INDICATIONS FOR A BONE/JOINT SPECT/SPECT CT SCAN: 
When routine dynamic planar imaging is insufficient is, or is projected to be, insufficient for the following suspected conditions:^1,2,3,4,5,6

MALIGNANCY
Note: For known bone metastases, whole body planar bone scan for staging and restaging is typically sufficient

• Screening evaluation of patients with malignancy presenting with elevated alkaline phosphatase, bone pain, or new pathological fracture
• Staging or restaging evaluation when recent overlapping whole body imaging (CT or PET/CT of the neck, chest, abdomen and pelvis) has not been performed, cannot be performed, or is inconclusive in evaluation of bone metastases
• Staging and restaging for radionuclide bone therapy for predominant bone metastases

INFECTION

• Osteomyelitis: A plain X-ray AND an MRI of the area have been performed, unless MRI is contraindicated, technically limited or inconclusive^5,6
• Discitis: MRI is contraindicated, technically limited or inconclusive

BONE VIABILITY

• Detection of early avascular necrosis, bone infarct, or bone graft viability when patient has had a plain X-ray; and MRI is contraindicated or inconclusive⁷

TRAUMA

• Extremities: Detection of stress fractures and other occult skeletal trauma when there is persistent pain in the suspected area after negative or inconclusive X-ray and MRI⁸
• Spine:
  • For indications such as spondylolysis or determination of age of fracture after CT/MRI is inconclusive⁹
  • Spondylolysis evaluation in a child, with persistent pain after MRI and conservative treatment, in determining further treatment plan^10,11

INCONCLUSIVE

• Inconclusive MRI/CT
• Identification of a primary etiology (via most reactive/ inflammatory changes) when multiple etiologies are identified by MRI/CT, AND intervention planning is needed (includes primary facet joint target localization)^{9,12,13,14,15,16}

POSTOPERATIVE

• Evaluation of persistent symptoms in postoperative spine/joints/bones, after X-ray and CT are negative/inconclusive^{9,17,18,19,20,21,22}

EXTREMITIES

• For evaluation of unexplained extremity pain when clinical criteria and other imaging (X-ray, AND MRI/ Ultrasound/ CT) evaluation is inconclusive (e.g., differentiating complex regional pain syndrome from other causes of pain)^23,24,25,26

FOLLOW-UP

• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

NOTE: Inconclusive includes the scenario when imaging findings do not explain patient clinical symptoms or lack of treatment efficacy.
 

Description/Background
SPECT: Single-photon emission computed tomography (SPECT) is a nuclear medicine imaging technique used to localize data from gamma ray emitting injected radiopharmaceuticals to specific anatomical locations within the patient. The resulting 3D images can be reconstructed in multiple planes, much like a CT scan. The ability to manipulate the imaging data into distinct multiplanar slices improves the diagnostic capability and spatial resolution while using the same pharmaceutical as with traditional planar bone scan. Radiopharmaceuticals used vary based on the clinical indication. The technique is applied in brain, cardiac, pulmonary, abdominal, endocrine, and musculoskeletal imaging.

SPECTCT: SPECTCT (Single-photon emission computed tomography with computed tomography) is now available in many places. The CT portion helps to correct the attenuation (decrease) of photons from the target, as it gets absorbed/reflected through the soft tissues before it reaches the detector. It also helps with anatomic localization much like the CT of PETCT. The CT aspect of SPECTCT may or may not be of diagnostic quality depending on the vendor. However, SPECTCT is now more common among newer gamma imaging scanners.

SPECTCT leads to increased specificity and accuracy.

BONE SPECT/SPECTCT: Due to advances in cross-sectional imaging, the technique currently has limited indications for detecting bone pathology. It is most commonly used in patients who have been found to have an unexpected single area abnormality on a planar (screening) bone scan. It is also used in those who cannot undergo MRI or CT imaging or to clarify the findings on MRI or CT. Although vast majority of bone scan indications have been replaced by MRI or CT over the decades, the recent advent of SPECT has shown comparable or complementary performance versus MRI for some indications as those listed above.^23,24,27,28 For patients with impaired renal function who cannot receive iodinated or gadolinium-based contrast agents or undergo MRI for other reasons, SPECT/ SPECTCT imaging can improve the performance of conventional planar nuclear bone imaging.

TRACERS: Nuclear medicine bone imaging is commonly performed with Technetium-99m-MDP (methylene diphosphonate). For indications such as infection or inflammation, Indium-111/ Technetium-99m-HMPAO (hexamethylpropyleneamine oxime) labelled white blood cells, or Gallium-67 (for spine/sternum) can be used. Gallium is typically used for discitis evaluation, and imaging can be carried out to 2 – 3 days post tracer injection for better target-to-background ratio. Technetium-99m sulfur colloid scan is typically used concordantly for marrow mapping, to distinguish bone marrow from infection site.

Although 18F-labelled sodium fluoride (NaF) PET scanning is highly sensitive for detecting bone lesions, its routine use has not replaced conventional bone scanning due to the latter’s “effectiveness, widespread availability, low cost and favorable dosimetry”.⁴ If a bone SPECT / SPECTCT is not sufficient, specific PET tracers that detect both soft tissue and bone metastases (e.g., F18- FDG, F18- Fluciclovine, Ga68-Dotatate) have replaced the need for a separate NaF PET.

CRPS: In the evaluation of complex regional pain syndrome (CRPS), formerly reflex sympathetic dystrophy, three phase bone scintigraphy (flow, blood pool, and delayed images) and MRI imaging sensitivities reported in the medical literature, ranges widely.²⁶ In general, scintigraphy is more specific than MRI. SPECT imaging, however, is not routinely used for this indication.
 

INDICATIONS FOR NON-BONE INFECTION / INFLAMMATION SPECT/SPECT CT:  
When primary standard modality of CT / CTA / MRI / Ultrasound are inconclusive, limited, or cannot be done,²⁹ including:

• Fever of Unknown Origin when CT/MR are negative/inconclusive/limited.
• Non-bone infection/inflammation when primary standard imaging is negative/ inconclusive, including infections related to
  • Transplant and vascular grafts when ultrasound / CTA are negative/inconclusive/limited.^30,31
  • Prosthetic valves, when echocardiography AND Coronary CTA are inconclusive.³²
  • Cardiac implantable devices when echocardiography is inconclusive.³²
     

Description/Background
Infection-seeking tracers labelled with single-photon-emitting radionuclides include autologous leukocytes [white blood cells (WBC)] labelled with 99mTc-hexamethylpropyleneamine oxime (HMPAO) or 111In-diethylenetriaminepentaaceticacid (DTPA). Imaging is typically completed the same day (for Technetium-Tc labelled agents) or the second day (for Indium-labelled agents). CT portion of SPECT CT localizes the infection agent accumulation to the anatomic site. The tracer activity is not affected by artifact from implants and devices. They are typically used when other modalities such as CT or MRI have not yielded conclusive results or have not explained clinical status.

For infections related to vascular grafts, nuclear medicine modalities are particularly useful to mapping the extent of the infection (focal uptake) for surgical planning. Primary imaging is first done with ultrasound for extracavitary graft and CTA for intracavitary graft.³⁰
 

INDICATIONS FOR TUMOR SPECT/SPECT CT:  

• Iodine imaging for subsequent post thyroidectomy staging of differentiated thyroid cancers, in the setting of:³³
  • Post thyroidectomy neck CT/MR showing residual unresectable thyroid tissue/ disease in the neck
  • Distant metastases as seen on CT/MR
  • Post thyroidectomy unstimulated thyroglobulin > 5 – 10 ng/ml
  • Radioactive iodine therapy is being considered for high risk or recurrent tumor
  • Post radioiodine treatment (post therapy scan)
  • During surveillance, with rising thyroglobulin or stable / rising antithyroglobulin antibodies or abnormal ultrasound neck

Note: Refer to neck SPECT/SPECTCT for thyroid nodules

• For initial or restaging of Neuroendocrine tumors (typically In111-octreotide and Iodine-123 MIBG), for any part of the body:³⁴
  • When CT/MRI OR PET imaging is not available, cannot be done, has contraindications, or is inconclusive.
  • I-131 MIBG: when I131 MIBG therapy is being considered.
  • In111-octreotide: Somatostatin analog therapy is being considered and Ga68 Dotatate PET is not available.
• Imaging during/post therapy with therapeutic agents such as 131 Iodine, 177Lu- Dotatate, 111In Zevalin, when it can change management
• Lymphoscintigraphy with sentinel node localizations, for preoperative planning in melanoma, breast, head and neck, and gynecological cancers
   

Description/Background
Thyroid cancers are imaged by Iodine-123 or Iodine-131 tracers. Prior to treatment, sometimes a whole body I-123 imaging may be done if it is an aggressive cancer or if there is a suspicion of metastases. Whole body imaging with I-131 is acquired up to 10 days post therapeutic dosage with I-131 for thyroid cancers. Subsequent surveillance is done by monitoring thyroglobulin, thyroglobulin antibodies, and ultrasound neck. If there is concern for recurrence, typically whole body I-123 or I-131 imaging is done after either stimulation (thyroid hormone withdrawal or thyrogen stimulation). SPECT/SPECTCT is frequently done of the neck and of any other areas that need clarification on planar imaging.

Indium octreotide and Iodine MIBG (meta-iodobenzylguanidine) imaging are used to assess neuroendocrine tumors for somatostatin (SSTR) receptors to enable treatment with somatostatin analogs, such as octreotide acetate (Sandostatin).
 
177Lu-Dotatate is a treatment for neuroendocrine cancers that have SSTR expression as seen on Gallium-68 PET or Indium-111 pentetreotide/Octreotide imaging. 90Y-ibritumomab tiuxetan (or Zevalin^®) is used as treatment for refractory non-Hodgkin’s lymphoma and may need initial biodistribution assessment with Indium-111 ibritumomab tiuxetan. Therapeutic agents have gamma or bremsstrahlung radiation that can be harnessed to image and evaluate the biodistribution of the therapeutic tracer.

Lymphoscintigraphy with sentinel node mapping is often used in early stage breast, melanoma, and gynecological cancers immediately prior to surgical resection of primary lesion. This evaluates initial lymph nodes draining the target region. These lymph nodes are resected during surgery to evaluate for possible involvement, in which case the cancer is upstaged. For exact anatomic correlation, SPECT/SPECTCT is preferred, but may not be performed due to time constraints before surgery. It is limited to newer systems with faster SPECTCT acquisition times or if planar imaging is inconclusive.
 

INDICATIONS FOR CARDIAC SPECT/SPECT CT
As addressed in MPI and MUGA guidelines. 

INDICATIONS FOR NECK SPECT/ SPECT CT (NON-CANCER)

• Parathyroid adenoma: Clinically or laboratory proven hyperparathyroidism AND ultrasound of the neck completed. If CT is already completed, it should be inconclusive.³⁵
• Thyroid: Abnormal thyroid tests and planar imaging is inconclusive for the location of a focal thyroid lesion.

Description/Background
Parathyroid adenomas are evaluated typically initially by cervical ultrasound. Parathryoid SPECT/ SPECTCT with Tc99m sestamibi or Iodine and sestamibi tracer combo has similar diagnostic performance to 4D-CT with less radiation dose.

Thyroid disorders that are diffuse typically do not need SPECT/ SPECTCT imaging. However, it may be needed in cases of differentiation of a single cold nodule in the background of multinodular goiter to direct biopsy. Iodine-123 tracer is typically used for these.

INDICATIONS FOR LUNG SPECT/SPECTCT: 

• Quantification of lung function prior to lung resection/radiation
• Evaluation of congenital cardiac, thoracic, or pulmonary disease, or lung transplants or bronchopleural fistulae³⁶
• Chronic thromboembolic pulmonary hypertension
• Suspected acute pulmonary embolism with comorbidities (such as COPD, left heart failure, pneumonia, tumor) AND chest x-ray has been performed, AND chest CTA cannot be performed or limited
• Calculation of lung shunt fraction prior to hepatic radioembolization

Description/Background
Ventilation perfusion scans are typically done for pulmonary embolism (PE) assessment when chest CTA cannot be performed, for young patients, or in pregnancy when they have a normal chest x-ray (due to lower radiation exposure). SPECT/SPECTCT of the ventilation images is markedly limited in the US as the two ventilation tracers used in the US (Tc99m DTPA, Xenon) are not highly amenable to SPECT imaging. This and the overdiagnosis of small insignificant PE on SPECT/SPECTCT, like CTA, have enabled planar images to be the preferred method of evaluation of acute PE. However, for the purposes of lung surgery evaluation, congenital heart disease, and chronic pulmonary hypertension, the lung perfusion images have more significance, and these are amenable to SPECT/ SPECTCT with further increases in sensitivity and specificity.

INDICATIONS FOR A BRAIN SPECT/ SPECT CT37  

• For preoperative localization of epileptic foci after EEG, Brain MRI and PET are done and insufficient^38,39
• DAT scan^40,41,42
  • To differentiate essential tremor and drug-induced parkinsonism from parkinsonian syndromes
  • For early/inconclusive parkinsonian features
  • For dementia: differentiating Dementia with Lewy Bodies (DLB) from other dementia types. If FDG PET was completed for this indication, it was inconclusive.
• To evaluate cerebrovascular reserve in planning appropriate endovascular/vascular intervention or neurovascular surgical approach^43,44 It can include:
  • Evaluation for vascular diseases such as Moyamoya.
  • Carotid balloon occlusion.
  • Hyperperfusion syndromes.
  • Shunting for idiopathic normal pressure hydrocephalus.⁴⁵
• Brain perfusion study for evaluation of brain death when CT or MRI already done and planar images are inconclusive⁴⁶
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.
   

Description/Background
Injected brain tracers used include 99mTc-bicisate (ECD; ethyl cysteinate dimer), 99mTc- exametazime (HMPAO; hexamethylpropylene amine oxime), and 99mTc-pentetate (DTPA; diethylenetriaminepentaacetic acid). I123 Ioflupane is used for DAT scan (Dopamine Transporter Scan). Brain studies are performed as a default with SPECT/SPECTCT unless it is a brain death scintigraphy. These tracers cross the blood brain barrier where they emit gamma rays that are detected by the imaging system. A 3D image of the brain is created using computerized techniques with the degree of radionuclide activity corresponding to neuronal activity or cerebral blood flow.

Epilepsy: 15% – 30% of patients with refractory focal epilepsy do not have distinct lesions on MRI. The next investigation for a possible surgically resectable epileptogenic focus includes PET. If this is negative or inconclusive, ictal (during seizure) brain SPECT/ SPECTCT can be obtained, which can reveal increased uptake at the epileptogenic area.

Stroke/Trauma/Presurgical planning: These situations are usually evaluated with brain MRI (or brain CT if there is a contraindication to brain MRI). However, if these results are inconclusive or limited, could not be performed, do not explain the clinical picture, or if additional information is needed for surgeries, Brain SPECT images are obtained, often to evaluate vascular reserve. Brain images are obtained at rest and after vasodilatory acetazolamide injection challenge. These may clarify inconclusive clinical or imaging abnormalities or assess vascular reserve for surgeries. This can also be done with other challenges as well, such as carotid balloon occlusion. In the assessment of transient ischemic disease, reduced perfusion can be seen earlier than changes on conventional imaging and may help plan appropriate therapeutic intervention. In traumatic brain injury (including whiplash, post-concussion syndromes), SPECT studies have shown areas of hypoperfusion without corresponding MRI or CT findings.⁴⁷

Brain Death: This is typically used in the ICU setting, when clinical assessment and electroencephalography are less reliable in diagnosing brain death because of conditions such as severe hypothermia, coma caused by barbiturates, electrolyte or acid–base imbalance, endocrine disturbances, drug intoxication, poisoning, and neuromuscular blockade. Brain death scintigraphy may also be helpful in patients who are being considered as possible organ donors or when family members require documentation of lack of blood flow.

Dementia: Brain SPECT imaging has been replaced by brain PET due to better resolution.

DAT scan (Dopamine transporter Imaging): I123 Ioflupane tracer demonstrates the location and concentration of dopamine transporters (DATs) in the synapses of striatal dopaminergic neurons. This is decreased in presynaptic parkinsonian syndromes (Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy) but is not affected in mimicking conditions such as essential tremor, drug-induced parkinsonism or psychogenic parkinsonism. It is also useful in the differentiation of Alzheimer dementia from Dementia with Lewy Bodies.
The latter is in the spectrum of parkinsonism but may or may not have clinical symptoms of parkinsonism, such as bradykinesia, rigidity, or tremor at rest.
 

INDICATIONS FOR A RADIONUCLIDE CISTERNOGRAPHY (CSF) SPECT/SPECT CT SCAN

• CSF imaging (for evaluation of hydrocephalus, leak, shunt, normal pressure hydrocephalus, spontaneous intracranial hypotension) when⁴⁵
  • Brain/spine or respective site imaging already performed with appropriate CT/ MRI / CT myelography, and deemed to be insufficient; AND
  • Planar images projected to be insufficient for localization of abnormality
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Description/BACKGROUND
Cerebrospinal fluid (CSF) flow studies for the evaluation of obstructive or non-obstructive hydrocephalus of various etiologies or CSF leaks (CSF cisternography) are performed after the intrathecal administration of radionuclide. The radionuclides used for CSF flow studies are Indium-111 DTPA for cisternography and leaks.⁴⁸ Persistence of activity in the lateral ventricles after 24 hours of imaging is diagnostic of normal pressure hydrocephalus. Cine phase contrast MRI is the preferred technique for evaluating CSF flow dynamics and helps determines which patients with NPH will benefit from treatment.^49,50

To evaluate ventriculoperitoneal shunt patency, Tc-99m DTPA radionuclide is injected into the shunt reservoir. Normal shunt patency is confirmed by showing activity along the entire course of the shunt, ultimately spilling into the abdominal cavity.

CSF leaks are more commonly acquired either iatrogenic or post-traumatic⁵¹ than congenital or spontaneous and can occur anywhere along the cranial spinal axis. Scintigraphy for detecting CSF leaks has been superseded by CT and MRI myelographic techniques or thin section skull base CT due to their better spatial resolution.^51,52 Diagnosis using scintigraphy requires intrathecal administration of radionuclide followed by imaging typically at 3,6, 24, and 48 hours. Pledgets can be placed in the nasal cavity or auditory canal in the setting of CSF rhinorrhea and otorrhea, respectively. CSF leak path is traced. Initial diagnostic imaging is typically done with high resolution CT, CT/MR cisternography.^53,54,55

Spontaneous idiopathic hypotension (SIH), also known as craniospinal hypotension, poses a diagnostic challenge due to its protean clinical symptoms, inconsistently demonstrated imaging findings on conventional MRI scanning, and lack of awareness of the diagnosis among clinicians. SIH often presents a variable mix of symptoms, including orthostatic headaches, visual defects or blurred vision, limb paresthesia, transient 3rd cranial nerve palsy, numbness in the face or limbs, cognitive deficits, behavioral changes, neck pain and stiffness, taste alteration, or parkinsonism. In this condition a CSF leak anywhere along the neuraxis is not detected in nearly one-third of patients thought to be due to the slow or intermittent nature of these leaks.⁵⁶ Radionuclide cisternography was found to be more sensitive than CT myelography in a few 
limited case series.^57,58,59 Imaging at multiple time points up to 48 hours, as well as direct and indirect signs, aid in the detection of intermittent or slow leaks, with lower radiation exposure than CT myelography.⁶⁰ SPECT-CT allows improved anatomical localization and characterization.^61,62
 

INDICATIONS FOR RENAL SPECT/SPECTCT^63,64

Complex clinical scenarios involving the following indications wherein cross-sectional imaging and routine dynamic planar imaging alone is, or projected to be, insufficient:

• Evaluation of renal collecting system for trauma, surgery, obstruction in ADULTS, or with signs, symptoms, and laboratory findings supporting the need for such an evaluation in adults; AND
  • CT has been performed and is inconclusive or contraindicated
• For evaluation of renal collecting system for obstruction or vesicoureteral reflux in children and young females:
  • After ultrasound and VCUG (voiding cystourethrography) / VUS (voiding urosonography) are inconclusive or discordant with clinical picture^63,65
• For diagnosis of reno-vascular hypertension with signs, symptoms, laboratory findings, or other imaging supporting the need for such a diagnosis when
  • Duplex ultrasound is inconclusive; AND
  • MRA or CTA cannot be performed or is contraindicated; AND
  • The patient has adequate renal function (GFR > 30) mL/min/1.73 m2) to undergo the study⁶³
• Further evaluation of renal perfusion and split function after completion of ultrasound, including in the setting of surgery, trauma, infection, congenital and mass abnormalities⁶³
• Diagnosis of renal transplant complications after ultrasound has been performed^31,63
• Evaluation of renal infections and discrimination of pyelonephritis from cortical scarring⁶³
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.
   

Description/Background
Renal scintigraphy remains an important technique for evaluation of the renal circulation, parenchyma, and collecting system. Through the acquisition of serial images over time and graphic depiction of radionuclide activity, information about renal blood flow and function not typically afforded by cross-sectional imaging can be achieved through qualitative and quantitative means. Tailored studies utilizing the administration of diuretic or angiotensin- converting enzyme inhibitors, in conjunction with the radionuclide imaging agent, allows for evaluation of suspected hydronephrosis or renovascular hypertension, respectively. The ability to create 3D multiplanar images with the SPECT/SPECTCT technique greatly improves the diagnostic capability over traditional planar imaging.

Tubular secretion agents, such as ⁹⁹mTc-MAG3, are used for diuretic renography because tubular tracers are much more efficiently extracted by the kidney than 99mTc-DTPA (diethylene triamine pentaacetic acid), and washout is therefore easier to evaluate. ⁹⁹mTc-DTPA is filtered
 
purely by the glomerulus and thus can be used both to image the kidney and to measure glomerular filtration rate. T- 99m DMSA (Dimercaptosuccinic acid) is especially useful for pyelonephritis and scar evaluations.

OVERVIEW
Diuresis renography can evaluate severity of urinary tract obstruction and can differentiate an obstructed collecting system from a dilated, but non-obstructing, system. It can also provide the differential function in each kidney. Multiple follow-up exams may be needed to detect gradual improvement or worsening.

Captopril renography is done by imaging before and after administration of acetylcholine esterase inhibitor in patients with high index of suspicion of renovascular hypertension. It is used to identify subgroup in whom hypertension caused by renal artery stenosis could potentially respond to revascularization.⁶³

Renal scintigraphy can be used to screen for postoperative complications in renal allograft dysfunction. These can include infarcts, acute tubular necrosis (ATN), collecting system obstruction, urine leaks, drug-induced nephrotoxicity, and rejection. ATN is differentiated from acute rejection as it usually occurs within the first few days after transplantation whereas acute rejection occurs from one week to months after transplantation. Baseline study may be for future comparison.

Renal scintigraphy can also be used to assess differential function in each kidney and in each segment of the kidney for further treatment implications in cases of surgery, trauma, infection, and congenital and mass abnormalities.
 

INDICATIONS FOR ABDOMEN/PELVIS SPECT/SPECT CT SCAN

• Hepatic radioembolization⁶⁶
  • For evaluation of pulmonary and gastrointestinal shunts or dosimetry calculations prior to procedure (typically utilizing Tc MAA)
  • Post-procedure imaging in lieu of PET to determine dose effect/dose toxicity (using the Y90 radiation itself)⁶⁷
• For evaluation of the following:
  • Intermittent/occult gastrointestinal bleeding after initial workup is indeterminate/contraindicated (scopes, CTA)⁶⁸
  • Indeterminate or vascular hepatic lesions or bleed, when CT/MRI are contraindicated/inconclusive^69,70
  • Indeterminate accessory splenic tissue/asplenia when CT/MRI are contraindicated/inconclusive⁷¹
• Liver transplant (and other hepatic surgery/radiation) preoperative and postoperative function and complications when ultrasound/CT/MR are indeterminate or contraindicated⁶⁹
• Localization of:
  • Suspected ectopic/residual gastric tissue (e.g., Meckel’s diverticulum)⁶⁸
  • Abnormalities in hepatobiliary scintigraphy (e.g., biliary abnormalities/leaks) when ultrasound (in infants) or CT is inconclusive/contraindicated⁶⁹
• Peritoneal imaging for evaluation of complications of shunts, dialysis, or peritoneal integrity, when CT is inconclusive/contraindicated68
• A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Description/Background
Most indications utilize a series of standard planar images over time to determine the progression of the radionuclide through the respective system. However, SPECT/SPECTCT improves anatomic localization, increases diagnostic certainty and accuracy, and decreases the need for delayed imaging.

99mTc-labeled autologous red blood cells (99mTc-RBCs) are injected in intermittent gastrointestinal bleeds and imaged intermittently up to 24 hours to localize bleeds. It can detect bleeding rates as low as 0.1 cc/min to 0.5 cc/min (vs CTA-0.3 – 1 ml/min and angiography 0.5 – 1 ml/min). SPECT/SPECTCT increases the sensitivity and specificity of bleeding-site localization. It has lower radiation exposure than CTA, particularly relevant in children (e.g., Meckel diverticulum studies).⁷²
 
Tc99m sulfur colloid (and sometimes Tc99m RBC) ARE used to identify indeterminate vascular hepatic lesions, such as hemangiomas and hemangioendotheliomas. Denatured Tc99m RBC is useful for identifying indeterminate accessory splenic tissue.

Hepatic radioembolization is used for liver-dominant malignancy or metastases that are unresectable. It involves intra-arterial injection of yttrium-90 (Y90)-labeled glass or resin microspheres. A Tc99m MAA nuclear scan (typically requiring SPECT) is performed before the actual treatment with Y90. MAA, which is similar in size to the Y90 microspheres, mimics the distribution of the Y90 particles and should embolize within the tumor’s hepatic arterioles, thus outlining the expected localization of the radiation. The scan is compared to a CTA/MRA to evaluate for any possible shunting of the treatment agent to the lungs or the GI tract. Coils can be placed as needed to minimize any shunting of Y90 to areas other than the desired target.

Post-procedure imaging (within 24 hours) with either SPECT or PET (at the discretion of the treating physicians) is then performed to confirm the final distribution of the Y90 and to calculate the actual radiation dose delivered to the tumor. Utilizing the Bremsstrahlung radiation of the Y90 embolization agent, SPECT or SPECT/CT can be completed with routine nuclear medicine collimators. However, due to their higher energy level (as compared to routine nuclear medicine agents), the Y90 photons scatter and/or pass through the collimator septa and degrade the image quality. Alternatively, PET scanning can be done, again using the Y90 treatment agent itself; but for PET via a minor decay pattern that emits a positron (32 in every one million decays) that is detectable with PET scanners. FDG PET may be needed later (ideally performed > 12 weeks after treatment) to access tumor response to this radiation, in accordance with the tumor-specific guidelines for FDG PET restaging so may still require inconclusive conventional imaging, if necessary for the type of cancer being treated.

Peritoneal imaging includes evaluation of patency of peritoneovenous shunts, diaphragmatic perforations, or peritoneal loculations, especially prior to intraperitoneal chemotherapy. This is accomplished by injection of Tc99m MAA into the peritoneal cavity.

SPECT/SPECTCT in hepatobiliary imaging can help localize abnormalities by distinguishing superimposed bowel activity and clarifying biliary abnormalities and bile leaks. It may obviate the need for delayed imaging and increase diagnostic certainty. Imaging is achieved utilizing the IV administration of Tc99m-labeled iminodiacetic acid, which is excreted by hepatocytes like bile.

Liver transplant complications are best evaluated by ultrasound, CT, and MR; however, limited applications in pediatric patients may exist when radiation doses or sedation considerations exist.
 

REFERENCES

31. Volkan-Salanci B, Erbas B. Imaging in Renal Transplants: An Update. Semin Nucl Med. Jul 2021;51(4):364-379. doi:10.1053/j.semnuclmed.2020.12.011
32. Galea N, Bandera F, Lauri C, Autore C, Laghi A, Erba PA. Multimodality Imaging in the Diagnostic Work-Up of Endocarditis and Cardiac Implantable Electronic Device (CIED) Infection. J Clin Med. Jul 14 2020;9(7)doi:10.3390/jcm9072237
33. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Thyroid Carcinoma Version 3.2021. National Comprehensive Cancer Network (NCCN). Updated October 15, 2021. Accessed January 14, 2022. https://www.nccn.org/professionals/physician_gls/pdf/thyroid.pdf
34. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Neuroendocrine and Adrenal Tumors Version 4.2021. National Comprehensive Cancer Network (NCCN). Updated December 14, 2021. Accessed January 14, 2022. https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf
35. Itani M, Middleton WD. Parathyroid Imaging. Radiol Clin North Am. Nov 2020;58(6):1071- 1083. doi:10.1016/j.rcl.2020.07.006
36. American College of Radiology (ACR), Society for Pediatric Radiology (SPR), Society of Thoracic Radiology (STR). ACR-SPR-STR practice parameter for the performance of pulmonary scintigraphy. American College of Radiology. Updated 2018. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Pulmonary_Scintigraphy.pdf
37. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM), Society of Nuclear Medicine and Molecular Imaging (SNMMI), Society for Pediatric Radiology (SPR). ACR-ACNM-SNMMI-SPR practice parameter for the performance of single-photon emission brain perfusion imaging (including SPECT and SPECT/CT). American College of Radiology. Updated 2021. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/brainperf-spect.pdf?la=en
38. Duncan JS, Winston GP, Koepp MJ, Ourselin S. Brain imaging in the assessment for epilepsy surgery. Lancet Neurol. Apr 2016;15(4):420-33. doi:10.1016/s1474-4422(15)00383-x
39. von Oertzen TJ. PET and ictal SPECT can be helpful for localizing epileptic foci. Curr Opin Neurol. Apr 2018;31(2):184-191. doi:10.1097/wco.0000000000000527
40. Buchert R, Buhmann C, Apostolova I, Meyer PT, Gallinat J. Nuclear Imaging in the Diagnosis of Clinically Uncertain Parkinsonian Syndromes. Dtsch Arztebl Int. Nov 1 2019;116(44):747-754. doi:10.3238/arztebl.2019.0747
41. Hustad E, Aasly JO. Clinical and Imaging Markers of Prodromal Parkinson's Disease. Front Neurol. 2020;11:395. doi:10.3389/fneur.2020.00395
42. Djang DS, Janssen MJ, Bohnen N, et al. SNM practice guideline for dopamine transporter imaging with 123I-ioflupane SPECT 1.0. J Nucl Med. Jan 2012;53(1):154-63. doi:10.2967/jnumed.111.100784
43. American College of Radiology. ACR Appropriateness Criteria®Cerebrovascular Disease. American College of Radiology (ACR). Updated 2016. Accessed March 14, 2022. https://acsearch.acr.org/docs/69478/Narrative/
44. American College of Radiology. ACR Appropriateness Criteria®Cerebrovascular Disease- Child. American College of Radiology (ACR). Updated 2019. Accessed November 2, 2021. https://acsearch.acr.org/docs/3102253/Narrative/
45. Moonis G, Subramaniam RM, Trofimova A, et al. ACR Appropriateness Criteria® Dementia. J Am Coll Radiol. May 2020;17(5s):S100-s112. doi:10.1016/j.jacr.2020.01.040
46. Donohoe KJ, Agrawal G, Frey KA, et al. SNM practice guideline for brain death scintigraphy 2.0. J Nucl Med Technol. Sep 2012;40(3):198-203. doi:10.2967/jnmt.112.105130
47. American College of Radiology. ACR Appropriateness Criteria® Head Trauma. American College of Radiology (ACR). Updated 2020. Accessed November 2, 2021. https://acsearch.acr.org/docs/69481/Narrative/
48. Ma HY, chun k, Milstein D, Freeman L. Clinical Utilities of Radionuclide Dynamic Cerebrospinal Fluid Studies. J Nucl Med. 2015;56(supplement 3):1893.
49. Damasceno BP. Neuroimaging in normal pressure hydrocephalus. Dement Neuropsychol. Oct-Dec 2015;9(4):350-355. doi:10.1590/1980-57642015dn94000350
50. Halperin JJ, Kurlan R, Schwalb JM, Cusimano MD, Gronseth G, Gloss D. Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. Dec 8 2015;85(23):2063-71. doi:10.1212/wnl.0000000000002193
51. Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal fluid leaks in adults. Radiology. Sep 2008;248(3):725-36. doi:10.1148/radiol.2483070362
52. Epstein NE. A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery. Surg Neurol Int. 2013;4(Suppl 5):S301-17. doi:10.4103/2152-7806.111427
53. Eljazzar R, Loewenstern J, Dai JB, Shrivastava RK, Iloreta AM, Jr. Detection of Cerebrospinal Fluid Leaks: Is There a Radiologic Standard of Care? A Systematic Review. World Neurosurg. Jul 2019;127:307-315. doi:10.1016/j.wneu.2019.01.299
54. Hiremath SB, Gautam AA, Sasindran V, Therakathu J, Benjamin G. Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach. Diagn Interv Imaging. Jan 2019;100(1):3-15. doi:10.1016/j.diii.2018.05.003
55. Lipschitz N, Hazenfield JM, Breen JT, Samy RN. Laboratory testing and imaging in the evaluation of cranial cerebrospinal fluid leaks and encephaloceles. Curr Opin Otolaryngol Head Neck Surg. Oct 2019;27(5):339-343. doi:10.1097/moo.0000000000000578
56. Lin JP, Zhang SD, He FF, Liu MJ, Ma XX. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain. Dec 2017;18(1):4. doi:10.1186/s10194-016-0708-8
57. Hashizume K, Watanabe K, Kawaguchi M, Fujiwara A, Furuya H. Comparison between computed tomography-myelography and radioisotope-cisternography findings in whiplash- associated disorders suspected to be caused by traumatic cerebrospinal fluid leak. Spine (Phila Pa 1976). May 20 2012;37(12):E721-6. doi:10.1097/BRS.0b013e31824ae5d1
58. Wiesemann E, Berding G, Goetz F, Windhagen A. Spontaneous intracranial hypotension: correlation of imaging findings with clinical features. Eur Neurol. 2006;56(4):204-10. doi:10.1159/000096487
59. Yoo HM, Kim SJ, Choi CG, et al. Detection of CSF leak in spinal CSF leak syndrome using MR myelography: correlation with radioisotope cisternography. AJNR Am J Neuroradiol. Apr 2008;29(4):649-54. doi:10.3174/ajnr.A0920
60. Martineau P, Chakraborty S, Faiz K, Shankar J. Imaging of the Spontaneous Low Cerebrospinal Fluid Pressure Headache: A Review. Can Assoc Radiol J. May 2020;71(2):174-185. doi:10.1177/0846537119888395
61. Novotny C, Pötzi C, Asenbaum S, Peloschek P, Suess E, Hoffmann M. SPECT/CT fusion imaging in radionuclide cisternography for localization of liquor leakage sites. J Neuroimaging. Jul 2009;19(3):227-34. doi:10.1111/j.1552-6569.2008.00270.x
62. Arai H, Yamamoto Y, Maeda Y, Aga F, Dobashi H, Nishiyama Y. SPET/CT imaging in radionuclide cisternography to detect cerebrospinal fluid leakage in spontaneous intracranial hypotension associated with SLE. Eur J Nucl Med Mol Imaging. Jul 2012;39(7):1225-6. doi:10.1007/s00259-012-2099-7
63. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice parameter for the performance of renal scintigraphy. American College of Radiology. Updated 2017. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice- Parameters/RenalScint.pdf?la=en
64. Blaufox MD, De Palma D, Taylor A, et al. The SNMMI and EANM practice guideline for renal scintigraphy in adults. Eur J Nucl Med Mol Imaging. Nov 2018;45(12):2218-2228. doi:10.1007/s00259-018-4129-6
65. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM), Society of Nuclear Medicine and Molecular Imaging (SNMMI), Society for Pediatric Radiology (SPR). ACR-ACNM-SNMMI-SPR practice parameter for the performance of radionuclide cystography. American College of Radiology. Updated 2020. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadionuclideCystog.pdf?la=en
66. Hong K, Akinwande O, Bodei L, et al. ACR-ABS-ACNM-ASTRO-SIR-SNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies. Brachytherapy. May-Jun 2021;20(3):497-511. doi:10.1016/j.brachy.2021.01.006
67. Kim SP, Cohalan C, Kopek N, Enger SA. A guide to (90)Y radioembolization and its dosimetry. Phys Med. Dec 2019;68:132-145. doi:10.1016/j.ejmp.2019.09.236
68. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM), Society of Nuclear Medicine and Molecular Imaging (SNMMI), Society for Pediatric Radiology (SPR). ACR-ACNM-SNMMI-SPR practice parameter for the performance of gastrointestinal tract, hepatic, and splenic scintigraphy. American College of Radiology. Updated 2020. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/GI-Scint.pdf
69. American College of Radiology (ACR), American College of Nuclear Medicine (ACNM), Society of Nuclear Medicine and Molecular Imaging (SNMMI), Society for Pediatric Radiology (SPR). ACR-ACNM-SNMMI-SPR practice parameter for the performance of hepatobiliary scintigraphy. American College of Radiology. Updated 2021. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Hepato-Scint.pdf
70. American College of Radiology. ACR Appropriateness Criteria® Liver Lesion-Initial Characterization. American College of Radiology (ACR). Updated 2020. Accessed November 8, 2021. https://acsearch.acr.org/docs/69472/Narrative/
71. American College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR-SPR practice parameter for the performance of liver and spleen scintigraphy. American College of Radiology. Updated 2015. Accessed January 14, 2022. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Liver-SpleenScint.pdf
72. Grady E. Gastrointestinal Bleeding Scintigraphy in the Early 21st Century. J Nucl Med. Feb 2016;57(2):252-9. doi:10.2967/jnumed.115.157289

ADDITIONAL RESOURCES

13. Chung M, Dubel GJ, Noto RB, et al. Acute Lower Gastrointestinal Bleeding: Temporal Factors Associated With Positive Findings on Catheter Angiography After (99m)Tc-Labeled RBC Scanning. AJR Am J Roentgenol. Jul 2016;207(1):170-6. doi:10.2214/ajr.15.15380
14. De Palma D. Radionuclide Tools in Clinical Management of Febrile UTI in Children. Semin Nucl Med. Jan 2020;50(1):50-55. doi:10.1053/j.semnuclmed.2019.10.003
15. Desai A, Bekelis K, Thadani VM, et al. Interictal PET and ictal subtraction SPECT: sensitivity in the detection of seizure foci in patients with medically intractable epilepsy. Epilepsia. Feb 2013;54(2):341-50. doi:10.1111/j.1528-1167.2012.03686.x
16. Dittmann H, Kopp D, Kupferschlaeger J, et al. A Prospective Study of Quantitative SPECT/CT for Evaluation of Lung Shunt Fraction Before SIRT of Liver Tumors. J Nucl Med. Sep 2018;59(9):1366-1372. doi:10.2967/jnumed.117.205203
17. Dyrberg E, Hendel HW, Løgager VB, et al. A prospective study determining and comparing the diagnostic accuracy of fluoride-PET/CT, choline-PET/CT, whole-body bone SPECT/CT and whole-body MRI for the detection of bone metastases in patients with prostate cancer. Eur J Hybrid Imaging. 2018;2(1):1-15.
18. Ekmekçi Ş, Diz-Küçükkaya R, Türkmen C, Adalet I. Selective Spleen Scintigraphy in the Evaluation of Accessory Spleen/Splenosis in Splenectomized/Nonsplenectomized Patients and the Contribution of SPECT Imaging. Mol Imaging Radionucl Ther. Feb 5 2015;24(1):1-7. Splenektomize ve Non-Splenektomize Hastalarda Aksesuar Dalak/Splenozis Saptanmasında Selektif Dalak Sintigrafisinin Rolü ve SPECT Görüntülemenin Katkısı. doi:10.4274/mirt.40085
19. Elojeimy S, Cruite I, Bowen S, Zeng J, Vesselle H. Overview of the Novel and Improved Pulmonary Ventilation-Perfusion Imaging Applications in the Era of SPECT/CT. AJR Am J Roentgenol. Dec 2016;207(6):1307-1315. doi:10.2214/ajr.15.15071
20. Elsayed M, Cheng B, Xing M, et al. Comparison of Tc-99m MAA Planar Versus SPECT/CT Imaging for Lung Shunt Fraction Evaluation Prior to Y-90 Radioembolization: Are We Overestimating Lung Shunt Fraction? Cardiovasc Intervent Radiol. Feb 2021;44(2):254-260. doi:10.1007/s00270-020-02638-8
21. Erba PA, Israel O. SPECT/CT in infection and inflammation. Clin Transl Imaging. 2014;2(6):519-535. doi:10.1007/s40336-014-0092-9
22. Erba PA, Leo G, Sollini M, et al. Radiolabelled leucocyte scintigraphy versus conventional radiological imaging for the management of late, low-grade vascular prosthesis infections. Eur J Nucl Med Mol Imaging. Feb 2014;41(2):357-68. doi:10.1007/s00259-013-2582-9
23. Falk N, Cole A, Meredith TJ. Evaluation of Suspected Dementia. Am Fam Physician. Mar 15 2018;97(6):398-405.
24. Feuerstein JD, Ketwaroo G, Tewani SK, et al. Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy. AJR Am J Roentgenol. Sep 2016;207(3):578-84. doi:10.2214/ajr.15.15714
25. Francis GL, Waguespack SG, Bauer AJ, et al. Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Jul 2015;25(7):716-59. doi:10.1089/thy.2014.0460
26. Frankle WG, Slifstein M, Talbot PS, Laruelle M. Neuroreceptor imaging in psychiatry: theory and applications. Int Rev Neurobiol. 2005;67:385-440. doi:10.1016/s0074-7742(05)67011-0
27. Furukawa Y, Long DE, Ellsworth SG. Functional liver-image guided hepatic therapy (FLIGHT): A technique to maximize hepatic functional reserve. Med Dosim. Summer 2020;45(2):117-120. doi:10.1016/j.meddos.2019.07.007
28. Garg AK, Suri A, Sharma BS, Shamim SA, Bal CS. Changes in cerebral perfusion hormone profile and cerebrospinal fluid flow across the third ventriculostomy after endoscopic third ventriculostomy in patients with aqueductal stenosis: a prospective study. Clinical article. J Neurosurg Pediatr. Jan 2009;3(1):29-36. doi:10.3171/2008.10.Peds08148
29. Genseke P, Wetz C, Wallbaum T, et al. Pre-operative quantification of pulmonary function using hybrid-SPECT/low-dose-CT: A pilot study. Lung Cancer. Apr 2018;118:155-160. doi:10.1016/j.lungcan.2018.02.010
30. Giammarile F, Alazraki N, Aarsvold JN, et al. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging. Dec 2013;40(12):1932-47. doi:10.1007/s00259-013-2544-2
31. Giammarile F, Bozkurt MF, Cibula D, et al. The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers. Eur J Nucl Med Mol Imaging. Jul 2014;41(7):1463-77. doi:10.1007/s00259-014-2732-8
32. Giovanella L, Avram AM, Iakovou I, et al. EANM practice guideline/SNMMI procedure standard for RAIU and thyroid scintigraphy. Eur J Nucl Med Mol Imaging. Nov 2019;46(12):2514-2525. doi:10.1007/s00259-019-04472-8
33. Gopalan D, Blanchard D, Auger WR. Diagnostic Evaluation of Chronic Thromboembolic Pulmonary Hypertension. Ann Am Thorac Soc. Jul 2016;13 Suppl 3:S222-39. doi:10.1513/AnnalsATS.201509-623AS
34. Gopalan D, Delcroix M, Held M. Diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir Rev. Jan 2017;26(143)doi:10.1183/16000617.0108-2016
35. Graebner AK, Tarsy D, Shih LC, et al. Clinical Impact of 123I-Ioflupane SPECT (DaTscan) in a Movement Disorder Center. Neurodegener Dis. 2017;17(1):38-43. doi:10.1159/000447561
36. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. Jan 2016;26(1):1-133. doi:10.1089/thy.2015.0020
37. Horger M, Eschmann SM, Pfannenberg C, et al. Added value of SPECT/CT in patients suspected of having bone infection: preliminary results. Arch Orthop Trauma Surg. Apr 2007;127(3):211-21. doi:10.1007/s00402-006-0259-6
38. Hope TA, Abbott A, Colucci K, et al. NANETS/SNMMI Procedure Standard for Somatostatin Receptor-Based Peptide Receptor Radionuclide Therapy with (177)Lu-DOTATATE. J Nucl Med. Jul 2019;60(7):937-943. doi:10.2967/jnumed.118.230607
39. Hort J, O'Brien JT, Gainotti G, et al. EFNS guidelines for the diagnosis and management of Alzheimer's disease. Eur J Neurol. Oct 2010;17(10):1236-48. doi:10.1111/j.1468- 1331.2010.03040.x
40. Horvat N, Marcelino ASZ, Horvat JV, et al. Pediatric Liver Transplant: Techniques and Complications. Radiographics. Oct 2017;37(6):1612-1631. doi:10.1148/rg.2017170022
41. Isaacson SH, Fisher S, Gupta F, et al. Clinical utility of DaTscan™ imaging in the evaluation of patients with parkinsonism: a US perspective. Expert Rev Neurother. Mar 2017;17(3):219-225. doi:10.1080/14737175.2017.1256205
42. Juhász C, John F. Utility of MRI, PET, and ictal SPECT in presurgical evaluation of non- lesional pediatric epilepsy. Seizure. Apr 2020;77:15-28. doi:10.1016/j.seizure.2019.05.008
43. Juni JE, Waxman AD, Devous MD, Sr., et al. Procedure guideline for brain perfusion SPECT using (99m)Tc radiopharmaceuticals 3.0. J Nucl Med Technol. Sep 2009;37(3):191-5. doi:10.2967/jnmt.109.067850
44. Kappadath SC, Lopez BP, Salem R, Lam MG. Lung shunt and lung dose calculation methods for radioembolization treatment planning. Q J Nucl Med Mol Imaging. Mar 2021;65(1):32-42. doi:10.23736/s1824-4785.20.03287-2
45. Kim S, Mountz JM. SPECT Imaging of Epilepsy: An Overview and Comparison with F-18 FDG PET. Int J Mol Imaging. 2011;2011:813028. doi:10.1155/2011/813028
46. Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension. AJR Am J Roentgenol. Jan 2016;206(1):8-19. doi:10.2214/ajr.15.14884
47. Kristiansen JF, Perch M, Iversen M, Krakauer M, Mortensen J. Lobar Quantification by Ventilation/Perfusion SPECT/CT in Patients with Severe Emphysema Undergoing Lung Volume Reduction with Endobronchial Valves. Respiration. 2019;98(3):230-238. doi:10.1159/000500407
48. Kupsch AR, Bajaj N, Weiland F, et al. Impact of DaTscan SPECT imaging on clinical management, diagnosis, confidence of diagnosis, quality of life, health resource use and safety in patients with clinically uncertain parkinsonian syndromes: a prospective 1-year follow-up of an open-label controlled study. J Neurol Neurosurg Psychiatry. Jun 2012;83(6):620-8. doi:10.1136/jnnp-2011-301695
49. Kupsch A, Bajaj N, Weiland F, et al. Changes in clinical management and diagnosis following DaTscan SPECT imaging in patients with clinically uncertain parkinsonian syndromes: a 12-week follow-up study. Neurodegener Dis. 2013;11(1):22-32. doi:10.1159/000337351
50. Labeur TA, Cieslak KP, Van Gulik TM, et al. The utility of 99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT for selective internal radiation therapy in hepatocellular carcinoma. Nucl Med Commun. Aug 2020;41(8):740-749. doi:10.1097/mnm.0000000000001224
51. La Fontaine J, Bhavan K, Lam K, et al. Comparison Between Tc-99m WBC SPECT/CT and MRI for the Diagnosis of Biopsy-proven Diabetic Foot Osteomyelitis. Wounds. Aug 2016;28(8):271-8.
52. Lake ST, Johnson PT, Kawamoto S, Hruban RH, Fishman EK. CT of splenosis: patterns and pitfalls. AJR Am J Roentgenol. Dec 2012;199(6):W686-93. doi:10.2214/ajr.11.7896
53. Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic renal artery stenosis--diagnosis and treatment. Mayo Clin Proc. Jul 2011;86(7):649-57. doi:10.4065/mcp.2011.0181
54. Le Roux PY, Robin P, Tromeur C, et al. Ventilation/perfusion SPECT for the diagnosis of pulmonary embolism: A systematic review. J Thromb Haemost. Nov 2020;18(11):2910-2920. doi:10.1111/jth.15038
55. MacDonald A, Burrell S. Infrequently performed studies in nuclear medicine: part 2. J Nucl Med Technol. Mar 2009;37(1):1-13. doi:10.2967/jnmt.108.057851
56. Mavriopoulou E, Zampakis P, Smpiliri E, et al. Whole body bone SPET/CT can successfully replace the conventional bone scan in breast cancer patients. A prospective study of 257 patients. Hell J Nucl Med. May-Aug 2018;21(2):125-133.
57. Metter D, Tulchinsky M, Freeman LM. Current Status of Ventilation-Perfusion Scintigraphy for Suspected Pulmonary Embolism. AJR Am J Roentgenol. Mar 2017;208(3):489-494. doi:10.2214/ajr.16.17195
58. Mettler F. Essentials of Nuclear Medicine Imaging. Elsevier; 2019.
59. Mikell JK, Dewaraja YK, Owen D. Transarterial Radioembolization for Hepatocellular Carcinoma and Hepatic Metastases: Clinical Aspects and Dosimetry Models. Semin Radiat Oncol. Jan 2020;30(1):68-76. doi:10.1016/j.semradonc.2019.08.005
60. Moradi F, Morris TA, Hoh CK. Perfusion Scintigraphy in Diagnosis and Management of Thromboembolic Pulmonary Hypertension. Radiographics. Jan-Feb 2019;39(1):169-185. doi:10.1148/rg.2019180074
61. Morsbach F, Sah BR, Spring L, et al. Perfusion CT best predicts outcome after radioembolization of liver metastases: a comparison of radionuclide and CT imaging techniques. Eur Radiol. Jul 2014;24(7):1455-65. doi:10.1007/s00330-014-3180-3
62. Mortensen J, Berg RMG. Lung Scintigraphy in COPD. Semin Nucl Med. Jan 2019;49(1):16-21. doi:10.1053/j.semnuclmed.2018.10.010
63. Mulaik M. Billing and Coding: Nuclear Medicine in the 2020 Spotlight. Radiology Today. 2020;21(1):8.
64. NCCN Imaging Appropriate Use Criteria™. National Comprehensive Cancer Network (NCCN). Updated 2021. Accessed November 4, 2021. https://www.nccn.org/professionals/imaging/default.aspx
65. Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. Crit Care. Sep 27 2016;20(1):299. doi:10.1186/s13054-016-1478-z
66. Otomi Y, Otsuka H, Terazawa K, et al. The diagnostic ability of SPECT/CT fusion imaging for gastrointestinal bleeding: a retrospective study. BMC Gastroenterol. Dec 10 2018;18(1):183. doi:10.1186/s12876-018-0915-7
67. Rahman M, Shad F, Smith MC. Acute kidney injury: a guide to diagnosis and management. Am Fam Physician. Oct 1 2012;86(7):631-9.
68. Rathore C, Kesavadas C, Ajith J, Sasikala A, Sarma SP, Radhakrishnan K. Cost-effective utilization of single photon emission computed tomography (SPECT) in decision making for epilepsy surgery. Seizure. Mar 2011;20(2):107-14. doi:10.1016/j.seizure.2010.10.033
69. Ravaioli A, Pasini G, Polselli A, et al. Staging of breast cancer: new recommended standard procedure. Breast Cancer Res Treat. Mar 2002;72(1):53-60. doi:10.1023/a:1014900600815
70. Seifert KD, Wiener JI. The impact of DaTscan on the diagnosis and management of movement disorders: A retrospective study. Am J Neurodegener Dis. 2013;2(1):29-34.
71. Serenari M, Bonatti C, Zanoni L, et al. The role of hepatobiliary scintigraphy combined with spect/ct in predicting severity of liver failure before major hepatectomy: a single-center pilot study. Updates Surg. Feb 2021;73(1):197-208. doi:10.1007/s13304-020-00907-2
72. Sidhu MK, Duncan JS, Sander JW. Neuroimaging in epilepsy. Curr Opin Neurol. Aug 2018;31(4):371-378. doi:10.1097/wco.0000000000000568
73. Silay MS, Spinoit AF, Bogaert G, Hoebeke P, Nijman R, Haid B. Imaging for Vesicoureteral Reflux and Ureteropelvic Junction Obstruction. Eur Urol Focus. Jun 2016;2(2):130-138. doi:10.1016/j.euf.2016.03.015
74. Silberstein EB, Buscombe JR, McEwan A, Taylor Jr A. Society of nuclear medicine procedure guideline for palliative treatment of painful bone metastases. Society of nuclear medicine procedure guidelines manual. 2003;3:147-153.
75. Skanjeti A, Dhomps A, Paschetta C, Tordo J, Delgado Bolton RC, Giammarile F. Lymphoscintigraphy for Sentinel Node Mapping in Head and Neck Cancer. Semin Nucl Med. Jan 2021;51(1):39-49. doi:10.1053/j.semnuclmed.2020.07.004
76. Society of Nuclear Medicine and Molecular Imaging (SNMMI). Procedure Standards. Society of Nuclear Medicine and Molecular Imaging. Updated 2021. Accessed January 18, 2022. http://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=6414
77. Tafti BA, Padia SA. Dosimetry of Y-90 Microspheres Utilizing Tc-99m SPECT and Y-90 PET. Semin Nucl Med. May 2019;49(3):211-217. doi:10.1053/j.semnuclmed.2019.01.005
78. Taïeb D, Hicks RJ, Hindié E, et al. European Association of Nuclear Medicine Practice Guideline/Society of Nuclear Medicine and Molecular Imaging Procedure Standard 2019 for radionuclide imaging of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging. Sep 2019;46(10):2112-2137. doi:10.1007/s00259-019-04398-1
79. Tamm AS, Abele JT. Bone and Gallium Single-Photon Emission Computed Tomography- Computed Tomography is Equivalent to Magnetic Resonance Imaging in the Diagnosis of Infectious Spondylodiscitis: A Retrospective Study. Can Assoc Radiol J. Feb 2017;68(1):41-46. doi:10.1016/j.carj.2016.02.003
80. Taylor AT, Brandon DC, de Palma D, et al. SNMMI Procedure Standard/EANM Practice Guideline for Diuretic Renal Scintigraphy in Adults With Suspected Upper Urinary Tract Obstruction 1.0. Semin Nucl Med. Jul 2018;48(4):377-390. doi:10.1053/j.semnuclmed.2018.02.010
81. Tennvall J, Fischer M, Bischof Delaloye A, et al. EANM procedure guideline for radio- immunotherapy for B-cell lymphoma with 90Y-radiolabelled ibritumomab tiuxetan (Zevalin). Eur J Nucl Med Mol Imaging. Apr 2007;34(4):616-22. doi:10.1007/s00259-007-0372-y
82. Thut DP, Kreychman A, Obando JA. ¹¹¹In-DTPA cisternography with SPECT/CT for the evaluation of normal pressure hydrocephalus. J Nucl Med Technol. Mar 2014;42(1):70-4. doi:10.2967/jnmt.113.128041
83. Tomassini F, D'Asseler Y, Linecker M, et al. Hepatobiliary scintigraphy and kinetic growth rate predict liver failure after ALPPS: a multi-institutional study. HPB (Oxford). Oct 2020;22(10):1420-1428. doi:10.1016/j.hpb.2020.01.010
84. Toney LK, Wanner M, Miyaoka RS, Alessio AM, Wood DE, Vesselle H. Improved prediction of lobar perfusion contribution using technetium-99m-labeled macroaggregate of albumin single photon emission computed tomography/computed tomography with attenuation correction. J Thorac Cardiovasc Surg. Nov 2014;148(5):2345-52. doi:10.1016/j.jtcvs.2014.04.036
85. Tong AK, Tham WY, Too CW, Tai DW, Chow PK, Ng DC. Molecular Imaging and Therapy of Liver Tumors. Semin Nucl Med. Sep 2020;50(5):419-433. doi:10.1053/j.semnuclmed.2020.04.004
86. Treglia G, Trimboli P, Huellner M, Giovanella L. Imaging in primary hyperparathyroidism: focus on the evidence-based diagnostic performance of different methods. Minerva Endocrinol. Jun 2018;43(2):133-143. doi:10.23736/s0391-1977.17.02685-2
87. Truant S, Baillet C, Gnemmi V, et al. The Impact of Modern Chemotherapy and Chemotherapy-Associated Liver Injuries (CALI) on Liver Function: Value of 99mTc-Labelled- Mebrofenin SPECT-Hepatobiliary Scintigraphy. Ann Surg Oncol. Apr 2021;28(4):1959-1969. doi:10.1245/s10434-020-08988-4
88. Tsai SY, Wang SY, Shiau YC, Yang LH, Wu YW. Clinical value of radionuclide shuntography by qualitative methods in hydrocephalic adult patients with suspected ventriculoperitoneal shunt malfunction. Medicine (Baltimore). Apr 2017;96(17):e6767. doi:10.1097/md.0000000000006767
89. Tsougos I, Kousi E, Georgoulias P, Kapsalaki E, Fountas KN. Neuroimaging methods in Epilepsy of Temporal Origin. Curr Med Imaging Rev. 2019;15(1):39-51. doi:10.2174/1573405613666170622114920
90. Vagal AS, Leach JL, Fernandez-Ulloa M, Zuccarello M. The acetazolamide challenge: techniques and applications in the evaluation of chronic cerebral ischemia. AJNR Am J Neuroradiol. May 2009;30(5):876-84. doi:10.3174/ajnr.A1538
91. Uliel L, Mellnick VM, Menias CO, Holz AL, McConathy J. Nuclear medicine in the acute clinical setting: indications, imaging findings, and potential pitfalls. Radiographics. Mar-Apr 2013;33(2):375-96. doi:10.1148/rg.332125098
92. Wan QC, Li JF, Tang LL, et al. Comparing the diagnostic accuracy of 4D CT and 99mTc-MIBI SPECT/CT for localizing hyperfunctioning parathyroid glands: a systematic review and meta- analysis. Nucl Med Commun. Mar 1 2021;42(3):225-233. doi:10.1097/mnm.0000000000001331
93. Wang M, Wu D, Ma R, et al. Comparison of V/Q SPECT and CT Angiography for the Diagnosis of Chronic Thromboembolic Pulmonary Hypertension. Radiology. Aug 2020;296(2):420-429. doi:10.1148/radiol.2020192181
94. Waxman AD, Bajc M, Brown M, et al. Appropriate Use Criteria for Ventilation-Perfusion Imaging in Pulmonary Embolism: Summary and Excerpts. J Nucl Med. May 2017;58(5):13n-15n.
95. Yu J, Zhang J, Li J, Zhang J, Chen J. Cerebral Hyperperfusion Syndrome After Revascularization Surgery in Patients with Moyamoya Disease: Systematic Review and Meta- Analysis. World Neurosurg. Mar 2020;135:357-366.e4. doi:10.1016/j.wneu.2019.11.065
96. Zafereo M, Yu J, Angelos P, et al. American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism. Head Neck. Jul 2019;41(7):2398-2409. doi:10.1002/hed.25781
97. Zink SI, Ohki SK, Stein B, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J Roentgenol. Oct 2008;191(4):1107-14. doi:10.2214/ajr.07.3642

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