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Functional Brain Imaging applied to bladder control
The new ( “ brain “ ) urodynamics
Brain Imaging Techniques
Technique
• SPECT• PET• fMRI
Tracing
99mTc-EC 15O in water
None (BOLD:blood oxygen level dependent)
fMRI BOLD
f-MRI (1.5 - 3 Tesla )
Esempi di compito
1 - Subject lies in the scanner
2 -Task is performed
( bladder filled manually or through distant urodynamic equipment)
3 - Scanner captures and process brain images
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Source : Fowler , AUA 2009
Source : Fowler C , AUA, 2009
How the brain works ?
Micturition Cycle
• Filling phase lasting 3 - 4 hours
• Voiding phase lasting 20 seconds
Bladder distention
Physiological• A- delta myelinated fibers ( low firing )
Pathological• C- unmyelinated fibers ( high firing )
Peak activation of brainstem areas during bladder filling
Fowler C , Griffiths D , 2010
L-region
Block,1996
M-region ( PMC )
Block , 1996
POSITRON EMISSION TOMOGRAPHY (PET) SCANS DURING BLADDER FILLING
PonsPeri-aqueductal grey
INSULA : “Visceral Cortex “The fifth lobe
Integrates internal sensations:
-Heart beat
-Gastric distention
-Bowel distention
-Bladder distention
-Orgasm-Addiction (cigarettes , cocaine , alcohol )
Insula activity during bladder filling
Peak activation of ACG during bladder filling
Fowler C ,Griffiths D, 2010
Peak deactivation of frontal areas with full bladder & activation during voiding
Fowler C ,Griffiths D , 2010
Brain representation of pelvic floor muscles
Buschbeck J , ICS 2009
Brain representation of pelvic floor muscles
Buschbeck J, ICS 2009
Kuhtz-Buschbeck J et a, Neuroimage ,2009
MICTURITION
Animated Work-up Model
Bladder Filling
Kavia and Fowler 04Courtesy CJF
Micturition
Kavia and Fowler 04Courtesy CJF
PMC
S2-4 in cauda equina
pelvic & pudendal ns
Brain Imaging & Micturition Literature to date
Poor Bladder Control ( urgency & DO)
Rosenberg LJ , Griffiths DJ, Resnick DM , J.Urol, 2005
DO &Urgency as different entities (Tadic ,2009)
STRESS INCONTINENCENeuroplastic Changes after PFM Training
Di Gangi H , 2009
BRAIN and BLADDERFrom Barrington cats
to human Functional Brain Imaging
Giancarlo VignoliUnità di Urodinamica & Uroginecologia
Casa Madre Fortunata Toniolo
Bologna
The twentiesNeuroanatomy
• Barrington FJF. The effect of lesion of the hind and mid brain on micturition in the cat. Q J Exp Physiol 1925;
The seventies Neurophysiology
“The understanding, diagnosis and management of neurologic dysfunction of the bladder have undergone considerablle changes during the last 2 decades. These changes were the result of animal experimentation into physiology and pharmacology and the accelerated use of biomedical engineering technology “ Bradley , WE J.Urol , 1976
Communications between brain and bladder
1. Cerebral Micturition Centre
2. Pontine Micturition Centre3. Spinal Cord4. Sacral Reflex Centre5. Pelvic nerve6. Pudendal nerve7. Urethra8. Sphincter9. Pelvic floor10. Bladder
11. Hypogastric nerve
The ninetiesNeuroscience
To be defined :Bladder afferent “noise”
Drake MJ ,Van Duyl WA BJU Int.,2005Drake MJ ,Van Duyl WA BJU Int.,2005
Bladder “ noise “ Structures involved ( Fry C , ICI 2008)
Application of Functional Imaging to Pathophysiological Conditions
URINARY RETENTIONBrain Activity in Fowler Syndrome
DasGupta R ,2005
• Healthy volunteer • Fowler S - Stimulator off
• Stimulator on