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. 2025 Oct 22;26(1):293.
doi: 10.1186/s12931-025-03374-8.

Dual-energy computed tomography derived pulmonary blood volume: association with pulmonary blood flow

Jakob Wittenstein #  1 , Rudi Apolle #  2   3   4   5 , Martin Scharffenberg  1 , Carolin Rothmann  1 , Sabine Müller  1 , Ralf-Thorsten Hoffmann  6 , Esther G C Troost  2   7   8   9   10 , Thea Koch  1 , Marcelo Gama de Abreu  1   11   12 , Robert Huhle  13
Affiliations

Dual-energy computed tomography derived pulmonary blood volume: association with pulmonary blood flow

Jakob Wittenstein et al. Respir Res. .

Abstract

Background: Distribution of ventilation and pulmonary perfusion are the major determinants of pulmonary gas exchange. To study and compare strategies of mechanical ventilation in respiratory research accurate and high-resolution methods are needed to derive distribution of ventilation and perfusion with minimal additional intervention or radiation allowing repeated measurements. Dual-energy computed tomography (DECT) is an imaging technique allowing for the derivation of regional pulmonary perfused blood volume, as a surrogate for pulmonary perfusion (PPDECT). Here accuracy of PPDECT is evaluated in comparison to pulmonary blood flow measured with fluorescence-labeled microspheres (PPFLM). Its feasibility of repeated measurements is evaluated.

Methods: Agreement between PPFLM and PPDECT was assessed by regression as well as Bland-Altman analysis in three anesthetized pigs using DECT and fluorescence labelled microspheres, respectively. Measurements were performed in two-lung and, after right sided thoracotomy, at one-lung ventilation with inhaled nitric oxide. PPFLM and PPDECT were assessed in three different regions of interest (ROI): the right (non-ventilated) and left (ventilated) upper and lower lung, yielding a total of 45 paired measurements over four hours. Persistent iodine accumulation was assessed by additional DECT scans before each contrast administration.

Results: Regression analysis revealed a good overall association (R2 = 0.81) between PPFLM and PPDECT, with PPDECT substantially overestimating PPFLM up to 30%, with limits of agreement of -18 and 18%, Low PPFLM was underestimated, while high PPFLM was overestimated by PPDECT, indicating a higher sensitivity of the later. Changes of PPDECT and PPFLM had a concordance of 69.4% for all measurements. Agreement and concordance were highest in ventilated and lowest in non-ventilated ROIs. No persistent iodine enhancement was detected in the lung parenchyma after repetitive measurements per hour.

Conclusions: Dual-energy CT based measurement of pulmonary perfusion shows promising results indicating its feasibility in translational research on strategies of mechanical ventilation.

Keywords: Dual-energy CT; Fluorescence labelled microspheres; Regional pulmonary perfusion; Shunt blood flow.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The protocol was approved by the Institutional Animal Care and Welfare Committee and the Government of Saxony, Germany (file: 25–5131/496/33) and the Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines were followed. Consent for publication: Not applicable. Competing interests: The authors of this manuscript declare relationships with the following companies: MGA: Dräger Medical, Ambu, GE Healthcare, and ZOLL. The other authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The other authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Figures

Fig. 1
Fig. 1
Time course of measurements and interventions. iNO: inhaled nitric oxide, DECT: dual-energy computed tomography
Fig. 2
Fig. 2
Imaging protocol of Dual-Energy Computed Tomography (DE)CT as performed at mean-lung volume for each measurement time point, its timing and derived measures with: gas fractions at end-expiration, end-inspiration and mean-lung volume (formula image and formula image), respectively; tidal gas volume difference (dV); virtual non-contrast (VNC), DECT for tracer enrichment analysis (Iodine pre); and DECT following tracer injection
Fig. 3
Fig. 3
Representative transversal slides during one-lung ventilation in the left lung and its absence in the right lung (A) and pulmonary perfusion from DECT formula image in both lungs (B)
Fig. 4
Fig. 4
Representative distribution of PPFLM shows the low resolution and substantial deviation from lung shapes due to the fluorescence labelled-microspheres analysis; central transversal slice between most caudal and most cranial lung (left) and a three-dimensional representation of PPFLM for the same scan seen from dorsal
Fig. 5
Fig. 5
Regression analysis (A) and Bland–Altman plot (B) suggest systematic under-/over-estimation of low/high pulmonary blood flow (PPFLM) by perfused pulmonary blood volume (PPDECT); limits of agreement (LoA), number of experiment (#)
Fig. 6
Fig. 6
Concordance plot of perfused pulmonary blood volume (PPDECT) determined by DECT imaging and pulmonary blood flow (PPFLM) as derived by Fluorescence-labelled microspheres. Change of PPDECT and PPFLM between measurements (dPPDECT and dPPFLM, respectively), TLV, two lung ventilation
Fig. 7
Fig. 7
Mean Hounsfield unit (HU) for VNC native images (light grey and white circles) as well as respective Iodine images (dark grey and black circles) in aerated (aer.) left and non-aerated (n.aer.) right lung (comp.), respectively; VNC: virtual non-contrast image
Fig. 8
Fig. 8
Ventilation (dV) is higher than perfusion formula image in gravity independent lung regions (ventral, cranial) and lower in dependent lung regions (dorsal, caudal), respectively
See this image and copyright information in PMC

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