Nuclear
Medicine
Table of Contents
Page no.
Brain Death Evaluation 5-6
Ventricular Peritoneal Shunt
Patency Study (V-P Shunt) 11
Cisternogram 12-13
Gastrointestinal Studies
Hepatobiliary (HIDA) Scan 14-15
Liver/Spleen Scan 16-17
Gastric Emptying (Routine = Solid) 18-19
Gastroesophageal Reflux (Milk Scan & Salivagram) 20-21
GI Bleeding Study (In-Vitro RBC Labeling Procedure) 22
Gastric Mucosa Localization (Meckel’s Scan) 23
Hemangioma Study 24
Pulmonary
Perfusion and Ventilation Imaging (Xenon-133) 25
Cardiac
Studies
Gated Heart Scans (In-Vivo
RBC Labeling Technique) 26-27
Pyrophosphate Infarct Scans 28
Rest Thallium - Redistribution 29-30
Stress Thallium - Redistribution 31-32
Persantine Thallium 35-36
Infection
Gallium Scans 37
Labeled White Blood Cell Scan 38-39
Renal / GU
Studies
Kidney Transplant Evaluation 40
2-Kidney Renal Scan 41
Lasix Renal Scan 42
Glucoheptonate Renal Scan 43
Voiding Cystourethrogram 45
Testicular Scan and Flow 46
Blood Flow
Technique 47
Bone /
Skeletal
Bone 48-49
Bone Mineral Density 50
Thyroid Studies
Thyroid Uptake 51-52
Thyroid Scan 53-54
Thyroid Whole Body Scan 55
Miscellaneous
Studies / Procedures
Pancreas Transplantation 56
SVC Flow 57
Salivary (Parotid)Scan 58
Shunt Patency (Leveen) 59
Parathyroid 60-61
Lymphoscintigraphy 62
Blood Volume (Cr-51 and I-125 RISA) 63-65
125-I RISA Plasma Volume 66-67
Schillings Test 68-69
Red Blood Cell Survival 70-71
Gastrointestinal Blood Loss 73
Radionuclide Therapy 74
Attached: AEHN Quality
Management Program for the
Therapeutic Use of
Radiopharmaceuticals
Brain Death Evaluation
A. Indications: Evaluation of cerebral blood flow in patients with suspected brain death.
Note: To adequately evaluate brain stem perfusion,
SPECT imaging is required.
Note: Patient must have clinical exam consistent
with brain death
(i.e., NO brainstem reflexes)
B. Patient preparation: None
C. Tracer:
1. 20-30 mCi
Tc-99m ECD (Neurolite)
2. 15-25 mCi
Tc-99m HMPAO (Ceretec)
3. If above not available:
a. 15-25 mCi Tc-99m
DTPA
b. 15-25 mCi Tc-99m Pertechnetate
D. Instrumentation: LEAP collimator with a large FOV gamma camera.
E. Procedure:
Adult:
1. Have the patient in the supine position
with the patient’s head as close to the camera as possible (anterior or
posterior position).
Label flow study
as anterior or posterior.
2. Inject
the tracer in an antecubital vein using an indwelling line (at minimum a
butterfly).
Very fast injection is
needed.
3. Acquire dynamic flow study beginning at the time of injection:
Computer set up - ADYN (Matrix 64, word mode, zoom = 1, frame = 2 sec x 30)
4. Acquire static images five (5) minutes following the recorded dynamic phase in the anterior, lateral, posterior, and vertex views. If positioning precludes any views, discuss with nuclear medicine physician.
Computer set up - (256 matrix, 500k/image, zoom = 1, word mode)
5. SPECT imaging may be obtained if brain tissue is visualized or to evaluate the brain stem
Baby variation: Same as above except:
1. Calculate a pediatric dose
2. Use a 1.6 zoom
Note: Have a physician check the
images before the patient leaves the Nuclear Medicine Department.
SPECT Brain with IMP
(IMP not currently available)
A. Indications:
1. Cerebrovascular disease: acute stroke, chronic stroke, TIA
2. Dementia (to distinguish Alzheimer’s from other dementias)
3. Head trauma
4. Epilepsy
5. Psychiatric disorders
6. Infectious processes
7. Degenerative cortical processes
Note: This study provides information
about cerebral blood flow not obtained by CT/MR.
B. Patient Preparation: Must be able to lie flat and hold still for about 1 hour
1. Severe spine disease, tremors, cough, orthopnea
2. If the patient will require sedation, please communicate this to the Nuclear Medicine Department by phone
3. Must not be taking MAO inhibitors or have a hypersensitivity to amphetamines
C. Tracer: 4 mCi I-123 Spectamine
D. Injection/Acquisition Procedure
1. Use the LEAP collimator
2. Inject 4 mCi of I-123 Spectamine intravenously
3. Table must be centered
4. Wait 20 minutes after injection of tracer. Have patient empty bladder. Place patient on imaging table making them as comfortable as possible. Bring the camera head as close to the patient’s head as possible (14 cm or less). Rotate the camera 360 degrees around the patient to be sure to clear the shoulders. You may move the table up or down to get closer but you may not move the table side to side. Start acquisition from the right lateral projection.
5. Type ‘SPECTAMINE.’ This protocol will automatically set up a 42 minute acquisition.
E. Processing
1. Type ‘IMPPROC.’ This protocol will allow you to go through a chain of processing commands including reconstruction, image summing, and photography.
2. Copy the raw data onto a floppy and keep the floppy with the patient’s folder
F. Variation #1: Redistribution Study
1. Redistribution studies are done in patients who are suspected of having cerebrovascular ischemia.
2. The redistribution study is done 2 hours after initial tracer injection.
3. Acquire the data using the ‘SPECTAMINE’ protocol as described above.
4. Process the data using the ‘IMPPROC’ protocol as described above.
SPECT Brain Scan with Ceretec or Neurolite
Note: If the patient will
require sedation, please communicate this to the Nuclear Medicine Department by
phone
A. Purpose: HMPAO (ceretec) and ECD (neurolite) diffuse across the intact brain blood barrier in proportion to regional blood flow. This study provides information about regional cerebral blood flow and function which is not obtainable by CT/MR.
B. Indications
1. Cerebrovascular disease: acute stroke, chronic stroke, TIA
2. Dementia (to distinguish Alzheimer’s from other dementias)
3. Head trauma
4. Epilepsy
5. Psychiatric disorders
6. Infectious processes
7. Degenerative cortical processes
C. Patient Preparation:
Must be able to lie flat and hold still
for about 30-60 minutes
D. Relative Contraindications:
1. Severe spine disease
2. Tremors
3. Cough
4. Orthopnea
E. Tracer: 20-30 mCi Tc-99m-Ceretec or Neurolite
F. GE: Injection/Acquisition Procedure
1. Use the HIGH RESOLUTION or LEAP collimator
2. Put in flowing I.V. 10 minutes before injection.
3. Inject 20-30 mCi of Tc-99m-Ceretec or Neurolite intravenously in a quiet, dark room. Patient eyes should be open.
4. Wait 1 hour (Ceretec) or 30 minutes (Neurolite) after injection of tracer.
5. Have patient empty bladder before scanning commences.
6. Place patient on imaging table making them as comfortable as possible. Bring the camera head as close to the patient’s head as possible (14 cm or less). Rotate the camera 360 degrees around the patient to be sure to clear the shoulders. You may move the table up or down to get closer but you may not move the table side to side. Table must be centered. Start acquisition from the right lateral projection.
7. Type ‘CERETEC.’ This protocol will automatically set up a 42 minute acquisition.
8. With Ceretec one never acquires a redistribution study.
G. Processing: Type ‘CTEC.’ This protocol will allow you to go through a chain of processing commands including reconstruction, image summing, and photography.
H. ADAC
1. Same, except High Resolution collimators
2. Do 64 steps total (6_ apart) 64 x 64 matrix 20 seconds/step
3. Take 1 planar brain - 2 minutes
Ventricular Peritoneal Shunt Patency Study
(V-P Shunt)
A. Indications: Evaluation of ventricular-peritoneal (or other central nervous system) shunt patency
B. Patient Preparation: None, but must be coordinated with Neurology/Neurosurgery
C. Tracer: 1 mCi of Tc-99m DTPA (for adults)
D. Injection/Acquisition Procedure
1. Use the LEAP collimator
2. A neurologist or neurosurgeon or their resident performs an injection directly into the portal of the shunt via a 3-way stopcock. The shunt is then flushed via the other stopcock connection.
3. Thirty 2-second images of the shunt resevoir are acquired.
4. Obtain a 30 minute anterior dynamic acquisition (matrix 64 x 64, word mode, zoom = 1, 30 sec images) over (the head and) the abdomen to see if the tracer moves.
5. Additional images may be necessary; e.g., if the material in the shunt does not drain into the abdomen, manual manipulation of the pump may be required.
E. Variations: Patient may need to sit up to allow gravity to assist drainage.
Note: Have a physician check the images before the patient leaves
the Nuclear Medicine Department.
Cisternogram
A. Indications
1. Evaluation of patients with symptoms of normal pressure hydrocephalus, dilated ventricles, confusion, headache, or memory loss
2. Detection of CSF leaks
3. Evaluation of CSF shunt or pump
B. Patient Preparation: None but must be coordinated with Neurology/Neurosurgery
C. Tracer: 1.5 mCi In-111-DTPA
D. Injection/Acquisition Procedure:
1. Labs: Consider obtaining PT/PTT results before procedure, particularly in patients with history of coagulopathy and patients on coumadin or heparin.
2. Use the medium energy collimator.
3. Patient receives a
lumbar puncture and injection by a neurologist or a neurology resident either
on the nursing unit or in the Nuclear Medicine Department. Inject the patient before
4. For normal pressure hydrocephalus:
a. Patient is brought to the Nuclear Medicine Department at 4, 24, and 48 hours post-injection routinely (72 hour images may be required).
b. Static images (128 x 128 matrix, word mode, zoom = 1).
c. Each day acquire 100,000 count image and note time. Acquire the other images for the same time. Note the time for acquisition on scan.
d. Images: anterior, posterior, lateral, and vertex.
5. For rhinorhea, otorrhea:
a. Pledgets may be inserted into the patient’s nostrils or ears 30-60 minutes BEFORE tracer is administered.
b. Plasma background:
i. 5 ml blood samples are drawn after the intrathecal injection and at time of pledget removal.
ii. 1 ml plasma samples are counted for 10 minutes (150-250 KEV window)
c. Two to four hours after the pledgets are inserted (when the activity has reached the basal cisterns), the patient comes down to the Nuclear Medicine Department to have the pledgets removed and counted to determine the presence of CSF.
d. Count pledgets in gamma well counter for 10 minutes.
e. Ratio of pledget activity (CPM) to average plasma activity (CPM) is calculated for each pledget.
f. Pledget / plasma activity of >1.5 times is significant for localization.
g. Blood samples are drawn at the time of the pledget insertion and when they are removed.
h. At 4 and 24 hours after injection, anterior, posterior, and both lateral views of the skull are obtained for 3 minutes.
6. For
spinal dural tears:
a. Immediately following injection, confirm intrathecal tracer by imaging lumbar region.
b. At appropriate intervals, obtain posterior and lateral images to follow tracer migration to the basal cisterns (3 min. or 500K counts).
c. Delayed images of spine and head up to 24-48 hours.
7. If the injection is done in the patient’s room, then you will probably need to bring the following items: Patient dose, LP tray, disposable gloves, sterile gloves, blue pads, plastic bag, survey meter.
Note: Have a physician check the images after each imaging session
before the patient leaves the Nuclear Medicine Department.
Hepatobiliary (HIDA) Scan
A. Indications
1.
Suspected cholecystitis
2.
Demonstration of choledochal cyst
3.
Occasionally helpful in the
evaluation of “cold” defects seen on routine liver imaging (e.g. focal nodular
hyperplasia)
4.
Evaluation of the jaundiced
patient (obstructive vs. non-obstructive)
5.
Detection of hepatitis
6.
Evaluation of biliary -
enteric anastamosis
7. Post-op trauma and bile leaks
8. Pediatrics: biliary
atresia vs. neonatal hepatitis
9. Gallbladder ejection
fraction
B. Patient
Preparation
1.
NPO for at least 4 hours,
preferably NPO overnight (except for water and meds)
2. If
possible, withhold Demerol or morphine for at least 4 hours prior to study
3. If no food for 4 days, Sincalide 20ng/kg (.02 ug/kg) in 250cc D5w over 30 minutes, wait 30 minutes
before IDA injection
C. Tracer: 5- 8 mCi Tc-99m
DISIDA or BRIDA, 8 if bili > 3
D. Injection/Acquisition
Procedure:
1. Use the LEAP or high
resolution collimator.
2. Patient receives an
I.V. injection of tracer and dynamic sequential anterior images of the liver and abdomen are
obtained for one hour post injection (ADYN 60 sec/frame x 60 frames; 64 x 64 matrix,
zoom = 1). Ant, R. Lat, and LAO statics for 2
minutes at 128 x 128.
3. Additional
views may be acquired for 4 - 24 hours, depending on the initial
findings and clinical problem.
4. If the initial image is
abnormal, then the patient should remain NPO until 4 hour image has been
completed
5. Patients requiring a 24
hour image may have liquids and light, fat-free food.
6. If the gallbladder is
not visualized within one hour and there are no morphine contraindications,
morphine sulfate 0.04 mg/kg may be given slowly (3 minutes) I.V. if small bowel activity is seen.
E. Patients
to r/o leak will need delayed 4 and possibly 24
hr images.
F. Image all drainage bags in post op patients for 1 minute
(128 x 128 matrix).
Note: Have a physician check the
images after first hour to determine what additional images are needed. If the study appears to be complete before 1
hour, then the physician may check it at that time.
G. Pediatric
Variation for Biliary Atresia
1. Phenobarbital
5 mg/kg/day in 3 divided doses for 7 days before scan.
2. Do Pediatric Hida scan. Patient may feed normally. 24 hour image will be
needed.
H. Ejection Fraction Determination for Chronic Acalculus Cholecystitis or Biliary Atresia
At 75 to 90 minutes, if gallbladder is full, give Sincalide
as above, E.F. = (gallbladder ROIT zero-gallbladder ROIT 30 minutes)
/gallbladder ROIT zero)
Liver/Spleen Scan
A. Indications
1. Detection,
evaluation and follow-up of hepatic masses including primary and secondary
tumors, abscesses, cysts and hematomas.
2. Detection
and evaluation of diffuse hepatic parenchymal disease such as cirrhosis and
fatty infiltration.
3. Evaluation
of size, shape, and position of both the liver and spleen.
4. Evaluation
of trauma to the liver and spleen.
5. Detection
of ectopic or accessory spleens.
6.
Evaluation of abnormal liver
chemistry studies.
7. Hepatitis,
possible lymphoma or infarct.
8. Congenital
hepatic abnormalities (polycystic disease)
9. Nutritional
and metabolic liver disease (evaluation of chemotherapy)
10. Functional
asplenia.
B. Patient
Preparation: None
C. Tracer: 6-8 mCi Tc-99m sulfur colloid
D. Injection/Acquisition Procedure
1. Use the LEAP or high resolution collimator.
2. Patient will receive an IV injection and wait 15-20 minutes before imaging.
3. If the patient can tolerate a SPECT acquisition it should be obtained by typing ‘ACQUIRE’ and selecting ‘LIVERTOMO’ (this is an automatic protocol enabling you to acquire the appropriate images). After the tomographic acquisition the protocol automatically queues up 3 static images.
4. If the patient cannot tolerate a SPECT acquisition you will obtain 6 static images (use the ‘LIVER MENU’ protocol). Static images are obtained using a 256 matrix for 750k counts/image.
E. Processing Procedure
1. For static images there is no processing.
2. For tomographic studies one reconstructs the data in three planes using the protocol ‘RECON’. Attenuation correction should be utilized.
3. Photograph the planar images and review them with a physician before the patient leaves the Nuclear Medicine Department.
4. For tomographic studies - one should calculate the liver and spleen volumes using the protocol ‘LSVOL’.
F. Miscellaneous
1. Patients should always be studied in the supine position.
2. Marker should be placed over the liver along the costal margin.
3. Be sure to minimize the breast shadow in female patients.
4. If the spleen is the organ of interest (e.g. cases of trauma) it may be desirable to acquire an LPO image.
Gastric
Emptying (Routine = Solid)
A. Indications
1. Evaluation of complaints of satiety, bloating, pain, gastric regurgitation or heartburn in untreated patients.
2. Evaluation of patients on cholinergic or anticholinergic medications.
3. Post-op gastric surgery patients.
B. Patient Preparation
1. Patient should be NPO
after
2. Patient must be able to eat an egg. If this is not possible, the nursing unit must notify the Nuclear Medicine Department so other foods can be prepared.
C. Tracer: Inject 1 mCi Tc-Sulfur Colloid into an egg white and scramble the entire egg.
D. Injection/Acquisition Procedure:
1. Use the LEAP collimator.
2. Patient will be instructed to ingest one scrambled egg with tracer.
3. Acquire a 200k anterior image and LAO 5 minutes after tracer administration and note the time for the acquisition. Use a 128 matrix.
4. Acquire additional anterior images and LAO (for the same acquisition time as the image in part b) starting 15, 45, and 90 minutes after tracer administration.
E. Processing Procedure
1. Photograph all images.
2. Determine the number of counts in the stomach on the 5 and 90 minute images using the RIRR command.
4. Normal gastric emptying is greater than 50% in 90 minutes.
F. Variation: Liquid Phase
1. A balanced food supplement with a tracer is given to the patient.
2. Imaging time will be 30 minutes with a possible delayed image at 60-90 minutes. Sometimes a 4 hour delay image is required to assess aspiration.
3. The acquisition technique will be a dynamic acquisition for 30 minutes (using 60 sec frames and a 64x64 matrix).
4. Normal liquid emptying is greater than 50% in 30 minutes.
5. To calculate the % emptying establish a ROI using the command RIRR. Generate a curve using CGEN. Get the stomach counting rates from frame 1 using the command ‘ISTA 1/1’. Now advance the image to frame 30 and get the ROI counting rate from this image by typing ‘ISTA 1/1’.
Gastroesophageal Reflux
A. Indications
1. Evaluation of esophageal motility in patients with complaints of dysphagia.
2. Detection and quantification of gastroesophageal reflux.
3. Detection of chronic pulmonary aspiration of gastric contents.
B. Patient Preparation
1. Patient should be kept NPO for at least 2 hours before procedure.
2. Patient should not be allergic to orange juice. If so, water will be substituted.
C. Tracer: Add 1 mCi
Tc-99m-Sulfur Colloid to 150cc of orange juice with 150cc of HCl (0.1
D. Injection/Acquisition Procedure
1. Use a LEAP collimator.
2. Check that patient does not have aneurysm, abdominal surgery, or kidney stone. Patient will be instructed to drink 300cc of an orange juice/normal dilute hydrochloric acid combination mixed with a tracer. Patient is instructed to avoid contamination.
3. About 5 minutes post-ingestion, the patient will be ready for positioning.
4. The patient will be supine and a large (thigh size) blood pressure cuff will be placed around the abdomen.
5. A physician will apply pressure in 20 mm Hg increments until reflux is detected, up to a maximum pressure of 100 mm Hg, or to the point at which the patient complains that the test is too uncomfortable.
6. 30 second images will be obtained at baseline and at each level of external pressure. An additional 30 second image will be obtained 30 minutes after tracer administration. (Acquisition protocol #43 on the STARPORT is an automatic protocol).
E. Processing Procedure: A 30 minute liquid gastric emptying value shall be determined from the initial image and the image obtained 30 minutes after tracer administration.
F. Variation - Pediatric “Milk Scan”
1. Try to coordinate with baby’s feeding time.
2. The nurse should provide the Nuclear Medicine Department with formula to which we add tracer. The amount of Tc-99m-Sulfur Colloid to be used is based upon the child’s weight and is calculated from the chart maintained in the hot lab.
3. After the baby is fed, pictures will be taken immediately, for about 30-60 minutes, to look for gastric reflux and emptying. The baby is placed upon the gamma camera in a supine position with the camera under the child. The camera is protected from contamination. Use a dynamic acquisition (ADYN) with a 32 x 32, 1.6 Zoom, and 15 second frames.
4. The baby will be brought back 4 hours post-ingestion to try to detect aspiration and this will take 10 minutes of imaging time. A 24 hour delayed image is optional.
G. Variation - Salivagram
1. 1 mCi Tc-99m sulfur colloid in .5cc of saline is dropped onto the anterior part of the tongue and allowed to mix with the saliva in the mouth.
2. The patient lies supine with the gamma camera positioned below the table. Posterior images are taken at 60 sec/frame for 60 minutes. The intensity setting should be such as to enhance the esophageal activity and any saliva which may be aspirated.
3. If no transit into the esophagus occurs within 20 minutes, a small volume of water (5 cc) may be administered.
4. Obtain anterior and posterior images for 5 minutes following study. Obtain laterals as needed.
5. Reformat the images to 1 min/frame for filming.
6. LEAP Collimator
7. Delayed scan may be needed for aspiration.
Note: Have a physician check the images before the patient leaves
the Nuclear Medicine Department.
GI
Bleeding Study
A. Indications: Detection and localization of gastrointestinal bleeding.
B. Patient Preparation
1. None
2. NGT should be placed/aspirated to r/o an UGI source.
3. Patient must be actively
bleeding during scan to accurately determine origin of blood loss.
C. Tracer: 25 mCi Tc-99m-RBC
D. Injection/Acquisition Procedure
1. Use LEAP collimator.
2. Label the blood using technique ‘B’. B is preferred.
3. Technique ‘B’:
a. Use the Mallinckrodt invitro Red Blood Cell labeling kit as per the instructions.
b. Use the acquisition macro (GI BLEED) listed on the “ACQUIRE” menu. This protocol sets up two 30 minute dynamic studies (60 sec/fr 64 x 64 matrix).
c. Position the patient in the supine position and acquire anterior images of the abdomen.
4. High and low anterior, LAO and RAO or lateral static images may be needed.
E. Processing: The two acquisitions can be combined using the PASTE protocol.
F. Variations: If the patient has poor veins and an in-vitro labeling is difficult then use the standard in-vivo labeling technique (e.g. MUGA procedure).
G. RBC Label Techniques
1. in vivo
2. in vitro
3. modified in vivtro
Note: Have a physician check the images before the patient leaves the Nuclear Medicine Department.
Gastric Mucosa Localization (Meckel’s Scan)
A. Indications
1. Child or adult with abdominal pain and/or rectal bleeding.
2. History of periodic episodes of abdominal discomfort.
B. Patient Preparation
1. Hold meal prior to study.
2. Pre-medicate patient with Cimetidine (Tagamet); 300 mg. for adults, dose will be adjusted by physician for children.
3. Nuclear medicine
control desk tech will contact referring physician to order the Tagamet on-call.
4. Medication should be given 45 minutes before the study.
C. Tracer: 10 mCi Tc99mO4 - Adjust dose for children
D. Injection/Acquisition Procedure
1. Use a LEAP collimator.
2. 10 mCi Tc-99m given i.v. 45 minutes after the Tagamet medication while the patient is supine and with the camera centered over the abdomen.
3 Collect a 60 minute dynamic acquisition (ADYN, 64 matrix, 60 second frames).
4. Collect static images (256 matrix, 1000k counts) after dynamic study. Anterior, oblique anteriors, right lateral, post-void.
E. Processing: None
Note: Have a physician check the images before the patient leaves the
Nuclear Medicine Department.
Hemangioma
Study
A. Indication: Differential diagnosis of hemangioma vs. tumor
B. Patient Preparation: None
C. Tracer: 25 mCi Tc99m-RBC in vitro
D. Injection/Acquisition Procedure
1. Use a LEAP collimator.
2. Follow procedure for in-vivtro technique as described in ‘GI-BLEED’
3. Flow study 3 sec/frame x 20 frames at 64 x 64 matrix word.
4. Dynamic 1 minute/frame x 20 frames at 64 x 64 matrix word.
5. Static images 128 x 128 2 minutes. Anterior, posterior, right lateral.
6. Wait 90 minutes after administration of labeled cells.
7. Use acquisition macro from ‘ACQUIRE’ menu, ‘LIVER’ subset. This will set up a tomographic acquisition (128 stops, 64 matrix, 10 sec/stop) and 3 static images (1000k counts each).
E. Processing
1. Reconstruct the tomographic images using protocol “RECON”. Use attenuation correction.
2. Photograph all transaxial, sagittal, and coronal images.
F. Variations: Before performing this study, one should try
to review any CT or
Note: Have a physician check the images before the
patient leaves the Nuclear Medicine Department.
Perfusion and Ventilation
Imaging (Xenon-133)
A. Indications
1. Diagnosis of pulmonary embolism, COPD
2. Quantification of lung perfusion or ventilation
B. Patient Preparation: Chest x-ray within 24 hours and sent with patient (if performed with portable x-ray machine).
C. Tracer: 15 mCi Xe-133 and 5 mCi Tc-99m-MAA
D. Injection/Acquisition Procedure
1. Use a LEAP or high resolution collimator.
2. Ventilation: Use 15 mCi Xe-133 gas via ventilation mask.
3. Perfusion: Use 5 mCi Tc-99m-MAA given intravenously. Patient must be in the supine position during injection to allow for even distribution of the tracer in the lungs.
4. There is an acquisition macro on the STARPORT for a combined V/Q scan (#33-AEMC LUNG).
5. For the ventilation scan it creates 8 posterior images (inspiration, equilibrium, and six 30 second washout images) with a 128 matrix.
6. For the perfusion scan it creates 8 static images - Posterior, LPO, RPO, LAO, RAO, Right Lateral, Left Lateral, and Anterior (128 matrix, 750k counts).
E. Processing: If the study was performed in order to quantitate relative function of the two lungs, then one determines the total lung counts for each lung on the posterior perfusion scan (or the inspiration ventilation scan) and calculates the percent of total activity located in each lung.
Note: Ventilation
scans can not be performed on patients with a tracheostomy or who are on a ventilator.
Note: Have a physician check the
images before the patient leaves the Nuclear Medicine Department.
Gated Heart Scans
A. Indications
1. Evaluation of heart function, including size, wall motion, ejection fraction, possible aneurysm, regurgitant fraction (valvular disease), intracardiac shunts.
2. Evaluation of cardiac status prior to and during use of cardio-toxic drugs.
B. Patient Preparation: Study acquisition requires a regular cardiac rhythm and a heart rate less than 120 bpm.
C. Tracer: 25 mCi 99m-TcO4-RBC in vivo label
D. Injection/Acquisition Procedure
1. Check the patient’s chart to exclude arrhythmias
2. Use the LEAP or high resolution collimator.
3. Label the patient’s red blood cells with 25 mCi TcO4 as follows:
a. Inject the patient with cold pyrophosphate
b. PYP kit is reconstituted with 4 ml of normal saline
c. Kit must be at room temperature before reconstruction
d. Use 2 ml cold PYP per patient unless:
i. Patient is on anti-coagulants
ii. Heparin lock is used for injection
iii. Other reason to suspect difficult tag.
iv. In the above cases use all 4 mls.
e. Wait 15-20 minutes after injection of cold PYP and inject patient with 25 mCi’s 99m TcO4.
4. Acquisition Technique
a. Position patient on imaging table and attach EKG electrodes.
b. Place electrodes on patient so that best tracing or beat pick up is made (one below left and one below right clavicle and one on lower left rib cage). Confirm the absence of arrhythmias.
c. Collect gated images of the heart in the anterior, 40 degree LAO best septal, and 70 degree LAO projection. Images should be acquired for 600 heart beats or 6,000,000 counts (which ever comes first). On the STARPORT the protocol is #3 and on the STARCAMs the protocol is A_GATE.
5. Processing Technique
a. Transfer the data to a STARCAM for processing.
b. Process the data using the protocol PAGEPROC for automatic processing (one must identify the center of the left ventricle). If there is any question regarding the validity of the E.F., repeat the analysis using the protocol PAGEP2FR.
Pyrophosphate
Infarct Scans
A. Indications: Detection and evaluation of acute myocardial infarction (most sensitive at 48-72 hours after suspected M.I.)
B. Patient Preparation: None
C. Tracer: 25 mCi Tc99m-PYP
D. Injection/Acquisition Procedure
1. Use the LEAP or high resolution collimator.
2. Give the patient an intravenous injection of 25 mCi Tc99m-PYP.
3. Wait 2 to 3 hours after injection
4. Collect 750,000 count images in the anterior, LAO40, and LAO70 projections. Use a 256 matrix.
5. If clinically feasible collect a tomographic acquisition of the chest 4 hours after tracer injection (64 stops, 64 matrix, 20 sec/view).
E. Processing Technique: If a tomographic acquisition was performed then reconstruct the data using the RECON protocol.
Note: Have a physician check the images before the patient leaves
the Nuclear Medicine Department.
Rest Thallium -
Redistribution
A. Indications
1. Evaluate ischemia at rest
2. When done in conjunction with an abnormal stress study this test is to determine if the defect seen on the stress study was due to stress induced ischemia or myocardial scar.
3. Detect viable myocardium
B. Patient Preparation
1. NPO for at least 2 hours before the study except H2O and meds.
2. Should remain NPO until after the 2nd images are completed; may drink decaffeinated beverages.
3. DIABETICS - consult with physician for modifications in fasting.
C. Tracer: 3.5 mCi Tl-201
D. Injection/Acquisition Procedure
1. Use the LEAP or high resolution collimator.
2. Inject 3.5 mCi Tl-201 intravenously with patient in upright position (to decrease splanchnic uptake).
3. Planar: 6 minute images are obtained using a 128 matrix and 1.33 Zoom in the anterior, LAO 40, and LAO 70 degree projections starting 20 minutes after tracer injection. Redistribution images are obtained 3 to 4 hours after tracer injection. (STARCAM protocols: STRESSTL or DELAYTL).
4. Tomographic: 20 minute and 3-4 hour delayed acquisitions are to be obtained (32 stops, 180 degrees of acquisition, 64 matrix, no zoom, 40 sec/stop). Start acquisition in the 45 degree RAO projection. (STARCAM protocols: BUACQST, BUACQDL).
E. Processing Technique
1. Planar: Use QTPROCESS
2. Tomographic: Use BURECON, BUPROCESS
F. Variations
1. If the rest study is acquired as a comparison to a stress study done on a different day, then no redistribution is needed.
2. Acquire the initial rest study using:
a. Planar: Find the stress study and queue up the delayed images
b. Tomographic: Find the stress study and queue up the delayed images.
3. Process the combined study as if it were a stress/redistribution study.
4. When the processing program asks for the time interval between the stress and the delayed images - use 240 min as an arbitrary value (this will only affect the washout image information).
Stress Thallium -
Redistribution
A. Indications
1. Detect CAD/evaluate known CAD
2. Identify scar/ischemia
3. Evaluate medical or surgical therapy of CAD.
B. Patient Preparation
1. NPO for at least 2 hours before the test except H2O and meds.
2. Should remain NPO until after 2nd images are obtained; may drink decaffeinated beverages.
3. DIABETICS - consult with physician for modifications in fasting.
C. Tracer: 3.2 Tl-201mCi at stress, 1 mCi Tl-201 15 minutes before delay scan.
D. Injection/Acquisition Procedure
1. Use the LEAP collimator.
2. Start an i.v. line in the patient before they begin to exercise on the treadmill and make sure that it is patent.
3. Inject Ci Tl-201 one minute before the termination of the stress test.
4. Have the patient continue to exercise for one minute after the injection of the Thallium (if possible).
5. Have the patient transferred to the imaging room and positioned under the camera as quickly as clinically feasible.
6. Acquisition Technique:
a. Acquire images (planar or tomographic) beginning about 10 minutes after tracer injection and again 3 to 4 hours later.
b. Planar Acquisition: (6 minutes, 128 matrix, 1.33 Zoom) in three views (Anterior, LAO40 “Best Septal”, LAO70). STARCAM protocol = STRESSTL, DELAYTL
c. Tomographic Acquisition (32 stop, 40 sec/stop, 180 degree, no zoom) Start acquisition in the 45 degree RAO projection. STARCAM protocol = BUACQST, BUACQDL
E. Processing Technique
1. Planar: Use protocol QTPROCESS
2. Tomographic: Use protocol BURECON, BUPROCESS
F. Variation
1. The stress study can be done on one day and compared to a rest study done on a different day. (This allows for a more accurate assessment of myocardial viability if the stress study is abnormal and the avoidance of unnecessary testing if the stress study is normal).
2. In this case the stress study is to be analyzed and the rest study is to be canceled if the stress study is normal. Process the stress study using protocols (Planar = QTPROCESS, Tomographic = BURECON + BUPROCESS).
Cardiolite
Myocardial Perfusion Imaging
A. Indications: Same as Thallium
B. Patient Preparation
1. STRESS: Patients should be NPO before the exercise for at least two hours. Avoid caffeine (coffee, tea, cola) before the test.
2. REST: The patient may eat lightly, but should avoid caffeine.
3. DIABETICS - consult with physician for modifications in fasting.
C. Tracer: Tc-99m-Cardiolite
D. Injection/Acquisition Procedure
1. Note: for all acquisitions use the STARCAM protocol ‘CARDIOLITE’
2. Use the high resolution collimator.
3.
Two Day Technique
a. Stress Acquisition:
i. Start an i.v. line in the patient before they begin to exercise on the treadmill and make sure that it is patent.
ii. Inject 30-40 mCi Tc-99m-Cardiolite 90 seconds before the termination of the treadmill exercise.
iii. Have the patient wait at least 20-60 minutes before imaging the heart.
iv. Acquire the images using the protocol ‘CARDIOLITE’
v. Imaging parameters:
1. Planar Acquisition: (5 minutes/image, 128 matrix, 1.33 Zoom) in three views (Anterior, LAO40, LAO70).
2. Tomographic Acquisition (64 stop, 20 sec/stop, 64 matrix, 180 degree, no zoom) Start acquisition in the 45 degree RAO projection.
vi. Scheduling:
1. Schedule the patient for a rest study to be done at least 2 days later.
2. The stress study shall be processed on the day of the acquisition, and the rest study can be canceled if the stress study is normal.
b. Rest Acquisition:
i. Inject the patient while at rest with 30-40 mCi of Tc-99m-Cardiolite.
ii. Have the patient wait at least 60 minutes before imaging.
iii. Acquire the images in the same manner as described under “Stress Acquisition” above.
iv. Note: Both stress and rest images should be either tomographic or planar - but we should never have one data set with one data format and the other data set with the alternative format.
4.
One Day Technique
a. Perform the stress study in the morning.
b. Use the procedure described under “Stress Acquisition” above except that one should use only 10.15 mCi Tc-99m-Cardiolite and the time/stop on the tomographic acquisitions is 20-25 seconds/stop (the acquisition protocol sets this up automatically).
c. After the stress study is completed, perform the rest study using the technique described under “Rest Acquisition” above using 35-45 mCi Tc-99m-Cardiolite.
5.
One Day Technique
a. Perform the stress study in the morning with low dose, rest study with high dose.
b. EKG Gate the high dose acquisition into 8 time bins if possible.
E. Processing Technique
1. Planar: Use protocol QTPROCESS
2. Tomographic: Use protocols CLRECON, CLPROCESS
Persantine Thallium
A. Indications: Same as “Thallium Stress – Redistribution,” except test performed on patients for whom exercise is not feasible or patients with left bundle branch block.
B. Patient Preparation
1. Same as Thallium Stress - Redistribution.
2. No xanthines (i.e. aminophylline, theodur) for 24 hours before test.
3. No caffeine (coffee, tea, cola) for 6 hours before the test.
C. Tracer: 3.2 mCi Tl-201 at stress, 1 mCi Tl-201 15 minutes before delay study.
D. Injection/Acquisition Procedure
1. Use the LEAP collimator.
2. All patients must have interview and good IV access before persantine is given.
3. The aminophylline must also be ready for infusion.
4. Patients are kept supine on EKG monitor for 45-60 minutes or until chest pain or significant side effects warrant termination of test.
5. At peak absorption or when chest pain occurs, inject with 3.5 mCi Tl-201. (Imaging to begin within 10 minutes).
6. After imaging begins, reverse pharmacologic effects of Persantine with 150 mg. aminophylline solution (1 mg./cc.), given IV over 10-15 minutes if the cardiologist feels that it is clinically indicated. (The aminophylline may be started at once if the patient complains of severe chest pain).
7. Acquisition Technique
a. Acquire images (planar or tomographic) beginning about 10 minutes after tracer injection and again 3 to 4 hours later.
b. Planar Acquisition: (6 minutes, 128 matrix, 1.33 Zoom) in three views (Anterior, LAO40, LAO70). STARCAM protocol = STRESSTL, DELAYTL
c. Tomographic Acquisition (32 stop, 40 sec/stop, 180 degree, no zoom) Start acquisition in the 45 degree RAO projection. STARCAM protocol = BUACQST, BUACQDL
E. Processing Technique
1. Planar: Use protocol QTPROCESS
2. Tomographic: Use protocol BURECON, BUPROCESS
F. Variation: I.V. Persantine
1. 0.57 mg/kg can be administered over 4 minutes.
2. The patient is exercised moderately for two minutes (except for patients with left bundle branch block) and Tl-201 is administered intravenously.
3. 75 mg aminophylline in 5 cc is given if needed by the cardiologist to reverse the effects of the persantine.
4. The patient is then imaged in the Nuclear Medicine Department.
Gallium
Scans
A. Indications
1. Diagnosis, evaluation and follow-up of malignancies, including lymphoma, leukemia, lung cancer, melanoma, Kaposi’s sarcoma, Burkitt’s lymphoma, hepatoma, seminoma, and anaplastic tumors.
2. Evaluation of thyroid nodules.
3. Diagnosis, evaluation and follow-up of inflammatory processes, especially infectious processes. may be of use in evaluating patients with cardiomyopathies, pericarditis, and pulmonary fibrosis as a predictor of response to steroids. The test is important in diagnosing osteomyelitis.
B. Patient Preparation: None
C. Tracer:
D. Injection/Acquisition Procedure
1. Patient will receive an
IV injection of
2. Acquisition Technique
a. Imaging for infection: Performed at 24 hours post-injection. Delayed views are performed 48-96 hours post-injection as directed by a physician.
b. Imaging for tumor: Performed at 48-72 hours post-injection with delayed views as directed by a physician.
c. Imaging for sarcoid: Performed 48-72 hours post-injection.
d. The acquisition should be performed using the medium energy collimator. One can acquire static images (256 matrix 750,000 counts/view) or a whole body mode scan. The camera should be set to use 3 separate energy peaks (use protocol Ga-67). A tomographic acquisition of the lungs can be performed if desired using 64 stops and 20 sec/stop with a 64 matrix.
E. Processing
1. If a tomographic acquisition was obtained then process it with protocol RECON.
2. For patients with lymphoma, a tomographic image should always be obtained. Check with physician whether to include chest, abdomen or both.
Labeled
White Blood Cell Scan
A. Indications
1. Detection and localization of acute inflammations, especially cellulitis and abscesses.
2. Fever of unknown origin less than 4-6 weeks duration.
3. Identifying splenic remnants, post-splenectomy.
4. Active inflammatory bowel disease.
5. Diagnosing liver abscesses in cirrhotic patients
6. Polynephritis or renal abscesses in patients with polycystic or multicystic kidneys.
7. Differential diagnosis of pulmonary infiltrates (infarct vs. pneumonia).
B. Patient Preparation: None
C. Tracer: 25 mCi Tc-99m-WBC
D. Injection/Acquisition Procedure
1. Use the LEAP or high resolution collimator.
2. Materials: Heparin (100 units in 1 -2 ml preservative free saline). Syringes (3 ml, 20 ml). Needles (21-23 gauge). Intracath 22-23 gauge (butterfly with line = optional).
3. Procedure for tagging: Blood labeling technique:
a. Order kit from Nuclear Pharmacy the day before the test.
b. Draw up 50cc of blood into the provided syringe. Send blood to Nuclear Pharmacy for labeling. Upon return of the blood, inject blood into the patient. Two people must sign that the correct patient was identified for reinjection.
4. Acquisition Technique:
a. Scan the patient 2 hours (abdomen) 4 hours (extremities) after the reinjection of the labeled white blood cells. May need 24 hour views.
b. Collect multiple static images of the regions of interest using a 256 matrix. Collect images for 10 minutes or 750,000 counts.
E. Variation
1. Imaging with In-111 labeled WBC.
a. Use medium energy collimator.
b. Blood labeling technique:
i. Order kit from Nuclear Pharmacy the day before the test.
ii. Draw up 50 cc of blood into the provided syringe
iii. Send blood to Nuclear Pharmacy for labeling
iv. Upon return of the blood - inject it into the patient. Two people must sign that the correct patient was identified for reinjection.
c. Imaging technique:
i. Image at 24 hours after tracer administration.
ii. Collect 128 matrix images for 10 minutes or 750 k counts.
Kidney Transplant Evaluation
A. Indications
1. Perfusion to transplanted kidney.
2. Evaluation of function.
3. ATN (acute tubular necrosis)
4. Obstruction- complete or partial (see lasix study)
5. r/o leak
6. Rejection
7. Rising serum creatinine
B. Patient Preparation: None (patient should be hydrated if possible)
C. Tracer: 15 mCi Tc-99m MAG3
D. Injection/Acquisition Procedure
1. Waterload the patient 30 minutes before the scan using 16 to 24 oz. of water unless there is a clinical contraindication.
2. Position the patient beneath the gamma camera in the supine position. Be sure that the gamma camera is equipped with the high energy collimator. Be sure that the transplanted kidney and bladder will be in the field of view.
3. The normal acquisition protocol is found under ACQUIRE (select the renal menu and item #3 on the menu). This will set up a 2 phase dual isotope study lasting 24 minutes. Phase one is 20 three second images and phase two is 26 thirty second images. 128 matrix, no zoom.
4. Using the 3 way stop cock technique, inject 15 mCi Tc99m MAG3 and start the camera.
E. Processing Technique: Process the data using protocol KIDPROCESS and selecting option #1 (transplant kidney).
2-Kidney Renal Scan
A. Indications
1. Perfusion to native kidney
2. Evaluation of function
3. Evaluation of ATN
4. Obstruction - complete or partial (see lasix renal)
5. Differential renal function
6. Evaluation of renal trauma
7. Evaluation of renal anatomy, (e.g. mass)
8. Evaluation of hypertension
B. Patient Preparation: None (patient should be hydrated)
C. Tracer: 15 mCi Tc-99m MAG3
D. Injection/Acquisition Procedure
1. Waterload the patient 30 minutes before the scan using 16 to 24 oz. of water unless there is a clinical contraindication.
2. Same as Transplant Study except that the camera is below the patient and centered on the kidneys. Be sure to collect pre-void bladder image and a post-void kidney image. If patient is unable to void then take a delayed image of the kidneys after the patient has been 5 minutes in the erect position.
E. Processing Technique: Use protocol KIDPROCESS and select the option for a two kidney study.
Lasix Renal Scan
A. Indications
1. Evaluation of degree of partial UPJ or UVJ obstruction
2. Evaluation of renal function in the presence of hydronephrosis/hydroureter
Note: PLEASE HAVE REFERRING PHYSICIAN CONTACT NUCLEAR
MEDICINE PHYSICIAN TO DISCUSS PATIENT’S CLINICAL STATUS PRIOR TO ORDERING
STUDY.
B. Patient Preparation: None (Patient should be hydrated. Bladder should be empty before scan begins.)
C. Tracer: 15 mCi Tc-99m-MAG3
D. Injection/Acquisition Procedure
1. Waterload the patient 30 minutes before the scan using 16 to 24 oz. of water unless there is a clinical contraindication.
2. Same as Transplant Procedure (except the length of data acquisition is 45 minutes) with Lasix 40mg. IV being administered during the imaging session.
3. 40 mg of lasix is to be given i.v. by a physician or nurse approximately 10 to 15 minutes into the study.
E. Processing Technique: Use protocol KIDPROCESS with option #3 (lasix processing protocol).
Glucoheptonate Renal Scan
A. Indications
1. Evaluate renal infection damage and function
Note: PLEASE HAVE REFERRING PHYSICIAN CONTACT
NUCLEAR MEDICINE PHYSICIAN TO DISCUSS PATIENT’S CLINICAL STATUS PRIOR TO
ORDERING STUDY.
B. Patient Preparation: Hydrate patient. Empty bladder.
C. Tc-99m Glucoheptonate 15 mCi I.V.
D. Injection/Acquisition Procedure
1. Waterload
2. Tc 99m renal scan for 21 minutes
3. Wait 2 hours
4. Take posterior static and SPECT scan (3 minutes)
E. Processing Technique: Use kidney process for a 2 kidney study.
Captopril Renal Scan
A. Indication: Evaluation of unilateral renal artery stenosis.
B. Patient Preparation
Note: PLEASE HAVE REFERRING PHYSICIAN CONTACT NUCLEAR
MEDICINE PHYSICIAN TO DISCUSS PATIENT’S CLINICAL STATUS PRIOR TO ORDERING
STUDY.
1. There is a list of medications which the patient should not be taking at the time of this study. The list is maintained at the front desk. The patient should be off of diuretics, Captopril, and ace inhibitors for 48 hours unless otherwise specified by the patient’s physician.
2. Normally the Captopril study is a two part procedure (as described below). If the patient has had a routine 2 kidney renal study (while not on Captopril) within the past 2 months, then the first data acquisition may be omitted. There is a flow sheet for the combined study which is attached to the procedure manual.
C. Tracer: 2 x (15 mCi Tc-99m MAG3)
D. Injection/Acquisition Procedure
1. One Day Technique
a. PART A: Patient is hydrated for 1 hour prior to start of study, baseline BP is recorded, procedure is the same as 2 kidney renal study, lasix 40 mg IV 3 minutes into study.
b. Wait 1 hour before starting Part 2.
c. PART B: Record BP, water as before, administer Captopril 25 mg. p.o.; BP is then monitored for 1 hour after which 2 IV injections of tracers are given and a second set of images is obtained using the standard 2 kidney renal study is performed again, 40 mg lasix IV 3 minutes into study.
2. Two Day Technique: This is the preferred method
a. Perform the two parts on separate days.
E Processing Technique: Use the routine 2 kidney processing protocol described above in “2-Kidney Renal Scans”.
Voiding
Cystourethrogram
A. Indications
1. Detection of vesicoureteral reflux (especially important in pediatric urology).
2. Determine effects of therapy on reflux.
B. Patient Preparation: An indwelling catheter should be inserted into the bladder by a resident in order for the study to be performed.
C. Tracer: 1 mCi 99m-TcO4
D. Injection/Acquisition Procedure
1. Use a LEAP collimator.
2. Administration: With the patient supine, the bladder is distended with 0.9% NaCl solution which contains a 1 mCi Tc-99m in 500 ml saline until reflux is identified or the patient complains of discomfort.
3. Imaging (patient supine, anterior projection, mark the right side)
a. Filling Phase: During bladder filling one should acquire a dynamic study (64 matrix, 30 sec/frame, 20 frames, 90 degree orientation is typical).
b. Static Phase: When completely filled acquire static images (128 matrix, 500000 count) in anterior, RAO, and LAO projections.
c. Emptying Phase: (patient sitting on bed pan, camera posterior to patient, Foley removed). Have the patient void and acquire a dynamic study (64 matrix, 15 sec/frame, 20 frames with a 180 degree orientation).
d. Repeat steps 1 thru 3 as 2nd acquisition.
e. Post void static: 128 matrix, 500000 count, anterior view.
E. Miscellaneous:
1. This scan has the ability to be a contamination hazard.
2. Please keep all radioactive materials in one place and wear gloves during the entire study.
Testicular
Scan and Flow
A. Indication: Differential diagnosis of epididymitis vs. testicular torsion.
B. Patient Preparation: None
C. Tracer:
15 mCi 99m-TcO4
D. Injection/Acquisition Procedure
1. Use a LEAP collimator.
2. Patient is instructed to lie supine with his legs in frog position with the penis pointed up and taped to the lower abdomen. A towel may be placed under the scrotal sack.
3. The camera is positioned for an anterior acquisition.
4. Patient receives an IV injection of 15 mCi 99m-TcO4.
5. Acquire a dynamic acquisition (128 matrix, 3 sec/frame x 20 frames, 1.33 zoom).
6. Acquire delayed images (256 matrix, 1000 kcounts) at 2, 4,6,8,10, and 15 minutes after tracer administration.
7. Mark the right side.
Note: Have a physician check the images before the patient leaves
the Nuclear Medicine Department.
Blood Flow Technique
A. This is a general guide for doing radionuclide blood flow studies.
B. It is important to achieve a compact bolus when doing a blood flow study. The following items should help to achieve this:
1. Always try to use a medial antecubital vein for the injection. Injecting in a lateral antecubital vein or a peripheral vein will cause the bolus to be strung out. Sometimes a central i.v. line will be available and this may be used as an alternative (check with the nurse if there is any question about which i.v. lines may or may not be used). In renal transplant patients if a good vein is not available, the patient’s dialysis shunt may be used. Always ask permission from the transplant office nurse before using the shunt as an injection site.
2. When injecting directly into a patient’s vein, use a 21 gauge butterfly. If a smaller gauge is used keep in mind that this will affect the size of the bolus. Never use smaller than a 23 gauge. Make sure to keep the infuser free by flushing with heparinized saline solution (10%).
3. Use a 10 cc flush with a three-way stopcock to inject the dose. Make sure to push the flush forcefully into the patient.
4. Always use at least 15 mCi when performing a blood flow study in order to achieve adequate counting statistics.
Bone
A. Indications
1. Primary or metastatic tumor
2. Spondylolysis
3. Renal osteodystrophy
4. Paget’s
5. Hyperparathyroidism
6. Low back pain.
B. Patient Preparation
1. Unless contraindicated, encourage patient to drink 2-3 glasses of water.
2. Have patient void frequently to eliminate tracer from the bladder.
3. Foley catheter drainage bag should be emptied frequently.
C. Tracer: 25 mCi 99m-Tc-MDP
D. Injection/Acquisition Procedure
1. Use the LEAP collimator.
Note: INCONTINENT PATIENTS SHOULD NOT BE INJECTED
UNLESS THEY ARE CATHETERIZED
2. For a routine Bone Scan the patient will be injected with 25 mCi Tc-99m-MDP while in the Nuclear Medicine Department or in their bed.
3. Acquisition Technique
a. Have the patient empty their bladder before beginning the scan.
b. Make sure the patient’s pockets are empty of all metal objects and remove all metal belt buckles or braces.
c. ADAC: Scan total body at 10 minutes/meter, take laterals of skull, if breast cancer patient take LAO/RAO chest.
d. STARCAM: Using the protocol listed on the ACQUIRE menu which sets up for 16 static images.
e. After the acquisition is completed the images should be shown to a physician for possible follow-up X-Rays.
E. Variations:
1. Triple Phase
a. Suggested indications: Occult, insufficiency, or stress fractures; heterotopic bone; osteomyelitis; avascular necrosis; RSD; evaluation of joint prosthesis.
b. At the time of tracer administration a flow study of the area of interest should be obtained using 3 second images for 1 minute. Blood pool images (750k, 256 matrix images) should be obtained of the area of interest and of the anatomically paired area)
c. Injection Technique: If the area of interest is one of the upper extremities then try to inject in a lower extremity. If one must inject in an upper extremity then use the arm which is not the area of interest. Apply the tourniquet, insert the needle (use of a butterfly is recommended), remove the tourniquet, WAIT 3 minutes, inject the tracer.
2. Tomographic Acquisition
a. Indication: Low back pain. Need for increased contrast resolution of any bony abnormality.
b. Acquisition technique: 128 stops at 10 sec/stop with a 64 matrix.
c. Processing technique: Use the RECON protocol to reconstruct the data in three planes. Use attenuation correction only for the lumbar spine. If there is excessive patient motion then ‘improve’ the raw data with the TGMC command.
F. Miscellaneous: In cases of RSD one should obtain blood pool images of all joints of the affected limb and of the contralateral limb.
Bone Mineral Density
A. Indications: Measurement of bone mineral content of the lumbar vertebrae and the femoral necks in patients suspected of osteopenia due to postmenopausal bone loss, Osteodystrophy, Hypercortisolism, Hyperparathyroidism, Medications, or Prolonged immobility/bed rest.
B. Patient Preparation: Remove all metal out of the lumbar spine region.
C. Tracer: None
D. Injection/Acquisition Procedure
1. Spine: The patient is placed supine on the Hologic bone densitometry unit with the legs elevated. The acquisition is performed in accordance with the built-in standard protocol.
2. Femur: The patient is placed supine on the Hologic bone densitometry unit with the legs flat and the foot of concern fastened to the foot brace. The acquisition is performed in accordance with the built-in standard protocol.
3. Forearm: The acquisition is performed in accordance with the built-in standard protocol.
E. Processing Technique: The acquired data (Spine, Femur of Foreamr) is processed using the standard processing technique which calculates an absolute value of bone mineral concentration and compares this value to age and sex matched controls.
Thyroid
Uptake
A. Indications
1. Evaluation for hypo- or hyperthyroidism, abnormal blood chemistries
2. Evaluation of anterior neck nodules
3. Swallowing or breathing abnormalities
4. Palpable goiter evaluation
5. Suspected lingual thyroid
6. Evaluation post thyroid surgery
7. Follow-up of patients exposed to thyroid radiation
B. Patient Preparation
1. Patient should be off all thyroid medications:
a. Thyroxine (synthroid) in any form within 3-4 weeks
b. Cytomel within 14 days
c. Amiodarone within 14 days
d. PTU within 3 days
e. Tapazole within 1 week
2. Patients who have had the following x-ray procedures must wait to be scanned according to the following guidelines:
a. IV urograms, myelograms, arteriograms, CAT scans (w/contrast), cardiac cath within 1 month
b. Oral cholecystograms within 3 months
3. Patient should be off oral iodides for 4 weeks
D. Tracer: 8 uCi I-131
E. Injection/Acquisition Procedure
1. Patient will be interviewed by MD. Patient will be instructed by MD to ingest a capsule of approximately 8 uCi of iodine-131.
2. The day the capsule is administered it is to be counted along with the room background under that patient’s file in the uptake probe’s computer.
3. The following day the patient returns for a 24 hour uptake study. To acquire this study one selects the correct patient file on uptake probe. Counts from the first day will exist. [The counts from the capsule will be automatically adjusted for decay by the computer after the 24 hr background determination is made]. One must again count the background. Place the patient on the table in the supine position and count the thyroid for 5 minutes.
4. Show the results to an MD before the patient leaves the Nuclear Medicine Department.
E. Variation:
In an infant the uptake can be determined using 50 uCi I-123 which should be administered in milk.
Thyroid
Scan
A. Indications
1. Evaluation for hypo- or hyperthyroidism, abnormal blood chemistries
2. Evaluation of anterior neck nodules
3. Swallowing or breathing abnormalities
4. Palpable goiter evaluation
5. Suspected lingual thyroid
6. Evaluation post thyroid surgery
7. Follow-up of patients exposed to thyroid radiation
B. Patient Preparation
1. Patients should be off all thyroid medications:
a. Thyroxine (synthroid) in any form within 3-4 weeks
b. Cytomel within 14 days
c. Amiodarone within 14 days
d. PTU within 3 days
e. Tapazole within 1 week
2. Patients who have had the following x-ray procedures must wait to be scanned according to the following guidelines:
a. IV urograms, myelograms, arteriograms, CAT scans (w/contrast), cardiac cath within 1 month
b. Cholecystograms within 3 months
3. Patients should be off oral iodides for 4 weeks
C. Tracer: 15 mCi 99m-TcO4
D. Injection/Acquisition Technique
1. Patient will be interviewed by a physician
2. Patient will receive an IV injection of 15 mCi TcO4.
3. Images will be performed 20 minutes post-injection and will take about 30 minutes to complete (256 matrix, anterior, anterior with marker, LAO, RAO views; 2.5 minutes or 300k counts [which ever takes shorter]). The pin-hole collimator is to be used. The acquisition parameters are defined in the default acquisition listed on the ACQUIRE menu.
4. Patient will again be evaluated by a physician and additional images may be required.
5. An ultrasound examination may be ordered if clinically indicated.
E. Variation:
If clinically indicated the study can be performed 24 hours after oral administration of 400 uCi I-123. Usual indications are the need to evaluate a solitary noted warm nodule as noted on a TcO4 scan.
Thyroid
Whole Body Scan
A. Indication: Evaluation and follow-up of thyroid cancer patients
B. Patient Preparation: None (Patient off Synthroid 4-6 weeks. Check TSH (should be > 50).
C. Tracer: I-131 as a liquid or a capsule
D. Injection/Acquisition Procedure
1. The dose of I-131 is determined by a Nuclear Medicine physician and may be given orally as a capsule or a liquid. (If the dose exceeds 30 mCi the patient must be treated as an inpatient). The dose is given by a Nuclear Medicine physician. If the dose exceeds 30 uCi of I-131, the Quality Management Program must be followed.
2. Acquisition Technique
a. Scans are obtained 48 hours after tracer administration (24 or 72 hour delayed scans are optional).
b. Whole body scans are obtained in the anterior and posterior projections on the STARCAM cameras using a high energy collimator, the I-131 energy settings, and the protocol I131BODY.
c. Spot views of the neck and chest and head are obtained (128 matrix, 300 seconds).
Note: Have a physician check the images before the patient leaves
the Nuclear Medicine Department.
Pancreas Transplantation
A. Indications: To evaluate the status of the pancreatic transplant for rejection, vascular occlusion, or perforation.
B. Patient Preparation: None
C. Tracer: 15 mCi Tc-DTPA
D. Injection/Acquisition
1. Patient receives an I.V. injection of the tracer and images are acquired for 6 minutes. (128 matrix, 20 frames @ 3 sec plus 20 frames @ 15 sec). You may use the Transplant protocol and terminate the study at 6 minutes if desired.
E. Processing: Reformat the images into 15 second frames and photograph (use IRFT).
F. Variations
1. If it is a combination Kidney/Pancreas transplant use the Transplant protocol with the high energy collimator and both DTPA and Hippuran.
2. If it is only a Pancreas transplant use just DTPA and the low energy collimator.
SVC Flow