Der Nuklearmediziner 2014; 37(03): 145-158
DOI: 10.1055/s-0034-1375663
CME-Fortbildung
© Georg Thieme Verlag KG Stuttgart · New York

Nuklearmedizinische Lungenemboliediagnostik – State of the Art

Nuclear Medicine for Pulmonary Embolism Diagnosis
W. M. Schäfer
1   Klinik für Nuklearmedizin, Kliniken Maria Hilf GmbH, Akademisches Lehrkrankenhaus der Uniklinik RWTH Aachen
,
D. Knollmann
1   Klinik für Nuklearmedizin, Kliniken Maria Hilf GmbH, Akademisches Lehrkrankenhaus der Uniklinik RWTH Aachen
› Author Affiliations
Further Information

Publication History

Publication Date:
18 August 2014 (online)

Zusammenfassung

Die nuklearmedizinische Lungenemboliediagnostik ist ein sehr sensitives und spezifisches Verfahren, wenn sie state-of-the-art durchgeführt wird. Hierzu zählen nicht nur der Einsatz der Perfusionsszintigrafie, sondern auch der ­Ventilationsszintigrafie und beides in 3-dimen­sionaler SPECT- oder besser noch in SPECT/CT-Technik.

Leider wird bei vielen Untersuchungen auf die Ventilation verzichtet, was – bedingt durch falsch-positive Befunde – die Spezifität deutlich reduziert oder aber es erfolgen nur planare Darstellungen, was sich negativ auf die Sensitivität ­auswirkt.

Die 3-dimensionale SPECT-Darstellung erlaubt eine überlagerungsfreie Betrachtung aller Lungenabschnitte und auch die Möglichkeit parametrische V/Q-ratio-Daten zu generieren.

Verglichen mit der CTPA liefert die V-/P-SPECT eine zumindest vergleichbare Sensitivität, eine in der Regel deutlich niedrigere Strahlenexposition, wenig technisch suboptimale Studien und keine Kontrastmittel-assoziierten Komplikationen.

Steht dann auch noch ein moderner Hybrid-Scanner als SPECT/CT zur Verfügung, kann die ­V/-P-SPECT um ein koregistriertes Low-dose-CT erweitert werden, was nachweislich die diagnostische Genauigkeit weiter steigert, dabei insbesondere die unklaren Befunde reduziert und so falsch-positive Befunde weitestgehend eliminiert.

Abstract

Ventilation–perfusion scanning is a sensitive and specific tool to investigate pulmonary embolism when it is performed state-of-the-art. For an accurate diagnosis from our point of view not only perfusion but also ventilation scanning is indispensable. Since planar imaging has severe limitations, SPECT – to generate fully 3-dimensional imaging data – or even better SPECT/CT should be used. Using SPECT-technique increases sensitivity and adding low-dose CT from SPECT/CT increases specificity.

Compared with CT pulmonary angiography V-/P-SPECT has at least a similar sensitivity, a lower radiation dose, fewer technically suboptimal studies, and no contrast-related complications. Any nuclear medicine department equipped with a modern hybrid scanner can now perform combined V-/P-SPECT/CT (using low-dose protocols) to further enhance diagnostic accuracy, esp. by avoiding false positive findings.

 
  • Literatur

  • 1 Bajc M, Neilly JB, Miniati M et al. EANM guidelines for ventilation/perfusion scintigraphy: part 1. Pulmonary imaging with ventilation/perfusion single photon emission tomography. Eur J Nucl Med Mol Imaging 2009; 36: 1356-1370
  • 2 Bajc M, Olsson B, Palmer J et al. Ventilation/perfusion SPECT for diagnostics of pulmonary embolism in clinical practice. J Intern Med 2008; 264: 379-387
  • 3 Bajc M, Olsson CG, Olsson B et al. Diagnostic evaluation of planar and tomographic ventilation/perfusion lung images in patients with suspected pulmonary emboli. Clin Physiol Funct Imaging 2004; 24: 249-256
  • 4 Barrett BJ, Parfrey PS. Clinical practice: preventing nephropathy induced by contrast medium. N Engl J Med 2006; 354: 379-386
  • 5 Collart JP, Roelants V, Vanpee D et al. Is a lung perfusion scan obtained by using single photon emission computed tomography able to improve the radionuclide diagnosis of pulmonary embolism?. Nucl Med Commun 2002; 23: 1107-1113
  • 6 Gutte H, Mortensen J, Jensen CV et al. Detection of pulmonary embolism with combined ventilation-perfusion SPECT and low-dose CT: head-to-head comparison with multidetector CT angiography. J Nucl Med 2009; 50: 1987-1992
  • 7 Hurwitz LM, Yoshizumi TT, Goodman PC et al. Radiation dose savings for adult pulmonary embolus 64-MDCT using bismuth breast shields, lower peak kilovoltage, and automatic tube current modulation. AJR 2009; 192: 244-253
  • 8 ICRP . Radiation dose to patients from radiopharmaceuticals (addendum 2 to ICRP publication 53). Ann ICRP 1998; 28: 1-126
  • 9 Jögi J, Jonson B, Ekberg M et al. Ventilation-perfusion SPECT with 99mTc-DTPA versus Technegas: a head-to-head study in obstructive and nonobstructive disease. J Nucl Med 2010; 51: 735-741
  • 10 Jones SE, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Radiology 2005; 237: 329-337
  • 11 Knollmann D, Meyer PT, Meyer A et al. V/P-SPECT-CT: Influence of attenuation correction on the homogeneity of lung perfusion SPECT. [abstract]. J Nucl Med 2012; 605
  • 12 Leblanc M, Paul N. V/Q SPECT and computed tomographic pulmonary angiography. Semin Nucl Med 2010; 40: 426-441
  • 13 Lemb M, Pohlabeln H. Pulmonary thromboembolism: a retrospective study on the examination of 991 patients by ventilation/perfusion SPECT using Technegas. Nuklearmedizin 2001; 40: 179-186
  • 14 Miles S, Rogers KM, Thomas P et al. A comparison of single-photon emission CT lung scintigraphy and CT pulmonary angiography for the diagnosis of pulmonary embolism. Chest 2009; 136: 1546-1553
  • 15 Miniati M, Pistolesi M, Marini C et al. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med 1996; 154: 1387-1393
  • 16 Palmer J, Bitzen U, Jonson B et al. Comprehensive ventilation/perfusion SPECT. J Nucl Med 2001; 42: 1288-1294
  • 17 Parker MS, Hui FK, Camacho MA et al. Female breast radiation exposure during CT pulmonary angiography. AJR 2005; 185: 1228-1233
  • 18 Reinartz P, Wildberger JE, Schaefer W et al. Tomographic imaging in the diagnosis of pulmonary embolism: a comparison between V/Q lung scintigraphy in SPECT technique and multislice spiral CT. J Nucl Med 2004; 45: 1501-1508
  • 19 Ridge CA, McDermott S, Freyne BJ et al. Pulmonary embolism in pregnancy: comparison of pulmonary CT angiography and lung scintigraphy. AJR 2009; 193: 1223-1227
  • 20 Roach PJ, Bailey DL, Harris BE. Enhancing lung scintigraphy with singlephoton emission computed tomography. Semin Nucl Med 2008; 38: 441-449
  • 21 Roach PJ, Schembri GP, Bailey DL. V/Q scanning using SPECT and SPECT/CT. J Nucl Med 2013; 54: 1588-1596
  • 22 Schaefer W, Esser J, Dautzenberg KJ et al. Ventilations(V)-und Perfusions(P)-SPECT-CT in der Lungenemboliediagnostik: Möglichkeiten der Reduktion und Objektivierung der Strahlenexposition. Nuklearmedizin 2014; 53: A24
  • 23 Schembri GP, Miller AE, Smart R. Radiation dosimetry and safety issues in the investigation of pulmonary embolism. Semin Nucl Med 2010; 40: 442-454
  • 24 Stein PD, Fowler SE, Goodman LR et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-2327
  • 25 Stein PD, Freeman LM, Sostman HD et al. SPECT in acute pulmonary embolism. J Nucl Med 2009; 50: 1999-2007
  • 26 Toney LK, Lewis DH, Richardson ML. Ventilation/perfusion scanning for acute pulmonary embolism: effect of direct communication on patient treatment outcomes. Clin Nucl Med 2013; 38: 183-187
  • 27 Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA 1990; 263: 2753-2759
  • 28 Wagner Jr HN, Sabiston Jr DC, McAfee JG et al. Diagnosis of massive pulmonary embolism in man by radioisotope scanning. N Engl J Med 1964; 271: 377-384
  • 29 Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ 2013; 347: f3368