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• VQ
• Pregnancy
Pre-test probability
• Total score
• If positive, CT PE protocol
• “Stop breathing”
Setting up the monitoring phase
– Peripheral
– Wedge-shaped
– Mixed consolidation
and groundglass
opacities
Pearls
• Suboptimal quality — “cannot evaluate”
• Anticoagulation risks:
– 7-10% morbidity in elderly
– mortality 1%1
• Occlusive or nonocclusive
Acute PE- Prognostic signs
• Shock, prolonged hypotension
• Dilated RV
• Bowing of interventricular
septum
• Ratio of transverse
diameter RV: LV > 0.9
• May not be related to long-
term mortality1
1Morris MF, et al. AJR 2012;198:1346-1352
Normal heart 9 weeks later, following
Acute PE , Right heart strain resolution of most of the pulmonary
emboli
Pulmonary Hypertension
• Main PA > 3 cm
• Quantum mottle
• Pulsation Artifact
• Intrapulmonary shunt
• Extrapulmonary shunt due to PFO
Transient interruption of the contrast
Known PFO
• Short-term R L shunt
• Use a longer scan delay
• Quiet respiration
• Not deep inspiration
– Further RA pressure risk of
paradoxical embolus
• Use a new IV
Pathologic Mimics
• Tumor emboli
– Expansion of involved PA
– Heterogeneously enhancing
• Webs
Chronic PE Acute PE 9 weeks earlier
Dual Energy CT
• Use of 2 tubes operating at different kVp
levels.
– Allows differentiation of materials with
large atomic numbers like iodine
• Motion artifact
• Parenchymal disease
– Consolidation
– Bullous disease
Radiology Report
• Exam is ____ QUALITY for evaluation of PE…
– Excellent: Excellent bolus, no artifact, can see to
proximal subsegmental PAs
– Good: Good bolus, not much artifact
– Moderate: Ok bolus, some artifact
– Low: Poor bolus (albeit ROI >100 HU) or artifact,
but can evaluate central PAs
– Nondiagnostic: Very poor bolus, cannot even
evaluate central PAs
Radiology Report
• …to the LEVEL of the ___ Pulmonary
arteries.
– Central (Main, Right and Left)
– Lobar
– Segmental
– Proximal Subsegmental
VQ and CTPA
• VQ useful in chronic thromboembolic
disease
– which can be difficult to detect on CTPA
Severe decreased perfusion of both lower lobes — high probability PE
Pregnancy
• Be aware of overdiagnosis