Role of MDCT in Identification of the Bleeding Site and the Vessels Causing Hemoptysis

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1 MDCT Detection of leeding Site and Vessels Causing Hemoptysis Chest Imaging Pictorial Essay ntoine Khalil 1 Muriel Fartoukh 2 Marc Tassart 1 ntoine Parrot 2 Claude Marsault 1 Marie-France Carette 1 Khalil, Fartoukh M, Tassart M, Parrot, Marsault C, Carette M-F Keywords: bronchial arteries, chest imaging, hemoptysis, lung disease, MDCT, pulmonary artery DOI: /JR Received September 6, 2005; accepted after revision December 7, Department of Radiology, P-HP Tenon Hospital, 4 Rue de la Chine, Paris, France. ddress correspondence to. Khalil (antoine_khalil@yahoo.fr). 2 Respiratory Intensive Care Unit, P-HP Tenon Hospital, Paris, France. WE This is a Web exclusive article. JR 2007; 188:W117 W X/07/1882 W117 merican Roentgen Ray Society Role of MDCT in Identification of the leeding Site and the Vessels Causing Hemoptysis OJECTIVE. MDCT has improved the management of hemoptysis by providing more precise depiction of bronchial and nonbronchial systemic arteries than conventional CT. The purpose of this article is to review the role of MDCT in the identification of the bleeding site and the vessels causing hemoptysis. CONCLUSION. Identification of the origin of the involved systemic arteries (bronchial and nonbronchial) or involved pulmonary artery on MDCT enables the interventional radiologist to treat them, especially in elderly patients with a tortuous aorta and atheroma. emoptysis usually results from H systemic hypervascularization of the lung by bronchial and nonbronchial systemic arteries in contact with the pleura [1]. Hemoptysis is related to pulmonary artery injury in up to 11% of cases [2]. efore starting the examination, the interventional radiologist needs information about the bleeding side, the underlying disease, and the vascular origin of the bleeding causing hemoptysis (bronchial artery, nonbronchial systemic artery, pulmonary artery, or a combination of these arteries). During the past decade, the use of CT has focused on locating the bleeding site and determining the cause of hemoptysis [3]. Recently, Yoon et al. [4] evaluated the accuracy of single-detector helical CT in predicting the presence of a nonbronchial systemic arterial supply in patients with massive hemoptysis. Yoon et al. [5] and Remy-Jardin et al. [6] suggested that MDCT angiography provides a more precise depiction of the bronchial arteries than conventional angiography. This article illustrates the role of MDCT in the identification of the bleeding site and the vessels causing hemoptysis. MDCT Protocol MDCT evaluation of systemic vascularization (bronchial and nonbronchial) was performed using a 16-MDCT scanner (Sensation 16, Siemens Medical Solutions). The imaging parameters were as follows: beam width, 12 mm; beam pitch, 1; and reconstruction thickness, 0.75 mm every 0.5 mm at 120 kv and 180 m. Eighty milliliters (25.6 g I) of nonionic contrast agent (iodixanol 652 [Visipaque 320, mersham Health]) was administered IV at a rate of 3.5 ml/s via an automated injector device (Injectron CT2, Medtron) through an 18-gauge IV catheter. region of interest was placed on the descending aorta. When the density reached 120 H, craniocaudal scanning started 6 seconds later from the lung apex to the lung base; imaging was performed with the patient in the supine position at maximal inspiration during a single breath-hold. We used real-time axial scrolling, interactive maximum intensity projection, and volume-rendered techniques to evaluate the origin and course of the bronchial and nonbronchial arteries. Identification of the leeding Site Hemoptysis can generate two major signs in the lung parenchyma namely, groundglass opacities, alveolar condensation, or both (Fig. 1). Sometimes atelectasis can be caused by clots obstructing the bronchi. These abnormalities may help identify the bleeding site when they are unilateral or located in one lobe. When they are bilateral, CT is less accurate for locating the bleeding site. In rare cases, MDCT can show extravasation of contrast medium into a bronchus (Fig. 2) or intrapulmonary shunting (Fig. 3). Visualization of the leeding Vessels The bronchial circulation is the most frequent source of hemoptysis, but various nonbronchial systemic arteries and pulmonary ar- W117

2 teries may also contribute, depending on the underlying disorder [7]. natomically, a bronchial artery is defined as a vessel coursing along a major bronchus. Nonbronchial systemic vessels enter the pulmonary parenchyma through the adherent pleura or the pulmonary ligament, and their course is not parallel to that of the major bronchi. ronchial rtery Origin ronchial arteries are the main source of the systemic arterial supply to the lungs and also are the major type of vessel involved in hemoptysis. It is helpful to identify the origin of bronchial arteries before treatment (Fig. 4). More than 30% of bronchial arteries have an anomalous origin, which is a cause of endovascular treatment failure. ronchial arteries that originate inside the area between the T5 and T6 vertebrae at the level of the left main bronchus are considered to be normal [1]. berrant bronchial arteries may originate from the aortic arch (Fig. 5), internal mammary artery, thyrocervical trunk (Fig. 6), subclavian artery (Fig. 7), costocervical trunk, brachiocephalic artery, pericardiacophrenic artery, inferior phrenic artery, or abdominal aorta. In patients with hemoptysis, 16-MDCT can depict and trace the bronchial arteries (Fig. 8) and, in most cases, can be used to detect the bronchial arteries causing hemoptysis [5]. Yoon et al. [5], in a retrospective study comparing MDCT and angiography in 22 patients with hemoptysis, found that MDCT depicted all bronchial arteries causing hemoptysis that were identified on angiography. Five bronchial arteries had aberrant origins in that series [5]. Furthermore, Yoon et al. [5] showed a significant difference of the traceability from the origin to the hilum between bronchial arteries causing hemoptysis and those not causing it (Fig. 8). Remy-Jardin et al. [6] reported that MDCT provided a more precise depiction of bronchial arteries than did conventional angiography. Those researchers found that 3D images were more accurate than transverse CT scans for detecting bronchial arteries with aberrant origins. Nonbronchial Systemic rteries In some patients, bronchial bleeding arises from nonbronchial systemic arteries. When enlarged vascular structures are found in extrapleural fat with pleural thickening (3 mm), they can be considered as nonbronchial systemic arteries that are potentially responsible for hemoptysis [1]. The nonbronchial systemic arteries involved in hemoptysis are usually the intercostal arteries (Fig. 3), inferior phrenic arteries (Fig. 9), pulmonary ligament arteries, internal mammary arteries (Fig. 10), and other collaterals from the subclavian arteries [1]. MDCT depicted 16 (62%) of 26 nonbronchial systemic arteries seen on angiograms in the study by Yoon et al. [5] and all five nonbronchial arteries in the series reported by Remy-Jardin et al. [6]. Once the bleeding site has been located on CT, vascularization of the nonbronchial systemic arteries should be systematically attempted, especially for nonbronchial systemic arteries that potentially vascularize the region involved, such as the inferior phrenic artery (lower lobes and inferior segment of the lingula), the intercostal arteries (posterior thickening), and the internal mammary artery (anterior segment of the upper lobes, right middle lobe, and lingula) [1, 4]. Pulmonary rtery Origin Several clinical and MDCT signs suggest the origin of bronchial bleeding is a pulmonary artery, such as the persistence of hemoptysis despite appropriate systemic artery embolization (Fig. 11), the presence of a proximal cavity, and visualization of a pulmonary artery bordering a cavity (especially in a necrotic tumor). Other causes of hemoptysis of pulmonary artery origin can be visualized on MDCT, such as Rasmussen aneurysm [8], aneurysm due to vasculitis (e.g., ehçet s syndrome), and trauma (especially due to a Swan-Ganz balloon catheter). References 1. Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. ronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. RadioGraphics 2002; 22: Sbano H, Mitchell W, Ind PW, Jackson JE. Peripheral pulmonary artery pseudoaneurysms and massive hemoptysis. JR 2005; 184: Revel MP, Fournier LS, Hennebicque S, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? JR 2002; 179: Yoon W, Kim YH, Kim JK, Kim YC, Park JG, Kang HK. Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT. Radiology 2003; 227: Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ. Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT. Radiology 2005; 234: Remy-Jardin M, ouaziz N, Dumont P, rillet PY, ruzzi J, Remy J. ronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology 2004; 233: Carette MF, Khalil, Parrot. Haemoptysis: aetiology and management [in French]. EMC-Pneumologie 2004; 1: Picard C, Parrot, oussaud V, et al. Massive hemoptysis due to Rasmussen aneurysm: detection with helicoidal CT angiography and successful steel coil embolization. Intensive Care Med 2003; 29: W118

3 MDCT Detection of leeding Site and Vessels Causing Hemoptysis Fig year-old man with hemoptysis. C, xial (), sagittal (), and coronal (C) MDCT reconstructions with 1-mm-thick slice viewed at lung window settings show ground-glass opacities on anterior segment of left upper lobe. Multiplanar MDCT reconstructions (not shown) did not add information about location of bleeding site to findings shown on axial image. Fig. 2 Iodine extravasation into bronchi of 57-yearold woman with hemoptysis. ronchoscopy (not shown) had revealed active bleeding on left side without identifying precise lobe, whereas MDCT depicts bleeding site on left upper lobe., Sagittal multiplanar reconstruction image on lung window setting shows contrast medium (arrow) in bronchi of left upper lobe with air bubbles (arrowheads)., Sagittal multiplanar reconstruction image on mediastinal window setting shows same density in bronchi (arrows) and left pulmonary artery (asterisk) as that shown in. W119

4 Fig year-old man with right upper lobe atelectasis due to tubercular sequelae complicated by aspergilloma was admitted for mild hemoptysis. Shunt was placed in pulmonary artery., Coronal thin-slab maximum-intensity-projection (MIP) image shows enhancement of pulmonary arteries (arrows) with reflux into right main pulmonary artery (arrowhead)., Coronal oblique thin-slab MIP shows enlargement of right bronchointercostal trunk (black arrow), bronchial artery (white arrows), and intercostal arteries. Note enlargement of intercostal arteries (black arrowheads) in comparison with other normal-sized intercostal arteries (white arrowheads). C, Right bronchointercostal trunk angiogram shows pulmonary artery shunt, with reflux from right superior pulmonary artery (arrows) into right main pulmonary artery (arrowhead). This pulmonary system shunting is related to systemic hypervascularization and is not major CT sign for bleeding site. Fig. 4 Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. C, Thin-slab maximum-intensity-projection (MIP) MDCT images of superior left bronchial artery (arrow, ), common lower bronchial trunk (arrow, ), and right bronchointercostal trunk (arrow, C). Note good visualization of bronchial artery divisions of right bronchointercostal trunk (arrowheads, C). (Fig. 4 continues on next page) W120

5 MDCT Detection of leeding Site and Vessels Causing Hemoptysis Fig. 4 (continued) Normal anatomy of bronchial arteries on MDCT in 45-year-old man admitted for treatment of mild hemoptysis. D, Right bronchointercostal trunk angiogram corresponding to C shows normal branching of bronchial arteries is from right intercostal trunk (arrowheads) or from descending thoracic aorta (arrow) between levels of T5 and T6 vertebrae. D C D E Fig. 5 nomalous origin of upper left bronchial artery from aortic arch in 65-year-old man. D, Four consecutive 3-mm thin-slab maximum-intensity-projection (MIP) images in axial plane show anomalous origin of upper left bronchial artery from right aspect of aortic arch (arrow, ) and trajectory under aortic arch (arrowheads, D). E, Coronal 8-mm thin-slab MIP image shows ectopic bronchial artery and its trajectory (arrowheads). Ostium of ectopic bronchial arteries is branching from descending thoracic aorta other than expected origin (i.e., outside level T5 T6), such as from level of aortic arch or from any aortic collateral vessel. W121

6 D E Fig. 6 nomalous origin of upper left bronchial artery from thyrocervical trunk in 72-year-old man. C, Serial axial 1-mm slices show origin (arrow, ) and course (arrowheads) of left bronchial artery. D and E, Three-dimensional volume-rendered image (D) and angiogram (E) show ectopic bronchial artery (arrowheads). Fig. 7 nomalous origin of right lower lobe bronchial artery from right subclavian artery in 64-year-old man with massive hemoptysis. Chest radiography examination (not shown) depicted hilar necrotic mass with disseminated bronchiectasis. ronchoscopy (not shown) did not locate bleeding site but showed infiltration of left upper lobe bronchus., xial 3-mm thin-slab maximum-intensity-projection (MIP) slice shows anomalous origin (arrow) of right lower lobe bronchial artery. (Fig. 7 continues on next page) W122

7 MDCT Detection of leeding Site and Vessels Causing Hemoptysis C Fig. 7 (continued) nomalous origin of right lower lobe bronchial artery from right subclavian artery in 64- year-old man with massive hemoptysis. Chest radiography examination (not shown) depicted hilar necrotic mass with disseminated bronchiectasis. ronchoscopy (not shown) did not locate bleeding site but showed infiltration of left upper lobe bronchus., Coronal 5-mm thin-slab MIP slice shows anomalous trajectory of lower lobe bronchial artery (arrows). C, Right subclavian artery angiogram obtained using humeral approach shows anomalous right bronchial artery (arrows) with anomalous trajectory. Fig. 8 Mediastinal and hilar trajectory of normotopic right bronchial artery in 61-year-old man with massive hemoptysis., xial 3-mm thin-slab maximum-intensity-projection (MIP) image shows tubular and punctiform enhanced vascular lesion through mediastinum and hilum (arrowheads)., Coronal 10-mm thin-slab MIP image shows enlarged right bronchial artery (arrow) from aorta to hilum (arrowheads). Note good visualization of bronchial arteries in right hilum. W123

8 C Fig. 9 Systemic nonbronchial artery hypervascularization in 29-year-old pregnant woman with massive hemoptysis. and, xial () and coronal () 1-mm slices show lingular and right middle lobe atelectasis (arrow, ) secondary to bronchiectasis. Lingular ground-glass opacities (asterisk) reveal bleeding site. C, Coronal 10-mm thin-slab maximum-intensity-projection image shows transpleural hypervascularization (arrows) from left inferior phrenic artery. D, Left inferior phrenic artery angiogram confirms systemic nonbronchial artery hypervascularization (arrow). D W124

9 MDCT Detection of leeding Site and Vessels Causing Hemoptysis Fig. 10 Systemic nonbronchial artery hypervascularization in 55-year-old woman with hemoptysis related to tubercular sequelae., xial 2-mm thick-slab image shows right internal mammary artery (arrow) is enlarged in comparison with left internal mammary artery (arrowhead) and reveals right middle lobe atelectasis (asterisk)., Coronal 5-mm thin-slab maximum-intensity-projection image shows right internal mammary artery hypertrophy with hypertrophic collateral (arrows) to right middle lobe atelectasis. Fig. 11 Pulmonary artery false aneurysm in patient described in Figure 7 (64-year-old man with massive hemoptysis) who was readmitted to ICU for hemoptysis recurrence (400 ml) 1 week after bronchial artery embolization with microparticles and microcoils. Repeat MDCT angiography depicted pulmonary artery false aneurysm., xial 3-mm thick-slab maximum-intensity-projection (MIP) image shows irregularity with enlargement of right upper lobe subsegmental pulmonary artery (arrow)., Oblique coronal 3-mm thick-slab MIP image clearly shows false aneurysm (arrow) and microcoil (arrowhead) from previous treatment session. C, Subsegmental pulmonary artery angiogram confirms false aneurysm (arrow). This subsegmental artery was occluded with coils. Hemoptysis did not recur during 1 year of follow-up. W125