Imaging Pearls ❯ Trauma ❯ Technique
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- “By synergizing cutting-edge imaging technologies, powerful software tools, and a meticulous retrospective analysis of real cases, the study managed to shed light on the intricate world of soft-tissue injuries. The detailed 3D models and cinematic renderings generated through this methodology not only enhance the accuracy of injury analysis but also lay the foundation for future advancements in forensic investigations, ultimately contributing to a more robust understanding of trauma within the human body. However, challenges such as the need for specialized training in rendering software and potential concerns regarding the authenticity of manipulated visualizations should be acknowledged and addressed.”
Advancements in Forensic Imaging: Soft Tissue Injury Analysis and Exploration with 3D Cinematic Rendering
Walter M Wallner-Essl, Johannes AR Pfaff and Jochen Grimm
Int J Forens Sci Res. 2024; 1(1): 1-6. - “In the realm of forensic imaging, the application of 3D cinematic renderings holds significant promise for accident investigations involving soft-tissue injuries. This technology emerges as a potent tool particularly in cases where accidents, such as vehicular collisions or workplace incidents, result in complex soft-tissue trauma. The ability to visualize and dissect these injuries in a dynamic three-dimensional space offers unparalleled insights into the mechanics of injury occurrence and serves as a crucial asset in establishing liability and understanding causative factors.”
Advancements in Forensic Imaging: Soft Tissue Injury Analysis and Exploration with 3D Cinematic Rendering
Walter M Wallner-Essl, Johannes AR Pfaff and Jochen Grimm
Int J Forens Sci Res. 2024; 1(1): 1-6. - “3D cinematic rendering has the potential to transform the landscape of forensic radiology by providing a dynamic and interactive platform for the analysis of soft-tissue injuries. This technique enhances the accuracy of injury interpretation, facilitates communication with legal professionals, and contributes to more informed decision-making in legal proceedings. As technology continues to evolve, further research and validation are needed to establish the reliability and admissibility of 3D cinematic renderings in forensic investigations. Therefore, additional research will be imperative to gain further insights into this topic. Nonetheless, the promising results of this study highlight the significant strides that have been made in advancing forensic imaging techniques. ”
Advancements in Forensic Imaging: Soft Tissue Injury Analysis and Exploration with 3D Cinematic Rendering
Walter M Wallner-Essl, Johannes AR Pfaff and Jochen Grimm
Int J Forens Sci Res. 2024; 1(1): 1-6. - “The application of 3D cinematic rendering unveiled a new dimension in the visualization of soft-tissue injuries. By allowing dynamic exploration of injuries from various angles and depths, this technique provided an unprecedented level of insight into the extent and mechanism of trauma. In cases of blunt force trauma, the ability to simulate tissue deformation helped elucidate the impact dynamics, aiding in the differentiation between accidental and intentional injuries. Furthermore, the interactive nature of the renderings facilitated clearer communication of findings to non-medical professionals involved in legal proceedings. The comparisons between cinematic rendering and volume rendering techniques, as shown in the figures, highlight the differences in visualization quality and spatial perception, clearly demonstrating the advantages of cinematic rendering.”
Advancements in Forensic Imaging: Soft Tissue Injury Analysis and Exploration with 3D Cinematic Rendering
Walter M Wallner-Essl, Johannes AR Pfaff and Jochen Grimm
Int J Forens Sci Res. 2024; 1(1): 1-6.
- ”WB-CT is typically performed with modern multi-detector CT (MDCT) scanners with a continuous acquisition, with thin (0.5–0.6 mm) collimation images reconstructed at 1 mm and 3 mm slices for imaging interpretation—the anatomic coverage extending from the head to the symphysis pubis. The authors’ institutional protocol involves a biphasic injection of 100 mL of iodinated contrast (350 mg/mL) at 4 cc/s for 15 seconds, then at a rate of 3 cc/s, followed by a 40-cc saline bolus at 4 cc/s. The fixed-time delay method is generally suitable, but issues arise in cases of abnormal anatomy, cardiac function, or severe arterial disease, impacting blood transit time. While bolus tracking is often favored in such scenarios, research shows improved efficiency witha fixed-time empiric delay of 20 or 25 seconds for patients over 55.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Post-processing techniques, including coronal and sagittal multiplanar reformations (MPR) and maximum intensity projections (MIPS) of the torso are also generated and submitted for interpretation. Separate dedicated coronal and sagittal reformations of the neck and thoracolumbar spine in both bone and soft-tissue algorithms are generated, with the liberal use of additional postprocessing techniques by the radiologist.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Second to intracranial hemorrhage, traumatic aortic injuries (TAI) are the next most common cause of motor vehicle collision (MVC) deaths, and it is estimated that 80% of patients with aortic injuries die before arriving at the hospital.MDCT has been found to be nearly 100% sensitive and specific for the detection of TAIs. Most TAIs occur at the isthmus. Abdominal TAIs are rare, and 25% represent an extension of a thoracic aortic injury.The infrarenal aortic segment is twice as commonly involved as the supra-renal segment. The presence of a vertebral body fracture should prompt the interpreter to closely scrutinize the aorta. Sagittal MPR reconstructions are especially useful in assessing the aorta.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Extraluminal gas, bowel wall discontinuity, mesenteric vessel irregularity, occlusion, or extravasation, and focal bowel wall thickening all have high specificities for bowel injury on CT. Other sources of free air in the setting of blunt trauma may be related to the extension of a pneumothorax or pneumomediastinum, barotrauma from mechanical ventilation, DI, chest tube placement, diagnostic peritoneal lavage (DPL), and intraperitoneal rupture of a recently instrumented bladder. Free fluid on CT, particularly if hyperdense, is the most sensitive finding for a bowel injury (BI), with a 90% to 100% sensitivity, but has only a 15% to 25% specificity.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Delayed CT imaging alone is not reliable in demonstrating a bladder injury, as the bladder is usually not fully distended. Therefore, a dedicated CT-cystogram should be performed with an attempt for optimal bladder distension. A total of 70% of bladder injuries are extraperitoneal and are associated with pelvic fractures (managed by placing a supra-pubic catheter), and 20% are intraperitoneal (requiring operative repair).”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Anatomic variants may also potentially mimic traumatic injuries. An aortic ductus diverticulum or aortic spindle may be confused for a pseudoaneurysm (PSA), a remnant patent or calcified ductus arteriosum may be misconstrued for a TAI, thymus may be confused for a mediastinal hematoma, while a splenic cleft or pancreatic lobulation can mimic a laceration. The absence of associatedfat stranding or fluid may hint that the finding is non-traumatic. Calcifications or foreign bodies may also resemble areas of hemorrhage, which can be differentiated by the area’s density and stable appearance in all phases of imaging.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “Integrating artificial intelligence (AI) in emergency radiology, particularly in the context of WB-CTbscans for polytraumatized patients, represents a substantial advancement in the diagnosis and subsequent management of traumatic injuries. A review of the current literature underscores the promising potential of AI to enhance the accuracy, efficiency, and predictive capabilities of radiological assessments in the emergency and trauma settings. Zhou and colleagues conducted a study on 133 patients comparing the results of rib fracture detection using initial CT and follow-up CT, revealing that AI-assisted diagnosis statistically significantly improved the overall accuracy for the detection of rib fractures.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076 - “The innovative application of AI extends beyond these examples. AI has been employed in the quantitative analysis of traumatic hemoperitoneum,70 highlighting its ability to aid in diagnosing and managing intrabdominal bleeding. Seyam and colleagues implemented an AI-based detection tool for intracranial hemorrhage (ICH) and evaluated its diagnostic performance, assessing clinical workflow metrics compared to pre-AI implementation.71 The study found that the tool demonstrated practical diagnostic performance with an overall accuracy of 93.0%, sensitivity of 87.2%, and a negative predictive value of 97.8%. However, it identified lower detection rates for specific subtypes of ICH, such as 69.2% for subdural hemorrhage and 77.4% for acute subarachnoid hemorrhage. It is important to define a clear framework for clinical integration, recognizing the limitations of AI.”
Trauma and ‘Whole’ Body Computed Tomography Role, Protocols, Appropriateness, and Evidence to Support its Use and When
Daniela Galan et al.
Radiol Clin N Am 62 (2024) 1063–1076
- Purpose: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists’ interpretations of cross-sectional exams performed on patients transferred to our trauma center.
Methods: Outside hospital CT and MRI exams performed on transfer trauma patients are routinely overread by subspecialist emergency radiologists, specifying either concordance or discordance with the interpretation by the community radiologist. We evaluated the discordant reports for clinical significance, defined as an additional finding or difference in interpretation which was likely to affect patient management. The total rate of significant discordances, rate by modality, rate by body region, and rate per patient transferred were calculated. The most common errors were identified, and the distribution of errors among individual community radiologists was examined.
Transfer patient imaging: discordances between community and subspecialist emergency radiologists
Michael G. Flowers et al.
Emergency Radiology (2022) 29:395–401 - Purpose: To determine the rate and nature of significant discordances between community and subspecialist emergency radiologists’ interpretations of cross-sectional exams performed on patients transferred to our trauma center.
Conclusion: There is frequent discordance between community and emergency radiologists’ interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value over- reading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.
Transfer patient imaging: discordances between community and subspecialist emergency radiologists
Michael G. Flowers et al.
Emergency Radiology (2022) 29:395–401 - Results: 9175 exams were reviewed. Significant discordances were encountered in 4.1% of exams: 3.9% for CT and 6.7% for MRI; 5.1% for head and neck exams, 3.3% for spine, 3.8% for torso, and 2.9% for extremities. The discordance rate per patient transferred was 7.7%. The most common discordances involved missing injuries to the cranio-cervical junction, missing or misinterpreting vascular injuries in the neck, and incompletely characterizing facial fractures. Discordances were evenly spread among 220 community radiologists.
Conclusion: There is frequent discordance between community and emergency radiologists’ interpretations of CT and MRI exams, leading to a change in transferred patient management. Thus, trauma center radiologists provide added value over- reading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.
Transfer patient imaging: discordances between community and subspecialist emergency radiologists
Michael G. Flowers et al.
Emergency Radiology (2022) 29:395–401 - “Allowing for a subjective definition of clinical significance as determined by radiologists, and understanding that our patient population is highly selective, we have identified a relatively frequent rate of discordance between community and subspecialty-trained emergency radiologists when it comes to interpreting cross-sectional exams of trauma patients. Slightly more errors are made on MRI than CT, and while the most common errors involved the head, neck, and spine, errors were distributed throughout the body. Errors were made by a wide number of community radiologists, as opposed to a small number of outliers. These findings suggest that trauma center radiologists provide added value overreading these patients’ exams. It is difficult to predict which patients or exams will contain discordances, justifying routine overreading of all such exams.”
Transfer patient imaging: discordances between community and subspecialist emergency radiologists
Michael G. Flowers et al.
Emergency Radiology (2022) 29:395–401
- “ For CT examination of blunt splenic injury, arterial phase is superior to portal venous phase imaging for pseudoaneurysm but inferior for active bleeding and parenchymal disruption; dual-phase CT provides optimal overall performance.”
Optimizing Trauma Multidetector CT Protocol for Blunt Splenic Injury: Need for Arterial and Portal Venous Phase Scans
Boscak AR et al.
Radiology 2013; 208:79-88 - “ Dual (arterial and portal venous) phase CT has better overall diagnostic performance than single (arterial or portal venous) phase CT for detection of splenic injuries after blunt trauma.”
Optimizing Trauma Multidetector CT Protocol for Blunt Splenic Injury: Need for Arterial and Portal Venous Phase Scans
Boscak AR et al.
Radiology 2013; 208:79-88
- “ With a single continuous acquisition, whole body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis”
Blunt Polytrauma: Evaluation with 64-Section Whole-Body CT Angiography
Dreizin D, Munera F
RadioGraphics 2012; 32:609-631 - “ In this article, we discuss potential indications for whole body CT angiography, the importance of the use of trauma scoring, the value of whole body CT angiography in detecting important, not to miss injuries at each anatomic level, the benefit of reviewing multiplanar reformation (MPR) and three dimensional (3D) images for timely and accurate interpretation; and potential pitfalls that should be avoided, as well as ongoing controversies and future trends.”
Blunt Polytrauma: Evaluation with 64-Section Whole-Body CT Angiography
Dreizin D, Munera F
RadioGraphics 2012; 32:609-631 - “ In this article, we discuss potential indications for whole body CT angiography, the benefit of reviewing multiplanar reformation (MPR) and three dimensional (3D) images for timely and accurate interpretation.”
Blunt Polytrauma: Evaluation with 64-Section Whole-Body CT Angiography
Dreizin D, Munera F
RadioGraphics 2012; 32:609-631 - Multiorgan Trauma Protocol for 64 MDCT and Beyond
1. Unenhanced brain CT
2. Enhanced scan from circle of Willis to the symphysis pubis
- 120 kVp
- 0.7 pitch
- 0.5 sec rotation time
- 0.6 mm collimation
- Images reconstructed at 3.0 (for radiologist) and 1.5 mm (for MPR and 3D) - Multiorgan Trauma Protocol for 64 MDCT and Beyond
- Scan delay is fixed at 20 seconds for patients under age 55 and 25 seconds for patients over 55 years of age
- Biphasic injection 100 ml bolus, 350 mg/ml non-ionic contrast at 4.0 cc/sec for 15 seconds, then 3.0 cc/sec for 13 seconds and then 30 ml of saline injected at 4 cc/sec
- No oral contrast
- Delayed scans are optional depending on the early images or clinical history
- Scan with arms above the head in all cases