Emergent transcatheter arterial embolization in hemodynamically unstable patients with blunt splenic injury

RATIONALE AND OBJECTIVES: Splenic preservation is currently the trend for treatment of patients with splenic trauma to avoid complications of splenectomy. This study aimed to evaluate the feasibility of emergent transcatheter arterial embolization (TAE) for hemodynamically unstable patients with blunt splenic injury. MATERIALS AND METHODS: In a period of 2 years, 65 patients of blunt splenic trauma were studied. Patients with initial systolic blood pressure < 90 mmHg and showed initial response including rapid response and transient response to the emergent fluid resuscitation were included. Angiography and TAE was undertaken if contrast medium extravasation or pseudoaneurysm formation was noted in the computed tomography (CT) images, according to the criteria of American Association for the Surgery of Trauma. All patients who underwent TAE were admitted for observation of the possibility of delayed rupture. RESULTS: Thirteen hemodynamically unstable patients who were responsive to initial fluid resuscitation received angiography due to abnormal CT findings including contrast agent extravasation in 12 patients, 2 patients with arteriovenous fistula, and 8 patients with pseudoaneurysm formation. TAE was successfully performed in all of these 13 patients, including 2 patients with associated left renal injuries and 1 patient associated with bilateral internal mammary arteries injuries, without complications. CONCLUSIONS: TAE is a safe and effective procedure for treating blunt splenic injury even in hemodynamically unstable patients who responded to initial fluid resuscitation.     

Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy

PURPOSE: To determine if contrast material-enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization. MATERIALS AND METHODS: During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome. RESULTS: There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment. CONCLUSION: Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.     

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.     

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50–80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.     

Penetrating trauma to the abdominal aorta: CT demonstration of active bleeding

Contrast-enhanced helical computed tomography (CT) is the imaging study of choice for evaluating the abdomen in hemodynamically stable patients following blunt trauma. Surviving victims of penetrating trauma, in contrast, are often hemodynamically unstable and may require urgent celiotomy with or without diagnostic peritoneal lavage (DPL) or ultrasonography. Abdominal CT is not routinely performed in this patient population, but may be done if the patient with penetrating abdominal trauma is stable on admission or becomes so with resuscitation. CT in this context can address questions regarding the location and extent of injury and help decide appropriate management. We present a case of a stabilized blunt and penetrating trauma patient with negative DPL and active retroperitoneal aortic extravasation demonstrated by CT. To our knowledge, penetrating injury to the aorta with active bleeding has not been previously seen on CT.     

Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery

The management and outcome of blunt splenic injury diagnosed with computed tomography (CT) were studied in 44 consecutive patients who were hemodynamically stable or whose condition stabilized rapidly with resuscitation. Celiac and splenic arteriography was used in the triage of patients for nonsurgical treatment or for hemostasis. Patients without arterial extravasation of contrast material at arteriography were treated with bed rest only (group 1, n = 19); patients who had such extravasation were treated with bed rest after percutaneous transcatheter coil occlusion of the proximal splenic artery (group 2, n = 17). Abdominal exploration without angiography or embolotherapy was begun if the patient or attending surgeon did not agree with the treatment protocol (group 3, n = 8). Treatment with bed rest alone was successful in 18 patients. Clinical control of hemorrhage was accomplished in all patients in group 2 and one patient in group 1. Thus, exploratory laparotomy was avoided in 34 of 36 patients (94%) in whom nonoperative management was attempted; splenic salvage was achieved in 35 of 36 patients (97%).     

Changes in splenic size after abdominal trauma

After blunt abdominal trauma, the spleen often increases in volume on serial computed tomographic (CT) scans. To determine the frequency and significance of such enlargement, the authors performed a retrospective analysis of 44 hemodynamically stable patients who had experienced recent blunt abdominal trauma. The severity of splenic, hepatic, or other visceral injuries seen on each CT scan was numerically scored, and the amount of intraperitoneal fluid was assessed. Twenty-five patients (57%) had over 10% enlargement (average enlargement, 56%) on follow-up scans. Increasing volume did not correlate with clinical deterioration or the need for splenectomy. It did correlate modestly with the amount of blood in the peritoneum on CT scans, the number of units of blood transfused, and two clinical indexes of systemic trauma. Therefore, an enlarging spleen is not a CT indicator of a deteriorating clinical condition. This phenomenon is most likely due to marked adrenergic stimulation after injury and changing fluid volumes.     

Usefulness of transcatheter arterial embolization for intercostal arterial bleeding in a patient with burst fractures of the thoracic vertebrae

A 25-year-old man was injured in a motorcycle accident and hemodynamically unstable on admission. Right hemothorax and fractures of the ninth, tenth, and 11th thoracic vertebrae were confirmed in chest X-ray. Tube thoracostomy in the right chest was performed and about 400 mL of blood was drained. Contrast-enhanced CT showed a large hematoma around the vertebrae fractures and contrast extravasation from the intercostal arteries. As hemodynamics of the patient was very unstable, angiography was immediately performed with massive fluid resuscitation. Angiography showed contrast extravasation from the bilateral ninth, tenth, and 11th intercostal arteries. Transcatheter arterial embolization (TAE) was performed using Gelfoam particles. The contrast extravasation had disappeared in all arteries. The hemodynamics of the patient gradually stabilized after TAE. On hospital day 44, he was transferred to a hospital near his home for an operation on the thoracic vertebrae and rehabilitation. When the reliability, rapidity, and low invasiveness of TAE for arterial bleeding are taken into consideration, we believed that this patient’s life could be saved by TAE.     

Blunt splenic trauma: delayed-phase CT for differentiation of active hemorrhage from contained vascular injury in patients

PURPOSE: To retrospectively evaluate delayed-phase computed tomography (CT) in the differentiation of active splenic hemorrhage requiring emergent treatment from contained vascular injuries (pseudoaneurysms or arteriovenous fistulas) that can be treated electively or managed conservatively. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant retrospective study; the informed consent requirement was waived. Forty-seven patients with blunt splenic injury diagnosed at CT after blunt abdominal trauma were evaluated. Abdominal and pelvic dual-phase CT was performed; images were obtained 60-70 seconds and 5 minutes after contrast material injection. Scans were reviewed in consensus by two radiologists. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale. Patients with intrasplenic hyperattenuating foci on portal venous phase images were classified as having active splenic hemorrhage (group 1) or a contained vascular injury (group 2) on the basis of delayed-phase imaging findings. Findings suggestive of active hemorrhage included areas that remained hyperattenuating or increased in size on delayed-phase images. The clinical outcome of these patients was determined by reviewing their medical records. Relationships between several factors were tested with the Fisher exact test, including (a) the presence or absence of hyperattenuating foci and management and (b) the presence of contained vascular injury or active extravasation and management. RESULTS: Portal venous phase CT revealed a focal high-attenuation parenchymal contrast material collection in 19 patients: nine patients were classified as group 1 and 10 were classified as group 2. All patients in group 1 underwent emergent splenectomy, and all patients in group 2 were initially treated without surgery. Significant differences in management were noted on the basis of whether hyperattenuating foci were seen on portal venous phase images (P < .001) and whether hyperattenuating foci seen at portal venous phase imaging were further characterized as active splenic hemorrhage or a contained vascular injury at delayed-phase CT (P < .001). CONCLUSION: In blunt splenic injury, delayed-phase CT helps differentiate patients with active splenic hemorrhage from those with contained vascular injuries.     

Factors affecting clinical outcome of patients who undergo transcatheter arterial embolisation in splenic injury

Transcatheter arterial embolisation (TAE) offers a less invasive approach to traditional laparotomy for the management of bleeding in the context of blunt splenic injury. This is a retrospective review study to identify clinical factors associated with clinical outcome of the patients who underwent this procedure. Of 65 patients with splenic injuries at our institution, 26 patients underwent TAE for management of bleeding. The following factors were assessed to determine their relationship to procedure outcomes: American Association for the Surgery of Trauma (AAST) grade, complications, age, shock index, injury severity score (ISS), haemoglobin (Hb), haematocrit (Ht), prothrombin time (PT), activated partial thromboplastin time (APTT), systolic blood pressure (BP), BP changes during TAE, blood transfused before TAE and timing of TAE. The overall good clinical outcome rate was 73.1% (19/26). Of the factors we assessed, absence of concomitant pelvic injury, higher Hb, higher Ht, higher BP, greater increases in BP during TAE and a decreased requirement for blood transfusions before TAE were associated with good clinical outcome of the patients who underwent TAE in splenic injury.     

Helical computed tomography characteristics of splenic and hepatic trauma in children subjected to nonoperative treatment

The purpose of this study was to present the radiological characteristics of abdominal computed tomography (CT) in the follow-up of splenic and hepatic injury in children. Children (n=24) less than 13 years old who had suffered blunt abdominal trauma and were diagnosed with splenic and hepatic injury by CT scan prospectively were enlisted in the study. The CT was performed immediately after the injury was suspected, and 7 and 60 days after the trauma. The clinical course of the patients was observed (red blood transfusion requirement, associated abdominal injuries, and hospital stay). The splenic and hepatic injuries varied from grade II to grade IV of the American Association for the Surgery of Trauma. The CT showed a reduction in the volume of the injury 60 days after the trauma. In this article the radiological findings will be shown and correlated with the clinical course of the patients. This study shows that CT is advantageous for detecting and grading splenic and hepatic injuries. These injuries can be managed nonoperatively in hospitals where CT is available for the evaluation of pediatric patients. Electronic Publication     

The role of arterial embolization in blunt splenic injury

Purpose

The aim of study was to evaluate the results of our experience with transarterial embolization based on a modified algorithm in patients with splenic injury.

Materials and methods

We collected data of patients admitted to our hospital from January 2006 to August 2008 for blunt splenic injury. During this period, 46 patients were admitted for splenic trauma, of whom 17 were treated surgically, 15 conservatively and 14 with percutaneous embolisation (13 men, mean age 44.8, mean injury severity score 18.5, six with grade IV and eight with contrast blush). Patients in shock were referred for laparotomy and splenectomy, whereas those who were haemodynamically stable or responsive to fluid resuscitation were further evaluated with computed tomography (CT). In the presence of imaging evidence of splenic injury ranging from grade I to grade III (n=15) a conservative approach was adopted, whereas haemodynamically unstable patients with grade V injury (n=17) were treated with splenectomy. Embolisation was performed in 14 patients with grade IV injury or in the event of contrast extravasation, regardless of injury grade. In patients with diffuse organ damage, we embolised the main splenic artery, whereas in the case of localised injury, embolisation was selective.

Results

Proximal embolization was required in eight cases and distal coil embolization in six. In 13 cases, we placed magnetic-resonance-compatible coils 4?C6 mm in diameter; only one patient was treated with gel-foam injection. Immediate technical success was achieved in all cases. In 13/14 patients (92.9%), no periprocedural complications were observed, whereas the remaining patient underwent splenectomy within 24 h due to recurrent bleeding.

Conclusions

On the basis of our algorithm, it is possible to reach a quick decision on the most appropriate treatment for patients presenting with blunt abdominal trauma, and splenic artery embolization seems to offer a reliable option in those with high-grade splenic injury or active bleeding.     

Blunt abdominal trauma: should US be used to detect both free fluid and organ injuries?

PURPOSE: To evaluate abdominal ultrasonography (US) for indirect (with free fluid analysis only) and direct (with free fluid and parenchymal analysis) detection of organ injury in patients with blunt abdominal trauma, with findings at computed tomography (CT) and/or surgery as the standard of diagnosis. MATERIALS AND METHODS: Abdominal US was performed at hospital admission in consecutive patients with blunt abdominal trauma. The presence of free peritoneal fluid and organ injury were recorded and compared with results of abdominal CT in all hemodynamically stable patients. When US results were considered false-negative for free fluid or organ injury compared with CT results, repeat US was performed within 6 hours. Admission and second US results were compared with CT and/or surgical results to determine sensitivity, specificity, negative predictive value, and positive predictive value of US with regard to the presence of free intraperitoneal fluid and/or organ injury. RESULTS: Two hundred five hemodynamically stable patients underwent abdominal US and CT. CT revealed free fluid in 83 patients and organ injury in 99. Thirty-one (31%) of 99 patients with organ injury did not have free fluid at CT. Three (10%) of the 31 patients required surgery or angiographic embolization. The sensitivity of admission US was 93% (77 of 83 cases) for the diagnosis of free fluid, 41% (39 of 99) for directly demonstrating organ injury, and 72% (71 of 99) for suggesting organ injury by means of both free fluid and organ analysis. At second US, these sensitivities were 96% (80 of 83 cases), 55% (54 of 99) and 84% (83 of 99), respectively. CONCLUSION: US is highly sensitive for the detection of free intraperitoneal fluid but not sensitive for the identification of organ injuries. In hemodynamically stable patients, the value of US is mainly limited by the large percentage of organ injuries that are not associated with free fluid.     

Optimizing multidetector CT for visualization of splenic vascular injury. Validation by splenic arteriography in blunt abdominal trauma patients

Nonoperative management of blunt splenic injury is the treatment of choice in hemodynamically stable patients. Detection of vascular injury by multidetector CT (MDCT) is the most significant factor predicting the need for endovascular treatment. This study evaluated the timing of the appearance of vascular lesions during angiography. Images from 20 patients embolized for pseudoaneurysms (PSA) were evaluated. Angiograms were reviewed for phase and timing of PSA. Admission MDCT was reviewed for injury grade and PSA. Initial MDCT evaluation indicated grade III and IV splenic injuries in 9 and 11 patients, respectively. PSA was seen on MDCT in 14/20 (70%) patients. Time from opacification of the aorta to vascular injury was 1.32 s for arterial phase injuries compared with 2.05 s for postcapillary injuries (P = 0.097). Angiography demonstrated 15 vascular injuries during the arterial and 5 in the venous phase. Of injuries seen during arterial phase angiography, 10/15 (66%) were identified on MDCT. Of the five injuries that exhibited postcapillary-phase findings, 4/5 (80%) demonstrated PSA (P = 0.5). Vascular lesions are a better indicator of subsequent clinical deterioration than splenic injury grade. PSAs are more frequently seen in postcapillary vascular injuries than arterial phase lesions with the current timing of MDCT. In a subset of patients in whom splenic injury grades III and IV warrant angiography, PSAs are not initially demonstrated on MDCT. Therefore, alteration of MDCT timing parameters to better correlate with arterial phase angiography may improve initial diagnosis of vascular injury.     

Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?

OBJECTIVE: The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). MATERIALS AND METHODS: The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. RESULTS: Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. CONCLUSION: TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.     

CT detection of hepatic and splenic injuries: usefulness of liver window settings

OBJECTIVE. This study was designed to assess the usefulness of liver window settings when performing abdominal CT for the detection and characterization of hepatic and splenic injuries. SUBJECTS AND METHODS. We prospectively evaluated helical abdominal CT scans for hepatic and splenic injuries in 300 consecutive patients with blunt abdominal trauma over a 4-month period. There were 204 males and 96 females with a mean age of 34 years (age range, 1-87 years). For each patient, initial CT diagnosis of hepatic or splenic injury was made from images obtained with standard abdominal window settings. CT scans were then immediately reinterpreted using additional images obtained at narrow window width (liver windows). Changes in conspicuity and characterization of injury were recorded. All CT examinations were performed with helical 7-mm collimation at a pitch of 1.5 after oral ingestion of diluted barium and during bolus IV administration of 125 mL of ioversol at a rate of 2-3 mL/sec. RESULTS. We detected hepatic or splenic injuries in 34 patients (11.3%). There were 19 hepatic injuries and 18 splenic injuries. Three patients had injuries to both liver and spleen. Conspicuity of hepatic or splenic injuries was mildly increased (+1 H) on liver windows in 16 patients, whereas the injury was equally conspicuous on both liver window and standard window images in 19 cases. In no case did review of the liver windows result in a change in grade of injury or reveal an injury that was not seen on standard abdominal window images. The total increased cost for printing liver windows was $5748. CONCLUSION. Routine use of liver window settings for abdominal CT in trauma patients has little clinical usefulness and is not cost-effective.     

钝性肝脾肾损伤的CT平扫与增强扫描比较

目的:比较CT平扫与增强扫描对肝脾肾钝性损伤的诊断能力。方法:回顾性分析临床疑似钝性肝脾肾损伤,并经手术和临床观察证实的CT平扫和增强扫描的患者84例。结果:平扫确定的损伤:肝12例,脾25例,肾5例;平扫可疑损伤:肝22例,脾15例,肾5例。增强确定的损伤:肝32例,脾40例,肾12例(全肾梗塞1例,局限性梗塞3例);对比剂外溢(活动性出血)3例;无可疑损伤。平扫无异常而增强确定有损伤:肝10例,脾5例,肾2例。增强显示的损伤灶比平扫范围明显大、病灶多、界限清楚。结论:CT增强扫描显示肝脾肾损伤明显优于平扫,延时扫描有助于发现活动性出血,应常规增强扫描。     

CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings

PURPOSE: To determine the contrast material-enhanced computed tomographic (CT) criteria for selection of hemodynamically stable patients with blunt hepatic injury for angiographic evaluation. MATERIALS AND METHODS: Seventy-two patients with blunt liver injury underwent CT and hepatic angiography. Hepatic injuries were graded with CT-based classification. Scans were assessed for evidence of contrast extravasation and laceration or contusion extending into the hepatic vein(s), inferior vena cava, porta hepatis, or gallbladder fossa. Medical, angiographic, and surgical records were reviewed to determine angiographic findings, surgical indications and findings, and outcomes. RESULTS: Compared with hepatic angiography, CT was 65% (11 of 17 patients) sensitive and 85% (41 of 48 patients) specific for detection of arterial vascular injury. When CT severity grades 2 and 3 were analyzed, the sensitivity and specificity of CT were 100% (three of three patients) and 94% (34 of 36 patients), respectively (P <.001). Injury involving at least one major hepatic vein was found in 15 (88%) of 17 patients who required liver-related surgery and in 23 (42%) of 55 of the other patients (P <.01). CONCLUSION: CT-based criteria, including hepatic injury grade, signs of arterial vascular injury, and presence or absence of major hepatic venous involvement assists in selecting patients for hepatic angiography and those at increased risk of ongoing or delayed hepatic bleeding or other posttraumatic complications.     

Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma.

PURPOSE: To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma. MATERIALS AND METHODS: Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST). RESULTS: A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum. CONCLUSION: Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.     

Using contrast-enhanced helical CT to visualize arterial extravasation after blunt abdominal trauma: incidence and organ distribution.

OBJECTIVE: We evaluated the incidence and organ distribution of arterial extravasation identified using contrast-enhanced helical CT in patients who had sustained abdominal visceral injuries and pelvic fractures after blunt trauma. SUBJECTS AND METHODS: Five hundred sixty-five consecutive patients from four level I trauma centers who had CT scans showing abdominal visceral injuries or pelvic fractures were included in this series. The presence or absence of arterial extravasation, as well as the anatomic sites of arterial extravasation, was noted. We obtained clinical follow-up data, including surgical or angiographic findings. RESULTS: In our series, 104 (18.4%) of 565 patients had arterial extravasation. Of the 104 patients, 81 (77.9%) underwent surgery, embolization, or both. The combined rate of surgery or embolization in patients with arterial extravasation was statistically higher than expected at all four institutions (p <0.001). The spleen was the most common organ injured, occurring in 277 (49.0%) of 565 patients, and arterial extravasation occurred in 49 (17.7%) of 277 patients with splenic injury. Several other visceral injuries were associated with arterial extravasation, including hepatic, renal, adrenal, and mesenteric injuries. CONCLUSION: Based on the limited reports of arterial extravasation in the nonhelical CT literature, the percentage (18%) of clinically stable patients in our study with CT scans showing arterial extravasation was higher than anticipated. This finding likely reflects the improved diagnostic capability of helical CT. Although the spleen and liver were the organs most commonly associated with arterial extravasation, radiologists should be aware that arterial extravasation may be associated with several other visceral injuries.