Non-Ischemic Finding on Gated SPECT Myocardial Perfussion Imaging to Explain Symptoms: Case Report

Turkiye Klinikleri J Med Sci 2010;30(4)

1384

t present, nuclear cardiology is the most widely used noninvasive

approach for assessing myocardial perfusion and viability.

Altho-ugh myocardial perfusion defects reflect functional ischemia,

the-re could also be ancillary findings pthe-redicting a risk of coronary artery

Non-Ischemic Finding on Gated SPECT

Myocardial Perfussion Imaging to

Explain Symptoms: Case Report

AABBSS TTRRAACCTT On myo car di al per fu si on scin tig raphy, pla nar pro jec ti on ima ges al low de tec ti on of both car di ac and non car di ac ab nor ma li ti es, which may af fect in ter pre ta ti on of the myo car di al per fu si on ima ges, and can exp la in pa ti ent’s symptoms so, in cre a sed and re du ced ex tra car di ac up ta kes sho uld be con si de red. We pre sent such a ca se de mons tra ting the im por tan ce of syste ma tic ins pec ti on of pla-nar pro jec ti ons. A 63-ye ar-old ma le with prog res si ve exer ti o nal dyspne a and fa ti gu e was re fer red for myo car di al per fu si on sing le pho ton emis si on com pu ted to mog raphy (SPECT) ima ging for eva lu-a ting isc he mic he lu-art di se lu-a se. In our clu-a se pllu-a nlu-ar pro jec ti on imlu-a ges de mons trlu-a ted lu-a llu-ar ge pho to pe nic are a aro und the he art and, mild in cre a sed lung up ta ke. Af ter we per for med CT ple u ral, pe ri car di al ef fu si ons, and pul mo nary ca pil lary en lar ge ment we re re a li zed. Af ter all this fin dings, pa ti ent had me di cal the raphy for he art fa i lu re and symptoms we re sub si ded. We sug gest that physi ci ans sho uld be ca re ful abo ut ins pec ti on of pla nar pro jec ti on, to mog rap hic, ima ges on GA TED car di ac SPECT study. Eva lu ti on per fu si on de fects only may not be eno ugh, to exp la in pa ti ent’s symptoms. KKeeyy WWoorrddss:: Car di ac-ga ted sing le-pho ton emis si on com pu ter-as sis ted to mog raphy;

pe ri car di al ef fu si on

Ö

ÖZZEETT Myo kard per füz yon sin tig ra fi sin de pla nar pro jek si yon imaj la rı, has ta semp tom la rı nı açık la -ya bi le cek ve ima jın yo ru mu nu et ki le ye bi le cek kar di ak ve kar di ak ol ma -yan anor mal lik le rin tes pit edil me si ne kat kı da bu lu nur. Bu yüz den eks tra kar di ak art mış ve azal mış ak ti vi te tutu lum la rı na dik kat edil me li dir. Pla nar pro jek si yon la rın sis te ma tik in ce len me si nin öne mi ni or ta ya çı ka ran bir va -ka yı bu ra da sun duk. Altmış üç ya şın da er kek bir has ta dan, eg zer siz ile or ta ya çı -kan iler le yi ci ne fes dar lı ğı şika ye ti se be biy le is ke mik kalp has ta lı ğı açı sın dan de ğer len di ril mek üze re myo kard per füz yon tek foton emisyon bilgisayarlı tomografi (SPECT) sin tig ra fi si is ten di. Va ka mız da, pla nar pro -jek si yon imaj la rın da kal bi çev re le yen ge niş fo to pe nik bir alan ve ak ci ğer ler de or ta dü zey de dif füz art mış ak ti vi te tu tu lu mu iz len di. CT ça lış ma sı uy gu lan dık tan son ra plev ral, pe ri kar di yal efüz yo -nun ve pul mo ner ka pil ler ge niş le me nin ol du ğu far ke dil di. Tüm bu bul gu lar dan son ra has ta ya kalp yet mez li ği ne yö ne lik te da vi uy gu lan dı ve has ta nın şika yet le ri ge ri le di. Biz, he kim ler ta ra fın dan gated kar di yak SPECT ça lış ma sın da pla nar pro jek si yon ve to mog ra fik gö rün tü le rin dik kat le in ce len me si ge rek ti ği ni sa vu nu yo ruz. Yal nız ca per füz yon de fekt le ri ni de ğer len dir mek has ta la rın semp -tom la rı nı açık la mak için ye ter li ol ma ya bi lir.

AAnnaahh ttaarr KKee llii mmee lleerr:: Kar di yak gated-tek-foton emisyon bilgisayar-yardımlı tomografi; pe ri kar di yal efüz yon

TTuurrkkiiyyee KKlliinniikklleerrii JJ MMeedd SSccii 22001100;;3300((44))::11338844--66

Melih Engin ERKAN, MD,

Ayşe Nurdan KORKMAZ, MD,

Huri Tilla İLÇE, MD,

Mesut AYDIN, MD,

Mustafa YILDIRIM, MD,

Ahmet Semih DOĞAN, MD

Departments of

a_{Nuclear Medicine,} b_Cardiology,

Düzce University Faculty of Medicine, Düzce

Ge liş Ta ri hi/Re ce i ved: 23.08.2008 Ka bul Ta ri hi/Ac cep ted: 29.12.2008 Ya zış ma Ad re si/Cor res pon den ce: Melih Engin ERKAN, MD

Düzce University Faculty of Medicine, Department of Nuclear Medicine, Düzce,

TÜRKİYE/TURKEY melihenginerkan@gmail.com

Cop yright © 2010 by Tür ki ye Kli nik le ri

Turkiye Klinikleri J Med Sci 2010;30(4)

1385

Nuclear Medicine Erkan et al

disease and fu tu re car di ac events. In cre a sed 99m

Tc-ses ta mi bi stress lung-he art ra ti o (LHR) (nor mal

li mit is less than 0.40) may add sig ni fi cant di ag nos

-tic va lu e as a mar ker of co ro nary ar tery di se a se and

re du ced ven tri cu lar func ti on, and por tends a wor

-se prog no sis.

_{The im por tan ce of are as with re du}

-ced tra cer up ta ke sho uld not be over lo o ked such as

pe ri car di al ef fu si ons.

_{We pre sent such a ca se de}

mons tra ting the im por tan ce of syste ma tic ins pec ti

-on of pla nar pro jec ti -ons.

CA SE REPORT

A 63-ye ar-old ma le with prog res si ve exer ti o nal

dyspne a and 50% ste no sis in left an te ri or des cen

-ding ar tery was re fer red for myo car di al per fu si on

SPECT ima ging. One-day phar ma co lo gi cal

(dyprida mol) study was per for med using Tc99m ses ta

-mi bi (10 mCi= 370 MBq stress, 30 mCi= 1110 MBq

rest). The stress elec tro car di og ram was ne ga ti ve for

isc he mi a. The to mog rap hic ima ges re ve a led isc he

-mi a on apex, and a fi xed de fect on an te ri or wall.

Pla nar pro jec ti on ima ges de mons tra ted a lar ge

pho-to pe nic are a sur ro un ding the he art (Fi gu re 1). An

in cre a sed mild dif fu se lung tra cer up ta ke was se en

(LHR was 0.54). Post stress and rest gated SPECT

ima ges we re no tab le with a left ven tri cu lar ejec ti

-on frac ti -on of 28%. Trans tho ra cic ec ho car di og ram

de mons tra ted re duc ti on in left ven tri cu lar systo lic

func ti on (30% EF), and pe ri car di al ef fu si on (Fi gu

re 2A). CT re ve a led bi la te ral ple u ral, and pe ri car

-di al ef fu si on, and pul mo nary ca pil lary en lar ge ment

du e to left ven tri cu lar fa i lu re (Fi gu re 2B). Pa ti ent

had me di cal the rapy for he art fa i lu re and

symp-toms seemed sub si ded in the first month vi sit.

Then, the pa ti ent un der went co ro nary in ter ven ti

on for the ste no tic le si ons res pon sib le for isc he

-mia.

DIS CUS SI ON

Pla nar pro jec ti on ima ges al low de tec ti on of both

car di ac and non car di ac ab nor ma li ti es in the car di

-ac fi eld of vi ew, such as pa ti ent mo ti on ar ti f-acts,

softtis su e and me tal lic at te nu a ti on ar ti facts, in ter

-fe ring sub di ap hrag ma tic ac ti vity, and ab nor mal

in jec ti onsi te ac ti vity, which may af fect in ter pre

-ta ti on of the myo car di al per fu si on ima ges.

_{Im por}

-tant me di as ti nal or ab do mi nal in ci den tal fin dings

may al so be ap pa rent on ins pec ti on of pro jec ti on

da ta with fre qu ency of as high as 2.8%. Alt ho ugh

me di as ti num and aro und he art (ar row), sug ges ti ve of pe ri car di al ef fu si on. No te mildly in cre a sed lung up ta ke.

FI GU RE 2: In ad di ti on to pe ri car di al ef fu si on (whi te ar rows) on ec ho car di og raphy (A) and CT (B), ple u ral ef fu si on (black ar rows) and vas cu lar en lar ge ment, due

Turkiye Klinikleri J Med Sci 2010;30(4)

1386

Erkan ve ark. Nükleer Tıp

the ma jor im pact of the se fin dings with usu ally

incre a sed up ta ke se ems to be de tec ti on of ma lig

-nancy, thyro id di se a se, ec to pic pa rath yro ids, or

inf lam ma ti on, the im por tan ce of are as with re du

-ced tra cer up ta ke sho uld not al so be over lo o ked

such as as ci tes, ef fu si ons or cysts.

Pe ri car di al ef fu si on may accompany cer ta in

car di ac and non car di ac di se a ses, ca u ses ha e mody

-na mic ab nor ma li ti es ran ging from un de tec tab le or

mild, to li fe thre a te ning, and is de tec ted by ec ho

-car di og raphy which is the most com mon and

sen-si ti ve met hod.

_{CT and MRI may al so be used and}

may be mo re ac cu ra te.

_{The di ag no sis of pe ri car}

-di al ef fu si on using myo car -di al per fu si on SPECT

study is un com mon but, are as of re du ced tra cer

upta ke aro und the he art re la ted to pe ri car di al ef fu si

-on which is unk nown be fo re the SPECT study,

may be cri ti cal for pro per in ter pre ta ti on of the

car-di ac scan or may le ad to im por tant car-di ag no ses.

The re are a few ca se re ports on di ag no sis of

pe ri car di al ef fu si on by ra di o nuc li de car di ac SPECT

study. Fo ur pe ri car di al ef fu si on ca ses with the

typ-i cal ap pe a ran ce of a “ha lo ” of pho to pe ntyp-ic are a

sur-ro un ding the he art on pla nar psur-ro jec ti on and to

mo-g rap hic ima mo-ges, and a “roc kin mo-g” mo ti on of the

he art on GA TED ima ges we re re por ted by Pa tel et

al.,

_{As kew et al.,}

_{and Her zog et al.,}

_{with typi}

-cal ap pe ran ce as men ti o ned be fo re.

_{One ca se was}

al so re por ted as the ec ho car di og ram had un de res

ti ma ted the amo unt of pe ri car di al ef fu si on com pa

-red to myo car di al per fu si on ima ging, by Spi eth ME

et al.

_{In our ca se, alt ho ugh the ap pe ran ce of}

pho-to pe nic ha lo was se en aro und the he art, the roc

k-ing mo ti on of the he art was not seen on GA TED

ima ges.

Pla nar pro jec ti on ima ges al low de tec ti on of

both car di ac and non car di ac ab nor ma li ti es which

may af fect in ter pre ta ti on of the myo car di al per fu

-si on ima ges, and can exp la in pa ti ent symptoms.

The physi ci an sho uld be ca re ful abo ut ins pec ti on

of pla nar pro jec ti on, to mog rap hic, and gated ima

-ges of car di ac SPECT study. Eva lu ti on of only

per-fu si on de fects may not be eno ugh to exp la in

pa ti ent’s symptoms.

1. Turkmen C, Cantez S. [Nuclear cardiology]. Turkiye Klinikleri J Int Med Sci 2005;1(42):67-86.

2. Higgins JP, Higgins JA, Williams G. Stress-in-duced abnormalities in myocardial perfusion imaging that are not related to perfusion but are of diagnostic and prognostic importance. Eur J Nucl Med Mol Imaging 2007;34(4):584-95.

3. Hendel RC, Gibbons RJ, Bateman TM. Use of rotating (cine) planar projection images in the interpretation of a tomographic myocardial perfusion study. J Nucl Cardiol 1999;6(2):234-40.

4. Patel AD, Abo-Auda WS, Gupta H, Iskandrian AE. Detection of pericardial effusion during Tc-99m sestamibi cardiac imaging. J Nucl Car-diol 2003;10(1):102-4.

5. Williams KA, Hill KA, Sheridan CM.

Noncar-diac findings on dual-isotope myocardial per-fusion SPECT. J Nucl Cardiol 2003;10(4): 395-402.

6. Raza M, Meesala M, Panjrath G, Ghanbarinia A, Jain D. Abnormal photopenic area on nu-clear perfusion imaging. J Nucl Cardiol 2005;12(5):607-9.

7. Gowda A, Chhabra A, Gavriluke A, Pedding-haus L, Jain D. Unusual photopenic area in the abdomen on myocardial perfusion imag-ing. J Nucl Cardiol 2006;13(4):e6-8. 8. Kanadasi M, Cayli M, Demirtas M.

[Peri-carditis: review]. Turkiye Klinikleri J Med Sci 2005;25(5):693-705.

9. Shabetai R. Pericardial effusion: haemody-namic spectrum. Heart 2004;90(3):255-6. 10. Tajik J. Echocardiography in pericardial

effu-sion. Am J Med 1977;63(1):29-40.

11. Feigenbaum H. Echocardiographic diagnosis of pericardial effusion. Am J Cardiol 1970;26(5):475-9.

12. Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modali-ties, and management. Compr Ther 1995; 21(7):378-85.

13. Askew JW, Christenson SD. Abnormalities on cardiac planar projection and tomographic im-ages: focus on pericardial effusions. Int J Car-diol 2008;127(2):266-8.

14. Herzog E, Krasnow N, DePuey G. Diagnosis of pericardial effusion and its effects on ven-tricular function using gated Tc-99m sestamibi perfusion SPECT. Clin Nucl Med 1998; 23(6):361-4.

15. Spieth ME, Schmitz SL, Tak T. Incidental mas-sive pericardial effusion diagnosed by my-ocardial perfusion imaging. Clin Med Res 2003;1(2):141-4.

REFERENCES

View publication stats View publication stats