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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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2
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Starekova J, Chu SY, Bluemke DA, Grist TM, Kusmirek JE, Nagle SK, Schiebler ML, Lubner MG, Nagpal P, Reeder SB. MRA as the Preferred Test for Pulmonary Embolism During the Iodinated Contrast Media Shortage of 2022: A Single-Center Experience. AJR Am J Roentgenol 2023; 221:736-746. [PMID: 37341181 DOI: 10.2214/ajr.23.29340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND. Closure of a GE Healthcare facility in Shanghai, China, in 2022 disrupted the iodinated contrast media supply. Technologic advances have addressed limitations associated with the use of pulmonary MRA for diagnosis of pulmonary embolism (PE). OBJECTIVE. The purpose of this study was to describe a single institution's experience in the use of pulmonary MRA as an alternative to CTA for the diagnosis of PE in the general population during the iodinated contrast media shortage in 2022. METHODS. This retrospective single-center study included all CTA and MRA examinations performed to exclude PE from April 1 through July 31 (18 weekly periods) in 2019 (before the COVID-19 pandemic and contrast media shortage), 2021 (during the pandemic but before the shortage), and 2022 (during both the pandemic and the shortage). From early May through mid-July of 2022, MRA served as the preferred test for PE diagnosis, to preserve iodinated contrast media. CTA and MRA reports were reviewed. The total savings in iodinated contrast media volume resulting from preferred use of MRA was estimated. RESULTS. The study included 4491 examinations of 4006 patients (mean age, 57 ± 18 [SD] years; 1715 men, 2291 women): 1245 examinations (1111 CTA, 134 MRA) in 2019, 1547 examinations (1403 CTA, 144 MRA) in 2021, and 1699 examinations (1282 CTA, 417 MRA) in 2022. In 2022, the number of MRA examinations was four (nine when normalized to a 7-day period) in week 1, and this number increased to a maximum of 63 in week 10 and then decreased to 10 in week 18. During weeks 8-11, more MRA examinations (range, 45-63 examinations) than CTA examinations (range, 27-46 examinations) were performed. In 2022, seven patients with negative MRA underwent subsequent CTA within 2 weeks; CTA was negative in all cases. In 2022, 13.9% of CTA examinations (vs 10.3% of MRA examinations) were reported as having limited image quality. The estimated 4-month savings resulting from preferred use of MRA in 2022, under the assumption of uniform simple linear growth in CTA utilization annually and a CTA dose of 1 mL/kg, was 27 L of iohexol (350 mg I/mL). CONCLUSION. Preferred use of pulmonary MRA for PE diagnosis in the general population helped to conserve iodinated contrast media during the 2022 shortage. CLINICAL IMPACT. This single-center experience shows pulmonary MRA to be a practical substitute for pulmonary CTA in emergency settings.
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Affiliation(s)
- Jitka Starekova
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Sheena Y Chu
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - David A Bluemke
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI
| | - Joanna E Kusmirek
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Prashant Nagpal
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI
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3
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Bergmann LL, Ackman JB, Starekova J, Moeller A, Reeder S, Nagle SK, Schiebler ML. MR Angiography of Pulmonary Vasculature. Magn Reson Imaging Clin N Am 2023; 31:475-491. [PMID: 37414473 DOI: 10.1016/j.mric.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Pulmonary MR angiography (MRA) is a useful alternative to computed tomographic angiography (CTA) for the study of the pulmonary vasculature. For pulmonary hypertension and partial anomalous pulmonary venous return, a cardiac MR imaging and the pulmonary MRA are useful for flow quantification and planning treatment. For the diagnosis of pulmonary embolism (PE), MRA-PE has been shown to have non-inferior outcomes at 6 months when compared with CTA-PE. Over the last 15 years, pulmonary MRA has become a routine and reliable examination for the workup of pulmonary hypertension and the primary diagnosis of PE at the University of Wisconsin.
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Affiliation(s)
- Liisa L Bergmann
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, HX332E, Lexington, KY 40536-0293, USA; Department of Medicine, University of Kentucky College of Medicine, 800 Rose Street, HX332E, Lexington, KY 40536-0293, USA.
| | - Jeanne B Ackman
- Massachusetts General Hospital, Department of Radiology, Division of Thoracic Imaging and Intervention Austin Building 202, 55 Fruit Street, Boston, MA 02114, USA
| | - Jitka Starekova
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Alexander Moeller
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Scott Reeder
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53705, USA.
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4
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Wucherpfennig L, Triphan SM, Weinheimer O, Eichinger M, Wege S, Eberhardt R, Puderbach MU, Kauczor HU, Heussel CP, Heussel G, Wielpütz MO. Reproducibility of pulmonary magnetic resonance angiography in adults with muco-obstructive pulmonary disease. Acta Radiol 2023; 64:1038-1046. [PMID: 35876445 DOI: 10.1177/02841851221111486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies support magnetic resonance angiography (MRA) as a diagnostic tool for pulmonary arterial disease. PURPOSE To determine MRA image quality and reproducibility, and the dependence of MRA image quality and reproducibility on disease severity in patients with chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF). MATERIAL AND METHODS Twenty patients with COPD (mean age 66.5 ± 8.9 years; FEV1% = 42.0 ± 13.3%) and 15 with CF (mean age 29.3 ± 9.3 years; FEV1% = 66.6 ± 15.8%) underwent morpho-functional chest magnetic resonance imaging (MRI) including time-resolved MRA twice one month apart (MRI1, MRI2), and COPD patients underwent non-contrast computed tomography (CT). Image quality was assessed visually using standardized subjective 5-point scales. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured by regions of interest. Disease severity was determined by spirometry, a well-evaluated chest MRI score, and by computational CT emphysema index (EI) for COPD. RESULTS Subjective image quality was diagnostic for all MRA at MRI1 and MRI2 (mean score = 4.7 ± 0.6). CNR and SNR were 4 43.8 ± 8.7 and 50.5 ± 8.7, respectively. Neither image quality score nor CNR or SNR correlated with FEV1% or chest MRI score for COPD and CF (r = 0.239-0.248). CNR and SNR did not change from MRI1 to MRI2 (P = 0.434-0.995). Further, insignificant differences in CNR and SNR between MRA at MRI1 and MRI2 did not correlate with FEV1% nor chest MRI score in COPD and CF (r = -0.238-0.183), nor with EI in COPD (r = 0.100-0.111). CONCLUSION MRA achieved diagnostic quality in COPD and CF patients and was highly reproducible irrespective of disease severity. This supports MRA as a robust alternative to CT in patients with underlying muco-obstructive lung disease.
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Affiliation(s)
- Lena Wucherpfennig
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Mf Triphan
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Oliver Weinheimer
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Monika Eichinger
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Wege
- Department of Pulmonology and Respiratory Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Ralf Eberhardt
- Department of Pulmonology and Respiratory Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
- Department of Pulmonology and Internal intensive care, Asklepios Clinic Barmbek, Hamburg, Germany
| | - Michael U Puderbach
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, Hufeland Hospital, Bad Langensalza, Germany
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Claus P Heussel
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Gudula Heussel
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
| | - Mark O Wielpütz
- Department of Diagnostic and Interventional Radiology, Subdivision of Pulmonary Imaging, 27178University Hospital Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg (TLRC), German Lung Research Center (DZL), Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, 27178University Hospital Heidelberg, Heidelberg, Germany
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Kirsch J, Wu CC, Bolen MA, Henry TS, Rajiah PS, Brown RKJ, Galizia MS, Lee E, Rajesh F, Raptis CA, Rybicki FJ, Sams CM, Verde F, Villines TC, Wolf SJ, Yu J, Donnelly EF, Abbara S. ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update. J Am Coll Radiol 2022; 19:S488-S501. [PMID: 36436972 DOI: 10.1016/j.jacr.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Carol C Wu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Travis S Henry
- Panel Chair, Division Chief of Cardiothoracic Imaging, Duke University, Durham, North Carolina; Co-Director, ACR Education Center HRCT Course; Chair
| | | | - Richard K J Brown
- Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Elizabeth Lee
- University of Michigan Health System, Ann Arbor, Michigan; Director M1Radiology Education University of Michigan Medical School; Associated Program Director Diagnostic Radiology Michigan Medicine; Director of Residency Education Cardiothoracic Division Michigan
| | - Fnu Rajesh
- MetroHealth Medical Center, Cleveland, Ohio; Primary care physician
| | | | | | | | - Franco Verde
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Stephen J Wolf
- Denver Health, Denver, Colorado; American College of Emergency Physicians; Director of Service for Emergency Medicine, Denver Health Medical Center, Denver Colorado; Co-Chair, American College of Emergency Physicians Clinical Policies Committee
| | - Jeannie Yu
- Deputy Chief of Medicine, VA Medical Center, University of California-Irvine, Irvine, California; Society for Cardiovascular Magnetic Resonance
| | - Edwin F Donnelly
- Specialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio; Ohio State University Medical Center: Chief of Thoracic Radiology, Interim Vice Chair of Academic Affairs, Department of Radiology
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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6
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Ludwig DR, Raptis CA, Bhalla S. Emergent Magnetic Resonance Angiography for Evaluation of the Thoracoabdominal and Peripheral Vasculature. Magn Reson Imaging Clin N Am 2022; 30:465-477. [PMID: 35995474 DOI: 10.1016/j.mric.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thoracoabdominal and peripheral vasculature pathologies include a variety of severe and life threatening conditions that may be encountered in the emergent setting. Computed tomography angiography (CTA) is the first-line modality for imaging of the vasculature in this context, but magnetic resonance angiography (MRA) also plays an important and emerging role in the evaluation of carefully selected patients. Intravenous (IV) iodinated contrast is necessary for CTA, although MRA is most useful in patients who cannot receive IV iodinated contrast for reasons including prior severe allergic-like reaction to iodinated contrast, poor IV access, or severe renal insufficiency. Gadolinium-based contrast agents are administered for MRA when possible, as they generally improve the diagnostic quality and shorten the duration of the exam. In most clinical situations, however, noncontrast MRA is sufficient to obtain a diagnostic evaluation. In this review, we discuss the key strengths and limitations of MRA performed in the emergent setting, highlighting the role of MRA in the diagnosis of acute aortic syndromes, aortitis, aortic aneurysm, pulmonary embolism, and peripheral vascular disease.
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Affiliation(s)
- Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
| | - Constantine A Raptis
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, Saint Louis, MO 63110, USA.
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7
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Schiebler ML, Fain S, van Beek E. Vascular imaging of the lung: perspectives on current imaging methods. Br J Radiol 2022; 95:20200759. [PMID: 32795175 PMCID: PMC9153715 DOI: 10.1259/bjr.20200759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This commentary will discuss the use of advanced non-invasive imaging methodology for the pulmonary vascular system with special attention to a rubric for the imaging and clinical team to use for any particular clinical situation.
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Affiliation(s)
- Mark L. Schiebler
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean Fain
- Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Edwin van Beek
- SINAPSE Chair of Clinical Radiology, Director Edinburgh Imaging facility QMRI, Honorary Consultant Radiologist, NHS Lothian Health Board, CO.19 Edinburgh Imaging, Queen’s Medical Research Institute, Edinburgh Bioquarter, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom
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8
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François CJ, Hecht EM, Roditi G, Finn JP. MR Angiography Series: Noncardiac Chest MR Angiography. Radiographics 2022; 42:E48-E49. [PMID: 35179985 DOI: 10.1148/rg.210212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review guides readers through the selection and setup of standardized noncardiac chest MRA protocols, including contrast-enhanced MRA (CE-MRA) and noncontrast MRA (NC-MRA), sequences that can be used in a variety of clinical situations. After reviewing basic principles described in the first three tutorials in this series on CE-MRA and NC-MRA, this online presentation details the use of MRA in specific clinical scenarios: thoracic aortic aneurysm, aortic dissection, congenital heart disease, vasculitis, central veins, and pulmonary embolus. Tips and tricks for optimization of the sequences, image acquisition, and image interpretation are provided. This module is the fourth in a series created on behalf of the Society for Magnetic Resonance Angiography (SMRA), a group of researchers and clinicians who are passionate about the benefits of MRA but understand its challenges. The full digital presentation is available online. ©RSNA, 2022.
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Affiliation(s)
- Christopher J François
- From the Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (C.J.F.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); Department of Radiology, NHS Greater Glasgow & Clyde, Glasgow, UK (G.R.); and Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, Calif (J.P.F)
| | - Elizabeth M Hecht
- From the Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (C.J.F.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); Department of Radiology, NHS Greater Glasgow & Clyde, Glasgow, UK (G.R.); and Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, Calif (J.P.F)
| | - Giles Roditi
- From the Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (C.J.F.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); Department of Radiology, NHS Greater Glasgow & Clyde, Glasgow, UK (G.R.); and Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, Calif (J.P.F)
| | - J Paul Finn
- From the Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (C.J.F.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); Department of Radiology, NHS Greater Glasgow & Clyde, Glasgow, UK (G.R.); and Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, Calif (J.P.F)
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9
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Atalay MK. Oligemia and Decreased Mortality in Pulmonary Embolism: Revisiting Westermark. Circ Cardiovasc Imaging 2021; 14:e013381. [PMID: 34549990 DOI: 10.1161/circimaging.121.013381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael K Atalay
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI
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10
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Brooke JP, Hall IP. Novel Thoracic MRI Approaches for the Assessment of Pulmonary Physiology and Inflammation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1304:123-145. [PMID: 34019267 DOI: 10.1007/978-3-030-68748-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Excessive pulmonary inflammation can lead to damage of lung tissue, airway remodelling and established structural lung disease. Novel therapeutics that specifically target inflammatory pathways are becoming increasingly common in clinical practice, but there is yet to be a similar stepwise change in pulmonary diagnostic tools. A variety of thoracic magnetic resonance imaging (MRI) tools are currently in development, which may soon fulfil this emerging clinical need for highly sensitive assessments of lung structure and function. Given conventional MRI techniques are poorly suited to lung imaging, alternate strategies have been developed, including the use of inhaled contrast agents, intravenous contrast and specialized lung MR sequences. In this chapter, we discuss technical challenges of performing MRI of the lungs and how they may be overcome. Key thoracic MRI modalities are reviewed, namely, hyperpolarized noble gas MRI, oxygen-enhanced MRI (OE-MRI), ultrashort echo time (UTE) MRI and dynamic contrast-enhanced (DCE) MRI. Finally, we consider potential clinical applications of these techniques including phenotyping of lung disease, evaluation of novel pulmonary therapeutic efficacy and longitudinal assessment of specific patient groups.
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Affiliation(s)
- Jonathan P Brooke
- Department of Respiratory Medicine, University of Nottingham, Queens Medical Centre, Nottingham, UK.
| | - Ian P Hall
- Department of Respiratory Medicine, University of Nottingham, Queens Medical Centre, Nottingham, UK.
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11
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Role of MRI in the Evaluation of Thoracoabdominal Emergencies. Top Magn Reson Imaging 2021; 29:355-370. [PMID: 33264275 DOI: 10.1097/rmr.0000000000000252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thoracic and abdominal pathology are common in the emergency setting. Although computed tomography is preferred in many clinical situations, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have emerged as powerful techniques that often play a complementary role to computed tomography or may have a primary role in selected patient populations in which radiation is of specific concern or intravenous iodinated contrast is contraindicated. This review will highlight the role of MRI and MRA in the emergent imaging of thoracoabdominal pathology, specifically covering acute aortic pathology (acute aortic syndrome, aortic aneurysm, and aortitis), pulmonary embolism, gastrointestinal conditions such as appendicitis and Crohn disease, pancreatic and hepatobiliary disease (pancreatitis, choledocholithiasis, cholecystitis, and liver abscess), and genitourinary pathology (urolithiasis and pyelonephritis). In each section, we will highlight the specific role for MRI, discuss basic imaging protocols, and illustrate the MRI features of commonly encountered thoracoabdominal pathology.
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12
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Schneider G, Massmann A, Fries P, Frenzel F, Buecker A, Raczeck P. Safety of Catheter Embolization of Pulmonary Arteriovenous Malformations-Evaluation of Possible Cerebrovascular Embolism after Catheter Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia/Osler Disease by Pre- and Post-Interventional DWI. J Clin Med 2021; 10:887. [PMID: 33671708 PMCID: PMC7926997 DOI: 10.3390/jcm10040887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This paper aimed to prospectively evaluate the safety of embolization therapy of pulmonary arteriovenous malformations (PAVMs) for the detection of cerebral infarctions by pre- and post-interventional MRI. Method One hundred and five patients (male/female = 44/61; mean age 48.6+/-15.8; range 5-86) with pre-diagnosed PAVMs on contrast-enhanced MRA underwent embolization therapy. The number of PAVMs treated in each patient ranged from 1-8 PAVMs. Depending on the size and localization of the feeding arteries, either Nester-Coils or Amplatzer vascular plugs were used for embolization therapy. cMRI was performed immediately before, and at the 4 h and 3-month post-embolization therapy. Detection of peri-interventional cerebral emboli was performed via T2w and DWI sequences using three different b-values, with calculation of ADC maps. Results Embolization did not show any post-/peri-interventional, newly developed ischemic lesions in the brain. Only one patient who underwent re-embolization and was previously treated with tungsten coils that corroded over time showed newly developed, small, diffuse emboli in the post-interventional DWI sequence. This patient already had several episodes of brain emboli before re-treatment due to the corroded coils, and during treatment, when passing the corroded coils, experienced additional small, clinically inconspicuous brain emboli. However, this complication was anticipated but accepted, since the vessel had to be occluded distally. Conclusion Catheter-based embolization of PAVMs is a safe method for treatment and does not result in clinically inconspicuous cerebral ischemia, which was not demonstrated previously.
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Affiliation(s)
- Guenther Schneider
- Clinic of Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Str. 1, 66421 Homburg, Germany; (A.M.); (P.F.); (F.F.); (A.B.); (P.R.)
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13
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Fu Q, Cheng Q, Kong X, Ma H, Lei Z. Diagnostic accuracy of true fast imaging with steady-state precession, MR pulmonary angiography and volume-interpolated body examination for pulmonary embolism compared with CT pulmonary angiography. Exp Ther Med 2020; 21:42. [PMID: 33273972 PMCID: PMC7706389 DOI: 10.3892/etm.2020.9474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/11/2020] [Indexed: 11/06/2022] Open
Abstract
The diagnostic performance of magnetic resonance (MR) sequences for displaying different levels of pulmonary artery involvement in pulmonary embolism (PE) has rarely been reported but is essential for critically ill and emergency patients. The aim of the present study was to analyze the diagnostic accuracy of true fast imaging with steady-state precession (true FISP), MR pulmonary angiography (MRPA) and volume-interpolated body examination (VIBE) for PE detection in comparison to CT pulmonary angiography (CTPA), which is the reference standard. A total of 21 patients with confirmed deep venous thrombosis suspected of having PE were enrolled. Emboli were evaluated on per-patient and per-vessel bases. The evidence of PE on a per-vessel basis was classified into central, lobar and segmental levels, and 27 vessel segments per patient were analyzed for a total of 567 vessel segments in all patients. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Receiver operating characteristic curves were drawn to compare differences in sequences. A total of 158 pulmonary vessels were involved with emboli on CTPA, 58 of which were identified by true FISP, 63 by MRPA and 94 by VIBE. On per-patient and per-vessel bases, the sensitivity was 81.3 and 36.7%, respectively, for true FISP, 82.4 and 56.3%, respectively, for MRPA, and 94.4 and 68.1%, respectively, for VIBE; the specificity was 80.0 and 99.8%, respectively, for true FISP, 100 and 99.2%, respectively, for MRPA, and 100 and 99.2%, respectively, for VIBE. The respective PPV was 92.9 and 98.3% for true FISP, 100 and 95.5% for MRPA, 100 and 96.9% for VIBE. The NPV was 57.1 and 80.3%, respectively, for true FISP, 50.0 and 88.2%, respectively, for MRPA, and 75.0 and 89.8%, respectively, for VIBE. In conclusion, enhanced VIBE surpassed the other two sequences in revealing PE, particularly in segmental analysis, which is essential for emergency patients who have contraindications for receiving iodinated contrast and those who have concerns about the ionizing radiation.
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Affiliation(s)
- Qing Fu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Qiguang Cheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Xiangchuang Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Hui Ma
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
| | - Ziqiao Lei
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, Hubei 430022, P.R. China
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14
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Salehi Ravesh M, Tesch K, Lebenatus A, Koktzoglou I, Edelman RR, Eden M, Langguth P, Graessner J, Jansen O, Both M. Clinical Value of Noncontrast-Enhanced Radial Quiescent-Interval Slice-Selective (QISS) Magnetic Resonance Angiography for the Diagnosis of Acute Pulmonary Embolism Compared to Contrast-Enhanced Computed Tomography and Cartesian Balanced Steady-State Free Precession. J Magn Reson Imaging 2020; 52:1510-1524. [PMID: 32537799 DOI: 10.1002/jmri.27240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Free-breathing noncontrast-enhanced (non-CE) magnetic resonance angiography (MRA) techniques are of considerable interest for the diagnosis of acute pulmonary embolism (APE), due to the possibility for repeated examinations, avoidance of side effects from iodine-based contrast agents, and the absence of ionizing radiation exposure as compared to CE-computed tomographic angiography (CTA). PURPOSE To analyze the clinical performance of free-breathing and electrocardiogram (ECG)-gated radial quiescent-interval slice-selective (QISS)-MRA compared to CE-CTA and to Cartesian balanced steady-state free precession (bSSFP)-MRA. STUDY TYPE Prospective. SUBJECTS Thirty patients with confirmed APE and 30 healthy volunteers (HVs). FIELD STRENGTH/SEQUENCE Radial QISS- and bSSFP-MRA at 1.5T. ASSESSMENT Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were computed to compare the pulmonary imaging quality between MRA methods. The pulmonary arterial tree was divided into 25 branches and an ordinal scoring system was used to assess the image quality of each pulmonary branch. The clinical performance of the two MRA techniques in accurately assessing APE was evaluated with respect to CE-CTA as the clinical reference standard. STATISTICAL TESTS Wilcoxon signed-rank and Spearman's correlation tests were performed. Sensitivity and specificity of the MRA techniques were determined using CE-CTA as the clinical reference standard. RESULTS Thrombus-mimicking artifacts appeared more frequently in lobar and peripheral arteries of patients with Cartesian bSSFP than with radial QISS-MRA (pulmonary trunk: 12.2% vs. 14.0%, P = 0.64; lobar arteries: 35.6% vs. 22.0%, P = 0.005, peripheral arteries: 74.4% vs. 49.0%, P < 0.001). The relative increases in SNR and of CNR provided by radial QISS-MRA with respect to Cartesian bSSFP-MRA were 30-35% (P-values of SNR/CNR, HVs: 0.09/0.09, patients: 0.03/0.02). The image quality of pulmonary arterial branches was considered good to excellent in 77.2% of patients with radial QISS-MRA and in 43.2% with Cartesian bSSFP-MRA (P < 0.0001). The clinical performance of radial QISS-MRA was higher than Cartesian bSSFP-MRA for grading embolism, with a total sensitivity of 86.0% vs. 80.6% and a specificity of 93.3% vs. 84.0%, respectively. DATA CONCLUSION Radial QISS-MRA is a reliable and safe non-CE angiographic technique with promising clinical potential compared to Cartesian bSSFP-MRA and as an alternative technique to CE-CTA for the diagnosis of APE. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Mona Salehi Ravesh
- Section Biomedical Imaging, Molecular Imaging North Competence Center (MOIN CC), Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany.,Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Karolin Tesch
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Annett Lebenatus
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Ioannis Koktzoglou
- Department of Radiology, NorthShore University HealthSystem, Evanston, Illinois, USA.,Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Robert R Edelman
- Department of Radiology, NorthShore University HealthSystem, Evanston, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthias Eden
- Department for Internal Medicine III, Molecular Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Patrick Langguth
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | | | - Olav Jansen
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein (UKSH), Kiel University, Kiel, Germany
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15
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Allen BD, Schiebler ML, François CJ. Pulmonary Vascular Disease Evaluation with Magnetic Resonance Angiography. Radiol Clin North Am 2020; 58:707-719. [PMID: 32471539 DOI: 10.1016/j.rcl.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pulmonary vascular assessment commonly relies on computed tomography angiography (CTA), but continued advances in magnetic resonance angiography have allowed pulmonary magnetic resonance angiography (pMRA) to become a reasonable alternative to CTA without exposing patients to ionizing radiation. pMRA allows the evaluation of pulmonary vascular anatomy, hemodynamic physiology, lung parenchymal perfusion, and (optionally) right and left ventricular function with a single examination. This article discusses pMRA techniques and artifacts; performance in commonly encountered pulmonary vascular diseases, specifically pulmonary embolism and pulmonary hypertension; and recent advances in both contrast-enhanced and noncontrast pMRA.
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Affiliation(s)
- Bradley D Allen
- Department of Radiology, Northwestern University Feinberg School of Medicine, 737 North Michigan Avenue, Suite 1600, Chicago, IL 60611, USA.
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
| | - Christopher J François
- Department of Radiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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16
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Olson MC, Lubner MG, Menias CO, Mellnick VM, Mankowski Gettle L, Kim DH, Elsayes KM, Pickhardt PJ. Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging Findings. Radiographics 2020; 40:875-894. [PMID: 32330086 DOI: 10.1148/rg.2020190097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality. In recent decades, US, CT, and MRI have surpassed catheter-based angiography as the imaging examinations of choice for evaluation of vascular structures and identification of thrombus owing to their ready availability, noninvasive nature, and, in the cases of US and MRI, lack of exposure to ionizing radiation. As a result, VTE and associated complications are commonly identified in day-to-day radiologic practice across a variety of clinical settings. A wide range of hereditary and acquired conditions can increase the risk for development of venous thrombosis, and many patients with these conditions may undergo imaging for unrelated reasons, leading to the incidental detection of VTE or one of the associated complications. Although the development of VTE may be an isolated occurrence, the imaging findings, in conjunction with the clinical history and vascular risk factors, may indicate a predisposing condition or underlying diagnosis. Furthermore, awareness of the many clinical conditions that result in an increased risk of venous thrombosis may aid in detection of thrombus and any concomitant complications. For these reasons, it is important that practicing radiologists be familiar with the multimodality imaging findings of thrombosis, understand the spectrum of diseases that contribute to the development of thrombosis, and recognize the potential complications of hypercoagulable states and venous thrombosis. Online DICOM image stacks and supplemental material are available for this article. ©RSNA, 2020.
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Affiliation(s)
- Michael C Olson
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Meghan G Lubner
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Christine O Menias
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Vincent M Mellnick
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Lori Mankowski Gettle
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - David H Kim
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Khaled M Elsayes
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
| | - Perry J Pickhardt
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, E3/311 Clinical Sciences Center, 600 Highland Ave, Madison, WI 53792 (M.C.O., M.G.L., L.M.G., D.H.K., P.J.P.); Department of Radiology, Mayo Clinic Scottsdale, Scottsdale, Ariz (C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.M.M.); and Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, Tex (K.M.E.)
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Tsuchiya N, Benson DG, Longhurst C, François CJ, Reeder SB, Repplinger MD, Schiebler ML. Interobserver agreement for the direct and indirect signs of pulmonary embolism evaluated using contrast enhanced magnetic angiography. Eur J Radiol Open 2020; 7:100256. [PMID: 32984448 PMCID: PMC7494795 DOI: 10.1016/j.ejro.2020.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Direct findings of pulmonary embolism on MRA chest exms had the highest interobserver agreement for vessel cutoff (k-.52, p value- ,.0001). Indirect findings for pulmonary embolism on MRA chest had the highest interobserver agreement for pleural effusions (k-.56, p value = .0001). There was high interobserver agreement for meaurement of the pulmonary artery and the right ventricle/left ventricle ratio.
Background Accurate diagnosis of pulmonary embolism (PE) using contrast enhanced MRA (CE-MRA) requires awareness of both the direct and indirect findings of PE. Purpose To evaluate reader agreement of the direct and indirect findings of PE on CE-MRA. Methods We evaluated pulmonary artery diameter, right ventricle/left ventricle ratio, and clot/vessel lumen signal intensity ratio. Also, eight direct and eight indirect findings of PE were interpreted twice by two radiologists with different experience levels. The prevalence, and intra- and inter-reader agreement for the direct and indirect findings of PE were recorded. Statistical analysis of the measurements was assessed using intraclass correlation while Cohen’s kappa test determined inter- and intra-reader agreement. Results We reviewed 66 positive CE-MRA exams, 10 of which cases were used for training. The largest PE for each of the remaining 56 cases (40 woman) were included in this analysis (38.9 ± 19.7 (mean age (years) ± S.D.)). The highest interobserver agreement for the direct findings were vessel cutoff (κ = 0.52, 95 % CI = (0.30, 0.74), p < .0001) and bright clot (κ = 0.51, 95 % CI = (0.26, 0.78), p = .0001). The highest interobserver agreement for the indirect findings were for atelectasis (κ = 0.67, 95 % CI = (0.49, 0.87), p < .0001), pleural effusions (κ = 0.56, 95 % CI = (0.32, 0.79), p = 0001) and blank slate sing (κ = 0.56, 95 % CI = (0.18, 0.94), p < .0001). Conclusion The indirect findings of atelectasis and pleural effusion had better interobserver reproducibility than the direct findings of vessel cutoff and bright clot. The intraobserver reproducibility of the direct and indirect findings is dependent on experience level. Summary statement Using contrast enhanced magnetic resonance angiography for the diagnosis of pulmonary embolism, the indirect findings of atelectasis and pleural effusion had better interobserver reproducibility than the direct findings of vessel cutoff and bright clot.
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Affiliation(s)
- Nanae Tsuchiya
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Radiology, University of Ryukyus, Okinawa, Japan
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
- Corresponding author at: Department of Radiology, University of the Ryukyus, Okinawa, Japan.
| | - Donald G. Benson
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Radiology, University of Arkansas for Medical Science College of Medicine, Little Rock, AR, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
| | - Colin Longhurst
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
| | - Christopher J. François
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
| | - Scott B. Reeder
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Michael D. Repplinger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Mark L. Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States
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Medson K, Vargas-Paris R, Nordgren-Rogberg A, Sigbergsdottir A, Nyrén S, Lindholm P. Primary diagnosis of pulmonary embolism with unenhanced MRI for patients not eligible for CTPA: Clinical outcome. Eur J Radiol Open 2019; 6:315-319. [PMID: 31692624 PMCID: PMC6804887 DOI: 10.1016/j.ejro.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose To follow up the clinical outcome of patients with suspected pulmonary embolism (PE), in those only imaged using unenhanced, free-breathing magnetic resonance imaging (MRI). Methods and materials Fifty-seven patients aged 29-99 years (mean 70, SD 18) that could not undergo Computed Tomography Pulmonary Angiography (CTPA) were offered alternative imaging diagnostics in parallel with ongoing methodological studies validating MRI vs CTPA. Contraindications included renal failure (n = 44), severe iodine contrast allergy (n = 10), pregnancy (n = 2) and radioactive iodine therapy (n = 1). The unenhanced MRI protocol was based on free-breathing, steady-state free precession with no cardiac or respiratory gating. Retrospective review of the electronic medical record (EMR) was made of 0-12 months post-imaging and was collected during 2012-2018. Results All 57 MRIs were of diagnostic quality and 12 pulmonary embolisms were diagnosed. Of the 57 patients, 44 were already on, or had started anticoagulation therapy due to clinical suspicion of PE. Four of the patients were put on anticoagulation after the positive MRI and 13 were taken off anticoagulation after a negative MRI report. Other diagnoses reported (considering dyspnea) were pleural effusion (n = 24), consolidation (n = 12) and pericardial effusion (n = 2). One patient had a deep vein thrombosis (DVT) within three months of our negative MRI result and then had a stroke within one year. Another patient suffered a stroke within three months of being diagnosed (by MRI) with PE and given anticoagulation as treatment. Conclusions Our method supported or altered clinical decision-making and treatment in this cohort. A diagnostic tool for PE without intravenous contrast agent or radiation is of great benefit for certain patients.
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Affiliation(s)
- Koshiar Medson
- Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.,Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Roberto Vargas-Paris
- Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.,Abdominal Radiology, Imaging and Physiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Anna Nordgren-Rogberg
- Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.,Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | | | - Sven Nyrén
- Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Solna (L1:00), SE-171 76 Stockholm, Sweden
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.,Thoracic radiology, Imaging and Physiology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
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Aziz MU, Hall MK, Pressacco J, Maki JH. Magnetic Resonance Angiography in Pulmonary Embolism: A Review. Curr Probl Diagn Radiol 2019; 48:586-591. [DOI: 10.1067/j.cpradiol.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022]
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20
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Knobloch G, Colgan T, Schiebler ML, Johnson KM, Li G, Schubert T, Reeder SB, Nagle SK. Comparison of gadolinium-enhanced and ferumoxytol-enhanced conventional and UTE-MRA for the depiction of the pulmonary vasculature. Magn Reson Med 2019; 82:1660-1670. [PMID: 31228293 DOI: 10.1002/mrm.27853] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the feasibility of ferumoxytol (FE)-enhanced UTE-MRA for depiction of the pulmonary vascular and nonvascular structures. METHODS Twenty healthy volunteers underwent contrast-enhanced pulmonary MRA at 3 T during 2 visits, separated by at least 4 weeks. Visit 1: The MRA started with a conventional multiphase 3D T1 -weighted breath-held spoiled gradient-echo MRA before and after the injection of 0.1 mmol/kg gadobenate dimeglumine (GD). Subsequently, free-breathing GD-UTE-MRA was acquired as a series of 3 flip angles (FAs) (6°, 12°, 18°) to optimize T1 weighting. Visit 2: After the injection of 4 mg/kg FE, MRA was performed during the steady state, starting with a conventional 3D T1 -weighted breath-held spoiled gradient-echo MRA and followed by free-breathing FE-UTE-MRA, both at 4 different FAs (6°, 12°, 18°, 24°). The optimal FA for best T1 contrast was evaluated. Image quality at the optimal FA was compared between methods on a 4-point ordinal scale, using multiphase GD conventional pulmonary MRA (cMRA) as standard of reference. RESULTS Flip angle in the range of 18°-24° resulted in best T1 contrast for FE cMRA and both UTE-MRA techniques (p > .05). At optimized FA, image quality of the vasculature was good/excellent with both FE-UTE-MRA and GD cMRA (98% versus 97%; p = .51). Both UTE techniques provided superior depiction of nonvascular structures compared with either GD-enhanced or FE-enhanced cMRA (p < .001). However, GD-UTE-MRA showed the lowest image quality of the angiogram due to low image contrast. CONCLUSION Free-breathing UTE-MRA using FE is feasible for simultaneous assessment of the pulmonary vasculature and nonvascular structures. Patient studies should investigate the clinical utility of free-breathing UTE-MRA for assessment of pulmonary emboli.
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Affiliation(s)
- Gesine Knobloch
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Radiology, Charité University Hospital, Berlin, Germany
| | - Timothy Colgan
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin M Johnson
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
| | - Geng Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
| | - Tilman Schubert
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Neuroradiology, Zurich University Hospital, Zurich, Switzerland
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Biomedical Engineering, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Medicine, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Emergency Medicine, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Medical Physics, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin.,Department of Pediatrics, University of Wisconsin-School of Medicine and Public Health, Madison, Wisconsin
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21
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Maki JH, Wilson GJ, Clark TJ. Evaluation of four injection profiles for uniform contrast-enhanced signal intensity profiles in MR angiography. J Magn Reson Imaging 2019; 50:1808-1816. [PMID: 31095810 DOI: 10.1002/jmri.26793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Gadolinium concentration variation during acquisition of contrast-enhanced MR angiography (CE-MRA) may lead to artifacts. PURPOSE To compare signal intensity (SI) profiles of four different contrast agent injection strategies during CE-MRA with the goal of minimizing SI variation during acquisition. STUDY TYPE Prospective. SUBJECTS Forty subjects randomized to receive one of four injection profiles of gadobenate dimeglumine (0.1 mmol/kg), either undiluted (0.5 M) or diluted to 40 ml total volume. Tested profiles: 1) nondiluted single-phase ("standard" NS; 1.6 ml/s), 2) diluted single-phase (DS; 1.6 ml/s), 3) diluted biphasic (DB; 9 ml @ 3.3 ml/s, 29 ml @ 1.4 ml/s), 4) patient-tailored protocol using linear prediction (DT). FIELD STRENGTH/SEQUENCE Time-resolved SI measured at 3T with spoiled gradient echo sequences having analogous parameters to those of CE-MRA. ASSESSMENT Plateau arrival time, rise time, duration, peak and tail SI, plateau quality (sum of squared residuals; SSR), average SI for each injection type derived were used. STATISTICAL TEST Two-tailed t-test. RESULTS Peak SI, arrival, and rise times were not significantly different between groups, excepting peak SI DB slightly > DS (P = 0.042). Duration of NS vs. the diluted groups was significantly shorter (all P < 0.0001), and DS duration was significantly shorter than that of DT and DB (NS 11.4 ± 3.5 vs. DS 22.9 ± 4.3, DB 25.4 ± 2.3, DT 28.3 ± 4.1 sec). Quality (SSR) of the 20-second plateau was significantly better for DS, DB, DT as compared with NS (all P < 0.001). DATA CONCLUSION Three different strategies to power-inject diluted gadobenate dimeglumine targeting a 20-second plateau produced SI profiles with longer duration, more consistent plateau, and no significant loss in peak SI. Such injection profiles may provide more uniform SI during CE-MRA, potentially reducing blurring artifacts. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;50:1808-1816.
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Affiliation(s)
- Jeffrey H Maki
- The Department of Radiology, University of Colorado Denver, Aurora, Colorado, USA.,Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Gregory J Wilson
- Department of Radiology, University of Washington, Seattle, Washington, USA.,Bayer Healthcare, Whippany, New Jersey, USA
| | - Toshimasa J Clark
- The Department of Radiology, University of Colorado Denver, Aurora, Colorado, USA
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22
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Update on MR imaging of the pulmonary vasculature. Int J Cardiovasc Imaging 2019; 35:1483-1497. [PMID: 31030315 DOI: 10.1007/s10554-019-01603-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/11/2019] [Indexed: 01/01/2023]
Abstract
Magnetic resonance imaging (MRI) plays an increasingly important role in the non-invasive evaluation of the pulmonary vasculature. MR angiographic (MRA) techniques provide morphological information, while MR perfusion techniques provide functional information of the pulmonary vasculature. Contrast-enhanced MRA can be performed at high spatial resolution using 3D T1-weighted spoiled gradient echo sequence or at high temporal resolution using time-resolved techniques. Non-contrast MRA can be performed using 3D steady state free precession, double inversion fast spin echo, time of flight or phase contrast sequences. MR perfusion can be done using dynamic contrast-enhanced technique or using non-contrast techniques such as arterial spin labelling and time-resolved imaging of lungs during free breathing with Fourier decomposition analysis. MRI is used in the evaluation of acute and chronic pulmonary embolism, pulmonary hypertension and other vascular abnormalities, congenital anomalies and neoplasms. In this article, we review the different MR techniques used in the evaluation of pulmonary vasculature and its clinical applications.
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23
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Magnetic resonance angiography imaging of pulmonary embolism using agents with blood pool properties as an alternative to computed tomography to avoid radiation exposure. Eur J Radiol 2019; 113:165-173. [PMID: 30927943 DOI: 10.1016/j.ejrad.2019.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the feasibility and accuracy of a combined magnetic resonance angiography (MRA) - magnetic resonance venography (MRV) protocol using contrast agents with blood pool properties, gadofosveset trisodium and gadobenate dimeglumine, in the evaluation of pulmonary embolus (PE) and deep venous thrombosis (DVT) as compared to the standard clinical reference imaging modalities; computed tomography pulmonary angiography (CTPA) and color-coded Duplex ultrasound (DUS). MATERIALS AND METHODS This prospective clinical study recruited patients presenting to the emergency department with clinical suspicion for PE and scheduled for a clinically indicated CTPA. We performed both MRA of the chest for the evaluation of PE as well as MRV of the pelvis and thighs to evaluate for DVT using a single contrast injection. MRA-MRV data was compared to the clinical reference standard CTPA and DUS, respectively. RESULTS A total of 40 patients were recruited. The results on a per-patient basis comparing MRA to CTPA for pulmonary embolus yielded 100% sensitivity and 97% specificity. There was a small subset of patients that underwent clinical DUS to evaluate for DVT, which demonstrated a sensitivity and specificity of 100% for MRV. CONCLUSIONS This single-center, preliminary study using contrast agents with blood pool properties to perform a relatively rapid combined MRA-MRV exam to image for PE and above knee DVT shows potential as an alternative imaging choice to CTPA. Further large-scale, multicentre studies are warranted.
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24
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Tsuchiya N, Beek EJRV, Ohno Y, Hatabu H, Kauczor HU, Swift A, Vogel-Claussen J, Biederer J, Wild J, Wielpütz MO, Schiebler ML. Magnetic resonance angiography for the primary diagnosis of pulmonary embolism: A review from the international workshop for pulmonary functional imaging. World J Radiol 2018; 10:52-64. [PMID: 29988845 PMCID: PMC6033703 DOI: 10.4329/wjr.v10.i6.52] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/25/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023] Open
Abstract
Pulmonary contrast enhanced magnetic resonance angiography (CE-MRA) is useful for the primary diagnosis of pulmonary embolism (PE). Many sites have chosen not to use CE-MRA as a first line of diagnostic tool for PE because of the speed and higher efficacy of computerized tomographic angiography (CTA). In this review, we discuss the strengths and weaknesses of CE-MRA and the appropriate imaging scenarios for the primary diagnosis of PE derived from our unique multi-institutional experience in this area. The optimal patient for this test has a low to intermediate suspicion for PE based on clinical decision rules. Patients in extremis are not candidates for this test. Younger women (< 35 years of age) and patients with iodinated contrast allergies are best served by using this modality We discuss the history of the use of this test, recent technical innovations, artifacts, direct and indirect findings for PE, ancillary findings, and the effectiveness (patient outcomes) of CE-MRA for the exclusion of PE. Current outcomes data shows that CE-MRA and NM V/Q scans are effective alternative tests to CTA for the primary diagnosis of PE.
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Affiliation(s)
- Nanae Tsuchiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0215, Japan
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Edwin JR van Beek
- Edinburgh Imaging, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom
| | - Yoshiharu Ohno
- Division of Functional and Diagnostic Imaging Research, Department of Radiology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Andrew Swift
- Department of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Jens Vogel-Claussen
- Department of Radiology, Carl-Neuberg Strasse 1, Hannover-Gr-Buchholz 30625, Germany
| | - Jürgen Biederer
- Radiology Darmstadt, Gross-Gerau County Hospital, Gross-Gerau 64521, Germany
| | - James Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2JF, United Kingdom
| | - Mark O Wielpütz
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, United States
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25
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Repplinger MD, Nagle SK, Harringa JB, Broman AT, Lindholm CR, François CJ, Grist TM, Reeder SB, Schiebler ML. Clinical outcomes after magnetic resonance angiography (MRA) versus computed tomographic angiography (CTA) for pulmonary embolism evaluation. Emerg Radiol 2018; 25:469-477. [PMID: 29749576 DOI: 10.1007/s10140-018-1609-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/25/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To compare patient outcomes following magnetic resonance angiography (MRA) versus computed tomographic angiography (CTA) ordered for suspected pulmonary embolism (PE). METHODS In this IRB-approved, single-center, retrospective, case-control study, we reviewed the medical records of all patients evaluated for PE with MRA during a 5-year period along with age- and sex-matched controls evaluated with CTA. Only the first instance of PE evaluation during the study period was included. After application of our exclusion criteria to both study arms, the analysis included 1173 subjects. The primary endpoint was major adverse PE-related event (MAPE), which we defined as major bleeding, venous thromboembolism, or death during the 6 months following the index imaging test (MRA or CTA), obtained through medical record review. Logistic regression, chi-square test for independence, and Fisher's exact test were used with a p < 0.05 threshold. RESULTS The overall 6-month MAPE rate following MRA (5.4%) was lower than following CTA (13.6%, p < 0.01). Amongst outpatients, the MAPE rate was lower for MRA (3.7%) than for CTA (8.0%, p = 0.01). Accounting for age, sex, referral source, BMI, and Wells' score, patients were less likely to suffer MAPE than those who underwent CTA, with an odds ratio of 0.44 [0.24, 0.80]. Technical success rate did not differ significantly between MRA (92.6%) and CTA (90.5%) groups (p = 0.41). CONCLUSION Within the inherent limitations of a retrospective case-controlled analysis, we observed that the rate of MAPE was lower (more favorable) for patients following pulmonary MRA for the primary evaluation of suspected PE than following CTA.
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Affiliation(s)
- Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA. .,Department of Radiology, University of Wisconsin, Madison, WI, USA.
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin, Madison, WI, USA.,Department of Medical Physics, University of Wisconsin, Madison, WI, USA.,Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA.,School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Aimee T Broman
- Department of Biostatistics, University of Wisconsin, Madison, WI, USA
| | - Christopher R Lindholm
- Department of Medicine, Dartmouth University, Geisel School of Medicine, Hanover, NH, USA
| | - Christopher J François
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA.,Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin, Madison, WI, USA.,Department of Medical Physics, University of Wisconsin, Madison, WI, USA.,Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA.,Department of Radiology, University of Wisconsin, Madison, WI, USA.,Department of Medical Physics, University of Wisconsin, Madison, WI, USA.,Department of Pediatrics, University of Wisconsin, Madison, WI, USA.,Department of Medicine, University of Wisconsin, Madison, WI, USA.,Department of Biomedical Engineering, University of Wisconsin, Madison, WI, USA
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin, Madison, WI, USA
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26
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Repplinger MD, Bracken RL, Patterson BW, Shah MN, Pulia MS, Harringa JB, Schiebler ML, Nagle SK. Downstream Imaging Utilization After MR Angiography Versus CT Angiography for the Initial Evaluation of Pulmonary Embolism. J Am Coll Radiol 2018; 15:1692-1697. [PMID: 29724625 DOI: 10.1016/j.jacr.2018.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To compare the proportion of emergency department (ED) patients who undergo subsequent chest CT or MR within 1 year of an initially negative scan for pulmonary embolism (PE). METHODS This single-center, retrospective, observational study examined the use of chest CT or MR for ED patients with MR angiography (MRA) negative for PE during April 2008 to March 2013. We compared the 1-year scan utilization for these cases to an age- and sex-matched cohort of patients who underwent CT angiography (CTA). We also calculated time to first follow-up scan and mean radiation dose in each arm. Trained data abstractors used a standardized protocol and electronic case report form to gather all outcomes of interest. Results are reported as means or proportions with their associated confidence intervals (CIs). RESULTS In all, 717 ED patients (430 MRAs and 287 CTAs) were included. At 1 year, the proportion undergoing subsequent imaging (MRA 16.7%, CTA 15.3%; difference = 1.4%, 95% CI 4.05%-6.86%) and time to first follow-up scan (difference = 13 days, 95% CI -22.69-48.7) did not differ between arms. Mean radiation dose per patient at 1 year was significantly higher in the CTA arm (9.82 mSv; 95% CI 9.12-10.53) compared with 2.92 mSv (95% CI 1.86-3.98) with MRA. Those with an index MRA were more likely to undergo subsequent MRAs (odds ratio 3.68; 95% CI 1.22-11.12) than those with an index CTA. However, in both arms, the majority (85%) of subsequent scans were CTAs. CONCLUSIONS When comparing patients initially undergoing MRA versus CTA for the evaluation of PE, there was no difference in downstream chest CT or MR use at 1 year.
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Affiliation(s)
- Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Rebecca L Bracken
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manish N Shah
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael S Pulia
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - John B Harringa
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
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27
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Kirsch J, Brown RKJ, Henry TS, Javidan-Nejad C, Jokerst C, Julsrud PR, Kanne JP, Kramer CM, Leipsic JA, Panchal KK, Ravenel JG, Shah AB, Mohammed TL, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 14:S2-S12. [PMID: 28473076 DOI: 10.1016/j.jacr.2017.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jacobo Kirsch
- Principal Author, Cleveland Clinic, Weston, Florida.
| | | | - Travis S Henry
- University of California San Francisco, San Francisco, California
| | - Cylen Javidan-Nejad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christopher M Kramer
- University of Virginia Health System, Charlottesville, Virginia; American College of Cardiology
| | | | | | - James G Ravenel
- Medical University of South Carolina, Charleston, South Carolina
| | - Amar B Shah
- Westchester Medical Center, Valhalla, New York
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Pamela K Woodard
- Specialty Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Suhny Abbara
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
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28
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Benson DG, Schiebler ML, Nagle SK, François CJ. Magnetic Resonance Imaging for the Evaluation of Pulmonary Embolism. Top Magn Reson Imaging 2017; 26:145-151. [PMID: 28777163 DOI: 10.1097/rmr.0000000000000133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pulmonary embolism (PE) is a leading cause of acute cardiovascular death throughout the world. Although computed tomography angiography (CTA) is the primary imaging study used to diagnose acute PE, pulmonary magnetic resonance angiography (MRA) is increasingly being used in patients with contraindications for CTA. This manuscript reviews the MRA techniques used for the diagnosis of PE and discuss how these techniques can be implemented in routine clinical practice. In addition, the efficacy and effectiveness of these techniques will be compared to other modalities.
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Affiliation(s)
- Donald G Benson
- *Department of Radiology †Department of Medical Physics ‡Department of Pediatrics, University of Wisconsin-Madison, Madison, WI
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29
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Sista AK, Kuo WT, Schiebler M, Madoff DC. Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. Radiology 2017. [DOI: 10.1148/radiol.2017151978] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Akhilesh K. Sista
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - William T. Kuo
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - Mark Schiebler
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - David C. Madoff
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
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30
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Diagnostic accuracy of magnetic resonance imaging in patients with suspected pulmonary embolism: A bivariate meta-analysis. Thromb Res 2017; 154:64-72. [DOI: 10.1016/j.thromres.2017.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/18/2017] [Accepted: 03/31/2017] [Indexed: 01/26/2023]
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31
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Johns CS, Schiebler ML, Swift AJ. Commentary on: Survey of UK imaging practice for the investigation of pulmonary embolism in pregnancy. Clin Radiol 2017; 72:702-703. [PMID: 28545683 DOI: 10.1016/j.crad.2017.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 12/20/2022]
Affiliation(s)
- C S Johns
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - M L Schiebler
- UW-Madison School of Medicine and Public Health, Madison, WI, USA
| | - A J Swift
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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32
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Benson DG, Schiebler ML, Repplinger MD, François CJ, Grist TM, Reeder SB, Nagle SK. Contrast-enhanced pulmonary MRA for the primary diagnosis of pulmonary embolism: current state of the art and future directions. Br J Radiol 2017; 90:20160901. [PMID: 28306332 DOI: 10.1259/bjr.20160901] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
CT pulmonary angiography (CTPA) is currently considered the imaging standard of care for the diagnosis of pulmonary embolism (PE). Recent advances in contrast-enhanced pulmonary MR angiography (MRA) techniques have led to increased use of this modality for the detection of PE in the proper clinical setting. This review is intended to provide an introduction to the state-of-the-art techniques used in pulmonary MRA for the detection of PE and to discuss possible future directions for this modality. This review discusses the following issues pertinent to MRA for the diagnosis of PE: (1) the diagnostic efficacy and clinical effectiveness for pulmonary MRA relative to CTPA, (2) the different pulmonary MRA techniques used for the detection of PE, (3) guidance for building a clinical service at their institution using MRA and (4) future directions of PE MRA. Our principal aim was to show how pulmonary MRA can be used as a safe, effective modality for the diagnosis of clinically significant PE, particularly for those patients where there are concerns about ionizing radiation or contraindications/allergies to the iodinated contrast material.
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Affiliation(s)
- Donald G Benson
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Mark L Schiebler
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael D Repplinger
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,2 Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Thomas M Grist
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,3 Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA.,4 Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Scott B Reeder
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,2 Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA.,3 Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA.,4 Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA.,5 Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Scott K Nagle
- 1 Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA.,3 Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, USA.,6 Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
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Johns CS, Swift AJ, Hughes PJ, Ohno Y, Schiebler M, Wild JM. Pulmonary MR angiography and perfusion imaging—A review of methods and applications. Eur J Radiol 2017; 86:361-370. [DOI: 10.1016/j.ejrad.2016.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
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Incidence of actionable findings on contrast enhanced magnetic resonance angiography ordered for pulmonary embolism evaluation. Eur J Radiol 2016; 85:1383-9. [PMID: 27423676 DOI: 10.1016/j.ejrad.2016.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/27/2016] [Accepted: 05/19/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE To determine the incidence of actionable findings on contrast-enhanced magnetic resonance angiography (MRA) scans performed for the primary diagnosis of pulmonary embolism (PE). MATERIALS AND METHODS This was a HIPAA-compliant and IRB-approved single center, retrospective study of consecutive series of patients evaluated with contrast-enhanced MRA for PE. The final radiology report of each MRA was reviewed. All technically adequate negative exams were included in the analysis. The findings were divided into three types: those requiring further action (actionable-Type 1) those not requiring follow-up (non-actionable-Type 2) and normal exams. We compared our results with the literature regarding the use of computed tomographic angiography (CTA) in this scenario using Fisher's exact test. RESULTS 580 MRA scans for PE were performed. There were 561/580 (97%) technically adequate exams. Of these, 514/580 (89%) were negative and 47/580 (8%) were positive for PE. In the PE negative group of 514 exams, Type 1 findings were identified in 85/514 (17%), 188/514 (36%) cases were Type 2 and 241/514 (47.0%) were Type 3. There was no significant difference between the incidence of Type 1 and the combination of Type 2 and Type 3 findings on MRA and the reported incidence of actionable findings derived from CTA negative exams for PE (p<0.5). CONCLUSION MRA as a first-line test for PE can identify actionable findings in those patients without PE, with an incidence similar to that reported in the literature for CTA.
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Bannas P, François CJ, Reeder SB. Magnetic Resonance Angiography of the Upper Extremity. Magn Reson Imaging Clin N Am 2016. [PMID: 26216777 DOI: 10.1016/j.mric.2015.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The magnetic resonance angiography (MRA) toolbox includes a wide array of versatile methods for diagnosis and therapy planning in patients with a variety of upper extremity vascular pathologies. MRA can provide excellent image quality with high spatial and high temporal resolution without the disadvantages of ionizing radiation, iodinated contrast, and operator dependency. Contrast-enhanced techniques are preferred for their robustness, image quality, and shorter scan times. This article provides an overview of the available MRA techniques and a description of the clinical entities that are well suited for evaluation with contrast-enhanced MRA.
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Affiliation(s)
- Peter Bannas
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792-3252, USA; Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany.
| | - Christopher J François
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792-3252, USA
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792-3252, USA; Department of Biomedical Engineering, University of Wisconsin-Madison, 1415 Engineering Drive, Madison, WI 53706, USA; Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI 53705-2275, USA; Department of Medicine, University of Wisconsin-Madison, 1685 Highland Avenue, Madison, WI 53705-2281, USA; Department of Emergency Medicine, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792, USA
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Baez JC, Seethamraju RT, Mulkern R, Ciet P, Lee EY. Pediatric Chest MR Imaging: Sedation, Techniques, and Extracardiac Vessels. Magn Reson Imaging Clin N Am 2016; 23:321-35. [PMID: 25952523 DOI: 10.1016/j.mric.2015.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Thoracic MR imaging in the pediatric population provides unique challenges requiring tailored protocols and a practical approach to pediatric issues, such as patient motion and sedation. Concern regarding the use of ionizing radiation in the pediatric population has continued to advance the use of MR imaging despite these challenges. This article provides a practical approach to thoracic vascular MR imaging with special attention paid to pediatric-specific issues such as sedation. Thoracic vascular anatomy and pathology are discussed with an emphasis on protocols that can facilitate accurate diagnosis.
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Affiliation(s)
- Juan C Baez
- Mid-Atlantic Permanente Medical Group, 2101 East Jefferson Street, Rockville, MD 20852, USA; Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ravi T Seethamraju
- Magnetic Resonance, Research and Development, Siemens Healthcare, 1620 Tremont St., Boston, MA 02120, USA
| | - Robert Mulkern
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Pierluigi Ciet
- Department of Radiology and Pediatric Pulmonology, Sophia Children's Hospital, Erasmus Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands; Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Nagle SK, Schiebler ML, Repplinger MD, François CJ, Vigen KK, Yarlagadda R, Grist TM, Reeder SB. Contrast enhanced pulmonary magnetic resonance angiography for pulmonary embolism: Building a successful program. Eur J Radiol 2015; 85:553-63. [PMID: 26860667 DOI: 10.1016/j.ejrad.2015.12.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/09/2015] [Accepted: 12/12/2015] [Indexed: 01/08/2023]
Abstract
The performance of contrast enhanced pulmonary magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism (PE) is an effective non-ionizing alternative to contrast enhanced computed tomography and nuclear medicine ventilation/perfusion scanning. However, the technical success of these exams is very dependent on careful attention to the details of the MRA acquisition protocol and requires reader familiarity with MRI and its artifacts. Most practicing radiologists are very comfortable with the performance and interpretation of computed tomographic angiography (CTA) performed to detect pulmonary embolism but not all are as comfortable with the use of MRA in this setting. The purpose of this review is to provide the general radiologist with the tools necessary to build a successful pulmonary embolism MRA program. This review will cover in detail image acquisition, image interpretation, and some key elements of outreach that help to frame the role of MRA to consulting clinicians and hospital administrators. It is our aim that this resource will help build successful clinical pulmonary embolism MRA programs that are well received by patients and physicians, reduce the burden of medical imaging radiation, and maintain good patient outcomes.
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Affiliation(s)
- Scott K Nagle
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States; Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, United States; Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, United States.
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | - Michael D Repplinger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States; Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | | | - Karl K Vigen
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | - Rajkumar Yarlagadda
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States; Diagnostic Radiology, P.C., Omaha, NE, United States
| | - Thomas M Grist
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States; Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, United States; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States; Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, United States; Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States; Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, United States
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Bannas P, Bell LC, Johnson KM, Schiebler ML, François CJ, Motosugi U, Consigny D, Reeder SB, Nagle SK. Pulmonary Embolism Detection with Three-dimensional Ultrashort Echo Time MR Imaging: Experimental Study in Canines. Radiology 2015; 278:413-21. [PMID: 26422185 DOI: 10.1148/radiol.2015150606] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To demonstrate the feasibility of free-breathing three-dimensional (3D) radial ultrashort echo time (UTE) magnetic resonance (MR) imaging in the simultaneous detection of pulmonary embolism (PE) and high-quality evaluation of lung parenchyma. MATERIALS AND METHODS The institutional animal care committee approved this study. A total of 12 beagles underwent MR imaging and computed tomography (CT) before and after induction of PE with autologous clots. Breath-hold 3D MR angiography and free-breathing 3D radial UTE (1.0-mm isotropic spatial resolution; echo time, 0.08 msec) were performed at 3 T. Two blinded radiologists independently marked and graded all PEs on a four-point scale (1 = low confidence, 4 = absolutely certain) on MR angiographic and UTE images. Image quality of pulmonary arteries and lung parenchyma was scored on a four-point-scale (1 = poor, 4 = excellent). Locations and ratings of emboli were compared with reference standard CT images by using an alternative free-response receiver operating characteristic curve (AFROC) method. Areas under the curve and image quality ratings were compared by using the F test and the Wilcoxon signed-rank test. RESULTS A total of 48 emboli were detected with CT. Both readers showed higher sensitivity for PE detection with UTE (83% and 79%) than with MR angiography (75% and 71%). The AFROC area under the curve was higher for UTE than for MR angiography (0.95 vs 0.89), with a significant difference in area under the curve of 0.06 (95% confidence interval: 0.01, 0.11; P = .018). UTE image quality exceeded that of MR angiography for subsegmental arteries (3.5 ± 0.7 vs 2.9 ± 0.5, P = .002) and lung parenchyma (3.8 ± 0.5 vs 2.2 ± 0.2, P < .001). The apparent signal-to-noise ratio in pulmonary arteries and lung parenchyma was significantly higher for UTE than for MR angiography (41.0 ± 5.2 vs 24.5 ± 6.2 [P < .001] and 10.2 ± 1.8 vs 3.5 ± 0.8 [P < .001], respectively). The apparent contrast-to-noise ratio between arteries and PEs was higher for UTE than for MR angiography (20.3 ± 5.2 vs 15.4 ± 6.7, P = .055). CONCLUSION In a canine model, free-breathing 3D radial UTE performs better than breath-hold 3D MR angiography in the detection of PE and yields better image quality for visualization of small vessels and lung parenchyma. Free-breathing 3D radial UTE for detection of PE is feasible and warrants evaluation in human subjects.
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Affiliation(s)
- Peter Bannas
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Laura C Bell
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Kevin M Johnson
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Mark L Schiebler
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Christopher J François
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Utaroh Motosugi
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Daniel Consigny
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Scott B Reeder
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
| | - Scott K Nagle
- From the Departments of Radiology (P.B., M.L.S., C.J.F., U.M., D.C., S.B.R., S.K.N.), Medical Physics (L.C.B., K.M.J., S.B.R., S.K.N.), Biomedical Engineering (S.B.R.), Medicine (S.B.R.), Emergency Medicine (S.B.R.), and Pediatrics (S.K.N.), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI 53792-3252
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Zhou M, Hu Y, Long X, Liu D, Liu L, Dong C, Wang J, Kong X. Diagnostic performance of magnetic resonance imaging for acute pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2015; 13:1623-34. [PMID: 26179627 DOI: 10.1111/jth.13054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/07/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND With ongoing technical developments, magnetic resonance imaging (MRI) has notably evolved for the assessment of the pulmonary vasculature. However, uncertainty persists about the performance of MRI for the diagnosis of acute pulmonary embolism (APE). OBJECTIVES To clarify the comprehensive role of MRI in diagnosing APE. METHODS Studies were identified through a search of Pubmed and Ovid databases, and the QUADAS-2 tool was applied for quality assessment of the included studies. RESULTS Fifteen studies based on patients and nine based on vessels were retrieved. The patient-based analysis yielded an overall sensitivity of 0.75 (95% confidence interval, 0.70-0.79) and 0.84 (0.80-0.87) for all patients and patients with technically adequate images, respectively, with an overall specificity of 0.80 (0.77-0.83) and 0.97 (0.96-0.98) and a pooled diagnostic odds ratio (DOR) of 51.07 (18.36-142.05) and 155.22 (86.83-277.47). On average, MRI was technically inadequate in 18.89% of patients (range, 2.10%-27.70%). A direct comparison of different MRI modalities showed that the combined MRI test had the highest pooled DOR and the lowest proportion of inconclusive images. Of note, heterogeneity and moderate quality were observed. On a vessel basis, the MRI had high sensitivity and specificity in larger-order vessels, but a significantly lower sensitivity of 0.55 (0.50-0.60) for subsegmental APE. CONCLUSIONS On a patient-based level, MRI yields high diagnostic accuracy for the detection of APE, especially in technically adequate images, and the inconclusive MRI examinations mainly result from motion artifact and poor arterial opacification. The combined MRI test appears to be a more promising diagnostic tool with greater power of discrimination than single techniques. From a vessel-based perspective, MRI exhibits a high diagnostic capability with proximal arteries, but lacks sensitivity for peripheral embolism.
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Affiliation(s)
- M Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Y Hu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Long
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - D Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - L Liu
- Tumor Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - C Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - J Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - X Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Abstract
OBJECTIVE Ferumoxytol is increasingly reported as an alternative to gadolinium-based contrast agents for MR angiography (MRA), particularly for patients with renal failure. This article summarizes more than 3 years of clinical experience with ferumoxytol-enhanced MRA for a range of indications and anatomic regions. CONCLUSION Ferumoxytol-enhanced MRA has many advantages including that it is safe for patients with renal failure and provides a lengthy plateau of vascular signal as a blood pool agent that allows longer navigated MRA sequences.
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Levin D, Seo JB, Kiely DG, Hatabu H, Gefter W, van Beek EJR, Schiebler ML. Triage for suspected acute Pulmonary Embolism: Think before opening Pandora's Box. Eur J Radiol 2015; 84:1202-11. [PMID: 25864020 DOI: 10.1016/j.ejrad.2015.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/26/2015] [Accepted: 03/23/2015] [Indexed: 12/22/2022]
Abstract
This is a review of the current strengths and weaknesses of the various imaging modalities available for the diagnosis of suspected non-massive Pulmonary Embolism (PE). Without careful consideration for the clinical presentation, and the timely application of clinical decision support (CDS) methodology, the current overutilization of imaging resources for this disease will continue. For a patient with a low clinical risk profile and a negative D-dimer there is no reason to consider further workup with imaging; as the negative predictive value in this scenario is the same as imaging. While the current efficacy and effectiveness data support the continued use of Computed Tomographic angiography (CTA) as the imaging golden standard for the diagnosis of PE; this test does have the unintended consequences of radiation exposure, possible overdiagnosis and overuse. There is a persistent lack of appreciation on the part of ordering physicians for the effectiveness of the alternatives to CTA (ventilation-perfusion imaging and contrast enhanced magnetic resonance angiography) in these patients. Careful use of standardized protocols for patient triage and the application of CDS will allow for a better use of imaging resources.
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Affiliation(s)
- David Levin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, M-15, M-Floor, Royal Hallamshire Hospital, Sheffield, UK
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School Boston, MA, USA
| | - Warren Gefter
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mark L Schiebler
- Department of Radiology, UW-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging 2014; 29:68-79. [PMID: 24552882 DOI: 10.1097/rti.0000000000000079] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pulmonary hypertension is a condition of varied etiology, commonly associated with poor clinical outcome. Patients are categorized on the basis of pathophysiological, clinical, radiologic, and therapeutic similarities. Pulmonary arterial hypertension (PAH) is often diagnosed late in its disease course, with outcome dependent on etiology, disease severity, and response to treatment. Recent advances in quantitative magnetic resonance imaging (MRI) allow for better initial characterization and measurement of the morphologic and flow-related changes that accompany the response of the heart-lung axis to prolonged elevation of pulmonary arterial pressure and resistance and provide a reproducible, comprehensive, and noninvasive means of assessing the course of the disease and response to treatment. Typical features of PAH occur primarily as a result of increased pulmonary vascular resistance and the resultant increased right ventricular (RV) afterload. Several MRI-derived diagnostic markers have emerged, such as ventricular mass index, interventricular septal configuration, and average pulmonary artery velocity, with diagnostic accuracy similar to that of Doppler echocardiography. Furthermore, prognostic markers have been identified with independent predictive value for identification of treatment failure. Such markers include large RV end-diastolic volume index, low left ventricular end-diastolic volume index, low RV ejection fraction, and relative area change of the pulmonary trunk. MRI is ideally suited for longitudinal follow-up of patients with PAH because of its noninvasive nature and high reproducibility and is advantageous over other biomarkers in the study of PAH because of its sensitivity to change in morphologic, functional, and flow-related parameters. Further study on the role of MRI image based biomarkers in the clinical environment is warranted.
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Pulmonary MRA: differentiation of pulmonary embolism from truncation artefact. Eur Radiol 2014; 24:1942-9. [PMID: 24863886 DOI: 10.1007/s00330-014-3219-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/14/2014] [Accepted: 05/05/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE Truncation artefact (Gibbs ringing) causes central signal drop within vessels in pulmonary magnetic resonance angiography (MRA) that can be mistaken for emboli, reducing diagnostic accuracy for pulmonary embolism (PE). We propose a quantitative approach to differentiate truncation artefact from PE. METHODS Twenty-eight patients who underwent pulmonary computed tomography angiography (CTA) for suspected PE were recruited for pulmonary MRA. Signal intensity drops within pulmonary arteries that persisted on both arterial-phase and delayed-phase MRA were identified. The percent signal loss between the vessel lumen and central drop was measured. CTA served as the reference standard for presence of pulmonary emboli. RESULTS A total of 65 signal intensity drops were identified on MRA. Of these, 48 (74%) were artefacts and 17 (26%) were PE, as confirmed by CTA. Truncation artefacts had a significantly lower median signal drop than PE on both arterial-phase (26% [range 12-58%] vs. 85% [range 53-91%]) and delayed-phase MRA (26% [range 11-55%] vs. 77% [range 47-89%]), p < 0.0001 for both. Receiver operating characteristic (ROC) analyses revealed a threshold value of 51% (arterial phase) and 47% signal drop (delayed phase) to differentiate between truncation artefact and PE with 100% sensitivity and greater than 90% specificity. CONCLUSION Quantitative signal drop is an objective tool to help differentiate truncation artefact and pulmonary embolism in pulmonary MRA. KEY POINTS • Inexperienced readers may mistake truncation artefacts for emboli on pulmonary MRA • Pulmonary emboli have non-uniform signal drop • 51% (arterial phase) and 47% (delayed phase) cut-off differentiates truncation artefact from PE • Quantitative signal drop measurement enables more accurate pulmonary embolism diagnosis with MRA.
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Magnetic resonance and computed tomography imaging of the structural and functional changes of pulmonary arterial hypertension. J Thorac Imaging 2013; 28:178-93. [PMID: 23612440 DOI: 10.1097/rti.0b013e31828d5c48] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The current Dana Point Classification system (2009) distinguishes elevation of pulmonary arterial pressure into pulmonary arterial hypertension (PAH) and pulmonary hypertension. Fortunately, PAH is not a common disease. However, with the aging of the First World's population, heart failure has become an important outcome of pulmonary hypertension, with up to 9% of the population involved. PAH is usually asymptomatic until late in the disease process. Although features that are indirectly related to PAH are found on noninvasive imaging studies, its diagnosis and management still require right heart catheterization. Imaging features of PAH include the following: (1) enlargement of the pulmonary trunk and main pulmonary arteries; (2) decreased pulmonary arterial compliance; (3) tapering of the peripheral pulmonary arteries; (4) enlargement of the inferior vena cava; and (5) increased mean transit time. The chronic requirement to generate high pulmonary arterial pressure measurably affects the right heart and main pulmonary artery. This change in physiology causes the following structural and functional alterations that have been shown to have prognostic significance: relative area change (RAC) of the pulmonary trunk, right ventricular stroke volume index, right ventricular stroke volume, right ventricular end-diastolic volume index, left ventricular end-diastolic volume index, and baseline right ventricular ejection fraction <35%. All of these variables can be quantified noninvasively and followed up longitudinally in each patient using magnetic resonance imaging to modify the treatment regimen. Untreated PAH frequently results in rapid clinical decline and death within 3 years of diagnosis. Unfortunately, even with treatment, fewer than half of these patients are alive at 4 years.
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