The Indeterminate CT Pulmonary Angiogram: Imaging Characteristics and Patient Clinical Outcome

PURPOSE: To retrospectively review imaging characteristics of indeterminate computed tomographic (CT) pulmonary angiograms for pulmonary embolism (PE) and patient outcome. MATERIALS AND METHODS: Investigational review board approval was obtained, informed consent was waived, and the study was HIPAA compliant. Retrospective review of 3612 CT pulmonary angiography reports created between July 1, 2001, and July 1, 2003, was performed with a keyword search for "indeterminate," "nondiagnostic," or "inadequate" (thereafter, all defined as "indeterminate") and yielded studies from 237 patients (mean age, 57 years; 117 men, 120 women). Randomly selected diagnostic studies were used to form a control group of 25 subjects (mean age, 64 years; eight men, 17 women). Electronic medical records were reviewed for follow-up imaging (repeat CT pulmonary angiography, conventional pulmonary angiography, ventilation-perfusion scintigraphy, or lower-extremity ultrasonography US), use of anticoagulation, placement of inferior vena cava (IVC) filters, clinical outcomes, and comments regarding indeterminate reading of CT angiograms. Studies (in patients and control subjects) were reviewed for PE, contrast attenuation in the main pulmonary artery (MPA), motion artifacts, image noise, and flow artifacts. Findings were compared with two-sample t tests assuming unequal variance. RESULTS: The cause cited for indeterminism was most often motion (74%), followed by poor contrast enhancement (40%). Contrast attenuation in the MPA was 245 HU +/- 80 (standard deviation) in patients and 339 HU +/- 88 in control subjects (P < .001). Only 46% of indeterminate studies met institutional criteria for adequate contrast attenuation in the MPA. Rereview of studies demonstrated five missed PEs. A total of 81 patients (33%) underwent follow-up imaging within 5 days, with one positive pulmonary angiogram and four positive lower-limb US scans. Reread or follow-up images depicted thromboembolic disease in 4.2% of patients. Nineteen patients (8%) with indeterminate final result were treated for thromboembolic disease with either anticoagulation or IVC filters. Reports on 22% of indeterminate studies contained recommendations for follow-up imaging, and those recommendations nonsignificantly increased the rate for those examinations from 13% to 19%. Review of discharge summaries showed 22% of studies are clinically interpreted as negative. CONCLUSION: The two major causes of indeterminism are motion artifacts and poor contrast enhancement.