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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3679_Библиотеки_им_академика_М_И_Перельмана
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220
27.1 Case Challenge #1
27.1.1 Problem
Clinical Highlights
A 58-year-old male undergoes evaluation for chest pain after coronary artery
stenting.
Images for Review
Fig. 27.1
a b
c
d
e
See Video 27.1a See Video 27.1b
See Video 27.1c
See Video 27.1d
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( a ) Stress “black-on-white” raw projection images at usual contrast setting for heart
(Video 27.1a, frame 1),
99m
Tc sestamibi
( b ) Stress “white-on-black” raw projection images at usual contrast setting for heart
(Video 27.1b, frame 1),
99m
Tc sestamibi
( c ) Stress “black-on-white” raw projection images with enhanced contrast setting
(Video 27.1c, frame 1),
99m
Tc sestamibi
( d ) Stress/rest processed SPECT images (HLA)
( e ) Stress and rest gated SPECT images (Video 27.1d, frame 1) (HLA)
Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Myocardium and pericardium: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ multinodular goiter
– Pleura: □ normal □ effusion
– Lungs: □ normal □ tuberculosis
– Myocardium and pericardium: □ normal □ pericardial effusion
– Right atrium and right ventricle: □ normal (right auricular appendage) □
abnormal (right auricular appendage)
– Vascular system: □ normal □ extravasation at injection site
• Abdomen
– Abdominal wall: □ normal □ cracked crystal
– Peritoneum: □ normal □ peritoneal dialysate
– Liver: □ normal □ post-thermal ablation cyst
– Spleen: □ normal □ cyst
– Stomach: □ normal □ chronic distension
– Kidneys and female reproductive system: □ normal □ end-stage kidneys
27.1 Case Challenge #1
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27.1.2 Solution
Additional Annotated Images
f
g
h
See Video 27.1e
See Video 27.1e
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( f ) Stress “black-on-white” raw projection image with enhanced contrast (Video
27.1e, frame 7),
99m
Tc sestamibi, “hot” right atrial focus ( blue oval )
( g ) Stress/rest processed SPECT images (HLA), “hot” right atrial focus ( yellow
ovals )
( h ) Stress and rest gated SPECT image (Video 27.1f, frame 7) (HLA), “hot” right
atrial focus ( yellow ovals on representative images)
The Pertinent Findings
• Chest:
– Right atrium and right ventricle: ■ hot □ cold
• Abdomen
– Not applicable
The Relevant Diagnosis(es)
• Chest:
– Right atrium and right ventricle: ■ normal (right auricular appendage)
• Abdomen
– Not applicable
Discussion
Chest
There is a discrete focus of radiopharmaceutical localization in the region of the
right atrium. It has an appearance characteristic of right auricular appendage, a
common and normal fi nding seen on the raw projection data (a, b, c, f). Note its
superior and deep location. It is enhanced by altering the color presentation (compare b to c and to f). The processed SPECT images (d, g) and the gated SPECT
images (e, h) confi rm its location and provide the key clue to its etiology and, thus,
its clinical signifi cance as a normal fi nding. It should not be misconstrued as a
pathologic mediastinal mass. The small, mild, fi xed apical defect is normal apical
thinning. Incidental note of “septal rocking” (e) of unclear etiology (no history or
left bundle branch block (LBBB) nor cardiac surgery).
The thyroid gland and injection sites (arms up) are not included in the
fi eld-of-view.
Abdomen
There is no abnormality.
Relevant Chapter(s)
Chapter 13
27.1 Case Challenge #1
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27.2 Case Challenge #2
27.2.1 Problem
Clinical Highlights
A 56-year-old female was found to have elevated calcium and parathormone (PTH)
levels. Parathyroid SPECT scintigraphy is performed to identify and localize the culprit
hyperfunctioning parathyroid gland as the cause of primary hyperparathyroidism.
Images for Review
Fig. 27.2
b
c
a
See Video 27.2a
( a ) Raw projection images (360° Video 27.2a, frame 1),
99m
Tc sestamibi
( b ) Axial, coronal, sagittal SPECT images
( c ) Axial, coronal, sagittal fused SPECT/CT images
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Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Parathyroid glands: □ hot □ cold
– Breasts: □ hot □ cold
– Chest wall: □ hot □ cold
– Pleura: □ hot □ cold
– Vascular system: □ hot □ cold
• Abdomen
– Abdominal wall: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ diffuse toxic goiter
– Parathyroid glands: □ normal □ parathyroid adenoma, ectopic
– Breasts: □ normal □ malignant mass
– Chest wall: □ normal □ contamination artifact
– Pleura: □ normal □ effusion
– Vascular system: □ normal □ extravasation at injection site
• Abdomen
– Abdominal wall: □ normal □ malfunctioning photomultiplier tube
– Liver: □ normal □ hepatocellular malignancy
– Biliary system and gallbladder □ normal □ biliary stricture with obstruction
– Spleen: □ normal □ malignant mass
– Stomach: □ normal □ free
99m
Tc pertechnetate
– Small intestine and large intestine: □ normal □ barium
27.2 Case Challenge #2
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27.2.2 Solution
Additional Annotated Images
d
See Video 27.2b
e
f
( d ) Raw projection image (Video 27.2b, frame 6),
99m
Tc sestamibi, deep mediastinal focus ( green circle ), right parotid gland ( orange arrow ), right submandibu-
lar gland ( pink arrow ), thyroid gland ( blue box )
( e ) Axial, coronal, sagittal SPECT images, deep mediastinal focus ( yellow ovals )
( f ) Axial, coronal, sagittal fused SPECT/CT images, deep mediastinal focus ( yel-
low ovals )
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The Pertinent Findings
• Chest
– Thyroid gland: ■ hot □ cold
– Parathyroid glands: ■ hot □ cold
– Breasts: □ hot ■ cold
• Abdomen
– Liver: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Thyroid gland: ■ normal
– Parathyroid glands: ■ parathyroid adenoma, ectopic
– Breasts: ■ normal
• Abdomen
– Liver: ■ normal
Discussion
Chest
On the images of the chest, the visualized salivary glands and thyroid gland are
normal (a, d). There is subtle but defi nite focal radiopharmaceutical localization
deep in the midline chest superior to the heart (a, d). The SPECT and SPECT/CT
images (the latter created with fusion software) localize the focus to the middle
mediastinum situated between the anterolateral aspect of the trachea and the great
vessels (b, c, e, f). The fi nal diagnosis is ectopic parathyroid adenoma deep in the
mediastinum as cause of primary hyperparathyroidism.
Why is this case presented in a book on SPECT MPI? Because this condition can
be discovered on SPECT MPI, and one should be aware of its presentation. As in
this case, fusion can be performed with software if there is a previous chest CT or
MRI. Also, in contradistinction to 27.1, this lesion is not related to the right atrium
and should not be misinterpreted as a normal fi nding.
Note that the relatively photopenic (“cold”) normal breast tissue does not compromise the examination.
Abdomen
The liver is seen because imaging commenced shortly after radiopharmaceutical
administration according to the parathyroid imaging protocol, and the
99m
Tc sesta-
mibi has not yet cleared through the normal physiologic mechanism (a, d).
Relevant Chapter(s)
Chapters 4, 5, 6, and 19
27.2 Case Challenge #2
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27.3 Case Challenge #3
27.3.1 Problem
Clinical Highlights
A 65-year-old female presents with acute worsening of chronic dyspnea.
Images for Review
Fig. 27.3
ab
c
d
See Video 27.3a See Video 27.3b
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( a ) Rest raw projection images (Video 27.3a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 27.3b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA) (with and without AC)
( d ) Stress/rest processed SPECT images (HLA) (with and without AC)
( e ) Stress and rest gated SPECT images (Video 27.3c, frame 1) (SA, VLA, HLA)
Characterize the Pertinent Finding(s)
• Chest
– Chest wall: □ hot □ cold
– Skeleton: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Adrenal glands: □ hot □ cold
e
See Video 27.3c
Fig. 27.3 (continued)
27.3 Case Challenge #3
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