusion-weighted magnetic resonance imaging (DWI) in conjunction with morphological methods to expand our understanding of this therapeutic approach. METHODS: Physiologically controlled Sprague-Dawley rats received 2-hour MCAo by the modified intraluminal suture method. Treated rats received 25% human serum albumin solution (1% by body weight) immediately after the MCA was reopened. Vehicle-treated rats received saline. Computer-based image averaging was used to analyze DWI data obtained 24 hours after MCAo and light-microscopic histopathology obtained at 3 days. In a matched series, plasma osmolality and colloid oncotic pressure, as well as brain water content, were determined. RESULTS: Albumin therapy, which lowered the hematocrit on average by 37% and raised plasma colloid oncotic pressure by 56%, improved the neurological score throughout the 3-day survival period. Within the ischemic focus, the apparent diffusion coefficient (ADC) computed from DWI data declined by 40% in vehicle-treated rats but was preserved at near-normal levels (8% decline) in albumin-treated rats (P<0.001). Albumin also led to higher ADC values within unlesioned brain regions. Histology revealed large consistent cortical and subcortical infarcts in vehicle-treated rats, while albumin therapy reduced infarct volume at these sites, on average, by 84% and 33%, respectively. Total infarct volume was reduced by 66% and brain swelling was virtually eliminated by albumin treatment. Microscopically, while infarcted regions of vehicle-treated rats had the typical changes of pannecrosis, infarcted zones of albumin-treated brains showed persistence of vascular endothelium and prominent microglial activation, suggesting that albumin therapy may help to preserve the neuropil within zones of residual infarction. CONCLUSIONS: These findings confirm the striking neuroprotective efficacy of albumin therapy in focal cerebral ischemia and reveal that this effect is associated with DWI normalization and a mitigation of pannecrotic changes within zones of residual injury.

Detection of suspected malignant patterns in three-dimensional magnetic resonance breast images.

In this article, a Boolean Neural Network (BNN) is used for the detection of suspected malignant regions in 3D breast magnetic resonance (MR) images. The BNN is characterized by fast learning and classification, guaranteed convergence, and simple, integer weight calculations. The BNN learning algorithm is incremental, which allows the addition and deletion of training patterns without unlearning those already learned. The incremental learning algorithm automatically reduces the training set and trains the network only with those examples estimated to be useful. The architecture is suitable for parallel hardware implementation using available Very Large Scale Integration (VLSI) technology. The BNN was trained by using a set of malignant, benign, and false-positive patterns, extracted by experts, from selected MR studies, by using an incremental learning algorithm. After training, the network was tested by means of a consistency checking test, cross validation techniques, and patterns from actual MR breast images. During the consistency test, the BNN was tested by using the same patterns used for training. The BNN classification accuracy in this case was 99.75%, proving the ability of the BNN to select useful patterns from the training set. Then, a leave one out cross-validation (LOOCV) test was done by using patterns from the training set and the classification accuracy was 90%. Next, an extended training set was created by shifting the original patterns in different directions. A cross-validation test was then performed by dividing the set of patterns into a training and a test set. Classification accuracy was compared to the nearest neighbor classifier. Results showed that the BNN achieved an average of 77% classification accuracy while requiring only 34% of the original training set. On the other hand, the nearest neighbor classifier achieved an accuracy of 57.9% while retaining the whole training set. Another test using actual MR slices different from the training set was done and results compared favorably to a radiologist's findings. Test results show the BNN's capability to detect suspected malignant regions in 3D MR images of the breast. The proposed BNN architecture can save the radiologist a great deal of time browsing MR slices searching for suspected malignancies.

MR angiography of the spine.

Postcontrast MR angiography complements the standard spinal MR imaging study by improving detection and display of normal and abnormal intradural vessels, primarily veins. Detection of abnormal veins facilitates diagnosis of spinal vascular malformations and vascular tumors. The most useful application has been in screening for spinal dural arteriovenous fistula, in which MR angiography demonstrates the medullary vein into which the fistula drains, thus allowing noninvasive identification of the spinal level of the fistula.

High-resolution magnetic resonance imaging to characterize the geometry of fatigued porcine bioprosthetic heart valves.

BACKGROUND AND AIMS OF THE STUDY: Porcine bioprosthetic heart valves (PBHV) continue to suffer from limited long-term durability. Failure of PBHV occurs mainly in the cusps and is characterized by mechanical damage, usually in conjunction with calcification. Mechanisms underlying calcification have received considerable attention, yet mechanical damage phenomena remain poorly understood. The structural response of PBHV cusps to in-vivo cyclic loading involves three primary factors: (i) mechanical properties; (ii) fiber architecture; and (iii) 3D geometry. Previous finite element studies have shown cuspal stress distribution to be highly sensitive to subtle changes in geometry, yet to date, cusp geometry has been largely ignored in studies of PBHV durability. METHODS: A non-destructive method was developed to quantify PBHV 3D geometry using high-resolution magnetic resonance (MR) imaging. Images were obtained in three orthogonal planes from virgin and accelerated tested (50 x 10(6) and 200 x 10(6) cycles) PBHVs to fully capture 3D cuspal geometry. Surface curvatures were computed using a local biquadric surface patch approach. RESULTS: Results indicated a tendency for cusps to permanently deform with accelerated testing, manifesting primarily as sagging of the cusp. This sagging induced areas of high curvature from the central belly region upwards to the nodulus of Aranti, corresponding to known locations of tissue failure. CONCLUSIONS: It is likely that the observed changes in cuspal geometry induce deleterious alterations in the stress distribution, independent of those related to mechanical properties and fiber structure, and contribute to valve failure. Our results suggest that PBHV designers should attempt to compensate for the deleterious geometric changes that occur post-implantation.

High-resolution diffusion-weighted MR of fresh and fixed cat spinal cords: evaluation of diffusion coefficients and anisotropy.

PURPOSE: To use high-resolution diffusion-weighted and calculated apparent diffusion coefficient (ADC) MR imaging to determine whether fixation and storage influence diffusion anisotropy in white matter tracts of cat spinal cord specimens. METHODS: Four cat cord specimens were imaged using a diffusion-weighted spin-echo sequence. Diffusion encoding was applied in the section-select axis (parallel to white matter tracts) and in the read axis (perpendicular to white matter tracts). Five sets of axial diffusion-weighted images were acquired with b values ranging from 0 to 800 s/mm2 and used to obtain calculated ADC images and to determine diffusion coefficients in different regions of the white matter tracts. RESULTS: After cord fixation, a decrease in T2 relaxation and spin density in the white matter caused the signal intensity to appear similar on diffusion-weighted images when the diffusion-probing gradient was applied along both the section-select and read axes. On the calculated ADC images, however, distinct differences in signal intensities were seen in the section-select and read axes. CONCLUSION: Although there is little difference in signal intensity in the white matter tracts on diffusion-weighted images when diffusion encoding is applied in the section-select or read axis in the fixed specimens, calculated ADC images confirm that diffusion anisotropy is maintained. Therefore, calculated ADC images may be helpful in the evaluation of fixed spinal cord specimens.

Spine MR angiography.

The use of MR angiography to evaluate spinal vessels is in an early stage of development. Both time-of-flight (3D) and phase-contrast (2D and 3D) techniques have been applied, and for both types of techniques, the vessels are best visualized following intravenous gadolinium administration. The vessels of interest are the millimeter-sized intradural arteries and veins, which are located on the cord surface and travel from the cord to the epidural space. Only the post gadolinium 3D TOF technique has been shown to display normal intradural vessels (thoracolumbar region), principally veins. Both TOF and PC techniques provide better delineation of enlarged intradural vessels associated with spinal vascular malformations than standard MR imaging alone. PC techniques are much less sensitive in detecting the arterial supply to dural arteriovenous fistula than intramedullary arteriovenous malformation. The TOF technique can predict the foraminal level of a dural fistula when an enlarged medullary vein, resulting from retrograde drainage, is present. MR angiography, in conjunction with MR imaging, is now suggested for screening of suspected spinal vascular malformation. Other applications such as vascular tumors and arterial or venous occlusive disease are under investigation.

Muscle fiber hypertrophy, hyperplasia, and capillary density in college men after resistance training.

Twelve male subjects with recreational resistance training backgrounds completed 12 wk of intensified resistance training (3 sessions/wk; 8 exercises/session; 3 sets/exercise; 10 repetitions maximum/set). All major muscle groups were trained, with four exercises emphasizing the forearm flexors. After training, strength (1-repetition maximum preacher curl) increased by 25% (P < 0.05). Magnetic resonance imaging scans revealed an increase in the biceps brachii muscle cross-sectional area (CSA) (from 11.8 +/- 2.7 to 13.3 +/- 2.6 cm2; n = 8; P < 0.05). Muscle biopsies of the biceps brachii revealed increases (P < 0.05) in fiber areas for type I (from 4,196 +/- 859 to 4,617 +/- 1,116 microns2; n = 11) and II fibers (from 6,378 +/- 1,552 to 7,474 +/- 2,017 microns2; n = 11). Fiber number estimated from the above measurements did not change after training (293.2 +/- 61.5 x 10(3) pretraining; 297.5 +/- 69.5 x 10(3) posttraining; n = 8). However, the magnitude of muscle fiber hypertrophy may influence this response because those subjects with less relative muscle fiber hypertrophy, but similar increases in muscle CSA, showed evidence of an increase in fiber number. Capillaries per fiber increased significantly (P < 0.05) for both type I (from 4.9 +/- 0.6 to 5.5 +/- 0.7; n = 10) and II fibers (from 5.1 +/- 0.8 to 6.2 +/- 0.7; n = 10). No changes occurred in capillaries per fiber area or muscle area. In conclusion, resistance training resulted in hypertrophy of the total muscle CSA and fiber areas with no change in estimated fiber number, whereas capillary changes were proportional to muscle fiber growth.

MR angiography of normal intradural vessels of the thoracolumbar spine.

PURPOSE: To identify and describe the normal intradural vessels detected on MR angiograms of the thoracolumbar spine. METHODS: Six adult subjects who had clinical evidence of myelopathy, yet normal findings at spinal digital subtraction angiography (DSA), were also studied without and with contrast-enhanced MR imaging and three-dimensional time-of-flight, single-slab MR angiography. Sagittal and coronal subvolume (targeted) maximum intensity projection images were compared with arterial and venous phase DSA images. Angiographic images were then compared with postmortem, formalin-fixed cord specimens. RESULTS: Recognizable intradural vessels were detected only on contrast-enhanced MR angiograms. These vessels corresponded to the posterior and/or anterior median (midline) veins and the great medullary veins. The median veins had variable but mild tortuosity. The medullary veins, which extended from the median veins and coronal venous plexus on the cord surface to the epidural venous plexus, were relatively straight and usually located at T-12 or L-1. The anterior spinal artery could partially contribute to the anterior midline vascular signal. CONCLUSION: The intradural vessels identified on contrast-enhanced MR angiograms are primarily veins, and these are usually the largest vessels on or near the cord surface. The limited number and minimal tortuosity of these veins may serve as a baseline for the examination of patients with clinically suspected arteriovenous malformation or fistula.

Spinal dural arteriovenous fistulas: evaluation with MR angiography.

PURPOSE: To show that postgadolinium three-dimensional time-of-flight MR angiography shows abnormal intradural vessels associated with spinal dural arteriovenous fistula better than routine MR imaging and provides screening information useful for subsequent diagnostic conventional angiography and/or posttreatment evaluation. METHODS: Precontrast and postcontrast MR imaging and MR angiograms, as well as subsequent digital subtraction angiograms, were obtained for eight patients with dural arteriovenous fistulas, diagnosed with digital subtraction angiography and verified with surgery. In four patients, MR studies also were obtained after surgery. RESULTS: All patients had cord hyperintensity of T2-weighted images and postgadolinium enhancement on T1-weighted images. Five had vessellike signal abnormalities in the subarachnoid space on MR. Abnormal intradural vessels were detected in all eight patients with MR angiography. Comparison with digital subtraction angiography revealed these vessels to be primarily enlarged veins of the coronal venous plexus on the cord surface. In six patients, the medullary vein draining the fistula was demonstrated, indicating the level of the fistula, later identified by digital subtraction angiography. After surgical obliteration of the fistula, the draining medullary vein and most or all of the abnormal coronal veins were no longer demonstrated, with decrease or resolution of cord hyperintensity on T2-weighted images. CONCLUSION: Postgadolinium, spinal MR angiography in cases of suspected dural arteriovenous fistula provides information about intradural veins that supplements the diagnostic value of the MR imaging results, facilitates the subsequent digital subtraction angiography study, and, in treated cases, reflects the success of surgery and/or embolization.

Proton MR spectroscopy of the brain in 14 patients with Parkinson disease.

PURPOSE: To determine whether the proton spectra from patients with clinically diagnosed Parkinson disease differ from the spectra of age-matched healthy subjects with respect to the major cerebral metabolite resonances as well as lactate. METHODS: Fourteen patients with Parkinson disease (38 to 81 years of age) and 13 healthy control subjects (37 to 81 years of age) were studied using image-guided, single-voxel (27-cm3 volume) proton MR spectroscopy of the occipital lobe. RESULTS: The peak area ratios of N-acetyl aspartate to creatine and N-acetyl aspartate to choline for Parkinson patients did not show a statistically significant difference from the corresponding ratios for control subjects. There was a very significant increase in the ratio of lactate to N-acetyl aspartate for patients with Parkinson disease, with the greatest increase (threefold) manifested by the subgroup (n = 4) with dementia. The difference in N-acetyl aspartate to choline between women (n = 7) with Parkinson disease and healthy women (n = 9) approached significance. No dependence of the peak ratios on age, duration of Parkinson disease, or medication (L-dopa) regimen was found. CONCLUSION: Preliminary results indicating an increase in cerebral lactate in patients with Parkinson disease support the hypothesis that Parkinson disease is a systemic disorder characterized by an impairment of oxidative energy metabolism. The larger increases for Parkinson patients with dementia may be diagnostically useful in assessing clinical course and in differentiating Parkinson disease from other causes of dementia. Additional studies are needed, though, to quantitate lactate changes and identify potential contributions from lipid resonances better.