Optimizing dynamic T2* MR imaging for measurement of cerebral blood flow using infusions for cerebral blood volume.

We describe an approach to measuring cerebral blood flow (CBF) based on independent measurements of cerebral blood volume (CBV) and mean transit time (MTT) with calculation of CBF by using the central volume theorem: CBF = CBV / MTT. This permits optimization of the individual acquisitions and analyses. In particular, measurement of CBV during contrast infusion, rather than simultaneously with MTT from a single bolus, yields values more consistent with those of other methods.

Cerebral blood volume measurements by T*2-weighted MRI and contrast infusion.

A reliable, accurate, and accessible method for measuring cerebral blood volume (CBV) has been developed based on T(*) (2)-weighted MRI and a 1-min infusion of gadolinium instead of a bolus. Computer simulations predict that this infusion CBV method will have a signal-to-noise ratio (SNR) 3-5 times greater than that obtained by area-under-the-curve (AUC) methods, with high accuracy over a wide range of arterial, tissue, and MRI conditions. In six healthy controls, the CBV was 1.87 +/- 0.44 in white matter (WM), 3.40 +/- 0.44 in deep gray matter (DGM), and 3.84 +/- 1.87 ml blood/100 g tissue in cortical GM (CGM). The mean GM/WM ratio was 1.94. In five patients with bilateral carotid disease, the corresponding values were 2.63 +/- 0.33, 4.72 +/- 0.33, and 5.27 +/- 2.40 ml blood/100 g tissue, all of which were significantly different from controls. AUC values were generally higher and failed to demonstrate differences between controls and patients. The infusion method shows great potential for providing reliable, accurate, and accessible CBV values with the ability to discriminate physiologic or pathological volume changes under a wide range of conditions.

Fluid-attenuated inversion recovery and diffusion- and perfusion-weighted MRI abnormalities in 117 consecutive patients with stroke symptoms.

BACKGROUND AND PURPOSE: Diffusion-weighted MRI (DWI) is highly sensitive to early cerebral ischemia, but its dependence on lesion location, acuity, and etiology remains unknown. Furthermore, although a marked perfusion-weighted MRI (PWI)-DWI mismatch may exist in a subset of acute strokes, the frequency and distribution of these mismatches have never been methodically characterized in an unselected population. To address these 2 issues, we evaluated echo-planar imaging in 117 consecutive patients with signs and symptoms of acute stroke. METHODS: Clinical diagnoses were determined by chart review. Fluid-attenuated inversion recovery (FLAIR), DWI, and PWI sequences were scored for lesion acuity, neuroanatomy, and vascular territory. Lesion and PWI-DWI mismatch volumes were determined by image analysis. RESULTS: DWI was more sensitive than was FLAIR for the detection of stroke for all subtypes in all anatomic distributions and at all tested time intervals. Although DWI exhibited its greatest benefit over FLAIR during the first 6 hours, it was still superior to FLAIR even after 24 hours. PWI abnormalities were detected in 49% of patients with DWI abnormalities. In the majority of these cases, the PWI-DWI mismatch was substantially larger than the DWI lesion itself. Both the largest DWI lesion volumes and the largest mismatch volumes occurred in patients with carotid disease. CONCLUSIONS: DWI nearly doubles the likelihood of detecting acute ischemic stroke lesions compared with FLAIR for all etiologies and in all anatomic locations. In the hyperacute period (0 to 6 hours), DWI more than triples the likelihood of acute-stroke detection over FLAIR. PWI reveals a measurable mismatch compared with DWI nearly 50% of the time; and in more than half of these patients, the ratio of the volume of the PWI lesion to the DWI lesion is several times larger than the core ischemic lesion itself. In the final analysis, approximately one fourth of all stroke patients present with a large volume of potentially salvageable tissue at risk for infarction.

A dose of 75 microg/kg/d of i.v. anti-D increases the platelet count more rapidly and for a longer period of time than 50 microg/kg/d in adults with immune thrombocytopenic purpura.

Treatment with 75 microg/kg/d intravenous (i.v.) anti-D was compared with 50 microg/kg/d in a prospective randomized study of 27 RhD-positive, human immunodeficiency virus-negative, adult, acute, non-splenectomized patients with immune thrombocytopenic purpura (ITP) and platelet counts < or = 30 x 109/l. The higher dose resulted in greater median d 1 (43 x 109/l vs. 7.5 x 109/l; P = 0.012) and d 7 (153 x 109/l vs. 64.5 x 109/l; P = 0.001) platelet increases despite no greater haemoglobin decrease. Children with acute ITP receiving 75 microg/kg/d had overnight platelet increases in seven out of nine cases. The duration of effect at the 75 microg/kg/d dose was 46 d vs. 21 d (P = 0.03). Adverse events were mild to moderate and ameliorated with prednisone and acetaminophen premedication.

Diffusion- and perfusion-weighted MR imaging of dural sinus thrombosis.

A patient with dural sinus thrombosis had progressively worsening symptoms and signs that resolved after intradural thrombolysis. Intradural sinus pressures were 54 mm Hg. Echo-planar MR imaging revealed complex abnormalities of diffusion and widespread delay in mean transit time that improved immediately after thrombolysis. This case suggests that diffusion- and perfusion-weighted imaging can provide valuable information noninvasively to help triage patients with dural sinus thrombosis between conservative and aggressive management.

Novel distal occluder washout method for prevention of no-reflow during stenting of saphenous vein grafts.

This study assessed safety of the distal occlusion washout (DOW) method for prevention of no-reflow during stenting of degenerated saphenous vein grafts (SVGs). The DOW method involves protection of distal native coronary circulation with an occlusive balloon during the pretreatment and washout steps prior to stenting. Outcomes of stenting of 23 grafts in 21 patients after pretreatment with the DOW method were evaluated. The mean graft age was 7.4 +/- 4.3 years. The mean treated lesion length was 53 +/- 28 mm. Total occlusions were treated in 6 grafts and thrombotic lesions in 10 nontotally occluded grafts. One non-Q-wave MI and one acute stent thrombosis were observed. No deaths, Q-wave MIs, or subacute thromboses occurred. Follow-up in 18/21 (85.7%) patients at 28 +/- 8 weeks demonstrated target graft revascularization in 1 (5%) patient. The DOW method prevented clinically significant no-reflow in all 23 degenerated SVGs stented.

Can experimental conditions explain the discrepancy over glutamate stimulation of aerobic glycolysis?

Uncertainty reigns over whether or not glutamate uptake in astrocytes leads to strong stimulation of glucose utilization, measured as accumulation of radioactive deoxyglucose-6-phosphate. This is an important issue, not only because glutamate is the major excitatory transmitter, but also because it has been postulated that glutamate-induced stimulation of glycolysis links brain excitation with activation of energy production. The effect of glutamate on deoxyglucose utilization in cultured rat and mouse astrocytes grown in different media and incubated under various conditions during the deoxyglucose assay has, therefore, been studied. Under most conditions, no stimulation occurred but rather a decrease in deoxyglucose utilization during exposure to glutamate; under certain conditions, the contribution of non-metabolized deoxyglucose to the intracellular 14C signal was significant.

Diffusion of radiotracers in normal and ischemic brain slices.

Diffusion in the extracellular space (ECS) is important in physiologic and pathologic brain processes but remains poorly understood. To learn more about factors influencing tissue diffusion and the role of diffusion in solute-tissue interactions, particularly during cerebral ischemia, we have studied the kinetics of several radiotracers in control and hypoxic 450-microm hippocampal slices and in 1,050-microm thick slices that model the ischemic penumbra. Kinetics were analyzed by nonlinear least squares methods using models that combine extracellular diffusion with tissue compartments in series or in parallel. Studies with 14C-polyethylene glycol confirmed prior measurements of extracellular volume and that ECS shrinks during ischemia. Separating diffusion from transport also revealed large amounts of 45Ca that bind to or enter brain as well as demonstrating a small, irreversibly bound compartment during ischemia. The rapidity of 3H2O entry into cells made it impossible for us to distinguish intracellular from extracellular diffusion. The diffusion-compartment analysis of 3-O-methylglucose data appears to indicate that 5 mmol/L glucose is inadequate to support glycolysis fully in thick slices. Unexpectedly, the diffusion coefficient for all four tracers rose in thick slices compared with thin slices, suggesting that ECS becomes less tortuous in the penumbra.

Restoring adenine nucleotides in a brain slice model of cerebral reperfusion.

Tissue adenine nucleotides are depleted during cerebral ischemia, impeding recovery after reperfusion. Although prior studies have attempted to prevent the initial loss of adenylates, the present study tests the hypothesis that stimulating synthesis of adenine nucleotides, through either adenosine kinase or adenine phosphoribosyltransferase, would result in significant cerebroprotection. To study the effects on neurons and glia directly while avoiding the influence of the cerebral vasculature, hippocampal brain slices were used for the model of transient ischemia with reperfusion. The standard brain slice insult of brief exposure to anoxia with aglycemia was modified based on studies which showed that a 30-minute exposure to air with 1 mmol/L glucose produced a stable, moderate reduction in ATP during the insult and that, 2 hours after return to normal conditions, there was moderate depletion of tissue adenine nucleotides and histologic injury. Treatments with 1 mmol/L adenosine, AMP, or adenine were equivalent in partially restoring adenine nucleotides. Despite this, only adenosine afforded histologic protection, suggesting a protective role for adenosine receptors. There also was evidence for metabolic cycling among adenine nucleotides, nucleosides, and purines. Adenosine may exert direct cerebroprotective effects on neural tissue as well as indirect effects through the cerebral vasculature.

Phenytoin-induced hyperglycaemia may confound rat cerebroprotection models.

1. The anticonvulsant phenytoin (PHT) has been used with variable success in animal models of cerebral ischaemia. Although PHT has been reported to alter glucose regulation in man, this potential effect has been largely ignored in animals. Because hyperglycaemia strongly influences the outcome of cerebral ischaemia, we sought to systematically delineate the effects of PHT on serum glucose in several rat strains. 2. We studied the PHT dose-response curve for serum PHT and glucose concentrations and several physiological variables. Phenytoin induces a significant, concentration-dependent hyperglycaemia, even in the ranges commonly used for humans and in animal models. 3. Hypothermia of several degrees was observed during PHT administration, but no hypotension or bradycardia was found. 4. Both hyperglycaemia and hypothermia must be considered when PHT is studied as a neuroprotective agent in animal models.

Simplified brain slice glucose utilization.

Brain slice glucose utilization (SGU) can be measured by methods analogous to those used for in vivo cerebral glucose utilization. In order to make this technique more accessible and applicable to a broad range of experimental conditions, we have derived a simplified operational rate equation and generated the table of apparent rate coefficients necessary to apply the equation under different experimental situations. Calculations of the apparent rate coefficients were based upon an eight-parameter kinetic model combined with Michaelis-Menten theory to account for changes in the rate constants as a function of buffer glucose concentration. The theory was tested with a series of experiments using rat brain slices. [14C]-2-deoxyglucose (2DG) and [14C]-3-O-methylglucose (3OMG). The errors involved in the simplified technique were estimated by a variety of techniques and found to be acceptable over a broad range of conditions. A detailed, practical protocol for the simplified method is presented.

Effects of dextran on hippocampal brain slice water, extracellular space, calcium kinetics and histology.

Hippocampal brain slices are valuable models for studying brain function but are compromised by several artifacts, including significant water gain and histologic injury, which occur under certain incubation conditions. Addition of colloid to Krebs-Ringer buffer (K-R) has been shown to eliminate water gain but has not achieved widespread acceptance. We confirm prior observations that dextran and PEG lessen the increase in slice mass during incubation in a dose-dependent manner with no water gain occurring at 4% concentrations. However, we also observe that addition of colloid to standard K-R induces severe neuronal pyknosis. Fortunately, the pyknosis can be eliminated by reduction in buffer osmolarity through adjustment of NaCl, producing markedly improved slice histology in dextran buffer, especially in the CA3 and CA4 regions of the hippocampus which are severely injured when incubated submerged in K-R at 37 degrees C. Extracellular space markers are not affected by either colloid. The volume of distribution for 45Ca is much larger in dextran buffers than in K-R and variability of 45Ca kinetics is also reduced. In the presence of dextran, hypoxia induces significant slice water gain, a relatively selective histologic injury and an alteration of tissue Ca2+ kinetics. Use of dextran buffers may eliminate many troubling brain slice artifacts.

Effects of K+, pH and glutamate on 45Ca kinetics in hippocampal brain slices.

Altered calcium homeostasis is likely to play a pathogenetic role in cerebral ischemia. In order to further understand which factors associated with ischemia contribute to disturbances of calcium metabolism, the influence of 3 isolated insults, 8 mM K+, pH 6.1 and 1 mM glutamate, on total tissue calcium were studied by analysis of steady-state kinetics of 45Ca in 500 microns hippocampal brain slices. 45Ca kinetics were analyzed with 2 bi-exponential models by non-linear least-squares analysis. Tissue wet weight/protein was measured simultaneously. Each experimental condition produced a unique tissue response. Raising K+ had no effect on tissue water but increased the rate of uptake of Ca2+ into the larger, rapidly equilibrating tissue Ca2+ space. Acidosis reduced tissue water and the amount of Ca2+ in the slowly equilibrating compartment due to enhanced efflux from that space. Glutamate increased tissue water in a time-dependent manner and increased the influx and amount of Ca2+ in the slowly equilibrating space. Combined insults revealed minimal interaction between K+ and acidosis or glutamate, but glutamate with acidosis worsened tissue injury. We discuss the relationship of this technique to other methods for studying tissue calcium and the significance of the observations regarding ischemia.

Preparative methods for brain slices: a discussion.

Criteria for slice health and factors that affect slice health were discussed by many of the participants in the conference. In addition to the standard parameters of slice health (energy metabolism, morphology, electrophysiological responsiveness) more subtle but possibly equally important manifestations of slice health were discussed. These included protein synthesis, and more subtle changes, of which we are becoming increasingly aware. The latter include synthesis of stress-related proteins, altered levels of phosphorylation, altered levels of proteolysis. These last were only touched on, but it is becoming apparent they do in fact constitute important manifestations of differences between the slice preparation and the in vivo tissue. They may well lead to quite different responses in slices from those that occur in vivo. While many ways of optimizing slice wellness were discussed, there was a fair consensus that certain adjustments will optimize the most widely measured aspects of cell function. These include the following, wherever possible. Use of young animals, use of the interface chamber, preparing slices with the vibratome, pre-treating animals with ice-cold cardiac perfusion before sacrificing, using pre-incubation media which reduce NMDA receptor activation, free radical formation and cell swelling. When possible these treatments should perhaps be continued into the normal incubation. This being said, many viewpoints were actually expressed in the discussion, and it should be read to get a feel for the usefulness of the different approaches.

Analysis of in vitro glucose utilization in a circadian pacemaker model.

An in vitro glucose utilization method, based upon 14C-2-deoxyglucose kinetics in brain slices, has been used to study circadian rhythms in hypothalamic slices containing the suprachiasmatic nucleus (SCN). Spontaneous SCN metabolic activity in vitro is similar to that observed in vivo with higher metabolic rates in subjective daytime and lower rates during subjective night. However, in vitro SCN metabolic activity during late subjective day is above that seen when glucose utilization is measured in vivo, suggesting that an inhibitory influence normally active in vivo is lost during slice isolation. Incubation of slices containing SCN in the presence of TTX exposes a TTX-insensitive component of metabolic activity in early subjective day, supporting prior suggestions that glucose utilization by the circadian oscillator continues in the absence of Na(+)-dependent action potentials. Studies with high Mg2+ concentrations are consistent with the hypothesis that most metabolic activity above the basal level observed with the glucose utilization method is related to synaptic activity. Pharmacological studies of the SCN brain slice model with radiotracers offer potential for analysis of both circadian rhythmicity and neural regulation.

Preservation of hippocampal brain slices with in vivo or in vitro hypothermia.

Hippocampal brain slices show CA1 injury similar to that seen after global ischemia in vivo. Cooling rats to 31 degrees C prior to sacrifice or cooling slices to 21 degrees C for 45 min increased the percentage of normal CA1 pyramidal cells after 5 h in vitro from 30% to over 80%. Brain slices also show a unique, consistent injury in dentate which is lessened by transient cooling to 21 degrees C but not by cooling the animal.

Ischemic brain slice glucose utilization: effects of slice thickness, acidosis, and K+.

Brain slices of varying thickness were used to modify retention of metabolic products in an in vitro model of ischemia. Past and present results reveal increased anaerobic glycolysis in 660-microns slices with accumulation of lactate as slice thickness reaches 1,000 microns. Brain slice glucose utilization and lactate content were measured in buffers of various extracellular K+ levels and pH in 540-, 660-, and 1,000-microns slices. Acidosis suppresses glucose utilization at all slice thicknesses without affecting tissue lactate. Studies of 2-deoxyglucose metabolites establish that the suppression of glucose utilization by acidosis is due entirely to inhibition of glucose phosphorylation without any effect on glucose uptake into tissue. The inhibition is reversible after 45 min at pH 6.1. The experiments with acidosis also suggest that persistent energy demands continue to stimulate phosphofructokinase despite the low pH so that glycolysis continues, with potential for injury. Increasing K+ increases glucose utilization and tissue lactate at all three thicknesses. Correlations of glucose utilization with lactate accumulation support the possibility that high K+ may exert a dual influence on the tissue metabolism, not only stimulating glucose utilization by inducing depolarization but also by influencing the removal of metabolic products.