ACR Appropriateness Criteria® Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm: 2023 Update.

Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update.

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

PURPOSE: Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. METHODS: A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. RESULTS: After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. CONCLUSIONS: The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Daytime, evening, and overnight: the 24-h radiology cycle and impact on interpretative accuracy.

PURPOSE: To assess the influence of time of day when a study is interpreted on discrepancy rates for common and advanced studies performed in the acute community setting. METHODS: This retrospective study used the databank of a U.S. teleradiology company to retrieve studies between 2012 and 2016 with a preliminary report followed by a final report by the on-site client hospital. Neuroradiology, abdominal radiology, and musculoskeletal radiology studies were included. Teleradiologists were fellowship trained in one of these subspecialty areas. Daytime, evening, and overnight times were defined. Associations between major and minor discrepancies, time of day, and whether the study was common or advanced were tested with significance set at p = .05. RESULTS: A total of 5,883,980 studies were analyzed. There were 8444 major discrepancies (0.14%) and 17,208 minor discrepancies (0.29%). For common studies, daytime (0.13%) and evening (0.13%) had lower major discrepancy rates compared to overnight (0.14%) (daytime to overnight, RR = 0.57, 95%CI: 0.45, 0.72, p < 0.01 and evening to overnight, RR = 0.57, 95%CI: 0.49,0.67, p < 0.01). Minor discrepancy rates for common studies were decreased for evening (0.29%) compared to overnight (0.30%) (RR = 0.89, 95%CI: 0.80,0.99, p = 0.029). For advanced studies, daytime (.15%) had lower major discrepancy rates compared to evening (0.20%) and overnight (.23%) (daytime to evening, RR = 0.77, 95%CI: 0.61, 0.97, p = 0.028 and daytime to overnight, RR = 0.66, 95%CI: 0.50, 0.87, p ≤ 0.01). CONCLUSION: Significantly higher major discrepancy rates for studies interpreted overnight suggest the need for radiologists to exercise greater caution when interpreting studies overnight and may require practice management strategies to help optimize overnight work conditions. The lower major discrepancy rates on advanced studies interpreted during the daytime suggest the need for reserving advanced studies for interpretation during the day when possible.

ACR Appropriateness Criteria® Thoracoabdominal Aortic Aneurysm or Dissection: Treatment Planning and Follow-Up.

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Characterization of fatal blunt injuries using postmortem computed tomography.

BACKGROUND: Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Postmortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation. METHODS: Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent noncontrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred prehospital/in-hospital. Univariate analysis was used to identify differences in injury patterns including multiple-trauma injury patterns. RESULTS: Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in multiple-trauma injury patterns. CONCLUSION: Fatal blunt injury patterns do not vary between prehospital and in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Traumatic abdominal wall hernias in the pediatric population: a 13-year institutional review.

BACKGROUND: Pediatric traumatic abdominal wall hernias are rare but potentially devastating injuries. Although classically considered to be caused by handlebar injuries from bicycle accidents, our anecdotal experience suggests pediatric traumatic abdominal wall hernias are far more likely to occur following road traffic accidents and have a high association with other significant intra-abdominal injuries. OBJECTIVE: The purpose of this study was to determine the frequency, mechanisms of injury, and associated injuries of traumatic abdominal wall hernias in the pediatric population. MATERIALS AND METHODS: This is a retrospective observational cohort study from two large urban level 1 trauma centers. Institutional trauma registries were queried from January 1, 2008, to December 31, 2020, for patients under 18 years of age diagnosed with traumatic abdominal wall hernias, excluding those without initial abdominopelvic CT imaging. Finalized CT reports and images were reviewed to confirm the presence of a traumatic abdominal wall hernia and document any associated secondary injuries. The medical record was reviewed to extract pertinent physical findings, interventions performed, and outcomes. Injury Severity Score (ISS) for each patient was calculated by the trauma registrar. RESULTS: A total of 19 patients with TAWH met inclusion criteria, with an overall frequency of 0.095% and a mean age of 10.6 years (range 3-17). Eleven patients were male (57.9%) with a mean ISS of 18.6 (range 1-48, including 63.2% with ISS > 15). The most common mechanism of injury was motor vehicle collision (N = 11, 57.9%) followed by bicycle accident (N = 3, 15.8%). A total of 17 (89.5%) had associated injuries, including 11 (57.9%) with intestinal injuries, 5 (26.3%) with pelvic fractures, 4 (21.1%) with femur fractures, 3 (15.8%) with splenic injuries, 3 (15.8%) with kidney injuries, and 3 (15.8%) with Chance fractures of the lumbar spine. All patients required surgery for the traumatic abdominal wall hernias and associated injuries. CONCLUSION: Pediatric traumatic abdominal wall hernias are more likely to be seen following motor vehicle collisions, with a majority (89.5%) having associated injuries, most frequently to the bowel (57.9%). Handlebar injuries were seen in a minority of patients (15.8%) and were less likely to be associated with additional injuries. CLINICAL IMPACT: Pediatric patients with a traumatic abdominal wall hernia on admission CT should be thoroughly evaluated for bowel injuries, especially in the setting of a motor vehicle collision.

Evaluation of federated learning variations for COVID-19 diagnosis using chest radiographs from 42 US and European hospitals.

OBJECTIVE: Federated learning (FL) allows multiple distributed data holders to collaboratively learn a shared model without data sharing. However, individual health system data are heterogeneous. "Personalized" FL variations have been developed to counter data heterogeneity, but few have been evaluated using real-world healthcare data. The purpose of this study is to investigate the performance of a single-site versus a 3-client federated model using a previously described Coronavirus Disease 19 (COVID-19) diagnostic model. Additionally, to investigate the effect of system heterogeneity, we evaluate the performance of 4 FL variations. MATERIALS AND METHODS: We leverage a FL healthcare collaborative including data from 5 international healthcare systems (US and Europe) encompassing 42 hospitals. We implemented a COVID-19 computer vision diagnosis system using the Federated Averaging (FedAvg) algorithm implemented on Clara Train SDK 4.0. To study the effect of data heterogeneity, training data was pooled from 3 systems locally and federation was simulated. We compared a centralized/pooled model, versus FedAvg, and 3 personalized FL variations (FedProx, FedBN, and FedAMP). RESULTS: We observed comparable model performance with respect to internal validation (local model: AUROC 0.94 vs FedAvg: 0.95, P = .5) and improved model generalizability with the FedAvg model (P < .05). When investigating the effects of model heterogeneity, we observed poor performance with FedAvg on internal validation as compared to personalized FL algorithms. FedAvg did have improved generalizability compared to personalized FL algorithms. On average, FedBN had the best rank performance on internal and external validation. CONCLUSION: FedAvg can significantly improve the generalization of the model compared to other personalization FL algorithms; however, at the cost of poor internal validity. Personalized FL may offer an opportunity to develop both internal and externally validated algorithms.

Performance of a Chest Radiograph AI Diagnostic Tool for COVID-19: A Prospective Observational Study.

Purpose: To conduct a prospective observational study across 12 U.S. hospitals to evaluate real-time performance of an interpretable artificial intelligence (AI) model to detect COVID-19 on chest radiographs. Materials and Methods: A total of 95 363 chest radiographs were included in model training, external validation, and real-time validation. The model was deployed as a clinical decision support system, and performance was prospectively evaluated. There were 5335 total real-time predictions and a COVID-19 prevalence of 4.8% (258 of 5335). Model performance was assessed with use of receiver operating characteristic analysis, precision-recall curves, and F1 score. Logistic regression was used to evaluate the association of race and sex with AI model diagnostic accuracy. To compare model accuracy with the performance of board-certified radiologists, a third dataset of 1638 images was read independently by two radiologists. Results: Participants positive for COVID-19 had higher COVID-19 diagnostic scores than participants negative for COVID-19 (median, 0.1 [IQR, 0.0-0.8] vs 0.0 [IQR, 0.0-0.1], respectively; P < .001). Real-time model performance was unchanged over 19 weeks of implementation (area under the receiver operating characteristic curve, 0.70; 95% CI: 0.66, 0.73). Model sensitivity was higher in men than women (P = .01), whereas model specificity was higher in women (P = .001). Sensitivity was higher for Asian (P = .002) and Black (P = .046) participants compared with White participants. The COVID-19 AI diagnostic system had worse accuracy (63.5% correct) compared with radiologist predictions (radiologist 1 = 67.8% correct, radiologist 2 = 68.6% correct; McNemar P < .001 for both). Conclusion: AI-based tools have not yet reached full diagnostic potential for COVID-19 and underperform compared with radiologist prediction.Keywords: Diagnosis, Classification, Application Domain, Infection, Lung Supplemental material is available for this article.. © RSNA, 2022.

Post-mortem computed tomography assessment of medical support device position following fatal trauma: a single-center experience.

PURPOSE: To evaluate the percentage of misplaced medical support lines and tubes in deceased trauma patients using post-mortem computed tomography (PMCT). METHODS: Over a 9-year period, trauma patients who died at or soon after arrival in the emergency department were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. Injury severity score (ISS) was calculated by the trauma registrar based on the injuries identified on PMCT. The location of support medical devices was documented in the finalized radiology reports. RESULTS: A total of 87 decedents underwent PMCT, of which 69% (n = 60) were male. For ten decedents, the age was unknown. For the remaining 77 decedents, the average age was 48.4 years (range 18-96). The average ISS for the cohort was 43.4. Each decedent had an average of 3.3 support devices (2.9-3.6, 95% CI), of which an average of 1 (31.3%, 0.8-1.2, 95% CI) was malpositioned. A total of 60 (69.0%) had at least one malpositioned medical support device. The most commonly malpositioned devices were decompressive needle thoracostomies (n = 25/32, 78.1%). The least malpositioned devices were intraosseous catheters (n = 7/69, 10.1%). Nearly one quarter (n = 19/82, 23.2%) of mechanical airways were malpositioned, including 4.9% with esophageal intubation. CONCLUSION: Malpositioned supportive medical devices are commonly identified on post-mortem computed tomography trauma decedents, seen in 69.0% of the cohort, including nearly one quarter with malpositioned mechanical airways. Post-mortem CT can serve as a useful adjunct in the quality improvement process by providing data for education of trauma and emergency physicians and first responders.

Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY).

SUMMARY: Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.

Multireader evaluation of radiologist performance for COVID-19 detection on emergency department chest radiographs.

BACKGROUND: Chest radiographs (CXR) are frequently used as a screening tool for patients with suspected COVID-19 infection pending reverse transcriptase polymerase chain reaction (RT-PCR) results, despite recommendations against this. We evaluated radiologist performance for COVID-19 diagnosis on CXR at the time of patient presentation in the Emergency Department (ED). MATERIALS AND METHODS: We extracted RT-PCR results, clinical history, and CXRs of all patients from a single institution between March and June 2020. 984 RT-PCR positive and 1043 RT-PCR negative radiographs were reviewed by 10 emergency radiologists from 4 academic centers. 100 cases were read by all radiologists and 1927 cases by 2 radiologists. Each radiologist chose the single best label per case: Normal, COVID-19, Other - Infectious, Other - Noninfectious, Non-diagnostic, and Endotracheal Tube. Cases labeled with endotracheal tube (246) or non-diagnostic (54) were excluded. Remaining cases were analyzed for label distribution, clinical history, and inter-reader agreement. RESULTS: 1727 radiographs (732 RT-PCR positive, 995 RT-PCR negative) were included from 1594 patients (51.2% male, 48.8% female, age 59 ± 19 years). For 89 cases read by all readers, there was poor agreement for RT-PCR positive (Fleiss Score 0.36) and negative (Fleiss Score 0.46) exams. Agreement between two readers on 1638 cases was 54.2% (373/688) for RT-PCR positive cases and 71.4% (679/950) for negative cases. Agreement was highest for RT-PCR negative cases labeled as Normal (50.4%, n = 479). Reader performance did not improve with clinical history or time between CXR and RT-PCR result. CONCLUSION: At the time of presentation to the emergency department, emergency radiologist performance is non-specific for diagnosing COVID-19.

A Prospective Observational Study to Investigate Performance of a Chest X-ray Artificial Intelligence Diagnostic Support Tool Across 12 U.S. Hospitals.

Importance: An artificial intelligence (AI)-based model to predict COVID-19 likelihood from chest x-ray (CXR) findings can serve as an important adjunct to accelerate immediate clinical decision making and improve clinical decision making. Despite significant efforts, many limitations and biases exist in previously developed AI diagnostic models for COVID-19. Utilizing a large set of local and international CXR images, we developed an AI model with high performance on temporal and external validation. Objective: Investigate real-time performance of an AI-enabled COVID-19 diagnostic support system across a 12-hospital system. Design: Prospective observational study. Setting: Labeled frontal CXR images (samples of COVID-19 and non-COVID-19) from the M Health Fairview (Minnesota, USA), Valencian Region Medical ImageBank (Spain), MIMIC-CXR, Open-I 2013 Chest X-ray Collection, GitHub COVID-19 Image Data Collection (International), Indiana University (Indiana, USA), and Emory University (Georgia, USA). Participants: Internal (training, temporal, and real-time validation): 51,592 CXRs; Public: 27,424 CXRs; External (Indiana University): 10,002 CXRs; External (Emory University): 2002 CXRs. Main Outcome and Measure: Model performance assessed via receiver operating characteristic (ROC), Precision-Recall curves, and F1 score. Results: Patients that were COVID-19 positive had significantly higher COVID-19 Diagnostic Scores (median .1 [IQR: 0.0-0.8] vs median 0.0 [IQR: 0.0-0.1], p < 0.001) than patients that were COVID-19 negative. Pre-implementation the AI-model performed well on temporal validation (AUROC 0.8) and external validation (AUROC 0.76 at Indiana U, AUROC 0.72 at Emory U). The model was noted to have unrealistic performance (AUROC > 0.95) using publicly available databases. Real-time model performance was unchanged over 19 weeks of implementation (AUROC 0.70). On subgroup analysis, the model had improved discrimination for patients with "severe" as compared to "mild or moderate" disease, p < 0.001. Model performance was highest in Asians and lowest in whites and similar between males and females. Conclusions and Relevance: AI-based diagnostic tools may serve as an adjunct, but not replacement, for clinical decision support of COVID-19 diagnosis, which largely hinges on exposure history, signs, and symptoms. While AI-based tools have not yet reached full diagnostic potential in COVID-19, they may still offer valuable information to clinicians taken into consideration along with clinical signs and symptoms.

Injury incidence and patterns associated with electric scooter accidents in a major metropolitan city.

PURPOSE: Despite increased use of e-scooters globally, actionable data around injury incidence and patterns associated with e-scooter accidents are limited. This study aimed to determine the prevalence of imaging exams, injury incidence, and patterns related to e-scooter injuries, with the hope of guiding an appropriate policy response. METHODS: This was a retrospective observational study of imaging exams ordered for injuries related to e-scooters seen in an Emergency Department (ED) setting within our health system from September 2018 through December 2019. Our institutional Radiology Information System (RIS) was searched for the presence of the word "scooter." Manual query of search results was conducted in the electronic medical record (EMR) and only studies confirmed to be related to e-scooters were included. RESULTS: A total of 477 radiologic studies performed on 192 unique patients were confirmed to be performed for injuries related to e-scooters. The median patient age was 28 years and 58.3% were male. One hundred forty patients (72.9%) had injuries identified on imaging, with an overall exam positivity rate of 44.4%. The most common injuries were soft tissue and musculoskeletal in nature. Over half (51.9%) of the entries with the keyword "scooter" were excluded because of lack of EMR specificity regarding scooter type. CONCLUSION: While this study showed that injuries following e-scooter accidents are common and frequently involve the face and extremities, it is limited by lack of documentation in the EMR. Further research with a standardized documentation protocol will be needed to better understand injuries patterns following e-scooter accidents.

American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings.

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05; P < .001), lower temperature (OR, 0.97; 95% CI: 0.97, 1.00; P = .03), and a lower hematocrit (OR, 0.96; 95% CI: 0.93, 0.99; P = .003) and were more likely to show ASH (OR, 8.05; 95% CI: 5.35, 12.26; P < .001) or CVI (OR, 2.70; 95% CI: 1.64, 4.44; P < .001) on CT images, have spleen-only injures (OR, 2.35; 95% CI: 1.45, 3.8; P < .001), and have been administered blood product for fewer than 24 hours (OR, 2.35; 95% CI: 1.58, 3.51; P < .001) compared with those chosen for NOM, after adjusting for key demographic and clinical variables. After adjustment, factors associated with a shorter LOS were female sex (OR, 0.84; 95% CI: 0.73, 0.96; P = .009), spleen-only injury (OR, 0.72; 95% CI: 0.6, 0.86; P < .001), higher admission hematocrit (OR, 0.98; 95% CI: 0.6, 0.86; P < .001), and presence of ASH at CT (OR, 0.74; 95% CI: 0.62, 0.88; P < .001). Conclusion Contained vascular injury and active splenic hemorrhage (ASH) were frequently reported, and rates of interventional radiologic management increased during the study period. ASH was associated with a shorter length of stay, and patients with ASH had eight times the odds of undergoing invasive treatment compared with undergoing nonoperative management. © RSNA, 2021 See also the editorial by Patlas in this issue.

Renal vein injuries: a 10-year, single institution experience with a rare injury following blunt abdominal trauma.

PURPOSE: To determine the incidence, injury type, injury associations, and management of patients with renal vein injuries following trauma. METHODS: This is a 10-year single-center retrospective observational study of patients with renal vein injuries identified on admission abdominopelvic CT following trauma. Our institutional trauma registry and radiology information system (RIS) was used to identify patients with renal vein injuries. The medical records and imaging exams were reviewed to determine venous injury type, associated injuries, management, and outcomes. RESULTS: Fifteen (15) patients with renal vein injuries (N = 9 right side) were identified out of 36,077 trauma evaluations, for an overall incidence of 0.042%. Eight (53.3%) were male with a mean age of 36.3 years (range 9-67 years) and a mean Injury Severity Score (ISS) of 32 (range 13-57). The most common imaging findings were pseudoaneurysm formation with or without intimal injury and intraluminal thrombus seen in 86.7% of the cohort. Twelve patients (80.0%) had other acute traumatic renal findings, most commonly an ipsilateral grade 4 or higher renal injury. Angiography was performed in 6 patients (40.0%), however no patients received renal vein specific endovascular evaluation, endovascular treatment, or surgical treatment of their renal vein injuries. Three patients were treated with long-term anticoagulation, of which one received an IVC filter. There were no known renal vein injury specific mortalities. CONCLUSIONS: Renal vein injuries are an extremely rare entity but can be detected on admission CT. The most common injury patterns include an intimal injury with intraluminal thrombus and pseudoaneurysm in combination with an intimal injury and intraluminal thrombus. Conservative, nonoperative management was successfully employed in all cases with no renal vein specific mortalities.

Traumatic abdominal wall injuries-a primer for radiologists.

Traumatic abdominal wall injuries encompass a broad clinical and radiological spectrum and are identified in approximately 9% of blunt trauma patients. The most severe form of abdominal wall injury-a traumatic abdominal wall hernia-is seen in less than 1.5% of blunt abdominal trauma patients. However, the incidence of concurrent intra-abdominal injuries in these patients is high and can result in significant morbidity and mortality. Although the diagnosis of abdominal wall injuries is typically straight forward on CT, associated injuries may distract the interpreting radiologist in more subtle cases. Thus, it is important for the radiologist to identify abdominal wall injuries and their associated injuries on admission CT, as these injuries typically require surgical correction early in the course of their management. Untreated abdominal wall injuries subject the patient to increased risk of delayed bowel incarceration and strangulation. Therefore, it is important for the radiologist to be knowledgeable of injuries to the abdominal wall and commonly associated injuries to provide optimal patient triage and expedite management.