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Multi–Detector Row CT of Hemoptysis¹

¹ From the Department of Radiology, Hospital Calmette, University Center of Lille, Blvd Jules Leclercq, 59037 Lille, France. Received December 15, 2004; revision requested April 13, 2005 and received June 2; accepted June 3. All authors have no financial relationships to disclose. Address correspondence to M.R. (e-mail: mremy-jardin{at}chru-lille.fr).

	Abstract

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
Hemoptysis is symptomatic of a potentially life-threatening condition and warrants urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multi–detector row computed tomographic (CT) angiography is a very useful noninvasive imaging modality for initial assessment of hemoptysis. The combined use of thin-section axial scans and more complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be the source of hemorrhage and that may require embolization. Conditions such as bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT. "Cryptogenic" hemoptysis is common among smokers and warrants subsequent follow-up imaging to exclude possible underlying malignancy. The bronchial arteries are the source of bleeding in most cases of hemoptysis. Contributions from the non-bronchial systemic arterial system represent an important cause of recurrent hemoptysis following apparently successful bronchial artery embolization. Vascular anomalies such as pulmonary arteriovenous malformations and bronchial artery aneurysms are other important causes of hemoptysis. Multi–detector row CT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management.

© RSNA, 2006

	LEARNING OBJECTIVES FOR TEST 1

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

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

• Discuss the pathophysiologic features and the most important direct causes of hemoptysis.
  
• Describe the complex anatomy and varied imaging appearances of the bronchial and non-bronchial systemic arteries.
  
• Enumerate the essential principles of thoracic CT angiography performed prior to embolization therapy for massive hemoptysis.
  

	Introduction

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
Hemoptysis, defined as bleeding that originates from the lower respiratory tract (1), is symptomatic of potentially serious or even life-threatening thoracic disease and warrants urgent investigation. The immediate risk posed by hemoptysis is airway compromise; thus, assessment of the clinical significance of an episode of hemoptysis should take into account not only the volume of expectorated blood but also the effects on the patient’s respiratory and cardiovascular reserves. The aim of initial diagnostic evaluation should be to identify the immediate source and importance of bleeding, but the assessment is not complete without a thorough inquiry into the underlying primary cause of the hemoptysis. Standard diagnostic algorithms have been based on combinations of conventional radiography, rigid or fiberoptic bronchoscopy, chest computed tomography (CT), and thoracic aortography (2). Recent important technologic advances in CT, particularly the development of multi–detector row CT, have introduced a comprehensive, noninvasive method of evaluating the entire thorax, allowing detailed assessment of the mediastinum and lung parenchyma. At the same time, these technologic advances allow high-resolution angiographic studies of the thoracic and upper abdominal vasculature, which are useful prior to anticipated bronchial artery embolization or surgical intervention (3,4). CT findings can also direct the endoscopist toward bronchial or parenchymal abnormalities and signal possible dangers such as peribronchial or endoluminal aneurysms. There have been few reports on the use of multi–detector row CT in the assessment of hemoptysis; most published experience has been based on single–detector row spiral CT technology (5–8).

In this article, we review the pathophysiologic features and causes of hemoptysis, describe the bronchial and nonbronchial systemic arterial anatomy, and discuss the initial evaluation of acute hemoptysis. We also discuss and illustrate the role of multi–detector row CT in hemoptysis with regard to its exquisite diagnostic capabilities and its potential influence on management decision making.

	Pathophysiologic Features and Causes of Hemoptysis

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
The lungs are supplied by a dual arterial vascular system composed of (a) the pulmonary arteries, which account for 99% of the arterial blood supply to the lungs and take part in gas exchange; and (b) the bronchial arteries, which are responsible for providing nourishment to the supporting structures of the airways and of the pulmonary arteries themselves (vasa vasorum) but do not normally take part in gas exchange (9). The bronchial vasculature feeding the intrapulmonary airways is situated close to the pulmonary arteries at the level of the vasa vasorum, and histologically the two systems are connected by anastomoses between the systemic and pulmonary capillaries (10). This communication between the bronchial and pulmonary arteries contributes to a normal right-to-left shunt that accounts for 5% of cardiac output (11).

In certain situations, the thin-walled capillary communications between the high-pressure systemic bronchial arterial system and the lower-pressure pulmonary arterial system can vasodilate and enlarge. Conditions causing reduced pulmonary arterial perfusion such as chronic thrombo-embolic disease and vasculitic disorders, in which there is a reduction in pulmonary arterial supply distal to the emboli, can lead to a gradual increase in the bronchial arterial contribution (6,12–15), thereby increasing the importance of bronchial-to-pulmonary artery anastomoses in regions of the lung that are deprived of their pulmonary arterial blood flow. Experimental studies have suggested that the increased bronchial arterial blood flow is due to neovascularization (12). The anastomotic vessels, which are subjected to increased systemic arterial pressure, are often thin walled and prone to rupture into the alveoli or bronchial airways, giving rise to hemoptysis.

Chronic inflammation can also lead to an increase in systemic arterial blood flow (16,17). Chronic inflammatory disorders such as bronchiectasis, chronic bronchitis, and chronic necrotizing infections (in particular, tuberculosis and mycotic lung disease) are associated with the release of angiogenetic growth factors such as vascular endothelial growth factor and angiopoietin 1, leading to neovascularization and vascular remodeling as well as an increase in the collateral supply from nearby systemic vessels (18,19). Such newly formed collateral vessels are usually fragile and "leaky" and prone to rupture. Neoplastic disease can also be responsible for such humor-mediated neovascularization.

On angiographic studies, systemic vessels responsible for an abnormal collateral blood supply to the lungs in episodes of hemoptysis appear as dilated, usually tortuous arteries with associated parenchymal staining by contrast material, systemic-to-pulmonary arterial shunting, and, rarely, contrast material extravasation at the points of bleeding (20–22). The bronchial arteries are implicated in the majority of cases. On occasion, bleeding may occur from nonbronchial systemic arteries or from the pulmonary arteries themselves.

The most common underlying causes of hemoptysis vary in reported studies depending on the geographic location of the study, the prevalence of tuberculosis, and the use of cross-sectional imaging (2). In most reports, bronchiectasis, chronic bronchitis, tuberculosis, and malignancy are the most important causes (2,23–26). These, along with less common causes, are listed in Table 1. "Cryptogenic" hemoptysis, for which no cause can be identified, is responsible for 3.0%–42.2% of episodes of hemoptysis (2,31, 32), particularly in smokers, but is a diagnosis of exclusion and might be expected to decrease in prevalence with more systematic use of CT.

	Systemic Arterial Blood Supply to the Lungs

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

Bronchial arteries that arise in the expected location from the descending thoracic aorta between the levels of T5 and T6 are called orthotopic bronchial arteries. Anomalous bronchial arteries, defined as bronchial arteries that originate outside the T5 through T6 range, are found in 8.3%–21% of cases of hemoptysis (4,35). This anomalous artery arises from the concavity of the aortic arch in most cases (14.7% of cadavers in a study by Cauldwell et al [33]), but it may less commonly originate from the lower thoracic aorta, subclavian arteries, thyrocervical trunk, costocervical trunk, brachiocephalic artery, internal mammary artery, pericardiophrenic artery, or inferior phrenic artery (3,4,33,35,36).

Bronchial arteries can be distinguished from nonbronchial systemic arteries in that their trajectory into the pulmonary parenchyma parallels the bronchovascular axes. In contrast, nonbronchial systemic collateral vessels do not run parallel to the airways and have a more unpredictable origin from infradiaphragmatic arteries or from the supraaortic great vessels or their branches. The most commonly implicated arteries include the inferior phrenic arteries, the musculophrenic and pericardiodiaphragmatic branches of the internal thoracic arteries, the posterior intercostal arteries, and branches from the thyrocervical trunk (3,8, 17,25). These arteries provide systemic collateral vessels that reach the lung parenchyma via the inferior pulmonary ligaments (in the case of the inferior phrenic arteries) or transpleural adhesions (in the case of branches from the intercostal and supraaortic arteries) and that form anastomoses with the pulmonary arterial circulation in regions of inflammation or neoplasia.

	Initial Evaluation of Acute Hemoptysis

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
The severity and natural course of hemoptysis are difficult to predict clinically. The initial evaluation of patients who present with acute hemoptysis includes estimation of the volume of expectorated blood and assessment of cardiorespiratory stability. Certain authors have attempted to discriminate between "major" and "massive" hemoptysis, and various definitions of severity have been proposed, ranging from 100 mL to 1 L of blood expectorated in 24 hours (24,37,38). Although the mortality rate rises as the volume of hemoptysis increases (2,24), any assessment of the severity of hemoptysis must take into account the patient’s cardiorespiratory status, bleeding activity, the possibility of "internalized" (eg, intrapleural, intrapericardial, or intracavitary) bleeding, and the risk of recurrent bleeding. In particular, the recognition of "sentinel bleeding" heralding imminent major hemorrhage is of critical importance but is often difficult on the basis of clinical findings alone (39,40).

Bronchoscopy, performed with either a rigid or a flexible fiberoptic endoscope, is useful in diagnosing active hemorrhage and in controlling the airway in patients with catastrophic hemorrhage (23). However, it is less useful in detecting underlying disease, and its capacity to help localize the site of bleeding is equivalent to that of radiography or CT (24,41). The airways are often filled with blood at the time of bronchoscopy, making evaluation of the distal airways difficult. Furthermore, irritation of the bronchial mucosa caused by lavage or by the endoscope itself can lead to recurrent bleeding. Certain advantages of bronchoscopy such as hemorrhage control with infusion of iced saline solution, balloon inflation, or yttrium aluminum garnet laser coagulation are of unproved efficacy and depend on the practitioner’s skills (23,42). In addition, biopsy of perceived endoluminal abnormalities performed at the time of bronchoscopy can have unforeseen consequences when the vascular nature of such anomalies is not recognized (43,44).

Radiography can help lateralize the bleeding with a high degree of certainty and can often help detect underlying parenchymal and pleural abnormalities (41). Although radiography is a useful initial examination, it needs to be complemented with more detailed evaluation. In a study by Herth et al (45), almost one-quarter of patients presenting with acute hemoptysis secondary to malignancy had normal chest radiographic findings. The authors recommended additional follow-up testing in patients presenting with hemoptysis in whom the underlying cause was not detected at initial radiography.

Contrast material–enhanced multi–detector row CT has the unparalleled advantage of allowing acquisition of high-quality images of the entire thorax in a rapid, safe, and noninvasive manner. Published studies on the efficacy of single–detector row spiral CT have already demonstrated the capacity of this imaging technique to help predict the site of bleeding as accurately as bronchoscopy and to help detect underlying disease with high sensitivity (2,24). Multi–detector row CT provides extended volume coverage with higher image resolution and even greater scanning speed (46,47). The aims of multi–detector row CT in the evaluation of hemoptysis are threefold: (a) to depict underlying disease with high sensitivity by means of detailed images of the lung parenchyma and mediastinum, and in particular to help detect early carcinoma; (b) to help assess the consequences of hemorrhage into the alveoli and airways, which may cause immediate clinical concerns as well as mask subtle underlying abnormalities; and (c) to provide a detailed "road map" of the thoracic vasculature by means of two-dimensional (2D) maximum-intensity-projection (MIP) reformatted images and three-dimensional (3D) reconstructed images. Such road maps are of great use to both the interventional radiologist anticipating arterial embolization and the thoracic surgeon contemplating surgery.

	Multi–Detector Row CT Technique

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
An extended spiral CT study of the thorax can easily be performed with a 16–detector row scanner during a single breath hold (normally lasting less than 15 seconds) in most patients. However, only a limited study with a four–detector row or single–detector row scanner may be possible, depending on the patient’s respiratory capacity. Image acquisition should be performed in a cranio-caudal direction from the base of the neck to the level of the renal arteries to include the supraaortic great vessels and the infradiaphragmatic arteries, which may be responsible for an abnormal collateral contribution to the lungs.

With current multi–detector row systems, optimal enhancement of both the pulmonary and systemic arteries is achieved with the injection of approximately 120 mL of a relatively high-density contrast material (350 mg/dL) at a rate of 4 mL/sec via an 18-gauge cannula into an antecubital vein or central venous catheter. The scan should be started during the phase of peak systemic arterial enhancement (Table 2). Images should be acquired with thin collimation and with the table movement adjusted to allow extended volume coverage during a single breath hold. By adjusting the exposure parameters and kilovoltage according to the patient’s weight, the radiation dose to the patient can be minimized without compromising image quality. In certain cases, it may be useful or even necessary to perform follow-up CT several months after the episode of hemoptysis to study the evolution of underlying parenchymal lung abnormalities or to exclude the possibility that a small malignancy may have been missed at initial CT. Repeat evaluation of the bronchial arteries is not usually necessary unless there is continued hemoptysis; consequently, follow-up imaging can be performed without intravenously administered contrast material and at low milli-amperage to minimize the radiation dose to the patient, which is of particular importance in young patients. Automatic dose modulation at the level of the thoracic inlet is not recommended, so as to avoid streak artifact from osseous structures and from high-density contrast material within the great veins.

	Data Manipulation and Image Interpretation

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

The lung parenchyma and gross soft-tissue structures can be adequately evaluated with a section thickness of 5 mm. Detailed analysis of the airways and lung interstitium requires thinner sections.

Thoracic CT angiography with a combination of multiplanar reformatted images can help identify the variable origins and courses of arteries that may be responsible for bleeding in cases of hemoptysis and can aid in planning the embolization of these arteries. The origins of orthotopic mediastinal bronchial arteries are best depicted on overlapping axial thin-section images (eg, 1-mm-thick sections at 0.75-mm increments) (Fig 1a). Two-dimensional MIP reformatted images in the coronal oblique and sagittal planes readily depict the tortuous trajectories of the bronchial arteries from their origins (descending thoracic aorta) to the lungs along the main bronchi (Fig 1b, 1c); reformatted images in straight coronal planes are better suited for analysis of the intercostal and internal mammary arteries; and axial reconstructed images are ideal for demonstrating the inferior phrenic arteries and branches from the celiac axis. The degree of obliquity of the reconstruction planes and the section thickness of the reformatted images normally have to be adjusted on a case-by-case basis to provide optimal depiction of the vessels in question.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (a) Axial 1-mm-thick CT scan obtained just below the aortic arch (window center, 50 HU; window width, 350 HU) shows enlarged bronchial arteries (arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions of the mediastinum. These findings represent the typical appearance of enlarged bronchial arteries on axial images. Although the origins of the bronchial arteries are well depicted on axial images, their further course is very tortuous, and the intrapulmonary direction of the artery can be difficult to ascertain. (b) Coronal thin-section MIP image clearly demonstrates an enlarged intercostobronchial artery (arrows) coursing into the pulmonary parenchyma parallel to the bronchial airways. (c) Coronal thin-section MIP image obtained in a different patient provides a detailed analysis of the entire intrapulmonary course of an intercosto-bronchial artery (arrows). = intracavitary mycetoma. (d) Reformatted image demonstrates how CT angiography can provide anatomic information that is useful for planning subsequent bronchial artery embolization.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (a) Axial 1-mm-thick CT scan obtained just below the aortic arch (window center, 50 HU; window width, 350 HU) shows enlarged bronchial arteries (arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions of the mediastinum. These findings represent the typical appearance of enlarged bronchial arteries on axial images. Although the origins of the bronchial arteries are well depicted on axial images, their further course is very tortuous, and the intrapulmonary direction of the artery can be difficult to ascertain. (b) Coronal thin-section MIP image clearly demonstrates an enlarged intercostobronchial artery (arrows) coursing into the pulmonary parenchyma parallel to the bronchial airways. (c) Coronal thin-section MIP image obtained in a different patient provides a detailed analysis of the entire intrapulmonary course of an intercosto-bronchial artery (arrows). = intracavitary mycetoma. (d) Reformatted image demonstrates how CT angiography can provide anatomic information that is useful for planning subsequent bronchial artery embolization.

View larger version (162K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (a) Axial 1-mm-thick CT scan obtained just below the aortic arch (window center, 50 HU; window width, 350 HU) shows enlarged bronchial arteries (arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions of the mediastinum. These findings represent the typical appearance of enlarged bronchial arteries on axial images. Although the origins of the bronchial arteries are well depicted on axial images, their further course is very tortuous, and the intrapulmonary direction of the artery can be difficult to ascertain. (b) Coronal thin-section MIP image clearly demonstrates an enlarged intercostobronchial artery (arrows) coursing into the pulmonary parenchyma parallel to the bronchial airways. (c) Coronal thin-section MIP image obtained in a different patient provides a detailed analysis of the entire intrapulmonary course of an intercosto-bronchial artery (arrows). = intracavitary mycetoma. (d) Reformatted image demonstrates how CT angiography can provide anatomic information that is useful for planning subsequent bronchial artery embolization.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.  Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (a) Axial 1-mm-thick CT scan obtained just below the aortic arch (window center, 50 HU; window width, 350 HU) shows enlarged bronchial arteries (arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions of the mediastinum. These findings represent the typical appearance of enlarged bronchial arteries on axial images. Although the origins of the bronchial arteries are well depicted on axial images, their further course is very tortuous, and the intrapulmonary direction of the artery can be difficult to ascertain. (b) Coronal thin-section MIP image clearly demonstrates an enlarged intercostobronchial artery (arrows) coursing into the pulmonary parenchyma parallel to the bronchial airways. (c) Coronal thin-section MIP image obtained in a different patient provides a detailed analysis of the entire intrapulmonary course of an intercosto-bronchial artery (arrows). = intracavitary mycetoma. (d) Reformatted image demonstrates how CT angiography can provide anatomic information that is useful for planning subsequent bronchial artery embolization.

In summary, a comprehensive range of reconstructed images that includes thick- and thin-section axial images obtained with both mediastinal soft-tissue and parenchymal lung window settings, as well as 2D MIP reformatted images in the coronal, sagittal, and axial planes and selected 3D volumetric and SSD reformatted images, are recommended for a thorough CT assessment of hemoptysis (Table 3).

	Assessment of the Lung Parenchyma

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 2d.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 2e.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 2f.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 2g.  Bronchiectasis in a 51-year-old man who presented with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe cystic bronchiectasis in the middle lobe and lingula. (b–g) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis in the right middle lobe and in the lower divisions of the left upper lobe (lingula). (c–g) Thin-section MIP images obtained in the sagittal (c), axial (d), and coronal (e, f ) planes and a 3D volumetric reformatted image (g) depict markedly dilated and tortuous bronchial arteries (arrows in c) and hypertrophic right and left inferior phrenic arteries (arrows in d–g) arising from the abdominal aorta and supplying the areas of bronchiectasis.

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  (a) Axial CT scan (1-mm-thick section) obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) in a patient with hemorrhage following an episode of hemoptysis demonstrates bronchial impaction from blood clot (arrow) in a subsegmental branch of the anterior segmental bronchus of the right upper lobe, a finding that helps localize the site of bleeding. (b) Axial CT scan (1-mm-thick section) (window center, –600 HU; window width, 1600 HU) obtained at the level of the right lower lobe in a patient with lymphangioleiomyomatosis who presented with recurrent hemoptysis depicts an air-fluid level in a pulmonary cyst (arrow), a finding that represents intracavitary blood. The consequences of hemoptysis in the lung parenchyma can obscure subtle underlying lesions such as intrabronchial tumors, and follow-up CT performed several weeks after the acute episode is always recommended.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  (a) Axial CT scan (1-mm-thick section) obtained with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) in a patient with hemorrhage following an episode of hemoptysis demonstrates bronchial impaction from blood clot (arrow) in a subsegmental branch of the anterior segmental bronchus of the right upper lobe, a finding that helps localize the site of bleeding. (b) Axial CT scan (1-mm-thick section) (window center, –600 HU; window width, 1600 HU) obtained at the level of the right lower lobe in a patient with lymphangioleiomyomatosis who presented with recurrent hemoptysis depicts an air-fluid level in a pulmonary cyst (arrow), a finding that represents intracavitary blood. The consequences of hemoptysis in the lung parenchyma can obscure subtle underlying lesions such as intrabronchial tumors, and follow-up CT performed several weeks after the acute episode is always recommended.

	Assessment of Pulmonary and Systemic Vasculature

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

Dieulafoy disease is a poorly understood condition characterized by abnormally dilated submucosal vessels that are prone to hemorrhage and has been described in the colon, the small intestine, and, more recently, the bronchial airways. It usually coexists with chronic inflammatory disorders such as chronic bronchitis and is thought to involve the pulmonary arterial system rather than the bronchial arteries (54,55). At fiberoscopic endoscopy, the visualization of a tangle of dilated submucosal blood vessels in the presence of mucosal inflammation should raise suspicion for Dieulafoy disease and alert the bronchoscopist to forego mucosal biopsy (43,44). To our knowledge, there have been no published CT descriptions of this vascular anomaly.

Life-threatening hemoptysis may occur, albeit uncommonly, following rupture of thin-walled pulmonary arteriovenous malformations (30,56). Pulmonary arteriovenous malformations with feeding arteries larger than 3 mm can be successfully treated with coil embolization therapy.

Bronchial Arteries
In 95% of cases of hemoptysis, the systemic arterial system is the origin of the bleeding (3). The value of bronchial artery embolization for the treatment of massive hemoptysis has been well described (20,21,57,58). Although there is poor correlation between bronchial arterial dilatation and the risk of hemorrhage (49), a diameter of more than 2 mm is considered abnormal (22) and, when arterial embolotherapy is being considered, usually indicates the vessel to be embolized. The bronchial arteries have highly tortuous but predictable trajectories that can easily be analyzed with a thorough knowledge of bronchial arterial anatomy (33). Because they course predominantly perpendicular to the scanning plane, on axial images they appear as a cluster of avidly enhancing nodules in the posterior mediastinum, usually just below the level of the aortic arch (22).

Although the bronchial arteries are the most common source of bleeding in hemoptysis, the actual hemorrhage usually occurs from fragile thin-walled anastomoses between distant bronchial arterial branches and pulmonary arteries that are under high systemic arterial pressure, located in the airway submucosa and too small to be directly visualized at CT. Active bleeding can rarely be detected at CT due to the presence of contrast material in the airway lumen (Fig 4). At conventional angiography, active hemorrhage can also manifest as staining of the lung parenchyma by contrast material (58).

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 4d.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 4e.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 4f.  Hemorrhage from the intercostobronchial trunk in a 64-year-old man with hemoptysis of 400 mL in 24 hours. (a) Posteroanterior chest radiograph obtained at the time of admission demonstrates no abnormality. (b, c) Axial thoracic CT scans obtained on a 16–detector row scanner with lung parenchymal window settings (window center, –600 HU; window width, 1600 HU) (b) and mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) (c) depict dense material (arrow) within the apical segmental bronchus of the right upper lobe. (d–f ) Sequential arteriograms of the intercostobronchial artery demonstrate immediate filling of the apical segmental bronchus with contrast material (arrow in e and f), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree. Embolization of this artery was successfully performed, with immediate cessation of hemoptysis.

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Bronchial artery aneurysm in a 37-year-old man with acute hemoptysis of 300 mL in 24 hours. (a) Posteroanterior chest radiograph demonstrates a cavitating mass in the right upper lobe, a finding that subsequently proved to be cavitating reactivation tuberculosis. (b–d) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan (1-mm-thick section) obtained with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts a dense nodular lesion (white arrow) within a necrotic mass in the right upper lobe. Enlarged bronchial arteries (black arrows) can be identified in the mediastinum. (c, d) On thin-section (3-mm) axial (c) and coronal (d) MIP images, the dense nodule (arrow) can be clearly identified as a bronchial artery aneurysm within the necrotic mass. Note the adjacent nodular calcifications in the wall of the mass. (e) Arteriogram shows the aneurysm (arrow) arising from a branch of the intercosto-bronchial artery, which was later successfully embolized.

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Bronchial artery aneurysm in a 37-year-old man with acute hemoptysis of 300 mL in 24 hours. (a) Posteroanterior chest radiograph demonstrates a cavitating mass in the right upper lobe, a finding that subsequently proved to be cavitating reactivation tuberculosis. (b–d) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan (1-mm-thick section) obtained with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts a dense nodular lesion (white arrow) within a necrotic mass in the right upper lobe. Enlarged bronchial arteries (black arrows) can be identified in the mediastinum. (c, d) On thin-section (3-mm) axial (c) and coronal (d) MIP images, the dense nodule (arrow) can be clearly identified as a bronchial artery aneurysm within the necrotic mass. Note the adjacent nodular calcifications in the wall of the mass. (e) Arteriogram shows the aneurysm (arrow) arising from a branch of the intercosto-bronchial artery, which was later successfully embolized.

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Bronchial artery aneurysm in a 37-year-old man with acute hemoptysis of 300 mL in 24 hours. (a) Posteroanterior chest radiograph demonstrates a cavitating mass in the right upper lobe, a finding that subsequently proved to be cavitating reactivation tuberculosis. (b–d) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan (1-mm-thick section) obtained with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts a dense nodular lesion (white arrow) within a necrotic mass in the right upper lobe. Enlarged bronchial arteries (black arrows) can be identified in the mediastinum. (c, d) On thin-section (3-mm) axial (c) and coronal (d) MIP images, the dense nodule (arrow) can be clearly identified as a bronchial artery aneurysm within the necrotic mass. Note the adjacent nodular calcifications in the wall of the mass. (e) Arteriogram shows the aneurysm (arrow) arising from a branch of the intercosto-bronchial artery, which was later successfully embolized.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 5d.  Bronchial artery aneurysm in a 37-year-old man with acute hemoptysis of 300 mL in 24 hours. (a) Posteroanterior chest radiograph demonstrates a cavitating mass in the right upper lobe, a finding that subsequently proved to be cavitating reactivation tuberculosis. (b–d) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan (1-mm-thick section) obtained with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts a dense nodular lesion (white arrow) within a necrotic mass in the right upper lobe. Enlarged bronchial arteries (black arrows) can be identified in the mediastinum. (c, d) On thin-section (3-mm) axial (c) and coronal (d) MIP images, the dense nodule (arrow) can be clearly identified as a bronchial artery aneurysm within the necrotic mass. Note the adjacent nodular calcifications in the wall of the mass. (e) Arteriogram shows the aneurysm (arrow) arising from a branch of the intercosto-bronchial artery, which was later successfully embolized.

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 5e.  Bronchial artery aneurysm in a 37-year-old man with acute hemoptysis of 300 mL in 24 hours. (a) Posteroanterior chest radiograph demonstrates a cavitating mass in the right upper lobe, a finding that subsequently proved to be cavitating reactivation tuberculosis. (b–d) Images from a thoracic CT angiographic study performed with a 16–detector row scanner. (b) Axial CT scan (1-mm-thick section) obtained with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts a dense nodular lesion (white arrow) within a necrotic mass in the right upper lobe. Enlarged bronchial arteries (black arrows) can be identified in the mediastinum. (c, d) On thin-section (3-mm) axial (c) and coronal (d) MIP images, the dense nodule (arrow) can be clearly identified as a bronchial artery aneurysm within the necrotic mass. Note the adjacent nodular calcifications in the wall of the mass. (e) Arteriogram shows the aneurysm (arrow) arising from a branch of the intercosto-bronchial artery, which was later successfully embolized.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Anomalous bronchial artery anatomy in a patient with acute hemoptysis. Coronal (a) and sagittal (b) thin-section multiplanar reformatted images from thoracic CT angiographic data obtained with a four–detector row scanner show bronchial arteries (arrows) arising from the concavity of the aortic arch. Bronchial arteries have ectopic origins outside the T5 through T6 range in 20% of cases, with the most common origin being the one shown in this case. Such arteries can be difficult to visualize on axial images alone.

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Anomalous bronchial artery anatomy in a patient with acute hemoptysis. Coronal (a) and sagittal (b) thin-section multiplanar reformatted images from thoracic CT angiographic data obtained with a four–detector row scanner show bronchial arteries (arrows) arising from the concavity of the aortic arch. Bronchial arteries have ectopic origins outside the T5 through T6 range in 20% of cases, with the most common origin being the one shown in this case. Such arteries can be difficult to visualize on axial images alone.

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Nonbronchial systemic arteries in a 42-year-old man with acute massive hemoptysis of approximately 300 mL in 24 hours. (a) Initial posteroanterior chest radiograph shows a multiloculated cavitating mass containing multiple air-fluid levels in the right upper lobe, a finding that represents reactivation tuberculosis. (b) Posterior 3D SSD image from thoracic CT angiographic data obtained with a 16–detector row scanner depicts an enlarged right internal mammary artery supplying hypertrophic mediastinal branches (arrows) to an area of the right upper lobe. Selective embolization of these vessels was subsequently performed. (c, d) Sequential arteriograms help confirm the finding in b (arrows). Such abnormally dilated nonbronchial systemic arteries are recruited into the lung parenchyma across transpleural adhesions, usually in the presence of chronic inflammatory disorders, and can be distinguished from ectopic bronchial arteries in that their trajectories do not follow the bronchial airways.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Nonbronchial systemic arteries in a 42-year-old man with acute massive hemoptysis of approximately 300 mL in 24 hours. (a) Initial posteroanterior chest radiograph shows a multiloculated cavitating mass containing multiple air-fluid levels in the right upper lobe, a finding that represents reactivation tuberculosis. (b) Posterior 3D SSD image from thoracic CT angiographic data obtained with a 16–detector row scanner depicts an enlarged right internal mammary artery supplying hypertrophic mediastinal branches (arrows) to an area of the right upper lobe. Selective embolization of these vessels was subsequently performed. (c, d) Sequential arteriograms help confirm the finding in b (arrows). Such abnormally dilated nonbronchial systemic arteries are recruited into the lung parenchyma across transpleural adhesions, usually in the presence of chronic inflammatory disorders, and can be distinguished from ectopic bronchial arteries in that their trajectories do not follow the bronchial airways.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  Nonbronchial systemic arteries in a 42-year-old man with acute massive hemoptysis of approximately 300 mL in 24 hours. (a) Initial posteroanterior chest radiograph shows a multiloculated cavitating mass containing multiple air-fluid levels in the right upper lobe, a finding that represents reactivation tuberculosis. (b) Posterior 3D SSD image from thoracic CT angiographic data obtained with a 16–detector row scanner depicts an enlarged right internal mammary artery supplying hypertrophic mediastinal branches (arrows) to an area of the right upper lobe. Selective embolization of these vessels was subsequently performed. (c, d) Sequential arteriograms help confirm the finding in b (arrows). Such abnormally dilated nonbronchial systemic arteries are recruited into the lung parenchyma across transpleural adhesions, usually in the presence of chronic inflammatory disorders, and can be distinguished from ectopic bronchial arteries in that their trajectories do not follow the bronchial airways.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 7d.  Nonbronchial systemic arteries in a 42-year-old man with acute massive hemoptysis of approximately 300 mL in 24 hours. (a) Initial posteroanterior chest radiograph shows a multiloculated cavitating mass containing multiple air-fluid levels in the right upper lobe, a finding that represents reactivation tuberculosis. (b) Posterior 3D SSD image from thoracic CT angiographic data obtained with a 16–detector row scanner depicts an enlarged right internal mammary artery supplying hypertrophic mediastinal branches (arrows) to an area of the right upper lobe. Selective embolization of these vessels was subsequently performed. (c, d) Sequential arteriograms help confirm the finding in b (arrows). Such abnormally dilated nonbronchial systemic arteries are recruited into the lung parenchyma across transpleural adhesions, usually in the presence of chronic inflammatory disorders, and can be distinguished from ectopic bronchial arteries in that their trajectories do not follow the bronchial airways.

View larger version (280K): [in this window] [in a new window] [Download PPT slide]   Figure 8.  Nonbronchial systemic arteries in a patient with massive hemoptysis. Three-dimensional volumetric reformatted images from thoracic CT angiographic data obtained with a 16–detector row scanner depict transpleural systemic-to-pulmonary anastomoses between distal branches of the internal mammary artery (the musculophrenic and lower anterior intercostal arteries) (arrow) and the pulmonary arteries.

Pseudosequestration, or purely vascular pulmonary sequestration, is a rare entity that may be responsible for hemoptysis from nonbronchial systemic arteries and that has traditionally been treated with surgical resection but may also be suitable for embolotherapy (29,66,67). Unlike bronchopulmonary sequestration, pseudosequestration is characterized by a purely vascular anomaly without involvement of the bronchial tree or lung parenchyma (67). There is usually a single systemic artery arising from the descending thoracic aorta that supplies a normal part of the lung, usually in the lung bases, with venous drainage via the pulmonary veins. Although purely vascular sequestrations are mostly asymptomatic and are usually discovered incidentally at chest radiography or thoracic CT, they may be complicated by massive hemoptysis, which can be effectively controlled with catheter embolization of the aberrant systemic artery (29,66). Other possible complications include thrombosis of the systemic artery, causing acute pulmonary infarction and pain (66), and left-sided heart failure due to left-to-left shunting (68).

Bronchial-to-Systemic Artery Communications
One of the most feared complications of bronchial and nonbronchial systemic artery embolotherapy is inadvertent embolization of a major spinal artery, with resultant paraplegia. The anterior spinal artery provides the main blood supply to the anterior two-thirds of the spinal cord and is heavily dependent on reinforcement from anterior medullary arteries from the thoracic aorta, which normally originate from the posterior intercostal arteries. The arteria radicularis magna (artery of Adamkiewicz) is responsible for reinforcing the anterior spinal artery in the distal thoracic and lumbar regions. It arises from the descending thoracic aorta between the levels of T9 and T12 in 75% of cases, but an origin between the levels of T5 and T8 is not uncommon (69). Anterior medullary arteries are occasionally observed during bronchial artery embolization but may arise from a posterior intercostal branch of the intercostobronchial trunk; a systematic search for the classic "hairpin" configuration of such arteries during bronchial angiography should be undertaken because it is crucial to avoid embolization of these vessels. At contrast-enhanced thoracic CT angiography for the evaluation of hemoptysis prior to embolization therapy, it may be possible to visualize the artery of Adamkiewicz (70); however, the fine caliber of this artery and the possibility of mistaking it for an anterior spinal vein make it difficult to identify with certainty.

Important communications can also exist between the bronchial and coronary arteries. In disease entities that cause diminished pulmonary arterial blood flow such as cyanotic congenital heart disease, chronic thromboembolic disease, and vasculitides such as Takayasu arteritis, shunting can occur from coronary arteries to pulmonary arteries via the bronchial arteries (14,71). Coronary-to-bronchial artery anastomoses are most often identified in the region of the retrocardiac "bare areas" of the heart, where the relatively wide pericardial reflections permit the development of communications between the coronary and extracoronary arteries (72). In situations of decreased pulmonary blood flow, anastomoses between the bronchial arteries and the pulmonary arteries at the level of the vasa vasorum are reinforced by collateral blood flow from the high-pressure coronary arterial system by way of coronary-to-bronchial arterial shunting. Coronary-to-bronchial arterial anastomoses normally arise from the atrial branches of both coronary arteries. Such shunting may be involved in the "pulmonary steal" syndrome that manifests in some patients as classic angina-like symptoms in the presence of angiographically normal coronary arteries (73). Conversely, in certain situations atherosclerotic coronary artery disease can promote the development of bronchial-to-coronary arterial shunting (74). Coronary-bronchial arterial anastomoses can be identified at thoracic CT angiography and constitute an important finding prior to anticipated bronchial artery embolization therapy (Fig 9).

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retrocardiac region.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

View larger version (75K): [in this window] [in a new window] [Download PPT slide]   Figure 9d.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 9e.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

View larger version (64K): [in this window] [in a new window] [Download PPT slide]   Figure 9f.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 9g.  Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Postero-anterior chest radiograph demonstrates severe cystic bronchiectasis in the lingula. (b–g) Images from thoracic CT angiographic data obtained with a four–detector row scanner. (b) Axial 5-mm-thick CT scan obtained at the level of the lingula with parenchymal lung window settings (window center, –600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis. (c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal soft-tissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area. (d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). An anastomosis with the left anterior descending artery was identified more distally on axial 1-mm-thick images (not shown). The systemic artery was identified as a dilated bronchial artery. (e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery. (f ) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum. (g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retro-cardiac region.

	Cryptogenic Hemoptysis

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

	Conclusions

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 
Massive hemoptysis is a medical emergency that requires prompt assessment. CT is a quick and noninvasive tool that is helpful in the diagnosis and management of hemoptysis, and its use should be considered in any patient who presents with this condition.

	Footnotes

 

Abbreviations: MIP = maximum intensity projection, SSD = shaded surface display, 3D = three-dimensional, 2D = two-dimensional

	References

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Pathophysiologic Features and... Systemic Arterial Blood Supply... Initial Evaluation of Acute... Multi-Detector Row CT Technique Data Manipulation and Image... Assessment of the Lung... Assessment of Pulmonary and... Cryptogenic Hemoptysis Conclusions References

 

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