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Pulmonary Embolism:

Pearls, Pitfalls and Protocols

Arun C. Nachiappan, MD
Associate Professor of Clinical Radiology
University of Pennsylvania
• No Financial Disclosure
• Design and implement CT PE protocols
that optimize diagnostic accuracy
• Identify and diagnose PE on CT and NM
• Recognize and avoid pitfalls in diagnosis
of PE such as imaging artifacts and
anatomic mimics
• Pre-test probability
• CT
• Protocol Technique
• Pearls and Pitfalls in Interpretation
• Artifacts
• Anatomic mimics
• Physiologic factors
• Pathologic mimics

• VQ
• Pregnancy
Pre-test probability

• Wells’ Criteria (Two tier


• Total score

Writing Group for the Christopher Study Investigators. JAMA 2006;295:172-179

Pre-test probability
• Wells’ score ≤ 4: “PE unlikely” (12% risk)
– D-Dimer
• If negative, no imaging or treatment
– potentially eliminate imaging studies in 50% of outpatients and
20% of inpatients
– So, complete elimination of radiation to patient in this subset

• If positive, CT PE protocol

• Wells’ score > 4: High: “PE likely” (37% risk)

– CT PE protocol
Writing Group for the Christopher Study Investigators. JAMA 2006;295:172-179
Protocol tips
• Contrast + Saline

• Can scan Caudal to Cranial

• “Stop breathing”
Setting up the monitoring phase

ROI on Main Pulmonary Artery

– High osmolality (like
Isovue 370)
– Relatively less
volume (60 - 80 ml)
– High injection rate
(3.5 – 4 ml/sec)
– ROI passes threshold
(100 – 120 HU)
Quality of Contrast Bolus

• < 100 HU: bad

• 100-200 HU: suboptimal

– can still see large embolus in central PAs (clot
is 20-40 HU)

• > 250 HU: good

• > 300 HU: excellent

ROI average density 480 HU
Radiation dose
kVp: Low 100 kVp by default
Energy closer to k edge of iodine, so better
contrast opacification than 120 kVp

Effective dose = 243 x 0.014 = 3.4 mSv

100 kV, ROI on main PA 745 HU
Effective dose 1.2 mSv
With Iterative reconstruction Filtered back projection only
• Adjust Window/Level

• Look at lung windows

• Always look for PE when there is

contrast on any exam
PE on non-PE protocol exams
• Recognize possible

– Peripheral

– Wedge-shaped

– Mixed consolidation
and groundglass
• Suboptimal quality — “cannot evaluate”

• If struggling on small vessel— better not

to call it
• Diagnosis of clinically unimportant

• Real pulmonary arterial filling defect,

visualized because of good-excellent
quality CT PE exams
• Normal function of the lung is to act as a
filtration unit for small clots1

• Anticoagulation risks:
– 7-10% morbidity in elderly

– mortality 1%1

1Goodman, et al. Radiology 2005;234:654-658


Increasing incidence of PE, but unchanged mortality

Sheh SH, et al. AJR 2012;198:1340-1345


Decreasing case-fatality rate

Sheh SH, et al. AJR 2012;198:1340-1345
Clot Location
• Hemodynamically Stable patients (89%)1
– Central worse than peripheral

• Hemodynamically Unstable patients

– Mortality unrelated to clot location1

1Vedovati MC, et al. Chest 2012;142:1417-24

Isolated Subsegmental PE
• 10% of PEs detected on CTPA1

• Do US proximal DVT in the legs.1 If negative

and patient is…
– Low risk for recurrent VTE (DVT or PE)
• Clinical surveillance (Not anticoagulation!)

– High risk for recurrent VTE

• Anticoagulation if permissible
1Kearon et al. CHEST 2016;149:315-352
Acute PE
• Abrupt obstruction of blood flow in a
pulmonary artery

• Central filling defect

• Occlusive or nonocclusive
Acute PE- Prognostic signs
• Shock, prolonged hypotension

• Right ventricular strain

Right heart strain

• Dilated RV
• Bowing of interventricular
• 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
Pulmonary Hypertension
• Main PA > 3 cm

• Ratio of Main PA / Ascending aorta > 1

Mahammedi A, et al. JTI 2013;28:96-103

Pitfalls — Artifacts
• Respiratory motion artifact

• Streak artifact in RUL

• Quantum mottle

• Pulsation Artifact

• Volume averaging on thicker slices

ROI average 152 HU
Anatomic Mimics
• Pulmonary vein

• Mucoid impacted bronchus

• Lymph nodes near vascular branchpoints

– Differentiate from chronic PE
Physiologic factors
• Abnormal venous inflow into the right
– Transient interruption of contrast (TIC)
from IVC
– SVC obstruction

• 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

• Primary malignancy: pulmonary artery


• PA in situ thrombus (not embolic)

– after pneumonectomy or lobectomy
Pulmonary Tumor Emboli
• Usually small emboli in subsegmental
– Vascular dilatation and beading

• Can be large emboli in main, lobar,

segmental PAs
• Prostate, breast, HCC, gastric and
pancreatic cancer
Pulmonary artery
• Features that help
distinguish PA sarcoma
– Filling defect occupying entire
luminal diameter of main/
proximal PA

– Expansion of involved PA

– Extraluminal tumor extension

– Heterogeneously enhancing

Chin Y, et al. JCAT 2004;28:34-39

PA In Situ Thrombus
Chronic PE
• Eccentric

• Smooth or nodular thickening along

vessel wall
– Need to distinguish from adjacent lymph
nodal tissue

• Webs
Chronic PE Acute PE 9 weeks earlier
Dual Energy CT
• Use of 2 tubes operating at different kVp
– Allows differentiation of materials with
large atomic numbers like iodine

• Iodine perfusion maps of the lungs

Artifacts with Dual Energy CT
• Beam hardening artifact

• Motion artifact

• Aberrant vascular supply to lung

• 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
– Central (Main, Right and Left)

– Lobar

– Segmental

– Proximal Subsegmental
• VQ useful in chronic thromboembolic
– which can be difficult to detect on CTPA
Severe decreased perfusion of both lower lobes — high probability PE

Leung AN, et al. AJRCCM 2011;184:1200-1208

NM scan in Pregnancy
• V/Q scan
– Consider lowering the dose for perfusion scan
– Consider using Xenon instead of Technetium
DTPA for ventilation scan

• Only Q scan (perfusion)

– Consider only doing Q scan with reduced dose,
while NOT doing the V scan, particularly if
facility has no Xenon capability
Contrast in Pregnancy
• Iodinated contrast is Pregnancy
Category B — ok to give

• Gadolinium contrast is Pregnancy

Category C — better not to give
More take home points
• Encourage pre-test probability assessment

• Use 1oo kV for better contrast, less dose

• Be aware of overdiagnosis

• Isolated subsegmental PE may not need


• Acute and chronic PE look different