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Thoracic Imaging |
1 Department of Diagnostic Radiology, Pusan National University Hospital and College of Medicine, South Korea (K.I.K.)
2 Department of Radiology, Vancouver Hospital and Health Sciences Centre, University of British Columbia, 855 W 12th Ave, Vancouver, British Columbia, Canada V5Z 1M9 (N.L.M., J.R.M.).
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: One hundred ten patients clinically suspected of having PE were examined with contrast-enhanced spiral CT and at least one other imaging modality: ventilation-perfusion scintigraphy, Doppler ultrasonography of deep leg veins, or pulmonary angiography. Chart review or telephone contact with the referring clinician was used to evaluate the contribution of spiral CT to the final clinical diagnosis.
RESULTS: Spiral CT helped correctly identify 23 of 25 patients with PE (sensitivity, 92%). In 57 (67%) of the 85 patients without PE, spiral CT provided additional information that suggested or confirmed the alternate clinical diagnosis: pneumonia (n = 14), cardiovascular disease (n = 10), pulmonary fibrosis (n = 7), trauma (n = 6), malignancy (n = 5), pleural disease (n = 4), postoperative changes (n = 4), and other (n = 7). In the remaining 28 patients, spiral CT scans were normal (n = 12), failed to produce findings supportive of the final clinical diagnosis (n = 13), or were false-positive for PE (n = 3; specificity, 96%).
CONCLUSION: Spiral CT has good sensitivity and specificity for the diagnosis of PE. In the majority of patients who do not have PE, it also provides important ancillary information for the final diagnosis.
Index terms: Computed tomography (CT), comparative studies, 60.11, 60.12112, 60.12115, 60.124, 60.12984 • Computed tomography (CT), helical, 60.12112, 60.12115 • Embolism, pulmonary, 60.72
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Several recent studies (4–9) have shown that contrast material–enhanced spiral CT has sensitivities and specificities of approximately 90% in the diagnosis of PE involving segmental or larger vessels. These levels of diagnostic accuracy, which surpass those of ventilation-perfusion (V-P) scintigraphy, have resulted in substantial clinical demand for this test in patients suspected of having PE (10).
In addition to screening for central and segmental PE, a spiral CT examination for PE also produces high-quality diagnostic images of the mediastinum, lung parenchyma, and chest wall. These images provide important additional diagnostic information, especially in the 70% of patients who are examined for PE but prove not to have emboli (9,11). The aim of this prospective study was to evaluate the utility of contrast-enhanced spiral CT in identifying other chest diseases within patients suspected of having acute PE.
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The trial was performed from June 1995 to May 1997. The location of the patients at the time of referral for the CT scanning for PE was recorded: 79 (72%) ward inpatients, four (4%) coronary care unit or intensive care unit patients, and 27 (25%) outpatients. The clinical features suggesting PE, imaging findings, final diagnosis, treatment, and the subsequent clinical course (3–27 months) were investigated by means of chart review or telephone contact with referring clinicians. All imaging studies were completed within 48 hours. Ethical approval was obtained from the local institutional review board.
Spiral CT scans were obtained in all 110 patients with use of a HiSpeed Advantage scanner (GE Medical Systems, Milwaukee, Wis). Contrast-enhanced CT evaluation of the central and segmental pulmonary arteries was performed from the level of the aortic arch to 2 cm below the inferior pulmonary veins. Scans were obtained in patients during suspended inspiration or during shallow breathing, depending on the patient's level of dyspnea. Scanning parameters included 3-mm collimation, a pitch of 1.8–2.0, 120 kVp, 320 mA, and 1-second scanning time. Images were reconstructed at 1.5-mm intervals by using the standard reconstruction algorithm and a field of view appropriate to the patient's size. A 180° linear interpolation algorithm was used for all spiral data sets.
A total volume of 180 mL of nonionic contrast material, either Optiray 320 (ioversol; Mallinckrodt, Pointe-Claire, Quebec, Canada) or Optiray 320 diluted by 50% with sterile normal saline solution, was injected with a power injector (Medrad MCT Plus; Medrad, Pittsburgh, Pa) through an 18–20-gauge catheter in the antecubital fossa, or, if available, through a central venous catheter at 3–5 mL/sec. The size and position of the catheter determined the flow rate used, with 4–5 mL/sec used for central catheters and 18-gauge peripheral catheters and 3 mL/sec used for 20-gauge peripheral catheters. There was no attempt to tailor the rate of contrast material injection to the patient's size. To eliminate kinking of the subclavian vein at the thoracic inlet, the arm in which contrast material was injected was placed at the patient's side, with the other arm above the patient's head. A timing bolus was not used, and imaging commenced 15–20 seconds after the initiation of contrast material injection.
Images were viewed at mediastinal (window width, 450 HU; window level, 35 HU), pulmonary vascular (window width, 250 HU; window level, 35 HU), and lung parenchymal (window width, 1,500 HU; window level, -700 HU) settings on a workstation. The presence of pulmonary embolism was noted, as was any other abnormality in the mediastinum, chest wall, or lung parenchyma. These findings were recorded prospectively by the subspecialty-trained chest radiologist on service that day (J.R.M., N.L.M.).
Other imaging tests for PE—which were V-P scintigraphy, Doppler ultrasonography (US) of the leg veins, and pulmonary angiography—were performed at the clinician's discretion. The V-P scintigrams were obtained by using standard techniques, and they were interpreted in conjunction with a chest radiograph by using the revised Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria (12). Both Doppler flow and compressibility of deep leg veins were evaluated in the US examination. Pulmonary angiograms were obtained in a digital angiography suite, with a minimum of two projections.
At the end of the diagnostic work-up, all available imaging and clinical information was evaluated by the referring clinician. The diagnosis of PE required two noninvasive imaging examinations with positive findings or a positive pulmonary angiogram. We assessed the effect of findings provided by the spiral CT examination on the final clinical diagnosis by means of chart review or telephone contact with the referring clinician.
The patients' hospital charts or the referring physicians' telephone comments were tabulated regarding the following parameters: (a) the signs and symptoms of PE leading to referral for spiral CT, (b) the spiral CT findings in the dictated final report, (c) the findings of all other imaging tests in the dictated reports, (d) the final decision regarding PE status and the therapy chosen, (e) the results of any other investigations pertinent to the final diagnosis (eg, needle aspiration biopsy, microbiologic culture, autopsy), and (f) the treatment and final outcome at 3–27 months follow-up.
Differences in parameters were assessed by using the 
2 test, with significance defined at the .05 level.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The major signs and symptoms that suggested the clinical diagnosis of PE included one or more of the following: nonspecific chest pain (n = 36), pleuritic chest pain (n = 34), dyspnea (n = 55), cough (n = 24), hypoxemia while breathing room air (n = 22), fever (n = 8), and hemoptysis (n = 4) (Table 1). There was no significant (all P > .05) association between any of these signs or symptoms and the subsequent detection of PE.
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Twelve of the 85 patients without PE had normal spiral CT scans of the chest. The 73 patients without PE and with abnormal spiral CT scans demonstrated one or more of the following findings: pleural effusion (n = 41), atelectasis (n = 26), air-space consolidation (n = 15), mediastinal or hilar lymphadenopathy (n = 8), pericardial effusion (n = 4), lung mass (n = 4), mediastinal mass (n = 2), multiple pulmonary nodules (n = 4), interstitial pulmonary fibrosis (n = 4), cardiomegaly (n = 4), enlarged central pulmonary vessels consistent with pulmonary arterial hypertension (n = 4), pleural enhancement in association with pleural effusion (n = 1), and emphysema (n = 1).
In 57 (67%) of the 85 patients who had negative findings of PE, spiral CT provided additional diagnostic information that suggested (n = 21) or supported (n = 36) the final clinical diagnosis. The final clinical diagnoses were pneumonia (n = 14) (Fig 1), cardiac or pericardial disease (n = 10), interstitial lung disease (n = 7) (Fig 2), trauma-related chest abnormalities (n = 6), primary or metastatic lung (Fig 3) or pleural (Fig 4) malignancy (n = 5), pleural disease (n = 4), postoperative changes (n = 4), pulmonary arterial hypertension (n = 3), viral pleuritis (n = 3), and mediastinal mass (n = 1).
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In 57 (67%) of the 85 patients without PE, spiral CT added diagnostic information that suggested an alternate diagnosis or was consistent with the final clinical diagnosis. This additional diagnostic information was not provided by the other currently used screening modalities for PE—that is, V-P scintigraphy and Doppler US—even though the scintigrams were interpreted in conjunction with the chest radiographs. This represents a diagnostic advantage for spiral CT in these patients.
In conjunction with the 23 of 25 patients who had positive findings of PE and in whom PE was correctly diagnosed at spiral CT, useful information was obtained in 80 (73%) of 110 patients. In this series, the most common diagnoses in patients without PE and with an abnormal chest CT scan included pneumonia (n = 14) cardiovascular disease (n = 10), interstitial lung disease (n = 7), traumatic changes (n = 6), lung or pleural malignancy (n = 5), and postoperative changes (n = 4). In 12 patients, the spiral CT study was normal. While a normal spiral CT study may have reassured both the referring clinician and the patient that no treatment was necessary, for the purpose of this study, a normal spiral CT study was classified as not providing any additional diagnostic information. The most common clinical diagnosis in patients with a normal chest CT study was nonspecific chest wall pain, presumably due to a viral illness (n = 8).
Seven (6%) of 110 spiral CT studies were interpreted as indeterminate because of motion artifact, poor contrast material opacification, or poor signal-to-noise ratio. There were three spiral CT examinations with false-positive and two with false-negative findings. Both patients with false-negative spiral CT findings underwent pulmonary angiography, which demonstrated subsegmental clot. These images highlight the current technical limitations of spiral CT due to limited spatial resolution, failure to track the contrast material bolus in real time, and limited x-ray tube current. These factors constrain current examinations to depiction of PE in central and segmental pulmonary arteries. Overall, 12 (11%) of 110 spiral CT examinations had indeterminate or incorrect interpretations.
The study has several limitations. The study did not consist of all consecutive patients clinically suspected of having PE. This was partially dictated by the study design, which included only patients in whom spiral CT could be performed within 24 hours of clinical presentation. It therefore excluded patients in whom there were delays in the appropriate clinical assessment or those patients in whom, for various reasons, it was not possible to perform spiral CT within 24 hours. This may have resulted in a selection bias toward inclusion of a larger proportion of inpatients compared with the number of outpatients. The effect of this possible selection bias on the results of this study cannot be accounted for. Furthermore, because angiograms were not obtained in all patients, the diagnosis of PE is biased toward those patients with segmental or larger emboli. This bias is similar to that in a previous study (9) in which spiral CT was used.
This prospective study was not designed to compare the diagnostic accuracy of CT with that of chest radiography in suggesting an alternate diagnosis for PE. In 82 patients, the pulmonary scintigrams were assessed in conjunction with the chest radiographs, and no alternate diagnosis was suggested. However, the analysis of the chest radiographs was not performed prospectively by a subspecialized chest radiologist. It is possible, and indeed likely, that in some patients an alternate diagnosis would have been suggested prospectively if the radiograph had been assessed by an expert observer.
In conclusion, spiral CT has good sensitivity and specificity for the diagnosis of PE and provides important ancillary information for the final diagnosis in patients who do not have PE. This ancillary information is not available with other PE imaging modalities, either noninvasive (ie, V-P scintigraphy, impedance plethysmography, and Doppler US) or invasive (ie, pulmonary angiography). As a result, we believe it is appropriate to consider spiral CT the first-choice examination for patients at risk of PE who manifest clinically important chest symptoms.
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Footnotes |
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Abbreviations: PE = pulmonary embolism PIOPED = Prospective Investigation of Pulmonary Embolism Diagnosis V-P = ventilation-perfusion
Author contributions: Guarantor of integrity of entire study, J.R.M.; study concepts and design, N.L.M.; definition of intellectual content, J.R.M.; literature research, K.I.K.; clinical studies, K.I.K.; data acquisition, K.I.K., J.R.M.; data analysis, J.R.M.; statistical analysis, J.R.M.; manuscript preparation, K.I.K., J.R.M.; manuscript editing and review, J.R.M.
Received March 24, 1998;
revision requested June 16, 1998; revision received July 31, 1998;
accepted October 14, 1998.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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