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Case Reports Commentary 1088 Thorax 1998;53:1088–1096 Case reports Thorax: first published as 10.1136/thx.53.12.1094 on 1 December 1998. Downloaded from Spiral CT pulmonary angiography is an Commentary eVective way of demonstrating pulmonary embolism in segmental and larger arteries.4 The basic sign of a filling defect within a well David M Hansell opacified pulmonary artery is straightforward enough. The case report by Oliver et al2 highlights the fact that there may be ancillary signs of pulmonary embolism on spiral CT The common feature of the reports by Franco scanning—in this case shift of the interven- et al1 and Oliver et al2 is the use of spiral (or volumetric) computed tomography to demon- tricular septum—which corroborates the diag- strate features which would not be readily nosis and, more controversially, provides prog- identifiable on conventional computed tomo- nostic information. Shift of the interventricular graphic (CT) scanning. The advantages of spi- septum and other signs of right ventricular ral CT over conventional CT scanning are dysfunction are readily demonstrated on echo- twofold: increased speed of data acquisition cardiography, but in cases of suspected pulmo- and volumetric (rather than slice by slice) data nary embolism echocardiography does not acquisition. The attribute of speed means that provide the breadth of information of a spiral most thoracic examinations can be performed CT examination. For example, additional signs within a single breath hold and the timing of of pulmonary embolism, including a mosaic intravenous contrast administration can be perfusion pattern of the lung parenchyma and precisely tailored, thus allowing reproducible radiographically cryptic pleural eVusions or enhancement of any desired part of the small pulmonary infarcts, can be readily picked vasculature—for example, the pulmonary ar- up on spiral CT scanning. Conversely, because teries in cases of suspected pulmonary embo- spiral CT scanning provides the “big picture”, lism. Because an entire volume of data is an alternative diagnosis may be shown by spiral acquired (with almost equal spatial resolution CT scanning in up to one third of patients in the three axes) it is possible to reconstruct investigated for suspected pulmonary images in any plane, including three- embolism.5 dimensional (3-D) reconstructions.3 Most ex- The application of image processing to volu- aminations acquired with spiral CT scanning metric spiral CT data can be broadly divided are presented as a series of transaxial slices, into graphic 3-D realisations—for example, http://thorax.bmj.com/ reflecting the traditional presentation of con- virtual reality bronchoscopy6—and the render- ventional CT images. ing of data so that it is suitable for quantitative In the report by Franco et al1 the clarity with analysis. However, progress towards routine which the anomalous arteries feeding the volumetric (3-D) depictions of spiral CT data sequestrated lung are shown on the 3-D recon- is likely to be slow.7 Even at this early stage of structions is striking. In the past a separate development it is possible to extract very preoperative examination (either aortography precise volumetric measures of abnormal lung; or possibly magnetic resonance angiography) the most obvious application is in the quantifi- to identify the vascular supply would have been cation of low attenuation lung (corresponding on September 25, 2021 by guest. Protected copyright. regarded as mandatory. Other imaging tests to emphysema) on inspiratory and expiratory such as radionuclide scintigraphy or ultra- spiral CT scans. Early results have shown sound may answer specific questions in cases of remarkably good correlation between the pulmonary sequestration, but the wealth of extent of low attenuation lung derived from information now available from a single spiral 3-D reconstructions of the lungs with func- CT examination is remarkable. Quite apart tional indices of air flow obstruction and air from their aesthetic appeal, the main benefit of trapping.8 With this new technique the entire these readily produced 3-D reconstructions is lungs are evaluated, unlike the conventional an easy appreciation of what can be complex “density mask” approach which can be applied anatomy. Nevertheless, claims for the increased only to individual CT sections, (which intro- diagnostic gain from these 3-D reconstructions duces problems with sampling). With the pow- should not be too extravagant: the anomalous erful combination of volumetric data from spi- vessels would be identifiable on images pre- ral CT scanning and advanced image sented in the standard transaxial format, processing, the excitement has only just begun. although without such immediacy. Further- more, demonstration of the venous drainage into the pulmonary circulation (for the classic 1 Franco J, Aliaga R, Domingo ML, et al. Diagnosis of pulmo- nary sequestration by spiral CT angiography. Thorax Royal Brompton intralobar sequestrations) may not be so read- 1998;53:1089–92. Hospital, London ily obtained with a single spiral CT examina- 2 Oliver TB, Reid JH, Murchison JT. Interventricular septal SW3 6NP,UK tion. However, the ability to extract so much shift due to massive pulmonary embolism shown by CT D M Hansell pulmonary angiography: an old sign revisited. Thorax information from a spiral CT examination rep- 1998;53:1092–4. 3 Remy J, Remy-Jardin M, Artaud D, et al. Multiplanar and Correspondence to: resents a substantial advance on conventional three-dimensional reconstruction techniques in CT: im- Dr D M Hansell. CT scanning. pact on chest diseases. Eur Radiol 1998;8:335–51. Commentary 1089 4 Remy-Jardin M, Remy J, Deschildre F, et al. Diagnosis of pul- datasets: a comparison with fibreoptic bronchoscopy. Clin Thorax: first published as 10.1136/thx.53.12.1094 on 1 December 1998. Downloaded from monary embolism with spiral CT: comparison with pulmo- Radiol 1997;52:837–41. nary angiography and scintigraphy. Radiology 1996;200:699– 7 Rubin GD, Napel S, Leung AN. Volumetric analysis of 706. volumetric data: achieving a paradigm shift. Radiology 5 Cross JJ, Kemp PM, Walsh CG, et al. A randomized trial of 1996;200:312–7. spiral CT and ventilation perfusion scintigraphy for the 8 Mergo PJ, Williams WF, Gonzalez-Rothi R, et al. diagnosis of pulmonary embolism. Clin Radiol 1998;53: Three-dimensional volumetric assessment of abnormally 177–82. low attenuation of the lung from routine helical CT: 6 Chinn RJS, Mellor J, Yang GZ, et al. Three dimensional inspiratory and expiratory quantification. AJR 1998;170: computed tomography bronchoscopy using clinical 1355–60. Thorax 1998;53:1089–1092 mal portion of the lung. More recently, other Diagnosis of pulmonary procedures have been advocated as a less inva- sive means of identifying the anomalous artery. sequestration by spiral Although conventional computed tomographic CT angiography (CT) scanning can show both abnormal lung parenchyma and the systemic arterial supply,3 it lacks the multiplanar images which limits its usefulness in the diagnosis of sequestration. José Franco, Roberto Aliaga, María L With the advent of helical technology, spiral Domingo, Pedro Plaza CT angiography is able to delineate the aorta and its branches. The role of CT scanning in evaluating suspected pulmonary sequestration 4 Abstract should therefore be re-evaluated. The diagnosis of pulmonary sequestration In this report we describe the use of spiral traditionally requires arteriography to CT angiography to image the aberrant sys- identify abnormal systemic vessels feed- temic artery in four cases of pulmonary ing the abnormal portion of the lung. sequestration. Non-invasive imaging techniques have recently been used to replace arteriogra- Methods phy. Conventional computed tomographic We performed four CT angiography studies (CT) scanning is, however, at a disadvan- with a PQ2000S helical scanner (Picker Inter- tage because of its inability to obtain national Inc, Highlands Heights, Ohio, USA). multiplanar images. The combination of Spiral volumetric CT scanning was performed slip ring CT scanning and computerised with 4 mm slide thickness, 4 mm table speed, three-dimensional reconstruction (spiral 3 mm reconstruction index, and smooth recon- CT angiography) can be used to visualise struction algorithm. A non-ionic contrast me- the anatomical detail of a wide range of dium (120 ml, iodine 300 mg/ml) was adminis- vessels within the lung. Four cases of pul- tered at a rate of 3 ml/s via the antecubital vein. http://thorax.bmj.com/ monary sequestration are reported which were successfully diagnosed using spiral CT angiography. Spiral CT scanning al- lows simultaneous imaging of anomalous vessels and lung parenchyma in a single examination and is particularly useful in the diagnosis and assessment of pulmo- nary sequestration. (Thorax 1998;53:1089–1092) on September 25, 2021 by guest. Protected copyright. Department of Keywords: pulmonary sequestration; spiral computed Pneumology tomography J Franco P Plaza Pulmonary sequestration is a rare congenital Department of Radiology pulmonary disorder defined as an area of dys- R Aliaga plastic and non-functioning pulmonary tissue M L Domingo with an anomalous systemic blood supply.1 It has been classically described in two forms— University Hospital intralobar sequestrations located within the Dr. Peset, Valencia, visceral pleura and surrounded by normal Spain lung, and extralobar sequestrations which have Correspondence to: a separate pleural covering. Both types are sup- Dr J Franco, Centro de plied with
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