Lung ventilation/perfusion SPECT for diagnosing pulmonary embolism. Is the required minimal P/V count rate ratio fulfilled in routine situation? Results from a multicentre survey.

UNLABELLED: V/P-SPECT is a sensitive and specific procedure for the detection or exclusion of pulmonary embolism. It is important to conform to the guidelines in order to obtain reliable results. The sequence usually starts with the ventilation, followed by the perfusion scan. According to the current guidelines the count rate of the second study should be at least 3 times that of the first study. It is not always easy to meet this requirement, particularly since the deposed quantity of ventilation activity is not well known. The aim was therefore to analyse data from a multicentre survey to determine whether this essential precondition was strictly met. METHODS: In a multicentre survey 48 tertiary hospitals were asked to submit projections of all V/P-SPECT studies performed in January 2014. In total, 286 complete data sets from 16 institutions could be evaluated. First, the count rates of the first projections from the V-studies were subtracted from those of the P-studies. The resulting count rates in the first SPECT projections were then divided to calculate the activity ratios between the pure perfusion and ventilation scans (P/V-ratio at least 3 according to the guidelines). RESULTS: The range of the P/V ratio was 0.57-78.71, the mean P/V ratio was 6.94 ± 9.56. For 71 of the 286 external V/P studies (about 25%) the P/V ratio was < 3, in 23 studies (about 8%) the ratio failed to even reach the factor 2. CONCLUSIONS: An activity ratio of 3 between the perfusion and ventilation scan was not reached in about 25% of the 286 V/P studies (in around 8% the P/V ratio was <2), so that V/P studies were performed inadequately in a considerable number of procedures. Controlling the count rate increase during the perfusion tracer application (e. g. by handheld monitor) is therefore essential to avoid insufficient data.

Preoperative assessment of relative pulmonary lobar perfusion fraction in lung cancer patients. A rather simple three-dimensional CT-based vs. planar image-derived quantification.

UNLABELLED: Preoperative quantification of (relative) pulmonary lobar perfusion fraction using scintigraphy is established in predicting lung function after pulmonary surgery. Aim was to develop an easy and truly anatomical method for relative pulmonary lobar perfusion fraction quantification using SPECT/CT and to compare results with those from planar analyses in lung cancer patients. PATIENTS, METHODS: 36 patients with operable lung cancer, borderline lung function referred to pre-operative quantification. Perfusion SPECT-data were acquired p.i. of 163±9 MBq 99mTc-MAA, subsequent low-dose-CT (SymbiaT, Siemens). Iterative Flash3D-reconstruction, manual 3D segmentation of all lobes using PMOD. VOI transfer to coregistered perfusion SPECT-data, calculation of lobar fractions. Model-based calculation of relative lobar fractions based on planar data, analysis of planar vs. 3D results using t-test. RESULTS: Significant differences (p<0.05) between the results from 3D method and planar imaging were found for right upper and middle lobe and both lower lobes. Maximum differences ranged from 10.9% (left upper lobe) to 22.9% (right upper lobe). CONCLUSIONS: Relative pulmonary lobar perfusion fraction can easily be obtained by an anatomically driven 3D quantification. Results yielded by this method and the traditional planar approach differed greatly, possibly affecting eligibility for lung surgery in individual patients. Considering these results a 3D approach should be used whenever possible.

[Stunning in radioiodine therapy of benign thyroid disease. Quantification and therapeutic relevance]. / Stunning in der Radioiodtherapie benigner Schilddrüsenerkrankungen: Effektquantifizierung und therapeutische Relevanz.

UNLABELLED: In radioiodine therapy of benign thyroid disease, a reduction of radioiodine uptake is known for consecutive administrations of 131I, which needs to be considered in therapy planning. AIM: Analysis of uptake reduction with regard on the time interval between radioiodine administration and the delivered dose to the thyroid tissue. PATIENTS, METHODS: 200 patients were enrolled in the study and distributed into two groups (matched for diagnoses), each containing 32 patients with Graves' disease (target dose 250 Gy), 24 with focal (400 Gy), 44 with disseminated thyroid autonomy (150 Gy). In one group, a second fraction of radioiodine was given after 48 h (2d) due to an unexpected low radioiodine uptake or effective half-life, whereas in the other group the second fraction was given after 96 h (4d). RESULTS: There was no significant difference between delivered doses due to the first fraction after four days: 2d: 86+/-48 Gy (extrapolated) vs. 4d: 87+/-41 Gy, p>0.05. In 2d, delivered dose at time of second administration was significantly lower (51+/-29 Gy) than in 4d (p<0.01). The radioiodine uptake of the second fraction relative to the initial uptake was significantly lower in the 4d (4d: 63+/-25% vs. 2d: 82+/-24%, p<0.01). In addition, a correlation between uptake reduction and delivered dose and an influence of the time interval between radioiodine administrations could be shown. CONCLUSIONS: Relative uptake of subsequent radioiodine fractions decreases with time after first administration and with increasing delivered dose to the thyroid. If a second fraction of 131I is given at an earlier time, the same therapeutic effect can be reached using lower amounts of activity, minimising radiation exposure and increasing efficiency of radioiodine therapy.

Positron emission tomography study of regional cerebral blood flow and flow-metabolism coupling during general anaesthesia with xenon in humans.

BACKGROUND: The effects of xenon on regional cerebral blood flow (rCBF) are controversial. Moreover, the precise sites of action at which xenon exerts its effects in the human brain remain to be established. METHODS: rCBF was sequentially assessed by H(2)(15)O positron emission tomography in six volunteers. rCBF was determined at baseline and during general anaesthesia induced with propofol and maintained with one minimum alveolar concentration xenon. rCBF measurements were started after the calculated plasma concentration of propofol had decreased to subanaesthetic levels (<1.0 microg ml(-1)). Changes in rCBF were calculated for 13 cerebral volumes of interest by measurement of a semi-quantitative perfusion index (PI). In addition, voxel-wise changes in rCBF were analysed using statistical parametric mapping. RESULTS: Xenon had only minor effects on PI in grey matter volumes of interest. In contrast, PI was increased in white matter [from 1.01 (0.11) to 1.24 (0.15) kcnt ml(-1) MBq(-1), P=0.05, mean (SD)]. Voxel-based analysis showed an increase of rCBF in white matter and a relative decrease of rCBF during xenon anaesthesia in distinct grey matter regions, particularly the orbito- and mesiofrontal cortex, cingulate gyrus, thalamus, hippocampus and bilateral cerebellum (P<0.05 corrected). When correlating PI with cerebral metabolic rate of glucose (previously obtained in another group of six volunteers using (18)F-fluorodeoxyglucose as tracer), the flow-metabolism coupling was preserved during xenon anaesthesia. CONCLUSIONS: Xenon exerted distinct regional effects on CBF: relative decreases in several cortical, subcortical, and cerebellar areas were accompanied by an increase in white matter. Flow-metabolism coupling was not impaired during xenon anaesthesia.

EANM/ESC guidelines for radionuclide imaging of cardiac function.

Radionuclide imaging of cardiac function represents a number of well-validated techniques for accurate determination of right (RV) and left ventricular (LV) ejection fraction (EF) and LV volumes. These first European guidelines give recommendations for how and when to use first-pass and equilibrium radionuclide ventriculography, gated myocardial perfusion scintigraphy, gated PET, and studies with non-imaging devices for the evaluation of cardiac function. The items covered are presented in 11 sections: clinical indications, radiopharmaceuticals and dosimetry, study acquisition, RV EF, LV EF, LV volumes, LV regional function, LV diastolic function, reports and image display and reference values from the literature of RVEF, LVEF and LV volumes. If specific recommendations given cannot be based on evidence from original, scientific studies, referral is given to "prevailing or general consensus". The guidelines are designed to assist in the practice of referral to, performance, interpretation and reporting of nuclear cardiology studies for the evaluation of cardiac performance.

[3D volume and SUV analysis of oncological PET studies: a voxel-based image processing tool with NSCLC as example]. / Dreidimensionale Uptake- und Volumenanalyse von onkologischen PET-Studien: Voxel-basiertes Bildverarbeitungstool am Beispiel von NSCLC.

AIM: The standardized uptake value (SUV) of 18FDG-PET is an important parameter for therapy monitoring and prognosis of malignant lesions. SUV determination requires delineating the respective volume of interest against surrounding tissue. The present study proposes an automatic image segmentation algorithm for lesion volume and FDG uptake quantitation. METHODS: A region growing-based algorithm was developed, which goes through the following steps: 1. Definition of a starting point by the user. 2. Automatic determination of maximum uptake within the lesion. 3. Calculating a threshold value as percentage of maximum. 4. Automatic 3D lesion segmentation. 5. Quantitation of lesion volume and SUV. The procedure was developed using CTI CAPP and ECAT 7.2 software. Validation was done by phatom studies (Jaszczak phantom, various "lesion" sizes and contrasts) and on studies of NSCLC patients, who underwent clinical CT and FDG-PET scanning. RESULTS: Phantom studies demonstrated a mean error of 3.5% for volume quantification using a threshold of 41% for contrast ratios >or=5 : 1 and sphere volumes >5 ml. Comparison between CT- and PET-based volumetry showed a high correlation of both methods (r = 0.98) for lesions with homogeneous FDG uptake. Radioactivity concentrations were underestimated by on average -41%. Employing an empirical threshold of 50% for SUV determination, the underestimation decreased to on average -34%. CONCLUSIONS: The algorithm facilitates an easy and reproducible SUV quantification and volume assessment of PET lesions in clinical practice. It was validated using NSCLC patient data and should also be applicable to other tumour entities.

Quantification of left ventricular volumes and ejection fraction from 16- and rebinned 8-frame gated 99mTc-tetrofosmin SPECT. Comparison of 4D-MSPECT and QGS.

AIM: Using 8-frames/cardiac cycle with gated SPECT underestimates end-diastolic volumes (EDV) and ejection fractions (LVEF), and overestimates end-systolic volumes (ESV). However, using 16-frames/cardiac cycle significantly decreases the signal-to-noise-ratio. We analyzed 16-frames and rebinned 8-frame gated SPECT data using common 4D-MSPECT and QGS algorithms. PATIENTS, METHODS: 120 patients were examined using gated SPECT on a Siemens Multispect 3 (triple-head gamma camera) 60 minutes after intravenous administration at rest of about 450 MBq (two-day protocol) or about 750 MBq (one-day protocol) (99m)Tc-tetrofosmin. Reoriented short axis slices (16-frames) were summed framewise (1+2,3+4, etc.) yielding 8-frame data sets. EDV, ESV and LVEF were calculated for both data sets using 4D-MSPECT and QGS. RESULTS: QGS succeeded with 119, 4D-MSPECT with 117 patients. For the remaining 116 patients, higher EDV (+0.8ml/+3.8 ml) and LVEF (+1.5%/+2.6%; absolute) and lower ESV (-1.7ml/-0.9 ml) (4D-MSPECT/QGS) were found for 16-frame runs. Bland-Altman limits were smaller for QGS than 4D-MSPECT [EDV 32/12 ml, ESV 21/10 ml, LVEF 17/7% (4D-MSPECT/QGS)]. CONCLUSION: Both algorithms showed the expected effects. Contour finding using QGS failed with only one data set, whereas contour finding using 4D-MSPECT failed with three data sets. Since the effects observed between the 8- and the 16-frame studies are relatively small and quite predictable, 8-frame studies can be employed in clinical routine with hardly any loss at all, plus contour finding appears less susceptible to error.

Dipyridamole/aspirin combination in secondary stroke prevention: effects on absolute myocardial blood flow and coronary vascular resistance.

OBJECTIVE: In the European Stroke Prevention Study (ESPS 2), oral administration of a fixed combination of 200 mg extended-release dipyridamole and 25 mg aspirin (twice daily) after ischemic stroke or transient ischemic attack, significantly reduced the risk of stroke compared to placebo as well as compared to aspirin or dipyridamole alone. However, the i.v. application of dipyridamole over 4 - 6 min is known to increase myocardial blood flow up to 6-fold, and thereby potentially provoke ischemic wall motion abnormalities in patients with coronary artery disease. We therefore assessed the cardiac side effects of the dipyridamole/aspirin combination on absolute myocardial blood flow (MBF) and coronary vascular resistance (CVR). METHODS: MBF and CVR were measured using 150-water positron emission tomography in 24 patients after stroke or transient ischemic attack, before and 6.7 +/- 1.9 days after starting the dipyridamole/aspirin combination (Aggrenox) therapy. RESULTS: Resting MBF increased by 39% (max. 112%), from 0.92 +/- 0.13 (ml x g(-1) x min(-1)) at baseline to 1.28 +/- 0.27 (ml x g(-1) x min(-1)) under ongoing dipyridamole/aspirin combination therapy (p < 0.0005). CVR consecutively decreased from 105.3 +/- 16.9 to 74.1 +/- 16.5 (mmHg x ml(-1) x g x min) (p < 0.0005). The relative increase in MBF correlated negatively with the body surface area. No correlation was found between relative MBF increase and duration of dipyridamole/aspirin combination therapy (range 4 - 10 days). CONCLUSIONS: Orally administered dipyridamole/aspirin combination therapy in secondary stroke prevention increases MBF and decreases CVR significantly. These cardiac side effects of the dipyridamole/aspirin combination should be taken into account in stroke patients with proven or suspected coronary artery disease, particularly in combination with a small body surface area.

Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning.

Two major complications of hip replacement are loosening and infection. Reliable differentiation between these pathological processes is difficult since both may be accompanied by similar symptoms. Our aim was to assess the diagnostic ability of triple-phase bone scanning (TPBS) and positron-emission tomography (PET) to detect and differentiate these complications in patients with a hip arthroplasty. Both TPBS and PET were performed in 63 patients (92 prostheses). The radiotracer for PET imaging was (18)F-fluorodeoxyglucose (FDG). Image interpretation was performed according to qualitative and quantitative criteria although the final diagnosis was based upon either surgical findings or clinical follow-up. The sensitivity, specificity and accuracy of PET was 0.94, 0.95 and 0.95 respectively, compared with 0.68, 0.76 and 0.74 for TPBS. We found that an image interpretation based exclusively upon quantitative criteria was inappropriate because of its low selectivity. The histological examination indicated that increased periprosthetic uptake of FDG in patients with aseptic loosening was caused by wear-induced polyethylene particles and the subsequent growth of aggressive granulomatous tissue.

Myocardial viability assessment by endocardial electroanatomic mapping: comparison with metabolic imaging and functional recovery after coronary revascularization.

OBJECTIVES: The objective of this study was to compare electroanatomic mapping for the assessment of myocardial viability with nuclear metabolic imaging using positron emission computed tomography (PET) and with data on functional recovery after successful myocardial revascularization. BACKGROUND: Animal experiments and first clinical studies suggested that electroanatomic endocardial mapping identifies the presence and absence of myocardial viability. METHODS: Forty-six patients with prior (> or =2 weeks) myocardial infarction underwent fluorine-18 fluorodeoxyglucose (FDG) PET and Tc-99m sestamibi single-photon emission computed tomography (SPECT) before mapping and percutaneous coronary revascularization. The left ventricular endocardium was mapped and divided into 12 regions, which were assigned to corresponding nuclear regions. Functional recovery using the centerline method was assessed in 25 patients with a follow-up angiography. RESULTS: Regional unipolar electrogram amplitude was 11.0 mV +/- 3.6 mV in regions with normal perfusion, 9.0 mV +/- 2.8 mV in regions with reduced perfusion and preserved FDG-uptake and 6.5 mV +/- 2.6 mV in scar regions (p < 0.001 for all comparisons). At a threshold amplitude of 7.5 mV, the sensitivity and specificity for detecting viable (by PET/SPECT) myocardium were 77% and 75%, respectively. In infarct areas with electrogram amplitudes >7.5 mV, improvement of regional wall motion (RWM) from -2.4 SD/chord +/- 1.0 SD/chord to -1.5 SD/chord +/- 1.1 SD/chord (p < 0.01) was observed, whereas, in infarct areas with amplitudes <7.5 mV, RWM remained unchanged at follow-up (-2.3 SD/chord +/- 0.7 SD/chord to -2.4 SD/chord +/- 0.7 SD/chord). CONCLUSIONS: These data suggest that the regional unipolar electrogram amplitude is a marker for myocardial viability and that electroanatomic mapping can be used for viability assessment in the catheterization laboratory.