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Glymphatic system evaluation using diffusion tensor imaging in patients with traumatic brain injury



Glymphatic system dysfunction has been reported in animal models of traumatic brain injury (TBI). This study aimed to evaluate the activity of the human glymphatic system using the non-invasive Diffusion Tensor Image-Analysis aLong the Perivascular Space (DTI-ALPS) method in patients with TBI.


A total of 89 patients with TBI (June 2018 to May 2020) were retrospectively enrolled, and 34 healthy volunteers were included who had no previous medical or neurological disease. Magnetic resonance imaging (MRI) with DTI was performed, and the ALPS index was calculated to evaluate the glymphatic system’s activity. Wilcoxon rank-sum test was used to compare the ALPS index between patients with TBI and healthy controls. ANOVA was done to compare the ALPS index among controls and patients with mild/moderate-to-severe TBI. Multivariate logistic regression analyses were used to identify independent clinical and radiological factors associated with the ALPS index. The correlation between Glasgow Coma Scale (GCS) score and the ALPS index was also assessed.


The ALPS index was significantly lower in patients with TBI than in healthy controls (median, 1.317 vs. 1.456, P < 0.0001). There were significant differences in the ALPS index between healthy controls and patients with mild/moderate-to-severe TBI (ANOVA, P < 0.001). The presence of subarachnoid hemorrhage (P = 0.004) and diffuse axonal injury (P = 0.001) was correlated with a lower ALPS index in the multivariate analysis. There was a weak positive correlation between the ALPS index and GCS scores (r = 0.242, P = 0.023).


The DTI-ALPS method is useful for evaluating glymphatic system impairment and quantifying its activity in patients with TBI.

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This work was supported by the Intramural Research Fund of Ajou University Medical Center and the National Research Foundation of Korea (NRF; MSIT; No.2021R1G1A1093677).

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Correspondence to Miran Han.

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The Institutional Review Board of Ajou University Medical Center (IRB No. AJIRB-MED-MDB-20–485) approved this study.

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The requirement for informed consent was waived for all trauma patients due to the retrospective nature of the study.

Written informed consent was obtained from all healthy volunteers for MRI acquisition and publication of their data.

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The authors declare no competing interests.

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Park, J.H., Bae, Y.J., Kim, J.S. et al. Glymphatic system evaluation using diffusion tensor imaging in patients with traumatic brain injury. Neuroradiology 65, 551–557 (2023).

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  • Traumatic brain injury
  • Glymphatic system
  • Diffusion tensor imaging