Neuroimaging abnormalities, neurocognitive function, and fatigue in patients with hepatitis C

April D Thames PhDSteven A Castellon PhDElyse J Singer MDRajakumar Nagarajan

PhDManoj K Sarma PhDJason Smith PharmDNicholas S Thaler PhDJonathan Hien Truong

MDDaniel Schonfeld BSM Albert Thomas PhDCharles H Hinkin PhD

Correspondence toDr Thamesathamesmednetuclaedu

Supplemental dataat Neurologyorgnn

Neuroimaging abnormalitiesneurocognitive function and fatigue inpatients with hepatitis C

ABSTRACT

Objective This study examined neurologic abnormalities (as measured by proton magnetic reso-nance spectroscopy imaging and diffusion tensor imaging) neurocognitive performance andfatigue among a sample of adults with hepatitis C virus (HCV) We hypothesized that HCV1individuals would demonstrate structural brain abnormalities and neurocognitive compromiseconsistent with frontostriatal dysfunction as well as increased fatigue compared to controls

Method Participants were 76 individuals diagnosed with HCV and 20 controls who underwent acomprehensive neurocognitive evaluation and clinical assessments A subset of the HCV1participants (n 5 29) and all controls underwent MRI

Results Individuals diagnosed with chronic HCV infection demonstrated greater fractional anisot-ropy in the striatum as well as greater mean diffusivity in the fronto-occiptal fasciculus and exter-nal capsule compared to HCV2 controls HCV1 participants also demonstrated lower levels ofN-acetylaspartate in bilateral parietal white matter and elevations in myo-inosital (mI) in bilateralfrontal white matter compared to HCV2 controls (all p values 005) HCV1 participants alsodemonstrated significantly poorer neuropsychological performance particularly in processingspeed and verbal fluency HCV1 patients reported higher levels of fatigue than controls andfatigue was significantly correlated with diffusivity in the superior fronto-occipital fasciculuselevations in mI in frontal white matter and overall cognitive performance

Conclusions Our results suggest that HCV-associated neurologic complications disrupt frontos-triatal structures which may result in increased fatigue and poorer cognitive performance partic-ularly in those cognitive domains regulated by frontostriatal regions Neurol Neuroimmunol

Neuroinflamm 20152e59 doi 101212NXI0000000000000059

GLOSSARYANOVA5 analysis of varianceCRLB5Cramer-Rao lower boundDTI5 diffusion tensor imaging FA5 fractional anisotropyFDR 5 false discovery rate FOV 5 field of view HCV 5 hepatitis C virus H-MRS 5 proton H magnetic resonance spec-troscopy MD 5 mean diffusivity MELD 5 Model for End-Stage Liver Disease mI 5 myo-inosital MRSI 5 proton magneticresonance spectroscopy imaging NAA 5 N-acetylaspartate PRESS 5 point-resolved spectroscopy TE 5 echo time TR 5repetition time VAS 5 Visual Analogue Scale VOI 5 volume of interest WAIS-III 5Wechsler Adult Intelligence Scale-ThirdEdition

In the United States approximately 32 million people have hepatitis C virus (HCV) withchronic infection in nearly 75ndash85 of cases1 HCV is thought to cross the blood-brain barrierprimarily by infecting surrounding monocytes and progenitor cells23 Consequently studieshave documented neurologic abnormalities and cognitive impairments among HCV1 individ-uals without advanced liver disease45

Studies using proton Hmagnetic resonance spectroscopy (H-MRS) have demonstrated lowerlevels of N-acetylaspartate (NAA) in frontal white matter and increases in myo-inosital (mI) andcholinecreatine values in the basal ganglia6ndash8 In a few studies that used diffusion tensor imaging(DTI) patients with HCV demonstrated lower fractional anisotropy (FA) in the inferior

From the David Geffen School of Medicine (ADT SAC EJS RN MKS NST MAT CHH) University of California Los AngelesGreater Los Angeles VA Healthcare System (SAC JS DS CHH) and Department of Infectious Disease (JHT) Kaiser PermanenteAntelope Valley Lancaster CA

Go to Neurologyorgnn for full disclosures Funding information and disclosures deemed relevant by the authors if any are provided at the end ofthe article The Article Processing Charge was paid by the University of California Los Angeles

This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial No Derivative 30 License whichpermits downloading and sharing the work provided it is properly cited The work cannot be changed in any way or used commercially

Neurologyorgnn copy 2015 American Academy of Neurology 1

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

fasciculus the inferior fronto-occipital fascic-ulus and the genu of the corpus callosumcompared to normal controls910

Neurocognitive studies have found thatHCV-infected individuals demonstrate increasedneurocognitive dysfunction compared to con-trols511ndash14 Selective deficits in attention concen-tration and psychomotor speed are mostcommonly reported across studies451516 andthese deficits are largely independent of suchfactors as liver fibrosis

In addition to cognitive dysfunction approx-imately 65ndash80 of chronically infected pa-tients complain of fatigue that is independent ofliver dysfunction17 In a study of HCV1 pa-tients moderate fatigue was associated withpoorer cognitive performance and reducedEEG brain activity compared to HCV1 pa-tients with mild fatigue8 Fatigue and cognitivedysfunction may share overlapping pathophysi-ologic mechanisms however very few studieshave had sufficiently large samples to examineneurocognitive abnormalities and fatigue intandem Therefore the objective of this studywas to examine neuroimaging abnormalities(H-MRS and DTI) neurocognitive perfor-mance and fatigue among a sample of HCV1patients

METHODS Our initial sample consisted of 87 HCV1 partic-

ipants who were recruited from several hepatology clinics and

infectious disease clinics located throughout the greater Los An-

geles catchment area Controls (n 5 21) were recruited from the

community through advertisements and flyers

Standard protocol approvals registrations and patientconsents All procedures received prior approval by the Univer-

sity of California Los Angeles and VA Greater Los Angeles

Healthcare System Institutional Review Board Committees for

studies involving human subjects All HCV1 patients participat-

ing in this study met clinical criteria for initiating HCV therapy

but had not yet begun treatment All data reported in the current

study were collected at participantsrsquo baseline visit As part of

procedures outlined in the parent study a nested cohort of

HCV1 participants underwent neuroimaging (n 5 29) There

were no statistically significant differences between HCV1 par-

ticipants who underwent neuroimaging and those who did not on

key demographic variables such as age sex ethnicity past drug

abuse current drug use Model for End-Stage Liver Disease

(MELD) score and psychiatric functioning (all p values

005) All participants provided informed consent prior to

undergoing procedures Inclusion criteria were as follows (1)

18 years of age (2) able to read and write in English (3) and

completed at least 6th grade education Exclusion criteria were as

follows (1) decompensated cirrhosisliver failure (detected by

blood tests or liver biopsy) with MELD scores 12 (2)

current or past psychotic spectrum disorder (3) significant

depression as judged by the study psychiatristspsychologists

(defined as current moderate or severe major depressive disorder)

or suicidal ideation (factors that were controlled for initiating

interferon treatment) (4) history of learning disability seizure

disorder closed-head injury with loss of consciousness in excess of

30minutes or any other neurologic disease (5) evidence of any other

CNS opportunistic infection or neoplasm (6) hepatitis B infection

(7) diagnosis of HIV infection as evidenced byHIV antibody testing

(8) recent illicit drug use (confirmed by urine toxicology) and (9)

contraindications for MRI (for the nested cohort who underwent

neuroimaging) After applying exclusion criteria our final sample

(those eligible for analysis) included 76 HCV1 participants and

20 controls (See supplementary table e-1 for clinical characteristics

of theHCV1 sample) TenHCV1 participants were determined to

be ineligible due to liver cirrhosis and 1 control participant tested

positive for stimulants at study visit

Brain MRI was performed using a 3-tesla Trio MRI scanner

(Siemens Medical System Erlangen Germany) High-resolution

MRI included T1-weighted images using a magnetization-

prepared rapid acquisition gradient-echo sequence using the follow-

ing parameters repetition time (TR)echo time (TE) 5 222022

msec inversion time5 900msec average5 1 matrix size5 2563

256 field of view (FOV) 5 240 3 240 mm2 slice thickness 5

1 mm number of slices 5 176 DTI was acquired using a single-

shot echo planar dual spin echo sequence with ramp sampling The

b-factor was set to 1000 smm2 TR 5 9600 msec TE 5 90

msec flip angle 5 90deg and averages 5 1 A total of 71 axial

sections were acquired using an image matrix of 1303 130 a slice

thickness of 2 mm with no interslice gap and an FOV of 256 3

256 mm2

Proton spectra were collected using the 2D proton magnetic

resonance spectroscopy imaging (MRSI) technique with the vol-

ume of interest (VOI) preselected by means of point-resolved

spectroscopy (PRESS) Volume-selective 2D MRSI was per-

formed on a 20-mm slab superior to the ventricles with TE of

30 msec and TR of 2000 msec The nominal voxel size was

282 cm3 (16 3 16 phase encode steps over an 18 3 20 cm2

FOV) Outer-volume saturation bands were applied to all 6 sides

of the VOI localized by the PRESS sequence to suppress the lipid

contamination

Participants completed a comprehensive neuropsychology test

battery We assessed attention using the Wechsler Adult Intelli-

gence Scale-Third Edition (WAIS-III) Letter-Number Sequencing

subtest18 and the Paced Auditory Serial Addition Test (only the first

50 trials)19 processing speed using the WAIS-III Digit Symbol and

Symbol Search subtests18 Trail Making Test Part A20 and Stroop

color naming and word reading21 learning and memory using the

Hopkins Verbal Learning Test-Revised22 and the Brief Visuospatial

Memory Test-Revised23 verballanguage fluency using the Con-

trolled Oral Word Association Test24 executive functioning using

Trail Making Test Part B and Stroop color-word interference

test2021 and motor speed using the Grooved Pegboard test25

Raw scores were converted into demographically adjusted t scoresgrouped by neurocognitive domain and averaged to create domain

t scores A global neurocognition score was calculated by averaging tscores from individual neuropsychological tests

Fatigue was assessed with the Visual Analogue Scale (VAS26)

The VAS contains 18 visual analogue lines with bipolar anchors

with descriptors relating to energy and fatigue Participants are

asked to place a mark between the anchors Internal consistency

of the VAS in our sample was high (Cronbach a 5 086) The

total score from the VAS-Fatigue subscale was examined in the

current study

DTI and MRSI postprocessing DtiStudio was used to create

FA and mean diffusivity (MD) maps We used RoiEditor for

2 Neurology Neuroimmunology amp Neuroinflammation


preprocessing procedures according to a modified version of the

active contour method27 and DiffeoMap Images were applied

to the JHU-MNI-SS template Dual-contrast large deformation

diffeomorphic metric mapping was used for nonlinear

transformations White matter parcellation map was used to

segment the brain into 130 regions based on anatomical

labeling which included both the gray and white matter Once

these regions were extracted the cortex and the surrounding

white matter were segmented using an FA threshold of $025

We focused our analyses on regions of the corona radiata insula

internal capsule external capsule striatum fronto-occiptial

fasciculus cingulum thalamus hippocampus and amygdala

based on prior studies9102829

For MRSI metabolites were quantitated in each voxel using

the frequency-domain fitting routine called LC-Model algorithm

which analyzes the in vivo brain spectrum as a linear combination

of individual simulated metabolite spectra that constitute the

basis set or prior knowledge30 We were able to quantify total

NAA_NAAG (NAA 1 NAA glutamate) total choline

(GPC_Pch) mI and glutamateglutamine (Glu_Gln) for regions

of frontal white and gray matter parietal white and gray matter

and basal ganglia (see figure 2) The metabolite ratios were nor-

malized with respect to creatine (309 ppm) The accuracy of the

quantitation was characterized using Cramer-Rao lower bound

(CRLB) and metabolite ratios with CRLB 30 were consid-

ered for further analysis

Preliminary analyses Demographic characteristics are pre-

sented in table No statistically significant differences were found

for potential confounding variables such as age years of education

ethnicity and estimated premorbid functioning (as measured by

the Wechsler Test of Adult Reading) (all p values 005) Groups

also did not differ in current drug use Between-groups analysis of

variance (ANOVA) was used to examine differences between HCV

and control groups on our 31 outcome variables of interest

neuroimaging (23 variables) neurocognitive assessment (7

variables) and fatigue (1 variable) Outcome variables were all

analyzed on a continuous scale and assumptions for performing

ANOVA and Pearson correlations were checked prior to running

analyses Next DTI and MRSI variables were correlated with

neurocognitive performance and fatigue

We used the false discovery rate (FDR)31 to correct for mul-

tiple comparisons with our outcome measures FDR is sometimes

preferred over family-wise error rate methods (eg Bonferroni)

because it provides greater statistical power and reduces the

chance of making type II errors

Sensitivity analysis was performed using GPower version

31 Given our available sample size of 96 for the neurocognitive

and fatigue data adjusted a level of 001 (for multiple compar-

isons) and power of 080 we had enough power to detect

medium effects (f 5 031) This is consistent with effect sizes

reported in previous investigations that have examined neurocog-

nitive differences between HCV1 patients and controls4817 For

neuroimaging analyses with a sample of 49 we had enough

power to detect medium to large effects This is also consistent

with the effect sizes reported by neuroimaging studies that have

compared HCV1 patients to controls1217

RESULTS DTI There were statistically significantgroup differences in FA in the striatum (F148 5 849p 0005) with the HCV group demonstrating higherFA levels than controls While group differences in FA inthe thalamus (F1485 46 p5 004) and insula (F1485386 p5 005) emerged these did not survive multiple

comparisons correction There were no statistically sig-nificant group differences in FA values among our otherbrain regions of interest (see figure 1A and table e-2)

Among the HCV1 group higher levels of FA inthe striatum were correlated with poorer overall neu-ropsychological performance (r29 52045 p5 001r29 52053 p5 0003) and the domain of languagefluency (r29 5 2041 p 5 002)

Individuals with chronic HCV infection demon-strated greater MD in the fronto-occiptal fasciculus(F148 5 186 p 00001) and external capsule(F148 5 108 p 5 0002) than controls (see figure1B) There was a statistical trend toward group MDdifferences in the insula (F148 5 386 p 5 005)however this did not survive correction for multiplecomparisons There were no statistically significantrelationships between MD in our regions of interestand neurocognitive performance

MRSI HCV1 participants demonstrated lower levelsof NAA in bilateral parietal white matter (F148 5

537 p5 002) and elevations of mI in bilateral frontalwhite matter (F148 5 948 p 5 0004) comparedto controls (see figure 3 and table e-3) For theHCV1 group greater levels of frontal white mattermI were significantly correlated with poorer cogni-tive performance in the domains of processingspeed (r29 52043 p5 002) and verballanguagefluency (r29 52041 p 5 0007) No other MRSIregions of interest correlated with neurocognitiveperformance Higher NAA in bilateral parietal

Figure 1 MRSI regions of interest

Proton magnetic resonance spectroscopy imaging (MRSI)regions of interest of frontal white parietal white and basalganglia

Neurology Neuroimmunology amp Neuroinflammation 3


white matter was significantly correlated with lowerdiffusivity in the fronto-occipital fasciculus (r29 5

2036 p 5 002) whereas greater levels of frontalwhite matter mI were significantly correlated withhigher diffusivity in the fronto-occipital fasciculus(r29 5 047 p 5 001)

Neurocognition HCV-infected individuals demon-strated poorer overall neurocognitive performance thancontrols (F194 5 56 p 5 002) Cognitive domainsthat contributed to global findings included reducedprocessing speed (F194 5 391 p 5 004) and verbalfluency (F194 5 852 p 5 0005) (see figure 4)

Fatigue As expected HCV1 participants reportedgreater fatigue (F194 5 741 p5 0008) than controlsAmong the HCV1 group fatigue was not correlatedwith any of theDTI regions (all p values 005) Higherfatigue scores correlated with higher levels of mI in frontalwhite matter (r29 5 053 p 001) Among HCV1patients higher fatigue scores correlated with poorer over-all neurocognitive performance (r75 5 2036 p

0001) and domains of attention (r75 5 2026 p 5

001) processing speed (r75 5 2031 p5 0002) andexecutive functioning (r75 5 2040 p 0001) Therewas no statistically significant correlation between fatigueand motor functioning

DISCUSSION The current study examined the ef-fects of chronic HCV infection on microstructuralbrain abnormalities cerebral metabolites fatigueand neurocognitive performance Major strengths ofthe current investigation include the use of DTI andMRSI in combination with measures of neurocogni-tive functioning and fatigue and the use of a controlgroup for comparison As hypothesized based on priorliterature we observed microstructural abnormalitiesin such areas as the striatum external capsule andfronto-occipital fasciculus which is consistent withprevious DTI studies of HCV910 and findingsamong individuals with HIV infection2829

We observed greater FA in gray matter regions ofthe striatum in HCV1 patients compared to healthyvolunteers Higher FA in the striatum has been foundamong patients with Huntington disease32 and isthought to be due to degeneration of efferent pathwaysthat increase the coherence of gray matter structures Ina study of patients with chronic subdural hematomaincreased FA was found in the striatum which reducedfollowing surgical intervention33 Therefore our find-ings are consistent with other investigations of neuro-pathology in regions that are affected in HCV

Increased diffusivity in the fronto-occipital tract andexternal capsule was also found in the HCV1 group

Table Demographic and drug use characteristics of the sample

Hepatitis C group (n 5 76) Control group (n 5 20)Fx2 pMeanpercentage (SD) Meanpercentage (SD)

Demographics

Age y 567 (55) 544 (55) 261 011

Education y 130 (22) 136 (17) 143 023

Sex male 785 500 823 001

Ethnicity 246 078

Caucasian 516 423

African American 290 345

Latino 151 231

AsianPacific Islander 22 00

American Indian 11 00

Other 11 00

Estimated IQ 985 (112) 1017 (105) 169 020

VAS-F subscale 308 (249) 190 (153) 521 002

Positive drug screening active use

Amphetamines 00 00 NA

Barbiturates 00 12 031 058

Benzodiazepines 00 85 228 013

Cocaine 00 00 NA

Marijuana 80 110 018 067

Opiates 00 37 094 033

Abbreviation VAS-F 5 Visual Analogue ScalemdashFatigue



compared to controls The fronto-occipital tract hasbeen suggested as modulating frontal lobendashrelated inhib-itory control and occipital lobendashrelated sensory inputs34

Alterations of this tract may interfere with integratingsensory information and inhibiting control over im-pulses and emotion which is problematic among drugabusers The external capsule contains a variety of dif-ferent nerve bundles and pathways connecting the cere-bral cortex to subcortical nuclei as well as connectingdifferent parts of the cortex to each other Thereforedisruption to fibers of the external capsule may result indysfunction of frontal-subcortical circuitry

HCV1 participants demonstrated lower levels ofNAA in bilateral parietal white matter and elevationsof mI in bilateral frontal white matter compared tocontrols which was associated with poorer perfor-mance in the cognitive domains of processing speedand verballanguage fluency Further there was a cor-respondence between our DTI and MRSI measuresSpecifically higher NAA in parietal white matter was

significantly correlated with lower diffusivity in thefronto-occipital fasciculus whereas greater frontalwhite matter mI was significantly correlated withhigher diffusivity in the fronto-occipital fasciculus

That stated our MRSI results were generally consis-tent with previousMRSI studies of HCV1 cohorts81235

although we did not observe abnormal cerebral metabo-lite levels in basal ganglia as was expected

However in the current study we were careful toexclude participants with medical (eg cirrhosis) andpsychiatric conditions that potentially could haveconfounded interpretation of the neuroimaging find-ings Through this process we may have excludedHCV1 individuals with more severe neurologic im-pairments and neuropathologic changes in subcorticalstructures that are detectable by H-MRS AlthoughHCV1 patients demonstrated poorer global neuro-cognitive performance than controls examination ofperformance data suggests normal range of perfor-mance (ie T 40) Again because of the use of

Figure 2 DTI values between the hepatitis C group and controls

(A) DTI FA values (B) DTI diffusion values Statistically significant at FDR-adjusted p value DTI5 diffusion tensor imagingFA 5 fractional anisotropy FDR 5 false discovery rate



stringent inclusionexclusion criteria this group maynot be fully representative of the general HCV1 pop-ulation Despite the potential recruitment of higher-functioning HCV1 individuals we still found thepoorer performance in the cognitive domains of pro-cessing speed and verbal fluency (relative to controls)

that has been reported across other studies45131516

and this performance was independent of such factorsas liver fibrosis and history of substance abuse

HCV1 participants also reported greater fatiguethan controls which was associated with abnormalitiesin frontal white matter whereas poorer cognitive per-formance was associated with abnormalities in bothfrontal white matter and subcortical structures Theseresults suggest that HCV-associated neurologic compli-cations that are specific to changes in frontal-subcorticalstructures give rise to both reduced cognitive perfor-mance and fatigue The specific cognitive deficitsobserved in verballanguage fluency and informationprocessing speed are all regulated by frontal-striatalstructures36 In our sample verbal fluency demonstratedthe greatest degree of performance difference betweenHCV1 and control groups and the strongest correla-tion with elevated levels of mI in frontal white matter

There are limitations to the current study Firstwhile structural neuroimaging methods are helpfulin identifying microstructural pathology that maynot be detected on standard MRI they do not pro-vide a clear understanding about the functions ofthese neural circuits Hence existing disruptions ina neural circuit may make a patient more vulnerableto developing symptoms such as fatigue Secondalthough we attempted to control for a number ofdemographic variables between HCV patients andcontrols we recognize that there are a myriad of

Figure 4 Neurocognitive performance differences

Neurocognitive performance differences between the hepatitis C group and controls 5 Statistically significant at FDR-adjusted p value

Figure 3 MRSI metabolite differences between the hepatitis C group and controls

Glu_Gln 5 glutamate 1 glutamine GPC_Pch 5 gylcerophosphocholine 1 phosphocholine (total choline) MRSI 5

proton magnetic resonance spectroscopy imaging NAA_NAAG 5 N-acetylaspertate 1 N-acetylaspartate glutamate 5

Statistically significant at FDR-adjusted p value



psychosocial differences (eg stress past drug use)that may account for the reduced cognitive perfor-mance and structural brain differences that wereobserved in the current study For instance we wereunable to examine past drug abuse differencesbetween our HCV1 and control groups becauseinformation on past drug abuse was not collectedfrom the controls We recognize that in order to pre-cisely rule out the effects of past drug abuse we wouldhave needed to recruit a sample of past drug abuserswho were HCV2 However considering that 61 ofour HCV1 patients reported a lifetime history ofcocaine or opiate use we attempted to address thisconcern by examining the effects of past drug abusewithin this subgroupWhile we did not find significantdifferences in our neuroimaging or neurocognitive dataas a function of past drug abuse (all p values 010)we cannot rule out the residual confounding effects ofdistant substance use on neurologic function

Despite these limitations the current study repre-sents a significant extension of the extant literature onHCVrsquos effects on neurologic and neurobehavioralfunctioning by demonstrating how abnormalities infrontalparietal and subcortical structures have inde-pendent and overlapping relationships with cognitiveperformance and fatigue

It has long been known that HCV is hepatotoxicincreasingly there is reason to believe that it is neuro-toxic as well While the precise pathophysiologicmechanism remains unclear findings from the cur-rent study as well as others have demonstrated thatHCV infection is associated with neurophysiologicand neurobehavioral abnormality While advancesin the pharmacologic treatment of HCV hold incred-ible promise there remain millions of HCV-infectedadults in the United States and approximately 100million worldwide Continued study of the neuro-logic effects of HCV is needed

AUTHOR CONTRIBUTIONSDr Thames was involved in the study design was responsible for con-

ducting statistical analyses of study hypotheses assisted with processing

of neuroimaging data and drafted the initial version of the manuscript

Dr Castellon was involved in the conceptualization of the parent study

provided scientific input on study design data collection and interpreta-

tion provided consultation for statistical analyses in the current study

provided critical revisions to the write-up of study findings and gave final

approval of the manuscript for submission Dr Singer was involved in the

conceptualization of the parent study design provided scientific input on

clinical and medical data collection and interpretation provided critical

revisions to the write-up of study findings and gave final approval of

the manuscript for submission Dr Nagarajan was involved in the study

design of the MR spectroscopy data acquisition and MR spectroscopy

postprocessing provided critical revisions to the write-up of MR spectros-

copy findings and interpretation and gave final approval of the manu-

script for submission Dr Sarma was involved in the study design of

the diffusion tensor imaging data acquisition and processing assisted with

the analyses provided critical revisions to the write-up of diffusion tensor

imaging findings and interpretation and gave final approval of the man-

uscript for submission Dr Smith was involved in the interpretation of

clinical data provided critical revisions to the manuscript draft and gave

final approval of the manuscript for submission Dr Thaler assisted with

statistical analyses of the neuropsychological data assisted with the write-

up of results provided critical revisions to manuscript drafts and gave

final approval of the manuscript for submission Dr Truong provided sci-

entific input on medical data acquisition provided critical revisions to the

manuscript draft and gave final approval of the manuscript for submis-

sion Mr Schonfeld was involved in data acquisition formatted the tables

and figures assisted with the write-up of the methods for the manuscript

and gave final approval of the manuscript for submission Dr Thomas

was responsible for the conceptualization and study design of the neuro-

imaging data provided scientific input on sequence parameters and data

analysis provided critical revisions to manuscript drafts and gave final

approval of the manuscript for submission Dr Hinkin is the PI of the

parent project and was responsible for the conceptualization of the study

design provided scientific oversight for all study phases provided critical

portions of manuscript drafts and gave final approval of the manuscript

for submission

STUDY FUNDINGFunding support for the current study was provided through the NIH

(RO1MH083553 PI CH Hinkin)

DISCLOSUREAD Thames has received research support from the NIMH and the

American Psychological Association Society for Clinical Neuropsychology

SA Castellon reports no disclosures E Singer is on the NIH study section

advisory board is a reviewer for ORAU grants and receives funding from

NIMH MINDS and NIDA R Nagarajan MK Sarma and J Smith

report no disclosures NS Thaler received research support from the NIH

JH Truong and D Schonfeld report no disclosures MA Thomas has

received research support from NIH and CDMRP-Prostate Cancer Research

Program CH Hinkin has received research support from NIH and from a

VA Merit Review Grant Go to Neurologyorgnn for full disclosures

Received July 24 2014 Accepted in final form November 21 2014

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34 Catani M Dellrsquoacqua F Vergani F et al Short frontal

lobe connections of the human brain Cortex 201248

273ndash291

35 Nagarajan R Sarma MK Thames AD Castellon SA

Hinkin CH Thomas MA 2D MR spectroscopy com-

bined with prior-knowledge fitting is sensitive to HCV-

associated cerebral metabolic abnormalities Int J Hepatol

20122012179365

36 Thames AD Foley JM Wright MJ et al Basal ganglia

structures differentially contribute to verbal fluency evidence

from Human Immunodeficiency Virus (HIV)-infected

adults Neuropsychologia 201250390ndash395



DOI 101212NXI000000000000005920152 Neurol Neuroimmunol Neuroinflamm

April D Thames Steven A Castellon Elyse J Singer et al hepatitis C

Neuroimaging abnormalities neurocognitive function and fatigue in patients with

This information is current as of January 14 2015

2015 American Academy of Neurology All rights reserved Online ISSN 2332-7812Published since April 2014 it is an open-access online-only continuous publication journal Copyright copy

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fasciculus the inferior fronto-occipital fascic-ulus and the genu of the corpus callosumcompared to normal controls910

Neurocognitive studies have found thatHCV-infected individuals demonstrate increasedneurocognitive dysfunction compared to con-trols511ndash14 Selective deficits in attention concen-tration and psychomotor speed are mostcommonly reported across studies451516 andthese deficits are largely independent of suchfactors as liver fibrosis

In addition to cognitive dysfunction approx-imately 65ndash80 of chronically infected pa-tients complain of fatigue that is independent ofliver dysfunction17 In a study of HCV1 pa-tients moderate fatigue was associated withpoorer cognitive performance and reducedEEG brain activity compared to HCV1 pa-tients with mild fatigue8 Fatigue and cognitivedysfunction may share overlapping pathophysi-ologic mechanisms however very few studieshave had sufficiently large samples to examineneurocognitive abnormalities and fatigue intandem Therefore the objective of this studywas to examine neuroimaging abnormalities(H-MRS and DTI) neurocognitive perfor-mance and fatigue among a sample of HCV1patients

METHODS Our initial sample consisted of 87 HCV1 partic-

ipants who were recruited from several hepatology clinics and

infectious disease clinics located throughout the greater Los An-

geles catchment area Controls (n 5 21) were recruited from the

community through advertisements and flyers

Standard protocol approvals registrations and patientconsents All procedures received prior approval by the Univer-

sity of California Los Angeles and VA Greater Los Angeles

Healthcare System Institutional Review Board Committees for

studies involving human subjects All HCV1 patients participat-

ing in this study met clinical criteria for initiating HCV therapy

but had not yet begun treatment All data reported in the current

study were collected at participantsrsquo baseline visit As part of

procedures outlined in the parent study a nested cohort of

HCV1 participants underwent neuroimaging (n 5 29) There

were no statistically significant differences between HCV1 par-

ticipants who underwent neuroimaging and those who did not on

key demographic variables such as age sex ethnicity past drug

abuse current drug use Model for End-Stage Liver Disease

(MELD) score and psychiatric functioning (all p values

005) All participants provided informed consent prior to

undergoing procedures Inclusion criteria were as follows (1)

18 years of age (2) able to read and write in English (3) and

completed at least 6th grade education Exclusion criteria were as

follows (1) decompensated cirrhosisliver failure (detected by

blood tests or liver biopsy) with MELD scores 12 (2)

current or past psychotic spectrum disorder (3) significant

depression as judged by the study psychiatristspsychologists

(defined as current moderate or severe major depressive disorder)

or suicidal ideation (factors that were controlled for initiating

interferon treatment) (4) history of learning disability seizure

disorder closed-head injury with loss of consciousness in excess of

30minutes or any other neurologic disease (5) evidence of any other

CNS opportunistic infection or neoplasm (6) hepatitis B infection

(7) diagnosis of HIV infection as evidenced byHIV antibody testing

(8) recent illicit drug use (confirmed by urine toxicology) and (9)

contraindications for MRI (for the nested cohort who underwent

neuroimaging) After applying exclusion criteria our final sample

(those eligible for analysis) included 76 HCV1 participants and

20 controls (See supplementary table e-1 for clinical characteristics

of theHCV1 sample) TenHCV1 participants were determined to

be ineligible due to liver cirrhosis and 1 control participant tested

positive for stimulants at study visit

Brain MRI was performed using a 3-tesla Trio MRI scanner

(Siemens Medical System Erlangen Germany) High-resolution

MRI included T1-weighted images using a magnetization-

prepared rapid acquisition gradient-echo sequence using the follow-

ing parameters repetition time (TR)echo time (TE) 5 222022

msec inversion time5 900msec average5 1 matrix size5 2563

256 field of view (FOV) 5 240 3 240 mm2 slice thickness 5

1 mm number of slices 5 176 DTI was acquired using a single-

shot echo planar dual spin echo sequence with ramp sampling The

b-factor was set to 1000 smm2 TR 5 9600 msec TE 5 90

msec flip angle 5 90deg and averages 5 1 A total of 71 axial

sections were acquired using an image matrix of 1303 130 a slice

thickness of 2 mm with no interslice gap and an FOV of 256 3

256 mm2

Proton spectra were collected using the 2D proton magnetic

resonance spectroscopy imaging (MRSI) technique with the vol-

ume of interest (VOI) preselected by means of point-resolved

spectroscopy (PRESS) Volume-selective 2D MRSI was per-

formed on a 20-mm slab superior to the ventricles with TE of

30 msec and TR of 2000 msec The nominal voxel size was

282 cm3 (16 3 16 phase encode steps over an 18 3 20 cm2

FOV) Outer-volume saturation bands were applied to all 6 sides

of the VOI localized by the PRESS sequence to suppress the lipid

contamination

Participants completed a comprehensive neuropsychology test

battery We assessed attention using the Wechsler Adult Intelli-

gence Scale-Third Edition (WAIS-III) Letter-Number Sequencing

subtest18 and the Paced Auditory Serial Addition Test (only the first

50 trials)19 processing speed using the WAIS-III Digit Symbol and

Symbol Search subtests18 Trail Making Test Part A20 and Stroop

color naming and word reading21 learning and memory using the

Hopkins Verbal Learning Test-Revised22 and the Brief Visuospatial

Memory Test-Revised23 verballanguage fluency using the Con-

trolled Oral Word Association Test24 executive functioning using

Trail Making Test Part B and Stroop color-word interference

test2021 and motor speed using the Grooved Pegboard test25

Raw scores were converted into demographically adjusted t scoresgrouped by neurocognitive domain and averaged to create domain

t scores A global neurocognition score was calculated by averaging tscores from individual neuropsychological tests

Fatigue was assessed with the Visual Analogue Scale (VAS26)

The VAS contains 18 visual analogue lines with bipolar anchors

with descriptors relating to energy and fatigue Participants are

asked to place a mark between the anchors Internal consistency

of the VAS in our sample was high (Cronbach a 5 086) The

total score from the VAS-Fatigue subscale was examined in the

current study

DTI and MRSI postprocessing DtiStudio was used to create

FA and mean diffusivity (MD) maps We used RoiEditor for
















































































Demographics

Age y 567 (55) 544 (55) 261 011

Education y 130 (22) 136 (17) 143 023

Sex male 785 500 823 001

Ethnicity 246 078

Caucasian 516 423


Latino 151 231



Other 11 00

Estimated IQ 985 (112) 1017 (105) 169 020

VAS-F subscale 308 (249) 190 (153) 521 002





Cocaine 00 00 NA

Marijuana 80 110 018 067

Opiates 00 37 094 033




































































for submission




















ology 20101391365ndash1374




















200441845ndash851






59651ndash657






201382686ndash692







316ndash322
















200541801ndash808






197744367ndash373







Resources 1999



Resources Inc 1997
































273ndash291





20122012179365


























Reprints

















































































Demographics

Age y 567 (55) 544 (55) 261 011

Education y 130 (22) 136 (17) 143 023

Sex male 785 500 823 001

Ethnicity 246 078

Caucasian 516 423


Latino 151 231



Other 11 00

Estimated IQ 985 (112) 1017 (105) 169 020

VAS-F subscale 308 (249) 190 (153) 521 002





Cocaine 00 00 NA

Marijuana 80 110 018 067

Opiates 00 37 094 033




































































for submission




















ology 20101391365ndash1374




















200441845ndash851






59651ndash657






201382686ndash692







316ndash322
















200541801ndash808






197744367ndash373







Resources 1999



Resources Inc 1997
































273ndash291





20122012179365


























Reprints




































































for submission




















ology 20101391365ndash1374




















200441845ndash851






59651ndash657






201382686ndash692







316ndash322
















200541801ndash808






197744367ndash373







Resources 1999



Resources Inc 1997
































273ndash291





20122012179365


























Reprints





59651ndash657






201382686ndash692







316ndash322
















200541801ndash808






197744367ndash373







Resources 1999



Resources Inc 1997
































273ndash291





20122012179365


























Reprints























Reprints




Neuroimaging abnormalities, neurocognitive function, and fatigue in patients with hepatitis C

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