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Cine imaging using water (saline) bolus for investigating swallowing problems (dysphagia) in Parkinson’s Disease1Department of NMR and MRI Facility, All India Institute of Medical Sciences, New Delhi, India, 2Department ENT, Lady Harding Medical College, New Delhi, India, 3Department Physiology, ESI Dental College, New Delhi, India, 4Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India, 5Department of Neurology, Lady Harding Medical College, New Delhi, India
Synopsis
Swallowing a basic oromotor function for survival, investigated with videofluoroscopy (VFS) and flexible endoscopic evaluation (FEES) have limitations either of ionizing radiation, soft-tissue details or of invasiveness. Further clinical examination is challenged with cognitive impairment in degenerative diseases, so non-invasive technique is required for appropriate management. Cine magnetic resonance imaging (dynamic MRI, dMRI) and T2 weighting visualize saline water hyperintensity signal for tissue-bolus contrast without any gadolinium agent. This pilot study reveals dMRI as sensitive non-invasive technique for measuring all the four phases. In motor degenerative diseases like Parkinson’s Disease aids detecting early signs of dysphagia for optimal intervention.
Purpose
Investigations available for swallowing problems is insufficient and any improvement in assessments will be useful in clinical practice1. Videoflouroscopy (VFS) has limitations of ionizing radiation exposure, soft tissue details and flexible endoscopic evaluation of swallowing (FEES) is invasive lacking quantitative parameters2,3. There is need of the reliable non-invasive technique that can investigate dysphagia in adult (ageing, neurodegenerative disorders and acquired lesions- stroke)4, and in children (cerebral palsy, movement disorders, other developmental)5. So a pilot study was planned to evaluate dynamic MRI (without any contrast agent) as clinical application for swallowing assessment.Introduction
Dysphagia, a swallowing problem may have multifactorial oromotor involvements that are difficult to visualize anatomically. Magnetic Resonance Imaging (MRI) is a non-invasive investigating tool for soft tissue contrast6 and T2 weighted dynamic MRI (dMRI) technique evaluates normal-saline water (NS) bolus movement7. In neurodegenerative disorders like Parkinson’s Disease (PD) muscle rigidity, slow, hesitant and incoordinated movements may play role in dysphagia involving oral, nasal and respiratory muscle groups, which are difficult to evaluate and under-reported with first aspiration pneumonia episode8,9. Dynamic MRI has been tried in many swallowing studies by creating natural organic contrast of bolus with soft tissues but the bolus used was either potassium rich (blue-berry juice10) or semisolid (thickened pineapple juice11) with maximum of ten frames per second (fps). Investigation of dysphagia needs better rate (fps) and water bolus as clinical simulate2.Methods
Sample consisted of 12 subjects (6 Male and 6 Female) with idiopathic PD and 6 healthy controls (HC; 3 Male and 3 Female) with age range of 45 to 72 years. Study was approved by the IEC and all the participants were recruited after informed written consent. The dMRI parameters were standardized on healthy adults (n = 5 with age range of 20 to 25 years), those were not included in the pilot study. MRI acquisition of dynamic single slice 2-D sagittal images on 1.5T system (Aera, Siemens Healthcare, Germany) using head, neck and large-flex-body (12H 4N and 4BFlex) coils with T2 trueFISP (trufi-cine) sequence. Parameters used were- field of view 280 (FOV), repetition time 162.54 msec, echo time 1.27 msec, flip angle 44 degrees, matrix of 206 x 256, band width of 975, single slice with slice thickness of 10mm, acquisition 19.2 fps (frames per sec i.e. 0.32 sec per frame) and total acquisition time of 8.53 minutes. The K-space acquisition was 80.47% with phase encoding direction as rows and 208 steps. As it was T2 weighted imaging so normal saline water appeared as bright contrast compared to soft tissues7. Boluses (boli) of normal saline (NS, 0.9%) acquired that were delivered in mouth (rate 2ml/sec), and swallowing parameters studied were (i) jaw movement, (ii) tongue positioning, (iii) bolus transit (iv) velar closure, (v) hyoid bone elevation, (vi) epiglottic closure, (vii) pharyngeal wave, (viii) arytenoid movement, (ix) residual bolus, (x) spooling of saliva or bolus. Clinical assessments included (a) Swallowing Disturbance Questionnaire12 (SDQ), (b) Clinical Assessment of Dysphagia in Neurodegeneration13 (CADN).Results and Discussion
The tissue-bolus contrast was distinct to define boundaries especially for (velum, pharyngeal wall, epiglottis, and arytenoids) the susceptibility prone regions (Figure-1). On dMRI the PD patients had significant difference in oral (tongue, velar posture), oropharyngeal (hyoid, transit time and residue) and oesophageal (arytenoid movement) phases. None of the subject was observed as positive on SDQ. On CADN all the patients with PD scored ‘no’ (zero score), or ‘subclinical’ (one score) signs of dysphagia similar to all the healthy control participants. So dynamic MRI, facilitated the diagnostic evaluations of swallowing7 using saline as bolus without any contrast agent4 for early dysphagia signs in PD. Also without exposing the subjects and clinician to ionizing radiation3,4,7.Conclusion
Dynamic MRI visualizes explicitly the vocal tract tissue-water bolus contrast (without gadolinium agent) and is reliable technique for detecting early dysphagia signs in PD before significant changes in clinical scores.Acknowledgements
No acknowledgement found.References
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