Sensor Fusion Robot Ekf

Abstract

Recognizing facial activity is a well-understood (but non-trivial) computer vision problem. However, reliable solutions require a camera with a good view of the face, which is often unavailable in wearable settings. Furthermore, in wearable applications, where systems accompany users throughout their daily activities, a permanently running camera can be problematic for privacy (and legal) reasons. This work presents an alternative solution based on the fusion of wearable inertial sensors, planar pressure sensors, and acoustic mechanomyography (muscle sounds). The sensors were placed unobtrusively in a sports cap to monitor facial muscle activities related to facial expressions. We present our integrated wearable sensor system, describe data fusion and analysis methods, and evaluate the system in an experiment with thirteen subjects from different cultural backgrounds (eight countries) and both sexes (six women and seven men). In a one-model-per-user scheme and using a late fusion approach, the system yielded an average F1 score of 85.00% for the case where all sensing modalities are combined. With a cross-user validation and a one-model-for-all-user scheme, an F1 score of 79.00% was obtained for thirteen participants (six females and seven males). Moreover, in a hybrid fusion (cross-user) approach and six classes, an average F1 score of 82.00% was obtained for eight users. The results are competitive with state-of-the-art non-camera-based solutions for a cross-user study. In addition, our unique set of participants demonstrates the inclusiveness and generalizability of the approach.

multimodal fusion, facial expressions, activity recognition, mechanomyography

Ntroduction

Facial expressions are a key means of communication in human interactions; they are sometimes more informa- tive than explicit verbal communication [3, 4]. They affect our social intelligence and ability to create interpersonal emotional connections . Consequently, monitoring fa- cial expressions has been investigated in many pervasive computing applications. Examples include novel human- computer interfaces [6, 7], learning feedback , and rec- ognizing a car’s driver’s fatigue or mood [9, 10].

Facial expression recognition is a complex problem for several reasons. First and foremost, its large interpersonal variability .

T Is Influenced By Cultural Background

[12, 13], age, sexes , race, and other person-specific characteristics, leading to a user-dependent solution in

Many Related Works (See Table 1). Recently, In ,

the authors have formally studied the impact of a sex- balanced dataset on the fairness of the results for facial expression recognition (happiness, sadness, surprise, fear, disgust, and anger).

They Conclude That Training With

the mixed dataset achieves the best results in all cases. Furthermore, fairness is compromised in training with a highly biased dataset, especially when classifying particu- lar expressions. In addition, different expression categories may have only minor differences (e.g., anger and sadness, as depicted in Figure 1).

Cameras are the most widely used solution to recog- nize expressions with an expected accuracy of more than 90.00% [16, 17, 18].

However, In Wearable Applications,

cameras are not always a suitable solution. First, placing a camera on the user’s body in an unobtrusive, suitable for everyday use, and simultaneously providing a good view of the entire face is difficult at best. Light conditions and occlusion can also be a problem. In addition, as the ex- ample of GoogleGlass has shown, having a permanently body-worn camera in everyday situations can be socially awkward and even illegal in some countries.

Omputer

vision-based methods also tend to have a larger memory footprint and power consumption than non-visual sensor- based solutions, such as the one presented in .

There has been significant interest in the wearable com- munity in non-visual sensing approaches for face monitor- ing.

However, As Related Work Describes, Most Systems

struggle to balance wearability constraints with the need to acquire clean and informative signals. The core of the problem is that facial muscle movements involve large ar- eas of the face that sensors cannot cover unobtrusively.

Additionally, sensor placement is limited to areas such as:

—Quaternion Qy –Quaternion Qz

Figure 1: Facial Muscle Activities Dictionary with Sensor Signal Examples; 7 Facial Expressions from Warsaw Photoset and 2 Gestures from . Two Channel Raw Audio Data, Thirteen Mel Frequency Cepstral Coefficients (Two Channel Audio-Monophonic), Force Sensitive Resistor, Piezoelectric Film, Orientation and Acceleration.

around glasses, on the head (e.g., under a cap), and around the ears. The challenge is to use those limited areas to capture information related to the overall facial activity.

Approaches that were previously studied include inertial

Measurement Unit (Imu) , Ultrasound , And Photo

reflective sensors . Acoustic sensing for face monitoring can be more compact, with a smaller data footprint and computational requirements, and lower power consump- tion compared to cameras [21, 23]. Nevertheless, the pri- vacy concern of camera/audio-based design still limits user acceptance.

A standard method for quantifying muscle movements is their electrical activation pattern, sensed by electromyo- graphy (EMG). EMG measurements rely on detecting weak electrical signals from the body. This technique requires a stable electrical connection to the skin surface, typically implemented using micro-needles embedded in the muscles or at least wet electrodes. Both options can be a challenge for use in everyday wearable settings . On the other

Hand, Mechanomyography (Mmg) Measures The Mechan-

ical signals resulting from the lateral movement of muscle fibers at low-frequency [25, 26]. MMG does not need an electrical connection with the skin and can be detected by various types of sensors, such as IMU, piezoelectric, microphones, pressure sensors, laser sensors, and many others .

Graphy (Ammg) Has Been Proposed. The Authors Used

stethoscope microphones distributed around the tempo- ralis, frontalis, and masseter muscles to detect ten facial expressions. An F1 score of 54.00% for the cross-user case (eight volunteers) shows promising results for a passive, privacy-aware method to detect facial muscle movements.

However, it is still not a pleasant solution to wear and is far from being a portable option.

N , A Pressure

mechanomyography (PMMG) solution has been presented with 38.00% accuracy in classifying seven Warsaw Photo- set facial expressions . The authors showed the potential of an unobtrusive, passive, textile, headband-based design for monitoring facial muscle activity.

Alternatively, multimodal approaches have been stud- ied to exploit the limitation of independent sensing modal- ities. The idea is to combine multiple data sources with complementary information to reduce ambiguity, add com- pleteness to the situation being studied ("gain in represen- tation"), improve the signal-to-noise ratio(assuming inde- pendent error sources), and increase the confidence in the model decision("gain in robustness"). In , the authors proposed a combination of IMU and 16 optical sensors in smart glasses to detect eight temporal facial gestures.

Obtaining F1 score results of 91.10 % for the case of one model per person for the recognition of facial action units

(Aus: Au12, Au27, Lp, Au1+2, Au4, Au43, Au46R,

AU61) . Optical sensors for facial muscle movements limit the system to stable light conditions. In , another solution based on the fusion of IMU and electrooculogra- phy is presented to recognize kissing gestures, obtaining an accuracy of 74.33% in a cross-user scheme. IMU is the common basis in the multimodal scheme, so it is a source of information to be considered.

This Work Proposes A Multimodal System That Fuses

complementary sensing modalities, such as inertial sensing IMU (orientation and acceleration), AMMG, and PMMG (force-sensitive resistor and piezoelectric film), integrated into a sports cap accessory. The facial expressions to be evaluated come from the Warsaw Photoset (seven expres- sions) and (two facial movements); thus, it will be sim- pler to compare with future solutions, see Figure 1.

N Summary, Our Contributions Are:

• We present a multimodal sensing alternative for fa- cial muscle motion monitoring based on inertial, pla- nar pressure and acoustic sensors distributed in a minimally obstructive wearable accessory (sports cap).

Furthermore, The Idea Can Be Adapted And Poten-

tially unobtrusively integrated into other head-worn platforms (e.g., glasses and headbands) without com- promising the sensing capability.

• We adopt a modular multimodal fusion method based on sensor-dependent neural networks using a late fu-

In Wearable/Embedded Devices With Tiny Dimensions

and reduce memory (4 MB to 16 MB Flash). • We conduct a user study with thirteen participants from diverse cultural backgrounds (eight countries) and both sexes (six women and seven men).

Unique Dataset Demonstrates The Inclusiveness And

generalizability of the results. For the evaluation, we

Use The Warsaw Photoset Plus Two Facial Gestures

from . • We evaluate the system using a hybrid fusion ap- proach with locally connected inception blocks with

Dimension Reduction Per Sensing Modality For The

best eight imitators of the facial expression dictio- nary in Figure 1, and six classes. The article is organized as follows. Section 2 reviews related work on facial expression monitoring with wear- ables and mechanomyography (MMG). Section 3 details the material and method, including the apparatus, experi- mental design, and information fusion approach. We show the experimental results and discuss our limitations in Sec- tion 4. In Section 5, we conclude the article and make some remarks for the future.

Related Work

This section examines previous research projects re- lated to InMyFace in the scope of facial monitoring with wearables and pressure/audio-based mechanomyography.

Table 1: Comparison with State-of-the-art Wearable Sensing Methods for Facial Activity Recognition

Facial Monitoring With Wearables

The wearable community has explored facial expression monitoring with different sensing modalities embedded in accessories. The various sensing methods include cameras [16, 35], IMU [31, 20], light , capacitive , piezo-

Electric , Electromyography (Emg) , Mechanomyo-

graphy [28, 2], audio based solutions [2, 33, 42], and many others. Table 1 shows a comparison of the state-of-the-art approaches.

A popular accessory to deploy sensors is glasses. Re- cently, capacitive sensors have been embedded in glasses in to recognize 12 facial gestures and head movements.

They explored two ways to deploy the electrodes; one in- volves injecting a 12V AC signal into the body to elevate the body’s potential and increase the signal-to-noise ratio, and the second one by generating a tremendous electric field close to the person’s face/eyes to remove the ground dependency in capacitive sensing [43, 44] and get good signals. Another active sensing approach in glasses is pre- sented in , using 17 photo-reflective sensors to classify eight facial expressions with results between 78.00-92.00% per user.

Ompact Wearable Cameras Were Deployed In

front of the face using glasses in . They focused on tracking facial muscle movement and generated a virtual avatar.

Amera And Photo-Sensor-Based Methods Share

the sensitivity to the light condition. In-ear wearable devices are a trend, with studies on facial expression recognition and the embedding of IMU

, Infrared , Electric Field And Ultrasonic Sen-

sors in the ear canal . A headphone-ultrasound device is proposed in and can track face deformation using the disturbances on the active-continuous sound signals being broadcast toward the face.

Is Proposed In . The Authors Used Their Own De-

signed earphones with pairs of speakers/microphones on both sides to propagate sound waves through the face. Based on the distortion on the microphones’ inputs, they then tracked the skin deformations of customized facial movements. The results in shows a promising future for a low-power and active audio system for facial move- ments tracking.

Active solutions could have negative consequences or long-term health effects, which physicians have not yet directly investigated. Some studies suggest the need for extensive research on standard technology used in wear- ables, such as radiation sources/waves around the body (e.g., WiFi and ultrasound) [46, 47, 48, 49, 50].

While

it may seem overly cautious or unrealistic at this stage of wearable technology, we want to maintain our effort to reduce the exposure of our volunteers and ourselves to sig- nals that have not yet proven to be risk-free.

In the present work, we focus on passive solutions such as the one presented in , where a textile pressure ma- trix (mechanomyography) was introduced into a headband design to classify seven facial expressions, with interme- diate results of up to 38.00% accuracy.

N Acoustic

mechanomyography (AMMG), another passive technique was employed with an F1 score of 54.00% in classifying ten facial muscle activities. Piezoelectric thin films (PEF) have been used in real-time to detect and classify skin deformation to decode facial movements in patients with amyotrophic lateral sclerosis. Their work is intended to be used in clinical settings for nonverbal communication and neuromuscular monitoring conditions. PEF sensing technology is lightweight, customized, and with mechan- ical harvesting capability ; therefore, we could claim that PEF technology is worthy of research and study in specific applications. Here, we proposed to fuse passive sensing such as; pressure mechanomyography (PMMG) us- ing a force-sensitive resistor (FSR) and piezoelectric film (PEF), inertial sensing based on orientation and accelera- tion, and acoustic mechanomyography (AMMG).

Echanomyography (Mmg)

Cyclic patterns of muscle contraction and relaxation are common in many everyday human activities, such as cycling, running, and laughing, to name a few. How the muscle activity pattern changes in intensity, duration, and frequency to understand human behavior is the topic of many research works. Electromyography (EMG) is a dom- setting; the standard procedure is to use surface or needle electrodes embedded in the muscle. EMG has limitations in terms of cost, is often restricted to a controlled environ- ment, and signal intensity is susceptible to skin impedance, age, and weight of the individual [52, 53]. In , the au- thors compared EMG with a fusion based on MMG and ac- celeration data for automatic segmentation and concluded that the results of the MMG+acceleration combination are similar to those of EMG, making the MMG option a suit- able solution for natural settings such as the home.

Echanomyography (Mmg) Is Also Suitable For As-

sessing skeletal muscle activities and monitoring fatigue and force imparted in muscle movement [54, 55]. In the literature, the measurement of MMG typically employs IMU , piezoelectric , microphones, pressure sensors, laser distance sensor, and others . Multimodal MMG solutions have been studied, as in ; The authors com- bined forearm acceleration and piezoelectric MMG sen- sors in the biceps brachii, brachioradialis, and pectoralis major to study mechanical muscle oscillations in patients with Parkinson’s condition. In , a myoelectric fusion (MMG+EMG) is proposed to overcome the unreliable sensor- skin interface in upper limb prosthesis manipulation. It follows from all the above that MMG is a broad and active area of research. In our work, there is particular interest in two categories of MMG; acoustic mechanomyography (AMMG) and pressure mechanomyography (PMMG).

Acoustic Mechanomyography (Ammg) Is Based

on monitoring muscle force (contraction/relaxation) by us- ing low-frequency signals (2-200 Hz) and power signals be- low 50 Hz . Using a microphone on the participants’ biceps brachii muscle during lifting activities in shows the AMMG as an alternative to the electromyogram for measuring muscle fatigue. In , the authors found that AMMG was significantly less influenced by motion artifact than the corresponding accelerometer spectra (p ≤0.05).

They conclude that condenser microphones are preferred for MMG recordings when mitigating motion artifact ef- fects is essential. This is especially true for kinesiological studies involving limb movement, such as cycling. AMMG for facial muscle movement recognition was introduced in . The stethoscope-based design in amplifies the in- tensity of muscle movement sounds at the expense of user comfort due to the large diameter. We propose to sense AMMG with two Inter-IC Sound (I2S) digital microphones on the frontalis muscle. I2S microphones are small com- pared to Electrec microphones in , and because they are digital microphones, their output is less disturbed by subtle movements of the wearable accessory.

Pressure Mechanomyography’S (Pmmg) Prime

purpose is to transduce muscle vibration changes by means of pressure patterns.

Pmmg Has Been Used For Facial

expression and cognitive load in . The authors have employed a textile pressure matrix (TPM) on the fore- head of twenty volunteers to recognize seven facial expres- sions from the Warsaw photoset . The 38.00% (14.00% chance-level) accuracy in recognizing seven facial muscle activities with an unobtrusive, textile, and passive sensing method shows encouraging results.

Nmyface Approach

Our system combines inertial, pressure, and audio sen- sors to recognize facial muscle activity from an unobtru- sive sports cap platform. Figure 1 presents the facial mus- cle movements dictionary. The IMU has already demon- strated its potential to distinguish various face- and head- related movements [29, 31].

Pmmg Provides A Flexible

and comfortable solution for facial gesture recognition with moderate accuracy . AMMG for facial muscle activity recognition was used in . However, the design was bulky and obtrusive to achieve high sensing accuracy. Combin- ing the three sensing modalities with an appropriate sensor fusion pipeline allows us to achieve high accuracy with an unobtrusive system.

System Architecture And Implementation

The prototype hardware is shown in Figure 2.

The

FSR sensors were distributed on the frontalis and tem- poralis muscles using a sports cap as a wearable acces- sory. Two Inter-IC Sound (I2S) microphones sampled at 44.1kHz were placed on the left/right side of the cap as shown in Figure 2. A custom printed circuit board (PCB) based on Teensy 4.1 1 and LoRaESP32 2 was used to sam- ple the sensor data. The integrated SD card of the Teensy 4.1 is used to store the acoustic data. The microphone openings are pointed towards the frontalis muscle to cap- ture the mechanical sound information (AMMG). The an- alyzed sound information comes from the muscle move- ments, so it is a privacy-aware system (no speech or am- bient sounds). Pairs of FSR and PEF were placed to the left and right of the temporalis muscle. The FSR and PEF were selected to measure the PMMG generated by facial muscle movements. An IMU was in the sports cap viewer to capture head movements related to facial expressions.

FSR, PEF, and IMU data were transferred by Bluetooth Serial (BT) to a cell phone application (Flutter Framework ) to save them in a JSON file for further analysis. The sampling rate was about 100 Hz for FSR, PEF, and IMU data. The Bluetooth communication scheme limited the data acquisition but is still fast enough to capture micro and macro expressions with a duration ≤200ms and du- ration ≥200 ms, respectively . Detailed sensor data acquisition diagrams are in Figure 2.

The sensor distribution (around the head) and the di- mensions/weights of the selected sensors, see Table 2, make our design suitable for integration into other head-related accessories such as headbands and glasses. In our sports cap, the dimensions and weight are negatively affected by the selected battery (1300 mAh) and the main board of the prototype (6.5 x 4.3 cm); both could be reduced in a future design and improve user comfort.

1Teensy 4.1, Paul Stoffregen: https://www.pjrc.com/store/teensy41.html

A: February 07, 2023

2LoraESP32, Sparkfun: https://www.sparkfun.com/products/18074

The Power Consumption Of The Prototype Is Around

0.22A at 4.97V (1.09 Watts continuous mode) 3. A number of possibilities exist for further power consumption reduc- tion based on the overall concept. On the one hand, FSR- PEF data could trigger IMU and audio data acquisition, reducing power consumption to 0.06A at 4.99V (0.3 Watts) when no pressure is detected in the temporalis muscle. On the other hand, PEF is a mechanical energy source. Me- chanical energy is considered ubiquitous ambient energy that can be converted into electric power . Employing piezoelectric as a mechanical energy harvesting mechanism is an active field of research [51, 62, 63]. Harvesting energy from human motion and at the same time classifying such motions has also been demonstrated before [64, 65, 62, 66] which could be employed to reduce the power consumption further.

In addition to mitigating power issues, the FSR has the advantage of being robust against motion artifacts. We thus recommend the use of the slope/gradient of the FSR signal as a possible trigger for automatic segmentation of the input data and to avoid motion artifacts. For example, the signal’s slope of acceleration data was automatically used to segment MMG data in . Finally, although we use off-the-shelf and non-textile FSR and PEF sensors for fast prototyping, it is noteworthy that both technologies are already available in textiles [28, 65, 67].

Ultimodal Sensor Fusion

Multimodal sensor fusion can be broadly classified into early and late fusion, depending on the position of the fusion within the processing chain . Our primary ap- proach is referred to as late fusion. The fusion is performed in the individually trained networks’ decision phase (con- fidence scores).

The Late Fusion Method Has The Advan-

tage of extracting the specific patterns of each sensor in- dependently and the parallel deployment of each sensor- dependent NN on multiple MCUs, reducing the recogni-

Tion Latency And Memory Requirement Per Mcu(≤2 Mb

per network). The main drawback of late fusion is the lim- ited potential to extract cross-correlation between sensing modalities and channels. Additionally, we also explored a hybrid fusion alternative. The fusion performed in the hidden layers of the neural network and before the deci- sion layer is called hybrid fusion. In our work, the hybrid fusion structure and evaluation are made considering the outcomes from the late fusion performance. An overview of the late fusion and hybrid fusion diagrams is depicted in Figure 3. The Figure 3a Left shows the concatenation of the sensor-dependent models after the decision phase us- ing an ensemble NN. The specific sensor-dependent mod- els are explained in Section 3.2.1. The Figure 3b Right presents the primary blocks of the hybrid fusion method.

The blocks consist of sensor inputs, inception blocks, and

U

Figure 2: Hardware Prototype and Data Collection Diagram. (A) Sports Cap with Sensors Distribution. B Sensor Placement on the Frontalis and Temporalis Muscles of the Participant. (C) Data Acquisition Diagrams with the Custom Printed Circuit Board.

Outputs Fused Sensor Data

1 https://www.mouser.de/datasheet/2/13/MF01A__c3_a2_c2_96_c2_a1_A01-1915118.pdf DLA: February 07, 2023 2 https://www.te.com/usa-en/product-CAT-PFS0010.html DLA: February 07, 2023 3 https://media.digikey.com/pdf/Data%20Sheets/Knowles%20Acoustics%20PDFs/SPH0645LM4H-B.pdf DLA : February 07, 2023 4 https://www.mouser.de/datasheet/2/783/BST_BNO055_DS000-1509603.pdf DLA: February 07, 2023

(B) Right

Figure 3: (a) Left Ensemble Multimodal Sensor Fusion Model Overview; Fusion in the Prediction Phase. (b) Right Hybrid Multimodal Sensor Fusion Model Overview; Fusion Within Hidden Layers, and Before Prediction. hybrid fusion NN. The details of each block are described in Section 3.2.2.

Ultimodal Ensemble Late Sensor Fusion

We employ sensor-based late fusion as depicted in Figure 3a Left and Figure 4. The data was divided by sen- sor type, and we implemented four sensor-dependent neu- ral networks (NN) models in Figure 4. This approach gives each NN the advantage of learning the unique properties of each modality and facilitates a simple fusion method.

In the initial step, the inputs to the sensor-dependent NNs were pre-processed in a sensor-specific manner, as de- scribed below. The data of each movement was processed as a whole instance. The NNs were developed using the TensorFlow framework (version 2.9.2). The training in- cluded early stopping with the patience equal to 30 and re- stored weights option equal to true to avoid overfitting and ran for 500 epochs. In the individual models, the learning rate was manually tuned for each participant, and for the case of one ensemble model for all participants (cross-user case), it was set to 0.03.

Ategorical Cross-Entropy Loss

function and Adagrad optimizer were used to optimize the sensor-type NN. The ensemble NN consisted of one fully connected layer of 20, Adam optimizer (0.01), and soft- max function with nine probability outputs, see Figure 3a Left Model Ensemble. The details of the sensor-type dependent NNs are explained below.

Pressure Mechanomyography (Pmmg) And Imu:

We sense PMMG with a combination of FSR and PEF. For the case of inertial sensing, the quaternions were se- lected for orientation to avoid the gimbal lock problem

And To Improve Stability. The Fsr, Pef, And Iner-

tial sensors (quaternions and acceleration) data were nor- malized by subtracting the average of the gesture’s first (starting point) and last values (ending point). Since each facial event is a temporal series with variable lengths, a dynamic resample procedure to 400 samples was applied [43, 44]. Then, the resampled signals were fed to a first- degree Butterworth low pass filter with a cut frequency of 5Hz to remove the ringing peak in the signal’s edges coming from the resample procedure and to highlight the low-frequency range.

Fsr And Pef Signals Were Treated As A Pair; Hence

they have a joint NN. Orientation and acceleration were processed in separate NNs. In total, three networks were trained for PMMG and inertial sensing. The NN struc-

Depicted In Figure 4 Model Mmg. The Network Con-

sisted of a convolution (conv)—max pooling (maxpool)- conv-maxpool-conv—fully connected (fc)-fc-softmax lay- ers with batch normalization and dropout on the convo- lution layers. The convolution layers contain 40 filters, a kernel size of 10, and the activation function ReLu. For max pooling, the pool size was (40, 40) for the first con- volution (400, 40) and (4, 40) for the second convolution (40, 40). The third convolution was of size (4, 40) without pooling. A flattening layer of 160 was followed by a fully connected layer of 100. The nine outputs for the differ- ent facial muscle activities in Figure 1 are then converted into probabilities by a fully connected layer and softmax function. A detailed view of the sensor-dependent neural network structure for the PMMG and IMU is shown in Figure 4 Top Model MMG.

Acoustic Mechanomyography (Ammg): As Shown

in Figure 2, two I2S microphones sampled at 44.1kHz were positioned on the sports cap to cover the frontalis mus- cle of the volunteer. The audio information was used as AMMG as proposed in but without the stethoscope to amplify the audio. Two channels of audio were resampled to 52000 (1.17 seconds). Muscle’s audio data was trans-

Authors:

Peder EZ Larson 1, 2,* , Jenna ML Bernard1, James A Bankson 3, Nikolaj Bøgh 4, Robert A Bok1, Albert P. Chen 5, Charles H Cunningham 6,7, Jeremy Gordon1, Jan-Bernd Hövener 8, Christoffer Laustsen 4, Dirk Mayer 9,10, Mary A McLean11 12, Franz Schilling13, James Slater1, Jean-Luc Vanderheyden5, 14, Cornelius von Morze 15, Daniel B Vigneron1, 2, Duan Xu1, 2, and the HP 13C

94143, Usa.

Denmark. 5 GE Healthcare, Menlo Park, California, USA. 6 Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.

8 Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Medicine, Baltimore, MD, USA. Cambridge, United Kingdom.

14Jlvmi Consulting Llc, Dousman, Wi, Usa

#See Acknowledgements for a list of all HP 13C MRI Consensus Group Members This work was supported by the ISMRM Hyperpolarized Media MR Study Group, the ISMRM Hyperpolarization Methods & Equipment Study Group, and the Hyperpolarized MRI Technology Resource Center (NIH/NIBIB grant P41EB013598).

Abstract

MRI with hyperpolarized (HP) 13C agents, also known as HP 13C MRI, can measure processes such as localized metabolism that is altered in numerous cancers, liver, heart, kidney diseases, and more. It has been translated into human studies during the past 10 years, with recent rapid growth in studies largely based on increasing availability of hyperpolarized agent preparation methods suitable for use in humans. This paper aims to capture the current successful practices for HP MRI human studies with [1-13C]pyruvate - by far the most commonly used agent, which sits at a key metabolic junction in glycolysis. The paper is divided into four major topic areas: (1) HP 13C-pyruvate preparation, (2) MRI system setup and calibrations, (3) data acquisition and image reconstruction, and (4) data analysis and quantification. In each area, we identified the key components for a successful study, summarized both published studies and current practices, and discuss evidence gaps, strengths, and limitations. This paper is the output of the “HP 13C MRI Consensus Group” as well as the ISMRM Hyperpolarized Media MR and Hyperpolarized Methods & Equipment study groups. It further aims to provide a comprehensive reference for future consensus building as the field continues to advance human studies with this metabolic imaging modality.

Keywords: Hyperpolarized MRI, metabolic imaging, carbon-13, pyruvate, dissolution dynamic

Introduction

MRI with hyperpolarized 13C agents, also known as hyperpolarized (HP) 13C MRI, has shown great potential as a novel imaging modality, particularly for its ability to probe metabolic processes in real time. The first human studies with HP [1-13C]pyruvate were performed in 2011 in prostate cancer patients (1).

Since then, there have been over 60 papers published with imaging results of human subjects from 13 different sites, with applications including prostate cancer, brain tumors, breast cancer, kidney cancer, pancreatic cancer, metastatic disease, liver disease, ischemic heart disease, diabetes and cardiomyopathies. The vast majority of these studies used [1-13C]pyruvate (1–63), where [2-13C]pyruvate (64) and 13C-urea (56) have been demonstrated too.

As clinical HP 13C MRI advances, there is a growing need to build consensus for best practices, which are critical for comparing data across sites, performing multi-site trials,deploying methods to new sites, partnering with vendors, and potentially for obtaining broader regulatory approvals.

In March 2022, we initiated an effort to build consensus within the HP 13C MRI community with this opportunity in mind, and it was greeted with strong enthusiasm. The “HP 13C MRI Consensus Group”, containing over 55 members from 27 sites, identified the area of greatest need and opportunity for consensus building to be HP [1-13C]pyruvate human

●

Pyruvate is the most mature and widely used HP agent and has the most significant translational evidence emphasizing the potential clinical impact.

●

Clinical trials, particularly multi-site trials, have the strongest need for consensus methods to ensure that data can be combined across sites. This work is a Position Paper for which the goal is to describe current successful practices and study methods for HP [1-13C]pyruvate human studies along with justification to support those practices. This is divided into four major topic areas: (1) HP 13C-pyruvate preparation, (2) MRI system setup and calibrations, (3) data acquisition and image reconstruction, and (4) data analysis and quantification (Fig. 1). The current successful practices and study methods include a literature review of published peer-reviewed journal papers showing human HP [1-13C]pyruvate study data, up to September 2022 (1–63), as well as new unpublished information from surveys of HP 13C study sites. Based on this information, we also highlight the evidence gaps, strengths, and limitations of current practices which are summarized at the end of each section.

Figure 1: Illustration of the HP 13C MRI human study process, including the 4 major areas covered in this paper: Hyperpolarized 13C-pyruvate preparation, MRI system setup and calibration, Acquisition and Reconstruction, and Data Analysis and Quantification.

Figure 2: Anatomical targets of HP [1-13C]pyruvate MRI human studies published up to September 2022.

Hyperpolarized 13C-Pyruvate Preparation

This section covers the processes for creating the HP agent, 13C pyruvate, and will include many aspects and considerations that are needed to safely and effectively prepare doses for metabolic imaging studies in human subjects. These include material, personnel, equipment and facility, fluid path preparation, quality control, and release.

It is helpful to understand that the specifications of a dose of 13C pyruvate suitable for in vivo MR HP metabolic imaging were shaped in part by early preclinical studies performed by GE HealthCare summarized in Ref. (65). In short, the safety of the two novel drug components, 13C pyruvate and the electron paramagnetic agent (EPA) AH111501, were demonstrated in those studies. The more precise formulation of the dose suitable for human use was then determined from clinical studies (66) that included two Phase 1 clinical trials in young and elderly healthy volunteers without hyperpolarization of the 13C nuclei and another Phase 1/2a dose escalation and imaging feasibility study with HP 13C pyruvate in 31 prostate cancer patients at the With the exception of the first HP 13C imaging clinical trial, which utilized a prototype device in a cleanroom (1), all HP 13C studies performed in humans to date have utilized the SPINlab polarizer (manufactured by GE HealthCare). Consequently all doses of the HP 13C pyruvate delivered by SPINlab have been produced using the “SPINlab Pharmacy Kit” that serves as the container-closure system for the various drug components (13C pyruvic acid and EPA mixture, dissolution medium, and neutralization and dilution medium) during sample polarization, dissolution and quality control (QC) processes. Thus many aspects of the HP sample preparation considerations discussed below are related to the SPINlab instrument and the consumables designed to be used with it (67).

General Considerations

While more than 860 patients or healthy subjects having been injected with HP 13C pyruvate as of January 2022 without reports of any serious adverse events (68), HP 13C pyruvate injection remains an investigational MR contrast agent and can only be administered by those with Investigational New Drug (IND) exemption from the Food and Drug Administration (FDA) in the USA, a Clinical Trial Application (CTA) in Canada, approval from National Research Ethics Committee Services in the UK, or approval from the relevant local regulatory body. Thus, methods and processes involved to produce a dose should have patient safety as the first priority. Since utilizing dissolution dynamic nuclear polarization (dissolution-DNP) for human use is still a relatively new development, there are no existing published regulatory guidelines specifically for this method.

There are two major production styles that determine how various sites approach the agent preparation. In the US, the most common approach is to rely on a sterilizing filter (“Terminal Sterilization”) to ensure sterility of the final product, akin to PET tracer production, where a starting molecule with a radioisotope is processed using various other ingredients to make the final, desired and injectable contrast agent within a necessarily short amount of time (69). For these sites, sterilization of the components and accessories upstream of this filter are not required, although many of them were manufactured and tested following Good Manufacturing Practice (GMP) or Good Laboratory Practice (GLP) requirements. The filling process is usually performed under an ISO 5 laminar flow hood, but a clean room or an isolator is not required.

This approach is typically accompanied by testing the integrity of the sterilizing filter prior to release of the dose for injection. Typically, post release endotoxin and sterility tests are performed using an aliquot reserved from each released dose.

In the UK and EU, the most common approach is to more-closely follow sterile pharmaceutical compounding guidelines (70), where all components and ingredients are required to be sterile or manufactured under GMP guidelines and are assembled and filled within a clean room environment or an isolator system (“Sterile Preparation”). Typically a batch of Pharmacy Kits for HP 13C pyruvate injection are prepared together. The sterility of the final dose is also ensured by batch validation testing, in addition to the sterility of the ingredients and the sterile compounding process. The endotoxin and sterility testing are performed for the process validation but are not performed for each injected dose.

Some institutions fill and assemble the Pharmacy Kit required for a specific study on the same day or the day prior to polarization, dissolution, and patient administration, but others have also demonstrated the feasibility of preparing a batch of kits, keeping them in a -20ºC freezer and using them over a period of a few months.

Beyond the obvious requirements that the process and the facility has to ultimately produce a dose that is safe to inject into a human, regulatory authorities will also focus on the question “Are you in control of your processes?”. To be in control of your process requires an in-depth and broad understanding of all processes involved in pre, post, and during the production process.

Personnel

It is typical and may be required to have licensed personnel involved in the production process depending on local regulations.Typically a pharmacist, radiopharmacist or other similarly qualified person (QP), in charge of the facility where the Pharmacy Kit filling and preparation is taking place, is responsible for the overall process and the release of the injectable dose.

Qualified cleanroom technicians are often involved in the Pharmacy Kit filling under the supervision of the pharmacist or QP. As is required for pharmaceutical compounding or PET tracer production, training requirements and training records for all personnel need to be maintained and available for audit by the FDA or equivalent.

Equipment And Facility

The facility and all equipment need to have standard operating procedures (SOPs) that describe how equipment is used, maintained, and calibrated to comply with relevant legislation. Currently, almost all the filling of the Pharmacy Kit takes place within a compounding laminar flow hood or isolator (typically ISO 5). At some sites, the filling is conducted within a cleanroom, while at others, it is conducted in a dedicated non-cleanroom space, reflecting differences in cleanroom approach and specifications between regulators worldwide (71). Some equipment or facilities, such as the compounding hood or cleanroom, may require external certified laboratories for testing.

Material Handling

Material handling guidelines (69,70) require SOPs detailing a system to track all of the materials involved in the HP production process for a particular patient dose, similar to current good manufacturing practice (cGMP) requirements for material handling for drug compounding. This includes acceptance standards, storage conditions, amount used in the patient dose for each ingredient and materials used in the assembly of the fluid path and Pharmacy Kit. Currently some users choose to open and inspect and sometimes modify the Pharmacy Kits upon arrival, but some users keep them in the sealed packaging until they are required for dose preparation.

Pharmacy Kit Filling And Assembling

As required by an IND or its equivalent, the preparation of the doses of HP 13C agent are detailed in the Chemistry, Manufacturing, and Control (CMC) section of an applicable regulatory submission; an example of this has been made available (72). It describes the processes of filling the Pharmacy Kit with the different components that make up the final drug product, and of assembling the final kit for either storage or immediate use in the polarizer. Special attention should be given to the laser welding process in order to satisfy installation qualification (IQ) and operational qualification (OQ). Typically, the final developed process is validated by process qualification (PQ) runs, during which 3 or more Pharmacy Kits are filled and used and the final HP 13C products are tested for endotoxin and sterility and to confirm that they meet the dose specifications for injections (usually including pyruvate concentration, residual EPA concentration, pH, liquid state polarization level and dose temperature). The data from 3 consecutive PQ runs are submitted as part of the IND submission (or its equivalent), and are often also reviewed by the Institutional Review Board (IRB) where the studies are conducted.

Quality Control And Dose Release

The quality control (QC) and dose release can be separated into two aspects: one is the QC and release of the filled Pharmacy Kit, and second is the QC and release of the HP 13C agent for injection, after polarization and dissolution. For institutions filling a batch of kits and storing them to use over a period of time, typically the batch can be released based on initial validation, environmental monitoring data from the day of kit production, and if filters are used during preparation of any of the components, filter integrity testing. But in some cases one or more kits are used for validation before the batch of kits are released for future use. For institutions that fill only the kits required for specific studies shortly before the experiment, the filled kits often do not go through separate release tests before they are used.

The quality control of the HP 13C pyruvate solution post dissolution is primarily performed to ensure that the agent meets the dose specifications (Table 1) before it is administered to the subject. These specifications target both safety (pH, residual EPA, temperature) and efficacy (pyruvate concentration, polarization, volume). Typically, the pyruvate concentration, residual EPA concentration, pH, dose temperature, dose volume, and liquid state polarization are measured by the QC accessory associated with the SPINlab polarizer. Some users perform a secondary measurement for one of the parameters, such as pH, using a different instrument or pH paper. For sites that do not go through a separate release testing process for batch filled kits, the integrity of the sterilization assurance filter, a part of the Pharmacy Kit, is typically tested as a part of the dose release. It is also common for these users to preserve an aliquot of the final HP 13C pyruvate solution for post-release endotoxin and sterility testing. This testing cannot be completed fast enough to test an individual dose prior to injection, but this is why other processes such as PQ runs and validation testing are done to minimize the chance a subject could be injected with a contaminated dose.

The Final Dose Release And Injection

should be done under the supervision of a licensed professional, based on local regulations.

Some Key Challenges

Many of the challenges associated with HP 13C pyruvate preparation can be attributed to the conditions required for the dissolution-DNP method of high magnetic field (~3-7 T) and very low temperature (~1 K) during polarization, with pressurized and superheated water necessary for the rapid dissolution event. These extreme conditions are quite challenging for the design of the container-closure and fluid path system. In particular, the cryogenic temperature in the polarizer requires special attention to any moisture or ambient (moist) air introduced into that portion of the fluid path, which can form an ice block at ~1 K. This ice can lead to flow restriction during the dissolution event and reduce the strength of the laser welded bond between the cryovial and its cap. This can ultimately produce failures in the dissolution step, including variations in final pyruvate concentration and pH that may fail to meet QC release criteria as well as fluid path ruptures that provide no available dose and result in polarizer down-time.

The polarization of the HP 13C pyruvate sample decays quickly over the span of a few minutes after dissolution, and thus the process of dissolution, QC for release, and injection should be completed as fast as possible to preserve the high polarization level achieved. Any delays in the preparation process, such as transportation time or equipment malfunction, can significantly reduce the final polarization and result in lower quality imaging data.

Current Practices

A summary of data collected from all sites performing clinical trials with HP 13C-pyruvate is shown in Fig. 3 and Table 1, including the specification of the final dose and how the quality control and release of the final dose are performed. There is a split in the Production Style, described in the General Considerations section above, with 8/13 sites using Sterile Preparation versus 5/13 using Terminal Sterilization. While many of the dose specifications show notable differences in acceptable ranges, all of these variations listed in tables have been successfully and safely been used to perform HP 13C pyruvate studies in humans. Their differences depend on the institutions’ preferences, resources and their particular regulatory situation. There is high similarity in pyruvate ranges, temperature ranges, EPA limits, and volume limits. There is modest variability in pH ranges and large variability in the endotoxin test limit. There is a 3-fold difference in acceptable polarization levels, which are measured to ensure a futile dose is not injected since the polarization is directly proportional to SNR. This reflects the decision by several sites to believe that useful data can be still be obtained with suboptimal polarizations.

Figure 3: Hyperpolarized agent preparation methods reported by sites currently performing HP

In House

Table 1: HP 13C-pyruvate preparation parameters, methods, and dose specifications used for quality control testing and release as well as validation. These were obtained from a survey of all sites performing clinical trials with HP [1-13C]pyruvate. The parameters used for product release are noted in bold text, otherwise these parameters are measured for batch validation or other QC measurements. The endotoxin and sterility testing are performed during process validation of the batch and/or post-injection, and largely depends on the agent production approach.

Summary

The overall safety record of HP 13C-pyruvate has been very strong, and the SPINlab hyperpolarizer has proven to provide high polarizations at human sized doses while meeting numerous QC and release criteria. A weakness remains the failure modes of the SPINlab Phamacy Kits (e.g. ice blocks, path ruptures), which are placed under extreme requirements particularly during dissolution. The preparation process still requires a high degree of expertise.

Therefore, there is a significant need to improve the reliability, robustness, and ease of operation for generating HP 13C-pyruvate doses for human studies. Furthermore, there is a divide between manufacturing and sterile compounding style preparation as well as other site-specific practices, resulting in variations in SOPs and justification required to relevant regulatory bodies. There have also been no comparisons between these approaches. It is also unclear what release criteria and QC parameters are truly required to ensure patient safety.

However, all of the reported methods are acceptable and approved by the appropriate regulatory authorities, and have led to the rapid expansion of successful human studies in recent years.

Mri System Setup And Calibrations

This section covers the MRI system setup, including the imaging system, RF coils, phantoms, and prescan calibration methods.

Imaging System

The main prerequisite for a given MRI scanner to be capable of supporting studies with HP 13C is its “broadband” capability to transmit and receive radiofrequency (RF) signal at the frequency of 13C, which is around 4 times lower than 1H. This does not come as a default on clinical MR devices. The transmit power of the broadband amplifier should also be sufficient to support the intended flip angle and RF pulse shape with the employed transmission RF coil(s) for 13C. Most studies to date use relatively low flip angles (< 90 degrees) for HP 13C in order to preserve polarization for time-resolved imaging. The capability to receive 13C signal on multiple channels is also desirable to increase SNR, as discussed further in the “RF coils” section.

The choice of magnetic field strength is primarily dependent on the metabolites’ frequency separation due to chemical shift dispersion and 1H imaging. High field strengths do not enhance hyperpolarized 13C signal as they do for 1H because the signal strength in a HP experiment relies on manipulating the population of quantum energy states outside of the MRI scanner.

However, the injected HP 13C-pyruvate and its metabolic products have greater frequency separation at higher fields, and it may thus be easier to separate and quantify these resonances at higher fields. This comes at the cost of a reduction in the achievable T2* and often reduced T1. As the initial polarization is independent of the imaging field strength it has been proposed that the increased T2* at 1.5T can potentially be exploited to increase SNR by adapting the acquisition bandwidth or reduce off-resonance imaging effects in cases when the decay of the transverse magnetization is dominated by T2* (73). In practice, 3T has been used in all published human 13C-pyruvate studies surveyed (Supporting Table S1), and comprises the majority of scanners currently in use for human studies (Table 3). A field strength of 3T is well-suited for 1H MRI anatomical reference and correlative imaging.

Stronger and more rapidly slewing magnetic field gradients support more rapid spatial encoding, particularly for metabolite-specific single-shot imaging using echo-planar imaging (EPI) or spiral imaging (See “Acquisition and Reconstruction”). Although the spatial resolution acquired for HP 13C imaging is typically much coarser than for 1H MRI, the factor of ~4 in gyromagnetic ratio leads to the same reduction factor in performance of the gradient system, so 13C experiments are potentially more limited by gradient hardware performance. To date, all human studies have used the commercially-available integrated gradient systems provided in clinical MRI scanners.

Optimization of scanner design has understandably focused on minimization of artifacts in 1H MRI, where devices such as room lights, the gradient amplifiers, and the motors driving the patient bed are checked to ensure that they do not produce RF interference at the 1H frequency, but artifacts may arise at other frequencies. Eddy current compensation is also not always appropriately adjusted for nuclei at other frequencies (74). In order to optimize for 13C, many sites have performed checks on phantoms for RF interference, gradient artifacts, and eddy currents (74), including the use of post-hoc gradient impulse response function characterisation and correction, and some vendors have fixed these issues as well.

Rf Coils

For HP 13C imaging studies in humans, RF coils for both 1H and 13C nuclei are needed, with 1H MRI providing an anatomical reference for registration and optional additional multiparametric MRI readouts. At the Larmor frequency of 13C nuclei, the relative contributions from coil noise compared to sample noise increase compared to 1H (73,75), although sample noise still is likely the dominant contributor for human-sized coils at 32.1MHz - the resonance frequency of 13C nuclei at 3T.

The key requirement for human 13C-pyruvate RF coils are that the coil geometry and sensitive volume must cover the volume of interest in the subject. Table 2 and Figure 4 shows coil configurations that have been used and optimized for applications in different anatomic regions.

Volume resonators are most commonly used for transmit, as they surround the subject to

Provide B1 Transmit Across The Fov (B1

+). While 1H relies on a large birdcage (“body”) coil built into the scanner, 13C transmit coils must be placed inside the bore. This takes up valuable space within the magnet, and also has led to the use of designs with relatively inhomogeneous

B1

+. Many human studies have used Helmholz pair resonators for transmit, including the “clamshell coil”, which has a notably inhomogeneous B1

+ Profile But Has Been Used Because Of

relatively easy integration into the scanner bore. B1

+ Variation Results In Variations In The Flip

angles that control the use of the hyperpolarized magnetization and creates errors in common HP metrics (9,76). The exception are head coils, where birdcage designs with highly

Homogeneous B1

+ can be placed around the head while easily fitting inside the bore. As with 1H MRI, higher SNR can typically be achieved by smaller receive coil elements, such as surface coils or phased arrays, and the majority of 13C receive coils used have layouts similar to 1H phased arrays.

RF coil quality control is important to ensure proper functioning of the coils to provide consistent imaging quality, especially with limited natural abundance 13C signal in vivo. It typically involves 1) a physical integrity check of the coil cables and connectors and 2) phantom SNR tests to check the coil’s performance and to monitor it over time (see Phantoms below). An useful reference for RF coil quality control is outlined in the MRI accreditation program of the American College of Radiology (77) and can be adapted for 13C coils.

Notably, configurations for brain and prostate studies used dual-tuned 1H/13C coil designs, which greatly simplify workflow and registration of 1H and 13C images, as no switching of coils is needed.

(1)

Table 2: RF coil configurations reported for human HP [1-13C]pyruvate studies.

Tx = Transmit

coil, RX = receive coil. The commonly used “clamshell” TX coil is a Helmholz pair design. For 1H RF configurations, all used the Body coil for TX unless otherwise noted, and “repositioned” indicates the 13C coil was removed for 1H imaging. One representative reference is listed for each configuration. The RF coil configurations reported in the reviewed papers are shown in Supporting Table S1.

Figure 4: Examples of RF coil configurations used for human HP [1-13C]pyruvate brain studies. (A,B) 13C Clamshell TX (Helmholz pair) and 2× 4-channel paddle RX arrays. (C) 13C Birdcage volume TX and 32-channel RX array (RX array slides into TX coil). (D) 13C Birdcage volume TX and 24-channel RX array, combined with a 1H 8-channel RX array. Image reproduced with permission from Ref (16).

Phantoms

Since hyperpolarized magnetization is non-renewable, phantoms containing 13C nuclei are important to: 1) test the multi-nuclear capabilities of the imaging system, including all parts of the signal excitation and receive chain; 2) perform calibration measurements before a scan with hyperpolarized nuclei; and 3) perform necessary pre-scan adjustments (see “Prescan Calibration” section). The phantoms currently in use are listed in Table 3. Their composition must provide sufficient 13C signal, with additional considerations of conductivity, stability, chemical shift(s) present, potential for dynamic imaging, and cost. The phantom geometries are typically either compact, in order to be used alongside the subject during a HP scan, or large enough to mimic the inner volume of a RF coil for system testing.

One popular compact design contains enriched 13C-urea at high concentration, typically 8 M, which provides a single resonance, placed inside a small container ~1 mL. The most common recipe mixes 13C-urea in a 90% water/10% glycerol solution, with glycerol used to increase the urea solubility and doping with a Gd-based contrast agent to shorten T1 which increases the potential SNR per unit time. For example, when Dotarem is added at a 3:1000 volume ratio the 13C-urea T1 is around 500 ms and T2 is around 100 ms. However, when testing pulse sequences influenced by T1 and T2, doping should be used carefully. This phantom is suitable for frequency calibration, transmit gain calibration, sequence testing, and as a fiducial marker when placed next to a patient. However, enriched 13C-urea has a relatively high cost compared to natural abundance compounds.

For larger volumes (>100 ml), the phantoms most often used contain undiluted ethylene glycol, glycerol, or dimethyl silicone. These compounds have sufficiently high carbon concentrations to provide sufficient 13C signal even with the 1.1% natural abundance of 13C. These larger phantoms matching the inner volume of an RF coil are useful for coil testing, including transmit

+) And Receive (B1

-) coil profile mapping, as well as to mimic acquisitions using in vivo FOV requirements. In this case, size and conductivity should match the expected subject size in order to mimic coil loading and get a realistic estimation of B1+. Large-volume natural abundance urea phantoms have also been used by some sites, but suffer from higher conductivity compared to biological tissues. Typically, it is easier to increase the conductivity and hence coil loading of the non-conductive phantom by adding NaCl to match physiological loading (16,78).

Dynamic phantoms that aim to mimic metabolite kinetics have also been developed (79–81), and have the potential to more closely mimic the HP experiment, but so far these are not widely used.

Prescan Calibration

Prior to performing an MRI acquisition, the so-called prescan procedure is used to set the shim parameters to maximize B0 homogeneity over the field of view (FOV) or a specific region of interest (ROI), the scanner center frequency (CF), the RF transmit gain, and the receiver gain.

While this calibration procedure is usually automated for 1H, the lack of sufficient natural abundance 13C signal prevents use of automated methods. (Although natural abundance 13C lipid signal has been detected, there are so far no reports on using this signal for prescan.) Table 3 shows current practices across sites.

Maximizing B0 homogeneity is independent of the nucleus and is therefore performed prior to 13C imaging using the 1H water signal and existing shimming tools, such as by a standard automated process (“Auto Shimming”) or using high order shimming routines. Similarly, the 13C CF can be calculated from the 1H CF using a predetermined scaling factor that depends on the target chemical shift (82). Another common approach used is to have a small, high-concentration 13C phantom, e.g. 8M 13C-urea, integrated in the RF coil or placed next to the scan subject (1). The reference frequency can also be based on real-time measurements after the HP injection but prior to imaging (83). Both the CF and B0 shimming are critical when using spectrally-selective RF pulses, as inmetabolite-specific imaging methods, where the desired excitation bandwidths are typically very narrow and frequency offsets can lead to a failure mode that is only apparent after injection.

The calibration of the RF transmit power is typically performed on a small, high-concentration 13C phantom placed near the region of interest during the scan or on a large 13C phantom of similar size and coil loading as the subject, prior to the subject scan. Reference power is often done by sweeping the power in a pulse-acquire sequence (53,62), or the Bloch-Siegert method (52,84). When using a small phantom, the location of the phantom, B1

+ Inhomogeneity As Well

as any shielding effects, e.g., when the phantom is integrated into a coil (1), may degrade the accuracy. Other methods include real-time Bloch-Siegert method measurements after the HP injection (83), and using the stronger natural abundance 23Na signal that is close enough to the 13C resonance frequency to be detected by 13C coils (82).

The receiver gain is predetermined, either systematically based on independent phantom measurements and assuming the dose and polarization of the HP compound is known prior to injection, or based on past HP imaging studies.

Power [Kw]

Phantom(s) - during study Phantom(s) - before study 13C Frequency

8

13C-bicarbonate doped with dimethyl silicone, various

Power [Kw]

Phantom(s) - during study Phantom(s) - before study 13C Frequency

Maximum Values

Table 3: Summary of the imaging systems, phantoms, and prescan procedures used at sites currently performing HP 13C-pyruvate human studies. These were obtained from a survey of all sites performing clinical trials with HP [1-13C]pyruvate. *Previously performed studies with a Siemens 3T Tim Trio. The imaging systems, phantoms, and prescan procedures reported in the reviewed papers are shown in Supporting Table S1.

Summary

Commercially available 3T MRI systems are by far the most commonly used for human HP 13C-pyruvate studies, although a systematic investigation of the impact of B0 has only recently been investigated (73). The multi-nuclear RF transmit and receive chain has proven sufficient for current acquisition strategies, although many sites have observed artifacts due to RF interference, gradient interference, and residual eddy currents when operating at the 13C frequency. A variety of 13C RF coils, tailored for numerous anatomical targets, have been successfully demonstrated, with the main limitation that most transmit coils take up a lot of additional space inside the bore and provide relatively inhomogeneous B1

+ Profiles. The

phantoms used have converged into generally 2 categories - small phantoms containing 13C-enriched compounds that can be used during the study and human-sized phantoms containing compounds with high carbon concentrations but without 13C enrichment that are used to test and calibrate the coils. There are no standardized compositions or geometry, and dynamic phantoms that recapitulate in vivo kinetics would be desirable but are still an emerging area. Prescan calibration procedures were not well defined in most publications, so we surveyed individual sites to determine current practices. Calibration procedures for the B0 field (13C CF and shimming) for most sites take advantage of 1H signal and methods, while methods

For Calibration Of B1

+ is more variable across sites, likely a reflection of remaining challenges in how to perform this calibration. Standardization of both phantoms and calibration procedures would synergistically improve the robustness and reproducibility of HP 13C studies.

Acquisition And Reconstruction

Data acquisition strategies in human HP [1-13C]pyruvate MRI studies must account for multiple chemical shifts, efficiently utilize the non-renewable HP magnetization, and acquire data quickly relative to metabolism and relaxation decay processes. These studies require spectral encoding to separate metabolites, necessitating pulse sequences that efficiently encode up to 5D data (3 spatial + 1 spectral + 1 temporal dimension). RF pulses must efficiently sample without immediately saturating the non-renewable HP magnetization, and sequences must acquire data quickly and be robust to both experimental and physiologic variation (e.g. B1

+ Inhomogeneity,

variation in perfusion) to ensure reproducibility and minimize scan-to-scan variability. This section covers current successful practices for data acquisition in human [1-13C]pyruvate studies, and accompanying 1H imaging, from different anatomic regions, including scan parameters and image reconstruction.

Acquisition And Reconstruction Methods

The acquisition methods used in human [1-13C]pyruvate studies can be classified into 3 categories: 1) MR spectroscopy or MR spectroscopic imaging (“MRS/I”), 2) chemical shift encoding methods, and 3) metabolite-specific imaging (Fig. 5).

Mrs/I Methods Specifically

resolve a spectrum that can be analyzed to extract expected as well as unexpected resonances, making this approach very robust. It was used in many initial studies (1).

Chemical Shift

encoding methods, most commonly the Iterative Decomposition of water and fat with Echo Asymmetry and Least-squares estimation (IDEAL) method, use imaging sequences acquired with multiple TEs and rely on a model-based separation of expected chemical shifts (85).

Metabolite-specific imaging methods use specialized RF pulses that are spatially and spectrally selective to excite individual metabolites which are then typically imaged with fast k-space trajectories such as echo planar imaging (EPI) or spirals (86).

Their Application To Different

organ systems is described below. The image reconstruction methods used in human [1-13C]pyruvate studies have typically been conventional methods (e.g. FFT, non-uniform FFT, or equivalent). The incorporation of accelerated imaging and advanced reconstruction methods including parallel imaging (4,57,87) and compressed sensing (7) has also been applied in human studies for improved spatial resolution, temporal resolution and coverage, but have the potential for additional artifacts as well as SNR losses due to ill-conditioning of the reconstruction (e.g. g-factor).

The Majority Of

published studies do not use accelerated imaging indicating the resolution and coverage achievable without acceleration is currently adequate for successful data collection. Performing coil combination, even with fully sampled data has also been shown to have specific challenges for HP human images: using naive sum-of-squares methods suffer from high noise amplification in the relatively low SNR regime of HP [1-13C]pyruvate (compared to 1H), motivating several HP 13C-specific methods that include data-driven coil sensitivity estimation which have shown obvious improvements over sum-of-squares (11).

More recently denoising techniques have been applied as post-processing of human HP data(41,42,44). The techniques applied are based on spatial-temporal singular value decomposition for unsupervised estimation of signal and noise components. They have shown improvements in apparent SNR in the brain and liver, while care must be taken to choose parameters such as the rank threshold to avoid oversmoothing and overfitting to the estimated signal components.

Prostate Studies

Prostate cancer was the first human application of HP [1-13C]pyruvate (1), and data was acquired with MRS/I methods: 1D dynamic MRS, single-slice 2D dynamic echo-planar spectroscopic imaging (EPSI), and single time point 3D EPSI. Advances in imaging strategies led to the development and application of new acquisition schemes, including undersampled 3D EPSI with compressed-sensing (7), model-based chemical shift encoding methods that use a priori information (47,59), and metabolite-specific EPI (10), all of which can provide volumetric whole-organ coverage and dynamic acquisitions.

The pyruvate bolus arrival in the prostate can vary by ± 10 s between patients, necessitating dynamic imaging to reliably and consistently capture the pyruvate bolus (18). For this reason, all currently ongoing studies acquire dynamic data. While MRS/I, chemical shift encoding, and metabolite-specific imaging can all achieve dynamic imaging, chemical shift encoding and metabolite-specific imaging provide greater dynamic and volumetric coverage (85). For scan prescriptions, the FOV is designed to provide full prostate coverage and typically to match the orientation of the anatomic imaging used for registration. Flip angles used in current studies are constant through time, as quantification with a variable-through-time flip scheme is highly sensitive to bolus timing (8) and errors in the RF transmit (B1 +) field (76).

Heart Studies

Data acquisition methods for 13C imaging in the heart must be designed to meet the demands of significant cardiac motion and blood flow. To cope with the periodic cardiac motion, most human heart studies to date used gating to the diastolic window, the longest cardiac cycle interval, which has reduced motion (2,22,28,30,35,36,38,45,52). The duration of the diastolic window limits the available data sampling time, making cardiac acquisitions the most time-constrained of the HP 13C MRI applications. The most common acquisition approach is metabolite-specific imaging with spiral k-space trajectories (2). Their single-shot imaging capability makes these methods particularly robust to motion effects. Furthermore, spiral k-space trajectories provide rapid k-space coverage and relatively benign flow and motion artifacts. The majority of studies have used 2D multi-slice acquisitions, but 3D encoding has also been used successfully (35).

Brain Studies

For HP 13C MRI of the human brain, the majority of studies have also used 2D (slice selective) acquisitions (10–12,14,16,28,33,40,41,44,51,53,60), with a trend toward volumetric coverage using 2D multi-slice metabolite-specific imaging. 3D metabolite-specific imaging of the whole brain, with phase encoding of the slice direction (34,57), has been shown to provide similar SNR efficiency (88) compared with multislice imaging. A number of studies have employed MRS/I (5,6,29,31–33,50,55) resulting in a spectrum from each voxel, which has the advantage of not requiring a priori information about which peaks to encode. This was important in early brain studies when it was not known which peaks would be detectable. Chemical shift encoding, using a set of images with different echo times and an iterative reconstruction of the individual resonances (i.e. the IDEAL approach (85)), has also been used (12,49,54), with the drawback that coverage in the slice direction was limited due to the time required to acquire multiple echo time images.

Abdomen And Breast Studies

The fundamental approaches to data acquisition and reconstruction in the abdomen and breast are largely similar to the aforementioned applications, but demand attention to particular challenges associated with these anatomic regions, especially relating to respiratory motion.

Although it has been shown that a basic 2D MRSI approach based on phase encoding and FID readout can be successfully applied for HP 13C imaging in breast (15) and kidney (13), major advantages in terms of spatiotemporal resolution and coverage have been realized using tailored approaches based on metabolite-specific imaging (43,62) and chemical shift encoding (43), which have facilitated multi-slice or 3D dynamic acquisitions over large FOVs in the abdomen (4,37,46).

The significant respiratory motion encountered in these regions can directly blur 13C images, and has further favored these rapid acquisition strategies. Motion also degrades B0 homogeneity, which can shift frequency-selective excitation profiles and introduce artifacts into rapid imaging readouts. This makes accurate determination of the acquisition center frequency and shimming essential in these regions which often cover large FOVs. (See “Prescan Calibration” section for more information). In some studies, breath-holding was used to minimize motion effects and enforce frame-to-frame data consistency (42). A pragmatic and reasonably effective approach for dealing with respiratory motion during 13C data acquisition is an initial breath-hold (as long as can be tolerated), followed by free-breathing (46,62).

1H Imaging

Collection of 1H imaging data is essential both for prescribing the 13C acquisition and for interpretation of the resulting 13C data. Multi-planar 1H scouts are acquired prior to 13C acquisition to enable graphical prescription of the 13C imaging region. All human HP 13C-pyruvate imaging studies acquire conventional MRI scans (e.g. T1- and T2-weighted volumes) for anatomic reference, aiming to cover at least the full 13C FOV. Acquiring these anatomic scans as close as possible to the time of 13C imaging (immediately before or after) minimizes potential misregistration between the data sets. Depending on the application, other advanced 1H sequences are also acquired (e.g. diffusion-weighted imaging for cancer imaging).

When contrast-enhanced data is acquired, it is done after 13C imaging, as paramagnetic contrast agents will accelerate 13C relaxation.

Reported Study Parameters

Figures 5 and 6, and Supporting Table S2 shows the reported acquisition study parameters for human HP [1-13C]pyruvate studies published as of September 2022. Figure 5 shows a mixture of MRS/I, metabolite-specific imaging, and chemical shift encoding methods have been successfully used, where spectroscopy-based methods have become less prevalent in recent studies. Figure 6 shows the acquisition timing, including the important start time and interval/temporal resolution, is quite variable across studies.

Figure 5: Acquisition methods used in published HP [1-13C]pyruvate human studies published up to September 2022, classified into: MR spectroscopy and spectroscopy imaging (MRS/I); chemical shift encoding methods, such as IDEAL, that use multiple TEs and model-based reconstructions; and metabolite-specific imaging methods that use spectrally-selective excitation to image a single resonance at a time.

Figure 6: Temporal acquisition characteristics reported in HP [1-13C]pyruvate human studies published up to September 2022. (a) Reported referencing of acquisition start times.

(B)

Acquisition start times reported when using dynamic imaging and when timing was reported relative to the end of the injection. (c) Temporal resolutions. “Not Applicable” indicates dynamic imaging was not used.

Summary

Three general categories of acquisition strategies have been used successfully for human HP 13C-pyruvate studies: MRS/I, model-based chemical shift encoding (e.g. IDEAL) methods, and metabolite-specific imaging methods. These have enabled successful studies in the prostate, heart, brain, abdomen, and breast. Recent studies increasingly have used the imaging-based strategies of metabolite-specific imaging and chemical shift encoding which are the fastest methods, although a heads-to–head comparison between techniques has not been performed.

Metabolite-specific imaging is quite popular because of its speed and compatibility with single-shot imaging, but is sensitive to B0 field variations and thus requires careful calibrations. Nearly all studies surveyed acquired data dynamically, allowing measurement of the bolus and metabolite kinetics. The exact timings and associated flip angles vary quite widely across reported studies, with no consensus yet as to how to choose these parameters. Image reconstruction is typically done directly using Fourier Transform methods, and accelerated imaging strategies are uncommon.

Data Analysis And Quantification

This section covers the analysis of data from human HP [1-13C]pyruvate studies, including modeling and metrics, visualization, as well as considerations for how to store data and metadata. Depending on study design, the analysis may need to give quantitative or semi-quantitative output reflecting a biological process or may just reflect a contrast between different regions of interest for quantitative evaluation.

Metrics

Figure 7: HP [1-13C]pyruvate raw data (A) have typically been quantified using four categories of metrics depending on the acquisition. Data acquired as a single time point are often quantified using normalized metabolite images or metabolite ratios (B). Dynamic data can be quantified using normalized metabolite images or metabolite ratios (B), or with metabolite timings such as time-to-peak (TTP) or pharmacokinetic (PK) models (C). The latter two require the data to be time-resolved. [1-13C]alanine and 13C-bicarbonate are analyzed similarly to [1-13C]lactate but omitted here for display.

Metabolite images are commonly used as summary metrics for HP MRI data, often including some form of normalization as well as summed over time as an area under the time curve (AUC) (17). These are analogous to the visual evaluation that is most used for routine clinical work (89,90). In these metabolite images, we expect that the [1-13C]pyruvate AUC signal is predominantly weighted towards perfusion and uptake, while [1-13C]lactate, [1-13C]alanine and 13C-bicarbonate AUCs represent metabolic conversion. The strength of this approach lies in its simplicity and relatively few underlying assumptions. Limitations to the use of single-metabolite images or AUCs include sensitivity to inhomogeneous coil profiles (57,87,91), the acquisition strategy and acquisition parameters, pyruvate polarization and concentration level, and signal relaxation rates (92). Further, the reader must be careful to interpret all the images in conjunction to better understand the underlying biology; for example, increased [1-13C]lactate in the presence of decreased [1-13C]pyruvate delivery can have a very different meaning compared to increased [1-13C]lactate with increased [1-13C]pyruvate delivery.

In an attempt to address variations in coil sensitivity, polarization level, and pyruvate delivery, AUC images are often computed by normalizing to a specified parameter, such as the maximum pyruvate or average lactate signals, or presented as a ratio such as lactate/pyruvate or divided by “total Carbon” - the sum total of HP 13C signal observed across all metabolites. The AUC ratios between metabolites and pyruvate are proportional to the corresponding forward kinetic rates (81,93), but are not directly comparable to rate constants when magnetization loss rates (e.g. relaxation and losses due to signal excitation) differ between studies. Similarly, the ratios between the produced metabolites (e.g. bicarbonate/lactate) can reflect the balance between downstream metabolic pathways (12,55). Care must be taken to consider how AUC images are calculated and normalized before comparing values between studies.

To further quantify the interpretation, pharmacokinetic (PK) modeling approaches were developed to compute the apparent kinetics of pyruvate-to-metabolite exchange (92,94–99). These yield semi-quantitative to quantitative apparent rate constants, given in s-1. Some models require a vascular input function, while others avoid this requirement (95). PK models can explicitly account for acquisition-specific details such as excitation angle and repetition time, and thus may reduce the effects of these details on quantification. An input-less model, provided in the Hyperpolarized-MRI-Toolbox (https://github.com/LarsonLab/hyperpolarized-mri-toolbox) (100) and thus frequently employed for human data, has been shown to fit well and robustly to prostate and brain data (8,20). PK models are quantitative in nature, arguably provide more relevant biological information (8,20), and appear to be reproducible across sites (51). However, rate constants derived from PK models are still apparent rates, and likely do not reflect a single biological characteristic.

Some additional considerations include whether complex or magnitude data is used, as the noise behaviors will impact the analysis differently. Additionally, cut-off thresholds or other criteria may be used to identify and avoid voxels with insufficient SNR before analysis to improve robustness (20,41).

Regardless of the analysis approach, the underlying biology is not always clearly represented by the data; instead, the metrics may be influenced by perfusion, barrier permeability, intercellular shuttles, enzyme activities, co-substrate concentrations, or combinations thereof, depending on the organ and disease of interest (19,43,94,101–103). This may be addressed by incorporating complementary information. As an example, HP 13C pyruvate data is influenced by perfusion, and thus addition of perfusion MRI could be important for interpretation (98,104,105).

All the methods outlined above have been explored in clinical studies, described in Supporting Table 3 and summarized in Figure 8. As of September 2022, approximately 52% of studies involving human subjects report rate constants derived from a PK model with a few different models reported. A nearly equal fraction (51%) of the studies report AUC ratio values.

Approximately 66% of these studies report metabolite-specific images or AUC values. About 40% report SNR values; this metric is particularly frequent in manuscripts that describe technical developments for clinical HP MRI. Approximately 16% of these studies summarize model-free metrics, and 10% report measurements from a single timepoint. Most studies report a combination of quantities.

Figure 8: Reported metrics used for analysis in HP [1-13C]pyruvate human studies published up to September 2022.

Visualization

A wide variety of approaches have been used for visualizing data from human HP 13C-MRI studies. The challenges and practical considerations are: 1) choosing the appropriate metrics to display, 2) how to encode the parameters (e.g. the colormap), and 3) choosing how to provide anatomical context and other multi-parametric data. The choice of visualization also depends on the goal which could be for diagnostic interpretation, but also quality control, reproducibility among readers and publication.

Metrics

The choice of HP 13C metrics is described in detail above. At this stage in HP 13C development where there is no standardized metric, often a combination of metabolite images and ratios or PK model parameters are shown.

Parameter Encoding

The mapping function chosen should provide an adequate, often quantitative, impression of the parameter mapped. There is a consensus in the visualization field that perceptually uniform maps are best suited to visualize continuous parameters, like the greyscale typically used by radiologists as well as other monochrome (black to blue) and color ranges (fire-type, rainbow-type) (106,107). Multi-color heatmaps have been the most frequently employed method for HP 13C data, while greyscale has infrequently been used but it ensures there is no coloring-based bias as well as facilitating later reuse (Fig. 9a). Among the color schemes employed in the clinical HP 13C literature, fire-type scheme seems to be the most common [similar to “Plasma” or “Inferno” in matplotlib.org]. Next most commonly employed is the rainbow-type scheme [similar to “Rainbow” in matplotlib.org].

Anatomical Context

HP MRI faces the challenge that it does not necessarily depict the anatomical features, similar to PET, and thus requires an anatomical reference. Most often, a grayscale anatomical image is overlaid with a HP colormap (Fig. 9c,d). This approach is very intuitive, but can skew perception as the grey-scale anatomical reference may affect the brightness of the HP data (e.g. signal in the skull). This bias does not occur when showing adjacent maps (Fig. 9a, b). Here, anatomical outlines may help to provide reference (Fig. 9b).

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