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Suspected Pulmonary Embolism: Enhancement of Pulmonary Arteries at Deep-Inspiration CT Angiography—Influence of Patent Foramen Ovale and Atrial-Septal Defect¹

¹ From the Department of Radiology, University of Vienna and Ludwig Boltzmann Institute for Clinical and Experimental Radiology, Vienna, Austria (C.B.H., S.G., K.F.L., M.M.T., C.C., C.J.H.); and Department of Radiology, Otto Wagner Hospital, Vienna, Austria (G.H.M.). From the 2000 RSNA scientific assembly. Received January 25, 2002; revision requested March 30; revision received June 17; accepted July 25. Address correspondence to C.B.H., Department of Radiology, University of California San Francisco, 505 Parnassus Ave L308, San Francisco, CA 94143-0628 (e-mail: christine.henk@univie.ac.at).

PURPOSE: To investigate if abnormal early contrast enhancement of the aorta and decreased attenuation of pulmonary arteries at deep-inspiration spiral computed tomographic (CT) angiography might be caused by a patent foramen ovale (PFO).

MATERIALS AND METHODS: Two hundred forty-four spiral CT angiographic images of the pulmonary arteries obtained during deep inspiration in patients suspected of having pulmonary embolism (PE) were reviewed for evidence of abnormal early enhancement of the aorta. In 45 patients, enhancement of the ascending aorta was equal to or more than that of the pulmonary arteries. Nonenhanced or contrast material–enhanced echocardiography was performed in 39 of these cases. All CT images with abnormal enhancement patterns were graded for contrast quality with respect to sufficient enhancement of pulmonary arteries (four grades) at three anatomic levels: right and left main and lobar and segmental branches. In addition, all spiral CT angiographic images were evaluated concerning the diagnosis of PE and the grouping of central (main pulmonary artery to proximal lobar arteries) and peripheral (beyond proximal lobar branches) locations of emboli. Mean attenuation values of ascending aortas and main pulmonary arteries in group 1 (n = 244) were compared with those in groups 2 and 3 (n = 45) by means of the two-tailed Student t test for unpaired data (P < .05).

RESULTS: Attenuation values for ascending aortas in group 1 were significantly lower than those in groups 2 and 3 (P < .001). Attenuation values in main pulmonary arteries were significantly higher in group 1 than in groups 2 and 3 (P < .001). Echocardiographic images showed an intracardiac right-to-left shunt in all 39 cases with abnormal contrast dynamics in the CT study (16% of the whole study population). Three patients had an atrial-septal defect, and 36 had a PFO. Images with a shunt had good (9%), intermediate (37%), fair (33%), and poor (23%) contrast of the pulmonary arteries. Sufficient vessel contrast for the diagnosis of PE could not be achieved in 27 of 45 patients with a shunt, but severe central PE could be ruled out. PE could be diagnosed in 31% of the 244 images, 58% were negative, and 11% were indeterminate.

CONCLUSION: A PFO may frequently lead to insufficient attenuation of the pulmonary arteries, which potentially limits the diagnosis of PE if the examination is performed during deep inspiration.

© RSNA, 2003

Index terms: Atrial septal defect, 514.141 • Computed tomography (CT), helical, 60.12115, 60.12116 • Embolism, pulmonary, 60.72 • Foramen ovale

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