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Crossed Cerebellar Hypermetabolism Demonstrated by FDG PET Ruixue Cui, MD, PhD, Na Niu, MD, and Fang Li, MD Abstract: Crossed cerebellar hypometabolism on 18F-FDG PET has been well described. However, crossed cerebellar hypermetabolism is rare. We described a case of crossed cerebellar hypermetabolism in a middle-aged woman. The patient underwent FDG PET to assess epileptogenic focus during her subclinical seizure episode, which was shown on video electroencephalography. The crossed cerebellar hypermetabolism was no longer visualized when her subclinical seizure was controlled. Key Words: seizure, crossed cerebellar hypermetabolism, FDG, PET (Clin Nucl Med 2014;39: 409Y412)

Received for publication October 29, 2013; revision accepted January 10, 2014. From the Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China. Conflicts of interest and sources of funding: This study is partially supported by a research grant (#81101075) from the National Science Foundation of China (to Dr Ruixue Cui). Reprints: Fang Li, MD, Department of Nuclear Medicine, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Wangfujing St, Dongcheng District, Beijing, 100730, People’s Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3904Y0409

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REFERENCES 1. Yoon EJ, Kim YK, Shin HI, et al. Cortical and white matter alterations in patients with neuropathic pain after spinal cord injury. Brain Res. 2013;1540: 64Y73. 2. Kamaleshwaran KK, Iyer RS, Antony J, et al. 18F-FDG PET/CT findings in voltage-gated potassium channel limbic encephalitis. Clin Nucl Med. 2013; 38:392Y394. 3. Hubele F, Bilger K, Kremer S, et al. Sequential FDG PET and MRI findings in a case of human herpes virus 6 limbic encephalitis. Clin Nucl Med. 2012; 37:716Y717. 4. Dadparvar S, Anderson GS, Bhargava P, et al. Paraneoplastic encephalitis associated with cystic teratoma is detected by fluorodeoxyglucose positron emission tomography with negative magnetic resonance image findings. Clin Nucl Med. 2003;28:893Y896. 5. Liu CH, Lin KJ, Wang HM, et al. Brain fluorodeoxyglucose positron emission tomography (18FDG PET) in patients with acute thallium intoxication. Clin Toxicol (Phila). 2013;51:167Y173. 6. Minoshima S. Imaging Alzheimer’s disease: clinical applications. Neuroimaging Clin N Am. 2003;13:769Y780. 7. Korsholm K, Law I. Effects of a ketogenic diet on brain metabolism in epilepsy. Clin Nucl Med. 2013;38:38Y39. 8. Talanow R, Ruggieri P, Alexopoulos A, et al. PET manifestation in different types of pathology in epilepsy. Clin Nucl Med. 2009;34:670Y674. 9. Alavi A, Mirot A, Newberg A, et al. Fluorine-18-FDG evaluation of crossed cerebellar diaschisis in head injury. J Nucl Med. 1997;38:1717Y1720. 10. Tatsch K, Koch W, Linke R, et al. Cortical hypometabolism and crossed cerebellar diaschisis suggest subcortically induced disconnection in CADASIL: an 18F-FDG PET study. J Nucl Med. 2003;44:862Y869. 11. Kim J, Lee SK, Lee JD, et al. Decreased fractional anisotropy of middle cerebellar peduncle in crossed cerebellar diaschisis: diffusion-tensor imagingpositron-emission tomography correlation study. AJNR Am J Neuroradiol. 2005;26:2224Y2228. 12. Kajimoto K, Oku N, Kimura Y, et al. Crossed cerebellar diaschisis: a positron emission tomography study with L-[methyl-11C]methionine and 2-deoxy-2[18F]fluoro-D-glucose. Ann Nucl Med. 2007;21:109Y113. 13. 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;37:878Y879.

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FIGURE 1. A 36-year-old woman had experienced intermittent seizure for 30 years. To consider potential surgical resection of the epileptogenic focus, she stopped taking antiseizure medicine and underwent video electroencephalography (VEEG) monitoring. Although she did not seem to have seizure clinically, the VEEG showed frequent seizure discharge from the right parietal lobe, indicating subclinical seizure episode.

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Crossed Cerebellar Hypermetabolism in FDG PET

FIGURE 2. FDG is known to be useful in the evaluation of different metabolic changes in the brain,1Y6 including seizure.7,8 FDG was intravenously administered during the patient’s subclinical seizure episode, and PET images of the brain were acquired 60 minutes later. The images clearly demonstrated a region of hypermetabolism in the right parietal lobe (thick arrow), which was consistent with the VEEG findings. Interestingly, there was a separate focus of hypermetabolism in the left cerebellum (thin arrow). The MRI images, which were acquired before the FDG PET scan, were revealed, but the images demonstrated no corresponding abnormality in the right parietal lobe or the left cerebellum.

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FIGURE 3. The patient received diazepam to inhibit her seizure and continued her VEEG monitoring. The next day, after the initial FDG PET scan, the VEEG showed that the seizure discharge from the right parietal lobe had been suppressed. FDG was subsequently administered, and a repeat PET scan of the brain was acquired. Interestingly, neither the right parietal lobe nor the left cerebellum still had hypermetabolic focus. The functional relationship between the cerebral region and contralateral cerebellum via the corticopontocerebellar pathway is commonly exemplified by crossed cerebellar diaschisis, which is defined as hypometabolism in the cerebellum contralateral to a supratentorial region of the brain. FDG PET findings of crossed cerebellar hypometabolism have been widely published.9Y13 Our case suggests that corticopontocerebellar pathway can also be presented as crossed cerebellar hypermetabolism.

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Crossed cerebellar hypermetabolism demonstrated by FDG PET.

Crossed cerebellar hypometabolism on 18F-FDG PET has been well described. However, crossed cerebellar hypermetabolism is rare. We described a case of ...
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