Hospital Estadual Bauru Av. Eng. Luís Edmundo C. Coube, 1-100 CEP: 17033-360 - Bauru/SP Fone: (14) 3103-7777 ORIENTAÇÕES OBRIGATÓRIAS PARA REALIZAÇÃO DE CATETERISMO CARDÍACO ANGIOGRAFIA VASCULAR PERIFÉRICA E ANGIOPLASTIA 1) Jejum de no mínimo 4 horas. Se o exame for realizado no período da tarde, o paciente deverá tomar o café da manhã entre 07 e 08 horas. Hidratar-s
Fixed defect. DDx: Hibernating Myocardium. May confirm with Thallium reinjection or FDG-PET.
Cardiac artifacts. Apical sparing implies artifact. Normal wall motion in area or defect.
MUGA is blood pool image. Utilize Tc99-RBCs. Two approaches: 1st pass (can be done with DTPA) in RAO immediately after injection. Equilibrium study: 20 minutes in 35 - 50 (45) degree LAO with cardiac gating. May do three views: AP, LAO, and steep LPO.
Sarcoid, PCP, lymphoma, osteomyelitis (> Diffuse lung uptake - Sarcoid, Infection (PCP, TB, In-111 for diskitis/osteomyelitis), amyloid.
MAI, CMV), lymphoma, Bleomycin, Amiodarone.
No liver activity. Liver Ferritin is bound to
Gallium binds to Transferrin in blood, Lactoferrin in area of infection, and Ferritin in the liver.
GaLLium: Lacrimal and Liver>spleen.
Gallium: lacrimal glands are key, but may be suppressed by tumor. Generally, spleen is not very Lymphomatosis
Lambda sign + Panda Sign
Panda Sign DDx: Sjogren's, HIV, Sarcoid, Treated lymphoma with non-bulky anterior mediastinal uptake. Note LACRIMAL
GLAND = GALLIUM. Fuzzy images are not
Tc99m. Indium has no bowel activity.
Abnormal intragastric transit from fundus to (gastroparesis) vs. mechanical (obstructing mass).
Tc99m Sulfur Colloid - cooked in egg or oatmeal. No GB at one hour = "ABNORMAL" (no Morphine Dose = 0.04 mg/kg (2-3 mg) over 1
diagnosis yet). Give 0.04 mg/kg MSO4 (2-3 minute Sincalide Dose = 0.02 mcg/kg (1-
mg). At 4 hours: - GB = Acute
cholecystitis . + GB at 4 hours = Chronic
Choecystitis. Rim Sign - 20% association
with Gangrenous Cholecystitis = increased
risk of perforation.
Increasing radiotracer collection around the Reappearing Liver: HIDA cleared, then liver liver ("turning the corner"). May be along "reappears" as leak tracks around it.
dome, subcapsular, pericolic, intraperitoneal. Delayed views if not seen.
Lack of clearance to bowel at 24 hours.
Phenobarbital Dose: 5mg/kg/day x 5 days.
DDx: Neonatal hepatitis or cholestasis - child. In adult = high grade CBD obstruction.
If Persistent Blood Pool (Heart): can say decreased uptake: cholestasis, hepatitis, biliary atresia.
anywhere along the duct. Also: Can say
NOTHING about the GB (can't exclude
cholecystitis ). HIDA=Hepatic
IminoDiacetic Acid. Say Hepatobiliary
Scan instead. Agent=mebrofenin at our
institution. Disofenin (DISIDA) also
Small bowel obstruction with enterogastric reflux Initial -> Delayed . FNH: Hot -> Hot.
HCC: Cold -> Hot. Adenoma: Cold ->
No cerebral perfusion on flow. No cortical Non-Brain Death: May still shows cerebellar
uptake on delays. Hot nose sign = shunting activity due to retained posterior circulation
to external carotid.
I-123/I-131 Pre-Therapy diagnostic scan (24h) and Post- Therapy Scan (5d). Gastric -> bowel, and bladder are normal. Residual Thyroid will light (may give star artifact).
In general: 1-131 -> fuzzy, low-resolution whole surgery (to increase TSH >50). Images at body images with low counts. No solid organ 24, 48, and 72 hours demonstrating subtle activity. May see colon only at late scan time.
activity in the mediastinum. May give water to atttempt clearance.
Use Pledgets to capture fluid. Place in well counter and compare to activity in blood.
Study performed to differentiate from ex- Flow into the ventricles is NOT normal.
vacuo hydrocephalus (atrophy). Dx: ventricular reflux that does NOT clear by 24 hours and delayed clearance of convexities.
Normal In-111 WBC distribution: Spleen>Liver, PNA. DDx: Colitis, enteritits, IBD, GIBleed.
Marrow, Soft Tissues will show some activity.
Focal uptake in liver. Malignancy does NOT Marrow distribution: Indium 111 vs. Sulfur Colloid. IN-111: Spleen>Liver, axial skeleton. Sulfur Colloid: Liver>Spleen - really hot>>>>axial skeletal marrow.
Photopenic Defect in vertebral body = pus 0.5 mCi In-111 WBC : Spleen>Liver>Marrow. NO
under pressure. Spinal Osteo is cold 50% bowel, NO bladder. 20 mCi Tc99m HMPAO WBC
of time. DDx: Mets.
Increasing activity without obstruction.
QC for Aluminum: Dipstick Test = colorimetric spot Diffuse liver uptake. DDx: Severe hepatitis, test from reaction with aurin tricarboxylic acid.
CHF (look at heart. Liver=blood pool), Amyloid, miliary mets.
Increased tracer activity distal to injection sight. "Monkey Arm" Associated with Fracture of Femoral Neck. DDx of AVN: SSD, Caisson, Steroids, EtOh, Pancreatitis, Obesity.
Left Ventricular uptake. Differentiate from Note: Hot Calvarium can be a normal variant, particularly in african-american population.
calcification, myocarditis, contusion, myocardial necrosis, amyloidosis.
Diffuse lung, stomach, and kidney uptake Metastatic calcifications - any process with an
elevated calcium-phosphate product - renal failure, metastatic calcification. Too unifrom to be hyperparathyroidism, sarcoidosis, milk-alkali syndrome. Dystrophic Calcification = calcification
in damaged tissue (trauma, tumor, vascular,
Tram-track distal periosteal uptake. Two
DDx: Periostitis seen in Venous Stasis, Thyroid forms: Primary HPOA (3-5%) =
Acropachy, Vitamin A Toxicity, Child Abuse .
pachydermoperiostosis - rare, AD.
Secondary HPOA : Pleural (fibroma,
mesothelioma), Cardiac (R-L Shunt),
Pulmonary (Bronchogenic CA, Infection,
Sarcoid, Hodgkins, Mets), Foregut Path
ology(Cirrhosis, IBD, infection, tumor),
Other, infected grafts. Pathophysiology is
DDx = stress fractures and shin splints
Nephrocalcinosis, Hypercalcemia, Radiation, ATN Colloid formation (Al), hepatic necrosis, amyloid, Prior Scan HPTH, hypercalcemia, pulmonary hemosiderosis.
Cold Defects : Mets most common = MM,
lymphoma, renal, thyroid , or NB.
Primary Bone Lesions = SBC, ABC, EG.
Vascular = AVN, infarct, radiation.
Artifacts. Infection in a closed space
(vertebra) secondary to increased
Abnormal uptake around joints with abnomal xray showing articular calcification/ossification. DDx: Metachondromatosis (enchondromas + osteochondromas).
Multifocal uptake with large confluent area. Enlarged bone: just doesn't look like mets.
Prior I-131 administration gives star artifact. Saturation effect produces loss of pereceived activity (fewer counts) Bowel Activity. DDx: Recent HIDA, Free Tc99 (must see thyroid, stomach!), brisk GIB, IBD (? Mechanism) Increased uptake on all three scans. Increased around all joints. Flow and pool may gradually decrease after 4-5 months.
Renal Failure, CHF, Edema, Lymphedema,
Metastatic calcifications - any process with an
elevated calcium-phosphate product - renal failure,
hyperparathyroidism, sarcoidosis, milk-alkali
syndrome. Dystrophic Calcification = calcification
in damaged tissue (trauma, tumor, vascular,
calcinosis - rare entity of unknown etiology. 50%-
associated abnormalities in their renal labs. The
calcifications are usually large, globular, and
located in the soft tissues over joints.
Risk of met in patient with primary cancer MDP = methylene diphosphonate - binds to and: Solitary Rib = 20%, Solitary Spine = hydroxyapatite - osteoblast activity. Also reacts with mitrochondrial calcium - Infarction: myocardial, splenic, cerebral. Cardiac contusion, cardiac surgery, unstable angina, and myopathies.
Back pain with negative planar. Must do SPECT.
Luminal: Free Tc99m. Parenchymal: Metastatic Calcification Focal bone uptake: Oblong, ovoid, may be DDx: Shin Splints - Elongated, linear and No Kidneys + Soft Tissue Activity = Renal Failure.
Skeleton) vs. Myelofibrosis or Metabolic disease (Appendicular Skeleton) = Renal osteodystrophy, HPTH, Paget's, osteomalacia, hypervitaminosis D.
Large patient older camera. Patient is scanned in multiple segments and then "zipped." Artifact if the patient moves.
Any bone marrow on MIBG is abnormal.
evident due to activity of the adrenal.
neurotransmitter precursor. Postive in any
neuroendocrine transmitter: Pheo, paraganglioma,
carcinoid, NB. MIBG
Distribution = Sympathetic innervation. HEART,
Salivary, liver, spleen, adrenal. Image at 1,2, 3
Octreotide Distribution : Spleen & Kidneys>>
Liver & Lungs. No heart.
Heart and Thyroid on initial image. Loss of Coexisting with Thyroid Abnormality: background thyroid on delay. If uptake in the thyroid, activity with focal cold spot - Follicular Adenoma.
Kidneys, Spleen > Liver. Any tumor with a Somatostatin Receptor Expressing Neoplasm: Carcinoid, Neuorendocrine, MTC, Other (Thymoma, astroctoma, meningioma, lymphoma, breast, pituitary).
Octreotide Distribution : Spleen & Kidneys>>
Liver & Lungs. No heart. "Hottest Kidneys on Any Scan" also demonstrated reactive LNs in chest which were also hot.
Normal elevation: Brown Fat (make the patient warm to reduce), muscle activity, vocal cords, bowel activity (look for focality).
Hemangioma may be hot or cold. DDx: Met/Myeloma Esophageal activity = esoph. CA, but right axillary activity = extravasated FDG.
Bilateral lung and hilar lymph node uptake. DDx = TB, sarcoid, and less likely malignancy (due to B) PET for lymphoma shows focal uptake. Thyroid scan/US with Bx = papillary thyroid ca.
Bone lesion on PET. Can do follow-up bone scan.
Again, Hemangioma may be hot or cold.
Renal Scan Normal flow. Cortical Retention - No Unilateral retention = RAS. Bilateral = ATN (no Renal Scan Avascular Mass = photopenic defect in Renal Scan Normal Flow. Central accumulation of tracer in the collecting system. Give Lasix. T1/2 <10 - normal. T1/2 >20 - obstruction.
Renal Artery Stenosis Renal Scan MAG3 (tubular agent) -> Unilateral
25 mg Captopril PO 1 hour before study.
Cortical Retention of Tracer (due to
(0.5mg/kg in peds). If normal study - renovascular HTN is excluded. If not, do normal renal scan. If change) following ACE administration
compared to normal baseline.
DTPA (filtration agent) -> Unilateral
decreased cortical uptake [absolute or
relative] with captopril compared to
Renal Scan Poor flow, poor function, delayed excretion in a BIG kidney. DDx: Infiltrative disease, Pyelonephritis, If large collecting system - obstruction.
Renal Scan Normal Flow (peak within 2-4 seconds of ATN: Good flow, good function, poor excretion.
contralateral iliac). No excretion on renogram.
Renal Scan Poor Flow, poor function, and delayed Hyperacute (in OR = complete thrombosis). Acclerated Acute = 3 days. Acute = 3 weeks. Chronic = 3 weeks. Accelerated, Acute, and Chronic all look the same on Renal Scan.
Liver spleen scan (Liver>Spleen). Study will Lung Activity: trapped in vascular bed.
Cirrhosis/Portal Hypertension cause shift of Sulfur Colloid: Alternative Name = Liver, Spleen Scan. Liver>Spleen>>Marrow. Don't see much else.
Hot lesion. Cannot excrete into biliary tree. All other hepatic lesions are cold on Sulfur Colloid.
Liver/spleen scan shows defect in liver. Correlate with CT. DDx = cyst,
hemangioma, or adenoma. FNH shows
tracer activity. Confirm hemangioma with
SC accumulation is secondary to increased blood flow or increased density of Kupfer Cells.
LUQ bleed with antero and retrograde flow. Note: Study is often divided into two 30 minute portions. Free tech will be excreted into urine and taken up in normal distribution.
LUQ, RUQ, Cecal, SB = four patterns.
Central rounded activity early = mesenteric blood Peripheral pooling early with centripetal In Vitro Tagging (ultratag). In Vivo. Modified In filling on delayed images. May see second RLQ nonmoving activity = meckels. DDx
Post-Partum Transient Tc Thyroid Diffuse low uptake in Thyroid. DDx: Sub-Thyrotoxicosis acute Thryroiditis (painful), Hypothyroidism, thyroidectomy, Thyroid hormone administration, Silent (viral) thyroiditis, Recent IV contrast, Drugs (Amiodarone), Ectopic thyroid (struma ovarii). Late phase of Hasmioto's pudendal flow). Trx: surgery to remove auto-immune phenomenom and contralateral orchiopexy.
+Flow & -Delay = infection. -Flow & - Delay = crescentic = epididymis. Torsion = normal Flow with photopenia on delay.
Flow study gets hot late - venous phase.
Testicular agent = Tc99m pertechnetate.
Risk of cancer: 10-20%. Rx: Biopsy. Trx: Sugery followed by total body Scan at 4-6 weeks 2 mCi I-131 (to avoid stunning).
Graves vs. Hashimoto's. Patient has +TPO Parathyroid MIBI: shows increased uptake in the antimbody but, patient is euthyroid (normal TSH), therefore not Graves. Ectopic thyroid activity ddx: ectopic thyroid, metastatic thyroid ca, swallowed tracer, contamination, reflux, zenker's barretts.
Contraindications: Pregnancy and Brain Mets. If Pulmonary mets (follicular) radiation fibrosis mCi. Follow with Thyroglobulin and retreat - ensues. Radiation precautions should involve the Mulfocal hot and cold spots. Cancer risk = 5%. Therapy is medical, but if use I-131 -> 30 mCi.
Solitary Hot Nodule with suppression of rest of gland. Focal photopenia = necrosis. Overall: 1% risk of cancer.
Large, uniformly hot with increased uptake I-131 therapy dose (10-20 mci): 100-200 mcCi x
gland weight (normal = 20g)/uptake percentage (nl = 10-30%). Treat with NSAIDs and B-blockade. Will feel better in a matter of weeks with hypothyroidism to follow.
Swyer-James gives matched defects with air- decreased perfusion with normal ventilation) = central obstruction to flow. DDx: Central tumor, saddle embolus, pulm artery hypoplasia, unilateral radiation.
V: Nebulized 50 mCi of Tc99m-DTPA - 250k LOW PROB : Small (<25%) defect(s) = low prob.
Matched defects = low prob. Triple match in
upper/middle lobes = low prob. Two large (or
equivalent) mismatches = HIGH PROB .
Everything else is INTERMEDIATE.
No perfusion to right lung. DDx: occlusion of the pulmonary artery.
Fuzzy images. Particularly noticeable when in only some of the images taken on a multi-head camera.
5 mci MAA (Q) 50 mci DTPA (V), DDx = Pulm Vasculitis, chronic PE, Post radiation, stenosis, other emboli Matched (or Reverse Mismatch) Defects: Mucus Plugging, Central Airway obstuciton, Endobronchial lesion, Aplasia, hypoplasia, pleural effusion, radiation.
Non-uniform distribution. DDx: Tumor or fat Rx: in PULM HTN: don't reduce radiation, reduce number of particles from 300K to 50K.
Activity in liver, thyroid, spleen, stomach, Brain activity = R-L shunt. May have to ask if see and brain. Free Tc99m does NOT go to
extraplural perfusion agent activity.
Triple match = intermediate probability unless Q defect >> V defect = high probability (non-PIOPED)
Effect of Face Mask Design on Inhaled Mass of Nebulized Albuterol,Hui-Ling Lin MSc RN RRT, Ruben D Restrepo MD RRT, Douglas S Gardenhire MSc RRT-NPS, BACKGROUND: Aerosol face mask design and the distance at which the face mask is held from the face affect the delivery of nebulized medication to pediatric patients. OBJECTIVE: To measure the inhaled mass of nebulized albuterol with 3 types of pedi