Serum levels of brain-derived neurotrophicfactor correlate with the number of T2 MRI lesions in multiple sclerosis

The objective of the present study was to determine if there is a relationship between serum levels of brain-derived neurotrophic factor (BDNF) and the number of T2/fluid-attenuated inversion recovery (T2/FLAIR) lesions in multiple sclerosis (MS). The use of magnetic resonance imaging (MRI) has revolutionized the study of MS. However, MRI has limitations and the use of other biomarkers such as BDNF may be useful for the clinical assessment and the study of the disease. Serum was obtained from 28 MS patients, 18-50 years old (median 38), 21 women, 0.5-10 years (median 5) of disease duration, EDSS 1-4 (median 1.5) and 28 healthy controls, 19-49 years old (median 33), 19 women. BDNF levels were measured by ELISA. T1, T2/FLAIR and gadolinium-enhanced lesions were measured by a trained radiologist. BDNF was reduced in MS patients (median [range] pg/mL; 1160 [352.6-2640]) compared to healthy controls (1640 [632.4-4268]; P = 0.03, Mann-Whitney test) and was negatively correlated (Spearman correlation test, r = -0.41; P = 0.02) with T2/FLAIR (11-81 lesions, median 42). We found that serum BDNF levels were inversely correlated with the number of T2/FLAIR lesions in patients with MS. BDNF may be a promising biomarker of MS.

Doppler-guided hemorrhoidal artery ligation with rectal mucopexy technique: initial evaluation of 42 cases

The treatment of hemorrhoidal disease (HD) by conventional hemorrhoidectomy is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. Doppler-guided hemorrhoid artery ligation (DGHAL) is a minimal-invasive surgical treatment for HD that has been used as an alternative method in order to reduce these inconveniences. OBJECTIVE: To analyze the initial results of the DGHAL technique associated with rectal mucopexy in the treatment of HD. METHODS:Forty-two patients with stage I, III and IV hemorrhoids who were submitted to DGHAL were analyzed from December 2010 to August 2011. Eleven patients (26%) were stage II; 21 (50%), stage III; and 10 (24%), stage IV HD. All patients were operated by the same surgeon under spinal anesthesia and using the same equipment and technique to perform the procedure. The 42 patients underwent ligation of six arterial branches followed by rectal mucopexia by uninterrupted suture. Nine patients needed concomitant removal of perianal skin tag. In the postoperative, the following parameters were evaluated: pain, tenesmus, bleeding, itching, prolapse, mucus discharge and recurrence. The mean postoperative follow-up lasted four months (one to nine months). RESULTS: Tenesmus was the most common postoperative complaint for 85.7% of patients followed by pain, in 28.6%, perianal burning, in 12.3%, mucus discharge and perianal hematoma in 4.7%. Two patients had severe postoperative bleeding and required surgical haemostasis, one of which needed blood transfusion. Ninety-five percent of the patients declared to be satisfied with the method. CONCLUSION: Even though DGHAL has complications similar to those of other surgical methods, its results present less postoperative pain, allowing faster recovery and return to work. Studies with more cases and a longer follow-up are still necessary to assess the late recurrence.

Diffusion of laser polarized gases in MRI

The use of Magnetic Resonance Imaging (MRI) as a diagnostic tool is increasingly employing functional contrast agents to study or contrast entire mechanisms. Contrast agents in MRI can be classified in two categories. One type of contrast agents alters the NMR signal of the protons in its surrounding, e.g. lowers the T1 relaxation time. The other type enhances the Nuclear Magnetic Resonance (NMR) signal of specific nuclei. For hyperpolarized gases the NMR signal is improved up to several orders of magnitude. However, gases have a high diffusivity which strongly influences the NMR signal strength, hence the resolution and appearance of the images. The most interesting question in spatially resolved experiments is of course the achievable resolution and contrast by controlling the diffusivity of the gas. The influence of such diffusive processes scales with the diffusion coefficient, the strength of the magnetic field gradients and the timings used in the experiment. Diffusion may not only limit the MRI resolution, but also distort the line shape of MR images for samples, which contain boundaries or diffusion barriers within the sampled space. In addition, due to the large polarization in gaseous 3He and 129Xe, spin diffusion (different from particle diffusion) could play a role in MRI experiments. It is demonstrated that for low temperatures some corrections to the NMR measured diffusion coefficient have to be done, which depend on quantum exchange effects for indistinguishable particles. Physically, if these effects can not change the spin current, they can do it indirectly by modifying the velocity distribution of the different spin states separately, so that the subsequent collisions between atoms and therefore the diffusion coefficient can eventually be affected. A detailed study of the hyperpolarized gas diffusion coefficient is presented, demonstrating the absence of spin diffusion (different from particle diffusion) influence in MRI at clinical conditions. A novel procedure is proposed to control the diffusion coefficient of gases in MRI by admixture of inert buffer gases. The experimental measured diffusion agrees with theoretical simulations. Therefore, the molecular mass and concentration enter as additional parameters into the equations that describe structural contrast. This allows for setting a structural threshold up to which structures contribute to the image. For MRI of the lung this allows for images of very small structural elements (alveoli) only, or in the other extreme, all airways can be displayed with minimal signal loss due to diffusion.

Ultrasuoni focalizzati guidati da imaging di risonanza magnetica: studio delle potenziali applicazioni in campo scheletrico, esempio n.1 - osteoma osteoide

La chirurgia con ultrasuoni focalizzati guidati da MRI (MR-g-FUS) è un trattamento di minima invasività, guidato dal più sofisticato strumento di imaging a disposizione, che utilizza a scopo diagnostico e terapeutico forme di energia non ionizzante. Le sue caratteristiche portano a pensare un suo possibile e promettente utilizzo in numerose aree della patologia umana, in particolare scheletrica. L'osteoma osteoide affligge frequentemente pazienti di giovane età, è una patologia benigna, con origine ed evoluzione non chiare, e trova nella termoablazione con radiofrequenza continua sotto guida CT (CT-g-RFA) il suo trattamento di elezione. Questo lavoro ha valutato l’efficacia, gli effetti e la sicurezza del trattamento dell’osteoma osteoide con MR-g-FUS. Sono stati presi in considerazione pazienti arruolati per MR-g-FUS e, come gruppo di controllo, pazienti sottoposti a CT-g-RFA, che hanno raggiunto un follow-up minimo di 18 mesi (rispettivamente 6 e 24 pazienti). Due pazienti erano stati esclusi dal trattamento MR-g-FUS per claustrofobia (2/8). Tutti i trattamenti sono stati portati a termine con successo tecnico e clinico. Non sono state registrate complicanze o eventi avversi correlati all’anestesia o alle procedure di trattamento, e tutti i pazienti sono stati dimessi regolarmente dopo 12-24 ore. La durata media dei trattamenti di MR-g-FUS è stata di 40±21 min. Da valori di score VAS pre-trattamento oscillanti tra 6 e 10 (su scala 0-10), i trattamenti hanno condotto tutti i pazienti a VAS 0 (senza integrazioni farmacologiche). Nessun paziente ha manifestato segni di persistenza di malattia o di recidiva al follow-up. Nonostante la neurolisi e la risoluzione dei sintomi, la perfusione del nidus è stata ritrovata ancora presente in oltre il 70% dei casi sottoposti a MR-g-FUS (4/6 pazienti). I risultati derivati da un'analisi estesa a pazienti più recentemente arruolati confermano questi dati. Il trattamento con MR-g-FUS sembra essere efficace e sicuro nel risolvere la sintomatologia dell'osteoma osteoide.

Lesion detection and classification in breast cancer: evaluation of approaches based on morphological features, tracer kinetic modelling and semi-quantitative parameters in MR functional imaging (DCE-MRI)

The diagnosis, grading and classification of tumours has benefited considerably from the development of DCE-MRI which is now essential to the adequate clinical management of many tumour types due to its capability in detecting active angiogenesis. Several strategies have been proposed for DCE-MRI evaluation. Visual inspection of contrast agent concentration curves vs time is a very simple yet operator dependent procedure, therefore more objective approaches have been developed in order to facilitate comparison between studies. In so called model free approaches, descriptive or heuristic information extracted from time series raw data have been used for tissue classification. The main issue concerning these schemes is that they have not a direct interpretation in terms of physiological properties of the tissues. On the other hand, model based investigations typically involve compartmental tracer kinetic modelling and pixel-by-pixel estimation of kinetic parameters via non-linear regression applied on region of interests opportunely selected by the physician. This approach has the advantage to provide parameters directly related to the pathophysiological properties of the tissue such as vessel permeability, local regional blood flow, extraction fraction, concentration gradient between plasma and extravascular-extracellular space. Anyway, nonlinear modelling is computational demanding and the accuracy of the estimates can be affected by the signal-to-noise ratio and by the initial solutions. The principal aim of this thesis is investigate the use of semi-quantitative and quantitative parameters for segmentation and classification of breast lesion. The objectives can be subdivided as follow: describe the principal techniques to evaluate time intensity curve in DCE-MRI with focus on kinetic model proposed in literature; to evaluate the influence in parametrization choice for a classic bi-compartmental kinetic models; to evaluate the performance of a method for simultaneous tracer kinetic modelling and pixel classification; to evaluate performance of machine learning techniques training for segmentation and classification of breast lesion.

Numerical methods for the dispersion analysis of Guided Waves

The use of guided ultrasonic waves (GUW) has increased considerably in the fields of non-destructive (NDE) testing and structural health monitoring (SHM) due to their ability to perform long range inspections, to probe hidden areas as well as to provide a complete monitoring of the entire waveguide. Guided waves can be fully exploited only once their dispersive properties are known for the given waveguide. In this context, well stated analytical and numerical methods are represented by the Matrix family methods and the Semi Analytical Finite Element (SAFE) methods. However, while the former are limited to simple geometries of finite or infinite extent, the latter can model arbitrary cross-section waveguides of finite domain only. This thesis is aimed at developing three different numerical methods for modelling wave propagation in complex translational invariant systems. First, a classical SAFE formulation for viscoelastic waveguides is extended to account for a three dimensional translational invariant static prestress state. The effect of prestress, residual stress and applied loads on the dispersion properties of the guided waves is shown. Next, a two-and-a-half Boundary Element Method (2.5D BEM) for the dispersion analysis of damped guided waves in waveguides and cavities of arbitrary cross-section is proposed. The attenuation dispersive spectrum due to material damping and geometrical spreading of cavities with arbitrary shape is shown for the first time. Finally, a coupled SAFE-2.5D BEM framework is developed to study the dispersion characteristics of waves in viscoelastic waveguides of arbitrary geometry embedded in infinite solid or liquid media. Dispersion of leaky and non-leaky guided waves in terms of speed and attenuation, as well as the radiated wavefields, can be computed. The results obtained in this thesis can be helpful for the design of both actuation and sensing systems in practical application, as well as to tune experimental setup.

Analysis of cone-beam ct dose in image-guided radiation therapy for brain and prostate cancer patients via gpu-based Monte Carlo simulations

La radioterapia guidata da immagini (IGRT), grazie alle ripetute verifiche della posizione del paziente e della localizzazione del volume bersaglio, si è recentemente affermata come nuovo paradigma nella radioterapia, avendo migliorato radicalmente l’accuratezza nella somministrazione di dose a scopo terapeutico. Una promettente tecnica nel campo dell’IGRT è rappresentata dalla tomografia computerizzata a fascio conico (CBCT). La CBCT a kilovoltaggio, consente di fornire un’accurata mappatura tridimensionale dell’anatomia del paziente, in fase di pianificazione del trattamento e a ogni frazione del medisimo. Tuttavia, la dose da imaging attribuibile alle ripetute scansioni è diventata, negli ultimi anni, oggetto di una crescente preoccupazione nel contesto clinico. Lo scopo di questo lavoro è di valutare quantitativamente la dose addizionale somministrata da CBCT a kilovoltaggio, con riferimento a tre tipici protocolli di scansione per Varian OnBoard Imaging Systems (OBI, Palo Alto, California). A questo scopo sono state condotte simulazioni con codici Monte Carlo per il calcolo della dose, utilizzando il pacchetto gCTD, sviluppato sull’architettura della scheda grafica. L’utilizzo della GPU per sistemi server di calcolo ha permesso di raggiungere alte efficienze computazionali, accelerando le simulazioni Monte Carlo fino a raggiungere tempi di calcolo di ~1 min per un caso tipico. Inizialmente sono state condotte misure sperimentali di dose su un fantoccio d’acqua. I parametri necessari per la modellazione della sorgente di raggi X nel codice gCTD sono stati ottenuti attraverso un processo di validazione del codice al fine di accordare i valori di dose simulati in acqua con le misure nel fantoccio. Lo studio si concentra su cinquanta pazienti sottoposti a cicli di radioterapia a intensità modulata (IMRT). Venticinque pazienti con tumore al cervello sono utilizzati per studiare la dose nel protocollo standard-dose head e venticinque pazienti con tumore alla prostata sono selezionati per studiare la dose nei protocolli pelvis e pelvis spotlight. La dose media a ogni organo è calcolata. La dose media al 2% dei voxels con i valori più alti di dose è inoltre computata per ogni organo, al fine di caratterizzare l’omogeneità spaziale della distribuzione.

Simulation Guided Navigation in cranio-maxillo-facial surgery: a new approach to improve intraoperative three-dimensional accuracy and reproducibility during surgery.

The aim of this PhD thesis " Simulation Guided Navigation in cranio- maxillo- facial surgery : a new approach to Improve intraoperative three-dimensional accuracy and reproducibility during surgery ." was at the center of its attention the various applications of a method introduced by our School in 2010 and has as its theme the increase of interest of reproducibility of surgical programs through methods that in whole or in part are using intraoperative navigation. It was introduced in Orthognathic Surgery Validation a new method for the interventions carried out according to the method Simulation Guided Navigation in facial deformities ; was then analyzed the method of three-dimensional control of the osteotomies through the use of templates and cutting of plates using the method precontoured CAD -CAM and laser sintering . It was finally proceeded to introduce the method of piezonavigated surgery in the various branches of maxillofacial surgery . These studies have been subjected to validation processes and the results are presented .

Parahydrogen induced polarization on a clinical MRI system : polarization transfer of two spin order

Hyperpolarization techniques enhance the nuclear spin polarization and thus allow for new nuclear magnetic resonance applications like in vivo metabolic imaging. One of these techniques is Parahydrogen Induced Polarization (PHIP). It leads to a hyperpolarized 1H spin state which can be transferred to a heteronucleus like 13C by a radiofrequency (RF) pulse sequence. In this work, timing of such a sequence was analyzed and optimized for the molecule hydroxyethyl propionate. The pulse sequence was adapted for the work on a clinical magnetic resonance imaging (MRI) system which is usually equipped only with a single RF transmit channel. Optimal control theory optimizations were performed to achieve an optimized polarization transfer. A drawback of hyperpolarization is its limited lifetime due to relaxation processes. The lifetime can be increased by storing the hyperpolarization in a spin singlet state. The second part of this work therefore addresses the spin singlet state of the Cs-symmetric molecule dimethyl maleate which needs to be converted to the spin triplet state to be detectable. This conversion was realized on a clinical MRI system, both by field cycling and by two RF pulse sequences which were adapted and optimized for this purpose. Using multiple conversions enables the determination of the lifetime of the singlet state as well as the conversion efficiency of the RF pulse sequence. Both, the hyperpolarized 13C spin state and the converted singlet state were utilized for MR imaging. Careful choice of the echo time was shown to be crucial for both molecules.

La navigazione neurochirurgica: analisi della tecnologia nello studio di un caso clinico reale

L’avvento delle tecniche di imaging volumetrico, quali la CT (Computed Tomography) e la MRI (Magnetic Resonance Investigation), ha portato ad un crescente interesse verso applicazioni di guida chirurgica che utilizzano processi di allineamento delle immagini diagnostiche provenienti da diverse modalità e di tecniche che ne permettono la visualizzazione in sala operatoria, in modo da fornire al chirurgo il maggior numero di informazioni cliniche possibili durante un intervento. Il crescente interesse verso questo tipo di applicazioni è dovuto anche allo sviluppo di dispositivi di imaging intra-operatorio quali archi a C-mobili radiologici, PC ad alte prestazioni e convertitori A/D 3D con precisione clinicamente accettabile. Questi ultimi due hanno conseguentemente portato a sviluppare ed implementare software dedicati alla pianificazione di un intervento chirurgico, permettendo quindi di elaborare digitalmente le immagini diagnostiche e ricostruire un modello che rappresenta l’effettiva anatomia del paziente. Questo processo nel suo complesso ha portato allo sviluppo di quelli che oggi vengono chiamati sistemi di navigazione chirurgica, abbreviati talvolta in IGSS (Imaging-Guided Surgery Systems), sistemi ovvero che permettono di utilizzare immagini pre-operatorie come guida durante la pratica chirurgica, caratterizzando quindi nuovi metodi di approccio alla chirurgia, le IGS (Image-Guided Surgery) appunto.

Modelli compartimentali per l'analisi di segnali ottenuti tramite DCE MRI per studi di perfusione epatica

Il presente lavoro di tesi si inserisce all'interno di uno studio dal titolo: "Strategia di posizionamento multi-step come approccio pragmatico per ridurre il rischio di encefalopatia epatica post-TIPS (shunt trans-giugulare porto-sistemico intraepatico) in pazienti cirrotici con ascite refrattaria". Il progetto di tesi si è concentrato sull'analisi dei segnali ottenuti tramite DCE MRI, con lo scopo di implementare in ambiente MatLab due modelli differenti (Dual input - Mono compartment e Dual input - Dual compartment) che descrivono la cinetica del tracciante all'interno del sistema vascolare epatico e valutare l'efficacia dei parametri di perfusione associati nella descrizione delle variazioni in termini di microcircolazione introdotte dall'inserimento del TIPS. Inizialmente si sono voluti valutare, tramite simulazione, gli effetti in termini di amplificazione del rumore e stima dei parametri perfusionali dell'approssimazione lineare nella conversione da intensità di segnale MR a concentrazione di mezzo di contrasto. Successivamente, sempre attraverso simulazioni, per entrambi i modelli considerati è stato scelto uno schema di model-fitting e quindi testata l'affidabilità in termini di accuratezza e precisione delle stime dei parametri ottenute in funzione del livello di rumore associato alle curve di intensità di segnale. Parallelamente all'implementazione dei modelli per la stima di parametri di perfusione, sono stati realizzati dei phantom con l'obiettivo di simulare il parenchima epatico prima e dopo l'arrivo del mezzo di contrasto e poter testare la sequenza utilizzata durante l'acquisizione dei dati su paziente. Infine sono stati considerati gli esami di DCE MRI effettuati su un campione di nove pazienti pre e post-TIPS, utilizzando per l'analisi dei segnali entrambi i modelli implementati in fase di simulazione e successivamente valutando le variazioni nel valori associati ai parametri di perfusione introdotte dall'inserimento del TIPS.

Geometria frattale: analisi della lacunarita cerebrale in MRI

La geometria frattale descrive la complessità strutturale di oggetti che presentano, entro certi limiti, invarianza a fattori di scala. Obiettivo di questa tesi è l’analisi di indici frattali della morfologia cerebrale e cerebellare da immagini di risonanza magnetica (MRI) pesate T1 e della loro correlazione con l’età. A tale scopo sono state analizzate la dimensione frattale (D0) e la lacunarità (λs), indice di eterogeneità strutturale, della sostanza grigia (GM) e bianca (WM), calcolate mediante algoritmi di box counting e di differential gliding box, implementati in linguaggio C++, e regressione lineare con scelta automatica delle scale spaziali. Gli algoritmi sono stati validati su fantocci 3D ed è stato proposto un metodo per compensare la dipendenza di λs dalle dimensioni dell’immagine e dalla frazione di immagine occupata. L’analisi frattale è stata applicata ad immagini T1 a 3T del dataset ICBM (International Consortium for Brain Mapping) composto da 86 soggetti (età 19-85 anni). D0 e λs sono state rispettivamente 2.35±0.02 (media±deviazione standard) e 0.41±0.05 per la GM corticale, 2.34±0.03 e 0.35±0.05 per la WM cerebrale, 2.19±0.05 e 0.17±0.02 per la GM cerebellare, 1.95±0.06 e 0.30±0.04 per la WM cerebellare. Il coefficiente di correlazione lineare tra età e D0 della GM corticale è r=−0.38 (p=0.003); tra età e λs, r=0.72 (p<0.001) (mostrando che l’eterogeneità strutturale aumenta con l’invecchiamento) e tra età e λs compensata rispetto al volume della GM cerebrale (GMV), r=0.51 (p<0.001), superiore in valore assoluto a quello tra età e GMV (r=−0.45, p<0.001). In un modello di regressione lineare multipla, dove l’età è stata modellata da D0, λ e GMV della GM corticale, λs è risultato l’unico predittore significativo (r parziale=0.62, p<0.001). La lacunarità λs è un indice sensibile alle variazioni strutturali dovute all’invecchiamento cerebrale e si candida come biomarcatore nella valutazione della complessità cerebrale nelle malattie neurodegenerative.

Preoperative MRI findings and functional outcome after selective dorsal rhizotomy in children with bilateral spasticity

PURPOSE: To identify MRI characteristics that may predict the functional effect of selective dorsal rhizotomy (SDR) in children with bilateral spastic paresis. METHODS: We performed SDR in a group of 36 patients. The gross motor functioning measure-66 (GMFM-66) was applied before and after SDR. Available cerebral MRIs were retrospectively classified into three diagnostic groups: periventricular leucomalacia (PVL; n = 10), hydrocephalus (n = 2), and normal (n = 6). In patients with PVL, we scored the severity of the MR abnormalities. We compared the changes in the GMFM-66 after SDR in the diagnostic groups. In patients with PVL, we correlated the severity of the MR abnormalities with the changes in the GMFM-66. RESULTS: The mean follow-up period was 5 years and 4 months (range, 1 year and 1 month to 9 years). The best improvement in gross motor function was observed in patients with normal MRI, and the slightest improvement was observed in patients with hydrocephalus. The severity of the PVL did correlate with the GMFM-66 score before SDR but not with the functional effect of SDR. CONCLUSION: We conclude that with respect to gross motor skills, the improvements after SDR are good in patients with no MRI abnormalities. In the patients with hydrocephalus, the improvements after SDR were insignificant. In patients with PVL, the improvements were intermediate and did not correlate with the degree of PVL.

Predicting and monitoring cancer treatment response with diffusion-weighted MRI

An imaging biomarker that would provide for an early quantitative metric of clinical treatment response in cancer patients would provide for a paradigm shift in cancer care. Currently, nonimage based clinical outcome metrics include morphology, clinical, and laboratory parameters, however, these are obtained relatively late following treatment. Diffusion-weighted MRI (DW-MRI) holds promise for use as a cancer treatment response biomarker as it is sensitive to macromolecular and microstructural changes which can occur at the cellular level earlier than anatomical changes during therapy. Studies have shown that successful treatment of many tumor types can be detected using DW-MRI as an early increase in the apparent diffusion coefficient (ADC) values. Additionally, low pretreatment ADC values of various tumors are often predictive of better outcome. These capabilities, once validated, could provide for an important opportunity to individualize therapy thereby minimizing unnecessary systemic toxicity associated with ineffective therapies with the additional advantage of improving overall patient health care and associated costs. In this report, we provide a brief technical overview of DW-MRI acquisition protocols, quantitative image analysis approaches and review studies which have implemented DW-MRI for the purpose of early prediction of cancer treatment response.