Quantitative measurement of regional cerebral blood flow with I-123 IMP SPECT: A correction of the microsphere model by global extraction between artery and internal jugular vein

Quantitative measurements of regional cerebral blood flow with N-isopropyl-(Iodine 123)p-iodoamphetamine (I-123 IMP) as a microsphere model were performed in forty cases. The regional cerebral blood flow values obtained with I-123 IMP were slightly underestimated compared with those of Xe-133 inhalation methods (y = 0.90x-2.1, r = 0.85, p less than 0.01). After correction by global extraction (87%) between the artery and internal jugular vein, which was measured in four patients by means of a catheter technique, the underestimation of the values obtained with I-123 IMP was improved (y = 1.0x-2.4, r = 0.85, p less than 0.01). Several problems in the accurate quantitative measurement of regional cerebral blood flow with I-123 IMP are discussed.     

Regional cerebral blood flow measured with I-123 IMP SPECT in a case of subcortical arteriosclerotic encephalopathy (Binswanger's disease).

N-isopropyl-p-[I-123] iodoamphetamine (I-123 IMP) SPECT studies were performed on a 75-year-old patient who could be clinically classified as subcortical arteriosclerotic encephalopathy (Binswanger's disease). Regional cerebral blood flow (rCBF) was quantitatively measured by a microsphere model, and was diffusely decreased in the whole brain (mean rCBF: 36 ml/100 g/minute). After a ventriculoperitoneal shunt operation, his clinical symptoms were markedly improved, and the improvement was validated by a 32% increase of mean rCBF. However, MRI and CT images showed no significant interval changes before and after the shunt operation. Regional rCBF measurement by I-123 IMP SPECT should be performed and plays an important role in the evaluation of Binswanger's disease.     

Mismatch between iodine-123 IMP and technetium-99m HM-PAO brain perfusion imaging in a patient with meningioma

The discrepancy between three methods for cerebral perfusion imagings in the case of a man with meningioma is presented. Imaging with N-isopropyl-P-[I-123] iodoamphetamine (IMP) showed no activity in the tumor. Imaging with Tc-99m hexamethylpropyleneamine oxime (HM-PAO) and the local cerebral blood flow (LCBF) image with Xe-133 inhalation showed high tumor activity. IMP is a more accurate method for imaging the brain tissue blood flow.     

N-isopropyl-p-[I-123]iodoamphetamine lung imaging in a patient with chronic pulmonary thromboembolism

A patient with a brain infarct was found to have chronic pulmonary embolism associated with perfusion defects on blood flow imaging with N-isopropyl-p-[I-123]iodoamphetamine (I-123 IMP). However, gradually increasing uptake of I-123 IMP was seen in later images, in areas distal to the embolus. The increased uptake to the embolized lung seemed to be through the systemic collateral circulation.     

Tomographic assessment of regional cerebral perfusion using intravenous I-123 HIPDM and a rotating gamma camera

The feasibility of assessing regional cerebral perfusion using the new brain imaging agent N,N,N'-trimethyl-N'-(2)-hydroxy-3-methyl-5-(123I) iodobenzyl)-1,3-propanediamine 2 HCl (I-123 HIPDM) and single photon emission computed tomography (SPECT) was evaluated in normal subjects and patients with cerebrovascular disorders. Following intravenous injection, I-123 HIPDM was rapidly extracted from the circulating blood by the brain (6.7%) and other organs. Its intracerebral distribution, as tomographically assessed by SPECT with a rotating gamma camera, reflected the distribution of blood flow within brain structures (gray and white matter, basal ganglia, etc.). Asymptomatic patients with history of transient ischemic attacks or minor stroke and angiographic evidence of internal carotid artery occlusion showed large cortical areas of reduced I-123 HIPDM distribution with normal or slightly positive CT. After extracranial-intracranial bypass surgery, reperfusion could be shown in previously ischemic areas. This study indicates the clinical usefulness of using I-123 HIPDM and gamma camera SPECT for the functional evaluation of brain disorders.     

Nuclear medicine for general radiologists: clinical application of brain SPECT

Brain SPECT studies are used to evaluate the cerebral hemodynamic changes in cerebrovascular diseases and other neuro-psychiatric disorders. I-123 and Tc-99m labeled radiopharmaceuticals widely used for brain perfusion SPECT studies include I-123 IMP, Tc-99m HMPAO, and Tc-99m ECD. I-123 IMP is suitable for the quantitative evaluation of cerebral blood flow, while Tc-99m HMPAO and Tc-99m ECD have problems owing to the non-linearity between cerebral radioactivity and cerebral blood flow. In addition, Tc-99m ECD does not show cerebral blood flow in the subacute phase of cerebral infarct or other conditions. Thus, it is important to consider the characteristics of radiopharmaceuticals and the clinical aspect of brain lesions in the interpretation of brain perfusion SPECT images. In this review, some useful information on brain perfusion SPECT is presented mainly as it relates to the cerebrovascular diseases.     

Viable tissue in an area of severely reduced perfusion demonstrated with I-123 iomazenil brain SPECT imaging of benzodiazepine receptors.

A 70-year-old woman who experienced transient left hemiparesis had 90% stenosis of the right internal carotid artery. CT revealed small low-density areas in the subcortical frontal area. Baseline cerebral blood flow was reduced, and vasoreactivity was poor in the right frontoparietal area according to I-123 IMP brain SPECT with acetazolamide. The distribution of I-123 iomazenil was normal on the delayed SPECT image but reduced in the early SPECT image, mimicking baseline cerebral blood flow. The distribution of I-123 iomazenil SPECT on the delayed image reflected the normal binding potential of the benzodiazepine receptor and thus identified viable tissue in an area of severely reduced perfusion. These findings were confirmed by positron emission tomography.     

N-isopropyl-p-[123I]iodoamphetamine SPECT in MELAS syndrome: comparison with CT and MR imaging

Regional cerebral perfusion was studied in three patients with the mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome, using single photon emission computed tomography (SPECT) with N-isopropyl-p-[123I]iodoamphetamine (IMP). Accumulation of the tracer was relatively decreased in the parietooccipital regions and also in the frontotemporal regions after stroke-like episodes. However, quantitative regional cerebral blood flow (rCBF) measurement showed that rCBF was relatively well preserved even at these sites, and a hyperemic state was observed at the sites of normal accumulation. IMP SPECT may be useful in the diagnosis and assessment of the progress of the MELAS syndrome.     

Brain perfusion measured by flow-sensitive alternating inversion recovery (FAIR) and dynamic susceptibility contrast-enhanced magnetic resonance imaging: comparison with nuclear medicine technique

The aim of this study was to compare cerebral perfusion images and regional cerebral blood flow (rCBF) of SPECT study with the images and regional intensity of relative cerebral blood flow (CBF) images acquired by contrast-enhanced perfusion MR imaging (pMRI) and flow-sensitive alternating inversion recovery (FAIR). Twelve patients with various cerebral diseases were underwent I-123-IMP SPECT, pMRI, and FAIR studies to measure rCBF. A total of 12 regions of interest (ROI) were created over cerebrum and cerebellum to acquire the corresponding rCBF from I-123-IMP study and regional average signal intensity from CBF images of pMRI and FAIR studies. Left-to-right (L/R) and cerebral-to-cerebellar (CCR) ratios were created from the rCBF of I-123-IMP and signal intensity of CBF images of pMRI and FAIR. Image quality of FAIR was the poorest among all; however, CBF images of pMRI and FAIR images show comparatively decreased intensity at the corresponding site of decreased perfusion on I-123-IMP images. Both FAIR and pMRI images showed high intensity along the sinuses, choroid plexus, and large vessels in sulci. No significant correlation was found among all imaging modalities. But L/R ratio of I-123-IMP showed significant correlation with those of pMRI and FAIR, but for CCR, significant correlation was observed only between I-123-IMP and FAIR. Perfusion images of both pMRI and FAIR may produce images comparable to SPECT study. But to calculate absolute CBF more easy-to-apply and accurate algorithms are needed to overcome the artifacts from large vessels. Received: 25 January 2000 Revised: 7 June 2000 Accepted: 8 June 2000     

New quantification of regional cerebral blood flow measurements by 123I-IMP SPECT with the rotating gamma camera--theory and validation of the look-up table method]

A new method of quantifying regional cerebral blood flow (rCBF) measurements by N-isopropyl-p-[123I]iodoamphetamine (123I-IMP) SPECT with a rotating gamma camera was designed. By assuming the 2 compartment model of the kinetic for 123I-IMP, two parameters of rCBF and distribution volume (Vd) of 123I-IMP from brom brain tissue to blood were obtained by the look-up table method and were derived from two simultaneous equations of the early and delayed images. The rCBF values of 3 cases (two normal adults and one brain infarct patient) were calculated by this method and were compared with the values of positron emission tomography (PET) measured at the same time. The average rCBF values in gray and white matter by this method were 40 ml/100 g/min, 27 ml/100 g/min, respectively and correlated significantly to rCBF values by PET (r = 0.598 (p less than 0.001)).     

Correct localization of epileptogenic focus with 1-123 iomazenil cerebral benzodiazepine receptor imaging: a case report of temporal lobe epilepsy with discordant ictal cerebral blood flow SPECT

A 26-year-old female with intractable epileptic seizures was studied with I-123 iomazenil cerebral benzodiazepine receptor, I-123 IMP inter-ictal and Tc-99m ECD ictal cerebral blood flow SPECT. The ictal cerebral blood flow SPECT indicated the location of the seizures to be in the left temporal lobe, where increased regional cerebral blood flow was noted in marked contrast to the inter-ictal SPECT. Ictal electroencephalograms (EEGs) recorded with scalp and sphenoidal electrodes also suggested the left temporal lobe as the location of the seizures. On I-123 iomazenil SPECT, however, decreased benzodiazepine receptor density was demonstrated in the right temporal lobe. MRI showed mild atrophy and abnormal signal intensity in the right temporal lobe. Ictal EEGs recorded with intracranial electrodes revealed that abnormal electrical activity of the brain always emerged from the right temporal lobe and then propagated to the contralateral side. Based on the findings of intracranial EEGs, partial resection of the right anterior temporal lobe including hippocampus was performed. After the surgery, no seizure occurred. Pathological examination of the surgical specimens revealed hippocampal sclerosis. This case suggested that cerebral benzodiazepine receptor imaging with I-123 iomazenil can be helpful for correct localization of epileptogenic foci.     

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.     

Cerebral abnormalities in cocaine abusers: demonstration by SPECT perfusion brain scintigraphy. Work in progress

Single photon emission computed tomography (SPECT) perfusion brain scans with iodine-123 isopropyl iodoamphetamine (IMP) were obtained in 12 subjects who acknowledged using cocaine on a sporadic to a daily basis. The route of cocaine administration varied from nasal to intravenous. Concurrent abuse of other drugs was also reported. None of the patients were positive for human immunodeficiency virus. Brain scans demonstrated focal defects in 11 subjects, including seven who were asymptomatic, and no abnormality in one. Among the findings were scattered focal cortical deficits, which were seen in several patients and which ranged in severity from small and few to multiple and large, with a special predilection for the frontal and temporal lobes. No perfusion deficits were seen on I-123 SPECT images in five healthy volunteers. Focal alterations in cerebral perfusion are seen commonly in asymptomatic drug users, and these focal deficits are readily depicted by I-123 IMP SPECT.     

Comparison of FDG-PET and IMP-SPECT in patients with dementia with Lewy bodies

OBJECTIVES: To investigate regional differences in cerebral glucose metabolism and blood flow of dementia with Lewy bodies (DLB), we studied 7 subjects with DLB and 20 normal controls using F-18 fluorodeoxyglucose (FDG) and positron emission tomography (PET) and then examined the same 7 subjects and 20 other normal controls with I-123 iodoamphetamine (IMP) and single photon emission computed tomography (SPECT). METHODS: The anatomically standardized images were produced with NEUROSTAT and the regional relative metabolic and perfusional values were calculated. RESULTS: The mean reduction ratios of FDG uptake in the DLB group relative to the mean normal controls in the parietal lobe and occipital lobe were 0.72 and 0.83, respectively, while the corresponding mean reduction ratios of IMP uptake were 0.81 and 0.88, respectively. In the DLB group, parietal FDG uptake was significantly lower than parietal IMP uptake (p < 0.05), occipital FDG uptake was significantly lower than occipital IMP uptake (p < 0.05), and parietal IMP uptake was significantly lower than occipital IMP uptake (p < 0.01), but there was no difference between parietal and occipital FDG uptake. CONCLUSIONS: Our findings suggest that parietal metabolism and perfusion are severely affected in DLB patients, though the occipital metabolic and perfusional reduction is thought to be a feature of DLB. FDG-PET is thought to be superior to IMP-SPECT in detecting functional changes in the DLB brain.     

Dynamic SPECT with technetium-99m HM-PAO in meningiomas--a comparison with iodine-123 IMP

Technetium-99m hexamethylpropyleneamine oxime ([99mTc]HM-PAO) has recently been introduced as an alternative to N-isopropyl-p-[123I]iodoamphetamine ([123I]IMP) for measurement of regional cerebral blood flow. This study compares dynamic SPECT studies using the two tracers in seven patients with meningiomas. Regions of interest were placed over the lesion and contralateral homologous presumed normal area. The counting-rate ratio for the lesion to the contralateral homologous area (L/N ratio) was then calculated in the first image. L/N ratios of [99mTc]HM-PAO single photon emission computed tomography (SPECT) were lower than those of [123I])IMP SPECT, particularly in hypervascular meningiomas. Furthermore, time-activity curves showed that the washout of [99mTc]HM-PAO in the tumors was very slow or incomplete, preventing an accurate assessment of vascularity of meningiomas with [99mTc]HM-PAO, as is generally possible with [123I]IMP.     

Critical cerebral blood flow thresholds studied by SPECT using xenon-133 and iodine-123 iodoamphetamine

Regional cerebral blood flow (rCBF) was assessed in patients with cerebrovascular diseases (CVD) by single photon emission computed tomography (SPECT) using 133Xe and N-isopropyl-p-[123I]iodoamphetamine ([123I]IMP). The purpose of this study was to determine the infarcted and symptomatic blood flow thresholds of cerebral cortex by SPECT. In the 133Xe inhalation method rCBF was calculated by employing the Celsis modification of the Kanno and Lassen algorithm. In the [123I]IMP SPECT quantitation was obtained by counting-rate ratio for the low flow lesion to the contralateral homologous region which was presumed to be normal (Lesion/Normal ratio, L/N ratio). The infarcted and symptomatic blood flow thresholds by 133Xe SPECT was 19-23 and 33-36 ml/100 g/min, respectively. While, those of L/N ratio in the [123I]IMP SPECT were 39-48 and 65-72%, respectively. There was a significant correlation between the ischemic degrees evaluated by 133Xe and [123I]IMP SPECT studies.     

Evaluation of crossed cerebellar diaschisis in 30 patients with major cerebral artery occlusion by means of quantitative I-123 IMP SPECT

Quantitative crossed cerebellar diaschisis (CCD) and the correlation with a reduction in supratentorial regional cerebral blood flow (rCBF) and cerebrovascular reserve capacity (CVR) were investigated in clinically stable patients with major cerebral artery occlusion by the iodine-123-N-isopropyl-p-iodoamphetamine (I-123 IMP) single photon emission computed tomography (SPECT) method. Thirty patients with major cerebral artery occlusion underwent SPECT by the I-123 IMP autoradiographic method. Regional CBF was measured in the cerebral hemisphere, frontal and parietal lobes, temporo-parietal lobe, and cerebellum both at rest and after administration of acetazolamide. Eighteen of 30 patients (60%) had CCD. CCD was significantly related to magnetic resonance imaging evidence of infarction. Quantitative CCD was 17% and the CVR in the cerebellum was preserved in patients with CCD. There was a significant difference in CBF and CVR between the affected and normal sides in all regions of interest in the patients without CCD [CBF (ml/100 g/min): hemisphere (H), normal side (N): 31.4 +/- 6.8, affected side (A): 27.5 +/- 7.4; p < 0.05. CVR: H, N: 0.56 +/- 0.38, A: 0.42 +/- 0.18; p < 0.01]. CCD is common in patients with major cerebral artery occlusion, and quantitative I-123 IMP SPECT is helpful in detecting CCD in clinically stable patients with occlusion of major cerebral arteries.     

Optimal inversion time for acquiring flow-sensitive alternating inversion recovery images to quantify regional cerebral blood flow

The purpose of this study was to correlate regional cerebral blood flow (rCBF) measured by I-123-IMP and flow-sensitive alternating inversion recovery (FAIR) studies with different inversion time (TI) values to find out the optimum TI that gives comparable rCBF and images on FAIR study. Nine patients with symptoms and signs of internal carotid or major cerebral arterial stenosis were enrolled in this study. Both I-123-IMP single photon emission computed tomography (SPECT) and FAIR images were acquired in all patients. Single-slice FAIR images (with different TI values) were acquired using a 1.5-T MRI unit. The rCBF was calculated from all I-123-IMP and FAIR images. Receiver operating characteristics (ROC) analysis was performed to detect hypoperfused segments on FAIR images. The rCBF calculated from FAIR and I-123-IMP studies were compared and correlated with each other. The ROC analysis showed no significant differences among the readers or TI values, but a trend of higher sensitivity, specificity, and accuracy was observed with TI of 1400 ms. The rCBF values of FAIR and I-123-IMP studies significantly correlated with each other. The FAIR images with TI value of 1400 ms gave more comparable CBF. A TI value of 1400 ms might be optimum for 1.5-T MR strength to get high quality FAIR images and comparable CBF. Electronic Publication     

A comparison of two cerebral perfusion tracers, N-isopropyl I-123 p-iodoamphetamine and I-123 HIPDM, in the human

Both N-isopropyl I-123 p-iodoamphetamine (IMP) and I-123 HIPDM have been advocated as radiotracers for assessing regional cerebral perfusion. We compared the biodistribution of the two tracers in 19 patients without evidence of neurological disease. Following intravenous injection, both tracers accumulated initially in the lung. Early after injection the fraction of the total brain uptake was higher for I-123 HIPDM than for I-123 IMP. The peak brain activity for I-123 IMP was higher than for I-123 HIPDM . Brain activity was unchanged with both tracers between 30 and 60 min after injection. Tomographic images were similar in appearance for both tracers. No eye uptake greater than background was observed with either tracer in any patient at 2, 24, and 48 hr. I-123 IMP is superior for tomographic imaging because of its higher brain uptake, whereas I-123 HIPDM may be superior for studies performed during rapid changes in blood flow.     

N-isopropyl I-123 p-iodoamphetamine brain scans with single photon emission computed tomography: mental sweating and EEG abnormality

We studied a patient with hyperhidrosis and electroencephalographic (EEG) abnormality using N-isopropyl I-123 p-iodoamphetamine (I-123 IMP) with single photon emission computed tomography (SPECT). EEG abnormality was found predominantly in the frontal area, and sharp wave bursts were induced by hyperventilation. Ictal and nonictal scans were obtained with simultaneous EEG recordings. Ictal scans revealed increased uptake of IMP in the frontal cortex, reflecting hyperperfusion to the frontal area. The ratio of IMP uptake of the frontal to the parietal cortex (F/P ratio) was calculated both in the ictal and nonictal phase. In the ictal phase, the F/P ratio was 1.23, compared with 0.91 in the nonictal phase. The data indicated altered regional cerebral blood flow with EEG abnormality and hyperventilation load. Although the relationship between sweating and cortical function is not fully understood, our study indicates that excessive mental sweating is related to frontal cortical dysfunction. I-123 IMP-SPECT seems valuable for topographical demonstration of epileptogenic lesions and understanding the pathophysiological process of mental sweating.