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Ulaner GA, Grigore C. False-Positive for Pulmonary Emboli on Ventilation/Perfusion Scan Due to Improper Patient Positioning During Tracer Administration. Clin Nucl Med 2023; 48:95-97. [PMID: 36127773 DOI: 10.1097/rlu.0000000000004391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT A 67-year-old woman presented with shortness of breath and a ventilation/perfusion scan was performed. Initial images demonstrated mismatched bilateral apical defects that would be classified as high probability for pulmonary emboli. However, it was unusual that the defects were only in the bilateral apices. Investigation discovered that 99m Tc-MAA was administered while the patient was in a seated position. Repeat scan the following day with the patient in the correct, supine, position during 99m Tc-MAA administration demonstrated no defects. In this case, incorrect patient positioning could have resulted in an incorrect diagnosis of pulmonary emboli and inappropriate treatment of the patient.
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Affiliation(s)
| | - Catalan Grigore
- Department of Radiology, Hoag Hospital Newport Beach, Newport Beach, CA
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Li D, Abele J, Sunner P, Varughese R, Hirji A, Weinkauf J, Nagendran J, Lien D, Halloran K. Mismatched Perfusion Defects on Routine Ventilation-Perfusion Scans after Lung Transplantation. Clin Transplant 2022; 36:e14650. [PMID: 35291045 DOI: 10.1111/ctr.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Incidental pulmonary embolism (PE) is a challenging entity with unclear treatment implications. Our program performs routine ventilation-perfusion (VQ) scans at 3-months post-transplant to establish airway and vascular function. We sought to determine the prevalence and prognostic implications of mismatched perfusion defects (MMPD) found on these studies, hypothesizing they would be associated with a benign prognosis. METHODS We studied VQ scans obtained routinely at 3-months post-transplant from double lung transplant recipients 2005-2016 for studies with MMPD interpreted as high or intermediate probability for PE. We tested the relationship between MMPD and 1-year survival via chi square testing, overall survival via Kaplan Meier analysis with log rank testing and peak forced expiratory volume in 1 second (FEV1) percent predicted via t-testing. RESULTS 373 patients met inclusion criteria, of whom 35 (9%) had VQ scans with MMPDs interpreted by radiologists as high or intermediate probability for PE. Baseline recipient and donor characteristics were similar between groups. 7 patients (20%) in the MMPD group were treated with therapeutic anticoagulation. Patients with MMPD had similar 1-year survival (100% vs. 98%, p = 1.00), overall survival (log rank p = 0.90) and peak FEV1% predicted (94% [SD 20%] vs. 92% [SD 21%]; p = 0.58). Anticoagulation did not affect these relationships. CONCLUSION Mismatched perfusion defects on routine post-transplant VQ scan were not associated with a difference in survival or lung function. A conservative approach to these changes may be a viable option in the absence of other anticoagulation indications. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- David Li
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jonathan Abele
- Department of Diagnostic Imaging and Radiology, University of Alberta, Edmonton, Canada
| | - Parveen Sunner
- Department of Diagnostic Imaging and Radiology, University of Alberta, Edmonton, Canada
| | - Rhea Varughese
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Alim Hirji
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Justin Weinkauf
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Dale Lien
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kieran Halloran
- Department of Medicine, University of Alberta, Edmonton, Canada
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Hadei SK, Alvandi M, Ramezani M, Aloosh O, Shaghaghi Z, Moradi A. Applying Wells score to inconclusive perfusion only modified PIOPED II (Prospective Investigation of Pulmonary Embolism Diagnosis II) readings in order to optimize the lung scintigraphy diagnostic yield in acute pulmonary embolism detection. Ann Nucl Med 2020; 34:521-526. [PMID: 32447628 DOI: 10.1007/s12149-020-01478-3] [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] [Received: 02/17/2020] [Accepted: 05/09/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE When using perfusion only modified PIOPED II criteria for PE detection, generated non-diagnostic scans are found to be the main diagnostic restriction. The objective of current study is to identify the role of Wells criteria added to inconclusive readings with the intent of enhancing the lung scintigraphy diagnostic yield. METHODS CTPA was performed in 34 suspected PE patients with inconclusive lung scintigraphy. They also were evaluated by Wells score and classified as low, intermediate and high probability. Overall prevalence and the rate of PE for each probability were calculated. Furthermore, NPV for scores < 2 and PPV for scores > 6 were computed. RESULTS Having a mean age of 59.75 ± 17.38 years, 7 (20.6%), 23 (67.6%) and 4 (11.8%) of cases had total criteria point count < 2, 2-6 and > 6, respectively. Using CTPA, 5 patients (14.7%) were diagnosed with PE. None of the patients with scores < 2 had PE with an associated NVP of 100%. Patients with scores 2-6 had a PE rate of 4.3% and 100% of patients with scores > 6 were diagnosed with PE, implying that the PPV of scores > 6 was 100%. CONCLUSION Adding Wells score to non-diagnostic scans allowed identification of PE to be done reliably, and provided further insight into how lung scintigraphy in conjunction with clinical assessment is a practical strategy not only for the patients unfit for performing CTPA but also in all the patients referred for PE evaluation.
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Affiliation(s)
- Seyed Kamaledin Hadei
- Department of Radiology, School of Medicine, Farshchian Cardiovascular Subspecialty Medical Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Alvandi
- Department of Nuclear Medicine and Molecular Imaging, Clinical Development Research Unit of Farshchian Heart Center, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Mehdi Ramezani
- Department of Radiology, School of Medicine, Farshchian Cardiovascular Subspecialty Medical Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Oldooz Aloosh
- Department of Internal Medicine, School of Medicine, Hazrat-E-Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Shaghaghi
- Department of Nuclear Medicine and Molecular Imaging, Clinical Development Research Unit of Farshchian Heart Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Abbas Moradi
- School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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Tak T, Karturi S, Sharma U, Eckstein L, Poterucha JT, Sandoval Y. Acute Pulmonary Embolism: Contemporary Approach to Diagnosis, Risk-Stratification, and Management. Int J Angiol 2019; 28:100-111. [PMID: 31384107 PMCID: PMC6679967 DOI: 10.1055/s-0039-1692636] [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] [Indexed: 01/14/2023] Open
Abstract
Pulmonary embolism (PE) affects over 300,000 individuals each year in the United States and is associated with substantial morbidity and mortality. Improvements in the diagnostic performance and availability of computed tomographic pulmonary angiography and D-dimer testing have facilitated the evaluation of patients with suspected PE. High clinical suspicion is required in those with risk factors and/or those that manifest signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells and modified Wells score or the PE rule-out criteria helpful in estimating the likelihood for PE. For those with confirmed PE, patients should be categorized and triaged according to the presence or absence of shock or hypotension. Normotensive patients can be further risk-stratified using validated prognostic risk scores, as well as by using imaging and cardiac biomarkers, with those having either signs of right ventricular dysfunction on imaging studies and/or abnormal cardiac biomarkers categorized as being at intermediate-risk and requiring close monitoring and hospital admission. Early discharge and/or home therapy are possible in those that do not manifest any high-risk features. The initial treatment for most patients that are stable consists of anticoagulation, with advanced therapies such as thrombolysis, catheter-based therapies, or surgical embolectomy deferred for those at high risk. Given the heterogeneous presentations of PE and various management strategies available, the development of multidisciplinary PE response teams has emerged to help facilitate decision-making in these patients.
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Affiliation(s)
- Tahir Tak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Swetha Karturi
- Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Umesh Sharma
- Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Lee Eckstein
- Department of Imaging Services, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Joseph T. Poterucha
- Division of Critical Care Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Pinho DF, Banga A, Torres F, Mathews D. Ventilation perfusion pulmonary scintigraphy in the evaluation of pre-and post-lung transplant patients. Transplant Rev (Orlando) 2018; 33:107-114. [PMID: 30415913 DOI: 10.1016/j.trre.2018.10.003] [Citation(s) in RCA: 5] [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: 10/04/2018] [Accepted: 10/20/2018] [Indexed: 12/18/2022]
Abstract
Lung transplantation is an established treatment for patients with a variety of advanced lung diseases. Imaging studies play a valuable role not only in evaluation of patients prior to lung transplantation, but also in the follow up of patients after transplantation for detection of complications. After lung transplantation, complications can occur as a result of surgical procedure, pulmonary embolism and ultimately chronic lung allograft dysfunction. Lung scintigraphy, which includes physiologic assessment of lung ventilation and perfusion by imaging, has become an important procedure in the evaluation of these patients, assuming a complementary role to high resolution anatomic imaging (computed tomography [CT]), as well as spirometry. The purpose of this atlas article is to demonstrate the uses of ventilation perfusion scintigraphy in the pre-transplantation setting for surgical planning and in the evaluation of complications post-lung transplantation based upon experience at our institution.
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Affiliation(s)
- Daniella F Pinho
- Department of Radiology, The University of Texas Southwestern Medical Center, United States.
| | - Amit Banga
- Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas Southwestern Medical Center, United States
| | - Fernando Torres
- Lung Transplant Program, Division of Pulmonary and Critical Care Medicine, Department of Medicine, The University of Texas Southwestern Medical Center, United States
| | - Dana Mathews
- Department of Radiology, The University of Texas Southwestern Medical Center, United States
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Moore AJE, Wachsmann J, Chamarthy MR, Panjikaran L, Tanabe Y, Rajiah P. Imaging of acute pulmonary embolism: an update. Cardiovasc Diagn Ther 2018; 8:225-243. [PMID: 30057872 DOI: 10.21037/cdt.2017.12.01] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Imaging plays an important role in the evaluation and management of acute pulmonary embolism (PE). Computed tomography (CT) pulmonary angiography (CTPA) is the current standard of care and provides accurate diagnosis with rapid turnaround time. CT also provides information on other potential causes of acute chest pain. With dual-energy CT, lung perfusion abnormalities can also be detected and quantified. Chest radiograph has limited utility, occasionally showing findings of PE or infarction, but is useful in evaluating other potential causes of chest pain. Ventilation-perfusion (VQ) scan demonstrates ventilation-perfusion mismatches in these patients, with several classification schemes, typically ranging from normal to high. Magnetic resonance imaging (MRI) also provides accurate diagnosis, but is available in only specialized centers and requires higher levels of expertise. Catheter pulmonary angiography is no longer used for diagnosis and is used only for interventional management. Echocardiography is used for risk stratification of these patients. In this article, we review the role of imaging in the evaluation of acute PE.
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Affiliation(s)
- Alastair J E Moore
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jason Wachsmann
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Murthy R Chamarthy
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lloyd Panjikaran
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Yuki Tanabe
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Prabhakar Rajiah
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
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Rawson JV, Cronin P. What Is Health Services Research? Acad Radiol 2018; 25:545-546. [PMID: 29631926 DOI: 10.1016/j.acra.2018.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 11/16/2022]
Affiliation(s)
- James V Rawson
- Radiology and Imaging, Medical College of Georgia, Augusta University, 1120 15th Street, Augusta, GA 30912.
| | - Paul Cronin
- Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109
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