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Living Well with Multiple Sclerosis
Beyond lesions: what advanced MRI may reveal about MS | S8E17
00:26:04
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- [00:01]
Bhavna Solanki
Total sodium concentration was increased in people with ms, but it was higher depending on what sort of Ms. You have. So if you had relapsing remitting or secondary progressive or primary progressive, the amount of sodium increase you got was sort of in line with how progressed the disease was, and also the sodium concentrations related to disability as well. And this isn't sodium just in the lesions that you can see in your standard mri. It's sodium that's changing in what looks like normal, healthy tissue.
- [00:32]
Podcast Producer/Host Announcement
Welcome to Living well with Ms. This show comes to you from Overcoming ms, the world's leading multiple sclerosis healthy lifestyle charity, which helps people live a full and healthy life. Through the Overcoming Ms. Program, we interview a range of experts and people with multiple sclerosis. Please remember, all opinions expressed are their own. Receive monthly tips and ideas about living well with Ms. By signing up for our newsletter@overcomingms.org Newsletter and now let's meet our guest.
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Podcast Host
Welcome to the latest edition of the Living well with Ms. Podcast. Joining me on this edition is Bhavna Solanki. So welcome Bhavna.
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Bhavna Solanki
Hi.
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Podcast Host
Bhavna is an MRI physicist with over 15 years of experience at the Queen Square center for Multiple Sclerosis in London, England, where her work focuses on developing novel MRI markers to better understand multiple sclerosis. Her research aims to uncover how Ms. Affects the brain at a chemical and cellular level and to translate these insights into tools that can help measure the effectiveness of new treatments and distinguish between different Ms. Subtypes. Welcome Bhavana. Yeah, welcome to the podcast.
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Bhavna Solanki
Thank you.
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Podcast Host
So to start off with, could you give us a bit of an introduction of yourself and your work?
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Bhavna Solanki
Yeah, thank you for the kind introduction you've already given. It's really nice to be on here. So I work as a researcher at the Queen Square Mets Centre University College, London, and my job as an MRI physicist is to develop MRI scans and to develop biomarkers to help understand Ms. Better at a cellular level, to measure different chemicals in the brain and things like that. And the way I do that is a bit like using the MRI machine, like a giant SLR camera, where if you want to get a different type of image, you have a different shutter speed or a different lens or different flash and you get a different looking image. So what we want is different looking images from our brain or spinal cord to tell us different things about what's going on.
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Podcast Host
So it's a. Because I think most of us probably think of it as a bit like an X ray but in 3D. But you're saying it does a lot more than that. It's not.
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Bhavna Solanki
It does a lot. So with the X ray, number one, it's. I guess it's similar in the same. You get an image of the part of the body with X rays, it's mostly bones. With mri, you're getting soft tissue contrast, so you're seeing muscles, fat, fluid in the body that you might not see in an X ray. And it's completely non invasive as well, so it doesn't matter how many you have, it's not going to harm you. I, as an MRI researcher, go in the MRI scanner a lot for many, many different studies to test sequences that we've developed. So, yeah, it's completely non invasive and it can tell you a lot more. Yeah.
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Podcast Host
And so you've come from a background as a physicist, but what led to your research interest in multiple sclerosis?
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Bhavna Solanki
So it's quite weird, actually. I started with astrophysics. I really enjoyed it. I wanted to learn how stars are made and things like that. But by the end of my degree, I wanted to do something that more directly help people. And there's actually a lot of overlap between the physics involved with looking at distant galaxies and looking inside your brain or spinal cord, because they both use radio waves and they use these little satellites, we call them RF coils in mri use these little satellites to collect the signal and then you use a fancy computer to make that into an image. And, um. So a lot of that I'd already sort of covered a bit and I felt, oh, I can help people more directly. So I went off, I did some research in diabetes, liver toxins and stroke models. And then I saw this job at UCL and it was really interesting. As an MRI physicist, they were the first center to do something called sodium MRI in the uk. And I thought, well, that's really exciting. It'll be a, you know, first. And it worked with this leading Ms. Research group, which was really exciting. But what really sparked my curiosity is the entire MRI scanner had been funded by the Ms. Society, a charity. So it really sparked my curiosity why they would invest so heavily in mri. And I've since learned how integral MRI is in MS, in understanding it, diagnosing it, monitoring it. And I've been there 15 years now, and there's just so much more to learn, so much more to do in this field and so many more ways that MRI can help us understand and hopefully stop Ms. Well, back to the
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Podcast Host
technical side of it. What is an MRI scan and how. How do they work? And what can you see? I think you mentioned a bit about what you can see with it, but
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Bhavna Solanki
so it's a bit like. So when you go for, say, an Ms. MRI scan to diagnose or monitor, what we're getting images of is the water inside your body and the hydrogen atoms. So these hydrogen atoms, if you think of the compass, for example, it acts like a compass needle. So when you're outside of the MRI machine, you have lots of compass needles all pointing in random directions. When you go inside an MRI machine, it's a bit like the compass aligning with the north. It will align with the magnetic field. And so all these hydrogen atoms are in alignment. And then what you do is you use a radio wave. And that's a. What that does. It knocks it out of alignment. All these spins, all these hydrogen atoms out of alignment. That's a bit like shaking your compass vigorously. Right? It's not going to be pointing north, but when he stops shaking, it goes back to pointing north. So these hydrogen atoms, when they go back to alignment, they get off, they give off a tiny signal, and that's the signal that we use to build an image of our brain or spinal cord in ms, for example, or any other part of the body, really, to enable an image. And I know you mentioned earlier that, you know, you go in an MRI scanner and you hear all these different noises and it goes like. That's really important because if we just got one, like, signal, we wouldn't know where it came from. So if you did have a lesion, you wouldn't know where it is. So what that noise is is something called gradient coils, and they basically label each bit in your body. So the computer knows exactly where that signal came from. And so you can build up an image. And when these hydrogen atoms go back to being in alignment and give off the signal, the rate at which they do that and how they do that really depends on their environment. And that's really key in MRI because it gives us a contrast between white matter and gray matter, between lesions, between even tumors and your normal appearing matter in the brain. And so there's sort of. That's kind of the nuts and bolts, I guess, of how you would get an image. And what you want to see in ms, for example, is where your lesions are if there's a new lesion. And so you want that contrast between the different tissues and the fluids in your body to be able to tell you that.
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Podcast Host
But can you tell if a lesion is active or not?
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Bhavna Solanki
Yeah. So you can tell a Lesion is active. Usually you would use something like a contrast, which you inject. So I'm a MRI physicist, clinicians can probably interpret this better than me. But basically what the contrasts do, it contains tiny little bits of metal. Gadolinium, for example, is one of them. And that helps any lesions that are active appear really bright. And so you know that you have a new lesion in the mri.
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Podcast Host
And why are they, why are MRI scans so important? They seem to be like the gold standard now, where they didn't exist 20, 30 years ago. You know, why are they so important in Ms. Diagnosis and monitoring?
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Bhavna Solanki
So the thing with ms, when a, when a patient with Ms. Presents in the clinic, they can have a number of symptoms which overlap with lots of other conditions. So it's really difficult to diagnose. But with an mri, what the clinicians are looking for and as part of the criteria to diagnose, diagnose Ms. Is lesions and new lesions. So lesions that are in different places, so there might be a spinal cord might be in different places in the brain. So spatial dissemination as well as dissemination in time. So if you have a new lesion as well, so having a new lesion shows up, there's something actively happening, there's more inflammation in your brain leading to the Ms. Lesions. So it's integral to the diagnosis of Ms.
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Podcast Producer/Host Announcement
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Podcast Host
And so I've had some different types of MRIs, but I'm not really sure why they were different. So what are the different types of MRIs that you can have and what different data do you get out of them?
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Bhavna Solanki
So it's, I mean, there's so many different types of mri. You know, there's ones that measure function in your brain, there's ones that measure the amount of cellular volume in your brain and things like that. But the really basic ones that you'd get if you went for an MRI scan and you were suspected or suspected of having MS, or it's a monitoring scan for MS, you'd probably have four main ones. So the first one is called a T2 rated scan. Basically what that shows you is the lesions in your brain show up really bright. And so that tells the clinician how much of your brain has been affected by lesions. So your lesion load, but Also in this T2 rated scan, your ventricles appear really, really bright. And so that can almost get in the way of seeing lesions that are around the ventricles. So that's the liquid right in the middle of your brain. So I don't know if you've ever seen MRI images. It's like a sort of butterfly in the middle of your brain. That's your ventricles. And it appears really bright in this image. And so another scan that they usually do is called a flare image. And in that you'll see that those ventricles actually appear really dark. So we've suppressed any signal from the ventricles, helps you see those lesions around the periventricular area, so around the ventricles. And that's really important because what the clinicians are looking for is how many lesions are there, how much space does it take up, and are there any new ones? And so you want to really get that scan in to make sure you're not missing any. One of the other ones that we do is T1 weighted scan. So that helps see if you've got these active lesions with the contrast like we talked about earlier. But another thing T1 weighted scans can do is they're really good at differentiating between gray and white matter. And that makes them really good for measuring brain volume and brain volume and reductions in brain volume. So brain atrophy has been shown to predict disability in Ms. So it can actually tell a clinician that this patient's symptoms may get worse. And so that's really important to know as well. A more recent one that's been added is something called susceptibility weighted imaging. It produces really weird looking images. Actually, sometimes they don't even look like a ray. But what we're trying to look for in that is something that they term pearls, which stands for paramagnetic rim lesions. And basically what they're telling you is this lesion is active, there's lots of chronic inflammation, there's lots of macrophages around it because there's lots of iron deposited around it, which affects the susceptibility in your MRI image. And so that also tells you about the severity of the disease. So they would be the main sort of core ones that you would be going through if you went for an Ms.
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Podcast Host
So are they different machines or is that.
- [12:39]
Bhavna Solanki
That's all in that one session. So when you're invited and you have your MRI appointment, they're running all four of them. Sometimes there might be added extra ones. They might have diffusion to measure the cellular volume and things like that as well. But when you're in this MRI scanner, you sometimes hear a pause and the noise of the scanner changes. So it might go from, dude, it's changing how it's collecting things to give you those different contrasts, to give you those different bits of information. So it doesn't just get one image. You usually have more than one image. And each one of those is really helpful in diagnosing and monitoring.
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Podcast Host
Okay, and, and then what about newer, more advanced scans? So we've heard about AD sodium scans and one hour
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Bhavna Solanki
scans, spectroscopy scans and
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Podcast Host
things like that are these completely different things.
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Bhavna Solanki
So, yeah, so Mr. Spectroscopy is one of the things I work on. It's quite an advanced technique. It wouldn't normally be run in the clinic. And that's still looking at these hydrogen atoms, but not the hydrogen atoms related to water. We're looking at different molecules in the brain. So it's a bit like if you took a blood test and you can measure lots of different things in it and depending on what you test for, you can measure that thing. Well, you're not really going to do that in the brain. So we can use spectroscopy to get a quick snapshot of things like how healthy are the cells there, how healthy are your neurons really important for transmitting signals in your brain? You know, how are the cells dying or is there cell membrane turnover? And what's the energy metabolism like in the brain? And these sorts of things we can measure with spectroscopy because they all have hydrogen atoms. All these molecules that are attached to those different processes have hydrogens attached to them. And we can measure that, we can differentiate them so we could tell one from the other. And we know that, for example, in ms, your structural scan that you'll get when you go for your normal diagnostic scanning, a lot of the tissue in there, for example, the white matter and gray matter, which doesn't have lesions, it looks completely normal, right? It looks like a normal healthy person's brain. However, we know that when we do spectroscopy in, say, the white matter, the metabolism is actually very different to what a normal, healthy control will be. For example, the markers that we see for neurons with spectroscopy are a lot lower in patients with Ms. So you can see that even though something will appear structurally normal, symbolically, it's really quite different. You also mentioned sodium mri, so that, like you said, you know, that's one of the things I focused on in ms, that's, that's a bit like we're not looking at hydrogen atoms anymore, we're looking at sodium. And that's a bit like say if you wanted to listen to a different radio station and listen to a different song or whatever. You tune your radio to a different frequency, right? That's exactly what we do with our mri. We say, listen to this frequency and it listens for signals in sodium which will behave similar to those hydrogen atoms, but they'll give you information on sodium instead. So in ms, when we developed these sequences and tested them in ms, we found that not only were they increased in people, total sodium concentration was increased in people with ms, but it was higher depending on what sort of Ms. You had. So if you had relapsing, remitting or secondary progressive or primary progressive, the amount of sodium increase you got was sort of in line with how progressed the disease was. And also the sodium concentrations related to disability as well. And this isn't sodium just in the lesions that you can see in your standard mri, it's sodium that's changing in what looks like normal, healthy tissue. So we're looking at things in a more like metabolic away or cellular way to get more information before we see those structural changes.
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Podcast Host
And so there's obviously a lot of this is going to feed into research and a lot of it. There's. I know there's research about MRIs as well. So how can a normal person with Ms. Or their care partners help with those research projects?
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Bhavna Solanki
So, in so, so many ways, the research process is quite a long process. You need to get them some funding to answer research questions. So even helping to build the research question, what's important to you, helping understand that what's not known. Why is it worth, you know, a charity or a funding body investing in that? And, you know, funding bodies are always looking for lay people and their opinions on research as well, because that's really important. Looking at ethics forms that we hand out for consenting volunteers, you know, are they understandable? And is what we're wanting to do something that somebody would want to do, or would you be scared away from it? And if so, how can we adapt it? But for me, as an MRI physicist, as somebody who develops MRI biomarkers, there's nothing I do that doesn't involve volunteers. I need healthy volunteers, so carers partners. I need people with pathology, so people with Ms. From different groups, from different backgrounds, different ages, genders, ethnicity, to really build up sample sizes which accurately reflect the population. And so my results aren't biased. My results come, you know, if I have a large enough group of volunteers to show it, I can show it's robust, I can show it's accurate. And so it really underpins. It's basically not translatable to the clinic. It's not useful to anybody without the help of the volunteers.
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Podcast Host
And what did your latest research project show then?
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Bhavna Solanki
So the latest research project I did actually carried on from the earlier work where we saw these total sodium concentration changes in normal appearing white matter. Because the next question that came along was, well, what's increasing it? There's, in that what you're measuring there is both things inside a cell, sodium inside a cell and sodium outside of a cell. So how do we know which one's increasing? Because the way you would treat that would be really different. If you want to prevent cellular increase in sodium, then you would try and use sodium blockers, for example. So we need to know what is happening there to be able to understand it better so we know we've got these increases. The latest project I did was actually funded by the Ms. Society and we used data we already had, we used data on the sodium that we already had and we used another MRI technique called diffusion weighted imaging. And what that helped us do is quantify which of how much of the voxel, so how much of each pixel actually contains intracellular volumes. And from that I could calculate the intracellular sodium, so how much sodium there is inside the cells. And I did this in healthy volunteers, volunteers with cis, volunteers with relapsing, remitting Ms. And secondary progressive Ms. And that's the data we had available to us. And we found that in the secondary progressive Ms. Patients we did have intracellular increase in sodium compared to healthy controls and relapsing, remitting and cis. This is all preliminary reasons and we do want to publish this. And we also found that there was this intracellular sodium also correlated with disability. So how far somebody can walk 25 meters or how fast they can walk correlated to how much sodium people have inside the cells in their brain. So that was a really interesting finding and we're hoping to publish that soon.
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Podcast Host
But you're not saying, you're not a sort of clinical level, so you're not saying don't eat salt.
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Bhavna Solanki
Oh, no.
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Podcast Host
So completely different.
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Bhavna Solanki
This isn't to do with the salt in your diet, this is to do with how your cells are regulating the sodium. There's a very delicate balance in the brain between the sodium inside the cells and outside the cells. Because basically when a neuron fires, that changes very, very dramatically to help that neuron fire sodium and transmit signal across the brain so that you can do other things like tap your fingers and get your heart to beat and things like that. So, you know, important things. So sodium is very important in helping your brain function. And the. And how it's regulated in the brain is very, very tightly. And so it's not to do with the diet. The diet will be taken care of and regulated with. You know, there's a very tight regulation in the body, from what I understand as a physicist, that is very tightly regulated. So it's not to do with how much sodium or salt you're taking in, it's to do with how the cells in the brain might have been changed and how they deal with sodium, rather than you having too much sodium to begin with.
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Podcast Host
Yeah, I just wanted. I didn't want people listening.
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Bhavna Solanki
Yeah, no, no, no, Please give me the takeaway message.
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Podcast Host
And so that's. So latest research, but what projects are you planning going forward? As a. As a final question, where do you go from?
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Bhavna Solanki
Yeah, we have quite a few interesting ones, so we want to expand on the one we just did. And, um, we need more volunteers for that so we can have bigger groups, more representative as well, just to ensure that the findings we got were correct and they're robust, they're accurate, and how sensitive our model is as well, to measure this intracellular sodium. So it's following that on. And we're also bringing together sodium mri, where you're measuring the amount of sodium in the brain. And the spectroscopy I talked about, so measuring different metabolites in the brain, because those metabolites, some of the ones you can measure, are neurotransmitters. And like I mentioned, sodium is really important in neurotransmission. So being able to measure the other neurotransmitters may help us pinpoint where things are going wrong and therefore what treatments would be helpful and if that's different at different stages in Ms. So we have a project at the moment where we're developing the MRI biomarkers, the Mr. Spectroscopy, to be able to measure those transmitters and then correlate the two. Another one we're hoping to work on is, again, we're just embracing what technology can give us now and embracing new MRI physics. So we want to use really fast MRI for diagnostic scans. So take your diagnostic scans from 20 minutes, 30 minutes to 10 minutes. So hopefully that's a nicer patient experience. Hopefully it saves NHS money, cuts, waiting lists. But obviously, you know, again, we need volunteers. We need people to give their time and so that we can check that they're just as sensitive as the scans people are having now, because what we wouldn't want is for them to be not as accurate or inferior in some way. So we want to test that they're non inferior to the standard scams that people have. So it's quite an important project because it would have a lot of impact because getting the monitoring scans is really important to check for these new lesions. If you have a new lesion, it would suggest that you may need you're not responding to the treatment that you're on anymore and that maybe there's changes needed in the treatment. And so being able to measure them and being sensitive to them is still really important. So yeah, go for your monitoring scans.
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Podcast Host
So with that, I'd like to thank you very much for joining us. That is certainly for me it's fascinating. I literally had no idea how it worked. I just went for my regular monitoring and a picture came out at the end of it. But yeah, that's absolutely fascinating and interesting that there is research and it is going forward and we might all of these things might progress towards improved treatment hopefully. So thank you very much for joining us. Bambias and Anki, thank you.
- [25:05]
Podcast Producer/Host Announcement
Thank you for listening to this episode of Living well with Ms. Please check out this episode's show notes@overcomingms.org podcast. You'll find useful links and bonus information there. Don't forget to subscribe to the podcast so you never miss an episode. And please rate and review the show to help others find us. This show is made possible by the Overcoming Ms. Community. Our theme music is by Claire and Mab Dean. Our host is Jeff Alex. Our videos are edited by Lorna Greenwood and I'm the producer, Regina Beach. Have questions or ideas to share? Email us@podcastvercomingms.org we'd love to hear from you. The Living Room with Ms. Podcast is for private, nonprofit, commercial use and exists to educate and inspire our community of listeners. We do not offer medical advice. For medical advice, please contact your doctor or other licensed healthcare professional.