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51 Cards in this Set

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what is the routine for cardiac thallium imaging
inject 2-3 mCi
image at 10 min with two windows, 69-87 keV and 167 keV
what predictive info does thallium give in MI
size of thallium infarct predicts income:
>40% of LV = 92% chance of mortality over next 9 months
<40% of LV = 7% mortality
what is adequate exercise in thallium cardiac stress imaging
85% of maxiumum HR (220-age) or 250 000 double product
when do you stop a stress test
symptoms
arrhythmia
2nd or 3rd degree heart block
ST depression over 3 mm
systolic BP decrease or HTN > 240/120
how do you tell if there was adequate exercise at imaging
no liver uptake
how often do areas of ischemia fill in delayed on standard thallium
15-35%

*pearl* reinjection reduces this to negligible
how is a dipyridamole stress test performed
give 140 ug/kg/min DP for 4 min
wait 7-9 min and inject thallium
wait 5 min and image

*pearl* reverse DP with 50-100mg of aminnophylline
how do you perform an adenosine stress test
give 140 ug/kg/min adenosine for 6 min
give thallium at 3 min
image 5 minutes later

*pearl* adenosine's half-life is seconds, so turn it off to reverse it
which type of lymphoma is best seen by gallium
hodgkin's > non-hodgkin's
which type of hodgkin's is toughest to see on gallium
lymphocyte predominant

*pearl* it also has the best prognosis
what tumors take up gallium
melanoma
lung ca
head and neck ca
sarcoma
gynecologic tumors
why must gallium be imaged late
so that kidney, lung and bowel activity is cleared - usually by 24 hours
ddx: lung uptake with gallium
Some Causes of Lung Uptake Are Tough to Remember Properly

sarcoid
CMV
lymphoma
UIP (IPF)
asbestosis/silicosis
TB/fungus
radiation/chemotherapy
PCP
when should you use gallium or indium in infection imaging
indium for most bone and belly imaging
gallium for spine imaging
how do you tell infection with bone scan and gallium imaging together
it's all relative
gallium > MDP uptake - infection
MDP > gallium - no infection
how do you image prostheses
sulfur colloid and gallium - sub out the marrow on SC from the gallium
on V/Q imaging, what is the drawback of Xe-133 imaging
low energy (keV = 81)
down scatter from Tc perfusion
what are pros and cons of radioaerosols in V/Q
pro: multiple views because aerosolized particles settle

con: no wash out info
what are the minimum requirements for particle size and number in V/Q
60 000 particles with 10-90 micron size
how do you perform a sestamibi stress cardiac study
2 ways to do it:
give 8 mCi
image 30 min later for rest
4 hours later give 20 mCi at peak stress
image 30 min later

if low likelihood of disease:
give 30 mCi for stress
- if normal: done
- if abnormal: redo next day with rest/stress
what are the benefits of first pass and MUGA with ventriculography
first pass:
rapid collection
measure at peak exercise
RV better measured

MUGA:
better counts/statistics
how is EF calculated with nucs
(end diastolic counts - end systolic counts)/end diastolic counts
when is MUGA not good to use
with afib or if >5-10% PVCs
what is a normal study for ventriculography
3 things:
no wall motion abnormality
normal chamber size
EF increases at least 5% with stress

*pearl* a decrease in EF with stress portends a bad prognosis
ddx: increased renal uptake of MDP
NO SCAR

nephrocalcinosis
obstruction
sulfur colloid/thallium
chemo
ATN
radiation
ddx: decreased renal uptake
renal failure
mets
superscan
paget's
ddx: superscan
mets
metabolic
- hyperparathyroidism
- osteomalacia
- renal failure
myelofibrosis
ddx: AVN
ASEPTICLeG

alcohol/anemia
sickle cell/SLE
exogenous steroids
pancreatitis
trauma
idiopathic
caisson's
leukemia/legg-perthes
gaucher's
in what situations is there a high chance of a solitary bone lesion being cancer
spine:
- 40-80% malignant
- higher if in pedicle/body
- lower endplate

pediatrics:
- 55% malignant
how may one image the parathyroid
3 options:
1. sestamibi
- early: uptake in both parathyroid and thyroid
- delayed: (4-6 hours) thyroid washes out, parathyroid retains

2. sestamibi minus iodine/pertechnetate

3. thallium minus iodine/pertechnetate
- subtracts thyroid - iodine/tech - from thyroid/parathyroid - thal and mibi
what drugs cause uptake on lung gallium studies
BANC

bleomycin
amiodarone
nitrofurantoin
cytoxan
ddx: resting cardiac wall-motion abnormality
contusion
infarct
severe ischemia
non-ischemic cardiomyopathy
valvular heart disease
endocarditis
abscess
what is the appearance of MI on ventriculography
ventricular dilatation
regional wall-motion abnormality
decreased EF

*pearl* EF < 35% in setting of MI = high mortality
ddx: sulfur colloid uptake in lung
DIC
EG
bone marrow transplant
trauma
infection
serum albumin elevation
radiopharmaceutical impurity
liver disease
malignancy
ddx: fatty liver infiltration
POoR ST. JUDE

pancreatitis
obesity
reye's syndrome
steroids
TPN
jejunoileal bypass
ulcerative colitis
DM
ETOH
ddx: solitary splenic lesion on sulfur colloid
infarct
abscess
hematoma
cyst
hemangioma
fibroma
hamartoma
lymphoma
met
ddx: liver hot spot on sulfur colloid
IVC/SVC obstruction
budd-chiari
regenerating nodule
FNH
ddx: absent perfusion to one lung
obstructing mass
post pneumonectomy
congenital heart disease with shunt procedure
sever parenchymal disease
massive pulmonary embolism
ddx: gallium uptake in kidneys
Nucs Scans Are Long And Tiring To Read Particularly Post-Chemo

neoplasm
sarcoid
abscess
liver failure
amyloid
TB/tuberous sclerosis
transplant
radiation
pyelonephritis
PAN chemo
where is gallium normally seen
glands (lacrimal, salivary)
nasopharynx
bone marrow
spleen
neutrophils
colon
thymus
minimal liver
ddx: delayed gastric emptying
DM
drugs
surgery
scleroderma
anorexia
amyloid
high grade obstruction
how do you do a CSF leak radionuclide cisternogram
use In-111 DTPA
inject via LP
image at 4,24 and later if necessary
include abdomen to see swallowed tracer if leaks into nose/mouth
measure pledgets from nose
- ratio of counts/gm nose: counts/gm serum
- if > 3.1 then positive for leak
ddx: meckel's scan uptake
GI DAMIT

GI tract
duplication cyst
AVM
meckel's diverticulum
inflammation (appendicitis)
tumor, hypervascular
ddx: non-visualized thyroid
subacute thyroiditis
IV contrast within 6 weeks
exogenous iodine
PTU, tapazole
foods (turnips, cabbage)
hypothyroidism
ectopic thyroid
surgery/radiation
infiltration
ddx: increased uptake in liver on MDP imaging
hepatoblastoma
hemangioendothelioma
lymphoma
hepatoma
cholangiocarcinoma
mets
aluminum breakthru
recent sulfur colloid study
amyloid
ddx: MIBG uptake
neuroblastoma
pheochromocytoma
carcinoid
medullary thyroid ca
evaluation for right to left shunt
use MAA, IV
look for uptake in brain and kidney
quantify by measuring:
- ROI of lungs
- ROI systemic (whole body - lung)
- divide systemic by systemic + lung
- normal = 1-10%
ddx: cold thyroid nodule
carcinoma
adenoma
colloid cyst
hematoma
focal thyroiditis
fibrosis
parathyroid adenoma
lymphoma
extrinsic mass
ddx: cold defect in vertebral body
hemangioma
met
infarct
XRT
osteomyelitis
brown tumor
what is the formula for I-131 treatment of:
- graves
- multinodular goitre
graves:
gland wt x 100/% uptake X 160 ug/g

MNG:
gland wt x 100/% uptake x 240 ug/g
what is I-131 treatment for cancer after:
- partial thyroidectomy
- total thyroidectomy
partial:
60-80 mCI for ablation

total: wait 4-6 weeks then 60-100 mci
follow thyroglobulin q6mo and retreat if increased