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ABNM CE > HomeStretch CRACK vol 1. NUCS > Flashcards

HomeStretch CRACK vol 1. NUCS Flashcards

1
Q

Bone scan - relatively hotter kidney = ?

A

hemochromatosis or chemotherapy

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2
Q

Timing of “flare phenomenon”

A

aka pseudoprogression

2 weeks to 3 months (some say up to 6 months)

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3
Q

Bone scan marked skull suture activity = ?

A

renal osteodystrophy

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4
Q

liver uptake on bonescan = ?

A

too much Al+3 chemical contamination in the Tc

Hepatoma or mets

Amyloidosis

Liver necrosis

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5
Q

Spleen uptake on a bone scan?

A

Auto-infarcted spleen in SCD

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6
Q

Bone scan with muscle uptake?

A

Rhabdo

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7
Q

Super hot mandible on bone scan?

A

Fibrous dysplasia

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8
Q

Which one is better for spine infection, Indium WBC or Ga scan?

A

GAllIUM is better for the spinal COllUNM

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9
Q

Sulfur Colloid Bone Scan & WBC imaging

A

Combined with Tc-Sulfur colloid and WBC study is poistive for infection if there is activity on the WBC scan, without corresponding Tc-sulfur colloid activity on the bone marrow image

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10
Q

Cold Lesions on Bone Scan?

A
  • Late radiation therapy chages/osteitis
  • Early osteonecrosis (AVN)
  • Infarction (very early or late)
  • Anaplastic tumor (Renal, thyroid, Neuroblastoma, Myeloma)
  • Artifact from prosthesis
  • Hemangioma (variable)
  • Bone cyst (w/o fracture)
  • Mature Heterotopic Ossification
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11
Q

Osteoid osteoma on boner scan

A

Focal and three phase hot

Double density or hotter spot within a hot area

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12
Q

Particle size for MAA

A

MAA = 10-100 micrometers

Sulfur colloid (unfiltered) = 1 micrometer

Ultrafiltered sulfur colloid and DTPA (inhaled portion) = 0.1 micrometers

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13
Q

Particle size for DTPA (inhaled)

A

MAA = 10-100 micrometers

Sulfur colloid (unfiltered) = 1 micrometer

Ultrafiltered sulfur colloid and DTPA (inhaled portion) = 0.1 micrometers

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14
Q

Particle size for sulfur colloid (filtered)

A

MAA = 10-100 micrometers

Sulfur colloid (unfiltered) = 1 micrometer

Ultrafiltered sulfur colloid and DTPA (inhaled portion) = 0.1 micrometers

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15
Q

Particle size for sulfor colloid (unfiltered)

A

MAA = 10-100 micrometers

Sulfur colloid (unfiltered) = 1 micrometer

Ultrafiltered sulfur colloid and DTPA (inhaled portion) = 0.1 micrometers

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16
Q

When do you reduce the particle amount in a V/Q scan?

What is the normal amount of particles? what do you reduce it down to?

How about in a neonate?

Will this reduce the dose?

A
  • Pregant people
  • Right to left shunts
  • Pulmonary HTN
  • Children
  • People with one lung
    • Normal particle count = 500,000
    • decrease it to 100,000
    • down to 10,000-50,000 in a neonate
      • Dose will not decrease. . .
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17
Q

Gallium, Indium, Thallium

Half-lives and energies

A
  • Gallium = 78 hours
    • 100, 200, 300, 400
  • Indium
    • 67 hours
    • 175 and 250
  • Thallium = 73 hours
    • major emissions are via characteristics xrays of its daughter product, Mercury 201
      • 69 and 81 KeV
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18
Q

Tc-99m in the thyroid - trapped or organified?

A

trapped and not organified

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19
Q

Breastfeeding versus Tc-99m, I-123 and I-131

A

Tc-99m = 12-24 hours

I-123 = 2-3 days

I-131 = contraindicated - pump and dump!

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20
Q

Does renal failure increase or decrease Iodine update

A

decrease it (since there is more circulating normal iodine)

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21
Q

Iodine uptake test

What dose do you give with I-131? How about I-123?

What is normal uptake at 6 hours? How about 24 hours?

A

I-131 = 5 micro curie

I-123 = 10-20 microcurie

normal uptake is 5-15 (say 10%) at 5 hours and 25 at 24 hours

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22
Q

Plummer disease

A

Multi-nodular toxic goiter

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23
Q

Dose for Iodine uptake scan? The imaged when?

A

I131 = 5 microCu

123 = 10microCu

4-6 hours (normal = 15% uptake)

24 hours (normal = 30% uptake)

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24
Q

I-131 dosing for hyperthyroidism and for cancer therapy

A
  • hyperthyroidism
    • 10 mCi for graves
    • 20 mCi for autonomous hyperfunction nodule
    • 30 mCi for multinodular goiter
  • Cancer: depends on stage
    • 100 for thyroid only
    • 150 for thyroid +nodes
    • 200 for distal
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25
Q

Thyroid scan that will take up Tc but NOT iodine at 24 hours?

A

Congenital enzyme deficiency that inhibits organification or drug blocking organification (propylthiouricyl)

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26
Q

Subacute thyroiditis labs and uptake pattern

A

Mimics graves but has DECREASED % RAIU

Low TSH and high T3/T4

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27
Q

Patient on dialysis needs I131 therapy. What do you do?

A

Give I131 right after dialysis to maximize the time I131 is on board.

Decrease dose as their is limited excretion until next dialize

Dialysate can go down sewer.

Tubing needs to be stored.

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28
Q

Wolf-Chaikoff effect

A

reduction in thyroid hormone levels caused by ingestion of a large amount of iodine.

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29
Q

When do I-131 treated patient’s need to be admitted to hospital?

A

NRC limit is 7mR/h at 1 meter from patient’s chest

33mCi of residual activity

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30
Q

What are the three renal tracers?

A

DTPA, MAG3, DMSA, (GH too)

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31
Q

Parathyroid adenoma dual phase versus dual tracer technique

A

Dual phase just uses Tc99m-Sestamibi and both early (10 minutes) and delayed (3 hours) scans are done

Dual tracer are used with two different tracers and then subtraction is done.

  • first agent is chosen cuz it goes to both thryoid and parathyroid (options are Tc99m-Sestamibi or 201-thallium chloride)
  • 2nd agent is chosen because it only goes to the thyrpid (I123 or pertechnetate)
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32
Q

Most common cause of hyperPTH?

A

hyperfunctioning adenoma

second is multiple gland hyperplasia

third is cancer

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33
Q

What are the three agents used in CNS nukes? Which two are similar?

A

HMPOA and ECD are similar (are extracted and can be used for parenchymal imaging; HMPOA washes out faster while ECD has better blood clearance [better brain to background ratio]).

DTPA: not extracted and can’t be used for parenchymal imaging. This has the advantage of being repeated without delay. main utility is for shunt studies, NPH and Brain death

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34
Q

FDG PET Brain Dementia Patterns:

  1. Normal
  2. Alzheimers
  3. Parkinsons
  4. LBD
  5. Picks
  6. Multi-infarct
A
  1. “Things look symettric, basal ganglia is 15% more than cortex, cerebellum is 15% < cortex, Thalamus = cortex
  2. Low posterior temporoparietal, cingulate gyrus first place abnormal
  3. identical to 3
  4. low in lateral occipital cortex (halluicinations!) cingulate island sign (opposite that of 2)
  5. “frontotemporal dementia”
  6. Scattered areas of decreased activity
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35
Q

DTPA

A

Filtered (GFR)

Good in people with normal renal function

critical organ = bladder

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36
Q

Before Tc-99m can be tagged to an RBC (beta chain of the Hg), what must be done first?

A

Must be reduced using stannous ion (tin)

This is the in vivo, in vivo/vitro and in vitro methods

37
Q

GI Bleed Sensitivity for RBC scan, CTA and Angiogram

A

RBC scan = 0.1 mL/min

CTA = 0.4 mL/min

Angiogram = 1.0 mL/min

38
Q

Vascular territories for:

  • Celiac
  • SMA
  • IMA
A
  • Celiac: Distal esophagus, Stomach, 1st part of the duodenum
  • SMA: 2nd-4th parts of duodenum, the rest of the small bowel and large bowel to the splenic flexure
  • IMA: distal ⅓ of transverse colon to the proximal rectum
39
Q

What are you looking for in a GI bleed RBC scan?

A
  1. Tracer outside vascular distribution
  2. Tracer that moves like bowel
  3. Tracer that increases in intensity overtime
40
Q

Dose of CCK?

Dose of Morpine?

Dose of phenobarb?

A

Dose of CCK = 0.02 microgram/KG over 60 minutes.

Dose of Morpine = 0.02 mg/kg over 60 minutes.

Dose of phenobarb = 5 mg/kg x 5 days

41
Q

Gastric Emptying Pharmacology Trivia

  • What are the prokinetic drugs and what to do with them?
  • What to do about opiates?
  • What are some anticholinergic/antisposmodic drugs and what to do with them?
  • What do you do with serotonin receptor antagonists (ie Zofran)?
A
  • Prokinetics = metoclopramide (reglan), tegaserod, erythromycin, and domperidone = STOP FOR 2 DAYS PRIOR TO EXAM
  • Opiates = STOP FOR 2 DAYS BEFORE EXAM
  • Anticholinergic drugs = Donnatal, Bentyl, Robinul, Levsin = STOP FOR 2 DAYS PRIOR TO EXAM
  • Can keep taking zofran!
42
Q

Meckels scan:

  • False Positives:
  • False negatives:
A
  • False Positives: Bowel irritation *ie recent scope or laxatives
  • False negatives: Recent in vivo labeling of RBCs, recent barium study (attenuated)
43
Q

What medications can you use to make a meckel’s scan better?

A

Pentagastric = enhances uptake of pertechnetate by gastric mucosa

H2 blockers = Cimetidine and Ranitidine = block secretion of the pertechentate out of gastric cells making it stick around for longer

Glucagon = slows gastric motility

44
Q

In a HIDA scan, what medications can cause prompt uptake with delayed biliary excretion?

A

Erythromycin, Estrogen (contraceptives), Anabolic steroids, chlorpromazine, sometimes statins

45
Q

HIDA scan: medications that cause prompt hepatic uptake with delated biliary excretion?

A
  • Erythromycin
  • Birth Control (Estrogens)
  • Anabolic steroids
  • Chlorpromazine
  • Sometimes statins
46
Q

HIDA SCAN BLITZ!

No bowel activity + persistent blood pool = ?

No bowel activity + blood pool goes away normally = ?

No gallballder activity x 4 hours (or 1 hour + morphine) = ?

Abnormal GB emptying (EF < 20%) = ?

A

Hepatic dysfunction (hepatitis)

CBD obstruction

Acute chole

Chronic chole

47
Q

Suspected renal artery stenosis renogram:

Normal scan?

What does the MAG3 graph look like?

What does it DTPA graph look like?

A

Normal scan = pre and post captoprils looks the same!

MAG3 = marked tracer retention (kind of looks like obstruction graph)

DTPA = decreased flow and uptake

48
Q

Diffuse pulmonary activity on a sulfur colloid scan = ?

A

excess aluminium in the colloid

49
Q

renal activity on sulfur colloid = ?

A

CHF

Alternatively in renal transplant can indicate rejectoins

other rare causes = coxsackie b virus, DIC and TTP

50
Q

MAG 3

A

secreted (threecreated) (ERPF)

concentrated better in poor kidney function

critical organ is bladder

51
Q

DMSA

A

binds to renal cortex

critical organ = kidney

52
Q

How does a kidney with renal artery stenosis look when using MAG3? How about DTPA?

A

MAG 3 = the sick kidney holds on the the tracer

DTPA = the sick kidney has decreased uptake and flow.

53
Q

Renal transplant nucs renogram - ATN versus rejection

A

both will have delayed excretion, but ATN has preserved flow and rejection has decreased flow

54
Q

Meningiomas can be hot on what scans?

A

Hot on Octreotide and MDP

55
Q

What medications interfere with the workings of MIBG?

A

Kids with neuroblastoma don’t need TLC or cocaine!

TCA’s, labetalol, Ca channel blockers and cocaine

56
Q

MIBG versus Octreotide

A

MIBG is superior for neuroBlastoma and non-malignant (adrenal) pheos

oCtreotide = superior for Carcinoid and malignant (extra-adrenal) pheos

57
Q

What is the dose for MDP scan? How long do you wait until you scan?

A

15-25 mCi

2-4 hours

58
Q

Critical organs for:

Indium prostascint (PMSA)

Indium WBC

Indium octreotide

A
  • Indium prostascint (PMSA) = Liver
  • Indium WBC = Spleen
  • Indium octreotide = Spleen!
59
Q

What is the best view for a MUGA scan?

A

left anterior oblique

60
Q

What gives a false low EF on MUGA?

A

Screwed up view with overlap of LV by the RV or great vessels

61
Q

What gives a false high EF on MUGA?

A

Wrong (high) background ROI (over the spleen)

62
Q

What is the only pet agent made with a generator? half life?

A

Rb-82; super short half life

63
Q

Cardiac scan artifacts

Breast tissue

left hemidiaphragm

LBBB

A

Breast tissue = anterior wall

left hemidiaphragm = inferior wall

LBBB = septal defect sparing apex

64
Q

Dipyridamole

A

vasodilator - inhibits breakdown of adenosine, lower side effect profile

no caffeine

65
Q

adenosine

A

vasodilator, no caffeine, worse side-effects relative to dipyridamole

66
Q

Tumors that are PET COLD

A
  • Low grade lung adenoCA
  • Carcinoid/Neuroendocrine
  • RCC
  • HCC
  • Peritoneal Bowel / Liver Implants
  • Anythin mucinous
  • Prostate
  • Extranodal marginal zone lymphomas (such as marginal zone lymphoma or MALT)
67
Q

Not cancer but PET HOT

A
  • Infection
  • Inflammation
  • Ovaries in follicular phase
  • Muscles
  • Brown fat (help this with propranalol, reserpine or diazepam)
  • Thymus
68
Q

SUV Calculation

A

SUV = FDG concentration at time “T” / (Dose/Body Weight)

69
Q

Indium critical organ trivia:

  • Indium prostascint =
  • Indium WBC =
  • Indium octreotide =
A
  • Indium prostascint = Liver
  • Indium WBC = Spleen
  • Indium octreotide = Spleen
70
Q

Sestamibi versus tetrofosmin?

A

Tetrofosmin is cleared from liver more rapidly and therefore decreases the chance of a hepatic uptake artifact

71
Q

Ragedenoson

A

vasodilator (selective A2a)

fewer side effects

no caffeine

72
Q

Dobutamine

A

Beta 1 agonist

better in patients with COPD or Asthma

avoid with LBBB

73
Q

aminophyline

A

antidote for adenosine

half-life shorter than dipryidaomele

74
Q

What are the three agents used for treatment of boner pain?

A

Strotium 89

Samarium 153

Radium 223 Xofigo

75
Q

Sr89

A

AKA Metastron

Works by complexing with hydroxyappetite where bone turnover is high

Pure beta emitter

Most boner marrow toxicity (longest recovery)

renal excretion

76
Q

Sm153

A

AKA Quadramet

Works by complexing with hydroxyappetite where bone turnover is high

steeper drop but faster recovery of plt and WBC from preinjection relative to Sr

Unlike Sr89, 28% of the decay is via gamma rays (103 kEv)

Beta emmitter with some immageable gamma rays

less boner marrow toxicity

renal excretion

77
Q

Ra223

A

AKA Xofigo

Behaves similar to Ca++ and is absorbed nto the bone matrix

alpha emmitter

least bone marrow toxicity (because alpha particles have a shorter range)

1 study showed one trial of survival benefit in prostate CA

Non-hematologic side-effects are more common than hematologic (ie dirrhea, fatigue, nausea, vomiting and bone pain make the list)

GI excretion

improved survival for prostate mets

Long half life of 11.4 days

78
Q

Yttrium-90

A

pure betta emmiter, maximum tissue penetration = 1 cm

particle size = 20-40 microns

dose typically is 100-1000 Gy

can image it’s 175 and 185 keV emissions

half-life = 64 hours

79
Q

What is radioimmune therapy?

A
  • first line or refractory treatment for NH-lymphoma
  • basically bind Y-90 to a mab
  • the Ab binds to the CD20 B-cell receptior
  • first give rituximab to block the CD20 receptors of circulating B-cells, then check with Indium-111 taged to the MAB (zevalin) to check for altered distribution, if you suspect that get a delayed, if altered = don’t treat, if okay, then blast them!
  • dont give with plt under 100K (most common side effect is
  • can send home after treatment, just give them a hand out with precautions
80
Q

Three scenarios for SPECT at the level of the kidneys

  1. Aorta/IVC present = ?
  2. No Aorta/IVC present = ?
  3. Hot Kidneys = ?
A
  1. RBC Scan → Hemangioma
  2. Sulfur Colloid Scan → FNH
  3. Octreotide Scan → Neuroendocrine tumor
81
Q

MIBG can be tagged to both I123 or I131. How may one tell the difference?

A

MIBG-I123 has more cardiac activity

Normal adrenals are usually not seen, but you can have feint uptake in the adrenals in about 75% of the time with MIBG-I123 (as apposed to 15% of the time with I131).

82
Q

Just like MIBG can be labeled with either I-123 or I-131, you can label WBCs with Tc or Indium

How to tell the difference?

Tc-WBC at 4 hours and 24 hours lung versus bowel uptake

A

Both will have hot spleens; Tc is a higher count study and cleaner

4 hours: Can see lung uptake

24 hours: lungs clearing up but you start to get some bowel uptake

83
Q

Wolf-Chaikoff effect

A

reduction in thyroid hormone levels caused by ingestion of a large amount of iodine.

84
Q

Tc HMPOA and ECD

A

Both agents pass through BBB and stick to gray matter proportional to CBF

HMPOA washes out faster (best imaged 15 min - 2hr post injection and uptake facors frontal lobe, thalamus and cerebellum)

ECD washout is slower, has better background clearance, and does not demonstrate intracerebral redistribution (best imaged 15 - 30 min post injection and uptake prefers occipitoparietal lobes).

85
Q

Tc-99m-DTPA brain imaging utility

A

Shunt studies, NPH and Brain Death

86
Q

High yield Thallium Generalizations / Uses

A

Toxo infection is thallium negative (don’t have human Na/K ATPase)

Lymphoma is thallium positive

Kaposi sarcoma is thallium positive (Ga negative)

Tumor is thallium positive while necrosis is gallium negative)

87
Q

Suspected renal artery stenosis renogram:

Normal scan?

What does the MAG3 graph look like?

What does it DTPA graph look like?

A

Normal scan = pre and post captoprils looks the same!

MAG3 = marked tracer retention (kind of looks like obstruction graph)

DTPA = decreased flow and uptake

88
Q

Absolute contraindications for Sr and Sm?

A

Pregnancy

Breastfeeding

renal failure

ABNM CE (12 decks)

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