Incidental CT findings in trauma patients: incidence and implications for care of the injured.

BACKGROUND: The evaluation of patients with head, neck, and torso trauma frequently includes high-definition spiral computed tomography (SCT) scanning, which can reveal non-injury-related lesions. These incidental findings vary in their importance, from trivial lesions to findings that may have a greater impact on the health of the trauma patient than the injuries that led to the SCT. We evaluated the incidence and clinical importance of incidental findings found on SCT, and the effectiveness of a trauma practice guideline calling for appropriate management and follow-up. METHODS: The trauma registry was accessed to identify patients evaluated at an urban Level I trauma center from January to November, 2002. Trauma registry data, inpatient chart records, and the digital record of the filmless radiology archives were reviewed. Demographic data, including age, sex, type and mechanism of injury, and outcome, were recorded. All CT studies were reviewed for incidental findings. Mucus retention cysts, sinusitis (except mastoiditis), degenerative joint disease, evidence of previous operation, and age-related cerebral atrophy were excluded. Incidental findings were divided into three categories based on clinical importance. Category 1 required attention before discharge. Category 2 required follow-up with primary doctor within 1 or 2 weeks, and Category 3 required no specific follow-up. Categories 1 and 2 were considered clinically significant findings. RESULTS: Complete data were available for 991 patients (677 men, 314 women). Eight hundred and forty-eight (85.6%) patients received at least one CT scan. A total of 289 incidental findings were discovered. Thirty-one patients (3.1%) had 36 Category 1 findings. There were 108 Category 2 and 145 Category 3 findings. When comparing those patients with at least one incidental finding, the incidence of incidental findings was higher in women than in men (34.1% versus 27.6%; p < 0.05). Older patients also had a higher incidence of all categories of findings (over 40 versus 40 and younger: 46.1% versus 19.9%; p < 0.001). SCT yielded 90 (62.5%) of the clinically significant incidental findings in the abdomen/pelvis, 29 (20.1%) in the chest, and 25 (17.4%) in the head and neck. The charts of only 15 (48.4%) of the patients with Category 1 findings adequately documented the management of the incidental finding. CONCLUSIONS: SCT for the evaluation of trauma patients reveals a significant number of incidental findings. These lesions are common in the abdomen and pelvis and show an increased incidence in women and among older patients. Although many require early follow-up and specialty physician referral, there was insufficient documentation of the management of these injuries. Incidental findings in the injured remain a significant challenge for trauma centers. An organized approach is required for successful follow-up and management.

Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage.

OBJECTIVES: Computed tomography (CT) followed by lumbar puncture (LP) is currently the criterion standard for diagnosing subarachnoid hemorrhage (SAH) in the emergency department (ED); however, this is based on studies involving a limited number of patients. The authors sought to assess the ability of CT angiography (CTA), a new diagnostic modality, in conjunction with CT/LP to detect SAH. METHODS: Consecutive patients presenting to the ED with symptoms concerning for SAH were approached. All patients had an intravenous catheter placed and underwent a noncontrast head CT followed by CTA. Patients whose CT did not reveal evidence of SAH or other pathology underwent LP in the ED. CTAs were read within 24 hours by a neuroradiologist blinded to the patient's history. RESULTS: A total of 131 patients were approached, 116 were enrolled, and 106 completed the study. In six of 116 patients (5.1%), aneurysm was found on CTA with normal CT and positive findings on LP; three had a positive CTA with normal CT and LP findings (one of which had a negative cerebral angiogram), and there was one false-positive CTA. Follow-up of all 131 patients showed no previously undiagnosed intracranial pathology. In this patient population, 4.3% (5/116) were ultimately found to have an SAH and/or aneurysm. CONCLUSIONS: In this pilot study, CTA was found to be useful in the detection of cerebral aneurysms and may be useful in the diagnosis of aneurysmal SAH. A larger multicenter study would be useful to confirm these results.