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. Viewer. (b) Confirmatory CT pulmonary angiogram demonstrates acute pulmonary embolism within the right main and left interlobar pulmonary arteries. 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. (2010) Radiology. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. These entities are caused by poor mixture of unenhanced blood and contrast material or if CT is performed too soon after the start of contrast material injection (,Fig 32). Chest wall abnormalities such as rib fractures and metastatic deposits may also mimic pulmonary embolism. (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. Mucus plugs in an 83-year-old woman with dyspnea. Figure 28b. If the quality of the study is poor, the radiologist should identify which pulmonary arteries have been rendered indeterminate and whether additional imaging is necessary. (Fig 1 modified and Figs 1-3 reprinted, with permission, from reference ,12. 55, No. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow).Download as PowerPointOpen in Image Acute pulmonary embolism in a 59-year-old man. Localized increase in vascular resistance in a 65-year-old man with dyspnea. Pulmonary CT angiography (CTA) has been firmly established as the modality of choice in suspected acute PE [2, 3]. Computed tomographic (CT) pulmonary angiography is becoming the standard of care at many institutions for the evaluation of patients with suspected pulmonary embolism. 33, No. (a) CT scan (window width = 400 HU, window level = 40 HU) demonstrates thrombus within the right interlobar artery (arrow). (a) CT scan shows peribronchovascular interstitial thickening caused by perivascular edema (arrow), a finding that can mimic chronic pulmonary embolism. Figure 22a. However, these artifacts can be removed with a standard algorithm (,,,Fig 27) (,30). On occasion, intravascular thrombosis is identified in a pulmonary artery stump. (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 Chronic pulmonary embolism in the same patient as in ,Figure 11. A region-of-interest measurement may be helpful if the attenuation is greater than 78 HU (,28). Generally, arteries course adjacent to the corresponding bronchi, with the exception of the apical-posterior segment of the left upper lobe and the lingular arteries, which may course independently for a short distance before rejoining the bronchi (,34). (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). Chronic pulmonary embolism can manifest as complete occlusive disease in vessels that are smaller than adjacent patent vessels. 5, Radiologic Clinics of North America, Vol. The posterobasal segment of the right lower lobe bronchus is dilated as well as mucus filled. Contrasted CT-angiography of the chest, often called a "PE protocol CT," has dramatically improved the diagnosis of pulmonary embolism. 5, Journal of the Korean Medical Association, Vol. Figure 36. (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 unenhanced pulmonary veins (arrows), which can mimic complete occlusive pulmonary embolism. Viewer. 3, Journal of Thoracic Imaging, 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. Figure 30b. Figure 20b. Figure 25b. 3, Canadian Association of Radiologists Journal, Vol. 6, No. Figure 23. A detector width of 5 mm may result in partial volume averaging of lymph nodes and vessel that simulates pulmonary embolism. Figure 22b. 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 Sagittal and coronal reformatted images can help identify these normal anatomic structures (,17). For patients with contraindications to conventional catheter pulmonary angiography. However, contiguous images will not demonstrate more apparent filling defects, and the margins are often not sharp. More distally, the pulmonary arteries were well enhanced. This artifact can be eliminated or reduced by reconstructing the raw data with a 50% overlap prior to three-dimensional image reconstruction. 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. 30, No. Figure 17. 188, No. 27, No. Intravenous Contrast Medium Administration and Scan Timing at CT: Considerations and Approaches1. Figure 20b. Viewer. Figure 30c. "Minimizing contrast media dose in CT pulmonary angiography with high-pitch technique". 3, 14 February 2017 | Internal and Emergency Medicine, 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). Note also the medium-sized left pleural effusion and atelectasis. (d) Subsequent angiogram demonstrates slight distortion of the posterobasal segment of the left lower lobe pulmonary artery (arrow) but no evidence of pulmonary embolism. 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). No embolism was present.Download as PowerPointOpen in Image 127, No. (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. 9, The Journal of Emergency Medicine, Vol. Flow-related artifact in a 73-year-old woman with chest pain. 196, No. Acute pulmonary embolism in a 42-year-old man who presented with chest pain and severe dyspnea. (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. 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. 1, Journal of Computer Assisted Tomography, Vol. The apparent pulmonary embolism is ill defined. 41, No. 2, 22 September 2015 | Journal of Magnetic Resonance Imaging, Vol. Figure 38. No timing bolus is necessary unless the patient has a known history of heart disease. 2, American Journal of Roentgenology, Vol. 15, No. The unenhanced or poorly enhanced blood within the affected vessel may mimic pulmonary embolism. Partial volume artifact in a 52-year-old woman with dyspnea. Lung algorithm artifact in a 70-year-old woman with dyspnea. 118, No. Figure 11. CT scan shows a flap (arrow) within a small right interlobar pulmonary artery. The apparent pulmonary embolism is ill defined. Beam-hardening artifact in a 63-year-old man with respiratory failure. 2, 9 May 2016 | Journal of Medical Imaging and Radiation Oncology, Vol. 3, Journal of the Korean Society of Radiology, Vol. These findings indicate the true nature of the patient’s condition.Download as PowerPointOpen in Image (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 18. The apparent pulmonary embolism is ill defined. 5, 1 January 2009 | RadioGraphics, Vol. (e) More oblique angiogram of the left pulmonary artery also demonstrates no evidence of pulmonary embolism (arrow). (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. 62, 7 August 2018 | Current Radiology Reports, Vol. 2, Singapore Medical Journal, Vol. Figure 27b. 55, No. 57, No. (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). 3, Clinics in Chest Medicine, Vol. (a) CT scan shows a flow artifact caused by a localized increase in vascular resistance (arrow), a finding that can mimic acute pulmonary embolism. Viewer. For that reason, your doctor will likely order one or more of the following tests. Ju Hee Yeo, Lifeng Zhou, Remy Lim. 30, No. This partial filling defect surrounded by contrast material produces the polo mint sign (arrow). Figure 35a. Note the collateral blood supply from a branch of the right hemidiaphragmatic artery (arrow).Download as PowerPointOpen in Image This partial filling defect surrounded by contrast material produces the polo mint sign (arrow). Motion artifact renders the diagnosis of pulmonary embolism at this anatomic level indeterminate. The chest field of view is the widest rib-to-rib distance acquired during breath hold after inspiration. 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). Viewer. Figure 28c. 3, 19 March 2018 | Current Radiology Reports, Vol. 2. 93, No. Chronic pulmonary embolism in a 27-year-old man with dyspnea. Each radiology department will have a slightly different method for achieving the same outcome, i.e. 2, Journal of Thoracic Imaging, Vol. Flow-related artifact in a 73-year-old woman with chest pain. Pulmonary embolism CT technique does not use gating. We use pulmonary embolism–specific settings with a window width and level of 700 and 100 HU, respectively (,,,,Fig 25c). (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. Small pulmonary emboli are noted in the left pulmonary artery. Chronic pulmonary embolism in a 60-year-old woman with dyspnea. 184, No. CT pulmonary angiogram is a medical diagnostic test that employs computed tomography angiography to obtain an image of the pulmonary arteries. Figure 35d. 07, No. Indeterminate CT pulmonary angiogram: Why and does it matter? 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