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DOI: 10.1055/s-2008-1077017
© Georg Thieme Verlag Stuttgart ˙ New York
V / Q-Szintigrafie zur Diagnostik der Lungenembolie – III. Vergleich mit der Mehrzeilen-Spiral-CT
Diagnosis of Lung Embolism by V / Q Scintigraphy – III. Comparison with Multislice-Helical CTPublication History
Publication Date:
02 December 2008 (online)
![](https://www.thieme-connect.de/media/nuklmed/200804/lookinside/thumbnails/10.1055-s-2008-1077017-1.jpg)
Zusammenfassung
Die V / Q-Szintigrafie erweist sich im Vergleich mit der moderneren Mehrzeilen-Spiral-CT beim Nachweis der akuten Lungenembolie in vielen Bereichen als ebenbürtig und bezüglich der Sensitivität sogar überlegen. Die Mehrzeilen-Spiral-CT erkennt zentrale Emboli mit hoher Sensitivität und Spezifität, beim Nachweis peripherer Emboli bestehen trotz methodischer Verbesserungen (Steigerung bis auf 64 Zeilen) noch Defizite. Insbesondere gemessen am Outcome ist die Sensitivität insgesamt immer noch zu gering (ca.75 %), die Ursache hierfür liegt weniger in der Abbildungsqualität als in der Befundung. Die V / Q-Szintigrafie weist Defizite beim Erkennen zentraler Emboli auf, die entweder gar keine hämodynamischen Auswirkungen haben oder nur teilokkludierend sind. Gemessen am Outcome ist die Sensitivität insgesamt dennoch hervorragend, die Anzahl symptomatischer sowie tödlicher Folgeembolien bei szintigrafisch unauffälligen, unbehandelten Patienten tendiert zu Null. Ausschlaggebend für die Prognose sind somit Emboli mit hämodynamischen Auswirkungen in der Primärdiagnostik. Anders als die V / Q-Szintigrafie erkennt die Mehrzeilen-Spiral-CT auch extrapulmonale Erkrankungen als Alternativdiagnosen, unter anderem die Aortendissektion. Das Risiko einer Tumorinduktion als Folge der Strahlenexposition ist nach einer Mehrzeilen-Spiral-CT um mehr als eine Größenordnung höher als bei der V / Q-Szintigrafie.
Abstract
V / Q scintigraphy can be seen to be equal in many areas to the more modern multislice-helical CT in detecting acute pulmonary embolism and even to be superior with respect to sensitivity. Multislice-helical CT recognizes central emboli with high sensitivity and specificity, but deficits still remain in detecting peripheral embolisms, despite methodical improvements (increase up to 64 slices). Especially measured on the outcome, the overall sensitivity is still too low (ca. 75 %), the reason for this lies less in the image quality than in the evaluation. V / Q scintigraphy has deficits in detecting central emboli which either have no hemodynamic effects or are only partially occluding. Measured on the outsome, the overall sensitivity is still excellent, the number of symptomatic and fatal late embolisms in scintigraphically normal, untreated patients tends toward zero. Decisive for the prognosis are thus embolisms with hemodynamic effects in primary diagnostics. Unlike V / Q scintigraphy, multislice-helical CT also recognizes extrapulmonary diseases as alternative diagnoses, among these aortic dissection. The risk of tumor induction following radiation exposure is higher with multislice-helical CT than with V / Q scintigraphy by more than one order of magnitude.
Schlüsselwörter
Lungenembolie - V / Q-Szintigrafie - Mehrzeilen-Spiral-CT - Sensitivität - Spezifität - Risiken
Key words
klung embolism - V / Q scintigraphy - multislice-helical-CT - sensitivity - specificity - risks
Literatur
- 1 Anderson D R, Kahn S R, Rodger M A et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA. 2007; 298 2743-2753
- 2 Bajc M, Olsson C G, Olssen B et al. Diagnostic evaluation of planar and tomographic ventilation/perfusion lung images in patients with suspected pulmonary emboli. Clin Physiol Func Imaging. 2004; 24 249-256
- 3 Brix G, Nekolla E, Griebel J. Strahlenexposition von Patienten durch diagnostische und interventionelle Röntgenanwendungen – Fakten, Bewertung und Trends. Radiologe. 2005; 45 340-349
- 4 Buhmann S, Herzog P, Liang M et al. Clinical evaluation of a computer-aided diagnosis (CAD) prototype for the detection of pulmonary embolism. Acad Radiol. 2007; 14 651-658
- 5 Burkill G J, Bell J R, Padley S P. Survey on the use of pulmonary scintigraphy, spiral CT and conventional pulmonary angiography for suspected pulmonary embolism in the British Isles. Clin Radiol. 1999; 54 807-810
- 6 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
- 7 Cauvain O, Remy-Jardin M, Remy J et al. Spiral CT angiography in the diagnosis of central pulmonary embolism: Comparison with pulmonary angiography and scintigraphy. Rev Mal Respir. 1996; 113 141-153
- 8 Chodick G, Ronckers C M, Shalev V et al. Excess lifetime mortality risk attributable to radiation exposure from computed tomography examinations in children. Isr Med Assoc J. 2007; 9 584-587
- 9 de Gonzalez A B, Kim K P, Samet J M. Radiation-induced cancer risk from annual computed tomography for patients with cystic fibrosis. Am J Roentgenol. 2007; 176 970-973
- 10 Einstein A J, Henzlova M J, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007; 298 317-323
- 11 Engelke C, Manstein P, Rummeny E L et al. Suspected and incidental pulmonary embolism on multidetector-row CT: analysis of technical and morphological factors influencing the diagnosis In a cross-sectional cancer centre patient cohort. Clin Radiol. 2006; 61 71-80
- 12 Freeman L M. Don't bury the V / Q scan: it's as good as multidetector CT angiograms with a lot less radiation exposure. J Nucl Med. 2008; 49 5-8
- 13 Geleijns J, Wondergem J. X-ray imaging and the skin: radiation biology, patient dosimetry and observed effects. Radiat Prot Dosimetry. 2005; 114 121-125
- 14 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
- 15 Hagen P J, Hartmann T J, Hoekstra O S et al. ANTELOPE Study Group: Comparison of observer variability and accuracy of different criteria for lung scan interpretation. J Nucl Med. 2003; 44 739-744
- 16 Hart D, Wall B F. UK population dose from medical x-ray examinations. Eur J Radiol. 2004; 50 285-291
- 17 Henry J W, Relyea B, Stein P D. Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest. 1995; 107 1375-1378
- 18 Henry J W, Stein P D, Gottschalk A et al. Pulmonary embolism among patients with a nearly normal ventilation/perfusion lung scan. Chest. 1996; 110 395-398
- 19 Hollingsworth C L, Yoshizumi T T, Frush D P et al. Pediatric cardiac-gated CT angiography: assesment of radiation dose. Am J Roentgenol. 2007; 189 12-18
- 20 Huda W, Vance A. Patient radiation doses from adult and pediatric CT. Am J Roentgenol. 2007; 188 540-546
- 21 Hull R D, Raskob G E, Coates G et al. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism. Chest. 1990; 97 23-26
- 22 Hurwitz L M, Reimann R E, Yoshhizumi T T et al. Radiation dose from contemporary cardiothoratic multidetector CT protocols with an anthropomorphic female phantom: implications for cancer induction. Radiology. 2007; 245 742-750
- 23 Infante J R, Torres-Avisbal M, Gonzalez F M et al. Effect of different observers on the interpretation of pulmonary perfusion scintigraphy. Rev Esp Med Nucl. 2002; 21 93-98
- 24 Jiménez D, Gómez M, Herrero R et al. Thromboembolic events in patients after a negative computed tomography pulmonary angiogram: A retrospective study of 165 patients. Arch Bronconeumol. 2006; 42 344-348
- 25 Johnson T R, Nikolaou K, Wintersperger B J et al. ECG-gated 64-MDCT angiography in the differential diagnosis of acute chest pain. Am J Roentgenol. 2007; 188 76-82
- 26 Kasper W, Konstatinides S, Geibel A et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997; 30 1165-1171
- 27 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
- 28 Linton O W, Mettler F A. National conference on pediatric patients. Am J Roentgenol. 2003; 181 321-329
- 29 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
- 30 McParland B J. Entrance skin dose estimates derived from dose-area product measurements in interventional radiological procedures. Br J Radiol. 1998; 71 188-195
- 31 Montes-Santiago J, Lado Castro-Rial M, Guijarro Merino R. on behalf of Grupo RIETE . Current diagnosis of pulmonary embolism in Spain: ventilation-perfusion lung scan versus helical CT. Findings from the National Health Service and RIETE Registry. Med Clin (Barc). 2008; 130 568-572
- 32 Moores L K, Collen J F, Woods K M et al. Practical utility of clinical prediction rules for suspected acute pulmonary embolism in a large academic institution. Thromb Res. 2004; 113 1-6
- 33 Moores L K, Jackson Jr W L, Shorr A F et al. Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography. Ann Intern Med. 2004; 141 866-874
- 34 Nashizawa K, Matsumotot M, Iwai K et al. Nishizawa survey of CT practice in Japan and collective effective dose estimation. Nippon Acta Radio. 2004; 64 151-158
- 35 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
- 36 Paul J F, Abada H AT. Strategies for reduction of radiation dose in cardiac multislice CT. Eur Radiol. 2007; 17 2028-2037
- 37 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
- 38 Perrier A, Roy P M, Sanchez O et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med. 2005; 352 1760-1768
- 39 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
- 40 Preston D L, Ron E, Tokuoka S et al. Solid cancer incidence in atomic bomb survivors: 1958–1998. Radiat Res. 2007; 168 1-64
- 41 Scatarige J C, Weiss C R, Diette G B et al. Scanning systems and protocols used during imaging for acute pulmonary embolism: how much do our clinical coleagues know?. Acad Radiol. 2006; 13 678-685
- 42 Schoepf U J, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology. 2004; 230 329-337
- 43 Schuemichen C. Pulmonary embolism: is multislice CT the method of choice? Against. Eur J Nucl Med Mol Imaging. 2005; 32 103-107
- 44 Shannoun F, Zeb H, Back C et al. Medical exposure of the population from diagnostic use ionizing radiation in Luxembourg between 1994 and 2002. Health Phys. 2006; 91 154-162
- 45 Shrimpton P C, Hillier M C, Lewis M A et al. National survey of doses from CT in the UK: 2006. Br J Radiol. 2006; 79 968-980
- 46 Sostmann H D, Stein P D, Gottschalk A et al. Acute pulmonary embolism: sensitivity and specifity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology. 2008; 246 941-946
- 47 Stein P D, Fowler S E, Goodman L R et al. PIOPED II Investigators: Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006; 354 2317-2327
- 48 Stein P D, Woodard P K, Weg J . Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006; 119 1048-1055
- 49 Teeuwisse W M, Geleijns J, Broerse J J et al. Patient and dose during CT guided biopsy, drainage and coagulation. Br J Radiol. 2001; 74 720-726
- 50 Tsalafoutas I A, Tsapaki V, Triantopoulou C et al. CT-Guided interventional procedures without CT fluoroscopy assistance: patient effective dose absorbed dose considerations. Am J Roentgenol. 2007; 188 1479-1484
- 51 van Beek E J, Kuyer P M, Schenk B E et al. A normal perfusion lung scan in patients with clinically suspected pulmonary embolism. Frequency and clinical validity. Chest. 1995; 108 170-173
- 52 van Rossum A B, Pattynama P M, Mallens W M et al. Can helical CT replace scintigraphy in the diagnostic process in suspected pulmonary embolism? A retrolective-prolective cohort study focusing on total diagnostic yield. Eur Radiol. 1998; 8 90-96
- 53 Van Strijen M J, De Monye W, Kieft G J et al. Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy. J Thromb Haemost. 2005; 3 7-25
- 54 Vanmarcke H, Paridaens J, Eggermont G. Ioniserende stralling. In: Millieu – en natuurrapport Vlaaderen, Vlaamse Millieu-maatschappij. Garant 2002: MIRAT report 2001
- 55 Weiss C R, Scatarige J C, Diette G B et al. CT pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicans. Acad Radiol. 2006; 13 434-446
- 56 Wittram C, Waltmann A C, Shepard J A et al. Discordance between CT and angiography in the PIOPED II study. Radiology. 2007; 244 883-889
Prof. Dr. C. Schümichen
Universität Rostock · Klinik und Poliklinik für Nuklearmedizin
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Email: carl.schuemichen@med.uni-rostock.de