COVID-19 pneumonia: microvascular disease revealed on pulmonary dual-energy computed tomography angiography
COVID-19 pneumonia: microvascular disease revealed on pulmonary dual-energy computed tomography angiography
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DOI：
10.21037/qims-20-708
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发表时间：
2020-09-01
影响因子：
2.8
通讯作者：
Aubry, Sebastien
中科院分区：
文献类型：
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作者：
Grillet, Franck;Busse-Cote, Andreas;Aubry, Sebastien
背景：最近的一些研究报道了COVID-19患者急性肺栓塞患病率增加。一些研究强调了局部肺血管内凝血病变的肺微血管病理改变，这可能解释了肺部计算机断层扫描（CT）血管造影发现的肺动脉血栓形成。本研究的目的是描述重症COVID-19患者肺双能CT （DECT）血管造影评估的肺灌注障碍。方法：本单中心回顾性研究纳入了85例连续的SARS-CoV-2逆转录聚合酶链反应诊断患者，这些患者于2020年3月16日至2020年4月22日期间接受了肺DECT血管造影。当患者有严重的临床症状或肿瘤活动性或免疫抑制时，进行肺DECT血管造影。两名胸部放射科医生进行了肺血管造影分析，以寻找肺动脉血栓形成，并对碘色图进行了盲法半定量分析，重点分析了实质缺血的存在。根据HU值对肺实质进行体积划分。DECT分析包括肺分割、肺总容积和肺灌注分布评估。结果：确诊肺动脉血栓29例（34%），以节段性肺动脉血栓为主（83%）。半定量分析显示，总体人群中68%的患者存在实质缺血，在有无肺动脉血栓方面差异无统计学意义（23 vs. 35， P=0.144）。读写器1和读写器2对脑实质缺血的一致性很高[0.74；四分位间距（IQR）： 0.59-0.89]。肺动脉血栓患者缺血体积明显高于肺动脉血栓患者[29 （IQR, 8-100）比8 (IQR, 0-45) cm(3)， P=0.041]。肺实质分为正常实质（59%，其中34%充血不足）、磨玻璃混浊（10%，其中20%充血不足）和实变（31%，其中10%充血不足）。结论：碘浓度图评价的肺灌注在COVID-19患者中表现出极大的异质性，正常实质中碘水平较低。肺动脉血栓形成患者肺缺血区更频繁、更大。肺DECT血管造影显示大量的肺缺血区，即使没有明显的肺动脉血栓形成。这可能反映了与COVID-19肺炎相关的微血栓形成。
Background: Increased prevalence of acute pulmonary embolism in COVID-19 has been reported in few recent studies. Some works have highlighted pathological changes on lung microvasculature with local pulmonary intravascular coagulopathy that may explain pulmonary artery thrombosis found on pulmonary computed tomography (CT) angiography. The objective of our study was to describe lung perfusion disorders assessed by pulmonary dual-energy CT (DECT) angiography in severe COVID-19 patients.Methods: This single center retrospective study included 85 consecutive patients with a reverse transcriptase-polymerase chain reaction diagnosis of SARS-CoV-2 who underwent a pulmonary DECT angiography between March 16th 2020 and April 22th 2020. Pulmonary DECT angiography was performed when the patient had severe clinical symptoms or suffered from active neoplasia or immunosuppression. Two chest radiologists performed pulmonary angiography analysis in search of pulmonary artery thrombosis and a blinded semi quantitative analysis of iodine color maps focusing on the presence of parenchymal ischemia. The lung parenchyma was divided into volumes based on HU values. DECT analysis included lung segmentation, total lungs volume and distribution of lung perfusion assessment.Results: Twenty-nine patients (34%) were diagnosed with pulmonary artery thrombosis, mainly segmental (83%). Semi-quantitative analysis revealed parenchymal ischemia in 68% patients of the overall population, with no significant difference regarding absence or presence of pulmonary artery thrombosis (23 vs. 35, P=0.144). Inter-reader agreement of parenchymal ischemia between reader 1 and 2 was substantial [0.74; interquartile range (IQR): 0.59-0.89]. Volume of ischemia was significantly higher in patients with pulmonary artery thrombosis [29 (IQR, 8-100) vs. 8 (IQR, 0-45) cm(3), P=0.041]. Lung parenchyma was divided between normal parenchyma (59%, of which 34% was hypoperfused), ground glass opacities (10%, of which 20% was hypoperfused) and consolidation (31%, of which 10% was hypoperfused).Conclusions: Pulmonary perfusion evaluated by iodine concentration maps shows extreme heterogeneity in COVID-19 patients and lower iodine levels in normal parenchyma. Pulmonary ischemic areas were more frequent and larger in patients with pulmonary artery thrombosis. Pulmonary DECT angiography revealed a significant number of pulmonary ischemic areas even in the absence of visible pulmonary arterial thrombosis. This may reflect microthrombosis associated with COVID-19 pneumonia.