On occasion, intravascular thrombosis is identified in a pulmonary artery stump. 6, 13 April 2012 | Der Radiologe, Vol. (c) Contiguous CT scan obtained immediately superior to a demonstrates a contrast material-filled pulmonary artery, a finding that confirms that the low attenuation seen in a was due to partial volume artifact.Download as PowerPointOpen in Image Bob: Pulmonary embolism (PE) accounts for 300,000 deaths per year. Adjacent beam-hardening artifacts are also seen.Download as PowerPointOpen in Image Respiratory motion artifact in a 61-year-old man with dyspnea. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). Chronic pulmonary embolism in a 60-year-old woman with dyspnea. Note the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow).Download as PowerPointOpen in Image Figure 22b. Each radiology department will have a slightly different method for achieving the same outcome, i.e. Stair step artifact consists of low-attenuation lines seen traversing a vessel on coronal and sagittal reformatted images (,Fig 29) and is accentuated by cardiac and respiratory motion. Pulmonary emboli have been identified on 1.5% of contrast-enhanced CT scans obtained for reasons other than evaluation for pulmonary embolism (,21). (a) On a CT scan, a pulmonary artery catheter causes adjacent beam-hardening artifacts within the main and right pulmonary arteries that mimic pulmonary embolism (arrows). 58, No. Figure 14. Contiguous images demonstrated the true nature of this finding. Localized increase in vascular resistance in a 65-year-old man with dyspnea. The Clinical Respiratory Journal, Vol. These findings indicate the true nature of the patient’s condition.Download as PowerPointOpen in Image (a) CT scan obtained with an edge-enhancing algorithm shows a lung algorithm artifact that mimics acute pulmonary embolism (arrows). Pulmonary artery stump in situ thrombosis in a 69-year-old man who had undergone right pneumonectomy for lung cancer. In acute pulmonary embolism that manifests as complete arterial occlusion, the affected artery may be enlarged. Peripheral wedge-shaped areas of hyperattenuation that may represent infarcts, along with linear bands, have been demonstrated to be statistically significant ancillary findings associated with acute pulmonary embolism (,Fig 8) (,18). 2, American Journal of Roentgenology, Vol. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). The posterobasal segment of the right lower lobe bronchus is dilated as well as mucus filled. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). Respiratory motion artifact in a 61-year-old man with dyspnea. Viewer. 3, American Journal of Roentgenology, Vol. Viewer. Figure 22a. The criteria for in situ thrombus include (a) thrombus at the surgical site only (,Fig 36) and (b) the absence of other pulmonary artery thrombi remote from the stump site (,37). In 17 patients with central pulmonary embolism, the raw data were used to perform reconstructions with 1-mm, 2-mm, and 3-mm section thicknesses. Computed Tomography (CT) is the mainstay of diagnostic imaging evaluation of thoracic disorders. Image noise in scans of a 39-year-old woman with chest pain. The vessels are seen as either normal, containing acute pulmonary embolism, containing chronic pulmonary embolism, or indeterminate. (b) CT scan produced with bone window settings clearly depicts the pulmonary artery catheter. Figure 16. 202, No. Figure 39. Figure 30c. 6, Journal of Computer Assisted Tomography, Vol. Figure 30d. Graph illustrates that the number of pulmonary angiographic studies performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .02). 55, No. On a CT scan, the pulmonary artery measures 41 mm in diameter (black line), a finding that indicates hypertension.Download as PowerPointOpen in Image Viewer. Contrast material–enhanced spiral CT of the veins of the lower extremities is performed with the same contrast material bolus that is used for chest CT. Partial volume artifact will become less of an issue with routine use of narrow detector widths. Sagittal and coronal reformatted images can help identify these normal anatomic structures (,17). The window width is equal to the mean attenuation of the main pulmonary artery plus two standard deviations, and the window level equals one-half of this value (,29). Respiratory motion artifact in a 61-year-old man with dyspnea. The lung algorithm is a high-spatial-frequency reconstruction convolution kernel used to improve the quality of images of the pulmonary vessels, bronchi, and interstitium. Graph illustrates that the number of ventilation-perfusion scans performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .0003). MATERIALS AND METHODS: A multi-detector row spiral CT protocol for the diagnosis of pulmonary embolism was used that consisted of scanning the entire chest with 1-mm collimation within one breath hold. (a) CT scan shows peribronchovascular interstitial thickening caused by perivascular edema (arrow), a finding that can mimic chronic pulmonary embolism. Flow-related artifact in a 73-year-old woman with chest pain. The review of sagittal and coronal reformatted images can help in difficult cases. Intravascular tumor emboli can manifest as large, acute pulmonary emboli that produce acute pulmonary hypertension by occluding main, lobar, or segmental pulmonary arteries. This partial filling defect surrounded by contrast material produces the polo mint sign (arrow). When used in conjunction with validated clinical decision tools like modified Wells criteria, CT-angiography is highly sensitive (good at detecting PE when it's there and ruling it out when it's not) and specific (generating few false-positive results). Small pulmonary emboli are noted in the left pulmonary artery. Acute central pulmonary embolism in an asymptomatic 87-year-old woman. Figure 23. Figure 17. Further imaging may be necessary, consisting of either repeat CT pulmonary angiography with an increased delay or pulmonary angiography. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. 44, No. An unusual case of false positive CTPA and an approach to diagnosis, Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism, An untreatable dyspnoea: more defendants under investigation, Systemic-pulmonary artery shunt: A rare cause of false-positive filling defect in the pulmonary arteries. 30, No. This finding is seen when viewed with mediastinal or pulmonary embolism-specific windows and manifests as a bright ring around pulmonary arteries, particularly if associated with a flow artifact. Viewer. 6, 1 November 2007 | Radiology, Vol. 4, American Journal of Veterinary Research, Vol. Pulmonary artery sarcoma in a 65-year-old woman with dyspnea. 3, 14 February 2017 | Internal and Emergency Medicine, Vol. Note the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow). Beam-hardening artifact in a 63-year-old man with respiratory failure. CT scan demonstrates pulmonary artery stump in situ thrombosis that affects the right pulmonary artery (arrow).Download as PowerPointOpen in Image This approach helps differentiate between a sharply marginated embolus and an ill-defined artifact. adequate enhancement of the pulmonary trunk and its branches. Motion artifact renders the diagnosis of pulmonary embolism at this anatomic level indeterminate. 1, Open Journal of Clinical Diagnostics, Vol. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. 3, Canadian Association of Radiologists Journal, Vol. CT scans demonstrate normal hilar lymph nodes in both upper lobes (arrows in a), adjacent to the right and left interlobar arteries (arrows in b), in the middle lobe and lingula (arrows in c), and in both lower lobes (arrows in d).Download as PowerPointOpen in Image Graph illustrates that the number of pulmonary angiographic studies performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .02). 66, No. For patients with contraindications to conventional catheter pulmonary angiography. Note also the fluid-filled, dilated esophagus. Figure 24b. In addition, a centrally located, hyperattenuating filling defect is occasionally identified at unenhanced CT, a finding that indicates acute central pulmonary embolism (,,,Fig 10) (,22). However, this pitfall can be recognized by observing veins on contiguous images to the level of the right atrium. (2010) Radiology. Acute pulmonary embolism in a 45-year-old woman who presented with chest pain. Figure 10b. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. (b) CT scan obtained with the standard algorithm does not demonstrate this artifact. A primary pulmonary artery sarcoma is an uncommon cause of an intraluminal arterial filling defect. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries. After reading this article and taking the test, the reader will be able to: List the diagnostic criteria for acute and chronic pulmonary embolism at CT pulmonary angiography. Viewer, Figure 2. Figure 21. Stair step artifact in an 84-year-old man with dyspnea and chest pain. 2, American Journal of Roentgenology, Vol. The chest field of view is the widest rib-to-rib distance acquired during breath hold after inspiration. Figure 30b. Supine Contrast IV: Up to 100 ml Omni 350. Figure 29. CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. The total cavopulmonary connection (TCPC), or Fontan procedure, diverts systemic venous blood directly into the pulmonary arteries and is the palliative surgery of choice for patients with a wide variety of congenital heart diseases with single-ventricle physiologic characteristics. Chest wall abnormalities such as rib fractures and metastatic deposits may also mimic pulmonary embolism. ), Figure 3. As CT scanners become faster, delaying initial image acquisition until approximately 5 seconds after inspiration should allow the transient interruption in contrast material to pass through the pulmonary circulation (,27). 51, No. 24, No. )Download as PowerPointOpen in Image 5, 24 March 2017 | Current Radiology Reports, Vol. 5, Radiologic Clinics of North America, Vol. Note also the medium-sized left pleural effusion and atelectasis. Figure 24a. 33, No. Acute pulmonary embolism in a 59-year-old man. 6, 10 October 2018 | Journal of Medical Imaging and Radiation Oncology, Vol. Recognition of this phenomenon is important because the unenhanced vessel may be normal or the poor contrast enhancement may obscure thrombus. (b, c) CT scans obtained immediately superior (b) and inferior (c) to a demonstrate an apparent ill-defined filling defect (arrow) that is too high in attenuation to represent pulmonary embolism. Viewer. (b) Repeat CT pulmonary angiogram demonstrates segmental pulmonary emboli within the medial and lateral segmental branches of the middle lobe artery (arrows). Figure 28a. Acute central pulmonary embolism in an asymptomatic 87-year-old woman. Figure 33. Figure 12. Tumor emboli in a 60-year-old man with dyspnea and primary renal cell carcinoma. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries.Download as PowerPointOpen in Image Figure 27a. 24, No. 29, No. For that reason, your doctor will likely order one or more of the following tests. CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). Pulmonary embolism is the third most common acute cardiovascular disease after myocardial infarction and stroke and results in thousands of deaths each year because it often goes undetected (,1,,2). Viewer. Figure 35d. Beam-hardening artifact in a 63-year-old man with respiratory failure. The British Journal of Radiology (2020): 20190995. Left-sided heart failure in a 56-year-old woman with dyspnea. Viewer. Chronic pulmonary embolism in the same patient as in ,Figure 12. 25, No. Figure 8. In addition, viewing the bronchus on contiguous images will demonstrate the true nature of the artifact. Tumor emboli in a 60-year-old man with dyspnea and primary renal cell carcinoma. Unlike acute pulmonary embolism, both pulmonary artery sarcoma and chronic pulmonary embolism demonstrate enhancement (,Fig 37) (,28,,38,,39); however, pulmonary artery sarcoma is lobulated and forms acute angles with the vessel wall (,Fig 37), whereas chronic pulmonary embolism forms obtuse angles (,Fig 12). Figure 10b. 07, No. Acute pulmonary embolism in a 58-year-old woman who presented with chest pain and dyspnea. These are important observations because acute pulmonary embolism may be identified even if it is not suspected clinically. Viewer. 1, Clinical Pulmonary Medicine, Vol. Small pulmonary emboli are noted in the left pulmonary artery. Small pulmonary emboli could be obscured by a large amount of image noise. Diagnosis of pulmonary embolism with d-dimer adjusted to clinical probability. 8, American Journal of Roentgenology, Vol. 1, Archivos de Bronconeumología (English Edition), Vol. Flow-related artifact in a 60-year-old woman with pleuritic chest pain. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries. Note also the fluid-filled, dilated esophagus. CT scans demonstrate normal hilar lymph nodes in both upper lobes (arrows in a), adjacent to the right and left interlobar arteries (arrows in b), in the middle lobe and lingula (arrows in c), and in both lower lobes (arrows in d). (b, c) CT scans obtained immediately superior (b) and inferior (c) to a demonstrate an apparent ill-defined filling defect (arrow) that is too high in attenuation to represent pulmonary embolism. Note also the fluid-filled, dilated esophagus. Figure 30d. Adjacent beam-hardening artifacts are also seen. Contrast-enhanced CT scan shows a heterogeneously enhancing, lobulated mass within the main pulmonary artery (arrow). This finding is seen when viewed with mediastinal or pulmonary embolism-specific windows and manifests as a bright ring around pulmonary arteries, particularly if associated with a flow artifact. (a) CT scan obtained with an edge-enhancing algorithm shows a lung algorithm artifact that mimics acute pulmonary embolism (arrows). Figure 37. 55, No. Figure 20a. CT scan clearly depicts image noise pixels within the contrast material-filled heart chambers, a confluence of which could be misinterpreted as pulmonary embolism (arrow). Acute PE is the third most common acute cardiovascular disease after myocardial infarction and stroke, and results in many deaths each year. Streak artifact in a 35-year-old woman with chest pain. Esophagitis and, rarely, esophageal rupture may also be identified, as well as pneumonia, lung cancer, and pleural disease, including pneumothorax and pleuritis. (a) Unenhanced CT scan demonstrates subtle regions of hyperattenuation (arrow). Viewer. 12, Archivos de Bronconeumología, Vol. Viewer. Identification of the normal accompanying pulmonary arteries (arrowheads) allows the correct interpretation of this finding.Download as PowerPointOpen in Image Studies show that the diagnostic yield of CTPA for pulmonary embolism varies between 6.7 % and 31 % [ 9, 10, 11, 12, 13, 14 ]. 2, Seminars in Ultrasound, CT and MRI, Vol. 8, The American Journal of Forensic Medicine and Pathology, Vol. Beam-hardening streak artifacts from dense contrast material within the superior vena cava are commonly seen and can overlie the right pulmonary and upper lobe arteries. 1, European Journal of Radiology, Vol. Flow-related artifact in a 60-year-old woman with pleuritic chest pain. CT scan reveals a small, recanalized pulmonary artery with contrast material in the central lumen (arrow). 5, No. Both acute and chronic pulmonary embolism cause intraluminal filling defects that should have a sharp interface with the intravascular contrast material. 1, 28 July 2016 | Journal of Medical Imaging and Radiation Oncology, Vol. Figure 27a. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Images obtained in large patients have more quantum mottle. CT scan reveals a small, recanalized pulmonary artery with contrast material in the central lumen (arrow).Download as PowerPointOpen in Image Viewer. Pulmonary embolism can be difficult to diagnose, especially in people who have underlying heart or lung disease. 30, No. Multisection CT venography is simple and accurate, and when combined with lung imaging it allows fast and comprehensive evaluation for thromboembolic disease (,14). (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. S2, 9 August 2014 | European Radiology, Vol. Viewer. All three factors are present in patients who have undergone resection for lung cancer. 245, No. Another acute pulmonary embolus affects the left main pulmonary artery (arrowhead).Download as PowerPointOpen in Image Accompanying CT findings in heart failure include diffuse ground-glass attenuation, interlobular septal thickening and diffuse peribronchovascular interstitial thickening, and bilateral pleural effusions (,,,Fig 34). 5, No. 2, American Journal of Roentgenology, Vol. Figure 16. The radiologist needs to determine the quality of a CT pulmonary angiographic study and whether pulmonary embolism is present. 5, No. No embolism was present.Download as PowerPointOpen in Image 11, The Egyptian Journal of Radiology and Nuclear Medicine, Vol. (b) CT scan (lung window) demonstrates the accompanying findings of diffuse peribronchovascular thickening, ground-glass attenuation, smooth interlobular septal thickening (arrows), and bilateral pleural effusions. 6, European Journal of Radiology Open, Vol. 202, No. Graph illustrates that the number of ventilation-perfusion scans performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .0003). Currently computed tomography pulmonary angiography (CTPA) has become a widely accepted clinical tool in the diagnosis of acute pulmonary embolism (PE).To report split-bolus single-pass 64-multidetector-row CT (MDCT) protocol for diagnosis of PE.MDCT split-bolus results in 40 patients suspicious of PE were analyzed in terms of image quality of target pulmonary vessels (TPVs) … 32, No. Criteria to be used for Chest CTA or a CT is requested for Pulmonary Emboli which cannot be approved based on Interqual or Milliman criteria. 12, Clinical Pulmonary Medicine, Vol. Acute pulmonary embolism in a 59-year-old man. More distally, the pulmonary arteries were well enhanced. CT scan shows a large tumor embolus within the right lower lobe pulmonary artery (arrow). Current pulmonary CTA techniques involve ever lower doses of contrast medium and radiation along with advanced postprocessing applications to enhance image quality, diagnostic accuracy, and provide added value in patient management. The following document is an updated CT protocol for all of the sites at which TRA-MINW is ... CTA Chest Pulmonary Embolism & Routine CT Abdomen + Pelvis W CTA Chest (pulmonary arterial) & CT Abdomen + Pelvis W (venous) Indication: Evaluate for pulmonary embolism (chest pain, shortness of breath, elevated D-dimer, etc.) 14, No. Figure 30a. CT scan demonstrates pulmonary artery stump in situ thrombosis that affects the right pulmonary artery (arrow). Viewer. This pitfall can be avoided by observing veins to the level of the right atrium on contiguous images (,33). (c) CT scan (window width = 700 HU, window level = 100 HU) demonstrates thrombus within the right interlobar artery and the medial segment of the middle lobe artery. CT scans demonstrate normal hilar lymph nodes in both upper lobes (arrows in a), adjacent to the right and left interlobar arteries (arrows in b), in the middle lobe and lingula (arrows in c), and in both lower lobes (arrows in d). 9, No. 3, American Journal of Roentgenology, Vol. Figure 22b. Accurate and reliable diagnosis of acute pulmonary embolism (PE) is crucial to enable rapid treatment and guide patient management . Image noise in scans of a 39-year-old woman with chest pain. However, the location of lymph nodes and their relationship to bronchi and vessels varies among patients (,32). (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. More distally, the pulmonary arteries were well enhanced. In addition, a centrally located, hyperattenuating filling defect is occasionally identified at unenhanced CT, a finding that indicates acute central pulmonary embolism (,,, Fig 10) (, 22). 6, No. Images are displayed with three different gray scales for interpretation of lung window (window width/level [HU] = 1500/600), mediastinal window (400/40), and pulmonary embolism–specific (700/100) settings. Viewer. 11, European Journal of Radiology, Vol. There are two principal approaches for performing a CTPA of high diagnostic quality: NB: This article is intended to outline some general principles of protocol design. 6, American Journal of Roentgenology, Vol. CT scan shows an acute pulmonary embolus with ancillary findings of a peripheral wedge-shaped area of hyperattenuation in the lung (arrow), a finding that may represent an infarct, as well as a linear band (arrowhead). 1, 8 August 2017 | Veterinary Radiology & Ultrasound, Vol. CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). Viewer. Localized increase in vascular resistance in a 65-year-old man with dyspnea. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. 29, No. (b, c) CT scans obtained immediately superior (b) and inferior (c) to a demonstrate an apparent ill-defined filling defect (arrow) that is too high in attenuation to represent pulmonary embolism. Figure 40. Figure 18. 5, Korean Journal of Radiology, Vol. Figure 35e. In the hope of catching this elusive diagnosis, many physicians have turned to computed tomography (CT). Its main use is to diagnose pulmonary embolism. Figure 6. ), Figure 4. These findings indicate the true nature of the patient’s condition. 31, No. Viewer. 3, Journal of Thoracic Oncology, Vol. Figure 5b. Localized increase in vascular resistance in a 65-year-old man with dyspnea. 4, The American Journal of Emergency Medicine, Vol. Collateral bronchial artery dilatation is also noted (arrowhead).Download as PowerPointOpen in Image However, these modified window settings can also increase the conspicuity of artifacts caused by image noise and flow. CT scans demonstrate normal hilar lymph nodes in both upper lobes (arrows in a), adjacent to the right and left interlobar arteries (arrows in b), in the middle lobe and lingula (arrows in c), and in both lower lobes (arrows in d).Download as PowerPointOpen in Image Its sensitivity is estimated between 60 % and 100 % and its specificity between 81 % and 98 % [ 5, 6, 7, 8 ]. (a) On a 3.75-mm-thick CT scan, partial volume averaging of vessel and lung creates an artifact that mimics pulmonary embolism within the anterior segment of the left upper lobe pulmonary artery (arrow). 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