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Spiral CT Images of Acute Massive Pulmonary Embolism

Before and After Thrombolysis

Kevin C. Chang, MD, PhD; Nitinkumar Bhatt, MD; William F. Graettinger, MD; ; Lee B. Darrah, MD

From the Department of Medicine and Radiology (L.B.D.), VA Medical Center, University of Nevada School of Medicine, Reno.

Correspondence to Kevin C. Chang, MD, PhD, Department of Medicine, University of Nevada School of Medicine, Reno, Veterans Administration Medical Center, 1000 Locust St, 111, Reno, NV 89520.

A73-year-old man was admitted to the intensive care unit because of sudden onset of dyspnea followed by syncope. On admission, the arterial blood gas (ABG) showed pH 7.45, PaCO₂ 25.2 mm Hg, PaO₂ 53 mm Hg, bicarbonate 17.6 mEq/L, and SaO₂ 89.5% with the patient breathing 2 L/min O₂ via nasal cannula. One year earlier, he had been diagnosed as having a pulmonary embolism, for which he received coumadin for 6 months. The diagnosis of recurrent pulmonary embolism was made, and the patient was empirically anticoagulated with intravenous heparin. Several hours after anticoagulation was started, the patient became hypotensive, and his respiratory condition deteriorated. A repeat ABG showed pH 7.49, PaCO₂ 21.3 mm Hg, PaO₂ 44 mm Hg, bicarbonate 16.4 mEq/L, and SaO₂ 84.6% with the patient on 100% oxygen through a nonrebreathing mask. A spiral CT scan of the thorax showed large intramural thrombi in both right and left pulmonary arteries (Figure, A and B). Because of the hemodynamic and respiratory significance of the emboli, the patient was given intravenous alteplase for thrombolysis. Approximately 4 hours after thrombolysis, the patient's respiratory condition improved dramatically, with an SpO₂ of 95% on room air. Follow-up spiral CT on the third day after thrombolysis showed resolution of intramural thrombi (Figure, C and D).

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Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.

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