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Authors: Alan D. Waxman, MD; Karl Herholz, MD; David H. Lewis, MD; Peter Herscovitch, MD; Satoshi
Minoshima, MD; PhD, Masanori Ichise, MD; Alexander E. Drzezga, MD; Michael D. Devous, Sr., PhD;
James M. Mountz, MD, PhD
The Society of Nuclear Medicine (SNM) has written and approved these guidelines as an educational tool
designed to promote the cost-effective use of high-quality nuclear medicine procedures or in the conduct of
research and to assist practitioners in providing appropriate care for patients. The guidelines should not be
deemed inclusive of all proper procedures nor exclusive of other procedures reasonably directed to obtaining the
same results. They are neither inflexible rules nor requirements of practice and are not intended nor should they
be used to establish a legal standard of care. For these reasons, SNM cautions against the use of these guidelines
in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment about the propriety of any specific procedure or course of action must be made by the
physician when considering the circumstances presented. Thus, an approach that differs from the guidelines is
not necessarily below the standard of care. A conscientious practitioner may responsibly adopt a course of action
different from that set forth in the guidelines when, in his or her reasonable judgment, such course of action is
indicated by the condition of the patient, limitations on available resources, or advances in knowledge or
technology subsequent to publication of the guidelines.
All that should be expected is that the practitioner will follow a reasonable course of action based on current
knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole
purpose of these guidelines is to assist practitioners in achieving this objective.
Advances in medicine occur at a rapid rate. The date of a guideline should always be considered in determining
its current applicability.
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Procedure Guideline for FDG-PET Brain Imaging v1.0 2
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Procedure Guideline for FDG-PET Brain Imaging v1.0 3
D. Radiopharmaceuticals
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Procedure Guideline for FDG-PET Brain Imaging v1.0 4
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Procedure Guideline for FDG-PET Brain Imaging v1.0 5
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Procedure Guideline for FDG-PET Brain Imaging v1.0 6
is used, the attenuation may be done (2) Contours should be defined for
following FDG injection due to a each individual transaxial slice.
high photon flux relative to (3) Correct shape and position of
emission data. the contours should be
b. Correction factors are obtained by reviewed prior to calculation of
measuring the ratio between a blank the corrected slices.
scan (performed without patient in d. It is important to note that the
scanner) and a transmission scan different mathematical correction
(performed with an external source procedures lead to systematic
when the patient is in position). differences in the resulting images,
Positional differences will result in making images obtained with
major artifacts. different correction procedures not
6. If repositioning of the patient is directly comparable (e.g. with
necessary, great care should be taken to statistical subtraction analyses on a
minimize positional differences. voxelwise basis).
7. Hybrid attenuation correction e. Differences may appear especially
(attenuation map calculated from a in the occipital and cerebellar
transmission measurement followed by regions.
a segmentation image): These methods f. Measured attenuation correction is
calculate an attenuation image based on preferable to calculated specially if
a short transmission measurement post emission techniques used.
followed by image segmentation. 10. Dynamic studies
8. CT-based attenuation correction of the a. Dynamic studies consist of a
brain in PET/CT-scanners. sequence of serial images in a
a. In CT-PET systems the photon limited field, starting at the time of
attenuation correction is obtained FDG administration and continuing
by means of a measured correction for 60-90 minutes.
matrix from a simultaneously (1) The acquisition modalities for
assessed CT scan in line with PET dynamic studies are only briefly
b. The CT map has to be transformed mentioned here because they
into a 511keV attenuation map by are not commonly used in
segmentation and absorption clinical routine.
correction and forward projection of (2) This type of acquisition is used
the data for use as attenuation to quantitatively assess the
correction data. regional rates of FDG
9. Mathematical attenuation correction - metabolism by determining
estimated attenuation correction based appropriate kinetic rate or
on the emission data: Not commonly influx constants.
performed since post emission (3) Determination of arterial input
attenuation systems now commonly function is needed.
available. (4) Measurements of FDG and
a. Correction procedures estimating glucose plasma levels are
the attenuation based on the required.
estimation of organ density from (5) A calibration factor between the
emission data (i.e. according to scanner events and in vitro
Chang). activity is needed and can be
b. Accurate skull attenuation lacking. attained by phantom imaging.
c. Shape contouring should be used if (6) Simplified methods for
available. calculation of regional
(1) Contours should include scalp metabolic rates of FDG using
and not just grey matter.
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Procedure Guideline for FDG-PET Brain Imaging v1.0 7
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Procedure Guideline for FDG-PET Brain Imaging v1.0 8
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Procedure Guideline for FDG-PET Brain Imaging v1.0 9
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Procedure Guideline for FDG-PET Brain Imaging v1.0 10
c. Consider the impact of atrophy or (1) The blank scan also serves for
structural lesions as well as partial attenuation correction.
volume effects. (2) This test takes a short time (30
d. If relevant clinical or additional minutes) and can be performed
testing results are not available for daily.
review, state the limitation of the d. Since many studies are performed
conclusions and recommend using CT for morphologic
additional test as indicated. comparison and fusion as well as
e. When studies are difficult to attenuation correction CT quality
interpret due to a pattern not control should be performed by a
commonly described using well- trained CT technologist and
accepted criteria, the report should physicist.
contain statements, which would 2. Performance tests can be usually
aid the referring physician to better carried out according to the
understand why a specific international recommendations
diagnostic entity could not be according to:
ascribed to the pattern noted. a. American guidelines are published
f. Caution should be mentioned in by NEMA (National Electrical
the reporting of quantitative Manufacturer Association).
information as limitations of the b. European guidelines are published
quantitative technique need to be by IEC (International Electrotechnical
clearly understood by the Committee).
interpreting physician before
issuing a report as normal or L. Pitfalls, Artifacts, Sources of Error
abnormal based on quantitative
findings.
1. Medications altering cerebral
K. PET scanner quality control
metabolism including
a. Sedatives
1. Clinical scanning should be
b. Drugs such as amphetamines,
accompanied by a strict quality control
cocaine
program consisting of specific
c. Narcotics
performance tests including:
d. Anti-psychotic medications
a. Normalization procedure: to ensure
e. Corticosteroids
the existence of an adequate
correction of the changes in
Most medications predominantly alter
efficiency among the crystals of the
global metabolism with modest effects on
detectors. This procedure takes
regional distribution.
several hours and can be performed
every month, providing that there
2. Hyperglycemia
are no detector failures.
3. Patient motion during the data
b. Setup scan: to ensure that all
acquisition may result in image artifacts
detectors are working properly.
and render the study non-interpretable.
(1) The setup scan changes the
4. Misregistration between the emission
detect gains to modify any
and transmission scans.
possible drifts.
5. Calculated attenuation using a per file
(2) This takes about two hours and
calculation may result in falsely
can be done weekly
increased activity in the superior aspect
c. Blank scan: to ensure that the
of the brain.
detectors have not drifted since the
6. Calculated attenuation does not correct
last normalization.
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Procedure Guideline for FDG-PET Brain Imaging v1.0 11
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Procedure Guideline for FDG-PET Brain Imaging v1.0 12
12. Messa C, Fazio F, Costa DC, Ell PJ. brain tumour patients: a comparison of
Clinical brain radionuclide imaging. preoperative 18-FDG-PET and
Sem Nucl Med 1995; 25: 111-143. intraoperative cortical electro-
13. Minoshima S, Frey KA, Koeppe RA et stimulation. Eur J Nucl Med 2001; 28:
al. A diagnostic approach in 1394-1403.
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dimensional stereotactic surface et al. Comparison of different methods
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Nucl med 1995; 36: 1238-1248 effect on the calculation of the
14. Minoshima S, Koeppe RA, Mintun MA metabolic rate of glucose.
et al. Automated detection of the Nuklearmedizin 2000; 39: 50-55
intercommissural line for stereotactic 20. Signorini M, Paulesu E, Friston K et al.
localization of functional brain images. Rapid Assessment of regional cerebral
J Nucl Me 1993; 34: 322-329 metabolic abnormalities in single
15. Phelps ME, Huang SC, Hoffman EJ et subjects with quantitative and
al. Tomographic measurement of local nonquantitative (18F) FDG PET: A
cerebral glucose metabolic rate in clinical validation of statistical
humans with F-18 2-fluoro-2-deoxy-d- parametric mapping. Neuroimage 1999;
glucose; validateion of method. Ann 9:63-80
Neurol 1979; 6: 371-388 21. Silverman DHS. Brain 18-F-FDG PET
16. Ruotsalainen U, Suhonen-Polvi H, in the diagnosis of neurodegenerative
Eronen E et al. Estimated radiation dose Dementias: Comparison with perfusion
to the newborn in FDG-PET studies. J of SPECT and with clinical evaluations
Nucl Med 1996; 37: 387-93 Lacking Nuclear imaging. J Nucl Med
17. Schelbert HR, Hoh CK, Royal HD et al. 45 (4): 594 - 607
Procedure guideline for tumor imaging 22. Society of Nuclear Medicine Brain
using fluorine-18-FDG. Society of Imaging Council. Ethical clinical
Nuclear Medicine. J Nucl Med 1998: practice of functional brain imaging. J
39: 1302-5. Nucl Med 1996; 37: 1256-1259
18. Schreckenberger M. Spetzger U, sabri
O et al. Localisation of motor areas in
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