Minimal aortic injury: a lesion associated with advancing diagnostic techniques.

BACKGROUND: With the increasing use of high-resolution diagnostic techniques, minimal aortic injuries (MAI) are being recognized more frequently. Recently, we have used nonoperative therapy as definitive treatment for patients with MAI. The current study examines our institutional experience with these patients from July 1994 to June 2000. METHODS: All patients suspected of blunt aortic injury (BAI) by screening helical CT (HCT) underwent confirmatory aortography with or without intravascular ultrasound (IVUS). MAI was defined as a small (<1 cm) intimal flap with minimal to no periaortic hematoma. RESULTS: Of the 15,000 patients evaluated by screening HCT, 198 (1.3%) were suspected of having BAI. BAI was confirmed in 87 (44%), and 9 (10%) of these had MAI. The initial aortogram was considered normal in five of the MAI patients. The correct diagnosis was made by IVUS (four patients), and video angiography (one patient). One MAI patient had surgery, and two (22%) died of causes not related to the aortic injury. Follow-up studies were done on the six MAI patients that were discharged. In two, the flap had completely resolved, and in one it remained stable. The remaining three patients formed small pseudoaneurysms. CONCLUSION: Ten percent of BAI diagnosed with high resolution techniques have MAI. These intimal injuries heal spontaneously and hence may be managed nonoperatively. However, the long-term natural history of these injuries is not known, and hence caution should be exercised in using this form of treatment.

Importance of delayed imaging for blunt renal trauma.

The advent of noninvasive computed tomography of the abdomen and pelvis for evaluation of blunt renal trauma has led to the practice of expectant management for hemodynamically stable patients. Although expectant management of higher grade injuries (American Association for the Surgery of Trauma Renal Injury Scale) would intuitively result in an increased frequency of urologic complications, this has not been previously examined in a large series of patients utilizing contemporary radiologic imaging techniques. A retrospective review of patients from a single institution within a recent 4-year period revealed 4 grade I, 13 grade II, 21 grade III, 7 grade IV, and 4 grade V injuries. None of grade 1, 15% of grade II, 38% of grade III, 43% of grade IV, and 100% of grade V injuries had one or more (15 major and 11 minor) urologic complications. The incidence of urinary complications correlated significantly with increasing grade (0%, 15%, 38%, 43%, and 100% for grades I to V, respectively; r = 0.94, p = 0.0158). Of the delayed urologic complications, 50% were diagnosed on follow-up imaging studies and 33% of them required intervention. Therefore we advocate repeat imaging 2 to 4 days after trauma resulting in grade III to V blunt renal lacerations to identify delayed complications that may require intervention.

Blunt bowel and mesenteric injuries: the role of screening computed tomography.

BACKGROUND: Early generation scanners have demonstrated poor sensitivity detecting blunt bowel/mesenteric injuries (BBMI). This study was aimed at determining the accuracy and role of helical scanners in BBMI. METHODS: Retrospective chart review of patients with BBMI, or computed tomographic scans suspicious of BBMI, from August of 1995 to December of 1998. RESULTS: One hundred of 8,112 scans (1.2%) were suspicious of BBMI. Of these suspicious scans, 53 patients had BBMI (true positive-TP) and 47 patients did not (false positive-FP). Seven patients with negative scans had BBMI (false negative-FN). Computed tomography contributed toward early surgery in 77% of patients who may have been delayed. Six patients developed intra-abdominal abscess. The abscess group had a significantly longer time interval from injury to surgery. Multiple findings were seen in 57% of true positive scans, whereas in 13% of false positive scans (p < 0.0001). An algorithm for management of BBMI is presented. CONCLUSION: Helical scanners have high accuracy in detecting BBMI. Single versus multiple findings are useful in managing these injuries.

Intracavitary urokinase for enhancement of percutaneous abscess drainage: phase II trial.

OBJECTIVE: To evaluate the effectiveness of urokinase as an abscess-cavity irrigant during percutaneous abscess drainage. SUBJECTS AND METHODS: In a prospective study, approved by the Food and Drug Administration and the review board at our institution, urokinase and saline were used as abscess-cavity irrigants. In the study group of 42 patients, half the patients were randomly placed into the urokinase group and the other half were placed into the control saline group. Doses used varied with the size of the abscess. Data collected from patient charts were evaluated with standard statistical methods. RESULTS: The results indicate definite benefits of the urokinase treatment. The length of stay (p = 0.0025) and treatment costs (p = 0.0021) were significantly less for the urokinase group. Other clinical parameters, including the febrile course, elevated WBC, and days of drainage, trended in a favorable fashion. CONCLUSION: Urokinase injected intracavitarily is an effective technique for shortening the treatment time and improves the clinical course for patients treated with percutaneous drainage techniques.

Screening helical CT for evaluation of blunt traumatic injury in the pregnant patient.

Pregnant patients who sustain severe blunt trauma are infrequently encountered in most practices. However, detection of internal injuries including those to the gravid uterus is essential since maternal disability or fetal loss are physical and psychologic catastrophes that have long-term effects on the mother and her family. Computed tomography (CT) is commonly used to detect blunt traumatic injuries and can play an important role in the screening of the injured pregnant woman. The normal gravid uterus and physiologic changes of pregnancy can confound CT interpretation. Inhomogeneous enhancement of placental cotyledons, hydronephrosis, and enlarged ovarian veins are normal findings. Avascular regions in the placenta indicate infarction or abruption with impending fetal demise. Although CT can demonstrate uterine rupture and retroperitoneal hemorrhage, direct detection of fetal injuries is rare. Fetal demise is more common when maternal injuries include trauma to the uterus. Although screening ultrasonography can depict fetal distress, use of screening CT allows a concurrent evaluation of multiple areas in the pregnant trauma patient including the uterus. CT is a useful diagnostic tool in the triage of the critically injured pregnant woman.

Helical CT grading of traumatic aortic injuries. Impact on clinical guidelines for medical and surgical management.

Helical CT is a reliable method for screening patients with blunt chest trauma for vascular and visceral injuries. Thoracic aortic injuries detected by CT examination affect the immediate clinical management and patient triage. This article describes the clinical indications and imaging protocols for helical CT of the chest used to detect aortic injuries, provides a grading system of the range of aortic injuries demonstrated by CT, and discusses the clinical management decisions that should be considered based on the CT grade of the aortic injury.

Imaging of acute traumatic aortic tear in patients with an aberrant right subclavian artery.

OBJECTIVE: This report describes the radiologic findings and discusses the clinical consequences of acute traumatic aortic tear occurring with an aberrant right subclavian artery. CONCLUSION: Identification of an aberrant right subclavian artery with acute traumatic aortic tear must be emphasized to reduce iatrogenic morbidity and mortality.

Traumatic rupture of the aortic isthmus: program of selective management.

Two hypotheses were investigated: (1) helical computed tomography (CT) of the chest on victims of decelerating trauma can yield a diagnosis of, or "rule out," a traumatic rupture of the aorta (TRA) without the need for an aortogram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol. Screening helical CT examinations were done on 6169 victims of blunt thoracic trauma; 47 were found to have TRA; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated with a proved TRA. It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries. Drugs (beta-blockers +/- vasodilators) to decrease the stress in the aortic wall were used in 93 patients when the diagnosis was suspected and were continued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done between 2 days and 25 months in 15 patients who were deemed to be excessive risks for emergency aortic repair; there were 2 deaths (13. 3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether repaired emergently, electively, or not at all, developed free rupture of the periaortic hematoma and death from TRA.

Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms.

OBJECTIVES: By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms. METHODS: The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management. RESULTS: Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. CONCLUSIONS: Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).

Prospective study of blunt aortic injury: helical CT is diagnostic and antihypertensive therapy reduces rupture.

OBJECTIVE: There were two aims of this study. The first was to evaluate the application of helical computed tomography of the thorax (HCTT) for the diagnosis of blunt aortic injury (BAI). The second was to evaluate the efficacy of beta-blockers with or without nitroprusside in preventing aortic rupture. SUMMARY BACKGROUND DATA: Aortography has been the standard for diagnosing BAI for the past 4 decades. Conventional chest CT has not proven to be of significant value. Helical CT scanning is faster and has higher resolution than conventional CT. Retrospective studies have suggested the efficacy of antihypertensives in preventing aortic rupture. METHODS: A prospective study comparing HCTT to aortography in the diagnosis of BAI was performed. A protocol of beta-blockers with or without nitroprusside was also examined for efficacy in preventing rupture before aortic repair and in allowing delayed repair in patients with significant associated injuries. RESULTS: Over a period of 4 years, 494 patients were studied. BAI was diagnosed in 71 patients. Sensitivity was 100% for HCTT versus 92% for aortography. Specificity was 83% for HCTT versus 99% for aortography. Accuracy was 86% for HCTT versus 97% for aortography. Positive predictive value was 50% for HCTT versus 97% for aortography. Negative predictive value was 100% for HCTT versus 97% for aortography. No patient had spontaneous rupture in this study. CONCLUSIONS: HCTT is sensitive for diagnosing intimal injuries and pseudoaneurysms. Patients without direct HCTT evidence of BAI require no further evaluation. Aortography can be reserved for indeterminate HCTT scans. Early diagnosis with HCTT and presumptive treatment with the antihypertensive regimen eliminated in-hospital aortic rupture.

Predicting clinical outcome of nonsurgical management of blunt splenic injury: using CT to reveal abnormalities of splenic vasculature.

OBJECTIVE: Using CT to grade blunt splenic injuries frequently does not predict clinical outcome. This retrospective, blinded study evaluated whether revealing a traumatic pseudoaneurysm or frank hemorrhage on an initial CT examination can be used to predict the successful clinical outcome of patients managed without surgery. MATERIALS AND METHODS: The medical and CT records of all patients with blunt splenic injury during a 5-year period were independently reviewed for vascular abnormalities. Also, the grade of injury was reconfirmed. Hemodynamically stable patients with injuries of grades 1-3 were managed without surgery. Clinical failure occurred if a patient required splenectomy or splenorrhaphy after any attempt of nonsurgical management. RESULTS: Two hundred sixty-three patients were treated for blunt splenic injuries. Eighty-two of these patients underwent emergent surgery on the basis of clinical and peritoneal lavage findings without CT examination. The remaining 181 (69%) patients were initially evaluated with emergent abdominal CT. Of these 181 patients, 72 (40% of those undergoing CT) were treated nonsurgically. Nonsurgical therapy failed in 11 (15%) of these 72 patients. Of these 11 patients, nine (82%) had a defined vascular abnormality of the spleen. Only eight (13%) of the remaining 61 patients who underwent CT and successful nonsurgical management had a vascular abnormality of the spleen. CONCLUSION: The failure rate in patients with nonsurgically managed blunt splenic injuries may be markedly reduced if patients with traumatic pseudoaneurysm or active hemorrhage revealed on emergent CT are treated with early surgical or endovascular repair.

Comparison of iodixanol with iohexol in excretory urography.

RATIONALE AND OBJECTIVES: We compared the safety and efficacy of iodixanol, a nonionic, dimeric, iodinated contrast agent, with that of iohexol, a monomeric agent, in adult excretory urography. METHODS: The study used a randomized, double-blind, parallel-comparison design to evaluate image quality, vital signs, laboratory values, and adverse reactions. Seventy-five patients from each of two centers were included. One third received iodixanol at 270 mg I/ml, one third received iodixanol at 320 mg I/ml, and one third received iohexol at 300 mg I/ml. The dose for every patient was 1 ml/kg of body weight. The radiographs were interpreted and evaluated for quality by the primary investigator at each center. There were no important differences among the three groups in terms of demographics. RESULTS: Evaluation of each phase of the radiographic study showed almost uniform good-to-excellent opacification, with no significant differences among the three agents. No significant differences existed for the three groups in terms of vital signs, hematology, blood and urine chemistry, and injection discomfort. There were no deaths or serious reactions during the study, nor was there a statistically significant difference among the number of adverse events for the three agents. CONCLUSION: Iodixanol at both 270 and 320 mg I/ml proved to be a safe and effective contrast material for intravenous urography. In this study, its profile was essentially indistinguishable from that of iohexol at 300 mg I/ml.

CT aortography of thoracic aortic rupture.

OBJECTIVE: Emergent aortography is commonly used to confirm and define a suspected thoracic aortic rupture detected by CT screening. We evaluated whether helical CT aortography can replace transcatheter aortography for critically injured patients. SUBJECTS AND METHODS: Over 22 months, 38 thoracic aorta and great vessel injuries were detected in 3229 patients with nontrivial blunt chest trauma who underwent helical CT screening. Planar, oblique, and curved two-dimensional reconstructions and three-dimensional shaded-surface display and maximum intensity projection volume-rendering techniques were used to evaluate the aortic injuries. Transcatheter aortography or surgery was performed in all stable patients. RESULTS: Twenty-eight of the injuries involved the descending thoracic aorta. All such injuries were best identified on axial images before CT angiography. CT angiography adequately showed tears over 15 mm long. Smaller tears required axial images for corroboration. CONCLUSION: Technically adequate axial helical CT detects and defines all injuries of the thoracic aorta. CT angiography supplements the conventional examination and can replace transcatheter aortography except for small tears or indeterminate studies.

A prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta.

OBJECTIVE: Recently, transesophageal echocardiography (TEE) has been proposed as the standard for the diagnosis of traumatic disruption of the aorta (TDA), replacing aortography. The purpose of this study was to evaluate the accuracy and practicality of TEE in the diagnosis of TDA. DESIGN: Prospective clinical trial. MATERIALS AND METHODS: Patients with blunt trauma admitted with a suspected diagnosis of TDA were evaluated with TEE and aortography. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients were evaluated with TEE and aortography. TEE was unsuccessful in five patients (15%). Of the remaining 29 patients, TEE results were true-positive in four and true-negative in 20. TEE results were false-positive in two patients, and three injuries were missed (two were proximal to the left subclavian artery, and one was a localized aortic disruption). Sensitivity and specificity of TEE were 57% and 91%, respectively, compared with aortography, for which sensitivity was 89% and specificity was 100%. CONCLUSION: Although the use of TEE in the diagnosis of TDA has several advantages, it is not more accurate than aortography. TEE should not replace aortography as the standard for the diagnosis of TDA.

Blunt traumatic aortic rupture: detection with helical CT of the chest.

PURPOSE: To determine the effectiveness of helical computed tomography (CT) as a screening device to detect traumatic aortic rupture. MATERIALS AND METHODS: Helical CT was used to examine 1,518 patients with nontrivial blunt trauma. Of these patients, 127 (8.37%) with abnormal CT scans of the mediastinum or aorta underwent thoracic aortography--89 patients solely for evaluation of mediastinal hematoma depicted at CT. Imaging abnormalities were correlated with surgical or clinical outcome. RESULTS: Twenty-one aortic injuries were identified that ranged from subtle intimal flaps to complete aortic disruption. Helical CT was more sensitive than aortography (100% versus 94.4%, respectively) but less specific (81.7% versus 96.3%, respectively) in detection of aortic injuries in patients who underwent both examinations. The association between CT findings and outcome was phi = 0.62 (chi2 = 49.1, 1 df, P < .01) and between aortography and outcome was phi = 0.85 (chi2 = 92.2, 1 df, P < .001). The P value of the difference between the phi coefficients was .10. CONCLUSION: Helical CT of the chest is effective for screening critically injured patients with possible blunt thoracic aortic injuries.

Treatment of adhesive capsulitis (frozen shoulder) with arthrographic capsular distension and rupture.

Sixteen patients with adhesive capsulitis of the shoulder were treated in an open trial of capsular distension with intraarticular injection of 30mL of fluid containing 8mL of 1% lidocaine, 2mL of corticosteroid, and 20mL of radiocontrast material. A capsular tear during arthrography occurred in all cases. Rupture usually occurred at the subscapular bursa or the subacromial bursa. Rupture at the distal bicipital sheath occurred in two patients and was not associated with pain relief. Thirteen patients experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months. Disruption of the constricted capsule by hydraulic distension seems to be the mechanism for achieving symptomatic relief in adhesive capsulitis.

Distention arthrography in the treatment of adhesive capsulitis of the shoulder.

PURPOSE: Adhesive capsulitis involving the glenohumeral joint (frozen shoulder) is an insidious and painful condition that results in gradual loss of joint motion. Recovery is frequently prolonged despite multiple therapeutic maneuvers. The authors investigate the mechanism of action and the long-term clinical result of distention arthrography for the treatment of patients with frozen shoulder. PATIENTS AND METHODS: Sixteen patients with adhesive capsulitis of the shoulder were treated with therapeutic capsular distention by using intra-articular injection of a 30-mL mixture of lidocaine, corticosteroid, and contrast media immediately following diagnostic arthrography. RESULTS: Capsular disruption was demonstrated in all cases. Thirteen patients (80%) experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months or more. Disruption occurred at the subscapular bursa in eight patients, the subacromial bursa in six, and the distal bicipital tendon sheath in two. These latter two patients had no pain relief. CONCLUSION: Arthrographic distention of the constricted capsule appears to be an excellent therapeutic intervention for achieving rapid symptomatic relief from adhesive capsulitis.