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63 Cards in this Set
- Front
- Back
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QA
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Al breakthrough <10 ug/ml; Mo breakthrough <0.15 uCi/1 mCi Tc99m; Mo breakthrough determined by counting eluate in well counter without and with lead shield; radiochemical purity determined with thin layer chromatography, free Tc04 migrates in saline and methanol, Tc99m compounds migrate in saline only; daily - extrinsic flood with collimator with Co57 sheet source (10 million counts), intrinsic flood without collimator with Tc-99m-O4 point source at ceiling; weekly – bar phantom; biweekly – SPECT floods (120 million counts)
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Poor image quality:
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wrong photopeak, patient too far from collimator, wrong type of collimator, wrong isotope, cracked crystal, cracked PMT, tracer contamination on crystal
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PIOPED criteria:
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high prob (>80%) - >2 large (>75%) segmental V/Q mismatches or arithmetic equivalent in moderate or large and moderate defects; intermediate prob (20-79%) – 1 moderate (25-75%) to 2 large segmental V/Q mismatches or arithmetic equivalent, single matched V/Q defect with clear CXR, triple matched defects; low prob (<20%) – nonsegmental perfusion defects, any perfusion defect with substantially larger CXR abnormality, matched V/Q defects with normal CXR, any number of small (<25%) perfusion defects with normal CXR; normal – no perfusion defects
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V/Q mismatch:
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PE, tumor compression of PA, hypoplastic PA, vasculitis, atelectasis (reverse mismatch)
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Matched V/Q defects:
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consolidation, COPD, atelectasis, tumor, bulla, pneumonectomy
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Lung scan (other):
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clumped MAA, stripe sign, fissure sign; R to L shunt – activity in kidneys and brain; central deposition of DTPA – COPD; liver uptake on perfusion study – SVC obstruction; liver uptake on ventilation study – fatty liver; delayed washin and washout on Xe study – air trapping; Xe leak – BPF
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Cardiac:
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perfusion defects – reversible is ischemia, fixed is infarct or hibernating; wall motion – normal, akinesis (scarred), hypokinesis (injured), dyskinesis (paradoxical wall motion, CABG, aneurysm), tardokinesis; RUG – adriamycin stopped if EF<45% or drops 15%
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Stress test endpoints:
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severe angina, hypotension, arrhythmias, AMI, fatigue, dyspnea, target workload achieved
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Pharmacologic stress:
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unable to exercise, use persantine (0.142 mg/kg/min) or adenosine, reverse with theophylline (50-100mg), use dobutamine if COPD on theophylline; use pharmacologic stress for LBBB (o/w may see reversible septal defect)
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Increased lung uptake on thallium
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LV failure, pulmonary venous HTN
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Viable myocardium:
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normal, reversible defect, fixed defect with >50% tracer uptake of normal myocardium; hibernating – blood flow and function chronically reduced; stunned – blood flow normal and function reduced
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False negative thallium:
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: submaximal exercise, noncritical stenosis, small ischemic area, medications
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False positive thallium:
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any cardiomyopathy, LBBB, infiltrative cardiac disease, ST attenuation
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Paradoxical septal movement
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septal ischemia, previous cardiac surgery, LBBB or pacemaker, RV overload
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Pyrophosphate uptake:
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MI, LV aneurysm, cardiomyopathy, myocarditis, pericarditis, amyloid
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GB not visualized:
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acute cholecystitis, prolonged fasting, recent meal, cholecystectomy, GB agenesis
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Biliary system not visualized
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biliary atresia, long-standing bile duct obstruction
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Low hepatic and renal activity:
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severe liver disease, neonatal hepatitis
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Bowel not visualized:
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choledocholithiasis, ampullary stenosis, CCK given pre-scan
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Abnormal tracer collections:
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bile leak, choledochal cyst, Caroli’s, duodenal diverticulum; rim sign specific for acute cholecystitis
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False negative HIDA:
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duodenal diverticulum simulating GB, accessory cystic duct
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False positive HIDA:
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recent meal, prolonged fasting, liver dysfunction, hyperalimentation
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Pharmacologic HIDA:
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if GB not seen in 60 min, can give morphine 0.04 mg/kg (2-3mg) and scan for additional 30 min, but don’t give if morphine allergy or CD obstruction; if bowel not seen at 60 min, can give CCK 0.02 ug/kg (1-2ug) and scan additional 30 min, also can evaluate GB EF (30% in 30 min), can give CCK prior to scan if distended; phenobarbitol 5 mg/kg/day x 5 days prior to scan for biliary atresia and delayed scan up to 24 hrs
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Sulfur colloid:
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focal liver uptake - FNH, regenerative nodule, Budd-Chiari (hot caudate), SVC or IVC obstruction; renal transplant uptake – rejection; colloid shift into marrow, spleen, lungs, kidneys – severe liver dysfunction; all hepatic masses cold except for FNH; filtered SC for sentinel node study – breast, melanoma
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Blood pool:
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hemangioma (2cm); if immediate uptake consider hypervascular met; heat damaged rbc – splenic remnant, splenosis, accessory spleen
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GI bleed scan:
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sensitivity 0.1 ml/min; uptake conforming to bowel with no change over time – IBD, TcO4 excreted into bowel; uptake conforming to bowel with progressive accumulation over time -–hemorrhage; uptake not conforming to bowel – aneurysm
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RLQ activity on Meckel scan
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Meckel’s diverticulum with ectopic gastric mucosa (25%), other duplication cyst with ectopic gastric mucosa, renal, active bleeding sites, tumor, IBD; prep with pentagastrin and cimetidine
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Gastric emptying:
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50% in 50 min; delayed – diabetic gastroparesis, obstruction; rapid - postoperative, PUD, ZE syndrome, drugs
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Focal renal cold defects
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tumor, cyst, abscess, scar, duplex collecting system, trauma, infarct; DMSA – pyelonephritis, scar
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Focal hot renal lesions:
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collecting system, leak, cross-fused ectopic, horseshoe
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Dilated ureter or collecting system:
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reflux (most common), obstructed or nonobstructed ureter (Lasix renogram to distinguish, delayed parenchymal clearance >20min)
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Delayed uptake and excretion (renal failure):
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prerenal – poor flow and uptake, unilateral, RAS (ascending pattern with captopril, beware of hypotension), RVT; renal – bilateral, ATN (nl uptake, poor excretion), GN (poor uptake and excretion), CRF; postrenal – obstruction
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Nonvisualized kidney:
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nephrectomy, ectopic kidney, renal artery occlusion, hyperacute rejection in transplant
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Renal transplant complications
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ATN, cyclosporine toxicity, acute rejection, obstruction, urinoma, lymphocele, hematoma, abscess
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Decreased testicular uptake:
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torsion, orchiectomy
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Increased testicular uptake:
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epididymoorchitis
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Ring sign:
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late torsion, tumor with central necrosis, abscess, trauma
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Focal hot bone lesions:
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tumor; inflammation – osteomyelitis, arthritis; congenital – OI, TORCH; metabolic – marrow hyperplasia, Paget’s, FD; trauma – fracture (rib fxs linear distribution), stress fx (e.g. Honda sign), avulsion injury, AVN, RSD, THR (negative within 6 mos), spondylolysis, child abuse; vascular – sickle cell; transient osteoporosis of hip; flare phenomenon – good response to chemotherapy
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Focal cold bone lesions:
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mets most common – myeloma, lymphoma, renal, thyroid, neuroblastoma; primary bone lesions – SBC, ABC, EG; vascular – infarction, AVN (get pinhole view), radiation; artifact – overlying pacemaker, barium, jewelry, prosthesis
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Positive 3-phase bone scan:
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osteomyelitis, healing fx, tumor, orthopedic implants, AVN, RSD, neuropathic osteoarthropathy; cellulitis – flow and blood pool positive, delayed negative; shin splints – flow and blood pool negative, delayed positive
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Superscan:
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diffuse high bone uptake, diminished soft tissue and renal activity, high sternal uptake, increased uptake at costochondral junction; mets (usu focal) – prostate (most common), breast, lung; metabolic – HPT, renal osteodystrophy, osteomalacia, Paget’s (hot and cold); myelofibrosis (large spleen)
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Diffuse periosteal uptake (tramtrack):
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HPO, child abuse, venous insufficiency, thyroid acropachy
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Extraosseous activity on bone scan:
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soft tissues – cellulitis, renal failure, radiotherapy ports, myositis ossificans, muscle injury, dermatomyositis, rhabdomyolysis, tumors with calcifications, neuroblastoma in child, sinusitis, SVC obstruction (upper body), IVC obstruction (lower body), lymphedema (arm + anterior ribs); injection abnormalities – infiltration, scatter, lymph node uptake, intraarterial injection (glove phenomenon); kidney – dehydration (most common cause), urinary tract obstruction, hypercalcemia, chemotherapy, radiation, Al contamination; breast – pregnancy, lactation, mastitis, inflammatory breast CA, steroids, radiation; stomach, GI – free TcO4, HPT, hypercalcemia, bowel infarction, prior MIBI scan; liver – mets, prior sulfur colloid scan, Al contamination; spleen – sickle cell, thalassemia, breast CA, lymphoma; lung – HPT, lung tumor, pulmonary hemosiderosis, alveolar microlithiasis, metastatic osteosarcoma, prior lung scan; pleural – malignant pleural effusion, pleural met, mesothelioma, chest wall tumor, fibrothorax; heart – MI, CM, myocarditis, pericarditis, amyloid; other – brain infarction, urine in socks contamination, skin contamination, vascular calcification, calcified fibroid, photopenic bowel from barium;
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hypercalcemia
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increased uptake in lung and stomach and kidney
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Al contamination
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increased uptake in liver and kidney
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excess TcO4
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increased uptake in soft tissues, salivary, thyroid, stomach, choroid plexus, decreased uptake in bone;
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bisphosphonates
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diffuse decreased uptake in bones
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amyloid
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diffuse increased uptake in myocardium
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Diffuse increased thyroid uptake:
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Graves, early Hashimoto’s thyroiditis, toxic MNG, functioning adenoma (focal)
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Diffuse decreased thyroid uptake:
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thyroiditis – subacute, postpartum, late Hashimoto’s; meds – thyroid hormone therapy, iodine intake or contrast, PTU, tapazole; thyroid ablation – surgery, I131; lingual thyroid; unilateral – surgery, replacement by hypofunctioning tumor, suppression by hot nodule, hemiagenesis
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Heterogeneous thyroid uptake:
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MNG, multiple autonomous nodules, Hashimoto’s, CA
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Cold nodule:
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adenoma/colloid cyst (85%), CA (10%), focal thyroiditis, hemorrhage, lymph node, abscess, parathyroid adenoma
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I-131 therapy:
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Graves 10-15 mCi, Plummer’s 30 mCi, residual tissue 30-100 mCi, mets 100-200 mCi
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Positive parathyroid scan:
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parathyroid adenoma, hyperplasia, thyroid adenoma, lymph node, CA
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Gallium positive scan:
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sarcoid (lambda and panda sign), PCP, lymphoma (thallium better for low-grade), osteomyelitis (better than wbc study for discitis/osteomyelitis), amyloid, parotid, lacrimal; KS is gallium(-)/thallium(+); increased lung uptake – sarcoid, PCP, TB, MAI, CMV, lymphoma, chemotherapy (bleomycin), lipiodol; increased parotid and lacrimal uptake – sarcoid, Sjogren’s, radiation
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Diffuse decreased gallium activity:
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hemochromatosis, iron overload, post-chemotherapy
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WBC scan:
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all infections in abdomen, osteomyelitis, vascular graft infection
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Neuroendocrine tumors
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MIBG (esp pheochromocytoma, give Lugol’s to protect thyroid), octreotide (hot spleen and kidneys)
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PET indications:
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SPN, NSCLC, melanoma, lymphoma, colorectal, residual/recurrent brain tumor vs radiation necrosis
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PET of SPN:
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false negative – small nodule <1cm, BAC, carcinoid; false positive – benign tumor, inflammation, infection
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Brain death:
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no flow to cerebral cortex, can get hot nose sign
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Focal brain cold defect:
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infarct, neoplasm, hemorrhage, crossed cerebellar diaschisis (contralateral cerebellum no uptake after stroke), interictal siezure focus; diagnostic patterns – Alzheimer’s (temporal, parietal), Pick’s (frontal, temporal), multiinfarct dementia
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Cisternogram:
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500 uCi In-111 DTPAintrathecal; evaluate for NPH (activity in lateral ventricles), CSF leak (check nasal pledgets), CSF shunt patency
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