Comparing free water imaging and magnetization transfer measurements in schizophrenia
Introduction
Although the etiology of schizophrenia is still unknown there is compelling evidence that white matter in the brain is implicated (Flynn et al., 2003, Friston and Frith, 1995, Hulshoff Pol et al., 2004, Kubicki et al., 2007, Shenton et al., 2001, Voineskos et al., 2010). Magnetic resonance imaging (MRI) techniques such as diffusion weighted imaging (DWI) (Le Bihan and Breton, 1985, Stejskal and Tanner, 1965) — or when a tensor is used to model the diffusion profile of the water molecules, referred to as diffusion tensor imaging (DTI) (Basser, 1995) — have been extensively used to study schizophrenia, with varying results. These differences in results may be due to differences in patient populations, MRI field strengths, MRI acquisition sequences used, and/or analysis techniques, but most likely are a result of a combination of these factors (Kubicki et al., 2013).
Although differences in the diffusion profile are reported for virtually all brain regions, the overall consensus is that these differences are most prominent in fiber bundles connecting to the fronto-temporal parts of the brain (Shenton et al., 2010). To compare diffusion profiles between subjects, a number of scalar measures have been introduced to describe certain aspects of the diffusion profile. These include fractional anisotropy (FA) (Basser and Pierpaoli, 1996) and mean diffusivity (MD), which represent the two most frequently measures used. Using these methods reductions in FA and increases in MD in patients with schizophrenia have been reported in several studies (Ellison-Wright et al., 2014, Kubicki et al., 2013, Shenton et al., 2010). However, the interpretation of reported differences in FA and MD is complicated because there are a number of possible underlying mechanisms that may be responsible. For instance, differences in fiber directionality, level of myelination and axonal diameter and, importantly, the degree of partial volume between different tissue types, will all result in differences in FA as well as MD (De Santis et al., 2014).
One way to increase the specificity of DWI measures is to compare them with other imaging contrasts (Kubicki et al., 2005b). In previous studies, DWI measurements were combined with magnetization transfer imaging (de Weijer et al., 2011, de Weijer et al., 2013, Kubicki et al., 2005a, Mandl et al., 2010, Mandl et al., 2013b, Palaniyappan et al., 2013, van den Heuvel et al., 2010), which measures the amount of signal that is transferred from macromolecules (including myelin) to the water molecules in the free water pool (Henkelman et al., 2001, Laule et al., 2007, Wolff and Balaban, 1994). Magnetization transfer ratio (MTR), a measure derived from the magnetization transfer images, is a putative measure of myelination because in white matter the myelin molecules form a large fraction of the macromolecules present. Since both FA and MTR are (amongst others) sensitive to myelin content, combining both imaging contrasts can help us to understand better the underlying mechanisms. Many studies used MTR to study white matter in schizophrenia albeit with varying results. Several studies reported on lower MTR values in schizophrenia (Bohner et al., 2012, Du et al., 2013, Foong et al., 2000, Kubicki et al., 2005a, Palaniyappan et al., 2013, Price et al., 2010), one study reported no differences (Antosik-Biernacka et al., 2006) while other studies reported on higher MTR signal in schizophrenia (de Weijer et al., 2011, de Weijer et al., 2013, Mandl et al., 2010, Mandl et al., 2013b). Of particular relevance here, in our previous study (Mandl et al., 2010) we combined MTR and FA with a focus on prefrontal fiber bundles, i.e., left and right uncinate fasciculus and the genu of the corpus callosum. These three fiber bundles were reconstructed using fiber tracking (Jones, 2008, Mori et al., 1999) and FA, MD and MTR values were measured along the reconstructed fiber bundles. The main finding was a statistically significantly higher MTR along the right uncinate fasciculus in schizophrenia patients, which was not accompanied by a higher FA. Since the MTR changes did not overlap with the FA changes, and since MTR is sensitive, but not specific to myelin changes, we speculated that the increased MTR finding is not related to myelin changes. It is also known that MTR is influenced by other mechanisms such as changes in T1 relaxation time, and modulation of neuroinflammation (Laule et al., 2007). Accordingly, we speculated that this higher MTR may reflect differences in the free water pool (e.g., water in the extracellular space) between groups. Our rationale was that an increase in free water in patients with schizophrenia would lead to prolonged T1 relaxation times (Kalus et al., 2005), which could then explain the measured increase in MTR.
Here, our goal was to further test the hypothesis that differences in bulk water contribute to the observed increased MTR by incorporating free-water imaging, which is a recently proposed post processing method that operates on DWI data and can estimate the fractional volume of free water in each voxel (Pasternak et al., 2009). In line with our hypothesis, a previous free-water study in schizophrenia found that there was an increase in the volume of the extracellular space in schizophrenia patients following their first psychotic episode (Pasternak et al., 2012). For this reason we reanalyzed the data from Mandl et al. (2010) to obtain free-water measures, and we added nine more major fiber bundles (Boos et al., 2013) (Fig. 1A) to the three bundles tested earlier. By combining the measures we tested whether differences in free water concentrations could indeed be an alternative explanation for the higher MTR values measured in patients with schizophrenia.
Section snippets
Subjects
Forty patients with schizophrenia and 40 healthy participants, matched for age, gender, handedness and parental education participated in this study. The healthy participants were recruited by means of local newspaper advertisements. The study was approved by the medical ethics committee for research in humans (METC) of the University Medical Center Utrecht, the Netherlands. All subjects participated after written informed consent was obtained. All participants underwent extensive psychiatric
Results
Using the fiber-based analysis we found statistically significantly higher MTR values for schizophrenia patients in the right uncinate fasciculus, the right inferior fronto-occipital fasciculus and the right arcuate fasciculus (see Fig. 2). The results for all fiber bundles are shown in Table 2. Note that the right uncinate finding is not a new finding but one that was already reported in the previous study.
Application of the Fisher's z transformation revealed no statistically significant group
Discussion
We compared white matter integrity in 12 fibers between schizophrenia and healthy controls using diffusion tensor imaging and magnetic transfer imaging. We find increased MTR values in the uncinate and arcuate fasciculus in patients with schizophrenia. However, we find no statistically significant differences for FAc, MDc or FW. Although in the patients with schizophrenia there were trend level increases in the MDc (splenium of the corpus callosum), decreases in the FAc (genu of the corpus
Role of funding source
This work was partially funded by grants from the NIH (nos. P41RR013218, P41EB015902, and R01MH074794). OP was partially supported by a NARSAD (National Alliance for Research on Schizophrenia and Depression) Young Investigator grant from the Brain & Behavior Research Foundation.
Contributors
René Mandl and Ofer Pasternak designed the study, performed the analysis, wrote the article and approved the final version of the manuscript. Wiepke Cahn, René Kahn and Hilleke Hulshoff Pol made a substantial contribution to the acquisition and interpretation of the data, critically reviewed the manuscript and approved the final version.
Marek Kubicki and Martha Shenton made a substantial contribution to the interpretation of the data, critically reviewed the manuscript and approved the final
Conflict of interest
All authors declare no conflicts of interest.
Acknowledgments
None.
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These authors contributed equally.