Parameters for successful nonoperative management of traumatic aortic injury

ObjectiveBlunt traumatic aortic injury is associated with significant mortality, and increased computed tomography use identifies injuries not previously detected. This study sought to define parameters identifying patients who can benefit from medical management.MethodsWe reviewed 4.5 years of blunt traumatic aortic injuries. Injury was classified as grade I (intimal flap or intramural hematoma), II (small pseudoaneurysm <50% circumference), III (large pseudoaneurysm >50% circumference), and IV (rupture/transection). Secondary signs of injury included pseudocoarctation, extensive mediastinal hematoma, and large left hemothorax. Follow-up, including computed tomography, was reviewed.ResultsWe identified 97 patients: 31 grade I, 35 grade II, 24 grade III, and 7 grade IV; 67(69%) male; mean age 47 ± 18.8 years, mean Injury Severity Score 38.8 ± 14.6; overall survival 76 (78.4%). Secondary signs of injury were found in 30 patients. Overall, 52 (53.6%) underwent repair, 45 undergoing thoracic endovascular aortic repair, with 2 (2.22%) procedure-related deaths, and 7 undergoing open repair. Five patients undergoing thoracic endovascular aortic repair required 7 additional procedures. In 45 medically managed patients, there were 14 deaths (31%), all secondary to associated injuries. Injury Severity Scores of survivors and nonsurvivors were 33 ± 10.8 and 48.6 ± 12.8, respectively (P < .001). Follow-up showed resolution or no change in 21 (91%) and a small increase in 2 grade I injuries.ConclusionsAll blunt traumatic aortic injury does not necessitate repair. Stratification by injury grade and secondary signs of injury identifies patients appropriate for medical management. Grade IV injury necessitates emergency procedures and carries high mortality. Grade III injury with secondary signs of injury should be urgently repaired; patients without secondary signs of injury may undergo delayed repair. Grade I and II injuries are amenable to medical management

Imaging of diaphragm injuries

Diaphragm injuries are uncommon consequences of blunt and penetrating trauma. Early diagnosis and repair prevent potentially devastating complications that typically result from visceral herniation through the posttraumatic diaphragm defect. Although clinical and radiographic manifestations frequently are nonspecific, the stalwarts of trauma imaging\u97chest radiography and CT\u97typically demonstrate these injuries. To render the appropriate diagnosis, the radiologist must be familiar with the varied imaging manifestations of injury, and maintain a high index of suspicion within the appropriate clinical setting

Multidetektor-CT bei Erwachsenen mit stumpfem Trauma der Halswirbelsäule

Zusammenfassung Die Bildgebung der Halswirbelsäule wurde seit der Einführung der 64-Zeilen-CT-Scanner im Jahr 2004 durch eine Reihe von Neuerungen weiterentwickelt. Immer umfangreicheres Evidenzmaterial spricht für den Einsatz der Multidetektor-CT als eigenständigen Screening-Test zum Ausschluss zervikaler Verletzungen bei polytraumatisierten Patienten mit Bewusstseinstrübung. Zunehmende Akzeptanz gewinnt bei den Wirbelsäulenchirurgen eine neue Grading-Skala, die auf CT- und MRT-Befunden und auf dem SLIC-Scoring-System für Verletzungen der Halswirbelsäule (Subaxial Injury Classification and Scoring System) basiert. Zurzeit werden die gebräuchlichen radiografischen Parameter für die Evaluation kraniozervikaler Distraktionsverletzungen unter Verwendung der Multidetektor-CT neu bewertet. Bislang werden die meisten Patienten mit stumpfem Trauma nicht operativ behandelt, doch haben neue Erkenntnisse bezüglich der Stabilität der Wirbelsäule sowie die Entwicklung neuer Operationstechniken und neuer Hardware dazu geführt, dass der aktuelle Trend bei den Behandlungsstrategien zunehmend in Richtung chirurgischer Interventionen geht. Für die Radiologen ist es daher unerlässlich zu bestimmen, anhand welcher Befunde sich Verletzungen, die wegen Instabilität des Bandapparats oder hoher Wahrscheinlichkeit von Nonfusion einer operativen Stabilisierung bedürfen, von jenen unterscheiden lassen, die klassischerweise stabil sind und allein mittels Halskragen oder Halo-Weste behandelt werden können. Dieser Artikel gibt einen Überblick über das Spektrum der Halswirbelsäulenverletzungen, vom kraniozervikalen Übergang bis zur subaxialen Wirbelsäule, und stellt die gebräuchlichsten Grading-Systeme für die einzelnen Verletzungsarten vor

Multidetector CT of blunt cervical spine trauma in adults

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type

MDCT diagnosis of penetrating diaphragm injury.

The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries

Improved chest wall trauma taxonomy : an interdisciplinary CWIS and ASER collaboration

PurposeChest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic.MethodsA collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens.ResultsAfter identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures.ConclusionsThe 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.Peer reviewe

Multidetector CT of Blunt Cervical Spine Trauma in Adults

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type