The Egyptian Journal of Radiology and Nuclear Medicine (2013) 44, 769–778

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology and Nuclear Medicine

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ORIGINAL ARTICLE

Multidetector CT chest with bronchial

and pulmonary angiography determining causes,
site and vascular origin of bleeding in patients
with hemoptysis
Ahmed Fathy Abdel-Ghany *, Mohamed Amin Nassef, Noha Mohamed Osman

Radiodiagnosis Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Received 9 December 2012; accepted 31 July 2013

Available online 27 August 2013

KEYWORDS Abstract Objective: To assess the role of MDCT chest with bronchial and pulmonary angiogra-
MDCT; phy in determining the cause, site of bleeding, and its vascular origin in patients presenting with
Hemoptysis; hemoptysis.
MDCT bronchial Materials and methods: Fifty patients suffering from hemoptysis were evaluated by MDCT with
angiography bronchial and pulmonary angiographic techniques.
Results: MDCT chest with angiography revealed the cause in 84% of cases, the site and vascular
origin in 76% of cases presenting with hemoptysis.
Conclusion: MDCT of the chest with bronchial and pulmonary angiography is considered a pri-
mary noninvasive imaging modality in the evaluation of patients with hemoptysis. It also serves
as a guide for other diagnostic or therapeutic procedures.
 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear
Medicine. Open access under CC BY-NC-ND license.

1. Introduction

Hemoptysis is defined as bleeding originating from the lower

* Corresponding author. Address: 81 Mohy El-Deen Abdel-Hameed,
Nasr City, Cairo, Egypt. Tel.: +20 1272964223, +20 222877807.
E-mail addresses: ahmedfathyalasmar@yahoo.com (A.F. Abdel-
Ghany), manassef@hotmail.co.uk (M.A. Nassef), drnohaosman@
yahoo.com (N.M. Osman).
Peer review under responsibility of Egyptian Society of Radiology and
Nuclear Medicine.
Production and hosting by Elsevier
respiratory tract (1). Although hemoptysis may cease tempo-
rarily, a possible life-threatening condition may still be present,
requiring complete evaluation and treatment (2). Hemoptysis’
severity is classically classified based on the amount of bleeding
(3). There are multiple causes of hemoptysis, from airway dis-
eases, parenchymal diseases, cardiovascular diseases, and other
causes (2). The common causes of bleeding from the large ves-
sels nowadays include cancer, bronchiectasis, tuberculosis, and
fungal infections. No cause is identified in 15–30% of all cases,

0378-603X  2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine.
Open access under CC BY-NC-ND license. http://dx.doi.org/10.1016/j.ejrnm.2013.07.011
770
and is termed idiopathic or cryptogenic hemoptysis (4). The
most common underlying causes of hemoptysis vary in re-
ported studies depending on the geographic location of the
study, the prevalence of tuberculosis, and the use of cross-sec-
tional imaging (5,6).
The bronchial arteries are the source of bleeding in most
cases of hemoptysis; while hemoptysis is related to pulmonary
artery injury in up to 11% of cases (7). Contributions from the
non-bronchial systemic arterial system represent an important
cause of recurrent hemoptysis following apparently successful
bronchial artery embolization. Vascular anomalies such as pul-
monary arteriovenous malformations and bronchial artery
aneurysms are other important causes of hemoptysis (5). Con-
ditions such as bronchiectasis, chronic bronchitis, lung malig-
nancy, tuberculosis, and chronic fungal infection are easily
detected with conventional CT (5).
MDCT permits a more sensitive, more rapid and accurate
assessment of the cause and consequences of hemorrhage into
the airways and helps guide subsequent management (5). CT is
superior to fiberoptic bronchoscopy in finding a cause of hem-
optysis, its main advantage being its ability to show distal air-
ways beyond the reach of the bronchoscope, and the lung
parenchyma surrounding these distal airways (4). Data suggest
that CT could replace bronchoscopy as the first-line procedure
for screening patients with severe hemoptysis (8). The addition
of MDCT angiography provides a more precise depiction of
the bronchial arteries than conventional angiography (7).
The aim of the current study is to describe the role of MDCT
chest with bronchial and pulmonary angiography in identify-
ing the site of bleeding and its vascular origin.
2. Materials and methods
This study was carried out on 50 patients suffering from hem-
optysis during the period between July 2011 and May 2012;
they were referred to perform MDCT chest with angiography
of the bronchial arteries in a private radiology center.
All patients were subjected to a complete clinical assess-
ment. Laboratory data were reviewed. Chest X rays were per-
formed for all patients prior to the CT study and were
reviewed for any abnormality. Other investigations done after
the CT study including bronchoscopy results, conventional
angiographic findings and histopathological reports were cor-
related to the CT results.
2.1. Patient preparation
All patients were instructed to fast for 4–6 h prior to the exam-
ination. All steps of the study were explained in details for each
patient. An IV access was secured.
2.2. Scan protocol
MDCT studies were obtained using GE (Light Speed Ultra
16; GE Medical Systems, Milwaukee, USA) with the follow-
ing parameters 140 kV, 140 mAs, collimation 16 · 0.75 and
pitch 1.5.
2.2.1. MDCT chest with bronchial and pulmonary angiography
CT imaging was acquired from the supraclavicular area to
the level of the ostia of the renal arteries, including the
A.F. Abdel-Ghany et al.
supra-aortic great vessels and the infra-diaphragmatic arteries,
which may also supply collateral branches to the lungs. With
current multidetector row systems, optimal enhancement of
both the pulmonary and systemic arteries was achieved with
the injection of 120 ml of a high-density, low osmolar non-io-
nic contrast medium (350 mg/dl) with an automated injector at
a rate of 4 ml/s connected to the IV access. The automatic bo-
lus-triggering software program was also systematically ap-
plied, with a circular region of interest positioned at the
descending aorta at the level of carina, craniocaudal scanning
started. Thoracic CT angiography with a combination of se-
lected reformatted images was acquired. Assessment of the
lung parenchyma and airways as well as the mediastinum
was always done as in routine CT chest studies, using both
lung parenchyma and mediastinal window settings.
2.2.2. Post processing techniques
Post-processing of the raw data was performed by GE ADW
4.0 work station, Milwaukee, USA with axial thin-section
images, multiplanner reformation (MPR), maximum intensity
projection (MIP), and volume-rendered (VR) techniques in or-
der to optimally evaluate the origins and courses of the bron-
chial arteries.
2.2.3. Data interpretation
(1) Assessment of the lung parenchyma to detect the site
and the cause of bleeding as well as any associated
findings.
(2) Assessment of the bronchial arteries as regards:
(a) Number of bronchial arteries detected on either side.
(b) The site of origin from the aorta.
(c) The level of origin related to vertebral bodies (ortho-
topic or ectopic) and related to tracheal carina (at the
level of tracheal carina or below it).
(d) The traceability of the bronchial arteries at their medias-
tinal course to the pulmonary hila.
(e) The diameter of the bronchial arteries at their origin.
(3) Assessment of the pulmonary circulation for any abnor-
mality that may cause hemoptysis (e.g. pulmonary
embolism, pulmonary AVM, pulmonary aneurysm).
A bronchial artery with a diameter greater than 2 mm was
considered abnormal. Enlarged vascular structures entering
the lung parenchyma through the inferior pulmonary ligament
or through the adherent pleura and associated with pleural
thickening (>3 mm) and lung parenchyma abnormalities were
regarded as nonbronchial systemic arteries responsible for
hemoptysis.
3. Results
The study included 50 patients (38 males and 12 females) com-
plaining of hemoptysis. The mean age of patients was 50 years
(range 20–80 years). The most commonly affected age group
was above 50 years (50% of patients).
Plain radiography was considered successfully contributing
in identification of the cause of hemoptysis in only 22/50 pa-
tients (44%). Fiberoptic bronchoscopy was done in 7 patients
(14%). It revealed the cause of bleeding in 6 patients (85.7%),
3 patients had central bronchogenic carcinoma (proved by
Multidetector CT chest with bronchial and pulmonary angiography determining 771

histopathological confirmation), 2 patients had focal endo-
bronchial mass and 1 patient had bronchiectasis. Biopsy was
taken from the 5 patients with central or endobronchial
masses. Conventional bronchial angiography was performed
after MDCT study in only 4 patients indicated for emboliza-
tion. Dilated bronchial arteries were identified in 3 patients
and dilated non bronchial systemic arteries were seen in one
patient.
In our study, MDCT identified the cause of hemoptysis in
total 42 out of 50 patients of the study (84%). Patients with
identified cause of hemoptysis were classified into: 35 patients
(70%) with lung parenchymal pathology [31 of which had
associated vascular abnormalities (62%) (Figs. 1 and 2) while
4 patients (8%) had no associated vascular abnormality
(Fig. 3)] and 7 patients (14%) had isolated vascular abnormal-
ities without parenchymal pathology detected (Fig. 4). Neither
parenchymal nor vascular abnormalities were detected as the
cause of hemoptysis in remaining 8 out of 50 patients of the
study (16%) (Table 1). A total of 38 patients (76%) had vascu-
lar abnormalities detected which were described in Table 1.
The lung parenchymal abnormalities detected in 35 out of
50 patients of the study were further clarified in Table 2.
In our study, MDCT chest with angiography detected 93
bronchial arteries in 32 out of 50 (64%) patients of the study
(34 right BAs; 2 patients had 2 double right sided BA, 59 left
BAs; 5 patients had single left sided BA)(Fig. 1). Twenty-five
out of 93 detected BAs were seen to be dilated (>2 mm) in
25 patients (19 right BAs and 6 left BAs) (Table 3). Forty-three
out of 93 detected bronchial arteries bronchial arteries were
traceable to the level of pulmonary hila.
As regards the ostia of bronchial arteries, our study showed
that 90% of the BAs seen were orthotopic (84 BAs), 9 (10%)
ectopic BAs (Table 3) were seen in 7 patients, 3 were right
sided [2 from the aortic arch (Figs. 4 and 5), 1 of which is di-
lated (Fig. 4) and 1 from the subclavian artery (SCA)] and 6
were left sided [5 from the aortic arch and 1 from lower part
of descending thoracic aorta].
The origins of orthotopic mediastinal bronchial arteries
were best depicted on overlapping axial thin-section images
(e.g. 1-mm-thick sections at 0.75 mm increments). Two-dimen-
sional MIP reformatted images in the coronal oblique and sag-
ittal planes readily depict the tortuous course of the bronchial
arteries from their origins (descending thoracic aorta) to the
lungs along the main bronchi; reformatted images in straight
coronal planes are better suited for analysis of the intercostal
and internal mammary arteries; and axial reconstructed images
are ideal for demonstrating the inferior phrenic arteries and
branches from the celiac axis.
Non-bronchial systemic source of bleeding was encoun-
tered in 8 patients (Table 1) in the form of: dilated intercostal
vessels with pleural thickening (>3 mm) and parenchymal
lung abnormalities were found in 5 patients and in the

Fig. 1 Axial (a) and coronal reformatted images (b) showing thin-walled cavitary lesion seen at the left upper lung lobe (white arrows).
Dilated tortuous orthotopic single left bronchial artery is seen directed toward the lesion in sagittal oblique reformatted MDCT
angiography (black arrow) (c) and 3D VR CT angiography (white arrow) (d).
772 A.F. Abdel-Ghany et al.

Fig. 2 A dilated orthotopic right bronchial artery (white arrows) (a and b) in a case of right sided bronchiectasis (arrow head) (c).

Fig. 3 Axial CT cuts, mediastinal window (a) and lung window (b) showing mass infiltrating the right main stem bronchus (white arrow
head) and distal bronchiectatic changes and consolidations (white arrow). (c) Coronal reformatted CT image showing the mass infiltrating
the right main stem bronchus (white arrow).
Multidetector CT chest with bronchial and pulmonary angiography determining 773

Fig. 4 Axial MDCT image (a) showing multiple enhancing dots at the mediastinum represent the markedly dilated and tortuous ectopic
right bronchial artery (black arrow) arising directly from the arch of aorta. Coronal MIP image (b) showing the abnormally dilated ectopic
right bronchial artery (white arrow). (c) Digital subtraction angiography confirming the MDCT findings.

Table 1 Source of bleeding detected by MDCT chest with angiography and its relation to an existing parenchymal abnormality.
Source of bleeding detected in 50 patients of the study With parenchymal abnormality Without parenchymal abnormality
Bronchial artery supply (50%) 25 patients 40% (20 patients) 10% (5 patients)
Non-bronchial systemic artery (16%) 8 patients 16% (8 patients) 0%
Pulmonary artery (10%) 5 patients 6% (3 patients) 4% (2 patients)
Not detected (24%) 12 patients 8% (4 patients) 16% (8 patients)

Table 2 Parenchymal abnormalities detected by MDCT and their relations to vascular source of bleeding.
Parenchymal abnormality Number of patients
Specific parenchymal abnormality 22 (44%)
Mass 16
Bronchiectasis 3
Tuberculosis and its sequelae e.g. cavitation 3
Non-specific parenchymal abnormality 13 (20%)
Consolidation/ground-glass opacity
Diagnosed as pneumonia 5
Non-specific 8
No parenchymal abnormality 7 (20%)
Bronchial artery vascular abnormality (dilatation/dysplasia) 5
Pulmonary artery vascular abnormality (Pulmonary embolism) 2
Unidentified abnormality 8 (16%)
774 A.F. Abdel-Ghany et al.

Table 3 The origin and diameter of the BAs detected by MDCT angiography.
Detected bronchial arteries Right (34) Left (59)
Dilated Non-dilated Dilated Non-dilated
Orthotopic (84) 19 12 6 47
Ectopic (9) 1 2 0 6

Fig. 5 Sequential axial MDCT images showing the ectopic right bronchial artery arising from the undersurface of aortic arch (arrow
head) (a and b) and the orthotopic left bronchial artery (white arrow) (c). Axial lung window image showing bilateral lung parenchymal
consolidations (arrow heads) (d).

remaining 3 patients vessels were seen across the dia-
phragm in one case it was originating from the celiac
trunk (Fig. 6).
The pulmonary circulation was found to be the source of
hemoptysis in 5 patients (Table 1), 4 of which had pulmonary
embolism (Fig. 7) and 1 patient had pulmonary parenchymal
lesion with the descending branch of left pulmonary artery
seen to be irregular and attenuated traversing inside the lesion
(Fig. 8).
4. Discussion
Hemoptysis is defined as bleeding arising from the lower
airways. It is a common and nonspecific sign, occurring in a
wide variety of diseases (9). Its presence always requires inves-
tigation, even if only a small quantity of blood is expectorated
(10). Identifying the etiology of hemoptysis and classifying it in
terms of the amount of blood expectorated play a fundamental
role in defining the treatment and deciding whether or not
hospital admission is necessary. In addition, the rate of
bleeding is the major determinant of mortality, and asphyxia
is the leading cause of death (11).
The etiology of hemoptysis can be divided into several
groups: infections; cardiovascular diseases; lung diseases;
cancer; vasculitis; coagulopathy; trauma; drug use; iatrogene-
sis; foreign body aspiration; and cryptogenic hemoptysis (9).
Cryptogenic hemoptysis, for which no cause can be identified,
is a diagnosis of exclusion and might be expected to decrease in
prevalence with more systematic use of CT (1,2). Massive hem-
optysis usually originates from the BAs, due to the high pres-
sure of that circuit (12,13).
The normal BA is a small vessel that arises directly from the
descending thoracic aorta and supplies blood to the airway of
the lung, esophagus, and lymph nodes (12,14,15). Bronchial
arteries show substantial anatomic variations in their origins,
branching patterns, and courses (15). The right intercosto-
bronchial trunk, which usually arises from the right posterolat-
eral aspect of the thoracic aorta at the level of the 5th thoracic
vertebra or 6th thoracic vertebra, is the most constant vessel.
In approximately 70% of cases, there are two left BAs. Right
and left BAs that arise from the aorta as a common trunk are
not unusual. BAs are identified in the posterior mediastinum as
dots or lines of increased attenuation (9). More than 30% of
BAs have an anomalous origin, which is a cause of endovascu-
lar treatment failure (8). Anomalous BAs may originate from
Multidetector CT chest with bronchial and pulmonary angiography determining 775

Fig. 6 A case of multicenteric bronchogenic carcinoma with bilateral suprarenal metastases. Axial CT images (a and b): large left lower
lung lobe mass (asterisk), with no definite clear fat plane between the mass and the left lateral aspect of the pericardium and invading the
lateral chest wall muscles. Abnormal dilated tortous NBSA (arrow head) is seen coursing toward the large mass through the diaphragm.
Axial image (c) showing bilateral large supra-renal masses (asterisks) and the origin of the NBSA from the celiac trunk. Three dimensional
VR image showing the origin of NBSA from the celiac trunk (white arrow) (d).

the aortic arch, internal mammary artery, thyrocervical trunk,
subclavian artery, costocervical trunk, brachiocephalic artery,
peri-cardiophrenic artery, inferior phrenic artery, or abdomi-
nal aorta (8).
The imaging modalities used in evaluation of hemoptysis
include chest radiograph, MDCT chest, MDCT bronchial
angiography and conventional bronchial arteriography (2).
Radiography can help lateralizing the bleeding and can often
help detecting underlying parenchymal and pleural abnormal-
ities (16). In our study, chest radiography contributed to the
diagnosis of hemoptysis in 22 of 50 patients (44%). This con-
cides with Revel et al. (8) who found that chest radiography
defines the site of bleeding in only 46% of patients. In our
study, MDCT identified the cause of hemoptysis in 42 of 50
patients (84%) and was not identified in 8 patients (16%). This
nearly agreed with the results of Khalil et al. (7) in which
MDCT scans showed the cause of bleeding in 48 of 53 patients
(90.5%).
Millar et al. (18), Hirshberg et al. (17) and in most
reports, bronchiectasis, chronic bronchitis, tuberculosis, fungal
776 A.F. Abdel-Ghany et al.

Fig. 7 Axial sequential MDCT pulmonary angiography images (a and b) showing pulmonary embolism involving both main pulmonary
arteries (black arrow heads).

Fig. 8 Left lower lung lobe consolidation and cavitation. Axial (a) and coronal reformatted images (b and c) showing the left descending
pulmonary artery being irregular, attenuated traversing through the parenchymal lesion (white arrows).

infection and malignancy are the most common important
causes of hemoptysis. In general this coincides with the results
of our study with the exception of chronic bronchitis, as most
of those patients were diagnosed clinically. Also Khalil et al.
(19) reported five major causes of hemoptysis representing
80% of their cases: bronchiectasis, active tuberculosis, lung
cancer, sequelae of tuberculosis, and cryptogenic causes. In an-
other recent study done by Soares Pires et al. (4), they revealed
that pulmonary tuberculosis sequelae and bronchiectasis were
the dominant diagnoses (22.2% and 15.8%, respectively), fol-
lowed by lung cancer. The etiology of hemoptysis was not
established in 6.3%.
Several studies including Revel et al. (8) and Khalil et al. (7)
described three types of nonspecific radiologic MDCT
abnormalities: (1) ground-glass opacities and/or (2) alveolar
consolidation; the latter abnormalities were considered to
reflect the filling of the alveolar lumen with blood, and (3)
atelectasis, induced by clots obstructing the bronchi. Presence
of alveolar filling, cavitation and/or a mass were considered to
be localizing lesions. Regarding the bleeding site localization in
the present study, the presence of bleeding was detected by
abnormal CT findings in the form of focal parenchymal
abnormality or opacity (either ground glass opacity or
consolidation) that is not gravity-dependent. Diffuse opacities
or predominantly in the dependent portion of the lungs were
considered non-localizing.
In our study, MDCT chest with angiography detected 93
bronchial arteries in 32 out of 50 (64%) patients of the study.
Yoon et al. (21), detected 52 bronchial arteries in 22 patients,
using 16 MDCT. Haponik et al. (20), in a retrospective study
Multidetector CT chest with bronchial and pulmonary angiography determining
of 32 patients with hemoptysis showed that CT correctly local-
ized site of bleeding in 23 of the 26 patients (88%) in whom a
site was identified by fiberoptic bronchoscopy.
As regards the ostia of bronchial arteries, our study showed
that 90% of the BAs seen were orthotopic (84 BAs), and 9
(10%) ectopic BAs were seen in 7 patients. This coincides with
Remy Jardin et al. (22), who found the ostia of the right and
left BAs to be orthotopic in 83% of cases on the right side
and in 73% of cases on the left side. They also found that
CT angiography was very helpful in depicting bronchial arter-
ies of ectopic origin. They found 4 (17%) of 23 right arteries
and 8 (27%) of 30 left arteries adequately depicted on CT angi-
ograms having an ectopic origin. In our study, 9 detected ecto-
pic bronchial arteries were seen in 7 patients (22%)[3 were
right sided: 2 from the aortic arch (1 of which is dilated) and
1 from the subclavian artery) and 6 were left sided (5 from
the aortic arch and 1 from the lower descending thoracic aor-
ta]. This nearly coincides with Hartmann et al. (23) study,
which evaluated 214 patients with hemoptysis on 4-, 16-, and
64-detector row MDCT scanners and detected the presence
of ectopic bronchial vessels in 36% of patients.
Morita et al. (24) studied the BA anatomy using 16 or 64-
detector row MDCT. An orthotopic origin was observed in
93% from the right intercostals bronchial trunk, 73% of direct
origin from the right BA, 79% from the common trunk of both
BAs, and 79% from the left bronchial arteries. Mori et al. (25),
found that among 41 patients who underwent 16-slice-MDCT
study, a total of 102 bronchial artery ostia were detected, 80
bronchial arteries were orthotopic (78.4%) and a total of 22 ec-
topic BAs were depicted (21.6%). Thirteen patients (42%) had
at least 1 BA of ectopic origin, dilatation and tortuosity of BAs
were found in 8 patients (40%).
We found that 43 out of 93 detected bronchial vessels
(46%) were traceable to the pulmonary hilum including the
25 dilated bronchial arteries. Yoon et al. (21), found 34
(65%) of 52 BAs were traceable from their origins to the hi-
lum. They found that the differences in percentage of traceabil-
ity to the hilum of bronchial arteries causing hemoptysis and
those not causing hemoptysis were statistically significant. Hel-
my et al. (26) also found that tortuosity and traceability of the
vessels directed toward the lesion are more important factors
in identification of the source and site of bleeding.
Conventional bronchial angiography was performed after
MDCT study in only 4 patients indicated for embolization. Di-
lated bronchial arteries were identified in 3 patients and dilated
non bronchial systemic arteries were seen in one patient. The
dilated arteries were readily detected by MDCT bronchial
angiography.
According to the study done by Yoon et al. (27), a pleural
thickness of more than 3 mm and the presence of systemic ves-
sels within an extra-pleural fat layer were considered CT crite-
ria for the presence of a NBSA supply. In our study, combined
findings including enlarged non-BAs, pleural thickening and
parenchymal abnormalities were considered as non-bronchial
source of bleeding. Non-bronchial source of bleeding was
encountered in 8 patients originating from intercostal arteries
in 5 patients and from the celiac artery in the remaining 3
patients.
Khalil et al. (28) found that of total 272 patients presenting
with hemoptysis, 13 patients (6.9%) had hemoptysis of pul-
monary artery origin. This agreed with result of other previous
reports of Sbano et al. (29). In our study, the pulmonary circu-
777
lation was found to be the source of hemoptysis in 10% of
cases (5 patients), 4 patients with pulmonary embolism and
one patient with the descending branch of left pulmonary ar-
tery being involved in a pulmonary parenchymal lesion.
There were some limitations in our study; we used a 16-
detector row MDCT device, Morita et al. (24) showed that
64 slice CT scanners showed the bronchial artery anatomy bet-
ter than 16 slice scanners. Another limitation is that the selec-
tive conventional angiography and bronchoscopy were
performed in a limited number of patients. To confirm our
observations, a larger study is needed in which inter-observer
variability, especially in defining BAs causing hemoptysis
and those not causing hemoptysis, is recommended with use
of MDCT and conventional angiography.
5. Conclusion
Applying the findings of the current study, it is concluded that
MDCT chest with bronchial and pulmonary angiography is
considered a primary noninvasive imaging modality in the
evaluation of patients with hemoptysis. It also serves as a guide
for other diagnostic or therapeutic procedures.
Conflict of interest
The authors have no conflict of interest to declare.
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