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Spect in concussion, vertebro basilar insufficiency and other neurological disorders

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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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