NeuroQ™ - Amazon Web Services
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1. with abundant neurofibrillary tangles in the hippocampus entorhinal cortex and neocortex as well as amyloid beta 1 42 staining plaques prominent throughout all areas of hippocampus entorhinal cortex and neocortex Synuclein staining to check for the presence of Lewy bodies was not performed Case Summary To summarize by the time of this PET scan Mr F had undergone extensive evaluation of his cognitive and motor symptoms including history and physical examinations by his internist neurologic examination by a dementia expert laboratory screening as well as multiple brain MRI studies two of them including contrast and subsequently a head CT The clinical examination led to diagnoses of corticobasal degeneration and depression the laboratory screen was negative and the structural imaging studies demonstrated only atrophy None of the above studies pointed to the presence of Alzheimer s disease and the patient correspondingly received no treatment specific to that diagnosis The presence of Alzheimer s disease however was clearly evident on both PET and autopsy examinations PET also revealed profound hypometabolism of associative visual cortex quantified by NeuroQ as falling as much as 12 standard deviations below normal metabolic levels suggesting Lewy body involvement which could also help to explain the prominence of the patient s central motor symptoms 28 References For Case Study 2 Journal Articles Knopma2. File EQuAL e Patient Name FDGBrain Main QC Slices EQuAL Data Save Help Study Date 14 Mar 1996 Starting Plane 24 5 Es 1 05D 1 0 5D 1 550 2 0 5D 2 5 5D lt 3 0 5D r 36 57 38 39 0 57 0 46 0 34 0 23 0 11 0 00 Select the axial plane which visually demonstrates the greatest asymmetric difference in metabolic activity within the temporal cortex The Extent Specified Quantified Asymmetry of Lobe EQuAL Analysis will be included with the NeruoQ 3 0 This program 1s useful for assessing maximal temporal asymmetry over a specified proportion of the temporal lobe which may help to predict whether patients will likely be free of seizueres during the years after neurosurgical resection of epileptogenic tissue To use EQuAL select the patient desired and launch NeuroQ from MCP Process the study as you would normally Once NeuroQ is finished reformatting the data select the EQuAL tab from the top of the screen Select the image that the user feels best exemplifies the asymmetrical defect Use the slider bar on the right hand side of the screen to see all slices See example above Once an image has been selected the EQuAL ROI screen will appear Follow the on screen instructions to get the Asymmetry Index AI 27 881 NeuroQ TM Analysis Version 3 0 Build 20080506 203302 File EQuAL Patient Name FDGBrain Main Slices Data Save Help Study Date 14 Mar 1996 Plane 25 Plane 27 Plane 28 Plane 23
3. SD from M AC REGIONAL HYPOMETABOLISM ROI Hame Magnitude of Difference 50 from M AC Positive sign corresponds to values Mean AC Negative sign corresponds to values Mean AC REGIOHAL AHD CLUSTER DATA rANC p36 Difference 0 46 is the most hypometabolic region rAVC p24 90 from M AC 12 73 is the region with the mast significant hypometabolism rAVC Difference 0 36 is the most hypometabolic cluster rAVC 5D from 15 74 is the cluster with the most significant hypometabolism MEAC Mean of Asymptomatic Control Group The left side of the window contains the NeuroQ M Analysis screen and the right side contains the NeuroQ M Display screen These displays are defined below 9 Note There is a possibility of 3 output files that can be created from the processing of the NeuroQ study if the user selects to save the files of these files will be saved in the patient s folder which contains their imaging data The files are as follows A file called NeuroQ Review File which contains the processed data for the patient using the indicated number of iterations When you enter the program the next time you can select just this file which will show the results for that patient with the number of iterations selected without having to reformat the patients study again b Afile called patientname ROldata dat which contains the information related to the region of interests g
4. Main QC Slices mi e EQuAL Data Gave Help Study Date 24 Mar 1999 Set Axial Plane Limits Removal of Scalp Activity Rigid Registration Original Reference Bae Processed Original Threshold Realigned amp Fused 50 J gt Reference Blend Aligned j Set Axial Plane Limits Set Axial Plane Limits 2 Upper Limi Lower Limi Accept This feature allows the user to set the upper and lower limits for reconstruction by clicking the up and down arrows to move the lines The limits can also be set by moving the cursor to a point on the image and click left to set the limit The limits should be set so that only the brain images are included in the reconstruction When the limits are set to the proper location check the Accept box 17 Removal of Scalp Activity Removal of Scalp Activity f M Original J a Processed 10 Threshold Process E Accept This feature allows for the removal of the scalp activity around the brain In some cases there is excessive scalp activity which can interfere with the reformatting of the patients study to match the normal template Move the slider bar to the desired threshold and then click on the Process button The processed images are shown in the bottom row Triangulation is enabled on these images by clicking left on any image and it will show you the plane for that location on the other two images When the
5. Reference Patient Nam Show Color Scale Study Date 1 List Region Abbreviations Hospital ID Demo3 Tracer FOG Color Scale ae a Show Color Scale provides a legend of the two dimensional color coding The number of Standard deviations is listed on the Y axis and the below the mean normal value is listed on the X axis b List Region Abbreviations will list the various abbreviations used in the application along with 0 05 0 10 0 15 0 20 025 0 30 0 35 their meaning i e rAVC right Associative meat re Visual Cortex 4 QC The Quality Control screen allows the user to apply some preprocessing steps including setting axial planes limits removing scalp activity and performing a rigid registration See Quality Control section below for a further description 5 Slices When the Slices button is selected it will bring up a new display window which initially will display the patients transaxial slices From the Slice Display menu item you can also select to display the sagittal or coronal slices This display is shown below 11 Rainbow 16 Level Bronson Blue to White am Red Blu V Red Temperature Blu sm Red el Std Gamma 11 Prism Red Purple Gm Wht Linear Rainbow He Steps Stem Special Haze E Blue Pastel Red Pastels B Hue Sat Lightness 1 Hue Sat Lightness 2 Hue Sat Value 1 Hue Sat Value 2 Purple Red Stripes The initial displa
6. images are acceptable check the Accept box 18 Rigid Registration Rigid Registration Reference Original Realiqned amp Fused hs E F 5 Reference Blend Original Process The Rigid Registration allows for applying additional registration prior to the reformatting process used in NeuroQ This additional registration is helpful in cases where the patients head has excessive tilt The top row shows the normal template as the reference image the middle row are the patients images and the bottom row are the fused reference and patient images after realignment Triangulation is enabled on these images by clicking left on any image and it will show you the plane for that location on the other two images When the images are acceptable check the Accept box 19 NeuroQ COMPARE DISPLAY SCREEN 81 NeuroQ TM Analysis Version 3 0 Build 20080506 203302 File Processing Displa Display Reference Region Metabolismi Study Comparison EQui Patient Name NeuroQ Study Compare 2001 Main Slices Compare PET CT EQuAL Data Save Help Study1 Date 01 Jan 2001 Normal Template with Cluster Regions e000 o Study2 Study e REGIOHAL AHD CLUSTER DATA ar ry a ICN p32 Difference 0 2710 is the most Decreased region ICN p30 Difference 30 0005 is the region with the largest Decrease ICN Difference 0 1850 is the most Decreased 36 42 cluster ICN Differe
7. visual cortex Huntington s Disease Caudate and lentiform nuclei affected early with gradual development of diffuse cortical hypometabolism Parkinson s Dementia Similar to Alzheimer s Disease but less sparing of visual cortex In early untreated Parkinson s disease basal ganglia may appear hypermetabolic 36 Dementia with Lewy Bodies Similar to Alzheimer s Disease but less sparing of occipital cortex aT Daniel Silverman MD PhD Nuclear Medicine Clinic Div Biological Imaging Dept Molecular and Medical Pharmacology University of California Los Angeles APPENDIX III CHECKLIST TO DETERMINE WHETHER FDG PET DEMENTIA EVALUATION IS INDICATED AND COVERED BY MEDICARE 1 Does the patient have diminished memory and other cognitive deficits which have been present for at least 6 months and which now impair her or his ability to function as s he normally would professionally socially or with respect to activities of daily living Yes continue to 2 No PET scan is not covered 2 Based on history physical examination and blood labs is evidence present for any of the following correctable conditions Depression Substance Abuse Malnourishment Medication Effects Cardiopulmonary compromise Anemia Hypoxemia Infection Thyroid dysfunction Renal or hepatic disorder Glucose or electrolyte calcium dysregulation Yes continue to 3 No continue to 4 3 After treatment of the above con
8. 76 Region Pt M AC SD fri riPL p16 105 0 04 078 0 27 671 rGFmpl 1 08 0 04 1 02 0 07 1 67 rSMp17 107 0 04 0 90 017 4 67 rAVCp18 1 02 0 04 077 0 25 553 riPL p18 1 08 0 03 075 0 32 9 42 rBroca p20 105 005 0 96 0 09 175 rPCC p20 142 0 03 1 00 0 12 3 69 IAYC p20 1 04 0 03 0 88 0 06 2 09 rAVC p20 IGFm tAVC Difference 0 35 is the most hypometabolic cluster rAVC 50 from M AC 15 74 is the cluster with the most Mean of Asymptomatic Control Group significant hypometabolism 1 File Menu this allows the user to print the current screen save the screen in various formats and allows the user to exit The options for save screen formats are listed to the right Note The DICOM Screen Capture allows the data to be saved in a format acceptable by PACS systems Processing Display Slice Display Reference Region lleuroO Demo Case3 Abn Dicom SC BMP JPEG TIFF PNG PPM Session ID Referring Ph L R 10 2 Processing Menu allows user to reformat the brain the default number of iterations is 20 and that value will be used if the Reformat option is selected from the Processing drop down list This processing step is described above in the Processing section 3 Display Menu the display menu allows you to display the Color Scale and a list of region abbreviations The options are shown below File Processing Slice Display
9. NeuroQ M Quantitative Analysis for Neuroimaging Technology Display and Analysis Program Version 3 0 Operator Guide rev d June 2008 Copyrights Trademarks Restrictions Copyright 2005 2008 by Syntermed Inc rights reserved Revision 07 Published 2008 Printed in the United States of America Syntermed reserves the right to modify the design and specifications contained herein without prior notice Please contact your local Sales Representative for the most current information No part of this documentation may be reproduced or transmitted in any form by any means electronic or mechanical without written permission of Syntermed NeuroQ is a registered trademark of Syntermed Inc Table of Contents OVERVIEW p M 4 INSTALLATION OE NEU ROO waisssscstsccecassdsscsssenbectsdssscevcansdscnssovesiunddssesadewisdeseseensdeiosedcosesentedesstestedeandssseds 5 LAUNCHING THE PROGRAM 6 REFERENCES CASE STUDY 2 a aevo ba nas end Ee ase iuuenes 20 REFERENCES FOR CASE oL o det eti inis A M E 20 APPENDIX II REGIONAL HYPOMETABLOSIM IDENTIFIED BY FDG PET 36 APPENDIX III MEDICARE CHECKLIST TO DETERMINE FDG PET DEMENTIA 38 APPENDIX IV USING CLINICAL BRAIN PET FOR EVALUATION OF DEMENTYIA 39 NeuroQ QUANTITATIVE ANALY
10. NeuroQ Review File This file can then be selected and the previous reformatted data and analysis will be displayed This avoids having to reformat the data 1f it needs to be displayed at another time 11 Help this option will display the version number of NeuroQ and also a description of what the colors mean in the NeuroQ display Version Version 3 0 Build 2005041 7 103530 IDL 5 4 Mar 23 200 Computer xob OS Windows Winds the analysis of 240 brain regions comparing the patient s scan to the scans of an asymptomatic control group BLUE shades represent areas that are not significantly hypormetabolic RED shades represent areas of mast severe and most statistically significant hypametabalism PURPLE shades represent areas where the hypometabolism may be smaller in magnitude but remains statistically significant due to low variance of activity in that area among normal subjects For more detailed information about a specific region click on the area of interest Online Manual 13 12 13 14 I5 16 17 18 19 Patient Information displays patient information Patient Brain Display displays the original patient brain transaxial slices Left Plane Slider controls the brain plane of the above patient brain display the current plane number is displayed above the slider slide to the left or right to access lower or higher planes respectively Normal Tem
11. Plane 30 0 1551 0 1876 0 2170 Draw a AOI around the temporal cortex of plane 28 on the side showing Add point with left button the greatest level of asymmetry Close region with right button Asymmetry Indiex Al is calculated and displayed below the images Clear ROI The propartion of pixels to use for asymmetry calculation can be adjusted using the Extent Specification slider bar 202 was found to be optimal 20 The Al optimal range was found to be 0 19 0 40 for achieving post surgical seizure free status gt Extent Specification The results of this study were by Lin et al from the Department of Molecular and Medical Pharmacology David Geffen School of Medicine UCLA Los Angeles was published in the May issue of the Journal of Nuclear Medicine Tina W Lin Michelle A Kung de Aburto Magnus Dahlbom Lynn L Huang Michael M Marvi Michael Tang Johannes Czernin Michael E Phelps and Daniel H S Silverman Predicting Seizure Free Status for Temporal Lobe Epilepsy Patients Undergoing Surgery Prognostic Value of Quantifying Maximal Metabolic Asymmetry Extending over a Specified Proportion of the Temporal Lobe J Nucl Med 2007 48 5 776 782 23 Description of Example Patient s 1 Demo Casel Normal Case gS Dekw This case demonstrates the quantitative output produced by NeuroQ when it is used to analyze a normal study The blue areas within the cluster regions indicate that the metabolic uptake w
12. SIS FOR NEUROIMAGING TECHNOLOGY Version 3 0 OVERVIEW The NeuroQ Display and Analysis Program has been developed to aid in the assessment of human brain scans through quantification of mean pixel values lying within standardized regions of interest and to provide quantified comparisons with brain scans derived from FDG PET studies of defined groups having no identified neuropsychiatric disease or symptoms 1 e asymptomatic controls AC The Program provides automated analysis of brain PET scans with output that includes quantification of relative activity in 240 different brain regions as well as measures of the magnitude and statistical significance with which activity in each region differs from mean activity values of brain regions in the AC database The new features of version 3 0 include NeuroQ Quality Control Screen PET CT display screen patient study comparison analysis and EQuAL a tool for evaluating temporal lobe Epilepsy This manual describes the display and analysis features of the Program and their end user operation Program Description The NeuroQ Program is indicated to 1 assist with regional assessment of human brain scans through automated quantification of mean pixel values lying within standardized regions of interest S ROI s and 2 assist with comparisons of the activity in brain regions of individual scans relative to normal activity values found for brain regions in FDG PET scans through quan
13. as all above the normal limit of 1 65 standard deviation Mr E was 71 years old when he was first referred to the UCLA Ahmanson 24 2 Demo Case2 Mildly Abnormal Patient History Eye mr rum Mr E was 71 years old when he was first referred to the UCLA Ahmanson Biological Imaging Division in December 2001 with concern for worsening memory He reported that he always had a poor memory but that over the preceding seven years he began to notice his memory getting worse including forgetting where he put his keys and forgetting names or faces Mr E had worked as a physicist for 25 years and taught physics at the University level for the following 20 years He reported no psychiatric hospitalizations illness or medication use Mr E had no significant medical history including hospitalizations or illness with the exception of prostate surgery for benign enlargement He did not use tobacco alcohol or other drugs and had no history of such use His physical examination neurologic exam and blood laboratory values including TSH B12 CBC ALT and Cr were within normal limits Mr underwent comprehensive neuropsychologic testing at the time of his first visit in 2001 and was found to be cognitively normal for his age Why was a PET scan obtained at this time This patient is seeking a diagnosis for his chief complaint a convincing history of cognitive decline His symptoms are unexplained by any factors identified
14. atic Control Group 4 The patient s transaxial slices must be reformatted to fit the normal template transaxial slices This 1s performed from the Processing menu item select Reformat from the drop down box as shown below The registration algorithm used for reformatting the patient s data is a robust spatial transformation method published by Henry Huang and Ed Hoffman along with their collaborators It was originally described in IEEE Tai et al IEEE Trans Nucl Sci NS 44 1997 4 1606 1612 fe Beier Deply Slee Dispiay Reference Recon Itera Hospital ID Demos Session ID Neurod Tracer FOG Referring Physician Unknown 5 For the most standard use of the Program 1 comparing an individual scan from the end user s site to NeuroQ s built in database it is recommended to use 20 iterations and this 1s the only option that normally will ever need to be selected The other choices in the Iterations pull down menu 1 2 5 10 and 15 have been retained in order to allow flexibility to use the tool in other ways for example 1 rapid testing of software operability by selecting a small number of iterations 2 processing a batch of scans acquired at the end user s site to create a new database with whatever number of iterations is desired 3 sequential use of the reiteration routine such as adding another 5 iterations to a scan that had already been re iterated 20 times in order to obtain a closer spatial f
15. ative dementias comparison with perfusion SPECT and with clinical evaluations lacking nuclear imaging J Nucl Med 45 594 607 Silverman DHS and Alavi A 2005 PET imaging in the assessment of normal and impaired cognitive function Radiologic Clin North Am Saunders Philadelphia 43 67 77 References For Case Study 3 Chang CY and Silverman DHS 2004 Accuracy of early diagnosis and its impact upon the management and course of Alzheimer s disease Expert Rev of Molec Diagnostics 4 1 63 69 Imamura T K Ishii M Sasaki et al Regional cerebral glucose metabolism in dementia with Lewy bodies and AD a comparative study using positron emission tomography Neurosci Lett 1997 235 49 52 Ishii Yamayji S Kitgaki H et al Regional cerebral blood flow difference between dementia with Lewy bodies and AD Neurology 1999 53 413 416 Knopman DS DeKosky ST Cummings JL Chui H Corey Bloom J Relkin N Small GW Miller B Stevens JC Practice parameter diagnosis of dementia an evidence based review Report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2001 56 1143 1153 20 Minoshima S Giordani B Berent 5 Frey Foster NL Kuhl DE Metabolic reduction in the posterior cingulate cortex in very early AD Ann Neurol 1997 42 85 94 Silverman DHS 2004 Brain F 18 FDG PET in the diagnosis of neurodegenerative dementias comparison with perfusion SPECT and with clinical evaluations lac
16. dition s do the deficits still persist Yes continue to 4 No PET scan is not indicated 4 Does the patient suffer from Alzheimer s disease in the judgment of a physician experienced in the diagnosis and assessment of dementia who evaluated this patient aided by a cognitive scales or neuropsychological tests b corroborating history from a well acquainted informant C laboratory tests including serum B12 and TSH levels and structural imaging MRI or CT __ Yes the physician judges the presence of Alzheimer s disease to be certain PET scan is not covered __ No the physician judges the absence of Alzheimer s disease to be certain PET scan is not covered Uncertain the physician judges that it is uncertain whether the patient suffers from Alzheimer s disease continue to 5 5 Does the patient exhibit symptoms e g early onset or prominence of social disinhibition awkwardness difficulties with language loss of executive function such that frontotemporal dementia is suspected as an alternative cause of the patient s cognitive deficits Yes continue to 6 No PET scan is not covered 6 Is it reasonable to expect that information obtained through FDG PET will help with diagnosis and management of the patient Yes continue to 7 No PET scan is not covered 7 Has the patient previously undergone SPECT or FDG PET for the same indication Yes the results were conclusive and the patient s condit
17. e assessment of normal and impaired cognitive function Radiologic Clin North Am Saunders Elsevier Philadelphia 2005 43 67 77 Moulin Romsee G Maes A Silverman D Mortelmans L Van Laere 2005 Cost effectiveness of 18F fluorodeoxyglucose positron emission tomography in the assessment of early dementia from a Belgian and European perspective Eur J Neurol 12 254 263 Daniel Silverman MD PhD Nuclear Medicine Clinic Div Biological Imaging Dept Molecular and Medical Pharmacology University of California Los Angeles Appendix I BRAIN PET SCAN VISUAL INTERPRETATION Examine for and document where appropriate a adequacy of the technical quality of scan acquisition reconstruction and display b presence of any evident structural abnormality including rating the degree of atrophy as either none slight mild moderate or severe c assessment of global level of cortical metabolism relative to the levels visually evident in basal ganglia thalamus and cerebellum d presence of any focal cortical abnormalities with locations specified as left or right dorsolateral prefrontal medial prefrontal anterior cingulate inferior frontal sensorimotor superior parietal inferior parietal parietotemporal superior temporal mid to inferior anterior lateral temporal mid to inferior posterior lateral temporal mesial temporal primary visual occipital associative visual occipital or posterior cingulate cortex e
18. e pattern that includes posterior cortical hypometabolism but is nevertheless inconsistent with AD as the most likely or sole cause of cognitive impairment P7 e g due to involvement of brain regions known to be preserved in AD and or lack of involvement of inferior parietal and posterior cingulate cortex abnormal in a neurodegenerative pattern that is most consistent with frontotemporal dementia P2 or a predominantly subcortical neurodegenerative process P3 34 PET Dementia Eval Cases nz284 138H 146L No progressive Progressive process process evident on evident on PET P PET N 7496 2696 n 210 n 74 117H 93L O1Ll 2 N3 P1 P2 P3 Normal Global Focal Parietal Frontal predom Hypometabol metabolism hypometabolism hypometabolism hypometabolism of caudate not meeting P and lentiform criteria BEEN temporal frontal No progressive Progressive No progressive Progressive dementia dementia found dementia dementia found 9196 8096 2096 9 191 n 59 n 15 n 19 113H 78L 14H 45L 7H 8L fana US Figure 1 PET patterns and presence of progressive disease in patients undergoing evaluation for dementia PET scans typical of each of six categories of cerebral metabolic patterns designated N1 N2 N3 P1 P2 are demonstrated Images displaying N1 P1 and P3 patterns were acquired with a Siemens ECAT EXACT HR scanner those displaying N2 N3 and P2 patterns were acqu
19. ection Interpretation A pattern of focal cortical inhomogeneities on PET all accounted for by areas of infarction on MRI implies dementia secondary to cerebrovascular disease which also often affects subcortical structures A pattern of focal cortical inhomogeneities on PET unmatched by MRI findings is consistent with a neurodegenerative disorder e g Alzheimer s disease Pick s disease other frontotemporal dementia dementia with Lewy bodies dementia of Parkinson s disease Huntington s disease Creutzfeldt Jacob disease or progressive subcortical gliosis see Table on page 1 for differential diagnostic considerations 39
20. ed Applications After installation Support Audio Visual User Manual s click on the Syntermed Icon on your desktop Toolbox to run the applications Quick Start Syntermed Live Syntermed Live AVI You need a Web browser to view the Syntermed Live AV2 NeuroQ documentation and you need to be SyncTool AV Blood Pool SPECT connected to the Internet in order to NeuroQ AVI Emory Reconstruction visit our web site or download the NeuroQ AV2 Emory Nl Limit Prograr support programs Click on the NeuroQ FAQ Multi Pinhole ovntermed Icon to go to our Web Site or the Syntermed Live Icon to see a Download Links s if required demo of our remote viewing solution obe Acrobat Intern Install Applications Install Syntermed Live Wi How Your Sludies Ga Wherever You Ga The Autoplay screen should automatically be displayed when the CD is put in the drive If it does not come up then go to the CD and click on the autorunNCTb exe file to bring up the screen Read the Read Me First document and then you can install the applications by clicking on the Install button If you want to review the user manual then click on the NeuroQ Manual button You can then run NeuroQ directly from the CD by clicking on the RUN button which will bring up the MCP program listing all of the demo patients LAUNCHING THE PROGRAM from the Windows operating system by double clicking on the Syntermed Icon on your desktop shown on the left
21. enerated during the processing c A file called patientname ROlImean dat which contains the mean values generated from the ROI analysis NeuroQ M ANALYSIS SCREEN Left Side 2 3 4 5 6 7 8 9 10 11 I File Processing Display ice Display Reference Region Metabolism Patient Name NeuroQ Demo Case3 Abn Mein Qc Slices Gorntare PETCT EQuAL Data Save Help Study Date 15 Aug 1996 Control and patient values are normalized to the average pixel value among all regions in each scan 12 p Normal Template with Cluster Regions 17 18 20 D 22 24 32 34 35 i 42 46 52 Region Mean AC Patient Pt Pt M AC SD from M AC REGIONAL HYPOMETABOLISM rGFs 0 18 ROI Hame rGFd i 222 Magnitude of Difference IGFs i 1 233 SD from M AC IGFd 1 215 Positive sign corresponds to values gt Mean ISM 4 j 045 Negative sign corresponds to values lt Mean rsM i REGIONAL AND CLUSTER DATA IsPL rAVC p3b Difference 0 46 is the mast hypometabolic rsPL d region rGFm 7 E rAVC p24 88D from M AC 12 73 is the region with the most significant hypometabolism iP cwm Reformatted Patient Brain Iterations 20 Sell J E a Patient Brain FDG Brain Normal 14 gt SD AC Patient Pt MEAC 3 45 rsPL p14 1 00 0 04 1 5 0 93 0 07 1
22. face projections of fluorine 18 FDG PET Journal of Nuclear Medicine 36 1238 1248 1995 Tai Y C Lin K P Hoh C K Huang S C Hoffman E J Utilization of 3 D Elastic Transformation in Registration of Chest X ray CT and Whole Body PET IEEE Trans Nucl Sci NS 44 4 1606 1612 1997 Silverman DHS Phelps ME Application of positron emission tomography to evaluation of metabolism and blood flow in human brain normal development aging dementia and stroke Molec Genetics and Metab 74 128 138 2001 Minoshima S Frey J H Burdette T Vander Borght Koeppe D E Kuhl Interpretation of metabolic abnormalities in Alzheimer s disease using three dimensional stereotactic surface projections 3D SSP and normal database Journal of Nuclear Medicine 36 237P 1995 30 Ishii K Sakamoto S Sasaki M Kitagaki H S Hashimoto M Imamura T Shimomura T Hirono N Mori E Cerebral glucose metabolism in patients with frontotemporal dementia J Nucl Medicine 39 1875 1878 1998 Silverman D H S Lu C S Wong G R Aung A M K Czernin J Phelps M E Small G W Dahlbom M Comparison of methods for comparing brain images of individual cognitively impaired patients to a normal group Journal of Nuclear Medicine 42 suppl 224P 2001 Silverman D H S Marseille D M Peng N X Dahlbom M Small G W Chen W Czernin J Phelps M E Comparing brain PET scans of individuals undergoin
23. g dementia evaluation to co registered normal databases effect of varying how Normal is defined Journal of Nuclear Medicine 44 suppl 17P 2003 3l ADDITIONAL REFERENCES Minoshima S Giordani B Berent S Frey K Foster NL Kuhl DE Metabolic reduction in the posterior cingulate cortex in very early Alzheimer s disease Ann Neurol 19977 42 85 94 Silverman DHS Small GW Chang CY Lu CS Kung de Aburto MA Chen W Czernin J et al Positron emission tomography in evaluation of dementia regional brain metabolism and long term outcome JAMA 2001 286 2120 2127 Silverman DHS Gambhir SS Huang HWC Schwimmer J Kim S Small GW Chodosh J Czernin J Phelps ME Evaluating early dementia with and without assessment of regional cerebral metabolism by PET a comparison of predicted costs and benefits J Nucl Med 2002 43 253 266 Silverman DHS Truong CT Kim SK Chang CY Chen W Kowell AP Cummings JL Czernin J Small GW Phelps ME Prognostic value of regional cerebral metabolism in patients undergoing dementia evaluation comparison to a quantifying parameter of subsequent cognitive performance and to prognostic assessment without PET Molec Gen and Metab 2003 80 350 355 Silverman DHS Brain F 18 FDG PET in the diagnosis of neurodegenerative dementias comparison with perfusion SPECT and with clinical evaluations lacking nuclear imaging J Nucl Med 2004 45 594 607 Silverman DHS and Alavi A PET imaging in th
24. in his history physical or laboratory work up Moreover for patients possessing his apparent high level of pre morbid intellectual ability and education it is common for loss of cognitive ability to be experienced while still being able to perform at levels considered to be within the normal ranges of standard neuropsychological tests PET Interpretation The scans from 2001 and 2004 each reveal mild parietal temporal hypometabolism more pronounced on the left right side of image NeuroQ analysis identifies mild abnormalities purple to red shades in parietal temporal and posterior cingulate regions with well preserved metabolism in other regions blue shades a pattern very suggestive of early Alzheimer s type changes occurring in this patient s brain 25 The pattern of cerebral metabolism in 2004 has slightly changed since 2001 Visually there appears to be slight interim worsening of parietal temporal hypometabolism Show combined figure with arrows on slide 3 here That impression is bolstered by the NeuroQ analysis which shows in its plane 22 1mage the left parietotemporal cortex advancing to a near red shade 12 and 4 standard deviations below normal in 2004 from the purple shade 9 and 3 SD below normal seen in 2001 Case Summary To summarize at a time when conventional clinical evaluation was not sufficiently sensitive to document cognitive abnormality in this 71 year old physicist reporting memory problem
25. ion has not substantially changed PET scan is not covered Yes but the results were not conclusive and at least a year has elapsed continue to Z8 __ Yes but there have been important changes in scope or severity of the patient s cognitive deficits since then continue to 8 No continue to 8 8 An FDG PET scan is considered reasonable and necessary by CMS The patient should be referred to a facility accredited to operate Nuclear Medicine equipment and the scan should be read by an expert with experience interpreting PET scans for the evaluation of dementia To request a color coded electronic copy of this Checklist e mail Dr Dan Silverman at uclasomdan 9 yahoo com 38 Daniel Silverman MD PhD Nuclear Medicine Clinic Div Biological Imaging Dept Molecular and Medical Pharmacology University of California Los Angeles APPENDIX IV USING CLINICAL BRAIN PET FOR EVALUATION OF DEMENTIA Indication Changes in memory language function personality or behavior noted by the patient friends and family and or physician for which the etiology is not evident or the symptoms have not been reversed within a reasonable period of time after initial presentation Acquisition Protocol FDG 10 mCi for 2D acquisitions 3 5 10 mCi for 3D acquisitions administered 1 v 40 min uptake period with eyes open in dimly lit quiet room followed by transmission and emission scans reconstructed with attenuation corr
26. ired with a Siemens ECAT 931 scanner Image set in black background was acquired using a GE Signa 1 5 T MRI scanner TR 2100 TE 80 H diagnosis established by histopathologic examination L outcome established by longitudinal monitoring 3 AD 1 AD progressive supranuclear palsy and 3 Creutzfeldt Jakob cases 86 AD 4 AD Lewy bodies 1 AD Parkinson s disease 1 AD cerebrovascular disease 1 AD Lewy bodies cerebrovascular disease 7 frontotemporal 6 Lewy body 3 subcortical gliosis 2 Creutzfeldt Jakob 1 progressive supranuclear palsy and 1 Kuf s lipofuscinois case Daniel Silverman MD PhD Nuclear Medicine Clinic Div Biological Imaging Dept Molecular and Medical Pharmacology University of California Los Angeles APPENDIX II CLINICAL BRAIN PET DIFFERENTIAL DIAGNOSIS OF DEMENTIA SYNDROMES Regional Hypometabolism Identified by FDG PET Etiology of Dementia Alzheimer s Disease Parietal temporal and posterior cingulate cortices affected early relative sparing of primary sensorimotor and primary visual cortex sparing of striatum thalamus and cerebellum Vascular Dementia Hypometabolic foci affecting cortical subcortical and cerebellar areas Frontotemporal Dementia Frontal cortex anterior temporal and mesiotemporal areas affected earlier and or with greater initial severity than parietal and lateral posterior temporal cortex relative sparing of primary sensorimotor posterior cingulate and
27. it in a case where the individual s original scan is structurally very different from the normal template scan 4 various research applications etc 6 Once the Reformat option has been selected an information box will be displayed informing you of the number of iterations you have selected information You have chosen to reformat with 20 iteration s This process may take awhile Please be patient omes 7 Click on the OK button and the patient s study will be reformatted to align with the normal template On a current processor 1 7GHz the reformatting will take approximately 2 3 minutes 8 Once the study is reformatted the final quantitative analysis output will be displayed which is shown below ES NeuroQ TM Analysis v3 0 Build 20070520 File Processing Display ice Display Reference Region Metabolism Patient Name NeuroQ Demo Case3 Abn Main ac Slices Gornpare PET CT EQuAL Data Save Help Study Date 15 Aug 1996 Hospital ID Demo3 Session ID NeuroG Control and patient values are normalized to the Tracer FDG Referring Physician Unknown average pixel value among all regions in each scan Normal Template with Cluster Regions Reformatted Patient Brain Iterations 20 E Region Patient Pt Pt M AC 50 from MAC rSM p14 rsPL p14 riPL p16 rGFm p17 rSM p17 rAVC p18 riPL p18 rBroca p20 rPCC p20 IAC p20 rANC p20 Patient Pt
28. king nuclear imaging J Nucl Med 45 594 607 Silverman DHS and Devous MD 2004 PET and SPECT imaging in evaluating Alzheimer s disease and related dementia In Nuclear Medicine in Clinical Diagnosis and Treatment a edition PJ Ell and SS Gambhir eds Churchill Livingstone Elsevier Recent Textbooks Silverman DHS and Melega WP 2004 Molecular imaging of biological processes with PET evaluating biologic bases of cerebral function In PET Molecular Imaging and Its Biological Applications ME Phelps ed Springer Verlag New York pp 509 583 Silverman DHS and Devous MD 2004 PET and SPECT imaging in evaluating Alzheimer s disease and related dementia In Nuclear Medicine in Clinical Diagnosis and Treatment 3 edition PJ Ell and SS Gambhir eds Churchill Livingstone Elsevier Silverman DHS Strommer JL Marseille DM Gambhir SS 2004 PET Brain Atlas In Nuclear Medicine in Clinical Diagnosis and Treatment 3 edition PJ Ell and SS Gambhir eds Churchill Livingstone Elsevier References Related to NeuroQ Development Silverman DHS and Melega WP Molecular imaging of biological processes with PET evaluating biologic bases of cerebral function in PET Molecular Imaging and Its Biological Applications pp 509 583 Springer Verlag New York 2004 Minoshima Satoshi Frey Kirk A Koeppe Robert A Foster Norman L and Kuhl David E A diagnostic approach in Alzheimer s disease using three dimensional stereotactic sur
29. n DS DeKosky ST Cummings JL Chui Corey Bloom J Relkin Small GW Miller B Stevens JC 2001 Practice parameter diagnosis of dementia an evidence based review Report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 56 1143 1153 Hoffman JM Welsh Bohmer KA Hanson M Crain B Hulette C Earl N Coleman RE 2000 FDG PET imaging in patients with pathologically verified dementia J Nucl Med 41 1920 1928 Silverman DHS Small GW Chang CY Lu CS Kung De Aburto MA Chen W Czernin J Rapoport SI Pietrini P Alexander GE Schapiro MB Jagust WJ Hoffman JM Welsh Bohmer KA Alavi A Clark CM Salmon E de Leon MJ Mielke R Cummings JL Kowell AP Gambhir SS Hoh CK Phelps ME 2001 Positron emission tomography in evaluation of dementia regional brain metabolism and long term outcome JAMA 286 2120 27 Silverman DHS Truong CT Kim SK Chang CY Chen W Kowell AP Cummings JL Czernin J Small GW Phelps ME 2003 Prognostic value of regional cerebral metabolism in patients undergoing dementia evaluation comparison to a quantifying parameter of subsequent cognitive performance and to prognostic assessment without PET Molec Gen and Metab 80 350 355 Chang CY and Silverman DHS 2004 Accuracy of early diagnosis and its impact upon the management and course of Alzheimer s disease Expert Rev of Molec Diagnostics 4 1 63 69 Silverman DHS 2004 Brain F 18 FDG PET in the diagnosis of neurodegener
30. nce 19 9624 is the cluster with the ROI Name left Thalamus lt 20 Diff largest Decrease Regional Decreases Magnitude of Difference 0 1568 Difference 15 3084 22 35 52 Difference Regions Cluster Regions neue Mean AC y 2 a Region Mean AC SDAC Study 1 Stud Study 2 1 96Diff 2 1 1 2 0 0 9678 09267 0 7417 01850 ror ee 0 3 a 0 9596 i 10233 10312 0 0078 0 7659 Ug ri 0 t 1 1202 1 1378 10724 00655 s p 0 ak 1 1594 11814 1 1557 0 0058 rGCa p17 U 4 0 0698 0 1568 mee 0 4 1 0128 1 0482 1 0546 0 0065 0 6183 Med E 1 1618 07 1 1976 1 2166 0 019 1 587 15 Diff 10 Diff 5 Diff The NeuroQ Compare Screen is enabled by selecting the two studies from the MCP screen and clicking on the launch button Once NeuroQ is launched it will show the most recent study in the main NeuroQ screen Click on the Compare button and the Compare display screen will be shown The oldest study is displayed in the top row the most recent in the middle row and the difference image is displayed in the bottom image to the right Use the middle slider bar in the middle row to step through the planes All images with the exception of the patient s images in the left hand column will move when the slider bar is moved left or right The difference image shows the regions in which there is at least a 1 standard deviation difference between the original and recent s
31. nd CT studies for the same patient and fuse those two data sets using scroll bars See the description of the PET CT feature below EQuAL Reprint of article in JNM about Extent Specified Quantified Asymmetry of Lobe EQuAL analysis which is a program that will be helpful for evaluating temporal metabolic asymmetry NeuroQ TM ROI Data Close Save Tables Save All Data this button will display the data screen which gives the mean average number of counts per second per pixel in ROJ for each of rGFs p3 729 20200 0 65722700 1 rGFd p3 956 69300 0 96226300 the 240 ROIs of the patient 1GFz p9 336 702300 0 84424700 norm refers to the mean lGFd p3 517 84500 0 73712000 15 9 999 61400 0 90004700 3 normalized to the average of rSM p5 889 49800 0 80170100 1 pio 1029 9800 0 92931700 all pixels in all ROI s rsPL pi 1119 6800 1 0091600 rGFd pili 1066 8800 0 96157500 default This beers 15 1 11 309 77000 0 99207600 shown below This data can rGFs pll 1026 0200 0 92474800 IGFs pili 1067 0000 0 96169300 be saved and then imported rSH pil 950 81700 0 85696700 h 15 11 1152 9200 1 0391200 into another application like 1 12 1043 9100 0 94087200 12 1002 4600 0 90351300 Excel for further analysis seris jail 1289 6700 i 1623700 Save this option when selected will save all of the reformatted data and analysis into single file called the
32. nd Study Comparison PROCESSING 3 The PET FDG brain files in DICOM format need to be selected and imported into the NeuroQ program Once this is done the initial NeuroQ screen will be displayed which is shown below The image on the left is mid transaxial slice of the patient The image in the middle represents the mid transaxial slice of the normal template The normal template images are from a high quality normal brain FDG PET scan acquired at UCLA and these are the images in which the 240 standardized regions of interest were defined Note The NeuroQ program can only handle brain data sets which contain actual brain data If slices are submitted to the NeuroQ program for reformatting which are outside of the brain region then including these images along with the images containing brain activity could result in inaccurate results 81 NeuroQ TM Analysis v3 0 Build 20070520 File Processing Display Patient Name NeuroQ Demo Case2 Mildly Abn Main Slices EQuAL Save Help Study Date 09 Aug 2004 pone d e ID Demo2 ID NeuroG Control and patient values are normalized to the pone d e FDG Physician Unknown average pixel value among all regions in each scan eon Reformatted Patient Brain Iterations 0 4 4 UN Brain FDG Brain Normal Hypometabolic Regions Region Mean AC Patient Pt Pt M AC 50 from MEAC Region Mean AC Patient Pt Pt M A amp C 50 from M amp C M amp C Mean of Asymptom
33. or you can go to the C Program Syntermed Files S yntermed Syntermed Demo 2008 MMCP folder and double click on Gemo za is the MCP exe application i y 1 There are multiple ways to launch the NeuroQ program You can launch it is launched the following screen will be displayed Y Syntermed Master Control Program for the 5yntermed Software Suite DEMO VERSION File Edit View Help ECTaolbox ERToolbo Neurol MPSPECT BPSPECT ENDG Patient Mame Study Date Type Neurol Demo Case 3 24 1333 Neurol Neurol Demo Cases Mildly Abn 59 2004 Neurol Demo Cases Abn 8 15 1335 Neurol 20 iteration Neurol Demo Cased Abn 8 15 1336 Maura Meurald EG uL 3 14 1335 Neurol 20 iteration Neurol Demo PET CT 17172007 Neurol 20 iterations Neurol Study Compare 2001 1172001 Neurol 20 iterations Neurol Study Compare 2006 11 2006 Neurol 20 iterations B studies This i a demo version of Syntermed software 2 There are three demo cases numbered 1 3 which have not yet been processed There is also one study Demo Case 3 that has already been reformatted that is included in the list and is called NeuroQ 20 iterations If you select the NeuroQ 20 iterations study then it will bring up the study that has already been processed For the other studies you will need to process them There are also demo cases for EQuAL PET CT a
34. plate Brain based on an archetypal normal brain with no clinical or metabolic signs of neurodegenerative disease ROI values for each plane are drawn in with a white outline Middle Plane Slider controls the brain plane of the normal brain display and the reformatted patient brain display at right the current plane number is displayed above the slider slide to the left or right to access lower or higher planes respectively simultaneously for both displays Reformatted Patient Brain brain is based on specified number of reiterations of the original patient brain scan this display only appears after reiteration of brain 1mages All abnormal regions will be displayed in a two dimensional coded color scale click on the Help button for color coding explanation Table of Abnormal Regions displays all regions having internally normalized region of interest ROI radiotracer uptake values falling more than 1 65 standard deviations below the mean value in the Hypometabolic operation and more than 1 65 standard deviations above the mean value in the Hypermetabolic operation for a symptomatic control group regions are displayed in abbreviated form with the plane number after the the last row of the table gives a total of the Pt M AC and SD from columns Table of Cluster Values the ROI cluster value is based on the average of the represented region across all planes where it 1s assessed 14 Ne
35. pometabolism displays the most hypometabolic regions and performs calculations accordingly Hypermetabolism displays the most hypermetabolic regions and performs calculations accordingly NOTE default is Hypometabolism File Processing Display Reference Region 3717 Patient Name NeuroQ Demo Case3 Abn study Date 15 Aug 1996 Hypermetabalism E Color Scale From the Display menu item you can select Show Color Scale to provide a legend of the two dimensional color coding 50 0 05 0 10 0 15 0 20 0 25 0 30 0 35 Mean AC Patient 4 Brain Plane Displays includes schematic display of each of the 47 ROI clusters shown at the normal template planes numbered below each image Refer to the Show Color Scale description for color coding explanation Clicking on a ROI causes the full name and numerical characterization of that region to appear in the Data Display area 5 5 Data Display displays information based on the last ROI cluster the user clicked on 6 Regional and Cluster Data gives the most hypometabolic or hypermetabolic and most significant regions and clusters 16 euroQ M QUALITY CONTROL SCREEN The Quality Control Screen is comprised of three sections Set Axial Plane Limits Removal of Scalp Activity and Rigid Registration 1 NeuroQ TM Ana File Processing Disple lysis Version 3 0 Build 20080506 203302 Patient Name NeuroQ Demo Case1 Nml
36. presence of any focal non cortical abnormalities including in left or right caudate nucleus head lentiform nucleus thalamus cerebellar cortex midbrain pons and f any additional findings The cerebral metabolic findings noted from this systematic review of the PET should be correlated whenever possible with the structural information documented on CT or MHI with respect to cerebrovascular disease atrophic changes and other structural imaging findings Metabolic evidence of neurodegenerative processes e g Alzheimer s disease Pick s disease and other frontotemporal dementia dementia with Lewy bodies dementia of Parkinson s disease Huntington s disease is most strongly supported by identification of areas of regional hypometabolism unmatched by structural findings i e greater than could be expected for the degree of any generalized structural atrophic changes noted and not accounted for by cerebrovascular changes BRAIN PET SCAN CATEGORIES FOR DEMENTIA EVALUATIONS ocans obtained in the evaluation of cognitive impairment can be classified into one of 7 main interpretive categories Figure 1 adapted from Silverman et al JAMA 2001 286 2120 2127 normal N1 or normal except for age appropriate atrophic changes N2 abnormal only in a non neurodegenerative pattern N3 abnormal in a neurodegenerative pattern involving posterior cortical hypometabolism consistent with presence of AD P1 abnormal in a neurodegenerativ
37. revealed progression of cerebral atrophy 1995 Brain MRI revealed moderate generalized cerebral atrophy which is not significantly changed when compared to the scan of 1994 The scan is otherwise within normal limits 1996 Brain MRI with and without contrast revealed stable appearance of cerebral cortical atrophy 1997 Head CT revealed cerebral atrophy but is otherwise negative Why should the patient get a PET scan at this point in his evaluation 27 Mr has documented cognitive decline and motor symptoms noted on neurologic examination The symptoms are unexplained by his general history physical examination laboratory screen and structural neuroimaging tests which are largely unremarkable Although he was evaluated by a prominent dementia expert who did not suspect Alzheimer s disease there are no tests short of brain biopsy documented to be as accurate as FDG PET in the identification of Alzheimer s disease that the neurologist did nor could do to exclude the possibility of that now treatable condition Clinical Follow up Mr F continued to progressively deteriorate with respect to cognitive and motor symptoms also developing a seizure disorder before his death that proved resistant to medical therapy An autopsy was performed in 2000 at the Alzheimer s Disease Center for which the patient s neurologist was Director and the final diagnosis was Alzheimer disease Braak and Braak Stage VI CERAD definite
38. s PET was already documentably mildly abnormal both by visual and quantitative analyses From 2001 to 2004 neuropsychologic performance with respect to immediate and delayed memory for Word associations contextual information rote list learning and complex visual stimuli declined across testing sessions indicating significant cognitive deterioration within those abilities according to the neuropsychologist By 2004 Mr E s performance met criteria for Mild Cognitive Impairment performing between one and two standard deviations below the mean established for his same age peers on at least 5096 of the memory tasks The combination of this clinical progression with the posterior predominant pattern of hypometabolism affecting especially parietal temporal cortex 1s most consistent with the presence of incipient Alzheimer s disease Armed with the FDG PET information his managing physician prescribed an anti Alzheimer s combination regimen including both donepezil and memantine in advance of the second neuropsychologic testing session On his current regimen he continues to achieve 30 30 on the Mini Mental State Examination MMSE 26 3 Demo Case3 Severely Abnormal Patient History Mr F was 603 years old when he underwent FDG PET in August 1996 for symptoms of decreased memory language and visual skills The cognitive decline had been noted for at least 2 years as had been sensory and motor deficits of his left upper e
39. titative and statistical comparisons of S ROT s The program requires the operator to select the patient s FDG Brain scan Following a number of internal checks on the data e g accurate radiopharmaceutical the operator has to initiate the elastic spatial reformatting or normalization of the patient s scan into a standardized volumetric space Following this step the program determines the uptake in 240 ROIs normalized to the uptake in the subject s sensorimotor cortical region S ROI The uptake in the ROIs is then compared to a normal data base of uptakes based upon uptake in the corresponding S ROIs determined in 50 normal subjects without identified neuropsychiatric disease Any region with an uptake below 1 65 S D of the mean established from the normal data base is considered abnormal Installation of NeuroQ The commercial versions of the applications are downloaded from our web site http www syntermed com downloads NeuroQ htm once the software has been purchased the software license is sent to enable the applications The demo version of NeuroQ can be installed from our Syntermed Demo CD which contains all of our software products To install from the Demo CD first insert the CD into your drive and the autoplay program will be displayed E Syntermed Demo CD 2008 Syntermed Demo CD 2008 This CD ROM contains the programs and Documentation documentation needed to install and operate I 2j the Synterm
40. tudy This analysis 1s helpful to monitor the progression of dementia over a period of time 20 NeuroQ PET CT DISPLAY SCREEN NeuroQ TM Analysis Version 3 0 Build 20080506 203302 File Patient Name NeuroO Demo PET CT Main ac Slices PET CT EQuAL Data Save Help Study Date 01 Jan 2007 S 5 PET Max Level 100 x CT Level CT Window Preset Windows 3 75 NEURO 502 The PET CT display allows for displaying both the PET and CT brain images from the same patient The PET brain images are contained in the top row The PET brain images brightness can be changed by sliding the PET Max Level slider up or down The CT images are contained in the middle row The CT brain images window level can be changed by manipulating the sliders for CT Level and CT Window up or down The user also has the option picking preset windows for Neuro or Bone in the Preset Windows drop down box The bottom row contains the fused images The PET CT slider bar allows the user to display only the PET slider all the way up only the CT slider all the way down or fused slider in the middle Various levels of fusion can be displayed by moving the slider up or down Triangulation is enabled on the PET CT and Fused images by clicking left on any 1mage and it will show you the plane for that location on the other two images 21 EQuAL ANALYSIS 81 NeuroQ 1M Analysis Version 3 0 Build 20080506 203302
41. uroQ DISPLAY SCREEN Right Side 1 2 3 l M File Processing Display Slice Display Reference Region Metabolism Patient Name NeuroQ Demo Case3 Abn Study Date 15 Aug 1996 e Normal Template with Cluster Regions REGIONAL HYPOMETABOLISM ROI Name left pos Cinqulate Cortex Magnitude of Difference 0 09 50 from M AC 2 46 Positive sign corresponds to values gt Mean AC Negative sign corresponds to values Mean AC REGIONAL AND CLUSTER DATA rAVC p36 Difference 0 46 is the most hypometabolic region rAVC p24 SD from 12 73 is the region with the most significant hypometabolism rAVC Difference 0 36 is the most hypometabolic cluster rAVC 50 from M AC 15 74 is the cluster with the most significant hypametabalism 15 1 File Menu user can choose the option to Print Save or Quit 2 Reference Region Menu user can select which cluster among Pons Cerebellum Sensorimotor Thalamus or Whole Brain to base the normalization of the regions on NOTE the default normalization is based on the whole brain File Processing Display Slice Display Metabolism Patient Name MeuroQ Dem 25215280 Pons P Study Date 15 Aug 1996 Greeti i Hospital ID Demo3 Cortex END Tracer FDG Referring Phy Thalamus T R L E _ 3 Metabolism Menu Hy
42. xtremity Mr F s past medical history was positive for pyelonephritis prostatitis and prostate surgery for benign enlargement The patient had a history of heavy alcohol use in the past but had discontinued drinking and did not use tobacco or other drugs nor have a history of such use He was a lawyer as was his wife and they had two small children His physical examination other than his neurologic exam was normal His neurologist noted upon exam that the patient got two of three items correct regarding orientation and three of four words remembered correctly at 3 minutes and that he had marked apraxia of the upper extremities with left worse than right plus mild Parkinsonism with a mask face cranial nerves were intact and reflexes were normal Blood laboratory tests obtained one month prior to PET were normal including CBC electrolytes BUN creatinine glucose calcium Fk ego Sapo cholesterol and liver enzymes VDRL and TSH tests obtained the following year were also normal The neurologist following Mr F an internationally recognized expert on dementia and Director of a university based Alzheimer s Disease Center diagnosed him with corticobasal degeneration and depression for which he was treated with the antidepressant sertraline Structural Neuroimaging 1992 Brain MRI revealed mild enlargement of the lateral ventricles otherwise unremarkable 1994 Brain MRI with and without contrast
43. y will show the patients slices in inverted scale An option is provided to display the slices using other color tables by clicking on the CM Color Map button located above the color table bar A list of color tables will be displayed as shown to the left You can select any of these color tables and the display will change to reflect this new table Changing top bottom contrast At the top of the color bar is a value of 100 and at the bottom a value of 0 If you position your cursor over one of these numbers click left hold down and move the value up or down you can adjust the contrast in the image The upper value 100 when moved down will lower the upper value producing a brighter image The lower value 0 when moved up will increase the lower value resulting in reducing counts in the image at the low end of the scale or darken the image Note to go back to the previous screen click on the Main button 12 10 E NeuroQ TM Help The Quantitative display fright is a schematic summary representing Compare The compare screen allows the user to compare two studies from the same patient performed at different times This analysis provides a Difference Image between the two studies showing which regions showed a change in hypo or hyper metabolic activity between the two studies See the description of the Compare feature below PET CT The PET CT screen allows the user to display both the PET a
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