BACKGROUND: Lewy body disease is, after Alzheimer's disease, the second most common cause of senile degenerative dementia with progressive cognitive deterioration, fluctuation of cognitive and motoric functions and psychotic symptoms. It is characterized histologically by the occurrence of Lewy bodies in allocortical, neocortical and subcortical structures. The aim of this study was to measure the cortical glucose metabolism using FDG PET (2-[18F]fluoro-2-deoxy-D-glucose position emission tomography) compared to normal subjects. PATIENTS AND METHODS: Five patients (5 m, mean age 75 y) with clinically suspected diffuse Lewy body disease (DLB) were studied with FDG PET. PET studies of the head were performed with a Siemens ECAT-ART PET-scanner with attenuation correction using 137-Cs point sources. RESULTS: We found the same distribution pattern of diffuse glucose hypometabolism in the entire cortical region with relative sparing of the primary sensory-motor cortex in all the patients. The few cases reported in the literature so far describe findings similar to ours. CONCLUSION: The pattern of diffuse glucose hypometabolism in the entire cortex including the occipital region seems to be a typical feature of DLB that is distinctive from dementia of Alzheimer's disease

D Neary

DC Costa

DN Levine

E Donnemiller

EJ Byne

F Lebert

FH Lewy

G McKhann

G Ransmayr

G Waldemar

GM Goodwin

H Foerstl

H Soininen

Horst Koehn

IG McKeith

J Brunberg

K Kosaka

KK Gnanalingham

L Hansen

LA Hansen

M Suzuki

Peter Knoll

RL Albin

S Minoshima

S Mirzaei

Siroos Mirzaei

Thomas Bruecke

WR Gibb

Z Walker

English

PubMed

Springer - Publisher Connector

Assessment of diffuse Lewy body disease by 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET)

BioMed CentralBMC Nuclear Medicine
ssOpen AcceResearch article
Assessment of diffuse Lewy body disease by 
2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography 
(FDG PET)
Siroos Mirzaei*1, Peter Knoll1, Horst Koehn1 and Thomas Bruecke2
Address: 1Ludwig Boltzmann Institute of Nuclear Medicine, Wilhelminenspital, Austria and 2Department of Neurology, Wilhelminenspital, 
Vienna, Austria
Email: Siroos Mirzaei* - siroos.mirzaei@nuk.wil.magwien.gv.at; Peter Knoll - peter.knoll@nuk.wil.magwien.gv.at; 
Horst Koehn - horst.koehn@nuk.wil.magwien.gv.at; Thomas Bruecke - thomas.bruecke@neu.wil.magwien.gv.at
* Corresponding author    
DementiaFDG PETLewy body disease
Abstract
Background: Lewy body disease is, after Alzheimer's disease, the second most common cause of
senile degenerative dementia with progressive cognitive deterioration, fluctuation of cognitive and
motoric functions and psychotic symptoms. It is characterized histologically by the occurrence of
Lewy bodies in allocortical, neocortical and subcortical structures. The aim of this study was to
measure the cortical glucose metabolism using FDG PET (2-[18F]fluoro-2-deoxy-D-glucose
position emission tomography) compared to normal subjects.
Patients and Methods: Five patients (5 m, mean age 75 y) with clinically suspected diffuse Lewy
body disease (DLB) were studied with FDG PET. PET studies of the head were performed with a
Siemens ECAT-ART PET-scanner with attenuation correction using 137-Cs point sources.
Results: We found the same distribution pattern of diffuse glucose hypometabolism in the entire
cortical region with relative sparing of the primary sensory-motor cortex in all the patients. The
few cases reported in the literature so far describe findings similar to ours.
Conclusion: The pattern of diffuse glucose hypometabolism in the entire cortex including the
occipital region seems to be a typical feature of DLB that is distinctive from dementia of Alzheimer's
disease.
Background
Dementia with Lewy bodies (DLB) has been established
as the second most common senile degenerative dementia
after Alzheimer's disease (AD) [1–3]. Lewy bodies, first
described in 1912 by F.H. Lewy are distinctive neuronal
inclusions that may be seen in several different neurode-
generative processes [4]. Lewy bodies are eosinophilic
structures located within the cytoplasm of neurons. They
are characteristically circular with a dense protein core sur-
rounded by a peripheral halo. They are thought to be the
result of altered neurofilament metabolism and/or trans-
port due to neuronal damage and subsequent degenera-
tion, causing an accumulation of altered cytoskeletal
elements. 5–10% of asymptomatic individuals have pre-
sumably insignificant numbers of Lewy bodies, usually lo-
cated in the substantia nigra. [5]. Diagnostic criteria for
DLB have been defined to allow clinical diagnosis [3]. Un-
til quite recently, post mortem examination provided the
Published: 20 February 2003
BMC Nuclear Medicine 2003, 3:1
Received: 19 December 2002
Accepted: 20 February 2003
This article is available from: http://www.biomedcentral.com/1471-2385/3/1
© 2003 Mirzaei et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all 
media for any purpose, provided this notice is preserved along with the article's original URL.Page 1 of 4
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BMC Nuclear Medicine 2003, 3 http://www.biomedcentral.com/1471-2385/3/1definitive diagnosis. However, while these clinical criteria
have high specificity (90–97%), they have low sensitivity
(22–75%) [6]. The central clinical feature required for a
diagnosis of DLB is a progressive and fluctuating cognitive
decline with recurrent visual hallucinations, systematized
delusions and spontaneous parkinsonian symptoms. Re-
peated falls, syncope, transient loss of consciousness and
neuroleptic sensitivity are also clinically characteristic. In
AD, in contrast, the progressive decline of memory is
prominent and neuropsychiatric features usually occur in
the later stages [7]. Moderate parkinsonian signs can be
observed during both AD and DLB evolution [8]. Thus, in
some cases, the clinical distinction of patients with DLB
from those with AD may be difficult because of overlap-
ping symptoms such as cognitive decline, psychiatric signs
and parkinsonism. When the initial presentation of DLB
is characterized by impaired cognition, the disease can
mimic AD [5,9].
Differentiation of the two diseases from each other can be
achieved by neuropsychological evaluation, which can
disclose impaired performance of similar severity in both
diseases with regard to attention, frontal lobe function
and motor sequencing in DLB and AD [10]. In practice,
differential diagnosis by the use of this method is most
likely to be realized in specialized centers of neurology
and psychiatry. A previous study has shown that noninva-
sive imaging modalities such as PET or SPECT may be use-
ful methods for the diagnosis of dementing disorders,
especially in the differential diagnosis of dementia and
depression of the elderly [11]. In another study, it was
found that in depression, symmetrically metabolic chang-
es are found in the prefrontal cortex, and these changes
improve with treatment [12], which was not typical for
dementia.
In AD, the abnormal pattern of regional cerebral blood
flow (rCBF) that is characteristic of the disease is bilateral-
ly decreased perfusion in the temporal and parietal re-
gions [13]. However, heterogeneous patterns of rCBF
deficits have been seen in AD on examination with
SPECT. This heterogeneity may reflect either different
stages of the disease or cognitive subtypes [14]. In DLB,
temporoparietal hypoperfusion has been shown to be as-
sociated with occipital hypoperfusion, which could ex-
plain the visual hallucinations in this illness [15].
The aim of this study was to evaluate FDG-PET brain im-
aging in assessing clinically manifested DLB by measuring
regional glucose metabolism.
Methods
Five patients (5 males, mean age 75 y, age range 69–79)
with fulfilled clinical criteria for DLB were referred to our
department for PET examination. The disease duration
was 3 ± 1 y. Every patient underwent a psychological ex-
amination including MMSE (mini mental state examina-
tion). Magnetic resonance imaging (MRI) of the brain was
performed in all the patients. The data gathered from the
patients were compared to the PET brain images from a
normal data base in our department (six normal subjects,
2 males, 4 females, mean age 63, age range 45–79). The
normal subjects had no history of neurological or psychi-
atric disease. The PET images were obtained 30 minutes
after i.v. injection of 150 MBq FDG using a Siemens
ECAT-ART (CTI, Knoxville, TN, USA). Attenuation correc-
tion of the images was made with an additional transmis-
sion scan using two 137-Cs point sources [16].
Reconstruction was performed using the filtered back pro-
jection method (FBP) applying a Gaussian filter (FWHM
4.0 mm) and a zoom factor of 2.50. An acquisition matrix
size of 128 × 128 was chosen. Six regions of interest (ROI)
were drawn on a 10 mm thick transaxial brain slice at 4.5
cm parallel to the cantomeatal line (CML) and two ROIs
in the central region, and the SUVs of these regions were
measured. Z scores for each patient were calculated ac-
cording to the formula of Albin et al [17], as follows:
Z score = (patient regional SUV - controls regional SUV
(mean value))/ controls regional SUV standard
deviation).
A Z score of ≤ -2 was considered to be significant.
Results
Diffuse reduced glucose uptake in the entire cortical re-
gion with relative sparing of the central region (Figure 1),
but including the occipital cortex was determined in all
the patients, which was less remarkable in patient 2. The
mean SUV in the patient group was 3.30 ± 0.30 vs. 6.10 ±
0.70 in the normal subjects. The detailed Z-scores of the
patients' cerebral metabolic patterns are shown in Table 1.
MRI of the brain showed a mild degree of cortical atrophy
in three of the patients without further specific pathologic
findings.
Discussion
Postmortem examination remains the only way to defini-
tively confirm the diagnosis of DLB, which is based on ev-
idence of Lewy bodies in the cortex, the subcortical
regions (nucleus basalis of Meynert) and the brain stem
(substantia nigra and locus coeruleus) [5,18,19]. With the
promise of neuroprotective treatments, early diagnosis is
increasingly important. A more extensive cholinergic def-
icit has been observed in DLB compared with AD [9]. This
observation explains the beneficial effects of cholinergic
therapy in DLB (cholinesterase inhibitor), which has been
shown to improve impaired cognitive functions [20]. This
implies that early diagnosis would greatly improve the ef-
fectiveness of the treatment.Page 2 of 4
(page number not for citation purposes)
BMC Nuclear Medicine 2003, 3 http://www.biomedcentral.com/1471-2385/3/1Although clinical criteria have been defined for DLB [3],
development of objective measures to confirm clinical
findings would be helpful in clinical routine. Recent
studies have suggested that functional imaging with
dopaminergic presynaptic ligands and postsynaptic D2 re-
ceptors like 123I-FP-CIT and 123I-iodobenzamide help to
distinguish DLB from AD, since there are loss of dopamin-
ergic neurons in DLB [21–23]. Another study demonstrat-
ed reduced vesicular monoamine transporter type 2
expression in patients with DLB indicating degeneration
of nigrostriatal projections [24]. The patients described in
this report fulfilled the clinical criteria for DLB. The PET
examination revealed that all patients had glucose hy-
pometabolism in the entire cortex with relative sparing of
the primary sensory-motor cortex. In addition there was
marked hypometabolism in the occipital cortex, which
corresponds with results from other studies [1,25]. This
characteristic pattern of cortical hypometabolism includ-
ing the occipital areas could be a result of diaschisis due to
disruption of intracortical connections. Diaschisis is de-
fined as depression of regional neuronal metabolism and
cerebral blood flow caused by dysfunction in anatomical-
ly separate but functionally related neuronal regions [26].
The results in this study were obtained in routine hospital
work. We did not measure the arterial input function, as
performed by Albin et al, since we consider it too invasive
and inconvenient to the patient for routine use.
Conclusion
With the limitation that occipital hypometabolism may
be manifested not only in DLB [27], we propose the use
of a combination of FDG-PET and striatal dopamine ter-
minal imaging as a supplement to the clinical examina-
tion to establish the final diagnosis of DLB and as the
basis for a differentiated therapy.
Figure 1
m, 75 y, Brain FDG-PET shows a diffuse glucose hypometabolism with relative sparing of the central region
Table 1: Z scores of patient regional mean SUV compared to controls
Patient Nr. r.fr. l.fr. r.tp. l.tp. r.oc. l.oc. r.c. l.c.
P1 -2.7 -3.1 -3.1 -3.4 -3.0 -3.1 -1.4 -2.3
P2 -1.8 -2.1 -2.3 -2.0 -2.9 -3.1 -1.4 -0.6
P3 -2.9 -3.2 -2.6 -3.4 -2.6 -2.9 -1.8 -1.9
P4 -2.3 -2.7 -2.3 -3.1 -2.3 -2.7 -1.9 -1.7
P5 -2.6 -3.0 -2.7 -3.5 -2.7 -3.1 -2.2 -2.1
r. = right, l. = left, fr. = frontal, pt. = temporoparietal, oc. = occipital, c. = centralPage 3 of 4
(page number not for citation purposes)
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Authors' contribution
SM designed the study, performed the statistical analysis
and drafted the manuscript.
PK performed the quality control of the examination
procedure.
HK participated in the design of the study.
TB participated in the design of the study and preparation
of the manuscript.
All authors read and approved the final manuscript.
References
1. Byne EJ, Lennox G and Godwin-Austen R Diffuse Lewy body dis-
ease: clinical features in 15 cases. J Neurol Neurosurg Psychiatry
1989, 52:709-717
2. Hansen L, Salmon D, Galasko D, Masliah E, Katzman R, DeTeresa R,
Thal L, Pay MM, Hofstetter R and Klauber M The Lewy body vari-
ant of Alzheimer's disease: a pathological and clinical entity.
Neurology 1990, 40:1-8
3. McKeith IG, Galasko D, Kosaka K, Perry EK, Dickson DW, Hansen
LA, Salmon DP, Lowe J, Mirra SS, Byrne EJ, Lennox G, Quinn NP, Ed-
wardson JA, Ince PG, Bergeron C, Burns A, Miller BL, Lovestone S,
Collerton D, Jansen EN, Ballard C, de Vos RA, Wilcock GK, Jellinger
KA and Perry RH Consensus guidelines for the clinical and
pathologic diagnosis of dementia with Lewy bodies (DLB):
report of the consortium on DLB international workshop.
Neurology 1996, 47:1113-1124
4. Lewy FH Paralysis agitans. In: Pathologische Anantomie. Handbuch der
Neurologie (Edited by: Lewandowsky M) Berlin: Springer Verlag 1912, 920-
933
5. Hansen LA and Noville RL Lewy body disease. Curr Opin Neurol
Neurosurg 1992, 5:889-894
6. Ransmayr G, Wenning GK, Seppi K, Jellinger K and Poewe W De-
menz mit Lewy-Körperchen. Nervenarzt 2000, 71:929-935
7. McKhann G, Drachman D, Folstein M, Katzman R, Price D and Stadlan
EM Clinical diagnosis of Alzheimer's disease: report of the
NINCDS-ADRDA Work Group under the auspices of De-
partment of Health and Human Services Task Force on
Alzheimer's disease. Neurology 1984, 34:939-944
8. Soininen H, Laulumaa V, Helkala EL, Hartikainen P and Riekkinen PJ
Extrapyramidal signs in Alzheimer's disease: a 3-year follow-
up study. J Neural Transm Park Dis Dement Sect 1992, 4:107-119
9. Foerstl H, Burns A, Luther P, Cairns N and Levy R The Lewy body
variant of Alzheimer's disease: clinical and pathological
findings. Br J Psychiatry 1993, 162:385-392
10. Gnanalingham KK, Byrne EJ, Thornton A, Sambrook MA and Bannis-
ter P Motor and cognitive function in Lewy body dementia:
comparison with Alzheimer's and Parkinson's diseases. J Neu-
rol Neurosurg Psychiatry 1997, 62:243-252
11. Costa DC, Pilowsky LS and Ell PJ Nuclear Medicine in neurology
and psychiatry. Lancet 1999, 354:1107-11
12. Goodwin GM Functional imaging, affective disorder and
dementia. Br Med Bull 1996, 52:495-512
13. Neary D, Snowden JS, Shields RA, Burjan AWI and Northen B Single
photon emission tomography using 99mTc-HMPAO in the
investigation of dementia. J Neurol Neurosurg Psychiatry 1987,
50:1101-1109
14. Waldemar G, Bruhn P, Kristensen M, Johnsen A, Paulson OB and Las-
sen NA Heterogeneity of neocortical cerebral blood flow def-
icits in dementia of the Alzheimer type: a 99mTc-d,1-
HMPAO SPECT study. J Neurol Neurosurg Psychiatry 1994, 57:285-
295
15. Donnemiller E, Heilmann J, Wenning GK, Berger W, Decristoforo C,
Moncayo R, Poewe W and Ransmayr G Brain perfusion scintigra-
phy with 99mTc-HMPAO or 99mTc-ECD and 123I-β-CIT
single-photon emission tomography in dementia of the
Alzheimer-type and diffuse Lewy body disease. Eur J Nucl Med
1997, 24:320-325
16. Mirzaei S, Knoll P and Köhn H Comparison of different methods
for attenuation correction in brain PET. Nuklearmedizin 2000,
39(6):N95
17. Albin RL, Minoshima S, D'Amato CJ, Frey KA, Kuhl DA and Sima AA
Fluoro-deoxyglucose positron emission tomography in dif-
fuse Lewy body disease. Neurology 1996, 47:462-466
18. Gibb WR, Luthert PJ, Janota I and Lantos PL Cortical Lewy body
dementia: clinical features and classification. J Neurol Neurosurg
Psychiatry 1989, 52:185-192
19. Kosaka K, Yoshimura M, Ikeda K and Budka H Diffuse type of Lewy
disease: progressive dementia with abundant cortical Lewy
bodies and senile changes of varying degree – a new disease?
Clin Neuropathol 1984, 3:185-192
20. Lebert F, Souliez L and Pasquier F Tacrine and symptomatic
treatment in Lewy body dementia. In: Dementia with Lewy bodies.
Clinical, Pathological and Treatment Issues (Edited by: Perry R, McKeith I,
Perry E) Cambridge: Cambridge University Press 1996, 439-448
21. Walker Z, Costa DC, Ince P, McKeith IG and Katona CLE In-vivo
demonstration of dopaminergic degeneration in dementia
with Lewy bodies. The Lancet 1999, 354:646-647
22. Walker Z, Costa DC, Livingston G, Walker RW, Jansen A and Katona
CL Lewy body dementia: the study of post-synaptic dopamin-
ergic receptors with 123I-IBZM SPET. Eur J Nucl Med 1997,
24:609-614
23. Walker Z, Costa DC, Walker RW, Shaw K, Gacinovic S, Stevens T,
Livingston G, Ince P, McKeith IG and Katona CL Differentiation of
dementia with Lewy bodies from Alzheimer's disease using
a dopaminergic Presynaptic ligand. J Neurol Neurosurg Psychiatry
2002, 73:134-140
24. Suzuki M, Desmond TJ, Albin RL and Frey KA Striatal monoamin-
ergic terminals in Lewy body and Alzheimer's dementias.
Ann Neurol 2002, 51:767-771
25. Minoshima S, Foster NL, Sima AA, Frey KA, Albin RL and Kuhl DE
Alzheimer's disease versus dementia with Lewy bodies:
cerebral metabolic distinction with autopsy confirmation.
Ann Neurol 2001, 50:358-365
26. Brunberg J, Frey K, Horton J and Kuhl  Crossed cerebellar dias-
chisis: occurence and resolution demonstrated with PET
during carotid temporary ballon occlusion. AKNR 1992, 13:58-
61
27. Levine DN, Lee JM and Fischer CM The visual variant of Alzhe-
imer's disease: a clinicopathologic case study. Neurology 1993,
43:305-313
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Assessment of diffuse Lewy body disease by 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET)

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