Pulmonary hypertension (PH) is a complex disorder and may be related to a variety of diseases. It may arise in association with chronic thromboembolic pulmonary hypertension (CTEPH) or pulmonary embolism (PE). Knowledge of the radiological features is required to characterize and accurately diagnose the conditions and may improve the outcome. This study was designed to evaluate the clinical characteristics and the computerized tomography angiography findings in patients with PH, PE and CTEPH. Contrast-enhanced CT scans were acquired in 55 Sudanese patients with PE, 20 patients with PH, 25 patients with CTEPH and 50 normal subjects who were considered as control group. The CT diagnostic criteria for all cases were characterized. The clinical signs, parenchymal abnormalities, pulmonary tree and cardiac segments in all groups were characterized and compared with the control group. The results showed that the most common clinical characteristics were found to be chest pain, dyspnea, lower limb swelling, tachycardia and syncope which were correlated significantly with the presence of the disease. In all patients groups, the pulmonary vascular segments, cardiac segments and lung parenchyma changes were detected and were significantly different from the normal control subjects at p ≤ 0.01. It was found that CT angiography has a significant role in the diagnostic evaluation of these groups of patients. CT imaging is acceptably used in diagnosis, defining cause, quantifying heart segments and parenchyma changes in order to assess the feasibility of surgery, monitoring and therapeutic planning.
Pulmonary hypertension (PH) is a complex disorder [
According to the diagnostic approach to PH that was proposed in 1997 by Reaside and Peacock [
Therefore early and appropriate diagnosis and treatment are required; in this study, we evaluated the clinical characteristics, the CT findings in PH, PE and CTEPH patients. We have expressed the technique for CT angiography and the CT diagnostic criteria for all cases and correlated the findings with normal control. Knowledge of the radiological signs is required to detect and accurately diagnose the condition and may improve the outcome. In the current study the pulmonary artery tree, heart segments and associated lung parenchyma findings have been evaluated and the added value of CT in prediction of estimating PH comparing with the normal control group was analyzed.
This study is a descriptive analytical study, it was done at Royal Care International Hospital and Doctor’s Clinic Radiology Departments; Data were collected during the period from October 2013 to December 2015.
A sample of 55 patients with clinically diagnosed as PE was enrolled, their mean ages were 54.20 ± 14.21 ranged from 28 - 95 years old and a sample of 20 patients with PH, mean ages were 60.4 ± 13.96 ranged from 29 - 75 years and 25 patients with CTEPH were enrolled, their mean ages were 61.24 ± 9.5 ranged from 47 - 85 years old. 50 normal subjects were considered as control, their mean ages was 50.7 ± 14.5 ranged from 21 - 76 years old. The sample included both genders; the total number of females were 92 (61.3%), female patients who were affected with PE = 37 (67.3%), PH = 10 (50.0%) and CTEPH = 11 (44.0%), the normal control constituting 34 (68.0%). Total number of male patients were 58 (38.7%) and who were affected with PE = 18 (32.7%), PH = 10 (50.0%) and CTEPH = 14 (56.0%) and the normal male controls constituting 16 (32.0%).
All were examined by using CT. Those were referred to CT examination were with clinical presentation including shortness of breath, chest pain, swallowing in legs. The selection criteria for PE and PH were those who were diagnosis were based on clinical findings. The normal control group was those who were scanned for CT angiography and their findings are without cardiac, pulmonary or lung parenchyma disorders. For the selection criteria of the CTEPH patients; the diagnosis is made principally through CT imaging findings and clinical setting. We considered the key feature of CTEPH is that: in the CTPA findings of CTEPH; the presence of thrombosis, occlusion, and post stenotic dilatation in the pulmonary arteries, changing of lung pattern, presence of collaterals and puluroparenchemal changes are considered the CT findings in CTEPH.
Exclusion criteria were non availability of medical records, or have contraindication of intravenous iodinated contrast. Verbal consent was firstly obtained from all potential participants. The aims, benefits of the present study were explained to all participants in details. Medical, history of all study subjects posing as (sample) were thoroughly reviewed directly from participants themselves and those with conditions that may in any way, alter the findings of the current study were excluded.
Toshiba (64 multi-slice detector) in Royal Care International Hospital and Neo soft (64 multi-slice detector) in Doctor’s Clinic.
CTA was obtained during spiral data acquisition, the entire area of interest was scanned during the injection of contrast. Images were captured when vessels are fully opacified to demonstrate either arterial or venous phase enhancement through the acquisition of both data sets (arterial and venous). A ROI (region of interest) is positioned over the pulmonary artery at the level of the carina. After commencing the injection a (tracker scan) Hounsfield level at the ROI was monitored and the scan is the triggered when the density at the ROI reaches a preset value. Detector width-reconstruction/(mm) = 0.625 - 1.25. Scan direction and extension-caudal-cranial direction scan from hemi diaphragm to the lung apex. Imaging review and post-processing, imaging should be reviewed at three setting: Mediastinal window (window width-window level (400 - 40 HU), Pulmonary embolism-specific window (700 - 1000 HU), Lung window (l500 - 600 HU). Patients were instructed on breath-hold- ing techniques. Collimation (1 - 2 mm),
1) Pulmonary artery: The widest short axis diameter of the main pulmonary artery at the level of carina and the transverse diameter of the right and left main pulmonary branches as well as the distal portions on the same image slice were measured.
2) Right ventricle: The right ventricular cavity was measured in the axial plane at their widest points between the inner surfaces of the free wall and the interventricular septum; where the interventricular septal configuration was measured in (mm).
4) Right atrial: The right atrial diameter was measured on the axial mid-chamber view that showed the centre of tricuspid annulus and the superior right atrial wall.
Evaluation of patients with suspected pulmonary hypertension requires proper investigations to confirm the diagnosis, clarify and determine the specific cause. Thus, evaluating patients with pulmonary hypertension involves four steps: suspicion, detection, classification and functional evaluation [
Our sample demonstrate that the patients affected with PH after affected with PE were 25 patient with the most affected ages were between 51 - 60 years constituting 11 (44.0%), where those who were affected with PE only were 18 (32.7%) for the same age group however the PH percentage were distributed in all group of ages between 21 years and ages ˃ 71 years old. This was presented in
Classification of patients according to their complaints has been studied as seen in
The main clinical finding was chest pain. In PE patients; leg swelling was found in only 2 (3.6%) of the cases, it is important to acknowledge a history of deep vein thrombosis (sign: as lower limb swelling) as an element that can guide the diagnosis, but it lacks sensitivity. Previous studies had mentioned that many patients with CTEPH haven’t had a documented DVT [
The classic multidetector computed tomography pulmonary angiography (CTPA) findings of pulmonary hy- pertension were divided into three categories: vascular, cardiac, and parenchymal [
Type of Disease | Total | |||||
---|---|---|---|---|---|---|
Patients with PE* N = 55 | Patients with PH** N = 20 | Patients with CTEPH*** N = 25 | Normal Subjects N = 50 | |||
Age | 21 - 30 | 3 (5.5%) | 1 (5.0%) | 0 (0.0%) | 5 (10.0%) | 9 (6.0%) |
31 - 40 | 7 (12.7%) | 3 (15.0%) | 0 (0.0%) | 12 (24.0%) | 22 (14.7%) | |
41 - 50 | 11 (20.0%) | 0 (0.0%) | 4 (16.0%) | 10 (20.0%) | 25 (16.7%) | |
51 - 60 | 18 (32.7%) | 4 (20.0%) | 11 (44.0%) | 8 (16.0%) | 41 (27.3%) | |
61 - 70 | 11 (20.0%) | 7 (35.0%) | 6 (24.0%) | 12 (24.0%) | 36 (24.0%) | |
˃71 | 5 (9.1%) | 5 (25.0%) | 4 (16.0%) | 3 (6.0%) | 17 (11.3%) |
*pulmonary embolism (PE), **pulmonary hypertension (PH), ***chronic thromboembolic pulmonary hypertension (CTEPH).
Patient Complain | Type of Disease | ||
---|---|---|---|
Patients with PE N = 55 | Patients with PH N = 20 | Patients with CTEPH N = 25 | |
Chest Pain | 38 (69.1%) | 19 (95.0%) | 18 (75.0%) |
Short of Breathing | 33 (60.0%) | 16 (80.0%) | 22 (88.0%) |
Leg Swelling | 2 (3.6%) | 0 (0.0%) | 0 (0.0%) |
Tachycardia | 1 (1.8%) | 0 (0.0%) | 2 (8.0%) |
Syncope | 1 (1.8%) | 0 (0.0%) | 0 (0.0%) |
CT Findings | Type of Disease | ||
---|---|---|---|
Patients with PE (N = 55) | Patients with PH (N = 20) | Patients with CTEPH (N = 25) | |
Pleural Effusion | 21 (38.2%) | 2 (10.0%) | 3 (12.0%) |
Consolidation | 25 (45.5%) | 6 (30.0%) | 14 (56.0%) |
Ground Glass Opacity | 3 (5.5%) | 3 (15.0%) | 3 (12.0%) |
Mosaic Appearance | 5 (9.1%) | 2 (10.0%) | 7 (28.0%) |
Abnormal Right Ventricle Morphology | 11 (20.0%) | 6 (30.0%) | 9 (36.0%) |
Cardiomegally | 0 (0.0%) | 1 (5.0%) | 6 (24.0%) |
cases with PH, 2 (10.0%). Similar findings were mentioned by another similar study done by Eduardo Jose et al., 2012 [
In order to diagnose the CTEPH, CTPA features should be identified. We classify the features of chronic pulmonary thromboembolism as vascular signs or parenchymal signs. The vascular signs include direct pulmonary artery signs and signs due to pulmonary hypertension. The parenchymal signs include mosaic perfusion pattern, focal ground glass opacities. This method and findings was similar to the study done by Eva Castañer, et al. (2009) [
Ground glass opacity was also been detected as a complication of PH in CTEPH. Similar previous studies have mentioned that the parenchymal signs as centrilobular ground-glass nodules are common in patients with pulmonary hypertension [
Consolidation scored the high frequency in both CTEPH and PE, cardiomegally constituting 6/25 (24.0%) of the CTEPH cases. The current study showed that 30% of patients with (PH) and 36% with (CTEPH) have abnormal right ventricle morphology and supposed that the hypertrophied right ventricle made it spherical shape and greater than the left ventricle. The justification of this fact is that the demand of the right ventricle for oxygen exceeds the available supply, causing chamber dilation that leads to tricuspid regurgitation, a result of tricuspid annular dilatation and incomplete valve closure, these processes eventually result in right-sided heart morphology changes, this process is described well is other related studies [
Pulmonary trunk diameter in PH patients and CTEPH was found to be larger than patients with (PE) and normal control. The maximum width were found to be 55 mm and 42 mm which were consistent with the diagnostic criteria of pulmonary hypertension, that was mentioned previously that the enlargement of the main pulmonary artery to a diameter of more than 29 mm occurs in the presence of pulmonary hypertension [
The maximum changes in diameter differs from the normal by 1.81 mm, 4.13 mm, 5.2 mm for the right main pulmonary artery diameter and 1.49 mm, 4.26, 4.56 mm left main pulmonary artery diameter in PE, PH and CTEPH respectively with the maximum changes detected in the PH cases (
Cardiac signs in PH are the adaptation and failure of the right side of the heart that may be seen as right ventricular hypertrophy, straightening or leftward bowing of the interventricular septum; right ventricular dilatation and other findings [
Variables | Cases | N | Mean (mm) ± Std. Deviation | Minimum (mm) | Maximum (mm) |
---|---|---|---|---|---|
Right Atrium Diameter (mm) | PE | 55 | 49.51 ± 8.54 | 33.20 | 87.30 |
PH | 20 | 60.31 ± 11.49 | 37.50 | 90.70 | |
CTEPH | 25 | 57.42 ± 9.19 | 41.70 | 84.70 | |
Normal | 50 | 46.43 ± 6.44 | 36.70 | 77.00 | |
Right Ventricle Diameter (mm) | PE | 55 | 46.03 ± 6.23 | 32.90 | 68.30 |
PH | 20 | 51.41 ± 6.34 | 41.30 | 64.60 | |
CTEPH | 25 | 51.31 ± 5.94 | 36.50 | 58.70 | |
Normal | 50 | 42.25 ± 3.85 | 35.60 | 53.70 | |
Inter-Ventricular Septum Width (mm) | PE | 55 | 11.38 ± 1.82 | 8.30 | 20.80 |
PH | 20 | 10.81 ± 2.14 | 6.00 | 12.90 | |
CTEPH | 25 | 12.16 ± 1.98 | 5.70 | 15.30 | |
Normal | 50 | 11.00 ± 1.13 | 8.30 | 13.00 | |
Myocardium Thickening | PE | 55 | 7.1636 ± 0.97 | 5.50 | 10.50 |
PH | 20 | 6.95 ± 0.66 | 6.20 | 9.20 | |
CTEPH | 25 | 7.37 ± 0.88 | 6.10 | 9.10 | |
Normal | 50 | 6.95 ± 0.77 | 5.30 | 9.60 | |
Pulmonary Trunk Diameter (mm) | PE | 55 | 28.00 ± 3.70 | 19.50 | 37.10 |
PH | 20 | 34.54 ± 6.97 | 26.00 | 55.00 | |
CTEPH | 25 | 33.86 ± 3.63 | 27.20 | 42.30 | |
Normal | 50 | 25.17 ± 3.33 | 19.00 | 34.30 | |
Right Main Pulmonary Artery Diameter (mm) | PE | 55 | 20.70 ± 3.33 | 15.40 | 29.70 |
PH | 20 | 23.02 ± 3.63 | 19.20 | 31.50 | |
CTEPH | 25 | 24.09 ± 2.05 | 19.20 | 27.50 | |
Normal | 50 | 18.89 ± 2.81 | 12.90 | 25.10 | |
Left Main Pulmonary Artery Diameter (mm) | PE | 55 | 21.05 ± 3.37 | 15.20 | 30.00 |
PH | 20 | 23.82 ± 3.54 | 18.90 | 33.70 | |
CTEPH | 25 | 24.122.19 | 20.00 | 29.10 | |
Normal | 50 | 19.56 ± 3.02 | 14.10 | 26.70 | |
Right Distal Pulmonary Artery Diameter (mm) | PE | 55 | 3.21 ± 0.40 | 2.50 | 4.50 |
PH | 20 | 3.34 ± 0.30 | 2.70 | 3.70 | |
CTEPH | 25 | 3.43 ± 0.39 | 2.50 | 4.10 | |
Normal | 50 | 3.22 ± 0.32 | 2.50 | 4.10 | |
Left Distal Pulmonary Artery Diameter (mm) | PE | 55 | 3.23 ± 0.38 | 2.60 | 4.80 |
PH | 20 | 3.31 ± 0.35 | 2.50 | 3.90 | |
CTEPH | 25 | 3.42 ± 0.38 | 2.40 | 4.20 | |
Normal | 50 | 3.15 ± 0.29 | 2.40 | 3.80 |
of the studied cases, these were presented in
Tables 5-7 presented the significant difference between the variables which have been evaluated in patients with and without PE, PH and CTEPH. Right atrium, right ventricle, pulmonary trunk, right main pulmonary artery, left main pulmonary artery diameters measurements were changed significantly in both patients with PE and PH when compared with the norms. While in CTEPH all of the anatomical structures which have been evaluated including (heart segments, pulmonary tree) were differed significantly at p ≤ 0.05. Numerous studies have investigated the correlation between CT measurements of the pulmonary artery and the presence of PH. Overall,
Independent Samples Test* | ||
---|---|---|
Patients with and without PE | t-test for Equality of Means | |
t | Sig. (2-tailed) | |
Right Atrium Diameter (mm) | 2.071 | 0.041 |
Right Ventricle Diameter (mm) | 3.692 | 0.000 |
Inter-Ventricular Septum Width (mm) | 1.281 | 0.203 |
Myocardium thickening (mm) | 1.233 | 0.220 |
Pulmonary Trunk Diameter (mm) | 4.100 | 0.000 |
Right Main Pulmonary Artery Diameter (mm) | 2.982 | 0.004 |
Left Main Pulmonary Artery Diameter (mm) | 2.370 | 0.020 |
Right Distal Pulmonary Artery Diameter (mm) | −0.101 | 0.920 |
Left Distal Pulmonary Artery Diameter (mm) | 1.170 | 0.245 |
*Correlation is significant at p ≤ 0.05.
Independent Samples Test* | ||
---|---|---|
Patients with and without PH | t-test for Equality of Means | |
t | Sig. (2-tailed) | |
Right Atrium Diameter (mm) | 6.418 | 0.000 |
Right Ventricle Diameter (mm) | 7.389 | 0.000 |
Inter-Ventricular Septum Width (mm) | −0.480 | 0.633 |
Myocardium Thickening (mm) | 0.025 | 0.980 |
Pulmonary Trunk Diameter (mm) | 7.624 | 0.000 |
Right Main Pulmonary Artery Diameter (mm) | 5.092 | 0.000 |
Left Main Pulmonary Artery Diameter (mm) | 5.059 | 0.000 |
Right Distal Pulmonary Artery Diameter (mm) | 1.482 | 0.143 |
Left Distal Pulmonary Artery Diameter (mm) | 1.934 | 0.057 |
*Correlation is significant at p ≤ 0.05.
Independent Samples Test* | ||
---|---|---|
Patients with and without CTEPH | t-test for Equality of Means | |
t | Sig. (2-tailed) | |
Right Atrium Diameter (mm) | 6.013 | 0.000 |
Right Ventricle Diameter (mm) | 7.956 | 0.000 |
Inter-Ventricular Septum Width (mm) | 3.208 | 0.002 |
Myocardium Thickening (mm) | 2.120 | 0.037 |
Pulmonary Trunk Diameter (mm) | 10.323 | 0.000 |
Right Main Pulmonary Artery Diameter (mm) | 8.198 | 0.000 |
Left Main Pulmonary Artery Diameter (mm) | 6.694 | 0.000 |
Right Distal Pulmonary Artery Diameter (mm) | 2.529 | 0.014 |
Left Distal Pulmonary Artery Diameter (mm) | 3.453 | 0.001 |
*Correlation is significant at p ≤ 0.05.
the measurement of the main pulmonary artery size by using CT shows a moderate to strong correlation with PH [
The significant difference that was noticed in the measurements done in both normal patients and patients with CTEPH give the evaluation of the pulmonary artery and its branches an important approach; because the pulmonary artery size was associated with unexpected death [
In summary, although CT measurements of pulmonary artery dimensions have shown a correlation with the presence of PH, PE and CTEPH; the strength of the correlation is highly variable. Future studies could focus on specific disease and changes in the pulmonary artery size as a marker of prognosis, disease activity, and treatment response, rather than as an isolated measure. CT measures of pulmonary artery size are simple and can suggest a possible reason for dyspnea but it should be interpreted cautiously and not be used solely in either screening or guiding management in the patients with suspected PH or patients with PE and CTEPH. Our results suggest that right ventricle, right atrium dilation on CTPA may represent an additional marker of severe PE, PH and CTEPH and such patients should be considered as being at increased risk of adverse outcome. The current findings were reliable with Aran Singanayagam et al. (2010) scientific findings [
Limitations: Firstly, the presence of artifacts during breath holds technique because it is difficult to be done regarding the patients complain as shortness in breathing and chest pain. Secondly, relying on simple measurement might only provide limited information. However, our study in different patients’ diseases shows the value of uncomplicated measurements in axial CT images that are frequently performed as a first line examination. Third drawback was that our analysis involved relatively few patients and small sample size. Finally, using only the clinical features in diagnosing of PH without using another imaging or laboratory method; however a large set of data on various CT changes in different diseases were characterized.
Knowledge of the radiological features of PH, PE and CTEPH is mandatory for accurately diagnosing the condition and possibly will improve the outcome. Awareness of the various disease entities associated with PH and knowledge of the entire spectrum of their CT imaging features are essential. In the current study the pulmonary artery tree, cardiac segments and associated lung parenchyma findings have been evaluated and the added value of CT in prediction of estimating PH comparing with the normal control group was analyzed. It was found that CTA plays an important role in the diagnostic evaluation of patients with PH. CT imaging is acceptably used in establishing the diagnosis, defining the cause, quantifying heart segments and parenchyma changes in order to assess the feasibility of surgery, therapeutic planning and monitoring patients with PH.
Salah Eldein Hassan Aloub,Caroline Edward Ayad,Mohammed Elfadil Mohammed Gar Elnabi, (2016) Findings Associated with Pulmonary Hypertension: CT Angiography Based Study. Open Journal of Radiology,06,191-201. doi: 10.4236/ojrad.2016.63026