Radiology through images
Perfusion defects in pulmonary perfusion iodine maps: Causes and semiology
Defectos de perfusión en el mapa de iodo pulmonar: causas y semiología
A. Bustos Fiore
, M. González Vázquez, C. Trinidad López, D. Mera Fernández, M. Costas Álvarez
Corresponding author
Servicio de Radiodiagnóstico, Hospital POVISA, Vigo, Pontevedra, Spain
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Bustos Fiore, M. González Vázquez, C. Trinidad López, D. Mera Fernández, M. Costas Álvarez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Bustos Fiore" "email" => array:2 [ 0 => "arianabustos@hotmail.com" 1 => "arianacristela@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "González Vázquez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Trinidad López" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Mera Fernández" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Costas Álvarez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital POVISA, Vigo, Pontevedra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Defectos de perfusión en el mapa de iodo pulmonar: causas y semiología" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1124 "Ancho" => 1500 "Tamanyo" => 188900 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fifty-four-year-old male with one mass in the left superior lobe. (a) Axial CTA image with mediastinum window showing one mass in the left superior lobe (white arrow). Axial (b) and coronal (c) reconstructions of the iodine map with absence of color that are consistent with the mass seen on the CTA image (white arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The dual-energy computed tomography (DECT) allows us to characterize and differentiate chemical elements using different attenuation spectrums of X-rays based on kilovoltage (kV) in order to detect functional alterations in the presence of subtle morphological or densitometrical alterations. Some of the applications of dual energy are obtaining studies “without virtual contrast”; characterizing cystinic lithiasis; and assessing urate deposit in diseases such as gout. When it comes to the thorax, the computed tomography angiography (CTA) is the modality of choice for the diagnosis of acute pulmonary thromboembolisms (PTEs). Ever since the dual energy technique was first introduced, we have had the opportunity to obtain angiographic images of pulmonary arteries and perfusion maps of the pulmonary parenchyma<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> simultaneously, in such a way that now it is possible to obtain a higher diagnostic accuracy and more precise information on the severity of PTEs.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of this paper is to describe the utility of pulmonary perfusion maps in order to give functional information on the PTEs and make correct differentiations of perfusion defects that are not due to PTEs.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Technique and post-processing of dual energy pulmonary CTA</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dual energy is based on the principle that certain materials have different attenuation when using different kilovoltages (kV). Air, water, and fat have the same attenuation coefficient when using different kVs, and cannot be distinguished using dual energy, unlike iodine, calcium, and uric acid, xenon, and gadolinium that are materials that can be characterized.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> Every material has a specific attenuation coefficient between two energies, which is known such as the “dual-energy index” (DEI). Some substances may have similar attenuation coefficients when using a certain kVs, such as calcium and iodine, but different DEIs when using different kVs, meaning that we can differentiate them when using two (2) different spectrums of energy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">With the actual CT machines, we can conduct dual energy studies using three (3) different techniques: dual source CT scan, fast kV commutation, and multilayer “sandwich” detectors.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,4,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The dual source CT scan uses two (2) X-ray tubes with their respective detector panels placed perpendicularly to the gantry and operates, at the same time, with different kVs, in such a way that we can obtain a series of high-energy images at 140<span class="elsevierStyleHsp" style=""></span>kV, and another series of low-energy images at 80<span class="elsevierStyleHsp" style=""></span>kV.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">We should remember that</span> the DECT allows us to characterize and differentiate materials using the different attenuation coefficients of X-rays of every material based on the kV used.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The post-processing of the data obtained using the dual energy CT scan is based on the theory of “material decomposition”, that allows us to obtain images defined by voxels that only contain the material we are interested in.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> When it comes to the lung, contrast-only images are consistent to what we call iodine map or pulmonary perfusion map and provide information of the pulmonary parenchyma vascularization.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> It is important to say that this information speaks about the concentration of iodine in the pulmonary parenchyma, and not about true perfusion, for whose detection we would need dynamic studies.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At our center, we conduct DECT studies when on suspicion of PTE. We use a dual source CT machine (Somaton Definition Flash, Siemens Medical Solutions, Forchheim, Germany) integrated by two X-ray tubes working with different energies: tube B (80<span class="elsevierStyleHsp" style=""></span>kV at 252<span class="elsevierStyleHsp" style=""></span>mAs) and tube A (140<span class="elsevierStyleHsp" style=""></span>kV at 126<span class="elsevierStyleHsp" style=""></span>mAs). Post-processing takes place in a working station (Syngo Multimodality, Siemens Healthcare) using the “lung PBV” (lung pulmonary blood volume) software. One hundred (100)<span class="elsevierStyleHsp" style=""></span>ml of iopromide (300<span class="elsevierStyleHsp" style=""></span>mg/ml) are administered at a flow rate of 5<span class="elsevierStyleHsp" style=""></span>ml/s followed by an injection of 20<span class="elsevierStyleHsp" style=""></span>ml of saline solution at the same flow rate. Delay time is estimated using the bolus tracking technique by placing the region of interest (ROI) in the ascending aorta; the CT acquisition starts at densities of 100 HU, which is how we can obtain the adequate contrast staining of the pulmonary parenchyma while keeping the adequate staining of the pulmonary arteries for the detection of thrombi. At other centers, the ROI is placed in the pulmonary artery followed by a 7<span class="elsevierStyleHsp" style=""></span>s-delay in order to achieve a correct opacification of the pulmonary parenchyma. Acquisition takes place in the caudal-to-cranial direction in order to avoid artifacts due to the high concentration of contrast in the subclavian vein, or the superior vena cava.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Images are post-processed in the working station and one iodine map of the pulmonary parenchyma is obtained using attenuation thresholds between −950 and −600 HU, in such a way that tissues with densities outside this range such as pulmonary arteries, atelectasis, and tumors are excluded even though they have iodine. The iodine map is represented with a color scale that can be normalized with respect to any iodine structure; to this end, one ROI is placed in the left atrium so that a similar color scale can be obtained in all patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">The semiology of iodine maps</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Normal iodine map</span><p id="par0050" class="elsevierStylePara elsevierViewall">It is one homogeneous color map in the entire pulmonary parenchyma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There is a slight anterior–posterior gradient with higher iodine content in the pulmonary segments.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Perfusion defects due to PTE</span><p id="par0055" class="elsevierStylePara elsevierViewall">In the acute PTE, perfusion defects appear as areas with different degrees of hypoperfusion, of triangular morphology, and peripheral base, that affect a vascular territory whose size depends on the caliber of the blood vessel involved. Normally, the repletion defect can be identified in the corresponding tributary blood vessel. The greatest utility of iodine maps is the detection of small defects, which allows us to diagnose PTE in sub-segmental branches that have gone misdiagnosed when analyzing the images of conventional CTA (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), but iodine maps are also useful in the PTE of main branches in order to assess all kinds of parenchymal perfusion defects, and any possible functional repercussions (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In the chronic PTE, triangular perfusion defects of peripheral base undistinguishable from the acute PTE can be seen (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>). The degree of alteration in pulmonary perfusion and the capacity to visualize perfusion defects in the iodine maps will depend on the complete obstruction of the blood vessel, and on the development of systemic collaterals. The analysis of CTA images using multiplanar representation allows us to differentiate them when networks, bands, membranes, or filiform defects of the blood vessel filling can be seen. Also, images “without virtual contrast” for the detection of mural calcifications can be useful here.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">We should remember that</span> the iodine map increases diagnostic safety and sensitivity compared to conventional pulmonary CTAs when it comes to finding small perfusion defects due to PTE in sub-segmental branches.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Perfusion defects not due to PTE</span><p id="par0070" class="elsevierStylePara elsevierViewall">These defects may be due to a true perfusion alteration, or diseases, or artifacts that are out of the range used in the iodine map (pseudo-defects):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0075" class="elsevierStylePara elsevierViewall">Consolidations and masses of pulmonary parenchyma</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Consolidations and masses of pulmonary parenchyma have soft tissue attenuation coefficients. Since we obtain the iodine map in density ranges between −950 and −600 HU), these lesions are out the map and what we see is the absence of color (<a class="elsevierStyleCrossRefs" href="#fig0030">Figs. 6 and 7</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">We may have issues when conducing differential diagnoses only with pulmonary infarction (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>), that also as a triangular morphology of peripheral base and one homogeneous perfusion defect in the iodine map compared to consolidations that show heterogeneous perfusion defects.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">We should remember that</span> perfusion defects in the iodine map should match the defects found on conventional images with lung and mediastinum windows to be able to diagnose defects due to other lesions of pulmonary parenchyma.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0095" class="elsevierStylePara elsevierViewall">Fibrosing lung disease</p></li></ul></p><p id="par0100" class="elsevierStylePara elsevierViewall">There is a lack of color that is consistent with the areas of fibrosis with irregular morphology and similar distribution to that of the underlying condition (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(3)</span><p id="par0105" class="elsevierStylePara elsevierViewall">Emphysema</p></li></ul></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The regions of emphysema and bullae do not have flow and appear as colorless regions in the iodine map with the typical emphysematous morphology. The assessment of patients with pulmonary emphysema rests not only on the amount of tissue destroyed, but also on the state of pulmonary perfusion in a healthy parenchyma.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> DECTs allow us to detect the extension of emphysema and determine its repercussion in pulmonary vascularization<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>).<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(4)</span><p id="par0115" class="elsevierStylePara elsevierViewall">Mosaic perfusion pattern</p></li></ul></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">On the CT scan, the “ground-glass” pattern is defined as mild opacities that do not let us see the pulmonary blood vessels contained. Recognizing the “ground-glass” pattern and determining its causes is extremely important. It may be due to partial filling of the air space, interstitial thickening, or both, but also to an increased volume of capillary blood volume. In this last situation, it is more usual due to flow redistribution as a consequence of destructive/obstructive changes in pulmonary circulation. The “ground-glass” pattern causes hemodynamics and it can be identified by the presence of an increased vascular diameter in regions of increased density, and also by higher concentrations of iodine in the maps of pulmonary perfusion.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(5)</span><p id="par0125" class="elsevierStylePara elsevierViewall">Artifacts</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">The iodine map shows perfusion defects due to artifacts, and it is important to differentiate them from the perfusion defects in the PTE. They can be distinguished according to their morphology and are related to the CTA Images.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Beam hardening artifacts:</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Costal arch artifacts: Costal arches cause artifacts that look like perfusion defects and on the axial cuts they may look like PTE defects. Normally, they can be seen in the anterior side of the lung and can be identified because on the coronal and sagittal projections they are seen as regions of absence of linear perfusion following the trajectory of the ribs.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Artifact due to a high concentration of contrast through SVC and right subclavian vein: areas of absence of color, of linear morphology, that can have a black or white appearance. This artifact can be minimized using one bolus of saline solution after the administration of contrast and after conducting the caudal-to-cranial direction study.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Movement artifacts (patient, cardiac, or respiratory movements): they look like a white line on the iodine map adjacent to the left cavities (beating heart artifact) or diaphragms (respiratory artifact).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Metallic artifacts: the iodine map shows perfusion defects or absence of color of linear morphology that are related to the CTA images and suggestive of metallic material (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>).</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Other artifacts:</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">FOV (field of view) artifacts: on the DECT, tube A has one FOV of 50<span class="elsevierStyleHsp" style=""></span>cm of diameter, and tube B one FOV of 33<span class="elsevierStyleHsp" style=""></span>cm. The region outside the FOV shown with a dotted line cannot be characterized and looks like a region with absence of perfusion on the iodine map. The FOV limitations can be seen when the tube B operates at 80<span class="elsevierStyleHsp" style=""></span>kV; in first-generation machines the FOV has 26.8<span class="elsevierStyleHsp" style=""></span>cm in diameter, and in second-generation machines, the diameter of the FOV is 33<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0060">Fig. 12</a>).</p><elsevierMultimedia ident="fig0060"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Artifacts in obese patients: the image noise in obese patients gives rise to multiple artifacts that look like hypoperfused areas/absence of perfusion of linear morphology, giving a sort of heterogeneous appearance that most times will not let us interpret the iodine map.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Artifact due to error in the technique used when administering contrast: it is advisable to place the ROI in the ascending aorta, because if erroneously placed in the pulmonary artery, the contrast will not have enough time to pass through the pulmonary parenchyma and reach the veins. That is why the concentration of iodine in the pulmonary parenchyma is lower and there are regions with absence of color on the iodine map that are not true perfusion defects (<a class="elsevierStyleCrossRef" href="#fig0065">Fig. 13</a>).</p><elsevierMultimedia ident="fig0065"></elsevierMultimedia></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">We should remember that</span> in order to obtain optimal quality iodine maps, one region of interest (ROI) should be placed in the ascending aorta.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">The applicability of DECT for the diagnosis of PTEs allows us to find perfusion defects that are secondary to complete or partial obstructions of pulmonary arteries. However, not all perfusion defects are due to PTE, meaning that we need to distinguish them semiologically, and correlate them with the CTA images using multiplanar representation. The greatest utility of this technique is that it provides morphological and functional information in patients with PTE and allows us to detect PTE in sub-segmental branches.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors’ contributions</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">1.</span><p id="par0195" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study: ABF, MGV and CTL.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2.</span><p id="par0200" class="elsevierStylePara elsevierViewall">Study Idea: ABF, MGV, CTL, DMF and MCA.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">3.</span><p id="par0205" class="elsevierStylePara elsevierViewall">Study Design: ABF, MGV, CTL, DMF and MCA.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">4.</span><p id="par0210" class="elsevierStylePara elsevierViewall">Data Mining: ABF, MGV and DMF.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">5.</span><p id="par0215" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation: ABF, MGV and CTL.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">6.</span><p id="par0220" class="elsevierStylePara elsevierViewall">Statistical Analysis: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">7.</span><p id="par0225" class="elsevierStylePara elsevierViewall">Reference: ABF, MGV, CTL, DMF and MCA.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">8.</span><p id="par0230" class="elsevierStylePara elsevierViewall">Writing: ABF, MGV and CTL.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">9.</span><p id="par0235" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks: ABF, MGV, CTL, DMF and MCA.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">10.</span><p id="par0240" class="elsevierStylePara elsevierViewall">Approval of final version: ABF, MGV, CTL, DMF and MCA.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interests</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests associated with this article whatsoever.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1060306" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1009158" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1060305" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1009157" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Technique and post-processing of dual energy pulmonary CTA" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "The semiology of iodine maps" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Normal iodine map" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Perfusion defects due to PTE" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Perfusion defects not due to PTE" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Authors’ contributions" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-02" "fechaAceptado" => "2017-11-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1009158" "palabras" => array:4 [ 0 => "Pulmonary embolism" 1 => "Dual energy" 2 => "Lung perfusion" 3 => "Iodine map" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1009157" "palabras" => array:4 [ 0 => "Tromboembolismo pulmonar" 1 => "Energía dual" 2 => "Perfusión pulmonar" 3 => "Mapa de iodo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the usefulness of dual-energy CT for obtaining pulmonary perfusion maps to provide morphological and functional information in patients with pulmonary embolisms. To review the semiology of perfusion defects due to pulmonary embolism so they can be differentiated from perfusion defects due to other causes: alterations outside the range used in the iodine map caused by other diseases of the lung parenchyma or artifacts.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT angiography of the pulmonary arteries is the technique of choice for the diagnosis of pulmonary embolisms. New dual-energy CT scanners are useful for detecting perfusion defects secondary to complete or partial obstruction of pulmonary arteries and is most useful for detecting pulmonary embolisms in subsegmental branches.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Objetivo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Describir la utilidad de la tomografía computarizada con energía dual (TCED) en la obtención de mapas de perfusión pulmonar para aportar información morfológica y funcional en el tromboembolismo pulmonar (TEP). Revisar la semiología de los defectos de perfusión debidos a TEP y diferenciarlos de los defectos no debidos a TEP que son alteraciones que quedan fuera del rango utilizado en el mapa de iodo y están causados por otras enfermedades del parénquima pulmonar o por artefactos.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La angiografía por TC de las arterias pulmonares es la técnica de elección en el diagnóstico de TEP. Las nuevas TC con energía dual son útiles para detectar defectos de perfusión secundarios a obstrucción completa o parcial de las arterias pulmonares, y tiene su mayor utilidad en la detección de TEP en ramas subsegmentarias.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bustos Fiore A, González Vázquez M, Trinidad López C, Mera Fernández D, Costas Álvarez M. Defectos de perfusión en el mapa de iodo pulmonar: causas y semiología. Radiología. 2018;60:303–311.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">All the authors have read and approved the final version of this paper.</p>" ] ] "multimedia" => array:13 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 885 "Ancho" => 900 "Tamanyo" => 112159 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Healthy 55-year-old male. Normal iodine map in coronal reconstruction.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 741 "Ancho" => 1350 "Tamanyo" => 117694 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fifty-four-year-old male with PTE in right sub-segmental branches. (a) Coronal reconstructions of the iodine map with perfusion defects of triangular morphology and peripheral base (white arrows). (b) Coronal reconstructions of CTA with one repletion defect in the right inferior sub-segmental artery (b) (white arrow).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1200 "Ancho" => 1500 "Tamanyo" => 189928 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Sixty-two-year-old male with acute bilateral PTE with complete obstruction of the left main pulmonary artery and its lobar and segmental branches, and partial obstruction of the right main pulmonary artery. (a) Coronal reconstruction of the iodine map with complete hypoperfusion of left lung (white arrow). (b) Axial reconstruction of the iodine map with a small perfusion defect of triangular morphology and peripheral base in right lung (white arrow). (c) Axial CTA image with repletion defects in both main pulmonary arteries and left lobar arteries in relation to the mural thrombus (white arrows).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 584 "Ancho" => 1400 "Tamanyo" => 74678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fifty-six-year-old female with chronic PTE. (a) Axial CTA image with one partial thrombus in the main right pulmonary artery and its lobar branches (white arrows) not causing complete obstruction. (b) Sagittal reconstruction of the iodine map with two (2) regions of noticeable hypoperfusion of triangular morphology and peripheral base (white arrows) in relation to the obstruction of sub-segmental branches.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 671 "Ancho" => 1400 "Tamanyo" => 103069 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Eighty-eight-year-old female with chronic bilateral PTE. (a) Coronal reconstruction of the iodine map with perfusion defects in both inferior lobes in relation to the chronic PTE (white arrows). (b) The coronal reconstruction of the CTA shows one peripheral repletion defect with a reduced diameter of the blood vessel and hypertrophy of the bronchial artery (white arrows).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1142 "Ancho" => 1500 "Tamanyo" => 205986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Eighty-six-year-old male with pneumonia in the right inferior lobe. Axial (a) and coronal (b) reconstructions of the iodine map with one region of absence of color in the right inferior lobe (white arrows). (c) Axial CTA image with lung window with presence of one consolidation with aerial bronchogram (white arrow).</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1124 "Ancho" => 1500 "Tamanyo" => 188900 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fifty-four-year-old male with one mass in the left superior lobe. (a) Axial CTA image with mediastinum window showing one mass in the left superior lobe (white arrow). Axial (b) and coronal (c) reconstructions of the iodine map with absence of color that are consistent with the mass seen on the CTA image (white arrows).</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1040 "Ancho" => 1500 "Tamanyo" => 159925 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Fifty-two-year-old female with pulmonary infarctions in the middle lobe and right inferior lobe due to PTE. (a) Axial CTA image with mediastinum window showing one hypodense lesion of triangular morphology and peripheral base in relation to pulmonary infarction (white arrow). Axial (b) and coronal (c) reconstructions of the iodine map with absence of color in the periphery of the middle lobe and right inferior lobe that are consistent with the pulmonary infarctions seen on the CTA image (white arrows).</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 553 "Ancho" => 1400 "Tamanyo" => 88812 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Fifty-eight-year-old male with pulmonary fibrosis. (a) Axial reconstruction of the iodine map with irregular linear regions with absence of color (white arrow). (b) Axial CTA image with lung window with areas of fibrosis that are consistent with defects of the iodine map (white arrow).</p>" ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 564 "Ancho" => 1400 "Tamanyo" => 97397 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Seventy-eight-year-old male with severe panlobular emphysema. (a) Axial CTA image with lung window with emphysematous areas (asterisks). (b) Axial reconstruction of the iodine map with absence of color of rounded morphology that is consistent with emphysematous regions (asterisks).</p>" ] ] 10 => array:7 [ "identificador" => "fig0055" "etiqueta" => "Figure 11" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr11.jpeg" "Alto" => 721 "Ancho" => 1400 "Tamanyo" => 119859 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Sixty-five-year-old male with material of osteosynthesis in the spine. (a) Coronal CTA reconstruction with mediastinum window showing the metallic material of the spine. (b) Coronal reconstruction of the iodine map with perfusion defects seen as black bands in right hemithorax (white arrows).</p>" ] ] 11 => array:7 [ "identificador" => "fig0060" "etiqueta" => "Figure 12" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr12.jpeg" "Alto" => 988 "Ancho" => 1500 "Tamanyo" => 171186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Healthy fifty-three-year-old female. (a) Axial image with mediastinum window showing one dotted line on the left and inside the costal arches (white arrow). Coronal (b) and axial (c) reconstructions of the iodine map with absence of color of linear and peripheral morphology in relation to the FOV artifact (white arrows).</p>" ] ] 12 => array:7 [ "identificador" => "fig0065" "etiqueta" => "Figure 13" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr13.jpeg" "Alto" => 526 "Ancho" => 1400 "Tamanyo" => 99384 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Healthy fifty-six-year-old female. (a) Coronal reconstruction of the iodine map with perfusion defects seen as black bilateral linear bands in relation to the erroneous placement of one ROI in the pulmonary artery (white arrows). 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