Brain Perfusion Imaging of a Large Population: Arterial Spin Labelling MRI in UK Biobank

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.

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.

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.

Author response:

We thank the editors and reviewers for their generally positive and thoughtful feedback on this work. Below are provisional responses to some of the concerns raised:

Reviewer 1:

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.

We agree that this was a short acquisition compared to most ASL protocols, necessitated by the strict time-keeping requirements for running such a large study. We apologise if this was not clear in the original manuscript, but due to this time constraint and the use of a segmented readout (which was not Look-Locker) there was only time available for a single average at each PLD. This does mean that the perfusion weighted images at each PLD are relatively noisy, although the image quality with this sequence was still reasonable, as demonstrated in Figure 1, with perfusion weighted images visibly above the noise floor. In addition, as has been demonstrated theoretically and experimentally in recent work (Woods et al., 2023, 2020), even though the SNR of each individual PLD image might be low in multi-PLD acquisitions, this is effectively recovered during the model fitting process, giving it comparable or greater accuracy than a protocol which collects many averages at a single (long) PLD. As also noted by the reviewers, this approach has the further benefit of allowing ATT estimation, which has proven to provide useful and complementary information to CBF. Finally, the fact that many of the findings in this study pass strict statistical thresholds for significance, despite the many multiple comparisons performed, and that the spatial patterns of these relationships are consistent with expectations, even in the white matter (e.g. Figure 6B), give us confidence that the perfusion estimation is robust. However, we will consider adding some additional metrics around SNR or fitting uncertainty in a revised manuscript, as well as clarifying details of the acquisition.

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?

We agree this is an important point to clarify. In this work we decided not to use the haematocrit to directly estimate the T1 of blood for each participant a) because this would result in slight differences in the model fitting for each subject, which could introduce bias (e.g. the kinetic model used assumes instantaneous exchange between blood water and tissue, so changing the T1 of blood for each subject could make us more sensitive to inaccuracies in this assumption); and b) because typically the haematocrit measures were quite some time (often years) prior to the imaging session, leading to an imperfect correction. We therefore took the pragmatic approach to simply regress each subject’s average haematocrit reading out of the IDP and voxelwise data to prevent it contributing to apparent correlations caused by indirect effects on blood T1. However, we agree with the reviewer that this certainly would mask the effects of anaemia in this cohort, so for researchers interested in this condition a different approach should be taken. We will update the revised manuscript to try to clarify these points.

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.

We appreciate the reviewer’s point that there is still debate about the relationship between white matter hyperintensities and perfusion. We therefore agree that this observed relationship therefore does not validate the methodology in the sense that it is an expected finding, but it does demonstrate that the data quality is sufficient to show significant correlations between white matter hyperintensity volume and perfusion, even in white matter regions, which would not be the case if the signal there were dominated by noise. Similarly, the clear spatial pattern of perfusion changes in the white matter that correlate with DTI measures in the same regions also suggests there is sensitivity to white matter perfusion. However, we will update the wording in the revised manuscript to try to clarify this point.

Reviewer 2:

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.

We apologise if any of the presented information was unclear and will try to improve this in our revised manuscript. To clarify, the spatial maps associated with other (non-ASL) IDPs were generated by calculating the correlation between the ASL CBF or ATT in every voxel in standard space with the non-ASL IDP of interest, not the values of the other imaging modality in the same voxel. No region-based masking was used for this comparison. This allowed us to examine whether the correlation with this non-ASL IDP was only within the same brain region or if the correlations extended to other regions too.

We also agree that the associations between ASL and resting fMRI are not easy to interpret. We therefore tried to be clear in the manuscript that these were preliminary findings that may be of interest to others, but clearly further study is required to explore this complex relationship further. However, we will try to clarify how the results are presented in the revised manuscript.

In relation to partial volume effects, we did indeed use only a global measure of cortical thickness in the deconfounding and we acknowledged that this could be improved in the discussion: [Partial volume effects were] “mitigated here by the inclusion of cortical thickness in the deconfounding process, although a region-specific correction approach that is aware of the through-slice blurring (Boscolo Galazzo et al., 2014) is desirable in future iterations of the ASL analysis pipeline.” As suggested here, although this is a coarse correction, we did not feel that a more comprehensive partial volume correction approach could be used without properly accounting for the through-slice blurring effects from the 3D-GRASE acquisition (that will vary across different brain regions), which is not currently available, although this is an area we are actively working on for future versions of the image analysis pipeline. We again will try to clarify this point further in the revised manuscript.

References

Woods JG, Achten E, Asllani I, Bolar DS, Dai W, Detre J, Fan AP, Fernández-Seara M, Golay X, Günther M, Guo J, Hernandez-Garcia L, Ho M-L, Juttukonda MR, Lu H, MacIntosh BJ, Madhuranthakam AJ, Mutsaerts HJ, Okell TW, Parkes LM, Pinter N, Pinto J, Qin Q, Smits M, Suzuki Y, Thomas DL, Van Osch MJP, Wang DJ, Warnert EAH, Zaharchuk G, Zelaya F, Zhao M, Chappell MA. 2023. Recommendations for Quantitative Cerebral Perfusion MRI using Multi-Timepoint Arterial Spin Labeling: Acquisition, Quantification, and Clinical Applications (preprint). Open Science Framework. doi:10.31219/osf.io/4tskr

Woods JG, Chappell MA, Okell TW. 2020. Designing and comparing optimized pseudo-continuous Arterial Spin Labeling protocols for measurement of cerebral blood flow. NeuroImage 223:117246. doi:10.1016/j.neuroimage.2020.117246