Do Preliminary Chest X-ray Findings Define the Optimum Role of Pulmonary Scintigraphy in Suspected Pulmonary Embolism?

doi:10.1053/crad.2000.0670

Clinical Radiology

Volume 56, Issue 5, May 2001, Pages 397-400

https://doi.org/10.1053/crad.2000.0670 Get rights and content

Abstract

AIM: To investigate if preliminary chest radiograph (CXR) findings can define the optimum role of lung scintigraphy in subjects investigated for pulmonary embolism (PE). MATERIALS AND METHODS: The CXR and scintigraphy findings from 613 consecutive subjects investigated for suspected PE were retrieved from a radiological database. Of 393 patients with abnormal CXRs, a subgroup of 238 was examined and individual radiographic abnormalities were characterized. CXR findings were related to the scintigraphy result. RESULTS: Scintigraphy was normal in 286 subjects (47%), non-diagnostic in 207 (34%) and high probability for PE in 120 (20%). In 393 subjects (64%) the preliminary CXR was abnormal and 188 (48%) of scintigrams in this group were non-diagnostic. Individual radiographic abnormalities were not associated with significantly different scintigraphic outcomes. If the preliminary CXR was normal (36%), the proportion of non-diagnostic scintigrams decreased to 9% (19 of 220 subjects) (P < 0.05). CONCLUSION: In subjects investigated for PE, an abnormal CXR increases the prevalence of non-diagnostic scintigrams. A normal pre-test CXR is more often associated with a definitive (normal or high probability) scintigram result. The chest radiograph may be useful in deciding the optimum sequence of investigations.Forbes, K. P. N., Reid, J. H., Murchison, J. T.(2001). Clinical Radiology56, 397–400.

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Cited by (61)

“Pulmonary embolism diagnostics of pregnant patients: What is the recommended clinical pathway considering the clinical value and associated radiation risks of available imaging tests?”
2017, Physica Medica
Pulmonary embolism (PE) during pregnancy remains the leading preventable cause of maternal morbidity and mortality in the developed countries. Diagnosis of PE in pregnant patients is a challenging clinical problem, since pregnancy-related physiologic changes can mimic signs and symptoms of PE. Patient mismanagement may result into unjustified anticoagulant treatment or unnecessary imaging tests involving contrast-related or/and radiation-related risks for both the expectant mother and embryo/fetus. On the other hand, missing or delaying diagnosis of PE could lead to life-threatening conditions for both the mother and the embryo/fetus. Thus, a timely and accurate diagnostic approach is required for the optimal management of pregnant patients with suspected PE. Aim of the current review is to discuss a pregnancy-specific clinical pathway for the early diagnosis of PE with non-ionizing radiation- and ionizing radiation-based imaging modalities taking into account previously reported data on diagnostic value of available imaging tests, and radiation related concerns.
Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease
2017, Radiologia
El diagnóstico precoz de la embolia pulmonar (EP) es uno de los factores más importantes que afectan al pronóstico, pero el cuadro clínico es con frecuencia muy inespecífico y puede simular otras enfermedades. Por ello, las pruebas de imagen, sobre todo la angiografía mediante tomografía computarizada (angio-TC) de arterias pulmonares, se han convertido en la piedra angular para establecer el diagnóstico de EP. La gran disponibilidad y el alto rendimiento diagnóstico de la angio-TC pulmonar ha provocado un aumento significativo en el número de exploraciones, con el consiguiente aumento de la exposición de la población a la radiación y al contraste yodado. Por ello, a pesar de la menor precisión de otras técnicas (gammagrafía, ecografía de venas de miembros inferiores…), el papel de estas continúa vigente en determinadas circunstancias, y por otra parte, ha generado el desarrollo de protocolos optimizados de angio-TC pulmonar dirigidos a reducir la dosis de radiación (disminuyendo el kilovoltaje) y de contraste. Describimos las características técnicas y semiológicas, las ventajas y las limitaciones de cada una de las pruebas de imagen disponibles para diagnosticar la EP, cuyo conocimiento nos ayudará a elegir entre ellas según el caso. Finalmente se comentan algunos datos sobre el aumento del empleo de la angio-TC, su repercusión clínica, su «sobreuso» y las dudas sobre su coste-efectividad.
Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its “overuse”, and doubts about its cost-effectiveness.
Accuracy of X-ray with perfusion scan in young patients with suspected pulmonary embolism
2015, Thrombosis Research
Citation Excerpt :
Moreover, young patients have less co-morbidity than elderly patients. Consequently, this may improve the diagnostic yield of an X/Q scan in this subgroup of patients [11,12]. The aim of this study was to prospectively investigate the sensitivity, specificity, PPV, negative predictive value (NPV) and the positive and negative likelihood ratio of the X/Q-scan according to the PISAPED criteria in comparison to CTPA in patients aged ≤ 50 years, with suspected PE.
Computed tomography pulmonary angiogram (CTPA) has become the standard test in the diagnostic workup of patients with suspected pulmonary embolism (PE). However, young patients may have an increased risk of cancer with CTPA. Perfusion scanning combined with chest X-ray (X/Q) may offer an adequate alternative, but has never been prospectively validated. We directly compared this strategy with CTPA in patients aged ≤ 50 years with suspected PE.
Consecutive patients with a likely clinical probability or an abnormal D-dimer level underwent both CTPA and X/Q. Two trained and experienced nuclear physicians independently analyzed the X/Q-scans. The accuracy of X/Q according to the PISAPED criteria was calculated in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Seventy-six patients were included, with a PE rate of 33%. The inter-observer agreement for X/Q-scan reading was high (κ = 0.89). After consensus reading, 21 patients (28%) were categorized as ‘PE present’, 53 (70%) as ‘PE absent’, and two (2.6%) as ‘non-diagnostic’. In 22%, there was a discrepancy between the X/Q-scan and CPTA for the diagnosis or exclusion of PE. The PPV and NPV were 71% and 83%, respectively.
In patients with a high risk of PE, a diagnostic strategy of chest X-ray and perfusion scanning using the PISAPED criteria seems less safe than CTPA. Additional studies should further investigate this diagnostic algorithm.
Diagnosis pulmonary embolism in pregnancy: Contribution of lung scintigraphy. Retrospective study about 116cases
2013, Medecine Nucleaire
L’embolie pulmonaire pendant la grossesse représente une des premières causes de mortalité maternelle. Le but de notre travail est d’évaluer chez les femmes enceintes (FE) avec suspicion d’embolie pulmonaire la prévalence des lésions révélées par la scintigraphie pulmonaire de perfusion ainsi que les relations pouvant exister entre ces lésions parenchymateuses et les différents facteurs de risque cliniques et biologiques.
Il s’agit d’une étude rétrospective colligeant 116 patientes enceintes adressées pour suspicion d’embolie pulmonaire. L’âge médian était de 30 ans avec des extrêmes allant de 15 à 47 ans et le terme gestationnel médian était de 31 semaines avec des extrêmes de 12 à 40 semaines. La suspicion d’embolie pulmonaire a été établie devant la présence de signes cliniques (dyspnée, douleur thoracique et de palpitations). Aucune patiente n’avait bénéficié d’une radiographie pulmonaire. Les patientes ont bénéficié d’une scintigraphie pulmonaire de perfusion planaire avec une activité injectée de 40 à 50 MBq de macroagrégats d’albumine humaine (MAA) marqués au ^99mTc. Les résultats scintigraphiques ont été classés selon les critères de PIOPED, en fonction de la probabilité d’EP. Les scintigraphies avec une probabilité faible ou intermédiaire ont été incluses dans un même groupe, celui de résultats indéterminés.
La scintigraphie était positive (avec une forte probabilité) chez 16 patientes (13,8 %), normale chez 78 patientes (67,2 %) et classée comme non concluante chez 22 patientes (18,9 %). Chez les 16 patientes avec une scintigraphie positive, les lésions ont intéressé le poumon gauche dans 10 cas (62,5 %), le poumon droit dans 1 cas (6,25 %) et ont été bilatérales dans 5 cas (31,25 %).
En cas de suspicion d’embolie pulmonaire chez une femme enceinte, le choix de la technique d’imagerie dépend, d’une part, de son apport diagnostique et, d’autre part, de ses effets indésirables. La scintigraphie pulmonaire reste l’examen à réaliser en premier chez les FE avec une radiographie pulmonaire. Chez les autres, c’est l’angioscanner qui doit être réalisé en première intention.
Pulmonary embolism during pregnancy is a leading cause of maternal mortality. The aim of our study was to evaluate pregnant women with suspected pulmonary embolism prevalence of lesions on the lung perfusion as well as the relationship between the parenchymal lesions and various clinical factors and biological risk.
This is a retrospective study of 116 pregnant patients referred for suspected pulmonary embolism. The median age was 30 years, ranging from 15 to 47 years and the median gestational term was 31 weeks with a range of 12 to 40 weeks. Suspicion of pulmonary embolism was established with the presence of clinical signs (dyspnea, chest pain and palpitations). No patient had received a chest radiograph. The patients underwent planar perfusion scintigraphy with injected activity of 40 to 50 MBq of macroaggregates of human albumin (MAA) labeled with 99mTc. The scintigraphic results were classified according to the PIOPED criteria, depending on the likelihood of EP. The scans with low or intermediate probability were included in the same group, that of indeterminate results.
The scan was positive (with high probability) in 16 patients (13.8%), normal in 78 patients (67.2%) and classified as inconclusive in 22 patients (18.9%). In 16 patients with a positive scan, the lesions were interested the left lung in 10 cases (62.5%), the right lung in 1 case (6.25%) and were bilateral in 5 cases (31.25%).
In cases of suspected pulmonary embolism in a pregnant woman, the choice of imaging technique depends on both its diagnostic value and also its adverse effects. Lung scintigraphy is the examination to be carried out first in pregnant women with a chest radiograph. In others, it is that angiography should be performed as first line.
Acute and Chronic Pulmonary Embolism: An In-depth Review for Radiologists Through the Use of Frequently Asked Questions
2012, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
Its most important limitation is the higher number of nondiagnostic results when compared with MDCTPA.66 However, as emphasized by the PIOPED II investigators, the proportion of patients with a nondiagnostic V/Q scan is much lower in the presence of a normal chest radiograph than an abnormal chest radiograph.9,20,67,68 In fact, studies have shown that V/Q combined with the Wells score results in a PPV and NPV >90%,11,66 and a low probability V/Q scan is as reliable as MDCTPA in excluding PE in low or moderate clinical probability patients.69
In this article, the authors review the role of the different imaging modalities in the diagnostic workup of patients with suspected acute or chronic pulmonary embolism (PE). The authors also discuss the current guidelines for the diagnosis of acute PE based on the pretest probability clinical assessment and outline the current recommendations for special patient populations. The recent guidelines from the American Thoracic Society/Society of Thoracic Radiology for the assessment of suspected PE in pregnancy are also reviewed. Finally, the imaging findings in acute and chronic PE are illustrated.
Chest Pain Syndromes in Pregnancy
2012, Cardiology Clinics

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^f1: Author correspondence and guarantor of study: Dr J. T. Murchison, Royal Infirmary of Edinburgh, 1 Lauriston Place, Edinburgh EH3 9YW, U.K.

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Regular ArticleDo Preliminary Chest X-ray Findings Define the Optimum Role of Pulmonary Scintigraphy in Suspected Pulmonary Embolism?

Abstract

Clin Radiol

Clin Radiol

Am J Cardiol

Clinical Radiology

A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study

Arch Intern Med

JAMA

Pulmonary embolism exclusion: a practical approach to low probability using the PIOPED data. Prospective investigation of pulmonary embolism diagnosis

Eur J Nucl Med

Modified PIOPED criteria used in clinical practice

J Nucl Med

Regular Article
Do Preliminary Chest X-ray Findings Define the Optimum Role of Pulmonary Scintigraphy in Suspected Pulmonary Embolism?