Original article
Transmission scanning in emission tomography
Dale L. Bailey
MRC Cyclotron Unit, Hammersmith Hospital, London, UK
&misc:Received: 19 February 1998 / Accepted: 19 March 1998
&p.1:Abstract. Attenuation correction in single-photon
(SPET) and positron emission (PET) tomography is now
accepted as a vital component for the production of arte-
fact-free, quantitative data. The most accurate attenua-
tion correction methods are based on measured transmis-
sion scans acquired before, during, or after the emission
scan. Alternative methods use segmented images, as-
sumed attenuation coefficients or consistency criteria to
compensate for photon attenuation in reconstructed im-
ages. This review examines the methods of acquiring
transmission scans in both SPET and PET and the man-
ner in which these data are used. While attenuation cor-
rection gives an exact correction in PET, as opposed to
an approximate one in SPET, the magnitude of the cor-
rection factors required in PET is far greater than in
SPET. Transmission scans also have a number of other
potential applications in emission tomography apart
from attenuation correction, such as scatter correction,
inter-study spatial co-registration and alignment, and
motion detection and correction. The ability to acquire
high-quality transmission data in a practical clinical pro-
tocol is now an essential part of the practice of nuclear
medicine.
&kwd:Key words: Attenuation correction – Transmission scans
– Single-photon emission tomography – Positron emis-
sion tomography
Eur J Nucl Med (1998) 25:774–787
Introduction
Transmission scanning with radionuclides was first sug-
gested by Mayneord in 1952 [1] and therefore has exist-
ed for as long as nuclear medicine “imaging” studies
have. The first reference to producing two-dimensional
density distributions of transmitted photons for use in
conjunction with emission scanning appeared in 1966
[2]. Transmission scanning was used to match anatomi-
cal contours to the radionuclide distribution measured by
a rectilinear scanner. Interestingly, these measurements
Correspondence to: D.L. Bailey, MRC Cyclotron Unit, Hammer-
smith Hospital, DuCane Rd, London. W12 0HS, United Kingdom&/fn-block:
were made simultaneously with the emission scan,
something which is now viewed as highly desirable for
practical usage in a busy clinical department. The radio-
nuclides used in these early applications included thuli-
um-170, americium-241, and iodine-125. Anger et al.
measured transmission on the Mark II Whole Body
Scanner [3] and, later, a gamma camera with techne-
tium-99m flood sources [4, 5]. Sorenson et al. used a
99mTc point source with a dual-headed rectilinear scan-
ner to acquire simultaneous emission-transmission data
[6], and Tothill and Galt used uncollimated point sources
of 99mTc, iodine-131 and cesium-137 with a rectilinear
scanner for quantitative planar measurements [7]. All of
these applications predated the introduction of single-
photon (SPET) and positron emission (PET) tomogra-
phy. At the time of the development of the first PET sys-
tems in the 1970s, transmission scanning was developed
for the purposes of attenuation correction using either a
ring source of a positron emitter (fluorine-18) [8] or a
point source single-photon emitter such as barium-133
[9]. Various planar attenuation correction methods for
gamma cameras based on the use of transmission scans
also appeared around this time [10–12]. Today, transmis-
sion tomographic scanning has become routinely accept-
ed in both SPET and PET, especially when it is com-
bined with the emission scan in a simultaneous acquisi-
tion protocol. The aim of this review is to examine the
development and current and future uses of transmission
scans in emission tomography.
Methods
Transmission data acquisition
Transmission measurements in SPET appeared in the
late 1970s around the time that single-photon tomogra-
phy was being developed. Budinger and Gullberg dis-
cussed the use of measured transmission data but point-
ed out the impracticality of having to acquire two sepa-
rate data sets [13]. Jaszczak et al. used a xenon-133 line
source to obtain body contours [14] simultaneously with
the emission data on a dual-head gamma camera for use
in the iterative attenuation correction algorithm devel-
oped by his co-worker, Chang [15]. In the same paper,
European Journal of Nuclear Medicine
Vol. 25, No. 7, July 1998 – © Springer-Verlag 1998

Jaszczak discussed an alternative method for obtaining
body contours from Compton scattered photons for de-
lineating the patient’s outline to use with the same cor-
rection algorithm. Both approaches initially started with
a single, mean attenuation coefficient within the body
outline. Maeda et al. used transmission computed to-
mography for anatomical delineation of the lung in
SPET [16] while others started to investigate the use of
transmission studies quantitatively for attenuation cor-
rection in SPET [17]. Unfortunately, the latter work is
not well known or cited as it was published in Japanese.
The current interest in the use of transmission data
for attenuation correction in SPET commenced with the
work of Malko et al., who used an uncollimated 99mTc
flood source to measure transmission prior to the admin-
istration of the radiopharmaceutical 99mTc-sulphur col-
loid [18]. Greer et al. reported the performance charac-
teristics of an uncollimated 99mTc flood source for trans-
mission tomography and suggested that the data could
be suitable for use in attenuation correction [19]. As
both studies used 99mTc as both the transmission and the
emission source, the method was impractical for routine
use in producing attenuation-corrected SPET reconstruc-
tions. At the same time in Australia, we had started us-
ing gadolinium-153 as the transmission radionuclide in
an uncollimated flood source for simultaneous emission-
transmission measurements with 99mTc [20]. 153Gd was
produced for us in the high flux atomic reactor (HIFAR)
at the Australian Nuclear Science and Technology Orga-
nisation (ANSTO) in an (n,γ) reaction with 152Gd. The
use of 153Gd had already been documented for bone min-
eral measurements and lung densitometry [21]. With
photon energies of 97 and 103 keV and a long half-life
(242 days), 153Gd offered a transmission source that was
practical to use and could be separated from the 99mTc
photons using energy discrimination on the gamma cam-
era. There were two significant drawbacks to this meth-
od: (a) the transmission data contained a high proportion
of Compton-scattered emission photons from 99mTc in
the 100 keV±10% energy window which corrupted the
data, and, (b) as the flood source was uncollimated,
many of the transmission photons accepted were also
scattered, producing measures of “effective” or broad-
beam attenuation coefficients (µ) rather than narrow-
beam values. The former problem was dealt with by esti-
mating the scatter component from the upper energy
emission window into the lower energy transmission
window and subtracting it. The latter problem was not
dealt with in this implementation, but the use of broad-
beam µ values partially offset the scatter in the emission
window, which was not corrected explicitly.
At approximately the same time SPET was becoming
widely disseminated and the method of choice for myo-
cardial perfusion studies. This coincided with the gener-
al availability of multi-head gamma cameras, which af-
forded more flexibility in developing simultaneous emis-
sion-transmission scanning protocols. The triple-headed
systems, in particular, could use a fan-beam collimator
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998
775
Fig. 1. Schematic examples of some of the transmission geome-
tries for SPET. From top left, clockwise, they are: transmission
flood source or one moving line source, the profiled multiple line
source method where the source size indicates the relative activity
of the source, the fan beam and focussed line source approach on
a triple-headed camera, and finally, the dual moving line sources
on a double-headed camera&ig.c:/f
and a stationary line source fixed at the collimator’s fo-
cus to measure simultaneous, narrow-beam transmission
and emission [22]. The major disadvantage of the meth-
od, though, is severe truncation of the transaxial field of
view (Fig. 1) for most applications apart from the head
[23]. Various strategies have been devised for dealing
with this problem such as combining data from conju-
gate views with an asymmetrically focussed collimator
[24, 25] or using a parallel slant hole collimator [26].
The alternative approach which emerged at the same
time and has found widespread acceptance is the use of a
scanning line source with parallel hole collimators [27].
The technique employs both strict physical collimation
of the source and electronic windowing of the detector to
separate the emission and transmission data. Such a
system offers a flexible approach to simultaneous emis-
sion-transmission measurements as the radionuclides
used can be of higher, lower or the same energy as each
other. Additionally, as the system uses parallel hole col-
limation there is no truncation of the transaxial field of
view. The drawbacks of the system are that it requires a
slightly more complex mechanical design, it does not
work with triple-headed SPET systems due to geometri-
cal constraints, and there is a slight decrease in emission
count rate (~10%) due to the use of the scanning trans-
mission window. However, the cross-talk between the
emission and transmission windows is sufficiently low
(typically <5%) and the configuration produces high-
quality, narrow-beam attenuation factors.
PET measurements have traditionally been corrected
for attenuation using measured transmission data. The
776
Fig. 2. Schematic examples of some of the transmission geome-
tries for PET. From top left, clockwise, they are: ring sources of a
positron emitter measuring transmission (coincidence mode), ro-
tating rod positron sources (coincidence mode), rotating single-
photon source where a “coincidence” is made between the source
position and photons detected on the opposing side of the ring,
and finally, fixed rod sources on a rotating, partial ring tomograph
(coincidence mode)&ig.c:/f
reasons that this has been the case for PET, and that this
has only come more recently in SPET, is that in PET the
correction for attenuation is exact, as attenuation is inde-
pendent of the origin of the annihilation along a line of
response, and because PET started out in the research
domain where there was greater emphasis on accurate
quantitative measurements and less emphasis on practi-
cal aspects of data acquisition. The transmission ring
source approach (Fig. 2), which is still in widespread use
today, uses radioactive rings [8], usually containing the
positron emitting radionuclides gallium-68/germanium-
68 (half-lives 68 min and 270.8 days respectively [28])
which co-exist in transient equilibrium. The rings are
mechanically moved in front of the detectors and coinci-
dence events are recorded by the detector near the anni-
hilation event and the detector in the opposing fan,
which records the other photon of the pair after it has
passed through the subject. The energy of the transmis-
sion photons and emission photons is the same in this
case. There is usually one transmission ring per ring of
detectors in discrete systems such as those based on the
“block” design [29]. In a manner similar to the way the
2D flood source in SPET transmission measurements
was “collapsed” in one dimension to give a 1D line
source which could be electronically windowed, the con-
tinuous ring sources in PET were collapsed radially into
“rod” sources which were continuously rotated about the
subject [30]. A major limitation of this approach is the
local dead time on the detector block that is near the rod
source. However, in favour of the method was the ability
to window the transmission data so that events were only
accepted when the line of response recorded between
two detectors was collinear with the known location of
the rod. This has two effects: (a) reduced scatter in the
transmission measurements, and more importantly, (b)
provision of a means of separating emission and trans-
mission data to allow either post-injection transmission
[31–33] or even simultaneous emission-transmission
measurements [34, 35]. Windowed rotating rod sources
remain the transmission source geometry of choice in
PET at present. PET transmission measurements have
also been used in their own right and not just as a meth-
od for generating factors which corrected for photon at-
tenuation, such as in estimating lung density [36] in PET
studies.
Until very recently, nearly all PET systems manufac-
tured since 1990 had been designed to operate in both
2D and 3D modes [37], and transmission measurements
were usually acquired with the septa in place in 2D
mode with rotating rod sources. However, PET systems
are now being constructed which operate exclusively in
3D and a reappraisal of the optimal transmission acquisi-
tion system for these “open” volumetric systems has
been required. In an early paper on PET system design
and performance, Derenzo et al. suggested the use of a
single-photon emitting point source of 133Ba [9]. This
approach has recently been implemented on a number of
commercial tomographs [38–40]. When using a single-
photon source in a modern PET system, a mechanism is
required to form a “coincidence” event between the de-
tector which records a valid single photon and the detec-
tor on the opposing side of the tomograph which is clos-
est to the current location of the rotating point source. In
the whole body 3D system in our laboratory, the ECAT
EXACT 3D [41, 42], there is a 48-turn helix of stainless
steel filled with water, through which a point source of
137Cs (half-life =30.2 years, E =0.662 MeV) is pumped
γ
at a velocity of approximately 1 m·s–1. As this is a total-
ly uncollimated system, a high proportion of the events
that are recorded are scattered. However, as this is a sin-
gle-photon counting system, more radioactivity can be
used and consequently count rates are increased by ap-
proximately an order of magnitude, to produce highly
precise data which are biased due to the scattered pho-
tons. Strategies for dealing with this will be examined in
the following section.
Transmission data processing
The calculation of the transmission factors through the
object of interest is the same for SPET and PET. The
transmitted count rate through the subject is compared
on a pixelwise basis with a transmission scan without
the subject in place, often referred to as a “blank” scan.
The standard exponential attenuation equation is used:
Nx=N0 e–∫µ(x)dx, (1)
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998
 777

where Nx and N0 are the attenuated and unattenuated

count rates (units: counts·s–1) respectively, µ is the linear
attenuation coefficient (units: cm–1), and x is the distance
(units: cm) from the source to the detector. The attenua-
tion coefficients for the body range from air values
(close to zero) in the cranial sinuses, through very low
values in the lungs, to fat, tissue and cortical bone,
which has the highest value. The attenuation coefficient
depends on a number of factors including photon energy,
scattering cross-section of the material, and electron Fig. 3. The concept of broad-beam and narrow-beam transmis-
density, and has typical values for water, which is almost sion, shown for a simple single channel detector. In the narrow-
the same as tissue, of 0.15 cm–1 for 140-keV photons beam case (top) the majority of photons that are scattered will not
and 0.096 cm–1 for 511-keV photons. The linear attenua- be counted. This is due to the collimation of both source and de-
tion coefficient is a measure of the probability of the tector. The difference between the count rates with and without
photon being absorbed per unit length in the object. the object in place is due to both total attenuation within the ob-
Equation 1 can be rearranged to give the integral of at- ject and scattering out of the line of sight of the detector. In the
broad-beam case (lower) the source is uncollimated and this al-
tenuation coefficients for any projection in this manner:
lows photons with original trajectories that would not have been

z µ ( x ) dx = log FH NN IK ,
0 (2)
e mated detector. A similar number of photons would be expected
x
which, as the left-hand side of the equation is now just a
simple summation of a single variable, is amenable to
reconstruction with standard back projection methods.
Attenuation coefficients are often referred to as “narrow-
beam” or “broad-beam” depending on whether they con-
tain scattered transmission photons or not. Figure 3 illus-
trates the simplest example of this with a single detector
measuring uncollimated and collimated sources. Ideally,
narrow-beam transmission measurements are required
for attenuation correction, and, as in Fig. 3, this is deter-
mined by the geometry of the transmission and acquisi-
tion system.
In applying the transmission factors in emission to-
mography, we will deal with the PET case first, as it is
the simplest. Figure 4 shows the attenuation paths for
single-photon and annihilation (coincidence) radiation
detection. For coincidence detection, Eqn. 1 is modified
as both photons pass through the full thickness of the
object for each angle and we therefore have an attenua-
tion equation of:
Nx=N0 e–∫µ(a+b)dx,
where the integral now is a constant, independent of the
point source location along the chord, for any projection.
This is not the case in SPET as the attenuation to the de-
tector varies with depth in the object as the photons are
only recorded in one direction. For a distributed source,
with multiple emission points along any projection, the
emission count rate recorded is:
Cx=∫C0(x) · (e–∫µ(x))dx,
where Cx is the integrated count rate from each of the at-
tenuated point sources C0(x). In PET, the term in brack-
ets is a constant and therefore we can rewrite the equa-
tion as:
Cx=α∫C0 (x)dx
counted to be scattered back into the acceptance angle of the colli-
to be scattered out of the line of sight and attenuated as the nar-
row-beam case, but the count rate will be higher in the broad-
beam case due to the acceptance of scattered events. This lowers
the effective attenuation coefficient value&ig.c:/f
Fig. 4. Attenuation for a point source in SPET is measured by dis-
tance a as single photons only are counted. In the PET case both
photons are counted and therefore the attenuation for the event is
a+b, the total thickness through the object at the projection angle
shown. The attenuation for the projection is independent of the
position along the chord for the projection in the PET case, and
(3) provides an exact correction. In SPET the attenuation varies with
the position of the point source along the chord, as the position is
usually not known&ig.c:/f
for any particular line of response. The attenuation cor-
rection factor (ACF) for each line of response is there-
fore just 1/α. The correction is an exact one in PET, and
is the reason that PET attenuation correction is regarded
as accurate. In SPET, the attenuation term in brackets
varies with the depth of the point source in the subject,
(4)
and therefore the correction term cannot be moved out-
side the integral.
In practice, PET transmission and blank scans are
measured and the ratio calculated, often after some spa-
tial filtering (smoothing) to reduce statistical variations
in the recorded count rates. The blank is usually ac-
(5) quired for a longer duration than the transmission scan

European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998

778
to reduce the statistical noise. It can be seen from Eq. 1
that the ratio of the blank count rate (N0) divided by the
transmission count rate (Nx) gives the attenuation correc-
tion factor directly for the line of response. The PET
transmission scan is ideally acquired before the radio-
pharmaceutical is administered, but this often leads to
long clinical protocols which are not ideal. Post-injec-
tion transmission using electronically windowed rotating
rod sources of 68Ge helps by allowing the transmission
scan to be acquired immediately before or after the
emission scan. Short duration transmission scans
(~2–3 min), often interleaved with the emission data in a
whole-body acquisition protocol, have been employed
but often further processing is required such as spatial
filtering or image processing classification tools such as
tissue segmentation [43–45]. The use of tissue classifica-
tion techniques requires that the natural logarithm of the
ratio of blank-to-transmission count rates are recon-
structed first, as the segmentation techniques are applied
to the reconstructed volume. Once the data have been
adjusted to the “correct” attenuation coefficients, the at-
tenuation correction factors are derived by forward pro-
jection at the appropriate angles to form attenuation cor-
rection projections which match the emission data. Si-
multaneous emission-transmission scanning aids this
further, but care must be taken by using rod sources with
reasonably low activities as the scatter and random coin-
cidences from the rod sources are recorded in the emis-
sion window, and therefore degrade the quality of the
primary data [46] as well as causing count losses due to
dead time.
When using a single-photon point source for PET
transmission measurements, post-processing of the data
is required. Firstly, the point source most frequently em-
ployed at present is 137Cs, which has a higher energy
photon than the 511 keV from the emission annihilation
radiation; therefore the measured transmission must be
modified to account for the difference. This is relatively
straightforward and a simple exponent can be used [40].
The larger issue is the high amount of scattered trans-
mission photons acquired in 3D systems, especially with
the bismuth germanate (BGO) detectors used in the ma-
jority of PET devices. The energy resolution of BGO in
a scanner is around 15%–25% full-width at half-maxi-
mum at 511 keV, and therefore energy discrimination is
not particularly helpful for excluding scattered photons.
This is less of a problem for NaI(Tl)-based devices as
they have superior energy resolution. Another system
which produces high-quality scatter-free data is the con-
tinuously rotating partial ring tomograph (ECAT ART)
[47], which uses collimated point sources of 137Cs [48].
One significant advantage of single-photon transmission
in PET is the very high photon flux recorded, and this
leads to high-quality scans compared with coincidence
measurements. This, in principle, makes the tissue clas-
sification and segmentation task easier and more robust.
At present, we use the local threshold segmentation
method [45] on the EXACT 3D system with data from
the 137Cs point source. Segmentation and reclassification
deals with both the difference in photon energy and the
inclusion of scattered photons in one step. The method is
automated and rapid to apply, adding 3–5 min to the pro-
cessing time on a Sparc 5 workstation for the segmenta-
tion and classification of 95 planes of data. Alternative
methods that have been proposed for dealing with the
scatter in single-photon transmission measurements in
PET include a dual-energy window scatter correction
[40] and reclassification using artificial neural networks
[49].
In SPET, the attenuation correction term cannot be
separated from the emission count rate recorded and
therefore all SPET methods for attenuation correction
are approximations. The majority of procedures for at-
tenuation correction using measured transmission data in
SPET are applied either during or after the emission re-
construction. One well-known approach is the modified
version of the Chang method [15]. The original method
in this paper used a body contour which contained a sin-
gle attenuation factor, which was modified in an iterative
manner. The emission data are reconstructed without
correction, and an average attenuation correction factor
based on the calculation of the sum of attenuation coeffi-
cients from each point in the object to the detector is de-
rived and multiplied with the uncorrected emission re-
construction. The correction term for each point in the
image [A(x,y)] is found from
−1
LM M
A ( x , y ) = 1 ∑ e − µ a ( x , y, θ i )
OP , (6)
N
M i =1 Q
where M is the number of projection angles over 360°.
The emission data are then forward projected, with at-
tenuation from the assumed body contour, and compared
with the acquired data. Differences are calculated for
each projection element and these are back projected in
the conventional manner and corrected for attenuation.
The reconstructed “difference” image is then used to
modify the first estimate of the corrected emission re-
construction. This updated emission reconstruction is
again forward projected, differences calculated and back
projected, and so on, iteratively. In the modified version,
the reconstructed attenuation image is substituted for the
assumed body contour and single µ value [20, 50]. An
example of an attenuation reconstruction and the corre-
sponding attenuation correction map is shown in Fig. 6.
An alternative is to use the ratio of the projections, rath-
er than the difference, to calculate the error term before
back projection [17].
Iterative reconstruction techniques for emission
tomographic reconstruction are becoming more routine-
ly used clinically due to improvements in algorithms and
hardware. In particular, the maximum likelihood, esti-
mation maximisation (ML-EM) algorithm [51, 52] and
the optimally partitioned, block-iterative version known
as ordered subset EM (OSEM) [53] have found wide-
spread clinical acceptance in both SPET and PET. In ap-
plying these techniques in PET, the data are usually cor-
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998

rected for attenuation prior to reconstruction due to the
exact properties of the correction, but in SPET, the data
can be incorporated into the reconstruction process by
inclusion in the transition matrix, along with other fac-
tors which model physical aspects of the data collection
process such as scatter, depth-dependent resolution and
anatomical boundaries.
Comparison of attenuation correction in PET
and SPET
There is growing interest in the clinical use of PET in
nuclear medicine. It is possible to use a modified dual-
headed gamma camera in coincidence mode to record
annihilation radiation [54]. It will be useful, therefore, to
compare the impact that attenuation correction has on
coincidence imaging, compared with SPET, and to as-
sess the need for transmission scans for attenuation cor-
rection.
For this study, modified versions of the method of
Chang [15] have been used for calculating both single-
Fig. 5. Examples of correction schemes for SPET and PET. In
SPET, the method of Chang calculates the attenuation factor e–µa
for a number of angles and takes the average for each point within
the object as an approximate average attenuation to that point.
This can be modified iteratively. In PET, the attenuation is given
directly by the factor eµ(a+b) for each projection. Following the
method of Chang, this can be used to calculate average attenua-
tion within the object to compare with the SPET case, although
this is not the method used for attenuation correction in PET&ig.c:/f
Fig. 6. An example of an attenuation image and the corresponding
calculated attenuation factors using the Chang method. Attenua-
tion is greatest towards the centre of the body, as expected&ig.c:/f
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998
779
photon and annihilation coincidence attenuation correc-
tion factors. The aim is to give some idea of the attenua-
tion correction factors required, rather than to produce
exact corrections. Figures 5 and 6 demonstrate the
Chang attenuation correction calculation using measured
transmission data for SPET. By modifying the limits of
the summation in Eq. 6 to calculate the total attenuation
for any ray in both directions (a+b in Fig. 5), an average
attenuation to each point in the section can be calculated
for PET, analogous to the SPET case. This has been
done for the following imaging situations: (a) thallium-
201 in SPET, (b) 99mTc in SPET, (c) 18F in SPET, and (d)
18F in PET coincidence mode. The transmission scan
shown in Fig. 5 was scaled so that the tissue attenuation
coefficient values were appropriate for each of the pho-
ton energies corresponding to the three cases above (i.e.,
70 keV, 140 keV and 511 keV), namely µ=0.18 cm–1,
0.15 cm–1 and 0.095 cm–1 respectively. The transmission
scan used was originally recorded in single-photon mode
on the EXACT 3D scanner using 137Cs as the source.
The first three cases used the single-photon calculation
of Eq. 6 and the final case for coincidence mode used
the modified equation. It should be stressed that this is
not how PET attenuation correction factors are applied
in practice, but has merely been done to give an indica-
tion of the average attenuation to each point in the body,
and to allow comparison with the SPET situation.
Scatter correction
While the primary motivation for acquiring transmission
data has been for accurate attenuation correction, the da-
ta have found application in other areas. One area that
has received considerable attention has been the use for
transmission data in scatter correction. This is perhaps
an obvious application as attenuation and scatter are so
closely related. The use here in SPET predates that in
PET. Mukai et al. [55] used attenuation data to modify a
convolution kernel which was applied to the attenuation
corrected projections to derive an estimate of scatter.
They used CT scans to provide the attenuation data.
Ljungberg and Strand used measured attenuation (“den-
sity”) maps with Monte Carlo simulation to study the
distribution of scatter, but this was not practical for rou-
tine correction purposes [56, 57]. Once there was ready
access to transmission data from simultaneous emission-
transmission scans in SPET, we developed a method for
incorporating this into scatter correction by modifying
the estimates of scatter fraction for each projection ele-
ment [58]. The scatter model used was a convolution of
the photopeak data with a predetermined “scatter kernel”
(k) [59, 60]. The transmission projection data were con-
verted to attenuation projections using Eq. 2. Work from
Siegal and Wu aimed at measuring the “buildup” of pho-
tons between the chest wall and the centre of the left
ventricle to estimate left ventricular volume from planar
gamma camera measurements had demonstrated that if
780
the transmission factors were known the buildup, or
scatter, could be estimated from the equation:
Nx
= 1 − (1 − e − µ d )n , (7)
N0
where d is the depth in tissue and n is the buildup factor
at infinite depth, B(∞) [61–63]. Narrow-beam transmis-
sion factors were essential for this method. We used this
approach in SPET and developed a transmission-depen-
dent scatter correction [64]. The transmission data re-
placed the term e–1µd in Eq. 7, and the only factor re-
quired was B(∞), which was determined a priori with ex-
perimental measurements. This method has been im-
proved by using a Gaussian basis function for the esti-
mation of the scatter component [65]. An alternative
method developed by Welch et al. used the reconstructed
attenuation map to calculate the expected scatter distri-
bution in the projections [66]. This method is computa-
tionally intensive; however, it is well suited to inclusion
in the EM-ML algorithm.
In 3D PET, the reconstructed attenuation data have
also been used for calculation of the predicted scatter
distribution [67, 68]. The method tends to use coarse
matrices for the calculation to reduce the computation
required. This approach has been found to be accurate,
although it remains susceptible to the influence of scat-
ter from outside the coincidence field of view, in areas
which are not measured by either the transmission or
emission scans.
Further uses of transmission data
Motion detection and correction. &p.1:Subject and organ
movement degrade the image quality obtainable in both
SPET and PET, unless it can be corrected for. Cardiac
gating is an example where organ movement is mea-
sured and compensation made, by recording in small
cardiac temporal sub-intervals. For gross subject move-
ment, transmission scanning offers a potential method
for tracking and correcting this motion which should be
potentially more robust than using the emission data, as
the emission distribution may change with time. We
have used this approach to record dynamic planar emis-
sion-transmission scans with a scanning line source to
measure the clearance of inhaled radioaerosols from the
lung [69].
Movement can also lead to misalignment between the
transmission and emission scans if they are recorded se-
quentially. This will result in an inaccurate attenuation
correction being applied. A method has been described
in PET which derives the translation and rotation after
movement based on emission data, and then applies
these transforms to the attenuation reconstruction to re-
orient it into the corresponding location [70]. The data
are forward projected in this new space to provide the at-
tenuation correction factors. This ensures that the emis-
sion data have the correct attenuation factors applied,
and is particularly useful for dynamic studies. Similar
methods could be used in SPET.
Definition of anatomical regions of interest. &p.1:As the at-
tenuation images display density differences, it is possi-
ble to use the data to define regions of interest based on
anatomical landmarks. The data have limited density
resolution for discerning differences between soft tissues
(as opposed to X-ray CT), but can be used for the tho-
rax, in particular. This is a return to the original use of
transmission scanning in nuclear medicine, but in tomo-
graphic mode. More recently, transmission scans have
been used to define the lung regions for application to
functional images of ventilation and lung clearance in
both planar and SPET measurements [71, 72]. It is con-
ceivable that using the high photon flux and resolution
of single-photon transmission measurements in 3D PET
it will be possible to separate bone and soft tissue re-
gions from attenuation images to define further regions
of interest.
Intrinsic correction for limited spatial resolution. &p.1:Trans-
mission scans have been used in PET studies to correct
for cardiac movement and partial volume effects due to
the limited spatial resolution of the system. Iida devel-
oped the concept of the myocardial tissue fraction to
overcome the limitations in measuring tracer concentra-
tion in the myocardium due to motion and the small
transmural wall thickness. This was originally done by
compartmental modelling and estimating the volume of
distribution from oxygen-15 labelled water studies,
which is proportional to tissue fraction [73]. Subse-
quently, a transmission-based technique was developed
which involved the subtraction of a C-[15O] blood vol-
ume scan from the attenuation image, which produced
an image of the extravascular density [74]. The ratio of
these two parameters gave a measure of the perfusable
tissue fraction which was independent of the partial vol-
ume effect. In effect, the limited resolution in each mea-
surement was used to cancel out the limitation of finite
resolution in the final measurement.
Spatial co-registration and anatomically guided recon-
struction. &p.1:Spatial co-registration of an individual’s re-
constructed data with other image data is becoming in-
creasingly utilised. The simplest example in nuclear
medicine is the comparison of myocardial perfusion pro-
files with normal data bases. Co-registration of paired
scans in an individual acquired at different times is also
utilised [75]. These techniques match a single study to
another, or possibly to a group of others, in a standard,
defined spatial co-ordinate system. The problem with us-
ing functional images to perform this is that they often
have patterns of distribution which differ from normals
or other individuals with the same disease. Anatomical
data are often likely to match more closely, and are less
likely to change over a short period of time, unlike, for
example, stress and redistribution myocardial perfusion
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998
 781

images. One possible use of transmission data acquired with transmission-dependent attenuation and scatter cor-
in a simultaneous protocol would be to co-register paired rection. In the same chest phantom, a “blood pool” distri-
PET-PET, SPET-SPET or PET-SPET scans using the at- bution of emission activity demonstrated an absolute ac-
tenuation reconstructions. The transformation matrix de- curacy of within 5% of the true value in the heart using
fined by this can then be applied to the emission data, as the same methods. Narita et al. [65] found that in both
they are perfectly spatially co-registered with the attenu- simulated and experimental data the accuracy of the final
ation data. In neuroscience research, emission data are reconstructed image was within 3% of the true values, al-
often transformed to a standard stereotaxic space such as though this is perhaps optimistic for human studies. Nev-
that of Talaraich and Tourneaux [76] for the purposes of ertheless, it appears that the algorithms that exist now are
group or single subject versus group comparisons [77]. capable of producing data with a high degree of accuracy
This necessitates an elastic transformation of each sub- in SPET under well-supervised and controlled condi-
ject’s brain to the standard space [78]. The high defini- tions. These methods were recently applied to SPET
tion provided by structural imaging helps to improve the [123I]-IMP regional cerebral blood flow (rCBF) measure-
accuracy of this process [79]. ments in comparison with [15O]-H2O PET rCBF mea-
Finally, the use of iterative reconstruction methods al- surements and found to be within 10% of each other [83].
lows incorporation of prior information, if it is known,
about the expected distribution of radioactivity. In the
simplest case this may be to constrain the reconstruction
to positive values within the body outline. More sophis-
ticated approaches use anatomical information from X-
ray CT or MRI that has been segmented to classify tis-
sues with different expected concentrations of the radio-
tracer. This information is then used to “encourage” the
reconstruction with predefined probabilities or weigh-
tings in certain areas [80–82]. In one sense this can be
thought of as an intrinsic partial volume correction tech-
nique. In the brain, differences are usually ascribed to
grey matter, white matter, and ventricles for blood perfu-
sion and metabolic radiotracers. Clearly, the course reso-
lution of attenuation data from PET and SPET would not
allow this degree of classification, but body boundaries
and lung fields would provide sufficient contrast for use
in this type of scheme. Sufficient contrast exists in the
head with SPET and PET attenuation images to classify
pixels into bone, soft tissue and sinuses.

Results

Accuracy of attenuation and scatter correction in PET

and SPET

Given the vast amount of effort that has focussed on at-

tenuation and scatter correction, a reasonable question to
ask is what the current capability of SPET and PET is in
producing accurate reconstructions.
It is clear that both attenuation and scatter correction
are required for SPET and 3D PET, as they both contain
a large scatter component (30%–50%) in the photopeak
energy window. In SPET, the paper by Mukai et al. [55]
quoted absolute accuracy after scatter correction within
9% of the known values in a multi-component test object
Fig. 7a–d. Examples of attenuation correction factor maps for
over a range of radioactivity concentrations with both at-
SPET and PET. The maps correspond to (a) 201Tl in SPET, (b)
tenuation and scatter correction. Meikle et al. [64] 99mTc in SPET, (c) 18F in SPET and (d) 18F in PET mode. The y-
showed that without scatter correction the values in lung axis values in the plots are the magnitude of the corrections,
in a heterogeneous chest phantom were overestimated by which range from maxima of approximately 9 for 201Tl down to 3
35% (using measured transmission data for attenuation for 18F in SPET to nearly 20 in PET. The plots are for profiles at
correction), and improved to within 4% of the true value the location of the horizontal cross-hair&ig.c:/f

European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998

782
3D PET has mostly been employed in cerebral studies
to date. In phantom data emulating this situation, we have
found 3D PET to be as accurate as 2D measurements
[84]. The generally accepted gold standard, 2D PET mea-
surements, are usually accurate to within 5% [85]. A
number of authors have reported on the accuracy of 3D
PET measurements modelling neurotransmitter and re-
ceptor uptake and density parameters, by simulation, ex-
perimentation and in human subjects [86–88] using a va-
riety of scatter correction approaches. These studies have
again found that 3D PET with scatter and attenuation
correction is as accurate as 2D PET, with reported agree-
ment to within better than 5%. The chest and abdomen
have seen little published for scatter correction in 3D
PET to date and remain a challenge for the future [89].
Comparison of attenuation correction in PET and SPET
The results and profiles through the maps of attenuation
correction factors for the four situations in SPET and
PET are shown in Fig. 7. All of the corrections peak to-
wards the centre of the body along an axis incorporating
heart and spine. In the SPET measurements, the greatest
correction factors (~9–10) are required for the low-ener-
gy photons from 201Tl (lead X-rays), and the lowest
maximum correction factors for 18F (~3). In PET, how-
Fig. 8. Two examples of cardiac scans in
coincidence mode with [18F]-DG are
shown. Both subjects were males. The
data were acquired on the EXACT 3D
large field of view PET system at Ham-
mersmith Hospital, with transmission re-
corded in single-photon mode using a
137Cs source and processed with local
threshold segmentation. The images are
transverse sections of 5 mm thickness. In
the top row, the lack of attenuation cor-
rection (left) overestimates the uptake in
the anterolateral wall. The uptake in the
lateral (free) wall and the anterior wall of
the right ventricle are also overestimated
compared with the corrected case (right).
The reconstructed counts have been re-
distributed preferentially to areas of low-
er attenuation, noticeable in the enhance-
ment in the lung fields and the absence
of counts in the region of spine and later-
al chest wall. In the lower case, there is
an apparent decrease in the posterior and
septal walls, consistent with an attenua-
tion artefact (left). After correction
(right), there is more equal distribution
of counts in these areas relative to the an-
terior wall&ig.c:/f
ever, the maximum correction factors average around 20.
This is due to the longer path length for the two photons
at each projection. In fact, individual correction factors
in the projections (where the corrections are applied in
PET before reconstruction) for some lines of response
through the body may reach factors of 70–100 [85]. This
is independent of whether the device recording the coin-
cidence events is a full-ring conventional PET system or
a modified dual-headed gamma camera. As the initial
impetus to commercially develop routine attenuation
correction in SPET was to remove the attenuation arte-
facts which confounded myocardial perfusion studies it
would seem a retrograde step to commence cardiac coin-
cidence work with gamma cameras without attenuation
correction, as the effect of attenuation is now very much
greater. Examples of an [18F]-DG cardiac scan recon-
structed with and without scatter correction are shown in
Fig. 8. At least one manufacturer has realised this and
offers a transmission measurement system for their coin-
cidence gamma camera.
Discussion
Transmission scanning was “rediscovered” in nuclear
medicine in the mid-1980s for the purposes of improv-
ing the quantitative accuracy of SPET emission studies.
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998

The first widespread application that it has found is in
attenuation correction of myocardial perfusion SPET
studies [90], where the heterogeneous density of the tho-
rax and chest wall could cause attenuation artefacts in a
variety of locations. These artefacts reduced the overall
specificity of the test by creating false-positive or equiv-
ocal scans. It has already been shown that correction for
attenuation reduces these artefacts [91] and, in particu-
lar, has a dramatic impact on specificity in single-vessel
disease [92, 93]. The widespread introduction of attenu-
ation-corrected cardiac SPET has been slow due to is-
sues such as re-education of observers reporting the
scans and the need for new data bases of normals for
comparative purposes. However, most gamma camera
manufacturers now offer some form of simultaneous
emission-transmission scanning facility for attenuation
correction. For clinical use, simultaneity would appear
to be mandatory.
Alternative methods for improving attenuation cor-
rection without the need for transmission scanning exist.
The consistency criteria described by Natterer [94] have
been used to derive attenuation correction maps consis-
tent with the measured projection data [95]. Alternative-
ly, appropriately scaled CT [96, 97] or segmented MRI
data can be used. These methods suffer from the usual
problems of working with multi-modality images, name-
ly, accurate co-registration from the different modalities.
Another suggested method used a small injection of a
lung perfusion radiotracer to outline the lungs, from
which an approximate correction could be derived [98].
However, the advantge of a transmission scan recorded
simultaneously with the emission scan, and therefore
spatially co-registered and easily accessible, has an over-
whelming attraction in both SPET and PET, and is likely
to become the standard practice. This has been achieved
in SPET with a number of the different arrangements for
transmission scanning, but has not yet become a practi-
cal reality in PET.
Transmission data are finding uses in further improv-
ing the accuracy of quantification in emission tomogra-
phy, particularly in scatter correction. This is equally
true for SPET and PET. There is potential in the future
to use the transmission data to monitor subject move-
ment and derive corrections, as the attenuation distribu-
tion is unlikely to change in the course of a study.
There is also interest in developing high-resolution
structural imaging to be used in conjunction with func-
tional emission tomographic data. Hasegawa and col-
leagues have developed a combined SPET-CT system
[99, 100], and Townsend and colleagues are working on
a combined rotating PET-CT system [101]. The systems
can use the X-ray CT data for attenuation and scatter
correction, but also have particular attraction for inter-
ventional procedures such as combined functional/struc-
tural guided fine-needle biopsy. As the functional emis-
sion and structural anatomical images are acquired se-
quentially or interleaved on the same device the task of
accurately co-registering these should be simpler than at
European Journal of Nuclear Medicine Vol. 25, No. 7, July 1998
783
present when different scanners with different scanning
couches and patient positioning are used. There have
been some recent developments in simultaneous multi-
modality PET-MRI also. The PET group at UCLA have
used a small animal PET system based on the new inor-
ganic scintillator lutetium oxyorthosilicate (LSO) [102]
in a conventional MRI scanner [103, 104]. The system
uses optical fibres to transport the light from the scintil-
lator crystals to the photomultiplier tubes, thus avoiding
problems from the magnetic field which would perturb
the electrons in the tubes. Their collaborators in London
have developed a prototype PET-NMR spectroscopy
scanner for studying the physiology of the isolated rat
heart using similar technology [105].
Conclusion
It is still quite early days for the routine use of transmis-
sion scanning in SPET, and for simultaneous emission-
transmission measurements in PET. A number of obsta-
cles still need to be addressed before the use of these ac-
quisition and processing techniques are widely accepted
and become routine. These include:
1. Simultaneous measurements. Clearly, for practical
reasons, simultaneous emission-transmission measure-
ments are highly desirable. Simultaneous acquisition
adds little or no time to the scan duration, and therefore
will have a high compliance. In SPET, the scanning line
source and the focussed line/fan-beam collimator are
flexible approaches that are now being used routinely
with both 99mTc and 201Tl in cardiac scanning. While
similar methods have been developed for PET, purely
practical considerations, such as using appropriately low
amounts of radioactivity in coincidence transmission
sources [35] or adequately separating the emission and
transmission data when using a high activity 137Cs point
source, have delayed its widespread introduction. This is
particularly true in whole body PET surveys. The ques-
tion of whether a simultaneous measurement can be
made with dual-headed gamma cameras in coincidence
mode is still open for debate.
2. Higher sensitivity and more efficient acquisition
schemes. Transmission scanning in SPET and PET can
often lead to high noise in the attenuation correction data
which propagates through into the final reconstructed
emission images. The transmission data often require
some processing to suppress this, and clearly, higher
sensitivity and more efficient transmission acquisitions
schemes would help. While 153Gd has many desirable
properties for SPET transmission acquisition and attenu-
ation correction, it is a relatively low-energy photon
which is highly attenuated, and this leads to very low
count rates in some projections through the average sub-
ject. The profiled line source approach [106] addresses
this issue to some extent by placing higher concentration
transmission sources towards the centre of the field of
view, which is often the thicker section of the body.
784
3. Flexible emission-transmission radionuclide com-
binations. Attenuation correction will find application
for all forms of SPET and PET studies, and therefore re-
strictions such as having the transmission radionuclide
energy lower than the emission radionuclide in SPET
will prove a limitation. The scanning line source ap-
proach provides this flexibility already.
Transmission scanning in emission tomography pro-
vides more than just artefact reduction in myocardial
perfusion scanning, and will see increasing utility in pro-
viding quantitative measurements in SPET and PET in
the realm of functional imaging.
&p.2:Acknowledgements. I am grateful to Steve Meikle, PhD, of the
Department of Nuclear Medicine, Royal Prince Alfred Hospital,
Sydney, for the valuable comments and suggestions he made re-
garding this paper.
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