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"PULMONARY EMBOLISM"

December 23, 2020 Edit this post

“ Patients are typically risk stratified first with the modified Wells score , with those at high risk proceeding to CT pulmonary angiograph...

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Patients are typically risk stratified first with the modified Wells score, with those at high risk proceeding to CT pulmonary angiography and low-risk patients having a D-dimer test. CTPA sensitivity is 83% (increased slightly by doing a CT venogram at the same time) and specificity is 96%.
US

•  Used to assess the deep veins of the legs, as most pulmonary embolisms (PEs) originate here.
•  Expanded, non-compressible vessel.
•  Reduced venous flow on calf compression.

CT

•  Occlusive/non-occlusive filling defect that forms an acute angle with the vessel wall.
•  Look for peripheral wedge-shaped foci of consolidation (pulmonary infarct) and, more rarely, mosaic attenuation of the lung (pulmonary oligaemia).
•  Chronic PE—forms an obtuse angle with the vessel wall, crescentic arrangement within the vessel. There may be webs, calcification or collateralisation. Mosaic attenuation is seen more commonly than with acute PE.
•  Check for evidence of acute right heart strain (e.g. enlarged right ventricle, reflux of contrast to the hepatic veins, bowing of the intraventricular septum towards the left ventricle and pulmonary hypertension).

NUCLEAR MEDICINE
•  Sensitivity is similar to a CTPA test, but less specific.
•  V/Q is now usually performed either in pregnancy (depending on local guidelines) or when renal failure precludes the use of intravenous contrast.
INTERVENTION
•  Catheter-directed thrombolysis/mechanical thrombectomy may be considered for certain patients with life-threatening PE.
Chronic thromboembolism. High-resolution computed tomography image demonstrating mosaic attenuation. The hypoattenuating regions are abnormal and reflect oligaemia. The vessels within the hypoattenuating regions are small (white arrow).

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