Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

Abstract

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Keywords: energy trauma; high speed; major trauma; motor vehicle crash; trauma.

Figure 1

US (A) and enhanced-CT (B, venous phase) of a 32 year old male who sustained major trauma. US scans of the liver shows a subtle hypoechoic area (A, arrow). Enhanced-CT allows exhaustive evaluation of the suspected liver injury, depicting the whole extension of the liver laceration (B, arrow) and excluding the presence of vascular injuries, thus allowing safe conservative management of the patient.

Figure 2

Enhanced-CT of a 56-year old male who sustained major trauma. Arterial (A) and portal venous phase (B). There is a small volume hemoperitoneum and multiple contained vascular injuries (A, arrow) that can be seen only in the arterial phase. The patient underwent angiography which confirmed CT findings (C), followed by successful embolization (D).

Figure 3

Enhanced-CT of a 54-year old male involved in major trauma (car accident). The multiphasic CT study allowed characterization of bleeding as arterial in origin, as seen on the arterial phase (A, arrow). Contrast extravasation persisted in the subsequent two phases (B,C, arrows). The patient then underwent angiography and embolization with absorbable material. Follow-up CT performed at 1st (D) and 4th (E) day after embolization showed no signs of bowel wall necrosis.

Figure 4

Enhanced-CT acquired in a 43-year old male who sustained major trauma (motor vehicle accident). Admission CT acquired in arterial (A) and portal venous (B) phases shows the presence of a contained vascular injury (pseudoaneurysm) within the splenic laceration (A, arrow). The pseudoaneurysm is associated with an arterio-venous fistula, demonstrated by early opacification of the splenic vein (curved arrow) in the arterial phase, synchronous with that of the splenic artery. The pseudoaneurysm is faintly seen in the following portal venous phase (B), and the arterio-venous fistula is not identifiable in this phase. The patient was scheduled for angiography and embolization but whilst awaiting the procedure, the vascular injury caused a spontaneous splenic rupture with active extrasplenic bleeding (C, arrow) which increased in the subsequent phase (D, arrow). Figure 4A was presented in the poster C-12530 Splenic Emergencies: value of US exploration for the diagnosis at ECR 2020.

Figure 5

Enhanced-CT of a 37-year old male with multiple injuries due to high energy blunt trauma (car accident). The CT study demonstrates hemoperitoneum (A,B, asterisks), liver lacerations (A, arterial phase, arrow; B, portal venous phase, arrow) and a perirenal hematoma (C–E asterisks). The availability of multiple phases excluded the presence of active bleeding or active urine extravasation. The patient was managed conservatively.