Differences due to collimator blurring in cardiac images with use of circular and elliptic camera orbits.

BACKGROUND: In cardiac imaging systems, an elliptic acquisition orbit about the patient can be used to enhance resolution of single photon emission computed tomography (SPECT) images by minimizing the distance between the object imaged and the rotating detector system. In this study artifacts from images acquired with the standard circular acquisition are compared with those acquired with various elliptic acquisitions. METHODS AND RESULTS: With the use of elliptic camera orbits of different eccentricities, simulated projection data were generated from a slice through the left ventricle (LV). The projection data included a simulation of the degradation due to the depth-dependent response of the collimator. As is common in many clinical systems, SPECT images were reconstructed with the standard filtered backprojection algorithm without correction for the collimator response. When the ratio of the major-to-minor axis of the acquisition arc is changed from 1 (circular) to 1.5 (elliptic), reconstructed SPECT images show an additional loss of counts (about 10%) in the apical region of the LV. The severity of the apical defect is also dependent on the starting angle of the acquisition arc. When the starting angle is changed from 0 degrees (detector parallel to the major axis of the LV) to 60 degrees, the ratio between the minimum count in the apical region and the maximum count in the left ventricular myocardial wall decreases by as much as 20%. CONCLUSIONS: SPECT image artifacts from elliptic acquisitions are significantly more severe than those from circular acquisitions. Because of the significant difference in images reconstructed from circular and elliptic acquisitions, standardized normal files acquired from circular acquisitions should not be used for comparisons with patient data acquired from elliptic acquisitions.

Attenuation artifacts in SPECT: effect of wrap-around lung in 180 degrees cardiac studies.

UNLABELLED: We estimated that in 75%-90% of PET 82Rb patients the left lung appeared to wrap around the anterior aspect of the left ventricle. We used clinical PET 82Rb myocardial perfusion studies as the input to a SPECT computer simulation model to determine if patients with left lung wrap-around displayed consistent artifacts in reconstructed SPECT images. In particular, we sought an explanation for the hot lateral wall seen in SPECT images from normal female and male patients. METHODS: Attenuated SPECT 201Tl emission data were simulated from a mid-ventricular slice in 10 randomly selected clinical PET 82Rb studies with left lung wrap-around. In these same cases, the influence of left lung wrap-around was removed by assigning the left lung an attenuation coefficient which matched that of the heart. Five randomly selected clinical PET 82Rb studies without left lung wrap-around were also processed with our model. RESULTS: In all 10 cases with left lung wrap-around, reconstructed SPECT images showed the hot lateral wall artifact with a mean septal-to-lateral wall count ratio of 0.86. With left lung wrap-around removed in the same 10 patients, reconstructed images did not show hot lateral wall (mean septal-to-lateral wall count ratio = 1.07). The 5 cases without left lung wrap-around did not show hot lateral wall (mean septal-to-lateral wall count ratio = 1.04) and the ratios changed little with the filling of the left lung (mean septal-to-lateral wall count ratio = 1.05). CONCLUSION: Results of our PET-to-SPECT computer simulation model showed that the hot lateral wall artifact found in SPECT myocardial perfusion images was related to the orientation and positions of the left ventricle and the left lung.

Diagnosis of coronary artery disease in women: roles of three dimensional imaging with magnetic resonance or positron emission tomography.

Diagnosis and assessment of coronary artery disease (CAD) is especially difficult in women. The history of chest discomfort and various noninvasive tests each have particular problems, which indicate the need to consider more accurate tests such as cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET). MRI of cardiac function at rest and during dobutamine stress has good accuracy, and MR Myocardial perfusion imaging (MPI) with gadolinium DTPA looks promising. The most exciting MR method is cineangiography (MRA), which images blood flow through the coronary arterial lumen as an intense signal. In an initial clinical trial this method showed excellent sensitivity and fair specificity in patients in whom adequate images could be obtained. MR spectroscopy (MRS) has imaged changes in high energy phosphates in patients with severe coronary stenoses during handgrip exercise, but is still experimental. PET MPI corrects the images for attenuation problems that limit the use of other radionuclide imaging procedures in women more than in men. Many studies show excellent sensitivity and specificity to diagnose CAD by PET MPI. In view of its clinical validation and the safety of dipyridamole relative to dobutamine, PET MPI appears to be the best test for assessing CAD in women. The greater accuracy of PET (or perhaps of fully developed MRI/MRA systems) will produce better clinical outcomes and cost-effectiveness for most patients than will less accurate modalities, despite their higher initial cost.

Comparison of cost-effectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease.

BACKGROUND: To compare cost-effectiveness and utility of four clinical algorithms to diagnose obstructive coronary atherosclerotic heart disease (CAD), we compared exercise ECG (ExECG), stress single photon emission computed tomography (SPECT), positron emission tomography (PET), and coronary angiography. METHODS AND RESULTS: Published data and a straightforward mathematical model based on Bayes' theorem were used to compare strategies. Effectiveness was defined as the number of patients with diagnosed CAD, and utility was defined as the clinical outcome, ie, the number of quality-adjusted life years (QALY) extended by therapy after the diagnosis of CAD. Our model used published values for costs, accuracy, and complication rates of tests. Analysis of the model indicates the following results. (1) The direct cost (fee) for each test differs considerably from total cost per delta QALY. (2) As pretest likelihood of CAD (pCAD) in the population increases, there is a linear increase in cost per patient tested but a hyperbolic decrease in cost per effect and cost per utility unit, ie, increased cost-effectiveness and decreased cost per utility unit. (3) At pCAD < 0.70, analysis of the model indicates that stress PET is the most cost-effective test, with the lowest cost per utility, followed by SPECT, ExECG, and angiography, in that order. (4) Above a threshold value of pCAD of 0.70 (for example, middle-aged men with typical angina), proceeding directly to angiography as the first test showed the lowest cost per effect or utility. This quantitative model has the advantage of estimating a threshold value of pCAD (0.70) at which the rank order of cost-effectiveness and cost per utility unit change. The model also allows substitution of different values for any variable as a way to account for the uncertainties of clinical data, ie, changing costs, test accuracy and risk, etc. This procedure, called sensitivity analysis, showed that the rank order of cost-effectiveness did not change despite changes in several variables. CONCLUSIONS: (1) Estimation of total costs of diagnostic tests for CAD requires consideration not only of the direct cost of the test per se (eg, test fees) but also of the indirect and induced costs of management algorithms based on the test (eg, cost/delta QALY). (2) It is essential to consider the clinical history (pCAD) when selecting the clinical algorithm to make a diagnosis with the lowest cost per effect or cost per utility unit. (3) Stress PET shows the lowest cost per effect or cost per utility unit in patients with pCAD < 0.70. (4) Angiography shows the lowest cost per effect or cost per utility unit in patients with pCAD > 0.70.

Comparison of modalities to diagnose coronary artery disease.

The purpose of this review is to compare several modalities available for detection of coronary artery disease (CAD). We compare the clinical history, rest/exercise electrocardiogram (ECG), rest/stress left ventricular (LV) function by radionuclide or echocardiographic methods, myocardial perfusion imaging (MPI) by single photon emission computed tomography (SPECT) or positron emission tomography (PET), contrast coronary angiography, magnetic resonance imaging (MRI), spectroscopy (MRS) and angiography (MRA), and ultrafast cine computed tomography (UFCT) to assess LV function, myocardial perfusion, and coronary calcification. We compare the modalities by answering six questions: (1) Does the modality provide unique clinical information? (2) What is the observer error? (3) What are sensitivities and specificities to detect CAD? (4) What patient selection criteria should be applied for each modality? (5) What incremental benefit is obtained from one modality versus another modality? and (6) Where do the modalities fit in the overall scheme of diagnostic testing for CAD? PET MPI appears to be the best noninvasive test for CAD, followed by SPECT thallium-201 and then dobutamine echocardiography. MRA and UFCT may soon play a larger role because they visualize the arteries. Contrast coronary angiography remains the gold standard despite its limitations. Exercise ECG is the least accurate test. The choice of tests critically depends on patient selection--based on clinical history, age, gender, and risk factors to estimate the pretest, clinical probability of CAD.

Absence of defects in SPECT thallium-201 myocardial images in patients with systemic hypertension and left ventricular hypertrophy.

Hypertension is common in patients undergoing stress and delayed single-photon emission computed tomography (SPECT) thallium-201 myocardial perfusion imaging. Investigators have reported that patients with end-stage renal disease and left ventricular hypertrophy due to hypertension have diminished lateral/septal count ratios on stress and delayed imaging mimicking lateral myocardial infarction in approximately 35% of patients. Subsequently, hypertension has been cited as a frequent cause of thallium-201 artifacts. The purpose of this study was to compare myocardial SPECT thallium-201 distribution in a broader group of patients with left ventricular hypertrophy resulting from hypertension with normal file subjects in order to determine the prevalence of abnormal studies and to compare the lateral/septal count ratio. Average counts in all myocardial regions in the male study group (n = 16) were compared with those in the normal male file patients (n = 49), with particular attention to the lateral and septal walls. In the group of 16 men with hypertension and left ventricular hypertrophy, as a whole, the mean lateral/septal wall count ratio was 4.4% lower (1.09 +/- 0.07) than that in the normal file (1.14 +/- 0.07; p < 0.01). At 3-hour delay, the ratio was virtually the same in the study group (1.06 +/- 0.09) as in the normal file (1.08 +/- 0.06; p = NS). Most important, for clinical purposes no patient had a defect, defined as a lateral/septal count ratio > 2.0 SD below normal limits. All thallium-201 studies were interpreted as normal. In conclusion, myocardial thallium-201 distribution is normal in patients with left ventricular hypertrophy due to hypertension.

Defects on SPECT "perfusion" images can occur due to abnormal segmental contraction.

UNLABELLED: Technetium-99m-sestamibi images reflect tracer distribution at the time of injection. This "stay put" indicator allowed us to separate the effects of segmental left ventricular dysfunction per se versus myocardial blood flow on SPECT "perfusion" images in ten dogs. METHODS: An electromagnetic flow probe and hydraulic occluder were placed on the LAD coronary artery. Sonomicrometry was used to measure segmental wall shortening. At peak myocardial blood flow induced by adenosine, 35-45 mCi 99mTc-sestamibi were injected without occlusion. At 1 hr postinjection, during normal contraction, 40-50 msec end-diastolic and end-systolic SPECT images (#1) were acquired to reflect normal myocardial blood flow distribution. Later, during total LAD occlusion, and without reinjection of isotope, another gated scan (#2) was acquired. RESULTS: Coincident with abnormal contraction, large severe systolic defects [(28 +/- 5)% more severe compared to the baseline-scan #1; p < 0.01], and milder diastolic defects [(12 +/- 8)% more severe compared to the baseline-scan #1; p < 0.01] were observed during scan #2. Thus, abnormal contraction alone produced defects on SPECT images. CONCLUSION: Accordingly, defects in myocardial perfusion images must be interpreted as representing the integrated result of the combination of blood flow and segmental contraction heterogeneity.

Apparent change in cardiac geometry during single-photon emission tomography thallium-201 acquisition: a complex phenomenon.

We investigated the frequency and extent of changes in heart position and geometry independent of body motion during stress single-photon emission tomography (SPET) thallium-201 myocardial perfusion imaging. Following an exercise treadmill test, patients had a 22.1-min SPET acquisition which was followed immediately by a static image acquisition for 1 min with the camera position identical to the first view of the SPET study. Point sources were placed on the body to monitor patient motion. Cardiac motion was assessed by an approach which mimicked a cross-correlation technique applied to cardiac count profiles along the horizontal and vertical directions from the first view of the SPET study and the static image. A large percentage (87.5%) of cases had some degree of horizontal or vertical motion. Pixel shifts in cardiac position of > or = 2 pixels (12 mm) occurred in 60% of patients. In 37% of patients who moved the cardiac motion was consistent with simple translation of the heart and thus amenable to correction using proposed SPET motion-correction programs. The peak heart rate achieved during stress and the ratio of the heart rate immediately before SPET acquisition to the resting heart rate were determined to be independent predictors of patient motion during SPET acquisition. Cardiac motion changes were minimal at (13.3 +/- 2.2) min after cessation of exercise. The implications of these findings for the accuracy of SPET 201Tl require further investigation.

Inhomogeneity of gated and ungated SPECT technetium-99m-sestamibi bull's-eyes in normal dogs: comparison with thallium-201.

By computer simulation, we have previously hypothesized, independent of the isotope imaged, that differences in view-to-view resolution and attenuation patterns predictably cause count density distortions in SPECT images. We tested the simulation predictions for both ECG-gated and ungated SPECT 99mTc-sestamibi and SPECT 201Tl myocardial perfusion images in normal dogs. In agreement with the predictions of the computer model, distortions in SPECT 99mTc-sestamibi myocardial perfusion images are virtually equivalent to SPECT 201Tl, dependent on the exact SPECT acquisition orbit and markedly different for a posterior 180 degrees acquisition arc compared to an anterior 180 degrees acquisition arc. Furthermore, ungated and gated SPECT 99mTc-sestamibi images show similar count inhomogeneities. These results suggest that little is to be gained from a 360 degrees acquisition with SPECT 99mTc-sestamibi, and that image distortions from gated or ungated SPECT 99mTc images with 180 degrees orbits will be similar to those in SPECT 201Tl images.

Knowledge-based system for boundary detection of four-dimensional cardiac magnetic resonance image sequences.

A strategy for a knowledge-based system to detect the interior and exterior boundaries of the left ventricle from time-varying cross-sectional images obtained by ECG-gated magnetic resonance imaging (MRI) is discussed. The system uses both fuzzy set theory and Dempster and Shafer theory to manage the knowledge and to control the flow of system information for more efficient use of limited computational resources and memory space. The key to the approach is that it performs edge detection on images through integration and unification of knowledge and information from edge candidates on all the slices and phases of the acquired cardiac MRI dataset. The analysis system does not base decisions on individual measurements, but on consensus opinions by combining many knowledge sources, some of which may not be completely accurate.

Automatic detection of brain contours in MRI data sets.

A software procedure is presented for fully automated detection of brain contours from single-echo 3-D MRI data, developed initially for scans with coronal orientation. The procedure detects structures in a head data volume in a hierarchical fashion. Automatic detection starts with a histogram-based thresholding step, whenever necessary preceded by an image intensity correction procedure. This step is followed by a morphological procedure which refines the binary threshold mask images. Anatomical knowledge, essential for the discrimination between desired and undesired structures, is implemented in this step through a sequence of conventional and novel morphological operations, using 2-D and 3-D operations. A final step of the procedure performs overlap tests on candidate brain regions of interest in neighboring slice images to propagate coherent 2-D brain masks through the third dimension. Results are presented for test runs of the procedure on 23 coronal whole-brain data sets, and one sagittal whole-brain data set. Finally, the potential of the technique for generalization to other problems is discussed, as well as limitations of the technique.

Comparison of single-photon emission computed tomographic (SPECT) myocardial perfusion imaging with thallium-201 and technetium-99m sestamibi in dogs.

OBJECTIVES: The purpose of the present study was to compare single-photon emission computed tomographic (SPECT) myocardial images of technetium-99m (Tc-99m) sestamibi and thallium-201 (Tl-201) isotopes in the same dog undergoing partial coronary occlusion during pharmacologic vasodilation. BACKGROUND: To date, no controlled study has been reported comparing SPECT Tc-99m sestamibi with SPECT Tl-201 imaging during stress with anatomic and physiologic standards. METHODS: Mongrel dogs were anesthetized with chloralose and instrumented to record left anterior descending coronary blood flow and aortic pressure. Partial coronary occlusion with a hydraulic cuff reduced coronary vascular conductance, which is equal to the coronary blood flow normalized to aortic pressure during peak vasodilation with intravenous adenosine. Each dog received 5 mCi of Tl-201, then 30 mCi of Tc-99m sestamibi during partial coronary occlusion at peak vasodilation. Tomographic myocardial imaging was performed in a 180 degrees anterior arc scan for 33.5 min, first with Tl-201, and later, without moving the dog, for 33.5 min with Tc-99m sestamibi. Postmortem staining defined the region underperfused because of its dependence on the artery that was partially occluded. RESULTS: In seven dogs with moderate reduction in coronary blood flow, coronary vascular conductance decreased with partial coronary occlusion (47 +/- 12%) during Tl-201 imaging and (47 +/- 8%, p = NS) during Tc-99m sestamibi imaging. The underperfused region was 23.9 +/- 6.4% of total left ventricular mass. Counts in the defects were 39% higher (0.86 +/- 0.08 of normal counts) for Tc-99m sestamibi than for Tl-201 (0.64 +/- 0.09 of normal counts, p < 0.001), and the defect on SPECT Tc-99m sestamibi images occupied only a fraction (0.37 +/- 0.30) of the area of the defect on the Tl-201 images of the same dog. Bull's-eye displays constructed from the pathologic slices showed that the Tl-201 defect size was closer to the underperfused region of the left ventricular mass determined pathologically than was the Tc-99m sestamibi defect size. In four additional dogs a severe, near total coronary occlusion was created during Tl-201 and Tc-99m sestamibi administration. In these dogs, similar defect contrast (0.55 +/- 0.12 vs. 0.62 +/- 0.09, p = NS) and areas (0.18 +/- 0.07 vs. 0.18 +/- 0.11, p = NS) were observed with Tl-201 and Tc-99m sestamibi, respectively. CONCLUSIONS: Tomographic myocardial imaging with Tc-99m sestamibi during moderately severe partial coronary occlusion underestimated the area of the defect relative to Tl-201 or to the pathologic reference standard in dogs. Defect contrast was sharper with tomographic myocardial Tl-201 than with tomographic myocardial Tc-99m sestamibi during moderately severe partial coronary occlusion.

Effects of time required for reperfusion (thrombolysis or angioplasty, or both) and location of acute myocardial infarction on left ventricular functional reserve capacity several months later.

The purpose of this study was to determine whether reperfusion of acute myocardial infarction (AMI) by recombinant tissue-type plasminogen activator (rt-PA) or percutaneous transluminal coronary angioplasty, or both, would improve left ventricular (LV) function when it is measured several months later at rest or maximal bicycle exercise, or both. Radionuclide angiography was performed in 44 patients 5 months (range 6 weeks to 9 months) after AMI to assess function, and tomographic myocardial thallium-201 imaging was performed at maximal exercise and delayed rest to determine whether there was any evidence of myocardial ischemia. As expected, no patient had chest pain or redistribution of a thallium defect during the exercise test, because patients had undergone angioplasty (n = 28) or coronary bypass graft surgery (n = 5) where clinically indicated for revascularization. The LV ejection fraction was plotted as a function of the time elapsed between the onset of chest pain and the time when coronary angiography confirmed patency of the infarct-related artery (achieved in 91% of 44 patients by rt-PA [n = 31] or percutaneous transluminal coronary angioplasty [n = 9] ). Functional responses differed markedly between patients with anterior (n = 20) versus inferior (n = 24) wall AMI. LV ejection fraction during exercise correlated with time to reperfusion in patients with an anterior wall AMI (r = -0.58; standard error of the estimate = 11.9%; p less than 0.02) but not in patients with an inferior AMI (r = 0.10; standard error of the estimate = 13.1%; difference not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal SPECT thallium-201 bull's-eye display: gender differences.

The bull's-eye technique synthesizes three-dimensional information from single photon emission computed tomographic 201TI images into two dimensions so that a patient's data can be compared quantitatively against a normal file. To characterize the normal database and to clarify differences between males and females, clinical data and exercise electrocardiography were used to identify 50 males and 50 females with less than 5% probability of coronary artery disease. Results show inhomogeneity of the 201TI distributions at stress and delay: septal to lateral wall count ratios are less than 1.0 in both females and males; anterior to inferior wall count ratios are greater than 1.0 in males but are approximately equal to 1.0 in females. Washout rate is faster in females than males at the same peak exercise heart rate and systolic blood pressure, despite lower exercise time. These important differences suggest that quantitative analysis of single photon emission computed tomographic 201TI images requires gender-matched normal files.