Radiological Diagnosis of

Pulmonary Hypertension

Fatema Ali Al-Khater

210007782

Radiographic Features

Plain X-Ray

By the time the diagnosis of

pulmonary arterial hypertension is made,

90% of patients have an abnormal chest

radiograph .

-low sensitivity and specificity.

Plain film

-elevated cardiac apex due to

right ventricular hypertrophy.

-enlarged right atrium.

-prominent pulmonary

outflow tract.

-enlarged pulmonary arteries.

-pruning of peripheral

pulmonary vessels.

(+ve) Findings :

Comment on the pulmonary artery

The X-ray shows gross enlargement of the cardiac shadow. The right border

extends far to the right indicating gross right atrial enlargement

Lateral chest radiograph shows filling of the retrosternal airspace

(arrow), a result of right ventricular dilatation.

Chest radiograph reveals enlargement of the pulmonary

vasculature and the central pulmonary arteries (arrows).

Secondry hypertension By atrial septal defect

Lateral CXR of the same patient, showing

enlarged pulmonary artery.

Cardiomegaly and prominent bilateral pulmonary arteries in the

hilar areas can be seen in the posteroanterior chest radiograph

Computed Tomography

1- CT is good , noninvasive , used to

confirm presence of pulmonary

hypertension.

2- It is useful in delineating the anatomic

detail of the pulmonary vasculature.

3-CTPA is the best method for

demonstrating emboli.

4- Contrast-enhanced images may show

intraluminal abnormalities in the arteries and

veins and can detect emboli if it’s large.

Advantages of CT

PH signs on CT

Extr-acardiac

Cardiacparenchymal

Enlarged pulmonary trunk >29 mm diameter is

often used as a general predictive cut-off

Enlarged pulmonary arteries

Mural calcification in central pulmonary arteries

Evidence of previous pulmonary emboli

Extra-cardiac vascular

signs:

T angiogram shows dilatation (29 mm or more) of

the main pulmonary artery.

Axial contrast-enhanced CT scan ,shows central pulmonary

artery dilatation with aneurysmal enlargement of the left lower

lobe pulmonary artery .

-Right ventricular hypertrophy: defined as wall

thickness of more than 4 mm.

-Straightening or bowing (towards the left

ventricle) of the interventricular septum

- Right ventricular dilatation

- Decreased right ventricular ejection fraction

- Dilatation of the inferior vena cava and

hepatic veins

- Pericardial effusion

Cardiac signs :

right ventricular myocardium (white arrow) is more than 4

mm thick. Straightening of the interventricular septum

(black arrow) also is seen.

right ventricular dilatation, which is defined as a diameter ratio (the ratio

of the right ventricular diameter [black arrow] to the left ventricular

diameter [white arrow]) greater than 1:1 at the midventricular level.

reflux of contrast material into the inferior vena cava,

which is dilated, and hepatic veins

Centrilobular ground-glass nodules (Cholesterol

granuloma).

Neovascularity: tiny serpiginous intrapulmonary

vessels that often emerge from centrilobular

arterioles.

Parenchymal signs:

Axial contrast-enhanced CT scan shows corkscrewlike

peripheral pulmonary arteries (arrows), findings

indicative of plexogenic arteriopathy.

Axial contrast-enhanced CT scan shows an eccentric wall-

adherent thrombus (arrow) in the right interlobar

pulmonary artery .

Axial contrast-enhanced CT scan shows:

-right atrial and ventricular enlargement with inverted interventricular

septum

- right ventricular hypertrophy,

- -eccentric chronic thrombus causing a crescent-shaped intraluminal

filling defect (arrow) in the left lower lobe pulmonary artery.

Axial contrast-enhanced CT scan shows a thrombotic

mass (straight arrows) in the right main pulmonary

artery.

Echocardiography

- It’s performed to estimate the pulmonary artery

systolic pressure and to assess right ventricular size,

thickness, and function.

- evaluate right atrial size, left ventricular systolic

and diastolic function, and valve function.

- detecting pericardial effusions and intracardiac

shunts.

- uses Doppler ultrasound to estimate the

pulmonary artery systolic pressure.

Advantages

1. Right ventricular enlargement

(RVE).

2. Right ventricular hypertrophy

(RVH).

3. Right atrial enlargement

(RAE).

4. Functional tricuspid

regurgitation (TR) with a

high velocity regurgitant jet

by Doppler (TR jet).

5. The interventricular septum

is shifted toward the left

ventricular cavity.

Main findings

The short axis view from a 2-D echocardiogram shows

significant right ventricular pressure and volume

overload as a result of pulmonary hypertension.

The short axis view from a 2-D echocardiogram shows

significant right ventricular pressure and volume overload as

a result of pulmonary hypertension.

Angiography

Right heart catheterization may be

required.

-Pulmonary angiography is the most

accurate modality for evaluating the

anatomy and pathophysiology of

pulmonary hypertension

-The disadvantage :

it is an invasive procedure as one cannulates

the right side of the heart and thea

pulmonary artery.

Selective right pulmonary arteriogram demonstrates large central

pulmonary arteries and attenuation of the peripheral vessels.

Pulmonary hypertension. Selective left pulmonary arteriogram

reveals large central pulmonary arteries and attenuation of the

peripheral vessels

Angiograms showing a healthy pulmonary artery (left) and a

pulmonary artery with numerous blockages (right).

Magnetic resonance

Imaging

The disadvantages with MRI:

-include limitations in individuals with cardiac-

pacemakers and defibrillators.

- its limited availability and cost, and difficulty in

assessing estimate PA pressures with MRI.

MRI with contrast enhancement allows one to

distinguish between the pulmonary vasculature

and mediastinal adenopathy

Advantages :

Cardiac MRI showing dilated right ventricle

(Axial View )

Cardiac MRI showing dilated right

ventricle (Sagittal view).

Magnetic Resonance Angiography

from a patient with PH

Magnetic Resonance Angiography in patient with Chronic

Thromboembolic Pulmonary Hypertension.

-The main radiological features in Diagnosis

of pulmonary Hypertension in :

-plain –X-Ray.

-Computed tomography.

-Echocardiography.

-MRI.

-Angiography.

- Advantages / Disadvantages of each one .

Summary

References

Thank you

Any Question?