Augmentation of perivascular space visualization in basal ganglia and white matter hyperintensity lesion is a meaningful finding for subsequent cognitive decline.

BACKGROUND: Cerebral small vessel disease (CSVD) causes cognitive decline and perivascular space enlargement is one of the image markers for CSVD. PURPOSE: To search for clinical significance in the time-course augmentation of perivascular space in basal ganglia (BG-PVS) for cognitive decline. MATERIAL AND METHODS: This study population included 179 participants from a community-based cohort, aged 70 years at baseline. They had undergone magnetic resonance imaging (MRI) studies two or three times between 2000 and 2008. Based on the severity of BG-PVS or white matter hyperintensity lesions (WMHL) in 2000, the participants were divided into low-grade or high-grade groups, respectively. In addition, their time-course augmentation was evaluated, and we created a categorical BG-PVS WMHL change score based on their augmentation (1 = neither, 2 = BG-PVS augmentation only, 3 = WMHL augmentation only, 4 = both). Cognitive function was assessed based on the Mini-Mental State Examination (MMSE); the change was defined as the difference between scores in 2000 and 2008. We used simple or multiple regression analysis for MMSE score change according to MRI findings and clinical characteristics that were probably related to cognitive decline. RESULTS: In univariate analysis, MMSE score change was negatively associated with BG-PVS high grade at baseline and BG-PVS WMHL change score 4; this remained significant in multivariate analysis. In the final model based on the Akaike Information Criterion, BG-PVS WMHL change score 4 was associated with a 3.3-point decline in subsequent MMSE score. CONCLUSIONS: This study suggested that augmentation in both BG-PVS and WMHL was associated with subsequent cognitive decline.

Evaluation of the extracranial "multifocal arcuate sign," a novel MRI finding for the diagnosis of giant cell arteritis, on STIR and contrast-enhanced T1-weighted images.

BACKGROUND: While early diagnosis of giant cell arteritis (GCA) based on clinical criteria and contrast-enhanced MRI findings can lead to early treatment and prevention of blindness and cerebrovascular accidents, previously reported diagnostic methods which utilize contrast-enhanced whole head images are cumbersome. Diagnostic delay is common as patients may not be aware of initial symptoms and their significance. To improve current diagnostic capabilities, new MRI-based diagnostic criteria need to be established. This study aimed to evaluate the "multifocal arcuate sign" on short tau inversion recovery (STIR) and contrast-enhanced T1-weighted (CE-T1W) images as a novel extracranial finding for the diagnosis of GCA. METHODS: A total of 17 consecutive patients (including five with GCA) who underwent CE-T1W and whole-brain axial STIR imaging simultaneously between June 2010 and April 2020 were enrolled. We retrospectively reviewed their MR images. The "multifocal arcuate sign" was defined as "multiple distant arcuate areas with high signal intensity in extracranial soft tissues such as subcutaneous fat, muscles, and tendons." Extracranial abnormal high-signal-intensity areas were classified as "None," when no lesions were detected; "Monofocal," when lesions were detected only in one place; and "Multifocal," when lesions were detected in multiple places. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of "Multifocal" areas were calculated using cross tabulation. Fisher's exact test was used to compare "Multifocal" areas in five patients with GCA and those with other diseases. In addition, mean Cohen's kappa and Fleiss' kappa statistics were used to compare inter-reader agreement. RESULTS: The sensitivity, specificity, PPV, and NPV of the "multifocal arcuate sign" in patients with GCA were 60%, 92-100%, 75-100%, and 85-86%, respectively. Significantly more patients with GCA had "Multifocal" areas compared to those with other diseases (Fisher's exact test, p = 0.008-0.027). Mean Cohen's kappa and Fleiss' kappa for inter-reader agreement with respect to the five GCA patients were 0.52 and 0.49, respectively, for both STIR and CE-T1W sequences. CONCLUSIONS: The new radiologic finding of "multifocal arcuate sign" on STIR and CE-T1W images may be used as a radiologic criterion for the diagnosis of GCA, which can make plain MRI a promising diagnostic modality.

The time-course augmentation of perivascular space enlargement in the basal ganglia among a community-dwelling elder population.

PURPOSE: We examined whether time-course augmentation of perivascular space enlargement in the basal ganglia (BG-PVS) reflected cerebral small vessel disease (CSVD) severity by considering white matter hyperintensity lesion (WMHL) as an indicator for CSVD. MATERIALS AND METHODS: This study population included 416 older participants from a community-based cohort. They participated in magnetic resonance imaging (MRI) studies more than once during the study period. The grades for BG-PVS and WMHL were evaluated by visual rating scales; BG-PVS time-course augmentation in 4-9 years was also evaluated. At baseline, the participants were asked about their smoking and drinking history, and medical history. They also underwent a blood examination and their office blood pressure (BP) examination. In addition, 24-h ambulatory BP monitoring was also performed within the study period. RESULTS: Of the 416 participants, 48 participants (11.5%) had BG-PVS time-course augmentation. The participants with BG-PVS augmentation had significantly lower LDL levels, hyper-nighttime BP, and lower nighttime BP fall in univariate analysis (p = 0.03, p = 0.03, p = 0.003, respectively). In multivariate analysis, lower nighttime BP fall and male sex showed significance (p = 0.02, 0.03, respectively). Additionally, BG-PVS time-course augmentation was significantly associated with subsequent WMHL severity in univariate analysis (p < 0.001), which remained significant in multivariate analysis adjusted by imaging and demographic factors (p = 0.03). In multivariate analysis, additionally adjusted by the clinical factors, the significance disappeared (p = 0.07). CONCLUSION: This study revealed that the lower nighttime BP fall in ambulatory blood pressure monitoring was a factor significantly associated with BG-PVS augmentation. Moreover, the BG-PVS time-course augmentation would be a notable finding that was associated with the subsequent WMHL.

Association of ADC of hyperintense lesions on FLAIR images with TERT promoter mutation status in glioblastoma IDH wild type.

Background: Although mutations in telomerase reverse transcriptase (TERT) promoter (TERTp) are the most common alterations in glioblastoma (GBM), predicting TERTp mutation status by preoperative imaging is difficult. We determined whether tumour-surrounding hyperintense lesions on fluid-attenuated inversion recovery (FLAIR) were superior to those of contrast-enhanced lesions (CELs) in assessing TERTp mutation status using magnetic resonance imaging (MRI). Methods: This retrospective study included 114 consecutive patients with primary isocitrate dehydrogenase (IDH)-wild-type GBM. The apparent diffusion coefficient (ADC) and volume of CELs and FLAIR hyperintense lesions (FHLs) were determined, and the correlation between MRI features and TERTp mutation status was analyzed. In a subset of cases, FHLs were histopathologically analyzed to determine the correlation between tumor cell density and ADC. Results: TERTp mutations were present in 77 (67.5%) patients. The minimum ADC of FHLs was significantly lower in the TERTp-mutant group than in the TERTp-wild-type group (mean, 958.9 × 10-3 and 1092.1 × 10-3 mm2/s, respectively, P < 0.01). However, other MRI features, such as CEL and FHL volumes, minimum ADC of CELs, and FHL/CEL ratio, were not significantly different between the two groups. Histopathologic analysis indicated high tumor cell density in FHLs with low ADC. Conclusion: The ADC of FHLs was significantly lower in IDH-wild-type GBM with TERTp mutations, suggesting that determining the ADC of FHLs on preoperative MRI might be helpful in predicting TERTp mutation status and surgical planning.

Effect of cerebrospinal fluid area mask correction on 123I-FP-CIT SPECT images in idiopathic normal pressure hydrocephalus.

BACKGROUND: Cerebrospinal fluid (CSF) area mask correction reduces the influence of low [123I]-N-fluoropropyl-2b-carbomethoxy-3b-(4-iodophenyl) nortropane (123I-FP-CIT) accumulation in the volume of interest (VOI) by CSF area dilatation on the specific binding ratio (SBR) calculated using the Southampton method. We assessed the effect of CSF area mask correction on the SBR for idiopathic normal pressure hydrocephalus (iNPH) characterized by CSF area dilatation. METHODS: We enrolled 25 patients with iNPH who were assessed using 123I-FP-CIT single-photon emission computed tomography (SPECT) before shunt surgery or the tap test. The SBRs with and without CSF area mask correction were calculated, and changes in quantitative values were verified. Additionally, the number of voxels in the striatal and background (BG) VOI before and after CSF area mask correction were extracted. The number of voxels after correction was subtracted from that before correction, and the volume removed by the CSF area mask correction was calculated. The volumes removed from each VOI were compared to verify their effect on SBR. RESULTS: The images of 20 and 5 patients with SBRs that were decreased and increased, respectively, by CSF area mask correction showed that the volumes removed from the BG region VOI were higher and lower, respectively than those in the striatal region. CONCLUSIONS: The SBR before and after CSF area mask correction was associated with the ratio of the volume removed from the striatal and BG VOIs, and the SBR was high or low according to the ratio. The results suggest that CSF area mask correction is effective in patients with iNPH. TRIAL REGISTRATION: This study was registered in the UMIN Clinical Trials Registry (UMIN-CTR) as UMIN study ID: UMIN000044826. 11/07/2021.

Comparison of accuracy between augmented reality/mixed reality techniques and conventional techniques for epidural anesthesia using a practice phantom model kit.

BACKGROUND: This study used an epidural anesthesia practice kit (model) to evaluate the accuracy of epidural anesthesia using standard techniques (blind) and augmented/mixed reality technology and whether visualization using augmented/mixed reality technology would facilitate epidural anesthesia. METHODS: This study was conducted at the Yamagata University Hospital (Yamagata, Japan) between February and June 2022. Thirty medical students with no experience in epidural anesthesia were randomly divided into augmented reality (-), augmented reality (+), and semi-augmented reality groups, with 10 students in each group. Epidural anesthesia was performed using the paramedian approach with an epidural anesthesia practice kit. The augmented reality (-) group performed epidural anesthesia without HoloLens2Ⓡ and the augmented reality (+) group with HoloLens2Ⓡ. The semi-augmented reality group performed epidural anesthesia without HoloLens2Ⓡ after 30 s of image construction of the spine using HoloLens2Ⓡ. The epidural space puncture point distance between the ideal insertion needle and participant's insertion needle was compared. RESULTS: Four medical students in the augmented reality (-), zero in the augmented reality (+), and one in the semi-augmented reality groups failed to insert the needle into the epidural space. The epidural space puncture point distance for the augmented reality (-), augmented reality (+), and semi-augmented reality groups were 8.7 (5.7-14.3) mm, 3.5 (1.8-8.0) mm (P = 0.017), and 4.9 (3.2-5.9) mm (P = 0.027), respectively; a significant difference was observed between the two groups. CONCLUSIONS: Augmented/mixed reality technology has the potential to contribute significantly to the improvement of epidural anesthesia techniques.

A Case with Anti-ganglioside Antibodies Showing Multiple Cranial Nerve Palsies Detected on Gadolinium-enhanced Magnetic Resonance Imaging.

The anti-GQ1b IgG antibody is often accompanied by other anti-ganglioside antibodies, which induces various neurological symptoms. We herein report a patient with anti-ganglioside antibodies, including anti-GQ1b IgG and anti-GT1a IgG antibodies, showing bilateral ophthalmoplegia, facial nerve palsies, dysarthria, dysphagia, dysesthesia in both hands, and enhancement of the bilateral oculomotor, abducens, and facial nerves on gadolinium (Gd)-enhanced T1-weighted brain magnetic resonance imaging (MRI). He was first treated with intravenous immunoglobulin, which improved ophthalmoplegia, bulbar palsies, and dysesthesia of hands, but the facial nerve palsies worsened, and Gd enhancement of the brain nerves persisted. High-dose methylprednisolone therapy subsequently improved the facial nerve palsies and Gd enhancement of the cranial nerves. This is the first case with anti-ganglioside antibodies presenting with multiple cranial nerve palsies that was followed to track the changes in the Gd enhancement of cranial nerves on MRI.

Association between visualization of the perivascular space and morphological changes in the brain among the community-dwelling elderly.

PURPOSE: We aimed to investigate the association between perivascular space (PVS) visible on MRI and brain atrophy or morphological change using quantitative indexes. METHOD: This population-based cohort study included 216 older participants. The PVS in basal ganglia (BG-PVS) and cerebral white matter (WM-PVS) was evaluated using a four-point visual rating scale. We segmented brain parenchyma and CSF, and calculated the CSF/intracranial volume ratio, which represents atrophic change. WM lesions were classified using the Fazekas scale. We introduced a new category "idiopathic normal pressure hydrocephalus (iNPH)-like conformation", which was based on two quantitative indexes: Evans index and callosal angle. The association between PVS grade and demographic or morphological factors was evaluated. RESULTS: A stepwise increase in the CSF/intracranial volume ratio with BG-PVS grade progression and a stepwise decrease with WM-PVS grade progression were observed. A higher CSF/intracranial volume ratio was significantly related to a higher BG-PVS grade in a univariate analysis, but this significance disappeared in a multivariate analysis. The iNPH-like group was significantly related to a lower WM-PVS grade in a univariate analysis, and this significance remained in a multivariate analysis. CONCLUSIONS: The association between BG-PVS enlargement and atrophic changes was verified. On the contrary, WM-PVS showed a different trend, and a lower WM-PVS grade was associated with an iNPH-like conformation. This result implies that the less-visible WM-PVS on imaging as well as BG-PVS enlargement would reflect abnormal brain change.

In vivo [18F]THK-5351 imaging detected reactive astrogliosis in argyrophilic grain disease with comorbid pathology: A clinicopathological study.

Quantification of in vivo reactive astrogliosis, which represents neural inflammation and remodeling in the brain, is an emerging methodology for the evaluation of patients with neurodegenerative diseases. [18F]THK-5351 is a positron emission tomography (PET) tracer for monoamine oxidase B (MAO-B), a molecular marker of reactive astrogliosis. We performed in vivo [18F]THK-5351 PET in a patient who at autopsy was found to have argyrophilic grain disease (AGD) with comorbid pathology to visualize reactive astrogliosis for the first time. We aimed to validate an imaging-pathology correlation using [18F]THK-5351 PET and the autopsy brain. The patient, a 78-year-old man, was pathologically diagnosed with AGD combined with limbic-predominant age-related transactive response DNA-binding protein of 43 kDa encephalopathy and Lewy body disease without Alzheimer disease-related neuropathological changes. Reactive astrogliosis in the postmortem brain was abundant in the inferior temporal gyrus, insular gyrus, entorhinal cortex, and ambient gyrus where premortem [18F]THK-5351 signals were high. We found a proportional correlation between the amount of reactive astrogliosis in the postmortem brain and the in vivo [18F]THK-5351 standardized uptake value ratio (r = 0.8535, p = 0.0004). These results indicated that reactive astrogliosis in AGD with comorbid pathology could be identified and quantified by in vivo MAO-B imaging.

A retrospective preliminary study of intrapancreatic late enhancement as a noteworthy imaging finding in the early stages of pancreatic adenocarcinoma.

OBJECTIVE: To characterize intrapancreatic late enhancement (ILE) observed in the early stages of pancreatic adenocarcinoma (PAC). METHODS: Among 203 patients pathologically diagnosed with PAC between October 2011 and February 2021, 32 patients with pre-diagnostic abdominal contrast-enhanced CT performed from 6 months to 5 years before the diagnosis were enrolled in this study. Indirect findings (IFs) on pre-diagnostic CT, including ILE, were evaluated and examined for various clinical data and time intervals to diagnosis (TIDs). The detected ILE was quantitatively evaluated, and the effect of ILE awareness on lesion detection by two radiologists and their interobserver agreement were assessed. RESULTS: Among the 32 patients, 23 showed IFs. ILE was observed in 14 patients (63%), with a median TID of 17 months (interquartile ratio [IQR]: 9.3-42.3). ILE alone was observed in eight patients (35%), ILE with focal pancreatic parenchymal atrophy (FPPA) was observed in five patients (22%), and ILE with main pancreatic duct abnormalities (MPDA) was observed in one patient (4%). Pancreatic head lesions were significantly more frequent in patients with ILE alone than in patients with FPPA or MPDA (p = 0.026). The median long-axis diameters of the region with ILE and ILE-to-pancreas contrast were 10 (IQR: 5-11) mm and 24 (IQR: 17-33) HU, respectively. Awareness of ILE led observers to detect two or three more pancreatic head lesions, and interobserver agreement increased from poor agreement (k = 0.17) to moderate agreement (k = 0.55). CONCLUSION: ILE is a significant IF for early PAC detection. KEY POINTS: • Intrapancreatic late enhancement (ILE) is a significant indirect finding in the early detection of pancreatic adenocarcinoma. • ILE without other indirect findings is expected to help detect pancreatic head lesions. • Image evaluation focusing on ILE can increase lesion detection and improve the interobserver agreement.

A Headrest Made of Extruded Polystyrene Reduces the Influence of Attenuation Correction on Human Brain SPECT Images.

Previous reports suggest that a headrest made of carbon significantly influences cerebral blood flow in the anterior and posterior regions by image reconstruction and attenuation correction (AC). The present study aimed to develop a headrest that reduces the influence of the AC process on human brain SPECT. Methods: To validate the performance of a headrest made of extruded polystyrene (XPS), 10 healthy controls and 43 patients with cerebrovascular disease underwent 99mTc-ethyl cysteinate dimer SPECT using a carbon headrest and an XPS headrest. We evaluated the anterior-to-posterior and middle-to-posterior ratio of the brain regions in filtered backprojection (FBP) Chang AC, ordered-subset expectation maximization (OSEM) Chang AC, and OSEM CT-based AC. Results: The anterior-to-posterior ratio was significantly higher with the carbon headrest than with the XPS headrest in FBP Chang AC and OSEM Chang AC (P < 0.001). There was no significant difference between the materials in OSEM CT-based AC. The middle-to-posterior ratio did not differ to a statistically significant extent in any correction process. Conclusion: Acquisition of brain SPECT images with an XPS headrest and processing by the FBP or OSEM Chang AC method enables the influence of the headrest to be reduced, especially in anterior and posterior brain regions.

Changes in vascular supply pattern associated with growth of nonfunctioning pituitary adenomas.

Background: The vascular supply to nonfunctioning pituitary adenomas (NFPAs) differs compared with that of the anterior lobe of the normal pituitary gland. In this study, we aimed to identify feeding arteries and flow dynamics using 3.0 T magnetic resonance imaging (MRI) in NFPAs. Methods: We divided 77 cases of NFPA into three groups according to the time-intensity curve (TIC) pattern by dynamic MRI. We also investigated the presence of feeder arteries as a flow void signal on T2-weighted imaging (T2WI). Results: According to the TIC, 39 cases demonstrated an ascending pattern, 10 cases demonstrated a descending pattern, and 28 cases demonstrated a monophasic pattern. Tumor size in the ascending group was larger compared with the descending group (P = 0.0036). Flow void signals were identified in 51 of 77 cases (66.2%) on T2WI. Tumor size was larger in tumors with a flow void signal compared with those without (P < 0.0001). Flow void signals were more frequently observed in the group of ascending pattern compared with the group of monophasic and descending pattern (P = 0.032 and P = 0.003, respectively). Particularly on the caudal side, the difference between the ascending group and the monophasic and descending groups was remarkable (P = 0.0035 and P < 0.0001, respectively). Conclusion: We successfully evaluated the blood supply pattern by the TIC analysis and identified flow voids using 3.0 T MRI. Blood supply pattern was significantly associated with NFPA size. These results suggested that NFPA hemodynamics changes during tumor growth.

Comparing Medial Temporal Atrophy Between Early-Onset Semantic Dementia and Early-Onset Alzheimer's Disease Using Voxel-Based Morphometry: A Multicenter MRI Study.

BACKGROUND: Early-onset Semantic dementia (EOSD) and early-onset Alzheimer's disease (EOAD) are often difficult to clinically differentiate in the early stages of the diseases because of the overlaps of clinical symptoms such as language symptoms. We compared the degree of atrophy in medial temporal structures between the two types of dementia using the voxel-based specific regional analysis system for Alzheimer's disease (VSRAD). METHODS: The participants included 29 (age: 61.7±4.5 years) and 39 (age: 60.2±4.9 years) patients with EOSD and EOAD, respectively. The degree of atrophy in medial temporal structures was quantified using the VSRAD for magnetic resonance imaging data. Receiver operating characteristic (ROC) analysis was performed to distinguish patients with EOSD and EOAD using the mean Z score (Z-score) in bilateral medial temporal structures and the absolute value (laterality score) of the laterality of Z-score (| right-left |) for indicating the degree of asymmetrical atrophy in medial temporal structures. RESULTS: The EOSD group had significantly higher Z and laterality scores than the EOAD group (Zscores: mean ± standard deviation: 3.74±1.05 vs. 1.56±0.81, respectively; P<0.001; laterality score: mean ± standard deviation: 2.35±1.23 vs. 0.68±0.51, respectively; P<0.001). In ROC analysis, the sensitivity and specificity to differentiate EOSD from EOAD by a Z-score of 2.29 were 97% and 85%, respectively and by the laterality score of 1.05 were 93% and 85%, respectively. CONCLUSION: EOSD leads to more severe and asymmetrical atrophy in medial temporal structures than EOAD. The VSRAD may be useful to distinguish between these dementias that have several clinically similar symptoms.

MRI Grading Scale Predicts Ambulatory Function After Radiotherapy for Metastatic Spinal Cord Compression: A Prospective Single-Institution Observational Study.

INTRODUCTION: Although magnetic resonance imaging (MRI) is an important modality for the diagnosis of metastatic spinal cord compression (MSCC), there are only a few reports on MSCC findings and symptoms after radiotherapy. We aimed to reveal the factors related to ambulatory function after treatment, including the MRI findings, in a prospective observational study. METHODS: Patients with suspected MSCC who were treated with radiotherapy were included in this study. Orthopedic surgeons evaluated the neurological function according to the Frankel grade. All patients underwent spinal MRI, and the degree of spinal cord compression was assessed by a radiologist and a radiation oncologist using an MRI grading scale. One month after treatment, orthopedic surgeons reassessed the Frankel grade. Twenty-three patients who were evaluated 1 month after radiotherapy were included in the analysis. RESULTS: Before radiotherapy, 17 patients were ambulatory and six were unable to walk. Furthermore, 13 patients were diagnosed with grade 3 compression on MRI (spinal cord compression with no cerebrospinal fluid seen on axial T2-weighted imaging). Patients with grade 3 MSCC were significantly more likely to be non-ambulatory at 1 month. CONCLUSIONS: The MRI grading scale for MSCC may be a prognostic factor for ambulatory function after radiotherapy. MRI findings could aid in determining the indication for radiotherapy.

Dopamine Transporter Imaging for Frontotemporal Lobar Degeneration With Motor Neuron Disease.

Introduction: Frontotemporal lobar degeneration (FTLD) is a clinical syndrome with pathological heterogeneity, including Pick's disease and trans-activating response region (TAR) DNA-binding protein with a molecular mass of 43 kDa (TDP-43) proteinopathy (FTLD-TDP). A previous study reported abnormal findings on dopamine transporter (DAT) imaging in 30% of patients with frontotemporal dementia (FTD) in FTLD. However, the previous study did not consider the pathological heterogeneity of FTD regarding the pathomechanism leading to abnormal DAT findings. Recently, abnormal DAT findings were reported in two patients with FTLD with motor neuron disease (MND), of which FTLD-TDP type B was the most common pathological presentation. This study investigated the DAT findings of patients with a final diagnosis of FTLD-MND to determine the frequency of occurrence of DAT abnormalities in FTLD-MND. Methods: Twenty patients with FTLD who underwent DAT single photon emission computed tomography (DAT-SPECT) were screened, and six patients with a final diagnosis of FTLD-MND were ultimately included. The patients' DAT-SPECT findings were analyzed visually and quantitatively. Neuronal loss and astrogliosis in brain regions (substantia nigra, caudate, and putamen) that could possibly affect DAT findings were evaluated in the three pathologically confirmed cases. Result: All six patients with FTLD-MND showed abnormal visual DAT-SPECT findings. In addition, in a quantitative assessment, the specific binding ratio in the striatum calculated by the Southampton method was below the lower limit of the 95% prediction interval of the healthy controls by age in all the present cases. Interestingly, three of the six patients showed abnormal findings on DAT-SPECT more than half a year before the onset of MND. Neuronal loss and astrogliosis in brain regions that may affect DAT findings were observed in three pathologically confirmed cases. Conclusion: Dopamine transporter single photon emission computed tomography revealed abnormal findings in patients with FTLD-MND, which may manifest even before the onset of MND symptoms. We believe that the possibility of future development of MND should be considered if DAT-SPECT shows abnormal findings in FTLD.

Preoperative Apparent Diffusion Coefficient of Peritumoral Lesion Associate with Recurrence in Patients with Glioblastoma.

Additional resection beyond contrast enhanced lesion on MRI is recently considered to prolong survival in glioblastoma. Prediction of future recurrent site in the peritumoral lesion on preoperative MRI could be useful for surgical planning. The objective of this study was to determine if the preoperative ADC value was associated with the site of future recurrence in patients with glioblastoma. We retrospectively analyzed 21 patients with primary GBM. The ADC value on MRI were analyzed before and after operation and at recurrence. The region of interests (ROIs) were set to cover almost the FLAIR high-signal lesion surrounding contrast enhanced lesion. We determined whether the value of ADC on MRI was correlated with the spot of future recurrence. Among 1844 ROIs determined in the FLAIR high-signal lesion on preoperative MRI, new enhanced lesions occurred in 186 sites. The other 1258 sites showed no change or decrease in size on follow up MRI, and the other 400 sites were removed in first operation. The pre-operative ADC values of sites corresponding to future recurrence were significantly lower than that of non-recurrent sites (p <0.001). We suggest that a low ADC values in FLAIR high-signal lesion is corresponding to recurrence, and useful for predicting recurrence of the lesion in cases of GBM. These results will be helpful for planning of surgery or radiation therapy and facilitate future prospective studies on GBM.

Case Report: Changes in Regional Cerebral Blood Flow in Chronic Akathisia of a Depressed Patient Before and After Electroconvulsive Therapy Treatment.

Akathisia, which characterized by subjective restlessness and objective hyperactivity, is induced mostly by antipsychotics and antidepressants. Chronic akathisia is defined as persistence of symptoms for more than 3 months. The pathophysiology of chronic akathisia remains unclear. This report describes a depressed patient, a 66-year-old woman with a diagnosis of major depressive disorder, with chronic akathisia. Her regional cerebral blood flow (rCBF) was measured using single photon emission computed tomography (SPECT) before and after the treatment with electroconvulsive therapy (ECT). She had experienced akathisia-like symptoms three times prior because of risperidone, escitalopram, and clomipramine administration, accompanied by major depression. After levomepromazine was added to quetiapine to treat insomnia, she developed akathisia symptoms such as a sense of restlessness and inability to sit in one place for a few minutes. These antipsychotics were withdrawn. Propranolol was administered, leading to no apparent improvement for 8 months. After she was diagnosed as having major depressive disorder and chronic akathisia, she received 10 sessions of bilateral ECT. Her depressive symptoms improved greatly. Akathisia disappeared completely after ECT. SPECT revealed that rCBF was decreased in the middle frontal gyrus and parietal lobe, that it was increased in the thalamus, fusiform gyrus, and cerebellum before ECT, and that these abnormalities in rCBF were approaching normal levels after ECT. Findings presented in this report suggest ECT as a beneficial treatment for chronic akathisia. Altered rCBF in the middle frontal gyrus, parietal lobe, thalamus, fusiform gyrus, and cerebellum, and especially decreased rCBF in the parietal lobe, may be related to the pathophysiology of chronic akathisia.

Comparison of Alzheimer's disease patients and healthy controls in the easy Z-score imaging system with differential image reconstruction methods using SPECT/CT: verification using normal database of our institution.

OBJECTIVE: The easy Z-score imaging system (eZIS) analysis is used for the diagnosis of dementia by cerebral blood flow on single photon emission computed tomography (SPECT). Differences in the acquisition and reconstruction conditions in SPECT may affect the eZIS analysis results. The present study aimed to construct our institutional normal database (NDB) and Alzheimer's disease (AD)-specific volumes of interest (VOIs) in eZIS analysis, and to compare the differential diagnostic ability between healthy controls (HC) and patients with AD in the image reconstruction filtered back projection (FBP) and ordered subset expectation maximization (OSEM) methods. METHODS: An NDB was constructed at our institution from 30 healthy individual using the FBP and OSEM reconstruction methods. We divided 51 HC and 51 AD patients into two groups, one for AD disease-specific VOI construction (HC, AD) and the other for NDB verification (HC, AD); image reconstruction was performed using FBP and OSEM. The areas of reduced blood flow in AD patients were compared with those of HC using the two types of image reconstruction methods. We used AD disease-specific VOI and NDB from each reconstruction method in eZIS analysis and compared the differential diagnostic ability for HC and AD with the different reconstruction methods. RESULTS: Comparing the areas of reduced blood flow in AD patients using the different image reconstruction methods, OSEM showed decreased blood flow in the medial region of the temporal lobes compared to FBP. Comparing the differential diagnostic ability for HC and AD using eZIS, the Severity, Extent, and Ratio showed higher values in the analysis performed using OSEM image reconstruction compared to FBP. CONCLUSION: With the 99mTc-ECD SPECT, the eZIS analysis equipped with our institutional AD-specific VOI and NDB using OSEM image reconstruction could distinguish HC from AD better than eZIS analysis using FBP image reconstruction. This study is registered in UMIN Clinical Trials Registry (UMIN-CTR) as UMIN study ID: UMIN000042362.

Influence of a Headrest on Reconstruction and Attenuation Correction of Human Brain SPECT Images.

Previous reports suggest that a headrest significantly influences anterior and posterior cerebral blood flow. The present study aimed to clarify the influence of a headrest on reconstruction and attenuation correction (AC) of brain SPECT images. Methods: We evaluated the influence on cerebral blood flow in the anterior region (brain segments A + B), middle region (segments D + F), and posterior region (segment G) of the brain using filtered backprojection-AC based on the method of Chang (FBP-ChangAC), ordered-subset expectation maximization-ChangAC (OSEM-ChangAC), OSEM CT-based AC (OSEM-CTAC), and OSEM with no attenuation correction (OSEM-NoAC) with and without a headrest. The subjects were 17 healthy volunteers who underwent 99mTc-ECD SPECT. We compared the A + B/G and the D + F/G ratios of 99mTc-ECD SPECT images in each group. Results: For FBP-ChangAC, OSEM-ChangAC, and OSEM-NoAC, there were significant differences in A + B/G ratio between images obtained with a headrest and those obtained without. On the other hand, for OSEM-CTAC, there were no significant differences in A + B/G ratio regardless of whether a headrest was used. For FBP-ChangAC and OSEM-NoAC, there were significant differences in D + F/G ratio between images with a headrest and those without. For OSEM-CTAC and OSEM-ChangAC, there were no significant differences in D + F/G ratio regardless of whether a headrest was used. Conclusion: The influence of a headrest on image reconstruction and AC should be considered if FBP-ChangAC, OSEM-ChangAC, or OSEM-NoAC is used but not if OSEM-CTAC is used.