Viewer. Figure 23. Figure 4. Viewer. (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. Viewer. Figure 30c. CT scan shows an acute pulmonary embolus with ancillary findings of a peripheral wedge-shaped area of hyperattenuation in the lung (arrow), a finding that may represent an infarct, as well as a linear band (arrowhead). Figure 12. Computed Tomography (CT) is the mainstay of diagnostic imaging evaluation of thoracic disorders. 4, American Journal of Veterinary Research, Vol. Chronic pulmonary embolism in the same patient as in ,Figure 11. S2, 9 August 2014 | European Radiology, Vol. 52, No. 57, No. Contrasted CT-angiography of the chest, often called a "PE protocol CT," has dramatically improved the diagnosis of pulmonary embolism. Acute pulmonary embolism in a 66-year-old man who presented with chest pain and dyspnea. CT scan shows streak artifact from dense contrast material within the superior vena cava (arrows). (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. These intravascular tumors manifest as unilateral, lobulated, heterogeneously enhancing masses at CT (,38,,39). Figure 29. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries.Download as PowerPointOpen in Image Partial volume artifact will become less of an issue with routine use of narrow detector widths. (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. 3, Journal of Thoracic Imaging, Vol. Beam-hardening artifact in a 63-year-old man with respiratory failure. 1, Archivos de Bronconeumología (English Edition), Vol. Chronic pulmonary embolism in a 62-year-old man with dyspnea. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. Our CT techniques are shown in the ,Table. Another acute pulmonary embolus affects the left main pulmonary artery (arrowhead). Its main use is to diagnose pulmonary embolism. 30, No. Although pulmonary angiography has lower mortality and morbidity rates (<1% and 5%, respectively) than anticoagulation therapy (1%–2% and 5%–25%), it has not gained widespread acceptance and is not universally available (,9–,11). Figure 18. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). Pulmonary embolism positivity rate was non-significantly higher in the timing bolus vs the empiric timing group (19% and 13%, P=0.1). Respiratory motion artifacts are the most common cause of indeterminate CT pulmonary angiography and can cause misdiagnosis of pulmonary embolism. Viewer. Figure 14. Flow-related artifact in a 73-year-old woman with chest pain. Small pulmonary emboli could be obscured by a large amount of image noise. Figure 25 illustrates the effect of different window settings on detection of pulmonary embolism. 9, No. Viewer. (b) CT scan (window width = 552 HU, window level = 276 HU) shows acute pulmonary embolism within the medial segment of the middle lobe artery (arrow) that was missed on the image in a. More distally, the pulmonary arteries were well enhanced. 12, 6 September 2014 | Current Radiology Reports, Vol. Identification of the catheter with bone window settings (,,,Fig 22) or on contiguous images or the scout image will demonstrate the true nature of this pitfall. 55, No. Peripheral wedge-shaped areas of hyperattenuation that may represent infarcts, along with linear bands, have been demonstrated to be statistically significant ancillary findings associated with acute pulmonary embolism (,Fig 8) (,18). (b) CT scan produced with bone window settings clearly depicts the pulmonary artery catheter. They may demonstrate vascular distention and local extravascular spread (,40). Tumor emboli rarely have such an appearance at CT. Protocol for 16-Section CT of Pulmonary Embolism. The current standard of care for members with suspected pulmonary embolism is a spiral CT scan, also called a CTA, CT PA (computed tomography pulmonary angiography), MDCT (multidector CT) or helical CT scan. Note also the medium-sized left pleural effusion and atelectasis. 12, No. Chronic pulmonary embolism in a 27-year-old man with dyspnea. 5, No. 6, 28 June 2017 | Respirology Case Reports, Vol. The low-attenuation abnormality due to partial volume averaging of vessel and lung can simulate pulmonary embolism (,,,Fig 20b). 5, The Egyptian Journal of Radiology and Nuclear Medicine, Vol. 116, No. 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). CT scan shows complete occlusion of vessels in the left lung (arrowheads) that are smaller than adjacent patent vessels. 36, No. Figure 28c. Occult Pulmonary Embolism in Intensive Care Unit Patients Undergoing Chest Computed Tomography Scan: Incidence and Effect on Outcomes, Multi-phase postmortem CT angiography: recognizing technique-related artefacts and pitfalls, Chronic Pulmonary Emboli and Radiologic Mimics on CT Pulmonary Angiography, Primary pulmonary artery myxoma: a rare case, Acute pulmonary embolism in the era of multi-detector CT: a reality in sub-Saharan Africa, Acute and Chronic Pulmonary Embolism: An In-depth Review for Radiologists Through the Use of Frequently Asked Questions, 80-kV Pulmonary CT Angiography With 40 mL of Iodinated Contrast Material in Lean Patients: Comparison of Vascular Enhancement With Iodixanol (320 mg I/mL)and Iomeprol (400 mg I/mL), The role of thoracic imaging in the intensive care unit, Prospectively ECG Gated CT pulmonary angiography versus helical ungated CT pulmonary angiography: Impact on cardiac related motion artifacts and patient radiation dose, Imaging of Congenital and Acquired Disorders of the Pulmonary Artery, Current Role of Imaging in the Diagnosis and Management of Pulmonary Hypertension, Computerassistiertes Diagnoseverfahren für die Mehrschichtcomputertomographie zur Beurteilung der pulmonalarteriellen Strombahn. Chronic pulmonary embolism in the same patient as in ,Figure 11. 2, 9 May 2016 | Journal of Medical Imaging and Radiation Oncology, Vol. Viewer. Partial volume artifact in a 52-year-old woman with dyspnea. Figure 10b. The phrase just spin them echoes in many hospital departments, suggesting that when in doubt about whet… (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. Pulmonary embolism is the third most common acute cardiovascular disease after myocardial infarction and stroke and results in thousands of deaths each year because it often goes undetected (,1,,2). This finding is seen when viewed with mediastinal or pulmonary embolism-specific windows and manifests as a bright ring around pulmonary arteries, particularly if associated with a flow artifact. 6, European Journal of Radiology Open, Vol. 30, No. Figure 26. (b) CT scan (window width = 552 HU, window level = 276 HU) shows acute pulmonary embolism within the medial segment of the middle lobe artery (arrow) that was missed on the image in a. Viewer. Figure 25b. Note also the medium-sized left pleural effusion and atelectasis. Figure 34a. 2, Singapore Medical Journal, Vol. (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 3, Clinics in Chest Medicine, Vol. 1. 44, No. )Download as PowerPointOpen in Image Figure 31. 1, Clinical Pulmonary Medicine, Vol. Intravenous Contrast Medium Administration and Scan Timing at CT: Considerations and Approaches1. Respiratory motion artifact in a 61-year-old man with dyspnea. 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). CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. Localized increase in vascular resistance in a 65-year-old man with dyspnea. 62, 7 August 2018 | Current Radiology Reports, Vol. Figure 36. Stair step artifact in an 84-year-old man with dyspnea and chest pain. (b) Repeat CT pulmonary angiogram demonstrates segmental pulmonary emboli within the medial and lateral segmental branches of the middle lobe artery (arrows). 66, No. Unlike true emboli, however, these apparent abnormalities are not well-defined filling defects. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image Introduction: Use of CT in the investigation of pulmonary embolism in radiosensitive patients such as pregnant and young female patients entails the need for protocol optimization. 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). Note the dilated collateral bronchial artery (arrowhead).Download as PowerPointOpen in Image Viewer. Acute pulmonary embolism in a 58-year-old woman who presented with chest pain and dyspnea. 4, Seminars in Roentgenology, Vol. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). Figure 35c. The artifact can be recognized by its nonanatomic, radiating nature.Download as PowerPointOpen in Image 11, European Journal of Radiology, Vol. Pulmonary artery stump in situ thrombosis in a 69-year-old man who had undergone right pneumonectomy for lung cancer. 25, No. Figure 10a. 26, No. Acute pulmonary embolism in a 42-year-old man who presented with chest pain and severe dyspnea. Figure 30d. 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). Supine Contrast IV: Up to 100 ml Omni 350. Pulmonary CT angiography (CTA) is the imaging modality of choice in suspected acute pulmonary embolism (PE). (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image 191, No. Noninspiratory imaging important to avoid transient attenuation artifact, due to contrast dilution from mixing of IVC blood if patient Valsalvas. 3, 5 December 2015 | European Radiology, Vol. (b) CT scan shows acute emboli that affect subsegmental arteries of the laterobasal segment (arrows).Download as PowerPointOpen in Image Tumor emboli are often associated with recent and organizing thrombi (,41,,42). 4, Radiologic Clinics of North America, Vol. Currently computed tomography pulmonary angiography (CTPA) has become a widely accepted clinical tool in the diagnosis of acute pulmonary embolism (PE).To report split-bolus single-pass 64-multidetector-row CT (MDCT) protocol for diagnosis of PE.MDCT split-bolus results in 40 patients suspicious of PE were analyzed in terms of image quality of target pulmonary vessels (TPVs) … 10, 11 April 2018 | Insights into Imaging, Vol. Viewer. Pulmonary emboli have been identified on 1.5% of contrast-enhanced CT scans obtained for reasons other than evaluation for pulmonary embolism (, 21). CT scan shows an acute pulmonary embolus with ancillary findings of a peripheral wedge-shaped area of hyperattenuation in the lung (arrow), a finding that may represent an infarct, as well as a linear band (arrowhead).Download as PowerPointOpen in Image 127, No. Figure 17. 73, No. The normal-appearing contrast material–filled accompanying pulmonary artery should provide a clue regarding this artifact. Figure 26. A partial filling defect surrounded by contrast material, producing the “polo mint” sign on images acquired perpendicular to the long axis of a vessel (,,,Fig 5) and the “railway track” sign on longitudinal images of the vessel (,Fig 6). Figure 5a. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). Use high concentration ≥350 mgI/mL for larger patients (higher enhancement). Graph illustrates that the number of ventilation-perfusion scans performed per inpatient with suspected thromboembolic disease decreased significantly between 1992 and 2001 (P = .0003). (b) CT scan produced with bone window settings clearly depicts the pulmonary artery catheter. 2, Annals of Thoracic and Cardiovascular Surgery, Vol. 3, No. Tumor emboli in a 60-year-old man with dyspnea and primary renal cell carcinoma. For that reason, your doctor will likely order one or more of the following tests. 24, No. (b) Repeat CT pulmonary angiogram demonstrates segmental pulmonary emboli within the medial and lateral segmental branches of the middle lobe artery (arrows). CT scan shows pulmonary arterial wall calcification (arrows), a secondary sign of chronic pulmonary embolism.Download as PowerPointOpen in Image Flow-related artifact in a 73-year-old woman with chest pain. Acute PE is the third most common acute cardiovascular disease after myocardial infarction and stroke, and results in many deaths each year. Sagittal and coronal reformatted images can help identify these normal anatomic structures (,17). Figure 16. CT scan shows a flap (arrow) within a small right interlobar pulmonary artery. 55, No. 64, No. 6, Journal of Computer Assisted Tomography, Vol. 04, The American Journal of Cardiology, Vol. 8, American Journal of Roentgenology, Vol. 3, 12 November 2017 | Iranian Journal of Radiology, Vol. 2, Revista Argentina de Radiología, Vol. Viewer. There are two principal approaches for performing a CTPA of high diagnostic quality: NB: This article is intended to outline some general principles of protocol design. Hilar lymph nodes in the lungs can be conveniently divided into upper lobe, interlobe, middle lobe (lingular), and lower lobe groups (,31,,32). 26, No. Figure 25c. More commonly, tumor emboli are small and occlude subsegmental arteries and arterioles, leading to progressive dyspnea and subacute pulmonary hypertension (,41). 93, No. Images are acquired with a standard algorithm and viewed with IMPAX version 4.1 software (AGFA, Teterboro, NJ). The apparent pulmonary embolism is ill defined. (b) CT scan shows acute emboli that affect subsegmental arteries of the laterobasal segment (arrows). 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.Download as PowerPointOpen in Image (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). Adjacent beam-hardening artifacts are also seen.Download as PowerPointOpen in Image Graph illustrates that the number of CT studies performed for pulmonary embolism per inpatient increased significantly between 1992 and 2001 (P = .006). (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. (c) Contiguous CT scan obtained immediately superior to a demonstrates a contrast material-filled pulmonary artery, a finding that confirms that the low attenuation seen in a was due to partial volume artifact.Download as PowerPointOpen in Image 31, No. 3, 10 January 2014 | Expert Review of Cardiovascular Therapy, 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). iodinated contrast-induced thyrotoxicosis, saline flush during contrast administration, CT colonography reporting and data system, a small ‘test’ quantity of contrast is injected and sequential axial slices at a set region of interest are acquired to calculate the time of peak contrast enhancement and determine an optimal scan delay, below the carina at the level of the pulmonary trunk with an ROI on the pulmonary artery, 20 mL of non-ionic contrast with a 10 mL saline chaser at 4.5/5 mL/s, monitor contrast enhancement peak over time via a time-enhancement curve, as the time-enhancement curve will only begin recording after the scan delay. This artifact can be eliminated or reduced by reconstructing the raw data with a 50% overlap prior to three-dimensional image reconstruction. Localized increase in vascular resistance in a 65-year-old man with dyspnea. The computed tomography pulmonary angiogram (CTPA/CTPE) is a commonly performed diagnostic examination to exclude pulmonary emboli. (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. Lung algorithm artifact in a 70-year-old woman with dyspnea. 05, American Journal of Roentgenology, Vol. CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). The artery is enlarged compared with adjacent patent vessels.Download as PowerPointOpen in Image 6, 13 April 2012 | Der Radiologe, Vol. 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. + (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. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. Does the anatomic distribution of acute pulmonary emboli at MDCT pulmonary angiography in oncology-population differ from that in non-oncology counterpart? 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. Figure 8. Murphy A, Cheng J, Pratap J, Redman R, Coucher J. Dual-Energy Computed Tomography Pulmonary Angiography: Comparison of Vessel Enhancement between Linear Blended and Virtual Monoenergetic Reconstruction Techniques. CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). 2, American Journal of Roentgenology, Vol. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). (c) Contiguous CT scan obtained immediately superior to a demonstrates a contrast material-filled pulmonary artery, a finding that confirms that the low attenuation seen in a was due to partial volume artifact.Download as PowerPointOpen in Image (b) CT scan (window width = 552 HU, window level = 276 HU) shows acute pulmonary embolism within the medial segment of the middle lobe artery (arrow) that was missed on the image in a. Chronic pulmonary embolism in a 62-year-old man with dyspnea. Three protocols followed the above CM injection, protocol-1 (P-1) with immediate exposure, protocol-2 (P-2) with exposure after 10 sec.-delayed, and protocol-3 (P-3) with exposure after injection of 30ml saline (3ml/sec. CT scan shows tumor emboli that manifest as vascular dilatation and beading of subsegmental arteries of the posterobasal segment of the right pulmonary artery (arrow).Download as PowerPointOpen in Image In a study evaluating trends in the use of inpatient thoracic radiology at an academic medical center over a 10-year period, Wittram et al (,12) showed that the use of CT in patients with suspected thromboembolic disease has increased significantly (,Figs 1,–,3) (,12). Transient interruption of contrast enhancement is likely related to inspiration and to unenhanced blood entering the right atrium, right ventricle, and pulmonary arteries from the inferior vena cava just prior to image acquisition (,27). Figure 31. 61, No. 244, No. Note the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow).Download as PowerPointOpen in Image 12, Clinical Pulmonary Medicine, Vol. In the hope of catching this elusive diagnosis, many physicians have turned to computed tomography (CT). Small pulmonary emboli are noted in the left pulmonary artery. 5, No. Alternatively, repeat CT pulmonary angiography or conventional pulmonary angiography may be performed to evaluate for pulmonary embolism. 51, No. (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 the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow). 3. Localized increase in vascular resistance in a 65-year-old man with dyspnea. Tumor embolus in a 78-year-old woman with dyspnea and endometrial stromal sarcoma that invaded the inferior vena cava. (b) CT scan obtained with the standard algorithm does not demonstrate this artifact. Note also the medium-sized left pleural effusion and atelectasis. 85, No. Classification of a pulmonary embolism may be based upon: 1. the presence or absence of hemodynamic compromise 2. temporal pattern of occurrence 3. the presence or absence of symptoms 4. the vessel which is occluded Partial volume artifact in a 52-year-old woman with dyspnea. CONCLUSION: A simple empiric timing protocol for CTPA has robust performance compared to a timing bolus protocol. Pulmonary Embolism, CT Perfusion; Pulmonary Embolism, Standard Protocol; Pulmonary Hypertension; Pulmonary Nodules; Right Coronary Artery Stent; Serous Cystic Neoplasm; Small bowel lymphoma; Stenosis of the Left Anterior Descending Artery; Three-Vessel Disease; Transplant (Postoperative Study) A preliminary study, Imaging Findings in Chest Computed Tomography: Initial Experience in a Developing Country, Noncontrast and Contrast-Enhanced Pulmonary Magnetic Resonance Angiography, Relation Among Clot Burden, Right-Sided Heart Strain, and Adverse Events After Acute Pulmonary Embolism, CT pulmonary angiography of adult pulmonary vascular diseases: Technical considerations and interpretive pitfalls. Figure 11. Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. 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