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Incidental Detection of Pulmonary Emboli on Routine MDCT of the Chest

¹ Department of Radiology, University of Chieti, Ospedale Clinicizzato "SS. Annunziata," Via dei Vestini, Chieti 66013, Italy.
² Present address: Department of Radiology, Ospedale di Bassano del Grappa Via dei Lotti, Bassano del Grappa (VI) 36100, Italy.

Received February 4, 2004; accepted after revision April 2, 2004.

 
Address correspondence to M. L. Storto (ml.storto{at}radiol.unich.it).

Abstract

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OBJECTIVE. The objectives of our study were to assess the prevalence of pulmonary embolism incidentally detected on routine MDCT of the chest and to determine whether the use of wide window settings can improve detection of unsuspected pulmonary embolism.

MATERIALS AND METHODS. A retrospective review of routine contrast-enhanced MDCT scans of the chest obtained in 589 patients was undertaken. CT angiograms obtained for suspected pulmonary embolism or thoracic aorta disease were not considered. Image evaluation was performed on a dedicated workstation during two separate review sessions using different window settings: standard, with a width of 400 H and level of 40 H; and wide, with a width of 600 H and level of 100–150 H. The quality of vascular enhancement was recorded.

RESULTS. Eight examinations were excluded because of poor quality. Unsuspected pulmonary embolism was present in 20 (3.4%) of 581 patients with an inpatient prevalence of 4.0% (19/474) and outpatient prevalence of 0.9% (1/107). Fourteen patients (70.0%) with unsuspected pulmonary embolism had cancer. The proximal extent of pulmonary embolism involved the main pulmonary artery in five patients, a lobar artery in five, and a segmental artery in 10; isolated subsegmental thrombi were never found. The use of wide window settings allowed detection of pulmonary embolism in two more patients than did the standard settings.

CONCLUSION. Unsuspected pulmonary embolism can be found in a significant number of patients undergoing a routine MDCT study of the chest, with a higher prevalence among inpatients with malignancy. The use of wide window settings is recommended when interpreting routine CT scans of the chest to improve detection of unsuspected pulmonary embolism.

Introduction

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Pulmonary embolism is a common disorder associated with considerable morbidity and mortality. Pulmonary embolism is estimated to occur in approximately 650,000 patients annually in the United States and accounts for as many as 50,000 deaths [1, 2]. Although these numbers are staggering, the true incidence of pulmonary embolism is likely higher because an unknown number of patients with this condition are undiagnosed or misdiagnosed. A high frequency of asymptomatic pulmonary embolism has been reported in patients with deep venous thrombosis [3, 4]. Silent pulmonary embolism also is reported to occur in patients with neoplastic disease, patients with hypercoagulation, and patients who have sustained trauma [5]. Clinically unsuspected pulmonary embolism occasionally may be detected in patients undergoing CT of the chest for various reasons. The reported incidence of incidental pulmonary embolism varies from 0.5% with conventional sequential CT scanners to 1.5% with single-detector CT scanners [5–7].

With the introduction of MDCT scanners and their high acquisition speed, thin collimations frequently are used for routine studies of the chest, which has resulted in increased spatial resolution and improved visualization of peripheral pulmonary arteries [8, 9]. The objectives of this retrospective study were to assess the prevalence of pulmonary embolism incidentally detected on routine MDCT scans of the chest and to determine whether the use of wide window settings can improve detection of unsuspected pulmonary embolism.

Materials and Methods

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Patient Population
A computer search was performed to identify patients who had undergone contrast-enhanced CT of the chest at our institution between January 1, 2001, and December 31, 2001. All CT angiographic examinations performed for suspected pulmonary embolism or thoracic aorta disease were excluded from the study.

A total of 589 patients, 416 men and 173 women, with a mean age of 63.4 ± 12.7 (SD) years (range, 18–97 years), were enrolled. Of these, 480 were inpatients and 109 were outpatients. In 410 patients (69.6%), the CT examination of the chest was performed for staging or follow-up of a known neoplasm. In the 179 remaining patients, clinical indications for CT were characterization of a pulmonary nodule detected on a preliminary chest radiograph (n = 58), hemoptysis of unknown cause (n = 25), infiltrative or infectious lung disease (n = 25), pleural disease or pleural effusion (n = 21), and trauma and other chest radiographic abnormalities (n = 50).

CT
CT scans were acquired on a 4-MDCT scanner (Volume Zoom, Siemens Medical Solutions) from the thoracic inlet through the diaphragm, during a single breath-hold. Patients were scanned in the craniocaudal direction using a collimation of 4 x 1 mm and a table speed of 7 mm per rotation or a collimation of 4 x 2.5 mm and a table speed of 15 mm per rotation, 0.5-sec rotation time, 140 kVp, and 120 mAs. At the end of acquisition, contiguous 5-mm-thick axial images were reconstructed in all patients using a standard reconstruction kernel. The total scanning duration ranged between 10 and 22 sec depending on the scanning protocol.

Eighty milliliters of nonionic contrast material (300 mg I/mL of iomeprol, Iomeron 300, Bracco) were injected through an antecubital vein at a rate of 3 mL/sec using an automatic injector (EnVision CT, Medrad); scanning started 25 sec after the beginning of contrast administration.

Image Evaluation
All images were reviewed retrospectively at a dedicated workstation by two chest radiologists, and a decision was made by consensus. Reviewers were blinded to the patient's name, clinical history, and symptoms. CT scans were assessed for the presence of pulmonary embolism and distribution of thrombi within the main, lobar, segmental, or subsegmental pulmonary arteries. Reviewers also were asked to indicate their confidence level in interpreting the CT images and diagnosing pulmonary embolism, and a single per-patient score was recorded (pulmonary embolism definitely present, pulmonary embolism possibly present, pulmonary embolism possibly absent, pulmonary embolism definitely absent). Pulmonary embolism was considered to be present when either a complete or a partial filling defect, defined as an area of low attenuation, could be identified in adequately opacified arteries. The evaluation was performed during two review sessions: images were assessed first using the standard settings for viewing CT scans of the mediastinum at our institution (width, 400 H; level, 40 H), whereas for the second session, wider window settings (width, 600 H; level, 100–150 H) were used. Cases were presented in a different order for each session; a 1-week interval separated the review sessions.

The degree of pulmonary artery opacification was determined by means of regions of interest at the level of the pulmonary trunk or the left main pulmonary artery. Opacification was considered good when vessel attenuation was greater than 150 H, satisfactory when it was less than 150 H but greater than 100 H, and poor when it was less than 100 H.

The radiology reports and medical records of patients with unsuspected pulmonary embolism were also reviewed for detection of emboli at the time of CT, correlative studies (pulmonary scintigraphy, lower extremity venous Doppler sonography), follow-up CT studies, and resultant therapy.

Statistical Analysis
The association between the presence of incidental pulmonary embolism and the patient status and clinical history was determined and tested for significance using the Student's t test.

Results

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Among the 589 CT scans evaluated, 581 (98.6%) showed either a good (n = 537) or a satisfactory (n = 44) degree of pulmonary artery opacification. The degree of pulmonary artery opacification was considered poor in the remaining eight patients (1.4%), and they were excluded from further analysis.

CT findings indicative of pulmonary embolism were present in 20 (3.4%) of 581 patients with analyzable scans. The prevalence of unsuspected pulmonary embolism in our study was 4.0% among inpatients (19/474 patients) and 0.9% among outpatients (1/107 patients). The age range of these 20 patients was 54–79 years (mean, 66.1 ± 6.7 years).

Of the 20 patients with unsuspected pulmonary embolism, 14 had an underlying malignant disease, including bronchogenic carcinoma (n = 8), mesothelioma (n = 2), colon carcinoma (n = 2), neck neoplasm (n = 1), and renal neoplasm (n = 1). CT was performed for characterization of a solitary nodule in two patients and for evaluation of mediastinal enlargement seen on a radiograph in one. The remaining three patients had diffuse infiltrative lung disease. The prevalence of malignancy among patients with unsuspected pulmonary embolism was significantly higher than the prevalence of benign diseases (64.7% vs 35.3%, respectively; p < 0.05).

The proximal extent of emboli involved the right or left pulmonary artery in five patients, a lobar artery in five, and a segmental artery in 10 patients. Thirteen patients showed multiple filling defects, whereas isolated emboli were identified within segmental arteries in five patients and lobar arteries in two. None of the patients in our study showed isolated subsegmental filling defects; however, subsegmental emboli were seen in combination with larger emboli in eight patients.

Eighteen (90%) of the 20 patients with unsuspected pulmonary embolism were identified during the first review session, after revision of CT images with the standard window settings. The use of wider window settings allowed detection of pulmonary embolism in two additional patients (Figs. 1A and 1B). Moreover, the use of wider window settings resulted in a significant reduction in the number of cases classified as indeterminate (e.g., pulmonary embolism possibly present or possibly absent) and an increase in the number of cases interpreted as negative for pulmonary embolism (51 vs 14 and 512 vs 547, respectively).

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —64-year-old woman with unsuspected pulmonary embolism in segmental artery of right lower lobe. Partial filling defect in posterior basal segmental artery of right lower lobe (arrow, B) that was not seen on CT image viewed with standard mediastinal window settings (A); however, it was identified on image viewed with wider window settings (B).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —64-year-old woman with unsuspected pulmonary embolism in segmental artery of right lower lobe. Partial filling defect in posterior basal segmental artery of right lower lobe (arrow, B) that was not seen on CT image viewed with standard mediastinal window settings (A); however, it was identified on image viewed with wider window settings (B).

Revision of the original radiology reports and medical records of the patients in our study group showed that 14 (70%) of the 20 patients with unsuspected pulmonary embolism were prospectively identified at the time of CT, nine of whom underwent correlative studies that supported the diagnosis of pulmonary embolism. These studies included CT pulmonary angiography with positive findings in four patients, lower extremity Doppler sonography in eight patients (six were positive), and perfusion pulmonary scintigraphy in two patients. In six patients (30%) the presence of pulmonary embolism was identified only retrospectively—that is, at the time of the present study. In four of these patients, a follow-up CT examination of the chest was performed. The follow-up examination showed progression of pulmonary embolism in one patient (Figs. 2A, 2B, 2C) and no change in three patients. In the group of patients in whom the diagnosis of pulmonary embolism was initially missed, emboli were located in the lobar and segmental pulmonary arteries; three patients had isolated segmental emboli (Fig. 3).

View larger version (53K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —70-year-old man with lung cancer and silent pulmonary embolism in segmental artery of right lower lobe. CT scan obtained through right lower lobe shows partial filling defect in lateral basal segmental artery (arrow). This was not seen at time of CT, and diagnosis of pulmonary embolism was missed.

View larger version (55K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —70-year-old man with lung cancer and silent pulmonary embolism in segmental artery of right lower lobe. CT scans obtained 3 months later show progression of pulmonary embolism with multiple filling defects in segmental arteries of right lower lobe (B) and in right middle and inferior lobar arteries (C). Pulmonary embolism was correctly diagnosed at this time.

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —70-year-old man with lung cancer and silent pulmonary embolism in segmental artery of right lower lobe. CT scans obtained 3 months later show progression of pulmonary embolism with multiple filling defects in segmental arteries of right lower lobe (B) and in right middle and inferior lobar arteries (C). Pulmonary embolism was correctly diagnosed at this time.

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —56-year-old man with pulmonary metastases from colon carcinoma and isolated segmental pulmonary embolism. CT scan through left upper lobe shows partial filling defect (arrow) in anterior segmental artery. This finding was missed by reporting radiologist at time of CT.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Silent pulmonary embolism is a well-known entity that may occur in a high percentage of patients. In an autopsy study, the diagnosis was unsuspected in 14 (70%) of 20 patients who died from pulmonary embolism [10]. Although in a selected series of patients without severe cardiovascular disease silent pulmonary embolism had a good prognosis and the anticoagulant treatment did not influence the resolution rate of pulmonary embolism [11], most authors believe that occult pulmonary emboli may be the antecedent of more serious and clinically obvious emboli and may need to be treated [7].

A high frequency of asymptomatic pulmonary embolism has been reported in patients with deep venous thrombosis both above and below the knee. In one study, nearly 40% of patients with deep venous thrombosis but without symptoms of pulmonary embolism had evidence of pulmonary embolism on ventilation–perfusion scanning [3]. In a different series of 622 outpatients with proximal deep venous thrombosis undergoing pulmonary scintigraphy, the estimated frequency of silent pulmonary embolism was 39.5–49.5% [4]. A similar incidence of silent pulmonary embolism in association with deep venous thrombosis was observed in patients examined with helical CT [12].

Asymptomatic pulmonary embolism may occur also in patients with different risk factors including neoplastic disease, hypercoagulation, and trauma. Because CT scans of the chest are obtained frequently in these patients for various clinical indications, the incidental detection of pulmonary emboli on routine contrast-enhanced CT is not rare. A 1% prevalence of unsuspected pulmonary embolism was found by Winston et al. [7] in a retrospective analysis of routine helical CT examinations. Similarly, Gosselin et al. [5] found that among 785 consecutive patients referred for thoracic CT, 12 (1.5%) had clinically unsuspected pulmonary embolism. In our study, the prevalence of pulmonary embolism incidentally detected on routine CT scans of the chest was approximately two and three times higher than previously reported. Our increased detection rate may be explained by the improved image quality and better visualization of peripheral pulmonary vessels achievable with MDCT. As a matter of fact, both Winston et al. and Gosselin et al. used single-detector CT scanners coupled with large collimations ranging between 5 and 10 mm that might have hampered the visibility of small isolated segmental and subsegmental thrombi [5]. Because MDCT scanners are characterized by high acquisition speed, we were able to scan the entire thorax within 10–22 sec using collimations as narrow as 2.5 or 1 mm. The increased spatial resolution, together with a more homogeneous contrast material column and reduced motion artifacts, may have contributed to the improved detection rate of asymptomatic pulmonary embolism in our study. We did not try to compare 2.5- and 1-mm collimations.

In both our study and the study by Gosselin et al. [5], the prevalence of unsuspected pulmonary embolism was higher among inpatients (4% and 5%, respectively) and patients with neoplastic disease (70% and 83%, respectively). Even though the percentage of patients with malignancy in our study was smaller than that reported by Gosselin et al. (69.6% vs 74.9%, respectively), we found a higher prevalence of unsuspected pulmonary embolism. This result may be attributable to the different CT technique and the increased spatial resolution of our scanning protocol.

The use of wide window settings—in the order of 600 H for window width and 100–150 H for window level—also might have contributed to the higher prevalence of silent pulmonary embolism observed in our study. If analysis of CT images had been based on only the images obtained with standard window settings in our department, pulmonary embolism would have been detected in 18 patients instead of 20 patients and the overall detection rate would have decreased to 3%. As nicely shown by Brink et al. [13] in a porcine model, nonocclusive thrombi are best depicted as filling defects when displayed with a modified window referenced to the right or left main pulmonary artery attenuation. Computing this window requires measurement of the attenuation value within the main pulmonary artery; the window width is then set equal to the measured mean attenuation plus 2 SDs, whereas the window level is set equal to this value divided by 2 [13]. For the sake of simplicity, we prefer the use of an empiric window setting (width, 600 H; level, 100–150 H) that allows adequate visibility of intraluminal filling defects (Figs. 1A and 1B).

The use of an incorrect display window could also partly explain the six cases of silent pulmonary embolism missed by the reporting radiologist at the time of CT. Other possible causes of misdiagnosis could have been the site and size of emboli in the three patients with isolated segmental thrombi and the presence of other and more evident pathologic findings that captured the radiologist's attention—the so-called satisfaction of search phenomenon [14]. As a matter of fact, two of the six patients with missed pulmonary embolism had lung cancer, one had metastatic disease from colon carcinoma, two had pleural effusion, and one, pulmonary sarcoidosis.

Some limitations of our study need consideration. Because of the retrospective design of our study, a confirmatory examination was available in only nine of the 20 patients with pulmonary embolism. Another potential limitation is the relatively large section width used for reconstruction of axial images. We routinely reconstruct MDCT axial images using 5-mm section width, which usually suffices for most routine settings without a considerable increase in the number of images to reconstruct and review [15]. However, although we were able to detect subsegmental emboli in eight patients, the use of thinner section widths would have reduced partial volume effects further and improved the visibility of peripheral arteries [16–18].

Our results confirm that unsuspected pulmonary embolism can be found in a significant number of patients undergoing routine MDCT of the chest, with a higher prevalence among inpatients with malignancy. For this reason, CT scans of the chest should be evaluated carefully for the presence of pulmonary embolism, especially in these high-risk patients. We also recommend the use of wide window settings for the interpretation of routine MDCT images to improve detection of unsuspected pulmonary emboli.

References

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