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Assessment of Pulmonary Hypertension

Posted Mar 31, 2011 Updated Apr 10, 2023
By Yuka Okajima MD , Yoshiharu Ohno MD PhD , George R. Washko MD , Hiroto Hatabu MD PhD
35 min read

Rationales and Objectives

Pulmonary hypertension (PH) is a life-threatening condition, characterized by elevated pulmonary arterial pressure, which is confirmed based on invasive right heart catheterization (RHC). Noninvasive examinations may support diagnosis of PH before proceeding to RHC and play an important role in management and treatment of the disease. Although echocardiography is considered a standard tool in diagnosis, recent advances have made computed tomography (CT) and magnetic resonance (MR) imaging promising tools, which may provide morphologic and functional information. In this article, we review image-based assessment of PH with a focus on CT and MR imaging.

Conclusions

CT may provide useful morphologic information for depicting PH and seeking for underlying diseases. With the accumulated technological advancement, CT and MRI may provide practical tools for not only morphologic but also functional assessment of patients with PH.

Pulmonary hypertension (PH) is a life-threatening condition, characterized by elevated pulmonary arterial pressure (PAP) and secondary right ventricular (RV) failure. It has been defined as a mean PAP greater than or equal to 25 mm Hg at rest, based on right heart catheterization (RHC) .

Numerous causes of PH exist. The latest clinical classification—Dana Point classification—comprises five major categories that share pathologic, clinical, and therapeutic features and is intended to standardize diagnosis and treatment and to conduct clinical trials in a well-characterized group of patients ( Table 1 ) .

Table 1

Clinical Classification of Pulmonary Hypertension (Dana Point, 2008)

Adapted from Simonneau et al .

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ALK-1, activin receptor-like kinase 1 gene; BMPR2, bone morphogenetic protein receptor, type 2; HIV, human immunodeficiency virus.

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Computed tomography

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CT Findings of PH

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Precapillary PH

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Figure 1, Contrast enhanced chest computed tomography images of a 38-year-old female with pulmonary veno-occlusive disease with pulmonary hypertension. (a) The main pulmonary arterial diameter is dilated and the pulmonary artery/ascending aorta ratio is larger than 1. (b) The dilated right atrium and ventricle and the right ventricle hypertrophy are seen. The intraventricular septum is bowing toward the right. (c) The diameter of the segmental pulmonary artery is larger than the outer diameter of the adjacent bronchiole. There are diffuse ill-defined centrilobular ground-glass opacities and subpleural septal thickening.

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CTEPH (Group 4)

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Postcapillary PH

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PVOD and PCH (Group 1′)

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Evaluation of the Presence and Severity of PH

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Morphologic evaluations

Evaluation of the pulmonary vasculature

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Figure 2, The method of measuring the cross-sectional area of small pulmonary vessels using ImageJ software. (a) Computed tomography image of lung field segmented within the threshold values from −500 Hounsfield units (HU) to −1024 HU. (b) Binary image converted from segmented image (a) with window level of −720 HU. Pulmonary vessels are displayed in black . (c) Mask image for particle analysis after setting vessel size parameters within 0 to 5 mm 2 and the range of circularity within 0.9 to 1.0. Reprinted with permission from Matsuoka et al (54) .

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Cardiac evaluation

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Table 2

Approximate Partition Values for Upper Limits of Normal for the Assessment of Cardiac Morphology

Adapted from Hoey et al .

Parameter Value (mm) Diameter of main pulmonary artery 29 Transverse diameter of right ventricle 45 Thickness of right ventricular free wall 3 Transverse diameter of right atrium 35 Thickness of interventricular septum 13 Transverse diameter of left ventricle 55 Thickness of left ventricular free wall 11 Anteroposterior diameter of left atrium 45

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Pulmonary parenchyma

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Functional evaluation

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New Investigations and Future Directions

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Figure 3, A 70-year-old normal male. (a) Axial first-pass perfusion computed tomography (CT) map from 320-detector row CT data shows that pulmonary blood flow is increased in the dorsal region compared to the ventral region, reflecting gravity effect. (b) 320-detector row CT so-called area-detector CT obtains volumetric dynamic CT data without helical scan, and can also provide coronal perfusion map from same data set. On the coronal plane, regional difference of perfusion parameters is not observed in both lungs as compared with the axial plane.

Figure 4, A 73-year-old male with pulmonary emphysema and organizing pneumonia. Left: Computed tomography (CT) image shows severe pulmonary emphysema in both lungs and a mass in the right upper lobe (segment 2), which was diagnosed as organizing pneumonia with biopsy and follow-up CT examinations. Right: Axial first-pass perfusion CT map from 320-detector row CT data shows decreased pulmonary blood flow in the areas corresponding to pulmonary emphysema, compared to that of normal lung parenchyma.

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Magnetic resonance imaging

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Large Vessels

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Figure 5, A 66-year-old male with acute pulmonary embolism. (a) Contrast-enhanced multidetector computed tomography demonstrates thrombi ( arrows ) in right main pulmonary artery, and bilateral interlobar, segmental, and subsegmental pulmonary arteries. (b) Source images of time-resolved contrast-enhanced magnetic resonance angiography (L to R: ventral to dorsal) show thrombi in bilateral main, interlobar, segmental and subsegmental pulmonary arteries, and heterogeneously reduced pulmonary parenchymal perfusion in both lungs.

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(diastoliccross−sectional area)−(systoliccross−sectional area)systoliccross−sectional area×100 (

diastolic

cross

−

sectional area

)

−

(

systolic

cross

−

sectional area

)

systolic

cross

−

sectional area

×

100

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Cardiac Evaluation

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New Investigations and Future Directions

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Figure 6, Quantitative pulmonary perfusion parameter maps for a 69-year-old female patient with collagen tissue disease and pulmonary arterial hypertension. (a) Image maps (L to R: ventral to dorsal) of pulmonary blood flow (PBF) from coronal three-dimensional (3D) dynamic magnetic resonance (MR) data show heterogeneously and markedly reduced regional PBF in the gravitational and isogravitational directions. The mean PBF was 118.0 ± 34.2/100 mL/min. (b) Image maps (L to R: ventral to dorsal) of pulmonary blood volume (PBV) from coronal 3D dynamic MR data show heterogeneously and markedly reduced regional PBV in the gravitational and isogravitational directions. The mean PBV was 12.5 ± 5.2/100 mL. (c) Image maps (L to R: ventral to dorsal) of mean transit time (MTT) from coronal 3D dynamic MR data show heterogeneously prolonged regional MTT in the gravitational and isogravitational directions. The mean MTT was 6.4 ± 2.8 seconds.

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Conclusion

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Acknowledgments

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Academic Radiology, Volume 18, Issue 4
Journals General Radiology
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