Seher Unal

Frontal and occipital perfusion changes in dissociative identity disorder

The aim of the study was to investigate if there were any characteristics of regional cerebral blood flow (rCBF) in dissociative identity disorder. Twenty-one drug-free patients with dissociative identity disorder and nine healthy volunteers participated in the study. In addition to a clinical evaluation, dissociative psychopathology was assessed using the Structured Clinical Interview for DSM-IV Dissociative Disorders, the Dissociative Experiences Scale and the Clinician-Administered Dissociative States Scale. A semi-structured interview for borderline personality disorder, the Hamilton Depression Rating Scale, and the Childhood Trauma Questionnaire were also administered to all patients. Normal controls had to be without a history of childhood trauma and without any depressive or dissociative disorder. Regional cerebral blood flow (rCBF) was studied with single photon emission computed tomography (SPECT) with Tc99m-hexamethylpropylenamine (HMPAO) as a tracer. Compared with findings in the control group, the rCBF ratio was decreased among patients with dissociative identity disorder in the orbitofrontal region bilaterally. It was increased in median and superior frontal regions and occipital regions bilaterally. There was no significant correlation between rCBF ratios of the regions of interest and any of the psychopathology scale scores. An explanation for the neurophysiology of dissociative psychopathology has to invoke a comprehensive model of interaction between anterior and posterior brain regions.

Evaluation of regional cerebral blood flow changes in panic disorder with Tc99m-HMPAO SPECT

OBJECTIVE To evaluate the differences in regional cerebral blood flow (rCBF) and rCBF asymmetry index values of panic disorder patients and a control group, using Tc99m-HMPAO SPECT. In addition, the influence of comorbid agoraphobia on the rCBF and rCBF asymmetry index values of the panic disorder patients was also investigated. METHOD The rCBF and rCBF asymmetry index values of 22 panic disorder patients, 9 with agoraphobia and 13 without agoraphobia, and 19 healthy controls were obtained using SPECT. Both (1) the panic disorder and control groups and (2) panic disorder groups with and without agoraphobia were compared in terms of the measured values. RESULTS A decrease in blood perfusion in the bilateral frontal region, a relative increase in blood perfusion in the right medial frontal and right superior frontal regions and a relative blood flow increase in the right medial frontal region according to rCBF asymmetry index values were determined in panic disorder patients. In the patients with agoraphobia, the decrease in blood perfusion in the right occipital region, and the relative increase in the right superior temporal region according to rCBF asymmetry index values were significantly higher than those in subjects without agoraphobia. CONCLUSION The decrease in the rCBF in the bilateral inferior frontal regions in panic patients may be related to the amygdala activation decreasing cerebral blood flow in the frontal region and/or the hyperactivation of the locus ceruleus. The explanations of the etiology of panic disorder are valid only if they are supported with clinical evidence from future studies.

HMPAO SPECT Study of Regional Cerebral Blood Flow in Dissociative Identity Disorder

Abstract The aim of the study was to in ves ti gate if there were any char ac ter is tics of re gional c e re bral blood flow (rCBF) in dissociative iden tity dis or der. Fif teen pa tients with dissociative iden tity dis or der and eight healthy vol un teers par tic i pated in the study. The clin i cal di ag no sis of dissociative iden tity dis or der was con firmed us ing the Struc tured Clin i cal In ter view for DSM-IV Dissociative Dis or ders. The Struc tured Clin i cal In ter view for DSM-III-R was also ad min is tered to all pa tients in or der to screen comorbid psy chi at ric con di tions. Re gional ce re bral blood flow was stud ied us ing a SPECT sys tem with Tc99m-hexamethyl -propylenamine (HMPAO) as a tracer. The rCBF ra tio was de creased in orbito-fron tal re gion bi lat er ally and in creased in left (dom i nant hemisphere) lat eral tem po ral re gion among pa tients with dissociative iden tity dis or der when com pared to the con trol group. The struc tured in ter view di ag no ses of con cur rent or life time ma jor de pres sion, PTSD, psy chotic dis or der, or on go ing drug treat ment were not sig nif i cantly re lated to perfu sion in these re gions. There was no sta tis ti cally mean ing ful dif fer ence in rCBF ra tios be tween host and al ter per son al ity states. Our find ings sug gest that orbitofron tal and left (dom i nant hemi sphere) lat eral tem poral re gions are af fected in dissociative iden tity dis or der. A rep li ca tion of this study on a larger group of drugfree dissociative pa tients and var i ous psy chi at ric con trol groups would lead to more de fin i tive find ings.

Diagnostic value of PET/CT is similar to that of conventional MRI and even better for detecting small peritoneal implants in patients with recurrent ovarian cancer.

ObjectiveThe aim of this study was to evaluate the diagnostic value of 2-(fluorine-18)-fluoro-2-deoxy-D-glucose (18F-FDG) PET/CT in comparison with MRI for the detection of recurrent ovarian cancer. MethodsForty-seven patients with suspected ovarian cancer recurrence after total ablative or cytoreductive surgery, as well as neoadjuvant or adjuvant chemotherapy, who had undergone 18F-FDG PET/CT imaging were recruited for the present study. All patients also underwent MRI within a month of 18F-FDG PET/CT for the same purpose. Recurrent cancer in the abdomen and pelvis was evaluated in each of the 47 patients and classified as either distant metastasis or local pelvic recurrence involving the vaginal stump, peritoneal implants, supradiaphragmatic region, and/or abdominal and pelvic lymph nodes. Special attention was paid to peritoneal implants. These were divided into five groups according to size of the implants: less than 0.5 cm (group 1), 0.5–1 cm (group 2), 1–2 cm (group 3), 2–3 cm (group 4), and larger than 3 cm (group 5). PET/CT findings were compared with abdominopelvic MR findings. Statistical analysis was carried out using the Wilcoxon signed rank test. ResultsThirty-nine of 47 patients were found to have recurrent ovarian cancer. Both PET/CT and MRI were negative for recurrence in six patients. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of PET/CT were 97.5, 100, 100, 87.5, and 97.8%, respectively, whereas those of MRI were 95, 85.7, 97.4, 75, and 93.6%, respectively. For the peritoneal implants in groups 2 and 3, the sensitivity, negative predictive value, and diagnostic accuracy values of PET/CT were significantly better than those of MRI (P<0.05). ConclusionThe present study revealed that PET/CT is similar to conventional MRI for the detection of recurrent ovarian cancer. PET/CT has greater accuracy in the detection of small-to-medium-sized (<2 cm) peritoneal implants compared with MRI. This may affect surgical decision making.

Comparison of Tc-99m methylene diphosphonate, Tc-99m human immune globulin, and Tc-99m-labeled white blood cell scintigraphy in the diabetic foot

Purpose The aims of this prospective study were to evaluate the contribution of Tc-99m methylene diphosphonate (MDP), Tc-99m human immune globulin (HIG), and Tc-99m white blood cell (WBC) to the diagnosis of osteomyelitis in the diabetic foot and to evaluate the surgical or medical therapy with Tc-99m HIG and Tc-99m WBC scans. Methods Twenty patients (15 men, 5 women) with suspected pedal osteomyelitis were included in the study. All patients had type II diabetics. Three- and four-phase bone scintigraphy (3P-MDP, 4P-MDP), early (e) and late (l) HIG, and WBC scans were completed within 1 week in all patients. The lesion-to-background ratios were calculated for early and late images of the feet for all scans and named as the indices. Eight weeks after the end of medical or surgical therapy, Tc-99m HIG and Tc-99m WBC scans were repeated in 10 patients. The difference in indices between 3P-MDP and 4P-MDP for osteomyelitis and indices for osteomyelitis, cellulitis, and inflammation in Tc-99m HIG and Tc-99m WBC in early and late scans were tested for significance. Results In 20 patients, 53 lesions were investigated. Among these 53 lesions were 25 sites of proved osteomyelitis, 6 sites of cellulitis, and 22 sites of inflammation confirmed by radiography, microbiologic culture, and clinical evaluation. 4P-MDP was more specific than 3P-MDP for detecting osteomyelitis (50% and 67%, respectively). There was also a significant difference between the mean indices of 3P-MDP and 4P-MDP (P < 0.000). The index values were increased in 4P-MDP scans. There was no significant difference between the indices of early and late Tc-99m HIG scans for inflammation, cellulitis, and osteomyelitis. Early and late Tc-99m WBC scans did not show a significant difference in differentiating osteomyelitis. However, Tc-99m WBC scans could differentiate aseptic inflammation from infection (P < 0.031) in early and late scans. There was a significant difference of index values between pre- and post-treatment Tc-99m HIG and Tc-99m WBC scans. The best combination of scans for detecting osteomyelitis was 4P-MDP with WBC scans, with an accuracy rate of 92%. Conclusions These results show that four-phase bone scintigraphy with early Tc-99m WBC scanning is preferred for detecting osteomyelitis of the diabetic foot. To evaluate the response to therapy, Tc-99m WBC scans are the preferred method, but if this is not available, Tc-99m HIG scanning can be used.

Pathogens Isolated From Deep Soft Tissue and Bone in Patients With Diabetic Foot Infections

BACKGROUND We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. It is widely believed that soft-tissue cultures are adequate in the determination of causative bacteria in patients with diabetic foot osteomyelitis. The culture results of specimens taken concurrently from soft-tissue and bone infections show that the former does not predict the latter with sufficient reliability. We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. METHODS Forty-five patients with diabetic foot infections were enrolled in the study. Patients had to have clinically suspected foot lesions of grade 3 or higher on the Wagner classification system. In patients with clinically suspected osteomyelitis, magnetic resonance imaging, scintigraphy, or histopathologic examination were performed. Bone and deep soft tissue specimens were obtained from all patients by open surgical procedures under aseptic conditions during debridement or amputation. The specimens were compared only with the other specimens taken from the same patients. RESULTS The results of bone and soft-tissue cultures were identical in 49% (n = 22) of cases. In 11% (n = 5) of cases there were no common pathogens. In 29% (n = 13) of cases there were more pathogens in the soft-tissue specimens; these microorganisms included microbes isolated from bone cultures. In four patients (9%) with culture-positive soft-tissue specimens, bone culture specimens remained sterile. In one patient (2%) with culture-positive bone specimen, soft-tissue specimen remained sterile. CONCLUSION Culture specimens should be obtained from both the bone and the overlying deep soft tissue in patients with suspected osteomyelitis whose clinical conditions are suitable. The decision to administer antibiotic therapy should depend on these results.

99Tcm-polyclonal IgG scintigraphy in the detection of infected hip and knee prostheses

We investigated the usefulness of 99Tc(m)-polyclonal human IgG (99Tc[m]-HIG) scintigraphy in the diagnosis of infected hip and knee prostheses. Twenty-nine scintigraphic studies were performed in 27 patients (17 females, 10 males) with a suspected prosthetic infection. As some patients had bilateral prostheses, a total of 35 prostheses were evaluated. There were 25 hip replacements and 10 knee prostheses. The images were analysed both visually and quantitatively. The scintigraphic results were compared with the culture results of surgical specimens and also with clinical follow-up after 3 months. Increased uptake was observed in 22 prostheses, of which 12 were true-positive and 10 were false-positive results. Staphylococci were the agents most commonly isolated. In all false-positive patients, aseptic inflammation was diagnosed. Based on quantitative analysis, no statistically significant difference was found between the true-positive and false-positive cases. For the prostheses as a whole, the sensitivity, specificity, positive predictive value and negative predictive value were 100%, 41%, 54% and 100% respectively. For the hip prostheses alone, these values were 100%, 53%, 57% and 100% respectively. Taking its high sensitivity and predictive value into consideration, 99Tc(m)-HIG scintigraphy can be used as a screening test to help eliminate prosthetic infection.

Tc-99m MIBI accumulation in remnant thymus: a cause of false-positive interpretation in parathyroid imaging

A 17-year-old boy, who was suspected of having hyperparathyroidism, was admitted for parathyroid imaging. Tc-99m pertechnetate Tc-99m MIBI subtraction scintigraphy was performed. A focal increased activity accumulation was observed visually after Tc-99m MIBI injection in the lower left lobe of the thyroid extending inferiorly, which was interpreted as parathyroid adenoma. At surgery, a left thyroidectomy was performed and no parathyroid abnormality was observed, but a 3 ± 2 ± 3 cm mass, which was thought to be a thymic remnant, was removed. Histopathologic examination of this specimen revealed an involuted thymic tissue. Three months after surgery, Tc-99m MIBI imaging was repeated and no activity accumulation was seen in the neck.

Evaluation of coronary artery abnormalities in Williams syndrome patients using myocardial perfusion scintigraphy and CT angiography

BACKGROUND Sudden death risk in Williams syndrome (WS) patients has been shown to be 25-100 times higher than in the general population. This study aims to detect coronary artery anomalies and myocardial perfusion defects in WS patients using noninvasive diagnostic methods. METHODS This study features 38 patients diagnosed with WS. In addition to physical examination, electrocardiography, and echocardiography, computed tomography (CT) angiography and rest/dipyridamole stress technetium-99m sestamibi ((99m)Tc-sestamibi) single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy (MPS) were performed. RESULTS Twenty-one (55%) patients were male; 17 (45%) were female. The average patient age was 12 ± 5 years (2.5-26 years); the average follow-up period was 7.2 ± 4.2 years (6 months-18 years). Cardiovascular abnormalities were found in 89% of patients, the most common one being supravalvar aortic stenosis (SVAS). CT angiography revealed coronary anomalies in 10 (26%) patients, the most common ones being ectasia of the left main coronary artery and proximal right coronary artery as well as myocardial bridging. SVAS was present in 80% of patients with coronary artery anomalies. (99m)Tc-sestamibi SPECT MPS revealed findings possibly consistent with myocardial ischemia in 29% of patients, and ischemia in 7 out of 10 patients (70%) with coronary anomalies shown on CT angiography (p = 0.03). CONCLUSIONS Coronary artery abnormalities are relatively common in WS patients and are often accompanied by SVAS. CT angiography and dipyridamole (99m)Tc-sestamibi SPECT MPS seem to be less invasive methods of detecting coronary artery anomalies and myocardial perfusion defects in WS patients.

Tc-99m nanocolloid and Tc-99m MDP three-phase bone imaging in osteomyelitis and septic arthritis. A comparative study.

The aim of this study was to compare Tc-99m nanocolloid scintigraphy with Tc-99m MDP bone imaging in the diagnosis of osteomyelitis and septic arthritis. Overall, 31 Tc-99m MDP bone scans and 39 Tc-99m nanocolloid studies were performed in 34 patients (15 female, 19 male; mean age, 14.88 years ± 19.00 years) who were suspected of osteomyelitis and/or septic arthritis. The final diagnoses were established by needle aspiration, cultures, radiography, clinical course, and, in some patients, with CT, ultrasonography, and biopsy. The sensitivity, specificity, and accuracy were 100%, 75%, and 92%, respectively for both Tc-99m MDP and Tc-99m nanocolloid scans in detecting osteomyelitis. For septic arthritis, Tc-99m MDP bone imaging showed 100%, 85%, and 94%, and Tc-99m nanocolloid scans showed 90%, 59%, and 76%, sensitivity, specificity, and accuracy, respectively. These results show that, although both scans are in good agreement for osteomyelitis, for septic arthritis nanocolloid is not specific enough to recommend it to be a complementary method to MDP bone scans.