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General Nuclear Medicine Part 2
 

General Nuclear Medicine Part 2

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    General Nuclear Medicine Part 2 General Nuclear Medicine Part 2 Presentation Transcript

    • For Medical Students
    • Liver scanHepatobiliary scintigraphyGI Tract• GI bleeding study• Meckel’s diverticulum• Gastroesophageal studiesBrain scanNuclear cardiology J SRIPRAPAPORN
    • THE LIVERThe biggest organ, 1500 gAnatomy: 4 parts- Right, Left, Caudate, andQuadrate lobesHistology: Hepatocytes or polygonal cells RE cells (Kupffer’s cells) phagocytosisBlood Supply: Portal vein 75 % Hepatic artery 25 % J SRIPRAPAPORN
    • LIVER-SPLEEN SCAN (Routine Liver Scan)Tracer: 99mTc-sulfer colloid/ phytateRoute : IV injectionMechanism : Phagocytosis by RE cells (liver,spl,BM)Visualization : Liver and SpleenTechnique: Patient preparation : none Imaging : 15-20 min. Pi. Static 6 views ; Ant, Post, RL, LL, RAO, LAO SPECT imagesDiagnosis : Diffuse & focal lesions focal defect(s) -nonspecific (abscess, metastasis, cyst etc.) J SRIPRAPAPORN
    • LIVER-SPLEEN SCANNormal Liver Scan Abnormal Liver Scan: Multiple focal defects J SRIPRAPAPORN
    • Tc-99m RBC LIVER SCANAim: hepatic hemangioma [hemangioma is themost common benign liver tumor ]U/S: Typical hyperechoic mass in 60%CT scan: Classical findings in 50-75%MRI has an accuracy of between 90-95%Tc-RBC imaging is the most specific test for Dxcavernous hemangioma. (Sens 90% for lesions >1.5-2 cm; Spec approaches 100%; Acc 90-95%).With SPECT lesions down to about 1 cm in size canbe detected [SPECT sensitivity by size: 1.5 cm(100%), 1 cm (65%), 0.5 cm (20%)]. Ref: www.auntminnie.com J SRIPRAPAPORN
    • HEPATIC HEMANGIOMA Vascular Study SPECT 3-D imageImaging: Flow, Static, Delayed***Positive : activity with time hot lesion J SRIPRAPAPORN
    • Liver scanHepatobiliary scintigraphyGI Tract• GI bleeding study• Meckel’s diverticulum• Gastroesophageal studiesBrain scanNuclear cardiology J SRIPRAPAPORN
    • HEPATOBILIARY IMAGING J SRIPRAPAPORN
    • HEPATOBILIARY IMAGINGTracers : 99mTc-IDA derivatives (Tc-99m DISIDA,Mebrofenin)Route : IV injectionMechnism : Carrier-mediated, non sodium dependentorganic anion transport processTechnique : - Fasting 4-6 hr - Dynamic study for at least 1 hour +/- delayed imagingVisualization : Liver and biliary system includinggallbladder until excretion into small bowel (normal =within 1 hour) J SRIPRAPAPORN
    • HEPATOBILIARY IMAGING: INDICATIONSGallbladder disease : Acute cholecystitis* • Non-visualization of the GB after 4 hrs • sen > 95% , spec > 98%Biliary tract obstruction DDx biliary atresia vs neonatal hepatitisBiliary leakage J SRIPRAPAPORN
    • NORMAL HEPATOBILIARY IMAGINGVisualization :Liver andbiliary system including Right & left hepatic ducts Common hepatic duct Common bile duct Tc-99m DISIDA Gallbladder Until excreted into small bowelWithin 1 hour J SRIPRAPAPORN
    • DISIDA Scan-Dynamic Study J SRIPRAPAPORN
    • Is it normal study ?No visualization of GB Acute cholecytitis J SRIPRAPAPORN
    • DDx Nonvisualized GBAcute cholecystitisSevere chronic cholecystitisProlonged fastingIntercurrent severe illnessAcute pancreatitisSevere liver diseaseS/P cholecystectomy Ac chole wo gallstone ! J SRIPRAPAPORN
    • False-negative TestIt is found less than 5% of patients, and may be associated with: Incomplete cystic duct obstruction Acalculous cholecystitis Accessory cystic duct Duodenal diverticulum simulating GB activity J SRIPRAPAPORN
    • NEONATAL JAUNDICEDDx biliary atresia & neonatal jaundiceSen 97-100%, spec 82-94%, and accuracy of 91%Findings of BA: Good hepatic uptake No visualization of GB Non-visualization of the biliary tree and bowelFindings of neonatal hepatitis Variable hepatic uptake // Fn. Visualization of GB Presence of radioactivity excretion into small bowel J SRIPRAPAPORN
    • BILIARY ATRESIAEarly images 24-hr image J SRIPRAPAPORN
    • HB Scintigraphy in BANormal uptake and excretion of the tracer ina jaundiced neonate excludes the diagnosisof biliary atresia.Children should be studied before age of 3monthsBeyond 3 months of age, the prolongedobstruction will begin to affect liver functionand hepatic extraction of the tracer willdeteriorate making differentiation fromhepatitis more difficult. J SRIPRAPAPORN
    • Liver scanHepatobiliary scintigraphyGI Tract• GI bleeding study• Meckel’s diverticulum• Gastroesophageal studiesBrain scanNuclear cardiology J SRIPRAPAPORN
    • GI BLEEDING STUDYBleeding from lower GI tractActive bleeding is necessary for positiveimaging.Preparation: NPOPosition: Supine- anterior abdomenTc99m-SC or Tc99m-RBC* (intermittent)Imaging: Flow 1 min Dynamic imaging for 1-2 hr with additional delayed images as required. J SRIPRAPAPORN
    • GI BLEEDING •Tc-99m RBC •Hepatic flexureExtravasation of the tracer into bowel lumen Focal area of increased activity, move // bowel movementPattern depends on site of bleeding & bowel peristalsis J SRIPRAPAPORN
    • GI BLEEDING CINE MODE SA-ING THONGKAMST, Date: 4-6-07GIV002-07 J SRIPRAPAPORN
    • Tc-99m RBC Scan vs AngiographyMore sensitive Less sensitiveLess specific More specific-causeLess anatomical details Better anatomical detailsLess invasive More invasiveLower risk Higher riskSimpler Needs more skills J SRIPRAPAPORN
    • MECKEL’S DIVERTICULUMRemnant of omphalomesenteric ductGastric mucosal lining*Common cause of lower GI bleeding in small childrenImaging: Principal: Localization of ectopic gastric mucosa Patient preparation: NPO 4 hr Radiopharm: Tc-99m pertechnetate IV. Sequential imaging for 1-2 hr. Positive findings: Focal hot spot (RLQ) // stomach activity Sen 85%, spec 95% J SRIPRAPAPORN
    • MECKEL’S DIVERTICULUM Stomach Stomach M Bladder U. Bladder J SRIPRAPAPORN
    • GASTRO-ESOPHAGEAL STUDYEsophageal transit studyGastroesophageal reflux study (milkscan)Gastric emptying study J SRIPRAPAPORN
    • GE REFLUX STUDY (MILK SCAN)Indication: To detect GE reflux:-regurgitation of gastric contentsesophagusTracers : Tc-99m phytate, Tc-99m SC 300uCiTechnique : NPO, oral tracer adm. within 30 s Supine imaging over EG junction Dynamic imaging for >10-20min. Views: anterior ( & posterior)Positive : Activity from the stomachesophagus [N < 3 %, Abn >4 %] J SRIPRAPAPORN
    • GE Reflux (Milk Scan) Rdn study provides higher sensitivity but less anatomical details than esophagogram Sensitivity and specificity for detecting GER are 75%-100% and 93%. Ref: J Nucl Med 2004; Mariani G, et al. Radionuclide gastroesophageal motor studies. 45: 1004-1028Ravelli, A. M. et al. Chest 2006;130:1520-1526 J SRIPRAPAPORN
    • Liver scanHepatobiliary scintigraphyGI Tract• GI bleeding study• Meckel’s diverticulum• Gastroesophageal studiesBrain scanNuclear cardiology J SRIPRAPAPORN
    • BRAIN IMAGING1. Conventional Rdn. brain 2. Cerebral perfusion imaging SPECT Tracers: Tc- 99m Radiopharm.: I-123 IMP , pertechnetate, Tc-99m Tc-99m HMPAO*, Tc- DTPA*, Tc-99m 99m ECD glucoheptonate Lipophilic tracers, can Hydrophilic tracers: pass intact BBB. cannot pass normal BBB. Uptake: proportion to (Normally no tracer regional cerebral blood accumulation in the brain flow tissue) Indications: CVD, Disrupted BBB epilepsy, dementias, abnormal uptake parkinsonism, ect. J SRIPRAPAPORN
    • SPECT BRAIN IMAGING Picker-Prism J SRIPRAPAPORN
    • APPLICATIONSBrain death: Tc-99m DTPA, Tc-99m HMPAO,TC-99M ECDCerebrovascular diseaseFocal seizureDementiaPsychitric disordersOthers J SRIPRAPAPORN
    • NORMAL BRAIN SPECT www.derriford.co.uk/nucmed J SRIPRAPAPORN
    • BRAIN DEATHFlow study : no appreciable intracerebralblood flow in either the internal carotid orposterior cerebral circulations.Planar static images: “Hot nose” sign due toshunting of flow from int carotid to ext carotidsystem, which supplies face & scalp.Tc-99m HMPAO SPECT: No cerebral uptake Www.cseserv.engr.scu.edu/StudentWebPages/ DZepeda/brainscin.html J SRIPRAPAPORN
    • BRAIN DEATH Tc-99m HMPAOFlow Static SPECT J SRIPRAPAPORN
    • STROKE 3DStroke at left temporoparietal region www.derriford.co.uk/nucmed J SRIPRAPAPORN
    • FOCAL SEIZURE www.derriford.co.uk/nucmed J SRIPRAPAPORN
    • ALZHIEMER’S DISEASE S P E C T Decreased perfusion at bilateral parieto-temporal regions www.derriford.co.uk/nucmed J SRIPRAPAPORN
    • ALZHIEMER’S DISEASE PET J SRIPRAPAPORN
    • PARKINSON DISEASEA labeled amino acidcalled F-DOPA is usedwith PET to see if yourbrain has a deficiency indopamine synthesis.Striatral uptake PET J SRIPRAPAPORN
    • Liver scanHepatobiliary scintigraphyGI Tract• GI bleeding study• Meckel’s diverticulum• Gastroesophageal studiesBrain scanNuclear cardiology J SRIPRAPAPORN
    • NUCLEAR CARDIOLOGYRadionuclide angiocardiography * Equilibrium gated blood pool study (GBP or MUGA study)*Myocardial infarct imagingMyocardial perfusion imaging** J SRIPRAPAPORN
    • RADIONUCLIDE ANGIOCARDIOGRAPHYFirst pass Rdn. angiocardiographyEquilibrium gated blood pool study(MUGA study)** J SRIPRAPAPORN
    • FIRST PASS RDN. VENTRICULOGRAPHYTracers: Tc-99m agentsIndications: Diagnosis of SVC obstruction (first pass) Calculation of ejection fraction: RVEF, LVEF • EF = (ED-ES)/ED J SRIPRAPAPORN
    • Equilibrium MUGATracer: Tc-99m RBCFindings Cardiac shape and size Wall motion*: global, regional Stroke volume (ED counts - ES counts) Ejection fraction (EF): LV, RV • EF = (ED counts - ES counts) / (ED counts) • Normal LVEF is typically 60-70%. (LVEF < 50% is definitely abnormal • RVEF should > 41%. J SRIPRAPAPORN
    • Equilibrium MUGAFindings (cont.) LV outputs • Phase analysis: dyskinesis eg. aneurysm • Amplitude analysis Diastolic ventricular functionIndications DDx CAD from cardiomyopathy Plan Rx valvular heart disease Monitoring cardiac toxicity from chemotherapeutic agent eg. adriamycin J SRIPRAPAPORN
    • Equilibrium MUGA J SRIPRAPAPORN
    • J SRIPRAPAPORN
    • MYOCARDIAL INFARCT IMAGINGTracer: Tc-99m pyrophosphate (PYP)Mechanism: Bind to calcium in AMIIndication: Dx AMI J SRIPRAPAPORN
    • MYOCARDIAL PERFUSION IMAGING Tracers: Thallium-201 (Tl-201) Tc-99m MIBI (Cardiolyte) Tc-99m tetrofosmin Principle: Myocardial perfusion of LV* Technique Acquire rest & stress images Stress: exercise or pharmacological tests J SRIPRAPAPORN
    • EXERCISE STRESS TEST J SRIPRAPAPORN
    • PHARMACOLOGICAL STRESS TEST Dipyridamole (Persantin) Dobutamine Adenosine J SRIPRAPAPORN
    • MYOCARDIAL PERFUSION IMAGINGImaging techniques Planar images: 2D SPECT images*: 3D • short axis, • long axis-LH, LV Gated SPECT: contractile function (LVEF)Interpretation Compare between rest & stress images • Fixed perfusion defect: infarct • Transient perfusion defect: ischemia J SRIPRAPAPORN
    • Heart Orientation & Heart Plane J SRIPRAPAPORN
    • Planes & SPECT Images LAT SEP J SRIPRAPAPORN
    • MYOCARDIAL PERFUSION IMAGING: INDICATIONSScreening - preoperative evaluationDetection of CADEvaluation of extent & severityAssess myocardial viabilityPlan of Rx: revascularization vs medical RxPost MI evaluationPrognosis of CAD patientsAssess outcome & efficacy of Rx (F/U)Dx restenosis after revascularization J SRIPRAPAPORN
    • Normal Tc-99m MIBI MPISTRESS SHORT AXISREST LONGSTRESS HORIZONTAL AXISREST J SRIPRAPAPORN
    • Normal Myocardial Perfusion Scintigraphy Polar Map Bull’s Eye J SRIPRAPAPORN
    • Fixed Defect:Inferolateral Wall MI J SRIPRAPAPORN
    • Reversible Defect:Anteroseptal Wall Ischemia J SRIPRAPAPORN
    • MPI: SummaryMyocardial perfusion study is an noninvasivenuclear medicine study that evaluate regionalmyocardial perfusion as well as LVcontraction-EF and regional wall motion in asingle setting. J SRIPRAPAPORN