Allen R. Goode

Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease

OBJECTIVES We hypothesized that combining functional assessment to perfusion enhances the ability of electrocardiographic gating Tc-99m sestamibi single photon emission computed tomography (gated SPECT) myocardial perfusion imaging (MPI) to detect defects in multiple vascular territories in patients with severe three-vessel coronary artery disease (3VD). BACKGROUND In patients with 3VD, perfusion defects in multiple vascular territories may not always be evident due to globally reduced perfusion. METHODS Gated SPECT MPIs were interpreted sequentially with perfusion first, followed by combined perfusion/function, in 143 patients with angiographic 3VD and a control group of 112 non-3VD patients. All patients underwent coronary arteriography within one month of MPI. RESULTS In 3VD patients, combined perfusion/function analysis yielded significantly greater numbers of abnormal segments/patient (6.2 +/- 4.7 vs. 4.1 +/- 2.8, p < 0.001) and more defects in multiple vascular territories (60% vs. 46%, p < 0.05) than perfusion alone. In the control group, there were no differences between the combined perfusion/function and perfusion alone interpretations. Multivariate analysis of 15 different clinical, stress, and scintigraphic variables in all patients revealed age (p < 0.0001) and number of abnormal vascular territories by combined perfusion/function (p < 0.0001) to be the most powerful predictors of 3VD. Addition of functional data to clinical, stress, and perfusion yielded a significant increase in the predictive value of 3VD (global chi-square: 131.7 vs. 89.8, p < 0.00001). Specificity of combined perfusion/function analysis was not lower than perfusion alone (72% vs. 69%, p = NS). CONCLUSIONS; Adjunctive assessment of function with perfusion by gated SPECT MPI enhances the detection of defects in multiple vascular territories in patients with severe 3VD, without adversely affecting its specificity.

Performance of a PSPMT based detector for scintimammography

In breast scintigraphy, compact detectors with high intrinsic spatial resolution and small inactive peripheries can provide improvements in extrinsic spatial resolution, efficiency and contrast for small lesions relative to larger conventional cameras. We are developing a pixelated small field-of-view gamma camera for scintimammography. Extensive measurements of the imaging properties of a prototype system have been made, including spatial resolution, sensitivity, uniformity of response, geometric linearity and energy resolution. An anthropomorphic torso phantom providing a realistic breast exit gamma spectrum has been used in a qualitative study of lesion detectability. A new type of breast imaging system that combines scintimammography and digital mammography in a single upright unit has also been developed. The system provides automatic co-registration between the scintigram and the digital mammogram, obtained with the breast in a single configuration. Intrinsic spatial resolution was evaluated via calculation of the phase-dependent modulation transfer function (MTF). Measurements of extrinsic spatial resolution, sensitivity and uniformity of response were made for two types of parallel hole collimator using NEMA (National Electrical Manufacturers Association) protocols. Geometric linearity was quantified using a line input and least squares analysis of the measured line shape. Energy resolution was measured for seven different crystal types, and the effectiveness of optical grease coupling was assessed. Exit gamma spectra were obtained using a cadmium zinc telluride based spectrometer. These were used to identify appropriate radioisotope concentrations for the various regions of an anthropomorphic torso phantom, such that realistic scatter conditions could be obtained during phantom measurements. For prone scintimammography, a special imaging table was constructed that permits simultaneous imaging of both breasts, as well as craniocaudal views. A dedicated breast imaging system was also developed that permits simultaneous acquisition and superposition of planar gamma images and digital x-ray images. The intrinsic MTF is nonstationary, and is dependent on the phase relationship between the signal and the crystal array matrix. Averaged over all phases, the MTF is approximately 0.75, 0.57 and 0.40 at spatial frequencies of 1.0, 1.5 and 2.0 cycles per cm, respectively. The phase averaged line spread function (LSF) has a FWHM value of 2.6 mm. Following uniformity corrections, the RMS deviations in flood images are only slightly greater than is predicted from counting statistics. Across an 80 mm section of the active area, the differential linearity is 0.83 mm and the absolute linearity 2.0 mm. Using an anthropomorphic torso phantom with detachable breasts, scatter radiation similar to that observed exiting the breast of scintimammography patients was observed. It was observed that scattered gamma rays can constitute the majority of the radiation incident on the detector, but that the scatter-to-primary ratio varies significantly across the field of view, being greatest in the caudal portion of the breast, where scatter from the liver is high. Using a lesion-to-breast concentration ratio of 6:1, a 1.0 cm3 simulated breast lesion was detectable in lateral images obtained with both the developmental camera and with a clinical camera, while a 0.35 cm3 lesion was detectable in neither. Utilization of the dual x-ray transmission, gamma emission breast imaging system greatly increases the conspicuity of scintimammographic lesions relative to prone imaging, as well as greatly facilitating the localization and identification of structures in the gamma image. The prototype imaging gamma detector exhibits spatial resolution superior to that of conventional cameras, and comparable uniformity of response and geometric linearity. Because of light losses in the crystals, the energy resolution is inferior to that of single crystal NaI(Tl) came

Detection of regional pulmonary perfusion deficit of the occluded lung using arterial spin labeling in magnetic resonance imaging.

Detection of regional perfusion deficit in the lung has been demonstrated using an arterial spin labeling technique called flow‐sensitive alternating inversion recovery with an extra radiofrequency pulse (FAIRER). A pulmonary artery was occluded using a nondetachable balloon catheter to simulate an acute pulmonary embolism in 3 of 10 rabbits. Inflating the balloon occludes the artery, and deflating the balloon allows for reperfusion. Perfusion imaging was performed pre‐occlusion, during occlusion, and after reperfusion. Signal enhancement due to perfusion of the pulmonary parenchyma was observed in the perfusion images with negligible artifacts. The perfusion deficit of the pulmonary parenchyma was detected distal to the site of occlusion in all three rabbits. Return of the pulmonary parenchymal perfusion was observed after reperfusion. Magnetic resonance imaging using FAIRER can detect signal loss due to absence of perfusion caused by pulmonary embolism. J. Magn. Reson. Imaging 2000;11:97–102.

Integrated CT-SPECT system for small animal imaging

We are developing a scanner for simultaneous acquisition of x-ray computed tomography (CT) and single photon emission tomography (SPECT) images of small animals such as mice and rats. The scanner uses a cone beam geometry for both the x- ray transmission and gamma emission projections by using an area x-ray detector and pinhole collimator, respectively. The CT and SPECT data set are overlaid to form a coregistered structural-functional 3D image. The CT system includes a single CCD-based x-ray detector and a microfocus x-ray source. The SPECT scanner utilizes tungsten pinhole collimators and arrays of CsI(Tl) scintillation detectors. We describe considerations and the early performance of a prototype scanner.

Optimization of breast imaging procedure with dedicated compact gamma cameras

Results are presented on studies conducted with various prototypes of a dedicated small field-of-view (SFOV) gamma camera for use in radiopharmaceutical studies of the breast. Since the experience in the clinical use of such instruments is limited, these experiments were conducted to test various clinical imaging implementations. Both planar and tomographic techniques were utilized to image various compressed and noncompressed breast phantoms. Lesion contrast was used to quantify the lesion visibility of each case. The results of this study indicate that lesion contrast is optimized with planar imaging of the compressed breast and that contrast is also dependent on lesion-to-detector distance. Based on these observations, planar imaging conducted with a system comprised of two opposed detectors providing compression to the breast would be optimal. The opposed views would ensure the minimization of lesion-to-detector distance, especially for lesions whose location is not known a-priori.

Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter?

AIM To estimate the fetal radiation exposure using thermoluminescent dosimeters (TLDs) in pregnant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and assess its relevance. METHODS Data on thirty-five therapeutic ERCPs conducted in pregnant patients from 2001 to 2009 were retrieved from a prospective database. Techniques to minimize fluoroscopy time were implemented and the fluoroscopy times captured. TLDs were placed on the mother to estimate the fetal radiation exposure and the results were compared to the maximum allowed dose of radiation to the fetus [0.005 gray (Gy)]. Obstetrics consultations were obtained and the fetus was monitored before and after the ERCP. Fluoroscopy was performed at 75 kVp. ERCP was performed with the patients supine by dedicated biliary endoscopists performing more than 500 cases a year. RESULTS A total of 35 pregnant patients underwent ERCP and biliary sphincterotomy (14 in first trimester, 11 in second trimester, and 10 in third trimester). Mean maternal age was 25 years (range 16-37 years) and mean gestational age was 18.9 wk (range 4-35 wk). Mean fluoroscopy time was 0.15 min (range 0-1 min). For 23 women, the estimated fetal radiation exposure was almost negligible (< 0.0001 Gy) while for 8 women, it was within the 0.0001-0.0002 Gy range. Three women had an estimated fetal radiation exposure between 0.0002 and 0.0005 Gy and 1 woman had an estimated fetal radiation exposure greater than 0.0005 Gy. Complications included 2 post-sphincterotomy bleeds, 2 post-ERCP pancreatitis, and 1 fatal acute respiratory distress syndrome. One patient developed cholecystitis 2 d after ERCP. CONCLUSION ERCP with modified techniques is safe during pregnancy, and estimating the fetal radiation exposure from the fluoroscopy time or measuring it via TLDs is unnecessary.

Gamma-ray detectors for breast imaging

Breast cancer is the most common cancer of American women and is the leading cause of cancer-related death among women aged 15 - 54; however recent years have shown that early detection using x-ray mammography can lead to a high probability of cure. However, because of mammographys low positive predictive value, surgical or core biopsy is typically required for diagnosis. In addition, the low radiographic contrast of many nonpalpable breast masses, particularly among women with radiographically dense breasts, results in an overall rate of 10% to 25% for missed tumors. Nuclear imaging of the breast using single gamma emitters (scintimammography) such as 99mTc, or positron emitters such as F-18- fluorodeoxyglucose (FDG) for positron emission tomography (PET), can provide information on functional or metabolic tumor activity that is complementary to the structural information of x-ray mammography, thereby potentially reducing the number of unnecessary biopsies and missed cancers. This paper summarizes recent data on the efficacy of scintimammography using conventional gamma cameras, and describes the development of dedicated detectors for gamma emission breast imaging. The detectors use new, high density crystal scintillators and large area position sensitive photomultiplier tubes (PSPMTs). Detector design, imaging requirements, and preliminary measured imaging performance are discussed.

A system for dual modality breast imaging

Scintimammography is a promising nuclear imaging modality currently under evaluation as a complementary diagnostic tool for X-ray mammography. However, current scintimammography imaging protocols, using large, conventional Anger cameras and prone patient positioning, result in low sensitivity for small lesions, and do not provide a means for direct correlation between structures in the scintigram and in the mammogram. The authors are developing a dedicated breast imaging system that provides both digital X-ray transmission and gamma emission images with the breast in a consistent configuration under mild compression. The current system uses a 20 cm/spl times/30 cm digital mammography detector and a 10 cm/spl times/10 cm gamma detector. The inactive peripheries of each detector about 7 mm wide on the chest wall edge. The resulting fused image contains correlated functional and structural information, and overcomes many of the problems associated with conventional prone scintimammography. The authors present system performance characteristics and examples of dual modality breast images.

Development of a small-field-of-view scintimammography camera: measurements and simulations

We report on studies of a small field of view scintimammography camera based on a position sensitive PMT and a crystal scintillator array. A 5 inch R3292 Hamamatsu PMT was coupled to a variety of scintillators, including pixelized NaI(Tl), CsI(Na) and YAP. Laboratory and phantom studies were performed to compare performances of the above scintillator sensors with special emphasis on spatial resolution and scatter rejection. The results of Monte Carlo simulations for different pixel sizes are also presented.

Dedicated small field of view SPECT system based on a 5" PSPMT and crystal scintillator array for high resolution small animal cardiac imaging

We have developed and evaluated a high resolution small animal single photon emission computed tomography (SPECT) imaging system using a small field-of-view gamma camera based on a 10 cm diameter Hamamatsu R3292 position sensitive PMT and NaI(Tl) crystal array. The instrument was designed primarily to image myocardial perfusion as well as heart and lung uptake of molecular-targeted tracers in rodent models. In the present study, we evaluated the system performance by imaging a stationary micro SPECT phantom and a variety of in vivo small animal models. Using a magnification factor of 1.57 and a 0.5 mm pinhole collimator, the reconstructed phantom images showed a spatial separation of individual rods as small as 1.6 mm. A myocardial perfusion study which was performed on a rat yielded high quality tomographic slices of the heart which clearly revealed both left and right ventricular walls and chambers. Such high resolution cardiac imaging was made possible due to the high intrinsic spatial resolution of the detector combined with pinhole collimation and OSEM reconstruction methodology. The system proved to be a very useful tool for use in molecular imaging of targeted probes.