Traumatic aortic injury: Computed tomography angiography imaging and findings revisited in patients surviving major thoracic aorta injuries

Abstract

Blunt chest trauma related acute thoracic aortic injury (TAI) is a life-threatening condition that requires prompt diagnosis and appropriate management because of high mortality. Computed tomography angiography (CTA) is the imaging of choice for evaluation of patients with major chest trauma findings suspicious of TAI on chest radiography. This case series describes the CTA findings in four high-velocity incident survivors with associated TAIs, discusses the injury type and treatment, and reviews the literature.

Keywords: TAI; computed tomography angiography; major chest trauma; thoracic aortic injuries; traumatic aortic injury.

FIGURE 1

(a) Chest radiography in a 36-year-old male patient involved in a motor vehicle accident. There is widening of the mediastinum (arrow) with a left apical pleural cap (star) and veiling of the left lung field in keeping with a left haemothorax. There is depression of the left main bronchus (triangle), and the silhouette of the aortic knuckle is maintained. (b) Computed tomography angiography demonstrating a mediastinal haematoma (star) and a type 2 aortic injury with an intimal flap and a pseudoaneurysm (arrow). (c) Digital subtraction angiogram image prior to stenting delineating the false aneurysm (arrows) beyond the origin of the left subclavian artery. (d) Digital subtraction angiogram image post successful endovascular aneurysm repair with the stent in place (arrow). (e) Follow-up computed tomography angiography indicates the stent in place with no complications (arrow).

FIGURE 2

(a) Chest radiography in a 23-year-old male involved in a pedestrian vehicle accident indicates a widened mediastinum (arrow), loss of the aortic knuckle (star), retro-cardiac double density and a widened right paraspinal line (triangle). (b) Coronal computed tomography angiography image with a type 2 aortic injury, complicated by thrombus formation (arrow). Also note the large mediastinal haematoma (star). (c) Sagittal digital subtraction angiogram after endovascular aneurysm repair with the stent in place (arrow). (d) Follow-up computed tomography angiography post stenting. (e) Sagittal computed tomography angiography abdomen demonstrating subtle thrombus within the coeliac artery (arrow). (f) Segmental infarction revealed within the right kidney (arrow).

FIGURE 3

(a) Chest radiography in a 22-year-old male involved in a motor vehicle accident as a front passenger with a widened right paraspinal line (arrow), widened mediastinum (star) and depression of the left main bronchus, all signs pointing towards a vascular injury. Also note the tension pneumothorax on the left (circle) with contralateral mediastinal shift. (b) Computed tomography angiography in the same patient indicating the aortic injury and false aneurysm (arrow) at the isthmus. (c) Initial digital subtraction angiogram image pre-stenting revealing the pseudoaneurysm (arrow). (d) Digital subtraction angiogram image with the stent in place (arrow). (e) Follow-up computed tomography angiography demonstrating a leak around the stent (arrow). (f) A second endovascular stent was placed to treat the endoleak, sagittal oblique digital subtraction angiogram image with double stents (arrow).

FIGURE 4

(a) A 45-year-old male jumped from the fourth floor and sustained multiple injuries. Initial computed tomography angiography revealed a traumatic type 2 aortic injury with an intimal flap, thrombus and false aneurysm (arrow). (b) Sagittal oblique digital subtraction angiogram image with the stent in place (arrow). No complications seen.

FIGURE 5

Annotated diagram of different aortic segments. Aortic root (0 in red), segment 1 in blue, segment 2 in green and segment 3 in orange. Isthmus represents the area at the orange and green junction.

FIGURE 6

Drawing of aortic injury grading findings at computed tomography angiography: (a) Grade 1: isolated intramural haematoma, (b) Grade 2: involvement of the intima and media, and (c) Grade 3: involvement of intima, media and adventitia.