Central Nervous System

Imaging

Rong Tian
 Brain structure
大脑

The brain has three main COMPOSITION OF THE CEREBRUM

parts: the cerebrum, the The brain consists of gray matter (40%)
cerebellum, and the brain and white matter (60%)
stem (medulla)

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 NOURISHMENT OF THE BRAIN:
Although the brain is only 2% of the
body's weight, it uses 20% of the oxygen
supply and gets 20% of the blood flow
If brain cells do not get oxygen for 3 to
5 minutes, they begin to die
It is very important to keep the blood
supply

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 PROTECTION

The blood-brain barrier ：

Cerebrospinal fluid (CSF)
protects the brain from chemical
surrounds the brain and intrusion from the rest of the
cushions the brain and body.
 Blood flowing into the brain is
spinal cord from jolts filtered so that many harmful
4 chemicals cannot enter the brain.
 Abnormal of brain

Structure abnormal：tumor、
inflammation、hemorrhage

Functional abnormal：

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 Brain Imaging
 CT Scan: Computerized Axial
Tomography
 MRI: Magnetic Resonance Imaging
 fMRI: Functional Magnetic Resonance Imaging
 PET Scan: Positron Emission Tomography Scan
 SPECT : Single Photon Emission Computerized
Tomography
 EEG: Electroencephalograph
 -the brain can look quite normal anatomically,
despite the being quite marked abnormalities of function -

X-RAYS

Computerized they show the static

Axial Tomography structure [anatomy] of
the brain
- not -
how it actually
MRI
works!

Magnetic Resonance
Imaging
 Functional Brain Imaging

Proton Emission
Tomography

Single Proton Emission

Computerized
Tomography functional
Brain Imaging
allows us to see how
the brain actually
works and whether
there are areas of
abnormal activity
functional
Magnetic Resonance
Imaging
 Nuclear Medicine imaging

Instruments
SPECT、SPECT/CT
PET 、PET/CT
Image methods

 Brain perfusion image

 Metabolic image

 Cistenograph
SPECT Cerebral Perfusion Imaging

 Mechanism of imaging

How to interpret the imaging

Applications
Mechanism of imaging
Uptake Mechanism of
pharmaceutical

 Can diffuse through the BBB:

Small molecular size，
lipophilic ，neutral charge

 Can stay in brain for enough

long time: hydrophilic

 Brain extraction is
proportional to rCBF
 Radiopharmaceuticals

1 Iodine-123 isopropyl iodoamphetamine

(I-123 IMP,) –first SPECT reagent

limitations:

high energy: 529keV, scatter

Unstable after labeling

2 Technetium-99m Reagents
Advantage :
 Lower energy
 Good image quality
Stable after labeling
Radio- Peak Blood First- Brain washout
phamaceuti activiity(mi half- pass uptake(%)
cals n) life extracti
on(%)

I-123 IMP 20 slow >95 6.5-8.3 Redistribution

Tc-99m 5 slow 70- 3.5-7.0 15% over 15min

HMPAO 80 Gray/white:2.5/1

Tc-99m 5 rapid >70 5.0-7.0 6%/ hr high

ECD brain/background
Gray/white: higher
Protocol

20 mCi Tc-99m ECD or HMPAO

Position collimators as close as
possible to patient’s head
Begin scanning 15 min or later after
injection
360 degree
Reconstruction
 Image Interpretation
Cerebrum :
Cerebral cortex :
 gray matter
white matter

The blood flow and the metabolism in gray matter are

3-4 times higher than that in white matter.
uptake of radioactivity mainly reflects the
distribution of rCBF of gray matter
Normal distribution

somewhat heterogeneous

bilaterally symmetrical

The following can be seen

Cerebellum ,Temporal, Parietal

•Frontal lobes,occipital,Basal
ganglia, Thalamus
 Abnormal
Appearance:
Decreased uptake in abnormal area
Increased uptake in abnormal area
Crossed cerebellar diaschisis
Luxury perfusion

Criterions:
At least three slices abnormal at the same plane
At least one slice abnormal at two different
plane
Clinical Applications

1 Cerebrovascular Disease

2 Differentiation of Dementia

3 Epilepsy

4 Others：
Cerebrovascular Disease
Stroke
 Stroke is the most common neurologic disease,
affecting 5% of the population over 65.
 Strokes can either be due to ischemic or hemorrhagic
processes.
Characterized by acute onset of focal neurologic
symptoms due to ischemic injury to the nerve cells
was the first application for SPECT cerebral
perfusion imagine.
The goal of imaging in a patient with acute stroke?

 Exclude hemorrhage
 Differentiate between irreversibly affected brain
tissue and reversibly impaired tissue (dead tissue
versus tissue at risk)
 Identify stenosis or occlusion of major extra- and
intracranial arteries

In this way we can select patients who are
candidates for thrombolytic therapy.
 Diagnostic imaging in stroke

CT
Advantages
 Excludes hemorrhagic
Disadvantages：
Sensitivity is low in 48h after stroke
MRI
Higher Sensitivity for Ischemia
Can detect early disease several hours
after happening of stroke
SPECT imaging appearance

Decreased rCBF can be seen immediately after

the acute cerebra-vascular event.

Sensitivity : 85% for nonlacunar strokes.

During the first 8 hours after infarction, only
20% of CT scans are positive, whereas 90% of
SPECT scans are abnormal.
Specificity : 88%-98%.
2 Dementia

The loss of memory and other

cognitive skills due to changes in
the brain caused by disease or
trauma
one of the major causes of
morbidity in the elderly generation.
 It becomes worse with the time
goes on
It is a big social problem for
heath care systems.
The most common types of primary dementia
include:

Alzheimer's disease
 Parkinson's dementia
Pick’s disease
Vascular dementia (multiinfarct dementia)
AIDS dementia
CT and MRI are excellent tools to exclude
secondary, in particular anatomic causes of
dementia, but they are of limited value in defining
primary degenerative brain diseases, especially
in the early stages

Cerebral perfusion imaging has shown

clinical utility in the differential diagnosis.
 Alzheimer’s disease
 A common cause of
dementia.
 The classic pattern:
bilateral posterior parietal-
temporal hypoperfusion.
 Predictive value is more
than 80%.
Unilateral, frontal or
multiple small defects were
not predictive of AD
Parkinson's dementia

 Symptoms: a decrease
in spontaneous movement,
gait difficulty, postural
instability, rigidity, and
tremor
 In the early stage
the abnormal is in
the basal ganglia.
The cortex could
be influenced and
Differentiation is
difficult from
Alzheimer’s disease

 PET and Receptor

imaging is useful

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Vascular dementia

 Multifocal
reductions in
perfusion imaging
with stroke

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Pick’s Dementia

Frontal
lobe

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3 Seizure disease : Epilepsy

Pathological findings: sclerosis,main

in the temporal lobe
EEG has poor spatial resolution
and is limited by the area of brain
sample.
EEG may be misleading.
CT and MRI have low sensitivity.
F-18-FDG PET and SPECT
perfusion agents can localize epileptic
foci
4 Brian death

5 Neuropsychiatric Disorders:

The role is uncertain. Functional

imaging is more useful.
1990, there was a report said that the brain
function will change when somebody is operating
computer and this change can be detected with
PET

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 Metabolic image

Cerebral glucose metabolic imaging

Cerebral Oxygen metabolic imaging

 Cerebral amino acid metabolic imaging

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PET Cerebral glucose metabolic imaging
Mechanism of uptake
Agent for glucose metabolism imaging

18F-FDG
Glucose
(fluorol-deoxyglucose)
Glucose metabolism
 Protocol

 Patients are studied in the fasting state because

hyperglycemia results in decreased cerebral uptake of
FDG.

 Dose is typically 5 to 10 mCi.

 Imaging begins 30 to 60 minutes after injection.

 Scan time: 10-20minutes.

 PET/CT System
• Isotope production
• Tracer production
CYCLOTRONS

• Imaging
CHEMISTRY SYSTEMS
SCANNER
 Normal distribution
 Relative uptake of F-18 FDG is directly related to
regional glucose consumption
 Uptake in gray matter is 3 to 4 times higher than
that in white matter. But it is symmetrical.
Abnormal distribution

Increased focal or regional uptake occurs with

increased metabolism (malignant tumors and
ictal seizure foci).

Decreased uptake is seen in areas of reduced

regional glucose metabolism (stroke, organic
dementia).
Clinical applications

Demential
Localization of partial complex seizure
disorder
Brain tumor
Others
SPECT and PET are similar in:

The clinical indications

Scintigraphic pattern

Interpretation

Exception : in malignant
F-18 FDG: increase
Tc-99m agents : decreased
Questions:
What is the difference in mechanism of uptake
between F-18 FDG and Tc-99m Cerebral perfusion
agents?

How can SPECT OR PET be useful in the differential

diagnosis of dementia?

What is the expected PET or SPECT pattern in

Seizures disease?
 Crossed cerebellar diaschisis

Definition: Decreased tracer

accumulation in one of the
cerebral hemisphere, at the
same time,decreased activity
is also seen in contralateral
cerebellar . This is ascribed
to functional disconnection
of the contralateral
hemisphere from the
cerebral cortex
Lucury Perfusion

Increased perfusion may

be seen in the region of

infarct after a recent stroke

(1-10days),caused by an

uncoupling of blood flow

from metabolism and

oxygen demand
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Ictal identification of epileptic focus:
Hypermetabolism and hyperperfusion area
is seen in the right parietal lobe
Ictal identification of epileptic focus.
Hypermetabolism and hyperperfusion area is seen in the right temporal lobe
Normal contiguous transverse slices of F-18 FDG
PET
Dementia

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 Seizer’s Disease

CT FDG PET fusion image Coronal FDG PET

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 女性，14岁，反复癫痫发作10年，脑电图示异常脑电（右颞区局灶性
改变），普通MRI阴性。颞叶MRI同样显示病灶
 PET显像右颞FDG摄取异常减低。
 手术病理：神经细胞减少、神经元变性、胶质细胞增生(gliocyte
proliferation
 Comparison of SPECT and PET

 Although ictal studies are most sensitive, they are technically highly
demanding and must be done with SPECT.
 Ictal PET would not be practical given the half-life of F-18 FDG.
 Interictal studies are far less sensitive, although interictal PET is
superior to interictal SPECT.
 Ictal SPECT has a sensitivity of nearly 90% in temporal lobe seizures,
and the abnormal areas are generally more extensive than any
structural abnormality on MRI.
 However, sensitivity for extratemporal seizures is much lower, on the
order of 50% to 75%.
 Interictal FDG PET and SPECT is approximately 70% sensitive for
seizure localization.

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 Ictal SPECT F-18 FDG
MRI

Frontal lobe

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 tumor

Diagnosis
Stage: detect metastasis
Follow up: Differentiate between recurrent and scar

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 患者，女性，65岁。右额顶星形胶质细胞瘤(glioma)术后并
放疗15年。CT示：原肿瘤部位有增强。PET显像见该部位明
显FDG摄取增高，考虑复发并且肿瘤升级。
患者，男，52岁，顶叶胶质瘤2级术后，MRI示顶叶手术部位高信号，为鉴别复发或
瘢痕(Scar)进行PET检查。PET示左侧顶叶FDG代谢增高灶,手术证实肿瘤复发。
PET显示脑转移灶呈高代谢
 Cisternography
• Outline
– CSF anatomy and physiology
– Cisternography
– Clinical application
• Normal pressure hydrocephalus
• CSF Shunt evaluation
• CSF leak
 CSF ANATOMY AND PHYSIOLOGY

• CSF axis can be divided into three distinct

regions
– Ventricles
– The brain subarachnoid space
– Spinal subarachnoid space
 arachnoid villi

• The production and

resorption of CSF
- secretion : Choroid
plexuses located in the lateral,
third and fourth ventricles Basal
- Absorption : The arachnoid cistern
villi which project into the
parasagittal venous sinuses
and to a much lesser extent
through the epidural veins of
the vertebral column

The direction of CSF flow

 Cisternography
Radiopharmaceutics
Indium-111 DTPA
Tc-99m DTPA/HSA

Protocol
Dose: 5-10mci (<1ml)
lumbar subarachnoid space
Imaging was done at different time point
Successful Injection is very important
Imaging Interpretation

Cisternogram images
related to anatomy
Imaging Interpretation

Migration Speed

ventricular reflux

abnormal activity
Normal imaging appearance

Interhemispheric fissure
Persistent lateral
ventricular reflux
(ventricular penetration)

bean sprout
1H

2H

5H

24H
Clinical applications
1 Hydrocephalus
The pathological changes of Hydrocephalus
is that the ventricular cavities enlarged with a
pathological increase in CSF volume.
It is divided into :
Obstructive : :
Non-communicating : obstruction between
lateral ventricular and
basal cisterns; MRI
Communicating: extraventricular obstruction
affecting basal cisterns,cerebral
convexities, and arachnoid villi
CSF imaging

Nonobstructive Generalized: cerebral atrophy

Localized: porencephaly, MRI, CT
Application 2: CSF shunts evaluation

• Types of CSF shunts:

– Ventriculoperitoneal,
ventriculoatrial,
lumboperitoneal
shunts
– Current ventricular
systems: proximal
tubing, reservoir/valve,
distal tubing
 CLINICAL APPLICATION 3----CSF leakage

• Etiology： trauma, surgical procedure, tumor,

spontaneously
• Sites of leakage: any where along spinal and brain
subarachnoid spaces
– The majority of leakage site: nasopharyngeal region
– CSF rhinorrhea: skull base from frontal sinuses to temporal
bone
– Otorrhea：
• CSF leakage in the head region

rhinorrhea
Otorrhea
• Pledgets placement
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