Swyer-James Syndrome in a 7-Year-Old Female.

Swyer-James syndrome is a rare syndrome that occurs as a result of repeated bronchiolitis and pneumonitis in childhood. Most cases are asymptomatic, and subsequent diagnosis may not occur until adulthood. We present the case of a 7-year-old female with Swyer-James syndrome, which was initially diagnosed and treated as asthma. The patient developed respiratory distress and atelectasis which were treated with biphasic cuirass ventilation. This case suggests that Swyer-James syndrome should be a concern in patients with chronic cough and wheezing, and highlights the importance of taking a careful history and appropriate radiological investigations for diagnosis. Once Swyer-James syndrome is diagnosed, prophylaxis and appropriate management of respiratory infections becomes important.

Cognitive impairment and cerebral hypoperfusion in a CADASIL patient improved during administration of lomerizine.

A 64-year-old woman was admitted to our hospital for recurrent stroke and cognitive impairment and was diagnosed with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Iodine-123 iodoamphetamine single photon emission computed tomography showed hypoperfusion in the whole brain, but cerebral blood flow increased dramatically after the administration of acetazolamide in the cerebral cortex. Lomerizine, a diphenylmethylpiperazine Ca2+ channel blocker, can selectively increase cerebral blood flow. Cognitive decline and cerebral hypoperfusion improved during 2-year administration of lomerizine in this CADASIL patient, and thus, lomerizine is a potential candidate for treating cognitive impairment in CADASIL patients.

Intense F-18 FDG accumulation in idiopathic tumoral calcinosis.

An elderly Japanese woman presented to our hospital with a 5-month history of a growing mass on her right cheek. She did not complain of local pain, headache, hearing difficulty, or tinnitus. CT and MRI showed a dense calcified mass and F-18 fluorodeoxyglucose (FDG) PET demonstrated intense accumulation in the mass. Resection of the mass was performed and it was histologically diagnosed as idiopathic tumoral calcinosis.

Nuclear medicine practice in Japan: a report of the sixth nationwide survey in 2007.

OBJECTIVE: The Subcommittee on the Survey of Nuclear Medicine Practice in Japan has performed a nationwide survey of nuclear medicine practice every 5 years since 1982 to provide detailed information on its present status. METHODS: Questionnaires were sent to all institutions known to the Japan Radioisotope Association to conduct nuclear medicine examinations. The questionnaires addressed the number and kind of nuclear medicine examinations performed as well as the kind and dose of the radiopharmaceuticals used during the month of June 2007. The annual number of total or specific examinations was then estimated. RESULTS: Of the institutions sent questionnaires, 1219 were for in vivo study, 49 for in vitro study, and 212 for positron emission tomography (PET) study. Of these, 92.2% provided answers. A total of 1569 gamma cameras were installed in 1119 institutions, of which 70% were dual-head cameras. The estimated total annual number of in vivo examinations expressed by the number of administered radiopharmaceuticals was 1.41 million, representing a decrease of 11.5% when compared with that of the previous survey (2002). The frequency of study with respect to single-photon emission computed tomography (SPECT) slightly increased to 42.3% from 39.9% in the previous survey. The most frequently performed scintigraphy was bone (38.3%), followed by myocardium (26.2%) and brain perfusion (14.1%). Brain perfusion scintigraphy slightly increased, whereas tumor scintigraphy decreased by one-half when compared with the previous survey. The most commonly used radiopharmaceutical for each scintigraphy was (99m)Tc-HMDP for bone, thallium-201 ((201)Tl)-chloride for myocardium, gallium-67 ((67)Ga)-citrate for tumor, and technetium-99m-ethylcysteinate dimmer ((99m)Tc-ECD) for brain. The number of PET institutes increased from 36 to 212. (18)F-fluorodeoxyglucose ((18)F-FDG)-PET dramatically increased 14.8-fold during the past 5 years. Radionuclide therapy also increased. (131)I therapy for thyroid cancer and hyperthyroidism was conducted yearly in 2373 and 4146 patients, respectively. A total of 13.1 million in vitro radioassays were carried out yearly, the number of which has been decreasing continuously since 1992. CONCLUSIONS: It was proved that the content of nuclear medicine practice in Japan has changed considerably in the past 5 years. Namely, (18)F-FDG-PET and radionuclide therapy increased. This report might be useful for understanding the present trends of nuclear medicine practice in Japan.

Evaluation of autonomic malfunction in idiopathic normal pressure hydrocephalus.

OBJECTIVE: The autonomic nervous system plays an important role in urinary disturbance which is one of the main symptoms of idiopathic normal pressure hydrocephalus (iNPH); thus, the focus of the present study was to identify the autonomic function parameters that would be useful as clinical indicators of iNPH. METHODS: The subjects consisted of 18 iNPH patients (group N) and 31 normal controls (group C). Before and after a lumbar puncture test, they were examined for CVR-R and total heart rate. A power spectral analysis of R-R interval variability of their 24-hour Holter ECGs was also done. High frequency (HF) was an indicator of parasympathetic activity, while the low to high frequency ratio (L/H) was used as an indicator of sympathetic activity. Urinary incontinence was evaluated using the overactive bladder symptom score (OABSS) questionnaire and bladder capacity. Correlations between the above indicators and clinical indicators of iNPH, such as the mini-mental state examination and the Evans index, were examined. RESULTS: The HF values (ms(2)) were 190.3 in group C and 237.2 in group N; the difference was statistically significant. In group N, the HF value after the lumbar puncture test was lower (160.3) than the value before the lumbar puncture test, confirming that the increased parasympathetic state returned to a near normal level after CSF drainage. A significant positive correlation was noted only between the pre-lumbar puncture HF value and the OABSS. CONCLUSION: iNPH is associated with increased parasympathetic activity, and the lumbar puncture test and shunt surgery may correct this autonomic imbalance to near normal levels.

Effect of vascular stenosis on perfusion-weighted imaging; differences between calculation algorithms.

PURPOSE: To determine the most suitable postprocessing technique for magnetic resonance (MR) perfusion imaging in patients with vascular stenosis, by comparing the cerebral blood flow (CBF) maps of single photon emission tomography (SPECT) and perfusion MR imaging (MRI). MATERIALS AND METHODS: In 15 consecutive patients (14 men and one woman, mean age 73.9 +/- 6.0 years) with stenosis of common carotid artery (CCA) or internal carotid artery (ICA) of more than 75%, both brain perfusion MRI and brain perfusion SPECT were performed. From perfusion MR images, CBF maps were calculated with the first moment, singular value decomposition (SVD), and block circulant SVD (b-SVD) methods, and CBF maps from each algorithm were compared with those from SPECT. RESULTS: The b-SVD method had the best correlation with SPECT (R = 0.814), followed by the first moment method (R = 0.776) and the SVD method (R = 0.723). The b-SVD method has the least mean difference with SPECT (0.118), the first moment method also had less difference (0.121), and the SVD had greatest mean difference (0.164). CONCLUSION: Our results suggest that in patients with vascular impairment the b-SVD method will be the technique of choice rather than SVD or first moment method.

Correlation between anosognosia and regional cerebral blood flow in Alzheimer's disease.

The purpose of this study was to determine the brain regions associated with anosognosia in Alzheimer's disease (AD). Anosognosia for memory disturbance was assessed in 29 probable AD patients, based on the discrepancy between questionnaire scores of the patients and their caregivers. In I-123-IMP single photon emission computed tomography (SPECT), a significant association was found between anosognosia and decreased perfusion in the orbitofrontal cortex, using regression analysis. This result is consistent with the previous studies that have reported an association between frontal dysfunction and anosognosia, and further suggests that the orbitofrontal cortex specifically associates with anosognosia in AD within the frontal cortex.

Regional cerebral blood flow changes associated with interoceptive awareness in the recovery process of anorexia nervosa.

BACKGROUND: An abnormality in regional cerebral blood flow (rCBF) in anorexia nervosa (AN) patients has been reported. There are very few studies that have investigated the rCBF changes in the recovery process of AN. METHODS: For eight female AN patients, we performed (123)I-IMP single photon emission computed tomography (SPECT) and four psychological assessments (Eating Disorder Inventory (EDI), Eating Attitude Test (EAT), Self-Rating Depression Scale (SDS) and State-Trait Anxiety Inventory (STAI)) both before and after inpatient-behavioral therapy. SPECT images were analyzed using statistical parametric mapping software. We also performed correlational analysis between rCBF and clinical variables. RESULTS: Following treatment, the patients showed significant body weight recovery. They showed significant improvement in EAT, SDS, STAI and a subscale of EDI - interoceptive awareness (IA) - but not in total EDI or other EDI subscales. Significant rCBF increases were observed in the precuneus, posterior cingulate cortex (PCC), right dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC) and medial prefrontal cortex (MPFC) by the treatment. Significant correlation was observed between rCBF of right DLPFC and IA score before treatment. CONCLUSIONS: Changes of rCBF in right DLPFC, ACC, MPFC, PCC and precuneus were related to the AN recovery process and might be associated with improvement of IA following treatment.

Age-related changes in the hemodynamics of the femoral head as evaluated by early phase of bone scintigraphy.

OBJECTIVE: The femoral head is reported to be in a markedly hypoemic state as compared with other tissues even under normal conditions, and it is therefore necessary to understand its hemodynamics to investigate the pathogenesis of hip disorders. It is known that aspects of intraosseous hemodynamics including blood flow and blood pool can be evaluated soon after radioisotope administration. In this study, hemodynamic changes in the femoral head according to gender and age were examined by investigating accumulation of radioisotope in the tissue during the early phase of bone scintigraphy. METHODS: The subjects of this study consisted of 58 joints of 31 men and 75 joints of 41 women, whose ages ranged from 15 to 87 years (average age: 67.9 years). Images of bone scintigraphy were obtained for 15 to 20 minutes at 5 minutes and at 3 hours after radioisotope administration. The ratio of accumulation in the femoral head to that in the diaphysis (head-to-diaphysis ratio, HD ratio) was calculated. RESULTS: HD ratios obtained 15-20 minutes later ranged from 0.01 to 7.35 (1.88 +/- 0.91, mean +/- SD). HD ratios decreased with age, and a significant inverse correlation was observed between age and HD ratio, demonstrating a correlation coefficient of -0.27 (p = 0.001). The HD ratio among men was 0.01-3.57 (1.66 +/- 0.71), while that among women was 0.53-7.35 (2.05 +/- 1.01), and a significant difference was observed in HD ratio between men and women (p = 0.02). There was a significant difference in HD ratios between men and women in their teens to forties (p = 0.03), while no significant differences was observed in the other age groups.. HD ratios obtained 3 hours later ranged from 0.44 to 6.32 (1.95 +/- 0.79, mean +/- SD), and no significant correlation was observed between age and HD ratio, demonstrating a correlation coefficient of -0.14. CONCLUSION: The present study demonstrated that blood flow and blood pool of the femoral head decrease with aging particularly in women. This hemodynamic deterioration of the femoral head caused by aging may have an effect on the onset and progression of hip disorders by influencing bone metabolism.

A region-of-interest template for three-dimensional stereotactic surface projection images: initial application to the analysis of Alzheimer's disease and mild cognitive impairment.

OBJECTIVE: To construct a region-of-interest (ROI) template for Z-score images of three-dimensional stereotactic surface projections (3-D SSP) and to assess whether the ROI template can be a useful tool for evaluation of brain perfusion abnormalities of neurological disorders. MATERIALS AND METHODS: We constructed the ROI template for Z-score images of 3-D SSP based on the standardized magnetic resonance imaging data of 10 healthy volunteers. We assigned a total of 26 ROIs to Z-score images and superimposed it on Z-score images constructed from the brain perfusion SPECT data of 15 patients with Alzheimer's disease and 10 patients with mild cognitive impairment (MCI) who developed Alzheimer's disease within the following 2 years. We then obtained the mean Z-scores of each ROI and examined them to determine whether the hypoperfusion typical of Alzheimer's disease had been demonstrated quantitatively. We also visually inspected the Z-score image of each patient in both groups to determine whether the areas with the highest Z-scores were demonstrated within the ROIs of regions typical of Alzheimer's disease. RESULTS: In the patients with Alzheimer's disease, our ROI template quantitatively demonstrated hypoperfusion in regions typical of the disease and the Z-scores were very high. In the MCI patients, the mean Z-scores of the ROI in the posterior cingulated gyrus were the highest among all regions. Visual inspection of the Z-score images of each patient in both groups confirmed that the areas with the highest Z-scores were demonstrated within the ROIs in regions typical of Alzheimer's disease in all cases. CONCLUSION: Use of 3-D SSP methods and our ROI template enables automated quantitative evaluation of brain function images over the entire brain surface. In addition, the ROI template may facilitate visual interpretation of functional images of individual patients with neurological disorders.

Do short-time SPECT images of bone scintigraphy improve the diagnostic value in the evaluation of solitary lesions in the thoracic spine in patients with extraskeletal malignancies?

OBJECTIVE: Single photon emission computed tomography (SPECT) images provide many details of the anatomical structure. Also about bone scintigraphy, there are many reports of the improvement of diagnosis by SPECT images. Although SPECT is useful, it requires much time. So to perform SPECT for all cases is difficult in the clinical situation. Recently, due to technical improvements in gamma cameras, we can get SPECT images in a short time. We examined diagnosis of solitary hot spots of thoracic spine in cancer patients using short-time SPECT. And we considered whether short-time SPECT contributes to the precise diagnosis of the lesion. MATERIAL AND METHODS: We performed bone scintigraphy image acquisition and both planar and short-time SPECT of the chest. Short-time SPECT was acquired in 6 minutes. We selected 36 cases with malignancy, whose bone scintigraphy demonstrated a solitary accumulation hot spot in the thoracic spine. Three experienced radiologists in nuclear medicine and 4 beginners diagnosed the images. They interpreted planar, short-time SPECT and maximum intensity projection (MIP) view of the chest of each case. The observers' response data were analyzed with receiver operating characteristic (ROC) curve analysis. RESULTS: Of the three types of images, the Az (the area under ROC curve) values of short-time SPECT were the highest in all the observers except for only one beginner. Compared with experienced observers, beginners scored lower Az values of short-time SPECT. MIP images were constructed using SPECT data, but the Az values of MIP images were not higher than those of planar images. As to diagnosis, beginners tended to interprete most of the accumulations as metastatic lesions. CONCLUSION: Short-time SPECT can be helpful to some degree, but to provide greater benefit, the observers require considerable exercise and experience.

Assessment of the solid-state gamma camera to depict axillary sentinel lymph nodes in breast cancer patients.

PURPOSE: The solid-state gamma camera is now commercially available offering the advantages of a compact and portable system, currently used mainly in the cardiac region. We evaluate the ability of the solid-state gamma camera to depict axillary sentinel lymph nodes (SLNs) in breast cancer patients. MATERIALS AND METHODS: Preoperative SLN lymphoscintigraphy (LSG) was performed in 19 patients with breast cancer using the solid-state gamma camera. Immediately thereafter, we performed a second LSG using a single detector Anger-type gamma camera, and compared the findings from the two cameras. RESULTS: Concordant results were obtained in 12 (63%) patients with both cameras. In 4 (21%) patients, axillary SLNs were correctly identified only with the solid-state gamma camera. In these patients, the distance between the SLN and the radiopharmaceutical injection site was closer than that of patients who had concordant results (p = 0.001). CONCLUSION: We can depict correctly axillary SLNs with the solid-state gamma camera in comparison with the Anger-type gamma camera. This technique would be useful for assessing SLNs in breast cancer patients.

Pitfalls of FDG-PET for the diagnosis of osteoblastic bone metastases in patients with breast cancer.

PURPOSE: The purpose of this study was to investigate the pitfalls of using 2-[18F]-fluoro-2-deoxy-D: -glucose positron emission tomography (FDG-PET) for the evaluation of osteoblastic bone metastases in patients with breast cancer by comparing it with (99m)Tc-hydroxymethylene diphosphonate bone scintigraphy. METHODS: Among the 89 breast cancer patients (mean age 59+/-15 years) who had undergone both FDG-PET and bone scintigraphy within 1 month between September 2003 and December 2004, 55 with bone metastases were studied. The bone metastases were visually classified by multi-slice CT into four types according to their degree of osteosclerosis and osteolysis-osteoblastic, osteolytic, mixed and invisible-and compared in terms of tracer uptake on FDG-PET or bone scintigraphy and SUV(mean) on FDG-PET. Differences in the rate of detection on bone scintigraphy and FDG-PET were analysed for significance by the McNemar test. RESULTS: The sensitivity, specificity and accuracy of bone scintigraphy were 78.2%, 82.4% and 79.8% respectively, and those of FDG-PET were 80.0%, 88.2% and 83.1%, respectively, revealing no significant differences. According to the CT image type, the visualisation rate of bone scintigraphy/FDG-PET was 100%/55.6% for the blastic type, 70.0%/100.0% for the lytic type, 84.2%/94.7% for the mixed type and 25.0%/87.5% for the invisible type. The visualisation rates of bone scintigraphy for the blastic type and FDG-PET for the invisible type were significantly higher. The SUV(mean) of the blastic, lytic, mixed and invisible types were 1.72+/-0.28, 4.14+/-2.20, 2.97+/-1.98 and 2.25+/-0.80, respectively, showing that the SUV(mean) tended to be higher for the lytic type than for the blastic type. CONCLUSION: FDG-PET showed a low visualisation rate in respect of osteoblastic bone metastases. Although FDG-PET is useful for detection of bone metastases from breast cancer, it is apparent that it suffers from some limitations in depicting metastases of the osteoblastic type.

Diagnosis of Alzheimer's disease using brain perfusion SPECT and MR imaging: which modality achieves better diagnostic accuracy?

PURPOSE: The purpose of this study was to compare the accuracy of MR imaging and brain perfusion single-photon emission tomography (SPECT) in diagnosing Alzheimer's disease (AD). METHODS: The transaxial section display of brain perfusion SPECT, three-dimensional stereotactic surface projection (3D-SSP) SPECT image sets, thin-section MR imaging of the hippocampus and perfusion MR imaging were evaluated in 66 subjects comprising 35 AD patients and 31 subjects without AD. SPECT and MR imaging were visually interpreted by two experts and two novices, and the diagnostic ability of each modality was evaluated by receiver operating characteristic (ROC) analysis. RESULTS: In the experts' interpretations, there was no significant difference in the area under the ROC curve (Az) between 3D-SSP and thin-section MR imaging, whereas the Az of transaxial SPECT display was significantly lower than that of 3D-SSP (3D-SSP: 0.97, thin-section MR imaging: 0.96, transaxial SPECT: 0.91), and the Az of perfusion MR imaging was lowest (0.63). The sensitivity and specificity of each modality were, respectively, 80.0% and 96.8% for 3D-SSP, 77.1% and 96.8% for thin-section MR imaging, 60.0% and 93.5% for transaxial SPECT display and 34.3% and 100% for perfusion MR imaging. In the novices' interpretations, the Az, sensitivity and specificity of 3D-SSP were superior to those of thin-section MR imaging. CONCLUSION: Thin-section hippocampal MR imaging and 3D-SSP image sets had potentially equivalent value for the diagnosis of AD, and they were superior to transaxial SPECT display and perfusion MR imaging. For avoidance of the effect of interpreters' experience on image evaluation, 3D-SSP appears to be optimal.

FDG-PET in a case of multiple bone metastases of gastric cancer.

F-18 2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) is useful for surveys to detect bone metastasis because of its greater specificity than bone scintigraphy. However, FDG-PET is also known to yield false-positive results in acute fractures and inflammatory lesions, and distinguishing between benign and malignant lesions is difficult, even when semiquantitative methods are used. We report a case of multiple bone metastases of gastric cancer. One of the bone lesions that was positive for FDG uptake was benign, suggesting that FDG-PET can yield false-positive results.

Pattern of 111In-chloride bone marrow scintigraphy in myelodysplastic syndrome; comparison with clinical characteristics.

111In-chloride bone marrow scintigraphy (bone marrow scintigraphy) was performed in patients with myelodysplastic syndrome (MDS), tracer accumulation was classified into patterns, and the relationship between the accumulation patterns and prognostic factors was investigated to assess the usefulness of bone marrow scintigraphy. The subjects were 14 patients diagnosed with MDS. Accumulation of the bone marrow scintigraphy tracer was classified according to the degree of accumulation in the axial bone marrow and peripheral expansion. International Prognostic Scoring System (IPSS), which are frequently used for prognostic evaluation of MDS, and conversion to leukemia were investigated in prognostic factors. We also investigated the relationship between enlargement of the liver and spleen and the prognostic factors. The accumulation patterns were as follows: pattern I, The normal accumulation pattern (2 cases); pattern II, the expanded accumulation pattern (6 cases); pattern III, low accumulation pattern (5 cases); and pattern IV, heterogeneous accumulation pattern (1 case). The relationships between the two prognostic factors and accumulation patterns were investigated, and the prognosis was found to be significantly poorer in the patients with the low accumulation pattern than the expanded accumulation pattern. Enlargement of the liver and spleen was not significantly correlated with the prognostic factors.

123I-Metaiodobenzylguanidine uptake in the nape of the neck of children: likely visualization of brown adipose tissue.

UNLABELLED: The distribution of radioiodinated metaiodobenzylguanidine (MIBG) has been studied primarily in patients with neuroendocrine tumors-in pediatrics, particularly with neuroblastomas. Sometimes, symmetric accumulation in which no tumor is identified is seen in the nape-of-the-neck region. We estimated visually whether accumulation was found in the nape of the neck and studied the characteristics of the accumulation. METHODS: Retrospectively, we investigated 266 (123)I-MIBG scintigraphic studies performed on pediatric patients who had been treated for neuroendocrine tumors or who were suspected of having such tumors. RESULTS: Accumulation in the nape of the neck was seen in 32 of 266 studies (12%); in none of these cases was the accumulation identified as a tumor by other imaging modalities or follow-up studies. In the same individuals, the accumulation varied and it was observed more often during winter. CONCLUSION: Symmetric (123)I-MIBG accumulations in the nape-of-the-neck region observed in children are thought to be related to the uptake in brown adipose tissue.

Transient aphasia as late-onset seizure after embolization for dural arteriovenous malformation.

Tc-99m HMPAO single photon emission computed tomography was performed in a patient who had experienced aphasia for 3 days. The patient had a medical history of subarachnoid hemorrhage and intracranial hemorrhage. Both of these hemorrhages were related to a dural arteriovenous malformation that was embolized after the onset of the cerebral vascular events. Focal hyperperfusion was seen in the left temporal lobe adjacent to a perfusion defect corresponding to the old cerebral hemorrhage. The finding was interpreted as the focus of the patient's epilepsy. His aphasia resolved after the administration of anticonvulsant medication for several days.