Myocardial perfusion imaging (SPECT)

A report skeleton for stress and rest gated myocardial perfusion SPECT. It follows the required and recommended elements of the ASNC standardised reporting guideline, with 17-segment semiquantitative scoring, summed scores, TID, gated function and a statement on attenuation correction.

Based on: ASNC standardised reporting of nuclear cardiology procedures (Tilkemeier 2017); EANM myocardial perfusion SPECT guideline, 2015 revision (Verberne 2015); AHA 17-segment model (Cerqueira 2002)

MYOCARDIAL PERFUSION SPECT

CLINICAL INDICATION:
  [Suspected CAD / known CAD, new symptoms / pre-operative risk / viability / other]
  Symptoms: [ ]; risk factors: [ ]; prior revascularisation: [PCI / CABG, date]
  Medication withheld: [beta-blocker / nitrates / caffeine abstinence [ ] h]

TECHNIQUE:
  Protocol: [1-day rest/stress / 1-day stress/rest / 2-day / stress-only]
  Radiopharmaceutical: [99mTc-sestamibi / 99mTc-tetrofosmin / 201Tl]; rest [ ] MBq, stress [ ] MBq
  Stress: [treadmill exercise (protocol [ ], [ ] min, [ ] METs) / regadenoson / adenosine / dipyridamole / dobutamine / combined]
  Heart rate: rest [ ], peak [ ] bpm ([ ]% of maximum predicted heart rate)
  Blood pressure: rest [ ], peak [ ] mmHg; response [normal / hypotensive / hypertensive]
  Symptoms during stress: [none / angina / dyspnoea / other]; reason for termination: [ ]
  Stress ECG: [no ischaemic changes / ST depression [ ] mm in [leads] / non-diagnostic because of [LBBB / paced rhythm / resting ST changes]]; arrhythmia: [ ]
  Attenuation correction: [none / CT-based / transmission source / prone imaging], [stress only / stress and rest]
  Gating: [stress / rest / both]

COMPARISON:
  [Prior MPI dated [ ] / none]

FINDINGS:
  Image quality: [good / adequate / limited by [subdiaphragmatic activity / motion / attenuation]]
  Extracardiac activity: [none / [ ]]
  Increased lung uptake: [no / yes]; RV uptake: [normal / increased]
  LV cavity size: [normal / dilated at stress and rest]
  Perfusion defect(s):
    Location (17-segment model): [segments]
    Size: [small (1–2 segments) / medium (3–4 segments) / large (≥5 segments)]
    Severity: [mild (10 to <25% reduction) / moderate (25 to <50%) / severe (≥50%) / absent uptake]
    Reversibility: [reversible / mildly reversible / moderately reversible / predominantly reversible / predominantly fixed / fixed]
  Segment score: 0 normal, 1 mildly reduced, 2 moderately reduced, 3 severely reduced, 4 absent uptake
  SSS [ ]  SRS [ ]  SDS [ ] (SDS = SSS − SRS)
  Ischaemic extent: SDS / 68 × 100 = [ ]% of LV; stress defect extent: SSS / 68 × 100 = [ ]%
  Transient ischaemic dilation: [absent / present]; TID ratio [ ] (normal limit applied [ ])
  Gated SPECT: LVEF [ ]% at [post-stress / rest]; EDV [ ] mL; ESV [ ] mL
    LVEF category: [hyperdynamic ≥70% / normal ≥55 to <70% / low normal 50–55% / mildly reduced 45 to <50% / moderately reduced 35 to <45% / severely reduced <35%]
    Regional wall motion and thickening: [normal / hypokinesis / akinesis / dyskinesis of [segments]]

17 SEGMENTS: basal (1 anterior, 2 anteroseptal, 3 inferoseptal, 4 inferior, 5 inferolateral, 6 anterolateral); mid (7–12, same walls); apical (13 anterior, 14 septal, 15 inferior, 16 lateral); 17 apex

IMPRESSION:
  1. [Normal myocardial perfusion / [size], [severity], [reversible / fixed] defect in the [territory], consistent with [ischaemia / infarction / ischaemia and infarction]]
  2. Ischaemic extent [ ]% of LV; TID [absent / present]
  3. LVEF [ ]%, [normal / reduced]; regional wall motion [ ]
  4. [Comparison with prior study]
  5. Stress ECG: [ ]; symptoms: [ ]

Before you sign

• Score each of the 17 segments 0–4, allowing for attenuation artefacts. Divide the summed scores by 68, the maximum possible score, to express defect and ischaemia extent as a percentage of the LV.
• The presence or absence of TID is a required report element; the TID ratio is optional. If you give the ratio, quote the normal limit you applied.
• State whether attenuation correction was used, which method (CT, transmission source or prone imaging), and whether it was applied to stress, rest or both.
• Report peak heart rate as a percentage of maximum predicted. Vasodilator stress is for patients who cannot reach at least 85% of age-predicted maximum heart rate.
• Assign defects to coronary territories with caution. Standard territories often do not match an individual patient's coronary anatomy, so name the segments and not only the artery.
• Give the LVEF with the phase it was measured in (post-stress or rest), and describe regional wall motion and thickening in 17-segment terms.
• Comment on extracardiac activity, lung uptake (especially with thallium) and RV uptake, and compare with prior studies.

Sources

1. Tilkemeier PL, Bourque J, Doukky R, Sanghani R, Weinberg RL. ASNC imaging guidelines for nuclear cardiology procedures: standardized reporting of nuclear cardiology procedures. J Nucl Cardiol. 2017;24:2064–128.
2. Verberne HJ, Acampa W, Anagnostopoulos C, et al. EANM procedural guidelines for radionuclide myocardial perfusion imaging with SPECT and SPECT/CT: 2015 revision. Eur J Nucl Med Mol Imaging. 2015;42:1929–40.
3. Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. Circulation. 2002;105:539–42.