XavierCortez,TristanRaniga

Dr.Manns
BME330SectionS
1November2011
ComputedTomographicPulmonaryAngiographyforDiagnosingPE
Pulmonaryembolism(PE)isaseriousmedicalconditioninwhichalungartery
experiencesasuddenblockage.Thisblockagecanbeattributedtoseveralcauses,butmost
commonlytheblockageisabloodclotthatoriginatesfromanotherpartofthebody.Everyyear,
250,000peoplearehospitalizedand/ordieintheUnitedStatesbecauseofpulmonaryembolism.
ItisestimatedthatPEcauses5%to10%ofalldeathsinhospitalsanditisthethirdleadingcause
ofcardiovascularmortality1.AlthoughPEisaveryseriouscondition,withapromptdiagnosisit
canbesuccessfullytreated.ThechallengethatcliniciansfaceisthatPEremainsoneofthemost
difficultconditionstodiagnoseaccurately.
Overthepastthirtyyears,ventilationperfusion(V/Q)lungscanninghasbeenthe
preferreddiagnosticchoiceofdoctorsforpulmonaryembolisms(PE)1.Thismethodmeasures
thecirculationofairandbloodinapatientslungs.Theventilationportioncalculatestheairs
abilitytoreachallpartsofthelungs,andtheperfusionportiondetermineshowwellbloodisable
tocirculatewithinthelungs.TheV/Qmethodhasbeenusedtotestpatientsforpulmonary
embolisms,butitdoesnotgiveadefinitepositiveornegativediagnosis,butratherapercentof
beingpositiveforPE.Forexample,anormalV/QscanexcludesthediagnosisofPE.Ahigh
probabilityV/Qscanhasan85%to90%predictivevalue,withanincidenceofPEinonly25%
to30%ofpatients.MostpatientswithsuspectedPEhaveloworintermediateV/Qscansandthe
incidenceofPErangesfrom10%to40%inthesepatients.Thisdiagnosticuncertaintyisamajor
limitationofventilationperfusionlungscanning1.
Withinthepastdecade,theuseofcomputedtomographicpulmonaryangiography
(CTPA)hasbeenusedasaformofdiagnosisforPEbecauseitcangivedoctorsapositiveor
negativediagnosisforpulmonaryembolism1.CTPAhelpsgivedoctorsadefinitiveanswerof
whetherornotapatientispositiveforPE,unlikeV/Qscanning,whichgivesaprobabilityof
beingpositive.TheuseofCTPAisbecomingmorewidespreadbecauseitgivescliniciansa
definitiveresultanditcanalsodetectothernonthromboticcausesofpatientsymptoms1.Oneof
thelimitationsofCTPAisthatitexposesthepatienttoradiationfromXrays,whereas
ventilationperfusionscanningdoesnotuseanyformofradiation.AnotherlimitationofCTPA
isitsaccuracyindiagnosingsmallperipheralemboli3.Asaresult,CTPAhasnotgained
unanimousacceptanceasthereferencestandardforimagingPE.
ItisdifficulttosaywhetherCTPAisbetterthanV/Qscanning.Inrecentstudies,ithas
beenshownthatCTPAisatleastaseffectiveasV/QscansinrulingoutPEandactually
diagnosesmorepulmonaryembolismsthanV/Qscanning.Despitethis,V/Qscanningshould
stillplayaroleintheinvestigationofPE.AnormalV/Qscanessentiallyexcludesthediagnosis
ofPE.AnondiagnosticV/Qscanincombinationwithnegativevenousultrasonographicresults
alsoexcludesPE.Becauseofexposuretoradiationandotheradverseeffects,theuseofCTPA
shouldbelimitedonlytopatientswhohaveanondiagnosticV/Qscanresultandahighclinical
likelihoodforpulmonaryembolism.

XavierCortez,TristanRaniga
Dr.Manns
BME330SectionS
1November2011

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References
Anderson,DavidR.,SusanR.Kahn,etal."TomographicPulmonaryAngiographyvs
VentilationPerfusionLungScanninginPatientsWithSuspectedPulmonaryEmbolism."
TheJournaloftheAmericanMedicalAssociation298.23(2007):2743753.Web.
<http://jama.amaassn.org/content/298/23/2743.full.pdf+html>.
Donato,AnthonyA.,SwapnilKhoche,JosephSantora,andBrentWagner."Clinical
OutcomesinPatientswithIsolatedSubsegmentalPulmonaryEmboliDiagnosedby
MultidetectorCTPulmonaryAngiography."ThrombosisResearch126.4(2010):
E266270.Print.
Schoepf,U.J.,andP.Costello."CTAngiographyforDiagnosisofPulmonaryEmbolism:
StateoftheArt."Radiology230.2(2004):32937.Print.
Venkatesh,S.K.(2011),CTpulmonaryangiographyforpulmonaryembolism:role
beyonddiagnosis?.InternationalJournalofClinicalPractice,65:iiiv.doi:
10.1111/j.17421241.2011.02660.x

XavierCortez,TristanRaniga
Dr.Manns
BME330SectionS
1November2011

TechnicalDescriptionofCT
ComputedTomographicPulmonaryAngiographyusescomputedtomography(CT)asits
medicalimagingmodality.Computedtomographyisknownasapowerfulnondestructive
evaluation(NDE)techniqueforproducing2Dand3Dcrosssectionalimagesofanobjectfrom
flatXrayimages.1CTimagesareabletocapturethedensity,shape,internaldefects,and
dimensionsoftheobjectbeingimaged.Whenanobjectisbeingimaged,itisplacedbetweenthe
radiationsourceandtheimageintensifier.Acomputerisconnectedtotheimageintensifierand
aturntableunitwherethexrayimagesarecollectedcanbecorrelatedtothepositionofthetest
component.1Thecomputerthenusesspecializedsoftwaretoconverttherawdataintocross
sectionalimagesoftheobject.
Acomputedtomographyimageisattainedwhenseveralimagesorslicesofanobjectare
puttogethertoformafinalimage.Thecrosssectionalslicesaretakenin2D,butwhenallof
theimagesareputtogethera3Dpictureisformed.Toattaintheseimages,aCTscanis
accomplishedbyrevolvingaroundtheobject.Eachsliceisashadowandinordertofully
understandthecompleteimage,slicesmustbetakenfromvariousangles.Theslicesaretaken
byrevolvingtheradiationsourceandtheimagedetectoraroundtheobject.Whenallofthese
slicesaretakenfromthevariousangles,theyareputtogether.Whenputin3Dform,animage
canthenbemanipulatedandslicedinvariouswaystoprovideathoroughunderstandingofthe
structure.1
CTPAProtocolfromtheDepartmentofThoracicRadiologyatMassachusettsGeneralHospital
CTPAuses16and64MDCT(multidetector)scannerstoacquiretheimagesina
caudalcranialdirection.Forboth16and64sliceMDCT,thepeakvoltageis140kVandthe
currentusedis380mA.8Thisprocedurerequirestheuseofacontrast,whichisusually
administeredintravenously,butcanalsobeadministeredorally.WhenIVisused,theatecubital
veinandan18or20gaugecatheterispreferred.8ImagesareviewedonaPACSmonitorusing
IMPAXversion4.1.InterpretationofchestCTismoreaccuratewhenviewedonaworkstation
asopposedtoviewingonhardcopyfilm.8Theimagesaredisplayedwiththreedifferentgray
scalesforinterpretationoflungwindow,mediastinalwindow,andpulmonaryembolismspecific
settings.Theseadditionalsettingsareusefulbecausepulmonaryembolismcanbemissedwhena
casewithverybrightcontrastisviewedonlyonmediastinalwindowsettings.8CTimage
reformationcanhelptodifferentiatebetweensomepatient,technical,anatomic,andpathologic
factorsthatmimicpulmonaryembolism.8Respiratorymotionartifactsarethemostcommon
causeofanindeterminateCTPAscan.Toreducetheseartifacts,patientscanholdtheirbreath.
Thebreathholdrequiredfor16MDCTisapproximately10seconds.For64MDCTitisless
than3seconds.8

XavierCortez,TristanRaniga
Dr.Manns
BME330SectionS
1November2011

CTSystem1

XavierCortez,TristanRaniga
Dr.Manns
BME330SectionS
1November2011

CTPAprotocoltables2
References
1."ComputedTomography."NDTResourceCenter.Web.01Nov.2011.<http://www.ndt
ed.org/EducationResources/CommunityCollege/Radiography/AdvancedTechniques/computedto
mography.htm>.
2.Wittram,C."HowIDoIt:CTPulmonaryAngiography."AmericanJournalofRoentgenology
188.5(2007):1255261.