Abdominal Solid Organ Injury

Transcription

1 Abdominal Solid Organ Injury 8 th Nordic Course Stockholm, Sweden May 19-22, 2014 K.SHANMUGANATHAN M.D.

2 ABDOMINAL TRAUMA OBJECTIVES Splenic injury Late arterial / early p-v phase imaging Liver injury

3 Blunt Splenic Injury

4 BLUNT SPLENIC INJURY Most commonly injured organ MDCT - 98% accurate Vascular lesions (AB & VI) 83% 20% rib fractures Grading systems HM, KS, SEM, et al. JACS 2008 ; 206:685-93

5 Grade I I II II III III IV IVA V IVB Splenic Grading systems GRADE INJURY DESCRIPTION Description of Injury Hematoma Subcapsular, < 10% surface area Laceration Capsular tear, < 1 cm parenchymal depth Subcapsular hematoma <1 cm thick Hematoma Laceration <1 Subcapsular, cm parenchymal 10-50% depth surface area; Laceration Parenchymal Intraparenchymal, hematoma <1 cm < diameter 5cm in diameter Subcapsular 1-3 hematoma cm parenchymal 1 3 cm thick depth which does Laceration 1 3 not cm involve parenchymal a trabecular depth vessel Parenchymal hematoma 1 3 cm in diameter Hematoma Subcapsular, > 50% surface area or expanding; Splenic capsular ruptured disruption. subcapsular or parenchymal hematoma Subcapsular hematoma >3 cm thick Laceration > 3 cm parenchymal depth or involving trabacular Laceration >3 cm parenchymal depth vessels Parenchymal hematoma >3 cm in diameter Laceration Laceration involving segmental or hilar vessels Active intraparenchymal and subcapsular splenic bleeding producing major devascularization (>25% of spleen) Splenic vascular injury (pseudoaneurysm or arteriovenous fistula) Laceration Shattered spleen Completely shattered spleen Vascular Hilar vascular injury which devascularizes spleen Active intraperitoneal bleeding

6 TRAUMA WHOLE BODY MDCT PROTOCOLS MDCT Contrast Volume I 2 mg/ml Rate Delay Detector width Pitch Rotation time Bolus * Pro 16- slice 150 ml 300 mg/ml N.Saline 90ml 6mL/sec 60ml 4mL/sec 50ml 5mL/sec c Bolus pro 90 HU 0.75 mm sec Ascending Aorta 40 & 64-slice < 50 yrs 100 ml 350 mg/ml N.Saline 50ml 6mL/sec 50ml 4mL/sec 50ml - 5mL/sec 18 sec mm sec Nil 40 & 64 -slice > 50 yrs 100 ml 350 mg/ml N.Saline 50ml 6mL/sec 50ml 4mL/sec 50ml - 5mL/sec Bolus pro 90 HU mm sec Ascending Aorta

7 Optimizing Trauma MDCT Protocol for Blunt Splenic Injury: Need for Arterial and Portal Venous Phase Scans Sens/ Spec PA (pseudoaneurysm) AB (active 96 bleeding) / 100 NVI (nonvascular injury) PSH (perisplenic hematoma) Arterial 70 / / / / 95 Portal Venous 17 / / / / 97 Combined 92 / / / / 97 Boscak AR, Shanmuganathan K, Mirvis SE et al. Radiology Feb 28.

8 Common Splenic Injuries

9 BLUNT SPLENIC INJURY VASCULAR LESIONS Active bleeding Vascular injury PSA & A-V fistula Infarcts

10 Contrast Extravasation

11 BLUNT SPLENIC INJURY ACTIVE BLEEDING Irregular or linear area Increases in size ( delayed phase) Seen - only on delayed imaging

12 BLUNT SPLENIC INJURY MDCT Active Bleeding AB Seen in 10% (40/392) AB MDCT (16 slice) 84% Sen, 98% Spc, 95% Acc Splenectomy - 60% (24/40) Embolization 94% (16/17) HM, KS, SEM, et al. JACS 2008; 206:685-93

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15 Arterial P-V phase

16 Vascular Injury

17 BLUNT SPLENIC INJURY VASCULAR INJURY Pseudoaneurysm Arterio-venous fistula

18 BLUNT SPLENIC INJURY VASCULAR INJURY Defined Low attenuation area Washout isoattenuation or hyperattenuation

19 Splenectomy - 9% (4/46) HM, KS, SEM, et al. JACS 2008 ; 206: BLUNT SPLENIC INJURY MDCT Vascular injury (PSA & AVF) VI Seen in 12% (46/392) VI MDCT (16 slice) 63% Sen, 94% Spc, 95% Acc Embolization 95% (40/42)

20 Why Late arterial/ Early P-V Images? Demonstrates parenchymal vascular injury (PSA & fistulas) not seen on p-v phase images

21 48 year old male with past history of cirrhosis (Hep C), GI bleeds, thrombocytopenia (platelets 78 K/Mc L) was admitted following a fall down multiple steps at home. Had an abnormal INR/ prothrombin time 15.7

22 P-V phase 3 day follow-up Arterial phase Admission

23 Arterial phase P-V Phase

24 Splenic Infarcts

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26 Liver Injury

27 BLUNT LIVER INJURY Injury - 2 ND most common Nonsurgical management - 50 % - 96% Hemorrhage - mortality Rx multi-disciplinary approach IR & SURGERY

28 PAP,SEM,KS, et al. Radiology 2000;216:417-27

29 BLUNT LIVER INJURY VASCULAR INJURY Active bleeding hepatic artery, portal, or hepatic veins Pseudoaneurysm - rare Fistula - three types A-V fistula, P-V fistula, A-P fistula

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32 Late arterial phase P-V phase

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36 Late arterial phase 3 days post injury P-Vphase