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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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321
( a ) Rest raw projection images (Video 29.2a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.2b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, VLA, HLA)
( d ) Stress gated SPECT images (Video 29.2c, frame 1) (SA, VLA, HLA)
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
• 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 □ lymphoma
– Parathyroid glands: □ normal □ ectopic hyperplasia
– Breasts: □ normal □ soft-tissue attenuation artifact
– Chest wall: □ normal □ Holter monitor
– Skeleton: □ normal □ multiple metastases
– Pleura: □ normal □ mesothelioma
– Lungs: □ normal □ posttransplant asymmetry
– Mediastinum: □ normal □ lymphoma
– Myocardium and pericardium: □ normal □ “hot” mass
– Right atrium and right ventricle:
□ normal □ dilatation
– Vascular system: □ normal □ chest port injection site
– Lymphatic system: □ normal □ necrotic axillary lymph nodes, malignant
– Diaphragm: □ normal □ muscular (soft-tissue attenuation)
29.2 Case Challenge #26
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• Abdomen
– Abdominal wall: □ normal □ overlying patient’s arms and hands
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ hepatitis
– Biliary system and gallbladder: □ normal □ cholecystectomy
– Spleen: □ normal □ infarct
– Stomach: □ normal □ duodenogastric refl ux and fl uid
– Small intestine and large intestine: □ normal □ visualization of large intestine
– Adrenal glands: □ normal □ cystic neoplasm
– Kidneys and female reproductive system: □ normal □ left nephrectomy
– Vascular system: □ normal □ extravasation
29.2.2 Solution
Additional Annotated Images
( e ) Rest raw projection image (Video 29.2d, frame 16),
99m
Tc sestamibi, duodenum
( blue box )
( f ) Stress raw projection image (Video 29.2e, frame 16),
99m
Tc sestamibi, hepatic
fl exure of large intestine ( yellow box ), duodenum ( blue box )
ef
See Video 29.2d See Video 29.2d
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The Pertinent Findings
• Chest
– Breasts: □ hot ■ cold
• Abdomen
– Biliary system and gallbladder: □ hot ■ cold
– Stomach: ■ hot ■ cold
– Small intestine and large intestine: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Breasts: ■ soft-tissue attenuation artifact
• Abdomen
– Biliary system and gallbladder: ■ cholecystectomy
– Stomach: ■ duodenogastric refl ux and fl uid
– Small intestine and large intestine: ■ visualization of large intestine
Discussion
Chest
The breast tissue creates an attenuation artifact on the heart (a, b, c, d). On processed
images (c), there is a medium-size, severe, fi xed anteroseptal-apical perfusion defect
that represents myocardial scar (her “heart attack”?); there is no ischemia. There is
anteroseptal-apical akinesis, but preserved global function with LVEF greater than
60 % (d). Thus, despite the potential for breast attenuation artifact, this perfusion
defect is “real” and correlates with “true” coronary artery disease.
Abdomen
The gallbladder is absent (a, b). The rest raw images (a, e) demonstrate duodenal
(“C-loop”) activity that could be mistaken for the gallbladder. The fi rst portion of
the duodenum is posterior and gravity dependent in the supine position used for
imaging. The gallbladder is usually anteriorly situated, whereas the duodenum is
posteriorly situated, and should appear focally intense and constant during the
acquisition. On later same-day stress raw (b, f) images, large intestinal activity is
seen in the right upper quadrant. As is the case for the early duodenal activity, activity in the hepatic fl exure of the large intestine could be misconstrued as
gallbladder.
On stress raw images (b), the stomach appears “cold” due to water ingestion, but
there is no artifactual attenuation effect on the processed images (c).
Relevant Chapter(s)
Chapters 6 , 20 , 22 , and 23
29.2 Case Challenge #26
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29.3 Case Challenge #27
29.3.1 Problem
Clinical Highlights
A 62-year-old male presents with chronic disease.
Images for Review
Fig. 29.3
ab
c
See Video 29.3a See Video 29.3b
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( a ) Rest raw projection images (Video 29.3a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.3b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)
( d ) Stress and rest gated SPECT images (Video 29.3c, frame 1) (SA, VLA, HLA)
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
d
See Video 29.3c
Fig. 29.3 (continued)
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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 □ multinodular goiter
– Parathyroid glands: □ normal □ multiple adenomas
– Breasts: □ normal □ gynecomastia
– Chest wall: □ normal □ jewelry
– Skeleton: □ normal □ myelofi brosis
– Pleura: □ normal □ bilateral effusions
– Lungs: □ normal □ hyperinfl ation
– Mediastinum: □ normal □ esophageal malignancy
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ enlargement
– Vascular system: □ normal □ extravasation around chest port during injection
– Lymphatic system: □ normal □ metastatic neoplasm
– Diaphragm: □ normal □ hiccups
• Abdomen
– Abdominal wall: □ normal □ umbilical hernia
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ cirrhosis
– Biliary system and gallbladder: □ normal □ calculous cholecystitis, chronic
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy
– Small intestine and large intestine: □ normal □ visualization of large intestine
– Adrenal glands: □ normal □ metastasis
– Kidneys and female reproductive system: □ normal □ atrophic left kidney
– Vascular system: □ normal □ chest port for injection
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29.3.2 Solution
Additional Annotated Images
( e ) Coronal CT most anterior through the liver, gallbladder with gallstones ( blue
circle ), and stomach ( yellow circles , outer wall and inner lumen), perihepatic
ascites ( pink line )
( f ) Coronal CT most posterior through the stomach ( yellow outline ) and splenic
fl exure ( orange boxes ), heart for reference ( red box )
The Pertinent Findings
• Chest
– Not applicable
• Abdomen
– Peritoneum: □ hot ■ cold
– Liver: □ hot ■ cold
– Biliary system and gallbladder: □ hot ■ cold
– Stomach: ■ hot □ cold
– Small intestine and large intestine: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Not applicable
• Abdomen
– Peritoneum: ■ ascites
– Liver: ■ cirrhosis
– Biliary system and gallbladder: ■ calculous cholecystitis, chronic
– Stomach: ■ gastropathy
– Small intestine and large intestine: ■ visualization of large intestine
ef
29.3 Case Challenge #27
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Discussion
Chest
There are no abnormal fi ndings.
Abdomen
There is ascites and poor visualization of the liver (a, b, e), consistent with cirrhosis.
There might be visualization of the gallbladder on stress raw images (b), but it is
diffi cult to separate from the “hot” large intestine. On the rest raw images (a), the
gallbladder is out of the fi eld-of-view and cannot be evaluated. There are multiple
large calcifi ed gallstones (e).
Marked gastric activity appears on the rest raw images (a). On the stress raw
images (b), the gastric activity is even more marked; this likely represents gastropathy. There is also marked activity in the large intestine (splenic fl exure) that overlaps
the stomach on the raw images (a, b); their anatomic relationships are correlated on
CT images (f). The gastric activity and large intestinal activity are problematic
because they create a signifi cant processing artifact affecting the adjacent inferior
myocardial wall where there is a fi xed perfusion defect (c). This is almost certainly
an artifactual defect because the gated SPECT images demonstrate normal wall
motion and thickening (d).
Relevant Chapter(s)
Chapters 18 , 19 , 20 , 22 , and 23
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29.4 Case Challenge #28
29.4.1 Problem
Clinical Highlights
A 56-year-female presents with three-vessel coronary calcifi cations on chest CT
and a long history of hypertension.
Images for Review
Fig. 29.4
ab
See Video 29.4a See Video 29.4b
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d
See Video 29.4c
c
Fig. 29.4 (continued)
29 Self-Assessment Cases: Advanced
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