PROCEDURE GUIDELINES Procedure Guideline for Myocardial Perfusion Imaging

H. William Strauss, D. Douglas Miller, Mark D. Wittry, Manuel D. Cerqueira, Ernest V. Garcia, Abdulmassi S. Iskandrian, Heinrich R. Schelbert and Frans J. Wackers Stanford University Medical Center, Stanford, California; St. Louis University Health Sciences Center, St. Louis, Missouri; Georgetown University Medical Center, Washington, D.C.; Emory University Hospital, Atlanta, Georgia; Allegheny University of the Health Sciences, Philadelphia, Pennsylvania; University of California Los Angeles School of Medicine, Los Angeles, California; and Yale University School of Medicine, New Haven, Connecticut

likely represents scar.* Recording data with both SPECT and Key Words: myocardial perfusion imaging; practice guideline; electrocardiogram (ECG) gating permits evaluation of the heart; infarction; ischemia; technetium; thallium relationship of perfusion to regional function. J NucíMed 1998; 39:918-923 PART III: COMMON INDICATIONS (TABLE 1) PART I:PURPOSE A. Assessment of the (i) presence, (ii) location, (iii) extent and (iv) severity of myocardial ischemia and scar.f The purpose of this guideline is to assist nuclear medicine practitioners in recommending, performing, interpreting and B. Determination of the significance of anatomic lesions reporting the results of myocardial perfusion imaging studies. detected by angiography. C. Assessment of myocardial viability. PART II: BACKGROUND INFORMATION AND PART IV: COMMON CLINICAL SETTINGS FOR DEFINITIONS Myocardial perfusion imaging is a procedure that utilizes an MYOCARDIAL PERFUSION IMAGING intravenously administered radiopharmaceutical to depict the A. Known or suspected CAD. distribution of nutritional blood flow in the myocardium. 1. Diagnose acute or chronic CAD (presence and sever ity). Perfusion imaging is useful to identify areas of relatively or 2. Determine prognosis (risk stratification based on ex absolutely reduced myocardial blood flow associated with tent of myocardium in jeopardy, cavitary dilatation ischemia or scar. The distribution of perfusion following and lung uptake). radiopharmaceutical injection can be assessed at rest, cardio vascular stress or both. These images can be recorded with either single-photon or positron imaging techniques utilizing radiopharmaceuticals that are extracted and retained for a TABLE 1 Summary of Clinical Indications for Myocardial Perfusion Imaging variable period of time by the myocardium. The relative regional distribution and clearance of a radiopharmaceutical in •Diagnosis of coronary artery disease the myocardium can be recorded with planar or tomographic -presence single-photon techniques or quantitated using positron imaging -location (coronary territory) techniques. The data can be analyzed utilizing visual inspection -extent (number of vascular territories involved) and/or by quantitative techniques. Some Food and Drug Ad- ministration-(FDA-)approved radiopharmaceuticals employed •Assessment of the degree of coronary stenosis and impact on regional for myocardial perfusion imaging include (a) single-photon perfusion tracers 20l"n and the WrnTc-labeled radiopharmaceuti •Assessment of myocardial viability cals such as sestamibi, tetrofosmin and teboroxime and (b) the positron-emitting tracer 82Rb. -ischemia versus scar -prediction of improvement in function following revascularization Patients with significant coronary artery stenosis due to abnormal coronary vasoreactivity or obstructive coronary artery •Risk assessment (prognosis) in patients disease (CAD) have a zone of diminished radiopharmaceutical -after myocardial infarction concentration in the area of decreased perfusion. If this area of -preoperative for major surgery who may be at risk for coronary events decreased tracer concentration is worse when the tracer is administered during stress than when the tracer is administered •Monitoring of treatment effect -after coronary revascularization at rest, the zone of decreased tracer concentration is most likely -medical therapy for congestive heart failure or angina due to ischemia. If the area of diminished tracer concentration -lifestyle modification remains unchanged, even after injection at rest, the lesion most

For correspondence or reprints contact: Wendy J.M. Smith, Director of Health Care Policy, Society of Nuclear Medicine, 1850 Samuel Morse Dr., Reston, VA 20190-5316, or by e-mail at [email protected]. "Depending on the clinical circumstance, such fixed abnormalities may represent Note: All 26 SNM-approved procedure guidelines are available on the Society's home high-grade obstruction to zones of viable, hibernating myocardium. When 201T1is used page. We encourage you to download these documents via the Internet at www. as the radiopharmaceutical, delayed imaging may be useful to distinguish these lesions snm.org. If you would like information on the development process of this guideline or from scar. When "Tc-sestamibi is used as the radiopharmaceutical, administering to order a compendium of all 26 procedure guidelines for $20.00, contact Marie Davis, nitroglycerin prior to injection at rest may help make this distinction. Society of Nuclear Medicine, at (703) 708-9000, ext. 250, or by e-mail at TScar (fibrosis) is often due to infarction. However, similar fixed abnormalities may be [email protected]. seen in patients with cardiomyopathy.

918 THEJOURNALOFNUCLEARMEDICINE•Vol. 39 •No. 5 •May 1998 3. Differentiate between coronary and noncoronary eti TABLE 2 ologies in patients with acute chest pain syndromes Modalities for Stress Myocardial Perfusion Imaging seen in the emergency room. •Exercise Stress B. Follow-up of patients with known CAD. -submaximal Evaluate the immediate and long-term effects of: -symptom limited 1. Revascularization procedures (such as coronary artery -maximal bypass grafting, angioplasty, etc.) in patients with recurrent symptoms. •Pharmacologie Stress 2. Medical or drug therapy. -vasodilators 3. Dietary and lifestyle modifications. adenosine C. Known or suspected congestive heart failure. dipyridamole Differentiate ischemie from idiopathic cardiomyopathy. -Ino/chronotopic arbutamine PART V: PROCEDURE dobutamine A. Patient Preparation dobutamine + atropine 1. Rest Injected Myocardial Perfusion Imaging A fasting state is generally preferred (but not neces sary) prior to rest myocardial perfusion imaging. It is of the radiopharmaceutical to reverse the effects of not generally necessary to withhold medications prior the vasodilator. This is not required for adenosine to perfusion imaging. Good intravenous access is due to its short duration of action, required for the administration of the radiopharma- b. Ino/chronotropic adrenergic agents may be adminis ceutical. Radiopaque objects in the area of the thorax tered to increase myocardial oxygen demand (i.e., should be removed prior to imaging; implanted ra- dobutamine, arbutamine). Drugs that may blunt the diopaque objects (metal, silicone, etc.) should be chronotropic response to adrenergic stimulant stress noted as potential attenuators of cardiac activity. with dobutamine or arbutamine should be noted (i.e., 2. Exercise (All stress procedures must be supervised by beta-adrenergic blocking agents). In some patients a qualified health care professional and performed in atropine may be required to increase the heart rate accordance with American Heart Association/Ameri response from dobutamine. Patients should be fast can College of Cardiology guidelines.) ing for a minimum of 4 hr prior to pharmacologie A fasting state is recommended for a minimum of 4 stress testing. Although these agents are in routine hr prior to the stress study. In general, patients clinical use for this indication, they have not re undergoing a stress study should be hemodynamically ceived FDA approval for this specific purpose. and clinically stable for a minimum of 48 hr prior to B. Information Pertinent to Performing the Procedure testing. Patients who are unable to exercise for non- A cardiovascular medical history and cardiorespiratory cardiac reasons (e.g., severe pulmonary disease, ar examination, including baseline vital signs, should be thritis, amputation, neurological disease, etc.) may be obtained prior to stress studies. Specific areas in the stressed pharmacologically with drugs designed to medical history requiring attention are the indication cause coronary hyperemia or increased cardiac work. for the examination, medications, symptoms, cardiac In patients who are capable of performing adequate risk factors and prior diagnostic or therapeutic proce exercise stress, exercise is generally preferred. If not dures. A 12-lead ECG should be reviewed for evidence medically contraindicated, it is recommended that of acute ischemia, arrhythmia or conduction distur medications such as beta-blocking drugs that may bances (i.e., left bundle branch block) prior to stress alter the heart rate and blood pressure (BP) response myocardial perfusion imaging. Diabetic patients re to exercise be withheld for diagnostic studies. A quiring insulin should be evaluated on a case-by-case secure intravenous line should be established for the basis to optimize diet and insulin dosing on the day of administration of the radiopharmaceutical during the examination. stress. Patients undergoing exercise stress should C. Precautions/Contraindications wear comfortable clothing and walking shoes. 1. Exercise Stress 3. Pharmacologie Stress (see Table 2.) The relative contraindications to exercise testing are Two types of pharmacologie stress are useful to unstable angina with recent (<48 hr) angina or evaluate myocardial perfusion: congestive heart failure, documented acute myocar a. Vasodilator stress agents may be administered to dial infarction (MI) within 2-4 days of testing, create coronary hyperemia (i.e., dipyridamole, aden- uncontrolled systemic (systolic >220 mmHg, dia- osine). Caffeine-containing beverages and methyl- stolic >120 mmHg) or pulmonary hypertension, un xanthine-containing medications that may interfere treated life-threatening arrhythmias, uncompensated with the coronary hyperemia produced by vasodila congestive heart failure, advanced atrioventricular tor stress agents should be discontinued for at least block (without a pacemaker), acute myocarditis, acute 12 hr prior to pharmacologie stress imaging (or pericarditis, severe mitral or aortic stenosis, severe longer for long-acting methylxanthine preparations). obstructive cardiomyopathy and acute systemic ill When possible, patients may also undergo low-level ness. Relative contraindications to exercise stress exercise to minimize symptoms associated with the include conditions that may interfere with exercise, vasodilators and to minimize subdiaphragmatic such as neurologic disease, orthopedic disease, ar tracer uptake. When dipyridamole is employed as thritic disease, severe pulmonary disease, peripheral the vasodilator, aminophylline (or a caffeinated bev vascular disease, severe deconditioning or inability to erage) may be administered following administration comprehend the exercise protocol.

PROCEDUREGUIDELINEFORMYOCARDIALPERFUSIONIMAGING•Strauss et al. 919 2. Pharmacologie Stress TABLE 3 Radiation Dosimetry for Adults* Patients with a history of bronchospasm, pulmonary disease (i.e., asthma or pulmonary hypertension), receivingthe prior intubation for severe pulmonary disease, sys largestradiation temic hypotension (BP systolic <90 mmHg), severe doseTmGy(rad)0.54Kidneys(2.0)0.036Gallbladder(0.13)0.034UU(0.13)0.031Gallbladder(0.11)0.018Kidneys(0.067)Effectivedose1"mSv(rem)0.23(0.85)0.0085(0.032)0.011(0.039)0.0067(0.025)0.0048(0.018) mitral valve disease and prior hypersensitivity to dipyridamole or adenosine should not undergo vaso Radiopharmaceutical201TI-chloride""Tc-sestamibi""Tc-teboroxime99nTc-tetrofosmin82RbAdministeredactivityMBq(mCi)75-150 dilator stress with dipyridamole or adenosine. Patients requiring methylxanthine-containing medications to i.V.(2-4)750-1 control their bronchospasm should not be tested with vasodilator agents. Ino/chronotropic agents may be i.V.(20-30)1100 employed in these patients. Patients with advanced (second- or third-degree) atrioventricular block or sick sinus syndrome should i.v.(30-50)750-1500100-1 850 not be tested with adenosine due to its negative dromotropic (SA + AV node) effect. Additional contraindications to vasodilator agents include MI i.V.(2CMO)11 within 2 days, unstable angina within 48 hr, severe aortic stenosis, severe obstructive hypertrophie car- 00-1i.v.(30-50)Organ850 diomyopathy and severe orthostatic hypotension. The use of dipyridamole or adenosine is not recommended in pregnant or lactating females. Ino/Chronotropic Agents *See package insert for full prescribing information and complete radia Ino/chronotropic agents are contraindicated in pa tion dosimetry. tients with ventricular tachyarrhythmias. These agents tper MBq (per mCi). should be used with caution in patients with unstable ULI = Upper large intestine. angina, obstructive or hypertrophie myopathy and early following acute infarction. 3. Cardiac Emergency Precautions dose of 201T1may be 4mCi/injection and the dose of the Life support instrumentation and emergency drugs 99mTc-labeled agents may be 30mCi/injection. A se must be available in the immediate vicinity of the cure intravenous line is required for the safe adminis stress laboratory. A physician or other trained medical tration of these radiopharmaceuticals. personnel currently certified in advanced cardiac life L. Image Acquisition support (ACLS) must be immediately available dur Data can be acquired using planar imaging, SPECT or ing the stress and recovery phases. Continuous elec- a combination of both techniques. trocardiographic monitoring must be performed dur 1. Planar Imaging ing the stress and recovery phases. Vital signs (heart Images should be recorded in at least three standard rate and BP) and a 12-lead ECG should be recorded at views: anterior view, left anterior oblique view to regular intervals throughout the stress and recovery optimize visualization of the septum (usually 45°)and phases. The patient should be questioned at regular left lateral view (preferably recorded with the patient intervals (e.g., every 1 or 2 min) for symptoms of in the right lateral decubitus position to minimize myocardial ischemia or side effects of pharmacologie attenuation from the abdomen). Additional views may stress agents using a standardized scale (e.g., 1 = very be required to account for unusual cardiac orientation light to 10 = most severe). Patients with implanted within the thorax. Acquisition is performed with a defibrillator devices may require temporary adjust gamma camera equipped with either a low-energy ment of their device to prevent stress-induced trigger all-purpose or high-resolution parallel-hole collima- ing. Failure of equipment is an absolute indication to tor, with the camera as close to the chest as possible. stop exercise. Images should be acquired in a fashion so that the 4. OSHA, NRC and State Regulatory Guidelines heart occupies approximately 35%-50% of the usable It is mandatory that all regulatory guidelines for the field of view. Efforts should be made to ensure that safe handling of syringes, needles, radioactive mate the rest and stress views are oriented in a comparable rials and patient waste be followed at all times. fashion. Images of diagnostic quality can be obtained D. Radiopharmaceuticals (see Table 3.) if a minimum of 500,000 counts are recorded in each The following single-photon-emitting radiopharmaceu- view (a minimum of 400 cts/cm2 of normal myocar ticals are FDA approved for use as myocardial perfu dium). The timing of imaging following injection of sion tracers: 201T1,99mTc-sestamibi, 99nTc-teboroxime the radiopharmaceutical will vary with the radiophar and 99mTc-tetrofosmin. The following positron-emit maceutical (immediate images are required for 9Tc- ting radiopharmaceutical is approved for use as a teboroxime, within 10 min of injection for 201T1,and myocardial perfusion tracer: s2Rb. Under most circum within 30 min-60 min for Tc-sestamibi and stances, the dosimetry of these radiopharmaceutical s 99mTc-tetrofosmin). Anatomic structures that may at limits the maximum administered dose for a combined tenuate myocardial activity (i.e., breast tissue) should rest and stress study (performed on the same day) to a be positioned in identical fashion for the rest and total of 4 mCi of 201T1, 40 mCi of 99mTc-labeled stress studies. radiopharmaceuticals and 50 mCi of 82Rb. When rest 2. SPECT and stress studies are performed on separate days, the Depending on available instrumentation, SPECT im-

920 THE JOURNALOFNUCLEARMEDICINE•Vol. 39 •No. 5 •May 1998 ages can be recorded with either a 180°or 360° should be displayed in a standardized format, as collection. The patient should be placed in a comfort recommended by the American Heart Association/ able position on the SPECT table. The left arm should American College of Cardiology, Society of Nuclear be positioned away from the field of acquisition. Data Medicine and American Society of Nuclear Cardiol are usually recorded with the patient in the supine ogy. Computer-assisted quantitative analysis can be position; however, in patients likely to have signifi used to measure regional myocardial activity, to cant diaphragmatic (abdominal) attenuation, prone evaluate the size and severity of perfusion abnormal imaging may produce a better result. Either a step- ities and to measure regional clearance of the radio- and-shoot acquisition with 32 or 64 stops separated by pharmaceutical from the myocardium on serial im 3°-6°or continuous acquisition may be used. The ages. When ECG gated myocardial perfusion studies duration of acquisition at each stop varies with the are recorded, these data should be evaluated both as protocol and radiopharmaceutical that is utilized (gen summed, ungated data (as described above) and in a erally 40 sec/image for 20IT1 and low-dose 99mTc- cinematic format to evaluate regional wall motion and sestamibi/tetrofosmin, and 25 sec/image for high-dose thickening. 99mTc-sestamibi/tetrofosmin). ECG gating for the ac F. Interventions quisition of cardiac function on 99mTc radiopharma Stress tests are described above. ceutical perfusion studies may be accomplished with G. Processing the placement of nonradiopaque electrodes and a Data processing is described in the guideline on gating device. SPECT images are acquired using SPECT imaging (see Society of Nuclear Medicine either a general all-purpose or high-resolution colli- Procedure Guideline for General Imaging). The myo mator. A planar anterior view image may be acquired cardial perfusion images can be analyzed for the prior to the initiation of the SPECT acquisition to relative activity in each section of myocardium and that measure lung radiopharmaceutical uptake (i.e., lung- result compared to the information in à normal data to-heart activity ratio). Transmission images may be base. Prior to quantifying the data, the images should acquired with certain tomographic SPECT imaging be reviewed for artifacts due to attenuation or zones of systems to enhance attenuation correction during unexpected increased activity. In the absence of arti processing. Appropriate filtering and smoothing algo facts, the zones of myocardium for quantification are rithms should be applied, based on recommendations selected, the myocardial borders are defined and the for the radiopharmaceutical that is utilized. programs then calculate and display the relative distri 3. PET bution of activity. As with other forms of quantitation, To minimize misalignment between emission and these data are useful to supplement the interpretation of transmission images, pharmacologie stress is pre an experienced observer. ferred in these patients. After recording the transmis H. Interpretation/Reporting sion images, the relative distribution of perfusion is Prior to interpreting the images, the data should be evaluated at rest followed by evaluation at stress. reviewed for artifacts due to attenuation or zones of Image acquisition usually commences at about 90 sec unexpected increased activity that may alter the appear after the intravenous administration of 82Rb and ance of the myocardium. In the absence of artifacts, the continues for 6 min-9 min. images are evaluated for areas of decreased radiophar 4. Image Evaluation maceutical concentration in the stress or rest images The interpreting physician should initially assess the and for changes in regional count density when gated overall quality of the myocardial perfusion study for data are recorded. Zones of myocardium with tracer possible artifacts, image processing problems, patient concentration below normal at rest are usually associ motion and image quality prior to visual analysis or ated with myocardial scar. Lesions seen at stress that quantitative interpretation. Planar and SPECT images improve on the rest injected study are usually due to should be viewed on a computer display to permit ischemia. Additional parameters that are particularly adjustment of contrast and brightness. Prior to recon useful on planar 201T1images are increased lung uptake struction, the SPECT projection data should be re or left ventricular cavitary dilatation, as markers of viewed as a cine display to detect patient motion. severe left ventricular dysfunction. In patients injected Significant patient motion during image acquisition with 20IT1at rest to detect decreased perfusion to areas may necessitate the reprocessing or reacquisition of of viable myocardium, the initial images are compared these studies. The data should be reconstructed using to those recorded several hours later. An increase in the either a filtered backprojection or iterative reconstruc relative concentration of tracer seen initially to that tion algorithm. recorded later indicates viable myocardium. Initially the reconstructed studies should be as I. Quality Control sessed for patient positioning and adequacy of pro (See general guidelines and American Society of Nu cessing. Rest and stress images should be appropri clear Cardiology guidelines on myocardial perfusion ately aligned and presented in a format that permits imaging.) direct comparison. Rest and stress images should be J. Sources of Error normalized to ensure the comparability of background 1. Radiopharmaceutical Dose Delivery—Interstitial and target activity for interpretation following visual (nonintravenous) injection of the radiopharmaceutical review of raw data and reconstructed tomographic due to a malfunctioning intravenous catheter will views. Computer-generated image displays can be reduce delivery of the radiopharmaceutical to the viewed in either gray scale or color. Excess contrast, myocardium and alter radiopharmaceutical uptake which can make small differences in perfusion appear and clearance kinetics. A low-count image should as lesions, should be avoided. In general, images raise concern regarding adequate delivery of the

PROCEDUREGUIDELINEFORMYOCARDIALPERFUSIONIMAGING•Strauss et al. 921 radiopharmaceutical and prompt imaging of the injec PART VI: DISCLAIMER tion site for confirmation of the infiltrated dose. The Society of Nuclear Medicine has written and approved 2. Patient Motion—Voluntary or involuntary patient guidelines to promote the cost-effective use of high-quality motion during image acquisition will create image nuclear medicine procedures. These generic recommendations blurring and artificial defects in the myocardium. cannot be applied to all patients in all practice settings. The Careful attention to patient comfort and stability guidelines should not be deemed inclusive of all proper proce during the acquisition may prevent major motion dures or exclusive of other procedures reasonably directed to artifacts. Minor motion artifacts can often be cor obtaining the same results. The spectrum of patients seen in a rected by reprocessing of data. specialized practice setting may be quite different than the 3. Suboptimal Stress Level—Failure to achieve the gen spectrum of patients seen in a more general practice setting. The der- and age-predicted 85% peak maximal heart rate appropriateness of a procedure will depend in part on the will reduce the sensitivity of this procedure for detec prevalence of disease in the patient population. In addition, the tion of CAD. Concomitant medications that attenuate resources available to care for patients may vary greatly from one medical facility to another. For these reasons, guidelines or block the action of pharmacologie stress agents cannot be rigidly applied. may have a similar effect. 4. Inappropriate Image Processing—Inappropriate fil Advances in medicine occur at a rapid rate. The date of a guideline should always be considered in determining its tering of raw backprojected tomographic data may current applicability. significantly degrade image quality. Recommended filters and cutoff limits should be applied to the PART VII: ISSUES REQUIRING FURTHER processing of tomographic myocardial perfusion data. CLARIFICATION Inappropriate count normalization of stress and rest None images may cause noncomparability of images for diagnostic analysis. 5. Attenuation Artifacts—Failure to recognize and ac PART VIII: CONCISE BIBLIOGRAPHY count for the presence of soft-tissue attenuation (often 1. American Heart Association/American College of Cardiol due to breast, obesity, abdominal structures, etc.) can ogy Task Force on Assignment of Diagnostic and Thera hamper accurate image analysis by creating false- peutic Cardiovascular Procedures, Committee on Radionu- positive lesions on the rest and/or stress images. clide Imaging. Guidelines for clinical use of cardiac 6. Standardization of Nomenclature—Society of Nu radionuclide imaging: a report of the American Heart clear Medicine-approved nomenclature should be Association/American College of Cardiology Task Force on used to describe anatomic areas in each of the three Assessment of Diagnostic and Therapeutic Cardiovascular reconstructed orthogonal tomographic views and on Procedures, Committee on Radionuclide Imaging, devel each of the three planar images to avoid diagnostic oped in collaboration with the American Society of Nuclear Cardiology. Circulation 1995;91:1278-1303. inconsistencies and render comparisons to previous studies easier. Prior studies should be reviewed for 2. Cardiovascular Imaging Committee, American College of comparison to the current study in order to note Cardiology. Standardization of cardiac tomographic imag ing. J Am Coll Cardiol 1992;20:255-256. differences (i.e., new findings) in comparison to any prior study. 3. Committee on Exercise and Cardiac Rehabilitation, Amer 7. Noncomparability of Views/Tomographie Slices— ican Heart Association. Guidelines for clinical exercise testing laboratories: a statement for health care professionals Comparable views and tomographic slices should be from the Committee on Exercise and Cardiac Rehabilita displayed for comparison of the rest and stress (or tion, American Heart Association. Circulation 1995;91: redistribution) data. 912-921. 8. Review of Raw Data—Prior to examination of recon 4. American College of Physicians/American College of Car structed tomographic cuts, the raw tomographic data diology/American Heart Association Task Force on Clinical acquisition should be reviewed in a rotational cine Privileges in Cardiology. Clinical competence in exercise matic format for the presence of attenuation artifacts testing: a statement for physicians from the American and zones of increased activity (e.g., lung, liver, College of Physicians/American College of Cardiology/ bowel or renal activity and other lesions) that may American Heart Association Task Force on Clinical Privi alter the appearance of the myocardium on the recon leges in Cardiology. J Am Coll Cardiol 1990;16:1061-1065. structed data. If possible, steps should be taken to 5. Committee on Advanced Cardiac Imaging and Technology, compensate for these problems, or the acquisition Council on Clinical Cardiology, American Heart Associa may have to be repeated. tion; Cardiovascular Imaging Committee, American Col 9. Region-of-Interest (ROI) Placement—For quantita lege of Cardiology; American Heart Association; and Board tive analysis of regional myocardial and lung activity, of Directors, Cardiovascular Council, Society of Nuclear it is necessary to ensure that ROI s do not include Medicine. Standardization of cardiac tomographic imaging. activity from adjacent structures. Calculation of the JNuclMed 1992;33:1434-1435. lung-to-heart activity ratio should include a similar- sized ROI in lung and myocardium not including the PART IX: LAST HOUSE OF DELEGATES APPROVAL anterior and anterolateral wall where lung and myo DATE cardium activity overlap. Attempts should be made to January 14, 1996 include only cardiac activity in ROIs utilized for quantitative analysis of radiopharmaceutical uptake PART X: NEXT ANTICIPATED APPROVAL DATE and clearance. 1998

922 THEJOURNALOFNUCLEARMEDICINE•Vol. 39 •No. 5 •May 1998 ACKNOWLEDGMENTS Society of Nuclear Medicine, for project coordination, data Henry D. Royal, MD, immediate past-chair of the Guidelines collection and editing; and members of the Guideline Develop and Communications Committee, Commission on Health Care ment Subcommittee, Julia Blust, CNMT, Jeffrey Dobkin, MD, Policy and Practice, for overall coordination and oversight of the Gary Heller, MD, Steven Port, MD, and David Price, MD, who Society of Nuclear Medicine Guideline Development Project; contributed their time and expertise to the development of this Wendy J.M. Smith, MPH, Director of Health Care Policy, information.

Procedure Guideline for Brain Perfusion SPECT Using Technetium-99m Radiopharmaceuticals

Jack E. Juni, Alan D. Waxman, Michael D. Devous, Sr., Ronald S. Tikofsky, Masanori Ichise, Ronald L. Van Heertum, B. Leonard Holman, Robert F. Carretta and Charles C. Chen William Beaumont Hospital, Royal Oak, Michigan; Cedars Sinai Medical Center, Los Angeles, California; University of Texas Southwestern Medical Center, Dallas, Texas; College of Physicians and Surgeons of Columbia University, Harlem Hospital Affiliation, New York, New York; Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada; Columbia- Presbyterian Medical Center, New York, New York; Brigham and Women 's Hospital, Boston, Massachusetts; Suiter Roseville Medical Center, Roseville, California; Saint Francis Medical Center, Peoría,Illinois

a. Evaluate patient for ability to cooperate. Key Words: SPECT; brain perfusion scintigraphy;practice guide b. Place patient in quiet, dimly lit room. line; cerebrovascular circulation c. Keep patient's eyes and ears open. J NucíMed 1998;39:923-926 d. Ensure that patient is seated or reclining comfort ably. e. Place intravenous access at least 10 min prior to PART I: PURPOSE injection to permit accommodation. The purpose of this guideline is to assist nuclear medicine f. Explain importance of no head motion. practitioners in recommending, performing, interpreting and g. Instruct patient not to speak or read. reporting the results of brain perfusion SPECT studies using 99mTc radiopharmaceuticals. h. Have no interaction with patient prior to, during or up to 5 min postinjection. PART II: BACKGROUND INFORMATION AND B. Information Pertinent to Performing the Procedure DEFINITIONS Relevant patient data suggested for optimal interpretation of SPECT of the brain is a technique for obtaining tomographic scans include patient history (including any past drug use or images of the three-dimensional distribution of a radiopharma- trauma), neurologic exam, psychiatric exam, mental status ceutical that reflects regional cerebral perfusion (1-4). exam (e.g., Folstein mini-mental status examination or other neuropsychological test), recent morphologic imaging stud PART III: COMMON INDICATIONS ies (e.g., CT, MRI) and current medications and when last A. Detection and evaluation of cerebrovascular disease. taken. B. Evaluation of patients with suspected dementia. C. Precautions C. Presurgical localization of epileptic foci. 1. Demented patients must be closely monitored at all Additional indications, not listed here, are under active times. evaluation, many of which appear promising at this time. 2. Patients with neurologic deficits may require special care and monitoring. PART IV: PROCEDURE 3. Sedation should be given after injection of radiopharma- A. Patient Preparation ceutical when possible. 1. Prearrivai D. Radiopharmaceutical No special preparation required. 1. Radiopharmaceuticals (See Tables 1 and 2.) 2. Preinjection a. Technetium-99m-HMPAO (exametazime [unstabi- The most important aspect of patient preparation is to lized]). achieve a consistent environment at the time of injection b. Technetium-99m-HMPAO (exametazime [stabi and uptake. lized]). c. Technetium-99m-bicisate (ethyl cystine dimer For correspondence or reprints contact: Wendy J.M. Smith, Director of Health Care Policy, Society of Nuclear Medicine, 1850 Samuel Morse Dr., Reston, VA 20190-5316, [ECD]). or by e-mail at [email protected]. Note: All 26 SNM-approved procedure guidelines are available on the Society's home 2. Radiopharmaceutical Preparation page. We encourage you to download these documents via the Internet at www. a. Use fresh generator eluate (<2 hr old) for optimal snm.org. If you would like information on the development process of this guideline or results with 99mTc-HMPAO. to order a compendium of all 26 procedure guidelines for $20.00, contact Marie Davis, Society of Nuclear Medicine, at (703) 708-9000, ext. 250, or by e-mail at b. Do not use pertechnetate obtained from a generator [email protected]. that has not been eluted for 24 hr or more.

PROCEDUREGUIDELINEFORBRAINPERFUSIONSPECT •Juni et al. 923