extended series of imaging of trauma sequential along multi system affection

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
‫ا‬ُ‫الو‬َ‫ق‬
‫ك‬َ‫ن‬‫ا‬َ‫ح‬‫ب‬ُ‫س‬َ‫ن‬‫ل‬ َ‫م‬‫ل‬ِ‫ع‬َ‫ال‬َ‫ا‬‫ن‬َ‫ت‬‫َلم‬‫ع‬‫ا‬َ‫م‬ ‫إال‬ ‫ا‬
َ‫ح‬‫ال‬ ُ‫م‬‫ي‬ِ‫ل‬َ‫ع‬‫ال‬ َ‫ت‬َ‫ن‬َ‫أ‬ َ‫إنك‬ُ‫م‬‫ي‬ِ‫ِك‬
‫العظيم‬ ‫هللا‬ ‫صدق‬
(‫البقرة‬ ‫سورة‬–‫اآلية‬32)

2. Body Trauma –
Radiological view
By
Hossam Massoud
National cancer institute - cairo
university

4. Manifestations;
Primary manifestation
Secondary manifestation
Vascular effect of trauma

5. Primary manifestation
 Skull fractures
 Fissure fractures
 Depressed fractures
 Extracerebral
haematomas
 Extradural haematoma
 Subdural haematoma
 Subarachnoid haematoma
 Intraaxial lesions
 Cerebral parenchymal
contusion
 White matter shearing
injury (DAI)

6. Secondary manifestation
 Major secondary effect
of trauma
 Cerebral herniation
 midline shift
 Traumatic ischaemia
/ infarction
 Diffuse cerebral
oedema
 Hydrocephalus.
 Brain death

7. Vascular effect of trauma
 Primary vascular injuries
 Laceration and intimal tear
 Dissection and transection.
 Thrombosis and occlusion.
 Arteriovenous fistula
 Dural sinus / cortical veins laceration or occlusions
 Seconday vascular effects
 Occlusion caused by cerebral herniations (ACA, PCA or
lenticulostraite arteries)
 Flow reduction caused by marked increase of intracranial
pressure

8. CT Indication
 Loss of consciousness or amnesia
 Glasgow coma scale score below 15
 Focal neurological abnormality
 Intoxication.
 Depressed skull fracture / penetrating injury
 Patient age below 2 and above 60y
 Bleeding disorder / anticoagulation

9. Skull fractures
 Types
Linear
Depresed
Diastatic

10. Extra axial haemorrhage
 Types
 Epidural haematoma
 Subdural haematoma
 Subarachnoid haematoma

11. Epidural haematoma
 Etiology
 Forceful impact of calvarium
fracture
 Transient depression of skull
fragment lacerates dural artery

Blood collects between inner
table and outer layer of dura

Dural is stripped away from
inner table forming biconvex
mass

12. Epidural haematoma- CT
findings
 Oftenly accompanied with fracture.
 Biconvex / lenticular
 Extra axial
 Hyperdense mass
 Few cases might be hypodense
 Rapid / active bleeding
 Aneamia

13. Epidural haematoma- CT
findings
Biconvex
Extra axial
Hyperdense mass

14. Subdural haematoma
 Etiology
Sudden deceleration of head
stretch & tear cortical
veins as they cross the
potential subdural space
Incidence  10-20%
Location
Between dura and arachnoid
Frontoparietal
may be bilateral

15. Subdural haematoma- CT
findings
 Acute;
 Sub acute;
 Chronic;

16. Subdural haematoma- CT
findings
Acute
Crescent shaped

Hyperdense
or
mixed (active
bleeding)

17. Subdural haematoma- CT
findings
Subacute
Crescent isodense with
underlying cortex

18. Chronic
 Crescent
 Hypodense
 May have
sepitations.

19. Subarachnoid haematoma
 Moderate to severe head injury
 Worse prognosis.
 Similar to aneurysmal SAH blood filling the
cisterns and sulci

20. Subarachnoid haematoma
CT Findings
 Hyperdensity
smearing the
cisterns and sulci
 Associated diffuse
axonal injury

21. Diffuse axonal injury
(DAI-Shearing effect)
 About 50% of all primary intra-axial injuries are
DAI.
 most common cause of significant morbidity in
CNS trauma.
Etiology
Acceleration / deceleration / rotation forces
o Deform
o Tear axons
o Tear penetrating vessel

22. Diffuse axonal injury
(DAI-Shearing effect)
Location
 Subcortical white matter
 Posterior limb internal
capsule
 Corpus callosum
 Dorsolateral midbrain

23. CT Findings
 may be normal despite
the patient's
presentation with a
profound neurological
deficit.
 ill-defined areas of high
density or hemorrhage
in the characteristic
locations

24. Cerebral Contusion
 Brain impacts an
osseous ridge or a
dural fold
 Foci of punctate
hemorrhage or edema
are located along
gyral crests
 Locations
 Frontal lobe - anterior
pole, inferior surface
 Dorsolateral midbrain
 Inferior cerebellum

25. Intraventricular Hemorrhage
 Commonly associated
with associated with
 Diffuse axonal injury
 Deep gray matter
injury
 Brainstem contusion

28. Proportionate inter-spinouts distances

31. Neural arch fracture of C1
DD
Stable with less neurological injuries

37. 5
Pitfall

38. Burst fracture

41. Facet joints
Normally;

42. Facet Injury (perched / locked
facets)
 Unilateral locked
facet
 Bowtie
 Bilateral locked
facet;
 Anterolistheisis with
neurological deficit

52. Thoracic trauma may involve
injuries to:
1- chest wall / Thoracic cage.
2- Diaphragm.
3- Lung and pleura.
4- Tracheobronchial tree.
5- heart and Mediastinum
1
2
34
5

53. 1- Chest wall injuries
–Chest wall contusion
–Rib fractures
–Flail chest (more than 2 ribs in more
than 2 sites)
–Sternal fractures
–Fractures of the clavicle and shoulder
girdle
–Fracture spine.

54. •Multiple rib fractures

55. Rib Fractures
• Associations;
• First Rib 1 only  facial fractures
• Ribs 1, 2 and 3  Serious Trauma 
Ruptured bronchus
• Ribs 4 to 9  pneumothorax, contusion
• Ribs 10 to 12  lacerations of liver/spleen

56. Complications
• Abnormal Collections Of blood & Air
– Pleura == hemothorax & Pneumothorax
– Mediastinum== hemo & Pneumomediastinum
– Pericardium == hemo & Pneumopericardium
– Subcutaneous emphysema
– Others
•==

57. Complications

58. Sternal fractures;
•high-morbidity, with a mortality 25-45%.
•Usually complicated.
Post.rib Fracture
contusions
Sternal
Fracture

59. Fractured sternum (arrowed)

61. Pulmonary Contusion
• Most common finding in
blunt chest injury
• It presents mild Hemorrhage
into lungs
• Appears within 6 hours of
injury
• Clears in 48 hours
• Usually at point of impact
The 3 components of a
pulmonary contusion include
edema, hemorrhage, and
atelectasis .

62. •Sternal Fx.
•Retrosternal hge
•Lung contusion
•HT

63. Pulmonary Laceration
(Traumatic Lung Cyst)
• Usually not apparent at first because of
surrounding contusion
• Laceration of the lung parenchyma
Usually occurs subpleural under point
of maximum impact
• Half are solid, half are cystic
• Takes up to 6 months to clear

64. Pneumothorax
• A pneumothorax refers to a
collection of gas in the pleural
space resulting in collapse of the
lung on the affected side.
• A tension pneumothorax is air
within the pleural space that is
under pressure; displacing
mediastinal structures and
compromising cardiopulmonary
function.
• A traumatic pneumothorax results
from blunt or penetrating injury that
disrupts the parietal or visceral
pleura.

65. Traumatic Pneumothorax
• Must see visceral pleural white line
• Absence of lung markings peripheral to
pleural line

66. Pneumomediastinum & pneumopericardium
Continuous diaphragm sign
Pneumopericardium
# above great Vs

67. Hemomediastinum

68. Rupture of the Diaphragm
• Left hemidiaphragm affected almost
always
• May not occur for weeks after trauma
• Hernia may contain omentum,
stomach,
large and small bowel, spleen, kidney
• DD == eventration & hernia.

69. Radiological features
• Air-fluid levels or abnormal air collection above
diaphragm
• Abnormal elevation of one (usually left)
hemidiaphragm with or without herniated
gastric fundus or colon
• Contralateral tension displacement of
mediastinum
• Abnormal location of NG tube
• DD of herniation by coronal +/- contrast
images

71. Introduction
 Trauma is the leading cause of death
under the age of forty.
 Of all traumatic deaths, abdominal
trauma is responsible for 10%.
 Initial clinical examination and 1st aid
management followed by other
diagnostic options.

72. Diagnostic tools
 Physical
examination
 Laboratory tests
 Observation
 Diagnostic imaging
 Exploratory
labarotomy
 Diagnostic
Imaging;
 Plain Radiography
 Ultrasound
 CT
 Contrast studies
Plain Radiography
•Fractures
•Air under the diaphragm
•Foreign bodies
Ultrasonographphy
•Parenchymal
injuries (less
sensitive)

74. Findings to look for;
 Hemoperitoneum
 Pneumoperitoneum
 Organ Laceration
 Contusions
 Hematomas (peri ,
Subcapsular or
intra)
 Devascularization of
organs or parts of
organs
 Contrast blush
=active
extravasation

75. Spleen
 The spleen is the most commonly injured
solid organ in about 25% of all patients
with abdominal trauma
I
IIIII
IIIIV Shattered
Hemoperitonium

76. Contrast blush

77. Contrast blush
 DD;
 Active arterial extravasation
 Post-traumatic Pseudoaneurysm
 Post-traumatic AV fistula

78. laceration
hematoma
Hge

79. Liver

80. Liver
 2nd most commonly involved solid organ in the
abdomen after the spleen.
 Liver injury is the most common cause of death (many
major vessels in the liver, like the IVC, hepatic veins,
hepatic artery and portal vein).
 Posterior segment of the right liver lobe is the most
frequently injured part (involves the bare area and this
can lead to retroperitoneal bleeding rather than bleeding
into the peritoneal cavity).

81. I-IIII
IIIIII

82. G-V
>10 cm Subcap. He + C. blush

83. Stellate laceration
Branching laceration
Avulsed right hepatic vein
G-V
Active bleeding
Active bleeding

84. Similar to spleen + G-VI due to 2 lobes of liver

85. Pancreas
 Pancreatic injuries account for 3-10% of all abdominal
injuries.
 The mechanism of injury usually involves
compression between the spine and abdominal
wall during a forceful blow to this area.
 Pancreatic injuries are often associated with other
injuries and carry a relatively high mortality rate,
approximately 25%.
 50% of pancreatic trauma related deaths are due to
hypovolemic shock from major visceral hemorrhage.
 For this reason, rapid and accurate diagnosis of
pancreatic injury is vital.

86. laceration
Contusion +hge
Avulsion + hge
Ductal # +pseudo cyst
Pancreatitis + dudenal hge
pseudo cyst +gerota’s F
Associations &
complications

87. Kidneys