Download PDF
Der Nuklearmediziner 2008; 31(4): 279-289
DOI: 10.1055/s-2008-1077016
Lungendiagnostik

© Georg Thieme Verlag Stuttgart ˙ New York

V / Q-Szintigrafie zur Diagnostik der Lungenembolie – I. Durchführung und Beurteilung

Diagnosis of Lung Embolism by V / Q Scintigraphy – I. Application and InterpretationC. Schümichen1
  • 1Klinik und Poliklinik für Nuklearmedizin, Universität Rostock
Further Information

Publication History

Publication Date:
02 December 2008 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Die V / Q-Szintigrafie ist auch heute noch zur Diagnostik der Lungenembolie hervorragend geeignet. Die Kombination von Ventilations- und Perfusionsszintigrafie ist in dieser Abfolge die Regel. Geeignete Tracer für die Ventilationsszintigrafie sind Technegas und Krypton-81m und erst in zweiter Linie ein Feuchtaerosol. Als Mindestanforderung sollten 6–8 planare Projektionen aufgenommen werden. Optimal ist die Akquisition in SPECT-Technik. Korrelat der Lungenembolie ist ohne diagnostische Einschränkung der regionale Perfusionsausfall bei erhaltener Ventilation (V / Q-Mismatch). Eine Befundung nach PIOPED-Kriterien ist abzulehnen. Auf teilokkludierende Emboli ist zukünftig verstärkt zu achten, da sie auch Einfluss auf die Prognose haben. Relevante Nebendiagnosen betreffen die Atemwegsobstruktion (V / Q-Match bei wirksamem Euler-Liljestrand-Reflex) sowie den funktionellen Rechts-Links-Shunt (V / Q-Reverse-Mismatch bei gestörtem Euler-Liljestrand-Reflex).

Abstract

V / Q scintigraphy remains even today exceptionally well-suited for diagnosis of pulmonary embolism. The combination of ventilation and perfusion scintigraphy in this sequence is standard. Suitable tracers for ventilation scintigraphy are Technegas and Krypton-81m, with wet aerosols as second-choice alternatives. Acquisition in SPECT-technique is optimal. Regional perfusion defects with maintained ventilation (V / Q mismatch) correlate to pulmonary embolism without diagnostic limitations. Evaluation by means of PIOPED criteria should be rejected. Increased attention should be paid to partially-occluding embolisms, since they also influence the prognosis. Relevant alternative diagnoses refer to respiratory tract obstruction (V / Q match with intact v. Euler-Liljestrand reflex) and functional right-left shunt (V / Q reverse mismatch with impaired v. Euler-Liljestrand reflex).

Schlüsselwörter

Lungenemboliediagnostik - V / Q-Szintigrafie - PIOPED-Kriterien - teilokkludierende Emboli

Key words

lung embolism diagnosis - V / Q scintigraphy - PIOPED criteria - partially-occluding emboli

Literatur

  • 1 Arnason T, Wells P S, Forster A J. Appropriateness of diagnostic strategies for evaluating suspected venous thrombembolism.  Thromb Haemost. 2007;  97 195-201
    PubMedGoogle Scholar
  • 2 Baile E M, King G G, Muller N L et al. Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism.  Am L Respir Crit Care Med. 2000;  161 1010-1015
    PubMedGoogle Scholar
  • 3 Bajc M, Olsson C G, Olsson B et al. Diagnostic evaluation of planar and tomographic ventilation / perfusion lung images in patients with suspected pulmonary emboli.  Clin Physiol Functional Imaging. 2004;  24 249-256
    CrossrefPubMedGoogle Scholar
  • 4 Bomanji J, Alawadhi H, Beale A et al. Clinical outcomes of patients with suspected pulmonary embolism using 99Tcm-Technegas as a ventilatory agent for lung scanning.  Nucl Med Commun. 1992;  13 467-477
    CrossrefPubMedGoogle Scholar
  • 5 Burrage J W, Causer D A. Comparison of scatter doses from a multislice and a single slice CT scanner.  Australas Phys Eng Sci Med. 2006;  29 257-259
    PubMedGoogle Scholar
  • 6 Camner P, Anderson M, Philipson K et al. Human bronchiolar deposition and retention of 6-, 8- and 10-micrograms particles.  Exp Lung Res. 1997;  23 517-535
    PubMedGoogle Scholar
  • 7 Coche E, Verschuren F, Keyeux A et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi-detector row spiral CT and planar ventilation-perfusion scintigraphy.  Radiology. 2003;  229 757-765 ,  Erratum in: Radiology 2004; 232: 627–628
    CrossrefPubMedGoogle Scholar
  • 8 Creutzig H, Gonda S, Saure D. Early changes in acute pulmonary embolism as seen in the scintigram and on x-ray film (author's tran).  Rontgenblatter. 1981;  34 402-407
    PubMedGoogle Scholar
  • 9 Garg K, Sieler H, Welsh C H et al. Clinical validity of helical interpreted as negative for pulmonary embolism: implications for patient treatment.  Am J Roentgenol. 1999;  172 1627-1631
    PubMedGoogle Scholar
  • 10 Ghuysen A, Ghaye B, Willems V et al. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism.  Thorax. 2005;  60 956-961
    CrossrefPubMedGoogle Scholar
  • 11 Goodman L R, Lipchik R J, Kuzo R S et al. Subsequent pulmonary embolism: risk after a negative helical CT pulmonary angiogram-prospective comparison with scintigraphy.  Radiology. 2000;  215 535-542
    PubMedGoogle Scholar
  • 12 Henry J W, Relyea B, Stein P D. Continuing risk of thromboemboli among patients with normal pulmonary angiograms.  Chest. 1995;  107 1375-1378
    CrossrefPubMedGoogle Scholar
  • 13 ICRP Publication 53 .Radiation dose to patients from radiopharmaceuticals. Oxford: Pergamon Press; 1988
    Google Scholar
  • 14 ICRP Publication 80 . Radiation dose to patients from radiopharmaceuticals. Addendum 2 to ICRP Publication 53.  Annals of the ICRP. 1998;  28 1-126
    PubMedGoogle Scholar
  • 15 Kahn D, Bushnell D L, Dean R. Clinical outcome of patients with a “low probability” of pulmonary embolism on ventilation-perfusion lung scan.  Arch Intern Med. 1989;  149 377-379
    CrossrefPubMedGoogle Scholar
  • 16 Kawakami K, Iwamura A, Goto E et al. Kinetics and clinical application of 99mTc-technegas.  Kaku Igaku. 1990;  27 725-733
    PubMedGoogle Scholar
  • 17 Kearon C, Ginsberg J S, Douketis J et al. Canadian Pulmonary Embolism Diagnosis Study (CANPEDS) Group: An evaluation of D-dimer in the diagnosis of pulmonary embolism: a rendomized trial.  Ann Intern Med. 2006;  144 812-821
    CrossrefPubMedGoogle Scholar
  • 18 Kim Y K, Lee K S, Chung M P et al. Pulmonary involvement in Churg-Strauss syndroma: an analysis of CT, clinical, and pathologic findings.  Eur Radiol. 2007;  17 3157-3165
    CrossrefPubMedGoogle Scholar
  • 19 Koller C J, Eatough J P, Bettridge A. Variations in radiation dose between the same model of multislice CT scanner at different hospitals.  Br J Radiol. 2003;  76 798-802
    CrossrefPubMedGoogle Scholar
  • 20 Lee M E, Biello D R, Kumar B. “Low-probability” ventilation perfusion scintigramms: clinical outcomes in 99 patients.  Radiology. 1985;  156 497-500
    PubMedGoogle Scholar
  • 21 Loewy J, O'Brodovich H, Coates G. Ventilation scintigraphy with submicronic radioaerosol as an adjunct in the diagnosis of congenital lobar emphysema.  J Nucl Med. 1987;  28 1213-1217
    PubMedGoogle Scholar
  • 22 Lorut C, Ghossains M, Horellou M H et al. A noninvasive diagnostic strategy including spiral computed tomography in patients with suspected pulmonary embolism.  Am J Respir Crit Care Med. 2000;  162 1413-1418
    PubMedGoogle Scholar
  • 23 McQuenn A S, Worthy S, Keir M J. Investigating suspected acute pulmonary embolism – what are hospital clinicians thinking?.  Clin Radiol. 2008;  63 642-650
    CrossrefPubMedGoogle Scholar
  • 24 Monaghan P, Provan I, Murray C et al. An improved radionuclide technique for the detection of altered pulmonary permeability.  L Nucl Med. 1991;  32 1945-1949
    PubMedGoogle Scholar
  • 25 Moser K M, Fedullo P F, LitteJohn J K et al. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis.  JAMA. 1994;  271 223-225
    CrossrefPubMedGoogle Scholar
  • 26 Nielsen H K, Husted S E, Krusell L R et al. Silent pulmonary embolism in patients with deep venous thrombosis. Incidence and fate in a randomized, controlled trial of anticoagulation versus no anticoagulation.  J Intern Med. 1994;  235 457-461
    CrossrefPubMedGoogle Scholar
  • 27 Otmani A, Tribouilloy C, Leborgne L et al. Diagnostic value of echocardiography and thoratic spiral CT angiography in the diagnosis of acute pulmonary embolism.  Ann Cardiol Angiol. 1998;  47 707-715
    PubMedGoogle Scholar
  • 28 Parent F, Maitre S, Meyer G et al. Diagnostic value of D-dimer in patients with suspected pulmonary embolism: Results from a multicentre outcome study.  . 2006;  ,  Epub
    PubMedGoogle Scholar
  • 29 Parker J A, Coleman R E, Siegel B A et al. Procedure guideline for lung scintigraphy: 1.0. Society of Nuclear Medicine.  J Nucl Med. 1996;  37 1906-1910
    PubMedGoogle Scholar
  • 30 Partsch H, Oburger K, Mostbeck A et al. Frequency of pulmonary embolism in ambulant patients with pelvic vein thrombosis: a prospective study.  J Vasc Surg. 1992;  16 715-722
    CrossrefPubMedGoogle Scholar
  • 31 Perrier A, Howarth N, Didier D et al. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism.  Ann Intern Med. 2000;  235 88-97
    PubMedGoogle Scholar
  • 32 PIOPED Investigators . Value of the ventilation / perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).  J Amer Med Ass. 1990;  263 2753-2759
    PubMedGoogle Scholar
  • 33 Reinartz P, Wildberger J E, Nowak B et al. SPECT in der Lungenemboliediagnostik: Evaluation der PIOPED Kriterien bei Verwendung tomographischer Datensätze.  Nuklearmedizin. 2004;  43 A 35
    PubMedGoogle Scholar
  • 34 Rodger M A, Bredeson C N, Jones G et al. The bedside investigation of pulmonary embolism diagnosis study: a double-blind rendomized controlled trial comparing combinations of 3 bedside tests vs ventilation-perfusion scan for the initial investigation of suspected pulmonary embolism.  Arch Intern Med. 2006;  266 181-187
    PubMedGoogle Scholar
  • 35 Romano L, Pinto A, Giovine S. Helical CT as preferred imaging modality in the diagnosis of pulmonary embolism.  Radiol Med (Torino). 2001;  102 320-324
    PubMedGoogle Scholar
  • 36 Schoepf U J, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art.  Radiology. 2004;  230 329-337
    CrossrefPubMedGoogle Scholar
  • 37 Schümichen C. Lunge. Nuklearmedizin. Stuttgart / New York: Thieme; 1996: 259–277
    Google Scholar
  • 38 Schümichen C. Szintigraphische Diagnostik der akuten Lungenembolie – aktueller Stand.  Der Nuklearmediziner. 1998;  21 31-45
    PubMedGoogle Scholar
  • 39 Schümichen C. Pulmonary embolism: is multislice CT the method of choice? Against.  Eur J Nucl Med Mol Imaging. 2005;  32 103-107
    CrossrefPubMedGoogle Scholar
  • 40 Segal J B, Eng J, Tamariz L J et al. Review of the evidence on diagnosis of deep venous thrombosis and pulmonary embolism.  Ann Fam Med. 2007;  5 63-73 ,  Review
    CrossrefPubMedGoogle Scholar
  • 41 Stabin M G, Gelfand M J. Dosimetry of pediatric nuclear medicine procedures.  Q J Nucl Med. 1998;  42 93-112
    PubMedGoogle Scholar
  • 42 Stein P D, Fowler S E, Goodman L R et al. Multidetector computed tomography for acute pulmonary embolism.  N Engl J Med. 2006;  354 2383-2385
    CrossrefPubMedGoogle Scholar
  • 43 Stein P D, Saltzman H A, Weg J G. Clinical characteristics of patients with acute pulmonary embolism.  Am J Cardiol. 1991;  68 1723-1724
    CrossrefPubMedGoogle Scholar
  • 44 Stein P D, Woodard P K, Weg J G et al. PIOPED II Investigators. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.  Am J Med. 2006;  119 1048-1055
    CrossrefPubMedGoogle Scholar
  • 45 Tunariu N, Gibbs S J, Win Z et al. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thomboembolic pulmonary disease as a cause of pulmonary hypertension.  J Nucl Med. 2007;  48 680-684
    CrossrefPubMedGoogle Scholar
  • 46 Van Ommen C H, Peters M. Acute pulmonary embolism in childhood.  Thromb Res. 2006;  118 13-25 ,  Epub 2005 Jun 29. Review
    CrossrefPubMedGoogle Scholar
  • 47 Velmahos G C, Vassiliu P, Wilcox A et al. Spiral computed tomography for the diagnosis of pulmonary embolism in critically ill surgical patients: a comparison with pulmonary angiography.  Arch Surg. 2001;  136 505-511
    PubMedGoogle Scholar
  • 48 Weiss C R, Haponik E F, Diette G B et al. Pretest risk assessment in suspected acute pulmonary embolism.  Acad Radio. 2008;  15 3-14
    PubMedGoogle Scholar
  • 49 Wells P S, Ginsberg J S, Anderson D R. Use of clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med. 1998;  129 995-1005
    PubMedGoogle Scholar
  • 50 Winer-Muram H T, Rydberg J, Johnson M S et al. Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus subtraction pulmonary arteriography.  Radiology. 2004;  233 806-815
    CrossrefPubMedGoogle Scholar
  • 51 Winer-Muram H T, Boone J M, Brown H L et al. Pulmonary embolism in pregnant patients: fetal radiation dose with helical CT.  Radiology. 2002;  224 487-492
    CrossrefPubMedGoogle Scholar
  • 52 Worsley D F, Coupland DB, Lentie B C et al. Ascending aortic dissection causing unilateral absence of perfusion on lung scanning.  Clin Nucl Med. 1993;  18 941-944
    CrossrefPubMedGoogle Scholar
  • 53 Worsley D F, Alavi A. Comprehensive analysis of the results of the PIOPED study. Prospective investigation of pulmonary embolism diagnosis study.  J Nucl Med. 1995;  36 2380-2387
    PubMedGoogle Scholar

Prof. Dr. C. Schümichen

Universität Rostock · Klinik und Poliklinik für Nuklearmedizin

Gertrudenplatz 1

18057 Rostock

Phone: +49 / 3 81 / 4 94 91 01

Fax: +49 / 3 81 / 4 94 91 02

Email: carl.schuemichen@med.uni-rostock.de