NM Protocols

NM Protocols

CSF
1. Pathologies
  1. Normal Pressure Hydrocephalus (NPH)
    1. Diminished CSF absorption at arachnoid villa in dural sinus causing increased pressure
    2. Distended ventricles distort periventricular limbic system - causes dementia symptoms
  2. Leakages
    1. Causes: Trauma, surgery, hydrocephalus, congenital defects
    2. Symptoms: Rhinorrhoea, Otorrhoea, headache, drowsiness, meningitis, neurological changes and air in the brain
2. Methods
  1. Method 1 (NPH and leakages)
    1. 200MBq of 99mTc-DTPA via lumbar puncture (intrathecal)
      1. posterior lumbar - 2mins, 128 matrix
        Ant/post and Lt/Rt lat head images (128matrix) @ 2,6,24hours
        2 and 6 hours image for 2mins
        24hours image for 5mins
  2. Method 2 (VP shunts)
    1. 40MBq of 99mTc-DTPA: Admin via shunt reservoir
      1. Ant Head Dynamic: 1min/frame for 30mins (128 matrix)
      2. Planars (ant and rt lat abdomen)
        2mins, 128 matrix
        @30mins
        @2 hours
        @4 hours
        10mins, 128matrix
        @24 hours
3. VP shunt
  1. Normalises intracranial pressure by regulating flow of CSF
  2. Drains CSF from lat ventricle to peritoneal space (or pleural space)
Brain
1. Methods
  1. Standard
    1. 800MBq of Neurolite or ceretec (IV), patient at rest
    2. 45mins post injection, standard SPECT (but with a zoom of 2)
  2. Brain Death
    1. Dynamic: ant/post, 3sec/frame for 20 frames (128matrix) - followed by standard brain scan
  3. Diamox challenge
    1. Day 1: standard scan
    2. Day 2: 1ml of diamox given half an hour before a standard scan
2. Pathologies
  1. Alzheimer's
    1. hypoperfusion in the parietotemporal lobes
    2. Forgetfulness, cognitive impairment, confusion
  2. DLB
    1. Tremors,visual disturbances, slowness, motor disfunction
    2. Similar to AD but with occipital and cerebellar involvement
  3. Vascular Dementia
    1. heterogenous uptake within the brain
  4. TIA
    1. Normal on first scan but hypoperfusion after diamox challenge
  5. Epilepsy
    1. 2 scans 48hrs apart (ictal/interictal)
      1. Ictal: localised hyperperfusion
        Interictal: normal perfusion
Parathyroid
1. Pathologies
  1. Adenoma
    1. Symptoms: muscle weakness, abnormal reflexes, depression of the nervous system, fatigue, confusion, kidney stones, metastatic calcification and anorexia
    2. Diagnosis
      1. Increased serum PTH and Ca2+
      2. Decreased serum inorganic phosphate
2. Methods
  1. Subtraction (supine, neck extended)
    1. 1. Thyroid Scan
      1. 40MBq of pertechnetate
      2. Image 20mins post IV
        Ant Neck, 4mins (zoom of 2), 128 matrix.
    2. 2.Early MIBI
  2. Washout/Delayed (supine, neck extended)
    1. Early @ 15mins
      1. Ant Static, 128matrix
        Neck, 10mins (zoom of 2)
        Neck and chest, 5mins
      2. SPECT/CT
        64 projections @40secs per projection
    2. Delayed @ 2 hours
      1. *Repeat early images (if no washout repeat at 3 or 4 hours)
3. Sestamibi
  1. 600MBq
  2. Taken up by mitochondria in the thyroid and parathyroid.
  3. Retention is higher in adenomas (due to a greater negative mitochondrial and transmembrane electric potentials)
  4. Is a lipophilic cation
Lymphatics
1. RP's (99mTc)
  1. Sulphur colloid
    1. large particle size (50-2000nm), slow clearance
  2. Antimony sulphide colloid
    1. Agent of choice! Migrates rapidly through lymph vessels, good node retention, comprehensive and accurate
    2. fairly uniform and ideal size (10-15nm), colloid is stable
    3. Add 1GBq of pertechnetate in 1ml of saline and then HCl to a vial containing antimony trisulphide. Heat in a boiling water bath for 30mins then allow to cool. Add a phosphate buffer (pH 5.5-6.5). Filter through a 0.2micro(m) filter.
  3. HSA
    1. poor retention
  4. Rhenium colloid
    1. ultrafiltered, 50nm range
2. Pathologies
  1. Lymphoedema
    1. Lymphatic dysfunction resulting in accumulation of interstitial fluid containing high molecular weight proteins
    2. Symptoms: mass swelling, fatigue, physical impairment, bacterial or fungal infections are common
3. Methods
  1. Legs
    1. 10cm/min (256*1024matrix)
    2. 4 scans after injection followed by repeat scans at 2 and 4hrs
  2. Sentinel node
    1. supine-arm above head
    2. dynamic: 30 frames @ 60sec per frame
      1. Statics: ant/post/lats 2mins, 128matrix
        SPECT: 64 projections @ 40sec per projection, 128matrix
Infection
1. Pathologies
  1. Osteomyelitis
    1. 3 phase bone scan first followed by a white cell or gallium scan (if bone scan is positive)
  2. Inflammatory Bowel Disease
    1. Crohn's Disease
    2. Ulcerative Colitis
  3. Pyrogen of Unknown Origin
    1. bacteria, viruses, cancer, allergic reactions, trauma or autoimmune disease (Induces a fever)
    2. stimulates the release of prostaglandin E2 which acts on the hypothalamus
2. RP's
  1. 67Ga Citrate
    1. Binds to transferrin then migrates to infection site and binds to lactoferrin (large amounts in abcess fluid)
    2. Liver, spleen, kidney, adrenal, bowel and skeletal uptake
  2. WBC
    1. 111In (20MBq)
      1. ADVANTAGES: doesn't elute from leukocyte cytoplasm, no bowel accumulation, no leukocyte damage, long half life, can do dual imaging
      2. DISADVANTAGES: cyclotron produced, expensive, poor imaging characteristics, auger electrons, only low dose possible
    2. 99mTc-HMPAO (800MBq)
      1. ADVANTAGES: Short half life, readily available, good imaging characteristics
      2. DISADVANTAGES: elutes from leukocyte cytoplasm, hepatic and renal clearance, leukocyte damage, short half life, short shelf life
3. Methods
  1. White Cell
    1. 20MBq of 111In WBC or 800MBq of 99mTc (HMPAO) WBC's
      1. Early (4hrs post admin)
        Planar, 128 matrix
        10mins for 111In
        5mins for HMPAO
      2. Delayed (24hrs post admin)
        Planar: 10mins, 128 matrix, FOV: affected region
        SPECT: 64 projections at 40sec/projections
  2. IBD
    1. 20MBq of 111In (IV)
    2. Imaging at 30, 2, 4, 24hrs
      1. Abdo/pelvis (ant/post/lats) 10mins, 128 matrix
  3. Post-Surgical
    1. Ant/Post and Lats over the effected area
      1. Imaging @ 2, 4, 24hrs
        20MBq of 111In WBCs (IV)
        10mins, 256 matrix
        800MBq 99mTc WBCs (IV)
        5mins @ 2 and 4hrs, 256 matrix
        10mins @ 24hrs, 256 matrix
  4. Pyrogen of Unknown Origin
    1. 111In WBC
      1. 20MBq (IV)
      2. WB scan 8cm/min, 256*1024
        4 and 24hours
    2. 67Ga Citrate
      1. 400-600MBq (IV)
      2. WB scan 10cm/min, 256*1024
        48hours

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