prof. mona mansour professor of pulmonary medicine ain shams university
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Imaging of Pulmonary Embolism. BY. Prof. Mona Mansour Professor of Pulmonary Medicine Ain Shams University. - PowerPoint PPT PresentationTRANSCRIPT
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Prof. Mona MansourProfessor of Pulmonary Medicine
Ain Shams University
Prof. Mona MansourProfessor of Pulmonary Medicine
Ain Shams University
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• Pulmonary embolism refers to embolic occlusion of the pulmonary arterial system. The majority of cases result from thrombotic occlusion and therefore the condition is frequently termed pulmonary thrombo-embolism
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• Diagnosis Pulmonary embolism may be difficult because no reliable non
invasive imaging method.
• In United States: estimated incidence of PE exceeds 600.000 cases per year.
• 30% mortality if untreated.
• Mortality in treated cases 2.5%
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1- Clinical assessment:
• Wells score
• Geneva score
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Revised GenevascoreVariable
PointsWells score
Points variablePoints
Predisposing factorsPredisposing factors
Age >65 yrs.+1Pervious DVT or PE+1.5
Pervious DVT or PE+3Recent surgery or
immobilization+1.5
Surgery or fracture within 1 month
+2Cancer
+1
Active malignancy+2
Symptoms Symptoms
Unilateral lower limb pain+3
Haemoptysis+2Haemoptysis+1
Clinical signs Clinical signs
Heart rate 75-94 > 95 beats
+3+5
Heart rate >100 +1.5
Pain in lower limb vein at palpation and unilateral oedema
+4Clinical signs of DVTAlternative diagnosis
than PE
+3
+3Clinical probabilityTotalClinical probabilityTotal
Low Intermediate High
0-34-10> 11
Low Intermediate High
0-12-6> 7
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2- Serological tests: • D Dimer (ELISA)
• Screening test in patients with low and moderate probability clinical assessment
a. Normal D-Dimer has almost 100% negative predictive value
b. Raised D-Dimer is non specific: we need further investigation
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3- Radiological features:
Plain film:
Fleishner sign: Enlarged pulm. Artery (20%)
Hampton hump: Perpheral wedge of air
space opacity implies
lung infarction (20%)
Westermark sign: Regional oligaemia (10%)
Pleural effusion: 35%
Elevated diaphragm:
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Nuclear medicine V/Q scan:• High probability scan is defined as two or more
unmatched segmental perfusion defects.
• Normal perfusion scan is very safe for excluding PE.
• Combination of non diagnostic V/Q scan + low clinical probability can exclude PE.
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Computed Tomography with Pulmonary Angiography (CTPA):
• Acute pulmonary embolism:
• Filling defect (polo mint) sign.
• Central filling defect from thrombus surrounded by a thin rim of contrast.
• Saddle embolus
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Computed Tomography with Pulmonary Angiography (CTPA):
• Chronic pulmonary embolism:
• Webs or bands
• Abrupt narrowing or complete obstruction of pulmonary arteries
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Computed Tomography with Pulmonary Angiography (CTPA):
• Acute or Chronic right ventricular dysfunction:
a- Abnormal position of interventricular septum
b- RVD: LVD ratio > 1
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Computed Tomography with Pulmonary Angiography (CTPA):
• Subacute to Chronic emboli:
a- Pulmonary infarction
B- Pulmonary hypertension
C- Chronic cor pulmonale
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Gadolinium Enhanced Pulmonary Magnetic Resonance Angiography (MRI):
• Pulmonary arterial signs in MRA:
a- abrupt decrease
B- parenchymal sign
C- pulmonary hypertension
The use of MR venography could also help diagnosis of PE
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•MRI is more expensive than VQ scan, but cheaper than angiography.
•MRI does not require hospitalization
•Non nephrotoxic
•No ionizing radiation
• Safe rapid, accurate, cost effective imaging.
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Compression Ultrasonography (CUS)
•Diagnosis of DVT may indirectly suggest the diagnosis of PE
•Anticoagulants are most often the initial therapy for DVT and PE
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Limitations:
•Not Definite for PE
•Normal proximal bilateral venous ultrasonography don't rule out PE
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Pulmonary angiography:
•Invasive
•CT angiography offers better results, non invasive
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Echo cardiography:
•In shock or hypotension, absence of echo signs of Rt. over load or dysfunction excludes PE.
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