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SPECT IN CONCUSSION, VERTEBROBASILAR INSUFFICIENCY AND OTHER NEUROLOGICAL DISORDERS

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Title: SPECT IN CONCUSSION, VERTEBROBASILAR INSUFFICIENCY AND OTHER NEUROLOGICAL DISORDERS


1
SPECT IN CONCUSSION, VERTEBRO-BASILAR
INSUFFICIENCY AND OTHER NEUROLOGICAL DISORDERS
  • Novel applications and insights

Deepak Agrawal, MBBS, MS, MCh. Fellow, Pediatric
Neurosurgery BC Childrens Hospital, UBC
2
LEARNING OBJECTIVES
  • To understand uses of Single Photon Emission
    Computed Tomography (SPECT) in patients with
    post-concussion syndrome and vertebrobasilar
    insufficiency
  • To be familiar with the use of SPECT as an
    investigative and research tool in neurosciences

3
Imaging Brain function using SPECT
All India Institute of Medical Sciences, New Delhi
4
Imaging Brain function using SPECT
  • All India Institute of Medical Sciences, Delhi
  • 1200 bed tertiary centre
  • Annual budget of CAD 250 million
  • Imaging
  • 6 CT scanners
  • 2 1.5 T MRI scanners, a 4.7 Tesla animal MRI/MRS
    scanner, and a 9.4 Tesla NMR spectrometer.
  • 1 PET, 2 SPECT scanners

5
Imaging Brain function using SPECT
  • IMAGING TECHNIQUES
  • STRUCTURAL- MRI, CT
  • FUNCTIONAL- SPECT, PET, fMRI
  • (SPECT-Single Photon Emission Computed Tomography)

6
Imaging Brain function using SPECT
  • Functional Imaging
  • PET- Gold standard
  • SPECT - More widely available
  • - Much cheaper
  • - Still able to provide much of the same
    information

7
Imaging Brain function using SPECT
  • UNDERLYING PRINCIPLES OF SPECT
  • Biochemical interactions between brain tissue and
    injected substance (HMPAO, ECD, Iophane)
  • These substances are labeled with radioactive
    tracers (99mTc-HMPAO, 99mTc-ECD, 123I-iophane)

8
Imaging Brain function using SPECT
  • UNDERLYING PRINCIPLES
  • Radiopharmaceutical injected IV
  • Crosses BBB proportionate to blood flow
  • Enters Neuronal tissue stereoisomeric change
  • Become trapped inside the neurons

9
Imaging Brain function using SPECT
  • UNDERLYING PRINCIPLES
  • Increased neuronal activity increased neuronal
    uptake of radiopharmaceutical Increased
    perfusion on SPECT
  • This image of cerebral perfusion indirectly
    reflects cerebral metabolism

10
Imaging Brain function using SPECT
  • BRAIN SPECT
  • Brain perfusion - HMPAO,ECD
  • HMPAO-Hexa Methyl Propylene Amine Oxine
    ECD-Ethylene Cysteinate Dimer
  • Imaging of neurotransmitter systems - Ioflupane

11
Imaging Brain function using SPECT
  • APPLICATIONS
  • Dementias
  • Alzheimers?perfusion TP regions B/L
  • Normal perfusion Subcortical region
  • Vascular Dementia?perfusion Subcortical
    regions

12
Imaging Brain function using SPECT
  • APPLICATIONS
  • Epilepsy
  • Established role in epilepsy
  • SISCOM (Subtraction Ictal SPECT Coregistered
    with MRI)

13
Imaging Brain function using SPECT
  • APPLICATIONS
  • Trauma
  • Can show abnormalities in pts with normal CT
    MRI
  • Sensitivity can reach 80 compared to 5 for CT
    and 60 for MRI in minor head injuries
  • Kant R, Smith-Seemiller L, Isaac G, Duffy J.
    Tc-HMPAO SPECT in persistent post-concussion
    syndrome after mild head injury comparison with
    MRI/CT. Brain Inj 199711115.

14
Imaging Brain function using SPECT
  • APPLICATIONS
  • Parkinsonism
  • Dopamine transporter imaging- assessing the
    presynaptic dopaminergic function

15
Imaging Brain function using SPECT
  • APPLICATIONS
  • Research tool
  • before after pharmacotherapy, psychotherapy
    surgery

16
Imaging Brain function using SPECT
  • APPLICATIONS
  • Dementias
  • Epilepsy
  • Trauma
  • Parkinsonism
  • Stroke
  • Research tool-(before after pharmacotherapy,
    psychotherapy, surgery)

17
Imaging Brain function using SPECT
  • APPLICATIONS
  • Dementias
  • Epilepsy
  • Trauma
  • Parkinsonism
  • Stroke
  • Research tool-(before after pharmacotherapy,
    psychotherapy, surgery)

18
SPECT in TRAUMA
19
Imaging Brain function using SPECT
  • TRAUMA
  • 90 of all HI are supposedly minor
  • Post concussion syndromeincluding symptoms such
    as headache, irritability, poor concentration,
    memory disturbances, dizziness, anxiety, and
    depressionhas been reported to occur in up to
    80 of the patients following minor HI.
  • Hugenholtz H, Stuss DT, Stethem LL, Richard MT
    How long does it take to recover from a mild
    concussion? Neurosurgery 22853858, 1988
  • Wood RL. Understanding the 'miserable minority'
    a diasthesis-stress paradigm for
    post-concussional syndrome. Brain
    Inj.200418(11)1135-53

20
Medial Temporal Injury In Pediatric
Postconcussion Syndrome
Deepak Agrawal, Naveen K, C S Bal, A K
Mahapatra Departments of Neurosurgery and
Nuclear medicine, All India Institute of Medical
Sciences, New Delhi
21
Temporal lobe damage in minor head injury
  • WHY MEDIAL TEMPORAL LOBE?
  • Hippocampus is especially vulnerable to insults
    such as ischemia, hypoxia, and seizures
  • Extent of hippocampal damage can be correlated
    with severity of memory impairment

Rempel-Clower NL, Zola SM, Squire LR, Amaral DG.
Three cases of enduring memory impairment after
bilateral damage limited to the hippocampal
formation. J Neurosci 1996165233-5255.
22
Temporal lobe damage in minor head injury
  • OBJECTIVES
  • Look for medial temporal hypoperfusion (MTH) on
    SPECT in children with minor head injury
  • To evaluate MTH on SPECT as a risk factor for
    development of persistent postconcussion syndrome
    (PPCS) at three months

23
Temporal lobe damage in minor head injury
  • MATERIALS AND METHODS
  • PROSPECTIVE STUDY
  • One year period
  • Children 18 yrs of age

24
Temporal lobe damage in minor head injury
  • MINOR HEAD INJURY
  • Loss of consciousness lt30 minutes.
  • GCS score 13 to 15.
  • Posttraumatic amnesia lt24 hours.

criteria published by the members of the Mild
Traumatic brain injury Interdisciplinary Special
Interest Group (BISIG) Kay T, Harrington DE,
et al. Definition of mild traumatic brain injury.
J Head Trauma Rehabil 1993886
25
Temporal lobe damage in minor head injury
POST CONCUSSION SYNDROME (2 or more of the
following)
  • Headache
  • Dizziness and vertigo
  • Memory deficits
  • Behavioral and emotional disturbances.

DSM IV criteria Brown SJ, Fann JR, Grant I
Postconcussion disorder time to acknowledge a
common source of neurobehavioural morbidity. J
Neuropsychiatry Clin Neurosci 615-22, 1994
26
Temporal lobe damage in minor head injury
INVESTIGATIONS
  • CT head
  • SPECT scan brain
  • (Within 72 hours at 3 months)

27
Temporal lobe damage in minor head injury
SPECT METHODOLOGY
  • SPECT scanning was done using 99Tcm-ECD on a dual
    headed GE 'Varicam' scanner.
  • The final data was displayed on a 10 grade color
    scale and semi quantitative analysis performed.

28
Temporal lobe damage in minor head injury
  • STUDY DESIGN

29
Temporal lobe damage in minor head injury
  • RESULTS (SPECT)
  • 13/14 (93) patients with initial MTH continued
    to have persistent MTH
  • 0/16 (0) of patients in control group developed
    subsequent MTH at 3 months

30
Baseline
At 3 months
31
Temporal lobe damage in minor head injury
RESULTS Persistent post concussion syndrome
(PPCS)
12/14 (86) children developed PPCS in the MTH
group, compared to 2/16 (12.5) children in the
control group P0.0003
32
Temporal lobe damage in minor head injury
  • CONCLUSIONS
  • Children with MTH are more likely to develop
    persistent post concussion syndrome
  • SPECT may help in identification and
    prognostication in this subgroup of children

33
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34
  • SPECT AS A PLATFORM FOR TESTING VARIOUS
    INTERVENTIONS

35
ROLE OF PIRACETAM IN POST-CONCUSSION SYNDROME A
PROSPECTIVE RANDOMIZED STUDY
  • Deepak Agrawal, K Naveen, CS Bal, AK Mahapatra
  • Departments of Neurosurgery and Nuclear
    medicine,
  • ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW
    DELHI, INDIA

36
Piracetam in minor head injury
  • Piracetam
  • Discovered 30 years ago by UCB pharma
  • GABA derivative, does not work via GABA pathways.
  • Mechanism of action remains unknown
  • Has beneficial effects on the CBF by decreasing
    the adhesivity, aggregation, and increasing the
    deformability of erythrocytes.
  • Nootropic

37
Piracetam in minor head injury
  • Why Piracetam?
  • Already approved for use in Europe India for a
    variety of disorders including head injury
  • Minimal side effects- More than 12 g of piracetam
    has been given as daily dose in acute stroke
    without appreciable side effects
  • De Deyn PP, Reuck JD, Deberdt W, Vlietinck R,
    Orgogozo JM. Treatment of acute ischemic stroke
    with piracetam. Members of the Piracetam in Acute
    Stroke Study (PASS) Group. Stroke 1997 28
    2347-52.

38
Piracetam in minor head injury
  • OBJECTIVE
  • To look for changes in cerebral perfusion on
    SPECT, following administration of Piracetam, in
    patients with post-concussion syndrome (PCS),

39
Piracetam in minor head injury
MINOR HEAD INJURY
  • 1. Loss of consciousness lt30 minutes.
  • 2. GCS score 13 to 15.
  • 3. Posttraumatic amnesia lt24 hours.

criteria published by the Mild Traumatic brain
injury Interdisciplinary Special Interest Group
(BISIG) Kay T, Harrington DE, et al.
Definition of mild traumatic brain injury. J Head
Trauma Rehabil 1993886
40
Piracetam in minor head injury
  • POST CONCUSSION SYNDROME
  • (2 or more of the following)
  • Headache
  • Dizziness and vertigo
  • Memory deficits
  • Behavioral and emotional disturbances.

DSM IV criteria based on recommendation of Brown
et al. Brown SJ, Fann JR, Grant I Postconcussion
disorder time to acknowledge a common source of
neurobehavioural morbidity. J Neuropsychiatry
Clin Neurosci 615-22, 1994
41
Piracetam in minor head injury
  • MATERIALS AND METHODS
  • Prospective study
  • Adult patients (18-60 yrs)

42
Piracetam in minor head injury
INVESTIGATION
  • CT head
  • SPECT scan brain
  • Within 72 hours of injury

43
Piracetam in minor head injury
SPECT
  • Circular region of interest (ROI) with a radius
    of 9.1mm (6 pels) in the basal ganglia, thalamus,
    temporal lobe, visual cortex and brain stem were
    used.

44
Piracetam in minor head injury
45
Piracetam in minor head injury
  • Semiquantitative analysis of the data done using
    semiautomatic brain quantification programs
    (Xpertpro, Entegra with Neurogam).

ABNORMAL SPECT SCAN
Regional cerebral perfusion lt10 of
contralateral lobe, or in case of bilateral
involvement, less than 20 of cerebellum
46
Piracetam in minor head injury
STUDY DESIGN
47
  • RESULTS
  • Significant rise in the post treatment ratio in
    the piracetam group (mean 0.959) as compared to
    the controls (mean 0.882) (p lt.001)
  • Nine patients (90) also had improvement in their
    symptoms of PCS, compared to only three patients
    in the control group (p0.01).

48
Piracetam in minor head injury
  • CONCLUSIONS
  • Cerebral perfusion defects occur in majority of
    the cases of postconcussion syndrome following
    minor head injury.
  • Piracetam reverses cerebral perfusion deficits
    and may result in accelerated symptomatic
    improvement in patients with postconcussion
    syndrome.

49
Piracetam in minor head injury
CONCLUSIONS
  • THIS PRELIMINARY STUDY SHOWED OBJECTIVELY THAT
    LOW DOSE PIRACETAM MAY BENEFIT PATIENTS WITH
    POSTCONCUSSION SYNDROME

50
Imaging Brain function using SPECT
51
CRANIO-CERVICAL JUNCTION ANOMALIES AS A CAUSE OF
VERTEBRO-BASILAR INSUFFICIENCY
  • Deepak Agrawal, Naveen K, SS kale, C S Bal,
  • A K Mahapatra
  • Departments of Neurosurgery and Nuclear
    medicine,
  • All India Institute of Medical Sciences, New
    Delhi-110029

52
  • SPECT IN VERTEBROBASILAR INSUFFICIENCY
  • Can SPECT reliably assess the posterior fossa?
  • YES!
  • Delecluse F, Voordecker P, Raftopoulos
    C.Vertebrobasilar insufficiency revealed by
    xenon-133 inhalation SPECT. Stroke 198920952-6.
  • Foster NL, Mountz JM, Bluelein LA, Ackermann RJ,
    Petry NA, Kuhl DE. Blood flow imaging of a
    posterior circulation stroke. Use of technetium
    Tc 99m hexamethylpropyleneamine oxime and single
    photon emission computed tomography. Arch Neurol
    198845687-90.
  • Shuke N, Nagasawa K, Yamamoto W, Usui K, Sako K,
    Nakai H, Tanaka T, Aburano T. Demonstration of
    positional posterior cerebral ischemia on
    cerebral blood flow SPECT. Clin Nucl Med
    200126559-60.

53
SPECT In vertebrobasilar insufficiency
  • BACKGROUND
  • Association of VBI with CCJ anomalies is severely
    underestimated
  • X-rays of the Cx spine are done in only 30 of
    pts with VBI only 11 pts have proper
    flexn/extn x-rays done
  • Lorenstan KJ, Schrospshire LC, Ahn HS.
    Congenital odontoid aplasia and posterior
    circulation stroke in childhood. Ann Neurol
    198823-410-413

54
SPECT In vertebrobasilar insufficiency
  • BACKGROUND
  • Posterior circulation ischemia has a higher
    morbidity and mortality
  • Fifty percent of these patients who are managed
    conservatively progress to develop infarction

55
SPECT In vertebrobasilar insufficiency
  • BACKGROUND
  • Diagnosing even a percentage of the patients with
    VBI as having CCJ anomalies may have major
    therapeutic prognostic implications.

56
SPECT In vertebrobasilar insufficiency
  • Pathogenesis VBI in CVJ Anomalies

57
SPECT In vertebrobasilar insufficiency
  • Clinical rarity of posterior circulation
    infarcts in CCJ anomalies is thought to be due to
    duplication of VA and the adequacy of the
    circulation of Willis
  • However we feel that
  • patients symptomatic for VBI are not routinely
    evaluated for CCJ anomalies which remain
    undiagnosed

58
SPECT In vertebrobasilar insufficiency
  • Aims and Objectives
  • Using 99Tc ECD brain SPECT to document the
    presence of posterior circulation cerebral
    ischemia in patients with CCJ anomalies and
    correlate with symptoms of VBI.

59
SPECT In vertebrobasilar insufficiency
  • PROSPECTIVE STUDY DONE OVER A SIX MONTH PERIOD

60
SPECT In vertebrobasilar insufficiency
  • VBI GROUP
  • Pts with features suggestive of VBI (Drop
    attacks, episodic vertigo, visual disturbances
    and dysarthria)
  • CONTROL GROUP
  • Patients without symptoms of VBI

61
SPECT In vertebrobasilar insufficiency
  • STUDY DESIGN

AAD Atlanto-axial dislocation
62
SPECT In vertebrobasilar insufficiency
  • Operative procedure
  • Combined TOO and Occipito-cervical fusion from
    occiput to C3, using contoured loop and
    sublaminar wiring with bone graft placement.
  • Both procedures were carried out in a single
    sitting.

63
SPECT In vertebrobasilar insufficiency
  • Patients with reducible AAD, requiring only
    occipito-cervical fusion were excluded from the
    study to maintain pt uniformity.
  • Postoperatively the neck was immobilized using a
    Philadelphia collar for a period of three months.

64
SPECT In vertebrobasilar insufficiency
SPECT
  • SPECT scanning was done using 99Tcm-ECD on a dual
    headed GE 'Varicam' scanner.
  • ROI were drawn in the cerebellum and basal
    ganglia and C/BG calculated on each side.

65
SPECT In vertebrobasilar insufficiency
  • OBSERVATIONS
  • Radiology (Preop)
  • AAD 19
  • BI 15
  • Occipitalisation of atlas 14
  • Klippel-Feil anomaly 9
  • Small cerebellar infarcts 2
  • (Both in VBI group)

66
SPECT In vertebrobasilar insufficiency
  • RESULTS
  • (Preoperative SPECT)
  • Decreased cerebellar perfusion in 75 (9/12) of
    the patients in the VBI group compared to 14
    (1/7) in the control group
  • (p0.019)

67
SPECT In vertebrobasilar insufficiency
  • RESULTS
  • Following surgery, eight patients (88.9) in the
    VBI group and none in the control group had
    improvement in cerebellar perfusion.
  • All eight patients showing improvement on SPECT
    also had improvement in their symptoms of VBI
    following surgery

68
SPECT In vertebrobasilar insufficiency
Baseline
At 1 month postop
69
SPECT In vertebrobasilar insufficiency
  • Two pts in VBI group developed meningitis in the
    postoperative period had a further decrease in
    cerebellar perfusion on the follow up SPECT scan.
  • Another 2 pts in VBI group had small cerebellar
    infarcts on preop MRI did not show improvement
    in cerebellar hypoperfusion following surgery.

70
SPECT In vertebrobasilar insufficiency
  • Ours is the only study of its kind documenting
    hypoperfusion in posterior circulation territory
    in patients with CCJ anomalies.
  • This hypoperfusion may represent a state of
    chronic VBI, expected in such patients MAY BE
    REVERSIBLE following surgery.

71
SPECT In vertebrobasilar insufficiency
  • CONCLUSIONS
  • Our study shows that rigid immobilization
    (provided by occipito-cervical fusion in our
    patients) by itself may confer protection from
    VBI

72
SPECT In vertebrobasilar insufficiency
  • RECOMMENDATION
  • CCJ anomalies-potentially treatable cause of VBI
  • Recommend that in patients with VBI, a high index
    of suspicion be kept for CCJ anomalies and x-rays
    of the cervical spine with flexion-extension
    views be done on all patients.

73
  • Agrawal D, Gowda NK, Bal CS, Kale SS, Mahapatra
    AK. Have Cranio-Vertebral Junction Anomalies Been
    Overlooked as a Cause of Vertebro-basilar
    Insufficiency? Spine (In print)

74
  • Acknowledgements
  • Naveen K Gowda (Nuclear Medicine)
  • Prof A K Mahapatra (Neurosurgery)

75
  • THANK YOU
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