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PET, CT, and MRJ in the Evaluation Applications CONTINUING EDUCATION PET, CT, and MRJ in the Evaluation of Neuropsychiatric Disorders: Current Applications Paul R. Jolles*, Peter R. Chapmant, and Abass Alavi Division ofNuclear Medicine, Department ofRadiology, Hospital ofthe University of Pennsylvania, Philadelphia, Pennsylvania Positron emission tomography (PET) is emerging as a very useful clinical tool and is adding a greatdealto ourunderstandingofthepathophysiologyofcentralnervoussystem(CNS) disorders.Althoughcomputedtomography(CT)andmagneticresonanceimaging(MRI)have hada dramaticimpactonpatientmanagement,thereisoftenanimportantassociated functionabnormalitywhichisbestassessedbyPET.Innormalagingandindementia,theCT andMRIbrainchangesofatrophyandwhitematterabnormalitiesarefrequentlynonspecific. PEThasbeenmorediagnostic,showingcharacteristicregionalmetabolicabnormalities. Evaluation of brain tumors such as astrocytomas with PET has demonstrated better correlation with histologic grade compared to CT. Unlike CT or MRI, PET can help to distinguishradiationnecrosisfromrecurrenttumor,andcandifferentiatetheextentof metabolically active tumor from surrounding edema. PET is useful in evaluating stroke patients,providingbetterprognosticinformationanddemonstratingabnormalitiessoonerthan CT.Inepilepsy,PETappearsto besuperiorto MRIinlocalizingseizurefociinpatientswith partialseizures.In headtraumapatients,metabolicpatternsare beingdeSCribedwhichwill likelyhaveaneffecton patientmanagement.Theuseof PETin schizophreniahasyielded very interesting results, with common patterns of metabolic abnormalities being demonstrated. CT and MRI in these patients have not been very useful. PET has also shown promise in movement disorders such as Huntington's disease. It is now clear that PET is alreadydinicallyusefulandcanprovidevaluableinformationunobtainablebyCTandMRI.As newradioligandsaredeveloped,PETiscertainto assumeanevenmoreimportantroleinthe future. J NuciMed30:1589—1606,1989 he past two decades have been witness to remark the brain have a functional component, sometimes in able progress in our understanding of brain structure the absence of an anatomic lesion. Today, brain func and function, with advances in anatomic and functional tion is best evaluated with positron emission tomogra brain imaging playing a major role. Computed tomog phy (PET). Although lacking the resolution of CT or raphy (CT) and, more recently, magnetic resonance MRI, the advantage of PET over the anatomic imaging imaging (MRI) have provided exceptional anatomic modalities is that biologically important atoms such as detail. However, these modalities are unable to assess nitrogen and carbon can be incorporated into novel the global or regional functional status of the brain. It compounds which allow mapping of regional brain is well known that virtually all abnormalities affecting function and metabolism (Fig. 1). The capabilities of feredby PET enable researchersto measure and image ReceivedMay 19, 1989;revision accepted May 31, 1989. regional blood flow, oxygen and glucose metabolism, Forreprintscontact:AbassAlavi,MD, Div. of NuclearMedi protein synthesis, and neurotransmitter/neuroreceptor cine, Dept. of Radiology, Hospital of the University of Pennsyl systems. With PET now moving from the research vania, Philadelphia,PA 19104. laboratoryinto the clinical nuclear medicine arena, we *pre@ntaddress: Department of Radiology,University of Ar have indeed entered a new era in brain imaging. This kansas for Medical Sciences, 4301 West Markham St., Little Rock, Arkansas72205. paper will deal with the application of PET, CT, and t Present address: Nuclear Medicine & Ultrasound Associates, MRI as currently used in the clinical evaluation of P.O.Box6, Westmead.NSW2145,Australia. common brain abnormalities. Volume30 •Number10 •October1989 1589 to be a common underlying condition (10,11). How ever, the same changes have been found in subjects without hypertension or other identifiable vascularrisk 0 factors (12), and it is possible that several etiologies may be involved. Our preliminary data suggest that deep white matter lesions do not have a significant effect on regional or global metabolic rates. The findings seen on PET in normal aging are some what controversial. Several investigators have reported that there is probably no significant decrease in whole brain glucose metabolism using fiuonne-l8 (‘8F)fluo rodeoxyglucose (FDG) (13—15),although there are other reports showing a decline (16,1 7). However, a number of investigatorshave describeddiminished re gional glucose metabolism in healthy elderly subjects 1―SSin the temporal, parietal,somatosensory, and especially the frontal regions (1 7-21). Relative preservation of posterior metabolism (particularlyin the calcarine cor tex) has also been reported(20,21). A summary of our regional metabolic data in normal aging is presented in Table 1. Whetheror not there is a definite decreasein cerebral a 0 a * blood flow (CBF) or cerebral oxygen metabolic rate FIGURE 1 (CMRO2)as measuredby PET has not been established. RepresentativetransaxialimagesfromanFDG-PETstudy Some workers have described no change with normal ofa young,normalsubjectareshownfromthelevelofthe high convexity (upper left) to the cerebellum (lower right). aging using the nitrous oxide CBF technique (16,22); Notethatthecorticalandsubcorticalstructuresarewell others have reported diminished CBF and/or CMRO2 delineated,andappearrelativelysymmetricbetweenhem (23-26). Although controversial, these findings suggest ispheres. that there may be regional abnormalities in cerebral metabolism in normal aging using PET. There has been much interest in evaluating the AGING AND DEMENTIA changes which occur in the brain in the dementing disorders. The most common cause of dementia is Evaluation of the brain in aging and dementia has Alzheimer's disease (AD), which accounts for at least been extensive, with functional imaging (PET) appear half of the cases. Other causes include multiple infarc ing to have greater sensitivity in detecting early regional tions (multi-infarctdementia) (MID), AD, and MID in changes than CT or MRI. In the normal elderly popu combination, and other less common etiologies such as lation, pathologic studies have reportedregionalneuron normal pressure hydrocephalus, mass lesions, infec loss in the frontal, parietal and temporal lobes (1—3). tions, AIDS, and metabolic/nutritional disorders (27- Typical changes seen on anatomic imaging in these 30). individuals include generalizedventricularenlargement The CT and MRI findings in AD include ventricular and cortical sulcal atrophy; of these findings, sulcal and cortical sulcal enlargement, which are more pro atrophy and the width of the third ventricle appear to be better correlated with aging using CT (4—6).Both TABLE 1 MRI and CT demonstrate the ventricularsystem quite Significant Regional Hypometabolism: Individual ROll well, with MRI being superiorto CT in delineating the Frontal ________Temporal cortical sulci due to lack of beam hardening artifacts. Mtenor corpuscallosum Middletemporalgyms White matter abnormalities are also common in the Cingulate gyms healthy elderly subject, manifesting as periventricular Frontaleye fields _____Parietal Frontalpole Superiorpanetal and/or focal deep white matter hyperintensities on Middlefrontalgyms lObUle MRI, or hypodensities on CT. MRI is the more sensitive Sensonmotor in detecting these lesions (7). Although there is general Primarysensorycortex agreement that the occurrence of white matter abnor malities increases with age (8,9), the actual underlying . 59 ROls in each hemisphere (1 1 8 comparisons by two-tailed pathologic mechanism is controversial. Most reports t-test[youngvs.oldercontrols]). conclude that these abnormalities represent areas of ROlssignificantatp = 0.001. hypoperfusion or infarction, with hypertension found [Reprintedwith permissionRef.(15)]. 1590 Jolles,Chapman,Alavietal TheJournalofNudearMedicine nounced than those seen in normal aging (31-33). However, no findings unique to AD have yet been However, these findings are not specific for AD and described;our own preliminary data showed no signif may be found in many other types of nondementing icant differences between AD patients and controls brain disorders. Focal temporal lobe atrophy with en (37). largement of the surrounding cerebrospinal fluid (CSF) The use of FDG PET in dementia shows promise, as space has been describedin AD patients using CT (34); several types ofdementing disorders have been reported thus far, this appears to be the only anatomic imaging to demonstrate characteristic metabolic patterns. A findingreportedwhich is saidto distinguishAD patients number of studies (21,38,39) have described dimin from normal elderlysubjectswith an 80—90%accuracy. ished regional glucose metabolism in AD patients in White matter disease has also been described in AD the parietal and temporal lobes; the frontal lobes may patients. At present, there is much debate in the litera also demonstrate hypometabolic changes, particularly ture as to whether AD patients have a greater degree of in severe cases (Fig. 2). Relatively preserved glucose white matter abnormality compared to normal elderly metabolism has been noted in the primary visual and controls. Overall,the data suggestthat AD patients and sensonmotor cortices, as well as the cerebellum (Fig. normal controls cannot be reliablydistinguished by the 3). The visual cortex glucose metabolism especially number of focal deep white matter lesions. However, remains quite
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