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Role of MDCT in Identification of the Bleeding Site and the Vessels Causing Hemoptysis

¹ Department of Radiology, AP-HP Tenon Hospital, 4 Rue de la Chine, 75020 Paris, France.
² Respiratory Intensive Care Unit, AP-HP Tenon Hospital, Paris, France.

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —45-year-old man with hemoptysis. Axial (A), sagittal (B), and coronal (C) MDCT reconstructions with 1-mm-thick slice viewed at lung window settings show ground-glass opacities on anterior segment of left upper lobe. Multiplanar MDCT reconstructions (not shown) did not add information about location of bleeding site to findings shown on axial image.

View larger version (176K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —45-year-old man with hemoptysis. Axial (A), sagittal (B), and coronal (C) MDCT reconstructions with 1-mm-thick slice viewed at lung window settings show ground-glass opacities on anterior segment of left upper lobe. Multiplanar MDCT reconstructions (not shown) did not add information about location of bleeding site to findings shown on axial image.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —45-year-old man with hemoptysis. Axial (A), sagittal (B), and coronal (C) MDCT reconstructions with 1-mm-thick slice viewed at lung window settings show ground-glass opacities on anterior segment of left upper lobe. Multiplanar MDCT reconstructions (not shown) did not add information about location of bleeding site to findings shown on axial image.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Iodine extravasation into bronchi of 57-year-old woman with hemoptysis. Bronchoscopy (not shown) had revealed active bleeding on left side without identifying precise lobe, whereas MDCT depicts bleeding site on left upper lobe. Sagittal multiplanar reconstruction image on lung window setting shows contrast medium (arrow) in bronchi of left upper lobe with air bubbles (arrowheads).

View larger version (33K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Iodine extravasation into bronchi of 57-year-old woman with hemoptysis. Bronchoscopy (not shown) had revealed active bleeding on left side without identifying precise lobe, whereas MDCT depicts bleeding site on left upper lobe. Sagittal multiplanar reconstruction image on mediastinal window setting shows same density in bronchi (arrows) and left pulmonary artery (asterisk) as that shown in A.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —45-year-old man with right upper lobe atelectasis due to tubercular sequelae complicated by aspergilloma was admitted for mild hemoptysis. Shunt was placed in pulmonary artery. Coronal thin-slab maximum-intensity-projection (MIP) image shows enhancement of pulmonary arteries (arrows) with reflux into right main pulmonary artery (arrowhead).

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —45-year-old man with right upper lobe atelectasis due to tubercular sequelae complicated by aspergilloma was admitted for mild hemoptysis. Shunt was placed in pulmonary artery. Coronal oblique thin-slab MIP shows enlargement of right bronchointercostal trunk (black arrow), bronchial artery (white arrows), and intercostal arteries. Note enlargement of intercostal arteries (black arrowheads) in comparison with other normal-sized intercostal arteries (white arrowheads).

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —45-year-old man with right upper lobe atelectasis due to tubercular sequelae complicated by aspergilloma was admitted for mild hemoptysis. Shunt was placed in pulmonary artery. Right bronchointercostal trunk angiogram shows pulmonary artery shunt, with reflux from right superior pulmonary artery (arrows) into right main pulmonary artery (arrowhead). This pulmonary system shunting is related to systemic hypervascularization and is not major CT sign for bleeding site.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. Thin-slab maximum-intensity-projection (MIP) MDCT images of superior left bronchial artery (arrow, A), common lower bronchial trunk (arrow, B), and right bronchointercostal trunk (arrow, C). Note good visualization of bronchial artery divisions of right bronchointercostal trunk (arrowheads, C).

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. Thin-slab maximum-intensity-projection (MIP) MDCT images of superior left bronchial artery (arrow, A), common lower bronchial trunk (arrow, B), and right bronchointercostal trunk (arrow, C). Note good visualization of bronchial artery divisions of right bronchointercostal trunk (arrowheads, C).

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. Thin-slab maximum-intensity-projection (MIP) MDCT images of superior left bronchial artery (arrow, A), common lower bronchial trunk (arrow, B), and right bronchointercostal trunk (arrow, C). Note good visualization of bronchial artery divisions of right bronchointercostal trunk (arrowheads, C).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. Right bronchointercostal trunk angiogram corresponding to C shows normal branching of bronchial arteries is from right intercostal trunk (arrowheads) or from descending thoracic aorta (arrow) between levels of T5 and T6 vertebrae.

View larger version (41K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Anomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. Four consecutive 3-mm thin-slab maximum-intensity-projection (MIP) images in axial plane show anomalous origin of upper left bronchial artery from right aspect of aortic arch (arrow, A) and trajectory under aortic arch (arrowheads, B-D).

View larger version (46K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Anomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. Four consecutive 3-mm thin-slab maximum-intensity-projection (MIP) images in axial plane show anomalous origin of upper left bronchial artery from right aspect of aortic arch (arrow, A) and trajectory under aortic arch (arrowheads, B-D).

View larger version (56K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Anomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. Four consecutive 3-mm thin-slab maximum-intensity-projection (MIP) images in axial plane show anomalous origin of upper left bronchial artery from right aspect of aortic arch (arrow, A) and trajectory under aortic arch (arrowheads, B-D).

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —Anomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. Four consecutive 3-mm thin-slab maximum-intensity-projection (MIP) images in axial plane show anomalous origin of upper left bronchial artery from right aspect of aortic arch (arrow, A) and trajectory under aortic arch (arrowheads, B-D).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5E —Anomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. Coronal 8-mm thin-slab MIP image shows ectopic bronchial artery and its trajectory (arrowheads). Ostium of ectopic bronchial arteries is branching from descending thoracic aorta other than expected origin (i.e., outside level T5-T6), such as from level of aortic arch or from any aortic collateral vessel.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Anomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. Serial axial 1-mm slices show origin (arrow, A) and course (arrowheads) of left bronchial artery.

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Anomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. Serial axial 1-mm slices show origin (arrow, A) and course (arrowheads) of left bronchial artery.

View larger version (86K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Anomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. Serial axial 1-mm slices show origin (arrow, A) and course (arrowheads) of left bronchial artery.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —Anomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. Three-dimensional volume-rendered image (D) and angiogram (E) show ectopic bronchial artery (arrowheads).

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6E —Anomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. Three-dimensional volume-rendered image (D) and angiogram (E) show ectopic bronchial artery (arrowheads).

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Anomalous origin of right lower lobe bronchial artery from right subclavian artery in 64-year-old man with massive hemoptysis. Chest radiography examination (not shown) depicted hilar necrotic mass with disseminated bronchiectasis. Bronchoscopy (not shown) did not locate bleeding site but showed infiltration of left upper lobe bronchus. Axial 3-mm thin-slab maximum-intensity-projection (MIP) slice shows anomalous origin (arrow) of right lower lobe bronchial artery.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Anomalous origin of right lower lobe bronchial artery from right subclavian artery in 64-year-old man with massive hemoptysis. Chest radiography examination (not shown) depicted hilar necrotic mass with disseminated bronchiectasis. Bronchoscopy (not shown) did not locate bleeding site but showed infiltration of left upper lobe bronchus. Coronal 5-mm thin-slab MIP slice shows anomalous trajectory of lower lobe bronchial artery (arrows).

View larger version (167K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Anomalous origin of right lower lobe bronchial artery from right subclavian artery in 64-year-old man with massive hemoptysis. Chest radiography examination (not shown) depicted hilar necrotic mass with disseminated bronchiectasis. Bronchoscopy (not shown) did not locate bleeding site but showed infiltration of left upper lobe bronchus. Right subclavian artery angiogram obtained using humeral approach shows anomalous right bronchial artery (arrows) with anomalous trajectory.

View larger version (61K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —Mediastinal and hilar trajectory of normotopic right bronchial artery in 61-year-old man with massive hemoptysis. Axial 3-mm thin-slab maximum-intensity-projection (MIP) image shows tubular and punctiform enhanced vascular lesion through mediastinum and hilum (arrowheads).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —Mediastinal and hilar trajectory of normotopic right bronchial artery in 61-year-old man with massive hemoptysis. Coronal 10-mm thin-slab MIP image shows enlarged right bronchial artery (arrow) from aorta to hilum (arrowheads). Note good visualization of bronchial arteries in right hilum.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Systemic nonbronchial artery hypervascularization in 29-year-old pregnant woman with massive hemoptysis. Axial (A) and coronal (B) 1-mm slices show lingular and right middle lobe atelectasis (arrow, A) secondary to bronchiectasis. Lingular ground-glass opacities (asterisk) reveal bleeding site.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Systemic nonbronchial artery hypervascularization in 29-year-old pregnant woman with massive hemoptysis. Axial (A) and coronal (B) 1-mm slices show lingular and right middle lobe atelectasis (arrow, A) secondary to bronchiectasis. Lingular ground-glass opacities (asterisk) reveal bleeding site.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —Systemic nonbronchial artery hypervascularization in 29-year-old pregnant woman with massive hemoptysis. Coronal 10-mm thin-slab maximum-intensity-projection image shows transpleural hypervascularization (arrows) from left inferior phrenic artery.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9D —Systemic nonbronchial artery hypervascularization in 29-year-old pregnant woman with massive hemoptysis. Left inferior phrenic artery angiogram confirms systemic nonbronchial artery hypervascularization (arrow).

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —Systemic nonbronchial artery hypervascularization in 55-year-old woman with hemoptysis related to tubercular sequelae. Axial 2-mm thick-slab image shows right internal mammary artery (arrow) is enlarged in comparison with left internal mammary artery (arrowhead) and reveals right middle lobe atelectasis (asterisk).

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —Systemic nonbronchial artery hypervascularization in 55-year-old woman with hemoptysis related to tubercular sequelae. Coronal 5-mm thin-slab maximum-intensity-projection image shows right internal mammary artery hypertrophy with hypertrophic collateral (arrows) to right middle lobe atelectasis.

View larger version (73K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —Pulmonary artery false aneurysm in patient described in Figure 7 (64-year-old man with massive hemoptysis) who was readmitted to ICU for hemoptysis recurrence (400 mL) 1 week after bronchial artery embolization with microparticles and microcoils. Repeat MDCT angiography depicted pulmonary artery false aneurysm. Axial 3-mm thick-slab maximum-intensity-projection (MIP) image shows irregularity with enlargement of right upper lobe subsegmental pulmonary artery (arrow).

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —Pulmonary artery false aneurysm in patient described in Figure 7A, 7B, 7C (64-year-old man with massive hemoptysis) who was readmitted to ICU for hemoptysis recurrence (400 mL) 1 week after bronchial artery embolization with microparticles and microcoils. Repeat MDCT angiography depicted pulmonary artery false aneurysm. Oblique coronal 3-mm thick-slab MIP image clearly shows false aneurysm (arrow) and microcoil (arrowhead) from previous treatment session.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —Pulmonary artery false aneurysm in patient described in Figure 7A, 7B, 7C (64-year-old man with massive hemoptysis) who was readmitted to ICU for hemoptysis recurrence (400 mL) 1 week after bronchial artery embolization with microparticles and microcoils. Repeat MDCT angiography depicted pulmonary artery false aneurysm. Subsegmental pulmonary artery angiogram confirms false aneurysm (arrow). This subsegmental artery was occluded with coils. Hemoptysis did not recur during 1 year of follow-up.

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