Journal
ARCHIVES OF NEUROLOGY
Volume 68, Issue 3, Pages 329-337Publisher
AMER MEDICAL ASSOC
DOI: 10.1001/archneurol.2010.295
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Funding
- Bristol-Myers Squibb
- Danone
- Elan
- Eli Lilly
- Forest
- Janssen
- Medivation
- Pfizer
- Novartis
- OctaPharma
- Sonexa
- National Institutes of Health [AG22394, AG30006]
- National Alzheimer's Coordinating Center [AG16976]
- Michigan [AG08671]
- University of California at Davis [10129]
- University of Pennsylvania [AG10124]
- University of California at Irvine [AG16573]
- Duke University [AG028377]
- Indiana University [AG10133]
- University of Pittsburgh [AG05133]
- University of Texas Southwestern Medical Center at Dallas [AG12300]
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Objective: To evaluate the cause of diagnostic errors in the visual interpretation of positron emission tomographic scans with fludeoxyglucose F 18 (FDG-PET) in patients with frontotemporal lobar degeneration (FTLD) and patients with Alzheimer disease (AD). Design: Twelve trained raters unaware of clinical and autopsy information independently reviewed FDG-PET scans and provided their diagnostic impression and confidence of either FTLD or AD. Six of these raters also recorded whether metabolism appeared normal or abnormal in 5 predefined brain regions in each hemisphere frontal cortex, anterior cingulate cortex, anterior temporal cortex, temporoparietal cortex, and posterior cingulate cortex. Results were compared with neuropathological diagnoses. Setting: Academic medical centers. Patients: Forty-five patients with pathologically confirmed FTLD (n=14) or AD (n=31). Results: Raters had a high degree of diagnostic accuracy in the interpretation of FDG-PET scans; however, raters consistently found some scans more difficult to interpret than others. Unanimity of diagnosis among the raters was more frequent in patients with AD (27 of 31 patients [87%]) than in patients with FTLD (7 of 14 patients [50%]) (P=.02). Disagreements in interpretation of scans in patients with FTLD largely occurred when there was temporoparietal hypometabolism, which was present in 7 of the 14 FTLD scans and 6 of the 7 scans lacking unanimity. Hypometabolism of anterior cingulate and anterior temporal regions had higher specificities and positive likelihood ratios for FTLD than temporoparietal hypometabolism had for AD. Conclusions: Temporoparietal hypometabolism in FTLD is common and may cause inaccurate interpretation of FDG-PET scans. An interpretation paradigm that focuses on the absence of hypometabolism in regions typically affected in AD before considering FTLD is likely to misclassify a significant portion of FTLD scans. Anterior cingulate and/or anterior temporal hypometabolism indicates a high likelihood of FTLD, even when temporoparietal hypometabolism is present. Ultimately, the accurate interpretation of FDG-PET scans in patients with dementia cannot rest on the presence or absence of a single region of hypometabolism but rather must take into account the relative hypometabolism of all brain regions.
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