Dual-energy CT for differentiating acute and chronic pulmonary thromboembolism: an initial experience

  • Seung-seob Kim
  • Jin HurEmail author
  • Young Jin Kim
  • Hye-Jeong Lee
  • Yoo Jin Hong
  • Byoung Wook Choi
Original Paper


The purpose of this study was to prospectively evaluate the diagnostic capability of single-phase dual-energy CT (DECT) angiography to differentiate acute and chronic pulmonary thromboembolism (APTE, CPTE). We prospectively enrolled 26 patients (M:F = 9:17; mean age, 61 years old) with a filling defect in the pulmonary artery on DECT angiography. They were divided into two groups—APTE and CPTE—based on the clinical criteria. Two investigators quantitatively measured the following parameters at the embolism and main pulmonary artery: CT attenuation density [Hounsfield unit (HU) values], iodine-related HU value (IHU), and iodine concentration (IC, mg/ml). These parameters of the embolism and their ratio divided by those of the main pulmonary artery were compared between APTE and CPTE groups. Among 26 patients, 15 were categorized into the APTE group and 11 into the CPTE group. The mean HU, IHU, and IC values of emboli were significantly different between the APTE and CPTE groups (32.2 ± 17.0 vs. 52.1 ± 13.6 HU; P = 0.016, 7.2 ± 2.8 vs. 27.3 ± 12.7 HU; P < 0.001, and 0.57 ± 0.23 vs. 1.56 ± 0.67; P < 0.001). The mean HU, IHU, and IC ratios between emboli and main pulmonary arteries were also significantly different between the two groups (0.085 ± 0.046 vs. 0.156 ± 0.064 HU; P = 0.003, 0.023 ± 0.013 vs. 0.099 ± 0.053; P < 0.001, and 0.048 ± 0.035 vs. 0.130 ± 0.064; P = 0.001). DECT angiography using a quantitative analytic methodology can be used to differentiate between APTE and CPTE.


Dual energy computed tomography (DECT) Acute pulmonary thromboembolism (APTE) Chronic pulmonary thromboembolism (CPTE) Embolus Quantitative analysis 



Acute pulmonary thromboembolism


Chronic pulmonary thromboembolism


Dual energy computed tomography


Hounsfield unit


Iodine-related HU


Iodine concentration


Main pulmonary artery


Pulmonary artery


Pulmonary thromboembolism


Region of interest


Conflict of interest

The authors report no conflict of interest regarding this manuscript.


  1. 1.
    Wittram C, Meehan MJ, Halpern EF, Shepard JA, McLoud TC, Thrall JH (2004) Trends in thoracic radiology over a decade at a large academic medical center. J Thorac Imaging 19(3):164–170PubMedCrossRefGoogle Scholar
  2. 2.
    Mayo J, Thakur Y (2014) Acute pulmonary embolism: from morphology to function. Semin Respir Crit Care Med 35(1):41–49PubMedCrossRefGoogle Scholar
  3. 3.
    Mayo J, Thakur Y (2013) Pulmonary CT angiography as first-line imaging for PE: image quality and radiation dose considerations. AJR Am J Roentgenol 200(3):522–528PubMedCrossRefGoogle Scholar
  4. 4.
    Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD (2007) Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 245(2):315–329PubMedCrossRefGoogle Scholar
  5. 5.
    Wagenvoort CA (1995) Pathology of pulmonary thromboembolism. Chest 107(1 Suppl):10S–17SPubMedCrossRefGoogle Scholar
  6. 6.
    Jamieson SW, Auger WR, Fedullo PF, Channick RN, Kriett JM, Tarazi RY, Moser KM (1993) Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period. J Thorac Cardiovasc Surg 106(1):116–126 discussion 126–117PubMedGoogle Scholar
  7. 7.
    Jamieson SW, Kapelanski DP, Sakakibara N, Manecke GR, Thistlethwaite PA, Kerr KM, Channick RN, Fedullo PF, Auger WR (2003) Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 76(5):1457–1462 discussion 1462–1454PubMedCrossRefGoogle Scholar
  8. 8.
    Morris TA (2013) Why acute pulmonary embolism becomes chronic thromboembolic pulmonary hypertension: clinical and genetic insights. Curr Opin Pulm Med 19(5):422–429PubMedGoogle Scholar
  9. 9.
    Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F, Albanese P, Biasiolo A, Pegoraro C, Iliceto S, Prandoni P, Thromboembolic Pulmonary Hypertension Study G (2004) Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 350(22):2257–2264PubMedCrossRefGoogle Scholar
  10. 10.
    Klok FA, Mos IC, van Kralingen KW, Vahl JE, Huisman MV (2012) Chronic pulmonary embolism and pulmonary hypertension. Semin Respir Crit Care Med 33(2):199–204PubMedCrossRefGoogle Scholar
  11. 11.
    Hasegawa I, Boiselle PM, Hatabu H (2004) Bronchial artery dilatation on MDCT scans of patients with acute pulmonary embolism: comparison with chronic or recurrent pulmonary embolism. AJR Am J Roentgenol 182(1):67–72PubMedCrossRefGoogle Scholar
  12. 12.
    Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JA, McLoud TC (2004) CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics 24(5):1219–1238PubMedCrossRefGoogle Scholar
  13. 13.
    Wittram C, Maher MM, Halpern EF, Shepard JA (2005) Attenuation of acute and chronic pulmonary emboli. Radiology 235(3):1050–1054PubMedCrossRefGoogle Scholar
  14. 14.
    Sherrick AD, Swensen SJ, Hartman TE (1997) Mosaic pattern of lung attenuation on CT scans: frequency among patients with pulmonary artery hypertension of different causes. AJR Am J Roentgenol 169(1):79–82PubMedCrossRefGoogle Scholar
  15. 15.
    Azarian R, Wartski M, Collignon MA, Parent F, Herve P, Sors H, Simonneau G (1997) Lung perfusion scans and hemodynamics in acute and chronic pulmonary embolism. J Nucl Med 38(6):980–983PubMedGoogle Scholar
  16. 16.
    Johnson TR, Krauss B, Sedlmair M, Grasruck M, Bruder H, Morhard D, Fink C, Weckbach S, Lenhard M, Schmidt B, Flohr T, Reiser MF, Becker CR (2007) Material differentiation by dual energy CT: initial experience. Eur Radiol 17(6):1510–1517PubMedCrossRefGoogle Scholar
  17. 17.
    Lu GM, Zhao Y, Zhang LJ, Schoepf UJ (2012) Dual-energy CT of the lung. AJR Am J Roentgenol 199(5 Suppl):S40–S53PubMedCrossRefGoogle Scholar
  18. 18.
    Takahashi N, Hartman RP, Vrtiska TJ, Kawashima A, Primak AN, Dzyubak OP, Mandrekar JN, Fletcher JG, McCollough CH (2008) Dual-energy CT iodine-subtraction virtual unenhanced technique to detect urinary stones in an iodine-filled collecting system: a phantom study. AJR Am J Roentgenol 190(5):1169–1173PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Fedullo PF, Rubin LJ, Kerr KM, Auger WR, Channick RN (2000) The natural history of acute and chronic thromboembolic disease: the search for the missing link. Eur Respir J 15(3):435–437PubMedCrossRefGoogle Scholar
  20. 20.
    Fedullo P, Kerr KM, Kim NH, Auger WR (2011) Chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med 183(12):1605–1613PubMedCrossRefGoogle Scholar
  21. 21.
    Fink C, Johnson TR, Michaely HJ, Morhard D, Becker C, Reiser M, Nikolaou K (2008) Dual-energy CT angiography of the lung in patients with suspected pulmonary embolism: initial results. Rofo 180(10):879–883PubMedGoogle Scholar
  22. 22.
    Geyer LL, Scherr M, Korner M, Wirth S, Deak P, Reiser MF, Linsenmaier U (2012) Imaging of acute pulmonary embolism using a dual energy CT system with rapid kVp switching: initial results. Eur J Radiol 81(12):3711–3718PubMedCrossRefGoogle Scholar
  23. 23.
    Hoey ET, Gopalan D, Ganesh V, Agrawal SK, Qureshi N, Tasker AD, Clements L, Screaton NJ (2009) Dual-energy CT pulmonary angiography: a novel technique for assessing acute and chronic pulmonary thromboembolism. Clin Radiol 64(4):414–419PubMedCrossRefGoogle Scholar
  24. 24.
    Lu GM, Wu SY, Yeh BM, Zhang LJ (2010) Dual-energy computed tomography in pulmonary embolism. Br J Radiol 83(992):707–718PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Pontana F, Faivre JB, Remy-Jardin M, Flohr T, Schmidt B, Tacelli N, Pansini V, Remy J (2008) Lung perfusion with dual-energy multidetector-row CT (MDCT): feasibility for the evaluation of acute pulmonary embolism in 117 consecutive patients. Acad Radiol 15(12):1494–1504PubMedCrossRefGoogle Scholar
  26. 26.
    Ko JP, Brandman S, Stember J, Naidich DP (2012) Dual-energy computed tomography: concepts, performance, and thoracic applications. J Thorac Imaging 27(1):7–22PubMedCrossRefGoogle Scholar
  27. 27.
    Wu HW, Cheng JJ, Li JY, Yin Y, Hua J, Xu JR (2012) Pulmonary embolism detection and characterization through quantitative iodine-based material decomposition images with spectral computed tomography imaging. Invest Radiol 47(1):85–91PubMedCrossRefGoogle Scholar
  28. 28.
    Menzel H, Schibilla H, Teunen D (2000) European guidelines on quality criteria for computed tomography. Publication No. EUR 16262 EN. European Commission, LuxembourgGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Seung-seob Kim
    • 1
  • Jin Hur
    • 1
    Email author
  • Young Jin Kim
    • 1
  • Hye-Jeong Lee
    • 1
  • Yoo Jin Hong
    • 1
  • Byoung Wook Choi
    • 1
  1. 1.Department of Radiology, Research Institute of Radiological Science, Severance HospitalYonsei University College of MedicineSeoulSouth Korea

Personalised recommendations