1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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):
ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN
10/20/2014

10. SUMMARY OF HYPOMETABOLISM REGIONS PATTERNNL 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 :
ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN
ARCCCNM/AOFNMB Meeting 2014 in OSAKA, JAPAN
10/20/2014

11. 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

12. 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

13. THANK YOU
Courtesy of Antokgraphy