RESUMO
INTRODUCTION: Pulmonary infarction is a common sequela of pulmonary embolism (PE) but lacks a diagnostic reference standard. CTPA in the setting of acute PE does not reliably differentiate infarction from other consolidations, such as reversible alveolar hemorrhage or atelectasis. We aimed to assess the diagnostic accuracy for recognizing pulmonary infarction on CT in the acute phase of PE, with follow-up CT as reference. MATERIALS AND METHODS: Initial and follow-up CT scans of 33 patients with acute PE were retrospectively assessed. Two radiologists independently evaluated the presence and size of suspected pulmonary infarction on the initial CT. Confirmation of infarction was established by detection of residual densities on follow-up CT. Sensitivity, specificity and interobserver variability were calculated. RESULTS: In total, 60 presumed infarctions were found in 32 patients, of which 34 infarctions in 21 patients could be confirmed at follow-up. On patient-level, observers' sensitivity/specificity were 91 %/9 %, and 73 %/46 %, respectively, with interobserver agreement by Kappa's coefficient of 0.17. Confirmed infarctions were usually larger than false positive lesions (median approximate volume of 6.6 mL [IQR 0.84-21.3] vs. 1.3 mL [IQR 0.57-6.5], p = 0.040), but still small. An occluding thrombus in a supplying vessel was predictive for confirmed infarction (OR 11, 95%CI 2.1-55), but was not discriminative. CONCLUSIONS: Pulmonary infarction is a common finding in acute PE, and generally small. Radiological identification of infarction was challenging, with considerable interobserver variability. Complete obstruction of the supplying (sub)segmental pulmonary artery was found as the strongest predictor for pulmonary infarction but was not demonstrated to be discriminative.
Assuntos
Embolia Pulmonar , Infarto Pulmonar , Tomografia Computadorizada por Raios X , Humanos , Embolia Pulmonar/diagnóstico por imagem , Masculino , Feminino , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/complicações , Idoso , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodos , Estudos Retrospectivos , Doença Aguda , Idoso de 80 Anos ou maisAssuntos
Embolia Gordurosa , Infarto Pulmonar , Humanos , Embolia Gordurosa/diagnóstico por imagem , Embolia Gordurosa/etiologia , Embolia Gordurosa/complicações , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/etiologia , Tomografia Computadorizada por Raios X , Masculino , Pessoa de Meia-Idade , FemininoRESUMO
A case is presented where a patient with Eisenmenger's syndrome is successfully treated for infection of chronic pulmonary arterial thrombosis with good effect. The evidence for antibiotic and anticoagulant therapy in this patient group is discussed.
Assuntos
Complexo de Eisenmenger , Hipertensão Pulmonar , Infarto Pulmonar , Trombose , Humanos , Complexo de Eisenmenger/complicações , Complexo de Eisenmenger/terapia , Hipertensão Pulmonar/complicações , Infarto Pulmonar/complicações , Infarto Pulmonar/diagnóstico por imagem , Pulmão , Trombose/complicações , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológicoRESUMO
Infected cavitating pulmonary infarction is a rare complication of pulmonary embolism with a high mortality rate. Surgical excision for this complication has been used in past decades. Abrupt cavitation and a large oval-shaped lung abscess caused by acute thromboembolic pulmonary infarction during anticoagulation are rare. We present a 70-year-old man who suffered from pleuritic pain and breathlessness, accompanied by nausea and vomiting for 1 day. A physical examination showed tachycardia and tachypnea with moist rales in the left upper chest. High D-dimer levels, leukocytosis, respiratory failure and left upper lobe consolidation were found on plain computed tomography (CT). CT pulmonary angiography was performed 2 days after the previous CT scan because pulmonary embolism was suspected. This scan showed emboli in the main, right upper, middle, lower and left upper pulmonary arteries with deteriorated left upper lobe consolidation and cavitation. Thromboembolic pulmonary infarction and an abscess were diagnosed. Enoxaparin 60 mg was administered every 12 hours for 10 days, followed by rivaroxaban, antibiotics and drainage of the hydrothorax. The patient improved after the strategy of non-surgical treatment and was discharged approximately 1 month later. The patient had an uneventful course during rivaroxaban 20 mg once daily for 1 year.
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Abscesso Pulmonar , Embolia Pulmonar , Infarto Pulmonar , Tromboembolia , Idoso , Humanos , Abscesso Pulmonar/complicações , Abscesso Pulmonar/diagnóstico por imagem , Masculino , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/cirurgia , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Infarto Pulmonar/complicações , Infarto Pulmonar/diagnóstico por imagemAssuntos
Endocardite Bacteriana/complicações , Micrococcus luteus/patogenicidade , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/microbiologia , Antibacterianos/uso terapêutico , Criança , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Feminino , Humanos , Micrococcus luteus/isolamento & purificação , Infarto Pulmonar/tratamento farmacológico , Infarto Pulmonar/etiologia , Tomografia Computadorizada por Raios XAssuntos
Dor no Peito/fisiopatologia , Neoplasias Cardíacas/diagnóstico por imagem , Mixoma/diagnóstico por imagem , Células Neoplásicas Circulantes/patologia , Embolia Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico por imagem , Angiografia por Tomografia Computadorizada , Ecocardiografia , Eletrocardiografia , Neoplasias Cardíacas/patologia , Neoplasias Cardíacas/fisiopatologia , Neoplasias Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Mixoma/patologia , Mixoma/fisiopatologia , Mixoma/cirurgia , Embolia Pulmonar/patologia , Embolia Pulmonar/fisiopatologia , Infarto Pulmonar/patologia , Infarto Pulmonar/fisiopatologia , Resultado do TratamentoRESUMO
A 75-year-old woman was admitted to hospital with haemoptysis, fever and shortness of breath. She had undergone a right video-assisted thoracoscopic surgery upper lobectomy for an apical lung cancer 4 weeks earlier, and had been treated with antibiotics for 1 week prior to admission for a suspected postoperative lung abscess. Review of preoperative imaging found that she possessed a lobar pulmonary artery variant, with postoperative imaging confirming that the right lower lobe segmental pulmonary artery had been divided alongside the upper lobe vessels. The diagnosis of a lung abscess was thus revised to a cavitating pulmonary infarct. There are numerous variations of the pulmonary vasculature, all of which have the potential to cause a range of serious vascular complications if not appreciated preoperatively. Measures to mitigate the risk of complications resulting from vascular anomalies should be considered by both radiologists and surgeons, with effective lines of communication essential to safe working.
Assuntos
Neoplasias Pulmonares/cirurgia , Artéria Pulmonar/anormalidades , Artéria Pulmonar/cirurgia , Infarto Pulmonar/etiologia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Idoso , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Complicações Pós-Operatórias/etiologia , Artéria Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico por imagem , Radiografia Torácica , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: To evaluate chest-computed-tomography (CT) scans in coronavirus-disease-2019 (COVID-19) patients for signs of organizing pneumonia (OP) and microinfarction as surrogate for microscopic thromboembolic events. METHODS: Real-time polymerase-chain-reaction (RT-PCR)-confirmed COVID-19 patients undergoing chest-CT (non-enhanced, enhanced, pulmonary-angiography [CT-PA]) from March-April 2020 were retrospectively included (COVID-19-cohort). As control-groups served 175 patients from 2020 (cohort-2020) and 157 patients from 2019 (cohort-2019) undergoing CT-PA for pulmonary embolism (PE) during the respective time frame at our institution. Two independent readers assessed for presence and location of PE in all three cohorts. In COVID-19 patients additionally parenchymal changes typical of COVID-19 pneumonia, infarct pneumonia and OP were assessed. Inter-reader agreement and prevalence of PE in different cohorts were calculated. RESULTS: From 68 COVID-19 patients (42 female [61.8%], median age 59 years [range 32-89]) undergoing chest-CT 38 obtained CT-PA. Inter-reader-agreement was good (k = 0.781). On CT-PA, 13.2% of COVID-19 patients presented with PE whereas in the control-groups prevalence of PE was 9.1% and 8.9%, respectively (p = 0.452). Up to 50% of COVID-19 patients showed changes typical for OP. 21.1% of COVID-19 patients suspected with PE showed subpleural wedge-shaped consolidation resembling infarct pneumonia, while only 13.2% showed visible filling defects of the pulmonary artery branches on CT-PA. CONCLUSION: Despite the reported hypercoagulability in critically ill patients with COVID-19, we did not encounter higher prevalence of PE in our patient cohort compared to the control cohorts. However, patients with suspected PE showed a higher prevalence of lung changes, resembling patterns of infarct pneumonia or OP and CT-signs of pulmonary-artery hypertension.
Assuntos
Infecções por Coronavirus/patologia , Pneumonia Viral/patologia , Artéria Pulmonar/patologia , Infarto Pulmonar/diagnóstico por imagem , Tromboembolia/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19 , Infecções por Coronavirus/diagnóstico por imagem , Feminino , Humanos , Pulmão/irrigação sanguínea , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
Since the presence of "bubbly consolidation" (central lucencies) on a multi-slice computed tomography pulmonary angiography (MCTPA) is one of the highly specific imaging appearances of infarct secondary to pulmonary embolism, we investigated the ultrasound characteristics of these infarctions. In this study, 118 patients with MCTPA diagnosis of acute pulmonary embolism were enrolled. Pulmonary infarctions were detected in 21 patients (17.7%), of which 10 (47.6%) showed the typical appearance of bubbly consolidation on MCTPA. Lung ultrasound (LUS) was performed to evaluate the characteristics of the infarcts highlighted by MCTPA. The bubbly consolidations showed a very peculiar echographic aspect represented by a triangular hypoechoic consolidation with sharp margins, the absence of air bronchograms and a mostly central roundish hyperechoic area. Air lucencies within a pulmonary infarct is hypothesized to represent the coexistence of aerated non-infarcted lung with the infarcted lung in the same lobule. The ultrasound appearance confirms this hypothesis, so we named the roundish hyperechoic area the "survived lung." This picture was found in all patients with a diagnosis of bubbly consolidation on MCTPA (100%). Χ2 between MCTPA and LUS regarding the bubbly consolidation diagnosis is 17.18 (df = 1; p value = 0.00003). Bubbly consolidations show a very typical appearance on LUS. Their detection suggests further investigations (MCTPA or point-of-care multi-organ ultrasonography).
Assuntos
Angiografia/métodos , Infarto Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Infarto Pulmonar/etiologia , Ultrassonografia , Adulto JovemAssuntos
Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/etiologia , Infarto Pulmonar/etiologia , Adulto , COVID-19 , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico , Infarto Pulmonar/diagnóstico por imagemRESUMO
Pulmonary thromboembolism may be accompanied by pulmonary infarction. Even though pulmonary thromboembolism (PTE) is a frequently found cause of death at autopsy, pulmonary infarction accompanying PTE is a less common finding and may therefore easily be misinterpreted as infectious or cancerous lung disease. Appearance of pulmonary infarction in post-mortem imaging and acquisition parameters helping to identify pulmonary infarctions are not described yet. Based on a case of a 50-year-old man who died due to PTE and presented pulmonary infarction, we suggest using a pulmonary algorithm in post-mortem computed tomography combined with post-mortem magnetic resonance imaging of the lungs using conventional T1- and T2-weighted sequences.
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Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico , Autopsia/métodos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
The clinical diagnosis of pulmonary embolism is often difficult, as symptoms range from syncope and chest pain to shock and sudden death. Adding complexity to this picture, some patients with non-diagnosed pulmonary embolism may undergo unenhanced imaging examinations for a number of reasons, including the prevention of contrast medium-related nephrotoxicity, anaphylactic/anaphylactoid reactions and nephrogenic systemic fibrosis, as well as due to patients' refusal or lack of venous access. In this context, radiologists' awareness and recognition of indirect signs are cornerstones in the diagnosis of pulmonary embolism. This article describes the indirect signs of pulmonary embolism on chest X-ray, unenhanced CT, and MRI.
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Imageamento por Ressonância Magnética/métodos , Imagem Multimodal/métodos , Embolia Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Diagnóstico Diferencial , Humanos , Achados Incidentais , Pneumopatias/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Infarto Pulmonar/diagnóstico por imagem , Trombose/diagnóstico por imagemRESUMO
OBJECTIVE: To determine the incidence of the reversed halo sign (RHS) in patients with pulmonary infarction (PI) due to acute pulmonary embolism (PE), detected by computed tomography angiography (CTA) of the pulmonary arteries, and to describe the main morphological features of the RHS. METHODS: We evaluated 993 CTA scans, stratified by the risk of PE, performed between January of 2010 and December of 2014. Although PE was detected in 164 scans (16.5%), three of those scans were excluded because of respiratory motion artifacts. Of the remaining 161 scans, 75 (46.6%) showed lesions consistent with PI, totaling 86 lesions. Among those lesions, the RHS was seen in 33 (38.4%, in 29 patients). RESULTS: Among the 29 patients with scans showing lesions characteristic of PI with the RHS, 25 (86.2%) had a single lesion and 4 (13.8%) had two, totaling 33 lesions. In all cases, the RHS was in a subpleural location. To standardize the analysis, all images were interpreted in the axial plane. Among those 33 lesions, the RHS was in the right lower lobe in 17 (51.5%), in the left lower lobe in 10 (30.3%), in the lingula in 5 (15.2%), and in the right upper lobe in 1 (3.0%). Among those same 33 lesions, areas of low attenuation were seen in 29 (87.9%). The RHS was oval in 24 (72.7%) of the cases and round in 9 (27.3%). Pleural effusion was seen in 21 (72.4%) of the 29 patients with PI and the RHS. CONCLUSIONS: A diagnosis of PE should be considered when there are findings such as those described here, even in patients with nonspecific clinical symptoms.
Assuntos
Angiografia por Tomografia Computadorizada/métodos , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Infarto Pulmonar/diagnóstico por imagem , Infarto Pulmonar/epidemiologia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Estudos Transversais , Feminino , Humanos , Incidência , Pulmão/diagnóstico por imagem , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Derrame Pleural/epidemiologia , Artéria Pulmonar/patologia , Embolia Pulmonar/patologia , Infarto Pulmonar/patologia , Estudos Retrospectivos , Adulto JovemRESUMO
ABSTRACT Objective: To determine the incidence of the reversed halo sign (RHS) in patients with pulmonary infarction (PI) due to acute pulmonary embolism (PE), detected by computed tomography angiography (CTA) of the pulmonary arteries, and to describe the main morphological features of the RHS. Methods: We evaluated 993 CTA scans, stratified by the risk of PE, performed between January of 2010 and December of 2014. Although PE was detected in 164 scans (16.5%), three of those scans were excluded because of respiratory motion artifacts. Of the remaining 161 scans, 75 (46.6%) showed lesions consistent with PI, totaling 86 lesions. Among those lesions, the RHS was seen in 33 (38.4%, in 29 patients). Results: Among the 29 patients with scans showing lesions characteristic of PI with the RHS, 25 (86.2%) had a single lesion and 4 (13.8%) had two, totaling 33 lesions. In all cases, the RHS was in a subpleural location. To standardize the analysis, all images were interpreted in the axial plane. Among those 33 lesions, the RHS was in the right lower lobe in 17 (51.5%), in the left lower lobe in 10 (30.3%), in the lingula in 5 (15.2%), and in the right upper lobe in 1 (3.0%). Among those same 33 lesions, areas of low attenuation were seen in 29 (87.9%). The RHS was oval in 24 (72.7%) of the cases and round in 9 (27.3%). Pleural effusion was seen in 21 (72.4%) of the 29 patients with PI and the RHS. Conclusions: A diagnosis of PE should be considered when there are findings such as those described here, even in patients with nonspecific clinical symptoms.
RESUMO Objetivo: Verificar a incidência do sinal do halo invertido (SHI) associado a infartos pulmonares (IP) relacionados ao tromboembolismo pulmonar (TEP) agudo, identificado por angiotomografia (angio-TC) de artérias pulmonares, e demonstrar as principais características morfológicas do SHI. Métodos: Foram avaliadas 993 angio-TCs, após estratificação de risco clínico para TEP entre janeiro de 2010 e dezembro de 2014. TEP foi encontrado em 164 pacientes (16,5%), sendo que três exames foram descartados devido a artefatos de movimentação respiratória. Dos 161 exames restantes, em 75 (46,6%) foram identificadas imagens compatíveis com IP, totalizando 86 lesões; o SHI foi observado em 33 (38,4% dos pacientes) dessas lesões. Resultados: Dos 29 pacientes com lesões características de IP com o SHI, 25 pacientes (86,2%) apresentavam lesão única e 4 (13,8%), lesão dupla. Todas as imagens compatíveis com SHI eram de localização subpleural. Para padronizar a análise, todas as imagens foram interpretadas no plano axial. Em relação à distribuição lobar das 33 lesões, o SHI estava localizado no lobo inferior direito, em 17 (51,5%); no lobo inferior esquerdo, em 10 (30,3%); na língula, em 5 (15,2%) e no lobo superior direito, em 1 (3,0%). Áreas de baixa atenuação no interior dos IPs com o SHI foram observadas em 29 das 33 lesões (87,9%). O SHI apresentava formato ovalado em 24 (72,7%) dos casos e formato arredondado, em 9 (27,3%). Derrame pleural foi encontrado associado aos IP com o SHI em 21 pacientes (72,4%). Conclusões: O achado de imagens com essas características, mesmo em pacientes com sintomatologia inespecífica, deve alertar para a possibilidade do diagnóstico de TEP.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/diagnóstico por imagem , Infarto Pulmonar/epidemiologia , Infarto Pulmonar/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Derrame Pleural/epidemiologia , Artéria Pulmonar/patologia , Embolia Pulmonar/patologia , Brasil/epidemiologia , Doença Aguda , Incidência , Estudos Transversais , Estudos Retrospectivos , Infarto Pulmonar/patologia , Pulmão/patologia , Pulmão/diagnóstico por imagemRESUMO
Background Pleural effusion remains largely unexplored in patients with pulmonary embolism and concurrent pulmonary infarction. The aim of the study was to investigate the relationship between the size of pulmonary infarction and pleural effusion as well as the time course of pleural effusion in patients with pulmonary infarction. Patients and methods Data from 103 patients with pulmonary infarction was retrospectively analysed along with patient comorbidities, size of pulmonary infarction, presence and size of pleural effusion with the time between the onset of clinical symptoms of pulmonary infarction and CT study. Results Assessment of possible correlations between the size of pulmonary infarction and age revealed a significant negative correlation. There was a highly significant difference (p = 0.005) in the mean size of pulmonary infarction in patients with effusion (34.5 cm3) compared to those without it (14.3 cm3), but the size of the effusion had no correlation with the size of pulmonary infarction. The size of the effusion peaked between 4th-5th day after the onset of clinical symptoms of pulmonary infarction. In the first 5 days after the onset of clinical symptoms of pulmonary infarction a significant correlation was found between the size of the effusion and time with approximation of 1.3 mm/12 h. Conclusions The data shows that patients with a pleural effusion are more likely to have a larger pulmonary infarction than those without it. If present, the effusion can be expected to increase in a relatively slow linear fashion in the first 5 days after the onset of clinical symptoms of pulmonary infarction.
Assuntos
Angiografia por Tomografia Computadorizada/métodos , Derrame Pleural/diagnóstico por imagem , Infarto Pulmonar/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pleural/etiologia , Infarto Pulmonar/complicações , Estudos RetrospectivosRESUMO
The purpose of this case presentation is to discuss right upper quadrant pain as an atypical presenting symptom in pulmonary infarction and review the typical computed tomography (CT) imaging features of pulmonary infarction to improve diagnostic accuracy. Pulmonary infarction results from occlusion of distal arterial vasculature within the lung parenchyma leading to ischemia, hemorrhage, and ultimately necrosis. Patients with lung infarction typically present with pleuritic chest pain and may have associated signs or symptoms of pulmonary thromboembolism or deep vein thrombosis. In this case study, a 34-yr-old female devoid of any symptoms indicative of either pulmonary embolism or deep vein thrombosis presented with right upper quadrant pain 1 mo status post open reduction internal fixation for a left ankle fracture. Multiple clinic visits spanning approximately 7 d were significant for a right lower lobe opacity seen on CT of the abdomen which was presumed to represent community acquired pneumonia as a source for the patient's RUQ pain. The patient presented to the emergency department 1 wk later (6 wk following her initial surgery) complaining of left lower extremity swelling and was subsequently diagnosed with a left lower extremity DVT via ultrasound. CT of the pulmonary arteries was negative for PE but identified a right lower lobe opacity which in retrospect was consistent with pulmonary infarction.