Evaluation of the role of chest computed tomography in the management of trauma patients

The role of chest computed tomography (CT) in the management of trauma patients is evolving. The present study reviews the chest radiographic and chest CT findings in a group of trauma patients to determine the clinical impact of findings noted exclusively on chest CT.Fifty-five trauma patients examined with chest radiography and chest CT and whose clinical charts were available for review were retrospectively identified. There were 46 men and 9 women, with a mean age of 39 years. The presence (and size) of pneumothorax, hemothorax, pulmonary contusion, and fractures was tabulated for the chest radiographs and CT scans. The presence of mediastinal widening on chest radiographs and all mediastinal findings on CT were noted. The results of aortography, when applicable, were correlated. The clinical charts were reviewed to assess the impact of CT findings on patient management.Pneumothorax (P<0.05), hemothorax (P<0.05), pulmonary contusions, and fractures were noted more frequently on chest CT than on chest radiography. However, clinical management was affected in only three (5%) of these patients. Chest CT findings related to the mediastinum affected patient management in 13 (24%) patients. CT obviated the need for aortography in 7 of 10 patients with mediastinal widening on chest radiographs. Six other patients had aortography, four for mediastinal hematoma with a normal-appearing aorta on contrast medium-enhanced CT, and two for mediastinal hematoma and aortic injury on CT.Despite detection of significantly more pneumothoraces and hemothoraces on chest CT, clinical management was affected in only a small minority (5%) of cases. CT did prove useful in evaluating the mediastinum, obviating the need for aortography in 7 of 10 patients with a widened mediastinum on chest radiography and accurately diagnosing the presence and site of aortic injury in the two patients with that diagnosis.     

Pancreatic trauma: The role of computed tomography for guiding therapeutic approach

AIM: To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach.METHODS: CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as “pancreatic injury”, “pancreatic contusion”, “pancreatic laceration”, “peri-pancreatic fluid”, “pancreatic active bleeding”. All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid).RESULTS: One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases.CONCLUSION: CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.     

Potential of ultrasound in the pediatric chest

Ultrasound (US) of chest, even with inherent limitations of the US beam and air, has been useful in many pediatric chest conditions. It has extended its role and is now widely used by many subspecialists in medicine. This review article will cover techniques, indications, and applications of chest US in neonates, infants and children, including also different common as well as some rare and modern aspects and applications, such as pleural effusion, pneumothorax, pulmonary lesions, mediastinum, diaphragm, and chest wall. Other related imaging modalities are also briefly discussed.     

Multi-detector row computed tomography and blunt chest trauma

Blunt chest trauma is a significant source of morbidity and mortality in industrialized countries. The clinical presentation of trauma patients varies widely from one individual to another and ranges from minor reports of pain to shock. Knowledge of the mechanism of injury, the time of injury, estimates of motor vehicle accident velocity and deceleration, and evidence of associated injury to other systems are all salient features to provide for an adequate assessment of chest trauma. Multi-detector row computed tomography (MDCT) scanning and MDCT-angiography are being used more frequently in the diagnosis of patients with chest trauma. The high sensitivity of MDCT has increased the recognized spectrum of injuries. This new technology can be regarded as an extremely valuable adjunct to physical examination to recognize suspected and unsuspected blunt chest trauma.     

Multi-detector row computed tomography: imaging in acute aortic syndrome

Acute aortic syndromes (AAS) encompass a spectrum of emergencies. These include those non-traumatic disease entities of the aorta namely, penetrating atherosclerotic ulcer, intramural haematoma, dissection and aneurysm rupture. The various types of AAS cannot be reliably differentiated on clinical grounds alone. Acute thoracic aortic injury is usually included in this group even though clinical presentation is different, i.e., in the context of trauma, the imaging features are very similar. Differentiation of AAS from acute coronary syndrome (ACS) is important, however, it must be remembered that ACS may occur as a result of AAS. Now electrocardiogram (ECG)-gating technology is widely available, ECG-gated multi-detector row computed tomography (MDCT) is a powerful clinical tool in the acute emergency setting, which enables rapid and specific diagnosis of aortic pathology. ECG-gated MDCT significantly reduces motion artefact, avoids potential pitfalls in diagnosis and often provides diagnostic information about the coronary arteries. It should be used as a first-line imaging technique. This article examines the role of MDCT imaging and cardiac gating in the assessment of AAS and discusses the differentiation of this spectrum of aortic diseases with reference to the key imaging findings as obtained by experience in our institution.     

Computed tomography of the thorax in HIV disease

A wide variety of thoracic disorders can arise in patients infected with the human immunodeficiency virus (HIV), although recent developments in the therapeutic management of AIDS patients has resulted in a changing pattern of chest disease. The use of CT in the diagnosis and management of these thoracic manifestations is discussed along with the CT appearances of the various infectious and non-infectious complications of the acquired immune deficiency syndrome (AIDS) which are commonly encountered in clinical practice. Received: 28 September 1998; Revision received: 28 December 1998; Accepted: 26 January 1999     

Measurement of orbital volumes following trauma using low-dose computed tomography

We describe a simple CT technique for the assessment of enophthalmos and measurement of orbital volumes following trauma. The technique uses original diagnostic CT images, standard CT software and involves no additional radiation dose or scan time. The results of this technique in 66 patients with orbital trauma are presented. The incidence of post-traumatic enophthalmos was significantly raised in association with combined blow-out fractures of the floor and medial wall of the orbit and where orbital blow-out fractures occurred in conjunction with zygomatic injury. Patients without bony imjury had a traumatised orbit volume less than 1 cm³ greater than the non-traumatised side in all cases. Intra-observer reproducibility of the measurement of difference in volume between traumatised and non-traumatised orbit was ± 0.3 cm³ (1 SD). In patients with fracture, increase in orbital volume by more than 2 cm³ compared with the contralateral orbit was strongly associated with enophthalmos (sensitivity 100%, positive predictive value 69%). We conclude that routine volumetric assessment following orbital trauma provides a clinically useful, objective assessment of the risk of post-traumatic enophthalmos and that an increase in orbital volume greater than 2 cm³ is an indication for surgical repair.Correspondence to: R. W. Whitehouse     

Standardized reporting systems for computed tomography coronary angiography and calcium scoring: A real-world validation of CAD-RADS and CAC-DRS in patients with stable chest pain

ObjectivesTo assess the prognostic implications of standardized reporting systems for coronary computed tomography angiography (CCTA) and coronary artery calcium scores (CACS) in patients with stable chest pain.BackgroundThe Coronary Artery Disease Reporting And Data System (CAD-RADS) and Coronary Artery Calcium – Data and Reporting System (CAC-DRS) aim to improve communication of CACS and CCTA results, but its influence on prognostication is unknown.MethodsImages from 1769 patients who underwent CCTA as part of the Scottish Computed Tomography of the HEART (SCOT-HEART) multi-center randomized controlled trial were assessed. CACS were classified as CAC-DRS 0 to 3 based on Agatston scores. CCTA were classified as CAD-RADS 0 to 5 based on the most clinically relevant finding per patient. The primary outcome was the five-year events of fatal and non-fatal myocardial infarction.ResultsPatients had a mean age of 58 ± 10 years and 56% were male. CAC-DRS 0, 1, 2 and 3 occurred in 642 (36%), 510 (29%), 239 (14%) and 379 (21%) patients respectively. CAD-RADS 0, 1, 2, 3, 4A, 4B and 5 occurred in 622 (35%), 327 (18%), 211 (12%), 165 (9%), 221 (12%), 42 (2%) and 181 (10%) patients respectively. Patients classified as CAC-DRS 3 were at an increased risk of fatal or non-fatal myocardial infarction compared to CAC-DRS 0 patients (hazard ratio (HR) 9.41; 95% confidence interval (CI) 3.24, 27.31; p < 0.001). Patients with higher CAD-RADS categories were at an increased risk of fatal or non-fatal myocardial infarction, with patients classified as CAD-RADS 4B at the highest risk compared to CAD-RADS 0 patients (HR 19.14; 95% CI 4.28, 85.53; p < 0.001).ConclusionPatients with higher CAC-DRS and CAD-RADS scores were at increased risk of subsequent fatal and non-fatal myocardial infarction. This confirms that the classification provides additional prognostic discrimination for future coronary heart disease events.     

Mobile computed tomography in the trauma/critical care environment: Preliminary clinical experience

This study reviews the initial clinical experience using a portable computed tomographic (CT) scanner in the trauma resuscitation unit (TRU), intensive care units (ICUs), and operating rooms (ORs) of a large trauma center. Data were collected on the first 200 patients scanned within the trauma center (including 92 in the TRU, 92 in the ICUs, and 16 in the ORs) over the first 5 months of operation. Evaluation forms were completed by interpreting radiologists, CT technicians operating the system, and nurses/clinicians involved with patients being scanned. Information sought included subjective image quality, ease of use, software and hardware limitations, accessibility to and monitoring of patients during scanning, mobility, and perceived advantages or limitations compared to fixed CT. Radiation scatter also was measured to determine the safety of the scanner for portable use.CT scans of 224 body regions performed in 200 patients included: cranium (163), cervical spine (21), abdomen/pelvis (14), chest (12), face (8), thoracic/lumbar spine (4), and temporal bone (2). Image quality was judged subjectively as excellent (107), good (99), poor (6), or artifact degraded (12). Patient transfer to the scanner was judged to be easy (63) or fair/difficult (4). Patient accessibility and monitoring during scanning was assessed as easy (61) or fair/difficult (6). Access in the smaller TRU bays was more difficult than in the ICU or OR. Cited advantages over fixed CT included decreased risk and cost of transport, quicker assessment of cranial injury on admission, and more rapid postcraniotomy assessment. Limitations cited were relatively slow scan speed, slightly poorer image quality, and technical limits on scanning multiple body regions. Radiation scatter was 25% of the ALARA (as low as reasonably achievable) target for the scanner operator. Initial clinical experience with mobile CT in the TRU, ICU, and OR of a major trauma center shows application for focused admission scanning, assessment of critically ill ICU patients, and immediate postoperative assessment after craniotomy. The system has been incorporated easily into the trauma center and has been accepted enthusiastically. Further technical improvements are anticipated to extend the range of applications in this clinical setting.     

Diagnostic accuracy of computed tomography and ultrasound for the diagnosis of acute appendicitis: A systematic review and meta-analysis

IntroductionThe diagnosis of acute appendicitis remains challenging. This review determined the current diagnostic accuracy of CT and ultrasound for suspected acute appendicitis in adults.MethodsThis systematic review adhered to the PRISMA for diagnostic test accuracy guidelines. A systematic search was undertaken in appropriate databases. Screening of potential titles and abstracts, full-text retrieval, methodological quality assessment using QUADAS, and data extraction was performed. Meta-analyses were performed for relevant subgroups, and sensitivity analysis was completed to account for outliers. GRADE was utilized to assess the certainty of findings.Results31 studies evaluating CT, 10 evaluating US, and six evaluating both were included. Pooled sensitivity and specificity for CT was 0.972 [0.958, 0.981] and 0.956 [0.941, 0.967] respectively, and 0.821 [0.738, 0.882] and 0.859 [0.727, 0.933] for US, respectively. When analyzing subgroups based on the use of contrast enhancement, sensitivity and specificity was highest for CT with intravenous and oral contrast (0.992 [0.965, 0.998], 0.974 [0.936, 0.99]), compared to CT with intravenous contrast (0.955 [0.922, 0.974], 0.942 [0.916, 0.960]). Low-Dose CT produced comparable values (0.934 [0.885,0.963], 0.937 [0.911, 0.955]) relative to these subgroups and standard dose non-contrast CT (0.877 [0.774,0.937], 0.914 [0.827, 0.959]). US studies which excluded equivocal findings demonstrated significantly greater values than the remainder of US studies (p < 0.0001).ConclusionThe updated diagnostic test accuracies of CT, US and relevant subgroups should be implemented in light of factors such as dose, cost, and timing.Implications for practiceFor diagnosis of adult acute appendicitis:? CT with intravenous plus oral contrast enhancement yields statistically significantly greater diagnostic accuracy than CT with intravenous contrast alone.? Low-dose CT yields comparable sensitivity and specificity to standard-dose CT.? Ultrasound studies which exclude equivocal results may overinflate sensitivity and specificity.     

Prevalence and significance of thoracic pathology first detected on the lung base images of abdominal computed tomographic scans

The purpose of this study was to examine the prevalence and significance of pathology present on the lung base images of abdominal computed tomographic (ACT) scans, but not apparent on the chest radiographs, in two distinct patient populations. The reports of 853 consecutive ACT scans performed in patients at an urban Veterans Affairs hospital (DVAMC) (mean age = 69 years) and 1152 consecutive inpatient and emergency department ACT scans performed at an inner city level I trauma center (UMDNJ) (mean age = 39 years) were reviewed retrospectively. The original images of all ACT scans for which lung base abnormalities were reported were re-interpreted by two radiologists and compared with findings on chest radiographs taken within 48 hours. The degree of correlation between the two studies was analyzed, and the clinical impact of all findings incidentally imaged on ACT but not apparent on the chest radiograph were assessed. At UMDNJ, 51 ACT reports (4.4%) and at DVAMC, 95 reports (11.1%) described lung base pathology. The most common findings at both institutions were pleural effusions, with 23 and 42 depicted at UMDNJ and DVAMC, respectively. At UMDNJ, the remaining abnormalities included 7 pneumothoraces, 5 infiltrates, 1 bleeding artery, and 1 case of multiple nodules, whereas at DVAMC, the next most frequent lower thoracic pathology findings were asbestos pleural plaques (11 patients), multiple nodules (10 patients), and solitary masses (9 patients). Lung base pathology not visible on chest radiography was present in 25 of 37 cases at UMDNJ (68%) and 38 of 89 cases at DVAMC (43%), of which a total of 19 were relevant to further patient management (30%). Three of the five such clinically relevant discrepancies at UMDNJ were pneumothoraces, and 12 of 14 at DVAMC were malignancies. Overall, 0.4% of ACT scans at UMDNJ and 1.7% at DVAMC revealed previously undetected lesions relevant to patient care (P=0.012). In certain subpopulations, especially elderly patients with known carcinomas and victims of trauma, the lung base images of ACT often present findings that may alter clinical management.     

Attenuation-based automatic kilovolt (kV)-selection in computed tomography of the chest: Effects on radiation exposure and image quality

Objectives

To evaluate an automated attenuation-based kV-selection in computed tomography of the chest in respect to radiation dose and image quality, compared to a standard 120 kV protocol.

Materials and methods

104 patients were examined using a 128-slice scanner. Fifty examinations (58 ± 15 years, study group) were performed using the automated adaption of tube potential (100–140 kV), based on the attenuation profile of the scout scan, 54 examinations (62 ± 14 years, control group) with fixed 120 kV. Estimated CT dose index (CTDI) of the software-proposed setting was compared with a 120 kV protocol. After the scan CTDI volume (CTDIvol) and dose length product (DLP) were recorded. Image quality was assessed by region of interest (ROI) measurements, subjective image quality by two observers with a 4-point scale (3 – excellent, 0 – not diagnostic).

Results

The algorithm selected 100 kV in 78% and 120 kV in 22%. Overall CTDIvol reduction was 26.6% (34% in 100 kV) overall DLP reduction was 22.8% (32.1% in 100 kV) (all p < 0.001). Subjective image quality was excellent in both groups.

Conclusion

The attenuation based kV-selection algorithm enables relevant dose reduction (∼27%) in chest-CT while keeping image quality parameters at high levels.     

Interventricular septal mass: an unusual manifestation of sarcoidosis demonstrated on helical computed tomography

The diagnosis of cardiac sarcoidosis can be difficult to establish. We present the case of a 33-year-old woman in whom a contrast-enhanced helical computed tomographic examination of the thorax demonstrated an interventricular septal mass. Subsequent open biopsy confirmed cardiac sarcoidosis.     

Sonography and computed tomography of a gossypiboma and in vitro studies of sponges by ultrasound case report

A case of retained surgical sponge was imaged by ultrasound and computed tomography (CT). Sonography revealed a hypoechoic mass with areas of high echoes and acoustic shadowing. An experiment revealed that the high echoes were attributed partly to the presence of numerous interfaces of sponges. The sonographic detection of a mass with high echoes casting acoustic shadows should alert radiologists to the possibility of retained surgical sponges even if there is no gas or calcification on CT scans.     

Computed tomography of ocular trauma

A wide variety of ocular (eyeball and related soft tissues) injuries resulting from concussive (blunt) and penetrating trauma can be diagnosed by computed tomography (CT). CT can show intraorbital and intraocular emphysema and themorrhage, lens dislocation and subluxation, globe rupture associated with corneal and scleral lacerations, retinal and choroidal detachment, optic nerve injury, and extraocular muscle injury. CT also can localize foreign bodies, and identify injuries caused by them and determine their nature. Not only may CT provide useful information when ocular trauma is clinically suspected, but trauma head and face CT scans may identify unsuspected ocular injuries in the multiple trauma patient. It is imperative that orbital contents be scrutinized carefully on both soft tissue and bone windows of all trauma head and face CT scans in order that clinically significantly ocular injuries not be overlooked.     

The role of computed tomography in the diagnosis and management of clinically occult post-traumatic small bowel perforation

PurposeTo evaluate the use of computed tomography [CT] in the diagnosis of occult post-traumatic small bowel perforation and to discuss the role of CT in the management of this patient group.MethodThis review includes three patients who presented with mild abdominal symptoms following minor blunt abdominal trauma. Initial radiographs and laboratory investigations were unremarkable but their symptoms failed to resolve and contrast-enhanced CT was performed for further evaluation.ResultsIn each case the CT appearances were indicative of localised small bowel perforation, with no evidence of other visceral injury. In two patients pockets of free intraperitoneal air were present closely related to the second part of the duodenum suggesting injury at this site. In the third case, a thickened proximal jejunal loop was demonstrated with free air and fluid in the adjacent mesentery consistent with a focal perforation. These CT findings were subsequently confirmed at laparotomy.ConclusionCT is an accurate diagnostic tool in the assessment of clinically and radiologically occult traumatic small bowel injury. The use of CT should be considered in patients who have unresolving abdominal symptoms even after apparently insignificant abdominal trauma.     

Dumbbell-shaped thoracic hibernoma: computed tomography and magnetic resonance imaging findings

Hibernoma is an uncommon, benign soft tissue tumor that arises in brown adipose tissue. The computed tomography (CT) and magnetic resonance imaging (MRI) findings of hibernomas are similar to those of well-differentiated liposarcoma or angiolipoma. We report the unique appearance of a rare thoracic wall hibernoma, which appeared as a dumbbell-shaped lipomatous tumor across an intercostal region. A dynamic contrast-enhanced study on MRI revealed early enhancement, which corresponded to the branching low-signal intensity on T2-weighted images of the mass.     

Blunt abdominal trauma: Computed tomography, ultrasound, or diagnostic peritoneal lavage: When and by whom?

The most important imaging decision that the clinician must make regarding the patient who sustains blunt abdominal trauma (BAT) is whether the patient is stable enough to undergo computed tomography (CT). CT is the most sensitive and specific examination for the evaluation of BAT. If the patient is unstable, the clinician has three choices: surgery, diagnostic peritoneal lavage, or ultrasound (US). If the patient then stabilizes, a CT scan should be obtained even if the US is negative.     

Thoracic computed tomography in victims of blunt trauma: changes in utilization after the introduction of helical technology

Purpose: In blunt trauma, CT of the thorax is often performed because of the limitations of plain film chest radiography in accurately depicting injuries to the thoracic aorta. The advent of helical CT has allowed the entire chest to be imaged more expeditiously. We will evaluate the extent to which this ability to rapidly obtain additional images of the thorax has increased the utilization of chest CT in blunt trauma. Methods: The radiologic records of all victims of blunt trauma who underwent total body CT (TBCT), which included abdomen, pelvis, and chest images, in the 10 months before and 10 months after our institution acquired helical CT (HCT), were retrospectively evaluated. Results: In the 10 months before we obtained HCT, 520 conventional CT of the abdomen and pelvis were completed, of which only 11 (2.1 %) included images of the full thorax. After HCT was instituted, 684 abdomen and pelvis CT were performed, of which 59 (8.6 %) were ordered with the entire chest. Of the 11 conventional TBCT, 6 (55 %) showed findings in the chest; in 2 of these cases (18 %) the abnormalities were confined exclusively to the thorax. Similarly, of the 59 helical TBCT, 31 (53 %) depicted traumatic abnormalities in the thorax, and in 23 of these cases (39 %) injuries were only within the chest. In 4 of the latter the injuries were mediastinal hematomas, 1 of which (25 %) was confirmed angiographically to represent an aortic laceration. Conclusion: The speed and ease with which additional images can be obtained by HCT has greatly increased utilization of cross-sectional imaging of the thorax after blunt trauma (approximately four-fold). Over half of these depict traumatic injuries.     

Significance of incidental pericardial effusion on computed tomography in cardiac trauma: A report of two cases

We describe computed tomographic (CT) findings in two patients with cardiac injury who required emergency surgery. Chest CT revealed an unexpected low-density area, indicating pericardial effusion. We emphasize that, given the situation of trauma, an incidental low-density area covering more than two slices along the inferior border of the heart suggests pericardial effusion, which may be caused by cardiac injury.