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Clinical and Imaging Profiles of Pulmonary Embolism: a Single Dandan et al. International Journal of Emergency Medicine (2020) 13:47 International Journal of https://doi.org/10.1186/s12245-020-00303-y Emergency Medicine ORIGINAL RESEARCH Open Access Clinical and imaging profiles of pulmonary embolism: a single-institution experience Omran Al Dandan1† , Ali Hassan1*† , Hossain AbuAlola1 , Alaa Alzaki2 , Abrar Alwaheed2 , Mohannad Alalwan2, Malak Al Shammari3 , Nouf AlShamlan3 and Hind S. Alsaif1 Abstract Background: Pulmonary embolism (PE) is a common life-threatening condition with non-specific clinical presentations. The diagnosis of PE depends highly on imaging studies, which may also provide prognostic information. This study aimed to describe the clinical and imaging profiles of patients with PE, emphasizing the differences between central and peripheral PE. Methods: After ethics review board approval, this retrospective observational study examined the non-negative results in adult patients who underwent computed tomography pulmonary angiography (CT-PA) at our hospital between May 2016 and December 2019. Demographic and clinical information and imaging findings were collected from the electronic medical records. Results: The study included 85 cases that were identified after re-interpreting the 103 non-negative CT-PA scans. Six cases were excluded for incomplete data and 12 cases were false-positive. Central PE was found in 63.5% of the cases. Obesity was the most common risk factor seen in 37.6% of the cases. Furthermore, 9.4% of the patients had sickle cell disease, which tended to be associated with peripheral PE. There was no difference between the peripheral and central PE in most clinical and imaging parameters evaluated (P > 0.05). However, patients with isolated subsegmental PE were more likely to develop hemoptysis (P = 0.04). Conclusion: This study suggests that patients with obesity and sickle cell disease constitute an important proportion of all PE cases. Furthermore, the clinical and imaging profiles in patients with peripheral PE are similar to those in patients with central PE. Future research should focus on the clinical value of peripheral PE in patients with sickle cell disease. Keywords: Computed tomography angiography, Pulmonary embolism, Sickle cell disease, Obesity Background presentations. Delaying or missing the diagnosis might Pulmonary embolism (PE) is a form of thromboembolic result in significant morbidity and mortality [1]. disease that is potentially life-threatening. The global Although the clinical features and risk factors for PE burden of PE has not been estimated; however, it ac- have been widely studied, a detailed evaluation of the counts for 100,000 deaths in the USA annually [1]. Des- geographic locations of these studies reveals that most pite being a common condition, PE can pose a were conducted in Europe, North America, and the Far diagnostic challenge because of its variable East. Little is known about the characteristics of patients with PE in the Middle East, particularly in Saudi Arabia. * Correspondence: [email protected] It would be of particular interest to explore the risk pro- †Omran Al Dandan and Ali Hassan contributed equally to this work. 1Department of Radiology, King Fahd Hospital of the University, Imam file for PE in this uncharted area, considering the rela- Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia tively higher prevalence of certain hematological Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Dandan et al. International Journal of Emergency Medicine (2020) 13:47 Page 2 of 10 disorders that may be associated with a thrombotic ten- assessed risk factors included immobilization, recent sur- dency [2, 3]. gery or trauma, presence of a previous venous thrombo- The definitive diagnosis of PE depends heavily on im- embolic disease, smoking status, obesity, sickle cell aging studies, with computed tomography pulmonary disease, use of a central venous catheter, exogenous es- angiography (CT-PA) being the imaging modality of trogen use, and a previously existing malignancy. choice. Additionally, because of its ability to establish a diagnosis of PE by demonstrating filling defects in the Clinical profile of pulmonary embolism pulmonary vasculature, CT-PA may allow the assess- Data on the clinical symptoms and signs at presenta- ment of other parameters, such as cardiovascular and tion, vital signs, clinical severity, management, and pleuroparenchymal features, that are prognostically rele- outcomes were recorded. The clinical severity of PE vant [4–6]. was assessed using the Pulmonary Embolism Severity This study sought to describe the clinical and imaging Index (PESI) [8], which is the most validated prognos- profiles of patients with PE who presented at an aca- tic tool for PE [9]. demic institution in the Eastern Province of Saudi Ara- bia. We also aimed to investigate whether there is any Imaging profile of pulmonary embolism difference between the profiles of central and peripheral Data on the chest radiographs and CT-PA scans were PE. The findings of this study will broaden our current obtained. The images were assessed for the presence of knowledge of PE in Saudi Arabia. filling defects in the pulmonary vasculature and for pleuroparenchymal abnormalities. Methods Study design and setting Definitions After ethics review board approval, we conducted a Hypoxia was defined as an oxygen saturation < 95% on retrospective study, wherein the clinical and imaging room air, tachycardia was defined as a heart rate > 100 profiles of PE were investigated. Particular emphasis was bpm, and hypotension was defined as blood pressure < placed on the differences between central and peripheral 90/60 mmHg. Obesity was defined as a body mass index PE. The study was conducted at the King Fahd Hospital ≥ 30 kg/m2, and immobilization was defined as bed rest of the Imam Abdulrahman Bin Faisal University. for more than 3 days. Recent surgery was defined as any surgery under general or regional anesthesia in the 4 Study population weeks prior to the PE diagnosis. Central PE was defined The Radiology Information System was searched to as occurring in the pulmonary trunk, main pulmonary identify all the requests for CT-PA scans between May arteries, or lobar pulmonary arteries; peripheral PE was 2016 and December 2019 for both hospitalized patients defined as occurring exclusively in the segmental or sub- and those in the Emergency Department (ED). Eligible segmental pulmonary arteries. Low-risk PE was defined participants were adult patients who underwent CT-PA as corresponding to PESI classes I–II, while high-risk PE to rule out PE. Exclusion criteria were as follows: (1) age was defined as corresponding to PESI classes III–V. < 18 years; (2) pregnancy; (3) purpose of scan was not to rule out PE; (4) chronic venous thromboembolism. Imaging interpretation Where more than one CT-PA scan had been carried out All images were independently interpreted by two con- on the same patient within the same clinical encounter, sultant radiologists, one of whom had fellowship training only the most recent scan was included, as other scans in chest imaging. Both radiologists were blinded to all were assumed to be of suboptimal image quality. patient information, and any discrepancies in interpret- ation were resolved by consensus. Data collection A structured data collection form was used to collect Statistical analysis data from the patient electronic medical records. Data Data were compiled using the QuestionPro platform (Se- included information related to demographics, as well as attle, WA, USA) and analyzed using IBM SPSS for Win- clinical and imaging profiles of PE. dows, version 25 (IBM Corp., Armonk, NY, USA). Categorical variables are presented as percentages and Background demographic information frequency distributions. Continuous variables are pre- Details of age, sex, comorbidities, risk factors, and clin- sented as median and interquartile range (IQR). The ical setting (ED vs. hospitalized patient) were collected. Kolmogorov–Smirnov and Shapiro–Wilk tests were used The Charlson Comorbidity Index (CCI) was used to as- to determine whether the data had a normal distribu- sess comorbidities. The CCI score can range from 0 to tion. Continuous data were compared using the inde- 37 and includes 17 different components [7]. The pendent t test or Mann–Whitney U test, as appropriate. Dandan et al. International Journal of Emergency Medicine (2020) 13:47 Page 3 of 10 Categorical variables were compared using the chi- respectively. The segmental and subsegmental arteries squared test or Fisher’s exact test, as appropriate. The were involved in 70 (82.4%) and 66 (77.6%) cases, re- significance level was set to α = 0.05. Due to the small spectively (Fig. 2), with only 8 cases having exclusive in- sample size, multivariable logistic regression was not volvement of subsegmental arteries. The background conducted. characteristics of the patients with central and peripheral PE are summarized in Table 1. Results Patient characteristics Severity of the pulmonary embolism The study involved 103 CT-PA scans with PE diagnosis The median PESI score was 55 (IQR 37–73).
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