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Case Studies

Here are a number of case studies which provide opportunities for our practitioners to share their experiences and learning.

This is a growing area of our website, so check back regularly for new case studies.

Case Studies

In this section, please find some additional information about some of the Nuclear Medicine examinations.

Tibial Stress Fracture

History:
This patient presented with pain over the distal right tibia for 6 weeks.

X-rays were unremarkable.

Scan Findings:
Both the Blood Pool and the Delayed images show localised uptake in a linear appearance along the posterolateral aspect of the right distal tibia.

Diagnosis:
These images are most typical of a linear or spiral stress fracture involving the distal right tibia.

Tibial Stress Fracture

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De Quervain’s Tenosynovitis

History:
This patient presented with pain over the distal right tibia for 6 weeks.

X-rays were unremarkable.

Scan Findings:
There is a linear area of increased vascularity on the radial side of the right wrist (red arrow). The bony images show only faint uptake along the medial cortex of the distal radius (blue arrow), consistent with reactive change due to overlying soft tissue inflammation.

The small green arrows demonstrate active arthritic changes throughout the fingers.

Diagnosis:
The scan appearances are typical of active soft tissue inflammation / de Quervain’s tenosynovitis along the radial side of the right wrist.

De Quervain’s Tenosynovitis

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Calcaneal Stress Fracture

History:
Swelling and tenderness of the right heel for 2 weeks. ? stress fracture. Past history of osteoporosis with previous stress fracture.

Scan Findings:
There is a linear band of markedly increased vascular and bony uptake through the body of the posterior calcaneum on the right.

Diagnosis:
Clearly demonstrated stress fracture of the posterior right calcaneum.

Calcaneal Stress fracture

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Multiple Rib Fractures

History:
Patient presented with left sided chest wall pain for several weeks after coughing.

Scan Findings:
There are multiple areas of increased uptake in the lateral left sided ribs. A further focus is seen in a lateral right sided rib.

There is also evidence of degenerative change about the L4/5 disc on the left, early arthritic change in the left knee, mild trochanteric bursitis and possible maxillary sinusitis.

Scan Diagnosis:
Multiple left sided rib fractures. A BMD scan was performed and osteopenia confirmed.

Multiple Rib Fractures

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Myocardial Perfusion Scans

In this section, please find some additional information about some of the Nuclear Medicine examinations.

Normal Myocardial Perfusion Scan

Normal Myocardial Perfusion Scan

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Pre-Stent

History:
Known IHD, CABG 2003. Recent symptoms of angina.

The resting ECG showed sinus rhythm, LAD. During exercise there was down sloping ST segment depression in V6 at peak stress. These changes became more positive in the recovery period though slowly responded to O2, GTN and Aminophylline reversal.

Stress perfusion scan:
Moderately large defect in the distal anterior wall and apex.

Rest perfusion scan (following sublingual GTN): Normal.

Gated Images: Post CABG wall motion changes in the septum with mildly reduced septal thickening (normal>50%). Estimated LVEF 50%.

Conclusion:
Positive ECG changes in the absence of chest pain on dipyridamole infusion (with exercise).

The myocardial perfusion scan demonstrates a moderately large area of inducible ischaemia in the anterior wall and apex (LAD territory).

The resting left ventricular ejection fraction is at lower limits of normal.

Pre-Stent

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Post-Stent

History:
The same patient then went on to have a stent following the abnormal perfusion study, but now complained of exertional dyspnoea with possible nocturnal angina.

The resting ECG showed SR with ST segment flattening in the lateral leads. During this stress test there were no ischaemic changes.

Stress perfusion scan:
Subtle perfusion defect was seen in the basal anterior wall (estimated at 5% of the LV) with a further small abnormality in the distal anterior wall towards the apex.

Rest perfusion scan (post s/l GTN): Normal.

Gated Images: Post CABG wall motion changes in the septum. Function was otherwise normal with an estimated LVEF of 60% (normal >50%).

Conclusion:
When compared to the prior study there has been marked improvement to perfusion in the anterior wall, apex and septum. The myocardial perfusion scan does show however a small area of inducible ischaemia in the basal anterior wall (vascular territory unclear though probably a branch of the LAD). There is possibly a 2nd small area of ischaemia in the antero-apical region.

The resting left ventricular systolic function appears normal.

Post-Stent

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QPS/QGS Display

QGS Display page:
This page demonstrates any reversible areas of myocardium and the corresponding vessel supply to that area.

Click to enlarge

QPS Display page:
This page demonstrates the cardiac wall motion to demonstrate any areas that have decreased function.

Click to enlarge

Parathyroid Scan

In this section, please find some additional information about some of the Nuclear Medicine examinations.

Parathyroid Scan

History:
Patient presented with elevated calcium and PTH, suspicious of a parathyroid adenoma.

Scan Findings:
There is a solitary focus of tracer uptake which demonstrates retention relative to the thyroid gland in the lower left neck. This is located inferior to the lower pole of the left lobe of the thyroid. Tracer distribution throughout the neck and mediastinum is otherwise physiological.

Diagnosis:
These images demonstrate clearly a parathyroid adenoma which is located inferior to the left lobe of the thyroid.

Click to enlarge

Top image: Initial anterior image

Bottom image: 3 hour delayed image

Thyroid Scans

In this section, please find some additional information about some of the Nuclear Medicine examinations.

Cold Nodule

History:
Multiple small nodules on ultrasound, largest 1cm in diameter in the right lobe. ? cold.

Scan Findings:
There is irregular tracer uptake seen throughout both lobes with a prominent photopenic area in the mid pole of the right lobe.

Diagnosis:
Multinodular gland with a dominant cold nodule in the mid pole of the right lobe.

Click to enlarge

Autonomous Nodule

History:
Suppressed TSH. Symptoms of fatigue and weight gain. Ultrasound demonstrates solid nodules in both lobes of the thyroid.

Scan Findings:
There is diffusely increased tracer uptake in the large nodule in the left lobe (red arrow) and the smaller nodule in the upper pole of the right lobe of the thyroid (blue arrow). The thyroid elsewhere is not visible, which is consistent with suppression of uptake. The thyroid to background uptake ratio is moderately elevated measuring 18.8:1 (normal range 3 – 8:1).

Diagnosis:
Autonomously functioning nodules in both lobes of the thyroid. A review by an endocrinologist with consideration of antithyroid medications to achieve a euthyroid state is suggested. Treatment with radioactive iodine may be required for long term control of these toxic nodules.

Anterior (Pinhole)

Graves Disease

History:
Clinically hyperthyroid. ? Grave’s disease.

Scan Findings:
There is diffusely increased tracer uptake throughout both lobes of the thyroid which appears at the upper limits of normal in size. The thyroid to background uptake ratio is markedly elevated measuring 55.3 (normal range 3 – 8).

Diagnosis:
The scan appearances are typical of active Grave’s disease

Click to enlarge