Pulmonary Infarction - Radiology Reference Article

Pulmonary infarction | Radiology Reference Article | Radiopaedia.
org 08/09/2021, 07:33
Pulmonary infarction
Pulmonary infarction is one of the key complications of pulmonary
embolism (PE).
Epidemiology
Pulmonary infarction occurs in the minority (10-15%) of patients with PE 1.

Although in a necropsy study of those with lethal PE, 60% of cases
developed infarction 2.
Until recently it was felt that pulmonary infarction was more common in
older patients with comorbidities, especially coexisting cardiovascular
disease and underlying malignancy, but rare in the young and otherwise
healthy.
However recent work has questioned the orthodox thinking with evidence
that greater patient stature, decreased age and smoking of cigarettes are
independent risk factors for developing pulmonary infarction 2,3. Indeed a
recent study showed that heart failure, malignancy and pneumonia were
not risk factors for the development of pulmonary infarction 2.
Moreover, the greater the embolic burden, the higher the likelihood of
developing lung infarction 1,4-6.
Many studies have found that infarction is more common in the right lung,
however the reason for this is not known 2,3.
Clinical presentation
Pleuritic chest pain, on its own, or with sudden breathlessness, are the
most frequent presenting symptoms. Hemoptysis is significantly less
common (<20% radiologically-diagnosed infarctions in a 2015 study of
335 patients) 3,7.
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Pulmonary infarction | Radiology Reference Article | Radiopaedia.org 08/09/2021, 07:33
Pathology
The lungs are not commonly infarcted, as they are supplied by two
vascular systems with many anastomoses between them:
pulmonary vascular system

carries blood from the right ventricle through the pulmonary
arteries to the alveolar capillary system
from there, blood flows through the pulmonary veins into the left
atrium and the systemic circulation
bronchial vascular system
consists of bronchial arteries that are responsible for the
majority of oxygen supply to the lung parenchyma
form a broad network with pre- and postcapillary anastomoses
to the pulmonary system
bronchial arteries have the ability to increase their flow by up to
300%
Thus, an occlusive pulmonary vascular lesion does not usually result in

infarction because of alternative perfusion via collateral pathway.
In addition the lung also receives oxygen from the inspired air itself 3.
Following an occlusive pulmonary embolus, the bronchial arteries are

recruited as the primary source of perfusion for the pulmonary capillary
network. The higher pressure of the bronchial arteries, in combination
with locally increased vascular permeability and capillary endothelial
injury, is thought to result in local pulmonary capillary hemorrhage.
Usually these parenchymal findings are transient; the blood cells

extravasated into the alveolar and bronchial cavities are resorbed, and the
tissue regenerates. However, the injury may progress to infarction in
certain circumstances:
reduced flow in the bronchial arteries (e.g. shock, hypotension, use of

vasodilators)
increased pulmonary venous pressure (e.g. elevated pulmonary
venous pressure, interstitial edema)
In these case, visceral perfusion is catastrophically compromised and the

insult progresses to infarction. The necrotic parenchyma will be replaced
by fibrous tissue and leads to a collagenous plate-like mass with pleural
retraction 4-6.
The lungs are most at risk for infarction when distal vessels ≤3 mm in
diameter are occluded, as opposed to central pulmonary artery occlusion
3-5. This is because there is more likely to be sufficient collateral
circulation in a central obstruction.
Radiographic features
In the acute/subacute setting, it may be difficult to differentiate ischemic

pulmonary hemorrhage from actual lung infarction. The evolution of
findings over time is helpful, as hemorrhage without infarction usually
resolves within a week, while infarction evolves over months and results in
parenchymal scarring.
It is important to note that infarction invariably occurs in a subpleural

location, whilst malignancy or pneumonia can occur centrally 3.
Plain radiograph
Typical chest radiographic findings include 1,8:
wedge-shaped (less often rounded) juxtapleural opacification

(Hampton hump) without air bronchograms
more often in the lower lobes
in the case of pulmonary hemorrhage without infarction, the opacities
resolve, usually within a week, by maintaining their shape (the so
called "melting sign")

in the case of infarction, it requires months to heal and may leave a
linear scar
CT
Peripheral wedge-shaped pulmonary consolidations are a classic

manifestation of pulmonary infarct, particularly in the setting of a PE.
Recognized features include 1,8:
wedge-shaped (less often rounded) juxtapleural opacification

(Hampton hump) without air bronchograms
consolidation with internal air lucencies, "bubbly consolidation"
represents non-infarcted aerated lung parenchyma co-existing
side-by-side with infarcted lung in the same lobule 9
convex borders with a halo sign
secondary to adjacent hemorrhage
decreased in normal lung enhancement
may be scattered areas of low attenuation within the lesion
(necrosis)
sometimes appears as hyperenhancement of the infarct
perimeter
cavitation: may be seen in septic embolism and infection of a bland
infarct (cavitatory pulmonary infarction)
PET-CT
A rim sign has been described on FDG-PET of pulmonary infarction, with

mild peripheral tracer uptake, and an absence of uptake centrally 10.
Treatment and prognosis
Treating the underlying pulmonary embolism by providing

cardiopulmonary support is the initial treatment. Anticoagulation is
commenced in patients without risk of active bleeding. If the emboli are

massive, thrombolysis is also an option. In some cases, embolectomy, and
placement of vena cava filters are required.
Differential diagnosis
For peripheral wedge-shaped lesions on CT, consider:
pulmonary hemorrhage (ischemia change without infarction)

septic pulmonary emboli
Bronchial circulation - Wikipedia 08/09/2021, 07:36
Bronchial circulation
The bronchial circulation is the part of the circulatory system that
supplies nutrients and oxygen to the cells that constitute the lungs, as well
as carrying waste products away from them. It is complementary to the
pulmonary circulation that brings deoxygenated blood to the lungs and
carries oxygenated blood away from them in order to oxygenate the rest
of the body.
In the bronchial circulation, blood goes through the following steps:
1. Bronchial arteries that carry oxygenated blood to the lungs

2. Pulmonary capillaries, where there is exchange of water, oxygen,
carbon dioxide, and many other nutrients and waste chemical
substances between blood and the tissues
3. Veins, where only a minority of the blood goes through bronchial
veins, and most of it through pulmonary veins.[1]
Blood reaches from the pulmonary circulation into the lungs for gas
exchange to oxygenate the rest of the body tissues. But bronchial
circulation supplies fully oxygenated arterial blood to the lung tissues
themselves. This blood supplies the bronchi and the pleura to meet their
nutritional requirements.
Because of the dual blood supply to the lungs from both the bronchial and
the pulmonary circulation, this tissue is more resistant to infarction. An
occlusion of the bronchial circulation does not cause infarction, but it can
still occur in pulmonary embolism when the pulmonary circulation is
blocked and the bronchial circulation cannot fully compensate for it.[2]
References
1. "bronchial circulation (anatomy)". GPnotebook. Retrieved 2015-01-
https://en.wikipedia.org/wiki/Bronchial_circulation#cite_note-McConnell2007-2 Page 1 of 2
Bronchial circulation - Wikipedia 08/09/2021, 07:36
04.
2. Thomas H. McConnell (2007). The Nature of Disease: Pathology for
the Health Professions. Lippincott Williams & Wilkins. pp. 81–.
ISBN 978-0-7817-5317-3.
This respiratory system article is a stub. You can help Wikipedia by

expanding it.
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Pulmonary infarction | Radiology Reference Article | Radiopaedia.

org 08/09/2021, 07:33

Pulmonary infarction occurs in the minority (10-15%) of patients with PE 1.

pulmonary vascular system

Thus, an occlusive pulmonary vascular lesion does not usually result in

Following an occlusive pulmonary embolus, the bronchial arteries are

Usually these parenchymal findings are transient; the blood cells

reduced flow in the bronchial arteries (e.g. shock, hypotension, use of

In these case, visceral perfusion is catastrophically compromised and the

circulation in a central obstruction.

In the acute/subacute setting, it may be difficult to differentiate ischemic

It is important to note that infarction invariably occurs in a subpleural

Typical chest radiographic findings include 1,8:

wedge-shaped (less often rounded) juxtapleural opacification

called "melting sign")

Peripheral wedge-shaped pulmonary consolidations are a classic

Recognized features include 1,8:

wedge-shaped (less often rounded) juxtapleural opacification

A rim sign has been described on FDG-PET of pulmonary infarction, with

Treatment and prognosis

Treating the underlying pulmonary embolism by providing

commenced in patients without risk of active bleeding. If the emboli are

For peripheral wedge-shaped lesions on CT, consider:

pulmonary hemorrhage (ischemia change without infarction)

In the bronchial circulation, blood goes through the following steps:

1. Bronchial arteries that carry oxygenated blood to the lungs

This respiratory system article is a stub. You can help Wikipedia by

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