NUCLEAR MEDICINE

OF THE BRAIN

SAFUAN AWANG
WHY NOT CT/MRI

 Brain disorders start with functional abnormalities that result in either

an increase or decrease in glucose metabolism at a cellular level.
These functional changes precede the formation of an abnormal
mass, the shrinkage of brain tissue, or other abnormalities
 PET and PET/CT imaging can show precise areas of increased
or decreased glucose metabolism in the brain.
 Radionuclide angiography
 PET/SPECT
 Radionuclide cisternography
 Table 7.2 -- RADIOPHARMACEUTICALS COMMONLY USED FOR A RANGE CLINICAL PROBLEMS

Radiopharmaceuti
Clinical problem Imaging technique cal Biological behaviour
Head
Cerebrovascular accident Cerebral perfusion 99m Tc HMPAO Uptake proportional to
SPECT blood flow
Hydrocephalus
CSF rhinorrhoea Cerebrospinal fluid In DTPA
111 Marker of CSF flow.
(CSF) study (intrathecal)
Encephalitis Blood–brain barrier 99m Tc HMPAO Passage across
(BBB) study disrupted BBB
Dementia Cerebral perfusion 99m Tc HMPAO Uptake proportional to
SPECT blood flow
18F
Cerebral Marker of glucose
metabolism PET fluorodeoxyglucose metabolism
Epilepsy (presurgical localization) Ictal SPECT 99mTc HMPAO Uptake proportional to
blood flow
18F
Interictal PET Marker of glucose
fluorodeoxyglucose metabolism
  Two high-powered imaging
instruments in nuclear
medicine
 use the tomographic
approach
 and range in the same
general size ,category and
PET AND cost,

SPECT  especially designed to monitor

dynamic processes such as blood
SCANNING flow and cell metabolism.
 SPECT instrument preceded
in general use,, the later PET
technology.
 Both instruments use a Gamma
camera to detect gamma ray photons
emitted from the radioisotopes used in
imaging the body.
Image of a typical positron emission
tomography (PET) facility
PET/CT-System with 16-slice CT; the ceiling mounted device is an injection
pump for CT contrast agent
 POSITRON EMISSION
TOMOGRAPHY= PET

= technique that permits noninvasive in vivo

examination of metabolism, blood flow, electrical
activity, neurochemistry
 Concept:
 The system detects pairs of gamma rays emitted indirectly by a
positron-emitting radionuclide (tracer), which is introduced
into the body on a biologically active molecule.
 Labeling:
 PET compounds---- radiolabeled with positron-emitting
radionuclides
• modern PET scanners
three dimensional imaging
with the aid of a CT X-ray scan performed on the
patient during the same session,
in the same machine.

• HYBRID PET/CT IMAGING

 INDICATIONS OF PET
IMAGING
A----ONCOLOGIC
1-Brain tumor:
a) tumor grading +estimation of prognosis
b) Localization of optimal biopsy site(most malignant area---
max.uptake)
2 radionecrosis versus residual / recurrent tumor
• decreased FDG uptake in necrosis
3 response to chemo- / radiation therapy
4 prediction of patient's average survival in pediatric
primary brain tumors:
• 6 months if FDG uptake = gray matter;
• 1-2 years if FDG uptake > white matter;
• 2.5 years if FDG uptake = white matter;
• 3 years if FDG uptake < gray matter
B-NON ONCOLOGIC
INDICATIONS (PET)
1. Refractory epilepsy-- pre-surgical evaluation.
2. Alzheimer disease. Dementia differential
diagnosis.
3. Parkinson disease.
4. Huntington disease, senile chorea
5. Schizophrenia
6. Stroke, cerebral vasospasm.
 CONTRAINDICATIONS(PET)

 Recent chemotherapy---min. interval of 2-3 wks

recommended

 Recent radiotherapy–--- min. interval of 8-12 wks

recommended

 Poorly controlled diabetes

RADIOPHARMACEUTICALS

 GLUCOSE METABOLISM
 for measurements of metabolic rate + mapping of functional activity
 C-11 glucose:
rapid uptake, metabolization, and excretion by brain
 F-18 fluorodeoxyglucose (FDG):
diffuses across blood-brain barrier --the brain is normally a r rapid user of
glucose, since brain pathologies greatly decrease brain metabolism of glucose
 The consumption of FDG--- indicates the extent of brain activity.
 By indicating the consumption of FDG, PET imaging gives---------a key to
the working of a patient's brain
 TECHNIQUE(FDG PET IMAGING)

 FDG = glucose analogue tracer 2-[fluorine-18] fluoro-2-

deoxy-D-glucose

 Preparation:
 fasting for 4-18 hours (FDG tumor uptake is diminished by an
elevated serum glucose level)
 Dose: 10 mCi (370 MBq)
 Physical half-life: 110 minutes
 Imaging time:
 50-60-70 minutes after administration (trade-off between
decreasing background activity and declining counting
statistics)
 BRAIN PET IN
ONCOLOGY

RECURRENCE VS RADIATION NECROSIS,

 BRAIN
PET

To distinguish functionally important brain areas

DEMENTIA

 - Definition

 Dementia is a clinical syndrome characterized by acquired

losses of cognitive and emotional abilities severe enough to
interfere with daily functioning.
 Dementia in Alzheimer's disease
 Vascular dementia
 Dementia in other diseases classified elsewhere
Fronto temporal lobe D
Lewy body disease
Dementia in Huntington's disease
Dementia in Parkinson's disease
Dementia in [HIV] disease
Dementia in other specified diseases
 Unspecified dementia
 THESE DIAGNOSTIC INDICATIONS FOR BRAIN PET: accompanied
by pre-test considerations ,supporting clinical data and prerequisite
information:

 1----REFRACTORY SEIZURES/EPILEPSY
 2----FRONTO-TEMPORAL LOBE DEMENTIA AND ALZHEIMER’S DISEASE
 AIM’s CRITERIA TO DETERMINE
IF FDG-PET DEMENTIA EVALUATION IS INDICATED

 The use of FDG-PET scan in the diagnosis of Alzheimer’s disease (AD) and Fronto-Temporal Lobe
Dementia(FTD) is Approved provided
 The patient’s clinical symptoms meet the diagnostic criteria for (AD), (FTD)
 a comprehensive clinical evaluation which has included:comprehensive medical history,physical and
mental status exam
 neuropsychological testing, laboratory testing, and structural imaging ---MRI or CT----to aid in identifying
structural, metabolic, and chemical abnormalities as a cause for cognitive impairment.
Alzheimer's dementia(Case 1)
severely reduced FDG activity ---in the bilateral parietal, temporal lobe and
frontal lobe. The primary sensorimotor cortex, visual cortex, basal ganglia,
thalamus and cerebellum are normal and spared
Alzheimer's
dementia (Case 2)

an area of

reduced FDG activity

10-50% seen in the
bilateral
parietal, temporal
lobes.

FDG uptake in
the rest
of the cerebral
cortex, subcortical gray
matter, cerebellum is
within normal range.
 DEMENTIAS--------------

 Diffuse Lewy body disease

 after Alzheimer's disease, the second most
common cause of senile degenerative dementia
 It is characterized histologically by the occurrence of
Lewy bodies in allocortical, neocortical and
subcortical structures.
LEWY BODY DISEASE-----diffuse cerebral hypometabolism
Occipital cortex is also affected(difference from AD)
Frontotemporal
dementia

There is mild-moderate
hypometabolism
involving both frontal
and contiguous temporal
lobes.
The brain otherwise has
normal symmetric
metabolism without
focal abnormality.

 FRONTO TEMPORAL

LOBE DEMENTIA.
 PARKINSONS DISEASE

 PET scans are FDA-approved for the diagnosis of

dementia, but not for the diagnosis of Parkinson’s
disease.
 In cases where the expert is not sure of the
diagnosis
– is it essential tremor or Parkinson’s,
 or where a potentially risky procedure is being
considered (e.g. deep brain stimulation surgery), it is
reasonable to recommend a PETscan or DaTscan.
DaTscan (Ioflupane I 123 injection, also known as
phenyltropane)
-------------a radiopharmaceutical agent which is
injected into a patient’s veins in SPECT imaging.
-----------contains a dopamine transporter
radioligand
-----------used to assess striatal uptake
An example DaTscan; demonstrates essential tremor on the left (normal DaT), and
a parkinsonian syndrome on the right (decreased DaT). DaT/SPECT scans focus
on the activity of the dopamine transporter
 PARKINSONS DISEASE (PET

 SCAN)
Parkinson's disease
decreased activity in the left caudate and putamen ;;;relatively symmetric thalamic FDG uptake
 FDG uptake in the rest of the cerebral cortex, subcortical gray matter, cerebellum is
within normal range.
a PET scan ;top : a normal scan.

middle :abnormalities in the putamen (red uptake in the figure)

lower :a return to an almost normal scan following the introduction of levodopa.

A(SPECT) brain perfusion scan(Huntington's
disease).
Areas of highest tracer uptake
--white/orange
(high blood flow);
lowest uptake -- blue/black (low blood flow).
markedly reduced uptake in the caudate nuclei
bilaterally (outlined by white dashed lines).
The adjacent thalami are normal. Activity in
the cortex is essentially normal. High activity
in the visual cortex is secondary to visual
stimulation the patient received in the partially
darkened room.
 PET------- FOR
EPILEPSY

Surgery for Epilepsy

1. Surgery is indicated for refractory focal epilepsy.

2. PET is indicated only for pre-surgical evaluation,

not for diagnosis.
  : During a seizure, the region where the
seizure started has the greatest amount of
blood flow.
SUBTRACTIO  the patient is injected with a tracer that
helps to measure blood flow. The injection is
N most helpful when it is given within 20
seconds of when the seizure started.
 A SPECT scan is then done within two-
three hours and the brain region(s) with
ICTAL SPECT greatest blood flow are identified. Although
this scan is done hours after the tracer is
SCAN injected, an accurate image of blood flow
during the seizure (ictal) is obtained since
the tracer remains in the brain for up to four
hours.
 Another SPECT (inter-ictal) scan is done at another
time when the patient is not having a seizure (inter-
ictal).
 The two scans are digitally subtracted and the
resulting image provides valuable information
about where the seizures begin.
 PET------- IN
EPILEPSY

abnormally high activation of the left part of the brain of a patient during an
epileptic seizure
PET------- IN
EPILEPSY
 EPILEPSY - LESIONAL
MESIAL TEMPORAL SCLEROSIS
(MTS)

 MRI:
Atrophy, enlarged temporal horn.
Increased T2 signal.
Bilateral changes in 10%.

PET:
Hyp
omet
aboli
sm

Path
Mesial Temporal Sclerosis (MTS)
 SPECT

 A Single Photon Emission Computed Tomography

(SPECT) scan is a type of nuclear imaging test that
shows how blood flows to tissues and organs.
 The test differs from a PET scan in that the tracer
stays in your blood stream rather than being
absorbed by surrounding tissues, thereby limiting
the images to areas where blood flows. SPECT scans
are cheaper and more readily available than higher
resolution PET scans.
 SPECT IMAGING IN CEREBROVASCULAR
DISEASE
 Measurement of regional cerebral blood flow (rCBF)
 Diagnosis and prognosis of cerebro-vascular
disease
 SPECT: superior to CT/MRI in detecting cerebral
ischemia—
 rCBF imaging: effective in acute phase, less sensitive
in the subacute phase
-8h: SPECT-80%; CT-20%
-72h: SPECT=CT/MRI
 False negative: lacunar infarctions, luxury
perfusion(2~28 days)
 RADIOPHARMACEU
TICALS
 REGIONAL CEREBRAL BLOOD FLOW IMAGING
 Inert gases are effective markers---LIKE

 breathing of carbon monoxide (C-11 and O-15), which concentrates

in RBCs

 Xe-133 inhalation / injection into ICA / IV injection after dissolution

in saline
 BUT

 Tc-99m HMPAO brain SPECT(high extraction efficiency by brain

tissue)
 R CBF IMAGING( HMPAO
TECHNIQUE)
 requires no patient preparation.
 typical activity of 500 MBq is injected intravenously.
 patient in a quiet stable environment.
 Images obtained from 20 min to several hours after
injection because the tracer distribution in the brain
is stable during this time.
 Volumetric data are displayed in standardised
axial.coronal and sagittal planes, and colour displays
are used .
 SPECT
r CBF imaging
IMAGING
Massive infarction of the right middle cerebral artery territory. Note severe
ischaemia of the Frontal, temporal and parietal cortex and also of the basal ganglia
on right.------99m Tc—HMPAO brain SPECT
99 Tc-exametazime brain SPECT: axial, coronal and right
parasagittal images showing very extensive perfusion deficits during the
acute ischaemic phase (top row) and substantial improvement several
months later after clinical recovery (bottom row).
(PET) scan of the brain of a stroke
patient. Colour- coding is:
high brain activity (yellow, red);
low activity (blue to black).
At upper right is a lesion (blue)
showing an area of brain damage
with reduced blood flow and low
activity due to stroke.
Brain stress test: vasodilatory response to CO2 or
acetazolamide
--compare resting images and vasodilated images
(20~30min after acetazolamide injection)
--diseased or at-risk areas show little or no
response
Normally ,there shud b 40%increase over
resting flow.
 PET BRAIN SCAN -
BENEFITS
 Pinpointing brain abnormalities and whether these abnormalities are caused by:
Alzheimer's disease, blood flow shortages, depression, or some other reason
 Assisting surgery for individuals with uncontrollable seizures by localizing the
brain
site of seizure activity
 Analyzing muscle tremor and evaluate whether it this is caused by Parkinson's
disease or some other movement disorder
 Evaluating brain tumors and determine whether they are benign (alive tissue
and non-cancerous) or malignant (dead tissue and cancerous)
 Assessing such medical conditions as degenerative brain diseases, movement
disorders, and dementias
 Assisting surgical operations by identifying the areas of the brain responsible for
such critical functions as movement and speech
 Analyzing the effectiveness of chemotherapy by examining cites of possible cancer
recurrence and distinguishing whether this structural change is due to tumor re-
growth or is a form of scar tissue
 Diagnosing Alzheimer’s earlier
 Differentiating Alzheimer’s disease from other types of dementia
 Monitoring the progression of the disease and the effectiveness of the treatment
THANK
YOU