Magnetic Resonance Spectroscopy Diagnosis of Neurological Diseases

342 Pages·1999·55.126 MB·\342

by  Else Rubaek Danielsen (Editor), Brian Ross (Editor)

Magnetic Resonance
Spectroscopy Diagnosis
of
Neurological Diseases

Magnetic Resonance
Spectroscopy Diagnosis
of
Neurological Diseases
Else Rub~k Danielsen
Brian Ross
Huntington Medical Research Institute
Pasadena, California
Boca Raton London New York
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First published 1999 by Marcel Dekker, Inc.
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ISBN-13: 978-0-8247-0238-0 (hbk)
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Libarary of Congress Cataloging-in-Publication Data
Danielsen, Else Rubrek
Magnetic resonance spectroscopy diagnosis of neurological diseases
/Else Rubrek Danielsen, Brian Ross
p. cm.
Includes index.
ISBN: 0-8247-0238-7
1. Nuclear magnetic resonance spectroscopy-Diagnositic use.
2. Brain-Diseases-diagnosis. I. Ross, Brian.
II. Title.
[DNLM: 1. Brain Diseases-diagnosis. 2. Nuclear Magnetic
Resonance. 3. Brain Chemistry. 4. Brain Diseases-pathology. WL
348 D186m 1998]
RC386.6.N83D36 1998
616.8'047548-dc21
DNLM/DLC
for Library of Congress 98-44756
CIP
Preface
Who is this book for? Many thousands of patients around the staff of the Huntington Medical Research Institute's
the world undergo MRS examinations of the brain. MRS is (HMRI) MRS Unit in Pasadena, California between 1995
"high-tech" medicine, and there is a serious lack of clini and 1997. Case studies assembled for that tutorial-style
cally relevant books to which physicians and others outside course proved educational to all, participants and teachers
the small field of magnetic resonance physics may turn for alike, and provided the idea for a teaching manual that
guidance. We conceived the idea of an atlas of common would be less ephemeral than patient files and MRIs on
neuropathologies as reflected in the MRS that could fill this X-ray film. Several of the often repeated difficulties en
gap for the busy clinician/neurologist. This book is the countered during these courses have been taken into ac
result: some 72 clinical cases, and well over 100 spectra are count and incorporated in a method of reading each spec
presented in a standard format with only a minimum of trum that, we hope, minimizes errors, highlights artifacts
technical information. With an eye to practical needs, the and maximizes useable clinical information.
maximum of help in reading and interpreting each spectrum However, even earlier than the Huntington courses, a
is provided in the associated text. Clinical spectra covering weekly clinical readout of brain MRS modeled on the usual
most of the common (and some not-so-common) neurologi medical grand round was conducted for the benefit of refer
cal entities are shown. Reading this book, and then acquir ring physicians (mostly, but not exclusively, neurologists or
ing and reading some MRS studies of patients on their own neurosurgeons), staff radiologists, surgical and medical res
should allow all clinicians to confidently read MRS studies idents of affiliated hospitals, and HMRI research fellows.
as they appear in the literature and in their own Clinical This organization, which came into existence at HMRI
practices. Finally, for the practicing neuroradiologist faced during the 1992 Presidential campaign adopted a name
with the task of writing a report for the use of the referring unmistakably that of the soon-to-be White House cat—
doctor and for the insurance provider (thereby ensuring Socks! SoCCSS, the Southern California Clinical Spectro
reimbursement for their work), one reading of this book scopy Service, remains in existence to provide a forum for
should establish a routine and enhance the intellectual and sharing clinical interpretation and advice among many
diagnostic interest of this newly expanding branch of their MRS proponents throughout southern California and the
specialty. world. A number of the instructive cases assembled in this
The origins of this book are to be found in a series of book come from this source. This fact alone should con
clinical magnetic resonance spectroscopy courses run by vince the skeptic that MRS can be a rigorous diagnostic
iii
IV Preface
tool. The message we wish to convey (beyond the central and beyond who through their better understanding of the
one, that there is valuable diagnostic information in the variations of clinical neurological disease, can stretch the
noninvasive biochemical analysis of the brain) is that when clinically useful interpretation of MRS beyond the some
applied in a rigorous way, proton MRS achieves greater what limited range we offer here.
diagnostic power than might have been expected. The bold We thought hard about the format of this book and are
diagnostic patterns are recognized by everyone, and even particularly grateful for the encouragement and ideas of
survive technical limitations of less-than-optimal MR scan fered by Graham Garratt and Kerry Doyle at Marcel Dekker,
ners. But a new level of confidence is achieved as the Inc. After consulting many colleagues, in the end we have
neurologist sees how robustly reproducible—even across taken a highly didactic approach. Hopefully this will not
state and international boundaries—are even the finest de unduly offend those already expert. Our hope is that by the
tails of the MR brain spectrum. At this point, MRS has simple-minded approach, anyone will become comfortable
achieved the status of a routine medical screening test, in reading a brain MRS; no one will be put off by the mystique
which the known and the hitherto unknown features of the of peaks or the imagined complexity of biochemistry and
scan can be incorporated in the physician's decision tree to thereby become inhibited from discovering the diagnostic
arrive at a new, more certain, or a more rapid diagnosis. value of the scan. Instead we hope the MR spectrum will
Throughout this book there are clinical brain spectra, the become what it actually is, a fingerprint of brain chemistry,
initial meaning of which was not immediately clear, but which is to be read for its diagnostic value. Normal and
which became so only after several days or weeks and after abnormal will be instantly recognized by the clinician,
highly focused consideration of other clinical or laboratory much as the abnormal EKG, protein electrophoretic strip,
data available in the workup of the patient. This exciting and M-mode cardiac ultrasound are currently recognizable.
process stimulated many of us to share our approach with Once this is routine, MR spectra should hold no terrors.
our colleagues in medicine. We hope this will expand the
number of patients to whom MRS is offered and also will Else Rubaek Danielsen
more deeply involve experts from neurological disciplines Brian Ross
Acknowledgments
Thanks are due to many who helped in the production of technologists, physicians, MR field-service engineers, and
this book: first, former and current colleagues at Huntington MR physicists, all of whom brought some special expertise
Medical Research Institutes, who have contributed in many to our handling of the basic MRS examination and quality
ways, in particular by acquiring MR spectra, but also by assurance.
providing invaluable suggestions, and assisting in general Ms. Maureen Brooks deserves special mention for pro
(in alphabetical order: Stefan Blüml, David Dubowitz, viding reimbursement seminars, through which very few
Thomas Ernst, Neil Farrow, Angela Geissler, Luke Haseler, of the participants could afford to doze! This attention was
Tuan Hoang, Keiko Kanamori, Roland Kreis, Jung-Hee rewarded in 1998 by the issuance of the first CPT code for
Lee, Jennifer Mandigo, Thomas Michaelis, Rex Moats, clinical magnetic resonance spectroscopy; this, as every
Mary Munoz, Truda Shonk, Sandra de Silva, Jeannie Tan, American reader will be aware, is an accolade that every
John Videen). Nationally and internationally, there has new medical technology needs in order to be accepted into
been a necessary engineering effort to sustain MRS capa routine clinical practice. Without any note of cynicism, if
bility on clinical MR scanners over many years even when MRS were not so recognized, it could hardly survive in the
its ultimate clinical utility was in doubt. These people, men face of intense competition from a host of neurological
tioning some but not by any means all, showed faith in their diagnostic tools available to the modern physician.
own MR physics skills, when financial imperatives often Very special thanks are due to Dr. Roland Kreis, Boswell
indicated otherwise (in alphabetical order: David Gurr, Fellow at HMRI and California Institute of Technology
Ralph Hurd, Peter Luyten, Peter Martin, James Murdoch, (1991-1993), who implemented the first quantitative lo
Thomas Raidy, Pom Salasuta, Rolf Sauter, James Tropp, calized MRS pulse sequences, obtained the first data in
Peter Webb, Wicklow); teachers of several MRS Courses healthy volunteer of all ages, and initiated a vast number of
(in alphabetical order: Edguardo Arcinue, Emanuel Ca the clinical studies upon which this book relies so heavily.
banis, Russell Caldwell, David Dubowitz, Patricia Gifford, A large number of figures (see below) are taken from the
Luke Haseler; Bruce Miller, Rex Moats, Joseph Norfray, published works of Dr. Kreis.
Truda Shonk (who also acquired a large number of the Also deserving special thanks are Dr. Stefan Blüml,
spectra from HMRI), Leslie Watson (who also acquired all Research Fellow at HMRI and the Schulte Research Foun
spectra from Rancho Los Amigos); students who attended dation; Dr. Thomas Michaelis, Boswell Fellow at HMRI
courses and taught all of us a great deal. This includes MR
and California Institute of Technology (1994-1995); and
VI Acknowledgments
Dr. Thomas Ernst, Research Fellow at HMRI, who all have Academic Press (Magn. Reson. Med.): 2.12
been invaluable sources for discussion and support during Williams & Wilkins (Magn. Reson. Med.): 3.36, 6.4(i)
the preparation of the book and in the years before, as well Society of Magnetic Resonance in Medicine: 3.1
as having contributed to maintaining the clinical MRS John Wiley & Sons (NMR in Biomed.): 3.2, 3.14, 3.18
program. Eur. J. Radiol.: 3.4, 6.2D
Faith in the future of clinical MRS has been constant and RSNA: 3.4, 6.1 (modified), 6.2A, 6.8
reflected in encouragement of the Executive Director (Dr. (JCAT): 3.5, 3.8
W. Opel), chairman and members of the Board of Trustees Based on Agarwal: 3.7 and 3.17
of HMRI. J Biochem. (modified): 3.10
Stockier et al. : 3.15
Moffett et al.: 3.19
Acknowledgments Pediatrics: 3.24, 6.7
Saunders (or modified from): 3.31, 6.2C, 6.4(ii-iv)
Several of the figures shown were produced at HMRI by or Keusler et al.: 3.32
in part by the following: Kreis: 2.11,2.12, 3.2, 3.3, 3.4,3.22, Istituto Superiore di Sanita, Rome, Italy, 1994 (Eurospin
3.34, 4.2, 4.3, 6.2D, 6.3, 6.4 panel (i), 6.5B; Bliiml: 3.24, Annual): 3.33
3.6, 6.6, 6.7; Ernst: 3.27, 3.31, 4.2, 4.3, 6.1, 6.2, 6.3, 6.6, Am. J. Neuroradiol.: 6.IB
6.5B; Haseler: 3.24, 6.6, 6.7; Mandigo: 2.3, 3.2, 3.9, 4.1G; Lancet: 6.2B
Michaelis: 6.5A; Moats: 6.1; Shonk: 6.1, 6.2. Raven Press (MR Quarterly): 6.3A, 6.5A
We are grateful for permission to reproduce the follow Cambridge University Press: 6.3B, 6.5B,C
ing published figures (other acknowledgements are pro J. Clin. Invest.: 6.3C,D
vided in the text): modified from JMRI: 6.6.
Contents
Preface ni
Acknowledgments v
CHAPTER 1: INTRODUCTION TO MAGNETIC RESONANCE SPECTROSCOPY 1
I. A Brief History of Clinical Magnetic Resonance Spectroscopy 1
II. Motivation 2
A. A Working Knowledge of Brain Chemistry in Medicine 2
B. Clinical Indications for MRS 2
C How to Read and Interpret the MR Spectrum 2
III. A More Detailed Look at MRS: The Single Volume of Interest 3
IV Philosophy of Single Volume of Interest MRS 3
V Method of Single VOI Adopted in This Book 4
VI. Three Simple Rules for Understanding an MR Spectrum of the Brain 4
A. Rule One: Spectra Are Read in Terms of Peak Ratios 4
B. Rule Two: Uniform Clinical Methods Yield Identical Spectra 4
C Rule Three: MRS Is a Quantitative Technique 4
Further Reading 4
CHAPTER 2: BASIC PHYSICS OF MRS 5
I. Introduction 5
A. What Is an MRI? 5
B. What Is an MR Spectrum? 5
II. Measurement Protocol Choices 6
A. What Do We Mean by Localization ? 6
B. STEAM and PRESS 7
C. Choice of STEAM Versus PRESS 7
D. How Does the Echo Time Affect the Spectrum? 7
E. How Does the Repetition Time Affect the Spectrum? 8
vii