Professional Documents
Culture Documents
CSMC
2013
Professor of Medicine
David Geffen School of Medicine at UCLA
1
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess Perfusion Defects
– Semiquantitative visual assessment
– Quantitative assessment
• Assess
A R
Regional
i l Ventricular
V t i l Function
F ti
• Check for Additional Abnormalities
• Incorporate all clinical information into final report
CHACHR 64 M #1111-1364
2
Teaching Points
Prone and Supine
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
– Most common:
– Patient motion
– Breast/diaphragmatic attenuation
– Adjacent extra-cardiac radioactivity
– Poor count statistics
– Misregistration (particularly with CT AC)
– ECG-gating errors
3
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess perfusion defects
• Location (presumed vessel)
17-Segment Scoring
Short Axis Short Axis Short Axis Vertical Long Axis
Apical Mid Basal Mid
Anterior
Antero Antero
Anterior
5 Septal 11 Lateral
1 12 16
6 10
Septal 2 4 Lateral 17 Apex
7 9 13 15
3 8 Infero Infero
Inferior
14
Septal Lateral
Inferior
0 = Normal
1 = Slight reduction of uptake
2 = Moderate reduction of uptake
3 = Severe reduction of uptake
4 = Absent of radioactive uptake
AHA writing group on myocardial segmentation and registration for cardiac
imaging. Circulation 2002;105:539-542
4
Distribution of Perfusion Defects in During Balloon Inflation
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess perfusion defects
• Location (presumed vessel)
• Magnitude (extent/severity)
5
Segmental Scoring of Perfusion Defects:
5 point scale
0= N
0 Normall
1= slight (equivocal) reduction of uptake
2= moderate reduction of uptake
3= severe reduction of update
4= absence of radioactive uptake
4
6
Assessment of Risk by SPECT/PET MPI
Summed scores
• Summed Stress Score (SSS) = sum of 17 stress scores
7
Advantages of expressing perfusion defect
magnitude by “percent myocardium”
• “The summed difference score was 8”: ambiguous
– How many segments were employed in the system?
– What points could a segment have?
– Was it better to have a small score or a large score?
• “10% of the myocardium was ischemic”: intuitive
o revascularization
of e ascu a a o as well e as *
log Hazard Ratio
o
M di l R
Medical Rx
clinical, hx, stress SPECT data
4
3
Revasc*
2
*p<0
p<0.001
001
1
0
8
DEFECT SIZE (EXTENT) : Equivocal
STRESS
REST
# of segments: 1-2
SSS: 2-3
S-TPD: 3-4 %
9
DEFECT SIZE (EXTENT) : Equivocal
STRESS
REST
# of segments: 1-2
SSS: 2-3
S-TPD: 3-4 %
STRESS
REST
# of segments: 2
SSS: 4-5
S-TPD: 5 - 7%
10
DEFECT SIZE (EXTENT): SM - MED
STRESS
REST
# of segments: 2
SSS: 4-5
S-TPD: 5 - 7%
STRESS
REST
# of segments: 3
SSS: 6 - 7
S-TPD: 8 - 10%
11
DEFECT SIZE (EXTENT): MEDIUM
STRESS
REST
# of segments: 3
SSS: 6 - 7
S-TPD: 8 - 10%
STRESS
REST
# of segments: ≥ 4
SSS: > 7
S-TPD: > 10 %
12
DEFECT SIZE (EXTENT): LARGE
STRESS
REST
# of segments: ≥ 4
SSS: > 7
S-TPD: > 10 %
Mild/Equiv
(Score 1)
Moderate
(Score 2)
Severe
(Score 3)
Absent (4)
13
DEFECT SEVERITY (QUANT)
Mild / Moderate
Equivocal (2)
(1)
Equivocal 1 segment: 2
14
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess perfusion defects
• Location (presumed vessel)
• Magnitude (extent/severity)
• Reversibility
R ibili
Systematic Interpretation of
SPECT or PET MPI
Perfusion Defect Reversibility
• Reversible • Ischemia
• Partially reversible • Ischemia
• Nonreversible • Possible infarct
(“fixed”) – Attenuation
– Severe ischemia
15
Systematic Interpretation of
SPECT or PET MPI
4D M-SPECT
Cedars-Sinai
Emory Cardiac
QGS/QPS/QPET
Tool Box
16
Quantitative vs Visual Assessment of Serial SPECT MPI
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess Perfusion Defects
– Semiquantitative visual assessment
– Quantitative assessment
• Assess
A R
Regional
i l Ventricular
V t i l Function
F ti
17
INTERPRETATION OF Function
on Myocardial Perfusion SPECT/PET
Quality Control
Rotating Summed Projections
Counts
Flashing
Motion
Heart-rate Histogram
Time-volume Curve
Interpretation of LV Function
on Myocardial Perfusion SPECT/PET
Regional Function
• Gray Scale
• Observe Endocardial Motion/myocardial thickening
• 17 Segment Scoring
• Contours On And Off
Ejection Fraction
• Verify Contours (Cine)
• Inspect Time-volume Curve
18
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess Perfusion Defects
– Semiquantitative visual assessment
– Quantitative assessment
• Assess
A R
Regional
i l Ventricular
V t i l Function
F ti
• Check for Additional Abnormalities
19
Suggested Thresholds for TID
Exercise Pharm
Dual isotope
rest Tl-201/stress Tc-99m 1.22 1.36
Systematic Interpretation of
SPECT or PET MPI
• Check for technical sources of error
• Assess Perfusion Defects
– Semiquantitative visual assessment
– Quantitative assessment
• Assess
A R
Regional
i l Ventricular
V t i l Function
F ti
• Check for Additional Abnormalities
• Incorporate all clinical information into final report
20
Systematic Interpretation of
SPECT or PET MPI
Reporting
21
Systematic Interpretation of
SPECT or PET MPI
Integration of Test Results: Nuclear Variables
• Perfusion • Non-perfusion
Non perfusion
– Extent & severity of – Lung uptake
perfusion defects – RV uptake
stress – TID
rest – LV function
• LVEF
reversible • LVEF fall
• Stress WMA
• Symptoms/clinical presentation
• CAC/angiographic and other imaging findings
22
Iansro KE 51
Iansro KE 51
23
Iansro KE 51
Iansro KE 51
24
Iansro KE 51
Final Report
100
entage surviving
>8 MET
75
5-8 MET
50
<5 MET
25
Perce
N=6,213
F/U 6.2 + 3-7 yrs
0
0 3.5 7.0 10.5 14.0
Years follow-up
Myers et al. NEJM, 346: 793, 2002
25
Underestimation of the Extent of CAD by
SPECT MPI
26
RJ 75 F ATA/SOB, DM, no walk adeno
STRESS
REST
RJ 75 F ATA/SOB, DM, no walk adeno
STRESS
REST
CAC 1463
(97th %)
27
FO 60 M ATA/SOB, AF, HF, no walk adeno
STRESS
REST
FO 60 M ATA/SOB, AF, HF, no walk adeno
STRESS
REST
CAC 0
28
AC Scan (ultralow dose) ECG-gated CAC scan
492 cases
Scored within
1 category in
93% of cases
29
Interpretation of SPECT/PET MPI
Components of Final Report
• Reason for test
• Technical quality
• Type stress/doses/protocol
• Magnitude and location of reversible defect (ischemia)
• Magnitude and location of non-reversible defect
• LVEF and changes from rest, ESV, and regional wall motion,
TID, lung uptake, RV uptake
• Overall impression (comment re: high-risk markers, if present
• Comparison to previous studies
• Answer to specific question being asked
30
The Nuclear Cardiology Report (ICANL)
Tilkemeier PL
JNC 2011;18:858
31