Publications by authors named "Mordechai Lorberboym"

36 Publications

Anatomic Asymmetry in Sentinel Lymph Node Detection in Endometrial Cancer.

J Minim Invasive Gynecol 2020 Dec 26. Epub 2020 Dec 26.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (Drs. Tal, Grinstein, Elyashiv, Ben Shem, Peled, and Levy); Department of Nuclear Medicine (Drs. Goshen and Oksman), Edith Wolfson Medical Center, Holon; Department of Nuclear Medicine, Shamir Medical Center, Tzrifin, Sackler School of Medicine, Tel Aviv University (Dr. Lorberboym), Tel Aviv, Israel.

Study Objective: To determine whether the concomitant use of indocyanine green (ICG) with technetium-99m-filtered sulfur colloid (Tc99m-FSC) improves bilateral sentinel lymph node (SLN) detection rate in endometrial cancer and whether anatomic concordance of pelvic lymph nodes exists and can be used to predict SLN location in cases of unilateral mapping failure.

Design: Retrospective cohort study.

Setting: Tertiary academic medical center in Holon, Israel.

Patients: Patients diagnosed with endometrial cancer, who underwent SLN mapping with Tc99m-FSC, ICG, or both, at our center between 2014 and 2019.

Interventions: A total of 111 patients were included in the study. SLN mapping using Tc99m-FSC was performed in 101 (91.9%) patients, and ICG injection was given to 64 (57.6%) patients of whom 55 (49.5%) received both. We compared SLN detection rates (unilateral and bilateral) and anatomic symmetry for each method alone and for a combination of the 2.

Measurements And Main Results: The overall detection rate for unilateral SLNs was 96.4%; 96.9% with ICG, 93.1% with gamma-probe, and 98.2% by combining both methods. The total bilateral detection rate was 72.1%, with ICG performing better as a single tracer than Tc99m-FSC (75% vs 63.4%, respectively). In 55 women in whom both tracers were used, the bilateral detection rate was significantly higher compared with Tc99m-FSC alone. Symmetric pelvic anatomic concordance of SLN was found in only 35 of 80 patients with bilateral SLN detection (43.8%).

Conclusion: The combination of preoperative radioisotope injection and intraoperative ICG administration may yield the best bilateral SLN detection rate. In cases of unilateral mapping failure, one cannot rely on the anatomic location of the ipsilateral SLN detected to harvest the complementary node because the symmetric concordance is poor.
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http://dx.doi.org/10.1016/j.jmig.2020.12.029DOI Listing
December 2020

The role of exposure to pesticides in the etiology of Parkinson's disease: a F-DOPA positron emission tomography study.

J Neural Transm (Vienna) 2019 Feb 13;126(2):159-166. Epub 2018 Nov 13.

Department of Nuclear Medicine, Yitzhak Shamir Medical Center, 70300, Zerifin, Israel.

Susceptibility to Parkinson's disease (PD) is believed to involve an interaction between genetic and environmental factors. The role of pesticides as a risk factor of PD and neurodegeneration remains controversial. An asymmetric decrease in ligand uptake on F-DOPA positron emission tomography (PET), especially in the dorsal putamen, is a sensitive marker of PD. The aim of this study was to examine the pattern of ligand uptake on F-DOPA PET in patients with PD exposed or not exposed to pesticides. The main sample included 26 Israeli patients with PD, 13 who were exposed to pesticides and 13 who were not, matched for age and disease duration. All underwent F-DOPA PET imaging, and an asymmetry index of ligand uptake between the ipsilateral and contralateral caudate, putamen, and whole striatum was calculated. No significant between-group differences were found in demographic variables, clinical asymmetry index (P = 0.15), or asymmetry index of ligand uptake in the putamen (P = 0.84), caudate (P = 0.78) and striatum (P = 0.45). Comparison of the F-DOPA results of the Israeli cohort with those of 17 non-pesticide-exposed patients with PD from Austria yielded no significant differences, further validating our findings. Our observations suggest that although exposure to pesticides might be a risk factor for PD, it does not have an effect on the asymmetry pattern in the nigrostriatal system over non-exposure. We assume that once the disease process is initiated in pesticide-exposed patients, the pathogenic mechanism does not differ from that of idiopathic PD.
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http://dx.doi.org/10.1007/s00702-018-1951-8DOI Listing
February 2019

Can early dopamine transporter imaging serve as a predictor of Parkinson's disease progression and late motor complications?

J Neurol Sci 2018 07 7;390:255-260. Epub 2018 May 7.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Nuclear Imaging Department, Edith Wolfson Medical Center, Holon 5822012, Israel. Electronic address:

Background: The role of nuclear imaging in predicting Parkinson's disease (PD) progression is unclear. This study investigated whether the degree of reduced striatal dopamine transporter binding at diagnosis of PD predicts later motor complications and time to disease progression.

Methods: We retrospectively studied 41 patients with early PD who underwent I-FP-CIT SPECT and were followed thereafter with a mean disease duration of 9.51 ± 3.18 years. The association of quantitatively analyzed I-FP-CIT binding in striatal subregions with the development of motor fluctuations, dyskinesias, freezing of gait (FOG) and falls as well as the time to Hoehn and Yahr (H&Y) stage 3 was evaluated.

Results: Logistic regression models controlling for age at diagnosis, sex, disease duration, and L-dopa dose revealed that I-FP-CIT binding in the putamen and striatum significantly predicted FOG (OR = 0.02, p = 0.03; OR = 0.01, p = 0.04; respectively) but not falls. Cox proportional hazard analysis did not reveal significant relationship between I-FP-CIT binding and motor fluctuations, dyskinesias, or H&Y stage 3.

Conclusions: Our results suggest that a more severe depletion of presynaptic dopamine in early PD is a bad prognostic sign in terms of FOG development. These findings, if replicated, may point to dopaminergic transmission as part of the mechanism underlying FOG in PD.
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http://dx.doi.org/10.1016/j.jns.2018.05.006DOI Listing
July 2018

Self-limited Rheumatoid Meningitis as a Presenting Symptom of Rheumatoid Arthritis.

Isr Med Assoc J 2018 Apr;20(4):262-264

Department of Allergy, Immunology and Rheumatology Clinic, Wolfson Medical Center, Holon, Israel.

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April 2018

Perspective: Identification of genetic variants associated with dopaminergic compensatory mechanisms in early Parkinson's disease.

Front Neurosci 2013 15;7:52. Epub 2013 Apr 15.

Biological Psychiatry Laboratory, Department of Psychiatry, Hadassah - Hebrew University Medical Center Jerusalem, Israel.

Parkinson's disease (PD) is slowly progressive, and heterogeneity of its severity among individuals may be due to endogenous mechanisms that counterbalance the striatal dopamine loss. In this perspective paper, we introduce a neuroimaging-genetic approach to identify genetic variants, which may contribute to this compensation. First, we briefly review current known potential compensatory mechanisms for premotor and early disease PD, located in the striatum and other brain regions. Then, we claim that a mismatch between mild symptomatic disease, manifested by low motor score on the Unified PD Rating Scale (UPDRS), and extensive Nigro-Striatal (NS) degeneration, manifested by reduced uptake of [(123)I]FP-CIT, is indicative of compensatory processes. If genetic variants are associated with the severity of motor symptoms, while the level of striatal terminals degeneration measured by ligand uptake is taken into account and controlled in the analysis, then these variants may be involved in functional compensatory mechanisms for striatal dopamine deficit. To demonstrate feasibility of this approach, we performed a small "proof of concept" study (candidate gene design) in a sample of 28 Jewish PD patients, and preliminary results are presented.
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http://dx.doi.org/10.3389/fnins.2013.00052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3625833PMC
April 2013

Association of the ZFPM2 gene with antipsychotic-induced parkinsonism in schizophrenia patients.

Psychopharmacology (Berl) 2012 Apr 24;220(3):519-28. Epub 2011 Sep 24.

Biological Psychiatry Laboratory, Department of Psychiatry, Hadassah-Hebrew University Medical Center, Ein Karem, Jerusalem, 91120, Israel.

Rationale: Antipsychotic-induced parkinsonism (AIP) is a severe adverse affect of antipsychotic drug treatment. Recently, our group performed a genome-wide association study (GWAS) for AIP severity, and identified several potential AIP risk variants.

Objectives: The aim of this study was to validate our original AIP-GWAS susceptibility variants and to understand their possible function.

Methods: We conducted a validation study of 15 single-nucleotide polymorphisms (SNPs) in an independent sample of 178 US schizophrenia patients treated for at least a month with typical or atypical antipsychotics. Then, a sample of 49 Jewish Israeli Parkinson's disease (PD) patients with available neuroimaging ([(123)I]-FP-CIT-SPECT) data was analyzed, to study association of confirmed AIP SNPs with level of dopaminergic deficits in the putamen.

Results: Using logistic regression and controlling for possible confounders, we found nominal association of the intronic SNP, rs12678719, in the Zinc Finger Protein Multitype 2 (ZFPM2) gene with AIP (62 affected/116 unaffected), in the whole sample (p = 0.009; P = 5.97 × 10(-5) in the GWAS), and in the African American sub-sample (N = 111; p = 0.002). The same rs12678719-G AIP susceptibility allele was associated with lower levels of dopaminergic neuron related ligand binding in the contralateral putamen of PD patients (p = 0.026).

Conclusions: Our preliminary findings support association of the ZFPM2 SNP, rs12678719, with AIP. At the functional level, this variant is associated with deficits in the nigrostriatal pathway in PD patients that may be related to latent subclinical deficits among AIP-prone individuals with schizophrenia. Further validation studies in additional populations are required.
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http://dx.doi.org/10.1007/s00213-011-2499-6DOI Listing
April 2012

Malignant pheochromocytoma of the urinary bladder: challenges in diagnosis and management.

Isr Med Assoc J 2011 May;13(5):311-3

Department of Medicine D, Wolfson Medical Center, Holon, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

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May 2011

Residual striatal dopaminergic nerve terminals in very long-standing Parkinson's disease: a single photon emission computed tomography imaging study.

Mov Disord 2011 Feb 11;26(2):327-30. Epub 2010 Oct 11.

Department of Neurology, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel.

Molecular imaging studies of Parkinson's disease (PD) progression mostly focus on the first 5 years after disease onset, demonstrating rapid initial nigrostriatal neuronal loss. The fate of residual functional dopaminergic nerve terminals in patients with long-standing PD has not yet been specifically explored. Therefore, we performed [(123)I]-FP-CIT single photon emission computed tomography (SPECT) in 15 patients with very long-standing PD (mean disease duration 20.6 ± 6.3 years). Measurable uptake of [(123)I]-FP-CIT was still detected in the striata of all patients. As seen in early stages, reduction of tracer uptake in the putamen was more prominent than in the caudate nucleus. Asymmetry in tracer uptake between the two putamen and caudate nuclei was preserved. These findings indicate that degeneration of dopaminergic neurons in PD is not total even after many years of illness. Data should be considered in exploring underlying causes of progressive loss of nigrostriatal dopaminergic neurons and development of future novel dopaminergic therapeutic strategies in PD.
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http://dx.doi.org/10.1002/mds.23380DOI Listing
February 2011

Early outcome of acute ischemic stroke in hyperlipidemic patients under atorvastatin versus simvastatin.

Clin Neuropharmacol 2010 May;33(3):129-34

Department of Neurology, Wolfson Medical Center, Holon; and Sackler Faculty of Medicine, Tel Aviv University, Israel.

Background: Studies designed to evaluate the efficacy of atorvastatin on stroke suggest that, in addition to cholesterol lowering, this drug may play a role in poststroke neuroprotection. The objective of this historical-prospective study was to analyze the efficacy of atorvastatin (40-80 mg) or simvastatin (at an optimal dose) during the first 2 weeks after stroke in hyperlipidemic patients treated with simvastatin before stroke onset.

Methods: Medical records of all adult (aged >18 years) patients diagnosed with acute stroke were reviewed. Subjects were categorized on the basis of poststroke treatment exposure: atorvastatin (40 or 80 mg) or simvastatin (at an optimal dose). Each patient was examined using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). Blood lipid profile was determined. All tests were performed at baseline and at 4 weeks after stroke.

Results: A total of 371 patients (249 male and 122 female) were included. Subjects who received simvastatin were significantly older than those who received either dose of atorvastatin. Baseline differences in functional scores were not detected across treatment groups. Two weeks after stroke, subjects exposed to simvastatin had significantly poorer NIHSS and mRS scores than did subjects exposed to either atorvastatin dose. Atorvastatin 80 mg was associated with significantly better outcome compared with either of the other treatment groups. These differences persisted even after controlling for age and baseline scores.

Conclusions: Early outcome measured by NIHSS and mRS was better in acute stroke patients treated with atorvastatin than in those treated with simvastatin. These differences may reflect a neuroprotective effect unique to atorvastatin.
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http://dx.doi.org/10.1097/WNF.0b013e3181d47863DOI Listing
May 2010

Use of a single [123I]-FP-CIT SPECT to predict the severity of clinical symptoms of Parkinson disease.

Neurol Sci 2009 Aug 5;30(4):301-5. Epub 2009 Jun 5.

Department of Neurology, Rabin Medical Center, Beilinson Campus, 49100, Petah Tiqwa, Israel.

The aim of this study was to assess the ability of a single SPECT performed in the early stage of Parkinson's disease (PD) to predict disease severity in 19 patients with early PD. [(123)I]-FP-CIT striatal uptake was expressed as a ratio of specific:nonspecific uptake for defined brain areas. Clinical severity was determined by the UPDRS at baseline and 12-15 months following the SPECT procedure. [(123)I]-FP-CIT uptake in the contralateral putamen and striatum was correlated with UPDRS score at baseline, with a more significant correlation after 1-year interval. [(123)I]-FP-CIT uptake in all areas was correlated with bradykinesia and rigidity subscores only at follow up visit. Significant correlations were found between [(123)I]-FP-CIT uptake in the contralateral striatum, putamen and caudate and the difference between motor scores of 1-year interval (DeltaUPDRS). These results suggest that disease severity might be anticipated by a single SPECT at an early stage of the disease.
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http://dx.doi.org/10.1007/s10072-009-0100-4DOI Listing
August 2009

The use of 99mTc-recombinant human annexin V imaging for differential diagnosis of aseptic loosening and low-grade infection in hip and knee prostheses.

J Nucl Med 2009 Apr 16;50(4):534-7. Epub 2009 Mar 16.

Department of Nuclear Medicine of the Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Unlabelled: The aim of this study was to assess the pattern of annexin V uptake in hip and knee prostheses suspected of being infected.

Methods: A total of 7 patients undergoing revision surgery for hip or knee prostheses were studied; 5 patients had total hip replacements, and 2 had total knee replacements. Infection was confirmed by pathology, culture results, laboratory evaluation, and clinical follow-up. All patients also underwent a bone scan before surgery.

Results: Annexin V scan findings were positive in 5 patients and negative in 2. Annexin V uptake was either focal (n = 4) or linear (n = 1). There were 4 true-positive, 2 true-negative, 1 false-positive, and no false-negative annexin V studies. Annexin V uptake was either more extensive or less extensive than, and usually was incongruent with, (99m)Tc-methylene diphosphonate uptake.

Conclusion: Our findings suggest that annexin V imaging shows greater uptake with infection than with aseptic loosening and has a high negative predictive value for prosthetic infection.
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http://dx.doi.org/10.2967/jnumed.108.059345DOI Listing
April 2009

I-123 MIBG cardiac scintigraphy and autonomic test evaluation in multiple sclerosis patients.

J Neurol 2008 Feb 20;255(2):211-6. Epub 2008 Feb 20.

Department. of Nuclear Medicine, E. Wolfson Medical Center, Holon, Israel.

Autonomic symptoms are common in multiple sclerosis (MS) patients and may cause significant disability. The purpose of this study was to evaluate direct cardiac sympathetic denervation in MS patients with I-123 MIBG cardiac scintigraphy compared with other parasympathetic electrophysiological examinations of autonomic dysfunction. Ten patients with MS and 7 age- and sex-matched control subjects were prospectively evaluated. The neurological deficit and disability stages of the patients were rated according to the Kurtzke Expanded Disability Status Scale (EDSS). Autonomic tests included the R-R interval, Valsalva ratio and standup test. All patients and control subjects had planar and SPECT cardiac scintigraphy with I-123 MIBG injection. Seven MS patients had relapsing-remitting (R-R) type and three had secondary progressive type (SP). A pathological MIBG cardiac washout rate was found in 3/10 MS patients, all of them with SP-MS. The other seven had normal washout rates. No correlation was found between the scan and the individual parasympathetic autonomic test results. I-123 MIBG myocardial scintigraphy may detect direct disturbances of the sympathetic cardiac function in patients with MS in addition to parasympathetic dysfunction tests and can be an important additional means of assessing autonomic pathways. Determination in MS of the co-existence of autonomic dysfunction, especially the cardiac sympathetic involvement in the SP type, may aid in evaluation of disease severity and cardiac function follow-up.
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http://dx.doi.org/10.1007/s00415-008-0652-xDOI Listing
February 2008

123I-FP-CIT SPECT imaging of dopamine transporters in patients with recurrent sudden falls: are such falls a distinct entity?

J Nucl Med Technol 2007 Dec 15;35(4):232-6. Epub 2007 Nov 15.

Department of Neurology, Rabin Medical Center, 4 Kaplan Street, Petah Tiqwa 41900, Israel.

Unlabelled: Recurrent falls in older people are commonly associated with abnormalities that involve several parts of the central nervous system, especially with basal ganglion pathology. The aim of the present study was to evaluate the integrity of striatal dopamine transporters (DaTs) by use of (123)I-N-3-fluoropropyl-2beta-carbomethoxy-3beta-(4-iodophenyl)tropane ((123)I-FP-CIT) SPECT of striatal DaTs in patients with recurrent sudden falls.

Methods: Twenty-one patients without a definite neurologic diagnosis for recurrent sudden falls were enrolled in a cross-sectional study. SPECT with a DaT ligand was performed 180 min after injection of 185 MBq of (123)I-FP-CIT with a dual-head gamma-camera.

Results: DaT SPECT findings were normal in 15 of 21 patients (71%). Of those, 73% had abnormal MRI findings suggestive of atherosclerotic lesions. Eleven patients with normal DaT SPECT findings had mild parkinsonian symptoms. There was no correlation of the SPECT results with patient age, duration of occurrence of falls, or frequency of falls, and there was no significant difference in the relative distributions of SPECT findings between patients with and patients without parkinsonian symptoms or vascular risk factors.

Conclusion: Recurrent sudden falls are, in most cases, not attributable to the degeneration of the nigrostriatal system.
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http://dx.doi.org/10.2967/jnmt.107.040238DOI Listing
December 2007

Drug-induced thyrotoxicosis: the surgical option.

Isr Med Assoc J 2007 Feb;9(2):79-82

Department of Nuclear Medicine, Wolfson Medical Center, Holon, Israel.

Background: Drug-induced thyrotoxicosis is not uncommon. It may worsen life-threatening arrhythmias and may be refractory to medical treatment. Near-total thyroidectomy presents a valid alternative to medical therapy and should be considered early in the management of the disease.

Objectives: To assess whether near-total thyroidectomy was a viable approach for our patients.

Methods: Twelve patients--7 men and 5 women, aged 63 to 82 years--presented with drug-induced fulminant thyrotoxicosis following 1 to 12 months of amiodarone treatment (11 patients, mean 7 months) and after a 6 months course of interferon-alpha treatment (one patient). Medical therapy included propylthiouracil in doses up to 1200 mg/day in all patients and a beta-receptor antagonist in seven. Five patients had to stop amiodarone treatment and start high doses of steroids. A thyroid scan was performed in all patients using 5 mCi of Tc-99m pertechnetate. The thyroid scan showed absent uptake of the tracer in the thyroid bed in all patients, precluding the use of radioablation.

Results: Four patients (three with AIT and one with interferon therapy) who did not respond to 3 months of medical therapy required surgical thyroidectomy due to severe unremitting thyrotoxicosis. A near-total thyroidectomy resulted in rapid correction of thyrotoxicosis, enabling continuation of the anti-arrhythmic drug. There were no intraoperative or postoperative arrhythmias. Subsequently, all patients recovered rapidly and remained well and euthyroid on thyroxine replacement therapy.

Conclusions: Since surgery results in rapid control of thyrotoxicosis and permits continued therapy with amiodarone, we suggest that near-total thyroidectomy warrants consideration as a definitive treatment for resistant amiodarone or interferon-induced thyrotoxicosis.
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February 2007

Prospective evaluation of malignant middle cerebral artery infarction with blood-brain barrier imaging using Tc-99m DTPA SPECT.

Brain Res 2006 Oct 14;1113(1):194-9. Epub 2006 Aug 14.

Department of Neurology of the Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Malignant middle cerebral artery (MMCA) infarction is associated with severe brain edema which may lead to a rapid deterioration of consciousness, increase of intracranial pressure, brain midline shift and finally, herniation. We examined the correlation between the degree of the blood-brain barrier (BBB) permeability and MMCA.

Methods: Twenty-five consecutive patients (17 men and 8 women, mean age 62.1+/-10.1) were included in the study. Each patient had a daily clinical examination, and the neurological deficits were scored using NIHSS score. A CT without contrast material was performed in all patients. (99m)Tc-DTPA SPECT was performed at 36 h after the stroke. A quantitative index of BBB breakdown (disruption index) was calculated.

Results: The mean volume of stroke was 138+/-87 cm(3). The mean DTPA disruption index was 6.6+/-4.6 (range 1.0-21.0). The mean NIHSS score was 14+/-4 (p=0.2). Five of 25 patients had brain herniation as evidenced on brain CT. The volume of stroke was only marginally elevated in patients with herniation (p=0.062). All patients showed significant, inverse correlation between NIHSS score and DTPA uptake (r=-0.43, p=0.033). There was a significant correlation between the extent of DTPA distribution (more than one vascular territory) and the occurrence of herniation (p<0.001).

Conclusions: DTPA-SPECT imaging is a reliable complementary predictive tool in patients with an MCA stroke. The specific pattern found on DTPA SPECT, compatible with diffuse BBB disruption, may be of value in predicting "malignant MCA."
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http://dx.doi.org/10.1016/j.brainres.2006.07.030DOI Listing
October 2006

In vivo imaging of apoptosis in patients with acute stroke: correlation with blood-brain barrier permeability.

Brain Res 2006 Aug 30;1103(1):13-9. Epub 2006 Jun 30.

Department of Nuclear Medicine of the Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: We wished to determine the ability of radiolabeled annexin V to concentrate at sites of ischemic injury in patients with acute cerebral stroke. Secondly, we sought to correlate annexin V imaging in these patients with the degree of blood-brain barrier (BBB) breakdown.

Methods: Twelve patients with acute stroke had a complete neurological examination, including the National Institutes of Health (NIH) stroke scale and the Glasgow Coma Score (GCS). A non-contrast CT scan was performed on all patients. A SPECT of the brain was obtained 2 h after injection of annexin V. The integrity of the BBB was evaluated in seven patients using Tc-99m-DTPA brain SPECT.

Results: All patients had an infarct in the MCA territory. Eight patients had abnormal increased annexin V activity, which was more common in patients with cortical strokes (P = 0.01). The concentration of annexin had no correlation to the volume of stroke, but it was significantly and inversely related to the GCS on admission (r = -0.7, P = 0.02). Foci of apoptosis were noted contralateral to the affected hemisphere as well. All seven patients who underwent DTPA SPECT showed breakdown of the BBB. DTPA uptake was significantly and positively associated with NIH score (r = 0.80, P = 0.01) and inversely associated with GCS (r = -0.89, P = -0.03).

Conclusion: This study shows that it is possible to identify in vivo regions of ischemic neuronal injury using radiolabeled annexin V in patients with acute stroke. Annexin imaging can play a major role in the selection of therapy in the initial period following stroke in adults.
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http://dx.doi.org/10.1016/j.brainres.2006.05.073DOI Listing
August 2006

Fat intolerance in developmentally impaired children with severe feeding intolerance.

J Child Neurol 2006 Feb;21(2):167-70

Pediatric Gastroenterology Unit, E. Wolfson Medical Center, Holon, Israel.

Children with a variety of genetic, metabolic, and neurologic disorders can suffer from severe feeding intolerance that is unresponsive to medical, surgical, and nutritional therapy. Developmentally disabled tube-fed children with severe upper gastrointestinal symptoms that persisted after fundoplication who were unresponsive to all medical, surgical, and nutritional interventions underwent a thorough gastrointestinal evaluation, including gastroscopy, pH-metry, upper gastrointestinal barium series, and gastric emptying studies. They were placed on a low-fat diet, and the symptoms before and after the diet were compared. The patients were then rechallenged with incremental increases in fat until the symptoms recurred or the patients reached their former fat concentration. Six children meeting the study criteria were evaluated. Four of these patients had a significant improvement in symptoms, oral intake and feeding tolerance with a decrease in fat intake, and relapse of symptoms when fat calories were increased. Improvement occurred in children who had been intolerant to duodenal feeding. We were subsequently able to wean two children from tube feeding. Dietary fat can provoke upper gastrointestinal symptoms in children with gastric and intestinal dysmotility. Short-term manipulation of dietary fat intake can improve tolerance to feeding.
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http://dx.doi.org/10.1177/08830738060210020301DOI Listing
February 2006

Auditory hallucinations in acute stroke.

Behav Neurol 2005 ;16(4):211-6

Department of Neurology, Edith Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Israel.

Auditory hallucinations are uncommon phenomena which can be directly caused by acute stroke, mostly described after lesions of the brain stem, very rarely reported after cortical strokes. The purpose of this study is to determine the frequency of this phenomenon. In a cross sectional study, 641 stroke patients were followed in the period between 1996-2000. Each patient underwent comprehensive investigation and follow-up. Four patients were found to have post cortical stroke auditory hallucinations. All of them occurred after an ischemic lesion of the right temporal lobe. After no more than four months, all patients were symptom-free and without therapy. The fact the auditory hallucinations may be of cortical origin must be taken into consideration in the treatment of stroke patients. The phenomenon may be completely reversible after a couple of months.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478837PMC
http://dx.doi.org/10.1155/2005/641953DOI Listing
May 2006

[123I]-FP/CIT SPECT imaging for distinguishing drug-induced parkinsonism from Parkinson's disease.

Mov Disord 2006 Apr;21(4):510-4

Department of Nuclear Medicine Edith Wolfson Medical Center, Holon, Israel.

Parkinsonism in patients taking neuroleptic medications might be induced by dopamine receptor blockade alone or by dopamine blockade with nigrostriatal dysfunction. The differentiation between Parkinson's disease (PD) and drug-induced parkinsonism (DIP) is difficult to assess on clinical grounds alone. In this study, we have evaluated the clinical characteristics and striatal binding of (123)I-FP-CIT (N-omega-fluoropropyl-2beta-carboxymethoxy-3beta-{4-iodophenyl}tropane) in patients who developed DIP. A total of 20 patients (mean age, 62 +/- 13 years) who developed parkinsonism while on neuroleptic agents and 10 age-matched controls were enrolled. [123]-FP-CIT single-photon emission computed tomography (SPECT) was performed in all subjects. Neurological assessment was performed with the Motor part of the Unified Parkinson's Disease Rating Scale. [123]-FP-CIT binding of the entire striatum, caudate, and putamen was calculated. Patients were divided into two subgroups according to SPECT results for comparison of clinical characteristics. There were 9 patients who had normal scans and 11 who showed significantly diminished striatal binding, suggesting degeneration of the nigrostriatal system. Subanalyses of abnormal scans revealed significantly diminished binding in the caudate (P < 0.001 for right and left caudate) and putamen (P = 0.002 and P < 0.05 for right and left putamen, respectively). There were no differences in clinical features between patients with normal and abnormal scans. Symptoms included asymmetric tremor, bradykinesia, and rigidity in both groups. Freezing gait was present in two patients with normal scans. These results indicate that DIP is clinically indistinguishable from PD. Brain imaging with FP-CIT helps to determine whether DIP is entirely drug-induced or an exacerbation of subclinical PD.
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http://dx.doi.org/10.1002/mds.20748DOI Listing
April 2006

Prognostic significance of blood brain barrier permeability in acute hemorrhagic stroke.

Cerebrovasc Dis 2005 17;20(6):433-7. Epub 2005 Oct 17.

Department of Neurology, Edith Wolfson Medical Center, Holon, Israel.

Background: Blood brain barrier (BBB) disruption is accompanied by edema in the surrounding areas of the intracerebral hemorrhage (ICH). The aim of the study was to clarify the correlation between BBB breakdown and outcome in ICH.

Patients: Twenty-seven patients with primary ICH were included in the study. Each patient underwent CT and DTPA-SPECT, and the National Institutes of Health (NIH) and modified Rankin score were performed as well.

Results: DTPA-SPECT had a significant correlation with the modified Rankin score after 3 months (p = 0.008) and 6 months (p = 0.01). The CT scan was directly correlated with the NIH score on days 1, 7 and 30 (p = 0.01, p = 0.01 and p = 0.04, respectively). No correlation was found between DTPA-SPECT and CT scan data.

Conclusions: The degree of BBB breakdown, as imaged by the DTPA-SPECT technique, was directly correlated with the late functional outcome. The CT scan has an inverse correlation with the NIH score. These findings may have broad clinical implications.
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http://dx.doi.org/10.1159/000088981DOI Listing
January 2006

The hot skull sign on bone scans of obese patients resulting from disparate soft tissue attenuation.

Clin Nucl Med 2005 Oct;30(10):680-1

Department of Nuclear Medicine, Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

We have frequently observed diffusely increased skull activity on bone scans of obese patients, who do not have evidence of metabolic or metastatic bone disease. Skull activity of 25 obese patients were compared to that of age and sex-matched nonobese 25 patients visually and quantitatively. The results clearly indicated that diffusely increased skull activity is significantly more common on bone scans of obese patients because of disparate attenuation of overlying soft tissues. This knowledge will help obviate the need for additional radiologic and/or laboratory tests in search of other conditions associated with hot skull, ie, Paget's disease and metabolic bone disorders such as renal osteodystrophy and primary hyperparathyroidism.
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http://dx.doi.org/10.1097/01.rlu.0000178233.91440.b6DOI Listing
October 2005

Preoperative technetium Tc 99m sestamibi SPECT imaging in the management of primary hyperparathyroidism in patients with concomitant multinodular goiter.

Arch Surg 2005 Jul;140(7):656-60

Department of Nuclear Medicine, The Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Hypothesis: Preoperative parathyroid and thyroid imaging using technetium Tc 99m sestamibi scintigraphy-single-photon emission computed tomography (Tc 99m MIBI SPECT) and technetium Tc 99m sodium pertechnetate, respectively, in patients with parathyroid adenomas and concomitant multinodular goiters enables the selection of those suitable for minimally invasive radio-guided surgery.

Design: One hundred thirty patients with primary hyperparathyroidism were treated surgically during a 30-month period. Forty-one of these 130 patients had an associated multinodular goiter. All patients underwent planar and SPECT parathyroid scintigraphy using Tc 99m MIBI, and thyroid scintigraphy with technetium Tc 99m pertechnetate 2 to 5 days before surgery. On the morning of surgery each patient was reinjected with Tc 99m MIBI for intraoperative localization and validation. Minimally invasive radio-guided parathyroidectomy was performed using a handheld gamma-detection device with a thyroid probe. Removed glands were submitted for histopathologic examination for comparison with the scintigraphic results. Quantitative analysis of parathyroid activity was performed.

Results: Minimally invasive, radioguided parathyroidectomy was successfully performed in 21 (51%) of 41 patients who had a concomitant multinodular goiter. The remaining 20 patients underwent standard neck exploratory surgery because of associated thyroid disease; 5 of them had malignant thyroid disease. Among the 41 patients planar scintigraphy correctly identified 28 adenomas (68%). Single-photon emission computed tomographic imaging identified an additional 11 adenomas for a sensitivity of 95% and a specificity of 100%. Moreover, SPECT imaging correctly identified malignant thyroid nodules in 4 of 5 patients. Technetium Tc 99m MIBI retention was noted in only 25 adenomas (61%) while the remaining adenomas demonstrated a rapid washout. The average uptake ratio of parathyroid counts to maximum thyroid activity was significantly correlated with parathyroid hormone levels before surgery (P = .04).

Conclusions: Our data encourage the use of preoperative SPECT imaging of parathyroid adenomas in patients who have multinodular goiters to select those suitable for minimally invasive radioguided surgery. This technique also offers important information regarding thyroid nodules that are suspicious for malignancy. The intraoperative gamma-probe technique enables the surgeon to focus his or her search, provides instant feedback regarding the progress of the operation, reduces surgical trauma and complications, and yields better cosmetic results. Patients with higher presurgical parathyroid hormone levels may especially benefit from radioguided surgery.
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http://dx.doi.org/10.1001/archsurg.140.7.656DOI Listing
July 2005

Neonates with extra-renal pelvis: the first 2 years.

Pediatr Nephrol 2005 Jun 19;20(6):763-7. Epub 2005 Apr 19.

Institute of Nephrology, E. Wolfson Medical Center, Holon, Israel.

Extra-renal pelvis (ERpel) is a common ultrasonographic finding among neonates who have undergone recurrent ultrasound examinations for a better definition of prenatal renal pelvic dilatation. This study tries to determine whether or not ERpel has important prognostic implications. Seventy-nine neonates (17 female) were examined. All had a diagnosis of prenatal renal pelvis dilatation, which was shown by postnatal ultrasound to be ERpel. Sixty ERpel neonates were examined 1.5 months to 2.5 months after the ultrasound (US) diagnosis by both Tc-99m diethylene triamine penta-acetic acid (DPTA) dynamic renal scanning and (99m)Tc-pertechnetate direct cystography. Clinical assessment, urine cultures and renal ultrasound follow-up were maintained for 2 years. The proportion of urinary tract infections (UTIs) in patients with ERpel was compared with that of the total neonatal and infantile population with normal US scans in the region of our hospital. Associated minor congenital malformations were found in 12 of 79 neonates (15.2%). Four had a family history of ERpel. Among 60 neonates who underwent renal scanning, 36 (60%) were found to have urinary retention in the collecting system. Another nine (15%) had vesico-ureteral (VU) reflux, of which seven had urinary retention. Fifteen (25%) showed normal isotope imaging. Urinary tract infection was diagnosed in 16 ERpel neonates in whom only one exhibited VU reflux (grade 2). The incidence of neonatal UTI in the ERpel group was more than that of either neonatal or infantile UTI in those with normal US scans in the local population (20.2% vs 1.2% and 4.3%, respectively). Fifty-three infants completed a 2-year follow-up. Repeat renal ultrasonography indicated that one infant (1.8%) had developed bilateral hydronephrosis, 12 (22.6%) had unchanged findings, 18 (40%) showed an improvement (decrease of ERpel width or resolution in one side) and, in 22 (41.5%) infants, the condition had resolved. No clinical or kidney function deterioration was observed. Seven patients (13.2%) each had one episode of UTI during the 2-year follow-up period; none of them had VU reflux. Neonatal ERpel is more frequent in male infants. It is associated with greater rates of minor congenital malformations, VU reflux and UTI than in the general population of the same ages. The increased UTI incidence is not attributed to VU reflux.
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http://dx.doi.org/10.1007/s00467-005-1851-7DOI Listing
June 2005

Analysis of red cell mass and plasma volume in patients with polycythemia.

Arch Pathol Lab Med 2005 Jan;129(1):89-91

Division of Nuclear Medicine of the Department of Radiology, The Mount Sinai Medical Center, The Mount Sinai School of Medicine, New York, NY, USA.

Context: Polycythemia describes an increased proportion of red blood cells in the peripheral blood. In absolute polycythemia, there is increased red cell mass (RCM) with normal plasma volume, in contrast with apparent polycythemia, in which there is increased or normal RCM and decreased plasma volume. In order to deliver the appropriate treatment it is necessary to differentiate between the two.

Objective: A retrospective analysis of RCM and plasma volume data are presented, with special attention to different methods of RCM interpretation.

Design: The measurements of RCM and plasma volume in 64 patients were compared with the venous and whole-body packed cell volume, and the incidence of absolute and apparent polycythemia was determined for increasing hematocrit levels. Measurements of RCM and plasma volume were performed using chromium 51-labeled red cells and iodine 125-labeled albumin, respectively. The measured RCM of each patient was expressed as a percentage of the mean expected RCM and was also defined as being within or outside the range of 2 SD of the mean. The results were also expressed in the traditional manner of mL/kg body weight.

Results: Twenty-one patients (13 women and 8 men) had absolute polycythemia. None of them had an increased plasma volume beyond 2 SD of the mean. When expressed according to the criteria of mL/kg body weight, 17 of the 21 patients had abnormally increased RCM, but 4 patients (19%) had a normal RCM value. Twenty-eight patients had apparent polycythemia. The remaining 15 patients had normal RCM and plasma volume.

Conclusions: The measurement of RCM and plasma volume is a simple and necessary procedure in the evaluation of polycythemia. In obese patients, the expression of RCM in mL/kg body weight lacks precision, considering that adipose tissue is hypovascular. The results of RCM are best described as being within or beyond 2 SD of the mean value.
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http://dx.doi.org/10.5858/2005-129-89-AORCMADOI Listing
January 2005

Efficacy of acetylcholinesterase inhibitors in frontotemporal dementia.

Ann Pharmacother 2004 Nov 12;38(11):1967-8. Epub 2004 Oct 12.

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http://dx.doi.org/10.1345/aph.1D445DOI Listing
November 2004

123I-FP-CIT SPECT imaging of dopamine transporters in patients with cerebrovascular disease and clinical diagnosis of vascular parkinsonism.

J Nucl Med 2004 Oct;45(10):1688-93

Department of Nuclear Medicine, Edith Wolfson Medical Center, Holon, Israel.

Unlabelled: The purpose of our study was to prospectively evaluate the striatal uptake of 123I-labeled N-(3-fluoropropyl)-2beta-carbomethoxy-3beta-(4-iodophenyl)nortropane (FP-CIT) and the response to l-dopa therapy in patients with cerebrovascular disease (CVD) who develop clinical symptoms of vascular parkinsonism (VP).

Methods: Twenty consecutive patients who developed VP in the course of CVD were prospectively enrolled in the study. All patients had CT evidence of CVD (17 patients had lacunar infarcts, 3 patients had territorial strokes). The clinical stage of the patients was assessed using the Hoehn and Yahr scale, and the severity of the symptoms was measured using the Unified Parkinson's Disease Rating Scale score. Ten age-matched subjects were used as controls. SPECT was performed 180 min after injection of 185 MBq 123I-FP-CIT using a dual-head gamma-camera. The ratio of the mean specific-to-nonspecific striatal binding for the entire striatum, caudate, and putamen was calculated in all patients and compared with that of controls. Putamen-to-caudate binding ratios were compared as well. The response to therapy was compared between patients with normal and abnormal 123I-FP-CIT binding.

Results: No correlation was found between any of the clinical variables and response to therapy in patients with VP. Nine patients had normal striatal 123I-FP-CIT binding with no significant differences in striatal or subregional binding ratios compared with those of the controls. In contrast, 11 patients had significantly diminished striatal binding compared with that of controls (P < 0.001). Subanalyses showed significantly decreased binding in the caudate (P < 0.04 and P < 0.01 for the right and left caudate, respectively), diminished binding in the putamen (P < 0.04 and P < 0.01 for the right and left putamen, respectively), and a decreased putamen-to-caudate ratio on the right side (P < 0.001). The latter ratio was not significant on the left. Two of the 3 patients with territorial strokes had significantly diminished striatal 123I-FP-CIT binding in the hemisphere contralateral to the CT lesion. All 9 patients with normal scan findings had a poor response to L-dopa. Six of 11 patients with abnormal studies had no response to L-dopa, whereas 5 patients had a good response (P < 0.03).

Conclusion: The diagnosis of VP cannot be accurately confirmed on the basis of clinical features alone because CVD may alter the typical presentation of PD. Functional imaging with 123I-FP-CIT is highly recommended in patients with CVD who develop symptoms of VP to confirm or exclude the existence of nigrostriatal dopaminergic degeneration. Identifying a subset of patients with reduced 123I-FP-CIT binding in the striatum is important for better treatment selection.
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October 2004

Dynamic radioisotope scintigraphy for gastric banding adjustment.

Obes Surg 2004 Apr;14(4):520-3

Department of Surgery B, Kaplan Hospital, Rehovot, Israel.

Background: Gastric banding is today a common restrictive procedure to treat morbid obesity. After operation, adjustment of the band is required to adequately restrict food intake, allowing better results. The aim of this study was to evaluate the results of a unique method of adjustment using dynamic radioisotope scintigraphy.

Methods: 40 patients after Laparoscopic Adjustable Gastric Banding (LAGB) were prospectively divided into 2 equal groups, and the results of adjustment analyzed using the conventional method of fluoroscopic image and barium swallow (FA Group), and our proposed new method of dynamic radioisotope scintigraphy (DRS Group) using Tc99-phytate labeled plain yogurt.

Results: After 6 months follow-up, the FA group lost 12.34%, while the DRS group lost 20.34% of their initial weight. In the FA group, we found that 95% of the patients needed re-adjustments versus only 25% in the DRS group (P <0.0001). Vomiting was more frequent in the FA group than in the DRS group, mean 0.65 and 0.2, respectively (P < 0.009). The radiation exposure was 4 times higher in the FA group, but the cost of the 2 adjustment procedures was similar.

Conclusion: DRS is a more physiologically friendly and accurate method of gastric banding adjustment than the conventional barium swallow adjustment; it also results in a better weight loss during the first 6 months after operation.
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http://dx.doi.org/10.1381/096089204323013532DOI Listing
April 2004

Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy.

Arch Surg 2004 Apr;139(4):433-7

Departments of Surgery A and Nuclear Medicine, Edith Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Hypothesis: Early, postinjection technetium Tc 99m sestamibi scintigraphy-single-photon emission computed tomography (MIBI-SPECT) can be used as the only localizing study for focused parathyroidectomy in patients with primary hyperparathyroidism.

Design: During a 26-month period, 82 consecutive patients with primary hyperparathyroidism underwent a standard planar scan using a double-tracer subtraction technique for localization. On the morning of surgery, each patient received radiolabeled technetium Tc 99m sestamibi for intraoperative detection and validation. We performed an early, postinjection SPECT study for comparison with the planar study.

Results: The SPECT study revealed a sensitivity of 96% vs 78% for the planar study. The SPECT study was helpful in locating adenomas in 10 patients with multinodular goiter disease, of whom 3 patients had ectopic adenomas and 2 patients had 2 adenomas each. A significant correlation was noted between uptake ratio and preoperative parathyroid hormone levels (r = 0.41; P =.04). No recurrent or persistent hyperparathyroidism was reported during a follow-up period of at least 6 months.

Conclusions: Our results encourage the use of preoperative SPECT as the only localizing study on the morning of the operation, both to select patients for minimally invasive radioguided surgery and to provide accurate 3-dimensional information on deeply seated or ectopic adenomas. This approach lowers the costs of preoperative localization and intraoperative validation to a single study. The intraoperative gamma probe technique enables the surgeon to focus the search, provides instant feedback regarding the progress of the operation, reduces surgical trauma and complications, and yields better cosmetic results.
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http://dx.doi.org/10.1001/archsurg.139.4.433DOI Listing
April 2004

Technetium 99m ethylcysteinate dimer single-photon emission computed tomography (SPECT) during intellectual stress test in children and adolescents with pure versus comorbid attention-deficit hyperactivity disorder (ADHD).

J Child Neurol 2004 Feb;19(2):91-6

Department of Nuclear Medicine, Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Children and adolescents with the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnosis of attention-deficit hyperactivity disorder (ADHD) can have comorbid conditions such as conduct disorder, oppositional defiant disorder, and obsessive-compulsive disorder (comorbid type). The purpose of our study was to compare the pattern of regional cerebral perfusion in these two groups of children with ADHD during a computerized performance test. Nineteen children and adolescents were enrolled in the study. Seven boys and one girl with pure ADHD (group 1: mean age 12 years, range 9-16 years) and nine boys and two girls with comorbid ADHD (group 2: mean age 11 years, range 8-16 years) were studied by single-photon emission computed tomography (SPECT). The patients were not receiving any medication for at least 48 hours prior to the study. All patients were injected with 99mTc-ethylcysteinate dimer while doing a computerized performance test. Nine age-matched control children (five boys and four girls, mean age 12 years, range 9-17 years) with a normal brain SPECT served as controls. All patients in group 2 showed significantly decreased perfusion in the temporal lobes (P < .005). Five patients had decreased frontal lobe perfusion. Additionally, two patients in group 2 had decreased perfusion in the basal ganglia (not significant). Four of eight patients in group 1 had decreased frontal lobe perfusion (not significant). In addition, two patients had bilateral temporal lobe abnormalities, whereas two patients had a normal SPECT. Three patients in group 1 also had decreased basal ganglia perfusion. In contrast to previous studies of brain perfusion in ADHD that focused mainly on frontal and prefrontal cortical abnormalities, our study demonstrates that temporal lobe perfusion abnormalities are more common in patients with the comorbid type of ADHD. We postulate that these findings can have therapeutic implications and explain the decreased response to stimulants in this group of patients.
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http://dx.doi.org/10.1177/08830738040190020201DOI Listing
February 2004

Correlation of 99mTc-DTPA SPECT of the blood-brain barrier with neurologic outcome after acute stroke.

J Nucl Med 2003 Dec;44(12):1898-904

Department of Nuclear Medicine, Sackler Faculty of Medicine, Edith Wolfson Medical Center, Tel Aviv University, Tel Aviv, Israel.

Unlabelled: We conducted a study on humans to determine whether quantitative evaluation of blood-brain barrier (BBB) breakdown using the (99m)Tc-diethylenetriaminepentaacetic acid ((99m)Tc-DTPA) SPECT technique at the peak time of stroke evolution can predict neurologic outcome.

Methods: Thirty consecutive patients with acute stroke of the middle cerebral artery occurring >24 h and <48 h before admission were included in the study. Each patient underwent a complete neurologic examination according to the Scandinavian stroke score at 72 h after the stroke (S1) and again at 30 d (S2). The difference between initial and late scores was calculated (Delta S) and used to evaluate the change in neurologic status. A CT scan was obtained on all patients to determine the volume of stroke. The integrity of the BBB was evaluated using (99m)Tc-DTPA brain SPECT. A quantitative index of BBB disruption was defined as the ratio of the mean counts/pixel in the infarcted region compared with the mean counts/pixel in the contralateral nonaffected hemisphere. SPECT perfusion imaging was also performed with (99m)Tc-hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) at 24 h after the (99m)Tc-DTPA study. The relative perfusion in the infarct region was expressed as the percentage of contralateral perfusion.

Results: The mean (99m)Tc-DTPA disruption index was 6.8 +/- 6.9 (range, 1-26.2). Seven patients (23%) had no BBB disruption. Statistical analysis showed that the disruption index was negatively correlated with Delta S (r = -0.423, P < 0.02). A disruption index of <2.5 was associated with a significantly better neurologic outcome (mean Delta S, 17.5 +/- 9.5) compared with patients with an index of >2.5 (mean Delta S, -0.85 +/- 4.97, P < 0.0001) with a sensitivity of 95% and a specificity of 89%. S2 was significantly correlated with S1 (r = 0.738, P < 0.001) and with Delta S (r = 0.656, P < 0.001). Perfusion abnormalities on the (99m)Tc-HMPAO SPECT studies ranged between 12% and 90% (mean, 37.6% +/- 17.8%) compared with those on the contralateral nonaffected side. No correlation was found between (99m)Tc-HMPAO uptake and Delta S, infarct volume by CT, or disruption index. The CT volume measurements were negatively correlated with S2 (r = -0.560, P < 0.004) but not with Delta S.

Conclusion: (99m)Tc-DTPA SPECT of the BBB combined with quantitative analysis in patients with acute stroke is significantly related to clinical outcome, with a distinct prognostic cutoff threshold of 2.5. The use of this radionuclide brain SPECT technique represents a unique application of conventional nondiffusible brain agents.
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December 2003
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