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. 1973 Jul;49(573):487–502. doi: 10.1136/pgmj.49.573.487

The role of lung imaging in pulmonary embolism

Fred S Mishkin, Philip M Johnson
PMCID: PMC2496152  PMID: 4602128

Abstract

The advantages of lung scanning in suspected pulmonary embolism are its diagnostic sensitivity, simplicity and safety. The ability to delineate regional pulmonary ischaemia, to quantitate its extent and to follow its response to therapy provides valuable clinical data available by no other simple means. The negative scan effectively excludes pulmonary embolism but, although certain of its features favour the diagnosis of embolism, the positive scan inherently lacks specificity and requires angiographic confirmation when embolectomy, caval plication or infusion of a thrombolytic agent are contemplated. The addition of simple ventilation imaging techniques with radioxenon overcomes this limitation by providing accurate analog estimation or digital quantitation of regional ventilation: perfusion (V/Q) ratios fundamental to understanding the pathophysiologic consequences of embolism and other diseases of the lung.

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Selected References

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  1. Allgood R. J., Wolfe W. G., Ebert P. A., Sabiston D. C., Jr Effects of carbon dioxide on bronchoconstriction after pulmonary artery occlusion. Am J Physiol. 1968 Apr;214(4):772–775. doi: 10.1152/ajplegacy.1968.214.4.772. [DOI] [PubMed] [Google Scholar]
  2. Arborelius M., Jr Influence of unilateral hypoventilation on distribution of pulmonary blood flow in man. J Appl Physiol. 1969 Jan;26(1):101–104. doi: 10.1152/jappl.1969.26.1.101. [DOI] [PubMed] [Google Scholar]
  3. BALL W. C., Jr, STEWART P. B., NEWSHAM L. G., BATES D. V. Regional pulmonary function studied with xenon 133. J Clin Invest. 1962 Mar;41:519–531. doi: 10.1172/JCI104505. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. BENTIVOGLIO L. G., BEEREL F., STEWART P. B., BRYAN A. C., BALL W. C., Jr, BATES D. V. STUDIES OF REGIONAL VENTILATION AND PERFUSION IN PULMONARY EMPHYSEMA USING XENON133. Am Rev Respir Dis. 1963 Sep;88:315–329. doi: 10.1164/arrd.1963.88.3P1.315. [DOI] [PubMed] [Google Scholar]
  5. BERGOFSKY E. H., BASS B. G., FERRETTI R., FISHMAN A. P. PULMONARY VASOCONSTRICTION IN RESPONSE TO PRECAPILLARY HYPOXEMIA. J Clin Invest. 1963 Aug;42:1201–1215. doi: 10.1172/JCI104806. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. BRYAN A. C., BENTIVOGLIO L. G., BEEREL F., MACLEISH H., ZIDULKA A., BATES D. V. FACTORS AFFECTING REGIONAL DISTRIBUTION OF VENTILATION AND PERFUSION IN THE LUNG. J Appl Physiol. 1964 May;19:395–402. doi: 10.1152/jappl.1964.19.3.395. [DOI] [PubMed] [Google Scholar]
  7. Bass H., Banas J. S., Jr, Dalen J. E. Pulmonary function studies. Aid to diagnosis of pulmonary embolism. Arch Intern Med. 1970 Aug;126(2):266–268. doi: 10.1001/archinte.126.2.266. [DOI] [PubMed] [Google Scholar]
  8. Bass H., Heckscher T., Anthonisen N. R. Regional pulmonary gas exchange in patients with pulmonary embolism. Clin Sci. 1967 Oct;33(2):355–364. [PubMed] [Google Scholar]
  9. Bell T. K., Ferguson R., McIlrath E. I., Weaver J. A. Radioisotope scanning of the lungs. Thorax. 1968 Jan;23(1):24–32. doi: 10.1136/thx.23.1.24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Blaisdell F. W., Lim R. C., Jr, Amberg J. R., Choy S. H., Hall A. D., Thomas A. N. Pulmonary microembolism. A cause of morbidity and death after major vascular surgery. Arch Surg. 1966 Nov;93(5):776–786. doi: 10.1001/archsurg.1966.01330050080012. [DOI] [PubMed] [Google Scholar]
  11. Bliek A. J., Bachynski J. E. wo severe reactions following a pulmonary scan in a patient with idiopathic pulmonary haemosiderosis. J Nucl Med. 1971 Feb;12(2):90–92. [PubMed] [Google Scholar]
  12. Brashear R. E., Mishkin F. S., Ross J. C. Effects of iron (113mIn) hydroxide particles on pulmonary diffusing capacity and pulmonary artery pressure. Invest Radiol. 1969 Jan-Feb;4(1):19–23. doi: 10.1097/00004424-196904010-00003. [DOI] [PubMed] [Google Scholar]
  13. Dalen J. E., Banas J. S., Jr, Brooks H. L., Evans G. L., Paraskos J. A., Dexter L. Resolution rate of acute pulmonary embolism in man. N Engl J Med. 1969 May 29;280(22):1194–1199. doi: 10.1056/NEJM196905292802202. [DOI] [PubMed] [Google Scholar]
  14. Davis M. A. 99mTc-iron hydroxide aggregates. Evaluation of a new lung-scanning agent. Radiology. 1970 May;95(2):347–352. doi: 10.1148/95.2.347. [DOI] [PubMed] [Google Scholar]
  15. Dawson A. Regional pulmonary blood flow in sitting and supine man during and after acute hypoxia. J Clin Invest. 1969 Feb;48(2):301–310. doi: 10.1172/JCI105986. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. DeLand F. H. The fate of macroaggregated albumin used in lung scanning. J Nucl Med. 1966 Dec;7(12):883–895. [PubMed] [Google Scholar]
  17. DeNardo G. L., Goodwin D. A., Ravasini R., Dietrich P. A. The ventilatory lung scan in the diagnosis of pulmonary embolism. N Engl J Med. 1970 Jun 11;282(24):1334–1336. doi: 10.1056/NEJM197006112822402. [DOI] [PubMed] [Google Scholar]
  18. Duffy G. J., DeNardo G. L., Abington R. B. Origin and evolution of radioactive pulmonary emboli in man. Radiology. 1968 Dec;91(6):1175–1180. doi: 10.1148/91.6.1175. [DOI] [PubMed] [Google Scholar]
  19. Dworkin H. J., Smith J. R., Bull F. E. Reaction after administration of macroaggregated albumin for a lung scan. N Engl J Med. 1966 Aug 18;275(7):376–376. doi: 10.1056/NEJM196608182750709. [DOI] [PubMed] [Google Scholar]
  20. ENSON Y., GIUNTINI C., LEWIS M. L., MORRIS T. Q., FERRER M. I., HARVEY R. M. THE INFLUENCE OF HYDROGEN ION CONCENTRATION AND HYPOXIA ON THE PULMONARY CIRCULATION. J Clin Invest. 1964 Jun;43:1146–1162. doi: 10.1172/JCI104999. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. FREIMAN D. G., SUYEMOTO J., WESSLER S. FREQUENCY OF PULMONARY THROMBOEMBOLISM IN MAN. N Engl J Med. 1965 Jun 17;272:1278–1280. doi: 10.1056/NEJM196506172722406. [DOI] [PubMed] [Google Scholar]
  22. Freeman L. M., Zelefsky M. N., Meng C. H., Kaplan N. The relative merits of lung scanning and angiography in the diagnosis of pulmonary embolism. Bull N Y Acad Med. 1968 Sep;44(9):1159–1182. [PubMed] [Google Scholar]
  23. Friedman W. F., Braunwald E. Alterations in regional pulmonary blood flow in mitral valve disease studied by radioisotope scanning. A simple nontraumatic technique for estimation of left atrial pressure. Circulation. 1966 Sep;34(3):363–376. doi: 10.1161/01.cir.34.3.363. [DOI] [PubMed] [Google Scholar]
  24. Gilday D. L., James A. E., Jr Lung scan patterns in pulmonary embolism versus those in congestive heart failure and emphysema. Am J Roentgenol Radium Ther Nucl Med. 1972 Aug;115(4):739–750. doi: 10.2214/ajr.115.4.739. [DOI] [PubMed] [Google Scholar]
  25. Gilday D. L., Poulose K. P., DeLand F. H. Accuracy of detection of pulmonary embolism by lung scanning correlated with pulmonary angiography. Am J Roentgenol Radium Ther Nucl Med. 1972 Aug;115(4):732–738. doi: 10.2214/ajr.115.4.732. [DOI] [PubMed] [Google Scholar]
  26. Gize R., Dizon M., Mishkin F. Analysis of the fissure sign. J Nucl Med. 1971 Dec;12(12):822–824. [PubMed] [Google Scholar]
  27. Goodwin D. A., Stern H. S., Wagner H. N., Jr Ferric hydroxide particles labeled with indium in 113m for lung scanning. JAMA. 1968 Oct 7;206(2):339–343. [PubMed] [Google Scholar]
  28. Gottschalk A., Usher M. S., Turner D. A., Polcyn R. E., Quinn J. L., 3rd The scintillation camera with diverging collimator: physical parameters and a clinical evaluation. Semin Nucl Med. 1971 Apr;1(2):206–215. doi: 10.1016/s0001-2998(71)81018-8. [DOI] [PubMed] [Google Scholar]
  29. Hildner F. J., Ormond R. S. Accuracy of the clinical diagnosis of pulmonary embolism. JAMA. 1967 Nov 13;202(7):567–570. [PubMed] [Google Scholar]
  30. Hopkins G. B. Pulmonary angiothrombotic granulomatosis in drug offenders. JAMA. 1972 Aug 21;221(8):909–911. [PubMed] [Google Scholar]
  31. James A. E., Jr, Conway J. J., Chang C. H., Cooper M., White R. I., Strauss H. W. The fissure sign: its multiple causes. Am J Roentgenol Radium Ther Nucl Med. 1971 Mar;111(3):492–500. doi: 10.2214/ajr.111.3.492. [DOI] [PubMed] [Google Scholar]
  32. Johnson P. M., Parker B. R., Cosgriff S. W., Ellis K. Lung scanning in detecting pulmonary embolic disease. N Y State J Med. 1969 Nov 15;69(22):2870–2874. [PubMed] [Google Scholar]
  33. Johnson P. M. The role of lung scanning in pulmonary embolism. Semin Nucl Med. 1971 Apr;1(2):161–184. doi: 10.1016/s0001-2998(71)81015-2. [DOI] [PubMed] [Google Scholar]
  34. King E. G., Wood D. E., Morley T. P. The use of macroaggregates of radioiodinated human serum albumin in brain scanning. Can Med Assoc J. 1966 Aug 27;95(9):381–389. [PMC free article] [PubMed] [Google Scholar]
  35. LOPEZ-MAJANO V., CHERNICK V., WAGNER H. N., Jr, DUTTON R. E. COMPARISON OF RADIOISOTOPE SCANNING AND DIFFERENTIAL OXYGEN UPTAKE OF THE LUNGS. Radiology. 1964 Oct;83:697–698. doi: 10.1148/83.4.697. [DOI] [PubMed] [Google Scholar]
  36. Lloyd T. C., Jr Influence of blood pH on hypoxic pulmonary vasoconstriction. J Appl Physiol. 1966 Mar;21(2):358–364. doi: 10.1152/jappl.1966.21.2.358. [DOI] [PubMed] [Google Scholar]
  37. Loken M. K. Camera studies of lung ventilation and perfusion. Semin Nucl Med. 1971 Apr;1(2):229–245. doi: 10.1016/s0001-2998(71)81020-6. [DOI] [PubMed] [Google Scholar]
  38. Lopez-Majano V., Tow D. E., Wagner H. N., Jr Regional distribution of pulmonary arterial blood flow in emphysema. JAMA. 1966 Jul 11;197(2):81–84. [PubMed] [Google Scholar]
  39. Lopez-Majano V., Twining R. H., Goodwin D. A., Wagner H. N., Jr Reproducibility of lung scans. Invest Radiol. 1967 Nov-Dec;2(6):410–418. doi: 10.1097/00004424-196711000-00020. [DOI] [PubMed] [Google Scholar]
  40. Mack J. F., Wellman H. N., Saenger E. L., Friedman B. I. Clinical experience with oblique views in pulmonary perfusion camera-imaging in normal and pathological anatomy. Radiology. 1969 Mar;92(4):897–902. doi: 10.1148/92.4.897. [DOI] [PubMed] [Google Scholar]
  41. McIntyre K. M., Sasahara A. A. Correlation of pulmonary photoscan and angiogram as measures of the severity of pulmonary embolic involvement. J Nucl Med. 1971 Nov;12(11):732–738. [PubMed] [Google Scholar]
  42. McIntyre K. M., Sasahara A. A. Hemodynamic alterations related to extent of lung scan perfusion defect in pulmonary embolism. J Nucl Med. 1971 Apr;12(4):166–170. [PubMed] [Google Scholar]
  43. Mishkin F. S., Brashear R. E., Reese I. C. Evaluation of regional perfusion and ventilation using xenon 133 and the scintillation camera. Am J Roentgenol Radium Ther Nucl Med. 1970 Jan;108(1):60–70. doi: 10.2214/ajr.108.1.60. [DOI] [PubMed] [Google Scholar]
  44. Mishkin F. S. The lateral view in lung scanning as an aid in differential diagnosis. Dis Chest. 1968 Jun;53(6):743–749. doi: 10.1378/chest.53.6.743. [DOI] [PubMed] [Google Scholar]
  45. Moser K. M., Harsanyi P., Rius-Garriga G., Guisan M., Landis G. A., Miale A., Jr Assessment of pulmonary photoscanning and angiography in experimental pulmonary embolism. Circulation. 1969 May;39(5):663–674. doi: 10.1161/01.cir.39.5.663. [DOI] [PubMed] [Google Scholar]
  46. Moser K. M., Miale A., Jr Interpretive pitfalls in lung photoscanning. Am J Med. 1968 Mar;44(3):366–376. doi: 10.1016/0002-9343(68)90108-3. [DOI] [PubMed] [Google Scholar]
  47. Moser K. M., Tisi G. M., Rhodes P. G., Landis G. A., Miale A., Jr Correlation of lung photoscans with pulmonary angiography in pulmonary embolism. Am J Cardiol. 1966 Dec;18(6):810–820. doi: 10.1016/0002-9149(66)90424-3. [DOI] [PubMed] [Google Scholar]
  48. Newhouse M. T., Wright F. J., Ingham G. K., Archer N. P., Hughes L. B., Hopkins O. L. Use of scintillation camera and 135-xenon for study of topographic pulmonary function. Respir Physiol. 1968 Mar;4(2):141–153. doi: 10.1016/0034-5687(68)90048-0. [DOI] [PubMed] [Google Scholar]
  49. Poulose K., Reba R. C., Wagner H. N., Jr Characterization of the shape and location of perfusion defects in certain pulmonary diseases. N Engl J Med. 1968 Nov 7;279(19):1020–1025. doi: 10.1056/NEJM196811072791903. [DOI] [PubMed] [Google Scholar]
  50. Quinn J. L., 3rd Perfusion scanning in chronic obstructive lung disease. Semin Nucl Med. 1971 Apr;1(2):185–194. doi: 10.1016/s0001-2998(71)81016-4. [DOI] [PubMed] [Google Scholar]
  51. ROBIN E. D., FORKNER C. E., Jr, BROMBERG P. A., CROTEAU J. R., TRAVIS D. M. Alveolar gas exchange in clinical pulmonary embolism. N Engl J Med. 1960 Feb 11;262:283–287. doi: 10.1056/NEJM196002112620604. [DOI] [PubMed] [Google Scholar]
  52. ROBIN E. D., JULIAN D. G., TRAVIS D. M., CRUMP C. H. A physiologic approach to the diagnosis of acute pulmonary embolism. N Engl J Med. 1959 Mar 19;260(12):586–591. doi: 10.1056/NEJM195903192601204. [DOI] [PubMed] [Google Scholar]
  53. Rhodes B. A., Zolle I., Buchanan J. W., Wagner H. N., Jr Radioactive albumin microspheres for studies of the pulmonary circulation. Radiology. 1969 Jun;92(7):1453–1460. doi: 10.1148/92.7.1453. [DOI] [PubMed] [Google Scholar]
  54. SWENSON E. W., FINLEY T. N., GUZMAN S. V. Unilateral hypoventilation in man during temporary occlusion of one pulmonary artery. J Clin Invest. 1961 May;40:828–835. doi: 10.1172/JCI104316. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Sasahara A. A., Belko J. S., Simpson R. G. Blended scintiscans of lungs with a dual detector system. Radiology. 1967 Feb;88(2):363–365. doi: 10.1148/88.2.363. [DOI] [PubMed] [Google Scholar]
  56. Sasahara A. A., Cannilla J. E., Belko J. S., Morse R. L., Criss A. J. Urokinase therapy in clinical pulmonary embolism. A new thrombolytic agent. N Engl J Med. 1967 Nov 30;277(22):1168–1173. doi: 10.1056/NEJM196711302772203. [DOI] [PubMed] [Google Scholar]
  57. Sasahara A. A., Cannilla J. E., Morse R. L., Sidd J. J., Tremblay G. M. Clinical and physiologic studies in pulmonary thromboembolism. Am J Cardiol. 1967 Jul;20(1):10–20. doi: 10.1016/0002-9149(67)90105-1. [DOI] [PubMed] [Google Scholar]
  58. Surprenant E. L. Lateral lung scanning, anatomic and physiologic considerations. Am J Roentgenol Radium Ther Nucl Med. 1967 Mar;99(3):533–542. doi: 10.2214/ajr.99.3.533. [DOI] [PubMed] [Google Scholar]
  59. Szucs M. M., Jr, Brooks H. L., Grossman W., Banas J. S., Jr, Meister G., Dexter L., Dalen J. E. Diagnostic senstivity of laboratory findings in acute pulmonary embolism. Ann Intern Med. 1971 Feb;74(2):161–166. doi: 10.7326/0003-4819-74-2-161. [DOI] [PubMed] [Google Scholar]
  60. TAPLIN G. V., JOHNSON D. E., DORE E. K., KAPLAN H. S. LUNG PHOTOSCANS WITH MACROAGGREGATES OF HUMAN SERUM RADIOALBUMIN. EXPERIMENTAL BASIS AND INITIAL CLINICAL TRIALS. Health Phys. 1964 Dec;10:1219–1227. doi: 10.1097/00004032-196412000-00043. [DOI] [PubMed] [Google Scholar]
  61. Tow D. E., Wagner H. N., Jr, Holmes R. A. Urokinase in pulnonary embolism. N Engl J Med. 1967 Nov 30;277(22):1161–1167. doi: 10.1056/NEJM196711302772202. [DOI] [PubMed] [Google Scholar]
  62. Tow D. E., Wagner H. N., Jr Recovery of pulmonary arterial blood flow in patients with pulmonary embolism. N Engl J Med. 1967 May 11;276(19):1053–1059. doi: 10.1056/NEJM196705112761902. [DOI] [PubMed] [Google Scholar]
  63. Twining R. H., Lopez-Majano V., Wagner H. N., Jr, Chernick V., Dutton R. E. Effect of regional hypercpnia on the distribution of pulmonary blood flow in man. Johns Hopkins Med J. 1968 Aug;123(2):95–103. [PubMed] [Google Scholar]
  64. WAGNER H. N., Jr, SABISTON D. C., Jr, MCAFEE J. G., TOW D., STERN H. S. DIAGNOSIS OF MASSIVE PULMONARY EMBOLISM IN MAN BY RADIOISOTOPE SCANNING. N Engl J Med. 1964 Aug 20;271:377–384. doi: 10.1056/NEJM196408202710801. [DOI] [PubMed] [Google Scholar]
  65. WEST J. B., DOLLERY C. T. Distribution of blood flow and ventilation-perfusion ratio in the lung, measured with radioactive carbon dioxide. J Appl Physiol. 1960 May;15:405–410. doi: 10.1152/jappl.1960.15.3.405. [DOI] [PubMed] [Google Scholar]
  66. Wagner H. N., Jr Current status of lung scanning. Radiology. 1968 Dec;91(6):1235–1237. doi: 10.1148/91.6.1235. [DOI] [PubMed] [Google Scholar]
  67. Wenger N. K., Stein P. D., Willis P. W., 3rd Massive acute pulmonary embolism. The deceivingly nonspecific manifestations. JAMA. 1972 May 8;220(6):843–844. [PubMed] [Google Scholar]
  68. Wilson J. E., 3rd, Pierce A. K., Johnson R. L., Jr, Winga E. R., Harrell W. R., Curry G. C., Mullins C. B. Hypoxemia in pulmonary embolism, a clinical study. J Clin Invest. 1971 Mar;50(3):481–491. doi: 10.1172/JCI106516. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Winebright J. W., Gerdes A. J., Nelp W. B. Restoration of blood flow after pulmonary embolism. Arch Intern Med. 1970 Feb;125(2):241–247. [PubMed] [Google Scholar]

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