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C h e s t I m a g i n g • Pe r s p e c t i v e
How I Do It: CT Pulmonary Angiography
Wittram C OBJECTIVE. The purpose of this article is to describe the techniques to improve motion artifacts, vascular enhancement, flow artifacts, body habitus image noise, vascular opacification in parenchymal lung disease, streak artifacts, and the indeterminate CT pulmonary angiogram. In addition, this article will illustrate the diagnostic criteria of acute and chronic pulmonary emboli. CONCLUSION. Pulmonary embolism is the third most common acute cardiovascular disease, after myocardial infarction and stroke, and it leads to thousands of deaths each year because it often goes undetected. For the more than 25 years that the direct signs of pulmonary embolism have been available to the radiologist on CT, this noninvasive technique has produced a paradigm shift that has raised the standard of care for patients with this disease. ulmonary embolism is the third most common acute cardiovascular disease, after myocardial infarction and stroke, and results in an estimated 200,000–300,000 hospitalizations and 37,000–44,000 deaths per year in the United States . In 1980, Godwin et al.  were among the first to describe pulmonary embolism on contrast-enhanced CT. In 1990, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study results were published . This large multicenter trial compared ventilation–perfusion (V/Q) scintigraphy with pulmonary angiography and established the diagnostic characteristics of pulmonary embolism on V/Q scintigraphy. The sensitivity of V/Q scintigraphy was found to be 98%, with a specificity of 10% . The potential of the noninvasive technique, CT pulmonary angiography (CTPA), has now been realized at most institutions; it has become the test of choice and thus the de facto standard of care . Recent studies have shown the sensitivity of thin-slice MDCTPA to be 90–100% and the specificity to be 89–94% for the detection of pulmonary emboli to the level of the subsegmental arteries, using pulmonary angiography as the gold standard [5, 6]. A much larger multicenter study has been recently published: The PIOPED II study, which used a composite gold standard, showed that CTPA has a sensitivity of 83% and specificity of 96% for the detection of pulmonary embolism and that combined CTPA and CT venog-
Keywords: chest, CT arteriography, CT technique, embolism DOI:10.2214/AJR.06.1104 Received August 18, 2006; accepted after revision November 8, 2006.
of Thoracic Radiology, Massachusetts General Hospital, Founders 202, 55 Fruit St., Boston, MA 02114. Address correspondence to C. Wittram. CME This article is available for CME credit. See www.arrs.org for more information.
AJR 2007; 188:1255–1261 0361–803X/07/1885–1255 © American Roentgen Ray Society
raphy have a sensitivity of 90% and specificity of 95% for the detection of venous thromboembolic disease . The PIOPED II study found that patients with a low or intermediate clinical probability of pulmonary embolism and normal results on CTPA had a high negative predictive value for PE (96% for patients with a low probability and 89% for patients with an intermediate probability); however, the negative predictive value was 60% in patients with a high probability before CTPA. The positive predictive value of abnormal findings on CTPA was high (92–96%) in patients with an intermediate or high clinical probability but much lower (58%) in patients with a low likelihood of pulmonary embolism. Therefore, additional testing is recommended when the clinical probability is inconsistent with the imaging results . A limitation of the PIOPED II study was that the composite gold standard was not 100% accurate for the diagnosis of venous thromboembolic disease; it therefore follows that the performance of CT was likely better than the results indicate. In the PIOPED II study, among 824 patients with a reference diagnosis and a completed CT study, CTPA was inconclusive in 51 because of poor image quality . A recent study that evaluated the causes of indeterminate CTPA findings found an indeterminate rate of 6.6% . The most common cause was motion artifacts in 74% of the cases; other reasons included poor enhancement (40%), patient habitus (7%), parenchymal disease (12%), and streak artifacts (7%) . The
AJR:188, May 2007
How to Reduce Motion Artifacts Respiratory motion artifacts are the most common cause of an indeterminate CTPA and 1256 AJR:188. A rapid change in position of vessels on contiguous images also confirms motion artifact. the mean attenuation value is 33 H (SD. The minimum attenuation of adjacent opacified blood to identify this outlying chronic thrombus is 211 H. –600 H). 1. we should calculate the highest possible attenuation of an acute pulmonary embolism to be the mean plus 3 SDs.25 55 1.2. Previous work has defined the attenuation values of acute and chronic pulmonary emboli . and for 64-MDCT. if the patient breathes during image acquisition. there is more excursion of the lower lobes compared with the upper lobes.375:1 140 380 0. and pulmonary embolism–specific (window width. 40 H). At the moment. Indirect CT venography will not be dealt with in detail in this article. In dyspneic patients. 15 H) . The frequency of examinations devoid of motion artifacts is significantly higher for MDCT. 10]. Images are viewed on a PACS monitor using IMPAX version 4. showed that the detection of a low-contrast abnormality is not accurate when the SD of the mean of the abnormality exceeds the difference in the means of the lesion and the surrounding region . purpose of this article is to describe the techniques used to improve the quality of CT pulmonary angiography and to illustrate the diagnostic criteria of acute and chronic pulmonary emboli. . mediastinal window (window width.25/1.375:1 140 380 0. which equates to 78 H. less than 3 seconds. However. femoral. 100 H) settings because pulmonary embolism can be missed when a case with very bright contrast is viewed only on mediastinal window settings . For IV access. Because it is important to detect all pulmonary emboli. technical.5 Standard Large Rib to rib Large Patient (> 250 lb [113 kg]) 2. Images of the iliac.5/1. The pulmonary embolism–specific settings also help to differentiate between a sharp margined embolus and an ill-defined artifact.or 20-gauge catheter is preferred. They are best seen on lung window settings that show composite images of vessels . which has a shorter breath-hold than single-detector CT [14. May 2007 .375:1 140 380 1. The implementation of higher order MDCT scanners should lower the indeterminate CTPA rate due to respiratory motion. respectively. Also.Wittram TABLE 1: 16-MDCT Pulmonary Angiography Protocol Parameter Detector width/reconstruction (mm) Table speed/rotation (mm) Pitch Peak kilovoltage Milliamperes Rotation time (s) Algorithm Scanning field of view Display field of view Normal-Sized Patient 1. CT Technique At the moment. respectively. For acute pulmonary emboli. at our institution. window level. the highest possible attenuation value of chronic pulmonary emboli with 3 SDs is calculated to be 180 H. Motion artifact renders the diagnosis of pulmonary embolism at the affected anatomic level indeterminate.625/1. A low-density abnormality that simulates pulmonary embolism may result from partial voluming of vessel and lung . anatomic. Lightspeed (GE Healthcare) 16. window level. The images are displayed with three different gray scales for interpretation of lung window (window width. According to Meaney et al.25 13. 350 H. Combining these values with experimental work by Meaney et al.0 Standard Large Rib to rib can be a cause of misdiagnosis of pulmonary embolism. and pathologic factors that mimic pulmonary embolism and true pulmonary embolism . oxygen supplementation can help the patient provide the desired period of apnea.0 Standard Large Rib to rib TABLE 2: 64-MDCT Pulmonary Angiography Protocol Parameter Detector width/reconstruction (mm) Table speed/rotation (mm) Pitch Peak kilovoltage Milliamperes Rotation time (s) Algorithm Scanning field of view Display field of view Normal-Sized Patient 0. we need attenuation in the artery of at least one more SD.5 6. the antecubital vein and an 18. Therefore. The mean attenuation and SD values for chronic pulmonary embolism are 87 and 31 H. 700 H. Multiplanar reformation images through the longitudinal axis of a vessel can be used to overcome some of the difficulties encountered with axial-orientated images of obliquely or axially orientated arteries . the final figure therefore equals 93 H. Pulmonary Artery Enhancement Theory An increase in the attenuation of blood on CT may be obtained with intravascular contrast material containing the atoms of iodine or gadolinium.75 1. . and popliteal veins are obtained 3 minutes after the onset of the initial contrast injection .75% of all acute emboli. modified window settings can also increase the conspicuity of artifacts caused by image noise and flow. window level.5 Standard Large Rib to rib Large Patient (> 250 lb [113 kg]) 0.562:1 140 380 1.88 0. The CT parameters are given in Tables 1 and 2. 15]. this would include 99.1 (AGFA) because there is improved accuracy in viewing chest CT cases on a workstation compared with hard-copy film [9. it is possible to calculate the minimum amount of IV attenuation required to perceive pulmonary emboli on CT.5 55 1. the breath-hold required for 16-MDCT is approximately 10 seconds. reformatted images can help to differentiate between some patient. The theoretic minimum attenuations of blood required to see all acute and chronic pulmonary venous thromboemboli are 93 and 211 H. Meaney et al. The caudal–cranial direction is used because most emboli are located in the lower lobes and.and 64-MDCT scanners are used to acquire the images of the thorax in a caudal–cranial direction.500 H.25/2.625/1. Contrast-enhanced helical CT of the veins of the lower extremities is performed using the same contrast bolus as used for chest CT.
it is necessary to adjust the display window widths and levels [17–19]. whereas in the study by Gosselin et al. the enhancement threshold might never be reached. AJR:188. . the decision of the reviewer to interpret a study as adequate or indeterminate will be affected by the interplay of factors that include the size of the suspected embolism. Prescanning hyperventilation is likely the cause. in which case a different venous access site may be necessary. then poor venous flow due to stenosis or obstruction may be a factor . Flow Artifacts A transient interruption of contrast material consists of a portion of the pulmonary artery that shows relatively poor enhancement between areas of higher attenuation both proximally and distally [24. Wittram and Yoo  showed that the artifact results from an increase in flow of unopacified blood from the inferior vena cava. and the amount of image noise. May 2007 1257 . used single-detector CT whereas Wittram and Yoo used MDCT. the recirculation of contrast material causes a cumulative effect on enhancement over time . therefore. but Gosselin et al.and sexmatched controls. The solution to transient interruption of contrast flow of the pulmonary arteries is to reduce the volume of unopacified blood entering the right atrium from the inferior vena cava. Empiric scanning delay also has the advantage of reducing operator error and motion artifacts by removing the added complexity of when to start the study based on a threshold value. To comprehensively evaluate for venous thromboembolic disease. Also. this allows a high intensity of contrast enhancement in the pulmonary arterial system. The injection duration has an important influence in optimizing contrast delivery in CT. whereas bolus tracking starts the CT scan earlier on the rise of the enhancement curve and results in worse pulmonary artery enhancement. However. the start of the scanning is calculated to equal the injection time minus half the scanning time. the anatomic level of the vessel being evaluated. The patients in the study by Gosselin et al. so that an increase in time increases the enhancement of the pulmonary arteries during the injection. is that the patients in the study by Wittram and Yoo were instructed to “take a breath in and hold it” before image acquisition. This enhancement advantage is most optimally used with the empiric delay technique.5 3 2. and to improve pulmonary embolism conspicuity. As the injection duration increases. If the size of the IV access catheter does not allow 4 mL/s. The hyperventilation before inspiration and the breath-hold is likely the exacerbating factor of this artifact. one aims to be midscan at the peak of pulmonary artery enhancement.and high-attenuation areas is ill-defined. Because the venous return from the inferior vena cava to the right atrium is exaggerated with Fig. Although no published data as yet can validate this statement. 1—Transient interruption of flow of contrast material in 59-year-old woman. it was present in 37% of the study group. An interesting major difference between the studies. prescan hyperventilation should be dropped. patients need to receive a large contrast material bolus to evaluate the lower-limb veins . this leaves the technologist uncertain as to when to start image acquisition. Timing of Bolus Several techniques are available for contrast delivery on CT studies. were instructed to have five respiratory cycles of hyperventilation followed by a command of full inspiration 2 seconds before initial images were obtained . Comparing patients with this artifact with age.CT Pulmonary Angiography TABLE 3: Empirical Timing Delay for CT Pulmonary Angiography After IV Administration of 370 mg I/mL Timing Delay (s) 16-MDCT Injection Amount injected (mL) Rate of injection (mL/s) 4 3. and the timing is appropriate. there is no extravasation of contrast material. Interface between low. A high injection rate with a uniphase injection bolus of 4 mL/s of contrast material is preferred . The first-pass effect is optimized by the use of contrast material with 370 mg I/mL. then the delay needs to increase. A repeat CTPA after hydration of the patient is recommended. If an indeterminate scan occurs with standard delay due to poor enhancement.and 64-MDCT scanners. in cases with poor function of the right side of the heart. 23].5 2 22 26 32 39 50 30 34 40 49 61 26 30 36 43 53 31 35 42 51 63 Normal-Size Patient 110 Large Patient (> 250 lb [113 kg]) 130 64-MDCT Normal-Size Patient 110 Large Patient (> 250 lb [113 kg]) 130 To detect abnormalities with low differences in CT contrast. However. with the implementation of faster scanners. CT would start later on the rise of the enhancement curve. 25] (Fig. the number of detectors should not affect the appearance of this artifact. Coronal oblique reformatted image through right posterior basal segmental artery from CT pulmonary angiography shows segment of poor opacification (arrow) between areas of higher attenuation both proximally and distally. Using an empiric scanning delay on 16. What can be done to avoid this flow phenomenon? A review of the literature shows that the transient interruption of contrast artifact was seen in 3% of the study population in that study . One could argue that when the triggering threshold for bolus tracking is increased. preliminary work appears to support this observation [22. 1). as illustrated in Table 3. and a possible explanation of the difference in frequency. Injection of contrast material can be considered in two components: first pass and recirculation. Both studies used the same injection rate.
Although our experience is anecdotal. The reason for this rationale is that the legs and pelvis are not imaged and that the quantity of iodine to the fetus is also reduced. if a diagnosis of pulmonary embolism cannot be confidently confirmed or refuted and the study is indeterminate. TABLE 4: Empirical Timing Delay for CT Pulmonary Angiography for Pregnant Patients After IV Administration of 70 mL of 370 mg I/mL Rate of Injection (mL/s) 4 3. In addition. Parenchymal Disease Consolidation can cause a focal increase in vascular resistance and focal poor vascular opacification . some patients with indeterminate CTPA findings will need further imaging. we verbally instruct our patients not to perform an exaggerated inspiration and the CT technologist prompts the patient to “hold your breath” before image acquisition. the quantity of contrast material needs to be adapted to the patient’s size . May 2007 . the volume of contrast material should be reduced to 70 mL and the timing adjusted accordingly (Table 4). However. Note good opacification of right lower lobe pulmonary arteries (arrows). also note poor opacification of right lower lobe pulmonary arteries (arrows). and additional imaging with V/Q scintigraphy or pulmonary angiography may be necessary. Localized increase in vascular resistance can result from lung consolidation or atelectasis . A regionof-interest measurement may be helpful in this decision if the attenuation is greater than 78 H. a repeat CT will not improve this problem. a central A B Fig. indicating localized increase in vascular resistance in right lower lobe arteries.5 3 2. Streak artifact from high-density contrast material in the superior vena cava can obscure adjacent pulmonary arteries. 2) and can be a cause of misdiagnosis of pulmonary embolism . heightened respiratory movements . Recognition of this phenomenon is important because the poorly opacified vessel may be normal or the poor contrast enhancement may obscure thrombus.5 mL/s using scan delay of 35 seconds. the artery may be enlarged in comparison with pulmonary arteries of the same order of branching [31–33] (Fig. second. In practice. Bristol-Myers Squibb) at rate of 1. or pulmonary angiography. The diagnostic criteria for acute pulmonary embolism include. 2) because image acquisition is performed at the end of the injection. In larger patients.Wittram Streak Artifacts Streak artifact that obscures pulmonary vessels because of metallic implants can make a study indeterminate. However. However. Direct Signs of Acute and Chronic Embolism Both acute and chronic pulmonary emboli are identified as intraluminal filling defects that show a sharp interface with IV contrast material. 2).5 2 Timing Delay (s) 16-MDCT 12 15 18 23 30 64-MDCT 16 18 21 26 33 1258 AJR:188. the clinician might not require further imaging in cases with a low clinical pretest probability for pulmonary embolism. Patient Habitus Two major issues are related to imaging pulmonary arteries of large patients: image noise and the volume of IV contrast material. the reconstruction width will decrease the sensitivity of pulmonary embolism detection . complete arterial occlusion with failure to opacify the entire lumen. Staging CT was performed with injection of 65 mL of Isovue 370 (iopamidol. it is important to be systematic and review one vessel at a time and ignore the consolidation or any other pathology that might distract the attention of the reviewer. 2—Localized increase in vascular resistance in 69-year-old woman with breast cancer who has right-sided talc pleurodesis. Note good opacification of left lower lobe pulmonary arteries (arrowheads). the frequency of this artifact will be reduced with the use of empiric timing delay (Fig. for optimal pulmonary artery enhancement. any case with adequate enhancement and no or minimal motion can be confidently interpreted. B. it is recommended that the radiologist decide at which anatomic level the study is indeterminate. CT pulmonary angiogram 3 days after A using 110 mL of Isovue 370 at 4 mL/s and 22-second scanning delay. as with all radiology interpretation. A. either repeating CTPA with an increased delay or pulmonary angiography. As for reviewing vessels surrounded by consolidation. which is the upper value of acute pulmonary emboli . V/Q scintigraphy (if the lungs are clear on CT). if the radiologist can clear the vessels to the level of the segmental arteries. for example. In this manner. it is likely due to the wider temporal window of contrast injection that occurs with empiric timing delay compared with other techniques (Fig. This image illustrates that peripheral vascular resistance can be overcome with large volume of contrast material injected rapidly and by acquiring images at very end of injection. this is an uncommon artifact with empiric timing delay. For patients weighing more than 250 lb (113 kg). and the subsegmental arteries are indeterminate. it is necessary to increase the radiation dose to decrease the amount of image noise.5 mm. The focal slow pulmonary artery flow can be a cause of an indeterminate CTPA (Fig. Right lower lobe shows volume loss and consolidation. to simplify the protocol. However. Further imaging may be necessary. with ultrasound scan of the legs after hydration. 110 mL of 370 mg I/mL contrast material is used for patients weighing 250 lb (113 kg) or less and 130 mL of 370 mg I/mL contrast material is used for those weighting more than 250 lb (113 kg) (Tables 1 and 2). a repeat CTPA. Further study is required to assess the possible benefits of these maneuvers. first. The frequency of this artifact can be reduced by using a saline bolus immediately after the contrast material injection . For pregnant patients. The Indeterminate CTPA This article discusses the solutions to the common causes of an indeterminate CTPA. the protocol is modified to help decrease display image noise and improve scan quality by increasing reconstruction width to 2. 3).
A mosaic pattern of lung attenuation is identified on the lung window settings. are required to make a diagnosis of acute or chronic pulmonary thromboembolic disease. 3—Acute pulmonary embolism in 27-year-old woman. Additional indirect signs seen in chronic pulmonary embolism include poststenotic dilatation. and enlargement of the bronchial arteries . or a decrease in the flow rate due to acute pulmonary embolism. 5). some morphologic abnormalities that indicate right ventricular failure can be quantified by CTPA. 4). and a subsequent embolism may be fatal. Acute emboli are also noted in right lateral basal segmental and left posterior basal subsegmental arteries. and interstitial lung disease (in which the abnormal lung is more opaque). this finding is more often seen on angiography than on CT. 6). a peripheral intraluminal filling defect that makes an acute angle with the arterial wall [32. AJR:188. enlargement of the main pulmonary artery. 7). a band or web in a contrast-filled artery [32. 33] (Fig. Severity of Acute Pulmonary Embolism After the initial embolic event. 33] (Fig. this discrepancy is thought to be related to the larger temporal window of IV contrast material for CT as compared with angiography. In my experience. A. A Fig. Axial image of thrombus (A) was acquired at level of arrow. and an intraluminal filling defect with an acute pulmonary embolism morphology that has been present for more than 3 months . Centrally located thrombus. May 2007 1259 . a large acute central pulmonary embolism can cause oligemia and a reversible decrease in vessel diameter. Because the indirect signs have a differential diagnosis. 4—Acute pulmonary embolism in 27-year-old woman. Emboli are also noted in right lower lobar and left anteromedial basal segmental arteries. Eccentrically located embolism (arrow) forms acute angle with vessel wall. The diagnostic criteria for chronic pulmonary embolism include complete occlusion of a vessel that is permanently smaller than pulmonary arteries of the same order of branching [32. Right ventricular strain or failure is optimally monitored on echocardiography. as shown on CT angiography. The three major causes of mosaic lung attenuation are airways disease. the patient may be at risk for circulatory collapse secondary to right heart failure. It has been suggested that the early detection of acute right ventricular failure allows the implementation of the most appropriate therapeutic strategy . CT pulmonary angiogram shows thrombus (arrow) that expands diameter of right posterior basal subsegmental artery compared with pulmonary arteries of same order of branching (arrowheads). The most robust CT sign is right ventricular dilation (in which the greatest right ventricle short-axis measurement is wider than the max- Fig. this radiologic sign is difficult to identify in cases of acute pulmonary embolism but manifests as mosaic attenuation in cases of chronic pulmonary embolism. Indirect Signs of Acute and ChronicPulmonary Embolism These signs include nonuniform arterial perfusion for both acute and chronic pulmonary embolism. they are helpful only as indicators of the sites of the direct radiologic signs of pulmonary embolism. B. For a long time we have been at a stage at which the direct radiologic signs. and third. Nonuniform arterial perfusion due to acute pulmonary embolism can uncommonly manifest as a mosaic pattern of attenuation on CT. However.CT Pulmonary Angiography Fig. 33] (Fig. a peripheral eccentric filling defect that makes an obtuse angle with the vessel wall [32. is often identified on angiography [34. 5—Acute pulmonary embolism in 28-year-old woman. this CT equivalent of the Westermark sign has been previously illustrated . has well-defined margins and is completely surrounded by contrast material (arrow). B arterial filling defect surrounded by IV contrast material  (Fig. Curved reformatted image of posterior basal segmental artery of right lower lobe shows that central arterial filling defect (seen in A) cannot occur in isolation without embolism draping over vessel branch point or touching vessel wall at some point. 33] (Fig. 8). Occasionally. Oligemia. contrast material flowing through apparently thickwalled arteries that are smaller due to recanalization [32. 33] (Fig. 35]. 9). chronic pulmonary embolism (in which the abnormal region is more radiolucent). tortuous vessels. in right posterior basal segmental artery.
30%. 2. Conclusion For more than 25 years. A. organized thrombus is identified surrounding column of contrast material (arrowheads). A Fig. Curved coronal reformatted CT image viewed on maximum intensity projection shows abrupt vessel narrowing that affects posterior basal segmental artery of right lower lobe. 20%. 1.2 cm. Curved coronal reformatted CT image viewed on lung window setting shows pouch defect (arrow) of anterior basal segmental artery of right lower lobe. 40%. At more cephalad level. In addition.6. The greater the right ventricle–to–left ventricle short-axis ratio in acute pulmonary embolism. 10—Acute right ventricle dilatation in 33-year-old woman with large acute pulmonary embolism clot burden. maximum short-axis diameter (black rule) of left ventricle measures 3.3 is associated with a 50% chance of death . Contracted or obliterated artery (arrowheads) is shown peripheral to site of chronic obstruction. 6—Chronic pulmonary embolism in 37-year-old woman. 1.2 cm. Fig. eccentric filling defect (arrow) that forms obtuse angle with vessel wall. A ratio of 1. Axial CT image obtained at level of right lower lobe pulmonary artery shows broad-based. Note abrupt convergence of contrast material.9. Axial CT image of right lower lobe pulmonary artery shows band or web (arrow) surrounded by contrast material.Wittram Fig. leading to thin column of more distal IV contrast material (arrow). 8—Chronic pulmonary embolism in 65-year-old man. May 2007 . CT pulmonary angiography right ventricle–to–left ventricle ratio equals 1.1. 10). 7—Chronic pulmonary embolism in 60-year-old man. the greater the risk of death . 1. smoothly margined.0 is associated with a 5% chance of death. which is associated with chronic pulmonary embolism. and a ratio of 2. Subcarinal and right hilar lymphadenopathy is also noted. Fig. 9—Chronic pulmonary embolism in 54-year-old man. B. 10%.3. and this noninvasive technique 1260 AJR:188.7. Maximum short-axis diameter (black rule) of right ventricle measures 5. imum left ventricle short-axis measurement)  (Fig. the direct signs of pulmonary embolism have been available to the radiologist on CT. B Fig.
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