Atlas of Hybrid Imaging Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 1: Brain and Neck: Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT 0323904548, 9780323904544

Table of contents :
Front Cover
Atlas of Hybrid Imaging
Atlas of Hybrid Imaging
Copyright
Dedication
Contents
Preface
Acknowledgments
1 - Brain
1.1 PET/CT
1.1.2 Sagittal
1.1.3 Coronal
1.1.1 Axial
1.2 PET/MRI
1.2.1 Axial
1.2.2 Sagittal
1.2.3 Coronal
1.3 Clinical cases, tricks, and pitfalls
1.3.1 18F-FDG
1.3.2 18F-flutemetamol
1.3.3 18F-DOPA
1.3.4 18F-FET
1.3.5 68Ga-DOTATOC
1.3.6 18F-choline
1.3.7 99mTc-MDP
References
2 - Neck and maxillofacial region
Introduction: 3D-CT volume rendering of anatomy
2.1 PET/MRI
2.1.1 Axial
2.1.2 Sagittal
2.1.3 Coronal
2.2 Clinical cases, tricks, and pitfalls
2.2.1 18F-FDG
2.2.2 68Ga-DOTATOC
2.2.3 18F-Choline
2.2.4 131I
2.2.5 99mTc-MIBI
References
Index
Vol. 1
Back Cover

Citation preview

Atlas of Hybrid Imaging Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 1: Brain and Neck

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Atlas of Hybrid Imaging Sectional Anatomy for PET/CT, PET/MRI and SPECT/CT Vol. 1: Brain and Neck .

Mario Leporace Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Ferdinando Calabria Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Eugenio Gaudio Department of Human Anatomy, “La Sapienza” University, Rome, Italy

Orazio Schillaci Department of Biomedicine and Prevention, “Tor Vergata” University, Rome, Italy

Alfonso Ciaccio Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Antonio Bagnato Department of Nuclear Medicine and Theranostics, Cosenza Hospital, Italy

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2023 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www. elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-0-323-90454-4 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Stacy Masucci Acquisitions Editor: Katie Chan Editorial Project Manager: Sam W. Young Production Project Manager: Omer Mukthar Cover Designer: Christian J. Bilbow Typeset by TNQ Technologies

Dedication To my wife Fedora, my great love, and Luigivittorio and Niccolo`, my beloved children.

ML

To Giuliana, my best friend and one true love, and to Vittoria and Francesca Junia, the sweetest things of our life.

FC

To Ida, my beloved wife.

EG

To Nicoletta, Maria Beatrice, and Agnese Felicia.

OS

To my father Severino, better than a hundred teachers. AC To Mariella.

AB

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Contents Preface Acknowledgments

ix xi

1. Brain Introduction: 3D-CT volume rendering of anatomy Introduction: 3D-MRI volume rendering of anatomy 1.1 PET/CT 1.1.1 Axial 1.1.2 Sagittal 1.1.3 Coronal 1.2 PET/MRI 1.2.1 Axial 1.2.2 Sagittal 1.2.3 Coronal 1.3 Clinical cases, tricks, and pitfalls 1.3.1 18F-FDG 1.3.2 18F-flutemetamol 1.3.3 18F-DOPA 1.3.4 18F-FET 1.3.5 68Ga-DOTATOC 1.3.6 18F-choline 1.3.7 99mTc-MDP References

2 6 10 10 28 40 52 52 70 82 94 94 101 104 108 109 110 110 111

2. Neck and maxillofacial region Introduction: 3D-CT volume rendering of anatomy 2.1 PET/MRI 2.1.1 Axial 2.1.2 Sagittal 2.1.3 Coronal 2.2 Clinical cases, tricks, and pitfalls 2.2.1 18F-FDG 2.2.2 68Ga-DOTATOC 2.2.3 18F-Choline 2.2.4 131I 2.2.5 99mTc-MIBI References Index

114 122 122 142 156 168 168 178 178 179 180 180 183

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Preface The advent of hybrid scanners in nuclear medicine has considerably improved quality of the discipline. To date, SPECT/CT and PET/CT play a crucial role in diagnosis, treatment planning, and assessment of response to therapy in oncology, with novel applications in neurology, cardiology, and infectious diseases. More recently, PET/MRI has considerably enlarged the panorama of hybrid imaging and is opening new challenges in neurooncology, oncology, and neurodegenerative disorders. In fact, the high sensitivity provided by nuclear medicine imaging finds a valid counterpart in the better specificity provided by the low-dose CT, generally associated with PET, and, when possible, SPECT scans. The added value of this coregistered low-dose CT is defined by a better diagnostic accuracy due to higher specificity, allowing adequate anatomical localization of pathologic functional findings and accurate depiction of false-positive or false-negative cases that can occur in clinical practice with all radiopharmaceuticals. All PET scans in oncology are coregistered with a low-dose CT for attenuation correction and anatomical landmarks. The CT component of a PET/CT scan is also an authentic trait d’union between nuclear medicine imaging and contrast enhanced CT and MRI, being an anatomical basis for comparison of functional imaging with advanced morphological imaging. This feature is of the utmost importance; in fact, though not accurate as full-dose contrast-enhanced CT, the lowdose CT of PET/CT offers significant anatomical information (i.e., on the lungs, bones, and soft tissues) strengthening confidence in diagnosis and helping nuclear physicians to compose more exhaustive medical reports. These characteristics will have a significantly higher impact in PET/MRI realm, considering the large availability of sequences, the optimal power resolution limit of MRI, and correlative advanced studies of molecular imaging as DiffusionWeighted Imaging or MR Spectroscopy. Therefore, the challenge for nuclear physicians in the rising era of hybrid imaging is due to the following: l l

the definitive transition from 2D to 3D medical images; accurate knowledge of anatomical landmarks in multiplanar hybrid views.

The 2.0 nuclear medicine should be aimed to improve the quality of postprocessing and reports in order to optimize the dialogue with radiologists as well as oncologists and clinicians of diverse specialties. It is also necessary to state that the versatility of 18F-FDG (the miliar stone among PET tracers), and the rapid development of a large amount of PET tracers, enlarged PET molecular imaging to new fields of interest in neurology, cardiology, infectious diseases, and neurooncology, while new molecular frontiers are under investigation. Some of these new molecular probes, 18FeNaF, amyloid tracers, amino acid radiopharmaceuticals such as 18F-FET, 18 F-DOPA, radiolabeled choline, and 68Ga-labeled somatostatin analogues, significantly expanded the panorama of molecular imaging with PET. Finally, the advent of theragnostics, a new discipline where diagnosis and therapy are strictly linked and modulated by radiopharmaceuticals and PET imaging, imposes to improve the knowledge of sectional anatomy for an optimal assessment of response to therapy. It is worth to mention that hybrid, molecular imaging is the pillar of the new era of nuclear medicine, an eclectic discipline which is skin changing and evolving as leading medical specialty. Several atlas are already available for intepretation of CT and MRI, but these volumes are generally aimed to radiologists. In our opinion of nuclear physicians and radiologists with expertise on hybrid imaging, a volume focused on residents in nuclear medicine and/or radiology or young specialists is still needed, as a daily guide to medical reports; however, it could easily be useful for nuclear physicians and/or radiologists aiming to improve experience in hybrid imaging or for specialists interested in diagnostic imaging (radiotherapists, cardiologists, neurologists, etc.). The aim of our book is to give to young nuclear physicians and radiologists a rapid, concise guide to radiological anatomy as support for nuclear medicine findings, with emphasis on the role of coregistered CT and MRI in improving

ix

x Preface

diagnosis and correctly detect false-positive and false-negative cases. Therefore, each chapter is focused on a specific segment of the human body, with three-dimensional introductive views followed by commented low-dose CT views in every plane, to depict sectional anatomy. Terminology of anatomical landmarks is preferentially in accordance with the International Anatomical Terminology, following guidelines of the Federative International Programme for Anatomical Terminology (FIPAT) of the International Federation of Associations of Anatomists (IFAA), with the addendum, when proper, of a correlative radiological synonym in routine practice. All low-dose CT views are associated with corresponding PET/CT views and, as standard of quality imaging, contrastenhanced CT or MRI. CT, MRI, and PET/CT images are also provided, when needed, by brief comments on their features, especially on the visual and/or semiquantitative assessment of tracer uptake in tissues, in order to introduce the reader to the analysis of fused PET/CT images, in color scale. This volume provides a complete coverage of CT sectional anatomy of the brain, neck, thorax, abdomen, and pelvis, while special chapters are focused on the musculoskeletal system, cardiac imaging, and lymph nodes. PET/MRI schemes are also provided for some peculiar anatomical districts as the brain, neck, and pelvis. Anatomical terms and descriptions are prevalently based on Terminologia Anatomica. Moreover, only literature data explain the most commonly used PET tracers, depicting their peculiar molecular pathways, the physiological distribution, common pathologic findings, and diagnostic pitfalls. The currently available atlas of imaging, only focused on anatomy, does not address these contents. At the end of each chapter, a special paragraph shows and discusses clinical cases, pitfalls, and anatomical variants, in order to explain peculiarities, intrinsic properties, concordance, or mismatches between nuclear medicine findings and CT or MRI, as well as teaching points to explain radiological imaging criteria. Clinical cases and pitfalls are referred to several PET and SPECT radiopharmaceuticals, in order to show and discuss peculiar conditions linked to specific tracers. Essential references are reported in order to allow the readers to refer back to any source that can be linked to covered topics. We hope to have centered our ambitious scope: to offer to nuclear physicians and colleagues a rapid, easy to consult, didactic guide toward hybrid, molecular imaging. Mario Leporace Ferdinando Calabria

Acknowledgments We wish to express very great appreciation to our colleagues for their recommendations, enthusiastic encouragement, and help in difficult situations: Rosanna Tavolaro, Maria Toteda, Stefania Cardei, and Antonio Lanzillotta. A debt of gratitude is owed to our Roman colleagues for their valuable suggestions: Armando Mancinelli and Mauro Di Roma. A special thanks to Professor Antonio Cerasa: we carefully followed your experience! We would like to particularly extend thanks to Daniela de Silva and technicians radiologists, and nurses of our department for their work and patients care. Humbly, we are grateful to our professors and to the pioneers of our discipline for letting us see further by standing on their shoulders.

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Chapter 1

Brain Abstract The 18F-FDG is the miliar stone in brain evaluation, due to peculiar neuronal glucose metabolism, allowing accurate depiction of functional areas in the cortex, striatum, talamus and cerebellum, showed in this chapter, which are not visible with traditional radiologic methods. Nevertheless, the high rate of distribution in gray matter does not support its use in brain tumors imaging. Moreover, PET/CT with 18FFDG can be considered almost only PET, due to few diagnostic information provided by co-registered low-dose CT. Hybrid PET/MRI opened new perspectives in neuro-oncology, for the better MRI resolution and the low brain uptake of several aminoacid radiopharmaceuticals, while amyloid tracers and 18F-DOPA also expanded the diagnostic PET panorama to neurodegenerative diseases. We also describe hybrid imaging in diagnosis of tracer-avid brain lesions incidentally detected at PET/SPECT imaging (i.e. 18 F-choline, 68Ga-DOTATOC, and 99mTc-MDP), with emphasis on correlative MRI findings. Keywords: PET/MRI

18

F-choline;

18

F-DOPA;

18

F-FDG;

18

F-FET;

Atlas of Hybrid Imaging. https://doi.org/10.1016/B978-0-323-90454-4.00006-9 Copyright © 2023 Elsevier Inc. All rights reserved.

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F-Flutemetamol;

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Ga-DOTATOC; Brain; Enhancement; PET/CT;

1

2

Atlas of Hybrid Imaging

Introduction: 3D-CT volume rendering of anatomy 1

2

3

4

5

6

8

7

9

1 2 3 4 5

Parietal bone Frontal bone Sphenoid (greater wing) Temporal bone Sphenoid (lesser wing)

6 7 8 9

Nasal bone Zygomatic bone Maxilla Mandible

Brain Chapter | 1

1

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5

6

7

8

9

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11

1 2 3 4 5 6

Parietal bone Frontal bone Sphenoid (greater wing) Etmoid Zygomatic bone Lacrimal bone

7 8 9 10 11

Temporal bone Nasal bone Occipital bone Maxilla Mandible

3

4

Atlas of Hybrid Imaging

1

2

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4 6

5 7

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1 2 3 4 5 6

Cranial teca Zygomatic process (temporal bone) Superciliary arch Mandible (ramus) Nasal bone Mastoid process (temporal bone)

7 8 9 10 11

Temporal process (zygomatic bone) Mandible (body) Anterior nasal spine Mental foramen (mandible) Oblique line (mandible)

Brain Chapter | 1

1

2

3

4

1 Anterior cranial fossa 2 Middle cranial fossa

3 Posterior cranial fossa 4 Foramen magnum

5

6

Atlas of Hybrid Imaging

Introduction: 3D-MRI volume rendering of anatomy 1

2

3

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5

1 Interhemispheric fissure 2 Frontal lobes 3 Temporal lobes

4 Lateral sulcus (Sylvian fissure) 5 Cerebellum

Brain Chapter | 1

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1 2 3 4

Frontal lobe Central sulcus (Rolandic fissure) Lateral sulcus (Sylvian fissure) Parietal lobe

5 Temporal lobe 6 Occipital lobe 7 Cerebellum

7

8

Atlas of Hybrid Imaging

Brain Chapter | 1

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4 6

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7 9

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12 14

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1 2 3 4 5 6 7

Corpus callosum (splenium) Lamina quadrigemina Corpus callosum (body) Grey matter White matter Mesencephalon (midbrain) Corpus callosum (genu)

8 9 10 11 12 13 14

Fourth ventricle Corpus callosum (rostrum) Pons Third ventricle Cerebellum Hypohysis Medulla oblongata

9

1.1 PET/CT 1.1.1 Axial

18F-FDG

is

normally enhanced in the brain, in both white maer and gray maer, with considerably higher gradient in the gray maer, due to neuronal acvity [1].

Brain Chapter | 1

1

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1 Prefrontal medial 2 Prefrontal lateral 3 Sensorimotor See Ref [1]

4 Parietal superior 5 Precuneus

11

Brain Chapter | 1

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7

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1 2 3 4

Prefrontal medial Prefrontal lateral White matter Sensorimotor

5 Parietal inferior 6 Parietal superior 7 Precuneus

13

Distribution of 18F-FDG in the brain offers the possibility to evaluate functional areas in the brain, not visible with traditional radiologic methods [2]. These areas are showed in this chapter.

Brain Chapter | 1

1

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1 2 3 4 5 See Ref [2]

Prefrontal medial Prefrontal lateral Anterior cingulate Sensorimotor Parietal inferior

6 7 8 9 10

White matter Posterior cingulate Precuneus Occipital lateral Falx cerebri

15

Enlargement of cerebral ventricles may occur in several neurological diseases or psychiatric disorders [3]. This feature should be keep into account when examining patients with dementia.

Brain Chapter | 1

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1 2 3 4 5 6 See Ref [3]

Prefrontal medial Anterior cingulate Prefrontal lateral Caudate nucleus Parietal inferior Thalamus

7 8 9 10 11 12

Temporal lateral Posterior cingulate Precuneus Occipital lateral Primary visual Falx cerebri

17

Caudate and putamen nuclei are normally visualized in 18F-FDG PET. The uptake in the striatum may decrease in Parkinson’s Disease [4]. However, the main role of 18F-FDG PET in this field should be considered when investigating patients with parkinsonian syndromes and cognitive impairment [5].

Brain Chapter | 1

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1 2 3 4 5 See Refs [4,5]

Prefrontal medial Anterior cingulate Prefrontal lateral Caudate nucleus Putamen nucleus

6 7 8 9 10

Thalamus Temporal lateral Primary visual White matter Occipital lateral

19

Occipital cortex is characterized by the highest gradient of 18F-FDG uptake, due to activity of visual cortex. Globally, elevated glucose levels can interfere with 18F-FDG uptake in the brain [6].

Brain Chapter | 1

1

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6 8

5

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1 2 3 4 See Ref [6]

Prefrontal medial Prefrontal lateral Temporal lateral Mesencephalon

5 Occipital lateral 6 White matter 7 Primary visual

21

Brain Chapter | 1

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1 2 3 4

Lateral rectus muscle Medial rectus muscle Temporal lateral Mesencephalon

5 6 7 8

Temporal mesial White matter Occipital lateral Primary visual

23

Brain Chapter | 1

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1 2 3 4

Temporal mesial Temporal lateral Pons Cerebellar vermis

5 Cerebellar anterior lobe 6 Occipital lateral 7 Visual primary

25

Brain Chapter | 1

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1 3

1 Cerebellar vermis 2 Cerebellar anterior lobe 3 Cerebellar posterior lobe

27

1.1.2 Sagittal

Brain Chapter | 1

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1 2 3 4

Sensorimotor Parietal inferior Prefrontal lateral Temporal lateral

5 Occipital lateral 6 White matter 7 Left cerebellar hemisphere

29

Tentorium membrane can be easily recognized in CT images as hyperdense line separating cerebellum from occipital cortex [7].

Brain Chapter | 1

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16 1 2 3 4 5 6 7 8

See Ref [7]

Sensorimotor Parietal superior Prefrontal lateral Parietal inferior Putamen nucleus Precuneus Caudate nucleus Occipital lateral

9 10 11 12 13 14 15 16

Thalamus Visual primary Prefrontal medial Temporal lateral Lateral rectus muscle Cerebellar anterior lobe Temporal mesial Cerebellar posterior lobe

31

Brain Chapter | 1

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Falx cerebri Sensorimotor Prefrontal medial Parietal superior Anterior cingulate Precuneus Posterior cingulate

8 9 10 11 12 13

Occipital lateral Thalamus Primary visual Mesencephalon Pons Cerebellum

33

Brain Chapter | 1

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Falx cerebri Sensorimotor Prefrontal medial Parietal superior Anterior cingulate Precuneus Posterior cingulate

8 9 10 11 12 13

Occipital lateral Thalamus Primary visual Mesencephalon Pons Cerebellum

35

Brain Chapter | 1

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Sensorimotor Parietal superior Prefrontal lateral Parietal inferior Putamen nucleus Precuneus Caudate nucleus Occipital lateral

9 10 11 12 13 14 15 16

Thalamus Visual primary Prefrontal medial Temporal lateral Lateral rectus muscle Cerebellar anterior lobe Temporal mesial Cerebellar posterior lobe

37

Brain Chapter | 1

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1 2 3 4

Sensorimotor Parietal inferior Prefrontal lateral Temporal lateral

5 Occipital lateral 6 White matter 7 Right cerebellar hemisphere

39

1.1.3 Coronal

Falx cerebri can be visualized in non-enhanced CT as a thin, hyperdense band, separating two brain hemispheres [8]. Midline shift is one of the most important features clinicians use to evaluate the severity of brain compression by tumors or other diseases pathologies [9].

Brain Chapter | 1

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1 Prefrontal lateral 2 Anterior cingulate 3 Prefrontal medial See Refs [8,9]

4 White matter 5 Lateral rectus muscle 6 Medial rectus muscle

41

Brain Chapter | 1

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6 8

7 9

1 2 3 4 5

Prefrontal lateral Prefrontal medial White matter Sensorimotor Parietal inferior

6 7 8 9

Caudate nucleus Lateral ventricles Temporal mesial Temporal lateral

43

Brain Chapter | 1

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Prefrontal medial Prefrontal lateral White matter Sensorimotor Lateral ventricles Caudate nucleus

7 8 9 10 11

Putamen nucleus Parietal inferior Temporal mesial Fourth ventricle Temporal lateral

45

Brain Chapter | 1

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Prefrontal lateral Parietal superior Sensorimotor Prefrontal medial Parietal inferior Posterior cingulate

7 8 9 10 11

Talamus Temporal lateral Temporal mesial Mesencephalon Pons

47

Brain Chapter | 1

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1 2 3 4 5

Parietal superior Precuneus Parietal inferior Visual primary Temporal lateral

6 7 8 9

Occipital lateral Posterior cerebellar lobe Cerebellar vermis Anterior cerebellar lobe

49

Brain Chapter | 1

1

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1 2 3 4 5

Precuneus Parietal superior Parietal inferior Visual primary Temporal lateral

6 7 8 9

White matter Occipital lateral Cerebellar vermis Posterior cerebellar lobe

51

1.2 PET/MRI 1.2.1 Axial

Brain Chapter | 1

1

2 4

3

5

1 Prefrontal lateral 2 Prefrontal medial 3 Sensorimotor

4 Parietal superior 5 Precuneus

53

Metabolism of sensorimotor cortex is usually preserved in several kinds of dementia, as Alzheimer’s Disease and Fronto-temporal dementia [6].

Brain Chapter | 1

1

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1 2 3 4 See Ref [6]

Prefrontal lateral Prefrontal medial Sensorimotor Parietal inferior

5 White matter 6 Parietal superior 7 Precuneus

55

Non enhanced T1-weighted MR imaging of the brain displays an accurate anatomical depiction, with better power resolution than CT, allowing distinction among gray matter (in dark gray) and white matter (in soft gray) [10].

Brain Chapter | 1

1

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1 2 3 4 5 See Ref [10]

Prefrontal lateral Prefrontal medial White matter Sensorimotor Anterior cingulate

6 7 8 9 10

Posterior cingulate Parietal inferior Precuneus Occipital lateral Falx cerebri

57

In the early evaluation of neurodegenerative diseases, PET positive findings can be observed prior of corresponding morphologic abnormalities in correlative MRI. In case of concomitant MRI pathologic findings, hybrid PET/MRI may offer a new chance to improve early and differential diagnosis of several kinds of dementia [11].

Brain Chapter | 1

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1 2 3 4 5 6 7 See Ref [11]

Prefrontal medial Anterior cingulate White matter Lateral ventricles Prefrontal lateral Caudate nucleus Thalamus

8 9 10 11 12 13 14

Parietal inferior Posterior cingulate Temporal lateral Precuneus Occipital lateral Visual primary Falx cerebri

59

T1 weighted MRI can help to detect cortical heterotopy in patients with epilepsy, undergoing a hybrid PET/MRI study for the research of the epileptogenic focus [12].

Brain Chapter | 1

1

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12

1 2 3 4 5 6 See Ref [12]

Prefrontal medial Anterior cingulate White matter Prefrontal lateral Putamen nucleus Caudate nucleus

7 8 9 10 11 12

Thalamus Lateral ventricle Occipital lateral Temporal lateral Visual primary White matter

61

Brain Chapter | 1

1

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3

4 6

5 7

8

1 2 3 4

Prefrontal lateral Prefrontal medial White matter Mesencephalon

5 6 7 8

Temporal lateral Temporal mesial Visual primary Occipital lateral

63

18F-FDG

PET can be performed in patients with focal epilepsy being considered for surgery, in particular when MRI is non specific. PET is more likely to be helpful in patients with suspected mesial temporal foci [13].

Brain Chapter | 1

1

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1 2 3 4 See Ref [13]

Medial rectus muscle Lateral rectus muscle Temporal lateral Temporal mesial

5 6 7 8

Mesencephalon White matter Occipital lateral Visual primary

65

Brain Chapter | 1

1

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3

4 6

5 7

8

9

1 2 3 4 5

Medial rectus muscle Lateral rectus muscle Temporal lateral Temporal mesial Pons

6 7 8 9

Cerebellar vermis Cerebellar anterior lobe Occipital lateral Visual primary

67

Brain Chapter | 1

1

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1 Cerebellar vermis 2 Anterior cerebellar lobe 3 Posterior cerebellar lobe

69

1.2.2 Sagittal

Brain Chapter | 1

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1 2 3 4

Sensorimotor Parietal inferior Prefrontal lateral Occipital lateral

5 Temporal lateral 6 White matter 7 Left cerebellar hemisphere

71

Brain Chapter | 1

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10 12

11

14

13

1 2 3 4 5 6 7

Sensorimotor Parietal superior Prefrontal lateral Parietal inferior Putamen nucleus Precuneus Caudate nucleus

8 9 10 11 12 13 14

Occipital lateral Prefrontal medial Visual primary Thalamus Temporal lateral Cerebellar anterior lobe Cerebellar posterior lobe

73

Brain Chapter | 1

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1 2 3 4 5 6 7 8

Falx cerebri Sensorimotor Prefrontal medial Parietal superior Posterior cingulate Precuneus Anterior cingulate Occipital lateral

9 10 11 12 13 14 15

Lateral ventricles Primary visual Thalamus Mesencephalon Pons Cerebellum Spinal cord

75

Brain Chapter | 1

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1 2 3 4 5 6 7 8

Falx cerebri Sensorimotor Prefrontal medial Parietal superior Posterior cingulate Precuneus Anterior cingulate Occipital lateral

9 10 11 12 13 14 15

Corpus callosum Primary visual Thalamus Mesencephalon Pons Cerebellum Spinal cord

77

Brain Chapter | 1

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1 2 3 4 5 6 7

Sensorimotor Parietal superior Prefrontal lateral Parietal inferior Putamen nucleus Precuneus Caudate nucleus

8 9 10 11 12 13 14

Occipital lateral Prefrontal medial Visual primary Thalamus Temporal lateral Cerebellar anterior lobe Cerebellar posterior lobe

79

Brain Chapter | 1

1

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1 2 3 4

Sensorimotor Parietal inferior Prefrontal lateral Occipital lateral

5 Temporal lateral 6 White matter 7 Right cerebellar hemisphere

81

1.2.3 Coronal

Brain Chapter | 1

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1 Prefrontal lateral 2 Anterior cingulate 3 Prefrontal medial

4 White matter 5 Lateral rectus muscle 6 Medial rectus muscle

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Brain Chapter | 1

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1 2 3 4 5

Prefrontal lateral Prefrontal medial White matter Sensorimotor Parietal inferior

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In neurology and neurooncology, combined PET and MRI provides greater diagnostic accuracy than either modality alone. In comparison to PET/CT, the better power resolution of MRI is also linked to lower radiation exposure and simultaneous data acquisition, minimizing motion artifacts [14].

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1.3 Clinical cases, tricks, and pitfalls 1.3.1

18

F-FDG

FIGURE 1.1 This figure summarizes brain 18F-FDG PET findings of a 67-year-old patient with 4 years history of loss of memory and clinical suspicion of Alzheimer’s disease. Axial PET views show several areas of cortical glucidic deficit in both hemispheres (a), confirming clinical diagnosis. The classic pattern of impaired metabolism in Alzheimer’s disease concerns involvement of the posterior cingulate gyri, precuneus, posterior temporal, and parietal lobes. Semiquantitative assessment of 18F-FDG brain uptake (b) may improve confidence in diagnosis, also underlying differences between two hemispheres; in fact, the involvement may be asymmetric or unilateral. A key point of advanced neurodegenerative diseases (Alzheimer’s disease, dementia with Lewy bodies, and fronto-temporal dementia) is the sparing of the sensorimotor cortex. PET 3D volume rendering (c) also confirms greater uptake reduction in the right hemisphere. Fronto-temporal dementia may be characterized by hypometabolism in the frontal and anterior temporal lobes with involvement of the anterior cingulate gyrus. On the other hand, the involvement of the occipital lobes presents low sensitivity but is highly specific for the clinical diagnosis of dementia with Lewy bodies [6].

FIGURE 1.2 This figure shows brain 18F-FDG PET findings of a 67-year-old woman with clinical suspicion of fronto-temporal dementia. Axial PET views (a) show cortical glucidic deficit in left frontal and temporal regions and low hypometabolism in the contralateral cerebellar hemisphere, due to initial crossed cerebellar diaschisis. The pattern of impaired metabolism in fronto-temporal dementia generally concerns involvement of cortex in frontal and temporal lobes, unilateral or bilateral. Semiquantitative assessment of 18F-FDG brain uptake (b) may improve diagnosis, also underlying differences between two frontal regions. These data are also confirmed by PET 3D volume rendering (c).

FIGURE 1.3 A patient with Alzheimer’s disease was examined by means of brain 18F-FDG PET, showing a pattern of decreased cerebral metabolism in the temporal and frontal-parietal cortex bilaterally, most prominent in the left brain hemisphere. Conversely, a significant reduction of 18F-FDG uptake was recorded in right cerebellar hemisphere, due to crossed cerebellar diaschisis. Crossed cerebellar diaschisis is the condition of unilateral cerebellar hypometabolism as a remote effect of supratentorial dysfunction of the brain in the contralateral hemisphere. The mechanism implies the involvement of the cortico-ponto-cerebellar fibers [15].

FIGURE 1.4 Brain 18F-FDG PET/MRI in a 67-year-old male patient with history of cognitive impairment and slow and progressive worsening in the two years prior the scan. Axial PET view (a) shows cortical hypometabolism in left parietal and temporal regions, in association with atrophy and significant increase of temporal sulci in corresponding MRI T1 (b) and PET/MRI (c) views [16]. Interestingly, metabolic activity of frontal lobes was relatively preserved. This condition is suspicious of Alzheimer’s disease. Simultaneous acquisition of brain PET/MRI on a hybrid PET/MRI scanner can minimize motion artifact and support a more confident diagnosis, on the basis of a hybrid evaluation of functional and metabolic data in a single imaging session.

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FIGURE 1.5 A 19-year-old woman with known Moyamoya disease was examined by means of 18F-FDG PET/MRI. Several sites of cerebral deficit of tracer uptake were detected, particularly in right frontal region, as evident in axial PET view (a). This finding was linked to hypointensity of right frontal lobe with enlargement of cortical sulci on correlative T1-weighted view (b) and diffuse hyperintensity on Fluid-Attenuated Inversion Recovery (FLAIR) view (c), perfectly corresponding to PET hypometabolism in fused PET/MRI (d).

FIGURE 1.6 A patient in follow-up of gastric cancer underwent whole body PET/TC with 18F-FDG. Whole body scan was negative but showed focal uptake in intrasellar region in PET/CT view (a), corresponding to hypodensity in correlative CT (b). Sagittal T1-weighted MRI views prior (c) and after (d) contrast administration show an intrasellar node with regular margins and homogenous contrast enhancement, corresponding to pituitary adenoma. Sagittal PET/MRI (e) well describes this finding, also showed in coronal T2-weighted view (f).

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FIGURE 1.7 Brain 18F-FDG PET/CT, contrast-enhanced CT, and MRI of a patient with sphenoid lesion. Axial (a) and sagittal (a’) PET/CT show focal sellar uptake (white arrows); brain CT with bone window level displays bone remodeling of sella and infiltration of sphenoid sinus (b, b’, curved arrows) due to a lesion with intense contrast enhancement in postcontrast axial (c, black arrow) and sagittal (c’, black arrow) CT views. Patient also underwent MRI of the brain, confirming pathologic intrasellar tissue, infiltrating the sphenoid sinus, with better power resolution, as displayed in sagittal FLAIR (d) and postcontrast T1 (d’)-weighted views in postcontrast T1-weighted views (d’). All metabolic and morphologic findings allowed diagnosis of intrasellar chordoma. Although intrasellar chondroid chordomas are extremely rare, they should be considered in the differential diagnosis of tumors located in the sella turcica [17].

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FIGURE 1.8 A 65-year-old woman examined by whole body 18F-FDG PET/CT for suspicion of lung metastases, four years following left mastectomy for breast cancer. Whole body PET showed several foci of tracer uptake in both lungs, corresponding to centimetric lung metastases, as displayed in axial PET/CT (a) and CT (b) details of the thorax. In the brain, some areas of low metabolism were detected, particularly in association with edema in right frontal and parietal regions, as showed in axial PET/CT (c) and PET/MRI (d) views. Brain MRI confirmed metastases with high enhancement in right frontal and parietal regions after contrast administration (e), with surrounding edema, evident in FLAIR view (f). Brain metastases were clearly non-18FFDG-avid in fused PET/CT and PET/MRI. Brain metastases can show a wide range of glucose metabolism; occasionally, may be also identified as areas of metabolic deficit. Such findings in 18F-FDG PET/CT of the brain can be adequately depicted by MRI [18]. Other tracers as 18F-FLT, 18F-DOPA, or 18FFET may be superior to 18F-FDG in detecting brain lesions, due to their lower rate of physiological distribution in the brain [19].

FIGURE 1.9 A 59-year-old patient during staging of lung cancer examined by 18F-FDG PET/CT of the brain and whole body. Pathologic uptake in right lung was detected, in the primary lesion, evident in axial PET/CT (a) and CT (b) views. Axial CT (c) and PET/CT (d) views of the brain show several brain metastases with different hybrid patterns, as predominantly hypodense with edema, non-18F-FDG-avid (white arrow), as subcortical small, hyperdense lesions with tracer uptake and surrounding edema (black arrow) or hypometabolic and hypodense lesions with peripheral 18F-FDG-avid thickening (curved arrows). Interestingly, as a consequence of intracranial lesions, shift of midline intracranial structures can also be noticed, as emphasized by the red dashed line [20].

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FIGURE 1.10 A 68-year-old patient with brain metastases from unknown primary, detected at brain 18F-FDG PET. Whole body PET did not help to find primary tumor. It is known that diagnostic accuracy of 18F-FDG PET/CT is superior to contrast-enhanced CT and MRI in detecting cancer of unknown primary although with moderate sensitivity and specificity [21], ranging from 30% to 50 % of rate success in identifying primary lesion [22]. In this patient, brain metastases are clearly visible as 18F-FDG-avid, higher than cortical activity, in right frontal region and in the left precuneus in axial PET/ CT views (a, b), surrounded by edema, more evident in axial fused PET/MRI (c, d) and correlative DWI axial views (g, h), due to better power resolution of MRI. Conversely, a reduction of metabolic activity in the left cerebellar hemisphere is evident in axial PET/MRI (g), due to cerebellar diaschisis, crossed to contralateral cortical deficit, without significant anatomical alterations on MRI (h).

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FIGURE 1.11 A 55-year-old woman with breast cancer, previously submitted to left mastectomy, was examined by whole body 18F-FDG PET/CT, not showing relapse of disease. Hypodense tissue with intense tracer uptake was detected in the right maxillary sinus, as showed in axial (a) and coronal (b) PET/CT views and correlative CT views (c, d). This finding was considered as acute sinusitis. Inflammation may show 18F-FDG uptake due to activated macrophages and granulocytes [23]. Correlative CT may help in detecting hypodense tissue and preservation of the bony structures.

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F-flutemetamol

FIGURE 1.12 Axial PET views of the whole brain in different color scales display physiological distribution of 18F-flutemetamol, only confined in the white matter, in the brain of a patient with mild cognitive impairment. Extracellular amyloid plaques comprise the hallmark neuropathologies of Alzheimer’s disease. Amyloid PET radiopharmaceuticals such as 18F-flutemetamol possess proven sensitivity to detect brain amyloid pathology in vivo, as confirmed in subsequent autopsy studies. A negative amyloid PET scan of the brain can help to exclude the diagnosis of amyloid-related dementia [24].

FIGURE 1.13 A 71-year-old male patient was examined by 18F-flutemetamol PET/MRI of the brain for mild cognitive impairment. PET displayed diffuse tracer uptake in white matter, particularly in both frontal regions, due to amyloid deposition, as showed in axial PET view (a), in association with cortical atrophy of both fronto-temporal lobes in T1-weighted axial view (b). These findings are eloquently summarized in PET/MRI view (c) performed on hybrid PET/MRI scanner. PET/MRI confirmed the diagnosis of amyloid-related dementia.

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FIGURE 1.14 A patient with 2 years history of cognitive impairment and loss of memory was examined with dual tracer PET/CT of the brain, respectively, with 18F-FDG and 18Fflutemetamol. Axial 18F-FDG PET (a) and PET/CT (a’) views of the skull base show deficit of glucose metabolism in both parietal and temporal regions. This finding is associated with 18 diffuse enhancement of Fflutemetamol in amyloid plaques in correlative PET (b) and PET/CT (b’) views of the skull base, confirming amyloid-related dementia and supporting clinical diagnosis of Alzheimer’s disease [24].

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FIGURE 1.15 This clinical case concerns a 64-year-old patient with mild cognitive impairment examined with both 18F-FDG and 18F-flutemetamol brain PET scans. 18F-FDG axial PET view in different color scale (a, a’) shows mild reduction of the uptake in both parietal region. Conversely, correlative 18Fflutemetamol axial PET view (b, b’) does not show amyloid plaques.

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F-DOPA

FIGURE 1.16 A 78-year-old patient with a two years history of tremor of the hands was examined by means of 18F-DOPA PET/MRI of the brain on hybrid PET/MRI scanner, not showing pathologic findings. Axial PET (a) and PET/MRI (b) views show normal distribution pattern of 18F-DOPA in the substantia nigra. Correlative T1-weighted MRI (c) axial view displays nonspecific enlargement of cortical sulci in both temporal regions.

FIGURE 1.17 A 73-year-old patient with parkinsonian syndrome examined with 18F-DOPA PET/MRI of the brain. Axial PET (a) and PET/MRI (b) views show deficit of tracer uptake in the basal ganglia, more evident in both putamen nuclei and in the right caudate, supporting diagnosis of Parkinson’s disease. MRI on T1-weighted axial view (c) did not show anatomical abnormalities.

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FIGURE 1.18 A 45-year-old patient with previous hemorrhagic stroke due to ruptured aneurysm of the right middle cerebral artery developed extrapyramidal syndrome with postural rigidity and pronounced bradykinesia. 123I-Ioflupane SPECT (a) showed absent tracer uptake in the striatum, while brain PET/CT displayed residual 18F-DOPA uptake in caudate and putamen nuclei, bilaterally reduced, more evident than SPECT with 123I-ioflupane. MRI did not show morphological abnormalities in the striatum while evidenced ex vacuo dilatation of the right ventricle, particularly in the posterior horn, due to previous stroke, as evident in T2- (c) and T1 (d)-weighted views. In Parkinson’s disease and parkinsonisms, SPECT with 123I-ioflupane depicts presynaptic dopaminergic system, while 18F-DOPA PET may accurately detect the monoaminergic disturbances and cellular damage, especially in the late phase of the diseases [25,26]; therefore, due to upregulation of 18F-DOPA uptake, residual tracer uptake may be observed in this subject in PET. MRI allowed to exclude vascular damage in the striatum.

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FIGURE 1.19 This figure displays a 36-year-old patient with left frontal astrocitoma, submitted two years before surgical resection in craniotomy. Brain 18F-DOPA PET/CT (a) showed diffuse subcortical uptake in right frontal lobe, close to the anterior horn of the ipsilateral ventricle, while no uptake was recorded in surgical lacuna in left frontal region, documented in correlative axial CT (b). MRI imaging showed nonhomogenous tissue in right frontal lobe, with intense contrast enhancement, as displayed in axial T1-weighted view (c), confirming the diagnosis. PET/MRI fusion, obtained with T2-weighted view (d), summarizes all findings.

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FIGURE 1.20 A 52-year-old male previously submitted to surgical excision of left parietal astrocitoma, undergone 18F-DOPA PET/CT of the brain, during follow-up. Axial nonenhanced brain CT (a) only shows slightly hyperdense tissue in left parietal region, with high tracer uptake in coregistered PET/CT (b) particularly close to the falx cerebri, highly suspicious for tumor relapse. MRI, subsequently performed, confirmed diagnosis, showing intense contrast enhancement on the borders of surgical lacuna in postcontrast T1 view (c). PET and MRI data (d), fused in postprocessing, are congrous, indicating brain tumor relapse [27].

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F-FET

FIGURE 1.21 Brain PET/MRI with 18F-FET of a 48-year-old male patient previously submitted to right parietal craniotomy with surgical excision of glioblastoma (9 months before the scan). Axial PET/MRI (a) does not show pathologic tracer uptake. Conversely, axial T2weighted MRI (b) displays hyperintensity in right inferior parietal region, corresponding to the postsurgical lacunar area. PET performed in addition to advanced MRI provides important information regarding tumor metabolic properties, particularly when performed simultaneously, on hybrid PET/MRI scanners. 18F-FET PET/MRI improves specificity in detection of brain tumor relapse [28].

FIGURE 1.22 18F-FET PET/MRI of the brain performed during staging of a patient with astrocitoma. Axial PET view (a) shows pathologic tracer uptake in the right cerebellar hemisphere, corresponding to a hypointense lesion with hemosiderin cap sign in correlative axial T2-weighted view (b), due to previous hemorrhage. Axial PET/MRI (c) view summarizes all findings.

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FIGURE 1.23 A 55-year-old male patient undergone surgical excision of right frontal glioblastoma. One year after, 18F-FET PET/CT and MRI diagnosed disease relapse. In particular, axial PET/CT view (a) shows two foci of intense tracer uptake, respectively, in left parafalcine frontal region and in right parietal superior region. Axial postcontrast T1-weighted MRI view (b) well depicts pathologic enhancement in the same regions. All findings are summarized in PET/MRI (c) with T2-weighted view.

1.3.5

68

Ga-DOTATOC

FIGURE 1.24 A 54-year-old woman was examined by whole body 68Ga-DOTATOC PET/CT during follow-up of neuroendocrine lung tumor. No pathologic foci of tracer uptake were detected at whole body imaging. 3D-PET of the brain (a) and axial PET/CT view (b) showed focal tracer uptake in the left parietal, parafalcine region. Correlative MRI confirmed a hypointense lesion in axial T2-weighted view (c), with mild enhancement on postcontrast T1 (d), appearing as hypointense on diffusion weighted images (e) and in parafalcine region, as showed in sagittal T1 view (f). MRI diagnosed a meningioma [29]. Fused axial (g)and sagittal PET/MRI (h) views summarize all cited findings, also showing physiological tracer uptake in the pituitary gland.

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F-choline

FIGURE 1.25 A patient was examined for restaging prostate cancer 9 months following radical prostatectomy with whole body 18F-choline PET/CT (PSA 0.3 ng/mL at the time of the scan). No localizations of disease were detected. However, axial PET/CT view (a) shows focal tracer uptake in the left brain hemisphere, close to the ipsilateral optical nerve, as displayed in related axial PET/MRI (b). Gadolinium administration in axial T1-weighted view (c) allows to identify a hyperintense lesion with mild contrast enhancement, corresponding to a small meningioma. Tracer avid meningiomas are detected in a minority of prostate cancer patients examined by 18F-choline [30]. Correlative imaging with MRI can be useful in correct identification of these findings.

1.3.7

99m

Tc-MDP

FIGURE 1.26 A 56-year-old female patient underwent bone scan with 99mTc-MDP for suspicion of algodystrophy. No findings linked to the disease under study were detected in whole body planar images, (a) while diffuse and intense tracer uptake was documented in the cranial teca, in left parietal region, better showed in lateral left planar scintigraphic detail (b). Patient underwent MRI. Axial T1-weighted view (c) shows a meningeal tumor protruding into the cranial teca and the scalp, involving the skull and deforming underlying brain, with nonhomogeneous contrast enhancement after gadolinium administration (d). Radiologic features allowed diagnosis of malignant meningioma.

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FIGURE 1.27 In a patient with prostate cancer, previously submitted to radiotherapy, 99mTc-MDP axial SPECT/CT views of the brain (a, b) show mild uptake in the brain, corresponding to calcifications of falx cerebri in correlative CT views with bone window level (c, d). CT of SPECT/CT may be of help in detecting these sources of false positive findings in patients examined with 99mTc-MDP bone scan.

References [1] [2] [3] [4]

[5] [6] [7] [8] [9]

Sokoloff L. Relation between physiological function and energy metabolism in the central nervous system. J Neurochem 1977;29:13e26. Talairach J, Tournoux P. Co-planar stereotaxic atlas of the human brain: 3-D proportional system: An approach to cerebral imaging. Thieme; 1988. Hyde TM, Weinberger DR. The brain in schizophrenia. Semin Neurol 1990;10(3):276e86. Walker Z, Gandolfo F, Orini S, Garibotto V, Agosta F, Arbizu J, et al. Clinical utility of FDG PET in Parkinson’s disease and atypical parkinsonism associated with dementia. EANM-EAN Task Force for the recommendation of FDG PET for dementing neurodegenerative disorders. Eur J Nucl Med Mol Imaging 2018;45:1534e45. Meyer PT, Frings L, Rücker G, Hellwig S. (18)F-FDG PET in Parkinsonism: differential diagnosis and evaluation of cognitive impairment. J Nucl Med 2017;58:1888e98. Brown RKJ, Bohnen NI, Wong KK, Minoshima S, Frey KA. Brain PET in suspected dementia: patterns of altered FDG metabolism. Radiographics 2014;34:684e701. Krol G, Sze G, Malkin M, Walker R. MR of cranial and spinal meningeal carcinomatosis: comparison with CT and myelography. AJR Am J Roentgenol 1988;151:583e8. Osborn AG, Anderson RE, Wing SD. The false falx sign. Radiology 1980;134:421e5. Liao CC, Xiao F, Wong JM, Chiang IJ. Automatic recognition of midline shift on brain CT images. Comput Biol Med 2010;40:331e9.

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[10] Ringstad G, Valnes LM, Dale AM, Pripp AH, Vatnehol SS, Emblem KE, et al. Brain-wide glymphatic enhancement and clearance in humans assessed with MRI. JCI Insight 2018;12(3):e121537. [11] Barthel H, Schroeter ML, Hoffmann KT, Sabri O. PET/MR in dementia and other neurodegenerative diseases. Semin Nucl Med 2015;45:224e33. [12] Calabria FF, Cascini GL, Gambardella A, Labate A, Cherubini A, Gullà D, et al. Ictal 18F-FDG PET/MRI in a Patient With Cortical Heterotopia and Focal Epilepsy. Clin Nucl Med 2017;42:768e9. [13] Cendes F, Theodore WH, Brinkmann BH, Sulc V, Cascino GD. Neuroimaging of epilepsy. Handb Clin Neurol 2016;136:985e1014. [14] Nensa F, Beiderwellen K, Heusch P, Wetter A. Clinical applications of PET/MRI: current status and future perspectives. Diagn Interv Radiol 2014;20:438e47. [15] Calabria F, Schillaci O. Recurrent glioma and crossed cerebellar diaschisis in a patient examined with 18F-DOPA and 18F-FDG PET/CT. Clin Nucl Med 2012;37:878e9. [16] Chen Y, Wang J, Cui C, Su Y, Jing D, Wu L, et al. Evaluating the association between brain atrophy, hypometabolism, and cognitive decline in Alzheimer’s disease: a PET/MRI study. Aging (Albany NY) 2021;26:13. [17] Sakakibara Y, Taguchi Y, Nakamura H, Onodera H, Wakui D, Ikeda T, et al. A case of primary intrasellar chondroid chordoma. No Shinkei Geka 2019;47:901e7. [18] Nia ES, Garland LL, Eshghi N, Nia BB, Avery RJ, Kuo PH. Incidence of brain metastases on follow-up 18F-FDG PET/CT scans of non-small cell lung cancer patients: should we include the brain? J Nucl Med Technol 2017;45:193e7. [19] Calabria F, Chiaravalloti A, Di Pietro B, Grasso C, Schillaci O. Molecular imaging of brain tumors with 18F-DOPA PET and PET/CT. Nucl Med Commun 2012;33:563e70. [20] Swift PS, Phillips T, Martz K, Wara W, Mohiuddin M, Chang CH, et al. CT characteristics of patients with brain metastases treated in RTOG study 79-16. Int J Radiat Oncol Biol Phys 1993;25:209e14. [21] Avci NC, Hatipoglu F, Alacacıoglu A, Bayar EE, Bural GG. FDG PET/CT and conventional imaging methods in cancer of unknown primary: an approach to overscanning. Nucl Med Mol Imaging 2018;52:438e44. [22] Talbot JN, Kerrou K, Gutman F, Périé S, Grahek D, Roulet E, et al. FDG-PET in localization of cancers of unknown primary origin. Presse Med 2006;35:1371e6. [23] Molteni M, Bulfamante AM, Pipolo C, Lozza P, Allevi F, Pisani A, et al. Odontogenic sinusitis and sinonasal complications of dental treatments: a retrospective case series of 480 patients with critical assessment of the current classification. Acta Otorhinolaryngol Ital 2020;40:282e9. [24] Brendel M, Schnabel J, Schönecker S, Wagner L, Brendel E, Meyer-Wilmes J. Additive value of amyloid-PET in routine cases of clinical dementia work-up after FDG-PET. Eur J Nucl Med Mol Imaging 2017;44:2239e48. [25] Morbelli S, Esposito G, Arbizu J, Bartherl H, Boellard R, Bohnen NI. EANM practice guideline/SNMMI procedure standard for dopaminergic imaging in Parkinsonian syndromes 1.0. Eur J Nucl Med Mol Imaging 2020;47:1885e912. [26] Ibrahim N, Kusmirek J, Struck AF, Floberg JM, Perlman SB, Gallagher C, et al. The sensitivity and specificity of F-DOPA PET in a movement disorder clinic. Am J Nucl Med Mol Imaging 2016;6:102e9. [27] Calabria F, Cascini GL. Current status of 18F-DOPA PET imaging in the detection of brain tumor recurrence. Hell J Nucl Med 2015;18:152e6. [28] Overcast WB, Davis KM, Ho CY, Hutchins GD, Green MA, Graner BD, et al. Advanced imaging techniques for neuro-oncologic tumor diagnosis, with an emphasis on PET-MRI imaging of malignant brain tumors. Curr Oncol Rep 2021;23:34. [29] Afshar-Oromieh A, Wolf MB, Kratochwil C, Giesel FL, Combs SE, Dimitrakopoulou-Strauss A, et al. Comparison of 68Ga-DOTATOC-PET/CT and PET/MRI hybrid systems in patients with cranial meningioma: initial results. Neuro Oncol 2015;17:312e9. [30] Calabria F. Fifty shades of meningioma: challenges and perspectives of different PET molecular probes. Clin Transl Imaging 2017;5:403e5.

Chapter 2

Neck and maxillofacial region Abstract Neck malignant tumors are commonly encountered in clinical practice. 18F-FDG PET/CT is useful in tumor staging, detection of cancer of unknown origin, treatment planning, and evaluation of response to therapy. Tracers as 131I and 99mTc are still useful in diagnosis of peculiar diseases, especially on hybrid SPECT/CT. Moreover, tracer-avid lesions of the neck can be observed in neuroendocrine tumors or prostate cancer patients, respectively, examined by 68Ga-DOTATOC or 18F-choline PET/CT. The low-dose CT of PET/CT provides significant information about morphologic features of metabolic findings. This chapter is a guide to image interpretation of hybrid PET/ CT of the neck, in relation to the gold standard imaging tool, the MRI. Although 18F-FDG PET/CT has gained in popularity and improved neck cancers management, nuclear physicians should be aware of its potentiality and limits. The combination of 18F-FDG PET/CT and MRI or ultrasound imaging can reduce the number of diagnostic pitfalls.

Keywords:

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F-choline;

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F-FDG;

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Atlas of Hybrid Imaging. https://doi.org/10.1016/B978-0-323-90454-4.00003-3 Copyright © 2023 Elsevier Inc. All rights reserved.

Tc-MIBI; Enhancement; Neck; Parathyroid; PET/CT; PET/MRI; Thyroid

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Introduction: 3D-CT volume rendering of anatomy

1

2

3

1 Hyoid bone 2 Thyroid cartilage 3 Cricoid cartilage

Suprahyoid neck

Neck and maxillofacial region Chapter | 2

Nasal Cavity

Oral Cavity

Infrahyoid neck

Hyoid level

NASOPHARYNX

Superior: sphenoid sinus Inferior: horizontal line through the soft palate Anterior: nasal choanae Posterior: pharingeal wall Lateral: cartilaginous end of eustachian tube (torus tubarius)

OROPHARYNX

Superior: soft palate Inferior: valleculae Anterior: oral cavity Posterior: superior and middle constrictor muscle

HYPOPHARYNX (laryngopharinx)

Superior: valleculae Inferior: cricopharingeal muscle Rilevant subsites: piriform sinus (formed by invaginations between the aryepliglottic fold medially and the thyroid cartilage laterally and anteriorly)

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a

b

c

a Sectional anatomy of the suprahyoid neck at the level of the nasopharynx b Sectional anatomy of the suprahyoid neck at the level of the oropharynx c Sectional anatomy of the infrahyoid neck at the level of the thyroid gland

Neck and maxillofacial region Chapter | 2

a

b

MS

SMS PS

PVS

PVS

c

VS

CS

PVS PCS

Superficial layer of the deep cervical fascia Middle layer of the deep cervical fascia Deep layer of the deep cervical fascia Carotid seath

Buccal space (BS) Parapharyngeal space (PS) Pharyngeal mucosal space (PMS) Masticator space (MS) Parotid space (PS) Carotid space (CS) Retropharyngeal space (RS) Perivertebral space (PVS) Posterior cervical space (PCS) Sublingual space (SLS) Submandibular space (SMS) Visceral space (VS)

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In clinical practice the imaging of the LARINX [1] includes three anatomical subsites partially based on embryologic development: The supraglottis extends from the tip of the epiglottis to the laryngeal ventricles. The glottis contains the true vocal cords and anterior and posterior commissures. The subglottis extends from the undersurface of the true vocal cords to the inferior edge of the cricoid cartilage.

See Ref [1]

Neck and maxillofacial region Chapter | 2

Pyriform sinus

Pyriform sinus

Fa

ls

Tr

o ev

u

ca

o ev

c

o lc

c al

rd

or

d

Laryngeal ventricle

The laryngeal ventricle (ventricle of Morgagni) is a bilateral fusiform airspace located between the true and false vocal cords.

E H TC CC AC

Epiglottis Hyoid bone Thyroid cartilage Cricoid cartilage Arytenoid cartilage

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Nasal septum

Choanae

Turbinate

rius

uba

st Toru

Torus

tubar

ius

Lateral Lateral Nasopharynx pharyngeal (roof and posterior wall) pharyngeal recess (Rosenmuller’s fossa) recess (Rosenmuller’s fossa)

Posterior wall of hypopharynx Glottis Free edge of epiglotties Vallecula Base of the tongue

Vallecula

Glossoepiglottic fold

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Postcricoid mucosa

ye

pi

gl

ot

tid

Ar

ye

pi

gl

ot

tid

fo

ld

Ar

ifor

fo

ms

inu

s

ld

False vocal cords Laryngeal surface of epiglottis

ord

l cord False

al c

Posterior commissure

ord

voc

Laryngeal ventricle

al c

lse

voca

voc

Fa

ocal

e Tru

cord

Anterior commissure

True v

Py

rif

m or

sin

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us

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Preantral (maxillary) fat pad Maxilla (palatine process) Right maxillary sinus Right inferior nasal concha Right masseter muscle Nasal septum Right pterygoid fossa Left inferior nasal concha Right lateral pterygoid muscle Left pterygoid process

11 Right torus tubarius 12 Nasopharynx 13 Right lateral pharyngeal recess (Rosenmuller’s fossa) 14 Left external auditory canal 15 Right external ear 16 Left head of mandible 17 Right longus capitis muscle 18 Left internal carotid canal 19 Clivus

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Maxilla (alveolar process) Orbicularis oris muscle Hard palate Left buccinator muscle Right ramus of mandible Left parotid duct Right pterygoid muscles Soft palate Right styloid process

10 11 12 13 14 15 16 17

Left masseter muscle Atlas (lateral mass) Left parotid gland (superficial lobe) Right longus capitis muscle Left parotid gland (deep lobe) Dens of axis Nasopharynx Atlas (anterior arch)

Waldeyer's ring is a ring of lymphoid tissue located in the nasopharynx and oropharynx at the entrance to the aerodigestive tract and includes the palatine, pharyngeal, lingual and tubal tonsils [2].

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See Ref [2]

Mandible (body) Orbicularis oris muscle Right levator anguli oris muscle Tongue Right masseter muscle Uvula Right ramus of mandible Oropharynx Right parotid gland

10 11 12 13 14 15 16 17 18

Left medial pterygoid muscle Right longus capitis muscle Left palatine tonsil Right sternocleidomastoid muscle Left digastric muscle (posterior belly) Right obliquus capitis inferior muscle Axis (body) Nuchal ligament Spinal cord

Physiologic 18F-FDG uptake can be seen in the neck lymphatic structures, due at least in part to accumulation of FDG within macrophages and lymphocytes. Uptake in the Waldeyer’s ring will often be symmetric, even from benign conditions such as infection or inflammation. Malignancy will usually manifest as asymmetric FDG uptake [3].

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See Ref [3]

Right platysma Mentalis muscle Genioglossus muscle Mandible (body, alveolar process) Root of tongue Left sublingual gland Right masseter muscle Left submandibular gland Lingual tonsil

10 11 12 13 14 15 16 17 18

Left ramus of mandible Right parotid gland Oropharynx Right sternocleidomastoid muscle Superior constrictor muscle of pharinx Right spinalis capitis muscle Spinal cord Axis (body) Left semispinalis capitis muscle

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Right genioglossus muscle Mandible (body, mental protuberance) Root of tongue Left mylohyoid muscle Oropharynx Left platysma Hypopharynx Left submandibular gland Right carotid artery e internal jugular vein

10 11 12 13 14 15 16 17 18

Epiglottis Right parotid gland Left parotid gland Right sternocleidomastoid muscle Middle constrictor muscle of pharinx Right spinalis cervicis muscle Spinal cord Cervical vertebra (C3, body) Left semispinalis capitis muscle

131

18F-FDG

is physiologically taken up by the salivary glands and subsequently excreted through the saliva. Therefore, the parotid and submandibular glands usually demonstrate symmetric low to moderate 18F-FDG uptake [4].

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1 2 3 4 5 6 7 8 9 10 See Ref [4]

Right platysma Geniohyoid muscle Hyoid bone (body) Left epiglottic vallecula Right submandibular gland Hypopharynx Right piriform recess Inferior constrictor muscle of pharinx Right carotid artery e internal jugular vein Left platysma

Right sternocleidomastoid muscle Cervical vertebra (C4, body) Right levator scapulae muscle Spinal cord Right semispinalis capitis muscle Cervical vertebra (C4, spinous process) Right spinalis and semispinalis cervicis muscle 18 Right trapezius muscle 11 12 13 14 15 16 17

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Thyroid cartilage lamina (right) Glottis Ventricular folds (false cords) Left thyrohyoid muscle Right sternocleidomastoid muscle Arytenoid cartilage (left) Right carotid artery e internal jugular vein Cricoid cartilage

9 10 11 12 13 14 15 16

Right scalene muscles (anterior, middle and posterior) Left supraclavicular fossa Right levator scapulae muscle Intervertebral space (C4/C5) Right spinalis and semispinalis cervicis muscle Spinal cord Right trapezius muscle Cervical vertebra (C5, spinous process)

With talking and phonation, 18F-FDG uptake may occur within the genioglossus, cricopharyngeus, and posterior cricoarytenoid muscles [4].

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Thyroid cartilage lamina (right) Glottis Vocal folds (true cords) Anterior laryngeal commisure Right sternocleidomastoid muscle Left thyrohyoid muscle Right carotid artery e internal jugular vein 8 Cricoid cartilage 1 2 3 4 5 6 7

See Ref [4]

9 10 11 12 13 14 15 16

Right scalene muscles (anterior, middle and posterior) Left supraclavicular fossa Right levator scapulae muscle Cervical vertebra (C6, body) Right spinalis and semispinalis cervicis muscle Spinal cord Right trapezius muscle Cervical vertebra (C6, spinous process)

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Right sternocleidomastoid muscle Trachea Thyroid gland (right lobe) Left sternohyoid muscle Right internal jugular vein Left common carotid artery Esophagus Left supraclavicular fossa

9 10 11 12 13 14 15 16

Right scalene muscles (middle and posterior) Left scalene muscles (anterior) Right first rib Cervical vertebra (C7, body) Right semispinalis thoracis muscle Spinal cord Right rhomboid minor muscle Dorsal vertebra (D1, spinous process)

A typical finding of brown adipose tissue related 18FFDG uptake is symmetrical tracer uptake in the supraclavicular, mid-axillary, paraspinal and superior mediastinal regions. These areas show fat attenuation (−50 to −150 Hounsfield units [HU]) on the corresponding CT images [5].

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Right sternocleidomastoid muscle Trachea Right clavicle Left sternocleidomastoid muscle Right internal jugular vein Thyroid gland (left lobe) Right common carotid artery Left supraclavicular fossa

See Ref [5]

9 10 11 12 13 14 15 16

Right scalene muscles (middle and posterior) Esophagus Right first rib Dorsal vertebra (D1, body) Right second rib Spinal cord Right semispinalis thoracis muscle Left rhomboid minor muscle

2.1.2 Sagittal

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Right temporalis muscle Right external auditory (acoustic) meatus Articular tubercle of right zigomatic process Mastoid process with mastoid cells Zigomatic process of right temporal bone Occipital belly of right epicranius muscle

7 8 9 10 11 12

Right Right Right Right Right Right

lateral pterygoid muscle splenius capitis muscle condylar process of mandible semispinalis capitis muscle parotid gland digastric muscle (posterior belly)

143

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Lateral wall of right orbit Right temporalis muscle Articular tubercle of right zigomatic process Right external auditory (acoustic) meatus Right masseter muscle Occipital belly of right epicranius muscle Right condylar process of mandible

8 9 10 11 12 13 14

Mastoid process with mastoid cells Right angle of mandible Right digastric muscle (posterior belly) Right platysma Right semispinalis capitis muscle Right parotid gland Right sternocleidomatoid muscle

145

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Right eyeball Orbital fat Preantral (maxillary) fat pad Right temporalis muscle Right maxillary sinus Right tympanic cavity Articular tubercle of right zigomatic process Mastoid process with mastoid cells

9 10 11 12 13 14 15 16

Body of mandible Right splenius capitis Right platysma Right semispinalis capitis muscle Right submandibular gland Right trapezius muscle Right sternocleidomastoid muscle Right levator scapulae muscle

147

The pre-epiglottic space (PES) is a triangular fat-containing space between the epiglottis and hyoid bone [6].

At 18F-FDG PET the clival lesions can be unidentified due to the proximity to the intense uptake of the brainstem therefore they must be carefully sought [7].

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Inferior nasal concha Sphenoidal sinus Nasopharynx Pharyngeal tonsil Maxilla (alveolar and palatine process) 6 Longus capitis muscle 7 Soft palate and uvula 8 Oropharynx 1 2 3 4 5

See Refs [6,7]

9 Body of mandible 10 Epiglottis 11 Root of tongue (genioglossus and mylohyoid muscle) 12 Glottis 13 Hyoid bone 14 Cricoid cartilage 15 Thyroid cartilage 16 Trachea

149

PET/MRI could be legi mate alterna ve to PET/CT in the diagnos c workup neck cancer pa ents. Intravenous MR contrast medium may be applied only i he exac umor extent or infiltra on of crucial structures is of concern or if perineural spread is an cipated [8].

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See Ref [8]

Left eyeball Orbital fat Preantral (maxillary) fat pad Left temporalis muscle Left maxillary sinus Left tympanic cavity Articular tubercle of left zigomatic process Mastoid process with mastoid cells

9 10 11 12 13 14 15 16

Body of mandible Left splenius capitis Left platysma Left semispinalis capitis muscle Left submandibular gland Left trapezius muscle Left sternocleidomastoid muscle Left levator scapulae muscle

151

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Lateral wall of left orbit Left temporalis muscle Articular tubercle of left zigomatic process Left external auditory (acoustic) meatus Left masseter muscle Occipital belly of left epicranius muscle Left condylar process of mandible

8 9 10 11 12 13 14

Mastoid process with mastoid cells Left angle of mandible Left digastric muscle (posterior belly) Left platysma Left semispinalis capitis muscle Left parotid gland Left sternocleidomatoid muscle

153

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Left temporalis muscle Left external auditory (acoustic) meatus Articular tubercle of left zigomatic process Mastoid process with mastoid cells Zigomatic process of left temporal bone Occipital belly of left epicranius muscle

7 8 9 10 11 12

Left Left Left Left Left Left

lateral pterygoid muscle splenius capitis muscle condylar process of mandible semispinalis capitis muscle parotid gland digastric muscle (posterior belly)

155

2.1.3 Coronal

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Right extraocular muscles Left optic nerve and orbital fat Nasal septum Etmoidal cells Right zygomatic bone Left nasal conchae Right ramus of mandible Left maxillary sinus

9 10 11 12 13 14 15 16

Right masseter muscle Palatine process of maxilla Body of mandible and alveolar process Alveolar process of left maxilla Body of tongue Left mylohyoid muscle Lingual septum Left platysma

157

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Right optic nerve in optic canal Left temporal lobe Right pterygoid fossa Sphenoidal sinus Right masseter muscle Left lateral pterygoid muscle Right ramus of mandible Nasopharynx

9 10 11 12 13 14 15 16

Right submandibular gland Soft palate and uvula Right platysma Left medial pterygoid muscle Body of tongue Hyoid bone Laryngeal cavity Thyroid cartilage

159

Focal increased 18F-FDG uptake within the neck on PET can potenally simulate a neoplasc process bu s commonly encountered as result of physiological uptake within lymphoid ssue, as in the adenoid, palatine, and base of tongue tonsillar tissue of the Waldeyer ring [4].

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1 2 3 4 5 6 7 8 9 See Ref [4]

Right temporal lobe Left temporal muscle Right lateral pterygoid muscle Sphenoidal sinus Right ramus of mandible Pharyngeal tonsil Right medial pterygoid muscle Nasopharynx Right submandibular gland

10 11 12 13 14 15 16 17

Uvula Right platysma Left parotid gland Epiglottis Glottis Infraglottic cavity Thyroid cartilage Sternocleidomastoid muscles

161

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Right temporal lobe Sphenoidal sinus Right condylar process of mandible Clivus Right styloid process Longus capitis muscle Hyoid bone Cervical vertebrae

9 10 11 12 13 14 15

Right platysma Left parotid gland Right sternocleidomastoid muscle Thyroid cartilage Infraglottic cavity Cricoid cartilage Suprasternal space (of Burns)

163

PET/MRI enables differen a on o umor recurrence from radia on therapy–induced changes. Familiarity with PET/MRI features of expected findings, poten al complica ons, and treatmen ailure a er radia on therapy increases diagnos c confidence when interpre ng images o he irradiated neck [9].

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See Ref [9]

Right temporal lobe Pons Right tympanic cavity Left internal acoustic canal Dens of axis Left external auditory canal Right parotid gland

8 9 10 11 12 13 14

Atlas Right sternocleidomastoid muscle Body of axis Right scalene muscle Left internal jugular vein Trachea Transverse process of cervical vertebra

165

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Right temporal lobe Foramen magnum Cerebellum Left mastoid process Right obliquus capitis muscle Atlas (posterior arch) Right sternocleidomastoid muscle

8 9 10 11 12 13 14

Spinous process of axis Right longissimus capitis muscle Spinal cord Multifidus muscle Left scalene muscle Right scalene muscle Trachea

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2.2 Clinical cases, tricks, and pitfalls 2.2.1

18

F-FDG

FIGURE 2.1 A 56-year-old patient, examined by means of 18F-FDG PET/CT for staging histologically proven laryngeal cancer, after one year history of gradual-onset hoarseness of voice, unrelieved by symptomatic treatments. PET Maximum Intensity Projection (a) displays intense tracer uptake in the neck, corresponding to irregular thickening along the medial margin of the true right vocal cord, as evident in correlative axial PET/CT and CT views (bee).

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FIGURE 2.2 This picture summarizes PET/CT findings in a 67-year-old patient during staging of laryngeal squamous carcinoma. PET Maximum Intensity Projection (a) shows two areas of pathologic 18F-FDG uptake in the neck, respectively, corresponding to a contrast enhancing, supraglottic laryngeal thickening, evident in axial PET/CT (b) and CT (c) views, and a left cervical lymphadenopathy, with hypodense internal core without tracer accumulation neither contrast enhancement, due to necrosis, as showed in axial PET/CT (d) and CT (e) views. FIGURE 2.3 A 45-year-old woman, previously submitted to thyroidectomy for papillary thyroid cancer, underwent 18F-FDG PET/CT during follow-up. Axial (a) and coronal (b) PET/CT views show intense tracer accumulation in the lower portion of the left thyroid loggia. Ultrasonography, subsequently performed, displays nonhomogeneous, isoechoic tissue in the same site (c, arrow), with intense vascular pattern at power Doppler (d), due to disease relapse.

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FIGURE 2.4 A 53-year-old patient with nasopharyngeal cancer, examined with 18F-FDG PET/CT. PET Maximum Intensity Projection (a) shows intense tracer uptake in the nasopharynx. This finding is confirmed in the posterior wall of nasopharynx in axial PET/CT (b) and low dose CT views (c, arrow) and in bilateral cervical metastatic lymphadenopaties in axial PET/CT (d) and low dose CT (e, arrows) views. Sagittal PET/CT (f) and low dose CT (g, arrow) views well display the thickening of nasopharyngeal mucosa.

FIGURE 2.5 A 61-year-old male examined by 18F-FDG PET/CT for staging histologically proven tonsil carcinoma. PET Maximum Intensity Projection (a) shows pathologic tracer uptake in the oral lesion. Axial PET/CT (b) better displays 18F-FDG uptake in the right tonsil, in a tissue with homogeneous contrast enhancement at full-dose CT with soft-tissue window settings (c, arrow), protruding into the ipsilateral pterygopalatine fossa as evident in axial PET/CT (d) and contrast enhanced CT (e, arrow), due to diffusion through neurovascular structures. Low 18F-FDG uptake is normally visualized in the lymphatic tissues of the Waldeyer’s ring due to tracer accumulation in macrophages and lymphocytes. Physiological uptake in lymphoid tissue can be generally symmetrical; therefore, image interpretation is straightforward. Nevertheless, head and neck lymphoma and squamous cell carcinoma of the pharynx may be detected at PET/CT imaging [5]. In such cases, it is imperative to look for associated anatomical abnormality on CT.

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FIGURE 2.6 A 44-year-old patient with histologically proven oral lymphoma examined by means of 18F-FDG contrast-enhanced PET/CT. PET Maximum Intensity Projection (a) shows pathologic uptake in the oral lesion. Axial PET/CT (b) and CT (c, arrow) views display the uptake in the lesion of the right side of the hard palate, which can be better visualized in correlative coronal PET/CT (d) and CT (e, arrow) views.

FIGURE 2.7 Whole body 18F-FDG PET/CT findings in a 55-year-old male patient examined for staging lymphoma of the maxillary sinus. PET Maximum Intensity Projection (a) shows pathologic and diffuse tracer uptake in the maxillary sinuses and no other localizations of disease. Axial PET/CT and CT details (bee, arrows) show intense 18F-FDG uptake in pathologic tissue of both maxillary sinuses, protruding into the oral cavity through the left maxillary alveolar process, with homogeneous contrast enhancement.

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FIGURE 2.8 PET Maximum Intensity Projection (a), in a patient with known thymoma, confirms pathologic tracer uptake in the mediastinal lesion, without other pathologic findings. 18F-FDG uptake, due to voluntary muscular activity, is detected in the postcricoid region, bilaterally, in axial PET/CT (b) and CT (c) views. 18F-FDG accumulation in the postcricoid region is related to phonation activity involving the posterior cricoarytenoid muscles [4].

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FIGURE 2.9 A 29-year-old man examined by whole body 18F-FDG PET/CT during follow-up of Hodgkin’s lymphoma. Whole body PET Maximum Intensity Projection (a) is negative for disease relapse, showing diffuse and bilateral tracer uptake in the neck, evident in the sternocleidomastoid muscles, as displayed in axial (b, c) and coronal (d, e) PET/CT and CT views. Monolateral or bilateral sternocleidomastoid contraction is a benign condition occasionally showing 18F-FDG uptake which may be easily recognizable with hybrid PET/CT evaluation [10].

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FIGURE 2.10 PET/CT findings in a 69-year-old patient with squamous cell carcinoma of the left fossa of Rosenmüller [11]. Coronal PET/CT (a) and contrast-enhanced CT (b) show asymmetrical left posterolateral pharyngeal recess, due to 18F-FDGavid tissue with linear contrast enhancement, also evident in axial PET/CT (c) and CT (d) details. No other pathologic findings were detected at whole body imaging.

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FIGURE 2.11 18F-FDG PET/CT findings in a patient during staging of pharyngeal cancer. Whole body PET Maximum Intensity Projection (a) shows intense tracer uptake in the cervical lesion, better displayed as pathologic tissue of the posterior pharyngeal wall, with a right cervical lymph node metastasis, in axial (b, c) and sagittal (d) PET/CT views. Contrast-enhanced CT, performed with PET/CT, shows mild contrast enhancement in the lesion (eeg), which is better delineated at MRI, as evident in axial T2-weighted views (h, i) and sagittal postcontrast T1-weighted detail (l).

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FIGURE 2.12 Human brown adipose tissue [12] detected by 18F-FDG PET/CT in a 23-year-old woman during follow-up of Hodgkin’s lymphoma. Whole body PET Maximum Intensity Projection (a) is negative for disease relapse, only showing diffuse tracer uptake in the neck and thorax, without corresponding abnormalities at contrast-enhanced CT, as displayed in axial PET/CT (b) and CT (c) views and coronal PET/CT (d) and CT (e) views. The 18 F-FDG uptake in brown adipose tissue in supraclavicular and paraspinal regions increases greatly after patient’s exposure to cold and is a common pitfall in clinical practice.

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FIGURE 2.13 Whole body 18F-FDG PET/CT in a 54-year-old patient with right ethmoid sinus cancer. PET Maximum Intensity Projection in sagittal view (a) displays intense tracer uptake in the right sino-nasal region, corresponding to a hypontense lesion of the right ethmoid sinus, as evident in correlative coronal PET/MRI (b) and T2-weighted MRI (c, arrow) views and axial PET/MRI (d) and T2-weighted MRI (e) views. No other pathologic findings were documented.

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Atlas of Hybrid Imaging

68

Ga-DOTATOC

FIGURE 2.14 A 55-year-old patient was examined by means of whole body 68Ga-DOTATOC PET/CT during follow-up of cecal carcinoid. No areas of pathologic tracer uptake were detected. PET Maximum Intensity Projection (a) showed single focus of 68Ga-DOTATOC uptake in the neck, in a left infracentimetric cervical node, displayed in axial PET/CT (b) and low-dose CT (c) views and coronal PET/CT (d) and low-dose CT (e, arrow) views. Ultrasonography, performed after PET/CT scan, confirmed a juxtathyroid node (f, arrow). A suspicion of parathyroid adenoma was done. PTH value, subsequently measured, was 148 pg/mL, confirming the diagnosis [13].

2.2.3

18

F-Choline

FIGURE 2.15 A 68-year-old patient was examined by 18F-Choline PET/CT due to biochemical relapse of prostate cancer, one year after radical prostatectomy. PSA was 3.8 ng/mL at the time of the scan. PET Maximum Intensity Projection (a) showed a single bony metastasis, 18F-choline avid, in the right ilium. Moreover, a further area of tracer uptake was detected in an infracentimetric left cervical node, showed in axial PET/CT (b) and low-dose CT (c) views. Ultrasonography, subsequently performed, confirmed a 9 mm wide iso-hypoechoic node (d) with intense vascular pattern at power Doppler (e). Measurement of parathyroid hormone (205 pg/mL) confirmed clinical suspicion of parathyroid adenoma [14,15].

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131

I

FIGURE 2.16 A patient in long-term follow-up with thyroid carcinoma, already submitted to thyroidectomy. 131I whole body scan in anterior view (a) showed radioiodine-avid focus in the neck, corresponding to a node in the right thyroid loggia, evident in correlative axial SPECT/CT (b) and CT (c, arrow) views. Ultrasound, subsequently performed, helped to diagnose disease relapse, confirming a hypoechoic, 8 mm wide node in the right thyroid loggia (d). 131I-SPECT/CT could be used as a complementary tool to planar whole body scan, in the evaluation of patients with differentiated thyroid carcinoma in long-term follow-up to early identify neck lymph node metastases [16].

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99m

Tc-MIBI

FIGURE 2.17 A 44-year-old woman with rising levels of parathyroid hormone (89 pg/mL) was examined by 99mTc and 99mTc-MIBI scintigraphy. No significant findings were detectable at thyroid imaging with 99mTc (a), while an area of intense tracer uptake was evident in delayed imaging with 99mTcMIBI (b). Dual-tracer subtraction parathyroid imaging (c) and, subsequently, SPECT (d) confirmed this metabolic finding. Axial SPECT/CT (e) and CT (f, arrow) diagnosed a parathyroid adenoma [14,17].

References [1] Connor S. Laryngeal cancer: how does the radiologist help? Cancer Imaging 2007;28(7):93e103. [2] Arambula A, Brown JR, Neff L. Anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils. World J Otorhinolaryngol Head Neck Surg 2021 27;7:155e60. [3] Blodgett TM, Fukui MB, Snyderman CH, Branstetter BF, McCook BM, Townsend DW, et al. Combined PET-CT in the head and neck: part 1. Physiologic, altered physiologic, and artifactual FDG uptake. Radiographics 2005;25:897e912. [4] Gray BR, Koontz NA. Normal patterns and pitfalls of FDG uptake in the head and neck. Semin Ultrasound CT MR 2019;40:367e75. [5] Purohit BS, Ailianous A, Dulguerov N, Becker CD, Ratib O, Becker M. Insights Imaging 2014;5:585e602. [6] Yadav U, Singh RB, Chaudhari S, Srivastava S. Comparative study of preoperative airway assessment by conventional clinical predictors and ultrasound-assisted predictors. Anesth Essays Res 2020;14:213e8. [7] Olson JT, Wenger DE, Rose PS, Petersen IA, Broski SM. Chordoma: (18)F-FDG PET/CT and MRI imaging features. Skeletal Radiol 2021;50:1657e66. [8] Kuhn FP, Hüllner M, Mader CE, Kastrinidis N, Huber GF, von Schulthess GK, et al. Contrast-enhanced PET/MR imaging versus contrast-enhanced PET/CT in head and neck cancer: how much MR information is needed? J Nucl Med 2014;55:551e8. [9] Varoquaux A, Rager O, Dulguerov P, Burkhardt K, Ailianou A, Becker M. Diffusion-weighted and PET/MR imaging after radiation therapy for malignant head and neck tumors. Radiographics 2019;40:367e75. [10] Bennett O, Kumar ASR, Agnew J. Focal inflammatory myositis on 18F-FDG PET/CT. Clin Nucl Med 2016;41:469e71. [11] Ozturk K, Gencturk M, Caicedo-Granados E, Li F, Cayci Z. Positron emission computed tomography and magnetic resonance imaging features of sinonasal small round blue cell tumors. Neuroradiol J 2020;33:48e56. [12] Santhanam P, Ahima RS, Mammen JS, Giovanella L, Treglia G. Brown Adipose Tissue (BAT) detection by (18)F-FDG PET and thyroid hormone level(s)-a systematic review. Endocrine 2018;62:496e500. [13] Tuzcu SA, Pekkolay Z. Multiple endocrine neoplasia type 2A syndrome (MEN2A) and usefulness of 68Ga-DOTATATE PET/CT in this syndrome. Ann Ital Chir 2019;90:497e503.

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[14] Petranovic Ovcaricek P, Giovanella L, Carrió Gasset I, Hindié E, Huellner MW, et al. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging 2021;48:2801e22. [15] Calabria F, Chiaravalloti A, Cicciò C, Gangemi V, Gullà D, Rocca F, et al. PET/CT with (18)F-choline: physiological whole bio-distribution in male and female subjects and diagnostic pitfalls on 1000 prostate cancer patients: (18)F-choline PET/CT bio-distribution and pitfalls. A southern Italian experience. Nucl Med Biol 2017;51:40e54. [16] Spanu A, Nuvoli S, Marongiu A, Gelo I, Mele L, Piras B, et al. Neck lymph node metastasis detection in patients with differentiated thyroid carcinoma (DTC) in long-term follow-up: a 131 I-SPECT/CT study. BMC Cancer 2020;20:239. [17] Quak E, Lasne Cardon A, Ciappuccini R, Lasnon C, Bastit V, Le Henaff V, et al. Upfront F18-choline PET/CT versus Tc99m-sestaMIBI SPECT/CT guided surgery in primary hyperparathyroidism: the randomized phase III diagnostic trial APACH2. BMC Endocr Disord 2021;21:3.

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Index Note: ‘Page numbers followed by “f ” indicate figures and “t ” indicate tables.’

Vol. 1 Atlas of Hybrid Imaging Brain and Neck Alveolar process, 125, 129, 157, 171f Alzheimer’s Disease, 94fe95f, 101fe102f Amyloid plaques, 101fe103f Anterior cingulate, 15, 17, 19, 33, 35, 41, 57, 59, 61, 75, 77, 83, 94f Anterior cranial fossa, 5 Anterior laryngeal commisure, 137 Anterior nasal spine, 125 Articular tubercle of zigomatic process, 143, 145, 147, 151, 153, 155 Aryepiglottic fold, 121f Arytenoid cartilage, 119e121, 135 Astrocitoma, 106fe108f Atlas, 125, 165, 167 Axis, 125, 127, 129, 165, 167 Brain metastases, 98fe99f Brown adipose tissue, 176f Buccal space, 117 Buccinator muscle, 125 Carotid artery, 131, 133, 135, 137, 139, 141 Carotid space, 117 Cecal carcinoid, 178f Central sulcus, 127 Cerebellar anterior lobe, 25, 27, 31, 37, 49, 67, 69, 73, 79, 91 Cerebellar diaschisis, 94fe95f, 99f Cerebellar posterior lobe, 27, 31, 37, 49, 51, 69, 73, 79, 91, 93 Cerebellar vermis, 25, 27, 49, 51, 67, 69, 91, 93 Cerebellum, 6e7, 9, 30f, 33, 35, 75, 77, 167 Cervical vertebra, 131, 133, 135, 137, 139, 163, 165 Choanae, 115t, 120f Clavicle, 141 Clivus, 123, 163 Common carotid artery, 139, 141 Condylar process of mandible, 143, 145, 153, 155, 163 Corpus callosum, 9, 77 Cranial teca, 4, 110f Cricoid cartilage, 114, 119e121, 135, 137, 149, 163

Deep cervical fascia, 117f Dens of axis, 125, 165 Digastric muscle (posterior belly), 127, 143, 145, 153, 155 Dorsal vertebra, 139, 141 Epicranius muscle, 143, 145, 153, 155 Epiglottic vallecula, 133 Epiglottis, 119e121, 121f, 131, 149, 161 Esophagus, 139, 141 Etmoid, 3, 157 Etmoidal cells, 157 External auditory canal, 123, 165 External ear, 123 Extraocular muscles, 157 False vocal cord, 119f, 121f Falx cerebri, 15, 17, 33, 35, 40f, 57, 59, 75, 77, 107f, 111f Foramen magnum, 5, 167 Fossa of Rosenmüller, 174f Fourth ventricle, 9, 45, 87 Frontal bone, 2e3 Frontal lobes, 6, 95f Fronto-temporal dementia, 94f Genioglossus muscle, 129, 131 Geniohyoid muscle, 133 Glioblastoma, 133 Glottis, 120f, 135, 137, 149, 161 Gray matter, 15, 56f Hard palate, 125, 171f Hodgkin’s lymphoma, 173f, 176f Hyoid bone, 114, 119e121, 133, 149, 159, 163 Hypohysis, 9 Hypopharynx, 115t, 120f, 131, 133 Inferior constrictor muscle of pharynx, 133 Inferior nasal concha, 123, 149 Infrahyoid, 115f, 116 Interhemispheric fissure, 6 Internal carotid canal, 123 Internal jugular vein, 131, 133, 135, 137, 139, 141, 165 Intervertebral space, 135 Jugular vein, 131, 133, 135, 137, 139, 141, 165

Lacrimal bone, 3 Lamina quadrigemina, 9 Laryngeal cancer, 168f Laryngeal ventricle, 119f, 121f Laryngopharinx, 115t Larynx, 118f Lateral pharyngeal recess (Rosenmuller’s fossa), 120f, 123 Lateral pterygoid muscle, 123, 143, 155, 159, 161 Lateral rectus muscle, 23, 31, 37, 41, 65, 67, 83 Lateral sulcus (Sylvian fissure), 6e7 Levator anguli oris muscle, 127 Levator scapulae muscle, 133, 135, 137, 147, 151 Lingual tonsil, 129 Longus capitis muscle, 123, 125, 127, 149, 163 Lymphoma, 170fe171f, 173f, 176f Macrophages, 100f, 170f Mandible, 2e4, 123, 125, 127, 129, 131, 143, 145, 147, 149, 151, 153, 155, 157, 159, 161, 163 Masseter muscle, 123, 125, 127, 129, 145, 153, 157, 159 Masticator space, 117 Mastoid cells, 143, 145, 147, 151, 153, 155 Mastoid process (temporal bone), 4, 143, 145, 147, 151, 153, 155, 167 Maxilla, 2e3, 100f, 123, 125, 149, 157 Maxillary sinus, 123, 147, 151, 157, 171f Medial pterygoid muscle, 127, 159, 161 Medial rectus muscle, 23, 41, 65, 67, 83 Medulla oblongata, 9 Meningioma, 109fe110f Mental foramen (mandible), 4 Mentalis muscle, 129 Mesencefalus, 21, 23, 33, 35, 47, 63, 65, 75, 77, 89 Mesencephalon (midbrain), 9 Metastasis, 175f, 178f Middle constrictor muscle of pharinx, 131 Moyamoya Disease, 96f Mylohyoid muscle, 131, 149, 157 Nasal bone, 2e4

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184 Index

Nasal choanae, 115t, 120f Nasal septum, 120f, 123, 157 Nasopharynx, 115t, 116, 120f, 123, 125, 149, 159, 161, 170f Occipital bone, 3 Occipital lateral (region), 15, 17, 19, 21, 25, 31, 33, 35, 37, 39, 49, 51, 57, 59, 61, 63, 65, 67, 71, 73, 75, 77, 79, 81, 91, 93 Occipital lobe, 7, 94f Orbicularis oris muscle, 125, 127 Oropharynx, 115t, 116, 127, 129, 131, 149 Palatine tonsil, 127 Papillary thyroid carcinoma, 169f Parapharyngeal space, 117 Parathyroid adenoma, 178f, 180f Parietal bone, 2e3 Parietal inferior (region), 13, 15, 17, 29, 31, 37, 39, 43, 45, 47, 49, 51, 55, 57, 59, 71, 73, 79, 81, 85, 87, 89, 91, 93, 108f Parietal lobe, 7, 94f Parietal superior (region), 11, 13, 31, 33, 35, 37, 47, 49, 51, 53, 55, 73, 75, 77, 79, 89, 91, 93, 109f Parkinson’s Disease, 18f, 104fe105f Parkinsonian syndrome, 18f, 104f Parotid duct, 125 Parotid gland, 125, 127, 129, 131, 143, 145, 153, 155, 161, 163, 165 Parotid space, 117 Pharyngeal cancer, 175f Pineal gland, 109f Piriform recess, 133 Pituitary adenoma, 96f Platysma, 129, 131, 133, 145, 147, 151, 153, 157, 159, 161, 163 Pons, 9, 25, 33, 35, 47, 67, 75, 77, 89, 165 Postcricoid mucosa, 121f Posterior cervical space, 117 Posterior cingulate, 15, 17, 33, 35, 47, 57, 59, 75, 77, 89, 94f Posterior cranial fossa, 5 Preantral (maxillary) fat pad, 123, 147, 151 Precuneus, 11, 13, 15, 17, 31, 33, 35, 37, 49, 51, 53, 55, 57, 59, 73, 75, 77, 79, 91, 93, 94f, 99f

Prefrontal lateral (region), 11, 13, 15, 17, 19, 21, 29, 31, 37, 39, 41, 43, 45, 47, 53, 55, 57, 59, 61, 63, 71, 73, 79, 81, 83, 85, 87, 89 Prefrontal medial (region), 11, 13, 15, 17, 19, 21, 31, 33, 35, 37, 41, 43, 45, 47, 53, 55, 57, 59, 61, 63, 73, 75, 77, 79, 83, 85, 87, 89 Primary visual (region), 17, 19, 21, 23, 25, 31, 35, 37, 49, 51, 59, 61, 63, 65, 67, 73, 75, 77, 79, 91, 93 Prostate cancer, 110fe111f, 178f Pterygoid fossa, 123, 159 Pterygoid muscles, 125 Pterygoid process, 123 Pyriformis sinus, 118f, 121f Retropharyngeal space, 117 Rhomboid minor muscle, 139, 141 Rib, 139, 141 Rolandic fissure, 7 Root of tongue, 129, 131, 149 Scalene muscles, 135, 137, 139, 141 Sella turcica, 97f Semispinalis capitis muscle, 129, 131, 133, 143, 145, 147, 151, 153, 155 Semispinalis thoracis muscle, 139, 141 Sensorimotor (region), 11, 13, 15, 29, 31, 33, 35, 37, 39, 43, 45, 47, 53, 55, 57, 71, 73, 75, 77, 79, 81, 85, 87, 89, 94f Sinus piriformis, 115t Sinusitis, 100f Soft palate, 115t, 125, 149, 159 Sphenoid (greater wing), 2e3, 97f, 115t, 149, 159, 161, 163 Sphenoid sinus, 97f, 115t Spinal cord, 75, 77, 127, 129, 131, 133, 135, 137, 139, 141, 167 Spinalis and semispinalis cervicis muscle, 133, 135, 137 Spinalis capitis muscle, 129 Spinalis cervicis muscle, 131 Splenius capitis muscle, 143, 155 Sternocleidomastoid muscle, 127, 129, 131, 133, 135, 137, 139, 141, 147, 151, 161, 163, 165, 167, 173f Sternohyoid muscle, 139 Styloid process, 125, 163

Sublingual gland, 129 Submandibular gland, 129, 131, 133, 147, 151, 159, 161 Superciliary arch, 4 Superior constrictor muscle of pharinx, 129 Supraclavicular fossa, 135, 137, 139, 141 Suprahyoid, 115f, 116 Temporal bone, 2e4, 143, 155 Temporal lateral (region), 17, 19, 21, 23, 25, 29, 31, 37, 39, 43, 45, 47, 49, 51, 59, 61, 63, 65, 67, 71, 73, 79, 81, 85, 87, 89, 91, 93 Temporal lobe (region), 6e7, 94f, 101f, 159, 161, 163, 165, 167 Temporal mesial (region), 23, 25, 31, 37, 43, 45, 47, 63, 64f, 65, 67, 85, 87, 89 Temporal process (zygomatic bone), 4 Temporalis muscle, 143, 145, 147, 151, 153, 155 Third ventricle, 9 Thyrohyoid muscle, 135, 137 Thyroid cartilage, 114, 115t, 119e121, 135, 137, 149, 159, 161, 163 Thyroid gland, 116, 139, 141 Thyroid loggia, 169f, 179f Tongue, 120f, 127, 129, 131, 131f, 149, 157, 159 Torus tubarius, 115t, 120f, 123 Trachea, 139, 141, 149, 165, 167 Trapezius muscle, 133, 135, 137, 147, 151 True vocal cord, 119f, 121f Ultrasonography, 169f, 178f Uvula, 127, 149, 159, 161 Ventricular folds (false cords), 135 Visceral space, 117 Visual primary (region), 17, 19, 21, 23, 25, 31, 35, 37, 49, 51, 59, 61, 63, 65, 67, 73, 75, 77, 79, 91, 93 Vocal folds (true cords), 137 Waldayer’s ring, 170f White matter, 9, 13, 19, 21, 23, 29, 39, 41, 43, 45, 51, 55, 56f, 57, 59, 61, 63, 65, 71, 81, 83, 85, 87, 93, 101f Zygomatic process (temporal bone), 4