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Trauma: Vascular Trauma Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Trauma ❯ Vascular Trauma

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  • "The “hard” or overt signs of extremity arterial injury include active pulsatile bleeding; rapidly expanding hematoma; palpable thrill/audible bruit; or classic signs of severe acute limb ischemia (a.k.a. 5 “P”: pulselessness, pallor, paresthesia, pain, and paralysis). The presence of these hard signs correlates with high probability of vascular injury and need of invasive management. In cases where hard signs are present and intervention is indicated, exact localization and characterization of the vascular injury is necessary (ie, multiple extremity fractures or shotgun wound), and the trauma team may pursue CTA imaging if the clinical condition permits and the study can be obtained in a timely fashion.”
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “The “soft” signs of extremity arterial injury include history of arterial bleeding at the scene of trauma or in transit; proximity of a penetrating wound or blunt injury to an artery; small nonpulsatile hematoma over an artery; and neurologic deficit originating in a nerve adjacent to a named artery. The incidence of arterial injuries in such trauma patients ranges from 3% to 25%, depending on which individual soft sign or combination of signs is present. In patients presenting with soft signs and ankle brachial index (ABI) or arterial pressure index (API) less than 0.9, further imaging (CTA or duplex ultrasound) is usually indicated.”
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “The continuous advances of CT technology have improved image quality, permitted faster acquisition and imaging reconstruction times, and allowed incorporation of postprocessing techniques to routine readings with the use of curved multiplanar reformats, maximum intensity projection (MIP), bone subtraction, trajectography, and three dimensional (3D) volume-rendering.”  
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “At our institution, the submillimeter isotropic voxel data set is routinely reconstructed at 1.5 and 3.0 mm in the conventional axial plane and submitted for evaluation. Multiplanar reconstructions on sagittal and coronal planes along the axis of the extremity as well as MIP images are also obtained by technologists at the scanner. 3D volume rendering images and curved planar reformats, including trajectography, can be requested or constructed using postprocessing software available on the workstations.”  
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “There are 5 recognized types of acute vascular injuries with corresponding imaging findings.: (1) intimal tears (intimal flaps, surface disruptions, or subintimal/intramural hematomas), (2) full thickness vessel wall defects with pseudoaneurysms or hemorrhage, (3) complete transections with active hemorrhage and/or occlusion, (4) arteriovenous fistulas (AVF), and (5) spasm. Low-grade intimal injuries and/or intramural hematomas are more often associated with blunt trauma and can lead to secondary occlusion. Full thick wall defects, complete transections, and AVF usually occur with penetrating trauma. Spasm is a temporary finding more common in young patients, which can occur after blunt or penetrating trauma.”
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “Arterial transections occur when the circumference of the vessel is disrupted and usually leads to active contrast extravasation from the proximal segment and/or thrombotic occlusion of the disconnected distal artery. As for traumatic venous injuries in the extremity, wall defects in many peripheral veins seem to heal when local tissue pressure is applied which prevents significant extravasation of blood in most traumatic cases.”
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “Metallic projectiles retained in soft tissues, bone fragments, and orthopedic hardware can result in significant artifacts, commonly limiting the evaluation of adjacent vessels, and obscuring or creating“false” vascular injury imaging findings. Often, adequate contrast opacification of the vessels and the use of multiplanar reformats still alloevaluation of large vessels and the diagnosis of major traumatic injuries. In cases where the streak artifact precludes the evaluation of the vascular bed in question, DSA may be indicated to evaluate and exclude the presence of vascular injury. Recent imaging advancements using metal artifact reduction algorithms and/or DECT have shown to decrease metal and/or bone fragment artifacts, improving visualization of the of the soft-tissues and bones details, and as such can be useful to evaluate vascular injuries.”
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • • Peripheral vascular injuries account for 40% to 75% of all vascular injuries treated in civilian trauma centers.
    • Extremity vascular injury is more often associated with penetrating trauma (75% to 80% of cases in urban trauma centers) than blunt trauma (5%–25% of cases), and among the penetrating mechanisms, more often after a gunshot wound than a stab wound.  
    • CTA is a highly effective tool for the detection and characterization of peripheral vascular injuries with proven outstanding sensitivities in the range of 95% to 100%, specificities of 87% to 100%, and accuracy around 93%.
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • • Patient preparation is key to obtain optimal diagnostic images of the peripheral vessels. Adequate IV access, iodine contrast flow, patient position, and lack of motion are all important to avoid the formation of imaging artifacts and allow adequate imaging evaluation.  
    • AVF is differentiated from asymmetric hyperemia and early venous return on the injured extremity by having the contrast density in the opacified venous segment of the fistula approaching the adjacent artery.
    Computer Tomography Angiography of Peripheral Vascular Injuries
    Fabio M. Paes, MD, Felipe Munera
    Radiol Clin N Am 61 (2023) 141–150
  • “Traumatic thoracic aortic injury is a surgical emergency with very high morbidity and mortality rate. Timely detection of aortic injury and its extent is a crucial step in patient management to allow early surgical intervention. At present, multidetector CT (MDCT) angiography is the study of choice to evaluate for acute traumatic aortic injury due to very high accuracy, easy access to CT scanners in the emergency department, and short acquisition time. Three dimensional(3D) rendering of MDCT datasets, including volume rendering (VR) and maximum intensity projections (MIPs), are a valuable adjunct to standard imaging planes for a more comprehensive review of the aortic anatomy that are particularly helpful for communication of critical findings to non-radiologists including emergency medicine physicians and surgeons.”
    Visualization of acute aortic injury with cinematic rendering.
    Al Khalifah A, Zimmerman SL, Fishman EK.  
    Emerg Radiol. 2022 Sep 1. doi: 10.1007/s10140-022-02086-6. Epub ahead of print. 
  • "The CR technique is a unique advanced volume-rendering algorithm that utilizes a new lighting model to generate photorealistic images from MDCT volumetric datasets. The creation of volumetric images using other VR techniques is achieved by utilizing a local lighting model that models the path of individual beams of light from a light source and creating a surface whenever these simulated light beams face anatomic details within the MDCT dataset. The difference of the CR lighting model is that it uses a global illumination model requiring advanced calculations to create 3D images. This model includes not only the direct light path, but also other indirect illumination beams created by reflection from a multitude of sources in the datasets. The result is that a model allows for a higher degree of photorealistic visualization of the contours, shadowing, and 3D spatial relationships of the aorta and other adjacent anatomical structures.”
    Visualization of acute aortic injury with cinematic rendering.
    Al Khalifah A, Zimmerman SL, Fishman EK.  
    Emerg Radiol. 2022 Sep 1. doi: 10.1007/s10140-022-02086-6. Epub ahead of print. 
  • "All cases were patients undergoing workup for high risk trauma in our emergency department. CT angiography was ordered for timely diagnosis given the high sensitivity and specificity. CR was performed on a dedicated 3D workstation to delineate any subtle contour abnormality of the aorta and increase the confidence of the diagnosis. Additionally, surgical treatment options to manage acute aortic injuries include endovascular aortic stent graft or open surgical repair making CR a useful tool for preoperative surgical planning.”
    Visualization of acute aortic injury with cinematic rendering.
    Al Khalifah A, Zimmerman SL, Fishman EK.
    Emerg Radiol. 2022 Sep 1. doi: 10.1007/s10140-022-02086-6. Epub ahead of print. 
  • Background: Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important.
    Main body: Blunt thoracic aortic injury may be fatal if not diagnosed and treated expeditiously. Endovascular options allow safe and effective management of these dangerous injuries. This paper describes the overview of blunt thoracic aortic trauma, the epidemiology, presentation, diagnosis, and treatment options with a focus on endovascular management.  
    Conclusion: Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.  
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62 
  • Background: Blunt thoracic aortic injury, a life-threatening concern, remains the second most common cause of mortality among all non-penetrating traumatic injuries, second only to intracranial hemorrhage. Kinetic forces from the rapid deceleration are the impetus for the injury mechanism and are graded accordingly. Given the prevalence of trauma as a public health problem, contemporary management considerations are important. and treatment options with a focus on endovascular management.  
    Conclusion: Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular options have become the mainstay of blunt thoracic aortic injury treatment whenever feasible with satisfactory results and long-term outcomes.  
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62 
  • “Up to 80% of patients presenting with blunt thoracic aortic injury(BTAI) die before hospitalization, and in the remaining survivors, in- hospital mortality is as high as 46%. While this is a potentially lethal injury, it is rare and accounts for 1.5% of thoracic trauma.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • "Rapid deceleration is the universal mechanism of this injury. Most commonly, there are multiple other life- threatening injuries present with less than 20% having this as an isolated injury making the diagnosis and initial next steps challenging. BTAI is defined as a tear in the aorta that is a result of a combination of shear and stretch forces, rapid deceleration, increased intravascular pressure and compression of the aorta between the anterior chest wall and vertebrae.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • "Injury can occur along the entire length of the aorta, essentially from the ascending aorta to the iliac bifurcation, although the injury typically occurs areas of aortic tethering, notably the aortic isthmus.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • “Blunt thoracic aortic trauma is associated with other major entities of chest trauma, including, but not limited to, sternal fracture, 1st/2nd rib fractures, clavicle and/or scapular fractures, pneumothoraces, hemothoraces, flail chest, pulmonary contusions, diaphragm injury, tracheobronchial disruption and esophageal injuries; these should raise suspicion for BTAI.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • "Injuries are assigned one of 4 grades based on CTA imaging: grade 1 (intimal tear), grade II (intramural hematoma), grade III (pseudoaneurysm) and grade IV (rupture). Currently, the recommendation is to proceed with surgical repair of Grade II-IV injuries [20]. For grade I injuries, it is well established that no intervention is necessary as these tend to resolve on their own with conservative management. Grade II injures do fall into a “gray zone” between medical management and operative intervention although more recent studies do document that nonoperative is safe with close follow up.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • "Blunt thoracic aortic injury requires a high index of suspicion based on mechanism of injury in the trauma population. Endovascular approaches have slowly replaced open surgical repair for the management of this pathology. Clearly, such patients that present with blunt thoracic injury should be relegated to centers that specialize in the polytrauma patient as it is their concurrent injuries that are the focus of their critical care.”
    Blunt thoracic aortic injury – concepts and management  
    Nicolas J. Mouawad et al.
    Journal of Cardiothoracic Surgery (2020) 15:62
  • “The CT findings of TAI can be divided into direct signs of injury and indirect or associated findings. Direct findings of aortic injury include intramural hematoma, intimal flap and pseudoaneurysm. Injuries that only involve the intima, classified as minimal aortic injuries, should only have direct findings of TAI. Minimal aortic injuries can present with an intimal flap, intraluminal aortic thrombus or intramural hematoma. With the improvement in technology allowing thinner CT slice thickness minimal aortic injuries are being diagnosed more frequently.”
    Traumatic aortic injury: CT findings, mimics, and therapeutic options  
    Ethany L. Cullen et al.
    Cardiovasc Diagn Ther 2014;4(3):238-244 
  • "Ductal remnants, a diverticulum or small bump, are normal remnants of the embryologic ductus arteriosus. This normal variant can simulate injury and can be very perplexing for the inexperienced or unaware radiologist. The ductal diverticulum is a remnant of the closed or partially closed ductus arteriosus which connects the pulmonary artery to the aorta in fetal circulation. Ductal remnants are located at the inferior surface of the aortic arch near the aortic isthmus which leads to their confusion with TAIs. Ductal remnants are typically smooth walled and have obtuse margins that are continuous with the aortic wall and are often calcified. The presence of calcification can be very helpful in distinguishing a ductal remnant from a TAI with the presence of calcification favoring a benign ductal remnant.”
    Traumatic aortic injury: CT findings, mimics, and therapeutic options  
    Ethany L. Cullen et al.
    Cardiovasc Diagn Ther 2014;4(3):238-244 
  • "Mediastinal hematomas can be due to injury to other structures including the pulmonary artery, great vessels or mediastinal veins, or even fractures of vertebral bodies. Presence of a mediastinal hematoma should prompt a careful search for an aortic, pulmonary artery or great vessel injury. In the absence of an identified arterial injury the hematoma is likely venous. A preserved fat plane around the aorta or hematoma centered away from the aorta is less likely to be associated with aortic injury and more likely to be venous.”
    Traumatic aortic injury: CT findings, mimics, and therapeutic options  
    Ethany L. Cullen et al.
    Cardiovasc Diagn Ther 2014;4(3):238-244 
  • "The best way to distinguish a true aortic root injury from motion artifact is to repeat thoracic imaging with ECG gating; and echocardiography can be a reasonable alternative. The difference between a study done without and with ECG gating is illustrated in. In our institution all of the chest CT done as part of a trauma survey are acquired without ECG gating. Since the majority of TAIs are at the aortic isthmus, which is typically well seen on non-gated studies, we feel the additional radiation exposure and time required for setup and acquisition of an ECG gated study is not necessary for every patient.”
    Traumatic aortic injury: CT findings, mimics, and therapeutic options  
    Ethany L. Cullen et al.
    Cardiovasc Diagn Ther 2014;4(3):238-244 
  • “Blunt aortic injuries (BAI) represent the second leading cause of death from motor vehicle crashes accounting for 15% of all motor vehicle accident-associated deaths. Death occurs at the scene of the accident in 70–90% of the cases. According to historical case series, the majority of the patients with BAI (75%) who arrive to the hospi- tal alive are hemodynamically stable, but only 10% survive more than 6 h. Patients arriving to the hospital alive most frequently present with injury at the aortic isthmus where periadventitial tissue seems to provide some degree of protection against free rupture. The majority of patients with BAI have an associated closed head injury, multiple rib fractures, lung contusions, or orthopedic injuries.”
    Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy  
    Rachel Elizabeth Payne et al.
    European Journal of Trauma and Emergency Surgery (2019) 45:951–957
  • “The SVS AI grading system is based on the following criteria: (grade I) intimal tear; (grade II) intramural hematoma; (grade III) pseudoaneurysm; (grade IV) rupture. Under this system, grade I-II are considered mild and grade III-IV are considered severe. In our investigation, we created criteria for radiographic severe injury and used this as a binary variable (severe versus the others) rather than creating a full grading system.”
    Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy  
    Rachel Elizabeth Payne et al.
    European Journal of Trauma and Emergency Surgery (2019) 45:951–957
  • “Radiographically severe injuries were those meeting any of the following criteria: total/partial aortic transection, active contrast extravasation, or the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma and/or mediastinal hematoma thicker than 10 mm, or significant left pleural effusion. We evaluated multiple inju- ries where a pseudoaneurysm was found in isolation, without significant associated hematoma or extravasation, which did not meet criteria for RSI. Thus, many injuries that would be graded III by the SVS system were not included in our RSI classification since they did not meet our selection criteria.”
    Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy  
    Rachel Elizabeth Payne et al.
    European Journal of Trauma and Emergency Surgery (2019) 45:951–957
  • “Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”
    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury  
    Steven P. Rowe & Pamela T. Johnson & Elliot K. Fishman
    Emergency Radiology (2018) 25:209–213 
  • "Among these is the ductus diverticulum—a remnant of the ductus arteriosus that arises from the lesser curvature of the aortic arch, which can be mistaken for a traumatic aortic pseudoaneurysm, dissection, or incomplete rupture. The distal aortic arch, and in particular the undersurface, is the most common location for acute traumatic aortic injury. Differentiation of a ductus diverticulum from an aortic injury can be difficult, but it is of paramount importance in order to spare patients the morbidity of unnecessary thoracic surgery. This becomes more challenging in the setting of other thoracic traumatic injury, especially mediastinal hematoma, as demonstrated in this case report.”
    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury  
    Steven P. Rowe & Pamela T. Johnson & Elliot K. Fishman
    Emergency Radiology (2018) 25:209–213 
  • "Postprocessing with 2D multiplanar reconstructions and 3D rendering has become standard of care in CT angiography. One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases. The potential added value of cinematic rendering in accurately identifying and characterizing vascular pathology will require further study as this new 3D visualization methodology becomes more widely available.”
    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury  
    Steven P. Rowe & Pamela T. Johnson & Elliot K. Fishman
    Emergency Radiology (2018) 25:209–213 
  • “A number of artifacts can mimic a traumatic injury of the thoracic aorta. The classic example is that of the cardiac pulsation artifact, especially in the ascending aorta. If there is any doubt, CT angiography with ECG-gating or a transoesophageal echocardiogram will allow this pathology to be excluded in stable patient. Nonetheless, there remain a number of pitfalls that require particular attention.”
    Traumatic injuries of the thoracic aorta:The role of imaging in diagnosis and treatment
    F.Z. Mokranea et al.
    Diagnostic and Interventional Imaging (2015) 96, 693—706
  • “Nonetheless, there remain a number of pitfalls that require particular attention:
    •pseudo ruptures: on lateral aortic imaging there is an accumulation of contrast material in a wall crevice, andthis finding varies in terms of whether or not it points to a pathology. It is usually a congenital abnormality, such as a dilation at the aortic insertion into an arterial canal, known as ductus diverticulum. Sometimes these images correspond to acquired conditions, such as aneurysms or simple or complicated plaques of atherosclerosis.”
    Traumatic injuries of the thoracic aorta:The role of imaging in diagnosis and treatment
    F.Z. Mokranea et al.
    Diagnostic and Interventional Imaging (2015) 96, 693—706
  • • mediastinal haematoma of venous origin: not all mediastinal bleeding corresponds to aortic injury. The literature describes trauma injuries to the great veins like the supe-rior vena cava. These injuries are rare but they can be life-threatening;
    • mediastinal haematoma secondary to an extra-aortic injury. It is important to know how to detect abnormalitiesof the supra-aortic vessels, possibly using 3D reconstruct-ions. These dangerous lesions are a therapeutic challenge.They are often associated with aortic injuries although they can sometimes be isolated.
    Traumatic injuries of the thoracic aorta:The role of imaging in diagnosis and treatment
    F.Z. Mokranea et al.
    Diagnostic and Interventional Imaging (2015) 96, 693—706
  • “Fistula formation between the aorta and IVC can be an acute complication of abdominal aortic aneurysm rupture or repair, or rarely due to trauma. Spontaneous aortocaval fistula may present with abdominal or back pain, pulsating abdominal mass, continuous abdominal bruit, pelvic and lower extremity venous hypertension, shock, or congestive heart failure. This diagnosis is suggested on contrast- enhanced CT when there is early enhancement of the IVC similar to the aorta. Fistulous communication between the aorta and IVC may be directly visualized. Treatment can be surgical or endovascular.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “IVC injury is a rare event for both blunt and penetrating traumas and has a high mortality rate. While some patients with IVC trauma are too unstable for imaging, CT signs of IVC injury include retroperitoneal hematoma with or without IVC contour abnormality and active contrast extravasation. Hepatic laceration may coexist, and injuries of the retrohepatic IVC carry a poor prognosis. Given the low intraluminal pressure, self-tamponade can occur in the absence of significant concomitant disruption of the surrounding soft tissues.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • ”Flattened IVC constitutes one of the CT signs of clinically significant hypoperfusion in adult blunt trauma patients (i.e., hypoperfusion complex) along with flattened renal veins, active contrast extravasation, free peritoneal fluid, and small bowel enhancement and dilation. Collapsed IVC may also be a helpful predictor of clinical outcome in pediatric and elderly trauma patients, in whom heart rate and blood pressure may be less reliable indicators of hypovolemia.”
    The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
    David S. Shin et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
  • “Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”


    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
  • “Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum.”

    
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
  • “Postprocessing with 2D multiplanar reconstructions and 3D rendering has become standard of care in CT angiography. One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases.”


    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
  • “One of the most pronounced advantages of cinematic rendering is the production of realistic shadowing effects, allowing for very clear representation of the relative positions of objects within the imaged volume; this is well demonstrated in Fig. 1, where the shadowing from the aortic arch onto the underlying ductus diverticulum and pulmonary arterial vasculature allows the viewer to easily grasp the internal arrangement of these structures. Although the rate of incorrectly diagnosed traumatic aortic injuries was low even in the era when invasive aortography was the primary imaging modality, and has remained low with CT angiography as the frontline modality, the consequences of a missed diagnosis (potential death from massive hemorrhage) or an overcalled finding (unnecessary thoracotomy) underscore the importance of any new technique to improve diagnostic accuracy or diagnostic confidence.”


    MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury 
Steven P. Rowe1 & Pamela T. Johnson1 & Elliot K. Fishman
Emergency Radiology (2018) 25:209–213
  • “Three-dimensional postprocessing is a critical step in the interpretation of lower extremity CTA. Maximum intensity projections (MIPs), oblique or 
curved multiplanar reformats, 3-D VR images, and shaded surface displays can be used to augment analysis of the reconstructed cross-sectional axial images.Curved multiplanar reformats, which use the central axis of a vessel (also known as the centerline) to flatten and project the entire course of a vessel in a single plane, are particularly useful for evaluating vascular patency.”


    Computed Tomography Angiography of the Lower Extremities.
Cook TS.
Radiol Clin North Am. 2016 Jan;54(1):115-30
  • Arterial Trauma: CT Findings
    - active extravasation
    - subcutaneous or intra- muscular hematoma
    - pseudoaneurysm
    - vessel narrowing/stretching
    - occlusion
    - arteriovenous fistula
  • “Examples of anatomic landmarks include the lateral margin of the first rib that demarcates the boundary between the subclavian artery and the axillary artery, and the inferior margin of the tendons of the latissimus dorsi and teres major muscles that delineate the transition between the axillary artery and brachial artery. The normal location of the branch point of the brachial artery into the radial and ulnar arteries is at the level of the antecubital fossa near the coronoid process of the ulna.Conventional branching anatomy is seen in approximately 70% of individuals.”


    Computed Tomography Angiography of the Upper Extremities
Dave RB, Fleischmann D.
Radiol Clin North Am. 2016 Jan;54(1):101-14
  • “Examples of anatomic landmarks include the lateral margin of the first rib that demarcates the boundary between the subclavian artery and the axillary artery, and the inferior margin of the tendons of the latissimus dorsi and teres major muscles that delineate the transition between the axillary artery and brachial artery. The normal location of the branch point of the brachial artery into the radial and ulnar arteries is at the level of the antecubital fossa near the coronoid process of the ulna. Conventional branching anatomy is seen in approximately 70% of individuals.”


    Computed Tomography Angiography of the Upper Extremities
Dave RB, Fleischmann D.
Radiol Clin North Am. 2016 Jan;54(1):101-14
  • “The utility of CTA in the setting of trauma has been recognized. However, it’s less well-known and varied clinical applications in the subacute setting are also important and include presurgical anatomic mapping including identification of variant arterial anatomy, evaluation of connective disorders, vasculitis, overuse syndromes, AV fistula/grafts, vascular malformations, compression syndromes, and assessment of perivascular pathology. Volume- 
rendered, maximum intensity projection, and mul- tiplanar reformat images are indispensable for evaluating the data set.”

    
Computed Tomography Angiography of the Upper Extremities
Dave RB, Fleischmann D.
Radiol Clin North Am. 2016 Jan;54(1):101-14
  • “Direct MDCT angiography findings of arterial injuries include active extravasation, luminal narrowing, lack of luminal contrast opacification, filling defect, arteriovenous fistula, and pseudoaneurysm. Important descriptors are location and length of defect, degree of luminal narrowing, and presence of distal arterial supply reconstitution. Proximal arterial injuries include the subclavian, axillary, and brachial arteries. Distal arterial injuries include the ulnar and radial arteries, as well as the palmar arterial arches. Concomitant venous injury, musculoskeletal injury, and nerve damage are common.”


    Multidetector CT and three-dimensional CT angiography of upper extremity arterial injury.
Fritz J, Efron DT, Fishman EK.
Emerg Radiol. 2015 Jun;22(3):269-82.
  • “The subclavian artery continues as the axillary artery after crossing the lateral margin of the first rib. Its major branches include the superior thoracic, thoracoacromial, lateral thoracic, subscapular, and anterior and posterior humer- al circumflex arteries. These branches supply muscles of the shoulder girdle, humerus, scap- ula, and chest wall. After coursing beyond the inferior lateral margin of the teres major mus- cle, the axillary artery becomes the brachial artery.” 


    CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients 
Bozlar U et al.
AJR 2013; 201:745–752
  • “The brachial artery courses along the medial aspect of the upper arm and gives rise to the deep brachial artery and smaller arteries around the elbow joint. Anteriorly in the antecubital fossa, the brachial artery divides into the radial and ulnar arteries. The radial recurrent artery and the posterior and anterior ulnar recurrent arteries arise immediately beyond the origins of their respective arteries to form anastomoses with branches of the brachial and deep brachial arteries. The radial artery courses along the radial side of the forearm to the wrist, traverses the snuffbox, and turns medially to give rise to the deep palmar arch.” 


    CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients 
Bozlar U et al.
AJR 2013; 201:745–752
  • “Arterial injuries of the upper extremities occur in the setting of both blunt and penetrating trauma. Posttraumatic vascular abnormalities include spasm, external compression, dissection , occlusion or transection , arteriovenous fistula (AVF) development , pseudoaneurysm formation, rupture, and transection.”

    CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients 
Bozlar U et al.
AJR 2013; 201:745–752
  • “In difficult cases, pseudoaneurysms can easily be differentiated from extravasation if late phase imaging is performed. Pseudoaneurysms maintain their shape and follow opacification characteristics of the aorta, whereas in arterial extravasation, contrast material spreads along tissue planes and has increased attenuation compared with parent arteries on delayed images.”

    CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients 
Bozlar U et al.
AJR 2013; 201:745–752
  • “CTA is an important diagnostic imaging modality for the evaluation of upper extremity arterial abnormalities. High-quality CTA of the upper extremities is feasible on modern CT scanners using optimized scanning and con- trast injection technique. Its 24-hour availabil- ity, rapid acquisition, minimal invasiveness, and display of both vascular and musculoskeletal structures makes it particularly attrac- tive for the evaluation of patients with blunt or penetrating trauma to the upper extremity. .” 


    CT Angiography of the Upper Extremity Arterial System: Part 1—Anatomy, Technique, and Use in Trauma Patients 
Bozlar U et al.
AJR 2013; 201:745–752
  • “Arterial injuries included transection (24.3%), occlusion (17.3%), partial transection/flow limiting defect (24.5%), pseudoaneurysm (9.0%), and other injuries including intimal defects (22.7%). Nonoperative management was undertaken in 276 (50.9%), with failure in 4.0%. Definitive endovascular and open repair were used in 40 (7.4%) and 126 (23.2%) patients, respectively.”


    The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes.
DuBose JJ et al.
J Trauma Acute Care Surg. 2015 Feb;78(2):215-22
  • “A total of 542 injuries from 14 centers (13 American College of Surgeons-verified Level I and 1 American College of Surgeons-verified Level II) have been captured since February 2013. The majority of patients are male (70.5%), with an Injury Severity Score (ISS) of 15 or greater among 32.1%.”


    The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry: multicenter data on modern vascular injury diagnosis, management, and outcomes.
DuBose JJ et al.
J Trauma Acute Care Surg. 2015 Feb;78(2):215-22
  • “Arterial injuries were categorized into 116 penetrating (73.0%) and 43 blunt (27.0%) mechanisms. Arterial distribution involved was as follows: 13 axillary (8.2%), 40 brachial (25.2%), 52 radial (32.7%), 51 ulnar (32.1%), and 3 other (1.9%). The types of arterial injuries were as follows: 69 transection (43.4%), 68 laceration (42.8%), 16 occlusion (10.1%), 3 avulsion (1.9%), and 3 entrapment (1.9%).”


    A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.
Franz RW et al.
Ann Vasc Surg. 2012 Jul;26(5):655-64
  • “One patient (0.7%) required a primary above-elbow amputation. The majority of injuries (96.8%) receiving vascular management underwent surgical intervention--76 primary repair (49.7%), 41 ligation (26.8%), 31 bypass (20.3%), and 5 endovascular (3.3%). Conservative treatment was the primary strategy for five arterial injuries (3.3%). Of the patients receiving vascular intervention, three (2.2%) required major and three (2.2%) required minor amputations during hospitalization and no patients expired.”


    A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.
Franz RW et al.
Ann Vasc Surg. 2012 Jul;26(5):655-64
  • “The current multidisciplinary team management approach with prompt surgical management resulted in successful outcomes after upper-extremity arterial injuries. No outcome differences between penetrating and blunt or between proximal and distal arterial injuries were calculated. This management approach will continue to be used.”


    A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.
Franz RW et al.
Ann Vasc Surg. 2012 Jul;26(5):655-64
  • “CT is the procedure of choice to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, musculoskeletal lesions, and vessels injuries and is useful for assessing medicolegal aspects as trajectory and the anatomical structures at risk.”

    Imaging assessment of gunshot wounds.
Reginelli A et al.
Semin Ultrasound CT MR. 2015 Feb;36(1):57-67.
  • “Indication for total body computed tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical care are not diagnosed, or hemostasis may be preliminary reached in the emergency room. Hemodynamically stable patients with no history and clinical examination showing suspected vascular damage are allowed in the radiology department for obtaining a total body CT scan with intravenous contrast medium and then transferred to the surgical ward trauma for observation.”


    Imaging assessment of gunshot wounds.
Reginelli A et al.
Semin Ultrasound CT MR. 2015 Feb;36(1):57-67.
  • “Multi-detector computed tomography angiography (MDCTA) of the lower extremities is an integral part of the decision-making process of lower extremity trauma. MDCTA can be integrated into multiphasic whole-body trauma MDCT and has replaced the traditional gold standard of catheter-based angiography as the preferred technique for the initial assessment of lower extremity trauma in many institutions worldwide. Advances in MDCT technology enable high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced image visualization for the noninvasive and accurate diagnosis of vascular, including hematoma, active extravasation, vasospasm, stenosis, external compression, occlusion, intimal injury and dissection, arteriovenous fistulas, and pseudoaneurysm formation.”


    State-of-the-art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls, and pitfalls.
Fritz J, Efron DT, Fishman EK.
Emerg Radiol. 2013 Jun;20(3):175-84
  • “Advances in MDCT technology enable high speed simultaneous evaluation of both complete lower extremities, rapid image reconstruction, and advanced image visualization for the noninvasive and accurate diagnosis of vascular, including hematoma, active extravasation, vasospasm, stenosis, external compression, occlusion, intimal injury and dissection, arteriovenous fistulas, and pseudoaneurysm formation.”


    State-of-the-art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls, and pitfalls.
Fritz J, Efron DT, Fishman EK.
Emerg Radiol. 2013 Jun;20(3):175-84
  • “Multi-detector computed tomography angiography (MDCTA) of the lower extremities is an integral part of the decision-making process of lower extremity trauma. MDCTA can be integrated into multiphasic whole-body trauma MDCT and has replaced the traditional gold standard of catheter-based angiography as the preferred technique for the initial assessment of lower extremity trauma in many institutions worldwide.”


    State-of-the-art 3DCT angiography assessment of lower extremity trauma: typical findings, pearls, and pitfalls.
Fritz J, Efron DT, Fishman EK.
Emerg Radiol. 2013 Jun;20(3):175-84
  • “ CT angiography findings indicative of arterial injury were observed in 24 patients (30%) and a total of 43 arterial injuries were noted; the most common form was focal narrowing/spasm (n?=?16, 37.2%); the most common artery involved was the superficial femoral artery (n?=?12, 50%). In qualitative assessment of images based on a 4-point grading system, both readers considered CT angiography diagnostically excellent (grade 4) in most cases. Surgical findings were consistent with CT angiography and follow-up of patients' medical records showed no arterial injuries in patients with normal findings on initial imaging.”
    Computed tomography angiography of lower extremities in the emergency room for evaluation of patients with gunshot wounds.
    Adibi A et al.
    Eur Radiol. 2014 Jul;24(7):1586-93
  • “Our findings demonstrate that CT angiography is an effective imaging modality for evaluation of lower extremity gunshot wounds and could help limit more invasive procedures such as catheter angiography to a select group of patients.”
    Computed tomography angiography of lower extremities in the emergency room for evaluation of patients with gunshot wounds.
    Adibi A et al.
    Eur Radiol. 2014 Jul;24(7):1586-93
  • “ Direct MDCT angiography findings of arterial injuries include active extravasation, luminal narrowing, lack of luminal contrast opacification, filling defect, arteriovenous fistula, and pseudoaneurysm. Important descriptors are location and length of defect, degree of luminal narrowing, and presence of distal arterial supply reconstitution. Proximal arterial injuries include the subclavian, axillary, and brachial arteries. Distal arterial injuries include the ulnar and radial arteries, as well as the palmar arterial arches. Concomitant venous injury, musculoskeletal injury, and nerve damage are common.”
    Multidetector CT and three-dimensional CT angiography of upper extremity arterial injury.
    Fritz J, Efron DT, Fishman EK.
    Emerg Radiol. 2014 Dec 11. [Epub ahead of print]
  • “ Direct MDCT angiography findings of arterial injuries include active extravasation, luminal narrowing, lack of luminal contrast opacification, filling defect, arteriovenous fistula, and pseudoaneurysm. Important descriptors are location and length of defect, degree of luminal narrowing, and presence of distal arterial supply reconstitution.”
    Multidetector CT and three-dimensional CT angiography of upper extremity arterial injury.
    Fritz J, Efron DT, Fishman EK.
    Emerg Radiol. 2014 Dec 11. [Epub ahead of print]
  • “Originally thought to be a rare occurrence, blunt cerebrovascular injuries (BCVIs) are now diagnosed in approximately 1% of blunt trauma patients. Early imaging of patients has resulted in the diagnosis of BCVIs during the asymptomatic phase, thus allowing prompt treatment. Although the ideal regimen of antithrombotic therapy has yet to be determined, treatment with either antiplatelet agents or anticoagulation has been shown to markedly reduce BCVI-related stroke rate. BCVIs are rare, potentially devastating injuries; appropriate imaging in high-risk patients should be performed and prompt treatment initiated to prevent ischemic neurologic events.”
    Imaging for blunt carotid and vertebral artery injuries
    Burlew CC, Biffi WL
    Surg Clin North Am 2011 Feb;91(1)217-31
  • “The incidence of "indirect" cervical arterial injuries with craniofacial gunshot wounds is comparable to or slightly higher than those seen in pure blunt trauma. Screening patients with craniofacial gunshot injuries with CT angiography may yield unexpected cervical vascular injuries remote from the penetrating tract.”
    Craniofacial gunshot injuries: an unrecognized risk factor for blunt cervical vascular injuries
    Steenburg SD, Silker CE
    Eur Radiol 2012 Sep;22(9):1837-43
  • “Contrast material-enhanced helical computed tomographic (CT) angiography is increasingly being used to evaluate trauma patients in stable condition who are at risk for vascular injuries. It allows characterization of traumatic vascular lesions in the neck such as partial or complete occlusion, pseudoaneurysm, intimal flap, dissection, and arteriovenous fistula. In the same setting, CT angiography provides valuable additional information about the cervical soft tissues, aerodigestive tract, spinal canal, and spinal cord.”
    Vascular injuries of the neck and thoracic inlet :helical CT-angiographic correlation
    Nunez DB Jr et al.
    Radiographics 2004. July-Aug 24(4);1087-98
  • “CT angiography may be limited by artifacts from metallic fragments and occasionally by abundant soft-tissue air or streak artifacts in the shoulders. In such cases, conventional angiography is necessary for optimal assessment of vascular injuries. CT angiography can be used as a noninvasive alternative to conventional angiography in patients suspected to have vascular injuries but without initial indications for surgical treatment.”
    Vascular injuries of the neck and thoracic inlet :helical CT-angiographic correlation
    Nunez DB Jr et al.
    Radiographics 2004. July-Aug 24(4);1087-98
  • Vascular Trauma: CT Findings

    Arterial injuries

    • Pseudoaneurysm
    • Active arterial hemorrhage
    • AV fistulae
    • Occlusion
    • Intimal injury
    • vasospasm
  • "Multiphasic imaging also allows for the definitive differentiation between arterial and venous sources of hemorrhage."

    CT of Blunt Abdominal and Pelvic Vascular Injury
    Vi M et al.
    Emerg Radiol (2010) 17;21-29

  • Pelvic Trauma: Vascular Injuries
    - Occlusion
    - Dissection
    - Arteriovenous fistula
    - Pseudoaneurysm
    - Active arterial extravasation
    - Venous injuries
  • "Pelvic CT angiography has significant clinical utility in the evaluation of patients with blunt pelvic trauma. The ability to characterize arterial injuries and to differentiate arterial injuries from venous injuries is important for ensuring appropriate and timely treatment."

    Detection of Vascular Injuries in Patients with Blunt Pelvic Trauma by Using 64-Channel Multdetector CT
    Kertesz JL et al.
    RadioGraphics 2009; 29:151-164

     

  • "CTA is efficient and accurate in the evaluation of clinically significant lower extremity arterial injuries after trauma."

    CT Angiography Signa of Lower Extremity Vascular Trauma
    Gakhal MS, Sartip KA
    AJR:193, July 2009 DOI:10.2214/AJR.08.2011

  • Vascular Injuries in Pelvic Fractures
    - Active arterial extravasation
    - Occlusion
    - Intimal injury and occlusion
    - Pseudoaneurysm
    - Arterial dissection
    - Arteriovenous fistulae
    - Venous injury

     

  • "The application of MDCT technology, specifically 64MDCT, to pelvic CTA is useful in evaluating for potential vascular injuries and may be integrated into admission trauma imaging in order to triage patients with blunt pelvic trauma and its utility in detecting and characterizing vascular injury, including the differentiation of arterial from venous hemorrhage."

    Pelvic CT angiography: application to blunt trauma using 64MDCT
    Uyeda J et al.
    Emerg Radiol (2010) 17; 131-137

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