Interesting Signs in Nuclear Medicine

Gopinath Gnanasegaran, MBBS, MSc, MD, FRCP,* Cherry Sit, BSc,*

Ruolei Chen, MBBS, FRCR, Kanhaiyalal Agrawal, MD,* and
Ignac Fogelman, MD FRCP*
Classic radiological and nuclear medicine signs have been reported extensively because of a
myriad of pathophysiological processes. When encountered, they aid in diagnosis of
conditions and add condence for the reader, at times even hinting at a specic diagnosis.
The naming of signs is commonly associated with objects from everyday life to establish
familiarity with visual ndings. Association of signs and disease comes with regular practice
and improves understanding of the image and its underlying cause. In this article, we have
collated nuclear medicine signs reported in the literature since 1970.
Semin Nucl Med 45:560-590 C 2015 Elsevier Inc. All rights reserved.

Introduction

adiology is the specialty of imaging that aids in detection,

treatment, and monitoring diseases. It aids a wide variety
of specialties in determining causes of medical problems based
on images. Nuclear medicine imaging is a subspecialty that
helps by giving functional information about tissue organs. In
both PET and SPECT imaging, radioactive tracers are injected
into the patients, and images are taken after distribution of the
tracer within the body. The uptake is interpreted to identify
normal biodistribution, or signicant abnormal radiotracer
accumulation, which might indicate an underlying disease.
Classic radiological signs have been reported extensively
because of a myriad of pathophysiological processes. When

encountered, they aid in diagnosis of conditions and add

condence for the reader, at times even hinting at a specic
diagnosis. The naming of signs is commonly associated with
objects from everyday life to establish familiarity with visual
ndings. Association of signs and disease comes with regular
practice and improves understanding of the image and its
underlying cause. It is also important to be aware of rare signs, as
they may cause serious misinterpretation in a moment of panic.
Although the areas of uptakes in nuclear medicine usually
correlate with the area of disease, there are cases of scans that
produced unusual ndings caused by unexpected pathophysiology or anatomical abnormalities. In this article, we have
collated nuclear medicine signs 1-151 system wise, as reported
in the literature (Tables 1-9 and Figs. 1-24).

*Department of Nuclear Medicine, Guys and St Thomas NHS Foundation

Trust, London, UK.
Department of Radiology, Guys and St Thomas NHS Foundation Trust,
London, UK.
Address reprint requests to Gopinath Gnanasegaran, MBBS, MSc, MD FRCP,
Department of Nuclear Medicine, Guys & St Thomas NHS Foundation
Trust, London, SE1 7EH, UK. E-mail: gopinath.gnanasegaran@nhs.net

560

http://dx.doi.org/10.1053/j.semnuclmed.2015.06.003
0001-2998/& 2015 Elsevier Inc. All rights reserved.

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Interesting signs in nuclear medicine

561

Table 1 Nuclear Medicine Signs in Radionuclide Musculoskeletal Imaging1-60 (Figs. 1-7)

Sign and Diagnosis

Radiotracer Scan Appearance and Comments

Abe Lincoln sign: Pagets disease of the

mandible
Black beard sign: Pagets disease of the
mandible
Bull horn or bull head sign:
sternocostoclavicular hyperostosis
(SCCH) and pustulotic arthro-osteitis
(PAO)

99mTc-MDP

Increased tracer uptake in the mandibles. Nahum et al1

99mTc-MDP

Backpack sign: muscle uptake

18

Buttery sign: hyperostosis frontalis

99mTc-MDP

Increased tracer uptake involving the

mandibles.
Characteristic bullhead-like high tracer
uptake in the sternocostoclavicular
region with the manubrium sterni
representing the upper skull and the
inamed sternoclavicular joints
corresponding to the horns. The
bullhead sign is reported to be a typical
and highly specic scintigraphic
manifestation of SCCH and PAO in
radionuclide bone scans.
Bilateral intense 18F-FDG uptake in
suprascapular and lower neck muscles.
Increased uptake in frontal skull bone.
Thickening of the internal table of the
frontalis interna.
Reduced or photon-decient area in the
hip due to uid in the hip joint under
pressure.
Photopenic center surrounded by a region
of hyperemia and reactive change. Cold
area indicates avascularity and reduced
delivery of radiopharmaceuticals.
Small area of focal-avid radionuclide
activity, corresponding to the nidus
superimposed on regional mild activity
on background.
Increased tracer uptake in the supraorbital
rims. Unusual variant of bony
metastases to the skull.
Poor visualization of the kidney and
diffuse tracer uptake in the bones
caused by alteration in the
biodistribution resulting from skeletal
disease.
Increased tracer uptake in the L1 spinous
process and spinal canal at the level of
scoliosis.
Increased tracer uptake in the patellae
when compared with that in the distal
femur or proximal tibia of the ipsilateral
leg. No diagnostic value.
Fracture lines running vertically through
both the left and right sacral ala, medial
to the sacroiliac (SI) joints, and a
transverse fracture just below the level
of the SI joints.
Increased uptake in the vertebral body,
posterior elements, and the spinous
process. Suggestive of Pagets disease
than metastases even in patients with
cancer.
Increased tracer uptake involving the
sphenoid wing, like pirate wearing an
eye patch.

99mTc-MDP

F-FDG

Cold hip sign: impaired perfusion to joint 99mTc-MDP

capsule
Doughnut sign: avascular necrosis of
bone of hip

99mTc-MDP

Double-density sign: osteoid osteoma

99mTc-MDP

Eyebrow sign: bony metastases

99mTc-MDP

Faint kidney sign or absent kidney,

missing kidney sign: metabolic
superscan or superscan of malignancy

99mTc-MDP

Hot spur sign: diastematomyelia

99mTc-MDP

Hot patella sign: no diagnostic value

99mTc-MDP

Honda sign: insufciency stress fracture

involving pelvis

99mTc-MDP

Mickey mouse (mouse face) sign: Pagets 99mTc-MDP

disease of vertebra

Pirate sign: brous dysplasia

99mTc-MDP

Reference

Mailander3
Freyschmidt and
Kasperczyk5

Zaher et al6
Ceylan and Caner7

Uren and Howman-Giles8

Dumont et al9

Helms et al12

Gyetvai and Stadalnik13

Sy et al14

Thomas et al17

Kipper et al18
Fogelman et al19

Fujii et al20 and Balseiro

et al21

Kim et al22

Singnurkar and Rush24

Harisankar et al25

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G. Gnanasegaran et al.

562
Table 1 (continued )
Sign and Diagnosis

Radiotracer Scan Appearance and Comments

Reference

Tram line or double stripe sign:

hypertrophic pulmonary
osteoarthropathy (HPOA)
Seat belt sign: rib fractures

99mTc-MDP

Sreekumar26

Push up sign: pectoral muscle strain

99mTc-MDP

Tie sign and striped tie sign: metabolic

bone disease

99mTc-MDP

Saddle sign: bilateral thigh adductor

muscle injury

99mTc-MDP

Sit up sign: rectus abdominis muscle

strain

99mTc-MDP

99mTc-MDP

Totem pole sign: retained barium from GI DXA or bone

investigation
densitometry scan

Yarmulke sign: Paget disease of skull

99mTc-MDP

Hot skull sign: normal variant in obese

patients

99mTc-MDP

Lizzie Borden sign: increased intracranial 99mTc-MDP

pressure

Doughnut sign: (osseous and

nonosseous): giant cell tumors,
aneurysmal bone cyst,
coccidioidomycosis, angioblastic
meningioma, multiple myeloma,
hemangioendothelioma, and bone
metastasis
Rim sign: symmetrical renal defect

99mTc-MDP

99mTc-MDP

Intense bilateral symmetrical cortical

uptake of tracer in tibia, bula, and
femur.
Increased uptake in costochondral
junctions. Diagonal rib fractures in
pattern of seat belt injury.
Increased tracer uptake in pectoral
muscles after vigorous upper torso
exercises 48 hours before examination.
Prominent tracer uptake in the sternum
(additional scan ndings include
increased tracer uptake in the calvarium
and mandible, and beading of the
costochondral junctions (rosary beads)
Increased tracer uptake in bilateral thigh
adductor compartments. Muscle injury
resulting from vigorous horseback
riding.
Increased tracer uptake in rectus
abdominis muscles uptake after
vigorous sit-up exercises.
DXA scan demonstrated wings
extending outward from the L4 vertebra,
which had twice the density of its
neighboring vertebrae, creating the
appearance of a totem pole. The wings
were caused by the presence of barium
in the large bowel at the time of the initial
scan.
Inhomogenous tracer uptake in the skull
due to mixed osteolytic and
osteosclerotic in patients with pagetic
disease of skull.
Diffusely increased skull activity, which is
signicantly more common in normal
bone scans of obese patients because of
disparate attenuation of overlying soft
tissues. However, hot skull, or diffuse
increased activity in the skull, is a
nonspecic nding as it is also seen as a
normal pattern in postmenopausal
women, or in patients with hyperparathyroidism and osteomalacia.
Widening of the sutures with a wide void
of radioactivity in the skull (increased
intracranial pressure associated with
subdural hematomas). Appears as
photopenia in line of sagittal suture.
Nonspecic sign seen in several osseous
and nonosseous conditions. Scan
showing photopenic center (necrosis)
surrounded by a region of hyperemia
(increased osteoblastic reaction) and
reactive change.

Nakamoto and Taylor28

Mackie et al29

Bahk30
Fogelman31

Mackie et al32

Sabnis et al33

Spencer et al34

Kunin and Strouse35

Lorberboym et al36

Murray et al37

Dhawan et al38, Nocera

et al39, Veluvolu et al11,
Clarke et al41, McNamara
et al42, Hirano et al43, and
Sty et al40

Photopenic center surrounded by a rim of Choong44

increased tracer uptake in each kidney in
a patient with non-Hodgkins lymphoma.

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Interesting signs in nuclear medicine

563

Table 1 (continued )
Sign and Diagnosis

Radiotracer Scan Appearance and Comments

Reference

Pelvic doughnut sign or pseudobladder

sign: Pregnancy

99mTc-MDP

Mandell and Harcke45

Sanders et al46
Veluvolu et al47

Delta sign: Normal variant representing

the site of deltoid muscle insertion

99mTc-MDP

Hot clot sign: deep venous thrombosis

99mTc-MDP

Clover and heart signs: Pagets disease of 99mTc-MDP

the vertebra

Sickle sign: diffuse activity around the

calvarium

99mTc-MDP

Salt-and-pepper sign:
hyperparathyroidism
Pale vertebra sign: porotic vertebra

99mTc-MDP

Rosary sign: metabolic bone disease

99mTc-MDP

Cold rib sign: bone destruction

99mTc-MDP

99mTc-MDP

Stocking glove sign: intra-arterial injection 99mTc-MDP

Hot forearm sign and hot hand sign:
intra-arterial injection
String of pearls sign: traumatic rib
fractures
Short pants sign: Pagets disease

18

F-FDG

99mTc-MDP
99mTc-MDP

Ring of increased tracer uptake with a

photon-decient center toward the
bladder, not seen on 2-hour delayed
image. Patient subsequently conrmed
to be eight weeks pregnant. The uterus
and placenta represent the ring of
increased tracer uptake with the less
vascular embryo and amniotic sac
accounting for the photon-decient
center.
Focus of increased tracer uptake in the
upper third of humerus (bilateral or
unilateral) corresponding to the deltoid
tuberosity (differential diagnosis: bone
metastasis)
Focal Tc-99m MDP uptake on bone
scanning in regions of deep venous
thrombosis (DVT). It is speculated that
this uptake may be related to localized
calcication or ossication, which is
occasionally observed on radiographs of
patients with chronic DVT.
Increased tracer uptake in a vertebra in a
heart and clover fashion are highly
specic (probably pathognomonic) of
Pagets disease of the vertebra.
Diffuse activity around the calvarium seen
in patients at cytotoxic therapy (side
effect). Frontal and lateral view of the
skull is useful in excluding sinister
pathology.
Diffuse pinpoint or speckled appearances
in the skull.
Generalized reduced uptake in the porotic
spine.
Beaded increased tracer uptake in the
costochondral junctions.
Reduced tracer uptake in the rib (bone
destruction with adjacent soft tissue
mass).
Increased tracer uptake in the hand
resembling stocking glove sign due to
intra-arterial tracer injection.
Appearance of intra-arterial administration
of 18F-FDG
Linear increased uptake in the ribs
representing traumatic fractures
Increased tracer uptake in the spine,
pelvis, and upper femoral disease
(Pagets disease)

Fink-Bennett and VicunaRios48

Lim et al49

Zuckier et al51

Rots-Sala et al53

Creutzig and Dach54

Bahk30
Bahk30
Bahk30
Valds Olmos et al55

Andrews et al56
Giammarile et al57
Kumar58
Learning radiology.com59
Matthews et al60

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G. Gnanasegaran et al.

564
Table 2 Nuclear Medicine Signs in Radionuclide Oncology Imaging62-71 (Figs. 8 and 9)
Sign

Radiotracer

Scan Appearance and Comments

Reference

Radioiodine hot hand sign:

radioiodine contamination

131I

Schechter
et al61

Helmet sign: radioiodine

contamination

131I

Nose ring sign: nose ring artifact

(radioiodine in sweat or nasal
secretions)

131I

Necklace sign: radioiodine

contamination

131I

Handkerchief sign: radioiodine

contamination

131I

Chilaiditi sign: anatomical variant of

colon

18

Raccoon eyes sign: MIBG

superscan in patients with
neuroblastoma
Straight line sign: diffuse peritoneal
carcinomatosis

131/123 IMIBG

Posttherapy whole-body scan with concomitant

increased tracer uptake in the hands in a patient
receiving 131Iodine therapy after total thyroidectomy
for differentiated thyroid cancer that was conrmed
as radioactive contamination.
Posttherapy scan in a woman revealed intense uptake
along the periphery of the skull or scalp. It was found
that between the 131I therapy and the scan, she had
not washed her hair to preserve the hair extensions
she had placed, and that she applied a petroleumbased jelly to the scalp to prevent drying.
A 131I posttherapy scan of a woman with a history of
follicular thyroid cancer showed a focus of tracer
uptake in the nasopharynx in the anterior view, which
was anterior and supercial in the lateral view,
corresponding to a small metal ring in the right naris
(false positive).
A 131I scan of a woman with history of papillary thyroid
carcinoma suggested evidence of disease
recurrence at the base of her neck on the left side
with near-undetectable thyroglobulin levels. Repeat
scans were performed as this was thought to be false
positive. A scan without her necklace showed no
evidence of 131Iodine uptake in the neck, whereas
one of the necklace alone showed uptake.
Nasal and salivary secretions were discharged onto a
handkerchief and paper tissue following
administration of radioiodine 131I and the patient
placed the contaminated item in the pocket.
Presence of a colon loop between the liver and the
diaphragm. This anatomical variant is known as the
Chilaiditi sign. Absence or abnormality of suspensory
ligaments of the transverse colon or of the falciform
ligament can contribute to its occurrence.
Marked increased tracer activity around the orbits in a
grossly abnormal MIBG scan

Pituitary sign: physiological uptake

in pituitary gland

F-FDG

18

F-FDG

99mTc(V)
DMSA

Seen as a vertical straight line demarcating the

boundary between diffusely increased activity in the
peritoneum and the much lower normal activity in the
retroperitoneum owing to diffuse peritoneal
carcinomatosis. The appearances were due to diffuse
metastatic hypermetabolism spread uniformly
throughout the abdominal and pelvic peritoneum,
with much lower levels of metabolic activity in normal
retroperitoneum.
Tracer uptake in the pituitary gland (normal
biodistribution).

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Ash et al62

Dick et al63

Beaulieu
et al64

Pochis et al65

Roy et al66
Lu et al67

Bohdiewicz
et al69
Lin70

Watkinson
et al71

Interesting signs in nuclear medicine

565

Table 3 Nuclear Medicine Signs in Radionuclide Lung Imaging72-79 (Figs. 10 and 11)
Sign and Diagnosis

Radiotracer
and Type of
Tracer

Scan Appearance and Comments

Reference

Checkerboard Sign:
pulmonary tumor
microemboli
Stripe sign: pulmonary
emphysema

V/Q scan

Fink-Bennett et al72

Fissure sign: pleural effusion

V/Q scan

Pseudostripe sign:
hypoperfusion of lung

99mTc-MAA
perfusion scan

Changing stripe sign:

suspicious for Pulmonary
embolism

99mTc-MAA
perfusion scan

Hot clot sign or artifact:

incidental focal 18F-FDG
accumulation in lung
parenchyma without
abnormal CT ndings

18

Appears as small peripheral subsegmental

perfusion-ventilation mismatched defects or
have a checkerboard appearance.
Refers to an area of focal hypoperfusion that fails
to extend to the pleural surface, leaving a
peripheral rim of perfused parenchyma.
Experimental evidence suggests that the stripe
sign is caused by central pulmonary
emphysema. Differentials: pulmonary
emphysema, resolving PE, cigarette smoking,
pulmonary hypertension, and lobar collapse.
Linear area of reduced or absent radionuclide
uptake along the distribution of the major and
minor ssures on a lung perfusion scan.
Commonly seen in patients with pleural
effusion in supine position.
Hypoperfusion in lower lung zones with a thin
peripheral stripe of perfusion medially along the
mediastinal pleural surface of the left thorax in
the posterior view.
Stripe sign often excludes PE. However, the
authors present a case of stripe sign that
disappeared on serial perfusion imaging. The
authors conclude a changing stripe sigh may be
suspicious for a PE.
Focal increased FDG uptake with no denite CT
correlate, which disappears on subsequent
rescanning, because of faulty injection
technique. (Microemboli secondary to
agglutination of FDG by erythrocytes may lead
to transient obstruction of small pulmonary
arterioles and could often be mistaken for
metastasis.)

V/Q scan

F-FDG PET

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Sostman and
Gottschalk73
Ergn et al74

Cheema76

Feldman and
Schabel77

Watanabe et al78

Ozdemir79

G. Gnanasegaran et al.

566
Table 4 Nuclear Medicine Signs in Radionuclide Cardiac Imaging80-87 (Figs. 12 and 13)
Sign and Diagnosis

Radiotracer and
Type of Scan

Scan Appearance and Comments

Reference

Movahed sign: right ventricular

overload
Teardrop sign: hypertrophic
cardiomyopathy

Gated SPECT
imaging
99mTc- pertecnetate
gated blood pool
imaging

Murarka et al80

Nu sign: pleural effusion

201

Fisherman's Waders sign:

inferior vena cava obstruction

99mTc-MDP

Hurricane sign: artifact due to

patient motion
Pulmonary tongue sign:
pulmonary hypertension

201

D-shaped ventricle similar to ones seen on

echocardiography.
In patients with hypertrophic cardiomyopathy,
left ventricle appears bulbous in the apical
region with narrowing at the base during
diastole, leading to a teardrop appearance.
Photon-decient region caused by separation
of the heart from the pulmonary tissue,
indicative of an effusion. Differential:
pericardial or pleural effusion.
Increased soft tissue uptake below the level of
the midchest was seen in bone scan, found
to be due to inferior vena cava thrombosis
associated with nephrotic syndrome.
MPI shows hurricane sign represent an artifact
due to patient motion.
Pulmonary tongue a right ventricle phase
abnormality in MUGA studies in patients
with pulmonary hypertension.
Reduced left ventricular cavitary activity (black
hole sign) in perfusion images of anteroapical
transmural myocardial infarction

TI

Black hole sign: anteroapical

transmural myocardial
infarction

Thallium SPECT

99mTc- pertecnetate
gated blood pool
imaging
201
TI SPECT

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Al-Bahar et al82

McDonald et al83

Chu et al84

Sorrell et al85
Bahar et al86

Civelek et al87

Interesting signs in nuclear medicine

567

Table 5 Nuclear Medicine Signs in Hepatobiliary and Gastrointestinal Systems88-111 (Figs. 14 and 15)
Sign

Radiotracer and
Type of Scan

Scan Appearance and Comments

Hot rim or rim sign (gall

bladder): acute
cholecystitis

99mTc-DISIDA
cholescintigraphy

Appearance of a curvilinear, pericholecystic rim of

Cawthon et al88
increased hepatic tracer activity adjacent to a
Lim and Sohn89
photopenic gall bladder fossa. Differential: gangrenous Powell et al93
cholecystitis.

Late rim sign: chronic

acalculous cholecystitis
Ectopic rim sign

99mTc-DISIDA
cholescintigraphy
99mTc-HIDA
cholescintigraphy

Rim sign (liver): liver

abscess

99mTc-mebrofenin

Ring sign (pancreas):

infected pancreatic
pseudocyst
Radionuclide dance sign:
intussusception
Dilated cystic duct sign or
nubbin sign: cystitis with
transient cystic duct
visualization secondary to
obstruction of cystic duct
Dilated common duct sign:
sphincter of Oddi
dyskinesia
Pericholecystic hepatic
activity (PCHA)sign or
phantom gall bladder

67Ga-Citrate

Late rim sign visualized at 25 minutes after injection of Spieth et al94

radiotracer.
Hepatobiliary scan demonstrated nonvisualization of the Haygood et al95
gall bladder or rim sign in the gall bladder fossa. Instead
there was curvilinear area of increased activity in the
region of the ssure for the ligamentum teres or
common hepatic duct (ectopic rim). The authors
propose the edematous compression of liver
parenchyma may produce an ectopic rim sign if
inammation comes in contact with another portion of
the liver.
Photopenic area in the hepatic lobe surrounded by a rim McDonald and
of activity greater than that of the adjacent parenchyma. Davani96
Gowda et al97
Ring of increased tracer uptake with a central photon- Kennedy et al98
decient region in the midabdomen.

99mTc-pertechnetate
99mTc-HIDA
cholescintigraphy

99mTc-HIDA
cholescintigraphy
99mTc-HIDA
cholescintigraphy

Krishnamurthy-Bobba sign: 99mTc-HIDA

cholescintigraphy
scintigraphic
cholecystokinin-induced
bile reux
Tail sign: biliary leak after
99mTc BULIDA
surgery
cholescintigraphy

Scintigraphic murphy sign

99mTc-HIDA
cholescintigraphy

Relative photon-decient area secondary to absent

bowel seen in the right iliac fossa region.
Appearance of focus of activity between common bile
duct and gall bladder fossa post morphine injection.
Acute cholecystitis with transient cystic duct
visualization secondary to obstruction of cystic duct
calculus.
Normal gall bladder response with marked dilation of
common bile duct post CCK

Reference

Sty et al99
Achong and
Oates100
Coleman et al101

DeRidder et al102

Arose et al103
Variant of rim sign: Increased pericholecystic hepatic
activity with around conguration and aped in the rst
5 minutes of the study. Confusion with normal gall
bladder can be avoided by observing lling of
intrahepatic biliary radicals later in the study than
before.
Reux sign in cholescintigraphy after administration of a Brar105
gall bladder contracting agent (sensitive nding
indicating the presence of biliary dysfunction).
Scan showed abnormal accumulation of activity tracking Shikare et al107
down the right lobe resembling a tail attached to the
inferior portion of the right hepatic lobe (tail sign). The
bile leak detected on cholescintigraphy showed
abnormal radiotracer pathways away from anatomical
tract.
Focal gall bladder tenderness is the most important
Colletti et al108
physical nding in suspected acute cholecystitis.
Authors describe a technique using palpation of the
abdomen with the placement of a radioactive marker on
the point of maximum tenderness. Correlation of the
marked area to the location of the gall bladder fossa is
made. Authors conclude integration of palpation and
scintigraphy may enhance the cholescintigraphic
diagnosis of acute cholecystitis.

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G. Gnanasegaran et al.

568
Table 5 (continued )
Sign

Radiotracer and
Type of Scan

Scan Appearance and Comments

Dimple sign: hepatic vein

thrombosis(Budd-Chiari
syndrome)

99mTc-Sulfur colloid

Hot spot on the scan represents predominant areas of Gooneratne

preserved liver tissue in a patient with hepatic vein
et al109
thrombosis. However, other conditions such as
abscess, hemangioma, focal nodular hyperplasia, and
hepatic adenoma may show focal increased uptake.
Palestro et al110
Artifactually increased activity may result from a
malpositioned central venous catheter, free
pertechnetate in the stomach, or an overlying breast.
An unusual variation of this last artifact, also known as
the hot stripe sign, was encountered during routine
liver-spleen imaging.
Joseph et al111
Pericholecystic hyperperfusion on ow images with a
pericholecystic rim of increased activity (PCHA) on
delayed planar and SPECT of the liver was seen in a
patient with a history of multiple renal transplants
admitted with cramping right lower quadrant abdominal
pain. Conrmed acutely perforated gangrenous
gallbladder and occluded cystic duct.

Hot stripe sign: an unusual 99mTc-SC liver-spleen

variation
scintigraphy

Rim sign: complicated or

advanced stage of acute
cholecystitis

99mTc-sulfur colloid
scintigraphy

Reference

Table 6 Nuclear Medicine Signs in Radionuclide Imaging of Genitourinary System112-124 (Figs. 16-19)
Sign

Type of Scan

Scan Appearance and Comments

Reference

Doughnut sign: pyometra

67Ga-Citrate

Kao et al112

Hourglass sign: fused pelvic

kidney

99mTc-DTPA

Doughnut-shaped accumulation in the lower

abdominal region different from urinary bladder
activity.
Hourglass uptake demonstrating functional fused
pelvic kidneys without obstruction.

Cobra head sign: ureterocele

99mTc-DTPA/
MAG3

Hydronephrotic kidney with a hydroureter and

associated saccular outpouching at its distal end
consistent with ureterocoele.

Riaz et al114
Caliskan et al115

Lady bug sign: scrotal hydrops

99mTcpertechnetate

Increased tracer uptake in the scrotal wall, median

raphe, and testicles.
Differentials: Hydrocele and hypoproteinemia
causing scrotal swelling.

Barrett and
Buozas116

Bull's eye sign: testicular torsion

99mTc-DTPA

Rim of increased tracer uptake with a photondecient center around testis indicative of
subacute and late stages of testicular torsion.

Mishkin123

Pseudobull's eye sign: (a) patent

processus vaginalis,
(a) periappendicular abscess,
and (b) urinoma

99mTc-DTPAtesticular scan

Melton117

Renal subcapsular rim sign: renal

vein thrombosis

99mTc-DTPArenogram

Rim of increased tracer uptake with a photondecient center around testis. However,
ultrasound revealed peritesticular uid
secondary extension of periappendicular
abscess and second case demonstrated
urinoma (ureterovesical anastomotic leak).
Radiotracer was injected injection via left foot vein.
Radionuclide angiogram showed transit of tracer
through vertebral collateral veins suggesting
vena caval obstruction.

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Karacalioglu
et al113

Howman-Giles
et al124

Interesting signs in nuclear medicine

569

Table 7 Nuclear Medicine Signs in Radionuclide Brain Imaging125-130 (Fig. 20)

Sign and Diagnosis

Type of Scan

Scan Appearance and Comments

Reference

Hot nose sign: cerebral death

99mTc-HMPAO

Appelt et al125

Hollow skull sign: cerebral death

99mTc-HMPAO

Dened as the presence of early, increased

activity in the nasopharyngeal secondary to
occlusion of internal carotid artery with ow
recouted via the external carotid artery. The hot
nose sign is a descriptive term that is associated
most frequently in the radiology literature with
cerebral death.
Tracer uptake of the cranium and a hollow skull
with no visualization of any brain tissue,
suggesting brain death.
Differential diagnosis between Alzheimer and
frontotemporal disease. Reduction in RCBF in
the posterior cingulate/retrosplenial region is
often seen in the presence of Alzheimer's
disease (posterior cingulate sign).
Sparing of the posterior cingulate relative to the
precuneus and cuneus is an imaging feature of
DLB on 18F-FDG scan.

Posterior cingulate sign: Alzheimer disease 99mTc-HMPAO

SPECT

Cingulate island sign: dementia with Lewy

bodies (DLB)

18

F-FDG

Abdel-Dayem
et al128
Bonte et al129

Lim et al130

Table 8 Nuclear Medicine Signs in Radionuclide Thyroid Imaging131-139 (Figs. 21 and 22)
Sign and Diagnosis Radiotracer

Scan Appearance and Comments

Fish eye sign: benign

thyroid adenoma

99mTc-pertechnetate

Benign thyroid adenoma. Focus of functioning Goldstein et al131

tissue within an area of decreased activity
appears as sh eye sign. Although this sign is
not pathognomonic of a benign process, it
has not yet been described in a malignant
case.

Reference

Owl's eye sign:

thyroid cyst

99mTc-pertechnetate

Thyroid cyst. Caused by a focus of functioning Oates E. Clin Nuc Med.

18(11):1003, 1993
tissue overlapping a large cold area in a
Ashkar and Smoak136
nodule that has cystic, degenerative, and
necrotic changes. Large photopenic area with
a central focal area of increased uptake gives
the appearance of Owl's eye.
Differentials: Thyroid cyst, functioning nodule,
and papillary cancer of the thyroid.

Hockey stick sign:

thyroid hemi
agenesis

99mTc-pertechnetate

Thyroid scan showing normal right lobe or

isthmus and thyroid with absent left lobe.

Melnick and Stemkowski138

Damle et al139

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G. Gnanasegaran et al.

570
Table 9 Nuclear Medicine Signs in Radionuclide Imaging of Infection and Inammation140-151 (Figs. 23 and 24)
Sign

Radiotracer and
Scan

Scan Appearance and Comments

Reference

Panda sign: sarcoidosis

67

Focal accumulation of 67Ga in the nasopharynx,

parotid gland, and lacrimal gland, distributed
symmetrically, produces a distinct pattern, the
Panda sign that is strikingly similar to the dark
marking of the giant panda.

Kurdziel140
Sulavik et al141

Lambda sign: sarcoidosis

67

A distinctive intrathoracic lymph node uptake of 67Ga Yoshimizu142

resembling the Greek letter lambda is referred to as Sulavik et al143
the lambda sign only observed in sarcoidosis.
Simultaneously with panda sign is highly specic or
suspicious for sarcoidosis.

Cervical collar sign: periarteritis

nodosa

67

Halo sign: gangrenous

cholecystitis
Incomplete rim sign

111

Halo sign: encapsulated

hematoma
Hot halo sign: pyogenic
pericarditis

99mTcpertechnetate
111
In-leukocyte

Negative heart sign: highly

abnormal pulmonary
67
Gallium uptake

67

Leopard-man sign: systemic

sarcoidosis

67

Beard sign: facial acne

67

Lower abdominal doughnut

sign: pyometra

67

Ring sign: pneumonia

67

Intense tracer uptake in the subcutaneous region of

the posterior neck forming a collar shape in a
patient with cutaneous involvement of periarteritis
nodosa.
Halo of 111In-Leukocyte activity seen around gall
bladder fossa.
Incomplete rim of 67Ga activity at the periphery
corresponding to an area of displaced intestine
(complete rim sign is suggestive of abscess and
incomplete rim may result from large mass
displacing structures that take up 67Ga).
Central area of decreased activity surrounded by an
halo of increased activity.
Rim or halo of increased 111In-WBC activity around
the cardiac margin extending superiorly to the root
of the vessels.
Comparison of pulmonary uptake with that over the
cardiac area is suggested as a simple and reliable
method of conrming that the level of pulmonary
activity is normal or abnormal. In highly abnormal
cases, the cardiac area is seen as a negative heart
image because of the considerably increased
activity in the lungs. This sign is best seen with
abnormal diffuse uptake but is also seen with
abnormal focal uptake.
Gallium-67 scintigraphy showed multiple hot spots in
the soft tissues, skin, muscles, mediastinum, and
lachrymal glands, producing a diffuse dappled
pattern.
Marked tracer uptake by the soft tissue of the face in
a beard pattern in a 16-year-old boy being treated
for multifocal osteomyelitis. The increased soft
tissue uptake was because of severe facial acne.
Scan revealed a doughnut-shaped tracer
accumulation in the lower abdominal region.
Combined 67Ga and Tc-99m MDP bone scan
conrmed activity in the uterus (shape of the urinary
bladder on bone scan was different from that of the
Ga-67-avid lesion); pyometra was conrmed during
operation.
Focal increased tracer uptake in a lung lesion with
reduced uptake in the center (ring-shaped uptake of
67
Ga in a patient with AIDS and pneumonia due to
Cryptococcus neoformans).

Ga-Citrate

Ga-Citrate

Ga-Citrate

In-Leukocyte

67

Ga-Citrate

Ga-Citrate

Ga-Citrate

Ga-Citrate

Ga-Citrate

Ga-Citrate

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Klaas et al144

Bauman et al145
Causey et al146

Rivera et al127
Coupland et al147

Cooke et al148

Fayad et al149

Taillefer et al150

Kao et al112

Banzo et al151

Interesting signs in nuclear medicine

Figure 1 (A) Abe lincoln or black beard sign: Pagets disease of the mandible. 99mTc-MDP bone scan shows increased tracer
uptake in the mandible (Pagets disease). (Reproduced with permission from Fogelman et al.2) (B) Pirate sign: brous
dysplasia. 99mTc-MDP bone scan shows increased tracer uptake involving the sphenoid wing, like pirate wearing an
eyepatch. (Reproduced with permission from Fogelman et al.2) (C) Buttery sign: hyperostosis frontalis. 99mTc-MDP
bone scan shows increased uptake in frontal skull bone. Thickening of the internal table of the frontalis interna.
(Reproduced with permission from Ceylan and Caner.7) (D and E) Lizzie Borden sign: increased intracranial pressure.
99mTc-MDP bone scan shows widening of the sutures with a wide void of radioactivity in the skull (Reproduced with
permission from Murray et al.37) (F) Yarmulke sign: Pagets disease of skull. 99mTc-MDP bone scan shows inhomogenous
tracer uptake in the skull owing to mixed osteolytic and osteosclerotic in patients with pagetic disease of skull. (Reproduced
with permission from Kunin and Strouse.35) (G-I) Doughnut sign. 99mTc-MDP bone scan shows photopenic center
(necrosis) surrounded by a region of hyperemia (increased osteoblastic reaction) and reactive change. (Reproduced with
permission from Nocera et al39 and Dhawan et al38)

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571

G. Gnanasegaran et al.

572

Figure 2 (A) Faint or absent or missing kidney sign. 99mTc-MDP bone scan shows poor visualization of the kidney and
diffuse tracer uptake in the bones caused by alteration in the biodistribution resulting from skeletal disease. (B) Delta or
deltoid sign: normal variant representing the site of deltoid muscle insertion. A 99mTc-MDP bone scan shows a focus of
increased tracer uptake in the upper third of left humerus corresponding to the deltoid. (Reproduced with permission from
Hunter and Fogelman.50) (C) Hot patella sign: a 99mTc-MDP bone scan shows increased tracer uptake in the patellae
compared with the distal femur or proximal tibia. (Reproduced with permission from Kipper et al.18) (D) Tie sign:
Metabolic bone disease. Prominent tracer uptake in the sternum. (E) Eyebrow signbony metastases. Increased tracer
uptake in the supraorbital rims. (Reproduced with permission from Gyetvai and Stadalnik.13) (F-H) Double-density sign:
osteoid osteoma. (F) Anteroposterior radiograph of right femoral neck shows a radiolucency (arrows) containing a faint
calcic density. (G) 99mTc-MDP bone scan, posterior view: increased radionuclide uptake has occurred throughout the
right proximal femur with a second area of increased uptake in the femoral neck, which corresponds to the nidus.
(H) 99mTc-MDP bone scan, anterior view: increased radionuclide uptake is present throughout the acetabulum with a
second area of increased uptake noted at the 2-oclock position (arrow), which corresponded to the nidus. (Reproduced
with permission from Helms et al.12) (I) Totem pole sign: retained barium from GI investigation. A DXA scan demonstrated
wings extending outward from the L4 vertebra that had twice the retained density of its neighboring vertebrae, creating
the appearance of a totem pole. The wings were caused by the presence of barium in the large bowel at the time of the
initial scan. (Reproduced with permission from Spencer et al.34)

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Interesting signs in nuclear medicine

Figure 3 (A) Honda sign: insufciency stress fracture involving the pelvis. 99mTc-MDP bone scan showing increased tracer
uptake running vertically through both the left and right sacral ala, medial to the sacroiliac (SI) joints, and a transverse
fracture just below the level of the SI joints. (B) Seat belt sign: rib fractures. 99mTc-MDP bone scan showing increased
uptake in costochondral junctions. (Reproduced with permission from Nakamoto and Taylor.28) (C) Tramline sign
HPOA. 99mTc-MDP bone scan shows intense bilateral symmetrical cortical uptake of tracer in femora. (D) Push up sign:
pectoral muscle strain or uptake. 99mTc-MDP bone scan shows increased tracer uptake in pectoral muscles. (Reproduced
with permission from Mackie et al.29) (E) Saddle sign: bilateral thigh adductor muscle injury. 99mTc-MDP bone scan
shows increased tracer uptake in bilateral thigh adductor compartments. (Reproduced with permission from Mackie
et al.32) (F) Sit up sign: rectus abdominis muscle strain. 99mTc-MDP bone scan shows increased tracer uptake in rectus
abdominis muscles. (Reproduced with permission from Sabnis et al.33)

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573

G. Gnanasegaran et al.

574

Figure 4 The hot spur sign: diastematomyelia. (A and B) 99mTc-MDP bone scan shows increased tracer uptake in the L1
spinous process and spinal canal at the level of scoliosis. (C) An axial CT scan shows a bony spur. (Reproduced with
permission from Thomas et al.17) (D) Hot skull sign: normal variant in obese patients. 99mTc-MDP bone scan shows
diffusely increased skull activity. (Reproduced with permission from Lorberboym et al.36)

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Interesting signs in nuclear medicine

Figure 5 Rim sign: symmetrical renal defect. 99mTc-MDP scan shows

the photopenic center surrounded by a rim of increased tracer uptake
in each kidney in a patient with non-Hodgkin's lymphoma. (Reproduced with permission from Choong.44)

575

Figure 6 (A and B) Pseudobladder sign: pregnancy. 99mTc-MDP bone

scan: (A) The immediate blood pool shows a nearly globular
hyperemic structure in the location of the urinary bladder with a
photopaenic area. The ow study was obtained immediately after
emptying the bladder. (B) The 3-hour delayed scan showed only a
small bladder with minimal urinary activity. Ultrasound obtained a
week later showed a pregnant uterus with an estimated gestational age
of 12 to13 weeks (Reproduced with permission from Veluvolu
et al.47) (C) Mickey Mouse (Mouse Face) sign: Paget's disease of
vertebra. 99mTc-MDP scan shows increased uptake in the vertebral
body, posterior elements, and the spinous process.

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G. Gnanasegaran et al.

576

Figure 7 Hot forearm sign and hot hand sign: Intra-arterial injection. 18F-FDG scan shows abnormally increased uptake
in the forearm and hand following intra-arterial injection. (Reproduced with permission from Kumar.58)

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Interesting signs in nuclear medicine

Figure 8 (A) Helmet sign: radioiodine contamination. 131I posttherapy scan in a woman revealed intense uptake along the
periphery of the skull or scalp. (Reproduced with permission from Ash et al.62) (B and C) Necklace sign: radioiodine
contamination. A 131I scan of a woman with history of papillary thyroid carcinoma suggested evidence of disease
recurrence at the base of her neck on the left side with near-undetectable thyroglobulin levels. Repeat scans were performed
as this was thought to be false positive. A scan without her necklace showed no evidence of 131Iodine uptake in the neck
(not shown), while one of the necklace alone showed uptake. (Reproduced with permission from Beaulieu et al.64) (D and
E) Straight line: sign of diffuse peritoneal carcinomatosis. 18F-FDG scan show a vertical straight line demarcating the
boundary between diffusely increased activity in the peritoneum and the much lower normal activity in the
retroperitoneum due to diffuse peritoneal carcinomatosis. (Reproduced with permission from Lin.70) (F) Pituitary sign:
99mTc(V)DMSA scan shows focal uptake in the pituitary gland. (Reproduced with permission from Watkinson et al.71)
(G) Raccoon eyes sign: A 123I-MIBG Marked increased tracer activity around the orbits in a grossly abnormal MIBG scan.
(Reproduced with permission from Bohdiewicz et al.69). (H and I) Chilaiditi sign: 18F-FDG PET shows increased uptake in
the right thorax, which corresponds to a colon loop between the liver and the diaphragm on CT (I). (Reproduced with
permission from Roy et al.66)

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577

G. Gnanasegaran et al.

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Figure 9 (A) Handkerchief sign: radioiodine contamination. Anterior and posterior images show increased tracer uptake in
the oral cavity, stomach, and bladder with further focal increate tracer in the right hip. However, delayed images several
days later after removal of contaminated handkerchief show disappearance of tracer activity. (Reproduced with permission
from Pochis et al.65) (B) Radioiodine hot hand sign: contamination. 131I Posttreatment posterior and anterior whole-body
scan, before cleaning, disclosed foci of abnormal I-131 uptake throughout the left chest, which is suggestive of mediastinal
and pulmonary metastases. Tracer activity in both hands suggests radioactive contamination. (Reproduced with permission
from Schechter et al.61)

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Interesting signs in nuclear medicine

Figure 10 (A-D) Checkerboard sign: pulmonary tumor microemboli. (A) Anterior and (C) posterior perfusion images of the
lungs reveal rectangular areas of reduced Tc-99m MAA within the upper lung elds (the checkerboard sign). (B) Anterior
and (D) posterior images of the lungs reveal a more homogeneous distribution of Tc-99m DTPA aerosols in the upper lung
elds. (Reproduced with permission from Fink-Bennett et al.72) (E) Stripe sign: pulmonary emphysema. 99mTc-MAA
perfusion scan shows an area of focal hypoperfusion that fails to extend to the pleural surface, leaving a peripheral rim of
perfused parenchyma. (Reproduced with permission from Sostman and Gottschalk.73) (F) Fissure sign: pleural effusion.
99mTc-MAA perfusion scan shows linear area of reduced or absent radionuclide uptake along the distribution of the major
and minor ssures on a lung perfusion scan. (Reproduced with permission from Cheema.76)

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579

G. Gnanasegaran et al.

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Figure 11 Hot clot sign: incidental focal F-18 FDG accumulation in lung parenchyma without abnormal CT ndings on
18F-FDG PET/CT. There is focal and intensely elevated FDG uptake with maximum standardized uptake value (SUVmax)
of 28.8 at the medial aspect of the anterior right upper lobe. CT images disclosed no lesion at this spot. The scan was
repeated with a lower dose CT protocol conned to the thoracic region. This time, the FDG uptake dened earlier was no
longer visible, proving that FDG hot clot and lung metastasis were ruled out. (Reproduced with permission from
Ozdemir.79)

Figure 12 Movahed sign: right ventricular Overload: Gated 99mTc SestaMIBI myocardial perfusion scan showing normal
LV perfusion, a D-shaped LV, and increased uptake in the RV wall. SPECT imaging shows D-shaped ventricle similar to
ones seen on echocardiography. (Reproduced with permission from Bashir and Shabo.81)

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Interesting signs in nuclear medicine

Figure 13 Nusigneffusion: (A) 201Tl scan. Photon-decient region caused by separation of the heart from the pulmonary
tissue, indicative of an effusion. (Reproduced with permission from McDonald et al.83) (B) Teardrop sign: hypertrophic
cardiomyopathy. In patients with hypertrophic cardiomyopathy, left ventricle appears bulbous in the apical region on
gated blood pool imaging with narrowing at the base during diastole, leading to a teardrop appearance. (Reproduced with
permission from Al-Bahar et al.82)

Figure 14 Hot rim or Rim sign (gall bladder): acute cholecystitis.

99mTc-DISIDA cholescintigraphy shows a curvilinear, pericholecystic
rim of increased hepatic tracer activity adjacent to a photopenic
gallbladder fossa. (Reproduced with permission from Cawthon
et al.88)
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G. Gnanasegaran et al.

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Figure 15 Rim sign (liver): liver abscess. (A) CT scan shows a hepatic abscess in the right lobe of the liver. (B) 99mTcmebrofenin scan shows a photopenic area in the hepatic lobe surrounded by a rim of activity greater than that of the
adjacent parenchyma (arrows). (Reproduced with permission from McDonald and Davani.96) (C) Radionuclide dance sign:
intussusception. 99mTc-pertechnetate scan shows a relative photon-decient area secondary to absent bowel seen in the
right iliac fossa region. (Reproduced with permission from Sty et al.99)

Figure 16 Pseudobulls eye sign: patent processus vaginalis. (A) Rim of increased tracer uptake with a photon-decient
center around the testis. However, ultrasound revealed peritesticular uid, which proved to be secondary extension of
periappendicular abscess via a patent process vaginalis, and a second case (B) demonstrated urinoma (ureterovesical
anastomotic leak). (Reproduced with permission from Melton et al.117)
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Interesting signs in nuclear medicine

Figure 17 (A and B) Signet ring sign: dilated renal pelvis. (A) 99mTc-MAG3 dynamic renography regrouped images. In the
early phase of the dynamic renography, there is a photopenic area in the lower portion of the right kidney, surrounded by a
rim of uptake, as shown at 2 minutes (arrow). On the following frames, this area lls with tracer, but the tracer seems to
predominantly concentrate laterally, suggesting that the renal pelvis may face the right anterolateral abdominal wall. The
photon-decient nature of the lower portion of the right kidney is likely to be because of the position of the lower portion of
the right kidney further away from the gamma camera when compared with the upper portion; the dilated renal pelvis with
nonradiolabeled urine within it (as expected in the early phase of the renogram) contributed further to the photon
attenuation. (B) 99mTc MAG3 dynamic renography early parenchymal phase of the study. This shows a photopenic area
surrounded by uptake in the lower portion of the right kidney, with good tracer uptake in the upper pole (arrow). These
ndings were later conrmed to represent a malrotated kidney with hydronephrosis. (Reproduced with permission from
D'Sa et al.121) (C and D) Cobra sign: ureterocoele. Dynamic renal scan shows a hydronephrotic left kidney with a
hydroureter and associated saccular outpouching at its distal end, consistent with ureterocoele. (Reproduced with
permission from Riaz et al.114)

Figure 18 Lady bug sign: scrotal hydrops. 99mTc-pertechnetate scan

shows increased tracer uptake in the scrotal wall, median raphe, and
testicles. Differentials: Hydrocele and hypoproteinemia causing scrotal
swelling. (Reproduced with permission from Barrett and Buozas.116)
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Figure 19 (A and B) Hourglass sign: fused pelvic kidney. (A) 99mTc-DTPA scan shows hourglass uptake demonstrating
functional fused pelvic kidneys without obstruction. (Reproduced with permission from Karacalioglu et al.113)

Figure 20 (A) Hollow skull: a sign of brain death. 99mTc-hexamethylpropyleneamine oxime (HM-PAO) cerebral perfusion
imaging. (A)Tracer uptake of the cranium and a hollow skull with no visualization of any brain tissue suggesting brain
death. (Reproduced with permission from Abdel-Dayem et al.128) (B and C) Hot nose sign: a sign of brain death. 99mTcHMPAO cerebral perfusion imaging. (B) Early arterial phase image and (C) delayed phase image both demonstrate no ow
to the cerebral hemispheres and abnormal increased nasopharyngeal activity (arrows). (Reproduced with permission from
Appelt et al.125)
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Interesting signs in nuclear medicine

Figure 21 (A) Owl's eye sign:. There is a large photopenic area with a central focal area of increased uptake in the left lobe of
thyroid, which gives the appearance of an owl's eye. Caused by a focus of functioning tissue overlapping a large cold area
in a nodule that has cystic degeneration and necrotic changes. Differentials: thyroid cyst, functioning nodule, and papillary
cancer of the thyroid. (Reproduced with permission from Al-Kordi and Elgazzar.134) (B) Fish eye sign: Thyroid scan shows
a focus of functioning tissue within an area of decreased activity appears as sh eye sign. Although this sign is not
pathognomonic of a benign process. (Reproduced with permission from Gulaldi.132) (Color version of gure is available
online.)

Figure 22 Hockey stick sign: thyroid hemi agenesis. 99mTc-pertechnetate thyroid scan showing normal right lobe or isthmus and thyroid
with absent left lobe. However, simliar scan appearances can also be
seen in patients post lobectomy. (Reproduced with permission from
Damle et al.139)
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Figure 23 (A) Panda sign: sarcoidosis. 67Ga scan shows focal accumulation in the nasopharynx, parotid gland, and lacrimal
gland, distributed symmetrically, produces a distinct pattern, the Panda sign that is strikingly similar to the dark marking
of the giant panda. (Reproduced with permission from Sulavik et al.143) (B) Lambda sign: sarcoidosis. 67Ga scan shows a
distinctive intrathoracic lymph node uptake resembling Greek letter lambda is referred to as the lambda sign.
Simultaneously with panda sign is highly specic or suspicious for sarcoidosis. (Reproduced with permission from
Yoshimizu.142) (C) Cervical collar sign: Periarteritis Nodosa. 67Ga scan shows intense tracer uptake in the subcutaneous
region of the posterior neck forming a collar shape in a patient with cutaneous involvement of periarteritis nodosa.
(Reproduced with permission from Klaas et al.144) (D) Beard sign: facial acne. 67Ga scan shows marked tracer uptake by the
soft tissue of the face in a beard pattern in a 16-year-old boy being treated for multifocal osteomyelitis The increased soft
tissue uptake was due to severe facial acne. (Reproduced with permission from Taillefer et al.150)

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Interesting signs in nuclear medicine

Figure 24 Halo sign: encapsulated hematoma. 99mTc-pertechnetate

scan shows a central area of decreased activity surrounded by an halo
of increased activity. (Reproduced with permission from Rivera
et al.127)

Acknowledgments
Journals (a) Clin Nucl Med, (b) Rev Esp Med Nucl, (c) Joint
Bone Spine, (d) J Nucl Med, (e) Semin Nucl Med, (f) Kaku
Igaku, (g) JAMA, (h) Indian J Endocrinol Metab, (i) Eur J Nucl
Med, (j) World J Nucl Med, (k) Pak J Nucl Med, (l) Ann Nucl
Med, (m) Radiology, and (n) Nucl Med Commun.

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