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This permits the use of acquisition protocols that specifically detect scintillation events from photons from a particular radionuclide symptoms of anxiety buy discount provestra 30 pills on line, and can allow for simultaneous acquisition of images using two radionuclides of different energies. In simplistic terms, a photomultiplier array visualizes all of the light produced by a given scintillation event, although each individual photomultiplier tube visualizes only a portion of the light. By summing all of the signals from all of the photomultiplier tubes in an array, it is possible to know the total amount of light for a given scintillation event. In actuality, not all photons interact in a linear fashion with respect to energy and light generation because of the combined effects of Compton scatter and instrumental uncertainty. The gamma camera can be set up to acquire only events that meet certain energy criteria, or fall within an "energy window" around the photopeak. This energy window is generated by a pulse-height analyzer, which rejects the photon signals that do not fall within a predetermined range surrounding the photopeak. Event Localization A gamma camera uses the concept of proportional energy generation from scintillation events to ascribe arithmetically each event to a particular location within the crystal. This method allows for image generation in the setting of low counts, scatter, and noise. This method of image reconstruction also permits the image to be reconstructed using information acquired from an attenuation map, correcting for nonuniform attenuation. After reconstruction by filtered back projection or iterative reconstruction, a tomographic image can be displayed and statistically quantified and interpreted. Procedures are required to ensure that energy peaking, uniformity, linearity, resolution, and sensitivity fall within standard norms. When analyzing the emissions from a point source of radioactivity, the photomultiplier tubes directly overlying the point source in either the X or the Y planes detect the most scintillation events (greatest number of "counts"). Position logic circuitry is used to place this particular photon emission in a given set of X, Y coordinates. These advances include multidetector imaging systems that allow for a smaller size imaging system, allowing imaging rooms to use less floor space. Solid-state, semiconductor-based detectors, such as cadmium zinc telluride, have the potential to improve energy and spatial resolution, decrease scan times, reduce radiation exposure, and allow for simultaneous dual-isotope imaging in small footprint imaging systems. Image Generation When a scintillation event has been localized and falls within the required energy window for detection, the generation of an image can occur. First, the analog signal obtained from the energy peak needs to be converted to a digital signal using an analog-to-digital converter. This digital signal can be transformed from a spatial domain to a frequency domain by way of the Fourier transformation. When the event localized digital information is in the frequency domain, it can be used for the construction of an image. This method requires the raw projection data to be passed through a so-called ramp filter to omit certain frequencies (filter "cutoff") and enhance other frequencies ("power") to optimize image quality. Filters function to remove inherent reconstruction artifacts (particularly the "star" artifact inherent in back projection), optimize the signal-to-noise ratio in image reconstruction, and provide image enhancement. This method allows for rapid image reconstruction, but loss of image information occurs because of filtering. Iterative methods use mathematical equations to model the particular imaging physics and geometry of the acquisition and to reconstruct the image after discriminating the image into pixels. An understanding of these principles helps the clinician select the appropriate and safest imaging study for the patient and recognize potential sources of imaging error and artifacts. Radioactive decay can produce alpha particles, beta particles, positrons, and gamma photons. Photons interact with matter via the photoelectric effect, Compton scatter, and pair production. Attenuation occurs when photons interact with matter, proportional to the attenuation coefficient for the interacting matter. I I Gamma cameras are composed of a collimator, a scintillation crystal, a light pipe, photomultiplier tubes, a pulseheight analyzer, position circuitry, an analog-to-digital converter, and a display device. The relationship between the degree of coronary stenosis and the maximal hyperemic response was first reported more than 30 years ago. Nonreversible myocardial perfusion defects normally relate to necrosis or infarction. Current imaging protocols allow the accurate assessment of relative regional perfusion and myocardial function at rest and stress based on regional blood flow heterogeneity. Redistribution is thought to represent areas of ischemic but viable myocardium, whereas fixed, nonredistributing defects are thought to represent nonviable, fibrotic scar. When 201Tl alone is used, a variety of different acquisition protocols of stress imaging have been employed, including redistribution and reinjection imaging. Overall sensitivity of several stress-redistribution-reinjection studies averaged 85% with a lower specificity (averaging 47%), suggesting that this protocol tends to overestimate the potential for contractile function recovery. After an intravenous injection, the initial myocyte uptake is mainly determined by regional myocardial perfusion, whereas the integrity of the cell membrane is predominantly important for delayed imaging of tracer retention (potassium ion total distribution). A negative mitochondrial gradient charge is essential for its accumulation and retention within the myocyte. This lack of significant redistribution means that separate rest and stress injections are standard with 99mTclabeled compounds. Different acquisition protocols can be used with these agents, including 2-day stress/rest, same-day rest/stress, same-day stress/rest, and dual-isotope protocols. Two-Day Protocol From a technical point of view, to optimize imaging quality, the 2-day stress/rest is one of the most preferred acquisition protocols. The main advantage is the use of two high doses of Tc 99m labeled compounds, which enables high-quality images to be obtained because of the elevated high count rate. The stress study should be performed first because the rest study can be omitted if the stress study is normal.

The "intrinsic resolution" of a particular gamma camera refers to the accuracy of the positioning circuitry and computer algorithms to determine the location of a scintillation event symptoms 24 hour flu buy provestra on line. Photon counts Energy Discrimination In addition to being able to determine the physical location of a scintillation event, a photomultiplier array can discriminate the energy of the exciting photon. Obviously, the major disadvantage is the delay in reporting of the final analysis. If the study is performed for the diagnosis of myocardial ischemia, the stress portion should be done first because that will avoid the reduction of contrast that a previously resting injection would have on a stress-induced defect. If detection of viable myocardium or assessment of the reversibility of a perfusion defect is the indication, performance of the resting study first may be preferable. As with all Tc 99m labeled compounds, imaging should begin between 60 and 90 minutes after injection to allow hepatobiliary clearance and to minimize subdiaphragmatic activity if vasodilators were administered. To enhance the washout of gastrointestinal activity from liver and gallbladder, fluids or a fatty meal can be suggested. Dilsizian and colleagues10 described the utility of quantitative Tc 99m sestamibi imaging when the severity of decrease in Tc 99m sestamibi uptake within irreversible defects was considered or when an additional redistribution image was acquired after the rest injection for detection of dysfunctional but viable myocardium. A significant inverse linear relationship has been described between Tc 99m sestamibi uptake and myocardial fibrosis in biopsy specimens. These tracers may prove to be of more value in the near future, considering the key role that oxidative metabolism plays in preservation of myocardial function. Dual-Isotope Protocols Dual-isotope imaging protocols using Tc 99m labeled compounds and 201Tl are based on the ability of the Anger camera to collect data from the two different energy windows representing each radiotracer. Separate acquisition times can reduce the necessity of downscatter correction that can diminish 201Tl contrast images, leading to an overestimation of defect reversibility; this can be achieved by acquiring 201Tl data sets before the administration of Tc 99m because of the very limited (2. One of the major advantages is the possibility of measuring contractile function and the left ventricular ejection fraction. The principal difference between stress methods relates to the mechanisms used to disclose regional myocardial blood flow abnormalities as an indication of coronary stenosis. It is critical to select the most appropriate test by the indication on a patient by patient basis. When the goal is to evaluate exercise tolerance, the duration of the exercise, symptoms developed, and hemodynamic changes are the primary factors to consider. Exercise testing is performed on the treadmill according to the Bruce protocols and allows the assessment of different hemodynamic variables, such as exercise capacity, blood pressure, and heart rate responses. It is imperative that the intravenous injection of the radiotracer be performed at maximal stress and that exercise continue for at least an additional 60 seconds to ensure optimal myocardial concentration. The traditional goal of the test as an acceptable level of cardiac workload has been the achievement of at least 85% of the maximum predicted heart rate (220 - age). A maximal stress test may satisfy diagnostic purposes if it goes beyond the hemodynamic threshold of triggering the ischemic symptoms. However, it may not reveal the full amount of jeopardized myocardium and may be inadequate for the evaluation of cardiac risk in a patient scheduled to have major noncardiac surgery. A submaximal exercise test (not achieving 85% of the targeted heart rate) may still be a valid alternative for evaluation of ischemic risks after cardiac events. To achieve the most adequate level of cardiac stress and to avoid suboptimal stress testing, patients should discontinue antianginal medications (blockers and calcium blockers for 36 to 48 hours and long-acting nitrates for 12 hours). All caffeine, including beverages and chocolate, especially before pharmacologic stress testing, should be avoided for at least 24 to 48 hours to avoid block of the endothelial receptors and their dilatory effect. Pharmacologic Stress Protocols these tests are generally performed in those patients who cannot achieve an adequate level of exercise. The two types of drugs used for pharmacologic stress are vasodilators and inotropics such as dobutamine. Coronary local autoregulatory mechanisms maintain adequate regional blood flow at rest, even when a significant coronary stenosis is present. For this reason, patients may be asymptomatic at rest, having normal myocardial perfusion studies. The hyperemic pharmacologic stress response is based on the ability of the coronary vessel to preserve its vasodilatory response. When this autoregulation fails, the vessel is unable to augment the supply required for an increased demand, producing therefore a related image defect. This is a manifestation of a decreased coronary flow reserve when it is considered as the ratio between the peak myocardial blood flow achieved at stress and its counterpart at rest. Normal vessels increase their blood flow four to five times after adequate stress. Vasodilators Dipyridamole and adenosine are the most commonly used coronary vasodilators. Briefly, dipyridamole is a pyrimidopyrimidine that has been widely used since 1987. Its blocks the cellular reuptake of adenosine, increasing its extracellular concentration, which produces vasodilation. Dipyridamole denies the extracellular access to the activity of red cell membrane­bound adenosine deaminase. The coronary dilating effect is related to the A2 receptor binding and activation mediated by G proteins, which ultimately result in vascular smooth muscle relaxation and vasodilation. The stimulation of the A1 receptor in the sinus and atrioventricular nodes reduces the sinus rate and the atrioventricular conduction that may cause heart block during stress testing. Individuals with normal coronary arteries increase their blood flow up to four times of the resting levels. Symptomatic myocardial ischemia is less commonly produced with vasodilators, possibly owing to the lower oxygen demands as opposed to exercise. As with exercise, it appears preferable to withhold antianginal medications and calcium blockers for at least 24 hours before imaging; some studies have suggested that they may diminish the extent of myocardial perfusion defects. A mild increase in the incidence of ischemia has been described by the addition of low-level exercise to the pharmacologic stress, which may add more diagnostic sensitivity to the test.

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Because of a relatively longer biologic half-life of dipyridamole medicine 831 discount provestra amex, the radiotracer is administered at 6 minutes after the start of the dipyridamole infusion. In addition, side effects may last for several minutes, but can be rapidly reversed by intravenous infusion of aminophylline, which acts by competitively inhibiting adenosine binding to its receptors. Compared with adenosine, dipyridamole is equally effective in producing coronary vasodilation, and has a lower overall incidence of side effects, including induction of atrioventricular block. Dipyridamole can be used in patients with prolonged P­R interval and in elderly patients with poor tolerance to side effects. Severe hypotension, ventricular tachycardia and hemodynamically unstable sustained supraventricular tachycardia, and atrial fibrillation with rapid ventricular response are indications for termination of dobutamine. Other side effects of dobutamine include chest pain, dyspnea, palpitations, hypertension, anxiety, nausea, and vomiting. Contraindications to dobutamine include ventricular tachycardia, atrial fibrillation with rapid ventricular response, uncontrolled hypertension, hypotension, hypertrophic obstructive cardiomyopathy or aortic stenosis with severe left ventricular outflow obstruction, recent aortic dissection, and coronary artery dissection. Although modest differences exist, overall accuracy of the most common protocols is comparable. When using same-day protocols with Tc 99m radiotracers, however, the resting study should be performed first to avoid "false-positive" fixed defects. If the resting study is performed first, the subsequent stress activity is much higher (approximately three times higher), and the increased blood flow at stress (approximately 2. The number of potential false-negative results for ischemia is small because the resting activity has a relatively small contribution to the stress imaging. Contraindications to Vasodilator Stress Testing Vasodilators are contraindicated in patients with severe chronic obstructive pulmonary disease and asthma, particularly patients currently receiving treatment with -agonists. Because high levels of adenosine block the -agonist activity of bronchodilators, patients with chronic or reactive airways disease may experience bronchoconstriction and respiratory compromise. Unstable angina, persistent hypotension with systolic blood pressure less than 90 mm Hg, high-grade atrioventricular block without a pacemaker, uncontrolled arrhythmias, and severe aortic stenosis are also contraindications. Because xanthines block adenosine receptors, these should be discontinued at least 24 hours before vasodilator stress testing. Acquisition Protocols the following protocols are suggested guidelines for an average-sized 70-kg man. For larger patients, increasing administered activity, imaging time, or both may partially compensate for the loss in detected true counts and subsequent decrease in image quality. Generally, the multiheaded gamma camera parameters for acquisition are similar for thallium 201 and Tc 99m radiotracers. This can be performed routinely without adversely increasing imaging time or Pharmacologic Protocols-Dobutamine Dobutamine is a -adrenergic agent with a biologic halflife of 2 minutes. It acts by increasing myocardial contraction and heart rate, which subsequently increases myocardial oxygen demand and blood flow. Intravenous administration starts at an initial dose of 5 to 10 µg/kg/min for 3 minutes, with subsequent increases to doses of 20 µg/kg/min, 30 µg/kg/min, and 40 µg/kg/min in 3-minute stages, or until the goal of reaching 85% of maximal heart rate target is achieved. The gated images are reconstructed and displayed in cine format for evaluation as described subsequently. A limitation of this technique is the requirement of a relatively regular rhythm over the imaging period. In patients with atrial fibrillation or other markedly irregular rhythms, the ventricular function from gating cannot be reliably assessed. Stress imaging begins approximately 15 minutes to 1 hour after the stress injection of 1. The time interval between radiotracer administration and the beginning of imaging varies. Delayed imaging may favor improved liver clearance; however, earlier imaging may reduce bowel activity. An advantage of this protocol is the short time interval between the initial resting injection and the stress study. The major disadvantage of this protocol relates to differences in final image quality. Thallium 201 has a lower photopeak energy, for which gamma cameras have inferior energy resolution and spatial resolution compared with higher gamma ray energies. The lower thallium 201 images also contain a larger percentage of Comptonscattered gamma rays than do images acquired at higher energies. These factors, combined with lower administered activity at lower resting blood flow, all contribute to overall lower true counts and the need for greater degree of filtering. Care is taken specifically to process these different radiotracer studies with specific protocols. These differences also need to be taken into account during interpretation of these studies. Two-Day Protocol Rest-Stress Tc 99m Radiotracer Protocol this protocol is very similar to the above-described 1-day protocol. This protocol may be used in patients with a higher body mass index who may require a higher resting activity for adequate image quality. The 24-hour delay allows the relatively higher resting Tc 99m activity to decay and avoid interference with the stress perfusion. Image Interpretation Postprocessing Tomographic images typically are reconstructed from the raw projection data with filtered back-projection and lowpass filtering. New algorithms have become commercially available that replace filtered backprojection by iterative reconstruction techniques, some versions of which incorporate depth-dependent collimator imaging characteristics and attenuation correcting data, both of which may improve overall image quality, particularly for low count perfusion images.