Implementation of Ventilation/Perfusion SPECT in Diagnostics beyond Pulmonary Embolism
Main Article Content
Abstract
Scintigraphic pulmonary studies are designed to demonstrate patterns of ventilation and perfusion. It is crucial to make an image of both ventilation and perfusion for a proper diagnostic interpretation of any disorder. In pulmonary embolism, there are areas with absent perfusion and preserved ventilation. Pulmonary embolism is diagnosed when there is more than one sub-segment showing a ventilation/perfusion mismatch, representing an anatomic lung unit. Ventilation/perfusion single-photon emission computed tomography (V/P SPECT) is recommended as the first-choice imaging technique for the diagnosis of acute pulmonary embolism and is the golden standard for the diagnosis of chronic pulmonary embolism. Antigravitational perfusion distribution from posterior to anterior region indicates pulmonary congestion (heart failure). As ventilation is usually less affected, the typical pattern is a non-segmental ventilation/perfusion mismatch in dorsal regions of the lung. Some other diseases cause declines in both ventilation and perfusion resulting in a “matched” functional defect. Acute pneumonia causes frequently reverse mismatches. Later in the progress of the pneumonia matched defects may be seen. Using Technegas for the ventilation study over radiolabeled liquid aerosols enable grading of airway obstruction in chronic obstructive pulmonary disease. Areas of absent/decreased ventilation with usually less pronounced perfusion defects (reverse mismatch) are typical for the damage of lung parenchyma (emphysema).
Minimizing radiation exposure without sacrificing image quality and diagnostic accuracy are essentials for an imaging test that follows good clinical practice. An optimal combination of radiopharmaceuticals, nuclide activities and acquisition times for ventilation and perfusion, collimators, and imaging matrix yield an adequate ventilation perfusion SPECT study in approximately 20 minutes of imaging time. Ventilation/perfusion SPECT is using a holistic interpretation strategy based on all relevant information about the patient and all ventilation/perfusion patterns. The method allows quantification of lung function and measurement of the extent of functional deteriorations that have impact on the diagnostics and treatment.
Following the recent European Association of Nuclear Medicine guideline of ventilation/perfusion SPECT allows diagnostics of comorbidities such as obstructive lung disease, pulmonary congestion, and pneumonia separately or simultaneously with pulmonary embolism.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Bajc M, Olsson B, Palmer J, Jonson B. Ventilation/perfusion SPECT for diagnostics of pulmonary embolism in clinical practice. J Intern Med. 2008;264:379-387. https://doi.org/10.1111/j.1365-2796.2008.01980.x.
3. Grüning T, Drake BE, Farrell SL, Nokes T. Three-year clinical experience with VQ SPECT for diagnosing pulmonary embolism: Diagnostic performance. Clin Imaging. 2014;38:831-835. https://doi.org/10.1016/j.clinimag.2014.04.003.
4. Gutte H, Mortensen J, Jensen CV, et al. Detection of pulmonary embolism with combined ventilation-perfusion SPECT and low-dose CT: head-to-head comparison with multidetector CT angiography. J Nucl Med. 2009;50(12):1987–1992. https://doi.org/10.2967/jnumed.108.061606.
5. Leblanc M, Leveillee F, Turcotte E. Prospective evaluation of the negative predictive value of V/Q SPECT using 99mTc-Technegas. Nucl Med Commun. 2007;28(8):667-672. https://doi.org/10.1097/MNM.0b013e32827a8e99.
6. Lemb M, Pohlabeln H. Pulmonary thromboembolism: A retrospective study on the examination of 991 patients by ventilation/perfusion SPECT using Technegas. Nuklearmedizin. 2001;40(6):179-186.
7. Reinartz P, Wildberger JE, Schaefer W, Nowak B, Mahnken AH, Buell U. Tomographic imaging in the diagnosis of pulmonary embolism: a comparison between V/Q lung scintigraphy in SPECT technique and multislice spiral CT. J Nucl Med. 2004;45:1501–1508.
8. Mahdavi R, Caronia J, Fayyaz J, et al. Agreement between SPECT V/Q scan and CT angiography in patients with high clinical suspicion of PE. Ann Nucl Med. 2013;27:834–838. https://doi.org/10.1007/s12149-013-0753-1.
9. Kan Y, Yuan L, Meeks JK, Li C, Liu W, Yang J. The accuracy of V/Q SPECT in the diagnosis of pulmonary embolism: a meta-analysis. Acta Radiol. 2015;56:565–572. https://doi.org/10.1177/0284185114533682.
10. Bajc M, Neilly JB, Miniati M, Schümichen C, Meignan M, Jonson B. EANM guidelines for ventilation/perfusion scintigraphy: Part 1. Pulmonary imaging with ventilation/perfusion single photon emission tomography. Eur J Nucl Med Mol Imaging. 2009;36:1356–1370. https://doi.org/10.1007/s00259-009-1170-5.
11. Bajc M, Neilly JB, Miniati M, Schümichen C, Meignan M, Jonson B. EANM guidelines for ventilation/perfusion scintigraphy: Part 2. Algorithms and clinical considerations for diagnosis of pulmonary emboli with V/P(SPECT) and MDCT. Eur J Nucl Med Mol Imaging. 2009;36:1528–1538. https://doi.org/10.1007/s00259-009-1169-y
12. Bajc M, Schümichen C, Grüning T, Lindqvist A, et al. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. European Journal of Nuclear Medicine and Molecular Imaging. 2019;46:2429–2451. https://doi.org/10.1007/s00259-019-04450-0.
13. Burch WM, Tetley IJ, Gras JL. Technetium-99m ‘pseudogas’ for diagnostic studies in the lung. Clin Phys Physiol Meas. 1984;5:79–85.
14. Jögi J, Jonson B, Ekberg M, Bajc M. Ventilation-perfusion SPECT with 99mTc-DTPA versus Technegas: a head-to-head study in obstructive and nonobstructive disease. J Nucl Med. 2010;51:735–741. https://doi.org/10.2967/jnumed.109.073957.
15. Bajc M, Markstad H, Jarenbäck L, Tufvesson E, Bjermer L, Jögi J. Grading obstructive lung disease using tomographic pulmonary scintigraphy in patients with chronic obstructive pulmonary disease (COPD) and long-term smokers. Ann Nucl Med. 2015;29:91–99. https://doi.org/10.1007/s12149-014-0913-y.
16. Bajc M, Chen Y, Wang J, et al. Identifying the heterogeneity of COPD by V/P SPECT: a new tool for improving the diagnosis of parenchymal defects and grading the severity of small airways disease. Int J Chron Obstruct Pulmon Dis. 2017;12:1579–1587. https://doi.org/10.2147/copd.S131847.
17. Ciofetta G, Piepsz A, Roca I, et al. Guidelines for lung scintigraphy in children. Eur J Nucl Med Mol Imaging. 2007;34:1518–1526. https://doi.org/10.1007/s00259-007-0485-3.
18. Palmer J, Bitzén U, Jonson B, Bajc M. Comprehensive ventilation/perfusion SPECT. J Nucl Med. 2001;42:1288–1294.
19. Olsson CG, Bitzén U, Olsson B, et al. Outpatient tinzaparin therapy in pulmonary embolism quantified with ventilation/perfusion scintigraphy. Med Sci Monit. 2006;12:PI9–13.
20. Astani SA, Davis LC, Harkness BA, Supanich MP, Dalal I. Detection of pulmonary embolism during pregnancy: Comparing radiation doses of CTPA and pulmonary scintigraphy. Nucl Med Commun. 2014;35(7):704–711. doi:10.1097/mnm.0000000000000114
21. Isidoro J, Gil P, Costa G, De Lima JP, Alves C, Ferreira NC. Radiation dose comparison between V/P-SPECT and CT-angiography in the diagnosis of pulmonary embolism. Physica Medica. 2017;41:93-96. http://dx.doi.org/10.1016/j.ejmp.2017.04.026
22. Wagner HN Jr. The use of radioisotope techniques for the evaluation of patients with pulmonary disease. Am Rev Respir Dis. 1976;113:203–218.
23. Le Roux P-Y, Palard X, Robin P, et al. Safety of ventilation/perfusion single photon emission computed tomography for pulmonary embolism diagnosis. Eur J Nucl Med Mol Imaging. 2014;41:1957–1964. https://doi.org/10.1007/s00259-014-2763-1.
24. Elf JE, Jogi J, Bajc M. Home treatment of patients with small to medium sized acute pulmonary embolism. J Thromb Thrombolysis. 2015;39(2):166–172. doi: 10.1007/s11239-014-1097-y.
25. Begic A, Jögi J, Hadziredzepovic A, Kucukalic-Selimovic E, Begovic-Hadzimuratovic S, Bajc M. Tomographic ventilation/perfusion lung scintigraphy in the monitoring of the effect of treatment in pulmonary embolism: serial follow-up over a 6-month period. Nucl Med Commun. 2011;32:508–514. https://doi.org/10.1097/MNM.0b013e328344dfd5.
26. Begic A, Opanković E, Čukić V, et al. Impact of ventilation/perfusion single-photon emission computed tomography on treatment duration of pulmonary embolism. Nucl Med Commun. 2015;36:162–167. https://doi.org/10.1097/MNM.0000000000000224.
27. Alhadad A, Miniati M, Alhadad H, Gottsater A, Bajc M. The value of tomographic ventilation/ perfusion scintigraphy (V/PSPECT) for follow-up and prediction of recurrence in pulmonary embolism. Thromb Res. 2012;130:877–881. https://doi.org/10.1016/j.thromres.2012.09.002.
28. Couturaud F, Sanchez O, Pernod G, et al. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: the PADIS-PE randomized clinical trial. JAMA. 2015;314:31–40. https://doi.org/10.1001/jama.2015.7046.
29. Couturaud F. Guided duration of anticoagulation after unprovoked venous thromboembolism using D-dimer testing. Eur Respir J. 2016;47:1313–1314. https://doi.org/10.1183/13993003.00212-2016.
30. Tunariu N, Gibbs SJ, Win Z, et al. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J Nucl Med. 2007;48:680–684. https://doi.org/10.2967/jnumed.106.039438.
31. Bajc M. Value of ventilation/perfusion SPECT detecting extensive pulmonary embolism in a patient with pneumonia. Thromb Haemost. 2005;93:993–994.
32. Begic A, Opankovic E, Cukic V, Lindqvist A, Miniati M, Bajc M. Ancillary findings assessed by ventilation/perfusion tomography. Impact and clinical outcome in patients with suspected pulmonary embolism. Nuklearmedizin. 2015;54:223–230. https://doi.org/10.3413/Nukmed-0748-15-06.
33. Friedman WF, Braunwald E. Alterations in regional pulmonary blood flow in mitral valve disease studied by radioisotope scanning. A simple nontraumatic technique for estimation of left atrial pressure. Circulation. 1966;34:363–376.
34. Pistolesi M, Miniati M, Bonsignore M, et al. Factors affecting regional pulmonary blood flow in chronic ischemic heart disease. J Thorac Imaging. 1988;3:65–72.
35. Jögi J, Palmer J, Jonson B, Bajc M. Heart failure diagnostics based on ventilation/perfusion single photon emission computed tomography pattern and quantitative perfusion gradients. Nucl Med Commun. 2008;29:666–673. https://doi.org/10.1097/MNM.0b013e328302cd26.
36. Jögi J, Al-Mashat M, Rådegran G, Bajc M, Arheden H. Diagnosing and grading heart failure with tomographic perfusion lung scintigraphy: validation with right heart catheterization. ESC Heart Fail. 2018;5(5):902-910. https://doi.org/10.1002/ehf2.12317.
37. Nasr A, Lindqvist A, Bajc M. Ventilation defect typical for COPD is frequent among patients suspected for pulmonary embolism but does not prevent the diagnosis of PE by VP SPECT. EC Pulmonol Respir Med. 2017;4:85–91.