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High-Resolution CT and CT Angiography of Peripheral Pulmonary Vascular Disorders¹

¹ From the Department of Radiology, St George’s Hospital, London, England (C.E., S.G.); the Departments of Diagnostic Radiology (E.S.) and Pediatrics (J.F.), Hanover Medical School, Hanover, Germany; and the Department of Radiology, General Hospital Vienna, University of Vienna, Austria (C.S.P., M.P.). Presented as an education exhibit at the 2000 RSNA scientific assembly. Received November 27, 2001; revision requested January 14, 2002 and received February 19; accepted February 22. Address correspondence to C.E., Department of Radiology, Technische Universität München, Klinikum rechts der Isar Ismaninger Strasse 22, 81675 Munich, Germany (e-mail: cengelke@hotmail.com).

	Abstract

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 
Peripheral pulmonary vascular disorders that can be evaluated with computed tomography (CT) include various disease entities with overlapping imaging features and a wide range of clinical manifestations. The overall accuracy of CT in the diagnosis of pulmonary vascular disorders increases with improved spatial resolution, administration of a high-flow contrast material bolus, and the use of cardiac gating. The integration of high-resolution CT and CT angiographic techniques into one scanning protocol has important clinical implications for multisection CT and makes it the imaging modality of choice in the evaluation of this complex group of disorders.

© RSNA, 2002

Index Terms: Lung, CT, 60.12116, 60.12118 • Lung, diseases, 60.281, 60.60, 60.72, 60.91 • Lung, ground-glass opacification • Lung, hemorrhage Lung, interstitial disease, 60.917 • Lung, nodule, 60.281 • Lung, vascular disease • Pulmonary angiography, 60.12116

	LEARNING OBJECTIVES FOR TEST 1

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Describe high-resolution CT and CT angiographic findings in peripheral pulmonary vascular disorders.
  
• Demonstrate integrated high-resolution CT and CT angiographic techniques for investigating pulmonary vascular and parenchymal abnormalities.
  
• Identify specific peripheral pulmonary vascular disorders on the basis of combined clinical and radiologic findings.
  

	Introduction

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 
The peripheral pulmonary vasculature can be affected by various disease entities with overlapping radiologic features and a wide spectrum of clinical manifestations. Multisection computed tomography (CT), high-resolution CT, and CT angiography are helpful in evaluating these disease entities.

In this article, we describe high-resolution CT and CT angiographic technique and related artifacts. We also discuss and illustrate the CT morphologic features of all main groups of peripheral pulmonary vascular disorders in relation to their clinical settings. These disorders are illustrated with use of single or multisection CT with multiplanar and three-dimensional postprocessing techniques such as sliding thin-slab maximum intensity projection (MIP) to elucidate their vascular nature. All diagnoses were confirmed histologically if CT findings were nonspecific.

	Examination Technique

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 
High-Resolution CT
Standard high-resolution CT technique (1-mm collimation, 10-mm intersection gap, high-resolution reconstruction kernel) is sufficient for evaluating changes in the lung parenchyma associated with peripheral pulmonary vascular disorders. Additional expiratory scans are required to distinguish between air trapping and other causes of altered lung attenuation. Scans obtained with the patient in the prone position allow differentiation of hypostasis in the dependent portions of the lungs from true pathologic tissue.

CT Angiography
CT angiography performed with standard parameters on a 1-second single-section helical CT scanner is capable of displaying the central, segmental, and some of the subsegmental pulmonary arteries. A section collimation of 3 mm, a table feed of 5 mm per rotation, and a reconstruction increment of 1–2 mm are generally used. The scanning range is from the dome of the diaphragm to just above the level of the aortic arch (approximately 12 cm).

Better spatial resolution is obtained with a subsecond single-section helical CT scanner and reduced collimation (usually 2-mm collimation and a table feed of 4 mm per rotation). A collimation of 1 mm is possible with 0.75-second scanners with a table feed of 3 mm per rotation. With this protocol, the central pulmonary arterial system from the dome of the diaphragm to the aortic arch can be covered in 30 seconds. The pitch of 3 exceeds the generally recommended limit of 2. However, the longitudinal resolution of 1.7 mm full width at half maximum (FWHM) is substantially better than with collimations of 2 or 3 mm (FWHM = 2.6 mm and 3.6 mm, respectively) (1,2). Subsegmental 5th- and 6th-order arteries can be visualized to good advantage. In addition, reconstruction of axial high-resolution CT scans is possible with high-resolution filter kernels.

Multisection CT allows CT angiography with very high spatial resolution. For multisection CT in a cooperative patient who can sustain a 20–30-second breath hold, a collimation of 4 x 1 mm or 4 x 1.25 mm is used, with a pitch of 6–7. Images with an effective section width of 1.25–1.6 mm are reconstructed every 0.7–1 mm. Depending on the rotation speed of the scanner, the table speed varies between 9.375 mm/sec (0.8-second rotation, pitch of 6) and 14 mm/sec (0.5-second rotation, pitch of 7). With this examination protocol, the whole lung can be covered in 20–30 seconds, yielding nearly isotropic data sets for subsequent reconstruction of arbitrary cut planes with multiplanar reformatting and various three-dimensional rendering techniques. With multisection CT angiography, the demonstration of subsubsegmental 6th-order vessels is excellent. Such scanning protocols allow reconstruction of high-resolution CT scans at any position and spatial orientation within the data volume (3,4). If the patient is not able to hold the breath for a long time, a protocol with a wider collimation of 4 x 2.5 mm and a pitch of 6–7 is recommended. This will allow coverage of the central pulmonary vessels from the dome of the diaphragm to the top of the aortic arch within 6.4 and 4 seconds, respectively and will substantially reduce breathing artifacts.

For single-phase bolus injection, 150 mL of nonionic contrast material is injected at 4 mL (or more) per second. If this is immediately followed by injection of 40–60 mL of saline solution at the same injection rate, the bolus is flushed from the injection veins, resulting in a longer contrast plateau with fewer high-contrast artifacts. Semiautomatic bolus tracking with a region of interest in the right ventricle is generally used and is a very reliable technique in patients with accelerated pulmonary circulation.

Artifacts
Many factors can degrade the quality of pulmonary CT angiography, including inappropriate delivery of contrast material and artifacts related to pulsation, partial volume rendering, and breathing. Poor vascular enhancement resulting in nondiagnostic examinations may be due to low volumes of contrast material (<120 mL), low injection rates (<4 mL/sec), or incorrect bolus timing. Pulsation artifacts predominantly affect the lung parenchyma of the lingular segments of the left upper lobe, the middle lobe, and both lower lobes and are particularly severe in obliquely oriented vessels, which are also prone to partial volume artifacts. Pulsation artifacts can appear as intra- and paravascular streaks or vessel beading. Partial volume artifacts are increased by limited spatial resolution, resulting in stair-step and beading artifacts in oblique vessels on multiplanar reformatted or three-dimensional reformatted images (Fig 1). These artifacts are generally more severe in peripheral vessels. Breathing can periodically decrease vascular contrast material enhancement, and the resulting artifacts should not be mistaken for intraluminal filling defects (6–8). The overall accuracy of CT in the diagnosis of pulmonary vascular disorders increases with improved spatial resolution, administration of a contrast material bolus, and the use of cardiac gating.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Artifacts of small pulmonary vessels as seen on sliding thin-slab MIP images obtained from CT angiographic data. (a) Stair-step artifacts in oblique branches (arrowheads) due to insufficient spatial resolution. (b) Partial-volume and stair-step artifacts (arrowheads) give segments of vessels along the reconstruction plane a beaded appearance. (c) Pulsation of lung parenchyma around branches with partial volume rendering results in shifting of vessel segments with streaks (arrowheads) inside or next to the real vessel lumen. (Fig 1 reprinted, with permission, from reference 5.)

View larger version (64K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Artifacts of small pulmonary vessels as seen on sliding thin-slab MIP images obtained from CT angiographic data. (a) Stair-step artifacts in oblique branches (arrowheads) due to insufficient spatial resolution. (b) Partial-volume and stair-step artifacts (arrowheads) give segments of vessels along the reconstruction plane a beaded appearance. (c) Pulsation of lung parenchyma around branches with partial volume rendering results in shifting of vessel segments with streaks (arrowheads) inside or next to the real vessel lumen. (Fig 1 reprinted, with permission, from reference 5.)

View larger version (69K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Artifacts of small pulmonary vessels as seen on sliding thin-slab MIP images obtained from CT angiographic data. (a) Stair-step artifacts in oblique branches (arrowheads) due to insufficient spatial resolution. (b) Partial-volume and stair-step artifacts (arrowheads) give segments of vessels along the reconstruction plane a beaded appearance. (c) Pulsation of lung parenchyma around branches with partial volume rendering results in shifting of vessel segments with streaks (arrowheads) inside or next to the real vessel lumen. (Fig 1 reprinted, with permission, from reference 5.)

	CT Findings

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Peripheral pulmonary embolism. Sliding thin-slab MIP images were obtained from single-section CT angiographic data (section collimation, 1 mm; table feed, 3 mm; reconstruction increment, 0.5 mm). (a) Subsegmental (right anterior upper lobe subsegment) (double arrowheads) and subsubsegmental (left anterior upper lobe subsubsegment) (single arrowhead) embolism. Such findings can be emphasized with sliding thin-slab MIP performed parallel to vessel orientation if the vessel is occluded by embolic material. Identification of thrombotic material is more difficult in small peripheral "in-plane" vessels due to partial volume artifacts, stair-step artifacts, pulsation artifacts, and vessel beading. (b) In equivocal cases, subsegmental branches of similar size and orientation can help identify differences in contrast enhancement in vessels affected by emboli (arrowheads).

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Peripheral pulmonary embolism. Sliding thin-slab MIP images were obtained from single-section CT angiographic data (section collimation, 1 mm; table feed, 3 mm; reconstruction increment, 0.5 mm). (a) Subsegmental (right anterior upper lobe subsegment) (double arrowheads) and subsubsegmental (left anterior upper lobe subsubsegment) (single arrowhead) embolism. Such findings can be emphasized with sliding thin-slab MIP performed parallel to vessel orientation if the vessel is occluded by embolic material. Identification of thrombotic material is more difficult in small peripheral "in-plane" vessels due to partial volume artifacts, stair-step artifacts, pulsation artifacts, and vessel beading. (b) In equivocal cases, subsegmental branches of similar size and orientation can help identify differences in contrast enhancement in vessels affected by emboli (arrowheads).

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Chronic pulmonary embolism. Axial single-section CT angiogram (section collimation, 1 mm; table feed, 3 mm; reconstruction increment, 0.5 mm) (a) and coronal reformatted image (b) demonstrate chronic pulmonary embolism with the classic mosaic perfusion pattern (ie, hypoperfusion of the affected lung segments and relative hyperperfusion of normal lung areas). Note that vessels in hypoattenuating lung areas are smaller in caliber than those in hyperattenuating areas.

View larger version (92K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Chronic pulmonary embolism. Axial single-section CT angiogram (section collimation, 1 mm; table feed, 3 mm; reconstruction increment, 0.5 mm) (a) and coronal reformatted image (b) demonstrate chronic pulmonary embolism with the classic mosaic perfusion pattern (ie, hypoperfusion of the affected lung segments and relative hyperperfusion of normal lung areas). Note that vessels in hypoattenuating lung areas are smaller in caliber than those in hyperattenuating areas.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Pulmonary embolism with infarcts. Coronal thin-slab MIP image obtained from single-section CT angiographic data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm) (a) and corresponding axial image (soft-tissue windowing) (b) demonstrate infarction of the right posterior upper lobe segment. Pulmonary infarcts occur in pulmonary embolism if the bronchial artery collateral supply to the pulmonary parenchyma is insufficient. This is common in pulmonary infection or malignancy, which may induce bronchial artery thrombosis. Acute pulmonary infarction classically appears as wedge-shaped ground-glass attenuation with slightly increased volume initially (*), followed by consolidation and then volume loss and fibrosis or cavitation.

View larger version (57K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Pulmonary embolism with infarcts. Coronal thin-slab MIP image obtained from single-section CT angiographic data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm) (a) and corresponding axial image (soft-tissue windowing) (b) demonstrate infarction of the right posterior upper lobe segment. Pulmonary infarcts occur in pulmonary embolism if the bronchial artery collateral supply to the pulmonary parenchyma is insufficient. This is common in pulmonary infection or malignancy, which may induce bronchial artery thrombosis. Acute pulmonary infarction classically appears as wedge-shaped ground-glass attenuation with slightly increased volume initially (*), followed by consolidation and then volume loss and fibrosis or cavitation.

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 5.  Primary pulmonary hypertension in a 32-year-old woman with average systolic pulmonary arterial pressures of 140-150 mm Hg. CT scan shows enlargement of the central pulmonary arterial system with tapering to the periphery and corkscrew-shaped arteries. Peripheral plexiform arteriopathy (not shown) was also present. (Reprinted, with permission, from reference 5.)

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Sickle cell disease in a 29-year-old woman. CT scans show multiple small peripheral pulmonary infarcts (arrowheads) following sickling crises. The scan in b also demonstrates widespread mild inter- and intralobular interstitial thickening associated with ground-glass attenuation, a finding that typically represents interstitial fibrosis.

View larger version (92K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Sickle cell disease in a 29-year-old woman. CT scans show multiple small peripheral pulmonary infarcts (arrowheads) following sickling crises. The scan in b also demonstrates widespread mild inter- and intralobular interstitial thickening associated with ground-glass attenuation, a finding that typically represents interstitial fibrosis.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 7.  Septic pulmonary embolism. CT scan shows mycotic pneumonia with infiltration or hemorrhage into the surrounding acini (halo sign) as well as solid and subsolid nodules (arrows). Additional CT findings that are suggestive of septic embolism include the feeding vessel sign, cavitating nodules, and small peripheral (cavitating) infarcts.

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Parasitic pulmonary embolism. (a, b) CT scans demonstrate rupture of an Echinococcus cyst (E granulosus) (*) into the inferior vena cava ( in b). (c, d) CT scans show peripheral pulmonary embolism of scolices (c) with subpleural calcified daughter cysts (arrowheads in d). Massive central pulmonary arterial embolism can occur in hydatid disease or in ascariasis in association with acute pulmonary arterial thrombosis.

View larger version (93K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Parasitic pulmonary embolism. (a, b) CT scans demonstrate rupture of an Echinococcus cyst (E granulosus) (*) into the inferior vena cava ( in b). (c, d) CT scans show peripheral pulmonary embolism of scolices (c) with subpleural calcified daughter cysts (arrowheads in d). Massive central pulmonary arterial embolism can occur in hydatid disease or in ascariasis in association with acute pulmonary arterial thrombosis.

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Parasitic pulmonary embolism. (a, b) CT scans demonstrate rupture of an Echinococcus cyst (E granulosus) (*) into the inferior vena cava ( in b). (c, d) CT scans show peripheral pulmonary embolism of scolices (c) with subpleural calcified daughter cysts (arrowheads in d). Massive central pulmonary arterial embolism can occur in hydatid disease or in ascariasis in association with acute pulmonary arterial thrombosis.

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 8d.  Parasitic pulmonary embolism. (a, b) CT scans demonstrate rupture of an Echinococcus cyst (E granulosus) (*) into the inferior vena cava ( in b). (c, d) CT scans show peripheral pulmonary embolism of scolices (c) with subpleural calcified daughter cysts (arrowheads in d). Massive central pulmonary arterial embolism can occur in hydatid disease or in ascariasis in association with acute pulmonary arterial thrombosis.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Tumor embolism in a 43-year-old woman with breast cancer who presented with progressive dyspnea. (a) High-resolution CT scan demonstrates features of pulmonary lymphangitic carcinomatosis with irregular interlobular septal thickening in both upper lobes. (b) High-resolution CT scan shows extensive bilateral pulmonary artery tumor emboli, with nodular thickening of the pulmonary arteries along the bronchovascular bundles and terminal branching patterns peripherally. The bronchial walls are normal.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Tumor embolism in a 43-year-old woman with breast cancer who presented with progressive dyspnea. (a) High-resolution CT scan demonstrates features of pulmonary lymphangitic carcinomatosis with irregular interlobular septal thickening in both upper lobes. (b) High-resolution CT scan shows extensive bilateral pulmonary artery tumor emboli, with nodular thickening of the pulmonary arteries along the bronchovascular bundles and terminal branching patterns peripherally. The bronchial walls are normal.

Talc, cellulose, and starch embolism can be seen in chronic drug abusers, who practice venous injection of drugs in tablet form that contain these materials as filler components, or with use of cotton as filter material. Embolization to pulmonary arterioles and capillaries causes obstruction and often thrombosis with transient pulmonary hypertension, acute pulmonary hypertension syndrome with sudden death, or chronic pulmonary hypertension (26,28,29).

Pulmonary mercury embolism can occur accidentally from venous sampling with mercury-sealed syringes or in patients who attempt suicide by venous injection. The diagnosis is generally made at conventional radiography and does not require CT (26,30–33).

Coils or other foreign bodies occasionally embolize to the pulmonary circulation as a result of attempted treatment of peripheral arteriovenous communications or systemic venous intervention. CT angiography is usually indicated to confirm the location of the coil in the chest and to exclude a pulmonary arteriovenous malformation (PAVM).

Pulmonary Arterial Thrombosis
Pulmonary arterial thrombosis without classic pulmonary embolism can occur as a complication of disorders such as pneumonia (especially tuberculosis), autoimmune-related or other thrombophilia (eg, systemic lupus erythematosus), and nephrotic syndrome). Bronchogenic carcinoma, primary pulmonary artery malignancy, pulmonary artery interruption, and massive parasitic embolism can also induce pulmonary arterial thrombosis. The prognosis of acute main pulmonary arterial thrombosis is poor, and sudden death is a well-documented complication (20). The CT angiographic appearance is identical to that of embolic occlusion that includes all peripheral arterial branches.

Pulmonary Vascular Tumor Invasion
Although tumor invasion of the central pulmonary artery can occasionally be seen in stage IV bronchogenic malignancy or metastatic disease (Fig 10), the preoperative identification of arterial wall infiltration presents a major diagnostic problem. CT angiography is often misleading in cases of extrinsic compression, and, conversely, does not display vascular involvement reliably except in advanced cases of intraluminal tumor growth. It remains unclear whether circumferential tumor encasement of the pulmonary artery is associated with a high rate of wall infiltration, as in the thoracic aorta. It is likely that endovascular or transesophageal ultrasound will be advantageous in this patient group (34). Peripheral pulmonary vascular tumor invasion can be demonstrated at high-resolution CT by the presence of perifocal pulmonary hemorrhage (Fig 10).

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Pulmonary vascular tumor invasion. (a) CT angiogram obtained in a patient with bronchogenic carcinoma reveals advanced pulmonary artery tumor invasion (*). CT angiography is diagnostic in cases of intraluminal tumor. (b) CT scan obtained in a patient with neurofibromatosis I and metastatic schwannoma demonstrates perifocal ground-glass attenuation, a finding that reflects the presence of pulmonary hemorrhage. This CT feature is well recognized as a manifestation of peripheral invasion of pulmonary vessels in patients with high-grade malignancy.

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Pulmonary vascular tumor invasion. (a) CT angiogram obtained in a patient with bronchogenic carcinoma reveals advanced pulmonary artery tumor invasion (*). CT angiography is diagnostic in cases of intraluminal tumor. (b) CT scan obtained in a patient with neurofibromatosis I and metastatic schwannoma demonstrates perifocal ground-glass attenuation, a finding that reflects the presence of pulmonary hemorrhage. This CT feature is well recognized as a manifestation of peripheral invasion of pulmonary vessels in patients with high-grade malignancy.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Leiomyosarcoma of the pulmonary artery in a patient with pulmonary metastatic disease. Single-section CT angiograms (section collimation, 3 mm; table feed, 5 mm; reconstruction increment, 2 mm) obtained 5 months after attempted pulmonary endatherectomy for suspected recurrent pulmonary embolism show recurrent bilateral pulmonary artery tumors. Tuberous segmental pulmonary artery expansion by the tumor nodules (*) is also noted. Enhancement is present in the right lower lobe artery nodule (arrowheads in a).

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Leiomyosarcoma of the pulmonary artery in a patient with pulmonary metastatic disease. Single-section CT angiograms (section collimation, 3 mm; table feed, 5 mm; reconstruction increment, 2 mm) obtained 5 months after attempted pulmonary endatherectomy for suspected recurrent pulmonary embolism show recurrent bilateral pulmonary artery tumors. Tuberous segmental pulmonary artery expansion by the tumor nodules (*) is also noted. Enhancement is present in the right lower lobe artery nodule (arrowheads in a).

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Leiomyosarcoma of the pulmonary artery. (a) Multisection CT angiogram (section collimation, 4 x 1 mm; table feed, 6 mm; reconstruction increment, 0.7 mm) shows a right main pulmonary artery tumor (*) with unenhanced apposition thrombus (arrowheads) across the main pulmonary artery bifurcation. The tumor appears as an expansile enhancing clot with protrusion into the main pulmonary artery bifurcation. (b) Coronal thick-slab MIP image demonstrates lack of contrast enhancement in the right peripheral pulmonary vessels, probably due to thrombosis of the right peripheral branches. (Fig 12 reprinted, with permission, from reference 5.)

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Leiomyosarcoma of the pulmonary artery. (a) Multisection CT angiogram (section collimation, 4 x 1 mm; table feed, 6 mm; reconstruction increment, 0.7 mm) shows a right main pulmonary artery tumor (*) with unenhanced apposition thrombus (arrowheads) across the main pulmonary artery bifurcation. The tumor appears as an expansile enhancing clot with protrusion into the main pulmonary artery bifurcation. (b) Coronal thick-slab MIP image demonstrates lack of contrast enhancement in the right peripheral pulmonary vessels, probably due to thrombosis of the right peripheral branches. (Fig 12 reprinted, with permission, from reference 5.)

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 13.  Pulmonary Kaposi sarcoma in a patient with AIDS. Bronchoalveolar lavage was negative for P carinii pneumonia. High-resolution CT scan demonstrates interstitial thickening in a perihilar and peribronchovascular distribution and coalescent masslike alveolar attenuation, findings that raised suspicion for Kaposi sarcoma. As in this case, the presence of superimposed infection can obscure radiologic findings, and often the characteristic flamelike appearance of nodular areas or perihilar attenuation is not present. The diagnosis of Kaposi sarcoma was confirmed at postmortem examination. (Reprinted, with permission, from reference 5.)

Pulmonary Arteriovenous Shunting
PAVMs are, in the majority of cases, associated with Rendu-Weber-Osler disease. Many PAVMs are discovered incidentally in adulthood, with patients often being asymptomatic due to accommodation to the chronic pulmonary hypoxemia. CT angiography performed in conjunction with conventional angiography has an important role in screening for PAVMs, with a sensitivity greater than 95% (52). CT angiography facilitates planning of transarterial embolization by providing three-dimensional images of complex malformations (Fig 14). These 3D images are especially helpful in malformations with more than one feeding vessel. A diameter of 3 mm or more for the feeding PAVM vessels is considered an indication for embolization (53). Untreated or occult PAVMs can increase in size over time, with increasing shunt volumes inducing hypoxemia, together with an increased risk of stroke and PAVM rupture (Fig 15).

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 14.  Multiple peripheral PAVMs in a patient with Rendu-Weber-Osler disease. Coronal volume-rendered image (posterior view) obtained from multisection CT angiographic data (section collimation, 4 x 1 mm; table feed, 6 mm; reconstruction increment, 0.7 mm) clearly depicts serpiginous peripheral pulmonary vessels (arrowheads), the supplying and draining branches and the vascular segments of arteriovenous communication. Two PAVMs have been treated with coil embolization (arrows). (Reprinted, with permission, from reference 5.)

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 15.  PAVM rupture in a 63-year-old man who presented with acute hemothorax. The patient had no previous history of or clinical suspicion for arteriovenous malformation. CT scan demonstrates a ruptured large PAVM (*), a finding that was confirmed at lobectomy.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Diffuse pulmonary arteriovenous shunting in a 28-year-old pregnant woman. Axial (a) and sagittal (b) sliding thin-slab MIP images obtained from ultra-low-dose multisection CT data (effective dose <0.5 mSv) show dilatation of pulmonary arteries and veins in the right lower lobe (*) with a reticular vascular pattern in the lung periphery (arrowheads). (Fig 16 reprinted, with permission, from reference 5.)

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Diffuse pulmonary arteriovenous shunting in a 28-year-old pregnant woman. Axial (a) and sagittal (b) sliding thin-slab MIP images obtained from ultra-low-dose multisection CT data (effective dose <0.5 mSv) show dilatation of pulmonary arteries and veins in the right lower lobe (*) with a reticular vascular pattern in the lung periphery (arrowheads). (Fig 16 reprinted, with permission, from reference 5.)

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 17.  Hepatopulmonary syndrome in a patient with advanced liver cirrhosis and clinical evidence of right-to-left shunting. Sliding thin-slab MIP image obtained from single-section CT angiographic data (section collimation, 1 mm; table feed, 3 mm; reconstruction increment, 0.5 mm) demonstrates centrilobular vessel-associated micronodules connected by multiple arcade-like dilated subpleural vessels in the lower lobe (arrowheads).

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 18a.  Takayasu arteritis. (a) Axial sliding thin-slab MIP image obtained prior to steroid therapy shows central pulmonary arterial wall thickening (arrowheads) and tapering of the lumen at the pulmonary artery bifurcation and left and right main arteries. (b) Axial sliding thin-slab MIP image obtained after corticosteroid and immunosuppressive therapy and right pulmonary artery stent placement (*) shows improvement in the caliber of the central and peripheral pulmonary arteries of the right lung (arrows). (Fig 18 reprinted, with permission, from reference 5.)

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 18b.  Takayasu arteritis. (a) Axial sliding thin-slab MIP image obtained prior to steroid therapy shows central pulmonary arterial wall thickening (arrowheads) and tapering of the lumen at the pulmonary artery bifurcation and left and right main arteries. (b) Axial sliding thin-slab MIP image obtained after corticosteroid and immunosuppressive therapy and right pulmonary artery stent placement (*) shows improvement in the caliber of the central and peripheral pulmonary arteries of the right lung (arrows). (Fig 18 reprinted, with permission, from reference 5.)

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  PAN in a 15-year-old boy. Selective pulmonary arteriography was normal. (a) Axial sliding thin-slab MIP image obtained from single-section spiral CT data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm) prior to therapy shows lobular and small geographic areas of ground-glass attenuation at pulmonary vascular bifurcations, findings that represent focal pneumonitis (confirmed at open lung biopsy). (b) Axial sliding thin-slab MIP image obtained 3 weeks after corticosteroid and immunosuppressive therapy demonstrates marked improvement. (c) Corresponding renal digital subtraction angiogram demonstrates multiple microaneurysms with a pearllike configuration.

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  PAN in a 15-year-old boy. Selective pulmonary arteriography was normal. (a) Axial sliding thin-slab MIP image obtained from single-section spiral CT data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm) prior to therapy shows lobular and small geographic areas of ground-glass attenuation at pulmonary vascular bifurcations, findings that represent focal pneumonitis (confirmed at open lung biopsy). (b) Axial sliding thin-slab MIP image obtained 3 weeks after corticosteroid and immunosuppressive therapy demonstrates marked improvement. (c) Corresponding renal digital subtraction angiogram demonstrates multiple microaneurysms with a pearllike configuration.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 19c.  PAN in a 15-year-old boy. Selective pulmonary arteriography was normal. (a) Axial sliding thin-slab MIP image obtained from single-section spiral CT data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm) prior to therapy shows lobular and small geographic areas of ground-glass attenuation at pulmonary vascular bifurcations, findings that represent focal pneumonitis (confirmed at open lung biopsy). (b) Axial sliding thin-slab MIP image obtained 3 weeks after corticosteroid and immunosuppressive therapy demonstrates marked improvement. (c) Corresponding renal digital subtraction angiogram demonstrates multiple microaneurysms with a pearllike configuration.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 20a.  Active ANCA-positive microscopic polyangiitis in a 57-year-old man with hemoptysis. CT scans display focal perivascular areas of ground-glass attenuation in a peripheral (a) and perihilar (b) distribution (arrows), findings that are consistent with pulmonary hemorrhage.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 20b.  Active ANCA-positive microscopic polyangiitis in a 57-year-old man with hemoptysis. CT scans display focal perivascular areas of ground-glass attenuation in a peripheral (a) and perihilar (b) distribution (arrows), findings that are consistent with pulmonary hemorrhage.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 21a.  Wegener vasculitis. (a) CT scan shows focal pulmonary hemorrhage with lobular ground-glass attenuation (arrowheads). A perivascular distribution, which is a feature of PAN, is not obvious in Wegener disease. (b) CT scan obtained in a different patient demonstrates subacute-chronic pulmonary hemorrhage with widespread consolidation and interstitial areas of increased attenuation that include the interlobular septa.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 21b.  Wegener vasculitis. (a) CT scan shows focal pulmonary hemorrhage with lobular ground-glass attenuation (arrowheads). A perivascular distribution, which is a feature of PAN, is not obvious in Wegener disease. (b) CT scan obtained in a different patient demonstrates subacute-chronic pulmonary hemorrhage with widespread consolidation and interstitial areas of increased attenuation that include the interlobular septa.

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 22.  Active Churg-Strauss syndrome. CT scan demonstrates small centrilobular nodules with ground-glass attenuation coalescing to larger nonsegmental areas of consolidation (arrowheads), one of them with vascular association. (Reprinted, with permission, from reference 5.)

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 23.  Acute systemic lupus erythematosus pneumonitis. CT scan reveals extensive ground-glass attenuation throughout both lungs (arrows), interlobular septal thickening, bilateral lower lobe consolidations (complete on the left side [arrowheads]), and minimal pleural effusion. (Reprinted, with permission, from reference 5.)

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 24.  Goodpasture syndrome. CT scan demonstrates lobular ground-glass attenuation and smooth interlobular and centrilobular interstitial thickening, findings that represent diffuse pulmonary hemorrhage. (Reprinted, with permission, from reference 5.)

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 25.  Idiopathic primary pulmonary hemosiderosis in a patient with lactose intolerance (Heiner syndrome). High-resolution CT scan demonstrates diffuse lobular ground-glass attenuation and interlobular and intralobular interstitial thickening, findings that represent diffuse pulmonary hemorrhage.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 26a.  Pulmonary trauma secondary to a motor vehicle accident. Sliding thin-slab MIP images were obtained from single-section CT angiographic data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm). (a) Image shows pneumothorax and parenchymal hemorrhage along the shock wave (steering wheel impact). (b) Image obtained in a 28-year-old man demonstrates traumatic rupture of the right lower lobe artery and active hemorrhage into the right side of the chest (arrowheads). CT angiography is indicated only if the patient is stable and the major surgical access unclear. The patient was treated successfully with right lower lobectomy but died 2 weeks later from septicemia.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 26b.  Pulmonary trauma secondary to a motor vehicle accident. Sliding thin-slab MIP images were obtained from single-section CT angiographic data (section collimation, 2 mm; table feed, 4 mm; reconstruction increment, 1 mm). (a) Image shows pneumothorax and parenchymal hemorrhage along the shock wave (steering wheel impact). (b) Image obtained in a 28-year-old man demonstrates traumatic rupture of the right lower lobe artery and active hemorrhage into the right side of the chest (arrowheads). CT angiography is indicated only if the patient is stable and the major surgical access unclear. The patient was treated successfully with right lower lobectomy but died 2 weeks later from septicemia.

Iatrogenic pulmonary artery pseudoaneurysms, commonly induced by Swan-Ganz catheters, are prone to rupture and, like infectious aneurysms, require early treatment with embolization.

Nontraumatic Pulmonary Artery Aneurysms
Infection is an important pathogenetic factor in (peripheral) pulmonary artery pseudoaneurysm formation. It occurs with pulmonary aspergillosis (Fig 27) and, rarely, with tuberculosis (Rasmussen aneurysm) and syphilis. Once infection has been demonstrated with CT angiography, early embolization is indicated because rupture is usually fatal.

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 27.  Mycotic pulmonary artery aneurysm. CT scan shows a peripheral pulmonary artery aneurysm (*). The aneurysm ruptured after treatment of the underlying aspergillus pneumonia with amphotericin B, and exsanguination into the right side of the chest was subsequently seen.

Aneurysmal pulmonary artery disease in connective tissue disorders is a well-recognized complication of cystic arterial medial necrosis and Marfan syndrome.

Bronchial artery aneurysms can be idiopathic or occur in association with pulmonary artery aplasia, trauma, infection, silicosis, and vasculitis (including Behçet disease, Hughes-Stovin syndrome, and PAN). PAN rarely causes pulmonary artery aneurysms (26).

Developmental Abnormalities of the Pulmonary Arteries
Developmental pulmonary artery abnormalities should be evaluated with magnetic resonance angiography to avoid the ionizing irradiation of children. However, lack of patient compliance or the need to determine the relationship of the vascular abnormality to the bony chest may still require the use of preoperative CT angiography.

Congenital aneurysms of the pulmonary arteries are usually located in the central pulmonary arterial system. They are often associated with other pulmonary or cardiovascular abnormalities. Differentiation from peripheral pulmonary artery aneurysms is normally straightforward.

Congenital systemic arterial supply to the lung is commonly found in bronchopulmonary sequestration. The systemic vessel originates most often from the inferior thoracic or superior abdominal aorta (Fig 28), but other supply from supraaortic, chest wall, pericardiacophrenic, or abdominal aortic side branches has been described. Information about the vascular supply is important prior to embolization or surgery. In general, dual-phase CT angiography in both the pulmonary arterial and systemic arterial phases should be performed as part of a single examination to evaluate the relationship to both vascular systems. Acquired systemic arterial pulmonary supply can be found in various entities including aspergilloma, tuberculosis or other inflammation, neoplasia, posttraumatic or postsurgical conditions, and chronic pulmonary arterial or venous obstruction and is commonly associated with hemoptysis and bronchiectasis. CT angiography can help exclude bronchial artery aneurysms or a Rasmussen aneurysm in tuberculosis in affected patients. Digital subtraction angiography and embolization are required for treatment of significant hemoptysis.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 28a.  Extralobar sequestration in the right lower lobe. (a, b) CT scans show an abnormal systemic arterial supply (arrow) that originates within the abdomen above the celiac artery (a) between the diaphragmatic crura (b). This sequestrated segment had normal venous drainage into the left atrium. (c, d) CT scans demonstrate extensive calcification (arrowheads) at the superior aspect of the sequestrated segment. Note also the systemic artery that enters the sequestrated segment (arrow). (Fig 28 reprinted, with permission, from reference 5.)

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 28b.  Extralobar sequestration in the right lower lobe. (a, b) CT scans show an abnormal systemic arterial supply (arrow) that originates within the abdomen above the celiac artery (a) between the diaphragmatic crura (b). This sequestrated segment had normal venous drainage into the left atrium. (c, d) CT scans demonstrate extensive calcification (arrowheads) at the superior aspect of the sequestrated segment. Note also the systemic artery that enters the sequestrated segment (arrow). (Fig 28 reprinted, with permission, from reference 5.)

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 28c.  Extralobar sequestration in the right lower lobe. (a, b) CT scans show an abnormal systemic arterial supply (arrow) that originates within the abdomen above the celiac artery (a) between the diaphragmatic crura (b). This sequestrated segment had normal venous drainage into the left atrium. (c, d) CT scans demonstrate extensive calcification (arrowheads) at the superior aspect of the sequestrated segment. Note also the systemic artery that enters the sequestrated segment (arrow). (Fig 28 reprinted, with permission, from reference 5.)

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 28d.  Extralobar sequestration in the right lower lobe. (a, b) CT scans show an abnormal systemic arterial supply (arrow) that originates within the abdomen above the celiac artery (a) between the diaphragmatic crura (b). This sequestrated segment had normal venous drainage into the left atrium. (c, d) CT scans demonstrate extensive calcification (arrowheads) at the superior aspect of the sequestrated segment. Note also the systemic artery that enters the sequestrated segment (arrow). (Fig 28 reprinted, with permission, from reference 5.)

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 29a.  Proximal interruption of the left pulmonary artery in a patient with complex cardiac malformation and a right descending aorta. (a, b) CT scans obtained after unsuccessful treatment with bypass grafting onto the left main pulmonary artery (*) demonstrate complete left pulmonary arterial thrombosis (arrowheads) with collateral bronchial arterial supply (arrows). Note that there is no mediastinal shift as in pulmonary artery aplasia or agenesis. (c) Curved multiplanar reformatted image shows chronic occlusion of the left pulmonary artery (arrows) with collateralization by enlarged bronchial arteries. No collateral aortic or intercostal supply via the pleural plexus was depicted.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 29b.  Proximal interruption of the left pulmonary artery in a patient with complex cardiac malformation and a right descending aorta. (a, b) CT scans obtained after unsuccessful treatment with bypass grafting onto the left main pulmonary artery (*) demonstrate complete left pulmonary arterial thrombosis (arrowheads) with collateral bronchial arterial supply (arrows). Note that there is no mediastinal shift as in pulmonary artery aplasia or agenesis. (c) Curved multiplanar reformatted image shows chronic occlusion of the left pulmonary artery (arrows) with collateralization by enlarged bronchial arteries. No collateral aortic or intercostal supply via the pleural plexus was depicted.

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 29c.  Proximal interruption of the left pulmonary artery in a patient with complex cardiac malformation and a right descending aorta. (a, b) CT scans obtained after unsuccessful treatment with bypass grafting onto the left main pulmonary artery (*) demonstrate complete left pulmonary arterial thrombosis (arrowheads) with collateral bronchial arterial supply (arrows). Note that there is no mediastinal shift as in pulmonary artery aplasia or agenesis. (c) Curved multiplanar reformatted image shows chronic occlusion of the left pulmonary artery (arrows) with collateralization by enlarged bronchial arteries. No collateral aortic or intercostal supply via the pleural plexus was depicted.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 30.  Congenital alveolar capillary dysplasia in a 2-year-old girl. CT scan shows typical findings of widespread ground-glass attenuation (dark bronchus signs) and smooth interlobular septal thickening. The medial middle lobe segment (S5) is less affected by the interstitial process but displays air trapping. The patient died 6 months later from progressive respiratory failure.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 31a.  Pulmonary capillary hemangiomatosis in an 11-year-old boy. High-resolution CT scans display subpleural centrilobular ground-glass nodules (arrowheads in a) and smooth interlobular (arrowheads in b), intralobular, and peribronchovascular (arrows in a) interstitial thickening. The patient died from progressive respiratory failure 7 months after the initial diagnosis.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 31b.  Pulmonary capillary hemangiomatosis in an 11-year-old boy. High-resolution CT scans display subpleural centrilobular ground-glass nodules (arrowheads in a) and smooth interlobular (arrowheads in b), intralobular, and peribronchovascular (arrows in a) interstitial thickening. The patient died from progressive respiratory failure 7 months after the initial diagnosis.

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 32.  Pulmonary veno-occlusive disease in a patient with pulmonary arterial pressures of 90/40 mm Hg. High-resolution CT scan shows mild interlobular septal thickening and more marked patchy centrilobular ground-glass attenuation reflecting interstitial and early alveolar edema. Cardiac catheter examination demonstrated stretched prominent pulmonary arteries that ended abruptly. (Courtesy of Prof Pierre Schnyder, University of Lausanne, Switzerland; reprinted, with permission, from reference 5.)

View larger version (81K): [in this window] [in a new window] [Download PPT slide]   Figure 33a.  Unilateral pulmonary venous thrombosis in a patient who had undergone surgical repair of bilateral partial anomalous pulmonary venous return. The procedure consisted of right upper lobe interposition grafting between the short anomalously connected vein and the left atrium. CT scans demonstrate thrombosis of the right upper lobe vein (arrow in a) and in the region of the interposition graft anastomosis (arrows in b).

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 33b.  Unilateral pulmonary venous thrombosis in a patient who had undergone surgical repair of bilateral partial anomalous pulmonary venous return. The procedure consisted of right upper lobe interposition grafting between the short anomalously connected vein and the left atrium. CT scans demonstrate thrombosis of the right upper lobe vein (arrow in a) and in the region of the interposition graft anastomosis (arrows in b).

	Conclusions

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 
CT angiography and high-resolution CT are valuable in the noninvasive diagnosis of peripheral pulmonary vascular disorders. The integration of both techniques into one scanning protocol has important clinical implications and places multisection CT, with its excellent spatial resolution, at the hub in the evaluation of this complex group of disorders.

	Footnotes

 
Abbreviations: AIDS = acquired immunodeficiency syndrome, FWHM = full width at half maximum, PAVM = pulmonary arteriovenous malformation

	References

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Examination Technique CT Findings Conclusions References

 

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