Breath-hold Challenge Research Articles

Reliable quantification of BOLD fMRI cerebrovascular reactivity despite poor breath-hold performance

Cerebrovascular reactivity (CVR) can be mapped using BOLD fMRI to provide a clinical insight into vascular health that can be used to diagnose cerebrovascular disease. Breath-holds are a readily accessible method for producing the required arterial CO2 increases but their implementation into clinical studies is limited by concerns that patients will demonstrate highly variable performance of breath-hold challenges. This study assesses the repeatability of CVR measurements despite poor task performance, to determine if and how robust results could be achieved with breath-holds in patients. Twelve healthy volunteers were scanned at 3T. Six functional scans were acquired, each consisting of 6 breath-hold challenges (10, 15, or 20s duration) interleaved with periods of paced breathing. These scans simulated the varying breath-hold consistency and ability levels that may occur in patient data. Uniform ramps, time-scaled ramps, and end-tidal CO2 data were used as regressors in a general linear model in order to measure CVR at the grey matter, regional, and voxelwise level. The intraclass correlation coefficient (ICC) quantified the repeatability of the CVR measurement for each breath-hold regressor type and scale of interest across the variable task performances. The ramp regressors did not fully account for variability in breath-hold performance and did not achieve acceptable repeatability (ICC<0.4) in several regions analysed. In contrast, the end-tidal CO2 regressors resulted in “excellent” repeatability (ICC=0.82) in the average grey matter data, and resulted in acceptable repeatability in all smaller regions tested (ICC>0.4). Further analysis of intra-subject CVR variability across the brain (ICCspatial and voxelwise correlation) supported the use of end-tidal CO2 data to extract robust whole-brain CVR maps, despite variability in breath-hold performance. We conclude that the incorporation of end-tidal CO2 monitoring into scanning enables robust, repeatable measurement of CVR that makes breath-hold challenges suitable for routine clinical practice.

EFFECTS OF NICOTINE WITHDRAWAL ON PANIC-LIKE RESPONSE TO BREATH HOLDING: A PLACEBO-CONTROLLED, DOUBLE-BLIND, CROSSOVER PATCH STUDY

Cigarette smoking may increase the likelihood of developing panic disorder. Periods of nicotine withdrawal, in particular, may promote panic in individuals high in anxiety sensitivity. We examined the importance of nicotine withdrawal in the occurrence of smoking and panic. We utilized a placebo-controlled, double-blind, randomized, crossover design. Fifty smokers underwent a breath-holding (BH) challenge after the transdermal administration of nicotine on one test day and a placebo on another test day. Physiological and psychological variables were assessed at baseline as well as directly before and after the challenges. Nicotine abstinence induced a decrease in heart rate and systolic blood pressure (BP) before the BH procedure (heart rate: 78.80 ± 11.43 under nicotine, 70.88 ± 10.83 under placebo; systolic BP: 124.90 ± 11.34 under nicotine, 121.18 ± 13.44 under placebo) and shorter BH duration relative to the nicotine patch condition. Nicotine abstinence did not, though, increase fear reactivity to the challenge. The findings for heart rate and BP are consistent with the stimulant properties of nicotine. The reduced capacity to maintain apnea under placebo might be due to carbon dioxide (CO2 ) hypersensitivity during periods of nicotine abstinence. The negative findings regarding fear reactivity might be due to BH being a relatively weak anxiogen. Future researchers are encouraged to employ CO2 -inhalation procedures to study the relationship between nicotine withdrawal and panic.

Optimal quantitation of the cerebral hemodynamic response in functional near-infrared spectroscopy

We have compared cerebral hemodynamic changes measured by near-infrared spectroscopy (NIRS) with simultaneously acquired BOLD fMRI signals during breath hold challenge in humans. The oxy- and deoxyhemoglobin concentration changes were obtained from the same broadband NIRS data using four different quantitation methods. One method used only two wavelengths (690 nm and 830 nm), and three other methods used broadband data with different spectral fitting algorithms. We found that the broadband techniques employing spectral derivatives were significantly superior to the multi-wavelength methods in terms of the correlation with the BOLD signals. In two cases out of six we found that the time courses of the deoxyhemoglobin changes produced by the two-wavelength method were qualitatively inconsistent with the BOLD fMRI signals.

Breathhold‐regulated blood oxygenation level‐dependent (BOLD) MRI of human brain at 3 tesla

To investigate the cerebrovascular response to repeated breathhold challenges using blood oxygenation level-dependent (BOLD) MRI at 3T and compare the results with previous data at 1.5T. Six normal volunteers and six patients with brain tumors were recruited for this 3T study. For the normal group, BOLD MRI during repeated breathholds of different durations (five to 30 seconds) were acquired. Maximum signal change, full-width at half-maximum (FWHM) and onset time (defined as the time to the first half-maximum) were determined by curve fitting. The fractional activation volume was also calculated. Patients performed a 10- or 15-second breathhold paradigm according to individual capability. Significant BOLD signal increases in the gray matter for a breathhold period as short as 5 seconds at 3T, instead of 10 seconds at 1.5T. The fractional activation volume vs. breathhold duration reached a plateau of 49.54 +/- 7.26% at 15 seconds at 3T, which was higher and shorter than that at 1.5T. The maximum signal changes were significantly larger (a 69% increase) at 3T than at 1.5T. In the patient group, there were BOLD signal increases in gray matter but not in tumor bulk or perifocal edema, which agreed with the results previously found at 1.5T. BOLD MRI at 3T is more sensitive for detecting breathhold-regulated signal changes than at 1.5T, which allows a shorter and more feasible breathhold paradigm for clinical applications in patients with brain tumors.

Transcranial Doppler study of cerebrovascular reactivity: Are migraineurs more sensitive to breath-hold challenge?

Transcranial Doppler sonography (TCD) of cerebrovascular reactivity has been used to study migraine interictally. However, the previous TCD findings had been quite varied at the post breath-hold period. Autonomic responses were usually studied with cardiac information. The aim of this study was to use TCD as a tool to examine difference in cerebrovascular reactivity between migraineurs and non-headache controls by measuring interictally the whole time course of cerebral blood flow velocity (CBFV) during and after a breath-hold challenge. The percentage change of CBFV was derived in the left and right middle cerebral arteries in 10 migraineurs and 10 controls during and after a 20 s breath-hold. Three phases of CBFV change were identified with an initial positive phase above baseline, a middle negative phase during breath-hold, and a late positive phase which started before the cessation of breath-hold and continued for a period after. In addition to CBFV, we also extracted and utilized the information of the cardiac cycle duration (CC) derived from the time course of CBFV. The percentage change of CC was derived from time intervals between every two points of inflexion in CBFV. Two undershoots of CC change were shown at the transitions of breathing motions. We found evidence that migraineurs had significant difference of CBFV change at the middle negative phase during breath-hold and the pronounced undershoots of CC change compared to non-headache controls.

Low radiation dose ECG-gated chest CT angiography on a 256-slice multidetector CT scanner

Computed tomography angiography (CTA) of the thorax other than cardiac CTA, is utilized for a multitude of conditions and ranges in application from a diagnostic test, to presurgical planning and postsurgical follow-up. Helical CTA without electrocardiogram (ECG) gating has been routinely utilized for the evaluation of thoracic vasculature. However, its applicability can be limited in the evaluation of the thoracic aorta and pulmonary vasculature because of the artifacts resulting from cardiac motion. Traditional retrospective ECG-gated helical scans address this issue but at the price of a high radiation dose to the patient. In this paper we review CTA dose reduction strategies for non-coronary indications, examine field of view requirements, and discuss breath hold challenges for ECG-gated acquisitions. In addition, we present clinical examples performed using low-dose prospective gating technique for evaluation of the aorta acquired on a 256-slice multidetector computed tomography system.

The respiration response function: The temporal dynamics of fMRI signal fluctuations related to changes in respiration

Changes in the subject’s breathing rate or depth, such as a breath-hold challenge, can cause significant MRI signal changes. However, the response function that best models breath-holding-induced signal changes, as well as those resulting from a wider range of breathing variations including those occurring during rest, has not yet been determined. Respiration related signal changes appear to be slower than neuronally induced BOLD signal changes and are not modeled accurately using the typical hemodynamic response functions used in fMRI. In this study, we derive a new response function to model the average MRI signal changes induced by variations in the respiration volume (breath-to-breath changes in the respiration depth and rate). This was done by averaging the response to a series of single deep breaths performed once every 40 s amongst otherwise constant breathing. The new “respiration response function” consists of an early overshoot followed by a later undershoot (peaking at approximately 16 s), and accurately models the MRI signal changes resulting from breath-holding as well as cued depth and rate changes.

Cerebrovascular response time to a breath-holding challenge

To evaluate the timecourse of cerebrovascular reserve response to breath-holding. Using simultaneous bilateral transcranial Doppler (TCD) recordings from the MCA during a breath-holding challenge, we measured the time interval between baseline and peak blood flow velocity values in 25 patients with critical unilateral internal carotid artery (ICA) stenosis (> 85% lumen diameter reduction), in 9 patients with a non-critical (70-85%) ICA-stenosis and in 27 normal controls. Normal controls and patients with non-critical stenosis reached peak MCA velocities on both sides almost simultaneously. For the patients with critical stenosis the peak response time ipsilateral to the stenosis was delayed 2.40 +/- 3.43 sec compared to the opposite side. This delay resolved after carotid endarterectomy. In response to a breath-holding challenge unilateral critical ICA stenosis is associated with a significant ipsilateral prolongation of the rise time from baseline to peak MCA velocity.

Comparison between hyperventilation and breath-holding in panic disorder: Patients responsive and non-responsive to both tests

Our aim was to compare the demographic and psychopathological features of panic disorder (PD) patients who underwent hyperventilation and breath-holding challenge tests, and to describe the features of patients who had a panic attack after both tests versus those patients who did not experience panic after either test. Eighty-five PD patients were induced to hyperventilate (30 breaths/min) for 4 min, and a week later to hold their breath for as long as possible four times with a 2-min interval in between. Anxiety scales were applied before and after the tests. Patients who responded with a panic attack to both tests (BPA, n = 25) were compared with patients who experienced spontaneous panic attacks but did not panic in response to the two tests (NPA, n = 16). The BPA group had a significantly higher presence of respiratory symptoms during a panic attack. The criteria for the respiratory PD subtype were fulfilled in 18 (72.0%) BPA patients and in 6 (37.5%) NPA patients. The BPA patients had a later onset of panic disorder and a higher familial prevalence of PD. Our data suggest that there is a distinction between PD patients who were sensitive to both hyperventilation and breath-holding tests and PD patients who were not affected by the challenge tests. The panic attack may be a final common pathway for different types of stimuli, and respiratory tests may characterize different PD subgroups.

Separating respiratory-variation-related fluctuations from neuronal-activity-related fluctuations in fMRI

Subtle changes in a subject's breathing rate or depth, which occur naturally during rest at low frequencies (<0.1 Hz), have been shown to be significantly correlated with fMRI signal changes throughout gray matter and near large vessels. The goal of this study was to investigate the impact of these low-frequency respiration variations on both task activation fMRI studies and resting-state functional connectivity analysis. Unlike MR signal changes correlated with the breathing motion (∼0.3 Hz), BOLD signal changes correlated with across-breath variations in respiratory volume (∼0.03 Hz) appear localized to blood vessels and regions with high blood volume, such as gray matter, similar to changes seen in response to a breath-hold challenge. In addition, the respiration-variation-induced signal changes were found to coincide with many of the areas identified as part of the ‘default mode’ network, a set of brain regions hypothesized to be more active at rest. Regions could therefore be classified as being part of a resting network based on their similar respiration-induced changes rather than their synchronized neuronal activity. Monitoring and removing these respiration variations led to a significant improvement in the identification of task-related activation and deactivation and only slight differences in regions correlated with the posterior cingulate at rest. Regressing out global signal changes or cueing the subject to breathe at a constant rate and depth resulted in an improved spatial overlap between deactivations and resting-state correlations among areas that showed deactivation.

Suffocation and respiratory responses to carbon dioxide and breath holding challenges in individuals with panic disorder

Objective Findings showing that individuals with panic disorder (PD) are prone to experience panic attacks when inhaling CO 2-enriched air have given rise to the hypothesis that physiological systems underlying the experience of suffocation may be important in the etiology of PD. In this study, we tested several predictions stemming from this view. Methods Forty individuals with PD and 32 controls underwent both a breath-holding challenge and a CO 2 rebreathing challenge. A wide array of physiological and psychological responses, including continuous measurements of subjective suffocation, was recorded. Results Individuals with PD experienced elevated physiological reactivity to both challenges and greater levels of suffocation sensations during the rebreathing challenge. Furthermore, PD individuals who experienced a panic attack in response to the rebreathing challenge exhibited faster but shallower breathing during the challenge than did other PD individuals. Conclusion Findings are consistent with theories linking PD to hypersensitive brain systems underlying the experience of suffocation. The possibility that subjective suffocation was in part mediated by peripheral interoceptive disturbances (vs. brainstem dysregulation) is discussed.

35% Carbon dioxide and breath-holding challenge tests in panic disorder: a comparison with spontaneous panic attacks

Respiration and its control mechanisms may represent an important system involved in abnormal anxiety. Our aim was to compare the demographic and clinical features of patients with panic disorder (PD) with agoraphobia (DSM-IV) who had a panic attack after both the 35% carbon dioxide (CO(2)) test and the breath-holding test (CPA group), and compare them with PD patients who did not have a panic attack after both tests (NPA group). We examined 76 patients with PD who were administered a 35% CO(2)test and a breath-holding test within a 1-week interval. Anxiety scales were applied before and after each test. A panic attack was induced in 50 (65.8%) patients during the CO(2)test (chi(2) = 28.44, df = 1, P<.001) and in 40 (52.6%) patients during the breath-holding test (chi(2) = 15.35, df = 1, P = .036). All patients who had a panic attack during the breath-holding test also had a panic attack during the CO(2)test (n = 40; CPA group). Twenty-six (34.2%) patients with PD did not have a panic attack after both respiratory tests (NPA group). The CPA group had more (chi(2) = 21.67, df = 1, P = .011) respiratory PD subtype. In the CPA group, the disorder started earlier (Mann-Whitney, P<.001), had a higher familial prevalence of PD (chi(2) = 18.34, df = 1, P = .028), and had more previous depressive episodes (chi(2) = 23.59, df = 1, P<.001). Our data suggest that there is an association between respiratory PD subtype and the response to respiratory challenge tests: CO(2)and breath-holding. The CPA may be confirmed as a subgroup of respiratory PD subtype.

A temporal comparison of BOLD, ASL, and NIRS hemodynamic responses to motor stimuli in adult humans

In this study, we have preformed simultaneous near-infrared spectroscopy (NIRS) along with BOLD (blood oxygen level dependent) and ASL (arterial spin labeling)-based fMRI during an event-related motor activity in human subjects in order to compare the temporal dynamics of the hemodynamic responses recorded in each method. These measurements have allowed us to examine the validity of the biophysical models underlying each modality and, as a result, gain greater insight into the hemodynamic responses to neuronal activation. Although prior studies have examined the relationships between these two methodologies through similar experiments, they have produced conflicting results in the literature for a variety of reasons. Here, by employing a short-duration, event-related motor task, we have been able to emphasize the subtle temporal differences between the hemodynamic parameters with a high contrast-to-noise ratio. As a result of this improved experimental design, we are able to report that the fMRI measured BOLD response is more correlated with the NIRS measure of deoxy-hemoglobin ( R = 0.98; P < 10 −20) than with oxy-hemoglobin ( R = 0.71), or total hemoglobin ( R = 0.53). This result was predicted from the theoretical grounds of the BOLD response and is in agreement with several previous works [Toronov, V.A.W., Choi, J.H., Wolf, M., Michalos, A., Gratton, E., Hueber, D., 2001. “Investigation of human brain hemodynamics by simultaneous near-infrared spectroscopy and functional magnetic resonance imaging.” Med. Phys. 28 (4) 521–527.; MacIntosh, B.J., Klassen, L.M., Menon, R.S., 2003. “Transient hemodynamics during a breath hold challenge in a two part functional imaging study with simultaneous near-infrared spectroscopy in adult humans”. NeuroImage 20 1246–1252.; Toronov, V.A.W., Walker, S., Gupta, R., Choi, J.H., Gratton, E., Hueber, D., Webb, A., 2003. “The roles of changes in deoxyhemoglobin concentration and regional cerebral blood volume in the fMRI BOLD signal“ Neuroimage 19 (4) 1521–1531]. These data have also allowed us to examine more detailed measurement models of the fMRI signal and comment on the roles of the oxygen saturation and blood volume contributions to the BOLD response. In addition, we found high correlation between the NIRS measured total hemoglobin and ASL measured cerebral blood flow ( R = 0.91; P < 10 −10) and oxy-hemoglobin with flow ( R = 0.83; P < 10 −05) as predicted by the biophysical models. Finally, we note a significant amount of cross-modality, correlated, inter-subject variability in amplitude change and time-to-peak of the hemodynamic response. The observed co-variance in these parameters between subjects is in agreement with hemodynamic models and provides further support that fMRI and NIRS have similar vascular sensitivity.

Transient hemodynamics during a breath hold challenge in a two part functional imaging study with simultaneous near-infrared spectroscopy in adult humans

During a breath hold (BH) challenge, functional MR imaging using flow-sensitive alternating inversion recovery (FAIR) and blood oxygenation level dependent (BOLD) contrast was performed with simultaneous near-infrared spectroscopy (NIRS). Time courses for the BOLD signal, cerebral blood flow (CBF), absolute deoxyhemoglobin (Hb) concentration, and relative concentration changes for total hemoglobin (HbT) were generated to (1) characterize the relationship between transient BOLD responses and the transient hemodynamic response, and (2) compare results from previous empirical animal experiments. During this mild hypercapnia task, the increase in the BOLD signal during the task indicated that an increase in CBF outweighed the competing effect of a volume-induced increase in Hb. After the task, the increase in the concentration of Hb mirrored the posttask undershoot in the BOLD and CBF data. Finally, we found a strong linear relationship between R2* and absolute Hb, except for outlier points in the Hb time series corresponding to the task cessation, which suggests there are differences in measurement sensitivity between BOLD and NIRS.

Changes in baseline cerebral blood flow in humans do not influence regional cerebral blood flow response to photic stimulation

The effect of changes in baseline regional cerebral blood flow (rCBF) values on the cerebral blood flow response during neuronal activation was studied with functional magnetic resonance imaging (fMRI). Using a breath-holding challenge as a hypercapnic stimulus, rCBF alterations during photic stimulation under normo- and hypercapnia were determined in nine volunteers. With breath-holding, baseline rCBF in areas corresponding to the visual cortex significantly increased from 54 +/- 5 ml/100 g/min to 85 +/- 9 ml/100 g/min (P < 0.001). Despite this significant change in baseline flow values, the rCBF increase during visual stimulation was very similar under normo- and hypercapnic conditions (28 +/- 8 ml/100 g/min versus 26 +/- 8 ml/100 g/min, respectively). This study supports the notion that within wide physiologic variations, task-induced cerebral blood flow changes are independent of baseline rCBF values.