1. Whole body MDCT in trauma -Detection of vascular injuries
P. Mehta, S. S. Hedgire, T. Kalyanpur,
K. S. Narsinghpura, V. Kasi, M. P. Cherian
KOVAI MEDICAL CENTER & HOSPITAL,
COIMBATORE
INDIA

2. Evolution of CT First generation ct-1973 Multislice spiral ct-1998
X-ray tube
First generation ct-1973
Multislice spiral ct-1998
Dual source ct-2005
Single detector
Multiple detectors

3. MDCT 2. Periodic motion of focal spot in Z axis (flying focal spot)
Increase in number of slices by 1. Increasing number of rows of detectors
2. Periodic motion of focal spot in Z axis (flying focal spot)

4. but also clarity
MDCT - Not only speed

5. Whole body MDCT and trauma
Timely localisation of active bleeding sources.
determining the presence and extent of other organ
injuries
serves as a baseline for monitoring of conservative
treatment.
Replaced conventional angiography and plain film
radiography in most trauma centers.

6. Whole body MDCT-protocol
Plain CT – Head.
CECT
1. Arterial phase: From circle of willis through symphysis pubis.
2. Venous phase: From
base of lungs through
symphysis pubis.

7. 3D display 2D/MPR Axial images IMAGE ANALYSIS
Maximum intensity projection.
Volume rendering technique
2D/MPR
Shaded Surface Display
Endoluminal Virtual Angioscopy

8. Timely detection of vascular injury can be life saving

9. Vascular injuries Arterial injuries Active arterial hemorrhage
Occlusion
Dissection
Pseudoaneurysm
Transection

10. Vascular Injuries Other arterial injuries: Arteriovenous fistula
Intimal injury
Spasm
Venous injuries:
Active venous hemorrhage
Contour irregularity
Venous thrombosis.

11. Role of dual phase DIFFERENTIATE PSEUDOANEURYSM & AV FISTUALA
EXTRAVASATION
DIFFERENTIATE
Attenuation more than the aorta in venous phase
Attenuation similar
to aorta in venous phase

12. Interpretation of vascular injury
Site and type of injury
Extent of injury
Diameter of vessel
proximal and distal to
injury
Percent of vascular
narrowing
Integrity of distal tissue
Proximity to other vessels.
Abormal anatomy of vessel.

13. Acute Traumatic Aortic injury(ATAI)
Serious outcome in trauma.
95% morbidity and mortality if untreated.
MDCT -investigation of choice.
Thoracic aortic injuries - 20 times more
common than abdominal aortic injuries.

14. Common signs *Periaortic hemorrhage
*Aortic pseudoaneurysm
*Periaortic hemorrhage
*Displacement of esophagus and trachea, irregular aortic contour
*Dissection/intimal flap

15. Uncommon signs *luminal clot at site of intimal injury
*sudden change in aortic caliber or small aortic caliber in lower chest and abdomen,
*peridiaphragmatic hemorrhage

16. Complete aortic rupture
Extremely rare.
Commonest site: Aortic isthmus.

17. Complete aortic rupture
Classical sign: active extravasation of contrast from aorta with adjacent hematoma
Steenburg S D et al. Radiology 2008;248:

18. Aortic Pseudoaneurysm
Secondary to disruption of inner layers / entire vessel, with blood contained by adventitia or perivascular soft tissues.

19. Aortic psudoaneurysm
Well circumscribed, lobulated, focal outpouching of contrast enhanced blood that communicates with aorta.
Kaewlai R et al. Radiographics 2008;28:

20. Complications of pseudoaneurysm
1.Rupture and hemorrhage
2.Thrombosis and distal emboli.

21. Aortic dissection Pathognomonic sign: Identification of intimal flab.
INTIMAL FLAP
Pathognomonic sign:
Identification of
intimal flab.
False lumen:
a.Decreased density of
contrast.
b.Larger in caliber
c.Acute angle with outer
wall
Hayter R G et al. Radiology 2006;238:

22. Extension into major branches
MDCT demonstrates
Integrity of
distal organs
Extent of dissection
Extension into major branches

23. Acute intramural hematoma(AIH)
Synonym : Non communicating aortic dissection.
Progression:
a. Rupture of aortic wall externally.
b. Rupture internally - communicating
aortic dissection
Differential diagnosis: Mural thrombus

24. Acute intramural hematoma
Hyperdense on plain CT.
Hypodense on CECT.
Hematoma

25. Imaging pitfalls Technical: Patient motion.
Cardiac pulsation/Breathing.
Streak artifacts.
Poor contrast enhancement.
Anatomical
Vein: Left superior intercostal vein, hemi azygos
vein simulate dissection when abutting the
aorta.
Artery: Infundibulum at the origin of bronchial and
intercostal arteries.
Atypical ductus bump
Normal post isthmic aortic dilatation.

26. Imaging pitfalls
Atypical ductus bump
Ductus remnant

27. Hemoperitoneum
Its presence warrants careful evaluation. Hemoperitoneum : Unclotted blood: 30-45HU Clotted blood: HU. Active arterial extravastion: HU.

28. Mesenteric Injuries Specific findings
Mesenteric hemorrhage flows into interloop space.
Specific findings
Active extravasation
Vascular beading
Abrupt termination
of vessel

29. Mesenteric Injuries NON SPECIFIC FINDINGS Mesenteric hematoma
Fat stranding
Abnormal thickening and enhancement of bowel

30. Solid abdominal visceral trauma
MDCT evaluation
changes CT grading of trauma
Making difference in management

31. Liver
Active bleed
Management changed towards non surgical management based on CT input
MDCT - further pushing it towards Endovascular management

32. SPLENIC VASCULAR INJURY/
Spleen
MDCT
SPLENIC VASCULAR INJURY/
ACTIVE BLEED
EMBOLIZATION /
SURGERY

33. Spleen- pseudoaneurysm Spleen-Active bleed
Arterial phase
Delayed phase –
Wash out of contrast

34. Pitfalls in MDCT Technical factors: 1. Poor bolus timing
2. Early scanning in venous phase-pseudothrombus .
3. Single phase acquisition – venous injuries missed.
4. High resolution kernel reconstruction – optimal for
evaluation of bone not for vessel.
5. Retained extravasated contrast material
mimic active bleeding in follow-up CT.

35. Pitfalls in MDCT Patient factors: 1. Motion artifatcs.
2. Beam hardening artifacts
from metals/IV contrast – create
pseudolesions /hide subtle lesion
Beam hardening artifact

36. Multi-slice CT and Interventional Radiology
An ideal combination in life threatening vascular injuries associated with Trauma

37. Role of MDCT in interventional radiology.
As a road map to targeted angiography of bleeding vessel and embolisation.
For planning the procedure in case of stent grafts.
Post procedural follow up to look for patency of stent and stent graft leak.

38. Therapeutic options in polytrauma
A.Embolisation
a.CECT:Pseudoaneurysm from gastro duodenal aretery.
b.Preembolisation DSA - pseudoaneurysm from gastroduodenal aretry.
c.Postembolisation DSA: Complete occlusion of pseudoaneurysm.

39. Therapeutic options in polytrauma
B. Stent grafts
a.CECT: Aortic rupture
with mediastinal
hematoma
b.DSA and Stent grafting.
c. Follow up CT: No active
extravastion of contrast
from aorta.

40. Conclusion
Whole body MDCT- the modality of choice in evaluation of traumatic vascular injuries.