Elsevier

NeuroImage

Volume 60, Issue 4, 1 May 2012, Pages 2379-2388
NeuroImage

Multi-stage segmentation of white matter hyperintensity, cortical and lacunar infarcts

https://doi.org/10.1016/j.neuroimage.2012.02.034Get rights and content

Abstract

Cerebral abnormalities such as white matter hyperintensity (WMH), cortical infarct (CI), and lacunar infarct (LI) are of clinical importance and frequently present in patients with stroke and dementia. Up to date, there are limited algorithms available to automatically delineate these cerebral abnormalities partially due to their complex appearance in MR images. In this paper, we describe an automated multi-stage segmentation approach for labeling the WMH, CI, and LI using multi-modal MR images. We first automatically segment brain tissues (white matter, gray matter, and CSF) based on the T1-weighted image and then identify hyperintense voxels based on the fluid attenuated inversion recovery (FLAIR) image. We finally label the WMH, CI, and LI based on the T1-weighted, T2-weighted, and FLAIR images. The segmentation accuracy is evaluated using a community-based sample of 272 old adults. Our results show that the automated segmentation of the WMH, CI, and LI is comparable with manual labeling in terms of spatial location, volume, and the number of lacunes. Additionally, the WMH volume is highly correlated with the visual grading score based on the Age-Related White Matter Changes (ARWMC) protocol. The evaluations against the manual labeling and ARWMC visual grading suggest that our algorithm provides reasonable segmentation accuracy for the WMH, CI, and LI.

Introduction

Magnetic resonance imaging (MRI) has been widely used to detect a variety of cerebral abnormalities, such as white matter hyperintensity (WMH), cortical infarct (CI), and lacunar infarct (LI), that are of clinical importance. The WMH is thought to reflect small vessel cerebrovascular disease (Pantoni, 2002, Young et al., 2008), and may contribute to age-associated cognitive decline (Carmichael et al., 2010, He et al., 2010, Jokinen et al., 2009, Marquine et al., 2010, Ota et al., 2009, Vannorsdall et al., 2009), and increase the risk of dementia (Debette and Markus, 2010). CIs, as the name suggests, are infarcts in the cortical regions caused by cerebral artery occlusion most commonly by emboli, whereas LIs are subcortical infarcts due to the blockages of small penetrating arteries in the deep brain region with sizes up to approximately 15 mm (Ropper, 2005, Xavier et al., 2003). Previous studies suggest that both types of cerebral infarcts are associated with cognitive decline and increase the likelihood of dementia and stroke (Bennett et al., 2005, Carey et al., 2008, Jokinen et al., 2011, Jokinen et al., 2009, Schneider et al., 2004, Tripathi et al., 2011). Hence, it is of clinical importance to identify these cerebral abnormalities for potential early prevention, diagnosis, and treatment in cerebrovascular and neurodegenerative diseases.

Due to the complex mechanisms underlying cerebrovascular diseases, the appearance of the WMH, CI, and LI is heterogeneous in terms of their location, size, and image intensity on MRI. Up to now, visual inspection is still a common approach used to quantify the severity of these cerebral abnormalities. However, it is laborious and time consuming and therefore impractical in large-scale imaging studies. In addition, visual inspection is biased to raters and hence, highly dependent on inter and intra rater reliabilities (Kapeller et al., 2003, Prins et al., 2004, Vannorsdall et al., 2009), which in turn decrease the sensitivity in subsequent statistical analyses (Garrett et al., 2004, Van Straaten et al., 2006).

In recent years, major progress has been made on the development of semi- or fully automated segmentation for the WMH. Wen and Sachdev (2004) and Ramirez et al. (2011) introduced semi-automated approaches by choosing empirical thresholds based on the descriptive statistics of the image intensity and then manually modifying false WMH areas. Jack et al. (2001) and Gibson et al. (2010) developed fully automated approaches that first employ empirical thresholds before applying linear fitting or fuzzy clustering to segment the WMH. However, both approaches are based only on fluid attenuated inversion recovery (FLAIR) images that are less sensitive in the posterior fossa. In addition, they may overestimate the WMH due to its typical high intensity appearance in cortical areas, the septum, pellucidum, and flow artifacts in the 4th ventricle where a large percentage of the false positive WMH is detected. To partially address these issues, Gibson et al. (2010) further applied a white matter mask to remove this false positive WMH. More advanced methods have been developed based on Markov random field model (Schwarz et al., 2009), k-nearest neighbor (Anbeek et al., 2004, Wen et al., 2009), and neural classification (Dyrby et al., 2008), which require training images with the WMH labels. The segmentation accuracy of these methods relies on the representative training data that may be difficult to select due to the heterogeneous nature of the WMH. Different from these methods with a need of training samples, Admiraal-Behloul et al. (2005) proposed a fuzzy inference system to classify the WMH based on both anatomical locations and intensity values from the T2-weighted MRI and FLAIR. This approach is robust to a wide range of image intensities and contrasts. However, as it uses the prior masks of the intra-cranial, white matter, gray matter, and cerebrospinal fluid (CSF) in the Montreal Neurological Institute (MNI) brain template, segmentation accuracy is highly dependent on the alignment of individual subjects to the MNI template. Similar approaches using the above mentioned machine learning techniques have been proposed for the automated segmentation of multiple sclerosis lesions as well (Shiee et al., 2010, Warfield et al., 2000, Wu et al., 2006, Zijdenbos et al., 2002).

The CI and LI have thus far been manually identified by neuroradiologists in most of the existing studies (Bennett et al., 2005, Carey et al., 2008, Jokinen et al., 2011, Jokinen et al., 2009, Schneider et al., 2004, Tripathi et al., 2011). A few fully automated LI segmentation approaches have been proposed using the T1- and T2-weighted images (Uchiyama et al., 2007, Yokoyama et al., 2007). Uchiyama et al. (2007) first applied the top hat transform and then binarized the T2-weighted MR image for labeling LI voxels. Next, support vector machine classification was used to eliminate the LI false positives. Yokoyama et al. (2007) searched for LI candidates using a binarization approach at multiple threshold levels and then removed false positive LIs based on intensity thresholds and the shape of the LI. Since the size of the LI is relatively small and its appearance in the T1 and T2-weighted MRI is similar to CSF and the WMH, the method is limited to identifying LIs using only T1- and T2-weighted MR images. Sasaki et al. (2008) demonstrated that combining the FLAIR with the T1- and T2-weighted MR images increases the segmentation accuracy of the LI.

In this paper, we employ multi-modal MR images and present a multi-stage segmentation approach to automatically delineate the WMH, CI, and LI. Since the T1-, T2-weighted, and FLAIR images are commonly used in hospitals for determining cerebral abnormalities and have been recommended by previous studies (Debette and Markus, 2010, Jokinen et al., 2011, Jokinen et al., 2009, Kapeller et al., 2003, Sasaki et al., 2008, Van Straaten et al., 2006), our approach takes these three MRI modalities in order to increase the sensitivity and specificity of the abnormal white matter classification. Moreover, we developed our segmentation algorithm based on a series of simple image analysis operations, including Gaussian mixture models, region growing, and morphological operations, without the need of a training set. Hence, our method overcomes the difficulties in the selection of a representative training set, customarily faced by other existing approaches (Anbeek et al., 2004, Dyrby et al., 2008, Schwarz et al., 2009, Wen et al., 2009). Furthermore, our framework automatically labels the WMH, CI, and LI at the same time whereas existing methods often segment the WMH (Admiraal-Behloul et al., 2005, Anbeek et al., 2004, Dyrby et al., 2008, Gibson et al., 2010, Jack et al., 2001, Schwarz et al., 2009, Wen and Sachdev, 2004, Wen et al., 2009) or the LI alone (Uchiyama et al., 2007, Yokoyama et al., 2007). Finally, we evaluate the segmentation accuracy of the WMH, LI, and CI through comparison with manual labels and visual grading using a dataset of 272 old adults.

Section snippets

Methods

We now present a multi-stage segmentation technique (Fig. 1) based on T1-, T2-weighted, and fluid attenuated inversion recovery (FLAIR) magnetic resonance (MR) images. After correcting for intensity inhomogeneity, removing the brain skull, and aligning within-subject T2-weighted and FLAIR images to the corresponding T1-weighted image, the brain tissues (white matter, gray matter, CSF) and hyperintense regions are respectively identified using the T1-weighted MRI and FLAIR. We then further

Results

To evaluate the segmentation accuracy, we selected 272 subjects (131 males and 141 females; age: 70.7 ± 6.3 years; age range: 60 to 86 years) from the ongoing epidemiological aging cohort recruited by the Memory Aging & Cognition Center at the National University of Singapore. Every subject underwent MRI scans that were performed on a 3T Siemens Magnetom Trio Tim scanner using a 32-channel head coil at the Clinical Imaging Research Center of the National University of Singapore. The image protocols

Discussion

We present a multi-stage automated segmentation framework for delineating the white matter hyperintensity, cortical and lacunar infarcts from the T1-, T2-weighted, and FLAIR images. This segmentation algorithm contains several key components, including hyperintensity region initialization and refinement based on two-stage Gaussian mixture models, as well as the classification of brain abnormalities. To our knowledge, this is the first paper on the automated segmentation of the cortical infarct.

Acknowledgments

The work was supported by grants A*STAR SICS-09/1/1/001, a center grant from the National Medical Research Council (NMRC/CG/NUHS/2010), the Young Investigator Award at the National University of Singapore (NUSYIA FY10 P07), and the National University of Singapore MOE AcRF grants.

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