2. Diamond 5. Prolonged benign exertional headache: its clinical characteristics and
response to indomethacin. Headache l982;22:96—98.
3. Paulson GW, Zipf RE, Beekman IF. Pheochromocytoma causing exereise-related
headache and pulmonary edema. Ann Neurol I974;5:96—99.
4. Massey EM. Effort headache in runners. Headache l982;22:99—l00.
5. Oleson J, Larsen B, Lauritzen M. Focal hyperemia followed by spreading oligemia and
impaired activation ofrCBF in classic migraine. Ann Neurol 198l;9:344—352.
6. Lauritzen M, Olsen T5, Lassen NA, et al. Changes in regional cerebral blood flow
during the course of classic migraine attacks. Ann Neurol l983;I3:633—64l.
7. Podreka I, Suess E, Goldenberg G, et al. Initial experience with technetium-99m-
HMPAO brain SPECT. J Nucl Med l987;28:l657—l666.
8. Battistella PA, Ruffilli R, Pozza FD, Ct at. Technetium-99m-HMPAO SPECT in
pediatric migraine. Headache l990;30:646—649.
9. Appenzeller 0. Altitude headache. Headache I972; 12:126—129.
10. Symonds C. Cough headache. Brain I956;79:557—568.
11. Paulson GW, Klawans HL. Benign orgasmic cephalgia. Headache 1974; 13:181—
187.
12. Lichtenstem B. So-called cough headache. Transactions Chicago Neurological Soci
ety. Arch Neurol 196l;4:ll2—ll3.
13. Seto H, Shimizu M, Futatsuya R, et at. Basilar artery migraine: reversible ischemia
demonstrated by 99mTCHMPAO brain SPECT. C/in NucI Med I994;l9:2l5—
218.
ever, recently encountered a case of radiation necrosis in which
the patient demonstrated high uptake of MET, FDG and Tl.
CASE REPORT
A 37-yr-old woman was admitted to our hospital with frequent
seizures ofthe left face and arm for 2 wk. Twenty-one years earlier,
the patient had undergone surgical resection ofthe ependymoma in
the anterior horn of the right lateral ventricle through a frontal
transcortical approach. Postoperative radiation therapy was per
formed with 30 Gy/15 Fraction (F) of whole-brain irradiation(14
x 16cm)withadditionallocalregionalirradiation(6X9 cm)of
30 Gy/15 F by using 60Co gamma rays, both irradiations were
weighed on the right side by 2:1, followed by whole-spine
irradiation with 30 Gy/l5 F to prevent spinal dissemination. The
patient was free of anyclinical symptomsfor 21 yr after the above
therapy and suddenly developed seizures of the left face and arm 2
wk before admission. Her seizures began with an abnormal
sensation in her left arm, followed by rapid grimace like contrac
tions of the lower half of the left face and jerking pronating
supinating movements of the forearm. Postictally, mild weakness
in these areas occurred for about 1 hr. Despite treatment with 400
mg of sodium valproate and 200 mg of zonisamide, she developed
frequent seizures several times a day during her hospitalization.
MM (Tl-weighted spin-echo images were obtained with Se
quences of 500/18/1 (TRITE/excitations). T2-weighted fast spin
echo images were obtained with 2500/1 10/1) demonstrated a Tl
and T2-prolonged lesion in the right frontal lobe just posterior to
the surgical defect of the previous corticotomy (Fig. lÀ). The
Tl-weighted MR image after the administration of Gd-DTPA (0.1
mmol/kg) demonstrated patchy enhancements on the lesion (Fig.
lB).
MET-PET images (acquired 15 postadministration of 370 MBq
MET) demonstrated widespread, high uptake in the right frontal
lobe (Fig. 2A). The most intense uptake was observed in the area
just posteriorto the surgicaldefect, which was 3.2 times that of the
contralateral frontal cortex. FDG-PET images (acquired 20 mm
after administration of 185 MBq FDG) also demonstrated high
uptake in the area (Fig 2B), which was 1.2 times that of the
contralateral frontal cortex. The cerebral blood flow increased in
the right frontal lobe and was 1.7 times that of the contralateral
frontal cortex (Fig. 2C). The Tl-SPECT images (obtained 15 mm
after administration of 148 MBq TI) also demonstrated an abnor
We report a case of high uptake of 11C-methionine(MET),18F-FDG
(FDG)and @°111-CI(11)in brain radiation necroais. Twenty-one years
previously,the patient had undergone surgery and radiationtherapy
consietingof6O-Gyforependymoma inthe anteriorhornofthe nght
lateral ventricle. The clinical features consisting of frequent seizures
of the left face and arm suddenly appeared 2 wk before admission.
MRIdepicted a T@and T2-prolongedlesion inthe rIghtfrontallobe.
Abnormallyhigh uptake in this area demonstrated by MET-PET,
FOG-PET, li-SPECT or HMPAO-SPECT suggested the presence of
a recurrent tumor. A craniotomy was then performed and an
intraoperative eiectrocorticogram showed continuous epileptic
spikes in the lesion. The epileptic foci were resected and the
histological features of the lesion were consistent with radis@on
necrosis. After surgery, the seizures disappeared and the postop
erathieexaminationswithMET-PET,FDG-PET,li-SPECT and HM
PAO-SPECT no longer showed abnormally high uptake. Hyperme
tabolism and hyperperfusion related to epileptiC fits are therefore
thought to result in high uptake of MET, FDG and TI in radiation
necrosis.
Key Words radiation necrosis; thallium-201-chloride;carbon-il
methionine; fluorine-l8-FDG; SPECT; PET
J NucIMed1996;37:1174-1176
Brainradiationnecrosisisoneofthelatecomplicationsof
radiotherapy for tumors of the central nervous system. The
recurrence of clinical symptoms suggesting a recurrence of the
tumor may also represent radiation necrosis of the brain.
Distinguishing between radiation necrosis and tumor recurrence
may be difficult with either CT (1 ) or MRI (2) because the
information provided by these modalities are based on struc
tural changes and is not specific to any histological lesion type.
PET has been used to evaluate the metabolic activity of tumors
by using I1C-L-methionine (MET) and [‘8F]fluorodeoxyglu
cose (FDG). Both MET-PET and FDG-PET have been reported
to be useful in detecting primary brain tumors (3,4) as well as
differentiating recurrent tumors from radiation necrosis after
radiotherapy (5,6). SPECT with 201T1 chloride (Tl) also has
been reported to be useful in differentiating recurrent tumors
from brain radiation necrosis after treatment (7,8). We, how
Received Jul. 31, 1995; revision accepted Nov. 13, 1995.
For correspondence or reprints contact Masayuki Sasald, MD, PhD, Department of
Radiology, Faculty of Med@ine, Kyushu University, 3-1-1 Maidashi, Higeahi-ku,
Fukuoka 812-82, Japan.
1174 THEJOURNALOFNUCLEARMEDICINE•Vol. 37 •No. 7 •July 1996
Hyperperfusion and Hypermetabolism in Brain
Radiation Necrosis with Epileptic Activity
Masayuki Sasaki, Yuichi Ichiya, Yasuo Kuwabara, Tsuyoshi Yoshida, Tooru Inoue, Takato Morioka, Kei Hisada,
Masashi Fukui and Kouji Masuda
Departments ofRadiology and Neurosurgery, Faculty ofMedicine, Kyushu University, Fukuoka, Japan
