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MINOSHIMA CNS Molecular Imaging.Pptx Molecular Imaging in Neurology Clinic 2019 Perfusion Glucose Dopamine Amyloid Molecular Imaging in CNS Diseases Satoshi Minoshima, MD, PhD Department of Radiology and Imaging Sciences CBF SPECT FDG PET DAT SPECT Amyloid PET University of Utah Current Clinical Applicaons FDGWhich PET patient shows hasmore Alzheimer’s marked abnormalities. disease? • FDG PET – Demena: Alzheimer vs frontotemporal – Epilepsy: Pre-surgical localizaon – Brain tumor: Recurrence vs. necrosis • Amyloid PET – Possible Alzheimer; mild cognive impairment • Dopamine SPECT – Benign tremor vs. neurodegenerave Parkinsonian – Demena: Alzheimer vs. Demena with Lewy bodies Alzheimer’s disease No dementia FDG PET Case: 67 yrs, dementia, MMSE 23/30 J Nucl Med 1995;36:1238-1248 Case: 57 yrs female, impaired word comprehension, agnosia Minoshima et al. 2002 Left Temporal Lobe Epilepsy Left Temporal Lobe Epilepsy Intractable seizure: Pre-surgical FDG PET Statistical Mapping – Z-score Maps Male, 38 years old, memory loss, generalized tonic/clonic seizure Limbic Encephalitis Amyloid PET Robin Smithuis, Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands Alzheimer’s Disease Amyloid and Tau PET Neurofibrillary tangle Tau Senile Plaque Amyloid VA North Texas Health System William Jagust et al., Neuron 2016; The Telegraph March 2, 2016 Negative Positive Dose and Imaging Timing Radiotracer Recommended Waiting Period Acquisition Dose/Activity 18F-Florbetapir 370 MBq (10 30-50 minutes 10 minutes mCi) 18F-Florbetaben 300 MBq (8 mCi) 45-130 minutes 20 minutes 18F- 185 MBq (5 mCi) 90 Minutes 20 minutes Flutemetamol Rowe CC and Villemagne VL J Nucl Med 2011;52:1733-1740 Chet Mathis, ALZForum TI-weighted images from old MRI scanner? Is this amyloid PET positive or negative? Is this amyloid PET positive or negative? Negave amyloid PET • Indicates sparse to no amyloid plaques • Inconsistent with a neuropathological diagnosis of AD and reduces the likelihood that a paent's cognive impairment is due to AD. Is this amyloid PET positive or negative? Is this amyloid PET positive or negative? Posive amyloid PET • Indicates moderate to frequent amyloid plaques • This amount of amyloid plaque is present in AD paents, but may also in paents with other neurologic condions & in older people with normal cognion. • A posive scan DOES NOT establish a diagnosis of AD, or other cognive disorder. Appropriate Situations 1) Possible Alzheimer’s disease (AD) with an atypical clinical Imaging Dementia—Evidence for course or an etiologically mixed presentation Amyloid Scanning (IDEAS) Study 2) Unexplained Mild Cognitive Impairment (MCI), persistent and progressive A Coverage with Evidence Development 3) Atypically early age of onset (65 years or less in age) Longitudinal Cohort Study Sponsored by: Alzheimer’s Association Managed by: American College of Radiology American College of Radiology Imaging Network Advisor: Centers for Medicare & Medicaid Services (CMS) IDEAs Aims PET-MRI Scanner: Structure, Amyloid, Perfusion • Aim 1: To assess the impact of Aβ PET imaging on the management of paents meeng Appropriate Use Criteria (AUC) • Aim 2: To assess the impact of Aβ PET imaging on hospital admissions and emergency room visits in paents enrolled in the study cohort over 12 months Drzezga, Barthel, Minoshima, Sabri, J Nucl Med 2014 FDA Approval Jan 2011 Dopamine Transporter SPECT [F-18]DOPA [C-11]DTBZ [F-18]FP-DTBZ [C-11]MPH [I-123]β-CIT [I-123]FP-CIT [I-123]Altropane [Tc-99m]TRODAT [C-11]RAC [I-123]IBF D2 [I-123]IBZM DaTscan: Current Indicaon Parkinsonian Syndrome • • Differenate essenal tremor (ES) from Progressive supranuclear palsy (PSP) Parkinsonian syndrome (idiopathic Parkinson’s • Mulple system atrophy (MSA) disease, mul-system atrophy, and • Demena with Lewy body disease (DLB) progressive supranuclear palsy, etc) • Corco-basal (ganglionic) degeneraon (CBD) • Frontotemporal demena (FTD) • Differenal diagnosis of DLB from AD (Europe) • A rigid variant of Hunngton’s disease • Wilson’s disease • Others “Comma” “Dot” www.fda.gov/downloads/AdvisoryCommittees/.../UCM186404.pdf www.fda.gov/downloads/AdvisoryCommittees/.../UCM186404.pdf Case Most appropriate • findings 66 year old female • Tremor 1. Normal uptake • Family history 2. Decreased uptake in the putamen • Essenal tremor versus Parkinson’s disease 3. Decreased uptake in the caudate nucleus 4. Significant asymmetry Case Most appropriate findings • 65 year old male 1. Normal uptake • Current diagnosis of Parkinson’s disease 2. Decreased uptake • Fine tremor, both hands, gait slowing, rigidity in the putamen 3. Decreased uptake • Worsening motor symptoms in the caudate • MRI microvascular disease nucleus • Quesonable levodopa responsiveness 4. Significant asymmetry Most appropriate Most appropriate findings: findings: 1. Increased 1. Increased background background uptake uptake 2. Normal caudate 2. Normal caudate uptake uptake 3. Decreased 3. Decreased striatal uptake striatal uptake 4. Significant 4. Significant asymmetry asymmetry Different Types of Region of Interest Specific Binding or Binging Potential (simplified) = (striatal uptake – background) / background Morton et al, Nuc Med Commun 2005;26:1139 Morton et al, Nuc Med Commun 2005;26:1139 MR-guided High intensity Focused Ultrasound (HIFU) Summary • Clinically available molecular imaging • Demena, epilepsy, movement disorders • FDG PET and stascal mapping • Amyloid PET and Appropriate Use Criteria • DAT SPECT for movement disorders Dobrakowski, et al., Interv Neuroradiol. 2014;20(3):275-82 New FDA-approved Non-invasive Therapy for Essenal Tremor Salt Lake City – UU, The Temple, Sundance Film Festival, Goldman Sachs, Adobe What the Neurosurgeon Needs to Know • Presurgical Imaging Brain Tumor Imaging: What the Surgeon Needs to Know • Intraoperative Imaging • Postoperative Imaging Sarah T. Menacho, M.D. Assistant Professor of Neurosurgery and Critical Care Brain and Spine Imaging Conference 8/8/2019 Pre-Surgical Imaging Differential Diagnosis • Tumor • Differential Diagnosis • Stroke • What further imaging is recommended • Demyelinating • Imaging interpretation • Vascular Malformation • Radiation Necrosis • Pineal lesions • LMD • Lymphoma When Not To Operate • Admitted to MICU, intubated, on pressors, GCS 11T • 58 year old female presenting with altered mental status, fever, elevated wbc count following recent lumbar fusion surgery • 66 year old male with 1 month of headaches, recently • Pathology: Renal Cell Carcinoma treated for sinus infection without relief • Taken to OR for transsphenoidal biopsy Further Imaging Recommended MR Spectroscopy • fMRI • MR spectroscopy • CTA/DSA • CT C/A/P • Lab Values • LP Imaging Interpretation • 33 year old female with first-time seizure episode • Eloquent cortex • Proximity to vasculature • Extension into the ventricle • Osseous Invasion • All of the above affects my ability to obtain a GTR, and changes how I counsel the patient • fMRI obtained to locate Wernicke’s area • Pathology: AA Intraoperative Imaging • 17 year old female with progressively worsening headaches • OR for right frontal craniotomy and resection of tumor in Postoperative Imaging intraoperative MRI suite • Gross Total Resection? • Complications? • Radiology Humor “Interval placement of right frontal approach ventriculostomy catheter” Some Imaging is Obvious… • 53 year old male found down on the ski slopes at Deer Valley Thank You! Questions? • Karen Salzman, M.D. • Brad Wright, M.D. • Anne Osborne, M.D. • Jeff Anderson, M.D., PhD • Richard Wiggins, M.D. • Chris Davidson, M.D. • Troy Hutchins, M.D. • Edward Quigley, M.D. • Lubdha Shah, M.D. Acute Pediatric CNS Disorders Disclosures • Author – Elsevier, Wolters Kluwer, and CRC Press • Honoraria for teaching • Compensaon Gary L. Hedlund, D.O. – Medical-legal case review & tesmony University of Utah School of Medicine Department of Radiology Salt Lake City, Utah Seizing 4-year-old male Courtesy Dr. Nicholas Satovick DDx Varicella-Zoster Cerebellis • Infectious / Autoimmune • Toxic / Metabolic • Neoplastic • Other Opioid Toxicity Neuroectodermal Tumor Hemophagocyc Heat Stroke Lymphohisocytosis (HLH) Heat Stroke Overview Heat Stroke Risks in Pediatrics • Core body temperature > 40°C • Children and infants are more vulnerable to • Thermoregulatory failure heat stroke! • Multi-organ failure – High surface area : body mass • Signs and symptoms: – Lower proximal to distal heat conductance – severe fatigue, diarrhea, erythematous hot dry skin, – Less robust total sweat producon diaphoresis, nausea, emesis, dizziness, confusion, – Insufficient acclimaon to high heat condions à seizure, weakness, tachycardia inadequate HSP synthesis Heat Shock Proteins and Heat Stress Pathophysiology of Heat Stroke • Heat stress acvates HSP • HSP acvaon: Protects cells from the • Mimics Sepsis – increased metabolic demand, splanchnic hypoperfusion effects of the inflammatory acute-phase hypotension, rhabdomyolysis, hepato-renal failure response • Cytokine elevaon • Biologically adapve • Coagulaon cascade • Other roles of HSPs: • Endothelial-cell injury and diffuse vascular thrombosis – protein translocaon • DIC even aer core temperature normalizaon – apoptosis inhibion • Acvaon of heat shock proteins (HSP) Neuroimaging Spectrum Obtunded 6-year-old male • Several pathophysiological alteraons – Tropism for Purkinje cells • Parenchymal T2 prolongaon • Variable diffusivity alteraons • Occasional hemorrhage – Associated brain injury • Thalami (paramedian nuclei) • Hippocampi • Splenium of corpus callosum • Interarterial watershed zones DDx • ANE/H1N1 • MELAS /
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