T- hy Versus Pulmonary An@omphy in the osis of Acute Madve Pulmotilrry Embolism

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F ~ p u t e d T ~ m o g i l a p h y V e r s u s P i

^'

InaryAmglogrsiphyInthe of Acute Massive Pulmonary e m - l i ~

Alain G. Blum, MD, François Delfau, MD, Bruno Grignon, MD, Daniel Beurrier, MD, Francois Chabot, MD, Michel Claudon, MD, Nicolas Danchin, MD, and Denis Regent, MD

Reprinted from the July 1 issue

The Amerlcan Journal of Cardiology

A Yorke Medlcal Journal

Published by The Cahners Publishlng Company, a Division of Reed Publlshlng USA

Printed in the U.S.A.

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T- hy Versus Pulmonary An@omphy in the osis of Acute Madve Pulmotilrry Embolism

Alain G. Blum, MD, Francois Delfau, MD, Bruno Grignon, MD, Daniel Beurrier, MD, .Francpis Chabot, MD, Michel Claudon, MD, Nicolas Danchin, MO, and Denis Regent, MO

S

piral-computed tomogaphy (Cï) is a new imaging m d t y implemented on a continuously rotating Ci' scanner, taking advantage of a colltinuous table feed.' Recent studies demonstrated the advantage of this tech- nique to study the rnediastinal ve~sels.~J Using this tech- nique, we designed a s p d ï c protaml adapted to the emergency situation of acute puimonary embolism. This new pmmoI was prospectively e v a l d in 10 patients with suspected massive puimmary anboiism

{PE).

Ten patients (4 men and 6 women, aged 18 to 76

years [average 433) with suspected acue massive PE utdenvent spiral CT andpu~mnaty angi~graphy~ Three of these patients with confirmed PE undcrwetu nau spi- ral CT and pulmonaqv angiography to jollow the evolu- tion of the thrombi treated with thmbolytic therapy.

Thus, a total of 13 spiral CTs were perfomed and com- pured with pulmonur). angiograpiy. Six of them were perjformed before pulmonary angiography. The delay be- tween CT and pulmonary angiogruphy was cl2 hours, except in 1 case where there was a 36-hour span. Spi- ml CT was pe$urrne$ with a Somatom Plus S scanner {Siemens, Erlangen, Germny) using a 5 m thick col- limarion, a 5 mmis table feed, reconstruction of over- lapped images (3 mm intervals), and ra total scranning time of40 second.^. Therefore, the length of the scanning volume was 20 cm. Seventy ml of sodium oxitalramate {Telebrix 30, Guerhet, Aulnay-sous-Bois, France) was injected inro un antecubital iein at the raite of 1.5 mlts

witk a delay

of

15 secod.~. The acquisition wais per- f o m d wWTthout altering the patient's hreathing pattern.

The patient left the table as soon as the acquisition was completed. l n ail, the procedure lasted <5 minurcslpa- tient, inctuding positioning. Pulmoriary angiography

Rom the Dtpamnentp of Radiology, Cardiology, and Respiratory Dis-

eapcs, CHU Bmbois, Vdotuvrc. 545 1 1, F m e . Manuxript receiveà October 4,1993; reviscd manilscript d v c d Novcrnbcr 29,1993, and

~ c e p t e d Nwember M.

T A B U I Cornparison of Diagnoses Obtained with Spiral Computed Tomography K T ) and Pulmonary Angiography (PA)

Spiral CT

t -

+ ^PA 71* 1 O*

- ^PA ^2* ^268'

' N u m m d (hmmbi.

+

-

^Mc6tw^Pywlrmmry a n g i m p h y or spiral ormputed mmogmphy.

-

^Nddctceted by pulmwrprj a i i d ~ a p h y u spml mmputed tnmmphy.

was perfarmed with selective rigki and i& puimonary arteriogramr recorded in the p s t e m t e r i o r pmjec- tbns. In 6 cares, adiitioml obli$ue pmjections wem recorded.

T h CT scatts and pulmonav angiograms wem d- wted raitubrnly by 2 radtoiogists {AS. and FD.) and a

&cision wus reached by consensus. The 2 rea&rs were unaware of the jindings of 1 technique when the other technique was anaiyzed. The total number of main, lo- b a ~ and segmental pulntotmy thrombi or e h l i de- tected with spiral CT was determinedfor euch lmg and

comprmred wifh the angiographie findings wing the K stcatistics as a means of assessing agreement.

Amang the IO original patients, m s s i v e PE wac di- cagnwed with both spiml CT and pulmoncary angwgra- phy in 7 cases. Three patients had no PE. PE was also detected with both techniques in the 3 mnsrnll~d pa-

tients. .Therefore, using pulmonaty angiography as the reference, the sensitivi~ and speci$ci@ of spiral CT were 100%. Seyen@-one thrombi were detected with both spi- ral CT and pulmonaty angiography (Figure 1 ). ï h o s e p mental thrombi depicted with spiral CT were noor secn with pulmonaqv angiography. This was due tu s m l l thrombi t h t could not be detected with unilateral an- giagram. Ten segmentai thmmbi diagnosed

with

pul- monary angiography were not depicted with spiral CT

and 268 arteries were considered normai with both

96 ME AMERlCAN JOURNAL OF CARDKXOGY VOLUME 74 U L Y 1,1994

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RQWlE 1. Pu- mogm rd iplnl- tom- ( C ï l of a pe0iint wtth mi#rC*. -ta ml-

Mi3dlim. A, rlgW

-

obllque -am ihorvlng t m m M 1ii thi

-

^puliii#uy^-y

-

œ m w h d h

L n t h e ~ u e p . r l o k a r t . r y i o p ~ ~ w h i L o l ~ p u l # n i t r y ~ l ~ o c l ~ h i r t R s ~ r e n t m l

~ d a i e ~ ~ r m ( # s d r ~ d C n ~ ~ l a C a ~ ( ~ ~ 1 . ~ i p i r n l ~ i ~ d o p l e t .

~ t h i w i b l h i t L i k B m r l n p d r i # i r y a r t ~ ( ~ u r o i v ) d i n t h i ~ w n t n l ~ o l t h e M q p o r

k a ( ~ ~ G ~ C T i ~ r h w s l l n g t h r a i a b i I * ~ s n ~ i p p e i l o b m ~ f e i p u i a n w v h I n ~ I l n ~ l i * ~ k r l # ~ ~ m w J , d a m I I # s r i i t b s I s W p u l # i a y & i r ) i ( ~ W n M d ) ~ j o L b A O t ~ ~ I h . ~

~ a m . ~ l p t s I ~ ~ d . m o n ~ ~ ~ m k i C C . t h m m k i s l n t h m ~ m i C n p u l ~ a r k i y ~ ~ ~ 1 a n d tLmRibi In the li- artaki

methods (Table 1). Thewforc. ^cistrong agtzment be-

m e n spiral

CT

and pulmomwy angwgraphy was mted (K ⁼OB).

The diagîosis of cenû.al

PE

can be reached with con- ventional CI' or magnetic resmmce imaghg. Howèver, these techniques have not gained t h accutacy of pul- monary a n g i o g q h y , ~ Spiral

CT

is a new methoci whose accuracy was dmonslrakd by Rq-Jardia et

aL3

The advancage of our protaxi is &, although we used reduced volume of conmst medim and a very simple injection technique, the acmacy of the method remains excellent.

This is pbabiy explained by tbe tecimical chnirac- teristics of spiral CT. The data used to reconstnict 1 slice are q u i r d in 1 second, therefm, motion artifacts are greatly r e d u d c o m p d wiîh conventional

CT

and the patient can quietly breathe without signikant aiteration

of image quality. Because the total acquisition time is very short (40 seconds), a very good vascular opacjhca-

tion can be obtained with h - d o s e c o n m t mediaa2 This technique appem to be quick and safe because the exmination time _forthe patimt iu very shoa, mak-

ing mOnimhg &es- The low dose of contrafit mediinn, the slow rate ~f injection, imd the peripheral site of b jection make this examination rninimally iwasiv e ^,

Similar ta i m u n g and Doppler echocardhgra- phy, which permit mesment of cardiwasimhr corn- promise: spiral CT r e p m t s a mfe and effective diagnostic tdfor scute and masive pulmona~y em- Mism. Because ^thipmethod is efficient in detecüng emboii in the second to fourth division puhonary vessds, it is pmbably also wdi suited for diagn- submassive PE, but most Ukely ineffective in diag- noshg peripheral

P L

B R I E REPORTS 97

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w i h puhnrniay angiogmphy. Rdiology 1992,185:381-387.

4. AMaPcm PO. Mwh EC. himanmy mboli&m: diagnosii with multiple fmap hg uduiitk. 1987;164:297312

A Shah HR. B w k CB, h sOL Waikw CW. Cornputod tornography and

~aonsnce imeging in the d i a g n o l oî pulmonq thmmboembD1ic dis cast. J lXw(1c Inragiq 1988;4:5Ml.

0. CMw PC. Edi~cardioaphic waluation d pulmonary mbcliwn and ib m e p p ~ m thwapeutfc Intewendons. C k s i 1992;t01:1513-162S.

98 THE AWWCAN JOURNAL OF CARDK)LOGY YOUIW 74 JULY 1,1994

8 Copyright. The American Journal of Cardiology, July 1, 1994.