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Pulmonary Infarction Thorax: first published as 10.1136/thx.28.2.198 on 1 March 1973. Downloaded from Thlorax (1973), 28, 198. Radiographic signs of pulmonary embolism and pulmonary infarction S. TALBOT, B. S. WORTHINGTON, and E. J. ROEBUCK General Hospital, Nottingham A comparative analysis of the radiographic features in a group of patients dying with pulmonary embolism and/or pulmonary infarction, and a group without but suspected of having the condi- tions before death, showed that two radiologists could diagnose pulmonary infarction correctly in 70% of cases. The most useful radiographic sign was elevation of the diaphragm often with slight atelectasis and a small unilateral effusion. The plain chest radiograph was of little value in diagnosing pulmonary embolism without infarction. Many radiographic signs of pulmonary embo- death (mean 1-96 days, SD 12), and six, of whom lism and infarction have been described in three had fibrosed infarcts, within three weeks. Three clinical cases (Fleischner, 1959; Westermark, cases of sudden massive embolism had radiographs taken shortly after symptoms occurred and within 1938). However, pulmonary embolism and infarc- four hours tion are frequently wrongly diagnosed, often being of death. missed and sometimes diagnosed when pulmon- copyright. ary infection or carcinoma are present. Marshall TABLE I (1965) stressed three radiological signs of infarc- PATHOLOGY OF NECROPSY CASES tion, namely, the shadow produced by the lesion, Pathological Diagnosis No. of Necropsies evidence of a pleural effusion, and a raised dia- Control No emboli or infarcts 57 phragm. Less frequent features associated with Thromboembolism Pulmonary emboli only 17 http://thorax.bmj.com/ Pulmonary infarction 3 embolism are increased radiotranslucency, pul- only monary oedema, and prominent main pulmonary Pulmonary embolism 46 arteries. These may, however, occur in other con- and infarction ditions, and it was therefore decided to take a control group of patients to find if any of these Twenty-three per cent of these cases had fractured changes are usually diagnostic of infarction, and femurs, and 6-9% died following abdominal surgery. also to show whether radiologists can diagnose Although it was difficult to identify the time of onset pulmonary embolism and infarction from routine of embolism or infarction this was usually a few days To be certain of the from death (4x8 days, SD 2-9 days). Clinical features on September 29, 2021 by guest. Protected plain radiographs. diagnosis, which in retrospect were typical of pulmonary emboli / only patients in whom necropsy evidence was infarction were recorded for 39 patients. These were available were studied. haemoptysis (10 patients), sudden dyspnoea (21 PATIENTS AND METHODS patients), pleuritic pain (9 patients), angina (3 patients), and syncope (5 patients). Often there was gradual From the hospital necropsy records of 1967 to 1970 deterioration with confusion and coma. Signs of con- inclusive, cases of pulmonary embolism and infarction solidation were noted in 15 patients and signs of a were selected if they had a chest radiograph. From 'pleural effusion' in five patients. Often the radio- the case records the date of the radiograph in relation graphs were performed to elucidate coincidental to death was determined, and radiographs showing infections or cardiac failure. evidence of infarction (>3 cm in diameter) or embolism The pathological examination included examination which was later proved at necropsy were selected. of the major, lobar, and segmental vessels. If thrombus This usually meant that only cases in whom infarction was firmly adherent it was assumed that embolism had been present for 48 hours or cases with necropsy had occurred at least 48 hours before death, and if evidence of fresh infarction, who had had a radio- lightly adherent at least 24 hours before death. Addi- graph performed from 12 to 24 hours before death, tional fresh embolism was not considered. There was were included. Of the 66 cases with emboli/infarction one case with an organized fibrosed pulmonary arterial (Table 1), 57 had radiographs within one week of occlusion, which was probably embolic. 198 Thorax: first published as 10.1136/thx.28.2.198 on 1 March 1973. Downloaded from Radiographic signs of pulmonary embolism and pulmonary infarction 199 At necropsy only 16 cases had unilateral emboli: the correct diagnosis, either by diagnosing infarc- of the 63 cases with emboli, 21 had major pulmonary tion or embolization when they were present or by artery emboli (±other emboli), 20 had lobar emboli not doing so when they were absent. Below this (± segmental emboli), and 22 had segmental emboli the incorrect diagnoses are analysed by a similar only. Of the 49 cases with infarcts, massive lobar method. infarcts were found in 7, infarction (>3 cm) in 35, and multiple small infarcts (<3 cm) were found in 7. At the time of the radiograph, in 31 cases there was right lower lobe infarction and in 23 cases left TABLE III lower lobe infarction: eight were bilateral. There RADIOLOGICAL DIAGNOSIS' CORRELATED WITH PATHOLOGICAL DIAGNOSIS were two cases with right upper lobe infarction alone, and of three left upper lobe infarctions two also had Radiologist A Radiologist B infarction elsewhere. There was one case with an Emboli Infarcts Emboli Infarcts abscess secondary to a right lower lobe infarction. A control series consisted of 57 radiographs from Correct diagnosis 66 92 71 81 Incorrect 57 31 52 42 1969 to 1970 on patients in whom the diagnosis of diagnosis pulmonary embolism or infarction was suspected Correct positive 19 24 27 17 Correct negative 47 68 44 64 at the time of their radiographs, but who did not Incorrect positive 13 6 16 10 have these conditions at necropsy; 24-5% were sur- Incorrect negative 44 25 36 32 gical cases. The causes of death in this control group 'A positive radiological diagnosis was made if there were radiological were usually pneumonia (29 cases), left ventricular features of infarction or emboli. failure (10 cases), myocardial infarction (7 cases), and carcinoma (6 cases). The percentage correct diagnosis of pulmonary The combined series of radiographs were then shown infarction was 74-7% for A and 65-8 % for B. to two radiologists, A and B, without the patient's The percentage correct diagnosis of pulmonary name or the pathological features being known and embolism was 53-6% for A and 57-7% for B. they were asked to comment on the radiological Thus the diagnosis was correct in 70% of features and whether they thought pulmonary infarc- patients with pulmonary infarction and in 55% copyright. tion was present. They also commented on the visibility of patients with pulmonary embolism. of the pulmonary vessels and whether they were normal or compatible with embolism. (If the lobar The probability of these figures being due to vessels were obscured by consolidation, they were con- chance for radiologist A was <0 01 for infarction sidered abnormal.) They commented on any other but not significant for emrbolization, xe being 24-6 features suggestive of embolism, and particularly and 0-75 respectively. For radiologist B, X2=6 54 http://thorax.bmj.com/ cardiomegaly, pleural effusions, pulmonary oedema, (P<O0O1) for infarction and X2=2-86 (P<0 10) for and pulmonary venous engorgement. Elevation of the embolism. diaphragm was noted if the right side was more than 1 inch higher than the left, or if the left side was higher than the right. TABLE IV All available radiographs were examined, but RADIOGRAPHIC FEATURES RELATED TO PATHOLOGY IN portable supine radiographs were included only when CASES OF PULMONARY EMBOLISM/INFARCTION AND CONTROL CASES they were part of a series of examinations. Table II shows the type of radiographs performed for both Pulmonary Emboli/Infarcts Controls controls and patients with pulmonary emboli/ (66 cases) (57 cases) on September 29, 2021 by guest. Protected infarction. Cardiomegaly 41 21 No cardiomegaly 24 36 Elevated diaphragm 26 5 Bilateral pleural 5 5 TABLE II effusions NUMBER AND FORM OF RADIOGRAPHIC EXAMINATIONS Unilateral large 4 8 effusion Unilateral small 12 7 No. of Necropsies effusion Radiographic Examination Pulmonary venous 11 10 Control Pulmonary Emboli/Infarcts hypertension Bilateral shadowing 8 7 Multiple examinations 12 21 Linear atelectasis 3 0 PA and lateral 9 9 PA only 26 23 AP only 10 13 The figures refer to the numbers of patients in each group with this radiological feature. Table IV shows some radiological features that RESULTS are usually associated with infarction and embo- An analysis of the correct and incorrect diag- lism. The only two that had significant association noses is shown in Table III. Below this are details were elevation of the diaphragm (Fig. 1) and of the patients on whom the radiologists made cardiomegaly (one radiograph was not assessed for Thorax: first published as 10.1136/thx.28.2.198 on 1 March 1973. Downloaded from -20-0 S. Talbot, B. S. Worthington, and E. J. Roebuck .W::, .i copyright. FIG. 1. Radiograph of a patient who subsequently died with pulmonary embolism/infarction: note high right diaphragm and cardiomegaly. http://thorax.bmj.com/ cardiomegaly). Correlation of an elevated dia- bined in the pathological and radiographic phragm and pulmonary infarction was most sig- analysis, as in Table V (for radiologist A, X3= nificant (x2=33 3, P<O01). This, therefore, seems 6&93, P<0 01, and for radiologist B, X2=3*24, P< to be a significant sign of pulmonary infarction, 0-10). Agreement between radiologists is expressed although it did occur in one case of subphrenic in Table VI (e2=42-7, P<001 for infarction; abscess, in one case of basal atelectasis, and in x= 10-4, P<001 for emboli). The time of the on September 29, 2021 by guest. Protected three cases of pneumonia. Obese patients or radiograph in relation to the age of the infarction patients having supine radiographs usually had made no difference to diagnostic accuracy.
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