Corroboration of Spiral CT angiography with D-dimer Assays in the accurate diagnosis of Pulmonary Embolism with assessment of its Image quality
Pulmonary embolism is a frequent cause of mortality and morbidity. Aim of this study was to evaluate the utility of spiral computed tomographic angiography in determining the prevalence of pulmonary embolism in a clinically suspicious group and to assess the image quality of a single source computed tomography in diagnosis of pulmonary embolism. We have also investigated the reliability of D-dimer test in ruling out pulmonary embolism.
Materials and Methods:
50 patients clinically suspected of having pulmonary embolism were examined with contrast-enhanced spiral computed tomography in the hospital affiliated to Zhengzhou University from August 2014 to December 2015.
Image quality, was assessed by analyzing the attenuation in the pulmonary trunk and its branches in comparison with the background noise. Mean attenuation values and standard deviation were recorded and displayed in Hounsfield Units. The computed tomography values, standard deviation values and signal-noise ratio obtained were then statistically analyzed using SPSS 17.0 software.
D-dimer test results were also obtained for the patients suspected of pulmonary embolism using rapid D-dimer testing and a reference range of 0–0.3 µg/l was considered as normal.
Spiral computed tomography was a valuable method for identifying 20 patients with pulmonary embolism (sensitivity, 100%). It could correctly exclude pulmonary embolism in 28 out of 30 non - pulmonary embolism cases yielding a specificity of 94%.In 10 of the 20 patients devoid of pulmonary embolism; Spiral computed tomography provided an alternate clinical diagnosis. In the remaining 10 patients, spiral computed tomographic angiography scans were normal. The statistical analysis of the computed tomography values standard deviation and signal-noise ratio of the pulmonary trunk and pulmonary artery (without right or left predilection) showed a p-value>0.05. D-dimer Test showed elevated levels in 18 patients who were diagnosed with pulmonary embolism on spiral computed tomography scans. 8 patients without pulmonary embolism on spiral computed tomography scans also showed elevated D-dimer levels. The remaining 22 patients had normal D-dimer levels.
Spiral computed tomography has a good sensitivity and specificity for the diagnosis of pulmonary embolism. In the majority of patients who did not have pulmonary embolism, it provided important ancillary information for the final diagnosis.
Therefore, combining Spiral computed tomography scan with a D-dimer Test is more effective in the accurate diagnosis of pulmonary embolism.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL; ESC Scientific Document Group . 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2019; 31 (1)
Wendelboe AM, Raskob GE. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res. 2016 Apr 29:1340-1347. (2)
Zhang LJ, Zhao YE, Wu SY, Yeh BM, Zhou CS, Hu XB, Hu QJ, Lu GM. Pulmonary embolism detection with dual-energy CT: experimental study of dual-source CT in rabbits. Radiology. 2009 Jul;252:61-70 (3)
Huisman MV, Barco S, Cannegieter SC, Le Gal G, Konstantinides SV, Reitsma PH, Rodger M, Vonk Noordegraaf A, Klok FA. Pulmonary embolism. Nat Rev Dis Primers. 2018 May 17;4:18028.(4)
van Erkel AR, van Rossum AB, Bloem JL, Kievit J, Pattynama PM. Spiral CT angiography for suspected pulmonary embolism: a cost-effectiveness analysis. Radiology. 1996 Oct;201:29-36. (5)
Bauer RW, Kerl JM, Weber E, Weisser P, Korkusuz H, Lehnert T, Jacobi V, Vogl TJ (2010) Lung perfusion analysis with dual energy CT in patients with suspected PE-influence of window settings on the diagnosis of underlying pathologies of perfusion defects. Eur J Radiol. doi:10.1016/j. ejrad.2010.09.009 (6)
Bjorkdahl P, Nyman U (2010) Using 100- instead of 120-kVp computed tomography to diagnose PE almost halves the radiation dose with preserved diagnostic quality. ActaRadiol (7) 51:260-270
Bounameaux H, Perrier A, Righini M. Diagnosis of venous thromboembolism: an update. Vasc Med 2010;15(8):399-406
Carrier M, Righini M, Wells PS, et al. Subsegmental PE diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J ThrombHaemost 2010;8(9): 1716-1722
Kooiman J, Klok FA, Mos IC, et al. Incidence and predictors of contrast-induced nephropathy following CT-angiography for clinically suspected acute PE. J ThrombHaemost 2010;8(10):409-411
Mamlouk MD, vanSonnenberg E, Gosalia R, et al. PE at CT angiography: implications for appropriateness, cost, and radiation exposure in 2003 patients. Radiology 2010;256 (11):625-632
Stein PD, Chenevert TL, Fowler SE, et al; PIOPED III (Prospective Investigation of PE Diagnosis III) Investigators. Gadolinium-enhanced magnetic resonance angiography for PE: a multicenter prospective study (PIOPED III). Ann Intern Med 2010;152(12):434-443, W142-3
Pontana F, Remy-Jardin M, Duhamel A, Faivre JB, Wallaert B, Remy J (2010) Lung perfusion with dual-energy multi-detector row CT: can it help recognize ground glass opacities of vascular origin? AcadRadiol (13)17:587-594
Bjorkdahl P, Nyman U (2010) Using 100- instead of 120-kVp computed tomography to diagnose PE almost halves the radiation dose with preserved diagnostic quality. ActaRadiol (14) 51:260-270
Stein PD , Matta F , Musani MH , Diaczok B . Silent pulmo- nary embolism in patients with deep venous thrombosis: a systematic review . Am J Med .2010 ; 123 ( 15 ): 426-431 .
CerianiE ,Combescure C , Le Gal G , et al . Clinical prediction rules for PE: a systematic review and meta- analysis . J ThrombHaemost .2010 ; 8 (16 ): 957 - 970 .
Smith SB ,Geske JB , Maguire JM , Zane NA , Carter RE , M orgenthaler T I. E arly anticoagulation is associated with reduced mortality for acute PE . Chest. 2 010; 137 (17): 1382-1390 .
Douma RA , le Gal G , Söhne M , et al . Potential of an age adjusted cut-off value to improve the exclusion of PE in older patients: a retrospective analysis of three large cohorts .BMJ .2010 (18) ; 340 : c1475 .
Carrier M , R ighini M , W ells P S, e t al. S ubsegmentalpulmo- nary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta- analysis of the management outcome studies . J ThrombHaemost .2010 ; 8 ( 19 ): 1716-1722
Pasha S M, K lok F A, S noep J D, e t al. S afety of excluding acute PE based on an unlikely clinical probability by the Wells rule and normal concentration: a meta- analysis .ThrombRes .2010 ; 125 ( 20 ): e123 - e127 .
Meyer G, Roy PM, Gilberg S, Perrier A. PE. BMJ 2010 (21);340:c1421
Courtney DM, Kline JA, Kabrhel C, Moore CL, Smithline HA, Nordenholz KE. et al. Clinical features from the history and physical examination that predict the presence or absence of PE in symptomatic emergency department patients: results of a prospective, multicenter study. Ann Emerg Med. 2010;55(22):307-315
Agnelli G ,Becattini C . Acute PE .N Engl J Med .2010 ; 363 (2 3 ): 266 - 274 .
LIU XIAO-BO,LIU JIN-GANG,LIU LI-QUN,et al(Department of Cardiothoracic Surgery,Hospital Affiliated to Weifang Medical College,Weifang 261031,China);THE EFFECT OF CT ON THE THERAPY OF PE[J];ActaAcademiaeMedicinae Qingdao Universitatis; (24) 2010-06
HUANG Ze-He,ZHONG De-Jun,JIANGSheng,et al Dept.ofRadiology,Qinzhou First People's Hospital,Qinzhou 535000,China;Diagnosis value of multi-slice spiral CT angiography to PE[J];ActaMedicinae Sinica (25);2010-03
Engbers MJ, van HylckamaVlieg A, Rosendaal FR. Venous thrombosis in the elderly: incidence, risk factors and risk groups. J ThrombHaemost 2010-8(26):
Douma RA, le Gal G, SöhneM, et al. Potential of an age adjusted cut-off value to improve the exclusion of PE in older patients: a retrospective analysis of three large cohorts. BMJ 2010;340:c1475 (27) doi: 10.1136/bmj.c1475
Chae EJ, Seo JB, JangYM, et al. Dual-energy CT for assessment of the severity of acute PE: pulmonary perfusion defect score compared with CT angiographic obstruction score and right ventricular/left ventricular diameter ratio. AJR Am J Roentgenol 2010;194(28):604-610
GalipienzoJ , García de Tena J , Flores J , Alvarez C , Alonso- Viteri S , Ruiz A . Safety of withholding anticoagulant therapy in patients with suspected PE with a negative multislice computed tomography pulmonary angiogra- phy .Eur J Intern Med .2010 ; 21 ( 29 ): 283 -288 .
Salaun P Y, C outuraudF , L E Duc-Pennec A , e t al. N on- invasive diagnosis of PE. Chest. 2011; 1 39( 30 ) : 1294 - 1298 .
ZHOUZhi-peng,WANGHai-long,DU Zhen-zong,etal.Department of Radiology,Affiliated Hospital of Guilin Medical College,Guangxi541001,P.R.China;Study of chronic pulmonary thromboembolism model in rabbits with 64-slice spiral CT[J];Radiologic Practice; (31) 2011-04
Davies HE, Wathen CG, Gleeson FV. Risks of exposure to radiological imaging and how to minimise them.BMJ.2011 (32);342:589-593.
den Exter PL, Hooijer J, Dekkers OM, Huisman MV. Risk of recurrent venous thromboembolism and mortality in patients with cancer incidentally diagnosed with PE: a comparison with symptomatic patients. J ClinOncol 2011;29(33): 2405-2409.
QuirozR , K ucher N , Z ou K H, e t al. C linical validity of a negative computed tomography scan in patients with sus- pected PE: a systematic review . JAMA. 2012; 293 ( 34 ): 2011 .
Blachere H, Latrabe V, Montaudon M, et al. PE revealed on helical CT angiography: comparison with ventilation-perfusion radionuclide lung scanning. AJR Am J Roentgenol 2011;(35) 174:1041-1047.
Greess H, Wolf H, Baum U et al. Dose reduction in computed tomography by attenuation-based online modulation of tube current: evaluation of six anatomical regions. EurRadiol 2011; (36)10:391-394.
Ghaye B, Szapiro D, I. Mastora et al. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis? Radiology 2011; (37)219:629-636
Coche EE, Hammer FD, Goffette PP. Demonstration of pulmonary embolism with dynamic gadolinium-enhanced spiral CT. EurRadiol 2011; (38)11:2306-2309.
Mastora I, Remy-Jardin M, Suess C et al. Dose reduction in spiral ct angiography of thoracic outlet syndrome by anatomically adapted tube current modulation. EurRadiol 2011; (39)11:590-596.
Crawford T, Yoon C, Wolfson K, et al. The effect of imaging modality on patient management in the evaluation of pulmonary thromboembolism. J Thorac Imaging 2011; (40)16:163-169.
Koenig SJ, Narasimhan M, Mayo PH. Thoracic ultrasonography for the pulmonary specialist. Chest. 2011;140(41):1332-1341
Kory PD, Pellecchia CM, Shiloh A, Mayo PH, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139(42):538-542
MacKenzie JD, Nazario-Larrieu J, Cai T, Ledbetter MS, Duran- Mendicuti MA, Judy PF, Rybicki FJ (2011) Reduced-dose CT: effect on reader evaluation in detection of PE. Am J Roentgenol (43)189:1371-1379
ZHANG Yong-kang 1, LIU Yun 2*, CHEN De-jie 1, LIAO Xiao-feng 1, WANG Jiang-ping 1, HUANG Hua-jun 1. Department of General Surgery 1, Department of Obstetrics and Gynecology 2, the Central Hospital of Xiangyang City, Xiangyang 441021, Hubei, CHINA;Diagnostic and therapeutic experiences of 22 cases of acute mesenteric ischemia[J];Hainan Medical Journal; (44) 2012-23
Zhang Li,ZengWenbing,WangMingquan,HeZeqing,LiuXinghua,TanQinghua(Diagnostic Center of CT and MR,ChongqingSanxia Central Hospital,Wanzhou,Chongqing 404000,China(45));MSCT pulmonary angiography in the diagnosis of PE applied research(with 22 cases analysis)[J];Chongqing Medicine;2012-24
Dunn et al, Wolf JP, Dorfman DM, Fitzpatrick P, Baker JL, Goldhaber SZ. Normal levels in emergency department patients suspected of acute PE.J Am CollCardiol.2012;40(46):1475–1478. doi: 10.1016/S0735-1097(02)02172-1
Revel MP, Sanchez O, Couchon S, et al. Diagnostic accuracy of magnetic resonance imaging for acute PE: results of the "IRM-EP" study. J ThrombHaemost 2012 Feb 9. (47) doi:10.1111/j.1538-7836.2012.o4652.
Prologo JD, Glauser J. Variable diagnostic approach to suspected PE in the ED of a major academic tertiary care center. Am J Emerg Med 2012 (48); 20:5-9.
Schoepf U, Holzknecht N, Helmberger TK, et al. Subsegmental pulmonary emboli: improved detection with thin-collimation multi–detector row spiral CT. Radiology 2012 (49); 222:483-490.
Leveau P. Diagnostic strategy in PE. National French survey.Presse Med 2012 (50); 31:929-932.
LIULian-rong,FANYong,ZHAOXin-qian,XINGZhi-hengDept of radiology,TianjinHaihe hospital 300350,China;The Diagnostic Values of Multi-slice Spiral CT Pulmonary Angiography in PE[J];Journal of Clinical Pulmonary Medicine (51);2012-03
Sheh SH, Bellin E, Freeman KD, Haramati LB. PE diagnosis and mortality with pulmonary CT angiography versus ventilation-perfusion scintigraphy: evidence of overdiagnosis with CT?.AJR Am J Roentgenol. 2012 Jun. 198(52):1340-5.
Alderson P. O., Martin E. C.PE: diagnosis with multiple imaging modalities. Radiology 2012 (53)
in the diagnostic workup of suspected pulmonary thrombo-embolism at high altitude.Medical Journal Armed Forces India68, 142-144. Online publication date: 1-Apr-2012 (54).
Chandra S, Sarkar PK, Chandra D, Ginsberg NE, Cohen RI. Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography. BMC Pulm Med. 2013 (55);13:9.
PEI Guang-hua,ZENG Chun Department of Radiology Songzi People′s Hospital,Jingzhou,Hubei 434200,China;Clinical value of 16-slice spiral CT in the diagnosis of PE[J];Journal of Clinical Pulmonary Medicine (56);2013-06
Hirai LK, Takahashi JM, Yoon HC. A prospective evaluation of a quantitative assay in the evaluation of acute PE.J VascIntervRadiol.2013;18(57):970-974. doi: 10.1016/j.jvir.2013.04.020.
Marten K, Engelke C, Obenauer S et al. Diagnostic performance of retrospectively ecg-gated multislice CT of acute pulmonary embolism, DiagnostischerStellenwert der retrospektiven EKG-Triggerung in der Mehrschicht-Spiral-CT der akutenLungenembolie. FortschrR”ntgenstr 2013 (58); 175:1490-1495.
Chaye B, Remy –Jardin M. Non traumatic thoracic emergencies: CT diagnosis of acute PE : the 1st 10 years in : BaertA.L,Gourtsoyiannis N. Emergency Radiology Categorial courses ECR, Germany : Springer-Verlag Berlin Heidelberg 2013 (59):231:231-246.
The PIOPED Investigators Value of the ventilation/perfusion scan in acute PE.J.A.M.A. 2013(60).
PE manifested as acute coronary syndrome after arthroscopic anterior cruciate ligament reconstruction.Formosan Journal of Musculoskeletal DisordersOnline publication date: 1-Aug-2013(61).
Stein P. D., Hull R. D., Saltzman H. A., PineoG.Strategy for diagnosis of patients with suspected acute PE.Chest 2013 (62)
Bounameaux H., de Moerloose P., Perrier A., ReberG.Plasma measurement ofas diagnostic aid in suspected venous thromboembolism: an overview.Thromb. Haemost; 2014-06(63)
Ginsberg J. S., Brill-Edwards P. A., Demers C., Donovan D., Panju A. in patients with clinically suspected PE.Chest 2014 (64)
Pulmonary Embolism Incidence and Fatality Trends in Chinese Hospitals from 1997 to 2008(65): A Multicenter Registration Study
Bagaria V, Modi N, Panghate A, et al. Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study. Postgrad Med J. 2006 (66);82:136-9.
This work is licensed under a Creative Commons Attribution 4.0 International License.