DOI: 10.1148/rg.1103035043
Thrombotic and Nonthrombotic Pulmonary Arterial Embolism: Spectrum of Imaging Findings1
Daehee Han, MD2,
Kyung Soo Lee, MD,
Tomas Franquet, MD,
Nestor L. Müller, MD,
Tae Sung Kim, MD,
Hojoong Kim, MD,
O Jung Kwon, MD and
Hong Sik Byun, MD
1 From the Department of Radiology and Center for Imaging Science (D.H., K.S.L., T.S.K., H.S.B.) and the Division of Pulmonary and Critical Care Medicine (H.K., O.J.K.), Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135–710, Korea; and the Department of Radiology, Vancouver Hospital and Health Sciences Center, Vancouver, British Columbia, Canada (T.F., N.L.M.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 25, 2003; revision requested March 24 and received April 17; accepted April 21. Address correspondence to K.S.L. (e-mail: melon2@samsung.co.kr).
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Figure 1a. Acute pulmonary embolism and deep venous thrombosis (DVT) in a 48-year-old woman. (a) Contrast material-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the basal subsegmental pulmonary artery shows multifocal low-attenuation emboli (arrows) in segmental and subsegmental arteries in the right lower lobe. (b) Contrast-enhanced indirect CT venogram (5-mm collimation) obtained at the level of the pelvic inlet 3 minutes after injection shows large low-attenuation thrombi filling the left common iliac vein (arrow).
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Figure 1b. Acute pulmonary embolism and deep venous thrombosis (DVT) in a 48-year-old woman. (a) Contrast material-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the basal subsegmental pulmonary artery shows multifocal low-attenuation emboli (arrows) in segmental and subsegmental arteries in the right lower lobe. (b) Contrast-enhanced indirect CT venogram (5-mm collimation) obtained at the level of the pelvic inlet 3 minutes after injection shows large low-attenuation thrombi filling the left common iliac vein (arrow).
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Figure 2. Acute pulmonary embolism in a 41-year-old woman. Coronal gadolinium-enhanced three-dimensional pulmonary MR angiogram shows a large embolus (arrows) in the proximal right interlobar artery. (Courtesy of Jin Sung Lee, MD, Asan Medical Center, Seoul, Korea.)
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Figure 3a. Chronic pulmonary embolism in a 55-year-old man. (a) Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly. (b) Contrast-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right interlobar pulmonary artery (arrows). (c) Perfusion lung scan (right posterior oblique view) obtained after administration of Tc-99m macroaggregated albumin shows multisegmental defects, which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas (not shown). (d) Pulmonary arteriogram shows abrupt cutoff in rounded fashion (pouching defect) of the lower lobar arteries (arrow). (e) Photograph of the thromboembolectomy specimen shows organized emboli filling the enlarged central pulmonary arteries. Note how the central thrombus is organized in concave fashion, creating a pouching defect (arrows).
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Figure 3b. Chronic pulmonary embolism in a 55-year-old man. (a) Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly. (b) Contrast-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right interlobar pulmonary artery (arrows). (c) Perfusion lung scan (right posterior oblique view) obtained after administration of Tc-99m macroaggregated albumin shows multisegmental defects, which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas (not shown). (d) Pulmonary arteriogram shows abrupt cutoff in rounded fashion (pouching defect) of the lower lobar arteries (arrow). (e) Photograph of the thromboembolectomy specimen shows organized emboli filling the enlarged central pulmonary arteries. Note how the central thrombus is organized in concave fashion, creating a pouching defect (arrows).
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Figure 3c. Chronic pulmonary embolism in a 55-year-old man. (a) Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly. (b) Contrast-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right interlobar pulmonary artery (arrows). (c) Perfusion lung scan (right posterior oblique view) obtained after administration of Tc-99m macroaggregated albumin shows multisegmental defects, which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas (not shown). (d) Pulmonary arteriogram shows abrupt cutoff in rounded fashion (pouching defect) of the lower lobar arteries (arrow). (e) Photograph of the thromboembolectomy specimen shows organized emboli filling the enlarged central pulmonary arteries. Note how the central thrombus is organized in concave fashion, creating a pouching defect (arrows).
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Figure 3d. Chronic pulmonary embolism in a 55-year-old man. (a) Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly. (b) Contrast-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right interlobar pulmonary artery (arrows). (c) Perfusion lung scan (right posterior oblique view) obtained after administration of Tc-99m macroaggregated albumin shows multisegmental defects, which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas (not shown). (d) Pulmonary arteriogram shows abrupt cutoff in rounded fashion (pouching defect) of the lower lobar arteries (arrow). (e) Photograph of the thromboembolectomy specimen shows organized emboli filling the enlarged central pulmonary arteries. Note how the central thrombus is organized in concave fashion, creating a pouching defect (arrows).
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Figure 3e. Chronic pulmonary embolism in a 55-year-old man. (a) Chest radiograph shows enlargement of the central pulmonary arteries along with cardiomegaly. (b) Contrast-enhanced pulmonary CT arteriogram (1.25-mm collimation) obtained at the level of the bronchus intermedius shows eccentric thrombus along the medial margin of the narrowed right interlobar pulmonary artery (arrows). (c) Perfusion lung scan (right posterior oblique view) obtained after administration of Tc-99m macroaggregated albumin shows multisegmental defects, which did not match the findings seen on a ventilation lung scan obtained with Tc-99m Technegas (not shown). (d) Pulmonary arteriogram shows abrupt cutoff in rounded fashion (pouching defect) of the lower lobar arteries (arrow). (e) Photograph of the thromboembolectomy specimen shows organized emboli filling the enlarged central pulmonary arteries. Note how the central thrombus is organized in concave fashion, creating a pouching defect (arrows).
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Figure 4a. Chronic pulmonary embolism in a 62-year-old woman. (a) Unenhanced thin-section (1-mm collimation) CT scan obtained at the level of the right inferior pulmonary vein shows calcified thrombi (arrows) in the right middle and lower lobe arteries. (b) CT scan (lung window) obtained at the level of the basal portion of the left lung shows mosaic areas of hypoperfusion (large arrows). Note also the nodular branching structure (small arrow), a finding that suggests bronchiolitis.
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Figure 4b. Chronic pulmonary embolism in a 62-year-old woman. (a) Unenhanced thin-section (1-mm collimation) CT scan obtained at the level of the right inferior pulmonary vein shows calcified thrombi (arrows) in the right middle and lower lobe arteries. (b) CT scan (lung window) obtained at the level of the basal portion of the left lung shows mosaic areas of hypoperfusion (large arrows). Note also the nodular branching structure (small arrow), a finding that suggests bronchiolitis.
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Figure 5a. Septic pulmonary embolism in a 28-year-old intravenous drug abuser with human immunodeficiency viral infection. Repeated blood cultures disclosed a positive culture for Nocardia. (a) Radiograph shows multiple cavitary nodules throughout both lungs. (b) CT scan (10-mm collimation) obtained at the level of the azygos arch demonstrates the feeding vessel sign (vessel leading directly to the nodule) in several nodules (arrows).
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Figure 5b. Septic pulmonary embolism in a 28-year-old intravenous drug abuser with human immunodeficiency viral infection. Repeated blood cultures disclosed a positive culture for Nocardia. (a) Radiograph shows multiple cavitary nodules throughout both lungs. (b) CT scan (10-mm collimation) obtained at the level of the azygos arch demonstrates the feeding vessel sign (vessel leading directly to the nodule) in several nodules (arrows).
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Figure 6a. Pulmonary hydatid embolism caused by rupture of a mediastinal hydatid cyst into the right pulmonary artery in a 22-year-old woman. The patient underwent pulmonary transplantation due to severe pulmonary arterial hypertension. (a) CT scan (5-mm collimation, lung window) obtained at the level of the left inferior pulmonary vein shows enlarged or engorged branches of the pulmonary arteries in the bilateral lower lung zones (arrows). (b) Photomicrograph (original magnification, x12; elastic stain) of the pathologic specimen shows a multilayered membrane of a hydatid cyst filling the pulmonary artery lumen.
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Figure 6b. Pulmonary hydatid embolism caused by rupture of a mediastinal hydatid cyst into the right pulmonary artery in a 22-year-old woman. The patient underwent pulmonary transplantation due to severe pulmonary arterial hypertension. (a) CT scan (5-mm collimation, lung window) obtained at the level of the left inferior pulmonary vein shows enlarged or engorged branches of the pulmonary arteries in the bilateral lower lung zones (arrows). (b) Photomicrograph (original magnification, x12; elastic stain) of the pathologic specimen shows a multilayered membrane of a hydatid cyst filling the pulmonary artery lumen.
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Figure 7a. Fat embolism in a 58-year-old woman who presented with sudden dyspnea. The patient had undergone intramuscular injection of some fatty materials into the buttock several days earlier. (a) Radiograph shows bilateral ground-glass areas of increased opacity. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the aortic arch shows widespread patchy ground-glass attenuation and consolidation. A follow-up radiograph obtained 10 days later (not shown) revealed complete resolution of the ground-glass patterns. (Case courtesy of Jin Sung Lee, MD, Asan Medical Center, Seoul, Korea.)
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Figure 7b. Fat embolism in a 58-year-old woman who presented with sudden dyspnea. The patient had undergone intramuscular injection of some fatty materials into the buttock several days earlier. (a) Radiograph shows bilateral ground-glass areas of increased opacity. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the aortic arch shows widespread patchy ground-glass attenuation and consolidation. A follow-up radiograph obtained 10 days later (not shown) revealed complete resolution of the ground-glass patterns. (Case courtesy of Jin Sung Lee, MD, Asan Medical Center, Seoul, Korea.)
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Figure 8a. Amniotic fluid embolism in a 40-year-old woman. The patient experienced sudden respiratory distress shortly after giving birth by cesarean section. (a) Radiograph shows bilateral widespread airspace consolidation. Endotracheal intubation was performed. (b) On a follow-up radiograph obtained 3 days later, the extent of the parenchymal areas of increased opacity has decreased. A chest tube was inserted into the right pleural space to relieve the right pleural effusion.
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Figure 8b. Amniotic fluid embolism in a 40-year-old woman. The patient experienced sudden respiratory distress shortly after giving birth by cesarean section. (a) Radiograph shows bilateral widespread airspace consolidation. Endotracheal intubation was performed. (b) On a follow-up radiograph obtained 3 days later, the extent of the parenchymal areas of increased opacity has decreased. A chest tube was inserted into the right pleural space to relieve the right pleural effusion.
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Figure 9a. Tumor embolism from cholangiocarcinoma in a 62-year-old man. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the basal segmental bronchi shows a pleura-based, wedge-shaped area of high attenuation (large arrows) and numerous nodules, some of which demonstrate tree-in-bud appearance (small arrows). (b) Photomicrograph (original magnification, x12; hematoxylin-eosin [H-E] stain) of the biopsy specimen obtained at video-assisted thoracoscopic surgery demonstrates endovascular tumor emboli (thin arrow) surrounded by infarcted lung tissue (thick arrows). (Case courtesy of Eun-Young Kang, MD, Korea University Guro Hospital, Seoul, Korea.)
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Figure 9b. Tumor embolism from cholangiocarcinoma in a 62-year-old man. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the basal segmental bronchi shows a pleura-based, wedge-shaped area of high attenuation (large arrows) and numerous nodules, some of which demonstrate tree-in-bud appearance (small arrows). (b) Photomicrograph (original magnification, x12; hematoxylin-eosin [H-E] stain) of the biopsy specimen obtained at video-assisted thoracoscopic surgery demonstrates endovascular tumor emboli (thin arrow) surrounded by infarcted lung tissue (thick arrows). (Case courtesy of Eun-Young Kang, MD, Korea University Guro Hospital, Seoul, Korea.)
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Figure 10a. Pulmonary tumor thrombotic microangiopathy caused by metastatic gastric carcinoma in a 57-year-old man. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the left basal trunk shows multifocal tree-in-bud appearances (arrows) caused by tumor emboli. (b) Photograph of the autopsy specimen shows accentuated and enlarged centrilobular axial interstitium in the peripheral lung (arrows), a finding that corresponds to the tree-in-bud appearance seen at CT. (c) Photomicrograph (original magnification, x40; H-E stain) of an arteriole shows small nests of tumor cells (arrows). The vessel lumen is occluded mainly by lamellated fibrointimal proliferation that surrounds the tumor cell nests.
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Figure 10b. Pulmonary tumor thrombotic microangiopathy caused by metastatic gastric carcinoma in a 57-year-old man. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the left basal trunk shows multifocal tree-in-bud appearances (arrows) caused by tumor emboli. (b) Photograph of the autopsy specimen shows accentuated and enlarged centrilobular axial interstitium in the peripheral lung (arrows), a finding that corresponds to the tree-in-bud appearance seen at CT. (c) Photomicrograph (original magnification, x40; H-E stain) of an arteriole shows small nests of tumor cells (arrows). The vessel lumen is occluded mainly by lamellated fibrointimal proliferation that surrounds the tumor cell nests.
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Figure 10c. Pulmonary tumor thrombotic microangiopathy caused by metastatic gastric carcinoma in a 57-year-old man. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the left basal trunk shows multifocal tree-in-bud appearances (arrows) caused by tumor emboli. (b) Photograph of the autopsy specimen shows accentuated and enlarged centrilobular axial interstitium in the peripheral lung (arrows), a finding that corresponds to the tree-in-bud appearance seen at CT. (c) Photomicrograph (original magnification, x40; H-E stain) of an arteriole shows small nests of tumor cells (arrows). The vessel lumen is occluded mainly by lamellated fibrointimal proliferation that surrounds the tumor cell nests.
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Figure 11. Incidentally found air embolism in an asymptomatic 59-year-old man. Routine contrast-enhanced chest CT scan (5-mm collimation) shows two small air bubbles in the main pulmonary artery (arrows).
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Figure 12a. Talc embolism in a 26-year-old woman. The patient had a 4-year history of heroin and methadone abuse. (a) Targeted view of the left lung from a chest radiograph shows widespread involvement of the lung by pinpoint micronodules. (b) CT scan (5-mm collimation, lung window) obtained at the level of the basal trunk shows extensive patchy areas of increased attenuation in both lungs. (c) Follow-up radiograph obtained 6 years later shows coalescent areas of increased opacity (progressive massive fibrosis) in the bilateral middle lung zones (arrows). Note also the emphysematous right upper lung zone. (d) Thin-section (1.5-mm collimation) CT scan (mediastinal window) obtained at the subcarinal level shows coalescent areas of increased attenuation (progressive massive fibrosis) posteriorly in both lungs. Note also the areas of high attenuation within the masses (arrow), a finding that suggests talc deposition.
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Figure 12b. Talc embolism in a 26-year-old woman. The patient had a 4-year history of heroin and methadone abuse. (a) Targeted view of the left lung from a chest radiograph shows widespread involvement of the lung by pinpoint micronodules. (b) CT scan (5-mm collimation, lung window) obtained at the level of the basal trunk shows extensive patchy areas of increased attenuation in both lungs. (c) Follow-up radiograph obtained 6 years later shows coalescent areas of increased opacity (progressive massive fibrosis) in the bilateral middle lung zones (arrows). Note also the emphysematous right upper lung zone. (d) Thin-section (1.5-mm collimation) CT scan (mediastinal window) obtained at the subcarinal level shows coalescent areas of increased attenuation (progressive massive fibrosis) posteriorly in both lungs. Note also the areas of high attenuation within the masses (arrow), a finding that suggests talc deposition.
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Figure 12c. Talc embolism in a 26-year-old woman. The patient had a 4-year history of heroin and methadone abuse. (a) Targeted view of the left lung from a chest radiograph shows widespread involvement of the lung by pinpoint micronodules. (b) CT scan (5-mm collimation, lung window) obtained at the level of the basal trunk shows extensive patchy areas of increased attenuation in both lungs. (c) Follow-up radiograph obtained 6 years later shows coalescent areas of increased opacity (progressive massive fibrosis) in the bilateral middle lung zones (arrows). Note also the emphysematous right upper lung zone. (d) Thin-section (1.5-mm collimation) CT scan (mediastinal window) obtained at the subcarinal level shows coalescent areas of increased attenuation (progressive massive fibrosis) posteriorly in both lungs. Note also the areas of high attenuation within the masses (arrow), a finding that suggests talc deposition.
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Figure 12d. Talc embolism in a 26-year-old woman. The patient had a 4-year history of heroin and methadone abuse. (a) Targeted view of the left lung from a chest radiograph shows widespread involvement of the lung by pinpoint micronodules. (b) CT scan (5-mm collimation, lung window) obtained at the level of the basal trunk shows extensive patchy areas of increased attenuation in both lungs. (c) Follow-up radiograph obtained 6 years later shows coalescent areas of increased opacity (progressive massive fibrosis) in the bilateral middle lung zones (arrows). Note also the emphysematous right upper lung zone. (d) Thin-section (1.5-mm collimation) CT scan (mediastinal window) obtained at the subcarinal level shows coalescent areas of increased attenuation (progressive massive fibrosis) posteriorly in both lungs. Note also the areas of high attenuation within the masses (arrow), a finding that suggests talc deposition.
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Figure 13a. Talc embolism in a 37-year-old male drug abuser. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the left interlobar artery shows diffuse pulmonary involvement with ill-defined centrilobular small nodules (arrows). Note also the nodular branching structures (tree-in-bud appearance). (b) Photomicrograph (original magnification, x40; H-E stain) of the pathologic specimen shows necrotizing vasculitis at the center of the secondary pulmonary lobule (arrow).
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Figure 13b. Talc embolism in a 37-year-old male drug abuser. (a) Thin-section (1.5-mm collimation) CT scan obtained at the level of the left interlobar artery shows diffuse pulmonary involvement with ill-defined centrilobular small nodules (arrows). Note also the nodular branching structures (tree-in-bud appearance). (b) Photomicrograph (original magnification, x40; H-E stain) of the pathologic specimen shows necrotizing vasculitis at the center of the secondary pulmonary lobule (arrow).
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Figure 14a. Iodinated oil embolism in a 45-year-old woman with sudden dyspnea. The patient had a large primary liver carcinoma containing arteriovenous shunting and had undergone transarterial hepatic chemoembolization with a mixture of adriamycin and iodinated oil (Lipiodol; Guerbet, Roissy, France) 1 day earlier. (a) Chest radiograph obtained 1 day after chemoembolization shows patchy areas of lung nodules and consolidation bilaterally. Note also the multifocal areas of iodinated oil uptake in the liver (arrows). (b) Thin-section (1-mm collimation) CT scan (lung window) obtained at the level of the inferior pulmonary vein shows multifocal patchy areas of ground-glass attenuation in both lungs. Several high-attenuation nodules are also noted (arrows). (c) Thin-section (1-mm collimation) CT scan (targeted mediastinal window) obtained at the same level as b shows nodules with calcific attenuation in the right lower lobe (arrows), a finding that suggests iodinated oil uptake in metastatic nodules.
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Figure 14b. Iodinated oil embolism in a 45-year-old woman with sudden dyspnea. The patient had a large primary liver carcinoma containing arteriovenous shunting and had undergone transarterial hepatic chemoembolization with a mixture of adriamycin and iodinated oil (Lipiodol; Guerbet, Roissy, France) 1 day earlier. (a) Chest radiograph obtained 1 day after chemoembolization shows patchy areas of lung nodules and consolidation bilaterally. Note also the multifocal areas of iodinated oil uptake in the liver (arrows). (b) Thin-section (1-mm collimation) CT scan (lung window) obtained at the level of the inferior pulmonary vein shows multifocal patchy areas of ground-glass attenuation in both lungs. Several high-attenuation nodules are also noted (arrows). (c) Thin-section (1-mm collimation) CT scan (targeted mediastinal window) obtained at the same level as b shows nodules with calcific attenuation in the right lower lobe (arrows), a finding that suggests iodinated oil uptake in metastatic nodules.
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Figure 14c. Iodinated oil embolism in a 45-year-old woman with sudden dyspnea. The patient had a large primary liver carcinoma containing arteriovenous shunting and had undergone transarterial hepatic chemoembolization with a mixture of adriamycin and iodinated oil (Lipiodol; Guerbet, Roissy, France) 1 day earlier. (a) Chest radiograph obtained 1 day after chemoembolization shows patchy areas of lung nodules and consolidation bilaterally. Note also the multifocal areas of iodinated oil uptake in the liver (arrows). (b) Thin-section (1-mm collimation) CT scan (lung window) obtained at the level of the inferior pulmonary vein shows multifocal patchy areas of ground-glass attenuation in both lungs. Several high-attenuation nodules are also noted (arrows). (c) Thin-section (1-mm collimation) CT scan (targeted mediastinal window) obtained at the same level as b shows nodules with calcific attenuation in the right lower lobe (arrows), a finding that suggests iodinated oil uptake in metastatic nodules.
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Figure 15. Cement embolism in a 29-year-old woman. The patient had recently undergone cyanoacrylate embolization for intracerebral arteriovenous malformation. Targeted view of the right lung from a chest radiograph shows widespread small pulmonary nodules with increased opacity, a finding that represents cement emboli.
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Figure 16a. Polymethylmethacrylate embolism following percutaneous vertebroplasty in a 64-year-old woman. (a) CT scan (7-mm collimation, mediastinal window) obtained at the level of the inferior portion of the left atrium shows radiopaque emboli in the segmental and subsegmental levels of the pulmonary arteries (arrows). (b) CT scan obtained at the level of the pelvic inlet shows tortuous paravertebral veins filled with polymethylmethacrylate (arrows). The vertebral body has been reinforced with this material. (Case courtesy of Joon Beom Seo, MD, Asan Medical Center, Seoul, Korea.)
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Figure 16b. Polymethylmethacrylate embolism following percutaneous vertebroplasty in a 64-year-old woman. (a) CT scan (7-mm collimation, mediastinal window) obtained at the level of the inferior portion of the left atrium shows radiopaque emboli in the segmental and subsegmental levels of the pulmonary arteries (arrows). (b) CT scan obtained at the level of the pelvic inlet shows tortuous paravertebral veins filled with polymethylmethacrylate (arrows). The vertebral body has been reinforced with this material. (Case courtesy of Joon Beom Seo, MD, Asan Medical Center, Seoul, Korea.)
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Figure 17a. Catheter embolism in a 60-year-old woman. (a) Targeted view of the left lung from a chest radiograph shows a catheter in the lung base (arrow). (b) CT scan (10-mm collimation) obtained at the ventricular level shows the severed central venous catheter in the left lower lobe (arrow).
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Figure 17b. Catheter embolism in a 60-year-old woman. (a) Targeted view of the left lung from a chest radiograph shows a catheter in the lung base (arrow). (b) CT scan (10-mm collimation) obtained at the ventricular level shows the severed central venous catheter in the left lower lobe (arrow).
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Copyright © 2003 by the Radiological Society of North America.
