1039
What Becomes of Pulmonary lnfarcts?
American Journal of Roentgenology 1979.133:1039-1045.
Peter J. McGoldrick1 Thomas G. Rudd1’2 Melvin M. Figley1 James P. Wilhelm3
In 32 patients, 58 angiographically proven pulmonary infarcts were followed for 3 months or longer by serial chest radiography. Complete clearing was seen in 29 (50%) of the infarcts on chest radiography. In the other 29 infarcts that left residual findings, linear scars were identified in 1 4, pleural diaphragmatic adhesions in nine, and localized pleural thickening in six; in all cases the features were diminutive when compared with the original abnormality. Follow-up perfusion lung images at similar time intervals to the chest films were available for 44 infarcts. Seven of these showed complete resolution and the other 37 showed a residual but much smaller perfusion defect. None of the patients had known preexisting pulmonary disease. The frequency of permanent radiographic scarring seemed to be the same at all ages.
Pulmonary tions and mentation
embolism problems of the
infarction.
There
eventually
organized
becomes appearances
lung 1979;
accepted
revi-
Presented in part to the Fleischner Society, Monterey, California, May 1975, and at the annual meeting of the American Roentgen Ray Society, Toronto, Ontario, Canada, March 1979. I Department of Radiology, university of Washington, SB-05, Seattle, WA 98195. Address reprint requests to M. M. Figley. 2 Department of Medicine, university of Washington,
Seattle,
Department Portland, OR
WA
of Radiology, 97227.
AJR 133:1039-1045, December 1979 0361 -8o3x/79/1336-1o39 $00.00 © American Roentgen Ray Society
Hospital.
patients
met
the
ative
references
reaction.
effusion-was
replaced
to the
after
by a fibrous
of
records
who
had
outlined
pulmonary
the
radiologic
were
scar. and
the
that
In these
trial
Simon
[5]
alluded
[6-8]
dis-
in man. result
of
National
comprehensive
from
of and
et al. [9] assessed the by means of serial survey of the radio-
embolism
infarcts
in
appear-
descriptions late 1 930s
Fleischner
systematic
end
patients
exceptionally below.
any
proven
of 26
infarct
of
to docupulmonary
radiographic classic in the
Secker-Walker aware
manifesta-
stuffed with blood and necrosis break down and necrotic tissue
pulmonary
not
its acute
pulmonary
infarction
Urokinase
Pulmonary
radiographic
and
six
32 patients,
others
filming.
were
58 infarcts
Of
added
were
who
evaluated.
and Methods
word
without
are
by
studied,
infarct
authorities
thromboembolic and
we
criteria
Materials
and
perfusion
study
Trial
the
some
for
little has been devoted of its complications,
area becomes the red cells
of angiographically
facilitated
The Emanuel
a few
healed
we
retrospective
Embolism
98195.
of attention
rather of one
communications.
pulmonary However,
outcome
Our
was
in later
of
scans.
graphic after
1, 1979.
of the
it briefly
restoration
10,
only
the infarcted occur. Then,
cussed
April
been
early 1 940s. Initially, of lung tissue may to the
August
have
deal
yet
of
Smith
Received
a great
the healed pulmonary infarct since the original [1 ] and Fleischner, Hampton, and Castleman [2-4]
ances
sion
attracts
in management, long-term residuals
is derived “to
vascular necrosis For
from
indicate
any occlusion”
of lung purposes
considered
the
opacity [10].
tissue
and
of this
study,
to
represent
Latin
infartire
that This also any
meaning
develops
in the
definition
includes opacity
pulmonary
to stuff lung
encompasses
hemorrhage, in the infarction.
in and
periphery
those infarcts
atelectasis,
lung-infiltrate, While
is used
and is not
of
with repar-
atelectasis, this
by
as a result
or
a strict
McGOLDRICK
1040
pathologic
definition,
it is a practical
one
consistent
with
that
Fraser and Pare [10]. The patients accepted for study satisfied the following (1 ) clinical suspicion of acute pulmonary embolic disease; giographic
proof
of embolus
as demonstrated
the pulmonary artery supplying chest radiographs of conventional nique
in erect
months graphic
position;
(4)
by filling
defect
follow-up
films
for
in the
area
of infarction
available. In the National the examinations
on
previous
films
Urokinase Pulmonary were at close intervals,
week of the illness,
thus allowing
when
6
were
Embolism Trial subjects, often daily during the first
documentation
Pleuritic
pain,
embolism
American Journal of Roentgenology 1979.133:1039-1045.
hemoptysis,
pulmonary
and
pleural
infarction
Of our 32 patients,
[1 1 ].
rub
in the
are
often
1 5 had
considered
pain
alone
as possible,
at one
time
display
recorded
were
observations
(M.M.F.
,
P.J.M.)
abnormalities and
all radiographs
in a large
were
studying
were
of a given area
the
for
were
studied
as
consensus
of
as atelectasis,
change
two
day
as to its exact of
the
first
Urokinase
second
angiogram
week, films thus
or
We
month,
available.
initial
to our day
Embolism
The
3 months,
6 months,
structures.
were of more
recording.
patients
of
one
had
effusion
was
display
manner
group
by another
as
observer
a percentage
of total
percentage
of perfusion
nine
segments
with
lung each
the
chest
at
to
a particular
infarct
per
as
any
and
were
(T.G.R.).
The
initial
perfusion.
For
purposes
deficit, right
each lung
defect
1
2
1
1
was
contributing
total,
might
as
58
recover
defect.
29
of
perfusion
radiographic 32
14
two-thirds
Many
infarction
its
were
and
0
2
2
0
0
1
0
0
9
6
1 29
leaving
a 33%
encountered
These
not included
1 8 male
0 6 2 6 11
perfusion,
defects
abnormality.
and were
patients,
required
ment
that
patients
not
without
represented
embolus
in this study.
1 4 female,
in the
records
were
for
study
24
be mailed
so the complete
available
in our
received received
original
returned,
were
had
hr after
all
1 9-81
urokinase,
first
to the
other
three
years
group
was
six
old
few
We
and
processing.
treat-
eight
of
streptokinase,
the
and
Thereafter,
20
14
patients
six received heparin, and three was available on the treatment could
the outcome,
too
for
of the acute
However,
angiography.
patients.
influenced
away
records
patients.
heparin and Coumadin, Coumadin. No information
not
since
other
determine
if the
type
the number
of patients
were
numerous
variables
too
for significance.
The horiof
homoge-
a
assigned the
to have 6%
32
0 2 0 1 1
Observations
lobe,
of estimating
lung was considered segment
80-89
patient.
studied
Total
1
and at 1 year when
defined
films
1
in each a
neous opacity with very discrete medial margins based against the pleura. Decubitus films were not usually available for confirmation of its presence. Infiltrate was any coalescent opacity not considered to be atelectasis or effusion. The radiographs were studied independent of knowledge of lung scan information, but in conjunction with the pulmonary angiograms. On a separate occasion, anterior, posterior, and, when available, lateral perfusion lung images were assembled chronologically in the same
0
1
given
strep-
as: (1 ) a platelike density, usually a few days or (2) an approximation
Pleural
2
2
of treatment
The
also
assessments
localized than
4
2
heparin
of the
with urokinase,
progress
3
70-79
Not all were
The
day
selection
for
Trial
performed
lnfarcts
recognition
Atelectasis was defined zontal, that cleared within regional
the
led
24 hr later after treatment 1
permitting
as
Pulmonary
heparin.
2 weeks, were
of occurrence
angiogram
National tokinase,
time
60-69
Trial The
the first angiogram was day 1 , although the embolic episode had taken place in all instances within the preceding few days. Uncertainty
0 3 0 2 4
The
or effusion
intervals.
Pleural
(tablel). Their medical backgrounds included the usual conditions that may be complicated by venous thrombosis, but none had known lung disease under medical management. Eight had known heart disease, and three of these had a history of congestive heart failure; all three were in the 50-59 age group. The structure of the National Urokinase Pulmonary Embolism
observers
infiltrate,
at follow-up
0 1 2 3 6
without
assembled
a group.
the films jointly as an entire display.
categorized
evaluated
patient
and
Adhe-
2 9 1 1 12
associated
and
1 1 had two or more of these features. One was asymptomatic and in the other five, records were insufficient for evaluation. Although perfusion lung images were not required for inclusion in our study, 25 patients had these examinations at time intervals similar to their chest films, with perfusion defects in the region suspected to be infarcted on the radiograph. To assess the radiographic changes as consistently and objec-
tively
matic
2 15 3 7 23
residual
of pulmonary
pleuritic
Linear
1 8 2 4 11
of the full devel-
presence
lution
10-19 20-29 30-39 40-49 50-59
Totals
opment of the characters of the infarct. Films were taken at diminishing frequency thereafter, for a minimum of 3 months in two patients, 6 months in nine patients, and 1 2 months or longer in 21 patients. No postmortem material was available as no patients died. to indicate
farcts
Diaphragsions
of radioabnorthese
1979
of Infarcts
No complete Reso-
No. In-
tients
within
at least
Radiography
No. Pa-
Age (yrs)
the area of infarction; (3) initial posteroanterior and lateral tech-
available
1: Chest
December
No. Scars
criteria: (2) an-
after angiography or until complete resolution abnormality; and (5) absence of any radiographic
mality
TABLE
of
AJR:133,
ET AL.
and
each left lung segment contributing 5% oftotal perfusion. On followup images, the fraction ofthe original perfusion defect that remained was also estimated. Thus, an initial left two-segment defect, 10% of
widely
radiographic varying
abnormalities
extent
of the volume
the
shadows.
appearances
in these
character.
of infarcted
and no attempt was such as ‘ ‘ Hampton’s
shaped
and
lung
patients
Quantitative
were
were
not considered
feasible
to describe
classic appearances humps’ or inverted, truncated-coneHowever, cavitation, which could modify made
‘
of the
healed
infarct,
was
considered
did not occur in any case. Of the 58 infarcts, 45 associated with effusion and 26 with atelectasis. There 30 infarcts
lower
identified
lobe,
identified
in the
the reverse in the
Regression
middle of
left lower
of the usual lobe
these
and
one
abnormalities
lobe
and
was
well
underway
within
five were
in the
lingula.
took
place
3 months.
In those
at 1 year, the residual the process of repair
changes complete.
but
were were
22 in the right
distribution;
patient, was usually evident by 2-4 weeks, and times complete in that interval. In every instance, follow-up films ingly fixed and
of
estimates
in every was someresolution
patients were
with seem-
AJA:133,
December
PULMONARY
1979
INFARCTS
1041
Fig. 1 -55-year-old man with right lower lobe infarct 12 days after herniorrhaphy. A, Infiltrate with typical “Hampton’s hump” configuration plus effusion. B, Complete clearing evident by 3 months. Diminution of right lower lobe artery. C, Posterior perfusion image. 15% defect on day 1. D, 20% residual at 6 months.
I
American Journal of Roentgenology 1979.133:1039-1045.
.1A
D
C
Complete
observed cleared
clearing
of all
in 29 of the completely
Residual
within
radiographic
58
radiographic infarcts.
abnormalities All
but
three
was of these
3 months (table 1) (fig. 1). abnormalities were characterized
as linear pulmonary scars, pleural diaphragmatic adhesions, and localized pleural thickening. Of the 29 infarcts that did not clear completely, residual linear scars were identified in 14 (table vascular
1) (fig. structures,
2).
These although
usually were in the line of the two were vertical. Pleural dia-
phragmatic
adhesions,
identified
4-6
cm
phrenic
angle
(fig.
3). Localized pleural of which diminished
in six, each
observation. Follow-up usually infarct.
Only
One left perfusion
and
nine
about
identified
long
in
usually
2-4
instances,
cm
of these
were
the
costo-
thickenings were over the period of
a residual pleural nodule (fig. 4). lung images in 25 patients were
multiple and within a 3-12 month This allowed us to follow the resolution seven
from
44
infarcts
had
no
period after the of 44 infarcts.
residual
defect
on
McGOLDRICK
1042
ET AL.
AJR:133,
Fig. after lower
2-37-year-old
woman
radical hysterectomy. lobe infiltrate with
B,
At 6 months.
C,
Posterior
perfusion
#{176}‘o defect.
small
Horizontal image
D, At 6 months,
1979
16 days A, Right effusion.
linear scar. at day 1. 50% resid-
American Journal of Roentgenology 1979.133:1039-1045.
21 ual.
December
C
the
D
last
scan
scar;
the
well
before
of the
other
six
the
series. all
perfusion
One
had
of these
complete returned
had
a small
perfusion defects consistently disappeared than did the radiographic abnormalities. The residual perfusion defects by lung analyzed Of the
with 29
reference
infarcts
that
to radiographic cleared
pleural
radiographic to normal (table
completely
clearing 2). The
more
slowly
22
imaging on
(table radiography,
were 3).
follow-up
perfusion
complete
clearing.
radiographic only 43
outcome
had
showed
two of
siderably residual strong
residual, of
44
which
22
images Of had
showed
the
infarcts, smaller
than
and
the 29 follow-up
complete
residual initially.
defect
was
equal
evidence
for
recurrent
to
only
clearing.
perfusion defects In the one case the initial defect, embolization.
five
infarcts perfusion
of these that left a imaging,
However,
were where there
in
conthe was
American Journal of Roentgenology 1979.133:1039-1045.
AJA:133,
December
Fig.
3-27-year-old
C, After
3 years.
PULMONARY
1979
woman Residual
taking
pleural
oral contraceptives.
diaphragmatic
A, Day 1. Left lower
adhesion
near
costophrenic
earliest with
stage
blood;
break
up. Necrosis
Later
the
with some situations
tion
on
the
size
and
eventually
drawing in which
in of the necrosis
the relatively pulmonary
rapidly hemorrhage
red
occur
organized stage
alveoli
the
may
this
smaller
require tified
last
of the
always
infarct.
of
weeks In time, scar
farction
the
infarcts
usually
in 50%
of lung of our
patients
concept that an infarct with extravasated blood ing of these
features
occur. Although
radiographic
of 58
tissue.
The
complete
is clearly
clearing
consistent
without
demonstrable
not den-
with
may represent lung tissue or serum and that subsequent
partial
healing.
the
may
aspect
the
disease.
Our
findings
are
in
the
pleural
surface
and
often
ending
a
in
lungs
may
be
permanently
damaged
by
in-
by these observations. Indeed, six in patients under age 40 led to permanent changes None of these patients had known heart or other lung
disease. heart
evident
In the failure,
three
there
infarcts
showed
cluding
the
1
of
with those of Fleischner, Hampton, and Castleand Simon [5], who described a dense single line
is clearly
are
findings
bearing
with
50%
changes.
these
left
of
small
whether
also.
numbers
given
age
of patients
of the
infarct
will
in table
40-49
age
decade
statistical
the
in-
scar,
data
the
in each
meaningful
any
The of
infarcts
that
two,
radiographic
exception
the
known congestive but one of these
resolution;
residual
the
for
suggest
All
defect
the
Although
too
on
a
perfusion
that,
had
infarcts.
radiographic
that
roughly
groups
who
four
complete
one
show
residual
patients were
a residual
also
group,
suffused clear-
cicatrization
B, At 6 months,
left
in these correlation,
patient
has
little
proceed
to
scar
formation.
infarcts,
clearing
even
features were diminutive abnormality. On casual
dismissed
in
after
the
other
thought
29
event.
when
dealing
However,
to be total
cases
when compared observation they
as insignificant long
the
was
prior
be suspected from the shape and location scars, particularly if they were associated perfusion pearance
does
this
normal
in five.
clearing infiltrates have been [1 1 ] and incomplete infarc-
of an infarct
and effusion.
shadow.
That
to
pleura [1 2]. In those parenchyma does not
the definition
infiltrate,
reaching
nodular
formation from
a fibrous
overlying of lung
cells
concurrently.
with
may
become blood
of
showed
above,
necrosis
graphs
atelectasis,
accordance man [2-4]
[1 2].
As outlined
29
walls
becomes
the
ages,
and
depending becomes
infarction infarct
of alveolar
tissue
months
of
as the
process
granulation
occur, termed
with
studies
In the
lesion
infarct
angle.
Discussion
packed
1043
INFARCTS
with could
with
the
in
residual
the original readily be
chest
infarction with
defects
happens
ocytosed lung
overlying radiography,
and
on
was
the
clearing
identified 44
seven;
in
clears.
heals
infarct
or
infarcts in 32 in 29 instances
in the
infarcts 37,
infarcts? the
retraction
58
scans,
infarct the
pleural
complete
pulmonary
is absent,
parenchyma
might
total disapfew clinical
to
parenchyma
radio-
of the diminutive
images. Perhaps this feature of near of infarcts accounts for the relatively
What lung
other were
persisting,
When
When there to an area thickening.
patients (50%);
29 instances.
As
judged
by
to
scarring
As judged
but
much
smaller,
of with
followed
residual
to complete
of
is phag-
is necrosis of fibrosis
were
followed very
necrosis
blood
extravasted
by lung
clearing perfusion
in
1044
McGOLDRICK
ET AL.
AJR:133,
December
Fig. 4-74-year-old heminandibulectomy
man 6
weeks
1979
who
had
before
American Journal of Roentgenology 1979.133:1039-1045.
embolic episode. A, Day 1. Two infarcts in left lower lobe. B, At 7 months. Lower infarct cleared completely. upper infarct left pleural nodule with overlying linear scar (arrow). C, Posterior perfusion lung image on day 1. Two defects; 18% deficit. D, At 4 months, 20% residual.
A
--
B ‘a
I.
$
,&.1J I’
b
SI’S
4
S
‘-----kr-S S
C
D
.
S S S
I
AJA:133,
TABLE
December
PULMONARY
1979
2: Perfusion
Imaging
ACKNOWLEDGMENTS
of lnfarcts
10-19
1
2
2
0
0
We thank Dr. John Blackmon and the cardiology staff at university of Washington Hospital for information deriving from their participation in the National Urokinase Pulmonary Embolism Trial;
20-29
6
8
1
6
1
the
30-39
2
3
1
1
1
Medical films
Age
(yrs)
No.
Patients
No.
complete
Infarcfs
clearing
(no)
50% Residual (no)
40-49
2
3
1
2
0
50-59
10
22
2
60-69
3
4
0
19 4
1 0
70-79
1
2
0
2
0
44
7
25
Totals
34
TABLE 3: Comparison
of lnfarcts
by Radiography
Radiology
.
2.
and Lung
on Lung
Scan
No complete
Complete Residual
Clearing
K: The
85-93,
1938
clearing defect: residual
16 1
50%
Complete Residual
Smith
Castleman
lnfarcts
5
and
Room
Department
the lung. AJR
Scan Finding
Record
Records
REFERENCES
3
1
American Journal of Roentgenology 1979.133:1039-1045.
1045
INFARCTS
I, Paraskos and
J:
pulmonary
1977
on pulmonary
Disease,
edited
Stratton,
1965,
infarction
by Sasahara pp 86-92
A,
What Becomes of Pulmonary lnfarcts?
American Journal of Roentgenology 1979.133:1039-1045.
Peter J. McGoldrick1 Thomas G. Rudd1’2 Melvin M. Figley1 James P. Wilhelm3
In 32 patients, 58 angiographically proven pulmonary infarcts were followed for 3 months or longer by serial chest radiography. Complete clearing was seen in 29 (50%) of the infarcts on chest radiography. In the other 29 infarcts that left residual findings, linear scars were identified in 1 4, pleural diaphragmatic adhesions in nine, and localized pleural thickening in six; in all cases the features were diminutive when compared with the original abnormality. Follow-up perfusion lung images at similar time intervals to the chest films were available for 44 infarcts. Seven of these showed complete resolution and the other 37 showed a residual but much smaller perfusion defect. None of the patients had known preexisting pulmonary disease. The frequency of permanent radiographic scarring seemed to be the same at all ages.
Pulmonary tions and mentation
embolism problems of the
infarction.
There
eventually
organized
becomes appearances
lung 1979;
accepted
revi-
Presented in part to the Fleischner Society, Monterey, California, May 1975, and at the annual meeting of the American Roentgen Ray Society, Toronto, Ontario, Canada, March 1979. I Department of Radiology, university of Washington, SB-05, Seattle, WA 98195. Address reprint requests to M. M. Figley. 2 Department of Medicine, university of Washington,
Seattle,
Department Portland, OR
WA
of Radiology, 97227.
AJR 133:1039-1045, December 1979 0361 -8o3x/79/1336-1o39 $00.00 © American Roentgen Ray Society
Hospital.
patients
met
the
ative
references
reaction.
effusion-was
replaced
to the
after
by a fibrous
of
records
who
had
outlined
pulmonary
the
radiologic
were
scar. and
the
that
In these
trial
Simon
[5]
alluded
[6-8]
dis-
in man. result
of
National
comprehensive
from
of and
et al. [9] assessed the by means of serial survey of the radio-
embolism
infarcts
in
appear-
descriptions late 1 930s
Fleischner
systematic
end
patients
exceptionally below.
any
proven
of 26
infarct
of
to docupulmonary
radiographic classic in the
Secker-Walker aware
manifesta-
stuffed with blood and necrosis break down and necrotic tissue
pulmonary
not
its acute
pulmonary
infarction
Urokinase
Pulmonary
radiographic
and
six
32 patients,
others
filming.
were
58 infarcts
Of
added
were
who
evaluated.
and Methods
word
without
are
by
studied,
infarct
authorities
thromboembolic and
we
criteria
Materials
and
perfusion
study
Trial
the
some
for
little has been devoted of its complications,
area becomes the red cells
of angiographically
facilitated
The Emanuel
a few
healed
we
retrospective
Embolism
98195.
of attention
rather of one
communications.
pulmonary However,
outcome
Our
was
in later
of
scans.
graphic after
1, 1979.
of the
it briefly
restoration
10,
only
the infarcted occur. Then,
cussed
April
been
early 1 940s. Initially, of lung tissue may to the
August
have
deal
yet
of
Smith
Received
a great
the healed pulmonary infarct since the original [1 ] and Fleischner, Hampton, and Castleman [2-4]
ances
sion
attracts
in management, long-term residuals
is derived “to
vascular necrosis For
from
indicate
any occlusion”
of lung purposes
considered
the
opacity [10].
tissue
and
of this
study,
to
represent
Latin
infartire
that This also any
meaning
develops
in the
definition
includes opacity
pulmonary
to stuff lung
encompasses
hemorrhage, in the infarction.
in and
periphery
those infarcts
atelectasis,
lung-infiltrate, While
is used
and is not
of
with repar-
atelectasis, this
by
as a result
or
a strict
McGOLDRICK
1040
pathologic
definition,
it is a practical
one
consistent
with
that
Fraser and Pare [10]. The patients accepted for study satisfied the following (1 ) clinical suspicion of acute pulmonary embolic disease; giographic
proof
of embolus
as demonstrated
the pulmonary artery supplying chest radiographs of conventional nique
in erect
months graphic
position;
(4)
by filling
defect
follow-up
films
for
in the
area
of infarction
available. In the National the examinations
on
previous
films
Urokinase Pulmonary were at close intervals,
week of the illness,
thus allowing
when
6
were
Embolism Trial subjects, often daily during the first
documentation
Pleuritic
pain,
embolism
American Journal of Roentgenology 1979.133:1039-1045.
hemoptysis,
pulmonary
and
pleural
infarction
Of our 32 patients,
[1 1 ].
rub
in the
are
often
1 5 had
considered
pain
alone
as possible,
at one
time
display
recorded
were
observations
(M.M.F.
,
P.J.M.)
abnormalities and
all radiographs
in a large
were
studying
were
of a given area
the
for
were
studied
as
consensus
of
as atelectasis,
change
two
day
as to its exact of
the
first
Urokinase
second
angiogram
week, films thus
or
We
month,
available.
initial
to our day
Embolism
The
3 months,
6 months,
structures.
were of more
recording.
patients
of
one
had
effusion
was
display
manner
group
by another
as
observer
a percentage
of total
percentage
of perfusion
nine
segments
with
lung each
the
chest
at
to
a particular
infarct
per
as
any
and
were
(T.G.R.).
The
initial
perfusion.
For
purposes
deficit, right
each lung
defect
1
2
1
1
was
contributing
total,
might
as
58
recover
defect.
29
of
perfusion
radiographic 32
14
two-thirds
Many
infarction
its
were
and
0
2
2
0
0
1
0
0
9
6
1 29
leaving
a 33%
encountered
These
not included
1 8 male
0 6 2 6 11
perfusion,
defects
abnormality.
and were
patients,
required
ment
that
patients
not
without
represented
embolus
in this study.
1 4 female,
in the
records
were
for
study
24
be mailed
so the complete
available
in our
received received
original
returned,
were
had
hr after
all
1 9-81
urokinase,
first
to the
other
three
years
group
was
six
old
few
We
and
processing.
treat-
eight
of
streptokinase,
the
and
Thereafter,
20
14
patients
six received heparin, and three was available on the treatment could
the outcome,
too
for
of the acute
However,
angiography.
patients.
influenced
away
records
patients.
heparin and Coumadin, Coumadin. No information
not
since
other
determine
if the
type
the number
of patients
were
numerous
variables
too
for significance.
The horiof
homoge-
a
assigned the
to have 6%
32
0 2 0 1 1
Observations
lobe,
of estimating
lung was considered segment
80-89
patient.
studied
Total
1
and at 1 year when
defined
films
1
in each a
neous opacity with very discrete medial margins based against the pleura. Decubitus films were not usually available for confirmation of its presence. Infiltrate was any coalescent opacity not considered to be atelectasis or effusion. The radiographs were studied independent of knowledge of lung scan information, but in conjunction with the pulmonary angiograms. On a separate occasion, anterior, posterior, and, when available, lateral perfusion lung images were assembled chronologically in the same
0
1
given
strep-
as: (1 ) a platelike density, usually a few days or (2) an approximation
Pleural
2
2
of treatment
The
also
assessments
localized than
4
2
heparin
of the
with urokinase,
progress
3
70-79
Not all were
The
day
selection
for
Trial
performed
lnfarcts
recognition
Atelectasis was defined zontal, that cleared within regional
the
led
24 hr later after treatment 1
permitting
as
Pulmonary
heparin.
2 weeks, were
of occurrence
angiogram
National tokinase,
time
60-69
Trial The
the first angiogram was day 1 , although the embolic episode had taken place in all instances within the preceding few days. Uncertainty
0 3 0 2 4
The
or effusion
intervals.
Pleural
(tablel). Their medical backgrounds included the usual conditions that may be complicated by venous thrombosis, but none had known lung disease under medical management. Eight had known heart disease, and three of these had a history of congestive heart failure; all three were in the 50-59 age group. The structure of the National Urokinase Pulmonary Embolism
observers
infiltrate,
at follow-up
0 1 2 3 6
without
assembled
a group.
the films jointly as an entire display.
categorized
evaluated
patient
and
Adhe-
2 9 1 1 12
associated
and
1 1 had two or more of these features. One was asymptomatic and in the other five, records were insufficient for evaluation. Although perfusion lung images were not required for inclusion in our study, 25 patients had these examinations at time intervals similar to their chest films, with perfusion defects in the region suspected to be infarcted on the radiograph. To assess the radiographic changes as consistently and objec-
tively
matic
2 15 3 7 23
residual
of pulmonary
pleuritic
Linear
1 8 2 4 11
of the full devel-
presence
lution
10-19 20-29 30-39 40-49 50-59
Totals
opment of the characters of the infarct. Films were taken at diminishing frequency thereafter, for a minimum of 3 months in two patients, 6 months in nine patients, and 1 2 months or longer in 21 patients. No postmortem material was available as no patients died. to indicate
farcts
Diaphragsions
of radioabnorthese
1979
of Infarcts
No complete Reso-
No. In-
tients
within
at least
Radiography
No. Pa-
Age (yrs)
the area of infarction; (3) initial posteroanterior and lateral tech-
available
1: Chest
December
No. Scars
criteria: (2) an-
after angiography or until complete resolution abnormality; and (5) absence of any radiographic
mality
TABLE
of
AJR:133,
ET AL.
and
each left lung segment contributing 5% oftotal perfusion. On followup images, the fraction ofthe original perfusion defect that remained was also estimated. Thus, an initial left two-segment defect, 10% of
widely
radiographic varying
abnormalities
extent
of the volume
the
shadows.
appearances
in these
character.
of infarcted
and no attempt was such as ‘ ‘ Hampton’s
shaped
and
lung
patients
Quantitative
were
were
not considered
feasible
to describe
classic appearances humps’ or inverted, truncated-coneHowever, cavitation, which could modify made
‘
of the
healed
infarct,
was
considered
did not occur in any case. Of the 58 infarcts, 45 associated with effusion and 26 with atelectasis. There 30 infarcts
lower
identified
lobe,
identified
in the
the reverse in the
Regression
middle of
left lower
of the usual lobe
these
and
one
abnormalities
lobe
and
was
well
underway
within
five were
in the
lingula.
took
place
3 months.
In those
at 1 year, the residual the process of repair
changes complete.
but
were were
22 in the right
distribution;
patient, was usually evident by 2-4 weeks, and times complete in that interval. In every instance, follow-up films ingly fixed and
of
estimates
in every was someresolution
patients were
with seem-
AJA:133,
December
PULMONARY
1979
INFARCTS
1041
Fig. 1 -55-year-old man with right lower lobe infarct 12 days after herniorrhaphy. A, Infiltrate with typical “Hampton’s hump” configuration plus effusion. B, Complete clearing evident by 3 months. Diminution of right lower lobe artery. C, Posterior perfusion image. 15% defect on day 1. D, 20% residual at 6 months.
I
American Journal of Roentgenology 1979.133:1039-1045.
.1A
D
C
Complete
observed cleared
clearing
of all
in 29 of the completely
Residual
within
radiographic
58
radiographic infarcts.
abnormalities All
but
three
was of these
3 months (table 1) (fig. 1). abnormalities were characterized
as linear pulmonary scars, pleural diaphragmatic adhesions, and localized pleural thickening. Of the 29 infarcts that did not clear completely, residual linear scars were identified in 14 (table vascular
1) (fig. structures,
2).
These although
usually were in the line of the two were vertical. Pleural dia-
phragmatic
adhesions,
identified
4-6
cm
phrenic
angle
(fig.
3). Localized pleural of which diminished
in six, each
observation. Follow-up usually infarct.
Only
One left perfusion
and
nine
about
identified
long
in
usually
2-4
instances,
cm
of these
were
the
costo-
thickenings were over the period of
a residual pleural nodule (fig. 4). lung images in 25 patients were
multiple and within a 3-12 month This allowed us to follow the resolution seven
from
44
infarcts
had
no
period after the of 44 infarcts.
residual
defect
on
McGOLDRICK
1042
ET AL.
AJR:133,
Fig. after lower
2-37-year-old
woman
radical hysterectomy. lobe infiltrate with
B,
At 6 months.
C,
Posterior
perfusion
#{176}‘o defect.
small
Horizontal image
D, At 6 months,
1979
16 days A, Right effusion.
linear scar. at day 1. 50% resid-
American Journal of Roentgenology 1979.133:1039-1045.
21 ual.
December
C
the
D
last
scan
scar;
the
well
before
of the
other
six
the
series. all
perfusion
One
had
of these
complete returned
had
a small
perfusion defects consistently disappeared than did the radiographic abnormalities. The residual perfusion defects by lung analyzed Of the
with 29
reference
infarcts
that
to radiographic cleared
pleural
radiographic to normal (table
completely
clearing 2). The
more
slowly
22
imaging on
(table radiography,
were 3).
follow-up
perfusion
complete
clearing.
radiographic only 43
outcome
had
showed
two of
siderably residual strong
residual, of
44
which
22
images Of had
showed
the
infarcts, smaller
than
and
the 29 follow-up
complete
residual initially.
defect
was
equal
evidence
for
recurrent
to
only
clearing.
perfusion defects In the one case the initial defect, embolization.
five
infarcts perfusion
of these that left a imaging,
However,
were where there
in
conthe was
American Journal of Roentgenology 1979.133:1039-1045.
AJA:133,
December
Fig.
3-27-year-old
C, After
3 years.
PULMONARY
1979
woman Residual
taking
pleural
oral contraceptives.
diaphragmatic
A, Day 1. Left lower
adhesion
near
costophrenic
earliest with
stage
blood;
break
up. Necrosis
Later
the
with some situations
tion
on
the
size
and
eventually
drawing in which
in of the necrosis
the relatively pulmonary
rapidly hemorrhage
red
occur
organized stage
alveoli
the
may
this
smaller
require tified
last
of the
always
infarct.
of
weeks In time, scar
farction
the
infarcts
usually
in 50%
of lung of our
patients
concept that an infarct with extravasated blood ing of these
features
occur. Although
radiographic
of 58
tissue.
The
complete
is clearly
clearing
consistent
without
demonstrable
not den-
with
may represent lung tissue or serum and that subsequent
partial
healing.
the
may
aspect
the
disease.
Our
findings
are
in
the
pleural
surface
and
often
ending
a
in
lungs
may
be
permanently
damaged
by
in-
by these observations. Indeed, six in patients under age 40 led to permanent changes None of these patients had known heart or other lung
disease. heart
evident
In the failure,
three
there
infarcts
showed
cluding
the
1
of
with those of Fleischner, Hampton, and Castleand Simon [5], who described a dense single line
is clearly
are
findings
bearing
with
50%
changes.
these
left
of
small
whether
also.
numbers
given
age
of patients
of the
infarct
will
in table
40-49
age
decade
statistical
the
in-
scar,
data
the
in each
meaningful
any
The of
infarcts
that
two,
radiographic
exception
the
known congestive but one of these
resolution;
residual
the
for
suggest
All
defect
the
Although
too
on
a
perfusion
that,
had
infarcts.
radiographic
that
roughly
groups
who
four
complete
one
show
residual
patients were
a residual
also
group,
suffused clear-
cicatrization
B, At 6 months,
left
in these correlation,
patient
has
little
proceed
to
scar
formation.
infarcts,
clearing
even
features were diminutive abnormality. On casual
dismissed
in
after
the
other
thought
29
event.
when
dealing
However,
to be total
cases
when compared observation they
as insignificant long
the
was
prior
be suspected from the shape and location scars, particularly if they were associated perfusion pearance
does
this
normal
in five.
clearing infiltrates have been [1 1 ] and incomplete infarc-
of an infarct
and effusion.
shadow.
That
to
pleura [1 2]. In those parenchyma does not
the definition
infiltrate,
reaching
nodular
formation from
a fibrous
overlying of lung
cells
concurrently.
with
may
become blood
of
showed
above,
necrosis
graphs
atelectasis,
accordance man [2-4]
[1 2].
As outlined
29
walls
becomes
the
ages,
and
depending becomes
infarction infarct
of alveolar
tissue
months
of
as the
process
granulation
occur, termed
with
studies
In the
lesion
infarct
angle.
Discussion
packed
1043
INFARCTS
with could
with
the
in
residual
the original readily be
chest
infarction with
defects
happens
ocytosed lung
overlying radiography,
and
on
was
the
clearing
identified 44
seven;
in
clears.
heals
infarct
or
infarcts in 32 in 29 instances
in the
infarcts 37,
infarcts? the
retraction
58
scans,
infarct the
pleural
complete
pulmonary
is absent,
parenchyma
might
total disapfew clinical
to
parenchyma
radio-
of the diminutive
images. Perhaps this feature of near of infarcts accounts for the relatively
What lung
other were
persisting,
When
When there to an area thickening.
patients (50%);
29 instances.
As
judged
by
to
scarring
As judged
but
much
smaller,
of with
followed
residual
to complete
of
is phag-
is necrosis of fibrosis
were
followed very
necrosis
blood
extravasted
by lung
clearing perfusion
in
1044
McGOLDRICK
ET AL.
AJR:133,
December
Fig. 4-74-year-old heminandibulectomy
man 6
weeks
1979
who
had
before
American Journal of Roentgenology 1979.133:1039-1045.
embolic episode. A, Day 1. Two infarcts in left lower lobe. B, At 7 months. Lower infarct cleared completely. upper infarct left pleural nodule with overlying linear scar (arrow). C, Posterior perfusion lung image on day 1. Two defects; 18% deficit. D, At 4 months, 20% residual.
A
--
B ‘a
I.
$
,&.1J I’
b
SI’S
4
S
‘-----kr-S S
C
D
.
S S S
I
AJA:133,
TABLE
December
PULMONARY
1979
2: Perfusion
Imaging
ACKNOWLEDGMENTS
of lnfarcts
10-19
1
2
2
0
0
We thank Dr. John Blackmon and the cardiology staff at university of Washington Hospital for information deriving from their participation in the National Urokinase Pulmonary Embolism Trial;
20-29
6
8
1
6
1
the
30-39
2
3
1
1
1
Medical films
Age
(yrs)
No.
Patients
No.
complete
Infarcfs
clearing
(no)
50% Residual (no)
40-49
2
3
1
2
0
50-59
10
22
2
60-69
3
4
0
19 4
1 0
70-79
1
2
0
2
0
44
7
25
Totals
34
TABLE 3: Comparison
of lnfarcts
by Radiography
Radiology
.
2.
and Lung
on Lung
Scan
No complete
Complete Residual
Clearing
K: The
85-93,
1938
clearing defect: residual
16 1
50%
Complete Residual
Smith
Castleman
lnfarcts
5
and
Room
Department
the lung. AJR
Scan Finding
Record
Records
REFERENCES
3
1
American Journal of Roentgenology 1979.133:1039-1045.
1045
INFARCTS
I, Paraskos and
J:
pulmonary
1977
on pulmonary
Disease,
edited
Stratton,
1965,
infarction
by Sasahara pp 86-92
A,
