Intern Journal reading Multi–Detector Row CT of Hemoptysis

Hemoptysis Expectoration of blood from the respiratory tract Massive: >100 to >600 mL over a 24-h period →not reliable Potential risk: Underlying tumor Massive hemoptysis induced impaired gas exchange

Etiology Source other than the lower respiratory tract   Upper airway (nasopharyngeal) bleeding   Gastrointestinal bleeding Tracheobronchial source   Neoplasm (bronchogenic carcinoma, endobronchial metastatic tumor, Kaposi's sarcoma, bronchial carcinoid)  Bronchitis (acute or chronic)   Bronchiectasis Broncholithiasis   Airway trauma   Foreign body  Pulmonary parenchymal source   Lung abscess  Pneumonia   Tuberculosis   Mycetoma ("fungus ball")   Goodpasture's syndrome   Idiopathic pulmonary hemosiderosis   Wegener's granulomatosis   Lupus pneumonitis   Lung contusion  Primary vascular source   Arteriovenous malformation   Pulmonary embolism  Elevated pulmonary venous pressure (esp. mitral stenosis)  Pulmonary artery rupture secondary to balloon-tip pulmonary artery catheter manipulation Miscellaneous/rare causes  Pulmonary endometriosis   Systemic coagulopathy or use of anticoagulants or thrombolytic agents

Lung arterial supply Pulmonary artery Bronchial artery Non-bronchial artery Bleeding from the artery itself Fragile anastomosis from neovascularization→caused by increased bronchial artery, chronic inflammation…etc Cryptogenic hemoptysis

Bronchoscopy Useful diagnostic tool Can help maintain airway Can’t detect the underlying etiology Difficult to examination with massive blood in airway Would cause recurrent hemorrhage

Maximum Intensity Projection Technique The connectivity algorithm starts with picking a surface value and seed point as input. The next subsequent step is to find out and mark out those points which lie on the surface of our interest. In the construction of surface step, this method only considers those marked points [8]. This 3D reconstruction technique includes the procedure shown in figure 5.

http://www.cs.umbc.edu/~ebert/693/NLiao/node5.html

CT Fast examination Could detail the lung tissue and recognize the underlying problem “Road map” for further intervention

Lung Parenchyma presence of liquified material in segmental and lobar bronchi and hazy consolidation or ground-glass infiltrates in the lung parenchyma Bronchiectasis Lung carcinoma acute and chronic lung infections (in particular, tuberculosis and aspergillosis) cardiogenic pulmonary edema

Pulmonary arteries Acute thromboembolic disease Vascular invasion with tumor or tuberculosis Rasmussen aneurysm, sentinel bleeding Pulmonary arteriovenous malformation With feeding artery > 3mm

Bronchial arteries 95% bleeding origin Abnormal dilatation in bronchial artery: >2mm May bleeding from the thin wall anastomosis Could only detect by contrast in airway lumen or angiography Bronchial aneurysm Orthotopic and anomalous origin

Bronchial arteries have ectopic origins outside the T5 through T6 range in 20% of cases

Non-Bronchial systemic artery Abnormally dilated arteries that course into the lungs along trajectories 41%–88% of cases of massive hemoptysis The CT evaluation of hemoptysis should always be extended, if possible, to include the supraaortic great vessels and the upper abdomen Pseudosequestration

Bronchial-to-Systemic Artery Communications inadvertent embolization of a major spinal artery, with resultant paraplegia. Coronary-to-bronchial artery anastomoses cyanotic congenital heart disease chronic thromboembolic disease vasculitides such as Takayasu arteritis, “Pulmonary steal” syndrome

Cryptogenic hemoptysis diagnosis of exclusion prevalence of approximately 3%–42% 6% of such patients will present with unresectable lung carcinoma within the next 3 years risk rises to 10% among patients who are over 40 years old

Conclusion CT is a quick and noninvasive tool that is helpful in the diagnosis and management of hemoptysis, and its use should be considered in any patient who presents with this condition.

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