Nuclear Imaging

Nuclear imaging is the radiologic examination using radiopharmaceuticals, which are

radioactive substances taken up by specific types of cells. Nuclear medicine is more
concerned with the functional and molecular aspects of the organ or pathology being
investigated rather than the structure. Radiopharmaceuticals are administered to the patient
and in vivo distribution is recorded. Nuclear imaging has been widely used to diagnose and
follow up certain diseases. Multiple organ systems can be evaluated, including the
cardiovascular system, where ischemia is detected; endocrine system, where thyroid activity is
evaluated; hepatobiliary system, where cystic duct obstruction can be seen; and skeletal
system where tumors/metastasis or fractures are localized.

Last updated: February 21, 2023

CONTENTS

Terminology and Technological Aspects

Hepatobiliary Iminodiacetic Acid Scan
Ventilation and Perfusion Scan
Bone Scan
Cardiac Scan
Thyroid Scan
Other Imaging Modalities by System
References

Terminology and Technological Aspects

Mechanism
 Nuclear medicine differs from the rest of radiology because it involves functional rather
than structural imaging.
Radioisotopes: unstable forms of an element that emit detectable particles as they decay
into more stable forms
Radiopharmaceuticals:
Artificially produced isotopes bound to pharmaceuticals (radioisotope + an organic
molecule)
Administered to patients and used in nuclear medicine
The organic molecule allows isotopes to concentrate within a specific target organ.
The radioisotope emits detectable ionizing radiation (high-energy rays) when it
decays, which is visualized during imaging.

Image creation
Equipment:
The machine is equipped with a gamma camera that detects radiation and forms an
image.
Components of the gamma camera:
Collimator: 1st layer between the patient and the crystal. The collimator is made of
lead with holes to reduce scatter.
Crystal: emits faint light after interacting with gamma rays
Photomultiplier tubes: detect and convert light from the crystal into electrical signals
Electronics for processing data: analyze signals and produce viewable images
Imaging techniques:
Single-photon emission computed tomography (SPECT):
Uses gamma-emitting radioisotopes
A 3D nuclear imaging made by multiple 2D images acquired at different angles
PET:
Uses positron-emitting radioisotopes
Superior image quality (contrast and resolution) but more expensive
Combined imaging techniques:
CT (PET-CT or SPECT-CT) or MRI is integrated.
Improved localization of lesions
A SPECT/CT system with relevant components labeled in the photograph on the right
Image (https://commons.wikimedia.org/wiki/File:NM19_290.jpg): “NM19 290” by Kieran Maher. License: Public Domain
(https://creativecommons.org/licenses/publicdomain/)

Common nuclear medicine exams

Hepatobiliary iminodiacetic acid (HIDA) scan
Ventilation and perfusion (VQ) scan
Bone scan
Cardiac scan
Thyroid scan

Hepatobiliary Iminodiacetic Acid Scan

 HIDA scan (cholescintigraphy):
Examination of the gallbladder
The radiopharmaceutical is normally taken up by the liver and excreted through the
biliary system as bile.
Radiopharmaceutical: technetium-99m iminodiacetic acid
Isotope: technetium-99m
Indications:
Acute cholecystitis with equivocal ultrasound findings
Biliary atresia
Biliary leak
Biliary dyskinesia: Cholecystokinin is administered and gallbladder ejection fraction
is calculated.
Contraindication: allergy to the radiotracer (anaphylaxis)

Table: Interpretation of HIDA scans

Imaging finding Interpretation

Bile ducts visible Normal hepatic function

Filling of the gallbladder Patent cystic duct

Radiotracer is seen in the duodenum Patent common bile duct

No radiotracer is seen in the gallbladder Obstructed gallbladder (acute cholecystitis)

No radiotracer is seen in the duodenum Biliary atresia

Radiotracer outside the biliary system Biliary leak

Ventilation and Perfusion Scan
Phases:
Ventilation phase:
The patient breathes in the radiopharmaceutical, typically Xenon-133, in the
form of an aerosol (other option: technetium-99m
diethylenetriaminepentaacetate (DTPA)).
Small particles then are deposited into the alveoli and images are acquired.
Perfusion phase:
An injectable radiopharmaceutical (technetium-99m macroaggregated albumin
(MAA)) is administered.
Technetium-99m MAA enters the pulmonary vessels and images are acquired.
Indications:
For evaluation of pulmonary embolism when CT pulmonary angiography is
contraindicated:
IV contrast allergy
Pregnancy
Renal failure
Preoperative estimates of lung function: preparation for surgical excision
Contraindication: allergy to radiotracers (anaphylaxis)
Normal VQ scan findings:
Normal perfusion: uniform uptake in the lungs with areas of photopenia in the
region of the heart and hila
Normal ventilation: radiotracer homogeneously washing into the lung with quick
washout and no evidence of air trapping
Always obtain a chest radiograph prior to a VQ scan to exclude consolidation, which
gives a false-positive result.
Table: VQ scan interpretation based on Prospective Investigation of
Pulmonary Embolism Diagnosis (PIOPED) revised criteria

Category Findings

High probability of More than 2 large mismatched segmental defects

pulmonary embolism

Intermediate 1. 2 large, mismatched segmental defects (borderline high

probability of probability)
pulmonary embolism 2. 1 moderate to 2 large, segmental defects or any other pattern
difficult to characterize as high or low probability (true
intermediate probability)
3. Single matched defect with a normal chest radiograph
(borderline low probability)

Low probability for 1. Non-segmental perfusion defects

pulmonary embolism 2. Any perfusion defect with a substantially larger radiographic
finding
3. Matched ventilation/perfusion defect with a normal chest
radiograph
4. Any amount of small perfusion defects with a normal chest
radiograph

Normal No matched or mismatched defects

Bone Scan
 The skeletal system can be assessed using nuclear medicine.
The radiopharmaceutical that is used chemoadsorbs to the hydroxyapatite crystals
in the bone matrix; thus, areas of bone turnover can be identified.
Increased bone turnover is seen in fractures, tumors, and acute infection.
Isotope: technetium-99m
Radiopharmaceutical: methylene diphosphonate
Imaging:
Images are obtained 4 hours after injection, allowing the radiotracer to be taken up
by the bone.
Anterior and posterior images are obtained.
Indications:
Bony metastases screening
Evaluation of fractures (e.g., stress fracture) that are not visible on a radiograph
Infections

Table: Interpretation of bone scan

Results Description Accuracy Examples

Normal Symmetric uptake True negative False negative

Urinary bladder and skull are
normally bright
Normal skeleton Purely lytic
metastasis

Abnormal Asymmetric increased uptake True positive False positive

Osteoblastic Degenerative
metastasis changes
Fractures Osteomyelitis

Cardiac Scan
Also known as myocardial perfusion imaging
Detects variation in blood flow and myocardial extraction of radiotracers
Materials:
Isotopes:
Technetium-99m
Thallium-201
Radiopharmaceuticals:
Sestamibi
Teboroxime
Procedure:
In normal coronary arteries, significant arterial dilatation is seen in response to
exercise/stress.
Stenotic areas do not show dilatation; thus, ischemia and ECG changes occur.
In a cardiac scan, stress is either:
Induced by exercise by running on a treadmill
Pharmacologically induced by giving adenosine or dobutamine to those who
cannot run
Imaging is obtained at both stress and rest.
Radiopharmaceuticals are injected when 85% of the maximum predicted heart rate
(MPHR) is reached.
Indications:
Myocardial ischemia or infarction evaluation
Wall-motion abnormalities: performed using ECG-gated SPECT scan
Calculate left ventricular ejection fraction
Normal cardiac scan obtained in 3 different planes:
The top row of each set is performed under cardiac stress.
Bottom row of each set is performed at rest.
Normal flow to all aspects of the heart at both rest and stress
Abnormal cardiac scans:
Myocardial ischemia: areas of photopenia (i.e., decreased uptake) under stress,
which improve at rest
Myocardial infarction: persistent photopenia (i.e., decreased uptake) despite rest
state
Thyroid Scan
The thyroid gland transports iodine; thus, radioiodine is used to detect the function of the
whole gland or nodules.
Radiopharmaceuticals:
Radioactive iodine (iodine-123)
Technetium-99 pertechnetate
Indications:
Thyroid nodules
Patients with thyrotoxicosis
Patients with thyroid cancer:
Distant metastasis (whole body scan)
Local residual disease
Therapeutic use: radioactive thyroid ablation (in Graves’ disease or thyroid
carcinoma) using higher doses of radioactive iodine (iodine-131 destroys thyroid
cells)
Contraindications:
Pregnancy
Lactation

Table: Interpretation of thyroid scan

Uptake Pattern Diagnosis

Increased Nodular (hot nodule) Toxic adenoma

Diffuse Graves’ disease

Normal Symmetric uptake with no defects

Decreased Nodular (cold nodule) Thyroid cancer

Diffuse Hashimoto thyroiditis

Other Imaging Modalities by System
 Imaging of the CNS (brain, spinal cord, and vertebral column):
Radiography is often used to evaluate fractures of the vertebral column.
CT is a good choice to determine head trauma and exclude intracranial hemorrhage
.
MRI provides more detailed images of the brain and spinal cord, allowing
identification of infarction, tumors, disc herniation, and demyelinating disease.
Pulmonary radiology and imaging of the mediastinum:
Radiography is the preferred initial imaging study for viewing lung pathology.
CT provides more detailed views of the lung parenchyma, mediastinal structures,
and vasculature.
MRI is not often used, but may be employed for evaluating malignancies and cardiac
disease.
Ultrasound can be used for rapid bedside-trauma assessment and for guiding
procedures (thoracentesis).
Breast imaging:
Mammography is often the initial choice for breast cancer screening.
MRI can be used to further evaluate and stage breast cancers.
Ultrasound is helpful in the evaluation of lymph nodes and in guiding biopsy.
Imaging of the abdomen and renal imaging:
Radiography is often used to evaluate for kidney stones, bowel obstruction, and
pneumoperitoneum. In addition, barium may be used to assess swallowing and
bowel function.
CT and MRI provide more detailed assessments of the abdominal viscera and
vasculature.
Nuclear medicine can be used to assess gallbladder function, gastric emptying, and
GI bleeding.
Imaging of the uterus and ovaries:
Ultrasound is the most commonly used modality to evaluate the ovary and uterus,
including assessing pregnancies and determining the cause of
abnormal uterine bleeding.
CT and MRI provide more detailed views and are often useful in assessing cysts,
malignancies, and benign masses.
Imaging of the musculoskeletal system:
Radiography is often used to exclude fractures.
CT is more sensitive to bone pathology, including osteomyelitis.
MRI is preferred for soft-tissue evaluation, such as assessing for malignancy and
myositis.
Bone scan can be useful in determining occult fractures, osteomyelitis, and
metabolic bone disease.

References
1. Brandon, D.C., Thomas, A.J., Ravizzini, G.C. (2014). Introduction to nuclear medicine.
https://accessmedicine.mhmedical.com/content.aspx?bookid=1562&sectionid=95875470
(https://accessmedicine.mhmedical.com/content.aspx?bookid=1562&sectionid=95875470)
2. Elsayes, K.M., Oldham, S.A. (Eds.) (2014). Introduction to Diagnostic Radiology. McGraw-Hill.
3. Chen, M.M., Whitlow, C.T. (2011). Chapter 1. Scope of Diagnostic Imaging. In Chen M.M., Pope T.L., Ott D.J.
(Eds.). Basic Radiology, 2e. McGraw-Hill.