Nuclear medicine in general practice Dr Reza Garzan MD, FRACP, FAANMS
• Myocardial perfusion study • Bone scans in general practice • Thyroid scans in general practice
Gamma camera
Detection of gamma rays
Myocardial perfusion Imaging
How is it performed? Rest/Stress protocol : Radiopharmaceutical injected at rest and then post stress. Same day or two day protocol
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)
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
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
ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging J Am Coll Cardiol . 2009;53(23):2201-2229. doi:10.1016/j.jacc.2009.02.013
Ischemic cascade
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
Cardiac planes
• 67-year-old-man, with episodes of chest pain at rest
• 74- year-old, with DM and exertional chest and throat pain, unable to complete exercise stress test
• Moderate to large amount of reversible ischemia in LAD territory
Small MI in distal LAD territory
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
• Bone Scans
• 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)
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
Normal whole body bone scan
Case 1 • 50 year old female, pain in bilateral hands , history of fall 4 days back on outstretched hands. Xray : normal
Blood flow and blood pool images
Delayed images
SPECT/CT
• Fracture of bilateral trapezium
Case 2 • 76 year-old female, active walker, pain in the left foot since 3/52, ? Stress Fx
Blood flow and blood pool images
Blood pool images
SPECT/CT
• Active arthritis of tarsometatarsal joint
Case 3 • 85-year-old female, Chronic ulcer in the left foot, close to 1 st MTP joint.
Blood pool images
Delayed images
SPECT/CT
• Osteomyelitis of the distal left 1 st metatarsal bone
Case 4 • 47 -year-old male, right 2 nd metatarsal pain after a long walk
Blood flow and blood pool images
Delayed images
SPECT/CT
• Stress fracture of distal right 2 nd metatarsal
Case 5 • 52 year old female, with back pain for investigation
Delayed SPECT/CT images
• 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.
Case 6 • 68-year-old man with right foot and heel pain after long walk.
• Right Achilles tendon enthesopathy
Thyroid scans • Thyrotoxicosis • Assessment of thyroid nodules
Radiopharmaceutical : Tc-99m Pertechnatate ( TcO4)
• 69 year-old man presenting with thyrotoxicosis
• Hot autonomous functioning nodule
• 65 year-old female, presenting with thyrotoxicosis
• Graves’ disease • Positive TSH receptor antibodies can confirm the diagnosis
• 30-year-old female presenting with post- partum hyperthyroidism
Thank you!
International Leadership in Family Medicine/General Practice Dr John
PINET Personalized Integrated Evidence-Based Medicine teaching for trainees
Nuclear Medicine Technologists Assessing Whether a Myocardial Perfusion Rest
NEW APPROACHES IN INPATIENT MEDICINE THAT MIGHT CHANGE YOUR PRACTICE Jack
General Practice Forward View: Sheffield Perspective GPFV commitment to
in vivo Imaging Using Nanoparticles Keon Wook Kang, MD, PhD Department of
PET-MR Project Dr. J. Bomanji Head of Department and Clinical Lead Dept of
SELENE MIT Nuclear Space Research Andrew C. Kadak Professor of the Practice
Elba Etchebehere, MD.PhD Full Professor, Nuclear Medicine Division,
PET Radiopharmaceutical Production in North Macedonia Ana Ugrinska
Frontal Dummies Frontal Dummies Latest Developments Latest Developments
6/30/2015 The Inconvenient Truth: A Discussion of the Risk of Post-Traumatic
H E A LTH B U LLE TI N S HEALTH BULLETINS BETTER SAFE WELCOAS ONLINE BULLETIN
Public Hearings; experience so far Valproate / Quinolones Nathalie Bere
Investors presentation February 2017 Disclaimer 2 The information included
Barry Gendron, D.O. Medical Director, Musculoskeletal Service Line Wentworth
An evaluation of the use of the pro forma as an effective tool for assessment
Breaking down data silos for improved insight a data transparency perspective
Self Defense Thank you for joining Brandie M. Lea On April 20, 2016 1)
Canadian Heart and Stroke No conflict of interests Passionate about
Roger Williams Medical Center Providence , RI Providence, RI Introduction
Understanding chronic disease and patient assistance programs for plan members