Spiral Computed Tomography for Acute Pulmonary Embolism

In many institutions, spiral CT is becoming established as the first-line imaging test in daily clinical practice. With spiral CT, thrombus ... HomeCirculationVol.109,No.18SpiralComputedTomographyforAcutePulmonaryEmbolism FreeAccessReviewArticlePDF/EPUBAboutViewPDFViewEPUBSections ToolsAddtofavoritesDownloadcitationsTrackcitationsPermissions ShareShareonFacebookTwitterLinkedInMendeleyRedditDiggEmail JumptoFreeAccessReviewArticlePDF/EPUBSpiralComputedTomographyforAcutePulmonaryEmbolismU.JosephSchoepf,MDSamuelZ.Goldhaber,andMDPhilipCostelloMDU.JosephSchoepfU.JosephSchoepfFromtheDepartmentofRadiology(U.J.S.,P.C.)andCardiovascularDivision,DepartmentofMedicine(S.Z.G.),BrighamandWomen’sHospital,HarvardMedicalSchool,Boston,Mass.Searchformorepapersbythisauthor,SamuelZ.GoldhaberSamuelZ.GoldhaberFromtheDepartmentofRadiology(U.J.S.,P.C.)andCardiovascularDivision,DepartmentofMedicine(S.Z.G.),BrighamandWomen’sHospital,HarvardMedicalSchool,Boston,Mass.Searchformorepapersbythisauthor,andPhilipCostelloPhilipCostelloFromtheDepartmentofRadiology(U.J.S.,P.C.)andCardiovascularDivision,DepartmentofMedicine(S.Z.G.),BrighamandWomen’sHospital,HarvardMedicalSchool,Boston,Mass.SearchformorepapersbythisauthorOriginallypublished11May2004https://doi.org/10.1161/01.CIR.0000128813.04325.08Circulation.2004;109:2160–2167AbstractThereisstillconsiderabledebateabouttheoptimaldiagnosticimagingmodalityforacutepulmonaryembolism.Ifimagingisdeemednecessaryfromaninitialclinicalevaluationsuchasd-dimertesting,optionsincludenuclearmedicinescanning,catheterpulmonaryangiography,andspiralCT.Inmanyinstitutions,spiralCTisbecomingestablishedasthefirst-lineimagingtestindailyclinicalpractice.WithspiralCT,thrombusisdirectlyvisualized,andbothmediastinalandparenchymalstructuresareevaluated,whichmayprovideimportantalternativeoradditionaldiagnoses.However,limitationsfortheaccuratediagnosisofsmallperipheralemboli,withareportedmissrateofupto30%withsingle-slicespiralCTsofar,havepreventedtheunanimousembraceofspiralCTasthenewstandardofreferenceforimagingpulmonaryembolism.Theclinicalsignificanceofthedetectionandtreatmentofisolatedperipheralpulmonaryemboliisuncertain.EvidenceisaccumulatingthatitissafepracticetowithholdanticoagulationinpatientswithsuspectedpulmonaryembolismonthebasisofanegativespiralCTstudy.RemainingconcernsabouttheaccuracyofspiralCTforpulmonaryembolismdetectionmaybeovercomebytheintroductionofmultidetector-rowspiralCT.Thiswidelyavailabletechnologyhasimprovedvisualizationofperipheralpulmonaryarteriesanddetectionofsmallemboli.Themostrecentgenerationofmultidetector-rowspiralCTscannersappearstooutperformcompetingimagingmodalitiesfortheaccuratedetectionofcentralandperipheralpulmonaryembolism.Inthisreview,weassessthecurrentroleandfuturepotentialofCTinthediagnosticalgorithmofacutepulmonaryembolism.Pulmonaryembolism(PE)isproteaninnature,continuestomasqueradeasotherillnesses,andisfrequentlyoverlookedandmisdiagnosed,attimesevenbyexperiencedclinicians.NoninvasiveimagingtestsforPEareincreasinglysophisticatedandprovidepreviouslyunimaginablefineresolutionofperipheralpulmonaryarteries.Despitetechnicalprogress,imagingthepulmonaryarterieshasremainedcostlyandpotentiallyharmful,evenwithnoninvasiveapproaches.Therefore,imagingtestscannotbeorderedoneverypatientwhopresentswitharemotepossibilityofPE.Accordingly,diagnosticalgorithmshavebeendevelopedtorationalizetheuseofnoninvasiveimagingtests.Ideally,thereisaprogressionfromclinicalassessmenttofundamentalnonimagingtestsbeforeimagingofthepulmonaryarteriesensues(Table1).Thediagnosticprocesscanidentifyotherimportantillnesses(suchasmyocardialinfarctiononECGorpneumoniaorpneumothoraxonchestradiograph).BedsidetestshavebeenrefinedtoassesstheclinicallikelihoodofPE.ThetestdevelopedbyWellsandcolleagues,1forexample,isasimplequestionnaireforpatientswithpossiblePE.With7basicquestions,thetestcanrapidlyassesstheclinicalprobabilityofPE. TABLE1.DiagnosticApproachestoAcutePE:StrengthsandWeaknessesTestStrengthsWeaknessesWellsquestionnaire1RapidbedsidestratificationoflikelihoodofPEInfluencedbyonesubjectivequestion:whetheralternativediagnosesaremorelikelythanPEArterialbloodgases:hypoxemia2Rapid;widelyavailableDoesnotdiscriminatewellbetweenpatientswithandwithoutPEArterialbloodgases:A-Agradient3Rapid;widelyavailableNormalgradientpresentinasmanyas20%ofpatientswithPEd-dimer4,5Rapid;widelyavailable;highnegativepredictivevalueNotspecific;lowpositivepredictivevalueElectrocardiogram9–11Universallyavailable;mayindicaterightheartstrainNotspecific;maybenormaldespitePEChestx-ray12MayidentifymimicsofPE:pneumonia,pneumothorax,congestiveheartfailureMaybenormaldespitePE;patientsmayhaveconcomitantPEandpneumoniaorPEandcongestiveheartfailureVenousultrasound13–16MayidentifyDVT,thusestablishingthepresenceofvenousthrombosisMaybenormaldespitePE(becauseDVTembolized)CTvenography17,18MayobviatevenousultrasonographyifDVTisdetectedLowsensitivityforcalfDVT;radiationexposureEchocardiography20Identifiespatientsathighriskifrightventriculardysfunctionisdetected;onrareoccasionswillvisualizethePEUsuallynormaldespitePELungscanning30,31Avoidscontrastinjection;usefulifnormalorhighprobabilityOftennondiagnosticPulmonaryangiography23–25Classicallyconsideredthe“goldstandard”;detaileddisplayofpulmonaryvascularmorphology,oligemicareasofperfusion,manifestationsofantecedent,chronicemboli(webs,pouches,laminatedclot,vesselfenestrations),andvenousdrainageInvasive;laborintensive;costly;highinterobservervariabilityfordetectionofsubsegmentalemboliSpiralCT29,33,37,38,40,51–60Defactofirstlineimagingtestinclinicalpractice;widelyavailable;directvisualizationofthrombusandofalternativeoradditionaldiagnoses;costeffective;highnegativepredictivevalueforclinicallyrelevantPERequiresuseofiodinatedcontrastmaterial;radiationexposureArterialbloodgasanalysis2andcalculationofalveolar-arterialoxygentensiondifference3arenotreliabletoolstodetectpatientswhohavePE.Theprincipalblood-screeningtesthasbecomethed-dimerassay.d-dimertestingishighlysensitiveandhasaveryhighnegativepredictivevalue,soitisanexcellentscreeningtestforemergencydepartmentpatients.AtBrighamandWomen’sHospital’sEmergencyDepartment,with1106consecutiveassaysforsuspectedPE,thesensitivitywas97%andthenegativepredictivevaluewas99.6%.4Similarresultshavebeenobtainedinotheremergencydepartments.5Initialevaluationandtestingshouldbecompletedwithinseveralhoursintheemergencydepartmentsetting.Atthatpoint,thedecisiontoproceedwithdirectchestimagingforPEmustensue.d-dimerislessusefulforpatientswhoarealreadyhospitalizedbecausethelevelsareelevatedinmanyillnessesthatmimicPE,suchaspneumoniaandmyocardialinfarction.d-dimerlevelsarealsoelevatedinpatientswithcancerandsepsis,thosewhoarepregnant,andthoseinthepostoperativestate.Toincreasetheprecisionofthediagnosticworkup,thestandardizedclinicalassessmentandd-dimertestresultcanbeusedtogethertohelpdecidewhichpatientswarrantfurtherworkup.6–8Ordinarily,theworkupforPEcanstopifthed-dimerELISAisnormal.Whileawaitingresultsofthed-dimer,mostpatientsshouldundergoECGandchestradiography.TheECGmaybenormalinpatientswithmassivePE.Sometimes,therearesignsofright-sideheartstrainsuchasnegativeTwavesintheprecordialleads,9rightbundle-branchblock,theclassicS1Q3T3pattern,10andtherecentlydescribedQrinleadV1.11Thechestradiographmaybenormal,eveninpatientswithmassivePE.Themostcommonradiographicabnormalityiscardiomegaly.12TheutilityofvenousultrasonographicscreeningofpatientswithoutlegsymptomswhohavesuspectedPEiscontroversial.13–16Ifadiagnosisofdeepvenousthrombosis(DVT)canbeestablishedinapatientwithsymptomsofPE,thecourseoftherapyismostoftenpredetermined.However,thisapproachmaymissmorethanhalfofpatientswithPE,15probablybecausetheDVThasoftencompletelyembolizedtothelungs.Also,venousultrasonographyisnotoriouslyinsensitivefordiagnosingDVTinasymptomaticpatients.13,14,16IfCTisusedastheprimaryimagingtestforsuspectedPE,thefeasibilityofcombiningCTangiographyofthepulmonaryarterieswithCTvenographyofthedeepvenoussystemforacomprehensiveevaluationforvenousthromboembolismhasbeendemonstrated.17,18Finally,echocardiographyisnotrecommendedasaroutineimagingtesttodiagnosesuspectedacutePE.Instead,echocardiographyismostusefulforriskstratificationandprognosticationafterthediagnosisofPEhasbeenestablished.19,20ImagingAcutePEPulmonaryAngiography,NuclearMedicineLungScanning,andMRACatheterpulmonaryangiographyhasbeenhailedasthe“goldstandard”techniqueforPEdiagnosisandhastheadvantageofprovidingsimultaneoushemodynamicinformationthatmaybeusefulforpatientmanagement.Inreality,however,thistestisinfrequentlyperformed.21,22Themorbidityandmortalityratesforthisinvasivetestarereportedtorangefrom3.5%to6%and0.2%to0.5%,respectively.23–25Useofnuclearmedicineimaging,oncethefirstimagingstudyforsuspectedPE,isindecline26,27becauseofthehighpercentageofindeterminatestudies(73%ofallperformed28)andpoorinterobservercorrelation.29Revisedcriteriafortheinterpretationofventilation-perfusionexaminations30,31andnoveltechnologiesinnuclearmedicinesuchasSPECT32candecreasetheproportionofindeterminatescintigraphicstudiesbutcannotoffsetthelimitationsinherenttoafunctionalimagingtest.33Differentfromotherimagingtests,ventilation-perfusionscintigraphyisanindirecttestforPEbasedonassessmentofpulmonaryperfusion.Thisdiffersfromimagingmodalitiesthatallowdirectvisualization(Figure1)ofPEandotherthoracicpathology.DownloadfigureDownloadPowerPointFigure1.Contrast-enhanced16-sliceCTexaminationof72-year-oldmanwithextensive,acutecentralPEwith“saddleembolus”(arrows)extendingintobothcentralpulmonaryarteries.Coloredvolume-renderingtechniqueseenfromananterior(A)andanteriocranial(B)perspectiveallowsintuitivevisualizationoflocationandextentofembolism.Contrast-enhancedMRA34,35hasacquisitionprotocolsthatlacksufficientspatialresolutionforreliableevaluationofperipheralpulmonaryarteries.35,36Moreimportant,thismodalityhasnotseenwidespreaduseintheacutelyillpatientwithsuspectedPEbecauseofalackofgeneralavailability,relativelylongexaminationtimes,anddifficultiesinpatientmonitoring.SpiralCTforImagingAcutePEInmanyinstitutions,spiralCTisbecomingthefirst-lineimagingtestfortheassessmentofpatientswithsuspectedacutePEindailyclinicalpractice.Bothmediastinalandparenchymalstructuresareevaluated,andthrombusisdirectlyvisualized(Figure1).ManypatientswithaninitialsuspicionofPEreceiveotherdiagnoses,37sometimessuchpotentiallylife-threateningdiseasesasaorticdissection,pneumonia,lungcancer(Figure2),andpneumothorax.38WithspiralCT,aspecificcauseforthepatients’symptomsandimportantadditionaldiagnosescanbeestablishedinmanycases.33Inaddition,notonlyintravascularthromboembolicfillingdefectsbutalsoothermanifestationsofprecedentpulmonarythromboembolic,includingparenchymalinfarction(Figure3),pleuraleffusion,vascularremodeling(dilation,pouches,thromboticwallthickening),andoligemia(Figure4),canreadilybevisualizedwithspiralCT.TheinterobserveragreementforspiralCTisbetterthanfornuclearscintigraphy.29,39SpiralCTalsoappearstobethemostcost-effectivemodalityinthediagnosticalgorithmofPEcomparedwithalgorithmsthatdonotincludespiralCT.40DownloadfigureDownloadPowerPointFigure2.Contrast-enhanced16-sliceCTexaminationofpatientwithacutedisseminatedpulmonaryemboli(arrows).Asanincidentalfinding,examinationalsorevealsfocallunglesion(openarrow)inleftupperlobethatwaslaterconfirmedtobestageIsmall-celllungcancer.DownloadfigureDownloadPowerPointFigure3.PatientstatusafteracutePE.Wedge-shapedareaofconsolidation(arrows)inepidiaphragmalportionoflowerlobeofleftlungrepresentsinfarctionoflungparenchymasecondarytoacutePE.Showniscontrast-enhanced16-slicemultidetector-rowspiralCTexaminationwithmultiplanarreformationinmidcoronal(left)andleftsagittal(right)plane.DownloadfigureDownloadPowerPointFigure4.Sixteen-slicemultidetector-rowspiralCTangiograminpatientwithrecurrentthromboembolicdisease.Displaysarecoronalmaximum-intensityprojection(A),coronalminimum-intensityprojection(B),andvolume-renderedtechniqueseenfromposterior(C).Pulmonaryarteries(PA)inrightlowerlobearemostaffectedbyPEandappearobliterated,withnormal-sizedpulmonaryveinsreturningtoleftatrium(LA).Lungperfusioninlowerlobesoflungisdiminishedbutmaintainedinupperlobes(B).Bloodflowtorightlowerlobeismaintainedviabronchialarteries(BA),whicharehypertrophied(arrowinAandC)andhaveformedcollateralsbypassingoccludedandobliteratedpulmonaryarteries.PVindicatespulmonaryveins.SpiralCTLimitationsforImagingPeripheralPulmonaryEmboliThemainimpedimentforspiralCThasbeenlimitationsofthismodalityfortheaccuratedetectionofsmallperipheralemboli.41–43Earlystudiescomparingconventionalsingle-slicespiralCTwithselectivepulmonaryangiographydemonstratedthehighaccuracyofspiralCTfordetectingPEfromthemainpulmonaryarterytothesegmentalarteriallevel41,44,45butsuggestedthatsubsegmentalpulmonaryembolimaybeoverlookedbyspiralCTscanning.Witholdergenerationsofconventionalsingle-slicespiralCTscanners,false-negativeratesofupto30%41–43werereported.DetectionandTreatmentofIsolatedPeripheralPulmonaryEmboli:ClinicalSignificanceLimitationsfortheaccuratediagnosisofisolatedperipheralemboliwithsingle-slicespiralCTsofarhavepreventedtheunanimousembraceofspiralCTasthenewstandardofreferenceforimagingPE.Theclinicalsignificanceofsuchisolatedperipheralemboli,however,insubsegmentalorsmallerpulmonaryarteriesintheabsenceofcentralemboliisuncertain.Ithasbeenshownthat6%28to30%46ofpatientswithdocumentedPEpresentwithclotsonlyinsubsegmentalandsmallerarteries.Itisspeculatedthatoneimportantfunctionofthelungistopreventsmallembolifromenteringthearterialcirculation.Suchembolimayformeveninhealthyindividuals,althoughthisnotionhasneverbeensubstantiated.47Controversyalsoexistsaboutthetreatmentofsmallemboliandwhetherthiswillresultinimprovedclinicaloutcome.48,49ItisassumedthatthepresenceofsuchembolimayindicatecurrentDVTthatpotentiallyheraldsmoresevereembolicevents.37,46,50Aburdenofsmallperipheralemboliisalsothoughttohaveprognosticrelevanceinindividualswithcardiopulmonarydisease46andforthedevelopmentofchronicpulmonaryhypertensioninpatientswiththromboembolicdisease.46Althoughtheaccuracyofconventionalsingle-slicespiralCTforthedetectionofisolatedperipheralembolimaybelimited,encouragingdataareaccumulatingonthehighnegativepredictivevalueofanormalspiralCTstudy29,51–60(Table2).Accordingtotheseretrospective29,51–58andprospective59,60studies,patientoutcomeisnotadverselyaffectedifanticoagulationiswithheldonthebasisofanegativespiralCTstudy.ThenegativepredictivevalueofanormalspiralCTstudyishigh,comparesveryfavorablywithcatheterpulmonaryangiography,61andapproaches98%,regardlessofwhetherunderlyinglungdiseaseispresent.55,56ThefrequencyofasubsequentclinicaldiagnosisofPEorDVTafteranegativespiralCTpulmonaryangiogramislow,lowerthanthatafteranegativeorlow-probabilityV-Qscan.29,53Thus,evensingle-slicespiralCTappearstobeareliableimagingtoolforexcludingclinicallyrelevantPE,soitappearsthatanticoagulationcanbesafelywithheldwhenthespiralCTscanisnormalandofgooddiagnosticquality.53,57,59,60TABLE2.PatientOutcomeifAnticoagulationIsWithheldontheBasisofaNegativeSpiralCTStudyinPatientsWithSuspectedPE:Peer-ReviewedPublicationsReferenceYearJournalPatientsWithoutAnticoagulationBasedonNormalCT,nFollow-UpPeriodDocumentedDVT/PEinPatientsWithoutAnticoagulation,nNegativePredictiveValueofNormalCTforRulingoutPE,%Garg511999AJRAmJRoentgenol786mo199Lomis521999JVascIntervRadiol1006–24mo0100Goodman532000Radiology1983mo299Blachere292000AJRAmJRoentgenol104124–479d396.2Gottsater542001EurRadiol2153mo399.1Ost552001AmJMed716mo396Tillie-Leblond562002Radiology18512mo398Swensen572002MayoClinProc9933mo899Nilsson582002ActaRadiol4413mo499.1Musset592002Lancet5073mo998.8VanStrijen602003AnnInternMed2463mo199.2AdvantagesofMultidetector-RowSpiralCTforPEImagingRemainingconcernsabouttheaccuracyofspiralCTforPEdetectionmaybeovercomebytheintroductionofmultidetector-rowspiralCT.Multidetector-rowspiralCT,withsimultaneousacquisitionof4sectionsperscannerrotationinsteadofasinglesection,firstbecameavailablein1998.62,63Theadvantagesoffast,high-resolutionimageacquisitionwithmultidetector-rowspiralCTledtothewidespreadembraceofthismodality,withcloseto3000installedunitsintheUnitedStates.Thecurrentgenerationof4-,6-,8-,10-,and16-slicemultidetector-rowspiralCTscannersnowallowsacquisitionoftheentirechestwith1-mmorsubmillimeterresolutionwithinashortsinglebreath-hold(<10secondsinthecaseofthe16-sliceCT)(Figure5).Coveringsubstantialpartsofthehumananatomywithever-finerspatialresolutionhasobviousadvantagesforimagingPE.Shorterbreath-holdtimesbenefitpatientswithunderlyinglungdiseaseandreducethepercentageofnondiagnosticCTscans.64High-resolutionmultidetector-rowspiralCTdatacanbetransformedeasilyfor2Dand3Dvisualization.Thismay,insomeinstances,improvePEdiagnosisbutisgenerallyofgreaterimportanceforconveyinginformationonlocalizationandextentofembolicdiseaseinamoreintuitivedisplayformat(Figure1).DownloadfigureDownloadPowerPointFigure5.Normalpulmonaryvesselsin56-year-oldmanpresentingwithmildchestpainafterlong-distanceflight.Contrast-enhanced16-sliceCTexaminationcoversentirechestwithin10-secondexaminationtime,allowinganalysisofeventhemostperipheralpulmonaryvesselswithexquisitedetail.Coronalreconstructionisshownbymaximum-intensityprojection(A)and3Dvolume-renderingtechniques(B).Probablythemostimportantadvantageofmultidetector-rowspiralCTisimproveddiagnosisofsmallperipheralemboli(Figure6).Thedegreeofaccuracythatcouldbeachievedforthevisualizationofsubsegmentalpulmonaryarteriesandforthedetectionofemboliinthesevesselswithpreviouslyavailablemodalities(single-slice,dual-slice,andelectron-beamCT)wasfoundtorangebetween61%and79%.41,65–67Thehighspatialresolution(ie,0.6×0.6×0.6mminthex,y,andzextensions)ofmultidetector-rowspiralCTdatasetsnowallowsevaluationofpulmonaryvesselsdownto6th-orderbranchesandsignificantlyincreasesthedetectionrateofsegmentalandsubsegmentalpulmonaryemboli.68–70Thisimproveddetectionrateislikelyduetotheaccurateanalysisofprogressivelysmallervesselsbyuseofthinnersections.Animalexperimentsthatuseartificialemboliasanindependentgoldstandardindicatethathigh-resolution4-slicemultidetector-rowspiralCTisatleastasaccurateasinvasivepulmonaryangiographyforthedetectionofsmallperipheralemboli.Theinterobservercorrelationforconfidentdiagnosisofsubsegmentalemboliwithhigh-resolutionmultidetector-rowspiralCTexceedsthereproducibilityofselectivepulmonaryangiography.69,71,72DownloadfigureDownloadPowerPointFigure6.Contrast-enhanced16-sliceCTexaminationwith0.75-mmslicethicknessin45-year-oldmanwithDVTinleftcalfafterlong-distanceflight.Isolatedperipheralpulmonaryembolusinsubsegmentalpulmonaryarteryinlowerlobeofleftlungisvisualizedon3consecutivetransaxialsections(arrowsinA)andonoblique-sagittalmultiplanarreformat(arrowinB).The3Dvolume-rendereddisplayseenfromposteriorshowsisolatedperipheralfillingdefect(arrowinC)withinotherwisenormalpulmonaryvasculartree.Thetrueaccuracyofmultidetector-rowspiralCTforthedetectionofsmallperipheralemboliinpatientswithsuspectedPEwillbedifficulttodetermine.Asadirectresultofhigh-resolutionimagingcapabilities,smallperipheralclotsthatmayhavegoneunnoticedinthepastarenowfrequentlyseen,ofteninpatientswithminorsymptoms(Figure6).Itappearshighlyunlikelythatpulmonaryangiographywillbeperformedonapatientmerelytoprovethepresenceofasmall(2to3mm)isolatedembolus.Theefficacyofmultidetector-rowspiralCTinpatientssuspectedofhavingacutePEiscurrentlybeingassessedbytheProspectiveInvestigationofPulmonaryEmbolismDiagnosis(PIOPED)II73study.Thisprospectivemulticenterstudybeganrecruitingpatientsin2001andisexpectedtocompleterecruitmentin2004.IncontrasttotheoriginalPIOPED28study,whichusedcontrastpulmonaryangiographyastheprimaryreferencetestforPE,PIOPEDIIusesacompositereferencetestforvenousthromboembolismthatisbasedontheventilation/perfusionlungscan,venouscompressionultrasoundofthelowerextremities,digitalsubtractionpulmonaryangiography,andcontrastvenographyinvariouscombinationstoestablishthePEstatusofthepatient.73ConclusionsCThasbecomeanattractivemeansforasafe,highlyaccurate,cost-effectivediagnosisofacutePEandmayprovidealternativediagnosesandexplanationsforsymptomsintheabsenceofPE.Multidetector-rowspiralCTtechnologyhasovercomepastlimitationsofCTandisemergingasapreferredmodalityforimagingpatientswithsuspectedacutePE.New-generationmultidetector-rowspiralCTscannersnowchallengecatheterpulmonaryangiography,oncethestandardofreference,fortheaccuratedetectionofPE.FootnotesCorrespondencetoU.JosephSchoepf,MD,DepartmentofRadiology,BrighamandWomen’sHospital,HarvardMedicalSchool,75FrancisSt,Boston,MA02115.E-mail[email protected] References 1WellsPS,AndersonDR,RodgerM,etal.Derivationofasimpleclinicalmodeltocategorizepatientsprobabilityofpulmonaryembolism:increasingthemodelsutilitywiththeSimpliREDD-dimer.ThrombHaemost.2000;83:416–420.CrossrefMedlineGoogleScholar2SteinPD,GoldhaberSZ,HenryJW,etal.Arterialbloodgasanalysisintheassessmentofsuspectedacutepulmonaryembolism.Chest.1996;109:78–81.CrossrefMedlineGoogleScholar3SteinPD,GoldhaberSZ,HenryJW.Alveolar-arterialoxygengradientintheassessmentofacutepulmonaryembolism.Chest.1995;107:139–143.CrossrefMedlineGoogleScholar4DunnKL,WolfJP,DorfmanDM,etal.NormalD-dimerlevelsinemergencydepartmentpatientssuspectedofacutepulmonaryembolism.JAmCollCardiol.2002;40:1475–1478.CrossrefMedlineGoogleScholar5KlineJA,NelsonRD,JacksonRE,etal.CriteriaforthesafeuseofD-dimertestinginemergencydepartmentpatientswithsuspectedpulmonaryembolism:amulticenterUSstudy.AnnEmergMed.2002;39:144–152.CrossrefMedlineGoogleScholar6WellsPS,AndersonDR,RodgerM,etal.Excludingpulmonaryembolismatthebedsidewithoutdiagnosticimaging:managementofpatientswithsuspectedpulmonaryembolismpresentingtotheemergencydepartmentbyusingasimpleclinicalmodelandD-dimer.AnnInternMed.2001;135:98–107.CrossrefMedlineGoogleScholar7KruipMJ,SlobMJ,SchijenJH,etal.UseofaclinicaldecisionruleincombinationwithD-dimerconcentrationindiagnosticworkupofpatientswithsuspectedpulmonaryembolism:aprospectivemanagementstudy.ArchInternMed.2002;162:1631–1635.CrossrefMedlineGoogleScholar8KruipMJ,LeclercqMG,vanderHeulC,etal.Diagnosticstrategiesforexcludingpulmonaryembolisminclinicaloutcomestudies:asystematicreview.AnnInternMed.2003;138:941–951.CrossrefMedlineGoogleScholar9FerrariE,ImbertA,ChevalierT,etal.TheECGinpulmonaryembolism:predictivevalueofnegativeTwavesinprecordialleads:80casereports.Chest.1997;111:537–543.CrossrefMedlineGoogleScholar10DanielKR,CourtneyDM,KlineJA.Assessmentofcardiacstressfrommassivepulmonaryembolismwith12-leadECG.Chest.2001;120:474–481.CrossrefMedlineGoogleScholar11KucherN,WalpothN,WustmannK,etal.QRinV1:anECGsignassociatedwithrightventricularstrainandadverseclinicaloutcomeinpulmonaryembolism.EurHeartJ.2003;24:1113–1119.CrossrefMedlineGoogleScholar12ElliottCG,GoldhaberSZ,VisaniL,etal.Chestradiographsinacutepulmonaryembolism:resultsfromtheInternationalCooperativePulmonaryEmbolismRegistry.Chest.2000;118:33–38.CrossrefMedlineGoogleScholar13JongbloetsLM,LensingAW,KoopmanMM,etal.Limitationsofcompressionultrasoundforthedetectionofsymptomlesspostoperativedeepveinthrombosis.Lancet.1994;343:1142–1144.CrossrefMedlineGoogleScholar14WellsPS,LensingAW,DavidsonBL,etal.Accuracyofultrasoundforthediagnosisofdeepvenousthrombosisinasymptomaticpatientsafterorthopedicsurgery:ameta-analysis.AnnInternMed.1995;122:47–53.CrossrefMedlineGoogleScholar15TurkstraF,KuijerPM,vanBeekEJ,etal.Diagnosticutilityofultrasonographyoflegveinsinpatientssuspectedofhavingpulmonaryembolism.AnnInternMed.1997;126:775–781.CrossrefMedlineGoogleScholar16MacGillavryMR,SansonBJ,BullerHR,etal.Compressionultrasonographyofthelegveinsinpatientswithclinicallysuspectedpulmonaryembolism:isamoreextensiveassessmentofcompressibilityuseful?ThrombHaemost.2000;84:973–976.CrossrefMedlineGoogleScholar17LoudP,GrossmanCD,KlippensteinDL,etal.CombinedCTvenographyandpulmonaryangiography:anewdiagnostictechniqueforsuspectedthromboembolicdisease.AJRAmJRoentgenol.1998;170:951–954.CrossrefMedlineGoogleScholar18ChamMD,YankelevitzDF,ShahamD,etal.Deepvenousthrombosis:detectionbyusingindirectCTvenography:thePulmonaryAngiography-IndirectCTVenographyCooperativeGroup.Radiology.2000;216:744–751.CrossrefMedlineGoogleScholar19RibeiroA,LindmarkerP,JohnssonH,etal.Pulmonaryembolism:one-yearfollow-upwithechocardiographyDopplerandfive-yearsurvivalanalysis.Circulation.1999;99:1325–1330.CrossrefMedlineGoogleScholar20GoldhaberSZ.Echocardiographyinthemanagementofpulmonaryembolism.AnnInternMed.2002;136:691–700.CrossrefMedlineGoogleScholar21CrawfordT,YoonC,WolfsonK,etal.Theeffectofimagingmodalityonpatientmanagementintheevaluationofpulmonarythromboembolism.JThoracImaging.2001;16:163–169.CrossrefMedlineGoogleScholar22PrologoJD,GlauserJ.VariablediagnosticapproachtosuspectedpulmonaryembolismintheEDofamajoracademictertiarycarecenter.AmJEmergMed.2002;20:5–9.CrossrefMedlineGoogleScholar23MillsSR,JacksonDC,OlderRA,etal.Theincidence,etiologies,andavoidanceofcomplicationsofpulmonaryangiographyinalargeseries.Radiology.1980;136:295–299.CrossrefMedlineGoogleScholar24SteinP,AthanasoulisC,AlaviA,etal.Complicationsandvalidityofpulmonaryangiographyinacutepulmonaryembolus.Circulation.1992;85:462–468.CrossrefMedlineGoogleScholar25HudsonER,SmithTP,McDermottVG,etal.Pulmonaryangiographyperformedwithiopamidol:complicationsin1,434patients.Radiology.1996;198:61–65.CrossrefMedlineGoogleScholar26SchibanyN,FleischmannD,ThallingerC,etal.EquipmentavailabilityanddiagnosticstrategiesforsuspectedpulmonaryembolisminAustria.EurRadiol.2001;11:2287–2294.CrossrefMedlineGoogleScholar27LeveauP.Diagnosticstrategyinpulmonaryembolism:NationalFrenchsurvey.PresseMed.2002;31:929–932.MedlineGoogleScholar28PIOPEDInvestigators.Valueoftheventilation/perfusionscaninacutepulmonaryembolism.JAMA.1990;95:498–502.GoogleScholar29BlachereH,LatrabeV,MontaudonM,etal.PulmonaryembolismrevealedonhelicalCTangiography:comparisonwithventilation-perfusionradionuclidelungscanning.AJRAmJRoentgenol.2000;174:1041–1047.CrossrefMedlineGoogleScholar30SteinPD,RelyeaB,GottschalkA.Evaluationofindividualcriteriaforlowprobabilityinterpretationofventilation-perfusionlungscans.JNuclMed.1996;37:577–581.MedlineGoogleScholar31SteinPD,GottschalkA.Reviewofcriteriaappropriateforaverylowprobabilityofpulmonaryembolismonventilation-perfusionlungscans:apositionpaper.Radiographics.2000;20:99–105.CrossrefMedlineGoogleScholar32BajcM,BitzenU,OlssonB,etal.Lungventilation/perfusionSPECTintheartificiallyembolizedpig.JNuclMed.2002;43:640–647.MedlineGoogleScholar33GargK,WelshCH,FeyerabendAJ,etal.Pulmonaryembolism:diagnosiswithspiralCTandventilation-perfusionscanning:correlationwithpulmonaryangiographicresultsorclinicaloutcome.Radiology.1998;208:201–208.CrossrefMedlineGoogleScholar34MeaneyJ,WegJG,ChenevertTL,etal.Diagnosisofpulmonaryembolismwithmagneticresonanceangiography.NEnglJMed.1997;336:1422–1427.CrossrefMedlineGoogleScholar35OudkerkM,vanBeekEJ,WielopolskiP,etal.Comparisonofcontrast-enhancedmagneticresonanceangiographyandconventionalpulmonaryangiographyforthediagnosisofpulmonaryembolism:aprospectivestudy.Lancet.2002;359:1643–1647.CrossrefMedlineGoogleScholar36GuptaA,FrazerCK,FergusonJM,etal.Acutepulmonaryembolism:diagnosiswithMRangiography.Radiology.1999;210:353–359.CrossrefMedlineGoogleScholar37HullR,RaskobGE,GinsbergJS,etal.Anoninvasivestrategyforthetreatmentofpatientswithsuspectedpulmonaryembolism.ArchInternMed.1994;154:289–297.CrossrefMedlineGoogleScholar38vanRossumAB,PattynamaPM,MallensWM,etal.CanhelicalCTreplacescintigraphyinthediagnosticprocessinsuspectedpulmonaryembolism?Aretrolective-prolectivecohortstudyfocusingontotaldiagnosticyield.EurRadiol.1998;8:90–96.CrossrefMedlineGoogleScholar39vanRossumAB,vanErkelAR,vanPersijnvanMeertenEL,etal.AccuracyofhelicalCTforacutepulmonaryembolism:ROCanalysisofobserverperformancerelatedtoclinicalexperience.EurRadiol.1998;8:1160–1164.CrossrefMedlineGoogleScholar40vanErkelAR,vanRossumAB,BloemJL,etal.SpiralCTangiographyforsuspectedpulmonaryembolism:acost-effectivenessanalysis.Radiology.1996;201:29–36.CrossrefMedlineGoogleScholar41GoodmanLR,CurtinJJ,MewissenMW,etal.Detectionofpulmonaryembolisminpatientswithunresolvedclinicalandscintigraphicdiagnosis:helicalCTversusangiography.AJRAmJRoentgenol.1995;164:1369–1374.CrossrefMedlineGoogleScholar42DruckerEA,RivitzSM,ShepardJA,etal.Acutepulmonaryembolism:assessmentofhelicalCTfordiagnosis.Radiology.1998;209:235–241.CrossrefMedlineGoogleScholar43PerrierA,HowarthN,DidierD,etal.Performanceofhelicalcomputedtomographyinunselectedoutpatientswithsuspectedpulmonaryembolism.AnnInternMed.2001;135:88–97.CrossrefMedlineGoogleScholar44Remy-JardinM,RemyJ,DeschildreF,etal.DiagnosisofpulmonaryembolismwithspiralCT:comparisonwithpulmonaryangiographyandscintigraphy.Radiology.1996;200:699–706.CrossrefMedlineGoogleScholar45TeigenCL,MausTP,SheedyPFII,etal.Pulmonaryembolism:diagnosiswithcontrast-enhancedelectronbeamCTandcomparisonwithpulmonaryangiography.Radiology.1995;194:313–319.CrossrefMedlineGoogleScholar46OserRF,ZuckermanDA,GutierrezFR,etal.Anatomicdistributionofpulmonaryemboliatpulmonaryangiography:implicationsforcrosssectionalimaging.Radiology.1996;199:31–35.CrossrefMedlineGoogleScholar47TetalmanMR,HofferPB,HeckLL,etal.Perfusionlungscaninnormalvolunteers.Radiology.1973;106:593–594.CrossrefMedlineGoogleScholar48NovellineR,BaltarowichO,AthanasoulisC,etal.Theclinicalcourseofpatientswithsuspectedpulmonaryembolismandanegativepulmonaryangiogram.Radiology.1978;126:561–567.CrossrefMedlineGoogleScholar49CauvainO,Remy-JardinM,RemyJ,etal.SpiralCTangiographyinthediagnosisofcentralpulmonaryembolism:comparisonwithpulmonaryangiographyandscintigraphy.RevMalRespir.1996;13:141–153.MedlineGoogleScholar50PatriquinL,KhorasaniR,PolakJF.Correlationofdiagnosticimagingandsubsequentautopsyfindingsinpatientswithpulmonaryembolism.AJRAmJRoentgenol.1998;171:347–349.CrossrefMedlineGoogleScholar51GargK,SielerH,WelshCH,etal.ClinicalvalidityofhelicalCTbeinginterpretedasnegativeforpulmonaryembolism:implicationsforpatienttreatment.AJRAmJRoentgenol.1999;172:1627–1631.CrossrefMedlineGoogleScholar52LomisNN,YoonHC,MoranAG,etal.ClinicaloutcomesofpatientsafteranegativespiralCTpulmonaryarteriogramintheevaluationofacutepulmonaryembolism.JVascIntervRadiol.1999;10:707–712.CrossrefMedlineGoogleScholar53GoodmanLR,LipchikRJ,KuzoRS,etal.Subsequentpulmonaryembolism:riskafteranegativehelicalCTpulmonaryangiogram:prospectivecomparisonwithscintigraphy.Radiology.2000;215:535–542.CrossrefMedlineGoogleScholar54GottsaterA,BergA,CentergardJ,etal.Clinicallysuspectedpulmonaryembolism:isitsafetowithholdanticoagulationafteranegativespiralCT?EurRadiol.2001;11:65–72.CrossrefMedlineGoogleScholar55OstD,RozenshteinA,SaffranL,etal.Thenegativepredictivevalueofspiralcomputedtomographyforthediagnosisofpulmonaryembolisminpatientswithnondiagnosticventilation-perfusionscans.AmJMed.2001;110:16–21.CrossrefMedlineGoogleScholar56Tillie-LeblondI,MastoraI,RadenneF,etal.RiskofpulmonaryembolismafteranegativespiralCTangiograminpatientswithpulmonarydisease:1-yearclinicalfollow-upstudy.Radiology.2002;223:461–467.CrossrefMedlineGoogleScholar57SwensenSJ,SheedyPF2nd,RyuJH,etal.Outcomesafterwithholdinganticoagulationfrompatientswithsuspectedacutepulmonaryembolismandnegativecomputedtomographicfindings:acohortstudy.MayoClinProc.2002;77:130–138.CrossrefMedlineGoogleScholar58NilssonT,OlaussonA,JohnssonH,etal.NegativespiralCTinacutepulmonaryembolism.ActaRadiol.2002;43:486–491.CrossrefMedlineGoogleScholar59MussetD,ParentF,MeyerG,etal.Diagnosticstrategyforpatientswithsuspectedpulmonaryembolism:aprospectivemulticentreoutcomestudy.Lancet.2002;360:1914–1920.CrossrefMedlineGoogleScholar60vanStrijenMJ,deMonyeW,SchiereckJ,etal.Single-detectorhelicalcomputedtomographyastheprimarydiagnostictestinsuspectedpulmonaryembolism:amulticenterclinicalmanagementstudyof510patients.AnnInternMed.2003;138:307–314.CrossrefMedlineGoogleScholar61HenryJW,RelyeaB,SteinPD.Continuingriskofthromboemboliamongpatientswithnormalpulmonaryangiograms.Chest.1995;107:1375–1378.CrossrefMedlineGoogleScholar62Klingenbeck-RegnK,SchallerS,FlohrT,etal.Subsecondmulti-slicecomputedtomography:basicsandapplications.EurJRadiol.1999;31:110–124.CrossrefMedlineGoogleScholar63HuH,HeHD,FoleyWD,etal.Fourmultidetector-rowhelicalCT:imagequalityandvolumecoveragespeed.Radiology.2000;215:55–62.CrossrefGoogleScholar64Remy-JardinM,Tillie-LeblondI,SzapiroD,etal.CTangiographyofpulmonaryembolisminpatientswithunderlyingrespiratorydisease:impactofmultisliceCTonimagequalityandnegativepredictivevalue.EurRadiol.2002;12:1971–1978.CrossrefMedlineGoogleScholar65Remy-JardinM,RemyJ,ArtaudD,etal.Peripheralpulmonaryarteries:optimizationofthespiralCTacquisitionprotocol.Radiology.1997;204:157–163.CrossrefMedlineGoogleScholar66QanadliSD,HajjamME,MesurolleB,etal.Pulmonaryembolismdetection:prospectiveevaluationofdual-sectionhelicalCTversusselectivepulmonaryarteriographyin157patients.Radiology.2000;217:447–455.CrossrefMedlineGoogleScholar67SchoepfUJ,HelmbergerT,HolzknechtN,etal.Segmentalandsubsegmentalpulmonaryarteries:evaluationwithelectron-beamversusspiralCT.Radiology.2000;214:433–439.CrossrefMedlineGoogleScholar68GhayeB,SzapiroD,MastoraI,etal.Peripheralpulmonaryarteries:howfarinthelungdoesmulti-detectorrowspiralCTallowanalysis?Radiology.2001;219:629–636.CrossrefMedlineGoogleScholar69SchoepfU,HolzknechtN,HelmbergerTK,etal.Subsegmentalpulmonaryemboli:improveddetectionwiththin-collimationmultidetector-rowspiralCT.Radiology.2002;222:483–490.CrossrefMedlineGoogleScholar70PatelS,KazerooniEA,CascadePN.Pulmonaryembolism:optimizationofsmallpulmonaryarteryvisualizationatmulti-detectorrowCT.Radiology.2003;227:455–460.CrossrefMedlineGoogleScholar71DiffinD,LeyendeckerJR,JohnsonSP,etal.Effectofanatomicdistributionofpulmonaryembolioninterobserveragreementintheinterpretationofpulmonaryangiography.AJRAmJRoentgenol.1998;171:1085–1089.CrossrefMedlineGoogleScholar72SteinPD,HenryJW,GottschalkA.Reassessmentofpulmonaryangiographyforthediagnosisofpulmonaryembolism:relationofinterpreteragreementtotheorderoftheinvolvedpulmonaryarterialbranch.Radiology.1999;210:689–691.CrossrefMedlineGoogleScholar73GottschalkA,SteinPD,GoodmanLR,etal.OverviewofprospectiveinvestigationofpulmonaryembolismdiagnosisII.SeminNuclMed.2002;32:173–182.CrossrefMedlineGoogleScholar Previous Backtotop Next FiguresReferencesRelatedDetailsCitedByParasuramanSandGoldhaberS(2006)VenousThromboembolisminChildren,Circulation,113:2,(e12-e16),Onlinepublicationdate:17-Jan-2006.KucherN,RossiE,DeRosaMandGoldhaberS(2006)MassivePulmonaryEmbolism,Circulation,113:4,(577-582),Onlinepublicationdate:31-Jan-2006.QuirozR,KucherN,SchoepfU,KipfmuellerF,SolomonS,CostelloPandGoldhaberS(2004)RightVentricularEnlargementonChestComputedTomography,Circulation,109:20,(2401-2404),Onlinepublicationdate:25-May-2004.SchoepfU,KucherN,KipfmuellerF,QuirozR,CostelloPandGoldhaberS(2004)RightVentricularEnlargementonChestComputedTomography,Circulation,110:20,(3276-3280),Onlinepublicationdate:16-Nov-2004. May11,2004Vol109,Issue18ArticleInformationMetrics Download:2,678 https://doi.org/10.1161/01.CIR.0000128813.04325.08PMID: 15136509 OriginallypublishedMay11,2004 KeywordsdiagnosisembolismimagingthrombosisPDFdownload TitleCaptionTitleCaptionTitleCaptionTitleCaption