Publications · Brochures Brain Imaging A Technologist’s Guide Produced with the kind Support of Editors Fragoso Costa, Pedro (Oldenburg) Santos, Andrea (Lisbon) Vidovič, Borut (Munich) Contributors Arbizu Lostao, Javier Pagani, Marco Barthel, Henryk Payoux, Pierre Boehm, Torsten Pepe, Giovanna Calapaquí-Terán, Adriana Peștean, Claudiu Delgado-Bolton, Roberto Sabri, Osama Garibotto, Valentina Sočan, Aljaž Grmek, Marko Sousa, Eva Hackett, Elizabeth Testanera, Giorgio Hoffmann, Karl Titus Tiepolt, Solveig Law, Ian van de Giessen, Elsmarieke Lucena, Filipa Vaz, Tânia Morbelli, Silvia Werner, Peter Contents Foreword 4 Introduction 5 Andrea Santos, Pedro Fragoso Costa Chapter 1 Anatomy, Physiology and Pathology 6 Elsmarieke van de Giessen, Silvia Morbelli and Pierre Payoux Chapter 2 Tracers for Brain Imaging 12 Aljaz Socan Chapter 3 SPECT and SPECT/CT in Oncological Brain Imaging (*) 26 Elizabeth C. Hackett Chapter 4 Imaging in Oncological Brain Diseases: PET/CT 33 EANM Giorgio Testanera and Giovanna Pepe Chapter 5 Imaging in Neurological and Vascular Brain Diseases (SPECT and SPECT/CT) 54 Filipa Lucena, Eva Sousa and Tânia F. Vaz Chapter 6 Imaging in Neurological and Vascular Brain Diseases (PET/CT) 72 Ian Law, Valentina Garibotto and Marco Pagani Chapter 7 PET/CT in Radiotherapy Planning of Brain Tumours 92 Roberto Delgado-Bolton, Adriana K. Calapaquí-Terán and Javier Arbizu Chapter 8 PET/MRI for Brain Imaging 100 Peter Werner, Torsten Boehm, Solveig Tiepolt, Henryk Barthel, Karl T. Hoffmann and Osama Sabri Chapter 9 Brain Death 110 Marko Grmek Chapter 10 Health Care in Patients with Neurological Disorders 116 Claudiu Peștean Imprint 126 n accordance with the Austrian Eco-Label for printed matters. Eco-Label with the Austrian for n accordance Printed i Printed (*) Article was written with the kind support of and in cooperation with: 3 Foreword During the past two decades the European becoming standards as diagnostic tools. Association of Nuclear Medicine (EANM) has Following its recent development, PET/MRI become a leading institution for research has also found many suitable clinical ap- and education in all aspects of nuclear med- plications in brain imaging that have helped icine (NM), including tracer development, this new hybrid technique to find a role in scanning technology and multimodality and clinical practice and research protocols. hybrid imaging. Within the last 5 years, the EANM has followed the “Go Clinical” motto, I would like to thank all those who have with the intention of advancing the role contributed to this project as authors and of NM into clinical and research protocols. reviewers, without whom the book would This challenge was accepted by the EANM not have been possible. I would also like to Technologist Committee (TC), which has thank SNMMITS (Society of Nuclear Medi- attempted to ensure that technologists’ cine and Molecular Imaging Technologist education, research and daily practice have Section) and the EANM Neuroimaging a strong clinical impact. This intention is also Committee for their help and high-quality reflected in the decision to dedicate the contributions. Technologist Guide 2015 to brain imaging. Special thanks are due to Pedro Fragoso EANM Technologist guides are developed Costa, Andrea Santos and Borut Vidovic for and printed on a yearly basis for presenta- their incredible enthusiasm and compe- tion at the EANM Annual Congress. They tence in dealing with the editorial duties are specifically aimed at NM technologists, and organisational work. Finally I remain ex- radiographers and all other healthcare pro- tremely grateful to the EANM Board, EANM fessionals working or intending to work in a Executive Office, Technologist Committee nuclear medicine department. and all the EANM committees involved in the project. After dedicating three books specifically to PET/CT, we have focussed on specific clini- With my warmest regards, cal fields in which NM has a strong impact on clinical procedures, such as myocardial Giorgio Testanera perfusion imaging and brain imaging. Brain Chair, EANM Technologist Committee imaging was strongly influenced by the PET/CT revolution and is now also a field of high interest for radiopharmaceutical research, thanks to the development of 11C tracers, somatostatin analogues and amyloid-based tracers, which are rapidly 4 Introduction Andrea Santos, Pedro Fragoso Costa Neurological disorders are already affecting In this book, we begin by describing the hundreds of millions of people worldwide, of brain’s anatomy, physiology and pathology whom more than 50 million suffer from epi- (Chapter 1). After this, tracers for brain imaging lepsy and around 35.6 million have Alzheim- are discussed (Chapter 2). The following two er’s disease or other dementias. Furthermore, chapters provide an overview on the imaging greater life expectancy and the overall ageing of oncological disease by means of SPECT or of the general population in both developed SPECT/CT and PET/CT techniques (Chapters 3 and developing countries will contribute to and 4). Imaging in neurological and vascular continued increases in the prevalence of many brain diseases is also analysed, focussing first chronic and progressive physical and mental on SPECT and SPECT/CT technology and conditions, including neurological disorders [1]. then on PET/CT (Chapters 5 and 6). The use of PET/CT in brain tumour radiotherapy planning Diagnostic nuclear medicine investigations is discussed in Chapter 7. The application of EANM have evolved from being a research modality the emerging technology of PET/MRI for brain in the evaluation of function and disease of imaging is approached in Chapter 8. Brain im- the central nervous system to an established aging in the case of suspicion of brain death clinical tool in neurology. During recent years, is described in Chapter 9. The final chapter is new technologies and techniques have been devoted to the special health care and surveil- developed in order to improve the quality of lance needs of patients affected by neurologi- the images acquired, thereby enhancing the cal disorders. This extended overview of neu- clinical impact of these techniques. More- roimaging techniques and the clinical state over, radiopharmaceutical development of art will provide a valuable tool to all clinical has allowed SPECT and PET imaging to be- staff, including not only technologists but also come increasingly acute and to cover more physicians, physicists and students interested pathologies. From metabolism to perfusion, in this particular field. brain function has been studied in a variety of conditions, including dementia, epilepsy, The EANM Technologist Committee would movement disorders and brain tumours. like to thank all the authors who have kindly offered their time and expertise, which have These advances represent a challenge for tech- been fundamental to the creation of this book. nologists, given that each new technique and piece of equipment requires optimisation of Andrea Santos protocol design. In the neuroimaging context, Pedro Fragoso Costa technologists also play a key role in patient care, which can be particularly challenging ow- Reference: ing to the inability of patients suffering from 1. Neurological disorders: Public health challenges. neurological disorders to cooperate and also Geneva: World Health Organisation, 2006. the demanding nature of the examinations. 5 Chapter 1 Anatomy, Physiology and Pathology Elsmarieke van de Giessen, Silvia Morbelli and Pierre Payoux The brain serves many important functions, largest structure of the brain and is also divid- including movements, thoughts, learning, ed into left and right hemispheres, which are memory, language, integration and inter- connected through the corpus callosum. The pretation of our senses, and critical functions cerebrum is covered with the cerebral cortex such as respiration. To understand imaging that is folded into gyri and sulci to increase its of the brain it is essential to have knowledge surface. The cerebral cortex can be divided of the anatomy and its normal function. This into four lobes: frontal, parietal, temporal and chapter provides an overview and describes occipital. The frontal lobes are located in the several common brain pathologies. front of the brain and include the primary mo- tor cortex and prefrontal cortex, which is im- Anatomy portant for cognitive and executive functions. Brain structures The temporal lobes are located on both sides The brain consists of three major structures: the of the brain and contain the auditory cortex. brainstem, cerebellum and cerebrum (Fig. 1). On the medial sides of the temporal lobes are The brainstem is the lower structure of the the hippocampus, important for memory for- brain, extending into the spinal cord at the mation, and the amygdala, involved in emo- point where it leaves the skull. It is an impor- tions. The occipital lobes are at the back of the tant relay station and consists of the midbrain, brain and are essential for processing visual pons and medulla oblongata. The medulla information. The parietal lobes are located oblongata is important for primitive functions in between the frontal and occipital lobes; like respiration, blood pressure and heart rate. they include the somatosensory cortex and are involved in integrating sensory informa- tion to form a perception. The basal ganglia are located subcortically, close to the centre of the cerebrum. They play an important role in controlling and regulating activities of the motor system and in