Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma.

BACKGROUND: Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. METHODS: This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. RESULTS: Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). CONCLUSION: Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Clinical utility of colour flow Doppler ultrasonography in planning anterolateral thigh flap harvest.

BACKGROUND: The anatomic variability of cutaneous perforators contributes to the technical challenges of anterolateral thigh (ALT) free flap harvest. The objective of this study was to assess the accuracy and clinical utility of preoperative colour flow Doppler (CFD) ultrasonography in evaluating planned ALT flap donor sites. METHODS: A prospective study of the infrainguinal vasculature (profunda femoris and lateral circumflex femoral arteries) in 16 consecutive patients scheduled for ALT free flap transfer for reconstruction of head and neck surgical defects was undertaken. All patients underwent CFD ultrasonography. The location of perforators and the thigh thickness determined by CFD ultrasonography were correlated with the actual intraoperative findings using a scatter plot and paired t-test. RESULTS: Two patients were diagnosed with bilateral silent infrainguinal claudication, which precluded safe use of the ALT donor site. In two other patients, the planned ALT donor site ipsilateral to the defect was not used because of silent infrainguinal claudication diagnosed by CFD ultrasonography. In the 14 patients who underwent ALT flap harvest, CFD ultrasonography identified 48 perforators, which coincided with 43 actual perforators found intraoperatively. CFD ultrasonography demonstrated a statistically significant correlation with the actual perforator locations (Spearman coefficient .76; p = .55). Although CFD ultrasonography tended to underestimate flap thickness, there was a statistically significant correlation (Spearman coefficient .94; p ≤ .0001) with the actual flap thickness. CONCLUSION: CFD ultrasonography has clinical utility in facilitating decision making and planning ALT flap harvest.

Active extravasation of arterial contrast agent on post-traumatic abdominal computed tomography.

OBJECTIVE: To evaluate the use of emergent dynamic intravenous contrast-enhanced computed tomography (CT) in the diagnosis of active arterial extravasation in patients admitted to hospital after blunt abdominal trauma. METHODS: Four-hundred and ninety-eight consecutive emergent contrast-enhanced computed tomographic images of the abdomen and pelvis were retrospectively reviewed. The presence of and site(s) of active arterial extravasation were recorded. Two radiologists reviewed the images and compared the site(s) of extravasated arterial contrast agent with the site(s) of active hemorrhage established at angiography (n = 9) or surgery (n = 4). RESULTS: Twenty-eight patients' computed tomographic images were identified as showing signs of extravasation of contrast agent representing active arterial bleeding. A total of 49 sources of active arterial extravasation were identified, 37 in 19 patients. A pelvic source of active arterial hemorrhage was most frequent and was typically associated with unstable pelvic fractures (n = 18). Other sources of active arterial hemorrhage included the liver (n = 3), spleen (n = 2), retroperitoneum (n = 1), kidney (n = 1), mesentery (n = 1), abdominal wall (n = 3) and lumbar region (n = 1). Only 9 of 28 patients became sufficiently hemodynamically unstable to warrant angiography. All 9 patients had a pelvic source of arterial extravasation on contrast-enhanced CT, and 7 demonstrated active bleeding requiring embolization. The contrast-enhanced computed tomographic images correctly indicated the anatomical source of bleeding in all 7 cases. CONCLUSION: In patients who have experienced blunt abdominal trauma, attention should be paid to the computed tomographic features of active arterial hemorrhage. In our series, the pelvis was the most common source of active arterial bleeding, which was typically associated with unstable pelvic fractures.

Computed tomography of traumatic abdominal wall hernia and associated deceleration injuries.

We retrospectively reviewed the computed tomographic (CT) examinations of 15 cases of abdominal wall hernia due to abdominal trauma; 13 patients had been injured in motor vehicle accidents (11 of those were belted in). All hernias were correctly identified on CT and confirmed intraoperatively. Traumatic abdominal wall hernia proved an important indicator of associated visceral injury, especially to the bowel (n = 6) and mesentery (n = 10). Careful review of the bowel and mesentery should thus be undertaken when disruption of the abdominal wall is documented. Radiologists should be aware, however, that CT findings may correlate poorly with severity of injury in these areas. In these instances, close clinical correlation and, sometimes, rescanning may be necessary.