The British Journal of Radiology, 73 (2000), 12061208

2000 The British Institute of Radiology

Short communication

Proton magnetic resonance spectroscopy and

morphometry of the hippocampus in chronic fatigue
syndrome
1,2

J C W BROOKS, PhD, 1N ROBERTS, PhD, 1G WHITEHOUSE, DSc, FRCR and

3
T MAJEED, FRCP
1

Magnetic Resonance and Image Analysis Research Centre, University of Liverpool, Liverpool L69 3BX,
Pain Relief Foundation, Clinical Sciences Centre, Lower Lane, Liverpool L9 7AL and 3Department of
Neurology, Royal Preston Hospital, Preston PR2 9HT, UK
2

Abstract. Seven patients with chronic fatigue syndrome (CFS) were matched with ten healthy
control subjects of similar age. Hippocampal volume, obtained from magnetic resonance images
using an unbiased method, showed no difference between the two groups, whereas proton
magnetic resonance spectroscopy showed a signicantly reduced concentration of N-acetylaspartate in the right hippocampus of CFS patients (p50.005).

The hippocampus has a critical role both in

working memory and in long-term memory
storage and retrieval. The right hippocampus is
8% smaller compared with controls in patients
with combat-related post-traumatic stress disorder
(PTSD), a condition in which there is impaired
memory function [1]. Patients with chronic fatigue
syndrome (CFS) also have reduced ability at
verbal and non-verbal memory tasks [2].
Proton magnetic resonance spectroscopy (1HMRS) is a method of assessing the concentration
of cerebral metabolites. The major metabolite
peaks visible on 1H spectra include: N-acetylaspartate (NAA) compounds, a putative marker of
neuronal density and probably also function;
creatine/phosphocreatine (Cr), an indicator of
cellular bioenergetics; choline-containing compounds (Cho), a constituent of cell membranes
and a precursor of acetylcholine; and myo-inositol
(mI), thought to be a glial cell marker. Reduced
concentration of NAA has been reported in the
hippocampi of patients with PTSD, especially in
the right hippocampus [3, 4]. To our knowledge,
there have been no reports of hippocampal
volume estimation and 1H-MRS in CFS.

Received 23 March 2000 and accepted 7 July 2000.

Address correspondence to Dr JCW Brooks, Magnetic
Resonance and Image Analysis Research Centre,
University of Liverpool, Pembroke Place, Liverpool
L69 3BX, UK.
1206

Materials and methods

Seven patients with a clinical diagnosis of CFS,
based on the denition of Holmes et al [5], were
recruited for this study (ve males, two females;
age 2640 years). Ten healthy male subjects (age
2141 years) underwent neuropsychological
screening and formed a control group. Written
informed consent was obtained from patients and
controls. All MR data were acquired on a 1.5 T
Signa whole body MRI system (General Electric,
Milwaukee, USA). A high resolution T1 weighted
image volume was acquired in the plane approximately perpendicular to the long axis of the
hippocampus using the three-dimensional fast
inversion recovery prepared GRASS pulse
sequence (124 contiguous slices, 1.6 mm thick,
TE53.5 ms, ip angle530 , TI5450 ms, eld
of view520 cm). Morphometric analysis was
performed using Analyze software (Mayo
Foundation, MN, USA), and unbiased estimates
of the volume of both hippocampi were obtained
using the Cavalieri method in combination with
point counting [6].
Spectra were acquired with the STEAM
sequence and the following parameters: TE530,
72 and 144 ms; TR53 s; 128 averages; and an 8
step phase cycle. From inspection of the high
resolution T1 images, a 36161 cm3 voxel was
positioned to contain the right hippocampus, with
its largest dimension parallel to the long axis.
Time constraints limited the 1H-MRS examination to the right hippocampus. Imaging-based
compartmentation [7] was performed, with the
cerebrospinal uid (CSF) fraction of the voxel
The British Journal of Radiology, November 2000

Short communication: 1H-MRS and morphometry of the hippocampus in CFS

determined from heavily T2 weighted images

acquired with a fast spin echo sequence, and
total water fraction of the voxel (brain water plus
CSF) determined from proton density weighted
images acquired with a fast spoiled gradient echo
sequence. Spectra were analysed using the timedomain VARPRO technique available in MRUI
software. Metabolite T2 relaxation times were
calculated by loglinear tting of peak areas
against TEs of 30 ms, 72 ms and 144 ms. Briey,
calibration of the metabolite signal intensities was
performed as follows. Signal amplitudes were
corrected for T1 (published values [8]) and
T2 relaxation (calculated) time differences.
Compartmentation analysis enabled correction
for the presence of CSF in the selected voxel.
Subsequently, metabolite signal amplitudes were
converted to absolute concentrations, expressed in
millimoles per litre of brain tissue, by referencing

to the signal recorded from an external standard

containing pure water.

Results
Comparison of hippocampal volume between
CFS patients and controls showed no signicant
difference (Figure 1). The mean volume (SE) of
the right hippocampus was 2.970.12 cm3 in
CFS patients and 3.200.10 cm3 in controls.
Typical spectra recorded from CFS patients and
controls are presented in Figure 2. The mean
(SE) concentrations for NAA, Cr and Cho in
CFS patients were 10.80.6, 8.60.5 and
2.50.2 mmol l21 of brain tissue, respectively.
The corresponding values for controls were
14.10.7, 10.91.1 and 3.10.2 mmol 121 of
brain tissue. The reduction in NAA concentration
was statistically signicant (p50.005).

Hippocampal volume (cm3)

Discussion

Figure 1. Unbiased estimates of the volume of the

right (circles) and left (triangles) hippocampus in
chronic fatigue syndrome patients (solid symbols) and
in controls (open symbols). Also shown are the
means and error bars (2 SE) for estimated volumes.

(a)

Hippocampal volumes of CFS patients examined in the present study were not signicantly
smaller than those measured in controls, the
absolute volumes being in the normal range for
subjects aged between 20 and 40 years [9]. Whilst
we did not standardize recorded hippocampal
volumes for differences in intracranial volume,
only a weak correlation has been found between
these two measurements [9]. The concentrations
of NAA, Cr and Cho were reduced in patients
compared with controls, although this was
signicant only for NAA. By using an external
standard to calibrate metabolite concentrations,
we excluded the possibility that these reductions
were due to a change in brain water content. The
observed fall in NAA may be interpreted in
several ways: either as a reduction in neuronal
and/or glial cell density, or as reecting reduced
neuronal and/or glial cell metabolism.

(b)

Figure 2. Spectra recorded from a 3 cm3 voxel placed over the right hippocampus (a) in a patient with chronic
fatigue syndrome and (b) in a healthy control subject. Spectra were acquired with the STEAM sequence, with
TE/TM/TR572/13.7/3000 ms and 128 averages. mI, myo-inositol; Cho, choline-containing compounds; Cr, creatine/
phosphocreatine; NAA, N-acetylaspartate. ppm, parts per million.
The British Journal of Radiology, November 2000

1207

J Brooks, N Roberts, G Whitehouse and T Majeed

provided by Aad van den Boogaart (http://

carbon.uab.es/mrui/mruiHomePage.html). MRUI
development is currently funded by the European
Union project TMR/Networks ERB-FMRXCT970160.

References

Figure 3. Right hippocampal N-acetylaspartate (NAA)

concentrations plotted for patients and controls.
Mean concentration and error bars (2 standard
errors) are also shown. The observed difference is
signicant ( p50.005).

The recent nding that mature oligodendrocytes in cell culture contain similar amounts of
NAA to that found in neurons [10] precludes
further comment about the cellular origin of the
fall in NAA in CFS. Given that hippocampal
volume is preserved in CFS, it is likely that the
NAA decrease reects reduced neuronal/glial
metabolism rather than reduced cell density.
The possibility that these changes might be age
related [11] was excluded through the use of agematched controls. However, the patient and
control groups were not precisely sex matched,
and this may have contributed to the differences
observed in this study, although a recent paper [8]
did not report sex-dependent modication of
hippocampal metabolite concentrations. Future
work will be to match these results with clinical
details in individual cases, stratifying patients
according to their psychopathology, and to
compare psychometric testing with NAA levels
in CFS patients.

Acknowledgments
We wish to thank the ME Association of Great
Britain for their support of this project, and Dr
Enis Cezayirli and Dr Clare Mackay for their
assistance in obtaining the hippocampal volume
measurements. The MRUI software package was

1208

1. Bremner JD, Randal P, Scott TM, Bronen RA,

Seibyl JP, Southwick SM, et al. MRI-based
measurement of hippocampal volume in patients
with combat-related post-traumatic stress disorder.
Am J Psychiatry 1995;152:97381.
2. Tiersky LA, Johnson SK, Lange G, Natelson BH,
DeLuca J. Neurospychology of chronic fatigue
syndrome: a critical review. J Clin Exp
Neuropsychol 1997;19:56086.
3. Shuff N, Amend D, Marmar CR, Weiss DS, Neglan
TC, Schoenfeld F, et al. Changes of hippocampal
NAA and volume in post traumatic stress disorder.
In: Proceedings of the 7th Annual Meeting of the
Society of Magnetic Resonance in Medicine; 1997
April 1218; Vancouver, Canada. Berkeley, CA:
Society of Magnetic Resonance in Medicine,
1997:1231.
4. Freeman TW, Cardwell D, Karson CN, Komoroski
RA. In vivo proton magnetic resonance
spectroscopy of the medial temporal lobes of
subjects with combat-related post-traumatic stress
disorder. Magn Reson Med 1998;40:6671.
5. Holmes GP, Kaplan JE, Gantz NM, Komaroff AL,
Schonberger LB, Straus SE, et al. Chronic fatigue
syndrome: a working case denition. Ann Int Med
1988;108:3879.
6. Roberts N, Puddephat MJ, McNulty V. The benet
of stereology for quantitative radiology. Br J Radiol
2000;73:67997.
7. Brooks JCW, Roberts N, Kemp GJ, Martin PA,
Whitehouse GH. Magnetic resonance imaging
based compartmentation and its application to
measuring metabolite concentrations in the frontal
lobe. Magn Reson Med 1999;41:8838.
8. Choi CG, Frahm J. Localized proton MRS of the
human hippocampus: metabolite concentrations
and relaxation times. Magn Reson Med 1999;
41:2047.
9. Mackay CE, Roberts N, Mayes AR, Downes JJ,
Foster JK, Mann D. An exploratory study of the
relationship between face recognition memory and
the volume of medial temporal lobe structures in
healthy young males. Behav Neurol 1998;11:320.
10. Bhakoo KK, Pearce D. In vitro expression of Nacetyl aspartate by oligodendrocytes: implications
for proton magnetic resonance spectroscopy signal
in vivo. J Neurochem 1999;74:25462.
11. Schuff N, Amend DL, Knowlton R, Norman D,
Fein G, Weiner MW. Age-related metabolite
changes and volume loss in the hippocampus by
magnetic resonance spectroscopy and imaging.
Neurobiol Aging 1999;20:27985.

The British Journal of Radiology, November 2000