MRI Spectroscopy : Neurosurgery Notes

 


1. MR spectroscopy provides a measure of brain chemistry.
2. The most common nuclei that are used are 
• 1H (proton)
• 23Na (sodium)
• 31P (phosphorus). 
• Proton spectroscopy is easier to perform and provides much higher signal-to-noise than either sodium or phosphorus.
3. MRS can be performed within 10-15 minutes and can be added on to conventional MR imaging protocols. 
4. It can be used to serially monitor biochemical changes in tumors, stroke, epilepsy, metabolic disorders, infections, and neurodegenerative diseases. 
5. They require interpretation and should always be correlated with the MR images before making a final diagnosis.
6. MR spectroscopy is conducted on the same machine as conventional MRI. 
7. Spectroscopy is a series of tests that are added to the MRI scan of brain or spine to measure the chemical metabolism of a suspected lesion.
8. There are several different metabolites, or products of metabolism, that can be measured to differentiate between tumor types.
9. Each metabolite appears at a specific ppm, and each one reflects specific cellular and biochemical processes 
• NAA: is a neuronal marker and decreases with any disease that adversely affects neuronal integrity. 
• Creatine: provides a measure of energy stores. 
• Choline: is a measure of increased cellular turnover and is elevated in tumors and inflammatory processes.



 

10. The common way to analyze clinical spectra is to look at metabolite ratios, namely NAA/Cr, NAA/Cho, and Cho/Cr.
11. For MR imaging, the total signal from all the protons in each voxel is used to make the image. 
12. If all the signal were used for MRS, the fat and water peaks would be huge and scaling would make the other metabolite peaks invisible. 
13. Fat and water are eliminated. Fat is avoided by placing the voxel for MRS within the brain, away from the fat in bone marrow and scalp.
14. SINGLE-VOXEL MR SPECTROSCOPY 
• Less advance. 
• Volume averaging
• Small area of coverage. 
• acquires spectra from single small voxel. 
• short acquisition times. 
• Histologically simpler lesions. 
  
15. MR SPECTROSCOPIC IMAGING/MULTI-VOXEL. 
•  more technically advanced technique.
• small voxel size
• dec. volume averaging 
• large volume of coverage 
• acquires spectra from numerous small voxels.
• long acquisition times. 
• For complex lesions
16. Multi-voxel spectroscopy is best to detect infiltration of malignant cells beyond the enhancing margins of tumors. 
17. Finally, MRS can direct the surgeon to the most metabolically active part of the tumor for biopsy to obtain accurate grading of the malignancy.
18.  As a general rule, the single voxel, shortTE technique is used to make the initial diagnosis. 
19. Multi-voxel, longTE techniques are used to further characterize different regions of a mass and to assess brain parenchyma around or adjacent to the mass. 
20. Multi-voxel, longTE techniques are also used to assess response to therapy and to search for tumor recurrence.
21. MRS can be used to determine the degree of malignancy. 
• As malignancy increases, NAA and creatine decrease, and choline, lactate, and lipids increase. 
• NAA decreases as tumor growth displaces or destroys neurons. 
• Very malignant tumors have high metabolic activity and deplete the energy stores, resulting in reduced creatine. 
• Very hypercellular tumors with rapid growth elevate the choline levels. 
• Lipids are found in necrotic portions of tumors 
• Lactate appears when tumors outgrow their blood supply and start utilizing anaerobic glycolysis.
• Key feature of gliomas is elevated choline beyond the margin of enhancement due to infiltration of tumor into the adjacent brain tissue. 
• Elevated alanine is a signature of meningiomas.
22. Voxel placement in single-voxel MR spectroscopy studies of brain tumors is critical to the accurate characterization of lesion histopathology. 
• Specifically, inclusion of the edge of an enhancing lesion in the MR spectroscopy voxel improves accuracy . 
• Voxel placement in the centre of a lesion with frank cavitation increases the likelihood that cellular breakdown products will dominate the spectral pattern.
• To get an accurate assessment of the tumor chemistry, the spectroscopic voxel should be placed over an enhancing region of the tumor, avoiding areas of necrosis, hemorrhage, calcification, or cysts.
23. A common clinical problem is distinguishing tumor recurrence from radiation effectsseveral months following surgery and radiation therapy. 
• Elevated choline is a marker for recurrent tumor. 
• Radiation change generally exhibits low NAA, creatine, and choline on spectroscopy. 
• If radiation necrosis is present, the spectrum may reveal elevated lipids and lactate.
24. Cerebral Ischemia and Infarction: When the brain becomes ischemic, it switches to anaerobic glycolysis and lactate accumulates. 
• Markedly elevated lactate is the key spectroscopic feature of cerebral hypoxia and ischemia.
• If cerebral infarction ensues, lipids increase.
25. MR spectroscopy is not routinely used in the acute setting of head injuries. 
• when the patient has stabilized, MRS is helpful to assess the degree of neuronal injury and predict patient outcomes. 
• In the case of diffuse axonal injury, imaging often underestimates the degree of brain damage. 
• Clinical outcome correlates inversely with the NAA/Cr ratio. 
• The presence of any lactate or lipid indicates a worse prognosis.
26. Brain abscesses destroy or displace brain tissue, so NAA is not present. 
• The voxel should include the abscess cavity to detect the breakdown products of these lesions. 
• Lactate, cytosolic acid, alanine, and acetate are characteristic metabolites in bacterial abscesses. 
• Toxoplasmosis and tuberculomas show prominent peaks from lactate and lipids.
27. MRS in AIDS:
• Extent of NAA depletion correlates directly with the degree of dementia in AIDS. 
• MRS distinguishes the common focal brain lesions in AIDS patients. 
• Choline : 
• Elevated in lymphoma, 
• Decreased in toxoplasmosis, tuberuloma cryptococcoma. 
• Lactate and lipids
• elevated in toxoplasmosis 
• Lactate
• Decreased in Tuberculoma and cryptococcoma.

References

• https://www.slideshare.net/airwave12/mr-spectroscopy
• https://radiopaedia.org/articles/mr-spectroscopy-1