Pulmonary vasculitis in Hughes-Stovin syndrome (HSS): a reference atlas and computed tomography pulmonary angiography guide—a report by the HSS International Study Group
Authors: Emad Yasser , Ragab Yasser , Robinson Cal , Pankl Sonia , Young Pablo , Fabi Marianna , Bawaskar Parag , Ibrahim Ossama , Erkan Doruk , Barman Bhupen , Tekavec-Trkanjec Jasna , Jayakrishnan Balakrishnan , Kindermann Michael , Kechida Melek , Guffroy Aurelien , Silva Rafael S. , Frikha Faten , Abou-Zeid Alaa , Hassan Maged , Farber Harrison W. , Abdelbary Mohamed H. , Tornes Leticia , Margolesky Jason , El-Shaarawy Nashwa , Bennji Sami , Agarwala Manoj Kumar , Saad Ahmed , Amezyane Taoufik , Ghirardo Sergio , Cruz Vitor , Niemeyer Bruno , Al-Zeedy Khalfan , Al-Jahdali Hamdan , Jaramillo Natalia , Demirkan Serkan , Kably Issam , Kim Jung Tae , Rasker Johannes J. 
Published: September 2021

Abstract
Introduction
Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by widespread venous/arterial thrombosis and pulmonary artery aneurysms (PAAs), which is associated with serious morbidity and mortality. All fatalities reported in HSS resulted from unpredictable fatal suffocating hemoptysis. Therefore, it is necessary to recognize pulmonary complications at an early stage of the disease.

Objectives
The aims of this study are to develop a reference atlas of images depicting the characteristic features of HSS by computed tomography pulmonary angiography (CTPA). To make a guide for physicians by developing a classification of PAAs according to the severity and risk of complications associated with each distinct lesion type.

Methods
The Members of the HSS International Study Group (HSSISG) collected 42 cases, with high-quality CTPA images in one radiology station and made reconstructions from the source images. These detailed CTPA studies were reviewed for final image selection and approved by HSSISG board members. We classified these findings according to the clinical course of the patients.

Results
This atlas describes the CTPA images that best define the wide spectrum of pulmonary vasculitis observed in HSS. Pulmonary aneurysms were classified into six radiographic patterns: from true stable PAA with adherent in-situ thrombosis to unstable leaking PAA, BAA and/or PAP with loss of aneurysmal wall definition (most prone to rupture), also CTPA images demonstrating right ventricular strain and intracardiac thrombosis.

Conclusion
The HSSISG reference atlas is a guide for physicians regarding the CTPA radiological findings, essential for early diagnosis and management of HSS-related pulmonary vasculitis.

Key Points• The Hughes-Stovin syndrome (HSS) is a systemic vasculitis characterized by extensive vascular thrombosis and pulmonary artery aneurysms (PAAs) that can lead to significant morbidity and mortality.• All fatalities reported in HSS were related to unpredictable massive hemoptysis; therefore, it is critical to recognize pulmonary complications at an early stage of the disease.• The HSS International Study Group reference atlas classifies pulmonary vasculitis in HSS at 6 different stages of the disease process and defines the different radiological patterns of pulmonary vasculitis notably pulmonary artery aneurysms, as detected by computed tomography pulmonary angiography (CTPA).• The main aim of the classification is to make a guide for physicians about this rare syndrome. Such a scheme has never been reached before since the first description of the syndrome by Hughes and Stovin since 1959. This classification will form the basis for future recommendations regarding diagnosis and treatment of this syndrome.