Semi-quantitative Assessment Using [18F]FDG Tracer in Patients with Severe Brain Injury

Summary

[¹⁸F]-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography is useful for studying glucose metabolism related to brain function. Here, we present a protocol for an [¹⁸F]FDG tracer set-up and semiquantitative assessment of the region-of-interest analysis for targeted brain areas associated with clinical manifestations in patients with severe traumatic brain injury.

Abstract

Patients with severe traumatic brain injury (sTBI) have difficulty knowing whether they are accurately expressing their thoughts and emotions because of disorders of consciousness, disrupted higher brain function, and verbal disturbances. As a consequence of an insufficient ability to communicate, objective evaluations are needed from family members, medical staff, and caregivers. One such evaluation is the assessment of functioning brain areas. Recently, multimodal brain imaging has been used to explore the function of damaged brain areas. [¹⁸F]-fluorodeoxyglucose positron emission tomography-computed tomography ([¹⁸F]FDG-PET/CT) is a successful tool for examining brain function. However, the assessment of brain glucose metabolism based on [¹⁸F]FDG-PET/CT is not standardized and depends on several varying parameters, as well as the patient's condition. Here, we describe a series of semiquantitative assessment protocols for a region-of-interest (ROI) image analysis using self-produced [¹⁸F]FDG tracers in patients with sTBI. The protocol focuses on screening the participants, preparing the [¹⁸F]FDG tracer in the hot lab, scheduling the acquisition of [¹⁸F]FDG-PET/CT brain images, and measuring glucose metabolism using the ROI analysis from a targeted brain area.

Introduction

Patients with sTBI are presented with unforeseeable neurological difficulties over the course of rehabilitation that include motor deficits, sensory deficits, and psychiatric instability¹. Although clinical assessment is generally performed verbally, patients with sTBI such as unresponsive wakefulness syndrome or minimally conscious state have particular difficulty in knowing whether they are accurately expressing their thoughts and emotions because of disorders of consciousness, disrupted higher brain function, and verbal disturbances^2,3. Family members, medical staff, and caregivers a....

Protocol

This study was performed in compliance with the institutional review board (approval No. 07-01) and adhered to the tenets of the Declaration of Helsinki. Informed consent for medical record and brain image use was obtained from the patients’ legal representatives. The study was conducted after approval by the institutional ethics committee (2017-14). This protocol was made following the guidelines of the Japanese Society of Nuclear Medicine and European Association of Nuclear Medicine as a reference

Discussion

This protocol provides the means to conduct a series of brain-glucose metabolic assessments with [¹⁸F]FDG-PET/CT using self-produced [¹⁸F]FDG tracer at a single institution.

The production of [¹⁸F]FDG tracer follows the procedure described in the FDG synthesizer operator manual; however, caution is necessary regarding three points. First, the bombardment time and energy (step 2.5) should be adjusted according to the number of patients. Second, attention should .......

Materials

Name	Company	Catalog Number	Comments
20ml syringe	Terumo	SS-20ESZ
10ml syringe	Terumo	SS-10ESZ
1ml syringe	Terumo	SS-01T
Protective plug	Top	ML-KS
Three-way cock L type 180°	Terumo	TS-TL2K
Extension tube	Top	X1-50
Indwelling needle 22G or 24G	Terumo	SR-OT2225C
Tegaderm transparent dressing	3M	1624W
Hepaflash 10U/ml 10ml	Terumo	PF-10HF10UA
Auto dispensing and injection system	Universal Giken Co., Ltd.	UG-01
Fluid for auto dispensing and injection system	Universal Giken Co., Ltd.	UG-01-001
Millex-GS Syringe Filter Unit	Millipore	SLGSV255F
Air needle	Terumo	XX-MFA2038
Check valve	Hakko	23310100
Saline 500ml	HIKARI pharmaceutical Co., Ltd.	18610155-3
Yukiban 25x7mm	Nitto	3252
Elascot No.3	Alcare	44903221
Presnet No.3 27x20mm	Alcare	11674
Steri Cotto a 4x4cm	Kawamoto	023-720220-00
StatstripXp3	Nova Biomedical	11-110
Statstrip Glucose strips	Nova Biomedical	11-106
JMSsheet	JMS	JN-SW3X
Injection pad	Nichiban	No.30-N
Stepty	Nichiban	No.80
Advantage Workstation	GE Healthcare	Volume Share 7. version 4.7
Discovery MI PET/CT	GE Healthcare
EV Insite	PSP
GE TRACERlab MXFDG synthesizer reagent kit	ABX	K-105TM
TRACERlab MXFDG cassette	GE Healthcare	P5150ME
Extension tube	Universal Giken Co., Ltd	AT511-ST-001
TSK sterilized injection needle 18x100	Tochigiseiko	AT511-ST-004
TSK sterilized injection needle 18x60	Tochigiseiko	AT511-ST-002
TSK sterilized injection needle 21x65	Tochigiseiko	AT511-ST-003
Seal sterile vial -N 5ml	Mita Rika Kogyo Co., Ltd.	SSVN5CBFA
k222 TLC plate	Universal Giken Co., Ltd.	AT511-01-005
Anion-cation test paper	Toyo Roshi Kaisha	7030010
Endospecy ES-24S set	Seikagaku corporation	20170
Sterile evacuated vial	Gi phama	10214
5ml syringe	Terumo	SS-05SZ
Extension tube	Top	X-120
Finefilter F	Forte grow medical Co.Ltd.	F162
Millex FG	Merck	SLFG I25 LS
Vented Millex GS	Merck	SLGS V25 5F
Injection needle 18x38	Terumo	NN-1838R
Injection needle 21x38	Terumo	NN-2138R
Water-18O	Taiyo Nippon Sanso	F03-0027
Distilled water	Otsuka phrmaceutical
Hydrogen gas G1	Hosi Iryou Sanki
Helium gas G1	Hosi Iryou Sanki
Nitrogen G1	Hosi Iryou Sanki
TRACERlabMXFDG	GE Healthcare
Sep-Pak Light Accell Plus QMA	WATERS
Sep-Pak Plus tC18	WATERS
Sep-Pak Plus Alumina N	WATERS
HPLC with 3.9 X 300 mm columns	WATERS
US-2000	Universal Giken CO. Ltd.
Kryptofix222	Merck
EG Reader SV-12	Seikagaku Corporation
UG-01	Universal Giken Co., Ltd.
syngo.via	Siemens Healthineers
Advantage Workstation Volume Share 7, version 4.7	GE Healthcare
Q clear	GE Healthcare
CRC-15PET dose calibrator	CAPINTEC, INC.