MDCT of 220 consecutive patients with suspected acute pulmonary embolism: incidence of pulmonary embolism and of other acute or non-acute thoracic findings

PURPOSE: This study was undertaken to evaluate the incidence of pulmonary embolism (PE) and other clinically relevant thoracic findings discovered on contrast-enhanced multidetector computed tomography (MDCT) examination in patients with a suspicion of acute PE. MATERIALS AND METHODS: We retrospectively reviewed 220 reports of 40-row MDCT exams in consecutive patients (101 men, 119 women; mean age 55 years+/-18) suspected for acute PE. Presenting symptoms and risk factors were recorded. Image quality and incidence of PE and other clinically relevant thoracic findings were evaluated. RESULTS: MDCT were diagnostic in 96.8% of patients. Nineteen patients (8.6%) were positive for PE. Signs and symptoms were present in 82.7% (182) and risk factors in 38.2% (84) of the population. Clinically relevant thoracic findings were detected in 45.9% (101) of the patients. Ten patients had PE and other thoracic findings. Half of the patients (110) had neither PE nor other clinically relevant thoracic findings. CONCLUSIONS: Chest MDCT, with an excellent overall image quality, provided an explanation for the clinical presentation in about 50% of emergency department patients studied and was useful in detecting PE and other thoracic diseases with symptoms mimicking PE. However, half of the exams were negative.     

Acute pulmonary embolism: comparison of standard axial MDCT with paddlewheel technique

PURPOSE: The purpose of this study was to evaluate the ability of rotated paddlewheel reformations for the detection of central and peripheral pulmonary embolism (PE) compared to standard axial multi detector CT (MDCT) images. MATERIAL AND METHODS: CT scans of 35 patients with PE were reviewed by three independent readers for the detection of pulmonary emboli using standard axial CT scans and reformatted paddlewheel technique. All images were evaluated in random order. MDCT examinations were performed with a collimation of 1.25 mm, a pitch of six and a reconstruction interval of 0.8mm. For each patient MIP were reformatted by using a paddlewheel arrangement with 5mm slab thickness and 5 degrees rotation. Standard of reference for PE was a consensus reading of the axial images by all three readers. RESULTS: The overall sensitivity for the axial images for the three readers ranged between 91% and 96%; for paddlewheel reformations from 78% to 83%; the specificity for both methods was 98-99%. Inter- and intraobserver agreement was also higher for axial images than for paddlewheel reformations. CONCLUSION: Comparing standard axial MDCT scans and reformatted paddlewheel images no significant difference for the detection of central PE was found, whereas for the detection of peripheral emboli standard axial images showed a significant higher percentage of detecting PE than paddlewheel reformations.     

MDCT for the diagnosis of acute pulmonary embolism

With the advent of multidetector CT, pulmonary CT angiography (MD-CTPA) has substantially gained in spatial resolution and is the accepted method of choice to diagnose and rule out acute pulmonary embolism down to the subsegmental level. This article reviews means to optimize scanning technique and contrast injection protocols dependent on the scanner type used. It summarizes recent publications on the performance of MD-CTPA with special emphasis on the diagnostic accuracy, interpretation and clinical role of (isolated) peripheral emboli. Diagnostic algorithms are outlined that describe the role of CT in context with the pretest probability, the D-Dimer, lower limb sonography and scintigraphy.     

MDCT for the diagnosis of acute pulmonary embolism

With the advent of multidetector CT, pulmonary CT angiography (MD-CTPA) has substantially gained in spatial resolution and is the accepted method of choice to diagnose and rule out acute pulmonary embolism down to the subsegmental level. This article reviews means to optimize scanning technique and contrast injection protocols dependent on the scanner type used. It summarizes recent publications on the performance of MD-CTPA with special emphasis on the diagnostic accuracy, interpretation and clinical role of (isolated) peripheral emboli. Diagnostic algorithms are outlined that describe the role of CT in context with the pretest probability, the D-Dimer, lower limb sonography and scintigraphy.     

支气管动脉扩张在肺动脉栓塞中的意义

目的探讨支气管动脉扩张在肺动脉栓塞中的意义。方法回顾性分析48例肺动脉栓塞病例的影像及临床资料,并设立对照组,观察支气管动脉扩张出现的几率并分析其临床意义。结果在肺动脉栓塞组及对照组中,支气管动脉出现分别为41例、12例,两组间差异有统计学意义(χ2=1157,P<001)。肺动脉栓塞组的支气管动脉扩张数为27例,对照组无支气管动脉扩张。肺动脉栓塞病例又分为中心组和周围组,支气管动脉扩张出现在中心组14例,周围组13例,两组间差异有统计学意义(χ2=542,P<005)。结论当肺动脉栓塞出现支气管动脉扩张时,提示肺动脉栓塞程度较严重。     

Clinicians' response to radiologists' reports of isolated subsegmental pulmonary embolism or inconclusive interpretation of pulmonary embolism using MDCT

OBJECTIVE: The purpose of our study was to investigate clinician response and patient outcome associated with the radiologist's report of isolated subsegmental pulmonary emboli (ISSPE) or indeterminate or inconclusive results on MDCT for venous thromboembolism. MATERIALS AND METHODS: All patients were examined using 8- or 16-MDCT. Reported findings on combined CT pulmonary angiography and CT venography of 1,435 consecutive patients were analyzed retrospectively. The charts of patients of interest with ISSPE or with indeterminate or inconclusive pulmonary embolism results were analyzed for clinician response and recurrent symptoms of venous thromboembolism in both treated and untreated patients during the following 3 months. RESULTS: We studied 207 patients of interest, and follow-up was available on 192 (92.8%) (67 ISSPEs, 125 inconclusive). Of the 192 patients, 25 (37%) of 67 patients with ISSPE and 108 (86%) of 125 patients with inconclusive results did not receive anticoagulation. Two patients with ISSPE and two patients with inconclusive results returned with new symptoms suggesting recurrent venous thromboembolism, but no venous thromboembolism was found. Thirteen (10%) of 133 untreated patients died without clinical evidence of recurrent venous thromboembolism. In 61 patients who received anticoagulation (42/67 [63%] ISSPE and 17/125 [14%] inconclusive), five patients returned with venous thromboembolism symptoms. None had recurrent emboli. Two (3%) of 61 patients who received anticoagulation died of other diseases. CONCLUSION: Patients with ISSPE more commonly received anticoagulation than not. In the patients who did not receive anticoagulation, no recurrent pulmonary embolism was identified on follow-up. In most patients with inconclusive findings on CT pulmonary angiography, clinicians chose to withhold anticoagulation without additional imaging workup. No adverse effects of this clinical decision were uncovered.     

The effect of single-detector CT versus MDCT on clinical outcomes in patients with suspected acute pulmonary embolism and negative results on CT pulmonary angiography

OBJECTIVE: We sought to compare the clinical outcomes of patients in whom pulmonary embolism (PE) has been ruled out with single-detector CT versus MDCT, given the improved visualization of subsegmental clots with the latter and the recent increase in use of CT for evaluation of PE. SUBJECTS AND METHODS: Two cohorts of patients undergoing CT for suspected PE with either single-detector CT (3-mm collimation and pitch of 1.7) or MDCT (2-mm collimation and pitch of 1) scanners were prospectively observed and compared using predefined criteria for evidence of subsequent thromboembolic disease during the 6 months after the acquisition of their initial scan. RESULTS: Ninety-eight patients were scanned using a single-detector CT scanner. Of these, none had evidence of subsequent PE or deep venous thrombosis (DVT), and six (6.1%) died of unrelated causes. Of the 100 patients scanned using an MDCT scanner, one (1.0%) had a subsequent nonfatal PE 2 months after the initial scanning, one (1.0%) had DVT 1 month after the initial scanning, and eight (8.0%) died of unrelated causes. No significant difference was found in either the probability of subsequent thromboembolic events (chi(2) = 0.3183, degrees of freedom [df] = 1, p = 1) or frequency of unrelated deaths (chi(2) = 0.2655, df = 1, p = 0.7829) between patients scanned using single-detector CT or MDCT protocols. CONCLUSION: Our results show that patients with suspected acute PE and negative CT results have acceptable clinical outcomes in the absence of anticoagulation treatment up to 6 months after acquisition of their initial scan. Furthermore, we found that the increased visualization of smaller, more peripheral arteries afforded by multislice technology did not affect clinical outcome.     

Follow-up CT pulmonary angiograms in patients with acute pulmonary embolism

Computed tomographic (CT) angiography is associated with a non-negligible lifetime attributable risk of cancer. The risk is considerably greater for women and younger patients. Recognizing that there are risks from radiation, the purpose of this investigation was to assess the frequency of follow-up CT angiograms in patients with acute pulmonary embolism. This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in three emergency departments from January 2013 to December 2014. Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients. At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %). Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %). Among young women (aged ≤29 years) with pulmonary embolism, 10 of 21 (47.6 %) had at least 1 follow-up and 4 of 21 (19.0 %) had 2 or more follow-ups in 1 year. Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up. Follow-up CT angiograms were obtained in a significant proportion of patients with pulmonary embolism, including young women, the group with the highest risk. Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women.     

MR angiography with sensitivity encoding (SENSE) for suspected pulmonary embolism: comparison with MDCT and ventilation-perfusion scintigraphy

OBJECTIVE: The aim of our study was to determine the utility of time-resolved contrast-enhanced MR angiography combined with sensitivity encoding (SENSE) for patients with pulmonary embolism. SUBJECTS AND METHODS. Forty-eight consecutive patients (26 men and 22 women; age range, 27-73 years; mean age, 55 years) with suspected pulmonary embolism underwent chest radiography, contrast-enhanced MDCT, MR angiography with SENSE, ventilation-perfusion scintigraphy, and pulmonary angiography. MR angiography with SENSE was performed using IV administration of gadolinium contrast medium with a 3D turbo field-echo pulse sequence (TR/TE, 4.0/1.2; flip angle, 30 degrees ) on a 1.5-T scanner. Capabilities of diagnosing pulmonary embolism using MR angiography (data set A), contrast-enhanced MDCT (data set B), contrast-enhanced MDCT with MR angiography (data set C), ventilation-perfusion scintigraphy (data set D), and contrast-enhanced MDCT with ventilation-perfusion scintigraphy (data set E) were determined by receiver operating characteristic analysis, using the results of pulmonary angiography as the reference standard. The diagnostic capability of each data set was analyzed on a per-vascular zone and a per-patient basis with the McNemar test. RESULTS: Sensitivity and specificity of data set A were 83% and 97%, respectively, on a per-vascular zone basis and 92% and 94%, respectively, on a per-patient basis. Specificity and accuracy of data set A were significantly higher than those of data set D on a per-patient basis (p < 0.05). CONCLUSION: Time-resolved MR angiography with SENSE is effective for the diagnosis of pulmonary embolism.     

Application of a new pulmonary artery obstruction score in the prognostic evaluation of acute pulmonary embolism: comparison with clinical and haemodynamic parameters

Purpose

Evaluation of computed tomography (CT) pulmonary angiography parameters revealing pulmonary embolism (PE) severity with particular attention to pulmonary obstruction indexes. Comparison with clinical and hemodynamic data and determination of predictive role in the development of chronic pulmonary heart disease.

Materials and methods

This retrospective study analyzes 45 not consecutive patients from November 2007 to December 2008 with CT angiography diagnosis of acute PE. Included in the study are patients at the first documented episode of acute PE, with 6 month follow-up. Patients with severe pre-existent cardiopulmonary pathology or neoplastic diseases were excluded from the study. CT angiography evaluated right ventricular (RV)/left ventricular (LV) ratio, obstruction index according to Qanadli and Total Clot Burden (Ghanima score). PE indexes were compared with Troponin I measurement and echocardiography result; at last hospitalization and intensive care time were reported.

Results

A significant association was found between Ghanima and Qanadli score: the two indexes are equivalent in quantification of pulmonary arterial obstruction (p<0.001). Among others CT parameters, the new Ghanima score evidenced the best accuracy to detect patients evolving to chronic pulmonary heart disease (76%). This value is higher than that of echocardiography (71%). Troponins showed highest accuracy (82%).

Conclusions

Ghanima score can be used in emergency CT angiography diagnosis as prognostic marker for a quickly risk stratification of pulmonary heart disease or death in patients with acute PE. This approach allows to obtain, with just one test, both the diagnosis and a rather accurate acute PE risk stratification.     

肺灌注/通气显像与肺动脉造影诊断肺栓塞的对比分析

目的：评价肺灌注／通气显像诊断肿栓塞的价值。方法：回顾性分析45例疑肺栓塞患者的肺核素显像结果，并与肺动脉造影检查对照。结果：肺动脉造影诊断为肺栓塞的患者26例，有180个肺动脉支为充盈缺损，其肺灌注显像示167个节段呈完全肺段性或亚肺段缺损，符合率为92．7％。肺动脉造影显示为86个肺动脉支为部分充盈缺损，肺灌注显像有63个肺段或亚肺段缺损，符合率为73．2％（P＜0．01）。肺核素显像对肺栓塞诊断的灵敏度为92．3％，特异性为84．2％，阳性预测值和阴性预测值均为88．9％。26例肺动脉造影诊断为肺栓塞的患者，有23例行肺通气显像，通气／灌注均不匹配。结论：肺灌注／通气显像对肺栓塞诊断具有重要的临床价值。     

急性肺栓塞的心电图诊断分析

目的分析急性肺栓塞患者心电图特征及其意义。方法回顾性分析21例临床确诊的急性肺栓塞患者的心电图特征。结果 21例急性肺栓塞患者心电图出现改变者19例（90.5%）,其中窦性心动过速者9例（42.9%）,SⅠ〉0.1mV者11例（52.4%）,TⅢ倒置者10例（47.6%）,QⅢTⅢ者9例（42.9%）,SⅠQⅢTⅢ者7例（33.3%）,TV1倒置者16例（76.2%）,TV1~V2倒置者9例（42.9%）,TV1~V3倒置者6例（28.6%）,TV1~V4倒置者5例（23.8%）,TV1~V5倒置者3例（14.3%）,CRBBB者2例（9.5%）,ICRBBB者4例（19.0%）,顺钟向转位者7例（33.3%）,电轴右偏者3例（14.3%）。结论急性肺栓塞的心电图具有非特异性和多样性的特点,熟悉常见的心电图征象有助于病情的评估和判断,应仔细观察并密切结合其它辅助检查早期识别。     

Correlation of CT angiographic pulmonary artery obstruction scores with right ventricular dysfunction and clinical outcome in patients with acute pulmonary embolism

Objective

To correlate CTA pulmonary artery obstruction scores (OS) with right ventricular dysfunction (RVD) and clinical outcome in patients with acute pulmonary embolism (PE).

Materials and methods

In a prospective study of 50 patients (66 ± 12.9 years) with PE pulmonary artery OS (Qanadli, Mastora, and Mastora central) were assessed by two radiologists. To assess RVD all patients underwent echocardiography within 24 h. Furthermore, RVD on CT was assessed by calculating the right ventricular/left ventricular (RV/LV) diameter ratios on transverse (RV/LVtrans) and four-chamber views (RV/LV4ch) as well as the RV/LV volume ratio (RV/LVvol). OS were correlated with RVD and the occurrence of adverse clinical outcomes (defined as death, need for intensive care treatment, or cardiac insufficiency ≥NYHA III).

Results

Mean Mastora, Qanadli, and Mastora central OS were 26.4 ± 17.7, 12.6 ± 9.9 and 7.5 ± 9, respectively. Echocardiography demonstrated moderate and severe RVD in 10 and 5 patients, respectively. Patients with moderate and severe RVD showed significantly higher Mastora central scores than patients without RVD (14 ± 10.8 vs. 5.9 ± 7.8 [p = 0.05]; 17.6 ± 13.2 vs. 5.9 ± 7.8 [p = 0.038]). A relevant correlation (i.e. r ≥ 0.6) between OS and CT parameters for RVD were only found for the Mastora score and the Mastora central score (RV/LV4ch: r = 0.61 and 0.68, RV/LVvol: r = 0.61 and 0.6). 18 patients experienced an adverse clinical outcome. None of the OS differed significantly between patients with and without adverse clinical outcome.

Conclusion

Pulmonary artery obstruction scores can differentiate between patients with and without RVD. However, in this study, obstruction scores were not correlated to adverse clinical outcome.     

Chest multidetector computed tomography (MDCT) in patients with suspected acute pulmonary embolism: diagnostic yield and proportion of other clinically relevant findings

Purpose

The authors evaluated the diagnostic yield of chest multidetector computed tomography (MDCT) in acute pulmonary embolism (PE) and the proportion of other clinically relevant findings in a large cohort of consecutive inpatients and patients referred from the emergency department (outpatients).

Materials and methods

A total of 327 radiological reports of chest MDCT scans performed for suspected acute PE in 327 patients (158 men, 169 women; mean age 69 years, standard deviation 17.33 years; 233 inpatients, 94 outpatients) were retrospectively evaluated and classified into four categories: 1, positive for PE; 2, negative for PE but positive for other findings requiring specific and immediate intervention; 3, completely negative or positive for findings with a potential for significant morbidity requiring specific action on follow-up; 4, indeterminate. The distribution of findings by categories among the entire population and inpatients and outpatients separately was calculated (chi-square test, ??=0.05).

Results

In the entire population, the diagnostic yield (i.e. proportion of cases classified as category 1) was 20.2% (66/327). Proportions of cases classified as categories 2, 3 and 4 were 27.5% (90/327), 44.3% (145/327) and 7.9% (26/327), respectively. No statistically significant difference was found between inpatients and outpatients (p=0.193).

Conclusions

In patients with suspected acute PE, chest MDCT provides evidence of conditions requiring immediate and specific intervention (i.e. categories 1 and 2) in nearly 50% of cases, without differences between inpatients and outpatients.     

Bronchial and nonbronchial systemic arteries in patients with hemoptysis: depiction on MDCT angiography

OBJECTIVE: In this pictorial essay, we show the usefulness of MDCT angiography for visualization of the bronchial and nonbronchial systemic feeder vessels responsible for hemoptysis. CONCLUSION: By providing thin-section transaxial, multiplanar reconstruction, and 3D images, CT angiography using MDCT allows comparable or better images than conventional angiography with respect to the depiction of bronchial or nonbronchial systemic arteries. CT angiography is particularly useful for visualizing the ectopic origin of bronchial arteries and nonbronchial systemic collateral arteries.