ORIGINAL RESEARCH ADULT BRAIN Structural Brain Changes following Long-Term 6° Head-Down Tilt Bed Rest as an Analog for Spaceflight D.R. Roberts, X. Zhu, A. Tabesh, E.W. Duffy, D.A. Ramsey, and T.R. Brown ABSTRACT BACKGROUND AND PURPOSE: Following long-term spaceflight, a subset of the National Aeronautics and Space Administration astro- nauts present with visual impairment and increased intracranial pressure, known as visual impairment and intracranial pressure syndrome. We investigated structural brain changes following long-term head-down tilt bed rest as a spaceflight analog. MATERIALS AND METHODS: Volumetric analysis was performed on structural pre- and post–bed rest brain MR images. RESULTS: Comparing post–bed rest to pre–bed rest images, we found the following: 1) no significant group differences in GM, WM, CSF, or ventricular volumes; 2) shift of the center of mass of the brain upward and posterior rotation of the brain relative to the skull; 3) a significant correlation between posterior brain rotation and changes in ventricular volume; and 4) significant increases in brain tissue density in regions at the vertex, including the frontoparietal lobes, with contraction of adjacent extra-axial CSF spaces, and significant decreases in tissue density in areas along the base of the brain, including the orbitofrontal cortex. CONCLUSIONS: We observed widespread morphologic changes with brain tissue redistribution in response to gravity changes; possible associated functional changes are unknown. The observation that ventricular change is correlated to posterior brain rotation suggests an alteration in CSF homeostasis. Ultimately, to elucidate any structural changes that may play a role in visual impairment and intracranial pressure syndrome, volumetric analysis of pre- and postflight structural scans of astronauts is needed. ABBREVIATIONS: BR ϭ bed rest; ICV ϭ intracranial volume; IIH ϭ idiopathic intracranial hypertension; NASA ϭ National Aeronautics and Space Administration; VIIP ϭ visual impairment and intracranial pressure ollowing long-term missions aboard the International Space strated ophthalmologic findings, with disc edema in 5 astronauts FStation, increased intracranial pressure and papilledema have and globe flattening in 5. Lumbar punctures were performed in 4 1 been documented in the National Aeronautics and Space Admin- of these astronauts with opening pressures of 21–28.5 cm H2O . istration (NASA) astronauts. In 1 report1 investigating 7 astro- In the 1 astronaut who underwent repeated lumbar punctures, the nauts following 6 months of spaceflight, all astronauts demon- opening pressure remained elevated 19 months following space- 1 flight at 22 cm H2O . The etiology of these findings is currently unclear; however, it has been hypothesized that they may result Received February 5, 2015; accepted after revision March 4. from loss of gravitational hydrostatic pressure gradients and large From the Departments of Radiology and Radiological Sciences (D.R.R., X.Z., A.T., cephalad fluid shifts. NASA has coined the term “visual impair- E.W.D., T.R.B.) and Neurosciences and Neuroscience Research (D.R.R., X.Z.), Medical University of South Carolina, Charleston, South Carolina; and Care Coordination ment and intracranial pressure [VIIP] syndrome” to describe this Institute (D.A.R.), Department of Medicine, University of South Carolina School of constellation of signs and symptoms in astronauts and has likened Medicine, Greenville, South Carolina. VIIP syndrome to Earth-based idiopathic intracranial hyperten- This work was funded by NASA, grant number NNJ04HF70G. The authors wish to dedicate this article to Ali Tabesh, PhD. sion (IIH) or pseudotumor cerebri. Paper previously presented at: American Society of Neuroradiology and the Foun- A traditional ground-based analog used by NASA and other dation of the ASNR Symposium, May 17–22, 2014; Montreal, Quebec, Canada. international space agencies to study physiologic changes associ- Please address correspondence to Donna R. Roberts, MD, Department of Radiol- ated with long-term spaceflight has been to place healthy subjects ogy and Radiological Sciences, 96 Jonathan Lucas St, MSC 323, Charleston, 2,3 SC 29425-3230; e-mail: [email protected] in 6° head-down tilt bed rest for varying periods. Anecdotally, Indicates open access to non-subscribers at www.ajnr.org Russian scientists first devised the head-down-tilt protocol in the Indicates article with supplemental on-line tables. early 1970s on the basis of reports by Russian cosmonauts who Indicates article with supplemental on-line photos. had the sensation of slipping off the foot of the bed on return to http://dx.doi.org/10.3174/ajnr.A4406 Earth after long-duration missions.3 The foot of the bed was 2048 Roberts Nov 2015 www.ajnr.org raised until it felt horizontal to help the cosmonauts sleep.3 As an take and hydration with no net water gain or loss.2 Monitors were analog for spaceflight, the reduction in Gz gravitational stimuli present 24/7 to ensure subject compliance. during bed rest results in an upward shift of body fluids, unload- Initial plans were for all subjects to remain at bed rest for 90 ing the upright weight of the body, reduced work against the force days, and the first 4 subjects followed this protocol. The second of gravity, and lower extremity inactivity.3 As a result, many of the group of subjects, unfortunately, was removed from the Flight physiologic changes of spaceflight can be reproduced, including Analogs Facility earlier than planned due to extreme weather. decreased cardiac output, orthostatic intolerance, muscle atro- These subjects had undergone 42, 44, 49, and 52 days of bed rest at phy, and bone loss. This model has been applied extensively to the time of the evacuation. investigate cardiovascular and musculoskeletal deconditioning, immunologic response, and cognitive functioning.2,3 MR Imaging We previously acquired structural MR imaging brain scans of Two brain MR imaging structural scans were obtained for each subjects participating in a NASA-sponsored long-term bed rest subject: one immediately before bed rest (pre–bed rest scan) study.4 Given the recent interest in intracranial adaptation to and another toward the end of bed rest (referred to as the spaceflight, we decided to perform a volumetric analysis of the post–bed rest scan). On the first day of bed rest, BR1, the sub- structural MR imaging dataset to assess any potential alterations jects walked to the MR imaging scanner facility and laid down in brain structure or CSF distribution that may shed light on the on the MR imaging table for acquisition of the pre–bed rest spectrum of findings noted in VIIP syndrome. The results of this scans. Immediately on completion of the MR imaging session, analysis are presented here. the subjects were moved from the scanner table while remain- ing supine and placed in a hospital bed in the 6° head-down-tilt position. Subjects then remained in this position throughout MATERIALS AND METHODS the bed rest period. For the 4 subjects who required emergent Bed Rest Study Protocol evacuation from the Flight Analogs Facility, end-of–bed rest Eight healthy volunteers (age, 33 Ϯ 7.4 years; 3 women) under- imaging was performed on the day of evacuation, (ie, on days went long-term bed rest at the NASA Flight Analogs Facility at the BR42, BR44, BR49, and BR52). On that day, while still in bed University of Texas Medical Branch, Galveston, as part of a multi- rest, the subjects were moved from their beds onto the MR investigator study.2 Informed consent was obtained, and the imaging table, only shifting from head-down-tilt to supine. study was approved by the appropriate institutional review Structural scans were immediately acquired, and these were boards. Subject recruitment included radio, television, and news- considered the post–bed rest scans. Following the scanning paper announcements and a Web site (www.bedreststudy.com). session, subjects were allowed to sit up and prepare for evacu- The study protocol has been described in detail elsewhere.2 Before ation. For the 4 subjects who underwent 90 days of bed rest, bed rest, subjects were admitted to the NASA Flight Analogs Fa- MR imaging was performed on both day BR60, with the sub- cility and underwent a NASA-modified Air Force Class III phys- jects remaining in the supine position only shifting from their ical examination and psychological assessment. Subjects then re- bed to the scanner table after which they continued on bed rest mained in the unit for 11–14 days before the start of bed rest for for another 30 days, and day BR90. These subjects were not pre–bed rest data collection performed by other investigators and allowed to return to ambulation until BR90; however, given were free to ambulate normally. Male subjects were admitted into the shortened bed rest duration experienced by the evacuation the study just after providing informed consent. Women were subjects, for comparison purposes, in this report, the BR60 admitted so that the time of their next menses would occur 2 days scans were considered the post–bed rest scans for these sub- 2 before entering the bed rest phase of the study. For ease of refer- jects. Therefore, considering all 8 subjects, the post–bed rest ence, study days during the pre–bed rest period are referred to as scans described in this report were obtained between days BR-x, with BR-1 being the last day before bed rest. The first day in BR42 and BR60. BR is referred to as BR1. After bed rest following return to normal The structural MR images consisted of T1-weighted 3D ambulation, subjects remained in the unit for 2 weeks to undergo echo-spoiled gradient-echo images acquired on a 1.5T scanner reconditioning. (GE Healthcare, Milwaukee, Wisconsin). Images were ac- Throughout the bed rest portion of the study, the subjects’ quired in either transverse or coronal planes, at either 1.0- or beds were placed in a 6° Trendelenburg position.