CASES SERIES BRAIN FDG PET SCAN IN DEMENTIA PATIENTS Hajimemashite, Watashi wa ryan desu, Indonesia kara kimashita. My presentation is not about an analytical study. It is a case series that I experienced in my hospital using brain FDG PET scan in dementia patients. Ryan Yudistiro1,3,4, Ivana D Mulyanto1,3, Rocksy Fransisca VS2,3, Anyeliria Sutanto2,3, Feliana2,3, Yoshito Tsushima,4 1Nuclear Medicine Department, MRCCC Siloam Hospital Semanggi, Jakarta, Indonesia; 2Neurology Department-Memory Clinic, Siloam Hospital Lippo Village, Banten, Indonesia; 3School of Medicine, Universitas Pelita Harapan, Karawaci, Banten, Indonesia; 4Diagnostic Radiology and Nuclear Medicine Department, Gunma University Hospital, Maebashi, Japan

BACKGROUND Difficulty in determining cause of dementia No single reliable test Neuroimaging as diagnostic tool Brain FDG PET scan = biomarker imaging Reduction of glucose metabolic activity (hypometabolism) in specific brain regions As we know, clinicians often face difficulty finding the cause of dementia. There is no single reliable test in clinical use and we need to do pathologic confirmation for definitive diagnosis, which is almost impossible while the patients are alive. Nowadays, neuroimaging has significant roles as in diagnosing dementia. Besides functional MRI, brain FDG PET is considered an imaging biomarker in dementia. Reduction of glucose metabolic activity in specific brain regions can suggest a specific diagnosis. ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

OBJECTIVE MATERIAL AND METHOD To describe the specific glucose hypometabolism pattern of brain FDG PET scan MATERIAL AND METHOD Resting state Clinical diagnosis made by neurologist No structural abnormality Visual qualitative and automated analyses by NeuroQTM 3.0 software The goal of our presentation is to describe the use of brain FDG PET in our first dementia patients. The patients were already diagnosed clinically by neurologists. We used protocols comparable to other centers and used visual and automated analyses in interpreting brain FDG PET scans. ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

RESULTS Study period: July – November 2013 Range of age: 22 – 79 years old Range of MMSE: 0/30 – 29/30 Ten cases (5 females): Alzheimer Disease (AD) = 4 Frontotemporal dementia (FTD) = 2 Mild cognitive impairment (MCI) = 2 Primary Progressive Aphasia (PPA) = 1 Normal aging (NL) = 1 We scanned the patients since July to November in 2013 With range of age was between 22 and 79 years old And range of MMSE was between 0 to 29 There are ten patients including AD, FTD, MCI, PPA, and Normal Aging ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

NL (72, F) Mild memory impairment This is one example of Normal Aging images We can see in the visual image there are no reduce FDG uptake in brain regions and from NeuroQ images there are all in blue color, which is according to color scale blue is normal metabolism meanwhile red or pink is hypometabolism Mild memory impairment No psychological and behavioral change MMSE= 29/30 No hypometabolic region 10/20/2014

AD (77, F) Memory loss for last 2 years MMSE = 12/30 Hypometabolic region: Right posterior cingulate cortex Temporoparietal lobe regions This is example of Alzheimer Disease images from 77 years old female with MMSE was 12. From visual images we can see asymmetrical reduce FDG uptake in right side of posterior cingulate cortex and temporoparietal lobe regions 10/20/2014 ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN

Memory loss for last 2 years Psychological and behavioral changes FTD (58, F) Memory loss for last 2 years Psychological and behavioral changes MMSE= 26/30. Hypometabolic regions: Left frontal lobe Temporal lobe Anterior cingulate cortex This is one of FTD patient images who are 58 years old female with physiological and behavioral changes. We can see hypometabolic regions predominantly in left frontal, temporal, and anterior cingulate cortex. ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

MCI (22, M) Mild disorientation No psychological and behavioral changes Mild hypometabolism region: Posterior cingulate cortex Temporoparietal lobes This is MCI patients images who were 22 years old male that had significance memory impairment that is more pronounced than expected by age but not severe enough to meet criteria for dementia. There were some mild hypometabolism regions seen in left posterior cingulate cortex, and temporoparietal lobes. ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

DISCUSSION Hypometabolism reflects reduction of perisynaptic glial cell activity* Reduced neuronal expression of nuclear genes encoding brain metabolism** Our imaging findings were similar to those described in the literature From literature said that hypometabolism that can be identified by brain FDG PET scan reflects reduction of perisynaptic glial cell activity This phenomenon may be due to reduced neuronal expression of nuclear genes encoding brain metabolism *Bohnen et al; J Nucl Med 2012; 53:59–71 **Liang et al; PNAS. 2008;105(11):4441-4446 ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

SUMMARY OF HYPOMETABOLISM REGIONS PATTERN NL AD DLB FTD Hippocampal - ++ + Inferior Parietal Lobe Lateral Temporal Lobe Posterior Cingulate Cortex Prefrontal Cortex Occipital Cortex Sensorimotor Cortex From Mosconi multicenter study that published in 2008 concluded that hypometabolism pattern can be present in hippocampal, parietal, temporal, and posterior cingulate for Adand also possible in frontal In contrast in FTD, hypometabolism can be present predominantly in frontal and temporal that also possible to be present in hippocampal and posterior cingulate cortex - = Absent; ++ = present; + = possible NL= Normal; AD= Alzeimer Disease; DLB= Dementia with Lewy Bodies; FTD= Fronto-Temporal Disease Adapted from Mosconi et al., JNM 2008 49:390-398 ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

FDG PET Diagnosis Performance of AD Reference Sensitivity (%) Specificity (%) Accuracy (%) Mosconi et al., 2007 100 Ng et al., 2007 80 60 68 Chen et al., 2008 90 85 88 Mosconi et al., 2008 99 98 McMurtray et al., 2008 93 89 Overall 96 By using this hypometabolism pattern, brain FDG PET showed excellent diagnosis performance that can be seen in multiple cross sectional cohort study by Bohnen et al in 2012 Adapted from Bohnen et al; J Nucl Med 2012; 53:59–71 ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

CONCLUSION Brain FDG PET scan can be used as diagnostic tool in dementia by identifying the patterns of glucose hypometabolism Finally, we concluded that brain FDG PET scan can be used as diagnostic tool in dementia by identifying the pattern of glucose hypometabolism ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN 10/20/2014

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