Summary & Conclusion Introduction Methods Background RESULTS Methods An audit on the indications, outcome and impact of the Dopamine Transporter (DAT-SPECT or DaT ) scans on the diagnosis and management of patients in the Plymouth University NHS Trust Hospital from 2013-2015 Shakya Bhattacharjee, Registrar, Neurology, Plymouth Hospital NHS Trust, UK Dr Camille Carroll, Honourary Consultant , Plymouth Hospital NHS Trust , UK Introduction  TABLE 4: Impact of DaT scan results on diagnosis and management of patients with parkinsonism Methods ( continued) Place of study: Department of Nuclear Medicine & Neurology, Plymouth Hospital NHS Trust Year of study: 2013-2015 Study Design: Restrospective observational Study Standards: Guidelines of the ( European Association of Nuclear Medicine Neuroimaging (EANM) 2010 and Society of Nuclear Medicine (SNM) 2012 as yardsticks Source of information: patient charts, Hospital Nuclear Medicine database We collected the following details of the DAT scan: Indication for the DaT scan History/information provided for the DaT scan Source of referral method of analysis ( quantitative, semi-quantitative ) Outcome of the DaT scan & DVR values Impact of DaT scan on the diagnosis and management Statistical Methods: Microsoft XL 2010 and graphpad software 123I-ioflupane is a molecular imaging agent used to demonstrate the location and concentration of dopamine transporters (DAT) in the synapses.1,2,3 DAT is the presynaptic transmembrane protein of the dopaminergic synapse It transports dopamine from the synaptic cleft back into the presynaptic neuron. The European Medicine Agency approved DAT scan in 2000 and Federal Drug Administration (FDA) in 2011.1,2 Condition No of cases change in Post DAT scan diagnosis Change in diagnosis Change in treatment (drug stopped) (new drug started ) Idiopathic Parkinson’s Disease (IPD) 190 94   96 Levodopa -40, MAOI -30, Dopamine agonist - 5 Levodopa -45, MAOI -10, Dopamine agonist-25 IPD from Vascular parkinsonism 5 3 2 Levodopa stopped -1 Levodopa- 2, Rasagiline-1 Clinical diagnosis: Essential tremor (ET) : ET from PD 18 14 4 Propranolol - 2 4 ( Rasagiline 2, levodopa 2) Clinically Drug induced parkinsonism (DPD)- (DPD) from degenerative parkinsonism 8 (Valproate -4, Lithium -2, Chorpromazine -1, Risperidone -1), 6 Chlorpromazine -1 valproate - 1 New Levodopa -1 Clinically Dystonia - Dystonia from Young onset PD from Levodopa in 2 Functional tremor from IPD 1 Supportive for Parkinson Plus syndrome (Multisystem Atrophy (MSA), Progressive Supranuclear palsy (PSP) , Corticobasal diseases 4 ( MSA-2 CBD-2) Clinical Diagnosis: Lewy Body Dementia (LBD) Non Lewy body dementia from LDB 22 10 12 Levodopa 5 outside recommendations ( progression of IPD, distinguish IPD from LBD, PSP etc Methods Background Indications for DAT scan ( EANM 2010 and SNM/FDA 2012 Guidelines )1,2 Early diagnosis of Parkinsonism Essential tremor from tremor due to presynaptic parkinsonian syndromes ( IPD,PSP,MSA,DLB,CBD) Drug Induced Parkinsonism from Presynaptic Parkinsonism Lewy Body Dementia from Alzheimer’s disease /non Lewy Body Dementia Young onset Parkinsonism from Dopa Responsive Dystonia Psychogenic from True Parkinsonism Visual grading of DAT scan4 Normal: Comma with full stop Grade 1: asymmetrical loss of putaminal tail—‘comma with full stop’ Grade 2: bilateral loss of putaminal tail ‘two full stops’ Grade 3: Partial to complete loss of caudate and putaminal signal ‘disappearing full stops’ Unclassified : vascular parkinsonism DaT semi-quantitative analysis technique Distribution Volume Ratio ( DVR) was taken as Semiquantitative measure of local DaT availability Our Nuclear Medicine department used visual and semi-quantitative analysis Statistical Parametric Mapping ( SPM) software (version SPM8, Wellcome Trust Centre for Neuroimaging, Institute of Neurology, UCL, London, UK) was used DVR of the whole striatum was calculated by studying the ROI Caudate nucleus and Putamen Stereotactic normalisation on MNI plane RESULTS TABLE 1: Demographics and clinical status of parkinsonian patients Parameters Total number Total patients 265 male 140 Female 125 Mean Age+ standard deviation 71.65 (8.01 years)   Median Modified H & Y stage + standard deviation 1.5 ( 0.35) Mean duration of symptoms before DaT scan 4.35 ( 1.08 ) years Tremor predominant Idiopathic Parkinson’s Disease 45 Akinetic Rigid type Idiopathic Parkinson’s Disease 40 Summary & Conclusion DaT scan was requested by the Neurology: 72%, Geriatrics: 20%, GP - 5%, but no direct referral from Psychiatry Nearly 2.5% scan requests were outside established indications Inadequate history on the DaT request ( 60-80%) by the requesting doctors Good final conclusion of the DaT report with corroboration of the Image with scans and if any other artefacts though the report does not contain important parameters like dose of Isotope, grade of abnormality, time of imaging after isotope injection etc 7 DaT scan had equivocal results 6 scans created artefact by the patient’s poor neck position or neck rotation– however adjustments were made while reporting 2 patients each with NPH and antipsychotic intake had abnormal DaT ( unmasked PD?) Impact of DaT scan in clinical Practice of the Trust DaT scan changed the clinical diagnosis of almost 50% of PD, 55% of Lewy Body Dementia, 25% of Drug induced parkinsonism and 22% of Essential Tremor Methods TABLE 2: Outcome of the DaT scans in Plymouth Hospital NHS Trust DAT result Number Bilateral abnormal uptake unilateral abnormal uptake Not mentioned about symmetry though abnormal uptake Degree or grade of tracer uptake abnormality ( Benamer et al)( n=26)   Asymmetrical Symmetrical Right Left 1 2 3 unspecified Positive/ abnormal 123 40 28 11 10 34 31 78 12 Negative/ normal 126 Equivocal Claustrophobia 7 2 ( static DaT scan) References Table 3 : Tracer uptake in the Basal Ganglia David S.W. Djang et al. SNM Practice Guideline for Dopamine Transporter Imaging with 123I-Ioflupane SPECT 1.0. J Nucl Med;53:2012. 154-63 2 Jacques Darcourt,Jan Booij,Klaus Tatsch et al. EANM procedure guidelines for brain neurotransmission SPECT using 123I-labelled dopamine transporter ligands, version 2. Eur J Nucl Med Mol Imaging. 2010;37:443-50.   3. FDA prescribing information for DaTscan Website. http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/022454sOrig1s000Lbl.pdf (accessed 2 Feb 2011). 4. Bajaj N, Hauser RA, Grachev ID. Clinical utility of dopamine transporter single photon emission CT (DaT-SPECT) with (123I) ioflupane in diagnosis of parkinsonian syndromes. J Neurol Neurosurg Psychiatry 2013;84:1288-95. Distribution Volume Ratio (DVR) ( marker of tracer uptake) Tremor predominant PD Non-tremor predominant PD   P value (<0.05 was significant) Number of cases 45 40  xxx DVR value of the more diseased side (mean+ standard deviation ) 1.98 (0.2565) 1.8 (0.289) 0.0035 DVR value of the other side /less diseased side of the parenchyma (mean+ standard deviation ) 2.17 (0.283) 2 (0.285) 0.006203   Here