Self-Assessment Cases: Advanced

and Vincent L. Sorrell2



(1)
Division of Nuclear Medicine and Molecular Imaging Department of Radiology, University of Kentucky, Lexington, Kentucky, USA

(2)
Division of Cardiovascular Medicine Department of Internal Medicine Gill Heart Institute, University of Kentucky, Lexington, Kentucky, USA

 



Electronic supplementary material

The online version of this chapter (doi: 10.​1007/​978-3-319-25436-4_​29) contains supplementary material, which is available to authorized users.



29.1 Case Challenge #25



29.1.1 Problem



Clinical Highlights


A 35-year-old female presents with “yellow eyes.”


Images for Review




A330381_1_En_29_Fig1_HTML.gif



Fig. 29.1




  • (a) Rest raw projection images (Video 29.1a, frame 1),99mTc sestamibi


  • (b) Stress raw projection images (Video 29.1b, frame 1),99mTc sestamibi


Characterize the Pertinent Finding(s)






  • Chest



    • Thyroid gland: □ hot □ cold


    • Parathyroid glands: □ hot □ cold


    • Breasts: □ hot □ cold


    • Chest wall: □ hot □ cold


    • Skeleton: □ hot □ cold


    • Pleura: □ hot □ cold


    • Lungs: □ hot □ cold


    • Mediastinum: □ hot □ cold


    • Myocardium and pericardium: □ hot □ cold


    • Right atrium and right ventricle: □ hot □ cold


    • Vascular system: □ hot □ cold


    • Lymphatic system: □ hot □ cold


    • Diaphragm: □ hot □ cold


  • Abdomen



    • Abdominal wall: □ hot □ cold


    • Peritoneum: □ hot □ cold


    • Liver: □ hot □ cold


    • Biliary system and gallbladder: □ hot □ cold


    • Spleen: □ hot □ cold


    • Stomach: □ hot □ cold


    • Small intestine and large intestine: □ hot □ cold


    • Adrenal glands: □ hot □ cold


    • Kidneys and female reproductive system: □ hot □ cold


    • Vascular system: □ hot □ cold


State Your Relevant Diagnosis(es)






  • Chest



    • Thyroid gland: □ normal □ diffuse toxic goiter


    • Parathyroid glands: □ normal □ adenoma, substernal location


    • Breasts: □ normal □ lactation


    • Chest wall: □ normal □ cross talk from another radioactive source


    • Skeleton: □ normal □ Gaucher disease


    • Pleura: □ normal □ neoplasm, metastatic


    • Lungs: □ normal □ postoperative change


    • Mediastinum: □ normal □ thymoma


    • Myocardium and pericardium: □ normal □ pericardial mass


    • Right atrium and right ventricle: □ normal □ prominent right auricular appendage


    • Vascular system: □ normal □ retention in central port


    • Lymphatic system: □ normal □ lymphoma


    • Diaphragm: □ normal □ eventration, left hemidiaphragm


  • Abdomen



    • Abdominal wall: □ normal □ urinary contamination


    • Peritoneum: □ normal □ malignant metastatic implants


    • Liver: □ normal □ cirrhosis


    • Biliary system and gallbladder: □ normal □ cholecystectomy


    • Spleen: □ normal □ splenomegaly


    • Stomach: □ normal □ gastropathy with fluid distension


    • Small intestine and large intestine: □ normal □ diminished bile flow


    • Adrenal glands: □ normal □ hemorrhagic mass


    • Kidneys and female reproductive system: □ normal □ hyperfunctioning state (hepatic failure)


    • Vascular system: □ normal □ abdominal aortic aneurysm


29.1.2 Solution



Additional Annotated Images


None.


The Pertinent Findings






  • Chest



    • Not applicable


  • Abdomen



    • Liver: □ hot ■ cold


    • Biliary system and gallbladder: □ hot ■ cold


    • Spleen: ■ hot □ cold


    • Stomach: ■ hot ■ cold


    • Small intestine and large intestine: □ hot ■ cold


    • Kidneys and female reproductive system: ■ hot □ cold


The Relevant Diagnosis(es)






  • Chest



    • Not applicable


  • Abdomen



    • Liver: ■ cirrhosis


    • Biliary system and gallbladder: ■ cholecystectomy


    • Spleen: ■ splenomegaly


    • Stomach: ■ gastropathy with fluid distension


    • Small intestine and large intestine: ■ diminished bile flow


    • Kidneys and female reproductive system: ■ hyperfunctioning state


Discussion



Chest

There are no significant findings.


Abdomen

The liver and the small intestine are poorly visualized, suggesting severe liver dysfunction and reduced biliary clearance of the radiopharmaceutical (a, b). The patient has known autoimmune hepatitis, awaiting transplant. The gallbladder is surgically absent; however, in patients with such impaired bile flow, differential diagnosis of gallbladder non-visualization would include underlying liver dysfunction and not necessarily acute or chronic cholecystitis. The stomach appears collapsed on rest raw images (a) but appears distended and “cold” on stress raw images (b) after water ingestion. This pattern is characteristic of cirrhosis-related gastropathy. There is markedly greater visualization of the kidneys, the alternate route of biological clearance of the radiopharmaceutical (a, b); renal clearance compensates for liver dysfunction.


Relevant Chapter(s)


Chapters19,20,21,22,23, and25


29.2 Case Challenge #26



29.2.1 Problem



Clinical Highlights


A 66-year-old female provides a history of diabetes mellitus, coronary artery disease, and previous “heart attack.”


Images for Review




A330381_1_En_29_Fig2a_HTML.gifA330381_1_En_29_Fig2b_HTML.gifA330381_1_En_29_Fig2c_HTML.gif



Fig. 29.2




  • (a) Rest raw projection images (Video 29.2a, frame 1),99mTc sestamibi


  • (b) Stress raw projection images (Video 29.2b, frame 1),99mTc sestamibi


  • (c) Stress/rest processed SPECT images (SA, VLA, HLA)


  • (d) Stress gated SPECT images (Video 29.2c, frame 1) (SA, VLA, HLA)


Characterize the Pertinent Finding(s)






  • Chest



    • Thyroid gland: □ hot □ cold


    • Parathyroid glands: □ hot □ cold


    • Breasts: □ hot □ cold


    • Chest wall: □ hot □ cold


    • Skeleton: □ hot □ cold


    • Pleura: □ hot □ cold


    • Lungs: □ hot □ cold


    • Mediastinum: □ hot □ cold


    • Myocardium and pericardium: □ hot □ cold


    • Right atrium and right ventricle: □ hot □ cold


    • Vascular system: □ hot □ cold


    • Lymphatic system: □ hot □ cold


    • Diaphragm: □ hot □ cold


  • Abdomen



    • Abdominal wall: □ hot □ cold


    • Peritoneum: □ hot □ cold


    • Liver: □ hot □ cold


    • Biliary system and gallbladder: □ hot □ cold


    • Spleen: □ hot □ cold


    • Stomach: □ hot □ cold


    • Small intestine and large intestine: □ hot □ cold


    • Adrenal glands: □ hot □ cold


    • Kidneys and female reproductive system: □ hot □ cold


    • Vascular system: □ hot □ cold


State Your Relevant Diagnosis(es)






  • Chest



    • Thyroid gland: □ normal □ lymphoma


    • Parathyroid glands: □ normal □ ectopic hyperplasia


    • Breasts: □ normal □ soft-tissue attenuation artifact


    • Chest wall: □ normal □ Holter monitor


    • Skeleton: □ normal □ multiple metastases


    • Pleura: □ normal □ mesothelioma


    • Lungs: □ normal □ posttransplant asymmetry


    • Mediastinum: □ normal □ lymphoma


    • Myocardium and pericardium: □ normal □ “hot” mass


    • Right atrium and right ventricle: □ normal □ dilatation


    • Vascular system: □ normal □ chest port injection site


    • Lymphatic system: □ normal □ necrotic axillary lymph nodes, malignant


    • Diaphragm: □ normal □ muscular (soft-tissue attenuation)


  • Abdomen



    • Abdominal wall: □ normal □ overlying patient’s arms and hands


    • Peritoneum: □ normal □ ascites


    • Liver: □ normal □ hepatitis


    • Biliary system and gallbladder: □ normal □ cholecystectomy


    • Spleen: □ normal □ infarct


    • Stomach: □ normal □ duodenogastric reflux and fluid


    • Small intestine and large intestine: □ normal □ visualization of large intestine


    • Adrenal glands: □ normal □ cystic neoplasm


    • Kidneys and female reproductive system: □ normal □ left nephrectomy


    • Vascular system: □ normal □ extravasation


29.2.2 Solution



Additional Annotated Images






  • (e) Rest raw projection image (Video 29.2d, frame 16),99mTc sestamibi, duodenum (blue box)


  • (f) Stress raw projection image (Video 29.2e, frame 16),99mTc sestamibi, hepatic flexure of large intestine (yellow box), duodenum (blue box)


The Pertinent Findings






  • Chest



    • Breasts: □ hot ■ cold


  • Abdomen



    • Biliary system and gallbladder: □ hot ■ cold


    • Stomach: ■ hot ■ cold


    • Small intestine and large intestine: ■ hot □ cold


The Relevant Diagnosis(es)






  • Chest



    • Breasts: ■ soft-tissue attenuation artifact


  • Abdomen



    • Biliary system and gallbladder: ■ cholecystectomy


    • Stomach: ■ duodenogastric reflux and fluid


    • Small intestine and large intestine: ■ visualization of large intestine


Discussion



Chest

The breast tissue creates an attenuation artifact on the heart (a, b, c, d). On processed images (c), there is a medium-size, severe, fixed anteroseptal-apical perfusion defect that represents myocardial scar (her “heart attack”?); there is no ischemia. There is anteroseptal-apical akinesis, but preserved global function with LVEF greater than 60 % (d). Thus, despite the potential for breast attenuation artifact, this perfusion defect is “real” and correlates with “true” coronary artery disease.


Abdomen

The gallbladder is absent (a, b). The rest raw images (a, e) demonstrate duodenal (“C-loop”) activity that could be mistaken for the gallbladder. The first portion of the duodenum is posterior and gravity dependent in the supine position used for imaging. The gallbladder is usually anteriorly situated, whereas the duodenum is posteriorly situated, and should appear focally intense and constant during the acquisition. On later same-day stress raw (b, f) images, large intestinal activity is seen in the right upper quadrant. As is the case for the early duodenal activity, activity in the hepatic flexure of the large intestine could be misconstrued as gallbladder.

On stress raw images (b), the stomach appears “cold” due to water ingestion, but there is no artifactual attenuation effect on the processed images (c).


Relevant Chapter(s)


Chapters6,20,22, and23


29.3 Case Challenge #27



29.3.1 Problem



Clinical Highlights


A 62-year-old male presents with chronic disease.


Images for Review




A330381_1_En_29_Fig3a_HTML.gifA330381_1_En_29_Fig3b_HTML.gifA330381_1_En_29_Fig3c_HTML.gif



Fig. 29.3




  • (a) Rest raw projection images (Video 29.3a, frame 1),99mTc sestamibi


  • (b) Stress raw projection images (Video 29.3b, frame 1),99mTc sestamibi


  • (c) Stress/rest processed SPECT images (SA, HLA, VLA) (without and with AC)


  • (d) Stress and rest gated SPECT images (Video 29.3c, frame 1) (SA, VLA, HLA)


Characterize the Pertinent Finding(s)






  • Chest



    • Thyroid gland: □ hot □ cold


    • Parathyroid glands: □ hot □ cold


    • Breasts: □ hot □ cold


    • Chest wall: □ hot □ cold


    • Skeleton: □ hot □ cold


    • Pleura: □ hot □ cold


    • Lungs: □ hot □ cold


    • Mediastinum: □ hot □ cold


    • Myocardium and pericardium: □ hot □ cold


    • Right atrium and right ventricle: □ hot □ cold


    • Vascular system: □ hot □ cold


    • Lymphatic system: □ hot □ cold


    • Diaphragm: □ hot □ cold


  • Abdomen



    • Abdominal wall: □ hot □ cold


    • Peritoneum: □ hot □ cold


    • Liver: □ hot □ cold


    • Biliary system and gallbladder: □ hot □ cold


    • Spleen: □ hot □ cold


    • Stomach: □ hot □ cold


    • Small intestine and large intestine: □ hot □ cold


    • Adrenal glands: □ hot □ cold


    • Kidneys and female reproductive system: □ hot □ cold


    • Vascular system: □ hot □ cold


State Your Relevant Diagnosis(es)






  • Chest



    • Thyroid gland: □ normal □ multinodular goiter


    • Parathyroid glands: □ normal □ multiple adenomas


    • Breasts: □ normal □ gynecomastia


    • Chest wall: □ normal □ jewelry


    • Skeleton: □ normal □ myelofibrosis


    • Pleura: □ normal □ bilateral effusions


    • Lungs: □ normal □ hyperinflation


    • Mediastinum: □ normal □ esophageal malignancy


    • Myocardium and pericardium: □ normal □ effusion


    • Right atrium and right ventricle: □ normal □ enlargement


    • Vascular system: □ normal □ extravasation around chest port during injection


    • Lymphatic system: □ normal □ metastatic neoplasm


    • Diaphragm: □ normal □ hiccups


  • Abdomen



    • Abdominal wall: □ normal □ umbilical hernia


    • Peritoneum: □ normal □ ascites


    • Liver: □ normal □ cirrhosis


    • Biliary system and gallbladder: □ normal □ calculous cholecystitis, chronic


    • Spleen: □ normal □ splenomegaly


    • Stomach: □ normal □ gastropathy


    • Small intestine and large intestine: □ normal □ visualization of large intestine


    • Adrenal glands: □ normal □ metastasis


    • Kidneys and female reproductive system: □ normal □ atrophic left kidney


    • Vascular system: □ normal □ chest port for injection


29.3.2 Solution



Additional Annotated Images






  • (e) Coronal CT most anterior through the liver, gallbladder with gallstones (blue circle), and stomach (yellow circles, outer wall and inner lumen), perihepatic ascites (pink line)


  • (f) Coronal CT most posterior through the stomach (yellow outline) and splenic flexure (orange boxes), heart for reference (red box)


The Pertinent Findings






  • Chest



    • Not applicable


  • Abdomen



    • Peritoneum: □ hot ■ cold


    • Liver: □ hot ■ cold


    • Biliary system and gallbladder: □ hot ■ cold


    • Stomach: ■ hot □ cold


    • Small intestine and large intestine: ■ hot □ cold


The Relevant Diagnosis(es)






  • Chest



    • Not applicable


  • Abdomen



    • Peritoneum: ■ ascites


    • Liver: ■ cirrhosis


    • Biliary system and gallbladder: ■ calculous cholecystitis, chronic


    • Stomach: ■ gastropathy


    • Small intestine and large intestine: ■ visualization of large intestine


Discussion



Chest

There are no abnormal findings.


Abdomen

There is ascites and poor visualization of the liver (a, b, e), consistent with cirrhosis. There might be visualization of the gallbladder on stress raw images (b), but it is difficult to separate from the “hot” large intestine. On the rest raw images (a), the gallbladder is out of the field-of-view and cannot be evaluated. There are multiple large calcified gallstones (e).

Marked gastric activity appears on the rest raw images (a). On the stress raw images (b), the gastric activity is even more marked; this likely represents gastropathy. There is also marked activity in the large intestine (splenic flexure) that overlaps the stomach on the raw images (a, b); their anatomic relationships are correlated on CT images (f). The gastric activity and large intestinal activity are problematic because they create a significant processing artifact affecting the adjacent inferior myocardial wall where there is a fixed perfusion defect (c). This is almost certainly an artifactual defect because the gated SPECT images demonstrate normal wall motion and thickening (d).


Relevant Chapter(s)


Chapters18,19,20,22, and23


29.4 Case Challenge #28



29.4.1 Problem



Clinical Highlights


A 56-year-female presents with three-vessel coronary calcifications on chest CT and a long history of hypertension.


Images for Review




A330381_1_En_29_Fig4a_HTML.gifA330381_1_En_29_Fig4b_HTML.gifA330381_1_En_29_Fig4c_HTML.gif



Fig. 29.4




  • (a) Rest raw projection images (Video 29.4a, frame 1),99mTc sestamibi


  • (b) Stress raw projection images (Video 29.4b, frame 1),99mTc sestamibi


  • (c) Stress/rest processed SPECT images (SA, HLA, VLA)


  • (d) Stress gated SPECT images (Video 29.4c, frame 1) (SA, VLA, HLA)


Characterize the Pertinent Finding(s)






  • Chest



    • Thyroid gland: □ hot □ cold


    • Parathyroid glands: □ hot □ cold


    • Breasts: □ hot □ cold


    • Chest wall: □ hot □ cold


    • Skeleton: □ hot □ cold


    • Pleura: □ hot □ cold


    • Lungs: □ hot □ cold


    • Mediastinum: □ hot □ cold


    • Myocardium and pericardium: □ hot □ cold


    • Right atrium and right ventricle: □ hot □ cold


    • Vascular system: □ hot □ cold


    • Lymphatic system: □ hot □ cold


    • Diaphragm: □ hot □ cold


  • Abdomen



    • Abdominal wall: □ hot □ cold


    • Peritoneum: □ hot □ cold


    • Liver: □ hot □ cold


    • Biliary system and gallbladder: □ hot □ cold


    • Spleen: □ hot □ cold


    • Stomach: □ hot □ cold


    • Small intestine and large intestine: □ hot □ cold


    • Adrenal glands: □ hot □ cold


    • Kidneys and female reproductive system: □ hot □ cold


    • Vascular system: □ hot □ cold


State Your Relevant Diagnosis(es)






  • Chest



    • Thyroid gland: □ normal □ free99mTc pertechnetate


    • Parathyroid glands: □ normal □ ectopic adenoma


    • Breasts: □ normal □ soft-tissue attenuation artifact


    • Chest wall: □ normal □ photomultiplier tube malfunction


    • Skeleton: □ normal □ anemia


    • Pleura: □ normal □ effusion


    • Lungs: □ normal □ congestive heart failure


    • Mediastinum: □ normal □ solid mass


    • Myocardium and pericardium: □ normal □ effusion


    • Right atrium and right ventricle: □ normal □ hypertrophy


    • Vascular system: □ normal □ extravasation


    • Lymphatic system: □ normal □ lymphoma, multifocal


    • Diaphragm: □ normal □ flattening


  • Abdomen



    • Abdominal wall: □ normal □ metallic object


    • Peritoneum: □ normal □ ascites


    • Liver: □ normal □ postoperative effect


    • Biliary system and gallbladder: □ normal □ cholecystectomy


    • Spleen: □ normal □ enlargement


    • Stomach: □ normal □ duodenogastric reflux


    • Small intestine and large intestine: □ normal □ duodenal stasis


    • Adrenal glands: □ normal □ neoplasm


    • Kidneys and female reproductive system: □ normal □ large left renal cyst


    • Vascular system: □ normal □ extravasation


29.4.2 Solution



Additional Images






  • (e) Axial image from chest CT at level of LAD coronary artery


  • (f) Axial image from chest CT at level of left circumflex coronary artery


The Pertinent Findings






  • Chest



    • Breasts: □ hot ■ cold


  • Abdomen



    • Biliary system and gallbladder: □ hot ■ cold


    • Stomach: ■ hot □ cold


    • Small intestine and large intestine: ■ hot □ cold


The Relevant Diagnosis(es)






  • Chest



    • Breasts: ■ soft-tissue attenuation artifact


  • Abdomen



    • Biliary system and gallbladder: ■ cholecystectomy


    • Stomach: ■ duodenogastric reflux


    • Small intestine and large intestine: ■ duodenal stasis


Discussion



Chest

Breast attenuation artifact is evident on review of the raw data (a, b). Take note of how the curvilinear edge of the breast overlies most of the heart but spares the inferior wall. This observation permits one to predict (correctly) that there will be an attenuation effect on the anterior wall and that the inferior wall will not be subject to that same effect, thus creating relative differences in the processed perfusion pattern. As predicted, there is a characteristic large, moderately severe, fixed anterior myocardial wall perfusion defect (c). Normal wall thickening and wall motion (d, especially on the VLA images) favor attenuation artifact rather than myocardial scar.

Normal myocardial perfusion in the setting of extensive coronary artery and vascular calcifications, as seen on routine chest CT (e, f), is an important and relatively common clinical situation that confirms that there is coronary atherosclerosis in the absence of significant stenosis.


Abdomen

There is non-visualization of the gallbladder (a, b) (history of cholecystectomy). Prominent duodenal activity (note: posterior location) and marked gastric activity due to duodenogastric reflux are more apparent on stress raw images (b) compared to rest raw images (a). The gastric activity creates a “bleeding in” artifact involving the adjacent inferolateral myocardial wall on the stress processed images (c). There is normal function on gated SPECT images (d).


Relevant Chapter(s)


Chapters6,20,22, and23


29.5 Case Challenge #29



29.5.1 Problem



Clinical Highlights


A 66-year-old male has a recent abdominal surgical history.

Jul 6, 2017 | Posted by in GENERAL RADIOLOGY | Comments Off on Self-Assessment Cases: Advanced

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