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nuklearmedizin-berlin.net - SPANDAU: Parkinsondiagnostik
nuklearmedizin-berlin.net - Wednesday, 12. May 2021
Druckversion der Seite: Parkinsondiagnostik
URL: nuklearmedizin-berlin.net/en/untersuchungsspektrum/parkinsondiagnostik.html

Parkinsondiagnostik

Allgemein

"Parkinson-Syndrom" ist ein Sammelbegriff für eine heterogene Gruppe der Bewegungsstörungen. Bei Diagnosestellung und der Differenzierung der Parkinson-Syndrome am Krankheitsbeginn ergeben sich nicht selten Schwierigkeiten aufgrund überlappender Symptomatik. Nuklearmedizinische Verfahren erlauben eine dreidimensionale in-vivo Darstellung und Quantifizierung des dopaminergen Systems und besitzen eine hohe Sensitivität bei der Früherkennung von neurodegenerativen Parkinson-Syndromen. Die breite klinische Anwendung der nuklearmedizinischen Parkinsondiagnostik ist mit der Einführung der kommerziell erhältlichen Radiopharmaka für die SPECT (Single-Photon-Emissions-Computer-Tomographie) möglich geworden.

Methode
Dopamintransporter(DAT) SPECT

Bei neurodegenerativen Parkinson-Sydromen (Morbus Parkinson, Lewy-Body Demenz, Multisystematrophie, supranukleäre Blickparese, kortikobasale Degeneration) ist der Dopamingehalt im synaptischen Spalt vermindert. Als Folge sinkt die Expression der Dopamintransporter im präsynaptischen Teil der Synapse. Dieser Dopamintransporter-Mangel kann mit Hilfe einer Hirn-SPECT Untersuchung detektiert werden. Hierfür wird das Radiopharmakon 123I-FP-CIT (Datscan®) eingesetzt. Die Methode besitzt eine sehr hohe Treffsicherheit in der Früherkennung von neurodegenerativen Parkinson-Syndromen, kann aber zwischen unterschiedlichen Erkrankungen nicht unterscheiden. Die Kosten der 123I-FP-CIT-SPECT Untersuchungen werden durch alle gesetzliche und private Kassen erstattet.

D2-Rezeptoren SPECT

Bei sogenannten atypischen Parkinson-Syndromen (z.B. Multisystematrophie, supranukleäre Blickparese) wird häufig neben einem Dopaminmangel häufig auch eine Schädigung von D2-Rezeptoren (Bindungsstellen) beobachtet. Hirn-SPECT mit dem Radopharmakon 123I-IBZM (Marker der D2-Rezeptoren) ist im Einzelfall hilfreich, um Morbus Parkinson von den atypischen Parkinson-Syndromen zu differenzieren. Dieses Verfahren kann auch medikamenten-induzierte Parkinson-Syndrome diagnostizieren, bei welchen typischerweise eine Blockade von D2-Rezeptoren nachweisbar ist. In der Regel ist eine 123I-IBZM SPECT Untersuchung nur dann sinnvoll, wenn ein pathologischer Befund der 123I-FP-CIT SPECT vorliegt und ein klinischer Verdacht auf ein atypisches Parkinson-Syndrom besteht. Im Falle eines pathologischen Befundes kann mit hoher Sicherheit von einer atypischen neurodegenerativen Parkinson-Erkrankung ausgegangen werden. Ein unauffälliger Befund kann jedoch ein atypisches Parkinson-Syndrom nicht ausschließen.

Vollautomatische Auswertung

Voraussetzung für eine sichere Diagnose ist die präzise Quantifizierung der SPECT-Daten. Die übliche manuelle oder semiautomatische Auswertung ist aufgrund der hohen Untersucherabhängigkeit suboptimal und kann sogar irreführend sein. Deshalb führen wir in unsrem Institut zusätzlich zu der visuellen Beurteilung der SPECT-Aufnahmen eine untersucherunabhängige vollautomatische Auswertung von SPECT Daten durch. Hierfür verwenden wir die BRASSTM(Brain Analysis)-Software der Fa. "HERMES", welche als ein diagnostisches "Goldstandard" in der nuklearmedizinischen Parkinsondiagnostik gilt. Hierbei wurden die SPECT-Daten dreidimensional auf ein Template angepaßt und mit einem Normalkollektiv verglichen.

Ablauf

Bei 123I-FP-CIT-SPECT Untersuchungen ist keine spezielle Vorbereitung nötig. Antiparkinsonische Medikamente können weiter eingenommen werden.

Ergebnisse der 123I-IBZM SPECT kann durch eine Reihe neuroaktiver Medikamente beeinträchtigt werden. Diese Medikamente können striatale D2-Rezeptoren blockieren und zu einem „falsch positiven“ Scan führen. Vor den Untersuchungen müssen daher folgende Medikamente (nach Rücksprache mit dem behandelnden Neurologen) für mindestens 2-fache Eliminationszeiten pausiert werden:

Dopaminagonisten (je nach HWZ für 1-2 Wochen, Cabaseril für 3 Wochen
Neuroleptika (sowohl typische als auch atypische!) für 10 Tage; bei depot-Neuroleptika bis zu 3 Monaten.
Antiemetika, z.B. Metoclopramid (Dopaminantagonisten) für 24 Stunden
Kalzium-Antagonisten von Klasse B (Flunarizin, Cinnarizin) für 24 Stunden
Reserpin für eine Woche
Nach Aufklärung und Anamneseerhebung durch den zuständigen Nuklearmediziner, wird eine geringe Menge der radioaktiven Substanz in eine Armvene injiziert. Allergische Reaktionen oder ein Einfluss der Substanz auf den Stoffwechsel sind hierbei nicht zu erwarten. Ca. 3 bis 4 Stunden nach der Verabreichung werden Hirn-SPECT Aufnahmen angefertigt. Die eigentliche Aufzeichnung der Bilder dauert ca. 30 min.  Falls vorhanden, sollten CT- bzw. MRT- Hirnaufnahmen mitgebracht werden. Die Wartezeit von 3 bis 4 Stunden muss der Patient nicht bei uns verbringen, er kann sich frei bewegen und auch essen.

Patient mit tremordominanten Morbus Parkinson. 123I-FP-CIT SPECT zeigt eine verminderte Dopamintransporter-Dichte in Basalganglien (insb. rechts). Hingegen findet sich in der 123I-IBZM SPECT eine regelrechte D2-Rezeptor-Besetzung.

Patient mit atypischem Parkinson-Syndrom (pMSA). 123I-FP-CIT SPECT zeigt eine verminderte Dopamintransporter-Dichte in Basalganglien (insb. links). Die 123I-IBZM SPECT zeigt eine ebenfalls linksbetonte D2-Rezeptorenschädigung.

Patient mit Medikamenten-induziertem Parkinson-Syndrom. 123I-FP-CIT SPECT zeigt eine intakte Dopamintransporter-Dichte in Basalganglien uns schließt somit eine neurodegenerative Erkrankung aus. In der 123I-IBZM SPECT Nachweis einer D2-Rezeptoren-Blockade durch ein atypisches Neuroleptikum.