Abdominal compartment syndrome: what radiologist needs to know

The intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are life-threatening conditions with a significant rate of mortality; therefore, early detection is paramount in their optimal management. IAH is diagnosed when the intra-abdominal pressure (IAP) is more than 12 mmHg. It can occur when the intra-abdominal volume increases (ileus, ascites, trauma, pancreatitis, etc.) and/or the abdominal wall compliance decreases. IAH can cause decreased venous flow, low cardiac output, renal impairment, and decreased respiratory compliance. Consequently, these complications can lead to multiple organ failure and induce the abdominal compartment syndrome (ACS) when IAP rises above 20 mmHg. The diagnosis is usually made with intravesical pressure measurement. However, this measurement was not always possible to obtain; therefore, alternative diagnostic techniques should be considered. In this setting, computed tomography (CT) may play a crucial role, allowing the detection and characterization of pathological conditions that may lead to IAH. This review is focused on the pathogenesis, clinical features, and radiological findings of ACS, because their presence allows radiologists to raise the suspicion of IAH/ACS in critically ill patients, guiding the most appropriate treatment.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT

PURPOSE

This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated.

MATERIALS AND METHODS

In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system.

RESULTS

One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively.

CONCLUSIONS

In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Non-Operative Management of Polytraumatized Patients: Body Imaging beyond CT

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

High-flow post-traumatic priapism: diagnostic and therapeutic workup

Priapism is a prolonged penile tumescence or erection unrelated to sexual stimulation that lasts more than 6 h. High-flow priapism is a rare condition usually due to a perineal trauma with the formation of an arterio-cavernosal fistula between a cavernosal artery and the lacunar spaces of the penis. High-flow priapism is usually diagnosed by clinical examination and color Doppler ultrasound, and the gold standard therapeutic management is represented by digital subtraction angiography. We report a case of a young patient with high-flow priapism after a motorcycle blunt perineal trauma, examining in detail the specific color Doppler ultrasound findings, the diagnostic workup and the therapeutic management.

Role of Multidetector Computed Tomography in the Diagnosis of Colorectal Perforations

Colonic perforations can be classified into perforations that occur at the site of a localized pathologic process and cecal perforations that occur secondary to distal colonic obstructions. Rectal perforations may result from foreign bodies inserted into the rectum; moreover, deep rectal biopsies, polypectomy, improper cleansing enema, or thermometer placement may also lead to rectal perforation. Correct identification of the cause and site of the perforation is crucial for appropriate management and surgical planning. Multidetector row computed tomography has a pivot role in planning the type of operative treatment, the prognosis, and in assessing those patients who have clinical symptoms of peritonitis but no radiographic signs of perforation.