__ II IIII I III I I II III I IIIII I Evolution of Technetium-99m-HMPAO SPECT and Brain Mapping in a Patient Presenting with Echolalia and Palilalia

Rudi A. Dierckx, Jos Saerens, Peter P. De Deyn, Werner Verslegers, Peter Marien, and Johan Vandevivere

Departments of Nuclear Medicine and Neurology, A.Z.-Middelheim, Antwerp and Laboratory of Neurochemistry, Born Bunge Foundation, University of Antwerp, Antwerp, Belgium.

pronounced symptoms on the left. The patient had refused all A 78-yr-otd woman presented with transient echolalia and medication (LDOPA 100 mg, benserazide 25 mg rid, and biperi- palilalia. She had suffered from Parkinson's disease for 2 yr. deenchiorohydrate 2 mg 2.5/day) several days before admission. Routine laboratory examination showed hypotonic hyponatre- Routine laboratory examination demonstrated a low serum mia, but was otherwise unremarkable. Brain mapping re- sodium, 124 mEq/liter; a normal potassium, 4.3 mEq/liter; a low vealed a bifrontal delta focus, more pronounced on the right. chlonde, 89 mEq/liter, and a normal bicarbonate, 26 mEq/liter. Single photon emission computed tomography (SPECT) of Serum osmolality was 272 mOsm/kg; urinary osmolality, 713 the brain with technetium-99m labeled d,I hexamethyfpropyl- mOsm/kg; and urinary sodium, 14.4 mEq/24 hr. Other labora- ene-amine oxime (~r"Tc-HMPAO), performed during the acute tory examinations including thyroid hormone levels were normal. episode showed relative frontoparletat hypoactivity. Brain Neurologic examination on admission demonstrated a slight mapping performed after disappearance of the echolalia and rest tremor and coghwheel rigidity, more pronounced on the left; palilalia, which persisted only for 1 hypokinesia and mutism, with only slight mimic and motor responses to verbal stimuli. Echolalia is a pathologic language behavior character- Bilateral Babinski signs and disinhibition reflexes, including ized by contextually inappropriate repetition of verbal snout, masseter and palmomental reflexes, were present. stimuli uttered by the interlocutor (1). Palilalia, on the On the 14th day after admission, her mental status had nor- other hand, entails the involuntary repetition twice or malized. Because of increased extrapyramidal symptoms LDOPA more of one's own terminal sounds, words, phrases, or treatment was restarted. The patient was discharged 3 wk after sentences (2). Actual topographic knowledge of associated hospitalization. lesions in echolalia and palilalia is mostly based on post- mortem studies of patients with dementia, especially Pick's Complementary Examinations disease (1,2). We report on the evolution of ~9rnTC- Computed tomography (CT) scan of the brain after contrast injection on Day 4, magnetic resonance imaging (MRI) on Day HMPAO SPECT and brain mapping in a patient present- 14, and echo-Dopplertomography of the carotid vessels were ing with transient echolalia and palilalia. unremarkable. On Day 5, an electroencephalogram (EEG) dem- onstrated a diffuse slow background activity ofa b,a-rhythm with PATIENT REPORT a mean amplitude of 40 uV. There were numerous monomorph A 78-yr-old woman was admitted because of spatial and tem- discharges of a delta activity of 2.93 Hz with an amplitude of 200 poral disorientation and excitation with verbal aggression. She uV, more pronounced in the frontal region. No graphoepileptic had suffered from Parkinson's disease for 2 years, with more changes were noted. Brain mapping of 3-sec epochs of stationary 6 discharges revealed a reproducible and consistent delta focus of 426.8 uV Received January 14, 1991; revision accepted April 29, 1991 with a peak frequency of 2.93 Hz, more markedly on the right For reprints contact: Rudi A. Dierckx, MD, Nucleaire Geneeskunde, side (Fig. 1). This focus was also detected by quantified analysis O.CM.W.-Antwerpen, A.Z.-Middelheim, Lindendreef 1, 13-2020 Antwerpen, ~-~gium. of the diffusely slowed background activity.

SPECT in Echolalia and Palilalia • Dierckx et al 1619 • , ~ .._~m ...... ~---~ FIGURE 2. First two rows: ~mTc-HMPAO SPECT of the brain FIGURE 1. Brainmapping on Day 5: demonstration of a frontal on Day 4, performed during exacerbation of the symptomatology. deltafocus, more markedly on the right side. Sagittal slices are depicted progressing from right to left, with the nose oriented towards the left side of the picture. This SPECT examination shows a bifrontoparietal defect, larger on the right. Last two rows: control ~"q'c-HMPAO SPECT of the brain on On Day 4, brain SPECT examination was performed using 15 Day 19 after disappearance of echolalia and palilalia. The bifron- mCi of ~"Tc-labeled hexamethylpropyleneamineoxime (Amer- toparietal defect is now small when compared with the first sham. UK)and a single head rotating gammacamera (Orbiter 75, examination. Siemens, FRGI with a low-energy all-purpose collimator inter- faced to an Elscint computer. The study was initiated 10 rain ~st-radiopharmaceutical injection. A total of 64 projection im- ages were acquired over a 360* rotation, 30 sec/frame, radius of nature of the finding can be excluded. Also, although not rotation 15 cm. The reconstruction was performed using filtered completely overlapping, the focus of brain mapping backprojection with a Shepp-Logan-Hanning filter. pointed to the same location. Brain mapping is the topo- Transaxial slices were reoriented parallel to the orbitomeatal axis and coronal and sagittal plane images were created. SPECT graphic representation of the quantified analysis of the of the brain demonstrated a large bifrontoparietal defect, larger bioelectrical activity of the brain. on the right (Fig. 2). A repeat brain SPECT on Day 11 showed In both echolalia and palilalia, frontal lobe involvement the same disturbances. Control brain mapping on Day 15, how- has been demonstrated, but their simultaneous occurrence ever, was normal. A third SPECT on Day 19 showed a smaller represents an exception. In this patient, symptomatology bifrontoparietal defect. proved transient and upon re-examination no neuropsy- chological findings suggestive of frontal lobe type dementia DISCUSSION were found. Finally, a vascular event or seizure disorder Echolalia has been reported to occur in a variety of seems improbable because of the history and complemen- neurologic and psychiatric syndromes and diseases. It has tary examinations. been noted in the presence of a lesion involving the pos- The patient presented suffered from Parkinson's disease. terior pan of the temporal cortex with preservation of the Few investigators have reported on the occurrence of midtemporal convolution, the inferior frontal speech area changes in regional cerebral blood flow in patients with and the arcuate fasciculus, connecting the two (3). Palilalia Parkinson's disease (5-8). The predominant symptoma- has been noted in epilepsy (4) and during electrical stim- tology, lateralization, and treatment may play a role in the ulation of the inferior part of the ascendent parietal and pattern found but have remained unchanged during the especially frontal convolutions of the left hemisphere evolution of SPECT findings in our patient. and the foot of the third frontal convolution of the Tentatively, the acute interruption of the parkinsonian right hemisphere (4). It has also been described during medication or, more likely, the hyponatremia caused the stimulation of the internal side of the first frontal convo- .symptoms. Hyponatremia was attributed to extrarenal loss lution (4). and resolved after l week under proper treatment. Hypo- Finally, it has also been noted in postencephalitic Par- thetically, the functional changes demonstrated may have kinson and pseudobulbar syndromes (2). In these cases, it been secondary to a metabolic or toxic encephalopathy, is usually associated with diffuse pallidostriatal disease (2). based on the assumption that these parameters indirectly In the patient presented, SPECT was performed because might reflect local brain metabolism. of a normal CT scan and MRI in the presence of major acute neuropsychological changes. SPECT demonstrated CONCLUSIONS a large bifrontoparietal defect. Because of the size and the Echolalia and papilalia may be related to functional confirmation of the defect by repeat SPECT, an accidental changes in the frontoparietal regions. Two functional im-

1620 The Joumal of Nuclear Medicine • Vol. 32 ,, No. 8 ° August 1991 aging techniques, 99mTc-HMPAO SPECT and mapping of REFERENCES the brain, revealed focal dysfunction, whereas morphologic 1, Brain R. Speech disorders. London: Butterwonhs, 1965. imaging techniques, such as CT scan and MRI did not 2. Critchley M. Aphasiology and other aspects t!f language. London: Edward detect any structural lesion. In the patient presented, the Arnold, 1970. electrophysiologic changes temporally correlated well with 3. Darley FL, Aronson AE, Brown JK. Motor speech disorders. Philadelphia: WB Saunders, 1975. the clinical evolution while brain SPECT remained abnor- 4, Lecours AR, Lhermitte F. L'aphasie, Paris: Fiammarion, 1979. mal. Finally, subclinical dysfunction as demonstrated by 5. Podreka I, Suess E, Brticke T, et al. SPECT-Untersuchungen mit ~"-Tc- perfusion SPECT may persist for weeks. hexamethy-propylen-amme-oxim (9~Tc-HMPAO) beim Parkinson-Syn- drom und bei Demenz. Nucl Med 1987:26:96-99. 6. Smith F'W, Gemmell HG, Sharp PF, Besson JAO. Technecium-99m HMPAO imaging in patients with basal ganglia disease. Br J Radio/ ACKNOWLEDGMENTS 1988:61:914-920. 7. Costa IX?, Ell PJ, Burns A, et al. CBF tomograms with ~mTc-HMPAO in The authors wish to thank Andre Dobbeleir, for his technical patients with dementia (Alzheimer type and HIV) and Parkinson's dis- ease--initial results. J Cerebr Blood Flow Metab 1988;8:S 109-115. advice and the personnel of the Department of Nuclear Medicine 8. Neumann C, Baas H, Hefner R, Hot G. SPECT-Befunde bei Hemiparkin- for their assistance during the investigations. son-Syndrom mit WmTc-HMPAO. Nud Med 1989:28:92-94.

SPECT in Echolalia and Palilalia • Dierckx et al 1621