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

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. 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. 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. Visit Our Website
www.EMGuidewire.com
for a complete archive of Chest X-Ray Presentations and much more!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

8. 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

9. 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.

10. 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!

12. Widened Mediastinum: > 6 cm on PA film, > 8 cm on AP or supine film

13. 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.

15. 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

16. Apical Cap
Tracheal
Deviation
Loss Of The
Aortopulmonary
Window

17. 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

18. 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

19. 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

20. 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)

21. Cases

22. 67 Year-Old In A
Single Vehicle MVC
Against A Tree
Wide
Mediastinum
Loss Of The
Aortopulmonary
Window

23. 67-year-old In A Single
Vehicle MVC Against A Tree
Traumatic
Pseudoaneurysm

24. Successfully Deployed
Endovascular Stent
Graft
67-year-old In A Single
Vehicle MVC Against A Tree

25. 33-year-old Male On A
Moped Struck By A Car
Wide
Mediastinum
Traumatic Aortic Disruption

26. Traumatic Aortic Disruption
33-year-old Male On A
Moped Struck By A Car

27. Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury
Wide
Mediastinum
Traumatic Aortic Disruption

28. Traumatic Aortic Disruption
Young Adult In A
Motor Vehicle
Crash:
 Femur fracture
 Splenic injury

29. Young Adult In A Motor Vehicle Crash
Thoracic Endovascular Aortic Repair [TEVAR]
Coarctation Of The Thoracic Aorta

30. 21-year-old On A
Motorcycle That
Collided Head-On
With A Car
Wide Mediastinum
And Loss Of The
Aortopulmonary
Window
Traumatic Aortic Disruption

31. 21-year-old On A Motorcycle That Collided Head-On With A Car
Prior CXR Now
Traumatic Aortic Disruption

32. Traumatic Aortic Disruption
21-year-old On A Motorcycle That Collided Head-On With A Car

33. Traumatic Aortic Disruption
21-year-old On A Motorcycle That Collided Head-On With A Car

34. 55-year-old
Pedestrian Struck
Wide Mediastinum
Tracheal Deviation
And Loss Of The
Aortopulmonary
Window
Traumatic Aortic Disruption & Multiple Rib Fractures

35. 55-year-old Pedestrian Struck
Traumatic Aortic Disruption

36. Traumatic Aortic Disruption
Successfully
Deployed TEVAR
55-year-old Pedestrian Struck

37. Pedestrian
Struck By An
SUV
What is your interpretation?

38. Pedestrian
Struck By An
SUV
Traumatic Aortic Disruption [TAD]
 Typically a high mechanism of injury.
 MVC, pedestrian struck, fall from a height.
Wide
Mediastinum

39. Our Patient
Aortic
Laceration

40. 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

41. 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

42. Based on EAST Recommendations

43. 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.

44. 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!