Functional Cerebral SPECT and PET Imaging. Ronald L Van Heertum, Ronald S Tikofsky, Masanori Ichise (editors). Lippincott Williams & Wilkins 2010, Philadelphia, 480 pages, 900 illustrations, $229.00.

A full decade has passed since the previous (third) edition of Functional Cerebral SPECT and PET Imaging. During this interval, significant growth in molecular imaging with a focus on new tracer development and advances in instrumentation and image processing has altered the field dramatically.  More sensitive and specific radiopharmaceutical imaging biomarkers coupled with the capabilities of higher spatial and temporal resolution, multimodality imaging, and motion correction have enhanced both the research and clinical effectiveness of these tools.

The book attempts to make up for lost time and has included authors who are well known experts in the field.

It is organized into three sections: Section I contains six chapters on “General Aspects of SPECT/PET Brain Imaging” that overview the basics of physics, chemistry, and functional image analysis principles of both modalities. There is some degree of overlap to the distribution of this section’s material.  An excellent comprehensive introductory chapter covers SPECT instrumentation, radiopharmaceuticals, and technical factors, while separate chapters address “PET Physics and Instrumentation and PET Radiopharmaceuticals.” Despite its title, the latter chapter makes highly frequent mention of SPECT agents. Chapter 5: “Normal Structural and Functional Neuroanatomy for SPECT and PET Imaging,” is immediately followed by “Functional Anatomy and SPECT Imaging” and reads with a sense of déjà vu.  The structural anatomy covered in Chapter 5 is, for the most part, overly simplistic.  A half-page drawing depicting little more than the lobes of the brain, a schematic indicating the orientations of the sagittal, coronal, and transaxial imaging planes, and a basic description of the purpose of the ventricular system make one think the editors’ targeted readership for this book may be those who know little about either the brain or imaging. Chapter 6 recounts the neurological syndromes of six individual patients coupled with historic musings on brain-behavior relationships; of its 19 references, only 3 are post-1985 and five are from the 1800s. While this may make for interesting reading, its appropriateness in this book (and particularly in this section) is questionable.  The highlight of this section is the very well done chapter on “Neuroreceptor Imaging and Kinetic Modeling,” which guides the reader from the basic elements of the synapse through kinetic equations with seamlessness and clarity few can master.

The second of the three sections focuses on “Clinical Disease States.” Herein are nine chapters that collectively cover the neuropsychiatric syndromes in which SPECT and/or PET are applied clinically and/or in a research context.  These include the true routine (and reimbursable) clinical uses of these modalities in epilepsy (two chapters), brain tumors, and, in limited cases, dementia. Additionally, there are chapters on cerebrovascular disease, movement disorders, traumatic brain injury, psychiatric disorders, and addictive disorders.

Chapter 7 on the “Diagnosis of Dementia” is clearly written and serves as basic standard fare. There have been dramatic advances in dementia imaging over the past several years, including the development and widespread research use of beta-amyloid agents for early detection of Alzheimer’s disease. Unfortunately, this transformative strategy is relegated to less than a half page at the chapter’s end with no figures.  Chapter 8 on “Cerebrovascular Disease SPECT/PET” shows excellent examples of functional nuclear medicine images of chronic stroke; CT and MR images mostly fall short of state-of-the-art.  The portion on PET measures of hemodynamics in stroke is very well written. A chapter on “Epilepsy: PET” is particularly well presented, and puts in context past research that taught us about seizure mechanisms (e.g., opiate receptor imaging), newer research directions, and the clinical context of PET (which remains limited to presurgical evaluation).  The complementary SPECT epilepsy chapter is very practical, including protocols for imaging.  It further covers details of ictal, post-ictal, and inter-ictal perfusion patterns, sensitivities and specificities of combined SPECT imaging through a meta-analysis of the literature and technical scanning and analysis considerations.

One curiosity of Section II is the apparent disconnect between the relative attention paid to the covered topics and the breadth of the literature in these areas. For example, the editors offer little more than four pages of text on PET in brain tumors, a topic with a fairly extensive literature, yet emission tomography in traumatic brain injury, which has a more limited literature and clarity of findings, is an 18-page chapter. Psychiatric disorders, which make up a large bulk of research brain PET and SPECT imaging research, are contained in a single brief chapter.

Section III consists of cases organized into vignettes each with a brief clinical history, representative images, a description of the imaging findings, and a concise teaching point. These are not presented as “unknowns,” as the diagnosis is boldly stated at the top of the page. Some cases are either generally or awkwardly described (e.g., “bleed of the left middle cerebral artery,” “chronic perfusion failure”) and may leave the reader with questions.  Normal volunteer cases appear at the end of this section rather than at the beginning.

Figures are large, generally of sufficient resolution and clarity, and there are numerous color pictures. The major exception to this praise pertains to neuroradiological studies. Correlative CTs or MRIs are often missing or not optimally windowed or selected (e.g., non-contrast T1W or T2W in a tumor case when a contrasted image would be most helpful). The section that would have most benefited from a neuroradiologist’s eye is clearly Section III.  Cases 18-21 and 18-31 mistakenly refer to MRIs in figures that depict CT images. Case 18-35 refers to a “MRI of the vessels of the head or neck” that revealed a large left parasellar carotid aneurysm; the transaxial T2-weighted image in the corresponding figure is above the internal carotids and shows no evidence of aneurysm. Case 18-37 describes a MRI showing “moderate cerebral atrophy, possibly degenerative,” yet ignores the focal right occipital encephalomalacia nicely corresponding to the hypoperfusion in the SPECT. Lastly, a coronal FLAIR image in Case 19-14 suggests right hippocampal hyperintensity characteristic of mesial temporal sclerosis; however, it is described in the text as negative.  More frequent use of arrows when describing focal lesions may have been helpful to the reader.

Overall, this book seems to try to appeal in part to a number of different possible audiences.  However, I had difficulty reaching a conclusion as to who was truly the intended readership.  There is clearly some excellent content, including portions of the introductory segment (Section I) and several disease-focused chapters (Section II) that summarize both the current state of research and clinical use of brain SPECT and PET.  Unfortunately, the apparent lack of coordination among the writings, disproportionate emphasis among topics, and a flawed case section (Section III) that both eschews the neuroradiological input in patient work-ups and contains numerous errors substantially detract from the added value of the fourth edition of Functional Cerebral SPECT and PET Imaging.