Influence of arm positioning on tomographic thallium-201 myocardial perfusion imaging and the effect of attenuation correction

Abstract.

Lateral attenuation in single-photon emission tomography (SPET) myocardial perfusion imaging (MPI) has been attributed to the left arm if it is held by the patient's side during data acquisition. As a result MPI data are conventionally acquired with the arms held above the head. The aims of this study were to determine the effect of imaging arms down on reconstructed tomographic images depicting regional myocardial thallium-201 distribution and to assess whether attenuation-corrected (AC) myocardial perfusion images acquired arms down could replace uncorrected (NC) images acquired arms up for routine clinical service. Twenty-eight patients referred for routine MPI underwent sequential 180° emission/transmission imaging for attenuation correction using an L-shaped dual-headed gamma camera (GE Optima) fitted with two gadolinium-153 scanning line sources. Delay data were acquired twice: once supine with the arms up and then supine with the arms down. Detector radius of rotation (ROR) for arms up and arms-down studies was recorded. For each data set, count density was measured in 17 segments of a polar plot and segmental uptake expressed relative to study maximum. Oblique images were assessed qualitatively by two observers blinded to study type for tracer distribution and overall quality. Transmission maps were assessed for truncation. Mean detector ROR was 190 mm for arms-up studies and 232 mm for arms-down studies (P<0.05). Population mean segmental relative uptake values for NC arms-up studies were higher than for NC arms-down studies, with the greatest difference seen anterolaterally. Nevertheless, the majority (24/28) of oblique NC arms-up and NC arms-down images appeared similar and only four (14%) NC arms-down studies showed additional areas of reduced count density (one anterior and three lateral). Corresponding AC arms-down studies showed that count density within the anterior defect improved to normal but the lateral reductions persisted, and in two of these three studies the arms-down transmission map was distorted. Population mean segmental relative uptake values for NC arms-down studies were lower than for AC arms-down studies apart from three anterolateral segments where NC arms-down values were higher. Of 28 AC arms-down studies, 11 (39%) were of reduced quality compared with NC arms-up studies because of poorer spatial resolution and because AC enhances liver activity compared with NC. It is concluded that arm positioning influences reconstructed tomographic images depicting regional ²⁰¹Tl distribution, particularly anterolaterally. There is lateral undercorrection in approximately 10% of AC arms-down studies, possibly because of attenuation map truncation. Image quality is reduced in about one-third of AC arms-down studies compared with NC arms-up studies. These data suggest that this attenuation correction method is not sufficiently robust to allow routine acquisition of MPI data with the arms down.