The operator will then be prompted to select the appropriate study for normal file comparison under

the Bullseye normal patient 7444444447. The dataset BUARRAY and the normal file will be displayed
and the three stress plots will be generated. Note that only the upper third of the blackened pixel and
standard deviation arrays will be filled in.

When the stress processing is complete all of the review options will be available. Just the stress data
will be presented in the review options.

10.2 To Process Delay Data

Once the stress data has been processed, type BUPROCESS to enter the Bullseye protocol. Select
option 1 to process data just as before. When the second menu is displayed, select option 2 to
process delay data.

The protocol will check to see that the stress data is already processed, and that both the stress and
delay data have not already been processed.

The protocol will then check that the type of reconstruction used to generate the delay short axis
images matches the type of reconstruction used the generate the stress images. If stress and delay
images were generated with different types of reconstruction, the protocol will notify you of this and
not allow you to continue.

The redistribution time will be displayed and the operator will be prompted to approve or redefine this
time. The next prompt will be to select the apical and base slices, and the centre and radius of search
for the delay data as described in the Image Processing and Analysis section of this manual.

The delay short axis dataset will then be displayed as a snake on the lower half of the display. The
dataset BUARRAY will also be displayed. Note that the upper third of this dataset - the stress profiles
- has already been filled in. The middle and lower portions of this dataset - the delay and washout
profiles - will then be generated.

The operator will then be prompted to select the appropriate study for normal file comparison under
the Bullseye normal patient 7444444447. The dataset BUARRAY, the normal file, the three stress
plots, and the blackened pixel and standard deviation arrays will be displayed. The delay, washout,
and reversibility plots will then be generated. Note that the remaining portions of the blackened pixel
and standard deviation arrays will now be filled in.

When the delay processing is complete, all the review options will be available. Both the stress and
delay data will be presented in the review options.

This data can be reprocessed, either with a different number of standard deviations or by selecting
option 3 - Process both stress and delay data" from the second menu.

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 11. REPROCESS DATA WITH DIFFERENT CENTRE AND RADIUS

It is possible to reprocess processed data with a different centre or a different radius of search. This

option applies to processed stress data as well as to processed stress and delay data.

Type in `BUPROCESS' to enter the Bullseye processing protocol once you have selected the

appropriate patient and study. The following menu will be displayed:

Bullseye Protocol

1 Process data
2 Review data

3 Reprocess data with different center and radius

4 Reprocess data with different number of standard deviations

5 Transfer individual patient to normal patient 7444444447

6 Create a new normal file in patient 7444444447
0 Exit

Enter appropriate option and press the SEND FORM key.

? :

SEND FORM
Type in a `3' and press to select this option.

At the start of this option, appropriate portions of the scratchpad will be zeroed, and the plots and

arrays will be deleted, if they exist.

The central image of the stress short axis dataset will be displayed in quadrant 1. The following text

screen will appear:

Position cursor over center of heart on stress image

The operator should position the cursor in centre of myocardial cavity in quadrant 1. Once the centre

END
is selected, press to finish.

The next message will appear:

Use the cine control to look at the cursor position on all the stress short
axis images

Enter 1 to reposition the cursor or 44to proceed and press SEND FORM

The operator has the option to cine through all the stress short axis images in quadrant 1 to check for

cursor alignment.

SEND FORM
At this point the operator can reposition the cursor by selecting 1 and pressing or

proceed by selecting 444and pressing4 SEND FORM

.

Upon continuing with the processing, the operator will be prompted to adjust the size of the box

around the myocardium defining the limits of search from the centre point.

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 The following message will be displayed:

Use SIZE key to determine radius – ROI is already positioned

A box ROI will be displayed on the stress short axis images in quadrant 1. This box will be displayed

centered around the user selected centre. The operator can then adjust the size of this box using the

TRACKER BALL and SIZE

key. One half of the larger side of this box will be used as the limit of radial

search for the generation of circumferential profiles. Make sure the box encompasses the entire left

ventricular myocardium.

END
After the box is sized and positioned press to continue.

The following message will be displayed:

Use the cine control to look at the ROI position on all the short axis
images
Enter 1 to resize box ROI or 44to proceed and press4 SEND FORM
.

The operator has the option to cine through all of the stress short axis images to check the ROI

location.

At this point, the operator can either resize the box by pressing 1 or proceed by pressing 4.
In a similar manner, you will be prompted to position the centre and size the radius of search on a

central delay short axis image in quadrant 2. The centre will initially be displayed on the delay image

at the cursor position selected for the stress image.

Once the centre locations and size of radii of search are selected, processing will continue as usual.

The BUARRAY dataset will be generated, the operator will be prompted to select the appropriate

study under the Bullseye normal patient, and all of the plots and arrays will be generated.

All of the review options will be available for selection once the processing is complete.

Review option q10, Centre and Radius Information, will display the x and y co-ordinates of the stress
and delay centres, and the length of the stress and delay radii of search.

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 12. REPROCESS DATA WITH DIFFERENT NUMBER OF STANDARD
DEVIATIONS

The number of standard deviations for comparison to normal files for the stress, delay and washout
plots is set to 2.5, and for the reversibility plots to 1.5. It is possible, however, to change either number
and reprocess the data.

Once you have selected the appropriate patient and study, type in BUPROCESS to enter the Bullseye
processing protocol. Both the stress and delay data for this patient should be completely processed.
The following menu will be displayed:-

Bullseye Protocol

1 Process data
2 Review data

3 Reprocess data with different center and radius

4 Reprocess data with different number of standard deviations

5 Transfer individual patient to normal patient 7444444447

6 Create a new normal file in patient 7444444447
0 Exit

Enter appropriate option and press the SEND FORM key.

? :

Type in a `4' and press SEND FORM to select this option.

The protocol will first check to make sure that both the stress and delay data have been processed.

You will then see the following messages:

The number of standard deviations for blackout is set to 2.5

Enter 4 to continue or 1 to change4q of SD’s & SEND FORM key.

If you want to change the number of standard deviations for comparison to normal files for the stress,
delay, and washout plots, type in a `1' and press SEND FORM . Type in a `4' and press SEND FORM to
continue using 2.5 standard deviations.

If you are changing the number of standard deviations, you will be prompted to enter the new number
of standard deviations:

Enter q of SD’s for blackout and press SEND FORM key

Type in the new number of standard deviations and press SEND FORM . In this case, blackout" refers
to the stress. delay, and washout plots. The number of standard deviations will be updated on the
alphanumeric screen.

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 The following message will be displayed:

Enter 4 to continue or 1 to change4q of SD’s & SEND FORM key.

Type in a `1' and press SEND FORM 4'

to further modify the number of standard deviations, or type in a `

and press SEND FORM to continue with the number of standard deviations displayed.

In a similar manner, the number of standard deviations for reversibility (1.5) will be displayed, and you

can modify this number or continue using 1.5 standard deviations.

Once the number of standard deviations has been selected, processing will continue as usual. The

plots and arrays will be deleted, if they exist. You will be prompted to select the appropriate study

under the Bullseye normal patient, and all the plots and arrays will be generated.

All of the review options will be available for selection once the processing is complete. The number

of blackout and reversibility standard deviations will be clearly marked on the appropriate review

modes.

This option can also be used to generate reversibility plots and scores on previously processed data.

The apical and basal slices, centres and radii defined during the initial processing will be used for

reprocessing. For this purpose keep the number of standard deviations at 2.5 and 1.5, respectively.

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 13. GENERATION OF USER CREATED NORMAL LIMITS

Male and female normal files are supplied with the Bullseye software. The user can use these as

supplied or generate an entirely new normal file.

If a new normal file is to be created, a new study must first be created under the Bullseye normal

patient 7444444447. Use the FSLP command to select the normal patient, and the FCRS command
to create a new study under this patient. Any study name is acceptable.

Process each patient to be included in the new normal file completely, that is, make sure that both the

stress and delay data have been processed. When processing has been completed, select the

patient and study containing the processed data and then type in BUPROCESS to enter the Bullseye

protocol. The following menu will be displayed:

Bullseye Protocol

1 Process data
2 Review data

3 Reprocess data with different center and radius

4 Reprocess data with different number of standard deviations

5 Transfer individual patient to normal patient 7444444447

6 Create a new normal file in patient 7444444447
0 Exit

Enter appropriate option & press SEND FORM key

? :

Type in a 5 and press SEND FORM .

The dataset BUARRAY will be displayed in quadrant 1. The values in this dataset will be normalised

and displayed in quadrant 2. The stress and delay values will adjusted to a maximum level, and the

washout values will be adjusted to exactly 4 hours.

The reversibility values will be created and displayed in quadrant 2 even if they do not exist in the

dataset displayed in quadrant 1. This means that you do not have to reprocess previously processed

data to create a normal file with reversibility.

The normalised values will be transferred to the normal patient.

You will then be prompted to select a study under the normal patient. Select the study created for this

purpose. Do not select the Emory studies.

Once a study is selected, the normalised values will be stored as a dataset under this study. The

dataset name will start with the letters `PN' followed by the first 10 characters in the patient code. The

entire patient code and the patient name will be stored in the comments for this dataset. Comments

can be displayed with either the FDID or FMOD commands. In this way you can be absolutely certain

which patients are concerned in the study.

If the dataset to be transferred already exists under the selected study, that is, if it was already

transferred, a message will be displayed to inform you of this fact.

Continue to transfer individual patients to the new study until all the patients to be included in the new

normal file are there. This process can take place over any length of time.

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 Datasets can be deleted from this study with the delete dataset command FDLD.

To create the new normal file, select option 6. Create a new normal file in patient 7444444447, from
the main menu of BUPROCESS.

The protocol will select the normal patient 7444444447 and prompt you to select the study. Select the
study where all the datasets have been transferred. Do not select the Emory studies.

If the normal file STUDYNORM already exists within the selected study, a message will be displayed
to inform you of this fact. This dataset will be deleted if you continue, or you can use ESCAPE .

The protocol will then check through all the `PN' datasets in the selected study looking for
inconsistencies.

A new normal file can be created from datasets that all contain reversibility, or from datasets none of
which contain reversibility. If some of the datasets have reversibility and some do not then the
protocol will notify you of this fact and not allow you to continue.

Likewise, a new normal file can be created from datasets all generated with the contrast
reconstruction or all with the quantitative reconstruction. If the datasets were generated some with
each type of reconstruction, the protocol will notify you of this and not allow you to continue.

If no inconsistencies are found, the protocol will sift through all the datasets in the selected study.
Each dataset whose name starts with the letters `PN' will be displayed in quadrant 1. As each dataset
is displayed, it will be added to a work image in quadrant 3

The mean and standard deviation images for the new normal file will be created in quadrant 4. These
two images will be appended to form the new normal file STUDYNORM". The format of this file is
described further in Appendix A.

If the ring and sector tables RING_TABLE and SEC_TABLE do not exist under the current study, the
protocol will go to a study where they do exist and transfer them back.

To remove a patient from the newly created normal file, first select the normal patient 7444444447 and
the appropriate study. Use the delete dataset command, FDLD, to delete individual datasets. Check
the comments of each dataset first to identify correctly the original patient name. Then recreate the
normal file using option 6 of the Bullseye main menu.

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 14. REFERENCES

1. DePasquale EE, Nody AC, DePuey EG, et al. Quantitative rotational thallium-201
tomography for identifying and localizing coronary artery disease. Circulation 1988: 77:
316-327.

2. Garcia EV, DePuey EG, and DePasquale EE. Quantitative Planar and tomographic
thallium-201 myocardial perfusion imaging. Cardiovasc Intervent Radiol 10:374-383,
1987.

3. Depuey EG, Guertler-Krawczynska E, Robbins WL. Thallium-201 SPECT in coronary

artery disease patients with left bundle branch block. J Nucl Med 29:1479-1485, 1988.

4. Cloninger KG, DePuey EG, Garcia EV, et al. Incomplete redistribution in delayed
thallium-201 single photon emission computed tomographic (SPECT) images: an
overestimation of myocardial scarring. J Am Coll Cardiol 12:955-63, 1988.

5. Eisner RL, Noever T, Nowak D, et al. Use of cross-correlation function to detect patient
motion during SPECT imaging. J Nucl Med 28: 97-101, 1987.

6. Eisner R, Churchwell A, Noever T, et al. Quantitative analysis of the tomographic

thallium-201 myocardial bullseye display: critical role of correcting for patient motion.
J Nucl Med 29:91-97, 1988.

7. Garcia EV, DePuey EG, et al. Quantification of rotational thallium-201 myocardial

tomograms: a multicentre trial using bullseye polar maps and standard normal limits.
J Nucl Med 28: 673 (poster), 1987.

8. Klein L, Garcia EV, DePuey G, et al. Reversibility bullseye: a new polar bullseye map to
quantify reversibility of stress induced SPECT Tl-201 myocardial perfusion defects.
J Nucl Med 28:642 (abstract), 1987.

9. Luna E, Klein L, Garcia EV, et al. Reversibility bullseye polar map: accuracy in detecting
myocardial ischemia. J Nucl Med 29:951 (poster), 1988.

10. DePuey EG, Garcia EV: Optimal Specificity of Thallium-201 SPECT through recognition of
imaging artifacts. J Nucl Med 30:441-449, 1989.

11. Garcia EV, DePuey EG, et al. Quantification of Stress induced Tl-201 myocardial perfusion
defects: a multicenter trial using bullseye polar maps and standard normal limits. (AHA),
1989.

12 Klein JL, Garcia EV, et al. Reversibility Bullseye: A new polar Bullseye map to quantify
reversibility of stress induced SPECT Tl-201 myocardial perfusion defects. J Nucl Med
31:1240-1246, 1990.

13 Garcia EV, DePuey EG, et al. Quantification of the reversibility of stress induced SPECT
Tl-201 myocardial perfusion defects: a multicenter trial using Bullseye polar maps and
standard normal limits. J Nucl Med 31:1761-1765, 1990.

14 Eisner RL, Tamas MJ, Cloniger K et al. Normal SPECT Thallium-201 Bullseye Display:
gender differences. J Nucl Med 29:1901-1909, 1988.

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 APPENDIX A
Data Format and Storage
The STARCAM system stores the data that are displayed as round Bullseye plots in a rectangular 15
(rows) by 40 (columns) array.
The rows in the rectangular arrays correspond to the slices and the columns to the angular position.
The algorithm generating these arrays always ensures (using an interpolation technique) that 15
slices are present, even if this was not the number of oblique slices selected by the operator.
The 40 angular positions on each slice mean that each column represents an angle increment of 9
degrees.
Indicated in the figure below are some anatomical correspondences on the rectangular array.
Slices
Apex slice #1

15 x 40 array

Base slice #15

Angle
Antero- Antero- Infero Infero Antero-
lateral septal septal lateral lateral
(1:30) (10:30) (7:30) (4:30) (1:30)
The arrays for stress, delay, washout and reversibility are stored in a 64 x 64 static image named
BUARRAY.
Format of dataset BUARRAY - created during Bullseye processing and stored with each patient.

stress data

delayed data

washout data

reversibility data

Single Frame 64 x 64 Image

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 This is also the format of the datasets BLKARRAY and STDARRAY. BLKARRAY contains the
blackened pixel information, and STDARRAY contains the standard deviation information.
Format of Dataset STUDYNORM - normal file supplied with the Bullseye package or created by the
user.

Two-Frame 64 x 64 Image

Frame #1:

stress data

delayed data

washout data

reversibility data

Frame #2:

stress errors

delayed errors

washout errors

reversibility errors

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 Datasets Created During Processing
The following datasets are created and stored during processing:-
STRBOX Stress box ROI
DLYBOX delay box ROI
STRREG stress raw plot
STRBLK stress blackened pixel plot
STRSTD stress standard deviation plot
CLRMAP colour map
BLKARRAY blackened pixel array
STDARRAY standard deviation array
DLYREG delay raw plot
DLYBLK delay blackened pixel plot
DLYSTD delay standard deviation plot
WOREG washout raw plot
WOBLK washout blackened pixel plot
WOSTD washout standard deviation plot
REVREG reversibility raw plot
REVBLK reversibility blackened pixel plot
REVSTD reversibility standard deviation plot
DESARRAY descriptor array
BUARRAY raw profiles array
BUPARAMS scratchpad

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 APPENDIX B
Emory Normal Files
The Emory normal files supplied with the Bullseye software consist of a male and a female normals
file.
The normal files are stored under the Bullseye patient 7444444447. The male normal file resides
under the study EMORY M V2, and the female normal file under the study EMORY F V2.
The `V2' at the end of each of these study names indicates the second version of the original Emory
normal files. This second version now includes the portions of the normal file needed for reversibility.
There are 20 males in the Emory male normals file. The average age is 40 years and the age range is
28 to 69 years. Three of the 20 males were older than 45 years of age.
There are 16 females in the Emory female normals file. The average age is 38 years and the age range
is from 27 to 54 years.
Each of the individuals selected for these normal files has low likelihood (<5%) of coronary artery
disease determined on the basis of age, sex, symptom classification, and the results of stress
electrocardiography rather than having normal coronary arteriograms.
The following criteria define the normal patients:-
1. These patients have a normal treadmill electrocardiographic response to exercise (<0.5mm) of
horizontal ST segment depression or (<1.0mm of upsloping ST segment depression) achieved
during adequate stress (>=85% of maximal predicted heart rate).
2. These patients are asymptomatic or have nonanginal chest pain but do not have typical or
atypical angina pectoris. Chest pain is considered nonanginal if it has one or less of the qualities
that describe typical angina pectoris: substernal location; precipitation by exertion; relief with 10
minutes by rest or nitroglycerin.
3. If the patients are asymptomatic with a negative stress ECG, males and females of any age
qualify.
4. If the patients have nonanginal chest pain and a negative stress electrocardiogram, females of
up to age 65 and males up to age 45 are defined as having a low likelihood of angiographically
significant coronary artery disease and are thus appropriate.
5. No other patient groups are included in this low likelihood category.

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 APPENDIX C - Registers used by Bullseye Protocols
This is a description of the scratchpad registers used by the Bullseye processing protocols and
saved as the dataset BUPARAMS.
REGISTER CONTENTS STRESS DELAY
Number of Frames @S10 @S30
Time of Acquisition @S11 @S31
Apical Frame Number @S12 @S32
Base Frame Number @S13 @S33
(Base fr # - apical fr #)/2 @S14 @S34
Middle Frame of Short Axis Dataset @S15 @S35
Centre x location @S17 @S37
Centre y location @S18 @S38
Centre x - 12 pixels @S19 CENTRE X - (@S23/2) @S39
Centre y - 12 pixels @S20 CENTRE Y - (@S23/2) @S40
X size of box ROI @S21 @S41
Y size of box ROI @S22 @S42
Larger of @S21, @S22 @S23 @S43
Radius of search @S25 @S45
Maximum of stress dataset @S1
(used for windowing)
Redistribution time in minutes @S50
Number of standard deviations @S51
Flag to redefine redistribution time @S52
Flag to reposition stress centre @S55
Mode of processing - stress only(1),
delay only(2), or both (3) @S56
Flag to reposition delay centre @S57
Flag to resize delay box ROI @S58
Flag to resize stress box ROI @S59
Processing completion flag - stress & delay @S60
Processing completion flag - stress only @S61
Response to review menu @S65
Profiles adjusted flag @S70
Flag to indicate stress type of reconstruction
(1) = new, 44= old @S75
Delay type of reconstruction
(1) = new (4) = old @S76
Normal file type of reconstruction
(1) = new (4) = old @S77
Number of SD's for reversibilty @S80
Process completion flag for
reversibility @S81
Process completion flag for
feature extraction @S82
X,Y locations of defect numbers @S90 - @S97
Scaling factor - to scale stress images
down to delay level @S100
User response to reselect normal file @S101
Flag - if 1 normal file does not have
reversibility @S102

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 The following text registers are also used by the Bullseye processing protocols. The text registers are
automatically saved with the scratchpad registers in the BUPARAMS dataset.
@T8 provides a convenient way of checking which normal file was used during processing.
Current patient code @T1
Current patient study @T2
Current patient name @T3
Normal patient code @T7
Normal patient study @T8

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