Acute Development of Traumatic Intracranial Aneurysms After Civilian Gunshot Wounds to the Head.

In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH.

Blunt Cerebrovascular Injury-Like Injury Observed in Patients With Craniofacial Self-Inflicted Gunshot Wounds.

BACKGROUND: Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population. METHODS: An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed. RESULTS: Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P  = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P  = 0.02). CONCLUSIONS: Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations.

Segmental Bowel Hypoenhancement on CT Predicts Ischemic Mesenteric Laceration After Blunt Trauma.

OBJECTIVE. The objectives of this study were to examine the performance of CT in the diagnosis of ischemic mesenteric laceration after blunt trauma and to assess the predictive value of various CT signs for this injury. MATERIALS AND METHODS. In this retrospective study, consecutive patients with bowel and mesenteric injury diagnosed by CT or surgery from January 2011 through December 2016 were analyzed. Two radiologists evaluated CT images for nine signs of bowel injury. The outcome evaluated was ischemic mesenteric laceration. Univariable analysis followed by logistic regression was performed. RESULTS. The study included 147 patients (96 men and 51 women; median age, 35 years; age range, 23-52 years). Thirty-three patients had surgically confirmed ischemic mesenteric lacerations. CT signs that correlated with ischemic mesenteric laceration were abdominal wall injury, mesenteric contusion, free fluid, segmental bowel hypoenhancement, and bowel hyperenhancement adjacent to a hypoenhancing segment. The regression model developed after inclusion of clinical variables identified two predictors: segmental bowel hypoenhancement (adjusted odds ratio, 22.9 [95% CI, 7.9-66.2; p < .001] for reviewer 1 and 20.7 [95% CI, 7.2-59.0; p < .001] for reviewer 2) and abdominal wall injury (adjusted odds ratio, 5.26 [95% CI, 1.7-15.9; p = .003] for reviewer 1 and 5.3 [95% CI, 1.9-15.0; p = .002] for reviewer 2), which yielded an AUC of 0.87 for predicting injury. For reviewer 1 and reviewer 2, the sensitivities of CT in detecting the injury were 72.3% (95% CI, 54.5-86.7%) and 78.8% (95% CI, 61.0-91.0%), respectively, whereas the specificities were 94.7% (95% CI, 88.9-98.0%), and 92.1% (95% CI, 85.5-96.3%), respectively. CONCLUSION. CT has limited sensitivity but good specificity for detecting ischemic mesenteric laceration, with segmental bowel hypoenhancement considered the most predictive imaging sign.

Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist.

After the nasal bones, the mandible is the second most common site of facial fractures, and mandibular fractures frequently require open reduction. In the trauma injury setting, multidetector computed tomography (CT) has become the cornerstone imaging modality for determining the most appropriate treatment management, fixation method, and surgical approach. Multidetector CT is also used to assess the adequacy of the reduction and evaluate potential complications in the postoperative period. For successful restoration of the mandible's form and function, as well as management of posttraumatic and postoperative complications, reconstructive surgeons are required to have a detailed understanding of mandibular biomechanics, occlusion, and anatomy. To provide added value in the diagnosis, treatment planning, and follow-up of mandibular fractures, radiologists should be aware of these concepts. Knowledge of the techniques commonly used to achieve occlusal and anatomic reduction and of the rationale behind the range of available treatment options for different injury patterns-from isolated and nondisplaced fractures to multisite and comminuted fractures-also is essential. This article focuses on the use of multidetector CT for pre- and postoperative evaluation of mandibular fractures and outlines fundamental concepts of diagnosis and management-beginning with an explanation of common fracture patterns and their biomechanical underpinnings, and followed by a review of the common postoperative appearances of these fractures after semirigid and rigid fixation procedures. Specific considerations regarding fractures in different regions of the tooth-bearing and non-tooth-bearing mandible and the unique issues pertaining to the edentulous atrophic mandible are reviewed, and key features that distinguish major from minor complications are described. (©)RSNA, 2016.

Volumetric analysis of pelvic hematomas after blunt trauma using semi-automated seeded region growing segmentation: a method validation study.

OBJECTIVE: Manually segmented traumatic pelvic hematoma volumes are strongly predictive of active bleeding at conventional angiography, but the method is time intensive, limiting its clinical applicability. We compared volumetric analysis using semi-automated region growing segmentation to manual segmentation and diameter-based size estimates in patients with pelvic hematomas after blunt pelvic trauma. MATERIALS AND METHODS: A 14-patient cohort was selected in an anonymous randomized fashion from a dataset of patients with pelvic binders at MDCT, collected retrospectively as part of a HIPAA-compliant IRB-approved study from January 2008 to December 2013. To evaluate intermethod differences, one reader (R1) performed three volume measurements using the manual technique and three volume measurements using the semi-automated technique. To evaluate interobserver differences for semi-automated segmentation, a second reader (R2) performed three semi-automated measurements. One-way analysis of variance was used to compare differences in mean volumes. Time effort was also compared. Correlation between the two methods as well as two shorthand appraisals (greatest diameter, and the ABC/2 method for estimating ellipsoid volumes) was assessed with Spearman's rho (r). RESULTS: Intraobserver variability was lower for semi-automated compared to manual segmentation, with standard deviations ranging between ±5-32 mL and ±17-84 mL, respectively (p = 0.0003). There was no significant difference in mean volumes between the two readers' semi-automated measurements (p = 0.83); however, means were lower for the semi-automated compared with the manual technique (manual: mean and SD 309.6 ± 139 mL; R1 semi-auto: 229.6 ± 88.2 mL, p = 0.004; R2 semi-auto: 243.79 ± 99.7 mL, p = 0.021). Despite differences in means, the correlation between the two methods was very strong and highly significant (r = 0.91, p < 0.001). Correlations with diameter-based methods were only moderate and nonsignificant. Mean semi-automated segmentation time effort was 2 min and 6 s and 2 min and 35 s for R1 and R2, respectively, vs. 22 min and 8 s for manual segmentation. CONCLUSION: Semi-automated pelvic hematoma volumes correlate strongly with manually segmented volumes. Since semi-automated segmentation can be performed reliably and efficiently, volumetric analysis of traumatic pelvic hematomas is potentially valuable at the point-of-care.

Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study.

PURPOSE: Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined. MATERIALS AND METHODS: This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures. RESULTS: Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury. CONCLUSION: CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery. KEY POINTS: • The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm.

OBJECTIVES: To determine the specific CT findings of penetrating neck wound profile predicting aerodigestive injuries, diagnostic performance of CTA and to propose a modified selective management algorithm to reduce nontherapeutic invasive procedures. METHODS: We retrospectively evaluated CTAs of 102 patients to determine the presence of various CT signs. "Trajectory"-based signs included trajectory of the wound extending into the aerodigestive tract and trajectory violating the deep neck spaces. "Conventional" signs included transcervical injury; wall defect; air or blood in the deep neck spaces; irregular or thickened aerodigestive tract; and active mucosal bleeding. RESULTS: Trajectory of the wound extending into the aerodigestive tract (sensitivity 76 %, specificity 97 %) and trajectory of the wound violating the suprahyoid deep neck spaces or the infrahyoid visceral space (sensitivity 97 %, specificity 55 %) were the best predictors of injury on regression analysis. The most specific "conventional" CT signs were "wall defect" and "active mucosal bleed", but had very low sensitivity. The sensitivity of CTA for detecting an injury ranged from 89.5 % to 92 %, specificity ranged from 62.5 % to 89 %. CONCLUSION: CTA can be a useful technique in detecting aerodigestive injury. Our proposed management algorithm can exclude an injury with high degree of confidence (sensitivity 97 %). KEY POINTS: • Trajectory-based CT signs predict aerodigestive injury after penetrating neck trauma. • Surgery should be considered when trajectory extends into the infra-arytenoid aerodigestive tract. • Endoscopy or exploration should be considered when trajectory violates deep neck spaces. • This modified approach can decrease negative explorations and invasive diagnostic procedures.

MDCT of complications and common postoperative findings following penetrating torso trauma.

Victims of penetrating torso trauma often present with findings that necessitate emergent exploratory laparotomy, precluding scanning with multidetector computed tomography (MDCT) until the postoperative period. This article reviews the wide range of complications as well as expected findings that may be encountered at MDCT performed postoperatively. Little has been written to guide the radiologist in interpreting these often complex and potentially confusing studies.