• Describe the techniques used to improve the quality of MD-CTPA • Illustrate the diagnostic criteria of chronic and acute pulmonary emboli • Illustrate common artifacts and pitfalls in imaging and diagnosis 3. 33, No. Because the venous return from the inferior vena cava to the right atrium is exaggerated with heightened respiratory movements , we verbally instruct our patients not to perform an exaggerated inspiration and the CT technologist prompts the patient to “hold your breath” before image acquisition. Localized increase in vascular resistance can result from lung consolidation or atelectasis . Involvement of the lung volume was estimated to be between 25% and 50%. 67, No. Diagnostic yield of CT pulmonary angiography in the diagnosis of pulmonary embolism: A single center experience Zhonghua Sun1* and Jing Lei2 1Department of Medical Radiation Sciences, Curtin University, Perth, Western Australia, 6845, Australia 2Department of Medical Imaging, First Affiliated Hospital of Kunming Medical Chronic pulmonary emboli and radiologic mimics on CT pulmonary angiography: a diagnostic challenge. 45, No. Radiology 2005; 237: 329-337. There are two principal approaches for performing a CTPA of high diagnostic quality: 11, Journal of Medical Virology, Vol. Author contributions: Guarantors of integrity of entire study, F.G., J.B., E.D. A review of the literature shows that the transient interruption of contrast artifact was seen in 3% of the study population in that study , whereas in the study by Gosselin et al. 9, CardioVascular and Interventional Radiology, Vol. 7, Journal of Proteome Research, Vol. Purpose: To retrospectively review imaging characteristics of indeterminate computed tomographic (CT) pulmonary angiograms for pulmonary embolism (PE) and patient outcome. The technique for CT pulmonary angiography with single-section helical CT involves the following parameters: 3-mm collimation, 2-mm reconstruction interval, pitch of 2, and an average acquisition time of 24 seconds. Both acute and chronic pulmonary emboli are identified as intraluminal filling defects that show a sharp interface with IV contrast material. If an indeterminate scan occurs with standard delay due to poor enhancement, there is no extravasation of contrast material, and the timing is appropriate, then poor venous flow due to stenosis or obstruction may be a factor , in which case a different venous access site may be necessary. The focal slow pulmonary artery flow can be a cause of an indeterminate CTPA (Fig. Pulmonary CT Angiography Protocol Adapted to the Hemodynamic Effects of Pregnancy. Interestingly, extent of lesions was not associated with pulmonary embolus. Question Given increasing concerns of imaging overuse for pulmonary embolism, has the use of computed tomographic pulmonary angiography (CTPA) decreased over time?. In dyspneic patients, oxygen supplementation can help the patient provide the desired period of apnea. It is regarded as a highly
sensitive and specific test for pulmonary embolism.
3. The frequency of examinations devoid of motion artifacts is significantly higher for MDCT, which has a shorter breath-hold than single-detector CT [14, 15]. It followed the ethical guidelines of the Declaration of Helsinki. However, modified window settings can also increase the conspicuity of artifacts caused by image noise and flow. BACKGROUND: Patent foramen ovale (PFO) in patients with acute pulmonary embolism (PE) represents a risk factor for mortality, but this has not been evaluated for CT pulmonary angiography (CTPA). However, in cases with poor function of the right side of the heart, the enhancement threshold might never be reached; this leaves the technologist uncertain as to when to start image acquisition. 7, 23 October 2020 | RadioGraphics, Vol. Pulmonary embolism (PE) is a common condition with high mortality and morbidity. This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. Each radiology department will have a slightly different method for achieving the same outcome, i.e. It has been suggested that the early detection of acute right ventricular failure allows the implementation of the most appropriate therapeutic strategy . No radiation … Chest CT plays an important role in optimizing the treatment of patients with coronavirus disease 2019 (COVID-19) while also eliminating alternate diagnoses or added pathologic conditions, particularly for acute pulmonary embolism (1). 64, No. The interobserver correlations for diagnosis of subsegmental PE with multidetector spiral CT exceed the reproducibility of selective pulmonary angiography. CT pulmonary angiography: Has replaced conventional pulmonary angiography as the reference standard for pulmonary embolism diagnosis because of its ease of performing and high sensitivity and specificity. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. For a long time we have been at a stage at which the direct radiologic signs, as shown on CT angiography, are required to make a diagnosis of acute or chronic pulmonary thromboembolic disease. The delivery of chest CT imaging for suspected pulmonary embolism has continued to climb in the U.S. despite concerns of overuse, according to a study published Friday. 30, No. Key Points. One could argue that when the triggering threshold for bolus tracking is increased, CT would start later on the rise of the enhancement curve. AJR Am J Roentgenol. 6, Journal of Thrombosis and Thrombolysis, Vol. Nevertheless, our results suggest that patients with severe clinical features of COVID-19 may have associated acute pulmonary embolus. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA, The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society, https://doi.org/10.1148/radiol.2020201544, Open in Image
Supplement_3, QJM: An International Journal of Medicine, American Journal of Therapeutics, Vol. Also, reformatted images can help to differentiate between some patient, technical, anatomic, and pathologic factors that mimic pulmonary embolism and true pulmonary embolism . doi: 10.1148/radiol.2020201561. 12, JACC: Cardiovascular Imaging, Vol. Offers alternative diagnosis when pulmonary embolism is absent. 27, No. Pulmonary embolism is the third most common acute cardiovascular disease, after myocardial infarction and stroke, and results in an estimated 200,000-300,000 hospitalizations and 37,000-44,000 deaths per year in the United States . 5, Clinical Medicine (Russian Journal), Vol. However, the number of detectors should not affect the appearance of this artifact. 4, No. Pulmonary Vascular Manifestations of COVID-19 Pneumonia, Pulmonary Sequelae in Convalescent Patients after Severe Acute Respiratory Syndrome: Evaluation with Thin-Section CT, Quantitative Burden of COVID-19 Pneumonia on Chest CT Predicts Adverse Outcomes: A Post-Hoc Analysis of a Prospective International Registry, Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study, Dual-Energy CT Pulmonary Angiography (DECTPA) Quantifies Vasculopathy in Severe COVID-19 Pneumonia, 3D Multiplanar Imaging in the Diagnosis and Management of Lung Transplantation Complications, Manifestations of Eosinophilic Diseases of the Lung, Infectious Respiratory Emergencies: HRCT Findings and Differential Diagnosis. Patients with pulmonary embolus were more likely to require care in the critical care unit and to require mechanical ventilation compared with those without pulmonary embolus. Prologo JD, Gilkeson RC, Diaz M, Asaad J.Department of Radiology, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106. 6, Indian Journal of Medical Specialities, Vol. In this manner, any case with adequate enhancement and no or minimal motion can be confidently interpreted. Therefore, the highest possible attenuation value of chronic pulmonary emboli with 3 SDs is calculated to be 180 H. The minimum attenuation of adjacent opacified blood to identify this outlying chronic thrombus is 211 H. The theoretic minimum attenuations of blood required to see all acute and chronic pulmonary venous thromboemboli are 93 and 211 H, respectively.  were among the first to describe pulmonary embolism on contrast-enhanced CT. 11, World Journal of Radiology, Vol. The first-pass effect is optimized by the use of contrast material with 370 mg I/mL. 12, International Journal of Legal Medicine, Vol. Because the indirect signs have a differential diagnosis, they are helpful only as indicators of the sites of the direct radiologic signs of pulmonary embolism. AJR Am J Roentgenol. Consecutive patients with suspected PH undergoing routine CT pulmonary angiography and right … Combining these values with experimental work by Meaney et al. C, D, Coronal CT reformations (mediastinum windows) show bilateral lobar and segmental pulmonary embolism (arrows). CT Pulmonary Angiography: A Comparative Analysis of the Utilization Patterns in Emergency Department and Hospitalized Patients Between 1998 and 2003. A rapid change in position of vessels on contiguous images also confirms motion artifact. Pulmonary angiography 1. Occasionally, a large acute central pulmonary embolism can cause oligemia and a reversible decrease in vessel diameter; this CT equivalent of the Westermark sign has been previously illustrated . CT pulmonary angiography (CTPA) is a medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries. At the same time the structure of the heart is also well visualised and so the examination is sometimes simply called a cardiac CT. 6, Academic Emergency Medicine, Vol. 7-8, Diabetes & Metabolic Syndrome: Clinical Research & Reviews, Vol. 4, Journal of Stroke and Cerebrovascular Diseases, Vol. were instructed to have five respiratory cycles of hyperventilation followed by a command of full inspiration 2 seconds before initial images were obtained . How is a CTPA performed? CT angiography may provide more precise anatomical details than other angiography exams such as conventional catheter angiography and magnetic resonance imaging (MRI). For IV access, the antecubital vein and an 18- or 20-gauge catheter is preferred. 50, No. At the moment, the breath-hold required for 16-MDCT is approximately 10 seconds, and for 64-MDCT, less than 3 seconds. 50, No. This article outlines the approaches necessary to improve the quality of CT pulmonary angiography and summarizes the diagnostic criteria for acute and chronic pulmonary emboli. P < .05 was indicative of a significant difference. Radiology 2005: 235; 1050-1054. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. This enhancement advantage is most optimally used with the empiric delay technique, whereas bolus tracking starts the CT scan earlier on the rise of the enhancement curve and results in worse pulmonary artery enhancement. 1, Egyptian Journal of Radiology and Nuclear Medicine, Vol. Consolidation can cause a focal increase in vascular resistance and focal poor vascular opacification . The potential of the noninvasive technique, CT pulmonary angiography (CTPA), has now been realized at most institutions; it has become the test of choice and thus the de facto standard of care . Iodinated contrast medium is administered as a … 12, European Journal of Internal Medicine, Vol. What can be done to avoid this flow phenomenon? The pulmonary vasculature may be evaluated with various invasive and noninvasive methods. 0, No. By Carole A. Ridge et al. 14, No. Prescanning hyperventilation is likely the cause; with the implementation of faster scanners, prescan hyperventilation should be dropped. The pulmonary vasculature may be evaluated with various invasive and noninvasive methods. CT Angiography for Chest With Contrast (CECT Angiography for Chest ). 98, No. 43, No. 4, The American Journal of Cardiology, Vol. 103, Journal of Stroke and Cerebrovascular Diseases, Vol. CT scans were obtained 10 days after the onset of coronavirus disease 2019 symptoms on the day the patient was transferred to the intensive care unit. A mosaic pattern of lung attenuation is identified on the lung window settings. We acknowledge the preliminary nature of these findings, including its retrospective nature and limited sample size. Pictorial Essay. A, B, Axial CT images (lung windows) show peripheral ground-glass opacities (arrow in A) associated with areas of consolidation in dependent portions of the lung (white arrowhead). In contrast, its role in CTEPH is less well defined. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. doi: 10.1148/radiol.2020201561. The CT parameters are given in Tables 1 and 2. (2)North Bristol Lung … However, previous reports suggested coagulopathy associated with COVID-19 infection (2,3). Conclusion: Normal CT Pulmonary Angiogram. Author information: (1)Department of Radiology, Westbury-on-Trym, Bristol, England. 5). Three authors (F.G., J.B., P.C.) To determine the clinical factors associated with pulmonary embolus, we considered the CT extent of lesions, need for invasive mechanical ventilation, demographic characteristics, and presence of comorbidities as potential independent variables in a logistic regression model. 30, No. Hounsfield unit values of acute and chronic pulmonary emboli. Our routine protocol for patients with severe clinical features of COVID-19 infection was multidetector pulmonary CT angiography using a 256-slice multidetector CT scanner (Revolution; GE Healthcare, Milwaukee, Wis) after intravenous injection of 60 mL iodinated contrast material (Iomeprol, 400 mg of iodine per milliliter; Bracco Imaging, Milan, Italy) at a flow rate of 4 mL/sec, triggered on the … Key point: CT is the preferred modality for imaging of suspected pulmonary embolism in pregnancy… Historically, catheter-directed pulmonary angiography has been used most commonly for the diagnosis of suspected pulmonary embolism (PE). Wijesuriya S(1), Chandratreya L(1), Medford AR(2). What is a CT pulmonary angiogram? The upper abdominal solid organs and bowel have a normal arterial phase appearance within the field of view. A CTPA is performed in the radiology department scanning room, with the patient lying flat (supine) on a CT table. The caudal-cranial direction is used because most emboli are located in the lower lobes and, if the patient breathes during image acquisition, there is more excursion of the lower lobes compared with the upper lobes. Respiratory motion artifacts are the most common cause of an indeterminate CTPA and can be a cause of misdiagnosis of pulmonary embolism. CT angiography is well positioned to become the gold standard for imaging of the pulmonary vasculature. CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. 7, Revista Española de Anestesiología y Reanimación (English Edition), Vol. • Wittram C, Maher MM, Halpern E, Shepard JO. This article discusses the solutions to the common causes of an indeterminate CTPA. Readers were blinded to patient status as well as to clinical and biologic features. A ratio of 1.0 is associated with a 5% chance of death; 1.3, 10%; 1.7, 20%; 1.9, 30%; 2.1, 40%; and a ratio of 2.3 is associated with a 50% chance of death . In addition to standard CT studies of the lungs for infection and cancer, high-resolution CT studies of the lungs for diagnosis and evaluation of treatment effectiveness for diffuse lung disease (a group of disorders causing progressive scarring of lung tissue) are now routine. 47, No. If the size of the IV access catheter does not allow 4 mL/s, then the delay needs to increase, as illustrated in Table 3. 12, No. Pulmonary embolism is a common condition with considerable morbidity and mortality. CT angiography for pulmonary embolism detection: the effect of breathing on pulmonary artery enhancement using a 64-row detector system. Materials and methods: Investigational review board approval was obtained, informed consent was waived, and the study was HIPAA compliant. Monitoring Treatment Responses in Patients with Pulmonary TB Using Serial Lung Gallium-67 Scintigraphy, Review. 4, Advances in Difference Equations, Vol. The positive predictive value of abnormal findings on CTPA was high (92-96%) in patients with an intermediate or high clinical probability but much lower (58%) in patients with a low likelihood of pulmonary embolism. At one university hospital, such imaging has increased more than fivefold. Finally, 100 patients with COVID-19 infection and severe clinical features were included and examined with contrast material–enhanced CT (Fig 1). These signs include nonuniform arterial perfusion for both acute and chronic pulmonary embolism; this radiologic sign is difficult to identify in cases of acute pulmonary embolism but manifests as mosaic attenuation in cases of chronic pulmonary embolism. 0, 8 December 2020 | Radiology, Vol. Pulmonary embolism (PE) is a common condition with high mortality and morbidity. Sometimes a lesion will be hypovascular compared to the normal tissue and in some cases a lesion will be hypervascular to the surrounding tissue in a certain phase of enhancement. Using contrast injected into the blood vessels, images are created to look for blockages, aneurysms (dilations of walls), dissections (tearing of walls), and stenosis (narrowing of vessel). 2, No. 0, No. 98, No. The requirement for written informed consent was waived. Important clinical markers were not available that may explain or be associated with pulmonary embolus, including d-dimer level (only 22 of the 100 patients had d-dimer levels available). For the more than 25 years that the direct signs of pulmonary embolism have been available to the radiologist on CT, this noninvasive technique has produced a paradigm shift that has raised the standard of care for patients with this disease. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments, Original Research. 82, © 2021 Radiological Society of North America, COVID-19 patients and the radiology department - advice from the European Society of Radiology (ESR) and the European Society of Thoracic Imaging (ESTI). In practice, if a diagnosis of pulmonary embolism cannot be confidently confirmed or refuted and the study is indeterminate, it is recommended that the radiologist decide at which anatomic level the study is indeterminate; for example, if the radiologist can clear the vessels to the level of the segmental arteries, and the subsegmental arteries are indeterminate, the clinician might not require further imaging in cases with a low clinical pretest probability for pulmonary embolism. The three major causes of mosaic lung attenuation are airways disease, chronic pulmonary embolism (in which the abnormal region is more radiolucent), and interstitial lung disease (in which the abnormal lung is more opaque). However, the frequency of this artifact will be reduced with the use of empiric timing delay (Fig. 48, No. 2013;200:522-528. Recognition of this phenomenon is important because the poorly opacified vessel may be normal or the poor contrast enhancement may obscure thrombus. Of 2003 patients diagnosed with COVID-19, 280 were hospitalized during the study period. However, some patients with indeterminate CTPA findings will need further imaging, with ultrasound scan of the legs after hydration, a repeat CTPA, V/Q scintigraphy (if the lungs are clear on CT), or pulmonary angiography. 12, International Journal of Antimicrobial Agents, Vol. AJR 2011; 197:1058-1063. Less complication than conventional (elevated pulmonary ... against which all other modalities have beenmeasured. by Julius Renne et al. CT angiography may also cost less than catheter angiography. CT pulmonary angiogram (or CTPA) is a special test used primarily to look for the presence of pulmonary embolism (blood clots in the lung). 10, Frontiers in Cell and Developmental Biology, Vol. Because it is important to detect all pulmonary emboli, we should calculate the highest possible attenuation of an acute pulmonary embolism to be the mean plus 3 SDs; this would include 99.75% of all acute emboli, which equates to 78 H. According to Meaney et al. 10A, 10B). Please check CT Angiography Chest With Contrast price in Delhi-NCR and other details here. At multivariable analysis, pulmonary embolus was associated with invasive mechanical ventilation and male sex. An increase in the attenuation of blood on CT may be obtained with intravascular contrast material containing the atoms of iodine or gadolinium. The frequency of this artifact can be reduced by using a saline bolus immediately after the contrast material injection . 1 Because clinical signs or symptoms are often non‐specific, diagnosis relies on imaging tests, which include radioisotope ventilation perfusion scanning and, more commonly over recent years, computed tomography pulmonary angiography (CTPA). 12, No. 2004 Oct;183(4):1093-6 All analyses were performed with R version 3.4.4 software (R Core Team 2017, R Foundation for Statistical Computing, Vienna, Austria). See www.arrs.org for more information. ; clinical studies, F.G., J.B.; statistical analysis, P.C. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 2–4 CTPA is a standard procedure that obtains a CT volume while intravenously injected iodinated contrast media (CM) opacifies the pulmonary arteries. For patients weighing more than 250 lb (113 kg), it is necessary to increase the radiation dose to decrease the amount of image noise. Coronal oblique reformatted image through right posterior basal segmental artery from CT pulmonary angiography shows segment of poor opacification (arrow) between areas of higher attenuation both proximally and distally. Indirect CT venography will not be dealt with in detail in this article. 11, Journal of Cardiothoracic and Vascular Anesthesia, Baylor University Medical Center Proceedings, Vol. Yilmaz Ö, Üstün ED, Kayan M, et al. The most common cause was motion artifacts in 74% of the cases; other reasons included poor enhancement (40%), patient habitus (7%), parenchymal disease (12%), and streak artifacts (7%) . 2A, 2B). Comparing patients with this artifact with age- and sex-matched controls, Wittram and Yoo  showed that the artifact results from an increase in flow of unopacified blood from the inferior vena cava. 56, No. Non-invasive imaging techniques have recently been used to replace arteriography. 173, No. This article is available for CME credit. The diagnostic criteria for acute pulmonary embolism include, first, complete arterial occlusion with failure to opacify the entire lumen; the artery may be enlarged in comparison with pulmonary arteries of the same order of branching [31-33] (Fig. 8, Journal of Clinical Medicine, Vol. They are best seen on lung window settings that show composite images of vessels . 4, No. The patient receives an intravenous injection of contrast and then the heart is scanned using a … Coronary CT angiography (CCTA) is the use of CT angiography to assess the arteries of the heart. 4, No. The main objective of our study was to evaluate pulmonary embolus in association with COVID-19 infection by using pulmonary CT angiography. 1, 15 December 2020 | Radiology, Vol. Contrast is injected, and the pulmonary arterial tree becomes visible under fluoroscopy. CT imaging was performed from the diaphragm to the upper calves at 3 and 3.5 minutes after administration of contrast material (after completion of pulmonary angiography), yielding a typical total of 18-20 venous images (5- to 10-mm sections acquired at 5-cm intervals). From the Department of Radiology. Computed tomography (CT) pulmonary angiography is widely used in patients with suspected pulmonary hypertension (PH). used single-detector CT whereas Wittram and Yoo used MDCT. If the address matches an existing account you will receive an email with instructions to reset your password. 67, No. Two major issues are related to imaging pulmonary arteries of large patients: image noise and the volume of IV contrast material. For CT Angiography, there is no need for sedation or general anesthesia. , we need attenuation in the artery of at least one more SD; the final figure therefore equals 93 H. The mean attenuation and SD values for chronic pulmonary embolism are 87 and 31 H, respectively. 6, 9 July 2020 | Radiology: Cardiothoracic Imaging, Vol. 9, Journal of Thrombosis and Haemostasis, Vol. What Is a Pulmonary Angiography? Conventional computed tomographic (CT) scanning is, however, at a disadvantage because of its inability to obtain multiplanar images. The solution to transient interruption of contrast flow of the pulmonary arteries is to reduce the volume of unopacified blood entering the right atrium from the inferior vena cava. 5, Academic Emergency Medicine, Vol. 9, Clinical and Applied Thrombosis/Hemostasis, Vol. 1, European Respiratory Journal, Vol. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections. CTA (CTPA – CT pulmonary angiography) has been the technique of choice for detection of pulmonary embolism for at least the last decade . 101, No. Optimizing the utilization of CT pulmonary angiogram (CTPA) for the diagnosis and workup of acute chest pain can provide an opportunity to reduce unnecessary radiation and … Patients with unenhanced chest CT scans were excluded. Over the past two decades, however, catheter angiography has become almost entirely supplanted by CT angiography (CTA), which is now the … Recent studies have shown the sensitivity of thin-slice MDCTPA to be 90-100% and the specificity to be 89-94% for the detection of pulmonary emboli to the level of the subsegmental arteries, using pulmonary angiography as the gold standard [5, 6]. 92, No. , it is possible to calculate the minimum amount of IV attenuation required to perceive pulmonary emboli on CT. Meaney et al. In my experience, this finding is more often seen on angiography than on CT; this discrepancy is thought to be related to the larger temporal window of IV contrast material for CT as compared with angiography. Both CT pulmonary angiography and perfusion scanning are well-established techniques for evaluating PE. Our results showed frequent (23%) pulmonary embolus in patients with COVID-19. 6, Journal of Medical Virology, Vol. Therefore, we routinely performed contrast-enhanced CT for patients with COVID-19 with severe clinical features to evaluate the lung parenchyma as well as to evaluate other complications that may result in respiratory distress. adequate enhancement of the pulmonary trunk and its branches. 92, No. Figure 2: Images from pulmonary CT angiography in a 68-year-old man. In cases of discordance, a simultaneous reading to reach consensus was achieved. Classification of a pulmonary embolism may be based upon: 1. the presence or absence of hemodynamic compromise 2. temporal pattern of occurrence 3. the presence or absence of symptoms 4. the vessel which is occluded The hyperventilation before inspiration and the breath-hold is likely the exacerbating factor of this artifact. 52, No. 14, European Respiratory Journal, Vol. The CT Coronary Angiogram is a simple procedure without any pain and anxiety . CTPA was introduced in the 1990s as an alternative to ventilation/perfusion scanning, which relies on radionuclide imaging of the blood vessels of the lung. 7), contrast material flowing through apparently thick-walled arteries that are smaller due to recanalization [32, 33] (Fig. What is a CT pulmonary angiogram? 18, No. Wide availability and ease of performance, in conjunction with robustly high sensitivity, specificity and accuracy, have made CT pulmonary angiography (CTPA) the imaging technique of choice for acute pulmonary embolism. 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