Ferrari Cristina, Cimino Alessandra, Bianco Giacomo, Iuele Francesca, Di Palo Alessandra, Fanelli Margherita, Niccoli-Asabella Artor, Rubini Giuseppe
Nuclear Medicine Unit, D.I.M.-University of Bari "Aldo Moro", Bari, Italy.
Hell J Nucl Med. 2017 Sep-Dec;20 Suppl:166.
Pulmonary Embolism (PE) is an emergency condition that requires immediate treatment. As the symptoms and the risk factors are nonspecific, PE differential diagnosis is often required. Even if angio-CT is considered the gold standard for PE diagnosis, the frequent allergic condition and/or chronic renal failure of patients make, in most cases, not possible the use of contrast enhancement in emergency with even more increasing use of Lung Perfusion Scintigraphy (LPS), as a simple and fast examination with no preparation/contraindication. The aim of our study is to highlight the role of LPS in the management of patients (pts) with suspected PE admitted to our hospital as an emergency in the "on-call" 24 hours (hrs) service.
We retrospectively revised 2166 LPS performed for suspected PE from January 2012 to December 2016, of which 1730 were urgent. LPS was performed according to the EANM guidelines in the 4 standard projections. The relation between symptoms, risk factors, dosage of D-dimers, other imaging diagnostic tools and LPS results were evaluated by contingency tables and Odds Ratio (OR).
The origin unit of pts was: emergency (56.7%), pneumology (10.8%), neurology (4.8%), internal medicine (6.5%), surgery (5.2%), cardiology (3.3%) and other departments (11.2%). 59.3% of the examinations were performed during the on-call 24 hrs service. Symptoms were chest pain in 39%, dyspnea in 75%, cough in 22%. In 34% were present two symptoms, while 10% were asymptomatic. D-dimer dosage before LPS was increased in 97% (>500 ug/L). 55.5% had only one risk factor, 18.7% had two or more risk factors. 75.5% of pts had previously performed another diagnostic exam (Chest X-ray in 57%, chest CT in 8.4%, both in 10.1%) while 24.5% did not undergo previous diagnostic exam. The Chest X-ray and/or chest CT resulted negative in 25.4%, suspected for PE in 24.4%, non-specific with pleural effusion in 18.8% and non-specific with inflammatory interstitial diseases in 31.4%. LSP resulted positive for PE in 17% and then treated; LPS resulted negative in the remnant 83%. LPS results were associated with those of CT and Rx (χ=17.5 P=0.001). LPS resulted positive in 13.8% with negative Chest X-ray and/or CT, in 23.4% with suspected PE, in 15.2% with pleural effusion and in 14.7% with inflammatory interstitial diseases. Furthermore LPS resulted positive in 17.32% without previous diagnostic exam. The increased value of D-Dimers (>500ng/ml) observed in 97% was not predictive of PE (OR=0.598 P=0.152). A similar result was observed for cough (OR=1.146 P=0.395) and chest pain (OR=0.927 P=0.601). Conversely, dyspnea appeared to be a significant symptom of PE (OR=1.596 P=0.003). The presence of risk factors is not predictor of PE detected by LPS (OR=1.297 P=0.089).
LPS has a key role in the early diagnosis but even more in the exclusion of PE, optimizing the management of pts who do not require admission to intensive care unit with high costs and limited availability. LPS confirms to be a simple, quick and inexpensive examination. It does not require preparation and has no side effect so it can be performed in all types of pts including pregnant women, politraumatized and complicated patients, with great impact on resource optimization for intensive care units. Our multi-year and large-scale experience related to a metropolitan area suggests that, to date, given the great demand and relevance of this examination, Nuclear Medicine Units must necessarily be organized in order to provide LPS as emergency in on-call 24 hrs service.
肺栓塞（PE）是一种需要立即治疗的紧急病症。由于其症状和危险因素不具有特异性，常常需要进行PE鉴别诊断。尽管血管CT被认为是PE诊断的金标准，但患者频繁出现的过敏情况和/或慢性肾衰竭，在大多数情况下，使得在紧急情况下无法使用造影剂增强，随着肺灌注闪烁扫描（LPS）的使用越来越多，它作为一种简单快速且无需准备/禁忌的检查方法。我们研究的目的是突出LPS在我院作为“随叫随到”24小时服务的紧急情况收治的疑似PE患者管理中的作用。
我们回顾性分析了2012年1月至2016年12月期间因疑似PE进行的2166例LPS检查，其中1730例为紧急检查。LPS按照欧洲核医学协会（EANM）指南在4个标准投照位进行。通过列联表和优势比（OR）评估症状、危险因素、D - 二聚体剂量、其他影像诊断工具与LPS结果之间的关系。
患者的来源科室为：急诊科（56.7%）、呼吸科（10.8%）、神经内科（4.8%）、内科（6.5%）、外科（5.2%）、心内科（3.3%）和其他科室（11.2%）。59.3%的检查是在随叫随到的24小时服务期间进行的。症状表现为胸痛的占39%，呼吸困难的占75%，咳嗽的占22%。34%的患者有两种症状，10%的患者无症状。LPS检查前D - 二聚体剂量升高的占97%（>500μg/L）。55.5%的患者只有一个危险因素，18.7%的患者有两个或更多危险因素。75.5%的患者之前进行过其他诊断检查（胸部X线检查占57%，胸部CT检查占8.4%，两者都做的占10.1%），而24.5%的患者之前未进行过诊断检查。胸部X线和/或胸部CT检查结果为阴性的占25.4%，疑似PE的占24.4%，伴有胸腔积液的非特异性表现占18.8%，伴有炎症性间质性疾病的非特异性表现占31.4%。LSP检查结果显示PE阳性的占17%，随后进行了治疗；其余83%的检查结果为阴性。LPS结果与CT和X线检查结果相关（χ = 17.5，P = 0.001）。胸部X线和/或CT检查结果为阴性时LPS检查结果阳性的占13.8%，疑似PE时阳性的占23.4%，伴有胸腔积液时阳性的占15.2%，伴有炎症性间质性疾病时阳性的占14.7%。此外，在未进行过先前诊断检查的患者中LPS检查结果阳性的占17.32%。观察到97%的患者D - 二聚体升高（>500ng/ml）对PE并无预测价值（OR = 0.598，P = 0.152）。咳嗽（OR = 1.146，P = 0.395）和胸痛（OR = 0.927，P = 0.601）也得到类似结果。相反，呼吸困难似乎是PE的一个重要症状（OR = 1.596，P = 0.003）。危险因素的存在并不能预测LPS检测到的PE（OR = 1.297，P = 0.089）。
LPS在早期诊断中起关键作用，但在排除PE方面作用更大，优化了对不需要入住重症监护病房（成本高且床位有限）的患者的管理。LPS被证实是一种简单、快速且廉价的检查方法。它无需准备且无副作用，因此可以在所有类型的患者中进行，包括孕妇、多发伤患者和复杂患者，对重症监护病房的资源优化有很大影响。我们在一个大都市地区多年的大规模经验表明，迄今为止，鉴于这种检查的巨大需求和相关性，核医学科室必须进行合理安排，以便在随叫随到的24小时服务中提供LPS紧急检查。
