1. Advances in Pulmonary Embolism Imaging Kelly MacLean; David Tso; Ferco Berger; Anja Reimann; Chris Davison; Joao Inacio; Ahmed Albuali; Savvas Nicolaou ASER 2010
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11. Modified Wells Criteria Wells PS et al. Thromb Haemost 2000 Mar; 83(3):416-20. Clinical symptoms of DVT (leg swelling, pain with palpation) 3.0 Other diagnosis less likely than PE 3.0 Heart rate >100 1.5 Immobilization or surgery in previous 4 weeks 1.5 Previous DVT/PE 1.5 Hemoptysis 1.0 Malignancy 1.0 PE Likely >4 PE Unlikely </= 4
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13. The Christopher Study – Workup Algorithm Writing Group for the Christopher Study Investigators JAMA. 2006; 295:172-179. Patient with clinically suspected pulmonary embolism Modified Wells Score PE Unlikely D-Dimer ELISA PE Likely MDCT-PA Indicated Normal Abnormal
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28. MDCT Findings Large saddle thrombus with extensive clot burden. Arrows demonstrating tram-track sign (A), rim sign (B), complete filling defect (C), and a fully non-contrasted vessel (D) A B C D
34. Contrast seen in IVC, indicating RV strain Bilateral mosaic attenuation
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38. Diagnostic Imaging Algorithm Adapted from Agnelli G; Becattini C. N. Engl. J. Med. 2010;363:266-74. Elevated D-Dimer or High clinical probability MDCT-PA V/Q Scan if contraindication to contrast Negative PE confirmed May consider venous U/S but will be positive in less than 1% of patients Diagnostic Non-diagnostic PE confirmed PE ruled out Venous U/S
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Editor's Notes
ASER limits to 40 slides per presentation. Suggest tightening intro to make more succint
Discuss pathophysiology of tissue death, preload, RV strain
Incorporate this into a table with Signs & Symptoms together
Perhaps cut out this table and stick with summaries points
Zoom into MDCT
Using positive U/S as diagnosis of PE would mean: Sensitivity 29% Specificity 97% Benefits: Avoid 14% of lung scans and 9% of angiograms Drawbacks: Unnecessary treatment in false positives (13%)
Flow chart
David/Dr. Nicolaou – should I mention here anything about pros/cons of adding lower-limb CT venography?
Incorporate PIOPED III Trial into limitations section next slide
CT- PA: spell out acronym CT able to determine other causes
Awaiting Charles Uh for protocols Need to get VGH protocols
Need to make arrows more accentuated, use “Shapes” under drawing tools in Powerpoint Make image bigger,
Increase afterload, can’t generate enough pressures Restate why contrast may end up in IVC
Mosaic attenuation – should use lung window
Is it okay we use these slides – technically is this presentation for educational purposes? Question: How do we score clot burden?
Please have this in lung windows
Where is CXR in this diagram. Also need to eliminate Venous U/S since it’s not done.
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