Nuclear medicine in general practice. Dr Reza Garzan MD, FRACP, FAANMS

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1 Nuclear medicine in general practice Dr Reza Garzan MD, FRACP, FAANMS

2 Myocardial perfusion study Bone scans in general practice Thyroid scans in general practice

3 Gamma camera

4 Detection of gamma rays

5 Myocardial perfusion Imaging

6 How is it performed? Rest/Stress protocol : Radiopharmaceutical injected at rest and then post stress. Same day or two day protocol

7 Radiopharmaceuticals Tc-99m Sestamibi (MIBI) Sestamibi (MIBI) : Lipophilic agent, diffuses from blood into the myocardial cell and is retained in mitochondria Tc-99m : Short physical half life of 6hrs, good energy gamma rays ( better quality pictures)

8 Radiopharmaceuticals Thallium (TI-201): Behaves physiologically much like K ion, and is transported across the myocardial cell membrane via Na-K ATPase Long half life and low energy photons, so much less commonly used nowadays

9 Modes of stress Exercise Pharmacologic Vasodilator ( Adenosine, Dipyridamole) : Dilate the coronary arteries, but the stenosed vessels are not able to dilate as much as normal coronary arteries are able to. Contraindicated in asthma and severe COPD. Dobutamine : Sympathomimetic

10 ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging J Am Coll Cardiol. 2009;53(23): doi: /j.jacc

11

12 Ischemic cascade

13

14 What information do we get from MPS? Perfusion (rest and stress) Wall motion (rest and stress), systolic function, LVEF Symptoms If exercise, exercise capacity ECG changes

15 Cardiac planes

16 67-year-old-man, with episodes of chest pain at rest

17

18

19 74- year-old, with DM and exertional chest and throat pain, unable to complete exercise stress test

20

21 Moderate to large amount of reversible ischemia in LAD territory

22

23 Small MI in distal LAD territory

24 Prognostic value of normal ( low -risk) and moderately to severely abnormal (high-risk) myocardial perfusion SPECT in estimating annual rates of cardiac death and nonfatal myocardial infarction

25

26 Bone Scans

27 Radiotracer injected, ( Tc-99m HDP) Early phase images immediately ( presence or absence of hyperaemia/normal or abnormal vascularity) Delayed phase images in about 3-4 hrs ( osteoblastic activity)

28 Common applications of bone scans in general practice Stress fractures Sports injuries Suspected fractures with normal x-ray Arthritis/assessment of facet joint arthropathy Osteomyelitis Staging and restaging of prostate, breast and lung cancers Metabolic bone disease e.g. Paget s disease Assessment of painful THR and TKR

29 Normal whole body bone scan

30 Case 1 50 year old female, pain in bilateral hands, history of fall 4 days back on outstretched hands. Xray : normal

31 Blood flow and blood pool images

32 Delayed images

33 SPECT/CT

34 Fracture of bilateral trapezium

35 Case 2 76 year-old female, active walker, pain in the left foot since 3/52,? Stress Fx

36 Blood flow and blood pool images

37 Blood pool images

38 SPECT/CT

39 Active arthritis of tarsometatarsal joint

40 Case 3 85-year-old female, Chronic ulcer in the left foot, close to 1 st MTP joint.

41 Blood pool images

42 Delayed images

43 SPECT/CT

44 Osteomyelitis of the distal left 1 st metatarsal bone

45 Case year-old male, right 2 nd metatarsal pain after a long walk

46 Blood flow and blood pool images

47 Delayed images

48 SPECT/CT

49 Stress fracture of distal right 2 nd metatarsal

50 Case 5 52 year old female, with back pain for investigation

51 Delayed SPECT/CT images

52 Intensely increased radiotracer uptake in the left L5/S1 facet joint, consistent with left L5/S1 facet joint arthropathy Can be useful for investigation of cervical facet joint arthropathy too.

53 Case 6 68-year-old man with right foot and heel pain after long walk.

54

55

56 Right Achilles tendon enthesopathy

57 Thyroid scans Thyrotoxicosis Assessment of thyroid nodules

58 Radiopharmaceutical : Tc-99m Pertechnatate ( TcO4)

59 69 year-old man presenting with thyrotoxicosis

60

61 Hot autonomous functioning nodule

62 65 year-old female, presenting with thyrotoxicosis

63

64 Graves disease Positive TSH receptor antibodies can confirm the diagnosis

65 30-year-old female presenting with postpartum hyperthyroidism

66

67

68 Thank you!

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