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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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341
( a ) Rest raw projection images (Video 29.6a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.6b, frame 1),
99m
Tc sestamibi
( c ) Stress/rest SPECT images (SA, HLA, VLA) (without and with AC)
( d ) Stress and rest gated SPECT images (Video 29.6c, 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 29.6c
Fig. 29.5 (continued)
29.6 Case Challenge #30
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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 □ adenoma
– Breasts: □ normal □ hematoma
– Chest wall: □ normal □ injection site artifact
– Skeleton: □ normal □ anemia
– Pleura: □ normal □ effusion
– Lungs: □ normal □ malignancy
– Mediastinum: □ normal □ malignancy
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ hypertrophy
– Vascular system: □ normal □ injection site
– Lymphatic system: □ normal □ axillary lymph nodes
– Diaphragm: □ normal □ eventration, right hemidiaphragm
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ hydatid cyst
– Biliary system and gallbladder: □ normal □ obstructed common bile duct
– Spleen: □ normal □ splenectomy
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ visualization of large intestine
– Adrenal glands: □ normal □ cystic enlargement
– Kidneys and female reproductive system: □ normal □ left nephrectomy
– Vascular system: □ normal □ extravasation, left arm
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29.6.2 Solution
Additional Annotated Images
None
The Pertinent Findings
• Chest
– Chest wall: ■ hot □ cold
– Vascular system: ■ hot □ cold
• Abdomen
– Stomach: ■ hot ■ cold
The Relevant Diagnosis(es)
• Chest
– Chest wall: ■ injection site artifact
– Vascular system: ■ injection site
• Abdomen
– Stomach: ■ duodenogastric refl u x
Discussion
Chest
There is intense, ill-defi ned, and variable activity across the top of the fi eld-of-view
during the stress acquisition (b); this is not seen on the rest acquisition (a). The
patient was too weak to keep his arms above his head, and the technologist held
them in place throughout the acquisition (a, b). The activity is related to extravasation at the injection site which periodically slipped into the fi eld-of-view as his arms
moved (b). There was no signifi cant detrimental effect from this “hot” artifact on the
processed images (c, d).
However, motion affected the quality of the examination and the confi dence in
the interpretation. Both sets of images are compromised by motion artifact (a, b, c,
d). There is minimal motion on the rest data (a) but marked motion on the stress data
(b). Both original and motion-corrected stress data sets were reviewed with the rest
images; there was no signifi cant change in the appearance of the apparent small,
severe, reversible apical defect. During a follow-up examination one year later, the
patient was able to cooperate, and the examination was normal.
Abdomen
There is a “beating gallbladder” due to motion on the stress images (b). There is a
“hot” stomach at rest (a) and a “cold” stomach at stress (b), consistent with variable
duodenogastric refl ux.
Relevant Chapter(s)
Chapters 7 , 14 , and 22
29.6 Case Challenge #30
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29.7 Case Challenge #31
29.7.1 Problem
Clinical Highlights
A 44-year-old male with NASH cirrhosis presents for routine preoperative risk
stratifi cation. Unable to exercise, he underwent regadenoson stress.
Images for Review
Fig. 29.7
ab
c
See Video 29.7a See Video 29.7b
See Video 29.7c
( a ) Current: stress raw projection images (Video 29.7a, frame 1),
99m
Tc sestamibi
( b ) Previous: stress raw projection images (Video 29.7b, frame 1),
99m
Tc sestamibi
( c ) Original: stress raw projection images (Video 29.7c, frame 1),
99m
Tc sestamibi
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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
– 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 □ benign neoplasm
– Parathyroid glands: □ normal □ adenoma
– Breasts: □ normal □ gynecomastia
– Chest wall: □ normal □ cracked crystal
– Skeleton: □ normal □ sarcoma
– Pleura: □ normal □ effusion
– Lungs: □ normal □ pneumonectomy
– Mediastinum: □ normal □ thymoma
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ dilatation due to valvular heart
disease
– Vascular system: □ normal □ retention in central veins
– Lymphatic system: □ normal □ axillary lymph nodes, malignant
– Diaphragm: □ normal □ herniation of small intestine
29.7 Case Challenge #31
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• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ cirrhosis
– Biliary system and gallbladder: □ normal □ chronic cholecystitis
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy
– Small intestine and large intestine: □ normal □ malposition
– Adrenal glands: □ normal □ cystic neoplasm
– Kidneys and female reproductive system: □ normal □ partial left nephrectomy
– Vascular system: □ normal □ extravasation
29.7.2 Solution
Additional Images
d
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( d ) Current: stress/rest processed SPECT images (SA, HLA, VLA) (without and
with AC)
( e ) Current: stress and rest gated SPECT images (Video 29.7d, frame 1) (SA, VLA,
HLA)
The Pertinent Findings
• Chest
– Not applicable
• Abdomen
– Liver: □ hot ■ cold
– Biliary system and gallbladder: ■ hot ■ cold
– Spleen: ■ hot □ cold
– Stomach: ■ hot □ cold
The Relevant Diagnosis(es)
• Chest
– Not applicable
e
See Video 29.7d
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• Abdomen
– Liver: ■ cirrhosis
– Biliary system and gallbladder: ■ chronic cholecystitis
– Spleen: ■ splenomegaly
– Stomach: ■ gastropathy
Discussion
Chest
The chest is normal. Heart size is at the upper level of normal for a male; there is no
change during over serial examinations. His vasodilator nuclear stress tests have
been normal, with LVEF ranging from 62 to 68 %. The current processed images
and gated images are shown in Fig. 29.9d, e.
Abdomen
Minimal to no ascites is apparent on serial contemporaneous CT scans (not shown).
Note a small liver (a, b, c). A “small” gallbladder is intermittently visualized: it is
seen on the current (a) and original (c) serial examinations, but is not identifi ed on
the one in-between (b). This pattern is suggestive of chronic gallbladder disease.
Review of previous examinations is an important step in interpretation.
Note an enlarged spleen (a, b, c), consistent with underlying cirrhosis. On the
current examination, there is faint gastric activity which might signal gastropathy.
Relevant Chapter(s)
Chapters 19 , 20 , 21 , and 22
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29.8 Case Challenge #32
29.8.1 Problem
Clinical Highlights
An 87-year-old female with left bundle branch block and heart failure.
Images for Review
ab
c
See Video 29.8a See Video 29.8b
Fig. 29.8
29.8 Case Challenge #32
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( a ) Rest raw projection images (Video 29.8a, frame 1),
99m
Tc sestamibi
( b ) Stress raw projection images (Video 29.8b, frame 1),
99m
Tc sestamibi
( c ) Stress processed SPECT images (SA, HLA, VLA)
( d ) Stress gated SPECT (Video 29.8c, 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 29.8c
Fig. 29.8 (continued)
29 Self-Assessment Cases: Advanced
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