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Helical CT for the Evaluation of Acute Pulmonary Embolism

Department of Radiology, University of Michigan, 1500 E Medical Center Dr., TC2910D, Ann Arbor, MI 48109-0326.

View larger version (78K): [in a new window]   Fig. 1A —42-year-old man who was hypoxic on room air; patient was paraplegic from spinal cord injury due to high-speed motorcycle crash. CT scan shows bilateral central pulmonary embolism (long thick arrows), subsegmental emboli (long thin arrow), and right lower lobe superior segment pulmonary infarct (short arrows). Note "tram-track" sign in inferior segmental artery of lingula (arrowheads).

View larger version (74K): [in a new window]   Fig. 1B —42-year-old man who was hypoxic on room air; patient was paraplegic from spinal cord injury due to high-speed motorcycle crash. CT scan shows rim sign in left lower lobe pulmonary artery (long arrow), small left effusion (arrowheads), and pulmonary infarct (short arrows).

View larger version (124K): [in a new window]   Fig. 2 —67-year-old woman with glioblastoma multiforme and right-sided chest pain. Sagittal CT reformation image shows subsegmental pulmonary emboli (long arrows) and large wedge-shaped pulmonary infarct posteriorly (short arrows).

View larger version (70K): [in a new window]   Fig. 3 —36-year-old woman with history of recurrent pulmonary embolism. CT scan obtained using lung window settings shows mosaic attenuation: areas of ground-glass attenuation with enlargement of pulmonary arteries and areas of low attenuation due to diminished blood flow from presence of emboli.

View larger version (77K): [in a new window]   Fig. 4A —24-year-old man who presented with end-stage renal disease secondary to diabetes, right atrial mass, and 3-week history of pneumonia. CT scan shows large central pulmonary embolism (arrow) in right main pulmonary artery. Note pericardial effusion (arrowheads).

View larger version (110K): [in a new window]   Fig. 4B —24-year-old man who presented with end-stage renal disease secondary to diabetes, right atrial mass, and 3-week history of pneumonia. CT scan shows cavitary right lower lobe mass (long white arrow) representing lung abscess with adjacent empyema (short white arrows). Note incidental right atrial myxoma (black arrow) and small pericardial effusion (arrowheads).

View larger version (79K): [in a new window]   Fig. 5 —33-year-old man who had undergone pelvic surgery for trauma. CT scan shows poor bolus of contrast material in pulmonary arteries and beam-hardening artifact (arrow) from high amount of contrast material in superior vena cava, which accounts for low attenuation in right main pulmonary artery, making evaluation for subtle pulmonary embolism difficult.

View larger version (118K): [in a new window]   Fig. 6 —76-year-old man with acute dyspnea and hypotension after sigmoid colectomy. CT scan shows Swan-Ganz catheter (black arrow) in right main pulmonary artery, with adjacent streak artifact. Note low-attenuation abnormality posterior to right main pulmonary artery (white arrow), which may represent pulmonary embolism or beam-hardening artifact from Swan-Ganz catheter. Moderate-sized bilateral pleural effusions with adjacent atelectasis are also seen.

View larger version (82K): [in a new window]   Fig. 7 —48-year-old man with acute onset of shortness of breath and pleuritic chest pain. CT scan shows low-attenuation abnormality posterior to both upper lobe segmental pulmonary arteries (arrows). This normal lymph node tissue may be confused for pulmonary embolism, particularly if hard-copy images are used for interpretation.

View larger version (88K): [in a new window]   Fig. 8A —68-year-old man with metastatic prostate cancer, left-sided chest pain, and dyspnea. Axial CT scan shows multiple subsegmental filling defects that mimic subsegmental emboli in right lower lobe. However, these are mucoid-impacted subsegmental bronchi (arrows). Note small enhancing arteries adjacent to dilated mucous-filled bronchi.

View larger version (88K): [in a new window]   Fig. 8B —68-year-old man with metastatic prostate cancer, left-sided chest pain, and dyspnea. Sagittal reformatted CT scan shows large central right hilar tumor (long arrows) that is causing mucoid impaction of segmental and subsegmental lower lobe bronchi (short arrows). Low-attenuation branching mucoid impaction mimics pulmonary embolism.

View larger version (102K): [in a new window]   Fig. 9 —53-year-old man with end-stage ischemic cardiomyopathy and bronchiolitis obliterans. CT scan shows extensive bilateral air-space disease. Despite severity of parenchymal disease, segmental pulmonary embolism (arrow) is shown in left lower lobe.

View larger version (91K): [in a new window]   Fig. 10A —31-year-old woman on oral contraceptive pills who presented with an acutely swollen right lower extremity and dyspnea. CT scans of pelvis (A) and extremities (B) show acute deep venous thrombosis with thrombi in distal inferior vena cava (arrow, A) and right popliteal vein (arrow, B).

View larger version (51K): [in a new window]   Fig. 10B —31-year-old woman on oral contraceptive pills who presented with an acutely swollen right lower extremity and dyspnea. CT scans of pelvis (A) and extremities (B) show acute deep venous thrombosis with thrombi in distal inferior vena cava (arrow, A) and right popliteal vein (arrow, B).

View larger version (74K): [in a new window]   Fig. 11 —66-year-old woman with pleuritic chest pain and shortness of breath. Indirect CT venography image shows "streaming" of contrast material in both superficial femoral veins (arrows) that accounts for rim of higher attenuation with low-attenuation center. This mimic of deep venous thrombosis is due to scanning too early, before optimal opacification of veins. Note contrast material is denser in superficial femoral arteries.

View larger version (76K): [in a new window]   Fig. 12 —72-year-old man with ischemic heart disease and suspected pulmonary embolism. Indirect CT venography image obtained at level of mid thighs shows dense contrast material in superficial femoral arteries (long arrows); no contrast material is seen in femoral veins (short arrows) because of poor venous return.

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