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Myocardial Uptake of 99mTc-HDP and Reduced Perfusion on CT in Subacute Myocardial Infarction Emmanouil Panagiotidis, MD, MSc,* Gemma Price, MD,* Stephen Harland, MD,Þ Jamshed Bomanji, MD, PhD,* and Irfan Kayani, MD* Abstract: A 65-year-old man with known bone metastases from prostate cancer and no cardiac history attended for a restaging bone scan (BS). Diffuse increased 99m Tc-HDP activity in the heart was noted, new since a BS 3 months earlier. A restaging contrast-enhanced CT scan on the same day showed reduced myocardial perfusion in the anterior, apical, and septal walls. On direct questioning, he described an episode of severe exertional chest pain the day before. Myocardial infarction was confirmed and treated with primary percutaneous coronary intervention. New cardiac uptake on BS, raising the possibility of myocardial infarction, is a red alert for clinicians. Key Words: cardiac infarction
99m
Tc-HDP uptake, CT perfusion, subacute myocardial
(Clin Nucl Med 2014;39: e117Ye120) Received for publication December 4, 2012; revision accepted August 26, 2013. From the *Institute of Nuclear Medicine, and †Department of Oncology, University College London Hospitals NHS Trust, London, United Kingdom. Conflicts of interest and sources of funding: none declared. Reprints: Emmanouil Panagiotidis, MD, MSc, Institute of Nuclear Medicine, University College London Hospital, 235 Euston Rd London NW1 2BU, United Kingdom. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3901Ye117
Clinical Nuclear Medicine
& Volume 39, Number 1, January 2014
REFERENCES 1. al-Nahhas AM, Jinnouchi S, Anagnostopoulos C, et al. Clinical significance of technetium-99m methylene diphosphonate myocardial uptake: association with carcinoma of the prostate. Eur J Nucl Med. 1995;22:148Y153. 2. Perez LA, Hayt DB, Freeman LM. Localization of myocardial disorders other than infarction with 99mTc-labelled phosphate agents. J Nucl Med. 1976; 17:241Y246. 3. Peller PJ, Ho VB, Kransdorf MJ. Extraosseous Tc-99m MDP uptake: a pathophysiologic approach. Radiographics. 1993;13:715Y734. 4. Kida T, Hujita Y, Sasaki M, et al. Myocardial and vascular uptake of a bone tracer associated with secondary hyperparathyroidism. Eur J Nucl Med. 1986;12:151Y154. 5. Buja LM, Parkey RW, Bonte FJ, et al. Pathophysiology of ‘‘cold spot’’ and ‘‘hot spot’’ myocardial imaging agents used to detect ischemia or infarction. Cardiovasc Clin. 1979;10:105Y123. 6. Shriki JE, Shinbane J, Lee C, et al. Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation. AJR Am J Roentgenol. 2012;198:496Y504. 7. McKie SJ, Hardwick DJ, Reid JH, et al. Features of cardiac disease demonstrated on CT pulmonary angiography. Clin Radiol. 2005;60:31Y38. 8. Foley PW, Hamaad A, El-Gendi H, et al. Incidental cardiac findings on computed tomography imaging of the thorax. BMC Res Notes. 2010;3:326.
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FIGURE 1. Whole-body bone scan (BS) (A) performed 3 hours after the administration of 650 MBq 99mTc-HDP in a 65-year-old man showed multiple osteoblastic deposits in the axial and appendicular skeleton, consistent with widespread bone metastases from prostatic carcinoma. Whole-body BS (B) after 3 months from the previous BS and 1 day after myocardial infarction (MI) demonstrates multiple osteoblastic foci of tracer throughout the skeleton with no significant changes in comparison with that of the previous BS. However, there is diffuse intense myocardial 99mTc-HDP uptake (arrows), a new finding compared with that of the previous BS. Multiple causes of 99mTc-HDP uptake in the myocardium have been described in the literature either contributed to cardiac etiology, such as coronary disease, heart failure, MI, pericarditis, and cardiomyopathy, or noncardiac etiology, such as hypercalcemia, secondary hyperparathyroidism, radiation therapy, and amyloidosis.1Y4 Ischemic damage to cellular membranes results in the rapid intracellular influx of calcium, which precipitates as a salt within the mitochondria, whereas denatured proteins further act as substrates for calcium deposition.5 99mTc-HDP localizes in irreversibly damaged or dying muscle cells if some residual blood flow is present. Ten percent of normal perfusion is required for sufficient 99mTc-HDP delivery for visualization of infarcted tissues. After 7 to 10 days, areas of infarction are often no longer 99mTc-HDP avid.5 Whole-body BS (C) 3 months after MI and primary percutaneous coronary intervention shows no myocardial 99mTc-HDP uptake (arrows) and multiple osteoblastic foci of tracer throughout the skeleton, unchanged compared with that of previous scans.
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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 1, January 2014
99m
Tc-HDP Uptake in Subacute Myocardial Infarction
FIGURE 2. The contrast-enhanced CT scan (A, transaxial; B, coronal slice) of the chest 3 months before MI showed physiological perfusion in the left ventricle. The contrast-enhanced CT scan of the chest 1 day after MI (C, transaxial; D, coronal slice) revealed reduced subendocardial perfusion in the left ventricle mainly affecting the anterior, septal, and anterolateral walls (arrows). The increased use of CT in the evaluation of patients for a variety of indications provides the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.6Y8
FIGURE 3. The constrast-enhanced transaxial slice CT 1 day after MI (A) showed the left anterior descending lesion, and 3 months after MI (B), it revealed the stent inserted in the culprit left anterior descending lesion (arrows). * 2013 Lippincott Williams & Wilkins
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FIGURE 4. A multigated acqusition scan (A) 3 months before MI showed well-preserved left ventricular ejection fraction. A second scan (B) 2 weeks after MI showed severe impaired left ventricular pump function with abnormal phase and amplitude values mainly affecting the anterior, septal, and anterolateral walls.
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Myocardial Uptake of 99mTc-HDP and Reduced Perfusion on CT in Subacute Myocardial Infarction Emmanouil Panagiotidis, MD, MSc,* Gemma Price, MD,* Stephen Harland, MD,Þ Jamshed Bomanji, MD, PhD,* and Irfan Kayani, MD* Abstract: A 65-year-old man with known bone metastases from prostate cancer and no cardiac history attended for a restaging bone scan (BS). Diffuse increased 99m Tc-HDP activity in the heart was noted, new since a BS 3 months earlier. A restaging contrast-enhanced CT scan on the same day showed reduced myocardial perfusion in the anterior, apical, and septal walls. On direct questioning, he described an episode of severe exertional chest pain the day before. Myocardial infarction was confirmed and treated with primary percutaneous coronary intervention. New cardiac uptake on BS, raising the possibility of myocardial infarction, is a red alert for clinicians. Key Words: cardiac infarction
99m
Tc-HDP uptake, CT perfusion, subacute myocardial
(Clin Nucl Med 2014;39: e117Ye120) Received for publication December 4, 2012; revision accepted August 26, 2013. From the *Institute of Nuclear Medicine, and †Department of Oncology, University College London Hospitals NHS Trust, London, United Kingdom. Conflicts of interest and sources of funding: none declared. Reprints: Emmanouil Panagiotidis, MD, MSc, Institute of Nuclear Medicine, University College London Hospital, 235 Euston Rd London NW1 2BU, United Kingdom. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3901Ye117
Clinical Nuclear Medicine
& Volume 39, Number 1, January 2014
REFERENCES 1. al-Nahhas AM, Jinnouchi S, Anagnostopoulos C, et al. Clinical significance of technetium-99m methylene diphosphonate myocardial uptake: association with carcinoma of the prostate. Eur J Nucl Med. 1995;22:148Y153. 2. Perez LA, Hayt DB, Freeman LM. Localization of myocardial disorders other than infarction with 99mTc-labelled phosphate agents. J Nucl Med. 1976; 17:241Y246. 3. Peller PJ, Ho VB, Kransdorf MJ. Extraosseous Tc-99m MDP uptake: a pathophysiologic approach. Radiographics. 1993;13:715Y734. 4. Kida T, Hujita Y, Sasaki M, et al. Myocardial and vascular uptake of a bone tracer associated with secondary hyperparathyroidism. Eur J Nucl Med. 1986;12:151Y154. 5. Buja LM, Parkey RW, Bonte FJ, et al. Pathophysiology of ‘‘cold spot’’ and ‘‘hot spot’’ myocardial imaging agents used to detect ischemia or infarction. Cardiovasc Clin. 1979;10:105Y123. 6. Shriki JE, Shinbane J, Lee C, et al. Incidental myocardial infarct on conventional nongated CT: a review of the spectrum of findings with gated CT and cardiac MRI correlation. AJR Am J Roentgenol. 2012;198:496Y504. 7. McKie SJ, Hardwick DJ, Reid JH, et al. Features of cardiac disease demonstrated on CT pulmonary angiography. Clin Radiol. 2005;60:31Y38. 8. Foley PW, Hamaad A, El-Gendi H, et al. Incidental cardiac findings on computed tomography imaging of the thorax. BMC Res Notes. 2010;3:326.
www.nuclearmed.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
e117
Clinical Nuclear Medicine
Panagiotidis et al
& Volume 39, Number 1, January 2014
FIGURE 1. Whole-body bone scan (BS) (A) performed 3 hours after the administration of 650 MBq 99mTc-HDP in a 65-year-old man showed multiple osteoblastic deposits in the axial and appendicular skeleton, consistent with widespread bone metastases from prostatic carcinoma. Whole-body BS (B) after 3 months from the previous BS and 1 day after myocardial infarction (MI) demonstrates multiple osteoblastic foci of tracer throughout the skeleton with no significant changes in comparison with that of the previous BS. However, there is diffuse intense myocardial 99mTc-HDP uptake (arrows), a new finding compared with that of the previous BS. Multiple causes of 99mTc-HDP uptake in the myocardium have been described in the literature either contributed to cardiac etiology, such as coronary disease, heart failure, MI, pericarditis, and cardiomyopathy, or noncardiac etiology, such as hypercalcemia, secondary hyperparathyroidism, radiation therapy, and amyloidosis.1Y4 Ischemic damage to cellular membranes results in the rapid intracellular influx of calcium, which precipitates as a salt within the mitochondria, whereas denatured proteins further act as substrates for calcium deposition.5 99mTc-HDP localizes in irreversibly damaged or dying muscle cells if some residual blood flow is present. Ten percent of normal perfusion is required for sufficient 99mTc-HDP delivery for visualization of infarcted tissues. After 7 to 10 days, areas of infarction are often no longer 99mTc-HDP avid.5 Whole-body BS (C) 3 months after MI and primary percutaneous coronary intervention shows no myocardial 99mTc-HDP uptake (arrows) and multiple osteoblastic foci of tracer throughout the skeleton, unchanged compared with that of previous scans.
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* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 1, January 2014
99m
Tc-HDP Uptake in Subacute Myocardial Infarction
FIGURE 2. The contrast-enhanced CT scan (A, transaxial; B, coronal slice) of the chest 3 months before MI showed physiological perfusion in the left ventricle. The contrast-enhanced CT scan of the chest 1 day after MI (C, transaxial; D, coronal slice) revealed reduced subendocardial perfusion in the left ventricle mainly affecting the anterior, septal, and anterolateral walls (arrows). The increased use of CT in the evaluation of patients for a variety of indications provides the unique opportunity to recognize findings consistent with MI in patients who may not have a prior diagnosis of ischemic heart disease.6Y8
FIGURE 3. The constrast-enhanced transaxial slice CT 1 day after MI (A) showed the left anterior descending lesion, and 3 months after MI (B), it revealed the stent inserted in the culprit left anterior descending lesion (arrows). * 2013 Lippincott Williams & Wilkins
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FIGURE 4. A multigated acqusition scan (A) 3 months before MI showed well-preserved left ventricular ejection fraction. A second scan (B) 2 weeks after MI showed severe impaired left ventricular pump function with abnormal phase and amplitude values mainly affecting the anterior, septal, and anterolateral walls.
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* 2013 Lippincott Williams & Wilkins
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