Asuncion Camille Ann, Mejia Maria Margarita, Liwanag Harvy Joy
ASMPH Batch 2012
The Medical City – RADIOLOGY Rotation
I.
Case Presentation
II.
Salient Features
A.
B.
III.
Pertinent History
Pertinent Physical Examination
Differential Diagnoses and Diagnostics
A.
B.
C.
D.
E.
Asthma
Pneumonia
Coronary Artery Disease
Dissecting Aortic Aneurysm
Pulmonary Embolism
IV.
Diagnostic Approach (PIOPED and ESC)
A. Triple Rule-Out by CT Angiography
1.
2.
3.
4.
5.
6.
B.
Procedure
Indications
Contraindications
Applicability to age group
Costing
Expected Findings
Other Considerations
Primary Impression
V.
A. Epidemiology
B. Pathophysiology
C. Clinical Correlations
VI.
Summary
50 y/o
chief complaint: chest pain and difficulty of breathing
sudden in onset
pain was stabbing and non-radiating
DOB associated with bouts of cough
Differentials?
Fresh from a 17-hour flight
Pain in the calf pain, relieved by rest
 Past Medical
 HPN, controlled
 DM, uncontrolled
 No previous surgeries
Differentials?
 OB-Gyne
 G5P5 (5005)
 History of OCP intake
 Personal and Social
 Non-smoker, non-alcohol beverage drinker
 OFW from Europe
Vitals: stable, afebrile
 Clear breath sounds, (-) retractions, (-) alar flaring
 Right leg edema with slight
discoloration
 Unequal pulses in lower extremities
ECG: Nonspecific ST wave elevation
Urinalysis and CBC unremarkable
Results of cardiac enzymes: pending
Differentials?
Differential
Rule-in
Rule-out
Laboratories & Other
Diagnostics
Radiologic
Studies
Asthma
(+) difficulty of
breathing and
cough
(+) acute attack
(-) history of
asthma
Clear breath
sounds
Blood WU: Eosinophils ,
IgE & allergic skin testing
Pulmonary function tests
Peak flow monitoring
Metacholine- or
histamine-challenge
testing
PA and
lateral Chest
X-rays to
rule-out
pneumomediastinum
Pneumonia
(+) difficulty of
breathing and
cough
(+) acute onset
(+) DM 
prone to
infections
Clear breath
sounds
(-) fever
Normal
WBC
Sputum gram stain
and/or culture and
sensitivity
CBC
Bronchoalveolar lavage
(BAL)
PA chest xray
Differential
Rule-in
Rule-out
Laboratories &
Other diagnostics
Radiologic Studies
Coronary
artery
disease
(+) chest pain
(+) acute
attack
(+) history of
hypertension
and DM
(-) radiation
Stable VS
Non-specific
ECG
findings
Blood WU: CBC,
thyroid function tests
Lipid profile
Cardiac enzyme
serum markers
ECG
Echocardiography
CT angiography
Intravascular
ultrasound
Optical coherence
tomography
Aortic
dissection
(+) chest pain
Uneven
pulses
Stable VS
Blood WU: CBC,
(-) back pain BUN, creatinine,
LDH, D-dimer
Cardiac enzymes
Smooth muscle
myosin heavy-chain
assay
Echocardiography
ECG
PA Chest x-ray 
mediastinal
widening (40%);
right tracheal
deviation; pleural
effusion
CT scan – for
hemodynamically
stable patients
Differential
Rule-in
Pulmonary
embolism
(+) chest pain
(+) history of air
travel
Multiparous
(+) difficulty of
breathing and
coughing
Acute attack
Uneven pulses
Rule-out
-----
Laboratories & Other Radiologic
Diagnostics
Studies
D-dimer
Serum troponin
Brain natriuretic
peptide
Arterial blood gases
ECG
Chest radiography
(PA and lateral)
CT Angiography
Color flow doppler
(for
thrombophlebitis)
Pulmonary Embolism
RATIONALE
Expected Findings
ECG
Assess status of R ventricle, risk T wave inversion (V1-V4), QR
stratification
Pattern (V1), S1Q3T3 type and
incomplete or complete R
bundle branch block
CXR
Exclude other causes of
dyspnea and chest pain
Plate-like atelectasis, pleural
effusion, elevation of
hemidiaphragm
CBC
Hemodynamic stability or
anemia, check for infection
Usually normal
CARDIAC
ENZYMES
Markers of myocardial injury
High
ABG
Assess blood oxygenation
Hypoxemia but 20% have N
PaO2 and D(A-a)O2
D-Dimer
Rapid ELISA
Indicates presence of an acute
clot
High



First radiologic study done for chest pain
and/or dyspnea
Consider radiation exposure, age of patient,
pregnancy
Costing: P560-690 (TMC)




Normal or near-normal
Enlarged right descending pulmonary artery
(Palla’s sign)
Focal oligemia (Westermark’s sign)
Peripheral wedge-shaped density above the
diaphragm (Hampton’s hump)
Westermark’s
sign
Palla’s
sign
Hampton’s
Hump

Clinical Judgment  Prospective Investigation
On Pulmonary Embolism Diagnosis (PIOPED)
 Clinical probability (low, moderate, high)
▪ Clinical prediction rules (Geneva, Wells)
 PIOPED I: V/Q scan
 PIOPED II: CTA
 PIOPED III: Gd-MRA






PROCEDURE: Uses 64-MDCT technology
Single, non-invasive test for “acute chest pain dilemma”
CAD, PE, AD
Protocol:
 Includes lung apex and base
 Longer contrast injection
Patient Preparation:
 Beta-blockers and nitrates (lower heart beat and dilate
coronaries)
 ECG gating
 Oxygen may be inhaled
COSTING: P20,000-P27,000 (TMC)
Halpern E, 2009
Low to moderate risk for acute coronary syndrome
(ACS)
 Symptoms attributed to acute pathologic
conditions of the aorta or pulmonary arteries
(dyspnea, acute chest pain)

Halpern E, 2009
ABSOLUTE CONTRAINDICATIONS
RELATIVE CONTRAINDICATIONS
Hypersensitivity to iodinated contrast
agent
History of allergies or allergic reactions
to other medications
Renal insufficiency (serum creatinine
level of >1.5 mg/dL)
Congestive heart failure
History of thromboembolic disorders
Multiple myeloma
Hyperthyroidism
Pheochromocytoma
Atrial fibrillation
Inability to perform breath hold for 15 s
Hoffman et al., 2006
-
central intravascular filling defect within the vessel
lumen (“doughnut sign”, “Polo mint sign”)
-
eccentric tracking of contrast material around a
filling defect
-
complete vascular occlusion
http://radiographics.rsna.org/content/24/5/1219/F13.expansion.html
-
Smooth filling defects making an obtuse angle with
a vessel wall
http://radiographics.rsna.org/content/24/5/1219/F13.expansion.html
-
Lung Parenchyma  oligemia
-
Lung Parenchyma  pulmonary hemorrhage
(peribronchovascular thickening, ground-glass
attenuation, smooth interlobular septal thickening)
http://radiographics.rsna.org/content/24/5/1219/F13.expansion.html
-
Lung Parenchyma  pulmonary infarction
(peripheral wedge-shaped pleural-based
opacification)
Acute Embolus
Chronic Embolus
Central, within vascular lumen
Eccentric and contiguous with vessel
wall
Vessel cutoff sign
Reduces arterial diameter by >50%
Evidence of recanalization within
thrombus
Presence of an arterial web
Central PE
(Central Vascular Zones)
Peripheral PE
(Peripheral Vascular Zones)
main pulmonary artery
segmental and subsegmental arteries of
the right upper lobe
left and right main pulmonary arteries
right middle lobe
anterior trunk
right lower lobe
right and left interlobar arteries
left upper lobe
left upper lobe trunk
lingula
the right middle lobe artery
left lower lobe
right and left lower lobe arteries





Second-line (to CTA) diagnostic test
Radiologic modality for patients who cannot
tolerate IV contrast
Uses radio-labeled inhaled gases (e.g. xenon,
krypton)
High probability scan: two or more segmental
perfusion defects with normal ventilation
90% positive predictive value for highprobability scans
Pulmonary Embolism
Category: acute pulmonary infarction or
acute embolism without infarction
Epidemiology: 1 per 1000 (USA)
Pathophysiology
•
•
•
•
•
Venous thrombosis: venous stasis, injury to the
intima, enhanced coagulation properties of
blood
Thrombus formation: platelet nidus on the
valves of the veins of the lower extremities 
accretion & growth  red fibrin thrombus 
break off (embolus) or occlusion

Clinical Presentation: chest /abdominal pain, difficulty of
breathing, productive cough, wheezing, fever, seizures,
syncope, decreasing level of consciousness, new onset
atrial fibrillation, flank pain, delirium (in elderly patients)

Most common symptoms (PIOPED): dyspnea (73%),
pleuritic chest pain (66%), cough (37%), hemoptysis
(13%)

Most common physical signs (PIOPED): tachypnea
(70%), rales (51%), tachycardia (30%), fourth heart
sound (24%), accentuated pulmonic component of
the second heart sound (23%)

Most common symptoms (PIOPED): dyspnea (73%),
pleuritic chest pain (66%), cough (37%), hemoptysis
(13%)

Most common physical signs (PIOPED): tachypnea
(70%), rales (51%), tachycardia (30%), fourth heart
sound (24%), accentuated pulmonic component of
the second heart sound (23%)
Risk factors: immobilization, travel (4 hours or more
in the past month), surgery (within the last 3
months), malignancy, history of thrombophlebitis,
trauma, smoking, stroke, paresis, paralysis, heart
failure, COPD
 Case application:






Patient presented with dyspnea and chest pain
History of travel (17 hours) and immobilization
Pregnancy (G5P5)
Thrombophlebitis – unilateral edema
Use of OCPs

Anticoagulation & Fibrinolysis
 Heparin, Warfarin



Maintenance of hemodynamic stability
Monitoring of oxygenation and cardiac
function
Consider embolectomy

Combination of mechanical and
pharmacologic modalities
 Compression stockings
 Mini-doses of anticoagulants (heparin)






Helical CT Pulmonary Angiography for Acute
Pulmonary Embolism
[Appl Radiol 31(4):21-30, 2002. © 2002
Anderson Publishing, Ltd]
http://www.medscape.com/content/2002/00/
43/30/433087/433087_fig.html
PIOPED II
ESC CPGs on Pulmonary Embolism
Harrisons Principles of Internal Medicine
Asuncion Camille Ann, Mejia Maria Margarita, Liwanag Harvy Joy
ASMPH Batch 2012
The Medical City – RADIOLOGY Rotation