CASE: Acute on Chronic PE without RV strain

EXAM QUALITY:

HIGH

1. Can see clearly to the proximal subsegmental level
2. ROI on main PA = 300 HU (ROI > 300 HU is often high quality if no/minimal limitation.)
3. LIMITATIONS: No major limitations

• Here, pulmonary motion artifact does not limit evaluation, so no need to mention

PE FINDINGS:

ACUTE ON CHRONIC PE.

ACUTE PE, bilateral, small clot burden:

• RUL subsegmental
• RML segmental
• RLL segmental
• RLL segmental
• Lingular segmental

CHRONIC PE, left-sided:

• LLL lobar: the LLL basal trunk as well as its segmental branches are contracted in caliber and nonopacified, which are chronic PE features. It is important to look at prior exam to see if present previously.

ANCILLARY FINDINGS:

Right atrial thrombus with well-defined margins. This is different from mixing artifact which has ill-defined margins and is much more common.

SVC thrombus.

No sign of RV strain (RV/LV ratio <1).

IMPRESSION:

Acute on chronic pulmonary embolism.

• Acute bilateral PE with a small clot burden most proximally involving the segmental level in the right lower lobe and lingula.
• Chronic left-sided PE most proximally involving the lobar level in the left lower lobe.

No sign of right ventricular strain. RV/LV ratio is < 1, normal.

CREATED BY:

Arun Nachiappan MD, Ali Dhanaliwala MD, Sophia O'Brien MD.

Questions or comments? Please contact narun@upenn.edu