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EMGuideWire's Radiology Reading Room: Blunt Aortic Injury

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EMGuideWire's Radiology Reading Room: Blunt Aortic Injury

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The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD

The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD

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EMGuideWire's Radiology Reading Room: Blunt Aortic Injury

  1. 1. Blunt Aortic Injury Rachel Plate, MD & Oriane Longerstaey, MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Charlotte, North Carolina Bryant Allen, MD & Michael Gibbs, MD Faculty Editors The Chest X-Ray Mastery Project™
  2. 2. Disclosures This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center. The goal is to promote widespread mastery of CXR interpretation. There is no personal health information [PHI] within, and all ages have been changed to protect patient confidentiality.
  3. 3. Process Many are providing clinical cases, and presentations are shared with all contributors on our departmental educational website. Contributors from many Carolinas Medical Center departments, and now… Brazil, Chile, and Tanzania. We will review a series of CXR case studies and discuss an approach to the diagnoses at hand: BLUNT AORTIC INJURY.
  4. 4. Visit Our Website www.EMGuidewire.com for a complete archive of Chest X-Ray Presentations and much more!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. Traumatic Aortic Disruption CXR Findings 1. Wide mediastinum 2. Abnormal aortic contour 3. Loss of aortopulmonary window 4. Tracheal deviation to the right 5. Depressed left mainstem 6. Left apical cap 7. Deviated nasogastric tube 8. Widened left paratracheal stripe 9. Left Hemothorax
  8. 8. TAD Findings Defined 1. Wide mediastinum: > 6 cm on PA film, > 8 cm on AP or supine films 2. Abnormal aortic contour: convexity caused by hematoma 3. Loss of aortopulmonary window: Straight or convex window 4. Left apical cap: Density in the apex of the lung caused by extra- pleural hemorrhage 5. Widened left paratracheal stripe: A left paratracheal stripe is an opacity between left upper lobe and left trachea. A left paratracheal stripe is uncommonly seen on CXR.
  9. 9. Presence of CXR findings in known TAD Traumatic Aortic Disruption CXR Findings 1. Wide mediastinum 2. Abnormal aortic contour 3. Loss of aortopulmonary window 4. Tracheal deviation to the right 5. Depressed left mainstem 6. Left apical cap 7. Deviated nasogastric tube 8. Widened left paratracheal stripe 9. Left Hemothorax 85% 24% 19% 19% CXR Normal in 7% of known TAD!
  10. 10. Widened Mediastinum: > 6 cm on PA film, > 8 cm on AP or supine film
  11. 11. Aortopulmonary window should be concave. The space is bound by the aorta anteriorly, posteriorly, and superiorly, pulmonary artery inferiorly, trachea medially, and left lung pleural laterally.
  12. 12. TAD Chest X-Ray Findings 1. Wide mediastinum 2. Abnormal aortic contour 3. Loss of aortopulmonary window 4. Tracheal deviation to the right 5. Depressed left mainstem 6. Left apical cap 7. Deviated nasogastric tube 8. Widened left paratracheal stripe 9. Left Hemothorax Practice identifying the above findings in blue on this TAD CXR
  13. 13. Apical Cap Tracheal Deviation Loss Of The Aortopulmonary Window
  14. 14. Incidence & Demographics Around 7500-8000 cases per year in the US Occurs in <1% of MVC patients However, accounts of ~16% of MVC deaths 70% male 67% obese One study showed average patient with grade I-II aortic injuries was more likely to be male and the average age of cohort was 41 years
  15. 15. Mechanism of Injury Rapid deceleration • Anatomically, the heart and great vessels (SVC, IVC, pulmonary arteries & veins and aorta) are mobile within the thoracic cavity • Descending abdominal aorta is fixed to posterior chest wall • Injury commonly originates near the terminal section of the aortic arch, also known as the isthmus, just distal to the take-off of the left subclavian artery Ridiculous mortality • 80% die prehospital • 30% of survivors die < 24hrs
  16. 16. Types of Traumatic Aortic Disruptions Laceration Tear in the vessel intima (innermost layer of the vessel wall), typically oriented transversely in trauma Transection Laceration of all three layers of vessel wall (intima, media, adventitia) Pseudoaneurysm Hematoma contained by vessel adventitia Minimal Aortic Injury <1 cm intimal flaps with no or minimal hematoma
  17. 17. Grading of Aortic Injuries Grade I intimal tear or flap Grade II intimal hematoma without change in external contour of aorta Grade III pseudoaneurysm with change in external contour of aorta, but without evidence of extravasation of IV contrast Grade IV evidence of extravasation of IV contrast (transection)
  18. 18. Cases
  19. 19. 67 Year-Old In A Single Vehicle MVC Against A Tree Wide Mediastinum Loss Of The Aortopulmonary Window
  20. 20. 67-year-old In A Single Vehicle MVC Against A Tree Traumatic Pseudoaneurysm
  21. 21. Successfully Deployed Endovascular Stent Graft 67-year-old In A Single Vehicle MVC Against A Tree
  22. 22. 33-year-old Male On A Moped Struck By A Car Wide Mediastinum Traumatic Aortic Disruption
  23. 23. Traumatic Aortic Disruption 33-year-old Male On A Moped Struck By A Car
  24. 24. Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury Wide Mediastinum Traumatic Aortic Disruption
  25. 25. Traumatic Aortic Disruption Young Adult In A Motor Vehicle Crash:  Femur fracture  Splenic injury
  26. 26. Young Adult In A Motor Vehicle Crash Thoracic Endovascular Aortic Repair [TEVAR] Coarctation Of The Thoracic Aorta
  27. 27. 21-year-old On A Motorcycle That Collided Head-On With A Car Wide Mediastinum And Loss Of The Aortopulmonary Window Traumatic Aortic Disruption
  28. 28. 21-year-old On A Motorcycle That Collided Head-On With A Car Prior CXR Now Traumatic Aortic Disruption
  29. 29. Traumatic Aortic Disruption 21-year-old On A Motorcycle That Collided Head-On With A Car
  30. 30. Traumatic Aortic Disruption 21-year-old On A Motorcycle That Collided Head-On With A Car
  31. 31. 55-year-old Pedestrian Struck Wide Mediastinum Tracheal Deviation And Loss Of The Aortopulmonary Window Traumatic Aortic Disruption & Multiple Rib Fractures
  32. 32. 55-year-old Pedestrian Struck Traumatic Aortic Disruption
  33. 33. Traumatic Aortic Disruption Successfully Deployed TEVAR 55-year-old Pedestrian Struck
  34. 34. Pedestrian Struck By An SUV What is your interpretation?
  35. 35. Pedestrian Struck By An SUV Traumatic Aortic Disruption [TAD]  Typically a high mechanism of injury.  MVC, pedestrian struck, fall from a height. Wide Mediastinum
  36. 36. Our Patient Aortic Laceration
  37. 37. Imaging CXR is often performed on trauma patients and if you see the previously mentioned findings, have a high suspicion for aortic injury • However, CXR will be normal in 7% of cases TEE • Not a lot of supporting literature • Can look at aortic root for regurgitation of the valve or involvement of the root for preoperative planning CT Angiography • Sensitivity 98%, Specificity 100% • Will help determine type of injury and assist in pre-operative planning
  38. 38. Management • Open Surgical Repair • Left sided thoracotomy, systemic heparinization • Up to 30% mortality • Complications: paraplegia, renal impairment, CNS lesions, hemothorax • Endovascular • Becoming preferred, manage blood pressure per vascular if repair is delayed • Complications: endoleak, access complications • Less risk of spinal cord ischemia and ESRD, decreased mortality • Contraindications: severe aortic valve regurgitation, disruption involving aortic root, connective tissue disorder • If hemodynamically, stable, delay definitive management until other life-threatening injuries have been addressed
  39. 39. Based on EAST Recommendations
  40. 40. References Bizzarri, F., Mattia, C., Ricci, M. et al. Traumatic aortic arch false aneurysm after blunt chest trauma in a motocross rider. J Cardiothorac Surg 3, 23 (2008). https://doi.org/10.1186/1749-8090-3-23 McLoud, Theresa C., et al. "The apical cap." American Journal of Roentgenology 137.2 (1981): 299-306. Gibbs, Jerry M., et al. "Lines and stripes: where did they go?—From conventional radiography to CT." Radiographics 27.1 (2007): 33-48. Osgood, Michael J., et al. "Natural history of grade I-II blunt traumatic aortic injury." Journal of vascular surgery 59.2 (2014): 334-342. Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multicenter trial of the American Association for the Surgery of Trauma. J Trauma. 1997 Mar;42(3):374-80. Nagpal P, Mullan BF, Sen I, Saboo SS, Khandelwal A. Advances in Imaging and Management Trends of Traumatic Aortic Injuries. CardioVascular and Interventional Radiology. 2017;40(5):643-654. doi:10.1007/s00270-017- 1572-x. Yahia DAA, Bouvier A, Nedelcu C, et al. Imaging of thoracic aortic injury. Journal de Radiologie Diagnostique et Interventionnelle. 2015;96(1):79-88.
  41. 41. If you have interesting cases of Aortic Injury, we invite you to send a set of Digital PDF Images and a brief descriptive Clinical History to: Bryant.Allen@atriumhealth.org Your de-Identified case(s) will be posted on our education website and you and your institution will be recognized!

Editor's Notes

  • On AP films, “wide” mediastinum can be difficult to interpret. Looks for loss of the aortic notch!!

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