Cerebral Single Photon Emission Computed Tomography Research Articles

Clinical features and effects of shunt surgery in patients with progressive supranuclear palsy and idiopathic normal pressure hydrocephalus

This study aimed to retrospectively review the frequency and clinical features of 13 patients with progressive supranuclear palsy (PSP) and idiopathic normal pressure hydrocephalus (iNPH). All patients were found to have PSP-Richardson's syndrome (PSP-RS). Shunt surgery was effective in 5 of 11 patients (45.5%). A comparison of these 5 patients who responded to shunt surgery versus the remaining 6 patients revealed a significant difference in the reduction of frontal lobe blood flow on cerebral perfusion single-photon emission computed tomography (SPECT) (P = 0.018). These results suggest that PSP-RS is common in patients with PSP and iNPH and indicate the usefulness of cerebral perfusion SPECT in estimating the effect of shunt surgery.

Assessment of Impaired Cerebrovascular Reactivity in Chronic Cerebral Ischemia using Intravoxel Incoherent Motion Magnetic Resonance Imaging

BackgroundThe severity of chronic cerebral ischemia can be assessed using cerebrovascular reactivity (CVR) to acetazolamide (ACZ) challenge, which is measured by single-photon emission computed tomography (SPECT); however, this is an invasive method. We investigated whether intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI) can assess impaired CVR in preoperative patients with chronic cerebral ischemia and compared it to SPECT-CVR. MethodsForty-seven patients with unilateral cervical carotid artery stenosis underwent diffusion-weighted MRI with 11 b-values in the range of 0–800 s/mm2 and cerebral perfusion SPECT with the ACZ challenge. The perfusion fraction (f) and diffusion coefficient (D) of the IVIM parameters were calculated using a bi-exponential model. The f and D values and these ratios of the ipsilateral middle cerebral artery territory against the contralateral side were compared with the CVR values of the affected side calculated from the SPECT data. ResultsThe IVIM-f and D values in the affected side were significantly higher than those in the unaffected side (median: 7.74% vs. 7.45%, p = 0.027; 0.816 vs. 0.801 10−3mm2/s, p < 0.001; respectively). However, there were no significant correlations between the f or D values and SPECT-CVR values in the affected side. In contrast, the f ratio showed a moderate negative correlation with the SPECT-CVR values (r = -0.40, p = 0.006) and detected impaired CVR (< 18.4%) with a sensitivity/specificity of 0.71/0.90. ConclusionThe IVIM perfusion parameter, f, can noninvasively assess impaired CVR with high sensitivity and specificity in patients with unilateral cervical carotid artery stenosis.

Investigation of the new non-invasive semi-quantitative method of 123I-IMP pediatric cerebral perfusion SPECT.

In pediatric cases requiring quantification of cerebral blood flow (CBF) using 123I-N-isopropyl-p-iodoamphetamine (123I-IMP) single-photon emission computed tomography (SPECT), arterial blood sampling is sometimes impossible due to issues such as movement, crying, or body motion. If arterial blood sampling fails, quantitative diagnostic assessment becomes impossible despite radiation exposure. We devised a new easy non-invasive microsphere (e-NIMS) method using whole-body scan data. This method can be used in conjunction with autoradiography (ARG) and can provide supportive data for invasive CBF quantification. In this study, we examined the usefulness of e-NIMS for pediatric cerebral perfusion semi-quantitative SPECT and compared it with the invasive ARG. The e-NIMS estimates cardiac output (CO) using whole-body acquisition data after 123I-IMP injection and the body surface area from calculation formula. A whole-body scan was performed 5 minutes after the 123I-IMP injection and CO was estimated by region of interest (ROI) counts measured for the whole body, lungs, and brain using the whole-body anterior image. The mean CBF (mCBF) was compared with that acquired via ARG in 115 pediatric patients with suspected cerebrovascular disorders (age 0–15 years). Although the mCBF estimated by the e-NIMS indicated a slight deviation in the extremely low- or high-mCBF cases when compared with the values acquired using the invasive ARG, there was a good correlation between the two methods (r = 0.799; p < 0.001). There were no significant differences in the mCBF values based on physical features, such as patients’ height, weight, and age. Our findings suggest that 123I-IMP brain perfusion SPECT with e-NIMS is the simplest semi-quantitative method that can provide supportive data for invasive CBF quantification. This method may be useful, especially in pediatric brain perfusion SPECT, when blood sampling or identifying pulmonary arteries for CO estimation using the graph plot method is difficult.

Detection of impaired cerebrovascular reactivity in patients with chronic cerebral ischemia using whole-brain 7T MRA

BackgroundCerebrovascular reactivity (CVR) to acetazolamide (ACZ) on single-photon emission computed tomography (SPECT) can be used to assess the severity of chronic cerebral ischemia; however, this is an invasive method. We examined whether whole-brain magnetic resonance angiography (MRA) at 7T could non-invasively detect impaired CVR in patients with chronic cerebral ischemia by demonstrating the leptomeningeal collaterals (LMCs). MethodsFifty-seven patients with symptomatic unilateral cervical stenosis underwent whole-brain time-of-flight MRA at 7T and cerebral perfusion SPECT before/after the ACZ challenge. MRA images were visually assessed based on 6-point grading systems to evaluate the development of LMCs toward the middle cerebral artery (MCA) and antegrade flow of MCA. CVR of the affected side was calculated from the SPECT data. Subsequently, we compared the LMC grades on MRA with CVR on SPECT. ResultsCVR was significantly lower in grades ≥ 2 of LMCs than in grades 0–1 (P < 0.05) when applying LMCs from the anterior cerebral artery (ACA) and/or posterior cerebral artery (PCA). These differences were more evident than those in the grading of the antegrade MCA flow. The LMC grades from ACA/PCA readily detected reduced CVR (< 18.4%) with a sensitivity/specificity of 0.79/0.82. ConclusionThe development of LMCs on whole-brain MRA at 7T can non-invasively detect reduced CVR with a high sensitivity/specificity in patients with unilateral cervical stenosis.

A functional evaluation of cerebral perfusion for coronary artery bypass grafting patients.

We evaluate the utility of providing a pulsatile blood flow by applying off-pump coronary artery bypass grafting (CABG) or intra-aortic balloon pumping (IABP) with conventional CABG to prevent perioperative stroke in patients with cerebral hypoperfusion on single-photon emission-computed tomography (SPECT). A total of 286 patients underwent isolated CABG with a cerebral magnetic resonance angiography (MRA) evaluation between 2006 and 2015. Seventy-five had significant stenosis and/or occlusion of craniocervical vessels; the other 211 had no significant stenosis. Cerebral SPECT was performed for 49 (SPECT group) of the 75 patients. The SPECT group was further divided into a normal perfusion (NP) (n = 37); and a hypoperfusion (HP) (n = 12). In the present study we compared the NP group and the 211 patients with no significant stenosis (as a control group) to the HP group. No strokes occurred in the HP group, and 1 stroke occurred at the time of operation in the control group. Postoperative stroke within 30days occurred in 3 patients in the control group; the difference was not statistically significant. The long-term stroke-free rates of the HP and Control group did not differ to a statistically significant extent. The functional evaluation of cerebral perfusion by SPECT is important when patients have significant stenotic lesions on cerebral MRA. Maintaining an adequate pulsatile flow by off-pump CABG or IABP with conventional CABG will help prevent perioperative stroke, even if cerebral hypoperfusion is detected by SPECT.

Prediction of Cerebral Hyperperfusion After Carotid Artery Stenting by Cerebral Angiography and Single-Photon Emission Computed Tomography Without Acetazolamide Challenge.

Definitive preoperative predictors of cerebral hyperperfusion following carotid artery stenting are yet to be established. To determine the preprocedural risk factors for cerebral hyperperfusion phenomenon (CHP) following carotid artery stenting. Patients undergoing preprocedural single-photon emission computed tomography (SPECT) and cerebral angiography prior to their first carotid artery stenting were monitored for occurrence of CHP. In addition to patient characteristics, we investigated imaging parameters, such as cerebral blood flow, cerebral vasoreactivity, and asymmetry index on SPECT, and presence of near occlusion and leptomeningeal anastomosis on cerebral angiography. Out of 100 patients (mean age: 73.0 ± 7.6 years; 85 men), 9 developed CHP. On multivariate logistic regression analysis, asymmetry index (%) on SPECT (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.70-0.93, P = .003) and presence of leptomeningeal anastomosis on cerebral angiography (OR 72.1, 95% CI 3.52-1480, P = .006) were independent predictors of CHP. Combined use of cerebral angiography and SPECT may obviate the need for acetazolamide challenge to predict the risk of CHP following carotid artery stenting.

Biomarkers Differentiating Dementia withLewy Bodies from Other Dementias: AMeta-Analysis.

Several nuclear imaging and cerebrospinal fluid (CSF) biomarkers are under investigation, aimed at facilitating the differential diagnosis of dementias. To quantitatively synthesize data on test performance in differentiating dementia with Lewy bodies (DLB) from other dementias. We searched PubMed (January 2000- March 2015) for English-language publications that assessed a selected set of five imaging and three CSF biomarkers for this purpose. We meta-analyzed measures of agreement between biomarker results and clinical diagnosis. Forty-five publications were eligible. The majority of evidence was based on studies that enrolled representative disease populations. For differentiating between DLB and Alzheimer's disease (AD) or other dementias, metaiodobenzylguanidine scintigraphy and dopamine transporter (DAT) single photon emission computed tomography (SPECT) showed, respectively, excellent (summary kappa = 0.85; 95% confidence interval [95% CI], 0.74-0.96) and good (summary kappa = 0.71; 95% CI, 0.43-0.99) agreement. Metaiodobenzylguanidine scintigraphy appeared superior to fluorodeoxyglucose- positron emission tomography (summary kappa = 0.53; 95% CI, 0.36-0.69) and cerebral blood flow SPECT (summary kappa = 0.40; 95% CI, 0.33-0.47). For differentiating DLB from AD, CSF t-tau levels (summary kappa = 0.68; 95% CI, 0.55-0.82) performed comparably to metaiodobenzylguanidine scintigraphy and DAT SPECT. Sparse direct comparative evidence failed to corroborate these indirect comparisons. Metaiodobenzylguanidine scintigraphy and DAT SPECT are highly concordant with clinical diagnosis in differentiating DLB from other dementias. However, given the limitations in the study design, the applicability of these results to real-world differential diagnosis remains unclear. Prospective studies targeting patients with atypical presentations that adopt gold standard tests would reliably estimate the true test performance of these promising biomarkers.

The utility of cerebral perfusion SPECT analysis using SPM8, eZIS and vbSEE for the diagnosis of multiple system atrophy-parkinsonism.

Although a correct diagnosis is important for appropriate management, accurately differentiating between multiple system atrophy with predominant parkinsonism (MSA-P) and Parkinson's disease (PD) is often difficult because of similarities in the early-stage symptoms. The aim of this study was to evaluate the diagnostic value of cerebral perfusion single photon emission computed tomography (SPECT) and voxel-based analysis for diagnosing MSA-P patients. Thirty-eight subjects (9 with early-stage MSA-P, 11 with PD, and 18 controls) were included in this study. Z-scores suggestive of hypoperfusion were calculated between patients and controls using statistical parametric mapping (SPM) 8 and easy Z-score imaging system (eZIS) programs. A voxel-based stereotactic extraction estimation (vbSEE) program was performed to determine the target volumes of interest (VOIs) in the putamen, pons, and cerebellum, and quantify Z-scores as "extent" (the rate of voxels with a Z-score >2.0 in these VOIs) and "severity" (average Z-scores in these VOIs). These parameters were used as the determinant in receiver operating characteristic (ROC) analyses. The extent and severity of the cerebellar VOIs were higher in MSA-P patients than in PD patients. In ROC analyses, the extent and severity of the cerebellar VOI exhibited the highest areas under the curves of 0.86 and 0.84, and accuracies of 90 and 90 %, respectively. The diagnostic value of significant cerebellar hypoperfusion was the highest for differentiating MSA-P from PD. This voxel-based analysis of cerebral perfusion SPECT using the SPM8, eZIS, and vbSEE programs is useful for clinically diagnosing MSA-P.

Computer-assisted system for diagnosing degenerative dementia using cerebral blood flow SPECT and 3D-SSP: a multicenter study.

Due to increasing numbers of patients with dementia, more physicians who do not specialize in brain nuclear medicine are being asked to interpret SPECT images of cerebral blood flow. We conducted a multicenter study to determine whether a computer-assisted diagnostic system Z-score summation analysis method (ZSAM) using three-dimensional stereotactic surface projections (3D-SSP) can differentiate Alzheimer's disease (AD)/dementia with Lewy bodies (DLB) and non-AD/DLB in institutions using various types of gamma cameras. We determined the normal thresholds of Z-sum (summed Z-score) within a template region of interest for each single photon emission computed tomography (SPECT) device and then compared them with the Z-sums of patients and calculated the accuracy of the differential diagnosis by ZSAM. We compared the diagnostic accuracy between ZSAM and visual assessment. We enrolled 202 patients with AD (mean age, 76.8 years), 40 with DLB (mean age 76.3 years) and 36 with non-AD/DLB (progressive supranuclear palsy, n = 10; frontotemporal dementia, n = 20; slowly progressive aphasia, n = 2 and one each with idiopathic normal pressure hydrocephalus, corticobasal degeneration, multiple system atrophy and Parkinson's disease) who underwent N-isopropyl-p-[(123)I] iodoamphetamine cerebral blood flow SPECT imaging at each participating institution. The ZSAM sensitivity to differentiate between AD/DLB and non-AD/DLB in all patients, as well as those with mini-mental state examination scores of ≥24 and 20-23 points were 88.0, 78.0 and 88.4 %, respectively, with specificity of 50.0, 44.4 and 60.0 %, respectively. The diagnostic accuracy rates were 83.1, 72.9 and 84.2 %, respectively. The areas under receiver operating characteristics curves for visual inspection by four expert raters were 0.74-0.84, 0.66-0.85 and 0.81-0.93, respectively, in the same patient groups. The diagnostic accuracy rates were 70.9-89.2 %, 50.9-84.8 % and 76.2-93.1 %, respectively. The diagnostic accuracy of ZSAM to differentiate AD/DLB from other types of dementia or degenerative diseases regardless of severity was equal to that of visual assessment by expert raters even across several institutions. These findings suggested that ZSAM could serve as a supplementary tool to help expert evaluators who differentially diagnose dementia from SPECT images by visual assessment.

Neuroimaging characteristics of dementia with Lewy bodies.

This review summarises the findings and applications from neuroimaging studies in dementia with Lewy bodies (DLB), highlighting key differences between DLB and other subtypes of dementia. We also discuss the increasingly important role of imaging biomarkers in differential diagnosis and outline promising areas for future research in DLB. DLB shares common clinical, neuropsychological and pathological features with Parkinson’s disease dementia and other dementia subtypes, such as Alzheimer’s disease. Despite the development of consensus diagnostic criteria, the sensitivity for differential diagnosis of DLB in clinical practice remains low and many DLB patients will be misdiagnosed. The importance of developing accurate imaging markers in dementia is highlighted by the potential for treatments targeting specific molecular abnormalities as well as the responsiveness to cholinesterase inhibitors and marked neuroleptic sensitivity of DLB. We review various brain imaging techniques that have been applied to investigate DLB, including the characteristic nigrostriatal degeneration in DLB using positron emission tomography (PET) and single-photon emission computed tomography (SPECT) tracers. Dopamine transporter loss has proven to reliably differentiate DLB from other dementias and has been incorporated into the revised clinical diagnostic criteria for DLB. To date, this remains the 'gold standard' for diagnostic imaging of DLB. Regional cerebral blood flow, 18 F-fluorodeoxygluclose-PET and SPECT have also identified marked deficits in the occipital regions with relative sparing of the medial temporal lobe when compared to Alzheimer’s disease. In addition, structural, diffusion, and functional magnetic resonance imaging techniques have shown alterations in structure, white matter integrity, and functional activity in DLB. We argue that the multimodal identification of DLB-specific biomarkers has the potential to improve ante-mortem diagnosis and contribute to our understanding of the pathological background of DLB and its progression.

Early Diagnosis of Alzheimer's Disease and Parkinson's Disease Associated with Dementia Using Cerebral Perfusion SPECT

Background: Since patterns of cognitive dysfunction in mild Parkinson's disease associated with dementia (PDD) are similar to those in mild Alzheimer's disease (AD), it is difficult to accurately differentiate between these two types of dementia in their early phases using neuropsychological tests. The purpose of the current study was to investigate differences in cerebral perfusion patterns of patients with AD and PDD at the earliest stages using single photon emission computed tomography (SPECT). Methods: We consecutively recruited 31 patients with mild PDD, 32 patients with mild probable AD and 33 age-matched healthy subjects. All subjects underwent ^99mTc-hexamethylpropyleneamine oxime perfusion SPECT and completed general neuropsychological tests. Results: We found that both mild PDD and AD patients showed distinct hypoperfusion in frontal, parietal and temporal regions, compared with healthy subjects. More importantly, hypoperfusion in occipital and cerebellar regions was observed only in mild PDD. Conclusion: The observation of a significant decrease in cerebral perfusion in occipital and cerebellar regions in patients with mild PDD is likely useful to differentiate between PDD and AD at the earliest stages.

Periodic lateralized epileptiform discharges (PLEDs) in cerebral lupus correlated with white-matter lesions in brain MRI and reduced cerebral blood flow in SPECT

This is a case report on an uncommon correlation between periodic lateralized epileptiform discharges (PLEDs) and white-matter lesions in cerebral lupus, and with a reduced cerebral blood flow (CBF) in single-photon emission computed tomography (SPECT). A 47-year-old woman with a long-term history of systemic lupus erythematosus (SLE) presented with a seizure followed by frontal lobe dysfunction clinically. An electroencephalogram (EEG) showed bilateral independent PLEDs in the frontal region. A magnetic resonance image of the brain showed white-matter changes in the frontal periventricular region. Cerebral angiogram did not reveal any evidence of vasculitis. A cerebral SPECT with tracer injected during the EEG showing PLEDs showed a reduction in CBF in the frontal regions. Clinical recovery was observed with intravenous immunoglobulin. This case shows that PLEDs can be seen with white-matter changes in SLE.

Combination of Preoperative Cerebral Blood Flow and 123I-Iomazenil SPECT Imaging Predicts Postoperative Cognitive Improvement in Patients Undergoing Uncomplicated Endarterectomy for Unilateral Carotid Stenosis

The purpose of the present study was to determine whether preoperative cerebral blood flow (CBF) or cortical central benzodiazepine receptor binding potential as measured by brain perfusion or (123)I-iomazenil (IMZ) single-photon emission computed tomography (SPECT) imaging, respectively, can predict cognitive improvement after uncomplicated carotid endarterectomy (CEA). Neuropsychological testing was performed preoperatively and after 1 month postoperatively in 140 patients who underwent CEA for unilateral internal carotid artery (ICA) stenosis (≥ 70%). Brain perfusion SPECT using N-isopropyl-p-[(123)I]-iodoamphetamine and IMZ SPECT was also performed before surgery. SPECT data were analyzed using a 3-dimensional stereotaxic region-of-interest template. Fourteen patients (10%) showed improved cognitive function postoperatively. Logistic regression analysis demonstrated that, among the variables tested, low relative CBF in the cerebral hemisphere ipsilateral to surgery was significantly associated with postoperative cognitive improvement (95% confidence interval: 0.623-0.868; P = 0.0003). The combination of reduced relative CBF and moderately reduced relative uptake of IMZ identified development of postoperative cognitive improvement with 100.0% sensitivity, 84.9% specificity, a positive predictive value of 42.4%, and a negative predictive value of 100%. Further, in a subgroup of patients with reduced relative CBF and moderately reduced relative uptake of IMZ, the difference between these 2 values was significantly greater in patients with postoperative cognitive improvement than in those without (P < 0.0001). The combination of preoperative CBF and cortical central benzodiazepine receptor binding potential as determined by SPECT can predict cognitive improvement after CEA.

Cerebral blood flow effects of the nitric oxide donor, nitroglycerin and its drug combinations in the non-human primate model.

Nitroglycerin (CAS 55-63-0, Nitrocene) has successfully been used in the management of angina during the last several decades. Although important information on the pharmacological actions and efficacy of nitroglycerin have been extracted, to date, limited research has been conducted on its effects on cerebral blood flow. In recent years, with the aid of SPECT (single photon emission computed tomography) and PET (positron emission tomography) it has been shown that marked cerebral blood flow changes occur under treatment of a wide variet of drugs. Illucidation of the pharmacological mode of action of nitroglycerin has gained momentum with the discovery of nitric oxide (NO) as an endogenous mediator and with the knowledge that nitroglycerin acts as a NO donor. The present study investigated the effects of nitroglycerin (0.25 microgram/kg/min over 10 min) on the cerebral blood flow, using 99mTc-HMPAO (hexamethylpropylene amine oxime) and SPECT, in an anaesthetised primate model, as well as the effects of its drug interactions with therapeutic agents that influence cerebrovascular dynamics, e.g. sumatriptan, nimodipine and acetazolamide. The present study with nitroglycerin indicates that the response time to measure cerebral blood flow effects seems to be present and an important factor as the transient is relatively short. The current treatment regime with nitroglycerin indicates a slight increase, when compared with control control results, although not significant, except for regional significant increases in particular the occipital regions of the brain. Drug interaction between nitroglycerin and nimodipine may occur as a reduction of 20% in cerebral blood flow from the control control was observed in this case. The results for the combination of nitroglycerin with sumatriptan showed a further increase of the cerebral blood flow to near significance, when compared with the control results and is significantly increased (+27%) when compared with sumatriptan treatment alone. Effective treatment with sumatriptan may therefore be compromised with simultaneous administration of nitroglycerin or NO donor drugs. The combination of nitroglycerin and acetazolamide suggested that the increase in cerebral blood flow is primarily attributed to the influence of acetazolamide. The cerebral blood flow effects of these drugs and possible interactions during an angina attack need to be investigated.

Brain SPECT Imaging in Clinical Practice

Back to table of contents Previous article Next article Communications and UpdatesFull AccessBrain SPECT Imaging in Clinical PracticeDaniel Amen, M.D.Daniel AmenNewport Beach, Calif.Search for more papers by this author, M.D.Published Online:1 Sep 2010https://doi.org/10.1176/appi.ajp.2010.10060814AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I agree with the statement by Bryon Adinoff, M.D., and Michael Devous, Ph.D. (1), in their Letter to the Editor published in the May 2010 issue of the Journal, that “it is likely that, within the next decade, Dr. Amen's claims [and fervent hope] will be realized in that psychiatrists will enjoy the ability to diagnose and prescribe treatments based, in part, upon neuroimaging findings” (1, p. 598). Imaging is now being used by psychiatrists here in the United States, in Canada, and abroad to aid patients. I cannot imagine anything more damaging to the imaging field, however, than encouraging medical board investigations for those who are early adopters. The California Medical Board investigated my use of single photon emission computed tomography (SPECT) 13 years ago, found no violation, and encouraged me to publish our findings, which I have done.One would think that a more enlightened attitude toward a field, as plagued by uncertainties as psychiatry still is, would welcome the practical application of neuroimaging. In 2001, Camargo wrote “Brain SPECT is rapidly becoming a clinical tool in many places, particularly in dementias, head injury, [obsessive compulsive disorder] OCD, Tourette's, schizophrenia, depression, panic disorder, and drug abuse” (2). Additionally, Brockman demonstrated SPECT's usefulness in choosing between treatments for depression (3).Our work is based on hundreds of texts and scientific articles, including 26 articles and the chapter on functional imaging in the Comprehensive Textbook of Psychiatry that I co-authored (4). Respected hospitals, such as Sierra Tucson, have added SPECT to their armamentarium. Thoughtful clinicians would never use SPECT in isolation, and contrary to what was written about me, I have never recommended such use.Clinical practice and careful observations have provided researchers with important hypotheses to test, and I have successfully invited researchers to use our database of rigorously diagnosed patients, including SPECT when indicated, to advance neuroimaging, and I extend the same invitation here.The Society of Nuclear Medicine has never formally approached me to perform a study. Plus, I would never engage in a charade where I was expected to give a diagnosis from a scan. That is not how imaging is or should be practiced. The notion of Adinoff and Devous that SPECT is dangerous is disingenuous. Devous recently wrote, “SPECT and PET have no more risk than MRI-based procedures” (5).The hope that SPECT and other imaging modalities will be as routine and useful to psychiatry as imaging the heart is to cardiology has animated my practice for nearly 20 years. It, indeed, is starting to happen. My hope is that our journal will help translate imaging research into clinical practice rather than threaten practitioners who have been trying to make it happen.Newport Beach, Calif.accepted for publication in June 2010.Dr. Amen is the CEO and owner of Amen Clinics, Inc.Reference1. Adinoff B , Devous MD: Scientifically unfounded claims in diagnosing and treating patients. Am J Psychiatry 2010; 167:598–598Link, Google Scholar2. Camargo EE: Brain SPECT in neurology and psychiatry. J Nucl Med 2001; 42:611–623Medline, Google Scholar3. Brockmann H , Zobel A , Joe A , Biermann K , Scheef L , Schuhmacher A , von Widdern O , Metten M , Biersack HJ , Maier W , Boecker H: The value of HMPAO SPECT in predicting treatment response to citalopram in patients with major depression. Psychiatry Res 2009; 173:107–112Crossref, Medline, Google Scholar4. http://www.amenclinics.com/meet-dr-amen/credentials/Google Scholar5. Devous MD: SPECT functional brain imaging, in Functional Cerebral SPECT and PET Imaging. Edited by Van Heertum RLTikofsky RSIchise M. Philadelphia, Lippincott, Williams and Wilkins, 2009Google Scholar FiguresReferencesCited byDetailsCited ByThe Potential for Medicolegal Abuse: Diffusion Tensor Imaging in Traumatic Brain Injury18 March 2014 | AJOB Neuroscience, Vol. 5, No. 2Triangulating perspectives on functional neuroimaging for disorders of mental health8 August 2013 | BMC Psychiatry, Vol. 13, No. 1AJOB Neuroscience, Vol. 3, No. 4Journal of Neurotrauma, Vol. 29, No. 14 Volume 167Issue 9 September 2010Pages 1125-1125 Metrics PDF download History Accepted 1 June 2010 Published online 1 September 2010 Published in print 1 September 2010

ACCURACY OF FLUOROPROPYL‐2β‐CARBOMETHOXY‐3β‐(4‐ IODOPHENYL) NORTROPANE DATSCAN FOR THE DIAGNOSIS OF LEWY BODY DEMENTIA

To the Editor: Dementia with Lewy bodies (DLB), the second main cause of dementia after Alzheimer's disease, is responsible for 15% to 25% of neurodegenerative dementia. Diagnosis at an early stage is sometimes difficult. Diagnostic criteria have been established and reviewed to facilitate diagnosis.1 Evaluation of dopamine transporter with fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropane (single photon emission computed tomography (SPECT)), referred to as DaTSCAN (General Electric Health Care, Chalfont St. Giles, UK), appears useful in differentiating Alzheimer's disease from DLB. An 84-year-old woman presented with a 2-year fluctuating cognitive decline associated with recurrent visual hallucinations. Her neurological examination was normal. Her past medical history included chronic atrial fibrillation and hypertension. The first suspected diagnosis was Alzheimer's disease because of the progressive evolution and the neuropsychological test showing altered episodic memory. Her Mini-Mental State Examination score was 25. Her brain computed tomography (CT) scan showed global atrophy. Treatment with a neuroleptic drug was started to reduce hallucinations but was stopped because of worsening cognitive decline. The patient was transferred to the Geriatrics Department at CHU La Miletrie, Poitiers, France. Clinical examination did not show any parkinsonism. Daily visual hallucinations continued. The patient exhibited a misidentification delusion (Capgras syndrome), because she believed she saw her son's double. Biological blood testing was normal. Electroencephalography was requested because of suspected temporal lobe epilepsy, but no evidence was found. Cerebral perfusion SPECT was performed that showed a distinct reduction of cortical perfusion with occipital affect, which is uncommon in Alzheimer's disease. The association between fluctuating cognitive decline and recurrent visual hallucinations suggested DLB, despite the absence of parkinsonian syndrome. DaTSCAN was performed and showed distinct dopamine transporter asymmetry at the expense of the right striatum (Figure 1), which strengthened the diagnostic hypothesis. Treatment with an acetylcholinesterase inhibitor resulted in rapid cognitive improvement and reduced hallucinations. After 36 months of follow-up, the patient was free of clinical parkinsonian syndrome. DaTSCAN shows distinct dopamine transporter asymmetry with lack of binding in the right putamen. This case report confirms the usefulness of SPECT imaging with DaTSCAN to facilitate the diagnosis of dementia. A European, multicenter, prospective, longitudinal study reported a mean sensitivity of 78% and specificity of 97% with the use of DaTSCAN to ascertain the diagnosis of Parkinson's disease.2 DaTSCAN is also helpful for patients with hallucinations.3 This case underscores the accuracy of DaTSCAN SPECT to optimize the diagnosis in patients with uncertain degenerative disease. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Odile Bouverie: study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of letter. Rémi Coudroy and François Salmon:and Roger Gil analysis and interpretation of data and preparation of manuscript. Isabelle Merlet-Chicoine and Roger Gil: analysis and interpretation of data. Marc Paccalin: study concept and design, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: No sponsor's role.

Evaluation of brain perfusion in specific Brodmann areas in Frontotemporal dementia and Alzheimer disease using automated 3-D voxel based analysis

Introduction. Brain perfusion studies with single-photon emission computed tomography (SPECT) have been applied in demented patients to provide better discrimination between frontotemporal dementia (FTD) and Alzheimer's disease (AD). Aim. To assess the perfusion of specific Brodmann (Br) areas of the brain cortex in FTD and AD patients, using NeuroGam processing program to provide 3D voxel-by-voxel cerebral SPECT analysis. Material and methods. We studied 34 consecutive patients. We used the established criteria for the diagnosis of dementia and the specific established criteria for the diagnosis of FTD and AD. All the patients had a neuropsychological evaluation with a battery of tests including the mini-mental state examination (MMSE).Twenty-six patients (16 males, 10 females, mean age 68.76±6.51 years, education 11.81±4.25 years, MMSE 16.69±9.89) received the diagnosis of FTD and 8 patients (all females, mean age 71.25±10.48 years, education 10±4.6 years, MMSE 12.5±3.89) the diagnosis of AD. All the patients underwent a brain SPECT. We applied the NeuroGam Software for the evaluation of brain perfusion in specific Br areas in the left (L) and right (R) hemispheres. Results. Statistically significant hypoperfusion in FTD compared to AD patients, was found in the following Br areas: 11L (p<0.0001), 11R, 20L, 20R, 32L, 38L, 38R, 44L (p<0.001), 32R, 36L, 36R, 45L, 45R, 47R (p<0.01), 9L, 21L, 39R, 44R, 46R, 47L (p<0.05). On the contrary, AD patients presented significant (p<0.05) hypoperfusion in 7R and 39R Br areas. Conclusion. NeuroGam processing program of brain perfusion SPECT could result in enhanced accuracy for the differential diagnosis between AD and FTD patients.

99mTc-HMPAO Brain Perfusion Single-Photon Emission Computed Tomography in Children with Down Syndrome: Relationship to Epilepsy, Thyroid Functions, and Congenital Heart Disease

In recent years, it has been possible for patients with Down syndrome to live longer with advanced medical treatment and social support. As a result, the problems of these patients, such as thyroid diseases, leukemia, and Alzheimer disease, would be encountered more frequently. In this study, we aimed to perform the brain perfusion of children with Down syndrome by technetium 99m hexamethylpropylene amine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) and to determine the relationship between brain perfusion and epilepsy, thyroid function tests, congenital heart disease, and level of mental and motor development. Thirty patients with Down syndrome, aged between 1 and 15 years, were included in our study. Demographic data, the existence of epilepsy and congenital heart defects, the level of mental and motor development, serum levels of thyroid hormones, and autoantibodies were determined. All patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI). Cerebral SPECT was performed in all cases to evaluate the brain perfusion pattern. According to the visual evaluation of cerebral SPECT results, hypoperfusion was detected in 11 cases (37%). Patients with cerebral hypoperfusion (group 1) and patients with normal cerebral perfusion (group 2) were compared. There was no difference between group 1 and group 2 in terms of demographic data, congenital heart defects, IQ levels, thyroid hormones, and autoantibodies, but the incidence of epilepsy was significantly higher in group 1 (P<.001). When motor and mental development levels were compared, it was found that cases in group 1 were significantly more retarded in personal-social and fine motor skills (P<.05). The present study showed that cerebral hypoperfusion in children with Down syndrome is mostly related to epilepsy and the other coexisting conditions, congenital heart disease and hypothyroidism. Patients with cerebral hypoperfusion also have more retarded developmental levels, especially in personal-social and fine motor skills.

Functional assessment of intracranial arachnoid cysts with TC99 m-HMPAO SPECT: a preliminary report

Many arachnoid cysts (AC) are detected incidentally in asymptomatic patients. Current neuroimaging methods provide only morphological details of the cysts, but they do not give information about cerebral function. While surgery is indicated in symptomatic patients, the management of asymptomatic individuals, who present with large cysts, is controversial. To ascertain the value of cerebral 99 mTc-HMPAO single photon emission computed tomography (SPECT) for detecting brain dysfunction in cases of intracranial ACs, aimed at allocating the patients for surgical or for conservative treatment. We studied prospectively 11 patients diagnosed with sylvian fissure ACs. The subjects underwent neurological examination, EEG, neuroimaging studies, neuropsychological testing, and cerebral perfusion studies with 99 mTc-HMPAO SPECT. The patients' ages ranged from 2 to 42 years (median 16 years). The study group consisted of ten symptomatic patients with ACs and one patient with an incidental cyst. Seven patients showed diminished regional cerebral blood flow (rCBF) in their initial cerebral SPECT. Four individuals underwent surgery. Seven patients showed normalization of rCBF after surgical or conservative treatment. Cerebral SPECT demonstrated impaired brain perfusion in 70% of symptomatic patients. The zone of decreased rCBF corresponded well with clinical symptoms and with neuroimaging findings. Patients exhibiting normal rCBF in SPECT studies remained or became asymptomatic during the follow-up time. Cerebral SPECT constitutes a valuable adjunct tool for correlating regional function with brain anatomy, and may be of help to allocate patients with ACs for surgical treatment or clinical observation. Further research on this field is warranted.

The prediction of rapid conversion to Alzheimer's disease in mild cognitive impairment using regional cerebral blood flow SPECT

Mild cognitive impairment (MCI) comprises a heterogeneous group with a variety of clinical outcomes and they are at risk for developing Alzheimer's disease (AD). The prediction of conversion from MCI to AD using the initial neuroimaging studies is an important research topic. We investigated the initial regional cerebral blood flow (rCBF) measurements using single photon emission computed tomography (SPECT) in individuals with 76 amnesic MCI (52 subjects converted to AD and 24 subjects did not convert to AD at 3-year follow-up) and 57 age- and gender-matched controls. We sought functional profiles associated with conversion to AD, then evaluated the predictive value of the initial rCBF SPECT. As compared with controls, AD converters demonstrated reduced blood flow in the bilateral parahippocampal gyri, precunei, posterior cingulate cortices, bilateral parietal association areas, and the right middle temporal gyrus. Non-converters also demonstrated significant reduction of rCBF in the posterior cingulated cortices and the right caudate nucleus when compared to controls. As compared with non-converters, converters showed reductions of rCBF in the bilateral temporo-parietal areas and the precunei. The logistic regression model revealed that reduced rCBF in the inferior parietal lobule, angular gyrus, and precunei has high predictive value and discriminative ability. Although a cross-validation study is needed to conclude the usefulness of rCBF SPECT for the prediction of AD conversion in individuals with MCI, our data suggest that the initial rCBF SPECT studies of individuals with MCI may be useful in predicting who will convert to AD in the near future.