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M.R.Spectroscopy
rain
A brief basic guide
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Introduction
Among the new emerging MRI techniques, brain MRS has proved to be of more interest, being
readily available & of important clinical applications.
In this simplified approach, I tried to provide the minimal required knowledge for the fellow specialist
colleagues, otherwise, MRS is a whole science by itself really worth the effort. Also, I preferred to
follow an easyeasy-toto-understand & betterbetter-toto-recall clinical approach rather than starting with the dull
sophisticated physics. Notes, illustrations, simple glossary and a list of book & internet references will help
better understanding the subject. Hoping you will enjoy as you proceed,
proceed, I welcome answering any
questions by ee-mail at amirmonirali@yahoo.com
Dr
Dr
What is MR spectroscopy?
MR spectroscopy is the use of magnetic resonance in
quantification of various metabolites (chemical
composition) and the study of their distribution in
different tissues.
Rather than displaying MRI proton signals on a gray
scale as an image depending on its relative signal strength,
MRS displays the quantities as a spectrum. The resonance
frequency of each metabolite is represented on a graph and
is expressed as parts per million (ppm). This is because the
resonance frequency is in MHz or 106 Hz.
Amirmir Monir
Monir
MRI
MRS
Compound
Nucleus
1H
1H, 31P
Concentration
80 Molar
Millimolar
Resonances
One frequency
Contrast parameters
Chemical shift
Spatial resolution
(sub-) millimeter
Centimeter(s)
Temporal resolution
(sub-) seconds
Minutes
, 13C , 19F
Main metabolites
The Good, The Bad, and The Ugly
Although there are several metabolites included in the spectrum
of the MRS, there are three main in the brain: N-acetyl aspartate
(NAA), choline (Cho), and the lactate and lipid groups (LL).
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The different nuclei that can be used with
MR spectroscopy include H 1, phosphorus 31,
carbon 13, fluorine 19 ,and sodium 23. The
hydrogen and phosphorus concentration in
central nervous system tissue is high enough to
be useful in clinical MR spectroscopy. At this
time, hydrogen is best suited for MR
spectroscopy because of its:
- high concentration,
- favorable relaxation time,
- high gyromagnetic ratio.
Creatine
The Cr peak is located at 3.03 ppm and has contributions from Cr, Cr phosphate,
GABA, lysine and glutathione. A secondary peak for Cr is at 3.94 ppm. The Cr
compounds are involved in energy metabolism via Cr kinase reaction and probably
serve as reserves for high-energy phosphates in cell metabolism. Because the Cr
peak is relatively resistant to change during disease states when compared with other
metabolites, it is usually used in the denominator of Cho/Cr and NAA/Cr ratios. The
Cr concentration is increased in hypometabolic disease states and is decreased in
hypermetabolic disease states.
Types of MRS
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Data acquisition
Once an MR image is obtained as a localizer
image, a volume of interest is selected. If a single
voxel is to be analyzed, then a single 3D region of
interest is selected.
Once the single voxel is obtained, the spectrum is collected based on the amount of protons in the
voxel. The proton signals are detected and represented as a free induction decay (FID). A Fourier
transform is applied to the FID, converting the temporal information into frequency information.
The resonant frequency is then plotted versus signal intensity on a spectrum, instead of the typical
gray-scale image. If multiple voxels are to be evaluated, then both a region of interest for evaluation
and a region of normal brain are selected for comparison. Of the single-voxel techniques, two
commonly used acquisition sequences are stimulated echo acquisition mode (STEAM) and point
resolved spectroscopy (PRESS).
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With twice the signal of STEAM, PRESS acquisitions are faster; however, spectral baselines
are better with STEAM sequences. Care must be taken when identifying voxels of interest
(especially for the normal brain comparisons), since significant regional differences in metabolite
distributions can be seen in both gray and white matter. Regions to be avoided when selecting
voxels include blood, bone, and cysts, since susceptibility artifacts may skew the expected normal
molecular distributions. Areas that are difficult to image include the posterior fossa and the spinal
cord (both of which encounter problems due to their proximity to bone), as well as tumors
containing cystic components, blood, or regions of calcification.
Data analysis
The three-step approach to spectral analysis
Step 1: The quality assurance phase. Is it an
adequate spectrum?
Step 2: Is Hunters angle normal?
Step 3: Starting from the right side of the graph,
count off the location and check quantities of The
Good, The Bad, and The Ugly. These are located
on the x axis at 2.02 ppm, 3.22 ppm, and the area
from 0.9 to 1.33 ppm.
Quality assurance
Just as a bad image can make interpretation difficult or impossible for diagnosis, a bad MRS may
not be interpretable. Substances that are difficult for MRS to image include bone, blood, cysts, and
cerebral spinal fluid (CSF). It is difficult to obtain spectra of bone and blood due to immobile
protons (bone) and shim difficulties (blood). Both CSF and cysts can contain lactate products and,
thus, may lead to inaccurately elevated lactate or lipids as well. When performing voxel
measurements, you should stay clear of these substances in all three imaging planes. Since the area
sampled is a voxel, it acquires signal from regions above and below the box that has been placed.
Examples of an adequate spectrum include good water suppression; otherwise the water peak on
the MRS spectrum is so abundant, it will overshadow the other metabolites. The normal water
concentration is 100,000 times the concentration of other metabolites. To detect these metabolites
successfully, the signal from water must be suppressed adequately. The water peak located at the far
left of the spectrum at 4.7 ppm can be suppressed using chemical shift selective excitation (CHESS)
or water elimination Fourier transform technique.
At present, CHESS is the most frequently used technique and involves presaturation of water
signal using one or more 90 presaturation pulses centered over the water resonance frequency.
Using this technique, the water signal can be suppressed by a factor of up to 1000. In contrast,
water elimination Fourier transform technique involves a 180 pulse centered over water and is less
efficient than CHESS for water suppression.
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Hunters angle
Hunters angle is a term coined from a neurosurgeon, Hunter
Sheldon. Instead of doing complex ratios and analysis of the
spectra, he simply used his pocket comb. He placed his comb on
the spectrum at approximately a 45 angle and connected several
of the peaks. If the angle and peaks roughly corresponded to the
45 angle, the curve was probably normal (Fig). If the peaks
strayed off the combs angle, the curve was abnormal (Fig). This
is a quick, useful method to read MRS and determine normal from
abnormal. It is important to remember, however, that this angle
was used with STEAM spectra from the brain only.
Hunters angle
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Radiation necrosis versus recurrent tumor. (A) Tumor recurrence. There is elevation of choline as well as lipid and lactate.
The choline elevation raises our suspicion of tumor. Note that the baseline water suppression has been altered to ease
interpretation. (B) Radiation necrosis. There is elevation only in the lipid lactate area. If the patient has the proper clinical
history and the time frame is correct, this is consistent with radiation necrosis and not recurrent tumor. We may elect to
follow this with additional MRS and MRI evaluations.
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Other diseases
In patients with Alzheimers disease, there is a decrease in
NAA levels and hippocampus atrophy, which may be useful in
distinguishing this disease from normal aging.
There are reports of a decrease in NAA levels and an increase in mI in patients with Alzheimers
disease. In patients with hepatic encephalopathy, there is an increase in glutamine, a decrease in
Cho, and a decrease in mI concentration. In Parkinsons disease, NAA, Cr, and Cho levels are
unchanged but lactate levels are elevated. The MR spectroscopy feature of brain abscess includes
increased acetate and succinate levels at 1.92 and 2.42 ppm, respectively.
Brain abscess in a 59-year-old man. (A) The postcontrast T1-weighted image shows a focal necrotic
space-occupying lesion in the left temporal lobe
with peripheral rim enhancement. (B) The proton
magnetic resonance spectroscopy of this lesion
shows elevated acetate and succinate levels at 1.92
ppm and 2.42 ppm, respectively (arrows). These
are key markers for brain abscess identification
(arrows). The broad peak between 1.0 to 1.5 ppm is
related to lipid and/or amino acids. Acquisition
parameters: Long echo-time spin-echo (point
resolved spectroscopy) sequence with repetition
time/echo time = 1500 ms/135 ms.
Pitfalls
MR spectroscopy is a technically demanding investigation and produces low SNR. The possible
causes of poor spectral quality on MR spectroscopy include hemorrhage, postoperative changes,
less than 200 acquisitions, small voxel size, and automatic shimming. These causes either result in
poor homogenity of the magnetic field or poor SNR, making the interpretation of spectroscopy data
unreliable. The presence of hemorrhage and postoperative changes within the volume of interest
often leads to poor-quality measurements due to susceptibility effects caused by hemosiderin. The
cortical brain lesions located close to the calvaria are often difficult to image on MR spectroscopy
because of susceptibility artifacts and contamination from lipids located outside the dura.
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References
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Dr
Amir Monir