Reviewer #1 (Public review):
The authors of this study developed a method to quantify calvarial bone marrow from MRI head scans, enabling the study of its composition in large datasets of adults, usually collected to study the brain. Bone marrow intensity can be semi-quantitatively measured in T1-weighted MRI scans due to the greater signal intensity of fat than watery red marrow. This is an ingenious use of the MRI-produced information for other important phenotypes, such as bone structure and marrow content. Different head types were tested for complying with the model, which is notable.
The model was also successfully validated using several publicly available MRI resources - real data - in (1) a dataset consisting of 30 individuals that were scanned 10 times each at 3-day intervals, and (2) the monozygotic (MZ) twin data from the Human Connectome Project cohort. Then the authors applied this validated method to head-MRI scans from the UK Biobank (n=33,042) to extract information on the spatial distribution of bone marrow adiposity (BMA) in the calvaria, allowing a GWAS to identify associated genes.
The authors revealed high heritability and identified 41 genetic loci significantly associated with the BMA trait, including six sex-specific loci. Of note, statistics estimate that 99% of BMA trait-influencing variants are shared with BMD (497 of 500 variants), which may mean these results demonstrate the biological relevance to bone health. Some of the BMA genes were found related to the Wnt pathway, including WNT16, WNT4, NXN; this is a "positive control", since the Wnt/β-catenin signaling pathway was suggested as an important determinant of BMA. Also, associations in genes (BMP4, DLX5, LGR4, LRP4, SFRP4) that are known to specifically influence adiposity, are encouraging. Integrating mapped genes with bone marrow single-cell RNA-seq data revealed patterns of adipogenic lineage differentiation and lipid loading.
The study also investigated the genetic overlap between BMA and twelve (or 13) "brain and body" traits and identified significant genetic correlations with BMI, cognitive ability, and Parkinson's disease.
In sum, since MRI head scans present a hitherto unexplored opportunity to address unresolved aspects of bone marrow biology, this study is both timely and innovative.
There are, however, some assumptions, findings, and their interpretation, which require more critical focus.
Sex-specificity is well described and studied here. Men have higher BMA than women, but post-menopausal women catch up in the BMA values. The authors believe that calvarial marrow has a number of features that make it particularly well-suited to the study of BMA process - which is clinically important in other bone sites. It has a simple "sandwiched" structure that they are able to model. This is true only to some extent: a condition called "Hyperostosis frontalis interna", of unknown etiology (described by Smith & Hemphill in 1956) - is characterized by irregular overgrowth of the inner table of the frontal bone (symmetric/bilateral). Although not of clinical significance, typically benign, studies report a prevalence of 12%; However, it's most common in postmenopausal women - where prevalences up to 49% in women over the age of 65 - have been reported. Thus, sexual dimorphism is obvious and the effect of estrogen is likely shared with whichever bone - and marrow - age-related pathology. So, for women not using HRT, this new layer of the bone might interfere with the calvarial BMA readings and in turn, affect the BMA-related analyses. The authors suspect that the effect of BMA on BMD may be biased in women; they should comment on those "with low BMD and high BMA" given that hyperostosis frontalis might be an issue. A strong effect of SNPs in the ESR1 chromosomal region might be akin to the above concern.
Then, there is a perfect overlap of the BMA SNPs that are shared with BMD (497 of 500 variants), which may prove a "face validity" of the MRI-derived BMA. However, the BMD in the study was heel-derived eBMD - which is a good proxy for osteoporosis and is mostly driven by trabecular bone. Thus, there might be a concern that the BMA metrics capture some trabecular BMD.
Next, integrating mapped genes with existing bone marrow single-cell RNA-sequencing data revealed patterns of adipogenic lineage differentiation and lipid loading. The problem here is that the scRNAseq studies of the Bone Marrow niche are overwhelmingly mouse. The authors might wish to justify why they are relevant to humans (in the absence of the human-specific scRNAseq).
For genetic correlation analysis, the authors selected 7 body and 6 brain traits. The latter traits reflect cognition (general cognitive ability and educational attainment) and brain-related disorders. This selection might seem arbitrary. The interpretation of genetic correlation with cognitive ability, education, and Parkinson's disease was attributed to the recently discovered vascular channels that link calvarial bone marrow to the meninges. This is a fascinating hypothesis, which requires functional proof. However, there might be simpler explanations. Thus, the diploe and the inner table of the calvarium are drained by the same veins as the dura. From the anatomy textbook, we know that diploic veins connect the pericranial and endocranial venous system through the skull.