医学影像学 核医学课件 Neurology-lecture-中大医院

NuclearNeurology

CentralNervousSystemChengXu

（程旭）Dept.ofNuclearMedicineJiangsuProvinceHospitalNanjingMedicalUniversity12ContactMeAddress:GuangzhouRoad300#,Nanjing,JiangsuProvince,China.

210029QQ:151729268Cheng7515@163.comTelephone:025-6813654934StatusofCNSNuclearImaging,ChinaBone&joint (40%)Cardiovascular (25%)Thyroid (15%)Tumor (10%)CNS (6%)Others (4%)cardiovascular25%Bone40%Tumor10%Thyroid15%CNS6%Others4%5TopicsofOralPresentationsandPostersONCOLOGYNEUROSCIENCEDEMENTIAMOVEMENTDISORDERCARDIOLOGY688(46%)254(17%)39(2.6%)29(1.9%)200(13%)29742(46%)280(18%)49(3.1%)27(1.7%)163(10%)2720052006SNM200662004ImageoftheYear72007ImageoftheYear(SNM)8CentralNervousSystem

NuclearImagingCerebralangiographyandblood–brainbarrierstudies(brainscan)Cerebralperfusiontomography(brainSPECT)BraintumorimagingCerebralmetabolicimagingBrainreceptorimagingRadionuclidecisternography

9WhatisSPECT?ThebrainusesSPECTCTandMRITwotechnologicaladvancementsSingle-headedtomulti-headedcameraAdvancementofcomputertechnologyCerebralPerfusionTomography(BrainSPECT)

10FDG-PETThalliumMIBIECD11SiemensDualHead-E.CAMSPECTCameraSiemenssingleHead-E.CAMSPECTCameraTripleHeadSPECT12PrincipleThebrainreceives20%ofthecardiacoutput,itsweightisonly2%ofbody.Thebrainreliesoncontinuousbloodflowtosupplyneeded.Thisregulationisrelativelyindependentofthesystemiccirculationandisdeterminedbyregionalcerebralfunctionandmetabolism.The‘trinity’ofmetabolism–function–blood-flowofthebrain.SPECTstudiesofbrainperfusionusing99mTclabelledradiopharmaceuticals.Reflecttheregionalcerebralbloodflow(RCBF)distributionindifferentareas.13PrincipleThetracersusedmustbeabletocrosstheBBB.Radiopharmaceuticalswithbasicproperties

Lipophilia,Electricallyneutral,SmallmoleculeTheycanremainfixedinthebrainlongenoughtobeimagedbylossthelipophilicity.14Radiopharmaceuticals

AllarehighlylipophylicagentsfreelyabletocrosstheintactBBB

HMPAO(Technetium-99m-hexamethylpropylamine

oxime)ConverttoahydrophilicformunabletorecrosstheBBBECD(Technetium-99m-bicisateethylcysteinate

dimer)RetainedbecauseofhydrolysisofitsestergroupIMP(I-123-isopropyliodoamphetamine)Probablycombinedtosomereceptorsiteinthebrain15

IMPHMPAOECDLabelisotope123I99mTc99mTcHalf-life13.3h6.02h6.02hAdultdose(MBq)150-186555-1110555-1110LabelingisotopeNoteasytoobtainEasytoobtainEasytoobtainLabelingpreparationCostismuchRigorousrequireforelutriantNorigorousrequireLabelingrateHighHigherHighStabilityinvitroStableStablein30minStablein6hUptakerateofbrain5.0%-8.0%3.5%-7.0%4.6%-7.6%RedistributionYesNoNoConcentrationinbloodLowHighLowUsingNotagileAgileAgile16ProtocolsStoptakingcaffeine,alcoholorotherdrugsknowntoaffectcerebralbloodflow(CBF)atleast1–3daysbeforethestudy.Patientsshouldbeinstructedtoavoidsmokingforatleastthedayofthetest.Themostimportantaspectofpatientpreparationistoevaluateandensuretheabilityofthepatienttocooperate.Patientsshouldbemaximumcomfort.Patientsareplacedinaquietdimlylitroomwithnodirectlightsourcefacingtheireyes,keeptheireyesopenorcloseddependsoneachdepartment’sprotocol.17ImageAcquisition

MultipledetectorsordedicatedSPECTgenerallyproducesuperiorresultsthansingle-detectorgeneralpurposeunits.However,highqualityimagescanbeobtainedonsingle-detectorinstrumentswithappropriatelylongerscantimes(5milliontotalcountsormorearedesirable).Thesmallestpossiblerotationradiusisusedwithappropriatesafeguards.Theradiusofrotationshouldnotexceed14cm.185cm10cm15cm20cm25cm30cm1920ImageInterpretation

Normal&AbnormalImageAnormalSPECTimagerevealshomogeneousanduniformtraceraccumulationthroughoutthecerebralcortex,withthecerebellumbeingtheareawiththemostintenseactivity.Physiciansareusuallyalertedthatsomethingiswronginoneofthreeways:toomuchactivityinacertainareatoolittleactivityinacertainareaasymmetricalareasofactivity,whichoughttobesymmetrical2122ImageInterpretationAruleofthumbfortheinterpretationisthatasymmetrybetweenbothsidesofmorethan15%Anydecreasedperfusioninthecerebralcortexoflessthan70%ofmaximumuptakeispathological.23ClinicalIndications

DetectionandevaluationofcerebrovasculardiseaseManagementofapatientwithepilepsyEvaluationofpatientswithsuspecteddementiaEvaluationofbraintumorAnxietydisordersandaffectivedisordersAddictionsManagementofpatientswithschizophreniaManagementofpatientswithmovementdisorders……24ClinicalIndications

DetectionandevaluationofcerebrovasculardiseaseStrokeTransientischemicattacks(TIA)Subarachnoidhemorrhage(SAH)Arteriovenousmalformation(AVM)Otherderangementsofcerebralhemodynamics

…………25CerebrovascularDisease:StrokeBackgroundStrokeisthethirdleadingcauseofdeathindevelopedcountries.CTisnormallyconsideredthemostcriticalinitialtestinpatientswithacutestroke.MRIperfusiontechniquesareunderexploration.False-negativerates7-20%foracutestroke26CerebrovascularDisease:Stroke

Background

rCBFalterationsoccurearlierandareinitiallybetterdefinedthanstructuralchanges.8hafterinfarctiononly20%ofCTscanswillbepositive,whileapproximately90%ofSPECTrCBFscanswillbepositiveatthesametimeinterval.ThesizeofthelesiononSPECTisgenerallylargerthanthatonCTorMRI.27CerebrovascularDisease:Stroke

FunctionAbnormityLuxuryperfusionAbnormalhyperperfusionaroundtheinfarctfoci.CrosseddiaschisisWhenonesidecerebrumcortexhaslowordefectradioactivityareas,theothersidecerebrumorcerebellumhasfoci,too.28CerebrovascularDisease:Stroke

CASE:LuxuryPerfusion

History46yearmanAhistoryofhypertensionDifficultyspeakingandconfusion5hourspriortoadmission.CTshowedalargeleftmiddlecerebralarteryinfarct,withoutevidenceofbleeding.Tc-99mHMPAOSPECT29Transaxialslicesinredscale

Transaxialslicesingreenscale

Focallyincreasedperfusioninvolvinglefttemporalcortex

30Sagittal

slicesinredscale

Sagittalslicesingreenscale

Focallyincreasedperfusioninvolvingtheleftfrontalandleftparietalcortex

31CerebrovascularDisease:Stroke

CrossedCerebellar

Diaschisis

CASE:HistoryA72yearoldmanAdmittedwithsymptomsofstrokeTc-99mHMPAOSPECT32Transaxialslicesinredscale

Transaxialslicesingreenscale

LargeleftfrontalandtemporallobeperfusiondefectDecreasedperfusiontotherightcerebellarhemisphereLargeleftmiddlecerebralarterystrokewithcrossedcerebellar

diaschisis

3334CerebrovascularDisease

TransientischemicAttacks(TIA)60%TIAwillgoontohaveacompletedstrokeStructuralimagingcontributeslittletoTIAThevalueofrCBFToassesstheseverityofpersistenthypoperfusionToassesstheresponseofanischemicareatomedicineorsurgery.35

ThesensitivityofrCBFimaginginTIAistime-dependentFrom60%inthefirst24hTobelow40%1weedaftertheevent!CerebrovascularDisease

TransientischemicAttacks(TIA)36ClinicalIndications

Epilepsy

EpidemiologyEpilepsyisoneofthemorecommontypesofneurologicaldisease.Itaffects0.5%to1%ofpersonsTheonsetofepilepsyismorecommoninthefirstyearoflifeandafterage65Personswithaffectedfamilymembersaremorelikelytodevelopepilepsy

AncillaryDiagnosticTestsElectroencephalography(EEG):ThemostimportantdiagnosticstudyCTand,especially,MRIareindispensablestudiesforthedetectionofstructuralabnormalitiesofthebrainRevealpotentialcausesofepilepsy37NeuronuclearimagingPresurgical

ictaldetectionofseizurefocusLocalizationofseizurefocusDifferentialdiagnosisofictusInterictaldetectionofseizurefocusDeterminationofseizuresubtypesMonitoringtherapy……ClinicalIndications

Epilepsy

38ClinicalIndications

Epilepsy

Nuclearperfusionimage

Ictalhyper-perfusionInter-ictal

hypo-perfusion3940ClinicalIndications

DementiaEtiologyofdementiaAlzheimer’sdisease(AD)VasculardementiaForntotemporaldementia(Pick’sdisease)Huntington’sdiseaseParkinson’sdementiaDementiawithlewybodies……41Themostcommoncauseofdementia(50-70%)Alzheimer'sdiseaseischaracterizedbycorticalatrophy,ventricularenlargement,anexcessofsenileplaquesandneurofibrillarytangles.Clinically,thereisprogressiveanddiffuseimpairmentofcognitivefunctions,primarilyrecentmemorylossPathologyisthedeathanddisappearanceofnervecellsinthecerebralcortex,leadingtoextremeconvolutionalatrophy,especiallyinthefrontal,parietalandmedialtemporalregions.

ClinicalIndications:Dementia

Alzheimer’sdisease(AD)42Bilateralparietotemporal

rCBFreductionsRelativesparingofprimarysensorimotorandprimaryvisualcortexSparingofstriatum,thalamusandcerebellumInearlystages,deficitsoftenasymmetricbutdegenerationeventuallyisevidentbilaterallyClinicalIndications:Dementia

Alzheimer’sdisease(AD)43Dementia:AlzheimersDisease(AD)

Case1

CaseHistory

A64yearoldmanProgressivememorylossTc-99mHMPAOSPECTstudy44Transaxialslicesinredscale

IMPRESSION:

Reducedperfusiontothetemporalandtheinferiorparietalcortexbilaterally.Symmetricuptakeinthebasalgangliaandthalami.

45Sagittalslicesinredscale

IMPRESSION:

Reducedperfusiontothetemporalandtheinferiorparietalcortexbilaterally.Symmetricuptakeinthebasalgangliaandthalami.

46Coronalslicesinredscale

IMPRESSION:

Reducedperfusiontothetemporalandtheinferiorparietalcortexbilaterally.Symmetricuptakeinthebasalgangliaandthalami.

DifferentialDiagnosis:Alzheimer'sdiseaseParkinson'sdiseasewithdementiaIfParkinson'sdiseasecanbeexcluded,theprobabilityofAlzheimer'sdiseaseisgreaterthan90%withthispattern.47ClinicalIndications

Dementia

Vasculardementia(multi-infact)10%ofalldemetias

Hypometabolismandhypoperfusionaffectingcortical,subcorticalandcerebellarareas.Multipleasymmetricinavasculardistribution48Dementia:Multi-infarct(Vascular)

Case

HistoryA66yearoldmanMRIshowedanoldrightoccipitalCVATc-99mHMPAOSPECTstudy

49Transaxialslicesingreenscale

IMPRESSION:Perfusiondefectsinvolvinglateralfrontal,posteriorparietal,andposteriortemporallobesontheleftside.Perfusiondefectsinvolvinganteriorfrontalcortexbilaterallyandtherightposteriortemporalcortex.Thereisalsoasymmetryofthebasalganglia.

50ClinicalIndications

DementiaFronttemporalDementia(Pick’sdisease)5-10%ofalldementiasCharacterizedbycerebralatrophyandlobarsclerosis.Frontalcortex,anteriortemporalandmesiotemporalareasaffectedearlierRelativesparingofprimarysensorimotorandvisualcortex51Dementia:Pick'sDisease(LobarAtrophy)

CASE

HISTORYA63yearoldwomanAtwoyearhistoryofmemoryloss52Transaxialslicesingreenscale

IMPRESSION:Perfusiondefectinvolvingleftfrontalandtemporallobes.53Sagittalslicesingreenscale

IMPRESSION:Perfusiondefectinvolvingleftfrontalandtemporallobes.54Coronalslicesingreenscale

IMPRESSION:Perfusiondefectinvolvingleftfrontalandtemporallobes.55Dementia:Pick'sDisease(LobarAtrophy)

CASEDifferentialdiagnosis:Pick'sdisease(rareandrequireshistopathologyforconfirmation)Vasculardementia(requiresCTandMRcorrelation)DementiaofthefrontaltypeAlzheimer'sdisease(unusualdistributionbutpossible)Progressivesupranuclearpalsy(accompaniedbyocularsignsandbasalgangliainvolvement)56ClinicalIndications

Dementia:Huntington’sdiseaseBackground2%ofalldementiasCaudateandlentiformnucleiaffectedearly,withgradualdevelopmentofdiffusecorticalinvolvement57ClinicalIndications

Dementia:Parkinson’sDementia<5%SimilartoADSoresparingofmesiotemporalareaLesssparingofvisualcortex58Dementia:Parkinson'sDiseaseDementia(P.D.D.)

Parkinson’sdementiaAn88yearoldmanwithclinicalPDDTc-99mHMPAOSPECTstudy

59Transaxialslicesingreenscale

IMPRESSION:Bilateralposteriortemporalandparietalperfusiondeficits.Increasedbackgroundactivity.

60Sagittalslicesingreenscale

IMPRESSION:Bilateralposteriortemporalandparietalperfusiondeficits.Increasedbackgroundactivity.

61Coronalslicesingreenscale

DifferentialDiagnosis:Parkinson'sdiseasedementiaAlzheimer'sdisease62BrainFunctionResearch63Todifferentiatebetweenrecurrentbraintumorandradiationnecrosisisadifficultdiagnosticproblem.Neitherthesymptomsnortheconventionalradiographicfindingsclearlydistinguishtumorfromnecrosis.Samplingerrorinbiopsyingsuchlesionsmayleadtomisdiagnosis.AssessmentofRecurrentBrainTumorby18F-FDGPETandSPECTUsing201Tl,99mTc-MIBI,and99mTc-ECD64Background201TlSPECTchangesinbloodflow,BBBbreakdown,transmembranetransportintoviabletumorcellproportionaltoNa/KATPase99mTc-MIBISPECTelectronicpotentialacrossthecellmembrane,bloodflow,metabolicactivityofthecell18F-FDGPETIncreasedexpressionofglucosetransportermolecules,Increasedhexokinase,reducedglucose-6-phosphotaseInvitrostudies:VialblecancercellnumberarebestcorrelatedwithFDGuptakeinbraintumor.65CasepresentationClinicalhistory49y/ofemale89-4:LefthypothalamustumorfoundatKHVGH.MRI:T1W1:homogeneous,hypointensity,enhancement(-).Biopsycannotbeperformedduetothedeeplocation.89-6:arrangedR/Tpresumedlow-gradeglioma.(61.2Gy/34fractions)91-7:Rightsideheadache.MRIfoundanewlesioninrightfrontalandcorpuscallosum胼胝体region,measuringabout2cm.66TIWIhypointensitywithheterogenousenhancementT2WIedemaaroundthelesion67Casepresentation18F-FDGPETatVGH,TaipeiHeadandneckandbra