Prepared by:

Dr Majid Al-Homiedan
Dr Yasser Al-Ghamdi

NUCLEAR
MEDICINE
CONTEST
1
•Which radiopharmaceutical commonly used for cystography?
•What is the advantage over MCUG?
•What is the difference between direct and indirect cystography?
•How is reflux graded with radiopharmaceutical cystography?
• Which radiopharmaceutical commonly used for cystography?
• What is the advantage over MCUG?
• What is the difference between direct and indirect cystography?
• How is reflux graded with radiopharmaceutical cystography?

 99mTc DTPA and 99mTc Sulfur colloid.

 More sensitive in detection of VUR and 50 to 200

times less radiation to the gonads.

 Direct: cathetrization and instillation of tracer inside

the bladder, indirect: performed after routine
renography.

 Mild reflux: confined to the ureter, moderate: reaches

the pelvicalyceal system, severe: distorted collecting
system and dilated tortuous ureters.
2
•Describe the scintigraphic findings?
•Give the diagnosis?
•What treatment options are appropriate for this patient?
•What would you expect the radioactive iodine uptake would be?
 • Describe the scintigraphic findings?
• Give the diagnosis?
• What treatment options are apropriate for this patient?
• What would you expect the radioactive iodine uptake would
be?

 Hot nodule in the right thyroid lobe with

supression of the remaining gland.

 Toxic autonomous thyroid nodule.

 Surgery and radioactive iodine 131I , therapy

with PTU or methimazole sometimes is used as
initial treatment.

 May be moderately elevated, but its often in the

normal range. Normal 24 hours uptake is 10%
to 30%.
3
•What is the radiopharmaceutical and mechanism of
distribution?
•What are the most common causes of acute testicular
pain?
•What is the mechanism of testicular torsion?
•What are the imagining findings and diagnosis in this
case?
• What is the radiopharmaceutical and mechanism of distribution?
• What are the most common causes of acute testicular pain?
• What is the mechanism of testicular torsion?
• What are the imagining findings and diagnosis in this case?

 99mTc pertechnetate, initial blood flow and distributes

in the extracellular fluid space.

 Acute epidydimitis, testicular torsion, torsion of the

testicular appendage.

 Developmental anomalies of testicular decent and

attachment predisposes to spermatic cord torsion, the
most common anomaly is the bell-clapper testis.

 Decreased blood flow to the left testicle and

photopenic on delayed image consistent with acute
testicular torsion.
4
•Describe the bone scan findings?
•Name two non-osseous systems that
should be evaluated on bone scan?
•Describe any other finding?
•What term can applied to this case?
• Describe the bone scan findings?
• Name two non-osseous systems that should be evaluated on bone scan
• Describe any other finding?
• What term can applied to this case?

 Increased radiotracer uptake in large majority of

visualized bones, especially the appendicular
skeleton with focal areas of increased uptake in
femur and tibia bilaterally.

 Soft tissues and genitourinary system.

 Faint activity in the kidneys, little soft tissue

activity seen.

 Superscan secondary to Osteomalacia.

5
Describe the findings?
Provide the differential diagnosis?
What is the likely diagnosis in this case ?
Discuss the pathogenesis?
 • Describe the findings?
• Provide the differential diagnosis?
• What is the likely diagnosis in this case ?
• Discuss the pathogenesis?

 Three phase study, abnormal increased blood flow and

blood pool of the distal right upper extremity, the delayed
phase shows increased activity in the bones in the same
distribution, with striking increase in periarticular activity.

 Reflex sympathetic dystrophy syndrome, disuse of limb

of new onset.

 Reflex sympathetic dystrophy syndrome (Sudek’s

atrophy).

 Neurogenic origin with loss of sympathetic autonomic

tone is the generally accepted explanation, although not
firmly established.
6
•Describe the bone scan findings?
•Provide the differential diagnosis?
•What are the phases of this disease?
•The patient may experience clinical symptoms related to another organ system, discuss the mechanism?
•Describe the bone scan findings?
•Provide the differential diagnosis?
•What are the phases of this disease?
•The patient may experience clinical symptoms related to another organ system,
discuss the mechanism?

 Abnormal high uptake in the left femur which appears

widened and bowed, increased uptake is seen in the pelvis
and left first metatarsal are also seen.

 Paget’s disease, fibrous dysplasia, chronic osteomyelitis

and primary bone tumors in particular osteosarcoma.

 Lytic, sclerotic and mixed.

 High output congestive heart failure, once believed to be

sue to arteriovenous malformation in the bone lesion, now
hyperemia and increased blood flow to the lesion and not
shunting.
7
•Describe the findings?
•What other imaging study should be ordered?
•What is the diagnosis and most likely common cause for this scan?
•Mention other causes of this condition?
•Describe the findings?
•What other imaging study should be ordered?
•What is the diagnosis and most likely common cause for this scan?
•Mention other causes of this condition?

General increased activity in the long bones with

pericorticalstriping along the medial and lateral aspects of
lower extremities (railroad tracking) characteristic.

Chest x-ray

Hypertrophic pulmonary osteoarthropathy, bronchogenic

cancer of the lung.

Mesothelioma, pulmonary mets, bronchiectasis, mediastinal

disease (hodgkin’s), lung abscess, asthma, cystic fibrosis,
CCHD, bacterial endocarditis,r egional enteritis, UC and
congenital billiary atresia.
This is the chest x-ray of the
patient
8
•Describe the difference between Grave’s disease and euthyroid scan appearance?
•What is the appropriate therapy for Grave’s disease?
•What are the usual administered doses of 131I uptake, 123I scan and Grave’s disease therapy?
•What are the short term and long term side effects of 131I therapy?
• Describe the difference between Grave’s disease and euthyroid scan
appearance?
• What is the appropriate therapy for Grave’s disease?
• What are the usual administered doses of 131I uptake, 123I scan and Grave’s
disease therapy?
• What are the short term and long term side effects of 131I therapy?

 May be similar, with large goiter the scan often has plumper appearance
with convex borders, the pyramidal lobe maybe seen.

 Surgery, seldom performed. PTU and methimazole sometimes used

initially particularly in patients with severe disease who require cooling
down, young children and pregnant patients. Most of the times treated
with radioactive iodine after 6 to 12 months of antithyroid medication.
Many patients are treated initially with 131I.

 131Iuptake (10 µCi), 123I scan and uptake (300 µCi), Grave’s disease
therapy 131I (5 to 15 mCi).

 Short term: exacerbation of hyperthyroidism, cardiac symptoms in elderly,

very rare thyroid storm. Long term: hypothyroidism, there is no increased
incidence of secondary cancers, reduction in fertility or congenital
defects.
9
•If the EEG is flat line, why is another study indicated?
•What are the clinical findings of brain death?
•List 2 different types of tracers with different mechanism that could be used in this study?
•What are the scintigraphic findings and diagnosis?
• If the EEG is flat line, why is another study indicated?
• What are the clinical findings of brain death?
• List 2 different types of tracers with different mechanism that could be used in this
study?
• What are the scintigraphic findings and diagnosis?

 A flat EEG can be caused by barbiturates, depressive

drugs or hypothermia.

 Deep coma, no brain stem reflexes or spontaneous

respiration, exclusion of reversible causes and the
cause of the brain dysfunction must be diagnosed.

 99mTc DTPA or Tc pertechnetate can be used as a

brain flow study. However Tc HM-PAO and 99mTc ECD
have the advantage of irreversible cellular binding on
the first pass allowing for delayed images.

 No blood flow to the cerebral cortex. Brain blood flow

study consistent with brain death.
10
•Name the radiophamaceutical used?
•List methods for preparation of this radiopharmaceutical?
•Describe the methodologies of radiolabling?
•List the advantage and disadvantage of the different radiolabling?
•Name the radiophamaceutical used?
•List methods for preparation of this radiopharmaceutical?
•Describe the methodologies of radiolabeling?
•List the advantage and disadvantage of the different radiolabeling?

 99mTc-labled RBCs.

 In-vivo, modified in-vivo and in-vitro methods.

 In-vivo: stannous pyrophosphate is adminstered IV and followed

in 15 min by 99mTc pertechnetate.
Modified in-vivo: 3 -5 mls of blood into syringe containing 99mTc
pertechnetate and anticoagulant, incubated for 10 mins and
agitated then infused.
In-vitro: blood is withdrawn and placed in a closed vial containing
stannous chloride and sodium hypochlorite to oxidize excess
extracellular stannous, then adding 99mTc pertechnetate followed
by 20 mins incubation before reinjection.

 The in-vivo method is simplest and least costly, but has the lowest
labeling efficiency. The in-vitro kit method has the highest labeling
efficiency but requires more time and cost.
THANK
YOU