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Brain Single Photon Emission Computed Tomography (SPECT) in Neuropediatrics By P. Uvebrantl,f. Bjure2 , A. Hedström 3 and s. Ekholm4

Abstract The clinical value in neuropediatrics of [99mTc]HM-PAO brain single photon emission cömputed tomography was preliminary evaluated by the consecutive investigation of 79 children. Planned epilepsy surgery was the most common indication for the investigation. In 56 children investigated because of epilepsy, SPECT yielded relevant information in 79 % of cases examined. The corresponding figures for magnetic resonance imaging and CT were 49 % of 35 and 36 % of 56 cases, respectively. All 22 children with an epileptic focus, ascertained by freedom from seizures after removal of the area or by consistent neurophysiological and neuroradiological findings, also had abnormal perfusion in the relevant area. Twenty-three children were examined because of neurological signs and symptoms other than epilepsy. SPECT findings were useful for elucidating neonatal brain impairments. Hypoperfused areas in the brain of asphyxiated infants and in posthemorrhagic hydrocephalus corresponded to neuroradiological and autopsy findings. SPECT was found to be an excellent tool when analysing cerebrovascular accidents. In cases with signs and symptoms of a diffuse severe encephalopathy, SPECT did not clarify the etiology but provided information on the distribution of the lesions and probable underlying pathophysiological mechanisms.

Keywords Single photon emISSIon computed tomography - Children - Epilepsy - Neuroimpairment

Introduction The introduction of neutral lipophilic radiotracers such as [99mTC]HM-PAO with the ability to penetrate the intact bloodbrain barrier has provided new possibilities for functional neuroimaging. A good agreement with the results of Received October 9, 1989; accepted December 12, 1989 Neuropediatrics 22 (1991) 3-9 © Hippokrates Verlag Stuttgart

other methods for measurement of the regional cerebral blood flow has been documented (2, 6). The availability and simplicity of the technique, compared with, for instance, positron emission tomography, makes single photon computed tomography (SPECT) a valuable tool in the hands of the neuropediatrician. The role of SPECT in the preoperative evaluation before epilepsy surgery has already been established (20, 25). Promising reports have also recently emerged on the usefulness of SPECT for exploring neurological impairments other than epilepsy (19, 28) ranging from ischemic brain lesions in the newbom (7) to dementia in the old (17). The present study was undertaken with the aim of evaluating the usefulness of SPECT in neuropediatric clinical practice.

Patients and methods The clinical material consisted of all 79 children, 40 boys and 39 girls, consecutively investigated during the period of January 1988 to August 1989. The subjects' ages at examination ranged from two weeks to 20 years, with a mean age of ten years. The indications for SPECT were epilepsy in 56 children and other neurological signs and symptoms in 23. After rest in a quiet room for 30 minutes a dose of 10 MBq [99mTc]HM-PAO per kilo body weight was injected by means of apreset intravenous cannula during EEG monitoring. EEG during injection was omitted in cases not investigated for a seizure disorder. SPECT imaging was performed under general anesthesia in all but 23 subjects. A rotating gamma camera GE 400 AlT with HR collimator was used. Sixty frames of 30 sec were attained and reconstructed as transaxial, coronal and sagittal slices as weIl as in a three-dimensional mode. Pathological regions were selected visually. Thirty-five magnetic resonance imaging (MRI) examinations were performed at four different centres, all using superconductive magnets operating at a field strength varying between 0.5 and 1.5 Tesla. All MR images were reviewed by an experienced neuroradiologist at Sahlgren Hospital (Ekholm), unaware of the SPECT findings. Extensive EEG investigations had been performed in the children suffering from epilepsy. A 16-channel video-EEG recording system was used in the 40 cases in which ictal recordings were obtained. With few exceptions, bilateral sphenoidal electrodes were used, and three children had chronic subdural strip electrode recordings.

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Departments of 1Pediatrics and 2Clinical Physiology, East Hospital, and Departments of 3Clinical Neurophysiology and 4Neuroradiology, Sahlgren Hospital, Gothenburg, Sweden

Neuropediatrics 22 (1991)

P. Uvebrant et al

Results

Epilepsy The SPECT findings in 56 ehildren with epilepsy were eorrelated to the proven or presumed origin of the seizures and to the result of 35 MRI and 56 CT-seans performed on the same subjeets. Twenty-two ehildren had a partial epilepsy from a foeus whieh was weIl defined. The foeus was restrieted in 15 cases (Table 1) and extensive, i. e. a whole hemisphere or parts of both frontal lobes, in seven cases (Table 2). SPECT indicated pathology in the relevant areas in all these ehildren, in 21 cases the affeeted region was seen as an area of hypoperfusion (Fig. 1) and only one showed an inereased perfusion in an area from whieh eontinuous epileptiform aetivity was simultaneously reeorded (Fig.2). In nine ehildren, hypoperfused areas were also reeorded separate from the seizure foeus. Relevant MRI and CT findings in these 22 ehildren were reeorded in 11 of 16 eases (69 %) and 10 of 22 eases (45 %), respeetively. Epilepsy surgery was performed in 11 ehildren; hemisphereetomy in four, reseetion of the temporal lobe in two, frontal lobe reseetion in one, fronto-eentral reseetion in one, temporal tumor reseetion in one and anterior callosotomy in two cases. An etiological diagnosis was found in 15 eases; seven had a prenatal, three a perinatal and five a postnatal origin (Table 3).

Fig. 1 rransaxial SPECr image in a 16-year-old boy with complex partial seizures. HM-PAO injected interictally. Note decreased perfusion in the left temporal lobe.

In 13 ehildren it was not possible to define the exaet foeus from whieh the epilepsy emerged. A presumed foeus was indicated by EEG reeordings, in one case by subdural strip electrode reeordings, in three by ietal video-EEG reeordings and in nine by scalp EEG reeordings only. Abnormalities in the presumed foeus were present in ten SPECT investigations, two out of ten MRI examinations and two out of 13 CT-scans (Table 4). The relevanee of these findings was, however, unelear.

Table 1 Partial epilepsy from a restricted, well-defined focus indicated by epilepsy surgery (4), intracranial EEG electrodes (2) or seizure recordings by video-EEG (9). SPECT, MRI and cr findings in 15 children.

SPEcr MRI cr

Relevant findings

Normal or irrelevant findings

n

(%)

n

(%)

n = 15

15*

(100)

o

n = 14 n = 15

9 6

( 64)

5

( 40)

9

( 0) (36) (60)

* Focal hypoperfusion 14, focal hyperperfusion 1.

Table 2 Partial epilepsy froman extensive but well-Iocalised focus, i. e. whole hemisphere or both frontal lobes. All subjects had been subjected to epilepsy surgery; hemispherectomy 4, frontal lobe resection 1 and anterior callosotomy 2. SPEcr, MRI and cr findings in 7 children.

SPEcr MRI cr

n=7 n=2 n=7

Relevant findings

Normal or irrelevant tindings

n

(%)

n

(%)

7 2

(100) (100) ( 86)

o o

( 0) ( 0) (14)

6

1

Fig. 2 Focal hyperperfusion in the left temporal lobe of an 11-year-old girl. HM-PAO injected during ongoing epileptiform activity in the left temporal region.

A multifoeal epilepsy was diagnosed in 18 ehildren. The diagnosis was based on 16-ehannel video-EEGreeorded seizures in 13 of the 18 eases. The definition of relevant SPECT, MRI and CT findings in these cases was the presenee of multiple areas of abnormal perfusion, signal or attenuation, respeetively. Based on this somewhat questionable definition, SPECT showed relevant abnormalities in 12 of 18, MRI in 4 of 9 and CT in 6 of 18 eases (Table 5). Children in this group eould be exemplified by a girl with eongenital varieellae and multiple intraeerebral ealeifieations and a girl with spastic

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Brain SPEer in Neuropediatrics

Neuropediatrics 22 (1991)

diplegia after preterm birth. Three children with primarily generalised epilepsy were investigated. CT-scans were normal as expected and MRI was not performed. The SPECT findings were diverse; one normal, one with multiple areas of hypoperfusion and one with localised hyperperfusion in the brainstern (Table 6).

5

Other indications Altogether 23 children were subjected 10 SPECT due to neurological symptoms other than epilepsy.

Neonatal neuroimpairments Etiological diagnoses in 15 children with a defined epileptic

focus. Prenatal n = 7 Early malformations Disturbed neuronal migration Sturge- Weber disease Tuberous sclerosis Hemimegalencephaly Late prenatal Fetal stroke

3

1 1 1

Perinatal n = 3 Severe perinatal asphyxia

3

Postnatal n = 5 Trauma Encephalitis Tumor

2 2 1

lable 4

Partial epilepsy. SPECT, MRI and CT findings in 13 children in whom the epileptogenic focus has not yet been defined by consistent clinical, neurophysiological andjor neuroradiological findings. Presented findings related to presumed foeus indicated by intracranial EEG recording (I), video-EEG-recorded seizures (3) and routine EEG findings (9). Relevant findings

SPECT MRI CT

n = 13 n = 10 n = 13

n

(%)

Normal or irrelevant findings (%) n

10 2 2

(77) (20) (15)

3 8 11

(23) (80) (85)

Three infants were examined at the ages of eight, two and six weeks, respectively, or in the two last cases, corrected for preterm birth at 37 and 32 weeks of gestation. The first baby was born at term, severely asphyxiated with Apgar scores 0 and 1 at one and five minutes~ respectively. This boy died three weeks after the SPECT examination, eleven weeks old. SPECT showed hypoperfusion in the parasagittal watershed areas betweeri the anterior and middle cerebral arteries (Fjg. 3), and decreased perfusion of the basal ganglia and upper brainstem. A CT-scan showed increased attenuation in the basal ganglia and at autopsy a status marmoratus was indicated in the same area. The second infant was born after 35 weeks of gestation with a birth weight of 1985 grams and Apgar scores 4 and 6. SPECT was performed because of intractable seizures starting some hours after birth. A CT-scan was normal, as was ultrasound, whereas SPECT showed areas with reduced perfusion in the left frontal and parieto-occipital regions. EEG indicated epileptiform activity predominating over the left hemisphere. The third baby, with a gestational age at birth of 26 weeks, developed a posthemorrhagic hydrocephalus and a ventriculo-peritoneal shunt was later inserted. SPECT showed a brain with a helmet-like appearance, due to the compression of the hemispheres (Fig.4), and reduced perfusion of the basal ganglia on the left side, corresponding to an earlier CT finding of intraparenchymatous extension of the cerebral hemorrhage.

lable 5

Partial epilepsy of multifocal origin. SPECT, MRI and CT findings in 18 children with multiple foci indicated by video-EEG-recorded seizures (13) or by routine EEG (5). Relevant findings

SPECT MRI CT

n = 18 n= 9 n = 18

n

(%)

12* 4

(67) (44) (33)

6

Normal or irrelevant findings (%) n 6**

5 12

(33) (56) (66)

* Multiple areas of hypoperfusion. ** Normal 2, Monofocal hypoperfusion 4.

labte 6 Primarily generalised epilepsy. SPECT and CT findings in three children with regular (2) or irregular (1) bilateral synchronous epileptiform EEG activity and absences with or without myoclonic seizures. Relevant findings

SPECT CT

n=3 n=3

n

(%)

Normal or irrelevant findings n (%)

07

(0) (0)

3* 3

o

(100) (100)

* Normal I, multifocal hypoperfusion I, local hyperperfusion on the right side of the upper brainstem 1.

Fig.3 A two-month-old boy born at term with severe asphyxia. The threedimensional SPECT reconstruction viewed from the front shows parasagittal hypoperfusion.

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Neuropediatrics 22 (1991)

P. Uvebrant et al

Two children were examined after episodes of cardiac arrest. An 18-month-old girl with diaphragmatic hernia and vomiting had a cardiac arrest after aspiration. She was investigated by SPECT ten days after the accident and was found to have a severe reduction of blood flow to the cerebral cortex whereas the brainstem, cerebellum and basal ganglias had preserved perfusion. The result was in good agreement with the clinical findings of decorticate rigidity with flexed arms, extended legs and minimal signs of contact ability. The second child was a 19-month-old boy who developed bradycardia and shortlasting cardiac arrest during·a squint operation. He regained consciousness after the general anesthesia but gradually became comatose during the following days. A CT-scan was normal but SPECT indicated a reduced blood flow in the occipitallobes, interpreted as the result of kinking of the posterior cerebral vessels over the tentorium, caused by cerebral edema. The boy recovered but was left witn impaired visual perception.

Traumatic lesions Fig. 4

The helmet-like appearance of the compressed hemispheres in a six-week-old girl with posthemorrhagic hydrocephalus. The girl was born after 26 weeks of gestation.

Cardio and cerebrovascular disease Ten children were examined. The diagnoses are given in Table 7. Two girls were investigated because of recurrent episodes of right-sided hemiparesis and dysarthria. Surgical correction of transposition of the great arteries (TGA) ad modum Mustard had been performed in one, and the other girl had multiple stenoses of the pulmonary arteries and an atrial septum defeci. CT-scan in the first case indicated pathology in the right hemisphere, i. e. not the side responsible for the symptoms, whereas SPECT showed bilateral areas with reduced perfusion with a left-sided predominance. In the other girl, there were congruent and adequate findings in both investigations. SPECT in a girl with Takayashu's disease and headache did not show any asymmetries in the regional cerebral blood flow. Four children were suspected to have cerebral arterio-venous malformations or angiomatosis. SPECT in these cases could not disclose any pathology. A two-month-old girl suddenly developed a left-sided hemiplegia. CT showed a one centimeter large bleeding in the thalamus on the right side. A reduced perfusion in a large area lateral to the lesion was seen on SPECT.

Table 7 Oiagnoses in ten children with cardio- or cerebrovascular disease subjected to SPEeT due to neurological symptoms.

Cardiovascular disorders n = 3 Transposition of the great arteries Multiple stenoses of the pulmonary arteries + ASO Takayashu's disease

Cerebrovascular disorders n = 5 Stroke

Sturge-Weber disease Arterio-venous malformation (3) Cardiac arrest n = 2

A four-year-old girl was examined one week after she had suffered head trauma in a car accident. A CT-scan showed a contusion in the left hemisphere which could explain her dysphasia but not a left-sided hemiparesis. The SPECT revealed a contre-coup lesion in the right hemisphere, not visualised by CT.

Oncologicalconditions One girl with acute lymphatic leukemia was examined during remission of the disease because of seizures. SPECT showed a focal hyperperfusion in the left temporal lobe and a simultaneous EEG disclosed seizure activity in the same area. The interpretation was that epileptogenic scarring had occurred secondary to irradiation and intrathecal methotrexate treatment.

Infectious diseases Two girls with sequelae after viral encephalitis were studied. A nine-year-old girl had an influenza B virus encephalitis at five years of age. After the infection, she was noted to have a severe impairment of visual perception. Despite a normal visual acuity, she could not recognise her own mother unless she heard her voice. SPECT showed an extensive bilateral occipital hypoperfusion with left-sided predominance (Fig.5). The other girl had a herpes virus encephalitis at one year of age. The infection resulted in a left-sided hemiplegia, mental retardation and intractable epilepsy. SPECT showed a reduced or absent regional cerebral perfusion in the centro-temporal region on the right side (Fig. 6). The affected part of the brain was removed with good effect on the seizures, improved ability to make contact and the development of pincer grasp in the right hand. Obviously, this function had earlier been inhibited by the seizure activity in the contralateral hemisphere. This girl is included in the epilepsy surgery cases reported above.

Early severe non-progressive encephalopathies Four of the infants examined showed early signs of severe encephalopathy such as no or minimal development beyond the neonatal period and a severe seizure disorder. Extensive neurometabolic investigations were not informative

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and the indication for SPECT was to elucidate the etiology of a presumed prenatal malformative nature. CT was in all cases normal or showed diffuse atrophy and hypsarrhythmia was present in the EEGs. SPECT showed multifocal abnormalities of the cerebral perfusion, in two cases with frontal predominance. Isolated right hemisphere pathology was found in a girl with a mild left-sided hemiplegia. SPECT in these very complex cases did not reveal the exact nature of the impairments but gave some information on the distribution of the lesions.

Two girls with Retfs syndrome were examined. In one the SPECT was performed at three years of age, in an early phase of the disease, and in the other in an advanced stage at the age of 13 years. The SPECT findings are yet inconelusive. Some hypoperfusion in the area around the third ventriele may be suspected. A boy with hydrocephalus, treated by ventrieulo-peritoneal shunting, showed signs of progressive dementia which could not be explained by dysfunetion of the shunt. SPECT indicated a diffuse eortieal hypoperfusion but gave no further information on the nature of the progressive signs and symptoms, which also included extrapyramidal impairment.

Fig. 5 Hypoperfusion of the occipital lobes after Influenza B virus encephalitis in a girl nine years of age. The girl had a severe impairment of visual perception. Despite anormal visual acuity, she could not recognise her own mother unless she heard her voice.

Diseussion The accuraey of SPECT in indieating regional abnormalities in the cerebral blood flow in areas responsible for focal epilepsy was very good in this study. Equally good or even better results have been published (3, 26). Ryding et al (22) found that SPECT adequately loealised the epileptie foeus in 93 % of 14 patients investigated. The results can be further improved by injecting the radiotracer during or within ten minutes of a seizure (15, 21), when a relative hyperperfusion is seen in the epileptic foeus. Regional perfusion is also increased when the EEG shows focal epileptiform discharges without elinieally evident seizures (9). The development of more stable tracer substances will facilitate such ictal studies. Intractable epilepsy in childhood seIdom presents itself as an isolated seizure disorder with a diserete lesion in, for example, the temporal lobe, but as part of a multihandicap with mental retardation and cerebral palsy. It may be very difficult to determine which part of an extended lesion or whieh of several impaired areas is responsible for the epilepsy. The seizure activity is often rapidly generalised, a fact that complicates the EEG identification of the primary foeus. SPECT seems to have an advantage, even over PET, in that regional blood flow is increased locally only in the region of the epileptic foeus, despite the generalised nature of the clinical seizure (14). In four children in this series, SPECT disclosed a single hypoperfused area despite multifocal EEG findings. It may weIl be that the SPECT, rather than the EEG findings, were adequate with respect to the origin of the epilepsy in these cases. SPECT findings in primarily generalised epilepsy have been diverse and confusing (16), as in the present study. Local hyperfusion in the upper brainstem, found in one girl may have relevance for the pathogenesis of this form of epilepsy. Aseries of children with primarily generalised epilepsy is currently being investigated after injeetion of 99mTc-HM-PAO during photostimulation and hyperventilation.

Fig. 6 Herpes virus encephalitis in a three-year-old girl. A severe reduction of perfusion is seen in the right fronto-central region.

Promising results of SPECT in neonatal brain impairments have been published (7, 12) and were achieved in the present study. Besides congruent findings with CT and ultrasound of structural lesions and periventricular leucomalacias, parasagittallesions, seen mainly in term infants (29), and other corticallesions were indicated. Further studies are required 10 clarify whether these findings have prognostic implications of long-term validity. New techniques in pediatric cardiac surgery have saved a lot of children with previously inoperable congenital heart disease. The outcome with respect to cerebrovascular sequelae is, however, still largely unknown.

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Progressive encephalopathies

P. Uvebrant et al

Neuropediatrics 22 (1991)

SPECT seems to be a suitable tool in the follow-up after extensive cardiac surgery in childhood. In cerebrovascular disease, SPECT was found by Shahar et al (23) to be a sensitive method for early diagnosis and localisation as weH as for the determination of the extent of regional cerebral blood flow impairment. The SPECT correlated with the clinical findings and EEG as weIl as with neuroradiology. Reduced regional blood flow often precedes CT abnormalities in ischemic stroke (8, 30) and is sometimes the only positive finding. In the present series, a girl with a sudden onset of hemiparesis was found by CT to have a smaH thalamic hemorrhage whereas SPECT indicated a large zone of surrounding hypoperfusion. SPECT also correct1y localised abnormalities in two children, one with TGA and one with posttraumatic hemiparesis, with no or contralateral CT findings. It was not possible in this study to demonstrate cerebral arteriovenous malformations, which were clinicaHy suspected in three cases. The SPECT findings in two children investigated after cardiac arrest were very informative. A girl with persistent clinical signs of decorticate rigidity was shown to have no or minute cortical perfusion, and a boy with residual symptoms in the form of impaired visual perception had occipital hypoperfusion. 99rnTc-HM-PAO SPECT has even been introduced as a non-invasive method for the determination of brain death in children (10). However, this method should not be used for the determination of brain death in newborn infants as the cerebral blood flow requirement for brain viability in newborn infants is extremely low (1). The improved survival rates in children with leukemia and other forms of cancer have increased the need for follow-up examinations aiming at early detection and prompt treatment of relapses, for instance within the brain. It is important and may be difficult to detect and differentiate such lesions, sometimes representing relapses, sometimes scarring after irradiation or cytostatic medication (27). The need for sensitive and complementary methods for such investigations is great. SPECT may be useful in this respect, as indicated by the present case, but further investigations are mandatory in order to define its role in the field of pediatric oncology. Two children in this study were investigated after viral encephalitis; informative results were achieved in both cases. Since the introduction of Aciclovir in the treatment of herpes virus infections, it has become important to obtain early indications of the nature of a suspected encephalitis. SPECT seems to be such an indicator, as in ischemic stroke SPECT reveals focal changes in regional perfusion earlier and more extensively than a CT-scan. In cases of early severe static encephalopathy, presumably with a dominating prenatal etiology, the SPECT findings were helpful in defining the extension but not the nature of the lesions. Even so, the information added may be important. Children with infantile spasms (4) and Lennox-Gastaut syndrome (5) sometimes have a well-Iocalised lesion as the cause of the seemingly generalised seizure disorder, and may be radically improved after surgical removal of the lesion. SPECT has proved to be useful in the diagnosis of Alzheimer's disease (11) and other forms of dementia (17). There are several progressive encephalopathies in the pediatric age-group in which laboratory findings so far are not helpful. The Retfs syndrome (13) can be taken as an example of progressive dementia in childhood with unknown etiology. A study is currently in progress to evaluate whether changes in regional

cerebra! blood flow in early and late stages of the disease can contribute to our understanding of the pathophysiology and facilitate the early differentiation of this syndrome from cases of infantile neuronal ceroid lipofuscinosis and infantile autism, two diagnoses often confused with the Retfs syndrome in early stages. A hydrocephalic boy with progressive dementia and extrapyramidal signs was investigated in this study. SPECT findings in this case were unrevealing, whereas a similar case described by Shahar et al (24) was shown to have a reduced blood flow in the basal ganglia. To sum up, brain SPECT using 99rnTc-HMP AG was found to provide important information in several clinical situations. There is a need for further work to determine what degree of asymmetry in the regional cerebral perfusion can be accepted as normal, and to quantify the regional blood flow in absolute values. Some attempts have been made (18) but standards are stilllacking, not least in the pediatric age-group. Pending the development of such standards, one has to rely on the visual impression when interpreting the SPECT findings. The applications of SPECT are likely to increase in the years to come. New radiotracers have been developed, some with the ability to label neuroreceptors. Such agents will help to clarify the pathogenesis in some neurological disorders of hitherto unknown etiology. References 1

Altman, D. 1., W.]. Powers,]. M. Perlman, P. Herschovitch, S. L. Volpe, ].]. Volpe: Cerebral blood flow requirement for brain viability in new-

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born infants is lower than in adults. Ann. Neurol. 24 (1988) 218-226 comparison with 133Xe. Nucl. Med. Commun. 8 (1987) 549-557 3

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Chiron, C., C. Raynaud, 1. ]ambaque, O. Dulac, S. Ricard, M. Bourguignon, A. Syrota: 133-Xe brain SPECT imaging in cryptogenic

West syndrome: correlations between regional cerebral blood flow and neuropsychological disorder. J. Nucl. Med. 28 (1987) 592 5 Chugani, H. T.,]. C. Mazziotta,]. Engel, M. E. Phelps: The LennoxGastaut syndrome: Metabolie subtypes determined by 2-deoxy-2 [18F] fluoro-D-glucose positron emission tomography. Ann. Neurol. 21 (1987) 4-13 6

Costa, D. C., B. E. iones, T.]. Steiner, B. S. Aspey, 1. D. Cullum, R. F. ]ewkes: Relative 99rnTC-HMPAO and 113Sn-microspheres distribution

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Gemmel, H. G., P. F. Sharp,]. A. O. Besson, K. P. Ebmeier, F. W. Smith:

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Hagberg, B.: Rett syndrome: Clinical pecularities, diagnostic approach, and possible causes. Pediatr. Neurol. 5 (1989) 75-83 Lee, B. 1., O. N. Markand, H. N. Wellman, A. R. Siddiqui, B. Mock, 1. Krepshaw, H. Kung: HIPDM single photon emission computed tomography brain imaging in partial onset secondarily generalized tonic-donic seizures. Epilepsia 28 (1987) 305-311 Lee, B. 1., O. N. Markand, H. N. Wellman, A. R. Siddiqui, H. M. Park, B. Mock, R. M. Worth, M. K. Edwards,]. Krepshaw: HIPDM-SPECT in patients with medically intractable complex partial seizures. Ictal study. Arch. Neurol. 45 (1988) 397-402 Leroy, R. F., M. D. Devous, A. K. Ajmani, K. K. Rao, F.]. Bonte: Regional cerebral blood flow determined by xenon 133 inhalation and SPECT scan among epileptics with primary generalized seizures. Neurology 38 (Suppl 1) (1987) 102 Neary, D.,]. S. Snowden, R. A. Shields, A. W. Buljan, B. Northen, N. MacDermott, M. C. Prescott, H.]. Testa: Single photon emission tomography using 99mTc-HM-PAO in the investigation of dementia. J. Neural. Neurosurg. Psychiatry 50 (1987) 1101-1109 Nickel, 0., B. Nägele- Wöhrle, P. Ulrich, D. Eissner, A. Roesler, W. Grimm, K. Hahn: RCBF-quantification with 99mTc-HMPAO-SPECT: Theory and first results. Eur. J. Nucl. Med. 15 (1989) 1-8 Reid, R. H., K. Y. Gulenchyn,]. R. Ballinger, E. C. G. Ventureyra: Clinical use of cerebral perfusion imaging with 9gmTc-HMPAO in pediatric patients. J. Nucl. Med. 29 (1988) 919 Rowe, C. C., S. F. Bercovic, S. T. B. Sia, M. Austin, W.]. McKay, P. F. Bladin: Localization of epileptic fod by postictal single photon computed tomography (SPECT) and 99mTc-HMPAO: comparison with ictal EEG in 22 patients. Neurology 38 (Suppl1) (1988) 157 Rowe, C. C., S. F. Berkovic, M. Austin, W.]. McKay, P. F. Bladin: Postictal SPECT in epilepsy. Lancet I (1989) 389-390 Ryding, E., 1. Rosen, D. Elmqvist, D. H. Ingvar: SPECT measurements with 99mTc-HM-PAO in focal epilepsy. J. Cereb. Blood Flow Metab. 8 (1988) 95-100 Shahar, E., R. Lambert, E. K. Cohen, D. L. Gilday,]. M. Ash, P. A. Hwang: Pediatric cerebrovascular disease: Alterations of regional cerebral blood flow detected by SPECT scanning with 99mTc-HMPAO. Abstract: XXIIlieme Congres Canadien des Sciences Neurologiques, Quebec, june 16-18, 1988 Shahar, E., R. Lambert, P. A. Hwang, H.]. Hoffman: Obstructive hydrocephalus - induced Parkinsonism. Decreased basal ganglia regional blood flow detected with 99Tc-HMPAO SPECT scanning. Abstract: XXIIlieme Congres Canadien des Sciences Neurologiques, Quebec, june 16-18,1988 Stefan, H., G. Pawlik, H. G. Böcher-Schwartz, H.]. Biersack, W. Bu", H. Penin, W. -D. Heiss: Functional and morphological abnormalities in temporallobe epilepsy: a comparison of interictal and ictal EEG, CT, MRI, SPECT and PET. J. Neurol. 234 (1987) 377-384 Stefan, H., C. Huhnen, H.]. Biersack, K. Reichmann: Initial experience with 99mTc-hexamethyl-propylene amine oxime (HM-PAO) single photon emission tomography (SPECT) in patients with focal epilepsy. Epilepsy Res. 1 (1987) 134-138 Stephani, U., G. Harten, H.]. Langermann, H. Riehm, F. Hane[eld: Cranial computed tomography of 64 children in complete remission of leukemia II: Relations to patient data and neurological complications. Neuropediatrics 14 (1983) 149-154 Taudorf, K., S. Vorstrup: Cerebral blood flow abnormalities in cerebral palsied children with normal CT-scan. Neuropediatrics 20 (1989) 33-40 Volpe, ]. ]., P. Herschowitch,]. M. Perlman, K. L. Kreusser, M. E. Raichle: Positron emission tomography in the asphyxiated term newborn: parasagittal impairment of cerebral blood flow. Ann. Neurol. 17 (1985) 287-296 Yeh, S. H., R. S. Liu, H. H. Hu, W.]. Wong, Y. K. Lo, Z. Y. Lai,]. C. Huang, S. L. Chang, S.]. Wang, F. L. Chu: Brain SPECT imaging with Tc-99m-HM-PAO in the early detection of cerebral infarction: Comparison with transmission computed tomography. J. Nucl. Med. 27 (1986) 888 Abstract 49

9

@) Hippokrates Neurodermitis Atopische Dermatitis

Grundlagen, Ernährung, Therapie Downloaded by: National University of Singapore. Copyrighted material.

Brain SPEer in Neuropediatrics

Von S.ILLING, Fellbach, und K.-J. GRONEUER, Münster 1991. 120 Seiten, 5 Abbildungen, 37 Tabellen, 17 x 24 cm, kartoniert DM 54,ISBN 3-7773-0998-2

Die Neurodermitis ist die häufigste chronische Krankheit bei Kleinkindern, kann aber in jedem Lebensalter vorkommen. Aufgrund vielfältiger Auslöser gibt es bis jetzt kein einheitliches therapeutisches Konzept. Ziel dieser Monographie ist es, einen Überblick über Ursachen, sinnvolle Diagnostik und rationelle Behandlung zu geben. Viele praktische Hinweise zur Therapie runden die Thematik ab. Der ernährungswissenschaftliche Bereich bildet dabei einen besonderen Schwerpunkt. Es werden die Grundzüge einer ausgewogenen Ernährung dargestellt, unter Hinweis auf Gefahren und Nutzen einzelner diätetischer Maßnahmen. Ich bestelle aus dem Hippokrates Verlag Stuttgart durch die Buchhandlung: ................ Expl. ILLING/GRONEUER, NeurodermitisAtopische Dermatitis. DM 54,ISBN 3-7773-0998-2

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