臨床精神医学講座 S10巻 精神科臨床における画像診断

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SPECTやPET、MRIなどの画像診断の進歩は、分子生物学等の発展に伴い、脳の形態や代謝の変化を測定することで、精神症状・疾患のより客観的な診断に役立っています。 本書は、その原理をわかりやすく説明し、実際の診療に役立つポイントと今後の可能性など画像診断の最前線を紹介します。

目次

  • 表紙
  • 執筆者一覧
  • 目次
  • 総論
  • I. 画像診断の原理と測定法
  • A. PET
  • 1. 概要
  • 2. 特徴―SPECTやMRIとの比較
  • a. 形態よりも機能を反映する画像
  • b. 局所放射能を定量的に測定 (物理学的定量性)
  • c. 血流・代謝・受容体等を定量的に測定 (生理学的定量性)
  • d. 投与する放射性物質はごく微量
  • e. 時間分解能はよくないが, 繰り返し測定可能
  • f. 画像にゆがみがない
  • 3. PETカメラの原理
  • a. PETカメラの本質は同時計数
  • b. PETは正確な吸収補正が可能
  • c. 2D収集と3D収集がある
  • d. SPECTカメラによるPET撮影
  • 4. 計測における注意点
  • a. 頭部の固定は極めて重要
  • b. 入力関数はきちんと測定せよ
  • c. 生理学データの測定を忘れるな
  • d. 被検者の状態をコントロールせよ
  • 5. 主な放射性薬剤のPET測定法
  • a. 生理学的定量化
  • b. 15O標識の3種類のガスによる脳血流・酸素代謝・血液量の測定
  • c. 15O-水による脳血流の測定
  • d. 18F-FDGによる糖代謝の測定
  • 6. 画像解析
  • a. レジストレーションと解剖学的標準化
  • b. 三次元表示
  • c. 部分容積効果
  • B. SPECT
  • 1. SPECT装置
  • 2. 脳血流SPECT用放射性医薬品
  • a. 133Xe
  • b. 123I-IMP
  • c. 99mTc-HMPAO
  • d. 99mTc-ECD
  • 3. 脳血流SPECT正常像
  • 4. 脳血流の定量化
  • a. 133Xe吸入または静注法
  • b. 123I-IMP静注法
  • c. 99mTc-HMPAOおよび99mTc-ECD静注法
  • 5. SPECTによる神経伝達物質・受容体のイメージング
  • a. 中枢性ベンゾジアゼピン受容体
  • b. ドパミンD2受容体
  • c. ドパミントランスポーター
  • C. MRI
  • 1. NMR
  • a. NMRの対象となる原子核
  • b. MRIの対象となる原子核
  • c. 原子核磁気モーメント
  • d. 巨視的磁化
  • e. 共鳴とRF
  • f. 緩和
  • g. NMR信号
  • 2. MRI
  • a. MRI検査を受けるときに注意すべきこと
  • b. 信号強度
  • 3. スピンエコー (SE) とグラディエントエコー (GRE)
  • a. SE
  • b. GRE
  • c. MRA
  • 4. 高速撮像法fast MR imaging
  • a. 高速グラディエントエコー法 (FGRE)
  • b. 高速スピンエコー法 (FSE)
  • c. 部分Fourier法
  • d. EPI
  • D. fMRI
  • 1. 超高磁場と高磁場のfMRIの発展
  • 2. fMRI原理と測定法の歴史
  • 3. MR信号と脳血流の関係の進歩
  • 4. fMRIとfNIRのブリッジ
  • 5. 理論的BOLDモデルによる局所脳血液量の解釈
  • 6. ダブルコントラスト説―酸化型ヘモグロビンと還元型ヘモグロビンの関与
  • 7. ベースライン磁化率への反磁性体酸化型ヘモグロビンのボリューム効果
  • 8. ベースライン・コンポーネント―コントロール項目
  • 9. 超高磁場と高磁場でのfMRI応用の比較
  • 10. 神経活動とのリンクと今後の可能性
  • E. diffusion MRI
  • 1. 拡散diffusionと核磁気共鳴
  • 2. 拡散テンソル
  • a. 一次元の拡散係数計測
  • b. 不変量の計測 (trace計測)
  • c. 三次元不等方性コントラスト
  • d. 固有値, 固有ベクトルの算出
  • 3. 生体における拡散現象の理解
  • F. event-related fMRI
  • 1. block design fMRIとevent-related fMRI
  • 2. event-related fMRIと脳の血流動態の変化
  • 3. event-related fMRIの解析
  • 4. event-related fMRIの特徴と異なる刺激による信号変化について
  • a. block design fMRIとevent-related fMRIについて
  • b. event-related fMRIによる中枢の刺激応答性に関する検討
  • G. MRS
  • 1. 原理
  • 2. MRSの臨床測定
  • 3. 測定例
  • a. 1H-MRSの応用
  • b. 31P-MRSの応用
  • c. 2D-MRSの応用
  • d. 19F-MRSの応用
  • e. 13C-MRSの応用
  • f. その他の核種のMRSの応用
  • H. MEG
  • 1. 原理
  • a. 脳磁場
  • b. 脳磁計
  • 2. 測定法
  • a. 被験者の留意点
  • b. 頭部形状入力
  • c. 測定
  • d. 電源解析
  • I. 光トポグラフィ (NIRS)
  • 1. 光による非侵襲イメージングの歴史
  • 2. 脳神経システムと脳機能計測方法論
  • 3. 光トポグラフィの原理と装置
  • a. 脳の表層構造と光散乱吸収
  • b. 光強度変調による計測位置エンコード法
  • c. 被験者とのインターフェイス
  • d. 光CTとの相違
  • 4. 光トポグラフィの応用
  • a. 言語領野の観測
  • b. 認知機能発達の観測
  • c. その他の応用分野
  • 5. 将来展望
  • J. 脳波トポグラフマッピング
  • 1. 脳波マッピングの目的と利点
  • 2. 脳波マッピングの発展
  • 3. マッピングを行うための脳波の処理過程
  • a. 脳波生データの記録
  • b. 一次処理
  • c. 二次処理
  • 4. 脳波マッピングの応用
  • a. 精神科領域への応用
  • b. 神経内科
  • c. 小児科
  • d. 認知神経科学および他の領域への応用
  • 5. 脳波マッピングの今後の展開
  • II. 画像解析法
  • A. SPM (statistical parametric mapping)
  • はじめに
  • a. 脳賦活試験と精神医学
  • b. 機能局在と機能統合
  • 1. 脳機能画像解析の基本理論
  • a. 機能分離に着目した解析法
  • b. 機能統合に着目した解析法
  • 2. ソフトウェアについて
  • a. 概要
  • b. 処理
  • B. HBA (human brain atlas), AIR (automated image registration)
  • 1. HBA
  • a. 基準脳
  • b. 肉眼解剖学的データベース
  • c. 解剖学的標準化
  • d. 解剖学的標準化の正確度
  • e. 細胞構築学的データベース
  • f. elastic transformation system
  • g. CBA (computerized brain atlas)
  • 2. AIR
  • a. AIR 1.0
  • b. AIR 3.0
  • c. AIRの臨床応用
  • C. ニューラルネットワークを用いたSPECT画像自動診断の可能性
  • 1. 標準脳という考え方
  • 2. ニューラルネットワークを用いた画像解析
  • a. 特徴マップ学習用画像の構成
  • b. 実際の疾患例での試み
  • c. ニューラルネットワークによる症例別分類
  • D. 3D-SSP
  • 1. 背景
  • 2. 3D-SSPの概要と実際の使用
  • a. 画像撮像・再構成
  • b. 3D-SSP
  • c. 実際の使用にあたって
  • 3. 症例呈示
  • 4. 考察
  • 各論―精神疾患への画像診断の応用
  • I. 痴呆性疾患
  • A. Alzheimer型痴呆
  • A-1. MRI
  • 1. 大脳半球
  • 2. 側頭葉内側部
  • 3. 無名質
  • A-2. PET (FDG)
  • 1. FDGの集積機序
  • 2. Alzheimer病における脳糖代謝
  • 3. 他の痴呆性疾患における脳糖代謝
  • 4. FDG-PETによる痴呆性疾患診断の可能性
  • A-3. PET (酵素)
  • 1. トレーサ開発
  • a. AChE活性測定の理論的背景
  • b. 片側nucleus basalis magnocellularis破壊ラットを用いた研究
  • 2. ヒトへの応用
  • a. 定量測定
  • b. 健常者における脳内AChE活性分布
  • c. 加齢による変化
  • d. Alzheimer病
  • e. 他の疾患におけるAChE活性測定
  • A-4. SPECT
  • 1. Alzheimer型痴呆におけるSPECT所見
  • a. 側頭・頭頂葉における脳血流低下
  • b. 側頭葉内側部における脳血流低下
  • c. SPECT所見の経時的変化
  • d. トレーサによる違い
  • e. SPECT診断の精度
  • 2. Alzheimer型痴呆に伴う白質病変との関係
  • 3. 鑑別診断
  • a. 側頭型Pick病
  • b. 多発梗塞性痴呆
  • B. 血管性痴呆
  • 1. 概念と定義の変遷
  • 2. 画像診断で何をとらえるか
  • 3. 病型・分類
  • 4. 動脈閉塞による脳梗塞に基づく血管性痴呆
  • 5. 多発性ラクナ梗塞に基づく血管性痴呆
  • 6. 白質病変に基づく血管性痴呆
  • 7. 脳出血による血管性痴呆
  • C. 非Alzheimer型痴呆
  • C-1. Lewy小体病とPick病
  • 1. Lewy小体を伴う痴呆
  • a. 疾患概念と診断基準
  • b. 形態画像所見
  • c. 機能画像所見
  • 2. Pick病
  • a. 疾患概念と診断基準
  • b. Pick病の画像所見
  • c. 前頭側頭痴呆の画像所見
  • C-2. Parkinson病, Huntington舞踏病, 進行性核上性麻痺
  • 1. Parkinson病
  • a. 病態生理
  • b. 錐体外路系
  • c. MRI
  • d. 脳血流・脳代謝画像
  • e. 神経伝達物質の画像診断
  • f. 大脳皮質による運動制御機構 (脳賦活検査)
  • 2. Huntington舞踏病
  • a. 病態生理
  • b. MRI
  • c. 脳血流・脳代謝画像
  • d. 神経伝達物質の画像診断
  • 3. 進行性核上性麻痺
  • a. 病態生理
  • b. MRI
  • c. 脳血流・脳代謝画像
  • d. 神経伝達物質の画像診断
  • D. その他の原因による痴呆
  • D-1. Creutzfeldt-Jakob病
  • 1. 概念・定義
  • 2. 歴史
  • 3. 分類
  • 4. 疫学
  • 5. 成因
  • 6. 病態・病理
  • 7. 症状・臨床経過
  • 8. 診断・鑑別診断
  • a. 検査所見
  • 9. 治療
  • D-2. 単純ヘルペス脳炎
  • 1. 概念・定義
  • 2. 歴史
  • 3. 分類
  • 4. 疫学
  • 5. 成因
  • 6. 病態・病理
  • 7. 症状
  • 8. 診断・鑑別診断
  • a. 検査所見
  • 9. 治療
  • 10. 臨床経過
  • 11. 予後
  • D-3. 一酸化炭素中毒と肝性脳症
  • 1. 一酸化炭素中毒
  • a. 一酸化炭素中毒症
  • b. 臨床症状
  • c. 病理所見
  • d. 画像所見
  • 2. 肝性脳症
  • a. 肝性脳症
  • b. 病理所見
  • c. 画像所見
  • D-4. 正常圧水頭症と硬膜下血腫
  • 1. 正常圧水頭症
  • a. 概念・症状
  • b. 画像診断
  • c. 手術適応
  • 2. 慢性硬膜下血腫
  • a. 概念・定義
  • b. 画像診断
  • c. 手術適応
  • II. てんかん
  • A. MRI
  • 1. 海馬硬化症 (内側側頭硬化症)
  • a. 病理・臨床
  • b. MRI所見
  • 2. 脳腫瘍
  • a. 神経節膠腫
  • b. 星細胞腫
  • c. dysembryoplastic neuroepithelial tumor
  • d. pleomorphic xanthoastrocytoma
  • 3. 大脳皮質形成障害
  • a. 限局性皮質異形成
  • b. 片側巨脳症
  • c. 結節性硬化症の皮質結節
  • d. 異所性灰白質
  • e. 小多脳回
  • 4. 血管奇形
  • a. 海綿状血管腫
  • b. 脳動静脈奇形
  • 5. その他
  • a. 瘢痕回
  • B. PET
  • 1. てんかんの脳血流代謝
  • 2. ベンゾジアゼピン受容体
  • 3. 局在診断におけるPET
  • a. 側頭葉てんかん
  • b. 前頭葉てんかん
  • c. 小児てんかん
  • 4. 脳機能マッピング
  • 5. 神経受容体機能の研究
  • C. SPECT
  • 1. てんかんの疾患概念とSPECT検査の意義
  • 2. 局所脳血流SPECT
  • a. SPECTによるてんかん患者の脳血流の測定法と評価法
  • b. てんかん患者の脳血流に影響を及ぼす諸要因
  • c. 発作間欠期の脳血流所見
  • d. 発作時の脳血流所見
  • e. 脳血流SPECTを用いたその他の評価事項
  • 3. 中枢性ベンゾジアゼピン受容体SPECT
  • 4. 今後の展望
  • D. MEG
  • 1. 歴史
  • 2. MEGで記録されるてんかん波の電流源
  • 3. MEGにおける電流源推定の方法
  • a. 等磁場線図法
  • b. moving dipole法
  • c. spatio-temporal source modeling
  • d. tomographic reconstruction method
  • 4. MEGと脳波で記録される棘波の違い
  • 5. MEGの各疾患への応用
  • a. 側頭葉てんかん
  • b. 大脳皮質てんかん
  • c. Landau-Kleffner症候群
  • E. 近赤外線脳機能マッピングを用いたてんかんの焦点診断
  • 1. 方法
  • 2. 計測例
  • 3. 計測成績
  • a. 誘発発作時のNIRS
  • b. 自然発作時のNIRS
  • 4. 考察
  • a. NIRS計測と脳血流
  • b. てんかん発作と脳血流
  • c. 焦点診断におけるNIRSの役割
  • III. 精神分裂病
  • A. MRI
  • 1. 検討方法
  • 2. 脳全体の変化
  • 3. 脳室の変化
  • a. 側脳室
  • b. 側脳室下角
  • 4. 局所の変化
  • a. 前頭葉
  • b. 上側頭回
  • c. 内側側頭葉構造
  • B. PET
  • 1. 分裂病症状と脳血流代謝
  • a. 陰性症状とhypofrontality
  • b. 分裂病症候と神経回路の異常
  • c. 幻聴時の脳血流代謝
  • 2. 分裂病の神経伝達機能異常
  • a. ドパミンD2受容体
  • b. ドパミンD1受容体
  • c. シナプス前ドパミン機能
  • d. セロトニン2 (5-HT2) 受容体
  • 3. 抗精神病薬による受容体占有の測定
  • C. SPECT
  • 1. 分裂病患者の局所脳血流
  • a. 安静時局所脳血流
  • b. 臨床症状との関連
  • c. 神経心理学的障害との関連
  • d. 眼球運動の異常との関連
  • e. 抗精神病薬治療との関連
  • f. 認知リハビリテーションの効果
  • 2. 分裂病患者におけるドパミン伝達機能
  • a. ドパミン受容体密度
  • b. 前シナプスからのドパミン放出
  • c. ドパミントランスポーター
  • 3. 分裂病患者におけるセロトニン伝達機能
  • 4. 分裂病患者におけるγ-アミノ酪酸 (GABA) 伝達機能
  • 5. 抗精神病薬の受容体占有特性
  • D. MRS
  • 1. 31P-MRS
  • a. 細胞膜リン脂質
  • b. 分裂病における細胞膜リン脂質異常の意味
  • c. エネルギー代謝
  • 2. 1H-MRS
  • a. N-アセチルアスパラギン酸
  • b. choline-containing compounds
  • c. アミノ酸
  • d. イノシトール
  • 3. MRSと抗精神病薬
  • 4. 19F-MRSと13C-MRS
  • 5. MRSの将来
  • a. 今後の課題
  • b. 今後の技術の向上がもたらすもの
  • c. 今後の臨床的研究の方向性
  • d. 遺伝・環境的要因とMRS
  • E. MEG―脳磁図による精神分裂病の機能画像診断の現状と可能性
  • 1. これまでの分裂病を対象としたMEG研究
  • 2. 分裂病の脳磁図研究の可能性
  • IV. 感情障害
  • A. MRI
  • 1. 脳全体の異常所見
  • a. 脳萎縮
  • b. 白質病変
  • 2. 脳局所の異常所見
  • a. 皮質領域
  • b. 皮質下領域
  • c. その他
  • B. PET
  • 1. 機能画像
  • 2. 脳血流, 代謝研究
  • a. 前頭葉
  • b. 側頭葉-辺縁系
  • c. 基底核
  • d. 視床
  • e. 帯状回
  • 3. 神経伝達機能研究
  • a. セロトニン
  • b. ドパミン
  • C. SPECT
  • 1. 脳血流研究
  • a. 横断的研究
  • b. 縦断的研究
  • 2. 受容体とトランスポーター
  • a. 受容体研究
  • b. トランスポーター
  • D. MRSおよびNIRS
  • 1. MRS (磁気共鳴スペクトロスコピー)
  • a. 臨床現場におけるMRSの現状
  • b. 7Li-MRS
  • c. 19F-MRS
  • d. 31P-MRSおよび1H-MRS
  • e. 断眠 / ECT (電気けいれん療法) による脳代謝変化の研究
  • f. その他
  • 2. NIRS
  • a. NIRSによる臨床研究の現状
  • b. 感情障害におけるNIRS研究
  • V. その他の精神障害
  • A. アルコール関連脳障害
  • 1. 萎縮性変化
  • a. 前頭萎縮
  • b. 側頭萎縮
  • c. 脳溝拡大
  • d. 側脳室拡大
  • e. 第三脳室拡大
  • f. 小脳萎縮
  • g. 乳頭体萎縮
  • h. 海馬萎縮
  • 2. 循環性障害
  • a. 基底核領域の障害
  • b. 白質の障害
  • c. 脳出血, 脳梗塞
  • 3. ビタミン欠乏性障害
  • a. Wernicke脳症
  • b. ペラグラ脳症
  • 4. 外傷性障害
  • 5. 浸透圧・循環要因
  • a. 橋中心性ミエリン溶解症
  • b. 橋外性ミエリン溶解症
  • 6. その他
  • a. 低血糖性昏睡
  • b. 一酸化炭素中毒
  • c. 重度肝障害・肝脳疾患型
  • d. 胎児性アルコール症候群
  • e. Marchiafava-Bignami症
  • f. メタノール中毒
  • 7. SPECT, PET, MRSなど
  • B. 不安障害
  • 1. パニック障害
  • a. 形態的画像
  • b. 機能的画像
  • c. 画像研究からの病態仮説
  • 2. 強迫性障害
  • a. 形態的画像
  • b. 機能的画像
  • c. 画像研究からの病態仮説
  • 3. 心的外傷後ストレス障害
  • a. 形態的画像
  • b. 機能的画像
  • c. 画像研究からの病態仮説
  • C. 摂食障害
  • 1. 画像解析研究の背景
  • 2. 形態的画像解析研究
  • 3. 機能的画像解析研究
  • D. 自閉症
  • 1. 画像研究の歴史
  • a. 形態画像
  • b. 機能画像
  • 2. 自閉症画像研究の今後の課題
  • 付. 脳ドックの現状と展望
  • 1. 脳ドックの目的―脳ドック学会ガイドラインより
  • 2. 脳ドックの現状
  • 3. 無症候性脳梗塞
  • a. 無症候性脳梗塞の画像診断基準
  • b. 血管周囲腔拡大との鑑別
  • c. 白質癒合性病変とunidentified bright objects (UBO)
  • d. 無症候性脳梗塞の頻度
  • e. 危険因子
  • f. 追跡調査による脳卒中発症頻度
  • g. 無症候性脳梗塞と精神症状
  • h. 無症候性脳梗塞, 白質障害と認知機能
  • i. 治療に対する考え方
  • 4. 無症候性脳血管病変の頻度
  • a. 無症候性狭窄性血管病変
  • b. 未破裂脳動脈瘤の頻度・危険因子, 治療
  • 5. 脳ドックの将来展望
  • 索引
  • 和文索引
  • 欧文索引
  • 奥付

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総論

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各論―精神疾患への画像診断の応用

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付. 脳ドックの現状と展望

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