European Radiology

, Volume 22, Issue 2, pp 310–317 | Cite as

Diagnostic accuracy of contrast-enhanced MR angiography and unenhanced proton MR imaging compared with CT pulmonary angiography in chronic thromboembolic pulmonary hypertension

  • Smitha RajaramEmail author
  • Andrew J. Swift
  • David Capener
  • Adam Telfer
  • Christine Davies
  • Catherine Hill
  • Robin Condliffe
  • Charles Elliot
  • Judith Hurdman
  • David G. Kiely
  • Jim M. Wild
Magnetic Resonance



To evaluate the diagnostic accuracy of contrast-enhanced MR angiography (CE-MRA) and the added benefit of unenhanced proton MR angiography compared with CT pulmonary angiography (CTPA) in patients with chronic thromboembolic disease (CTE).


A 2 year retrospective study of 53 patients with chronic thromboembolic pulmonary hypertension who underwent CTPA and MRI for suspected pulmonary hypertension and a control group of 36 patients with no CT evidence of pulmonary embolism. The MRI was evaluated for CTE and the combined diagnostic accuracy of ce-MRA and unenhanced proton MRA was determined. CE-MRA generated lung perfusion maps were also assessed.


The overall sensitivity and specificity of CE-MRA in diagnosing proximal and distal CTE were 98% and 94%, respectively. The sensitivity improved from 50% to 88% for central vessel disease when CE-MRA images were analysed with unenhanced proton MRA. The CE-MRA identified more stenoses (29/18), post-stenosis dilatation (23/7) and occlusions (37/29) compared with CTPA. The CE-MRA perfusion images showed a sensitivity of 92% for diagnosing CTE.


CE-MRA has high sensitivity and specificity for diagnosing CTE. The sensitivity of CE-MRA for visualisation of adherent central and lobar thrombus significantly improves with the addition of unenhanced proton MRA which delineates the vessel wall.


Chronic thromboembolic pulmonary hypertension Pulmonary embolism Contrast-enhanced MR angiography Non-contrast-enhanced proton MR angiography Pulmonary hypertension 



The authors S.R. and D.C. are funded by Pfizer and Bayer respectively through unrestricted research grants. The UK EPSRC (J.M.W.) and the Sheffield Cardio Vascular Biomedical Research Unit (A.J.S.).


  1. 1.
    Riedel M, Stanek V, Widimsky J, Prerovsky I (1982) Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest 81:151–158PubMedCrossRefGoogle Scholar
  2. 2.
    Moser KM, Bloor CM (1993) Pulmonary vascular lesions occurring in patients with chronic major vessel thromboembolic pulmonary hypertension. Chest 103:685–692PubMedCrossRefGoogle Scholar
  3. 3.
    Pengo V, Lensing AW, Prins MH et al (2004) Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 350:2257–2264PubMedCrossRefGoogle Scholar
  4. 4.
    Wartski M, Collignon MA (2000) Incomplete recovery of lung perfusion after 3 months in patients with acute pulmonary embolism treated with antithrombotic agents. THESEE Study Group. Tinzaparin ou Heparin Standard: Evaluation dans l’Embolie Pulmonaire Study. J Nucl Med 41:1043–1048PubMedGoogle Scholar
  5. 5.
    Remy-Jardin M, Louvegny S, Remy J et al (1997) Acute central thromboembolic disease: posttherapeutic follow-up with spiral CT angiography. Radiology 203:173–180PubMedGoogle Scholar
  6. 6.
    Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L (1999) Pulmonary embolism: one-year follow-up with echocardiography doppler and five-year survival analysis. Circulation 99:1325–1330PubMedGoogle Scholar
  7. 7.
    Daily PO, Johnston GG, Simmons CJ, Moser KM (1980) Surgical management of chronic pulmonary embolism: surgical treatment and late results. J Thorac Cardiovasc Surg 79:523–531PubMedGoogle Scholar
  8. 8.
    Jamieson SW, Auger WR, Fedullo PF et al (1993) Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period. J Thorac Cardiovasc Surg 106:116–126, discussion 126–117PubMedGoogle Scholar
  9. 9.
    Kauczor HU, Schwickert HC, Mayer E, Schweden F, Schild HH, Thelen M (1994) Spiral CT of bronchial arteries in chronic thromboembolism. J Comput Assist Tomogr 18:855–861PubMedCrossRefGoogle Scholar
  10. 10.
    Wittram C, Kalra MK, Maher MM, Greenfield A, McLoud TC, Shepard JA (2006) Acute and chronic pulmonary emboli: angiography-CT correlation. AJR Am J Roentgenol 186:S421–S429PubMedCrossRefGoogle Scholar
  11. 11.
    Remy-Jardin M, Remy J, Wattinne L, Giraud F (1992) Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique–comparison with pulmonary angiography. Radiology 185:381–387PubMedGoogle Scholar
  12. 12.
    Kreitner KF, Kunz RP, Ley S et al (2007) Chronic thromboembolic pulmonary hypertension—assessment by magnetic resonance imaging. Eur Radiol 17:11–21PubMedCrossRefGoogle Scholar
  13. 13.
    Kreitner KF, Ley S, Kauczor HU et al (2004) Chronic thromboembolic pulmonary hypertension: pre- and postoperative assessment with breath-hold MR imaging techniques. Radiology 232:535–543PubMedCrossRefGoogle Scholar
  14. 14.
    Lisbona R, Kreisman H, Novales-Diaz J, Derbekyan V (1985) Perfusion lung scanning: differentiation of primary from thromboembolic pulmonary hypertension. AJR Am J Roentgenol 144:27–30PubMedGoogle Scholar
  15. 15.
    Ryan KL, Fedullo PF, Davis GB, Vasquez TE, Moser KM (1988) Perfusion scan findings understate the severity of angiographic and hemodynamic compromise in chronic thromboembolic pulmonary hypertension. Chest 93:1180–1185PubMedCrossRefGoogle Scholar
  16. 16.
    Stein PD, Athanasoulis C, Alavi A et al (1992) Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation 85:462–468PubMedGoogle Scholar
  17. 17.
    Bergin CJ, Sirlin CB, Hauschildt JP et al (1997) Chronic thromboembolism: diagnosis with helical CT and MR imaging with angiographic and surgical correlation. Radiology 204:695–702PubMedGoogle Scholar
  18. 18.
    Schwickert HC, Schweden F, Schild HH et al (1994) Pulmonary arteries and lung parenchyma in chronic pulmonary embolism: preoperative and postoperative CT findings. Radiology 191:351–357PubMedGoogle Scholar
  19. 19.
    Ley S, Grunig E, Kiely DG, van Beek E, Wild J (2010) Computed tomography and magnetic resonance imaging of pulmonary hypertension: pulmonary vessels and right ventricle. J Magn Reson Imaging 32:1313–1324PubMedCrossRefGoogle Scholar
  20. 20.
    Sergiacomi G, Bolacchi F, Cadioli M et al (2010) Combined pulmonary fibrosis and emphysema: 3D time-resolved MR angiographic evaluation of pulmonary arterial mean transit time and time to peak enhancement. Radiology 254:601–608PubMedCrossRefGoogle Scholar
  21. 21.
    Ohno Y, Hatabu H, Murase K et al (2007) Primary pulmonary hypertension: 3D dynamic perfusion MRI for quantitative analysis of regional pulmonary perfusion. AJR Am J Roentgenol 188:48–56PubMedCrossRefGoogle Scholar
  22. 22.
    Ley S, Kreitner KF, Morgenstern I, Thelen M, Kauczor HU (2002) Bronchopulmonary shunts in patients with chronic thromboembolic pulmonary hypertension: evaluation with helical CT and MR imaging. AJR Am J Roentgenol 179:1209–1215PubMedGoogle Scholar
  23. 23.
    Jahnke C, Paetsch I, Schnackenburg B et al (2004) Coronary MR angiography with steady-state free precession: individually adapted breath-hold technique versus free-breathing technique. Radiology 232:669–676PubMedCrossRefGoogle Scholar
  24. 24.
    Deshpande VS, Shea SM, Laub G, Simonetti OP, Finn JP, Li D (2001) 3D magnetization-prepared true-FISP: a new technique for imaging coronary arteries. Magn Reson Med 46:494–502PubMedCrossRefGoogle Scholar
  25. 25.
    Hui BK, Noga ML, Gan KD, Wilman AH (2005) Navigator-gated three-dimensional MR angiography of the pulmonary arteries using steady-state free precession. J Magn Reson Imaging 21:831–835PubMedCrossRefGoogle Scholar
  26. 26.
    Ley S, Kauczor HU, Heussel CP et al (2003) Value of contrast-enhanced MR angiography and helical CT angiography in chronic thromboembolic pulmonary hypertension. Eur Radiol 13:2365–2371PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2011

Authors and Affiliations

  • Smitha Rajaram
    • 1
    • 5
    Email author
  • Andrew J. Swift
    • 1
    • 4
  • David Capener
    • 1
  • Adam Telfer
    • 1
  • Christine Davies
    • 3
  • Catherine Hill
    • 3
  • Robin Condliffe
    • 2
    • 4
  • Charles Elliot
    • 2
    • 4
  • Judith Hurdman
    • 2
  • David G. Kiely
    • 2
    • 4
  • Jim M. Wild
    • 1
    • 4
  1. 1.Unit of Academic Radiology, University of SheffieldSheffieldUK
  2. 2.Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
  3. 3.Department of RadiologySheffield Teaching Hospitals TrustSheffieldUK
  4. 4.Sheffield Cardiovascular Biomedical Research UnitSheffieldUK
  5. 5.Academic Unit of Radiology, C Floor, Royal Hallamshire HospitalSheffieldUK

Personalised recommendations