Changes in regional cerebral blood flow after electroconvulsive therapy for depression

Fifteen patients with major depression and normal results of magnetic resonance imaging or computed tomographic studies were treated by electroconvulsive therapy (ECT). The regional cerebral blood flow (rCBF) of these patients was imaged using Tc-99m hexamethylpropylene amineoxime single-photon emission computed tomography before and after treatment, and their images were compared with a population of 11 healthy volunteers. Before ECT treatment, the patients had hypoperfusion of the frontal region compared with the controls, and they had multiple areas of altered perfusion throughout the brain. Five of the patients had an excellent clinical response to ECT; these patients also showed changes toward normal in rCBF. The remaining patients had minimal to moderate clinical response and showed no significant change in rCBF. These results indicate that improvement in clinical status as a result of ECT is correlated with a change toward normal in rCBF.

Splanchnic erythrocyte content decreases during hemodialysis: a new compensatory mechanism for hypovolemia

Splanchnic and splenic erythrocyte volumes decrease during postural changes and exercise to help maintain central blood volume and cardiac output. The contribution of this compensatory mechanism to hemodynamic stability during dialysis has not been studied, however. In 8 ESRD patients, age 51.0 +/- 4.5 years old, we measured changes in the splanchnic/splenic erythrocyte volume during dialysis by tagging the patients' erythrocytes with technetium and following abdominal radioactivity over time. Splanchnic radioactivity decreased to 90.2 +/- 3.8% (mean +/- SEM) of the baseline value after 2 hr of accelerated fluid removal (3.7 +/- 0.4 liters) during dialysis (DUF), while it remained relatively unchanged after two hours of dialysis without fluid removal (DD) [106.5 +/- 2.3%, P (DUF vs. DD) = 0.03]. Splenic radioactivity decreased to 89.2 +/- 5.0% of the initial value during DUF versus 103 +/- 3.8% during DD, but the decrease was noted only during the last 30 minutes of DUF and did not attain statistical significance. Autonomic nervous system integrity was measured by the spontaneous variation of the R-R interval during deep respiration (E/I ratio) and by the Valsalva ratio. The mean E/I and Valsalva ratios in the eight patients were 1.13 +/- 0.03 (+/-SEM) and 1.42 +/- 0.1 respectively, suggesting reasonably adequate autonomic nervous system functioning. The results suggest that contraction of the splanchnic, and possibly the splenic, vascular beds occurs during fluid removal associated with hemodialysis. The resultant addition of erythrocytes to the circulation may help maintain central blood volume and cardiac output.

Delayed colonic transit in spinal cord-injured patients measured by indium-111 Amberlite scintigraphy

OBJECTIVE

Constipation is a major problem for patients with chronic spinal cord injury (SCI). However, it is not clear whether abnormal colonic transit is restricted to the rectosigmoid region or involves the entire colon. We assessed regional colonic transit with emphasis on the ascending and transverse segments in patients with chronic SCI and compared the results with those of controls using scintigraphic techniques.

METHODS

Seven patients with SCI below T1 and 10 control subjects were studied after oral ingestion of a capsule containing indium-111-labeled Amberlite (Sigma Chemical, St. Louis, MO) pellets. The capsule was coated with a pH-sensitive polymer that prevents disintegration until it reaches the ileocecal region. Assessments of the half-time of emptying and residence time of contents in ascending and transverse segments were made, as well as an assessment of the velocity of contents throughout the entire colon, including the descending colon.

RESULTS

A significantly slower half-time of emptying was found in SCI patients (ascending: 29 +/- 27 hr in SCI, 6.81 +/- 3.03 hr in controls, p < 0.01; ascending + transverse: 42 +/- 12 hr in SCI, 15.3 +/- 7.16 hr in controls, p < 0.01). The residence time of the median position of the contents was significantly prolonged in SCI patients (ascending: 31 +/- 23 hr in SCI, 8.75 +/- 4.68 hr in controls, p < 0.05; transverse: 26 +/- 3 hr in SCI, 5.0 +/- 4.4 hr in controls, p < 0.05). Overall, the velocity of the median position of contents throughout the entire colon was significantly lower in SCI (0.63 +/- 0.33 cm/hr in SCI, 2.58 +/- 1.20 cm/hr in controls, p < 0.001).

CONCLUSIONS

Patients with chronic SCI have prolonged colonic transit that involves the entire colon. Hence, treatment of constipation in these patients may need to include prokinetic agents as well as local rectal maneuvers.

Utility of late N-isopropyl-p-(iodine-123)-iodoamphetamine brain distribution in predicting outcome following cerebral infarction

BACKGROUND AND PURPOSE

The purpose of this study was to determine utility of late N-isopropyl-p-(iodine-123)-iodoamphetamine distribution in predicting neurological and language outcome.

METHODS

We prospectively studied 29 patients with unilateral hemispheric ischemic cerebral infarction using the neuroimaging method of single-photon emission computed tomography and the above tracer. Four different imaging measures reflecting late tracer distribution or redistribution and three measures indicative of the patients' overall neurological or language outcome at 3 months were used in the data analysis. All patients had neuroimaging within 30 days of infarction, and 14 patients were imaged within 10 days of infarction. Data analysis was performed for all patients combined and then separately on the groups imaged within 10 days of and more than 10 days after infarction.

RESULTS

The volume of the late image defect significantly correlated with one measure of neurological outcome in the whole group and in those imaged more than 10 days after cerebral infarction. However, these results are difficult to explain based on the present understanding of the physiology of late N-isopropyl-p-(iodine-123)-iodoamphetamine distribution.

CONCLUSIONS

We feel that the pattern of late N-isopropyl-p-(iodine-123)-iodoamphetamine distribution is probably not useful as an independent predictor of neurological and language outcome.

Evaluation of cerebral perfusion reserve using 5% CO2 and SPECT neuroperfusion imaging

Anatomic features of carotid artery stenosis, as defined angiographically, do not necessarily correlate with the hemodynamic significance of the narrowing. The concept of regional cerebral vasodilatory (or perfusion) reserve has been advocated as a means of defining the hemodynamic compromise associated with carotid lesions. We evaluated the feasibility of using SPECT imaging with 5% CO2 using I-123 IMP (N-isopropyl iodoamphetamine) or Tc-99m HMPAO (hexamethylpropylene amineoxime) to measure cerebral perfusion reserve. Imaging was performed on six asymptomatic subjects and one patient with a history of transient ischemic attacks but no evidence of carotid artery disease. A perfusion reserve index (PRI) was defined to represent the percent increase in blood flow during 5% CO2 breathing in regions supplied by the middle cerebral artery normalized for injected dose and changes in blood pressure. Significant increases in cerebral perfusion were seen in six of the seven subjects studied while breathing the 5% CO2 (P less than 0.01). The mean of the PRI values for the seven subjects was 32%, with a range of -5% to 58%. We conclude that SPECT imaging with IMP or HMPAO can be used to quantitatively measure the cerebral perfusion response to 5% CO2.

Prediction of language and neurologic recovery after cerebral infarction with SPECT imaging using N-isopropyl-p-(I 123) iodoamphetamine

Fourteen patients (10 with left-sided and 4 with right-sided cerebral infarction) were prospectively studied with single-photon emission computed tomography (SPECT) using N-isopropyl-p-(I 123) iodoamphetamine (IMP, SPECTamine) to determine its usefulness in predicting neurologic/language recovery after cerebral infarction. All neuro-SPECT imaging was performed within 30 days after infarction. Detailed assessment of neurologic and/or language recovery (after 3 months) was carried out prospectively in each patient. Patients with smaller volume IMP defects in the region of infarction demonstrated significantly better neurologic and language recovery than patients with large IMP defects. Analysis of the IMP "redistribution" phenomenon failed to demonstrate definitively a relationship with clinical recovery. It was concluded that the volume of the IMP defect can aid in predicting recovery potential after cerebral infarction.

Demonstration of focal hyperemia in acute cerebral infarction with iodine-123 iodoamphetamine

Focal hyperemia is known to occur in regions of acute cerebral infarction. Presented here are two cases in which SPECT images with 125I-labeled iodoamphetamine demonstrated focal areas of increased tracer concentration associated with cerebral infarction. These results may have important implications regarding the physiology of iodoamphetamine in cerebral infarction and, in particular, whether the distribution of this tracer is related to regional blood flow in this setting. In addition, interpretation of iodoamphetamine images in cerebral infarction should include consideration of this finding.

Functional image data acquisition and processing

In the production of functional images certain hardware and software considerations are necessary for the rapid and accurate determination of kinetic parameters. The advent of the digital scintillation camera has made available increased accuracy of quantitation and ease of image handling, although its integrated computer system may not be optimal for program development presently. To reduce the deleterious effects of Poisson noise on parameter estimation, the single or multiple application of easily implemented smoothing operators in space and time is recommended as a first step in image processing. The properties of these operators are conveniently expressed in terms of their variance. Following smoothing, count or variance thresholding is performed to reduce computer processing time and eliminate extraneous background from functional images. Time-activity curves can be fit by a variety of mathematical functions, the most useful of which is probably the finite Fourier series. In a simulated gated blood-pool study of the left ventricle, with and without an aneurysm, it is found that increased smoothing of the original image data results in more accurate parameter determinations, to the extent that small regions of dissimilar temporal behavior are not obliterated.

Effect of acute postinfusion lipemia and free fatty acids on myocardial contractility: assessment with radionuclide ventriculography

Equilibrium gated radionuclide ventriculography was used to evaluate the effect of intravenous fat-emulsion overload and excess of free fatty acids (FFA) on left ventricular ejection fraction (LVEF) in 20 patients with and without coronary artery disease (CAD). Fifteen of these patients had normal (greater than 50%) baseline LVEF and 5 had low (less than 50%) baseline LVEF. From 100 to 150 ml of 20% artificial fat emulsion (Liposyn) was infused over 20-25 min. At the end of the infusion, triglyceridemia reached 820 +/- 220 mg% and left ventricular ejection fraction decreased from baseline 62 +/- 19% (mean +/- SD) to 58 +/- 16% (P less than 0.05, paired t-test). After completion of Liposyn infusion, 5,000 U of heparin was administered intravenously and monitoring of LVEF was continued. One and one-half hours following heparin administration, plasma FFA levels reached 3.7 + 2.0 mmol/l and LVEF rose to 69 +/- 19% (P less than 0.001, paired t-test). Our data indicate that acute intravenous fat overload can suppress and high pathophysiologic levels of FFA can increase LVEF. This effect is more uniform and statistically more reliable in patients with normal LVEF. The study failed to demonstrate any significant difference in the effect of this pharmacologic intervention between patients with and without CAD.

A comparison of dobutamine infusion and supine bicycle exercise for radionuclide cardiac stress testing

We have compared the inotropic drug dobutamine to supine bicycle exercise as a means of inducing stress in radionuclide ventriculography studies. Dobutamine has the following properties, making it favorable for widespread usage: 1) ability to be given safely in a peripheral vein, 2) rapid onset, and 3) short duration of action. Each patient underwent supine bicycle progressive resistance testing of 2 minutes per stage followed 30 minutes later by dobutamine administration. Accuracy of diagnosis was 0.93 and sensitivity was 0.89 with dobutamine, while with bicycle the accuracy was 0.93 and sensitivity was 0.94. While not designed to replace supine bicycle testing, incremental infusions of dobutamine appear to be nearly equal in accuracy and sensitivity, providing a satisfactory technique for cardiac evaluation of previously excluded patients.

Radionuclide detection of blood-retinal barrier disruption in diabetes mellitus

Diabetic retinopathy is one of the leading causes of blindness in the United States today. Because early treatment of proliferative retinopathy offers the best chance for visual salvation, there is an essential need for methods of identifying eyes at high risk. Recent research has shown that subclinical leakage from retinal blood vessels is one of the earliest signs of retinopathy. The feasibility of using radionuclide techniques to quantitate blood-retinal barrier disruption is demonstrated by a study in which 23 diabetics and 7 nondiabetics were imaged with an Anger camera in the anterior Waters projection at 2 hours after the administration of Tc-99m DTPA. In the digitized images, regions of interest were placed over each orbit and over one of the cerebral hemispheres. Orbital counts were then compared to cerebral counts on a per pixel basis. Eye to brain ratios were found to be lowest for nondiabetics and highest for patients with proliferative retinopathy. Additionally, the dynamic analysis of the same radiopharmaceutical may allow investigators to further study the pathophysiology of the diabetic eye.

The use of radionuclide retinal scintigraphy for the assessment of retinopathy in diabetes mellitus

A computerized radiotracer technique for the detection of loss of retinal vascular integrity secondary to diabetes is presented. Radionuclide retinal scintigraphy with Technetium-99m DTPA was performed on 40 insulin-dependent diabetics and 10 nondiabetics. A ratio of eye to brain activity was used to eliminate errors associated with absolute counting. Ratios were found to be significantly higher in diabetics, especially those with active neovascularization. This technique may prove useful in the assessment and staging of eyes prone to retinopathy.

Time--domain analysis in gated cardiac blood pool studies

A technique is presented for producing functional images derived from equilibrium gated blood pool studies as a means of diagnosing cardiac disease. These functional images are based on characteristics associated with the time variation of the count rate (the time domain) at each point of the image matrix rather than on the Fourier transform of the time-activity curve (the frequency domain) which has gained recent attention. As examples of this method, we present images which display the statistical variance of the time-activity curve at each pixel, corrected for the expected contribution due to random statistical fluctuation, and images which display the time at which each pixel reaches its minimum count value. Variance and time-to-minimum images are comparable to Fourier amplitude and phase images, respectively, and have been found to be useful in facilitating the diagnosis of wall motion abnormalities. A major advantage of time-domain analysis is the wide variety of features of potential clinical significance which may be investigated.

Effect of chemical and radiochemical impurities from eluants on 99mTc-labeling efficiency

Occasionally, radiopharmaceuticals prepared from the eluates of 99Mo-99mTc generators that have not been eluted for several days contain large amounts of free pertechnetate, as tested by radiochromatography and biologically by administration to patients. We fing the most probable causes of poor 99mTc-labeling in these cases to be: a) the presence of a large concentration of 99TcO4-in eluants; b) insufficient stannous ions available for the complete reduction of Tc due to spontaneous oxidation of Sn in the vial and also due to oxidation of stannous ions by the presence of larger than expected concentrations of H2O2 and HO2 radicals in the eluant.

Absorbed radiation dose from radionuclidic impurities in several 123I-labeled radiopharmaceuticals

The radiation dose to patients from RISA, sodium iodohippurate, and rose bengal labeled with commercially available 123I and its accompanying radioimpurities has been studied. The extra radiation dose to target organs was found to range from 29% to 97% that due to 123I alone when the radiopharmaceutical is administered at calibration time. Additional delay in the time of administration increases the relative impurity dose.

Absorbed Radiation Dose from Radionuclidic Impurities in Several 123I-Labeled Radiopharmaceuticals

The radiation dose to patients from RISA, sodium iodohippurate, and rose bengal labeled with commercially available 123I and its accompanying radio-impurities has been studied. The extra radiation dose to target organs was found to range from 29% to 97% that due to 123I alone when the radiopharmaceutical is administered at calibration time. Additional delay in the time of administration increases the relative impurity dose.

Tc-99m labeled complexes of aldehydes and glutamate as cholescintigraphic agents

Tc-99m pyridoxylidene glutamate has proven to be an excellent biliary scanning agent, far superior in many respect to the commonly used I-131 rose bengal. The preparation of the compound as previously reported by Baker et al is too time consuming and requires the use of an autoclave which is not available in most nuclear medicine departments. In our facility, we have been preparing similar compounds using several aldehydes and monosodium glutamate to make labeled complexes having the same pharmacological characteristics. The mixture of monosodium glutamate, aldehyde, and Tc-99m pertechnetate is made slightly alkaline, purged with helium, and placed in a sealed vial. The vial, which is protected by a wire basket, is then heated in a laboratory oven at 130 degrees C for a period of 15 to 20 minutes. During this time, the technetium is reduced to a lower valence state and bound to the complex formed. Chromatographic data show that these compounds are chemically similar to that previously reported. The compounds prepared concentrate in the gall bladder of the rabbit in less than 10 minutes. Kinetic studies have been performed on dogs with a scintillation camera and small digital computer to measure rates of blood clearance, liver and gall bladder uptake, and excretion into the intestine. The aldehyde -- glutamate complex promises to be a useful scanning agent for the diagnosis of biliary and hepatocellular diseases.

Dual-channel facilitation of the 99mTc radiocardiogram

A refinement of the radionuclide-angiocardiogram is described using a low deadtime scintillation camera and hardwire data storage, processing, and display system for the purpose of anatomic definition of the passage of a radioactive bolus through the carciopulmonary circulation by dual-channel, dual-color, subtraction methodology. The summation of the bolus pathway is displayed as a static frame of reference for the sequential kinetic image. The technique is noninvasive and employs 15 mCi of 99mTc pertechnetate. This procedure may be employed as the conventional bolus study for determining the cardiac kinetics ordinarily obtained by the method. The opportunity of viewing the bolus position in relation to its entire pathway significantly facilitates defining the multiple areas of interest the observer may wish to study.

Tc-99m Labeled Complexes of Aldehydes and Glutamate as Cholescintigraphic Agents

Tc-99m pyridoxylidene glutamate has proven to be an excellent biliary scanning agent, far superior in many respect to the commonly used 1-131 rose bengal. The preparation of the compound as previously reported by Baker et al is too time consuming and requires the use of an autoclave which is not available in most nuclear medicine departments. In our facility, we have been preparing similar compounds using several aldehydes and monosodium glutamate to make labeled complexes having the same pharmacological characteristics. The mixture of monosodium glutamate, aldehyde, and Tc-99m pertechnetate is made slightly alkaline, purged with helium, and placed in a sealed vial. The vial, which is protected by a wire basket, is then heated in a laboratory oven at 130° C for a period of 15 to 20 minutes. During this time, the technetium is reduced to a lower valence state and bound to the complex formed. Chromatographic data show that these compounds are chemically similar to that previously reported. The compounds prepared concentrate in the gall bladder of the rabbit in less than 10 minutes. Kinetic studies have been performed on dogs with a scintillation camera and small digital computer to measure rates of blood clearance, liver and gall bladder uptake, and excretion into the intestine. The aldehyde — glutamate complex promises to be a useful scanning agent for the diagnosis of biliary and hepatocellular diseases.