Myocardial Ischemia Diagnosed by Dual-Energy Computed Tomography

Abstract

HomeCirculationVol. 117, No. 9Myocardial Ischemia Diagnosed by Dual-Energy Computed Tomography Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBMyocardial Ischemia Diagnosed by Dual-Energy Computed TomographyCorrelation With Single-Photon Emission Computed Tomography Balazs Ruzsics, MD, PhD, Heon Lee, MD, PhD, Eric R. Powers, MD, Thomas G. Flohr, PhD, Philip Costello, MD and U. Joseph Schoepf, MD Balazs RuzsicsBalazs Ruzsics Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author , Heon LeeHeon Lee Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author , Eric R. PowersEric R. Powers Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author , Thomas G. FlohrThomas G. Flohr Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author , Philip CostelloPhilip Costello Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author and U. Joseph SchoepfU. Joseph Schoepf Department of Radiology (B.R., H.L., P.C., U.J.S.) and Division of Cardiology (E.R.P., U.J.S.), Medical University of South Carolina, Charleston; Department of Radiology, Seoul Medical Center, Seoul, Republic of Korea (H.L.); and Department of Radiology, University of Tuebingen, Germany (T.G.F.). Search for more papers by this author Originally published4 Mar 2008https://doi.org/10.1161/CIRCULATIONAHA.107.745711Circulation. 2008;117:1244–1245For decades, dual-energy imaging has been used for tissue differentiation with several x-ray–based imaging modalities, exploiting the fact that the tissues in the human body show different absorption characteristics when penetrated with different x-ray spectra, spectra that are typically generated by different kV settings of the x-ray tube. Recently, dual-source computed tomography (CT) with 2 x-ray tubes and 2 detector arrays mounted in the same gantry has become available.1 After experience with earlier experimental prototypes, this dual-source CT for the first time enables the clinical acquisition of dual-energy CT studies simultaneously with a single scan.We used a dual-source CT scanner (Definition, Siemens, Forchheim, Germany) in dual-energy mode for performing coronary CT angiography in a 74-year–old woman with suspected coronary artery disease and prior abnormal nuclear rest/stress single-photon emission CT (SPECT). The CT scan was acquired with retrospective ECG-gating and the following scan parameters: 330-ms gantry rotation, pitch 0.2, and 32×2×0.6-mm collimation. One tube of the dual-source system was operated with 150 mAs/rot at 140 kV and the second tube with 165 mAs/rot at 80 kV. The scan was contrast medium–enhanced (70-mL Ultravist, 370-mg iodine/mL; Bayer, Wayne, NJ), using our routine clinical protocol. From the dual-energy scan, 3 different image reconstructions with 0.75-mm section width and 0.4-mm increment were performed using the routine dual-energy CT reconstruction algorithm implemented on the scanner platform. The first set of transverse gray-scale images was aimed at optimizing spatial and contrast resolution by merging 70% of the 140-kV spectrum and 30% of the 80-kV spectrum, which was used for 3-dimensional volume rendering (Figure 1A) and morphological diagnosis based on automatically generated curved multiplanar reformations (Figure 1B and 1C) of the coronary artery tree. Another set was based only on the 80-kV x-ray spectrum (Figure 2A and 2D) and yet another only on the 140-kV x-ray spectrum (Figure 2B and 2E). The myocardial blood pool was analyzed by determining the iodine content within the myocardium on the basis of the unique x-ray absorption characteristics of this element at different kV levels. The resulting color-coded “iodine map” representing the myocardial blood pool was then superimposed onto gray-scale multiplanar reformats of the myocardium in short-axis (Figure 2C) and long-axis (Figure 2F) views, from which the iodine content in the voxels had been digitally subtracted to generate a virtually nonenhanced scan.2Download figureDownload PowerPointFigure 1. Dual-energy CT scan reconstruction merging 70% of the 140-kV spectrum and 30% of the 80-kV spectrum shown as 3-dimensional volume rendering (A) and curved multiplanar reformations (B and C). Diffuse calcified atherosclerotic disease is seen throughout the vessel course with subtotal ostial stenosis (arrows) of the first diagonal branch, caused by extensive calcified and noncalcified plaque. D, Correlation with coronary catheter angiography.Download figureDownload PowerPointFigure 2. Multiplanar reformations in short-axis (A, B, and C) and long-axis (D, E, and F) views of dual-energy CT scan reconstructions based only on the 80-kV x-ray spectrum (A and D) and only on the 140-kV x-ray spectrum (B and E). The dual-energy CT–based “iodine map” representing the myocardial blood pool is superimposed onto virtually nonenhanced gray-scale images (D and F), showing myocardial blood pool deficit (arrows) in the first distal branch territory within the anterolateral wall of the left ventricle.Analysis of coronary CT angiographic images revealed diffuse atherosclerotic disease with subtotal ostial stenosis (Figure 1B and 1C) of the first diagonal branch, caused by extensive calcified and noncalcified plaque. These findings were subsequently confirmed at coronary catheterization (Figure 1F). The dual-energy iodine maps (Figure 2C and 2F) showed a myocardial blood pool deficit in the first diagonal branch territory within the anterolateral wall of the left ventricle. Findings at dual-energy CT blood pool imaging correlated well with the results at prior rest/stress SPECT thallium myocardial perfusion imaging (Figure 3), which showed ischemia in the same myocardial territory. Download figureDownload PowerPointFigure 3. Corresponding short-axis rest SPECT thallium myocardial perfusion study shows perfusion defect (arrows) in the same myocardial territory.In this patient, dual-energy CT imaging enabled comprehensive assessment of coronary artery anatomy and myocardial ischemia with a single contrast-enhanced CT scan in good correlation with coronary catheterization and myocardial perfusion imaging. This approach may be an interesting topic for further research to investigate the general validity of this technique.DisclosuresDr Flohr is an employee of Siemens. Dr Costello is a medical consultant to Bracco and receives research support from Siemens. Dr Schoepf is a medical consultant to Bayer, Bracco, General Electric, Medrad, Siemens, and TeraRecon and receives research support from Bayer, Bracco, General Electric, Medrad, and Siemens. The remaining authors report no conflicts.FootnotesCorrespondence to U. Joseph Schoepf, MD, Department of Radiology, Medical University of South Carolina, 169 Ashley Ave, Charleston, SC 29425. E-mail [email protected]References1 Flohr T, McCollough C, Bruder H, Petersilka M, Gruber K, Suss C, Grasruck M, Stierstorfer K, Krauss B, Raupach R, Primak A, Kuttner A, Achenbach S, Becker C, Kopp A, Ohnesorge B. First performance evaluation of a dual-source CT (DSCT) system. Eur Radiol. 2006; 16: 256–268.CrossrefMedlineGoogle Scholar2 Johnson T, Krauss B, Sedlmair M, Grasruck M, Bruder H, Morhard D, Fink C, Weckbach S, Lenhard M, Schmidt B, Flohr T, Reiser M, Becker C. 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Bastarrika G and Schoepf U (2008) Evolving CT Applications in Ischemic Heart Disease, Seminars in Thoracic and Cardiovascular Surgery, 10.1053/j.semtcvs.2008.11.012, 20:4, (380.e1-380.e14), Online publication date: 1-Dec-2008. March 4, 2008Vol 117, Issue 9 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.745711PMID: 18316501 Originally publishedMarch 4, 2008 PDF download Advertisement SubjectsAcute Coronary SyndromesComputerized Tomography (CT)ImagingMyocardial InfarctionNuclear Cardiology and PET