Chuppa Rustom PET and Dementias

Dr. Shemin Mehta 3rd year DNB Radiology Dr. Balabhai Nanavati Hospital

Dementia The Indian Perspective

In 2010, there are 3.7 million Indians with dementia and the total societal cost is about 14,700 crore The cost of taking care of a person with dementia is about Rs. 43,000/- annually While the numbers are expected to double by 2030, costs would increase three times Early detection allows early initiation of therapy to slow decline

Diagnosis
Dementia diagnosis is essentially clinical false negative in 50-90% Laboratory investigations play a supportive role Structural imaging in the form of CT and MRI is inadequate in early stages, as well as having low sensitivity and specificity Functional imaging, i.e. PET is more sensitive and allows further disease characterization

When to conduct a dementia evaluation

Patient/family concerns Functional impairment (driving, self-care) Changes in personality & behaviour Persistent cognitive deficit after delirium clears Abrupt change in cognitive, emotional or neurologic status Depression associated with reversible dementia (50% irreversible after 5 years)

Patterns
Alzheimers Disease posterior cingulate, parietal and temporal cortices frontal involvement as AD progresses Frontotemporal Dementia frontotemporal abnormality with preserved posterior functioning D/D from AD Vascular Dementia patchy hypometabolic pattern in cortical & subcortical regions Dementia with Lewy Bodies parietal, temporal deficits with frontal involvement as disease progresses (similar to AD) along with occipital hypometabolism

Case 1
70/M C/o forgetfulness, decreased comprehension, lack of responsiveness Insidious onset of symptoms CT - Moderate cerebral atrophy, prominence of sylvian fissures

MRI and MRS

Multiple bilateral lacunar infarcts Mild cerebral and cerebellar atrophy Periventricular white matter ischemia MRS reduced NAA, mI and Cho metabolic disorder

PET-CT findings, Evaluation with Scenium

Hypometabolism bilateral temporoparietal, frontal regions, both hippocampi, amygdala, mesial temporal lobe Occipital regions largely unaffected Alzheimers disease

Case 2
77/M H/o social disinhibition, aggressiveness CT moderate atrophic changes, mild periventricular ischemia

PET-CT findings, Evaluation with Scenium

Frontotemporal deficit Preserved posterior functioning Frontotemporal dementia (FTD)

Case 3
61/F C/o decreased attention and decreased cognition CT temporoparietal atrophy, moderate periventricular ischemia

PET-CT findings, Evaluation with Scenium

Parietal and temporal deficits Marked occipital hypometabolism Preserved frontal metabolism Lewy Body Dementia

PET Present Status

Adds to clinical picture improves diagnostic accuracy Dementia diagnosis sensitivity with PET 91.5 +/- 3.5%, sensitivity without PET 66 +/- 17% To differentiate AD from FTD Early identification of patients who will develop AD and other dementias Sensitive to AD-like hypometabolic changes in non-demented persons with APOE-4 risk for AD

PET Present Status

Predicts cognitive decline in patients with APOE4, normal elderly and persons with mild memory impairment Predicts progression from Mild Cognitive Impairment (MCI) to dementia Sensitive to preclinical cognitive changes in patients with high cognitive reserve Normal study reassures worried well Role in Age-Associated Memory Impairment (AAMI)

Future Trends
F18-FDDNP to visualise neurofibrillary tangles and senile plaques in AD; amyloid labelling to follow neuropathologic evolution of AD in living subjects F18-MPPF selective probe for serotonin 1A receptors as an index of hippocampal neuronal loss early detection and monitoring of dementias

Future Trends
Newer compounds like F18-FDOPA and others to study dopamine synthesis, dopamine transporter and vesicular transporter in Parkinsons disease

Future Trends
C11-PK11195 a peripheral BZD receptor agent shows increased uptake in AD, PD, multisystem atrophy, MND may correlate with disease severity and mark disease onset

References
PET in the Evaluation of Alzheimers Disease and Related Disorders Daniel Silverman The Dementia India Report 2010