RADIONUCLIDE IMAGING OF ACUTE PULMONARY EMBOLISM

doi:10.1016/S0033-8389(05)70327-4

Radiologic Clinics of North America

Volume 39, Issue 5, 1 September 2001, Pages 1035-1052

https://doi.org/10.1016/S0033-8389(05)70327-4 Get rights and content

Pulmonary embolism (PE) is a relatively common and potentially fatal disorder for which treatment is highly effective and improves patients' survival. The accurate and prompt diagnosis of acute PE requires an interdisciplinary team approach and may be difficult because of nonspecific clinical, laboratory, and radiographic findings.42, 74 The incidence of venous thromboembolism is approximately one in 1000 per year.⁵⁷ Approximately 10% of patients with PE die within 1 hour of the event.¹² In an autopsy series of 4077 patients, deep venous thrombosis (DVT) or PE was present in 24% of cases, and in 14% of cases PE was determined to be the cause of death.⁵⁶ For those patients who survive beyond the first hour following PE, treatment with heparin or thrombolytic agents is effective therapy.3, 7, 12, 24, 25 The overall mortality in patients with PE who are untreated has been reported to be as high as 30%.¹² Mortality from PE is highest among hemodynamically unstable patients and can be as high as 58%.²⁰ In contrast, the correct diagnosis and appropriate therapy significantly lower mortality to between 2.5% and 8%.3, 11 In a meta-analysis of 25 studies including 5523 patients the rate of fatal PE during anticoagulant therapy was 0.4% among patients presenting with DVT and 1.5% among patients presenting with PE.¹⁴ Although anticoagulant therapy is effective in treating PE and reducing mortality, it is not without some risk. The prevalence of major hemorrhagic complications has been reported to be as high as 10% to 15% among patients receiving anticoagulant or thrombolytic therapy.20, 32, 40 In one study investigating drug-related deaths among hospital patients, heparin was responsible for most drug-related deaths in noncritically ill patients.⁴⁶ The accurate and prompt diagnosis of PE is essential not only to prevent excessive mortality but also to avoid complications related to unnecessary anticoagulant therapy.

Section snippets

CLINICAL DIAGNOSIS OF PULMONARY EMBOLISM

In the clinical evaluation of patients with established PE risk factors, clinical signs and symptoms were similar in men and women.⁴⁷ The risk of PE does increase with age. Sedentary lifestyle, prolonged recovery phase following illness, congestive heart failure, malignancy, and increased hip fracture rates in the elderly are factors that increase the likelihood of PE.4, 19 The clinical findings of patients with suspected PE and no pre-existing cardiac or pulmonary disease were evaluated in a

VENTILATION-PERFUSION LUNG SCANNING IN PULMONARY EMBOLISM

The V/Q lung scan has been shown to be a safe noninvasive technique to evaluate regional pulmonary perfusion and ventilation. The technique has been widely used in the evaluation of patients with suspected PE.

PROSPECTIVE TRIALS

Data from multiple prospective and outcome-based large studies have reported on the efficacy of V/Q scanning in patients suspected of having acute PE.26, 27, 28, 30, 34, 45, 73 In a prospective study by Hull et al,²⁷ 874 patients suspected of having PE were enrolled. V/Q scan interpretations were grouped into three diagnostic categories: (1) normal; (2) non–high probability; and (3) high probability (mismatch defect involving at least 75% of a segment). The purpose of the study was to determine

INTERPRETATION CRITERIA

Several diagnostic criteria have been suggested for the interpretation of V/Q lung scans. In a study comparing the various interpretation algorithms, the PIOPED criteria had the highest likelihood ratio for predicting the presence of PE on pulmonary angiography. The PIOPED criteria, however, also had the highest proportion of V/Q scans interpreted as representing an intermediate probability of acute PE.⁷² Several revisions of the original PIOPED criteria have been made based on the observations

VENTILATION-PERFUSION LUNG SCANNING IN THE EVALUATION OF PULMONARY HYPERTENSION

Chronic pulmonary thromboembolism is a serious and potentially surgically treatable cause of PHT. It has been estimated that between 0.5% and 4% of patients with acute PE eventually develop chronic thromboembolic PHT.³⁷ Unfortunately, the clinical features, laboratory investigations, and other noninvasive investigations are often unreliable in distinguishing chronic thromboembolic PHT from primary and nonthromboembolic secondary PHT. Evaluation with pulmonary angiography is usually required to

COMPUTED TOMOGRAPHY ANGIOGRAPHY IN PULMONARY EMBOLISM

Both spiral and helical CT angiography and electron beam CT have been used to visualize and diagnose PE directly.50, 51, 53, 66, 67, 69, 70 With spiral CT angiography data are continuously and rapidly collected as the patient moves through the gantry. Volumetric datasets of the entire lungs can generally be acquired during a single breath, which eliminates respiratory misregistration. Electron beam CT is less widely available and has superior temporal resolution but inferior spatial resolution

PULMONARY ANGIOGRAPHY IN PULMONARY EMBOLISM

Pulmonary angiography has remained the definitive gold standard test for the diagnosis or exclusion of PE. The angiographic diagnosis of acute PE in PIOPED was based on the identification of an intraluminal filling defect or the trailing edge of a thrombus obstructing a vessel. In patients who had angiographic evidence of PE, reader agreement among angiographers was noted to be 86% (331 of 383) of cases. In patients with angiograms interpreted as negative or uncertain, PE reader agreement was

SUMMARY

From the prospective and outcome-based studies that have been carried out in the past few years, the following conclusions regarding the diagnostic evaluation of patients with suspected PE can be made:

1
A normal V/Q scan interpretation excludes the diagnosis of clinically significant PE.
2
Patients with a very-low- or low-probability V/Q scan interpretation and a low clinical likelihood of PE do not require angiography or anticoagulation.
3
Patients with a very-low- or low-probability V/Q scan

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Cited by (15)

Pulmonary Embolism
2012, Emergency Medicine Clinics of North America
Citation Excerpt :
Patients without cardiopulmonary disease had only blunting of the costophrenic angles, and none had an effusion more than one third of the hemithorax.67 Hampton hump is a wedge-shaped, pleural-based, apex central pulmonary opacity that is uncommon and has a sensitivity and specificity of 22% and 82%.111 The Westermark sign is relative oligemia usually in the presence of an ipsilateral dilated PA.
Investigating suspected acute pulmonary embolism - what are hospital clinicians thinking?
2008, Clinical Radiology
To assess local clinical knowledge of the appropriate investigation of suspected acute pulmonary embolism (PE) and this compare with the 2003 British Thoracic Society (BTS) guidelines as a national reference standard.
A clinical questionnaire was produced based on the BTS guidelines. One hundred and eight-six participants completed the questionnaires at educational sessions for clinicians of all grades, within a single NHS Trust. The level of experience amongst participants ranged from final year medical students to consultant physicians.
The clinicians were divided into four groups based on seniority: Pre-registration, Junior, Middle, and Senior. Forty-six point eight percent of all the clinicians correctly identified three major risk factors for PE and 25.8% recognized the definition of the recommended clinical probability score from two alternatives. Statements regarding the sensitivity of isotope lung imaging and computed tomography pulmonary angiography (CTPA) received correct responses from 41.4 and 43% of participants, respectively, whilst 81.2% recognized that an indeterminate ventilation–perfusion scintigraphy (V/Q) study requires further imaging. The majority of clinicians correctly answered three clinical scenario questions regarding use of D-dimers and imaging (78, 85, and 57.5%). There was no statistically significant difference between the four groups for any of the eight questions.
The recommended clinical probability score was unfamiliar to all four groups of clinicians in the present study, and the majority of doctors did not agree that a negative CTPA or isotope lung scintigraphy reliably excluded PE. However, questions based on clinical scenarios received considerably higher rates of correct responses. The results indicate that various aspects of the national guidelines on suspected acute pulmonary embolism are unfamiliar to many UK hospital clinicians. Further research is needed to identify methods to improve this situation, as both clinicians and radiologists have a duty to ensure that patients are appropriately investigated.
Ventilation perfusion scintigraphy and CT: Comparative study in the diagnosis of pulmonary thromboembolism [5]
2006, Medicina Clinica
Diagnosis of suspected venous thromboembolic disease in pregnancy
2006, Clinical Radiology
Venous thromboembolic disease is a leading cause of maternal mortality during pregnancy. Early and accurate radiological diagnosis is essential as anticoagulation is not without risk and clinical diagnosis is unreliable. Although the disorder is potentially treatable, unnecessary treatment should be avoided. Most of the diagnostic imaging techniques involve ionizing radiation which exposes both the mother and fetus to finite radiation risks. There is a relative lack of evidence in the literature to guide clinicians and radiologists on the most appropriate method of assessing this group of patients. This article will review the role of imaging of suspected venous thromboembolic disease in pregnant patients, highlight contentious issues such as radiation risk, intravenous contrast use in pregnancy and discuss the published guidelines, as well as suggesting an appropriate imaging algorithm based on the available evidence.
Helical CT and perfusion scintigraphy: Diagnosis of pulmonary embolus in the clinical practice
2004, Revista Espanola de Medicina Nuclear
El objetivo del presente trabajo fue comparar la tomografía computarizada helicoidal (TCH) y los estudios gammagráficos de perfusión pulmonar (PP) como primer método diagnóstico de tromboembolismo pulmonar (TEP) en la práctica clínica.
Se revisaron retrospectivamente54 pacientes con clínica de TEP agudo. A cada paciente se leasignó una probabilidad clínica pretest de TEP (muy probable,90 %; posible, 50 %; improbable, 10 %). El estudio de PP y laTCH se habían realizado en un intervalo igual o inferior a72 horas. Los estudios de PP se clasificaron siguiendo loscriterios del estudio PISAPED como normal o casi normal,anormal compatible con TEP y anormal no compatible con TEP.Los estudios de TCH se clasificaron como positivo para TEP,negativo para TEP o indeterminado. La referencia estándar fueel consenso basado en la PP, la TCH y la evolución clínica.Resultados: De los 54 pacientes, en 38 estudios los resultadosde la PP y la TCH fueron concordantes, en 13 para eldiagnóstico de TEP y 25 para la ausencia de TEP. Cuatroestudios fueron indeterminados para la TCH. En 12 pacienteslos estudios de PP y la TCH fueron discordantes. Hubo 4 falsosnegativos de la PP; 2 estudios con daño parenquimatoso y2 TEP crónicos. Cinco falsos positivos de la PP; 3 porcompresión vascular extrínseca y con una clínica poco probable.La TCH mostró 1 falso positivo por artefacto respiratorio y2 falsos negativos en trombos de localización subsegmentaria.Conclusión: En la práctica clínica puede realizarse undiagnóstico preciso de TEP agudo combinando la probabilidadclínica pretest con los estudios gammagráficos de perfusiónpulmonar. Los estudios con la TCH añaden información enaquellos pacientes que existe una discordancia entre laprobabilidad clínica y los resultados de la perfusión pulmonar.Los estudios con la TCH demuestran lesiones de distinto origenque el TEP que pueden ser las responsables de lasintomatología del paciente, pero resulta poco sensible para eldiagnóstico del embolismo en vasos subsegmentarios.
The purpose of this study was to compare helical CT with lung perfusion scintigraphy (LPS) as the initial investigations of patients with suspected pulmonary embolism (PE).
A total of 54 patients with clinicallysuspected acute PE were studied retrospectively. Each patientwas assigned a pretest clinical probability of acute PE (very likely,90 %; possible, 50 %; unlikely, 10 %). Within 72 hours ofpresentation, patients underwent LPS and contrastmaterial-enhanced helical CT. Perfusion LS was classifiedfollowing the PISAPED criteria as normal or near normal;abnormal consistent with PE or abnormal not consistent with PE.Helical CT studies were categorized as positive for PE, negativefor PE or non-diagnostic. The standard reference was aconsensus based on LS, helical CT and clinical outcome.Results: In 38 of the 54 patients, the results of LS a hCT wereconcordant, 13 with PE and 25 without. There were4 indeterminate hCT. In 12 patients LS and hCT were discordant.There were 4 LS false negative; 2 with parenchyma damage and2 chronic PE. There were 5 LS false negative; 3 extrinsicvascular compressions and one low clinical probability. Therewas 1 hCT false positive because of breathing artifact and 2 falsenegatives because of subsegmental emboli. Conclusion:Accurate diagnosis of acute PE is possible combining perfusionscanning and clinical probability. Helical CT has addedinformation in patients with discordant clinical probability andperfusion lung scan results. Helical CT demonstrated lesionsother than PE considered responsible for the patient’s symptoms,but it was insensitive to embolism of subsegmental branches.
Pulmonary embolism
2003, Emergency Medicine Clinics of North America

View all citing articles on Scopus

: Address reprint requests to Daniel F. Worsley, MD, University of British Columbia, Division of Nuclear Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, Canada, V5Z 1M9. e-mail: [email protected]

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RADIONUCLIDE IMAGING OF ACUTE PULMONARY EMBOLISM

Section snippets

CLINICAL DIAGNOSIS OF PULMONARY EMBOLISM

VENTILATION-PERFUSION LUNG SCANNING IN PULMONARY EMBOLISM

PROSPECTIVE TRIALS

INTERPRETATION CRITERIA

VENTILATION-PERFUSION LUNG SCANNING IN THE EVALUATION OF PULMONARY HYPERTENSION

COMPUTED TOMOGRAPHY ANGIOGRAPHY IN PULMONARY EMBOLISM

PULMONARY ANGIOGRAPHY IN PULMONARY EMBOLISM

SUMMARY

Chest

Ann Emerg Med

Lancet

Chest

Lancet

Semin Nucl Med

Chest

Chest

Pathol Res Pract

Chest

J Am Coll Cardiol

Am J Cardiol

Chest

Tc-99m-DTPA aerosol and radioactive gases compared as adjuncts to perfusion scintigraphy in patients with suspected PE:

Radiology

Ventilation-perfusion lung imaging and selective pulmonary angiography in dogs with experimental pulmonary emboli

J Nucl Med

Mortality in patients treated for PE

JAMA

A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and PE. The Worcester DVT Study

Arch Intern Med

Opinions regarding the diagnosis and management of venous thromboembolic disease. ACCP Consensus Committee on Pulmonary Embolism

Chest

Opinions regarding the diagnosis and management of venous thromboembolic disease. ACCP Consensus Committee on Pulmonary Embolism

Chest

D-dimer testing and acute venous thromboembolism: A shortcut to accurate diagnosis

Arch Intern Med

Neural networks in radiologic diagnosis: I. Introduction and illustration

Invest Radiol

Scintigraphic imaging of lower-extremity acute venous thrombosis

Advances in Therapy

The clinical course of PE

N Engl J Med

Natural history of PE

Prog Cardiovasc Dis

Ventilation-perfusion lung scintigraphy as a guide for pulmonary angiography in the localization of pulmonary emboli

Radiology

Risk of fatal PE in patients with treated venous thromboembolism

JAMA

Acute PE: Assessment of helical CT for diagnosis

Radiology

The use of modified PIOPED criteria in clinical practice

J Nucl Med

Ultrafast computed tomography in experimental PE

Invest Radiol

Pulmonary embolism

N Engl J Med

Detection of PE in patients with unresolved clinical and scintigraphic diagnosis: Helical CT versus angiography

AJR Am J Roentgenol

Assessment of D dimer assays for the diagnosis of deep vein thrombosis

J Lab Clin Med

Statisical considerations in lung scanning with Tc-99m albumin particles

Radiology

Management of deep vein thrombosis and PE: A statement for healthcare professionals

Circulation

Current concepts of thrombosis: Prevalent trends for diagnosis and management

Med Clin North Am

Cost-effectiveness of PE diagnosis

Arch Intern Med

A new non-invasive management strategy for patients with suspected PE

Arch Intern Med

A non-invasive strategy for the treatment of patients with suspected PE

Arch Intern Med

Evaluation of 99Tcm Technegas ventilation scintigraphy in the diagnosis of PE

Br J Radiol