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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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331
( a ) Rest raw projection images (Video 29.4a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.4b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest processed SPECT images (SA, HLA, VLA)
( d ) Stress gated SPECT images (Video 29.4c, 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 □ free
99m
Tc pertechnetate
– Parathyroid glands: □ normal □ ectopic adenoma
– Breasts: □ normal □ soft-tissue attenuation artifact
– Chest wall: □ normal □ photomultiplier tube malfunction
– Skeleton: □ normal □ anemia
– Pleura: □ normal □ effusion
– Lungs: □ normal □ congestive heart failure
– Mediastinum: □ normal □ solid mass
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle:
□ normal □ hypertrophy
– Vascular system: □ normal □ extravasation
– Lymphatic system: □ normal □ lymphoma, multifocal
– Diaphragm: □ normal □ fl attening
29.4 Case Challenge #28
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• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ postoperative effect
– Biliary system and gallbladder: □ normal □ cholecystectomy
– Spleen: □ normal □ enlargement
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ duodenal stasis
– Adrenal glands: □ normal □ neoplasm
– Kidneys and female reproductive system: □ normal □ large left renal cyst
– Vascular system: □ normal □ extravasation
29.4.2 Solution
Additional Images
( e ) Axial image from chest CT at level of LAD coronary artery
( f ) Axial image from chest CT at level of left circumfl ex coronary artery
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
– Small intestine and large intestine: ■ duodenal stasis
ef
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Discussion
Chest
Breast attenuation artifact is evident on review of the raw data (a, b). Take note of
how the curvilinear edge of the breast overlies most of the heart but spares the inferior wall. This observation permits one to predict (correctly) that there will be an
attenuation effect on the anterior wall and that the inferior wall will not be subject
to that same effect, thus creating relative differences in the processed perfusion pattern. As predicted, there is a characteristic large, moderately severe, fi xed anterior
myocardial wall perfusion defect (c). Normal wall thickening and wall motion (d,
especially on the VLA images) favor attenuation artifact rather than myocardial
scar.
Normal myocardial perfusion in the setting of extensive coronary artery and vascular calcifi cations, as seen on routine chest CT (e, f), is an important and relatively
common clinical situation that confi rms that there is coronary atherosclerosis in the
absence of signifi cant stenosis.
Abdomen
There is non-visualization of the gallbladder (a, b) (history of cholecystectomy).
Prominent duodenal activity (note: posterior location) and marked gastric activity
due to duodenogastric refl ux are more apparent on stress raw images (b) compared
to rest raw images (a). The gastric activity creates a “bleeding in” artifact involving
the adjacent inferolateral myocardial wall on the stress processed images (c). There
is normal function on gated SPECT images (d).
Relevant Chapter(s)
Chapters 6 , 20 , 22 , and 23
29.4 Case Challenge #28
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29.5 Case Challenge #29
29.5.1 Problem
Clinical Highlights
A 66-year-old male has a recent abdominal surgical history.
Images for Review
Fig. 29.5
a
See Video 29.5a
b
See Video 29.5b
c
See Video 29.5c
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e
See Video 29.5d
d
Fig. 29.5 (continued)
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( a ) Rest raw projection images (Video 29.5a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images contrast adjusted for the heart (Video 29.5b,
frame 1),
99m
Tc sestamibi
( c ) Stress raw projection images contrast adjusted for extracardiac structures (Video
29.5c, frame 1),
99m
Tc sestamibi
( d ) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)
( e ) Stress and rest gated SPECT images (Video 29.5d, 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
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State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ substernal goiter
– Parathyroid glands: □ normal □ carcinoma
– Breasts: □ normal □ gynecomastia
– Chest wall: □ normal □ metallic object
– Skeleton: □ normal □ sternal fracture
– Pleura: □ normal □ effusion
– Lungs: □ normal □ lobectomy
– Mediastinum: □ normal □ hiatal hernia
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ hypertrophy and pulmonary
hypertension
– Vascular system: □ normal □ extravasation
– Lymphatic system: □ normal □ axillary nodes related to extravasation
– Diaphragm: □ normal □ talking and laughing throughout acquisition
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ non-alcoholic steatohepatitis (NASH)
– Biliary system and gallbladder: □ normal □ cholecystostomy
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy and duodenogastric refl ux
– Small intestine and large intestine: □ normal □ prominent duodenum
– Adrenal glands: □ normal □ bilateral malignant masses
– Kidneys and female reproductive system: □ normal □ polycystic disease
– Vascular system: □ normal □ extravasation
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29.5.2 Solution
Additional Annotated Images
( f ) Follow up hepatobiliary images (Video 29.5e, frame 1),
99m
Tc iminodiacetic acid
(IDA)
( g ) Follow up hepatobiliary image (Video 29.5f, frame 55),
99m
Tc iminodiacetic acid
(IDA), gallbladder ( green oval )
( h ) Original hepatobiliary images (Video 29.5g, frame 1),
99m
Tc iminodiacetic acid
(IDA)
( i ) Original hepatobiliary image (Video 29.5h, frame 48),
99m
Tc iminodiacetic acid
(IDA), duodenum ( blue box ), stomach ( yellow outline )
The Pertinent Findings
• Chest
– Breasts: ■ hot □ cold
– Chest wall: □ 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
fg
hi
See Video 29.5g See Video 29.5h
See Video 29.5e See Video 29.5f
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The Relevant Diagnosis(es)
• Chest
– Breasts: ■ gynecomastia
– Chest wall: ■ metallic object
• Abdomen
– Abdominal wall: ■ metallic object
– Liver: ■ non-alcoholic steatohepatitis (NASH)
– Biliary system and gallbladder: ■ cholecystostomy
– Spleen: ■ splenomegaly
– Stomach: ■ gastropathy and duodenogastric refl ux
– Small intestine and large intestine: ■ prominent duodenum
Discussion
Chest
There is gynecomastia (a, b, c) with large breast tissue and slight periareolar uptake.
Incidental note is made of a subtle “cold” metallic object overlying the lower chest/
upper abdominal wall in the midline and projecting over the left hepatic lobe (a, b,
c). The heart is normal (d, e).
Abdomen
The liver is small, consistent with known history of non-alcoholic steatohepatitis
(NASH). There is non-visualization of the externally decompressed gallbladder (a,
b, c). However, external tubing containing radioactive bile courses across the superfi cial upper abdomen (a, b, c). Its presence is affi rmed by correlative hepatobiliary
scintigraphy (f) showing bile drainage into external cholecystostomy tubing (g).
Interestingly, on the original hepatobiliary scan (h), the gallbladder failed to visualize due to cystic duct obstruction and acute cholecystitis; note how this scan demonstrates the normal duodenal location (i) that can be used for anatomic reference
when interpreting MPI in order to avoid the interpretative pitfall.
On rest images, there is duodenogastric refl ux and/or gastropathy (a), while the
stomach appears “cold” at stress, likely related to fl uid ingestion. Interestingly, duodenogastric refl ux is demonstrated on hepatobiliary scan (i), which again can be
used for reference. Splenomegaly is quite apparent (a, b, c); it can be appreciated on
the hepatobiliary scan during the early blood pool phase (f, h). No ascites was present on same-day ultrasonography.
Relevant Chapter(s)
Chapters 6 , 7 , 17 , 19 , 20 , 21 , 22 , and 23
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29.6 Case Challenge #30
29.6.1 Problem
Clinical Highlights
A 60-year-old male has very weak arms. He has hypertension and hyperlipidemia
but no known coronary artery disease.
Images for Review
Fig. 29.6
ab
c
See Video 29.6a See Video 29.6b
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