Hans-Wilhelm Müller

Cortical GABA, striatal dopamine and midbrain serotonin as the key players in compulsive and anxiety disorders--results from in vivo imaging studies.

Various factors are discussed in the pathophysiology of anxiety disorders, including dysfunctions of the (DA)ergic, serotonin (5-HT)ergic and GABAergic system. We assessed the contribution of the individual synaptic constituents by subjecting all available in vivo imaging studies on patients with anxiety disorders to a retrospective analysis. On a total of 504 patients with obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), panic disorder (PD), phobia, or posttraumatic stress-disorder (PTSD) and 593 controls, investigations of VMAT2, DAT, SERT, D1, D2, 5-HTIA, 5-HT2A, GABA(A), and NK1 receptor binding in neostriatum, ventral striatum, thalamus, neocortex, limbic system, cingulate, midbrain/ pons or cerebellum were performed using either PET or SPECT. Separate analyses of the individual disorders showed significant decreases of striatal D2 receptors in OCD (-18%), mesencephalic SERT in OCD (-13%), frontocortical GABAA receptors in PD (-13%) and temporocortical GABAA receptors in GAD (-16%). Pooling of all disorders yielded a significant reduction of mesencephalic SERT (-13%), mesencephalic (-27%) as well as cingulate 5-HT1A receptors (-18%), striatal D2 receptors (-21%) and frontal (-14%), temporal (-14%), occipital (-13%) and cingulate GABAA receptors (-15%). The results show that DA, 5-HT, and GABA play a major role in all subtypes of anxiety disorders. In particular, the findings imply that the regulation state of DA as modulated by GABA and 5-HT may be crucial for the development of anxiety- and compulsion-related disorders. As GABA and 5-HT inhibit DAergic neurotransmission, the reductions of GABAA, 5-HT1A and SERT can be assumed to result in an enhanced activity of the mesolimbic DAergic system. This notion is also reflected by the decrease of striatal D2 receptor binding, which is indicative of an increased availability of synaptic DA.

Assessment of Large-Vessel Involvement in Giant Cell Arteritis with 18F-FDG PET: Introducing an ROC-Analysis–Based Cutoff Ratio

In the diagnosis of giant cell arteritis (GCA) with aortic involvement, 18F-FDG PET has been demonstrated to be a powerful tool. No other imaging method is able to directly detect acute inflammation within the aortic wall. However, because GCA is a rare PET indication, the assessment of GCA with 18F-FDG PET remains difficult and highly dependent on the experience of the investigator. This study aimed to semiquantify the relationship between aortic and liver uptake and to introduce a receiver operating characteristic (ROC)–based cutoff ratio to allow investigator- and experience-independent GCA diagnosis with optimal sensitivity and specificity. Ratios of aortic wall uptake versus liver uptake were calculated in a group of GCA patients and a control group. These data were assessed in an ROC analysis, and finally, a cutoff-ratio–optimizing strategy was applied. Methods: Twenty-three patients with initially suspected GCA (18 positive for GCA criteria, 5 negative) and 36 matched controls were included. The control subjects underwent PET for oncologic diagnostics. None had intrathoracic or hepatic disease or therapy-related tracer accumulation. Additionally, physiologic liver metabolism was ensured by the presence of normal liver enzymes. After defining regions of interest over the thoracic aorta and the liver, we calculated maximal standardized uptake value ratios. Sensitivities and specificities for cutoff ratios from 0.1 to 2.5 were estimated and were ultimately used to assess an optimal cutoff ratio for separating GCA patients from controls. To further investigate the usefulness of the resulting cutoff ratio, we tested it in a second control group with changed hepatic metabolism and elevated liver enzymes. Results: ROC analysis revealed optimal selectivity for a cutoff ratio of 1.0. This ratio led to a sensitivity of 88.9%, a specificity of 95.1%, and an accuracy of 94.4%. When this aorta-to-liver ratio was applied to the control group with pathologic liver metabolism, the resulting specificity was 95.6%. Conclusion: The 18F-FDG PET region-of-interest analysis with aorta-to-liver maximal standardized uptake value ratios is a reliable, investigator-independent indicator of GCA not affected by minor inflammation-associated changes in hepatic metabolism. Our results for a cutoff ratio of 1.0 prove that 18F-FDG PET is a method of high sensitivity and specificity for GCA-related large-vessel inflammation.

Dissociating neural correlates for nouns and verbs

Dissociations in the ability to produce words of different grammatical categories are well established in neuropsychology but have not been corroborated fully with evidence from brain imaging. Here we report on a PET study designed to reveal the anatomical correlates of grammatical processes involving nouns and verbs. German-speaking subjects were asked to produce either plural and singular nouns, or first-person plural and singular verbs. Verbs, relative to nouns, activated a left frontal cortical network, while the opposite contrast (nouns-verbs) showed greater activation in temporal regions bilaterally. Similar patterns emerged when subjects performed the task with pseudowords used as nouns or as verbs. These results converge with findings from lesion studies and suggest that grammatical category is an important dimension of organization for knowledge of language in the brain.

In vivo imaging of synaptic function in the central nervous system: II. Mental and affective disorders

This review gives an overview of those in vivo imaging studies on synaptic neurotransmission, which so far have been performed on patients with mental and affective disorders. Thereby, the focus is on disease-related deficiencies within the functional entities of the dopaminergic, serotonergic, cholinergic, histaminergic, glutamatergic, or GABAergic synapse. So far, in vivo investigations have yielded rather inconsistent results on the dysfunctions of specific synaptic constituents in the pathophysiology of the diseases covered by this overview. Among the more congruent results are the findings of increased synthesis (8 out of a total of 12 reports) and release of dopamine (4 out of 4 reports) in the striatum of schizophrenic patients, which supports the dopamine hypothesis of schizophrenia. Results on both dopaminergic and serotonergic neurotransmission are inconsistent in both major depressive disorder and bipolar illness, and fail to clearly agree with the dopamine and/or serotonin hypothesis of depression. The majority of in vivo findings suggest no alterations (25 out of a total of 50 reports on serotonin synthesis, transporter as well as receptor binding) rather than a deficiency (merely 13 out of these 50 reports) of cortical serotonergic neurotransmission in major depression, whereas a decrease of cortical serotonergic neurotransmission (3 out of a total on 5 reports) can be assumed in bipolar illness. In borderline personality disorder, an increased binding of serotonin transporter binding was observed (merely 1 report). Due to the limited evidence, this result only with due caution may be interpreted as an indication for increased availability of serotonin in the synaptic cleft. Patients with Tourette syndrome exhibited increases of DAT binding in the neostriatum (5 out of 10 reports) increases of dopamine storage and dopamine release in the ventral striatum (1 report, each). Moreover, striatal D2 receptor binding was found to be decreased in advanced stages of the disease. Results, tentatively, may be interpreted in terms of an increased dopaminergic neurotransmission in the mesolimbic system. There is limited evidence of decreased dopamine synthesis in both children and adults with attention-deficit/hyperactivity disorder (4 out of a total of 10 reports). These findings as well as the reduction of striatal dopamine release observed in adults (merely 1 report) are in line with the notion of mesocortical dopaminergic hypofunction in attention-deficit/hyperactivity disorder. Thereby, however, in children, results on dopamine synthesis indicate a deficiency in the ventral tegmentum rather than in the prefrontal cortex, whereas, with increasing age, the prefrontal cortex rather than the sites of origin of DAergic innervation become predominantly affected (merely 1 report, each). In anxiety disorders, varying results have been obtained for both pre- and/or postsynaptic dopaminergic, serotonergic and GABAergic binding sites. Thereby, results on posttraumatic stress disorder are homogenous reporting a decrease of GABA A receptor binding in all investigated brain regions including striatum, thalamus, neocortex and limbic system (2 out of 2 reports, each). Moreover, patients with obsessive-compulsive disorder displayed increases of dopamine transporter binding (2 out of 4 reports) and decreases of both D1 (merely 1 report) and D2 receptor binding (4 out of 5 reports), respectively. These findings, tentatively, may be interpreted in terms of an increased availability of synaptic dopamine in the neostriatum, which is compensated for both pre- and postsynaptically by increasing dopamine reuptake into the presynaptic terminal, and decreasing (inhibitory) signal transduction of efferent fibers. The observed reduction of GABA A receptor binding in frontocortical neurons (in 11 out of a total of 21 reports on anxiety disorders) is in line with this assumption. The inconsistency (and, partially, also incompleteness) of in vivo findings on mental and affective disorders constitutes a major result of this overview. Discrepancies indicate that the regulation state of synaptic constituents may not only vary between the subtypes of disorders but also between subject cohorts and, even, individual patients depending on variables such as the predominance of symptoms, medication status or onset and duration of disease. This, for the time being, limits the application of in vivo imaging methods for differential diagnosis of mental and affective disorders. In vivo imaging results on anxiety disorders, however, are of possible interest with regard to psychoanalysis, as they offer a neurochemical correlate for Freuds theories on the pathogenesis of anxiety- and compulsion-related disorders.

Diagnostic Accuracy of Combined FP-CIT, IBZM, and MIBG Scintigraphy in the Differential Diagnosis of Degenerative Parkinsonism: A Multidimensional Statistical Approach

In vivo molecular imaging of pre- and postsynaptic nigrostriatal neuronal degeneration and sympathetic cardiac innervation with SPECT is used to distinguish idiopathic Parkinson disease (PD) from atypical parkinsonian disorder (APD). However, the diagnostic accuracy of these imaging approaches as stand-alone procedures is often unsatisfying. The aim of this study was therefore to evaluate to which extent diagnostic accuracy can be increased by their combined use together with a multidimensional statistical algorithm. Methods: The SPECT radiotracers 123I-(S)-2-hydroxy-3-iodo-6-methoxy-N-[1-ethyl-2-pyrrodinyl)-methyl]benzamide (IBZM), 123I-N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropan (FP-CIT), and meta-123I-iodobenzylguanidine (MIBG) were used to assess striatal postsynaptic D2 receptor binding, striatal presynaptic dopamine transporter binding, and myocardial adrenergic innervation, respectively. Thirty-one PD and 17 APD patients were prospectively investigated. PD and APD diagnoses were established using consensus criteria and reevaluated after 37.4 ± 12.4 and 26 ± 11.6 mo in PD and APD, respectively. Test accuracy (TA) for PD–APD differentiation was computed for all logical (Boolean) combinations of imaging modalities by receiver-operating-characteristic analysis—that is, after multidimensional optimization of cutoff values. Results: Analysis showed moderate TA for PD–APD differentiation using each molecular approach alone (IBZM, 79%; MIBG, 73%; and FP-CIT, 73%). For combined use, the highest TA resulted under the assumption that at least 2 of the 3 biologic markers had to be positive for APD using the following cutoff values: 1.46 or less for IBZM, less than 2.10 for FP-CIT, and greater than 1.43 for MIBG. This algorithm distinguished APD from PD with a sensitivity of 94%, specificity of 94% (TA, 94%), positive predictive value of 89%, and negative predictive value of 97%. Conclusion: Results suggest that the multidimensional combination of FP-CIT, IBZM, and MIBG scintigraphy is likely to significantly increase TA in differentiating PD from APD. The differential diagnosis of degenerative parkinsonism may thus be facilitated.

Evidence of a modality-dependent role of the cerebellum in working memory? An fMRI study comparing verbal and abstract n-back tasks

In working memory (WM), functional imaging studies demonstrate cerebellar involvement indicating a cognitive role of the cerebellum. These cognitive contributions were predominantly interpreted as part of the phonological loop within the Baddeley model of WM. However, those underlying investigations were performed in the context of visual verbal WM which could pose a bias when interpreting the results. The aim of this fMRI study was to address the question of whether the cerebellum supports additional aspects of WM in the context of higher cognitive functions. Furthermore, laterality effects were investigated to further disentangle the cerebellar role in the context of the phonological loop and the visuospatial sketchpad. A direct comparison of verbal and abstract visual WM was performed in 17 young volunteers by applying a 2-back paradigm and extracting the % change in BOLD signal from the fMRI data. To minimize potential verbal strategies, Attneave and Arnoult shapes of non-nameable objects were chosen for the abstract condition. The analyses revealed no significant differences in verbal vs. abstract WM. Moreover, no laterality effects were demonstrated in both verbal and abstract WM. These results provide further evidence of a broader cognitive involvement of the cerebellum in WM that is not only confined to the phonological loop but also supports central executive subfunctions. The fact that no lateralization effects are found might be attributed to the characteristics of the n-back paradigm which emphasizes central executive subfunctions over the subsidiary slave systems.

Can the apparent diffusion coefficient be used as a noninvasive parameter to distinguish tumor tissue from peritumoral tissue in cerebral gliomas

To determine whether the apparent diffusion coefficient (ADC) can be used to distinguish between tumor tissue and peritumoral brain tissue in cerebral gliomas.

Striatal dopamine transporter density in drug naive patients with attention-deficit/hyperactivity disorder.

Background and aimDopamine transporters are the target of psychostimulants used for treatment of attention-deficit/hyperactivity disorder (ADHD). Therefore, the present study aimed to evaluate striatal dopamine transporter density in adult patients with ADHD. MethodsTwenty patients (11 female, nine male; mean age 35±7 years) and 20 control subjects (11 female, nine male, mean age 32±8 years) were examined with SPECT using the specific radiotracer 123I-FP-CIT. The ratio of striatal to cortical radioactivity concentration was used for semiquantitative evaluation of dopamine transporter binding potential (V3″). There was a significant influence of age (P<0.001) and a trend towards an influence of gender (P=0.053) on V3″. An ANCOVA with these covariates showed a slightly higher V3″ in the patients than in the control subjects (4.24±0.48 vs. 4.03±0.56; P=0.02). ConclusionThis study provides further in-vivo evidence for an involvement of the dopamine transporter in ADHD. However, compared to previous studies, the increase of dopamine transporter density in the patient group is less pronounced here.

Early detection of bony alterations in rheumatoid and erosive arthritis of finger joints with high-resolution single photon emission computed tomography, and differentiation between them

ObjectiveTo evaluate high-resolution multi-pinhole single photon emission computed tomography (MPH-SPECT) for the detection of bony alterations in early rheumatoid arthritis (ERA), early osteoarthritis (EOA) of the fingers and healthy controls.MethodsThe clinically dominant hands of 27 patients (13 ERA, nine EOA, five healthy controls) were examined by MPH-SPECT and bone scintigraphy. Additionally, magnetic resonance imaging (MRI) was performed in the ERA patients. Number of affected joints, localisation, pattern of tracer distribution and joint involvement were scored. Quantitative analysis was achieved by measurement of the region of interest (ROI) in all patients. The MPH-SPECT and MR images were fused in the ERA group.ResultsBone scintigraphy detected fewer joints (26 joints,13/22 patients) with increased tracer uptake than did MPH-SPECT (80 joints, 21/22 patients). Bone scintigraphy did not show recognisable uptake patterns in any group of patients. With MPH-SPECT central tracer distribution was typical in ERA (10/13 patients, EOA 2/9). In contrast, an eccentric pattern was found predominantly in EOA (7/9, ERA 2/13). Normalised counts were 4.5 in unaffected joints and up to 222.7 in affected joints. The mean uptake values in affected joints were moderately higher in the EOA patients (78.75, and 62.16 in ERA). The mean tracer uptake in affected joints was approximately three-times higher than in unaffected joints in both groups (ERA 3.64-times higher, EOA 3.58). Correlation with MR images revealed that bone marrow oedema and erosions matched pathological tracer accumulation of MPH-SPECT in 11/13. MPH-SPECT demonstrated increased activity in 2/13 patients with normal bone marrow signal intensity and synovitis seen on MR images.ConclusionMPH-SPECT is sensitive to early changes in ERA and EOA and permits them to be distinguished by their patterns of uptake.

Key players in major and bipolar depression--a retrospective analysis of in vivo imaging studies.

In the present study, we evaluated the contribution of the individual synaptic constituents of all assessed neurotransmitter systems by subjecting all available in vivo imaging studies on patients with unipolar major depressive disorder (MDD) and bipolar depression (BD) to a retrospective analysis. In acute MDD, findings revealed significant increases of prefrontal and frontal DA synthesis, decreases of thalamic and midbrain SERT, increases of insular SERT, decreases of midbrain 5-HT(1A) receptors and decreases of prefrontal, frontal, occipital and cingulate 5-HT(2A) receptors, whereas, in remission, decreases of striatal D₂ receptors, midbrain SERT, frontal, parietal, temporal, occipital and cingulate 5-HT(1A) receptors and parietal 5-HT(2A) receptors were observed. In BD, findings indicated a trend towards increased striatal D₂ receptors in depression and mania, decreased striatal DA synthesis in remission and decreased frontal D₁ receptors in all three conditions. Additionally, there is some evidence that ventrostriatal and hippocampal SERT may be decreased in depression, whereas in remission and mania elevations of thalamic and midbrain SERT, respectively, were observed. Moreover, in depression, limbic 5-HT(1A) receptors were elevated, whereas in mania a decrease of both cortical and limbic 5-HT(2A) receptor binding was observed. Furthermore, in depression, prefrontal, frontal, occipital and cingulate M2 receptor binding was found to be reduced. From this, a complex pattern of dysregulations within and between neurotransmitter systems may be derived, which is likely to be causally linked not only with the subtype and duration of disease but also with the predominance of individual symptoms and with the kind and duration of pharmacological treatment(s).