Central Nervous System

CENTRAL NERVOUS SYSTEM
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IMAGING
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CENTRAL NERVOUS SYSTEM IMAGING CLASSIFICATION

IMAGING
CLASSIFICATION
Brain Imaging Cerebrospinal

Fluid Imaging
BRAIN
BRAIN
IMAGING
IMAGING
CENTRAL NERVOUS SYSTEM IMAGING BRAIN IMAGING
TYPES OF BRAIN IMAGING
1. Planar Brain Imaging
2. SPECT Brain Imaging
3. PET Metabolic Brain

Imaging
1. Planar Brain Imaging
Which use radiopharmaceuticals that excluded

from normal brain tissue by the blood-brain
barrier and localize only in pathologic
processes that disrupt this barrier.
2. SPECT Brain Imaging
Which uses lipophilic radiopharmaceuticals that

routinely cross the blood-brain barrier to localize in
normal brain tissue and pathologic processes in
proportion to cerebral blood flow.
This is the most commonly used radionuclide brain

imaging technique .
3. PET Metabolic Brain

Imaging
Which uses functional positron-emitting

radiopharmaceuticals, such as radiolabeled
glucose, and neuroreceptor imaging.
PET techniques are not yet widely available in

clinical practice but show great promise.
Regional
Regional
Cerebral
Cerebral
Blood
Blood Flow
Flow
Tomography
Tomography
CENTRAL NERVOUS SYSTEM IMAGING REGIONAL CEREBRAL BLOOD FLOW
1. Principle
1. To use the radiopharmeceutical which can pass
through the Blood Brain Barrier (BBB).
—Lipophilic Electrically�neutral��Small�molecular�
weight
2. The amount of radiopharmeceutical that entering

cerebral tissue dependent on two factors:
A. the quantity of cerebral blood flow
B. the cerebral function
3. SPECT can display the distribution of activity of the
radiopharmeceutical and produce rCBF images.
2. Radiopharmeceuticals
The characters which the ideal
radiopharmeceuticals should be have:
1) It can pass through the BBB freely
2) it can be maintained in brain for 99mTc
enough long time.
3) the distribution in brain is definite.
99mTc-ECD ( 99mTc –ethyl-cysteinate dimer )
99mTc-HMPAO ( 99mTc -hexamethyl-propyleneamine oxime )

123I-IMD ( 123I-N-isopropyl-P-iodoamphetamine)
The characters which the ideal radiopharmeceuticals

should have
1) It can pass through the BBB freely: It is lipophilic，electrically�
neutral，small�molecular� weight, so it can cross the BBB and
localize in brain tissure.
2) It can be maintained in brain for enough long time. Once the
radiopharmeceuticals enter into the brain cell, their physical
character is changed from liposolubility to watersolubility. So they
can stay in brain for a long time.
3) The distribution in brain is definite.（ White� matter,� gray�
matter）
3. Methods
1) 30min to 60min before the test, patients should take KclO4
( Perchlorate) orally in order to prevent thyroid and choroids
plexuses to uptake the radiopharmeceutical.
2)� External sensory stimulus, such as pain, noise, and light, as well as
patient motion should be minimized.�
3) Five minutes after step 2), the radiopharmeceutical is
administrated through bolus intravenous injection.
4) A Nuclear Medicine instrument should be used at the same
time, and Regional Cerebral Blood Flow Tomography is obtained.
2)� External sensory stimulus, such as pain, noise, and light, as

well as patient motion should be minimized.
The patients should be stay in a room alone, with

eyeshield against light, with earplug against noise
and so on. The purpose of doing like this is trying to
minimize the external sensory stimulus.
Normal rCBF Tomography
1. the increased radioactivity in the cortical gray matter (hyperperfusion)

2. the decreased radioactivity in the cortical white matter (hypoperfusion
the blood flow in the gray matter is four fold greater than in the white
matter
3.no radioactivity in ventricles (no perfusion).
4. the radioactivity of two sides is symmetric.
Gray�matter white�matter

Post
Ant
Coronal Imaging

Left
Right
Sagittal Imaging

Top
Normal rCBF Tomography Bottom
Transaxial Imaging
Abnormal rCBF Tomography

1.Decreased activity or
defects in regional brain
The number of decreased activity areas or defects can be single
or multiple in cerebral cortex or in the cortical gray matter.
Common Diseases: TIA (Transient Ischemic Attack ), cerebral
infarction, cerebral hemorrhage, epilepsy between seizures, between
migraine attacks, brain abscess, brain tumors.
Normal rCBF Tomography Abnormal rCBF Tomography

REGIONAL CEREBRAL BLOOD FLOW ABNORMAL rCBF TOMOGRAPHY
2. Crossed Cerebellar Diaschisis

When the decreased activity or defect appears in one side
cerebral cortex, the contralateral cerebellar also shows decreased
activity. The mechanism appears to be an interruption of the
corticopontine-cerebellar pathway, but now this mechanism is
not very clear.
Common Diseases:
cerebrovascular disease, cerebral infarction
Normal rCBF Tomography Abnormal rCBF Tomography

3.Increased activity in regional brain

Single or multiple increased activity areas in
cerebral cortex or in the cortical gray matter.
Common Diseases:
epilepsy during seizures,
migraine�during the period of attack�, brain tumors.

4. Luxury perfusion:
The surrounding areas which locate nearby
the ischemia focus show increased activity. 正常对照
Common Diseases:
the areas which nearby
the focus of cerebral
infarction during the
subacute phase .

5. The larger size of the cortical

white matter and the deflection of
the brain midline
It is manifested on imaging by decreased activity in regional
brain with the larger size of the cortical white matter Normal rCBF
Tomography
and the deflection of brain midline.
Reason: Some pathologic changes

lead to the brain tissue ischemic,
edematous, and pressed
Common Diseases:
cerebral infarction
cerebral hemorrhage
brain tumor Abnormal rCBF Tomography
6. Indistinguishable Brain
Structure
The distribution of activity in
brain is disorder
Common Diseases:
head trauma,
brain ischemia,
blood brain barrier is damaged.
7. Ectopic Activity
Some activity is seen outside the brain, such
as, nasal cavity, lateral ventricle, scalp.
Common Diseases: cerebrospinal fluid
fistula, subdural hematoma, subarachnoid
hemorrhage.
8.Encephalatrophy
The cerebral cortex becomes
thinner
Diffusible decreased activity
in cortical gray matter
The size of ventricle and the
cortical white matter is bigger.
Common Diseases:
encephalatrophy,
dementia(depression in an
advanced stage)
Clinical application of rCBF
Clinical Application
1. TIA (Transient Ischemic Attack )

TIA is often detected by rCBF with high sensitivity. It shows the
hypoperfusion defects in corresponding areas.
Clinical Application
1. TIA (Transient Ischemic Attack )

The onset time of TIA is very short. After the onset,
the cerebral blood flow will recover again very fast. At
this time, the positive symptons and some laboratory
indices will disappear. So it is hard to diagnosis TIA.
But rCBF imaging can find some regional decreased
activity (hypoperfusion) after TIA onset.
Clinical application of rCBF Transient Ischemic Attack
The number of the hypoperfusion defects can be single or

multiple. The location of any focal hypoperfusion defect is
usually consistent with the clinical symptoms. The sensitivity
is time sensitive. That means, earlier test, higher sensitivity.
60% --------- in the 1st 24h

<40% -------- 1 week after onset
25% ---------- 3 months after onset
Clinical application of rCBF the advantages of rCBF
2.advantages
The Cerebral of rCBFInfarctionCompared with CT and
Tomography, comparing with CT MRI, rCBF can detect
and MRI, for detecting cerebral cerebral infarction 2-3d
earlier. In the acute
infarction:
cerebral infarction ,
A. rCBF Tomography can detect an because the cerebral blood
earlier stage disease: 2~3d earlier flow is interrupted, so there
is no radiotracer in this area.
At this time, the positive
rate is 90-95%, but CT,
MRI usually show normal.
After 2-3d later, CT, MRI
can detect it.
B. a high positive
rate: nearly 100%
C. the range displaying the

affected area is greater,
because the focus surroundings
also have simple ischemia
without anatomic changes.
MRI ECT
MRI
ECT
Clinical application of rCBF Characteristic expressions of rCBF in cerebral infarction
characteristic expressions of
rCBF in cerebral infarction
A. Luxury Perfusion
Several days after onset, the
rCBF Tomography pattern is
manifested by the phenomenon
of increased activity in
surrounding the infarct. That
means, collateral circulation is
built. This phenomenon often
exist in subacute phase of
cerebral infarction.
Clinical application of rCBF Characteristic expressions of rCBF in cerebral infarction
B. Crossed Cerebellar Diaschisis

diminished activity in the cerebellar
hemisphere contralateral to the
supratentorial(cerebral) abnormality
3. Epilepsy
1) increased activity(hyperperfusion)
is exhibited during seizures with ictal
studies.
2) decreased activity(hypoperfusion)
is exhibited between seizures with
interictal studies.
Ictal studies are more sensitive in the
detection of seizure foci than
interictal studies.
.
Ictal imaging ---- 85%-90%
Interictal imaging ----- 70%
4. Dementia Alzheimer
rCBF Tomography can disease, AD
identify the various types
of dementia.
1) Alzheimer’s disease (AD)

Symmetric bilateral temporal and parietal
perfusion defects
（Alzheimer disease,AD）
2) Multi-infarct Dementia
Patients with multi-infarct

dementia usually present
with multiple bilateral
asymmetric areas of
hypoperfusion scattered
throughout the cortex and
deep structures.
5. Head Trauma
1) In the setting of brain
trauma, SPECT brain perfusion
imaging appears to be more
sensitive and to detect
abnormalities earlier than CT and
MRI.
2) rCBF can show the
abnormal brain perfusion
3) It is displayed by the
decreased activity
4) Positive rate: 68%~77%
6. Brain Death
1) Absence of perfusion and
lack of cerebral activity can
confirm brain death
2) Brain death is an
irreversible brain lesion, all the
functions of brain are
irreversible lost.
7. Migraine
1) increased activity in the affected area
during ictal phase
2) decreased activity in intermission
3) normal activity when the clinical
symptoms disappear
4)CT and MRI often can not detect normal
migraine during its interictal phase
during ictal phase intermission

8. Brain Tumors
1) The positive rate for detecting brain tumors with rCBF
Tomography is similar to the one with CT or MRI
rCBF XCT
99mTc 201Tl 201Tl
2) If 99mTc- HMPAO Brain Perfusion Imaging shows some

focal defects in the region of abnormality after surgery and
radiotherapy, the defects may be caused by the radiation
necrosis or tumor recurrence. They can be distinguished by
conjunction with 201Tl imaging. A high degree of increased
thallium activity in the region of a 99mTc- HMPAO defect is
indicative of tumor recurrence, whereas a low degree is
consistent with pastradiation necrosis.
37
SPECT rCBF Tomography（ Transaxial Imaging ）

SPECT rCBF Tomography（Sagittal Imaging）
SPECT rCBF Tomography（Coronal Imaging）
THANKS
Department of Nuclear
Medicine,
the First Affiliated Hospital,
Chongqing Medical University
THE END

Central Nervous System

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Central Nervous System

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CENTRAL NERVOUS SYSTEM

CENTRAL NERVOUS SYSTEM

Brain Imaging Cerebrospinal

TYPES OF BRAIN IMAGING

1. Planar Brain Imaging

2. SPECT Brain Imaging

3. PET Metabolic Brain

1. Planar Brain Imaging

Which use radiopharmaceuticals that excluded

2. SPECT Brain Imaging

Which uses lipophilic radiopharmaceuticals that

This is the most commonly used radionuclide brain

3. PET Metabolic Brain

Which uses functional positron-emitting

PET techniques are not yet widely available in

2. The amount of radiopharmeceutical that entering

99mTc-ECD ( 99mTc –ethyl-cysteinate dimer )

99mTc-HMPAO ( 99mTc -hexamethyl-propyleneamine oxime )

The characters which the ideal radiopharmeceuticals

2)� External sensory stimulus, such as pain, noise, and light, as

The patients should be stay in a room alone, with

Normal rCBF Tomography

1. the increased radioactivity in the cortical gray matter (hyperperfusion)

Normal rCBF Tomography

Normal rCBF Tomography

Normal rCBF Tomography

Normal rCBF Tomography Bottom

Abnormal rCBF Tomography

Normal rCBF Tomography Abnormal rCBF Tomography

2. Crossed Cerebellar Diaschisis

Normal rCBF Tomography Abnormal rCBF Tomography

3.Increased activity in regional brain

Abnormal rCBF Tomography

Normal rCBF Tomography

Abnormal rCBF Tomography

5. The larger size of the cortical

Reason: Some pathologic changes

1. TIA (Transient Ischemic Attack )

1. TIA (Transient Ischemic Attack )

The number of the hypoperfusion defects can be single or

60% --------- in the 1st 24h

C. the range displaying the

B. Crossed Cerebellar Diaschisis

1) Alzheimer’s disease (AD)

Patients with multi-infarct

during ictal phase intermission

99mTc 201Tl 201Tl

2) If 99mTc- HMPAO Brain Perfusion Imaging shows some

SPECT rCBF Tomography（ Transaxial Imaging ）

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