Gustavo Borges Barbirato

Assessment of intra-arterial injected autologous bone marrow mononuclear cell distribution by radioactive labeling in acute ischemic stroke.

Objective: To evaluate the feasibility of monitoring the autologous mononuclear bone marrow (ABMMN) cells implanted into the brain after acute ischemic stroke by the technique of labeling with Tc-99m-HMPAO. Case Report: A 37-year-old man presented with aphasia, right-side hypoesthesia, and right homonymous hemianopsia after an acute ischemic stroke of the left middle cerebral artery. He was included in an autologous bone marrow mononuclear cell-based therapy research protocol about the safety of intra-arterial autologous bone marrow mononuclear cell transplantation for acute ischemic stroke. Nine days after the stroke he received 3.0 × 107 ABMMN cells delivered into the left cerebral middle artery via a balloon catheter. Approximately 1% of these cells were labeled with 150 MBq (4 mCi) Tc-99m by incubation with hexamethylpropylene amine oxime (HMPAO). Results: Brain perfusion images with Tc-99m ECD demonstrated hypoperfusion in the left temporal and parietal regions. The perfusion brain images were compared with tomographic views of the brain obtained 8 hours after ABMMN-labeled cell delivery, revealing intense accumulation of the ABMMN-labeled cells in the ipsilateral hemisphere. A whole-body scan was done and showed left brain, liver, and spleen uptake. Conclusions: Our results showed that Tc-99m HMPAO can be used to label ABMMN cells for in vivo cell visualization, and that brain SPECT imaging with labeled ABMMN cells is a feasible noninvasive method for studying the fate of transplanted cells in vivo. Additionally, our findings demonstrate the localization of these intra-arterially injected cells.

Value of combining activated brain FDG-PET and cardiac MIBG for the differential diagnosis of dementia: differentiation of dementia with Lewy bodies and Alzheimer disease when the diagnoses based on clinical and neuroimaging criteria are difficult.

Dementia with Lewy bodies (DLB) is the second most common cause of dementia. The diagnosis of DLB is particularly important because these patients show good response to cholinesterase inhibitors. Clinical and neuroimaging criteria for DLB have not been acceptable for predictive accuracy. We report a case of progressive dementia in which the differentiation of DLB and Alzheimer disease (AD) on the basis of clinical criteria alone was not possible. The patient was admitted to the hospital because he became worse after he had started treatment for severe AD. Both MRI and brain magnetic resonance spectroscopy were normal. The patient underwent myocardial scintigraphy with I-123 MIBG showing marked reduction in cardiac MIBG accumulation. The heart to mediastinum ratio of MIBG uptake was impaired in both early and delayed images. FDG-PET scan before and after activation with a visual attention task showed occipital cortex hypometabolism as compared with AD and a normal control. This case illustrates the value of combining activated brain FDG PET and cardiac MIBG. The association of these 2 techniques could be used as a potential diagnostic tool in a patient with dementia misdiagnosed as AD.

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

OBJECTIVE To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS). METHODS Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit (CPU) from December 2002 to April 2004, after exclusion of acute myocardial infarction (AMI) and high risk unstable angina they underwent stress MPS. RESULTS Selected 301 patients, 65.3 +/- 12.5 years and 164 (54.5%) male gender. The test was performed 13 +/- 12 hours after admission. Myocardial ischemia (ISQ) was found in 142 patients (47.2%). Male gender (n=94, p=<0.0001), history of diabetes mellitus (n=31, p=0.033), past of AMI (n=52, p=<0.0001), past of surgical myocardial revascularization (n=46, p=<0.0001) and past of percutaneous revascularization (n=68, p=<0.0001) presented correlation with ISQ. The follow-up was 697.7 +/- 326.6 days. No MPS variable correlated with the occurrence of primary outcome. Abnormal scintigraphy (n=76, p < 0.0001), ISQ (n=73, p < 0.0001) and post-stress left ventricular ejection fraction below 45% (n=21, p=0.006) correlated with secondary outcome. The presence of ISQ was the major variable in the multivariate analysis for the prediction of secondary outcome (RR = 6.5; CI 95% = 0.009). CONCLUSION Presence of ISQ was the major independent factor in prediction of adverse events for patients admitted into the CPU.

Psychiatric disorders and cardiovascular system: heart-brain interaction

Depression and anxiety are highly prevalent in patients with CAD and other CVD. Despite being frequent, these psychiatric disorders are usually ignored2,3. They have also been considered independent risk factors for CAD and CVD and believed to change its natural history4,5. Early identification and effective treatment of these disorders may contribute to the increased survival of patients with heart diseases6. This review is intended to discuss the prevalence and impact of depression and anxiety in patients with CAD or other forms of CVD. It discusses the mechanisms by which they change the prognosis of CVD. In addition, the instruments for screening and handling patients with CAD and concomitant depression will be addressed.

Prevalência de isquemia induzida por estresse mental

BACKGROUND The myocardial radionuclide imaging with mental distress seems to induce ischemia through a particular physiopathology when compared to radionuclide imaging with physical or pharmacological distress. OBJECTIVE To assess the prevalence of induced myocardial ischemia by mental distress in patients with thoracic pain and radionuclide imaging with normal conventional distress, with 99mTc-Sestamibi. METHODS Twenty-two patients were admitted with thoracic pain at emergency or were referred to the nuclear medicine service of our institution, where myocardial radionuclide imaging of distress or rest without ischemic alterations was carried out. The patients were, then, invited to go through an additional phase with mental distress induced by color conflict (Strop Color Test) with the objective of detecting myocardial ischemia. Two cardiologists and nuclear physicians performed the blind analysis of perfusional data and consequent quantification through Summed Difference Score (SDS), punctuating the segments that were altered after mental distress and comparing it to the rest period image. The presence of myocardial ischemia was considered if SDS > or = 3. RESULTS The prevalence of mental distress-induced myocardial ischemia was 40% (9 positive patients). Among the 22 studied patients, there were no statistical differences with regard to the number of risk factors, mental distress-induced hemodynamic alterations, usage of medications, presented symptoms, presence or absence of coronary disease and variations of ejection fraction and final systolic volume of Gated SPECT. CONCLUSION In a selected sample of patients with thoracic pain and normal myocardial radionuclide imaging, the research of myocardial ischemia induced by mental distress through radionuclide imaging may be positive in up to 40% of cases.

Uso da cintilografia miocárdica em repouso durante dor torácica para descartar infarto agudo do miocárdio

BACKGROUND Images of myocardial perfusion taken during an episode of chest pain have been used for patients in the emergency department. OBJECTIVE To evaluate the operating characteristics of 99mTc-Tetrofosmin scintigraphy during an episode of chest pain to exclude the diagnosis of acute myocardial infarction. METHODS One hundred and eight patients admitted with chest pain, or up to four hours after the end of symptoms and nondiagnostic electrocardiogram, underwent resting scintigraphy and measurement of troponin I concentrations. Patients with a history of myocardial infarction (MI) were not excluded (24 patients). Troponin I concentrations were determined at admission and 6 hours later. Nuclear physicians performed a blind analysis of the images, and myocardial infarction was confirmed whenever troponin I level increase was three times that of the control. RESULTS Resting perfusion image was abnormal in all 6 patients with MI. Only 1 patient had a normal image and increased troponin levels. Fifty-five patients had positive images without MI, and 46 patients had normal images and troponin levels. The prevalence of the disease was 6.5%. The sensitivity and specificity of the resting images during an episode of chest pain to diagnose MI was 85.7% and 45.5%, respectively. The negative predictive value was 97.7%. CONCLUSION Patients undergoing chest pain protocol with SPECT showed an excellent negative predictive value to exclude diagnosis of myocardial infarction. These results suggest that resting perfusion image is an important tool at the chest pain unit.FUNDAMENTO: A imagem de perfusao miocardica adquirida durante episodio de dor toracica tem sido utilizada nos pacientes na sala de emergencia. OBJETIVO: Avaliar as caracteristicas operacionais da cintilografia com 99mTc-Tetrofosmin durante episodio de dor toracica para descartar o diagnostico de infarto agudo do miocardio. METODOS: 108 pacientes admitidos com dor toracica ou ate quatro horas do termino dos sintomas e eletrocardiograma nao diagnostico realizaram cintilografia em repouso e dosagens de troponina I. Pacientes com passado de infarto do miocardio (IM) nao foram excluidos (24 pacientes). Troponina I foi dosada na admissao e seis horas apos. Medicos nucleares realizaram analise cega das imagens. Infarto do miocardio foi confirmado com elevacao da troponina I maior que tres vezes o controle. RESULTADOS: A imagem perfusional de repouso foi anormal em todos os seis pacientes com IM. Apenas um paciente apresentou imagem normal e elevacao da troponina. Outros 55 pacientes obtiveram imagem positiva sem IM e 46 pacientes com imagens e troponinas normais. A prevalencia da doenca foi 6,5%. A sensibilidade da imagem de repouso durante dor toracica para a evidencia de IM foi 85,7% e especificidade de 45,5%. O valor preditivo negativo foi 97,7%. CONCLUSAO: Pacientes submetidos ao protocolo de dor toracica com cintilografia de perfusao miocardica demonstraram um excelente valor preditivo negativo para afastar o diagnostico de infarto do miocardio. Estes resultados sugerem que a imagem de perfusao em repouso e uma ferramenta importante na unidade de dor toracica.

Use of resting myocardial scintigraphy during chest pain to exclude diagnosis of acute myocardial infarction

BACKGROUND Images of myocardial perfusion taken during an episode of chest pain have been used for patients in the emergency department. OBJECTIVE To evaluate the operating characteristics of 99mTc-Tetrofosmin scintigraphy during an episode of chest pain to exclude the diagnosis of acute myocardial infarction. METHODS One hundred and eight patients admitted with chest pain, or up to four hours after the end of symptoms and nondiagnostic electrocardiogram, underwent resting scintigraphy and measurement of troponin I concentrations. Patients with a history of myocardial infarction (MI) were not excluded (24 patients). Troponin I concentrations were determined at admission and 6 hours later. Nuclear physicians performed a blind analysis of the images, and myocardial infarction was confirmed whenever troponin I level increase was three times that of the control. RESULTS Resting perfusion image was abnormal in all 6 patients with MI. Only 1 patient had a normal image and increased troponin levels. Fifty-five patients had positive images without MI, and 46 patients had normal images and troponin levels. The prevalence of the disease was 6.5%. The sensitivity and specificity of the resting images during an episode of chest pain to diagnose MI was 85.7% and 45.5%, respectively. The negative predictive value was 97.7%. CONCLUSION Patients undergoing chest pain protocol with SPECT showed an excellent negative predictive value to exclude diagnosis of myocardial infarction. These results suggest that resting perfusion image is an important tool at the chest pain unit.FUNDAMENTO: A imagem de perfusao miocardica adquirida durante episodio de dor toracica tem sido utilizada nos pacientes na sala de emergencia. OBJETIVO: Avaliar as caracteristicas operacionais da cintilografia com 99mTc-Tetrofosmin durante episodio de dor toracica para descartar o diagnostico de infarto agudo do miocardio. METODOS: 108 pacientes admitidos com dor toracica ou ate quatro horas do termino dos sintomas e eletrocardiograma nao diagnostico realizaram cintilografia em repouso e dosagens de troponina I. Pacientes com passado de infarto do miocardio (IM) nao foram excluidos (24 pacientes). Troponina I foi dosada na admissao e seis horas apos. Medicos nucleares realizaram analise cega das imagens. Infarto do miocardio foi confirmado com elevacao da troponina I maior que tres vezes o controle. RESULTADOS: A imagem perfusional de repouso foi anormal em todos os seis pacientes com IM. Apenas um paciente apresentou imagem normal e elevacao da troponina. Outros 55 pacientes obtiveram imagem positiva sem IM e 46 pacientes com imagens e troponinas normais. A prevalencia da doenca foi 6,5%. A sensibilidade da imagem de repouso durante dor toracica para a evidencia de IM foi 85,7% e especificidade de 45,5%. O valor preditivo negativo foi 97,7%. CONCLUSAO: Pacientes submetidos ao protocolo de dor toracica com cintilografia de perfusao miocardica demonstraram um excelente valor preditivo negativo para afastar o diagnostico de infarto do miocardio. Estes resultados sugerem que a imagem de perfusao em repouso e uma ferramenta importante na unidade de dor toracica.

Radionuclide imaging of myocardium with mental stress in the investigation of thoracic pain

Thoracic pain is a common symptom in emergency services, and stress radionuclide imaging represents one of the phases of risk stratification in these individuals. However, a group of patients with negative functional exams after physical or pharmacological stress develops myocardial ischemia during this psychological stress. Alterations in vascular tonus as a response to endogenous mechanisms are the physiopathologic basis for such alterations. We report a case that illustrates how mental stress radionuclide imaging has the potential to be used in the assessment of myocardial ischemia non-detected by conventional methods in patients with suspicion of ischemic thoracic pain.Thoracic pain is a common symptom in emergency services, and stress radionuclide imaging represents one of the phases of risk stratification in these individuals. However, a group of patients with negative functional exams after physical or pharmacological stress develops myocardial ischemia during this psychological stress. Alterations in vascular tonus as a response to endogenous mechanisms are the physiopathologic basis for such alterations. We report a case that illustrates how mental stress radionuclide imaging has the potential to be used in the assessment of myocardial ischemia non-detected by conventional methods in patients with suspicion of ischemic thoracic pain.

Dissociation between myocardial perfusion scintigraphy and angiographic findings explained by intravascular ultrasonography.

An asymptomatic 70-year-old man was referred for exercise myocardial perfusion imaging. He had undergone percutaneous coronary angioplasty 2 years before the exam. The ramp protocol was interrupted in the 10th min because he developed horizontal ST-segment depression of 0.5 mV at 80 ms after the J point in multiple ECG derivations (figure, upper left). Tc-Sestamibi single photon emission computed tomography (SPECT) images acquired 60 min after

Rapid assessment of rest myocardial ischaemia in the Chest Pain Unit

A 76-year-old man with a history of coronary bypass graft surgery presented to the Chest Pain Unit with chest discomfort. He underwent myocardial perfusion imaging (MPI) with 99m Tc-sestamibi. Immediately after acquisition of the rest scan he developed a new chest pain episode and received an additional tracer injection. The new images showed hypoperfusion in the inferior and inferolateral walls that were not observed in the previous rest scan images (a arrows). A coronary angiogram revealed subtotal proximal occlusion of a saphenous vein graft to the right coronary artery (b arrow) which was submitted to successful stent implantation. Acute coronary syndrome results from the combination of intermittent thrombotic occlusion and vasoconstriction resulting in markedly decreased regional myocardial perfusion [1]. Abnormal rest MPI in patients with acute chest pain is highly associated with acute myocardial infarction or the need for subsequent coronary revascularization [2]. These images demonstrate the exquisite sensitivity of MPI to changes in rest myocardial perfusion over a short period.