Lungenarterienembolie

Zusammenfassung

Eine Lungenarterienembolie (LE) erfordert einen schnellen Diagnosealgorithmus, da sie unbehandelt mit einer hohen Morbidität und Mortalität einhergeht. Für das diagnostische Vorgehen sind die initiale klinische Wahrscheinlichkeit einer LE und das individuelle Risikoprofil des Patienten entscheidend. Ziel ist es, so schnell wie möglich eine Therapie einzuleiten oder eine LE zuverlässig auszuschließen. Die Computertomografie der Pulmonalarterien (CTPA) mit Mehrzeilen-CT-Systemen ist der Goldstandard im diagnostischen Vorgehen. Darüber hinaus kann die CTPA weitere relevante Informationen liefern, z. B., ob eine Rechtsherzbelastung vorliegt. Es gibt eine ganze Reihe von Scan- und Kontrastmittelprotokollen, mit denen das Ziel einer diagnostischen CTPA mit suffizientem Kontrastmittelenhancement in den Pulmonalarterien unter Vermeidung von Artefakten erreicht werden kann. Dieser Übersichtsartikel stellt eine praktische Handlungshilfe dar, um einen Patienten mit Verdacht auf LE leitliniengerecht radiologisch zu untersuchen.

Abstract

Pulmonary embolism (PE) requires a quick diagnostic algorithm, as the untreated disease has a high mortality and morbidity. Crucial for the diagnostic assessment chosen is the initial clinical likelihood of PE and the individual risk profile of the patient. The overall goal is to diagnose or rule out PE as quickly and safely as possible or to initiate timely treatment if necessary. CT angiography of the pulmonary arteries (CTPA) with multi-slice CT scanner systems presents the actual diagnostic reference standard. With CTPA further important diagnoses can be made, like presence of right ventricular dysfunction. There are different scan and contrast application protocols that can be applied in order to gain diagnostic examinations with sufficient contrast material enhancement in the pulmonary arteries while avoiding all kinds of artifacts. This review article is meant to be a practical guide to examine patients with suspected PE according to the actual guidelines.

Kernaussagen

• Die CTPA ist der Goldstandard der nicht invasiven Diagnostik der LE und liefert wichtige Zusatzinformationen wie das Vorliegen einer Rechtsherzbelastung.

• Die Revisionen der ESC-Leitlinien stärken im Vergleich von 2008 zu 2014 die Position der CTPA im Diagnosealgorithmus weiter.

• Niedrigere kV-Werte sind bei der CTPA im Hinblick auf eine geringere Strahlenbelastung und ein stärkeres Kontrastmittelenhancement zu bevorzugen, falls dies scannertechnisch umsetzbar ist.

• Neue technische Möglichkeiten wie z. B. die Dual-Energy-Technik oder das Ultra-High-Pitch-Verfahren können die Bildqualität und somit die Diagnostik weiter verbessern – sind jedoch noch nicht weit verbreitet.

• Kontrastmittelprotokolle und Atemkommandos sind die 2 Hauptfehlerquellen bei nicht diagnostischen CTPAs.

• Bei Schwangeren mit Verdacht auf eine LE sollte bei initial erfolglosem Ausschluss einer TVT mittels Ultraschall frühzeitig die weitere Bildgebung mittels CTPA (oder zentrenabhängig auch Szintigrafie) zum Einsatz kommen.

Keywords

Pulmonary embolism - CT pulmonary angiography - right ventricular dysfunction - diagnostic algorithms - protocols

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