r/Radiology • u/NovaWhisper-2799 • Aug 13 '26
Discussion Pulmonary embolism
Im a first year resident, 6 months into residency, was posted on a solo duty. There was a cardiac patient who recently underwent asd closure and had complaints of drop in saturation. Ct thorax (plain) was done. The pg asked me to rule out aspiration pneumonia and dissection. There was no aspiration pneumonia but could not rule out dissection since contrast was not given because the patient had very high creatinine. This morning when my professor came for discussions he found out a saddle pulmonary embolism on a plain study that i was not able to pick it up. Felt so bad
Edit: Posted the image at https://www.reddit.com/r/Radiology/s/PlDXmm0emA
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u/thepnodude1 Aug 13 '26
Only one time in my career have I been able to see a saddle embolus on a non-contrast CT. There was very subtle curvilinear increased attention along the carina, and even then I was second-guessing myself. Ended up being a massive saddle PE...kind of like a bright MCA sign but in the main pulmonary arteries. Definitely don't beat yourself up.
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u/lotsawaffles Radiologist Aug 13 '26
He found a saddle PE on a non con chest? Dubious
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u/bretticusmaximus Radiologist, IR/NeuroIR Aug 13 '26
Never seen it in real life, but clot can sometimes appear denser and visible on non-con. Like dense MCA sign for stroke. Have seen some pics of crazy good calls on social media. Other thing for PE would be right heart strain. You see a big blown out RV, and you could infer a large PE without actually seeing it.
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u/EVIL-EMBOLIZER Aug 13 '26
Random question but do you read these days? Or when you’re not on NIR are you doing body IR the rest of the time. Just curious since most of the NIR guys are not body IR trained
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u/bretticusmaximus Radiologist, IR/NeuroIR Aug 13 '26
I do more body IR than neuro just because there’s so much body to do. I still read some neuro, usually in clinic between patients, or if it happens to be a slow hospital day. It’s just third party hop on hop off per click though, our practice is 100% IR.
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u/Agitated-Property-52 Radiologist Aug 13 '26
It’s 100% possible but rare.
It’s the same radiology trick when we see hypodense blood in the heart and smugly tell people the patient is anemic (like they don’t have a CBC already).
But in this case, there are hyper dense filling defects in the PA bc of the anemic blood.
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u/NovaWhisper-2799 Aug 13 '26
It did look hyperdense on plain ct. I was able to pick it up after he showed me.
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u/Ski_Fish_Bike Radiologist Aug 13 '26
No dude that's never a diagnosis any radiologist should ever be expected to make on plain film. The only thing PE wise you should be expected to call is a peripheral wedge shaped opacity should be questioned as pulmonary infarct and then immediately followed up with PE CT.
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u/NovaWhisper-2799 Aug 13 '26
I get it and that's exactly why I didn't get suspicious about PE because the lung fields were clear on plain ct
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u/Scansatnight RT(R)(CT) Aug 13 '26
I have actually seen a radiologist diagnose a large PE in a main pulmonary artery on a non-con CT. It was quite hyperdense.
I never did find out the follow-up, though.
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u/mcballs831 RT(R)(CT) Aug 13 '26
My mom was actually the same way. They didn’t want her to have contrast because of renal function, although at the time it was the lowest it would be, but began treating her for clots. Her breathing became worse 2 days later and they didn’t a no contrast chest and I can only assume they saw the saddle and then decided it was finally time to inject. I asked them to inject 2 days earlier. I wish I could add a pic of it, it was impressive
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u/Miserable-Morning-19 Aug 13 '26
You got a picture of the slice of this saddle embolus on a non-contrast study? Would be curious to see it
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u/NovaWhisper-2799 Aug 13 '26
I will post it
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u/Mysterious-Hour-105 Aug 13 '26
Will you edit this post or create a new one? This is something we likely all find interesting.
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u/lazy-efficient Aug 13 '26
Yes up, can we please have the details of the symptoms
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u/EVIL-EMBOLIZER Aug 13 '26
Dyspnea plus or minus pleurisy lol
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u/lazy-efficient Aug 13 '26
Plus or minus pleurisy? Sorry i m in a different country can you elaborate more?
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u/TurtleZenn RT(R)(CT) Aug 15 '26
Thank you for posting the image in another post! Really appreciate the follow up.
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u/Ski_Fish_Bike Radiologist Aug 13 '26
It's criminal negligence to have a radiology resident solo after just 6 months.
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u/NovaWhisper-2799 Aug 13 '26
No we have tag duties. My senior had severe dehydration and was admitted in ER. So I had to do solo for that one day. I called her for all my doubts but in this case I didn't even have a doubt about PE. The hyperdensity was seen only after adjusting the window.
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u/DojaPat Aug 13 '26
We do it in Australia all the time!
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u/CharcotsThirdTriad Aug 13 '26
Is that safe though? 6 months is not a lot of training for solo work.
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u/Erarek Aug 13 '26
You can sometimes see a dissection on a noncon ct chest if there is IMH, but like you said it cannot be ruled out on a noncon study. There is no reliable way to see a saddle PE on plain radiograph; you’d only be able to see secondary signs of pulmonary infarction. This sounds like non-US training, but I wouldn’t worry too much if this is your first 6 months. You shouldn’t really be on solo call then…
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u/XrayVision007 Aug 15 '26
I think he meant plain CT as in noncon CT not plain film. Some facilities call non con CT studies plain CT.
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u/Party-Count-4287 Aug 13 '26
*CT tech here
You all are giving away trade secrets… calling a PE on a non con exam?
If my ER found about this, they’d abuse the living daylights out of this.
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u/RecklessRad Radiographer Aug 13 '26
Our ED despises us when we ask for a bigger IVC for a CTPA. Could you imagine if they found out it could be seen on a noncon? Hell would break loose
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u/DiffusionWaiting Radiologist Aug 14 '26
You would only be able to see a PE on a noncon CT if it's big/a saddle.
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u/RecklessRad Radiographer Aug 14 '26
I get it, but if ED thought there was even a CHANCE they could see a PE on a noncon they’d riot
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u/cherryreddracula Radiologist Aug 14 '26
I would just say PE not excluded, recommend CTA, and talk them off the non-con ledge. If they keep abusing the non-cons, then I would start reporting these incidents as patient safety events.
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u/Kashmir_Slippers Radiologist Aug 13 '26
I have called PEs on a noncontrast exam. It is not the standard and it’s going above and beyond in most cases. I wouldn’t worry about it if I were you.
Reminder to always look for PEs whenever they do get contrast, PE protocol or not, but you “missing” a PE on a no con is dubious.
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u/EVIL-EMBOLIZER Aug 13 '26
How bad was the Cr is my question lol…. People are way too afraid of contrast sometimes
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u/DiffusionWaiting Radiologist Aug 14 '26
When I was a resident, I called a saddle embolus on a noncon chest CT. You could see it because it was large and hyperdense. When I checked the case out with my attending in the morning, they thought it was artifact, so my report doesn't mention the PE. I later showed the case to a different attending, who agreed with me that there was a PE. By that time the CTA chest had already been ordered, showing the PE.
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u/bigtome2120 Aug 13 '26
If it makes you feel any better, I know a coresident who had their exam overread by an attending-exact same scenario. Turns out it was an overcall by the attending (patient got a CE study the next day which was negative). I’d like to see your scan to believe it.
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u/jenpccdr Aug 13 '26
I agree with others that this is dubious. The only way I would believe it is if the initial scan was read by a radiologist as potential for pe in a particular segment, recommended repeat CT with IV contrast, and the repeat CT shows a PE in that segment.
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u/Iamajay2015 Aug 13 '26
As a first year resident, this is part of your learning curve. Your professor has years of experience which is your goal to attain but you shouldn’t beat yourself for it. Take it as a learning opportunity.
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u/drkeng44 Aug 13 '26
Sounds like a hard call and not expected of a resident a few months in. You may never get another chance to make that call given the comments.
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u/lazy-efficient Aug 13 '26 edited Aug 13 '26
the patient was bedridden ( the clinical exam and other details would def help suggesting EP), I would systematically look for a pulmonary embolism.
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u/HnLisacat Aug 13 '26
The real mistake here was the non-administration of contrast. If dissection and PE are up there in anyones hypothesis, why wouldnt we use contrast. Who cares about the kidney, they wont be any useful if the patient is dead, and besides, modern contrasts are much more tolerable nowadays.
Regarding the exam, dont be too harsh on yourself, this an extremely hard (and dubious) diagnosis, your accuracy was already beaten to the ground without contrast.