Multimodality Anatomic and Molecular Imaging of Parkinson Disease and Atypical Parkinson Syndromes with MRI, Iodine 123 N-ω-Fluoropropyl-2β-Carbomethoxy-3β-(4-Iodophenyl) Nortropane SPECT (Dopamine Transporter SPECT), Iodine 123 Metaiodobenzylguanidine Cardiac Scintigraphy, and [18F] FDG-PET

Advances in molecular imaging techniques and the increasing availability of functional imaging are expanding the role of nuclear medicine in neuroradiology. Molecular imaging has a well-established role in the evaluation of extrapyramidal disorders. In this setting, functional assessment can be combined with structural imaging to make a more accurate diagnosis. This is particularly useful in a number of more clinically challenging pathologies. This review discusses the role and context of imaging in extrapyramidal disorders. Structural imaging with MR imaging in combination with iodine 123 N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) nortropane SPECT (dopamine transporter SPECT), iodine 123 metaiodobenzylguanidine cardiac scintigraphy, and [18F]FDG-PET can be used to differentiate various underlying disease processes including Parkinson disease, dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration.Learning Objective: To assess dopamine transporter studies qualitatively and semiquantitatively and categorize them as having normal, abnormal, or indeterminate findings and to understand the role of MR imaging, iodine 123 metaiodobenzylguanidine cardiac scintigraphy, and [18F] FDG-PET in advancing the differential diagnoses of patients with Parkinson disease and atypical parkinsonian syndrome

Surgery for Grave’s Disease

Graves’ disease (GD) is the commonest cause of hyperthyroidism followed by toxic nodular goitre. Patients presenting as goitre with clinical features of hyperthyroidism are to be carefully evaluated with biochemically with thyroid stimulating hormone (TSH), free thyroxine (fT4) and radionuclide scan (Technitium-99/Iodine-123). Those with GD also have raised thyroid receptor stimulating antibody levels. Patients are simultaneously evaluated for eye disease and managed accordingly. Initial treatment is rendering patient euthyroid using anti thyroid drugs (ATD) and if remission does not occur either continue medical therapy or proceed for definitive therapy by radioactive iodine ablation (RAI) or surgery. In last decades there is ample literature preferring surgery as preferred definitive therapy. Surgery in thyroid disease has become safer with development of many intra-operative adjuncts but it should be performed by high volume thyroid surgeon. The procedure of choice is near total or total thyroidectomy as it avoids recurrences. Patients who are not eligible or willing for surgery can be managed with RAI.

Spontaneous bilateral peri-orbital purpura: an important clinical sign of primary systemic amyloidosis

A 69-year-old woman presented with an 18-month history of recurrent bruising of the eyelids. She was otherwise asymptomatic and systems review was unremarkable. On examination, she had peri-orbital purpura and waxy papules at the inner canthus of both eyes. Macroglossia was also noted. Subcutaneous abdominal biopsy identified amorphous material in the dermis that stained positive for Congo red, with apple-green birefringence seen under polarised microscopy. Immunohistochemistry demonstrated antibodies against lambda light chains. Bone marrow biopsy identified further deposits of immunoglobulin light chain amyloid and a clonal infiltrate with 10%–20% plasma cells, confirming amyloidosis secondary to multiple myeloma. Iodine-123-labelled serum amyloid protein scintigraphy showed no abnormal uptake, thereby excluding significant amyloid deposits in the liver, spleen or kidneys. Cardiac MRI was consistent with early amyloid infiltration. We highlight the importance of dermatological manifestations in amyloidosis, to allow for early diagnosis, potentially limiting end organ involvement.

Abstract 13677: Usefulness of 2-year Iodine-123 Metaiodobenzylguanidine-based Risk Model for the Post-discharge Risk Stratification in Acute Decompensated Heart Failure Patients With Preserved Left Ventricular Ejection Fraction

Background: A four-parameter risk model including cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters has been recently developed for the prediction of 2-year cardiac mortality risk in patients with chronic heart failure (CHF) using a Japanese CHF database consisting of 1322 patients. However, there is no information available on the usefulness of 2-year MIBG-based cardiac mortality risk score for the prediction of post-discharge prognosis in patients with heart failure with preserved LVEF (HFpEF) who are admitted with acute decompensated heart failure (ADHF). Methods and Results: Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF) study, which is a prospective multicenter observational registry for ADHF patients with LVEF ≥50% in Osaka. We studied 239 patients who survived to discharge. Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk score was calculated using four parameters, including age, LVEF, NYHA functional class, and the cardiac MIBG heart-to-mediastinum ratio on delayed image. The patients were stratified into three groups based on the 2-year cardiac mortality risk score: low- (<4%), intermediate- (4-12%), and high-risk (>12%) groups. The endpoint was all-cause death. During a follow-up period of 1.6±0.8 years, 33 patients had all-cause death. Multivariate Cox analysis showed that 2-year MIBG-based cardiac mortality risk score was an independent predictor of all-cause death (p=0.0009). There was significant difference in the rate of all-cause death among the three groups stratified by 2-year cardiac mortality risk score (Figure). Conclusions: In this multicenter study, the 2-year MIBG-based cardiac mortality risk score was shown to be useful for the prediction of post-discharge clinical outcome in HFpEF patients admitted for ADHF.