Attenuation correction single-photon emission computed tomography myocardial perfusion imaging

doi:10.1053/j.semnuclmed.2004.09.003

Seminars in Nuclear Medicine

Volume 35, Issue 1, January 2005, Pages 37-51

https://doi.org/10.1053/j.semnuclmed.2004.09.003 Get rights and content

Clinicians now rely heavily on the results of single-photon emission computed tomography (SPECT) myocardial perfusion imaging for diagnosing coronary disease and for planning therapy. However, the technique is imperfect for these purposes, mainly because of technical limitations, the most prominent of which is the effect of soft-tissue attenuation on apparent tracer distribution. Providers have attempted to compensate for this by a number of indirect approaches. Recently, validated hardware and software solutions for directly correcting image data for soft-tissue attenuation have become widely available commercially. Optimal application requires an understanding of the technical details that differ somewhat from system to system, the quality control prerequisites, knowledge of the importance of the transmission map quality, and how dedicated SPECT and SPECT-computed tomography systems present different challenges. In addition, the clinical literature is expanding rapidly, including studies on diagnostic accuracy, image appearances, quantitative analysis, appropriate patients for attenuation correction, clinical utility, incremental value in relation to ECG-gating, and risk stratification.

Section snippets

Indirect approaches to addressing soft-tissue attenuation

Solutions to the impact of attenuation fall largely into the categories of historically indirect approaches and direct approaches involving measurement of patient-specific attenuation. Four indirect approaches are commonly used in daily nuclear cardiology practice to address the frequent problem of soft-tissue attenuation: adjunctive planar acquisitions, prone imaging, ECG-gating, and image quantitation.

Direct approaches to attenuation correction

The lack of widespread adaptation and standardization of all of the aforementioned “indirect” approaches to overcoming attenuation artifacts has led to a multifaceted effort to devise algorithms that directly address the problem. After “first-generation” attenuation correction solutions failed to achieve desired results, the Society of Nuclear Medicine and the American Society of Nuclear Cardiology published a blueprint for providers and industry describing what was perceived as the ideal:

Physics of attenuation

Attenuation of photons within the patient is generally accepted as the physical factor most affecting quantitative accuracy and interpretation of myocardial perfusion SPECT images.9, 12, 13 Physical models of attenuation describe a complex set of energy and tissue-dependent interactions as photons traverse the body.14 The energies of single photon-emitting radioisotopes (70–360 keV) and physical properties of tissues show the predominant effects are photoelectric absorption and Compton

Quality control for SPECT attenuation correction

It is well accepted that a high quality attenuation map applied appropriately is essential for accurate attenuation correction.4, 31, 32 Early publications of clinical attenuation correction studies commented little or not at all on quality control methods or criteria for acceptance of quality.33 High-quality attenuation maps provide a valuable indicator of the overall quality of the transmission study. Attenuation maps of high quality are characterized by high count density, minimal or no

Clinical issues

The literature contains considerable documentation of the role of attenuation correction in daily nuclear medicine practice. Its impact on diagnostic accuracy, performance in the obese, and incremental value to ECG-gating have been demonstrated. Gender-independent quantitation programs are increasingly available commercially, and patient outcome studies are beginning to appear in the literature.

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To assess the significance of attenuation correction on sensitivity, specificity and diagnostic accuracy of myocardial perfusion SPECT.
102 patients referred for myocardial perfusion imaging (MPI) were divided into two groups: 42 patients (mean age: 54.6 ± 12.6) were enrolled in the group A, who had undergone coronary artery angiography, within six months of the scan. 60 patients (mean age: 49.79 ± 11.3) were placed in the group B who had a <15% pretest likelihood of CAD. Both non-corrected (NC) and attenuation corrected (AC) images were visually analyzed according to 17-segment model of the left ventricular cavity. Visual assessment derived sensitivity, specificity, diagnostic accuracy and normalcy rate of NC and AC sets of images were compared using McNemar test.
Sensitivity, specificity and diagnostic accuracy for detection of coronary artery disease were found to be 100%, 11% and 79% respectively for NC images and 66%, 78% and 68% for AC images. The p value was found to be significant in only the RCA territory. Normalcy rates in the group B population were 19% for NC image set and 74% for the AC image set. No significant difference on basis of BMI was observed in attenuation corrected scans. The technique appears to be more valuable in men.
This study demonstrates that CT based attenuation corrected Tc-99mm sestamibi SPECT myocardial perfusion imaging significantly improved the specificity of the RCA territory compared with non-attenuation corrected Tc-99mm sestamibi SPECT myocardial perfusion imaging in both genders irrespective of BMI.
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Citation Excerpt :
Otherwise, if their anatomic characteristics are identical in the proximal and distal coronary lesions when all other factors affecting FFR are similar, FFR might become smaller in the proximal, than in the distal lesion. Different factors were identified between LAD and non-LAD FFR prediction, mainly because of prominent soft tissue attenuation artifacts in the inferoposterior region.19 Multivariate analyses identified stress TPD − rest TPD and LVEF at rest as powerful determinants in both LAD and non-LAD FFR prediction.
Although fractional flow reserve (FFR) and myocardial perfusion imaging (MPI) findings fundamentally differ, several cohort studies have revealed that these findings correlate. Here, we investigated whether flow-limiting FFR could be predicted from adenosine stress thallium-201 MPI with single-photon emission computed tomography (SPECT) findings derived from 84 consecutive, prospectively identified patients with stable coronary artery disease and 212 diseased vessels. Among them, FFR was measured in 136 diseased vessels (64%). The findings were compared with regional perfusion abnormalities including stress total perfusion defect (TPD) − rest TPD determined using quantitative perfusion single-photon emission computed tomography software. The FFR inversely correlated the most accurately with stress TPD − rest TPD (r = −0.552, p <0.001). Predictors of major vessels of interest comprising FFR <0.80, included stress TPD − rest TPD, the transient ischemic dilation ratio, left ventricular ejection fraction at rest and beta blockers for left anterior descending artery (LAD) regions, and stress TPD − rest TPD, left ventricular mass, left ventricular ejection fraction at rest, right coronary artery lesions, the transient ischemic dilation ratio, and age for non-LAD regions. The diagnostic accuracy of formulas to predict major vessels of interest with FFR <0.80 was high (sensitivity, specificity and accuracy for LAD and non-LAD: 84%, 87% and 86%, and 75%, 93% and 87%, respectively). In conclusion, although somewhat limited by a sample size and a single-center design, flow-limiting FFR could be predicted from MPI findings with a defined probability. A cohort study might validate our results and provide a novel adjunctive tool with which to diagnose functionally significant coronary artery disease from MPI findings.
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Figure 9 shows how different color displays can lead to different image interpretations. Soft tissue attenuation of tracer activity in the heart is a major cause of decreased accuracy for MPI, and frequently leads to interpretive uncertainty.62,63 Attenuation consists of photoelectric absorption and Compton scatter of cardiac emitted photons by overlying soft tissue and ventricular blood pool.
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View full text

Attenuation correction single-photon emission computed tomography myocardial perfusion imaging

Section snippets

Indirect approaches to addressing soft-tissue attenuation

Direct approaches to attenuation correction

Physics of attenuation

Quality control for SPECT attenuation correction

Clinical issues

J Nucl Cardiol

J Nucl Med

J Nucl Cardiol

J Nucl Cardiol

Am J Cardiol

J Nucl Cardiol

Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

Mol Imaging Biol

J Nuc Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

Am J Cardiol

J Am Coll Cardiol

Exercise echocardiography or exercise SPECT imaging

JAMA

Cost-effectiveness of diagnostic strategies for patients with chest pain

Ann Intern Med

Planar myocardial perfusion imaging acquisition and processing protocols, in Nuclear CardiologyThe Basics

Prone versus supine thallium myocardial SPECTA method to decrease artifactual inferior wall defects

J Nucl Med

Prognostic implications of combined prone and supine acquisitions in patients with equivocal or abnormal supine myocardial perfusion SPECT

J Nucl Med

Quantitative stress-redistribution thallium-201 SPECT using prone imagingMethodologic development and validation

J Nucl Med

How to detect and avoid myocardial perfusion SPECT artifacts

J Nucl Med

Physics in Nuclear Medicine

The Essential; Physics of Medical Imaging

Transmission scanning in emission tomography

Eur J Nucl Med

Determination of the attenuation map in emission tomography

J Nucl Med

Correction of nonuniform attenuation in cardiac SPECT imaging

J Nucl Med

scanning line source for simultaneous emission and transmission measurements in SPECT

J Nucl Med

SPECT quantificationA simplified method of attenuation and scatter correction for cardiac imaging

J Nucl Med

Description of a prototype emission-transmission computed tomography imaging system

J Nucl Med

Gamma camera mounted anatomical X-ray tomographyTechnology, system characteristics and first images

Eur J Nucl Med

Compensation of attenuation map errors from Tc-99m-sestamibi downscatter with simultaneous Gd-153 transmission scanning

J Nucl Med

The design and performance of a simultaneous transmission and emission tomography system IEEE

Trans Nuc Sci

Half-fanbeam collimators combined with scanning point sources for simultaneous emission-transmission imaging

J Nucl Med

Updated imaging guidelines for nuclear cardiology procedures, part 1

J Nucl Cardiol

Attenuation correction for cardiac SPECTClinical and developmental challenges

J Nucl Med

Limited incremental diagnostic values of attenuation-noncorrected gating and ungated attenuation correction to rest/stress myocardial perfusion SPECT in patients with an intermediate likelihood of coronary artery disease

J Nucl Med