Download Blunt Thoracic Aortic Trauma

Joaquim Havens, MS III
Gillian Lieberman, MD
10/21/02-11/17/02
Blunt Thoracic Aortic
Trauma
Joaquim Havens, Harvard Medical School Year III
Gillian Lieberman, M.D.
Joaquim Havens, MS III
Gillian Lieberman, MD
Aortic Trauma
• Rapid deceleration injury
– 70% result from motor vehicle accidents
– Falls and a few crush and blast injuries
• Imaging Modalities
– CXR-Chest CT-Aortogram
• Free rupture-rapidly fatal
– Grossly widened mediastinum, +hemothorax,
hemodynamic instability
• Controlled rupture- up to 90% survival
– No hemothorax, hemodynamicly stable
Simon: Factors predicting Early In-Hospital Death in Blunt Thoracic Aortic Injury,J Trauma,2001, 51(5): 906-911
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 1
• 84 year old female
• Motor vehicle accident
• Unrestrained
passenger
• Loss of Consciousness
• Death of driver
Chest Radiograph
Widened mediastinum
Indistinct aortic arch
Image courtesy Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Differential Diagnosis for A
Widened Mediastinum
• Traumatic
– Traumatic aortic
rupture
– Pseudoaneurysm
– Rupture of other
mediastinal vessels
– Collapse of upper lung
– Mediastinal hematoma
• Non-Traumatic
–
–
–
–
–
–
Aneurysm
Lymphoma
Tumors
Right aortic arch
Cysts
Esophageal lesions
Pais, Assessment of Vascular Trauma; Imaging in Trauma and Critical Care, 1992
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Joaquim Havens, MS III
Gillian Lieberman, MD
Chest Radiographs in Aortic
Trauma
• Mediastinal
ratio>0.25
• Mediastinal widening
• Indistinct aortic arch
contour
• NG tube displaced to
Right
• Left apical cap
• Fractured 1st and 2nd
ribs
Kadir S: Diagnostic Angiography 1986
Sen Spec
95 75
75
75
26
5
67
68
37
17
58
70
Image courtesy Joseph Makris, M.D./BIDMC 5
Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 1 CT
Aortic disruption at the
Level of the arch
Small intimal hematoma
No evidence of active
Extravasation of contrast
No pneumothoraces
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 1 Sagittal Reconstruction
Aortic Disruption
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Most Frequent Site of Aortic
Trauma
Distal to L subclavian at the level of the Ligamentum Arteriosum
Patient 1
Harris J, Harris W, The Radiology of Emergency Medicine 2nd Ed, 1981
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Joaquim Havens, MS III
Gillian Lieberman, MD
Thoracic Aortogram Patient 1
Pseudoaneurysm
RAO
Images courtesy Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 2 Chest Radiograph
• 25 year old male
• High speed MVA
• Question loss of
Consciousness
• CXR
– Trauma board artifact
– Left lateral chest wall
not included on the
film
– Inadequate film
Left apical cap?
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 2 CT
• Study by Demetriades et
al. in Archives of Surgery
1998
– Plain film sensitivity 55%
– Helical CT sensitivity 100%
Contour defect
• Recommend CT of all
patients with mechanism
suggestive of aortic
trauma
Image courtesy of Joseph Makris, M.D./BIDMC
Demetriades et al.,Archives of Surgery, 133(10), October 1998, 1084-1088
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 2 Aortogram
• Diagnosis Aortic Tear
• Angiography remains
gold standard
• Invasive
• Often only utilized if
CT indeterminate
• May be therapeutic if
severe pelvic fracture
Aortic tear
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 3 Chest Radiograph
•
•
•
•
23 year old female
High speed MVA
Intubated
CXR
– Allowing for technique
no gross abnormalities
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 3 CT
• Soft tissue density
within prevascular fat
• Mediastinal hematoma
cannot be ruled out
• Fake outs
– Residual thymus
– Aortic calcification
– Ductus Bump
Image Courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Patient 3 Aortogram
• Normal Aortogram
• No evidence for
dissection
• Diagnosis
– Residual thymus in a
young patient
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Radiology of Aortic Trauma
•
•
Suspected in any high speed
deceleration trauma
CXR
– Normal
•
•
•
– Mediastinal index>0.25
– Widened mediastinum
– Indistinct aortic contour
CT
– Regardless of CXR findings
Aortogram
– If CT indeterminate
Fake out-thymus, calcification,
ductus bump
Image courtesy of Joseph Makris, M.D./BIDMC
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Joaquim Havens, MS III
Gillian Lieberman, MD
Acknowledgements
•
•
•
•
Joseph Makris, M.D.
Gillian Lieberman, M.D.
Pamela Lepkowski
Larry Barbaras and Cara Lyn D’amour
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Joaquim Havens, MS III
Gillian Lieberman, MD
References
Demetriades et al.,”Routine Helical Computed Tomographic Evaluation of the
Mediastinum in High Risk Blunt Trauma Patients”, Archives of Surgery,
133(10), October 1998, 1084-1088
Harris J, Harris W, The Radiology of Emergency Medicine, 2nd Ed: Baltimore MD
Williams and Wilkins, 1981 333-340
Kadir S. Diagnostic Angiography, Philadelphia: WB Saunders, 1986
Pais, S, “Assesment of Vascular Trauma” in Imaging in Trauma and Critical Care,
Ed. Mirvis S and Young J. Baltimore MD. Williams and Wilkins 1992 485-513
Simon B, Leslie C,. “Factors predicting Early In-Hospital Death in Blunt Thoracic Aortic Injury”
J Trauma, 2001, 51(5): 906-911
18