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CT diagnosis of pulmonary artery dissection — potential pitfall of multidetector CT

We read with great interest the article entitled "CT findings of pulmonary artery dissection" by Neimatallah et al [1], highlighting the usefulness of CT in the diagnosis of this potentially fatal condition. I would, however, like to highlight a potential pitfall in using CT for the diagnosis of pulmonary artery dissection.

In retrospect, the pseudo-flap in the pulmonary artery represents motion artefact from aortic and cardiac pulsation. Such artefact has been described to mimic Stanford Type A dissections. It has been suggested that the presence of a superior vena cava (SVC) pseudo-flap is useful in distinguishing motion artefact from true aortic dissection [2]. Although no SVC pseudo-flap is seen in our case, an aortic root pseudo-flap (curved arrow in Figure 1) is present and alludes to the presence of motion artefact. In addition, reconstructed coronal images cannot be used to confirm the presence of a true flap, as it is simply a different view of the same artefact-containing dataset [2].

View larger version (85K): [in this window] [in a new window]   Figure 1. Axial CT showing the presence of a pulmonary artery pseudo-flap (arrow) in the same axial image as an aortic root pseudo-flap (curved arrow).

View larger version (93K): [in this window] [in a new window]   Figure 2. Coronal reconstruction of the CT dataset showing"persistence" of the pulmonary artery pseudo-flap (arrow).Recently, a 61-year-old man presented to our emergency department in shock with clinical features suspicious of acute pulmonary embolism. An urgent multidetector CT pulmonary angiogram was performed (Somatom Sensation 64 cardiac CT scanner; Siemens Medical Solutions, USA: 1 mm slice thickness, 0.3 s gantry rotation, 130 kV, 160 mAs). An apparent intimal flap (Figure 1, arrow) is noted extending from the main pulmonary trunk into the right main pulmonary artery. The flap is present in at least eight contiguous axial slices and is well demonstrated on coronal reconstruction (Figure 2) using a three-dimensional workstation (Leonardo; Siemens Medical Solutions). The findings were interpreted by the resident on duty to represent pulmonary artery dissection. Emergency cardiopulmonary bypass and exploration of the pulmonary artery with intention for graft repair of the dissection was performed. Intra-operatively, however, the pulmonary artery was found to be normal.

Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433., E-mail: druei{at}yahoo.com

Received for publication September 5, 2008. Accepted for publication October 6, 2008.

References

1. Neimatallah MA, Hassan W, Moursi M, Al Kadhi Y. CT findings of pulmonary artery dissection. BrĀ J Radiol. 2007;80:e61–3.[Abstract/Free Full Text]
2. Ko SF, Hsieh MJ, Chen MC, Ng SH, Fang FM, Huang CC, et al. Effects of heart rate on motion artifacts of the aorta on non-ECG-assisted 0.5-sec thoracic MDCT. Effects of heart rate on motion artifacts of the aorta on non-ECG-assisted 0.5-sec thoracic MDCT. AJR Am J Roentgenol 2005;184:1225–30.[Abstract/Free Full Text]

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