pulmonary embolism with right heart strain...pulmonary embolism - discussion • major risk factors...
TRANSCRIPT
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Pulmonary Embolism with Right Heart Strain
Saxon Hancock, MSIV
10/16/2019
RAD 4001 Diagnostic Radiology
Reviewed by: Dr. Manickam Kumaravel
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Clinical History
• History• 56 y/o M w/ PMHx of metastatic prostate cancer s/p radical prostatectomy
and recent diverging ileostomy has worsening O2 sat and SOB on 10/7
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Imaging at MD Anderson
• CXR
• CT Chest
• LE dopplers
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Baseline CT Chest
• Two weeks prior to symptom onset
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Bilateral PAs patent
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R. PA occlusion (red)L. PA occlusion (yellow)
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L. PA occlusions
R. PA occlusions
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RV
LV
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Aorta Pulmonary Artery
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Key Findings
• Low lung volumes on CXR
• Notable opacifications of bilateral pulmonary arteries
• Right ventricle measures larger than left ventricle
• Pulmonary artery measures larger than adjacent aorta
• Uncompressible LE veins
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Virchow’s Triad
• Long term inpatient has low mobility
• Metastatic prostate cancer
• Recent operation
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Pulmonary Embolism - Discussion
• Major risk factors in Virchow’s Triad
• Mortality rate of up to 30%
• Well’s Score:1. Clinical Signs/Sx of DVT
2. PE is #1 diagnosis or equal to #1 diagnosis
3. Pulse >100 BPM
4. 3 days of immobilization or surgery within last 4 weeks
5. Previously diagnosed DVT/PE
6. Hemoptysis
7. Malignancy treated within past 6 months or palliative
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Treatment
• Requires immediate treatment with LMWH unless the patient has contraindication
• This can be transitioned to DOACs or warfarin
• Anticoagulation should be continued for 3-6 months in first time clot with low suspected risk of recurrence
• For patients with malignancy this treatment period is extended based on clinical judgment
• Recurrence rate is as high as 21% in cancer patients
• Major bleeding events are also more frequent in cancer patients
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Radiologic Signs of PE
• Hampton’s Hump
• Westermark Sign
• Fleischner Sign
• Railway Sign
• Polo Mint Sign
Orange Arrow: Westermark Sign [Increased lucency of lung distal to occlusion.
Fleischner Sign: Enlargement of pulmonary artery
Hampton’s Hump: Wedge shaped infarct
Railway Track Sign: Central filling defect
Polo Mint Sign: Central filling defect
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ACR Appropriateness Criteria for Suspected Pulmonary EmbolismRadiologic Procedure Rating RRL
CXR 9 1
CTA Chest with IV Contrast 5 3
LE Doppler 3 0
https://acsearch.acr.org/docs/69404/Narrative/
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Cost of Imaging
CT Chest with Contrast
1417 3936
$3,344.00
Study Cost (Insured) Cost (Uninsured)
CXR 1 View $683 $246
CT Chest with Contrast $3963 $1417
BLE Doppler $2164 $779
https://www.memorialhermann.org/patients-caregivers/pricing-estimates-and-information/#accordion-1
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Summary
• 56 y/o M w/ PMHx of metastatic prostate cancer s/p radical prostatectomy and recent diverging ileostomy presented with worsening O2 sat and SOB was found to have bilateral PE on CT secondary to bilateral DVTs.
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References
1. McDermott S., Gilman M. Thoracic Imaging: The Requisites. Ch 11:238-258. 2010.
2. Goldacre MJ, Roberts S, Yeates D, Griffith M. Hospital admission and mortality rates for venous thromboembolism in Oxford region, UK, 1975-98. Lancet 2000; 355:1968.
3. Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005; 112:e28.
4. https://www.mdcalc.com/wells-criteria-pulmonary-embolism