INTERESTING IMAGE
99m
Tc-Mebrofenin SPECT/CT in Hepatic Infarction
Govind S. Mattay, BAS,* Cathal O’Leary, MD,†
Jacob G. Dubroff, MD, PhD,† and Austin R. Pantel, MD, MSTR†
Abstract: A 68-year-old man with hereditary hypercoagulability was re-
ferred to nuclear medicine for elevated aminotransferases after a recent
living-donor liver transplant. A hepatic infarction was suspected. A 99mTc-
mebrofenin SPECT/CT was performed and showed decreased radiotracer
uptake in a wedge-shaped distribution in the anterior liver suggestive of a he-
patic infarction. Subsequently, an enhanced MRI corroborated the diagno-
sis. Oral anticoagulation therapy was then initiated, and aminotransferases
soon normalized.
Key Words: hepatic infarct, HIDA, liver transplant, SPECT
(Clin Nucl Med 2021;46: e8–e10)
Received for publication March 18, 2020; revision accepted August 24, 2020.
From the *Perelman School of Medicine at the University of Pennsylvania; and
†Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, PA.
Conflicts of interest and sources of funding: none declared.
Correspondence to: Austin R. Pantel, MD, MSTR, Hospital of the University of
Pennsylvania, 1 Silverstein, 3400 Spruce St, Philadelphia, PA 19104. E-mail:
Austin.Pantel@pennmedicine.upenn.edu.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0363-9762/21/4601–00e8
DOI: 10.1097/RLU.0000000000003312
e8 www.nuclearmed.com
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Clinical Nuclear Medicine • Volume 46, Number 1, January 2021
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Clinical Nuclear Medicine • Volume 46, Number 1, January 2021 Tc-Mebrofenin SPECT/CT in Hepatic Infarct

FIGURE 1. A 68-year-old man with a prothrombin gene

mutation presented with elevated aminotransferases
11 days after liver transplantation. Hepatic biopsy revealed a
cholestatic injury pattern and was negative for acute cellular
rejection. Doppler ultrasound showed patent main and left
hepatic arteries; however, the right hepatic artery was not
seen. Acute kidney injury precluded CT angiography.
99m
Tc-mebrofenin SPECT/CT was performed to evaluate for
hepatic infarction. First, a low-dose CT of the abdomen was
obtained. Upon injection of 99mTc-mebrofenin 5.5 mCi,
anterior planar images of the abdomen were obtained for
4 minutes (image from 3–4 minutes shown). Planar images
demonstrated homogenous uptake of radiotracer in the liver
(thick black arrow) without focal defect. The spleen (white
arrow) and cardiac blood pool (thin black arrow) were seen.

FIGURE 2. 99mTc-mebrofenin SPECT/CT (A, axial SPECT; B, axial CT; C, axial fusion, D, coronal SPECT; E, coronal CT; F, coronal
fusion) revealed a geographic defect in radiotracer uptake in the liver (black arrows) with a corresponding hypodensity on CT
(white arrows), suggestive of hepatic infarction. Radiotracer was seen entering the duodenum excluding complete biliary
obstruction.

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Mattay et al Clinical Nuclear Medicine • Volume 46, Number 1, January 2021

FIGURE 3. Enhanced MR/MR cholangiopancreatography of the abdomen was performed the next day to confirm hepatic
infarct (A–D, axial T1-weighted fat-saturated portal-venous phase postcontrast MRI; E–H, axial SPECT fused with postcontrast
MRI). Postcontrast T1-weighted image showed a corresponding wedge-shaped area of decreased enhancement (white arrows),
consistent with hepatic infarction. Hypercoagulability due to the patient’s prothrombin gene mutation and recent surgery
likely contributed to the infarct. The patient was started on oral anticoagulation and aminotransferases normalized over 9 days.
Hepatic infarction secondary to vascular injury is a complication of liver transplant.1–3 Doppler ultrasound is first-line to assess
for hepatic artery thrombosis.4 CT or MR angiography may be utilized to support the diagnosis or in cases warranting further
investigation after ultrasound.3,5,6 In our case, the clinical team did not wish to initially administer iodinated contrast or
gadolinium in the setting of an acute kidney injury. As the patient was recovering well aside from persistently elevated
aminotransferases, SPECT/CT was first performed to evaluate for a focal infarct. Hepatobiliary radiotracers, including 99mTc-
mebrofenin, are typically indicated to assess for acute cholecystitis and biliary leak.7 99mTc-mebrofenin accumulation occurs in
viable hepatocytes via organic anion transporting polypeptides.8,9 SPECT imaging, if appropriately timed, could demonstrate
decreased radiotracer uptake in infarcted liver. 99mTc-sulfur colloid imaging was considered, as decreased uptake of this
radiotracer can suggest hepatic infarction.10 Because biliary obstruction was also a concern, 99mTc-mebrofenin was chosen to
also assess patency of the biliary tract. Case reports of planar imaging with hepatobiliary radiotracers suggesting hepatic
infarction have been published.9,11 Compared with planar imaging, our use of SPECT/CT enabled detection of the infarction
and allowed for improved anatomic correlation. We are cognizant that the assumption of static tracer distribution for SPECT
reconstruction was violated with imaging this dynamic process. Nonetheless, images were of diagnostic quality, and findings
were confirmed on MRI.

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