SELFUSTUDY TEST

GastrointestinalNuclear MedicineQuestions are taken from the Nuclear Medicine Self-StudyProgram I,

published by The Society of Nuclear MedicineDIRECTIONS

Thefollowingitemsconsistofa headingfollowedbynumberedoptionsrelatedtothatheading.Selectthoseoptionsyou think are true and those that you think are false.Answersmaybe found on page 1668.

3. Kirchner PT, Simon MA. The clinicalvalueof bone and galliumscintigraphy for soft tissuesarcomasofthe extremities.J BoneJoint Surg 1984;66:319—327.

4. Finn HA, Simon MA, Martin WB, Darakjian H. Scintigraphywith gallium67 citrate in staging of soft tissue sarcomas of the extremity. J Bone JointSurg1987;69:886—89l.

5. Berkerman C, Hoffer PB, Bitran JD. The role ofgallium-67 in the clinicalevaluation ofcancer. Semin NuciMed l984;14:296—323.

6. Wentz von K-U, IrngartingerA, Georgi P, Van Kaick A, Kieckow M,Vollhaber HH. Malignant pleural mesothelioma-accuracy ofGa-67 scintigraphy vs.computed tomography.ROFO 1986;145:61—66.

7. Sorek M, Rom WN, Goldsmith Si. Gallium-67 citrate in the staging ofdiffusepleural mesothelioma.[Abstract].J Nuc/Med 1978;19:692—693.

8. ArmasER,GoldsmithSi. Galliumscanningin peritonealmesothelioma.AiR 1985;144:563—565.

9. RamannaL, WaxmanA, BinneyG, Waxman5, MirraJ, Rosen G.Thallium-201 scintigraphy in bone sarcoma: comparison with gallium-67and technetium-MDPin the evaluationof chemotherapeuticresponse.JNuciMed 1990;31:567—572.

10. Kaufman JH, Cedermark Bi, ParthasarathyKL, Didolkar MS, Bakshi SP.The valueof Ga-67scintigraphyin soft tissuesarcomaand chondrosarcoma. Radiology1977;l23:131—134.

11. Howman-Giles R, Stevens M, Bergin M. Role of gallium-67 in management ofpaediatric solid tumours. Aust PedJ l982;l8:l20—l25.

12. Elias A, Ryan L, Sulkes A, Collins J, Aisner J, Antman KH. Response tomesna, doxorubicin, ifosfamide,and dacarbazine in 108 patients withmetastatic or unresectable sarcoma and no prior chemotherapy. J ClinOncoll989;7:1208—1216.

13. Antman KH, Ryan L, Elias A, Sherman D, Grier HE. Response toifosfamide and mesna: 124 previously treated patients with metastic orunresectablesarcoma.J Clin Oncol 1989;7:126—131.

14. Russell WO, Cohen J, Enzinger F, et al. A clinical and pathological stagingsystem for soft tissue sarcomas. Cancer 1977;40:l562—1570.

15. Zar JH. Biosiatistica/Analysis, 2nd edition. Englewood Cliffs, NJ: PrenticeHall; 1984:176—179.

16. MehtaCR, PatelNR. A networkalgorithmfor the exact treatmentofFisher's exact test in RxC contingency tables. J Am Stat Assn 1983;78:427—434.

A Ant LTrue statementsconcerningthe lactulose-H2breath test fordetecting bacterialovergrowthwithin the small intestine includewhichof thefollowing?

I . Up to 30% of patientswithbacterialovergrowthdo nothave bacterial flora capable of producing H2 frommetabolism of the standard 10-gm lactose load.

2. H2 may resultfrom normalhosttissuemetabolism.3. FastingH2 breathlevelsoccuraftercigarettesmoking.4. FastingH2 breathlevelsmay resultfromsmallintestinal

bacterial overgrowth.5. PatientswhohavenoriseinH2level(> 20 ppmH2)above

baseline after administration of 10 g of lactulose shouldbe retested with 30 g of lactulose.

Truestatementsconcerningcholecystokinin(CCK)cholescintigraphyincludewhichof thefollowing?

6. It isan appropriatescreeningtestforpatientswithupperabdominal pain of uncertain origin.

7. Itcan be usedto identifypatientswithsphincterofOddidyskinesia.

8. Use ofCCK increasesthe sensitivityofhepatobiliaryimaging for detecting mechanical cystic duct obstruction.

9. RapidbolusinjectionofCCKincreasesthepositivepredictive valueof CCK cholescintigraphyfor diagnosing biliarydyskinesia.

Truestatementsconcerningcholecystokinin(CCK)includewhichofthefollowing?

10. It is producedby the duodenalmucosa.11. All commercialformsof CCK retainphysiologicactivity

by reproducing the complete 33 amino acid polypeptidechain length.

12. It decreaseshepaticbile secretion.

lmmed 5 mm

15 mm

FIGURE 1.@ mm 60 mm

A 51-yr-oldman,fivedayspost-coronaryarterybypasssurgery,developsfever,nausea,andabdominalpain.Youareshownthispatient's99mTclidofeninhepatobiliarystudy(Fig.1).

Which of the followingcouldexplainthe findingsin theseimages? (continuedonpage1668)

1599Gallium-67Soft-TmssueSarcomas•Southeeetal

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SELF-STUDY TESTGastrointestinalNuclear Medicine

ANSWERS

Quantitative measurement ofregional pulmonary blood flow with positronemission tomography. JApp!Physio! 1986;60:3l7—326.

I I. Schuster DP, Marklin GF. The effect of regional lung injury or alveolarhypoxemia on pulmonary blood flow and lung water as measured bypositron emission tomography. Am Rev Respir Dis 1986;133:1037—1042.

12. Moerlein SM, Welch Mi. The chemistry ofgallium and indium as related

to radiopharmaceutical production. J Nuc!Med 1981;8:277—287.13. CooperJA, MalikAB.Pulmonarytransvascularfluxoftransferrin. JApp!

Physioll989;67:1850—1854.14. Schuster DP, Maridin OF. Effect ofchanges in inflation and blood volume

on regional lung density—aPET study: 2. J Compu: Ass: Tomogr 1986;10:730—735.

(continuedfrompage 1599)

13. insufficientperiodof fastingbeforethe study14. acute pancreatitis15. fastingfor 4 hr beforethe study16. acute or chroniccholecystitis

Reasonable approaches atthis pointto improve the diagnosticutilityofthe studyinFigure1 includewhichofthefollowing?

17. administermorphinesulfate,0.04mg/kg,intravenous,andcontinue imaging for an additional 30-45 mm

18. continueimagingfor an additional3 hr19. administersincalide,0.02pg/kg, intravenous,administer

a second dose of 99mTclidofenin, and image for 60 mm20. administer200 ml of waterby mouth

Which of the following characteristics among the 99mTcacetanilidoiminodiacetate(IDA)derivativesfavorshepatocyteuptakeand concentrationin the biliarytree?

21. the structureshouldcontaina nonpolargroup22. thestructureshouldbe lipophilic23. high urinaryexcretion24. low plasmaproteinbinding

LITEMS 6-5: CCKCholesclntlgraphyANSWERS:6, F; 7,1;8, F;9, FCCKcholescintigraphyshouldbeemployedto confirma surgeon'sand/orgastroenterologist'sclinical impressionthat rightupper quadrantpain and biliary colic are a manifestationof acalculous biliary diseasaIt should not be employed as a screening test in individuals with vagueabdominalpain,becausefalse@positivestudieswilloccursincethemax•imalgallbladderejectionfractionresponseto CCK in this patientpopulation hasyetto be determined.

CCKcholescintigraphycanbeemployedasa noninvasivemeansofidentifying patients with sphincter of Oddi dyskinesia, as some willdemonstratea CCKcholescintigraphicpatternindicativeofthis disorderA delayin biliary-to.boweltransitandfailureofthe sphincterofOdditorelaxafterCCKinfusion(thedilatedcommonductsign)arethecardinalscintigraphicfeaturesof thisdysfunctionaldisorderof the biliarytree

The mostaccuratetest for the detectionof acutecholecystitisishepatobiliaryscintigraphy.Itssensitivityexceeds95%withouttheuseof CCK. However,pretreatmentwith CCK is oftenemployed to improvethespecificityofthistestinpatientswithsludgeintheirgallbladdersorin those who have been fasting or undergoing total parenteralfeedingfor prolonged periods.

False-positiveCCKcholescintigramswilloccurifCCKisnotinfused(continued on page 1684)

ITEMS 1—B:Lactulos.-H2 Breath TestingANSWERS:1,T;2,F;3,T;4,T;5,TKingandToskeshavereviewedcarbohydrate.H2breathtestingfordetecting bacterialovergrowthand compared thesetestswith the 14C-xylosebreathtestandintestinalculture.AlthoughH2breathtestsareattractivebecauseof theireaseofperformanceandnonradioactivenature,theyare both inadequately sensitiveand specific. H2 breath tests are alsoaffectedby a numberolfactorsthatmakethcir interpretationproblematic.Cigarettesmoking within 1 hr beforethe test elevatesbreath H2;diarrheaandpriortreatmentwithantibioticsandenemasimpairbacterialproductionofH2.AlthoughearlierstudiessuggestedthatonlyanoccasionalpatientmaylackH2-producingbacteria,it isnowappreciatedthatup to 30%of patientsmaynotgeneratesignificantH2withtheusuallyempla@d10.gleotulose.H2test;insuchpatients,30goflactuloseshouldbe administered. It also appears that as many as 30% of patientswithculture-provenbacterialovergrowthmayhaveelevatedlevelsofbreathH2 in the fasting state.

1. King cE, TOSI@SPP The use of breath tests in the study ofmalabsorption. C/inGastroenterol1983;12:591-610.

2. KingcE, ToskesPPComparisonofthe 1-gram[1@CJxy1os@10-gramlactuloseH2breathtestsin patientswithsmallintestinebacterialovergrowth.Gastroenterology1986:91:1447-1451.

1668 The Journal of Nuclear Medicine •Vol. 33 •No. 9 •September1992

SELF-STUDY TEST

GastrointestinalNuclear MedicineQuestions are taken from the Nuclear Medicine Self-Study Program I,

published by The Society of Nuclear Medicine

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SELF-STUDYTESTMedicineGastrointestinal

NuclearANSWERS

I 1. Tourassi GD, Gloyd CE Jr. Munley MI, Bowsher JE, Coleman RE.Improved lesion detection in SPECT using MLEM reconstruction. IEEETrans NuciSci 1991;38:780—783.

12.SnyderDL, Miller MI. Theuseofsievesto stabilizeimagesproducedwiththe em algorithms for emission tomography. IEEE Trans Nuclear Sd1985;NS-32:3864—3872.

13. Snyder DL, Miller MI, Thomas U ir, Polifte DO. Noise and edge artifactsin maximum-likelihood reconstruction for emission tomography. IEEETrans Med Imaging 1987;MI-6:228—237.

14. Lange K. Convergence ofEM image reconstruction algorithms with Gibbssmoothing. IEEE Trans Med Imaging 1990;9:439-446.

15. Nunez J, Liacer J. A fast Bayesian reconstruction algorithm for emissiontomography with entropy prior converging to feasible images. iEEE TransMed Imaging1990;9:159—171.

16. Lalush DS, Tsui BMW. A new Gibbs prior for maximum a posteriorireconstruction in SPECT [Abstractj. J NuciMed 199l;32:936.

17. Tsui BMW, Zhao XD, Lalush DS, Frey ED, Gullberg GT. Evaluation ofiterativereconstructionmethods for use in SPECTimaging[Abstract].JNuciMed 1991;32:937.

18. Miller TR, Sampathkumaran KS. Digital filtering in nuclear medicine. JNuciMed 1982;23:66—72.

19. Sorenson JA, Phelps ME. Physics in nuclear medicine, second edition.

(continuedfrompage 1668)

Orlando: Grune and Stratton, Inc.; 1987:33 1—344,408—419,435—437,560.20. HoffmanEl, Ricci AR, vander SteeM, PhelpsME. ECAT 111—basic

design considerations. IEEE Trans Nuc/Sci 1983;NS-30:729—733.21. Miller TR, WallisJW. Fastmaximum-likelihoodreconstruction.J Nuci

Med 1992;33:1710—1711.22. King MA, LjungbergM, HademenosG, Glick SJ.A dual photopeak

window method for scatter correction [Abstract]. JNuclMed 199l;32:917.23. Miller Ml, RoysamB.Bayesianimagereconstructionfor emissiontomog

raphy incorporating Good's roughness prior on massively parallel processors. ProcNatlAcadSci 1991;88:3223—3227.

24. ButlerCS,Miller MI. Maximuma posterioriestimationfor SPECTusingregularization techniques on massively-parallel computers. 1991 IEEENuclear Science Symposium and Medical Imaging Conference, Santa Fe,NM, 1991:2001—2005.

25. McCarthy AW, Miller MI. Maximum-likelihood SPECT in clinical computation times using mesh-connected parallel computers. IEEE Trans NuciSci 1991;l0:426—436.

26. KaufmanL Implementingand acceleratingthe EMalgorithmforpositronemission tomography. IEEE Trans Med Imaging 1987;MI-6:37—51.

27. Rajeevan N, Penney BC, Byrne C. An accelerated 3D maximum likelihoodSPEd reconstruction. 1991 IEEE Nuclear Science Symposium and Modical ImagingConference,Santa Fe, NM, 1991:1963—1968.

slowlyovera 1-3 mmduration. Presumably,this is due to spasmof thecystic duct, which impairs emptying ofthe gallbladder andfalsely lowersthe gallbladderejectionfraction.Rfr.nc•s1. Pickleman J, Peiss AL, Henkin A, et al. The role of sincalide cholescintigraphy

in the evaluation of patients with acalcutous gallbladder disease. Arch Surg1985:120:693-697.

2. DeRidderP Fink-BennettD.Thedilatedcommonductsign.Apotentialindicatorof sphincter of Oddi dyskinesia. C/in Nod Med 1984;9:262-263.

ITEMS 10—12:PropertIes of CCKANSWERS:10,1; 11,F; 12,FCholecystokinin(CCK)isa33-amino@acidpolypeptidehormoneproduced by the duodenal mucosa in responseto fat, lipolyticproducts,aminoacidsand smallpolypeptidesin thesmallintestineItcausesthe galibladder to contract,thesphincterof Oddito relax,enhancesjejunal,ilealand, to a lesser extent, colonic motility, increases pyloric tone, andstimulatesthe secretionof pancreaticenzymesand bile.ThediffuseeffectsofCCKonintestinalmotilityexplainwhymanypatientsreport gurgling in the stomach―followingits injection. Itsactiveor cholecystokineticportionresidestotallyin itsC-terminaloctapeptidefragment.

Therearetwo commercialpreparationsofthe 33-amino-acid polypeptide cholecystokinin:Pancreozymin@vis produced by Boots Co., Ltd.,England,and Cholecystokinintmbythe KarolinksaInstitutein Stockholm.Bothsincalide,the C-terminaloctapeptide,and ceruletidediethylamine,the C-terminal decapeptide of cholecystokinin, are syntheticcholecystogogues.Sincalide(Kinevac@v)isproducedbySquibb&Sons,Inc.,andceruletidediethylamine(Tymtran'@)by AdriaLaboratories.Theireffectsonthegastrointestinalandhepatobiliarysystemareidenticaltothat of intact cholecystokinin.Rfrsncs1. Fink-Bennett D. The role of cholecytogogues in the evaluation of biliary tract

disorders. In: Freeman LM, WeissmannHS, eds. Nuclear Medicine Annual1985. New York: Raven Press: 1985:107-132.

ITEMS 13-IS and 17-20 False-PositiveSclntlgraphyforAcuteCholecystltlsANSWERS:13,T; 14,1@15,F; 16,1@17,1@18,1@19,T;20, FTheimagesinFigure1revealrapiduptakeoftheradiotracerbytheliver.Theintrahepaticandextrahepaticductsareseenby15mm.By30mm,thereistransitoftheradiotracerintotheduodenalsweep.However,thegallbladder is not visualizedthroughoutthe 60 mmofthe study.Hence,theremaybecompletecysticductobstruction(acutecholecystitis).Sincethe study wascarried out only to 60 mm,one cannot ascertainwhetherthegallbladdermayeventuallyvisualize(e.g.,onlychroniccholecystitis

may be present).Amongthe causesoffalse-positivestudies(i.e.,nonvisualizationofthe

gallbladder notdueto cysticduct obstruction)arean insufficientperiodoffasting and acutepancreatitis.Asmanyas50% of normal individualswhoare notfastedhavenonvisualizationofthe gallbladder Endogenousreleaseofcholecystokininandcontractionof thegallbladderfollowinga meal are presumed to preventgallbladder filling. A fast of at least 2hr, and preferably 4 hr is required before beginning cholescintigraphyto minimizethe effectof endogenous cholecystokinin.Prolonged fasting, for several days or more, such as may be encountered in postoperativepatientsor those receivingtotal parenteralfeeding, also maylead to a false-positivecholescintigraphic study, presumably becausethebilewithinthegallbladderisveryviscousor mixedwithsludge Undersuchcircumstances,it ishelpfulto administercholecystokinin30-60 mmbeforecholescintigraphy;thiswillcausecontractionofanormalgallbladder, which will then be in its refilling phase during the imaging study.It is generally agreed that acute pancreatitis may be a cause of nonvisualizationof the gallbladder, although controversyexists as to thepercentage of individuals with acute pancreatitis who will not havevisualizationof the gallbladder.

Sincenonvisualizationof the gallbladderat 60 mmmaybe due tochroniccholecystitisaswellasacutecholecystitis,severalapproacheshave been developed to distinguish betweenthem. Obtaining imagesup to 4 hr postinjectionhas been shown by many investigatorsto beuseful in separatingchronic cholecystitisfrom acute cholecystitis.Thegallbladder willeventuallyvisualizein patientswithchronic cholecystitissincethe cysticduct ispatent,althoughthe gallbladder may be scarredand sluggish. In patientswith acute cholecystitis,the cystic duct is virtually alwaysfunctionallyor anatomicallyobstructed, and the gallbladder will not visualize.

The false-positiverate for acute cholecystitis also can be reducedsignificantlyby medicating the patientwith a cholecystokininanalogue,or by useof morphinesulfateCholecystokiningivenintravenously(slowlyover 1-3 mm)emptiesa sludge-filledor distendedgallbladder,allowinga seconddoseof the hepatobiliaryagentto flowintothe gallbladder.lfthe cysticductisobstructed,thegallbladdercannotcontractagainstthe obstruction. Alternately,if the gallbladder fails to visualizeby 1 hr,0.04mg/kgmorphinesulfatedilutedin10mlofsalinemaybegivenintravenouslywith further imagingoverthe next30 mm.Morphine increasesthe tone of the sphincter of Oddi at the distal common bile duct. Theresultantincreasein pressurewithinthe biliarysystemisenough to overcomeapartialobstructionofthecysticduct,ortocausefillingofafibrosedgallbladder,thus bringing about earlier visualizationQfthe gallbladder.

(continuedon page 1695)

1684 The Journal of Nuclear Medicine •Vol. 33 •No. 9 •September1992

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(continuedfrompage1684)I

SELF-STUDYTEST I@ Gastrointestinal NuclearMedicineANSWERSChoy,

etal. havereportedan increasein specificityfor acutecholecystitis 4. WeissmannHS,SugarmanLA.BadiaJD,FreemanLM.Improvingthespecifici(from83% to 100%),compared to the use of delayed imaging without ty andaccuracyofTc-99m-IDAcholecystigraphywithdelayedviews.J Nucia lossof sensitivity. Med1980;21:P17.Occasionally,

it isdifficultto distinguishpooled activitywithinthe proximal duodenum from the gallbladder itself, or one may mistake pooled ITEMS 21—24: Factors Affecting 99mTc IDA Uptakeactivitywithinthe duodenumforthegallbladder.Intheseinstances,it ANSWERS:21,1@22,@ 23, F;24,Fisusefultoadminister200—300mlofwaterbymouth.Thiswillfacilitate Sincethe developmentof the originalIDAderivatives,work on theflushingofactivityfromtheduodenum,buthasnoeffectonthegallblad- molecularstructureof thesecompoundshasproceededin thedirecder.Sincethe duodenum isclearly identifiedin this patient,and activity tion of producing an agent with ideal biokinetics.The @mTcIDAagentswithinit isseento changeovertime,it shouldnotbe mistakenforthe arecarriedinbloodnonspecificallyboundtoplasmaproteins,particularlyga1lt@adderHenceimagingafteradministeringwatertothispatientwould albumin.Thelipophilicityofthecompoundisdirectlyrelatedtothelevelnot provide further useful information. of proteinbinding. Substitutionsof nonpolar groups on the phenyl ringRf•r.nc•s ofthemoleculemakeitmorelipophilic.Proteinbindingpreventsrenal1. Al-Sheikh W, Serafini A, Barkin J, Spoliansky G, Hourani M The role of excretion and promotes hepatic uptake. This is an important considera

hepatobiliaryscintigraphyin differentiatingacutecholecystitisfrom acute non- tion in the jaundiced patient where these agents compete for proteinbiliary pancreatitis.Am J Gastroenterol 1983;78:502-506. binding sites with bilirubin.

2. Bakar RJ, Marion MA. Biliaryscanning with Tc-99m-pyridoxylidene glutamate—Rf@ncestheeffect of food in normal subjects. [Concise Communication].J Nuci Med 1. LobergMD,NunnAD,PorterDW.Developmentofhepatobiliaryimagingagents.1977;18:793-795.

In:FreemanLM,WeissmannHS,eds.NuclearMedicineAnnual1981.New3.ChoyD,ShiEC,McLeanRG,HoschA,MurrayPC,HamJM.Cholescintigraphy York:Raven Press;1981:1-33.in

acute cholecystitis: use of intravenous morphine. Radiology 2. NicholsonRW,Herman KJ.ShieldsRA,TestaHJ.The plasma proteinbinding1984;151:204-207.of HIDA.EurJ NuciMed 1980;5:311-312.

12. Ell PH, Jarritt PH, Costa DC, et al. Functional imaging ofthe brain. SeminNuclMed 1987;17:214—229.

13. KuhI DE, Barrio JR. Huang SC, et al. Quantifying local cerebral bloodflowby N-isopropyl-p-I-l23-iodoamphetainine(IMP)tomography.JNuclMed 198223:196—203.

14. Sharp PF, Smith FW, Gemmell HG, et al. Technetium-99mHM-PAOstereoisomers as potential agents of imaging regional cerebral blood flow:human volunteer studies. JNuclMed l98627:l71—177.

15. LeeRGL,Hill IC, HolmanBL,etal. Predictivevalueofperfusiondefectsize using N-isopropyl-(I-l23)-p-iodoamphetamine emission tomographyin acute stroke. JNeurosurg 1984;61:449—452.

16. von Schulthess OK, Ketz E, Schubiger PA, et al. Regional quantitativenoninvasive assessment of cerebral perfusion and function with N-isopropyl-(I-123)..p-iodoamphetamine.JNuclMed 1985,26:9—16.

17.GemmellHG, SharpPF, SeasonJAO, et al. DifferentialdiagnosisindementiausingthecerebralbloodflowagentTc-99mHM-PAO:a SPECFstudy.J CompusAssist Tomogr1987;l1:398—402.

18.vanHeertumRL, O'ConnellRA. Functionalbrainimagingin theevaluation of psychiatric illness. Semin NuclMed 199l21:24—39.

19. Mountz JM, Foster NL, Ackermann RI, et al. SPECF imagingof moyamoya disease using Tc-99m-HM-PAO: comparison with computed tomographyfindings.JComputAssist Tomogr1988;12:247-250.

20. UedaT, KinoshitaK, WatanabeK, etal.Earlyanddelayedsinglephotonemission CT in various cerebral diseases using N-isopropyl-p-(I-123)-iodoamphetamine.Neuroradiology1988;30:123—131.

21. UedaT, KinoshitaK, WatanabeK, of al. Local cerebralblood flowmeasurement using 1-123 IMP SPECf in patients with cerebrovasculardiseases.NeurolMedChir(Tokyo)1987;27:4l5—421.

22. Takeuchi S, Tanaka R, Ishii R, et al. Cerebral hemodynamics in patientswith moyamoya disease. A study of regional cerebral blood flow by the‘“Xeinhalationmethod.SurgNeuroll98523:468-474.

23. BrunoA,AdamsHPJr,BilIerJ,etal.Cerebralinfarctionduetomoyarnoyadiseaseinyoungadults.Stroke1988;19:826—833.

24. Lord RS. Extracranial-intracranialbypass. In: Surgery ofocdusivecerebrovasculardisease.St. Louis;C. V. MosbyCo., 1986:395.

25. MatsusbimaY, Inaba Y. Moyamoyadiseasein children and its surgicaltreatment, introduction of a new surgical procedure and its follow-upangiograms. Childs Brain 1984;l 1:155—170.

Note:Forfurtherin-depthinformation,pleaserefertothe syllabuspagesincludedatthe beginningofNuclearMedicineSelf-StudyProgram I: Part I.

SPECT, Magnetic Resonance and Anglography in Moyamoya Disease •Ohashi et al 1695

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