NUCLEAR-MEDICINE-Copy.pptxbabaabahahahaahha

NUCLEAR MEDICINE
COLLEGE OF RAD-TECH
LNU-DAGUPAN
COMPILED NOTES:
DANIEL C. MONTES, RRT

Nuclear Medicine
 Introduction
 Principle
 Instrumentation
 Radiopharmaceuticals
 Clinical Applications
 Summary

•Radiopharmaceutical is a radioactive
drug used for diagnosis or therapy in a
tracer quantities with no pharmacological
effect.

CARBON-11
• Chemical Symbol: 11
C
• Chemical Form: Carbon-11 Choline
• Half-life: 20.334 minutes.
• Manufacturer: Mayo Clinic
• Trade name(s):
• Diagnostic use: Indicated for PET imaging of patients with
suspected prostate cancer recurrence based upon elevated
blood prostate specific antigen (PSA) levels following initial
therapy and non-informative bone scintigraphy,
computerized tomography (CT) or magnetic resonance
imaging (MRI) to help identify potential sites of prostate
cancer recurrence for subsequent histologic confirmation.

CARBON-14
C
• Chemical Form: Carbon-14 urea
• Half-life: 5,730 years
• Manufacturer: Kimberly-Clark
• Trade name(s): PYtest
• Diagnostic use: Detection of gastric urease as an aid
in the diagnosis of H.pylori infection in the stomach

FLUORINE-18
F
• Chemical Form: Fluorine-18 florbetapir
• Half-life: 109.771 minutes
• Manufacturer: Eli Lilly
• Trade name(s): Amyvid™
• Diagnostic use: Indicated for PET imaging of patients with
suspected prostate cancer recurrence based upon elevated blood
prostate specific antigen (PSA) levels following initial therapy and
non-informative bone scintigraphy, computerized tomography
(CT) or magnetic resonance imaging (MRI) to help identify
potential sites of prostate cancer recurrence for subsequent
histologic confirmation.

FLUORINE-18
F
• Chemical Form: Fluorine-18 sodium fluoride
• Manufacturer: Various
• Trade name(s):
• Diagnostic use: PET bone imaging agent to
delineate areas of altered osteogenesis

FLUORINE-18
F
• Chemical Form: Fluorine-18 fludeoxyglucose
• Manufacturer: Various
• Trade name(s):
• Diagnostic use:
As a PET imaging agent to:
> Assess abnormal glucose metabolism in oncology
> Assess myocardial hibernation
> Identify regions of abnormal glucose metabolism
associated with foci of epileptic seizures

GALLIUM-67
Ga
• Chemical Form: Gallium-67 Gallium Citrate
• Half-life: 3.26 days
• Manufacturer(s): Covidlen, Lantheus Medical Imaging
• Trade name(s): Neoscan (GE), DuPont Ga-67, Mallinckrodt Ga-67
• Diagnostic use:
Useful to demonstrate the presence/extent of:
>Hodgkin’s disease
>Lymphoma
>Bronchogenic carcinoma
>Aid in detecting some acute inflammatory lesions

INDIUM-111
In
• Chemical Form: Indium-111 Capromab Pendetide
• Manufacturer: Jazz Pharmaceuticals
• Trade name(s): ProstaScint®
• Diagnostic use: A diagnostic imaging agent in newly-diagnosed patients
with biopsy-proven prostate cancer, thought to be clinically-localized after
standard diagnostic evaluation (e.g. chest x-ray, bone scan, CT scan, or MRI),
who are at high-risk for pelvic lymph node metastases.
• A diagnostic imaging agent in post-prostatectomy patients with a rising PSA
and a negative or equivocal standard metastatic evaluation in whom there is a
high clinical suspicion of occult metastatic disease

INDIUM-111
In
• Chemical Form: Indium-111 Chloride
• Manufacturer: GE Healthcare, Covidien
• Trade name(s): Indiclor (Nycomed),Mallinckrodt In-111Cl
• Diagnostic use: For labeling monoclonal antibodies and
peptides

INDIUM-111
In
• Chemical Form: Indium-111 Diethylenetriamine penta-
acetic Acid (DTPA)
• Manufacturer: GE Healthcare
• Trade name(s): Indium DTPA In 111
• Diagnostic use: For use in radionuclide cisternography,
Cerebro spinal fluid imaging

INDIUM-111
In
• Chemical Form: Indium-111 Oxyquinoline
• Trade name(s): Indium-111 oxine
• Diagnostic use: Indicated for radiolabeling autologous
leukocytes which may be used as an adjunct in the detection
of inflammatory processes to which leukocytes migrate, such
as those associated with abscesses or other infection

INDIUM-111
In
• Chemical Form: Indium-111 Pentetreotide
• Manufacturer: Covidien
• Trade name(s): Octreoscan™
• Diagnostic use: An agent for the scintigraphic localization
of primaryand metastatic neuroendocrine tumors bearing
somatostatin receptors.
Imaging of neuroendocrine tumors.

INDIUM-111
In
• Chemical Form: Indium-111 Satumomab Pendetide
• Manufacturer:
• Trade name(s): OncoScint
• Diagnostic use: Imaging of metastatic disease associated
with colorectal and ovarian cancer.

IODINE-123
I
• Chemical Form: Iodine-123 Iobenguane
• Half-life: 13.22 hours
• Trade name(s): AdreView™
• Diagnostic use: Indicated for use in the detection of
primary or metastatic pheochromocytoma or neuroblastoma
as an adjunct to other diagnostic tests.
Neuroendocrine tumor imaging.

IODINE - 123
I
• Chemical Form: Iodine – 123 Ioflupane
• Manufacturer(s): GE Healthcare
• Trade name(s): DaTscan™
• Diagnostic use: Indicated for striatal dopamine transporter
visualization using SPECT brain imaging to assist in the evaluation
of adult patients with suspected Parkinsonian syndromes (PS) in
whom it may help differentiate essential tremor due to PS
(idiopathic Parkinson’s disease, multiple system atrophy and
progressive supranuclear palsy)

IODINE - 123
I
• Chemical Form: Iodine – 123 Sodium iodide
• Manufacturer(s): Cardinal Health, Covidien
• Trade name(s): Mallinckrodt, Amersham
• Diagnostic use: Indicated for use in the evaluation of thyroid:
• Function
• Morphology

IODINE - 125
I
• Chemical Form: Iodine – 125 Human serum albumin
• Manufacturer(s): IsoTex Diagnostics
• Trade name(s): Isojex, Jeanatope
• Diagnostic use: Indicated for use in the determination of:
• Total blood
• Plasma volume

IODINE - 125
I
• Chemical Form: Iodine – 125 Iothalamate
• Trade name(s): Glofil
• Diagnostic use: Indicated for evaluation of glomerular filtration

IODINE - 131
I
• Chemical Form: Iodine – 131 human serum albumin
• Trade name(s): Megatope
• Diagnostic use: Indicated for use in determinations of:
• Total blood and plasma volumes
• Cardiac output
• Cardiac and pulmonary blood volumes and circulation times
• Protein turnover studies
• Heart and great vessel delineation
• Localization of the placenta
• Localization of cerebral neoplasm

IODINE - 131
I
• Chemical Form: Iodine – 131 sodium iodide
• Manufacturer(s): Covidien, DRAXIMAGE
• Trade name(s): HICON™
• Diagnostic use: • Performance of the radioactive iodide (RAI) uptake
test to evaluate thyroid function
• Localizing metastases associated with thyroid malignancies
Therapeutic:
• Treatment of hyperthyroidism
• Treatment of carcinoma of the thyroid

IODINE - 131
I
• Chemical Form: Iodine – 131 tositumomab
• Manufacturer(s): GlaxoSmithKline
• Trade name(s): BEXXAR®
• Diagnostic use: Indicated for:
• Treatment of patients with CD20 antigen-expressing relapsed or
refractory, low grade, follicular, or transformed non-Hodgkin’s
lymphoma, including patients with Rituximab-refractory non-
Hodgkin’s lymphoma

MOLYBDENUM 99
Mo
• Chemical Form: Mo-99 generator
• Manufacturer(s): Covidien, Lantheus Medical Imaging
• Trade name(s): Ultra-TechneKow®
DTE, Technelite®
• Diagnostic use: Generation of Tc-99m sodium pertechnetate for
administration or radiopharmaceutical preparation.

NITROGEN-13
N
• Chemical Form: Nitrogen-13 Ammonia
• Half-life: 9.97 min
• Manufacturer(s): Various
• Trade name(s):
• Diagnostic use: Indicated for diagnostic Positron Emission
Tomography (PET) imaging of the myocardium under rest or
pharmacologic stress conditions to evaluate myocardial perfusion in
patients with suspected or existing coronary artery disease.

RADIUM-223
Ra
• Chemical Form: Radium-223 dichloride
• Half-life: 11.4 day
• Manufacturer(s): Bayer HealthCare Pharmaceuticals Inc.
• Trade name(s): Xofigo®
• Diagnostic use: Indicated for the treatment of patients with
castration-resistant prostate cancer, symptomatic bone metastases
and no known visceral metastatic disease.

RUBIDIUM-82
Ra
• Chemical Form: Rubidium-82 chloride
• Manufacturer(s): Bracco Diagnostics
• Trade name(s): Cardiogen-82®
• Diagnostic use: PET myocardial perfusion agent that is useful in
distinguishing normal from abnormal myocardium in patients with
suspected myocardial infarction.

SAMARIUM-153
Sa
• Chemical Form: Samarium-153 EDTMP
• Manufacturer(s): Jazz Pharmaceuticals
• Trade name(s): Quadramet®
• Diagnostic use: Indicated for relief of pain in patients with
confirmed osteoblastic metastatic bone lesions that enhance on
radionuclide bone scan.

STRONTIUM-89
Sr
• Chemical Form: Strontium-89 chloride
• Half-life: 50 days
• Manufacturer(s): Bio-Nucleonics, GE Healthcare
• Trade name(s): Metastron
• Diagnostic use: Indicated for the relief of bone pain in patients
with painful skeletal metastases that have been confirmed prior to
therapy.

TECHNETIUM-99M
• Chemical Symbol: 99m
Tc
• Chemical Form: Technetium-99m bicisate
• Manufacturer(s): Lantheus Medical Imaging
• Trade name(s): Neurolite®
• Diagnostic use: SPECT imaging as an adjunct to conventional CT or
MRI imaging in the localization of stroke in patients in whom
stroke has already been diagnosed.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m disofenin
• Manufacturer(s): Pharmalucence
• Trade name(s): Hepatolite®
• Diagnostic use: Diagnosis of acute cholecystitis as well as to rule
out the occurrence of acute cholecystitis in suspected patients with
right upper quadrant pain, fever, jaundice, right upper quadrant
tenderness and mass or rebound tenderness, but not limited to
these signs and symptoms.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m exametazine
• Trade name(s): Ceretec™
• Diagnostic use: • As an adjunct in the detection of altered regional
cerebral perfusion in stroke.
• Leukocyte labeled scintigraphy as an adjunct in the localization of
intra abdominal infection and inflammatory bowel disease.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m macroaggregated albumin
• Manufacturer(s): DRAXIMAGE
• Trade name(s): Pulmolite – CIS, Macrotec (Bracco), Technescan
MAA (Mallinckrodt), Amersham MAA
• Diagnostic use: An adjunct in the evaluation of pulmonary
perfusion (adult and pediatric)
• Evaluation of peritoneo-venous (LaVeen) shunt patency

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m mebrofenin
• Manufacturer(s): Bracco Diagnostics, Pharmalucence
• Trade name(s): Choletec®
• Diagnostic use: As a hepatobiliary imaging agent.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m medronate
• Manufacturer(s): Bracco Diagnostics, DRAXIMAGE, GE Healthcare,
Pharmalucence
• Trade name(s): MDP-Bracco™, MDP-25, MDP Multidose
• Diagnostic use: As a bone imaging agent to delineate areas of
altered osteogenesis.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m mertiatide
• Manufacturer(s): Covidien
• Trade name(s): Technescan MAG3™
• Diagnostic use: In patients > 30 days of age as a renal imaging agent for use in the
diagnosis of:
• Congenital and acquired abnormalities
• Renal failure
• Urinary tract obstruction and calculi
• Diagnostic aid in providing:
• Renal function
• Split function
• Renal angiograms
• Renogram curves for whole kidney and renal cortex

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m oxidronate
• Trade name(s): Technescan™HDP
• Diagnostic use: As a bone imaging agent to delineate areas of
altered osteogenesis (adult and pediatric use)

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m pentetate
• Manufacturer(s): DRAXIMAGE
• Trade name(s):
• Diagnostic use:
• Brain imaging
• Kidney imaging:
- To assess renal perfusion
- To estimate glomerular filtration rate

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m pyrophosphate
• Manufacturer(s): Pharmalucence, Covidien
• Trade name(s): Technescan™ PYP™
• Diagnostic use:
• As a bone imaging agent to delineate areas of altered osteogenesis
• As a cardiac imaging agent used as an adjunct in the diagnosis of acute
myocardial infarction
• As a blood pool imaging agent useful for:
- Gated blood pool imaging
- Detection of sites of gastrointestinal bleeding

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m red blood cells
• Trade name(s): UltraTag™
• Diagnostic use: Tc99m-labeled red blood cells are used for:
• Blood pool imaging including cardiac first pass and gated
equilibrium imaging
• Detection of sites of gastrointestinal bleeding

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m sestamibi
• Manufacturer(s): Cardinal Health, Covidien, DRAXIMAGE, Lantheus Medical
Imaging, Pharmalucence
• Trade name(s): Cardiolite®
• Diagnostic use: Myocardial perfusion agent that is indicated for:
• Detecting coronary artery disease by localizing myocardial ischemia (reversible
defects) and infarction (non-reversible defects)
• Evaluating myocardial function
• Developing information for use in patient management decisions
• Planar breast imaging as a second line diagnostic drug after mammography to assist
in the evaluation of breast lesions in patients with an abnormal mammogram or a
palpable breast mass

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m sodium pertechnetate
• Manufacturer(s): Covidien, Lantheus Medical Imaging
• Trade name(s):
• Diagnostic use: • Brain Imaging (including cerebral radionuclide angiography)*
• Thyroid Imaging*
• Salivary Gland Imaging
• Placenta Localization
• Blood Pool Imaging (including radionuclide angiography)*
• Urinary Bladder Imaging (direct isotopic cystography) for the detection of vesico-
ureteral reflux*
• Nasolacrimal Drainage System Imaging (*adult and pediatric use)

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m succimer
• Trade name(s):
• Diagnostic use: An aid in the scintigraphic evaluation of renal
parenchymal disorders.

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m sulfur colloid
• Manufacturer(s): Pharmalucence
• Trade name(s):
• Diagnostic use: • Imaging areas of functioning retriculoendothelial
cells in the liver, spleen and bone marrow*
• It is used orally for:
- Esophageal transit studies*
- Gastroesophageal reflux scintigraphy*
- Detection of pulmonary aspiration of gastric contents*

• Aid in the evaluation of peritoneo-venous (LeVeen)
shunt patency
• To assist in the localization of lymph nodes draining a
primary tumor in patients with breast cancer or
malignant melanoma when used with a hand-held
gamma counter.
(*adult and pediatric use)

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m tetrofosmin
• Trade name(s): Myoview™
• Diagnostic use: Myocardial perfusion agent that is indicated for:
• Detecting coronary artery disease by localizing myocardial ischemia
(reversible defects) and infarction (non-reversible defects)
• The assessment of left ventricular function (left ventricular ejection
fraction and wall motion)

TECHNETIUM-99M
Tc
• Chemical Form: Technetium-99m tilmanocept
• Manufacturer(s): Navidea Biopharmaceuticals, Inc
• Trade name(s): Lymphoseek®
• Diagnostic use: Indicated for lymphatic mapping with a hand-held
gamma counter to assist in the localization of lymph nodes draining
a primary tumor site in patients with breast cancer or melanoma.

THALLIUM-201
Tl
• Chemical Form: Thallium-201 chloride
• Half-life: 72.912 hrs
• Manufacturer(s): Covidien, GE Healthcare, Lantheus Medical
Imaging
• Trade name(s): DuPont, Mallinckrodt, Amersham
• Diagnostic use: • Useful in myocardial perfusion imaging for the
diagnosis and localization of myocardial infarction
• As an adjunct in the diagnosis of ischemic heart disease
(atherosclerotic coronary artery disease)
• Localization of sites of parathyroid hyperactivity in patients with
elevated serum calcium and parathyroid hormone levels.

XENON-133
Xe
• Chemical Form: Xenon-133 gas
• Manufacturer(s): Lantheus Medical Imaging
• Trade name(s): Xeneisol
• Diagnostic use: • The evaluation of pulmonary function and for
imaging the lungs
•Assessment of cerebral flow

YTTRIUM-90
Y
• Chemical Form: Yttrium-90 chloride
• Half-life: 64 hrs
• Manufacturer(s): Eckert & Ziegler Nuclitec, MDS Nordion
• Trade name(s):
• Diagnostic use: Indicated for radiolabeling:
• Zevalin®
used for radioimmunotherapy procedures

YTTRIUM-90
Y
• Chemical Form: Yttrium-90 ibritumomab tiuxetan
• Half-life: 64 hrs
• Manufacturer(s): Spectrum Pharmaceuticals
• Trade name(s): Zevalin
• Diagnostic use: Indicated for the:
• Treatment of relapsed or refractory, low-grade or follicular B-cell
non-Hodgkin’s lymphoma (NHL)
• Treatment of previously untreated follicular NHL in patients who
achieve a partial or complete response to first-line chemotherapy

INSTRUMENTATION
AND
QUALITY CONTROL

Geiger-Mueller (GM) counter
 Handheld, very sensitive, inexpensive survey instrument
used primarily to detect small amounts of radioactive
contamination.
 Pancake shaped, sometimes cylindrical
 Gas filled and has a high applied voltage from the
anode to cathode. This causes one ionization to result in
an “avalanche” of other electrons, allowing high
efficiency for detection of even a single gamma ray.
 The avalanche of electrons takes some time to
dissipate; as a result, “dead time” must occur before the
next ionization can be detected.
 Limited to exposure rates of up to 100mR/hour
 Most GM counters are equipped with a thin window
that allows detection of most beta rays, very weak beta
rays (such as tritium) cannot be detected.

NUCLEAR-MEDICINE-Copy.pptxbabaabahahahaahha

Ionization Chamber
Handheld survey instrument used to measure
low and high exposure rates.
They have an air or gas filled chamber but a
low efficiency for detection of gamma rays
Relatively low applied voltage from anode to
cathode; as a result, there is no avalanche
effect and no dead time problem.
Ionization chambers typically useful at
exposure rates ranging from 0.1 mR/hour to
100R/hour
A dose calibrator is a special type of an
ionization chamber

SODIUM IODIDE WELL COUNTER
 Well counters are common in nuclear medicine
laboratories for performing in vitro studies as well as
quality control assurance procedures. Many sodium
iodide well counters are designed for counting
radioactive samples in standard test tubes.
 There is a solid cylindrical sodium iodide crystal with
cylindrical well cut into the crystal, into which the test
tube is placed. A PMT is optically coupled to the crystal
base. Radiation from the sample interacts with the crystal
and is detected by the PMT and which feeds into a
scalar.
 The scalar readout directly reflects the amount of
radioactivity in the sample and is usually recorded in
counts for the time period during which the sample is
measured. In general, well counters can typically count
activity only up to about 1 µCi (37kBq).

SINGLE PROBE COUNTING SYSTEM
Single probe counting system using only one
crystalline detector are primarily used for
measuring thyroid uptake of radioactive
iodine.
The probe used for thyroid counting is actually
similar to the standard well counter in
concept, although it does not have the
central hole in the sodium iodide crystal.
The typical crystal is 5 cm in diameter and 5
cm in thickness, with a cone shaped (flat field)
collimator.
As with the well counter, a PMT is situated at
the crystal base.

DOSE CALIBRATOR
 Because it is important to calibrate a dose of isotope before
injection, the dose calibrator is an essential piece of
equipment in any nuclear medicine laboratory. A dose
calibrator is essentially a well-type ionization chamber
capable of measuring quantities in the millicurie (37MBq).
 It does not contain sodium iodide crystal. The chamber is
cylindrical and holds a defined volume pressurized inert gas
(usually argon). Within the chamber is a collecting electrode.
As a radiation emanates from the radiopharmaceutical in the
syringe, it enters the chamber and interacts with the gas,
causing ionization.
 An electrical differential applied between the chamber and
collecting electrode causes the ions to be captured and
measured. This measurements is used to calculate the dose
contained in the syringe. Limits for maximum activity to be
measured by dose calibrators are usually specified for 99m
Tc.

GAMMA CAMERA
 The most widely used imaging devices in nuclear
medicine are the simple gamma scintillation (Anger)
camera and the single-photon emission computed
tomography (SPECT) capable gamma camera.
 A gamma camera converts photons emitted by the
radionuclide in the patient into a light pulse and
subsequently into a voltage signal. This signal is used
to form an image of the distribution of radionuclide.
 The basic components of a gamma camera system
are the collimator, the scintillation crystal, an array
of photomultiplier tubes (PMTs), preamplifiers, a
pulse height analyzer (PHA) digital correction
circuitry, a cathode ray tube (CRT) and the control
console.

Collimator
The collimator is made of perforated or folded
lead and is interposed between the patient
and the scintillation crystal.
It allows the gamma camera to localize
accurately the radionuclide in the patient’s
body.
Collimator performs this function by absorbing
and stopping most radiation except that
arriving almost perpendicular to the detector
face.

The 2 basic types of collimators are pinhole and
multihole.
A pinhole collimator is used with gamma
camera is the , which consists of a lead
cone with only one hole in the end.
Pinhole collimators are routinely used for
very high resolution images of small
organs, such as the thyroid, and for
certain skeletal regions, such as hips or
wrists, especially in pediatric patients.

The parallel hole collimator is the most widely
used multihole collimator in nuclear medicine
laboratories.
It consist of parallel holes with long axis
perpendicular to the plane of the scintillation
crystal.
The lead walls between the holes are referred
to as septa.
The septa absorb most gamma rays that do
not emanate from the direction of interest;
therefore a collimator for high energy gamma
rays has much thicker septa than does a
collimator for low energy rays.

Crystal
 Radiation emerging from the patient and passing
through the collimator typically interacts with thallium
activated sodium iodide crystals.
 The main function of the crystal is to convert the
gamma ray into light.
 Crystals also can be made with thallium or sodium
activated cesium iodide or even lanthanum bromide,
but these are uncommon.
 The crystal is fragile and must have an aluminum
housing that protects it from moisture, extraneous light,
and minor physical damage. The crystal may be
circular and up to about 22 inches in diameter, but
most newer ones are square or rectangular.
 For most camera, a 6 to 10 mm crystal is used.

Photons Transducer
 A photomultiplier tube (PMT) convert’s light pulse into
electric signal of measurable magnitude.
 An array of these tubes is situated behind the sodium
iodide crystal and may be placed directly on the crystal,
connected to the crystal by light pipes, or optically
coupled to the crystal with silicon-like material.
 The signal intensity is processed by the pulse height
analyzer (PHA). The number of PMT is important for the
accurate localization of scintillation event; thus for spatial
resolution, the greater the number the number of PMTs, the
greater the resolution. Most gamma cameras use about 40
to 100 hexagonal, square or round PMTs.
Pulse Height Analyzer
 The basic principle of the PHA is to discard signals from
background and scattered radiation and/or radiation from
interfering isotopes.

Control console
 Image exposure time is selected by console and is
usually a preset count, a preset time, or preset
information density for the image accumulation.
 CRT image may be manipulated by an intensity
control, which simply affects the brightness of the
image, or by a persistence control, which regulates
the length of time the light dots composing the
image remain on the screen.
 Hard copy images on film may be obtained directly
from the computer, although most institutions now
display digital images on monitors and store the
images in PACS.

PET is a unique, three-dimensional,
tomographic imaging technique that is capable
of demonstrating the biochemical function of the
body’s organs and tissue. PET is different from
other imaging methods (x-ray, CT, ultrasound,
MRI), which primarily show structures of the body.
Information obtained from PET procedures is
important because the biochemical metabolism
and function of organs and tissues can reveal
whether they are diseased or healthy. Often PET
can detect abnormal function before the onset of
symptoms. This ability to detect disease in the
early stages and to measure responses to therapy
during treatment can help physicians plan the
most appropriate care for a patient.

The PET scanner is composed of
many individual detectors arranged
in a series of circular arrays designed
to detect simultaneously the 511-keV
(0.511-MeV) photons to create an
image.
This detection process is also
called coincidence imaging.

Although many positron-emitting elements are
known, PET primarily uses oxygen, nitrogen,
carbon, and fluorine. The first three of these
naturally occurring elements are known as the
“basic building blocks of life”; they are easily
substituted directly onto biomolecules and
incorporated into a wide variety of biochemical
compounds.
Some common compounds used in PET imaging
are 18
F-fluorodeoxyglucose (FDG)* (glucose
metabolism), 15
O-water (blood flow, blood
volume, and oxygen consumption), 13
N-ammonia
(blood flow or perfusion), and 11
C-methionine
(amino acid metabolism).

CYCLOTRON
PET requires a specialized device called a
cyclotron to produce the positron-emitting
elements. The cyclotron accelerates subatomic
particles such as protons in a circular orbit to
very high energies and then directs them into a
nonradioactive target material.
The end result is the production of a
radioactive material. The specific radioactive
material produced is dependent on three
things: (1) the type of target material used, (2)
the particle being accelerated, and (3) the
energy to which particles are accelerated.

Most PET tracers have very short half-lives
(120 seconds to 110 minutes), and the PET
scanner must be in close proximity to a
cyclotron. If a PET center is using only 18
F-FDG,
which has a 109.8-minute half-life, the tracer
can be shipped from an offsite cyclotron
production facility.
However, when shorter lived tracers are
being used such as 11
C, 15
O, or 13
N, the cyclotron
must be located at the site of the PET scanner.

PET/CT Fusion Technology (Coregistration)
ANATOMIC AND FUNCTIONAL IMAGE
COREGISTRATION
PET can be combined with other imaging
modalities to enhance the diagnosis of a specific
condition. The most common example is the
hybrid PET/CT scanner.
Because images produced by a PET scanner
primarily demonstrate the biochemical functions
that occur in the body, it is often helpful to have
the corresponding anatomic information
obtained by CT or MRI.

New technology that incorporates a PET
scanner with a CT scanner within a single
imaging system has produced the ability to
acquire functional PET and anatomic CT
images during a single imaging session. These
two image datasets can be displayed as a
single volume in which PET data are directly
merged onto the CT image.
Direct, accurate localization of
pathology found on a PET scan is permitted.
In addition, hybrid PET/CT units allow
attenuation correction to be performed by
the CT scanner.

Clinical Applications
ONCOLOGY
PET is a valuable tool for assessing the metabolism
of tumors. Generally, malignant cells have an
accelerated glucose metabolism because of their
unregulated growth; they readily use sugar as an energy
source. The glucose analog, FDG, also is taken up
readily by active tumors. PET scans for this application
generally are done to determine the initial sites of
cancers and to see whether cancer has spread to other
areas of the body.
An increase in glycolysis (increased use of sugar
by the cells) in a specific organ or region of the body is
an indicator of malignancy. PET may be used for the
initial diagnosis, for staging of a malignancy, and as a
follow-up technique for determining response to

CARDIOLOGY
Coronary Artery Disease - The leading
cause of heart failure is coronary artery disease.
Coronary artery disease begins when blood flow
to the heart is obstructed. Chest pain, heart
attack, and death may occur as a result of this
disease. PET can be used to assess how
coronary artery disease affects the normal
functioning of the heart.
A PET perfusion tracer such as 13N-
ammonia or rubidium chloride Rb 82 is used to
investigate whether certain areas of the heart
are receiving insufficient blood flow.

Software
 Image acquisition
 Processing
 Reconstruction
1. CT and PET images can be viewed side by side
2. The images can be viewed separately
3. The anatomical and functional images are fuse
together to produce the final image
4. Window width can be adjusted
5. The display color can be changed
6. Vertical, horizontal and 3D sections can be viewed.

SINGLE
PHOTON
EMISSION
COMPUTED
TOMOGRAPHY

The most basic type of SPECT system
comprises a conventional scintillation camera
mounted on a special gantry and connected
to an appropriate computer system.
This type of system enables a series of
images acquired around a patient to be
reconstructed to give a set of transaxial
images, similar to those obtained by X ray CT,
which constitute a 3-D image of that part of
the patient being scanned.

Gamma-ray photons emitted from the
internal distributed radiopharmaceutical
penetrate through the patient’s body and are
detected by a single or a set of collimated
radiation detectors.
Most of the detectors used in current
SPECT systems are based on a single or
multiple NaI(TI) scintillation detectors. In SPECT,
projection data are acquired from different
views around the patient.

 A SPECT scan is primarily used to view how blood
flows through arteries and veins in the brain. Tests
have shown that it might be more sensitive to
brain injury than either MRI or CT scanning
because it can detect reduced blood flow to
injured sites.
 SPECT scans is useful in detection of heart
problem, such as CAD and may evaluate low
blood flow at rest or during exercise.
 SPECT scanning is also useful for presurgical
evaluation of medically uncontrolled seizures. The
test can be performed between seizures
(interictal) or during a seizure (ictal) to determine
blood flow to areas where the seizures originate.

SOFTWARE
Image acquisition
Processing
Image manipulation possible to remove
overlying anatomy.
Reconstruction
The images can be viewed separately
Window width can be adjusted
The display color can be changed
Vertical, horizontal and 3D sections can
be viewed.

RADIONUCLIDE GASTRO-ESOPHAGEAL REFLUX
STUDY
Indications
 Diagnosis and quantification of suspected
gastroesophageal reflux
Radiopharmaceuticals
 Tc99m-colloid
 Tc99m-DTPA
Mixed with
 Adults and older children: 150-300 ml orange juice
 Infants and young: normal milk feed
Equipment
 Gamma camera
 Abdominal binder

Patient preparation
 Nil by mouth for 4-6 hours.
 Infants may be studied at normal feed
Technique
Physiologic test – adult and older children
 The liquid containing the tracer is given and
washed down with unlabeled liquid to clear
residual activity from the esophagus.
 The patient lies semi-recumbent with the
camera centered over the stomach and lower
esophagus.
 Dynamic imaging is commenced with 5-s 64x64
frames for 30-60 minutes.

Milk scan – infants and younger children
 The milk feed divided into two parts and one
mixed with the tracer
 The radiolabeled milk is given and washed
down with the remaining unlabeled milk.
 The child is placed either supine or prone,
according to natural behavior (although reflux
appears to occur more readily in the supine
position) with the camera anterior over the
stomach and esophagus
 Dynamic scan is commenced with 5-s 64x64
frames for 30-60 minutes.
 If pulmonary aspiration of feed is suspected,
later imaging at 4 hours may be performed.

Provocation with abdominal compression –
adults and older children
The abdominal binder is placed around the
upper abdomen.
The radiolabeled liquid is given
The patient lies supine with the camera
centered over the stomach and lower
esophagus.
A 30-s images is taken
The test is terminated as soon as a significant
reflux is seen.

RADIONUCLIDE GASTRIC EMPTYING
STUDY
Indications
 Investigation of symptoms suggestive of
gastroparesis
 Before or after gastric surgery
 Investigation of the effects of gastric motility
Contraindications
 High probability of vomiting
Equipment
 Gama camera, preferably dual-headed

 Liquid meal: Tc99m-tin colloid mixed with 200ml
orange juice or with milk or formula feed for
infants
 Solid meal: scrambled egg prepared with Tc99m-
colloid or DTPA.
 Dual isotope combined liquid and solid meal:
 Liquid: Tc99m-colloid mixed with 200ml orange
juice
 Solid: In111-labeled with beads incorporated into
a pancake containing 27 g fat, 18 g protein, 625
calories.

Patient preparation
Nil by mouth for 8 hours
No smoking or alcohol from midnight before
test
Where practical, stop medications affecting
gastric motility such as dopaminergic agonist
(e.g
metoclopramide,domperidone),cholinergic
agonist (e.g bethanechol), tricyclic
antidepressants and anticholinergic for 24
hours or more prior to the study.

Technique
 The patient ingests the meal as quickly as the
comfortably can.
 The patient is positioned standing.
 Every 5 min a pair of 1-min anterior and posterior
128x128 images is obtained.
 The patient sits and relaxes between images
 A liquid study should be continued for up to 60 min and
a solid study for up to 90 min. if it can be seen that the
majority of the meal has emptied inside this time, the
study may be terminated
 If emptying is very low, later pairs of images may be
acquired at intervals of 30-60 min

RADIONUCLIDE MECKEL’S DIVERTICULUM
SCAN
Indications
 Detection of a Meckel’s diverticulum as a cause
for gastrointestinal bleeding, obstruction or
abdominal pain
Contraindications
 Barium study in previous 2-3 days (barium causes
significant attenuation of gamma photons and
may mask a diverticulum)
 In-vivo, labeled red blood cell study in previous
few days
 Precautions and contraindications to any pre-
administered drugs should be observed.

 Tc99m-pertechnetate
 Injected Tc99m-pertechnetate localizes in
ectopic gastric mucosa within diverticulum.
Equipment
 Gamma-camera
Patient preparation
 Nil by mouth for 6 hours, unless emergency
 It may be possible to enhance detection by prior
administration of drugs, e.g pentagastrin,
cimetidine or ranitidine aied at increasing the
uptake of Tc99m-pertechnetate into gastric
mucosa.

Technique
 The bladder is emptied – a full bladder may
obscure the diverticulum
 The patient lies supine with the camera over the
abdomen and pelvis. The stomach must be
included in the field of view because diagnosis is
dependent on demonstrating uptake by gastric
mucosa
 Pertechnetate is administered i.v.
 Posterior and lateral images as required.
Complications
 Pre administered drug sensitivity and side effects.

RADIONUCLIDE IMAGING OF
GASTROINTESTINAL BLEEDING
Indications
 Gastrointestinal bleeding of unknown origin
Contraindications
 No active bleeding at time scheduled for study
 A Slow bleeding of less than approximately 0.5
ml min
 Barium study in previous 2-3 days (barium causes
significant attenuation of gamma photons and
may mask a bleeding site.

Tc99m- red blood cells
Tc99m-pertechnetate
Tc99m-colloid used alternative to
labelled red cells.
Equipment
Gamma camera
Patient preparation
The patient is asked to empty their
bladder before each image is taken.
Catheterization is ideal if appropriate.

Technique
 The patient lies supine
 The camera is positioned over the anterior abdomen
with the symphysis pubis at the bottom of the field of
view
 Tc99m-pertechnetate (in-vivo method) or Tc99m-
labelled with red cells (in-vitro or in-vivo/vitro methods)
are injected i.v.
 A 128x128 dynamic acquisition is began immediately
with 2-s images for 1 min to help demonstrate vascular
blood pool anatomy, followed by 1-min images up to
45 min. Dynamic imaging permits cinematic viewing of
images to detect bleed sites and movement through
bowel.
 Oblique and lateral views may help to localize any
abnormal collections of activity.

RADIONUCLIDE IMAGING OF THE
LIVER AND SPLEEN
Indications
 To assess liver for space occupying lesion –
essentially no longer performed because of
greater utility of CT, MR and US
 To characterize a focal liver lesion as possible
focal nodular hyperplasia
 To detect splenunculi (ectopic splenic tissue)
 Assessment of liver function
 Tc99m-tin or sulfur colloid

Patient preparation
 None.
Equipment
 Gamma camera
Technique
 Patient lies supine
 Image at 20 min post injection
 Film: anterior with costal margins markers,
posterior, left and right lateral
 An additional technique is first pass dynamic
flow study, which may occasionally be
performed to improve differential diagnosis of
liver masses.

RADIONUCLIDE HEPATOBILIARY
AND GALLBLADDER
RADIONUCLIDE IMAGING
Indications
 Suspected acute cholecystitis
 Assessment of gallbladder, common bile duct
and sphincter of Oddi function
 Assessment of neonatal jaundice where biliary
atresia is considered
 Suspected bile leaks after trauma or surgery
 Investigation of biliary drainage

Tc99m-trymethylbromo-iminodiacetic
acid (TBIDA)
Tc99m-iminodiacetic acid (IDA)
Tc99m-pertechnetate to demonstrate
stomach outline

Patient preparation
 Nil by mouth for 4-6 hours
 For investigation of biliary atresia, infants are
given Phenobarbital orally in two divided doses
for 3-5 days prior to the study to enhance
hepatic excretion of radiopharmaceutical.
Technique
 A dynamic study should be performed where it
is important to visualize the progress of the bile in
detail, e.g. post-surgery.
 The patient lies supine
 The radiopharmaceutical is injected i.v.

Films
 1-min 128x128 dynamic images are acquired for 45 min
after injection
 30-45 min post injection when gallbladder is well
visualized, a liquid fatty meal (e.g. 300ml full cream milk)
is given through a straw to stimulate gallbladder
contraction and imaging continued for a further 45 min.
 If the gallbladder and duodenum are not seen, static
images are obtained at intervals up to 4-6 hours.
 If images are suggestive of reflux, 100-200ml of water is
given through a straw to diffuse any activity in the
stomach and thereby differentiate it from nearly bowel
activity.
 If no bowel activity is seen by 4-6 h and its important
detect any flow of bile at all, e.g. suspected biliary
atresia, 1 24-h image should be taken.

Additional Techniques
 Cholecystokinin (CCK) and morphine provocation
 Pharmacological intervention can be used in combination
with TBIDA scanning to improve diagnosis affecting the
gallbladder, common bile duct and sphincter of Oddi.
 CCK causes gallbladder contraction and sphincter of Oddi
relaxation. An i.v. infusion of CCK is given over 2-3min when
the gallbladder is visualize 30-45 min after TBIDA
administration. Dynamic imaging is continued for a further of
30-40 min.
 Morphine causes sphincter of Oddi contraction. In a clinical
setting of suspected acute cholecystitis, if the gallbladder is
not observed by 60 min, an infusion of morphine over 1 min
can be given and imaging continued for a further 30 min.
Morphine provocation has also found success in diagnosis of
elevated sphincter of Oddi basal pressure.
Complications
 Monitor adverse reactions to CCK and morphine.

STATIC RENAL SCINTIGRAPHY
Indications
 Assessment of individual renal function
 Investigation of urinary tract infections, particularly in
children
 Assessment of reflux nephropathy
 Investigation of horseshoe and ectopic kidney
 Space occupying lesions
 Tc99m-dimercaptosuccinic acid (DMSA). Tc99-m-
DMSA gives the best morphological images of any
other renal pharmaceutical and is used for assessment
of scarring and most accurate assessment of renal
function.

Equipment
 Gamma camera
Technique
 The radiopharmaceuticals is administered i.v.
 Images are acquired at any time 1-6 h later.
 Images
 Posterior right oblique (RPO) and left posterior
oblique (LPO) views
 pinhole views may be useful in children
 Anterior images may be taken in cases of
suspected pelvic or horseshoe kidney and severe
scoliosis or if relative function is to be calculated.

Additional Techniques
 Single photon emission computed tomography
(SPECT) in the assessment of scaring and renal
masses/pseudotumors.
 Tc99m-mercaptoacetyltriglycine (MAG-3) may
be considered as a possible to DMSA; it gives
inferior kidney visualization more.
 Fast dynamic frames with motion correction
may be useful to reduce movement artefact,
particularly in young children.

DYNAMIC RENAL SCINTIGRAPHY
Indications
 Diagnosis of obstructed vs non-obstructive dilatation
 Diagnosis of renal artery stenosis
 Assessment of transplant renal failure
 Assessment of renal function following drainage
procedures to the urinary tract.
 Demonstration of vesicoureteric reflux
 Assessment of renal transplantation
 Renal trauma
 Tc99-MAG3
 Tc99m-diethylene triamine pentaacetic acid (DTPA)
 I123-orthoiodohippurate (hippuran)

Patient preparation
 The patient should be well hydrated with around 500ml of
fluid immediately before administration of tracer
Technique
 The patient lies supine or sits reclining with their back
against the camera
 The radiopharmaceutical is injected i.v and image
acquisition is started simultaneously
 Perform dynamic 128x128 acquisition with 10-15 s frame
for 30-40 min
 If significant retention in the kidneys is apparent at the
end of the imaging period, ask the patient to void and
walk around a minute, then take a further short image.
Films
 All posterior

RADIONUCLIDE LUNG VENTILATION/PERFUSION IMAGING
Indications
 Suspected pulmonary embolism
 Assessment of perfusion and ventilation abnormalities, e.g. in
congenital cardiac or pulmonary disease
 Quantitative assessment of right-to-left shunting (perfusion only)
 Quantitative assessment of differential perfusion and ventilation
before lung cancer, lung transplant or lung volume reduction
surgery
Perfusion
 Tc99m-macroaggregated albumin (MAA)
Ventilation
 Kr81m gas (expensive and limited availability)
 Tc99m-technegas
 Tc99m-DTPA aerosol
 Xe133 gas

Patient preparation
 For ventilation, familiarization with breathing equipment
 A current chest x-ray is required to assist with
interpretation
Technique
Perfusion
 The injection may be given in supine, semi recumbent or
sitting position
 The syringe is shaken to prevent particles settling
 A slow i.v. injection is given directly into vein over about
10 s.
 The patient must remain in position for 2-3 min while the
particles becomes fixed in the lungs
 Imaging may begin immediately, preferably in the sitting
position.

Ventilation
Kr81m-gas
This is performed at the same time as the
perfusion study
The patient is positioned to obtained
identical views to the perfusion images
and asked to breath normally through
the mouthpiece.
The air supply attached to the generator
is turned on and imaging commenced.

Tc99m-DTPA aerosol
 Tc99m-DTPA is drawn into 5ml syringe with 2 ml air,
then injected into the nebulizer and flushed
through with air
 The patient is positioned initially with their back to
the camera, sitting if possible.
 The nose-clip is placed on the patient who is
asked to breathe normally through the
mouthpiece. The air supply is turned on to deliver
a rate of 10L min.
 After reaching a sufficient count rate the air
supply is turned off. The patient should continue to
breathe through the mouthpiece for a further 15s
 The nose-clip is remove and the patient is given a
mouth wash, then imaging is commenced

Images
Anterior, posterior, left and right posterior
obliques.
Since perfusion and ventilation images are
directly compared it is important to have
identical views for each. Foam wedges
between the patients back and the camera
assist accurate oblique positioning.
Complications
Care should be taken when injecting MAA not
to induce respiratory failure in patients with
severe pulmonary hypertension. In these
cases, inject very slowly.

RADIONUCLIDE MYOCARDIAL PERFUSION IMAGING
Indications
 Diagnosis and assessment of extent and severity of
myocardial ischemia or infarction
 Assessment of myocardial viability
 Evaluation of prognosis
 Evaluation of effects of angioplasty and by-pass
surgery on myocardial perfusion with pre- and post-
intervention imaging
Contraindications
 Unstable angina
 Frequent ventricular arrhythmias at rest
 Contraindications to pharmacological stress agent
 Severe valvular disease, specially aortic valve stenosis

Tc99m-methoxyisobutilisonitrile (MIBI or
sestamibi)
Tc99m-tetrofosmin (myoview)
Tl201-thallous chloride
F18-FDG + blood flow PET
Rubidium-82 PET

Equipment
 SPECT-capable gamma camera, preferably dual-
headed
 Pharmacological stressing agent
(adenosine,dypiridamole or dobutamine) or
exercise (bicycle ergometer or treadmill)
 Nitroglycerin (tablets or sublingual spray) to
enhance resting uptake of ischemic but viable
segments
 ECG monitor
 Resuscitation facilities including defibrillator
 Aminophylline to reverse possible severe
bronchospasm after dipyridamole infusion
 Lidocaine to reverse serious arrhythmias caused by
dobutamine infusion

Patient preparation
Nil by mouth or light breakfast 4-6 h prior to
test
Cessation of cardiac medication on the day
of the test if possible. Avoid caffeine for 24 h
if using dypiradamole or adenosine.
Technique
The principle of the technique is to compare
myocardial perfusion under conditions of
pharmacological stress or physical exercise,
with perfusion at rest.

Stress regime
 Pharmacological stress has become increasingly widely
used instead of physical exercise. The optimal stress
technique aims to maximize coronary arterial flow. The
preferred pharmacological stressing agent is adenosine
infusion. Adenosine is a strong coronary vasodilator. It
reproducibly increases coronary artery flow by more than
maximal physical exercise.
 There are circumstances where adenosine is
contraindicated, e.g. asthma, second degree heart
block or systolic blood pressure < 100mmHg. Dobutamine
stress may be employed in these circumstances.
Tc99m-MIBI or tetrofosmin rest/stress test
 Because MIBI and tetrofosmin have minimal redistribution,
separate injections are needed for stress and rest studies.
Two-day protocols are optimal, but it is often more
convenient to perform both studies on the same day.

2-Day protocol (stress/rest)
 Initiate pharmacological stress or exercise
 Tetrofosmin is administered i.v. at maximal stress,
continuing the stress protocol for 2 min post injection
to allow uptake in the myocardium
 Images are acquired 15-30 min after tetrofosmin or
60-120 min after sestamibi injection.
 Depending on the clinical situation, if the stress scan
is completely normal the patient may not need to
return for the rest scan
 Preferably 2-7 days later, the patient return for the
rest scan
 Immediately, tetrofosmin i.v is administered and
process as for stress imaging

Th201 stress/rest test
Initiate pharmacological stress or exercise
Administer Tl201 at maximal stress, continuing
the stress protocol for 1 min post injection to
allow uptake in the myocardium
Image immediately (<5 min)
Image at rest 3-4 h after redistribution period
during which time patients should not eat
If fixed defects are present in exercise and rest
images and assessment of viability is required.

GALLIUM RADIONUCLIDE TUMOR IMAGING
Indications
 Assessment of residual masses after therapy and
early diagnosis of recurrence
 Gallium imaging has been used with variable
success in a variety of other tumors, e.g.
hepatoma, bronchial carcinoma, multiple
myeloma and sarcoma
 It has been used in suspected orthopedic
infection.
 Ga67-Gallium citrate, with a half-life of 78 hours

Equipment
Gamma camera, preferably with whole-body
and single photon emission computed
tomography (SPECT) facilities
Patient preparation
If the abdomen is investigated, laxatives may
be given (if not contraindicated) for 2 days
after injection of Ga67-citrate to clear bowel
activity.
Additionally, an enema or suppository may be
given on the day of imaging.

Technique
Ga67-citrate is administered i.v.
Images
48 and 72 h. Whole-body, spot views and
SPECT as appropriate. SPECT can increase
the sensitivity and specify of the
investigation
A radionuclide bone scan may be
performed prior to gallium imaging.

RADIONUCLIDE IMAGING OF THE INFECTION AND
INFLAMMATION
Indications
 Diagnosis and localization of obscure infection and
inflammation in soft tissue and bone
 Assessment of inflammatory activity in disorders such as
bowel disease e.g. Crohn’s.
 In111-labelled leucocytes
 Tc99m-hexamethylpropyleneamineoxime (HMPAO)-labeled
leucocytes
 Ga67-gallium citrate (formerly the most commonly used
agent)
 Tc99m- or In111-human immunoglobulin (HIG)
 Tc99m-sulesomab (Leukoscan)
 F18-FDG PET has been used to evaluate obscure infection or
suspected infection of orthopedic interest.

Technique
 The radiopharmaceuticals is administered
intravenously
 Image timing depends upon the radiopharmaceutical
used and suspected source of infection. Whole-body
imaging may be employed for all of the
radiopharmaceuticals:
 In111-lablled white cells. Static images are acquired
at 3 and 24 hours post injection. Further imaging at
48 h may prove helpful.
 Tc99m-HMPAO labelled white cells. For suspected
abdominal infection, image at 0.5 and 2 h, i.e.
before significant normal bowel activity is seen.
 Ga67-citrate. Images are acquired at 48 and 72 h.
for regions where normal bowel, urinary and blood
pool activity may obscure abnormal collection sites.

RADIONUCLIDE BONE SCAN
Indications
 Staging of cancer and response to therapy,
especially breast and prostate
 Assessment and staging of primary bone tumors
 Painful orthopedic prosthesis to differentiate infection
from loosening
 Bone or joint infection
 Trauma not obvious on x-ray
 Bone pain
 Avascular necrosis and bone infarction
 Assessment of non-accidental injury in children
 Metabolic bone disease for complications such as
fractures
 Arthropathies, e.g. rheumatoid

Tc99m-methylene diphosphonate (MDP)
Tc99m-diphosphonate
Patient preparation
The patient must be well hydrated

Technique
 Tc99m-diphosphonate is injected i.v. When
infection is suspected or blood flow to bone or
primary bone tumor is to be assessed, a bolus
injection is given with patient in position on camera.
 The patient should be encourage to drink of plenty
and empty the bladder frequently to minimize
radiation dose.
 The bladder is emptied immediately prior to
imaging to prevent obscuring the sacrum and bony
pelvis
 Delayed static imaging is performed > 2 h after
injection: up to 4 h for imaging of extremities and
up to 6 h for those patients on dialysis or in renal
failure.

Images
Standard
 The whole skeleton. The number of view will depend
upon the field of view of the camera and whether a
whole-body imaging facility is available
 Anterior oblique views of the thorax are useful to
separate sternum and spine uptake
 For examination of the posterior ribs, scapula or
shoulder, an extra posterior thorax view with arms
above the head should be taken to move the scapula
away from the ribs.
 For imaging small bones and joints, magnified view
should be taken with pinhole collimator if necessary.
 SPECT can be useful for lesion localization, e.g. in
vertebrae and joints and to detect avascular necrosis.

CENTRAL NERVOUS SYSTEM
Clinical Indications
 Brain Death
 Cerebrovascular Disease
 Brain Tumors
 Epilepsy
 Dementia
 Head Trauma
 Substance Abuse
 Neuropsychiatric Disorders and Behavioral
Dysfunction

The most common nuclear medicine imaging
procedures of the brain can be divided into three
different approach.
Planar brain imaging – which uses
radiopharmaceuticals that are perfusion agents.
Planar imaging is usually performed for brain death
studies only.
Technique
 Dynamic or angiographic study
 Delayed static
Pharmaceuticals
 Technetium-99m – DTPA/Pertechnetate
 Technetium-99m – HMPAO/ECD (ethyl cysteine
dimer)

SPECT brain perfusion imaging – which uses lipophilic
radiopharmaceuticals that routinely cross the blood-
brain barrier to localize in normal brain tissue and
pathologic processes in proportion to regional
cerebral blood flow
Technique
 SPECT brain perfusion imaging uses several groups
of lipophilic radiopharmaceuticals.
Pharmaceuticals
 Technetium99-m – HMPAO(exametazime or
Ceretec)
 Technetium99-m – ECD (bicisate or Neurolite)
 Thalium-201 chloride (use for diagnosis of recurrent
tumors versus radiation necrosis)

PET metabolic brain imaging – which uses
functional positron-emitting
radiopharmaceuticals.
Technique
 Provides physiologic test that may illustrate
pathologic conditions before morphologic
manifestations
 Use to evaluate seizure disorders, dementia, and
recurrent brain tumors.
 F18-Fluorodeoxyglucose

CEREBROSPINAL FLUID
IMAGING
 About 400 to 500 mL/day of CSF is formed in the
normal adult, largely in the choroid plexus of the
cerebral ventricular system.
 The total CSF volume ranges between 120 and 150
mL, of which 40 mL are contained within the
ventricular system.
Clinical Applications
 Investigation of suspected communicating
hydrocephalus (normal pressure hydrocephalus)
 Evaluation of CSF leaks
 Imaging the site of the leak
 Verification of diversionary CSF shunt patency

Technique
 For evaluation of CSF dynamics, anterior, posterior and
lateral gamma camera images of the head are
obtained at 6, 24, 48 and at 72 hours or longer if
necessary.
 After injection of Indium111-DTPA into lumbar
subarachnoid space, the activity ascends in the spinal
canal and reaches the basal cisterns at 2 to 4 hours.
 Indium-111 labeled DTPA – most widely used
radiopharmaceuticals for CSF dynamics studies. The
administration of indium-111 DTPA is accomplished by
lumbar puncture with a small-bore (22-gauge) needle
into the subarachnoid space.
 Tecnetium-99m-DTPA – for CFS shunt patency studies. It
may be injected into the shunt reservoir or tubing.

alpha particle – Nucleus of a helium atom, consisting of
two protons and two neutrons, having a positive charge
of 2.
analog – PET radiopharmaceutical biochemically
equivalent to a naturally occurring compound in the
body.
annihilation – Total transformation of matter into energy;
occurs after the antimatter positron collides with an
electron. Two photons are created; each equals the rest
mass of the individual particles.
arterialized venous blood – Arterial blood passed
directly to the venous system by shunts in the capillary
system after surface veins are heated to 104° F to 108° F
(40° C to 42.2° C).

atom – Smallest division of an element that exhibits all
the properties and characteristics of the element;
composed of neutrons, electrons, and protons.
becquerel (Bq) – Unit of activity in the International
System of Units; equal to 1 disintegration per second
(dps): 1 Bq = 1 dps.
beta particle – Electron whose point of origin is the
nucleus; electron originating in the nucleus by way of
decay of a neutron into a proton and an electron.
BGO scintillator – Bismuth germanate (Bi4Ge3O12)
scintillator with an efﬁciency twice that of sodium iodide.
BGO is used in nearly all commercially produced PET
scanners.
bit – Term constructed from the words binary digit and
referring to a single digit of a binary number; for
example, the binary of 101 is composed of 3 bits.

blood-brain barrier – Anatomic and physiologic feature
of the brain thought to consist of walls of capillaries in
the central nervous system and surrounding glial
membranes. The barrier separates the parenchyma of
the central nervous system from blood.
byte – Term used to deﬁne a group of bits, usually eight,
being treated as a unit by the computer.
CM line - Canthomeatal line, deﬁned by an imaginary
line drawn between the lateral canthus of the eye and
meatus of the ear.
cold spot – Lack of radiation being received or
recorded, not producing any image and resulting in an
area of no, or very light, density; may be caused by
disease or artifact.
collimator – Shielding device used to limit the angle of
entry of radiation; usually made of lead.

curie – Standard of measurement for radioactive
decay; based on the disintegration of 1 g of radium at
3.731010 disintegrations per second.
cyclotron – Device for accelerating charged particles to
high energies using magnetic and oscillating
electrostatic ﬁelds. As a result, particles move in a spiral
path with increasing energy.
daughter – Element that results from the radioactive
decay of a parent element.
deadtime – Time when the system electronics are
already processing information from one photon
interaction with a detector and cannot accept new
events to be processed from other detectors.
decay – Radioactive disintegration of the nucleus of an
unstable nuclide.

detector - Device that is a combination of a
scintillator and photomultiplier tube used to detect
x-rays and gamma rays.
deuteron - Ionized nucleus of heavy hydrogen
(deuterium), which contains one proton and one
neutron.
dose - Measure of the amount of energy deposited
in a known mass of tissue from ionizing radiation.
Absorbed dose is described in units of rads; 1 rad is
equal to 10−2 joules/kg or 100 ergs/g.
ejection fraction (cardiac) - Fraction of the total
volume of blood of the left ventricle ejected per
contraction.
electron - Negatively charged elementary particle
that has a speciﬁc charge, mass, and spin.

electron - capture Radioactive decay process in
which a nucleus with an excess of protons brings an
electron into the nucleus, creating a neutron out of
a proton, decreasing the atomic number by 1. The
resulting atom is often unstable and gives off a
gamma ray to achieve stability.
external radiation detector - Instrument used to
determine the presence of radioactivity from the
exterior. 18F-FDG Radioactive analog of naturally
available glucose. It follows the same biochemical
pathways as glucose; however, in contrast to
glucose, it is not totally metabolized to carbon
dioxide and water.
fission - Splitting of a nucleus into two or more parts
with the subsequent release of enormous amounts
of energy.

gamma camera - Device that uses the emission of
light from a crystal struck by gamma rays to
produce an image of the distribution of
radioactive material in a body organ.
gamma ray - High-energy, short-wavelength
electromagnetic radiation emanating from the
nucleus of some nuclides.
ground state - State of lowest energy of a system.
half-life (T1/2) - Term used to describe the time
elapsed until some physical quantity has
decreased to half of its original value.
homeostasis - State of equilibrium of the body’s
internal environment.

image coregistration - Computer technique that permits
realignment of images that have been acquired from
different modalities and have different orientations and
magniﬁcations. With realignment, images possess the same
orientation and size. Images can then be overlaid, one on
the other, to show similarities and differences between the
images.
in vitro - Outside a living organism.
in vivo - Within a living organism.
isotope - Nuclide of the same element with the same
number of protons but a different number of neutrons.
isotropic - Referring to uniform emission of radiation or
particles in three dimensions.
kinetics - Movement of materials into, out of, and through
biologic spaces. A mathematic expression is often used to
describe and quantify how substances traverse membranes
or participate in biochemical reactions.

light pipe - Tubelike structure attached to the
scintillation crystal to convey the emitted light to
the photomultiplier tube.
local cerebral blood flow (LCBF) - Description of
the parametric image of blood ﬂow through the
brain. It is expressed in units of milliliters of blood
ﬂow per minute per 100 g of brain tissue.
magnetic resonance imaging (MRI) - Technique
of nuclear magnetic resonance (NMR) as it is
applied to medical imaging. Magnetic resonance
is abbreviated MR. metastable Describes the
excited state of a nucleus that returns to its
ground state by emission of a gamma ray; has a
measurable lifetime.

neutron - Electrically neutral particle found in the
nucleus; has a mass of 1 mass unit. nuclear particle
accelerator Device to produce radioactive material by
accelerating ions (e.g., electrons, protons, deuterons) to
high energies and projecting them toward stable
materials. Accelerators include linac, cyclotron,
synchrotron, Van de Graaff accelerator, and betatron.
nuclear reactor - Device that under controlled
conditions is used for supporting a self-sustained nuclear
reaction.
nuclide - General term applicable to all atomic forms of
an element.
parametric image - Image that relates anatomic
position (the x and y position on an image) to a
physiologic parameter such as blood ﬂow (image
intensity or color). It may also be referred to as a
functional image.

parent - Radionuclide that decays to a speciﬁc
daughter nuclide either directly or as a member of a
radioactive series.
particle accelerator - Device that provides the energy
necessary to enable a nuclear reaction.
pharmaceutical - Relating to a medicinal drug.
photomultiplier tube (PMT) - Electronic tube that
converts light photons to electrical pulses.
photopenia - a decreased density that is seen on an x-
ray or scan.
pixel (picture element) - Smallest indivisible part of an
image matrix for display on a computer screen. Typical
images may be 128 × 128, 256 × 256, or 512 × 512 pixels.
positron - Positively charged particle emitted from
neutron-deﬁcient radioactive nuclei.

positron emission tomography (PET) - Imaging
technique that creates transaxial images of
organ physiology from the simultaneous
detection of positron annihilation photons.
proton - Positively charged particle that is a
fundamental component of the nucleus of all
atoms. The number of protons in the nucleus of
an atom equals the atomic number of the
element.
pulse height analyzer - Instrument that accepts
input from a detector and categorizes the
pulses on the basis of signal strength.
pyrogen-free - Free of a fever-producing agent
of bacterial origin.

quantitative - Type of PET study in which the ﬁnal
images are not simply distributions of radioactivity
but rather correspond to units of capillary blood
ﬂow, glucose metabolism, or receptor density.
Studies between individuals and repeat studies in
the same individual permit comparison of pixel
values on an absolute scale.
radiation - Emission of energy; rays of waves.
radioactive - Exhibiting the property of
spontaneously emitting alpha, beta, and gamma
rays by disintegration of the nucleus.
radioactivity - Spontaneous disintegration of an
unstable atomic nucleus resulting in the emission
of ionizing radiation.

radioisotope - Synonym for radioactive isotope. Any
isotope that is unstable undergoes decay with the
emission of characteristic radiation.
radionuclide - Unstable nucleus that transmutes via
nuclear decay.
radiopharmaceutical - Refers to a radioactive drug used
for diagnosis or therapy.
radiotracer - Synonym for radiopharmaceutical.
ray - Imaginary line drawn between a pair of detectors in
the PET scanner or between the x-ray source and
detector in a CT scanner.
reconstruction - Mathematic operation that transforms
raw data acquired on a PET tomograph (sinogram) into
an image with recognizable features.
rectilinear scanner - Early imaging device that passed
over the area of interest, moving in or forming a straight
line.

region of interest (ROI) - Area that circumscribes a
desired anatomic location on a PET image. Image-
processing systems permit drawing of ROI on images.
The average parametric value is computed for all
pixels within the ROI and returned to the radiographer.
resolution - Smallest separation of two point sources of
radioactivity that can be distinguished for PET or
SPECT imaging.
scintillation camera - See gamma camera.
scintillation detector - Device that relies on the
emission of light from a crystal subjected to ionizing
radiation. The light is detected by a photomultiplier
tube and converted to an electronic signal that can
be processed further. An array of scintillation
detectors is used in a gamma camera.

scintillator - Organic or inorganic material that
transforms high-energy photons such as x-rays or
gamma rays into visible or nearly visible light
(ultraviolet) photons for easy measurement.
septa - High-density metal collimators that separate
adjacent detectors on a ring tomograph to reduce
scattered photons from degrading image information.
single photon emission computed tomography
(SPECT) - Nuclear medicine scanning procedure that
measures conventional single photon gamma
emissions (99mTc) with a specially designed rotating
gamma camera.
sinogram - Two-dimensional raw data format that
depicts coincidence detectors against possible rays
between detectors.

target - Device used to contain stable materials and
subsequent radioactive materials during bombardment
by high energy nuclei from a cyclotron or other particle
accelerator. The term is also applied to the material
inside the device, which may be solid, liquid, or gaseous.
tracer - Radioactive isotope used to allow a biologic
process to be seen. The tracer is introduced into the
body, binds with a speciﬁc substance, and is followed
by a scanner as it passes through various organs or
systems in the body.
transmission scan - Type of PET scan that is equivalent to
a low-resolution CT scan.
washout - End of the radionuclide procedure, during
which time the radioactivity is eliminated from the body.

REFERENCES:
1. Essentials of Nuclear Medicine Imaging 6th
Edition
by Fred A. Metler Jr. and Milton J. Guiberteau
2. A Guide to Radiological Procedures 5th
Edition
by Frances Aitchison
3. Merrill's Atlas of Radiographic Positioning and
Procedures 13th
Edition
by Bruce W. Long, Jeannean H. Rollins and
Barbara Smith
4. Nuclear Medicine Manual – IAEA
5. Textbook of Radiographic Positioning and Related
Anatomy 8th
Edition
by Kenneth Bontrager and John Lampignano

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