The introduction of spiral CT has recently modified the diagnostic work-up of pulmonary embolism, because it is possible to depict noninvasively endoluminal clots in second-to-fourth-division pulmonary arteries. If this technique is currently considered a powerful imaging alternative for the detection of acute central emboli, it is mainly related to the possibility to obtain a uniform and high degree of arterial enhancement of pulmonary arteries down to 2-3 mm in diameter. Minimal experience in spiral CT angiography is necessary to achieve this goal and requires familiarity with both data acquisition and contrast medium injection. Numerous interpretive pitfalls exist in assessing spiral CT images, and certain caveats have to be heeded. However, their recognition becomes increasingly less problematic as the radiologist gains experience with spiral CT of the pulmonary vasculature. Therefore, the purpose of this article is to review the diagnostic approach to pulmonary embolism with spiral CT, with special emphasis on protocol parameters and scan interpretation.