SYMPOSIA
Diagnosing Pulmonary Embolism
New Computed Tomography Applications
Konstantin Nikolaou, MD, Sven Thieme, MD, Wieland Sommer, MD,
Thorsten Johnson, MD, and Maximilian F. Reiser, MD
Abstract: Computed tomographic pulmonary angiography has
become the standard of care for the evaluation of patients with
suspected pulmonary embolism (PE). In addition to the direct
depiction or exclusion of a pulmonary embolus in suspected PE, a
number of predictive markers have been established to evaluate the
patient’s prognosis in acute and in chronic PE. An accurate risk
stratification based on CT findings is crucial because optimal
management, monitoring, and therapeutic strategies depend on the
prognosis. With the recent introduction of the so-called ‘‘dual-
source’’ CT scanners, that is, a scanner consisting of 2 tubes and
2 detectors mounted orthogonally to each other, different tube
voltages can be used simultaneously, resulting in different energies
of the emitted x-ray spectra (dual-energy CT; DECT). Initial results
have shown that DECT is capable of iodine mapping of the
pulmonary parenchyma, reliably depicting the segmental defects in
iodine distribution in locations corresponding to embolic vessel
occlusions. This study deals with a number of actual topics on PE
imaging with multidetector CT and DECT, including the discus-
sion of the relevant imaging findings to assess the patient’s
prognosis, the potential and additional benefit of dual-energy
information on the parenchymal iodine distribution, the optimiza-
tion of scan protocols including low-radiation dose chest pain
protocols, and the discussion on future perspectives of CT in PE
patients, such as the role of computer-aided diagnostic tools or the
potential of ventilation imaging with DECT.
Key Words: pulmonary embolism, computed tomography, dual-
source computed tomography, dual-energy computed tomography
(J Thorac Imaging 2010;25:151–160)
C omputed tomographic pulmonary angiography (CTPA)
has become the standard of care for the evaluation
of patients with suspected pulmonary embolism (PE) in
most institutions. Acute PE is the third most common acute
cardiovascular disease after myocardial infarction and
stroke, and results in many deaths each year.1 Typically,
the initial diagnostic tests include the D-Dimer essay, with
an inherent good sensitivity, but rather poor specificity.2
Ventilation-perfusion scintigraphy (V/Q scan) had repre-
sented the standard imaging procedure before the introduc-
tion of contrast-enhanced (multi-) spiral CT. However,
From the Department of Clinical Radiology, University Hospitals
Munich, Grosshadern Campus, Ludwig-Maximilians-University of
Munich, Germany.
Reprints: Konstantin Nikolaou, MD, Department of Clinical Radio-
logy, Grosshadern Campus, Ludwig-Maximilians-University of
Munich, Marchioninistr. 15, 81377 Munich, Germany (e-mail:
konstantin.nikolaou@med.lmu.de).
Copyright r 2010 by Lippincott Williams & Wilkins
J Thorac Imaging  Volume 25, Number 2, May 2010
because of the lower diagnostic accuracy of V/Q scans,
with only moderate specificity,3 reduced availability and
longer acquisition times needed, CT has become the
modality of choice in suspected PE.4 Despite this recent
encouraging use of CTPA in PE patients, early meta-
analyses on single-slice spiral CTPA have detected strongly
varying diagnostic accuracies, with sensitivities ranging
from 53% to 100%, and specificities between 83% and
100%.5 With the introduction of the multidetector-row
CT (MDCT), diagnostic accuracy has improved consis-
tently over the recent years.6–8 The PIOPED II trial used
4-detector, 8-detector, and 16-detector-row CT scanners in
a multicenter setting and reached a combined sensitivity
and specificity of CTPA and CT venography of 90% and
95%, respectively,9 establishing the important role of
MDCT angiography as the main diagnostic test in PE.
Obviously, the diagnostic features as assessed by
CTPA can be helpful in acute PE, and in patients suffering
from chronic pulmonary hypertension, potentially leading
to pulmonary arterial hypertension in the latter course of
the disease, referred to as chronic thrombembolic pulmo-
nary hypertension. Acute PE may manifest as complete
arterial occlusion, with the affected artery often being
enlarged, or as partial filling defects that are often centrally
located. Chronic PE can manifest as complete occlusive
disease in vessels that are smaller than adjacent patent
vessels. Other CT pulmonary angiographic findings in
chronic PE include evidence of recanalization, webs or
flaps, and partial filling defects.
In addition to the direct depiction or exclusion of a
pulmonary embolus in suspected PE, a number of predictive
markers have been established to evaluate the patient’s
prognosis in acute and chronic PE. Accurate risk stratifica-
tion based on the CT findings is crucial because optimal
management, monitoring, and therapeutic strategies depend
on the prognosis.10 Most important, acute right-sided heart
failure is known to be responsible for circulatory collapse
and death in patients with severe PE. That is why a number
of studies have elaborated on the detailed assessment of the
right heart in acute and chronic PE settings, including
morphologic right heart dimensions and functional para-
meters implementing electrocardiogram (ECG)-gated CT
studies in PE patients.11,12
In 2006, the first MDCT scanner capable of dual-
energy CT (DECT) imaging was introduced. This scanner
type is the so-called ‘‘dual-source’’ CT scanner; that is, it
consists of 2 tubes and 2 detectors mounted orthogonally
to each other. With this type of CT scanner, different tube
voltages can be used simultaneously, resulting in different
energies of the emitted x-ray spectra.13 Initial results have
shown that DECT is capable of iodine mapping of the
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Nikolaou et al
pulmonary parenchyma, reliably depicting segmental de-
fects in iodine distribution in locations corresponding to
embolic vessel occlusions.14,15
The following study will deal with a number of actual
topics on PE imaging with MDCT and DECT, including
the discussion of relevant imaging findings to assess the
patient’s prognosis, the potential and additional benefit of
dual-energy information on the parenchymal iodine dis-
tribution, the optimization of scan protocols including low-
radiation dose chest pain protocols, and the discussion on
future perspectives of CT in PE patients, such as the role of
computer-aided diagnostic (CAD) tools or the potential of
ventilation imaging with DECT.
PROGNOSTIC VALUE OF CT IN PE PATIENTS
Risk stratification is important in patients with PE
because optimal management, monitoring, and therapeutic
strategies depend on the prognosis. Acute right-sided heart
failure is known to be responsible for circulatory collapse
and death in patients with severe PE. If untreated, PE is
fatal in up to 30% of patients, but the death rate can be
reduced to 2% to 10% if PE is diagnosed and treated
promptly.16 When PE is fatal, patients usually die after right
ventricular (RV) failure and circulatory collapse, which
frequently occur within the first hours after admission. This
suggests that RV dysfunction (RVD) should be diagnosed
rapidly to identify patients who could benefit from
fibrinolytic therapy.17
Acute right-sided heart failure can be assessed at CTPA
by measuring the dimensions of right-sided heart cavities or
upstream venous structures, such as the superior vena cava
or azygos vein. The magnitude and severity of PE can be
calculated by applying clot load scores in the pulmonary
arteries (Miller and Walsh scores18,19) or by applying adapted
or dedicated CT angiographic scores (Qanadli, Bankier, and
Mastora scores20–22). The advent of modern MDCT scanners
allows for CTPA to be performed with electrocardiographic
gating, permitting new advances in the assessment of acute
right-sided heart failure, such as measurement of the left
ventricular (LV) and RV ejection fraction.
The typical CT-based cardiovascular parameter mea-
surements that can be derived from a standard, nondual-
energy, non-ECG-triggered CTPA data set include RV and
LV short-axis measurements; RV short-axis to LV short-
axis (RV/LV) ratios; main pulmonary artery (PA), ascend-
ing aorta, azygos vein, and superior vena cava diameters;
and main PA diameter to aorta diameter ratios. Reflux of
contrast medium into the inferior vena cava, leftward
bowing of the interventricular septum, pleural or pericardial
effusion, pulmonary consolidation, infarct, plate-like atelec-
tasis, and mosaic ground-glass opacity can also be recorded.
Ghaye et al23 have retrospectively evaluated PA clot load
scores and the above-mentioned CT parameters in 82
consecutive PE patients. RV and LV short axis; RV/LV
ratio; azygos vein, superior vena cava, and aorta diameters;
and contrast medium reflux into the inferior vena cava were
significantly different between survivors and nonsurvivors
after an acute PE event. No significant relationship was
found between PA clot load and mortality rate. RV/LV
ratio and azygos vein diameter allowed correct prediction
of survival in 89% of patients. Quiroz et al24 described the
additional benefit of dedicated 4-chamber view reconstruc-
tions in PE patients. Their study on 63 PE patients
concluded that RV enlargement on the reconstructed CT
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J Thorac Imaging  Volume 25, Number 2, May 2010
4-chamber views predicts adverse clinical events in patients
with acute PE and that these data are superior to those from
axial views for identifying high-risk patients. Kamel et al25
compared the indices of RVD obtained from axial
transverse images with those derived from the reconstructed
4-chamber and short-axis views in patients with acute PE. In
the study cohort, RV/LV diameters and RV/LV areas
obtained from axial transverse images and the reconstructed
4-chamber views were not statistically different. The
investigators concluded that in patients with acute PE, the
indices of RVD derived from axial transverse images and
the reconstructed 4-chamber views yield comparative values.
Given the simplicity of the axial analysis, without the need
of time-consuming post-processing for reconstruction of
short-axis 4-chamber views and area measurements, the
axial diameter measurements and RV/LV ratios as derived
from the source data could serve as a routine screening tool
for risk stratification in acute PE.
In conclusion, risk stratification of patients with PE
is important because optimal management, monitoring,
and therapeutic strategies depend on prognosis. The above-
mentioned studies have shown that CTPA not only allows
the diagnosis of PE by directly depicting the clots, but
also enables an assessment of PE severity. Cardiovascular
CT findings, such as the RV/LV diameter ratio, have shown
a significant correlation with fatal outcome, whereas
quantification of PA clot load remains controversial.26,27
Many CT findings that may allow refinement of the risk
stratification are still under evaluation. Although more
complex morphologic and functional findings may be useful
for the assessment of treatment effectiveness, their effect on
prognosis in patients with severe PE is today still being
debated in the literature.
DECT OF LUNG PERFUSION
CT Pulmonary Perfusion Imaging: Background
In the diagnostic workup of PE or pulmonary arterial
hypertension, the assessment of regional lung perfusion
is an important part of diagnostic imaging. The estab-
lished imaging methods of pulmonary perfusion are nuclear
medicine modalities, that is, planar lung perfusion scinti-
graphy or single photon-emission computed tomography
(SPECT). In addition, magnetic resonance imaging (MRI) of
lung perfusion has emerged as an alternative tool. When
compared with nuclear medicine imaging methods, lung
perfusion MRI offers the advantage of a time-resolved
quantification of regional lung perfusion, allowing for the
calculation of semiquantitative (time-to-peak) and absolute
perfusion parameters (pulmonary blood flow and volume,
mean transit time).28–31 However, today, CTPA is the
method of choice in the diagnosis of acute PE, as outlined
above. Interestingly, the decisive criterion for the diagnosis of
PE differs between nuclear medicine methods and CTPA. In
V/Q (ventilation/perfusion) planar scintigraphy or SPECT,
the diagnosis of PE is made on the basis of a characteristic
ventilation and perfusion mismatch, that is, on a visualization
of functional parameter changes with a reduced perfusion in
lung areas that are normally ventilated. In CTPA, in contrast,
PE is primarily diagnosed on the basis of embolic clot
detection in the pulmonary arterial vasculature, that is, on
morphologic changes. This basic difference in the underlying
principle for the diagnosis of PE partially accounts for
differences in the diagnostic performance of CTPA and
nuclear medicine methods. Although both SPECT of
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J Thorac Imaging  Volume 25, Number 2, May 2010
pulmonary ventilation and perfusion and CTPA could be
shown to have a higher diagnostic accuracy when compared
with planar ventilation/perfusion (V/Q) scintigraphy,32–34
SPECT has shown slightly higher sensitivity in the detec-
tion of peripherally located PE when compared with CTPA
by visualizing peripheral perfusion defects resulting from
tiny clots at the subsegmental arterial level that are too
small to be detected in CT. Thus, it seems that despite
the quoted advantages of CT in the field of lung imaging,
the lack of functional information regarding pulmonary
parenchymal perfusion remains a potential drawback of
conventional CT. In the past, the only viable method for
lung perfusion imaging with CT was a dynamic CT scan of
selected lung regions during parenchymal contrast material
uptake. Although this method allows for an assessment of
dynamic, that is, time-resolved, perfusion parameters, the
main disadvantage with dynamic scanning is an increased
radiation dose and a limited coverage of the lungs, further
complicated in patients who are unable to hold their breath
during the time-resolved data acquisition.35,36
DECT of the Lung: Methods
With the introduction of DSCT and DECT, the concept
of iodine distribution mapping, that is, functional imaging
of organ ‘‘perfusion’’ and material differentiation, is now
accessible for clinical examinations, as initially shown by
Johnson et al.13 In principle, DECT imaging allows for
material differentiation based on the different absorption
characteristics of different types of tissue. Compared with
subsequent scans of the same volume at 2 energy levels, the
use of this technique enables simultaneous dual-energy image
acquisition in the same phase of contrast enhancement.
Iodine, a commonly used CT contrast material, is generally
known to produce higher attenuation at lower tube voltage
settings.37 Because of this effect, the spectral information
on images obtained at different voltage settings allows for the
differentiation of iodine from materials that do not exhibit
this behavior. Selective visualization of iodine distribution
in body tissues such as the pulmonary parenchyma is,
therefore, a potential advantage of dual-energy imaging. In
fact, real ‘‘perfusion’’ imaging would be based on a dynamic,
repetitive, that is, time-resolved, acquisition of the lung after
intravenous administration of contrast medium.38 DECT
images do not yield this type of dynamic perfusion
information because they display iodine distribution at only
a single time point, providing an iodine map of the lung
microcirculation (Fig. 1).15 Within normal lung parenchyma,
the iodine content of the capillary bed can thus be compared
with the ‘‘parenchymal’’ phase of a conventional or digital
angiogram. However, the enhancement within the lung
microvessels depends on a number of factors, such as the
volume and flow rate of the contrast agent administered,
and on the site of its administration.14 In addition, all the
anatomic structures through which the iodinated contrast
agent travels before and after the pulmonary capillary level
will affect iodine distribution within the lung microcircula-
tion, such as the systemic venous return, the right side of the
heart, large pulmonary arteries and veins, the left side of the
heart, the aorta, and peripheral arteries. Finally, the anatomic
status of the lung parenchyma needs to be included in the
analysis of DECT iodine maps. For example, an atelectatic
lung zone may remain perfused to a certain degree, but less
perfused than normally ventilated areas. Despite these
potential limitations of a single-time-point, DECT iodine
map of the lung, a good correlation between vessel
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Diagnosing Pulmonary Embolism
occlusion depicted at CTA and defects in the iodine
distribution on dual-energy scans could be found.39 In
conclusion, initial results indicate that iodine distribution in
the pulmonary parenchyma is closely related to pulmonary
perfusion, for example, as assessed by scintigraphy. In
addition, even if dual-energy acquisition does not corres-
pond to true perfusion imaging, as it visualizes only
blood volume and not blood flow, several advantages of
this imaging technique can be underlined. Compared with
scintigraphy and MRI, it is the only imaging modality
able to provide high-quality morphologic analysis and
functional information on the pulmonary circulation from
the same data set.
The first generation of DSCT scanners, introduced in
2005, had a rather small field of view of the second detector.
Therefore, in up to 80% of the cases, a small portion of the
peripheral lungs could not be assessed in the reconstructed
dual-energy images.40 The recently introduced second
generation of DSCT systems provides a field of view of the
second detector of 33 cm, enabling the depiction of the whole
lungs in most patients (Fig. 2). With regard to the radiation
dose of dual-source, DECT scans, the dose values for dual-
energy protocols have been reported to range from 229 to
382 mGy cm for chest/abdomen examinations.13 Investiga-
ting a cohort of 117 patients in the clinical context of acute
PE, Pontana et al41 reported a mean dose-length product of
280 mGy cm for DECT angiograms of the chest, correspond-
ing to an average effective patient dose of about 5 mSv. This
value is even lower than the European reference value of
650 mGy cm. Thus, even if the dose of DECT of the thorax
can be a little bit higher than the dose values reported for a
standard, single-source, single-energy thoracic CT, the
above-mentioned benefits of DECT of the lung in patients
with suspected PE seem to justify the moderate increase in
the overall radiation dose. It is the only technique allowing
for a direct comparison of CT angiograms acquired at
different energies in the same patient, at the same time point
after the injection of the contrast medium, and within strictly
similar hemodynamic conditions.
DECT of the Lung: Available Data and Clinical
Indications
Acute PE
To validate the diagnostic accuracy of DECT in
the detection of PE against pathologic analysis with the use
of an animal model, Zhang et al42 have evaluated the
feasibility and added value of DECT in the diagnosis of PE
in an animal model. After the injection of gelatin sponge
particles into the pulmonary artery, 8 rabbits underwent
contrast-enhanced dual-source CTPA from which blood
flow and fusion images were created. Immediately after CT,
the rabbits were killed, and a detailed pathologic determi-
nation of the location and number of lung lobes with PE
was performed. On the dual-energy blood flow images,
segments with an embolic region showed low perfusion
compared with segments with a normal pulmonary region.
The investigators concluded that DECT improved the
detection of acute PE in rabbits compared with CTPA
alone. Fused images (images that are a combination
of blood flow images and CT pulmonary angiograms),
which simultaneously provide morphologic and functional
information, provided complementary information that
maximized the accuracy of CT in the detection of PE. In
addition, it has already been shown by several investigators
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FIGURE 1. Sixty-year-old female patient with suspected PE. In the CTPA images, no embolism was found. From the same CT data set,
DE information can be derived. Here, DE iodine mapping [in axial (A) and sagittal (B) reconstructions] showed a homogeneous iodine
distribution without suspicion of a perfusion defect caused by an embolus, that is, in good correlation to the CT angiographic finding.

that DECT can detect endoluminal clots in patients on
averaged images of tubes A and B as efficiently as single-
source CTA.41 In this study, the authors have also validated
the detectability of perfusion defects beyond obstructive
clots. Perfusion defects in the adjacent lung parenchyma
have the typical territorial triangular shape well known from
pulmonary angiographic, scintigraphic, and MRI perfusion
studies (Figs. 3, 4). DECT angiography can lead to the
depiction of perfusion defects without direct identification
of peripheral endoluminal clots located within the subseg-
mental or more distal branches. Another advantage of
DECT is the ability to use the diagnostic information
available from tube B, set at 80 kV. As this tube voltage
optimizes the contrast-to-noise ratio within pulmonary
vessels, it can help detect peripheral endoluminal clots
known to be better visualized than on images acquired at
120 or 140 kV.43,44 The iodine map can also be used as an
additional parameter in the assessment of pulmonary artery
obstruction score in the clinical context of acute PE.
In another pilot study, Thieme et al45 compared the
diagnostic value of DECT in the assessment of pulmonary
perfusion with reference to pulmonary perfusion scinti-
graphy. For this purpose, 13 patients were included, who
underwent DECT and scintigraphy. The results were com-
pared by patient and by segment, and the diagnostic
accuracy of DECT perfusion imaging in the detection of PE
was calculated with regard to scintigraphy as the standard
of reference. The diagnostic accuracy of DECT pulmonary
iodine maps showed 75% sensitivity, 80% specificity, and a
negative predictive value of 66% per patient. Sensitivity per
segment amounted to 83% with 99% specificity, with 93%
negative predictive value. CTPA identified corresponding
emboli in 66% of patients with concordant perfusion
defects in DECT and scintigraphy. The investigators con-
cluded that DECT perfusion imaging is able to display
pulmonary perfusion defects with good agreement with
scintigraphic findings.
Chronic PE and Other Indications
DECT pulmonary angiography can also allow for the
depiction of perfusion defects in patients with chronic PE
or patients with chronic thrombembolic pulmonary hyper-
tension. A typical imaging characteristic of chronic PE
can be mosaic patterns of lung attenuation, that is, areas
of ground-glass attenuation mixed with areas of normal
lung attenuation, suggesting a redistribution of blood flow.

FIGURE 2. Comparison of 2 DE iodine distribution maps of the lung. On the left (A), an axial DE reconstruction image is shown from a
first-generation DSCT scanner. Here, the field of view of the second detector allows only for a reconstructed image of 26 cm. This is why
the DE information is not available in the lung periphery in many cases. With introduction of the second-generation DSCT system, the
second detector was increased in size, allowing for a reconstruction of 33 cm diameter for the second tube. This is sufficient for complete
DE information of the lungs in most patients (B).

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J Thorac Imaging  Volume 25, Number 2, May 2010
FIGURE 3. Sixty-seven-year-old female patient with massive bilateral PE. On the DE iodine maps combined with the CTPA images in
transverse (A) and coronal (B) orientation, several segmental perfusion defects can be observed (asterisks), with corresponding
thrombotic clots in the pulmonary arteries, as shown here on the right side (arrowheads).
Here, DECT could help to differentiate ground-glass
attenuation of vascular origin in PE patients (by means of
the high iodine content within the areas of ground-glass
attenuation) from ground-glass attenuation secondary to
bronchiolalveolar diseases.46 In addition, chronic PE can
lead to the development of calcifications within partially or
completely occlusive chronic clots and within pulmonary
artery walls when chronic PE is complicated by long-
standing and/or severe pulmonary hypertension. Such
calcifications within the pulmonary arteries can be detected
and differentiated from contrast within these vessels by means
of ‘‘virtual noncontrast imaging,’’ that is, subtraction of
iodine from the contrast-enhanced data sets, a function that
is always accessible from DECT data.
Besides acute and chronic PE, alterations in pulmo-
nary perfusion are present in numerous stages of smoking-
related respiratory diseases. Several structural changes in
the early stages of chronic obstructive pulmonary disease
have been described in experimental models, including
proliferation of smooth muscle fibers within peribronchio-
lar arterioles and deposition of collagen and elastin in the
FIGURE 4. Forty-year-old female patient with acute PE. The
transverse fused image showing the angiographic and perfusion
map information clearly indicates a complete perfusion defect
of right lung segment 1 (asterisk) with a decrease of vascular
diameters related to proximal embolic segmental vessel occlusion
(arrowhead) and a subsegmental perfusion defect in the left lung
segments 1 and 2 (asterisk).
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Diagnosing Pulmonary Embolism
thickened intima.47 In preliminary studies, Hoffman et al48
have shown increased heterogeneity of local mean transit
times of the contrast agent within the pulmonary micro-
vasculature of smokers with normal pulmonary function
tests. Recently, Pansini et al49 have assessed the pulmonary
perfusion on a lobar level in smokers, using DECT. Forty-
seven smokers and 10 nonsmokers underwent a DECT of
the chest. Emphysema was present in 37 smokers and
absent in 10 smokers. Smokers with an upper lobe pre-
dominance of emphysema (n=8) showed a significantly
lower contrast enhancement in the upper lobes compared
with smokers without emphysema. In addition, a correla-
tion was found between the difference in the percentage of
emphysema between the upper and lower lobes and the
difference in contrast attenuation in the corresponding
lobes. Thus, regional alterations of lung perfusion can be
depicted by DECT in smokers with emphysema.
CT IN PATIENTS WITH ACUTE CHEST PAIN
Clinical Aspects
The diagnosis of patients with acute chest pain
remains a challenging problem. There are approximately
6 million chest-pain-related emergency department visits
annually in the United States alone.50 Approximately 5.3%
of all emergency department patients are seen because of
chest pain, and reported admission rates are between 30%
and 72% for these patients.51 Comprehensive CTA proto-
cols for a complete assessment of the thoracic vessels, often
referred to as ‘‘triple rule-out’’ protocols, are increasingly
used in the differential diagnosis of chest pain. These
protocols aim to opacify pulmonary and coronary arteries
and the aorta simultaneously to rule out PE, coronary
artery disease, and aortic aneurysm or dissection in a single
examination. Currently, there are no guidelines that have
been published for the use of CT for acute chest pain. Initial
appropriateness criteria have recently been published.52
More general guidelines are currently under development.
In a recent consensus paper, the investigators discussed the
available evidence for the use of CT in chest pain patients,
to provide guidance to the practitioner and to provide a
basis for practice with evolving technologies.53 The authors
of this paper state clearly that in the emergency department
setting, the symptoms and clinical signs of patients with
chest pain are variable, but it is important to distinguish
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Nikolaou et al
life-threatening causes that need rapid or immediate
intervention from those that are less likely to be fatal but
still need in-patient treatment, and those that can be
managed supportively on an out-patient basis.54 Patients
who present to the emergency department with a suspected
PE can be risk-stratified using the Wells clinical decision
rule. The likelihood of PE is low if the score is 4 or less and
the D-dimer is negative.55 If the patient has a score greater
than 4, then further investigations are required to exclude
the diagnosis of PE. Hence, the most commonly used
imaging technique is a contrast-enhanced chest CT. A
negative CT study is associated with a low risk for
subsequent fatal and nonfatal venous thromboembolism.
Therefore, in the patient with undifferentiated chest pain
and a moderate-to-high probability of PE, a CT is indicated.
Technical Aspects and Optimization of Protocols
MDCT is currently the diagnostic test of choice for the
diagnosis of PE and acute aortic syndrome. As mentioned
above, alternative diagnoses may also be found or excluded
as causes of chest pain. If MDCT was robust enough
to additionally exclude an acute coronary syndrome in
patients without ST elevation, and sensitive enough to
indicate which patients with non-ST-elevation myocardial
infarction are likely to have treatable coronary disease, it
might be used to shorten the observational period for
patients with chest pain and suspected acute coronary
syndrome to either rule out cardiac causes for chest pain or
ensure timely institution of specific therapy. However, as
of today, there are no large prospective studies where
‘‘triple rule-out’’ MDCT has been used for this purpose,
and further research is desirable to better define the role
for these protocols. Quite a few studies have meanwhile
shown the feasibility of a simultaneous evaluation of these
vascular territories in 1 single breath-hold scan with good
sensitivity in the identification of the cause of chest
pain.56–60 However, a major limitation of initial MDCT
chest pain studies, especially in acutely ill patients, is the
restricted image quality of the coronary arteries in high
heart rates.61 With the advent of DSCT, cardiac imaging
has shown robust image quality and very good diagnostic
accuracy of coronary CTA, even in high heart rates.62,63
However, in first-generation DSCT scanners, triple rule-out
protocols have been associated with rather high volumes of
contrast (up to 150 mL) and highly effective radiation doses
in the range of 15 to 20 mSv.57 These facts were considered
as significant drawbacks of initial 64-slice CT and first-
generation DSCT triple-rule-out protocols.
With the recently introduced second-generation DSCT,
a new high-pitch dual spiral technique offers the possibility
to acquire an ECG-gated synchronized data set of the whole
chest in less than 1 second and at very low radiation doses
(Fig. 5). In a first study on the use of this second-generation
DSCT in chest pain patients, Sommer et al64 have compared
the dose of such a chest pain protocol to a standard, non-
ECG-gated chest scan and to a conventional, retrospectively
ECG-gated triple-rule-out protocol, in a phantom model
and in patients. The efficacy and dose of this dual spiral
protocol were compared in patients examined with this
high-pitch technique and a matched control group scanned
with the conventional technique. The equivalent dose
determined with thermoluminescent dosimeter measure-
ments in the phantom model amounted to 2.65, 2.68, and
19.27 mSv, respectively, for the new, high-pitch dual spiral
technique; the standard, non-ECG-gated chest scan; and the
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FIGURE 5. With introduction of the second-generation DSCT
systems, an ECG-gated contrast-enhanced CT of the thorax can
be performed in less than 1 second and with very low equivalent
radiation dose values, which are more than 5 times lower as
compared with earlier triple-rule-out CT protocols. Due to a table
speed of up to 43 cm per second, the scan of a 28 cm cranio-
caudal range takes about 0.6 to 0.7 seconds. The ECG trigger is
scheduled such that the lower part of the chest, incorporating
the heart, is scanned in diastole. The scan time of the entire heart
is about 250 to 300 ms, during 1 single heart beat.
conventional retrospective technique. There was no sig-
nificant difference in image noise. In the patient examina-
tions, the dose was 4.08±0.81 mSv with the high-pitch
protocol compared with 20.4±5.3 mSv in the matched
controls with the conventional technique, and 4.40±
0.83 mSv for the non-ECG-gated thorax scan. Scan times
were 0.7±0.1 seconds for the high-pitch scan and 15±3
seconds for the conventional chest pain scan. The aorta and
pulmonary arteries were shown in diagnostic quality in both
groups. Of the coronary artery segments, 95.4% were rated
as diagnostic in the high-pitch examinations (in heart rates
below 65 bpm), whereas 92.9% of coronary artery segments
were of diagnostic image quality with the conventional
approach (Figs. 6–8, for clinical examples with this high-
pitch protocol). There are other additional advantages in
scanning the entire chest with the high-pitch ultra-high
temporal resolution protocol; for example, in scanning adult
patients with limited ability to cooperate, or in patients from
intensive care units because of very short scan time. This fast
and low-dose high-pitch triple-rule-out protocol is also of
special interest in the diagnosis of PE, as one can exploit the
possibility of reduction or suppression of motion artifacts in
the heart and the surrounding mediastinal and parenchymal
structures. In summary, the high-pitch protocol is a very
promising means of scanning the entire thorax and could
become the standard CT angiographic protocol for chest
pain patients.
PERSPECTIVES AND CONCLUSIONS
Computer-aided Detection in the Diagnosis of PE
New tools could further enhance the diagnostic
performance of MDCT in the diagnosis of PE. Earlier
studies have evaluated the feasibility and performance of
CAD tools for the automated detection of segmental and
subsegmental pulmonary emboli. Schoepf et al65 have tested 1
such CAD tool (ImageChecker CT, R2 Technology, Inc) in
23 patients with PE and 13 patients without PE. Data
were collected with a 16-slice CT. The performance of the
CAD tool for the detection of emboli in the segmental and
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J Thorac Imaging  Volume 25, Number 2, May 2010
FIGURE 6. Sixty-one-year-old male patient examined with a
high-pitch DSCT triple-rule-out protocol because of unclear chest
pain. Scan time was 0.7 seconds. Equivalent radiation dose was
2.4 mSv. Contrast volume applied was 100 mL. No morphologic
correlate of the chest pain could be found, with normal depiction
of the aorta (black asterisk), the pulmonary artery (white asterisk),
the pulmonary arteries (white arrowheads), and the coronary
arteries (black arrowhead, right coronary artery).
subsegmental pulmonary arterial tree was assessed. A
consensus reading of 2 experienced radiologists revealed
130 segmental pulmonary emboli and 107 subsegmental
pulmonary emboli in the 23 patients with PE. All 23
patients with PE were correctly identified as having PE by
the CAD system. In vessel-by-vessel analysis, the sensitivity
of the CAD algorithm was 92% (119/130) for the detection
of segmental pulmonary emboli and 90% (92/107) for
subsegmental pulmonary emboli. The overall specificity,
positive predictive value, and negative predictive value of
the algorithm were 89.9%, 63.2%, and 97.7%, respectively.
The average false-positive rate of the CAD algorithm was 4.8
(range, 1 to 9) false-positive detection marks per case. The
investigators concluded that CAD of segmental and subseg-
mental pulmonary emboli based on 1-mm multidetector-row
FIGURE 7. Seventy-five-year-old male patient with acute chest pain examined with the high-pitch dual-source technique. There is a PE
in the right lower lobe pulmonary artery (A, arrowhead). In addition, there are extensive pleural effusions on both sides (B, asterisks).
The heart rate in this patient was 74 bpm. Scan time, equivalent radiation dose, and contrast volume in this patient amounted to 0.7
seconds, 3.5 mSv, and 100 mL, respectively.
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Diagnosing Pulmonary Embolism
CT studies is feasible. Application of CAD tools may
improve the diagnostic accuracy and decrease the interpreta-
tion time of CTA for the detection of pulmonary emboli in
the peripheral arterial tree and further enhance the accep-
tance of this test as the first-line diagnostic modality for
suspected PE.
Dual-energy Xenon Ventilation Imaging
of the Lung in PE Patients
In the evaluation of lung function, ventilation assess-
ment is an important component. Presently, ventilation
imaging is mainly realized using nuclear medicine methods33
or MRI with the inhalation of polarized noble gases, that is,
3
Helium or 129Xenon,66 or gadolinium chelate aerosols.67 A
drawback of these methods is the rather limited morphologic
information in scintigraphy or SPECT, as well as restricted
spatial resolution and lack of information on the pulmonary
microstructure in both MRI and nuclear medicine imaging.
Whenever high-resolution morphologic information on
structural changes of the lung parenchyma is needed, MDCT
is the first-line imaging modality that can provide this
important morphologic information, applying the so-called
high-resolution protocols. In combination with DECT,
comprehensive imaging for morphology, angiography, perfu-
sion, and ventilation could become feasible in PE patients.
The inert gas xenon has x-ray absorption characteristics
that resemble those of iodine and can therefore serve as an
inhalative contrast agent for CT ventilation imaging.68,69
Although there have been trials in the past decades to use
stable xenon gas for CT ventilation imaging, this method has
so far not been used in clinical care. These earlier approaches
were based on sequential chest scans, implying an increased
patient dose and potential misregistrations because of varying
levels of inspiration.70 With dual-source scanners, DECT
now has the potential to map xenon distribution patterns
by directly visualizing the inhaled xenon gas. Chae et al69
performed xenon-enhanced DECT in 12 patients at an
inspiratory xenon concentration of 30%, and showed the
technical feasibility of DECT ventilation imaging. Using
DECT with inhalation of xenon and intravenous iodine
administration, a comprehensive assessment of pulmonary
morphology and function, including both ventilation and
perfusion imaging, becomes possible with CT. Future studies
will deal with the use of DE ventilation imaging in
combination with DE perfusion mapping in patients with
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Nikolaou et al J Thorac Imaging  Volume 25, Number 2, May 2010

FIGURE 8. Fifty-five-year-old male patient with acute chest pain examined with the high-pitch dual-source technique. The whole thorax
can be depicted in a volume-rendering technique, giving an overview on all major vascular structures (A), scanned in 0.7 seconds, with
an adequate vascular opacification in all vascular territories. There is a PE in the left upper lobe pulmonary artery (B, arrowhead). In
addition, there are extensive pleural effusions on both sides (asterisks). Image quality is sufficient for dedicated cardiac postprocessing,
without any motion artefacts (C) (heart rate, 66 bpm). In addition to the PE, the coronary CT angiographic analysis revealed a
potentially significant stenosis in the middle segment of the left anterior descending coronary artery (D, arrowhead).

pulmonary functional impairment, for example, after PE, or
in cases of worsening of the gas exchange during intensive
care treatment, to evaluate the feasibility of a comprehensive
diagnostic evaluation including ventilation, perfusion, mor-
phology, and structure of the parenchyma. However, to
differentiate perfusion from ventilation information, 2 DECT
scans would have to be performed. The first scan with inhaled
xenon, and the second scan after intravenous administration
of iodinated contrast material, will have to be performed to
map the parenchymal distribution of iodine and to correlate
changes in ventilation and perfusion with structural or
vascular abnormalities. As inhaled xenon can have anesthetic
properties at higher concentrations,25,26 future studies will
also have to deal with the optimal inspiratory concentration
of the inhaled xenon.
Conclusions
As outlined above, MDCT, and especially DSCT, will
remain the most powerful and clinically most important tool
in the evaluation of PE patients. Routine MDCT pulmonary
angiography offers an accurate and quick depiction of the
pulmonary clots, and this method is available nearly every-
where. In addition, MDCT can provide crucial information
on the hemodynamic stability and prognosis of a patient
suffering from acute PE. New acquisition strategies, such as
dual-energy techniques (perfusion imaging, ventilation ima-
ging, direct thrombus imaging) and very fast and low-dose
acquisition protocols such as the second-generation DSCT
high-pitch chest pain protocol, will further strengthen this
position.
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