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Ahaneku CA, Akpu BB, Njoku CH, Elem DE, Ekeng BE. Pulmonary embolism presenting as delirium: an acute confusional state in an elderly patient-a case report. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023; 35:8. [PMID: 36777903 PMCID: PMC9899661 DOI: 10.1186/s43162-023-00193-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/24/2023] [Indexed: 02/07/2023] Open
Abstract
Background Large numbers of elderly patients are admitted to hospitals in acute confusional states. In many, the underlying causes are easily found; in some, correct diagnosis is difficult. Pulmonary embolism (PE), the most serious clinical presentation of venous thromboembolism, is often misdiagnosed because of its non-specific features including delirium. Case presentation A 73-year-old woman was admitted to our hospital in a confused state with no obvious risk factors of PE. D-dimer levels were elevated and contrast-enhanced high-resolution computed tomography (HRCT) of the chest confirmed the diagnosis of PE. She was treated with enoxaparin and discharged on dabigatran. Her symptoms had resolved at the time of discharge, and she has been stable for over three month's follow-up visit. Conclusion PE should be regarded as a differential in elderly patients with an acute confusional state despite the absence of obvious risk factors. Investigating for and treating when confirmed may save a life.
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Affiliation(s)
- Chidimma A. Ahaneku
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Respiratory Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Benard B. Akpu
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Cardiology, Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Chibueze H. Njoku
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Respiratory Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - David E. Elem
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Infectious Disease Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Bassey E. Ekeng
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Infectious Disease Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
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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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3
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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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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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5
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Sallam AA, Abo El Nasr MM, Elgebaly AS, El Feky WM. The use of tranexamic acid in elective lung surgery: a single-center experience. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_29_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Imaging in intensive care unit (ICU) is integral to patient management. The portable chest radiograph is the most commonly requested imaging examination in ICU, and, despite its limitations, it significantly contributes to the decision-making process. Multidetector CT (MDCT) is reserved for relatively complex and challenging clinical scenarios. Bedside ultrasound is emerging as a promising imaging modality as it does not subject the patients to risks and resources involved in the transportation of these patients to the CT facility. Ultrasound is an effective modality to triage patients and is being increasingly incorporated into the emergency and intensive care management algorithms.
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Affiliation(s)
- Ashish Chawla
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore, Singapore
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7
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Bunch PM, Fulwadhva UP, Wortman JR, Primak AN, Madan R, Steigner ML, Sodickson AD. Motion Artifact Reduction From High-Pitch Dual-Source Computed Tomography Pulmonary Angiography. J Comput Assist Tomogr 2018; 42:623-629. [PMID: 29613990 DOI: 10.1097/rct.0000000000000736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to compare quantitative and qualitative measures of aortic, cardiac, and respiratory motion artifact between high-pitch dual-source (DS) and single-source (SS) computed tomography pulmonary angiography (CTPA) protocols. METHODS This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study retrospectively reviewed 80 non-electrocardiogram-gated CTPA examinations acquired with a second-generation DS system at 100 kVp following 50 mL iodinated contrast injection - 40 consecutive SS and 40 consecutive DS studies. Quantitative measures of aortic, left ventricular, and diaphragmatic motion were recorded as the maximal excursion of a structure's "double image," and 3 independent readers performed qualitative motion assessments. Pulmonary arterial contrast enhancement, image noise, and radiation dose metrics were recorded. Statistical analyses were performed with 1-way analysis of variance and Fisher exact test. RESULTS Dual source outperformed SS technique in both quantitative and qualitative measures of motion. Mean distances between motion-artifact double images were reduced with DS protocol at each location (all P ≤ 0.004), and DS examinations were more likely to receive an assessment of no motion in all locations (all P < 0.0001). The DS protocol demonstrated increases in contrast enhancement, although increased image noise resulted in lower enhancement to noise ratio. Mean radiation dose was 60% lower using the DS protocol. CONCLUSION High-pitch DS CTPA significantly reduces artifacts resulting from ascending aortic, cardiac, and diaphragmatic motion.
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8
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Abstract
Acute chest pain is a leading cause of Emergency Department visits. Computed tomography angiography plays a vital diagnostic role in such cases, but there are several common challenges associated with the imaging of acute chest pain, which, if unrecognized, can lead to an inconclusive or incorrect diagnosis. These imaging challenges fall broadly into 3 categories: (1) image acquisition, (2) image interpretation (including physiological and pathologic mimics), and (3) result communication. The aims of this review are to describe and illustrate the most common challenges in the imaging of acute chest pain and to provide solutions that will facilitate accurate diagnosis of the causes of acute chest pain in the emergency setting.
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9
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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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10
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Clinical risk stratification of acute pulmonary embolism: comparing the usefulness of CTA obstruction score and pulmonary perfusion defect score with dual-energy CT. Int J Cardiovasc Imaging 2017; 33:2039-2047. [DOI: 10.1007/s10554-017-1188-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
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11
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Clinical Significance of Late Phase of Lung Perfusion Blood Volume (Lung Perfusion Blood Volume) Quantified by Dual-Energy Computed Tomography in Patients With Pulmonary Thromboembolism. J Thorac Imaging 2017; 32:43-49. [PMID: 27846051 DOI: 10.1097/rti.0000000000000250] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Using dual-energy computed tomography (DECT), we quantified the lung perfusion blood volume (PBV) in the late phase, which may reflect both the pulmonary artery and systemic collateral flow. We then investigated the clinical significance of late-phase lung PBV values. MATERIALS AND METHODS We retrospectively studied 206 patients (266 scans) who underwent early-phase and late-phase DECT. The patients were divided into 2 groups depending on whether or not they had pulmonary thromboembolism (PTE) (n=94 and 112). Patients with PTE were further divided into 2 subgroups, depending on whether they had acute PTE or chronic PTE (n=66 and 28). Pulmonary artery enhancement (PAenh) was measured on DECT. We then calculated the [lung PBV/PAenh] ratio in all patients during both the early and late phases for adjustment of timing. RESULTS The [late-phase lung PBV/PAenh] ratio was 0.092±0.029 in the group with PTE and 0.108±0.030 in the group without PTE, showing a significant difference between the 2 groups (P<0.0001). The [early-phase lung PBV values/PAenh]/[late-phase lung PBV values/PAenh] ratio was 0.68±0.19 and 0.84±0.20, respectively, also showing a significant difference between the 2 groups (P<0.0001). Finally, the [early-phase lung PBV/PAenh]/[late-phase lung PBV/PAenh] ratio was 0.71±0.19 in patients with acute PTE and 0.56±0.16 in patients with chronic PTE, and there was a significant difference between these 2 subgroups (P=0.0004). CONCLUSIONS It may be useful to determine late-phase lung PBV values in patients with PTE, because this parameter may reflect the systemic collateral flow, which is increased in chronic PTE.
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Panopoulos I, Specchi S, Soubasis N, Papastefanou A, Brellou G, Auriemma E. Multidetector computed tomographic pulmonary angiography in a cat with fatal heartworm disease. Vet Radiol Ultrasound 2017; 59:E71-E75. [DOI: 10.1111/vru.12508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 02/10/2017] [Accepted: 02/14/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Swan Specchi
- Istituto Veterinario di Novara; Granozzo con Monticello Italy
| | - Nektarios Soubasis
- Aristotle University of Thessaloniki School of Veterinary Medicine; Thessaloniki Greece
| | | | - Georgia Brellou
- Aristotle University of Thessaloniki School of Veterinary Medicine; Thessaloniki Greece
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13
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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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Unenhanced and Contrast-Enhanced MR Angiography and Perfusion Imaging for Suspected Pulmonary Thromboembolism. AJR Am J Roentgenol 2017; 208:517-530. [PMID: 28075625 DOI: 10.2214/ajr.16.17415] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This article discusses the basics of unenhanced MR angiography (MRA) and MR venography (MRV), time-resolved contrast-enhanced (CE) MRA and dynamic first-pass CE perfusion MRI, and unenhanced and CE MRV, in addition to assessing the clinical relevance of these techniques for evaluating patients with suspected pulmonary thromboembolism and deep venous thrombosis. CONCLUSION Since the 1990s, the efficacy of MRA or MRV and dynamic perfusion MRI for patients with suspected pulmonary thromboembolism and deep venous thrombosis has been evaluated. On the basis of the results of single-center trials, comprehensive MRI protocols, including pulmonary unenhanced and CE MRA, perfusion MRI, and MRV, promise to be safe and time effective for assessing patients with suspected pulmonary thromboembolism, although future multicenter trials are required to assess the real clinical value of MRI.
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15
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Reliability of D-Dimer test results in deciding the necessity of performing CTA in high risk population to establish the diagnosis of PE. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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16
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Systematic Comparison of Reduced Tube Current Protocols for High-pitch and Standard-pitch Pulmonary CT Angiography in a Large Single-center Population. Acad Radiol 2016; 23:619-27. [PMID: 26905455 DOI: 10.1016/j.acra.2016.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/15/2015] [Accepted: 01/10/2016] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES Benefits of iterative reconstruction (IR) algorithms combined with dose-reduction techniques have been shown at computed tomography pulmonary angiography (CTPA) in several medium to small patient collectives. In this study, we performed a systematic comparison of image quality to combinations of reduced tube current (RC) and IR for both standard-pitch (SP) single-source and high-pitch (HP) dual-source CTPA in a large, single-center population. MATERIALS AND METHODS Three hundred eighty-two consecutive patients (October 2010 through December 2012) received clinically indicated CTPA with one of four consecutively changed protocols: (1) HPSC: 180 mAs, weighted filtered back projection, pitch = 3; (2) HPRC: 90 mAs, IR, pitch = 3; (3) SPSC: 180 mAs, weighted filtered back projection, pitch = 1.2; and (4) HPRC: 90 mAs, IR, pitch = 1.2. Tube potential was 100 kV. Vascular attenuation and standardized signal-to-noise ratio (sSNR) were measured in the pulmonary trunk (sSNRPT) and on segmental artery level (sSNRS1, sSNRS10). Dose-length-product was recorded per series. Two independent investigators rated image quality. Kolmogorov-Smirnov test, Kruskal-Wallis test, and kappa statistics were used for statistical analysis. Median values are presented per group. RESULTS Image quality was consistent between all groups (observer 1: P = 0.118; observer 2: P = 0.122). Inter-reader consistency was very good (κ = 0.866, P < 0.001). Dose-length-product was significantly reduced in HP and RC groups (P < 0.001 for each; SPSC: 139.5 mGycm; HPRC: 92 mGycm; SPSC: 211 mGycm; HPRC: 137 mGycm). sSNR was comparable (sSNRPT overall: P = 0.052; sSNRS1 overall: P = 0.161; and sSNRS10 overall: P = 0.259). CONCLUSIONS Substantial dose reduction can be within a routine clinical setting without quantifiable loss of image quality either by HP pulmonary angiography or by a combination of IR and RC in either HP or SP acquisition.
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Karia S, Screaton N. Pulmonary embolism. IMAGING 2016. [DOI: 10.1183/2312508x.10002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Khan S, McCullagh L, Press A, Kharche M, Schachter A, Pardo S, McGinn T. Formative assessment and design of a complex clinical decision support tool for pulmonary embolism. EVIDENCE-BASED MEDICINE 2016; 21:7-13. [PMID: 26718820 PMCID: PMC10687829 DOI: 10.1136/ebmed-2015-110214] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Electronic health record (EHR)-based clinical decision support (CDS) tools are rolled out with the urgency to meet federal requirements without time for usability testing and refinement of the user interface. As part of a larger project to design, develop and integrate a pulmonary embolism CDS tool for emergency physicians, we conducted a formative assessment to determine providers' level of interest and input on designs and content. This was a study to conduct a formative assessment of emergency medicine (EM) physicians that included focus groups and key informant interviews. The focus of this study was twofold, to determine the general attitude towards CDS tool integration and the ideal integration point into the clinical workflow. To accomplish this, we first approached EM physicians in a focus group, then, during key informant interviews, we presented workflow designs and gave a scenario to help the providers visualise how the CDS tool works. Participants were asked questions regarding the trigger location, trigger words, integration into their workflow, perceived utility and heuristic of the tool. Results from the participants' survey responses to trigger location, perceived utility and efficiency, indicated that the providers felt the tool would be more of a hindrance than an aid. However, some providers commented that they had not had exposure to CDS tools but had used online calculators, and thought the tools would be helpful at the point-of-care if integrated into the EHR. Furthermore, there was a preference for an order entry wireframe. This study highlights several factors to consider when designing CDS tools: (1) formative assessment of EHR functionality and clinical environment workflow, (2) focus groups and key informative interviews to incorporate providers' perceptions of CDS and workflow integration and/or (3) the demonstration of proposed workflows through wireframes to help providers visualise design concepts.
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Affiliation(s)
- Sundas Khan
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Lauren McCullagh
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Anne Press
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Manish Kharche
- Department of Medical Informatics and Care Delivery Innovation, Cooper University Health Care, Camden, New Jersey, USA
| | - Andy Schachter
- Department of Information Technology, North Shore-LIJ Health System, Manhasset, New York, USA
| | - Salvatore Pardo
- Department of Emergency Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
| | - Thomas McGinn
- Department of Medicine, Hofstra North Shore—LIJ School of Medicine, Manhasset, New York, USA
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Screaton N, Karia S. Commentary on “Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg?”. Clin Radiol 2015; 70:1355-6. [DOI: 10.1016/j.crad.2015.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 08/03/2015] [Accepted: 08/04/2015] [Indexed: 01/08/2023]
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Gill MK, Vijayananthan A, Kumar G, Jayarani K, Ng KH, Sun Z. Use of 100 kV versus 120 kV in computed tomography pulmonary angiography in the detection of pulmonary embolism: effect on radiation dose and image quality. Quant Imaging Med Surg 2015; 5:524-33. [PMID: 26435916 DOI: 10.3978/j.issn.2223-4292.2015.04.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the effective radiation dose and image quality resulting from 100 versus 120 kilovoltage (kV) protocols among patients referred for computed tomography pulmonary angiography (CTPA). METHODS Sixty-six patients with clinical suspicion of pulmonary embolism (PE) were prospectively enrolled. Two CTPA protocols (group A: n=33, 100 kV/115 mAs; group B: n=33, 120 kV/90 mAs) were compared. Two experienced radiologists assessed image quality in terms of diagnostic performance and effect of artefacts. Image quality parameters [CT attenuation, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR)] and effective radiation dose between the two protocols were compared. RESULTS The contrast enhancement in central and peripheral pulmonary arteries was significantly higher in group A than in group B (P<0.001) with the identical SNR (P=0.26), whereas the CNR was significantly higher in group A than in group B (P<0.001). The effective radiation dose for the 100 and 120 kV scans was 3.2 and 6.8 mSv, respectively. CONCLUSIONS Reducing the tube voltage from 120 to 100 kV in CTPA allows a significant reduction of radiation dose without significant loss of diagnostic image quality.
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Affiliation(s)
- Maninderpal Kaur Gill
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
| | - Anushya Vijayananthan
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
| | - Gnana Kumar
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
| | - Kasthoori Jayarani
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
| | - Kwan-Hoong Ng
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
| | - Zhonghua Sun
- 1 Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ; 2 University of Malaya Research Imaging Centre (UMRIC), University of Malaya, Kuala Lumpur, Malaysia ; 3 Department of Medical Radiation Sciences, Faculty of Science and Engineering, Curtin University, Perth, Western Australia, Australia
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Ingrisch M, Maxien D, Meinel FG, Reiser MF, Nikolaou K, Dietrich O. Detection of pulmonary embolism with free-breathing dynamic contrast-enhanced MRI. J Magn Reson Imaging 2015; 43:887-93. [DOI: 10.1002/jmri.25050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/04/2015] [Accepted: 09/04/2015] [Indexed: 11/05/2022] Open
Affiliation(s)
- Michael Ingrisch
- Josef-Lissner-Laboratory for Biomedical Imaging; Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Daniel Maxien
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Felix G. Meinel
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Maximilian F. Reiser
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Konstantin Nikolaou
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
- Department of Diagnostic and Interventional Radiology; Eberhard-Karls-University; Tübingen Germany
| | - Olaf Dietrich
- Josef-Lissner-Laboratory for Biomedical Imaging; Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich; Munich Germany
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Quantification of lung perfusion blood volume with dual-energy CT: assessment of the severity of acute pulmonary thromboembolism. AJR Am J Roentgenol 2014; 203:287-91. [PMID: 25055261 DOI: 10.2214/ajr.13.11586] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the usefulness of quantification of lung perfused blood volume (PBV) with dual-energy CT (DECT) for assessment of the severity of acute pulmonary thromboembolism (PTE). MATERIALS AND METHODS We retrospectively analyzed the records of 72 patients with PTE and 168 without PTE who underwent DECT. The PTE patients were divided into high-, intermediate-, and low-risk groups based on clinical symptoms and right ventricular dysfunction. Correlations between quantification of whole-lung PBV and clinical severity were evaluated. Also evaluated was the relation between quantification of whole-lung PBV and right-to-left ventricular diameter ratio on CT images, which was used as an indicator of right ventricular dysfunction. RESULTS In the PTE and control groups, the whole-lung PBVs were 27.6 ± 7.9 and 29.9 ± 6.8 HU with a significant difference between them (p < 0.0281). In the high-, intermediate-, and low-risk PTE groups, the whole-lung PBVs were 16.0 ± 2.9, 21.0 ± 4.2, and 31.4 ± 5.8 HU with a significant difference between them (p < 0.05). There was no significant difference in whole-lung PBV between the control group and the low-risk PTE group, but there was a significant difference between the control group and the other two PTE groups. In PTE patients, whole-lung PBV had negative correlation with right-to-left ventricular diameter ratio (R = -0.567, p < 0.001). CONCLUSION Quantification of lung PBV with DECT is useful for assessment of the clinical severity of PTE and can be used as an indicator of right ventricular dysfunction.
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High-pitch ECG-synchronized pulmonary CT angiography versus standard CT pulmonary angiography: a prospective randomized study. AJR Am J Roentgenol 2014; 201:971-6. [PMID: 24147466 DOI: 10.2214/ajr.13.10597] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to compare high-pitch ECG-synchronized pulmonary CT angiography (CTA) with standard pulmonary CTA with regard to radiation dose and image quality in patients with suspected pulmonary embolism. SUBJECTS AND METHODS This prospective study was approved by the institutional review board, and participants provided informed consent. Patients with suspected pulmonary embolism (60% women; mean age, 57 ± 14 years) were randomized to undergo high-pitch ECG-synchronized pulmonary CTA (n = 26) or standard pulmonary CTA (n = 21). Two independent readers assessed subjective image quality of pulmonary arteries, cardiovascular structures, and pulmonary parenchyma. Signal intensity (SI) was measured in one segmental and three central pulmonary arteries. RESULTS High-pitch ECG-synchronized pulmonary CTA showed higher SI (p < 0.001) for pulmonary arteries. Image quality scores indicated improvement in assessment of cardio-vascular structures (p < 0.001), minimization of motion of central (p < 0.001) pulmonary arteries, and an increase in pulmonary arterial enhancement (p = 0.01) with high-pitch ECG-synchronized pulmonary CTA. Image quality scores for lung assessment were higher for standard pulmonary CTA (p < 0.001). The amount of contrast agent administered was similar between techniques (p = 0.86). Radiation dose was lower for high-pitch ECG-synchronized pulmonary CTA (p < 0.001). CONCLUSION High-pitch ECG-synchronized pulmonary CTA provides higher pulmonary arterial SI, decreased motion of central pulmonary arteries, and improved assessment of cardiovascular structures with similar contrast dose and lower radiation compared with standard pulmonary CTA.
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Young MD, Daniels AH, Evangelista PT, Reinert SE, Ritterman S, Christino MA, Thakur NA, Born CT. Predicting pulmonary embolus in orthopedic trauma patients using the Wells score. Orthopedics 2013; 36:e642-7. [PMID: 23672919 DOI: 10.3928/01477447-20130426-29] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The decision to perform computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) in orthopedic trauma patients is challenging. The Wells score is a commonly used clinical probability tool developed to determine the likelihood of PE and assist in determining the need for CTPA examination. This study evaluated the usefulness of the Wells score for predicting PE in patients admitted to the orthopedic trauma service. All patients who were admitted to the orthopedic trauma service at the authors' institution between 2001 and 2011 who underwent CTPA were identified. The Wells score was calculated retrospectively for each patient, and risk categories using the traditional and alternative interpretations of the Wells score were assigned. Pulmonary embolism was diagnosed in 27 (16%) of 169 patients who underwent CTPA. In total, 27 (0.39%) of 6854 patients admitted to the orthopedic trauma service were diagnosed with PE during initial hospitalization. Mean Wells score was 3.31 (95% confidence interval, ±.28) for the entire population, 3.32 for those without PE (95% confidence interval, ±.31), and 3.28 for those with PE (95% confidence interval, ±.72) (P=.91). Average times from admission to CTPA examination for those with and without PE were 6.18 and 5.7 days, respectively (P=.94). No significant correlation existed between the Wells score and CTPA results, indicating that the Wells score is limited in predicting PE risk in orthopedic trauma patients.
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Affiliation(s)
- Matthew D Young
- Division of Orthopaedic Trauma, Department of Orthopaedics, Warren Alpert Medical School, Brown University, 593 Eddy St, Providence, RI 02903, USA.
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Meinel FG, Graef A, Thieme SF, Bamberg F, Schwarz F, Sommer WH, Helck AD, Neurohr C, Reiser MF, Johnson TR. Assessing Pulmonary Perfusion in Emphysema. Invest Radiol 2013; 48:79-85. [DOI: 10.1097/rli.0b013e3182778f07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pena E, Dennie C. Acute and Chronic Pulmonary Embolism: An In-depth Review for Radiologists Through the Use of Frequently Asked Questions. Semin Ultrasound CT MR 2012; 33:500-21. [DOI: 10.1053/j.sult.2012.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Komissarova M, Chong S, Frey K, Sundaram B. Imaging of acute pulmonary embolism. Emerg Radiol 2012; 20:89-101. [PMID: 23151968 DOI: 10.1007/s10140-012-1080-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/01/2012] [Indexed: 12/26/2022]
Abstract
Acute pulmonary thromboembolism (PE) is a cardiovascular emergency associated with significant morbidity and a 5-35 % mortality for untreated pulmonary embolism. If promptly diagnosed and treated, the mortality rate can be significantly reduced. Diagnosis of acute PE continues to be a clinical challenge, with diagnostic imaging playing an important role. This review discusses the clinical challenges of diagnosing acute PE, presents an evidence-based review of the current tests and ever-evolving imaging technology, and highlights special considerations related to radiation dose, contrast media use, and pregnant patients.
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Affiliation(s)
- Maria Komissarova
- Divisions of Emergency, Cardiothoracic and Nuclear Radiology, Department of Radiology, University of Michigan, 1500 E. Medical Center Drive, TC B1-140D, Ann Arbor, MI 48109, USA
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Clot burden score in the evaluation of right ventricular dysfunction in acute pulmonary embolism: Quantifying the cause and clarifying the consequences. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Rodrigues B, Correia H, Figueiredo A, Delgado A, Moreira D, Ferreira Dos Santos L, Correia E, Pipa J, Beirão I, Santos O. [Clot burden score in the evaluation of right ventricular dysfunction in acute pulmonary embolism: quantifying the cause and clarifying the consequences]. Rev Port Cardiol 2012; 31:687-95. [PMID: 23062526 DOI: 10.1016/j.repc.2012.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 02/13/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pulmonary angiography by computed tomography (CT) is the method of choice for the detection of acute pulmonary embolism (PE). Studies have shown that the severity of PE can be estimated by clot burden scores. OBJECTIVE To evaluate the correlation between an angiographic clot burden score (Qanadli score - QS) and parameters of right ventricular dysfunction (RVD) in patients admitted for PE. METHODS We performed a retrospective study of 107 patients (60% female) admitted to an intensive care unit for PE (intermediate/high risk) between January 1, 2007 and September 30, 2011. Images from 16-slice multidetector CT angiography were reviewed in 102 patients and the QS calculated. Based on a cut-off of 18 points established by ROC curve analysis, two groups were formed (A<18 points vs. B ≥18 points) and the clinical, laboratory, ECG, echocardiographic and CT angiography parameters were compared. The statistical analysis was performed using SPSS. RESULTS The overall mean age was 61.4 years. With regard to symptoms at admission, there was a greater prevalence in group B of fatigue, chest pain and syncope (p=0.017), with higher Geneva and Wells scores and shock index. In terms of ECG parameters, heart rate and percentage of right bundle branch block, T-wave inversion (V(1)-V(3)) and S(1)Q(3)T(3) pattern (p=0.034) were higher in group B, as was the ECG score (p=0.009). Laboratory tests revealed that group B had higher troponin and d-dimers, with lower creatinine clearance by the MDRD formula (p=0.020) and PO(2)/FiO(2) ratio. Echocardiography showed higher pulmonary artery systolic pressure in group B, and CT angiography revealed larger right ventricular (RV) diameters and higher RV/LV ratio (p=0.002), and greater superior vena cava, azygos vein and coronary sinus diameters in this group. Pulmonary artery (PA) diameter and the PA/aorta ratio were similar. Interventricular septal bowing and reflux of contrast into the inferior vena cava (p=0.001) were greater in group B, and QS>18 was an independent predictor of RVD (RV/LV ratio>1) (OR: 10.85; p<0.001) (area under the curve on ROC analysis: 0.79; p<0.001). The percentage of patients receiving fibrinolytic treatment was higher in group B (p=0.045), and in-hospital mortality was similar in both groups (overall 4.9%). CONCLUSIONS QS >18 points proved to be an independent predictor of RVD in PE, and correlated linearly with variables associated with higher morbidity and mortality.
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Affiliation(s)
- Bruno Rodrigues
- Serviço de Cardiologia/Radiologia, Centro Hospitalar Tondela-Viseu, Hospital São Teotónio, Viseu, Portugal.
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Wang Z, Pei C, Ma L, Wang D, Zhou J, Wang W, Shen J, Xu Z, He J. Acute pulmonary embolism after pneumonectomy. J Thorac Dis 2012; 4:76-82. [PMID: 22295170 DOI: 10.3978/j.issn.2072-1439.2011.10.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 10/05/2011] [Indexed: 12/31/2022]
Abstract
Pulmonary embolism (PE) by occlusion of the pulmonary arterial bed may lead to acute life-threatening but potentially reversible right ventricular failure, one of the most severe complications of thoracic surgery. Still, the incidence of acute pulmonary embolism after surgery is reduced by comprehensive anticoagulant prevention, improved surgical techniques, appropriate perioperative management and early ambulation. However, there is difficulty in diagnosing PE after thoracic surgery due to the lack of specific clinical manifestations. So that optimal diagnostic strategy and management according to the clinical presentation and estimated risk of an adverse outcome is fundamental.
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Affiliation(s)
- Zongfei Wang
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Guangzhou Medical College; Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou, China
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Pulmonary embolism detection and characterization through quantitative iodine-based material decomposition images with spectral computed tomography imaging. Invest Radiol 2012; 47:85-91. [PMID: 22107805 DOI: 10.1097/rli.0b013e31823441a1] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess the diagnostic value of pulmonary embolism (PE) detection and characterization through quantitative iodine-based material decomposition images with spectral computed tomography (CT) imaging. MATERIALS AND METHODS Fifty-three patients underwent CT pulmonary angiography (CTPA) with spectral imaging mode with the simultaneous acquisition of 80 kVp and 140 kVp on a GE Discovery CT750HD scanner to generate monochromatic CTPA and material decomposition images. CTPA images were reviewed for the presence, localization, and degree (occlusive or nonocclusive) of PE. The iodine distribution in the lung parenchyma on the iodine-based material decomposition images was used to identify perfusion defects, which were then correlated to the CTPA findings. The iodine densities for the perfusion defects and the normal lung parenchyma were measured and statistically compared. Twelve PE patients underwent anticoagulation, and the iodine densities for the perfusion defects before and after the treatment were also measured and compared. The receiver operating characteristics curve was generated to assess the differential diagnostic performances of iodine density in distinguishing the presence or absence of PE and the occlusive or nonocclusive PE. RESULTS A total of 93 clots (51 occlusive and 42 nonocclusive) were found in 19 patients with lobar (26), segmental (54), or subsegmental (13) distribution. CTPA identified 88 clots initially and 5 more retrospectively with the help of iodine mapping. Thirty-three of 34 normal CTPA patients had symmetric iodine distribution. All occlusive clots and 11 nonocclusive clots showed clear evidence of iodine distribution defects. There was a significant difference for the iodine density among normal lung parenchyma (1.89 mg/mL [0.85-3.29 mg/mL]), nonocclusive perfusion defects (0.83 mg/mL [0.44-1.26 mg/mL]), and occlusive perfusion defects (0.27 mg/mL [0.00-0.62 mg/mL]) (P < 0.001). The iodine densities of perfusion defects before and after anticoagulation were significantly different (P < 0.001). Receiver operating characteristics analyses showed high discriminatory power for using the quantification of iodine density in distinguishing the presence or absence of PE and the occlusive or nonocclusive PE. CONCLUSIONS Spectral CT imaging generated both monochromatic CTPA images for morphologic analysis of PE and material decomposition images for quantitative depiction of pulmonary blood flow and perfusion defects. Quantification of iodine density may be used as a predictor in distinguishing the presence or absence of PE and the severity of PE.
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Blanke P, Apfaltrer P, Ebersberger U, Schindler A, Langer M, Schoepf UJ. CT Detection of Pulmonary Embolism and Aortic Dissection. Cardiol Clin 2012; 30:103-16. [DOI: 10.1016/j.ccl.2011.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Pulmonary blood volume imaging with dual-energy computed tomography: Spectrum of findings. Clin Radiol 2012; 67:69-77. [DOI: 10.1016/j.crad.2010.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 12/10/2010] [Accepted: 12/14/2010] [Indexed: 11/22/2022]
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Abrahams-van Doorn PJ, Hartmann IJC. Cardiothoracic CT: one-stop-shop procedure? Impact on the management of acute pulmonary embolism. Insights Imaging 2011; 2:705-15. [PMID: 23100045 PMCID: PMC3289035 DOI: 10.1007/s13244-011-0123-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 05/02/2011] [Accepted: 07/18/2011] [Indexed: 10/26/2022] Open
Abstract
In the treatment of pulmonary embolism (PE) two groups of patients are traditionally identified, namely the hemodynamically stable and instable groups. However, in the large group of normotensive patients with PE, there seems to be a subgroup of patients with an increased risk of an adverse outcome, which might benefit from more aggressive therapy than the current standard therapy with anticoagulants. Risk stratification is a commonly used method to define subgroups of patients with either a high or low risk of an adverse outcome. In this review the clinical parameters and biomarkers of myocardial injury and right ventricular dysfunction (RVD) that have been suggested to play an important role in the risk stratification of PE are described first. Secondly, the use of more direct imaging techniques like echocardiography and CT in the assessment of RVD are discussed, followed by a brief outline of new imaging techniques. Finally, two risk stratification models are proposed, combining the markers of RVD with cardiac biomarkers of ischemia to define whether patients should be admitted to the intensive care unit (ICU) and/or be given thrombolysis, admitted to the medical ward, or be safely treated at home with anticoagulant therapy.
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Affiliation(s)
- Pauline J Abrahams-van Doorn
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, 's-Gravendijkwal 230, NL-3015 CE, Rotterdam, The Netherlands,
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CT Imaging of Pulmonary Embolism: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9112-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Sun Z. Multislice computed tomography angiography in the diagnosis of cardiovascular disease: 3D visualizations. Front Med 2011; 5:254-70. [DOI: 10.1007/s11684-011-0153-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 08/11/2011] [Indexed: 10/17/2022]
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Cronin P, Kelly AM. Influence of population prevalences on numbers of false positives: an overlooked entity. Acad Radiol 2011; 18:1087-93. [PMID: 21703881 DOI: 10.1016/j.acra.2011.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 04/26/2011] [Accepted: 04/29/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Disease prevalence alters the number of true positives (TP), true negatives (TN), false negatives (FN), and false positives (FP), even if the sensitivity and specificity of a test stays the same. METHODS AND MATERIALS We illustrate this using data for the detection of suspected acute pulmonary embolism (PE) from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II). We chose PE because of the clinical significance of the disease, the low prevalence of PE in the patient population being tested with CTPA with the widespread adoption of CTPA, and the serious clinical consequences of anticoagulation therapy in FP patients. RESULTS Based on PIOPED II data (sensitivity 83%, specificity 96%), at a disease prevalence of approximately 5%, the number of FP patients is greater than the number of TP patients. Scaled to the US population, at a disease prevalence of 5%, there would be 139,800 FPs and 3,356,200 TNs. Assuming a mortality rate of 0.5% and a 3.0% rate of major bleeding secondary to anticoagulation therapy for well-controlled patients, if all FP patients received anticoagulation, there would be 699 deaths and 4194 major bleeding complications. CONCLUSIONS At a prevalence of approximately 5% for PE, the number of FPs approaches or is greater than the number of TPs for CTPA for the detection of suspected acute PE. Patients with FP results may receive unnecessary, potentially harmful treatment with anticoagulation therapy. Population prevalence of disease needs to be taken into account along with the diagnostic accuracy of a test, because this may significantly affect downstream patient outcomes.
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Abstract
OBJECTIVE The purpose of this article is to discuss the diagnostic role of pulmonary CT angiography (CTA) in the workup of pulmonary embolism (PE), including specific populations, and issues such as pulmonary CTA combined with indirect CT venography; radiation dose considerations; the management of isolated subsegmental PE; and new technologic developments, such as dual-source/dual-energy pulmonary CTA. CONCLUSION The role of pulmonary CTA will continue to grow with the emergence of MDCT and dual-energy CT and their improved capabilities. However, the need for any given CT examination should always be justified on the basis of the individual patient's benefits and risks.
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