Objective: The purpose of this study was to describe the performance of adjunctive radiologic ima... more Objective: The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury.
ABSTRACT We report a case of liver herniation through an occult diaphragmatic injury presenting a... more ABSTRACT We report a case of liver herniation through an occult diaphragmatic injury presenting as a solitary pulmonary nodule. The value of clinical history as well as the utility of helical computed tomography and magnetic resonance imaging in avoiding this pitfall are discussed.
PURPOSE The purpose of this study was to determine the percentage of all patients sustaining CT-d... more PURPOSE The purpose of this study was to determine the percentage of all patients sustaining CT-diagnosed blunt traumatic aortic injury (TAI) with minor injuries, the extent of associated mediastinal hemorrhage (MH), and clinical outcome of minor TAI treated without intervention. METHOD AND MATERIALS After IRB approval, the authors collected all cases of blunt TAI from our instititution's trauma and radiology registries from 2005 to 2011. For this retrospective study, admission chest CT was reviewed for each patient and categorized as major or minor TAI. Minor TAI included focal aortic contour abnormality, wall thickening, intimal flap(s), and/or shallow pseudoaneurysm. MH extent was graded as 0, 1 or 2 corresponding to absent, periaortic only, or more extensive. All follow-up CTs of patients with minor TAI were reviewed. Chart review for all minor TAI determined patient demographics, initial management and outcome at last follow-up. RESULTS There were 107 TAIs of which 36% (39/...
Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with... more Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury. Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions. Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in...
To review the literature and the authors' experience with admission contrast material-enhance... more To review the literature and the authors' experience with admission contrast material-enhanced computed tomography (CT) in patients admitted after blunt trauma. From January 1990 to December 1994, thoracic CT was performed to evaluate traumatic aortic injury in 677 patients with positive or equivocal findings at chest radiography. CT scans positive for mediastinal hemorrhage or aortic injury were retrospectively reviewed and interpreted by consensus, with angiographic and surgical confirmation. CT findings were negative for TAI in 570 (84%) of the 677 patients. Mediastinal hemorrhage was reported in 100 patients and was the only abnormality in 79 of them. Findings at angiography were negative for traumatic aortic injury in 77 (97%). CT signs of traumatic aortic injury in 21 patients included contour abnormality or pseudoaneurysm (n = 19), intimal flap(s) (n = 8), and pseudocoarctation (n = 3). Findings at angiography were positive for traumatic aortic injury in 19 (90%). For aor...
Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in s... more Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in screening for and facilitating the diagnosis of acute thoracic aortic injury in the patient with blunt chest trauma has shown favorable results. This has led some physicians to question whether conventional thoracic aortography is still the reference standard. The purpose of this review article is to summarize the epidemiology and pathophysiology of acute thoracic aortic injury, the current status of the individual imaging modalities in use, and the surgeon's perspective. Despite a burgeoning literature and a confounding array of clinical and imaging advances, timely diagnosis of acute thoracic aortic injury remains a challenge. To overcome this problem, some trauma centers have used CT, transesophageal echocardiography, or both, in their diagnostic algorithm for acute thoracic aortic injury. These diagnostic algorithms are individually tailored by each institution and are still under...
Nonsurgical management of blunt splenic injury in children is a well-established method to salvag... more Nonsurgical management of blunt splenic injury in children is a well-established method to salvage splenic function; however, nonsurgical management of adult blunt splenic trauma remains controversial. To assess the value of preoperative abdominal CT in predicting the outcome of blunt splenic injury in adults, a CT-based injury-severity score consisting of four grades was devised and applied in 39 adult patients with blunt splenic injury as the sole or predominant intraperitoneal injury detected with preoperative CT. While patients with high grades of splenic injury generally required early surgery, eight (35%) of 23 patients with initial grade 3 or 4 injury were treated successfully without surgery, and four (29%) of 15 patients with grade 1 or 2 injury initially treated nonsurgically required delayed celiotomy (n = 3) or emergency rehospitalization. Results show that while CT remains an accurate method of identifying and quantifying initial splenic injury, as well as documenting p...
To further define the computed tomographic (CT) criteria on which to guide the nonsurgical treatm... more To further define the computed tomographic (CT) criteria on which to guide the nonsurgical treatment of adult patients with blunt hepatic injury, the authors retrospectively reviewed abdominal CT scans obtained before surgery during a 35-month period. Blunt hepatic injury was diagnosed in 187 patients, and review revealed 37 patients in whom the liver was the site of sole or principal intraabdominal injury detected with the help of CT before surgery. A CT-based hepatic injury classification system partly derived from similar systems established with surgical assessment was devised to grade the severity of hepatic injury. CT-based injury scores ranging from grade 1 to 5 were compared with the clinical outcome in patients treated surgically and nonsurgically. Thirty-one patients (83.7%) were successfully treated without surgery, and four patients (10.8%) had findings at celiotomy that did not require further surgery. No patient who was initially treated without surgery required delaye...
PURPOSE To determine the utility of multidetector computed tomography (MDCT) of the face as a pre... more PURPOSE To determine the utility of multidetector computed tomography (MDCT) of the face as a predictor of traumatic optic neuropathy (TON) in patients with blunt trauma. METHOD AND MATERIALS Retrospective chart review of Ophthalmology database from 5/2008 to 12/2009 revealed 44 patients with clinical diagnosis of TON. Contralateral orbits in patients with TON and randomly selected 35 facial trauma patients without TON were evaluated as comparison group. The studies were analyzed by two trauma radiologists, blinded to the clinical diagnosis. Following CT findings were evaluated: facial fractures, extraconal hematoma, intraconal hematoma, hematoma tracking along the optic nerve, hematoma along the posterior wall of the globe, optic canal fracture, nerve impingement by optic canal fracture fragment, extraconal emphysema and intraconal emphysema. Radiological findings were correlated with clinical diagnosis to measure the sensitivity and specificity of each finding. Receiver operating ...
ABSTRACT The purpose of this retrospective study was to determine the CT findings diagnostic of c... more ABSTRACT The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.
The purpose of this study was to determine the optimal contrast concentration, volume, and inject... more The purpose of this study was to determine the optimal contrast concentration, volume, and injection rate for helical CT imaging of trauma patients requiring evaluation of the chest, abdomen, and pelvis. Two hundred forty patients were randomized into six different regimen groups for administration of iohexol nonionic intravenous contrast medium, each regimen containing 36 g iodine, with various injection rates,
Fat embolism syndrome (FES) is an uncommon but serious complication of traumatic injury and is fr... more Fat embolism syndrome (FES) is an uncommon but serious complication of traumatic injury and is frequently diagnostically challenging. In this paper, the authors present four patients who sustained lower extremity long bone injury and who had a normal Glasgow Coma Scale before orthopedic surgical intervention. However, postoperatively, significant neurological deterioration developed in these patients. While cranial computed tomography (CT) obtained immediately after surgery for acutely altered mental status was negative in two of the four patients, brain magnetic resonance imaging (MRI) demonstrated white and gray matter abnormalities accounting for the impaired neurological status in all cases. MRI findings in conjunction with clinical presentation established the diagnosis in all patients. MRI is indicated in any patient with orthopedic injuries who manifests an unexplained acute alteration in mental status, despite a normal head CT.
Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury.... more Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury. Chest radiographs are the initial and most commonly performed imaging study to evaluate the diaphragm after trauma. When chest radiography is indeterminate, spiral computed tomography (CT) with thin sections and reformatted images is the next study of choice, particularly because most hemodynamically stable patients with blunt diaphragm injury will require an admission CT examination to evaluate the extent and anatomical sites of coexisting thoracoabdominal injuries. Magnetic resonance imaging is used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.
ABSTRACT This study was undertaken to determine the incidence and spectrum of “equivocal” finding... more ABSTRACT This study was undertaken to determine the incidence and spectrum of “equivocal” findings on thoracic aortography performed: (a) to exclude traumatic aortic injury (TAI), and (b) to identify radiologic signs that might be useful in increasing diagnostic confidence. All cases of thoracic aortography performed during a 5-year period to evaluate possible major thoracic arterial injury were identified. Those with atypical or uncertain results were reviewed by the authors, and medical records were analyzed to determine initial diagnosis, management course, and clinical outcome. During the study period, 438 thoracic aortograms were performed, of which 45 (10.3%) had surgically proven aortic injury and another 7 (1.6%) had surgically verified injury to proximal aortic branches. Twenty-four of those 438 patients (5.5%) had atypical or uncertain findings on aortography. Of the 24 patients, 10 had findings suggestive of aortic ulceration rather than TAI, 8 had a diagnosis of atypical ductus diverticulum, and 6 were diagnostically confusing for various reasons. Among the 24 cases, 16 patients ultimately were diagnosed as true-positive for TAI based on surgical confirmation, representing 35% of all ruptured aortas diagnosed during the study. Three studies were true-negative based on observation and follow-up angiography. There was one false-positive and two false-negative diagnoses based on surgical findings. Two patients with a presumptive diagnosis of TAI were observed because of their advanced age. Atypical or equivocal angiographic results occur in approximately 5% of the blunt trauma patients studied for potential TAI, but occur in about one third of such patients ultimately proven to have TAI. Some radiologic clues are suggested to increase diagnostic confidence in interpreting atypical aortographic findings. Management approaches also are suggested for cases in which the results remain uncertain.
Objective: The purpose of this study was to describe the performance of adjunctive radiologic ima... more Objective: The purpose of this study was to describe the performance of adjunctive radiologic imaging in patients with cervical spine injury.
ABSTRACT We report a case of liver herniation through an occult diaphragmatic injury presenting a... more ABSTRACT We report a case of liver herniation through an occult diaphragmatic injury presenting as a solitary pulmonary nodule. The value of clinical history as well as the utility of helical computed tomography and magnetic resonance imaging in avoiding this pitfall are discussed.
PURPOSE The purpose of this study was to determine the percentage of all patients sustaining CT-d... more PURPOSE The purpose of this study was to determine the percentage of all patients sustaining CT-diagnosed blunt traumatic aortic injury (TAI) with minor injuries, the extent of associated mediastinal hemorrhage (MH), and clinical outcome of minor TAI treated without intervention. METHOD AND MATERIALS After IRB approval, the authors collected all cases of blunt TAI from our instititution's trauma and radiology registries from 2005 to 2011. For this retrospective study, admission chest CT was reviewed for each patient and categorized as major or minor TAI. Minor TAI included focal aortic contour abnormality, wall thickening, intimal flap(s), and/or shallow pseudoaneurysm. MH extent was graded as 0, 1 or 2 corresponding to absent, periaortic only, or more extensive. All follow-up CTs of patients with minor TAI were reviewed. Chart review for all minor TAI determined patient demographics, initial management and outcome at last follow-up. RESULTS There were 107 TAIs of which 36% (39/...
Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with... more Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury. Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions. Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in...
To review the literature and the authors' experience with admission contrast material-enhance... more To review the literature and the authors' experience with admission contrast material-enhanced computed tomography (CT) in patients admitted after blunt trauma. From January 1990 to December 1994, thoracic CT was performed to evaluate traumatic aortic injury in 677 patients with positive or equivocal findings at chest radiography. CT scans positive for mediastinal hemorrhage or aortic injury were retrospectively reviewed and interpreted by consensus, with angiographic and surgical confirmation. CT findings were negative for TAI in 570 (84%) of the 677 patients. Mediastinal hemorrhage was reported in 100 patients and was the only abnormality in 79 of them. Findings at angiography were negative for traumatic aortic injury in 77 (97%). CT signs of traumatic aortic injury in 21 patients included contour abnormality or pseudoaneurysm (n = 19), intimal flap(s) (n = 8), and pseudocoarctation (n = 3). Findings at angiography were positive for traumatic aortic injury in 19 (90%). For aor...
Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in s... more Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in screening for and facilitating the diagnosis of acute thoracic aortic injury in the patient with blunt chest trauma has shown favorable results. This has led some physicians to question whether conventional thoracic aortography is still the reference standard. The purpose of this review article is to summarize the epidemiology and pathophysiology of acute thoracic aortic injury, the current status of the individual imaging modalities in use, and the surgeon's perspective. Despite a burgeoning literature and a confounding array of clinical and imaging advances, timely diagnosis of acute thoracic aortic injury remains a challenge. To overcome this problem, some trauma centers have used CT, transesophageal echocardiography, or both, in their diagnostic algorithm for acute thoracic aortic injury. These diagnostic algorithms are individually tailored by each institution and are still under...
Nonsurgical management of blunt splenic injury in children is a well-established method to salvag... more Nonsurgical management of blunt splenic injury in children is a well-established method to salvage splenic function; however, nonsurgical management of adult blunt splenic trauma remains controversial. To assess the value of preoperative abdominal CT in predicting the outcome of blunt splenic injury in adults, a CT-based injury-severity score consisting of four grades was devised and applied in 39 adult patients with blunt splenic injury as the sole or predominant intraperitoneal injury detected with preoperative CT. While patients with high grades of splenic injury generally required early surgery, eight (35%) of 23 patients with initial grade 3 or 4 injury were treated successfully without surgery, and four (29%) of 15 patients with grade 1 or 2 injury initially treated nonsurgically required delayed celiotomy (n = 3) or emergency rehospitalization. Results show that while CT remains an accurate method of identifying and quantifying initial splenic injury, as well as documenting p...
To further define the computed tomographic (CT) criteria on which to guide the nonsurgical treatm... more To further define the computed tomographic (CT) criteria on which to guide the nonsurgical treatment of adult patients with blunt hepatic injury, the authors retrospectively reviewed abdominal CT scans obtained before surgery during a 35-month period. Blunt hepatic injury was diagnosed in 187 patients, and review revealed 37 patients in whom the liver was the site of sole or principal intraabdominal injury detected with the help of CT before surgery. A CT-based hepatic injury classification system partly derived from similar systems established with surgical assessment was devised to grade the severity of hepatic injury. CT-based injury scores ranging from grade 1 to 5 were compared with the clinical outcome in patients treated surgically and nonsurgically. Thirty-one patients (83.7%) were successfully treated without surgery, and four patients (10.8%) had findings at celiotomy that did not require further surgery. No patient who was initially treated without surgery required delaye...
PURPOSE To determine the utility of multidetector computed tomography (MDCT) of the face as a pre... more PURPOSE To determine the utility of multidetector computed tomography (MDCT) of the face as a predictor of traumatic optic neuropathy (TON) in patients with blunt trauma. METHOD AND MATERIALS Retrospective chart review of Ophthalmology database from 5/2008 to 12/2009 revealed 44 patients with clinical diagnosis of TON. Contralateral orbits in patients with TON and randomly selected 35 facial trauma patients without TON were evaluated as comparison group. The studies were analyzed by two trauma radiologists, blinded to the clinical diagnosis. Following CT findings were evaluated: facial fractures, extraconal hematoma, intraconal hematoma, hematoma tracking along the optic nerve, hematoma along the posterior wall of the globe, optic canal fracture, nerve impingement by optic canal fracture fragment, extraconal emphysema and intraconal emphysema. Radiological findings were correlated with clinical diagnosis to measure the sensitivity and specificity of each finding. Receiver operating ...
ABSTRACT The purpose of this retrospective study was to determine the CT findings diagnostic of c... more ABSTRACT The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.
The purpose of this study was to determine the optimal contrast concentration, volume, and inject... more The purpose of this study was to determine the optimal contrast concentration, volume, and injection rate for helical CT imaging of trauma patients requiring evaluation of the chest, abdomen, and pelvis. Two hundred forty patients were randomized into six different regimen groups for administration of iohexol nonionic intravenous contrast medium, each regimen containing 36 g iodine, with various injection rates,
Fat embolism syndrome (FES) is an uncommon but serious complication of traumatic injury and is fr... more Fat embolism syndrome (FES) is an uncommon but serious complication of traumatic injury and is frequently diagnostically challenging. In this paper, the authors present four patients who sustained lower extremity long bone injury and who had a normal Glasgow Coma Scale before orthopedic surgical intervention. However, postoperatively, significant neurological deterioration developed in these patients. While cranial computed tomography (CT) obtained immediately after surgery for acutely altered mental status was negative in two of the four patients, brain magnetic resonance imaging (MRI) demonstrated white and gray matter abnormalities accounting for the impaired neurological status in all cases. MRI findings in conjunction with clinical presentation established the diagnosis in all patients. MRI is indicated in any patient with orthopedic injuries who manifests an unexplained acute alteration in mental status, despite a normal head CT.
Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury.... more Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury. Chest radiographs are the initial and most commonly performed imaging study to evaluate the diaphragm after trauma. When chest radiography is indeterminate, spiral computed tomography (CT) with thin sections and reformatted images is the next study of choice, particularly because most hemodynamically stable patients with blunt diaphragm injury will require an admission CT examination to evaluate the extent and anatomical sites of coexisting thoracoabdominal injuries. Magnetic resonance imaging is used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.
ABSTRACT This study was undertaken to determine the incidence and spectrum of “equivocal” finding... more ABSTRACT This study was undertaken to determine the incidence and spectrum of “equivocal” findings on thoracic aortography performed: (a) to exclude traumatic aortic injury (TAI), and (b) to identify radiologic signs that might be useful in increasing diagnostic confidence. All cases of thoracic aortography performed during a 5-year period to evaluate possible major thoracic arterial injury were identified. Those with atypical or uncertain results were reviewed by the authors, and medical records were analyzed to determine initial diagnosis, management course, and clinical outcome. During the study period, 438 thoracic aortograms were performed, of which 45 (10.3%) had surgically proven aortic injury and another 7 (1.6%) had surgically verified injury to proximal aortic branches. Twenty-four of those 438 patients (5.5%) had atypical or uncertain findings on aortography. Of the 24 patients, 10 had findings suggestive of aortic ulceration rather than TAI, 8 had a diagnosis of atypical ductus diverticulum, and 6 were diagnostically confusing for various reasons. Among the 24 cases, 16 patients ultimately were diagnosed as true-positive for TAI based on surgical confirmation, representing 35% of all ruptured aortas diagnosed during the study. Three studies were true-negative based on observation and follow-up angiography. There was one false-positive and two false-negative diagnoses based on surgical findings. Two patients with a presumptive diagnosis of TAI were observed because of their advanced age. Atypical or equivocal angiographic results occur in approximately 5% of the blunt trauma patients studied for potential TAI, but occur in about one third of such patients ultimately proven to have TAI. Some radiologic clues are suggested to increase diagnostic confidence in interpreting atypical aortographic findings. Management approaches also are suggested for cases in which the results remain uncertain.
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