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Everything you need to know about Computed Tomography (CT) & CT Scanning

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

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  • “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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