Yin-Hui Siow MD, FRCPC Director of Nuclear Medicine Southlake Regional Health Centre
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1 Yin-Hui Siow MD, FRCPC Director of Nuclear Medicine Southlake Regional Health Centre
2 Today Introduction to CT Introduction to MRI Introduction to nuclear medicine Imaging the dementias
3 The Brain ~ 1.5 kg (3lbs) Fatty organ (60%) Consistency of soft tofu It takes 5 parts of the brain to laugh at a joke
4 Brain Priorities The jockstrap was invented in 1874 NHL made helmets mandatory in 1979
5 Introduction to CT Computerized Tomography Computerized Axial Tomography
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7 Advantages Very common Very fast
8 Disadvantages Ionizing radiation involved (lots) Primarily anatomic structures Very limited functional imaging Limited differentation between body structures
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11 Introduction to MRI Magnetic Resonance Imaging Images from magnetic fields and radiowaves No ionizing radiation
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15 Advantages High resolution Good contrast Great flexibility and potential No ionizing radiation
16 Disadvantages Long imaging time No movement Claustrophobia Expensive to buy and maintain Large, powerful magnets
17 Nuclear medicine Imaging modality Radioactive tracers Physiology vs anatomy
18 Brain SPECT Brain perfusion Activity proportional to blood flow Blood flow proportional to use SPECT (Single Photon Emission Computarized Tomography) allows different planes or slices
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22 Disadvantages Lack of surrounding structures Moderately long imaging time Similar appearance to different pathologies
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25 Right MCA Stroke
26 Large sulci causing perfusion defects
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29 Best of Both Worlds Combine functional imaging with anatomic imaging Studies interpreted together (We need new software and equipment!)
30 Why do want to recognize dementia on imaging?
31 Leading Causes of Death 2014 United States Number of deaths for leading causes of death Heart disease: 596,577 Cancer: 576,691 Chronic lower respiratory diseases: 142,943 Stroke (cerebrovascular diseases): 128,932 Accidents (unintentional injuries): 126,438 Alzheimer's disease: 84,974 Diabetes: 73,831
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34 Alzheimer s? Depression? Change in mood or personality Withdrawal from work or social Completing familiar tasks Memory loss disrupting daily life Changes in planning or solving problems Change in mood or personality Withdrawal from work or social Completing familiar tasks Memory loss disrupting daily life Changes in planning or solving problems
35 The Dementias Alzheimer s Disease 70% Vascular Dementia 20% Dementia with Lewy bodies Fronto Temporal Dementia Creutzfeldt-Jakob Disease Dementia from movement disorders
36 Where are we today when looking at dementia? CT & MRI for anatomic imaging SPECT for functional imaging
37 Alzheimer s Dementia CT & MRI Imaging Atrophy in: Parietal lobe Posterior cingulate gyrus Inferior frontal lobe entorhinal and hippocampal cortex
38 Normal vs atrophy
39 Parietal and Posterior Cingulate Atrophy
40 Atrophy of hippocampus
41 However 50% of normal controls also had atrophy in same distribution The British Journal of Radiology, 1993, 66, 23-27, Wyper,D. et al,
42 Alzheimer s Dementia CT & MRI Imaging Hippocampal atrophy most accurate for Alzheimer s Rate of hippocampal atrophy more accurate than cortical measurement alone
43 Alzheimer s Dementia SPECT Imaging Decreased perfusion posterior parietal temporal lobes, posterior cingulate cortex and inferior frontal lobes Posterior distribution
44 Typical Alzheimer s Pattern
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47 Alzheimer s Normal
48 Alzheimer s Microscopic Pathology plaques & tangles Intracellular Tau protein (neurofibrillary tangles) deposits Extracellular beta amyloid plaques
49 Future Alzheimer s Imaging Now, imaging of function Direct imaging of beta amyloid
50 New Alzheimer s Imaging PET compounds 11 C PIB 18 F - florbetapir (Amyvid)
51 11 C PIB Imaging
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53 Uses of Amyloid Imaging Confirmation of diagnosis Identify patients at risk Use in drug trials
54 Controversies with Amyloid imaging Lack of available treatment Insurance eligibility Social stigma Psychological impact
55 Multi Infarct Dementia CT & MRI Imaging Old and new infarcts Burden of small vessel ischemic disease with FLAIR Presence of hemosiderin deposits relating vascular risk factors, lacune infarcts and small vessel ischemia
56 Multi Infarct Dementia brain SPECT Variable distribution of perfusion defects Sensitivity much less than CT or MRI
57 Large Infarcts on CT
58 Multiple Infarcts on MRI
59 Multi infarct Dementia
60 Same patient
61 Same patient
62 Large burden of small vessel disease
63 MRI and Small Vessel Ischemic Disease
64 Microhemorrhages on MRI
65 Frontotemporal Dementias (FTD) Atrophy and decreased perfusion in frontal and anterior temporal lobes frontal distribution
66 Frontotemporal Dementias
67 Frontotemporal dementia Normal
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69 Dementia with Lewy Bodies (DLB) Looks like Parkinson s clinically and pathologically Atrophy striatum, midbrain, hypothalamus Preservation of hippocampus Looks like Alzheimer s on functional imaging Also involvement of occipital lobes
70 DLB AD normal
71 Summary Dementia distribution imaging Alzheimer s Posterior MRI & SPECT Multi infarct Variable MRI FTD Frontal MRI & SPECT DLB Posterior MRI & SPECT
72 Conclusions CT very accessible but limited utility Combined brain SPECT and MRI better PET amyloid imaging best Support the Southlake Foundation!
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