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( a ) Rest raw projection images (Video 28.12a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 28.12b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, VLA, HLA)
( d ) Stress gated SPECT images (Video 28.12c, frame 1) (SA, HLA, VLA)
Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Breasts: □ hot □ cold
– Chest wall:
□ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Lymphatic system: □ hot □ cold
– Diaphragm: □ hot □ cold
d
See Video 28.12c
Fig. 28.12 (continued)
28 Self-Assessment Cases: Intermediate
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• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Vascular system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ multinodular goiter
– Breasts: □ normal □ prostheses
– Chest wall: □ normal □ holter monitor
– Lungs: □ normal □ emphysema
– Mediastinum: □ normal □ left hilar mass
– Right atrium and right ventricle: □ normal □ dilatation
– Vascular system: □ normal □ contamination during injection
– Lymphatic system: □ normal □ right axillary metastases
– Diaphragm: □ normal □ elevated right hemidiaphragm
• Abdomen
– Abdominal wall: □ normal □ contamination artifact during injection
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ slow physiologic clearance
– Biliary system and gallbladder: □ normal □ chronic gallbladder disease
– Spleen: □ normal □ infarction
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ rapid transit into large
intestine
– Vascular system: □ normal □ injection site
28.12 Case Challenge #24
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28.12.2 Solution
Additional Images
( e ) Scout CT image of chest
The Pertinent Findings
• Chest
– Right atrium and right ventricle: □ hot ■ cold
– Diaphragm: ■ hot □ cold
• Abdomen
– Liver: ■ hot □ cold
– Biliary system and gallbladder: ■ hot ■ cold
– Stomach: ■ hot □ cold
– Small intestine and large intestine: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Right atrium and right ventricle: ■ dilatation
– Diaphragm: ■ elevated right hemidiaphragm
• Abdomen
– Liver: ■ slow physiologic clearance
– Biliary system and gallbladder: ■ chronic gallbladder disease
– Stomach: ■ duodenogastric refl ux
– Small intestine and large intestine: ■ rapid transit into large intestine
e
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Discussion
Chest
First take note of the elevated right hemidiaphragm and cardiomegaly (a, b), confi rmed by scout chest CT (e). There is biventricular enlargement with “thinned”
myocardial walls; the right atrium is dilated (a, b). The left ventricle demonstrates a
medium-sized, moderately severe, fi xed distal anterior wall defect and a large, moderately severe, fi xed inferior/inferolateral wall defect consistent with scars (c).
There is global hypokinesis with marked hypokinesis/akinesis of the anterior and
inferior/inferolateral walls; the LVEF is markedly reduced at 20 % (d). The right
ventricular function appears reduced as well (d).
Abdomen
The liver activity is prominent on both raw data sets (a, b) and suggests impaired
hepatic excretion of the radiopharmaceutical. While the gallbladder is well visualized on the stress raw images (a), it is not seen on the earlier rest raw images (b); this
pattern is abnormal and suggests chronic gallbladder disease with resistance in the
cystic duct.
On the rest images only, there is clearly a “hot” stomach, indicating duodenogastric refl ux, and it mostly clears with fl uid on the stress raw images (“cold”
stomach). The gastric activity, as well as the left hepatic lobe activity, can be seen
on the rest SA processed images; it is inferior to and separate from the inferior
myocardial wall. On the stress images, the gastrointestinal activity has reached the
ascending and transverse portions of the large intestine; anatomically, the transverse colon overlies the region of the stomach, and it can be diffi cult to distinguish
between the two.
Relevant Chapter(s)
13, 16, 19, 20, 22, and 23
28.12 Case Challenge #24
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© Springer International Publishing Switzerland 2017
M.E. Oates, V.L. Sorrell, Myocardial Perfusion Imaging - Beyond the Left
Ventricle: Pathology, Artifacts and Pitfalls in the Chest and Abdomen,
DOI 10.1007/978-3-319-25436-4_29
2 9
Self-Assessment Cases: Advanced
Electronic supplementary material The online version of this chapter (doi: 10.1007/978-3-319-
25436-4_29
) contains supplementary material, which is available to authorized users.
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29.1 Case Challenge #25
29.1.1 Problem
Clinical Highlights
A 35-year-old female presents with “yellow eyes.”
Images for Review
( a ) Rest raw projection images (Video 29.1a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.1b, frame 1),
99m
Tc sestamibi
Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Parathyroid glands: □ hot □ cold
– Breasts: □ hot □ cold
– Chest wall: □ hot □ cold
– Skeleton: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Myocardium and pericardium: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Lymphatic system: □ hot □ cold
– Diaphragm: □ hot □ cold
ab
See Video 29.1a See Video 29.1b
Fig. 29.1
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• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Adrenal glands: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
– Vascular system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ diffuse toxic goiter
– Parathyroid glands: □ normal □ adenoma, substernal location
– Breasts: □ normal □ lactation
– Chest wall: □ normal □ cross talk from another radioactive source
– Skeleton: □ normal □ Gaucher disease
– Pleura: □ normal □ neoplasm, metastatic
– Lungs: □ normal □ postoperative change
– Mediastinum: □ normal □ thymoma
– Myocardium and pericardium: □ normal □ pericardial mass
– Right atrium and right ventricle: □ normal □ prominent right auricular appendage
– Vascular system: □ normal □ retention in central port
– Lymphatic system: □ normal □ lymphoma
– Diaphragm: □ normal □ eventration, left hemidiaphragm
• Abdomen
– Abdominal wall: □ normal □ urinary contamination
– Peritoneum: □ normal □ malignant metastatic implants
– Liver: □ normal □ cirrhosis
– Biliary system and gallbladder: □ normal □ cholecystectomy
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy with fl uid distension
– Small intestine and large intestine: □ normal □ diminished bile fl ow
– Adrenal glands: □ normal □ hemorrhagic mass
– Kidneys and female reproductive system: □ normal □ hyperfunctioning state
(hepatic failure)
– Vascular system: □ normal □ abdominal aortic aneurysm
29.1 Case Challenge #25
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29.1.2 Solution
Additional Annotated Images
None.
The Pertinent Findings
• Chest
– Not applicable
• Abdomen
– Liver: □ hot ■ cold
– Biliary system and gallbladder: □ hot ■ cold
– Spleen: ■ hot □ cold
– Stomach: ■ hot ■ cold
– Small intestine and large intestine: □ hot ■ cold
– Kidneys and female reproductive system: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Not applicable
• Abdomen
– Liver: ■ cirrhosis
– Biliary system and gallbladder: ■ cholecystectomy
– Spleen: ■ splenomegaly
– Stomach: ■ gastropathy with fl uid distension
– Small intestine and large intestine: ■ diminished bile fl ow
– Kidneys and female reproductive system: ■ hyperfunctioning state
Discussion
Chest
There are no signifi cant fi ndings.
Abdomen
The liver and the small intestine are poorly visualized, suggesting severe liver dysfunction and reduced biliary clearance of the radiopharmaceutical (a, b). The patient
has known autoimmune hepatitis, awaiting transplant. The gallbladder is surgically
absent; however, in patients with such impaired bile fl ow, differential diagnosis of
gallbladder non-visualization would include underlying liver dysfunction and not
necessarily acute or chronic cholecystitis. The stomach appears collapsed on rest
raw images (a) but appears distended and “cold” on stress raw images (b) after
water ingestion. This pattern is characteristic of cirrhosis-related gastropathy. There
is markedly greater visualization of the kidneys, the alternate route of biological
clearance of the radiopharmaceutical (a, b); renal clearance compensates for liver
dysfunction.
Relevant Chapter(s)
Chapters 19 , 20 , 21 , 22 , 23 , and 25
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29.2 Case Challenge #26
29.2.1 Problem
Clinical Highlights
A 66-year-old female provides a history of diabetes mellitus, coronary artery disease, and previous “heart attack.”
Images for Review
Fig. 29.2
ab
See Video 29.2a See Video 29.2b
29.2 Case Challenge #26
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c
d
See Video 29.2c
Fig. 29.2 (continued)
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