Scintigraphic detection of post-pneumonectomy bronchopleural fistulae.

A total of 20 ventilation studies [16 with xenon-133 and four with technetium-99m diethylenetriamine pentaacetic acid (DTPA)] were performed in 11 patients with suspected post-pneumonectomy bronchopleural fistulae. The findings on the ventilation scan were correlated with bronchoscopy, taken as the gold standard for purposes of comparison. The sensitivity and specificity for 133Xe scans were 83% and 100% respectively, while the sensitivity for 99mTc-DTPA aerosol studies was poor at 0%. Special techniques for optimal visualization of the fistulae are enumerated.

Viable neurons with luxury perfusion in hydrocephalus.

A woman with hydrocephalus due to aqueductal stenosis had functional imaging of cerebral perfusion and metabolism to demonstrate the effects of endoscopic third ventriculostomy--a new form of internal surgical shunting. Technetium-99m-ECD SPECT and 18F-FDG PET showed regional luxury perfusion at the left frontal region. Three months after a successful third ventriculostomy, a repeated imaging of cerebral perfusion and metabolism showed resolution of luxury perfusion and global improvement of both perfusion and metabolism. This concurred with postoperative clinical improvement. The paired imaging of cerebral perfusion and metabolism provides more information than just imaging perfusion or metabolism. Thus, the detection of perfusion and metabolism mismatch may open a new window of opportunity for surgical intervention.

Myocardial viability studies using fluorine-18-FDG SPECT: a comparison with fluorine-18-FDG PET.

UNLABELLED: Multidetector SPECT systems equipped with a high-energy, or 511-keV collimator, have been proposed to offer a less expensive alternative to PET in myocardial viability studies with [18F]FDG. The objectives of this investigation included: (a) measuring the physical imaging characteristics of SPECT systems equipped with either a high-energy general-purpose collimator (HE), or the dedicated 511-keV collimator (UH), when imaging 511-keV photons, and comparing them with conventional FDG PET; and (b) directly and quantitatively comparing the diagnostic accuracy of SPECT, with either an UH or HE collimator, to that of PET in myocardial viability studies using 18F-FDG. METHODS: Physical imaging characteristics of SPECT and PET were measured and compared. Both SPECT and PET studies were performed in two groups of 18 patients each, with Group I using HE SPECT and Group II using UH SPECT. Myocardial perfusion studies were also performed using 82Rb PET at rest and during dipyridamole stress to identify areas of persistent hypoperfusion. For each myocardial region with a persistent perfusion defect, a perfusion-metabolism match or mismatch pattern was established independently, based on the results of 18F-FDG SPECT as well as PET. RESULTS: PET is superior to SPECT in all physical imaging characteristics, particularly in sensitivity and contrast resolution. PET had a sensitivity 40-80 times higher than that of SPECT, and its contrast resolution was 40-100% better than SPECT. Between FDG-SPECT using an HE collimator and that using a 511-keV collimator, the latter showed marked reduction in septal penetration (from 56% to 38%), improvement in spatial resolution (from 17 mm to 11 mm FWHM) as well as contrast resolution (from 34% to 45%), while suffering reduced system sensitivity (from 75 to 34 cpm/microCi). Patient studies demonstrated that although FDG-SPECT, using a HE or UH collimator, provided concordant viability information as FDG PET in a large majority of myocardial segments with persistent perfusion defects (88% and 90%, respectively), there is an excellent statistical agreement (kappa = 0.736) between SPECT with UH collimator and PET, while the agreement between SPECT using HE collimator and PET are moderate (kappa = 0.413). CONCLUSION: Despite its markedly inferior physical imaging characteristics compared with PET, SPECT with the dedicated 511-keV collimator offers a low-cost, practical alternative to PET in studying myocardial viability using [18F]FDG. SPECT systems with a high-energy, general-purpose collimator, on the other hand, are inadequate in such studies.

Regional body FDG-PET in postoperative recurrent hyperparathyroidism.

PURPOSE: The use of preoperative imaging studies in patients with persistent or recurrent hyperparathyroidism after initial operation is generally accepted to improve the success rate and minimize the morbidity from reoperative surgery. The purpose of this study was to define the performance of FDG-PET for the localization of hyperfunctioning parathyroid tissue prior to reoperation. METHOD: Twenty patients with biochemical evidence of recurrent or persistent hyperparathyroidism following previous neck surgery were investigated. Regional body PET imaging of the neck and upper chest (axial field of view 27.5 cm) was acquired 45 min after 5-10 mCi FDG was given intravenously. RESULTS: Subsequent surgery revealed solitary parathyroid adenomas in 14 patients, seven hyperplastic glands in 2 patients, and parathyroid carcinoma in 1 patients. FDG-PET correctly identified 79% (11/14) of the parathyroid adenomas, 29% (2/7) of the hyperplastic glands, and the parathyroid carcinoma. FDG-PET was negative in 79% (30/38) of the surgically identified normal parathyroid glands. Eight false-positive findings led to a positive predictive value of 64%. CONCLUSION: These preliminary data suggest that regional body FDG-PET is a promising procedure in the evaluation of patients with persistent or recurrent postoperative hyperparathyroidism.

Is image subtraction necessary in the clinical interpretation of single-day split-dose stress cerebral perfusion single-photon emission tomography using technetium-99m compounds?

The aim of this study was to validate a simplified semiquantitative method of evaluating a single-day stress cerebral perfusion test to obtain cerebrovascular reserve capacity (CVRC) for routine clinical uses. A split-dose protocol was tested in 36 pairs of technetium-99m hexamethylpropylene amino oxime baseline (low dose) and acetazolamide (high dose) stress brain single-photon emission tomographic (SPET) studies from 16 patients with cerebrovascular disease. The images were displayed on a semiquantitative color scale with (corrected) and without (uncorrected) image subtraction, dose adjustment, and decay correction. The representative CVRC was determined by placing 3x3 pixel regions of interest on midthalamic and midcerebellar slices. The corrected and uncorrected relative changes in CVRC were correlated using linear regression. The relative changes of corrected (x) and uncorrected (y) CVRC by quantitative analysis were highly correlated in a linear fashion (y=0.67x+0.002, r=0.998, P<0.0005). As predicted by theory, the slope was related to the ratio of split dose and independent of ROI sampling. Single-day split-dose stress brain SPET can be accurately performed without image subtraction and complicated dose adjustment or decay correction for clinical studies.

Present assessment of myocardial viability by nuclear imaging.

Prospective delineation of viable from nonviable myocardium in patients with coronary artery disease in an important factor in deciding whether a patient should be revascularized or treated medically. Two common techniques--single-photon emission computed tomography (SPECT) and positron-emission computed tomography (PET)--are used in nuclear medicine using various radiopharmaceuticals for the detection of myocardial viability in patients. Thallium-201 (201Tl) and technetium-99m (99mTc)-sestamibi are the common radiopharmaceuticals used in different protocols using SPECT, whereas fluoride-18 (18F)-fluorodeoxyglucose (FDG) and rubidium-82 (82Rb) are most widely used in PET. The SPECT protocols involve stress/redistribution, stress/redistribution/reinjection, and rest/redistribution imaging techniques. Many studies have compared the results of 201Tl and (99mTc)-sestamibi SPECT with those of FDG PET; in some studies, concordant results have been found between delayed thallium and FDG results, indicating that 201Tl, although considered a perfusion agent, shows myocardial viability. Discordant results in a number of studies have been found between sestamibi and FDG, suggesting that the efficacy of sestamibi as a viability marker has yet to be established. Radiolabeled fatty acids such as iodine-123 (123I)-para-iodophenylpentadecanoic acid and carbon-11 (11C)-palmitic acid have been used for the assessment of myocardial viability with limited success. 11C-labeled acetate is a good marker of oxidative metabolism in the heart and has been used to predict the reversibility of wall motion abnormalities. (18F)-FDG is considered the marker of choice for myocardial viability, although variable results are obtained under different physiological conditions. Detection of myocardial viability can be greatly improved by developing new equipment and radiopharmaceuticals of better quality.

Measurement of cardiac output with first-pass determination during rubidium-82 PET myocardial perfusion imaging.

In addition to providing useful clinical information, cardiac output determined during rubidium-82 positron emission tomographic (PET) myocardial perfusion studies can be used in the measurement of absolute regional myocardial blood flow using Sapirstein's method. This investigation was conducted to compare cardiac output values obtained by post-processing data acquired in a list mode PET myocardial perfusion study with those obtained using a technetium-99m-labeled red blood cell method on the same patients. Results from 14 patients showed that cardiac output can be accurately measured simultaneously in a 82Rb PET myocardial study, allowing determination of multiple perfusion and functional parameters of the heart, thus improving the cost-effectiveness of the 82Rb PET study.

Outcome of temporal lobe epilepsy surgery predicted by statistical parametric PET imaging.

UNLABELLED: PET is useful in the presurgical evaluation of temporal lobe epilepsy. The purpose of this retrospective study is to assess the clinical use of statistical parametric imaging in predicting surgical outcome. METHODS: Interictal 18FDG-PET scans in 17 patients with surgically-treated temporal lobe epilepsy (Group A-13 seizure-free, group B = 4 not seizure-free at 6 mo) were transformed into statistical parametric imaging, with each pixel representing a z-score value by using the mean and s.d. of count distribution in each individual patient, for both visual and quantitative analysis. RESULTS: Mean z-scores were significantly more negative in anterolateral (AL) and mesial (M) regions on the operated side than the nonoperated side in group A (AL: p < 0.00005, M: p = 0.0097), but not in group B (AL: p = 0.46, M: p = 0.08). Statistical parametric imaging correctly lateralized 16 out of 17 patients. Only the AL region, however, was significant in predicting surgical outcome (F = 29.03, p < 0.00005). Using a cut-off z-score value of -1.5, statistical parametric imaging correctly classified 92% of temporal lobes from group A and 88% of those from Group B. CONCLUSION: The preliminary results indicate that statistical parametric imaging provides both clinically useful information for lateralization in temporal lobe epilepsy and a reliable predictive indicator of clinical outcome following surgical treatment.

The incidence of scintigraphically viable and nonviable tissue by rubidium-82 and fluorine-18-fluorodeoxyglucose positron emission tomographic imaging in patients with prior infarction and left ventricular dysfunction.

BACKGROUND: Although reversible perfusion defects, perfusion-metabolism mismatch and match patterns are important for differentiating viable from nonviable myocardium, the frequency of these scintigraphic patterns has not been reported. The study objective was to establish the incidence of these scintigraphic patterns to estimate the clinical need for metabolic positron emission tomography for evaluating tissue viability in patients with prior myocardial infarction (MI). METHODS AND RESULTS: 82Rb perfusion images were interpreted to identify reversible or irreversible defects, followed by determination of their 18F-fluorodeoxyglucose (18F-FDG) uptake pattern. In 155 patients with prior MI, analysis of 613 abnormal segments showed reversible perfusion defects in 13%. The 87% irreversible defects, 18% showed perfusion-metabolism mismatch, whereas 69% showed the match pattern. Reversible perfusion defects and perfusion-metabolism mismatches were noted in 20% (31/155) and 29% (45/155) of patients, respectively, whereas the match pattern was noted in 51% (79/155) of patients. CONCLUSION: Irreversible perfusion defects were common in our patients with prior MI, and distinction between viable and nonviable tissue was not possible by perfusion imaging alone. The identification of hibernating myocardium was possible only with the additional 18F-FDG imaging in about one third of patients. This indicates a significant clinical demand for 18F-FDG imaging that identifies patients who will benefit from revascularization.

Use of positron emission tomography for prediction of perioperative and late cardiac events before vascular surgery.

The efficacy of myocardial perfusion imaging for cardiac-risk stratification of patients undergoing vascular surgery has been disputed recently. In comparison with conventional techniques, positron emission tomography (PET) has the benefit of permitting a true resting scan, allows accurate measurement of the extent of ischemia, and is highly specific for the diagnosis of coronary disease. We therefore investigated the use of PET for risk stratification at the time of vascular surgery and subsequent follow-up in 78 patients (aged 67 +/- 11 years, 52 men), selected for testing before the performance of extensive surgery or because of one or more clinical risk factors. Perfusion images were obtained by using a standard rubidium 82 protocol before and after dipyridamole-handgrip stress. With use of a quantitative color scale in a 24-segment model of the left ventricle, scans were reported as showing normal perfusion, resting defects, or stress-induced defects (deterioration > 15% with stress). After exclusion of 6 patients referred for myocardial revascularization, 72 patients were followed up in the perioperative period and for 18 +/- 12 months for late cardiac death, myocardial infarction, or unstable angina. Perioperative events occurred in 14 patients (5 with myocardial infarction and 9 with unstable angina), 10 of whom had ischemia at PET (sensitivity, 71%; predictive value of a positive test, 45%). Isolated resting perfusion defects were not associated with events. The presence of extensive ischemia (more than five segments) had a positive predictive value of 64%, and its absence gave a negative predictive value of 89%.(ABSTRACT TRUNCATED AT 250 WORDS)

Hibernating myocardium versus scar: severity of irreversible decreased myocardial perfusion in prediction of tissue viability.

PURPOSE: To determine whether quantitation of the relative severity of decreased perfusion in irreversible defects on myocardial perfusion images enables differentiation of viable hibernating myocardium from scar. MATERIALS AND METHODS: In 145 patients with previous myocardial infarction, 1,252 regions with irreversible defects proved by means of rubidium-82 rest-stress imaging were analyzed for relative severity (percentage decrease in perfusion). Myocardial tissue viability was determined by means of positron emission tomography with fluorine-18 fluorodeoxyglucose (FDG). RESULTS: The relative decreases in Rb-82 uptake in the 1,252 regions were categorized into nine levels of severity (30% to > or = 70%) in 381 regions of hibernating myocardium and 871 regions of scar. The values of relative decreased perfusion in the irreversible defects alone did not enable differentiation of hibernating myocardium and scar (P = .61). CONCLUSION: The results show no relationship between the relative severity of irreversible perfusion defects and the ability to distinguish between hibernating myocardium and scar.

Prognosis of patients with left ventricular dysfunction, with and without viable myocardium after myocardial infarction. Relative efficacy of medical therapy and revascularization.

BACKGROUND: The uptake of F-18 deoxyglucose into dysfunction segments after myocardial infarction identifies metabolically active (FDG+) or inactive (FDG-) myocardium. Although patients with FDG+ segments have been found to be at risk for adverse events, the prognostic significance of viable myocardium in relation to other influences on postinfarction prognosis, including revascularization, remain ill defined. The purpose of this study was to investigate the relative prognostic significance of FDG+ tissue and to establish whether myocardial revascularization in patients with viable tissue attenuates the risk of adverse outcome. METHODS AND RESULTS: One hundred thirty-seven patients with left ventricular dysfunction and resting perfusion defects after myocardial infarction underwent positron emission tomography with both dipyridamole stress Rb-82 perfusion imaging and FDG imaging. After the exclusion of 4 patients proceeding to transplantation, 2 with uninterpretable scans and 2 lost to follow-up, 129 patients were followed clinically for 17 +/- 9 months. Four groups were defined: patients with FDG+ dysfunctional myocardium who were revascularized (n = 49) or treated medically (n = 21) and those with FDG- segments who were revascularized (n = 19) or treated medically (n = 40). The groups of patients with FDG+ or FDG- findings, with and without revascularization, did not differ with respect to known determinants of postinfarction prognosis: age, left ventricular ejection fraction, or the prevalence of multivessel disease. Nonfatal ischemic events occurred in 48% of medically treated FDG+ patients compared with 8% of revascularized patients with FDG+ tissue (P < .001) and 5% of patients with FDG- myocardium (P < .001). Thirteen patients died from cardiac causes; 11 (85%) had a left ventricular ejection fraction of < 30%, and these patients were evenly distributed between FDG+ and FDG- groups. Using Cox's proportional hazards model, only the presence of FDG+ myocardium (odds ratio, 12.9; P < .001) and the absence of revascularization (odds ratio, 5.8; P = .002) independently predicted ischemic events, while only age (P = .02) and ejection fraction (P < .001) but not the presence of viable myocardium were predictive of death. CONCLUSIONS: Residual viable myocardium after myocardial infarction may act as an unstable substrate for further events unless it is revascularized. Despite this association, age and left ventricular dysfunction remained the strongest predictors of cardiac death after myocardial infarction in these patients with a spectrum of left ventricular dysfunction.

Radiopharmaceuticals for brain imaging.

Brain imaging is performed using radiopharmaceuticals by single photon emission computed tomography (SPECT) and positron emission tomography (PET). SPECT and PET radiopharmaceuticals are classified according to blood-brain-barrier permeability, cerebral perfusion and metabolism receptor-binding, and antigen-antibody binding. The blood-brain-barrier (BBB) SPECT agents, such as 99mTcO4-, [99mTc]DTPA, 201TI and [67Ga]citrate are excluded by normal brain cells, but enter into tumor cells because of altered BBB. These agents were used in the earlier period for the detection of brain tumors. SPECT perfusion agents such as [123I]IMP, [99mTc]HMPAO, [99mTc]ECD are lipophilic agents and therefore, diffuse into the normal brain. These tracers have been successfully used to detect various cerebrovascular diseases such as stroke, Parkinson disease, Huntington's disease, epilepsy, dementia, and psychiatric disorders. Xenon-133 and radiolabeled microspheres have been used for the measurement of cerebral blood flow (CBF). Important receptor-binding SPECT radiopharmaceuticals include [123I]QNE, [123I]IBZM, and [123I]iomazenil. These tracers bind to specific receptors in the brain, thus displaying their distribution in various receptor-related cerebral diseases. Radioiodinated monoclonal antibodies were used for the detection of brain tumors. PET radiopharmaceuticals for brain imaging are commonly labeled with positron-emitters such as 11C, 13N, 15O, and 18F, although other radionuclides such as 82Rb, 62Cu and 68Ga also were used. The brain uptake of [13N]glutamate, [68Ga]EDTA and [82Rb]RbCl depends on the BBB permeability, but these are rarely used for brain imaging. Several cerebral perfusion agents have been introduced, of which [15O]water, [13N]ammonia, and [15O]butanol have been used more frequently. Regional CBF has been quantitated by using these tracers in normal and different cerebral disease states. Other perfusion agents include [15O]O2, [11C]CO, [11C]CO2, [18F]fluoromethane, [15O]O2, [11C]butanol, and [62Cu]PTSM. Among the PET cerebral metabolic agents, [18F]fluorodeoxyglucose (FDG) is most commonly used to detect metabolic abnormalities in the brain. Various brain tumors have been graded by [18F]FDG PET. This technique was used to detect epileptic foci by showing increased uptake in the foci during the ictal period and decreased uptake in the interictal period. Differentiation between recurrent tumors and radiation necrosis and the detection of Alzheimer's disease have been made successfully by [18F]FDG PET. Other PET metabolic agents such as [11C]deoxyglucose, and [11C]methylmethionine have drawn attention in the detection of brain tumors. [18F]fluorodopa is a cerebral neurotransmitter agent, which has been found very useful in the detection of Parkinson disease that shows reduced uptake of the tracer in the striatum of the brain.(ABSTRACT TRUNCATED AT 400 WORDS)

Primary hyperparathyroidism: preoperative parathyroid imaging with regional body FDG PET.

PURPOSE: To explore the feasibility of use of positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) to localize abnormal parathyroid tissue. MATERIALS AND METHODS: Regional body FDG PET with attenuation correction was performed in 17 adult patients with primary hyperparathyroidism (HPT) prior to surgical neck exploration. The regional body FDG PET results were correlated with surgical and histopathologic findings. RESULTS: Surgical neck exploration revealed 18 parathyroid adenomas in 16 patients and four hyperplastic parathyroid glands in one patient. Regional body FDG PET allowed correct localization of 17 of the 18 parathyroid adenomas (94% sensitivity) and two of the four hyperplastic parathyroid glands (50% sensitivity). Three false-positive FDG PET findings were encountered, including two follicular thyroid adenomas. CONCLUSION: Regional body FDG PET is a promising procedure for preoperative localization of pathologic parathyroid tissue in patients with primary HPT.

Current status of the clinical applications of cardiac positron emission tomography.

At the present time, positron emission tomography (PET) has evolved into an accurate clinical diagnostic imaging procedure for coronary artery disease that provides unique information, presently unavailable from other imaging modalities, for the management of patients with previous myocardial infarction. The superior accuracy of PET for the diagnosis of coronary artery disease has had a positive influence on the management decision process to perform revascularization. In addition to the superior accuracy of PET compared with single photon emission computed tomography, PET has the advantage of being able to identify viable hibernating myocardium.

Planar imaging with single-head large-field-of-view cameras: are they still the workhorse?

The large-field-of-view (LFOV) scintillation camera was developed in 1975 with a field of view 50% larger than the conventional camera used at that time. Not only was the new model more adaptable to large-area imaging needs, such as lungs, bone, liver, and spleen, but it could be used for small-organ imaging with a converging collimator that yielded both high resolution and high efficiency. LFOV cameras still offer the most flexibility for all of the common procedures encountered in the nuclear medicine clinic. For those installations performing up to approximately 13 procedures a day, two LFOV cameras can handle the patient load, and little advantage would be gained by the use of the multihead cameras. For the busy laboratories, however, the increased patient throughput would be the primary advantage of the multihead systems. Dual LFOV systems offer an advantage in time for whole-body imaging procedures, and three-head systems in many installations have been devoted to myocardial perfusion and brain SPECT. Although the LFOV camera is still the dominant imaging device in nuclear medicine, it is expected that in the future more procedures will gravitate to the dedicated two and three multihead system, particularly with the increasing applications of both SPECT and quantification to conventional nuclear medicine procedures.

Parathyroid adenoma localization by PET FDG.

A patient with primary hyperparathyroidism was examined with positron emission tomography using [18F]-2-fluorodeoxyglucose. The radioactive tracer accumulated in a cervical mass that proved to be a parathyroid adenoma resulting in the correct preoperative localization of the parathyroid tumor.