Imaging of Hemoptysis | Radiology Board Review Case

Imaging of Hemoptysis (Case-based approach) | Radiology Board Review Case

Causes of hemoptysis

Common:

• Bronchiectasis 
• Tuberculosis, fungal infections.  
• Malignancy  
• Chronic bronchitis

Rare:

• Pulmonary embolism
• Vasculitis (Behcet’s disease, Takayasu arteritis, Goodpasture’s syndrome) 
• Congestive heart failure, diffuse alveolar hemorrhage. 
• Iatrogenic causes (pulmonary artery inflation devices, anticoagulants, trauma).
• Bronchial artery aneurysm.
• Pseudosequestration :  Systemic arterial supply to lung with normal bronchial connection (Sequestration – No communication with the bronchial tree). 
• Congenital disorders (pulmonary artery atresia or stenosis, pulmonary arteriovenous malformation)

Pathophysiology of hemoptysis

1. Pulmonary arteries : 99% of the arterial blood supply to the lungs and take part in gas exchange
2. Bronchial arteries : Nourishment to the supporting structures of the airways and of the pulmonary arteries themselves (vasa vasorum) but do not normally take part in gas exchange.

• Decreased PA flow or increased BA flow. 
• BA hypertrophy is neovascular. BA-PA anastomosis are thin walled – High pressure systemic flow – rupture. 
• Chronic inflammation (bronchiectasis, chronic bronchitis, and chronic necrotizing infections (in particular, tuberculosis and mycotic lung disease) -> release of angiogenetic growth factors -> increase in systemic arterial blood flow.
• MC source: Bronchial artery – 90 % of cases. 

Bronchial arteries anatomy

• Orthotopic:
  • Descending thoracic aorta, most commonly between the levels of T5 and T6. 
  • Right: Intercostobronchial trunk usually exists giving rise to one or more posterior intercostal arteries and a right bronchial arterial component. 
  • Left: Arises from the anterior aspect of the descending thoracic aorta. Because of its short mediastinal course, the left bronchial artery may be difficult to see clearly at single–detector row CT. 
  • Types of bronchial artery anatomy
• Anomalous/ectopic: Bronchial arteries that originate outside the T5 through T6 range.
• Non-bronchial systemic arteries 

Imaging tests for hemoptysis

• Initial investigation – Chest radiograph. 
• Ideal investigation – MDCT. 
• 2018 Korean Clinical Imaging Guideline for Hemoptysis. 
  • Contrast-enhanced chest CT scan is recommended to diagnose the cause of hemoptysis in all adult patients who have two risk factors for lung cancer (> 40 years old and > 30 pack-year smoking history).
  • Contrast-enhanced chest CT scan is recommended to diagnose the cause of hemoptysis in all adult patients with moderate hemoptysis (> 30 mL/24 hours) or recurrent hemoptysis.
  • Contrast-enhanced chest CT scan should also be considered in adult patients with massive hemoptysis (> 400 mL/24 hours) and preserved cardiopulmonary function.
• Bronchoscopy has an overall lower sensitivity than MDCT in detecting the underlying causes of bleeding  8% vs 77%, with MDCT but is useful for management.

Hemoptysis : CT Reporting checklist

• Lung parenchyma
  • Bronchiectasis 
  • Lung carcinoma
  • Acute and chronic lung infections (in particular, tuberculosis and aspergillosis)
  • Cardiogenic pulmonary edema
• Pulmonary arteries
  • Thromboembolic disease – non-massive hemoptysis 
  • Direct invasion by neoplastic disease or by necrotizing inflammatory disorders -Rasmussen aneurysms.
  • AVM
  • Dieulafoy disease
• Bronchial arteries

Bronchial artery evaluation on CT

• 95% of the cases of hemoptysis.
• Diameter more than 2mm abnormal. 
• Report anomalous and non-bronchial systemic arteries as failure to embolize this can cause recurrent hemoptysis.
• Bronchial-to-Systemic Artery Communications – Arteria radicularis magna (artery of Adamkiewicz), usually T9-12. Can lead to non-target embolization and complications.

Reference and further reading

• Multi-Detector Row CT of Hemoptysis

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