MDCT of blunt renal trauma: imaging findings and therapeutic implications.

OBJECTIVES: To show the wide spectrum of computed tomography (CT) findings in blunt renal trauma and to correlate them with consequent therapeutic implications. METHODS: This article is the result of a literature review and our personal experience in a level II trauma centre. Here we describe, discuss and illustrate the possible CT findings in blunt renal trauma, and we correlate them with the American Association for the Surgery of Trauma (AAST) classification and their therapeutic implications. RESULTS: CT findings following blunt renal trauma can be grouped into 15 main categories, 12 of them directly correlated with the AAST classification and 3 of them not mentioned in it. Non-operative management, which includes the "watchful waiting" approach, endourological treatments and endovascular treatments, is nowadays widely adopted in blunt renal trauma, and surgery is limited to haemodynamically unstable patients and a minority of haemodynamically stable patients. CONCLUSIONS: The interpretation of CT findings in blunt renal trauma may be improved and made faster by the knowledge of their therapeutic consequences. TEACHING POINTS: • The majority of blunt renal injuries do not require surgical treatment. • CT findings in blunt renal injury must be evaluated considering their therapeutic consequences. • Some CT findings in blunt renal trauma are not included in the AAST classification.

Basilar artery thrombosis: imaging and endovascular therapy.

PURPOSE: Basilar artery thrombosis represents a rare type of ischaemic stroke with a mortality rate of 80%-90% if not promptly treated. The aim of our study was to review our experience with computed tomography angiography (CTA) in the diagnosis of basilar artery thrombosis and its treatment with endovascular procedures. MATERIALS AND METHODS: Our retrospective study is based upon 59 nontrauma patients with episodes of sudden loss of consciousness. Patients were investigated using unenhanced brain CT followed by intracranial CTA (16-slice CT) when no parenchymal haemorrhage was detected. Patients with a CTA diagnosis of basilar artery thrombosis were considered for endovascular treatment. CTA accuracy was evaluated by considering the 12 patients who underwent endovascular angiography (the gold standard). The success of endovascular therapy was evaluated by considering the degree of microcirculatory reperfusion. RESULTS: After the exclusion of 33 patients affected by parenchymal or subarachnoid haemorrhage, the final study consisted of 26 patients who underwent CTA. Basilar artery thrombosis was diagnosed in 15 of them, and 12 were treated at our institution. The comparison between CTA and endovascular angiography showed 100% agreement in evaluating occlusion site and extension. Seven patients underwent intra-arterial lysis, and five underwent mechanical clot removal. CONCLUSIONS: CTA, with its wide availability and rapid execution times, is the most indicated examination in the case of suspected basilar artery thrombosis. Although there is a lack of randomised controlled prospective studies suggesting the most appropriate therapeutic approach to basilar artery thrombosis, our study lends weight to the role of interventional neuroradiology in the treatment of this condition.

CT Perfusion Evaluation of Cerebral Haemodynamics before and after Cranioplasty.

CT Perfusion imaging is usually applied to assess perfusion abnormalities in acute stroke. This prospective study applied the technique to monitor cerebral haemodynamics before and after cranioplasty. Cranioplasty is the surgical correction of a skull defect using autologous or heterologous material to obtain cosmetic repair, restoration of brain protection and neurological improvement (1). As far as we know the effect of cranioplasty on cerebral haemodynamics flow has been analysed by CT perfusion only in one article (2). We tested the examination as method of monitoring intracranial haemodynamics in a larger number of patients evaluating its reliability and efficacy. We prospectively examined cerebral haemodynamics with Perfusion CT before and after (two weeks, three and six months) cranioplasty in ten patients. The data evaluation of dynamic CT was done by an application software package on a workstation (Leonardo) permitting the use of visual assessment combined with quantitative analysis with ROIs. There was a comparison of CBF, CBV and TTP values between the regions of interest and mirror-image control regions, and in the three different examinations for each patient. After cranioplasty there was clearly an improvement in neurological symptoms and CT perfusion in the majority of cases showed a slight increase in CBF, CBV and decrease of TTP in the cerebral parenchyma close to the cranioplasty, not only on the symptomatic side but also on the opposite side. Even though there was neurological improvement and improved cranial perfusion from the first to the last examinations, our data were not statistically significant. The method is easily reproducible, well tolerated by all patients but has several limitations related to data processing and radiation exposure.

Detection of cerebral aneurysms in nontraumatic subarachnoid haemorrhage: role of multislice CT angiography in 130 consecutive patients.

PURPOSE: The leading cause of a nontraumatic subarachnoid haemorrhage is rupture of an intracranial aneurysm. The aim of this study was to assess the usefulness of multislice computed tomography angiography (CTA) in identifying and evaluating cerebral aneurysms by comparing it with intra-arterial digital subtraction angiography (DSA) and intraoperative findings. MATERIALS AND METHODS: During a 20-month period (June 2004 and February 2006), 130 patients with a CT diagnosis of nontraumatic acute subarachnoid haemorrhage were prospectively recruited to this study and underwent 16-detector CTA and DSA (57 men, 73 women; mean age 59.5 years). Twenty-five patients who underwent DSA alone postclipping were excluded. CTA and DSA were evaluated by the performing radiologist to assess the presence of one or more aneurysms and their morphological characteristics. RESULTS: CTA detected 133 aneurysms, whereas DSA identified 134: the aneurysm missed by CTA was 2 mm in size. CONCLUSIONS: CTA is fast and relatively noninvasive, and its sensitivity appears similar to that of DSA in detecting and evaluating intracranial aneurysms, even those smaller than 3 mm. This study confirms the value of CTA as the primary imaging technique in subarachnoid haemorrhage, with DSA reserved for selected patients.