HRCT Findings of Proximal Interruption of the Right Pulmonary Artery

Neonatal and Pediatric Pulmonary Vascular Disease

Pediatric patients are affected by a wide variety of pulmonary vascular diseases ranging from congenital anomalies diagnosed at birth to acquired diseases that present later in childhood and into adolescence. While some pulmonary vascular diseases present similarly to those seen in adults, other forms are unique to children. Knowledge of the characteristic imaging features of these diseases is essential to facilitate prompt diagnosis and guide clinical management.

Chest Computed Tomography Findings in Unilateral Pulmonary Fibrosis Secondary to Chronic Hypoperfusion

PURPOSE

Unilateral lung fibrosis is uncommon and few cases secondary to parenchymal hypoperfusion have been reported, requiring further understanding of this entity. This study aims to report the chest computed tomography (CT) findings of patients with unilateral lung fibrosis related to parenchymal hypoperfusion observed in our institution.

PATIENTS AND METHODS

Patients with a chest CT between 2004 and 2022 showing a condition causing hypoperfusion of either lung and ipsilateral unilateral lung fibrosis were retrospectively identified. Clinical and scintigraphic data were collected. Pattern and distribution of fibrosis were recorded, and its progression was evaluated when follow-up was available. In adequate CTs, fibrosis was quantified using data-driven textural analysis (DTA). Affected and contralateral lungs and baseline and follow-up data were compared using the Wilcoxon signed-rank test.

RESULTS

Thirteen patients (male: 7, female: 6, median age: 61 y) were included; 5 with congenital unilateral absence of a pulmonary artery and 8 with fibrosing mediastinitis. The mean scintigraphic perfusion of affected lungs was 3.3% ± 1.1 compared with 96.7% ± 1.1 contralaterally (n = 7, P = 0.017). Fibrosis had a UIP pattern in one case, indeterminate in the others, and was most commonly diffuse craniocaudally and peripheral or central axially. DTA in 12 patients showed a mean fibrotic score of 32% ± 24.6 compared with 0.5% ± 0.4 in the contralateral lungs ( P = 0.002). Median follow-up was 4.5 years (minimum to maximum: 1 to 13 y). Of 10 patients, fibrosis was progressive in 60%. DTA of 5 follow-up CTs showed increased reticulations ( P = 0.043).

CONCLUSION

In patients with lung hypoperfusion, the possible complication of lung fibrosis should be considered.

Congenital Lung Anomalies in Adults

Congenital lung anomaly (CLA) refers to a rare group of malformations that are typically identified prenatally or in early childhood. However, a significant proportion of cases evade detection until adulthood and either are incidentally discovered or manifest with symptoms of recurrent respiratory infection or pulmonary hemorrhage. While most CLAs have characteristic imaging findings at CT and MRI, they remain a diagnostic challenge due to the infrequency with which they are encountered in adults. Radiologists frequently play a pivotal role in suggesting the diagnosis and guiding appropriate management strategies, and recognition of characteristic imaging patterns is crucial for accurate diagnosis. The authors examine the imaging appearances and clinical manifestations in adult patients with CLA, with a focus on patients who have bronchopulmonary involvement and those with combined bronchopulmonary and vascular anomalies. Entities discussed include bronchogenic cyst, bronchial atresia, congenital lobar overinflation, congenital pulmonary airway malformation, proximal interruption of the pulmonary artery, bronchopulmonary sequestration, hypogenetic lung syndrome, placental transmogrification of the lung, and hybrid lesions. Common complications that may arise in these patients are discussed and illustrated. ©RSNA, 2024 Supplemental material is available for this article.

Unilateral intestinal lung disease misdiagnosed as rheumatoid lung disease. A case report of absent pulmonary artery

Unilateral absence of pulmonary artery (UAPA) is a congenital clinical abnormality that is rarely diagnosed in adulthood. Due to its rarity and heterogeneity as it pertains to its clinical presentation, it may be difficult to diagnose, often leading to misdiagnosis. We present a case of UAPA with unilateral pulmonary fibrosis which was misdiagnosed as rheumatoid arthritis-associated interstitial lung disease (RA-ILD). We describe the symptomology, physical examination findings, laboratory values and radiologic findings. We also describe the diagnostic challenges and approach to a patient presenting with unilateral interstitial lung disease (ILD) and highlight the importance of a comprehensive evaluation.

Fleischner Society: Glossary of Terms for Thoracic Imaging

Members of the Fleischner Society have compiled a glossary of terms for thoracic imaging that replaces previous glossaries published in 1984, 1996, and 2008, respectively. The impetus to update the previous version arose from multiple considerations. These include an awareness that new terms and concepts have emerged, others have become obsolete, and the usage of some terms has either changed or become inconsistent to a degree that warranted a new definition. This latest glossary is focused on terms of clinical importance and on those whose meaning may be perceived as vague or ambiguous. As with previous versions, the aim of the present glossary is to establish standardization of terminology for thoracic radiology and, thereby, to facilitate communications between radiologists and clinicians. Moreover, the present glossary aims to contribute to a more stringent use of terminology, increasingly required for structured reporting and accurate searches in large databases. Compared with the previous version, the number of images (chest radiography and CT) in the current version has substantially increased. The authors hope that this will enhance its educational and practical value. All definitions and images are hyperlinked throughout the text. Click on each figure callout to view corresponding image. © RSNA, 2024 Supplemental material is available for this article. See also the editorials by Bhalla and Powell in this issue.

Congenital pulmonary malformations

There are many congenital anomalies of the lung, some of which have no clinical symptoms and are detected incidentally, while others, particularly in the neonatal and infant period, are recognized by their typical signs, symptoms, and radiological appearance. Some congenital lung anomalies are so important that they can cause the death of the patient if not diagnosed and treated early. Classification of congenital lung anomalies is difficult since these anomalies may be related to the airway, arterial and venous vascular system, pulmonary parenchyma, and primitive anterior intestinal anomalies from which the lung originates, and some anomalies may have several etiologic origins. In this review, all subgroups of congenital pulmonary malformations will be discussed.

ERRATUM

[This corrects the article doi: 10.36416/1806-3756/e20200595].

Proximal interruption of the pulmonary artery: A review of radiological findings

OBJECTIVES

Proximal interruption of the pulmonary artery (PIPA) has various clinical manifestations. This review focused on and summarized the clinical and radiological features of PIPA, based on relevant literature studies.

METHODS

The study included a total of 25 PIPA cases in the Guangzhou Women and Children's Medical Center between January 2015 and December 2021. Conventional chest photographs and chest computed tomography angiography (CCTA) of patients with PIPA were analyzed and summarized.

RESULTS

The radiological results showed that 17 cases were right-sided and 8 cases were left-sided PIPA. Additionally, the percentage of pulmonary hypoplasia on the affected side was 44%, 36% for pulmonary hypertension, 28% for the mosaic sign, 20% for subpleural cystic lucency shadow, 20% for subpleural serrated shadow, 20% for collateral vessel thickening, 16% for subpleural band-like parenchyma, 12% for pneumonia, and 56% for patent ductus arteriosus.

CONCLUSION

The clinical manifestations of PIPA are non-specific. Awareness of this anomaly, based on radiological manifestations, particularly those observed on CCTA images, is important for ruling out alternative diagnoses and implementing appropriate management.

Consensus statement on thoracic radiology terminology in Portuguese used in Brazil and in Portugal

Effective communication among members of medical teams is an important factor for early and appropriate diagnosis. The terminology used in radiology reports appears in this context as an important link between radiologists and other members of the medical team. Therefore, heterogeneity in the use of terms in reports is an important but little discussed issue. This article is the result of an extensive review of nomenclature in thoracic radiology, including for the first time terms used in X-rays, CT, and MRI, conducted by radiologists from Brazil and Portugal. The objective of this review of medical terminology was to create a standardized language for medical professionals and multidisciplinary teams.

Unilateral proximal interruption of pulmonary artery with ipsilateral interstitial lung disease - A rare case report

Unilateral proximal interruption of pulmonary artery with ipsilateral occurrence of lung fibrosis is a very rare entity. This case report is about a 27 year old male who had complaints of progressive dysponea since 1 year. He had past history of recurrent lower respiratory tract infections. On auscultation, velcro crackles are heard on right side. Pulmonary function test showed restrictive pattern. Chest Radiography, High Resolution Computed Tomography and CT Pulmonary angiography were performed.

Asymmetrical Interstitial Lung Disease Suggested to Be Due to Hypoplasia of the Unilateral Pulmonary Artery: A Case Report with a 20-year Follow-up

We herein report a case of asymmetrical interstitial lung disease (ILD) that remained almost completely asymmetrical over time on chest computed tomography (CT). An open lung biopsy from the right lung showed severe pleural adhesion, obstruction of the pulmonary artery, and dilated systemic arteries in addition to the usual interstitial pneumonia pattern. Three-dimensional CT angiography showed partial defects of pulmonary arteries on the affected side. After excluding other known causes of ILD and gastroesophageal reflux, we suspected that decreased pulmonary artery perfusion in the present case may have been responsible for the observed asymmetrical unilateral fibrosis.

Imaging of the rare cystic lung diseases

When discussing cystic lung diseases, a certain group of diseases tends to receive the majority of attention. Other less frequently discussed cystic lung diseases are also important causes of morbidity in patients. Etiologies include genetic syndromes, lymphoproliferative diseases, infections, exogenous exposures, and a developmental abnormality. This review article focuses on the clinical and imaging features of these other cystic lung diseases.

MDCT angiographic findings of various congenital pulmonary artery anomalies in pediatric patients

Background

Congenital pulmonary artery anomalies are variable and need proper diagnosis and treatment. CT angiography with multiplanar reconstruction has the main role in the assessment of these anomalies and this non-invasive method should be the method of choice for preoperative planning and postoperative follow up.

The aim of the study is to assess the value of MDCT in the detection of pulmonary arteries anomalies in the pediatric population with complex congenital heart disease in conjunction with echocardiography as an alternative to conventional angiography and to determine the superiority of MDCT in the assessment of other abnormalities such as airway anomalies.

Results

In our retrospective study, 52 patients (28 male and 24 females, aged 1 day to 4 years: mean age 2 years) were examined with contrast-enhanced CT. CT examinations were done using a 128-section CT scanner (Siemens Somatom Definition AS) using non-ionic iodinated contrast media. 2D and 3D reconstructions were performed. The correlation was made with echocardiograms. All imaging studies were reviewed. The echo was done to all patients. Surgery and/or catheter angiography performed to all patients, their findings were reviewed and compared to CTA findings. Other abnormalities such as congenital airway anomalies are detected using axial MDCT images and reconstructed imaging techniques.

MDCT was accurate in revealing pulmonary artery anomalies. The commonest pulmonary artery anomaly was atresia, stenosis then hypoplasia. These anomalies may be isolated or associated with other congenital heart diseases. In the current study, MDCT could diagnose all cases of pulmonary arterial anomalies with 96% sensitivity, 100% specificity, 98% accuracy, 100% positive, and 94% negative predictive values. CT scans provide accurate information to assess complex spatial relationships of vascular airway compression frequently associated with CHD in the pediatric population.

Conclusion

MDCT scanner can be an alternative to diagnostic conventional angiography for the non-invasive assessment of the pulmonary artery. Higher quality multiplanar and 3D reconstruction achieved by the MDCT scanners offer a rapid, reliable and non-invasive technique that can be used for the evaluation and preoperative assessment of thoracic vascular and extra-vascular anatomy in infants and children with suspected congenital heart disease. CT technologies are constantly developing collaboration between radiologists, pediatric cardiologists, and anesthesiologists, which is essential for improving CT performance.

Pulmonary arteries: imaging of pulmonary embolism and beyond

The pulmonary arteries are not just affected by thrombus. Various acquired and congenital conditions can also affect the pulmonary arteries. In this review we discuss cross sectional imaging modalities utilized for the imaging of the pulmonary arteries. Acquired pulmonary artery entities, including pulmonary artery sarcoma (PAS), vasculitis, aneurysm, and arteriovenous malformations, and congenital anomalies in adults, including proximal interruption of the pulmonary artery, pulmonary sling, pulmonary artery stenosis, and idiopathic dilatation of the pulmonary trunk, are also discussed. An awareness of these entities and their imaging findings is important for radiologists interpreting chest imaging.

Developmental lung anomalies in adults: A pictorial review

Developmental lung anomalies represent a heterogeneous group of diverse, yet related abnormalities that involve the lung parenchyma, pulmonary vasculature or a combination of both-which usually present prenatally and in early childhood. However, a substantial number of cases go unnoticed during childhood and present either incidentally or with recurrent respiratory infections progressing into adulthood. Defective development of the tracheobronchial tree and the pulmonary vasculature are proposed to cause these developmental anomalies. Encountering these lung anomalies in adults is a diagnostic challenge given their rarity and they are often mistaken as other serious pathological conditions, resulting in unnecessary diagnostic tests and procedures. The developmental lung anomalies in adults can be broadly divided into three categories: bronchopulmonary anomalies encompassing congenital bronchial atresia, bronchogenic cysts, congenital lobar emphysema and congenital pulmonary airway malformations. Vascular anomalies include pulmonary agenesis-aplasia- hypoplasia complex, unilateral absence of the pulmonary artery, pulmonary artery sling, partial anomalous pulmonary venous return, pulmonary venous varix and pulmonary arteriovenous malformations. Finally combined lung parenchymal-vascular anomalies of the lung involve hypogenetic lung (scimitar) syndrome and bronchopulmonary sequestration. This article discusses the spectrum of these developmental anomalies of the lung, their etiopathogenesis, clinical and radiographic presentations in adults and management in brief.

Proximal Interruption of the Pulmonary Artery

Proximal interruption of the pulmonary artery (PIPA) is an uncommon developmental anomaly resulting in underdevelopment of the proximal portion of the pulmonary artery with preservation of the intrapulmonary segments. Clinical presentation ranges between an asymptomatic incidental finding to massive hemoptysis. When findings suggestive of PIPA are present radiographically, the diagnosis of PIPA can be definitively diagnosed with computed tomography or magnetic resonance pulmonary angiography. Other imaging modalities, such as nuclear perfusion scan and catheter angiography can help in the diagnosis.

Pictorial review of the pulmonary vasculature: from arteries to veins

Pathology of the pulmonary vasculature involves an impressive array of both congenital and acquired conditions. While some of these disorders are benign, disruption of the pulmonary vasculature is often incompatible with life, making these conditions critical to identify on imaging. Many reviews of pulmonary vascular pathology approach the pulmonary arteries, pulmonary veins and bronchial arteries as individual topics. The goal of this review is to provide an integrated overview of the high-yield features of all major disorders of the pulmonary vasculature. This approach provides a more cohesive and comprehensive conceptualisation of respiratory pathology. In this review, we present both the salient clinical and imaging features of congenital and acquired disorders of the pulmonary vasculature, to assist the radiologist in identifying pathology and forming a robust differential diagnosis tailored to the presenting patient. TEACHING POINTS: • Abnormalities of the pulmonary vasculature are both congenital and acquired. • Pathology of a single pulmonary vascular territory often affects the entire pulmonary vasculature. • Anomalous pulmonary venous flow is named as a function of its location and severity. • Bronchial arteries often undergo dilatation secondary to cardio-respiratory pathology.

Isolated unilateral absence of pulmonary artery in adulthood: a clinical analysis of 65 cases from a case series and systematic review

Background

Isolated unilateral absence of pulmonary artery (UAPA) in adulthood is a rare congenital anomaly. Although some case reports exist, the clinical symptomatology, lung parenchymal features, collateral circulation and therapeutic approaches in adult patients with isolated UAPA remain unknown. The objectives of this study are to investigate the clinical characteristics, elucidate the correlation between clinical symptomatology and radiology, and summarize treatment of adult patients with isolated UAPA.

Methods

Cases of adult patients with isolated UAPA who had been diagnosed at our hospital and identified from PubMed, EMBASE and Web of Science from 1990 to 2016 were analyzed.

Results

Hemoptysis was present in 41.5% of patients, exertional dyspnea in 41.5%, and recurrent respiratory infection in 35.4%. Lung parenchymal abnormalities were found on chest computed tomography (CT) scan, including bronchiectasis, which occurred in 30.2% of the patients, interstitial changes in 14.0%, and multiple bullae in 14.0% of the patients. Exertional dyspnea was more frequent in patients with pulmonary hypertension than in those without pulmonary hypertension (P<0.001). Recurrent respiratory infection were more frequent in patients with bronchiectasis than in those without bronchiectasis (P<0.001). Hypertrophic bronchial, phrenic, internal thoracic and intercostal arteries were found in 71.9%, 46.9%, 43.8%, and 43.8% of the patients, respectively. Pneumonectomy reduced hemoptysis in seven cases. Oral phosphodiesterase inhibitors or endothelin receptor antagonist improved exertional dyspnea in three cases with pulmonary hypertension.

Conclusions

Clinicians should be aware of undiagnosed cases of isolated UAPA in adults with unexplained hemoptysis or exertional dyspnea. Early recognition and management of isolated UAPA in adult patients are crucial to avoid the devastating effect of massive hemoptysis or severe pulmonary hypertension (PHT) in the long term.

Isolated unilateral proximal interruption of the pulmonary artery: findings of high-resolution computed tomography and three-dimensional volume rendering imaging of the pleura

A unilateral proximal interruption of the pulmonary artery is a rare entity that is commonly associated with other congenital cardiovascular anomalies. However, less frequently, this condition may occur as an isolated finding, and some patients are completely asymptomatic. We report 2 cases of asymptomatic patients who had an isolated unilateral proximal interruption of the pulmonary artery. Herein, the radiological imaging findings are described with an emphasis on interlobular septal thickening of the affected lung demonstrated with high-resolution computed tomography. Three-dimensional volume rendering imaging clearly demonstrated reticular opacities on the surface of the affected side of the pleura.

Bronchial arteries: anatomy, function, hypertrophy, and anomalies

The two main sources of blood supply to the lungs and their supporting structures are the pulmonary and bronchial arteries. The bronchial arteries account for 1% of the cardiac output but can be recruited to provide additional systemic circulation to the lungs in various acquired and congenital thoracic disorders. An understanding of bronchial artery anatomy and function is important in the identification of bronchial artery dilatation and anomalies and the formulation of an appropriate differential diagnosis. Visualization of dilated bronchial arteries at imaging should alert the radiologist to obstructive disorders that affect the pulmonary circulation and prompt the exclusion of diseases that produce or are associated with pulmonary artery obstruction, including chronic infectious and/or inflammatory processes, chronic thromboembolic disease, and congenital anomalies of the thorax (eg, proximal interruption of the pulmonary artery). Conotruncal abnormalities, such as pulmonary atresia with ventricular septal defect, are associated with systemic pulmonary supply provided by aortic branches known as major aortopulmonary collaterals, which originate in the region of the bronchial arteries. Bronchial artery malformation is a rare left-to-right or left-to-left shunt characterized by an anomalous connection between a bronchial artery and a pulmonary artery or a pulmonary vein, respectively. Bronchial artery interventions can be used successfully in the treatment of hemoptysis, with a low risk of adverse events. Multidetector computed tomography helps provide a vascular road map for the interventional radiologist before bronchial artery embolization.

Congenital absence of the right interlobar pulmonary artery: HRCT findings

We report a case of unilateral idiopathic pulmonary fibrosis-like changes in the right middle and lower lobe without lung volume changes and with normal upper lobe owing to congenital absence of the right interlobar pulmonary artery on chest computed tomography.

Congenital and acquired pulmonary artery anomalies in the adult: radiologic overview

Various congenital and acquired anomalies may affect the pulmonary arteries in adult patients. Congenital anomalies (proximal interruption, anomalous origin of the left pulmonary artery [pulmonary artery sling], and idiopathic dilatation of the pulmonary trunk) are usually found incidentally at chest radiography or computed tomography (CT). Acquired anomalies include diffuse or focal enlargement of the arteries because of pulmonary hypertension, aneurysm, and intravascular pulmonary metastasis; decreased arterial diameter because of bronchial carcinoma, mediastinal fibrosis, and Takayasu arteritis; and intraluminal filling defects due to pulmonary thromboembolism and pulmonary artery sarcoma. An awareness of the radiologic manifestations of the disease entities and potential pulmonary artery complications secondary to infection or vasculitis may enable an early diagnosis. CT angiography is becoming the standard method for evaluating patients in whom the presence of pulmonary embolism is suspected. CT assessment of the extent of heart effects in patients with pulmonary hypertension and pulmonary embolism is particularly important because such effects largely determine the prognosis.