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Hsu SY, Yeh LR, Chen TB, Du WC, Huang YH, Twan WH, Lin MC, Hsu YH, Wu YC, Chen HY. Classification of the Multiple Stages of Parkinson's Disease by a Deep Convolution Neural Network Based on 99mTc-TRODAT-1 SPECT Images. Molecules 2020; 25:E4792. [PMID: 33086589 PMCID: PMC7587595 DOI: 10.3390/molecules25204792] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/03/2022] Open
Abstract
Single photon emission computed tomography (SPECT) has been employed to detect Parkinson's disease (PD). However, analysis of the SPECT PD images was mostly based on the region of interest (ROI) approach. Due to limited size of the ROI, especially in the multi-stage classification of PD, this study utilizes deep learning methods to establish a multiple stages classification model of PD. In the retrospective study, the 99mTc-TRODAT-1 was used for brain SPECT imaging. A total of 202 cases were collected, and five slices were selected for analysis from each subject. The total number of images was thus 1010. According to the Hoehn and Yahr Scale standards, all the cases were divided into healthy, early, middle, late four stages, and HYS I~V six stages. Deep learning is compared with five convolutional neural networks (CNNs). The input images included grayscale and pseudo color of two types. The training and validation sets were 70% and 30%. The accuracy, recall, precision, F-score, and Kappa values were used to evaluate the models' performance. The best accuracy of the models based on grayscale and color images in four and six stages were 0.83 (AlexNet), 0.85 (VGG), 0.78 (DenseNet) and 0.78 (DenseNet).
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Affiliation(s)
- Shih-Yen Hsu
- Department of Medical Imaging and Radiological Science, I-Shou University, No. 8, Yida Road., Jiao-su Village Yan-chao District, Kaohsiung City 82445, Taiwan; (S.-Y.H.); (L.-R.Y.); (T.-B.C.); (Y.-H.H.)
| | - Li-Ren Yeh
- Department of Medical Imaging and Radiological Science, I-Shou University, No. 8, Yida Road., Jiao-su Village Yan-chao District, Kaohsiung City 82445, Taiwan; (S.-Y.H.); (L.-R.Y.); (T.-B.C.); (Y.-H.H.)
- Department of Anesthesiology, E-DA Cancer Hospital, I-Shou University, No.1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung City 82445, Taiwan
| | - Tai-Been Chen
- Department of Medical Imaging and Radiological Science, I-Shou University, No. 8, Yida Road., Jiao-su Village Yan-chao District, Kaohsiung City 82445, Taiwan; (S.-Y.H.); (L.-R.Y.); (T.-B.C.); (Y.-H.H.)
| | - Wei-Chang Du
- Department of Information Engineering, I-Shou University, No.1, Sec. 1, Syuecheng Road., Dashu District, Kaohsiung 84001, Taiwan;
| | - Yung-Hui Huang
- Department of Medical Imaging and Radiological Science, I-Shou University, No. 8, Yida Road., Jiao-su Village Yan-chao District, Kaohsiung City 82445, Taiwan; (S.-Y.H.); (L.-R.Y.); (T.-B.C.); (Y.-H.H.)
| | - Wen-Hung Twan
- Department of Life Sciences, National Taitung University, No.369, Sec. 2, University Road, Taitung 95092, Taiwan;
| | - Ming-Chia Lin
- Department of Nuclear Medicine, E-DA Hospital, I-Shou University, No.1, Yida Rd, Jiao-su Village, Yan-chao District, Kaohsiung 82445, Taiwan; (M.-C.L.); (Y.-H.H.)
| | - Yun-Hsuan Hsu
- Department of Nuclear Medicine, E-DA Hospital, I-Shou University, No.1, Yida Rd, Jiao-su Village, Yan-chao District, Kaohsiung 82445, Taiwan; (M.-C.L.); (Y.-H.H.)
| | - Yi-Chen Wu
- Department of Medical Imaging and Radiological Science, I-Shou University, No. 8, Yida Road., Jiao-su Village Yan-chao District, Kaohsiung City 82445, Taiwan; (S.-Y.H.); (L.-R.Y.); (T.-B.C.); (Y.-H.H.)
- Department of Information Engineering, I-Shou University, No.1, Sec. 1, Syuecheng Road., Dashu District, Kaohsiung 84001, Taiwan;
- Department of Nuclear Medicine, E-DA Hospital, I-Shou University, No.1, Yida Rd, Jiao-su Village, Yan-chao District, Kaohsiung 82445, Taiwan; (M.-C.L.); (Y.-H.H.)
| | - Huei-Yung Chen
- Department of Nuclear Medicine, E-DA Hospital, I-Shou University, No.1, Yida Rd, Jiao-su Village, Yan-chao District, Kaohsiung 82445, Taiwan; (M.-C.L.); (Y.-H.H.)
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Buchert R, Buhmann C, Apostolova I, Meyer PT, Gallinat J. Nuclear Imaging in the Diagnosis of Clinically Uncertain Parkinsonian Syndromes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:747-754. [PMID: 31774054 DOI: 10.3238/arztebl.2019.0747] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/01/2019] [Accepted: 08/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Parkinsonian syndromes are classified by etiology mainly on clinical grounds, that is, on the basis of the clinical manifestations and with the aid of conventional ancillary studies. In most cases, the clinical diagnosis is clear. In up to 30% of cases, however, the etiological classification remains uncertain after completion of the basic clinical diagnostic evaluation, and additional investigation with nuclear imaging may be indicated. In particular, cerebral single-photon emission computed tomography (SPECT) with dopamine transporter (DAT) ligands may be helpful. DAT-SPECT can be used to demonstrate or rule out nigrostriatal degeneration and thereby differentiate neurodegenerative parkinsonian syndromes from symptomatic parkinsonian syndromes and other differential diagnoses. Positron emission tomography (PET) with the glucose analogue [18F]fluorodeoxyglucose (FDG) can be used to identify disease-specific patterns of neuronal dysfunction/degeneration in order to differentiate the various neurodegenerative parkinsonian syndromes from one another. METHODS In this review, we summarize the current state of the evidence on DAT-SPECT and FDG-PET for the indications mentioned above on the basis of a selective review of the literature. RESULTS DAT-SPECT has been adequately validated as an in vivo marker for nigrostriatal degeneration. Studies using the clinical diagnosis of a movement disorders specialist over the course of the disease as a reference have shown that DAT- SPECT is 78-100% sensitive (median, 93%) and 70-100% specific (median, 89%) for the differentiation of neurodegenerative parkinsonian syndromes from symptomatic parkinsonism and other differential diagnoses in clinically unclear cases. DAT- SPECT scanning led to a change of diagnosis in 27-56% of patients (median, 43%) and to a change of treatment in 33-72% (median, 43%). FDG-PET enables the differentiation of atypical neurodegenerative parkinsonian syndromes from the idiopathic parkinsonian syndrome (i.e., Parkinson's disease proper) with high sensitivity and specificity (both approximately 90%), when the clinical diagnosis by a movement disorders specialist over the course of the disease is used as a reference. CONCLUSION DAT-SPECT has been well documented to be highly diagnostically accurate and to have a relevant influence on the diagnosis and treatment of patients with clinically uncertain parkinsonian or tremor syndrome. It has not yet been shown to improve patient-relevant endpoints such as mortality, morbidity, and health-related quality of life; proof of this will probably have to await the introduction of neuroprotective treatments. The current evidence for the high differential diagnostic accuracy of FDG-PET in neurodegenerative parkinsonian syndromes needs to be reinforced by prospective studies with neuropathological verification of the diagnosis.
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Affiliation(s)
- Ralph Buchert
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf; Department of Neurology, University Medical Center Hamburg-Eppendorf; Department of Nuclear Medicine, Medical Center-University of Freiburg; Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf
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Radiotracers for imaging of Parkinson's disease. Eur J Med Chem 2019; 166:75-89. [DOI: 10.1016/j.ejmech.2019.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/12/2019] [Accepted: 01/13/2019] [Indexed: 12/22/2022]
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In Vivo Assessment of Stem Cells for Treating Neurodegenerative Disease: Current Approaches and Future Prospects. Stem Cells Int 2017; 2017:9751583. [PMID: 28326106 PMCID: PMC5343274 DOI: 10.1155/2017/9751583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/07/2017] [Indexed: 12/13/2022] Open
Abstract
In recent years, stem cell-related therapies have been widely applied for treating neurodegenerative disease. Despite their potential, stem cell tracking and imaging techniques for the evaluation of in vivo proof-of-concept (PoC) therapies have not been sufficiently represented in the research area. This review summarizes the recent approaches that have been used for tracking and imaging engrafted stem cells in vivo. Furthermore, we introduce tissue clearing technology that can be applied to develop three-dimensional in vivo experiments. Monitoring stem cell survival and migration and graft-host relationships is a useful strategy to evaluate the therapeutic efficacy of regenerative medicine approaches in neurodegenerative disease.
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Park BN, Kim JH, Lee K, Park SH, An YS. Improved dopamine transporter binding activity after bone marrow mesenchymal stem cell transplantation in a rat model of Parkinson's disease: small animal positron emission tomography study with F-18 FP-CIT. Eur Radiol 2014; 25:1487-96. [PMID: 25504429 DOI: 10.1007/s00330-014-3549-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/09/2014] [Accepted: 12/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We evaluated the effects of bone marrow-derived mesenchymal stem cells (BMSCs) in a model of Parkinson's disease (PD) using serial F-18 fluoropropylcarbomethoxyiodophenylnortropane (FP-CIT) PET. METHODS Hemiparkinsonian rats were treated with intravenously injected BMSCs, and animals without stem cell therapy were used as the controls. Serial FP-CIT PET was performed after therapy. The ratio of FP-CIT uptake in the lesion side to uptake in the normal side was measured. The changes in FP-CIT uptake were also analyzed using SPM. Behavioural and histological changes were observed using the rotational test and tyrosine hydroxylase (TH)-reactive cells. RESULTS FP-CIT uptake ratio was significantly different in the BMSCs treated group (n = 28) at each time point. In contrast, there was no difference in the ratio in control rats (n = 25) at any time point. SPM analysis also revealed that dopamine transporter binding activity was enhanced in the right basal ganglia area in only the BMSC therapy group. In addition, rats that received BMSC therapy also exhibited significantly improved rotational behaviour and preservation of TH-positive neurons compared to controls. CONCLUSIONS The therapeutic effect of intravenously injected BMSCs in a rat model of PD was confirmed by dopamine transporter PET imaging, rotational functional studies, and histopathological evaluation. KEY POINTS • Mesenchymal stem cells were intravenously injected to treat the PD rats • Dopamine transporter binding activity was improved after stem cell therapy • Stem cell therapy induced functional recovery and preservation of dopaminergic neurons • The effect of stem cells was confirmed by FP-CIT PET.
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Affiliation(s)
- Bok-Nam Park
- Department of Nuclear Medicine and Molecular Imaging, School of Medicine, Ajou University, Woncheon-dong, Yeongtong-gu, Gyeonggi-do, Suwon, Korea, 443-749
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Kraemmer J, Kovacs GG, Perju-Dumbrava L, Pirker S, Traub-Weidinger T, Pirker W. Correlation of striatal dopamine transporter imaging with post mortem substantia nigra cell counts. Mov Disord 2014; 29:1767-73. [PMID: 25048738 DOI: 10.1002/mds.25975] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/05/2014] [Accepted: 06/24/2014] [Indexed: 11/10/2022] Open
Abstract
Dopamine transporter imaging is widely used for the differential diagnosis of parkinsonism. Only limited data are available on the relationship between striatal dopamine transporter binding and dopaminergic cell loss in the substantia nigra (SN). We analyzed postmortem SN cell counts in patients who had previously undergone dopamine transporter single-photon emission computed tomography (SPECT). Pathological diagnoses included Parkinson's disease (n = 1), dementia with Lewy bodies (n = 2), multiple system atrophy (n = 1), corticobasal degeneration (n = 2), atypical parkinsonism with multiple pathological conditions (n = 1), Alzheimer's disease (n = 1), and Creutzfeldt-Jakob disease (n = 1). [(12) (3) I]β-CIT SPECT had been performed in all subjects using a standardized protocol on the same triple-head gamma camera. The density of neuromelanin-containing and tyrosine hydroxylase-positive substantia nigra neurons/mm(2) was evaluated in paraffin-embedded tissue sections by morphometric methods. Mean disease duration at the time of dopamine transporter imaging was 2.3 years, and the mean interval from imaging to death was 29.3 months (range, 4-68 months). Visual analysis of dopamine transporter images showed reduced striatal uptake in all seven patients with neurodegenerative parkinsonism, but not in Alzheimer's and Creutzfeldt-Jakob disease cases. Averaged [(right+left)/2] striatal uptake was highly correlated with averaged SN cell counts (rs = 0.98, P < 0.0005 for neuromelanin- and rs = 0.96, P < 0.0005 for tyrosine hydroxylase-positive cells). Similar strong correlations were found in separate analyses for the right and left sides. Striatal dopamine transporter binding highly correlated with postmortem SN cell counts, confirming the validity of dopamine transporter imaging as an excellent in vivo marker of nigrostriatal dopaminergic degeneration.
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Affiliation(s)
- Julia Kraemmer
- Department of Neurology, Medical University of Vienna, Austria
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The role of SPECT imaging of the dopaminergic system in translational research on Parkinson's disease. Parkinsonism Relat Disord 2014; 20 Suppl 1:S184-6. [PMID: 24262177 DOI: 10.1016/s1353-8020(13)70043-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Imaging of the dopaminergic system with single photon emission computed tomography (SPECT), and particularly of the dopamine transporter (DAT) located in the striatum, is a well accepted tool in clinical practice to confirm or exclude loss of nigrostriatal dopamine (DA) neurons in patients suspected to suffer from Parkinson's disease (PD). SPECT techniques were developed successfully to image neurotransmitter systems, including the presynaptic DAT and postsynaptic dopamine D2/3 receptors, in rat and mouse models of PD. Here we review the results of preclinical SPECT studies of the dopaminergic system in rat and mouse models of PD. Initially, SPECT studies in animal models of PD were performed to validate that micro-SPECT is able to accurately assess parts of the dopaminergic system in small animals in-vivo. However, more recently, micro-SPECT DAT is increasingly used as a research tool to support the interpretation of human DAT SPECT studies in PD, including clinical trials examining the effects of potential neuroprotective drugs. Translational research with SPECT is an interesting development which may further increase our understanding of the pathophysiology and treatment of PD.
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Niñerola-Baizán A, Rojas S, Bonastre M, Tudela R, Lomeña F, Pavía J, Marin C, Ros D. In vivo evaluation of the dopaminergic neurotransmission system using [123I]FP-CIT SPECT in 6-OHDA lesioned rats. CONTRAST MEDIA & MOLECULAR IMAGING 2014; 10:67-73. [PMID: 24888455 DOI: 10.1002/cmmi.1608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 03/24/2014] [Accepted: 04/10/2014] [Indexed: 02/04/2023]
Abstract
The 6-hydroxydopamine (6-OHDA) rodent model of Parkinson's disease (PD) has been used to evaluate the nigrostriatal pathway. The aim of this work was to explore the relationship between the degree of 6-OHDA-induced dopaminergic degeneration and [(123)I]FP-CIT binding using single photon emission computed tomography (SPECT). Fourteen rats received a 6-OHDA injection (4 or 8 µg) into the left medial forebrain bundle. After 3 weeks, magnetic resonance imaging and scans with a small-animal SPECT system were performed. Finally, the nigrostriatal lesion was assessed by immunohistochemical analysis. Immunohistochemical analysis confirmed two levels of dopaminergic degeneration. Lesions induced by 6-OHDA diminished the ipsilateral [(123)I]FP-CIT binding by 61 and 76%, respectively. The decrease in tracer uptake between control and lesioned animals was statistically significant, as was the difference between the two 6-OHDA lesioned groups. Results concluded that [(123)I]FP-CIT SPECT is a useful technique to discriminate the degree of dopaminergic degeneration in a rat model of PD.
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Affiliation(s)
- Aida Niñerola-Baizán
- Unitat de Biofísica i Bioenginyeria, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina, Barcelona, Spain
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Bernsen MR, Vaissier PEB, Van Holen R, Booij J, Beekman FJ, de Jong M. The role of preclinical SPECT in oncological and neurological research in combination with either CT or MRI. Eur J Nucl Med Mol Imaging 2014; 41 Suppl 1:S36-49. [PMID: 24895751 PMCID: PMC4003405 DOI: 10.1007/s00259-013-2685-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 01/03/2023]
Abstract
Preclinical imaging with SPECT combined with CT or MRI is used more and more frequently and has proven to be very useful in translational research. In this article, an overview of current preclinical research applications and trends of SPECT combined with CT or MRI, mainly in tumour imaging and neuroscience imaging, is given and the advantages and disadvantages of the different approaches are described. Today SPECT and CT systems are often integrated into a single device (commonly called a SPECT/CT system), whereas at present combined SPECT and MRI is almost always carried out with separate systems and fiducial markers to combine the separately acquired images. While preclinical SPECT/CT is most widely applied in oncology research, SPECT combined with MRI (SPECT/MRI when integrated in one system) offers the potential for both neuroscience applications and oncological applications. Today CT and MRI are still mainly used to localize radiotracer binding and to improve SPECT quantification, although both CT and MRI have additional potential. Future technology developments may include fast sequential or simultaneous acquisition of (dynamic) multimodality data, spectroscopy, fMRI along with high-resolution anatomic MRI, advanced CT procedures, and combinations of more than two modalities such as combinations of SPECT, PET, MRI and CT all together. This will all strongly depend on new technologies. With further advances in biology and chemistry for imaging molecular targets and (patho)physiological processes in vivo, the introduction of new imaging procedures and promising new radiopharmaceuticals in clinical practice may be accelerated.
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Affiliation(s)
- Monique R. Bernsen
- Department of Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Pieter E. B. Vaissier
- Section Radiation Detection and Medical Imaging, Delft University of Technology, Delft, The Netherlands
| | - Roel Van Holen
- ELIS Department, MEDISIP, Ghent University, iMinds, Ghent, Belgium
| | - Jan Booij
- Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Freek J. Beekman
- Section Radiation Detection and Medical Imaging, Delft University of Technology, Delft, The Netherlands
- MILabs B.V., Utrecht, The Netherlands
| | - Marion de Jong
- Department of Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
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Karimi M, Tian L, Brown CA, Flores HP, Loftin SK, Videen TO, Moerlein SM, Perlmutter JS. Validation of nigrostriatal positron emission tomography measures: critical limits. Ann Neurol 2013; 73:390-6. [PMID: 23423933 PMCID: PMC3631302 DOI: 10.1002/ana.23798] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 09/28/2012] [Accepted: 10/29/2012] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Molecular imaging and clinical endpoints are frequently discordant in Parkinson disease clinical trials, raising questions about validity of these imaging measures to reflect disease severity. We compared striatal uptake for 3 positron emission tomography (PET) tracers with in vitro measures of nigral cell counts and striatal dopamine in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated monkeys. METHODS Sixteen macaques had magnetic resonance imaging and baseline PETs using 6-[18F]fluorodopa (FD), [11C]dihydrotetrabenazine (DTBZ), and 2beta-[11 C]carbomethoxy-3beta-(4-fluorophenyl)tropane (CFT). MPTP (0-0.31 mg/kg) infused unilaterally via the internal carotid artery produced stable hemiparkinsonism by 3 weeks. After 8 weeks, PETs were repeated and animals were euthanized for striatal dopamine measurements and unbiased counts of tyrosine hydroxylase-stained nigral cells. RESULTS Striatal uptake for each radiotracer (FD, DTBZ, CFT) correlated with stereologic nigral cell counts only for nigral loss<50% (r2=0.84, r2=0.86, r2=0.87, p<0.001 respectively; n=10). In contrast, striatal uptake correlated with striatal dopamine over the full range of dopamine depletion (r2=0.95, r2=0.94, r2=0.94, p<0.001; n=16). Interestingly, indices of striatal uptake of FD, DTBZ, and CFT correlated strongly with each other (r2=0.98, p<0.001). INTERPRETATION Tracer uptake correlated with nigral neurons only when nigral loss was <50%. This along with previous work demonstrating that nigral cell counts correlate strongly with parkinsonism ratings may explain discordant results between neuroimaging and clinical endpoints. Furthermore, strong correlations among striatal uptake for these tracers support lack of differential regulation of decarboxylase activity (FD), vesicular monoamine transporter type 2 (DTBZ), and dopamine transporter (CFT) within 2 months after nigrostriatal injury.
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Affiliation(s)
| | - LinLin Tian
- Neurology, Washington University, St. Louis, MO, USA
| | | | | | | | - Tom O. Videen
- Neurology, Washington University, St. Louis, MO, USA
- Radiology, Washington University, St. Louis, MO, USA
| | - Stephen M. Moerlein
- Radiology, Washington University, St. Louis, MO, USA
- Biochemistry and Molecular Biophysics, Washington University, St. Louis, MO, USA
| | - Joel S. Perlmutter
- Neurology, Washington University, St. Louis, MO, USA
- Radiology, Washington University, St. Louis, MO, USA
- Neurobiology, Washington University, St. Louis, MO, USA
- Occupational Therapy, Washington University, St. Louis, MO, USA
- Physical Therapy Washington University, St. Louis, MO, USA
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