Contributions of subdiaphragmatic activity,attenuation, and diaphragmatic motion to inferior wall artifact in attenuation-corrected Tc-99m myocardial perfusion SPECT

BACKGROUND: Subdiaphragmatic activity and diaphragmatic motion both contribute to inferior wall artifacts in technetium 99m myocardial perfusion single photon emission computed tomography (SPECT). METHODS AND RESULTS: We used an anthropomorphic phantom with ventricular wall activity, liver/spleen inserts containing variable Tc-99m activity, and variable vertical (diaphragmatic) motion amplitude. SPECT and transmission scans were obtained on a GE Optima NX camera. Data were processed by use of filtered backprojection or attenuation correction (AC). Resulting myocardial activity maps were analyzed with standardized inferior-anterior and anterior-lateral wall ratios. At a subdiaphragmatic-myocardial activity ratio of 0.5:1, inferior wall attenuation predominates, producing a cold artifact. AC corrects inferior wall activity to the level of the anterior wall irrespective of diaphragmatic motion. At a subdiaphragmatic-myocardial activity ratio of 1:1, inferior wall counts vary widely depending on the proximity of subdiaphragmatic activity to the ventricle. With increasing diaphragmatic amplitude, the overlap of subdiaphragmatic activity and inferior wall worsens, leading to a complex mixture of cold and hot artifacts, not corrected by AC. CONCLUSIONS: Concentration and proximity of subdiaphragmatic Tc-99m activity relative to myocardium comprise a major factor in the nature and severity of inferior wall artifacts. If the subdiaphragmatic Tc-99m concentration is equivalent to that in the myocardium, complex, potentially uninterpretable hot and cold inferior wall artifacts are produced.