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Crossed Cerebellar Diaschisis on F-18 FDG PET/CT imaging as long-term sequel to Carbon Monoxide poisoning
Poster Title: Crossed Cerebellar Diaschisis on F-18 FDG PET/CT imaging as long-term sequel to Carbon Monoxide poisoning
Submitted on 29 Oct 2020
Author(s): Muhammad Umar Khan, Jawaher Al-Ajmi, Zuhair Saleh Abdullah, Atif Dafallah
Affiliations: Nuclear Medicine Unit, Department of Medical Imaging, Jahra Hospital, Kuwait
This poster was presented at BIR2020
Poster Views: 57
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Poster Information
Abstract: Case Presentation: A 29-years-old lady was admitted to hospital for post-partum depression. She had previous history of repeated amnesia episodes. Ten years ago, she was caught up in a fire, comatosed and treated for CO poisoning. Presently, she underwent MRI-Brain for her symptoms of memory loss and depression. MRI features suggested changes secondary to previous CO poisoning with differential of granulomatous process (Sarcoidosis). Patient was referred to Nuclear Medicine Unit for F-18 FDG PET/CT imaging to evaluate possible granulomatous disease sites elsewhere. She was administered 8.3mCi(307.1MBq) F-18 FDG intravenously and images were acquired 60-minutes post-injection. Dedicated Brain sequence was also acquired. Results showed, generalized asymmetric reduced tracer uptake in left cerebrum with hypoperfusion in the contralateral cerebellar hemisphere, depicting characteristic pattern of CCD, indicating diminished glucose metabolism. Patchy reduced tracer uptake was also seen in left lentiform nucleus. No scintigraphic features to suggest sarcoidosis were ascertained outside the brain.

Discussion: Diaschisis is over a century old phenomenon that describes remote metabolic effects of insults to the brain [1]. CCD, first introduced by Monakow in 1914, is characterized by hypometabolism and functional deactivation in the cerebellar hemisphere contralateral to the supratentorial lesion [2]. This concept has been noticed in patients with cerebral infarction, supratentorial tumours, epilepsy, encephalitis, [3] and as a disruption of the cortico-ponto-cerebellar pathway by major damage to brain as in our case. CCD has been exhibited on F-18 FDG PET up to 20 years post cerebrovascular accident, suggesting the irreversibility of the injury once the acute phase is over [4]. Our findings concur with known evidence in demonstrating CCD as a long-term sequel to brain damage, which in this case appears secondary to CO poisoning.

Conclusion: CCD is a known complication to neurological insults (stroke, tumours, head injury, epilepsy, encephalitis, etc.), however, this is likely the first reported case of CCD on F-18 FDG PET/CT imaging illustrating long-term sequel to CO poisoning with characteristic scintigraphic features.
Summary: Crossed Cerebellar Diaschisis (CCD), is a known phenomenon studied by hybrid imaging modalities and demonstrates interruption of corticopontocerebellar tracts by neurological insults causing deafferentation and transneural metabolic depression of contralateral cerebellar hemisphere. We present a case of a young female, treated for Carbon Monoxide (CO) poisoning ten years ago, who demonstrated characteristic scintigraphic features of CCD on F-18-Fluoro-2-deoxy-D-glucose (FDG) PET/CT imaging.References: 1. Priftakis D, Rondogianni P, Datseris. A case of crossed cerebellar diaschisis on follow-up positron emission tomography/computed tomography with F-18 fluoro-D-glucose after treatment for glioblastoma. World J Nucl Med 2019; 18: 71-3.
2. Wiesendanger M, Constantin von Monakow (1853-1930). A pioneer in interdisciplinary brain research and a humanist. C R Biol 2006; 329: 406-18.
3. Han S, Wang X, Xu K, Hu C. Crossed Cerebellar Diaschisis: Three case reports imaging using a tri-modality PET/CT-MR system. Medicine 2016; 95: e2526.
4. Shih WJ, Huang WS, Milan PP. F-18 FDG PET demonstrates crossed cerebellar diaschisis 20 years after stroke. Clin Nucl Med 2006; 31: 259-61.
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