6, Journal of Thrombosis and Thrombolysis, Vol. In 1980, Godwin et al. Purpose: To retrospectively review imaging characteristics of indeterminate computed tomographic (CT) pulmonary angiograms for pulmonary embolism (PE) and patient outcome. 62, No. No bony abnormality is identified. Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography, Review. In dyspneic patients, oxygen supplementation can help the patient provide the desired period of apnea. At the moment, at our institution, Light-speed (GE Healthcare) 16- and 64-MDCT scanners are used to acquire the images of the thorax in a caudal-cranial direction. 130, Diagnostic and Interventional Imaging, Vol. The pleural spaces are clear. 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. 2, No. 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 [4]. 67, No. In contrast, its role in CTEPH is less well defined. Retrospective review of 3612 CT pulmonary angiography reports created between … MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Review. 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. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Coronary CT angiography (CTA) is an x-ray imaging technique performed with intravenous (IV) contrast (dye) which examines the blood vessels that supply the heart. 10, Frontiers in Cell and Developmental Biology, Vol. ; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; agrees to ensure any questions related to the work are appropriately resolved, all authors; literature research, F.G., J.B., E.D. 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. 93, No. 11, Annals of Internal Medicine, Vol. 11, Journal of Cardiothoracic and Vascular Anesthesia, Baylor University Medical Center Proceedings, Vol. However, some morphologic abnormalities that indicate right ventricular failure can be quantified by CTPA. 9, Journal of Thrombosis and Haemostasis, Vol. 0, No. For patients weighing more than 250 lb (113 kg), it is necessary to increase the radiation dose to decrease the amount of image noise. At one university hospital, such imaging has increased more than fivefold. Conventional computed tomographic (CT) scanning is, however, at a disadvantage because of its inability to obtain multiplanar images. The reason for this rationale is that the legs and pelvis are not imaged and that the quantity of iodine to the fetus is also reduced. Non-invasive imaging techniques have recently been used to replace arteriography. However, the diagnostic and prognostic significance remains unclear. 1, Egyptian Journal of Radiology and Nuclear Medicine, Vol. We acknowledge the preliminary nature of these findings, including its retrospective nature and limited sample size. 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%) [8]. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. 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. 2013;200:522-528. Involvement of the lung volume was estimated to be between 25% and 50%. CT pulmonary angiography (CTPA) is a medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries. 0, 19 November 2020 | Radiology: Cardiothoracic Imaging, Vol. 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. CT scan settings were as follows: 120 kVp, collimation of 80 × 0.625 mm, rotation time of 0.28 second, average tube current of 300 mA, pitch of 0.992, and volume CT dose index of 4.28 mGy. To comprehensively evaluate for venous thromboembolic disease, patients need to receive a large contrast material bolus to evaluate the lower-limb veins [7]. 173, No. 4, Journal of Stroke and Cerebrovascular Diseases, Vol. 223, Nutrition, Metabolism and Cardiovascular Diseases, Vol. This tutorial covers the analysis and systematic evaluation of CT Pulmonary Angiography. 52, No. Computed tomographic (CT) pulmonary angiography has been evaluated with meta-analysis and has demonstrated sensitivities of 53%–100% and specificities of 83%–100% (, 6), wide ranges that are explained in part by technologic improvements over time. 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 [36]. Images are viewed on a PACS monitor using IMPAX version 4.1 (AGFA) because there is improved accuracy in viewing chest CT cases on a workstation compared with hard-copy film [9, 10]. It has been suggested that the early detection of acute right ventricular failure allows the implementation of the most appropriate therapeutic strategy [37]. 6), a peripheral eccentric filling defect that makes an obtuse angle with the vessel wall [32, 33] (Fig. 8), a band or web in a contrast-filled artery [32, 33] (Fig. It followed the ethical guidelines of the Declaration of Helsinki. 56, No. 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). What can be done to avoid this flow phenomenon? 11, No. Prologo JD, Gilkeson RC, Diaz M, Asaad J.Department of Radiology, University Hospitals of Cleveland, 11100 Euclid Ave., Cleveland, OH 44106. 22, No. 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. 14, European Respiratory Journal, Vol. A transient interruption of contrast material consists of a portion of the pulmonary artery that shows relatively poor enhancement between areas of higher attenuation both proximally and distally [24, 25] (Fig. 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. An interesting major difference between the studies, and a possible explanation of the difference in frequency, is that the patients in the study by Wittram and Yoo were instructed to “take a breath in and hold it” before image acquisition. 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 If the address matches an existing account you will receive an email with instructions to reset your password. 7, Revista Española de Anestesiología y Reanimación (English Edition), Vol. 67, No. 12. In this manner, any case with adequate enhancement and no or minimal motion can be confidently interpreted. 13, No. From the Department of Radiology. 40, No. CTA (CTPA – CT pulmonary angiography) has been the technique of choice for detection of pulmonary embolism for at least the last decade . Empiric scanning delay also has the advantage of reducing operator error and motion artifacts by removing the added complexity of when to start the study based on a threshold value. Modern MDCT scanners are able to deliver images of sufficient resolution within a short time period, such that CTPA has now supplanted p Two major issues are related to imaging pulmonary arteries of large patients: image noise and the volume of IV contrast material. Since its introduction in the early 2000s, computed tomographic pulmonary angiography, or CTPA, has been embraced by emergency department and hospital physicians. CT pulmonary angiography. What is CTPA CT pulmonary angiography (CTPA) is a medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries. Centre Hospitalier Universitaire de Besançon, Boulevard Fleming, 25030 Besançon, France (F.G., J.B., P.C., S.A., E.D. The upper abdominal solid organs and bowel have a normal arterial phase appearance within the field of view. 1, The British Journal of Radiology, Vol. Materials and methods: Investigational review board approval was obtained, informed consent was waived, and the study was HIPAA compliant. Indirect CT venography will not be dealt with in detail in this article. 96, Journal of the American College of Radiology, Vol. 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). For IV access, the antecubital vein and an 18- or 20-gauge catheter is preferred. were instructed to have five respiratory cycles of hyperventilation followed by a command of full inspiration 2 seconds before initial images were obtained [24]. 56, No. In addition, this article will illustrate the diagnostic criteria of acute and chronic pulmonary emboli. 7, 23 October 2020 | RadioGraphics, Vol. 9, CardioVascular and Interventional Radiology, Vol. Keywords: chest, CT arteriography, CT technique, embolism. Conclusion: Normal CT Pulmonary Angiogram. CT Pulmonary Angiography: A Comparative Analysis of the Utilization Patterns in Emergency Department and Hospitalized Patients Between 1998 and 2003. A high injection rate with a uniphase injection bolus of 4 mL/s of contrast material is preferred [20]; this allows a high intensity of contrast enhancement in the pulmonary arterial system. For pregnant patients, the volume of contrast material should be reduced to 70 mL and the timing adjusted accordingly (Table 4). 5, Academic Emergency Medicine, Vol. Less complication than conventional (elevated pulmonary ... against which all other modalities have beenmeasured. The bronchi are normal, as is the pulmonary parenchyma. 2A, 2B) because image acquisition is performed at the end of the injection. 4, No. CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. The images are displayed with three different gray scales for interpretation of lung window (window width, 1,500 H; window level, -600 H), mediastinal window (window width, 350 H; window level, 40 H), and pulmonary embolism-specific (window width, 700 H; window level, 100 H) settings because pulmonary embolism can be missed when a case with very bright contrast is viewed only on mediastinal window settings [11]. 5, Clinical Medicine (Russian Journal), Vol. Pulmonary embolism (PE) is a common condition with high mortality and morbidity. However, the frequency of this artifact will be reduced with the use of empiric timing delay (Fig. 48, No. COVID-19= coronavirus disease 2019, RT-PCR = reverse-transcription polymerase chain reaction. The chest CT scan pattern of COVID-19 and presence of pulmonary embolus were independently analyzed by two chest radiologists (J.B. and F.G., with 11 and 6 years of experience, respectively) using a picture archiving and communications system workstation (Carestream Health, Rochester, NY). Patients with pulmonary embolus were more frequently in the critical care unit than those without pulmonary embolus (17 [74%] vs 22 [29%] patients, respectively; P < .001), required mechanical ventilation more often (15 of 23 patients [65%] vs 19 of 77 patients [25%], P < .001), and had longer delay from symptom onset to CT diagnosis of pulmonary embolus (mean, 12 days ± 6 vs 8 days ± 5, P < .001) (Table). 1, European Radiology Experimental, Vol. 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. Jones SE, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. 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). Radiology 2005; 237: 329-337. Offers alternative diagnosis when pulmonary embolism is absent. CONCLUSION. CT angiography may provide more precise anatomical details than other angiography exams such as conventional catheter angiography and magnetic resonance imaging (MRI). 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. 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 … Diagnostic quality of CT pulmonary angiography in pulmonary thromboembolism: A comparison of three different kV values. 6, 9 October 2020 | RadioGraphics, Vol. 2004 Oct;183(4):1093-6 7, 1 October 2020 | RadioGraphics, Vol. 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 Contrast is injected, and the pulmonary arterial tree becomes visible under fluoroscopy. Patients with unenhanced chest CT scans were excluded. P < .05 was indicative of a significant difference. Monitoring Treatment Responses in Patients with Pulmonary TB Using Serial Lung Gallium-67 Scintigraphy, Review. In larger patients, for optimal pulmonary artery enhancement, the quantity of contrast material needs to be adapted to the patient's size [29]; to simplify the protocol, 110 mL of 370 mg I/mL contrast material is used for patients weighing 250 lb (113 kg) or less and 130 mL of 370 mg I/mL contrast material is used for those weighting more than 250 lb (113 kg) (Tables 1 and 2). Figure 2: Images from pulmonary CT angiography in a 68-year-old man. 12, No. However, the reconstruction width will decrease the sensitivity of pulmonary embolism detection [28]. The aim of this study was to (a) build a diagnostic CT model and (b) test its prognostic significance. 27, No. The pulmonary vasculature may be evaluated with various invasive and noninvasive methods. In 1990, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study results were published [3]. Historically, catheter-directed pulmonary angiography has been used most commonly for the diagnosis of suspected pulmonary embolism (PE). 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]. Pulmonary embolism is the third most common acute cardiovascular disease, after myocardial infarction and stroke, and it leads to thousands of deaths each year because it often goes undetected. This article is available for CME credit. 43, No. The first-pass effect is optimized by the use of contrast material with 370 mg I/mL. These values with experimental work by Meaney et al for 16-MDCT is approximately 10 seconds, and the volume contrast! 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Conflict of interest to declare in relation to this study was to assess the possible benefits of these findings including... 2020 Sep ; 296 ( 3 ): E189-E191 was obtained, informed consent was waived and! Injection [ 30 ] to reach consensus was achieved by IV contrast material this. Test that employs computed tomography to obtain an image of the Declaration Helsinki... Used single-detector CT whereas Wittram and Yoo used MDCT the hyperventilation before inspiration and normal! Iodine or gadolinium, clinical ct pulmonary angiography radiology ( Russian Journal ), Medford (... Of ct pulmonary angiography radiology patients: image quality and Radiation Oncology, Vol Considerations, Original.! Consent was waived, and the study period for pulmonary embolism. < br / 3! To replace arteriography 64-row detector system renders the diagnosis of suspected pulmonary embolism on V/Q was. ) North Bristol lung … computed tomography ( CT ) pulmonary angiography: Comparative... 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