CT Imaging of Blunt and Penetrating Vascular Trauma DENNIS FOLEY MEDICAL COLLEGE WISCONSIN

CT Imaging of Blunt and Penetrating Vascular Trauma DENNIS FOLEY MEDICAL COLLEGE WISCONSIN

THORACO ABDOMINAL TRAUMA 0 10 20 30 40 50 60 5 cc/sec 30 secs 1.25 mm/ 55 mm Z1.375 2.5 mm/ 55 mm Z 1.375

Grade 1 Traumatic Aortic Injury

Initial scan Grade 2 Traumatic Aortic Injury 48 hour follow up

Differential Diagnosis TAI Grade 2 Ductus diverticulum Patent ductus arteriosus

DUCTUS DIVERTICULUM

Traumatic Aortic Injury Grade 1- small intimal tear or intramural hematoma Grade 2 pseudoaneurysm <50% aortic circumference Grade 3 pseudoaneurysm > 50% aortic circumference Grade 4 aortic transection and active hemorrhage

GRADE 2 TRAUMATIC AORTIC INJURY

3 MONTH FOLLOW UP

Management of TAI Observation ( Grade 1 and 2 ) TEVAR ( Grade 3 ) Surgery ( Grade 4 )

Thoracic Endovascular Aneurysm Repair TEVAR

GRADE 3 TRAUMATIC AORTIC INJURY

GRADE 4 TRAUMATIC AORTIC INJURY

Post TEVAR Complications Post TEVAR complications Endoleak Endograft collapse Stent migration Paraplegia Stroke Upper extremity ischemia

CHRONIC TRAUMATIC ANEURYSM

PSEUDOANEURYSM LCCA

TRAUMATIC TEAR INNOMINATE ARTERY

TRAUMATIC ANEURYSM DESCENDING AORTA

Intramural Hematoma RCA

Blunt Abdominal Aortic Injury Minimal ( injury limited to intima ) Significant ( associated hemorrhage / organ ischemia ) Dissection Pseudoaneurysm Branch Avulsion Thrombosis Transection

THORACO ABDOMINAL JUNC MINIMAL AORTIC INJURY

DISTAL ABDOMINAL AORTIC PS ANEURYSM PERI AORTIC HEMATOMA

Active Hepatic Hemorrhage ACTIVE SUBCAPSULAR HEPATIC HEMORHAGE PERI HEPATIC

Active Splenic Hemorrhage

GRADE 3 RENAL INJURY INTRA RENAL PERI RENAL HEMATOMA LACERATION> 1 CM, NO URINARY EXTRAVASATION

PERSISTENT HEMATURIA CLOT RETENTION ARTERIAL PHASE ACQUSITION SEGMENTAL ARTERIAL

Aorta Renal CT Angiogram

RIGHT RENAL ARTERIOGRAM

PDA ANEURYSM Focal saccular aneurysm of an hypertrophied pancreatico duodenal artery is usually related to Takayasu arteritis Segmental arterial mediolysis Median arcuate ligament compression of the Celiac Artery Blunt Abdominal Trauma

Median Arcuate Ligament Compression

Portal Vein Disruption

Abdominal Aortic Injury Risk Factors Blunt Abdominal Aortic Injury (BAAI ) Risk factors ( associated injuries ) Lumbar Spine Midline Intestine Retroperitoneal Organs Adjacent major arteries

BIFFL Grading Scheme Grade 1 intimal irregularity with dissection < 25% luminal narrowing Grade 2 Dissecting hematoma > 25% luminal narrowing of visible intramural flap Grade 3 Pseudoaneurysm or small AVF Grade 4 - Complete occlusion Grade 5 Transection ( active extrav ) or significant arteriovenous fistula

Cerebro Vascular CTA Injection / Acquisition MDCT CTA Arch, Carotid, Vertebral 4.0 10 20 30 6 CCS / SEC 8 SECS FIRST CIRCULATION 64 X 0.625, 0.984:1, 0.5 SECS

Intimal Disruption / Dissection ICAs

RVA RCA LCA LVA

Cerebro Vascular Injury Clinical findings Neurological defecit Cervical hematoma Seat belt injury Fractures Cervical spine Skull base Facial

Cerebro Vascular Injury Mechanism Compression Inferior neck Inertial tear ( hyper extension ) High Cervical Transection Basal skull fracture

Vertebral Artery Aneurysm

Vertebral Artery Aneurysm Coil Embolisation

Lower Extremity Arterial Trauma CTA is an accurate modality for evaluating arterial lesions in patients with extremity trauma and can replace DSA. Jens S et al European Journal of Vascular / Endovascular Surgery 2013 Sept; 46 (3):329-337

Lower Extremity CTA Injection / Acquisition 12 SECS 15 24 30 45 5 ML/SEC 18 SECS FIRST CIRCULATION ACQUISITION INTERVAL ~TABLE SPEED BEAM WIDTH, PITCH, ROT SPEED

Aorto Popliteal Transit Time RT POP AT=30 S FLOW VEL 70 CM AORTA AT=19 S 6.36 CM/S LT POP AT=28 S 7.77 CM/S

Traumatic Arterial Occlusion

Traumatic Arterial Aneurysm

Traumatic Aneurysm Subclavian Artery

Laceration Subclavian Artery

CT Angiography: Trauma Detection of Vascular injuries is vital Appropriate Injection/ Acquisition is critical Routine Arterial Phase imaging Thorax Suspect Carotid/ Cerebral or Extremity Arterial Injury