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3. How does nuclear medicine differ
from other imaging modalities used in
radiology, such as plain film, ultrasound
Figure 3-1. Line drawing showing the flow of information of a
(US), CT, and magnetic resonance
typical nuclear medicine study, such as a bone scan, obtained with
imaging (MRI)?
a gamma camera.
Plain films, US, CT, and MRI produce anatomic images
with very high spatial resolution. A viewer can see
anatomy very well, but function generally is not assessed. Nuclear medicine studies sacrifice spatial resolution, but in
return offer information about organ function.
Key Points: How Nuclear Medicine Differs from Other Imaging Modalities
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5. What
. . radiopharmaceutical agents are used in a V/Q scan?
A V /Q scan attempts to identify regions of lung that are aerated lung but not perfused (such regions are suspicious
for pulmonary embolism). The scan consists of two parts: a ventilation phase where the aerated lung is imaged, and
a perfusion phase that maps blood flow to the lungs. The two sets of images are compared for discrepancies. For the
ventilation portion of the study, xenon-133 and technetium (Tc)-99m diethylenetriaminepentaacetic acid (DTPA) are the
most commonly used agents. For the perfusion portion of the study, Tc-99m macroaggregated albumin (MAA) is used.
. .
6. How is a V/Q scan performed?
The ventilation portion is performed using either radioactive gas (xenon) or radioactive aerosol (Tc-99m DTPA). When
radioactive gas is used, the study is accomplished in three phases: single-breath/wash-in phase, equilibrium phase,
and washout phase. For studies that use radioaerosols, the radiopharmaceutical agent is placed in a special nebulizer
system, and the patient breathes through the mouthpiece until sufficient radioaerosol is delivered to the lungs. Tc-99m
remains in the lung long enough to obtain multiple views with a gamma camera. Tc-99m MAA is injected into a
peripheral vein to assess perfusion. The particles travel to the right side of the heart and then to the lungs, where they
are filtered or trapped in the pulmonary vascular bed. The emissions from the trapped particles are imaged with a
gamma camera.
. .
7. How are the results of a V/Q scan interpreted?
If an acute pulmonary embolism is present, the thrombus in the blood vessel prevents radiotracer from reaching the
portion of lung supplied by the vessel, and a perfusion defect results. An acute thrombus does not prevent air from
being distributed to the lung via bronchi, however, and the results of the ventilation scan are normal. This
. combination
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of a perfusion defect without a corresponding ventilation defect is called a mismatch. The results of a V /Q scan are
classified as low, intermediate, or high probability for a pulmonary embolism. The classification is based on the number
and size ofdefects, with higher numbers and sizes resulting in greater probability that an embolus is present.
8. What radiopharmaceutical agent is used in HIDA scan?
Tc-99mlabeled iminodiacetic acid (IDA) compounds are used. They share biologic activity with bilirubin and are also
taken up, transported, and excreted by hepatocytes.
9. How is HIDA scan performed?
The patient is required to fast for at least 4 hours, but not longer than 24 hours. If the test is performed after a recent meal,
the gallbladder may still be contracted, and this could lead to false-positive test results. After a prolonged fast, the gallbladder
may be filled with concentrated bile, and this may also lead to false-positive test results by preventing tracer accumulation in
the gallbladder. Tc-99m IDA is injected into a peripheral vein, followed by immediate imaging of the right upper quadrant.
10. How are the results of HIDA scan interpreted?
Because the tracer behaves similar to bilirubin, it should be taken up by hepatocytes and excreted into the bile ducts.
The liver should be visualized first, followed by visualization of the bowel and gallbladder. The appearance of tracer in
the bowel and gallbladder by 60 minutes after administration is defined as normal. Nonvisualization of the gallbladder
by 60 minutes is diagnostic of acute cholecystitis because this implies a functional obstruction of the cystic duct. Falsepositive results can be caused by chronic cholecystitis, hepatic insufficiency, and fasting for less than 4 hours or more
than 24 hours as previously described.
Key Points: Common Clinical Indications for a Nuclear Medicine Study
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scanner and analyzed by a computer to form an image. Because positronic decay produces two 511-keV photons that
travel in exactly opposite directions, acquisition of PET data is sometimes called coincidence detectiononly photons
of the correct energy that are detected simultaneously by detectors 180 degrees from each other are registered as true
events, and the rest are assumed to be noise.
23. What radiopharmaceutical agent is used in PET? What type of pathologic conditions
can it detect?
Fluorodeoxyglucose (FDG) is used in PET. This is a radionuclide combined with glucose, which is the currency of
metabolism for malignant and benign cells. Because malignant cells tend to grow and metabolize glucose faster than
healthy tissue, however, malignant cells use more of the tracer. PET uses the difference in metabolism to differentiate
normal from abnormal tissue.
Key Points: Main Radionuclides Used in Nuclear Medicine
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