PULMONARY EMBOLISM DEEP VENOUS THROMBOSIS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY PE AND DVT • • • • • • • • HISTORY AND PHYSICAL EXAMINATION LABORATORY TESTS CHEST RADIOGRAPHS NUCLEAR MEDICINE LUNG SCAN COMPUTED.
Download ReportTranscript PULMONARY EMBOLISM DEEP VENOUS THROMBOSIS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY PE AND DVT • • • • • • • • HISTORY AND PHYSICAL EXAMINATION LABORATORY TESTS CHEST RADIOGRAPHS NUCLEAR MEDICINE LUNG SCAN COMPUTED.
PULMONARY EMBOLISM DEEP VENOUS THROMBOSIS TERRENCE C. DEMOS, MD DEPARTMENT OF RADIOLOGY PE AND DVT • • • • • • • • HISTORY AND PHYSICAL EXAMINATION LABORATORY TESTS CHEST RADIOGRAPHS NUCLEAR MEDICINE LUNG SCAN COMPUTED TOMOGRAPHY SONOGRAPHY ANGIOGRAPHY MAGNETIC RESONANCE PULMONARY EMBOLUS VERSUS LUNG INFARCT • EMBOLUS RESULTS IN HEMORRHAGE • 90% DO NOT RESULT IN INFARCTION AND THE LUNG CLEARS BLOOD WITH NO RESIDUAL EFFECT • 10% HAVE A PERMANENT RESIDUAL DEFORMITY INDICATING INFARCTION PULMONARY EMBOLI - NO INFARCT LUNGS NORMAL 3 WEEKS LATER PULMONARY INFARCTS GROSS PATHOLOGY EVOLUTION OF INFARCT • EARLY- ILL DEFINED LUNG CONSOLIDATION – HEMORRHAGE AND EDEMA • LATER – BETTER DEFINED – PLEURAL BASED – TRUNCATED CONE SHAPE – MELTING SIGN – RETAINS ORIGINAL SHAPE WHILE GETTING SMALLER • OUTCOME – BECOMES LINE OPACITY, THICK PLEURA IN 3-6 WEEKS EVOLVING PULMONARY INFARCT PULMONARY INFARCT EVOLUTION HISTORY • CLASSIC (MASSIVE PE) • PLEURITIC PAIN, DYSPNEA, HEMOPTYSIS (20%) • TACHYPNEA, COUGH, APPREHENSION, FEVER, SYNCOPE • 1990 PIOPED STUDY • FREQUENCY OF SYMPTOMS SAME WHEN (+) OR (-) FOR PE RISK FACTORS • LOWER EXTREMITY VENOUS STASIS » IMMOBILIZATION • • • • POST OPERATIVE PATIENTS MALIGNANCY HEART DISEASE ESTROGEN CONTAINING COMPOUNDS • CONGENITAL COAGULATION ABNORMALITIES • PROTEIN S DEFICIENCY • PROTEIN C DEFICIENCY – LEIDEN FACTOR • ANTITHROMBIN III DEFICIENCY • ANTIPHOSPHOLIPED SYNDROME LABORATORY TESTS • LDH, SERUM BILIRUBIN, SGOT • (+) 20% OF PATIENTS WITH PE • FEVER, ELEVATED WBC • 25% PE & PRE-EXISTING HEART/ LUNG DISEASE pO2>80mm Hg • 10% HAD PE AND NORMAL A-a O2 GRADIENT (PIOPED STUDY) D-DIMER • SEMIQUANTITATIVE LATEX AGGLUTINATION (LA) – 98 PATIENTS WITH SUSPECTED PE STUDIED (D-DIMER, VQ SCAN, ANGIO) – 8/98 PATIENTS WITH NORMAL D-DIMER HAD PE ON ANGIOGRAMS • ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) – NEGATIVE PREDICTIVE VALUES 91-98% • CONCLUSION LA D-DIMER SHOULD NOT BE USED TO EVALUATE PATIENTS WITH SUSPECTED PE. CHEST RADIOGRAPH • ABNORMAL IN 85% OF PATIENTS • FINDING MOST OFTEN NONSPECIFIC – – – – PLEURAL BASED OPACITY PLEURAL EFFUSION LUNG CONSOLIDATION LOSS OF LUNG VOLUME • RADIOGRAPHS OF LIMITED VALUE • MAJOR IMPORTANCE IS TO IDENTIFY OTHER DISEASE MIMICING PE….. AND TO CORRELATE WITH V/Q SCAN PULMONARY INFARCT BILATERAL LUNG CONSOLIDATION MASSIVE PE SPARED UPPER LOBES PE AND PLEURAL BASED LESION 31/M POST-OP HERNIORRAPHY TACHYPNEA AND L PLEURITIC PAIN CHEST RADIOGRAPH THESE FINDINGS SUGGEST PE, BUT ARE UNCOMMON – ENLARGED HILUS —DUE TO CLOT IN VESSEL – WESTERMARK SIGN – HYPERLUCENCY AND DECREASED VESSELS – PLEURAL BASED ROUNDED OPACITY – HAMPTON’S HUMP PE WITH ENLARGED HILUS PE ENLARGED HILUS WESTERMARK SIGN HAMPTON’S HUMP V/Q LUNG SCAN PULMONARY EMBOLISM VENTILATION PERFUSION LUNG SCAN PERFUSION VENTILATION LUNG SCAN HIGH PROBABILITY V/Q LUNG SCAN SENSITIVE BUT NONSPECIFIC V/Q MISMATCHES (NONE TO 2 0R MORE LARGE SEGMENTAL) • HIGH PROBABILITY (13%) • PE > 80% *PE 96% * HIGH CLINICAL SUSPICION • INTERMEDIATE (39%) • LOW PROBABILITY (34%) • NORMAL (14%) • PE 20-79% • PE 0-19% *PE 4% * • PE < 2% LOW CLINICAL SUSPICION LOW PROB LUNG SCAN LOW PROBABILITY LUNG SCAN IMAGING PLUS CLINICAL PROBABILITY COMBINE HIGH OR LOW CLINICAL PROBABILITY WITH HIGH OR LOW PROBABILITY V/Q SCAN TO INCREASE THE ACCURACY OF V/Q SCAN AND DECREASE INDETERMINANT V/Q SCANS PIOPED STUDY JAMA 1990;263:2753-9 LOW PROB LUNG SCAN LUNG TRANSPLANTS LOW PROB LUNG SCAN CT ANGIOGRAPHY CENTRAL, LOBAR, SEGMENTAL VESSELS • SENSITIVITY > 90% • SPECIFICITY > 90% • INDETERMINENT 5% SUBSEGMENTAL – SENSITIVITY (L0W) SADDLE EMBOLUS SEGMENTAL EMBOLI SEGMENTAL EMBOLI SUBSEGMENTAL EMBOLI CT ANGIOGRAPHY • HELICAL (GE LightSpeed) CT – 1.25mm collimation, 6:1pitch, 4cc IVcontrast/sec • DIAGNOSTIC CRITERIA – PARTIAL OR COMPLETE FILLING DEFECTS – ( REFORMATTED IMAGES ) POST PARTUM DYSPNEA REFORMATTED IMAGE CT ANGIOGRAPHY PITFALLS • POOR VASCULAR ENHANCEMENT • BREATHING AND STREAK ARTIFACTS • DECREASE IN OVERALL ATTENUATION BETWEEN IMAGES • HILAR LYMPH NODES • SITE OF BIFURCATION OF ARTERIES • OBLIQUE VESSELS • PULMONARY VEINS • FLUID FILLED BRONCHI LYMPHADENOPATHY AND PE LYMPH NODES VERSUS PE FLUID FILLED BRONCHI REFORMATTED IMAGE ASPIRATION FLUID FILLED BRONCHUS BRONCHI VOLUME AVERAGING SIMULATES EMBOLI VESSEL BIFURCATION REFORMATED IMAGE PULMONARY EMBOLI LUNG PARENCHYMAL AND PLEURAL ABNORMALITIES • MOSAIC PATTERN – LARGER VESSELS IN HIGH ATTENUATION AREAS • HEMORRHAGE – GROUND GLASS OPACITY – CONSOLIDATION • PLEURAL BASED • TRIANGULAR TOWARD HILUS • PLEURAL EFFUSION PE LUNG PARENCHYMAL AND PLEURAL ABNORMALITIES MOSAIC PATTERN SMALL VESSEL OR SMALL AIRWAY DISEASE MOSAIC PATTERN NORMAL ANATOMY NORMAL ANATOMY PULMONARY EMBOLISM ANGIOGRAPHY ANGIOGRAPHY • HISTORICAL GOLD STANDARD • SUBSEGMENTAL EMBOLI – SUBSEGMENTAL OR MORE DISTAL EMBOLI 14/251 (6%) » (1990 PIOPED STUDY JAMA 1990 263;2753) – >50% INTEROBSERVER AGREEMENT » (AJR 1987149;469) – THE SIGNIFICANCE OF ISOLATED SUBSEGMENTAL EMBOLI IS UNKNOWN CENTRAL PULMONARY EMBOLUS ANGIOGRAM SELECTIVE ANGIOGRAM LOBAR EMBOLUS PULMONARY EMBOLISM MAGNETIC RESONANCE DEEP VENOUS THROMBOSIS SONOGRAPHY DVT • 50,000 PE DIAGNOSED PER YEAR • AUTOPSY STUDY... 80% UNDIAGNOSED • 200,000 DVT DIAGNOSED PER YEAR NORMAL FEMORAL VEINS SONOGRAPHY COMPRESSION NORMAL FEMORAL VEINS SONOGRAPHY COLOR DOPPLER SAPHENOUS VEIN CLOT SONOGRAPHY COMPRESSION AND DOPPLER DEEP VENOUS THROMBOSIS VENOGRAPHY DVT AND PE DVT AND PE VENOGRAM NO FILL OF POST TIBIAL VEINS DEEP VENOUS THROMBOSIS COMPUTED TOMOGRAPHY PE INFERIOR VENA CAVA CLOT FEMORAL VEIN CLOT AND PE POPLITEAL VEIN CLOT PULMONARY EMBOLI LEFT ATRIAL APPENDAGE CLOT HIPA POST AORTOCORONARY BYPASS SURG BYPASS CARDIOMYOPATHY SEGMENTAL EMBOLUS LEFT VENTRICULAR THROMBUS DEEP VENOUS THROMBOSIS MAGNETIC RESONANCE DEEP VENOUS THROMBOSIS PLETHESMOGRAPHY CHRONIC THROMBOEMBOLISM • PULMONARY ARTERY HYPERTENSION • ORGANIZED, RECANALIZED EMBOLI – VASCULAR ABNORMALITIES – – – – – – – – CENTRAL EMBOLI INTIMAL IRREGULARITY, WEBS, POST-STENOTIC DILATION MARKED VARIATION IN DIAMETER OF SEGMENTAL VESSELS ABRUPT NARROWING OF VESSELS POUCH-LIKE DEFECTS CALCIFIED PULMONARY ARTERIES BRONCHIAL ARTERY COLLATERAL VESSELS MOSAIC PATTERN OF LUNG PARENCHYMA CHRONIC PE PULMONARY HYPERTENSION WEBS CHRONIC PE CALCIFICATION AND WEBS CHRONIC PE IRREGULAR NARROWED PA CHRONIC PE MOSAIAC PATTERN AND WEBS CHRONIC PE CALCIFICATION CHRONIC RENAL FAILURE CALCIFIED PULMONARY INFARCTS DIAGNOSTIC EVALUATION SCHEMES BAKER WF Jr. MED CLINICS OF NA 1988;82:459-476 MICHIELS JJ SEM. IN THROMB & HEMOSTASIS 1998;24:413-417 TAI NRM BRITISH JOURNAL OF SURGERY 1999;86:853-868 RASKOB GE CURR OPINION IN HEMATOLOGY 1999;6;280-284 PATIENTS MASS-LIKE INFARCT HIGH DENSITY, MASS-LIKE INFARCT EVOLUTION HIGH DENSITY CLOT CT STUDIES 1 WEEK APART 55/M 2 MONTHS POST HEART TRANSPLANT PULMONARY ARTERY CATHETER INFARCT POST HEART TRANSPLANT SURGERY CAVITARY PULMONARY INFRARCT SUBACUTE BACTERIAL ENDOCARDITIS SEPTIC EMBOLIS TUMOR MICROEMBOLI INTRAVENOUS MERCURY INVASIVE ASPERGILLOSIS R/O POSTOP ABSCESS CHRONIC PE POSTOP COLOSTOMY DIVERTICULITIS