Đang tải... (xem toàn văn)
(BQ) Part 1 book Diagnostic imaging nuclear presents the following contents: Musculoskeletal (benign bone tumors, malignant bone tumors, surgical assessment, avascular necrosis, dysplasias,...), vascular and lymphatics, cardiovascular, chest and mediastinum, CNS.
Diagnostic Imaging Nuclear Diagnostic Imaging Nuclear Table of Contents Diagnostic Imaging Nuclear Cover Authors Dedication Foreword Preface Acknowledgments 10 Introduction 10 Section - Musculoskeletal 11 I Benign Bone Tumors 11 Osteoid Osteoma 11 Enchondroma 18 Fibrous Cortical Defect 22 Bone Cyst, Aneurysmal 26 Bone Cyst, Solitary 30 Giant Cell Tumor .37 II Malignant Bone Tumors 41 Skeletal Metastases 41 Superscan .51 Osteosarcoma 58 Ewing Sarcoma 68 Chondrosarcoma 75 Prostate Cancer, Bone Metastases 82 III Therapy 86 Palliation of Metastatic Bone Pain 86 IV Infection 93 Cellulitis 93 Osteomyelitis, Appendicular 100 Osteomyelitis, Axial .110 Osteomyelitis, Temporal Bone 114 Osteomyelitis, Feet .118 Osteomyelitis, Pediatric 125 V Metabolic Bone Disease 135 Hyperparathyroidism 135 Osteomalacia 142 Hypertrophic Osteoarthropathy 149 VI Dysplasias 159 Paget Disease 159 Fibrous Dysplasia 166 Melorheostosis .170 Multiple Enchondromatoses 177 Multiple Hereditary Exostoses .184 VII Avascular Necrosis 191 Osseous Necrosis 191 Legg-Calve Perthes Disease 198 VIII Surgical Assessment 202 Joint Prostheses, Painful 202 Failed Back Surgery Syndrome 206 IX Skeletal Trauma 216 Insufficiency Fracture 216 Fracture 226 Diagnostic Imaging Nuclear Trauma, Non-Accidental 230 Stress Fracture 234 X Regional Pain Evaluation .241 Arthritis, Non-Infectious 241 Complex Regional Pain Syndrome 248 Hip Pain 255 Wrist Pain .262 Calcaneal Pain .272 Knee Pain 279 XI Skeletal Muscle & Soft Tissues 286 Heterotopic Ossification 286 Skeletal Muscle Disorders .296 Amyloidosis 303 XII Bone Marrow Disorders 307 Hematoproliferative Disorders 307 Sickle Cell Disease, Bone Pain 317 Multiple Myeloma .324 Section - Vascular and Lymphatics 331 I Lymphatic 331 Lymphedema 331 Sentinel Lymph Node Mapping .335 II Vascular 342 Large Vessel Vasculitis 342 Atherosclerosis .346 Vascular Thrombosis .353 Vascular Graft Infection 357 Section - Cardiovascular .367 I Introduction and Overview 367 Cardiovascular Overview .367 II Cardiac 375 Cardiomyopathy 375 Valvular Heart Disease 385 Myocardial Ischemia .392 Myocardial Viability 402 Myocardial Infarction 409 Cardiac Transplant 419 Left-to-Right Intracardiac Shunts 426 Right-to-Left Intracardiac Shunts 430 Section - Chest and Mediastinum .434 I Introduction and Overview 434 VQ Scan Overview 434 II Lung Ventillation & Perfusion Abnormalities 443 VQ, Pulmonary Embolism 443 VQ, Quantitative 450 III Lung Infection & Inflammation .460 Pneumocystis Carinii Pneumonia 460 Interstitial Lung Disease 467 Granulomatous Disease 474 IV Lung Cancer 481 Solitary Pulmonary Nodule 481 Non-Small Cell Lung Cancer 488 Metastases, Lungs and Mediastinum 498 V Pleura 505 Pleural Disease, Malignant and Inflammatory .505 Diagnostic Imaging Nuclear VI Mediastinum .512 Thymic Evaluation 512 Pericardial Disease, Malignant and Inflammatory 519 Section - CNS .526 I Introduction and Overview 526 Brain Imaging Overview 526 II Vascular Assessment .531 Brain Death 531 Cerebral Vascular Occlusion 541 Blood Brain Barrier Disruption .548 III Seizure Assessment 552 Seizure Evaluation 552 IV Dementia & Neurodegenerative 562 Alzheimer Disease 562 Dementia and Neurodegenerative, Other .569 V Neurooncology .579 Gliomas and Astrocytomas 579 Primary CNS Lymphoma 586 Metastases, Brain 593 Radiation Necrosis vs Recurrent Tumor 600 VI CSF Imaging 610 CSF Leak 610 Ventricular Shunt Dysfunction .617 Normal Pressure Hydrocephalus 624 VII Miscellaneous .634 Heterotopic Gray Matter .634 Brain Infection and Inflammation 644 Psychiatry, Drug Addiction and Forensics 651 Section - Head and Neck 661 I Squamous Cell Carcinoma of the Head and Neck 661 SCCHN, Staging .661 SCCHN, Primary Unknown .668 SCCHN, Therapeutic Assessment - Restaging 672 II Miscellaneous Primary Head and Neck Tumors .679 Parotid and Salivary Tumors 679 Neuroendocrine Tumors, Head and Neck 683 III Miscellaneous 690 Lacrimal Complex Dysfunction 690 Section - Thyroid & Parathyroid 694 I Introduction and Overview 694 Thyroid Overview 694 II Parathyroid 702 Parathyroid Adenoma, Typical .702 Parathyroid Adenoma, Ectopic 710 III Hyperthyroidism 714 Graves Disease 714 Hashimoto Thyroiditis 721 Multinodular Goiter 728 Thyroid Adenoma, Hyperfunctioning .735 Subacute Thyroiditis 742 I-131 Hyperthyroid Therapy 749 IV Thyroid, Benign Miscellaneous .756 Ectopic Thyroid .756 Congenital Hypothyroidism 763 Diagnostic Imaging Nuclear Benign Thyroid Conditions, PET .770 V Thyroid Cancer 777 Well-Differentiated Thyroid Cancer .777 I-131 Thyroid Cancer Therapy .787 Well-Differentiated Thyroid Cancer, PET .794 Medullary Thyroid Cancer .801 Section - Gastrointestinal 808 I Introduction and Overview 808 GI Anatomy and Imaging Issues .808 II Biliary 812 Acute Calculous Cholecystitis 812 Acute Acalculous Cholecystitis 822 Chronic Cholecystitis .832 Biliary Leak 839 Common Bile Duct Obstruction .843 Choledochal Cyst 847 Biliary Bypass Obstruction .854 Biliary Atresia 858 Cholangiocarcinoma 865 Gallbladder Cancer 872 III Hepatic 879 Focal Nodular Hyperplasia 879 Hepatic Cirrhosis 886 Hypersplenism 896 Hepatic Metastases .903 Hepatoblastoma 910 Hepatocellular Carcinoma .917 Cavernous Hemangiomas 927 IV Adrenal 934 Adrenal Malignancy 934 Pheochromocytoma 944 Neuroblastoma .951 V Spleen 961 Asplenia-Polysplenia Syndromes 961 Accessory and Ectopic Splenic Tissue 968 VI Oropharynx & Esophagus .975 Esophageal Cancer 975 Esophageal Dysmotility 982 VII Stomach 989 Gastritis 989 Gastric Emptying Disorders 993 Gastric Carcinoma 1000 VIII Intestine 1007 Intestinal Cancer, Primary and Staging 1007 Intestinal Cancer, Therapy Eval - Restaging 1014 Meckel Diverticulum 1018 GI Bleeding Localization 1025 Inflammatory Bowel Disease 1032 IX Pancreas 1039 Pancreatitis 1039 Pancreatic Adenocarcinoma 1043 Islet Cell Tumors 1050 X Miscellaneous 1057 Intraabdominal Infection 1057 Diagnostic Imaging Nuclear Carcinoid Tumor 1067 GI Stromal Tumors 1074 Peritoneal Systemic Shunt Evaluation 1081 Diaphragmatic Patency Determination 1088 Intraarterial Hepatic Pump Evaluation 1092 Section - Genitourinary 1096 I Kidney 1096 Renal Cortical Scar 1096 Renal Ectopy 1103 Renovascular Hypertension 1110 Acute Renal Failure 1117 Renal Masses 1127 Renal Cell Carcinoma 1131 Pyelonephritis 1138 Renal Transplant 1145 Renal Function Quantification 1155 II Collecting System 1162 Obstructive Uropathy 1162 Reflux Uropathy 1169 Urinary Bladder and Epithelial Cancer 1176 III Testes 1183 Testicular Torsion 1183 Testicular Cancer 1190 IV Ovaries 1197 Ovaries, Normal and Benign Pathology 1197 Ovarian Cancer 1201 V Uterus 1208 Uterus, Normal and Benign Pathology 1208 Cervical Cancer 1212 Endometrial Cancer 1219 VI Prostate 1226 Prostate Cancer, Antibody Scan 1226 Section 10 - HemeOnc Procedures & Therapies 1230 I Therapy - Oncology 1230 Phosphorus-32 Therapies 1230 Hepatic Arterial Y-90 Microspheres 1234 Radiolabeled Antibody Therapy 1241 II Hematologic Procedures 1248 RBC Survival and Splenic Sequestration 1248 Red Cell Mass and Plasma Volume 1252 Schilling Test 1256 Section 11 - Oncology, Other 1260 I Lymphoma 1260 Lymphoma, Benign Mimics 1260 Hodgkin Lymphoma Staging 1267 Lymphoma Post-Therapy Evaluation 1274 Non-Hodgkin Lymphomas, Low Grade 1284 Non-Hodgkin Lymphoma Staging 1291 II Melanoma 1298 Melanoma Staging 1298 Melanoma Therapy Evaluation - Restaging 1305 III Breast Cancer 1312 Breast, Benign Disease 1312 Breast Cancer, Primary 1316 Diagnostic Imaging Nuclear Breast Cancer, Staging - Restaging 1326 IV Miscellaneous 1336 Adenocarcinoma of Unknown Primary 1336 Paraneoplastic Disorders 1340 Index 1348 A 1348 B 1349 C 1351 D 1353 E 1353 F 1354 G 1355 H 1356 I 1358 J 1359 K 1359 L 1359 M 1361 N 1362 O 1364 P 1365 Q 1366 R 1366 S 1367 T 1368 U 1370 V 1371 W 1371 Y 1371 Z 1371 Diagnostic Imaging Nuclear Diagnostic Imaging Nuclear Cover Authors Authors Kathryn A Morton MD Professor of Radiology University of Utah School of Medicine Salt Lake City, Utah Paige B Clark MD Assistant Professor of Nuclear Medicine Department of Radiology Wake Forest University Health Sciences Winston-Salem, North Carolina Todd M Blodgett MD Chief of Cancer Imaging Department of Radiology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Carl R Christensen MD Diagnostic Imaging Nuclear Assistant Professor of Radiology University of Utah School of Medicine Salt Lake City, Utah Janis P O'Malley MD Associate Professor of Radiology Director of Nuclear Medicine and Clinical PET University of Alabama Birmingham, Alabama Jeffrey S Stevens MD Associate Professor of Radiology Director of Nuclear Medicine Oregon Health and Science University Portland, Oregon Crispin A Chinn MD Director of Nuclear Medicine Providence St Vincent Hospital Portland, Oregon Alan D Waxman MD Director of Nuclear Medicine Co-Chair, Department of Imaging Cedars-Sinai Medical Center S Mark Taper Imaging Center Clinical Professor of Radiology University of Southern California School of Medicine Los Angeles, CA Robert W Nance Jr MD Assistant Professor Radiology/Nuclear Medicine Oregon Health and ScienceUniversity Portland, Oregon Anita J Thomas MD Assistant Professor of Nuclear Medicine Department of Radiology Wake Forest University Health Sciences Winston-Salem, North Carolina Ralph Drosten MD Assistant Professor of Radiology University of Utah School of Medicine Salt Lake City, Utah Thomas F Heston MD Medical Director Northwest Molecular Kellogg, Idaho Dedication Dedication To my husband, Mike Poler His unfailing support and encouragement made this book possible KAM For my family PBC Diagnostic Imaging Nuclear Foreword Diagnostic Imaging: Nuclear Medicine is organized and edited in the popular format used for other books in this series The lead author, Dr Morton is unusual in that she is both an excellent radiologist and an outstanding clinical nuclear medicine physician She is also well recognized and respected in the nuclear medicine research community Dr Clark is a vibrant rising star in the nuclear medicine field, both in clinical expertise as well as research The contributing authors represent a well-balanced cadre of some of the most experienced and respected names in nuclear medicine today, as well as experts with strong multimodality perspectives in diagnostic imaging Together, they are an unbeatable team The authors have succeeded in presenting a well-balanced and fair appraisal of the best imaging approach to a vast array of common and not-so-common clinical problems that face diagnostic imagers in nuclear medicine The book defines the appropriate role of nuclear medicine in the context of other powerful imaging modalities today This includes important protocol information to allow optimization of a “best practice” imaging approach to specific problems Hundreds of superb well-reproduced images and graphic illustrations are included, a hallmark of the Diagnostic Imaging series Important clinical information regarding the diseases addressed is also included The general organization is spare and direct in its bulleted format, with key points highlighted, making this a quick and easy reference for the practicing radiologist, nuclear medicine practitioner, as well as clinicians Diagnostic Imaging: Nuclear Medicine should withstand the test of time as well-worn addition to any radiology reading room Edward V Staab, MD Professor of Nuclear Medicine Department of Radiology Wake Forest University Health Sciences Winston-Salem, North Carolina Preface There are many outstanding radiology text books available today, addressing both general radiology as well as specific imaging subspecialties In the face of literally hundreds of available text books, the Amirsys Diagnostic Imaging series has risen rapidly in popularity as one of the best selling imaging text book series of all time Diagnostic Imaging: Nuclear Medicine rounds out this series, focusing on conventional nuclear medicine imaging, PET and PET/CT, radionuclide therapy, and the more commonly used in-vitro diagnostic determinations We have strived to fill an un-met need in providing a quick and practical guide for radiologists and nuclear medicine physicians “in the trenches” The bulleted format is easy to digest and conveys clinically relevant information concisely and rapidly, providing a real-time reference for the reading room The hundreds of images included are clear and convey typical and atypical examples of specific diagnoses, as well as “mimics” and potential pitfalls that complicate diagnostic accuracy This book is comprehensive in that it addresses the most common nuclear medicine diagnoses encountered in daily practice, as well those with which most imagers have less experience The book provides thorough and concise information regarding nuclear medicine diagnostic and therapeutic procedures, including appropriate study selection, protocol advice and interpretive guidance It also summarizes the key findings shown by CT, MR, ultrasound and other radiographic modalities for each diagnosis Most importantly, it addresses the most appropriate role for nuclear medicine within the framework of all imaging modalities and options available to answer a specific clinical question, without hype or subspecialty bias In short, this nuclear medicine book is practical, accessible and in-touch with the realities of multimodality diagnostic imaging Kathryn A Morton, MD Professor of Radiology University of Utah School of Medicine Salt Lake City, Utah Diagnostic Imaging Nuclear Coronal T1 C+ MR of patient at left shows enhancement of left temporal lobe and basal ganglia , corresponding to hypermetabolism on PET in patient with HSE TERMINOLOGY Abbreviations and Synonyms Herpes simplex encephalitis (HSE) Rasmussen encephalitis (RE) Creutzfeldt-Jakob disease (CJD), transmissible spongiform encephalopathy (TSE) Progressive multifocal leukoencephalopathy (PML) Opportunistic infection (OI) Definitions HSE: Parenchymal infection caused by herpes simplex virus type (HSV-1) Cerebral abscess: Focal pyogenic infection (bacterial, fungal, parasitic) Cerebritis: Brain inflammation due to infectious/noninfectious causes Encephalitis: Inflammation caused by various pathogens (most common = viral) RE: Chronic, unilateral brain inflammation, etiology unclear PML: Subacute demyelinating OI IMAGING FINDINGS General Features Best diagnostic clue o HSE: Abnormal MR signal and enhancement of medial temporal and inferior frontal lobes; cingulate gyrus and contralateral temporal lobe highly suggestive o Cerebral abscess: Depending on acuity, MR or CT enhancing ring, central low density, peripheral edema 646 Diagnostic Imaging Nuclear o Cerebritis: Acute = enhancement CT, MR; chronic = atrophy, hyperintensity on T2 MR Acute: Enhancement on CT, MR Chronic: Hyperintense T2 MR, atrophy o RE: Unilateral cerebral atrophy o OI: Variable appearance, most hyperintense on T2 Location o HSE: Limbic system most typically (temporal lobes, insula, subfrontal, cingulate gyri) Cerebral convexities, asymmetrical, basal ganglia often spared, atypical in children Usually bilateral; can be asymmetrical Children atypical: Primarily cerebral hemispheres P.5-71 o o o Cerebral abscess: Primarily gray-white junction, supratentorial, also atypical locations Atypical infectious encephalitis: Any location RE: Entire hemisphere, worse pre-central and inferior frontal Morphology o RE: Focal first, then hemispheric o Abscess: Ring enhancement = capsular stage Nuclear Medicine Findings PET o Hypermetabolic on F-18 FDG PET: Acute cerebritis (any cause), acute HSE, acute OI, abscess (centrally hypometabolic in subacute stage), limbic encephalitis o Isometabolic on F-18 FDG PET: Subacute encephalitis o Hypometabolic on FDG PET: Toxoplasmosis, PML, CJD (patchy hypometabolism), RE, chronic/burned out infection/inflammation o F-18 FDG PET: Limited ability to distinguish ring-enhancing lesions; however, toxoplasmosis = hypometabolic SPECT o Tc-99m ECD or HMPAO SPECT: Hypometabolic for most conditions o In-111 leukocytes: Inferior to F-18 FDG PET, relatively insensitive for nonpyogenic/chronic bacterial infections Tc-99m glucoheptonate blood brain barrier (BBB) scan: Focal breakdown in BBB ⇒ increased activity CT Findings CECT: Enhancement, mass effect, hemorrhage MR Findings T1WI o Decreased signal in gray and white matter, loss of gray-white junction, mass effect o Subacute hemorrhage ⇒ increased signal in edematous brain o Chronic: Atrophy and encephalomalacia T2WI o Increased signal o Subacute hemorrhage ⇒ increased signal in edematous brain FLAIR: Hyperintense DWI: May be hyperintense (restricted diffusion) T1 C+: Parenchymal, meningeal enhancement (may not be seen in early HSE) Imaging Recommendations Best imaging tool o MR > CT; however, false negatives in first few days of OI, HSE o F-18 FDG PET for problem-solving in unclear cases after MR/CT Protocol advice o F-18 FDG PET 10 mCi F-18 FDG IV 647 Diagnostic Imaging Nuclear After injection, patient should rest in darkened room Whole-brain image at 45-60 Fuse PET images to correlative MR: Increases sensitivity/specificity of PET findings DIFFERENTIAL DIAGNOSIS Limbic Encephalitis Rare paraneoplastic syndrome associated with primary tumor, often lung Imaging may be indistinguishable from HSE on MR and F-18 FDG PET Subacute symptom onset (weeks to months) vs acute in HSE Neoplasm Low grade gliomas often hypometabolic on F-18 FDG PET High grade gliomas hypermetabolic on F-18 FDG PET Metastases iso- or hypermetabolic to normal brain Primary CNS lymphoma hypermetabolic, ring-like on F-18 FDG PET P.5-72 Ischemia Typical vascular distribution (MCA, ACA, PCA) Acute onset F-18 FDG PET and Tc-99m ECD/HMPAO SPECT: Decreased uptake centrally; may have increased peripheral uptake = “luxury perfusion” equivalent Status Epilepticus Seizure focus o Ictal scan: Increased activity on F-18 FDG PET or Tc-99m ECD/HMPAO SPECT o Interictal scan: Decreased activity on F-18 FDG PET or Tc-99m ECD/HMPAO SPECT Active seizures may disrupt BBB, cause signal abnormalities and enhancement Temporal lobe epilepsy hyperperfusion may mimic herpes encephalitis PATHOLOGY General Features Etiology o HSE: HSV-1 infection, reactivation (adults), primary (infants and children) o Immunocompromised: OI, HSE o Underlying malignancy: Limbic encephalitis o CJD Inherited mutations in prion protein Acquired from infected prion-containing material Gross Pathologic & Surgical Features Encephalitis, cerebritis, acute pyogenic: Unencapsulated vascular congestion, hemorrhage, necrosis, edema Subacute abscess: Peripheral capsule, necrotic core CLINICAL ISSUES Presentation Most common signs/symptoms o Fever o Headache o Seizure o Altered mental status, focal or diffuse neurologic deficit (< 30%) o May progress to coma and death o CJD: Rapidly progressive dementia Demographics Gender: M = F Natural History & Prognosis Mortality: 50-70% (viral); 0-30% (abscess) Rapid diagnosis, early treatment can decrease mortality, may improve outcome (HSE, OI) 648 Diagnostic Imaging Nuclear In general, survival complicated by memory difficulties, hearing loss, medically intractable epilepsy, personality changes CJD: Unrelenting dementia, death RE: Hemiplegia, cognitive impairment in most cases Treatment Infectious: Antivirals/antibiotics, anti-seizure medications Abscess: Surgical drainage, antibiotics, anti-seizure medications Aseptic: Corticosteroids, anti-seizure medications, antiviral agents, alpha-interferon, immunoglobulin DIAGNOSTIC CHECKLIST Consider Immediate empiric antibiotics if infection suspected Stroke or tumor may mimic, history often helpful Consider limbic encephalitis if all clinical tests negative, subacute onset of symptoms Image Interpretation Pearls F-18 FDG PET: Useful for equivocal or problem cases o Ring-enhancing lesions on MR: Toxoplasmosis vs lymphoma o Determine acuity of infection/inflammation MR most sensitive (FLAIR and DWI) for diagnosis SELECTED REFERENCES Floeth FW et al: 18F-FET PET Differentiation of Ring-Enhancing Brain Lesions J Nucl Med 47(5):776-782, 2006 Fauser S et al: FDG-PET and MRI in potassium channel antibody-associated non-paraneoplastic limbic encephalitis: correlation with clinical course and neuropsychology Acta Neurol Scand 111(5):338-43, 2005 Küker W et al: Diffusion-weighted MRI in herpes simplex encephalitis Neuroradiology 46:122-5, 2004 Lee BY et al: FDG-PET findings in patients with suspected encephalitis Clin Nucl Med 29(10):620-5, 2004 Scheid R et al: Serial 18F-fluoro-2-deoxy-D-glucose positron emission tomography and magnetic resonance imaging of paraneoplastic limbic encephalitis Arch Neurol 61(11):1785-9, 2004 Chiapparini L et al: Diagnostic imaging in 13 cases of Rasmussen's encephalitis: can early MRI suggest the diagnosis? Neuroradiology 45(3):171-83, 2003 Engler H et al: Multitracer study with positron emission tomography in Creutzfeldt-Jakob disease Eur J Nucl Med Mol Imaging 30(1):85-95, 2003 Fiorella DJ et al: (18)F-fluorodeoxyglucose positron emission tomography and MR imaging findings in Rasmussen encephalitis AJNR Am J Neuroradiol 22(7):1291-9, 2001 Kassubek J et al: Limbic encephalitis investigated by 18FDG-PET and 3D MRI J Neuroimaging 11(1):55-9, 2001 10 Leonard JR et al: MR imaging of herpes simplex type encephalitis in infants and young children: a separate pattern of findings AJR Am J Roentgenol 174(6):1651-5, 2000 11 Weiner SM et al: Alterations of cerebral glucose metabolism indicate progress to severe morphological brain lesions in neuropsychiatric systemic lupus erythematosus Lupus 9(5):386-9, 2000 12 Hoffman JM et al: FDG-PET in differentiating lymphoma from nonmalignant central nervous system lesions in patients with AIDS J Nucl Med 34(4):567-75, 1993 13 Hanson MW et al: FDG-PET in the selection of brain lesions for biopsy J Comput Assist Tomogr 15(5):796-801, 1991 P.5-73 Image Gallery 649 Diagnostic Imaging Nuclear DDx: Brain Infection and Inflammation (Left) Axial T2 MR shows nonspecific, subtle areas of increased signal in patient with early CJD With disease progression, findings become more obvious (Right) Axial F-18 FDG PET in patient with CJD Large areas of marked hypometabolism in cortex , basal ganglia PET findings are often much more striking than MR/CT (Left) Axial F-18 FDG PET in patient with Rasmussen encephalitis (RE) shows diffuse right hemispheric hypometabolism Late in disease, diffuse hemicerebral atrophy occurs (Right) Axial FDG PET shows ring of hypermetabolism in left parietal lobe , typical appearance for cerebral abscess Central necrosis/hypometabolism occurs in subacute (capsular) stage 650 Diagnostic Imaging Nuclear (Left) Axial F-18 FDG PET in early cerebritis shows hypermetabolism in left temporal/parietal lobes and basal ganglia in patient with HSE (Right) Six months later, axial F-18 FDG PET in patient at left shows hypometabolism in left temporal/parietal lobes and basal ganglia , typical of late findings after HSE episode Psychiatry, Drug Addiction and Forensics Key Facts Imaging Findings Head injury: Patients with symptoms and negative anatomic studies often have abnormal SPECT scans Obsessive-compulsive disorder (OCD): Increased activity in anterior cingulate is most commonly described Schizophrenia: Decreased activity in frontal lobes, referred to as hypofrontality, is most commonly described Depression: Decreased activity in frontal lobes is most commonly reported finding Panic disorder and anxiety: Frontal hypoactivity has been described as well as basal ganglia hyperactivity Substance abuse: Diffuse cortical decreased activity seen with substances such as alcohol, marijuana, barbiturates, pain killers, narcotics, and nicotine Criminal and antisocial behavior: Decreased prefrontal, frontal, and temporal activity are most commonly described Violence: Increased cingulate activity, decreased prefrontal activity, temporal lobe increases and decreases often on the left, increased caudate and/or thalamic activity have been described Attention deficit disorder (ADD): Normal or decreased activity frontal and/or temporal lobes at baseline the most commonly described finding Toxic exposure and multiple chemical sensitivity: Variety of findings have been described in this controversial area including patchy cortical increases or decreases, and overall decreased cortical activity 651 Diagnostic Imaging Nuclear Axial brain SPECT shows decreased activity over the temporal tips trauma with negative anatomic studies This is a typical finding 652 in a symptomatic adult post head Diagnostic Imaging Nuclear Sagittal brain SPECT (in the same patient as left) shows decreased activity over the floor of the frontal lobe , a typical finding Other abnormalities are occipital and parietal TERMINOLOGY Definitions Brain imaging attempting to show functional rather than anatomic abnormalities IMAGING FINDINGS General Features Best diagnostic clue o Depends on the specific diagnosis o Resting versus stress studies can be valuable especially with ADD Nuclear Medicine Findings Head injury: Patients with symptoms and negative anatomic studies often have abnormal SPECT scans o Location of abnormality dependent on mechanism of injury Typical post-trauma distribution in tips of temporal lobes and floor of frontal lobes Location of abnormality will vary with mechanism of injury o Nuclear imaging is more sensitive than CT or MR, and may correlate better with clinical findings Obsessive-compulsive disorder (OCD): Increased activity in anterior cingulate is most commonly described o Also variably described are increased orbitofrontal cortex, increased basal ganglia, increased medial frontal, decreased frontal, decreased right caudate, decreased right thalamus 653 Diagnostic Imaging Nuclear Schizophrenia: Decreased activity in frontal lobes, referred to as hypofrontality, is most commonly described o Variably described are decreased basal ganglia, decreased temporal lobes, decreased left temporal lobe o Some studies show increased activity in visual or auditory cortex if tracer is injected during visual or auditory hallucinations o Some findings are likely related to effect of drugs used for treatment or recreation o SPECT patterns in mental illness may relate more closely with specific symptoms such as hallucinations than with specific psychiatric diagnoses P.5-75 SPECT findings that cross clinical classification boundaries are often associated with common symptoms Depression: Decreased activity in frontal lobes is most commonly reported finding o Variably described are decreased frontal poles, temporal lobes, anterior cingulate, left caudate o Severe depression may show generalized decreased cortical activity o Hypoactive areas often improve secondary to an attention task Task can be a standard mental performance task such as the Conner Performance Task Mental tasks such as math problems can be easily designed for individual patients if desired Task is administered from 10 minutes pre to 10 minutes post tracer injection Typical ADD response to stress, worsening in frontal and temporal lobes, is the opposite of depression o Patients depressed on a vascular basis from excessive antihypertensive medication will show same decreased frontal pattern Scan will normalize upon adjustment of medication and improvement of symptoms Panic disorder and anxiety: Frontal hypoactivity has been described as well as basal ganglia hyperactivity Substance abuse: Diffuse cortical decreased activity seen with substances such as alcohol, marijuana, barbiturates, pain killers, narcotics, and nicotine o Focal decreased activity seen most commonly with cocaine and crack Focal hypoactivity also seen with inhaled glue, paint, and solvents Abnormalities reverse if due to vascular spasm or persist if due to infarction o Pre-existing mental problems that predispose toward substance abuse may themselves cause perfusion abnormalities Some pre-existing abnormalities may improve with non prescribed drugs and illegal substances Decreased frontal lobe activity in depression often improved by stimulants Increased temporal lobe activity in violent patients may normalize with depressants Criminal and antisocial behavior: Decreased prefrontal, frontal, and temporal activity are most commonly described Violence: Increased cingulate activity, decreased prefrontal activity, temporal lobe increases and decreases often on the left, increased caudate and/or thalamic activity have been described Attention deficit disorder (ADD): Normal or decreased activity frontal and/or temporal lobes at baseline the most commonly described finding o Hypoactive or normal frontal and/or temporal lobes at rest often worsen secondary to an attention task o Attention task details described above under depression 654 Diagnostic Imaging Nuclear Toxic exposure and multiple chemical sensitivity: Variety of findings have been described in this controversial area including patchy cortical increases or decreases, and overall decreased cortical activity Imaging Recommendations Best imaging tool o ECD SPECT, Ceretec SPECT, and FDG PET Normal distribution and abnormal findings vary with the modality Best to adopt a single modality and SPECT agent and develop familiarity with it o SPECT: Numerous reports of findings, although definitive research has not yet confirmed diagnostic/therapeutic value o FDG PET: Less clinical experience in use for psychiatry, drug abuse or forensics than SPECT o MRI/fMRI/CT: No consistent findings Protocol advice o PET: 10 mCi FDG (fasting), image at 60 o SPECT: 20-30 mCi, image at 60-90 o Normal distribution on SPECT and PET varies with environment Infants and children have different normal appearance from adults P.5-76 SPECT normal distribution slightly different for HMPAO vs ECD ECD normal distribution varies slightly over time HMPAO: Amount of blood pool activity varies with time to imaging; consistent timing important Eyes should be consistently closed or open especially with SPECT, preferably open Movement, visual and auditory stimuli will affect the normal distribution Standard environment with SPECT should be maintained for 10 minutes after injection o SPECT imaging should be performed on multiple head cameras o Medications affecting brain function should be discontinued if possible unless effect is being assessed o SPECT collimation, filtering and image processing should be consistent o Image display parameters should be kept consistent, preferably using computer monitors over printed images Studies can be viewed in grayscale or color Beware of step color scales o Interpretation criteria should be consistent whether subjective, semiquantitative, or quantitative Beware of normal databases as screening of participants often does not consider psychiatric conditions, drugs, differences in equipment, acquisition, processing Subjective assessment is an acceptable protocol if consistently applied Reference should be made to a normal structure, often cerebellum, assuming no known cerebellar abnormality or cerebellar diaschisis If cerebellum is abnormal, reference structures can be pons or homotopic contralateral regions Additional nuclear medicine imaging options: Receptor imaging technologies not yet in practical use Correlative imaging features: Functional imaging abnormalities may or may not have anatomic correlates DIAGNOSTIC CHECKLIST Image Interpretation Pearls PET and SPECT normal distribution differ o Basal ganglia, thalamus and cerebellum hotter relative to cerebral cortex on SPECT than on PET 655 Diagnostic Imaging Nuclear o After early childhood, anterior to posterior gradient on PET but not SPECT PET frontal > occipital uptake to age 30 or 40, then frontal < occipital Forensic and ethical issues o Functional brain imaging in forensic situations such as criminal cases and personal injury is controversial o Diagnostic patterns for many psychiatric diagnoses are not generally agreed upon and have not been confirmed Scan findings often relate more to specific symptoms and less to disease classifications o Delineating brain scan abnormalities is not same as determining cause or prognosis Brain scan abnormalities are often unequivocal, but etiology or chronology may not be as clear cut Care should be taken attempting to extrapolate appearance of brain at time of imaging to its state at prior time when an antisocial action occurred Tracer can be injected during mental tasks, or under the effects of prescription drugs, recreational drugs, or alcohol SELECTED REFERENCES Oner O et al: Regional cerebral blood flow in children with ADHD: changes with age Brain Dev 27(4):279-85, 2005 Smith DJ et al: The use of single photon emission computed tomography in depressive disorders Nucl Med Commun 26(3):197-203, 2005 Benabarre A et al: Clinical value of 99mTc-HMPAO SPECT in depressed bipolar I patients Psychiatry Res 132(3):285-9, 2004 Carey PD et al: Single photon emission computed tomography (SPECT) of anxiety disorders before and after treatment with citalopram BMC Psychiatry 4:30, 2004 Graff-Guerrero A et al: Correlation between cerebral blood flow and items of the Hamilton Rating Scale for Depression in antidepressant-naive patients J Affect Disord 80(1):55-63, 2004 Hendler T et al: Brain reactivity to specific symptom provocation indicates prospective therapeutic outcome in OCD Psychiatry Res 124(2):87-103, 2003 Parsey RV et al: Applications of positron emission tomography in psychiatry Semin Nucl Med 33(2):12935, 2003 Volkow ND et al: Positron emission tomography and single-photon emission computed tomography in substance abuse research Semin Nucl Med 33(2):114-28, 2003 Kaya GC et al: Technetium-99m HMPAO brain SPECT in children with attention deficit hyperactivity disorder Ann Nucl Med 16(8):527-31, 2002 10 Soderstrom H et al: Reduced frontotemporal perfusion in psychopathic personality Psychiatry Res 114(2):81-94, 2002 11 Brower MC et al: Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review J Neurol Neurosurg Psychiatry 71(6):720-6, 2001 12 Camargo EE: Brain SPECT in neurology and psychiatry J Nucl Med 42(4):611-23, 2001 13 Videbech P et al: The Danish PET/depression project: PET findings in patients with major depression Psychol Med 31(7):1147-58, 2001 14 Soderstrom H et al: Reduced regional cerebral blood flow in non-psychotic violent offenders Psychiatry Res 98(1):29-41, 2000 15 Amen DG et al: High resolution brain SPECT imaging of marijuana smokers with AD/HD J Psychoactive Drugs 30(2):209-14, 1998 16 Amen DG et al: Visualizing the firestorms in the brain: an inside look at the clinical and physiological connections between drugs and violence using brain SPECT imaging J Psychoactive Drugs 29(4):307-19, 1997 17 Amen DG et al: Brain SPECT findings and aggressiveness Ann Clin Psychiatry 8(3):129-37, 1996 P.5-77 Image Gallery 656 Diagnostic Imaging Nuclear DDx: Marijuana Acute Exposure Effect (Left) Coronal brain SPECT shows relative decreased activity over the anterior cingulate gyrus in a depressed adult Bilateral temporal lobe defects are also present (Right) Coronal brain SPECT shows a normal amount of labeling of the anterior cingulate gyrus Bilateral temporal lobe defects are incidentally noted in this schizophrenic adult (Left) Coronal brain SPECT shows abnormally increased activity in the anterior cingulate gyrus in this adult with obsessive compulsive disorder Bilateral temporal defects are also seen (Right) Coronal brain SPECT shows a hot left caudate nucleus in this adult with OCD Also seen are bilateral temporal lobe defects Anterior cingulate labeling is borderline 657 Diagnostic Imaging Nuclear (Left) Right lateral brain SPECT shows no hot foci in adult with obsessive compulsive disorder on a study injected at rest (Right) Right lateral brain SPECT (in the same patient as left) shows increased activity along the cingulate gyrus on another study with tracer injection during performance of a mental attention task P.5-78 (Left) Coronal brain SPECT shows bilateral frontal decreased activity in this depressed adult See next image (Right) Sagittal brain SPECT (in the same patient as left) shows frontal lobe decreased activity between the arrows This nonspecific finding can also be seen in other disorders 658 Diagnostic Imaging Nuclear (Left) Coronal brain SPECT shows bilateral decreased temporal activity as well as a hot right caudate nucleus in an adult with a history of criminal violence (Right) Axial brain SPECT shows much less than average cerebellar activity The cerebellum should not be used as an internal standard in this patient (Left) Brain SPECT on base surface map of a rest injected study shows decreased bilateral frontal and temporal activity in a depressed adult (Right) Brain SPECT on base surface map (of same patient as left) injected during performance of an attention task shows significant improvement typical of depression P.5-79 659 Diagnostic Imaging Nuclear (Left) Brain SPECT on base surface map of a murderer shows significant defects in both frontal and temporal lobes (Right) Brain SPECT on this vertex surface map (same patient at left) shows additional bilateral parietal and occipital defects (Left) Coronal brain SPECT shows a left temporal hot spot coupled with bilateral temporal defects in an adult with a history of violent behavior (Right) Coronal brain SPECT shows increased thalamic , cingulate , and caudate activity as well as bilateral temporal decreased activity in an adult with a history of violence 660 ... 13 68 U 13 70 V 13 71 W 13 71 Y 13 71 Z 13 71 Diagnostic Imaging Nuclear Diagnostic Imaging Nuclear Cover Authors... Failure 11 17 Renal Masses 11 27 Renal Cell Carcinoma 11 31 Pyelonephritis 11 38 Renal Transplant 11 45 Renal Function Quantification... 11 55 II Collecting System 11 62 Obstructive Uropathy 11 62 Reflux Uropathy 11 69 Urinary Bladder and Epithelial Cancer 11 76 III Testes