Vascular diseases and old age mental disorders: an update of neuroimaging findings

Purpose of review To review neuroimaging findings that have been reported in samples of patients with cardiovascular disorders and their association with the onset of Alzheimer`s disease, vascular dementia, depression and bipolar disorder in the elderly and to highlight the implications of these findings to the knowledge about the pathophysiology of psychiatric disorders in old age, as well as their potential clinical implications. Recent findings Vascular risk factors, such as hypertension, diabetes, dyslipidemia, smoking habits and heart failure, have all been associated with signs of cerebrovascular dysfunction, including structural MRI findings of signal hyperintensities, lacunes and stroke and functional imaging findings of brain regional hypoperfusion and hypometabolism. Such brain abnormalities have been found to increase the risk of onset of psychiatric disorder (depression, bipolar and dementia) in old age. Summary As vascular risk factors are potentially modifiable when detected in midlife, the early characterization of brain changes associated with the presence of cardiovascular diseases holds promise to afford clinical applications in psychiatry, providing new perspectives for the prevention of old age psychiatric disorders.

Myocardial Perfusion Imaging Is a Strong Predictor of Death in Women

OBJECTIVES We sought to assess the prognostic value and risk classification improvement using contemporary single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) to predict all-cause mortality. BACKGROUND Myocardial perfusion is a strong estimator of prognosis. Evidence published to date has not established the added prognostic value of SPECT-MPI nor defined an approach to detect improve classification of risk in women from a developing nation. METHODS A total of 2,225 women referred for SPECT-MPI were followed by a mean period of 3.7 +/- 1.4 years. SPECT-MPI results were classified as abnormal on the presence of any perfusion defect. Abnormal scans were further classified as with mild/moderate reversible, severe reversible, partial reversible, or fixed perfusion defects. Risk estimates for incident mortality were categorized as <1%/year, 1% to 2%/year, and >2%/year using Cox proportional hazard models. Risk-adjusted models incorporated clinical risk factors, left ventricular ejection fraction (LVEF), and perfusion variables. RESULTS All-cause death occurred in 139 patients. SPECT-MPI significantly risk stratified the population; patients with abnormal scans had significantly higher death rates compared with patients with normal scans, 13.1% versus 4.0%, respectively (p < 0.001). Cox analysis demonstrated that after adjusting for clinical risk factors and LVEF, SPECT-MPI improved the model discrimination (integrated discrimination index = 0.009; p = 0.02), added significant incremental prognostic information (global chi-square increased from 87.7 to 127.1; p < 0.0001), and improved risk prediction (net reclassification improvement = 0.12; p = 0.005). CONCLUSIONS SPECT-MPI added significant incremental prognostic information to clinical and left ventricular functional variables while enhancing the ability to classify this Brazilian female population into low-and high-risk categories of all-cause mortality. (J Am Coll Cardiol Img 2011;4:880-8) (C) 2011 by the American College of Cardiology Foundation

Quantitative myocardial contrast echocardiography during pharmacological stress for diagnosis of coronary artery disease: a systematic review and meta-analysis of diagnostic accuracy studies

Aims We conducted a meta-analysis to evaluate the accuracy of quantitative stress myocardial contrast echocardiography (MCE) in coronary artery disease (CAD). Methods and results Database search was performed through January 2008. We included studies evaluating accuracy of quantitative stress MCE for detection of CAD compared with coronary angiography or single-photon emission computed tomography (SPECT) and measuring reserve parameters of A, beta, and A beta. Data from studies were verified and supplemented by the authors of each study. Using random effects meta-analysis, we estimated weighted mean difference (WMD), likelihood ratios (LRs), diagnostic odds ratios (DORs), and summary area under curve (AUC), all with 95% confidence interval (0). Of 1443 studies, 13 including 627 patients (age range, 38-75 years) and comparing MCE with angiography (n = 10), SPECT (n = 1), or both (n = 2) were eligible. WMD (95% CI) were significantly less in CAD group than no-CAD group: 0.12 (0.06-0.18) (P < 0.001), 1.38 (1.28-1.52) (P < 0.001), and 1.47 (1.18-1.76) (P < 0.001) for A, beta, and A beta reserves, respectively. Pooled LRs for positive test were 1.33 (1.13-1.57), 3.76 (2.43-5.80), and 3.64 (2.87-4.78) and LRs for negative test were 0.68 (0.55-0.83), 0.30 (0.24-0.38), and 0.27 (0.22-0.34) for A, beta, and A beta reserves, respectively. Pooled DORs were 2.09 (1.42-3.07), 15.11 (7.90-28.91), and 14.73 (9.61-22.57) and AUCs were 0.637 (0.594-0.677), 0.851 (0.828-0.872), and 0.859 (0.842-0.750) for A, beta, and A beta reserves, respectively. Conclusion Evidence supports the use of quantitative MCE as a non-invasive test for detection of CAD. Standardizing MCE quantification analysis and adherence to reporting standards for diagnostic tests could enhance the quality of evidence in this field.

Good surgical outcome in discordant ictal EEG-MRI unilateral mesial temporal sclerosis patients

Purpose:Video electroencephalography (vEEG) monitoring of patients with unilateral mesial temporal sclerosis (uMTS) may show concordant or discordant seizure onset in relation to magnetic resonance imaging (MRI) evidence of MTS. Contralateral seizure usually leads to an indication of invasive monitoring. Contralateral seizure onset on invasive monitoring may contraindicate surgery. We evaluated long-term outcome after anteromesial temporal lobectomy (AMTL) in a consecutive series of uMTS patients with concordant and discordant vEEG findings, uniformly submitted to AMTL on the MRI evidence of MTS side without invasive monitoring. Methods:We compared surgical outcome of all uMTS patients undergoing vEEG monitoring between January 1999 and April 2005 in our service. Discordant cases were defined by at least one seizure onset contralateral to the MRI evidence of MTS. Good surgical outcome was considered as Engel`s class I. We also evaluated ictal SPECT concordance to ictal EEG and surgical outcome. Results:Fifty-four patients had concordant (C) and 22 had discordant (D) scalp EEG and MRI. Surgical outcome was similar in both groups (C = 74% versus D = 86%). Duration of follow-up was comparable in both groups: C = 56.1 +/- 20.7 months versus D = 59.8 +/- 21.2 months (p = 0.83, nonsignificant). Discordant single-photon emission computed tomography (SPECT) results did not influence surgical outcome. Discussion:Surgical outcome was not influenced by contralateral vEEG seizure onset or contralateral increased flow on ictal SPECT. Although vEEG monitoring should still be performed in these patients, to rule out psychogenic seizures and extratemporal seizure onset, a potentially risky procedure such as invasive monitoring may not only not be indicated in this patient population, but may also lead to patients erroneously being denied surgery.

Interictal hyperemia correlates with epileptogenicity in polymicrogyric cortex

Objective: To investigate pathophysiological factors underlying the presence of interictal hyper-perfusion within the limits of the polymicrogyric (PMG) cortex in epileptic patients. Methods: Retrospective observational study on interictal perfusion by Single Photon Emission Computed Tomography (SPECT) in 16 patients with PMG and its correlations with a number of clinical and neurophysiological variables. Patients underwent video-EEG monitoring, neurological and psychiatric assessments, invasive EEG, and the interictal SPECT coregistered to Magnetic Resonance Imaging (MRI). Results: Patients with interictal hyperperfusion within the PMG cortex had a significantly higher spike rate on interictal EEG than patients with normal perfusion. Interictal hyperperfusion was not correlated to sex, age at epilepsy onset, age at evaluation, number of seizures per month, presence of initial precipitating insult (IPI), abnormal neurological examination, EEG findings, ictal serniology, and seizure outcome. The high interictal spike rate did not correlate to a high frequency of seizures per month. Conclusions: Our work provides further evidences for an intrinsic epileptogenesis of the PMG cortex during the interictal state, which accounts for the major rote of PMG tissue in seizure generation. These results might help to increase our understanding about epileptogenesis related to the PMG cortex, providing new toots for more tailored epilepsy surgery in PMG patients. (c) 2008 Elsevier B.V. All rights reserved.

Effect of power Doppler and digital subtraction techniques on the comparison of myocardial contrast echocardiography with SPECT

Objective-To compare the accuracy and feasibility of harmonic power Doppler and digitally subtracted colour coded grey scale imaging for the assessment of perfusion defect severity by single photon emission computed tomography (SPECT) in an unselected group of patients. Design-Cohort study. Setting-Regional cardiothoracic unit. Patients-49 patients (mean (SD) age 61 (11) years; 27 women, 22 men) with known or suspected coronary artery disease were studied with simultaneous myocardial contrast echo (MCE) and SPECT after standard dipyridamole stress. Main outcome measures-Regional myocardial perfusion by SPECT, performed with Tc-99m tetrafosmin, scored qualitatively and also quantitated as per cent maximum activity. Results-Normal perfusion was identified by SPECT in 225 of 270 segments (83%). Contrast echo images were interpretable in 92% of patients. The proportion of normal MCE by grey scale, subtracted, and power Doppler techniques were respectively 76%, 74%, and 88% (p < 0.05) at > 80% of maximum counts, compared with 65%, 69%, and 61% at < 60% of maximum counts. For each technique, specificity was lowest in the lateral wail, although power Doppler was the least affected. Grey scale and subtraction techniques were least accurate in the septal wall, but power Doppler showed particular problems in the apex. On a per patient analysis, the sensitivity was 67%, 75%, and 83% for detection of coronary artery disease using grey scale, colour coded, and power Doppler, respectively, with a significant difference between power Doppler and grey scale only (p < 0.05). Specificity was also the highest for power Doppler, at 55%, but not significantly different from subtracted colour coded images. Conclusions-Myocardial contrast echo using harmonic power Doppler has greater accuracy than with grey scale imaging and digital subtraction. However, power Doppler appears to be less sensitive for mild perfusion defects.

Estudo da influência do número de ciclos por projecção no cálculo da fracção de ejecção ventricular esquerda em estudos Gated-SPECT

Introdução - Gated-Single Photon Emission Computed Tomography (Gated-SPECT) do miocárdio usa-se cada vez mais na avaliação conjunta da perfusão do miocárdio e da função ventricular esquerda. O objectivo deste estudo é analisar a possível interferência do número de ciclos cardíacos (ciclos/projecção) e contagens totais por aquisição no cálculo da FEVE (fracção de ejecção do ventrículo esquerdo). Material e métodos - Foram incluídos 35 indivíduos a quem foram realizados estudos Gated-SPECT do miocárdio por indicação clínica. Em todos os pacientes foram adquiridos dois estudos em esforço: um com 25 ciclos! projecção (ES-25) e outro com 50 ciclos! projecção (ES-50), e dois estudos em repouso: um com 25 ciclos/projecção (ER-25) e outro com 12 ciclos! projecção (ER-1 2). Os valores da FEVE obtidos nos diferentes estudos foram tratados estatisticamente com o recurso à versão 14 SPSS. Resultados - Não houve diferenças estatisticamente significativas entre os valores de FEVE ES-25 e ES-50 (p=0.504) nem entre os valores de FEVE ER-25 e ER-12 (p=O.243). Conclusão - No caso da nossa amostra, o número de ciclos!projecção e consequentemente as contagens totais por aquisição não parecem ter influência de forma significativa no cálculo da FEVE%, nem em repouso nem após esforço.

Influência de diferentes parâmetros na diminuição da actividade extra-miocárdica nos estudos Gated-SPECT

A imagem de perfusão do miocárdio por tomografia computorizada de emissão de fotão único (SPECT, do acrónimo inglês Single Photon Emission Computed Tomography) é um dos exames complementares de diagnóstico mais indicados na cardiologia clínica. Os dois agentes tecneciados mais utilizados são o 99mTc-tetrofosmina e o 99mTc-sestamibi. Estes permitem avaliar a distribuição do fluxo sanguíneo no músculo cardíaco. O mecanismo de fixação é idêntico nos dois radiofármacos (RF’s). São excretados, do organismo, a partir do sistema hepatobiliar para o duodeno e para o intestino. Assim, o RF está presente tanto no coração como nos órgãos adjacentes. O coração encontra-se localizado sobre o diafragma, logo acima do lobo esquerdo do fígado e nas proximidades do estômago. Deste modo, os fotões difusos provenientes desses órgãos podem interferir com a interpretação das imagens SPECT, principalmente na parede inferior do ventrículo esquerdo, traduzindo-se na redução da razão alvo-fundo e na qualidade da imagem. Deste modo, a sensibilidade e a especificidade da Cintigrafia de Perfusão do Miocárdio (CPM) diminuem. Têm sido descritos na literatura vários métodos e técnicas para minimizar o efeito da actividade extra-miocárdica, como: a aquisição de imagens mais tardias, a ingestão de líquidos ou alimentos ricos em lípidos. Outras técnicas apontam para a alteração do posicionamento do paciente durante a aquisição. Assim, o objectivo deste estudo é identificar o protocolo da CPM a nível nacional e avaliar a percentagem de repetições de exames provocadas pela interferência de actividade extra-miocárdica.

Molecular imaging agents for detection of β-amyloid plaques in Alzheimer’s disease

The formation of amyloid structures is a neuropathological feature that characterizes several neurodegenerative disorders, such as Alzheimer´s and Parkinson´s disease. Up to now, the definitive diagnosis of these diseases can only be accomplished by immunostaining of post mortem brain tissues with dyes such Thioflavin T and congo red. Aiming at early in vivo diagnosis of Alzheimer´s disease (AD), several amyloid-avid radioprobes have been developed for b-amyloid imaging by positron emission tomography (PET) and single-photon emission computed tomography (SPECT). The aim of this paper is to present a perspective of the available amyloid imaging agents, special those that have been selected for clinical trials and are at the different stages of the US Food and Drugs Administration (FDA) approval.

Variabilidade introduzida pelo operador no processamento dos estudos Gated-SPECT do miocárdio

Introdução – Os estudos Gated – Single Photon Emission Computed Tomography (SPECT) são uma das técnicas de imagiologia cardíaca que mais evoluiu nas últimas décadas. Para a análise das imagens obtidas, a utilização de softwares de quantificação leva a um aumento da reprodutibilidade e exatidão das interpretações. O objetivo deste estudo consiste em avaliar, em estudos Gated-SPECT, a variabilidade intra e interoperador de parâmetros quantitativos de função e perfusão do miocárdio, obtidos com os softwares Quantitative Gated SPECT (QGS) e Quantitative Perfusion SPECT (QPS). Material e métodos – Recorreu-se a uma amostra não probabilística por conveniência de 52 pacientes, que realizaram estudos Gated-SPECT do miocárdio por razões clínicas e que integravam a base de dados da estação de processamento da Xeleris da ESTeSL. Os cinquenta e dois estudos foram divididos em dois grupos distintos: Grupo I (GI) de 17 pacientes com imagens com perfusão do miocárdio normal; Grupo II (GII) de 35 pacientes que apresentavam defeito de perfusão nas imagens Gated-SPECT. Todos os estudos foram processados 5 vezes por 4 operadores independentes (com experiência de 3 anos em Serviços de Medicina Nuclear com casuística média de 15 exames/semana de estudos Gated-SPECT). Para a avaliação da variabilidade intra e interoperador foi utilizado o teste estatístico de Friedman, considerando α=0,01. Resultados e discussão – Para todos os parâmetros avaliados, os respectivos valores de p não traduziram diferenças estatisticamente significativas (p>α). Assim, não foi verificada variabilidade intra ou interoperador significativa no processamento dos estudos Gated-SPECT do miocárdio. Conclusão – Os softwares QGS e QPS são reprodutíveis na quantificação dos parâmetros de função e perfusão avaliados, não existindo variabilidade introduzida pelo operador.

Relação entre função ventricular esquerda e os índices de captação miocárdio/pulmão em estudos Gated-SPECT

Introdução – A tomografia de emissão de fotão simples sincronizada com o sinal eletrocardiográfico (Gated-SPECT) é essencial para a avaliação conjunta da perfusão e da função ventricular esquerda (VE) do miocárdio. Objetivo – Investigar a relação entre a função VE e o índice de captação (IC) miocárdio/pulmão direito (M/PD) e M/P esquerdo (M/PE) nos estudos Gated-SPECT com 99mTc-Tetrofosmina. Metodologia – Amostra de 32 pacientes que realizaram estudos Gated-SPECT por indicação clínica, sendo subdividida em dois grupos: Grupo I (GI) – pacientes com a informação clínica de enfarte agudo do miocárdio (EAM); Grupo II (GII) – pacientes com a informação clínica de isquemia. Por cada paciente adquiriram-se imagens estáticas torácico-abdominais e dois estudos Gated-SPECT do miocárdio (protocolo de um dia esforço/repouso). Nas imagens estáticas definiram-se regiões de interesse (Regions of interest – ROI) para calcular os IC. Nos estudos Gated-SPECT utilizou-se o software Quantitative Gated SPECT/Quantitative Perfusion SPECT para calcular a Fração de Ejeção do Ventrículo Esquerdo (FEVE). Efetuou-se análise estatística descritiva para caracterização da amostra. Aplicou-se o teste de Spearman para avaliar a correlação entre a FEVE e os IC por grupo de pacientes. O Teste de Willcoxon foi usado para comparar FEVE em repouso e em esforço. Resultados – Nos estudos Gated-SPECT em esforço não se verificou correlação estatisticamente significativa entre a FEVE e os IC, para GI e GII; em repouso existe correlação positiva estatisticamente significativa entre a FEVE e os IC, para GI; para GII não se verificou correlação. Na comparação dos valores de FEVE em esforço e repouso nos dois grupos constatou-se a existência de diferenças estatisticamente significativas, sendo a FEVE em Esforço

Avaliação da viabilidade miocárdica pós-enfarte: Gated-SPECT versus Gated-PET

Mestrado em Medicina Nuclear - Ramo de especialização: Tomografia por Emissão de Positrões

The influence of number of counts in the myocardium in the determination of reproducible functional parameters in gated-SPECT studies simulated with GATE

Myocardial perfusion gated-single photon emission computed tomography (gated-SPECT) imaging is used for the combined evaluation of myocardial perfusion and left ventricular (LV) function. The aim of this study is to analyze the influence of counts/pixel and concomitantly the total counts in the myocardium for the calculation of myocardial functional parameters. Material and methods: Gated-SPECT studies were performed using a Monte Carlo GATE simulation package and the NCAT phantom. The simulations of these studies use the radiopharmaceutical 99mTc-labeled tracers (250, 350, 450 and 680MBq) for standard patient types, effectively corresponding to the following activities of myocardium: 3, 4.2, 5.4-8.2MBq. All studies were simulated using 15 and 30s/projection. The simulated data were reconstructed and processed by quantitative-gated-SPECT software, and the analysis of functional parameters in gated-SPECT images was done by using Bland-Altman test and Mann-Whitney-Wilcoxon test. Results: In studies simulated using different times (15 and 30s/projection), it was noted that for the activities for full body: 250 and 350MBq, there were statistically significant differences in parameters Motility and Thickness. For the left ventricular ejection fraction (LVEF), end-systolic volume (ESV) it was only for 250MBq, and 350MBq in the end-diastolic volume (EDV), while the simulated studies with 450 and 680MBq showed no statistically significant differences for global functional parameters: LVEF, EDV and ESV. Conclusion: The number of counts/pixel and, concomitantly, the total counts per simulation do not significantly interfere with the determination of gated-SPECT functional parameters, when using the administered average activity of 450MBq, corresponding to the 5.4MBq of the myocardium, for standard patient types.

Imaging in neurological and vascular brain diseases (SPECT and SPECT/CT)

Since the first in vivo studies of cerebral function with radionuclides by Ingvar and Lassen, nuclear medicine (NM) brain applications have evolved dramatically, with marked improvements in both methods and tracers. Consequently it is now possible to assess not only cerebral blood flow and energy metabolism but also neurotransmission. Planar functional imaging was soon substituted by single-photon emission computed tomography (SPECT) and positron emission tomography (PET); it now has limited application in brain imaging, being reserved for the assessment of brain death.

Radiopharmaceuticals for myocardial perfusion imaging: SPECT & PET

Myocardial perfusion imaging (MPI) is used on a daily basis to access coronary blood flow in patients that are suspected or have known Coronary Artery Disease (CAD). A Single Photon Emission Computed Tomography (SPECT) or and Positron Emission Tomography (PET) scan are used to access regional blood flow quantification either at rest or stress, the imaging acquisition is connected to an Electrocardiogram (ECG) and it is able to determine and quantify other myocardial parameters like myocardial wall thickness and wall motion. PET is not used so broadly due to its high procedure cost, the proximity with cyclotron, where are produced the majority of radiopharmaceuticals used in PET, due to their shor thalf-life. This work is intended to carry out a review of the tests relating to radiopharmaceuticals that are used in clinical practice in SPECT or PET for assessment of myocardial perfusion, also focusing very promising radiopharmaceuticals that are under investigation or in clinical trials with great potential for conventional nuclear medicine or PET, proceeding to a comparative analysis of both techniques and respective radiopharmaceuticals used.