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CTPA2

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18 views

CTPA2

Uploaded by

marymahmoud73737
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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OS

Normal CTPA
Multidetector computed tomography of the
pulmonary artery (CTPA)
CT pulmonary angiography (CTPA) is a medical diagnostic test
that employs computed tomography to obtain an image of the
pulmonary arteries.

CTPA was introduced in the 1990s as an alternative to


ventilation/perfusion scanning, which relies on
radionuclide imaging of the blood vessels of the lung.

Because of its minimally invasive nature and high sensitivity and


specificity, CTPA has evolved first-line imaging study for the
evaluation of suspected pulmonary embolism.
Anatomy
• The pulmonary trunk, also known as main
pulmonary artery (mPA), (TA: truncus
pulmonalis) is the solitary arterial output from
the right ventricle, transporting deoxygenated
blood to the lungs for oxygenation.
• The pulmonary trunk is approximately 50 mm
long and 30 mm wide (most authors use 29 mm
in males and 27 mm in females (axial width) as
the cut-offs of normal ).
• At the level of the transthoracic plane, the trunk emerges from
the fibrous pericardium and divides into the longer right and
shorter left pulmonary arteries in the concavity of the
aortic arch, anterior to left main bronchus and to the left of the
carina.
• The left coronary artery passes between the pulmonary trunk
(on the left) and the auricle of the left atrium.
• The pulmonary trunk gives off various branches. One of them is
the right interlobar artery. The interlobar artery is seen lateral to
the bronchus intermedius. The right interlobar artery typically
measures 16 mm in males and 15 mm in females on a PA chest
radiograph
• The right pulmonary artery is one of the
branches of the pulmonary trunk, branching at
the level of the transthoracic plane of Ludwig.
• It is longer than the left pulmonary artery and
courses perpendicularly away from the pulmonary
trunk and left pulmonary artery, between the
superior vena cava and the right main bronchus.
• As it courses to the right it has an almost
horizontal path inferior to the aortic arch and
carina, anterior to the esophagus and right main
bronchus, before dividing just prior to entering
the superior aspect of the hilum of the right lung
into the upper and lower trunks:
right Pulmonary branches

•the upper lobar artery (truncus


anterior) supplies the right upper lobe and courses
medial to the right main bronchus; it is smaller than
the descending interlobar artery
•the descending interlobar artery supplies the
right middle lobe and right lower lobe and courses
lateral to the right main bronchus
The normal upper limit in size can be variable but is
usually taken at around 20 mm .
Left pulmonary artery
The left pulmonary artery is typically a shorter vessel and passes
cephalad to the left main bronchus; it continues as an interlobar
artery and extends into the left upper and lower lobes of the
lung through segmental branches.
A separate branch supplying the left upper lobe may arise from
the left pulmonary artery before continuing as the interlobar
artery.
Comparisons of pulmonary arterial size in physiologically normal
patients and in those with pulmonary arterial hypertension
(PAH) resulted in suggested measurements for the upper limits
of normal vessel diameters. These values are 28.6 mm for the
main pulmonary artery, 28 mm for the left pulmonary artery, and
24.3 mm for the right pulmonary artery.
Distal to the origin of the upper lobe bronchi, the ratio of the
sizes of the pulmonary artery and adjacent bronchus is
approximately 1.3:1 to 1.4:1. This ratio approaches 1:1 in the
periphery.
Technique of CTPA

Images are acquired using a breath hold technique during the


pulmonary arterial enhancement phase following intravenous
contrast material injection.
There are two principal approaches for performing a CTPA of
high diagnostic quality:

test bolus: a small ‘test’ quantity of contrast is injected and


sequential axial slices at a set region of interest are acquired to
calculate the time of peak contrast enhancement and determine
an optimal scan delay

bolus tracking: ​sequential axial slices at a set region of interest


are conducted during the contrast injection until a threshold
enhancement is met, triggering a diagnostic scan
• The study is optimal when the pulmonary arteries are
opacified, and the aorta is not.
• Late acquisition will make it difficult to differentiate between
pulmonary arterial and pulmonary venous branches.
INDICATION

 Pulmonary embolism
 Pulmonary
arteriovenous
malformation

 Pat of triple rule out


CT examination for
acute chest pain
CONTRAINDICATION

 Renal failure

 Severe diabetes

 Allergic to contrast reactions

 Pregnant patients
PREPERATION
 Enquire about pregnancy from females.
 Renal parameters are to be checked.
 Nil oral preparation for 4-6 hours
 Informed consent is to be got from patient
 All metal objects are to be removed from the region of interest
 Patient is changed into hospital’s cotton apron.
 Enquire about allergic history
 A prominent vein in patients upper limb is catheterised with
18-20 guage venflon.
CONTRAST DOSAGE
The recommended dose of non-ionic iodinated
contrast medium is typically calculated based on
the patient’s weight:
• Adults: The dose is usually around 1-2 mL
per kg of body weight.
• Children: The dose can vary but is often in
the range of 1.5-2 mL per kg of body
it is injected intravenously into the patient using
pressure automat injector.
Contrast Injection
1. Contrast Medium: Non-ionic contrast medium is used, typically
60 mL, followed by a 100 mL saline chaser.
2. Injection Rate: The contrast is injected at a rate of 4.5-5 mL/s.
PATIENT POSITIONING

 Patient is positioned feet first with the help of laser


localizers at the level of sternal notch with coronal beam at mid-
axillary line
 Proper immobilization should be done
PATIENT POSITIONING

 Proper breath hold instructions should be given


 Ensure the patient connected IV lines, are long enough to
allow full travel of the couch without being pulled or entangled
while undergoing a CT
CT technique

Scout Scan: A preliminary scan from the apices of the lungs to the
diaphragm is performed to plan the main scan.
A region of interest (ROI) is set at the level of the pulmonary
trunk.

Scanning Parameters
1. Scan Extent: From the lung apices to the diaphragm.
2. Scan Direction: Caudocranial (from the feet towards the head).
3. Respiration Phase: Scans are typically performed during a
breath-hold at full inspiration to ensure optimal image quality
when reaches the threshold 100- 150 HU is reached
Image Acquisition and Analysis
1. Image Quality: The main pulmonary artery should have a density
of at least 250 HU for a diagnostic-quality scan.
2. Reconstruction: Images are reconstructed using high-resolution
algorithms to enhance the visualization of the pulmonary arteries.
POST PROCESSING

Volume rendering technique (VR) Maximum Intensity Projection (MIP)


Multi planar reconstruction (MPR)
Indirect MDCT venography

Contrast-enhanced helical CT of the veins of the lower


extremities is performed using the same contrast bolus as used
for chest CT.

Images of the iliac, femoral, and popliteal veins are obtained 3-4
minutes delay after the onset of the initial contrast injection.
CTPA
Right Side
Apical (A1)
Anterior (A3)
Lateral (A4)
Medial (A5)
Superior
(apical)
Medial basal (paracardiac) (A7) , Anterior basal (A8)
Lateral basal (A9) , Posterior basal (A10)
Left side
Apicoposterior (A1+2)
Anterior (A3)
Superior lingular (A4)
Inferior lingular (A5)
Superior (apical) (A6)
Anteromedial (A7+8)
Lateral basal (A9)
Posterior basal (A10)
Artefacts
Transient interruption of contrast
TIC is a flow artefact, that consists of relatively poor contrast
enhancement in the pulmonary arteries, while there is good
enhancement in the SVC and also in the aorta.

This vascular phenomenon occurs when the patient performs a


deep inspiration just before the scan starts, resulting in
increased venous return of unopacified blood from the inferior
vena cava (IVC).

More unopacified blood from the IVC than opacified blood from
the SVC enters the right atrium resulting in poor enhancement of
the pulmonary arteries.
Transient Interruption of Contrast:
Deep inspiration results in dilution
of contrast in the right atrium by
unopacified blood from the inferior
vena cava
1. Optimal
2. Too late.
3. Transient interruption of contrast
Motion Artifacts
Respiratory motion artifacts are the most common cause of an
indeterminate CTPA and can be a cause of misdiagnosis of
pulmonary embolism.

They are best seen on lung window settings that show


composite images of vessels. A rapid change in position of
vessels on contiguous images also confirms motion artifact.

At the moment, the breath-hold required for 16-MDCT is


approximately 10 seconds.

In dyspneic patients, oxygen supplementation can help the


patient provide the desired period of apnea.
Streak Artifacts
Streak artifact that obscures pulmonary vessels because of
metallic implants can make a study indeterminate.

Additional imaging with V/Q scintigraphy or pulmonary


angiography may be necessary.

Streak artifact from high-density contrast material in the


superior venacava can obscure adjacent pulmonary arteries.

The frequency of this artifact can be reduced by using a saline


bolus immediately after the contrast material injection.
Streak artifacts from SVC
ADVANTAGES
Less time consuming.
Non-invasive nature.
Almost all radiology departments have CT scan.
Less complication than conventional (elevated pulmonary artery
pressures).
Lesser volume of contrast needed.
Simple post procedure care.
Can be done in out patient basis.
Pathology

Pulmonary embolism

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