Filling out phenomenon with technetium-99m HM-PAO brain SPECT at the site of mild cerebral ischemia.

Although the distribution of [99mTc]hexamethylpropyleneamine oxime (HM-PAO) in the brain is said to be in a flow-related manner without temporal change, we present cases with leakage of [99mTc]HM-PAO (filling out phenomenon) in the delayed image of brain single photon emission computed tomography (SPECT) and clarify its clinical significance. The filling out phenomenon was observed in seven out of 21 cases of cerebrovascular disease and four cases of arteriovenous malformation. The leakage of [99mTc]HM-PAO was also confirmed by visual and semiquantitative analysis. In the pharmacokinetics of [99mTc]HM-PAO in the blood, the percent dose of plasma fraction at 4 hr was reduced to 54% of activity at 30 min. The percent dose of brain blood could be predicted as 3.36%/1 at 30 min and 2.35%/1 at 4 hr after correction with the hematocrit of the brain. The filling out phenomenon of [99mTc]HM-PAO was attributed to a significant reduction of blood activity of [99mTc]HM-PAO in the plasma. Since the initial image might mask reduced rCBF with an increase of rCBV, the late image would have an advantage in accurately evaluating rCBF from the clearance of [99mTc] HM-PAO bound to the plasma. Therefore, the filling out phenomenon of [99mTc]HM-PAO in late images of brain SPECT could show the area of mild cerebral ischemia accompanying cerebral vascular reserve.

Embolic distribution through patent foramen ovale demonstrated by (99m)Tc-MAA brain SPECT after Valsalva radionuclide venography.

UNLABELLED: Cryptogenic stroke might relate to paradoxical embolism stemming from right-to-left shunt caused by patent foramen ovale (PFO). We performed radionuclide venography using the Valsalva maneuver, followed by (99m)Tc-macroaggregated albumin (MAA) brain SPECT to investigate the fate of emboli originating from the lower extremities. METHODS: Ten patients (9 men, 1 woman; mean age, 61 +/- 17 y) with PFO underwent radionuclide venography with and without the Valsalva maneuver on the whole-body image, followed by brain SPECT with (99m)Tc-MAA to determine the cortical uptake that would detect right-to-left shunt. After counts in each region of interest (ROI) were normalized by comparison with the averaged count, the distribution of MAA was compared with that of (99m)Tc-hexamethyl-propyleneamine oxime (HMPAO) brain SPECT by drawing ROIs on frontal, temporoparietal (anterior circulation territory), occipital, and cerebellar areas (posterior circulation territory). RESULTS: The thyroid on the whole-body scan was visualized after the Valsalva maneuver in 2 of the 10 patients. In 7 of 10 patients, 56 ROIs in the visualized cortical uptake showed that the distribution of MAA correlated well with that of HMPAO according to the equation: HMPAO = -71.21 + 1.71 x MAA, (r = 0.575, P < 0.01). The excess difference in the relative counts in the posterior over anterior circulation territory was 5.6% and 16.1% of the HMPAO and MAA values, respectively. CONCLUSION: Brain SPECT with (99m)Tc-MAA was more sensitive than thyroid visualization in detecting right-to-left shunt. The excess flow in the posterior cerebral circulation indicated an increased likelihood of cerebral emboli originating from the lower extremities and indicated that the flow difference between HMPAO and MAA probably resulted from poor linearization of HMPAO in the high-flow area.

Detection of postural cerebral hypoperfusion with technetium-99m-HMPAO brain SPECT in patients with cerebrovascular disease.

Seventeen of 19 patients (67 +/- 8 yr, 17 males and 2 females) had more than 75% unilateral stenosis or occlusion of the internal carotid or middle cerebral artery and two patients had carotid endarterectomy that previously had 90% stenosis of the internal carotid artery. They were studied during upright 99mTc-HMPAO brain SPECT. HMPA was injected immediately after arising from a supine position. Patients were classified into Group A (n = 10) with occlusion of the internal carotid or the middle cerebral artery or Group B (n = 9) with more than 75% unilateral stenosis of the internal carotid or the middle cerebral artery and with carotid endarterectomy. Additional cerebral blood flow perfusion abnormalities between upright and supine 99mTc-HMPAO brain SPECT were detected in seven patients in Group A and in only one patient in Group B. Semiquantitative analysis showed that the asymmetric ratios between upright and supine positions changed significantly in Group A from 0.82 +/- 0.15 to 0.89 +/- 0.10 (p < 0.01), but not in Group B, from 0.89 +/- 0.11 to 0.92 +/- 0.12 (ns). Additional perfusion abnormalities were relevant to occlusion of the internal carotid or middle cerebral artery indicated postural cerebral hypoperfusion. We conclude that upright 99mTc-HMPAO brain SPECT visualizes postural cerebral hypoperfusion possibly related to silent cerebral ischemia.

Quantitative assessment of myocardial enhancement with iodinated contrast medium in patients with ischemic heart disease by using ultrafast x-ray computed tomography.

BACKGROUND AND RATIONALE: The authors report the quantitation of myocardial enhancement using iodinated contrast medium in patients with ischemic heart disease. Twenty-eight patients with chronic ischemic heart disease and 11 controls were examined by ultrafast computed tomography (CT) using 100-msecond scans. METHODS: The authors analyzed M/L (ratio of post-contrast incremental increases in the left ventricular myocardial and luminal CT number) in early and late phases after contrast injection. RESULTS: In controls, mean values of early and late M/L were 30% and 51%, respectively. In infarcted or severely ischemic segments, early M/Ls (19%, 16%) were significantly small (P less than .001), whereas late M/Ls (90%, 63%) were higher (P less than .001, .01) than controls. Segments with infarction or severe ischemia were differentiated from mild or nonsignificant ischemia by using this parameter (sensitivity, 99%; specificity, 88%). CONCLUSIONS: M/L is useful for detection of the ischemic myocardium.

Value of diffusion-weighted imaging and apparent diffusion coefficient in recent cerebral infarctions: a correlative study with contrast-enhanced T1-weighted imaging.

BACKGROUND AND PURPOSE: The clinical usefulness and the time course of diffusion-weighted imaging and apparent diffusion coefficient (ADC) in acute and subacute cerebral infarction have not yet been established, although it is known that contrast-enhanced T1-weighted spin-echo imaging can detect a subacute infarct. Our aim was to study which imaging technique is useful in detecting recent infarcts, and whether an increase in ADC or a decrease in signal intensity on diffusion-weighted images is correlated with enhancement on T1-weighted spin-echo images. METHODS: Forty-one infarctions with a duration of 9 hours to 27 days were studied in 29 patients. The ADC and signal intensity on diffusion-weighted images were compared with the contrast-enhancement ratio (CER) on T1-weighted spin-echo images (CER = signal intensity after contrast injection/signal intensity before contrast injection). RESULTS: ADC was linearly correlated with CER, and signal intensity on diffusion-weighted images was inversely correlated with CER. The correlation between ADC and age of the infarct in the subacute phase was weak. CONCLUSION: Diffusion-weighted and contrast-enhanced T1-weighted spin-echo images complement each other in detecting subacute infarcts. Neovascularization and disruption of the blood-brain barrier in infarcts can be important in increasing ADC in subacute infarcts.

Subtraction CT angiography with controlled-orbit helical scanning for detection of intracranial aneurysms.

PURPOSE: Our goal was to evaluate the utility of subtraction three-dimensional CT angiography for the detection of intracranial aneurysms. METHODS: Thirty-six patients with intracranial aneurysms were examined using newly devised controlled-orbit helical scanning and conventional angiography. Three-dimensional CT angiograms and subtraction 3-D CT angiograms were compared with conventional angiograms for their characterization of intracranial aneurysms. RESULTS: Fifty aneurysms were depicted on conventional angiograms, of which 48 (96%) were seen on the 3-D CT angiograms. Three-dimensional CT angiography was superior or equivalent to conventional angiography for depicting the shape, direction, and location of 33 (66%) of 50 aneurysms; however, it was often less useful than conventional angiography in delineating intracranial aneurysms adjacent to bone. Subtraction 3-D CT angiograms were obtained in 32 patients with a total of 46 aneurysms (in four cases, aneurysms were not depicted owing to excessive motion artifacts), and were superior or equivalent to conventional angiograms in all 46 cases. CONCLUSIONS: Subtraction 3-D CT angiography with the use of controlled-orbit helical scanning is effective in the detection of intracranial aneurysms.

Evaluation of the susceptibility effect on gradient echo phase images in vivo: a sequential study of intracerebral hematoma.

Susceptibility effect of intracerebral hematoma was estimated on the phase images of gradient echo (GrE). Thirty-five hematomas were studied 3 hr to 5 yr after the onset, a total of 72 times with use of phase and magnitude images of GrE, as well as T1-, T2-, and density-weighted spin-echo (SE) images at 1.5 T. On the basis of the theory of electromagnetism, phase shift to hematoma was calculated for simplified models with concentric distribution of paramagnetic susceptibility. All hematomas were well visualized by the phase images, the pattern of which changed sequentially. The distribution of paramagnetic susceptibility could be estimated by correlating the observed phase shifts with the calculated one. SE images were necessary to presume the type of magnetic substances. A probable hypothesis of the evolution of intracerebral hematoma is proposed.

Magnetic resonance imaging of pericardial malignant mesothelioma.

Magnetic resonance imaging of pericardial malignant mesothelioma in two patients is reported. Magnetic resonance imaging clearly depicted the tumor location and expansion, and was useful in delineating the anatomic extent of pericardial malignant mesothelioma.

Late enhancement of the left ventricular wall in hypertrophic cardiomyopathy by ultrafast computed tomography: a comparison with regional myocardial thickening.

Eight patients with hypertrophic cardiomyopathy (HCM) were examined by ultrafast computed tomography (UFCT) to investigate the relationship between late enhancement (LE) of the left ventricular (LV) wall after injection of contrast medium and the variations between minimum and maximum wall thickness of the LV. Late enhancement was usually found as a patchy, stained area in the myocardium on delayed phase volume mode images of UFCT. Out of 48 LV segments of the patients with HCM, 21 had LE. Normalized percentage regional wall thickening in the segments that had LE was significantly less than that in the segments that did not have LE (63.6 +/- 44.5% and 137.6 +/- 54.6%, respectively; p less than 0.001). This may reflect abnormal myocardial architecture.

Validation to eliminate vascular activity on 99Tcm-HMPAO brain SPECT for regional cerebral blood flow (rCBF) determination.

Since more than 15% of the injected dose of 99Tcm-HMPAO 10 min after injection labels plasma or red blood cells (RBC), the elimination of vascular activity from actual brain activity is mandatory to evaluate accurately regional cerebral blood flow (rCBF) with 99Tcm-HMPAO brain SPECT. The late image (4 h post-injection) will show a reduced vascular activity of approximately 30% compared to the initial image (30 min post-injection), due principally to a plasma fraction reduction of 54%, and an insignificant reduction of activity in the RBC fraction. The circulating RBC count can then be normalized for both the injected dose and total blood volume, because the entrapment mechanism of 99Tcm-HMPAO with RBC is the same as that with brain retention. After elimination of the vascular contribution using the RBC activity the mean counts in the 14 middle cerebral artery areas from seven cases on 99Tcm-HMPAO SPECT showed a good correlation (r = 0.85) with the initial slope index of 133Xe cerebrography. It was concluded that the elimination of the vascular activity on 99Tcm-HMPAO brain SPECT is needed to quantify rCBF accurately.

Ataxic hemiparesis following thalamic lacunar infarction.

A 60-year-old man developed left hemiparesis and homolateral ataxia with normal sensation and normal somatosensory evoked potentials. A lacunar infarct with gadolinium enhancement in the right dorsolateral part of the thalamus was demonstrated on magnetic resonance imaging. Thalamic lesion is a relatively rare cause of ataxic hemiparesis; most of the reported cases of ataxic hemiparesis caused by thalamic lesion were accompanied by sensory disturbances. This is an interesting case which suggested that the thalamic lesion could be responsible for the ataxic hemiparesis without a sensory disturbance.

Favorable biodistribution of 99mTc-ECD for brain SPECT comparing with 123I-IMP using alternative body scan.

In order to evaluate the lung and brain uptake of 99mTc ethyl cysteinate dimer (99mTc-ECD) and N-isopropyl-p-[123I]-iodoamphetamine (123I-IMP), alternative body scans were carried out in 15 cases of cerebrovascular disease. The biodistribution of 99mTc-ECD was 5.5 +/- 0.7%, 3.8 +/- 0.7% in the brain; 13.1 +/- 3.7%, 2.2 +/- 1.2%, in the lung at 15 min and at 4 hours, respectively, whereas that of 123I-IMP was 3.9 +/- 1.4%, 5.0 +/- 1.0% in the brain; 32.2 +/- 7.6%, 12.7 +/- 3.3%, in the lung at 15 min and at 4 hours, respectively. 99mTc-ECD accumulated in comparatively high amounts in the brain but remained low in the lung in the early image compared to 123I-IMP. However there was a high inverse correlation between brain and lung uptake of 123I-IMP (r = -0.82), but not of 99mTc-ECD (r = -0.18). We concluded that 99mTc-ECD had a better biodistribution in terms of low lung accumulation than 123I-IMP in brain SPECT.

Hemodynamic and metabolic state of hyperfixation with 99mTc-HMPAO brain SPECT in subacute stroke.

By means of positron emission tomography (PET), we investigated the hemodynamic and metabolic state of the hyperfixation identified as the increased accumulation with 99mTc-d,l-hexamethylpropyleneamine oxime (HMPAO) by single photon emission computed tomography (SPECT) in patients with subacute stroke. We studied four patients with subacute stroke having hyperfixed areas evaluated with CBF, CMRO2, OEF and CBV by PET. The hyperfixation rate with 99mTc-HMPAO was obtained by comparing the surplus rate with standardized CBF. The OEF and CMRO2 values in the hyperfixed areas of 4 patients were significantly lower than those in normal 5 controls (p < 0.01), but CBF and CBV were almost the same in patients and normal controls, but the hyperfixation rate of 0.30 +/- 0.15 in 4 patients correlated well with CBV (r = 0.97, y = 11.75x + 0.42; p < 0.05). Hyperfixation with 99mTc-HMPAO in the infarct area revealing a mismatch between CMRO2 and CBF meant relative luxury perfusion. The hyperfixation rate determined by 99mTc-HMPAO brain SPECT correlated with CBV in the PET study. We can conclude that one of the main factors which caused hyperfixation was vasodilatation as well as the blood brain barrier disruption and the neovascularization.

Increased bone mineral turnover without increased glucose utilization in sclerotic and hyperplastic change in fibrous dysplasia.

Fibrous dysplasia is a benign bone disorder. It is diagnosed by distinctive X-ray radiography, CT, and MRI findings. Although bone scintigraphy helps to identify the tumor origin according to accelerated bone turnover, the glucose metabolism in fibrous dysplasia has not yet been investigated. We reported a case of fibrous dysplasia in craniofacial bone which showed signs of the acceleration of bone mineral turnover without elevated glucose utilization by Technetium-99m-HMDP SPECT and Fluorine-18-FDG PET. We concluded that the growth of fibrous dysplasia needed the acceleration of bone mineral turnover without an increase in glucose metabolism.

31P in-vivo spectroscopic study by high-field whole-body MR system--an application to a case with arteriosclerosis obliterans.

31P in-vivo spectroscopy was performed by a 1.5-tesla whole-body MR system. The 31P spectrum for the calf muscle in a patient with arteriosclerosis obliterans having intermittent claudication was obtained every two minutes. When the spectrum after the workload was compared with that at rest, an increase in inorganic phosphate (Pi) and a decrease in phosphocreatine (PCr) were observed, resulting in a strong decrease in the PCr/Pi ratio. This method can measure the ischemic and recovery stages of energy metabolism in skeletal muscle noninvasively and continuously in addition to magnetic resonance imaging.

Transesophageal echocardiography for detecting intracardiac thrombi in embolic stroke.

The authors studied 56 patients with cardioembolic stroke to search for intracardiac thrombi by use of transesophageal and transthoracic echocardiography. Forty consecutive patients were examined within four weeks of stroke onset and the remaining 16 in the chronic stage. They also performed ultrafast computed tomography in 9 of them. Underlying heart disease was present in all subjects. Anticoagulant therapy had already been started in 29 at the time of examinations. Using their own criteria for echocardiography, they diagnosed intracardiac thrombus in 7 cases and valvular vegetation in 1. Six thrombi were located in the left atrial appendage, 4 of which were smaller than 10 mm in diameter. These small thrombi were not found by either transthoracic echocardiography or computed tomography. Transesophageal echocardiography appears to be superior to the other two methods, especially for detecting small intracardiac thrombi in the left atrial appendage.

Case report: stent placement in support of intravascular ultrasound in a woman with atypical lower abdominal aortic stenosis.

Localized stenosis confined to the distal abdominal aorta near the bifurcation is an atypical manifestation of atherosclerosis, particularly in a woman. We report the case of a middle-aged woman who presented with a focal stenosis accompanied by heavy calcification in the distal abdominal aorta. The lesion was successfully treated by Palmaz stent placement under intravascular ultrasound guidance.

Three-dimensional CT imaging of aneurysm of aberrant right subclavian artery.

We report a case of an aneurysm originating from an aberrant right subclavian artery, which was incidentally found as a compression deformity of the upper esophagus on a barium study in a 46-year-old man. Computed tomography (CT) clearly demonstrated the aneurysm of the aberrant right subclavian artery. In particular, reconstructed three-dimensional CT (3D-CT) was valuable in evaluating the positional relationships between the anomalous vessel with aneurysm and other structures.

Embolic stroke following carotid radiation angiopathy demonstrated with I-123 IMP brain SPECT.

Radiation angiopathy was developed by the process of accelerated atherosclerosis at the site of irradiation. The case of a 44-year-old man with right hemiparesis showing a high signal intensity in the left semioval center on MRI and a defect in the left temporo-parietal area with subsequent filling-in with I-123 IMP brain SPECT is reported. Digital subtraction angiography showed typical radiation angiopathy with ulceration in the left common carotid artery. Twenty-four years previously, he underwent curative irradiation of a neck mass that revealed Hodgkin's disease by biopsy. The emboli formed at the site of radiation-induced angiopathy and caused cerebral infarction. The perfusion abnormality in the territory of the embolic artery was detected by I-123 IMP SPECT. Long-term survivors of neck irradiation are at high risk for the development of carotid arterial disease and should be watched carefully.

[Three dimensional CT angiography using helical scanning].

Thirty-seven intracranial aneurysms were examined with three dimensional CT angiography (3D-CTA) using helical scanning. The raw data were acquired using a helical CT scanner (X vigor, Toshiba). The collimation was 1 mm or 2 mm, and the table speed was 1 mm or 2 mm/rotation. The contrast medium (iohexol 350) of 1.2-1.5 ml/body weight kg was intravenously injected at an initial rate of 1.5 ml/sec and a second rate of 1.0 ml/sec. The scan delay time was 40-45 sec after the injection of the contrast medium. The 3D-CTA was compared with cerebral angiography (CAG) in the detectability of aneurysms. The 3D-CTA was equal or superior to CAG in 22 aneurysms. The 3D-CTA was less useful in the most aneurysms adjacent to the bone such as aneurysms of internal carotid artery. The subtraction 3D-CTA was useful in the detection of those aneurysms which could not clearly be detected on the 3D-CTA.