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DOI: 10.1148/rg.261055062
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Can CT Pulmonary Angiography Allow Assessment of Severity and Prognosis in Patients Presenting with Pulmonary Embolism? What the Radiologist Needs to Know1

Benoît Ghaye, MD, Alexandre Ghuysen, MD, Pierre-Julien Bruyere, MD, Vincent D’Orio, MD, PhD and Robert F. Dondelinger, MD

1 From the Departments of Medical Imaging (B.G., P.J.B., R.F.D.) and Medicine (A.G., V.D.), University Hospital of Liege, Sart Tilman B35, B-4000 Liege, Belgium. Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received March 24, 2005; revision requested April 28 and received July 11; accepted August 18. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1.  Pathophysiologic cycle of major PE (4,5).

 

Figure 2
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  		Figure 2a.  Measurement of the short axes of the RV and LV on axial CT pulmonary angiograms. (a) The short axis of the RV is measured at the level of the tricuspid valve from inner wall to inner wall at the widest point, which is typically in the basal third of the ventricle. (b) The short axis of the LV is measured at the level of the mitral valve from inner wall to inner wall at the widest point, which also is typically in the basal third of the ventricle. Note that the short axes of the RV and LV may be located at different axial CT levels.

 

Figure 2
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  		Figure 2b.  Measurement of the short axes of the RV and LV on axial CT pulmonary angiograms. (a) The short axis of the RV is measured at the level of the tricuspid valve from inner wall to inner wall at the widest point, which is typically in the basal third of the ventricle. (b) The short axis of the LV is measured at the level of the mitral valve from inner wall to inner wall at the widest point, which also is typically in the basal third of the ventricle. Note that the short axes of the RV and LV may be located at different axial CT levels.

 

Figure 3
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  		Figure 3a.  Measurement of the short axes of the RV and LV on a reformatted four-chamber CT image obtained in a 54-year-old patient with nonsevere PE. Dashed lines on sagittal (a) and coronal (b) CT images of the heart are rotated to obtain the four-chamber image (c). The short axes of the RV and LV are 44.7 mm and 45.6 mm, respectively, resulting in a normal RV/LV diameter ratio of less than 1.

 

Figure 3
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  		Figure 3b.  Measurement of the short axes of the RV and LV on a reformatted four-chamber CT image obtained in a 54-year-old patient with nonsevere PE. Dashed lines on sagittal (a) and coronal (b) CT images of the heart are rotated to obtain the four-chamber image (c). The short axes of the RV and LV are 44.7 mm and 45.6 mm, respectively, resulting in a normal RV/LV diameter ratio of less than 1.

 

Figure 3
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  		Figure 3c.  Measurement of the short axes of the RV and LV on a reformatted four-chamber CT image obtained in a 54-year-old patient with nonsevere PE. Dashed lines on sagittal (a) and coronal (b) CT images of the heart are rotated to obtain the four-chamber image (c). The short axes of the RV and LV are 44.7 mm and 45.6 mm, respectively, resulting in a normal RV/LV diameter ratio of less than 1.

 

Figure 4
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  		Figure 4.  Moderate acute dilatation of the RV in a 55-year-old man with massive PE. Four-chamber CT image shows measurements for the short axes of the RV and LV, resulting in an RV/LV diameter ratio of 1.7. Note the PE in the right lower lobe PA (arrow).

 

Figure 5
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  		Figure 5a.  Calculation of PA clot load scores at CT pulmonary angiography in a 70-year-old woman who presented with cardiovascular shock. She underwent fibrinolytic therapy but died of PE 24 hours after admission. Axial CT pulmonary angiograms (displayed from inferior [a] to superior [e]) show multiple clots in the PAs. The PA clot load scores calculated according to Miller et al (45), Walsh et al (46), Qanadli et al (47), and Mastora et al (48) were 94%, 61%, 57%, and 57%, respectively.

 

Figure 5
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  		Figure 5b.  Calculation of PA clot load scores at CT pulmonary angiography in a 70-year-old woman who presented with cardiovascular shock. She underwent fibrinolytic therapy but died of PE 24 hours after admission. Axial CT pulmonary angiograms (displayed from inferior [a] to superior [e]) show multiple clots in the PAs. The PA clot load scores calculated according to Miller et al (45), Walsh et al (46), Qanadli et al (47), and Mastora et al (48) were 94%, 61%, 57%, and 57%, respectively.

 

Figure 5
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  		Figure 5c.  Calculation of PA clot load scores at CT pulmonary angiography in a 70-year-old woman who presented with cardiovascular shock. She underwent fibrinolytic therapy but died of PE 24 hours after admission. Axial CT pulmonary angiograms (displayed from inferior [a] to superior [e]) show multiple clots in the PAs. The PA clot load scores calculated according to Miller et al (45), Walsh et al (46), Qanadli et al (47), and Mastora et al (48) were 94%, 61%, 57%, and 57%, respectively.

 

Figure 5
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  		Figure 5d.  Calculation of PA clot load scores at CT pulmonary angiography in a 70-year-old woman who presented with cardiovascular shock. She underwent fibrinolytic therapy but died of PE 24 hours after admission. Axial CT pulmonary angiograms (displayed from inferior [a] to superior [e]) show multiple clots in the PAs. The PA clot load scores calculated according to Miller et al (45), Walsh et al (46), Qanadli et al (47), and Mastora et al (48) were 94%, 61%, 57%, and 57%, respectively.

 

Figure 5
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  		Figure 5e.  Calculation of PA clot load scores at CT pulmonary angiography in a 70-year-old woman who presented with cardiovascular shock. She underwent fibrinolytic therapy but died of PE 24 hours after admission. Axial CT pulmonary angiograms (displayed from inferior [a] to superior [e]) show multiple clots in the PAs. The PA clot load scores calculated according to Miller et al (45), Walsh et al (46), Qanadli et al (47), and Mastora et al (48) were 94%, 61%, 57%, and 57%, respectively.

 

Figure 6
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  		Figure 6.  Acute dilatation of the RV with leftward septal bowing in a 68-year-old woman who presented with severe dyspnea and severe hypotension. CT pulmonary angiography showed massive PE, and the PA clot load score calculated according to Qanadli et al (47) was 57%. She underwent a Trendelenburg intervention but died during the first 24 hours after admission. Axial CT pulmonary angiogram obtained at the level of the heart shows signs of cor pulmonale. Note the severe dilatation of the RV and the compression of the LV: The short-axis diameters of the RV and LV were 59.4 mm and 24 mm, respectively, and the RV/LV diameter ratio was 2.5. Also note the leftward bowing of the inter-ventricular septum (arrowhead).

 

Figure 7
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  		Figure 7a.  Severe dilatation of the RV with septal flattening in diastole in a 67-year-old woman with massive PE. The patient underwent fibrinolytic therapy immediately after diagnosis. (a, b) CT images of the short axes of the ventricles show that the RV is severely dilated relative to the LV. Unlike the LV, the RV demonstrates little variation in volume between systole (a) and diastole (b). Note the flattening of the interventricular septum in diastole. (c) CT image shows quantification of the septal flattening. The thin black lines delineate the endocardial borders of the inter-ventricular septum. The white lines are drawn perpendicular to the thin black lines at the mid distances of the endocardial borders. The radius of the interventricular septum (RIVS) is measured from the intersection of the white lines to the endocardial border (53).

 

Figure 7
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  		Figure 7b.  Severe dilatation of the RV with septal flattening in diastole in a 67-year-old woman with massive PE. The patient underwent fibrinolytic therapy immediately after diagnosis. (a, b) CT images of the short axes of the ventricles show that the RV is severely dilated relative to the LV. Unlike the LV, the RV demonstrates little variation in volume between systole (a) and diastole (b). Note the flattening of the interventricular septum in diastole. (c) CT image shows quantification of the septal flattening. The thin black lines delineate the endocardial borders of the inter-ventricular septum. The white lines are drawn perpendicular to the thin black lines at the mid distances of the endocardial borders. The radius of the interventricular septum (RIVS) is measured from the intersection of the white lines to the endocardial border (53).

 

Figure 7
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  		Figure 7c.  Severe dilatation of the RV with septal flattening in diastole in a 67-year-old woman with massive PE. The patient underwent fibrinolytic therapy immediately after diagnosis. (a, b) CT images of the short axes of the ventricles show that the RV is severely dilated relative to the LV. Unlike the LV, the RV demonstrates little variation in volume between systole (a) and diastole (b). Note the flattening of the interventricular septum in diastole. (c) CT image shows quantification of the septal flattening. The thin black lines delineate the endocardial borders of the inter-ventricular septum. The white lines are drawn perpendicular to the thin black lines at the mid distances of the endocardial borders. The radius of the interventricular septum (RIVS) is measured from the intersection of the white lines to the endocardial border (53).

 

Figure 8
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  		Figure 8a.  Perfusion of the lung parenchyma assessed with subtraction color-coded CT after experimental clot embolization in the PAs of a pig. Axial (a), coronal (b), and sagittal (c) CT images show multiple subsegmental perfusion defects, which are displayed in blue (arrow). The triangular perfusion defects are suggestive of emboli in small peripheral PAs. On the coronal and sagittal images, note the additional occluding subsegmental emboli (arrowhead in b and c) with resulting small peripheral perfusion defects (arrow). (Courtesy of Joachim Wildberger, MD, University Hospital of Aachen, Germany.)

 

Figure 8
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  		Figure 8b.  Perfusion of the lung parenchyma assessed with subtraction color-coded CT after experimental clot embolization in the PAs of a pig. Axial (a), coronal (b), and sagittal (c) CT images show multiple subsegmental perfusion defects, which are displayed in blue (arrow). The triangular perfusion defects are suggestive of emboli in small peripheral PAs. On the coronal and sagittal images, note the additional occluding subsegmental emboli (arrowhead in b and c) with resulting small peripheral perfusion defects (arrow). (Courtesy of Joachim Wildberger, MD, University Hospital of Aachen, Germany.)

 

Figure 8
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  		Figure 8c.  Perfusion of the lung parenchyma assessed with subtraction color-coded CT after experimental clot embolization in the PAs of a pig. Axial (a), coronal (b), and sagittal (c) CT images show multiple subsegmental perfusion defects, which are displayed in blue (arrow). The triangular perfusion defects are suggestive of emboli in small peripheral PAs. On the coronal and sagittal images, note the additional occluding subsegmental emboli (arrowhead in b and c) with resulting small peripheral perfusion defects (arrow). (Courtesy of Joachim Wildberger, MD, University Hospital of Aachen, Germany.)

 

Figure 9
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  		Figure 9a.  Calculation of the RV ejection fraction with CT in a 67-year-old woman with massive PE (same patient as in Fig 7). (a) After ECG-gated CT pulmonary angiography, the box for short-axis reformation is applied inside the CT raw data volume (images at top of computer screen). Reformatted short-axis CT sections are usually 5–8 mm thick. Multiple series of reformatted images are obtained every 5%–10% of the R-R cycle. (b) Computer screen shows series of short-axis images of the heart, which were generated every 10% of the R-R cycle. Manual contouring was then performed along the inner wall of the RV for each series by using dedicated software (Argus; Siemens Medical Solutions, Erlangen, Germany). (c) List of the results provided by the software shows that the end-systolic and end-diastolic volumes are dramatically enlarged, whereas the ejection fraction is reduced to 17%.

 

Figure 9
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  		Figure 9b.  Calculation of the RV ejection fraction with CT in a 67-year-old woman with massive PE (same patient as in Fig 7). (a) After ECG-gated CT pulmonary angiography, the box for short-axis reformation is applied inside the CT raw data volume (images at top of computer screen). Reformatted short-axis CT sections are usually 5–8 mm thick. Multiple series of reformatted images are obtained every 5%–10% of the R-R cycle. (b) Computer screen shows series of short-axis images of the heart, which were generated every 10% of the R-R cycle. Manual contouring was then performed along the inner wall of the RV for each series by using dedicated software (Argus; Siemens Medical Solutions, Erlangen, Germany). (c) List of the results provided by the software shows that the end-systolic and end-diastolic volumes are dramatically enlarged, whereas the ejection fraction is reduced to 17%.

 

Figure 9
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  		Figure 9c.  Calculation of the RV ejection fraction with CT in a 67-year-old woman with massive PE (same patient as in Fig 7). (a) After ECG-gated CT pulmonary angiography, the box for short-axis reformation is applied inside the CT raw data volume (images at top of computer screen). Reformatted short-axis CT sections are usually 5–8 mm thick. Multiple series of reformatted images are obtained every 5%–10% of the R-R cycle. (b) Computer screen shows series of short-axis images of the heart, which were generated every 10% of the R-R cycle. Manual contouring was then performed along the inner wall of the RV for each series by using dedicated software (Argus; Siemens Medical Solutions, Erlangen, Germany). (c) List of the results provided by the software shows that the end-systolic and end-diastolic volumes are dramatically enlarged, whereas the ejection fraction is reduced to 17%.

 

Figure 10
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  		Figure 10a.  Saddle clot passing through a patent foramen ovale in a 70-year-old woman who presented with PA hypertension secondary to massive acute PE. Axial CT pulmonary angiograms show a saddle clot (arrow) passing from the right atrium (a) through a patent foramen ovale (b) into the left atrium (c, d).

 

Figure 10
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  		Figure 10b.  Saddle clot passing through a patent foramen ovale in a 70-year-old woman who presented with PA hypertension secondary to massive acute PE. Axial CT pulmonary angiograms show a saddle clot (arrow) passing from the right atrium (a) through a patent foramen ovale (b) into the left atrium (c, d).

 

Figure 10
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  		Figure 10c.  Saddle clot passing through a patent foramen ovale in a 70-year-old woman who presented with PA hypertension secondary to massive acute PE. Axial CT pulmonary angiograms show a saddle clot (arrow) passing from the right atrium (a) through a patent foramen ovale (b) into the left atrium (c, d).

 

Figure 10
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  		Figure 10d.  Saddle clot passing through a patent foramen ovale in a 70-year-old woman who presented with PA hypertension secondary to massive acute PE. Axial CT pulmonary angiograms show a saddle clot (arrow) passing from the right atrium (a) through a patent foramen ovale (b) into the left atrium (c, d).

 

Figure 11
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  		Figure 11a.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11b.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11c.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11d.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11e.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11f.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 

Figure 11
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  		Figure 11g.  Massive PE, dilatation of the right side of the heart with septal flattening, incidentally discovered lung cancer, and multiple paraneoplastic venous thromboses in a 61-year-old woman who presented with increasing dyspnea and alteration of her general condition. The pathologic conditions were diagnosed with combined CT pulmonary angiography–CT venography. (a–d) Axial CT pulmonary angiograms obtained with a 16-detector-row scanner show the following findings: multiple PEs in the segmental PAs of both lower lobes and the middle lobe (arrows in a); a lung carcinoma in the left upper lobe (arrowhead in b); thrombi in the left innominate and left subclavian veins (arrow in b, arrows in c); and an RV that is dilated relative to the LV with associated flattening of the interventricular septum (arrowhead in d). (e–g) Axial CT venograms show multiple venous clots in the right great saphenous vein (arrow in e), left popliteal vein (arrow in f), and bilateral tibioperoneal trunks (arrows in g).

 




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