SPET brain imaging with 201 diethyldithiocarbamate in acute ischaemic stroke

High-resolution mapping of neuronal activity using the lipophilic thallium chelate complex TlDDC: protocol and validation of the method

In neurons the rate of K(+)-uptake increases with increasing activity. K(+)-analogues like the heavy metal ion thallium (Tl(+)) can be used, therefore, as tracers for imaging neuronal activity. However, when water-soluble Tl(+)-salts are injected systemically only minute amounts of the tracer enter the brain and the Tl(+)-uptake patterns are influenced by regional differences in blood-brain barrier (BBB) K(+)-permeability. We here show that the BBB-related limitations in using Tl(+) for imaging neuronal activity are no longer present when the lipophilic Tl(+) chelate complex thallium diethyldithiocarbamate (TlDDC) is applied. We systemically injected rodents with TlDDC and mapped the Tl(+)-distribution in the brain using an autometallographic (AMG) technique, a histochemical method for detecting heavy metals. We find that Tl(+)-doses for optimum AMG staining could be substantially reduced, and regional differences attributable to differences in BBB K(+)-permeability were no longer detectable, indicating that TlDDC crosses the BBB. At the cellular level, however, the Tl(+)-distribution was essentially the same as after injection of water-soluble Tl(+)-salts, indicating Tl(+)-release from TlDDC prior to neuronal or glial uptake. Upon sensory stimulation or intracortical microstimulation neuronal Tl(+)-uptake increased after TlDDC injection, upon muscimol treatment neuronal Tl(+)-uptake decreased. We present a protocol for mapping neuronal activity with cellular resolution, which is based on intravenous TlDDC injections during ongoing activity in unrestrained behaving animals and short stimulation times of 5 min.

Computed tomographic and transcranial Doppler sonographic findings in acute and subacute phases of middle cerebral artery strokes

PURPOSE

The aim of this study was to compare the sensitivities of visual and densitometric analyses of CT scans and transcranial Doppler sonograms (TCD) in detecting early changes in acute stroke.

METHODS

CT and TCD were each performed twice in 12 patients; first in the acute phase (within 28 hours of stroke onset), then in the subacute phase (mean +/- standard deviation, 6 +/- 3 days after onset) of a stroke. Hypodensity on the CT scans was evaluated visually, and the optical density of both the stroke region and the corresponding region on the unaffected side was measured. Measurement of flow parameters in the middle cerebral artery was carried out with TCD before or shortly (within 4 hours) after CT scanning.

RESULTS

In the acute phase, blood flow velocities were significantly lower on the affected side than they were on the unaffected side (means, 42 +/- 13 and 55 +/- 25 cm/second, respectively; p = 0.012). Marked asymmetry in flow velocity was found in 3 of the 4 patients who had normal CT scans in the acute phase. The asymmetry in flow velocity disappeared by the sixth day after the stroke. The resistance index did not correlate with the final infarct size.

CONCLUSIONS

In some patients, the use of TCD in acute stroke may show alterations that reflect tissue damage that is undetectable on CT. Therefore, CT and TCD should be considered complementary diagnostic tools in the acute phase of stroke.

Crossed cerebellar diaschisis after middle cerebral artery infarction

It is unclear whether crossed cerebellar diaschisis (CCD) is merely an epiphenomenon, as its clinical significance remains uncertain. We retrospectively analysed the positron emission tomographic (PET) findings in 28 patients with a chronic, stable middle cerebral artery (MCA) infarct and in 22 controls, using the steady state technique and 15O. Also, the Orgogozo scores on admission and at the time of the PET examination were compared in the patients with MCA infarction. Based on the asymmetry index and the 95% confidence limits for regional cerebellar blood flow (rCBF) and oxygen consumption (rCMRO2) in the control group, the stroke patients were subdivided in a group with (n = 8) and a group without (n = 20) CCD. The CCD group had lower values of rCMRO2 in the infarct and border areas compared to those of the non-CCD patients. The infarct location within the MCA territory was similar but the size was somewhat larger in the CCC group. The degree of neurological improvement was better in the non-CCD group. Although persistence of CCD has no real clinical significance it appears to be correlated to more severe and widespread ischaemia in the affected MCA territory and to the lack of significant clinical improvement.

Ipsilateral thalamic diaschisis after middle cerebral artery infarction

The significance of ipsilateral thalamic diaschisis (ITD) among patients with chronic, stable middle cerebral artery (MCA) infarcts was investigated. Twenty eight subjects with chronic MCA infarction and twenty two normal controls were studied with positron emission tomography (PET), using the steady state technique with 15O. Stroke patients were subdivided into a group with ITD (n = 12) and a group without ITD (n = 16). Patients with ITD had greater decreases of regional blood flow (rCBF) and oxygen consumption (rCMRO2) in the infarcted MCA territory, compared to MCA infarction without ITD. The neurological deficits at the time of PET scanning were similar between both groups. Extent of infarction by CT brain scan appeared more predominant in peri-insular regions of patients with ITD, while in non diaschisis patients infarcts were more widely distributed throughout the MCA territories. Occurrence of ITD and of crossed cerebellar diaschisis (CCD) did not correlate. Occurrence of ITD seems to be linked to diffuse reductions of blood flow and oxygen metabolism in cortical territories of the MCA. Mechanisms of ITD were different from those of CCD.

SPECT imaging of stroke

Single-photon emission computed tomography (SPECT) is a helpful tool for the management of stroke patients. Brain perfusion SPECT can help differentiate an ischemic event from peri-ictal phenomena such as Todd's paresis. Initial data suggest that SPECT may be useful in prognosticating the likelihood of an early stroke after a transient ischemic attack and in distinguishing lacunar from cortical stroke. After an acute stroke, early SPECT depicts the area of ischemia with greater accuracy than either computed tomography or magnetic resonance imaging. When the perfusion defect is large, the likelihood of hemorrhagic complications or herniation increases. Reperfusion of an arterial territory after thrombolysis can be documented more conveniently with SPECT than with angiography. SPECT before and after the injection of acetazolamide has been used to assess the vascular reserve in patients with severe stenosis of the proximal vessels of the cerebrovascular tree. Combined with transcranial Doppler studies, SPECT is used to document ischemia after subarachnoid hemorrhage. It has also been used to assess the effect of arterial ligation intended to treat arteriovenous malformations or aneurysms on brain perfusion and to evaluate ischemia secondary to pressure from an intracranial hemorrhage.

Contribution of diaschisis to the clinical deficit in human cerebral infarction

BACKGROUND AND PURPOSE

Regions of decreased cerebral blood flow are often seen on single-photon emission computed tomography (SPECT) after stroke and have been widely reported to add to the clinical deficit. However, such reports have not distinguished between correlation and causation. We analyzed 124 serial SPECT scans performed in 50 patients to assess the role of diaschisis in the clinical deficit after stroke.

METHODS

SPECT with the use of 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) was performed in a prospective, unselected series of 50 patients with cerebral infarcts studied at a median of 1.1, 6.8, and 95 days after ictus. Patients were also assessed with the use of the Canadian Neurological Scale, the Barthel Index, a neuropsychological evaluation, and infarct volume measurement.

RESULTS

One hundred twenty-four serial SPECT scans were done in 50 patients. Diaschisis was identified at 168 sites. There was insufficient correlation between diaschisis and the clinical measurements to support the suggestion that diaschisis independently causes clinical deficits beyond those due to the infarct itself. Unlike the clinical status, diaschisis showed little tendency to resolve during the 3-month follow-up period of the study. Several of the instances of correlation were shown to be of a noncausal kind, with both the diaschisis and the clinical deficit being due to the lesion directly; there was no known mechanism for the diaschisis to cause the clinical deficit.

CONCLUSIONS

Diaschisis does not independently add to the clinical deficit after stroke. It is more likely that it simply represents part of the damage done by the stroke.