(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. Figure 30a. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. The more common diseases that can be detected with CT include pericarditis, which may manifest as pericardial thickening or fluid; acute myocardial infarction, which may manifest as a filling defect within a coronary artery or as a perfusion defect of the myocardium; and aortic dissection. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. Figure 22b. Diagnosis of pulmonary embolism with d-dimer adjusted to clinical probability. Viewer. Viewer. Early detection of acute right ventricular failure allows implementation of the most appropriate therapeutic strategy. Figure 25 illustrates the effect of different window settings on detection of pulmonary embolism.Download as PowerPointOpen in Image Parenchymal density changes in acute pulmonary embolism: Can quantitative CT be a diagnostic tool? If the quality of the study is poor, the radiologist should identify which pulmonary arteries are rendered indeterminate and whether additional imaging is necessary. 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) 3, No. Does the anatomic distribution of acute pulmonary emboli at MDCT pulmonary angiography in oncology-population differ from that in non-oncology counterpart? Beam-hardening streak artifacts from dense contrast material within the superior vena cava are commonly seen and can overlie the right pulmonary and upper lobe arteries. 4, Contemporary Diagnostic Radiology, Vol. Very bright vessel contrast can obscure small pulmonary emboli. CT scan shows pulmonary arterial wall calcification (arrows), a secondary sign of chronic pulmonary embolism.Download as PowerPointOpen in Image CT scan demonstrates pericardial fluid (arrows) associated with pulmonary arterial hypertension secondary to chronic pulmonary embolism.Download as PowerPointOpen in Image Collateral bronchial artery dilatation is also noted (arrowhead). 3, Journal of Small Animal Practice, Vol. However, these modified window settings can also increase the conspicuity of artifacts caused by image noise and flow. Viewer. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). Left-sided heart failure in a 56-year-old woman with dyspnea. 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. 2, Annals of Thoracic and Cardiovascular Surgery, Vol. adequate enhancement of the pulmonary trunk and its branches. The dark regions of underperfused lung are seen to contain vessels (arrows) that are smaller than the adjacent patent vessels in the normally perfused lung. Alobeidi Hanan, Muhammed Alshamari and Jonas Widell et al. Localized increase in vascular resistance in a 65-year-old man with dyspnea. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. 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 Small pulmonary emboli could be obscured by a large amount of image noise. Figure 19. The apparent pulmonary embolism is ill defined. On a CT scan, the pulmonary artery measures 41 mm in diameter (black line), a finding that indicates hypertension.Download as PowerPointOpen in Image In 17 patients with central pulmonary embolism, the raw data were used to perform reconstructions with 1-mm, 2-mm, and 3-mm section thicknesses. Arrows indicate collateral bronchial arteries.Download as PowerPointOpen in Image CT scan shows the vascular bifurcation between the left lower lobe and lingular arteries as a curved line surrounded by contrast material (arrow). Chronic pulmonary embolism in the same patient as in ,Figure 12. 55, No. The computed tomography pulmonary angiogram (CTPA/CTPE) is a commonly performed diagnostic examination to exclude pulmonary emboli. 55, No. The chest field of view is the widest rib-to-rib distance acquired during breath hold after inspiration. More distally, the pulmonary arteries were well enhanced. CT scan shows complete occlusion of vessels in the left lung (arrowheads) that are smaller than adjacent patent vessels. (a) CT scan shows peribronchovascular interstitial thickening caused by perivascular edema (arrow), a finding that can mimic chronic pulmonary embolism. However, some morphologic abnormalities that suggest right ventricular failure can be quantified with CT pulmonary angiography. (b) CT scan (lung window) demonstrates the accompanying findings of diffuse peribronchovascular thickening, ground-glass attenuation, smooth interlobular septal thickening (arrows), and bilateral pleural effusions. Viewer. 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. 62, 7 August 2018 | Current Radiology Reports, Vol. 202, No. Figure 20a. Figure 8. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). No embolism was present. Figure 7. 3, Clinics in Chest Medicine, Vol. (a) CT scan shows poor enhancement of the interlobar and middle lobe pulmonary arteries due to flow-related artifact. (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. CT scan shows complete occlusion of vessels in the left lung (arrowheads) that are smaller than adjacent patent vessels. Arrows indicate collateral bronchial arteries. 5, No. Figure 31. Small pulmonary emboli are noted in the left pulmonary artery. Figure 10a. 8, No. Left-sided heart failure in a 56-year-old woman with dyspnea. The artifact can be recognized by its nonanatomic, radiating nature. Figure 34b. 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). Our CT techniques are shown in the ,Table. 205, No. Respiratory motion artifact in a 61-year-old man with dyspnea. Computed Tomography (CT) is the mainstay of diagnostic imaging evaluation of thoracic disorders. (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). These findings indicate the true nature of the patient’s condition. More distally, the pulmonary arteries were well enhanced. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. Figure 24b. 3, The British Journal of Radiology, Vol. Figure 30d. (b) CT scan obtained with the standard algorithm does not demonstrate this artifact. Acute central pulmonary embolism in an asymptomatic 87-year-old woman. 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). (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. The vessels are seen as either normal, containing acute pulmonary embolism, containing chronic pulmonary embolism, or indeterminate. Such detection can help determine further imaging needs and allow the timely initiation of appropriate therapy. Small pulmonary emboli are noted in the left pulmonary artery. Its sensitivity is estimated between 60 % and 100 % and its specificity between 81 % and 98 % [ 5, 6, 7, 8 ]. For example, vessels may appear normal to the level of the segmental arteries; however, the presence of pulmonary embolism in subsegmental arteries may remain indeterminate depending on the quality of the study. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. Figure 30c. CT CHEST, ABDOMEN AND PELVIS WITHOUT + CTA CHEST W IV AND CTA ABDOMEN W IV (Please order both exams) 71250, 74150, 72192 71275 and 74175 Pulmonary arteries Pulmonary embolism Pulmonary hypertension Hemoptysis None Yes CTA CHEST W IV 71275 Lower extremities Peripheral Artery Disease None Yes CTA PELVIS W/RUNOFFS 75635 For example, when acquiring images with a 1.25-mm detector width, a set of images with an overlap of 0.625 mm should be retrospectively generated. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). MR pulmonary angiography: Can it be used as an alternative for CT angiography in diagnosis of major pulmonary thrombosis? Partial volume artifact in a 52-year-old woman with dyspnea. Sagittal and coronal reformatted images can help identify these normal anatomic structures (,17). Check for errors and try again. The review of sagittal and coronal reformatted images can help in difficult cases. (a) CT scan shows poor enhancement of the interlobar and middle lobe pulmonary arteries due to flow-related artifact. 3, American Journal of Roentgenology, Vol. 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. Adjacent beam-hardening artifacts are also seen. 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). (a) CT scan (lung window) shows composite images of vessels (seagull sign) (arrows). Figure 25 illustrates the effect of different window settings on detection of pulmonary embolism. 41, No. The artery is enlarged compared with adjacent patent vessels. Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. Figure 20b. 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). 85, No. Identification of the normal accompanying pulmonary arteries (arrowheads) allows the correct interpretation of this finding. A mucus plug within a bronchus, which may also demonstrate peripheral wall enhancement related to inflammation, can mimic acute pulmonary embolism (,Fig 33). 26, No. 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. (a) CT scan shows a pulmonary embolus that affects the segmental artery of the laterobasal segment of the right lower lobe. Beam-hardening artifact in a 63-year-old man with respiratory failure. 4, The Journal of Thoracic and Cardiovascular Surgery, Vol. (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). CT scan shows a large chronic pulmonary embolus in the main and left main pulmonary arteries (arrowhead). CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). 1, 28 July 2016 | Journal of Medical Imaging and Radiation Oncology, Vol. 30, No. Viewer. Figure 13. Therefore, for patients weighing more than 250 pounds, we modify our protocol by increasing detector width to 2.5 mm, thereby decreasing image noise and improving scan quality. Figure 16. Lung algorithm artifact in a 70-year-old woman with dyspnea. (a) CT scan shows peribronchovascular interstitial thickening caused by perivascular edema (arrow), a finding that can mimic chronic pulmonary embolism. CT scan shows an eccentrically located thrombus that forms obtuse angles with the vessel wall (arrows). If the address matches an existing account you will receive an email with instructions to reset your password. Figure 40. Another acute pulmonary embolus affects the left main pulmonary artery (arrowhead).Download as PowerPointOpen in Image Viewer. For each lung, the main, lobar, segmental, and subsegmental arteries are examined for pulmonary embolism. More distally, the pulmonary arteries were well enhanced. Figure 25 illustrates the effect of different window settings on detection of pulmonary embolism. Localized increase in vascular resistance in a 65-year-old man with dyspnea. CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. (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.Download as PowerPointOpen in Image Image noise makes the evaluation of segmental and subsegmental vessels difficult and can cause indeterminate CT pulmonary angiography and misdiagnosis of pulmonary embolism (,Fig 21). In a review of microscopic pulmonary tumor emboli associated with dyspnea, Kane et al (,41) found that carcinomas of the prostate gland and breast were the most common causes, followed by hepatoma, then carcinomas of the stomach and pancreas (,41). CT scan shows a flap (arrow) within a small right interlobar pulmonary artery. Chronic pulmonary embolism in the same patient as in ,Figure 11. Viewer, Figure 1. Adjacent beam-hardening artifacts are also seen. Images obtained in large patients have more quantum mottle. 12, 6 September 2014 | Current Radiology Reports, Vol. CT scan shows an eccentrically located thrombus that forms obtuse angles with the vessel wall (arrows). 38, No. (,Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. Coronal reformatted image of the right interlobar artery and the posterobasal segment of the pulmonary artery demonstrates dense contrast material superior and inferior to a region of poorly enhanced blood (arrow).Download as PowerPointOpen in Image allergy) and time constraints. 6, American Journal of Roentgenology, Vol. The apparent pulmonary embolism is ill defined. 55, No. 43, No. Figure 11. 24, No. Partial volume artifact in a 52-year-old woman with dyspnea. 4, Circulation: Cardiovascular Imaging, Vol. The low-attenuation abnormality due to partial volume averaging of vessel and lung can simulate pulmonary embolism (,,,Fig 20b). 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. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. (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 11, European Journal of Radiology, Vol. Note the dilated collateral bronchial artery (arrowhead).Download as PowerPointOpen in Image Discuss the causes of indeterminate CT pulmonary angiography. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image 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). Left-sided heart failure in a 56-year-old woman with dyspnea. *Scanning delay is determined by dividing the acquisition time for lung imaging by 2 and subtracting the result from the total injection time (34 seconds). CT scan shows low-attenuation lines that traverse a vessel on coronal reformatted images (arrows). Pulmonary emboli have been identified on 1.5% of contrast-enhanced CT scans obtained for reasons other than evaluation for pulmonary embolism (,21). 3, Journal of Thoracic Imaging, Vol. The diagnostic criteria for acute pulmonary embolism include the following: Arterial occlusion with failure to enhance the entire lumen due to a large filling defect; the artery may be enlarged compared with adjacent patent vessels (,Fig 4). Viewer. Figure 10a. Chronic pulmonary embolism in the same patient as in ,Figure 11. Flow-related artifact in a 73-year-old woman with chest pain. 9, The Journal of Emergency Medicine, Vol. Viewer. Localized increase in vascular resistance in a 65-year-old man with dyspnea. 3, American Journal of Roentgenology, Vol. 3, Journal of Cardiothoracic and Vascular Anesthesia, Vol. (2019) Journal of medical imaging and radiation sciences. 4, The American Journal of Emergency Medicine, Vol. Figure 30d. Each protocol was started with a 3.5ml/sec.-injection of 100ml of CM (300mgI/ml) via vein in upper limb. Viewer. The normal-appearing contrast material–filled accompanying pulmonary artery should provide a clue regarding this artifact. 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. 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). (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). Note the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow).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). Studies show that the diagnostic yield of CTPA for pulmonary embolism varies between 6.7 % and 31 % [ 9, 10, 11, 12, 13, 14 ]. Figure 6. (,Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. 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). Rapid change in the position of vessels on contiguous images also confirms motion artifact. The radiologist needs to determine the quality of a CT pulmonary angiographic study and whether pulmonary embolism is present. Pulmonary embolism (PE) is a relatively common vascular disease with potentially life-threatening complications in the short term. (b) Contiguous CT scan obtained inferior to a demonstrates normal lung adjacent to the left upper lobe pulmonary artery. N Engl J Med 2019;381:2125-34. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. 11, No. (a) Unenhanced CT scan demonstrates subtle regions of hyperattenuation (arrow). 6, 1 November 2007 | Radiology, Vol. (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 findings indicate the true nature of the patient’s condition. The apparent pulmonary embolism is ill defined. Viewer. 5, American Journal of Roentgenology, Vol. (b) CT scan shows acute emboli that affect subsegmental arteries of the laterobasal segment (arrows).Download as PowerPointOpen in Image Figure 30b. 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. On a CT scan, the pulmonary artery measures 41 mm in diameter (black line), a finding that indicates hypertension. Ju Hee Yeo, Lifeng Zhou, Remy Lim. 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. Url '': '' /signup-modal-props.json? lang=us\u0026email= '' } the appropriate window width and level settings are important because! Every case of pleuritic chest pain main and left interlobar pulmonary artery should provide a regarding! 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