AUGUST, 1969

SERIAL BRAIN SCANNING WITH TECHNETIUM 99m

AND SCINTILLATION CAMERA*
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

By JYOJI HANDA, M.D., SACHIO NABESHIMA, M.D., HAJIME HANDA, M.D.,

KEN HAMAMOTO, M.D., TADAKO KOUSAKA, and KANJI TORIZUKA, M.D.
KYOTO, JAPAN

IT IS evident that the use of a scintilla- as a bolus. The scintillation cameraf was
tion camera and a short-lived radionu- set to image either the anteroposterior or
clide such as technetium 99 (TcI9m) has lateral view. The head was fixed to the
many advantages over the conventional table with an adhesive tape. Serial scinti-
scanner, particularly in brain scanning. It photographs were obtained immediately
permits the examination of severely ill, agi- after, 2 or 3, 5, 10, 15, 30, 5, 6o and, oc-
tated and uncooperative or young patients. casionally, 90 and 120 minutes after the
Multiple views are easily obtained, and, in injection, accumulating loX or i X 1o4
addition, a rapid imaging has made possible counts for each exposure. At the same inter-
serial scintiphotography. Utilizing this ap- val, accumulation for 6o seconds each and
proach, dynamics of an isotope bolus as it immediate read-out on the paper tape were
traverses the normal and pathologic vascu- performed with the memory scope and the
latures can be sequentially visualized.6’8 i ,6oo channel multiparameter analyzer. In
Furthermore, the read-out mode provided addition, rapid serial 3 or second expo-
by the I ,6oo channel analyzer permits dig- sures were obtained using a 35 mm. film.
ital assessment of the time course of isotope Determination of uptake ratio. From
uptake in multiple sites in the scintiphoto- among the serial scintiphotographs, the one
graph. Such a dynamic approach is ex- in which the focus was best demarcated was
pected to substantially increase the diag- selected and the corresponding paper tape
nostic accuracy in brain scanning. record of count rates was rearranged on the
In the present paper the results of serial sheet with a matrix of 40 by 40. Referring
brain scanning and analysis of the uptake to the scintiphotograph and the count rate
pattern by the use of a scintillation camera sheet,4 the uptake ratio was calculated as
and TcI9m are summarized. In some cases, follows:
xenon 133 (Xe133) and I’31-labeled macroag- F
gregates of human serum albumin (MAA- Uptake ratio = (arbitrary unit),
1131) were also used for brain scanning in an
attempt to determine the vascular charac-
where F= total counts in the matrix of 3
teiistics of brain lesions. by 3 which showed the highest count rates
in the focus B = total
and, counts in the
MATERIAL AND METHOD matrix of 3 by
3 which showed the lowest
count rates in the apparently normal brain.
The studies were performed on patients
under the care of the Department of Neuro-
Uptake ratios were calculated for the
rest of the serial scintiphotographs using
surgery, exclusively at the Central Radio-
isotope Division of Kyoto University Hos- the same co-ordinates for the 2 sets of 3 by
pital. 3 matrices, one for the focus and the other
for the normal brain.
TC9” SCANNING
MAA-1131 SCANNING
Tc9Im pertechnetate* in doses of 5 to Jo
MAA-I’31f in doses between 50 and 100
mc was injected into the antecubital vein
t Pho/Gamma Ill. Nuclear Chicago Co., Des Plaines, Ill.
*Dainabbott RI Laboratories, Tokyo. Macroscan- 131. Dainabbott RI Laboratories, Tokyo.

* From the Department of Neurosurgery and the Central Radioisotope Division, Kyoto University Medical School and Hospital.
Kyoto, Japan.

708
 VOL. io6, No. Serial Brain Scanning 709

J2c diluted with physiologic saline to 5 to XE SCANNING

JO cc. was injected into the carotid artery Xe133 II in closes of #{231}
to 10 mc dissolved in
employing a 19 gauge needle. The antero- 10 cc. of saline was injected into the carotid
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

posterior and lateral scintiphotographs of artery over a 30 second period. The scintil-
the head and the anteroposterior scintipho_ lation camera was set to image the antero-
tograph of the chest were obtained im- posterior or lateral view during the injec-
mediately after the injection. Map and pro- tion period. The count rates accumulated
file pictures and 1,600 channel count rate during this period were printed out in the
read-out data also were obtained. In sev- following 45 seconds. A second scintiphoto-
eral cases, MAA-I’3’ scanning was per- graph and accumulation were obtained for
formed by the use of a conventional recti- the next 30 seconds (75-105 seconds after
linear scanner. the onset of injection) and a print-out was
When injected into the vessels, macro- made during the following 45 seconds. The
aggregates of human serum albumin are procedures were repeated, covering a period
filtered out by the capillaries of the target of 15 to 20 minutes.
organ. If the aggregates labeled with I’s’ A 35 mm. film was exposed at the speed
are injected into the internal carotid ar- of I frame for each 30 second period. The
tery, their accumulation in the brain can whole series covered a period of 12 to i8
be externally collimated, and their distri- minutes starting from the onset of injec-
bution is expectedly proportional to the tion.9
volume of perfused capillary bed of the
brain.3’7 RESU LTS

Thus, it seems evident that the hot focus 5ERIAL TCSSm SCANNING

in a MAA-I’3’ scintiphotograph indicates The chronologic patterns of the serial

a high vascularity in the lesion. When a scintiphotographs are classified 3 into
considerable size of arteriovenous short- types. Type I lesion characterized
is by
circuit exists in the focus, a corresponding the maximum uptake in the earliest phase
amount of MAA-I’3’ is shunted away followed by a gradual decrease. Meningi-
through the fistula, and the focus may not
omas, arteriovenous anomalies and he-
be hot, but may appear cold. In this event, mangiomas belong to this type. In Type II
however, a shunted part of MAA-I’3’ is lesion the focus becomes progressively more
eventually entrapped in the pulmonary dense. This is observed in gliomas, sarco-
vascular bed and can be detected easily by mas, cerebral infarctions, brain abscesses
scanning the chest. and most of the metastatic carcinomas.
In the present study, the following as- Type III lesion consists of a persistently
sumptions are made: when the brain and cold focus and is experienced in intracere-
pulmonary scannings are performed follow- bral hematoma and cystic lesions.
ing the intracarotid injection of MAA-I’31, Figure I, 11-D represents a series of lat-
a hot focus in the brain represents a densely eral scintiphotographs in a case of arterio-
vascularized lesion, and a cold brain focus, venous malformation. The arteriovenous
without significant radioactivity in the anomaly in the right sylvian region and
lung, suggests a lesion with poor vascu-
drainage vessels, mainly the posterior por-
larity. High radioactivity in the lung, ir- tion of the superior sagittal sinus and the
respective of whether the brain focus is hot torcular Herophili, were well shown by in-
or cold, indicates the existence of arterio- creased radioactivity in the i minute scinti-
venous shunts in the territory of supply photograph (Fig. IA). A few minutes later,
of the injected artery, or most probably in a scintiphotograph (Fig. IB) became
the pathologic lesion. equivocal, showing a moderate concentra-

§ Scintillation Scanner Type 5CC-3o. Shimadzu Co., Kyoto. II Xeneicnl- 133. Union Carbide Co., Tuxedo, N. Y.
 710 I landa, Nal)eshima, Handa, Hamamoto, Kousaka and Torizuka AUGUST, 1969
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

lic. i. ‘Fe” serial scans of arteriovenous malformation in the right sylvian region.
Right lateral view. Note
that the highest radioactivity in the malformation and drainage vessels is seen the 0-I minute
in scinti-
photograph (1). (B) 5-6, (C) 60-61, and (D) 120-12 I minutes after the intravenous injection of iO mc of
Tc9911’.

tion of tracer in the torcular Herophili normal concentration of radioactivity

region. Later scintiphotographs (Fig. i, C showed an acute decrease, and later scinti-
and D) were essentially normal. photographs tended to normalize rapidly.
Figure 2 illustrates 3 second serial expo- In meningiomas and cavernous angioma,
sure records in the same patient. The arterio- the chronologic pattern of serial scintipho-
venous malformation and drainage vessels tographs is essentially similar to that of
were best shown during the initial cerebral arteriovenous malformation. The meningi-
circulation of Tc91’ injected as a bolus. oma appears immediately or shortly after
Arteriovenous malformations are best the intravenous injection of Tc99” as a lo-
demonstrated in the earliest scintiphoto- calized, dense and homogeneous focus with
graphs taken following a rapid intravenous a clear margin. After this, the focus loses
injection of Tc99”. Although the angio- its high radioactivity more or less rapidly,
graphic studies which provide precise mor- but the lesion generally remains distinct
phologic information, such as the type, at the end of the serial studies covering 6o
size and location of the lesion or the anat- to 120 minutes after the injection (Fig. 3,
omy of the niain feeding and draining 4-F). In some cases, however, the fall in
vessels, are indispensable for the diagnosis radioactivity is so rapid that the lesion
of cerebral arteriovenous malformations, practically disappears in 6o to 120 minutes,
all of the 7 cases in the present series as illustrated in Figure 4, A-D.
showed a definite abnormality in the scinti- Angiographic and histologic studies show
photographs taken immediately after ad- that no exact parallelism exists between the
ministration of Tc9Im. Thereafter, the ab- intensity of radioactivity in the focus and
 \OL. io6, No. Serial Brain Scanning 711
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

FIG. 2. Three second serial exposure records in the same case as in Figure i.
Right lateral view.

the vascularity of tumor. uallv increased and the scintiphotographs

Astrocytomas and oligodendrogliomas after 30 minutes showed a clear active focus
show the pattern of progressive accumula- (Fig. 5, D-F).
tion of radioactivity. Figure , 1-F illus- A similar pattern is noted also in cerebral
trates a series of scintiphotographs in a infarction, as illustrated in Figure 6, zI-F.
case of astrocytoma. Initially, the scinti- A carotid angiogram showed an avascular
photographs were equivocal (Fig. 5, 4 and focus in the right occipital region. The
B); i#{231}
minutes later, however, a blurred scintiphotograph obtained i minute after
uptake was noted in the central region injection (Fig. 61) showed that the cold
(Fig. SC). Following this, the uptake grad- central focus in the occipital region was
 712 Handa, Nabeshima, Handa, Hamamoto, Kousaka and Torizuka A Si, 1969
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

11G. . TcSsm serial scans of frontal parasagittal meningioma. Anteroposterior view. Note the sharply de-
marcated, dense, homogeneous focus characteristic of meningioma. (1) 0-I, (B) -6, (C) i-i6, (D) 30-31,
(F) 6o-6r, and (F) 90-91 minutes after the intravenous injection of 10 mc of Tc”.

surrounded b a zone of increased radio- gressive accumulation of radioactivity, in

activity which apparently corresponded to serial scintiphotographs. An exception was
the perifocal hvperemic area observed on the case of oligodendroglioma in which the
the angiogram. With time, the central focus serial scintiphotographs showed a rather
of softening slowly became impregnated regressive accumulation in the focus (Fig.
(I’ig. 6, B-F), and reached the maximum 10, 4-F; ii’ in Fig. 12; and Fig. 13C).
intensity at the end of the serial studies, Carotid angiography in this particular case
I 20 minutes after the intravenous admin- demonstrated a highly vascular midline
istration of Tc” (Fig. 6F). tumor with arteriovenous shunts.
Glioblastom as and sarcomas usually pro- In T\’pe III lesions the focus remains
duce early and active foci, but the radio- cold throughout the course of the serial
activity, unlike that of meningiomas, seems studies. Figure i I, 4, B and C demon-
to increase with time (Fig. 7, 4-F). In strates Tchim, MAA-P3’ and Xe13’ scinti-
carcinomas the results are less uniform. A photographs in a case of frontal intracere-
pattern of progressive increase in uptake bral hematoma due to ruptured angio-
was seen in most of the cases (Fig. 8, 4- matous malformation. The focus was per-
F). In a few cases, however, the uptake sistently cold in the serial TcSSm studies.
decreased with time (Fig. 9, 4-F).
FOCUS-TO-I1RAIN U1FAKE RATIO
In gliomas, the foci are sometimes dense
and uniform but more frequently the are The uptake ratio patterns are classified
ill-defined and have irregular margins. Gli- into 4 main groups. Characteristic samples
omas in general showed a pattern of pro- are illustrated in Figure 12.
 \OL. ic6, No. Serial Brain Scanning 713
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

--

-. .7

..-

- ---i.- -- ‘- -; #{149}--: .. : - ;.

‘1 #{149}-
.a--
--i: - -S.-.- - -
S. ‘.. - - / - -., -

11G. . Tc” serial scans of parasagittal meningioma. Left lateral view. Note the rapid fall of radioactivity in
the successive studies. (1) 0-I, (B) 20-2!, (C) 60-61, and (D) 120-121 minutes after the intravenous injec-
tion of JO mc of TcSSm.

In Group i, the uptake ratio showed the In 8 out of 10 cases of meningiomas and
highest value immediately or shortly after cavernous angioma, the uptake ratio
administration of Tcuim, then it decreased showed an initial increase, reached the
more or less rapidly. This group corre- maximum in minutes (6 cases) to io-i
sponds to Type I focus in the visual classi- minutes (2 cases), then decreased (i-b in
fication of serial scintiphotographs, and in- Fig. 12). In i case of meningioma, the up-
cludes the arteriovenous malformations, take ratio was maximum immediately after
meningiomas and cavernous angioma. injection. The remaining case of meningi-
In all 7 cases of arteriovenous anomalies, oma was unusual in that the uptake ratio
the uptake ratio showed the maximum showed a gradual increase throughout the
value immediately after the intravenous course of serial studies up to 6o minutes
injection of Tcuutk (o-i minute read-out), (Fig. i3B).
decreased rapidl\?, and reached the plateau As far as the uptake patterns are con-
in to 15 minutes. The uptake ratio there- cerned, Type II foci with progressive accu-
after remained essentially unchanged (i_a mulation of radioactivity are subdivided
in Fig. 12; and Fig. 134). The maximum into 2 groups (Groups ii and iii).
value of uptake changed widely, ranging In Group ii, the uptake ratio tended to
between 1.5 and 6.o. increase linearly during the course of serial
 714 Handa, Nabeshima, Handa, Hamamoto, Kousaka and Torizuka AUGUST, 1969
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

FIG. . TcsSm serial scans of astrocytoma. Left lateral view. Note the progressive accumulation of radio-
activity. (4) 0-1, (B) 5-6, (C) 15-16, (D) 30-3 i, (E) 60-61, and (F) 120-121 minutes after the intravenous
injection of io mc of Tc99”.

studies or reached the plateau in 30 to 6o 12). It is interesting to note that the pre-
minutes (ii in Fig. 12; and Fig. 13C). This operative diagnosis in this case was an ol-
type of uptake was observed in benign gli- factory groove meningioma extending into
omas and cerebral infarction, except for the ethmoid cells. The tumor showed an
the i case of oligodendroglioma illustrated abundant blood supply from the hyper-
in Figure 10, 4-F. In this particular case, trophied ophthalmic artery and the homo-
the uptake followed a regressive course geneous tumor stain remained in the ve-
much the same as in an arteriovenous mal- nous phase of the angiography, although the
formation (ii’ in Fig. 12). demonstration of arteriovenous fistulas
Group in comprises the glioblastomas, might have been atypical of meningioma.
metastatic carcinomas and sarcomas. The Group iv focus corresponds to Type III
uptake ratio showed an initial increase lesion in serial scintiphotographs. Spon-
similar to that in Group II foci, but this was taneous intracerebral hematoma is an ex-
followed by a decrease. The maximum ample of this group of uptake pattern
value of uptake was reached usually in 30 (Fig. ii, 4, B and C; and iv in Fig. 12).

to 45 minutes after an intravenous dose of The focus continued to be cold during the
Ic99” (iii in Fig. 12; and Fig. i3D). In I ex- course of study and the uptake ratio re-
ceptional case of ethmoid cell carcinoma mained below I .0 with negligible fluctu-
extending intracranially, the uptake ratio ation. Type III foci were observed also in
showed a regressive course similar to a brain abscesses and cystic tumors. Un-
meningioma (Fig. 9, 4-F; and III’ in Fig. fortunately, serial read-out data were not
 \OL. io6, No. Serial Brain Scanning 715

I -f .1

:i. T-’
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

. - -‘ - - - *

#{149}:- -

-- . ---

-- - - I -‘

.-
‘--5
#{149}1 S

- . S.

.i#{149}’ .,,..;..
-a

FIG. 6. Tc99m serial scans of cerebral

infarction. Right lateral view. Note the cold focus in the occipital region
surrounded by a zone of high
radioactivity in 1 (0-I minute scintiphotograph). Progressive accumulation
of radioactivity was observed in later studies. (B) i-i6, (C) 30-31, (D) 45-46, (F) 66i, and (F) 120-
121 minutes after the intravenous injection of 10 mc of Tc99”.

available in these cases, but it seems ap- circuits in the tumor (Fig. 14, 4, B and C).
parent that the uptake ratio, if it were de- Since meningiomas are generally supplied
termined, should have remained less than mostly by the external carotid branches,
the unit. the tumor, which showed a typical re-
gressive pattern in Tc99” serial studies, may
MAA-1131 AND XE133 SCANNING
appear cold in either MAA-I’3’ or Xe”
In arteriovenous anomalies, the focus scans, if the injection is made not into the
was cold in MAA-I’3’ scans. The pulmo- external but into the internal carotid ar-
nary scan always demonstrated the passage tery.
of a large amount of MAA-I’3’ to the lungs. In most of the cases with Group ii and iv
In Xe’33 scanning, the focus was hot during lesions, the focus was poorl vascularized
the 30 second period of intracarotid injec- as judged by MAA-P” and Xe” brain
tion, but the clearance was so rapid in the scans. A composite picture of Figure II
focus that it became cold in the second illustrates a case of spontaneous intracere-
scintiphotograph. bral hem atom a. As
described previously
In meningiomas, MAA-I” brain scan- the focus remained cold, and the uptake
ning showed a hot focus when the feeding ratio was approximatel\’ o.8 during the
artery was punctured. In some cases posi- course of serial TcIIm studies. In Xe’3’
tive lung scans were obtained also, suggest- scanning, the focus was definitely cold dur-
ing the existence of arteriovenous short- ing the 30 second period of intracarotid in-
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

Ia.1 ti. S. Tcem serial scans of metastatic carcinoma in the left paras'agi ttal region. .An teroposterior view. (A)
* I , (R) 5-6, (C) 30-3 I, (D)6 - 6 1 , ( E ) p 9 1 ,and (F)I 20-1 21 minutes after the intravenous injection of
ICb mc of Tcg".
 VOL. io6, No. Serial Brain Scanning 717
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

FIG. 9. Tc”m serial scans of ethmoid cell cancer extending intracranially. The initial high radioactivity in the
focus decreased with time. (4) 0-I, (B) 15-16, (C) 30-3 i, (D) 45-46, (F) 6o-6i, and (F) 120-121 minutes
after the intravenous injection of 10 mc of Tc’9”.

jection, and the wash-out was slower in the graphic findings. The considerable radio-
focus than in the surrounding normal activity n&ed in the lung also supported
brain. MAA-I” scans also demonstrated the angiographic demonstration of arterio-
the focus to be low in radioactivity. venous fistulas in the tumor.
Figure 15, A-D is an example of Xe”
DISCUSSION
serial scanning in another case of right
frontal cystic tumor. The focus remained It has been reported by several authors
cold during the serial scannings with Tc99’. that the morphologic and cbronologic pat-
Carotid angiograms showed an avascular, terns of isotope uptake differ from one type
cystic mass. A cold focus in the Xe” scans of lesion to another.
also supported the diagnosis of cystic Schlesinger, DeBoves and Taveras’#{176} re-
tumor, which was velifled later b\’ oper- ported the results of repeat brain scanning
ation. with RISA-I”. Lesions with abundant
In the case of a highly vascularized oh- blood suppl\ and unique hvpervascularity,
godendroglioma illustrated in Figure 10, such as arteriovenous anomalies and angio-
4-F, the uptake of Tc99’ showed a regres- blastic meningiomas, were best seen imme-
sive and not progressive accumulation of diately after injection. Meningiomas gen-
radioactivity as described previously. Ac- erally appeared by 24 hours after injection
cumulation of a large amount of MAA-I” and were most vivid within this period,
in the tumor was in good agreement with whereas ghiomas appeared at 24 hours but
the TcIIm scan pattern as well as the angio- became more obvious by 48 hours. Avascu-
 718 Handa, Nabeshima, Handa, Hamamoto, Kousaka and Torizuka AUGUST, 1969
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

11G. 10. Highly vascular oligodendroglioma. (A) Anteroposterior and (B) right lateral views of a Tc99m scan
depict the hot focus. (C) Anteroposterior and (D) right lateral views after the intracarotid injection of ioo
ic of MAA-P3’ show the rich vascularity of the tumor (arrows in D). (E) 0-30 second and (F) 75-105
second scintiphotographs after the intracarotid injection of io mc of Xe. Rapid washout suggests high
tumor blood flow. TcSsm serial scanning showed a regressive accumulation of radioactivity.

lar astrocytomas were poorly demon- with RISA-I”, Planiol’ classified the radio-
strated, and cystic lesions began to appear active foci into 4 main categories. The
in the late scan series and were best de- early and clear focus corresponded to a
lineated after 48 hours. Budabin’ also meningioma in 74 per cent of the cases. In
stressed the importance of early scanning the delayed and blurred focus, 63 per cent
in arteriovenous malformations using ei- were glioblastomas and 62 per cent were
ther RISA-I” or chlormerodrin-Hg197 as astrocytomas, whereas 71 per cent of met-
tracers. asta tic lesions showed the delayed and clear
Based on the numerical data obtained focus. The early and blurred type was the
 \OL. io6, No. Serial Brain Scanning 719

1 -
-f ..
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

--
--S

“:

---

focus was cold during injection and the washout was slow. These results suggest that the focus is poor in
vascularitv and 1)100(1 flow.

least frequently seen, and was found mostl time, and the foci often remained clear for
in gliomas. 24 hours or more. Abscesses, infarctions and
Economos and co-workers2 described the intracerebral hematomas also showed a
results of serial scanning with chiormero- progressive increase in radioactivity, but
drin-Hg20’ or Hg’97. In meningiomas, the the uptake was much lower than in the
maximum uptake occurred early; i.e., 1-2 gliomas.
hours after injection. After this the foci Our results with TcIIm serial scanning
lost their activity progressively and more compare favorably with these previous
or less rapidly. Gliomas could produce the studies. The uptake of TciIm may be either
early foci, but their uptake increased with progressive or regressive. The regressive
course of accumulation was observed most
often in arteriovenous malformations, men-
0 ingiomas and cavernous angioma. Few
I- cases of glioma and metastatic carcinoma
showed the regressive pattern. In contrast,
w gliomas, metastatic carcinomas, sarcomas,
abscesses and cerebral infarction showed
I-
the progressive accumulation of radio-
activity. The intracerebral hematomas and
cysts comprised another type of lesion and
demonstrated a persistently cold focus.
When the uptake ratios were determined
by use of the i ,6oo channel analyzer, how-
ever, the chronologic course of uptake
seemed to differ in arteriovenous malfor-
11G. 12. Characteristic samples of uptake ratio
mations from meningiomas. In arterio-
patterns: I-a. Arteriovenous malformation. i-b. venous anomalies, the uptake ratio was
Meningioma. II. Oligodendroglioma, astrocvtoma maximum immediately after injection,
and cerebral infarction. III. Glioblastoma, car- whereas in the majority of meningiomas,
cinoma and sarcoma. iv. Intracerebral hematoma.
the maximum uptake was reached 5 to 15
ii’ represents an atypical case of oligodendro-
glioma (Fig. 10, 4-F), and III’ an unusual case of
minutes later. Similarly, the lesions which
carcinoma, both of which showed a regressive pat- showed progressive accumulation of radio-
tern of uptake. activity in serial scintiphotographs also ex-
 720 Hancla, Nabeshima, Handa, Hamamoto, Kousaka and Torizuka AUGUST, 1969

A B
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

LU LU

0.

0 30 60 90 12OMIN.
nv. TIME

C D
so
0 0
I-
<4.0

LU LU
: 3.0

a-

0 30 60 - 90 - l2OMIft 0 30 60 90 120 M1L

i iv. TIME I LV. TIME

FIG. 13. Diagrams showing the uptake curve in: (4) Arteriovenous malformations, (B) meningiomas and
cavernous angioma, (C) astrocytomas, oligodendrogliomas and cerebral infarction, and (D) glioblastomas,
carcinomas and sarcomas.

hibited different behaviors. In one group that the radioactivity in the focus is mainly
the uptake ratio was low initially and in- due to a large quantity of blood pool in the
creased steadily or reached the plateau dur- anomalous vessels. Meningiomas and cav-
ing the period of study, but it never de- ernous angioma demonstrated the typical
creased. In the other group, the uptake tumor vasculature on the angiograms, and
ratio, after reaching the highest value in the Xe133 scan clearly showed the increased
30-45 minutes after injection, showed a tumor blood flow. A large amount of MAA-
gradual decrease, although the ratio at the 1131 was entrapped in the tumor, and in
end of the study remained still higher than several cases lung scanning also proved the
the initial value. Persistently cold foci com- existence of arteriovenous shunts. In the
prised the last group in which the uptake exceptional cases of glioma and metastatic
ratio never exceeded the unit. lesion which showed regressive patterns of
Since no case of arteriovenous malfor- uptake, carotid angiography demonstrated
mation in the present series had a recent tumors with extremely high vascularity.
hemorrhage or seizures, it seems apparent Xe’33 and MAA-I’3’ studies also suggested
 \OL. io6, No. Serial Brain Scanning 721
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

I-Il;. 14. (1 and B) Brain

/
md (C) lung
B
‘,
scans after injection of 100 ic of
MAA-1 - into the conu mon carotid
* I i

- artery in a case of sphenoid ridge

S -* meningioma. Note the accumula-
tion of a large amount of 1.A.A_P3i
in the tumor (arrows) and poor
perfusion of the hrain proper. A
posi ti se 1u rug scan dem (inst rates
tile existence of a rteri )ven( us
shunts- -a fact which was verified
j)\* carotid angi )gra phv.

C
the increased blood flow and a large vascu- Xe” and MAA-I” studies also supported
lar bed with or without arteriovenous this finding. In this group of lesions, local
shunts in the tumor. It seems plausible, breakdown or lack of a barrier mechanism
therefore, that the regressive pattern of up- might be the main factor responsible for
take depends primarily on the increased progressive accumulation of Tc99’; how-
blood pool in the focus and not necessarily ever, this remains to be studied further.
on the pathology of the lesion itself. In One case of cerebral infarction is of
cases where the large blood pool is the main, special interest in that the central focus
if not the only, mechanism of radioactivity, showed a typical progressive uptake,
then the chronologic course should follow whereas the perifocal hyperemic zone al-
the pattern of arteriovenous anomalies ready was impregnated in the early scinti-
(Group i_a), as has been suggested by photographs (Fig. 6, 4-F). The central
Budabin.’ In most of the meningiomas and softened focus and richly perfused perifocal
other highly vascularized tumors, however, area had apparently separate and indepen-
there seems to exist another additional dent mechanisms for isotope uptake.
mechanism of isotope uptake, which modi- The results of Xe”3 and MAA-I” scan-
fies the uptake curve in a varying degree ning were less uniform in Group iii focus,
(Group i-b). but the lesions which showed the focal
In the Group ii foci with progressive accumulation of MAA-I” and a rapid
accumulation of radioactivity increased clearance of Xe”3 also demonstrated a high
blood pool does not seem to play any sig- degree of tumor vasculature on angiog-
nificant role in the isotope uptake. Tumor raphy. The uptake of TcIIm resembles that
stain was never observed on angiograms; in Group II; however, the secondary de-
instead, the focus tended to be avascular. crease in uptake which is characteristic of
 722 I landa, Nabeshima, Handa, Hamamoto, Kousaka and Torizuka AUGUST, 1969
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

-
-.

o
-a

-
.0_
-

- - -
-:
-
-.(-.‘..

t E
Fig. 15. Xem scans in a case of cystic tumor in the right frontal lobe. Low blood flow in the focus was sug-
gested by the cold focus during injection of 10 mc of Xe” (4) and slow washout thereafter. (B) 75-105, (C)
150-ISO, and (D) 225-255 second scintiphotographs.

this group may be due to the vascular the scan data. The use of computer analysis
factor. It is interesting to note that the seems to be promising.
lesions which showed the uptake pattern of
SMRY
initial increase followed by decrease were
malignant tumors without a single excep- i. Serial brain scanning with gamma-
tion. ray scintillation camera and TcIIm per-
In Group iv lesions, X&” and MAA-I” technetate was performed and the chrono-
studies clearly showed the decreased blood logic patterns of serial scintiphotographs
flow and vascular bed in the focus, and in were related to the pathology.
Tc99” scanning the uptake ratio remained Regressive accumulation of radioactivity
less than a unit. All these scan data sug- of the focus was observed in arteriovenous
gested that the focus should be avascular, anomalies, meni ngiomas and angiom a,
and this was confirmed later by angiog- whereas the gliomas, metastatic carcino-
raphy and surger’. mas, sarcomas, infarctions and abscesses
Thus, it is concluded from the present showed a progressive course of isotope up-
study that the vascularity and blood flow take. In intracerebral hematomas and cys-
in the focus are the important factors in de- tic tumors the focus remained persistently
termining the time course of uptake in cold.
TcIIrn serial scanning. A more precise pre- 2. Chronologic patterns of the uptake
diction of tumor pathology seems to be pos- ratio were determined digitally and classi-
sible when the morphologic characteristics fied into 4 groups. In Group i, the uptake
of the focus are combined with the time ratio was maximum immediately or shortly
course of the isotope uptake in analyzing after injection and then decreased rapidly.
 VOL. m6, No. Serial Brain Scanning 723

In Group ii the uptake ratio showed a Congress Neurological Surgery, Excerpta

Medica Foundation, Amsterdam, 1966, pp.
gradual increase. In Group in, an initial in-
590-598.
crease was followed by a decrease, and in 3. HANDA, J., IWAYAMA, K., YONEKAWA, Y.,
Downloaded from www.ajronline.org by 114.120.234.250 on 04/15/16 from IP address 114.120.234.250. Copyright ARRS. For personal use only; all rights reserved

Group iv, the uptake ratio remained below Y05HIDA, Y., and HANDA, H. Use of MAAI’3’
1.0. in cerebral arteriovenous fistulas. AM. J.
3. Xe’33 and MAA-I’3’ scanning data ROENTGENOL., RAD. THERAPY & NUCLEAR
MED., 1968, zo, 18-28.
showed that the Group i lesions were rich
4. MACINTYRE, W. J., CHRISTIE, J. H., and CURTIS,
in vascular bed and had a high blood flow in G. S. Three-dimensional computer read-out
the focus. Group ii and iv lesions were of radioisotope scan data. Radiology, 1968, 90,
avascular and Group iii foci showed a less 22-26.

uniform vascular pattern. 5. PLANIOL, T. Gamma-encephalography after ten

Frog.
. It is concluded that the tumor vascu- years of utilization in neurosurgery.
Neurol. Surg., 1966, I, 93-147.
larity plays an important role in determin-
6. ROSENTHALL, L. Applications of gamma-ray
ing the regressive course of uptake of Tc99m. scintillation camera to dynamic studies in
Another mechanism of isotope uptake, man. Radiology, 1966, 86, 634-639.
presumably local breakdown or lack of 7. ROSENTHALL, L., AGUAYO, A., and STRATFORD,
barrier mechanisms, seems to be the main J. Clinical assessment of carotid and vertebral
artery injection of macroaggregates of radio-
factor in Group i I and i i i uptake patterns.
iodinated albumin (MARIA) for brain scan-
Joyoji Handa, M.D. ning. Radiology, 1966, 86, 499-505.
Department of Neurosurgery 8. ROSENTHALL, L. Detection of altered cerebral
Kyoto University Medical School arterial blood flow using technetium-99m
Sakyo-ku, Kyoto, Japan pertechnetate and gamma-ray scintillation
camera. Radiology, 1967, 88, 713-7 18.
REFERENCES 9. ROSENTHALL, L., MATHEWS, G., and STRATFORD,

1. BUDABIN, M. Diagnostic value of RIHSA and J. Radioxenon brain scanning with gamma-ray
chlormerodrin ‘97Hg brain scanning in intra- scintillation camera. Radiology, 1967, 89, 324-

cranial arteriovenous malformations. 7. Nu- 328.

clear Med., 1967,8, 879-890. 10. SCHLESINGER, E. B., DEBOVES, S., and TAVERAS,
. ECONOMOS, M., PROSSALENTIS, A.,and LEVEN- J. Localization of brain tumors using radio-
‘ris, A. Value of scanning with Hg203 in es- iodinated human serum albumin AM. J.
tablishing histological nature of expanding in- ROENTGENOL., RAD. THERAPY & NUCLEAR
tracranial processes. Proc. III. International MED., 1962, 87, 449462.