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21. Arnold JH, Anand KIS. Anesthesia and analgenia. In: Avery GB, Metcher MA,

accident (3). The diagnosis and management of BS withneuropsychiatric symptoms or signs [neuro-Behcet's syndrome(NBS)] are critical (4,5). Due to the lack of effective imagingtechniques, however, diagnosis of brain involvement in NBSpatients is difficult.

MRI has been used to detect structural lesions in NBSpatients (6—8).The most typical MRI findings in NBS are brainlesions of high signal intensity on T2-weighted images (6—8).In a significant proportion of patients with clinically evidentbrain involvement, however, brain MR images are normal (9).SPECT brain imaging with 99mTc@hexamethyl propyleneamineoxime (HMPAO) is an alternative modality that is used toassess regional cerebral blood flow (rCBF). Compared withMRI, 99mTcHMPAO brain images have proven to be moreaccurate in detecting brain involvement in autoimmune connective tissue disease and to have better correlation with clinicaldiagnosis (10—13).

In this study, we investigated the potential of 99mTc..HMpAObrain images compared with brain MRI to detect cerebralanomalies, including lesions ofthe gray and white matter, in BSpatients with neuropsychiatric symptoms or signs.

MATERIALS AND METhODS

PatientsThirteen patients (7 women, 6 men; aged 28—62yr) with BS

were enrolled in this study. The diagnosis of BS was established onthe basis of the criteria of the Behçet'sDisease Research Committee of Japan (14): the presence of a triple-symptom complex,including recurrent aphthous stomatitis, genital ulcers and relapsing uveitis. Besides this triad, additional features, including synovitis, cutaneous vasculitis and meningoencephalitis, are recognized

Involvement of the brain is one of the most important complicationsof Behçet'sdisease LBS).It is difficultto diagnose, however, becauseof the lack of effective imaging methods. Methods: Thirteen BSpatients with neuropsychiatric symptoms or signs [Neuro-Behçet'ssyndrome (NBS)] were included in this study. We combined tworoutine brain imaging modalities—brain SPECT with @“Tc-hexamethyl propyleneamine oxime (HMPAO)and brain MRI—withclinicalmanifestations to diagnose brain involvement Results Technetium-99m-HMPAObrainSPECTfindingswere abnormalin 100%(13/13) of patients. Brain MRIfindings were abnormal in 31 % (4/13)of patients. Gray matter was involved more commonly than whitematter. In the gray matter, the cerebral cortex was the mostcommonly involved area and the cerebellum was the least cornmonly involved area in NBS. Conclusion: SPECT is a more sensitiveand useful tool in detecting brain involvement in NBS patientscompared with brain MRI. The combination of HMPAO and MRI isnecessary to detect brain lesions in both gray and white matter inNBS.

Key Words: MRI; SPECT; Behçet's syndrome

J NucI Med 1998;391707—I710

Behcet'ssyndrome(BS)isararedisorderofunknownetiology and is characterized by recurrent oral and genitalaphthous ulcers, ocular inflammation and neurological involvement (1 ). Neurological complications occur in approximatelylO%—25%of all patients (2). Common neurological manifestations include cerebral venous thrombosis and cerebrovascular

Received Nov. 3, 1997; revision accepted Jan. 15, 1998.For correspondence or reprints contact: Chia-Hung Kao, MD, Department of Nudear

Medicine, Taichung Veterans General Hospital, 160 Taichung Harbor Rd., Section 3,Taichung 40705, Taiwan, Republic of China.

SPECT ANDMRI OF B@&ININNEURO-BEcHET'SSYNDROME•Kao et al. 1707

Technetium-99m-HMPAO SPECT and MRI ofBrain in Patients with Neuro-Behçet's SyndromeChia-Hung Kao, Jung-Liang Lan, Sheng-Ping ChangLai and Poon-Ung ChiengDepartments of Nuclear and Internal Medicine, Taichung Veterans General Hospital, Taichung; Department of NuclearMedicine, Chung-Shan Medical College and Dental Hospital, Taichung; and Department ofNuclear Medicine, NationalTaiwan University Hospital, Taipei, Taiwan, Republic of China

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#@1J

FiGURE 1.@ Technetium-99m-HMPAO brain SPECT in 51-yr-okiwoman reveals bilateral and multiplehypoperfusionareas in cerebral cortexand basalgangha(arrows).(B)BrainMRimage looksnormal.

as part of the syndrome. A neurological consultant evaluated thepatients for neuropsychiatric symptoms or signs. Neuropsychiatricsymptoms or signs associated with NBS were defined as those thatcould not be attributed to any other cause (such as uremia,hypertension or infection). Brain 99mTc@HMPAOand MRI werearranged on the same day as the neurologic assessment to detectcerebral anomalies.

Technetium-99m-HMPAO Brain ImagesTechnetium-99m-HMPAO was prepared from a freeze-dried kit

(Ceretec; Amersham International, Little Chalfont, Bucks, UnitedKingdom) by the addition of approximately 1250 MBq freshlyeluted 99mTcpertechnetate to 5 ml saline solution. The solutionwas injected no more than 30 mm after preparation. Patients wereplaced in a supine position in a quiet room with dimmed lights andwere allowed to relax with their eyes closed for I5 mm beforeintravenous administration of I 110 MBq (30 mCi) 99mTc@HMPAO.After 99mTcHMPAO injection, patients were asked not to move ortalk for at least 10 mm. The scan was obtained 90—120 mm afterinjection. During imaging, patients were in the supine position onthe imaging table with forehead and chin restrained. The scanningequipment consisted of a rotating, large-field-of-view, dual-headgamma camera (Helix HR; Elscint Ltd., Haifa, Israel) fitted with afanbeam collimator. Data were collected in a 64 X 64 matrix with1.3 zooming, through a 360°(180°for each camera head) rotationat three intervals, for 25 sec per arc interval. Approximately 7.5million counts were acquired. The SPECT images (coronal, sagittaland transaxial sections) were reconstructed using a Metz filter(power 5.00), backprojection and attenuation correction. Transaxialsections were reoriented parallel to the base of the brain to obtainsagittal and coronal reconstructions. The spatial resolution of thecamerawith fanbeamcollimatorwas6.3mmFWHM.To identifylocal areas of abnormal hypoperfusion, the brain SPECT imageswere interpreted visually by two experienced observers blinded tothe clinical information. Abnormal findings on 99mTc@HMPAObrain imaging consisted of heterogeneous rCBF in the gray matterof the cerebral cortex and basal ganglia/thalamus, with focalhypoperftision or visible asymmetry (Figs. 1 and 2). Otherwise, thefindings were considered to be normal (Fig. 3) (12,13,15).

Brain MRIContrast enhanced brain MR images were obtained using a Vista

MR2055 HP 1.O-T scanner (Picker International, Cleveland, OH),with a spin-echo Tl-weighted sequence of 500—750/20/1—2(repetition time/echo time/number of excitations), a proton densityweighted sequence of 2000—3000/20/1—2and a T2-weighted sequence of 2000—3000/80—100/1—2.The section thickness was 5—7mm with an intersection gap of 1 mm. To detect local areas ofabnormal signal intensity, the brain MR images were interpretedvisually by two experienced observers blinded to the clinicalinformation. Abnormal findings of brain MRI consisted of foci ofhigh signal intensity on T2-weighted images in the white matter ofthe brain stem, basal ganglia, cerebral hemispheres and cerebellum(Fig. 2). Otherwise the findings were considered normal (Fig. I)(16—19).

RESULTSThe detailed data are presented in Table I . The results

showed that 99mTcHMPAO brain SPECT was abnormal andhypoperli.ision lesions in gray matter were observed in 100%(13/13) of the patients. No white matter abnormalities werefound on 99mTcHMpAO brain SPECT. Brain MRI findingswere abnormal, and high-signal-intensity lesions were observedin the white matter in 31% (4/13) ofthe patients. No gray matterabnormalities were found on brain MRI. Gray matter wasinvolved more commonly than white matter: 12 patients withlesions in the cerebral cortex, 6 patients with lesions in the basalganglia and 2 patients with lesions in the cerebellum.

DISCUSSIONBS, originally described as a triple-symptom complex con

sisting of oral aphthous ulceration, genital ulceration andhypopyon iritis (20), is recognized now as having a widesystemic spectrum. It is generally rare but is more prevalent inJapan and many Mediterranean and Middle Eastern countries.Complications usually appear several months or even yearsafter presentation of the dermatologic features (1—3,9).Neurologic findings of the brain vary and include loss of vision,cranial nerve palsies, speech disorder, cerebellar ataxia, sensoryand motor disturbances and dementia. Histopathological findings of NBS consist of brain involvement in gray and white

1708 THE JOURNALOFNUCLEARMEDICINE•Vol. 39 •No. 10 •October 1998

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FiGURE 2. (A) Technetium-99m-HMPAObrainSPECTin 29-yr-old manreveals bilateraland multiplehypoperfusion areas in gray matter, includingcerebral cortex, basal gangliaand carebellum. (B) Brain MR image showsnormalgray matterbut high signalareainwhitematterofthe leftparietal-occipital lobe close to trigone of left lateralventricle(arrows).

matter (1—3,9). Early institution of corticosteroids or otherimmunosuppressive agents is necessary to obtain the bestresponse and to decrease the risk of fatality (2,21 ). Therefore,exact sensitivity data of diagnostic modalities, for detectingbrain anomalies in NBS patients, are important.

From a review of the literature, only a small number of casereports concerning the use of brain SPECT to evaluate rCBF inNBS have been published (22—28). Our results show that99mTcHMpAO brain SPECT, in conjunction with a highresolution, fanbeam collimator, is a sensitive method for detecting brain involvement in NBS patients. Compared with brainMRI, 100% (13/13) of patients had hypoperfusion areas in thegray matter on 99mTcHMpAO SPECT. In addition, withimproved fanbeam SPECT resolution (FWHM 6.3 mm), visualization of deep-seated structures ofthe brain, such as the basal

ganglia, has become possible. In this study, we were able todetect anomalies in the basal ganglia in 46% (6/13) of NBSpatients. However, these SPECT findings of multiple hypoperfusion lesions in the cerebral cortex are not specific, becausesimilar findings can be found in a variety of neuropsychiatricdisorders, including cocaine abuse, acquired immunodeficiencysyndrome dementia complex, multi-infarct dementia, chronicfatiguesyndrome,majorunipolardepressionandneuropsychiatric systemic lupus erythematosus (29—33). Therefore, thedefinite diagnosis of BS must depend on clinical observations.In addition, only 3 1% (4/1 3) of patients had abnormal signalintensity in the white matter on MRI.

Our results show that 99mTCHMpAO brain SPECT is moresensitive than MRI. These findings are consistent with previousreports (24,27,28). Discrepancies between the less obviousmorphological changes on MRI and the more conspicuousfunctional changes on 99mTc@HMPAO brain images are mostapparent in brain cortex and the basal ganglia (Fig. 1). Fromthese results, we believe that metabolic or functional changes inthe brain, such as fluctuations in rCBF, may be more easilydetected than changes in anatomic structure of the brain in NBS

@ atients. However, MRI seems to be more sensitive than

mTcHMPAO brain SPECT in detecting white matter lesions(Fig. 2).

CONCLUSIONIn this study, 99mTCHMpAO brain SPECT detected changes

in rCBF in gray matter in 69% (9/13) of NBS patients withnormal brain MRI findings. In addition, the brain abnormalitiesdetected by 9@Tc-HMPAO SPECT were more compatible withclinical symptoms or signs than brain abnormalities detected byMRI in NBS patients. Therefore, we conclude that 99mTc@HMPAO brain imaging, in conjunction with fanbeam SPECT,should be a standard procedure in evaluating brain involvementin NBS patients. However, MRI is also necessary for detecting

38 white matter lesions.

ACKNOWLEDGMENTSThis work was supported in part by a grant from the National

Science Council, Republic of China (NSC85-233 1B-075A-022).

SPECT ANDMRI OF BRAININNEURO-BFçHET'SSYNDROME•Kao et al. 1709

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3@Normal @Tc-HMPAObrain imaging findings in40-yr-oldhealthyman conaisted of homogeneous regknal cerebralbbod flowingraymatter

of cerebral cortex and basal ganglia/thalamuswithoutfocal hypoactivityor visibleasymmetry.

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Patientno.Age @yr) Sex@Tc-HMPAObrain

imagingBrainMRI

White matter Neuropsychiathc symptoms andsignsGraymatterWhite matterGray matter

Rt = right;Lt = left;Bil= bilateral;Co = cerebralcortex; Fr = frontallobe; P = parietallobe;T = temporal lobe;0 = occipitallobe;Ce = cerebellum;BG = basal gangla

TABLE IResults of Brain Technelium-99m-HMPAO SPECT and MRI in Neuro-Behçet'sPatients

1 62 F RtCo2 40 F LtBG3 29 M BilCo, BilCe, Ii BG4 51 F BilCo,BiIBG5 34 F BIICo,BilCe6 44 M BilFr7 55 M LtFr-T8 32 F BilCo9 63 M RtCo

10 49 M BilCo,RtBG11 28 M BilCo,LtBG12 37 F BiIP,LtBG13 38 F BiIP-T-O

Negat@,eNegativeAtFrNegativeNegativeNegativeNegativeNegativeLt

P-ONegativeNegativeNegativeNegativeNegativeBil

PNegativeN@NegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeLt

FrNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegativeNegative

Convulalon,LihemiparealsGaitdisturbanceDementia,bilcerebellarataxiaHeadache, speech disturbance,personalitychangeDementia,aphasia, bilcerebellarataxiaPersonalitychange, mutismSomnolence,aphasia, AthemiparesisSomnolence,mutismDementia,LthemiparesisHeadache, dementiaHeadacheDementiaHeadache, impairedvision

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