Iranian Journal of Nuclear Medicine

Iranian Journal of Nuclear Medicine

Lung perfusion scan findings and clinical predictors of pulmonary embolism in hospitalized COVID-19 patients: A cross-sectional analysis

Articles in Press

Document Type : Original Article

Authors
Maryam Alvandi 1, 2
Ehsan Rashidi 3
Zahra Shaghaghi 1, 4
Seyed Kamaledin Hadei 5
Tayeb Mohammadi 6
Reyhane Ahmadi 1
1 Clinical Research Development Unit, Farshchian Heart Center, Department of Nuclear Medicine and Molecular Imaging, School of Medicine, Hamadan University Medical Sciences, Hamadan, Iran
2 Cardiovascular Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
3 Student Research Committee, Hamadan University of Medical Sciences, Hamadan,
4 Cancer Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
5 Clinical Research Development Unit, Farshchian Heart Center, Department of Radiology, School of Medicine, Hamadan University Medical Sciences, Hamadan, Iran
6 Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
10.22034/irjnm.2026.130485.1752
Abstract
Introduction: Pulmonary embolism (PE) is a complication of COVID-19 requiring timely diagnosis. This study evaluated lung perfusion scintigraphic findings and their association with Wells clinical probability in patients with COVID-19 and suspected PE.
Methods: This retrospective cross-sectional study included 48 hospitalized patients with confirmed COVID-19 and suspected PE who underwent lung perfusion scintigraphy. Demographic characteristics, symptoms, Wells probability, D-dimer levels, and scintigraphic findings were extracted from records. Perfusion scintigraphy was performed without ventilation imaging and interpreted with chest radiography using modified PIOPED II criteria for perfusion-only imaging. Findings were categorized as PE present, PE absent, or nondiagnostic. Factors associated with PE-present findings were evaluated by Firth penalized logistic regression.
Results: Among 48 patients, 30 (62.5%) were women, mean age 65.9 ± 22.0 years. Dyspnea (75.0%) and cough (70.8%) were most common. Twenty-five patients (52.1%) had low Wells probability (<4), and 23 (47.9%) had high probability (≥4). PE-present findings occurred in 14 patients (29.2%), PE-absent findings in 21 (43.8%), and nondiagnostic findings in 13 (27.1%). High Wells probability was strongly associated with PE-present findings (aOR, 16.77; 95% CI, 3.37–166.82; P<0.001), whereas age and sex were not independently associated.
Conclusion: Lung perfusion scintigraphy interpreted with chest radiography may provide useful diagnostic information in selected patients with COVID-19 and suspected PE, particularly when CTPA is unsuitable. The association with Wells probability supports clinical pretest assessment when interpreting perfusion-only studies. However, scintigraphic classifications should be considered supportive rather than definitive evidence of PE, particularly without a consistent reference standard.
Keywords
Lung perfusion scintigraphy
Pulmonary embolism
COVID-19
Wells score
PIOPED II
Subjects
  1. Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, Bikdeli B, Ahluwalia N, Ausiello JC, Wan EY, Freedberg DE, Kirtane AJ, Parikh SA, Maurer MS, Nordvig AS, Accili D, Bathon JM, Mohan S, Bauer KA, Leon MB, Krumholz HM, Uriel N, Mehra MR, Elkind MSV, Stone GW, Schwartz A, Ho DD, Bilezikian JP, Landry DW. Extrapulmonary manifestations of COVID-19. Nat Med. 2020 Jul;26(7):1017-32.
  2. Khalid D, Al Zabadi H, Qaddumi J, Taha I. Risk factors for intensive care unit admission among COVID-19 patients in the West Bank, Palestine: a retrospective cohort study. Front Med (Lausanne). 2025 Sep 11;12:1634256.
  3. Pati I, Masiello F, Piccinini V, De Fulvio L, Massari MS, De Angelis V, Cruciani M. Risk of venous thromboembolism in infectious diseases: a literature review. Pathogens. 2025 Aug 18;14(8):816.
  4. Middeldorp S, Coppens M, van Haaps TF, Foppen M, Vlaar AP, Müller MCA, Bouman CCS, Beenen LFM, Kootte RS, Heijmans J, Smits LP, Bonta PI, van Es N. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020 Aug;18(8):1995-2002.
  5. Li JY, Wang HF, Yin P, Li D, Wang DL, Peng P, Wang WH, Wang L, Yuan XW, Xie JY, Zhou F, Xiong N, Shao F, Wang CX, Tong X, Ye H, Wan WJ, Liu BD, Li WZ, Li Q, Tang LV, Hu Y, Lip GYH; Thrombo-COVID-19 Collaborative. Clinical characteristics and risk factors for symptomatic venous thromboembolism in hospitalized COVID-19 patients: A multicenter retrospective study. J Thromb Haemost. 2021 Apr;19(4):1038-48.
  6. Gong M, Jiang R, Guo K, He X, Gu J. A predictive model for early detection of concomitant pulmonary embolism in patients with deep vein thrombosis immediately upon hospital admission. J Vasc Surg Venous Lymphat Disord. 2025 Nov;13(6):102299.
  7. Cellina M, Pavan M, Finardi N, Cicchetti F, Cè M, Biondetti P, Lanza C, Carriero S, Carrafiello G. Advancements in acute pulmonary embolism diagnosis and treatment: a narrative review of emerging imaging techniques and intravascular interventions. J Cardiovasc Dev Dis. 2025 Aug 29;12(9):333.
  8. Torremocha A, Tébar D, Jurado A. The role of non-invasive tests in pulmonary embolism. Interv Cardiol. 2025 Oct 14;20:e26.
  9. van Maanen R, Trinks-Roerdink EM, Rutten FH, Geersing GJ. A systematic review and meta-analysis of diagnostic delay in pulmonary embolism. Eur J Gen Pract. 2022 Dec;28(1):165-72.
  10. Gayed IW, Browne A, Kaur H. Perfusion lung scans during the pandemic: COVID-19 experience in a large trauma hospital. J Radiat Res Appl Sci. 2022 Sep;15(3):46–50.
  11. Sostman HD, Miniati M, Gottschalk A, Matta F, Stein PD, Pistolesi M. Sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute pulmonary embolism in PIOPED II. J Nucl Med. 2008 Nov;49(11):1741-8.
  12. Mezalek ZT, Khibri H, Ammouri W, Bouaouad M, Haidour S, Harmouche H, Maamar M, Adnaoui M. COVID-19 associated coagulopathy and thrombotic complications. Clin Appl Thromb Hemost. 2020 Jan-Dec;26:1076029620948137.
  13. Ortega-Paz L, Talasaz AH, Sadeghipour P, Potpara TS, Aronow HD, Jara-Palomares L, Sholzberg M, Angiolillo DJ, Lip GYH, Bikdeli B. COVID-19-associated pulmonary embolism: review of the pathophysiology, epidemiology, prevention, diagnosis, and treatment. Semin Thromb Hemost. 2023 Nov;49(8):816-32.
  14. Roncon L, Zuin M, Barco S, Valerio L, Zuliani G, Zonzin P, Konstantinides SV. Incidence of acute pulmonary embolism in COVID-19 patients: Systematic review and meta-analysis. Eur J Intern Med. 2020 Dec;82:29-37.
  15. Flacco ME, Acuti Martellucci C, Soldato G, Di Martino G, Carota R, De Benedictis M, Di Marco G, Parruti G, Di Luzio R, Caponetti A, Manzoli L. COVID-19 vaccination did not increase the risk of potentially related serious adverse events: 18-month cohort study in an italian province. Vaccines (Basel). 2022 Dec 23;11(1):31.
  16. Ali EW, Ibrahim IK. Multi-factorial mechanism behind COVID-19 related thrombosis. Med Arch. 2022 Feb;76(1):62-5.
  17. Veisi K, Rostampour N, Salari N, Farahmandfar F, Almasi T. Distribution of lung perfusion scintigraphy findings in pregnant women with suspected pulmonary embolism. Iran J Nucl Med, 2026 July; 34(2): 99-104.
  18. Nijkeuter M, Ginsberg JS, Huisman MV. Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy: a systematic review. J Thromb Haemost. 2006 Mar;4(3):496-500.
  19. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007 Jul 18;298(3):317-23.
  20. Shellock FG, Kanal E. Policies, guidelines, and recommendations for MR imaging safety and patient management. SMRI Safety Committee. J Magn Reson Imaging. 1991 Jan-Feb;1(1):97-101.
  21. Oudkerk M, van Beek EJ, Wielopolski P, van Ooijen PM, Brouwers-Kuyper EM, Bongaerts AH, Berghout A. Comparison of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary embolism: a prospective study. Lancet. 2002 May 11;359(9318):1643-7.
  22. Tremblay E, Thérasse E, Thomassin-Naggara I, Trop I. Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation. Radiographics. 2012 May-Jun;32(3):897-911.
  23. Kluge A, Müller C, Hansel J, Gerriets T, Bachmann G. Real-time MR with TrueFISP for the detection of acute pulmonary embolism: initial clinical experience. Eur Radiol. 2004 Apr;14(4):709-18.
  24. Mos IC, Klok FA, Kroft LJ, DE Roos A, Dekkers OM, Huisman MV. Safety of ruling out acute pulmonary embolism by normal computed tomography pulmonary angiography in patients with an indication for computed tomography: systematic review and meta-analysis. J Thromb Haemost. 2009 Sep;7(9):1491-8.
  25. Canale MP, Menghini R, Martelli E, Federici M. COVID-19-Associated endothelial dysfunction and microvascular injury: from pathophysiology to clinical manifestations. Card Electrophysiol Clin. 2022 Mar;14(1):21-8.
Iranian Journal of Nuclear Medicine

Articles in Press, Accepted Manuscript
Available Online from 27 September 2026