Retrospective study on PET-SPECT imaging in a large cohort of myotonic dystrophy type 1 patients.

The aim was to study brain involvement in myotonic dystrophy type 1 by single photon emission tomography (SPECT) and positron emission tomography (PET). 58 DM1 patients were subjected to SPECT; 17 to both SPECT and PET. SPECT patients were grouped as 'normally perfused' and 'abnormally perfused'; PET patients as 'normal performers' and 'abnormal performers'. To quantify hypoperfusion and/or hypometabolism, we used a semi-quantitative scale. To localize focal hypoperfusion/hypometabolism, nine cerebral areas of involvement were identified. The Chi-square, Wilcoxon, McNemar tests were used for statistics. SPECT showed abnormalities in 52/58 patients. PET showed an abnormal glucidic uptake in 15/17. Hypoperfusion was mild/moderate in 50/58 patients, mostly involving the left supratentorial areas. Abnormal glucidic uptake was mainly observed in the left frontal lobe. Abnormalities in blood perfusion and/or glucose metabolism are frequent in DM1. These abnormalities involve the left more often than the right hemisphere, the frontal lobe more than other lobes. Such abnormalities are more often cortical than subcortical.

[Intraoperative transesophageal echocardiography in the endovascular treatment of thoracic aortic aneurysms]. / L'utilizzo intraoperatorio dell'ecocardiografia transesofagea nel trattamento endovascolare degli aneurismi dell'aorta toracica.

AIM: Endovascular surgery is an efficacious alternative to conventional surgery in the treatment of descending thoracic aorta aneurysms. However, primary and delayed endoleaks are some endovascular technology's weak points. They are usually detected by angiography or angio CT, but many information may be obtained by transesophageal echocardiography (TEE) both as to endoleaks and to endograft's correct placement. Our purpose is to confirm, on the basis of our experience, the validity of this technique chosen both by us and by other groups with a wider casuistry. METHODS: We positioned endografts for the treatment of degenerative or post-traumatic aneurysms of the descending thoracic aorta using TEE, together with angiography, during surgery in 8 out of 9 patients. TEE was carried out on the same 8 patients also before surgery, and for some patients even in the follow-up together with angio CT, after 6 and 12 months. RESULTS: In the situations where TEE was used we found 5 cases of endoleaks and 1 of these was not detected by angiography because of its small dimensions. All of these endoleaks were immediately corrected with more angioplasty or graft extensions; in a case, where we could not utilize the TEE, the problem solved spontaneously after 30 days as it was confirmed both by angiography and angio TC. The statistical analysis with the Student t test is significant for P < 0.005. CONCLUSIONS: We think that using TEE during the placement of an endograft on the descending thoracic aorta may help to obtain useful information in addition to those that we can obtain with angiography. Therefore, this may lead to improve the technique and to reduce possible both immediate or delayed complications.

T wave normalization in infarct-related electrocardiographic leads during exercise testing for detection of residual viability: comparison with positron emission tomography.

OBJECTIVES: We investigated the sensitivity and specificity of exercise-induced T wave normalization (TWN) in infarct-related electrocardiographic leads (IRLs) for detection of residual viability in the infarct area. BACKGROUND: The meaning of exercise-induced TWN on IRLs is not yet well understood. Recent reports suggest that TWN during dobutamine echocardiography could indicate the presence of viable myocardium. METHODS: We evaluated 40 consecutive patients with a recent acute myocardial infarction and negative T waves in at least two IRLs. All patients underwent exercise testing; positron emission tomography (PET) with nitrogen-13 ammonia and fluorine-18 fluorodeoxyglucose; and coronary angiography. RESULTS: Twenty-four patients showed exercise-induced TWN: 18 at a work load < or =50 W (group la) and 6 at a work load > or =75 W (group 1b); 16 patients did not show TWN (group 2). On the PET study, viability in the infarct area was present in 17 patients (94%) from group la, in only 1 (16%) from group 1b and in 4 (25%) from group 2 (p < 0.0001). The sensitivity, specificity and diagnostic accuracy of exercise-induced TWN, in comparison with residual viability, were, respectively, 82%, 67%, 75% for TWN at every work load and 77%, 94%, 85% for TWN at a work load < or =50 W. Moreover, the sensitivity and diagnostic accuracy of TWN at the low work load were higher for anterior infarctions (87% and 88%, respectively). CONCLUSIONS: Exercise-induced TWN on IRLs at low work loads is a sensitive and specific index for the presence of residual viability in the infarct area. Sensitivity and diagnostic accuracy of this sign are higher for anterior infarctions.

Reduced striatal dopamine receptors in Alzheimer's disease: single photon emission tomography study with the D2 tracer [123I]-IBZM.

Many patients with Alzheimer's disease (AD) develop parkinsonian symptoms, suggesting an overlapping between AD and Parkinson's disease (PD). However, pathologic and neurochemical studies indicate that the involvement of the dopamine system may be different in the two conditions. Using single photon emission tomography, we determined the relative specific striatal uptake (striatum to cerebellum ratio) of the D2 receptor ligand [123I]-IBZM in 15 AD patients without overt extrapyramidal symptoms (three subjects presented mild rigidity and bradykinesia) and nine age-matched controls. Mean specific activity in striatal regions of AD patients (1.35 +/- 0.09) was significantly reduced from control mean (1.59 +/- 0.03). Because such changes were evident even in the absence of overt parkinsonian symptomatology, our data indicate that alterations of striatal D2 receptors may be part of the pathologic abnormalities of AD. In addition, the mechanisms underlying extrapyramidal symptoms in AD (decline of postsynaptic striatal dopamine receptors) appear different from the prevalent presynaptic nigrostriatal alterations typical of PD.

Brain positron emission tomography (PET) in chronic fatigue syndrome: preliminary data.

Chronic fatigue syndrome (CFS) has been widely studied by neuroimaging techniques in recent years with conflicting results. In particular, using single-photon emission computed tomography (SPECT) and perfusion tracers, hypoperfusion has been found in several brain regions, although the findings vary across research centers. The objective of this study was to investigate brain metabolism of patients affected by CFS, using [18F]fluorine-deoxyglucose (18FDG) positron emission tomography (PET). We performed 18FDG PET in 18 patients who fulfilled the criteria of the working case definition of CFS. Twelve of the 18 patients were females; the mean age was 34 +/- 15 years (range, 15-68) and the median time from CFS diagnosis was 16 months (range, 9-138). Psychiatric diseases and anxiety/neurosis were excluded in all CFS patients. CFS patients were compared with a group of 6 patients affected by depression (according to DSM IV-R) and 6 age-matched healthy controls. The CFS patients were not taking any medication at the time of PET, and depressed patients were drug-free for at least 1 week before the PET examination. The PET images examined 22 cortical and subcortical areas. CFS patients showed a significant hypometabolism in right mediofrontal cortex (P = 0.010) and brainstem (P = 0.013) in comparison with the healthy controls. Moreover, comparing patients affected by CFS and depression, the latter group showed a significant and severe hypometabolism of the medial and upper frontal regions bilaterally (P = 0.037-0.001), whereas the metabolism of brain stem was normal. Brain 18FDG PET showed specific metabolism abnormalities in patients with CFS in comparison with both healthy controls and depressed patients. The most relevant result of our study is the brain stem hypometabolism which, as reported in a perfusion SPECT study, seems to be a marker for the in vivo diagnosis of CFS.

Myocardial perfusion, glucose utilization and oxidative metabolism in a patient with left bundle branch block, prior myocardial infarction and diabetes.

A diabetic patient affected by insulin-dependent diabetes, significant stenosis of left anterior descending (LAD) coronary, thrombolyzed myocardial infarction and complete left bundle branch block (LBBB) was examined by PET. Myocardial perfusion, glucose utilization and oxidative metabolism were evaluated by 13N-ammonia, 18F-fluorodeoxyglucose (FDG) and 11C-acetate, respectively. Despite severe damage in 18F-FDG uptake in the septum, with a septum-to-lateral ratio (S/L R) equal to 0.38, the oxidative metabolism in this area, evaluated quantitatively by dynamic acquisition, was relatively preserved (S/L R = 0.82), with a distribution similar to perfusion (S/L R = 0.87). These data reveal selective damage in glucose utilization in the septum in LBBB, unrelated to perfusion reduction and with preserved oxidative metabolism. Moreover, our experience could suggest an overestimation of the necrotic area by 18F-FDG in LBBB patients.

Proposal of a modified scintigraphic method to evaluate duodenogastroesophageal reflux.

Hepatobiliary scintigraphy with 99mTc-HIDA offers a noninvasive method to detect duodenogastric reflux. Biliary reflux was graded using the persistence rather than the intensity of the radioactive refluxate: Grade 0 was considered the absence of reflux, minimal reflux, or reflux in the first 10-15 min; Grade 1 was repetitive reflux lasting less than 10 min; Grade 2 was persistent reflux; and Grade 3 was reflux up to the esophagus. Twenty-five patients with foregut symptoms were studied and results were compared to 24-hr gastric pH monitoring. Scintigraphy and pH monitoring agreed in 15 out of 25 patients (60%), but no correlation was found with the endoscopic findings. The rationale for this approach is based on pathophysiologic evidence that damage to gastric and/or esophageal mucosa is mainly related to the prolonged contact time with duodenal contents. This technique seems to allow a complete functional evaluation of the esophagogastroduodenal tract without causing adjunctive irradiation or discomfort to the patient.

Advantages of positron emission tomography (PET) with respect to computed tomography in the follow-up of lymphoma patients with abdominal presentation.

For abdominal lymphoma patients, fluorine-18 fluorodeoxyglucose positron emission tomography (PET) provides unique information on the presence of residual active disease. We provide an update on the largest reported cohort of patients whose management following induction therapy was based on routine PET and computed tomography (CT) restaging. Fifty-nine patients with Hodgkin's disease or aggressive non-Hodgkin's lymphoma presenting abdominal involvement (35% with bulky disease) were studied with both PET and CT following combined chemotherapy/radiation treatment. After treatment, 3/3 (100%) patients who were PET+/CT- relapsed, compared with 0/7 patients in the PET-/CT- subset. Among the 49 patients who were CT+, six of the 10 (60%) who were PET+ relapsed, as compared with only two of the 39 (5%) who were PET-. The actuarial relapse-free survival (RFS) rates were 0 and 100% in the PET+/CT- and PET-/CT- subsets, respectively. In the PET+/CT+ subset, RFS was 94% at 5 years. PET restaging is very valuable for the identification of patients who would need appropriate second-line therapy because of the presence of residual active abdominal disease and should be made widely available in combination with CT.

Alterations of striatal dopamine D2 receptors contribute to deteriorated response to L-dopa in Parkinson's disease: a [123I]-IBZM SPET study.

Single photon emission tomography with the ligand [123I]-IBZM was used to image central dopamine D2 receptors in Parkinson's disease patients. The aim was to assess striatal receptor densities in relation to response to L-Dopa therapy. In the parkinsonian patients group who were untreated until SPET study and in the group of patients with a sustained response to chronic L-Dopa, striatal [123I]-IBZM uptake did not differ significantly from mean values of the control group. On the contrary, significantly diminished uptake of [123I]-IBZM was found in the basal ganglia regions of the group of patients who developed a complicated/fluctuating response to chronic L-Dopa treatment. Our results indicate that striatal D2 receptor alterations in Parkinson's disease may contribute to the altered response to L-Dopa.

Does liver-disease aetiology have a role in cerebral blood-flow alterations in liver cirrhosis?

BACKGROUND: Studies using brain-imaging techniques have shown changes in regional blood flow (rCBF) in patients with liver cirrhosis. It remains unknown whether the aetiology of liver disease accounts for these changes. AIMS: To evaluate whether the aetiology of liver cirrhosis is associated with different patterns of rCBF. MATERIALS AND METHODS: A total of 50 patients with end-stage liver disease and no overt encephalopathy were studied. Thirteen age-matched subjects admitted to the neurology department for headache were used as controls. Exclusion criteria were focal brain lesions, severe brain atrophy and any abnormalities found on computed tomography scan suggesting other central nervous system diseases, alcohol intake or use of neuroactive drugs for at least 6 months. rCBF was assessed using single-positron-emission tomography (SPECT) with 99mTc-hexamethylpropylene amine oxime (99mTc-HM-PAO) as a tracer in all patients and controls. The Mann-Whitney U test was used for statistical analysis. RESULTS: The liver-disease aetiology was as follows: alcoholic (A) in 19 patients; viral (V) (hepatitis B virus, hepatitis D virus, hepatitis C virus) in 14 patients; alcoholic with concomitant viral (A + V) in five patients; and cholestatic (C) (primary biliary cirrhosis, primary sclerosing cholangitis) in 12 patients. SPECT showed significantly lower rCBF in cirrhotic patients than in controls for most cortical and subcortical regions and in alcoholic and viral patients than in cholestatic liver disease patients for some cortical regions. When patients were grouped according to previous alcohol abuse (including cases with a concomitant viral aetiology), rCBF was significantly lower in the frontal superior, medial and temporal inferior regions in the alcoholic group. CONCLUSIONS: Cerebral blood flow is significantly lower in patients with liver cirrhosis than in controls and, among cirrhotics, it is lower in alcoholic and viral cirrhosis than in cholestatic liver disease. In patients with previous alcohol abuse, cerebral blood flow was significantly more reduced in the frontal and temporal regions compared with patients without previous alcohol abuse.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up.

BACKGROUND AND HYPOTHESIS: The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms. METHODS: We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months. RESULTS: Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008). CONCLUSIONS: Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

A case of congenital hypoplasia of the right external iliac artery.

A 18 years male had congenital hypoplasia of the right external iliac artery and thrombosis of its narrowest part. Congenital megacolon, anal atresia and hyposomical nanism were also present. Surgical intervention was indicated because he was developing arterial insufficiency and muscular hypotrophy of the right leg. A bypass was performed with a reversed autogenous vein between the common iliac artery and the common femoral artery.

The role of fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) whole body scan (WBS) in the staging and follow-up of cancer patients: our first experience.

We report the results of FDG PET whole body scan in 75 cancer patients in whom tumor extent was defined by surgical, histological or cytological findings and clinical follow-up. Twenty-five had malignant lymphomas, 24 lung carcinomas, and 26 other types of solid tumors. Twenty-three patients were evaluated at disease onset, before therapy, and 37 at the moment of tumor recurrence; the remaining 15 patients were in complete remission after treatment and were taken as controls. Visual and quantitative PET results were compared with conventional imaging (US, CT scan and/or MRI, and Tc99m MDP bone scan). In the 60 patients with active disease, PET as well as conventional imaging were able to locate the primary tumor in all 23 patients studied at disease onset. However, with regard to lymph node and distant metastases, PET provided the same information as conventional imaging in 31 cases (51.6%), but revealed further neoplastic foci in 29 cases (48.4%), 21 in lymph nodes and 8 at distant sites. The sensitivity of PET, in comparison with conventional imaging, was 100% versus 100% for the detection of the primary tumor, 97.6% versus 55.8% for the localization of node metastases, and 100% versus 55.5% for the visualization of distant metastases. The specificity, calculated in the group of 15 disease-free patients, was 100% for PET and 86.6% for conventional imaging. The therapeutic approach was modified in 12 patients (20%) on the basis of the PET results. Furthermore, in 14 cases (23.3%) with advanced disease, PET provided complete information on tumor spread, otherwise obtainable only by taking together the results of all other diagnostic procedures. Our data indicate a higher accuracy of FDG PET whole body scan compared to conventional imaging techniques in the evaluation of metastatic spread both at initial diagnosis and during follow-up, with an important impact on therapeutic decision-making. Moreover, by providing complete information on tumor spread in some cases, PET can become a profitable tool in terms of cost reduction.

Treatment of Buerger's disease with electrical spinal cord stimulation--review of three cases.

Buerger's disease or obliterating thromboangiitis is an inflammatory pathologic condition affecting the distal vascular segments; it strikes young adults, especially males and heavy smokers. Medical and surgical treatment often fail to heal these patients, especially considering the frequent relapse of this disease linked with tobacco abuse--definitive healing often involves limb amputation. Electrical spinal cord stimulation is evaluated in this study with an analgesic aim and for improvement in skin microcirculation, with the goal of long-term healing of diseased limbs.

Identificaiton of chlamydia penumoniae DNA in caroitd plaques.

Chlamydia pneumoniae (CP) is a bacterium that in recent years has been investigated as an etiologic agent for atherosclerosis. It is a ubiquitous microorganism that has been isolated in various regions of the vascular system and its prevalence is about 10% in the patient population. This study involved a group of 43 patients (27 men, 16 women, mean age 68 years) who underwent carotid endarterectomy. About 9.3% of the patients yielded plaques that tested positive for the DNA genome of Chlamydia pneumoniae.

PET supports the hypothesized existence of a male sexual brain algorithm that may respond to treatment combining psychotherapy with virtual reality.

Could a brain circuit exist, verifiable using positron emission tomography (PET), that links coitus and its dysfunctions, such as impotence? Could re-establishing normal sexual functioning be linked with the normalization of some sort of altered brain metabolism utilizing a therapeutic project that uses psychodynamic psychotherapy integrating virtual reality (VR)? A Brain PET Scan and a self-administered sexual activity questionnaire were given to 11 heterosexual patients affected by impotence due to psychological causes, both before and approximately 6 months after a cycle of psychodynamic psychotherapy. Seven randomly-selected patients received psychotherapy with VR technology using the Optale Method. PET data, used to indicate glucose consumption in various brain areas, were compared with data from normal patients, and a statistical analysis was run. Alterations in cerebral metabolic functioning were displayed in the following areas: frontal cortex, nucleus caudatus, and thalamus. The seven patients who received psychotherapy with VR technology "normalized" in these same areas and attained satisfactory sexual performance. The existence of a male sex algorithm may be hypothesized that links the frontal cortex, nucleus caudatus, and thalamus, and explains its action on cortical motor areas and/or on the medial preoptic area of the hypothalamus, which may respond to treatment combining psychotherapy with VR.

[Giant aneurysm of the renal artery. Case report]. / Aneurisma gigante dell'arteria renale. Caso clinico.

A case of a giant aneurysm of the right renal artery is described. A female patient, 65 years old, normotensive, affected by a great aneurysm of 7 cm per 6 cm, localized in the renal ilus and determining a chronical pyeloneprosis is observed. She was operated on for nephrectomy because the aneurysm and the kidney were strictly closed. The patient recovered her health. The current status of the art is then analysed.

[Surgical treatment of post-mastectomy lymphedema of the upper limb]. / Il trattamento chirurgico del linfedema dell'arto superiore secondario a mastectomia.

The authors analyze their experience of surgical treatment of post-mastectomy lympho-edemas of the upper arm. They have performed 14 operations, each upon patients with praecox or later oedema, following Cariati's classification, and with median age of 56.5 years. Seven patients were present at the follow-up in 6 has been performed microsurgical lympho-venous anastomosis, in 1 a fasciotomy of the forearm and in 1 patient some silastic tubes were positioned in her subcutaneous tissue. An improvement of the subjective symptoms has been recorded in 57.14% of the patients, while the objective ones have improved in 50% of the patients. The authors think that the microsurgical treatment of the lymphedema post-mastectomy of the upper arm is the first choice nowadays.

[Value of TC99m-Nanocolloid spect in diagnosis and follow-up of necrotizing external otitis]. / La spect TC99m-nanocolloide nella diagnosi e follow up delle otiti esterne necrotizzanti.

Necrotizing external otitis (NEO), or malignant external otitis, a severe penetrating infection of the ear canal and the temporal bone, which occurs almost exclusively in diabetic or immunodepressed elderly patients, is caused in most cases by Pseudomonas aeruginosa while Staphylococcus epidermidis and Aspergillus fumigatus have been described as other possible agents. Recently bone scintigraphy, carried out above all employing SPECT, has been considered an important tool in diagnosis and follow-up of NEO. Many Authors confirm the role taken by Technetium99m-methylene-diphosphonate (MDP) and Gallium67-citrate bone scanning. Benecke suggested that response to therapy could be monitored with Ga67 or In111 scans. Two cases of NEO in which diagnosis and follow-up were made using Tc99m-nanocolloid (NC) SPECT are presented in this paper. The Authors discuss the advantages of this latter radiotracer, compared to those obtained with Ga67-citrate, in the follow-up evaluation of therapy efficacy. Tc99m-NC, in fact, is a better inflammation index in that its fixation on bone tissue is determined by the permeability of the basal membrane of vessels. Furthermore, with Tc99m-NC antibiotic therapy may be continued as long as necessary. Bone scintigraphy with other radiotracers may infact result positive for a long period after disease remission in that their fixation is linked to the one remodelling process.

18F-FDG-PET/CT.

[18F]FDG has been the first radiopharmaceutical used for human brain PET studies and still is the most used radiotracer worldwide for PET and PET/CT oncologic applications. In the assessment of brain tumors, in spite of its low sensitivity in some histological exams, chiefly low-grade lesions, its prognostic value remains of high clinical impact. Moreover, the reliability of [18F]FDG in examining not only the tumor itself, but also the functional state of the whole brain, makes this tracer a valuable tool for treatment decisions and patient management, even nowadays when new tracers (especially amino-acids) are available. In addition, [18F]FDG has a role in the differential diagnosis between relapse and necrosis when assessing aggressive tumors and to establish dedifferentiation in low-grade lesions. With the growing of available therapies, another emerging application of [18F]FDG is the monitoring of response to treatment, even though more evidence is needed to assess the best scanning time. Finally, the implementation of CT in PET devices most likely will improve the sensitivity and specificity of [18F]FDG, even though more data are needed to better understand which is the real advantage of PET/CT with respect to multimodality imaging. Currently, the possible added value of PET/CT is in the study of secondary brain lesions. It is believable that in the future we will keep on speaking about this "old" radiotracer, still alive.