Skip to main content

Advertisement

SpringerLink
Log in

Pitfalls in the Diagnosis of Acute Pulmonary Embolism on Computed Tomography: Common Pathologic and Imaging Mimics

  • Chest Imaging (T Henry, Section Editor)
  • Published:
Current Radiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Acute pulmonary embolism (PE) is the third most-common acute cardiovascular disease in the United States. Nearly 900,000 new diagnoses are made each year, with 250,000 associated hospitalizations and up to 100,000 deaths (Palacio et al. in Semin Roentgenol 50(3):217–225, 2015; Metter et al. in Am J Roentgenol 208(3):489–494, 2017; Jaff et al. in Circulation 123(16):1788–830, 2011). Timely and accurate diagnosis of acute PE is crucial for the prevention of most deaths associated with PE, even more so than optimal medical therapy (Palacio et al. in Semin Roentgenol 50(3):217–225, 2015; Jaff et al. in Circulation 123(16):1788–830, 2011; Raja et al. in Ann Intern Med 163(9):701, 2015).

Recent Findings

Computed tomography (CT) has emerged as the primary imaging modality used in the diagnosis of acute PE. Thus, radiologists play a key role in the correct diagnosis of acute PE, and must differentiate this diagnosis from other conditions that mimic the imaging findings of acute PE, as well as from artifacts associated with imaging techniques (Palacio et al. in Semin Roentgenol 50(3):217–225, 2015; Jaff et al. in Circulation 123(16):1788–830, 2011; Raja et al. in Ann Intern Med 163(9):701, 2015). Understanding how these diagnoses present on CT is necessary for improved patient care.

Summary

This article will discuss the diagnosis of acute PE with CT, the diagnosis of diseases that may be mistaken for acute PE, and how to identify imaging artifacts that may be mistaken for an acute PE.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16

Similar content being viewed by others

References

Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. •Palacio D, Benveniste MF, Betancourt-Cuellar SL, Gladish GW. Multidetector computed tomography pulmonary angiography pitfalls in the evaluation of pulmonary embolism with emphasis in technique. Semin Roentgenol. 2015;50(3):217–225. https://doi.org/10.1053/j.ro.2015.01.012. Palacio et al. provide a thorough review of common imaging pitfalls in the diagnosis of acute PE, including diagnostic errors related to image acquisition and imaging artifacts.

  2. Metter D, Tulchinsky M, Freeman LM. Current status of ventilation-perfusion scintigraphy for suspected pulmonary embolism. Am J Roentgenol. 2017;208(3):489–94. https://doi.org/10.2214/AJR.16.17195.

    Article  Google Scholar 

  3. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788–830. https://doi.org/10.1161/CIR.0b013e318214914f.

    Article  PubMed  Google Scholar 

  4. Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of patients with suspected acute pulmonary embolism: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701. https://doi.org/10.7326/M14-1772.

    Article  PubMed  Google Scholar 

  5. Hartmann IJC, Wittenberg R, Schaefer-Prokop C. Imaging of acute pulmonary embolism using multi-detector CT angiography: an update on imaging technique and interpretation. Eur J Radiol. 2010;74(1):40–9. https://doi.org/10.1016/j.ejrad.2010.02.007.

    Article  PubMed  Google Scholar 

  6. Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology. 2010;256(1):32–61. https://doi.org/10.1148/radiol.10090908.

    Article  PubMed  Google Scholar 

  7. •Wijesuriya S, Chandratreya L, Medford AR. Chronic pulmonary emboli and radiologic mimics on CT pulmonary angiography: a diagnostic challenge. Chest. 2013;143(5):1460–1471. https://doi.org/10.1378/chest.12-1384. Wijesuriya et al. provide a comprehensive, updated review of the accurate diagnosis of CPTD on CT and how to differentiate CPTD from acute PE.

  8. Wittram C, Maher M, Yoo A, Mannudeep K, Shepard J-A, McLoud T. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. RadioGraphics. 2004;24(5):1219–38. https://doi.org/10.1148/rg.245045008.

    Article  PubMed  Google Scholar 

  9. ••Devaraj A, Sayer C, Sheard S, Grubnic S, Nair A, Vlahos I. Diagnosing acute pulmonary embolism with computed tomography: imaging update. J Thorac Imaging. 2015;30(3):176–192. https://doi.org/10.1097/rti.0000000000000146. Devaraj et al. provide an updated review of recent literature regarding the utilization of CTPA in the diagnosis of acute PE, including how to optimize CTPA image acquisition and avoid common imaging pitfalls in the diagnosis of acute PE.

  10. •Unal E, Balci S, Atceken Z, Akpinar E, Ariyurek OM. Nonthrombotic Pulmonary artery embolism: imaging findings and review of the literature. AJR Am J Roentgenol. 2017;208(3):505–516. https://doi.org/10.2214/ajr.16.17326. In this article, Unal et al. discuss common pathologic, nonthrombotic mimics of acute PE and how to differentiate these mimics from acute PE.

  11. Bach AG, Restrepo CS, Abbas J, et al. Imaging of nonthrombotic pulmonary embolism: biological materials, nonbiological materials, and foreign bodies. Eur J Radiol. 2013;82(3):e120–41. https://doi.org/10.1016/j.ejrad.2012.09.019.

    Article  PubMed  Google Scholar 

  12. Egermayer P, Peacock AJ. Is pulmonary embolism a common cause of chronic pulmonary hypertension? Limitations of the embolic hypothesis. Eur Respir J. 2000;15(3):440–8.

    Article  CAS  PubMed  Google Scholar 

  13. Lang IM, Pesavento R, Bonderman D. Yuan JX-J. Risk factors and basic mechanisms of chronic thromboembolic pulmonary hypertension: a current understanding. Eur Respir J. 2013;41(2):462–8. https://doi.org/10.1183/09031936.00049312.

    Article  PubMed  Google Scholar 

  14. Hasegawa I, Boiselle PM, Hatabu H. Bronchial artery dilatation on MDCT scans of patients with acute pulmonary embolism: comparison with chronic or recurrent pulmonary embolism. Am J Roentgenol. 2004;182(1):67–72. https://doi.org/10.2214/ajr.182.1.1820067.

    Article  Google Scholar 

  15. Ley S, Kreitner K-F, Morgenstern I, Thelen M, Kauczor H-U. Bronchopulmonary shunts in patients with chronic thromboembolic pulmonary hypertension: evaluation with helical CT and MR imaging. Am J Roentgenol. 2002;179(5):1209–15. https://doi.org/10.2214/ajr.179.5.1791209.

    Article  Google Scholar 

  16. Agarwal P, Wolfsohn A, Matzinger J, Peterson R, Dennie C. In situ central pulmonary artery thrombosis in primary pulmonary hypertension. Acta Radiol. 2005;46(7):696–700. https://doi.org/10.1080/02841850500215501.

    Article  CAS  PubMed  Google Scholar 

  17. Hoeper MM, Mayer E, Simonneau G, Rubin LJ. Chronic thromboembolic pulmonary hypertension. Circulation. 2006;113(16):2011–20. https://doi.org/10.1161/CIRCULATIONAHA.105.602565.

    Article  PubMed  Google Scholar 

  18. Kwek BH, Wittram C. Postpneumonectomy pulmonary artery stump thrombosis: CT features and imaging follow-up. Radiology. 2005;237(1):338–41. https://doi.org/10.1148/radiol.2371041686.

    Article  PubMed  Google Scholar 

  19. Ye R, Zhao L, Wang C, Wu X, Yan H. Clinical characteristics of septic pulmonary embolism in adults: a systematic review. Respir Med. 2014;108(1):1–8. https://doi.org/10.1016/j.rmed.2013.10.012.

    Article  PubMed  Google Scholar 

  20. Chen Y, Gilman MD, Humphrey KL, et al. Pulmonary artery pseudoaneurysms: clinical features and CT findings. AJR Am J Roentgenol. 2017;208(1):84–91. https://doi.org/10.2214/AJR.16.16312.

    Article  PubMed  Google Scholar 

  21. Saad NEA, Saad WEA, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. RadioGraphics. 2005;25(suppl_1):S173–89. https://doi.org/10.1148/rg.25si055503.

    Article  PubMed  Google Scholar 

  22. Kluge A, Luboldt W, Bachmann G. Acute pulmonary embolism to the subsegmental level: diagnostic accuracy of three MRI techniques compared with 16-MDCT. AJR Am J Roentgenol. 2006;187(1):W7–14. https://doi.org/10.2214/AJR.04.1814.

    Article  PubMed  Google Scholar 

  23. Hosch W, Schlieter M, Ley S, Heye T, Kauczor H-U, Libicher M. Detection of acute pulmonary embolism: feasibility of diagnostic accuracy of MRI using a stepwise protocol. Emerg Radiol. 2014;21(2):151–8. https://doi.org/10.1007/s10140-013-1176-y.

    Article  PubMed  Google Scholar 

  24. Salomon O, Leshem Y, Gluck I, Grossman E, Apter S, Konen E. Pseudo pulmonary embolism in cancer patients: a new clinical syndrome. Blood Coagul Fibrinolysis. 2014;25(8):871–5. https://doi.org/10.1097/MBC.0000000000000174.

    Article  CAS  PubMed  Google Scholar 

  25. Bandyopadhyay D, Panchabhai TS, Bajaj NS, Patil PD, Bunte MC. Primary pulmonary artery sarcoma: a close associate of pulmonary embolism—20-year observational analysis. J Thorac Dis. 2016;8(9):2592–601. https://doi.org/10.21037/jtd.2016.08.89.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Newbigin K, Souza CA, Torres C, et al. Fat embolism syndrome: state-of-the-art review focused on pulmonary imaging findings. Respir Med. 2016;113:93–100. https://doi.org/10.1016/j.rmed.2016.01.018.

    Article  PubMed  Google Scholar 

  27. Hoang JK, Lee WK, Hennessy OF. Multidetector CT pulmonary angiography features of pulmonary embolus. J Med Imaging Radiat Oncol. 2008;52(4):307–17. https://doi.org/10.1111/j.1440-1673.2008.01961.x.

    Article  CAS  PubMed  Google Scholar 

  28. Tay KL, Ridley LJ. Contrast column interruption artefact in computed tomography pulmonary angiography. Australas Radiol. 2005;49(4):338–41. https://doi.org/10.1111/j.1440-1673.2005.01447.x.

    Article  CAS  PubMed  Google Scholar 

  29. Martinez S, Heyneman LE, McAdams HP, Rossi SE, Restrepo CS, Eraso A. Mucoid impactions: finger-in-glove sign and other CT and radiographic features. RadioGraphics. 2008;28(5):1369–82. https://doi.org/10.1148/rg.285075212.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Washington University School of Medicine, St. Louis, MO, 63110, USA

    Caroline L. Robb

  2. Mallinckrodt Institute of Radiology, 510 S. Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA

    Sanjeev Bhalla & Constantine A. Raptis

Authors
  1. Caroline L. Robb
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sanjeev Bhalla
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Constantine A. Raptis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Constantine A. Raptis.

Ethics declarations

Conflict of interest

Caroline L. Robb, Sanjeev Bhalla, and Constantine A. Raptis: each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical collection on Chest Imaging.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Robb, C.L., Bhalla, S. & Raptis, C.A. Pitfalls in the Diagnosis of Acute Pulmonary Embolism on Computed Tomography: Common Pathologic and Imaging Mimics. Curr Radiol Rep 6, 14 (2018). https://doi.org/10.1007/s40134-018-0273-9

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s40134-018-0273-9

Keywords

Search

Navigation