AN ATLAS OF SEGA NUCLEAR Mis SIN: SECOND EDITIONDSH | @ lgnae Fogelman and Michael SW. Maise Martin Dunite Lid 184 First published in the United Kingdom im 1944 by Martin Dunite Lid, 7-9 Pratt Street, London NW OAE First edition 1988 Second edition 154 Reprinted 145 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted if any form or by any means, without prior permission af the publisher. ACIP catalogue record of this book is available from the British Library. ISBN 185307 140-9 An Ailas of Climeal Nuclear Medicine Secomd Edition Slide Collection offers a unique teaching resource with over 6K) WMustrations from the book. presented im 35 mm sliche format, accompanied by booklets af captions, Please contact the Publisher at the above adelness. ‘Compsition by Scribe Design, Gillingham, Kent, UK ‘Origination by Image Publishing Lid Manufacture by Imago Publishing Ltd Printed and bound in Singapore EE —————————_—_CONTENTS hm a Acknowledgements vi Preface ii Note on single photon emission computed tomagraphy (SPECT) si Bone 1 Endocrine 11 Renal 169 Tumour — YD Brain 313 Cardiae 8 lung Liver and spleen — 5577, Miscellaneous studies 693. Index THWe would like to thank all the contributors of material to the Allas, who are identified by their contributions. We would also like to thank the staff of the Department of Nuckear Medicine at Guy's Hospital who have assisted in obtaining the mew material for this secomd edition. In particular, we acknowledge the valuable contribution made by Dr Petra Lewis to the Brain chapter. She has collated all the new material and ACKNO | assisted in the reconstruction of this chapter. Finally, our thanks again to the staff of Martin Dunitz for their constructive help throughout the preparation of this new edition. IF MNM SEMCPREF Although only five years have passed since the first edition of An Adlas of Clinical Nuclear Medicine was published, a number of new radiopharmaceuticals have been accepted into routine clinical practice and Single photon emission computed tomographic imaging (SPECT) has now become widely available. This edition of the Allis has been fully revised to cover these recent advances, while retaining the best of the material from the previous edition. In addition, there are new chapters on tumour imaging and Bastrointestinal studies. Without detracting from the comprehensivencss of the first edition, the book has been completely restructured to enhance its use as a teaching aid, Each chapter is divided into four sections: anatomy and physbology; radiopharmaceuti- cals; normal scans with variants and artefacts; and clinical applications. This. second edition of A Atle: of Clinica! Nuclear Moadicite retains the emphasis on obtaining functional information and iis relationship to solving clinical problems that was so central to the first edition, and it is hoped that it will continue to be a valuable source of information to all those involved in the field of nuclear medicine.NOTE ON SINGLE PH¢ ON EMISSION COMPUTED TOMOGRAPHY (SPECT) SPECT imaging is used to permit 3D reconstruction of data, increasing the sensitivity and anatomical local- ization of lesions in the skeleton, brain and heart. The sensitivity of localization of tumours is also increased with the use of SPECT acquisition reconstruction. The use of SPECT is becoming much more widely used and this second edition of An Alles of Clinizal Nuclear Medicine includes SPECT images in the Bone chapter for the spine, hips and knees, the Brain chapter, Heart chapter and Tumour chapter. The standard planes of reconstruction are shown diagrammatically below for use with these SPECT images. = Transaxial horizontalara BONE Bone scanning is usually exclusively performed using technetium-99m (“Te) labelled diphosphonate (Fig. 13), which shows exquisite sensitivity for skeletal abnormality, The technique has the limitation that Scan appearances may be non-specific; however, in many clinical situations recognizable patterns of scan abnormality are seen, which often suggest a specific diagnosis. The mechanism of tracer uptake on bene is mot fully understood, but it is believed that diphosphonate is adsorbed ante the surface of bone, with particular affinity for sites of new bone formation (Figs 1-1, 1.2}. Jt is thought that diphosphonate uptake on bone primarily reflects osteoblastic activity but is also dependent on skeletal vascularity, Thus bone scan images provide a functional display of skeletal activity. As functional change in bone occurs earlier than struc- tural change, the bone scan will often detect abnor: malities before they are seen on am x-ray Any diphosphonate which is not taken up by bome is excreted via the urinary tract, and im a normal study the kidneys are clearly visualized om the bone sean; indeed there are many examples of renal pathology which have been detected for the first time on the bone scan, It is also recognized that, on oceasion, there may be uptake of “Tc diphosphonate at non-skeletal sites. There have been many situations reported where this can occur, but it is believed that in all cases the common factor is the presence of local microcalcificaticn. CHAPTER CONTENTS 1.1) Anatemy/Physiology Mechanisen of diphosphonate uptake on bore Radiopharmaceuticals Chemical structures of diphosphonates ‘Normal scans with variants and artefacts Ld 1d 13.1 Normal bone scan 132 Three-phase bone scan 133 Bonescan itabion 134 0 Normal spect of the lumbar spine 13.5 0 Normal srrct of the hips and pelvis 134 Normal srect of the knees LA? Technical points 134 Variants 1.39 Artefacts 14 Clinical applications: 14.1 Investigation of bone pain 14.2 investigation of malignancy 143 Investigation of benign bane disease 14 MiscellaneousBONE 1.1 Mechanism of diphosphonate uptake on bone io” °° a i Fig. 14 [snr Adbsorhs onto surace bane Csteotslasts Mineralized ~ bone Marrow cavityBONE Lee ae dalai a eaen be. Um) Chemical structures of diphosphonates Fig. 1.3 OH CH, ” OH H oH Cheneloal street innes of | | | | diphosphonate compounds eased Ho—!——¢———"P —— 0H HO—P c——F—— oH fie bore seautetingg. | | Al tite present time Mann ds He most suvidely used agent: OH OH OH OH H OH HEDP, kydroryetlytulene diphosphamate; ile, methylene HEDe anne diphosphonate; Hath, Audroxymetiylene | diphasphonate: orp, oH a On a .CH,COOH | citeréerypropane | \ diphosphate, HP} —— C——F —. 0H ‘OH cH OH | | | OK OH OH = (eae nea oO} oH OH | Hun oro ad1.3.1 Normal bone scan R The cori mb ntl is part ite These areas high percentage of at hae resi ff rigghed deales saat thre anrimeanry tract aw AnteriorHowe Lee Relat UE eet eles MS a!&NORMAL SCANS WITH VARIANTS AND ARTEFACTSoONE NORMAL SCANS WITH VARIANTS AND ARTEFACTS 1.3.2 Three-phase bone scan The timing of bone scan images may depend upon the elinical problem under investigation. There is, at present, no complete agreement as to the optimum time interval between injection and static imaging, but it is customary to obtain images at between 2 and 4 hours. In certain circumstances a three-phase bone scan will provide valuable additional information with a Dynamic 1.3.3 Bone scan quantitation Visual assessment of tracer uptake in the sacroiliac joints is difficult, ard quantitation is recommended. Loptaine sa unt area Uptake adjacent bone funit area Sacrailiac joint (si) inden = regard to the vascularity of a lesion. This involves a dynamic flow study of the area of interest, with rapid sequential images taken every 2-3 seconds for 30 seconds. This is followed by a blood paol image at 5 minutes, when the radiopharmaceutical is still predor- inantly within the vascular compartment. Delayed static images are then obtained between 2 and 4 hours. scan of the downer finies. Bowe soar Tents 2 § © Belayed Several different methods have been proposed, one of which is shown in Fig. 1.8. Fig. 18 Sacredliac saat qucunbitat ioe.S WITH VARIANTS AND ARTEFACTS 1.3.4 Normal seect of the lumbar spine }" «= S # to ae pene: fat) Conoraal sectumns: (he) mu, ds best wernt the praneial eden, , pedicles cand facet joints tying 1g posh swith the hhady fing anterior | lateraily ard the spinews proce | Soe Ver “Or ‘WY’ c¢ TrawenialNORMAL SCANS WITH VARIANTS AND ARTEFACTS 1.3.5 Normal srect of the hips and pelvis vy ¥ oh oe he * ah “oe ver ver UR wo oF ote ote oe ofrit NORMAL SCANS WITH VARIANTS AND ARTEFACTS | GAD, A full bladder may produce ” artefacts on SPict rec due to high activity levels, C1 reconstructionHOHE NORMAL SCANS WITH VARIANTS AND ARTEFACTS 1.3.6 Normal srect of the knees 40 ae ae ae i, ah 4A AR AM aA*® 42 48 48 ae o24& S2& 24 Tibial plate ae 2e& Be Be ae sa & ss @ sa «& Tramsaial7 88 06 06 a6 @8 a8 a% ee t 4 4 . « ¢ ¢ ¢ tot be 4 ttBONE ee em is ee ey Normal seect of the knees in adolescenceBeat Dee ULCER leg, aby ge’, sect images must be interpreted with cavtion in adolescents and carted young adults as the epiphyses may appear asymmetrical, & & 5 é fe Sagitel, dt kee $e ¢@ ¢@ 8 Ff Sagittal, ight kneeSa net i ats a LE Ma Leia le Valk) 1.3.7 Technical points Localization of lesion * Prior to skeletal imaging, a patient should empty the bladder, since retained activity may lead to difficulties in scan interpretation, * [tis not possible to exclude abnormalities in the pelvis unless the bladder is empty, Hi the bladder obscures the pelvic bones, the pationt may be catheterized of a pelvic x-ray should be periormed, * Agqual view may be useful when bladder activity obscures the pelvis.NORMAL SCANS WITH VARIANTS AND ARTEFACTS Fig. LAS as fnem ice) Skull views oy SkullsHONE ee aan ak The importance of correct contrast et g : e+ % lf digital images are obtained, the data can he Fe reviewed and the contrast altered if necessary, With analogue images, the correct contrast has to be obtained af the outset; and ii the quality of images is inackery the stucly has to be repeated,BLE 1.3.8 Variants Calcification Fig. 1.24 y diphosphomate fhe thyme cartilage. bf to ie dint ir Nae middling be oF no efirical reference: Tracer aprake is sere fn the of the cosdal corti 1 ectrerene exc wrery be secur in elderfy suc card i oeeglt tin de dose eticificition of the ortilages but Fig. 1.26 A focal aren of increased tracer ieptanke bs ~~ al the upper tend far both pareti hat patethe sign, 7 should he comsnfened a norman haber arate site freseritiniy af fle abet ficial be cemisictered wien pardant; hoaeper, rile it i yr prrwsiciare shroud be alert to the prossitnli of coeristerct dsatse, particularly if tke prune sero in ary primary ualigramcy, ahserice a sia Spina bifida thy poles a seraall al wi-deficien! urea assocknted with the L5/St ich, on fhe x wns attribetable te incomplete partialBCI NORMAL SCANS WITH VARIANTS AND ARTEFACTS 1.3.9 Artefacts Free pertechnetate Activity at site of injection : Urine contamination Fig. 1.30 iternorFig. 1.33 Fig. 1.55The bone scan is widely used in clinical practice, and The clinical applications of bone scanning are listed is the most commonly requested investigation in amy below, and examples of the various clinical problems nuclear medicine department because of its sensitivity are given on subsequent pages. for lesion detection. The indications fora bone scan are continually being extended, but fall into four main Categories: * Investigation of bone pain * lavestigation of malignancy * Investigation of benign bone disease * Miscellancous 14.1 Investigation of bone pain LA Investigation of benign bone disease Metastatic tumour ‘Orthopaedic disorders. Benign bone tumour Benign bone tumours Trauma Infection Avascular necrosis Fracture Infection Exercise-related trauma Ostenmalacia Surgical trauma Paget's disease Degenerative disease Unexpected findings Metabolic bone disease 1.4.2 Investigation of malignancy Paget's disease Initial staging, Assessment of significance of x-ray lesions Discordant scan x-ray findings 144) Miscellaneous Assessment of extent of disexse Soft tissue accumulation of diphosphonate Monitoring progress of disease and response to Vascular abnormalities therapy Abnormalities of the renal tract Hypertrophic pulmonary osteoarthropathy Abnormalities of the urinary tract Primary bone tumours SS a— HOME cL ron 1.4.1 Investigation of bone pain Metastatic (tumour Benign bone tumour Osteoid osteomaFig. La tj fae) Bone sean i plained t vee: trait x-rays i $ ue Corespureulest see on 4 | L I Anterior, alelayeut e 11eh and One ries * Innon-accidental injury the bane scan may occasionally miss skull fractures, so a skull x-ray should be obtained routinely. * Sometioves, pinhole views of the epiphyses may be of value, since this is a common site of fracture; a lesion may not be apparent on the initial study, * Rib fractures at different stages of healing may be visualized, confirming repeated injury.Reflex sympathetic dystrophy syndrome BONE The reflex sympathetic dystrophy syndrome is poorly understood, and is often forgotten in clinical practice, Ih is seen most commonly following trauma, and symptoms include pain and tenderness, swelling and | dystrophic skin changes. Other terms applied to this syndrome include ® Causalma * Sudeck's alrophy * Acute atrophy * Post-traumatic osteoparosis of bone * Shoulder-hand syndrome dnereased pascularity heblereiscirmies. tu ff refer symp _ a Arizrioe a Rone scant 0 ferrova; ded feet. There és imeneased bracer unpre preserat in ail the dvees of hu deft ling. boat it ds rnest marirud af the fermoral weck, kre, auntie peledas (hp reflex sypapentbetic dheshropiey syrrdrosieg alread are Commarncendy ace ta paablernte ravi p been 1 oe bo “a—_———— aN Avascular necrosis Causes of avascular necrosis © Sickle cell disease * Vascular injury © Osteochondritis dissecans © Caisson disease * Trauma * Radiation * Steroid therapy * Gaucher's disease Sickle eel! disease wad of (deh itor While avascular bone is represented by a photor-deficient area on a bone scan, in practice this is seldom seen unless images are periormed early in the disease process. The most frequent finding ts increased tracer uptake; this reflects the healing responee by sumrounding bone,7 Fig, 149 ——_ fia, b) Bowe fee! din a 22-ger-old mont ano caunrprivel dndis crea! trocer yrenire fo ela & Deiewet Trawimna th kos breest ¢ ave fnectured————————$—$$———— fi head aca 10em a mot pene Infection read at bed Markers may help in the evaluation of a dynamic sudy, dinee | frequently difficult to know if a vascular blush corresponds exactly to a melabolically active lesan.ee maa eile hy Osteomalacia ie } = Paget's disease Fig. 1.56 Fig. 1.5 ay (bp1.4.2 Investigation of malignancy Although a bone scan lesion is a non-specific finding, characteristic scan appearances of multiple asymmetn- ‘hot spots’ throughout the skeleton are virtually diagnostic of metastases, ag *Initial staging The bene scan is important in the initial evaluation of ¥ since the knowbedkge t metastises are or are not present may alter subsequent management, The bone scan is extremely sensitive for patients with malig nd, in the case of carcinoma of the breast. whe routine radiograp a lead ti ighteen months fon average four months) for identification of metastases. ov detection, les , has with Recommended protec Bone scan ‘Obtain x-rays of aber canes mal sites to exclude be Ifsorays are normal, malignancy és likely Depending on clinical relevance, further inves! ion such as cr, sani casionally biopsy ma indicated Proceed to further imaging investigations if clini- cally indicated.Multiple my ja is the classic tion in which a rong hent false nei : P scan may be are purely lytic, with nc tle af this is shown \ el atvement is present. rays show multiple lytic les ston, In practice, however, it normal bone scan in amWhile the bone sean may underestimate the extent fisease inv multiple myeloma, 11 may, as in other situations, identify disease which is not apparent on x-rays. Radiography and bone scanting can be considered as complementary investigations, when accurate documentation of all sheletal distase is required. Although phatapaenic lesions are relatively uncommon, it is important io identify them since (hey usually indicate significant bony destruction, Photopaenic areas are seen in assnciation with agressive lytic disease, which does nat induce an osteoblastic response.Discordant scan/x-ray findings Solitary metastasis Extensive metastases on scan with / The bane scan may detect metastatic disease before any abnormality is a seen on x-rays. The knowbedge that skeletal metastases are presen! may antly alter patient management,Assessment of extent of disease Signiticance of solitary lesions Table 1.9) Incidence of solitary metistases by site in order of frequency Spine Pelvis Sternixm (in breast cancer} Ribs ‘Long bones Stoull Fig. Leo Fig. 1.70 A patient wrtit cirretnomat af the Areerst ard had feiferesely ahnaremai purl accumulation throughout the upper lnlf of he sderseiuine. No other alvinrmality uses preeseret dir Ue skeichon. The fradings indicated a sitory dastasts revoking the sherman, amd tieis mvfiriniod in nding rapiny, rrefirstasas jar titra. ie)oe = While ry pe controwersy as bo wi not obtained, some | = Sites such as the sternum, ribs ar scat will p phi ether routin dd metasiases are capula can b ovide clear visualization of these areas views of the skull shane will le mmiscedd r difficult to evaluate on routi ol Lower vely unommnen, they de occur, There has heen some imbs are necessary; however, if they are e radiography, whereas a hone1 GENE CLINE Localization problems Shrine thhraeys * Lesions should be visualized in two views whenever posiile | * On occasion, the precise localization of an almarmality may not be apparent, but will often be | clarified if additional views are obtained. @ Anterer Fig. 1.73 (hy anterior riew the aypearanc nthe posterior 0 racks Spi # ifs appermend that fhe lives pposterion!y ard @ Anterior Fig, 1.74 : Although the scans in far} Hime son ao Be-yeeatal mt welt sacnel melasiasis. Fig. 1.74 are obviously There is intensely tacressed tra oer Sacre eonemding jar init. Aa abnormal, the study emphasizes the potential impartance of obtaining a ‘squat’ view to separate the bladder from bore, tt i possible to imagine a siluation where an abnormality ts atteibater! ti ‘shine through’ from the bladder. 47Oberdynng &Boni CLINICAL APPLICATIO! Superscan Table 72 The ‘snperscan' Causes Helpful features Maligrancy uptake ng bones poorly visualized Hyperparathyresiciiarn Osteomalacia Delayed imaging ie normal subjectnerve Monitoring progress of disease and response to therapy The bone scan may be used to monitor progression of radiographic evidence of healing is slow to manifest, disease and response to therapy, since reliance on and mot possible in the presence of sclerotic metastases, symptoms alone can be misleading Furthermore, Fig. 1.78 | a S008 pollens serit ont serial studies | Lesion @ S. Phaotopaenic lesion Tittse ce af metastatic disease rm rib posterity. Che stabsequertt slater to} and & emoretits later ¢leb there bs tive upper fluor: studies obvaiteed 4 mor clear progression of discuse, dssocuation aevtty thee right kidney. staal (ip cabtiai tied J water Phere dats howe a f disease a i had cone sriginual study tre rig ted, with subseqiaert loss of function, a4woe CLINICAL APPLICATIONSThe tential 5c cbt APRA rapyy On weray, bes In a pationt with metastatic disease it may not be possible to evaluate response to therapy b indtial months, since apparent deterioration in scan findings may reflect bone healing, ta theBone scan respanse fo radiotherapy Bone scan appe: inces in patients who have received radiotherapy are often characteristic. (int he Baoraete Sco Uns reapuaesteal for cof Hie afte, Marked diticrent: tracer ftom ri righf auiterin che ¢ focaf areas oF Following radiatherapy, fracture ot the ribs may oocur spontaneously, This is seen most often in carcinoma of the breast.Hypertrophic pulmonary osteoarthrapathy Four cases of hypertrophic pulmonary ostecanhropathy as‘CLINICAL APPLICATI Primary bone tumours Tae 13 Classification of malignant primary hone fennours ‘Site of origin Tamour Skeletal connective tissues Other skeletal componentsec Delaved meres cmweca Slee nen neeneeeeent CLINICAL APPLICATIONSFly. 1204 Ar elderty mart iho presented with a sternal mers, The bone arare image of thr anterior ches? shows imcrrase”d tracer updabe in the sferanan, particudielyat the peripheral! borders, writ a relating pholon-deficieat anew wl its centne. Biopsy of the sternal ims repealed chomamiesancormdt. Giant cell tumours ao Onan Fig. 1.105 be Ejualibrisem A S2eyrorendd coum oft a rapidly growing stoefling of the sight corést cant at barge lishic fenton seem im fie distal radites ow xeray. The brine: scirit sdoors or crpacuber festow fa. bp hich accramlates dfiphosphomnte tcp ant delayed imaging. A grant cel? tumour ave ddentified at biopsy,Histioeytosis Histiocytosis * describes a triad of diseases in which there are focal accumulations of macrophages in wanious organs, including bome. The triad bs: uM Eosinophilic granuloma . - ” || LL * Letterer-Siwe disease * Hand—Schiller-Christian disease + Eosinophilic granuloma of bom Honet-Schiller-Christion disease A025 -porr-alid eeumnne perl orem Haml—Sehiiller— Christ rscese ard diabetes iresepriltes, The bone scant slams abnormal tracer aptabe i the right posterior Sth mand Gift ifs fax), feft tower Serene (hy art hott: tihiee (c), confirming Aistiocytir lesions ir tie bane marron at those sites. Lb iia a Posterior & Asteria © Anterior -- — a Anderior fh Amerie € Anterier a Attterior Fig. 1007 ig fe cath teosinnerpleifey geresneelguin cacin shows sites of disease in Har mauuditve far, loser coral (Uy, bide Achy aime raid rm aileave fal.WINE 1.4.3 Investigation of benign bone disease Orthopaedic disorders Causes of a paintul prosthesis * Loosening * Hetertopic ossification «© Infection * Development of metastases © Fracture Hip prostheses Looseving Fig. 1.708 faa, b) Baie seam riews of amderiur right Rip aeud upper femur, On the original staal, the scant appearances 7 pear after igsertion ofa right Ap prosthesis are norma. Mowruer, 2 year ater the patien! com plained of recurrence ef praia ine the righ beipy, ante Phe repeat sco shunts. focus of increnseal actinuty at fe hip of the prosthesis, The smn findings are typical ef Toosening uf a prostinesis. a yee post-iperetiinn Fig. L109 4.63-gorr-ofd weer ath bilaterat hips Prostheses ard pooja tm fue left Inijr, The hou scar fa, bp indicates uptake aroun! (he right prosthesrs, welch nridhait aanrrral limaits, Teens 9 iaicntased inptake at flee toy of the left femal curmpemeat consistent oetiir dewrserdirg, & Anterior positive for up ta one year after surgery—increased uptake beyond this time generally indicates pathelogy. With new cementless prostheses, increased uptake may be observed for seweral years after surgery with no evidence of pathology. ie Following hip replacement, the bone scan will normally be 5?CLINICAL APPLICATIONS Fig, L100 Case T | twill not be possible between infection and loosening ind a pbelled the bone sc lium or indie Aditioral ia eon Knee prostheses Increased diphosphonate uptake is normally seen fora Ga scan or white cell scan will be helpful in diagnas- varikle time interval following knee replacement ing infection in these cases. surgery and does not necessarily indicate pathology. A yj | Fig. tae na i | ATE ypeer oan widir senerc escent irritis E | attr onteoysen ei i 3 replacement. The petiend presented spiny * i iuretireudngpwriey aud senelldag of Mae right . knee, 7 fi The hove scam os cncremerd dhol 7 blood pool actiodty ta, bp aronemnd | " sat heats, Sener paittnke a4 Seere ire _ j c ie porastuesés, . i of the Anterat 7 ; , i é ing tthe @ Anterior. dy © Anteriar, equititrtun aad poo actinity, Lp tale fn the Hibial plaleaw wees rot significa i imeneiseal, Liter ews ai fed cor the bef - hiner a The scar fi vere those af septic F ith mo eohlence of ait j ostecunectitis. Ljptake in fhe tel kere lifendifiel a mesnalory comepranent od this patient’: ostevmtrtirritis 4 e | 3 = ? € Anterier, dchawed df Pintenor, deiowel © Anterior, Cea pe oF—— BONE Abasculier necrosts of lionate Fig. 1.008 tet, by) Home seater edewos of hairs ter a patient toto covaplited of peeine ir the right hue. X-nnys snigyestes! auescelar mer: f the timate bone. The bare sca confines a discrete fous of increased hercer uptake assacanted with the Jenate: There is alsa increased isood flame fo Hutt side. a Equititrnum B Delnaet Avascular necrosts fllowing fracture Fig. 1.009 dime sory cuss of amfertor peleds anid femora This padien? sustained a subcapital Fracture of the left fron, winch was fue neil compression screws. The blond’ pool doce fa shians reduced eascalnesty ti Wee Gaff feasanal head, Cn ihe dlelinved iemege (feb Shere is et obvious pliter-deficient area tt the region of the feff freoral head, togeiter peitit sour tncemesed tracer wyrtale a Me gfotter brochumter, cohvch prestmalshy rioflects sa rgical intermedi, The ace appoiniraces indicrie that the fest femoral fev is: rau Leweger ental * 5 3 @ Equilttrum & Delayedthe capital femoral epiphysis. sults tn abnormal greavth and reduced mobility fected hip. cc Delayed ty 6a—_—_ HONE Dee Benign bone tumours Osieord esteomaSee ag ee Fig, 1.129ES mine Fig. 1.127 fa, by eee fc) Xer Haemangioma af the J Spine may appear either photon-deibctent or show slightly increased tracer uptake on the bane scan studly,AL APPLICATI Infection Th with a 5 of peed to acly id be read from septic a pe; the following, cterized wasculla 1 that seen on f skele ivity in etic arthritis but nu, Oy the rac tive, A white cell sty sites af ve white cell ecific infect nega with antibicn in patients ’Fig. 1.0.0 ale ee ee) ina do patie i in dhe fr Delaved i)Fig. 1.152 a_Anterar.¢ Fig, 1133Fracture Fractured ribs =) OA na ' fa. by Bone sear adietes of posterior thoranic spine tran elderly Oe a! sumurit sevto fad suffered a fall ” > On the original hone scam multiple focal abmormalitics wre ' Preserct bit a Farieste pitt e right posterior ribs. The scar appeanaiices are diggnodtic of fracturr. On the repent stridy there 6 dines? complete rrsolrction, éndicating healing of the fractinnes Fractured neck of the iemur nat eas commpelaitied ev peat dit He fe follocating a fall. The x-rays mere norneal, del Nee bowie scant shiotces! fairretsed treorr eapfinbe i the leff fremoral weck, wife apperramces av fractere, Subsequent rays confirmed im impacted ir heft ferme neck Fractures from non-accidental injury =. | Fig 8 foe) Hone scan ina 2-morth olf girl neaitira history given by - : the meother of crackin sonmts in legge docrimg bathing. le Tie scour ddlewotitivs typstaker fat . Both femura, anterior rifts amd , the licoer thoracic spine, Te . - frotines ane typi! of froctwnce ¥ Front wor-aociaeretal dniiiry [+ * 1 terior be An r © AvateriorSe md eae PeCIren nica cat [rake Fig. L138 Fig. 1.139 whale hi estanSS Minna Knee trauma: meniscal tears A common sequel of trauma to the knees is a torn of increased uptake at the site of the tear, This uptake meniscus, The bene scan using tomography and is presumed to reflect on osteoblastic nesponse follow- dynamic imaging will assist in the diagnosis of the ing trauma to the meniscal attachment te the bone, meniscal tear, Meniscal tears appear as a crescentic anew 4 7 | i r 7 a Anttericn, epantbrtiaret b Antenor delayed & Pantera, delayed mote P ee 8h ge 8 af Teansrciat, srnct ve Conmul, sen Ff Sopital, rece Fig. Lt OO fete) Bore sears tar 12-weorr-ob? muane folloncinny at football dicjary. Tianhe is dracreseseal blond pool actioity in the ight live far) seit intense uptake je the media? and lateral eonnpithnents of the right dee secre on delayed imaging (b,c). Uiptiieappenrs ie rmvetne bodh the freuen and titi Tas finding is cnrfirmnd on SPECT emaging (dap), reticir shows erescentic uptake patterns (n the suede! and belered right tihiel platemv om the trapsaial slices tal}ard wptaie alsa in the loroer femur an the concmual amd sagittal slices de, fi These firufings are typecal of medial and lateral meriacad tenes oT utSurgical trauma Tharacapalasty Rib resection Fig. 1.006 a, Bone scan of a patient who Aad! nit resection for plasmacytoma. Note the absence of the right 6th rit posteriony. Focal abmoraaiities are seen iH the Fight Sth and 7th ribs posteriorty, There are metabolically artie fea Fibs, wih profelly represen? fractures following swryery,Degenerative disease idlentify PE Degenerative disease is a feature in the elderly. The sean, but serial ima will frequently itiation between dep astastic disease = is in elder current x-ray may A, poovsitive ctivitynerative disease of the spine: SPECT imaging@ Posters a? OL af. at: © Tromsaraal pelvic ina sith pie ie él planar amaying (bed). The findings are those of degeneratize al aHae Degenerative disease af the knees: sprct imaging a Aiterior al Tratiserretl, bbete Fig. 1.152 (ar) Anterior planar vier ef the fowes fn a 57-vear-ofd wei neitly bekederal ice pair. The planer imigintg stares partchy inptihe Ay both knees, The sence tmengieg th-af) confirms dine Patchy mature of the @luormatity faculzimg fhe feroaund coal tibiae corrsisteent ith degeneration disemse ont.Arthritis Osteourtleritis Prewdogane Meltipe fond 4 A if aoe i imenestsed teen aptade ave LE Lage ; present an the interphalangeal ‘ 5 joints, particularty invalring % tire distal jodnts, There is ? * Sa bilaterally imerewsed tracer j ‘ uptake af she first if é % carpanretacarpal joint, The sc - apparnances are dypically those ¢ o# osteoarthritis, a Equiliriue Delovel Fig. L156 Marked incense in Good pool fo) ard meetabolic acticnty (ly ef tfar hase of tine left dima) winfia! corpees cred estat Fiat dl patient soitis pserudiogaut. Rheumatoid arthritis oo. * wv Right areterior Loft anterior 6 Amteree Fig. 1.057 Fig. 1058 There is increased uptake of fracer ins both wrists, avith more focally increase? uptake in rrectvtiy santalll fod nls cof Me Farvads, Udnatr dewartion is appatrentt, The scan appearances ie typical of rhewmatodd arthritis Bone sca pieces: far, by chest; tic} pelbts: (aly Enwes. J There 5 fucremsed tracer uptake fy associations eettit bots boars ame! Enees (rare marked ont fhe left), aad the heftSacro The bone an is more sensitive than routine radiogra- detection i phy for t as ihustrated im Figg. 1 Sacnoiliac joints Bone scan Neray Norra Niue Narrmaal Fig. 1.060 th Be sceae et Fig. 1.161 Fig. Lde2 Peariatic Fig. 1.163CET AL APPLICATIONSAPPLICATICY Osteamalacia ‘Causes of osfeomalacti * Poor exposure to ultravioket light and low intake of * Peripheral resistance to vitamin D, eg vitamin D dietary vitamin D dependent rickets * Vitamin D malabsorption, eg coeliac disease + Hypophosphataemia, eg X-linked hypophosphat- © Abnormal vitamin 0 metabolism, eg chronic renil aemic (or vitamin D resistant) rickets failure * Hypophosphatasia * Inhibition of mineralization, eg by sium fuworiche. pmesert, [at AeINE Peeuckyiractures Table 1.6 Most common sites at colrich pseinlofrrctaces cane seer on dove scm Fibs 0% Seappula a Femar To Forearm 10% Pelvis 4% Fibula ine Resolution of metabolic features _Austevion, (i msoerdles Wy Ambertor, 2 mamilts pst-surgeny Fig. La70 Hone stmt if dhurrsicke eange ante {iy pelo dul femora iu a S0-pearsolf Asian commun with osteomalacia tof complained of pain én her ribs aud difficulty in aulking. The femge scars siune multiple focal fesinms ine the ribs, pric fom left qpper fener ana neck of the ejyint femur, There ds Senerally igh wpteake of tracer thronghowt the shelete rena! images ave mot misualiced, iat keeping sith metotalic itisensy, Focal lesions tn this case represer! parwdoiractunes, ss af fanp pusderriar sp Fig. 1.472 da, Home sere eves ie of tne exriggimal stanly dhe pretend tnd achive acromegaly, amd imcremseal tracer neprtenke 13 soca the cestachordnnl jection. Follearing ike tremsphemoidal vemocul of a pituitary hemowr, the scarrappemmmces ane csscntiaity anne! sith a clens nedeection in the aridity of the dracer saprtake at dite carsfeclivondnal pemefiats. Metabolic features are non-specific and may be seen where there is increased skeletal melabolien, from whatever case,Cu be a Brown turrewr t Fig. 1.176may bh tn patients welts MicCUNICAL APPLI Paget's disease Bane scan features of Paget's di * Intense uptake of tracer * Didfuse invelvement of bone * Emphasis of anatomical features, eg transverse processes in spine Ends of long bones atfected, rather than diaphyseal disease Fig. 1.180 art A The Bone expansion Deformity, C Palyestotic disease i bowing of a long bone ange ly over years lly present Spine and pelvis are the most commonly invelved Tishle 1.7 Incidence com hore scams Spine Clsvicke 1" Pelvis Ribs Femur 43% Motacarpal Tibia 44 Patella Shaul WS Manelible Scapula tah Forearm Humerus 17%Fig. Fig, 1.084 Fig, 1.485 atProgression af Pay Tih rus anal Further Ff 1oes lf changes occur in a bone scan over a relatively short period of time, they should not be atirituted to Paget's disease, and other pathology should be considered, Response to therapy Fig. 1.190 ta, byFig. 1.192 The bone scan is mot adequate to exclude fracture in patients with ts disease, This is because a8 increased tracer uplake associated with fracture may nel be recognized against high background activity, oeSoe a ee) patient with een is y not always be apparent. me narimally i pars ‘hartand metastases usually show characteristic scan patterns of abnormality and can be easily dif ated, radiographic examination is still required confinmation, becau each of these cond the other, an oocAsion ns can mimic a8Assessment of significance of x-ray lesions Iblic actrvity of a Jess Ae While a bone island usually appears normal on a bone scan, this. is not always the case, Fig. 1.186 ta bp oyea eal 1.4.4 Miscellaneous Soft tissue accumulation of diphosphonate There are many situations in which dipho=phonate common factor for may localize in soft tissues, and t these appears to be the presence microcalcifica Soit tissue accordion may Gocar in the following sites: * Infarcts * Muscle * Tumour * Amyloid * Fibroids © Systemic sclerosis ~_— Fig. L197 SplenicSe ae fo hypercaleae Ectopic calcification rela Fig. 1.2000 Fig 1201Pa APPLICATIC Tumour accumulati Fig. 1.205 Fig: 1.304 tii bib fay by Be Fig. 1.205 fat, ba) Bo On fa) a puts 13Fig. 1.208 1. (Db) Tiere scan + Ce tora. fe)ig. E203 is ainicx treIN aaa! Abnormalities of the renal tract {tis important to remember that abnorm- alities of the kidney may be diagnosed on a bone sca, Fig. 1.206 reased re alta Pelvic kiriney Fig. 1.208 Fig. 1209 foteee Abnormalities of the urinary tract Obstructed urimen Ht should not be assumed that a dilated callect- ing svstem is obstrncte fogNICAL APPLICATIONS AculENDOCRINE Thyroid The thyroid gland’s main function is to concentrate and organify inorganic todine, to store the iodinated compounds and then release them as active hormones into the circulation, As a result of this, radioactive iodine compounds, in particular “I, have been used for many years to investigate thyroid function. More recently, technetiumMm pertechnetate (""TcO,) has been shown to be concentrated by the thyroid but is not organified into the thyroid hormones, When thyroid imaging is performed with “Te, the scan appearances essentially provide a display of tracer uptake which is dependent on the trapping mechanism of the thyroid gland, but in practice it is possible to obtain the same information as with radioiodine, with afew rare exceptions, As "Te has near ideal physical Properties, it is the agent used most often for thyroid scanning. However, as cyclotron-produced isutopes ane becoming more available, "Il, which has considerable advantages over Ol for routine imaging, may alse be used for thyroid scanning although it is significantly more expensive. Adrenal Imaging the adrenal glands with radiemueclides is dependent on the metabolic activity of the adrenal cortex or the adrenal medulla. Such tests are only undertaken when biechemical investigations have confirmed the diagnosis, and are performed in conjunction with an anatomical imaging technique, which is usually the CT scan. Positive imaging with the compound @1/ "1 meta-todobengylguanidine (sinc) is a prerequisite before this agent can be used for therapy. Parathyroid A parathyroid adenoma may be imaged using, combined thallium-201 TI) and "=TeO, subtraction scanning. ="T1 localizes in glandular tissue according bo regional blood flow and atrase-dependent sodium! Potassium pump function and is taken up by both thyroid and parathyroid tissue, whereas “Te is taken up by the thyroid alone. Using a computer, it is possi- ble to subtract a “Te image of the patient's neck from one obtained with 2"'TL and identify parathyroid activ- ity. Visualization depends upon the size of the gland. In general, one would expect to visualize glands larger than 500mg, A normal parathyrowd (20 mg) gland will not be visualized by this technique. It is important to appreciate the normal anatomical position of parathyroid glands, the possible site of ectopic adenomas, and to be aware that supernumer- ary parathyroid glands may occur. Parathyroids in usual anatomical site 73% Ectopic parathyroid glands 235 Suptrnumerary (i¢ =4) parathyroid glands CHAPTER CONTENTS 21 Anatomy: Physiology 2 Thyroid Z Adrenal gland 213 Parathyroid 22 Radiopharmaceuticals 221 Thyroid imaging 222 Adrenal imaging 2235 Parathyroid imaging Normal seams with variants ana artefacts 22.1 Normal thyroid sean 232 Adrenomedtillary I wins imaging 2330 Normal adrenocortical scan 234 0 Nermal parathyroid scan Clinical applications 241 Cl ndications for thyroid scanning. 242 © Clinical indications for adrenal scanning 243 — Clinical indications for parathyroéd scanning Ld re)ENDOCRINE 2.1.1 Thyroid An understanding of the basic physiology of the thyroid and its control mechanisms is essential for the correct interpretation of thyroid scans. Figure 2.1 shows how the thyroid produces T,, T) and cT), and how T, contrels its own production via a negative feedback system. The eventual levels of thyroid Hypothalans Rise inhibits Ts | Ball stirmalates: 1220 [ Blend Tissues Hormone release Viz hormone in the blood are dependent on factors other than thyroid function alone. Figure 22 diagram- matically iNustrates the uptake of iodine (and radio- iodine), incorporation inte the thyroid hormone and telease of thyroid hormones into the blood under TSH stimulation. Fig. 24 Production of Ty, Tana FT i Eancoapenesdiioes tate Hae Hayerciel tif release of Hhyruid Rormennes nto the dood wader TSE ftrruilat ion.ON Dat esa Medutla Adrenaline Nomadrenaline 2.1.3. Parathyroid Fora glomeruli Zona fasiculaaa cores, Zona pectecularis: ‘, Cortisel Conticosterane Aldosterone Dvoryeorticosterone ee | mediastinum Intrath yroidal Noernal Jower Cervical mediastinum Fig. 23 of the audronal glands. Adrenomeduldery tissue. tical and medullary tfssue Diyramematic representa S Adrenocortical tisst Nate possible crimmadnenal sites af c Fig. 24 Wiile the greaf majority of cxeses of primvory hnyperparathiyratdism are duc tog siagie panetieprodf adenoma, parathyroid hyperplasée ard, more narely, aneltiple parathyroid daienomats cr provctiogroisl circingms may be present ait TitNO uae erie 2.2.1. Thyroid imaging Table 2% Radiophermacesticots in tinyrctid tmangemy Predection Decay Ty Energy (keV) source Te | Generaior thous 140 =] Cyclotzan 133 hosare 19 a amy Reactor A days Mt ™TeO, and radioiodine This important to appreciate the difference between the use of "ToO, and radioiodine (4, 1, =L I) for investigation of the thyroid, Figure 25 shows this diagrammatically. Very often "= TeQ, and radioiodine seans are identical. However, ""ToQ), is trapped but not bound, while tadiciodines are trapped and bound. The conse- quences. of this are as follows: ~Ted), ts only trapped aired neg bins Capillary Follicke us Hi Hours ea Radiolodine is tapped ana bon ‘Use Commer Thyroid imaging ‘Routine racliomuctide: cheap: low radiation dose Thyroid imaging Possibly best imaging agent; expensive amd poor avablability Cancer imaging. High radiation dose due to Uptake stadses A emission Therapy Oocasional differences in images will occur between “= TeX), and radigiodine, Radioiodine needs to be used for discharge tests with perchlorate (see page 134). Some cancers may trap but not bind radioiodine, ie could appear ‘hot’ on “*TcO, scans but ‘cold’ with Tachoiodine. ‘The overall uptake of tracer by the thyroid will be higher and Later with radioiodine as it is progres- sively incorporated into the gland—typically 30% at 34 hours compared with a peak uptake of about 45% at 20 minutes with “*TcO,. Fig. 25 Commpeerison of P= Tet radicnonhine f°, 2, - fn the dimestiga tion of the thuron. 2.2.2 Adrenal imaging 2.2.3 Parathyroid imaging Table 22) Radiophonmacenticals foradrenal imaging Table 2.9 Radiopharmaceuticals for perathyrotd i ‘Organ Hormone Radinpharmaceutical maging Adrenal cortex ‘Coctisal tf dedocholesicral Production source Decay T, Energy (ke¥) Allsboestiersirie “St wlenecholesiyrol = eee Generator hours 140 Adrenal medulla © Catecholamines = '™TSamc = Cyciotnon Ad bous pt 1a taENDCMC RINE 2.3.1 Normal thyroid scan TO), uptake f inte nd the thyreid in ed. The acti syringe Is py reo injection. 20 m 408 cled activity present in the thr + can be calculated, The normal rar TECTED ACTIVITY (Peas a ACTIVITY TH THYRDDD CREGO: zs RIGHT LOBE (= cad LOBE tx: Eat ur Tree cms 1.5 THYROID —— oy eats 4 1 LOE ¢x35 “ ACTIVITY COND (TOS ba 81GHT Loge: im | FT Lowe “aERIC RINE 2.3.2. Adrenomedullary "I misc imaging : be Pessterive t Anterior dt Posterior e¢ Antero Fig 2.9 Series.of 24-hour images with "1 aswecr fat,b) chest virws; (el oiew of abdowen: (al) abdomen and pelvis; fe) ciew of pelvis ard upper femora. Note slat tie myocardinen é mcrmaliy serra, and dutnends mene alse bx aiscandizend Adrenal uptake (3 more commonly seve nettit i uFECMO 2.3.3. Normal adrenocortical scan Initially a renal scan is obtained with “Tc dimercapto- succinic acid (owsa)., Using either mdioactive or small lead markers, the upper poles of wach kidney ane identi- fied and marks made on the patient's back with Fig, 240 snare derail rigs 2.3.4 Normal parathyroid scan ‘Renal cits scam 5 lags after intiectivn of D0 CE "Se sefemockalestenl, showing indelible ink for further reference, The radiopharma- ceutical fer adrenal imaging is then injected. Subseypent quantitation of adrenal uptake tracer may be of value in differentiating hyperplastic glands from normal. normally appears oie # higher than the: teft * The right adrenal appears more active than the leit because of its more posterior position. * The normal adrenal uptake is bess than, or equal to, 0.2% of the injected dove, ® The right adrenal ‘7 ws YA FT, «Tt Fig. 200 Neck ries; fake 'TT image: (bj Te, emages fe) TOO STD image oth Te), ewepe cubtractert dal BU TE image ait “Tod, image sidtracted, i << Tha Teth, 100% % ¢ 27) -"T20, #08 Normal parathyrodd glands and 30% of hyperplastic glands are not visualized by this technique, naENDOCRINE Aerie The clinical applications of endocrine scanning are listed below, and examples ef the various clinical problems are given on subsequent pages. 24.1 Clinical indications for dhyroid scanning 24.3) Clinical indications for parathyroid scanning, Assessment af thyroid modules Parathyroid adenoma Diagnosis of cause of thyrotenicosis. Multiple parathyroid adenomas Assessment of goitre Parathyroid carcinoma Evaluation of ectopic thyroid Secondary hyperparathyrotdicn Assessment of thyroid cancer Problems in parathyroid bocalization 24.2 Clinical indications for adrenal scanning Investigation of Cushing's syndrome Investigation of Conn’s syndrome (hyperaldesteranism| Investigation of pharochromocytoma, ——————_____ ees pT mg Copyrighted malernialINDOCR 2.4.1 Clinical indications for thyroid scanning Assessment of thyroid nodules A. clinically solitary thyroid module is one of the nodules and their scan findings. Figure 2.12 shows one commonest presentations of thyroid disease, The main systematic approach to investigation using the thyroid purpose of thyroid imaging is to detect and treat malig- scan. Other approaches would rely more heavily on nancy. Table 24 shows the common causes of thyroid ultrasound and use aspiration cytology, Table 240 Canvses of Sriyroie norleales Isntope sean finding: UMrasmeand Finding Functioning adenoma Increased uptake Echagenic (sulid} Multinostullir peste Multitocal Multiple nodules and cysts. Mondunctioning adenoma = Decreased! uptaioe Eeberpenic (salicdy Colloid nodule Decreased uptake Bebeygenic (solic Cyst Decreased uptake Echo free Haemorthagic cyst Decreased aptaioe ioe Malignant tumour Decreased uptake Echagenic (solid) Local thyroiditis Increased or decreased uptake = Echogenic (solid) or mo discrete besicm j= Normal —t Radiniodine scan TRH best Het’ nedule ————» Flat ————t Treat as ‘hot’ nodule Hat’ nodules Thyraid! sean Clinically solitery evodtule ———————— Muiltinostular ————- Simple prultineduilat Large ‘cold? reodailes pee —'itald? medule Utirbeound he Solicl (85%) Fig. 2.12 ‘Flow channel” |(CLINICAL APPLICATIONS— Pxneornpst The oblique viewThe importance af ‘markers® Fig. 218 Tiere: al wl) a cohere a reper coll iaew been miisheading Case 1 The thnproial som fib upporrs relatively moreual. The narters (bh) imdicote tat the darge palpate mein Ties echo tie nye toa thumoglersaal o Case 2A further 1 pratierst vith a palpable miidliic Byrd mactnele. The Avital sec fed appenes exertitlliy normal, Inve it te clones ex marker placement fad} that the imvidline noafsale is man ‘furmctivena, fe) is urererney! there és sr relutiovly decreased tracer uptake at the dimer eft dobre anhich correspamds the palpable note. (f) Th scant with podule marker. The not ryicnly remoned, | and Histol eramination renarled Hashiventi's flyer Whenever there isa palpable nodule, it is impertant to correlate clinical findings with scan appearances, and careful placing of markers may be necessary,Changes in cysts with time Figures 2.19, 2.20 and 2.21 show examples of partial and complete resolution of changes emo rhage int thyroid: cyst, Sequential scans are often invaluable in the assessment and management of thyroid nodules allowing hi at Bet fh Afier ratENTCCRENE Thyroid nodule: malignant Papillary cercimonue Follicular carcinoma Amaplastic carcinonnt Fig. 222 A non-functioning moulule at the Liver pote ov the right Luke the tinged. Papnilery carchnome eas Hscooenel af operation, Fig. 2.23 There are no reliable 4 ways of distinguishing a : benign thyraid nodule from a malignant thyroid nodabe on a thyroid scan, The appearance of lissue displacement should raise the suspicion of cancer, however, Armas it the left fab f the troll fa 2-year onan . A meu-fernctioning novfale is seein om Hee Te scar enicir ois solid on uldnnsonemd, A follépular oenchuom joa remmirce at operat intr Fig. 2.04 ‘Too euimeples af maaplastic camcatnierag of fae Hnyrada im ine fra atm at) lhe fet dodo he Uhyrcl appears mural but 45 ali uw the hey. The rig lobe is repstaoed dey a Larger tides seas inkl toms subsraucehly slosert in he drenplastic carcinama of the #ryrcial. Ure the second example fe Bae deft lobe of he thryresda aval fethereis ane aleraosd cormpletely replaced, with the exception of a sacl ceed fn ihc upper pote af tae bepé lobe:10 Wrotoxicosis alter nevi ius thy d Ssufeery Appearance ifiuse toxic godtre (Graves® disease) after thyraid- ectomy may be mish fe. The fethmus is almost always removed at thyroid surgery, There may bbe active pyramid | lobe or ectopic ie the te thyroid area, Thee updake is usually high, but, because of the smaller volume of tissue, may be in the normal range. The cases in Figs 2.43 and 2.44 Musteate the differences between hemithyraid- ectomy and subtotal thyroideetarty When the scan appearances are ‘unusual’, the possibility of previews surgery should be considered inneENDOCRINE Thyrotoxicosis due fo multiple toxic nodules Usually a diagnosis of thyrotoxicosis due to multiple toxic modules is made quite easily, as shown in Fig. 235. The features are well-demarcated nodules, evidence of suppressed perinodular thyroid tissue and an overall uptake that is offen within the normal range and generally lower than is seen with Graves’ disease. The normal suppressed Hssue is not taking up the tracer because the high T, production by the nodules has stopped ts production; without circulating ti, there is practically no function of the thyroid follicular cells, This situation is the reverse to that found in Graves’ disease, when the whole gland is uniformly Multiple toxic nodular thyrotoxicosis stimulated by sab. The demonstration of suppressed tissue may be diagnostically important and can be shown in three ways: + Repeating the scan after im Tsi injections + Repeating the scan after antithyroid dmg therapy in a dose sufficient to cause a rise in Te (endogenous TSH stimulation) * Repeating the scan after “I therapy, when the functional nodules will have reduced function and TSH will have risen to cause stimulation of previ- ously suppressed tissue 7 Fig. 2.35 tn) Teyrodd sewn dna ¥l-yeae- olf some ihe prescifed wcitiy dl gute asta Hnurotatiresis, (he) The Te uptake of 3.50% ts anitlin the normal FARR,PNTHOCE Crise 1 Thyritaricnas ta momaltiple ic snouts, Tih: intial stad fet) shcnws the Hevroiil te ii direst ef fe fu the | dlistica! cimtert of thyrntonicosés, are presumably functioning ator ‘The repent study (2), odsusimed fe three im injections of Tart, sec eran femae Enact 1 ft urrmal iatitounrs ative fo erdlogemoves Tat stimefation. € va mankedlur iucreased sptake, 1 al dhe upper pote of the right h Inqperfrartctinetding otras are res Loire functanal ond there is rece sly suppressed tissu, particularly erga lesb ipper pote of the lett tobe, Tle scene anne those of eesobetiont of the toxic i ig Tadiniodiee, coithh recowry af suppresses tiESCHOC ENE Radioiodine treatment for toxic nodular govire There are two situations when a follow-up scan after + By showing that the toxic nodules have resolved, the radigioding (1) therapy is clinically useful: clinician can be confident that a recurrence of thyro- tonicosis ts very unlikely, * By clearly establishing a diagnosis of toxic mesdules and net toxic diffuse goitre, long-term follow-up is These twe points are illustrated in the two cases in Fig, affected by the knowledge that hypothyreidism is 2.37. In the first there was doubt about the diagnosis; very rare in this growp of patients, in the second there was no doubt, bet the post-''l scan shows good resolution of nodules. Multis textc nodteles feels. Cha tlie repent scars leh, pil folly fica! area oF Case 2 Thr orginal study fc} shows the presence af maiiple ioxiy: moduides, The repeat sie tlh obtedned follomding shoves that (here fees ‘hod mortulies, usd——————$-_-_——__— CIE aa! Fig. 239 eliapse avid seuny repiuire frtlicy dine Hcy Case 1 On the sturdy dan) fhere rd nge hrtic cutive epocntscitd fER) radickodtine, sh mnalinle, roth re emer asthe mpllete: reset ime dine reve anf thee riorread erie Freatuale, gland. Ce fhe repeat the noctule te ety ptura of fumuction © O rmontits efePrgirenl stay 5 cliscomstineaued. f lobe of the dfnyne fifo bes eereadonis citar aif dirt firrne Where He paidiennt saalsespacestly av adgwifica med isi pelopengy Aryputiyrinssin. Ifa patient with a toxic nodule is treated with "1 while taking antithyroid drugs, there will be some ‘1 © uptake info suppressed tistve (see Fig. 2.29) and the Incidence af subsequent hypathyratdisn rises (rem nearly zero to 230%. Thyroid scanning before ""ltreatrnent is therefore advisable,Palpable ‘nodule’ in hyperthyroidism Thyrotonicosis ani single nodule THYROID SCAN Asymmetrical Functioning ‘Cold? reduale Congenital gland noxtule in Graver diseace hypoplasia ef Groves’ disezee | thyroid lobe MANAGEMENT Antithyroid drugs) Radivicdine Sungical Antithyroid: drugs’ ridiiiedine iherapy (ty treatment of mafiniodine therapy | Graves’ dinease ' ' OUTCOME as = a ae hypothyroid hypothyroid ‘hypothyroid hypothyroid—— IxpOC HDs Oat ATH et Low uptake of fracer in the presence of clinical hyperthyroidism Absent thynoid uplake of tracer ina patient with thyno- checking that the tracer has been given, several causes toxtcosis is usually a surprise finding on the scan. After should be considered, as illustrated in Fig. 2.41 ble 2.7 Conses and mechanisms of low tracer uptake tn thyrotoxicosis Cause Mechanism Subacute (le Charevain’'s thyriidites) Diaemagge: ber hae trys Suppressive of tort by rch Thymotusiconis associates! with high iodine ‘Swam ping, of the bily' ingestion including health fone ihe radioactive tracer is diluted in a evuch preparations imc! amicdarene, Lunges volume and theeclore propurt fess 45 akon inp by Lhe gl Pharmacological indibite Excess thyroid hormene administration Suppression of ra Extorpie thy raid hormone production (me siriema avait} Suppression eof TS140ENCORE Multinedular sovtre A simple non-texie multinodular goitre will appear enlarged on the scan with irregular, usually poorly defined areas of decreased and increased tracer accumulation, corresponding to areas of fibrosis, degeneration and functional regeneration. The overall tracer uptake will be within the normal range. The following points need attention: * Aneray examination is necesary fot confirmation of tracheal deviation. There is a possibility that toxic modules will Si eventually develop in all multinodular goitres and may subsequently cause thyrotoxieasis. A TRH test may be necessary for evaluation. If there is one non-functioning mass that is langer and different to the others, which could represent a malignancy, especially if-it corresponds to a distinct palpable mass, a histological examination may be mecessary for further evaluation. If there is any suggestion of retrosternal extension, an x-ray examination and radioiodine scan may be necessary for further evaluation. Fig. 248 faxsb) Tavs cise roltinadular gottre imide nusrsbocc palpalde nadile, Sn imniractges! as at 5 meentule, Ultrasensitive 11 estimation should be used to assess the: significance of a functioning nodule or nodules scan on a muftinodular 1 kirge steal tye a i : poltre. Suppression a ultrasensative 1h will confirm aulonornmrs function, Fig. 2.50 The ortgina! Neyruid sear fa) shows a ( jracreaseal tracer wpitaice dir the rreid-some af the left fofse. Im aubfition, there is.0 photon-adefiriend are in the region of the daflirss cmd flee purrker sore | fly indlicntes tard this correspomds to ot | palpable muistliter maul. The scat aypmarances are thowe of a wnaltinndeler ‘give, ath hetie Ayer aad discrete ens 6 Inypofumetioning nodules. ttor ENDROCIEINE ee partierat be teEMDIOC HI Goitre associated with law uptake of tracer om scan 7 Fig. 257 A patter! whe presented evi hiochest tel seud clinica! evidence of ic together othr dendeviness in the neck. A Neyroid scar at the thew tet) shacuved fore | uptake of tracer by the gland, A repeat sea » th), olvajaed when Heyroliilis had resolped, some nore, @ OG mnetits b drums . a Oromia Ah Free, septal had eT ape, septal 2k Fig. 258 Alnniie patient who presented with a tender, fire snoelling: on the right side of hes meck. Cnr dhe Origine! sone (ar) the left lobe of tie Miumaidf ippemes relitroely worm, but there is essetrally mo sipdake ion ine right. The seen findings raise the possibiléhy of neplacermemt of Wee right fobe of tine teyroid, arta earcinomne canmat be excluded. Am operation ants vevommantciidid, (nel uslere tie peter tists seine for necuent 3 aves deter the right-side! surRptows had vesulewnd, and be toes comppleintineg of jiding ava Ble left side of Fred mock. A nepedd scan aus abtelmed th) toftich shows clair improvement ta the might lobe of the Weyroid, with fon eptnke ort the let. Ohur month liter, the pahient ants asymptomatic. A dorther scan de) shows corral! improcrincat, altougit there bs stil slight reduction of dracer uptake by the left lobe of the teyrotf, Theis paricut rearescats an anisuall case of deyronfitis, frdtinlly dreninding ome doke of the thymotd caf subseqrertiy the ofler. mSCnietkint Thyroxine Gallium-67 can be used diagnostically in a patient with Hashimoto's thyroiditis who develops further swelling in the neck while taking T, replacement therapy, when a routine thyroid scan cannot be employed. Fig. 239 A patient ronth w past hestory of thuroid surgery ford multinodular gothre who res subsequnotly placed vn a suppressier dose of ttnpreucime. The initial sewer far), obfedmed sottdle dint peter aus receiciey tneroniite. sheers extremely Lou uptake of tracer. A Repel atioly fir nbeectecen of ter srletenl fh) wis obtained ane month after iscrmebimuurtionr if dinpreiciine. Whe scan uippwaramces int this case reptnesend a cowsbimation: of muilénidiner chartyge areal precios thyroid surgery. Fig. 2.60 ‘The thyrond scan (a) stones extremely poor aptake of trncer dnroughot tine teyroid, dn Hooping with the cféinical picture of fpodieynedaisnt dar to Hivstinrninte's thagroditis, The gatlinamr-07 (Ga) scant) Of tne rect enuf tinea shows imberrsely drerewsed brncer aceimebetiont in the region of the Heyman, anit rmich ess afritinig Pod mirorrfhefess abmormual fivler acttovty. Thies pation? had thigroval [yeupiing, eetich bea Krewe assorttion titlr Heshinecto’s Hrorrelttis. for aufdtitiem, there fs epndence af acting Iyenpticinnt dr dine haiar negiors.ENDOCRINE Veg Ce Evaluation of ectopic thyroid Thyroid development and possible efinical outcome Earby oribe origin OF the Bhyerote Thyritd descent and ectopic | Hig. ar thereid tissu ted —— Middle Shh mabdesoer Thyroid deoelopment. eat 4 \ Lingrial ) 1 thyroid Tonsil \ =" Thyruglossal ‘Superior ye Peer Nowrmall theyre Table 2.9 Scaur appearances for evaluation of ectopic thyrcid Description Oo Sean Lingual thymoid Functioning, midline, posterioe thind of temgine Thyroid noemally absent Thyroglossal cyst O Non-Fursctiomirig midline e) Normal thyraid Cy ee Ectopic maldescent Aa Functioning midbine nodule co Normal thyroid may be present or absent areal thiproiic (Y) Other, eg teratoma Sonmal thyroid uptake will be euppressed edhovary (atreima over) Functioning, tise in thir pelvis 47148Assessment af thyroid cancer Radionuclide thyroid scanning is used im the manage- (4) To assess the moetasta ment of thyroid cancer at several stages thyroid ca ov (3) To assess the suitability of the thyroid tumour for (1) In diagnosis (see the sec on cold nodules and radioiedine ("lj therapy, oltre) (2) To bel } (3) To assess the presence of residual functioning to thy ¢ presence of normal thyroid tissue ‘ y for thy “ft ot is essential to have a working knowledge id cancer behavios thyroid tun i coumulate trace bd turner Table 2.10 Comparisen of Heyrdid temours ase cot ability to accrrnulate tracer Hisaology: Paw papillary with me colledd formation Papiflary with follicular elements producing colloid Follicular Anaplastic Medullary Lymphoma amounts of Ml Tun1 ENDOCRINE } i j ifumcthivareg lat screech anon cece tnmatidertiang AT Gan resp A thyroid scan ta) revealed a “ool” toalale dn the right enif-fobe of the ryroid At surgery. a follicular carninomat us discopernd, Following total thuroddectomy, a 0 scare (hy neweaied teow fact of aval racer uptake fn the thyredd surgical bef A 3U00 MB (87 mCi) lkerapewbic dose of UT wees givens. ANivie siondies later, a repeat!" scam fc) showed 2 arma! focus of activity ter the merck (arrow), There hes deem clarr impromemient follinoieiy trenipry, bint there ts persistered resedual tisawe {furmowr|, and feertier "8 therapy anil be reqeairesd, © Solitary “cold” nodules have a prabability of malignancy of aleout 10%. * Differentiated thyroid cancer does not accumulate *"U at normal Tse stimulation, * Levels greater than 30 mU/litre of ts must be shown to be certain that a potentially functioning humour is not missed, * '" | isthe optimal Botepe for demonstrating small amounts ef resbiisal theewe, * Ab the thme of the first scan affer surgery, it is not possible to distinguish normal fram malignant thyroid tissue. * After a therapeutic dese of ‘|. any residual uptake after more than six months is likely to represent residual cancer. isla ERDOCRI NE furtag recetoed enemy sean 217 , slorgicall ecntmeinat cre far carcartonmd, arid ty Baas porfans performed 4 aoecks prs a L ua fF * Replacement rather than displacement is a feature of thyroid cancer. * Thyroid tumours do not take wp trecer until after ablation of the thyraid gland, when the rt has risen * Microschipic lung mielistises are hey will respond well to en seen with "when the chest q-ray ay is clear, Whale body radioiodine ("'l) sean While-bedy scans using “are undertaken bo assess nesidual thyroid cancer and metastases. The normal sites of radioiadine uptake, however, need te be known a0 that a correct interpretation can be made.UPAR SE Medullary carcinoma of the thyroid (vere) Te stan aprvarance tnt MTC Fig. 278 Taiyriief seam frei @-wiere—aled an ees presented with hone mutaeshises ainda wis subsequcmtiy foswd fo ere a feyrail suodisle (4 He right totes. This eons foamed to be sere af operation. if aco fron Mite dui eal Hae patient ity Fig. 2.78, discoprned ort routine acreemireg sof flr family, She wes fowl io fave a multinodyber goitre ure palpation, arad the scant confirmed this. Note fluet die san opwanmices fndicate diwniaant ‘ookd” nodiales i each tobe, A tiyraddectorry tees performed unfick cmfiemmed mediellany Prenat, | Fig. 280 Thyrodd scam from 0 G-yearsald toon fobo presented wrtth armas in flac right side of the thieodd, siretctag tom enews of Reduced pphribe Carries tefrich coene fiend Tobe arte at surgery * Large, dominant ‘oold” nodules in a multinodular gland may be malignant, « Medullary carcinoma may be iwmilial, * Medullary carcinoma of the thyroid may be bilateral, and multifocal, 156a, ETM MONE a Arierior © Posterior f Posterior “= Tefv) asa scan ina Severo man ath o past Iistoey of shirgery tv the thyrovd MIC nilin prresertioad toitir werk meses atl bone prin. There ane fora! areas of abmormalthy ft the righi side of the seek fac) taut thironghou! the skeet fal). *Teiv) maa is a cheap, available radiapharma- ceutical tor investigating patients with sac. 1s?— ERIDCMCRINE A MIG dpipeirances tn ATC Due to the low sensitivity of suec imaging in patients with arc (about 30"), MiG imaging should only be used to assess its potential for theragy in patients with known recurrent disease. isaAdrenal carcinama An adrenal carcinoma may have variallde uptake of tracer. While plake, here may mn ewen high uptake, wn in Fip there fs usually mo w he faint uptake a in the casebe Investigation of Conn’s syndrome (hyperaldosteronism) Table 2.72 Sonn oppeceences fir Coun's syndrome Cause Adenoena Bilateral hyperplasiaPNDCAC RIT Dexamethasone suppression best Dexamethasone is a potent synthetic glucocorticoid, which normally causes adrenal suppression. Hecause cof the low dosage used, it does not significantly inter- fere with steroid measurements in the blood or urine and is therefore used to help establish the cause of Cushing's syndrome. In the context of Conn's syndrome, one expects to visualize both adrenals but, Fig. 287 Fig. 2.08 if dexamethasone is given, an autonomously function: ‘ing adenoma will still be visualized but there will be suppression of the normal contralateral gland, When bilateral hyperplasia is present, both glands will still be visualized with low doses of dexamethasone, although there may be suppression when higher doses are used. View of allem 5 faye dfler injection of “Se sclenochalesteral frelile reccteineg dereminthasone. Jia thes case of Conte's symdrome thene és iablatennd Ieftesisled uptake trno the tremor, There ts tere poor tracer iptoke tints Hee normal righ . berause of deametiasone suppression, (Cowrtesy ef Ov K Heitor, Lomularr, LIK) adrenal lanl, Vise of attorneys afler injectume of ecomacibosnre The sanmreer cnieae of Curt’ ‘ssundrume isa brnfgot adrenal adenoma, Heavier, falotenomcsen mary he star ti bilateral Heyperpsesia. di tiie vies, ‘iluterafanfrenal uptake of racer is secm during 2 diexamefarsone suppression dest. Coovtiohtedt maeFSDOCw Investigation of phaeachromocytoma While phacochromocytomas are usually intra-adrenal occur anywhere trom the base of the skull te the (30%), and unilateral (90'%), itis nevertheless important bladder Ten per cent of tumours are malignant, and to detect those at extramedullary sites, which may novetaslases may take op “!l sim, Preopenniine i Aunterion, 1 mantlea ¢ Anterior. [A mantis f Posterior, 18 eeanithe Fig, 2.89 fof amc: scare irr a #T-year-oll ume wifi syeeyrtons of pharochrumacytorr anid adsed arfnry wat leeds There ic intense trecer uptake (he) the region of tie right adrenal glam Lt sorgery, a large tase toes remand evich due ireoeded the kidney. aA fiullowe-nyr stivaty wes Performed at TH stontties (lf) at wich nu alacrread i plake jes seen amd phe vt teva ais favre 164haeochr size, the a7 ytrormi miccytENIMOHCIRIME 2.4.3 Clinical indications for parathyroid scanning Parathyroid adenoma =F * an © The majority of parathyroid adenomas are assaciated with tlhe lower aspect of the thyroid lobes, * The majority of parathyroid adenomas will be apparent from subjective evaluation of the ="T) and *"TcQ, images. * Combined parathyroid adenoma. CO, imaging has approximately 70's sensitivity for a 165Pc tee Multiple parathyroid adenomas . The majority af para- thyroid carcinomas are functional, but non-functioning tumours may occasionally be found.ESDOCHINE In the more typical cases of secondary hyperparathyroidism approwirnatecly of hyperplastic glands will pot be visualized The case iustrated in Fig, 2.95 ie unusual, and scanning seldom reveals such striking changes.ENDCMC HIN Problems in parathyroid localization The main difficulty associated with parathyroid problem. The following cases lustrate some of these imaging occurs when there is an associated thyroid difficulties, Thyroid nodule b To, Fig. 2.96 fay =T1 image, dip Te, image. fe) Subtraction dmage: This study alin an mutouomones monte int tee right lobe of the dheoid with False positive parathyroid scans may he obtained saepression uf the bef lobe sere ar tine “Te sce fh) The sathtrction scan fc) shines tw : : : areas of" T] uplake- ome at the dmoer poe of the right [ob at the site of the paratiryri ____ When the thyroid contains adencima, ond one dn tine region af the suppreesed left hurd habe. a notrfunctioning or Aulonoercusly functioning nvdate. Multinodular goitre amr & Te, ¢=Tl-™TrO, KE Fig, 297 Extreme caution rus! be exercised when inler- fa) 2°77 via, AB) Ted, tena, Gch Seabtrenctic rt Tre Ted, sean shows a tmultinodinler gland weilie ne rereieed eveayyermienel wf tf Seg! Tobe of the tfeyreiif thar ble There is same mismatching betwen Tl amd Tet, 2 witha linge aren af TT wpetiske irr Ae Lower poste af the left fake fe) un matched Dy svar = TC, srptale. The acting Froufiigs ave dine fo ot bnege meudlvitonfular godbre. An atest study in the presence af thyraid mould lure tn he massice toaccewrit for these charges, aml tls is exhnemelyyserdébely. disease. When extensive multi- Fiodular change jrreseiat, Ube shutly may be uninterpretable, as dlustrated by the cases in Fig. 2.97, TinaCHAPTER RENAL Renal imaging with technetium-%m (*Te) labelled isotopes is widely performed and provides both anatomical and functional information relating to the urinary tract. However, the great strength of these studies, as is 50 often the case in nuclear medicine, is the functional data that is generated, since anatomical definition cannot approach the fine detail obtained with radiographic and ultrasonic investigations. In general, two types of investigation are commonly performed: static and dynamic imaging. Static imaging Renal images are usually obtained some 3 hours followe ing intravenous injection of “Te dimercaplosweccinic acid (osa). oMe4 is taken up by the proximal tubules and fixed there. Since rapid loss of tracer does not occur, several views of the kidneys can be obtained. This is of particular relevance in paediatrics, where it may be important to identify sites of cortical scarring (eg in children with recurrent urinary tract infection oF reflux), which, on occasion, are best seen on the oblique views. The static renal images obtained provide good definition of the cortical outline and, in addition, show the relative distribution of functional tisswe. The ratio of tracer uptake between kidneys provides a measure of divided renal function. By selecting regions of inter est within an individual kidney, if is also possible bo measure the relative function at these sites; this may be of particular relevance when a duplex system is present. Dynamic imaging Dynamic imaging is performed most often with "Te dicthyleneinamine pentaacetic acid (ptr), which bs a true chelate and is excreted by the kidney purely by glomerular filtration. In contrast to Osea, the tracer is rapidly excreted, and thus rapid sequential renal imaging must be performed. The images that are obtained provide information relating to renal vascular- ity, renal function and excretion. Following an intra- venous bolus of "Te pina, an image is obtained far the first 30 seconds which provides a ‘vascular image’, with the majer blosd vessels and perfusion to both kidneys, liver and spleen being visualized. The amount of activ- ity at each site reflects the relative vascularity. Renal function is assessed at 2 minutes after injection, when there is good renal visualization and an image will show the relative distribution of function between the Kidneys. Thereafter, cortical activity rapidly diminishes as the tracer is excreted by glomerular filtration. Hy 5 funubes, activity is normally seen in the collecting systems, and serial images are obtained up to 3) minutes which show progressive excretion of tracer. If there is. any suggestion of obstruction, it is important to mobilize the patient and obtain a subsequent image to ensure that there is no functional hold-up caused by patient position ing. If the question of obstruction has not been resolved, the study will need to be extended and further images obtained following diuretic administration. "Te aca is now becoming widely used as an alternative dynamic nenal imaging agent. The extraction efficiency of Maca is 25 times that of oTPa, leading to better image quality with a lower absorbed radiation dose. CHAPTER CONTENTS Anatomy! Physiolagy Radiophanmaceuticals Normal scans with variants amd artefacts 3 42 33 3.2.1 Normal static Te axes images 3.32 Quantitation of ovsa study 333° Normal srect pasa scans 334 0 Normal tessa variants 3.35 Normal dynamic Te oir images 3.34 Narmal p1ra quantitation 337 0 Normal "Te vcs study 338 0 Normal ors variants 34° Clinical applications a41 Renal function Obstruction Reflux nephropathy Trauma Renal failure Space-occupying beséons Congenital and ectopic abnormalities Vascular disorders and hypertension Renal transplant 16a= Os * Approximately 60° af injected owsa is taken up by the kidneys, but it should be ri bered that 10-13% is excreted. 1 the bladder is nat emptied before imaging and is included in the field of view, it will be clearly vicualived. However, on occasion, when the kidney is damaged, there may be visa with bladder visualization, mnction deruld ie calowlated from anterior and posterior increased excretion of * Percentage of divided images wirag f eometric meanDe ee aE PR iL az ay 3.3.3 Normal spect pMsA scans Fig. 26 foaby oeee ee eae Lm dsm) 3.3.4 Normal pmsa variants Duplex kidneys -% -_ Fig. 18 fie)De ioe ay Crossed renal ectapia Case 1 Fig, 210 ; fa BC Case 2 ’ & dENA De a ee ah) Complete failure af ascent (pancake kidney) When there is no ascent from the orginal sacral position, the two kidneys are fused in the midline of the pelvis. scant, Pancake kidney. at Anterior & Poster Pelvic kidney More frequently, one kidney only fails to ascend nermally, This ts offen associated with decreased function and obstruction, oe, br) cova scar, The righ dddrneny bo sscortmnal, The Aff Risfeacyr be feyLirgy die fie | pels | @ Antener fh Posterue i?EAL end hi ARTEFACTS 3.3.6 Normal oTPs quantitation a. ee = 7 Fig. Lid “yr Hi Lert Lasix washout ba howl sidfrsrw Li delegate LR as tt a 3.3.7 Normal "Te macs study Fig. 3.17 a € ot TH it le .RENAL ee aad bd 3.3.8 Normal prea variants Extrarenal pelvis Renal nephroptosis Positioning of a patient can affect the position of the kidney, a5 ilhestrated in Fig. 3.09, ) Downward displacement of the kidney (nephroptosis cause ignificant errors af quantil lients should be imaged in the supine ae vredece this source of error. position 181ta Delayed emptying of renal pelvis Fin, wip] Fig 220 4 a Coy) AL normal cari af a dynamic nema scare, shonineg se cca lation cf hee pats Ridaciy weittif the pela . sia L 1 | JL } wD etnites bo) minntes e Increased urine flow rate Ties, Tae er Fig. 3.21 ie € % ie | tarde) Repeat sty (af tee sane x! | patient as ar Fig, 3.2) anille | fmcreasal iffeineses. fc) ThA cone, shat shunting ritpsid cometimevenes cleveunnce maul erigtyitig of Hacer ae te al minwirs The case in Figure 3.21 illustrates the marked differences that cam occur simply as the result of physiological alterations, in this instance differences in urine flow, fa > ] Fig. 222 e ‘ fame} Grosset ectopnad, dria : @) study, A30-yeur who ines referred with right rae Joie praire cau Aut a previotesly iz ' diagnosed absent lef kidney, scan, na. eu shoes: the ppemnances af crammed it fet ureters ue hide fut crossing fo the of the renal mass (Croseecd hasedt heft kidney i wo 1-2 nutes 10 exinutes c 20 rimules taeRENAL The clinical applications of renal imaging are listed below, and examples of the various clinical problems are given on subsequent pages. 34.1. Renal function Renal function in urinary tract infection Renal tubular dysfunction Renal function with calculi Assesment of function after percutaneous renal sone removal 4.4.2 Obstruction Indications por radionuchide scans Appearance of obsiraction: DMSA scar Appearance of obstruction: DTPA sean. Assessment of obstruction Renal scan with diuretic washout sa scans if obstruction Difificultics in aserssing obstruction 34.3 Reflux nephropathy Role of radionuclide studies in reflux nephropathy Achvanttages of radionuclude studies over micturating eysography Demonstration of cortical scarring Renal scarring va and (TFs scans Demonstration of reflux 4440 Trauma Bullet injuries be the kidney Shrapnel injuries causing urinary beaks Assessment of kidneys following abdominal trauma Vascular study to assess trauma 24.5 Renal re Indications for renal scanning in acute renal Eailure Diagnosis of pre-renal failure Diagnosis of at Monitoring changes in the anuric patient Diagnosis of complications Assessmentaf probable prognosis Space-occupying lesions Inetications for radionuclide scans Causes of space-occupying lesions Pscudotumour Tumour Renal cyst Renal calcuhs Congenital and ectopic abnormalities Congenieal abnormalities Reduplication Cystic disease Abnormalities of fusion Abnormalities of ascrrt Vascular disorders and hypertension Indications fur asesaent of renal blood supply with radionuclictes Indications for investigation of hypertension with radionuclides. Renal artery stenogis (Ras) Renal infarct Preoperative assessment of aortic aneurysm Follow-up after surgery or angioplasty Fanctional assessment of angioplasty Postoperative assessirerit Renal transplant Renal transplant complications Normal renal transplant Acute rejection Chronic sepction Two cases of cortical scarring in renal transplants demonstrated on pate. scans Transplant «Tm Vascular complications Urinary complications Biopsy complications 187ae CLINICAL APPLICATION there is a grossly enlarged ¢ system occurs, For example, in estimated, © conical outline accu Accurate measurement of residual renal function may be difficult unction must be measured before filling ed at 20 minutes, it woulld bh collecting system prese function was me asl the case in Fi However, on the functi to select appropriate si tely and alse ry= > J fe i mires ac TE erimates, petdfiurrtic if Poat-poatrer churnge He de, ving fe Me left, which 3 aot obstructed vol ater Bere maslonfing amd was only performed P dtp porcturny reat e¢ tie pechior! fan’ been estate, amd Hand he anil ivoke up with change in posture * Functional studies in such cases provide the necessary confirma surgical treatment, and alo provide a baseline functional measurement for subsequent follow-up to assess the future growth of the kidney and the effect of surgical intervention. * When there is markedly decreased renal function, an impaired diuretic response may be obtained; thus false positives for obstruction can occur in the presence of dilatation. A doubling of the dow of diuretic is therefore eecommencled in this situation 7INA tata DMSA scans in obstruction 93Difficulties in assessing obstruction Fabe positive diagnosis of obstruction may occur: * When the patient is dehydrated * Hoollecting systems are grossly dilated, as washout is partially volume-dependent In neonates, because the Gre and hence the diuretic response to frusemide ks less * In the elderly, since the Grex may be decreased * With chronic renal failore 18) pramastes «study in ob lateal, possibly ofstrarted, netic fal} skoees poor C (study conjirens the eral obstriiction. is bess, compared! with older children, therefore ialve positives may oceur; this must be taken into accounl when investigating newborn infants. A-study showing lack of obstruction is of mone significance than one such as this, showing possible obstruction “Tt the diuretic is not given intravenously, ie is extravasated at the injection site * Too 5008 after operation for Ful obstruction * In the presence of gross reflux, False negative diagmosis rarely occurs, bul may dio sa: + Lf the obstruction és in the lower tract and measure mens are taken from the upper tract + The obstruction is intermittent, : LU oa TT] ie is) Be news nogStoeafyy 3 tgeh [re ® Obstruction may t Tuithenst, * A prominent photon-deficient area is frequently seen on infant studies and is due tomilk in the stomach after a recent feed, given to assist sedation 9HELA baat ae eu obstruction; postoperative follow-up Preoperative study Postoperative slivty After anhuistion rihiel tied reas prrrfurrencel fu costes Mist HME Right inaty with right-sided Aydrumephensés cure: fal) efinot on if Neca | right cullecting $5 Mar | furhoplesty, A es see ‘ pend function, Fierthermere, Merit systern, and die initial TA. a 2omin are wale eis annie nrpidiy witht gritty ah | © TA Gurr—_————— EEDAL Da The importance of diwetic in evcluding obstruction Preapenatio: study Tae TEST = LET cd] i pei si 3u ths a ex Fig. 247 Ae pedi diagrasts Following a pyeloplasty operation, a ces study may appear lo show persistent obstruction. Follow dic and delayed washout will he observed if the operation wats imaging, aotat i110 secorni’s b 1 eteuir © 5 mteutes cine pal Mies mreteric obstrection in @ 63-year-old mean teitir an ied following cystectory for corer of the Binder, Bilateral wreteric diletation uve no ont altrascnndd, teh A bred sts muininetes Calf the wnreters ds adgraifican! activity reataiming ira tae Heiratistration: Cf), there os mesh frassess (he presence of an obstrmction. ATM firmainiy sama oe MP raleuies dee) Pheer sveeis amd ureters; Fulfinetag déuretic nlc itty d8 sere ate tie small heel3.4.3. Reflux nephropathy Role of radionuclide studies in reflux nephropathy + Determination of presence or absence of renal scars * Measurement of individual kidney function + Identification of presence or absence of reflux. Table 3.2 Groves of vesicourcteric neftwr Grade MCUG Radionuclide staities 1 Reflux into the ureter oeily Dinect* method will detect Indirect* method may not u Reflux into ureter and upper collecting system with no eas oth radionuclide methods will on . : detect all grades but will mot As TL with progressive deyres y pir teria deen ac reliably sistirgcuish them Lntvazenal Recihax into the collecting tubules ‘Direct, instillation of tracer directly ints bladder “bridirect, utilizes the tracer excreted inte the bladder following « noutine Ors scan Advantages of radionuclide studies over micturaling cystography * Lower radiation doses * No catheterization * Simultaneous assessment of renal function. 203Cama Demanstration of cortical scarring Fig. Rag Fig. 2.50 harmaceutical af choice to shewmie! il contraction ft scars may bea* ofa well nol demonstrate scars as well as A * Calyceal dilatation without abstruction isa feature of previous reflus. Some features of reflux, including scarring dilatation of calyoes and visualization of the ureter, may be residual effects of previous reilux, and do mot indicate thal reilas is still Occurring. 207kina Demonstration of reflux Renal scars and pelvicalyceal dilatation show that reflux has occurred in the past. Other methods ane required to show that reflux is continuing. Reflux may be demonstrated as the bladder is filling (filling phase reflux} or during micturition (emptying phase reflux), The gold standard is the micturating cysteqram, but radionuclide methods are valuable adjuncts, especially for follow-up: Trhle 33 Comparison of direct and indirect radionmeliae imethouds Methed Advantages Direct Allage groups Low radiation dow Detoces grace 1 roth Indirect No catheterizathon Provides individual renal function information Filling phase reflux Exoretory phase of a dynamic study with ota or wacd Vestconretertc refine 15 meets bh 208 Disadvantages Requires catheterization ply ssitable over’ pears of age Only detects grades [I-IV rethux Fig. 261 Thee CTA acted fuk) sibistes dilatatioe of beth collecting systems. The TA curve (Db) denmorshrnies the ifernifient spikes camsed by srine refluring into the collecting systems* Reflus i about ¢ relay. In the particular case shown in Fig. 3.62 there evidence of reflux occurring while the bladder is full before urition commences. not always asso Pa Study may provide indema starring or damage of the kidneyPsA Emptying phase relax Emptying phase reflux can be performed in ane of two ways: the indirect method or the dinsct method. In the indirect method intravenously injected radionuclide is allowed to accumulate in the bladder, whereas in the direct method the radionuclide is instilled directly into the bladder, Indirect micturating reflux studies are difficult to pertorm, and are subject to errors, The following points should be noted: * The collecting systems must be allowed to drain as much as possible before commencing the investigation * There should be no patient movement, since false positives may occur * The presence of reflux should be confirmed on the images Bladder Ro | q 2 5 Right kidney ici 5 ei Leit kidney ai q = 5 i | & Wanker refilling, | Baseline Bsider drptying Time Demonstration of vesicoureteric reflux during michirition * After significant reflux, the bladder will refill as the kidney empties It is important to obtain a stable baseline for a few minutes before micturition In order to detect minor reflux, regions of interest (rod) should be drawn around the collecting system and net the whole kidney * T/A curves generated from renal eo0 should be displayed without the bladder to detect minor reflux. Bladder and renal T/A curves Bladder and renal T/A curves will increase the accuracy of detecting reflux. A typical reflux T)A curve is shown in Fig. 3.63. Fig. 63 Typical refiuy TA carve eff kidmey (RO! = reg th weceremal rag rs af interest}. dniey am refieaxing =, 7 — = t | LA fine ed jurrfusdi af f 10 weimutes fe), 2D mimetes tl) arid post prrenchyenal transit evAL Chronic renal impairment: nea Fig, 190 and ischavenic wart disease reve drorloped acute om chromic neva faire: The dyrearmric sire far) shri Adlateral poorty pertiesed kidneys Tike 2-eutreurte inne (Dy) shows neny poor selective sccremeletion coutrihuting 57% fo the total Gem, Cry the Bihan irute irenge fch dere és ery sieve trressit oof ———————————— sunll amnown of tracer. Eom * ota scans will only rarely contribute 10 Whe errma acat cous the management of palients with contracted won-specific appatrmnces of kidneys who are in chronic renal failure. pena alriiooh site in the bitneys, * AptrA study cannot exclude the presence of ‘generalized docrinse i obstruction in such cases. perfusion and fraction ait relatively sea traresil of tracer, Chronic renal impairment: aicd Fig. 97 A Mpyeneald nom ait a fomg history uf diabetes, Aypertersion avd gradually Fiaieg crea vnitie. The acl steuly face cunefipms symmetrical puor phite and profimged franict bi Ailaterally seal treineys. bf sinnye atic is the agent of choice in patients with renal failure, since the better renal extraction improves visualization.Wax Renal cyst Spleen’ Renal cyst ss The early 30 Aces second images . od the tis stan can be gsed to assess renal periusion of a lesion. Renal calculus 229cat ai Cystic disease Polycystic ki Salitary evs! Fig. L100 fae) nt Medullary sponge kidney Fig. 3.00Abnormalities of fusion Horseshoe kidney Fusion occurs between the lower poles. The conmect- ings be may function normally of act as a fibrous bridge. Tie axes of the kidney will incline towards Horseshoe didney midline, Obstruction, stone, and infection are common Complications, Fig: Snir fa, bye me id PryAbnormalities of ascent Pelvic Kicleey italy Oe Pancake kicine Fig. 4.005 Qe * lian ectopic kidney is sinpected, or only one kidney is seen on the posterior view, always obtain anterior views ‘ | which include the pelvis. | © Be sure that the 2 | ‘bladder’ is nota pelvic kite, * li necessary, re-image after micturition, (Cross-fused renal acta Fig. Laat fa, bead ovinute Fig. 3.107 A pelvic kidney may be confused with bladder activity ina neonale. under sith diveretic shiner poor ale3.4.8 Vascular disorders and hypertension Indications for assessment of renal blood Indications for investigation of hypertension supply with radionuclides with radionuclides + When diminished renal blood supply issuspected: + Patient under 40 years with seven: hypertension ja) Hypertension, due to renal artery stenosis * TVU stigyests features of renal artery sbenasis (b) Renal infarction * Renal bruit ti) Whole kidney * Hypertension associated with koown arterial (ii) Focal, eg embolus disease, eg Takayasu's disease * Pre and post-intervention follow-up: * Hypertension poorly controlled with antihyperten- (a) Before sungery for aortic ancuryam sives {b) Before surgery for renal artery stenosis * Deteriorating renal function. tc) Before angioplasty. Renal artery slenasis (RAs) Choice of racdiopharmaceutical + Sete onsa is rapid, reliable and cheap as a screen- + “Thippuran measures renal plasma flow. ma5 causes ing test. Significant RAS results in lower O64 uptake. decreased uptake and delayed intrarenal transit time. A difference of greater than 23% should be investigated + "Te macs is now a cheaper and more available further, alternative to = hippuran, 7 hippunii gray eco ire a pumtieut rofnr preateted with iypertension. fof) THA, carey, The stindy siines the defied accurmulation of 98 fieprenan dea moral steed Left kidney tuptnal of has, af minute brett mite £10 mieates 233@ U-30) socom f Fig. 2007 acd oF hippuran, because of their closer dependence on renal plasma flow, are more sensitive than otrs dor detecting impaired renal bleed flow, Quantitation of uplake, retention and transit times will add iniormation to the visual inspection of images. 236¢ da Fy ri?© eee ie wery sensitive for sepmental eas (64 and hippuran te He the: best suspie nal hyperte * bats and hippuran scans can be pe @luation of her may pre pred on the sare hospital visit, 28Bilateral ras | Presaagnogniin fac) i er Renal artery nd er fo pri * Radionuclide investigations depend ats asymmetry, and therefore symmetrical was may be missed, but prolonged transit times may be measurable i Fig. 3.116. nasa He) | * When was bs eri ‘contrast agents for x-ray procedures may cause renal failure. 234Renal infaret Fig. 1008 Fig. 2009 240)ata Functional assessment of angioplasty Features of ras affected! fy angiaplasty * Decreased renal blond flow * Decreased Ger * Delayed excretion * Prolonged mean parenchymal transit time, Presangroplasty ) Fig. 2725 a (RO se Post-angiolasti JadFig, 3.126 Renal artery scams, (amal) lar phase: fry (FY prot ef pcrsed AEnS Functional follow-ups with < rl lracers is the = e ss co | optimal method for bivestigating the effect of angiopl: je the effect of the stenoses is mare important than the _| appearance.Postoperative assessment Preoperative Fig. 12273.4.9 Renal transplant Renal transplant complications * Rejection: (bp Renal artery stenosis (a) Hyperacute (irreversible) fe) Renal venothrombosis (b} Acute (reversible) (d) Renal infarct (ce) Chronic * Urinary complications: * AIN (a) Leaks * Drugs — fosporin ib) Lymphococle * Vascular complications: (ce) Obstruction fa) Renal artery occlusion * Biopsy eomplicati Normal renal transplant @ UM weonds Fig, A128 Diprernic (0 246HENAL Quantitation Quantitative information can be obtained from a dynamic (1) Flow renal scan in trateplant patients, which may be of consid- i erable value in the sevial assessment of these pathents. The Rinna! ‘oon /ebial two main parameters which are measured are (1) flow (2) Uptake = nee cbeneat =~ 100 index which is derived from the first M0 seconds of the Eee nia study and reflects renal blood flow; and (2) uptake index Ee which is derived from the image at 1-2 minutes and reflects parenchymal function, _ _lliac area to peak ¥ 100 index Renal area to peak Fig, 3.124 Qnarahifation in a nenal tramspfaret pratient - Kidney Artery ww inden BTA + 44 Soeur Uptake = 589 ————— ‘Ml ensinwut anTTnY oe EUPAEY | pone ik 3 at O-30 seconds 5 msitites © Fig. 210 Chandida tion init poorly perfised, poorty jinochioniag (romsplant. da, be} Cyranmic bre score. fied Trampiunt renege carve with flew index amd mptiie index Tihs d2-serrofid woman doc at rel bteaspsloat perfearmedd wwbick frenetic soll david, Taw inerks after trotsplant the uriire outpet fell. The scan chowns @ poorly perfised, peaeriy flencticufny ceva at tnighs lem? inher ineficatienye pcr perfusion aed a donut aruba 247maHA F Fig. Lite Reecalrig B kidney ts, Marrenwy uptake in pelvisArav f aoidlr at efernnic He shonass Hee fe irmiceges. lnestrafes nell Nhe at i-sided renal transplant, togeti Tred series yf ciel features yf ATwamd chromic 4 Fig. 3039 Rema scarring in ehmomie rejeetivtt. DTPA inmity after fee grape and (lt) seve pole sear. 2 Progressive renal scarring is frequently seen in a chronic deteriorating transplant.RENAL Two cases of cortical scarring in renal transplants demonstrated an OMsa seans € ¢€ Fig. R00 Fig. 4047 * ATs is a Common finding postoperatively with non-related donor kidneys. The value of the ores scan is in monitoring the blood flow until fonction retumns, which may take several weeks,Vascular complications Acute vascular occlusion a Mbecowl br 10 seeeents Avascular grail may be due to: rombasis © End slape rejection * Hyperacute rejection * Venous occhiusinn, These are indistinguishable on the »[artery aneunsm ransplnt arse Fig. F145a MEMAL Urinary complications | Ureteric leaks * A functioning transplant is mecessary to detect a leak ee e+ ® Delayed views and views after micturition may be necessary F toe detect the beak. * Leaks are usu y, but net always, painiul.RENAL i Although 2 pelvic ureteric dilatation is seen in association with obstruction, the commonest case of a dilated collecting system is vesicourcterit reflux Fig. 3,953 stn é Failure of Obstrn J recowery af function from ats should be investigated with ultrasound fo exclude obstruction, foc) | decretaeal pes repay. a ster 257CHAPTER 4 TUMOUR Nuchear medicine has a significant rele to play in the management of ancology patients, contributing to both diagnosis and follow-up. In addition to diagnostic imaging, nuclear medicine techniques are also ted in the treatment of malignancy. Nuclear medicine investigations may be non-specilic. Non-specific investigations are investigations that demonstrate tumour sites (usually secondary sites) but are omet specific for malignancy. Non-specific techniques include technetium-99m (Te) liver/spleen colloid imaging for liver metastases, “Te diphospho- mate bone imaging for bone metastases, and thyroid imaging with “Tc pertechnetate ("TeO,) and “Tei dimercaptosuccinic acid (""Tolv) OMSa) for primary medullary thyroid carcinomas. Thallium-201 "Tl is also a radiopharmaceutical that, in addition bo its established use in myocardial imaging, may be used ta image tumours, Gallium-67 (Ga) citrate may be used fo image a vartety of tumours as well as sites of infec- tion and inflammation. Lastly, "Te nanocolloid may be used to visualize tumour deposits within bene marrow and “Te diethylenetriamine pentaacetic acid {otesl, the dynamic renal imaging agent, has also been used to image neurofibromas. Tumour imaging may also be undertaken with radioe pharmaceuticals that are specific for turnmeurs, such as iodine 173/130 netv-iodobenzylguanidine ("| MinG), whieh is specific for neuroendocrine tumours. fodine-131 (DT) is specific for follicular thyroid carci- nomas, and indium) ("In octreotide is specific for fimeurs expressing somabostatin, receptors. Tumour-associated menoclonal antibodies labelled with “In, “1/1 or Te have also been developed for tumeur imaging. While many of these are still under evaluation, a few are now commercially available. Tumour imaging studies contribute to the diagnosis, staging and follow-up of newplastic disease. If signifix cant tumour uptake is seen on the diagmestic shady, some ridiopharmaceuticals such as! and Mies may be used in therapeutic doses to treat the malignancy, CHAPTER CONTENTS 4.1 Radiopharmaceuticals 4.2 Normal seans with variants and artefacts 4.2.10 "Te liver/spleen colloid 4220 "Te diphosphonate 423 “TeO, 424 "Ga 425 *Ti 4.246 "Tolv) ova 427 ellancous non-specific techniques 428 Ltn 4.29 In octreotide 42.10) Monoclonal antibodies 43 Clinical applications 431 Te liver spleen colloid 43.2 “Te diphosphonate 4330 TO, 434 “Te nanocolloid 435 “Te tra 43.6 7 4a7 434 459 43.10 4 43.11 Momochonal antibodies 4312 Therapy= = -_;:-EE eee TUMOUR RADIOPHAR fable dT Radiophornacenticals for tumour imaging Radiopharmaceutical Now specific Te liver/ spleen celkaid Te sliphosphonate ele runacoilaid mele DTPA La | 280] acs in octreaticle Hine monoclonal antibodies Tumour demonstrated: Liver murtastarsis Primary bone tumours Done metastases Thyreid fimours Medullary thyroid carcinoma Medullary thyroid carcinema Ls Hepatoma Bronchial carcisvernsa Bone marrow burke deposits Neunnibromata Follicular thyroid carcinamms Neuroendocrine 6G ‘Sonal istabin-receptir reogghor-posi tive tumours: ‘Specific antigen-positive tumours Tale 4.2 Mecharisers of treerour localization for Hortowrspecific agents ‘Site af localization Intracellular Tumour cell membrane Surrounding newmal tissue Mechanism Metabolic.eg Receptor binding, ‘1 ponoelonal antibodies Uptake into nermal tise adjacent 10 turaur si, ey livery colloid uptake in normal Kuplter’s cells adjacent te liver metastasesSS TUMOUR 4.241 “=Tc liver/spleen colloid “Te collokd has a role in liver/spleen imaging by nature of its uptake in reticuloendothelial cells within these ongans. Replacement of liver tissue by tumour cells can be visualized as photon-deficient areas, @ Anterur bm Posterior © Right lateral ft Left Literal Fig. 4.0 toed) Normal fhe Kuupyter's + fiber aad the reticuivendobhelial ceils of the splecr. Ureifirrme uptake ts cells normal. Multiple repaired, leeever, the absence af pintoundefacient fesions dv aff ames of the liver and spleen, sare 261PUM De ae ate, | ak 4.2.2. ™=Tc diphosphonate 42.3 “"TcO, Te diphosphonate is taken up by the osteoblasts that are normally active throughout the skeleton. In the normal skeleton there is unifonm, symmetrical distel- bution of tracer, Fig. 4.2 ral whoke-fedy Lone sein, demouistraif ing wndform, trical sistritsution of tracer, “ToO, is tapped by thyroid follicular cells that are uniformly distributed throughout the gland in the normal thyroid, Fig. 43 a -TeO), soar, demimstrating the typical! appear third glarniTUM CALS 4.2.4 Ga Table 4.3 Nerenal distribution of * Always Variable Bone marrow © Spleen Liver Salivary glands Gut Lacrimal glands Nawal sinuses Sweat Kidneys (first 24 hours only) Breast flactation or pralactin-neleasing drugs} Hew waut {int ener cTanicully Helle enlon Sacro joints MITUAW Variants Breast uptake of “Ga Aunterar Fig? Anterior sia of thorar amd abvformen, Ga apteke is seer int both bresta The comemonest cairse off Brevis! captinke 3 afruy ademdtrdstration, wstualiy wn anliennetic, cobdelt camses yrolactin release. Fig. 4.8 A 23eucnr ofd inomunr witht marked "Ga accumulation in fer feasts, Tar patieat os swicequentiy discoceredt ta have a profactin secreting pitinitery ademomar causing galactorrhea, In *"Ga studies: * Faint salivary gland uptake may be normal * Slight avillary uptake may be caused hy “Ga being excreted in sweat, 265ee: PUM ee La ca Lenn En 4.2.5 ="TI =T] not only has a normal distribution in’ the myocardiom, but also in the liver, lungs, thyroid and skeletal muscle. The normal pattern of uptake must be understood if tumour imaging is to be undertaken, @ Amtevior Wr Posterior Fig. 4.9 (a, bb Wholesbty uorrretdt! altstrdbundacore,TAMIL ee 4.2.6 ™"Telv) DMsA “—Teiv) GvGA has lithe: mowspecific uptake. Uptake is faintly visualized in the axial skeleton, kidneys and bladder. At the usual imaging time of 2 hours, sigmifi- cant blood pool activity is identified in the region of the heart and great vessels, liver and testes. Breast visual- igathon may be a normal feature in wonwen and appears univelated to the menstrual cycle or pregnancy, Uptake in the region of the pituitary i noted in seme patients. aw Aateriar © Anteriar Fig. 4.10 Norman! nelle buch Tet) nats scare ia @ females (ib aroterior sien of frend ant neck: dB) alerior ciety of chest amd aldeuew; tc} amterior cleto of peleds: tlk posterior pivav of thorax: (e) posterior pew aif pellets. if Posterior ¢ Pislerine 4.2.7 Miscellaneous non-specific techniques “Te nanocolloid Te nanocolloid is token up inte the reticuloendothe- fal cells of the body, with significant bone marrow uplake. [In childhood the active marrow occupies much of the skeleton, but in adults the active marrow is normally located in the axial skeleton and proximal long bones only, The distribution is symmetrical, wn Tc DTPA Te orm is generally used asa dynamic renal imaging agent, [tis rapidly cleared from the blessdatream by the Kidneys and is excreted inks the bladder. There is litthe non-specific uptake,TIAL eee ie 4.2.8 V1] Mig Normal distribution Mite labelled with “Tor Eis taken up into tissues Normal tissues visualized include salivary glands, | containing chromoffin tissue and tissues with a rich myocardium, liver and adrenal glands. minc is excreted sympathetic and parasympathetic nerve supply. via the kidneys into the bladder, Liver Myocandise ‘tah = @ Anterior B Posterior c Anterior Fig. dd Series of 24-hour inmages with © arse: (ad aetfertor view of cheat; db) posterior here of chest; fc} amterior viece of abdounen; Gi) posterior evew af afdomen and peizis: teb anterior virar of pelpis aud upper femura, al Posterior @ Amlerioe 26druc PPL Staging of malignancy Management decisions in patients with newly diagnosed malignancy ane influenced by the presence of distant metastases at the time of presentation. The accurate staging of the disease is therefore essential to plin treatment and also to determing prognosis oe RightTUM Follow-up Te liver/spleen colloid imaging enables an estimate of the number, sive and distribution of metastases to be assessed. By inspection of serial studics, progression or regression of metastases can be readily assessed, Progression of disease Initial stird'y wae & Postevine © Left ineral dt Reght fa nous later Literal & Auteriar f Pesteror & Loft lateral HH GE roy carck af fle brverst age stiri ft hare anvelripte leper me fershitses 1 Te finerJspfeer colfodd imaging fad. Fowr movaties later she becmur cornell aad repent imanging teu) demonstrated progression, apilf nephicement af liner Hienioier, Linas uptake of cullonal ues visualized: Hele és a nne-sperific finding associated veillr preyournd eheluTlty.Regression af disease Fig. 20 ta, pT4.3.2 "Tc diphosphonate Diagnosis of metastases ‘One of the main indications for bone imaging using ‘“~Te diphosphonate is the diagnosis of metastases, The whole-body nature of a bone scan permits the extent of metastatic involvement to be assessed. Since the bone scan becomes positive ata metastatic site many months betore an aboormality can be detected on an xray, "Tc diphosphonate bone imaging is the investigation of choice fer patients with known malig nancy and clinically suspected bore metastases. Table 4.7 Tumours that commanty metastasize to the skeleton igftf Bone metastases in carcinoma of the bronchus @ Anterior b Auteriwe fe Anterive Fig. £20 ASO eier—old cevernoret role roses ot Avaarir Maeseary seriemiry 08 fla at canredincern caf thet dbnioaneteais denelopvad a patie int fle haf shrowlider, The bovar scam (a2) shanvs eptabe i the feveowd, right Ivins, fof shoulder aed left 4th rib at sles of metastatic sprond,—_—=—_{£_£_{_$_$_$_;_;_;_;_;___——————— TLMEILIR @ Aintener multiple arven pss Area cer CINMmactistasrs, Tie prtivat depelopeal anaemia ared « fanee sown Cnc) demorsstrited diffusely dnereasead tepthake Afrevsreglieut tite voxel? Slcehetont Laafimalniers wat Phe erat sib drovers bread carrer cared Ire | @ Posterior bh Posterior © Posterior petdirat bars feat in Bone metastases it carcinoma of the thyroicl rmaree evel at far: Ain Sif-yenr- peualsatite smass fhe sdetrrmar Tike howe scare (ia, Fe) eos Matic fs airy areal sacrum, with increwind uptake ant rghit faclnune, cual th tiyroid carcinomnr cms Bane neeladases from thyroid carcinoma are occasionally lytic, b Posterior aTUM Staging Management decisions, such as whether to embark on radical surgery following the initial diagnosis, an significantly influenced by an accurate assesament of the extent of disease at presentation. The "Tc diphos- phonate bone scan provides an extremely sensitive technique for identifying the presence of metastases. oe a Amicrir fe Posterior 280 Fig. 4.26 A S3-pearsald town with mewhy iMiegnused breast comere neuf palpainte aurillany eindies. The cetrafestretyy cane faa, Eek staonies iapehiniie fur dle nuorraabiriusee sherri an leg superioe acclubrelina, The door freudénys anne hose of niptustieses of brews! carcineme, couferiniiig sling 4 alisanar.-—_—__ —eum— TLIMELER Follow-up Since the bone scan can accurately define the presence and extent ef bone metastases, it can be used to monitor the patient throughout the course of the disease. erioration can be detected either by an imerease in uptake at the site of a known lesion, by an increase in size of a known lesion or by an increase in the number of bessans. Progression of disease Regression following successful therapy may be acccompanied by a transient increase in uptake at the site of a healing metastasis, Usually, however, thi uptake decreases in intensity, With time the actual number of lesions will reduce. ¢ Posterior, 3 meats a Posterior, 3 erumtite 2Bf@ Anterior, @ mois © Anterr, 12 A repeal bone scan should generally not be performed in under & months Y unless new syingtoms develop in the interim, Fig. 428 Add-year-old qomun athe recurrence af .concimomer in tine righ? frrestsd inc Worar patie, Tie initad Inoue seetet fant) shows nnltiple areas v uptake Hereughtsat Hee ribs und sterrermt. The pantie was fronted with chemotherapy annd a nepent scan ane wear finer icons Mone, injprepencnent Ural), oath less: iretvnnse: rater dn the storm auf ibs, There Fras: beer cannpri Litre eof the ceresical spine fesinins.Soft tissue uptake of diphosphonate Fig. 4.29 a Equid aa ee at) tp bieeie oa iinet, Diagnosis of primary bone tumours Primary bone tumours are associated with increased uptake af “le diphesphonate at the sites of primary and secondary divase (see Chapter 1, pages 546) soy ttsame Besson ir tive ual fo be ot primey Fig. 4.34 Etat ili thcrvictet tori Bric sarc right ih Vite hovar seat dae) slic itearey, The reve 3 haters eptake in the oe oF Huesca die) ants mormmiti.TLIMEALIR Benign bone disease in patients with malignancy Degenerative disease Osteaporatic collapse sree area bane acim et tine devel of LS fa patient with bree cancion auf back pain, The sete Rucdiugs ore mou-apmeific, boa? cea ray af dhés anew comfinirs deyemesa able. ora, dre Hae 3, Nhe sc should be perforiied at & aon tlh nedrectiour dir aprtiake af tine bewiows 13 beandgre. Radiation necrosis Fig. 4.37 fergovar rindi fiery te tins anna 12 awn radiapion arco ‘Tier pendiernt Ant ainedirry previvnaly amd the scan findings ave dive he rite da the flea! of raufiethierinpey. Anteriar4.3.3 ™TcO, Nodular change within the thyroid is net uncommen and is only due to malignaney ina small percentage of cases. The thyroid scan using = ToO, of 71 is the only imaging technique which enables the identifica- tion of functioning or non-functioning thyroid tissue to be made. Functioning thyroid tissue at the site of 4 nodule virtually exchides malignancy. In 10% of cases, non-functioning nedules which are solid on ultra- sound will be found to be malignant (see Chapter 2, pages 15062), Diagnosis of primary differentiated thyroid tumours Diagnosis of follicular carcinoma | Fig. 4.398 =i), dryer Patient with asyrmenetrical ‘goitre Htdead cet fhe (ef The scam shows greedy The combination of an wltraseame sean anel a "=ToO, scan is essential for determi subsequent management in patients with solitary thyraid nodules. 17) imaging in thyroid cancer Diagnosts of papillary carcinoma a Xonew fed performed & morntits later sours abrir Ppetsurpeny despite tlurruapey4.3.4 “Tc nanocolloid Table £8 Use af "le nanocelfoid for bone marrow dmmangringg aoe rena figeatsncy Dilagnosia of sites ef turrous ieviiteation Selection of sites irr bone marrow biopsy Asscasment of post-radiotherajy effects Tumour infiltration In patients with known malignancy, bone marrow scanning may be of value for determining suitable sites for biopsy, or for detecting metastases. Often, the at Pocterioy, [nike wurryem ceunnt b can will not provide mare information than other screening tests, sweh as the radionuclide bese scan, but on occasion dramatic results can be obtalaved, amfernr Tie putt pith Bra au Ss stint pedis aaa eater vince si ade lefveks, exseril ally’ > hese saat finelinigs. Fig. 42 fa} Boor Hheracds spire, (By) Beamee of toracic spite, cevi Aeft die ined Goth bore sco tems irre! ial hexintres uy conifer er mefrstutic iepoloement in i Humacic spinerie, Borie marr waite Site of biopsy for marrow aspiration 8 af Posterioy, home scat & Posterior Fig, $43 fab Bovue marron sour: materior =. (I Blovne seatre: muiterioe vicar af Ge) Botte nirroce scnn: prestevine tots. ful) Hane scan: posterior if peliis. ‘The potion w 2.yerer-ohd ine with fisufitng one fie hue scum piven is dycreaset frboer apiake ire the regivar of the bef femoral head, Findings on the morrow sewer avedrammic. with stribinghy tncrewseal Ane the [eft upper femme, etfe tine shalt, However, AA pets eel i flit ight 6s teoaribead veatiser ive of Bracer Ord aarll ated at Mae Fat or jhe, There baud ettesice eploventen! by doumuner, weyipe marr Fig. 44 Hane marvin searn: tah. aveterior views af petois; 1b} posterinr ecw of pelvis Whe potiersd eas a 28-yeurr-ol\t many itl rer Hodgkin's disease, He cows preoiousty treated reith tote! nodelar radiation and ws currently betreg considered for bore marroce inireest Aollinved tay ery fejgh-alose chermotinenapy and tierown renufesivn. The oracle tats wartied fo dma if there ows ot sealable site foe snnarrine Poepsay. Ht 35 apearevet thai trere harval nightie dry that right hearripetis, fel tte remavimder af the pets ant bly fenone show sligintty imcrotsed acti ‘The left reunipetis cows Mherefore efimser as we steitable site for manrrou dunrvestmoat bome marrow ts very sensitive ft external radiation. The fellas he effect of Sacroiliac 2094.3.5 “Te ttt, “= Tc DTPA hile nermally used for dynamic renal sites off rahThy 4.3.6 "Ga Table 4.6 Tiomeurs imaged with “Ga ‘Lymphores ronchial carcinoma ‘Mepatorna Others “Ga uptake in lymphoma Clinical indications for Ga scanning in lymphoma * As a baseline to establish that the tumour is "Gar * Follow-up as an adjinct to other investigations avid for subsequent tellow-wp * Follow-up when there is a systemic indication, og * Assessment for suspected hilar patholowy fever, pruritis, weight loss. * Pretreatment staging as an odfunct to olher staging procedures “Ga uptake ai sites of primary fymphoma a Anterior Fig. 49 Examples of Ga wecumeudation in fyeypshune, dah Anterior view tikntcrl siprruchenicatir avn vigipcr mucvtinstingad uptake, €le)-A showing fi clomicwdar and conc uptake, fe) Arterior 7 rudur updake auf rigiht axillary sfisease, brikttenal seaprrac 291am TUMOLa Fig. 4.50 Anterior ciew of chest auf upper ahdovuee, This puticat ines being juorstigated for Ait gland enlargement shoo ae chest ray, The WiGer study shons avid uptake die the glinuds bilsterally, Jinticatinng actloe diserse, Lamrpsberur ves siilseq uesitty caurfirmedd fu thés case. Fig, 451 ‘Diels puttin prresetntadd with seenerad malaise arid fuse aegrs oy dancin pleas Compressiine, A mulignmncy cous suspected. ihe Jritiol fepeshigadions eicfiedd megatine rents. A Gasom wes requested, qouf the study shows ipake je aul around nernes fu the brachial plextes, togetiver onitle sane focal auestinatinsad disease. A Tywapliatrad pews dingunsed by wundiestinal bvepsay, ata tthe pation! respomded avell hv obemothera py. & Ante. Ge Fig. 152 fa) Tod), dived sera, anterior even of heel, Markers are placed ona palpable wuss. (Bh Get stay, amiterior ico of arch emad chest. This patient preeented with e mage in Aer mock, dred this ues imitially Meouwylnt ta be ao tigroi! meoplasr, The thyredd sora, however, shou a normed Wryrnid, avid is clearly alisplaced by an externa? mass. The SiGe scan shops eid sapteke in the cervical glans cid aipper mediostireuny, Fis padivnt had a hyuphon, aot of teypraid origin,‘th & Snow Ga is a non-specific tumour seeks furmours. IL is rarely useful in the and has variable uptake in bane ential dia i ai8 of a ling mass. °7Ga uptake in hepatoma 297Puc “Ga uptake in other tumours @ uptake in colon ca pioestigated for f hupoctnitmdriae, qnarretly showers te Be cle ure carcimowar of like colore, “Ga uplake in lymphaplasmocyioma ap hacens pc poriw hepatis, bb. Tie “Gaunt Mame r aeTLASILA Amerie Interpretation of “Ga uptake by liver Fig. 458 "ea, slirnctyy focind rere nf cel ing Exot Armplacun anyairest @ buckigrowred F inst case We cided scorn fle) cout ig ne t ‘ fit cas th scm tlh Ca : d Anterior, i * © Ga uptake in the liver may be difficult to interpret. * A colloid liver scan should always te performed following a Ga stody, amel they showld be interpreted together, 205Se eae La 4.3.7— TI Although "Tl is primarily used as a myocardial imaging agent, it has p been used to diagnose a variety of tumours, Tumours in which “Tl uptake has been documented are: * Branchus * Ostensanema * Thyroid * Ewing's tumour © Breast * Hepatorma * Lymphoma * Oesophagus = Brain 27] imaging in recurrent thyroid cancer ArT] is taken up iby follicular, papill thyroid cancers. It has a particular role ment of patients with '“I-negative tumours such a5. nd medull a the ma Hurthlé cell tumours, and in patients who develop signs of local recurrence while on thyroxine and in whom 'l imaging is not possible. Fig. 4.62 sey4.3.8 Telv) OMSA is a non-specific humour imaging agent faken up into a number of different and disparate tumours. Its main use clinically is in the management af medullary thyroid carcinoma (snc), This rare mT e(v¥) DMSA Diagnosis of sic tumour is characterized by its slow growing nature and patients may survive many years despite distant metastases. Tel) twa is taken up at sites of both soft tissue and bome necumence, ee b Anterior © Righ krteral Iti ws performed. FViule the results oy Miic test anene atomteal, i muss, altrasoimad. In ciew of tae partie slong feistary of ainerhoen ad Left binteralTUMOR Staging Many patients with Mrc have metastases at the time of initial diagnosis, These are frequently asymp- tomatic, and in view of the slow growing nature of the disease, the presence of distant metastases docs not contraindicate aggressive surgery in the neck and mediastinum Table 4.7 Sites of spread in arc Local lymph nodes Modiastinial lymph reodes Sikeletun Liver Lungs story al MTC and shal siirted fo rise amd the patient deve pif ferries ariel Hf Ne tiara bead! ae aeFollow-up The main therapeutic tool in sire is sungery to all acces: sible lesions. “"Tely) basa performed before and after surgery enables the success al the surgery to be deter- mined. Fig. 4.65 Postoperative Tot) osesa sent int Palientt vith are, showing resivfaal tiene at the site of sairgery, 4. | Areterion Fig. ite A rare usin antl Sayer history of AS Tolv) owes scum fa) ins performed, sirace she patient nepreseriteel arith masses ur fhe rigint sddle af he neck, Tike sone cou firie necareeir! tremor, bit ufse ddpatifies fone Muelasteaes dar tive Left shou Ider od [eft embit. Fatlouving further surgery a repeat scvint Wb) showed residual teaour iit re mck. ‘The hour murtastises weere wnaltered, False positive uptake may be observed in patients whe have recently had a sternotomy or who have benign bone disease,43.9 7) MBG Table 4.7 sinc-accownlal ting tisiones rare, but, when sits will usually accumulate benign atitying, thi as the prima rt froin id ites Fig, 4.68 Case 1 ta) A fac 1 aA Case 2 (hb) A iB Aad ment sf therapeutic dises cxf read of the tumeur, th potential for trea T senpe scan permits ng these t murs withNICAL APPLICAT Neuroblastomaee TUM Carcinoid syndrome 7 eoiToad a Arrterion. liper/aney db Anitardie, "7 sane Amirricr, JO Fig. 71 fa) Anterior wien per isptoen sean. th) Anteri difomtinal viece of °F sap This gations! fend carci ndrontie and Mier metastases. Tie Hevr scart slurs escur-ly hy of newer upraake, but acidic tine suggestion of nore focal difects at the loser right lobe, sain uptinke a6 seensat His str, Fig. 4.72 —_—_— Ariterion 'T sane scan tb at 7 Junie ul ichint 24 hours ie ae petblent with carcinoid temaur, The I-hour image fa} shores relatively photoieteficient ances dnt die Feber ore Nee jirofuninantly blood pool dntige. Al Bf hours fc}, the dues accunrulates! in tie wrens. SPECT inmaging (Ba) confirms few! focafizotion tovirin the titer metastases. peobientt wine subseyqnaerttly fromaled spite © sera tee gener 472, this chapter. arect at 24 harurs with Aubo increases the sensitivity of liver yistawes detection.In octreotide 4.3.10 ‘Win octremide, an octapeptide analogue of somato- siatin, is a newly developed tumour imaging agent whose clinical role és still being defined. As the mecha- nism of uptake relies on the presence of somatostatin Tecepters on the tumour membrane, a positive study indscates that the tumour may respond t ervtcraba kita therapy. Similarly, a negative study indicates that somatostatin therapy is unlikely to be beneficial. "tn octreotide in M7 Table 4.8 Tueronrs showing "Un octreotide uptake Neuroblastoma Phapockromecytnena Carcineid, Pancreatic islet cell Glomus tameur Medullary thyroid Lymphoma Bevast Fig. 4.73 ‘Shy ontreotide sewn tr at patient soith primary micdulhiery Hgradd coacee. Tene bs mpstabe cat the site of the prinenry dani dn). No olfer sites af disease one ndendified fhyed a Amierior hb Anterior "Fn octreotide in breast cancer © Auterior Fig. £79 fa-e) "Jn octrewtiile sear ire @ patient cuit: breast numa cerebral metastas ahunving wptake in the right fromloparietil region af tae site of mehastasis. Right haterad € deft Literal #05‘In octreotide in carcinoid: camparison with '') wee wt Aasierioy, dn octreatae im octreotide 16CLINICAL APPLIC 4.3.11 Monoclonal antibodies Breast carcinoma fa) As brevta ca firdulevt porated a revest harm showing a7Se TLOMACILIOE Fig, 4,78 Grtennl view of right leg 2 dues ante af ebelted arti-inelanoma mononional anthoty, sfuving mpthake inte Bere Culmuentes tirelanirnan dlepasits ee datenal, 34 hours Fig. £79 Junterior blew ¢ est 24 farang after injection of U- labelled anti- malian moreciinit weitibedys, taut g uptake ine Left axdllire snelamoma rielustasis. Anterior, 24 Bowers SintOvarian carcinoma acer4.3.12 Therapy Although gamma (y) ray produetion is net essential in aradbonuclide used for therapy, a bow abundance af - photens permits imaging in the post-therapy period. Role of radionuclide imaging post-therapy ® Contin uptake al-known turour sites * Identity unknown tumour sites mot vis low tracer doses ® Permit approximate dosimetric calculations to be undertaken * Confirm retention at tumour site by delayed imaging. “therapy lized with a i ol @ Anterior bh Posterior aa Fig, 4.82 dade) Post therapy uvhote-lnty peti confirinniny: aptale fo rvcternead affsewse én sacthestirnarn, Al right finer a air dhe brcer acum is alee aa Fesioun far tin right dldnc pisinnlized, us eresTUMOUR Samarium-153 en therapy Bone scan a Autostar & sLatrrive co Asterioe ISat ETM dt Anterior FF Arderie ses Frome cHFCiNORRT ‘The patient reniferoeat padlintioe therapy for Inne pate wainyg sanmtrium-153 eerrar (See come), Tire post-theny Se core tal—f) shone uyrtake of bhe therapy aioe at sites of precions Te diphosphonate uptakeTuc “HY wieG therapy ib Posterior Fig. ht fingle) Prost-tecray paticnt Frinateal om inna "YMG Hous goad uplake Gr the lier, furegs, urtrit are! abelorénal fesinnes,BRAIN Radionuclide brain scans utilize three major groups of agents (sec Table 5.1), cach of which investigates a completely different physiological process. The blood-brain barrier (ean) agents such as techmetium- im diethylenetriamine pentaacetic acid ("Tc orral localize within the vasculature in a normal study, and ane only seen in the brain in regions when there has been breakdown of the blood-brain barrier or the formation of new “leaky” capillaries. Planar imaging, with these agents is usually performed, although single photon emission computed tomography (srpctT) may aid lesion localization. The cerebral perfusion agents sech as technetiom-44m Tel aso or iodine-123 C31 Mar are taken up inte the brain in proportion te the regional cerebral blood flow, A normal study with these agents will therefore show Tadiotracer within the brain, with abnormalities usually being indicated by areas of relatively decreased activity, In order to accurately define regional cerebral perfusion, sect imaging is usually vital. These radiotracers ane gradually supplanting the 8B: agents for many conditions such a5 the investigation of stroke, dementia and epilepsy because of their increased sensitivity amd specificity. However, 088 agents still have clinical utility, and may sometimes be the agents of choice. Static imaging with either she or cerebral perfusion tracers may be preceded by 4 dynamic blood flow study, whieh may provide valuable information about the extracranial vessels and major cerebral vasculature, Some lesions such as arterio-venous malformations will be best seen during the dynamic study, Repeated imaging in a Ban study over several hours can give useful information, since tumours in particular can show differences im the rates of accumulation of tracer with different humour histalogies. Turours may also be investigated using thallium-201 @"T1), The third group of agents used in brain scanning are those used to investigate cae dynamics, These are injected inte the subarachnoid space, An example is indium-111 U'ln) orta, Planar imaging is usually performed, Computed tomography (ct) or magnetic resonance IMI) scanning, when available, will usually be the primary investigation of choice in many neurological conditions. Radionuclide brain scans may be used as a screening method for patients, decreasing the sumber who will then require cr scans. In some conditions the ability of these studies to provide information abut function rather than anatomy aids diagnosis in the Presence of a normal cr sean. CHAPTER CONTENTS. Anatomy 5.11 Anatomical regions af the brain 5.12 Cerebral vasculature Radiopharmaceuticals Localization of blood-brain barrier agents 4.2 4.4 Normal scams with variants and artefacts 3.3.1) Normal ses agent ("Te ora scam 5.32 0 Normal “Te orea: dynamic vascular study 5.33 0 Normal regional cerebral perfusion study (Te HMPA 534 Cerebral perfusion agents: normal planar 535 i and artefacts im SPECT imaging 326 Normal "In DTPA cisternogram Clinical applications Sa.1 Suspected cerebral infarction Intracerebral haemorrhage Transient ischaemic atiacks ‘Carotid artery stenoses Subarachnoid haemorrhage Arterio-venous: malformations Brain death Suspected cerebral infection Suspected chronic subdural haematoma CSF beaks CoP shunts Evaluation of dementia or personality change Investigation of seizures Suspected intracerebral space-cccupying lesions Suspected cerebral metastases The donut sign Skull and scalp lesionsBRAIN ARO h 5.1.1 Abe regions of the brain Central sales i Conbral cartes lined Pa \ rruretnain Pariatooeeptal ( ‘Stem of sheen ‘Third wertricke linseod wits eee ependyma us pal il @ Sagittal b Corenal Fig. 30 fal Chaps cheoetig thre gevieral dryout of the marjor components of fie brary ire flue sagétial section, 6b) Diagram of a coronal section Hhroagh fe orrebricnr and brainstem, showing the general relotioreslipes of the deer misses of grew muetter. ald5.1.2 Cerebral vasculature Anicrior eerebeal artesy delle Posteriar ; Anterioe Posterior cerebral carebral ‘eurcbral cerebral ate artery | arary artery L aw Lateral & Medui Fig. 52 Diggrams demondenting te Wond supply to ike cerelral fremraphores: fa) Loferal events dh) macdial nicer, The three arteries of he crrebnal hemispheres, the areterior, uiidle and posterior cerebral arteries, arv connected via the Circle uf Wills, Obras proteagidas por diretios dle autarNormal distribution of uptake Uptake of cerebral perfusion agents ‘Hood perfissan Brain Mlood—brain barrier Fig. 5.8 CXagram sicing mormal distribution of nptule, Fig. 3.7 Pastor uptake of lipophitic tracer arith: 7U-B1P%: fiat pass extraction, ction: Inppirng tn brain, oeith oly a seal! amc of frocer returond do circulation "Te Hairact. With Of aver, sev nofistritnetion af ve ntctiotracer takes place, amd 92) scureméng mest ‘he completes within tie first Inu, sitBRAIN Pe ia ae Nm TTD am cali t iret Bae 5.3.1 Normal eee agent ("Tc ptra) scan [ Skull and scalp = Sagittal sinus | ‘Sagittal anus | Covers |Ceretn << tw a : — Skull and scalp ? * Toreulir | 9 Heraphili —Tranaverse | sinus \ Posterior fossa Orbit _> Sagittal eins “ Parotid glanels —Cerebram —Totcuilar Hererphili 318sa thas ee ee eee hn iar tik) 5.3.2 Normal "Tc prea: dynamic vascular study The dynamic brain scan is obtained by accumulating: images during the first passage of the injected bolus of ridiopharmace: through the brain. Images may be displayed in a variety of ways (eg 1-2 per secemd or ass by adding the arterial and venous phases separately). Anterior view Anterior cerebral archery | bide Cinch of Willis ——— ‘Carotid artery $-10 seconds ital siras Time Time-activity (TA) curves: can be ge regions of interes! crated from should be pois). Incividual vesse noted, and abnormal areas on the static brain scan ssed in conjunction with vascularity. 19Rats Da eR Ie Pe ae by Posterior view Fig. 5.00 (nal) aver fem a Posternor by Posterior ¢ Posterior . 8 KGcht hemispheres rN © Left hemisphere | * | ie e f Counts * F.20)LEAN See a eM tae Ra Om Ute eid Vertex view Fig. 00 farmadl L dai5.3.3. Normal regional cerebral perfusion study ("°"Tc Hmpao) basal gan will show njection, “Te bev i grey oiatter a the brain tissue in eof tracer, whe white matter avid uf al blood flow, The exact mecha h less somewhat unclear. Thus ancas with a hap! Transaxial slices SPECT MEL Fig, 5.12i a CORONAL SLICESARAIS AL SCANS WITH VARIANTS AND ARTEFACTS 5.3.4 Cerebral perfusion agents: normal planar images fad) Noreen! plaitar Te HAANAD images, L Anterior & Pesterdir c Left Lnteral 428ee Ge ME ia AAEM Lies 5.3.5 Unfortunately, be imaging, artefacts are easily introduced during the acquisition of processing, and may lead to misinter: e OE SPECT use of the comp Misinjection/delayed injection ie uur and must be injected within Injection after this time "Te HMar minutes o| al ation, prep will result in a high proportion of the tracer existing in the hydrophilic form, which is not taken by the brain but accumulates in soft tissues, This is easily Movement the patient's head dui nt arte Movement produce signific: defects (Fig. 5.18), Often these will prevent interpre- dy can acts, which may mimic fecal Variations and artefacts in spect imaging pretation of 5 important to be aware of these potential arb interpreting brain srr shadies. Pear att 1 the low bra by the high activity n activity (Fig. 54 same can the parotid glare, 1 eccur if a dose is misinjected, and occasionally if blood is withdrawn inte the syringe prior to injection. ial quality con Inject tnmediately aiter preparation, erably inte a fr rd shonule net t withdrawn into the syrinwe prber bo injecti tation of the study, or may lead to false interpretation if the clinician is unaware of the problem, The pationt’s head sheild always be irmmabilized firrnly with tag velcro to the study Small children or severely demented patients may require sedation, which should be given aiter he trac injection, brut before scanning. The patient should mvt be left unattended $29NORMAL SCANS WITH VARIANTS AND ARTEFACTS Positioning rly diffiec ike cant lernpe- i lobe since ral lobe metry, ep This seizures, Low count rate fery noesy studies ane elacts (Fig. 520),Uniformity and centre of rotation uniformity must be maintained than can be ‘by ntre of rotation of the camera must also be regularly checked: fs will be induced In spect the fie within much closer limits (usually tolerated with planar imaging. The Slice angle pat which the transaxial = have significant effects on the 5.22). This is particularly Sometimes special slices such as those orientated along the long axis of the temporal lobes need to be gener- ated in addition to transaxial, coral and sagittal in brain SPECT The ang studies are produced appearance of a stucly (F important if patients arc having repeated studies Externa ka line & vie placed on th external canthus of the ear wton the camera it radiobracer, To in the optimum sally required imiteally trial andl er nerd manviacturer, but whereve ssi y when using and black-and-white © roschenmves tend to uri multicgh abnormal VN False pacsitive om ne monochromatic tend te over i eme. Whe ah should be view bid » stud are urrently. Je shamulel ° 2 fi changes in colowr (ew red le yellow) should be in cerebral blacel (law mal colour scheme. In this ly be set for evel oi ‘normality’ will gradNORMAL SCANS WITH VARIANTS AND ARTEFACTS 5.3.6 Normal ''In otra cisternogram Following introduction of tracer into the ¢sF via lumbar demonstrate rapid flow of csr through the Sylvian puncture, it will appear in the basal cisterns after about fissure to the mx, where it is absorbed in ihe 2 hours, Subsequent images at 6 and 2 hours will parasagittal reg x Irat # perret richer =, Basal ¢, Ao Ina normal study: * No tracer should enter lateral ventricles * Tracer should have flowed over the cerebral cortex by 24 hours —__Although computed lomography (CT) and magnetic nesenance (Mik) brain imaging has far superseded that of radionuclide brain imaging. important roles remain for the latter when there is limited access to CT or MRI, the anatomical resolution of x-ray when infermation about cerebral blood flow is required and when information about the dynamics af csr flow is needed. The more important indications for brain imaging with Tadionuclides are listed below, and examples of the various clinical problems are given on subseqpent pages. SS 54.1 Suspected cerebral infarction HEE agents Features of cerebral infaretion ‘Cerebral perfusion agents with srect Appearance of middle cerebral artery (Mcab infarction Appearance of posterior cerebral artery (rca) infarction Appearance of anterior cerebral artery (aca) infarction Appearance of basal ganglia infarction Features that may help in the diagnosis of stroke “Lunsury’ perkusien Progress and resolution of scan appearances with time Intracerebral haemorrhage Cerebral perfusion agents Transient ischaemic allacks Cerebral perfusion agents Carotid artery stenoses BBB agents Cerebral perfusion agents Subarachnoid hacmorrhage Cerchral perfusion imaging Arterio-venous malformations BBB agents Cerebral perfusion agents Brain death HEE AgUTts ‘Cerebral perfimsion agents Suspected cerebral infection Cerebral abscesses Localized encephalitis Generalized encephalitis Ventriculitzs BAZ 543 ida 54.5 546 548 S44 Suspected chronic subdural haematoma Unilateral subdural haematoma Bilateral subxtural haematoma Extradural haematoma Trauma SAMO csr leaks SAQL csr shunts $4.12 Evaluation of dementia or personality change Alzheimer's disease Early Alzheimer's disease Asymmetric Alzheimer's disease Progression of disease Dementia with combined aetiologies Multiple infarct dementia Pick’s disease ‘Communicating hydrocephalus (ermal pressure hydrocephalust Advanced normal pressure hydrocephalas ‘Obstructive hydrocephalus Jakob-Creuteteld disease Cerebral atraphy Investigation of seizures Interictal study Frontal lobe seizures Ictal study Seizures caused by space-oocupying lesions Suspected intracerebral space-nccupying lesions Primary intracerebral tamer Frontal lobe Occipital lobe Parietal lobe Sphenaid ridge Temporal labe Posterior fossa Lateral ventricles Improved localization and detection with srect ST) errct imaging bor localization of brain tumours Suspected cerebral metastases: Features of cerebral melastases on the a8 brain scan Brain metastases demonstrated by ®"Te naira SPECT imaging Lymphoma Features helping im the diagnosis of spAceoccupying lesicns: Shape and position Value of delayed views The donut sign Skull and scalp lesions. Bruising Sebaceous cyst 540 5.4.16 5.4.17 4345.4.1 A clinical diagnosis of stroke (cerebral infarct) or haemorrhage is usually adequate, and imaging inves- tigations are not required. Occasionally, there may be some doubt about the diagnosis, in which case a brain scan isa valuable investigation. When scanning with Gn agents, a stroke will appear as a region of decreased flow on the dynamic image, and will appear positive on delayed imaging owing to 888 agents Suspected cerebral infarction diffusion oof the radiotracer across the leaky blood-brain barrier as well as avcumulation of extracellular fluid in amd around the infarct, With cerebral perfusion agents, decreased activity will be seen in accordance with the decreased perfusion te the Tegion of the stroke. With both types of agents, the abnormalities follow vascular territories, and will Molin he Anterior Nickle Anterior cerebral cerebral cerebral cerebral infarct infagct eerebral imtarct th Lanteral al Anterior Fig. 5.26 indicate the vessels involved and assist in the differential diagnosis. tide Posterior | | Anterior “Midalle cerchral cerebral} | cenelyal cerchral infarct \ {infarct | | infarct, infarct “a Posterine > cerebral infarct at Vertex fad) Dingreumutic represcatation af focaitzativn of mbviwrmalities seer in cerclrat (atarctivet, Features of cerebral infarction © The area of uptake will correspond te the anatomi- cal territory of a blood vessel © The uptake will increase with time from injection ti imaging * Usually, the dynamic blood flow study shows decreased blood flow, but increased blood flow may abo occur (ioury perhusion) * A static brain scan (bet not the dynamich may be negative immediately after the onset of a stroke, The positivity of the brain scan reaches a peak seven days after the onset,Cerebral perfusion agents with spect Trantsaxial stice | Fig. 5.27 Detgrartiiatiy sepredenittien of regional abmermualities seen bn —— = ecrelual fafarction, Anterior cerebral infarction Middle cerebral infarction |__-~ Posterior cercbral infarction p— Antenor cerebral inianction —= Middle cerebral infanctaon Posteriog cerebral infarction Saeitlal slice * An iniarct may not involve an entine vascular territory * Vascular territories show sore variation between individuals Middle cerebral indaretiim Posterine cerebral infarction JeCLINIC eek) Appearance of middle cerebral artery (sca) infarction ents sealer, eA Brae Cerebral perfusion studies are almarmal he stroke, and offen urs before cr or Me) abnormalities appearral py eTTeLS sionaN ICAL APPLICATIONS Appearance of anterior cerebral artery (aca) infarction Bens Appearance of basal ganglia infarction Cerebral pertusian a amsFeatures that may help in the diagnosis of stroke Blood flow ty tat atonal | 1 ‘ | Right beenisphere | Left hemisphere — O42 seconds 24 seconds | A | | 5 | ae | ad + | ‘ 4-6 seremnuls fA aocoeed s Tame © a Grates scones dan} weeterier wae: (Bp deft (ch chynamric steady; fel? computer generated curses. (vw the delayed static images there is a large drat of dncretsed Peace aptly lee Left iit tite (frontal region, extending one frove dine nnddlivee ir Hive Serra fyaneic 1 alocreserd lose tig Left cerebral hemisphere, hut particularly i the distritetion of the anterior cerebral arteru, ‘The compuler-geverafed curves show a manned fel far peek actedty on dine tefl, The scan Aidinigs represent o herge left-sided cenetiral infinret in the ifistriburion of the anterior ceretrat ou. Netrrtiveless, the size af the lesiee raises dilly of same middle cerebral wtery ry tirvediverme tnt ae * When the static brain scan images are atypical, as inv the / case illustrated in Fig. 5.23, the presence of markedly js decreased blood flow to that area will increase the probability of a cerebral infarct, because the main differential diagnosis, a glioma, will almost always have increased blood How, * When the static radionuclide brain scan is equivocally abnormal, with no specific features, the clear-cut loss of right middle cerebral perfusion makes an acute cerebral infarct almost certain.RAIS ifchior Fig. 336 Occasionally, the static brain scan may be completely normal, as im the case illustrated 6, The vasewlar study showing loss of blood flaw to the left side in a patient who has recently developed right-sided paresis will exclude a malignant space-oocupryin: igh degree of certainty, lesion as the cause with a byaa ee Le ‘Luxury’ perfusio mage iiarels. show deere. al inia called ‘luwury’ puri Most cerebral ii-sided cu bolewoel fle 158 F this poss vas to avoid repeorti {un An importani reer evil ine thi a ape of the lesion on the lateral view and the fact that it lies discretely within the posterior branches of the midalle cerebral ar gap Increased periusion (luxury' periusien) can " etirmes bi ute iiancts. I is clue to peri ingrowth af new capilh Vin subs, maxtnal at abou! 20 days, and is prodably C1 loss of vasorebor control anclmaAIN Progress and resolution of scan appearances with time an Sor weeks Frequently the cause of an equivocally abnormal a few di becomes clear on a n-peat stud later, This may particularly apply to cerebral infarcts foo early with een agents, which are scanned maximally abnormal at 4-7 days, although the abn may last several months or even years. (Cerebral perfusion images of strokes are immediately abrormal, and may show partial resolution with tim malities Not all ane brainscans of cerebral infarcts resolve, and some may remain initely, Thereiore the positive inde presence of an iniarct on the scan | dows mot inal le a recent ewer,NICAL APPLICATIONS 5.4.2. Intracerebral haemorrhage Cerebral perfusion agents haemorrhage tion af cer————— (CLINICAL APPLICATIONS 5.4.3 Transient ischaemic attacks Cerebral perfusion agentswoe ee SS CO eda eatin ed 5.4.4 Carotid artery stenoses at agents h Cerebral perfusion agents Stenases 0 awotid artery may produce ni v is insufficient collat- “ral Villis, Fig, 544Cu “AL APPLICATIONS 5.4.5 Subarachnoid haemorrhage Cerebral perfusion imaging The presence of blood in the csp which will decrease cereby vasospasm This will usually follow va: direct compressive effects free bee LO i detect vasospasm and vied with a poor jr in subaracDeedee 5.4.6 Arterio-venous malformations au8 agents blond flow with a disproportionally massively blood! volume is typical of an angiomatous rrmbattixene Cerebral perfusion agents appear as occupying lesions. 95.4.7 Brain death Abe agents These are conventionally used as an adjunct in cases of suspected brain death, os 3.3.3.3 33 8. seus * No visualization of sagittal sinus on immethale post-injection images. Te Fig. 549eee HAI 5.4.8 Suspected cerebral infection Intracerebral infection is usually suspected when an underlying of predisposing condition such as septi- cacmia of cyanotic heart disease is present, Cerebral abscesses Features af cerebral aliscesses * They are frequently multiple * They frequently demonstrate the donut sign because af central necrosis * A blood flow study is usually normal, but may be decreased. Increased blood flow is extremely rare. fT neygivre, secenuf dit tite peirictal rian. Both esi |, relutinety Paoloredeficient aren, ie Sey dlennomstiratte: Be domed sien. The semi fimnfings mere die to ‘ntielbpte ietracerebnial abscesses. mB " bh BsterionAI Bilateral subdural haematoma Small bilateral chronic subdoral haematomes may easily be mised because of thelr symmetrical appearances, Paints to are: id flow study showing compression of the cerebral cortes pw, SPO fichent than * The blo © On delayed images, the los of frontal lucency on the lateral vi the region al the frontal lobe shawl normally be more psloton-c the parietal and temporal lobes. T56eee Subdural haematoma nertusic et * The p sufficient siz fas a known haematoma is ofTrauma Brain contusion: ase agents @ Anterior peteritr © Bight fatima Hf caret, dy at Flue! site, 158CUNICAL APPLICATIONS | perfusion agents Brain contusion ¢5.4.10 csr leaks fc cisternography can be used to confirm ed CSP leaks. Radionucl and localize susp ® Any tracer oulside the cw space is abnormal. § inserted into the nasopharyna which are remowed all ts Fever (bood increase the ine! Counted along With a | uel Petes Si sitivity tor small leaks. erum ratios should be less than 1,321, ling the head forward mvre may increase erceming a valsalva sitivity, al dural leaks can also be localize det}5.4.11 csF shunts By injecting "In Dra (using sterile technique) inte the nserveir of a ventriculo-peritoneal, ventricula-atrial or lumbo-peritoneal shunt, the patency of the shumt can be assessed, eof the Radin nacey don the Fubiag, Fowr-hewr aldansdia ges fc) ov of traces ine thee pr | Fig. 5.60 Anterior howd trengy of Mocbet shu aff hours, Trape cae fal or porucimmand pons. with the peritoneum or circulation (eg kidneys). The * There should be rapid passage of the tracer distal nce i appea speed will depend on the csr pressure and ibow cate, but should be seen within 1-2 hears. * Proximal flow of (racer may or may not be seen, depending on the reservoir valve type. * [tts important te cheek for misinpection in the scalp, since this can produce systemic uptake, * Lumbar-peritoneal shunts can be checked by lumbar subarachnoid injection and following tracer passage inte the peritoneum, faya AI ea AL APPLICATIONS 5.4.12. Evaluation of dementia or personality change i * Typically, bilateral ‘ temporal andl parietal hypaperiusion is seen in Alzheimer's ci priusiven is usually eel inv thie all boles in early disease, as well as in the basal ganglia, visual and sensorimotor cortes and cerebellum,Early Alzheimer’s disease @ 8 e Asymmetric Alzheimer’s diseaseProgression of disease The frontal lobes may be involved in severe diseast. Eventually, a pal of marked pan-cortical hypoperfusion may be seen in very adva “il iidat ae al LO Dementia with combined aetiologies 5 (lise Stroke, being very comm with Alzheimer’s di Usually this is 15 , Confusion can arise ticularly in slices of the non-stroke the » parie hemispl Sh» Similar ee ~~“ irr pa a the ® Parkinson's ¢ can Ale hwiner’s. ast wil pears similarMultiple infarct dementia Multiple infarc® Tracer in the ventriches 6 always abnormal, * In communicating hydrocephalus tracer is seen in the lateral ventriches at 4 hours, rei al 24 hours ® Delayed imaging at 48 hours is occasionally pequired, * in severe disease there may be delayed ascent of the tracer aver the hemisphere * Ince fl atr rapidly emplics, iy radiotracer may pass into the lateral vemtricles, bartUAE Se te ae) Obstructive hydrocephalus Jakob—Creutzteld diseaseCerebral atraphy Fig. 5.80 Bh Anterior, fi 1 df hours i rior, 4 hearsee Frontal lobe seizures * The abnormalictal study \ injected dusi interictal study ise nay be 1 seieure fictal stu f be noted mi occur misin- the stud ® Hyperpertusion is 5 * Anent f brat 1, anal caution tm tes are seen to helpful in this becomes anally bilateral alin areas. The interictal study may t 5) studies m vial ¢ al the time of5.4.14 Suspected intracerebral space-occupying lesions due to mialfor: Spac ying lesions are most como ugh abscesses, arberico-ven and subi Tumours may either be py tastatic disease. Occasionally, Presenting symptom from elsewhere, Lung, breast and ¢ tumours, mations jural hacmatemas may present dary be the Primary intracerebral tumour radionucl Bood all d entity as ¢ solitary space in the bi kely to bea prin secondary dhFrontal labe Presentation of a frontal lobe tunoir is usally that of Progressive dementia, which often manifests itself Ehitially a 4 personality disorder A contralateral grasp reflex may be present Occipital lobe Ocopital lobe tumours may present with visual hall cinations, and there is usually an a ted contra eral hormonyineus Herba opi fa, hy Te he scum findings wen shit Benign lesions very rarely cross the midline, & PosteriorParietal lobe Parietal lobe lesions usually present with contralateral limb ws comment dkness, and foci] moter Hts an relatively hb Vertes Sphenoid ridge A sphenoid ridge meningioma may protrude into tt corbit, with unilateral proptesis Ptosis and diplopia may also occur id eptic atrophy. bh Anterior, Hood pow 9Vermis A typical presentation of a midline vermis | disturbance and truncal atas it there is associated vomiting and papilloedema caused usually without any by obstructive hydrocephalus. mus and often no atasia in the limbs. Freeuently icHT ES Waerinies sli a Left Lateral! I Pintenion The posterior fossa is hounded superiorly by the bentorium, not by the venous sinuses, Therefore, as in the cave illustrated in Fig, 5.4 the vermis lesion may appear to be above the posterior iossa Ince ince Jeslerior fissa. TI Cerebellopontine angle A cerebellapontine angh: tumour weually presents with unilateral nerve deaf and vertigo, Unilateral facial sensory loss with an absent comeal reflex is often seen. seubrariynee aLateral ventricles A glioma may arise from the corpus callosum and but progressive apathy, drowsiness, grow to invelve the ventricks. The scan appearances occasional memory disorders and general comyulsions may be those of a ‘butterfly’ glioma. Presentation is followed by bilatral parietal lobe signs may be seen. often non-specal 782Improved localization and detection with sercr spect may be performed using, ti cerebral perfusion ag improve the rate of detection and the localization agents as well as nis, This may significar sntall lesions.““'T spect imaging for localization of brain tumours Fig. 5.700)a Fig. 5.704 ta-«) es non-spectic focal periusion ng. Cecashmally t qual to nexcess of the sur I the defects orc infarctions shoul rriberivs, metastases rather (han m 786LAI Features helping in the diagnosis of space-occupying lesions Blood flow « As demonstrated in the cases in Figs 5.106 and 5.107, the meningioma arises from the meninges, whereas the glioma arises from brain tissue expanding concentrically from this. Both tumours, however, have equally increased blood flow, although frequently the meningioma has a Mood flow which is nl eioma and an intracerebral infarct can be difficult, Difterential points to nate are that in af least one view (the lateral) the meningioma is apparently spherical, whereas the cerebral infarct keeps to the distribution of the middle cerebral artery territory, Further, on the posterior view, ihe meningioma appears to be extending lowards the midline, Blood flow studies are alse of value, as these show increased blood flow to a meningioma and decreased blood flow bo an intarct. greater than that of an averay ® Differentiation between a meni 1aRny eee me lek Uniortunately, not all ghomas have an increased blow supp Figure. 3.00 duns an example of a hypovascular glioma, simul an important potential pitiall the leshenon the ante an anterior cerelral infarct, Thi Au rview crosses the midline t thee bet is a rare finding, but ful polet af differentiatic is the faet that tbe, #9)Value of delayed views Delayed views following a routine HBS agent brain scan may help to differentiate between the presence and absence of a lesion, and, bo some extent, between different lesions. The extent to which any single lesion becomes more or less prominent with time following injection depends largely on whether a positive brain scan is mainly dependent on blood volume or a breakdown of the blood-brain barrier, leaves the blood into the larger volume of the extra- cellular Muid, lesions that are dependent on visual- ization because of blood volume will become relatively less prominent, while lesions produced by blood-brain barrier breakdown will become more prominent. As bracer Positive Fag, 017 Diagramematic representation of tire valine of diekewed cers follomingg a routine Rew agent brit seam. 2-7 Metastasis Meningiome ene Metastasis | Arterioyencers malformation Venous lake L z Hours after injection Table 5.2 Differentiation of lesions based on changes in tracer uptake with time after injection Deczease wilh time after injection Vascular bumours Acrterio-venoas malformation, Angiomatons mallermation Skull anf mcailp Besa ‘Gliomas: Abscess Increase with Gimme aft Miva mctasiases ‘Subdural haerragorma ‘Cerebrovascular accident 79)RAIN PLICATI 5.4.16 The donut sign Fig. 5.115 Fig, 5.116 ed bya cerebral abscess. Ow Os it has often been s that the appeara dormit sign indicates a cerebral abscess, While cerebral abscesses may indeed show this sign, the finding is non-specific, Hlustrated by the cases in 5.11 4 18. Because of the prevalence of disease, the donut sige will more often be found in associ ee wil by ali. Fig. 5.417 Bowunl wey(hi) perdes viral eased bracer uuptal dsr dine Left Frourtal region. There é imcrosed suse his. area, The score fini prior, Alot pool Sehaceous cyst Any superficial scalp lesion may cause an abnormal brain scan- This example af a sebaceous cyst is.a typical example da, bb Te ora brain sean, There is an apparevet plintors-aleficiert iret dnt Ihe right sidte oy! Wee sill posteriorly, inboloing tne ewter table of fre skull, bint sith: noifefect lying serif, The Soin finulinige inere! dure tout large sefutceis * The importance af clinical exanin once (the dudy has been performed is illustrated by the lwo cases in Figs 5.121 and 5, Hoth lesions could be easily localized by manual palysati © Skull and scalp lesions may often provide a clue distorting the srav af the skull on one of the brain sean views. Intracerebral lesions newer ao igh! beteral, ae da this. I95at Left lateral = © 6.1.2 Normal coronary artery anatomy | Aorta Right . 2 Left coronary artery coronary (i / | artery ~ [ “i ~— | = Obras marginal branch Pieakisrderr al Fag. 6.2 Fig. 63 Nirwnal comowery: artery ametonrny, Cast of the sonal conanany tree: reET CARIMAL | OO —$ iy iat Le Lap —F = uy (window oot branch ‘annerutateral em branch wall Ineredateral wall Interivg wall = \ Apes ‘eralll od window Anterior Lat anterior obtiqne Left Lateral Fig. Norman! cormary artery trerituries t ventricle corresponding ta 2'7T anyncardind planar teas Lap, Inft materion descending artery: RCA, right coronary artery: Lars, Leff mugiee stew: CK, Left cireranfler artery: pr posterior descending artery, OM obtuse marginal anery, Coronary artery territories on spect views eral wall Anlerioe wall ‘ Apkerelat Lap Septum tap Posterolateral \, Lateral wall ‘wlll Le tex Indersor wall aa Shor avis Herizoutal dong ais nary artery territories iin the left perbricke corespindineg fo 77 amyncondial encr mews, 24D, lefonterivr descemting wrfery: RCA, right communry artery: Cx, lef cincumfler artery 4a)CARDIAL Table 6.20 Method ond radiophannaceuticals ‘Cardiac function Method Radiopharmaceutical Myocardial perfusion Exercise of dipyridamole stress pertusion scam Tl chloride Tc isunitriles: Yentricular furction, First pase or gated biced pool raclineuclidie angiogram “Telabelled ned blood oclls tic) Intracardiac shunt measurement First pans angiegram (1.9 R shank) TdO, ar Tic kat Microsphere trapping OR + L shut? “Te microspheres Cardiac chamber filling sequence First pass engioggran TO), Teoma or Te ac ‘Visualization of recently Tracer uptake ("hot spor! imaging! eTe pyrophosphate infarcted muscle ‘ee-antinevesio amtibocly Fig. 6.6 Rutciophirindceuticnls fir candice imaging. and great vessels) =TL oe Te leonitrile (enyoeardium) aTCARDIAC 6.3 NORMAL SCANS WI 6.3.1 First pass studies pass study depends on the rap Aa Fala ly ment of raclion ait lime-activity (T/A) curve will allow mea th if the shunt. "To med blood cells is tion using the gated je cardiac ch Fig. 6.7Dae ai a Ed Normal gated first pass studies for the assessment of right and left ventricular function Y ventricle it for me . Counts at end-diasinle — counts at encd-svetole Ejection fraction (%) 2 ~ 100 Cours at end-diastole — background 5%, Normal values eVvEF: mean 555 range 45 Lelt ventricle Fig. &1T Foruela for meas! Diastole oer ‘ systolic counts Ejection fraction (%) = — * 10K > counts — background Normal values iver mean 65%, range 55-75%CARDO 6.3.2 Gated blood pool studies There is a constant relationship between the electrical and mechanical phases of the heart. Time (seconds) OO Ot 02 1S Oe Ss oe OF oe Venbricle a . oo S- W | & | x” a 40 zo 2° wl i i Ei Heart sounds K T BOG r Events in the careiae cycle Fig. 6.13 Events ire ie confine ewele. Linking the bcc with the gamma camera and computer system permits images te be obtained of the heart cavities from 2 (systole and diastole) to multiple Utypically 16-32) moments in time throughout the cardiac cycle This is achieved by storing data from each part of the cycle inte a different memory of the data system until enowgh can be summed to produce a statistically satisfactory image typically 5-10 minutes. ‘Trigger = Record | Bet _ lendsystoticd Fig. 6.0 ECG: simple teu-yate systom for sustole dant dvestole, TY monitor e-cliaateic) 407Fig. 6.15 408Avtral contraction fp rate rer Dhastole Peak, filling rate Sastele Time 7 ieee 400CARDIAC Points to note in evaluating a gated study ‘What is the relative volume of the cardiac chambers? Do the wentrickes contract normally? Assess the end- diastolic and end-systolic volumes of the left and right ventricle, Assess the long axis shortening of the left ventricle on the anterior view. Are there any regional wall notion abnormalities thypokinesis, akinesis, paradoxical movenvent}? Calculation of ejection fraction The left ventricular ejection fraction (Lver) is caleu- Tated by defining the left ventricular region of inter- est (ROW and a background region. These ous are defined anatomically using standard computer Processing software. Threshold and second derivative methods are generally used, From the derived, background-corrected — time-activity curve, — the ejection fraction may be calculated. Again, this value is automatically calculated using standard nuclear medicine software. Left ventricular ejection fraction (iver) = Table 6.2 Errors in ejection fraction aneasarement * Are the atria contracting? This is the best way to assess the quality of the gating, * De the ventricles contract simultaneously, ie, could there be a conduction defect? * What changes occur during the stress studies? Ibis essential that adecpaate counts / frame are obained to accurately define the left ventricular region. The following parameters may also be calculated if adequate frames,‘cycle are acquired: * Lv peak emptying rate * Lv peak filling rate * Time to end-systole * Time from end-systole to diagnosis Counts in Ly at end-diastole — counts in LV at end-systole Counts in iv at end-diastoke — background counts Tao mich hackgroiand subtraction leg background acd over spleen, aorta Including the left atetuns in leit vestricl: nov ip systole, especially when the bell atriant is enlanged Toolittle background subtraction (eg L801, pleural or pericardial effusion) ‘Operestieeatiant End-disstolic Roi boo Large Linatewestimarion Poor separation of right and left ventricles Found (nom-wartable) background ane Variable gating Presence of anterior ancurysm LHL, leit ventricular bepertrophy, aaCURA’ be eee ae a bl and amplitude) | T/A curves are ge Using f Bes ner rie analysis, ed to each p al erns can be sivow aktil, Pep tr cobour shad sure of the ween the ma: n anc th B the ti he time wh pixel, irrespective when the difference oceurs—or phase maximum change occurs. In per » amplitude will indicate a well comtractin, but will alse be a reggioat Id be identi mine ross, paradox: however fied on the ph: would be quite amplitude obtain wptir arti CARDIAL Table 63 Choice of stress Stress Efieet Advantages Disadvantages Values for Lv0r respense Resting value Normal Abnormal Dynamic supine = Treand re Physiological = Technically difficult because of 55-75% <5 rise 2am oF erect bicycle: Te Patient movement or fall Fall in er onerciae Sensitivity drops rapidly bekrw maniznurn efloat Requires cooperation and agility Isometric stress tw Simple, no May not be sustained for long Slight T BF patient enough to collect data mawement 53-75% Riseor

Вам также может понравиться

• Fear: Trump in the White House

  

  От Everand

  Fear: Trump in the White House

  Bob Woodward

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (738)
• A Man Called Ove: A Novel

  

  От Everand

  A Man Called Ove: A Novel

  Fredrik Backman

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (4609)
• A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  

  От Everand

  A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  Dave Eggers

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (231)
• • Журналы
  • Подкасты
  • Нотное издание
• The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  

  От Everand

  The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  Viet Thanh Nguyen

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (119)
• Never Split the Difference: Negotiating As If Your Life Depended On It

  

  От Everand

  Never Split the Difference: Negotiating As If Your Life Depended On It

  Chris Voss

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (838)
• Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  

  От Everand

  Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  Gilbert King

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (265)
• The Little Book of Hygge: Danish Secrets to Happy Living

  

  От Everand

  The Little Book of Hygge: Danish Secrets to Happy Living

  Meik Wiking

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (399)
• Grit: The Power of Passion and Perseverance

  

  От Everand

  Grit: The Power of Passion and Perseverance

  Angela Duckworth

  Рейтинг: 4 из 5 звезд

  4/5 (587)
• The World Is Flat 3.0: A Brief History of the Twenty-first Century

  

  От Everand

  The World Is Flat 3.0: A Brief History of the Twenty-first Century

  Thomas L. Friedman

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (2219)
• Yes Please

  

  От Everand

  Yes Please

  Amy Poehler

  Рейтинг: 4 из 5 звезд

  4/5 (1891)
• The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  

  От Everand

  The Subtle Art of Not Giving a F*ck: A Counterintuitive Approach to Living a Good Life

  Mark Manson

  Рейтинг: 4 из 5 звезд

  4/5 (5794)
• Principles: Life and Work

  

  От Everand

  Principles: Life and Work

  Ray Dalio

  Рейтинг: 4 из 5 звезд

  4/5 (599)
• Team of Rivals: The Political Genius of Abraham Lincoln

  

  От Everand

  Team of Rivals: The Political Genius of Abraham Lincoln

  Doris Kearns Goodwin

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (234)
• Rise of ISIS: A Threat We Can't Ignore

  

  От Everand

  Rise of ISIS: A Threat We Can't Ignore

  Jay Sekulow

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (137)
• Shoe Dog: A Memoir by the Creator of Nike

  

  От Everand

  Shoe Dog: A Memoir by the Creator of Nike

  Phil Knight

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (537)
• The Emperor of All Maladies: A Biography of Cancer

  

  От Everand

  The Emperor of All Maladies: A Biography of Cancer

  Siddhartha Mukherjee

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (271)
• The Glass Castle: A Memoir

  

  От Everand

  The Glass Castle: A Memoir

  Jeannette Walls

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (1711)
• The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

  

  От Everand

  The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are

  Brene Brown

  Рейтинг: 4 из 5 звезд

  4/5 (1090)
• A Tree Grows in Brooklyn

  

  От Everand

  A Tree Grows in Brooklyn

  Betty Smith

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (1929)
• Her Body and Other Parties: Stories

  

  От Everand

  Her Body and Other Parties: Stories

  Carmen Maria Machado

  Рейтинг: 4 из 5 звезд

  4/5 (821)
• The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  

  От Everand

  The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  Ben Horowitz

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (344)
• John Adams

  

  От Everand

  John Adams

  David McCullough

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (2409)
• The Woman in Cabin 10

  

  От Everand

  The Woman in Cabin 10

  Ruth Ware

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (2322)
• Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  

  От Everand

  Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  Margot Lee Shetterly

  Рейтинг: 4 из 5 звезд

  4/5 (890)
• Martin Paul Eve (Auth.) - Pynchon and Philosophy - Wittgenstein, Foucault and Adorno-Palgrave Macmillan UK (2014)

  

  Документ238 страниц

  Martin Paul Eve (Auth.) - Pynchon and Philosophy - Wittgenstein, Foucault and Adorno-Palgrave Macmillan UK (2014)

  Pedro Lopez

  67% (3)
• Sing, Unburied, Sing: A Novel

  

  От Everand

  Sing, Unburied, Sing: A Novel

  Jesmyn Ward

  Рейтинг: 4 из 5 звезд

  4/5 (1103)
• Wolf Hall: A Novel

  

  От Everand

  Wolf Hall: A Novel

  Hilary Mantel

  Рейтинг: 4 из 5 звезд

  4/5 (3811)
• Angela's Ashes: A Memoir

  

  От Everand

  Angela's Ashes: A Memoir

  Frank McCourt

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (440)
• Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  

  От Everand

  Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  Ashlee Vance

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (474)
• The Art of Racing in the Rain: A Novel

  

  От Everand

  The Art of Racing in the Rain: A Novel

  Garth Stein

  Рейтинг: 4 из 5 звезд

  4/5 (4200)
• The Unwinding: An Inner History of the New America

  

  От Everand

  The Unwinding: An Inner History of the New America

  George Packer

  Рейтинг: 4 из 5 звезд

  4/5 (45)
• The Yellow House: A Memoir (2019 National Book Award Winner)

  

  От Everand

  The Yellow House: A Memoir (2019 National Book Award Winner)

  Sarah M. Broom

  Рейтинг: 4 из 5 звезд

  4/5 (98)
• The Perks of Being a Wallflower

  

  От Everand

  The Perks of Being a Wallflower

  Stephen Chbosky

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (2099)
• The Constant Gardener: A Novel

  

  От Everand

  The Constant Gardener: A Novel

  John le Carre

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (104)
• The Outsider: A Novel

  

  От Everand

  The Outsider: A Novel

  Stephen King

  Рейтинг: 4 из 5 звезд

  4/5 (1839)
• The Light Between Oceans: A Novel

  

  От Everand

  The Light Between Oceans: A Novel

  M.L. Stedman

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (789)
• Little Women

  

  От Everand

  Little Women

  Louisa May Alcott

  Рейтинг: 4 из 5 звезд

  4/5 (104)
• On Fire: The (Burning) Case for a Green New Deal

  

  От Everand

  On Fire: The (Burning) Case for a Green New Deal

  Naomi Klein

  Рейтинг: 4 из 5 звезд

  4/5 (73)
• Assesment of The Newborn Baby-Kuliah

  

  Документ66 страниц

  Assesment of The Newborn Baby-Kuliah

  Dhana Astika

  Оценок пока нет
• Brooklyn: A Novel

  

  От Everand

  Brooklyn: A Novel

  Colm Tóibín

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (1937)
• History of the stethoscope

  

  Документ2 страницы

  History of the stethoscope

  pswaminathan

  100% (1)
• FCPS-II General Medicine

  

  Документ38 страниц

  FCPS-II General Medicine

  Azfar Farogh

  50% (2)
• Manhattan Beach: A Novel

  

  От Everand

  Manhattan Beach: A Novel

  Jennifer Egan

  Рейтинг: 3.5 из 5 звезд

  3.5/5 (792)
• Bad Feminist: Essays

  

  От Everand

  Bad Feminist: Essays

  Roxane Gay

  Рейтинг: 4 из 5 звезд

  4/5 (1015)
• Postnatal Care

  

  Документ19 страниц

  Postnatal Care

  jomarie gamiao

  0% (1)
• CPAP

  

  Документ53 страницы

  CPAP

  vibhurocks

  Оценок пока нет
• Guideline For Medical Internship Program

  

  Документ41 страница

  Guideline For Medical Internship Program

  Mufaddal Madraswala

  50% (2)
• Steve Jobs

  

  От Everand

  Steve Jobs

  Walter Isaacson

  Рейтинг: 4.5 из 5 звезд

  4.5/5 (806)
• Induction of Labour: Maternity and Neonatal Clinical Guideline

  

  Документ30 страниц

  Induction of Labour: Maternity and Neonatal Clinical Guideline

  Fino Gunners

  Оценок пока нет
• (Literature in Context) Inger H. Dalsgaard - Thomas Pynchon in Context-Cambridge University Press (2019) 2 PDF

  

  Документ412 страниц

  (Literature in Context) Inger H. Dalsgaard - Thomas Pynchon in Context-Cambridge University Press (2019) 2 PDF

  Pedro Lopez

  Оценок пока нет
• (Modern American Literature) Pynchon, Thomas - Smith, Evans Lansing - Pynchon, Thomas - Thomas Pynchon and The Postmodern Mythology of The Underworld-Peter Lang Publishing Inc (2013) PDF

  

  Документ355 страниц

  (Modern American Literature) Pynchon, Thomas - Smith, Evans Lansing - Pynchon, Thomas - Thomas Pynchon and The Postmodern Mythology of The Underworld-Peter Lang Publishing Inc (2013) PDF

  Pedro Lopez

  Оценок пока нет
• Wp4 Appendicitis Management Protocol

  

  Документ21 страница

  Wp4 Appendicitis Management Protocol

  Pedro Lopez

  Оценок пока нет
• CCA DX y Criterios de Severidad Colecistitis Tokyo 2018

  

  Документ33 страницы

  CCA DX y Criterios de Severidad Colecistitis Tokyo 2018

  Ruben Lopez

  Оценок пока нет
• Heridas Faciales Sabatino2013

  

  Документ10 страниц

  Heridas Faciales Sabatino2013

  Pedro Lopez

  Оценок пока нет
• Pathological Gait Patterns in Coxa Retrotorta in Pediatric Population-Supplementary Examination For Preoperative Planning?

  

  Документ2 страницы

  Pathological Gait Patterns in Coxa Retrotorta in Pediatric Population-Supplementary Examination For Preoperative Planning?

  Gabriela Istrati-Stanciugel

  Оценок пока нет
• AO 2016-0042 Annex H-6b Checklist For Review of Floor Plans - Level 2 Hospital

  

  Документ6 страниц

  AO 2016-0042 Annex H-6b Checklist For Review of Floor Plans - Level 2 Hospital

  Niel Hagape

  Оценок пока нет
• Capsular Tension Rings:: Current Indications and Outcomes

  

  Документ12 страниц

  Capsular Tension Rings:: Current Indications and Outcomes

  Shahid Manzoor

  Оценок пока нет
• Bta Brochure 10-15 Complete

  

  Документ8 страниц

  Bta Brochure 10-15 Complete

  Pop Ion

  Оценок пока нет
• General Anaesthesia

  

  Документ53 страницы

  General Anaesthesia

  peter singal

  100% (2)
• Figo Staging Systems 2009 Uterine Sarcoma

  

  Документ1 страница

  Figo Staging Systems 2009 Uterine Sarcoma

  lokdonlub

  Оценок пока нет
• Elbow Examinationel

  

  Документ3 страницы

  Elbow Examinationel

  Aboud Abbassi

  Оценок пока нет
• Catalogo Rmo

  

  Документ301 страница

  Catalogo Rmo

  chachocara

  Оценок пока нет
• Integrative Literature Review

  

  Документ17 страниц

  Integrative Literature Review

  api-426049026

  Оценок пока нет
• Exam Bioelectricity TUDeft 10april2015 - Answers

  

  Документ12 страниц

  Exam Bioelectricity TUDeft 10april2015 - Answers

  Jan Matyáš

  Оценок пока нет
• NIMS Electronic Telephone Exchange Provisional Numbers

  

  Документ13 страниц

  NIMS Electronic Telephone Exchange Provisional Numbers

  Sumant Bhardvaj

  Оценок пока нет
• Sample Script Nursing

  

  Документ28 страниц

  Sample Script Nursing

  husnainjumi

  Оценок пока нет
• Interrelationship Between Periodontics and Restorative Dentistry

  

  Документ19 страниц

  Interrelationship Between Periodontics and Restorative Dentistry

  Superna Tiwari

  Оценок пока нет
• Power Point Pulse Oximetry

  

  Документ11 страниц

  Power Point Pulse Oximetry

  anon_47299004

  Оценок пока нет
• Epilepsy in African-Region

  

  Документ56 страниц

  Epilepsy in African-Region

  Jaiye Weiss

  Оценок пока нет
• Cleft Lip and Palate Care

  

  Документ16 страниц

  Cleft Lip and Palate Care

  Ismail Lubis

  Оценок пока нет
• 1 Classification of Extensively Damaged Teeth To Evaluate Prognosis - JCDA - Essential Dental Knowledge

  

  Документ9 страниц

  1 Classification of Extensively Damaged Teeth To Evaluate Prognosis - JCDA - Essential Dental Knowledge

  A Aran Prastyo

  Оценок пока нет
• Kristen Parker CV 2021

  

  Документ5 страниц

  Kristen Parker CV 2021

  api-536649999

  Оценок пока нет
• Presented by Dr. K. M. Rukhshad Asif Zaman Khan Department of Orthodontics and Dentofacial Orthopaedics

  

  Документ21 страница

  Presented by Dr. K. M. Rukhshad Asif Zaman Khan Department of Orthodontics and Dentofacial Orthopaedics

  Rukshad Asif Jaman Khan

  Оценок пока нет
• 3 Giving Suggestion (About Health)

  

  Документ9 страниц

  3 Giving Suggestion (About Health)

  dedeh rosita

  Оценок пока нет
• Hearing Related Quality of Life Outcomes For 2016 European Annals of Otorhi

  

  Документ6 страниц

  Hearing Related Quality of Life Outcomes For 2016 European Annals of Otorhi

  ElmoPranauskas

  Оценок пока нет
• 1ST Prelim Exam in Eng 7 - P

  

  Документ3 страницы

  1ST Prelim Exam in Eng 7 - P

  Reyna Gian

  Оценок пока нет