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Köse A, Karaca MK, Celik A, Biricik S, Ozeren M. Acute pulmonary thromboemboli due to a giant mobile thrombus. Clin Exp Emerg Med 2017; 4:117-118. [PMID: 28717783 PMCID: PMC5511961 DOI: 10.15441/ceem.16.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/07/2017] [Accepted: 02/14/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ataman Köse
- Department of Emergency Medicine, Mersin University School of Medicine, Mersin, Turkey
| | - Mehmet Kerem Karaca
- Department of Cardiovascular Surgery, Mersin University School of Medicine, Mersin, Turkey
| | - Ahmet Celik
- Department of Cardiology, Mersin University School of Medicine, Mersin, Turkey
| | - Serdar Biricik
- Department of Emergency Medicine, Mersin University School of Medicine, Mersin, Turkey
| | - Murat Ozeren
- Department of Cardiovascular Surgery, Mersin University School of Medicine, Mersin, Turkey
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The yield of CT pulmonary angiograms to exclude acute pulmonary embolism. Emerg Radiol 2013; 21:133-41. [DOI: 10.1007/s10140-013-1169-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 2011; 57:628-652.e75. [PMID: 21621092 DOI: 10.1016/j.annemergmed.2011.01.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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Cronin P, Weg JG, Kazerooni EA. The role of multidetector computed tomography angiography for the diagnosis of pulmonary embolism. Semin Nucl Med 2009; 38:418-31. [PMID: 19331836 DOI: 10.1053/j.semnuclmed.2008.07.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
From a radiological point of view, computed tomography pulmonary angiography (CTPA) has effectively become the de-facto first-line imaging test for the evaluation of pulmonary embolism (PE), as patients with a high-quality negative CTPA do not require further examination or treatment for suspected PE. We are likely to see further technical developments in CT technology in the near future. These advances will most likely further improve image quality. Several questions or issues remain, including strategies for further imaging when CT is inconclusive or contraindicated, issues regarding radiation exposure, the prevalence of PE in specific populations, best tests and pathways in specific patient groups, including patients with specific comorbidities such as oncology patients or patients with chronic obstructive pulmonary disease. Also, the question whether all PE patients need anticoagulation, the clinical effect of follow-up imaging, and the accuracy of different clinical prediction rules, remains.
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Affiliation(s)
- Paul Cronin
- Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan Medical Center, Ann Arbor, MI 48109-5030, USA.
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Multidetector computed tomography pulmonary angiography: does arm position affect pulmonary artery enhancement? J Comput Assist Tomogr 2008; 32:778-82. [PMID: 18830111 DOI: 10.1097/rct.0b013e318153fd2a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether arm position affects pulmonary artery enhancement in computed tomographic pulmonary angiography (CTPA). METHODS Study protocol had local ethics committee approval. Eighty-six patients who received 16 detector row CTPA for suspected pulmonary embolism were scanned with their contrast-injected arm resting at their side and compared with 94 patients who were scanned with both arms resting above their head. Two radiologists assessed pulmonary artery enhancement with a region-of-interest measurement of the main pulmonary artery density, scored the degree of beam-hardening artifact arising from the superior vena cava (SVC) and from the dependent arm that crossed the pulmonary arteries (1 = no artifact, 5 = artery obscured), and measured the degree of central venous compression of the injected veins at the thoracic inlet. A 2-tailed t test was performed to compare pulmonary artery density and central venous compression. RESULTS There was no difference in pulmonary artery enhancement between the 2 arm positions. Mean density of contrast in the main pulmonary artery was 329 Hounsfield units (HU) (95% confidence interval (CI), 310-350) in the arm-down group, compared with 325 HU (95% CI, 306-346) in the arm-up group (P = 0.65). Greater compression of the central veins occurred in the arm-up group (48.5%; 95% CI, 42.3%-54.8%) than in the arm-down group (22.3%; 95% CI, 16.8%-27.8%) (P < 0.05). There was also more beam hardening arising from contrast in the SVC in the arm-up group (P < 0.0001). CONCLUSIONS Arm position does not affect pulmonary arterial enhancement during CTPA. There was greater central venous compression and more beam-hardening artifact arising from the SVC when the arm was held above the head.
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MDCT of 220 consecutive patients with suspected acute pulmonary embolism: incidence of pulmonary embolism and of other acute or non-acute thoracic findings. Radiol Med 2008; 113:373-84. [PMID: 18493774 DOI: 10.1007/s11547-008-0262-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE This study was undertaken to evaluate the incidence of pulmonary embolism (PE) and other clinically relevant thoracic findings discovered on contrast-enhanced multidetector computed tomography (MDCT) examination in patients with a suspicion of acute PE. MATERIALS AND METHODS We retrospectively reviewed 220 reports of 40-row MDCT exams in consecutive patients (101 men, 119 women; mean age 55 years+/-18) suspected for acute PE. Presenting symptoms and risk factors were recorded. Image quality and incidence of PE and other clinically relevant thoracic findings were evaluated. RESULTS MDCT were diagnostic in 96.8% of patients. Nineteen patients (8.6%) were positive for PE. Signs and symptoms were present in 82.7% (182) and risk factors in 38.2% (84) of the population. Clinically relevant thoracic findings were detected in 45.9% (101) of the patients. Ten patients had PE and other thoracic findings. Half of the patients (110) had neither PE nor other clinically relevant thoracic findings. CONCLUSIONS Chest MDCT, with an excellent overall image quality, provided an explanation for the clinical presentation in about 50% of emergency department patients studied and was useful in detecting PE and other thoracic diseases with symptoms mimicking PE. However, half of the exams were negative.
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CT angiography in suspected pulmonary embolism: impact of patient characteristics and different venous lines on vessel enhancement and image quality. AJR Am J Roentgenol 2008; 190:W351-9. [PMID: 18492877 DOI: 10.2214/ajr.07.3402] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of our study was to compare image quality, patient characteristics, and different catheters in pulmonary CT angiography (CTA) performed with bolus tracking and z-axis automated tube current modulation (ATCM) in patients with suspected pulmonary embolism. SUBJECTS AND METHODS One hundred twenty-six patients were referred to undergo pulmonary CTA with bolus tracking and ATCM. Besides patient characteristics, the type, position, size, and side of venous catheters were documented. Pulmonary vessel enhancement and image noise were quantified; signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Subjective vessel contrast was assessed by two radiologists in consensus. RESULTS Patient age showed a moderate but significant positive correlation to vessel enhancement (r = 0.244, p = 0.006), CNR (r = 0.178, p = 0.046), and subjective image quality (r = 0.344, p < 0.001). Patient weight revealed a significant negative correlation to vessel enhancement (r = -0.496, p < 0.001), SNR (r = -0.446, p < 0.001), CNR (r = -0.425, p < 0.001), and subjective image quality (r = -0.422, p < 0.001). In univariate analysis, SNR and CNR were significantly higher in patients who received contrast medium through peripheral catheters (30 +/- 13 and 27 +/- 13, respectively) than in those in whom central catheters were used (22 +/- 8 and 19 +/- 7, p = 0.041 and p = 0.029, respectively). Neither patient sex nor catheter size, position, or side had any significant impact on image quality. CONCLUSION Patient age and weight showed significant impact on vascular attenuation and image quality in pulmonary CTA with bolus tracking and ATCM, whereas patient sex and different peripheral catheters did not significantly influence image parameters.
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Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007; 245:315-29. [PMID: 17848685 DOI: 10.1148/radiol.2452070397] [Citation(s) in RCA: 397] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Martine Remy-Jardin
- Department of Thoracic Imaging, Hospital Calmette, University Center of Lille, Boulevard Jules Leclerc, 59037, Lille, France.
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11
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Multidetector computed tomography for the diagnosis of acute pulmonary embolism. Curr Opin Pulm Med 2007; 13:384-8. [DOI: 10.1097/mcp.0b013e32821acdbe] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Subramaniam RM, Blair D, Gilbert K, Coltman G, Sleigh J, Karalus N. Withholding anticoagulation after a negative computed tomography pulmonary angiogram as a stand-alone imaging investigation: a prospective management study. Intern Med J 2007; 37:624-30. [PMID: 17543006 DOI: 10.1111/j.1445-5994.2007.01387.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Accurate diagnosis of pulmonary embolism (PE) is essential and it is not clear whether a computed tomography pulmonary angiogram (CTPA) could be used as a stand-alone imaging investigation. The aim of the study was to test the accuracy of the clinical outcome of a negative CTPA as a stand-alone imaging investigation to exclude PE. METHODS Five hundred and thirty-four consecutive patients who had a CTPA for diagnosis or exclusion of PE were recruited from March 2003 to October 2004. Four hundred and ninety-four patients had a helical CTPA as a stand-alone imaging investigation for diagnosis or exclusion of PE. A 3-month post-CTPA follow up was carried out in all patients to establish the clinical outcome accuracy of a negative CTPA as a stand-alone imaging investigation. RESULTS There were 387 (78.3%) negative and 107 (21.7%) positive CTPA examinations. The average age of the patients was 57.16 years (standard deviation 18.57). Among those with a negative CTPA who survived, one patient had deep vein thrombosis and 342 patients had no evidence of an episode of venous thromboembolism or PE at the 3-month follow up. Thirty-eight patients died within the 3-month follow-up period and one patient's death was attributed to suspected PE. The negative predictive value of a CTPA is 99.5% (95% confidence interval 98.1-99.9%). CONCLUSION Helical negative CTPA examination excludes clinically significant PE as a stand-alone imaging investigation. Where concurrent deep vein thrombosis is suspected, lower limb needs to be imaged by ultrasound if the CTPA is negative.
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Affiliation(s)
- R M Subramaniam
- Department of Radiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Guilabert JP, Manzur DN, Tarrasa MJT, Llorens ML, Braun P, Arques MPB. Can multislice CT alone rule out reliably pulmonary embolism? A prospective study. Eur J Radiol 2007; 62:220-6. [PMID: 17236735 DOI: 10.1016/j.ejrad.2006.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 11/23/2006] [Accepted: 11/24/2006] [Indexed: 12/01/2022]
Abstract
PURPOSE To evaluate the safety of withholding anticoagulation in patients with suspected acute pulmonary embolism after negative multislice computed tomography (MSCT) pulmonary angiography and lower-limb venography. MATERIALS AND METHODS A total of 383 consecutive patients with suspected acute pulmonary embolism were prospectively studied. Patients underwent MSCT pulmonary angiography and lower-limb venography, as well as pulmonary scintigraphy and lower-limb ultrasound examination. Patients with negative MSCT results for both pulmonary embolism and venous thrombosis were not administered anticoagulants and were followed up for 6 months to rule out thromboembolism. RESULTS At MSCT, 156 patients were positive for pulmonary embolism, venous thrombosis, or both; 224 were negative; and findings were inconclusive in three. False-negatives were five patients with high probability scintigram and two with venous thrombosis detected at US. A total of 184 patients with negative MSCT and without anticoagulation were followed up for 6 months. During this period of time just one recurrence of pulmonary embolism was detected. The negative predictive value of MSCT pulmonary angiography plus lower-limb venography was 95.8% (183/191). CONCLUSION MSCT is efficacious in diagnosing pulmonary embolism, with negative predictive values reported in the literature ranging from 94% to 100%. This enables omission of anticoagulation in patients with suspected pulmonary embolism after negative MSCT findings without the need for other diagnostic tests.
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Ghaye B, Dondelinger RF. CT Diagnosis of Acute Pulmonary Embolism. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Turner MO, Mayo JR, Müller NL, Schulzer M, FitzGerald JM. The value of thoracic computed tomography scans in clinical diagnosis: a prospective study. Can Respir J 2007; 13:311-6. [PMID: 16983446 PMCID: PMC2683318 DOI: 10.1155/2006/859870] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Computed tomography (CT) scans are used extensively to investigate chest disease because of their cross-sectional perspective and superior contrast resolution compared with chest radiographs. These advantages lead to a more accurate imaging assessment of thoracic disease. The actual use and evaluation of the clinical impact of thoracic CT has not been assessed since scanners became widely available. OBJECTIVE To identify patterns of utilization, waiting times and the impact of CT scan results on clinical diagnoses. DESIGN A before and after survey of physicians who had ordered thoracic CT scans. SETTING Vancouver General Hospital--a tertiary care teaching centre in Vancouver, British Columbia. SUBJECTS Physicians who had ordered CT scans. INTERVENTION Physicians completed a standard questionnaire before and after the CT scan result was available. MEASUREMENTS Changes in the clinical diagnosis, estimates of the probabilities for the diagnosis both before and after the CT scan, and waiting times. RESULTS Four hundred fifty-four thoracic CT cases had completed questionnaires, of whom 80% were outpatients. A change in diagnosis was made in 48% of cases (25% with a normal CT scan and 23% with CT scan findings that indicated a different diagnosis). The largest change in probability scores for the clinical diagnosis before and after the CT scan was 43.9% for normal scans, while it was 36.3% for a different diagnosis and 26.3% for the same diagnosis. High-priority scans were associated with decreased waiting time (--7.89 days for each unit increase in priority). CONCLUSIONS The CT scan results were associated with a change in diagnosis in 48% of cases. Normal scans constituted 25% of the total and had the greatest impact scores. Waiting times were highly correlated with increased urgency of the presenting problem.
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Affiliation(s)
- Mark O Turner
- Respiratory Division, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
| | - John R Mayo
- Department of Radiology, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
- Correspondence: Dr John Mayo, Department of Radiology, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-4111 ext 63193, fax 604-875-5498, e-mail
| | - Nestor L Müller
- Department of Radiology, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
| | - Michael Schulzer
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
| | - J Mark FitzGerald
- Respiratory Division, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia and Vancouver General Hospital, Vancouver Coastal Research Institute, Vancouver, British Columbia
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Johnson PT, Naidich D, Fishman EK. MDCT for suspected pulmonary embolism: multi-institutional survey of 16-MDCT data acquisition protocols. Emerg Radiol 2006; 13:243-9. [PMID: 17136378 DOI: 10.1007/s10140-006-0547-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 09/22/2006] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to determine the extent to which a consensus exists on multidetector row computed tomography (MDCT) protocol parameters for suspected pulmonary embolism (PE). In August of 2004, a questionnaire addressing a number of body MDCT protocols was mailed to 99 fellows of the Society of Computed Body Tomography, representing a total of 46 institutions. In May 2005, this was followed up with a second mailing. The survey requested details pertaining to protocols for the most advanced MDCT scanner in the department. The overall survey response rate of 37% (17/46) yielded 15 protocols for 16-MDCT imaging of suspected PE. This data was tabulated and revealed a consensus for the use of bolus tracking, rapid contrast infusion, caudo-cranial scanning, the narrowest detector row collimation, and thin (<2 mm) reconstruction sections. However, contrast infusion timing, contrast concentration, and implementation of radiation dose modulation were variable. This compilation of protocols reflects recently published studies advocating the use of narrow acquisition collimation and reconstruction sections for MDCT of suspected PE. Future studies are necessary to elucidate the optimal intravenous contrast infusion parameters and further assess the efficacy of reduced radiation dose protocols.
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Affiliation(s)
- Pamela T Johnson
- The Russell H. Morgan Department of Radiology and Radiologic Sciences, Johns Hopkins School of Medicine, 601 N. Caroline Street, Room 3251, Baltimore, MD 21287, USA
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Pleszewski B, Chartrand-Lefebvre C, Qanadli SD, Déry R, Perreault P, Oliva VL, Prenovault J, Belblidia A, Soulez G. Gadolinium-enhanced pulmonary magnetic resonance angiography in the diagnosis of acute pulmonary embolism: a prospective study on 48 patients. Clin Imaging 2006; 30:166-72. [PMID: 16632150 DOI: 10.1016/j.clinimag.2005.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2005] [Accepted: 10/01/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Gadolinium-enhanced pulmonary magnetic resonance angiography (MRA) can be an option in patients with a history of previous adverse reaction to iodinated contrast material and renal insufficiency. Radiation is also avoided. The aim of this study is to prospectively compare the diagnostic value of MRA with that of a diagnostic strategy, taking into account catheter angiography, computed tomography angiography (CTA), and lung scintigraphy [ventilation-perfusion (VQ)]. MATERIAL AND METHODS Magnetic resonance angiography was done in 48 patients with clinically suspected pulmonary embolism (PE) using fast gradient echo coronal acquisition with gadolinium. Interpretation was done with native coronal images and multiplanar maximum intensity projection reconstructions. Results were compared to catheter angiography (n=15), CTA (n=34), VQ (n=45), as well as 6-12 months clinical follow-ups, according to a sequenced reference tree. RESULTS The final diagnosis of PE was retained in 11 patients (23%). There were two false negatives and no false positive results with MRA. Computed tomography angiography resulted in no false negatives or false positives. Magnetic resonance angiography had a sensitivity of 82% and a specificity of 100%. CONCLUSION In our study, pulmonary MRA had a sensitivity of 82% and a specificity of 100% for the diagnosis of PE, with slightly less sensitivity than CTA. In the diagnostic algorithm of PE, pulmonary MRA should be considered as an alternative to CTA when iodine contrast injection or radiation is a significant matter.
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Affiliation(s)
- Bartlomiej Pleszewski
- Centre hospitalier de l'Université de Montréal (CHUM), Hôpital Saint-Luc, Radiology Department, St-Denis Street, Montreal, Quebec, Canada H2X 3J4
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Hargaden GC, Kavanagh EC, Fitzpatrick P, Murray JG. Diagnosis of pulmonary emboli and image quality at CT pulmonary angiography: Influence of imaging direction with multidetector CT. Clin Radiol 2006; 61:600-3. [PMID: 16784946 DOI: 10.1016/j.crad.2005.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Revised: 11/10/2005] [Accepted: 12/06/2005] [Indexed: 12/01/2022]
Abstract
AIM To determine whether there was a significant difference in the prevalence of emboli detected when patients underwent computed tomography pulmonary angiography (CTPA) in a craniocaudal direction versus a caudocranial direction. MATERIALS AND METHODS This was a prospective study of 203 consecutive patients attending for CTPA for suspected pulmonary embolus. Imaging was performed on a multisection Siemens Volume Zoom CT machine, with bolus tracking centred on the main pulmonary artery after intravenous administration of contrast at 3 ml/s. Patients were examined in a single breath-hold, from the top of the aortic arch to the highest point of the diaphragm, in a randomly assigned cranio-caudal (group A), or caudo-cranial (group B) direction. Images were reviewed on a workstation in a cranio-caudal direction jointly by two radiologists unaware of the original imaging direction. The presence, number and position of arterial emboli were noted, and a subjective assessment of overall image quality and opacification of upper and lower lobe vessels (grade 1, 2, 3, or 4) was made. RESULTS Emboli were detected in 46 patients. There was no significant difference in the prevalence of emboli detected in the two groups [group A craniocaudal direction n=22, group B caudocranial direction n=24 (p=0.76)]. Imaging direction did not significantly influence overall image quality (p=0.07), however, there was a significantly greater proportion of patients in group A with grade 1 opacification of the upper lobe arteries (p=0.02). CONCLUSION Imaging direction does not significantly influence the diagnosis of pulmonary emboli but it does significantly improve the upper lobe pulmonary arterial enhancement with fewer non-diagnostic images, and on that basis we recommend that craniocaudal direction be used for CTPA studies.
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Affiliation(s)
- G C Hargaden
- Department of Radiology, The Mater Misericordiae University Hospital, Dublin, Ireland.
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Raptopoulos VD, Boiselle PB, Michailidis N, Handwerker J, Sabir A, Edlow JA, Pedrosa I, Kruskal JB. MDCT Angiography of Acute Chest Pain: Evaluation of ECG-Gated and Nongated Techniques. AJR Am J Roentgenol 2006; 186:S346-56. [PMID: 16714608 DOI: 10.2214/ajr.04.1882] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to compare MDCT angiography protocols used in patients with acute chest pain caused by vascular, nonvascular, and cardiac abnormalities. SUBJECTS AND METHODS In four groups of 20 patients with chest pain each, four MDCT protocols were used based on monitoring vascular attenuation: pulmonary embolism (150 H at pulmonary artery), aortic dissection (200 H at aortic arch), chest pain (200 H at pulmonary artery), and chest pain with ECG gating (150 H at pulmonary artery). Vascular enhancement was assessed by attenuation measurements taken from locations in the pulmonary artery (n = 3) and thoracic aorta (n = 4). The appearance of the coronary artery in regard to opacification and motion was assessed on a scale of 1 to 5 (best). RESULTS The mean pulmonary artery and aorta attenuation (372 H and 352 H, respectively) was significantly higher (p < 0.005, Student's t test) and the number of vessel attenuation points measuring less than 200 H (1/140) was significantly smaller (p < 0.001, chi-square test) in the chest pain compared with the dissection (318 H, 310 H; 16/140), gated chest pain (304 H, 286 H; 17/14), and pulmonary embolism (302 H, 220 H; 28/140) groups. The median coronary artery visualization score was 4; the proximal regions received a significantly (p < 0.005, Mann-Whitney test) higher grade compared with the middle and distal regions (medians, 5, 4, and 2, respectively). Artifacts were noted on the gated scans. CONCLUSION The chest pain protocol can be used to assess both the pulmonary arteries and the thoracic aorta, whereas the ECG-gating protocol appears to be a promising adjunct for a comprehensive single chest pain protocol.
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Affiliation(s)
- Vassilios D Raptopoulos
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA
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Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354:2317-27. [PMID: 16738268 DOI: 10.1056/nejmoa052367] [Citation(s) in RCA: 986] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively. METHODS The Prospective Investigation of Pulmonary Embolism Diagnosis II trial was a prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging (CTA-CTV) for the diagnosis of acute pulmonary embolism. We used a composite reference test to confirm or rule out the diagnosis of pulmonary embolism. RESULTS Among 824 patients with a reference diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83 percent and the specificity was 96 percent. Positive predictive values were 96 percent with a concordantly high or low probability on clinical assessment, 92 percent with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA-CTV was inconclusive in 87 of 824 patients because the image quality of either CTA or CTV was poor. The sensitivity of CTA-CTV for pulmonary embolism was 90 percent, and specificity was 95 percent. CTA-CTV was also nondiagnostic with a discordant clinical probability. CONCLUSIONS In patients with suspected pulmonary embolism, multidetector CTA-CTV has a higher diagnostic sensitivity than does CTA alone, with similar specificity. The predictive value of either CTA or CTA-CTV is high with a concordant clinical assessment, but additional testing is necessary when the clinical probability is inconsistent with the imaging results.
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Affiliation(s)
- Paul D Stein
- Department of Research, St. Joseph Mercy Oakland Hospital, Pontiac, Mich, USA.
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Abstract
The educational objectives for this self-assessment module on imaging of pulmonary embolism are for the participant to exercise, self-assess, and improve his or her understanding of the evaluation of patients with suspected pulmonary embolism using CT angiography; gain familiarity with nonembolic conditions that may be found in patients who are studied with CT angiography for suspected pulmonary embolism; and gain familiarity with the phenomenon of paradoxical embolism, its manifestations on CT angiography, and its radiologic differential diagnosis.
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Affiliation(s)
- Pierre D Maldjian
- Department of Radiology, University Hospital, UMDNJ-NJ Medical School, 150 Bergen St., UH C-320, Newark, NJ 07103-2406, USA
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22
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Johnson PT, Fishman EK. IV Contrast Selection for MDCT: Current Thoughts and Practice. AJR Am J Roentgenol 2006; 186:406-15. [PMID: 16423946 DOI: 10.2214/ajr.04.1902] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The purpose of this article is to review studies evaluating how contrast concentration affects MDCT of the body and to report IV contrast infusion protocols from MDCT angiography and MDCT of abdominal tumors. CONCLUSION Higher concentrations (350 mg I/mL or greater) may improve visualization of small abdominal arteries. However, preliminary data comparing 300 mg I/mL to higher concentrations for MDCT of hypervascular hepatocellular carcinoma and pancreatic cancer have shown that higher concentrations may not increase tumor conspicuity.
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Affiliation(s)
- Pamela T Johnson
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, 601 N Caroline St., Rm. 3251, Baltimore, MD 21287
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23
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Holmquist F, Nyman U. Eighty-peak kilovoltage 16-channel multidetector computed tomography and reduced contrast-medium doses tailored to body weight to diagnose pulmonary embolism in azotaemic patients. Eur Radiol 2006; 16:1165-76. [PMID: 16447047 DOI: 10.1007/s00330-005-0117-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 11/07/2005] [Accepted: 11/24/2005] [Indexed: 11/24/2022]
Abstract
The aim of this study was to assess the feasibility of minimising contrast-medium (CM) doses using 80-peak kilovoltage (kVp) 16-channel multidetector computed tomography (MDCT) with CM dose tailored to body weight, when diagnosing pulmonary embolism (PE) in azotaemic patients. Twenty-nine patients (68-93 years; 38-79 kg) with an estimated glomerular filtration rate of 12-49 ml/min underwent 80 kVp MDCT at a median dose of 200 mg iodine (I)/kg and 15 s injection time. Pulmonary artery (PA) enhancement where compared with our own reference material using 320 mg I/kg at 120 kVp and with reported figures in the literature at 120-140 kVp and a 42 g iodine CM dose. Median (1st and 3rd quartiles) values regarding CM dose were 12.2 (9.9-12.8) g iodine; density of left main and lower lobe segmental PA 339 (275-395) Hounsfield units (HU) and 354 (321-442) HU, respectively. Those enhancement values were similar to those obtained from the reference population at 120 kVp and those reported in the literature at 120-140 kVp. One patient had a transient increase in plasma creatinine. Three months' follow-up revealed deep venous thrombosis among 1/18 patients with negative results from computed tomography (CT). We conclude that 80 kVp 16-channel MDCT to diagnose PE in azotaemic patients may be performed with markedly reduced CM doses, implying a lesser risk for CM-induced nephropathy.
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Affiliation(s)
- Fredrik Holmquist
- Department of Radiology, Malmö University Hospital, Lund University, 205 02 Malmö, Sweden.
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24
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Menna-Barreto SS. O desafio de diagnosticar tromboembolia pulmonar aguda em pacientes com doença pulmonar obstrutiva crônica. J Bras Pneumol 2005. [DOI: 10.1590/s1806-37132005000600012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Tromboembolia pulmonar aguda e exacerbação aguda de doença pulmonar obstrutiva crônica são doenças comuns. A doença pulmonar obstrutiva crônica é um fator clínico de risco para tromboembolia pulmonar aguda. As apresentações clínicas da tromboembolia pulmonar aguda e da exacerbação aguda da doença pulmonar obstrutiva crônica freqüentemente mimetizam-se tanto que pode ser difícil distingui-las. Anormalidades estruturais nos pulmões com doença pulmonar obstrutiva crônica tornam também difícil a interpretação de testes não invasivos de diagnóstico, como o mapeamento de ventilação e perfusão pulmonares. Assim, diagnosticar tromboembolia pulmonar aguda em pacientes com doença pulmonar obstrutiva crônica é uma tarefa desafiadora. Com o objetivo de atualizar o assunto e oferecer sugestões de conduta, nós avaliamos artigos abordando este tema, incluindo relatos e séries de casos, abordagens diagnósticas de tromboembolia pulmonar aguda e fizemos algumas reflexões. A probabilidade clínica de tromboembolia pulmonar aguda em cenários de doença pulmonar obstrutiva crônica é usualmente intermediária, o mapeamento de ventilação e perfusão pulmonares é predominantemente de probabilidade intermediária e os algoritmos de conduta os deveriam assim considerar.
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25
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Girard P. Approche diagnostique de la maladie thromboembolique veineuse. Presse Med 2005; 34:1418-26. [PMID: 16301973 DOI: 10.1016/s0755-4982(05)84203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The diagnosis of pulmonary embolism (PE) and deep venous thrombosis (DVT) has long been based on purely clinical grounds. Pulmonary angiography and scintigraphy, as well as venography, reveal the poor diagnostic value of signs and symptoms of PE and DVT, which are now reduced to the role of triggers for these diagnostic tests. The development of simpler, but still imperfect, diagnostic tools (mainly, D-dimer plasma level, venous compression ultrasound, clinical probability of PE or DVT, spiral CT pulmonary angiography) has led to the development of diagnostic strategies, which use combinations of tests, not to provide diagnostic certainty for every patient (presence or absence of clots), but rather to select populations of patients who need treatment and others who can safely remain untreated. Such pragmatic approaches must be validated in appropriate outcome studies. The choice of a diagnostic strategy should depend not only on the strategy's cost-effectiveness in the population under study but also on the local facilities and expertise required for its use.
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Affiliation(s)
- P Girard
- Département thoracique, Institut mutualiste Montsouris, 42, bd Jourdan, 75014 Paris.
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26
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Lake DR, Kavanagh JJ, Ravenel JG, Schoepf UJ, Costello P. Computed Tomography and Pulmonary Embolus: A Review. Semin Ultrasound CT MR 2005; 26:270-80. [PMID: 16273999 DOI: 10.1053/j.sult.2005.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolus (PE) is a common clinical condition with significant morbidity and mortality that remains a diagnostic challenge for clinicians. Although many tests exist, multi-detector computed tomography (MDCT) pulmonary angiography has recently emerged as the test of choice. MDCT technique, diagnostic criteria, prognosis assessment and common causes of misdiagnosis are reviewed with a look toward future trends.
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Affiliation(s)
- Douglas R Lake
- Division of Thoracic Imaging, Department of Radiology, Medical University of South Carolina, Charleston, SC 29425, USA.
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27
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Ghanima W, Almaas V, Aballi S, Dörje C, Nielssen BE, Holmen LO, Almaas R, Abdelnoor M, Sandset PM. Management of suspected pulmonary embolism (PE) by D-dimer and multi-slice computed tomography in outpatients: an outcome study. J Thromb Haemost 2005; 3:1926-32. [PMID: 16102097 DOI: 10.1111/j.1538-7836.2005.01544.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A prospective outcome study designed to evaluate a simple strategy for the management of outpatients with suspected pulmonary embolism (PE), based on clinical probability, D-dimer, and multi-slice computed tomography (MSCT). METHODS A cohort of 432 consecutive patients admitted to the emergency department with suspected PE was managed by sequential non-invasive testing. Patients in whom PE was ruled out were not given anticoagulants, but were followed-up for 3 months. RESULTS Normal D-dimer and low-intermediate clinical probability ruled out PE in 103 patients [24% (95% CI 20-28)]. Seventeen patients had normal D-dimer, but high clinical probability and proceeded to MSCT. All patients proved negative for PE. A total of 329 (76%) patients underwent MSCT examination. Pulmonary embolism was diagnosed in 93 patients [21.5% (95% CI 18-26)] and was ruled out by negative MSCT in 221 patients [51% (95% CI 46-56)]. MSCT scans were determined as inconclusive in 15 (4.5%) patients. No patient developed objectively verified venous thromboembolism (VTE) during the 3-month follow-up period. However, the cause of death was adjudicated as possibly related to PE in two patients, resulting in an overall 3-month VTE risk of 0.6% (95% CI 0-2.2%). The diagnostic algorithm yielded a definite diagnosis in 96.5% of the patients. CONCLUSIONS This simple and non-invasive strategy combining clinical probability, D-dimer, and MSCT for the management of outpatients with suspected PE appears to be safe and effective.
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Affiliation(s)
- W Ghanima
- Department of Medicine, Østfold Hospital Trust, Fredrikstad, Norway.
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28
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Abstract
OBJECTIVE In this article, we review the current role of CT pulmonary angiography and indirect CT venography for the evaluation of pulmonary thromboembolic disease. CONCLUSION With advances in MDCT technology, evaluation of pulmonary thromboembolic disease can now be performed with combined CT pulmonary angiography and CT venography as a "one-stop-shopping" test. CT pulmonary angiography is cost-effective, is accurate, has high interobserver agreement, and has an added advantage of detecting other life-threatening diseases in the chest that mimic pulmonary embolism.
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Affiliation(s)
- Smita Patel
- Department of Radiology, University of Michigan, 1500 E Medical Center Dr., TC2910D, Ann Arbor, MI 48109-0326, USA
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29
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Wildberger JE, Klotz E, Ditt H, Spüntrup E, Mahnken AH, Günther RW. Multislice computed tomography perfusion imaging for visualization of acute pulmonary embolism: animal experience. Eur Radiol 2005; 15:1378-86. [PMID: 15776240 DOI: 10.1007/s00330-005-2718-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 01/14/2005] [Accepted: 01/21/2005] [Indexed: 10/25/2022]
Abstract
The purpose of our animal study was to evaluate a new computed tomography (CT) subtraction technique for visualization of perfusion defects within the lung parenchyma in subsegmental pulmonary embolism (PE). Seven healthy pigs were entered into a prospective trial. Acute PE was artificially induced by fresh clot material prior to the CT scans. Within a single breath-hold, whole thorax CT scans were performed with a 16-slice multidetector-row CT scanner (SOMATOM Sensation 16; Siemens, Forchheim, Germany) before and after intravenous application of 80 ml of contrast medium with a flow rate of 4 ml/s, followed by a saline chaser. The scan parameters were 120 kV and 100 mAs(eff), using a thin collimation of 16x0.75 mm and a table speed/rotation of 15-18 mm (pitch, 1.25-1.5; rotation time, 0.5 s). Axial source images were reconstructed with an effective slice thickness of 1 mm (overlap, 30%). A new automatic subtraction technique was used. After 3D segmentation of the lungs in the plain and contrast-enhanced series, threshold-based extraction of major airways and vascular structures in the contrast images was performed. This segmentation was repeated in the plain CT images segmenting the same number of vessels and airways as in the contrast images. Both scans were registered onto each other using nonrigid registration. After registration both image sets were filtered in a nonlinear fashion excluding segmented airways and vessels. After subtracting the plain CT data from the contrast data the resulting enhancement images were color-encoded and overlaid onto the contrast-enhanced CT angiography (CTA) images. This color-encoded combined display of parenchymal enhancement of the lungs was evaluated interactively on a workstation (Leonardo, Siemens) in axial, coronal and sagittal plane orientations. Axial contrast-enhanced CTA images were rated first, followed by an analysis of the combination images. Finally, CTA images were reread focusing on areas with perfusion deficits indicating PE on the color-coded enhancement display. Subtraction was feasible for all seven studies. In one animal, opacification of the pulmonary arteries was suboptimal owing to heart insufficiency. In the remaining six pigs, a total of 37 perfusion defects were clearly assessable downstream of occluded subsegmental arteries, showing lower or missing enhancement compared with normally perfused lung parenchyma. Indeterminate findings from CTA showed typical PE perfusion defects in four out of six cases on CT subtraction. Additionally, 22 peripheral triangular-shaped enhancement defects were delineated. Nine of these findings were reclassified as definitely being caused by PE on second reading of the CTA data sets. Our initial results have shown that this new subtraction technique for perfusion imaging of PE is feasible, using routine contrast delivery. Dedicated examination protocols are mandatory for adequate opacification of the pulmonary arteries and for optimization of data sets for subsequent subtraction. Perfusion imaging allows a comprehensive assessment of morphology and function, providing more accurate information on acute PE.
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31
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Wildberger JE, Mahnken AH, Das M, Küttner A, Lell M, Günther RW. CT imaging in acute pulmonary embolism: diagnostic strategies. Eur Radiol 2005; 15:919-29. [PMID: 15662491 DOI: 10.1007/s00330-005-2643-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Revised: 12/21/2004] [Accepted: 12/27/2004] [Indexed: 10/25/2022]
Abstract
Computed tomography pulmonary angiography (CTA) has increasingly become accepted as a widely available, safe, cost-effective, and accurate method for a quick and comprehensive diagnosis of acute pulmonary embolism (PE). Pulmonary catheter angiography is still considered the gold standard and final imaging method in many diagnostic algorithms. However, spiral CTA has become established as the first imaging test in clinical routine due to its high negative predictive value for clinically relevant PE. Despite the direct visualization of clot material, depiction of cardiac and pulmonary function in combination with the quantification of pulmonary obstruction helps to grade the severity of PE for further risk stratification and to monitor the effect of thrombolytic therapy. Because PE and deep venous thrombosis are two different aspects of the same disease, additional indirect CT venography may be a valuable addition to the initial diagnostic algorithm-if this was positive for PE-and demonstration of the extent and localization of deep venous thrombosis has an impact on clinical management. Additional and alternate diagnoses add to the usefulness of this method. Using advanced multislice spiral CT technology, some practitioners have advocated CTA as the sole imaging tool for routine clinical assessment in suspected acute PE. This will simplify standards of practice in the near future.
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Affiliation(s)
- Joachim E Wildberger
- Department of Diagnostic Radiology, University Hospital, University of Technology (RWTH), Aachen, Germany.
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32
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Ravenel JG, Kipfmueller F, Schoepf UJ. CT angiography with multidetector-row CT for detection of acute pulmonary embolus. Semin Roentgenol 2005; 40:11-9. [PMID: 15732556 DOI: 10.1053/j.ro.2004.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- James G Ravenel
- Department of Radiology, Medical University of South Carolina, Charleston, SC, USA.
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