Usefulness of Video-EEG monitoring in patients with drug-resistant epilepsy.

OBJECTIVE: To evaluate the characteristics of patients on whom long-term Video-EEG monitoring is performed in a specialist centre and to assess its suitability to study refractory epilepsy patients. METHODS: A prospective analysis and study of Video-EEG monitoring was performed in a series of 100 refractory epilepsy patients from a single centre. The analysis included demographic data, the time until the first seizure, the methods used to provoke seizures, and the outcome (usefulness, change in the management, pharmacological and surgical improvement). A subgroup analysis based on diagnosis was performed. RESULTS: The study was performed mainly on young people (mean 34.4 years) and the first seizure appeared in a mean of 30hours, requiring most of the patients to withdraw the medication. Nevertheless, there were no cases of status epilepticus. The usefulness of the test was high in all the groups. The management was changed in 65% of the patients with pharmacological and surgical improvement. CONCLUSION: Long-term Video-EEG monitoring is a suitable test to study refractory epilepsy patients. The main problem in our country is accesibility.

[Interstitial nephritis demonstrated by 67Ga-citrate scintigraphy within a diagnosis of fever of unknown origin]. / Nefritis intersticial demostrada mediante gammagrafía con 67Ga-citrato en el contexto de fiebre de origen desconocido.

We present a clinical case of a 54-year-old woman that was admitted in our hospital with the diagnosis of fever of unknown origin. All the laboratory tests and imaging techniques did not manage to establish the fever's aetiology until a (67)Ga-citrate scan was performed and kidney uptake was observed, which lead to the clinical suspicion of drug-induced interstitial nephritis. The renal biopsy confirmed the diagnosis. This finding allowed corticoid therapy and cure.

[Brain SPECT in a case of Wernicke Korsakoff syndrome]. / SPECT cerebral en un caso de síndrome de Wernicke Korsakoff.

INTRODUCTION AND CLINICAL CASE: In this article we report a 44 year old male with chronic alcoholism as antecedent and Wernicke Korsakoff s syndrome, studied with brain CT, MR and SPECT. In this work we review the different conclusion obtained with different studies and in different stages of the chronic alcoholism disease. CONCLUSIONS: Although several authors have described impaired frontal blood flow in the Wernicke Korsakoff s syndrome, in our case the parietal, temporal and occipital cortex were the most affected.

[Cerebral SPECT in mitochondrial encephalomyopathy. A case report and a review of the literature]. / SPECT cerebral en la encefalomiopatía mitocondrial. Presentación de un caso y revisión de la bibliografía.

INTRODUCTION: We report a case of mitochondrial encephalomyopathy with a complex clinical picture followed-up in the Neurology Department, and fully investigated using different techniques, in whom the definite diagnosis was essentially based on finding ragged red fibres on muscle biopsy. CLINICAL CASE: The patient was 60 years old when the definite diagnosis was made. The illness had started in his youth and affected different systems and parts of the body. On laboratory investigation the serum lactic acid and lactic acid curve were normal, as were those of the cerebrospinal fluid. Further complementary tests were done, including imaging techniques (cerebral CAT, MR and SPECT). SPECT was done using 99Tc-HMPAO. Since it was a single case, we can affirm that the diagnosis of mitochondrial encephalomyopathy was made on muscle biopsy, supported by other complementary investigations, but without being able to classify the case among the various mitochondrial encephalopathies since the clinical features were common to several of them. CONCLUSION: More sequential studies are needed with different imaging techniques, in the same patient, carefully taking into account any slight modification in his clinical state, during the time elapsed between two consecutive serial follow-up studies.

[Quantification of bone scintigraphy as an objective method in the follow-up of radioisotopic synoviorthesis]. / Cuantificación de la gammagrafía ósea en dos fases como método objetivo en el seguimiento de la sinoviortesis radioisotópica.

This work tries to provide the clinicians an objective tool that can contribute to the assessment of the results of radioisotopic synoviorthesis (RS). This study aims to assess the value of the quantification of bone scintigraphy in blood pool and late phase of the affected joints treated with 90Y silicate, in order to observe the clinical improvement experienced by most of these patients. A total of 69 bone scintigraphies (BS) in blood pool and late phase have been quantified. They belonged to 23 patients who were treated with RS with 90Y. The first scintigraphy study was performed before the treatment, the second and the third ones were performed 2 and 6 months after treatment. In each BS we quantified the index: counts per pixel of healthy / affected joint. We also have calculated the fraction in the late phase: counts per pixel of healthy bone / counts per pixel of affected and healthy joint. For the comparative statistical analysis of the results we used the Student's t test. We considered statistical significance when p < 0.05. All the patients presented clinical improvement. If we compare the index obtained in BS 2 months after treatment and pre-treatment we find statistical significance (p < 0.05) in the increase of index in the anterior view and late phase. If we compare the index obtained in BS 6 month after treatment and pre-treatment, we find a statistically significant increase in the anterior (p < 0.01) and posterior (p < 0.05) view of the blood pool phase and the anterior view of late phase (p < 0.01). The fraction counts per pixel of healthy bone / counts per pixel of affected and healthy joint did not present a significant increase in any BS control (2 and 6 months). We recommend quantification using the index (counts per pixel healthy / affected joint ) proposed in this work, because it is easy to perform, cheap and reliable in the follow-up of patients treated with RS.

[Uptake of 99mTc-diphosphonates due to brain infarction]. / Captación de 99mTc-difosfonatos por un infarto cerebral.

The case of a patient who came to the Nuclear Medicine Department for a bone scintigraphy to rule out bone metastasis because of a lung neoplasm is presented. Some days before, the patient had suffered a right brain infarction. 99mTc-MDP uptake could be seen in the infarction area. Different mechanisms of 99mTc phosphates deposition in tissues other than bones are reviewed in this article.

[Check-ups with brain SPECT in electroconvulsive therapy in patients with severe drug-resistant depressive episodes and Parkinson's disease]. / Control con SPECT cerebral en la terapia electroconvulsiva en pacientes con episodio depresivo grave farmacorresistente y enfermedad de Parkinson.

We have studied three women (66,72 and 72 years) with Parkinson's disease of 11, 6 and 21 years of evolution and drug-resistant severe depressive episodes treated with electroconvulsive therapy (ECT). We have performed a brain SPECT (99mTc-HMPAO) before and after the ECT. The clinical improvement of the severe depressive episodes were measured using the Hamilton score. The first patient did not experience any clinical improvement (Hamilton score 42 to 42). In this patient the brain SPECT before treatment presented a reduced perfusion in the posterior parietal region, anterior cingulate cortex and medial frontal and parietal cortex. After the treatment, the brain SPECT did not present significant variations. The second patient presented a moderate clinical improvement (Hamilton score 46 to 36) and also presented moderate improvement in the neurological symptoms. The brain SPECT before the treatment showed reduced perfusion in the left temporal cortex and medium-posterior parietal cortex. After the treatment, it also did not reflect significant variations. The third patient experienced a very good response to the ECT sessions (Hamilton score 45 to 10) and also an improvement regarding the neurological symptoms. This patient presented a reduced perfusion in the medium-posterior parietal regions in the brain SPECT performed before the treatment; these regions presented a moderate improvement in the brain SPECT performed after the treatment. The patient who presented a significant neurological and psychiatric improvement also presented an improvement in the perfusion of the decreased areas in the brain SPECT and showed fewer alterations in the baseline brain SPECT compared with the others. The brain SPECT could have a prognostic (and confirmation) role regarding clinical improvement induced by ECT in resistant depression in Parkinson's disease. ECT is an alternative in treatment of severe depressive drug-resistant episodes associated to the Parkinson's disease.

[Evaluation of the usefulness of the antimyosin monoclonal antibody (AMA) uptake in the diagnosis of heart transplant (HT) rejection]. / Valoración de la utilidad del índice de captación de anticuerpos monoclonales antimiosina (AMA) en el diagnóstico de rechazo en el trasplante cardíaco (TC).

OBJECTIVE: To ascertain whether a given level of antimyosin monoclonal antibody (AMA) uptake in the endomyocardial biopsy (EMB) can identify patients with rejection. MATERIAL AND METHOD: 186 examinations were performed on 65 patients (8 women and 57 men) with orthotopic heat transplant (HT): Mean age 51 +/- 13 years. There were 3 examinations per patient (range 1-6). The studies were conducted 13 to 880 days after the HT. The C/p uptake indexes were obtained according to the Carrió y cols. method and the results were compared with the biopsy findings. Rejection was considered to be when the biopsy showed at least one site of necrosis. RESULTS: 1) We analyzed the C/P index in accordance with the post-HT interval and with the degree of rejection obtained by EMB. No group showed any significant differences between the patients with an without rejection (p > 0,05). 2) We applied a variable threshold based on post-HT interval, using an exponential curve defined on the basis of the interval of the values corresponding to patients without rejection and good progress compared with that of the rejection patients. This approach also did not contribute any improvement compared to the use of a fixed threshold due to the significant overlay of the values for patients with and without rejection. 3) Finally, we analyzed the individual evolution of the C/P indexes for each patient in terms of time. In patients whose clinical progress was good, the C/P indexes were observed to drop progressively over time. In those whose clinical progress was poor, abrupt increases in the index values were observed. CONCLUSION: We were unable to differentiate significantly between patients with and without rejection in EMB using fixed and variable thresholds of the C/P index. However, the different patterns of evolution for each patient provide information on the lack of complications and could be used as a follow-up technique.

[Bone scintigraphy in two cases of primary vertebral osteosarcoma in adults]. / Gammagrafía ósea en dos casos de osteosarcoma vertebral primario en edad adulta.

The primary vertebral osteosarcoma in adults is a rare tumor which represents less than 2% of all osteosarcomas. We present the cases of two men (40 and 33 years old) who began with pain and neurological compression symptoms. The imaging methods used to study the tumors were X-rays, CT, MRI and bone scintigraphy with 99mTc-HMDP. After the pathological diagnosis, the tumors were removed surgically and the treatment was completed with chemotherapy and radiotherapy. In this report the authors review the published cases of vertebral osteosarcoma, its epidemiology, clinical presentation and characteristics in the different imaging techniques.

[Soft tissue malignant fibrous histiocytoma. Visualization in bone scintigraphy]. / Histiocitoma fibroso maligno de partes blandas. Visualización en gammagrafía ósea.

Malignant fibrous histiocytoma (MFH) is the most common soft tissue malignant tumour in late adult life. MFH has been mentioned to have avid uptake of 67Ga citrate, and only 38% is uptake of 99mTc-MDP, although few cases of MFH have been reported. We present the case of a 73 years old male patient with MFH. In the blood pool phase of the bone scintigraphy, MFH was presented as an intense hyperactive lesion. In the late phase the tumor is one of the few MFH described to have avid uptake for 99mTc-MDP. In this work we also review some cases of MFH described and the different techniques used in the diagnosis and follow-up of these tumours.

[Thyroid scintigraphy and body scanning with 67 Ga in a case of primary thyroid lymphoma]. / Gammagrafía tiroidea y rastreo corporal con 67Ga en un caso de linfoma tiroideo primario.

The case of a 60-year old woman first presented a rapidly growing left cervical mass is presented. The fine needle aspiration-puncture (FNAP) lead to a diagnosis of thyroiditis. Due to the persistence of the symptoms, the FNAP was repeated again but was not conclusive, so that a surgical biopsy was performed. The pathological diagnosis was diffuse large cell primary thyroid lymphoma (PTL). The PTL is a rare entity that accounts for less than 1% of all the Non-Hodgkin's lymphomas. The thyroid scintigraphy showed the existence of a cold nodule in the left thyroid lobule and the 67Ga scan revealed a large abnormal lesion in the mediastinum that extended to the right latero-cervical region. After two chemotherapy courses, the 67Ga scan was normal.

[Bone scintigraphy and somatostatin receptor scintigraphy in pediatric patients with bone involvement in Langerhans cell histiocytosis]. / Gammagrafía ósea y gammagrafía de receptores de la somatostatina en pacientes pediátricos con histiocitosis de células de Langerhans ósea.

Langerhans cell histiocytosis (LCH) is a granulomatous disease which can involve multiples sites of the body. Diagnostic imaging is of utmost importance in the management of these patients. Up to now radiographic skeletal survey and bone scintigraphy (BS) have been used to assess bone involvement (both with low specificity). Magnetic resonance imaging (MRI) and CT have been used to assess visceral involvement but with the limitation that they cannot give information about the functional status. Recently somatostatin receptor scintigraphy (SSRS) has been proposed to detect active lesions and to monitor response to treatment. The aim of this study is to assess bone and somatostatin receptor scintigraphy in the detection of bone involvement in LCH in children. Twenty scintigraphies (12 SSRS and 8 BS) were performed in seven patients (3 girls and 4 boys) aged at diagnosis: 18 month-12 years (mean age 6 years). The findings obtained in the scintigraphies were compared with clinical evolution and other imaging techniques. Bone scintigraphy detected all the LCH bone lesions, and discovered one unknown lesion. SSRS scintigraphy visualised the active lesions in 3 patients (clinical and other imaging techniques were also positive). SSRS was negative in one patient classified as disease free and another in clinical remission. SSRS detected 2 new unknown bone lesions, but could not detect LCH bone lesions confirmed in other imaging techniques in 2 patients. Somatostatin receptor and Bone scintigraphy can be used to detect active LCH bone lesions in children and can help to monitor response to treatment. Further studies with more patients are needed to confirm the diagnostic usefulness of these techniques.

[Abdominal splenosis: an often underdiagnosed entity]. / Esplenosis abdominal: una entidad frecuentemente infradiagnosticada.

Splenosis is defined as the heterotopic autotransplantation of splenic tissue because of a ruptured spleen due to trauma or surgery. It is a benign and incidental finding, although imaging tests may sometimes orient toward malignancy simulating renal tumors, abdominal lymphomas, endometriosis, among other. We report the case of a 42-year old male in whom a MRI was performed after a study due to abdominal pain. Multiple enlarged lymph nodes were observed in the abdomen, suggestive of lymphoproliferative disease. As an important background, splenectomy was carried out due to abdominal trauma at age 9. After several studies, it was decided to perform a (99m)Tc-labeled heat-damaged red blood cell scintigraphy that showed multiple pathological deposits distributed throughout the abdomen, and even the pelvis, being consistent with splenosis.

[Diagnosis of vascular parkinsonism: correlation of the symptoms with neuroimaging and utility of SPECT with 123I-ioflupane]. / Diagnóstico del parkinsonismo vascular: correlación de la clínica con la neuroimagen y la utilidad de la SPECT con 123I-ioflupano.

INTRODUCTION: The concept of vascular parkinsonism (VP) has evolved since it was introduced by Critchley. The relationships between the clinical manifestations and neuroimagining of patients with VP to determine the utility of SPECT in its diagnosis have been established. MATERIAL AND METHODS: Retrospective study of patients with suspicion of VP according to Ziljmans 2004 criteria. RESULTS: A total of 22 patients were included. The most frequent risk factor was AHT. The most frequent manifestations were: bradykinesis, followed by gait disorder. Response to L-dopa was related with symptoms in lower limbs (p=0.014). The most frequent alterations on the magnetic resonance imaging were: atrophy with ventricular dilation followed by white matter lesions. The Hachinski scale was related with acute onset (p=0.022) and territorial infarction (p=0.039), and the Winikates with subcortical- paraventricular white matter lesions (p=0.036), and both with gender (male) (p=0.031), and stroke background (p=0.022). Alteration in gait was associated with paraventricular white matter lesions (p = 0.043), and other manifestations with lesions in the medulla (p=0,020). Tremor was associated with bilateral involvement of putamens in SPECT (p=0.039), strategic lesion with putamen involvement (p = 0.028) and lesions of periventricular white matter lesions with SPECT type 1 and 2 (p=0.045). There were no significant relationships of the SPECT with response to L-dopa or with the scales. Discussion. The different relationships between symptoms, scales and neuroimagin show the complexity of the subject and the need to use all of them in the diagnosis of VP.

Hodgkin's disease. Prognostic value of Gallium-67 scintigraphy.

AIM: The aim of this study is to assess the clinical impact of gallium-67 scintigraphy, before and after treatment, in patients with Hodgkin's disease, and to compare the overall survival between the patients whose gallium studies after treatment were negative and those whose studies remained positive. METHODS: We have studied 75 patients (40 women, 35 men) with Hodgkin's disease. All the patients underwent (67)Ga scintigraphy at the moment of the diagnosis (basal study) and in the case that basal study was positive (abnormal hyper-uptake focus) we performed follow-up studies after the treatment. We have calculated the overall survival among patients whose studies after treatment were negative (1(st) group) and those whose studies remained positive (2(nd) group) and between patients whose studies were negative at diagnosis (3(rd) group). RESULTS: Gallium scintigraphy was positive at diagnosis in 47 patients (62.6%). In 39 of them we were able to perform the follow-up study after treatment. The follow-up study was negative in 31 patients while in 8 patients the gallium scintigraphy remained positive. The overall survival was significantly higher (p<0.001) in the 1(st) group compared with the 2(nd) group. The overall survival was higher in the 1(st) group compared with the 3(rd) but statistic significance level was not reached. CONCLUSION: Our data suggest that: 1) in Hodgkin's disease (67)Ga scintigraphy is useful to establish the diagnosis of complete remission; 2) if the gallium scan remains positive after treatment, the prognosis of patients is worse than the prognosis of patients with a negative scan.

Esplenosis abdominal: una entidad frecuentemente infradiagnosticada / Abdominal splenosis: an often underdiagnosed entity

La esplenosis se define como el autotrasplante heterotópico de tejido esplénico como resultado de una rotura del bazo por trauma o cirugía. Es una condición benigna y de hallazgo casual, aunque en ciertas ocasiones las pruebas de imagen puedan orientar a malignidad simulando tumores renales, linfomas abdominales y endometriosis, entre otros. Presentamos el caso de un varón de 42 años al que, tras un estudio por dolor abdominal, se le realiza una resonancia magnética en la que se observan múltiples adenopatías en el abdomen que pueden orientar a un síndrome linfoproliferativo. Como antecedente importante, presenta esplenectomía por trauma abdominal a los 9 años. Tras varios estudios, se decide realizar una gammagrafía con hematíes desnaturalizados marcados con tecnecio-99m que muestra múltiples depósitos patológicos distribuidos por todo el abdomen e, incluso, la pelvis, siendo este hallazgo compatible con esplenosis(AU)

Splenosis is defined as the heterotopic autotransplantation of splenic tissue because of a ruptured spleen due to trauma or surgery. It is a benign and incidental finding, although imaging tests may sometimes orient toward malignancy simulating renal tumors, abdominal lymphomas, endometriosis, among other. We report the case of a 42-year old male in whom a MRI was performed after a study due to abdominal pain. Multiple enlarged lymph nodes were observed in the abdomen, suggestive of lymphoproliferative disease. As an important background, splenectomy was carried out due to abdominal trauma at age 9. After several studies, it was decided to perform a 99mTc-labeled heat-damaged red blood cell scintigraphy that showed multiple pathological deposits distributed throughout the abdomen, and even the pelvis, being consistent with splenosis(AU)

Utilidad de la monitorización Video-EEG en los pacientes con epilepsia farmacorresistente / Usefulness of Video-EEG monitoring in patients with drug-resistant epilepsy

Objetivo: Evaluar el patrón de pacientes a los que se realiza monitorización prolongada Video-EEG en un centro especializado en epilepsia y valorar la utilidad de dicha técnica en la epilepsia farmacorresistente. Métodos: Se realizó el estudio y análisis prospectivo de la monitorización de 100 pacientes consecutivos con epilepsia farmacorresistente correspondientes a un solo centro. Se analizaron los datos demográficos de la serie, el tiempo trascurrido hasta la primera crisis, las maniobras de provocación de crisis y el rendimiento de la prueba (utilidad del test, cambio de actitud, mejoría en el ajuste farmacológico y mejoría quirúrgica). Se realizó un subanálisis en diferentes grupos diagnósticos.Resultados: El estudio se realizó fundamentalmente en población joven (34,4 años) y la media de horas trascurridas hasta la primera crisis fue de 30, requiriendo en la mayoría de pacientes (90%) retirar la medicación antiepiléptica. Pese a ello, no se produjo ningún caso de status epiléptico. La utilidad del test fue elevada en todos los grupos permitiendo cambiar el manejo de los pacientes en un 65%, lo cual se tradujo en mejorías tanto a nivel farmacológico como quirúrgico.Conclusión: La monitorización prolongada Video-EEG es una técnica adecuada para el estudio de pacientes con una epilepsia farmacorresistente, siendo el mayor problema en nuestro medio su difícil accesibilidad (AU)

Objective: To evaluate the characteristics of patients on whom long-term Video-EEG monitoring is performed in a specialist centre and to assess its suitability to study refractory epilepsy patients. Methods: A prospective analysis and study of Video-EEG monitoring was performed in a series of 100 refractory epilepsy patients from a single centre. The analysis included demographic data, the time until the first seizure, the methods used to provoke seizures, and the outcome (usefulness, change in the management, pharmacological and surgical improvement). A subgroup analysis based on diagnosis was performed.Results: The study was performed mainly on young people (mean 34.4 years) and the first seizure appeared in a mean of 30hours, requiring most of the patients to withdraw the medication. Nevertheless, there were no cases of status epilepticus. The usefulness of the test was high in all the groups. The management was changed in 65% of the patients with pharmacological and surgical improvement. Conclusion: Long-term Video-EEG monitoring is a suitable test to study refractory epilepsy patients. The main problem in our country is accesibility (AU)

Diagnóstico precoz y diferencial de la disautonomía en la enfermedad de Parkinson mediante gammagrafía cardíaca con 123I-MIBG / Early differential diagnosis of dysautonomia in Parkinson's disease by means of cardiac scintigraphy with 123I-MIBG

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