Single-photon emission computed tomography
Intervention
A SPECT slice of the distribution of technetium exametazime within a patient's brain.
ICD-9-CM	92.0-92.1
MeSH	D015899
OPS-301 code:	3-72

Single-photon emission computed tomography (SPECT, or less commonly, SPET) is a nuclear medicine tomographic^[1] imaging technique using gamma rays. It is very similar to conventional nuclear medicine planar imaging using a gamma camera. However, it is able to provide true 3D information. This information is typically presented as cross-sectional slices through the patient, but can be freely reformatted or manipulated as required.

The basic technique requires injection of a gamma-emitting radioisotope (called radionuclide) into the bloodstream of the patient. On occasion, the radioisotope is a simple soluble dissolved ion, such as a radioisotope of gallium(III), which happens to also have chemical properties that allow it to be concentrated in ways of medical interest for disease detection. However, most of the time in SPECT, a marker radioisotope, which is of interest only for its radioactive properties, has been attached to a specific ligand to create a radioligand, which is of interest for its chemical binding properties to certain types of tissues. This marriage allows the combination of ligand and radioisotope (the radiopharmaceutical) to be carried and bound to a place of interest in the body, which then (due to the gamma-emission of the isotope) allows the ligand concentration to be seen by a gamma-camera.

Principles[link]

SPECT Siemens brand. It consists of two gamma cameras.

In the same way that a plain X-ray is a 2-dimensional (2-D) view of a 3-dimensional structure, the image obtained by a gamma camera is a 2-D view of 3-D distribution of a radionuclide.

SPECT imaging is performed by using a gamma camera to acquire multiple 2-D images (also called projections), from multiple angles. A computer is then used to apply a tomographic reconstruction algorithm to the multiple projections, yielding a 3-D dataset. This dataset may then be manipulated to show thin slices along any chosen axis of the body, similar to those obtained from other tomographic techniques, such as MRI, CT, and PET.

SPECT is similar to PET in its use of radioactive tracer material and detection of gamma rays. In contrast with PET, however, the tracer used in SPECT emits gamma radiation that is measured directly, whereas PET tracer emits positrons that annihilate with electrons up to a few millimeters away, causing two gamma photons to be emitted in opposite directions. A PET scanner detects these emissions "coincident" in time, which provides more radiation event localization information and, thus, higher resolution images than SPECT (which has about 1 cm resolution). SPECT scans, however, are significantly less expensive than PET scans, in part because they are able to use longer-lived more easily-obtained radioisotopes than PET.

Because SPECT acquisition is very similar to planar gamma camera imaging, the same radiopharmaceuticals may be used. If a patient is examined in another type of nuclear medicine scan but the images are non-diagnostic, it may be possible to proceed straight to SPECT by moving the patient to a SPECT instrument, or even by simply reconfiguring the camera for SPECT image acquisition while the patient remains on the table.

SPECT machine performing a total body bone scan. The patient lies on a table that slides through the machine, while a pair of gamma cameras rotate around her.

To acquire SPECT images, the gamma camera is rotated around the patient. Projections are acquired at defined points during the rotation, typically every 3–6 degrees. In most cases, a full 360-degree rotation is used to obtain an optimal reconstruction. The time taken to obtain each projection is also variable, but 15–20 seconds is typical. This gives a total scan time of 15–20 minutes.

Multi-headed gamma cameras can provide accelerated acquisition. For example, a dual-headed camera can be used with heads spaced 180 degrees apart, allowing 2 projections to be acquired simultaneously, with each head requiring 180 degrees of rotation. Triple-head cameras with 120-degree spacing are also used.

Cardiac gated acquisitions are possible with SPECT, just as with planar imaging techniques such as MUGA. Triggered by Electrocardiogram (EKG) to obtain differential information about the heart in various parts of its cycle, gated myocardial SPECT can be used to obtain quantitative information about myocardial perfusion, thickness, and contractility of the myocardium during various parts of the cardiac cycle, and also to allow calculation of left ventricular ejection fraction, stroke volume, and cardiac output.

HMPAO brain 3D SPECT for neuropsychiatric diagnosis[link]

Most SPECT scanner workstations can render the 2D slices in a variety of formats. In a 3D Surface View, the cortical surface of the brain is reconstructed from the 2D slices. Holes or defects in the surface of the brain actually represent decreases in perfusion, which may be related to decreases in neuronal activity.^[2] In a 3D Active View the interior of the brain is displayed as a lattice gridwork. Daniel Amen, a California-based physician who has utilized 3D SPECT scanning heavily in his medical practice, has standardized 3D Active Views such that average activity is shown in a blue color, higher activity is shown in red, and very high activity is shown in white.^[3] Some utility of brain HMAPO 3D SPECT scan in neuropsychiatric diagnosis and management has been found.^[4]

Application[link]

SPECT can be used to complement any gamma imaging study, where a true 3D representation can be helpful, e.g., tumor imaging, infection (leukocyte) imaging, thyroid imaging or bone scintigraphy.

Because SPECT permits accurate localisation in 3D space, it can be used to provide information about localised function in internal organs, such as functional cardiac or brain imaging.

Myocardial perfusion imaging[link]

Myocardial perfusion imaging (MPI) is a form of functional cardiac imaging, used for the diagnosis of ischemic heart disease. The underlying principle is that under conditions of stress, diseased myocardium receives less blood flow than normal myocardium. MPI is one of several types of cardiac stress test.

A cardiac specific radiopharmaceutical is administered, e.g., ^99mTc-tetrofosmin (Myoview, GE healthcare), ^99mTc-sestamibi (Cardiolite, Bristol-Myers Squibb). Following this, the heart rate is raised to induce myocardial stress, either by exercise or pharmacologically with adenosine, dobutamine, or dipyridamole (aminophylline can be used to reverse the effects of dipyridamole).

SPECT imaging performed after stress reveals the distribution of the radiopharmaceutical, and therefore the relative blood flow to the different regions of the myocardium. Diagnosis is made by comparing stress images to a further set of images obtained at rest. As the radionuclide redistributes slowly, it is not usually possible to perform both sets of images on the same day, hence a second attendance is required 1–7 days later (although, with a Tl-201 myocardial perfusion study with dipyridamole, rest images can be acquired as little as two hours post-stress). However, if stress imaging is normal, it is unnecessary to perform rest imaging, as it too will be normal; thus, stress imaging is normally performed first.

MPI has been demonstrated to have an overall accuracy of about 83% (sensitivity: 85%; specificity: 72%),^[5] and is comparable with (or better than) other non-invasive tests for ischemic heart disease.

Functional brain imaging[link]

Usually, the gamma-emitting tracer used in functional brain imaging is ^99mTc-HMPAO (hexamethylpropylene amine oxime). ^99mTc is a metastable nuclear isomer that emits gamma rays that can be detected by a gamma camera. Attaching it to HMPAO allows ^99mTc to be taken up by brain tissue in a manner proportional to brain blood flow, in turn allowing cerebral blood flow to be assessed with the nuclear gamma camera.

Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, the ^99mTc-HMPAO tracer (as well as the similar ^99mTc-EC tracer) is used to assess brain metabolism regionally, in an attempt to diagnose and differentiate the different causal pathologies of dementia. Meta-analysis of many reported studies suggests that SPECT with this tracer is about 74% sensitive at diagnosing Alzheimer's disease vs. 81% sensitivity for clinical exam (cognitive testing, etc.). More recent studies have shown the accuracy of SPECT in Alzheimer's diagnosis may be as high as 88%.^[6] In meta analysis, SPECT was superior to clinical exam and clinical criteria (91% vs. 70%) in being able to differentiate Alzheimer's disease from vascular dementias.^[7] This latter ability relates to SPECT's imaging of local metabolism of the brain, in which the patchy loss of cortical metabolism seen in multiple strokes differs clearly from the more even or "smooth" loss of non-occipital cortical brain function typical of Alzheimer's disease.

^99mTc-HMPAO SPECT scanning competes with fludeoxyglucose (FDG) PET scanning of the brain, which works to assess regional brain glucose metabolism, to provide very similar information about local brain damage from many processes. SPECT is more widely available, however, for the basic reason that the radioisotope generation technology is longer-lasting and far less expensive in SPECT, and the gamma scanning equipment is less expensive as well. The reason for this is that ^99mTc is extracted from relatively simple technetium-99m generators, which are delivered to hospitals and scanning centers weekly to supply fresh radioisotope, whereas FDG PET relies on FDG, which must be made in an expensive medical cyclotron and "hot-lab" (automated chemistry lab for radiopharmaceutical manufacture), then must be delivered directly to scanning sites, with delivery-fraction for each trip handicapped by its natural short 110-minute half-life.

Reconstruction[link]

Coded aperture mask for gamma camera

Reconstructed images typically have resolutions of 64×64 or 128×128 pixels, with the pixel sizes ranging from 3–6 mm. The number of projections acquired is chosen to be approximately equal to the width of the resulting images. In general, the resulting reconstructed images will be of lower resolution, have increased noise than planar images, and be susceptible to artifacts.

Scanning is time consuming, and it is essential that there is no patient movement during the scan time. Movement can cause significant degradation of the reconstructed images, although movement compensation reconstruction techniques can help with this. A highly uneven distribution of radiopharmaceutical also has the potential to cause artifacts. A very intense area of activity (e.g., the bladder) can cause extensive streaking of the images and obscure neighboring areas of activity. (This is a limitation of the filtered back projection reconstruction algorithm. Iterative reconstruction is an alternative algorithm that is growing in importance, as it is less sensitive to artifacts and can also correct for attenuation and depth dependent blurring).

Attenuation of the gamma rays within the patient can lead to significant underestimation of activity in deep tissues, compared to superficial tissues. Approximate correction is possible, based on relative position of the activity. However, optimal correction is obtained with measured attenuation values. Modern SPECT equipment is available with an integrated X-ray CT scanner. As X-ray CT images are an attenuation map of the tissues, this data can be incorporated into the SPECT reconstruction to correct for attenuation. It also provides a precisely registered CT image, which can provide additional anatomical information.

Typical SPECT acquisition protocols[link]

SPECT/CT[link]

In some cases a SPECT gamma scanner may be built to operate with a conventional CT scanner, with coregistration of images. As in PET/CT, this allows location of tumors or tissues which may be seen on SPECT scintigraphy, but are difficult to precisely locate with regard to other anatomical structures. Such scans are most useful for tissues outside the brain, where location of tissues may be far more variable. For example, SPECT/CT may be used in sestamibi parathyroid scan applications, where the technique is useful in locating ectopic parahyroid ademomas which may not be in their usual locations in the thyroid gland.^[8]

See also[link]

References[link]

Further reading[link]

• Herman, Gabor T. (2009). Fundamentals of Computerized Tomography: Image Reconstruction from Projections (2nd ed.). Springer. ISBN 978-1-85233-617-2. .
• Elhendy et al., Dobutamine Stress Myocardial Perfusion Imaging in Coronary Artery Disease, J Nucl Med 2002 43: 1634–1646
• A review on brain-imaging applications of SPECT: W. Gordon Frankle, Mark Slifstein, Peter S. Talbot, and Marc Laruelle (2005). "Neuroreceptor Imaging in Psychiatry: Theory and Applications". International Review of Neurobiology, 67: 385–440. doi:10.1016/S0074-7742(05)67011-0

External links[link]

Wikimedia Commons has media related to: Single photon emission computed tomography

• Human Health Campus, The official website of the International Atomic Energy Agency dedicated to Professionals in Radiation Medicine. This site is managed by the Division of Human Health, Department of Nuclear Sciences and Applications
• Nuclear Medicine Information
• The nuclear medicine and molecular medicine podcast – Podcast
• National Isotope Development Center Reference information on radioisotopes including those for SPECT; coordination and management of isotope production, availability, and distribution
• Isotope Development & Production for Research and Applications (IDPRA) U.S. Department of Energy program for isotope production and production research and development