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de Lange C, Rodriguez CM, Martinez-Rios C, Lam CZ. Urgent and emergent pediatric cardiovascular imaging. Pediatr Radiol 2024:10.1007/s00247-024-05980-y. [PMID: 38967787 DOI: 10.1007/s00247-024-05980-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
The need for urgent or emergent cardiovascular imaging in children is rare when compared to adults. Patients may present from the neonatal period up to adolescence, and may require imaging for both traumatic and non-traumatic causes. In children, coronary pathology is rarely the cause of an emergency unlike in adults where it is the main cause. Radiology, including chest radiography and computed tomography in conjunction with echocardiography, often plays the most important role in the acute management of these patients. Magnetic resonance imaging can occasionally be useful and may be suitable in more subacute cases. Radiologists' knowledge of how to manage and interpret these acute conditions including knowing which imaging technique to use is fundamental to appropriate care. In this review, we will concentrate on the most common cardiovascular emergencies in the thoracic region, including thoracic traumatic and non-traumatic emergencies and pulmonary vascular emergencies, as well as acute clinical disorders as a consequence of primary and postoperative congenital heart disease. This review will cover situations where cardiovascular imaging may be acutely needed, and not strictly emergencies only. Imaging recommendations will be discussed according to the different clinical presentations and underlying pathology.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Behandlingsvägen 7, 416 50, Gothenburg, Sweden.
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | | | - Claudia Martinez-Rios
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Christopher Z Lam
- Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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Hassan A, Maki R, Aljawad M, Alzayer A, Habeeb A, Alzaher A, Alawami A, Alaithan F, Adnan J. Beyond pulmonary embolism: Alternative diagnosis and incidental findings on CT pulmonary angiography in sickle cell disease. Emerg Radiol 2024; 31:321-330. [PMID: 38619803 DOI: 10.1007/s10140-024-02229-x] [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] [Received: 03/06/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Sickle cell disease (SCD) is a genetic hematological disorder associated with severe complications, such as vaso-occlusive crises, acute chest syndrome (ACS), and an increased risk of thromboembolic events, including pulmonary embolism (PE). The diagnosis of PE in SCD patients presents challenges due to the overlapping symptoms with other pulmonary conditions. Our previous study revealed that nearly 96% of computed tomography pulmonary angiography (CTPA) scans in SCD patients were negative for PE, highlighting a gap in understanding the significance of CTPA findings when PE is absent. METHODS In this retrospective follow-up study conducted at the Salmaniya Medical Complex in Bahrain, we examined SCD patients with HbSS genotypes who underwent CTPA from January 1, 2018, to December 31, 2021, for suspected PE, but the results were negative. The aim of this study was to identify alternative diagnoses and incidental findings from CTPA scans. Experienced radiologists reviewed the CTPA images and reports to assess potential alternative diagnoses and incidental findings, incorporating an additional analysis of chest X-rays to evaluate the diagnostic value of CTPA. Incidental findings were classified based on their location and clinical significance. RESULTS Among the 230 evaluated SCD patients (average age 39.7 years; 53% male) who were CTPA negative for PE, 142 (61.7%) had identifiable alternative diagnoses, primarily pneumonia (49.1%). Notably, 88.0% of these alternative diagnoses had been previously suggested by chest radiographs. Furthermore, incidental findings were noted in 164 (71.3%) patients, with 11.0% deemed clinically significant, necessitating immediate action, and 87.8% considered potentially significant, requiring further assessment. Notable incidental findings included thoracic abnormalities such as cardiomegaly (12.2%) and an enlarged pulmonary artery (11.3%), as well as upper abdominal pathologies such as hepatomegaly (19.6%), splenomegaly (20.9%), and gallstones (10.4%). CONCLUSION This study underscores the limited additional diagnostic yield of CTPA for identifying alternative diagnoses to PE in SCD patients, with the majority of diagnoses, such as pneumonia, already suggested by chest radiographs. The frequent incidental findings, most of which necessitate further evaluation, highlight the need for a cautious and tailored approach to using CTPA in the SCD population.
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Affiliation(s)
- Ali Hassan
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain.
| | - Reem Maki
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain
| | - Mahdi Aljawad
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Ali Alzayer
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Ali Habeeb
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Aqeel Alzaher
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Adnan Alawami
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Fatimah Alaithan
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Jalila Adnan
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain
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Hersi K, Ramani GV, Law JY, Sadek AS, Vaidya A, Gladwin MT, Cassady SJ. Diagnosis and management of chronic thromboembolic pulmonary hypertension (CTEPH) in sickle cell disease: A review. Pulm Circ 2024; 14:e12362. [PMID: 38803827 PMCID: PMC11128985 DOI: 10.1002/pul2.12362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 05/29/2024] Open
Abstract
Pulmonary hypertension in sickle cell disease (SCD) is a complex phenomenon resulting from multiple overlapping etiologies, including pulmonary vasoconstriction in the setting of chronic hemolytic anemia, diastolic dysfunction, and chronic thromboembolic disease. The presence of pulmonary hypertension of any cause in SCD confers a significant increase in mortality risk. Evidence to guide the management of patients with sickle cell disease and chronic thromboembolic pulmonary hypertension (CTEPH) is scant and largely the realm of case reports and small case series. Centered on a discussion of a complex young patient with hemoglobin hemoglobin SC who ultimately underwent treatment with pulmonary thromboendarterectomy, we review the available literature to guide management and discuss and overview of treatment of CTEPH in SCD, considering the unique considerations and challenges facing patients suffering from this multisystem disease.
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Affiliation(s)
- Kadija Hersi
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- National Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMarylandUSA
| | - Gautam V. Ramani
- Division of Cardiology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Jennie Y. Law
- Division of Hematology and Oncology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Ahmed S. Sadek
- Division of Cardiology, Department of MedicineLewis Katz School of Medicine at TemplePhiladelphiaPennsylvaniaUSA
| | - Anjali Vaidya
- Division of Cardiology, Department of MedicineLewis Katz School of Medicine at TemplePhiladelphiaPennsylvaniaUSA
| | - Mark T. Gladwin
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Steven J. Cassady
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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4
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Abramson Z, Rabe D, Persaud Y. Pulmonary Microvascular Occlusion in Sickle Cell Disease. J Pediatr Hematol Oncol 2024; 46:e212-e213. [PMID: 38408090 PMCID: PMC10956660 DOI: 10.1097/mph.0000000000002834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/25/2024] [Indexed: 02/28/2024]
Affiliation(s)
| | - Dawn Rabe
- Hematology, St. Jude Children’s Research Hospital, Memphis, TN
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Chamberlin JH, Ogbonna A, Abrol S, Maisuria D, Miller E, McGuire A, Knight H, O'Doherty J, Baruah D, Schoepf UJ, Munden RF, Kabakus IM. Enhancing diagnostic precision for acute chest syndrome in sickle cell disease: insights from dual-energy CT lung perfusion mapping. Emerg Radiol 2024; 31:73-82. [PMID: 38224366 DOI: 10.1007/s10140-024-02200-w] [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] [Received: 12/09/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Abstract
PURPOSE Acute chest syndrome (ACS) is secondary to occlusion of the pulmonary vasculature and a potentially life-threatening complication of sickle cell disease (SCD). Dual-energy CT (DECT) iodine perfusion map reconstructions can provide a method to visualize and quantify the extent of pulmonary microthrombi. METHODS A total of 102 patients with sickle cell disease who underwent DECT CTPA with perfusion were retrospectively identified. The presence or absence of airspace opacities, segmental perfusion defects, and acute or chronic pulmonary emboli was noted. The number of segmental perfusion defects between patients with and without acute chest syndrome was compared. Sub-analyses were performed to investigate robustness. RESULTS Of the 102 patients, 68 were clinically determined to not have ACS and 34 were determined to have ACS by clinical criteria. Of the patients with ACS, 82.4% were found to have perfusion defects with a median of 2 perfusion defects per patient. The presence of any or new perfusion defects was significantly associated with the diagnosis of ACS (P = 0.005 and < 0.001, respectively). Excluding patients with pulmonary embolism, 79% of patients with ACS had old or new perfusion defects, and the specificity for new perfusion defects was 87%, higher than consolidation/ground glass opacities (80%). CONCLUSION DECT iodine map has the capability to depict microthrombi as perfusion defects. The presence of segmental perfusion defects on dual-energy CT maps was found to be associated with ACS with potential for improved specificity and reclassification.
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Affiliation(s)
- Jordan H Chamberlin
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Alexis Ogbonna
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Sameer Abrol
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Dhruw Maisuria
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Emily Miller
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Aaron McGuire
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Heather Knight
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Jim O'Doherty
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
- Siemens Medical Solutions, Malvern, PA, USA
| | - Dhiraj Baruah
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - U Joseph Schoepf
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Reginald F Munden
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA
| | - Ismail M Kabakus
- Department of Radiology and Radiologic Science, Medical University of South Carolina, 25 Courtenay Dr, Charleston, SC, USA.
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Hamzaoui A, Louhaichi S, Hamdi B. [Lung manifestations of sickle-cell disease]. Rev Mal Respir 2023:S0761-8425(23)00107-9. [PMID: 37059617 DOI: 10.1016/j.rmr.2023.03.002] [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: 07/23/2022] [Accepted: 03/04/2023] [Indexed: 04/16/2023]
Abstract
Sickle-cell disease is an autosomal recessive genetic disorder of hemoglobin that causes systemic damage. Hypoxia is the main actor of sickle-cell disease. It initiates acutely the pathogenic cascade leading to tissue damages that in turn induce chronic hypoxia. Lung lesions represent the major risk of morbidity and mortality. Management of sickle-cell disease requires a tight collaboration between hematologists, intensivists and chest physicians. Recurrent episodes of thrombosis and hemolysis characterize the disease. New therapeutic protocols, associating hydroxyurea, transfusion program and stem cell transplantation in severe cases allow a prolonged survival until the fifth decade. However, recurrent pain, crisis, frequent hospital admissions due to infection, anemia or acute chest syndrome and chronic complications leading to organ deficiencies degrade the patients' quality of life. In low-income countries where the majority of sickle-cell patients are living, the disease is still associated with a high mortality in childhood. This paper focuses on acute chest syndrome and chronic lung manifestations.
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Affiliation(s)
- A Hamzaoui
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie.
| | - S Louhaichi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
| | - B Hamdi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
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Hassan A, Taleb M, Hasan W, Shehab F, Maki R, Alhamar N. Positive rate and quality assessment of CT pulmonary angiography in sickle cell disease: a case‒control study. Emerg Radiol 2023; 30:209-216. [PMID: 36947347 PMCID: PMC10031195 DOI: 10.1007/s10140-023-02126-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Pulmonary complications are common in sickle cell disease (SCD) and can mimic pulmonary embolisms (PEs), leading to potential overuse of computed tomography pulmonary angiography (CTPA). Maximizing the quality of CTPA is essential for its diagnostic accuracy. However, little is known about the positive rate and quality of CTPA in SCD. METHODS This retrospective case‒control study aimed to determine the positive rate and quality of CTPA studies performed to rule out PE in SCD (HbSS genotype) patients compared to a control group. Logistic regression analysis was used to identify independent factors associated with suboptimal CTPA studies, defined as a mean enhancement of < 210 HU in the pulmonary artery. RESULTS The study included 480 patients, consisting of 240 SCD patients and 240 controls. The positive rate of PE was 4.0%, with a similar rate in both SCD patients and the control group (4.2% vs. 3.8%, p = 0.08). However, SCD patients had significantly lower contrast enhancement of the pulmonary artery than the control group (266.1 ± 90.5 HU vs. 342.2 ± 116.1 HU, p < 0.01). Notably, 25.4% of SCD patients had suboptimal scans. The logistic regression model demonstrated that SCD was significantly associated with suboptimal pulmonary arterial contrast enhancement compared to the control group (OR = 4.4; 95% CI: 2.4-8.3). CONCLUSIONS This study revealed a relatively low positive rate of CTPA in both SCD patients and the control group. However, SCD was significantly associated with suboptimal image quality due to inadequate contrast enhancement of the pulmonary artery. Further research is needed to identify measures that can enhance the quality of CTPA studies in SCD patients and to establish a specific imaging protocol for this patient population.
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Affiliation(s)
- Ali Hassan
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain.
| | - Mohammed Taleb
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Wafa Hasan
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatema Shehab
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Reem Maki
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Nawal Alhamar
- Department of Radiology, Salmaniya Medical Complex, Manama, Bahrain
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El-Amin N, Lauzon SD, Nietert PJ, Kanter J. Which adults with sickle cell disease need an evaluation for pulmonary embolism? Br J Haematol 2021; 195:447-455. [PMID: 34472094 DOI: 10.1111/bjh.17552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 02/02/2023]
Abstract
Individuals living with sickle cell disease (SCD) are at an increased risk of venous thrombo-embolism (VTE) including pulmonary embolisms (PEs). There is a high mortality associated with PE in individuals with SCD. It can be difficult to diagnose PE since presenting symptoms of PE often mimic those of other forms of vaso-occlusive crisis in SCD. Currently, there are no validated models for predicting PEs in patients with sickle cell disease, which often leads to frequent CT scans and exposure to harmful radiation and intravenous contrast. The aim of this study was to evaluate different host variables and potential clinical biomarkers of patients with SCD including those used in the Wells score to assess predictability for PE in order to create a more accurate diagnostic algorithm to predict PE. A retrospective chart review was performed on 349 patients with SCD who underwent testing for a PE with a CT scan of the chest. Forward and backward stepwise model selection was performed to obtain a parsimonious model of the predictors of PEs. The incidence of PE in this population was 9·7%. Of the factors evaluated for this study, the Wells score was the only one with clinical significance. A Wells score greater than 4 had a sensitivity and specificity of 72·5% and 70·1%, respectively, and a score greater than 6 had a sensitivity and specificity of 50% and 87%, respectively. The Wells score is an acceptable clinical tool which may prove useful in individuals with SCD to predict who is most likely to have a PE and therefore should undergo a CT scan. A prospective study is needed to further confirm these findings.
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Affiliation(s)
- Nadirah El-Amin
- Division of Pediatric Hematology-Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Julie Kanter
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
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Kinger NP, Moreno CC, Miller FH, Mittal PK. Abdominal Manifestations of Sickle Cell Disease. Curr Probl Diagn Radiol 2020; 50:241-251. [PMID: 32564896 DOI: 10.1067/j.cpradiol.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/24/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022]
Abstract
Sickle cell disease is a debilitating hematologic process that affects the entire body. Disease manifestations in the abdomen most commonly result from vaso-occlusion, hemolysis, or infection due to functional asplenia. Organ specific manifestations include those involving the liver (eg, hepatopathy, iron deposition), gallbladder (eg, stone formation), spleen (eg, infarction, abscess formation, sequestration), kidneys (eg, papillary necrosis, infarction), pancreas (eg, pancreatitis), gastrointestinal tract (eg, infarction), reproductive organs (eg, priapism, testicular atrophy), bone (eg, marrow changes, avascular necrosis), vasculature (eg, vasculopathy), and lung bases (eg, acute chest syndrome, infarction). Imaging provides an important clinical tool for evaluation of acute and chronic disease manifestations and complications. In summary, there are multifold abdominal manifestations of sickle cell disease. Recognition of these sequela helps guide management and improves outcomes. The purpose of this article is to review abdominal manifestations of sickle cell disease and discuss common and rare complications of the disease within the abdomen.
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Affiliation(s)
- Nikhar P Kinger
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Frank H Miller
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Pardeep K Mittal
- Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA
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Incidence of Pulmonary Embolism in Sickle Cell Anemia Patients Undergoing Computed Tomography Pulmonary Angiography in the Emergency Department. J Thorac Imaging 2019; 34:W125-W126. [PMID: 30870307 DOI: 10.1097/rti.0000000000000409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mehari A, Igbineweka N, Allen D, Nichols J, Thein SL, Weir NA. Abnormal Ventilation-Perfusion Scan Is Associated with Pulmonary Hypertension in Sickle Cell Adults. J Nucl Med 2018; 60:86-92. [PMID: 29880507 DOI: 10.2967/jnumed.118.211466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/23/2018] [Indexed: 02/02/2023] Open
Abstract
Pulmonary hypertension (PH) in adults with sickle cell disease (SCD) is associated with early mortality. Chronic thromboembolic PH (CTEPH) is an important complication and contributor to PH in SCD but is likely underappreciated. Guidelines recommend ventilation-perfusion (V/Q) scintigraphy as the imaging modality of choice to exclude CTEPH. Data on V/Q scanning are limited in SCD. Our objective was to compare the performance of V/Q scanning with that of CT pulmonary angiography (CTPA) and to report clinical outcomes associated with abnormal V/Q findings. Methods: Laboratory data, echocardiography, 6-min-walk testing, V/Q scanning, CTPA, and right heart catheterization (RHC) were prospectively obtained. High-probability and intermediate-probability V/Q findings were considered to be abnormal. Included for analysis were 142 SCD adults (aged 40.1 ± 13.7 y, 83 women, 87% hemoglobin SS) in a stable state enrolled consecutively between March 13, 2002, and June 8, 2017. Results: V/Q results were abnormal in 65 of 142 patients (45.8%). CTPA was positive for pulmonary embolism in 16 of 60 (26.7%). RHC confirmed PH (mean pulmonary artery pressure ≥ 25 mmHg) in 46 of 64 (71.9%), of whom 34 (73.9%) had abnormal V/Q findings. Among those without PH by RHC (n = 18), 2 of 18 patients had abnormal V/Q findings. Thirty-three patients had a complete dataset (V/Q scanning, CTPA, and RHC); 29 of 33 had abnormal RHC findings, of whom 26 had abnormal V/Q findings, compared with 11 who had abnormal CTPA findings. There was greater concordance between V/Q findings and RHC (κ-value = 0.53; P < 0.001) than between CTPA and RHC (κ-value = 0.13; P = 0.065). The sensitivity and specificity for V/Q scanning was 89.7% and 75.0%, respectively, whereas CTPA had sensitivity of 37.3% and specificity of 100%. Abnormal V/Q finding swere associated with hemodynamic severity (mean pulmonary artery pressure, 35.2 ± 9.6 vs. 26.9 ± 10.5 mm Hg, P = 0.002; transpulmonary gradient, 21.5 ± 9.7 vs. 12.16 ± 11 mmHg, P = 0.005; and pulmonary vascular resistance, 226.5 ± 135 vs. 140.7 ± 123.7 dynes⋅s⋅cm-5, P = 0.013) and exercise capacity (6-min-walk distance, 382.8 ± 122.3 vs. 442.3 ± 110.6 m, P < 0.010). Thirty-four deaths were observed over 15 y. All-cause mortality was higher in the abnormal-V/Q group (21 [61.8%]) than in the normal-V/Q group (13 [38.2%]) (log-rank test, P = 0.006; hazard ratio, 2.54). Conclusion: V/Q scanning is superior to CTPA in detecting thrombotic events in SCD. Abnormal V/Q findings are associated with PH, worse hemodynamics, lower functional capacity, and higher mortality. Despite high sensitivity in detecting CTEPH, V/Q scanning is underutilized. We recommend the use of V/Q scanning in the evaluation of dyspnea in adult SCD patients given the important implications toward management.
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Affiliation(s)
- Alem Mehari
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland .,Division of Pulmonary Diseases, Howard University College of Medicine, Washington, District of Columbia; and
| | - Norris Igbineweka
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Darlene Allen
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Jim Nichols
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Nargues A Weir
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Inova Advanced Lung Disease Program, Falls Church, Virginia
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