Growing evidence indicates that appropriate incorporation of positron emission tomography (PET) into the evaluation of patients with early symptoms of cognitive decline can improve diagnostic and prognostic accuracy. In the present work, an explicitly defined role for PET and its associated impact on expected clinical outcomes were systematically examined.
We compared the relative value of two strategies for assessing whether Alzheimer's disease (AD) was responsible for cognitive decline in geriatric patients, and in subsequently managing those patients according to the recommended standards of the American Academy of Neurology (AAN). The first strategy was based on an approach already endorsed by the AAN, following evidence-based reviews carried out by its quality standards subcommittee. The second approach was based on many of the same AAN recommendations-with respect to initial general medical and neurologic examination, structural imaging and laboratory tests, as well as ultimate management-but additionally incorporated PET in appropriate cases, to determine the presence or absence of a pattern of regional cerebral metabolism characteristic of AD. Clinical outcomes accruing to each strategy were calculated using formalized tools of decision analysis.
The strategy making use of PET increased diagnostic accuracy, yielding decreased rates of both false negative (from 8.3 to 3.1%) and false positive (from 23.0 to 11.9%) diagnoses for AD, compared with the conventional strategy. When coupled with AAN treatment recommendations for patients having (or not having) non-severe AD, these differences in diagnostic accuracy corresponded to approximately a 62% decrease in avoidable months of nursing home care, and a 48% decrease in months of unnecessary drug therapy resulting from inaccurate diagnoses. The benefit in clinical outcome of the proposed strategy was maintained over a wide range of values for sensitivity, specificity, and projected impact on need for nursing home care.
Use of PET for evaluating early cognitive decline in geriatric patients can add valuable information to the clinical assessment, resulting in a greater number of patients being accurately diagnosed and properly treated. PET can be used to diminish disease-related and treatment-related morbidity of dementia, through earlier institution of appropriate management.
"One caveat is that the atlas-based normalization approach may not adequately capture hippocampal regions because of spatial distortion, thus decreasing the sensitivity of the ROI analysis for this region (Mosconi et al, 2005). Further, it is not known if the SSM approach is superior to other methods with potential utility in predicting cognitive decline and conversion to AD in MCI patients, for example, resting FDG PET (Silverman et al, 2002), hippocampal and entorhinal atrophy on structural MRI (de Leon et al, 2004), CSF tau and A-Beta levels (Blennow and Vanmechelen, 2003). Head-to-head comparison of these measures in larger samples of MCI patients followed longitudinally is needed to address this issue. "
[Show abstract][Hide abstract] ABSTRACT: Temporoparietal and posterior cingulate metabolism deficits characterize patients with Alzheimer's disease (AD). A H(2)(15)O resting PET scan covariance pattern, derived by using multivariate techniques, was previously shown to discriminate 17 mild AD patients from 16 healthy controls. This AD covariance pattern revealed hypoperfusion in bilateral inferior parietal lobule and cingulate; and left middle frontal, inferior frontal, precentral, and supramarginal gyri. The AD pattern also revealed hyperperfusion in bilateral insula, lingual gyri, and cuneus; left fusiform and superior occipital gyri; and right parahippocampal gyrus and pulvinar. In an independent sample of 23 outpatients with mild cognitive impairment (MCI) followed at 6-month intervals, the AD pattern score was evaluated as a predictor of cognitive decline. In this MCI sample, an H2(15)O resting PET scan was carried out at baseline. Mean duration of follow-up was 48.8 (SD 15.5) months, during which time six of 23 MCI patients converted to AD. In generalized estimating equations (GEE) analyses, controlling for age, sex, education, and baseline neuropsychological scores, increased AD pattern score was associated with greater decline in each neuropsychological test score over time (Mini Mental State Exam, Selective Reminding Test delayed recall, Animal Naming, WAIS-R digit symbol; Ps<0.01-0.001). In summary, a resting PET covariance pattern previously reported to discriminate AD patients from control subjects was applied prospectively to an independent sample of MCI patients and found to predict cognitive decline. Independent replication in larger samples is needed before clinical application can be considered.
[Show abstract][Hide abstract] ABSTRACT: Measurement of local cerebral glucose metabolism (lCMRGlc) by positron emission tomography (PET) and 18F-2-fluoro-2-deoxy-D-glucose (FDG) has become a standard technique during the past 20 years and is now available at many university hospitals in all highly developed countries. Many studies have documented a close relation between lCMRGlc and localized cognitive functions, such as language and visuoconstructive abilities. Alzheimer's disease (AD) is characterized by regional impairment of cerebral glucose metabolism in neocortical association areas (posterior cingulate, temporoparietal and frontal multimodal association cortex), whereas primary visual and sensorimotor cortex, basal ganglia, and cerebellum are relatively well preserved. In a multicenter study comprising 10 PET centers (Network for Efficiency and Standardisation of Dementia Diagnosis, NEST-DD) that employed an automated voxel-based analysis of FDG PET images, the distinction between controls and AD patients was 93% sensitive and 93% specific, and even in very mild dementia (at MMSE 24 or higher) sensitivity was still 84% at 93% specificity. Significantly abnormal metabolism in mild cognitive deficit (MCI) indicates a high risk to develop dementia within the next two years. Reduced neocortical glucose metabolism can probably be detected with FDG PET in AD on average one year before onset of subjective cognitive impairment. In addition to glucose metabolism, specific tracers for dopamine synthesis (18F-F-DOPA) and for (11C-MP4A) are of interest for differentiation among dementia subtypes. Cortical acetylcholine esterase activity (AChE) activity is significantly lower in patients with AD or with dementia with Lewy bodies (DLB) than in age-matched normal controls. In LBD there is also impairment of dopamine synthesis, similar to Parkinson disease.
Annals of Nuclear Medicine 05/2003; 17(2):79-89. DOI:10.1007/BF02988444 · 1.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Alzheimer's disease is the most common form of dementia in the elderly and its prevalence is rapidly rising. Although there is no cure for Alzheimer's disease, treatment can be administered to slow progression or delay the onset of symptoms. A major challenge is the early identification of patients who will develop Alzheimer's disease. As disease-modifying treatments become available, enhancing our ability to identify Alzheimer's early and accurately would allow intervention to slow, halt or even prevent disease progression or onset. Early recognition and intervention facilitates optimal care of Alzheimer's patients and delays the morbidity associated with this progressive illness.
Hanne Struyfs, Wim Van Hecke, Jelle Veraart, Jan Sijbers, Sylvie Slaets, Maya De Belder, Laura Wuyts, Benjamin Peters, Kristel Sleegers, Caroline Robberecht, Christine Van Broeckhoven, Frank De Belder, Paul M Parizel, Sebastiaan Engelborghs
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