Adams & Victor Positron Emission Tomography

This technique, commonly known as PET, measures the regional cerebral concentration of systemically administered radioactive tracers. Positron-emitting isotopes (usually 11C, 18F, 13N, and 15O) are produced in a cyclotron or linear accelerator and incorporated into biologically active compounds in the body. The concentration of the tracers in various parts of the brain is determined noninvasively, by detectors outside the body, and tomographic images are constructed by techniques similar to those used in CT and MRI. Local patterns of cerebral blood flow, oxygen uptake, and glucose utilization can be measured by PET scanning, and the procedure has proved to be of value in grading primary brain tumors, distinguishing tumor tissue from radiation necrosis, localizing epileptic foci, and differentiating types of dementing diseases. The ability of the technique to quantitate neurotransmitters and their receptors promises to be of importance in the study of Parkinson disease and other degenerative diseases. This technology is found in relatively few medical centers and requires costly facilities and support staff;it is therefore not utilized for routine diagnosis.

Single-Photon Emission Computed Tomography (SPECT)

This technique, which has evolved from PET, utilizes isotopes that do not require a cyclotron for their production. Here also radioligands (usually containing iodine) are incorporated into biologically active compounds, which, on decay, emit only a single photon. This procedure allows the study of regional cerebral blood flow under conditions of cerebral ischemia or during intense tissue metabolism. The restricted anatomic resolution provided by SPECT has limited its clinical usefulness, but its wider availability makes it appealing for clinical use. This has proved particularly true in helping to distinguish between Alzheimer dementia and a number of focal cerebral (lobar) atrophies and in the localization of epileptic foci in patients who are candidates for cortical resection. Once injected, the isotope localizes rapidly in the brain, with regional absorption proportional to blood flow, and is then stable for an hour or more. It is thus possible to inject the isotope at the time of the seizure onset, while the patient is undergoing video and electroencephalographic monitoring, and to scan the patient later. As with PET, the clinical potential of this technique has yet to be fully realized.

The widespread use of CT and MRI represents an important surrogate approach to the pathologic study of epilepsy. More than 25 years ago, Gastaut and Gastaut reported that in primary grand mal and absence epilepsies, CT abnormalities were found in approximately 10 percent of cases, whereas in the Lennox-Gastaut syndrome, the West syndrome, and partial complex epilepsies it was found in 52, 77, and 63 percent, respectively. Atrophy, calcification, and malformations were the most frequent changes. MRI and particularly the FLAIR images have proved to be a particularly sensitive means of detecting epileptogenic lesions of the medialbasal portion of the temporal lobes (mesial temporal sclerosis; Fig. 16-2). Repeatedly, patients are observed in whom MRI disclosed a cortical or subcortical developmental malformation such as a cortical heterotopia or another surgically treatable lesion of the temporal lobe, even after CT scanning had failed to do so. More subtle epileptogenic foci may be demonstrated by positron emission tomography (PET) or by interictal single-photon emission computed tomography (SPECT). Ictal SPECT, which shows hyperperfusion of the seizure focus, is a more demanding but also more sensitive and specific procedure.

Diagnostic Studies The most useful, but not definitive, ancillary tests in use are CT scanning and MRI (Fig. 39-3). In patients with advanced Alzheimer disease, the lateral and third ventricles are enlarged to about twice normal size and the cerebral sulci are widened. As stated previously, fine-section coronal MRI of the medial temporal lobes reveals a disproportionate atrophy of the hippocampi and a corresponding enlargement of the temporal horns of the lateral ventricles. Early in the disease, however, the changes do not exceed those found in many mentally intact old persons. For this reason, one cannot rely on imaging procedures alone for

diagnosis. CT and MRI scans are most valuable in excluding brain tumor, subdural hematoma, cerebral infarction, and hydrocephalus. The EEG undergoes a diffuse slowing, but only late in the course of the illness. The CSF is also normal, though occasionally the total protein is slightly elevated. Using the constellation of clinical data, CT scanning, and MRIalong with the age of the patient and time course of the diseasethe diagnosis of senile dementia of Alzheimer type is being made correctly in 85 to 90 percent of cases. Of some value in our experience have been studies of cerebral blood flow (single-photon emission tomography, or SPECT) and metabolism (positron emission tomography, or PET), which show diminished activity in the medial temporal lobes, sometimes early in the disease. Nevertheless, in most cases, when such changes were evident, the diagnosis was already obvious on clinical grounds alone. Our recent experience has been that the pattern of Alzheimer change on these blood flow and metabolic studies is too often applied indiscriminately.