NUCLEAR MEDICINE ACR ACCREDITATION

Hints and Tips:

Symbia S™, Symbia E™ and e.cam™ systems
with syngo MI Workplaces™

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TABLE OF CONTENTS

1. INTRODUCTION................................................................................................. 3
1.1 Purpose of the Document............................................................................................... 3

1.2 Scope................................................................................................................................ 3

1.3 ACR Phantom .................................................................................................................. 3

2. PREPARATION .................................................................................................. 4
2.1 Camera Quality Control .................................................................................................. 4

2.2 Scheduling and Documentation .................................................................................... 5

2.3 Supplies............................................................................................................................ 6

3. WORKFLOW TEMPLATES................................................................................ 7
3.1 Equipment Performance Workflow Templates............................................................. 7

3.2 Clinical Images Workflow Templates ............................................................................ 7

4. EQUIPMENT PERFORMANCE PROTOCOLS ................................................. 8

4.1 Flood Field Uniformity ........................................................................................... 8

4.2 Spatial Resolution.................................................................................................. 10

4.3 SPECT Phantom..................................................................................................... 16

5. CLINICAL MEASUREMENTS .......................................................................... 36

5.1 FAQ’s .............................................................................................................................. 36

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1. INTRODUCTION
1.1 Purpose of the Document
The American College of Radiology (ACR) has created a “Nuclear Medicine Accreditation
Program” to evaluate the quality of personnel, equipment performance, effectiveness of
quality control measures and the quality of the clinical images of Nuclear Medicine facilities.
Please refer to the ACR documents for Nuclear Medicine Accreditation for a detailed
explanation of the specific requirements for the accreditation program.
ACR testing can be divided into two categories:
• Equipment Performance
o Flood Field Uniformity
o Spatial Resolution
o SPECT Phantom
• Clinical Images
o Module 1- Planar: A whole body or spot bone and another whole body bone,
spot bone, hepatobiliary, perfusion lung or MUGA
o Module 2 - SPECT: Bone SPECT and another Bone SPECT, Brain SPECT,
Hepatic blood pool, Liver SPECT and SPECT Myocardial Perfusion
o Module 3 - Nuclear Cardiology: SPECT Myocardial Perfusion and a MUGA or
Gated SPECT

1.2 Scope
This document contains instructions for performing Nuclear Medicine ACR Accreditation on
the Symbia and e.cam Imaging Systems with software version of syngo MI Applications
2007A or higher.

1.3 ACR Phantom

The ACR requires that each site submit the following phantom analysis:
• Uniformity
• Resolution
• Contrast

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2. PREPARATION

2.1 Camera Quality Control

Prior to scheduling your system for the ACR tests, ensure that all of the camera quality control
is current.

Since the ACR equipment performance tests are performed with Tc-99m, Co-57, Tl-201 and
Ga-67. It is important for the quality control be completed for the low and medium energy
collimators that you will be using for these tests and your clinical images. In most cases,
these collimators would be the LEHR (low energy high resolution) and the ME or MELP
(medium energy) collimators.

The following performance tests are required annually:

• Intrinsic Uniformity
• System Uniformity
• Intrinsic or System Spatial Resolution
• Sensitivity
• Energy Resolution
• Count Rate Parameters
• Multiple Spatial Resolution
• Overall System Performance
• Systems Interlocks.

Please refer to Nuclear Medicine /PET Accreditation Program Requirements for more details
and your ACR accredited physicist about the report that must be submitted with the ACR
Accreditation

2.1.1 Verification Floods (Daily QC)

It is assumed that the user performs a regular regimen of daily camera QC, following
recommendations from the user’s manual. As a minimum requirement, however, the camera
should be peaked and tuned within one day of the phantom acquisitions. A daily 10 million
count flood should also be acquired to verify camera performance each day of the testing.
2.1.2 Calibration Floods (Monthly QC)
It is assumed that the user performs a regular regimen of monthly camera QC, following
recommendations from the user’s manual. An intrinsic flood calibration should be performed
within the month prior to the phantom acquisitions. An extrinsic calibration must have been
performed at least once on the system.

2.1.2.1 Intrinsic Calibration Flood Requirements

The camera should be peaked and tuned immediately preceding the intrinsic calibration
flood acquisition. A 15-25 uCi Tc-99m point is sufficient for this calibration, which should
be performed according to recommendations from the user manual. To verify that the
point source is not too hot, the dead time reported on the analyzer page should be
below 7% for both detectors. A 200 million count intrinsic calibration flood is
recommended for optimum Jaszczak imaging. If the existing calibration has fewer
counts, or if the number of counts in the existing calibration flood is not known, the
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intrinsic calibration flood should be performed again. The integral and differential
uniformity numbers should be recorded at the time the calibration is performed.

2.1.2.2 Extrinsic Calibration Flood Requirements (Only needed If collimator has been
damaged since installation.)
The camera should be peaked and tuned immediately preceding the extrinsic calibration
flood acquisition. A sheet source of up to 15 mCi Co-57 is sufficient for this calibration,
which should be performed according to recommendations from the user’s manual.
Please note that an intrinsic calibration flood needs to be acquired within 10 days of an
acquisition of an extrinsic calibration flood. To verify that the sheet source is not too hot,
the dead-time reported in the analyzer page should be below 7% for both detectors. A
fillable sheet source using 15 mCi Tc-99m in water can also be used but extreme care
should be used to ensure uniform mixing of the source.

A 120 million count extrinsic calibration flood is recommended for optimum Jaszczak
imaging. If the existing calibration flood has fewer counts, or if the number of counts in
the existing calibration is not known, the extrinsic calibration flood should be performed
again

2.1.3 180 COR/MHR/Head Alignment

It is assumed that the user performs a regular regimen of monthly camera QC. This regimen
should follow recommendations from the user’s manual. As a minimum requirement,
however, an MHR/COR/Head Alignment calibration should be performed within the month
prior to the phantom acquisitions. The date of the existing MHR/COR/Head Alignment
calibration should be recorded. The camera should be peaked and tuned immediately
preceding the MHR/COR acquisition. 5 point sources of up to 1 mCi Tc-99m or Co-57 are
sufficient for this calibration, which should be performed according to recommendations from
the user’s manual. Care should be taken to minimize the volume of activity in the points. If a
cotton wad is used to contain the activity, this wad should be made as small as possible.
Refer to the Quality Control and Assurance chapter in the user’s manual for normal values.

NOTES
 Use 5 point sources for the LEHR collimator.

 Use 3 point sources for the ME or MELP collimator

2.2 Scheduling and Documentation

Preparations for ACR testing should begin as soon as the phantom arrives. This will
significantly reduce the workload on the day of the test. The ACR tests should not be rushed.
If is the first time that the ACR testing is being completed, please allow an approximate 4 – 5
hours to perform the phantom setup and acquire the data.

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NOTES
 Sufficient time should also be allocated for image selection,
annotation, and filming. Phantom positioning and data acquisition,
including measurements described in this and the ACR
Accreditation documentation may be very time consuming.

ACR Documentation needed:

• To conduct the tests: ACR documents: “Site Scanning Instructions for Use of
the Nuclear Medicine Phantom for ACR Nuclear Medicine Accreditation
Program” and “Nuclear Medicine/PET Accreditation Program Requirements”.
• Refer to the ACR web site: http//www.acr.org for the latest changes in
requirements and general information concerning accreditation.

Prior to performing all ACR tests, ensure that all of the camera quality control is current.

2.3 Supplies
• ACR / Jaszczak flangeless phantom
• Phantom Holder
• Point source vials
• Sheet source
• ACR Documentation
• Nuclear Medicine ACR Accreditation Hint’s and Tips: Symbia S, Symbia E and
e.cam systems with syngo MI Workplaces.

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3. WORKFLOW TEMPLATES
3.1 Equipment Performance Workflow Templates
Table 1 contains the name of the workflow templates that have been created to acquire,
process, and display ACR test data. These workflows are available on workstations that are
running syngo MI Applications 2007B or higher.

These templates can be found in the ACR Category on the Command Module. If the
templates have not been loaded, they can be found on the Optional Workflow Template
CD.for Symbia systems and the service pack cd for e.cam systems.

Workflow Template (syngo MI

Application 2008A for Symbia and
Measurement 2007B for e.cam)
Field Uniformity Sec 4.1 ACR Tc99m Intrinsic Field Uniformity
ACR Co-57 Extrinsic Field Uniformity
ACR Tl-201 Intrinsic Field Uniformity
ACR Ga-67 Intrinsic Field Uniformity
ACR Co-57 Intrinsic Field Uniformity

Spatial Resolution Sec. 4.2.2 ACR Tc99m Spatial Resolution Bars

ACR Co-57 Spatial Resolution Bars
ACR Tl-201 Spatial Resolution Bars
ACR Ga-67 Spatial Resolution Bars
Sec. 4.2.3 ACR Tc99m Spatial Resolution Phantom
ACR Tl-201 Spatial Resolution Phantom
ACR Ga-67 Spatial Resolution Phantom

SPECT Images
Acquisition Sec. 4.3.4 ACR Phantom SPECT ACQ
Reconstruction Sec. 4.3.5 ACR Phantom Reconstruction

Processing Sec. 4.3.6 ACR SPECT Phantom Analysis

Table 1 ACR Workflows (ACR Workflow Category)

3.2 Clinical Images Workflow Templates

The clinical measurements are based upon the site’s daily acquisition and processing
workflows.

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4. EQUIPMENT PERFORMANCE PROTOCOLS

4.1 Flood Field Uniformity

4.1.1 Overview:
Field uniformity can be acquired either intrinsically with a point source or extrinsically with a
sheet source. The ACR protocol requires two acquisitions:
• Acquisition One – Tc-99m or Co-57
• Acquisition Two – Tl-201 or Ga-67

4.1.2 Configuration:
Intrinsic Flood Field Uniformity
A point source in a scatter free environment should be used. Source activity should be
targeted to achieve between 5 kcps and 25 kcps in window with no collimator on the detector.
The activity should be ~15-25 μCi for acquiring an intrinsic flood with the source between the
detectors
Acquisition with source between the detectors:
• Move the camera to the 180 degree configuration
• Rotate detector 1 to 0 degrees and fully retract the detectors
• Place the source in the source holder and center the source between the detectors
• Acquire using the appropriate Flood Field Uniformity workflow template

Alternatively, the point source can be placed 5 fields of view away (approximately 9 feet) and
images for each detector can be acquired separately. This can be accomplished with the
system in the 90 degree or outer room configurations.

Acquisition with the source placed 5 fields of view away:

• Move the camera to the 90 degree or Outer room configuration
• Rotate detector 1 to 90 or -90 degrees
• Place the point source 5 fields of view away and centered in the field of view
• Modify the Flood Field Uniformity workflow template to acquire the data one detector at
a time.

Extrinsic Flood Field Uniformity

A Co-57 sheet source or a well-mixed Tc-99m fillable phantom should be used.
• Move the camera to the 180 degree configuration
• Place the Co-57 sheet source on one detector
• Bring the other detector as to the source as possible

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• Simultaneously acquire the images from both detectors using the ACR Co-57 Extrinsic
Flood Uniformity workflow template.

4.1.3 Workflow Template

A list of the field uniformity workflows can be found in Section 3.1. These workflow templates
can be found in the ACR template category. An example of the activities and parameters of
those workflows can be found in Figure 1. An example of intrinsic flood field uniformity can be
found in Figure 2.

Figure 1: Workflow Template: ACR Tc99m Field Uniformity for source centered between the
detectors

NOTES
 The raw data is a pair of 8 million count floods. After passing through the Flood
Calculation activity, they are transformed into 5 million count floods in a 256 x 256
matrix.

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Figure 2: Example of an intrinsic flood field uniformity acquired with a Tc-99m point source

4.2 Spatial Resolution

4.2.1 Overview:

ACR has two protocols for measuring spatial resolution. For cameras that only acquire planar
images, the Planar Only Protocol should be followed. All others should follow the SPECT and
Planar Protocol

• Planar Only Protocol

o A resolution (bar) pattern is used
o Images are acquired extrinsically with a sheet source or intrinsically with a point
source
o The use of a Tc-99m fillable sheet source is preferred, but a Co-57 sheet
source is also acceptable.
o The images should be acquired in a 512 x 512 or the camera’s finest matrix.
o A zoom of 1.33-1.46 should be used.

• SPECT and Planar Protocol

o A flangeless Jaszczak phantom is imaged directly on the collimator face.
o This test is performed with Tc-99m

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4.2.2 Configuration: Planar Only Protocol

Extrinsic Spatial Resolution Acquisition
• Rotate detector 2 to 180 degrees
• Place the resolution (bar) pattern directly on the detector 2’s collimator face
• Place the sheet source on top on the resolution (bar) pattern
• Acquire the image using the ACR Co-57 Spatial Resolution Barstemplate
• Remove the sheet source and the resolution (bar) pattern
• Rotate the detectors so that detector 1 is at 180 degrees
• Place the resolution (bar) pattern directly on the detector 1’s collimator
• Place the sheet source on top on the resolution pattern
• Acquire the second image and complete the workflow.

Intrinsic Spatial Resolution Acquisition

For intrinsic spatial resolution measurements, a point source in a scatter free environment
should be used. Source activity should be targeted to achieve between 5 kcps and 25 kcps in
window with no collimator on the detector. For this acquisition, a weak uncollimated source
(~60-80 μCi) may be used to acquire the images intrinsically:
• Reconfigure the camera to 90 degrees.
• Rotate the camera so that one detector is at 180 degrees.
• Suspend the point source on the PPM boom or ceiling so that is shining down on the
detector that is being tested
• Gently place the resolution pattern directly on the detector
• Acquire the image using the ACR Tc-99m Spatial Resolution Bars workflow template
• Remove the resolution pattern
• Rotate the camera so that the other detector is at 180 degrees.
• Gently place the resolution pattern directly on the detector
• Acquire the second image and complete the workflow

4.2.3 Workflow Template

A list of the spatial resolution workflows can be found in Section 3.1. These workflow
templates can be found in the ACR template category. Parameters for the static acquisition in
the ACR Tc-99m Spatial Resolution Bars Workflow are shown in Figure 3.. Typical results with
a bar phantom with 2.0-3.5 mm bars shown in Figure 4.

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Figure 3: Workflow Template: ACR Tc-99m Spatial Resolution Bars

Figure 4: Example of a Tc99m point source Intrinsic Spatial Resolution Acquisition

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4.2.4 ACR Acceptance Criteria

ACR Acceptance Criteria

Test Satisfactory Marginal
Tc99m: 3.0 to 3.4 mm bars
Tc99m: 2.5 to 2.9 mm bars resolved
Intrinsic Spatial resolved Ga67/Tl201: 3.5 to 3.9 bars
Resolution Ga67/Tl201: 3.0 to 3.4 mm bars resolved
Tc99m: 3.4 to 3.9 mm bars
Tc99m: 3.0 to 3.4 mm bars resolved
System Spatial resolved Ga67/Tl201: 4.0 to 4.4 bars
Resolution Ga67/Tl201: 3.5 to 3.9 mm bars resolved

4.2.5 Configuration: Planar and SPECT Protocol

The spatial resolution for the Planar and SPECT protocol is acquired extrinsically using the
filled Jaszczak phantom. For details on source preparation and phantom filling please refer to
section 4.3.3

To acquire the image:

• Rotate detector 2 to 180 degrees

• Place an absorbent pad on the detector face.
• Place the Jaszczak phantom, on the rod side, in the center of the high resolution
collimator (See Figure 5)
• Acquire the image using the ACR Tc-99m Spatial Resolution Phantom Workflow
• Remove the phantom and the pad
• Rotate the detectors so that detector 1 is at 180 degrees
• Place an absorbent pad on the detector face.
• Place the Jaszczak phantom, on the rod side, in the center of the high resolution
collimator
• Acquire the second image and complete the workflow.

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Figure 5: Example of Phantom Placement

The rod and sphere sizes for flangeless Jaszczak SPECT Phantom that is included in the
Siemens ACR Phantom Kit are:

• Cold Rod Dimensions: 4.8 mm, 6.4 mm, 7.9 mm, 9.5 mm, 11.1 mm, 12.7 mm
• Solid Sphere Diameters: 9.5 mm, 12.7 mm, 15.9 mm, 19.1 mm, 25.4 mm, 31.8 mm

4.2.6 Workflow Template

A list of the spatial resolution workflows can be found in Section 3.1. These workflow
templates can be found in the ACR template category. Parameters for the static acquisition in
the ACR Tc-99m Spatial Resolution Phantom Workflow are shown in Figure 6. Typical results
are shown in Figure 7.

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Figure 6: Workflow Template: ACR Tc99m Spatial Resolution Phantom

Figure 7: Example of a Tc-99m Spatial Resolution Phantom Acquisition

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4.2.7 ACR Acceptance Criteria

ACR Acceptance Criteria

Test Satisfactory Marginal
Tc99m & LEHR: Tc99m & LEHR:
7.9 mm rods resolved with high 7.9 mm rods resolved with low
contrast contrast
ACR Phantom Ga67 & MELP: Ga67 & MELP:
Spatial 11.1 mm rods resolved with high 12.7 mm rods resolved with high
Resolution contrast contrast

4.3 SPECT Phantom

4.3.1 Phantom Filling

For the Tc-99m acquisitions use 10 to 20 mCi. For the Tl-201, use 6 mCi For Ga-
67acquisitions use 10 mCi
Proper filling of the phantom is essential. When filling the phantom, ensure that the activity is
mixed well and that all air bubbles are removed. The easiest way to ensure that the activity is
well distributed in the phantom is to mix up the water and the activity externally. After filling,
cover phantom with a plastic bag
If external mixing is not an option then follow the steps for internal mixing. Remove 1/3 of
water from the phantom. Add the activity to the phantom, seal, and mix well. Add water to fill
the phantom to 5/6 full volume, seal, and mix well. Add remaining water to phantom, trying to
prevent trapped bubbles, seal and mix well. Cover phantom with a plastic bag.

4.3.2 Phantom Positioning

Phantom alignment is critical to obtaining satisfactory composite images. Poor alignment of
the phantom with the rotation axis will degrade the resolution of the composite cold rod image.
To position the phantom
• Reconfigure detectors to 180°
• Place the phantom in the head holder with the largest rods positioned towards
Detector 1
• Ensure that the phantom is level. If necessary, use a counter-weight to help stabilize
the phantom on e.cam systems.
• Rotate the detectors so that Detector 1 is at 90° (Detector 2 will be @ -90°)
• Extend the pallet into the camera FOV so that the phantom is centered axially in FOV
• Adjust the pallet height so that the phantom is centered vertically in the FOV
• Adjust the radius of rotation of each detector to be as close as possible to the
phantom.

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• Rotate the detectors to ensure that they clear the phantom and the pallet. Adjust
radius if necessary. Note: The head with the smaller of the two detector radii should be
moved out so that both detectors have the same radius (approximately 21.5 cm or
closer
• Confirm phantom alignment, both axially and transaxilly, via the PPM

4.3.3 Acquisition
By default the template will be set up to acquire Tc99m. If using the template for Tl201, change
the series name to differentiate the study. If using Ga67, use the Gallium two peak preset (92
and 185 keV peaks) for optimal phantom imaging and change the series name. The Jaszczak
SPECT image should be set up with acquisition parameters of 128 views over 360°. ACR
recommends acquiring approximately 24M counts in the SPECT study. The acquisition time
per view field will need to be adjusted accordingly. The image size should be set to 128x128
and the image zoom should be set to 1.45. Uniformity corrections should be enabled. A
patient orientation of Head First is recommended but not required.

Select the ACR Phantom patient and launch the ACR Phantom SPECT ACQ workflow
template (Figure 8). The following information should be noted on the ACR Data Form:

Series Name:
Activity (mCi)
Collimator:
Matrix Size: 128 x128 (default)
Radius of Rotation
Orbit: Step and Shoot or Continuous (Step and Shoot is the default)
Orbit Shape: Circular or Non-Circular (Circular is recommended)
Acquisition Zoom: 1.45 (default)
Time/View: See ACR calculation below.
Slice Thickness: 3.37 (if using the zoom and matrix of 1.45 and 128 x 128)
Analyzer Setting: Refer to Analyzer Tab in Tomo Acquisition Activity

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Figure 8: Workflow Template: ACR Phantom SPECT ACQ

NOTES
 ACR Time/View Calculation
The time per view for the phantom acquisition is equal to:

24 million / (count rate x number of views).

In the ACR Phantom SPECT ACQ, the number of views is defaulted to 128)

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4.3.4 Processing

4.3.4.1 Reconstruction parameters

Tc-99m images should be reconstructed using Filtered Back Projection with a Shepp-Logan-
Hanning reconstruction filter and a cutoff frequency of 1.0 x Nyquist. Only the slices with
phantom activity in them need to be reconstructed. This corresponds to approximately 64
slices at a zoom of 1.45.

Select the ACR Phantom patient and launch the ACR Phantom Recon workflow
template(Figure 9). The following information should be noted on the ACR Data Form:

Isotope Tc-99m Ga-67 / Tl-201

Reconstruction Filter Shepp-Logan-Hanning Butterworth
Cutoff 1.0 0.3 – 0.35
Order n/a 5
Flood Correction Yes Yes
Attenuation Coefficient 0.11/cm 0.09/cm

Figure 9: Workflow Template: ACR Phantom Recon

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4.3.4.2 Attenuation correction

Chang’s attenuation correction should be applied following reconstruction, if a μmap of the
phantom is not available. The boundary can be drawn manually to closely follow the outline of
activity in the phantom, or generated automatically (Figure 10). For best results, choose
‘Apply Smoothing’ with a Kernel size of 9x9. Adjust the Edge Strength to tailor the boundary
close to the emission image. For Tc99m an attenuation coefficient of 0.11 to 0.12 cm-1 should
be used. For Tl201 or Ga67 employ a value of 0.09-0.10. The uniform correction map is defined
when ‘Create Boundaries’ is selected (this step must be executed after every change to the
Automatic boundary search parameters). Step through the slices to ensure that all of the
contours are acceptable. The correction is then applied when ‘Apply Correction’ is selected.

Figure 10: Workflow Template: ACR Phantom Recon: Chang’s Attenuation Correction

NOTES
 Cine the raw data. If there is a tilt in the cine, use the 3D Orientation activity
within this workflow to properly align the corrected transverse images.

4.3.5 SPECT Phantom Analysis

Select the reconstructed Jaszczak series and launch the ACR SPECT Phantom Analysis
workflow template to generate the following information:
• Uniformity Composite Image
• Resolution Composite Image
• Contrast Composite Image
• Contrast Composite Analysis (Regions of Interest and Curves)

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Figure 11 ACR Phantom: Coronal View

4.3.5.1 Uniformity Composite Image Generation

In the first Series Arithmetic Activity, select the Arithmetic tab. Shift-left-click to select 6 slices
from the uniform section of the phantom just under the lid, between sphere and end of
phantom (Figure 13)

. With these slices highlighted, click on the Composite tool in the toolbar (Figure 12):

Figure 12: Composite Tool

The composite image will then be displayed in the Operation Output: Composite Frames
series display at the bottom of the Arithmetic tab (Figure 13). The Rename Output Series
from the Series Arithmetic menu has been set so that the output series ‘Uniformity Composite
Image’ to distinguish it from other composite images. Additionally this output is connected to
Flexible Display so that the proper image size and annotations required by ACR can be edited
in this activity. Ensure that the image is clearly labeled with the image size, zoom, isotope and
total counts.

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Figure 13: ACR Phantom Uniformity Section

4.3.5.2 Resolution Composite Image Generation

In the second Series Arithmetic Activity, select the Arithmetic tab. Shift-left-click to select 16
slices from the cold rod section at the end of the phantom (Figure 14). With these slices
highlighted, click on the Composite tool in the toolbar

The composite image will then be displayed in the Operation Output: Composite Frames
series display at the bottom of the Arithmetic tab. The Rename Output Series from the Series
Arithmetic menu has been set so that the output series ‘Resolution Composite Image’ to
distinguish it from other composite images. Additionally this output is connected to Flexible
Display so that the proper image size and annotations required by ACR can be edited in this
activity. Ensure that the image is clearly labeled with the image size, zoom, isotope and total
counts.

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Figure 14: ACR Phantom Resolution Section

4.3.5.3 Contrast Composite Image

In the third Series Arithmetic Activity, select the Arithmetic tab. Shift-left-click to select 2 slices
from the cold sphere section in the upper third of the phantom (Figure 15). With these slices
highlighted, click on the Composite tool in the toolbar.

The composite image will then be displayed in the Operation Output: Composite Frames
series display at the bottom of the Arithmetic tab. The Rename Output Series from the Series
Arithmetic menu has been set so that the output series ‘Contrast Composite Image’ to
distinguish it from other composite images. Additionally this output is connected to Flexible
Display so that the proper image size and annotations required by ACR can be edited in this
activity. Ensure that the image is clearly labeled with the image size, zoom, isotope and total
counts.

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Figure 15: ACR Phantom Uniformity Section: Coronal View

4.3.5.4 Contrast Composite Analysis

The cold sphere contrast can be found by generating a line profile through the contrast
composite image. This must be done in the Series ROI and Curve activity.

Figure 16: Series ROI And Curve Activity

On the Processing tab of this acitivity, select the image frame, and click on the ROI tool .
The ROI Tool window (Figure 17) opens. Select Sphere from the ROI menu and the Line

Profile ROI. . Draw a single pixel profile through the center of the largest sphere in the
contrast image. Select No Sphere from the ROI menu and draw another single pixel line

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across the center of the Contrast image without intersecting any sphere if possible. The
profile should extend well outside the phantom on both sides.

Figure 17: Series ROI And Curve Activity: ROI Tool Window

After the lines are created, select the red line and generate the line plot by selecting the Line

Curve tool. . Repeat for the green line. Curves will appear in the Line Profile
Graph.

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Figure 18: Series ROI And Curve Activity: Processing Tab

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4.3.5.5 Displays
The Flexible Display Activity contains the following tabs that can be printed out onto individual
film or saved as jpegs: Uniformity, Resolution, Contrast, Contrast Analysis and Transverse (2).
There is also a print tab that combines all of the others into a 4:1 display that is suitable for
printing on a sheet of 11 x 14 film.

Figure 19: Flexible Display: Uniformity Tab

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Figure 20: Flexible Display: Resolution Tab

Figure 21: Flexible Display: Contrast Tab

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Figure 22: Flexible Display: Contrast Analysis Tab

• Note: This image does not have to be submitted. Only the numbers are needed.

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Figure 23: Flexible Display: Transverse Tabs (2)

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4.3.6 ACR Acceptance Criteria

ACR Acceptance Criteria

Test Satisfactory Marginal
Tc99m & LEHR: Tc99m & LEHR:
11.1 mm rods resolved w high 12.7 mm rods resolved w low
contrast contrast

Tl201 & LEHR: Tl201 & LEHR:

Spatial Resolution
12.7 mm rods resolved w high 15.9 mm rods resolved w low
(Rods)
contrast contrast

Ga67 & MELP: Ga67 & MELP:

12.7 mm rods resolved w high 15.9 mm rods resolved w low
contrast contrast
Tc99m & LEHR: Tc99m & LEHR:
19.1 mm spheres resolved with 12.7 mm spheres resolved with
high contrast low contrast

Tl201 & LEHR: Tl201 & LEHR:

Contrast (Spheres) 25.4 mm spheres resolved with 31.8 mm spheres resolved with
high contrast low contrast

Ga67 & MELP: Ga67 & MELP:

25.4 mm spheres resolved with
high contrast
Faint ring artifacts visualized in the
UNIFORMITY and in the complete
Uniformity set of all slices that are not
thought to be clinically significant
or vice versa
31.8 mm spheres resolved with
low contrast
Strong artifacts are seen in no
more than two slices of the
complete set

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4.3.7 Trouble Shooting

4.3.7.1 Camera QC
To ensure maximum image quality, the Monthly Intrinsic Flood Calibration should be updated
within the month preceding the study. The camera should be Peaked and Fine-Tuned before
the flood is acquired. The Intrinsic Flood Field Uniformity (uncorrected) should fall within
accepted levels.

Uniformity 3/8” 5/8”

Differential CFOV < 2.5% < 2.5%
Differential UFOV < 2.7% < 2.7%
Integral CFOV < 2.9% < 2.9%
Integral UFOV < 3.7% < 3.7%

Rings in the transverse reconstruction may be caused by inadequate counts in the flood
corrections. If the statistics of the flood corrections do not exceed the total counts in the
SPECT image (both the extrinsic and the intrinsic flood should be considered), the noise in the
flood image will dominate those in the image data. The flood noise is reinforced at every view,
and this results in rings in the reconstruction, especially near or at the center of the FOV. The
minimum flood counts required for this ACR acquisition are 200 million Intrinsic flood counts
and 120 million Extrinsic flood counts. If any uncertainty in the flood statistics exists, they
should be repeated. Flood corrections should be used in the SPECT images.
Poor resolution will result if the 180° MHR/COR/Head Alignment corrections are out of date.
Since this calibration takes a modest amount of time, it is recommended that the calibration be
performed just prior to the ACR acquisitions. The camera user manual discusses acceptable
limits for COR/MHR/Head Alignment values. In general, these calibration results should be
less than the following:

Symbia 5 Point Head Alignment Values (valid for low energy collimators)

Calibration Limit (Symbia) Limit (e.cam)

Center of Rotation < 5 mm < 10 mm
Axial Shift < 5 mm < 5 mm
Back Projection Angle < 0.8 degrees < 0.8 degrees

4.3.7.2 Phantom Filling

If a cold spot shows up in the uniformity image, the phantom may have been poorly mixed
after final fill of cold water. This water enters near the lid of the phantom, near the slices that
produce the uniformity composite image. Since there is no air space at this last fill to aid in
agitation, it is especially critical that enough time and effort is given to the final agitation of the
phantom. A small amount of food coloring may be added before the last fill to help show
when the phantom is adequately mixed.
If hot spots show up away from the image center, the phantom may have been poorly mixed
after injecting activity. For example, the injected activity tends to locate near the top flange on
the cold spot insert. If the phantom is not mixed after injection, the top of the flange (near the
center of the phantom) will appear hot relative to the surrounding volume. Since there is no
air space at this last fill to aid in agitation, it is especially critical that enough time and effort is
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given to the final agitation of the phantom. A small amount of food coloring may be added
before the last fill to help show when the phantom is adequately mixed.

4.3.7.3 Phantom Alignment

Since image resolution varies with the source to collimator separation, some care should be
taken to center the phantom on the rotation axis. This allows consistent resolution from view
to view and produces an optimum image.
SPECT image resolution is evaluated by how many cold rod ‘pie’ sections can be
distinguished in the Jaszczak phantom. Poor phantom alignment will result in indistinct pie
sections in the Resolution composite image. Since 16 slices are added to generate the
SPECT resolution image, it is critical that the images be well registered with one another. A
tilt of 1.5 mm over the 16 slices (5.3 cm) will significantly affect the resulting image.
Phantom alignment is usually adjusted by shimming under the edges with small amounts of
paper or foam padding. Highly attenuating material should not be used.

4.3.7.4 Acquisition Parameters

Make sure the camera is peaked before the acquisition. ACR stipulates that clinical analyzer
setting should be used. This distinction is important when selecting analyzers with multiple
peaks. The analyzer settings will impact the final image in the following ways:
• Acquisition time: Most importantly, if multiple peaks are not enabled, the acquisition
will take longer to attain the appropriate level of counts.
• Energy resolution: Secondly, lower energy peaks will have slightly lower energy
resolution. This contributes to a general reduction in image quality from Tc99m to
lower energy isotopes.
• Collimator penetration In addition, higher energy peaks will contribute more to
collimator penetration, and larger resolution.
Camera resolution, pixel size and image counts affect the phantom structure that can be
visualized in a SPECT study. Camera resolution limits the imaged contrast in the phantom.
Pixel size limits the resolution with which this imaged contrast can be measured. Image
counts dictate the noise level in the image, which may obscure the measured contrast if count
densities are low. Of these factors, ACR standards attempt to qualify the camera resolution,
which may vary from system to system.
The camera resolution will limit the recovered contrast in the phantom due to partial volume
effects. Typically, the imaged contrast is compromised for sphere diameters that are less than
twice the spatial resolution FWHM of the system. For SPECT imaging, the collimator
contributes significantly to the image spatial resolution, and thus limits the imaged contrast in
the smaller spheres and all of the cold rods. The planar resolution image limits the collimator
component by placing the phantom directly on the collimator for imaging.
The pixel size, which is 2.4 mm for the planar spatial resolution image, and 3.3 mm for the
SPECT image, limits the resolution with which the contrast can be measured. This pixel size
will inherently limit the ability of the camera to accurately image the cold rods in the smallest
rod section (4.8 mm diameter). Image digitization leads to an effective spatial resolution that
is approximately 1.3 times as large as the pixel size. As a larger pixel size is chosen, the
imaged features are further limited. It is important to set the image pixel size according to the
ACR standards.

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4.3.7.5 Phantom Counts

Camera resolution, pixel size and image counts affect the phantom structure that can be
visualized in a SPECT study. The image counts control the amount of Poisson noise in the
image, and as such limits the ability to image smaller structure with poorer recovered contrast.
The image count target of 24 Million set by the ACR instructions is not optimized for imaging
the smaller structures in the Jaszczak phantom.
To ensure the target count total in the phantom acquisition, it is recommended that the stop
condition of ‘Stop on Counts’ is used. Choose a count level equivalent to 24 Million counts
divided by the total number of views in the study
24 Million
Counts _ per _ View =
Number _ of _ Heads × Number _ of _ Views / Head

4.3.7.6 Filter Choice

The filter used in FBP reconstruction should be chosen to maintain the contrast for relevant
structure sizes in the image and reduce the contrast of small scale image structures that are
dominated by noise. ACR stipulates the filter choice (Shepp_Logan_Hanning with cutoff of
1.0) to most accurately reflect the true imaging characteristics of the system at all scale
lengths. Many clinical cardiac applications intend to limit the imaged structure size to the
heart wall thickness, and utilize a filter with a lower cutoff frequency to filter out more of the
Poisson noise. Thus, the SPECT phantom reconstruction for ACR will have typically more
noise than a clinical cardiac image. When the SPECT phantom is imaged with a filter typical
to cardiac imaging (such as a Butterworth Filter), the larger spheres are more clearly
visualized, and much of the smaller scale structure (real or noise) is lost.

4.3.7.7 Reconstruction Noise

SPECT image artifacts can be classified as one of three major types: 1. those associated with
the phantom that move when the phantom is moved, 2. those associated with detector-
specific performance that remain in the same slice after the phantom is moved, and 3. those
associated with image noise that do not persist through multiple acquisitions. Artifacts of type
1 are typically associated with phantom filling defects.
Because of low count limitations in most SPECT imaging scenarios, Poisson noise is a
significant factor in determining the quality of the reconstructed image. Typically, this noise is
uncorrelated from view to view, and averages out to a large degree in the final reconstruction.
Reconstruction filters contribute further to minimizing the impact of Poisson noise. However,
noise in the projection data may randomly correlate for a locus of image pixels, leading to
apparent small scale hot or cold spots in the reconstructed image. Since this correlation is
random, the artifact cannot be reproduced.

4.3.7.8 Chang’s AC
Chang’s attenuation correction is a multiplicative correction that is applied after reconstruction,
once the object outlines have been determined. Because of the ideal shape of the Jaszczak
phantom, it is most efficient to determine the boundary outlines manually. The circular outline
should be adjusted to closely match the outline of the phantom. The attenuation coefficient is
assumed to be constant within the boundaries. An attenuation coefficient of approximately
80% of the ideal value is typically assumed (0.12 cm-1).
This attenuation correction method calculates attenuation seen by a point of emission in the
image matrix, and averages over emission view angles. Since the correction is applied post-

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reconstruction, each individual projection continues to be incorrectly weighted in the back

projection reconstruction. This incorrect weighting means that the projection counts will be
less accurately focused in the back projection, particularly in views that see the most
attenuation. Counts are effectively diffused to another region in the phantom. As a result, the
applied correction overcorrects the phantom center and outer edge, and under corrects a
broad annulus of counts. To recover a flat profile through the center of the phantom, an
attenuation coefficient that is smaller than ideal is typically applied. This is illustrated in the
figures below.

Figure 24 Cylindrical Phantom Count Profile, for Ideal (shown in blue) and Attenuation-
Corrected (Changs’) Images. Results at left have used a coefficient of 0.15 cm-1 for
correction. Results at right have used a coefficient of 0.12 cm-1 for correction.

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5. CLINICAL MEASUREMENTS
5.1 FAQ’s
5.1.1 Determining whole body bone count density:
To determine the count density in a wholebody image, simply divide the number of counts in
the image by the area. The area of the image can be found activated by selecting Size within
the Properties dialog of the image. This dialog box can be displayed by right clicking on the
bottom window pane of the image.
The Size is displayed in mm2. This will need to be converted to cm2. Divide the number of
counts in the image by the converted size to get the count density of the view.
Example: In the following dataset, the Size of the image is: 1506930.37 mm2. To convert to
cm2, simply divide by 100. (1506930.73/100) = 15069.3 cm2 Now to calculate the counts
density, divide the number of counts (910000) by area in cm2 (15069.3). In this example the
count density would equal 60.37 cts/ cm2

Counts in image

Size
(Area)

Figure 25: Flexible Display Activity: Wholebody Display

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5.1.2 SPECT Radius of Rotation:

If Autocontour is used then the radius of rotation for the acquisition is variable. The
Autocontour feature keeps the detectors as close to the patient or object as possible during
the scan.

5.1.3 SPECT Filters used

If Iterative is used for SPECT reconstruction, the type of iterative method, the number of
iterations/subsets and the smooth will have to be written in. The form is set for the user to
type in filtered back projection values.

5.1.4 Myocardial Perfusion Imaging

The ACR form requests the total counts from the following angles:
Anterior
Shallow Oblique
Steep Oblique
While reviewing the projection data in Flexible Display, choose the images that best represent
these angles and write down the total counts from these images. See example below.

Figure 26: Flexible Display Activity: Raw Tomo Data Display

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5.1.5 Technologists initials on Hardcopy

The technologists should enter their initials in the Technologist field located on the Acquisition
Series prior to scanning is the best way to ensure that the information is stored with the
patient file. If this does not happen, the initials can be added to the file by using the Correct
file feature in the syngo browser. By adding it to the series information, it becomes a DICOM
attribute that can be displayed later in Flexible Display Annotation Tool. The final option is to
use the free text Annotation tool within Flexible Display.

Figure 27: syngo Browser

5.1.6 Bad Beat Rejection:

When acquiring a gated or gated SPECT study on the Symbia or e.cam, the choice of whether
to reject beats or not is done on the Gate Tab. The PVC group tells the system how to handle
the events detected during a preventricular contraction. If this option was activated during the
acquisition then any beat shorter than the value set in the PVC threshold will be ignored.
Also, any beats outside of the Beat Histogram window are not accepted.

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Figure 28: Gated Tomo Activity: Gate Tab

5.1.7 Scatter Correction

The default acquisitions on Symbia S, Symbia E and e.cams are not set up with a scatter
window. If the acquisition is not acquired with a scatter window that scatter correction can not
be applied.

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