[Detection of subclinical and overt hepatic encephalopathy and treatment control after L-ornithine-L-aspartate medication by magnetic resonance spectroscopy ((1)H-MRS)]. / Detektion und Therapieverlaufskontrolle der subklinischen und manifesten hepatischen Enzephalopathie nach Behandlung mittels L-Ornithin-L-Aspartat durch Protonen-Magnetresonanzspektroskopie ((1)H-MRS).

Hepatic encephalopathy (HE) is a common problem in liver cirrhosis and is associated with typical changes of cerebral metabolite pattern observed by proton magnetic resonance spectroscopy (MRS). In HE, a reduction of the cerebral myo-inositol (mI) and choline (Cho) and an increase of glutamine/glutamate (Glx) can typically be detected with this method. In the present study MRS was used to assess prospectively specific parameters of cerebral metabolism before and after 6 days of treatment with a low-protein diet and with L-ornithine-L-aspartate (LOLA). 6 patients with liver cirrhosis were included in this pilot study. According to standardized neuropsychological tests overt HE or subclinical HE was detected in all patients. All patients received a low-protein diet (< 60 g/d) and were treated additionally with LOLA (20 g QD i. v.). MRS examinations were done before and after 6 days of treatment and the results were compared with those of healthy volunteers. Before treatment mI/Cr ratios in the grey matter were reduced significantly in cirrhotic patients as compared to healthy volunteers (0.30 +/- 0.22 vs. 0.68 +/- 0.11; P = 0.028). In addition, patients showed a (non-significant) reduction of the Cho/Cr-ratio (0.19 +/- 0.03 vs. 0.25 +/- 0.02; P = 0.17) and an elevated Glx/Cr-ratio (1.84 +/- 0.63 vs. 1.29 +/- 0.31; P = 0.05). After 6 days of treatment a significant increase of the Cho/Cr ratio (0.23 +/- 0.03 vs. 0.19 +/- 0.03; P = 0.028) was detectable and 5 of the 6 patients showed a (not significant) decrease of the elevated Glx/Cr ratios. After cessation of treatment an improvement in neuropsychological tests as shown by number-connection testing (P = 0.046) as well as a decrease of elevated pre-treatment ammonia blood levels were noted. These findings, however, did not correlate with the Child-Pugh classification or evidence of clinical/subclinical HE. Using (1)H-MRS it is possible to observe a specific pattern of cerebral metabolites in patients with overt and subclinical HE. In this pilot study a fast change of cerebral metabolite pattern after specific therapy of HE with LOLA was detected. Therefore, future studies with larger patient groups are needed to establish (1)H-MRS as an objective method for detection and treatment control in overt and subclinical HE, especially when compared to commonly used parameters such as ammonia levels or standardized neuropsychological tests.

Proton MR spectroscopy in succinic semialdehyde dehydrogenase deficiency.

Succinic semialdehyde dehydrogenase (SSADH) deficiency is a rare hereditary disorder of the CNS catabolism of gamma-aminobutyric acid (GABA), leading to accumulation of the metabolite 4-hydroxybutyrate (GHB). Here the authors report on 1.5 and 3.0 T proton MR spectroscopy in a patient with SSADH deficiency. A characteristic pattern with clearly elevated GABA levels and traces of GHB was found in both the white and the gray matter of the brain. In vivo spectroscopy may be useful for diagnosis and monitoring SSADH deficiency.

Proton MR spectroscopy reveals lactate in infantile neuroaxonal dystrophy (INAD).

Changes of cerebral metabolites detected by proton MR spectroscopy in two cases of infantile neuroaxonal dystrophy are described. A 6 11/12-year-old boy and a girl (aged 4 1/12 years at the first and 5 2/12 years at the second examination) with infantile neuroaxonal dystrophy were investigated by magnetic resonance imaging and spectroscopy of the basal ganglia. The signal intensity of the cerebellar cortex was increased on T2-weighted, proton density, and fluid attenuated inversion recovery images. The long echo time (135 ms) spectra revealed the presence of lactate in the basal ganglia of both cases in all investigations. The N-acetylaspartate/creatine ratio was reduced in Case 1 and in the second investigation of Case 2. The choline/creatine ratio was always increased. As the diagnosis of infantile neuroaxonal dystrophy is made by a synopsis of various clinical, neuropathological, neurophysiological, and neuroradiological data, the presence of lactate in the basal ganglia spectra may help to narrow down the diagnosis and can support the decision to perform more invasive diagnostic procedures (such as biopsies of skin, conjunctiva or even of the brain).

Proton MR spectroscopy with metabolite-nulling reveals elevated macromolecules in acute multiple sclerosis.

Proton magnetic resonance spectroscopy has shown elevated signals in the spectral region of lipids in acute multiple sclerosis lesions. The metabolite-nulling technique allows the separation of macromolecules from other metabolites, such as lactate, N-acetyl-aspartate, creatine, choline and myo-inositol. Using this technique in studies on multiple sclerosis patients, we were able to differentiate macromolecules biochemically in acute and chronic multiple sclerosis lesions. Ten patients with acute, contrast-enhancing multiple sclerosis lesions, 10 patients with chronic lesions and 10 healthy control subjects were investigated with a 1.5 T whole body system, using a stimulated echo acquisition mode (STEAM) sequence with metabolite-nulling and outer volume saturation. Metabolites and macromolecules were quantitated absolutely. The 0.9 and 1.3 parts per million (p.p.m.) resonances of the macromolecules were significantly elevated in acute lesions compared with chronic lesions and healthy controls (P < 0.001 for 0.9 p.p.m., P < 0.05 for 1.3 p.p.m.). The macromolecular resonances at 2.1 and 3.0 p.p.m. in acute and chronic lesions were normal. N-acetyl-aspartate was significantly reduced in acute and chronic lesions compared with controls (P < 0.05 and P < 0.01, respectively). Choline was significantly elevated in acute lesions compared with controls (P < 0.05). Up to now, elevated resonances at 0.9 and 1.3 p.p.m. in acute lesions have been interpreted as lipids. In metabolite-nulled spectra, the macromolecular resonances did not fit those of lipids and might have been due to proteins or polypeptides containing the amino acids alanine, threonine, valine, leucine and isoleucine. These account for approximately 40% of the amino acids of myelin proteolipid protein and for approximately 20% of myelin basic protein. The increased macromolecular resonances at 0.9 and 1.3 p.p.m. may be interpreted as biochemical markers of myelin fragments and may be used as reliable markers of acute multiple sclerosis lesions as they provide clear discrimination among acute and chronic lesions and controls.

Reliable detection of macromolecules in single-volume 1H NMR spectra of the human brain.

In short echo time proton MR spectra of the brain, resonances from macromolecules are visible. The macromolecular resonances in the 0.5-2.0 ppm region can be affected by lipid contamination arising from fat-containing regions outside the selected volume of interest (VOI). This study demonstrates that considerable lipid contamination may remain in stimulated echo acquisition mode (STEAM) spectra even if the spoiling of unwanted coherences is sufficient and the VOI is placed 2 cm or more away from fat-containing regions. The observed contamination was attributed to residual remote out-of-volume excitation, although only very small out-of-slice ripples of less than 0.2% of the in-slice excitation were found in the calculated excitation profile of the RF pulses. Spatial presaturation of fat-containing regions led to a sufficient suppression of the contamination and enabled the detection of highly reproducible macromolecular resonances. Thus, in single-volume spectroscopy as well as in spectroscopic imaging (SI or CSI), the combination of volume selection and outer volume presaturation, each in three dimensions, is highly recommended to ensure accurate detection and reliable evaluation of even small pathological alterations in macromolecules, e.g., proteins or lipids, or other resonances in the 0.5-2.0 ppm region.

MR imaging and (1)H spectroscopy of brain metabolites in hepatic encephalopathy: time-course of renormalization after liver transplantation.

PURPOSE: To evaluate changes in hydrogen 1 magnetic resonance (MR) spectroscopic findings in overt or subclinical hepatic encephalopathy (HE) after liver transplantation and to compare these changes with clinical outcomes and basal ganglia high signal intensity (BGH). MATERIALS AND METHODS: Twenty-two patients scheduled for liver transplantation and 17 healthy control subjects were examined with (1)H MR spectroscopy and standard nonenhanced MR imaging. Eight patients underwent complete MR imaging and (1)H spectroscopic examinations before liver transplantation and at 3-4-week, 12-28-week, and 10-12-month follow-up after liver transplantation. RESULTS: Before liver transplantation, typical (1)H spectroscopic changes-decreased myo-inositol (mI)/creatine (Cr) and choline (Cho)/Cr ratios and an elevated glutamine and glutamate (Glx)/Cr ratio-were found in 21 patients. Eighteen patients had BGH at T1-weighted imaging. Three to 7 months after liver transplantation, the mI/Cr and Glx/Cr ratios were within the normal range in five of eight and eight of eight patients, respectively, without any residual signs of subclinical or overt HE; however, at MR imaging, seven patients still had BGH. CONCLUSION: After successful liver transplantation, renormalization of HE-specific brain metabolite changes is detected at (1)H spectroscopy and precedes the disappearance of BGH. The neuropsychologic signs of subclinical or overt HE follow the changes seen at (1)H spectroscopy rather than those seen at MR imaging.

Elimination of residual lipid contamination in single volume proton MR spectra of human brain.

Short echo time 1H NMR spectra of the human brain reveal signals from various metabolites. In addition, resonances from macromolecules are present that may provide further useful information in several brain diseases. The detection of all these signals is possible if excellent volume selection is obtained; even small lipid contamination from surrounding fat tissue leads to strong spectral contamination. It affects the macromolecule resonances in the 0.5 to 2.0 ppm region and some adjacent metabolite signals and jeopardizes their quantitative analysis. This paper demonstrates how spatial contamination from insufficiently dephased signals can be recognized, analysed, and removed in localized STEAM spectroscopy of the brain.

[MR proton spectroscopy to monitor the concentration changes in cerebral metabolites following a TIPS placement]. / MR-Protonenspektroskopie zur Verlaufsbeurteilung von Konzentrationsänderungen zerebraler Metaboliten nach TIPS-Anlage.

BACKGROUND AND AIMS: In chronic liver dysfunction with portal hypertension the risk of variceal bleeding can be lowered by intrahepatic portosystemic shunting (TIPS). Although less pronounced than in surgical shunting, hepatic encephalopathy (HE) is a well-known undesired side effect. In cerebral proton MR spectroscopy (MRS), HE can be detected by a specific pattern of brain metabolite changes (increase of glutamine/glutamate (Glx) and decrease of myo-inositol (ml) and choline (Cho)). The aim of this study was to examine whether, after TIPS implantation, there is a correlation of the reduction of the portosystemic pressure gradient (PSPG) and the cerebral metabolite changes and their correspondence to the clinical status. METHODS: We examined 10 cirrhotic patients (Child B, C) before and 3-20 days after TIPS implantation. Clinical examination was performed by a senior hepatologist. Localized MR spectra were acquired in parieto-occipital gray/white matter using a short echo time (TE = 5 ms) STEAM sequence. RESULTS: After TIPS we found an increase of Glx/(Cr + PCr) of 13%-40% and a decrease of ml(Cr + PCr) of 6%-46% with a positive (Glx: r = 0.71) respectively negative (ml: r = -0.59) correlation to the reduction of the PSPG. 7/10 patients with a reduction of the PSPG of more than 9 mmHg (9-17 mmHg) showed a clinical impairment of their HE. CONCLUSIONS: Short echo time cerebral MRS allows detection of finest HE specific metabolite changes and can therefore contribute positively to an individually optimized reduction of the PSPG during TIPS implantation.

Localized proton magnetic resonance spectroscopy of the cerebellum in detoxifying alcoholics.

An increased daily alcohol consumption results in neurological symptoms and morphological central nervous system changes, e.g. shrinkage of the frontal lobes and the cerebellar vermis. Brain shrinkage can be due to neuronal loss, gliosis, or alterations of (cell) membrane constitutes/myelin. Neuronal, glial, and metabolic changes can be measured in vivo with proton magnetic resonance spectroscopy. A total of 11 alcoholics and 10 age-matched volunteers were examined by magnetic resonance imaging and localized magnetic resonance spectroscopy at an echo time of 135 and 5 msec. Peak integral values were calculated for N-acetylaspartate (NAA), choline (Cho), myo-inositol (ml), glutamate/glutamine (Glx), and normalized to phosphocreatine/creatine (Cr). Patients had a significant shrinkage of the cerebellar vermis. NAA/Cr and Cho/Cr ratios were reduced in both sequences, but the NAA/Cr reduction was only significant in long echo time, although the Cho/Cr reduction was significant in short echo time. The ml/Cr and Glx/Cr ratios did not show any significant difference between volunteers and patients. The decrease of NAA/Cr in alcohol dependent patients is consistent with neuronal loss. The Cho/Cr decrease and an unchanged ml/Cr may reflect cell membrane modification or myelin alterations in alcohol-dependent patients. These changes lead to brain shrinkage, although hydration effects and gliosis are less likely.

MR imaging and localized proton MR spectroscopy in late infantile neuronal ceroid lipofuscinosis.

PURPOSE: Late juvenile neuronal ceroid lipofuscinosis (NCL) is a lysosomal neurodegenerative disorder caused by the accumulation of lipopigment in neurons. Our purpose was to characterize the MR imaging and spectroscopic findings in three children with late infantile NCL. METHODS: Three children with late infantile NCL and three age-matched control subjects were examined by MR imaging and by localized MR spectroscopy using echo times of 135 and 5. Normalized peak integral values were calculated for N-acetylaspartate (NAA), choline, creatine, myo-inositol, and glutamate/glutamine. RESULTS: MR imaging revealed volume loss of the CNS, most prominently in the cerebellum. The T2-weighted images showed a hypointense thalamus and hyperintense periventricular white matter. Proton MR spectra revealed progressive changes, with a reduction of NAA and an increase of myo-inositol and glutamate/glutamine. In long-standing late infantile NCL, myo-inositol became the most prominent resonance. Lactate was not detectable. CONCLUSION: MR imaging in combination with proton MR spectroscopy can facilitate the diagnosis of late infantile NCL and help to differentiate NCL from other neurometabolic disorders, such as mitochondrial or peroxisomal encephalopathies.