SCINTILLATION SCANNING IN PEDIATRICS

(1)

(Submitted August 5; revision accepted for publication October 29, 1965.)

ADDRESS: (C.K.) Department of Radiology, Albert Einstein College of Medicine, Eastchester Road and

\Iorris Park Avenue, New York 61, N.Y.

PEDIATRICS, Vol. 37, No. 5, Part I, May 1966 794

SCINTILLATION

SCANNING

IN PEDIATRICS

Chester

Kay,

M.D.,

Leonard

Freeman,

M.D.,

and

Norman

Avnet,

M.D.

Department of Radiology, Albert Einstein College of Medicine, Yeshiva University

W

HILE

it

has

been

possible

to

count

gamma

rays

electronically

since

1908,

when

the

Geiger

tube

was

developed,

it was

not

until

Cassen,

et al.1

developed

a

scintillation

counter

in

1950

that

modern

scintillation

scanning

became

possible.

The

heart

of

a scintillation

counter

is a crystal,

usually composed of sodium iodide

acti-vated

by

thallium,

coupled

to a

photomulti-plier

tube.

When

a gamma

ray

strikes

this

crystal

a

flash

of

light,

or

scintillation,

occurs.

This

scintillation

is

converted

into

an

electrical

pulse

by

the

photomultiplier

tube.

The

intensities

of

both

the

scintilla-tion

and

the

electrical

pulse

are

propor-tional

to

the

energy

of

the

gamma

ray.

Gamma

rays

emitted

by

a radioisotope

have

specific energies.

A

pulse

height

analyzer

and

discriminator

is included

in

most

scm-tillation

counters,

permitting

them

to count

only

the

gamma

rays

emitted

by

the

isotope

in

question

and

to

reject

gamma

rays

of

other

energies.

Further

developments

have

greatly

im-proved

the

methods

of

obtaining

and

re-cording

information

derived

from

the

pa-tient.

The

radiation

detector

is passed

over

the

portion

of

the

body

in

question

and

records

by

means

of

dots

on

x-ray

film

or

specially treated paper the intensity of

radi-ation

in

the

target

organ.

Presently

tinder

intensive investigation are

additional

re-finements such as increasing the effective

crystal size and developing new

radionu-clides

with

short half-lives, minimal beta

emission,

and

weaker

gamma

rays.

In

most

forms

of

scintillation

scanning

the patient is given a compound containing

a

radioisotope

which

concentrates

selec-tively

in

an

organ. Certain types of lesions

in

the

organ

do

not

concentrate

the

radio-isotope,

resulting

in

“filling

defects”

in

the

scan

of

that

organ.

In

some

cases,

such

as

in

brain

scanning

with

chlormerodrin-labelled

mercury197,

the

nuclide

is

con-centrated

by

abnormal

tissue

rather

than

by

normal

surrounding

tissue.

The

patient

must

lie

quietly

during

the

procedure. In some patients

mild

sedation

is used. The purpose of this paper is to call

attention

to

the

applicability

of

newer

scintillation

scanning

techniques

for

specific

organs in

the

pediatric

patient.

Thyroid

and

spleen scanning have been described

ade-quately elsewhere.2, 3

LIVER

SCANNING

Colloidal

gold98

is presently

the

agent

of

choice

for

scanning

the

liver.

It

has

a 2.7

day half-life and on disintegration produces

beta

particles

and

gamma

rays.

The

isotope

is injected intravenously in its metallic form

suspended

in

a colloidal

solution.

Colloidal

radiogold

is

insoluble,

inert,

and

in

the

dose

administered

for

scanning

shows

no

acute

toxicity.

The

dose

used

is 2.5

&c/kg

of

body

weight.

The

particles

are

phago-cytized

by

the

Kupffer

cells

of

the

liver

and

to

a lesser

extent

by

other

reticuloen-dothelial

cells.

A

non-functioning

area

in

the

liver

will

produce

a filling

defect

on

the

scan.

In

adults,

the

procedure

is used

pri-manly

for

the

evaluation

of

mass

lesions,

cirrhosis, hepatomegaly of uncertain

etiol-ogy, and in the preoperative evaluation of

cancer patients where hepatic metastases

are suspected. Diagnostic accuracy has

been

high.4

However,

present

techniques

do

not

usually

permit

detection

of

lesions

less than 2 cm in diameter. We scan

pa-tients

in

the

supine

and

right

lateral

pro-jections

whenever

a

mass

lesion

is

sus-pected.

(2)

how

scanning

of liver

can

play

an important

role

in

the

clinical

evaluation

of

mass

le-sions

in children.

CASE

I

C. V., a white female, presented at the age of 1 1 months with a history of abdominal swelling.

Her mother first noted the child’s abdominal

prom-inence at the age of 3 months. There were no

gastrointestinal or genitourinary 5Vn11)toI1s. Body

weight gain continued at a normal rate along the

25th percentile. The patient was referred to the

Bronx

Municipal

hospital Center because of an upper respirators’ tract infection.

Physical examination revealed an alert, active

child with a 15 15 cm firm mass filling the

right tipper quadrant and crossing the midline.

Hemogram, urinalysis, serum sodium, potassium,

chloride, and liver function studies were within

normal limits. Her bone marrow was normal. A

suI)ine film of the abdomen showed a large,

non-calcified mass displacing

the

stomach to the left,

and the transverse colon inferiorlv. An intravenous

urogram demonstrated normally positioned kidneys.

An aortogram showed abnormal vessels traversing

the iiass (Fig. 1). These suggested a malignant

lesion, 1)055ib1V a neuroblastona. Liver scan

utiliz-ing 24 zc of colloidal go1i’’ demonstrated a large

lesion partitlly replacing the right lobe of the liver,

and pushing the remainder of functioning hepatic

tissue to the left. A rim of functioning tissue was

preseit on the photoscan. We interpreted the mass

as originating in the liver.

At surgery, a large mass was noted in the right

(3)

FIG. 2. Above left, aortogram showing depression of the right renal artery (arrow) and draping of

vessels around the mass. Above right, later film from the aortogram showing abnormal vessels and

‘puddling within the mass. Below left, supine liver scan demonstrates replacement of hepatic tissue

in the inferior portion of the right lobe of the liver (arrow). Below right, lateral scan showing invasion

of the posterior and inferior portion of the hepatic parenchvma (arrow).

a hamartoma with several large cysts. The right

lobe

of

the liver was resected. The child was doing well 1 1 months after surgery.

CASE

II

K. L., a 9h-month-old male, presented with an

enlarging abdominal mass of uncertain duration.

The mother noted that the child had been anorec-tic, but there was no other history of genitourinary

or gastrointestinal complaints. The patient

ap-peared eniaciated, pale, and had a large, irregular,

firm abdominal mass which occupied both the

right and left upper quadrants. Hematocrit was

21%. Liver function studies were normal except for an elevated prothrombin time. Serum sodium,

p0-tassium, and chloride were nornal. A supine film

of the abdomen showed a large, non-calcified mass depressing the colon and pushing the stomach to

the left. An intravenous urogram demonstrated

in-ferior displacement of the right kidney with

ex-trinsic pressure on its upper calyx. A bone survey

was unremarkable. Bone marrow examination

showed a nornial distribution of hematopoeitic

cells with no tumor cells present. An aortogram

revealed depression of the right renal artery and

displacement of the aorta toward the left. The

suprarenal artery was depressed and gave rise to

abnormal vessels, suggesting a neuroblastoma (Fig.

2). A large part of the mass was avascular. A liver

scan using colloidal goldl9s demonstrated a mass in

the posterior part of the right lobe of the liver.

Surgical exploration disclosed ascites and a large

suprarenal mass which infiltrated the liver. Only

a biopsy was performed. This was interpreted as

neuroblastoma. The child (lid poorly

postopera-tively and expired 6 days after surgery.

CARDIAC

POOL

SCANNING

Angiocardiography,

successfully

per-formed

by

Nuvoli

in

1936,

has

become

an

accepted

technique

for

the

diagnosis

of

pericardial

effusion.

In

1958,

Rejoli,

et al.

(4)

radio-ARTICLES

Fic. 3. Photoscan superimposed on chest film. Note

symmetric enlargement of the cardiac silhouette

aroun(l the vascular l)001 of the heart in this

pen-cardial effusion.

iodinated

luiman

serum

albumin.*

Follow-mug

intravenous injection, the isotope

re-mains in the

blood

sufficiently

long

to

permit

a scan

of

the

chest

and

upper

ab-domen. This outlines the vascular

compart-ment of the heart and the upper part of the

liver. The scan is superimposed upon

a 6 ft

supine chest film. The vascular

compart-ment

of the

heart

on

the

scan

is compared

to

the

size

and

shape

of

the

cardiac

sil-houette

on

the

radiograph.

The

apposition

of cardiac and hepatic pickup is also noted.

The

dose

of

5

/tC

of

IHSA

per

kilogram

of body weight is preceded by 30 drops of

Lugol’s solution administered in 3 divided

doses orally the day before the scan to

block the thyroid’s uptake of radioactive

iodine. The technique is easy and safe and

delivers

little

whole

body

radiation

to

the

child.

Accuracy

is high.7

CASE

III

C. C., a 1-month-old white male, was admitted

to a nearby hospital with lethargy and respiratory

difficult of 1-month duration. He was an acutely

ill, febnile infant who had tachypnea and nuchal

rigidity. Lumbar puncture revealed cloudy

cere-brospinal

fluid

with many leucocytes. Blood

cul-#{176}IIISA or EISA, Squibb and Company, New

York, New York.

tune drawn at this time grew Hemophilus influenza, Type B. Chest x-ray was normal. The meningitis responded well to penicillin, chloramphenicol, and sulfisoxazole.

Seven days after admission the child developed

rales at both lung bases, peripheral pitting edema,

hepatomegaly, and recurrent tachypnea. Increase

in the size of the cardiac silhouette was seen on

a chest roentgenogram. Digitalization produced

minimal improvement and, on the seventeenth day

of hospitalization, the child was referred to the

Bronx Municipal Hospital Center where a cardiac

scan denonstrated a penicardial effusion (Fig. 3).

Pericardiocentesis returned only 3 cc of fluid. Open

penicardotomy was then performed, at which time

20 cc of cloudy, loculated, sterile fluid containing

many white cells was removed. The child

re-covered slowly and was discharged after

3-months hospitalization.

CASE

IV

G. S., a 12-year-old white female, presented a

history of having had an upper respiratory tract

infection 4 months prior to admission. Diffuse joint

swelling with pain followed. She subsequently

de-veloped fatigue, dyspnea on exertion, palpitations,

and orthopnea. Physical examination revealed

dis-tended neck veins, hepatomegaly, pitting edema of

her ankles, and a systolic murmur which was

loud-est to the left of the sternum in the fourth

inter-costal space. Rheumatic carditis with congestive heart failure was diagnosed. An electrocardiogram

suggested penicarditis. Chest roentgenogram

vealed a markedly enlarged cardiac silhouette with

prominent pulmonary vasculature. Digitalization produced some improvement. A cardiac scan

vealed a large pericardial effusion (Fig. 4) and

steroid therapy was started. Her symptoms

sub-Fic. 4. Pericardial effusion. The separation of the

vascular pool of the heart from the radioactivity

(5)

SCINTILLATION

SCANNING

sided and a repeat cardiac scan 3 weeks later showed a marked decrease in the amount of pen-cardial fluid. She was discharged 23 months after admission.

KIDNEY

SCANNING

Ftc. 5. Top, intravenous urogram showing

de-creased visualization of the left collecting

sys-tem. Center, left, aortogram demonstrating at-tenuation of interlobular arteries in upper pole

(arrow). There are two left renal arteries. Bottom,

Intravenously injected chlormerodrin

labelled

with

mercury’97

or

mercury203

is

rapidly

concentrated

by

the

tubular

cells

of

the

kidneys.

Mercury’97

emits

lower

energy

gamma

photons

than

mercury203,

and

hence

delivers

a

smaller

dose

to

the

kidney.

About

1.5

c/kg of body weight is

injected

intravenously.

The

patient

needs

no

special

preparation

for

the

procedure.

The

scan

is

done

with

the

child

in

the

prone

position.

Mercury-labelled

chlor-merodrin has now been used extensively

for renal and brain scanning, and only a

single

mild

hypersensitivity

reaction

has

been

reported.8

Fifty

to

60%

of

the

dose

is

excreted by the adult kidneys in

24

hours.

In

1 week

the

radioactivity

of

Hg’#{176}7is

almost

completely

cleared

from

the

kidney.0

Scans portray the size and shape of

func-tiomng kidneys. The presence of a poorly

functioning or non-functioning

area

in

a

kidney

produces

a

defect

permitting

dif-ferentiation

of cysts

and

renal

masses

which

(10

not

have

significant

functional

paren-chyma

from

kidneys

with

fetal

lobulation.

Gross unilateral or segmental functional

impairment

can

also l)e appreciated.

Simi-larly,

small

areas

of viable

tissue

not

visual-ized

011

urograms

can

be

demonstrated.

Information

gained

from

scanning

may

be

used

in

certain

cases

to

supplement

the

results of intravenous urography when

the

latter

is

not

completely

diagnostic.

Better

selection

of

cases

for

angiography

can

be

made.

Scanning

has

been

used

in

children

allergic

to

the

contrast

materials

used

for

urography. Satisfactory scans usually can

not

be

performed

when

the

blood

urea

nitrogen

level

rises

to 60 to 80 mg/100

ml.bo

In

uremia,

the

concentration

of the

isotope

in the

liver

increases.

\Ve

have

chosen

cases

which

demonstrate

the

value

of renal

scanning

in children

who

renal scan 3 weeks later. There is decreased

(6)

ARTICLES

have

had

renal

trauma

and

who

have

renal

masses.

CASE

V

R. S., an 8-year-old white male, developed

ab-dominal pain and hematuria after falling off a

swing and striking his abdomen on a rock. Physical

examination showed marked tenderness and

guard-ing on the left side of his abdomen and left

costo-vertebral angle tenderness. There was poor

visual-ization of the left psoas muscle and the left renal

outline on an abdominal radiograph. An

intra-venous urogram showed decreased visualization of

the left collecting system, most marked in the

upper pole (Fig. 5). An aortogram revealed similar

findings, along with some attenuation of the

inter-lobular arteries resulting in decreased flow of

con-trast niatenial to the area. The child was treated

conservatively and did well. Three weeks later a

renal scan was performed to evaluate the status

of the kidney; 46.5 sc of mercury” was injected.

Decreased activity in the upper third of the left

kidney was seen compatible with segmental

infarc-tion. The child has reniained normotensive during

the 5 months following trauma.

Serial

renal

scans

will

be

performed

on

this patient in the future. Thus, the scan

provides

us

with

a

simple,

low-dose

method

of

following

the

status

of

the

kidney.

CASE

VI

R. R., a 3,100 gm, white male, was the product of a normal pregnancy and delivery. At birth he

was noted to have bilateral flank masses,

poly-dactyly, and talipes equinovarus deformity of the

right foot. Intravenous urography on two occasions

demonstrated lobulated renal outlines and slight

calyectasis compatible with the type of congenital

renal dysplasia associated with cysts of varying

size (Fig. 6). The child had slight albuminunia.

The level of blood urea nitrogen was 23 mg/100 ml. An attempt to perform a retrograde pyelogram was unsuccessful.

At the age of 2 weeks an exploratory laporatomy

revealed that both kidneys were enlarged and

con-tamed numerous cortical cysts. The child’s blood

pressure was 135/75 at the age of 5 months.

In-ulin clearance was diminished. The child, now

2-years old, is still hypertensive. A renal scan

per-formed with 15 tc of Hg” revealed irregular

scalloped renal outlines bilaterally. The kidneys

were enlarged. The present diagnosis is bilateral

renal dysplasia with numerous parenchymal cysts.

BRAIN

SCANNING

Radioisotope

scanning

has

proved

to

be

a very

reliable

screening

procedure

for

the

detection

of

intracranial

lesions

in

adults.

Scanning

in multiple

projections

has

added

to

the

accuracy

of

the

procedure.

Ab-normalities are most easily detected in

the

cerebral

hemispheres.11

Lesions

in

the

pos-tenor

fossa,

midbrain,

pituitary

fossa

and

intraventricular

area

are

more

difficult

to

detect

because

concentration

of the

isotope

in

muscles

about

the

base

of the

skull

may

mask the concentration of these inferiorly located lesions.

Non-neoplastic diseases (such as local in-flammatory lesions, extra- and intracerebral

hematomas,

cerebrovascular

accidents

and

arteriovenous

fistulas)

also

produce

changes

on

brain

scans.”

Several radioactive pharmaceuticals have

been used. Radioiodinated human serum

albumin is employed by several large

insti-Fic. 6. Above, intravenous urogram showing

splayed calyces and lobulation of the renal outline.

Below, renal scan demonstrating scalloped renal outlines and filling defects. There is hepatic pickup

(7)

800

tutions in

this

country.

In

1960,

Blau

and

3 employed chlormerodrin tagged

with

mercury203.

For

dosimetric

reasons

dis-cussed earlier, mercury”7 has

been

sub-stituted

in many

laboratories.

The

isotope

is

concentrated

in

the

lesion,

at

least

in

part,

because

of

breakdown

of

the

blood-brain

barrier due

to

aberrations

of metabolism

in

the area of the lesion. The complete

mecha-nism

of

the

isotope’s

concentration

in

a

lesion

has

not

yet

been

elucidated.

About

10 c

of mercury197labelled

chlor-merodrin

per

kilogram

of

body

weight

is

injected

intravenously.

Blau

and

Bender’3

have

shown

that

the

administration

of

an

unlabelled

mercurial

diuretic,

such

as

mer-alluride, prior to

brain

scanning

reduces

the

renal

dose

threefold

in

adults.

A newer

compound,

technetium

99m

per-technetate, is being evaluated for brain

scanning,

and

it

appears

to

offer

better

resolution

with

less

dose

to

the

patient)4

Air

studies

and

cerebral

angiography

may

be avoided in some cases when brain scans

are used for screening purposes. The

pa-tient’s condition may be followed with

serial scans.

Two

cases

involving

neoplastic

and

non-neoplastic

lesions

follow.

CASE

VII

M. L., a 9-year-old white female, was admitted

to the hospital because of vomiting, bilateral

pa-pilledenia, and right hemiparesis. Skull films

showed left panietal intracranial calcification and

sutural diastasis. A left internal carotid angiogram

demonstrated a parietal mass. A vascular

“ohigo-dendroghioblastoma” was partially resected. The

patient received a tumor dose of 5,600 R in 60

days by telecobalt therapy. Her neurological

defi-cits disappeared and she did well for Ui years.

She then developed right hemiparesis associated

(8)

re-section of the neoplasm was again performed as a

(lecompressive procedure. Three months later a

brain scan was done showing an area of increased

activity in the left parietal region suggestive of

tumor (Fig. 7). The child then followed a

progres-sive downhill course. Nine months later a repeat

brain scan demonstrated further increase in activity

suggesting continued growth of the tumor. She

expired in 2 months. At autopsy there were

char-actenistics of a neuroblastorna. The exact diagnosis

is not knowi at this time.

CASE

VIII

\v. A.,

a 15-year-old Negro male with sickle cell

anemia, was admitted to the hospital for renal

evaluation. One year prior to the present admission

he developed generalized edema and proteinunia.

Renal biopsy showed evidence of chronic

glomeru-lonephnitis with focal renal scarring. He responded

to steroid therapy.

During his most recent admission, his hematocrit

was 20%. It was decided to attempt au exchange

transfusion and 500 cc of the patient’s blood was

exchanged for 750 cc of packed cells. After this

treatment his hematocrit rose from 20 to 30.

Twenty-four hours later he developed occipital

headaches and vomiting. Lumbar puncture 2 days

after the transfusion showed bloody cerebrospinal

fluid under increased pressure. A diagnosis of

sub-arachnoid hemorrhage was made. He developed

right hem iparesis and became seniicomatose.

Echo-encephalography showed no midline shift. A

bi-lateral carotid angiogram 8 days after the

trans-fusion showed slight attenuation of the left middle

cerebral artery (Fig. 8). The patient regained

con-sciousness on the ninth day. On the tenth day, a

brain scan clearly outlined an area of increased

activity in the distribution of the left middle

cere-bral artery suggestive of infarction.

The child has had recovery of motor function

hut

has

residual

perceptual

difficulty.

COMMENT

In

any

diagnostic

test

the

potential

risk

must

be

balanced

with

the

information

to

he

derived

from

the

procedure.

There

has

been

great

concern

about

radiation

expo-sure

to

children.15

Despite

the

fact

that

the

use

of radionuclides

is widespread,

little

experimental

data

derived

from

metabolic

studies

is

available

to

calculate

the

dose

received

during

an

isotopic

procedure

in

normal

and

abnormal

children.

The

paucity

of

data

has,

in

part,

been

due

to

the

reluc-tance

to

administer

a radioactive

substance

to

a

normal

child

solely

for

experimental

purposes.

There

is no

good

evidence

of just

how

much

radiation

is necessary

to produce

permanent,

significant

damage

to

various

organs,

if indeed,

there

are

threshold

levels.

Conversely,

no

significant

damage

has

yet

been

noted

in

children

or

adults

using

the

dose

levels

of the

isotopes

suggested

in this

paper.

Fic. 8. Left, internal carotid arteniogram showing slight attenuation of the branches of the middle cerebral artery. Right, AP brain scan outlines area of increased pickup on the left in the distribution

(9)

Radionuclide Newborn milhrad.s/ microenrie 1yr rniliirads/ inierocurie 5 yr rniilirads/ mieroeurie 10 yr n,illirad.s/ microenrie 15 yr ,nil/irads/ mieroeiirie Standard Man rnieroeurie

ColloidalAu 198 .5.4 1.4 0.9 0.6 0.54

ChlormerodrinHg03 2.1 0.84 0.53 0.36 0.23 0.20

R.I.S.A.131* t28.0 8.9 5.4 3.4 .I 1.7

Gastrointestinal series 300 .0 480 .0 70 .0 1100 .0 13000 1400

or barium enemat

Intravenous urogram 90 .0 190 .0 310 .0 480 .0 89() .0 97() .0

* Without thyroid 1)locke(l.

t

Using image intensifier. Five film tedinique.

TABLE I

\\HOLE BODY DOSE

Applying

available

data

and

physical

for-mulae,

Seltzer,

et al)

estimated

the

whole

body

and

target

dose

delivered

by

various

radionuclides

to

patients

in

the

pediatric

age group

(Table

I and

II).

They

compared

these

doses

with

those

received

during

an

intravenous urogram, gastrointestinal series,

or

barium

enema.

From

their

data,

it may

be

seen

that

the

whole

body

dose

from

P31,

Au’#{176}t,or

Hg”3,

using

the

quantity

sug-gested,

is

less

than

that

from

commonly

performed gastrointestinal or urological

radiographic

procedures.

The

dose

to

the

thyroid

is

probably

negligible

from

IHSA

if

the

gland

has

been

blocked

by

iodine

prior

to

its

administration.

Scintillation

scanning

is a procedure

that

is easily

performed.

In

selected

cases

it can

he

used

as

a

screening

procedure

for

or

instead

of

angiography.

Its

availability

is

increasing,

but

interpretation

should

be

carried

out

by

qualified

physicians

familiar

with

the

technique.

SUMMARY

Organ

scanning

is

one

of

the

newer,

more

exciting

developments

in

radiology.

The

principles

of

liver,

cardiac,

renal,

and

brain

scanning

and

their

application

to

pediatrics

are

discussed.

Estimates

of

dose

delivered

to

the

whole

body

and

target

organs

are

presented.

The

doses

are

usually

lower

than

from

commonly

performed

gas-trointestinal or urographic radiographic

ex-aminations.

Organ

scanning

can

be

used

in pediatrics

in

the

same

manner

as

any

procedure

en-tailing

a potential

risk.

One

must

weigh

the

potential

risk

with

the

information

that

can

he

derived

from

the

procedure.

TABLE II ORGAN DOSE Radionuelide Organ Neu’born ;nllhirads/ ,nicroeurie 1 yr ,nilhirads/ microcurie 5 yr ,nillirads/ inieroenrie 10 yr millirad8/ microcurie 1,5 yr m?Jlirads/ microcurie Sandard iIan milliraa’s/ . mieroenrie

Colloidal Au 198

(‘hiormerodrin Hg 203

Liver Kidney

0.49 0.66

O.2O 0.‘2

0. 1 0.14

0.08 0.09

0.05 0.07

(10)

1964.

REFERENCES

1. Cassen, B., Curtis, L., and Reed, C. : Sensitive

directional gamma ray detector.

Instrumen-tation for Nucleonics, 6:78, 1950.

2. Miller,

J.

M. : Application of Scintillation

Scan-ning in Thyroid Disease. In Quinn,

J.

L., III., Scintillation Scanning In Clinical

Medi-cine. Philadelphia: Saunders, 1964, p. 43.

3. Johnson, P. M., Wood, E. II., and Mooring,

S. L. : Splenic scintillation scanning. Amer.

1.

Roentgen., 86:757, 1961.

4. Nagler, \V., Bender, M. A., and Blau, M.:

Radioisotope scanning of the liven.

Castro-entenologv, 44:36, 1963.

5. Nuvoli, I. : Arteniografia DelI’aorta Toracica

Mediante Puntura Dell’aorta Ascendente 0

del Ventnicolo 5. Polichinico (sez. prat.

),

43:

227, 1936.

6. Rejoli, A. M., Maclntyre, W.

J.,

and Fniedell,

II. L.: A radioisotope method of

visualiza-tion of blood pools. Amer.

J.

Roentgen.,

79:129, 1958.

7. Sklaroff, D. M., and Charles, N. D.: Heart

Pool Scanning. In Quinn,

J.

L., III.,

Scintil-lation

Scanning In Clinical Medicine. Phila-delphia: Saunders, 1964, p. 104.

8. Neohydnin-197, Product Information Brochure.

Abbott

Laboratories,

North

Chicago,

Ill.,

1964.

9.

Izenstank,

J.

L., Burden,

J. J.,

Mardis, II. K.,

afl(l Varella, R.: Clinical indications for

kid-ney scanning. J.A.M.A., 188: 136, 1964.

10. McAfee,

J.

C., and Wagner, II. N., Jr.:

Visual-ization of renal panenchyma by

scintiscan-ning with Hg 203 neohydrin. Radiology, 75:

820, 1960.

11. Sklaroff, D., Polakoff, P. P., Lin, P. NI., and Charles, N. D. : Cerebral scanning with

ra-(lioactive Chlormerodnin (neohydrin).

Neu-rology, 13:79, 1963.

12. McAfee,

J.,

and Fueger, G. F.: The Value and

Limitations of Scintillation Scanning In The

l)iagnosis of Intracranial Tumors. In Quinn,

J.

L., III., Scintillation Scanning In Clinical

Medicine. Philadelphia: Saunders, 1964, p.

183.

13. Blau, M., and Bender, NI. A.: Radioinercury

(hg 203) labelled neohydnin: A new agent for brain tumor localization.

J.

Nucl.

Med.,

3:83, 1962.

14. Harper, P. V., Beck, R., Charleston, D., and Lathrop, K. A.: Optimization

of a scanning

method

using

Tc

99m.

Nucleonics,

22:50,

1964.

15. Seltzer, R. A., Kereiakes,

J.,

and

Saenger,

E. L.: Radiation exposure from radioisotopes

(11)

1966;37;794

Pediatrics

Chester Kay, Leonard Freeman and Norman Avnet

SCINTILLATION SCANNING IN PEDIATRICS

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