NNNR3182

RADIONUCLIDE IMAGING:
CENTRAL NERVOUS SYSTEM

By

Iza Nurzawani Che Isa, PhD

INTRODUCTION
CT, MRI
• Provide detailed anatomical and
structural information of the disease and
surrounding tissue
• Evaluation of tumors, strokes, subdural
hematoma, lesions of CNS

Scintigraphy, SPECT, PET

• Provide valuable functional and
perfusion information about the disease
that is not obtained through anatomic
imaging
• Evaluation of inflammatory processes,
vascular accidents (eg: TIAs), prolonged
neurologic deficit (eg: inability to speak)
 BASIC BIOLOGIC CONCEPTS FOR BRAIN
IMAGING
THE BLOOD-BRAIN BARRIER
(BBB)

Radiotracers do not cross Radiotracers cross normal

normal BBB BBB

• Normal brain appears non-active • Normal brain appears active

• In abnormal brain, radiotracers cross • In abnormal brain, it shows some
the broken BBB and show lesions as lesions as cold spots and some as
hot spots hot spots
• Eg: 99mTc-PTC, DTPA, GH and • Eg: (99mTc-HMPAO, 99mTc-
MAG3 , Brain Studies, 201TI ECD, 123I-IBZM, 123I-IQNB
 INTRODUCTION

Radionuclide brain scan

3 approaches

PET metabolic brain imaging

SPECT brain
perfusion
Planar brain imaging • uses lipophilic
radiopharmaceuticals that routinely • Uses functional positron-
• uses radiopharmaceuticals cross the blood-brain barrier (BBB) emitting
that are perfusion agents. to localize in normal brain tissue radiopharmaceuticals (eg:
and pathologic processes in radiolabelled
proportion to regional cerebral fluorodeoxyglucose) and
blood flow. neuroreceptor agents.
• Radiotracer (eg: 123I-IMP, 99mTc-
HMPAO, and 99mTc-ECD
1. PLANAR BRAIN IMAGING
1. PLANAR BRAIN IMAGING
Indications
• Localization of primary and metastatic tumors, abscesses, subdural hematomas
• Detection of vascular malformations, inflammatory or infectious diseases,
cerebrovascular diseases and TIAs
• Differentiation between contusions from simple concussions or brain tumors
from vascular accidents
• Evaluation of results of surgical procedures, radiation therapy or chemotherapy
• Evaluation of intracerebral inflammatory or degenerative diseases like AIDS,
multiple sclerosis, collagen disease
• to differentiate viable/recurrent tumor from radiation necrosis
1. PLANAR BRAIN IMAGING
Contraindications
• Patients too agitated, uncooperative or claustrophobic to remain still during
the scan

Patient preparation
• No special preparation needed. Sedative if patient is too agitated

Equipment
• Gamma camera, possibly with large FOV
• LEAP or LE, high sensitivity collimator
1. PLANAR BRAIN IMAGING
Radiopharmaceuticals
• Tc-99m pertechnetate, Tc-99m GH, Tc-99m DTPA, Tc-99m MDP, Ga-67,
TI-201, Tc-99m MIBI
Tc99m-DTPA
 preferred by some
because of its more rapid
blood clearance, and lack of
salivary and choroid plexus
activity.
Tc99m-Pertechnetate
 Inexpensive and readily
available, but has prolonged
blood pool activity and is
concentrated in the choroid
plexus and salivary glands.
This latter uptake can be
prevented by ingestion of
perchlorate.
1. PLANAR BRAIN IMAGING
Dose
• Adult dose range : 15-30 mCi (555-1110 MBq) for Tc-99m
: 2-4 mCi (74-148 MBq) for TI-201
• Paediatric range : one third of adult dose or
 1. PLANAR BRAIN IMAGING
Two
Techniques

Dynamic or angiographic study

 composed of rapid sequential images of the arrival of Delayed static images
the radioactive bolus in the cerebral hemispheres, which
essentially constitutes a qualitative measure of regional
brain perfusion
 particularly useful in patients with AVM.
 In this condition, gamma camera viewing of the
posterior of the head and neck shows:
1. early appearance of radioactivity over the
lesion (typical of AVM) compared to rest of the
brain
2. higher peak density of gamma emission and
3. delayed washout of radioactivity in the delayed
images.
1. PLANAR BRAIN IMAGING
Procedure (Static)
• Scan is begin 1-2 hour post-injection (200-800 k counts)
• Patient is placed in supine, camera anterior as close as possible with entire
cranium in the FOV, head flexed back facing straight up, place lead apron
around patient’s shoulders to shield counts coming from the body
• Take static images in anterior, posterior, right and left lateral, vertex view –
static images maybe required after 4 or more hours
• SPECT imaging: acquisition 360° rotation, 64 projections per rotation, 20
sec/stop (200k counts), 128x128 or 64x64 matrix, magnified. Position head
into camera view so that cerebrum and cerebellum are visualized. Start
taking images 15 min to 3 hours after injection.
1. PLANAR BRAIN IMAGING
Procedure (SPECT imaging)
• Computer settings: acquisition 360° rotation, 64 projections per rotation, 20
sec/stop (200k counts), 128x128 or 64x64 matrix, magnified.
• Position head into camera view so that cerebrum and cerebellum are
visualized.
• Start taking images 15 min to 3 hours after injection.
1. PLANAR BRAIN IMAGING
Normal finding
• Superior rim, sagittal sinus, transverse sinus, occipital sinus, facial activity
and salivary gland show increased concentration. No significant activity is
seen in cerebral cortex.
1. PLANAR BRAIN IMAGING
Normal finding

Pattern of distribution of activity in a normal static brain scan - prompt symmetric

perfusion that in the anterior projection
1. PLANAR BRAIN IMAGING
Abnormal finding
• Any localized accumulations of the tracer maybe caused due to break down
of the BBB and indicates a pathological process
1. PLANAR BRAIN IMAGING
Abnormal finding
A tumor in the left
parieto-occipital region
seen in planar brain scan
using Tc 99m
pertechnatate
 1. PLANAR BRAIN IMAGING
PEARLS

• An abnormal finding is non-specific.

It delineates an area of increased
vascular permeability secondary to a
variety of disease processes like
strokes and abscesses
• In static brain scans using non-BBB
penetrating radiotracers tumors of
the pituitary and Grades I and II
astrocytomas are often poorly
visualized.
2. BRAIN SCAN (SPECT)
(PERFUSION IMAGING)
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Indications
• Evaluation of blood flow
• Detection of vascular malformation, inflammatory, or infectious diseases,
cerebrovascular accidents, TIAs
• Evaluation of suspected arterial-venous malformation (AVM)
• Evaluation of intracerebral inflammatory or degenerative disease like AIDS,
multiple sclerosis, collagen disease
• Location of epileptic focus
• Evaluation of dementia
• Evaluation of cerebral flow reserve using pharmacological stress (Diamox)
• Determination or brain death
 2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Contraindications
• Patients too agitated, uncooperative or claustrophobic to remain still during the scan
Patient preparation
• Coffee, alcohol and other drugs that may affect cerebral blood flow should be withheld for
24 hours before the examination
• Neuropsychiatric and medication history and prior CT or MRI scans should be made
available at the time of reporting. Otherwise, no specific preparation needed. Mild
sedative if patient too agitated
Equipment
• Gamma camera, possibly with large FOV
• LEAP or LE, high sensitivity collimator
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Radiopharmaceuticals
Non-BBB penetrating
• Tc-99m pertechnetate, Tc-99m GH, Tc-99m DTPA, Tc-99m MDP

BBB-penetrating
• Tc-99m HMPAO, Tc-99m ECD

Dose
• Adult dose range : 15-30 mCi (555-1110 MBq) for Tc-99m based agent
• Paediatric range : one third of adult dose or
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Patient preparation
• Coffee, alcohol and other drugs that may affect cerebral blood flow should be
withheld for 24 hours before the examination
• Neuropsychiatric and medication history and prior CT and MRI scans should
be made available at the time of reporting. Otherwise no specific preparation
of the patient is required. Mild sedative if patient too agitated.
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Procedure (Non-BBB penetrating agents)
• Position patient supine, camera anterior as close as possible with entire
cranium in the FOV, head flexed back facing straight up
• Inject bolus and start camera immediately – for flow 2sec/frame for 60
seconds, take at least one blood pool image at the end of flow in the same
position (200-800k counts) – for dual headed camera, take images in both
positions
• static images can be taken after 1-2 hours (200-800k counts) in anterior,
posterior, right and left laterals, and vertex view (if necessary)
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Procedure (BBB penetrating agents)
• Position patient supine, camera anterior as close as possible with entire
cranium in the FOV, head flexed back facing straight up
• Inject bolus and start camera 15-90 minutes after injection (depending on
department protocol)
• Computer set-up: SPECT accusation 360° rotation, 64 projections per
rotation, 20sec/stop (200k counts), 128x128 or 64x64 matrix, magnified
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Normal finding
• Flow study: in arterial phase subclavian, carotid and cerebral arteries are
visualized symmetrically. In capillary phase, symmetric diffuse activity is
seen in both hemispheres. In. venous phase, sagittal sinus and jugulars are
seen. In blood pool image soft tissue and venous activity seen.
• In following static images, superior rim, sagittal sinus, transverse sinus,
occipital sinus, facial activity and salivary gland with increased concentration
seen perfusion SPECT study with BBB penetrating tracers will show
symmetric uptake, specially in the grey matter of the brain.
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)

Normal finding
(a)Single axial slice from normal brain SPECT showing symmetric distribution of tracer (b) single axial slice from
an abnormal brain SPECT showing hypoperfusion in the right posterior parietal region
2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Abnormal finding
• Flow study: focal areas of increased or decreased uptake other than normal
vascularity, abnormal appearance to vascularity, asymmetric flow, ‘flip flip’
sign, one side visualizing, unmatched activity in any phase on blood pool
image persistent, abnormal focal areas of increased or decreased uptake,
abnormal appearance to vascularity.
• A defect is seen in acute stroke. Hemorrhagic stroke cannot be differentiated
from other type of infarct
• Different types of dementia show characteristic patterns of hypoperfusion. A
seizure focus during interictal imaging will show hypoperfusion whereas
during ictal phase the same area will show hyperperfusion
 2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Abnormal finding

Tc99m HMPAO cerebral perfusion images show

scattered, multifocal, patchy areas of hypoperfusion
involving bilateral cerebral cortical regions. Also, there
is hypoperfusion involving the cerebellum bilaterally.
This is the typical pattern of perfusion abnormalities
that is observed in patients with AlDS dementia. (Image
courtesy of David H. Lewis, MD.)
 2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Abnormal finding

Axial images of Tc-99m ECD show

significantly reduced perfusion to the bilateral
parietal lobes and minimally reduced
perfusion to
temporal lobes. Perfusion to occipital lobes
and the sensorimotor cortex is preserved.
(Image courtesy of Bhasker R. Koppula, MD.)
 2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Abnormal finding

Coronal views confirm the findings noted on the

axial images. These images also show
preservation of perfusion to the basal
ganglia and thalami. (image courtesy of Bhasker
R. Koppula, MD.)
 2. BRAIN SCAN (SPECT) (PERFUSION
IMAGING)
Abnormal finding

Axial brain SPECT images performed using

Tc-99m ECD show significantly reduced
perfusion to the frontal lobes bilaterally. Also,
bilateral temporal lobes show decreased
perfusion though not as severely as the frontal
lobE
(Image courtesy of Bhasker R. Koppuia, MD.)
3. Cisternography
3. CISTERNOGRAPHY
Indications
• Evaluation of CSF flow in the spinal column and inside the brain
• Evaluation of normal pressure hydrocephalus
• Detection of CSF leak after trauma or otorrhea due to other causes
• Evaluation and detection of ventriculo-peritoneal or ventriculo-atrial shunt
obstruction or patency
• Evaluation of dispersal of intrathecally injected chemotherapy
3. CISTERNOGRAPHY
Contraindications
None

Patient preparation
• Prepare patient for spinal injection, preferably by experienced physician
• Instruct patient to lie flat for 2 hours after injection to minimize headache

Equipment
• Gamma camera
• LEAP/high resolution collimator, if In-111 is used, use ME, parallel hole collimator
3. CISTERNOGRAPHY

Radiopharmaceuticals
• Tc-99m DTPA or In-111 DTPA

Dose
• Adult dose range : 0.4-12 mCi (14.8 - 444 MBq) for Tc-99m based agent
: 0.5 – 1.5 mCi (18.5 – 55.5 Mbq) for In-111
3. CISTERNOGRAPHY
Patient preparation
• Radiopharmaceutical to be injected in the spinal canal with patient preferably
in left or right decubitus
• Position patient supine with camera anteriorly
• Obtain images within 1-2 hours after injection
• Acquire images of the head in anterior, lateral and the vertex views. Obtain
delayed images at 4, 24 or 48 hours
• For shunt patency, obtain delayed anterior abdominal images, particularly at
48 and 72 hours after injection
• For detection of CSF leak, insert pledgets or cotton swab, bilaterally either
before injection or within an hour after injection
3. CISTERNOGRAPHY
Patient preparation
• For better localization, placements are to be made at both cribriform plates, at each
spheno-ethmoid recess under the mandibular turbinate. Also place one in the buccal
mucosa for control
• Image injection site shortly after injection to confirm successful instillation of activity
• Place patient with heal flexed forward and downward or in position known to exacerbate
leakage
• Take images of the skull in anterior and lateral projections at 2, 4 and 6 hours
• Remove the pledgets after 6 hours
• Place in separate labeled pre-weighed tubes. Separately weigh and count in a well counter
• If leak is suspected, a delayed image after 24 hours maybe useful. Sometimes posterior
images maybe required if a leak is present in other views.
3. CISTERNOGRAPHY
Normal findings
• Activity appears in basal cisterns within 3 hours after lumbar injection. Then it
enters the inter-hemispheric and sylvian fissures, forming, neptunes triumvirate or
‘Viking helmet’ after 24 hours activity is seen over the convexity. No reflux into
ventricles is expected. If the shunt to the abdomen is patent, it will show an area of
an increased activity, particularly on the side of the shunt and becomes more intense
in delayed images. CSF leakage can be excluded if the counts are less than three
times of the background or buccal mucosa pledget.
 3. CISTERNOGRAPHY
Normal findings

Normal cisternography with Tc-

99m DTPA showing distribution
of activity at different time
periods
 3. CISTERNOGRAPHY
Abnormal findings
• Persistence of activity in lateral ventricle is ahnormal.
• Increase in CSF volume caused by overproduction, decreased absorption, blockage of
flow or cerebral atrophy are indicative of hydrocephalus.
• Non-obstructive hydrocephalus is mostly caused by cerebral atrophy
• Obstructive hydrocephalus is caused by obstruction of outflow from:
• non-comunicating hydrocephalus caused by blockage of CSF flow, and
• communicating obstructive hydrocephalus caused by extraventricular blockage that is cisterns or
villi.

• Normal pressure hydrocephalus shows ventricular reflux that persists for 24-48 hours.
There maybe delayed or lack of flow to the convexity
• Shunt blockage will show no activity in the peritoneal cavity or in the vascular system.
3. CISTERNOGRAPHY

Abnormal findings
• CSF leak (otorrhea or rhinorrhea) is demonstrated by activity in the pledgets (swab)
which should be 3-4 timess that of the background. The labeled pledges should help
in localizing the leak. Often the images show activity outside the cranium in case of
leakage.
3. CISTERNOGRAPHY
Abnormal findings

A B
 3. CISTERNOGRAPHY
Abnormal findings

A, B, C and D. Delayed 24-hour images

show pooling of the radiotracer in the
extrathecal space below the left
kidney, lateral to midline on the
anterior/posterior images. On the left
lateral image, the tracer is seen posterior to
the spinal canal. Findings are highly
suspicious for CSF leak from the lumbar
C
spinal canal. (Images courtesy of Bhasker D
R. Koppula, MD.)
ADDITIONAL READING

• https://www.auntminnie.com/index.aspx?sec=ref&sub=ncm
• https://rad.washington.edu/about-us/academic-sections/nuclear-medicine/nuc
lear-medicine-lectures/