Pulmonary embolism detection without intravenous contrast using electron density and Z-effective maps from dual-energy CT

Purpose: This study aims to evaluate the feasibility of using electron density (ED) maps combined with Z-effective (Zeff) images obtained from unenhanced dual-layer dual-energy CT (dl-DECT) scans of the chest for the detection of pulmonary embolism (PE). Materials and methods: A retrospective analysis was conducted on consecutive patients who underwent for contrast-enhanced chest CT (CECT) clinically suspected of PE or acute aortic syndrome. These scans were performed on a single dl-DECT scanner between October 2021 and November 2023. To distinguish emboli from circulating blood, color-coded maps were generated from the ED dataset superimposed on Zeff images, which were acquired from the unenhanced phase. Two radiologists with different levels of expertise independently assessed the presence of PE in the generated ED-Zeff maps, blinded to CECT results, which served as the reference standard. Diagnostic accuracy of ED- Zeff maps was assessed for each reader. Results: The final study cohort comprised 150 patients, with 92 males (mean age: 68±10years, range: 47-93years) and 58 females (mean age: 66 ±15years, range 38-89years). ED-Zeff maps demonstrated high diagnostic performance, yielding accuracy, sensitivity, and specificity, respectively, of 86.67% (113/150, 95% CI, 80.16%-91.66%), 85% (17/20, 95% CI, 79.89%-92.19%), and 86.92% (113/130, 95% CI, 79.89%-92.19%). Ed-Zeff maps were able to identify PE in 85% of positive cases. Cohen’s kappa coefficient indicated excellent intra- and interobserver agreement (κ≥0.9). Conclusion: ED maps combined with Zeff images from unenhanced dl-DECT scans represent a feasible tool for detecting PE and may prove useful in evaluating patients with contraindications to iodinated contrast.