CT diagnosis of cardiac and pericardial injuries

The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.     

Massive abdominal wall hemorrhage from injury to the inferior epigastric artery: a retrospective review

PURPOSE: To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients. MATERIALS AND METHODS: A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record. RESULTS: Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications. CONCLUSIONS: IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.     

Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma

OBJECTIVE: The aim of this study was to determine the imaging findings and the prevalence of active hemorrhage on contrast-enhanced multidetector CT in patients with blunt abdominal trauma. MATERIALS AND METHODS: Contrast-enhanced multidetector CT images of 165 patients with blunt abdominal trauma were reviewed for the presence of extravasated contrast agent, a finding that represents active hemorrhage. The site and appearance of the hemorrhage were noted on multidetector CT images. These findings were compared with surgical and angiographic results or with clinical follow-up. RESULTS: On multidetector CT images, active hemorrhage was detected in 22 (13%) of 165 patients with a total of 24 bleeding sites (14 intraperitoneal sites and 10 extraperitoneal sites). Active hemorrhage was visible most frequently as a jet of extravasated contrast agent (10/24 bleeding sites [42%]). Diffuse or focal extravasation was less frequently seen (nine [37%] and five [21%] bleeding sites, respectively). CT attenuation values measured in the aorta (mean, 199 H) were significantly higher than those measured in extravasated contrast material (mean, 155 H) (p < 0.001). Sixteen (73%) of 22 patients with active bleeding on multidetector CT images underwent immediate surgical or angiographic intervention. One patient received angiographic therapy 10 hr after undergoing multidetector CT, and five patients died between 1 and 3 hr after multidetector CT examination. CONCLUSION: Active hemorrhage in patients after blunt abdominal trauma is most frequently visible as a jet of extravasated contrast agent on multidetector CT. When extravasation is detected, immediate surgical or angiographic therapy is required.     

Traumatic injury of the internal mammary artery: embolization versus surgical and nonoperative management

The purpose of the study was to compare the outcomes, complications, and effectiveness of embolization versus surgical and nonoperative management in patients with injury to the internal mammary artery. Eighteen cases of angiographically proven internal mammary artery injury were identified by a retrospective review. Patient age range was 17–71 years (mean 34 years). Causes of vascular injury were equally divided (9 each) between penetrating and blunt trauma. Type of trauma, associated injury, plain film findings, treatment complications (immediate and delayed), and overall outcomes were assessed. Results of embolization versus surgical and nonoperative management were compared. Angiographic findings included occlusion, active hemorrhage, and pseudoaneurysm of the internal mammary artery. Of the 18 patients studied, 12 underwent embolization; 2 underwent surgical ligation, and 4 were managed by nonoperative observation. No patient died as a direct result of vascular injury; one died of renal failure unrelated to chest trauma and one other died of myocardial contusion. One patient who underwent embolization had delayed bleeding and two patients with conservative management developed a delayed hemothorax. This small series demonstrates that embolotherapy offers an effective, efficient, and safe alternative to conventional surgical management of internal mammary artery injuries. Electronic Publication     

Percutaneous management of hemorrhages in pelvic fractures

PURPOSE: To report our experience in the control of haemorrhage with the transcatheter embolisation technique. MATERIALS AND METHODS: Between 1999-2001, we treated 56 patients with important pelvic trauma. Forty-two were victims of car accidents and 14 of falls from great altitudes. Twenty presented acute symptoms due to blunt pelvic trauma, with massive bleeding, not treatable by drugs and blood transfusion. Diagnosis of pelvic haemorrhage was made with CT. When high-flow haemorrhage was found, the patient was referred for angiography. Embolisation was achieved after a diagnostic arteriography, with bilateral transfemoral approach and selective catheterisation of the internal iliac arteries. RESULTS: Technical success was achieved in 100% of cases: all the haemorragic sites were found and embolised. In only one patient with severe shock was it impossible to locate the site of contrast material extravasation on the first day; the patient was successfully treated on the second day with improvement of the clinical conditions. The obturator artery was involved in five cases, the gluteal artery in eleven. In eighteen patients, use of an angiographic catheter was sufficient to treat the haemorragic sites. Percutaneous control of the haemorrhage was obtained by using Gelfoam, Ivalon and coils. CONCLUSIONS: Percutaneous haemorrhage control is safe and effective, and not as costly or dangerous as the surgical option. We regard it as the treatment of choice in multiple trauma patients with important and high-flow pelvic haemorrhage.     

Active extravasation of arterial contrast agent on post-traumatic abdominal computed tomography.

OBJECTIVE: To evaluate the use of emergent dynamic intravenous contrast-enhanced computed tomography (CT) in the diagnosis of active arterial extravasation in patients admitted to hospital after blunt abdominal trauma. METHODS: Four-hundred and ninety-eight consecutive emergent contrast-enhanced computed tomographic images of the abdomen and pelvis were retrospectively reviewed. The presence of and site(s) of active arterial extravasation were recorded. Two radiologists reviewed the images and compared the site(s) of extravasated arterial contrast agent with the site(s) of active hemorrhage established at angiography (n = 9) or surgery (n = 4). RESULTS: Twenty-eight patients' computed tomographic images were identified as showing signs of extravasation of contrast agent representing active arterial bleeding. A total of 49 sources of active arterial extravasation were identified, 37 in 19 patients. A pelvic source of active arterial hemorrhage was most frequent and was typically associated with unstable pelvic fractures (n = 18). Other sources of active arterial hemorrhage included the liver (n = 3), spleen (n = 2), retroperitoneum (n = 1), kidney (n = 1), mesentery (n = 1), abdominal wall (n = 3) and lumbar region (n = 1). Only 9 of 28 patients became sufficiently hemodynamically unstable to warrant angiography. All 9 patients had a pelvic source of arterial extravasation on contrast-enhanced CT, and 7 demonstrated active bleeding requiring embolization. The contrast-enhanced computed tomographic images correctly indicated the anatomical source of bleeding in all 7 cases. CONCLUSION: In patients who have experienced blunt abdominal trauma, attention should be paid to the computed tomographic features of active arterial hemorrhage. In our series, the pelvis was the most common source of active arterial bleeding, which was typically associated with unstable pelvic fractures.     

Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography

Purpose

We investigated the role of multidetector-row computed tomography (MDCT) in identifying active bleeding and its source in polytrauma patients with pelvic vascular injuries with or without associated fractures of the pelvis.

Materials and methods

From January 2003 to December 2007, 28 patients (19 men and nine women, age range 16–80 years) with acute symptoms from blunt pelvic trauma and a drop in haematocrit underwent MDCT and angiography. Conventional radiography of the pelvis was performed in all patients at the time of admission to the emergency department. MDCT was performed with a four-row unit in 15 patients and a 16-row unit in the remaining 13 patients. The study included whole-body CT to identify craniocerebral, vertebral, thoracic, abdominal and pelvic injuries. CT was performed before and after rapid infusion (4–5 ml/s) of intravenous contrast material (120 ml) using a power injector. A triphasic contrast-enhanced study was performed in all patients. MDCT images were transferred to a workstation to assess pelvic fracture, site of haematoma and active extravasation of contrast material, visibility of possible vascular injuries and associated traumatic lesions. At angiography, an abdominal and pelvic aortogram was obtained in all cases before selective catheterisation of the internal iliac arteries and superselective catheterisation of their branches for embolisation purposes. Results related to identifying the source of bleeding at MDCT were compared with sites of bleeding or vascular injury identified by selective pelvic angiography. The sensitivity and positive predictive value (PPV) of MDCT were determined.

Results

MDCT allowed us to identify pelvic bleeding in 21/28 patients (75%), with most cases being detected in the delayed contrast-enhanced phase (13/21 cases, 61.9%). Injured arteries were identified on MDCT in 12/21 cases (57%): the obturator artery (n=9), internal iliac artery (n=6), internal pudendal artery (n=6) and superior gluteal artery (n=5) were most frequently injured. In 8/21 patients (28.6%), more than one artery was injured. Among the 12 patients in whom MDCT showed the presence of pelvic haemorrhage, there was agreement between MDCT and angiography in ten cases. Angiography confirmed the site of bleeding detected on MDCT and identified a second arterial haemorrhage in one patient. There was no agreement between MDCT and angiography in the last patient. MDCT showed a sensitivity of 42.85% and a PPV of 100% in identifying the injured arteries.

Conclusions

Arterial haemorrhage is one of the most serious problems associated with pelvic fracture, and it remains the leading cause of death attributable to such fractures. MDCT provides diagnostic information regarding the presence of small pelvic fractures and, thanks to the contrast-enhanced angiographic technique, it is capable of identifying pelvic bleeding, with the demonstration in some cases of it source. The presence of contrast material extravasation is an indicator of injury to a specific artery passing through the region of the pelvis where the extravasation is noted on MDCT. Urgent angiography and subsequent transcatheter embolisation are the most effective methods for controlling ongoing arterial bleeding in pelvic injuries.     

The diagnostic impact of computed tomography in blunt abdominal trauma

Sixty patients with blunt abdominal trauma were investigated by computed tomography, 21 within 48 h of injury, 39 within days and weeks. Organ laceration of the spleen, liver, pancreas and kidney and haematoma formation were comprehensively demonstrated and post-operative complications readily identified. Computed tomography is currently the radiological method of choice to evaluate injuries to abdominal organs.     

Acute myocardial infarction due to left anterior descending coronary artery dissection after blunt chest trauma

Cardiac complications of chest trauma range from arrhythmias to valvular avulsions to myocardial contusion, rupture, and rarely myocardial infarction. We describe a case of a young patient with blunt chest trauma after a motor vehicle accident in whom the diagnosis of myocardial infarction was established a week later because no electrocardiogram or cardiac biomarkers were obtained on presentation. Retrospective review of contrast-enhanced computed tomography (CT) of the chest done on presentation demonstrated a perfusion defect in the distribution of the left anterior descending artery (LAD). Subsequent coronary angiography demonstrated dissection in the proximal LAD. Our case illustrates the importance of electrocardiography and contrast-enhanced chest CT in initial evaluation of patients with blunt chest trauma and suspected injury to the coronary arteries.     

CT diagnosis of splenic infarction in blunt trauma: imaging features, clinical significance and complications

AIM: The object of this study is to describe the appearance, complications, and outcome of segmental splenic infarctions occurring after blunt trauma using computed tomography (CT). MATERIALS AND METHODS: Thirteen blunt trauma patients were identified with splenic infarction on contrast-enhanced CT. CT images were retrospectively reviewed and the percentage of infarcted splenic tissue and presence of splenic injury separate from the site of infarction were identified. Splenic angiograms were reviewed and follow-up CT images were assessed for interval change in the appearance of the infarcts. RESULTS: The mean age of patients was 32 years and the most common mechanism of injury was road traffic accident. The majority (54%) had 25-50% infarction of the spleen. Splenic angiograms were performed in nine patients and seven demonstrated wedge-shaped regions of decreased perfusion corresponding to the infarction seen on CT with no need for intervention. Eleven patients underwent a follow-up CT that demonstrated the following: no significant change in six, near-complete resolution in two, delayed appearance of infarction in one, abscess formation in one, and delayed splenic rupture in one. CONCLUSION: Segmental splenic infarction is a rare manifestation of blunt splenic trauma. The diagnosis is readily made using contrast-enhanced CT. The majority will decrease in size on follow-up CT and resolve without clinical sequelae. Resolution of infarction is also seen and these cases are best described as temporary perfusion defects. Splenic abscess or delayed rupture are uncommon complications that may necessitate angiographic or surgical intervention.     

The acute reversal sign: comparison of medical and non-accidental injury patients.

OBJECTIVES: (1) To compare the intracranial computed tomography (CT) appearances of patients admitted with various causes of hypoxic ischaemic encephalopathy. Children with known documented accidental trauma were excluded. (2) To compare our results with those in the published literature. MATERIALS AND METHODS: Seventy-three patients aged between 1 day and 15 years were admitted with clinical features of brain injury and underwent cranial CT. A retrospective review of their medical records and radiology was undertaken. Clinical and radiological data were collected. RESULTS: On the basis of the combination of the presenting clinical history, progress, outcome, long term follow up and radiology, two groups of patients were identified. Forty-seven children had been the victims of non-accidental injury (NAI). No child in this group had any associated medical condition or any other medical cause for brain injury. All 47 children demonstrated hypoxic ischaemic encephalopathy and had CT signs of cerebral oedema and 'Reversal Sign'. Intracranial haemorrhage was a highly associated feature. Subdural blood was demonstrated in all 47, acute interhemispheric fissure subdural in 42, intracerebral blood in 16 and intraventricular blood in nine. The remaining 26 children were found to have an identifiable 'medical' cause for brain injury. Acute reversal was demonstrated in 21 of this group. Intracranial haemorrhage was uncommon, found in only five and all five had an underlying predisposition to bleeding. No patient in this group demonstrated subdural blood. CONCLUSION: Non-accidental injury is strongly associated with the finding on CT of intracranial blood, particularly subdural haematoma and interhemispheric fissure bleeding in the presence of hypoxic ischaemic brain injury. The outlook is extremely poor whatever the underlying cause for hypoxic ischaemic brain injury.     

Computed tomography in the diagnosis of traumatic rupture of the thoracic aorta

Over a 26-month period, 25 patients admitted to the Trauma Unit at UCSD Medical Center following blunt trauma were investigated for suspected traumatic rupture of the thoracic aorta by computed tomography (CT) of the chest. A retrospective review of these patients was performed. Twenty-one (84%) also had CT of other body areas, most commonly the head or abdomen. Nine of the 25 patients subsequently had aortography; in 15 patients the CT findings were felt at the time to exclude rupture, and one patient was not investigated further because of severe head injuries. In general, if CT failed to show a mediastinal haematoma, aortography was not performed. However, five patients with CT evidence of a haematoma, including two with vertebral fractures, were not investigated by aortography. Two of the 25 patients (8%) had angiographically proven aortic ruptures; in both CT had shown not only a haematoma but also an abnormal outline of the aorta on contrast-enhanced scans. The haematoma was large in one patient and small in the other. Although 10 of the 25 patients had unenhanced scans, no case of aortic rupture is known to have been missed. During the same study period, 47 patients were investigated for suspected aortic rupture solely by aortography. Four patients (8% of this group) had aortic rupture, and two had subclavian or innominate artery ruptures. Only a minority (approximately one-quarter) also had CT of the head or abdomen. The role of CT in the diagnosis of traumatic rupture of the aorta is critically assessed in the light of our experience and a review of the literature.     

Treatment of acute thoracic aortic injury with commercially available abdominal aortic stent-grafts

Traumatic rupture of the thoracic aorta is a common cause of death after vehicle collisions. Associated injuries are common, and patients with lung injury, cardiac contusion, abdominal bleeding, and head injury comprise a group at high risk for conventional surgical or medical therapy. In this particular population, existing commercially available stent-grafts may provide a life-saving repair option. The Ancure and AneuRx stent-grafts, designed for abdominal aortic aneurysm application, were successfully placed in three patients. Accommodation for the short length of the delivery device was achieved by retroperitoneal iliac artery access. All patients had follow-up computed tomography (CT) without evidence of endoleak and were doing well with respect to their chest trauma after 5-9 months of follow-up.     

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

Purpose Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8–16 months) follow-up. Conclusions This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.     

CT of blunt abdominal and pelvic vascular injury

Computed tomography (CT) has been shown to be increasingly useful in the evaluation of blunt trauma patients with suspected abdominopelvic vascular injuries. CT findings of abdominopelvic vascular insult may be broadly characterized as end-organ abnormalities or direct evidence of vascular injury. End-organ abnormalities implying an underlying vascular insult include identifying an area of relative hypoperfusion in solid organ injury. Direct evidence of a vascular injury includes identifying an irregular or thrombosed vessel or an area of active hemorrhage, among other findings. This review article aims to review and illustrate these findings of blunt abdominopelvic vascular trauma. Also, evolving lessons from our level I trauma center in the use of multiphasic imaging to further characterize sources of a vascular blush and the differentiation of arterial from venous sources of active hemorrhage are discussed.     

Internal mammary artery embolization for hepatic tumors

Purpose To prospectively identify patients with collateral internal mammary artery (IMA) supply to hepatic tumors, and to embolize the IMA as part of palliative hepatic artery embolization (HAE). Methods Over a 4-year period, 222 patients were enrolled in an HAE protocol for inoperable liver tumors. All underwent abdominal computed tomography (CT) prior to preembolization diagnostic hepatic arteriography. When anterior subcapsular hepatic tumor was seen on the CT scan, patients underwent IMA arteriography as well. All arteries supplying tumor were embolized. Results Six patients had anterior subcapsular lesions identified on CT. IMA catheterization revealed that these lesions drew blood supply directly or indirectly from one or both IMAs in all six patients. All IMAs were embolized. Conclusion When an hepatic tumor is identified in an anterior subcapsular location prior to HAE, the IMA should be examined and, if significant tumor supply is demonstrated, these branches should be embolized.     

CT在闭合性肝损伤诊断和治疗中的应用价值

目的　评价CT在闭合性肝外伤诊断和治疗中的应用价值。方法　回顾性分析 2 2例闭合性肝损伤患者的CT和临床资料 ,观察CT对闭合性肝损伤诊断的敏感性和特异性 ,并将肝损伤CT表现与手术、临床治疗结果进行对照。结果　 2 2例闭合性肝损伤者 ,CT明确诊断 2 1例 ,1例发现腹腔积液。CT诊断的特异性为 95 .5 % ( 2 1/2 2 )。CT分级 :I级 1例 ,II级 10例 ,III级 8例 ,IV级 2例。 8例行非手术治疗 (II级 3例 ,III级 5例 ) ,成功 7例 ,1例因迟发性肝破裂而非手术疗法失败。 1例复查CT发现肝上胆汁聚积 ,经穿刺引流治愈。 14例行剖腹探查术 ,4例术中发现肝脏仍有活动性出血。结论　CT扫描能明确肝损伤的诊断 ,界定损伤类型及严重程度 ,指导合理地选择手术或非手术疗法 ,并能监测康复过程中并发症的发生     

Traumatic mesenteric bleeding managed solely with transcatheter embolization

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated solely with transcatheter arterial embolization (TAE) of the right colic marginal artery. A 56-year-old woman presented with mesenteric bleeding after being involved in a car accident. Computed tomography (CT) showed a large mesenteric hematoma and hemoperitoneum with no associated major injuries to other organs. There was a pseudoaneurysm with extravasation inside the hematoma. TAE was attempted to control bleeding during the preparation for surgical laparotomy. A superior mesenteric angiogram revealed a right colic marginal artery pseudoaneurysm. After successful TAE with microcoils, the affected colon perfusion was preserved via collateral circulation from the ileocolic artery. No ischemic gastrointestinal complications have occurred, and laparotomy has not been necessary during the 6 months after TAE. In isolated mesenteric injury cases, TAE may be a reasonable alternative to emergency laparotomy.     

Imaging of blunt hepatic trauma

This article focuses on the clinical role of high resolution computed tomography (CT) in the initial diagnosis and management of hemodynamically stable patients with blunt hepatic trauma. The increased utilization and diagnostic confidence afforded by CT has dramatically changed the surgical approach and need for laparatomy. The most important development has been the growing realization by many trauma surgeons that nonoperative management is often successful in stable patients who have CT evidence of isolated blunt hepatic trauma.     

Computed tomography of spontaneous intracranial haemorrhage due to haemostatic disorders in children

Intracranial haemorrhage is a serious problem in haemostatic disorders in children. Intracranial bleeding is sometimes more marked than suspected clinically. Computed tomography (CT) permits accurate, sensitive diagnosis of intracranial haemorrhage. We report 13 patients; 3 patients with hypoprothrombinaemia, 4 patients with thrombocytopenia or platelet dysfunction and 6 with haemophilia A, B or Von-Willebrand's disease. One patient with hypoprothrombinaemia had a subarachnoid hemorrhage (SAH), one a subdural haematoma (SDH) and the third a combination of SAH, SDH and intracerebral haematoma (ICH). One patient with thrombocytopenia or platelet dysfunction had a SDH, while the others had ICH. In the six patients with haemophilia A, B or Von-Willebrand's disease, there were four examples of ICH, five of SAH and six of SDH. A neurosurgical procedure was performed in only one patient. Three children died of serious intracranial complications with uncal herniation.