Evaluación de trastorno de personalidad a partir de estudios de Neuro-SPECT / Assessment of personality disorder by means of NeuroSPECT

We report on functional imaging results in 24 patients of Personality Disorder (P.D.) performed with NeuroSPECT by means of Tc99m HMPAO, in Basal state and during frontal cortical activation by means of the Wisconsin Card Sorting Test. Results demonstrate that we can make the diagnosis of P.D. when we detect significant hypoperfusion (- 2 Stand/ Deviations below the normal mean for the same age group) in the subgenual area (Area 25 of Brodmann) and in Area 24 of Brodmann, the anterior cingulated gyrus. Both areas are paradoxically more hypoperfused during the Wisconsin Test. Among patients diagnosed with P.D. NeuroSPECT can distinguish between patients of Cluster B from the ones from Cluster C in both Basal and Activation State, while Cluster A from B could be differentiated only in Basal State. On the other hand Motor Impulsivity patients could be differentiated from the Cognitive group due to paradoxical hypoperfusion in motor areas 1,2,3, and 4 of Brodmann. While the number of patients studied appears reduced these results demonstrate the capability of diagnosing Personality Disorder and also the capability to improved understanding of the subgroups of this Disorder.

Se comunican los resultados de 24pacientes con Trastornos de Personalidad estudiados mediante Neuro-SPECT HMPAO Tc99m, técnica de imagenología funcional cerebral en condicionas basales y durante activación de la corteza frontal ejecutiva mediante la prueba de Wisconsin. Los resultados demuestras fehacientemente que el diagnóstico de Trastorno de Personalidad se basa en la presencia de disminución de perfusión (- 2 Desviaciones Standard bajo el promedio normal para el mismo grupo etario) en el Cingulado Anterior y región subgenual, exageradas paradojalmente durante la prueba de Wisconsin. Dentro de los pacientes demostrados como Trastorno de Personalidad, Neuro-SPECT es capaz de distinguir los pacientes del Cluster B de los del Cluster C en ambos estados de medición,(Estado Basal vs Prueba de Wisconsin) mientras los Cluster A y B fueron diferenciables en estado Basal solamente. Por otra parte, la Impulsividad Motora pudo ser distinguida de la Cognitiva por la hipoperfusión paradojal de las áreas frontales de Brodmann motoras 1,2,3 y 4. Si bien el número total de pacientes reportados en este trabajo, es relativamente limitado, abre posibilidades interesantes a la imagenología funcional cerebral en estado basal y durante activación mediante la prueba de Wisconsin para el diagnóstico y exploración del Trastorno de Personalidad.

Neurospect: imagenología funcional en psiquiatría: [revisión] / Neurospect applications in psychiatry: [review]

Durante los últimos años la imagenología funcional representada por NeuroSpect se ha ido incorporando progresivamente al diagnóstico diferencial de las patologías psiquiátricas, especialmente trastornos del ánimo, psicosis, esquizofrenia, los trastornos cognitivos, enfermedad de Alzheimer, el trastorno obsesivo compulsivo, el déficit atencional y sobre todo los efectos cerebrales de neurotóxicos. En esta revisión publicaremos y comentaremos inicialmente los hallazgos en el infarto cerebral hiperagudo, durante y post su tratamiento mediante trombolisis arterial, como una forma de demostrar la sensibilidad y especificidad de NeuroSPECT en el trabajo clinico.. Sobre metodología comentaremos especialmente que efectuamos una doble reconstrucción de las imágenes, una sin corrección de atenuación para las imágenes laterales, anterior-posterior y la imagen superior de la corteza cerebral y una segunda reconstrucción con corrección de atenuación con un coeficiente de Chang de 0.1 y que aplicamos en las imágenes parasagitales y en la imagen inferior del cerebro, al cual además removemos el cerebelo con objeto de poder inspeccionar con facilidad los aspectos inferiores de los lóbulos occipitales y temporales; igualmente esta modalidad se emplea para el estudio de los ganglios basales. El software que empleamos, es el software OASIS de la compañía Segami Corporation USA. Las imagenes son adquiridas con un Sistema ECAM de dos cabezales Siemens Corp. y los resultados son comparados con una base de datos normales para el mismo grupo etario y los resultados entonces demostrados con una escala de colores calibrada en Desviacion Standard sobre y bajo el rango normal que aparece en color gris.

During the last years, functional imaging by means of Neuro SPECT has been progressively incorporated to the differential diagnosis of psychiatric disorders, particularly mood disorders, psychosis, schizophrenia, cognitive impairment, , Alzheimer’s Disease, obsessive-compulsive disorder, attention deficit disorder, and brain effects of neurotoxic exposure. This review will be initiated evaluating the findings in brain hyperacute infarction before and post arterial thrombolisis treatment in order to demonstrate the sensitivity and specificity of this imaging modality in clinical work. On methodology, we have to comment, furthermore, that we perform double image reconstruction, one without attenuation correction for the lateral images, posterior and anterior images and the superior image of the brain cortex. A second reconstruction is performed with attentuation corection by means of a Chang coefficient of 0.1, This is applied to the parasagital images and to the inferior image of the brain. In this last image, we remove the cerebellum in order to facilitate inspection of the inferior aspects of occipital and temporal lobes. We apply this modality also for the study of basal ganglia. The software that we have used is the Oasis Software of the Segami corporation of USA and brain imaging is performed by means of the Ecam Dual Head Siemens camera. We compare the clinical data with a normal, age matched database and display the results using a color scale defined by Standard Deviation below and above the normal mean for HMPAO Tc99m, while the normal range is depicted in color gray.

Angioplastía y stenting carotideo: serie clínica en Clínica Las Condes / Carotid angioplasty and stenting: clinical series at Clinica Las Condes

En este artículo se describe una serie clínica de angioplastía y stenting carotideo con sistema de protección distal para el tratamiento de la estenosis significativa del bulbo carotideo en Clínica Las Condes. El análisis de trabajos clínicos multicéntricos, junto a nuestros resultados, permite concluir que la angioplastía y stenting carotideo es una alternativa válida y de bajo riesgo para el tratamiento de la estenosis carotidea significativa.

In this article we describe a case series of carotid angioplasty and stenting with distal protection technique for the treatment of significant carotid bulb stenosis in Clínica Las Condes. The results of past clinical trials, and our case series allow us to conclude that carotid angioplasty and stenting is a valid alternative therapy with low risks associated, for the treatment of significant carotid stenosis.

Contribución de neurospect a la evaluación del ave isquémico: penumbra isquémica / Neurospect contribution in the acute brain ischemia: ischemic penumbra

El infarto cerebral agudo representa una emergencia clínica, potencialmente reversible si se trata con trombolisis durante las primeras 3 a 6 horas de evolución. La trombolisis tiene muchas ventajas para el paciente, pero también representa algunos riesgos como el desarrollo de una hemorragia intracerebral. Como consecuencia de un intenso trabajo de investigación contamos hoy día con importantes avances en diferentes técnicas de neuro-imágenes para evaluar la isquemia cerebral potencialmente reversible, incluyendo la resonancia magnética (RM) con difusión-perfusión, la tomografía computada (CT) con perfusión y estudios neurofuncionales como el SPECT cerebral y el PET. Este trabajo comunica los resultados en la evaluación por SPECT cerebral pre tratamiento endovascular en una serie de pacientes que presentaron isquemia cerebral aguda y fueron evaluados especialmente para signos de cambios en perfusión ínter hemisférico manifestado por aumento de perfusión del núcleo lentiforme del hemisferio sano, contra lateral a la lesión isquémica. MÉTODO: 20 pacientes fueron tratados en forma aguda por un infarto cerebral agudo siguiendo el siguiente protocolo: 1) Ingreso al Servicio de Urgencia y evaluación completa neurológica. 2) TAC cerebral para descartar presencia de hemorragia cerebral o de un infarto cerebral establecido. 3) Inyección endovenosa de 1100MBq Tc99mm HMPAO (Ceretecmr). 4) Angiografía cerebral convencional y trombolisis intra-arterialcerebral con TPA y posible angioplastía y colocación de stent. 5) Adquisición de imágenes de NeuroSPECT para evaluar penumbra isquémica (resultados pre-terapia). La adquisición de imágenes de NeuroSPECT fue inmediatamente después de la trombolisis usando una cámara de doble cabezal, Siemens ECAM, SHR colimador utilizando protocolo habitual. Las imágenes fueron procesadas con un software Neurogamde Segami Corp. previamente reportado en Alasbimn Journal 7(26): October 2004...

Acute brain infarct is a medical emergency potentially reversible if treated with thrombolysis, in the first 3 to 6 hours of evolution. Thrombolysis has many benefits, but it also has associated risks, mainly development of intracranial hemorrhage. The selection of which patient should receive this type of treatment has been an important research topic over the last decade. As a consequence Neuroimaging of brain infarct has significantly improved during the last few years. A variety of diagnostic studies are now available in the evaluation of brain infarct and in particular of potentially reversible brain ischemia, including magnetic resonance imaging (MRI) diffusion-perfusion, perfusion computed tomography (CT) and functional Neuroimaging techniques that include single-photon emission tomography (SPECT), and positron emission tomography (PET). The aim of this study is to present our experience with a group of patients that presented with acute brain ischemia and had a NeuroSPECT evaluation before intra-arterial thrombolysis with assessment of basal ganglia perfusion with definition of a new signs of interhemispheric blood flow control impairment. METHODS: Twenty patients were treated acutely for a significant ischemic stroke with the following protocol. 1) Admission, and complete neurological evaluation. 2) Brain CT scan performed to rule out hemorrhage or established infarct. 3) IV injection of 1100MBq Tc99m HMPAO (CeretecT.M.) 4) Conventional cerebral angiography and intra-arterial thrombolysis with TPA and /or angioplasty/stent if necessary. 5) NeuroSPECT assessment of ischemic penumbra (Pre-therapy results)NeuroSPECT image acquisition was performed immediately following arterial thrombolysis with a dual Head Camera, Siemens ECAM, SHR collimators and conventional protocol. Image processing was performed using the Neurogam, Segami Corp. Software as previously reported in Alasbimn Journal2(7): April 2000...

Síndrome de McLeod: compromiso multisistémico asociado a neuroacantocitosis ligada al cromosoma X, en una familia chilena / McLeod syndrome: Multisystem involvement associated with neuroacanthocytosis linked to X chromosome. Report of two related cases

Neurological abnormalities associated with spiculated, "acanthocytic" red cells in blood have been described as neuroacanthocytosis. This is a heterogeneous group of conditions that can be clearly subdivided on the basis of recent genetic findings. The McLeod Syndrome, one of the core neuroacanthocytosis syndromes, is a rare X-linked disorder caused by mutations of the XK gene, an X-chromosomal gene of unknown function characterized by haemopoietic abnormalities and late-onset neurological and muscular defects. We report two Chilean brothers with the McLeod phenotype who showed important psychiatric features. The diagnosis may be elusive if the presence of acanthocytosis is not properly studied. We describe a method which allowed the diagnosis that unmasked acanthocytosis. Otherwise the condition could have remained undiagnosed as it had been for decades in this family. This syndrome must be considered when assessing a familial movement disorder, specially affecting males with relevant psychiatric features. A reliable test for acanthocytosis assessment is available.

[McLeod syndrome: Multisystem involvement associated with neuroacanthocytosis linked to X chromosome. report of two related cases]. / Síndrome de McLeod: compromiso multisistémico asociado a neuroacantocitosis ligada al cromosoma X, en una familia chilena.

Neurological abnormalities associated with spiculated, "acanthocytic" red cells in blood have been described as neuroacanthocytosis. This is a heterogeneous group of conditions that can be clearly subdivided on the basis of recent genetic findings. The McLeod Syndrome, one of the core neuroacanthocytosis syndromes, is a rare X-linked disorder caused by mutations of the XK gene, an X-chromosomal gene of unknown function characterized by haemopoietic abnormalities and late-onset neurological and muscular defects. We report two Chilean brothers with the McLeod phenotype who showed important psychiatric features. The diagnosis may be elusive if the presence of acanthocytosis is not properly studied. We describe a method which allowed the diagnosis that unmasked acanthocytosis. Otherwise the condition could have remained undiagnosed as it had been for decades in this family. This syndrome must be considered when assessing a familial movement disorder, specially affecting males with relevant psychiatric features. A reliable test for acanthocytosis assessment is available.

Síndrome de Williams: estudio clínico, citogenético, neurofisiológico y neuroanatómico / Williams syndrome: clinical, cytogenetic, neurophysiological and neuroanatomic features in 44 patients

Background: Williams syndrome (WS) is a genetically based disorder caused by deletion of elastin and contiguous genes on chromosome 7q11.23. This syndrome is characterized by multiorganic involvement with dysmorphic facial features and a distinctive cognitive profile. It is an interesting model for elucidation of relationships between brain, cognition and genes. Patients have a visual-spatial cognition impaired with relative strengths in social and language abilities. Aim: To report clinical, cytogenetic, neurophysiological and neuroanatomic features in 44 patients referred as WS. Patients and methods: Forty four patients, aged 2 to 17 years, with the clinical diagnosis of Williams syndrome were studied with fluorescence in situ hybridization (FISH). In three cases, electrophysiological and neuroimaging studies were performed. Result: The deletion was confirmed in 23 patients. In three patients with neurophysiological studies, event related potentials suggested a cognitive difficulty in detecting and processing visual stimuli. Magnetic resonance imaging showed normal brain morphology. SPECT showed hypoperfusion of the right frontal lobe and bilateral anterior cingulum hyperperfusion. Conclusions: There are functional alterations in the brains of patients with Williams, which may be related to the cognitive deficits

Comparative functional study of 2 psychiatric pathologies by means of brainspect TC99 HMPO: major depression and borderline personality disorder / Estudio funcional comparativo de dos patologías psiquiátricas mediante spect cerebral TC 99 M HMPAO: depresión mayor y trastorno de personalidad

En el D.S.M.-IV, sistema clasificatorio de la Asociación Psiquiátrica Americana (1), que es el marco más usado en la investigación y comunicación en psiquiatría, se destaca que el Desorden Depresivo afecta entre el 5 por ciento y 9 por ciento de las mujeres y al 2 por ciento y 3 por ciento de los hombres, en tanto que el trastorno límite de la personalidad, corresponde al 2 por ciento de la población general. Ambos cuadros patológicos comparten las dimensiones de regulación del afecto y control de impulsos (2). La aproximación dimensional de los cuadros permite acercarse a los aspectos más biológicos de estas dos entidades. En éstas patologías se observan alteraciones importantes en al menos tres sistemas de neurotransmisión comunes como ser el sistema colinérgico, el noradrenérgico y el serotoninérgico (3), con rasgos conductuales. En esta investigación se efectúa una intracomparación, de un grupo de pacientes con Depresión Mayor y de Personalidad Límite, en condiciones basales versus condiciones de estimulación con test de Wisconsin, y una intercomparación entre los resultados en ambas patologías. En este trabajo se cuantifica los flujos cerebrales medidos con SPECT Tc 99 m HMPAO señalando el compromiso en zonas de la corteza cerebral que son parte de tres circuitos cerebrales segregados (4) como son el circuito órbito frontal, el cingulado anterior y el circuito dorsolateral prefrontal con sus aferencias y eferencias (5). En el análisis de los resultados se advierte un compromiso compartido en estructuras ligadas a la motivación, donde destaca el cingulado anterior, siendo mayor la hipofuncionalidad ante las exigencias del test de Wisconsin en los pacientes límites (P<0.00005 a derecha y 0.0003 a izquierda) que en los depresivos (P<0.002 a derecha y 0.003 a izquierda). Lo mismo ocurre con el área 32 de Brodmann (parte del sistema límbico), y el área 25 señalada por Damasio (6) como el área de la anhedonia donde el compromiso existe en ambas patologías. En forma exclusiva existe en los pacientes límites un compromiso significativo del área dorsolateral prefrontal o área ejecutiva frente a la exigencia del test de Wisconsin. Por otra parte en los pacientes depresivos se detectó una hipoperfusión mayor al 50 por ciento en el área órbito frontal relacionada a las emociones y a este cuadro (7) tanto en condiciones basales como de estimulación

Functional impairments in patients with borderline personality disorders demonstrated by neurospect HMPAO Tc99 in basal conditions and under frontal activation

We study a sample of 18 patients in basal conditions and 31 patients with diagnosis of Borderline Personality Disorder (DSM-IV Criteria) during cortical activation by means of the Wisconsin card sorting test and assessing function/cerebral blood flow by means of HMPAO Tc 99m NeuroSPECT. The results of changes of cerebral blood flow are shown statistically in a parametric image expressing standard deviations above or below the means of a normative data base for the corresponding age of the patient. We consider only as having significance levels below 2 standard deviations of the normal means . Over this parametric map we project a matrix of Brodmann areas developed by our group in order to precisely localize the areas of abnormality observed. We express our results as percentages of the areas of Brodmann that demonstrates hypoperfusion and we compare the results in a population studied in basal conditions (n=18) and (n=31) during activation by means of the Wisconsin card sorting test. In our results we highlight, in order of importance areas of paradoxical hypoperfusion in conditions of activation versus basal measurements in anterior cyngulate gyrus (Area 24) in both hemispheres. This is followed in importance by Subgenual area (Area 25), area 40 and area 32 in the left hemisphere, and area 28 in the right hemisphere, then followed by area 28 and area 36 in the left hemisphere, area M* and area 44 in both hemispheres, and areas 32, 9 and 46 of Brodmann in the right hemisphere. We concluded that there is a dysfunctional correlation of frontal function in borderline personality disorder. Particularly noticeable is the lack of motivation when there are changes in plans and conduct, lack of pleasure and loss of the meaning of a task during the cortical stimulation. In particular, the Brodmann areas 24, 25 and 32, linked to motivation show a wider involvement when they are exposed to changes in planning and in coping strategies, as it happens during the Wisconsin Test. Areas involved in the executive ability and intelligence also show, but not as noticeable, special change under these circumstances. Both facts can be clinically observed and also in the biography of the Borderline Patient