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CT Angiography for Diagnosis of Pulmonary Embolism: State of the Art¹

¹ From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115. Received November 14, 2002; revision requested January 8, 2003; revision received January 22; accepted March 4. Address correspondence to U.J.S. (e-mail: schoepf@bwh.harvard.edu).

View larger version (193K): [in a new window]   Figure 1a. Extensive acute central PE with "saddle embolus" extending into both central pulmonary arteries in a 72-year-old man. Contrast material-enhanced 16-detector row CT yielded coronal volume renderings in (a) anterocranial and (b) anterior perspectives, which allow intuitive visualization of the location and extent of embolus (arrows).

View larger version (181K): [in a new window]   Figure 1b. Extensive acute central PE with "saddle embolus" extending into both central pulmonary arteries in a 72-year-old man. Contrast material-enhanced 16-detector row CT yielded coronal volume renderings in (a) anterocranial and (b) anterior perspectives, which allow intuitive visualization of the location and extent of embolus (arrows).

View larger version (90K): [in a new window]   Figure 2a. Normal pulmonary vessels in a 56-year-old man who presented with mild chest pain after a long-distance flight. A contrast-enhanced 16-detector row CT examination covers the entire chest within 10 seconds, allowing analysis of even the most peripheral pulmonary vessels with exquisite detail. Coronal reconstruction using (a) maximum intensity projection and (b) volume-rendering techniques. The entire scanned volume is shown in Movie 1 (radiology.rsnajnls.org/cgi/content/full/2302021489/DC1).

View larger version (176K): [in a new window]   Figure 2b. Normal pulmonary vessels in a 56-year-old man who presented with mild chest pain after a long-distance flight. A contrast-enhanced 16-detector row CT examination covers the entire chest within 10 seconds, allowing analysis of even the most peripheral pulmonary vessels with exquisite detail. Coronal reconstruction using (a) maximum intensity projection and (b) volume-rendering techniques. The entire scanned volume is shown in Movie 1 (radiology.rsnajnls.org/cgi/content/full/2302021489/DC1).

View larger version (51K): [in a new window]   Figure 3a. Contrast-enhanced pulmonary CT angiography in a 43-year-old woman suspected of having acute PE. Lymphatic tissue (arrows) in mediastinum and pulmonary hilum may be misinterpreted as embolic filling defects in central pulmonary vessels by less experienced observers if (a) transverse sections alone are used for diagnosis, while (b) coronal multiplanar reformations from four-detector row CT allow better differentiation of lymphatic tissue and vessels and may reduce sources of diagnostic error.

View larger version (74K): [in a new window]   Figure 3b. Contrast-enhanced pulmonary CT angiography in a 43-year-old woman suspected of having acute PE. Lymphatic tissue (arrows) in mediastinum and pulmonary hilum may be misinterpreted as embolic filling defects in central pulmonary vessels by less experienced observers if (a) transverse sections alone are used for diagnosis, while (b) coronal multiplanar reformations from four-detector row CT allow better differentiation of lymphatic tissue and vessels and may reduce sources of diagnostic error.

View larger version (79K): [in a new window]   Figure 4. Contrast-enhanced thin-section pulmonary CT angiography in a 52-year-old man after right lung transplantation. Transverse 1-mm-thick sections show isolated pulmonary emboli (arrows) in segmental and subsegmental arteries in the right middle lobe of the lung and allow detailed visualization of course of obliquely oriented vessels and of isolated filling defects in segmental and subsegmental branches.

View larger version (109K): [in a new window]   Figure 5a. (a) Transverse contrast-enhanced 16-detector row CT image obtained with 0.75-mm collimation in a 62-year-old man with chest pain. Isolated peripheral pulmonary embolus (arrow) in sixth-order pulmonary arterial branch in segment 8 of the right lung is shown. (b) Lung window display of more caudal transverse section from same study shows subsequent pulmonary infarct (arrow) in the corresponding vascular territory in the right lower lobe. (c) Coronal volume-rendered display (anterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (85K): [in a new window]   Figure 5b. (a) Transverse contrast-enhanced 16-detector row CT image obtained with 0.75-mm collimation in a 62-year-old man with chest pain. Isolated peripheral pulmonary embolus (arrow) in sixth-order pulmonary arterial branch in segment 8 of the right lung is shown. (b) Lung window display of more caudal transverse section from same study shows subsequent pulmonary infarct (arrow) in the corresponding vascular territory in the right lower lobe. (c) Coronal volume-rendered display (anterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (131K): [in a new window]   Figure 5c. (a) Transverse contrast-enhanced 16-detector row CT image obtained with 0.75-mm collimation in a 62-year-old man with chest pain. Isolated peripheral pulmonary embolus (arrow) in sixth-order pulmonary arterial branch in segment 8 of the right lung is shown. (b) Lung window display of more caudal transverse section from same study shows subsequent pulmonary infarct (arrow) in the corresponding vascular territory in the right lower lobe. (c) Coronal volume-rendered display (anterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (49K): [in a new window]   Figure 6a. Contrast-enhanced 16-detector row CT study obtained with 0.75-mm collimation in a 57-year-old man with mild pleuritic chest pain. (a) Consecutive transverse sections show isolated peripheral pulmonary embolus (arrows) in a subsegmental pulmonary artery in segment 9 of the left lung. (b) Oblique sagittal multiplanar reformation also shows embolus (arrow). (c) Coronal volume-rendered display (posterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (157K): [in a new window]   Figure 6b. Contrast-enhanced 16-detector row CT study obtained with 0.75-mm collimation in a 57-year-old man with mild pleuritic chest pain. (a) Consecutive transverse sections show isolated peripheral pulmonary embolus (arrows) in a subsegmental pulmonary artery in segment 9 of the left lung. (b) Oblique sagittal multiplanar reformation also shows embolus (arrow). (c) Coronal volume-rendered display (posterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (196K): [in a new window]   Figure 6c. Contrast-enhanced 16-detector row CT study obtained with 0.75-mm collimation in a 57-year-old man with mild pleuritic chest pain. (a) Consecutive transverse sections show isolated peripheral pulmonary embolus (arrows) in a subsegmental pulmonary artery in segment 9 of the left lung. (b) Oblique sagittal multiplanar reformation also shows embolus (arrow). (c) Coronal volume-rendered display (posterior view) shows isolated peripheral filling defect (arrow) in otherwise normal pulmonary vascular tree.

View larger version (184K): [in a new window]   Figure 7a. Contrast-enhanced retrospective ECG-gated 16-detector row pulmonary CT angiography study in a 35-year-old man suspected of having PE. Sagittal volume-rendered images show paracardiac pulmonary vessels in left lower lung lobe. (a) During systole, severe stair-step artifacts (arrows) occur along the course of pulmonary vessels owing to transmitted cardiac motion. (b) During diastole, cardiac pulsation artifacts are substantially reduced, and almost motion-free depiction of paracardiac pulmonary vessels (arrows) can be achieved.

View larger version (192K): [in a new window]   Figure 7b. Contrast-enhanced retrospective ECG-gated 16-detector row pulmonary CT angiography study in a 35-year-old man suspected of having PE. Sagittal volume-rendered images show paracardiac pulmonary vessels in left lower lung lobe. (a) During systole, severe stair-step artifacts (arrows) occur along the course of pulmonary vessels owing to transmitted cardiac motion. (b) During diastole, cardiac pulsation artifacts are substantially reduced, and almost motion-free depiction of paracardiac pulmonary vessels (arrows) can be achieved.

View larger version (21K): [in a new window]   Figure 8. CT-based algorithm for imaging evaluation of patients clinically suspected of having PE. If diagnosis of DVT can be established in a patient suspected of having PE, the therapeutic regimen is usually predetermined and no further diagnostic work-up of pulmonary circulation is pursued. If no diagnosis of DVT can be established, CT angiography (CTA) of pulmonary circulation is performed; if results are positive for PE, the patient is treated. If a good quality CT study does not reveal PE, work-up can usually stop at this point. In the unlikely case of persistent high clinical suspicion of PE despite a negative good-quality pulmonary CT angiogram, there is the theoretical option of pursuing definitive diagnosis by means of conventional pulmonary angiography to exhaust all diagnostic means available. In cases where a poor-quality CT study does not allow one to establish or rule out with confidence PE or other sources of the patient’s symptoms, repeat pulmonary CT angiography is usually attempted.