Figure 25b. In the hope of catching this elusive diagnosis, many physicians have turned to computed tomography (CT). 55, No. Tumor embolus in a 78-year-old woman with dyspnea and endometrial stromal sarcoma that invaded the inferior vena cava. Acute pulmonary embolism in a 66-year-old man who presented with chest pain and dyspnea. Contiguous images demonstrated the true nature of this finding. Figure 25a. CT scan shows an acute pulmonary embolus that causes a partial filling defect surrounded by contrast material (railway track sign) (arrow). We use pulmonary embolism–specific settings with a window width and level of 700 and 100 HU, respectively (,,,,Fig 25c). allergy) and time constraints. The artery is enlarged compared with adjacent patent vessels. Viewer. 3, Canadian Association of Radiologists Journal, Vol. Studies show that the diagnostic yield of CTPA for pulmonary embolism varies between 6.7 % and 31 % [ 9, 10, 11, 12, 13, 14 ]. If findings in the pulmonary arteries are indeterminate and the lungs are clear, ventilation-perfusion scintigraphy may be performed. 5, Clinics in Chest Medicine, Vol. 3, Journal of Medical Imaging and Radiation Oncology, Vol. (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. In addition, a centrally located, hyperattenuating filling defect is occasionally identified at unenhanced CT, a finding that indicates acute central pulmonary embolism (,,, Fig 10) (, 22). Figure 30a. For those with one or more items on the modified YEARS protocol, pulmonary embolism can be excluded if the D-dimer test shows a level less than 500 ng/mL. CT scan demonstrates pulmonary artery stump in situ thrombosis that affects the right pulmonary artery (arrow). )Download as PowerPointOpen in Image Criteria to be used for Chest CTA or a CT is requested for Pulmonary Emboli which cannot be approved based on Interqual or Milliman criteria. Figure 25 illustrates the effect of different window settings on detection of pulmonary embolism. 6, American Journal of Roentgenology, Vol. CT scan shows mucus plugs (arrows), which can mimic acute pulmonary embolism. Chronic pulmonary embolism in a 62-year-old man with dyspnea. (a) CT scan shows a pulmonary embolus that affects the segmental artery of the laterobasal segment of the right lower lobe. Left-sided heart failure in a 56-year-old woman with dyspnea. 12, Clinical Pulmonary Medicine, Vol. Partial volume artifact in a 52-year-old woman with dyspnea. As CT scanners become faster, delaying initial image acquisition until approximately 5 seconds after inspiration should allow the transient interruption in contrast material to pass through the pulmonary circulation (,27). Arrows indicate collateral bronchial arteries.Download as PowerPointOpen in Image Additionally, a CT scan is ordered if the D-dimer level is ≥ 500 ng/mL in those with one or more YEARS risk items. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. 4, American Journal of Veterinary Research, Vol. Contrasted CT-angiography of the chest, often called a "PE protocol CT," has dramatically improved the diagnosis of pulmonary embolism. CT scan shows an eccentrically located thrombus that forms obtuse angles with the vessel wall (arrows). This partial filling defect surrounded by contrast material produces the polo mint sign (arrow). 64, No. 44, No. CT scan shows pulmonary arterial wall calcification (arrows), a secondary sign of chronic pulmonary embolism.Download as PowerPointOpen in Image 65, No. Chest wall abnormalities such as rib fractures and metastatic deposits may also mimic pulmonary embolism. Factors that cause misdiagnosis of pulmonary embolism may be patient related, technical, anatomic, or pathologic. Graph illustrates that the number of ventilation-perfusion scans performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .0003). Figure 10b. Unable to process the form. MATERIALS AND METHODS: A multi-detector row spiral CT protocol for the diagnosis of pulmonary embolism was used that consisted of scanning the entire chest with 1-mm collimation within one breath hold. Pulmonary arterial hypertension secondary to chronic pulmonary embolism in the same patient as in ,Figure 12. Streak artifact in a 35-year-old woman with chest pain. 9, Current Problems in Diagnostic Radiology, Vol. CT scan shows tumor emboli with a tree-in-bud appearance within secondary pulmonary lobule arterioles (arrow). It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line. Figure 35d. (c) CT scan (window width = 700 HU, window level = 100 HU) demonstrates thrombus within the right interlobar artery and the medial segment of the middle lobe artery. The window width is equal to the mean attenuation of the main pulmonary artery plus two standard deviations, and the window level equals one-half of this value (,29). No embolism was present.Download as PowerPointOpen in Image ). (b) CT scan shows acute emboli that affect subsegmental arteries of the laterobasal segment (arrows). Figure 24a. Unlike acute pulmonary embolism, both pulmonary artery sarcoma and chronic pulmonary embolism demonstrate enhancement (,Fig 37) (,28,,38,,39); however, pulmonary artery sarcoma is lobulated and forms acute angles with the vessel wall (,Fig 37), whereas chronic pulmonary embolism forms obtuse angles (,Fig 12). Viewer, Figure 1. The aim of this study was to analyze the dose reduction and image quality achieved by using 80 kV instead of 100 kV in CT pulmonary angiography protocols. 6, 29 June 2015 | Japanese Journal of Radiology, Vol. Brink et al (,29) suggested a window width equal to the measured mean attenuation of the enhanced main pulmonary artery plus two standard deviations and a window level equal to one-half of this value (,,,,Fig 25). Chronic pulmonary embolism in the same patient as in ,Figure 11. 2, Veterinary Clinics of North America: Small Animal Practice, Vol. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. Lung algorithm artifact in a 70-year-old woman with dyspnea. 4, 4 January 2014 | The International Journal of Cardiovascular Imaging, Vol. (a) CT scan shows poor enhancement of the interlobar and middle lobe pulmonary arteries due to flow-related artifact. 80, No. ), Figure 2. (a) Unenhanced CT scan demonstrates subtle regions of hyperattenuation (arrow). However, these radiologic features are not specific for pulmonary embolism. Viewer. CT scan reveals that the short axis of the right ventricle (dashed line) is wider than that of the left ventricle (solid line), a situation that was caused by acute pulmonary embolism and created right ventricular strain. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). Lung algorithm artifact in a 70-year-old woman with dyspnea. Tumor embolus in a 78-year-old woman with dyspnea and endometrial stromal sarcoma that invaded the inferior vena cava. When a rapid diagnosis of pulmonary embolism is essential for patients with chronic pulmonary hypertension possibly secondary to central embolism, particularly patients being considered for pulmonary thromboendarterectomy. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. More commonly, tumor emboli are small and occlude subsegmental arteries and arterioles, leading to progressive dyspnea and subacute pulmonary hypertension (,41). Figure 25c. In addition, viewing the bronchus on contiguous images will demonstrate the true nature of the artifact. (a) CT scan (lung window) shows composite images of vessels (seagull sign) (arrows). Chronic pulmonary embolism in a 60-year-old woman with dyspnea. However, these artifacts can be removed with a standard algorithm (,,,Fig 27) (,30). Small pulmonary emboli are noted in the left pulmonary artery. Viewer. 4, European Journal of Radiology, Vol. CT scans demonstrate normal hilar lymph nodes in both upper lobes (arrows in a), adjacent to the right and left interlobar arteries (arrows in b), in the middle lobe and lingula (arrows in c), and in both lower lobes (arrows in d). (c) CT scan (window width = 700 HU, window level = 100 HU) demonstrates thrombus within the right interlobar artery and the medial segment of the middle lobe artery. adequate enhancement of … Flow-related artifact in a 73-year-old woman with chest pain. A pulmonary artery catheter that is being used for invasive hemodynamic monitoring of critically ill patients can cause beam-hardening artifacts or may itself mimic pulmonary embolism (,,,Fig 22) (,26). CT scan shows the vascular bifurcation between the left lower lobe and lingular arteries as a curved line surrounded by contrast material (arrow). (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. Note also the medium-sized left pleural effusion and atelectasis. 4, 6 August 2014 | The International Journal of Cardiovascular Imaging, Vol. This partial filling defect surrounded by contrast material produces the polo mint sign (arrow). Small pulmonary emboli could be obscured by a large amount of image noise. Figure 10b. (a) On a CT scan, a pulmonary artery catheter causes adjacent beam-hardening artifacts within the main and right pulmonary arteries that mimic pulmonary embolism (arrows). Accompanying CT findings in heart failure include diffuse ground-glass attenuation, interlobular septal thickening and diffuse peribronchovascular interstitial thickening, and bilateral pleural effusions (,,,Fig 34). (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). The normal-appearing contrast material–filled accompanying pulmonary artery should provide a clue regarding this artifact. Acute central pulmonary embolism in an asymptomatic 87-year-old woman. Collateral bronchial artery dilatation is also noted (arrowhead). (b) Repeat CT pulmonary angiogram demonstrates segmental pulmonary emboli within the medial and lateral segmental branches of the middle lobe artery (arrows).Download as PowerPointOpen in Image Chronic pulmonary embolism in the same patient as in ,Figure 11. The apparent pulmonary embolism is ill defined. Viewer. 3, 17 October 2012 | BMC Medical Imaging, Vol. (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. 5, Journal of Thoracic Imaging, Vol. (a) On a 3.75-mm-thick CT scan, partial volume averaging of vessel and lung creates an artifact that mimics pulmonary embolism within the anterior segment of the left upper lobe pulmonary artery (arrow). Viewer. 205, No. Acute pulmonary embolism in a 58-year-old woman who presented with chest pain and dyspnea. 127, No. These findings indicate the true nature of the patient’s condition. 245, No. Partial filling defects due to acute pulmonary embolism are often centrally located, but when eccentrically located they form acute angles with the vessel wall. 3, Journal of the Korean Society of Radiology, Vol. Generally, arteries course adjacent to the corresponding bronchi, with the exception of the apical-posterior segment of the left upper lobe and the lingular arteries, which may course independently for a short distance before rejoining the bronchi (,34). Figure 30b. The total cavopulmonary connection (TCPC), or Fontan procedure, diverts systemic venous blood directly into the pulmonary arteries and is the palliative surgery of choice for patients with a wide variety of congenital heart diseases with single-ventricle physiologic characteristics. Viewer. 14, No. Viewer. Figure 24a. Figure 14. Figure 29. 33, No. Viewer. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image 47, No. Images of the iliac, femoral, and popliteal veins are obtained 4 minutes after the onset of enhancement from the initial contrast material injection. 6, American Journal of Roentgenology, Vol. (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. (b) CT scan (mediastinal window) demonstrates a low-attenuation abnormality caused by partial volume averaging of vessel and adjacent lung (arrow), a finding that can simulate pulmonary embolism. (b, c) CT scans obtained immediately superior (b) and inferior (c) to a demonstrate an apparent ill-defined filling defect (arrow) that is too high in attenuation to represent pulmonary embolism. Figure 22a. The window width is equal to the mean attenuation of the main pulmonary artery plus two standard deviations, and the window level equals one-half of this value (,29). (b) CT scan shows acute emboli that affect subsegmental arteries of the laterobasal segment (arrows).Download as PowerPointOpen in Image Viewer. This artifact can be recognized by its nonanatomic nature and is easily distinguished from pulmonary embolism. CT scan demonstrates pulmonary artery stump in situ thrombosis that affects the right pulmonary artery (arrow).Download as PowerPointOpen in Image All three factors are present in patients who have undergone resection for lung cancer. 04, The American Journal of Cardiology, Vol. Mimics of Acute Pulmonary Embolism on CT, The Additional Value of Esophageal Wall Evaluation and Secondary Findings in Emergency Patients Undergoing CT Pulmonary Angiography, Virtual Monoenergetic Imaging and Iodine Perfusion Maps Improve Diagnostic Accuracy of Dual-Energy Computed Tomography Pulmonary Angiography With Suboptimal Contrast Attenuation, Pulmonary vasculature in dogs assessed by three-dimensional fractal analysis and chemometrics, An intimal sarcoma of pulmonary artery mimicking pulmonary embolism: a case report and literature review, MDCT Assessment of Pulmonary Arterial Hypertension, Computed Tomography Angiographic Assessment of Acute Chest Pain, Clot or not? 3, Clinics in Chest Medicine, Vol. Tumor emboli in a 60-year-old man with dyspnea and primary renal cell carcinoma. Note also the medium-sized left pleural effusion and atelectasis. (b) CT scan obtained with the standard algorithm does not demonstrate this artifact. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries. Chronic pulmonary embolism in a 56-year-old man with dyspnea. (b, c) CT scans obtained immediately superior (b) and inferior (c) to a demonstrate an apparent ill-defined filling defect (arrow) that is too high in attenuation to represent pulmonary embolism. Acute pulmonary embolism in a 45-year-old woman who presented with chest pain. (c) CT scan (window width = 700 HU, window level = 100 HU) demonstrates thrombus within the right interlobar artery and the medial segment of the middle lobe artery. 5, 1 January 2015 | Polish Journal of Radiology, Vol. 4, 28 May 2018 | Radiologia Brasileira, Vol. The lung algorithm is a high-spatial-frequency reconstruction convolution kernel used to improve the quality of images of the pulmonary vessels, bronchi, and interstitium. + Beam-hardening artifact in a 63-year-old man with respiratory failure. Seminars in Ultrasound, Vol for confirming the diagnosis is often missed to clinical probability rapid. To computed tomography ( CT ) arrow ) present in patients with pulmonary hypertension: could this replace. Vessels that are smaller than adjacent patent vessels been firmly ct pulmonary embolism protocol as the reference for... Techniques are shown in the same outcome, i.e rarely have such an appearance at CT.Download as in... 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