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CT Imaging of Abdominal Trauma Injuries
- 1. IMAGING OF ABDOMINAL TRAUMA DR. DEVKANT LAKHERA
- 2. Abdominal trauma Trauma causes I0% of deaths worldwide Blunt trauma is more common
- 3. Imaging – Plain Radiography Preferred in hemodynamically stable patients X-ray chest erect PA view
- 4. Ultrasound Rapid technique Can be done bedside Hemodynamically unstable patients
- 5. Focused Assessment with Sonography for Trauma (FAST) To identify intra-abdominal free fluid – Hemoperitoneum Sensitivity – 80-100% for FF and injuries is 40-80 %
- 6. Transverse view epigastrium/ sub xiphoid view
- 8. Longitudinal view Right upper quadrant
- 9. Longitudinal view of left upper quadrant
- 10. FF seen between the spleen and left kidney
- 11. Transverse and longitudinal views suprapubic region
- 12. Role of CT scan More accurate for solid visceral assessment Quantification of hemorrhage Assessment of retroperitoneal injuries Most sensitive and imaging modality o choice for evaluation of abdominal trauma
- 13. Spleen Most common injured organ in blunt trauma (40% of all solid organ injuries) CECT is the investigation of choice Integrity of organs Extent of injury / Localization of parenchymal contusions, hematoma
- 14. Splenic hematoma Parenchymal Subcapsular
- 16. Delayed splenic rupture Bleeding due to splenic injury occurring more than 48 h after blunt trauma Due to ruptures of subcapsular splenic hematomas.
- 17. Splenic laceration Linear low attenuation defects between high attenuation vascular spleen.
- 18. Splenic cleft Superiorly located Absence of hemoperitoneum
- 21. Splenic infarct pyramidal wedge shaped apex pointing towards the hilum base on the splenic capsule.
- 22. Imaging considerations Images should be take 50-60 seconds after contrast for uniform enhancement of the spleen
- 23. Contrast blush The differential diagnosis is: Active arterial extravasation Post-traumatic pseudoaneurysm Post-traumatic AV fistula
- 24. American Association for the Surgery of Trauma (AAST) Grade I Subcapsular hematoma <10% capsular laceration <1 cm depth
- 25. Grade II Subcapsular hematoma 10-50% Parenchymal hematoma <5 cm Laceration 1-3 cm depth
- 26. Grade III Subcapsular hematoma >50% Intraparenchymal hematoma >5 cm Laceration >3 cm
- 27. Grade IV laceration hilar vessels major devascularisation (>25% of spleen)
- 28. Grade V Shattered spleen Hilar vascular injury with splenic devascularisation
- 29. Axial CECT scan shows nonenhancing spleen
- 30. Liver Second most commonly injured organ (20-30%) Right lobe most commonly affected (4:1) Penetrating injury
- 31. Hepatic Injuries Laceration (most common) Hematoma - subcapsular or intraparenchymal Active hemorrhage Major hepatic vein injury
- 32. Liver laceration Low attenuation defects in linear or stellate pattern.
- 33. Periportal tracking Blood tracking along periportal connective tissue
- 34. Grade I •Subcapsular hematoma : <10% •Laceration: capsular tear <1 cm
- 35. •Subcapsular hematoma: 10-50% •Intraparenchymal hematoma <10 cm •Laceration: 1-3 cm in parenchymal depth Grade II
- 36. •Subcapsular hematoma: >50% •Intraparenchymal hematoma >10 cm •Laceration: capsular tear >3 cm parenchymal depth Grade III
- 37. Grade IV •Parenchymal disruption involving 25-75% hepatic lobe •Active bleeding
- 38. Grade V •Laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud’s segments (one lobe)
- 39. Grade VI Hepatic Avulsion
- 40. Active contrast extravasation within liver parenchymal hematoma DSA showed a large pseudoaneurysm
- 41. Pancreas Least commonly injured solid organ (3-12 %). Seatbelt injuries : Compression against the vertebral column. Rarely an isolated injury
- 42. Clinical and biochemical findings Epigastric pain Elevated serum amylase in 60 % ( 95% Negative Predictive Value)
- 43. CT findings 40 % of pancreatic injuries may not be visible on CT in first 12 hrs
- 44. laceration/transection involving neck/proximal body of pancreas
- 45. Grade I- Minor contusion or laceration without duct injury Grade II- Major contusion or laceration without duct injury
- 46. Grade III Distal Pancreatic transection with duct injury
- 47. Grade IV :Proximal transection Grade V : Massive disruption of pancreatic head
- 48. Findings that may suggest pancreatic trauma Localized edema Retroperitoneal hematoma / fat infiltration. Fluid in lesser sac Thickening of anterior pararenal fascia
- 49. Bowel and mesentery injury Bowel and mesenteric injuries in 5% of blunt trauma MDCT is more sensitive than Clinical exam, USG, DPL
- 50. Direct findings –Pneumoperitoneum or pneumo-retroperitoneum
- 51. Direct findings Contrast extravastation Interloop fluid Bowel wall discontinuity
- 52. Less common signs Focal bowel wall thickening greater than 3 mm Mesenteric infiltration, thickening Abnormal bowel wall enhancement
- 53. Shock bowel Hypoperfusion state
- 54. Mesenteric injury Signs Contrast extravasation Beaded mesenteric vessels Hematoma Infiltration
- 55. Vascular injury – CT findings IVC injuries lumen is irregular and compressed by hematoma Active contrast extravasation.
- 56. Aortic injuries Contrast extravasation Large psoas or mesenteric hemorrhage, pseudo-aneurysm. Pelvic vasculature injuries are associated with pelvic fractures.
- 57. THANK YOU
- 58. THANK YOU
- 59. Imaging of Renal Trauma Computed tomography (CT) is the modality of choice Injury to the kidney is seen in approximately 8%– 10% of patients with blunt or penetrating abdominal injuries
- 60. Subcapsular hematoma (category I) Crescent shaped hyperdensity, located in the periphery of the kidney
- 61. Laceration Hypodense, irregularly linear areas, typically distributed along the vessels and filled with blood. They are best analyzed at arterial phase Superficial (<1 cm from the renal cortex) Deep (>1 cm from the renal cortex)
- 62. Simple renal laceration (category I)
- 63. Major renal laceration without involvement of the collecting system (category II <1 cm)
- 64. Major renal laceration involving the collecting system (category II)
- 65. Multiple renal lacerations (category III >1 cm)
- 66. Shattered kidney (category III)
- 67. Segmental renal infarction (category II)
- 68. Traumatic occlusion of the main renal artery (category III)
- 70. Vein Pedicle Injury Incomplete or absent opacification of the renal vein Persistent nephrogram Reduction in excretion Nephromegaly
- 71. Laceration of the renal vein (category III)
- 72. Urinoma/Urohematoma Presence of a more or less significant breach of the collecting tube system, with urine escape reflected by extravasation of contrast medium on delayed imaging, in an extrarenal location
- 73. Avulsion of the ureteropelvic junction (category IV)
Editor's Notes
- 50 % of trauma related deaths are due to RTAs
- Pneumoperitoneum, bony injuries, subcutaneous emphysema, Insensitve to detect hemoperitoneum ///This difference in sensitivity occurs because the x-ray beam is centered at the iliac crest on abdominal films, so that it penetrates air beneath the diaphragm obliquely rather than tangentially.///Present as soft tissue haze near paracolic gutters displacing the colon….
- Can be limited by bandages and dressing, subcutaneous emphysema and bowel shadows
- Initial assessment of acutely injured patient. Negatve FAST should be viewed as the absence of hemoperitoneum not absence of abdominal injury Less sensitive than CT but better than diagnostic peritoneal lavage
- Pericardial fluid and injury to the left lobe of liver….see the left lobe of liver and a 4 chambered heart view
- Anechoic separation between the pericardium and myocardium
- Right lobe of liver , kidney perihepatic ff, Fluid in morrisons pouch.
- Spleen, left kidney and perisplenic free fluid
- To view the urinary bladder and look for ff in pelvis and pouch of douglas
- rich vascular supply, fractured ribs splenomegaly//viable parenchyma will enhance.//Identifies great vessels// Factors,.
- Parenchymal hematomas appear as focal, poorly marginated hypodense areas.
- Lenticular configuration and flattening of the adjacent splenic parenchyma….
- following an apparently normal CT examination
- Superficial, linear hypodensity, usually less than 3 cm in length Fracture - involves two visceral surfaces, or if its length is more than 3 cm
- Preserved fat planes…On delayed film laceration margins appear to fill in and become less visible, and in splenic
- Clotted blood adjacent to the site of injury is of higher attenuation (45-70 HU) than unclotted blood (30- 45 HU) which flows Away.. location of highest attenuating blood clot
- Linear hypodense areas consistent with lacerations. Round and oval hypodense areas consistent with intrasplenic hematoma. Hemoperitoneum.
- More triangular and more peripheral
- Portal venous phase as heterogenous enhancement of spleen can simulate injury… Imaging early arterial for active extravastation/ traumatic pseudoaneurysm
- Active contrast HU 85-350 HU ..High attenuating, poorly marginated, pseudoaneurysm has a well defined margin, enhancement close to 10 hu of artery even on delayed, angiography//hematoma that forms as the result of a leaking hole in an artery
- Moderate volume of free intraperitoneal fluid, particularly around the spleen which has a small hypodense and superficial cleft posteriorly, suspicious for grade I laceration.
- not involving trabecular vessels hypodense laceration seen involving the posterior aspect of the spleen with intrasplenic hematoma.
- expanding or involving trabecular vessels intraparenchymal haematoma/laceration measuring > 5 cm which extends to the splenic hilum
- Extensive splenic lacerations extending to the hilum with areas of devascularisation. No evidence of active bleeding or pseudo-aneurysm. There is extensive haemoperitoneum throughout the abdominopelvic cavity. Cholecystectomy clips are noted along with extrahepatic and first order intrahepatic duct dilatation.
- The spleen is shattered. When assessing the need for surgery hemodynamic status is more important than CT appearance
- (devascularized).
- As with spleen CT is the diagnostic modality of choice
- Stellate / radiating lacerations -Bear claw pattern
- Blood / obstructed lymphatics at hila. D/t Overtransfusion after traum
- Liver (segment 7) subcapsular haematoma. Subcapsulatr hematomas indent the liver margin and are frequently identified in the right lobe of liver( anterolateral part of right lobe of liver) less chance for delayed rupture as spleen
- Acute hematomas show higher attenuation than normal liver parenchyma on unenhanced CT Superficial<3 cmDeep >3 cm
- or expanding Multiple deep linear branching hypodense lacerations are seen involving the posterior segment of right hepatic lobe with associated large hypodense subcapsular parenchymal hematoma. No evidence of contrast blush or active bleeding. Intact vascular pedicle.
- Large laceration in the right lobe of the liver with a perihepatic haematoma. Active contrast extravastation from the liver parenchyma into the perihepatic spac
- vascular: juxtahepatic venous injuries
- Role of surgery is more predictable by hemodynamic status of the patient
- The patient underwent coil embolization
- Elevated serum amylase is nonspecific and does not correlate with severity of injury…
- Axial CECT scans show a contusion involving the head of pancreas
- Axial CECT scan through pancreas ……… with a large collection seen anterior to pancreas
- Ct is insensitive to detect duct injuries MRCP may be done
- Specific sign is tracking of fluid between body of pancreas and splenic vein.
- Deceleration injuries shearing forces
- sagittal reformat (B) images of CECT shows a focal defect in wall of ileum (arrows) with air extending outside bowel lumen. An axial section at a different level with changed window settings shows the presence of pneumoperitoneum
- Presence of these signs mandate urgent laparotomy
- (intramural hematoma) entire descending colon distended with hyperdense contents representing hematoma with thinned out abnormally enhancing walls and air within the wall suggesting colonic injury
- Does not necessarily imply bowel rupture. Axial CECT scan through mid abdomen (A) shows diffuse thickening and hyperenhancement of jejunal loops. Flat ivc
- Shows infiltration and hematoma (arrows) in mesentric root representing mesentric injury
- Blunt injuries to IVC and aorta are rare..hepatic lacerations may extend to IVC , have a high mortality rate extreme hypovoluemia. Active extravastation in IVC lavceration
- Infrarenal better prognosis than perihepatic due to tamponading effect of retroperitoneum.