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
- Pulmonary arteries : 99% of the arterial blood supply to the lungs and take part in gas exchange
- 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
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Dr. Amar Udare, MD, DNB
Dr. Amar Udare is a board-certified radiologist. He is a clinical assistant professor at the University of Calgary. He has a passion for teaching (#FOAMrad and #FOAMed) and has been a semi-finalist for the 2018 and 2020 Aunt-Minnie Most effective Radiology Educator Awards. He has authored multiple peer-reviewed publications which can be accessed on PubMed and Google Scholar.