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Review article: Biomedical intelligence

Vol. 146 No. 3132 (2016)

Dual-energy computed tomographic imaging of pulmonary hypertension

  • Anne-Lise Hachulla
  • Frédéric Lador
  • Paola M Soccal
  • Xavier Montet
  • Maurice Beghetti
Cite this as:
Swiss Med Wkly. 2016;146:w14328


Dual-energy computed tomography (DECT) angiography of the chest provides a combined morphological and functional analysis of the lung, usually obtained in a single acquisition without extra radiation or injection of extra intravenous iodine contrast.

The parenchymal iodine maps generated by DECT are well correlated with scintigraphy, and are becoming an essential tool for evaluating patients with pulmonary vascular diseases.

With a single DECT acquisition, complete imaging of pulmonary hypertension is now available, displaying vascular anatomy, parenchymal morphology and functional assessment. Triangular pulmonary perfusion defects in chronic thromboembolic pulmonary hypertension may be clearly analysed even in the presence of distal arterial occlusion. Perfusion heterogeneities seen in patients with pulmonary arterial hypertension reflect mosaic perfusion and may be helpful for the diagnosis, severity assessment and prognosis of the disease. Vascular or parenchymal abnormalities can also be analysed with perfusion defects to determine their aetiology. Pulmonary arterial hypertension due to congenital heart disease can be assessed with a single DECT, even in the neonatal population. Furthermore, new applications are emerging with ventilation imaging or myocardial perfusion imaging obtained by DECT and should be considered.

In conclusion, DECT of the thorax enables the simultaneous and noninvasive assessment of vascular anatomy, parenchymal morphology and functional pulmonary imaging in various groups of PH.


  1. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D42–50.
  2. Galie N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Respir J. 2015;46(4):903–75.
  3. Galie N, Rubin L, Hoeper M, Jansa P, Al-Hiti H, Meyer G, et al. Treatment of patients with mildly symptomatic pulmonary arterial hypertension with bosentan (EARLY study): a double-blind, randomised controlled trial. Lancet. 2008;371(9630):2093–100.
  4. Humbert M, Sitbon O, Chaouat A, Bertocchi M, Habib G, Gressin V, et al. Pulmonary arterial hypertension in France: results from a national registry. Am J Respir Crit Care Med. 2006;173(9):1023–30.
  5. Lador F, Herve P. A practical approach of pulmonary hypertension in the elderly. Semin Respir Crit Care Med. 2013;34(5):654–64.
  6. Berger RM, Beghetti M, Humpl T, Raskob GE, Ivy DD, Jing ZC, et al. Clinical features of paediatric pulmonary hypertension: a registry study. Lancet. 2012;379(9815):537–46.
  7. Rich JD, Archer SL, Rich S. Noninvasive cardiac output measurements in patients with pulmonary hypertension. Eur Respir J 2013;42(1):125–33.
  8. Lador F, Herve P, Bringard A, Gunther S, Garcia G, Savale L, et al. Non-Invasive Determination of Cardiac Output in Pre-Capillary Pulmonary Hypertension. PloS one 2015;10(7):e0134221.
  9. Swift AJ, Rajaram S, Hurdman J, Hill C, Davies C, Sproson TW, et al. Noninvasive estimation of PA pressure, flow, and resistance with CMR imaging: derivation and prospective validation study from the ASPIRE registry. JACC Cardiovasc Imag. 2013;6(10):1036–47.
  10. Garcia-Alvarez A, Fernandez-Friera L, Mirelis JG, Sawit S, Nair A, Kallman J, et al. Non-invasive estimation of pulmonary vascular resistance with cardiac magnetic resonance. Eur Heart J. 2011;32(19):2438–45.
  11. Lau EM, Vanderpool RR, Choudhary P, Simmons LR, Corte TJ, Argiento P, et al. Dobutamine stress echocardiography for the assessment of pressure-flow relationships of the pulmonary circulation. Chest. 2014;146(4):959–66.
  12. Swift AJ, Rajaram S, Marshall H, Condliffe R, Capener D, Hill C, et al. Black blood MRI has diagnostic and prognostic value in the assessment of patients with pulmonary hypertension. Eur Radiol. 2012;22(3):695–702.
  13. Ameli-Renani S, Ramsay L, Bacon JL, Rahman F, Nair A, Smith V, et al. Dual-energy computed tomography in the assessment of vascular and parenchymal enhancement in suspected pulmonary hypertension. J Thorac Imaging. 2014;29(2):98–106.
  14. Ameli-Renani S, Rahman F, Nair A, Ramsay L, Bacon JL, Weller A, et al. Dual-energy CT for imaging of pulmonary hypertension: challenges and opportunities. Radiographics. 2014;34(7):1769–90.
  15. Karcaaltincaba M, Aktas A. Dual-energy CT revisited with multidetector CT: review of principles and clinical applications. Diagn Interv Radiol. 2011;17(3):181–94.
  16. Primak AN, Ramirez Giraldo JC, Liu X, Yu L, McCollough CH. Improved dual-energy material discrimination for dual-source CT by means of additional spectral filtration. Med Phys. 2009;36(4):1359–69.
  17. Fornaro J, Leschka S, Hibbeln D, Butler A, Anderson N, Pache G, et al. Dual- and multi-energy CT: approach to functional imaging. Insights Imaging. 2011;2(2):149–59.
  18. Johnson TR, Krauss B, Sedlmair M, Grasruck M, Bruder H, Morhard D, et al. Material differentiation by dual energy CT: initial experience. Eur Radiol. 2007;17(6):1510–7.
  19. Thieme SF, Johnson TR, Reiser MF, Nikolaou K. Dual-energy lung perfusion computed tomography: a novel pulmonary functional imaging method. Semin Ultrasound CT MR. 2010;31(4):301–8.
  20. Mettler FA, Jr., Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008;248(1):254–63.
  21. Zhang LJ, Yang GF, Zhao YE, Zhou CS, Lu GM. Detection of pulmonary embolism using dual-energy computed tomography and correlation with cardiovascular measurements: a preliminary study. Acta Radiol. 2009;50(8):892–901.
  22. Schenzle JC, Sommer WH, Neumaier K, Michalski G, Lechel U, Nikolaou K, et al. Dual energy CT of the chest: how about the dose? Invest Radiol. 2010;45(6):347–53.
  23. Ko JP, Brandman S, Stember J, Naidich DP. Dual-energy computed tomography: concepts, performance, and thoracic applications. J Thoracic Imaging. 2012;27(1):7–22.
  24. Boroto K, Remy-Jardin M, Flohr T, Faivre JB, Pansini V, Tacelli N, et al. Thoracic applications of dual-source CT technology. Eur J Radiol. 2008;68(3):375–84.
  25. Pontana F, Faivre JB, Remy-Jardin M, Flohr T, Schmidt B, Tacelli N, et al. Lung perfusion with dual-energy multidetector-row CT (MDCT): feasibility for the evaluation of acute pulmonary embolism in 117 consecutive patients. Acad Radiol. 2008;15(12):1494–504.
  26. Fink C, Johnson TR, Michaely HJ, Morhard D, Becker C, Reiser M, Nikolaou K. Dual-energy CT angiography of the lung in patients with suspected pulmonary embolism: initial results. RoFo. 2008;180(10):879–83.
  27. Sueyoshi E, Tsutsui S, Hayashida T, Ashizawa K, Sakamoto I, Uetani M. Quantification of lung perfusion blood volume (lung PBV) by dual-energy CT in patients with and without pulmonary embolism: preliminary results. Eur J Radiol. 2011;80(3):e505–509.
  28. Ferda J, Ferdova E, Mirka H, Baxa J, Bednarova A, Flohr T, et al. Pulmonary imaging using dual-energy CT, a role of the assessment of iodine and air distribution. Eur J Radiol. 2011;77(2):287–93.
  29. Chae EJ, Seo JB, Jang YM, Krauss B, Lee CW, Lee HJ, Song KS. Dual-energy CT for assessment of the severity of acute pulmonary embolism: pulmonary perfusion defect score compared with CT angiographic obstruction score and right ventricular/left ventricular diameter ratio. AJR Am J Roentgenol. 2010;194(3):604–10.
  30. Thieme SF, Ashoori N, Bamberg F, Sommer WH, Johnson TR, Leuchte H, et al. Severity assessment of pulmonary embolism using dual energy CT – correlation of a pulmonary perfusion defect score with clinical and morphological parameters of blood oxygenation and right ventricular failure. Eur Radiol. 2012;22(2):269–78.
  31. Bauer RW, Frellesen C, Renker M, Schell B, Lehnert T, Ackermann H, et al. Dual energy CT pulmonary blood volume assessment in acute pulmonary embolism – correlation with D-dimer level, right heart strain and clinical outcome. Eur Radiol. 2011;21(9):1914–21.
  32. Kang MJ, Park CM, Lee CH, Goo JM, Lee HJ. Focal iodine defects on color-coded iodine perfusion maps of dual-energy pulmonary CT angiography images: a potential diagnostic pitfall. AJR Am J Roentgenol. 2010;195(5):W325–30.
  33. Hoey ET, Agrawal SK, Ganesh V, Gopalan D, Screaton NJ. Dual energy CT pulmonary angiography: findings in a patient with chronic thromboembolic pulmonary hypertension. Thorax. 2009;64(11):1012.
  34. Nakazawa T, Watanabe Y, Hori Y, Kiso K, Higashi M, Itoh T, Naito H. Lung perfused blood volume images with dual-energy computed tomography for chronic thromboembolic pulmonary hypertension: correlation to scintigraphy with single-photon emission computed tomography. J Comput Assist Tomogr. 2011;35(5):590–5.
  35. Renard B, Remy-Jardin M, Santangelo T, Faivre JB, Tacelli N, Remy J, Duhamel A. Dual-energy CT angiography of chronic thromboembolic disease: can it help recognize links between the severity of pulmonary arterial obstruction and perfusion defects? Eur J Radiol. 2011;79(3):467–72.
  36. Hoey ET, Mirsadraee S, Pepke-Zaba J, Jenkins DP, Gopalan D, Screaton NJ. Dual-energy CT angiography for assessment of regional pulmonary perfusion in patients with chronic thromboembolic pulmonary hypertension: initial experience. AJR Am J Roentgenol. 2011;196(3):524–32.
  37. Soler X, Kerr KM, Marsh JJ, Renner JW, Hoh CK, Test VJ, Morris TA. Pilot study comparing SPECT perfusion scintigraphy with CT pulmonary angiography in chronic thromboembolic pulmonary hypertension. Respirology. 2012;17(1):180–4.
  38. Castaner E, Gallardo X, Ballesteros E, Andreu M, Pallardo Y, Mata JM, Riera L. CT diagnosis of chronic pulmonary thromboembolism. Radiographics. 2009;29(1):31–50; discussion 50–53.
  39. Pitton MB, Kemmerich G, Herber S, Schweden F, Mayer E, Thelen M. Chronic thromboembolic pulmonary hypertension: diagnostic impact of Multislice-CT and selective Pulmonary-DSA. RoFo. 2002;174(4):474–9.
  40. Tunariu N, Gibbs SJ, Win Z, Gin-Sing W, Graham A, Gishen P, Al-Nahhas A. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J Nucl Med. 2007;48(5):680–4.
  41. Thieme SF, Graute V, Nikolaou K, Maxien D, Reiser MF, Hacker M, Johnson TR. Dual Energy CT lung perfusion imaging--correlation with SPECT/CT. Eur J Radiol. 2012;81(2):360–5.
  42. Lisbona R, Kreisman H, Novales-Diaz J, Derbekyan V. Perfusion lung scanning: differentiation of primary from thromboembolic pulmonary hypertension. AJR Am J Roentgenol. 1985;144(1):27–30.
  43. Talwar A, Sarkar P, Patel N, Shah R, Babchyck B, Palestro CJ. Correlation of a scintigraphic pulmonary perfusion index with hemodynamic parameters in patients with pulmonary arterial hypertension. J Thorac Imaging. 2010;25(4):320–5.
  44. Pontana F, Remy-Jardin M, Duhamel A, Faivre JB, Wallaert B, Remy J. Lung perfusion with dual-energy multi-detector row CT: can it help recognize ground glass opacities of vascular origin? Acad Radiol. 2010;17(5):587–94.
  45. Lee CW, Seo JB, Lee Y, Chae EJ, Kim N, Lee HJ, et al. A pilot trial on pulmonary emphysema quantification and perfusion mapping in a single-step using contrast-enhanced dual-energy computed tomography. Invest Radiol. 2012;47(1):92–7.
  46. Chae EJ, Seo JB, Goo HW, Kim N, Song KS, Lee SD, et al. Xenon ventilation CT with a dual-energy technique of dual-source CT: initial experience. Radiology. 2008;248(2):615–24.
  47. Park EA, Goo JM, Park SJ, Lee HJ, Lee CH, Park CM, et al. Chronic obstructive pulmonary disease: quantitative and visual ventilation pattern analysis at xenon ventilation CT performed by using a dual-energy technique. Radiology. 2010;256(3):985–97.
  48. Chae EJ, Seo JB, Lee J, Kim N, Goo HW, Lee HJ, et al. Xenon ventilation imaging using dual-energy computed tomography in asthmatics: initial experience. Invest Radiol. 2010;45(6):354–61.
  49. Hachulla AL, Pontana F, Wemeau-Stervinou L, Khung S, Faivre JB, Wallaert B, et al. Krypton ventilation imaging using dual-energy CT in chronic obstructive pulmonary disease patients: initial experience. Radiology. 2012;263(1):253–9.
  50. Thieme SF, Hoegl S, Nikolaou K, Fisahn J, Irlbeck M, Maxien D, et al. Pulmonary ventilation and perfusion imaging with dual-energy CT. Eur Radiol. 2010;20(12):2882–9.
  51. Au VW, Jones DN, Slavotinek JP. Pulmonary hypertension secondary to left-sided heart disease: a cause for ventilation-perfusion mismatch mimicking pulmonary embolism. Br J Radiol. 2001:74(877):86–8.
  52. Ruzsics B, Lee H, Zwerner PL, Gebregziabher M, Costello P, Schoepf UJ. Dual-energy CT of the heart for diagnosing coronary artery stenosis and myocardial ischemia-initial experience. Eur Radiol. 2008;18(11):2414–24.
  53. Ko SM, Choi JW, Song MG, Shin JK, Chee HK, Chung HW, Kim DH. Myocardial perfusion imaging using adenosine-induced stress dual-energy computed tomography of the heart: comparison with cardiac magnetic resonance imaging and conventional coronary angiography. Eur Radiol. 2011;21(1):26–35.
  54. Schwarz F, Ruzsics B, Schoepf UJ, Bastarrika G, Chiaramida SA, Abro JA, et al. Dual-energy CT of the heart--principles and protocols. Eur J Radiol. 2008;68(3):423–33.
  55. Ko SM, Song MG, Chee HK, Hwang HK, Feuchtner GM, Min JK. Diagnostic performance of dual-energy CT stress myocardial perfusion imaging: direct comparison with cardiovascular MRI. AJR Am J Roentgenol. 2014;203(6):W605–613.
  56. Bauer RW, Kerl JM, Fischer N, Burkhard T, Larson MC, Ackermann H, Vogl TJ. Dual-energy CT for the assessment of chronic myocardial infarction in patients with chronic coronary artery disease: comparison with 3-T MRI. AJR Am J Roentgenol. 2010;195(3):639–46.
  57. Wichmann JL, Bauer RW, Doss M, Stock W, Lehnert T, Bodelle B, et al. Diagnostic accuracy of late iodine-enhancement dual-energy computed tomography for the detection of chronic myocardial infarction compared with late gadolinium-enhancement 3-T magnetic resonance imaging. Invest Radiol. 2013;48(12):851–6.

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