Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience

Purpose

The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma.

Materials and methods

We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O).

Results

In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively.

Conclusions

Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.     

Embolization Therapy for Traumatic Splenic Lacerations

Purpose

This study was designed to evaluate the clinical success, complications, and transfusion requirements based on the location of and agents used for splenic artery embolization in patients with splenic trauma.

Methods

A retrospective study was performed of patients with splenic trauma who underwent angiography and embolization from September 2000 to January 2010 at a level I trauma center. Electronic medical records were reviewed for demographics, imaging data, technical aspects of the procedure, and clinical outcomes.

Results

Fifty patients were identified (34 men and 16 women), with an average age of 48 (range, 16–80) years. Extravasation was seen on initial angiography in 27 (54%) and was absent in 23 (46%). All 27 patients with extravasation were embolized, and 18 of 23 (78.2%) without extravasation were embolized empirically. Primary clinical success was similar (>75%) across all embolization locations, embolic agents, and grades of laceration treated. Of 45 patients treated, 9 patients (20%) were embolized in the main splenic artery, 34 (75.6%) in the splenic hilum, and 2 (4.4%) were embolized in both locations. Partial splenic infarctions developed in 47.3% treated in the splenic hilum compared with 12.5% treated in the main splenic artery. There were four (8.9%) mortalities: two occurred in patients with multiple critical injuries and two from nonbleeding etiologies.

Conclusions

Embolization of traumatic splenic artery injuries is safe and effective, regardless of the location of treatment. Embolization in splenic hilar branches may have a higher incidence of infarction. The grade of laceration and agents used for embolotherapy did not impact the outcomes.     

Transjugular Endovascular Recanalization of Splenic Vein in Patients with Regional Portal Hypertension Complicated by Gastrointestinal Bleeding

Purpose

Regional portal hypertension (RPH) is an uncommon clinical syndrome resulting from splenic vein stenosis/occlusion, which may cause gastrointestinal (GI) bleeding from the esophagogastric varices. The present study evaluated the safety and efficacy of transjugular endovascular recanalization of splenic vein in patients with GI bleeding secondary to RPH.

Methods

From December 2008 to May 2011, 11 patients who were diagnosed with RPH complicated by GI bleeding and had undergone transjugular endovascular recanalization of splenic vein were reviewed retrospectively. Contrast-enhanced computed tomography revealed splenic vein stenosis in six cases and splenic vein occlusion in five. Etiology of RPH was chronic pancreatitis (n = 7), acute pancreatitis with pancreatic pseudocyst (n = 2), pancreatic injury (n = 1), and isolated pancreatic tuberculosis (n = 1).

Results

Technical success was achieved in 8 of 11 patients via the transjugular approach, including six patients with splenic vein stenosis and two patients with splenic vein occlusion. Two patients underwent splenic vein venoplasty only, whereas four patients underwent bare stents deployment and two covered stents. Splenic vein pressure gradient (SPG) was reduced from 21.5 ± 7.3 to 2.9 ± 1.4 mmHg after the procedure (P < 0.01). For the remaining three patients who had technical failures, splenic artery embolization and subsequent splenectomy was performed. During a median follow-up time of 17.5 (range, 3–34) months, no recurrence of GI bleeding was observed.

Conclusions

Transjugular endovascular recanalization of splenic vein is a safe and effective therapeutic option in patients with RPH complicated by GI bleeding and is not associated with an increased risk of procedure-related complications.     

Splenic Arterial Embolization in the Treatment of Severe Portal Hypertension Due to Pancreatic Diseases: The Primary Experience in 14 Patients

Objective

This retrospective study reports our experience using splenic arterial particle embolization and coil embolization for the treatment of sinistral portal hypertension (SPH) in patients with and without gastric bleeding.

Methods

From August 2009 to May 2012, 14 patients with SPH due to pancreatic disease were diagnosed and treated with splenic arterial embolization. Two different embolization strategies were applied; either combined distal splenic bed particle embolization and proximal splenic artery coil embolization in the same procedure for acute hemorrhage (1-step) or interval staged distal embolization and proximal embolization in the stable patient (2-step). The patients were clinically followed.

Results

In 14 patients, splenic arterial embolization was successful. The one-step method was performed in three patients suffering from massive gastric bleeding, and the bleeding was relieved after embolization. The two-step method was used in 11 patients, who had chronic gastric variceal bleeding or gastric varices only. The gastric varices disappeared in the enhanced CT scan and the patients had no gastric bleeding during follow-up.

Conclusions

Splenic arterial embolization, particularly the two-step method, proved feasible and effective for the treatment of SPH patients with gastric varices or gastric variceal bleeding.

     

Partial splenic embolisation using n-butyl cyanoacrylate: intraprocedural evaluation by magnetic resonance imaging

Objectives

To evaluate the use of diffusion-weighted imaging (DWI) for estimating infarcted splenic volume during partial splenic embolisation (PSE) using n-butyl cyanoacrylate (NBCA).

Methods

Twenty consecutive patients (57.2?±?11.7 years) with hypersplenism underwent PSE. Intrasplenic branches were embolised using NBCA via a 2.1-French microcatheter aiming at infarction of 50 to 80 % of total splenic volume. Immediately after PSE, signal intensities (SI) of embolised and non-embolised splenic parenchyma were measured on DWI. Semi-automated volumetry (SAV) on DWI was compared with conventional manual volumetry (MV) on contrast-enhanced CT 1 week after PSE. Platelet counts were recorded before and after PSE.

Results

The SI on DWI in the embolised parenchyma decreased significantly (P?<?0.01) to 24.7?±?8.1 % as compared to non-embolised parenchyma. SAV and MV showed a strong correlation (r?=?0.913 before PSE, r?=?0.935 after PSE, P?<?0.01) and significant (P?<?0.01) reduction of normal splenic volume was demonstrated on both SAV (71.9?±?12.4 %) and MV (73.6?±?9.3 %) after PSE. Based on the initial SAV, three patients (15 %) underwent additional branch embolisation to reach sufficient infarction volume. Platelet counts elevated significantly (522.8?±?209.1 %, P?<?0.01) by 2 weeks after PSE. No serious complication was observed.

Conclusion

Immediate SI changes on DWI after PSE allowed semi-automated splenic volumetry on site.

Key Points

? Partial splenic embolisation (PSE) is an important interventional technique for hypersplenism ? Diffusion-weighted MR reveals an immediate decrease in signal in the embolised parenchyma ? Such signal reduction permits semi-automated splenic volumetry on site. ? This allows precise quantification of the amount of parenchyma infarcted, avoiding additional PSE.     

Blunt thoracic aortic injuries: CT characterisation and treatment outcomes of minor injury

Objectives

Computed tomography (CT)-defined anatomical differentiation of minor and major blunt traumatic aortic injuries (TAIs) was applied to determine injury grade and management/outcomes in minor TAIs, and if the presence of peri-aortic mediastinal haematoma (MH) correlated with TAI grade.

Methods

Admission chest CT of blunt TAI cases during 2005–2011 were reviewed by consensus and categorised as major or minor. Minor was defined as pseudoaneurysm <10 % normal aortic lumen, intimal flap or contour abnormality. Presence/absence of MH was determined. Clinical management/outcome was ascertained from medical records.

Results

Of 115 TAIs, 42 were minor (33 with MH, 9 without). Among the 73 with major TAI, 3 had no MH. Twenty-six (62 %) minor TAI patients were managed medically, 12 (29 %) percutaneous stent-grafts, 2 (5 %) died of non-aortic causes and 2 (5 %) underwent surgery. Of 26 managed without intervention, none developed complications from TAI at last clinical or CT follow-up. The relationship between presence/absence of peri-aortic MH and grade of TAI was statistically significant.

Conclusions

More than a third of multi-detector (MD) CT-diagnosed TAIs were minor. Minor TAIs treated medically were stable at last follow-up, suggesting this is a reasonable initial management approach. Absence of MH cannot be relied upon to exclude minor TAI, indicating the need for careful direct aortic inspection.

Key Points

? MDCT can differentiate minor from major blunt traumatic aortic injuries. ? About one-third of MDCT-diagnosed blunt traumatic aortic injuries are minor. ? Minor aortic injuries are not necessarily accompanied by mediastinal haemorrhage. ? MDCT diagnosis of minor aortic injury supports application of medical management.     

Transcatheter embolisation of iatrogenic renal vascular injuries

Purpose

The aim of our study was to review our experience and long-term follow-up in the treatment of iatrogenic renal vascular injuries using transcatheter embolisation.

Materials and methods

Our retrospective analysis of cases collected in two interventional centres consists of a total of 21 patients who underwent renal arterial embolisation (RAE) for iatrogenic arterial kidney bleeding. Biopsy (n = 4), percutaneous nephrolithotomy (n = 4), nephron-sparing surgery (n = 4), guidewire-induced arterial perforation during coronary angiography or renal stenting (n = 3), percutaneous nephrostomy (n = 3), renal endopyelotomy/pyeloplasty (n = 2) and surgical nephrectomy were the iatrogenic causes. Seven patients presented with haemodynamic instability requiring blood transfusion (33.3 %), the remaining were haemodynamically stable (66.7 %). Diagnostic renal angiography revealed 9 actively bleeding vessels, 6 pseudoaneurysms, 4 arteriovenous fistulas and 1 arterio-calyceal fistula. In one patient selective renal arteriography was negative probably because the bleeding observed at CT angiography was self-limited. Twenty-one embolisation procedures were performed in 20 patients; one patient required a second embolisation 3 h after the first one. Embolisation was performed with microcoils, polyvinyl alcohol particles, embospheres, spongostan emulsion and vascular plug.

Results

The technical success rate was 100 %. The overall clinical success rate was 95 %. Apart from a patient who died due to disseminated intravascular coagulation, no major complications requiring intensive care treatment were encountered during or after the procedures. No patient required emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared after RAE.

Conclusions

Percutaneous treatment can be proposed as a first-line treatment in iatrogenic renal arterial injuries, resulting in a safe and effective procedure.     

Clinical outcome of active extravasation in splenic trauma

The purpose of this study was to determine the necessity for splenectomy in patients with active extravasation on contrast enhanced CT secondary to splenic trauma. We reviewed cases of splenic injury and classified these according to the American Association for the Surgery of Trauma (AAST) grading scale. The presence of active extravasation and associated injuries was assessed. Chart review was then performed to determine age, sex, mechanism of injury, indications for splenectomy, and clinical outcome. Of 82 cases evaluated, 12 grade I, 15 grade II, 30 grade III, 17 grade IV, and 8 grade V injuries were present. Eighteen patients were actively extravasating. Of extravasating patients, 13 eventually underwent open splenectomy or embolization and five (27.8%) were managed expectantly with success. Of grade IV injuries, 9/17 showed active extravasation, of which six underwent splenectomy. Of grade V injuries, 3/8 showed active extravasation, and all three underwent intervention. Splenectomy may not be necessary in appropriately chosen patients with active extravasation from the spleen in blunt abdominal trauma.     

Role of interventional radiology in treating obstetric haemorrhages

Purpose

The aim of this study was to evaluate the efficacy and the safety of selective uterine artery embolisation in patients with a high risk of haemorrhage due to obstetric issues.

Materials and methods

We retrospectively reviewed the angiographic examinations of 63 patients (average age ± SD, 32.6 years ± 4.8), affected by an obstetric disease with a high risk of haemorrhage (22 cases of ectopic pregnancy, 41 of postpartum haemorrhage) and treated with an interventional approach. In particular, we considered the rate of second treatment with interventional technique or conservative or radical surgery, the incidence of postprocedural complications, and the absorbed radiation dose.

Results

Immediate technical success, defined as the cessation of active bleeding, was achieved in all cases. Uterine artery embolisation was able alone to control the haemorrhage in 95.24 % of cases. Three patients required a second treatment to achieve haemostasis. No peri- or postprocedural complications were observed. At the 12-month follow-up after embolisation, 22/49 conservatively treated patients were found to be pregnant and successfully completed their pregnancy.

Conclusions

Selective uterine artery embolisation allows for safe and complete control of haemorrhage in patients with obstetric disease, with a very low incidence of complications and preservation of fertility.     

Immediate and long-term outcomes of bronchial and non-bronchial systemic artery embolisation for the management of haemoptysis

Objective

To evaluate the immediate and long-term results of arterial embolisation in the management of haemoptysis and to identify factors influencing outcome.

Methods

A retrospective analysis was carried out of the medical records and angiograms of 50 patients who underwent transarterial embolisation for haemoptysis.

Results

The most frequent causes of haemoptysis included bronchiectasis (16%), active tuberculosis (12%) and aspergilloma (12%). A total of 126 bronchial and non-bronchial systemic arteries were embolised in 62 procedures. Immediate cessation of haemoptysis was achieved in 43 patients (86%). Haemoptysis was controlled in 36 patients (72%), recurred in 14 (28%) and 11 (22%) required repeat embolisation. The worst outcomes were observed in patients with aspergilloma: all six suffered recurrent bleeding and three (50%) died from massive haemoptysis. Aspergilloma was also associated with an increased risk of haemoptysis recurrence (p?<?0.05). A good clinical outcome was achieved in those with active tuberculosis and malignancy. Complication rates were low and included transient chest pain, false aneurysm and one case of lower limb weakness.

Conclusion

Bronchial artery embolisation (BAE) is an effective and safe procedure for haemoptysis control in most cases. However, high recurrence and mortality rates are associated with aspergilloma. Early intervention with repeat embolisation is recommended in these patients and elective surgery should be considered.     

Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease

Purpose

To evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases.

Methods

Between Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue.

Results

Percutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients.

Conclusion

Percutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.     

Preoperative liquid embolization of cerebeller hemangioblastomas using N-butyl cyanoacrylate

Introduction

We aim to present and discuss clinical outcomes of preoperative liquid embolization of hemangioblastomas (HB) using N-butyl cyanoacrylate (NBCA).

Methods

From 1999 through 2010, 19 patients presenting with symptoms of vertigo and/or headaches were diagnosed with HB based on preoperative magnetic resonance imaging and cerebral angiographic findings at our institution. Preoperative embolization with NBCA was performed on tumors in 10 of 21 operations for 19 patients. For each of these patients, the lesion was pathologically confirmed as HB.

Results

Embolization had a favorable outcome in all patients. No permanent neurological complications were observed after preoperative embolization using NBCA. However, thalamic infarction and minor hemorrhage were observed in two patients with cerebellar HB.

Conclusion

The authors recommend NBCA as an embolization material for large cerebellar HB.     

Palliative embolisation for advanced bone sarcomas

Purpose

Managing patients with advanced bone sarcomas — namely, recurrent, unresectable and metastatic — is mostly aimed at palliation. The role of embolisation for pain relief for these patients has not been previously reported. We therefore performed this study to emphasise the palliative role of embolisation for pain relief of advanced bone sarcoma patients.

Materials and methods

We retrospectively studied 43 patients with advanced bone sarcomas treated with palliative embolisation with N-2-butyl-cyanoacrylate from 2004 to 2011. All patients had primary treatments including chemotherapy, radiation therapy, radiofrequency thermal ablation, and/or surgery for their advanced sarcomas and were referred for embolisation as end-stage treatment for continuous severe local pain. The effect of embolisation was evaluated with a pain score scale and analgesic use. Mean follow-up was 7 (range, 1–19) months); all patients were dead at the last follow-up.

Results

In all patients, angiography showed increased pathological vascularisation of the sarcomas; three to six feeding vessels were embolised in each procedure. Almost complete pain relief and >50% reduction in analgesic use was experienced by 36 patients with highly hypervascular sarcomas and sarcomas in the pelvis and shoulder girdle. Moderate pain relief and 50% reduction in analgesic use was experienced by seven patients with spinal and sacral lesions. Within the available follow-up, no patient had recurrent pain with the same intensity as before embolisation. All patients experienced ischaemic pain at the site of embolisation that resolved completely with analgesics. Six patients with advanced pelvic bone sarcomas experienced paraesthesias at the distribution of the sciatic nerve that resolved completely with methylprednisolone.

Conclusions

Embolisation is a safe and effective local palliative treatment for patients with advanced sarcomas, providing optimum pain relief with the least discomfort and the possibility of minor complications only.     

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study

Purpose

To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma.

Materials and methods

This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student’s t, chi-squared, and Cohen’s kappa tests.

Results

Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k =?0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p <?0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30 h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p <?0.05).

Conclusion

Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.

     

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

Objective

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

Methods

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

Results

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

Conclusion

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Key Points

? Pelvic artery embolisation (PAE) is an important therapeutic option for postpartum haemorrhage. ? It seems safe and effective for PPH with placenta accreta (PA). ? PAE preserves the uterus and does not impair subsequent menstruation. ? PAE has few major complications.     

Superselective arterial embolisation with a liquid polyvinyl alcohol copolymer in patients with acute gastrointestinal haemorrhage

Objectives

To evaluate the results of emergency embolisation in acute arterial bleeding of the gastrointestinal tract with a liquid polyvinyl alcohol copolymer from two centres.

Methods

We retrospectively analysed 16 cases (15 patients) of acute arterial bleeding of the gastrointestinal tract where emergency embolotherapy was performed by using the copolymer when acute haemorrhage was not treatable with endoscopic techniques alone. Cause of haemorrhage and technical and clinical success were documented.

Results

Arterial embolotherapy was successful in all 16 cases. The technical success rate was 100%. The cause of bleeding was pancreatitis in four, graft-versus-host disease (GVHD) of the colon in three, malignancy in three, angiodysplasia in two, ulcer in two and panarteritis nodosa and trauma in one each. There were no procedure-related complications. No bowel necrosis occurred because of embolisation. In 13 cases, the patients were discharged in good condition (81%); the three patients with GVHD died because of the underlying disease.

Conclusions

The copolymer seems to have great potential in embolotherapy of acute arterial gastrointestinal bleeding. In our series none of the patients had rebleeding at the site of embolisation and no clinically obvious bowel necrosis occurred.     

Embolisation of bone metastases from renal cancer

Purpose

This study was done to evaluate embolisation for palliative and/or adjuvant treatment of bone metastases from renal cell carcinoma and discuss the clinical and imaging results.

Materials and methods

We retrospectively studied 107 patients with bone metastases from renal cell carcinoma treated from December 2002 to January 2011 with 163 embolisations using N-2-butyl cyanoacrylate (NBCA). Mean tumour diameter before embolisation was 8.8 cm and mean follow-up 4 years. Clinical and imaging effects of treatment were evaluated at follow-up examinations with a pain score scale, analgesic use, hypoattenuating areas, tumour size and ossification.

Results

A clinical response was achieved in 157 (96%) and no response in six embolisations of sacroiliac metastases. Mean duration of clinical response was 10 (range 1–12) months. Hypoattenuating areas resembling tumour necrosis were observed in all patients. Variable ossification appeared in 41 patients. Mean maximal tumour diameter after embolisation was 4.0 cm. One patient had intraprocedural tear of the left L3 artery and iliopsoas haemorrhage and was treated with occlusion of the bleeding vessel with NBCA. All patients had variable ischaemic pain that recovered completely within 2–4 days. Postembolisation syndrome was diagnosed after 15 embolisations (9.2%). Transient paraesthesias in the lower extremities were observed after 25 embolisations (25%) of pelvis and sacrum metastatic lesions.

Conclusions

Embolisation with NBCA is recommended as primary or palliative treatment of bone metastases from renal cell carcinoma. Strict adherence to the principles of transcatheter embolisation is important to avoid complications.     

Criteria for the selective use of chest computed tomography in blunt trauma patients

Purpose

The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

Methods

This observational study prospectively included consecutive patients (≥16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

Results

We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age ≥55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <?3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with ≥1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

Conclusion

Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.     

Endovascular Treatment of Active Splenic Bleeding After Colonoscopy: A Systematic Review of the Literature

Purpose

Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures.

Methods

We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared.

Results

All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8 %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74 %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44 %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST.

Conclusion

We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.     

Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO)

Objectives

To evaluate the safety and efficacy of a new liquid embolic agent in brain arteriovenous malformation (bAVMs) embolisation.

Methods

A prospective, multicentre series was conducted at 11 interventional centres in Europe to evaluate embolisation of bAVMs with the new liquid embolic agent. Technical conditions, complications, clinical outcome and anatomical results were independently analysed.

Results

From December 2005 to December 2008, 117 patients (72 male; 45 female, aged 18–75 years) were included. Clinical presentation was mostly haemorrhage (34.2 %) and seizures (28.2 %). Most AVMs were located in the brain hemispheres (85.5 %). AVMs were <3 cm in 52.1 % of patients and ≥3 cm in 47.9 %. Morbidity was observed in 6/117 patients (5.1 %), related to haemorrhagic events in 2 cases and non-haemorrhagic complications in 4 cases. Five patients (4.3 %) died in relation to the treatment (bleeding in 4 patients and extensive venous thrombosis in 1). Complete occlusion of the AVM by embolisation alone was obtained in 23.5 % of patients. Complementary treatment was performed in 82.3 % of patients with partial AVM occlusion, mostly radiosurgery.

Conclusions

In this prospective, multicentre, European, observational series, the new liquid embolic agent proved to be suitable for BAVM embolisation, with acceptable morbidity and mortality and good efficacy.

Key Points

? Numerous interventional techniques have been used to embolise brain arteriovenous malformations (AVMs). ? This prospective multicentre study demonstrates the suitability of a liquid embolic agent. ? The safety of treatment using Onyx is acceptable. ? Such embolisation leads to complete AVM occlusion in 23.5 % of patients.