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5 Cervical Spine Pedicle Screw Accuracy in Open Fluoroscopic, Navigated and Template Guided Systems- a Systematic Review. Br J Surg 2022. [DOI: 10.1093/bjs/znac040.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
Pedicle screws provide excellent fixation for a wide range of indications; their adoption in the cervical spine has been slower than in the thoracic and lumbar spine, largely due to the smaller pedicle sizes and proximity to neurovascular structures in the neck. Recent years have seen the development of technology to improve accuracy and thereby safety in cervical pedicle screw placement over traditional fluoroscopic techniques, including intraoperative 3D navigation, computer assisted systems and physical templates with screw guides. We have performed a systematic review into the accuracy rates of the various systems.
Method
PubMed and Cochrane Library databases were searched; keywords "pedicle screw cervical spine" were searched; 9 valid papers involving 1427 screws were found.
Results
Accuracy rates were 80.6% for fluoroscopy, 91.4% for navigation methods, and 96.7% for templates.
Conclusions
Superior results for templates are complemented by reduced radiation exposure to patient and surgeon; however, the technology requires prolonged pre-operative planning to create the bespoke template, and the development of an infrastructure to allow for their rapid production and delivery is needed before they become more widely available.
Two broad methods of navigation currently exist: intraoperative CT scanning providing real-time 3D navigation and preoperative CT registration in relation to a fixed reference with intraoperative computer assistance. At present, these methods are more commonly used, due to their proven improved accuracy rates over fluoroscopy, availability in emergencies and alongside minimally invasive techniques.
Despite their novelty and limitations, templates provide promising accuracy scores, although practical considerations may inhibit their proliferation.
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AB0039 AGRIN REPAIRS BONE AND CARTILAGE IN VIVO. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Cartilage defects in the joints are reported in 61% of all arthroscopies1&2. The size of the cartilage repair market is estimated to be $2.195 million by 20253. Cartilage defects can evolve into osteoarthritis, in which abnormal load results in cartilage breakdown, joint pain and reduced mobility. Osteoarthritis is the leading cause of permanent disability and absenteeism and affects up to 1/3 of the people over 60yrs. In western countries osteoarthritis costs 1.5-2% of the GDP4. Joint replacement with a prosthesis restores some degree of independence but in up to 20% of patients it does not meet expectations 5 and has a limited life span. There is no pharmacological intervention that arrests or reverts the course of osteoarthritis, despite the desperate need.We previously published that agrin plays an important role in cartilage homeostasis6. The addition of agrin to chondrocytes in vivo resulted in enhanced cartilage formation, suggesting a potential role for agrin in cartilage repair.Objectives:Investigate the potential of agrin for use in cartilage repair.Methods:Critical size osteochondral defects were generated in mice and sheep and injected intraarticularly with type I collagen gel containing agrin or vehicle. Animals were monitored for 8 weeks or 6 months respectively. MicroCT, histological analysis, qPCR, linage tracking, reporter assays, chondrogenesis assay, immunohistochemistry were performed.Results:A single intraarticular administration of agrin induced regeneration of critical-size osteochondral defects in mice, restoring the tissue architecture and bone-cartilage interface. Agrin stem cells to the site of injury and, through simultaneous activation of CREB and suppression of canonical WNT signalling, induced GDF5 expression and differentiation into stable articular chondrocytes, forming stable articular cartilage. In sheep, agrin treatment resulted in regeneration of bone and cartilage, which promoted increased ambulatory activity.Conclusion:Agrin orchestrates repair morphogenesis at the joint surface by modulating multiple signalling pathways, supporting the therapeutic use of agrin for joint surface regeneration.References:[1]Curl, W. W. et al. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 13, 456–460 (1997).[2]Hjelle, K., Solheim, E., Strand, T., Muri, R. & Brittberg, M. Articular cartilage defects in 1,000 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 18, 730–734 (2002).[3]Cartilage Repair Market Size, Share, Industry Analysis 2018-2025 | AMR. Allied Market Research https://www.alliedmarketresearch.com/cartilage-repair-market.[4]Hiligsmann, M. et al. Health economics in the field of osteoarthritis: an expert’s consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin. Arthritis Rheum. 43, 303–313 (2013).[5]Dieppe, P., Lim, K. & Lohmander, S. Who should have knee joint replacement surgery for osteoarthritis? Int. J. Rheum. Dis. 14, 175–180 (2011).[6]Eldridge, S., et al. Agrin mediates chondrocyte homeostasis and requires both LRP4 and α-dystroglycan to enhance cartilage formation in vitro and in vivo. Annals of the rheumatic diseases 75 (6), 1228-1235 (2016).Acknowledgements:We thank the technical staff in the ARM Lab and Staff at the University of Aberdeen’s Animal Facility and Microscopy and Histology Facility for support. Funding: We gratefully acknowledge funding support of this work by the MRC (MR/L022893/1, MR/N010973/1,and MR/P026362/1), Versus Arthritis (19667, 21515, 20886, and 21621), Rosetrees Trust (A1205), the Medical College of St Bartholomew’s Hospital Trust, and the William Harvey Research Foundation.Disclosure of Interests:Suzanne Eldridge: None declared, Aida Barawi: None declared, Hui Wang: None declared, Anke Roelofs: None declared, Magdalena Kaneva: None declared, Zeyu Guan: None declared, Helen Lydon: None declared, Bethan Thomas: None declared, Anne-Sophie Thorup: None declared, Beatriz F Fernandez: None declared, Sara Caxaria: None declared, Danielle Strachan: None declared, Ahmed Ali: None declared, Kanatheepan Shanmuganathan: None declared, Costantino Pitzalis: None declared, James Whiteford: None declared, Fran Henson: None declared, Andrew McCaskie: None declared, Cosimo De Bari: None declared, Francesco Dell’Accio Consultant of: F.D. has received consultancy fees from Samumed and UCB.
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Quantification of Iodine Leakage on Dual-Energy CT as a Marker of Blood-Brain Barrier Permeability in Traumatic Hemorrhagic Contusions: Prediction of Surgical Intervention for Intracranial Pressure Management. AJNR Am J Neuroradiol 2019; 40:2059-2065. [PMID: 31727752 PMCID: PMC6975368 DOI: 10.3174/ajnr.a6316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/30/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic contusions are associated with iodine leakage. We aimed to identify quantitative iodine-based dual-energy CT variables that correlate with the type of intracranial pressure management. MATERIALS AND METHODS Consecutive patients with contusions from May 2016 through January 2017 were retrospectively analyzed. Radiologists, blinded to the outcomes, evaluated CT variables from unenhanced admission and short-term follow-up head dual-energy CT scans obtained after contrast-enhanced whole-body CT. Treatment intensity of intracranial pressure was broadly divided into 2 groups: those managed medically and those managed surgically. Univariable analysis followed by logistic regression was used to develop a prediction model. RESULTS The study included 65 patients (50 men; median age, 48 years; Q1 to Q3, 25-65.5 years). Twenty-one patients were managed surgically (14 by CSF drainage, 7 by craniectomy). Iodine-based variables that correlated with surgical management were higher iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusions. The regression model developed after inclusion of clinical variables identified 3 predictor variables: postresuscitation Glasgow Coma Scale (adjusted OR = 0.55; 95% CI, 0.38-0.79; P = .001), age (adjusted OR = 0.9; 95% CI, 0.85-0.97; P = .003), and pseudohematoma volume (adjusted OR = 2.05; 95% CI, 1.1-3.77; P = .02), which yielded an area under the curve of 0.96 in predicting surgical intracranial pressure management. The 2 predictors for craniectomy were age (adjusted OR = 0.89; 95% CI, 0.81-0.99; P = .03) and pseudohematoma volume (adjusted OR = 1.23; 95% CI, 1.03-1.45; P = .02), which yielded an area under the curve of 0.89. CONCLUSIONS Quantitative iodine-based parameters derived from follow-up dual-energy CT may predict the intensity of intracranial pressure management in patients with hemorrhagic contusions.
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Dual-Energy CT in Hemorrhagic Progression of Cerebral Contusion: Overestimation of Hematoma Volumes on Standard 120-kV Images and Rectification with Virtual High-Energy Monochromatic Images after Contrast-Enhanced Whole-Body Imaging. AJNR Am J Neuroradiol 2018; 39:658-662. [PMID: 29439124 DOI: 10.3174/ajnr.a5558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/11/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with hemorrhagic contusions, hematoma volumes are overestimated on follow-up standard 120-kV images obtained after contrast-enhanced whole-body CT. We aimed to retrospectively determine hemorrhagic progression of contusion rates on 120-kV and 190-keV images derived from dual-energy CT and the magnitude of hematoma volume overestimation. MATERIALS AND METHODS We retrospectively analyzed admission and follow-up CT studies in 40 patients with hemorrhagic contusions. After annotating the contusions, we measured volumes from admission and follow-up 120-kV and 190-keV images using semiautomated 3D segmentation. Bland-Altman analysis was used for hematoma volume comparison. RESULTS On 120-kV images, hemorrhagic progression of contusions was detected in 24 of the 40 patients, while only 17 patients had hemorrhagic progression of contusions on 190-keV images (P = .008). Hematoma volumes were systematically overestimated on follow-up 120-kV images (9.68 versus 8 mm3; mean difference, 1.68 mm3; standard error, 0.37; P < .001) compared with 190-keV images. There was no significant difference in volumes between admission 120-kV and 190-keV images. Mean and median percentages of overestimation were 29% (95% CI, 18-39) and 22% (quartile 3 - quartile 1 = 36.8), respectively. CONCLUSIONS The 120-kV images, which are comparable with single-energy CT images, significantly overestimated the hematoma volumes, hence the rate of hemorrhagic progression of contusions, after contrast-enhanced whole-body CT. Hence, follow-up of hemorrhagic contusions should be performed on dual-energy CT, and 190-keV images should be used for the assessment of hematoma volumes.
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A note on the obligate symbiotic association between crab Zebrida adamsii White, 1847 (Decapoda: Pilumnidae) and Flower Urchin Toxopneustes pileolus (Lamarck, 1816) (Camarodonta: Toxopneustidae) from the Gulf of Mannar, India. JOURNAL OF THREATENED TAXA 2015. [DOI: 10.11609/jott.o3878.7726-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Hyperintense Optic Nerve due to Diffusion Restriction: Diffusion-Weighted Imaging in Traumatic Optic Neuropathy. AJNR Am J Neuroradiol 2015; 36:1536-41. [PMID: 25882280 DOI: 10.3174/ajnr.a4290] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/23/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND PURPOSE Abnormal signal intensity of the optic nerve due to diffusion restriction may be seen in traumatic optic neuropathy. In addition to evaluating optic nerve hyperintensity on diffusion-weighted imaging, we compared the group differences of ADC values between the injured and uninjured contralateral nerve and identified the relation between measured ADC values and admission visual acuity. MATERIALS AND METHODS We retrospectively evaluated 29 patients with traumatic optic neuropathy who underwent MR imaging with DWI. Uninjured contralateral optic nerves were used as controls. Two attending radiologists, blinded to the side of injury, independently reviewed the DWI for the presence of signal-intensity abnormality and obtained ADC values after manually selecting the ROI. RESULTS Hyperintensity of the optic nerve was demonstrated in 8 of the 29 patients, with a sensitivity of 27.6% (95% CI, 12.8-47.2) and a specificity of 100% (95% CI, 87.9-100). ADC values were obtained in 25 patients. The mean ADC in the posterior segment of the injured nerve was significantly lower than that in the contralateral uninjured nerve (Welch ANOVA, F = 9.7, P = .003). There was a moderate-to-strong correlation between low ADC values and poor visual acuity in 10 patients in whom visual acuity could be obtained at admission (R = 0.7, P = .02). Patients with optic nerve hyperintensity presented with worse visual acuity. CONCLUSIONS Hyperintensity of the optic nerve due to diffusion restriction can serve as a specific imaging marker of traumatic optic neuropathy. When paired with reduced ADC values, this finding may be an important surrogate for visual acuity.
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Abstract
The hypothesis is that the mechanical mismatch between brain tissue and microelectrodes influences the inflammatory response. Our unique, mechanically adaptive polymer nanocomposite enabled this study within the cerebral cortex of rats. The initial tensile storage modulus of 5 GPa decreases to 12 MPa within 15 min under physiological conditions. The response to the nanocomposite was compared to surface-matched, stiffer implants of traditional wires (411 GPa) coated with the identical polymer substrate and implanted on the contralateral side. Both implants were tethered. Fluorescent immunohistochemistry labeling examined neurons, intermediate filaments, macrophages, microglia and proteoglycans. We demonstrate, for the first time, a system that decouples the mechanical and surface chemistry components of the neural response. The neuronal nuclei density within 100 µm of the device at four weeks post-implantation was greater for the compliant nanocomposite compared to the stiff wire. At eight weeks post-implantation, the neuronal nuclei density around the nanocomposite was maintained, but the density around the wire recovered to match that of the nanocomposite. The glial scar response to the compliant nanocomposite was less vigorous than it was to the stiffer wire. The results suggest that mechanically associated factors such as proteoglycans and intermediate filaments are important modulators of the response of the compliant nanocomposite.
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Emergency Radiology: The Requisites and Emergency Radiology: Case Review Series. AJNR Am J Neuroradiol 2009. [DOI: 10.3174/ajnr.a1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract No. 253 EE: Blunt Splenic Injury: Review of Current Imaging Techniques, Grading Systems, and Endovascular Treatments. J Vasc Interv Radiol 2009. [DOI: 10.1016/j.jvir.2008.12.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract No. 150: Non Operative Management of Blunt Trauma to the Liver by Transcatheter Embolization: Risk Factors for Late Rebleeding. J Vasc Interv Radiol 2009. [DOI: 10.1016/j.jvir.2008.12.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Diffusion tensor MR imaging in cervical spine trauma. AJNR Am J Neuroradiol 2008; 29:655-9. [PMID: 18238846 PMCID: PMC7978215 DOI: 10.3174/ajnr.a0916] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Accepted: 11/04/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to investigate the extent and severity of changes in spinal cord diffusion tensor imaging (DTI) parameters in patients with cervical cord injury. MATERIALS AND METHODS DTI was performed in 20 symptomatic patients (mean, 45.7 +/- 17.7 years of age; 2 women, 18 men) with cervical spine trauma and 8 volunteers (mean, 34.2 +/- 10.7 years of age; 6 men, 2 women). The whole cord and regional apparent diffusion coefficient (ADC), fractional anisotropy (FA), relative anisotropy (RA), and volume ratio (VR) of patients and volunteers were compared. DTI parameters were calculated in 16 patients. MR imaging demonstrated hemorrhagic cord contusions (n = 6), nonhemorrhagic cord contusions (n = 4), and soft-tissue injury (n = 6). Medical records were reviewed for extent of neurologic deficit. RESULTS Regional ADC values differed significantly between upper and mid and upper and lower (both, P < .004) cervical cord sections. FA was significantly different between upper and lower sections (P < .03). Whole cord ADC values were significantly lower in patients than in volunteers (P < .0001). Whole spine FA was not significantly decreased in patients (P < .06). ADC and FA values were significantly decreased at injury sites when compared with volunteers (P < .031 and .0001, respectively). The greatest differences in whole cord ADC, FA, RA, and VR were in patients with hemorrhagic cord contusions compared with healthy volunteers (P < .0001, .003, .0005, and .008, respectively). CONCLUSION DTI parameters are sensitive markers of cervical cord injury, with ADC showing the greatest sensitivity. Changes in DTI parameters are most marked at injury sites and reflect the severity of cord injury.
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Diagnosis of blunt traumatic aortic injury 2007: still a nemesis. Eur J Radiol 2007; 64:27-40. [PMID: 17376629 DOI: 10.1016/j.ejrad.2007.02.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 02/14/2007] [Indexed: 10/23/2022]
Abstract
In recent years, the use of multidetector computed tomography (MDCT) for the diagnosis of acute thoracic injury in blunt trauma has expanded. MDCT has shown high accuracy for the diagnosis or exclusion of injury to the aorta and its primary branches, decreasing the need for thoracic angiography and allowing earlier treatment of this often rapidly fatal lesion. With increasing use of MDCT, more subtle injuries and variants of vascular anatomy are being recognized that create pitfalls in the diagnosis. Of perhaps more concern is the recognition that aortic injury can occur with little or no associated mediastinal hematoma, the principle chest radiographic finding indicating a need for further imaging. The importance of recognizing unusual sites of aortic injury, congenital variants of mediastinal anatomy, the precise extent of injury, and the anatomic pathology present as key factors in deciding among treatment options is emphasized.
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Abstract
OBJECTIVE Chance-type fractures are subtle unstable injuries that are often associated with intraabdominal injuries. CT-based observations made during routine interpretations revealed involvement of a burst component to this fracture pattern and a clue on the transaxial images to its presence. The purpose of this review was to determine how often these features occurred in a retrospective study of a large sample because these findings influence diagnosis and management. MATERIALS AND METHODS A retrospective review of all patients identified from the University of Maryland Shock Trauma Center trauma registry and IDXRad system diagnosed with flexion-distraction injuries of the thoracolumbar spine over an 8-year period was performed. Three trauma radiologists assessed the admission spinal radiographs, CT studies with multiplanar images, and available MRI examinations. Imaging findings were confirmed by consensus. Abdominopelvic CT studies and surgical reports were reviewed for evidence and type of intraabdominal injury. A literature review of previous similar series was performed. RESULTS Fifty-three patients were identified for inclusion in the study. Associated intraabdominal injury occurred in 40% and most commonly involved the bowel and mesentery. A close examination of the fracture patterns on CT revealed that a burst-type fracture with posterior cortex buckling or retropulsion was a common finding (48%). Also, serial transaxial CT images often (76%) showed a gradual loss of definition of the pedicles that we refer to as the "dissolving pedicle" sign. The study showed that the horizontally oriented fracture planes through the posterior elements can often be recognized radiographically, but these fractures can be very subtle. CONCLUSION Intraabdominal injuries occurred in 40% of flexion-distraction thoracolumbar fractures in our study cohort, which is slightly lower than previously reported. About half of the patients with this injury displayed a burst-type component that could have a significant influence on surgical management. The dissolving pedicle sign can assist in recognition of this often subtle injury on transaxial CT.
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Abstract
The spleen is the intra-abdominal organ most often injured as a result of blunt trauma. Multidetector-row computed tomography (MDCT) plays an important role in the detection and characterization of splenic injury. It has been shown to be highly accurate and can detect splenic vascular lesions, the presence of which has been shown to be a predictor of failure of nonoperative management. The increased use of angiography and splenic artery embolization in the management of such injuries has led to improved success rates with nonoperative management. This article reviews the various appearances of the injured spleen and discusses the use of MDCT in the initial evaluation of injury. The indications for angiography and embolization are reviewed, with examples of appearances of the postembolization spleen.
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Abstract
CT is the imaging modality of choice to evaluate blunt abdominal trauma. With the advent of multidetector CT (MDCT), scanning times have progressively decreased while image resolution has increased owing to thinner collimation and reduced partial volume and motion artifacts. MDCT also allows high quality two-dimensional and three-dimensional multiplanar reformatted images to be obtained, which aid in the diagnosis of the complex multisystem injuries seen in the trauma patient. This article describes the authors' current imaging protocol with 16-detector MDCT, the spectrum of CT findings seen in patients with blunt abdominal injuries, and the role MDCT has in guiding injury management.
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Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review of 12 cases. Clin Radiol 2005; 60:1280-9. [PMID: 16291309 DOI: 10.1016/j.crad.2005.06.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 05/31/2005] [Accepted: 06/22/2005] [Indexed: 11/27/2022]
Abstract
AIM To determine the usefulness of multidetector-row CT (MDCT) with multiplanar reformatted (MPR) images in the sagittal and coronal plane in diagnosing acute right hemidiaphragmatic rupture. MATERIALS AND METHODS Twelve patients were identified who received chest and abdominal MDCT after major blunt trauma diagnosed with right diaphragmatic injury. Sagittal and coronal reformations were performed in all cases. The images were retrospectively reviewed by two experienced radiologists for signs of right diaphragm injury, such as direct diaphragm discontinuity, the "collar sign", the "dependent viscera sign", and intra-thoracic location of herniated abdominal contents. RESULTS Of the 12 cases of right hemidiaphragm rupture, diaphragm discontinuity was seen in seven (58%) cases, the collar sign in five (42%), the dependent viscera sign in four (33%), and transdiaphragmatic herniation of the right colon and fat in another. Two variants of the collar sign were apparent on high-quality sagittal and coronal reformations. The first, termed the "hump sign", describes a rounded portion of liver herniating through the diaphragm forming a hump-shaped mass, and the second, termed the "band sign," is a linear lucency across the liver along the torn edges of the hemidiaphragm. The hump sign occurred in 10 (83%) patients and the band sign in four (33%). CONCLUSION MDCT is very useful in the diagnosis of right hemidiaphragm injury caused by blunt trauma when sagittal and coronal reformatted images are obtained, and should allow more frequent preoperative diagnosis.
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Abstract
Abdominal ultrasonography (US) is gaining widespread acceptance as a valuable diagnostic tool in the initial evaluation of trauma victims. We investigated the utility of US as a follow-up radiologic study in nonoperative hepatic trauma. Patients with liver injury designated for non-operative management were prospectively studied over a 2-year period at our primary adult resource center for trauma. Computed tomography (CT) and radiologist-performed US were obtained at admission and at 1 week. The ability of US to detect lesions, fluid, and complications was evaluated by comparing with the corresponding CT. Twenty-five hepatic trauma patients in the study were successfully managed nonoperatively and had both initial and follow-up US and CT scans: 1 (4%) grade I, 5 (20%) grade II, 7 (28%) grade III, 7 (28%) grade IV, and 5 (20%) grade V. Four complications developed [biloma (3) and biliary fistula (1)] in 3 patients with grade IV injury and 1 with a grade II injury. Interval US appropriately detected a complication or confirmed the absence of complication in all (13/13, 100%) patients with low-grade (I–III) injury and only missed a small biloma in one patient with a grade IV injury. Interval US and CT agreement was 92 per cent for change in hemoperitoneum or parenchymal lesion. Ultrasonography is a convenient imaging modality in the evaluation of hepatic trauma. US is sufficient to detect or exclude complications in low-grade injuries. In high-grade injuries, US may be an adjunct to CT for definitive interval assessment.
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Ultrasonography for interval assessment in the nonoperative management of hepatic trauma. Am Surg 2005; 71:841-6. [PMID: 16468532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Abdominal ultrasonography (US) is gaining widespread acceptance as a valuable diagnostic tool in the initial evaluation of trauma victims. We investigated the utility of US as a follow-up radiologic study in nonoperative hepatic trauma. Patients with liver injury designated for nonoperative management were prospectively studied over a 2-year period at our primary adult resource center for trauma. Computed tomography (CT) and radiologist-performed US were obtained at admission and at 1 week. The ability of US to detect lesions, fluid, and complications was evaluated by comparing with the corresponding CT. Twenty-five hepatic trauma patients in the study were successfully managed nonoperatively and had both initial and follow-up US and CT scans: 1 (4%) grade I, 5 (20%) grade II, 7 (28%) grade III, 7 (28%) grade IV, and 5 (20%) grade V. Four complications developed [biloma (3) and biliary fistula (1)] in 3 patients with grade IV injury and 1 with a grade II injury. Interval US appropriately detected a complication or confirmed the absence of complication in all (13/13, 100%) patients with low-grade (I-III) injury and only missed a small biloma in one patient with a grade IV injury. Interval US and CT agreement was 92 per cent for change in hemoperitoneum or parenchymal lesion. Ultrasonography is a convenient imaging modality in the evaluation of hepatic trauma. US is sufficient to detect or exclude complications in low-grade injuries. In high-grade injuries, US may be an adjunct to CT for definitive interval assessment.
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Blunt Abdominal Trauma Patients: Can Organ Injury Be Excluded without Performing Computed Tomography? ACTA ACUST UNITED AC 2004; 57:1072-81. [PMID: 15580035 DOI: 10.1097/01.ta.0000092680.73274.e1] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to determine whether admission non-computed tomography (CT) criteria can exclude intra-abdominal injury in stable patients sustaining blunt abdominal trauma. METHODS Seven hundred fourteen hemodynamically stable patients with suspicion of blunt abdominal trauma were included in the study. Admission data for clinical examination, sonography, routine laboratory studies, chest/pelvic radiographic findings, and Glasgow Coma Scale (GCS) score were recorded. Each patient underwent helical abdominal CT. Injuries were considered major if they required surgery or angiographic intervention. At the authors' institution, angiography is routinely performed if there is a splenic injury of American Association for the Surgery of Trauma grade II or higher or a liver injury of American Association for the Surgery of Trauma grade III or higher. Statistical analysis was performed to determine the value of isolated and combined clinical, radiologic, and laboratory parameters in depicting an intra-abdominal injury with regard to CT results and clinical follow-up. RESULTS The best combination of criteria to identify a major abdominal injury was obtained when sonography, chest radiography, and three laboratory parameters (serum glutamic oxaloacetic transaminase, white blood cell count, and hematocrit) were normal: 22% (129 of 589) of patients without major injuries fulfilled these criteria. The only combination of criteria that completely excluded intra-abdominal injury was obtained when clinical criteria combined with a Glasgow Coma Scale score > 13, bedside radiologic studies, and laboratory data were all normal, but only 12% (68 of 578) of patients without abdominal injury fulfilled these criteria. CONCLUSION After blunt abdominal trauma, admission non-CT criteria can at best identify 12% of patients without intra-abdominal injuries and 22% of patients without major injuries.
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CT diagnosis of splenic infarction in blunt trauma: imaging features, clinical significance and complications. Clin Radiol 2004; 59:342-8. [PMID: 15041453 DOI: 10.1016/j.crad.2003.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2003] [Revised: 09/19/2003] [Accepted: 09/23/2003] [Indexed: 01/28/2023]
Abstract
AIM The object of this study is to describe the appearance, complications, and outcome of segmental splenic infarctions occurring after blunt trauma using computed tomography (CT). MATERIALS AND METHODS Thirteen blunt trauma patients were identified with splenic infarction on contrast-enhanced CT. CT images were retrospectively reviewed and the percentage of infarcted splenic tissue and presence of splenic injury separate from the site of infarction were identified. Splenic angiograms were reviewed and follow-up CT images were assessed for interval change in the appearance of the infarcts. RESULTS The mean age of patients was 32 years and the most common mechanism of injury was road traffic accident. The majority (54%) had 25-50% infarction of the spleen. Splenic angiograms were performed in nine patients and seven demonstrated wedge-shaped regions of decreased perfusion corresponding to the infarction seen on CT with no need for intervention. Eleven patients underwent a follow-up CT that demonstrated the following: no significant change in six, near-complete resolution in two, delayed appearance of infarction in one, abscess formation in one, and delayed splenic rupture in one. CONCLUSION Segmental splenic infarction is a rare manifestation of blunt splenic trauma. The diagnosis is readily made using contrast-enhanced CT. The majority will decrease in size on follow-up CT and resolve without clinical sequelae. Resolution of infarction is also seen and these cases are best described as temporary perfusion defects. Splenic abscess or delayed rupture are uncommon complications that may necessitate angiographic or surgical intervention.
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Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients. Radiology 2004; 231:775-84. [PMID: 15105455 DOI: 10.1148/radiol.2313030126] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air. MATERIALS AND METHODS During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined. RESULTS CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38). CONCLUSION Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.
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Abstract
Traumatic diaphragmatic injury (TDI) occurs in approximately 6% of patients after major blunt trauma to the abdomen. Detection of such injuries is often problematic because of nonspecific clinical signs and the presence of additional intra-abdominal injuries. As the use of nonsurgical management to treat solid organ injuries increases, helical computed tomography (CT) must play a much greater role in the detection of intra-abdominal injuries. Therefore, it is crucial that diaphragmatic injuries are not overlooked, as fewer will be diagnosed at exploratory laparotomy. This article reviews the recent advances in helical CT that are helpful in diagnosing TDI and addresses the selected application of magnetic resonance imaging.
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Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol 2001; 177:1247-56. [PMID: 11717058 DOI: 10.2214/ajr.177.6.1771247] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A prospective study was performed to determine the usefulness of triple-contrast helical CT in predicting peritoneal violation and the need for laparotomy in the treatment of penetrating torso trauma. SUBJECTS AND METHODS Triple-contrast helical CT scans were obtained in 104 hemodynamically stable patients with penetrating injuries to the torso (thoracoabdominal region including tangential wounds to the anterior abdomen, flank, back, and pelvis) over a 17-month period. The study group included 54 patients with gunshot wounds and 50 with stab wounds. No patient had a radiographic or clinical indication for immediate laparotomy. A positive finding on CT was defined as evidence of peritoneal violation or injury to the retroperitoneal colon, major vessel, or urinary tract. Patients with a positive CT, except patients with isolated liver injury or free fluid, underwent laparotomy. Patients with a negative finding on CT were initially observed. RESULTS CT studies were positive in 35 (34%) of 104 patients and negative in 69 (66%) of 104 of patients. Laparotomy was performed in 21 (60%) of 35 patients with positive CT; 19 (86%) of 22 were therapeutic, two (9%) were nontherapeutic, and one (5%) was negative (no injury was found). Nine patients with isolated hepatic injuries were successfully treated without laparotomy. Among patients with a negative CT, 67 (97%) of 69 were treated nonoperatively with success. CT had 100% (19/19) sensitivity, 96% (69/72) specificity, 100% (69/69) negative predictive value, and 97% (101/104) accuracy in predicting the need for laparotomy. CONCLUSION Triple-contrast helical CT can accurately predict the need for laparotomy and exclude peritoneal violation in penetrating torso trauma including tangential abdominal wounds.
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Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. THE JOURNAL OF TRAUMA 2001; 51:860-8; discussion 868-9. [PMID: 11706332 DOI: 10.1097/00005373-200111000-00007] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The nontherapeutic laparotomy rate in penetrating abdominal trauma remains high and the morbidity rate in these cases is approximately 40%. Selective management, rather than mandatory laparotomy, has become a popular approach in both stab wounds and gunshot wounds. The advent of spiral technology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the current utility of triple-contrast CT as a diagnostic tool to facilitate initial therapeutic management decisions in penetrating torso trauma. METHODS We studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. Patients underwent triple-contrast enhanced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visceral injury). Patients with positive CT, except those with isolated solid viscus injury, underwent laparotomy. Patients with negative CT were observed. RESULTS There were 75 consecutive patients studied: mean age 30 years (range 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. CONCLUSION In penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, and facilitate nonoperative management of hepatic injury. Adjunctive angiography and investigation for diaphragm injury may be prudent.
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Abstract
BACKGROUND The role of computed tomography in diagnosing hollow viscus injury after blunt abdominal trauma remains controversial, with previous studies reporting both high accuracy and poor results. This study was performed to determine the diagnostic accuracy of helical computed tomography in detecting bowel and mesenteric injuries after blunt abdominal trauma in a large cohort of patients. METHODS One hundred fifty patients were admitted to our Level I trauma center over a 4-year period with computed tomographic (CT) scan or surgical diagnosis of bowel or mesenteric injury. CT scan findings were retrospectively graded as negative, nonsurgical, or surgical bowel or mesenteric injury. The CT scan diagnosis was then compared with surgical findings, which were also graded as negative, nonsurgical, or surgical. RESULTS Computed tomography had an overall sensitivity of 94% in detecting bowel injury and 96% in detecting mesenteric injury. Surgical bowel cases were correctly differentiated in 64 of 74 cases (86%), and surgical mesenteric cases were correctly differentiated from nonsurgical in 57 of 76 cases (75%). CONCLUSION Helical CT scanning is very accurate in detecting bowel and mesenteric injuries, as well as in determining the need for surgical exploration in bowel injuries. However, it is less accurate in predicting the need for surgical exploration in mesenteric injuries alone.
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Abstract
OBJECTIVE A retrospective study was performed to assess CT sensitivity for diagnosing tracheal rupture. Intubated cadaver tracheas were examined to assess endotracheal tube balloon overdistention and deformity and to evaluate the relationship of balloon pressures to tracheal injury. MATERIALS AND METHODS Neck or chest CT scans of 14 patients with tracheal rupture and 41 control trauma patients with pneumomediastinum but without tracheal injury were reviewed and compared to assess the presence and location of extrapulmonary air, whether direct visualization of tracheal wall disruption was possible, the size and shape of endotracheal tube balloon, signs of transtracheal balloon herniation in intubated patients, and the location of the extratracheal endotracheal tube. Intact and experimentally injured cadaver tracheas were used to evaluate tube balloon pressure and configuration. RESULTS All 14 patients with tracheal rupture had deep cervical air and pneumomediastinum. Overdistention of the tube balloon occurred in 71% (5/7) of the intubated patients, and balloon herniation occurred in 29% (2/7). Direct tracheal injury was seen in 71% (10/14) of the patients as a wall defect (n = 8) or deformity (n = 2). Overall, CT was 85% sensitive for detecting tracheal injury. Patients with tracheal injury had a significantly lower incidence of pneumothorax (p = 0.01) than did the control group. The CT appearance of balloon herniation through defects in the cadaver tracheas closely mimicked those of patients with tracheal injury. The amount of balloon pressure required to rupture the intubated trachea was extremely high and rupture was difficult to obtain. CONCLUSION CT can reveal tracheal injury and can be used to select trauma patients with pneumomediastinum for bronchoscopy, leading to early confirmation and treatment.
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Inversion recovery versus T2-weighted sagittal MR imaging in cervical spinal cord injury. Emerg Radiol 2001. [DOI: 10.1007/pl00011862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
PURPOSE To determine complications after transcatheter embolization for blunt splenic injury as recognized with computed tomography (CT). MATERIALS AND METHODS From March 1997 to January 2000, 80 patients underwent transcatheter embolization after blunt splenic injury, of whom 53 underwent abdominal CT examination before and after embolization. Preembolization CT scans were reviewed to determine grade of injury, and postembolization CT scans were reviewed to identify complications secondary to embolization. Arteriography results were reviewed to determine findings and method and location of embolization. RESULTS Splenic infarcts occurred in 63% of patients after proximal embolization and in 100% of patients after distal embolization. Infarcts after distal embolization tend to be larger and occur just distal to the embolization material, whereas infarcts after proximal embolization tend to be smaller, multiple, and located in the periphery. Most infarcts resolved without sequelae. Seven patients developed gas within an infarct or subcapsular fluid collection. Two collections were drained and found to be sterile and one patient had a splenic abscess at laparotomy. CONCLUSIONS Infarcts are common after splenic embolization. Gas may be present within an infarct after embolization with Gelfoam; however, the presence of air/fluid level is a better predictor of abscess.
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Nonsurgical management of blunt splenic injury: use of CT criteria to select patients for splenic arteriography and potential endovascular therapy. Radiology 2000; 217:75-82. [PMID: 11012426 DOI: 10.1148/radiology.217.1.r00oc0875] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if contrast material-enhanced spiral computed tomography (CT) can be used to select patients with blunt splenic injuries to undergo arteriographic embolization. MATERIALS AND METHODS During a 15-month period, 78 patients who were hemodynamically stable and required no immediate surgery underwent contrast-enhanced spiral CT followed by splenic arteriography. CT scans were assessed for splenic vascular contrast material extravasation or posttraumatic splenic vascular lesions. Medical records were reviewed for splenic arteriographic results and clinical outcome. RESULTS There were 25 grade I, 12 grade II, 27 grade III, 12 grade IV, and two grade V splenic injuries. CT showed active contrast material extravasation in seven patients and splenic vascular lesions in 19 patients. At CT, splenic vascular contrast material extravasation was 100% (seven of seven patients) and a posttraumatic splenic vascular lesion was 83% (10 of 12 patients) sensitive on the basis of arteriographic or surgical outcome in predicting the need for transcatheter embolization or splenic surgery. Overall, CT had a sensitivity of 81% (17 of 21 patients), a specificity of 84% (48 of 57 patients), negative and positive predictive values of 92% (48 of 52 patients) and 65% (17 of 26 patients), respectively, and an accuracy of 83% (65 of 78 patients) in predicting the need for splenic injury treatment. CONCLUSION Contrast-enhanced spiral CT plays a valuable role in selecting hemodynamically stable patients with splenic vascular injury who may be treated with transcatheter therapy and potentially improves the success rate of nonsurgical management.
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Abstract
PURPOSE To determine the contrast material-enhanced computed tomographic (CT) criteria for selection of hemodynamically stable patients with blunt hepatic injury for angiographic evaluation. MATERIALS AND METHODS Seventy-two patients with blunt liver injury underwent CT and hepatic angiography. Hepatic injuries were graded with CT-based classification. Scans were assessed for evidence of contrast extravasation and laceration or contusion extending into the hepatic vein(s), inferior vena cava, porta hepatis, or gallbladder fossa. Medical, angiographic, and surgical records were reviewed to determine angiographic findings, surgical indications and findings, and outcomes. RESULTS Compared with hepatic angiography, CT was 65% (11 of 17 patients) sensitive and 85% (41 of 48 patients) specific for detection of arterial vascular injury. When CT severity grades 2 and 3 were analyzed, the sensitivity and specificity of CT were 100% (three of three patients) and 94% (34 of 36 patients), respectively (P <.001). Injury involving at least one major hepatic vein was found in 15 (88%) of 17 patients who required liver-related surgery and in 23 (42%) of 55 of the other patients (P <.01). CONCLUSION CT-based criteria, including hepatic injury grade, signs of arterial vascular injury, and presence or absence of major hepatic venous involvement assists in selecting patients for hepatic angiography and those at increased risk of ongoing or delayed hepatic bleeding or other posttraumatic complications.
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Abstract
OBJECTIVE The objective of this study was to determine the CT findings of traumatic lumbar hernia in 15 patients and to discuss the mechanism and treatment of injury. CONCLUSION CT can reveal traumatic lumbar hernia and show both the anatomy of disrupted muscular layers and the presence of herniated intraabdominal viscera or retroperitoneal fat.
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Abstract
Multiple imaging modalities are available for the preoperative diagnosis of diaphragmatic injury. Chest radiographs are the initial and most commonly performed imaging study to evaluate the diaphragm after trauma. When chest radiography is indeterminate, spiral computed tomography (CT) with thin sections and reformatted images is the next study of choice, particularly because most hemodynamically stable patients with blunt diaphragm injury will require an admission CT examination to evaluate the extent and anatomical sites of coexisting thoracoabdominal injuries. Magnetic resonance imaging is used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT.
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MR imaging of thoracic trauma. Magn Reson Imaging Clin N Am 2000; 8:91-104. [PMID: 10730237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Although MR imaging and MR angiography should not be considered a primary study for patients sustaining blunt or penetrating thoracic trauma, it has achieved importance as an ancillary problem-solving modality. In general, the authors have found MR imaging to be a useful ancillary study to confirm or exclude diaphragm injury, if spiral CT scan with reformations are equivocal; to help assess the aorta and mediastinum in cases of potential injury that are not clarified by CT scan or thoracic angiography; and to identify the true origin of trauma-related masses that may simulate thoracic neoplasms.
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Abstract
OBJECTIVE The purpose of this study was to determine the diagnostic sensitivity and specificity of helical CT with sagittal and coronal reformatted images in detecting diaphragmatic rupture after blunt trauma. MATERIALS AND METHODS Chest and abdominal helical CT scans obtained in 41 patients with suspected diaphragmatic injury after major blunt trauma were reviewed by three observers who were unaware of surgical findings. Coronal and sagittal reformatted images were reviewed for each patient as well. Findings consistent with diaphragmatic injury, such as waistlike constriction of abdominal viscera (i.e., the "collar sign"), intrathoracic herniation of abdominal contents, and diaphragmatic discontinuity were recorded. Sensitivity and specificity of helical CT were calculated on the basis of surgical findings and clinical follow-up. RESULTS Helical CT was performed preoperatively in 23 patients with diaphragmatic rupture (left, n = 17; right, n = 5; bilateral, n = 1). An additional 18 patients underwent helical CT to further evaluate suspicious findings seen on chest radiography at admission and were found to have an intact diaphragm. Sensitivity for detecting left-sided diaphragmatic rupture was 78% and specificity was 100%. Sensitivity for the detection of right-sided diaphragmatic rupture was 50% and specificity was 100%. The most common CT finding of diaphragmatic rupture was the collar sign, identified in 15 patients (sensitivity, 63%; specificity, 100%). Diaphragmatic discontinuity was seen in four patients. CONCLUSION Helical CT, especially with the aid of reformatted images, is useful in the diagnosis of acute diaphragmatic rupture after blunt trauma. Helical CT can be used to detect 78% of left-sided and 50% of right-sided injuries.
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Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology 1999; 212:423-30. [PMID: 10429699 DOI: 10.1148/radiology.212.2.r99au18423] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma. MATERIALS AND METHODS Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST). RESULTS A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum. CONCLUSION Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.
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Commentary and remarks from the USA. Emerg Radiol 1999. [DOI: 10.1007/s101400050026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Chest radiographs remain the initial imaging modality to rapidly screen patients with blunt chest trauma. Spiral CT is more sensitive and specific in diagnosing most thoracic pathology seen in blunt trauma patients. This article reviews the major clinical and radiologic findings that occur with blunt injuries to the chest, excluding mediastinal vascular injuries.
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Abstract
Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in screening for and facilitating the diagnosis of acute thoracic aortic injury in the patient with blunt chest trauma has shown favorable results. This has led some physicians to question whether conventional thoracic aortography is still the reference standard. The purpose of this review article is to summarize the epidemiology and pathophysiology of acute thoracic aortic injury, the current status of the individual imaging modalities in use, and the surgeon's perspective. Despite a burgeoning literature and a confounding array of clinical and imaging advances, timely diagnosis of acute thoracic aortic injury remains a challenge. To overcome this problem, some trauma centers have used CT, transesophageal echocardiography, or both, in their diagnostic algorithm for acute thoracic aortic injury. These diagnostic algorithms are individually tailored by each institution and are still under investigation; therefore, no definite conclusions can be reached.
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Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury. THE JOURNAL OF TRAUMA 1998; 45:922-30. [PMID: 9820704 DOI: 10.1097/00005373-199811000-00014] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to prospectively examine the accuracy of contrast-enhanced spiral thoracic computed tomography (CEST-CT) for direct detection of traumatic aortic injury resulting from blunt thoracic trauma. METHODS During a 25-month period, all blunt trauma patients who had abnormal mediastinal contours on admission chest radiographs underwent CEST-CT. The presence and location of mediastinal blood and any direct signs of aortic injury, such as pseudoaneurysm, were recorded. Computed tomographic results were compared with results of aortography, when performed, surgery, or clinical status at discharge. RESULTS There were 7,826 patients classified as having blunt trauma admitted during the study. Of these, 1,104 (14.3%) had CEST-CT performed. Mediastinal hemorrhage was detected on 118 (10.7%) of all thoracic computed tomographic scans. Direct evidence of aortic injury was detected in 24 patients (20.3%) with mediastinal hemorrhage and 2.2% of all patients undergoing CEST-CT. In this prospective series, CEST-CT was 100% sensitive based on clinical follow-up; it was 99.7% specific, with 89% positive and 100% negative predictive values and an overall diagnostic accuracy of 99.7%. CONCLUSION CEST-CT is a valuable ancillary study for the detection of traumatic aortic injury. Spiral computed tomography is accurate for the detection and localization of both hemomediastinum and direct signs of aortic injury.
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Abstract
Information provided by CT scan allows for determination of the extent of liver injury and identification of other nonhepatic abdominal injuries. This information, coupled with clinical assessment, can be used to optimize management. Contrast-enhanced CT scan can monitor progression or resolution of hepatic injuries, detect complications, and guide percutaneous treatment of some complications. This article discusses CT scanning technique; classification, sites, and mechanisms of liver injury; CT scan appearance of liver injury; and complications of hepatic trauma.
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Computed tomography exclusion of osseous paranasal sinus injury in blunt trauma patients: the "clear sinus" sign. J Oral Maxillofac Surg 1997; 55:1207-10; discussion 1210-1. [PMID: 9371108 DOI: 10.1016/s0278-2391(97)90167-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE This prospective study was designed to assess the association of clear paranasal sinuses (no free fluid) as shown by facial computed tomography (CT) with the absence of fractures involving the paranasal sinus walls. PATIENTS AND METHODS All facial CT scans performed during a 12-month period to rule out maxillofacial injury in blunt trauma patients were reviewed. The scans were made using 5-mm slice thickness and 4-mm table incrementation. They were assessed for the presence or absence of free paranasal sinus fluid (hemorrhage) and the presence and location of facial fractures. RESULTS A total of 366 CT scans of the face were performed during the study. Among them, 180 scans (49%) were identified that showed no evidence of free paranasal fluid. Twenty-two (12%) of these 180 CT studies showed isolated nasal fractures (n = 13) or zygomatic arch fractures (n = 9). No patient without free paranasal sinus fluid had any midfacial fracture involving a paranasal sinus wall (P < .001 by Fischer exact test). CONCLUSION The absence of free paranasal sinus fluid after facial trauma is a highly reliable criterion to exclude fractures involving the paranasal sinus walls. Other fractures involving osseous structures not contiguous with the paranasal sinus walls, such as nasal or zygomatic arch fractures, are not excluded. The CT "clear sinus" sign is a simple, rapid method to exclude paranasal sinus fractures.
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Abstract
Hepatic venous outflow obstruction (Budd-Chiari syndrome)is a rare sequel of abdominal trauma. Three cases of Budd-Chiari syndrome resulting from obstruction to the intrahepatic IVC by liver injury are reported. The CT findings include extrinsic compression of the intrahepatic inferior vena cava (IVC) by intraparenchymal and/or subcapsular hepatic haematoma, non-visualization or narrowing of one or more main hepatic veins with intravenous contrast-enhanced CT, and accumulation of low attenuation ascites. This entity should be distinguished from intraperitoneal bile leak or hemoperitoneum associated with major liver injury with which it could be confused. Decompression of the IVC and hepatic veins by surgical or percutaneous drainage of intrahepatic or subcapsular hematoma was curative in two of the three patients.
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Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). THE JOURNAL OF TRAUMA 1997; 42:617-23; discussion 623-5. [PMID: 9137247 DOI: 10.1097/00005373-199704000-00006] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury. METHODS Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions. RESULTS Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax; hematuria; pelvic fracture; and thoracolumbar spine fracture. CONCLUSIONS Up to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.
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Abstract
Chest drain placement is essential to the management of patients with abnormal thoracic collections of air or fluid. Frequently, in these critically ill patients, drain position can only be assessed by portable frontal radiographs. However, evaluation by axial chest CT in some cases reveals unexpected malplacement that may prompt repositioning to reduce morbidity and improve drain function.
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CT findings of mesenteric injury after blunt trauma: implications for surgical intervention. AJR Am J Roentgenol 1997; 168:425-8. [PMID: 9016219 DOI: 10.2214/ajr.168.2.9016219] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purposes of this study were to determine the spectrum of CT findings of mesenteric injury, to compare CT findings of mesenteric injury with surgical observations, and to assess the potential of CT to predict which patients with mesenteric injury require laparotomy. MATERIALS AND METHODS Blunt trauma patients admitted to our facility during a 5-year 4-month period with a CT or surgical diagnosis of mesenteric injury were identified from a radiology database and trauma registry. Patients with CT findings of full-thickness bowel injury associated with mesenteric injury or diagnostic peritoneal lavage performed before CT were excluded. CT scans of all patients were retrospectively reviewed both with and without knowledge of surgical results. Medical records of all study patients were reviewed to ascertain admission physical findings and surgical results. RESULTS Twenty-seven of 29 patients meeting the study criteria underwent laparotomy, and two others were managed conservatively. Among the 27 patients who had surgery. 24 (89%) had CT findings of mesenteric injury confirmed. Surgical findings showed CT scans to be falsely negative in two other patients and falsely positive in one other patient. No major discrepancies were found between retrospective CT review done with and without knowledge of the surgical findings. Two CT findings unique to patients whose injuries, in the judgment of the surgical team, required surgical repair were active extravasation of IV contrast material and bowel wall thickening associated with mesenteric findings. Physical findings did not correlate well with the type and clinical significance of the mesenteric injury. CONCLUSION The CT finding of mesenteric bleeding or bowel wall thickening associated with mesenteric hematoma or infiltration in the blunt trauma patient indicates a high likelihood of a mesenteric or bowel injury requiring surgery. The finding of focal mesenteric hematoma or infiltration without adjacent bowel wall thickening is nonspecific and can occur both in mesenteric or bowel lesions that require surgery and those that do not.
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