Brain Perfusion Imaging of a Large Population: Arterial Spin Labelling MRI in UK Biobank
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eLife Assessment
This important study reports on the relationships between cerebral haemodynamics and a number of factors that relate to genetics, lifestyle, and medical history using data from a large cohort. Compelling evidence suggests that brief arterial spin labelling MRI acquisition can lead to both expected observations about brain health, as manifested in cerebral blood flow, and biomarkers for use in diagnosis and treatment monitoring. The results can be used as a starting point for hypothesis generation and further evaluation of conditions expected to affect haemodynamics in the brain.
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Abstract
Blood flow to the brain is a sensitive marker of neuronal activity as well as of a number of diseases, including stroke, tumours and neurodegenerative conditions. Arterial spin labelling (ASL) is a non-invasive magnetic resonance imaging (MRI) method that can map brain perfusion, but the ability to identify relationships between blood flow and lifestyle, genetics and disease has been limited by the scale of ASL studies to date. Here, we describe the inclusion of ASL in the repeat-imaging component of the UK Biobank imaging study, a prospective epidemiological study that has acquired 100,000 first-scan datasets and aims to accumulate over 60,000 repeat-scan datasets in predominantly healthy participants, along with rich information about lifestyle factors, genetics and long-term health outcomes. The imaging protocol and analysis pipeline are outlined, along with preliminary analyses of the first 7,157 subjects (more than twice as many as the largest previous ASL study). Significant associations with a range of factors are found, including those relating to the heart and blood vessels, alcohol consumption, cognitive tasks, white matter lesions and health information, such as hearing loss and depression. ASL is shown to be more sensitive to many of these factors than other imaging modalities, complementing the existing range of structural and functional measures available in the protocol. This resource is available to researchers worldwide, which we hope will facilitate new insights into healthy brain function and pathophysiology, and potentially allow the identification of early markers of disease as long-term health outcomes accumulate.
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eLife Assessment
This important study reports on the relationships between cerebral haemodynamics and a number of factors that relate to genetics, lifestyle, and medical history using data from a large cohort. Compelling evidence suggests that brief arterial spin labelling MRI acquisition can lead to both expected observations about brain health, as manifested in cerebral blood flow, and biomarkers for use in diagnosis and treatment monitoring. The results can be used as a starting point for hypothesis generation and further evaluation of conditions expected to affect haemodynamics in the brain.
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Reviewer #1 (Public review):
Summary:
In this work, Okell et al. describe the imaging protocol and analysis pipeline pertaining to the arterial spin labeling (ASL) MRI protocol acquired as part of the UK Biobank imaging study. In addition, they present preliminary analyses of the first 7000+ subjects in whom ASL data were acquired, and this represents the largest such study to date. Careful analyses revealed expected associations between ASL-based measures of cerebral hemodynamics and non-imaging-based markers, including heart and brain health, cognitive function, and lifestyle factors. As it measures physiology and not structure, ASL-based measures may be more sensitive to these factors compared with other imaging-based approaches.
Strengths:
This study represents the largest MRI study to date to include ASL data in a wide age range of …
Reviewer #1 (Public review):
Summary:
In this work, Okell et al. describe the imaging protocol and analysis pipeline pertaining to the arterial spin labeling (ASL) MRI protocol acquired as part of the UK Biobank imaging study. In addition, they present preliminary analyses of the first 7000+ subjects in whom ASL data were acquired, and this represents the largest such study to date. Careful analyses revealed expected associations between ASL-based measures of cerebral hemodynamics and non-imaging-based markers, including heart and brain health, cognitive function, and lifestyle factors. As it measures physiology and not structure, ASL-based measures may be more sensitive to these factors compared with other imaging-based approaches.
Strengths:
This study represents the largest MRI study to date to include ASL data in a wide age range of adult participants. The ability to derive arterial transit time (ATT) information in addition to cerebral blood flow (CBF) is a considerable strength, as many studies focus only on the latter.
Some of the results (e.g., relationships with cardiac output and hypertension) are known and expected, while others (e.g., lower CBF and longer ATT correlating with hearing difficulty in auditory processing regions) are more novel and intriguing. Overall, the authors present very interesting physiological results, and the analyses are conducted and presented in a methodical manner.
The analyses regarding ATT distributions and the potential implications for selecting post-labeling delays (PLD) for single PLD ASL are highly relevant and well-presented.
Weaknesses:
At a total scan duration of 2 minutes, the ASL sequence utilized in this cohort is much shorter than that of a typical ASL sequence (closer to 5 minutes as mentioned by the authors). However, this implementation also included multiple (n=5) PLDs. As currently described, it is unclear how any repetitions were acquired at each PLD and whether these were acquired efficiently (i.e., with a Look-Locker readout) or whether individual repetitions within this acquisition were dedicated to a single PLD. If the latter, the number of repetitions per PLD (and consequently signal-to-noise-ratio, SNR) is likely to be very low. Have the authors performed any analyses to determine whether the signal in individual subjects generally lies above the noise threshold? This is particularly relevant for white matter, which is the focus of several findings discussed in the study.
Hematocrit is one of the variables regressed out in order to reduce the effect of potential confounding factors on the image-derived phenotypes. The effect of this, however, may be more complex than accounting for other factors (such as age and sex). The authors acknowledge that hematocrit influences ASL signal through its effect on longitudinal blood relaxation rates. However, it is unclear how the authors handled the fact that the longitudinal relaxation of blood (T1Blood) is explicitly needed in the kinetic model for deriving CBF from the ASL data. In addition, while it may reduce false positives related to the relationships between dietary factors and hematocrit, it could also mask the effects of anemia present in the cohort. The concern, therefore, is two-fold: (1) Were individual hematocrit values used to compute T1Blood values? (2) What effect would the deconfounding process have on this?
The authors leverage an observed inverse association between white matter hyperintensity volume and CBF as evidence that white matter perfusion can be sensitively measured using the imaging protocol utilized in this cohort. The relationship between white matter hyperintensities and perfusion, however, is not yet fully understood, and there is disagreement regarding whether this structural imaging marker necessarily represents impaired perfusion. Therefore, it may not be appropriate to use this finding as support for validation of the methodology.
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Reviewer #2 (Public review):
Summary:
Okell et al. report the incorporation of arterial spin-labeled (ASL) perfusion MRI into the UK Biobank study and preliminary observations of perfusion MRI correlates from over 7000 acquired datasets, which is the largest sample of human perfusion imaging data to date. Although a large literature already supports the value of ASL MRI as a biomarker of brain function, this important study provides compelling evidence that a brief ASL MRI acquisition may lead to both fundamental observations about brain health as manifested in CBF and valuable biomarkers for use in diagnosis and treatment monitoring.
ASL MRI noninvasively quantifies regional cerebral blood flow (CBF), which reflects both cerebrovascular integrity and neural activity, hence serves as a measure of brain function and a potential biomarker …
Reviewer #2 (Public review):
Summary:
Okell et al. report the incorporation of arterial spin-labeled (ASL) perfusion MRI into the UK Biobank study and preliminary observations of perfusion MRI correlates from over 7000 acquired datasets, which is the largest sample of human perfusion imaging data to date. Although a large literature already supports the value of ASL MRI as a biomarker of brain function, this important study provides compelling evidence that a brief ASL MRI acquisition may lead to both fundamental observations about brain health as manifested in CBF and valuable biomarkers for use in diagnosis and treatment monitoring.
ASL MRI noninvasively quantifies regional cerebral blood flow (CBF), which reflects both cerebrovascular integrity and neural activity, hence serves as a measure of brain function and a potential biomarker for a variety of CNS disorders. Despite a highly abbreviated ASL MRI protocol, significant correlations with both expected and novel demographic, physiological, and medical factors are demonstrated. In many such cases, ASL was also more sensitive than other MRI-derived metrics. The ASL MRI protocol implemented also enables quantification of arterial transit time (ATT), which provides stronger clinical correlations than CBF in some factors. The results demonstrate both the feasibility and the efficacy of ASL MRI in the UK Biobank imaging study, which expects to complete ASL MRI in up to 60,000 richly phenotyped individuals. Although a large literature already supports the value of ASL MRI as a biomarker of brain function, this important study provides compelling evidence that a brief ASL MRI acquisition may lead to both fundamental observations about brain health as manifested in CBF and valuable biomarkers for use in diagnosis and treatment monitoring.
Strengths:
A key strength of this study is the use of an ASL MRI protocol incorporating balanced pseudocontinuous labeling with a background-suppressed 3D readout, which is the current state-of-the-art. To compensate for the short scan time, voxel resolution was intentionally only moderate. The authors also elected to acquire these data across five post-labeling delays, enabling ATT and ATT-corrected CBF to be derived using the BASIL toolbox, which is based on a variational Bayesian framework. The resulting CBF and ATT maps shown in Figure 1 are quite good, especially when combined with such a large and deeply phenotyped sample.
Another strength of the study is the rigorous image analysis approach, which included covariation for a number of known CBF confounds as well as correction for motion and scanner effects. In doing so, the authors were able to confirm expected effects of age, sex, hematocrit, and time of day on CBF values. These observations lend confidence in the veracity of novel observations, for example, significant correlations between regional ASL parameters and cardiovascular function, height, alcohol consumption, depression, and hearing, as well as with other MRI features such as regional diffusion properties and magnetic susceptibility. They also provide valuable observations about ATT and CBF distributions across a large cohort of middle-aged and older adults.
Weaknesses:
This study primarily serves to illustrate the efficacy and potential of ASL MRI as an imaging parameter in the UK Biobank study, but some of the preliminary observations will be hypothesis-generating for future analyses in larger sample sizes. However, a weakness of the manuscript is that some of the reported observations are difficult to follow. In particular, the associations between ASL and resting fMRI illustrated in Figure 7 and described in the accompanying Results text are difficult to understand. It could also be clearer whether the spatial maps showing ASL correlates of other image-derived phenotypes in Figure 6B are global correlations or confined to specific regions of interest. Finally, while addressing partial volume effects in gray matter regions by covarying for cortical thickness is a reasonable approach, the Methods section seems to imply that a global mean cortical thickness is used, which could be problematic given that cortical thickness changes may be localized.
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Reviewer #3 (Public review):
Summary:
This is an extremely important manuscript in the evolution of cerebral perfusion imaging using Arterial Spin Labelling (ASL). The number of subjects that were scanned has provided the authors with a unique opportunity to explore many potential associations between regional cerebral blood flow (CBF) and clinical and demographic variables.
Strengths:
The major strength of the manuscript is the access to an unprecedentedly large cohort of subjects. It demonstrates the sensitivity of regional tissue blood flow in the brain as an important marker of resting brain function. In addition, the authors have demonstrated a thorough analysis methodology and good statistical rigour.
Weaknesses:
This reviewer did not identify any major weaknesses in this work.
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