Assessing Postconcussive Reaction Time Using Transport-Based Morphometry of Diffusion Tensor Images.

BACKGROUND AND PURPOSE: Cognitive deficits are among the most commonly reported post-concussive symptoms, yet the underlying microstructural injury is poorly understood. Our aim was to discover white matter injury underlying reaction time in mild traumatic brain injury DTI by applying transport-based morphometry. MATERIALS AND METHODS: In this retrospective study, we performed DTI on 64 postconcussive patients (10-28 years of age; 69% male, 31% female) between January 2006 and March 2013. We measured the reaction time percentile by using Immediate Post-Concussion Assessment and Cognitive Testing. Using the 3D transport-based morphometry technique we developed, we mined fractional anisotropy maps to extract the common microstructural injury associated with reaction time percentile in an automated manner. Permutation testing established statistical significance of the extracted injuries. We visualized the physical substrate responsible for reaction time through inverse transport-based morphometry transformation. RESULTS: The direction in the transport space most correlated with reaction time was significant after correcting for covariates of age, sex, and time from injury (Pearson r = 0.44, P < .01). Inverting the computed direction using transport-based morphometry illustrates physical shifts in fractional anisotropy in the corpus callosum (increase) and within the optic radiations, corticospinal tracts, and anterior thalamic radiations (decrease) with declining reaction time. The observed shifts are consistent with biologic pathways underlying the visual-spatial interpretation and response-selection aspects of reaction time. CONCLUSIONS: Transport-based morphometry discovers complex white matter injury underlying postconcussive reaction time in an automated manner. The potential influences of edema and axonal loss are visualized in the visual-spatial interpretation and response-selection pathways. Transport-based morphometry can bridge the gap between brain microstructure and function in diseases in which the structural basis is unknown.

Differences in Callosal and Forniceal Diffusion between Patients with and without Postconcussive Migraine.

BACKGROUND AND PURPOSE: Posttraumatic migraines are common after mild traumatic brain injury. The purpose of this study was to determine if a specific axonal injury pattern underlies posttraumatic migraines after mild traumatic brain injury utilizing Tract-Based Spatial Statistics analysis of diffusion tensor imaging. MATERIALS AND METHODS: DTI was performed in 58 patients with mild traumatic brain injury with posttraumatic migraines. Controls consisted of 17 patients with mild traumatic brain injury without posttraumatic migraines. Fractional anisotropy and diffusivity maps were generated to measure white matter integrity and were evaluated by using Tract-Based Spatial Statistics regression analysis with a general linear model. DTI findings were correlated with symptom severity, neurocognitive test scores, and time to recovery with the Pearson correlation coefficient. RESULTS: Patients with mild traumatic brain injury with posttraumatic migraines were not significantly different from controls in terms of age, sex, type of injury, or neurocognitive test performance. Patients with posttraumatic migraines had higher initial symptom severity (P = .01) than controls. Compared with controls, patients with mild traumatic brain injury with posttraumatic migraines had decreased fractional anisotropy in the corpus callosum (P = .03) and fornix/septohippocampal circuit (P = .045). Injury to the fornix/septohippocampal circuit correlated with decreased visual memory (r = 0.325, P = .01). Injury to corpus callosum trended toward inverse correlation with recovery (r = -0.260, P = .05). CONCLUSIONS: Injuries to the corpus callosum and fornix/septohippocampal circuit were seen in patients with mild traumatic brain injury with posttraumatic migraines, with injuries in the fornix/septohippocampal circuit correlating with decreased performance on neurocognitive testing.

Effect of the Suboccipital Musculature on Symptom Severity and Recovery after Mild Traumatic Brain Injury.

BACKGROUND AND PURPOSE: Neck musculature mass has been suggested as a biomechanical contributor to injury severity in mild traumatic brain injury. We sought to determine how the cross-sectional areas of the suboccipital muscles affect symptom severity, neurocognitive performance, and recovery time in patients with mild traumatic brain injury. MATERIALS AND METHODS: Sixty-four consecutive patients with mild traumatic brain injury underwent MR imaging and serial neurocognitive testing with the Immediate Post-Concussion Assessment and Cognitive Test. Cross-sectional areas of the rectus capitis posterior musculature were retrospectively obtained at C1, and cross-sectional areas of the remaining 7 suboccipital muscles were measured at C2. Cross-sectional area reproducibility was evaluated. Overall and individual muscle cross-sectional areas were correlated with symptom severity, neuropsychological testing, recovery time, and headache. RESULTS: Sixty-four patients with mild traumatic brain injury had imaging through C1, and 43 had imaging through C2. Reproducibility of cross-sectional area measurements was substantial (correlation coefficients = 0.9517-0.9891). Lower cross-sectional area of the rectus capitis posterior minor was correlated with greater symptom severity (r = 0.596, P < .0001), longer recovery time (r = 0.387, P = .002), poor verbal memory performance (r = 0.285, P = .02), and headache (r = 0.39, P = .001). None of the other cross-sectional areas were associated with symptom severity, recovery time, neurocognitive testing, or headache. CONCLUSIONS: In mild traumatic brain injury, the rectus capitis posterior minor is the only suboccipital muscle whose cross-sectional area is associated with symptom severity and worse outcome. Given the unique connection of this muscle to the dura, this finding may suggest that pathology of the myodural bridge contributes to symptomatology and prognosis in mild traumatic brain injury.

Qualitative and quantitative analysis of MR imaging findings in patients with middle cerebral artery stroke implanted with mesenchymal stem cells.

BACKGROUND AND PURPOSE: Mesenchymal stem cells have potential as a regenerative therapy in ischemic stroke. We sought to determine MR imaging findings after mesenchymal stem cell implantation in chronic middle cerebral artery infarcts and to compare brain volume changes in patients with mesenchymal stem cells with those in age-matched healthy controls and controls with chronic stable MCA infarcts. MATERIALS AND METHODS: We retrospectively identified 5 patients receiving surgical mesenchymal stem cell implantation to an MCA infarct from January 1, 2005, to July 1, 2013, with MR imaging immediately and 1 year postimplantation. Images at both time points were evaluated for any postimplantation complications. Structural image evaluation using normalization of atrophy software was used to determine volume changes between time points and compare them with those in healthy and age- and sex-matched controls with chronic, stable MCA infarcts by using Kruskal-Wallis and Mann-Whitney U tests. RESULTS: Susceptibility signal loss and enhancement at the implantation site were seen. No teratoma, tumor, or heterotopia was identified. Volumetric analysis showed a trend toward less overall volume loss after mesenchymal stem cell implantation (0.736; 95% CI, -4.15-5.62) compared with that in age- and sex-matched controls with chronic, stable MCA infarcts (-3.59; 95% CI, -12.3 to -5.21; P = .09), with a significantly greater growth-to-loss ratio in infarcted regions (1.30 and 0.78, respectively, P = .02). A trend toward correlation of growth-to-loss ratio with improvement in physical examination findings was seen (r = 0.856, P = .06). CONCLUSIONS: Postoperative changes consistent with stereotactic implantation were seen, but no teratoma, tumor, or heterotopia was identified. Initial findings suggest a trend toward less volume loss after mesenchymal stem cell implantation compared with that in age- and sex-matched controls with chronic, stable MCA infarcts, with a significantly greater growth-to-loss ratio in the infarcted tissue.

Evaluation of the intervertebral disk angle for the assessment of anterior cervical diskoligamentous injury.

BACKGROUND AND PURPOSE: The anterior diskoligamentous complex is important for cervical spinal stability. Subjective widening of the disk space after trauma has been used to gauge disruption of the anterior diskoligamentous complex on CT scanning, but no quantitative CT measurements exist to evaluate injury. The purpose of our study was to evaluate if an increased intervertebral disk angle could serve as a more sensitive, reproducible indicator of disruption of the anterior diskoligamentous complex compared with subjective assessment. MATERIALS AND METHODS: The intervertebral disk angle was retrospectively measured on CT scanning for 122 disk levels with disruption of the anterior diskoligamentous complex by MR imaging and 1095 disk levels with an intact anterior diskoligamentous complex by MR imaging. The intervertebral disk angle was measured between the anterior superior endplate and anterior inferior endplate, with angle apex at the midposterior disk. Area under the receiver operating characteristic curves for subjective disk widening and specific angle values were obtained. Intervertebral disk angle reproducibility was also evaluated. RESULTS: Intervertebral disk angle measurements were "substantially reproducible." No disk with an intact anterior diskoligamentous complex had an intervertebral disk angle greater than 18° or 2 standard deviations from the average intervertebral disk angle of the remaining disks. The area under the receiver operating characteristic curve for a criterion of subjective disk widening was 0.58. The area under the receiver operating characteristic curve for objective criteria, an intervertebral disk angle greater than 13 or above 1 standard deviation from normal values, was 0.85. The maximal area under the receiver operating characteristic curve was achieved if an intervertebral disk angle greater than 2 SD from the average angle of the other disks was used (0.86). CONCLUSIONS: Subjective disk widening does not accurately detect disruption of the anterior diskoligamentous complex on CT scanning; an elevated intervertebral disk angle provides a more sensitive and objective measurement to help direct further imaging in trauma patients.