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Functional Magnetic Resonance Imaging as it is Used in The Clinical Setting
Julie Kohut, CNMT
University of Cincinnati, College of Allied Health Sciences

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Abstract
Functional magnetic resonance imaging, also referred to as FMRI, has similar properties
and principals of a normal MRI. The main difference between the two is that FMRI
focuses more on the brain and the areas that are responsible for certain functions. The
history of the two and their similarities and differences in acquiring images will be
discussed. The focus will then be primarily on FMRI and how it is currently used and
developing today. Its usefulness in regards to cerebrovascular accident recovery, pre-
surgical tumor resection, and seizure studies will be evaluated. Both the advantages and
disadvantages of functional magnetic resonance imaging will be reviewed. In addition,
comparative methods for examining the brain such as positron emission tomography,
magneto encephalography, electroencephalography, and near-infrared spectroscopy will
be compared. Finally, the paper will answer the question of how functional magnetic
resonance imaging is used today and how it could be used in the near future with the help
of further research and studies.

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The diagnostic modality of magnetic resonance imaging has been used as a
noninvasive, non-ionizing form of imaging since 1977. A typical MRI is able to look at
the anatomy and pathology of the brain however, a functional MRI, also known as fMRI,
allows for the brain to be observed in a whole new form. This method came about a few
years later in the 1990s. Through fMRI, the blood flow to certain regions of the brain can
be analyzed. Brain mapping can help determine how the brain is functioning in relation to
certain stimuli and actions. It goes beyond the anatomical aspects of typical scans and can
give insight on how the brain is working and processing thoughts and information. It can
reveal the different areas of the brain as it is exposed to visual stimuli, speech, movement,
and sensations. With that information, critical answers and important brain capabilities
can be discovered.
MRI and fMRI basic principles.
Felix Bloch, Raymond Damadian, and Paul Lauterbur are responsible for
discovering magnetic resonance imaging. Because of their research, over twenty million
MRI scans are performed each year (Southers, 2013). Images are obtained by placing a
patient within a coil specific for the area of interest and then proceeding to place that
patient into the isocenter of the magnet through the bore. Since fMRI looks at the brain, a
head coil or brain coil is the coil of choice.
The hydrogen nucleus is abundant in the human body and makes up about eighty
percent of the atoms in the body (Southers, 2013). When these nuclei are placed inside
the magnet, they behave like miniature magnets with a north pole and a south pole. There
are three magnetic fields including the static or primary magnetic field, radio frequency
electromagnetic field or secondary magnetic field, and the gradient magnetic field

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(Southers, 2013). These hydrogen protons then undergo net magnetization and line up
either with or against the magnetic field, which then allows for the tissue and the patient
to become magnetized. In all instances, there will always be more lining up with, or
parallel to the magnetic field. “This interaction of the net magnetic vector with the static
field is the basis of magnetic resonance imaging” (Southers, 2013). Based on how the
protons move back the static field after being flipped with a radiofrequency pulse, the
type of tissue can be determined the contrast is shown, the location of the signal, and the
MRI image is produced.
Later in the 1990s, Seiji Ogawa further developed MRI by discovering how to
use blood flow to map areas of the brain, providing more information than regular MRI
images and thus creating fMRI (Watson, 2013). The basis for this concept is that
“oxygen-rich blood and oxygen-poor blood have a different magnetic resonance”
(Watson, 2013). Since active areas of the brain use more of the blood supply, fMRI
concludes that activity is occurring where there is more blood flow or BOLD signal. The
word BOLD refers to the words “blood oxygen level dependent”. “The measurement of
blood flow, blood volume and oxygen use is called the blood-oxygen-level-dependent
(BOLD) signal” (Watson, 2013). The more oxygenated the blood, the more signal it
produces. Therefore, fMRI may sometimes also be referred to as “BOLD imaging”.
Applications.
The functional MRI is used for a wide variety of purposes. It is most commonly
used in studies and research to develop new ideas about brain processing. Research
concerning the brain is endless with possibilities. Intensive studying of all different
thought processes, emotions, and stimuli are being examined. As of today, these studies

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are still a work in progress. However, several techniques have begun to be incorporated
into clinical procedures and patient care.
One beneficial form of this technique is that it can be used to study how a brain
will function or recover post stroke or cerebrovascular accident. One research study
concluded,
“individuals with chronic stroke who have impaired finger movement can be
trained to improve their finger control through intensive practice at a finger
movement tracking task and that the skill learned from such training is transferred
to a more functional finger grasp and release task” (Carey et al., 2002, p. 780).
Also, through this trial performed with a 3-tesla fMRI they discovered that this
improved function is due to brain reorganization. “Thus, with considerable room for
improvement still remaining, more work is needed to determine whether extended
treatment can produce further improvements beyond these initial findings” (Carey et al.,
2002, p. 781). Therefore, being able to see how a brain functions post stroke could lead to
more insight on what needs to be done to help patients recover. As more knowledge is
acquired, people who suffer weakness caused by strokes could one day gain back
movement of their arm.
Functional magnetic resonance imaging is also useful in evaluating brain tumors.
Pre-surgery scans may be done in order to find out which regions of the brain are affected
by the presence of the tumor. This can help them to determine which brain processes are
located in the area of the tumor that they want to remove. This allows surgeons to
determine which areas are affected by the tumor and conclude which functions will be
lost or diminished after tumor resection. With fMRI, scans can show regions responsible
for motor hand movement, tongue representation, and foot representation all of which are
necessary for a patient to function properly after surgery (Wengenroth et al., 2011,

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p.1517). Using fMRI brain mapping to find these significant areas can take the place of
other invasive means of finding these areas including placement of a grid of subdural
electrodes, intracarotid amobarbital test, and intraoperative cortical stimulation (Jezzard
& Buxton, 2006, p.790). These alternatives to fMRI are much more involved and could
require even more surgeries. Placing subdural electrodes involves implanting electrodes
through surgery before the main surgery is performed. In the intracarotid amobarbital
test, the brain hemispheres are put under anesthesia to assess the regions for language and
memory localization. In intraoperative cortical stimulation or ICS, the patient is awake
during surgery in order to find different control areas (Jezzard & Buxton, 2006, p.790).
Obviously, fMRI is a much more simple way of mapping the brain regions to use before
surgery. It is much less invasive, requires much less surgery time, and is easier on the
patient. “FMRI-based pre-surgical risk assessment correlated in 88% with a positive
postoperative clinical outcome” (Wengenroth et al., 2011, p. 1517). This percentage had a
positive outcome for fMRI surgeries and may not have had the same positive outcome
had it not been for the fMRI.
One concerning factor when using fMRI as a pre-surgery map tool is the tendency
for the brain to shift once the surgeon has opened the brain and pulled back the dura
mater (Haller & Bartsch, 2009, p. 2700). This movement, even though it may be subtle,
means that the regions located on the fMRI may be slightly shifted compared to what the
surgeon is viewing. When dealing with the brain and surgery in general there is no room
for any error even in the slightest of shifts. Trials through different technology may be
done to account for this. Since they expect the mater to shift the brain ever so slightly,
computer software is used to predict how it may shift and alter the regions of the brain as

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well as when compared to the fMRI.
Another clinical application functional magnetic resonance imaging can be used
for deals with finding the location of a seizure and analyzing what areas of the brain are
affected during that time. When fMRI is used to look at seizures, “the overall aim of the
analysis is to identify hemodynamic patterns reflecting the epileptic activity” (Chaudhary,
Duncan, & Lemieux, 2013, p.451). Often times, the fMRI is used at the same time as an
EEG. “EEG-fMRI has been shown to provide new and unique information on the brain
networks involved in relation to epileptic seizures” (Chaudhary et al., 2013, p.454). MRI
and fMRI require no movement and even slight movement can affect the quality of the
scan. Therefore, since seizures are usually accompanied by uncontrollable movement,
post processing of the image is mandatory (Chaudhary et al., 2013, p.450). The fMRI
looks to detect preictal hemodynamic changes in the brain (Chaudhary et al., 2013,
p.458). The BOLD signal is examined and used to see how blood flow may change in the
seconds before a seizure occurs as well as during and after. The information collected in
an fMRI and EEG study can lead to proper treatment of the patient to reduce symptoms.
For example in a recent study,
Spatial location of BOLD changes associated with myoclonic jerks of right foot
helped to localize an FCD from left frontal lobe which was confirmed with
intraoperative cortical mapping as seizure onset zone and resected resulting in
complete abolition of seizures (Chaudhary et al., 2013, p.462).
More cases and recent studies have further examined patients with frequent seizures in
which nothing was helping relieve their symptoms and these cases have led to positive
outcomes as well for example,
“In another patient with refractory epilepsy, who had undergone epilepsy surgery
twice without any appreciable success, fMRI showed widespread BOLD changes
involving the cortex, caudate nucleus, thalamus and other areas during the seizure

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(a pattern known to be present in generalized epilepsy). Consequently, the
antiepileptic drugs were changed to control generalized epilepsy and seizure
frequency reduced from 10/day to 1/month” (Chaudhary et al., 2013, p.462).
Even after surgeries and medication, the seizures in these cases did not decrease
until the fMRI and EEG was used to help in the treatment. Decreasing seizure frequency
from ten times each day to one time per month is drastic and life changing for that
person.
Advantages.
The greatest advantage of magnetic resonance imaging is the detailed contrast
resolution that can be acquired. Out of the numerous forms of imaging modalities, MRI is
advantageous in contrast and spatial resolution as well as viewing different densities and
tissue contrasts. Also, there are few risks associated with MRI. It does not use radiation
and therefore there is no risk of overexposure or other radiation safety dangers. A patient
can be scanned on any given day with no fasting or prep required. The risks that are
associated with MRI are preventable. These risks include screening patients to be sure
that they are MRI safe and contain no ferrous materials. Also, preventing unauthorized
individuals or objects from entering the room can prevent projectiles from injuring the
patient or the magnet.
Disadvantages.
As with all forms of imaging, there are disadvantages along with the advantages.
Depending on the patient and his or her ability to undergo the exam, it is a long test with
slight discomfort laying supine, requiring focus and very little motion. One disadvantage
of the fMRI is that different drugs and chemicals can affect the BOLD response and
cause error in the test. Nicotine, cannabis, and acetazolamide are capable of reducing the

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BOLD response while caffeine and theophylline have been shown to increase it (Haller &
Bartsch, 2009, p.2690). Checking what the patient is using can usually eliminate these
issues.
Another issue associated with fMRI is that the brain is always active in some way
whether it is thinking or responding to stimuli or sending signals to the body. Because of
this, it is often difficult to distinguish between the baseline, or resting state, of the brain as
compared to when it is stimulated or appropriate for the test.
Other forms of imaging.
Besides fMRI, the other means of imaging cerebral blood flow is positron
emission decay imaging also known as PET. PET incorporates the use of a radioactive
tracer injection before imaging. A study comparing the two techniques found that
Both the percentage change of CBF and extent of activation area using two image
modalities were examined, and their values agree well with each other. No
statistically significant difference was found between MRI and PET in the
assessment of functional CBF maps (Feng et al., 2004, p.445-446).
However, there are different reasons for choosing one over the other. If a patient
has a pacemaker or unsafe metal within his or her body, the patient cannot enter the
magnet and would benefit from PET. On the other hand, if a patient has already
undergone a lot of procedures involving radiation and is at risk for overexposure, an
fMRI would be better suited for that patient. Also, fMRI can be done repeatedly at any
time with no patient risks while PET requires more prep work. For example, PET
requires having the patient fast, having the glucose levels within the right ranges, and
allowing time for the tracer to circulate. Finally, fMRI offers better visualization of the
surrounding structures in the brain providing a clearer localization while PET only
displays a scout scan to inform you of the region of anatomy.

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Magneto encephalography or MEG is also capable of recording brain activity and
currents. However, this form of neuroimaging is not capable of localizing what it records.
As previously mentioned, EEG can be used to detect brain changes, but just like MEG, it
too cannot provide detailed location within the brain. Finally, NIRSI or near-infrared
spectroscopy imaging is another tool used to evaluate brain activity and cerebral blood
flow. NIRS is beneficial due to its ability to be more accessible and travel. Its downfall
however is that it can only scan cortical tissues whereas a functional MRI can scan the
entire brain (Fekete, Rubin, Carlson, & Mujica-Parodi, 2011, p.2080).
FMRI in the future.
Functional magnetic resonance imaging has already developed significantly since
its invention. While much more is known on the subject, there is still a great deal of room
for further development. There is much more research to be done in order for it to
become a more common form of imaging. This modality has the potential to be used in a
wide variety of studies. Clinically, it is already useful for patients with strokes, seizures,
epilepsy, depression, and Alzheimer’s. It is making advancements in understanding
schizophrenia, emotions, gender differences, responses to stimuli and events, and effects
of drug usage. There are endless possibilities of which fMRI could be useful.
This knowledge is even being developed in nonclinical settings as a tool for
marketing and advertising to see how to make products more marketable to humans
depending on their thought patterns shown on fMRI when exposed to the product. In
addition, another current area of investigation consists of using fMRI as a form of lie
detection. In a study working to develop lie detection techniques they found that,
“It is also clearly evident that controlling one's cerebral activity to avoid detection
is unfeasible. Taken together, this suggests that our work may have identified

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some extremely significant preliminary markers that have the promise to enhance
the development of valid and sensitive methods for the detection of malingering”
(Lee et al., 2002).
Therefore, fMRI has the potential to impact our knowledge on all aspects
concerning the human brain. It is useful for understanding human thought processes and
can help develop lie detection. Also, it is beneficial for better understanding diseases and
natural responses of humans. With more research, functional magnetic resonance imaging
will continue to advance and one day provide even more valuable information on the
human mind.

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References
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