Spect in concussion, vertebro basilar insufficiency and other neurological disorders

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  • This is the hospital I did my residency in as well the research using SPECT
  • 2. For our Imaging need we have
  • A number of imaging techniques are available for use in neurosciences and can be braodly divided into …
  • In..
  • The Biochemical interactions between brain tissue and injected substance (HMPAO,ECD, Iophane) form the underlying principle of SPECT. However to make these interactions recordable these substances have to be labeled with radioactive tracers ( 99m HMPAO, 99m ECD, 123 I-iophane)
  • And the radio activity of the trapped sbstances forms the basis of SPECT
  • Although SPECT can & is used for imaging the whole body, Brain SPECT has two important uses… 1 To see for regional cerebral perfusion and the most commonly used rediopharamceuticals for this purpose are the Hexam methyl .. And Ethylene Cysteine Dimer 2ndly For imaging of the neurotransmitter systems using radiopharmaceutical Ioflupane
  • It is well known tha…. In a presentation in this very auditorium a few weeks by my collegue on pediatric head injury and outcome prediction back it was c
  • The hippocampus is a key structure in the medial temporal lobe, and is located within the hippocampal formation, that also includes the dentate gyrus, subicular complex, and entorhinal cortex. & The reason we decided to target MTL in patients with concussion was …
  • Just to get a few definations out of the way-There are a number for different criteria defining minor head injury. We decided to stick to this definition as it is very simple to apply and has been around for a relatively long time to be validated
  • The definition of PCS is more tenacious and we used the DSM 4 criteria to define PCS. This critria include...
  • Our research on post concussion syndrome focussed on the medial temporal lobe. This research has been published in the JNS a couple of months back
  • We decided to use a pharmacological intervention and use SPECT to see its utility
  • To briefly describe this drug which we used in our next study
  • So we did not use much creativity and did the same study all over again, except that we used an intervention in the form of piracetam
  • The way SPECT methodology differed from the previous study was in quantification of the cerebral perfusion. Compared to visual scale previously we used Circular region of interest (ROI)
  • Radiotracer counts
  • During my posting in neurology department, I became interested in stroke. However, as the posting was of two months duration only, I could not conduct any studies. On return to my own department, I realized that many patients with cranio-cervical junction anomalies had features of posterior circulation ischemia.
  • We therefore decided to study CCJ anomalies as a cause of verterbro basilar insufficiency.
  • At the outset we were concerned whether SPECT could assess the posterior circulation adequately. A review of the literature however dispelled our doubts.
  • And the reason we rised this question was…
  • Spect in concussion, vertebro basilar insufficiency and other neurological disorders

    1. 1. SPECT IN CONCUSSION, VERTEBRO-BASILAR INSUFFICIENCY AND OTHER NEUROLOGICAL DISORDERS Novel applications and insights <ul><ul><li>Deepak Agrawal, MBBS, MS, MCh. </li></ul></ul><ul><ul><li>Fellow, Pediatric Neurosurgery </li></ul></ul><ul><ul><li>BC Children’s Hospital, UBC </li></ul></ul>
    2. 2. LEARNING OBJECTIVES <ul><li>To understand uses of Single Photon Emission Computed Tomography ( SPECT) in patients with post-concussion syndrome and vertebrobasilar insufficiency </li></ul><ul><li>To be familiar with the use of SPECT as an investigative and research tool in neurosciences </li></ul>
    3. 3. Imaging Brain function using SPECT All India Institute of Medical Sciences, New Delhi
    4. 4. <ul><li>All India Institute of Medical Sciences, Delhi </li></ul><ul><li>1200 bed tertiary centre </li></ul><ul><li>Annual budget of CAD $250 million </li></ul><ul><li>Imaging </li></ul><ul><li>6 CT scanners </li></ul><ul><li>2 1.5 T MRI scanners, a 4.7 Tesla animal MRI/MRS scanner, and a 9.4 Tesla NMR spectrometer. </li></ul><ul><li>1 PET, 2 SPECT scanners </li></ul>Imaging Brain function using SPECT
    5. 5. <ul><li>IMAGING TECHNIQUES </li></ul><ul><li>STRUCTURAL- MRI, CT </li></ul><ul><li>FUNCTIONAL- SPECT, PET, fMRI </li></ul><ul><li>(SPECT-Single Photon Emission Computed Tomography) </li></ul>Imaging Brain function using SPECT
    6. 6. <ul><ul><li>Functional Imaging </li></ul></ul><ul><ul><li>PET- Gold standard </li></ul></ul><ul><ul><li>SPECT - More widely available </li></ul></ul><ul><ul><li>- Much cheaper </li></ul></ul><ul><ul><li>- Still able to provide much of the same information </li></ul></ul>Imaging Brain function using SPECT
    7. 7. <ul><li>UNDERLYING PRINCIPLES OF SPECT </li></ul><ul><li>Biochemical interactions between brain tissue and injected substance (HMPAO, ECD, Iophane) </li></ul><ul><li>These substances are labeled with radioactive tracers ( 99m Tc-HMPAO, 99m Tc-ECD, 123 I-iophane) </li></ul>Imaging Brain function using SPECT
    8. 8. <ul><li>UNDERLYING PRINCIPLES </li></ul><ul><li>Radiopharmaceutical injected IV </li></ul><ul><li>Crosses BBB proportionate to blood flow </li></ul><ul><li>Enters Neuronal tissue – stereoisomeric change </li></ul><ul><li>Become ‘trapped’ inside the neurons </li></ul>Imaging Brain function using SPECT
    9. 9. <ul><li>UNDERLYING PRINCIPLES </li></ul><ul><li>Increased neuronal activity = increased neuronal uptake of radiopharmaceutical = Increased perfusion on SPECT </li></ul><ul><li>This image of cerebral perfusion indirectly reflects cerebral metabolism </li></ul>Imaging Brain function using SPECT
    10. 10. <ul><li>BRAIN SPECT </li></ul><ul><li>Brain perfusion - HMPAO,ECD </li></ul><ul><li>HMPAO -Hexa Methyl Propylene Amine Oxine; ECD -Ethylene Cysteinate Dimer </li></ul><ul><li>Imaging of neurotransmitter systems - Ioflupane </li></ul>Imaging Brain function using SPECT
    11. 11. <ul><li>APPLICATIONS </li></ul><ul><li>Dementias </li></ul><ul><li>Alzheimers: ↓ perfusion TP regions B/L </li></ul><ul><ul><ul><ul><ul><li>Normal perfusion Subcortical region </li></ul></ul></ul></ul></ul><ul><li>Vascular Dementia: ↓ perfusion Subcortical regions </li></ul>Imaging Brain function using SPECT
    12. 12. <ul><li>APPLICATIONS </li></ul><ul><li>Epilepsy </li></ul><ul><li>Established role in epilepsy </li></ul><ul><li>SISCOM ( S ubtraction I ctal S PECT C oregistered with M RI) </li></ul>Imaging Brain function using SPECT
    13. 13. <ul><li>APPLICATIONS </li></ul><ul><li>Trauma </li></ul><ul><li>Can show abnormalities in pts with normal CT & MRI </li></ul><ul><li>Sensitivity can reach 80% compared to 5% for CT and 60% for MRI in minor head injuries </li></ul><ul><li>Kant R, Smith-Seemiller L, Isaac G, Duffy J. Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: comparison with MRI/CT. Brain Inj 1997;11:115. </li></ul>Imaging Brain function using SPECT
    14. 14. <ul><li>APPLICATIONS </li></ul><ul><li>Parkinsonism </li></ul><ul><li>Dopamine transporter imaging- assessing the presynaptic dopaminergic function </li></ul>Imaging Brain function using SPECT
    15. 15. <ul><li>APPLICATIONS </li></ul><ul><li>Research tool </li></ul><ul><li>before & after pharmacotherapy, psychotherapy & surgery </li></ul>Imaging Brain function using SPECT
    16. 16. <ul><li>APPLICATIONS </li></ul><ul><li>Dementias </li></ul><ul><li>Epilepsy </li></ul><ul><li>Trauma </li></ul><ul><li>Parkinsonism </li></ul><ul><li>Stroke </li></ul><ul><li>Research tool-(before & after pharmacotherapy, psychotherapy, surgery) </li></ul>Imaging Brain function using SPECT
    17. 17. <ul><li>APPLICATIONS </li></ul><ul><li>Dementias </li></ul><ul><li>Epilepsy </li></ul><ul><li>Trauma </li></ul><ul><li>Parkinsonism </li></ul><ul><li>Stroke </li></ul><ul><li>Research tool-(before & after pharmacotherapy, psychotherapy, surgery) </li></ul>Imaging Brain function using SPECT
    18. 18. SPECT in TRAUMA
    19. 19. <ul><li>TRAUMA </li></ul><ul><li>90% of all HI are supposedly ‘minor’ </li></ul><ul><li>Post concussion syndrome—including symptoms such as headache, irritability, poor concentration, memory disturbances, dizziness, anxiety, and depression—has been reported to occur in up to 80% of the patients following minor HI. </li></ul><ul><li>Hugenholtz H, Stuss DT, Stethem LL, Richard MT: How long does it take to recover from a mild concussion? Neurosurgery 22 : 853–858, 1988 </li></ul><ul><li>Wood RL. Understanding the 'miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Brain Inj.2004;18(11):1135-53 </li></ul>Imaging Brain function using SPECT
    20. 20. Medial Temporal Injury In Pediatric Postconcussion Syndrome <ul><ul><li>Deepak Agrawal, Naveen K*, C S Bal*, A K Mahapatra </li></ul></ul><ul><li>Departments of Neurosurgery and *Nuclear medicine, All India Institute of Medical Sciences, New Delhi </li></ul>
    21. 21. <ul><li>WHY MEDIAL TEMPORAL LOBE? </li></ul><ul><li>Hippocampus is especially vulnerable to insults such as ischemia, hypoxia, and seizures </li></ul><ul><li>Extent of hippocampal damage can be correlated with severity of memory impairment </li></ul>Rempel-Clower NL, Zola SM, Squire LR, Amaral DG. Three cases of enduring memory impairment after bilateral damage limited to the hippocampal formation. J Neurosci 1996;16:5233-5255. Temporal lobe damage in minor head injury
    22. 22. <ul><li>OBJECTIVES </li></ul><ul><li>Look for medial temporal hypoperfusion (MTH) on SPECT in children with minor head injury </li></ul><ul><li>To evaluate MTH on SPECT as a risk factor for development of persistent postconcussion syndrome (PPCS) at three months </li></ul>Temporal lobe damage in minor head injury
    23. 23. <ul><li>MATERIALS AND METHODS </li></ul><ul><li>PROSPECTIVE STUDY </li></ul><ul><li>One year period </li></ul><ul><li>Children ≤ 18 yrs of age </li></ul>Temporal lobe damage in minor head injury
    24. 24. <ul><li>MINOR HEAD INJURY </li></ul><ul><li>Loss of consciousness <30 minutes. </li></ul><ul><li>GCS score 13 to 15. </li></ul><ul><li>Posttraumatic amnesia <24 hours. </li></ul>[criteria published by the members of the Mild Traumatic brain injury Interdisciplinary Special Interest Group (BISIG)] Kay T, Harrington DE, et al. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8:86 Temporal lobe damage in minor head injury
    25. 25. <ul><li>Headache </li></ul><ul><li>Dizziness and vertigo </li></ul><ul><li>Memory deficits </li></ul><ul><li>Behavioral and emotional disturbances. </li></ul>POST CONCUSSION SYNDROME: (2 or more of the following) Temporal lobe damage in minor head injury DSM IV criteria Brown SJ, Fann JR, Grant I: Postconcussion disorder: time to acknowledge a common source of neurobehavioural morbidity. J Neuropsychiatry Clin Neurosci 6:15-22, 1994
    26. 26. <ul><ul><ul><ul><ul><li>CT head </li></ul></ul></ul></ul></ul>INVESTIGATIONS <ul><ul><ul><ul><ul><li>SPECT scan brain </li></ul></ul></ul></ul></ul><ul><li>(Within 72 hours & at 3 months) </li></ul>Temporal lobe damage in minor head injury
    27. 27. <ul><li>SPECT scanning was done using 99Tcm-ECD on a dual headed GE 'Varicam' scanner. </li></ul><ul><li>The final data was displayed on a 10 grade color scale and semi quantitative analysis performed. </li></ul>SPECT METHODOLOGY Temporal lobe damage in minor head injury
    28. 28. <ul><li>STUDY DESIGN </li></ul>Temporal lobe damage in minor head injury 30 Children with minor head injury Normal CT head & Post concussion Syndrome (PCS) SPECT scan (within 72 hrs) Medial temporal hypoperfusion (n=14 )(“MTH”) No Medial temporal hypoperfusion (n=16 )(“ control” ) 3 months later Repeat SPECT & clinical evaluation (PPCS) 3 months later Repeat SPECT & clinical evaluation (PPCS)
    29. 29. <ul><li>RESULTS (SPECT) </li></ul><ul><li>13/14 (93%) patients with initial MTH continued to have persistent MTH </li></ul><ul><li>0/16 (0%) of patients in control group developed subsequent MTH at 3 months </li></ul>Temporal lobe damage in minor head injury
    30. 30. Baseline At 3 months
    31. 31. 12/14 (86%) children developed PPCS in the MTH group, compared to 2/16 (12.5%) children in the control group P=0.0003 Temporal lobe damage in minor head injury RESULTS Persistent post concussion syndrome (PPCS)
    32. 32. <ul><li>CONCLUSIONS </li></ul><ul><li>Children with MTH are more likely to develop persistent post concussion syndrome </li></ul><ul><li>SPECT may help in identification and prognostication in this subgroup of children </li></ul>Temporal lobe damage in minor head injury
    33. 34. <ul><li>SPECT AS A PLATFORM FOR TESTING VARIOUS INTERVENTIONS </li></ul>
    34. 35. ROLE OF PIRACETAM IN POST-CONCUSSION SYNDROME A PROSPECTIVE RANDOMIZED STUDY Deepak Agrawal, K Naveen*, CS Bal*, AK Mahapatra Departments of Neurosurgery* and Nuclear medicine*, ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI, INDIA
    35. 36. <ul><li>Piracetam </li></ul><ul><li>Discovered 30 years ago by UCB pharma </li></ul><ul><li>GABA derivative, does not work via GABA pathways. </li></ul><ul><li>Mechanism of action remains unknown </li></ul><ul><li>Has beneficial effects on the CBF by decreasing the adhesivity, aggregation, and increasing the deformability of erythrocytes. </li></ul><ul><li>“ Nootropic ” </li></ul>Piracetam in minor head injury
    36. 37. <ul><li>Why Piracetam? </li></ul><ul><li>Already approved for use in Europe & India for a variety of disorders including head injury </li></ul><ul><li>Minimal side effects- More than 12 g of piracetam has been given as daily dose in acute stroke without appreciable side effects </li></ul><ul><li>De Deyn PP, Reuck JD, Deberdt W, Vlietinck R, Orgogozo JM. Treatment of acute ischemic stroke with piracetam. Members of the Piracetam in Acute Stroke Study (PASS) Group. Stroke 1997; 28: 2347-52. </li></ul>Piracetam in minor head injury
    37. 38. <ul><li>OBJECTIVE </li></ul><ul><li>To look for changes in cerebral perfusion on SPECT, following administration of Piracetam, in patients with post-concussion syndrome (PCS), </li></ul>Piracetam in minor head injury
    38. 39. <ul><li>1. Loss of consciousness <30 minutes. </li></ul><ul><li>2. GCS score 13 to 15. </li></ul><ul><li>3. Posttraumatic amnesia <24 hours. </li></ul>MINOR HEAD INJURY [criteria published by the Mild Traumatic brain injury Interdisciplinary Special Interest Group (BISIG)] Kay T, Harrington DE, et al. Definition of mild traumatic brain injury. J Head Trauma Rehabil 1993;8:86 Piracetam in minor head injury
    39. 40. <ul><li>Headache </li></ul><ul><li>Dizziness and vertigo </li></ul><ul><li>Memory deficits </li></ul><ul><li>Behavioral and emotional disturbances. </li></ul>POST CONCUSSION SYNDROME: (2 or more of the following) DSM IV criteria based on recommendation of Brown et al. Brown SJ, Fann JR, Grant I: Postconcussion disorder: time to acknowledge a common source of neurobehavioural morbidity. J Neuropsychiatry Clin Neurosci 6:15-22, 1994 Piracetam in minor head injury
    40. 41. <ul><li>MATERIALS AND METHODS </li></ul><ul><li>Prospective study </li></ul><ul><li>Adult patients (18-60 yrs) </li></ul>Piracetam in minor head injury
    41. 42. <ul><ul><ul><ul><ul><li>CT head </li></ul></ul></ul></ul></ul>INVESTIGATION <ul><ul><ul><ul><ul><li>SPECT scan brain </li></ul></ul></ul></ul></ul><ul><li>Within 72 hours of injury </li></ul>Piracetam in minor head injury
    42. 43. <ul><li>Circular region of interest (ROI) with a radius of 9.1mm (6 pels) in the basal ganglia, thalamus, temporal lobe, visual cortex and brain stem were used. </li></ul>SPECT Piracetam in minor head injury
    43. 44. Piracetam in minor head injury
    44. 45. <ul><li>S emiquantitative analysis of the data done using semiautomatic brain quantification programs (Xpertpro, Entegra with Neurogam). </li></ul>Regional cerebral perfusion <10% of contralateral lobe, or in case of bilateral involvement, less than 20% of cerebellum ABNORMAL SPECT SCAN Piracetam in minor head injury
    45. 46. Piracetam in minor head injury STUDY DESIGN 20 PATIENTS WITH POSTCONCUSSION SYNDROME & ABNORMAL SPECT PIRACETAM GROUP CONTROL GROUP 10 PATIENTS 800 mg PIRACETAM (Cerecetam) TDS x 6 WEEKS CLINICAL EVALUATION & REPEAT SPECT AT 6 WEEKS 10 PATIENTS NO PIRACETAM CLINICAL EVALUATION & REPEAT SPECT AT 6 WEEKS
    46. 47. <ul><ul><li>Significant rise in the post treatment ratio in the piracetam group (mean: 0.959) as compared to the controls (mean: 0.882) (p= <.001) </li></ul></ul><ul><ul><li>Nine patients (90%) also had improvement in their symptoms of PCS, compared to only three patients in the control group (p=0.01). </li></ul></ul><ul><ul><li>RESULTS </li></ul></ul>
    47. 48. <ul><li>CONCLUSIONS </li></ul><ul><li>Cerebral perfusion defects occur in majority of the cases of postconcussion syndrome following minor head injury. </li></ul><ul><li>Piracetam reverses cerebral perfusion deficits and may result in accelerated symptomatic improvement in patients with postconcussion syndrome. </li></ul>Piracetam in minor head injury
    48. 49. <ul><li>THIS PRELIMINARY STUDY SHOWED OBJECTIVELY THAT LOW DOSE PIRACETAM MAY BENEFIT PATIENTS WITH POSTCONCUSSION SYNDROME </li></ul>CONCLUSIONS Piracetam in minor head injury
    49. 50. Imaging Brain function using SPECT
    50. 51. CRANIO-CERVICAL JUNCTION ANOMALIES AS A CAUSE OF VERTEBRO-BASILAR INSUFFICIENCY Deepak Agrawal, Naveen K*, SS kale, C S Bal*, A K Mahapatra Departments of Neurosurgery and *Nuclear medicine, All India Institute of Medical Sciences, New Delhi-110029
    51. 52. <ul><li>SPECT IN VERTEBROBASILAR INSUFFICIENCY </li></ul><ul><li>Can SPECT reliably assess the posterior fossa? </li></ul><ul><li>YES! </li></ul><ul><li>Delecluse F, Voordecker P, Raftopoulos C.Vertebrobasilar insufficiency revealed by xenon-133 inhalation SPECT . Stroke 1989;20:952-6. </li></ul><ul><li>Foster NL, Mountz JM, Bluelein LA, Ackermann RJ, Petry NA, Kuhl DE. Blood flow imaging of a posterior circulation stroke. Use of technetium Tc 99m hexamethylpropyleneamine oxime and single photon emission computed tomography . Arch Neurol 1988;45:687-90. </li></ul><ul><li>Shuke N, Nagasawa K, Yamamoto W, Usui K, Sako K, Nakai H, Tanaka T, Aburano T. Demonstration of positional posterior cerebral ischemia on cerebral blood flow SPECT . Clin Nucl Med 2001;26:559-60. </li></ul>
    52. 53. <ul><li>BACKGROUND </li></ul><ul><li>Association of VBI with CCJ anomalies is severely underestimated </li></ul><ul><li>X-rays of the Cx spine are done in only 30% of pts with VBI & only 11% pts have proper flex n /ext n x-rays done </li></ul><ul><li>Lorenstan KJ, Schrospshire LC, Ahn HS. Congenital odontoid aplasia and posterior circulation stroke in childhood. Ann Neurol 1988;23-410-413 </li></ul>SPECT In vertebrobasilar insufficiency
    53. 54. <ul><li>BACKGROUND </li></ul><ul><li>Posterior circulation ischemia has a higher morbidity and mortality </li></ul><ul><li>Fifty percent of these patients who are managed conservatively progress to develop infarction </li></ul>SPECT In vertebrobasilar insufficiency
    54. 55. <ul><li>BACKGROUND </li></ul><ul><li>Diagnosing even a percentage of the patients with VBI as having CCJ anomalies may have major therapeutic & prognostic implications. </li></ul>SPECT In vertebrobasilar insufficiency
    55. 56. <ul><li>Pathogenesis VBI in CVJ Anomalies </li></ul>SPECT In vertebrobasilar insufficiency Chronic low grade micro-trauma Repeated flex/extn of vessel Intimal damage Thrombosis Embolisation
    56. 57. <ul><li>Clinical rarity of posterior circulation infarcts in CCJ anomalies is thought to be due to duplication of VA and the adequacy of the circulation of Willis </li></ul><ul><li>However we feel that </li></ul><ul><li>patients symptomatic for VBI are not routinely evaluated for CCJ anomalies which remain undiagnosed </li></ul>SPECT In vertebrobasilar insufficiency
    57. 58. <ul><li>Aims and Objectives : </li></ul><ul><li>Using 99Tc ECD brain SPECT to document the presence of posterior circulation cerebral ischemia in patients with CCJ anomalies and correlate with symptoms of VBI. </li></ul>SPECT In vertebrobasilar insufficiency
    58. 59. <ul><li>PROSPECTIVE STUDY DONE OVER A SIX MONTH PERIOD </li></ul>SPECT In vertebrobasilar insufficiency
    59. 60. <ul><li>VBI GROUP </li></ul><ul><li>Pts with features suggestive of VBI (Drop attacks, episodic vertigo, visual disturbances and dysarthria) </li></ul><ul><li>CONTROL GROUP </li></ul><ul><li>Patients without symptoms of VBI </li></ul>SPECT In vertebrobasilar insufficiency
    60. 61. <ul><li>STUDY DESIGN </li></ul>SPECT In vertebrobasilar insufficiency AAD: Atlanto-axial dislocation 19 PATIENTS WITH IRREDUCIBLE AAD Clinical assessment & Brain SPECT on admission CONTROL GROUP (7 PTS) VBI GROUP (12 PTS) Transoral Odontoidectomy + Posterior Fusion Transoral Odontoidectomy + Posterior Fusion Rpt SPECT at 4 weeks Rpt SPECT at 4 weeks
    61. 62. <ul><li>Operative procedure </li></ul><ul><li>Combined TOO and Occipito-cervical fusion from occiput to C3, using contoured loop and sublaminar wiring with bone graft placement. </li></ul><ul><li>Both procedures were carried out in a single sitting. </li></ul>SPECT In vertebrobasilar insufficiency
    62. 63. <ul><li>Patients with reducible AAD, requiring only occipito-cervical fusion were excluded from the study to maintain pt uniformity. </li></ul><ul><li>Postoperatively the neck was immobilized using a Philadelphia collar for a period of three months. </li></ul>SPECT In vertebrobasilar insufficiency
    63. 64. <ul><li>SPECT scanning was done using 99Tcm-ECD on a dual headed GE 'Varicam' scanner. </li></ul><ul><li>ROI were drawn in the cerebellum and basal ganglia and C/BG calculated on each side. </li></ul>SPECT In vertebrobasilar insufficiency SPECT
    64. 65. <ul><li>OBSERVATIONS </li></ul><ul><li>Radiology (Preop) </li></ul><ul><li>AAD 19 </li></ul><ul><li>BI 15 </li></ul><ul><li>Occipitalisation of atlas 14 </li></ul><ul><li>Klippel-Feil anomaly 9 </li></ul><ul><li>Small cerebellar infarcts 2 </li></ul><ul><li>(Both in VBI group) </li></ul>SPECT In vertebrobasilar insufficiency
    65. 66. <ul><li>RESULTS </li></ul><ul><li>(Preoperative SPECT) </li></ul><ul><li>Decreased cerebellar perfusion in 75% (9/12) of the patients in the VBI group compared to 14% (1/7) in the control group </li></ul><ul><li>(p=0.019) </li></ul>SPECT In vertebrobasilar insufficiency
    66. 67. <ul><li>RESULTS </li></ul><ul><li>Following surgery, eight patients (88.9%) in the VBI group and none in the control group had improvement in cerebellar perfusion. </li></ul><ul><li>All eight patients showing improvement on SPECT also had improvement in their symptoms of VBI following surgery </li></ul>SPECT In vertebrobasilar insufficiency
    67. 68. SPECT In vertebrobasilar insufficiency Baseline At 1 month postop
    68. 69. <ul><li>Two pts in VBI group developed meningitis in the postoperative period & had a further decrease in cerebellar perfusion on the follow up SPECT scan. </li></ul><ul><li>Another 2 pts in VBI group had small cerebellar infarcts on preop MRI & did not show improvement in cerebellar hypoperfusion following surgery. </li></ul>SPECT In vertebrobasilar insufficiency
    69. 70. <ul><li>Ours is the only study of its kind documenting hypoperfusion in posterior circulation territory in patients with CCJ anomalies. </li></ul><ul><li>This hypoperfusion may represent a state of chronic VBI, expected in such patients & MAY BE REVERSIBLE following surgery. </li></ul>SPECT In vertebrobasilar insufficiency
    70. 71. <ul><li>CONCLUSIONS </li></ul><ul><li>Our study shows that rigid immobilization (provided by occipito-cervical fusion in our patients) by itself may confer protection from VBI </li></ul>SPECT In vertebrobasilar insufficiency
    71. 72. <ul><li>RECOMMENDATION </li></ul><ul><li>CCJ anomalies-potentially treatable cause of VBI </li></ul><ul><li>Recommend that in patients with VBI, a high index of suspicion be kept for CCJ anomalies and x-rays of the cervical spine with flexion-extension views be done on all patients. </li></ul>SPECT In vertebrobasilar insufficiency
    72. 73. <ul><li>Agrawal D, Gowda NK, Bal CS, Kale SS, Mahapatra AK. Have Cranio-Vertebral Junction Anomalies Been Overlooked as a Cause of Vertebro-basilar Insufficiency? Spine (In print) </li></ul>
    73. 74. <ul><li>Acknowledgements </li></ul><ul><li>Naveen K Gowda (Nuclear Medicine) </li></ul><ul><li>Prof A K Mahapatra (Neurosurgery) </li></ul>
    74. 75. <ul><li>THANK YOU </li></ul>

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