V 2018 4DM-UsersGuide - PET MFR Guide

Corridor4DM v2018
User’s Guide
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Corridor4DM V2018 ▪ User’s Guide UG_2018-01B

Chapter 8 Myocardial Blood Flow and
Reserve
Quantitative Coronary Flow Reserve (CFR)
The Reserve screen (Figure 8.1)
provides the capability to process
and review dynamic cardiac PET and
SPECT datasets from validated camera
systems. Dynamic datasets can be
used to estimate absolute myocardial
blood flow and coronary flow reserve
(CFR). Such measures often provide a
more reliable assessment of perfusion
abnormalities than conventional
quantification of myocardial perfusion.
Figure 8.1: The Corridor4DM Reserve Screen
CFR processing should be preceded
by the QA workflow on the MI Processing screen to verify accurate automated LV contour
generation on all datasets. These LV contours are used for ROI/bounds placement within the Reserve
screen and also to help do quality checks for patient motion and flow model processing.
Input Data
A dynamic dataset consists of a series of 3D image volumes
acquired at different time points (called frames) during
the first pass and uptake of the radiotracer in the heart.
When a dynamic dataset is loaded into Corridor4DM,
static images are automatically generated by summing the
frames from a portion of the dynamic series. The portion
of the dynamic series to be summed is configurable in
Preferences, on the Image Display page (Figure 8.2). Figure 8.2: Image Data section of the Image Display
Page within Preferences
Generally, the Summed Volume Start Time should be set
to a time after the tracer has cleared from the RV and LV blood pool, and the Summed Volume Stop Time
should be set to the end of the last frame. In addition, options are available to adjust smoothing filters that
can be applied to summed datasets. These summed static datasets are displayed on all image review and
processing screens, as well as the Reserve screen.
CFR QA, Processing, and Results Review

Stress and rest datasets are displayed and processed together on the Reserve screen which has two
modes: QA and Results Mode. The Reserve screen defaults to the QA Mode when unprocessed stress
and/or rest dynamic data is displayed. Once flow results are processed and saved, the Reserve screen
defaults to display the Results Mode.
QA Mode Workflow
1. Evaluate data for motion and correct frames if: Respiratory motion prevalent in dynamic
data and is known to affect flow and reserve results so it is important to evaluate every patient’s
Corridor4DM v2018 ▪ User’s Guide Chapter 8: Myocardial Blood Flow and Reserve ▪ 97
dynamic dataset(s) for the presence of
motion. To check this, click the Cine
tool in the toolbar and view the dynamic
frame sequences for motion of the
blood pool uptake spilling over into the
Corridor4DM-generated LV contours
(Figure 8.3), or for the LV tissue frames
to show tissue uptake outside of the LV
contours. Figure 8.3: Dynamic frame sequences with contours enabled
▪ To evaluate for motion frame-

by-frame, pause the Cine, and click the Cine tool drop-down arrow
(Figure 8.4) to access the frame slider. Scroll the slider through all
frames in the sequence and review the stress and/or rest slice viewports
Figure 8.4: Cine tool
below. with frame slider
▪ If motion is present, manually correct for motion in each frame where

the dynamic tracer activity does not align properly to the displayed LV
contours, by clicking directly on the image and dragging it to the desired
location. Alternatively, apply adjustments in the X (left/right) and/or Y
(up/down) directions (Figure 8.5) using the Fine Pan arrow tools where
each click represents 1 mm of movement. Adjust rotation (Z-direction)
Figure 8.5: Fine Pan
using the Fine Rotate tools located in the lower right corner of each arrow tools and Fine
viewport. Rotate tools
▪ All preliminary motion correction changes to the data appear on the

motion correction graph to the right of the viewports, showing X, Y, and
Z updates made throughout the frame sequence, in mm of motion. To
view preliminary flow results and apply the corrections, click the Apply
tool (Figure 8.6) after corrections are made.
Figure 8.6: Apply tool
2. Verify the bounds/ROI are properly positioned, depending on default
method selected: Turn the Cine tool off to view the bounds/ROI placement. Corridor4DM
defaults to the ROI method, with others available.
▪ When either the Factor Analysis or the Factor Analysis-Hybrid algorithms are applied, the
ellipsoid-cylindrical bounding volume can be dragged to
Prior to proceeding to the
Results Mode, check to change the height or width of the factor analysis bounds
verify the perfusion and in each viewport (Figure 8.7). The user should adjust the
flow normals databases size of the bounds to ensure inclusion of the blood pool
are selected for stress,
regions and to exclude non-cardiac regions. Figure 8.7: Factor Analysis algorithm
rest and CFR. Selection
 of these ensures CFR

quantification of
perfusion defect regions
▪ When the ROI algorithm is applied, the rectangular
ROI can be dragged to change the height or width of the
on the Reserve Results LV blood pool sampling region in the HLA and VLA
page, as well as other viewports (Figure 8.8). The user may increase the size
derived comparison
of the ROI to improve statistics in the LV blood Time
results to relative
perfusion polar maps. Activity Curve (TAC).
Figure 8.8: ROI algorithm
3. Corridor4DM automatically processes flow results when: any motion correction is
applied; changes are made to the ROI/Bounds; or a different flow model is selected for
processing. Both stress and rest datasets are processed at the same time. The processing is
fully automated and typically takes 1-2 minutes to complete for Factor Analysis, and a few
seconds to complete for ROI analysis.
4. Review Preliminary Results: Once processing completes, additional QA results display on

the QA Mode of the Reserve screen to permit detailed analysis of the acquisition, motion
correction, and kinetic flow model results. It is important to click
Save in the Control Panel once completed with Reserve processing
and QA. Once reviewed, to enter the Results Mode, click the Next
Figure 8.9: Next tool
button (Figure 8.9) in the Toolbar.
Preliminary Results Review in QA Mode

It is important to click Save in the Control Panel once completed with Reserve processing and QA.
Review the following information prior to continuing to the Results Mode.
Time Activity Curves (TACs)
When using the ROI algorithm, the user can assess the quality of the CFR processing results by also
reviewing the blood and tissue TACs (Figure 8.10). The RV curve (blue) is flat with a value of zero. The
LV curve (green) should peak and then gradually approach zero toward the end of the dynamic series.
The QA Images toggle is not available for the ROI algorithm.
After processing with the Factor Analysis algorithm, the Reserve screen provides two components to
assess the quality of the CFR processing results.
▪ First, the user should review the blood and tissue TACs (Figure 8.11). The RV curve peak
(blue) should be somewhat higher than the LV curve peak (green), and should occur earlier
than (to the left of) the LV curve peak. Both RV and LV curves should gradually approach
zero toward the end of the dynamic series. The myocardial tissue TACs should have peak
magnitudes that are lower than RV and LV TACs, and should be relatively flat.
Figure 8.11: TACs after Factor

Figure 8.10: Time Activity Curves Analysis algorithm is processed
Figure 8.12: QA
Images tool
Figure 8.13: Figure 8.14: Correspondence Figure 8.15: Correspondence
Correspondence of the RV of the LV factor to the LV of the tissue factor to the
factor to the RV blood pool. blood pool. myocardium.
▪ Second, the user should examine the factor analysis by clicking the QA Images tool
(Figure 8.12). The image viewports display the output of the factor analysis for stress and
rest. The user should confirm the factor analysis in the RV (Figure 8.13), LV (Figure 8.14),
and tissue factor images (Figure 8.15).
▪ If this is not the case, the flow results will be incorrect. The user can reassign the factor
analysis labels (RV, LV, and Tissue) in the image viewports by clicking the drop-down
button and selecting the correct label. The flow and CFR values are then recalculated
automatically.
Several tools are provided to modify the appearance of the TAC graphs:
Figure 8.16: Time Activity Curve check boxes
▪ LV, RV, Global, ANT, LAT, INF, SEP, APX check boxes (Figure 8.16): Allow the user
to selectively display the color-coded TACs on the graph (unchecking the RV or LV curves
automatically rescales the y-axis, and allow more detail to be seen in the relatively low
myocardial tissue TACs).
↓ ↓
▪ Start/Stop blue reference lines
(Figure 8.17): Allows manual updates
to the start and end point of CFR
analysis. Click and drag to the desired
point on the TAC.
▪ Right-click the Time Activity Curves

↑ Figure 8.17: Time Activity Curve start and stop lines ↑
to display the Curves Options window
(Figure 8.18) and further customize the
display by selecting any of the following:
- Kinetic Model: When checked, the kinetic

model fitted tissue TACs (solid line), the
measured tissue TACs (circular markers),
and kinetic model parameters (rate constants
K1, K2, K3, spillover values FV and RV, and
model fit error ChiSq) are displayed. When
Figure 8.18: Curve Options window
unchecked, only the measured tissue TACs are
displayed (solid line).
- Use Linear Scale: When unchecked, the vertical axes are converted to a log-scale.
- Time Normalize Graphs: When checked, scales the activity concentration in each
frame by the frame duration. When unchecked, no scaling is applied.
- Use Frame Index: When checked, graphs the activity concentration versus frame
index. When unchecked, graphs the activity concentration versus time.
- Sync Y Axis: Synchronizes the y-axis scales for stress and rest to compare curve
peaks more accurately.
LV Spillover
Corridor4DM displays stress and rest Spillover maps (Figure 8.19) next to the
TACs to help aide in the detection of patient motion after results have been
processed. The polar maps represent a summed image of the dynamic sequence.
These should show little to no activity with homogenous appearance, signifying
that blood pool activity is not spilling over into the LV contours displayed above
in the slice viewports. If the polar maps show mottled, heterogeneous activity,
this signifies a need to make additional motion correction changes in the
viewports above. Figure 8.19: Spillover maps
Flow Polar Maps
Preliminary stress, rest, and reserve flow calculations (Figure 8.20)

display in two columns:
▪ The middle column displays, top-down: the absolute stress,

rest, and reserve flow values in units of ml/min/g, sampled
over 460 sectors to provide a pixel-level flow polar map for
review.
▪ The right-most column displays the flow values without pixel

data included, called Stats maps. These show the absolute
flow and reserve value results based on the overlay map
selected. The global LV flow value is displayed at the 5 Figure 8.20: Flow Polar Maps
o’clock position just outside of each of these polar maps, for
stress, rest, and reserve.
❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾ ❿ ⓫ ⓬ ⓭
Figure 8.21: QA Mode Toolbar Options
QA Mode Toolbar Options (Figure 8.21):

1. Dual Colorbar Tool: The color control tool is comprised of the two colorbars separated by
a numbered panel. Right-click the colorbar to customize color schemes and adjust intensity
mappings. For more information on colorbar management, see the Colorbar Tools section.
2. Magnification Tool: Adjust the image display size.
3. Cine Tool: Activate/Deactivate cine of dynamic sequences. When active, motion correction
tools display on all viewports. When deactivated, using the frame slider from the drop-down
also activates the motion correction tools. Cine must be deactivated to view the flow ROI or
Bounds.
Prior to processing the 4. Processing Options Tool: Click to view and
flow results, check to select the available flow models defined to fit the
verify the perfusion and dynamic data for estimating myocardial blood
flow normals databases
are selected for stress,
flow and reserve. Click the Details icon next to the
rest and CFR. Selection Flow Model Name to view the characteristics of
 of these ensures CFR

quantification of
perfusion defect regions
each flow model (Figure 8.22). Corridor4DM can
be defaulted within Preferences to the preferred
Figure 8.22: Processing Options Tool
on the Reserve Results model for each tracer, to permit skipping this step
page, as well as other each time the data is launched.
derived comparison
results to relative ▪ For the ROI Compartment model, only the LV blood TAC is sampled from a ROI.
perfusion polar maps. The flow and CFR values are then calculated from the blood and tissue TACs using the
compartment model.
▪ The FlowQuant (FQ) ROI Lortie processing option samples the LV and blood TAC from
a ROI, but uniquely utilizes a constant distribution volume and frame time weighting in the
kinetic modeling.
▪ For the Factor Analysis (FA) model, the LV and RV blood time activity curves (TAC) are
estimated using the factor analysis algorithm. The flow and CFR values are then calculated
from the blood and tissue TACs using the compartment model.
NOTE: With v2018 and later, this model must be manually created.
▪ The Factor Analysis-Hybrid (FAH) model uses a subset of the pixels from Factor Analysis
for the RV and LV blood TACs. This derivative algorithm has shown improvements for
studies where there is significant overlap between the blood and tissue factors.
NOTE: With v2018 and later, this model must be manually created.
5. Residual Subtraction Toggle Tool: This tool is necessary in current SPECT dynamic
protocols using Tc99m-based tracers, where due to the longer half-life of approximately 6
hours, there is residual activity remaining in the heart from the first to the second acquisition.
This tool is enabled/available in cases where the time between the first and second
acquisitions is less than the time difference threshold, where the tracer level of the second
dataset hasn’t decayed to 5% or less from the first dataset acquisition time. Corridor4DM will
use the frame prior to the start of the input curve on the TAC of the second acquisition as the
baseline activity and subtract this from all subsequent frames in the dynamic sequence.
▪ To apply this tool, click to turn on Residual Subtraction in the Toolbar. Once the Residual
Subtraction tool is clicked, Corridor4DM automatically computes the second acquisition
with residual subtraction applied. To permanently save the CFR processing, click the Save
button in the Control Panel.
▪ Corridor4DM will disable this tool when the dataset acquisition times between the first and
second datasets meet or exceed the time difference threshold. The time difference threshold
is calculated taking into account the radiotracer’s half-life, decay ratio, and the timestamp
of the first and second acquisitions.
6. Contours Toggle Tool: Overlay Corridor4DM-generated LV surface contours on the images.
7. Auto Motion Correction Tool: This tool turns on and off the ability to automatically correct
the image data for motion that may occur during the dynamic acquisition.
8. Undo Tool: Once changes are made to correct for motion or ROI placement, this tool
becomes active to undo the last move with each click of the tool.
9. Reset Tool: Resets the screen to an unprocessed state.
10. QA Images Tool: Available for FA and FAH methods only. The image viewports display the
output of the factor analysis for stress and rest. The user should visually confirm the factor
analysis accurately identified the RV, LV, and tissue factor time points by showing RV blood
pool uptake, LV blood pool uptake and Tissue uptake in these viewports. Click the RV, LV or
Tissue viewport labels to change
assignments if necessary.
11. Frame Normalization Tool:

Available only when Cine mode
is on, this normalizes each frame
in the dynamic sequence to the
peak intensity in the volume.
12. Rate Pressure Product (RPP)

Figure 8.23: Rate Pressure Product tool
(Figure 8.23): RPP is defined
as the heart rate (HR) in beats-per-minute (bpm) multiplied by the systolic blood pressure
(SBP, in mmHg). RPP provides a measure of a patient’s cardiac workload and hemodynamic
response. Due to patient-to-patient variation in HR and SBP during stress and rest imaging,
this can affect the absolute coronary flow and coronary flow reserve values. The RPP tool is
available to provide RPP-normalized flow values on a case-by-
case need.
▪ Click the RPP toggle to access the RPP options window

(Figure 8.24), where stress and/or rest HR and blood
pressure are manually input. For the BP, enter the systolic
BP in the left field, and the diastolic BP in the right field.
▪ The RPP Reference value is defined at 9000, the mid-point

of the normal range (6000 – 12000) in the normal patient Figure 8.24: RPP options window
population. The RPP Reference is definable, but likely rarely
changed unless a particular RPP reference value is preferred.
▪ Once the HR and BP are entered, click the RPP corrected checkbox, and then click Apply,
to calculate new flow and reserve calculations for the patient.
▪ To see the dataset’s updated flow calculations, without calculating new reserve calculations,
after entering HR and BP, click Apply, but do not click the RPP normalization checkbox.
▪ Click the Reset button to reset the values.
▪ Click Save in the Corridor4DM Control Panel to save the reserve results and all other
Corridor4DM calculations before exiting the program. Once a dataset has been RPP-
normalized, the global flow value and tabular flow values for that dataset will display an
asterisk (*) next to them. Additionally, a footnote with an asterisk (*) appears below the
Flow Table Results.
13. Segmental Overlay Tool: Displays blue overlays on the Spillover, Flow, and Reserve polar
maps. Options range from the default vascular option to 20 segments.
14. Next Tool: Clicking this moves the user from QA Mode to Results Mode.
Once all data is confirmed in QA Mode, click the Next button in the Toolbar to enter the
Results Mode.
Results Mode Workflow:

Figure 8.25: Manual
1. Once the Next button is clicked, the Results Mode displays primary Processing tool
information needed to interpret flow and reserve findings. From this screen,
if changes to the results are desired, click the Manual Processing tool (Figure 8.25) in the
Toolbar to return to QA Mode.
Figure 8.26: Results Mode

2. In Results Mode, the dynamic input data is available to cine
and review LV contours while viewing statistical results of
the processing (Figure 8.26).
3. The Global Results Table (Figure 8.27) shows regional

results for perfusion (Stress Mean, Rest Mean) and absolute Figure 8.27: Global Results table
blood flow (Stress Flow, Rest Flow) for each of the vascular
territories (LAD, LCX, and RCA), as well as globally (TOT). Also shown is the regional CFR
(Reserve), which is the ratio of Stress to Rest blood
flows. The algorithms used for both Stress and Rest are
displayed beneath the table for reference.
4. Review the Polar Maps and Tables (Figure 8.28),

left-to-right, to compare relative perfusion findings to
absolute flow findings.
▪ The left-most column displays, top-down: the stress,

rest, and comparison of the two, in standard relative
distribution format.
- The default quant map display is Blackout,

where any sector with uptake below the
normal threshold is ‘blacked-out’ to Figure 8.28: Result Mode Polar Maps and Tables
distinguish it from normal uptake
sectors. Options for the quant map are available for
selection from the Quant Map Tool in the toolbar (e.g.,
Norm option shows normalized maps to peak intensity
within the myocardium).
▪ The left-middle column displays, top-down: the absolute stress,

rest, and reserve flow values in units of ml/min/g, sampled over
460 sectors to provide a pixel-level flow polar map for review.
▪ The right-middle column displays the flow values without pixel

data included, called Stats maps. These show the absolute flow Figure 8.29: Segmental Overlay
and reserve value results based on the overlay map selected. The Options dropdown
global LV flow value is displayed at the 5 o’clock position just

outside of each of these polar maps, for stress, rest, and reserve.
- The vascular overlay displays on the polar maps by default. Click the Segmental
Overlay Options tool in the toolbar (Figure 8.29) to select a different overlay (e.g.,
select 5 Seg option to review the walls).
▪ The right-most column displays a CFR Defect

Polar Map above a CFR Derived Polar Map
(Figure 8.30).
- The CFR Defect Polar Map shows areas of

perfusion defect on the Reversibility map in
the selected color scheme. All other sectors
are blacked out. Segmental overlays are not
allowed on this polar map. Defects are labeled
with reserve mean value, with a maximum of 5
non-contiguous defect regions allowed.
- The CFR Derived Polar Map incorporates

Figure 8.30: CFR Defect and Derived Polar Maps
the CFR Defect Polar Map results and the
Reversibility Polar Map results and compares
them in vascular territories and globally, to provide the map and the percentage
information below in the Derived Results Table. Region color in the polar map
corresponds with the text colors in the table, with exception of the black areas which
use white text due to the black background of the application.
○ Red: Areas quantified as normal perfusion and normal reserve. Table heading
shows as “Normal.”
○ Blue: Areas quantified as normal perfusion with abnormal reserve. Table heading
shows as “N Perf/ A Flow.”
○ Green: Areas quantified as abnormal perfusion with normal reserve. Table heading
shows as “A Perf/N Flow.”
Results Mode Toolbar Options (Figure 8.31):
❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽
Figure 8.31: Results Mode Toolbar
1. Dual Colorbar Tool: The color control tool is comprised of the two colorbars separated by
a numbered panel. Right-click the colorbar to customize color schemes and adjust intensity
mappings. For more information on colorbar management, see the Colorbar Tools section.
3. Cine Tool: Activate/Deactivate cine of dynamic sequences. When active, motion correction
tools display on all viewports. When deactivated, using the frame slider from the drop-down
also activates the motion correction tools. Cine must be deactivated to view the flow ROI or
Bounds.
4. Manual Processing Tool: Click to return to the QA Mode within the Reserve Screen.
6. Quant Map Menu: Controls the type of quantification (Quant) performed on the raw data.
See Chapter 3: Corridor4DM Screens and Controls for more information.
7. Segmental Overlays Menu: Changes the overlay used to calculate regional statistics for
the Quant or Comparison map. Note that the CFR Defect Polar Map is locked to not allow
overlays. The Derived Polar Map is locked to showing a vascular overlay to correspond with
results calculated in the Derived Results Table. See Chapter 3: Corridor4DM Screens and
Controls for more information.
8. Comparison Map Menu: Controls the information displayed in a comparison map,

representing data generated from a comparison of two datasets. See Chapter 3: Corridor4DM
Screens and Controls for more information.
▪ Prior to exiting Corridor4DM, ensure to click Save in the Control

Panel to save all perfusion and flow results information (Figure 8.32).
Figure 8.32: Save control
Chapter 9 Inflammatory Protocol Review
Inflammatory Screen
Sarcoidosis patients with cardiac involvement account for most deaths associated with the disease.
Identifying presence and extent of cardiac sarcoidosis before, during, and after immunosuppressive
therapy aides in determining a sarcoid patient’s prognosis, and guides whether treatments are working
to improve cardiac function.
Specific cardiac inflammatory preparation, dosing, and imaging protocols have been developed to
compare rest perfusion images to rest F-18 FDG PET/CT metabolic images. Active cardiac inflammation
is identified in areas where LV perfusion uptake is normal, and FDG LV uptake is abnormally high. In
order to identify cardiac inflammatory involvement, LV contours generated in Corridor4DM on the
rest perfusion dataset are indirectly registered and applied to the FDG study to identify if any FDG
activity is within the LV myocardial borders. Further, if there are focal areas of FDG activity within the
LV myocardium, quantitative SUV thresholding tools in combination with rest perfusion comparison
to normals databases provide regional and global results to identify normal, infarct, and mixed tissue
versus inflamed myocardium. Utilize the Inflammatory screen’s Indirect Registration Mode within
Corridor4DM to perform quality assurance and registration to processed inflammatory results and
review them in Results Mode.
Input Data
The Inflammatory workflow and screen include some data requirements the user should be aware of
prior to use.
Corridor4DM license requirements:
The Corridor4DM license must include the PET package (to launch the rest perfusion PET and F-18
FDG PET datasets) and Hybrid CT option if the CT datasets are to be passed to Corridor4DM for
purposes of indirect registration.
Note: If using rest SPECT data for the rest perfusion, the combined SPECT + PET license is required.
NM and PT attenuation maps can be used in place of the CT datasets or CT-attenuation maps.
Indirect registration processing requirements:
ALL of the following four (4) datasets must be launched in Corridor4DM in order for the Inflammatory
screen to be enabled/active:
1. Static/summed rest perfusion dataset (can be PET or SPECT but must be attenuation-corrected) and
2. Corresponding CT (or attenuation map) used for attenuation correction of rest perfusion dataset
3. Static/summed PET F-18 FDG Inflammatory dataset (hereafter referred to as the inflammatory
dataset) and
4. Corresponding CT (or attenuation map) used for attenuation correction of PET F-18 FDG dataset
Inflammatory workflow and screen requirements:
Because of current multiple uses of F-18 FDG (e.g., for viability and inflammatory protocols), it is
necessary to ensure that the F-18 FDG inflammatory dataset name includes a unique identifier, such as
“Sarcoid,” to ensure the Inflammatory workflow and screen will automatically be available for use.
Corridor4DM v2018 ▪ User’s Guide Chapter 9: Inflammatory Protocol Review ▪ 107

Gated rest perfusion • Corridor4DM includes the ability to add site-specific series
and Gated FDG-18 descriptions, called dataset matching strings. This is accomplished
datasets are also typically in Corridor4DM Preferences on the Dataset Matching Strings
reviewed in 4DM but
are not requirements
Page in the FDG Inflammatory field. Please see Chapter 12: User
for the Inflammatory Preferences for more information.
screen. They are usually
reviewed within other • As a fallback in cases where the FDG dataset does not include a
pages such as the MI unique identifier, Corridor4DM includes the capability to assign
Processing, AC Func the datasets as Inflammatory protocols.
 + Quant, and AC MPI
Summary screens to - While on the MI Processing screen, right-click in the Dataset
Figure 9.1: Right-click in the
Dataset Information Panel
evaluate functional
Information Panel (Figure 9.1) and select the F-18 FDG
results such as the LVEF
%, ED/ES Volumes, Inflammatory option in the Radiopharmaceutical drop-down
and wall motion. If menu for the F-18 FDG Dataset (Figure 9.2).
static and gated datasets
are present, the static • SUV calculations requirements:
datasets take precedence
to display on the - The rest perfusion and F-18 FDG datasets must include the
Inflammatory screen. injected radiopharmaceutical and dose, injection time, and
patient weight. This information can be input in the Dataset
Information window, accessed via right-click on the Dataset
Information Panel.
If all four datasets are not loaded, and the F-18 FDG dataset is not
properly named, the Inflammatory screen will not be available for use. If
the patient weight, radiopharmaceutical, injected dose, and injection time
are not entered, SUV will not calculate.
Inflammatory QA, Processing, and Results

Figure 9.2: Dataset
Review Information window
with F-18 FDG
The MI Processing and Inflammatory screens are utilized for this workflow. Inflammatory drop-
All other screens in the workflow are available for purposes of reviewing the down selected
standard gated and static/summed datasets for perfusion and functional review
as covered earlier in this chapter.
MI Processing Screen
As with all Corridor4DM
workflows, the user should
begin the quality assurance
of the automated processing
on the MI Processing screen
(Figure 9.3) to verify the
contours generated on the rest
perfusion dataset(s) properly
track the endo- and epicardial
surfaces of the left ventricle.
These will be used to indirectly
register and apply onto the FDG
datasets. For more information Figure 9.3: MI Processing screen

on QA and processing on the MI Processing screen, please see that section of this chapter.
After confirmation of the rest perfusion contours is completed, continue to the Inflammatory screen . The
F-18 FDG Gated and Static datasets in most cases will not have enough LV myocardial activity available
to permit automatic generation of accurate LV contours.
Inflammatory Screen
The Inflammatory screen includes two modes: Indirect Registration Mode and Results Mode. The
Indirect Registration Mode is initially displayed and utilized to verify the co-registration of the perfusion
and inflammatory datasets to their respective CT datasets.
Indirect Registration Mode
Figure 9.4: Inflammatory Screen
1. Click in the workflow screens list to display the Inflammatory screen (Figure 9.4). If the screen
is not available, verify that the datasets loaded meet the requirements
noted above.
2. The Indirect Registration Mode of the screen is utilized to:
a. Row 1 (Figure 9.5): Check the co-registration of the perfusion

dataset to its respective CT or attenuation map. Corridor4DM
automatically places the static SPECT or PET as the Object
(moveable overlay) and corresponding CT or attenuation map
Figure 9.5: Row 1 on the
dataset as the Target. Inflammatory screen
i. Use the plane slicers to triangulate to the heart in all

three viewports and scroll through slices using the slicers
or dog ears to verify alignment in all three planes (Transverse, Figure 9.6: Orientation
tool
Coronal, and Sagittal in default patient orientation).
ii. Click the Orientation Tool to switch to cardiac orientation (SA, HLA, VLA)
(Figure 9.6).
iii. If re-alignment is needed, click in a viewport to use the panning or fine/coarse pan/
rotate tools embedded on the selected viewports to ensure alignment of the datasets in all
viewports (Figure 9.7).

Figure 9.7: The panning or fine/course pan/rotate tools in the Transverse viewport
b. Row 2 (Figure 9.8): Check the co-registration of the
inflammatory dataset to its respective CT or attenuation map.
Repeat above steps to ensure alignment.
c. Row 3 (Figure 9.9): Displays the Row 1 CT or attenuation map

as the Object in blue, and the Row 2 CT or attenuation map
as the Target, in gray. On the Inflammatory screen, the right Figure 9.8: Row 2 on the
colorbar defines the Target color scheme for Rows 1, 2, and 3. Inflammatory screen
The Object color scheme in Row 3 can be changed within the
Preferences/Colorbars page, in the CT Colorbars section. For
more information on colorbar management, see the Colorbar
Tools section.
i. It is likely that these will be mis-aligned since they are

different imaging sessions and potentially acquired on
Figure 9.9: Row 3 on the
different scanner systems, requiring manual alignment. Care Inflammatory screen
should be exercised to ensure these are aligned as best
as possible, as this is the indirect registration step that
enables placing the perfusion dataset LV contours onto the
inflammatory dataset. Figure 9.10: Center Datasets
Tool
ii. If the datasets are grossly off-center, click the Center
Datasets Tool (Figure 9.10) to center them in the viewport before
making manual alignment changes.
Figure 9.11: Process Tool
iii. Once the alignment checks are completed in Indirect
Registration Mode, click the Process Tool (Figure 9.11) in the
Toolbar to proceed to the Results Mode of the Inflammatory screen.
❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾
Figure 9.12: Indirect registration mode toolbar
Indirect Registration Mode Toolbar Options (Figure 9.12):

1. Dual Colorbar Tool: The color control tool is comprised of the two colorbars separated by a
numbered panel. Right-click the colorbar to customize color schemes and adjust intensity mappings.
On the Inflammatory screen, the left colorbar defines the perfusion and inflammatory Object dataset
color schemes for rows 1 and 2. The right colorbar defines the Target color scheme for Rows 1, 2,
and 3. The Object color scheme in Row 3 can be changed within the Preferences/Colorbars page, in

the CT Colorbars section. For more information on colorbar management, see the Colorbar Tools
section.
3. Cine Tool: Activate/Deactivate cine of dynamic sequences. When active, motion correction tools
display on all viewports. When deactivated, using the frame slider from the drop-down also activates
the motion correction tools. Cine must be deactivated to view the flow ROI or Bounds.
4. Cardiac Orientation Toggle Tool: Displays the datasets in SA, HLA, and VLA orientation.
6. Undo Tool: Once changes are made to alignment, this tool becomes active to undo the last move
with each click of the tool.
7. Reset Tool: Resets the screen to an unprocessed state. Or, select Reload to display the last saved
Corridor4DM results file if one is present.
8. Process Tool: Applies manual corrections to the transformation matrices within each row; Fuses
the perfusion and inflammatory datasets with the co-registration applied in Row 3 and applies the
perfusion contours to the inflammatory dataset(s). Exits the user from the Indirect Registration
Mode and displays the Inflammatory Results Mode.
9. Return Tool: Tool is disabled until the Process Tool has been selected at least one time on the
Inflammatory screen. When available, the tool permits the user to return to the Inflammatory Results
Mode without applying any changes made within the current Indirect Registration Mode screen
session.
Inflammatory Results Mode

Results display once indirect registration processing completes. Interactive fused image results, perfusion
and SUV polar maps, regional and global results, and derived comparisons are available to provide
detailed quantitative analysis of the perfusion and inflammatory datasets.
1. Review and Verify Fused Image Displays: In the top row of images, the perfusion and inflammatory
datasets display in patient orientation as fused with the perfusion as the Object and the inflammatory
dataset as the Target, centered to the heart. Click the Orientation tool to update the viewport
displays to cardiac orientation. A maximum of two datasets can display on this mode of the screen
at one time.
a. Use the plane slicers or dog ears (Figure 9.13) to scroll through the fused dataset viewports
in all three planes to verify the datasets appear properly co-registered and the red contours
accurately track the LV for both datasets.
i. If there is any minor mis-registration noted, click in a viewport and pan the Object using
Figure 9.13: Plane slicers and dog ears in viewports

the left mouse, or use the fine/coarse pan/rotate tools that display. If
any changes are made, results immediately reprocess and display.
Figure 9.14: Relative
b. When the default Relative SUV Threshold option is selected SUV Threshold
(Figure 9.14), a Volume of Interest (VOI) is automatically drawn and
placed within the blood pool cavity near the base of the LV, to be
used as a background reference for SUV on the inflammatory dataset
(Figure 9.15).
Figure 9.15: Volume of
c. The VOI displays the SUV mean value, and the maximum SUV value Interest (VOI)
(in parentheses).
d. When the Relative SUV Threshold option is selected, the mean VOI SUV value is
multiplied by the factor noted in the drop-down menu. Click the drop-down to view and
update the multiplier value, which is 1.5 on default and can be set to a desired value within
the Inflammatory screen Preferences.
e. Click and drag a selected VOI to pan/move it. The Text can be moved by
clicking and dragging it to a desired location in the viewport.
f. When the Absolute SUV Threshold option is selected (Figure 9.16) the
Figure 9.16: Absolute
default absolute threshold is set to 2.7 on default. Click the drop-down SUV Threshold
to view the SUV slider or make adjustments. When this option is in use,
the VOI is not drawn or displayed on the fused images.
Figure 9.17: Polar Maps
2. Review Polar Map Results (Figure 9.17): Corridor4DM displays four polar maps in a row, all with
a 5-wall segmental overlay to match the tabular results presented below:
a. Left-most: The Perfusion Normalized polar map shows the perfusion dataset normalized
to peak intensity within the myocardium. The default is to display it as grayscale. This can
be updated to a different color scheme by right-clicking the right colorbar and selecting a
different color scheme. The global mean intensity value displays in the lower right-hand
corner outside of the polar map.
b. Left-middle: The Perfusion Blackout polar map shows the perfusion dataset with the
Blackout quant map applied, where any sectors that are abnormal as compared to the
normals database will be blacked out within the polar map. The percent of defect for each
of the 5-wall segments displays within each segment. The global percentage of LV defect
displays in the lower right-hand corner outside of the polar map.
c. Right-middle: The SUV inflammatory polar map shows the SUV value calculated for
each of the 5-wall segments and is displayed within the polar map. The colorbar default used
for SUV maps is Step 10 and cannot be changed. The global mean SUV and max SUV in
parentheses display in the lower right-hand corner outside of the polar map.
d. Right-most: The SUV Blackout polar map compares the inflammatory dataset to the SUV

threshold which is noted in parentheses next to the dataset title. Any area calculated as
higher than the SUV threshold value displays as blacked out. Percentage of abnormal SUV
uptake is displayed within each of the 5-wall segments. The global percentage of LV with
abnormal SUV as compared to the threshold is displayed in the lower right-hand corner
outside of the polar map.
Figure 9.18: Table of Regional and Global Results
3. Review the Table of Regional and Global Results: (Figure 9.18) The 5-wall and global results
for each of the following are provided in table format for visual comparison to polar map and image
displays:
a. Perf Blackout: Provides regional abnormal (defect) extent for each wall and globally.
b. Perf Def-Sev: Gives the number of standard deviations below the normal database mean
uptake for each wall and globally.
c. SUV Mean (Max): Gives the mean and maximum SUV value for each wall and globally.
d. SUV Blackout: Provides the regional SUV abnormal (defect) extent for each wall and
globally. The abnormal threshold is defined by the SUV threshold tool.
e. Relative SUV Threshold: The abnormal threshold value is displayed here. SUV larger than
this threshold are considered abnormal and indicative of cardiac inflammation.
Figure 9.19: Derived Map and Results Table
4. Review the Derived Map and Results Table (Figure 9.19): Corridor4DM quantifies results
comparing the perfusion and inflammatory results, displaying this in a single Derived polar map.
The map is color-coded with 5-wall segmental and global results displayed in a table next to it.
a. Red: Normal perfusion and normal SUV, noted as the “Normal” column with results in red
text.
b. Green: Abnormal perfusion and normal SUV, noted as the “Scar” column with results in
green text.
c. Blue: Normal perfusion and abnormal SUV, noted as the “Inflammatory” column with
results in blue text.
d. Black: Areas in the derived map that display abnormal perfusion and abnormal SUV display
as black in the Derived polar map, but in white text in the “Mixed” column.

Inflammatory Results Toolbar Options (Figure 9.20):
❶ ❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾
Figure 9.20: Inflammatory Results toolbar
1. Dual Colorbar Tool: The color control tool is comprised of the two colorbars separated by a
numbered panel. Right-click the colorbar to customize color schemes and adjust intensity mappings.
On the Inflammatory screen, the left colorbar defines the inflammatory Object dataset color scheme.
The right colorbar defines the perfusion Target color scheme and polar map displays. The SUV polar
map color scheme is Step 10 and not definable. For more information on colorbar management, see
the Colorbar Tools section.
3. Cine Tool: Activate/Deactivate cine of dynamic sequences. When active, motion correction tools
display on all viewports. When deactivated, using the frame slider from the drop-down also activates
the motion correction tools. Cine must be deactivated to view the flow ROI or Bounds.
4. Manual Processing Tool: Returns the user to the Indirect Registration mode of the Inflammatory
screen.
5. Undo Tool: Once changes are made to alignment, this tool becomes active to undo the last move
with each click of the tool.
6. Standard Deviation Threshold Slider Tool: Displays the perfusion defect threshold set and allows
adjustments for perfusion dataset defect quantification. Units are in Standard Deviations.
7. SUV Threshold Slider Tool: Provides two options for setting the SUV Abnormal Threshold:
Absolute and Relative.
• Relative SUV Threshold option (default): Uses an automatically drawn Volume of Interest
(VOI) within the blood pool region. The default value is set to 1.5 and this is multiplied by
the mean SUV within the VOI to define the SUV abnormal threshold.
• Absolute SUV Threshold option: A particular absolute value is defined as the SUV
abnormal threshold via a slider. The default is set to 2.7.
9. Cardiac Orientation Toggle Tool: Displays the datasets in SA, HLA, and VLA orientation.
Prior to exiting Corridor4DM, ensure to click Save in the Control Panel

to save all perfusion and Inflammatory results information (Figure 9.21).
Figure 9.21: Save control

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Corridor4DM V2018 ▪ User’s Guide UG_2018-01B

CFR QA, Processing, and Results Review

▪ To evaluate for motion frame-

▪ If motion is present, manually correct for motion in each frame where

▪ All preliminary motion correction changes to the data appear on the

 of these ensures CFR

4. Review Preliminary Results: Once processing completes, additional QA results display on

Preliminary Results Review in QA Mode

Time Activity Curves (TACs)

Figure 8.11: TACs after Factor

Figure 8.16: Time Activity Curve check boxes

▪ Right-click the Time Activity Curves

- Kinetic Model: When checked, the kinetic

Flow Polar Maps

Preliminary stress, rest, and reserve flow calculations (Figure 8.20)

▪ The middle column displays, top-down: the absolute stress,

▪ The right-most column displays the flow values without pixel

Figure 8.21: QA Mode Toolbar Options

QA Mode Toolbar Options (Figure 8.21):

2. Magnification Tool: Adjust the image display size.

 of these ensures CFR

6. Contours Toggle Tool: Overlay Corridor4DM-generated LV surface contours on the images.

11. Frame Normalization Tool:

12. Rate Pressure Product (RPP)

▪ Click the RPP toggle to access the RPP options window

▪ The RPP Reference value is defined at 9000, the mid-point

▪ Click the Reset button to reset the values.

Results Mode Workflow:

Figure 8.26: Results Mode

3. The Global Results Table (Figure 8.27) shows regional

4. Review the Polar Maps and Tables (Figure 8.28),

▪ The left-most column displays, top-down: the stress,

- The default quant map display is Blackout,

▪ The left-middle column displays, top-down: the absolute stress,

▪ The right-middle column displays the flow values without pixel

global LV flow value is displayed at the 5 o’clock position just

▪ The right-most column displays a CFR Defect

- The CFR Defect Polar Map shows areas of

- The CFR Derived Polar Map incorporates

Figure 8.31: Results Mode Toolbar

2. Magnification Tool: Adjust the image display size.

5. Contours Toggle Tool: Overlay Corridor4DM-generated LV surface contours on the images.

8. Comparison Map Menu: Controls the information displayed in a comparison map,

▪ Prior to exiting Corridor4DM, ensure to click Save in the Control

Corridor4DM license requirements:

Indirect registration processing requirements:

Corridor4DM v2018 ▪ User’s Guide Chapter 9: Inflammatory Protocol Review ▪ 107

Inflammatory QA, Processing, and Results

Corridor4DM v2018 ▪ User’s Guide Chapter 9: Inflammatory Protocol Review ▪ 108

Indirect Registration Mode

Figure 9.4: Inflammatory Screen

2. The Indirect Registration Mode of the screen is utilized to:

a. Row 1 (Figure 9.5): Check the co-registration of the perfusion

i. Use the plane slicers to triangulate to the heart in all

Corridor4DM v2018 ▪ User’s Guide Chapter 9: Inflammatory Protocol Review ▪ 109

c. Row 3 (Figure 9.9): Displays the Row 1 CT or attenuation map