clinical applications of diffusion tensor mri & fiber ...khmb 2003 seoul, korea yonsei...

Clinical Applications ofClinical Applications ofDiffusion Tensor MRI &Diffusion Tensor MRI &

Fiber TractographyFiber Tractography

SeungSeung--Koo Lee, M.D., Ph.D.Koo Lee, M.D., Ph.D.NeuroradiologyNeuroradiology Division, Department of RadiologyDivision, Department of Radiology

YonseiYonsei University College of Medicine University College of Medicine Seoul, KoreaSeoul, Korea

KHMB 2003Seoul, Korea

Yonsei University NeuroradiologySeoul, Korea

DTI & FT Protocol in DTI & FT Protocol in YonseiYonsei1.5T 1.5T InteraIntera (Philips Medical Systems) with explorer gradient (Philips Medical Systems) with explorer gradient (60mT/m)(60mT/m)

66--channel SENSE head coilchannel SENSE head coil

Single shot spin echo EPI with SENSE factor 2Single shot spin echo EPI with SENSE factor 2

TR: Shortest, TE: 70msec TR: Shortest, TE: 70msec

2.3 mm thickness, no gap, 96 matrix reconstructed to 128 2.3 mm thickness, no gap, 96 matrix reconstructed to 128 matrix, 2 NSA, 45 (child) to 55 (adult) slicesmatrix, 2 NSA, 45 (child) to 55 (adult) slices

Scan time: 7:28 Scan time: 7:28 –– 9:23 minutes according to slice #9:23 minutes according to slice #

FOV=220mm (RFOV 100%)FOV=220mm (RFOV 100%)

b=600, 32 diffusion direction (High angular diffusion MRI)b=600, 32 diffusion direction (High angular diffusion MRI)

PRIDE package (Philips Medical Systems)PRIDE package (Philips Medical Systems)



Fiber TractographyFiber TractographyCorticospinalCorticospinal tracttract Corpus Corpus callosumcallosum

Termination of Tracking: FA < 0.2 ~ 0.3 Angle < 0.75 ~0.85

Single Single vsvs Multiple Multiple ROIsROIs

LongitudinalPontine Fiber

PLIC

Crus Cerebri



Fiber TractographyFiber TractographyCorticospinal tract and fibers in brain stem

SCP

MCP

ICPCST

PLIC

CR

6 directions 32 directions



Fiber TractographyFiber TractographyOther fibersOther fibers

CST PeriventricularWhite Matter

ILF

SLF



Overview of Clinical DTIOverview of Clinical DTIStrokeStroke

Initial FA changes in ischemic tissueInitial FA changes in ischemic tissueThe value of FA maps in the evaluation of The value of FA maps in the evaluation of lacunarlacunar strokestrokeDTI & FT in acute strokeDTI & FT in acute stroke

PrePre--surgical planningsurgical planningCNS neoplasm and AVMCNS neoplasm and AVM

White matter diseaseWhite matter diseaseCerebellarCerebellar degenerationdegenerationDiffuse axonal injuryDiffuse axonal injuryWallerianWallerian degenerationdegeneration

Pediatric BrainPediatric BrainCongenital anomaliesCongenital anomaliesCerebral palsy (Cerebral palsy (periventricularperiventricular leukomalacialeukomalacia))



DTI & FT in StrokeDTI & FT in Stroke

•Initial FA changes in acute stroke

•FA maps in lacunar infarctions

•DTI & FT in acute stroke



FA of Ischemic TissueFA of Ischemic TissueInitially elevated and

decreased progressively

Cytotoxic edema with

preserved structure

Yang et al, Stroke 1999;30:2382-2390

Measurement and calculation

problem

Green et al, Stroke 2002;33:1517-1521



Localization of Localization of LacunarLacunar InfarctionInfarctionF/43 Pure motor stroke

M/70 Ataxic hemiparesis



Localization of Localization of LacunarLacunar InfarctionInfarctionDiagnostic accuracyDiagnostic accuracy

T2 + DWI:T2 + DWI: 70 ~ 90 %70 ~ 90 %T2 + DWI + FA:T2 + DWI + FA: 100%100%

InterInter--observer agreementobserver agreementT2WI + DWIT2WI + DWI

KappaKappa = 0.446= 0.446 (Moderate)(Moderate)Standard errorStandard error = 0.158= 0.15895% CI95% CI = 0.136 to 0.756= 0.136 to 0.756

T2WI + DWI + FA mapT2WI + DWI + FA mapPerfect agreementPerfect agreement (Kappa = 1)(Kappa = 1)

JeongJeong HK et al, Proceedings of Korean Soc HK et al, Proceedings of Korean Soc RadiolRadiol, 2003, 2003



DTI & FT in Acute StrokeDTI & FT in Acute StrokeM/65 Lt MCA infarctionM/65 Lt MCA infarction



DTI & FT in Acute StrokeDTI & FT in Acute StrokeDay1Day1 Day 7Day 7



PresurgicalPresurgical PlanningPlanning

•Evaluation of corticospinal tract

•Problems of peritumoral edema



F/65 Metastasis F/65 Metastasis –– AphagiaAphagia, normal motor function, normal motor function



M/63 Diffuse M/63 Diffuse AstrocytomaAstrocytoma –– Lt side weaknessLt side weakness



M/20 AVM M/20 AVM –– Motor Motor SxSx ((--))

F/52 F/52 MeningiomaMeningioma –– Lt side weaknessLt side weakness



DTI in CNS NeoplasmDTI in CNS NeoplasmInvasion Invasion vsvs periperi--tumoraltumoral edemaedema

FA is decreased in both situations.FA is decreased in both situations.

FT is based on the measurements of FA and FT is based on the measurements of FA and angles between ellipsoids.angles between ellipsoids.

Therefore, determination of tumor extent by DTI Therefore, determination of tumor extent by DTI seems to be inaccurate.seems to be inaccurate.

Further investigation is needed.Further investigation is needed.



•Cerebellar degeneration

•Diffuse axonal injury

•Wallerian degeneration

DTI & FT in White Matter DiseaseDTI & FT in White Matter Disease



Lee SK, Mori S, Kim DI et al. Epilepsia 2003;44

Neurodegenerative Diseases of CerebellumNeurodegenerative Diseases of Cerebellum



Neurodegenerative Diseases of CerebellumNeurodegenerative Diseases of Cerebellum

Lee SK, Mori S, Kim DI et al. Epilepsia 2003;44



WallerianWallerian Degeneration in Chronic InfarctDegeneration in Chronic Infarct

F/75 Spastic F/75 Spastic hemiplegiahemiplegia, Old Lt MCA infarct, Old Lt MCA infarct



Diffuse Axonal InjuryDiffuse Axonal Injury

L R



DTI & FT in Pediatric DiseasesDTI & FT in Pediatric Diseases

•Cerebral palsy

•Callosal agenesis

•Joubert syndrome

•Cortical dysplasia



PeriventricularPeriventricular LeukomalaciaLeukomalaciaNormal childNormal child Spastic cerebral palsySpastic cerebral palsy



PVL PVL –– Corpus Corpus CallosumCallosumNormal childNormal child Spastic cerebral palsySpastic cerebral palsy



PVL PVL –– PeriventricularPeriventricular FibersFibersNormal childNormal child Spastic cerebral palsySpastic cerebral palsy



PET & MRI of PVLPET & MRI of PVL



Partial Agenesis of CCPartial Agenesis of CC

Lee SK, Mori S, Kim DI et al. AJNR (In press)



Complete Agenesis of CCComplete Agenesis of CC

Lee SK, Mori S, Kim DI et al. AJNR (In press)



FA increases in the area of band FA increases in the area of band heterotopiaheterotopia

Band Band HeterotopiaHeterotopia



Band Band HeterotopiaHeterotopia



JoubertJoubert SyndromeSyndromeM/18m Unable to walk, delayed developmentM/18m Unable to walk, delayed development



JoubertJoubert SyndromeSyndromeIncreased connection from cerebellum to motor stripe via Increased connection from cerebellum to motor stripe via superior superior cerebellarcerebellar pedunclepeduncle



Current Problems of DTICurrent Problems of DTI--FTFTFiber tracking is operator dependentFiber tracking is operator dependent

Knowledge for detailed Knowledge for detailed neuroanatomyneuroanatomy

SolutionsSolutions

Standardization of ROIStandardization of ROI

Quantitative, volumetric data processingQuantitative, volumetric data processing

Threshold values affect fiber connectivityThreshold values affect fiber connectivity

Standardization of individual variation is necessaryStandardization of individual variation is necessary



ConclusionConclusionFiber tractography directly visualizes the aberrant or Fiber tractography directly visualizes the aberrant or modified fiber connections in congenital or modified fiber connections in congenital or acquired diseases.acquired diseases.

Powerful Powerful microanatomicalmicroanatomical imaging eventually imaging eventually represents the represents the neurologicneurologic function.function.

In a broad sense, DTI & FT are the objective In a broad sense, DTI & FT are the objective functional imaging because structural change functional imaging because structural change accompanies functional modification.accompanies functional modification.



AcknowledgementsAcknowledgements

YonseiYonsei UniversityUniversityRadiologyRadiology

Dong Dong IkIk KimKimSiSi Yeon KimYeon KimSeiSei Young KimYoung Kim

NeurologyNeurologyJiJi Hoe Hoe HeoHeoByungByung In LeeIn LeeKyoungKyoung HeoHeo

Pediatric NeurologyPediatric NeurologyHeung Dong KimHeung Dong Kim

Rehabilitation MedicineRehabilitation MedicineDeogDeog Young KimYoung KimEun Eun SookSook ParkPark

Johns Hopkins Johns Hopkins UnivUnivSusumu MoriSusumu Mori

Philips Medical SystemsPhilips Medical SystemsMarc Van Marc Van CauterenCauterenFrank Frank HoogenraadHoogenraad

clinical applications of diffusion tensor mri & fiber ...khmb 2003 seoul, korea yonsei...

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