Novel computed tomography scan scoring system predicts the need for intervention after splenic injury

Does delayed phase imaging in CT angiography provide additional information in patients with suspected active bleeding?

PURPOSE

We hypothesize that delayed phase imaging does not provide additional diagnostic information in patients who undergo multi-phasic CTA for suspected active bleeding.

METHODS

Data on patients who underwent multiphasic CTA (pre-contrast, arterial, porto-venous, and delayed phases) for suspected acute bleed were retrospectively collected between January 2019 and November 2021. CTA images were reviewed by a general radiologist, an interventional radiologist, and a body imaging radiologist independently. Each reader evaluated if delayed phase images provided additional information that would change the final impression of the CTA report. Additional information regarding bleeding location, time needed for delayed image acquisition, and radiation exposure were also obtained.

RESULTS

A total of 104 patients with CTAs were analyzed with an average age of 58 years ± 22. Studies rated with absent additional findings on delayed images were 102 (98.1%) by the interventional radiologist, 101 (97.1%) by the body imaging radiologist, and 100 (96.1%) by the general radiologist with percent agreement of 96.15% (kappa 0.54, p < 0.001). All the findings were characterized as unlikely to be clinically significant. Mean time added to complete a delayed phase images was 3.61 ± 3.4 min. The average CT dose length product (DLP) for the total exam was 3621.78 ± 2129.57 mGy.cm with delayed acquisition adding a mean DLP of 847.75 ± 508.8 mGy.cm.

CONCLUSION

Delayed phase imaging does not provide significant additional diagnostic information in evaluating patients with suspected active bleeding but is associated with increased examination time and radiation exposure.

Splenic artery embolisation for blunt splenic trauma: 10 years of practice at a trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has transformed the management of splenic trauma. The aim of this study was to review the outcomes and postprocedural management of blunt splenic trauma patients treated with SAE at a trauma centre over a 10-year period.

METHODS

Details of patients undergoing SAE for blunt trauma between January 2012 and January 2022 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information, splenic injury grades, embolisation efficacy, complications, and associated injuries and mortality. Data relating to Injury Severity Scores (ISS) and postprocedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained.

RESULTS

Thirty-six patients (24 male, 12 female) with a median age of 42.5 years (range 13-97 years) were identified. American Association for the Surgery of Trauma splenic injury grades were III (n = 7), IV (n = 20) and V (n = 9). Seventeen patients had isolated splenic injury and 19 had additional injuries to other organ systems. Median ISS was 18.5 (range 5-50). SAE succeeded first time in 35/36 cases, and upon the second attempt in 1/36 cases. No patients died because of splenic injury or SAE although four patients with polytrauma died owing to other injuries. SAE complications occurred in 4/36 cases. For survivors, vaccinations were administered in 17/32 cases, and long-term antibiotics were initiated in 14/32 cases. Formal follow-up imaging was arranged in 9/32 cases.

CONCLUSIONS

These data show that SAE is an effective means of controlling splenic haemorrhage secondary to blunt trauma with no patient requiring subsequent laparotomy. Major complications occurred in 11% of cases. Follow-up practice varied regarding further imaging, antibiotic and vaccination administration.

Alahmad Y, Jaleel Z, Ahmed Z, Kaassamali R, Hasani AA, Al-Thani H, Omar A. The predictive value of CTSI scoring system in non-operative management of patients with splenic blunt trauma: The experience of a level 1 trauma center

Background

The spleen is one of the most injured organs following blunt abdominal trauma. The management options can be either operative or non-operative management (NOM) with either conservative management or splenic artery embolization. The implementation of CT in emergency departments allowed the use of CT imaging as a primary screening tool in early decision-making. Consecutively, new splenic injury scoring systems, such as the CT severity index (CTSI) reported was established.

Aim

The main aim of this study is to evaluate the effect of the implementation of CTSI scoring system on the management decision and outcomes in patients with blunt splenic trauma over 8 years in a level 1 trauma center.

Methods

This is a retrospective study including all adult patients with primary splenic trauma, having NOM and admitted to our hospital between 2013 and 2021.

Results

The analyses were conducted on ninety-nine patients. The average sample age was 32.7 ± 12.3 years old. A total of (63/99) patients had splenic parenchyma injury without splenic vascular injury. There is a statistically significant association between CTSI grade 3 injury and the development of delayed splenic vascular injury (p < 0.05). There is an association between severity of initial CTSI score and the risk of NOM/clinical failure (p = 0.02).

Conclusion

Our findings suggest implementing such a system in a level 1 trauma center will further improve the outcome of treatment for splenic blunt trauma. However, CTSI grade 3 is considered an increased risk of NOM failure, and further investigations are necessary to standardize its management.

Predictors of need for endovascular intervention in hepatic trauma

PURPOSE

Non-operative management of hepatic trauma with adjunctive hepatic arterial embolization (HAE) is widely accepted. Despite careful patient selection utilizing CTA, a substantial proportion of angiograms are negative for arterial injury and no HAE is performed. This study aims to determine which CT imaging findings and clinical factors are associated with the presence of active extravasation on subsequent angiography in patients with hepatic trauma.

MATERIALS AND METHODS

The charts of 243 adults who presented with abdominal trauma and underwent abdominal CTA followed by conventional angiography were retrospectively reviewed. Of these patients, 49 had hepatic injuries on CTA. Hepatic injuries were graded using the American association for the surgery of trauma (AAST) CT classification, and CT images were assessed for active contrast extravasation, arterial pseudoaneurysm, sentinel clot, hemoperitoneum, laceration in-volving more than 2 segments, and laceration involving specific anatomic landmarks (porta hepatis, hepatic veins, and gallbladder fossa). Medical records were reviewed for pre- and post-angiography blood pressures, hemoglobin levels, and transfusion requirements. Angiographic images and reports were reviewed for hepatic arterial injury and performance of HAE.

RESULTS

In multivariate analysis, AAST hepatic injury grade was significantly associated with increased odds of HAE (Odds ratio: 2.5, 95% CI 1.1, 7.1, p = 0.049). Univariate analyses demonstrated no significant association between CT liver injury grade, CT characteristics of liver injury, or pre-angiographic clinical data with need for HAE.

CONCLUSION

In patients with hepatic trauma, prediction of need for HAE based on CT findings alone is challenging; such patients require consideration of both clinical factors and imaging findings.

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention

BACKGROUND.

Several ordinal grading systems are employed in deciding whether to perform angioembolization or splenectomy following blunt splenic injury. The 2018 AAST Organ Injury Scale (OIS) incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision-making.

PURPOSE.

To compare performance of CT volumetry-based quantitative modeling to the 1994 and 2018 AAST OIS and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or angioembolization (AE)

MATERIALS AND METHODS.

Adult BSI patients (age ≥ 18 years) scanned with dual-phase CT prior to intervention at a single level I trauma center from 2017-2019 were included in this retrospective study (n=174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included 1. SPY and 2. The composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. AUCs for ordinal systems and volumetric models were compared.

RESULTS.

Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85- SPY, 0.82-composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p=0.66, 0.14) for both endpoints, and were significantly improved over Thompson scoring (0.76, p=0.02; 0.77, p=0.04).

CONCLUSION:

Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring.

Study Type:

Prognostic

Level of Evidence:

IV

CT volumetry of blunt splenic injury-related features predicts splenectomy and angioembolization in adults and identifies clinically important target features for computer vision and automation research.

Non-operative management of blunt splenic trauma: evolution, results and controversies

The spleen is one of the most frequently affected organs in blunt abdominal trauma. Since Upadhyaya, the treatment of splenic trauma has undergone important changes. Currently, the consensus is that every splenic trauma presenting with hemodynamic stability should be initially treated nonoperatively, provided that the hospital has adequate structure and the patient does not present other conditions that indicate abdominal exploration. However, several topics regarding the nonoperative management (NOM) of splenic trauma are still controversial. Splenic angioembolization is a very useful tool for NOM, but there is no consensus on its precise indications. There is no definition in the literature as to how NOM should be conducted, neither about the periodicity of hematimetric control, the transfusion threshold that defines NOM failure, when to start venous thromboembolism prophylaxis, the need for control imaging, the duration of bed rest, and when it is safe to discharge the patient. The aim of this review is to make a critical analysis of the most recent literature on this topic, exposing the state of the art in the NOM of splenic trauma.

Splenic trauma, the way forward in reducing splenectomy: our 15-year experience

INTRODUCTION

The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital.

METHOD

A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes.

RESULTS

There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%.

DISCUSSION AND CONCLUSION

AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.

Emergency CT for assessment and management of blunt traumatic splenic injuries at a Level 1 Trauma Center: 13-year study

PURPOSE

To determine the relationship between multidetector computed tomography (MDCT) findings, management strategies, and ultimate clinical outcomes in patients with splenic injuries secondary to blunt trauma.

MATERIALS AND METHODS

This Institutional Review Board-approved study collected 351 consecutive patients admitted at the Emergency Department (ED) of a Level I Trauma Center with blunt splenic trauma between October 2002 and November 2015. Their MDCT studies were retrospectively and independently reviewed by two radiologists to grade splenic injuries according to the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) and to detect intraparenchymal (type A) or extraparenchymal (type B) active bleeding and/or contained vascular injuries (CVI). Clinical data, information on management, and outcome were retrieved from the hospital database. Statistical analysis relied on Student's t, chi-squared, and Cohen's kappa tests.

RESULTS

Emergency multiphase MDCT was obtained in 263 hemodynamically stable patients. Interobserver agreement for both AAST grading of injuries and vascular lesions was excellent (k = 0.77). Operative management (OM) was performed in 160 patients (45.58% of the whole cohort), and high-grade (IV and V) OIS injuries and type B bleeding were statistically significant (p < 0.05) predictors of OM. Nonoperative management (NOM) failed in 23 patients out of 191 (12.04%). In 75% of them, NOM failure occurred within 30 h from the trauma event, without significant increase of mortality. Both intraparenchymal and extraparenchymal active bleeding were predictive of NOM failure (p < 0.05).

CONCLUSION

Providing detection and characterization of parenchymal and vascular traumatic lesions, MDCT plays a crucial role for safe and appropriate guidance of ED management of splenic traumas and contributes to the shift toward NOM in hemodynamically stable patients.

Evidence-Based Management and Controversies in Blunt Splenic Trauma

PURPOSE OF REVIEW

The study aims to describe the evidence-based management and controversies in blunt splenic trauma.

RECENT FINDINGS

A shift from operative management to non-operative management (NOM) has occurred over the past decades where NOM has now become the standard of care in haemodynamically stable patients with blunt splenic injury. Splenic artery embolisation (SAE) is generally believed to increase the success rate of NOM. Not all the available evidence is that optimistic about SAE however. A morbidity specifically related to SAE of up to 47% has been reported. Although high-grade splenic injury is a prognostic factor for failure of NOM, an American research group has published a study in which NOM is performed in over half of haemodynamically stable patients with grade IV or V splenic injury without leading to an increased morbidity (in terms of complications) or mortality. Another area of current investigation in the literature is the exact indication for SAE. Although the generally accepted indication is the presence of vascular injury, a topic of current investigation is whether there might be a role for pre-emptive embolisation in patients with high-grade splenic injury. On the other hand, evidence is also emerging that not all blushes require an intervention (small blushes <1 or 1.5 cm do not). Lastly, the available evidence shows that splenic function is preserved after embolisation, and therefore, the routine administration of vaccinations seems not to be necessary. There might be a difference between proximal and distal embolisations; however, with regard to splenic function, in favour of distal embolisation.

SUMMARY

Nowadays, NOM is the standard of care in haemodynamically stable patients with blunt splenic injury. The available evidence (although with a relatively small number of patients) shows that splenic function is preserved after NOM, a major advantage compared to splenectomy. SAE is used as an adjunct to observation in order to increase the success rate of NOM. Operative management should be applied in case of haemodynamic instability or if associated intra-abdominal injuries requiring surgical treatment are present. Patient selection (which patient can be safely treated non-operatively, does every blush needs to be embolised?, which patients might be better off with direct operative intervention given the patient and injury characteristics) is an ongoing subject of further research. Future studies should also focus on long-term outcomes of patients treated with embolisation (e.g. total number of lifetime infectious episodes requiring antibiotic treatment or hospital admission, quality of life).

Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis

Background

Non-operative management (NOM) is the standard of care in hemodynamically stable patients with blunt splenic injury after trauma. Splenic artery embolization (SAE) is reported to increase observation success rate. Studies demonstrating improved splenic salvage rates with SAE primarily compared SAE with historical controls. The aim of this study was to investigate whether SAE improves success rate compared to observation alone in contemporaneous patients with blunt splenic injury.

Methods

We included adult patients with blunt splenic injury admitted to five Level 1 Trauma Centers between January 2009 and December 2012 and selected for NOM. Successful treatment was defined as splenic salvage and no splenic re-intervention. We calculated propensity scores, expressing the probability of undergoing SAE, using multivariable logistic regression and created five strata based on the quintiles of the propensity score distribution. A weighted relative risk (RR) was calculated across strata to express the chances of success with SAE.

Results

Two hundred and six patients were included in the study. Treatment was successful in 180 patients: 134/146 (92 %) patients treated with observation and 48/57 (84 %) patients treated with SAE. The weighted RR for success with SAE was 1.17 (0.94–1.45); for complications, the weighted RR was 0.71 (0.41–1.22). The mean number of transfused blood products was 4.4 (SD 9.9) in the observation group versus 9.1 (SD 17.2) in the SAE group.

Conclusions

After correction for confounders with propensity score stratification technique, there was no significant difference between embolization and observation alone with regard to successful treatment in patients with blunt splenic injury after trauma.

Splenic artery embolisation in the non-operative management of blunt splenic trauma in adults

Background: The purpose of this study was to evaluate the splenic salvage rate with angioembolisation in the non-operative management (NOM) of blunt splenic injury.Methods: We conducted a retrospective analysis of patients presenting to our Level I trauma centre with computed tomography (CT)-confirmed splenic injury following blunt trauma and in whom angioembolisation was utilised in the algorithm of NOM. Data review included CT and angiography findings, embolisation technique and patient outcomes.Results: Between January 2005 and April 2010, 60 patients with splenic injury following blunt trauma underwent NOM, which included splenic artery embolisation (SAE). All patients included in the study required a preadmission. CT scan was used to document the American Association for the Surgery of Trauma (AAST) grade of splenic injury. The average injury grade was 3.0. The non-operative splenic salvage rate following SAE was 96.7% with statistically similar salvage rates achieved for grades II to IV injuries. The quantity of haemoperitoneum and the presence of a splenic vascular injury did not significantly affect the splenic salvage rate. The overall complication rate was 27%, of which 15% were minor and 13% were major.Conclusion: SAE is a safe and effective treatment strategy in the NOM of blunt splenic injury. The quantity of haemoperitoneum, the presence of vascular injury and embolisation technique did not significantly affect the splenic salvage rate.

Splenic artery embolization: technically feasible but not necessarily advantageous

Background

The spleen is the second most commonly injured organ in cases of abdominal trauma. Management of splenic injury depends on the clinical status of the patient and can include nonoperative management (NOM), splenic artery embolization (SAE), surgery (operative splenic salvage or splenectomy), or a combination of these treatments. In nonoperatively managed cases, SAE is sometimes used to control haemorrhage. However, the indications for SAE have not been clearly defined and, in some cases, the potential complications of the procedure may outweigh its benefits.

Review of the literature

Through review of the literature we address the question of when SAE is indicated in combination with NOM of splenic injury, and whether SAE may delay needed surgical treatment in some cases. This systematic review highlighted the use of imperfect and inconsistent scoring systems in the diagnosis of splenic injury, the lack of consensus regarding indications for SAE, and the potential for severe morbidities associated with this procedure. Based on current literature and evidence we provide a new, non-verified, decision algorithm.

Conclusions

NOM+ SAE involves potential risks and operative management may be preferable to SAE for certain patients. To clarify current literature, we propose a new algorithm for blunt abdominal trauma that should be validated prospectively. New evidence-based protocols should be developed to guide diagnosis and management of patients with splenic trauma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13017-016-0100-7) contains supplementary material, which is available to authorized users.

An Overview of Splenic Embolization

OBJECTIVE

The purpose of this article is to define the role of splenic embolization in trauma patients and in patients presenting for treatment of thrombocytopenia and portal hypertension. This article reviews the indications, technical considerations, outcomes, and complications of splenic artery embolization.

CONCLUSION

Transcatheter splenic artery embolization has a major role in the management of traumatic splenic injuries and as an adjunctive procedure in the treatment of thrombocytopenia and portal hypertension.

The treatment of spleen injuries: a retrospective study

Background

Hemorrhage after blunt trauma is a major contributor to death after trauma. In the abdomen, an injured spleen is the most frequent cause of major bleeding. Splenectomy is historically the treatment of choice. In 2007, non-operative management (NOM) with splenic artery embolization (SAE) was introduced in our institution. The indication for SAE is hemodynamically stable patients with extravasation of contrast, or grade 3–5 spleen injury according to the Abbreviated Organ Injury Scale 2005, Update 2008. We wanted to examine if the introduction of SAE increased the rate of salvaged spleens in our trauma center.

Method

All patients discharged with the diagnosis of splenic injury in the period 01.01.2000 – 31.12.2013 from the University Hospital of North Norway Tromsø were included in the study. Patients admitted for rehabilitation purposes or with an iatrogenic injury were excluded.

Results

A total of 109 patients were included in the study. In the period 2000-7, 20 of 52 patients were splenectomized. During 2007-13, there were 6 splenectomies and 24 SAE among 57 patients. The reduction in splenectomies is significant (p < 0.001). There is an increase in the rate of treated patients (splenectomy and SAE) from 38 to 53 % in the two time periods, but not significantly (p = 0.65).

Conclusion

The rate of salvaged spleens has increased after the introduction of SAE in our center.

Trial registration

The study is registered at www.clinicaltrials.gov with the identification number NCT01965548.

The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology

Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.

Reliability of injury grading systems for patients with blunt splenic trauma

OBJECTIVES

The most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This 'Baltimore CT grading system' is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems.

METHODS

CT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values.

RESULTS

Overall weighted interobserver Kappa coefficients for the AAST and 'Baltimore CT grading system' were respectively substantial (kappa=0.80) and almost perfect (kappa=0.85). Average weighted intraobserver Kappa's values were in the 'almost perfect' range (AAST: kappa=0.91, 'Baltimore CT grading system': kappa=0.81).

CONCLUSION

The present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and 'Baltimore CT grading system' are equally high. Because of the integration of vascular injury, the 'Baltimore CT grading system' supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.

[Treatment practice in patients with isolated blunt splenic injuries. A survey of Swiss traumatologists]

BACKGROUND

The non-operative management (NOM) of blunt splenic injuries has gained widespread acceptance. However, there are still many controversies regarding follow-up of these patients. The purpose of this study was to survey active members of the Swiss Society of General and Trauma Surgery (SGAUC) to determine their practices regarding the NOM of isolated splenic injuries.

MATERIALS AND METHODS

A survey of active SGAUC members with a written questionnaire was carried out. The questionnaire was designed to elicit information about personal and facility demographics, diagnostic practices, in-hospital management, preferred follow-up imaging and return to activity.

RESULTS

Out of 165 SGAUC members 52 (31.5%) completed the survey and 62.8% of all main trauma facilities in Switzerland were covered by the sample. Of the respondents 14 (26.9%) have a protocol in place for treating patients with splenic injuries. For initial imaging in hemodynamically stable patients 82.7% of respondents preferred ultrasonography (US). In cases of suspected splenic injury 19.2% of respondents would abstain from further imaging. In cases of contrast extravasation from the spleen half of the respondents would take no specific action. For low-grade injuries 86.5% chose to admit patients for an average of 1.6 days (range 0-4 days) with a continuously monitored bed. No differences in post-discharge activity restrictions between moderate and high-grade splenic injuries were found.

CONCLUSION

The present survey showed considerable practice variation in several important aspects of the NOM of splenic injuries. Not performing further CT scans in patients with suspected splenic injuries and not intervening in cases of a contrast extravasation were the most important discrepancies to the current literature. Standardization of the NOM of splenic injuries may be of great benefit for both surgeons and patients.

Is non-operative management safe and effective for all splenic blunt trauma? A systematic review

Introduction

The goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.

Methods

For this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.

Results

We identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.

Conclusions

NOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

"Blush" on trauma computed tomography: not as bad as we think!

INTRODUCTION

Intravenous contrast extravasation (IVCE) on a trauma computed tomography has been quoted as a reason for intervention (angiographic embolization or operation). The new-generation computed tomographic (CT) scanners identify IVCE with increasing frequency. We hypothesized that most IVCEs do not require an intervention.

METHODS

This study was a retrospective evaluation of trauma patients with IVCE on abdomen or pelvis CT scan (January 2005-December 2009). Along with demographic and hemodynamic variables, the following characteristics of IVCE were examined as potential risk factors for intervention: maximal dimension, small (≤ 1.5 cm) versus large (>1.5 cm), contained versus free, and single versus multiple and location.

RESULTS

Sixty-nine patients with 81 IVCEs were identified: 48 IVCEs occurred in intra-abdominal solid organs, 18 IVCEs in the pelvic retroperitoneal space, and 15 IVCEs in the soft tissues or other locations. Thirty patients (43.5%) were managed without an intervention, and 39 patients (56.5%) required either an immediate (30 patients) or a delayed (9 patients) intervention. Multivariate analysis identified three independent predictors of an intervention: an admission systolic blood pressure of 100 mm Hg or lower, a large ICVE, and an Abbreviated Injury Score of the abdomen of 3 or higher. If all three independent predictors were present, 100% of patients received an intervention.

CONCLUSION

Nearly half of IVCEs on CT scan did not require an intervention. A hypotension at admission, a severe abdominal trauma, and a blush diameter of 1.5 cm or greater predicted the need for intervention.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

Blunt polytrauma: evaluation with 64-section whole-body CT angiography

Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.

[Multidisciplinary protocol for computed tomography imaging and angiographic embolization of splenic injury due to trauma: assessment of pre-protocol and post-protocol outcomes]

OBJECTIVES

To assess conservative treatment of splenic injury due to trauma, following a protocol for computed tomography (CT) and angiographic embolization. To quantify the predictive value of CT for detecting bleeding and need for embolization.

MATERIAL AND METHODS

The care protocol developed by the multidisciplinary team consisted of angiography with embolization of lesions revealed by contrast extravasation under CT as well as embolization of grade III-V injuries observed, or grade I-II injuries causing hemodynamic instability and/or need for blood transfusion. We collected data on demographic variables, injury severity score (ISS), angiographic findings, and injuries revealed by CT. Pre-protocol and post-protocol outcomes were compared. The sensitivity and specificity of CT findings were calculated for all patients who required angiographic embolization.

RESULTS

Forty-four and 30 angiographies were performed in the pre- and post-protocol periods, respectively. The mean (SD) ISSs in the two periods were 25 (11) and 26 (12), respectively. A total of 24 (54%) embolizations were performed in the pre-protocol period and 28 (98%) after implementation of the protocol. Two and 7 embolizations involved the spleen in the 2 periods, respectively; abdominal laparotomies numbered 32 and 25, respectively, and 10 (31%) vs 4 (16%) splenectomies were performed. The specificity and sensitivity values for contrast extravasation found on CT and followed by embolization were 77.7% and 79.5%.

CONCLUSIONS

The implementation of this multidisciplinary protocol using CT imaging and angiographic embolization led to a decrease in the number of splenectomies. The protocol allows us to take a more conservative treatment approach.

CT grading scales for splenic injury: why can't we agree?

INTRODUCTION

Computed tomography (CT) has been proven to be able to accurately diagnose splenic injury. Many have published CT splenic injury grading scales to quantify the extent of injury. However, these scales have failed at predicting clinical outcomes and therefore cannot be used to accurately predict the need for intervention. We hypothesised that low interrater reliability is the reason why these scales have failed at predicting clinical outcomes.

METHODS AND MATERIALS

This is a retrospective study of patients who were admitted to the Royal Perth Hospital with blunt splenic injury as coded in the trauma registry. The abdominal CT images of these patients were reviewed by three consultant radiologists and were graded using the six different splenic injury grading scales. We assessed interrater reliability between each of the scales using generalised kappa and proportion of agreement calculations.

RESULTS

The images of 64 patients were reviewed. The interrater reliability yielded a generalised kappa score of 0.32-0.60 and proportion of agreement ranging from 34.4% to 65.5%.

CONCLUSION

The six studied CT splenic injury grading scales did not have a high enough interrater reliability to be adequate for clinical use. The poor interrater reliability is likely to contribute to the failure of the scales at predicting clinical outcomes. Further research to improve the interrater reliability is recommended.

Angiointervention: high rates of failure following blunt renal injuries

BACKGROUND

Nonoperative management (NOM) of solid organ injury after blunt trauma is now standard. Recently, angioembolization (AE) has been used to extend NOM. Few data exist on evaluating NOM of blunt renal injuries (BRIs). We sought to determine the overall efficacy of NOM as well as the outcome of AE in patients with BRI.

METHODS

The trauma registry was used to identify all patients with BRI between January 2002 and December 2008. Medical records were reviewed for demographics, grade of injury, use of angiographic intervention, and outcome.

RESULTS

A total of 434 patients with BRI were identified, 416 of whom had planned NOM; 337 (81%) patients were successfully managed without further intervention for their BRI. In all, 79 (19%) patients underwent angiography; 22 (27.8%) of these patients underwent AE, and 6 (27.2%) failed 1.2 ± 0.8 days after AE. Patients who failed AE had a significantly higher blood transfusion requirement during the first 24 h of admission (p = 0.01). Seven patients not embolized failed 1.9 ± 1.9 days after angiography. Thus, of the 79 patients having angiography, 13 (16.5%) failed and required laparotomy to treat their BRIs. Overall failure rate of NOM was 3.1% (13/416). Patients who failed angiography, with or without AE, required more blood during the first 24 h after admission (p = 0.03).

CONCLUSIONS

NOM of BRI is safe and effective, with an overall failure rate of 3.1%. However, angiography with or without AE has substantial failure rates. Patients with higher-grade injuries and active vascular extravasation on admission computed tomography scan also fail NOM regardless of therapy. The blood transfusion requirement during the first 24 h may indicate who will require operative intervention following angiography. Close observation and/or early laparotomy are wise for these high-risk patients.

Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis

The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.

Multidetector computed tomography of acute vascular injury in blunt abdominal/pelvic trauma: imaging predictors of treatment

PURPOSE

The purpose of this study was to analyze the multidetector computed tomography (MDCT) morphologic characteristics of non-aortic acute vascular injuries (AVI) in patients with blunt abdominopelvic trauma that predict treatment.

METHODS

CT scans of 65 trauma patients with non-aortic AVI were reviewed. AVI morphology was categorized as linear or round. The organ of involvement, location of hemorrhage, initial size of hematoma, and hemodynamic status were recorded. Expansion rates of the hematoma were calculated in 40 patients who had delayed imaging. Multivariate regression was used to analyze the morphologic features of AVI and treatment.

RESULTS

Patients with linear AVI were four times more likely to require aggressive treatment (surgery or embolization) than those with a round morphology, independent of the hemodynamic status. There was no main effect of the organ involved, location of hemorrhage, initial bleed size, or expansion rate on the probability of aggressive treatment.

CONCLUSION

The location, initial size, and expansion rate of AVI are not significant predictors of aggressive treatment with surgery or embolization. Linear morphology of AVI, however, is more likely to require aggressive treatment than round AVI, independent of the hemodynamic status. Linear AVI likely reflects a spurting jet of active extravasation, whereas round AVI likely represents a pseudoaneurysm or slow bleed.

The role of arterial embolization in blunt splenic injury

PURPOSE

The aim of study was to evaluate the results of our experience with transarterial embolization based on a modified algorithm in patients with splenic injury.

MATERIALS AND METHODS

We collected data of patients admitted to our hospital from January 2006 to August 2008 for blunt splenic injury. During this period, 46 patients were admitted for splenic trauma, of whom 17 were treated surgically, 15 conservatively and 14 with percutaneous embolisation (13 men, mean age 44.8, mean injury severity score 18.5, six with grade IV and eight with contrast blush). Patients in shock were referred for laparotomy and splenectomy, whereas those who were haemodynamically stable or responsive to fluid resuscitation were further evaluated with computed tomography (CT). In the presence of imaging evidence of splenic injury ranging from grade I to grade III (n=15) a conservative approach was adopted, whereas haemodynamically unstable patients with grade V injury (n=17) were treated with splenectomy. Embolisation was performed in 14 patients with grade IV injury or in the event of contrast extravasation, regardless of injury grade. In patients with diffuse organ damage, we embolised the main splenic artery, whereas in the case of localised injury, embolisation was selective.

RESULTS

Proximal embolization was required in eight cases and distal coil embolization in six. In 13 cases, we placed magnetic-resonance-compatible coils 4-6 mm in diameter; only one patient was treated with gel-foam injection. Immediate technical success was achieved in all cases. In 13/14 patients (92.9%), no periprocedural complications were observed, whereas the remaining patient underwent splenectomy within 24 h due to recurrent bleeding.

CONCLUSIONS

On the basis of our algorithm, it is possible to reach a quick decision on the most appropriate treatment for patients presenting with blunt abdominal trauma, and splenic artery embolization seems to offer a reliable option in those with high-grade splenic injury or active bleeding.

Doppler ultrasound for the assessment of conservatively treated blunt splenic injuries: a prospective study

INTRODUCTION

The type and need for follow-up of non-operatively managed blunt splenic injuries remain controversial. The use of Doppler ultrasound to identify post-traumatic splenic pseudoaneurysms, considered to be the main cause of "delayed" splenic rupture, has not been well described.

PATIENTS AND METHODS

A 5-year prospective study was performed from 2004 to 2008. All patients with blunt splenic injury diagnosed with computerized tomography, who were treated non-operatively, were included in the study. Doppler ultrasound examination was performed 24-48 h post-injury. Consecutive Doppler ultrasound examinations were done on 7, 14 and 21 days post-injury for patients diagnosed with a splenic pseudoaneurysm. Demographic and clinical data were collected. Ambulatory follow-up continued for 4 weeks after hospital discharge.

RESULTS

A total of 38 patients were enrolled in the study. Grading of splenic injury demonstrated 19 (50%) patients with Grade I, 16 (42%) with Grade II and 3 (8%) with Grade III injuries. Two patients (5%) had pseudoaneurysms. All pseudoaneurysms underwent complete resolution within 2 weeks after diagnosis. No patients received blood products, or had angio-embolization or surgery during the study period. All patients were found to be asymptomatic and stable at the 4-week follow-up.

CONCLUSIONS

Doppler ultrasound can be an effective and a safe noninvasive modality for evaluation and follow-up of patients with blunt splenic injury. The utility and cost-effectiveness of routine surveillance requires further study.

Angiography and embolisation for solid abdominal organ injury in adults - a current perspective

Over the past twenty years there has been a shift towards non-operative management (NOM) for haemodynamically stable patients with abdominal trauma. Embolisation can achieve haemostasis and salvage organs without the morbidity of surgery, and the development and refinement of embolisation techniques has widened the indications for NOM in the management of solid organ injury. Advances in computed tomography (CT) technology allow faster scanning times with improved image quality. These improvements mean that whilst surgery is still usually recommended for patients with penetrating injuries, multiple bleeding sites or haemodynamic instability, the indications for NOM are expanding.

We present a current perspective on angiography and embolisation in adults with blunt and penetrating abdominal trauma with illustrative examples from our practice including technical advice.

Percutaneous transcatheter arterial embolization in haemodynamically stable patients with blunt splenic injury

Background

The nonoperative management of the blunt splenic injury in haemodynamically stable patients has become an accepted treatment in recent years. We present a case of the blunt splenic injury successfully treated by supraselective embolization with microspheres.

Case report.

A young hockey player was brought to the Emergency Department with the history of blunt abdominal trauma 2 h earlier. A Grade III splenic injury with haemoperitoneum was diagnosed on sonographic evaluation and the patient was treated with the selective distal splenic artery embolization with microspheres. Postprocedural ultrasound and computed tomography follow-up a year later revealed only a small area of parenchymal irregularity.

Conclusions

The percutaneous splenic arterial embolization has a major role in the management of traumatic splenic injuries. Embolization is particularly beneficial in injuries of grade III or higher.

The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience

INTRODUCTION

Nonoperative management (NOM) of blunt splenic injury has become the preferred treatment for hemodynamically stable patients. The application of splenic artery embolization (SAE) in NOM has been controversial. We hypothesized that incorporation of initial use of SAE into a practice protocol for patients at high risk for NOM failure (contrast extravasation or pseudoaneurysm on computed tomography, grade 3 injury with large hemoperitoneum, grade 4 injuries) would improve patient outcomes.

METHODS

A retrospective analysis of three continuums of practice was performed: group I (January 1991-June 1998), SAE not part of routine NOM; group II (July 1998-December 2001), introduction and discretionary use of SAE; and group III (January 2002-June 2007), standardized use of initial SAE for patients considered at high risk of nonoperative failure. The primary outcome measure was the success of NOM. Failure of NOM was defined as the need for abdominal operation. Secondary outcomes were mortality, length of stay, and splenic salvage.

RESULTS

Over 16 years, 815 patients with blunt splenic injury were treated at our level 1 trauma center. There were 222 patients in group I, 195 in group II, and 398 in group III. There was an increase in the use of SAE over time with a significant improvement in the utilization of NOM (61% in group I; 82% in group II; 88% in group III; p < 0.05). This was associated with an increase in successful NOM (77%, group I; 94%, group II; 97%, group III; p < 0.0001 group I vs. group II and III). Mortality, length of stay, and splenic salvage were similar in groups II and III but significantly improved when compared with group I.

CONCLUSIONS

The increased use of initial SAE in high-risk patients expanded the successful use of NOM but was not associated with other incremental improvements.

Blunt assault is associated with failure of nonoperative management of the spleen independent of organ injury grade and despite lower overall injury severity

OBJECTIVE

Nonoperative management (NOM) of blunt splenic injuries has become standard of care for its high success rate. We observe that many blunt assault (BA) patients fail NOM despite lower overall injury severity. We performed this study to determine whether BA is independently associated with failed initial NOM (FiNOM) of splenic injuries.

METHODS

Using the Trauma Registry at our level I center, we reviewed data of all patients with blunt splenic injuries, who did not undergo immediate operative management of the spleen, admitted from January 1, 1992 to December 31, 2007. Initial NOM was defined as any patient who did not undergo immediate (< or =12 hours after admission) operative intervention for the spleen or did not undergo operation for the spleen at any time during the admission. FiNOM was defined as any patient who underwent operative management of the spleen greater than 12 hours after admission. Logistic regression was performed to determine whether BA was independently associated with FiNOM.

RESULTS

FiNOM occurred in 57 of the 419 (13.6%) patients initially managed nonoperatively. FiNOM decreased significantly in non-BA patients from 15.8% (1992-1999) to 6.2% (2005-2007) (p = 0.05) over time. This was not true for BA patients (33.3% vs. 30%) (p = 0.78). FiNOM for BA patients was 36.1% (13 of 36) versus 11.5% (44 of 383) for all other mechanisms combined. FiNOM was increased across all Organ Injury Scale scores for the spleen in BA patients. BA was independently associated with FiNOM.

CONCLUSIONS

BA is associated with FiNOM independent of severity of splenic injury. Despite an increasingly successful policy of NOM in all blunt splenic injuries, this does not apply for BA. BA should be an important factor considered when initial NOM is contemplated for blunt splenic injury because of the high failure rates compared with all other mechanisms.

Computed Tomography Grading Systems Poorly Predict the Need for Intervention after Spleen and Liver Injuries

Computed tomography (CT) grading systems are often used clinically to forecast the need for interventions after abdominal trauma with solid organ injuries. We compared spleen and liver CT grading methods to determine their utility in predicting the need for operative intervention or angiographic embolization. Abdominal CT scans of 300 patients with spleen injuries, liver injuries, or both were evaluated by five trauma faculty members blinded to clinical outcomes. Studies were graded by American Association for the Surgery of Trauma criteria, a novel splenic injury CT grading system, and a novel liver injury grading system. The sensitivity and specificity of each methodology in predicting the need for intervention were calculated. The kappa statistic was used to determine interrater variability. Twenty-one per cent (39/189) of patients with splenic injuries visible on CT scans required interventions, whereas 14 per cent (21/154) of patients with liver injuries visible on CT required interventions. The overall sensitivity of all grading systems in predicting the need for surgery or angioembolization of the spleen or liver was poor; the specificity seemed to be fairly good. When evaluators were compared, the strength of agreement for the various scoring systems was only moderate. Anatomic CT grading systems are ineffective screening tools for excluding the need for operation or embolization after splenic or hepatic trauma. Although insensitive, CT is a good predictor (highly specific) of the need for intervention if certain definitive abnormalities are identified. Considerable inconsistency exists in interpretation of abdominal CT scans after trauma, even among experienced clinicians.

Angioembolization reduces operative intervention for blunt splenic injury

BACKGROUND

Nonoperative management for blunt splenic injury (BSI) has become gold standard, but the role of angiographic embolization (AE) is still controversial for bleeding. We postulated that splenic AE for BSI would have superior outcomes compared with operation and increase our splenic salvage rate.

METHODS

This was a retrospective study of all adult trauma patients admitted to our Level I center from 2000 through 2006. Multivariate analysis adjusting for age, Injury Severity Score, and Glasgow Coma Scale score was performed. Only patients who had a computed tomographic (CT) scan before surgery (CT + OR) were compared with those who had CT scans then AE.

RESULTS

Eighty-seven of 317 patients required initial intervention for their BSI, for a no intervention rate (no OR or AE) of 73% and a nonoperative rate of 89%. The groups had similar Injury Severity Score, mortality, and lengths of stay. The AE group was older (p < 0.01), had higher spleen Abbreviated Injury Score (p = 0.02), and required significantly fewer packed RBC transfusions, p < 0.01. The overall hospitalization costs were not different, but the number of intraabdominal complications was higher for the CT + OR group (36% vs. 6%, p < 0.01). Pneumonia, thromboembolic events, and pleural effusions were equivalent. There were no deaths from splenic hemorrhage.

CONCLUSION

Despite recent concerns that AE may be overutilized for BSI, this study showed a lower incidence of abdominal complications and blood utilization in the AE group despite an older age and higher splenic Abbreviated Injury Score. Use of AE decreased operative intervention by 16%.

Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients

BACKGROUND

To determine the accuracy of contrast-enhanced multidetector CT (MDCT) in demonstrating splenic vascular injury based on results of splenic angiography and operation.

STUDY DESIGN

This institutional review board-approved study included 392 hemodynamically stable blunt trauma patients whose admission MDCTs demonstrated splenic injury. Images were assessed for parenchymal injury grade, hemoperitoneum volume, and evidence of bleeding and nonbleeding splenic vascular injury. Splenic arteriography was performed for high splenic injury grade and splenic vascular injury. Medical records were reviewed to determine arteriographic interpretation, surgery indications and findings, outcomes, and demographics. Sensitivity, specificity, predictive values, and accuracy of MDCT in detecting vascular injury were calculated based on results of arteriography and operation.

RESULTS

Splenic vascular injury was seen in 22% of patients (86 of 392) on MDCT. Presence of a vascular injury correlated with the CT-based parenchymal splenic injury grade (p < 0.0001). Active splenic bleeding was associated with subsequent clinical deterioration (p < 0.0001). Overall, MDCT had a sensitivity of 76% (76 of 100); specificity of 90% (95 of 106); negative and positive predictive values of 80% (95 of 119) and 87% (76 of 87), respectively; and accuracy of 83% (171 of 206) in detecting vascular injury compared with reference standards. The success rate of nonoperative management was 96%.

CONCLUSIONS

MDCT provides valuable information to direct initial clinical management of patients with blunt splenic trauma by demonstrating both active bleeding and nonbleeding vascular injuries. Not all vascular injuries are detected on MDCT, and splenic angiography is still indicated for high-grade parenchymal injury.

Optimization of selection for nonoperative management of blunt splenic injury: comparison of MDCT grading systems

OBJECTIVE

The purpose of this study was to compare the usefulness of two CT grading systems of blunt splenic trauma in predicting which patients need surgery or angioembolization.

MATERIALS AND METHODS

Four hundred patients in hemodynamically stable condition admitted with blunt splenic injury were included in the study. All patients underwent contrast-enhanced MDCT. Grade of splenic injury was prospectively assigned according to the American Association for the Surgery of Trauma (AAST) splenic injury scale. Patients were treated with surgical intervention, splenic arteriography with or without embolization, or observation alone. All MDCT images were retrospectively reviewed and regraded according to a novel grading system that specifically incorporates the findings of active bleeding or splenic vascular injury, including pseudoaneurysm and arteriovenous fistula. Receiver operating characteristics curves were generated with both grading systems for all splenic interventions, and statistical analyses were performed.

RESULTS

The area under the ROC curves for the new splenic grading system for splenic arteriography, surgery, and both interventions exceeded 80%. The area under the curve for the new splenic grading system was greater than that for the AAST injury scale for all interventions. Differences were found to be statistically significant for splenic arteriography (p = 0.0036) and the combination of arteriography and surgery (p = 0.0006).

CONCLUSION

The proposed CT grading system is better than the AAST system for predicting which patients with blunt splenic trauma need arteriography or splenic intervention.

Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury

Imaging plays a critical role in the evaluation of patients with blunt abdominal trauma. In most institutions, computed tomography (CT) is the modality of choice when evaluating such patients. The purpose of this review is to highlight current techniques in trauma imaging and to review CT findings associated with solid organ, bowel, mesenteric, and diaphragmatic injury. In particular, emphasis is placed on the use of multidetector CT technology (MDCT), especially 64-row detector CT. The role of various techniques, including the use of oral and intravenous contrast, as well as the potential benefit of delayed imaging, is discussed.

Significance of contrast extravasation in patients with pelvic fracture

BACKGROUND

Contained contrast extravasation (CE) in solid organ injury is not well correlated with the need for operative intervention, but the significance of CE in patients with pelvic fracture is unknown.

METHODS

The trauma registry at a Level I trauma center was queried for all patients with pelvic fracture from January 1, 1998 to May 31, 2005. All computed tomography (CT) scans used helical technology. Demographic and injury information were abstracted from the trauma registry and medical record. CT and angiography reports of all patients were reviewed. Angiograms and abdominal and pelvic CT studies (AP-CT) of patients with CE were then reviewed by a radiologist.

RESULTS

A total of 604 patients with a pelvic fracture and an AP-CT were identified. Of these, 42 patients had a pelvic CE on CT study. Patients with CE had a higher Injury Severity Score (24.5 vs. 18.3, p<0.001) and higher mortality (24 vs. 6%, p<0.001). Twenty-five patients with CE underwent angiography, with CE confirmed in 19 patients and embolization performed in 17. Six patients without CE underwent angiography. CE was confirmed in two patients and both were embolized. A significantly higher number of patients undergoing angiography required ongoing transfusion.

CONCLUSIONS

CE is a marker of severe injury but does not mandate angiography. Associated injuries are common and other sources of blood loss must be excluded. CE is not reliable enough to exclude significant vascular injury, as the therapeutic embolization rate for CE-negative patients undergoing angiography is 33%.

64 MDCT in multiple trauma patients: imaging manifestations and clinical implications of active extravasation

The finding of active hemorrhage on computed tomography (CT) in trauma patients has been shown to have significant clinical implications and has been incorporated into numerous CT grading schema. As CT technology has advanced, the sensitivity for detection of active hemorrhage in the trauma population has significantly improved. Currently, with the improved spatial and temporal resolution afforded by 64 multidetector computed tomography (64 MDCT) technology, the clinical implications of the CT findings of active extravasation may need to be reconsidered. This article illustrates the various imaging manifestations of active extravasation throughout the body using 64 MDCT. Additionally, protocol issues specific to the findings of active hemorrhage using 64 MDCT are detailed, including novel interpretation techniques, which offer aid in detecting and characterizing hemorrhage. Finally, the clinical implication of active extravasation using this new technology is discussed. Although more sensitive to the detection of small hemorrhagic foci and with clinical implications highly dependent upon location, active bleeding remains as a salient finding that affects subsequent clinical management of trauma patients.

Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST)

BACKGROUND

Thoracic ultrasound (EFAST) has shown promise in inferring the presence of post-traumatic pneumothoraces (PTXs) and may have a particular value in identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). However, the diagnostic utility of hand-held US has not been previously evaluated in this role.

METHODS

Thoracic US examinations were performed during the initial resuscitation of injured patients at a provincial trauma referral center. A high frequency linear transducer and a 2.4 kg US attached to a video-recorder were used. Real-time EFAST examinations for PTXs were blindly compared with the subsequent results of CXRs, a composite standard (CXR, chest and abdominal CT scans, clinical course, and invasive interventions), and a CT gold standard (CT only). Charts were reviewed for in-hospital outcomes and follow-up.

RESULTS

There were 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR+) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR+ (46.7 and 36.3).

CONCLUSION

EFAST has comparable specificity to CXR but is more sensitive for the detection of OPTXs after trauma. Positive EFAST findings should be addressed either clinically or with CT depending on hemodynamic stability. CT should be used if detection of all PTXs is desired.