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Nuclear Medicine Pediatric Assessment, Protocols, and Interpretation

Author: Mehdi Djekidel Editor: Krishna Kumar Govindarajan Updated: 2/5/2024 7:06:46 AM

Introduction

Pediatric imaging relies heavily on morphological imaging using mostly nonionizing radiation techniques such as ultrasound (US) and magnetic resonance imaging (MRI). Computed tomography (CT) and nuclear medicine (NM) techniques still hold value and are used in high-yield indications. Although nuclear medicine exams have been around for a century, it is only with recent software and hardware improvements that they have gained an impactful clinical role.

Even though the Society for Nuclear Medicine was founded in 1954, the pediatric nuclear medicine organization known nowadays as the Pediatric Council was only created in the 1970s; we can date to 1946 an NRC report in pediatrics looking at radioisotopes in thyroid pathology. The American medical association (AMA) recognized nuclear medicine as an independent specialty in 1971, leading to the creation of the American Board of Nuclear Medicine (ABNM). The various modalities of nuclear medicine in children have led to prompt diagnosis, selection of appropriate procedures, and treatment resulting in improved outcomes.

Anatomy and Physiology

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Anatomy and Physiology

Children do not act as a scaled-down version of adults. They are unique in terms of anatomy, physiology, and pathology. The biology can be different even within the same disease type. For similar pathology, age can also be a critical prognostic determinant. Radiation exposure is a concern in pediatrics compared to adults. It is felt that children depending on their age, might be slightly more radiosensitive. Additionally, some nuclear medicine procedures evaluate physiological changes in vivo and real-time as they occur through pharmacologic interventions.

In other cases, nonradioactive drugs are used to prepare the patient and optimize radiopharmaceutical uptake for a specific study. There should also be special attention to potential interfering drugs with the uptake mechanism of the radiopharmaceutical. Examples of non-radioactive medications used for the preparation or during the exam include furosemide, acetazolamide, phenobarbital, cholecystokinin analog, angiotensin-converting enzyme inhibitors, adenosine analogs, and dobutamine.

Indications

Nuclear medicine techniques are highly sensitive. They play a major role in several instances in pediatrics. The major aspect that needs to be considered is that they are used as a standard of care or problem-solving tool, occasionally both, and how they will guide clinical management. The key indications for nuclear medicine techniques are the evaluation of:

  1. Lymphoma
  2. Sarcoma
  3. Neuroblastoma
  4. Pheochromocytoma and paraganglioma
  5. Miscellaneous tumors
  6. Thyroid cancer
  7. Congenital hypothyroidism
  8. Hyperparathyroidism
  9. Chronic urinary tract infections and kidney scarring
  10. Vesicoureteral reflux and scarring
  11. Obstructive uropathies
  12. Lymphodysplasias
  13. Biliary atresia
  14. Myocardial ischemia
  15. Meckel's diverticulum
  16. Medically refractory epilepsy
  17. Encephalitis
  18. Brain tumors
  19. Child abuse
  20. Lung perfusion pathology
  21. Gastrointestinal motility disorders
  22. Chronic microaspirations
  23. Gastroesophageal reflux
  24. Fever of unknown origin
  25. Evaluation of infectious foci/device infections

Contraindications

Nuclear medicine scans are very safe as the radiopharmaceutical contains a trace amount of the biological compound and therefore has no pharmacological effect. Contraindications would relate to the appropriateness of the test ordered according to the latest guidelines and appropriateness use criteria.

Other contraindications would be related to the use of sedation which is frequently needed in pediatrics. Additionally, when performed, close attention should be paid to any contraindications specific to administering a medication required for the test, including a pharmacological stressor, vasodilator, diuretic, or an angiotensin-converting enzyme inhibitor, or other.

Equipment

The latest equipment should be obtained. This is especially critical in pediatrics as newer scanners offer much higher temporal and spatial resolutions at lower injected doses, minimizing radiation exposure to the patient. Following strict quality control protocols in the radiopharmacy and the scanner, rooms are critical in delivering the highest quality and safe patient care.

Proper planned maintenance and upkeep of the nuclear medicine equipment is also essential in order to avoid equipment failures and artifacts that may affect the interpretation of studies. The latest total-body PET scanners offer the potential of imaging with a radiation exposure equivalent to a chest X-ray.[1][2][3] This is likely to be valuable and transformative in pediatric oncology patients that may require multiple successive scans to assess response to treatment and monitor disease progression.

Personnel

Fully trained, board-certified, and licensed nuclear medicine technologists under the supervision of a qualified, licensed, and board-certified nuclear medicine physician oversees the full spectrum of pediatric nuclear medicine. Specific expertise in pediatric nuclear medicine is also important. Certified child life specialists are an integral part of the care team. Qualified pediatric nurses are important for difficult intravenous access and for studies that require the administration of medications.

The anesthesiologist and anesthesiologist technologist play an important role in adult nuclear medicine practice that requires very rarely any sedatives. Proper communication between all these team members and advanced group coordination and planning for challenging cases is necessary.

Preparation

Preparation for an exam in pediatric nuclear medicine involves several aspects:

  1. As a rule, proper hydration is essential to optimize the study itself and decrease radiation exposure since hydration enhances rapid clearance of the radiopharmaceutical.
  2. Specific preparation will depend on the study performed and the radiopharmaceutical administered. For example, fasting for 4 to 6 hours is required for certain studies such as FDG PET (positron emission tomography) scans. However, this fast may be shortened to 2 or 3 hours in babies and for HIDA scans and gastric emptying studies.
  3. Special attention should be made to withhold any interfering medications.
  4. Child life involvement is frequently needed before the test to alleviate the child and family's anxiety and assist with the exam.
  5. A visit to nuclear medicine before the scan day and a tour of the scan room by the child may help prepare the child for the test.
  6. Making sure toys, snacks, ambiance, mood, relaxing music, and atmosphere are available is essential.
  7. Distraction devices are helpful in babies and younger children.
  8. Making sure that safe immobilization devices are available. This includes head holders or straps fitted to the patient's size; otherwise, they will not be effective.  
  9. Informing the anesthesia team and other team members of the specific requirements of the nuclear medicine test allows for a smooth and safe workflow on the day of the test.

Technique or Treatment

Over the past decade, nuclear medicine has witnessed significant advances in software, hardware, and novel radiopharmaceutical approvals. This includes SPECT, PET, and hybrid imaging. Many of these advancements have improved the quality of nuclear medicine imaging in children. The field has benefitted from a higher sensitivity and lower radiation exposure in pediatrics.

In children, the acquisition and reconstruction protocols require to be closely monitored. Lower doses may require longer acquisition times. A good balance between dose and imaging time is needed. Motion has to be closely monitored. Strapping, swaddling, and use of varying levels of sedation may be required. Involving the parents and child life experts is essential. Dynamic imaging may be useless if affected by artifacts and cannot be repeated without adding another radiopharmaceutical dose to the patient.

Using the latest software with at least half-time acquisitions and iterative reconstruction techniques is necessary when available. Special expertise is needed to optimize and not hinder quality. Knowledge of all these techniques and how they apply to each patient and what factors may affect them is essential.

Complications

Radiotracers have a very high safety profile because the active component used to target the specific biological process is present in trace amounts. Complications can be related to the intravenous cannulation process. The radiopharmaceutical injection rarely may cause a rash or swell at the injection site in case of extravasation. Very rarely, headaches and nausea have been reported. Additionally, complications/adverse events related to medication injected as a part of the procedure may be encountered, such as acetazolamide, dobutamine, adenosine, captopril, furosemide, and others.

Clinical Significance

Nuclear medicine techniques play an important role in the care of pediatric patients. They can diagnose, change management, monitor progression and assess response to therapies.[4][5][6] One should note that children are not small adults, and they frequently require adjustments.

  1. Time requirements: Nuclear medicine exams require at least 2 to 3 times the time it takes to perform a similar test in adults. Therefore, proper planning and scheduling are required, especially in a medical practice with a mixed adult and pediatrics patient population, to avoid mistakes in scheduling and allow for the proper time to perform the test.
  2. Early team involvement (child life, nursing, and anesthesia) in difficult cases.
  3. Proper understanding that there is a spectrum of findings in normal--negative exams. This ranges from a typical/textbook normal to a normal variant versus atypical normal.
  4. Proper understanding that there is a spectrum of findings in abnormal--positive exams. This ranges from a typical/textbook abnormal to an abnormal variant versus atypical abnormal.
  5. This spectrum knowledge is critical to avoid confusion every time an atypical presentation occurs.
  6. Proper understanding of the indication of the nuclear medicine exam. Some exams are ordered as a standard of care in all patients with similar pathology. At the same time, others are ordered as problem-solving tools. At other times both apply.
  7. Appropriate use criteria: Because nuclear medicine exams involve exposure to ionizing radiation, it is essential to follow the best medical practice, guidelines, and appropriate use criteria as defined by leading medical societies and the literature.[7][8][9][10]
  8. Optimized scanning time: Because children cannot lay still for the duration of scans, anesthesia may be used at times. Choosing the most appropriate imaging protocol that will provide diagnostic value in the least amount of time is needed. Purchasing the latest technology scanners will allow diagnostic quality imaging with a rapid scanning time with the equivalent of a chest X-ray or lower radiation exposure dose.[1][2][3][11]
  9. Optimized radiopharmaceutical activity: Purchasing the latest technology scanners will allow diagnostic quality imaging at very low radiopharmaceutical doses, the equivalent of a chest x-ray, or lower radiation exposure dose.[1][2][3][11] The image gently campaign was developed in late 2007 and since then has been advocating for lower radiation doses in nuclear medicine and diagnostic radiology. This campaign was accompanied by a harmonization in the injected radiopharmaceutical activities in pediatrics aiming for the ALARA principle.[12][13] As low as reasonably achievable to get a diagnostic scan. The clinical shift occurred from pretty images to diagnostic images with no artifacts.[14]
  10. Benefits/risk estimate: Physicians should carefully weigh the benefit-risk ratio before ordering an exam, as with any procedure or test. The benefit of using diagnostic and therapeutic nuclear medicine techniques in pediatrics is huge when best medical practice and guidelines are followed.  
  11. Indications:
  1. Lymphoma: 3rd most common malignancy in children. There are mostly two types: Hodgkin's lymphoma and non-Hodgkin's lymphoma. Better outcomes are noted in children compared to adults. However, long-term complications from treatment are center stage. Therefore, de-escalation treatment regimens are being explored that would improve outcomes and decrease immediate and late adverse effects. The role of FDG-PET is established in pediatric lymphomas and has become the standard of care in pediatric Hodgkin lymphoma initial staging, restaging, and response to therapy assessments.[15][16] Early PET response in HL is an important prognostic indicator. Newer protocols use dynamic response assessments with FDG PET to modulate therapy or deescalate treatments. This latter is a crucial element to decrease long-term adverse effects from anti-cancer treatment.[17][18][19][20][21][22][23]
  2. Sarcomas: Bone sarcomas account for approximately 6 percent of all childhood cancers, and osteosarcomas account for approximately 3 percent of childhood cancers overall. Bone scans can be used to evaluate multifocal disease. However, this is being replaced nowadays with FDG PET-CT scans for staging and restaging assessments. Although whole-body MRI (magnetic resonance imaging) is the mainstay of imaging, it may have some limitations at follow-up with prostheses artifacts and assessing response to treatment. A CT scan with thin slices is required to monitor for any lung metastasis. FDG PET-CT is very good at initial staging, restaging, therapy response assessments, and reports showing sensitivity and specificity in the '90s. One should pay close attention to the PET-CT protocol used and adjust the attenuation correction CT protocol to be able to detect small lung nodule metastasis. This is crucial considering the lung is the site of 80% of metastasis.[24][25][26] Quantitative parameters such as metabolic tumor volume and total lesion glycolysis may be best used to assess response to treatment.[27] FDG PET at 6 weeks can predict neoadjuvant chemotherapy effect on time to progression and pathologic response. FDG PET was also described to be of prognostic value.[28][24][29][30][31][24] The Children's oncology group recommends FDG PET and or SPECT Bone scanning at initial diagnosis and before any surgery or local control intervention. FDG PET or SPECT bone scanning is also recommended at follow-up surveillance on chemotherapy or post-chemotherapy patients if symptoms arise or if metastatic disease is present on a prior scan.
  3. Neuroblastoma: Represents 10% of solid tumors in children. It is the most common extracranial solid tumor.[32] 123-I Metaiodobenzylguanadine (MIBG) is used in conjunction with MRI or CT to stage these patients. MIBG is structurally similar to norepinephrine and concentrates in secretory granules of catecholamine-producing neural crest cells. It has high sensitivity and specificity of up to 90%.[33] Using the latest hybrid imaging SPECT-CT techniques is recommended.[34] Bone scans are rarely used nowadays but may be helpful if MIBG or PET radiopharmaceuticals are not readily available. Novel PET radiopharmaceuticals such as Iodine 124 MIBG, 18F FDOPA, and 68Ga DOTATATE show higher sensitivities and specificities.[35][36][37][38][39] The higher spatial resolution of PET imaging also allows for improved dosimetry when radionuclide therapies are contemplated.[40][41] FDG PET is also used in MIBG negative cases and may offer some prognostic value.[42][43][44] Considering the heterogeneity of the disease, combining two radiopharmaceuticals may potentially play an important role.[45] A novel fluorinated MFBG PET imaging probe is shown to be almost twice more sensitive than Iodine123 MIBG on a lesional analysis basis.[46]
  4. Pheochromocytoma/paraganglioma: These are rare pediatric tumors. Pheochromocytomas usually arise from the adrenals and paragangliomas from extra-adrenal locations. Pheocromoyctomas frequently will secrete catecholamines, and paragangliomas are quite variable. About two-thirds are sporadic, but several germline mutations have been described, such as RET, SDHD, SDHB, SDHC, SDHAF2, or SDHA, VHL, TMEM127, or MAX genes.[47][48][49] MIBG scans have traditionally been used to evaluate pheochromocytoma and paragangliomas. The overall limited accuracy has been partially overcome by the use of novel hybrid SPECT-CT techniques. However, newer techniques using PET radiopharmaceuticals are more sensitive and should preferably be used when available. FDG PET scans seem to be superior in patients with SDH mutations, and FDOPA scans are superior in non-SDH mutations.[50] FDA or FDG PET would be preferable for staging paragangliomas with RET mutations.[51] Alternatively, Gallium DOTATATE can be used with high accuracy to stage SDH-related paragangliomas located in the head and neck region. Some reports have also suggested the overall superior sensitivity on a lesional basis in paragangliomas in general.[50][52][48] In Pheochromocytomas, FDOPA and FDG are superior. Considering the heterogeneity of disease and lesions and considering the Theranostic paradigm using different radiotracers in the same patient may hold additional value.[53][54][52][55] MFBG, a newer PET analog to MIBG, demonstrates superior sensitivity and accuracy to the traditional SPECT MIBG scans with about twice the amount of lesions detected.[46][56][57] Further larger studies with pooled data from multiple centers are necessary to further elucidate the preferred radiopharmaceutical in a complex mutational landscape.
  5. Miscellaneous tumors: FDG PET scans are proven to be highly accurate in staging and restaging gastrointestinal stromal tumors and mixed germ cell tumors.[58][59][60][61][62][63] On the other hand, neuroendocrine tumors and insulinomas are easily characterized and staged with Gallium DOTATATE.[64][65][66][67] Note should be made that Gallium DOTATATE could be most of the time interchangeable with other similar Gallium DOTANOC, DOTATOC, or copper-based somatostatin receptor-based ligands.
  6. Thyroid cancer: Thyroid cancer is uncommon in children compared to adults. Papillary thyroid cancer is the most common type. Although locoregional lymph node and distant metastasis are more frequent than in adults, the prognosis is significantly better, and survival rates are extremely high even with distant metastasis with appropriate treatment.[68] Iodine scans with or without SPECT-CT and ultrasound are the standard imaging techniques.[69][70][71][72] The non-iodine avid disease can be imaged successfully with FDG PET.[73][74][75] Medullary thyroid cancer is rare but is best served by using FDOPA PET for staging and restaging when calcitonin levels are higher than 100 pg/ml.[74][76]
  7. Congenital hypothyroidism: Pertechnetetate scan is a fairly simple exam to perform. It can pretty accurately distinguish between several etiologies: athyrogenesis (no thyroid uptake), ectopic thyroid/lingual thyroid (uptake is noted outside the expected thyroid bed/lower neck), and thyroid hormone dysgenesis (normal thyroidal uptake). 
  8. Hyperparathyroidism: Hyperparathyroidism is rarely encountered in pediatrics and can be evaluated by a sestamibi scan. It can localize parathyroid adenomas. Precise localization in a eutopic or ectopic location can be obtained using hybrid imaging techniques.
  9. Chronic urinary tract infections and kidney scarring: DMSA scan with planar and SPECT imaging is the most sensitive technique currently available for clinical use to evaluate kidney scarring.[77][78][79][80][81] An initial report with PSMA PET has been published, although this is expensive and not widely available. PSMA PET is also not FDA-approved yet.
  10. Vesicoureteral reflux and scarring: A DMSA scan is also quite effective in detecting renal scarring in patients with vesicoureteral reflux.[82][83] 
  11. Obstructive uropathies: Ultrasound is the imaging of choice for patients' initial evaluation and follow-up with suspicion of obstructive uropathy. However, diuretic renograms are frequently used to confirm an obstruction and risk-stratify dilated collecting systems.[84][85] 
  12. Lymphodysplasias: Lymphoscintigrams with or without newer hybrid imaging SPECT-CT techniques are simple and accurate studies to evaluate abnormalities of the lymphatic system. It involves the intradermic, more or less subcutaneous injection of a colloid radiopharmaceutical. Indications include congenital lymphodysplasias, lymphedema, lymphatic leaks, lymphangiomas, lymphangiomatosis, Gorham Stout disease, and lymphangiectasia.[86][87][88][89][90][91] It is also helpful in the evaluation of chyluria, chyloperitoneum, and chylothoraces. Protein-losing enteropathies are more effectively evaluated using an HSA scan.[92][93][94][95]
  13. Biliary atresia (BA): Biliary atresia is deadly without early surgical intervention (Kasai procedure). Optimal outcomes occur when surgery is performed before 45 days of life. Delay in diagnosis can be accompanied by complications such as cirrhosis, portal hypertension, liver failure, a decrease in the success rate of the Kasai procedure, and even death. HIDA scans/hepatobiliary scans evaluate uptake in the liver as well as the hepatobiliary system. Radiopharmaceutical excretion into the bowel excludes BA. Proper preparation with phenobarbital 5-7 days before the scan is essential.[96][97][98][99][100] Jancelewicz et al. reported in a cohort of 212 babies (45 with BA) that a normal percutaneous cholangiogram, bowel excretion on a HIDA scan, and blood work variables consisting of a GGT <150U/L and conjugated bilirubin <2.5mg/dL excluded BA with a 100% sensitivity.[100]
  14. Myocardial perfusion: Cardiac MRI, echocardiography, and cardiac CT are the mainstays of pediatric imaging. Anatomical information is essential in cardiac congenital anomalies. MRI is nowadays able to provide reproducible stress-induced functional parameters. However, nuclear medicine myocardial perfusion imaging can still be used as a problem-solving tool. It is seldom needed but can be helpful to evaluate for ischemia and risk stratify patients alone or in combination with MR. Common indications are congenital heart disease repair, Kawasaki disease, hypoplastic heart, anomalous origin of the coronaries, coronary bridging, cardiac transplants, and other cardiomyopathies. SPECT or PET can be used with pharmacological stress. Although PET offers the advantage of absolute myocardial blood flow quantification, this should be used with caution, and proper expertise in children should be sought as normal values are quite different and higher compared to adults.[101][102][103][104][105][106][107][108]
  15. Meckel diverticulum: Meckel scan is a simple and highly accurate test to evaluate Meckel diverticulum with a reported sensitivity and specificity in the mid-'90s.[109] In the few negative cases with high clinical suspicion, a repeat exam may have an additional value in detecting the Meckel's diverticulum.[110] The addition of novel hybrid imaging techniques with SPECT-CT can be, in some cases, of additional value.[111]
  16. Medically refractory epilepsy: Nuclear medicine techniques are valuable in the presurgical workup of medically refractory epilepsy patients. Cerebral blood flow (CBF) SPECT and FDG PET imaging are essential exams to delineate the seizure onset zone (SOZ) required to be resected. Successful SOZ localization is needed for postsurgical seizure freedom. In patients with a clinical semiology amenable to CBF imaging, ictal-interictal subtraction offers accuracy in the '90s. Inter-ictal FDG PET imaging is also very useful in MRI negative cases to detect the SOZ. In MRI-positive cases, FDG PET delineation of the SOZ has also been reported to correlate with outcomes. 
  17. Encephalitis: FDG PET is the most sensitive imaging technique to evaluate brain changes in encephalitis. It can also be used to monitor treatment response and metabolic brain changes in cases that later on develop epilepsy.[112][113][114]
  18. Brain tumors: MRI is the gold standard and workhorse of imaging in pediatric brain tumors. However, in some cases, MRI fails to fully characterize a lesion. Aminoacid imaging with C11-methionine, FDOPA, or FET PET can be used as a problem-solving tool in differentiating radiation necrosis changes versus recurrence in radiation treatment planning, defining the surgical extent, and guiding biopsies.[115][116][117][118][119][120] 
  19. Child abuse: Non-accidental injury in babies and children is a challenging clinical conundrum. Diagnosis is crucial, and a high suspicion should always be maintained. Bone scan offers a high sensitivity exam that adds value as an adjunct to the traditional skeletal survey.[121][122][123][124][125][126] Bone scans can also be used in additional pathologies such as sports injuries, scoliosis, trauma, back pain after surgery, osteoid osteoma, and Langerhans histiocytosis. Fluoride PET bone scans offer a high resolution and may replace the traditional bone SPECT scan when available.[127]
  20. Lung perfusion pathology: Pulmonary artery anomalies and congenital cardiac malformations can be evaluated with MAA scans. Lung perfusion can be evaluated before and after an intervention.[128][129][130][131] Ventilation-perfusion scans can be used to assess unilateral hyperlucent lung.[132][128] 
  21. Gastrointestinal motility disorders: Delayed gastric emptying is frequently encountered in children. Solid or liquid-based gastric emptying studies can be used to assess gastric emptying.[133][134][135][136] The solid-based protocol is the most sensitive and preferred when the child can tolerate eating solid foods. Otherwise, the liquid-based protocol is more frequently used as pediatric patients frequently have feeding tubes. The gastric emptying liquid is also used in babies and very young children.
  22. Chronic microaspirations: Patients with chronic microaspirations have frequent repeated pulmonary infections. Salivagrams are relatively easy nuclear medicine tests that require little preparation and can detect microaspirations.[137][138] One drop of Technetium sulfur colloid or DTPA is administered on the tongue of the child/baby. Visualization of radiotracer accumulation in the lungs is consistent with aspiration. Using a technique administering 3 drops serially has a higher yield and sensitivity in detecting aspirations. Kim et al. showed that salivagrams and videofluoroscopic exams are complementary in detecting aspirations.[139] On the other hand, it showed that in 290 children, indwelling nasogastric tubes did not affect the positivity rate of salivagrams compared to pediatric patients without nasogastric tubes.[140]
  23. Gastroesophageal reflux: In contrast to salivagrams, gastroesophageal reflux studies or milk scans are also used to detect pulmonary aspiration. Jigang et al. compared both techniques in a cohort of 4186 patients and concluded that salivagrams have a much higher detection rate of 20.3% vs. 0.4% for gastroesophageal reflux studies.
  24. Fever of unknown origin: A variety of etiologies can be explored using FDG PET scans ranging from systemic inflammatory conditions, rheumatologic diseases/vasculidities, infectious processes, and oncology pathology.[141][142][143][144][145][146][147] Additionally, FDG PET scans are useful in evaluating conditions with increased inflammatory markers, even in the absence of fever. FDG PET scans can be used to evaluate response to therapies as well.
  25. Evaluation of device infections: FDG PET scans are used to evaluate cardiovascular devices and implanted musculoskeletal hardware.[148][149][147][150][151][152] They have demonstrated very high sensitivity and specificity.[153] It has been shown to be superior to echocardiography and cardiac CT. It has also been shown to be prognostic and correlates well with outcomes.[154][155] In contrast, white blood cell scans can also be used in the absence of FDG PET availability and, when used with hybrid imaging, SPECT-CT techniques offer high sensitivity, high specificity, and high reader confidence.[156][157]

Enhancing Healthcare Team Outcomes

Pediatric nuclear medicine is a niche field and requires expertise for optimal outcomes. Appropriate use of nuclear medicine exams and their impact on clinical management obviates concerns about radiation exposure. Highly skilled experts such as child life specialists, pediatric anesthesia technologists, pediatric anesthesiologists, pediatric nuclear medicine technologists, pediatric nurses, and pediatric nuclear medicine physicians are needed.

Proper communication and planning are essential. Following best medical practice and society guidelines is paramount. Standardized, harmonized protocols must be followed. An integrated simple and advanced collaborative pathway and constant case discussions between the nuclear medicine team and referring pediatricians and pediatric subspecialists (in oncology, surgery, neurology, neurosurgery, urology, nephrology, rheumatology, gastroenterology, and orthopedics) will deliver optimized outcomes. [Level 3, 4, and 5]

Media


(Click Image to Enlarge)
Encephalitis FDG PET
Encephalitis FDG PET Contributed by Djekidel Mehdi MD

(Click Image to Enlarge)
FDOPA Brain Tumor
FDOPA Brain Tumor Contributed by Djekidel Mehdi MD

(Click Image to Enlarge)
Rasmussen Encephalitis
Rasmussen Encephalitis Contributed by Djekidel Mehdi MD

(Click Image to Enlarge)
TLE Epilepsy
TLE Epilepsy Contributed by Djekidel Mehdi MD

(Click Image to Enlarge)
DMSA scan in pediatrics
DMSA scan in pediatrics Contributed by Mehdi Djekidel MD

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