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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
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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
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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)
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but also clarity MDCT - Not only speed
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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.
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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.
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3D display 2D/MPR Axial images IMAGE ANALYSIS
Maximum intensity projection. Volume rendering technique 2D/MPR Shaded Surface Display Endoluminal Virtual Angioscopy
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Timely detection of vascular injury can be life saving
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Vascular injuries Arterial injuries Active arterial hemorrhage
Occlusion Dissection Pseudoaneurysm Transection
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Vascular Injuries Other arterial injuries: Arteriovenous fistula
Intimal injury Spasm Venous injuries: Active venous hemorrhage Contour irregularity Venous thrombosis.
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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
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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.
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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.
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Common signs *Periaortic hemorrhage
*Aortic pseudoaneurysm *Periaortic hemorrhage *Displacement of esophagus and trachea, irregular aortic contour *Dissection/intimal flap
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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
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Complete aortic rupture
Extremely rare. Commonest site: Aortic isthmus.
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Complete aortic rupture
Classical sign: active extravasation of contrast from aorta with adjacent hematoma Steenburg S D et al. Radiology 2008;248:
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Aortic Pseudoaneurysm
Secondary to disruption of inner layers / entire vessel, with blood contained by adventitia or perivascular soft tissues.
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Aortic psudoaneurysm Well circumscribed, lobulated, focal outpouching of contrast enhanced blood that communicates with aorta. Kaewlai R et al. Radiographics 2008;28:
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Complications of pseudoaneurysm
1.Rupture and hemorrhage 2.Thrombosis and distal emboli.
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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:
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Extension into major branches
MDCT demonstrates Integrity of distal organs Extent of dissection Extension into major branches
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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
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Acute intramural hematoma
Hyperdense on plain CT. Hypodense on CECT. Hematoma
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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.
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Imaging pitfalls Atypical ductus bump Ductus remnant
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Hemoperitoneum Its presence warrants careful evaluation. Hemoperitoneum : Unclotted blood: 30-45HU Clotted blood: HU. Active arterial extravastion: HU.
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Mesenteric Injuries Specific findings
Mesenteric hemorrhage flows into interloop space. Specific findings Active extravasation Vascular beading Abrupt termination of vessel
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Mesenteric Injuries NON SPECIFIC FINDINGS Mesenteric hematoma
Fat stranding Abnormal thickening and enhancement of bowel
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Solid abdominal visceral trauma
MDCT evaluation changes CT grading of trauma Making difference in management
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Liver Active bleed Management changed towards non surgical management based on CT input MDCT - further pushing it towards Endovascular management
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SPLENIC VASCULAR INJURY/
Spleen MDCT SPLENIC VASCULAR INJURY/ ACTIVE BLEED EMBOLIZATION / SURGERY
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Spleen- pseudoaneurysm Spleen-Active bleed
Arterial phase Delayed phase – Wash out of contrast
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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.
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Pitfalls in MDCT Patient factors: 1. Motion artifatcs.
2. Beam hardening artifacts from metals/IV contrast – create pseudolesions /hide subtle lesion Beam hardening artifact
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Multi-slice CT and Interventional Radiology
An ideal combination in life threatening vascular injuries associated with Trauma
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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.
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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.
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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.
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Conclusion Whole body MDCT- the modality of choice in evaluation of traumatic vascular injuries.
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