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Functional imaging has been reported to have a limited impact in the diagnosis of insular epilepsies, showing unspecific or misleading features. However, recent studies have demonstrated that PET and SPECT may be helpful in identifying abnormalities pointing to insula and guiding invasive monitoring. FDG-PET may detect a focal or regional hypometabolism in about half of the cases, and its localization value is greatly improved by the coregistration with MRI. In addition, PET may help lateralize the insular seizures, and statistical analysis contributes to differentiate them from temporal and frontal lobe seizures. SEEG strategy benefits from PET findings, as electrode implantation within the main hypometabolic areas improves the concordance rate between the PET pattern and the localization of the epileptogenic zone. Finally, PET is a reliable tool for the detection of insular focal cortical dysplasias, especially in MRI negative cases. These findings are helpful for planning surgery in these difficult-to-treat epilepsies. SPECT regional cerebral blood flow (rCBF) imaging under both interictal and ictal conditions is a mainstay of localization of epileptogenic foci in subjects with medically intractable epilepsy contemplating surgical ablation of disease-causing focal brain anomalies. Its performance is excellent in patients with mesial temporal lobe epilepsy, but neocortical foci remain harder to evaluate, in particular because of their tendency to generalize more rapidly than the former. The specific case of insular epilepsy has been studied in a limited number of studies only, reporting on a few tens of patients overall. Although this limits the possibility of conducting well-powered statistical analysis of the sensitivity and specificity of interictal/ictal SPECT rCBF imaging in this condition, available results converge towards the conclusion that this technique offers useful and important information in the pre-operative assessment of patients afflicted by that often difficult to characterize disease.
A 65-year-old accountant presented to the consultation to investigate whether her memory lapses are the first manifestations of Fahr’s disease. She noticed, during the last few years, a progressive difficulty in accomplishing her tasks at work. She felt tired and described that it takes her more time to prepare her reports as compared to a few years ago. She needs to read her drafts several times in order to ensure her work is complete and accurate. She also described more dependence on her personal notes to remember her tasks such as lists for shopping. During meetings and conversations at work, she described difficulties recalling people’s names. She has started to search for words during conversations. Although inconvenient, the impact of these difficulties on her work remains minimal, and she continues to take good care of her home affairs. Her husband denies that the patient is underperforming at home. She described no difficulties completing her domestic, financial, and personal obligations.
A 75-year-old, right-handed man accompanied by his wife presented at initial consultation, with a history of mild difficulties with short-term recall for the past 2 years. Although he wrote down the time and place of upcoming appointments accurately, he repeatedly sought reassurance from his wife about them. He kept rechecking where things had been deposited. There was some hesitation for words during conversations.
Positron emission tomography (PET) imaging of brain amyloid beta is now
clinically available in several countries including the United States and
the United Kingdom, but not Canada. It has become an established technique
in the field of neuroimaging of aging and dementia, with data incorporated
in the new consensus guidelines for the diagnosis of Alzheimer disease and
predementia Alzheimer’s disease–related conditions. At this point, there are
three US Food and Drug Administration– and European Union–approved tracers.
Guided by appropriate use criteria developed in 2013 by the Alzheimer’s
Association and the Society of Nuclear Medicine and Molecular Imaging, the
utility of amyloid imaging in medical practice is now supported by a growing
body of research. In this paper, we aimed to provide an update on the 2012
Canadian consensus guidelines to dementia care practitioners on proper use
of amyloid imaging. We also wished to generate momentum for the industry to
submit a new drug proposal to Health Canada. A group of local, national, and
international dementia experts and imaging specialists met to discuss
scenarios in which amyloid PET could be used appropriately. Peer-reviewed
and published literature between January 2004 and May 2015 was searched.
Technical and regulatory considerations pertaining to Canada were
considered. The results of a survey of current practices in Canadian
dementia centers were considered. A set of specific clinical and research
guidelines was agreed on that defines the types of patients and clinical
circumstances in which amyloid PET could be used in Canada. Future research
directions were also outlined, notably the importance of studies that would
assess the pharmaco-economics of amyloid imaging.
This chapter talks about Mary who was admitted to Tertiary Hospital in early June of 2003 having stumbled to the ground being unable to get up. CT of her head confirmed general parenchymal volume loss with decreased attenuation periventricularly. No significant areas of ischemia or space-occupying lesions were noted. PET scan was suggestive of a neurodegenerative process of Alzheimer's type. No scan evidence of frontal lobe dementia. The diagnosis prior to the PET scan being performed was frontotemporal dementia. The final clinical diagnosis after the PET scan and on discharge was that of Alzheimer's type dementia. She was not started on acetylcholine esterase therapy. She was discharged to a low level residential facility. This case is interesting in that it does not on face value fit into one category of neurodegenerative disorders. False beliefs related to misinterpretation of the environment due to significant visual impairment is known as Charles-Bonnet syndrome.
This chapter conveys that a 65-year-old technical worker with previous management function had been unable to work because of pulmonary problems for 7 years. This highly educated man had been diagnosed with extrinsic allergic alveolitis 7 years ago. A diagnosis of subjective memory complaints (SMC) was made. The fact that cerebrospinal fluid (CSF) values were abnormal was not taken into account at that time because of lack of a clinical diagnosis of dementia. Referral to a psychiatrist was advised for evaluation of a possible mood disorder and for counseling on how to deal with his behavioral disturbances. SMC or subjective cognitive impairment (SCI) in the absence of mild cognitive impairment (MCI) or dementia is more and more accepted as a separate clinical entity. Depression, anxiety, disturbed sleep, fatigue, and loss of energy were responsible for a conversion from SCI to MCI, but subsequently reverted back to SCI after follow-up.