Value of spiral CT in hemodynamically stable patients following blunt chest trauma

Vancouver simplified grading system with computed tomographic angiography for blunt aortic injury

OBJECTIVE

Delineation of blunt aortic injury by computed tomographic angiography guides management of this potentially fatal injury. Two existing grading systems are problematic to apply and not linked to outcomes. A simplified computed tomographic angiography-based grading system, linked to clinical outcomes, was developed, and feasibility and reliability were evaluated.

METHODS

Retrospective review was performed of all blunt aortic injury cases presenting to a single provincial quaternary referral center designated for blunt aortic injury management between 2001 and 2009. Management, associated injuries, hospital survival, and cause of death were determined. Initial computed tomographic angiography was reviewed, and injuries were graded according to the new Vancouver simplified grading system by 2 study authors. Three additional trauma radiologists then graded the aortic injuries with the 2 existing systems and the simplified system. Interrater reliability was determined.

RESULTS

Forty-eight patients were identified. Two had minimal aortic injury (grade I), 7 had an intimal flap larger than 1 cm (grade II), 32 had traumatic pseudoaneurysm (grade III), 6 had active contrast extravasation (grade IV), and 1 could not be rated. Survivals were 100%, 90%, and 33% for grades I and II, III, and IV, respectively. Of grade III injuries, 14% were medically managed, 68% repaired endovascularly, and 18% repaired with open surgery. Interrater correlation was best with the simplified score, with only 0.5% of cases unable to be classified.

CONCLUSIONS

The Vancouver simplified blunt aortic injury grading system is easy to use and correlates with clinical outcomes. Prospective external validation is required.

Imaging Evaluation of Pediatric Chest Trauma

Following a discussion of the various imaging manifestations of pediatric chest trauma by anatomic location, the authors discuss their diagnostic approach to the pediatric multitrauma patient with an emphasis on chest imaging.

The Evolution of Chest Computed Tomography for the Definitive Diagnosis of Blunt Aortic Injury: A Single-Center Experience

BACKGROUND

Chest computed tomography (CT) is an excellent screening tool for blunt aortic injuries (BAIs). Aortography is considered the "gold standard" for diagnosis. Recent evidence suggests that new-generation, multislice, helical CT technology can accurately diagnose BAI.

METHODS

A retrospective review of aortograms performed to evaluate for BAI was compared with the results of CT and operative findings. BAIs definitively diagnosed by CT alone were also studied.

RESULTS

Between July 1, 1996, and June 30, 2002, 113 aortograms were obtained, with 28 BAI cases confirmed. Of these, 27 were congruently diagnosed by CT. Only one computed tomographic scan diagnostic for BAI had a subsequent negative aortogram. Seventeen BAIs were diagnosed with CT alone. Ten were confirmed operatively and seven were treated nonoperatively because of age, comorbid conditions, severity of injury, or the presence of small intimal defects.

CONCLUSION

CT technology has evolved to allow for the definitive diagnosis and treatment of BAI. Aortography should still be used where new-generation CT is not available.

Is helical computed tomography effective for diagnosis of blunt aortic injury?

Computed tomography has had a questionable role in diagnosing blunt aortic injury (BAI). The objective of this study was to determine the effectiveness of helical computed tomography of the thorax (HCTT) for detection of BAI. Trauma Registry data and medical records were reviewed for 2,854 patients admitted over a 32-month period. A total of 243 patients were identified at risk for BAI. Patients were evaluated for BAI because of chest radiograph, physical examination, or clinical suspicion. Eleven of 2,834 patients sustained BAI. Of 243 patients who sustained blunt torso trauma, 232 patients underwent HCTT. Eleven underwent aortography without HCTT. Sixteen patients had an abnormal HCTT, revealing 9 patients with BAI. No delayed BAI were encountered. HCTT effectively screens for BAI. Aortography can be more specifically applied as a diagnostic study when preceded by HCTT. HCTT should not be used as solitary study for BAI as some injuries identified by HCTT do not represent BAI.

Minimal aortic injury: a lesion associated with advancing diagnostic techniques

BACKGROUND

With the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000.

METHODS

All patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma.

RESULTS

Of the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms.

CONCLUSION

Ten percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.