The assessment of acute pulmonary embolism severity using CT angiography features

Detection and severity quantification of pulmonary embolism with 3D CT data using an automated deep learning-based artificial solution

PURPOSE

The purpose of this study was to propose a deep learning-based approach to detect pulmonary embolism and quantify its severity using the Qanadli score and the right-to-left ventricle diameter (RV/LV) ratio on three-dimensional (3D) computed tomography pulmonary angiography (CTPA) examinations with limited annotations.

MATERIALS AND METHODS

Using a database of 3D CTPA examinations of 1268 patients with image-level annotations, and two other public datasets of CTPA examinations from 91 (CAD-PE) and 35 (FUME-PE) patients with pixel-level annotations, a pipeline consisting of: (i), detecting blood clots; (ii), performing PE-positive versus negative classification; (iii), estimating the Qanadli score; and (iv), predicting RV/LV diameter ratio was followed. The method was evaluated on a test set including 378 patients. The performance of PE classification and severity quantification was quantitatively assessed using an area under the curve (AUC) analysis for PE classification and a coefficient of determination (R²) for the Qanadli score and the RV/LV diameter ratio.

RESULTS

Quantitative evaluation led to an overall AUC of 0.870 (95% confidence interval [CI]: 0.850-0.900) for PE classification task on the training set and an AUC of 0.852 (95% CI: 0.810-0.890) on the test set. Regression analysis yielded R² value of 0.717 (95% CI: 0.668-0.760) and of 0.723 (95% CI: 0.668-0.766) for the Qanadli score and the RV/LV diameter ratio estimation, respectively on the test set.

CONCLUSION

This study shows the feasibility of utilizing AI-based assistance tools in detecting blood clots and estimating PE severity scores with 3D CTPA examinations. This is achieved by leveraging blood clots and cardiac segmentations. Further studies are needed to assess the effectiveness of these tools in clinical practice.

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review

BACKGROUND

Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital.

CASE PRESENTATION

A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications.

CONCLUSIONS

The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.

The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism

Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.

Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism)

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p = 0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p = 0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p = 0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p = 0.32). In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Acute Pulmonary Embolism: Prognostic Role of Computed Tomography Pulmonary Angiography (CTPA)

Computed Tomography Pulmonary Angiography (CTPA) is considered the gold standard diagnostic technique in patients with suspected acute pulmonary embolism in emergency departments. Several studies have been conducted on the predictive value of CTPA on the outcomes of pulmonary embolism (PE). The purpose of this article is to provide an updated review of the literature reporting imaging parameters and quantitative CT scores to predict the severity of PE.

CHA2 DS2 -VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism

BACKGROUND

Accurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA₂ DS₂ -VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation.

HYPOTHESIS

This study aims to evaluate the association between CHA₂ DS₂ -VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA).

METHODS

One hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA₂ DS₂ -VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA.

RESULTS

PESI and CHA₂ DS₂ -VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA₂ DS₂ -VASc score and PESI score had a positive correlation. The area under the curve value for the CHA₂ DS₂ -VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity.

CONCLUSION

This study showed that not only CHA₂ DS₂ -VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA₂ DS₂ -VASc and PESI scores are able to predict RV dysfunction.

Role of multidetector CT in predicting patient outcome in cases of pulmonary embolism: correlation between imaging findings, ICU admissions and mortality rate

Background

Pulmonary embolism (PE) is a critical medical condition that requires prompt diagnosis and treatment to avoid serious morbidity and mortality risk. Multidetector CT pulmonary angiography (CTPA) is considered the first-line imaging modality for suspected acute PE. The presence of right heart strain, which supports the diagnosis, requires special attention. The aim of our retrospective study is to assess the reliability of CTPA hemodynamic indices in predicting patients’ outcome in cases of PE.

Results

Sixty patients were included in our study. CTPA parameters including main pulmonary artery (MPA) diameter, left ventricle (LV) diameter, right ventricle (RV)/LV ratio, and septal deviation had a clinical prognostic value for short-term 30-day mortality and ICU admission. Statistically significant relationship between MPA diameter > 29 mm, LV diameter, RV/LV ratio > 1, left-sided septal deviation and contrast reflux into the IVC/distal hepatic veins with ICU admission was observed with p values 0.031, 0.000, 0.000, 0.005 and 0.028 respectively. There was a statistically significant correlation between MPA diameter > 29 mm, LV diameter, RV/LV > 1 ratio and septal deviation with 30-day mortality with p values of < 0.001, 0.001, < 0.001 and 0.015 respectively. No significant correlation was found between 30-day mortality and contrast reflux to IVC with p value of 0.070.

Conclusions

CTPA measurements including MPA diameter, RV/LV ratio and septal deviation were found to be significantly correlated to ICU admission and 30-day mortality as predictors for PE severity. CT contrast reflux was found to be correlated to ICU admission; however, it was not significantly correlated to 30-day mortality.

Importance of computed tomography pulmonary angiography for predict 30-day mortality in acute pulmonary embolism patients

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The study provides a cut-off value of RV diameter and CT obstruction index by CTPA to predict acute PE patients' mortality.

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RV diameter of 53 mm or over and CT obstruction index >70 % is associated with increased 30-day mortality in APE patients.

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Increased RV diameter by CTPA is a better predictor of mortality than the clinical Pulmonary Embolism Severity Index (PESI).

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CTPA can be valuable as both the diagnostic and prognostic tool in APE patients.

Objective

The purpose of the present study was to assess the implications of different parameters of computed tomography pulmonary angiography (CTPA) to predict 30-day mortality in acute pulmonary embolism (APE) patients.

Material and Method

Patients who had clinical suspicion of APE and underwent CTPA were recruited in a retrospective cohort study. The findings of the CTPA included the parameters of right ventricular dysfunction (RVD), the severity of obstruction to the pulmonary artery by CT obstruction index, and the ratio of pulmonary trunk diameter and aorta. The endpoint of the study was established as the 30-day mortality associated with APE.

Results

A total of 238 patients with a confirmed APE diagnosis with CTPA were included in the study; 26 (10.9 %) of those patients died within 30 days. In patients with cancer and the Pulmonary Embolism Severity Index (PESI) class 5, the mortality rate was significantly higher. Compared with survivors, the mean CT obstruction index in the non-survivor group was significantly higher (p < 0.001). Higher mortality was associated with all RVD parameters identified by CTPA, such as the RV/LV ratio (p < 0.001), interventricular septum deviation grade 3 (p < 0.001), increased RV diameter (p < 0.001), and IVC contrast reflux (p < 0.001). The highest adjusted odds ratio was RV diameter at 1.094, followed by PESI and the CT obstruction index at 1.040.

Conclusion

CTPA-detected RVD parameters and CT obstruction index can predict a 30-day mortality rate in APE patients and be used for risk stratification. In APE patients, the RV diameter of 53 mm or greater and the CT obstruction index >70% is associated with increased 30-day mortality.