Multidetector CT in Blunt Abdominal Trauma:Imaging Findings and Pitfalls

Juyeon Lee; Jhii-Hyun Ahn

doi:10.3348/jksr.2019.80.3.445

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Lee and Ahn: Multidetector CT in Blunt Abdominal Trauma:Imaging Findings and Pitfalls

Review Article

J Korean Soc Radiol 2019;80(3):445-465.

Published online: 20 January 2019

DOI: https://doi.org/10.3348/jksr.2019.80.3.445

Multidetector CT in Blunt Abdominal Trauma:Imaging Findings and Pitfalls

Juyeon Lee, MD, Jhii-Hyun Ahn, MD^∗

Department of Radiology, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea

^∗Corresponding author Jhii-Hyun Ahn, MD Department of Radiology, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 20 Ilsan-ro, Wonju 26426, Korea. Tel 82-33-741-1474 Fax 82-33-732-8281 E-mail radajh@yonsei.ac.kr

Received 31 January 2019 Revised 21 April 2019 Accepted 29 April 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Owing to the developments in imaging modalities, imaging has become an essential element in the early evaluation of and decision-making algorithm for patients with trauma. In particular, CT technology has developed over the past decades, resulting in faster image acquisition and higher image quality. Currently, CT is the key imaging modality for triaging surgical and non-surgical treatment in patients with abdominal trauma and plays an important role in increasing the frequency and success rate of non-surgical treatment. Because rapid and accurate diagnosis of injury in patients with trauma can improve the patients' prognosis, radiologists should be famil-iar with the imaging findings, especially the CT findings, in patients with trauma. In this article, the authors reviewed the considerations when performing CT for evaluating abdominal trauma. In addition, they described the important imaging findings and pitfalls when diagnosing blunt trauma in various intra-abdominal organs.

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Fig. 1.

Active bleeding in a 49-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows contrast extravasation (arrows) at the mesentery.

Fig. 2.

The sentinel clot sign in a 59-year-old man after a motor vehicle accident. A. The non-enhanced axial CT image demonstrates the difference in density between the hemoperitoneum (32 HU, black asterisk) around the liver and the clot (69 HU, white asterisk) around the spleen. B. The contrast-enhanced CT image shows the lacerations (arrows) in the spleen. HU = Hounsfield unit

Fig. 3.

Liver laceration in an 18-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows irregular and linear low-attenuation areas (arrows) in the liver, consistent with a laceration.

Fig. 4.

Intraparenchymal hematoma in a 22-year-old man after beating. The contrast-enhanced CT image demonstrates an ill-defined, round, low-attenuation area (arrows) in the right posterior section of the liver.

Fig. 5.

Subcapsular hematoma versus perihepatic hematoma. A. Subcapsular hematoma in a 35-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows the elliptic collection of a low-attenuation area (arrows) between the liver capsule and the parenchyma, which caused indentation of the liver margin. B. However, such a finding is not seen in perihepatic hematoma (arrowheads) in a 24-year-old man after a motor vehicle accident.

Fig. 6.

Hepatic infarction in a 17-year-old man after a motor vehicle accident. A. The contrast-enhanced CT image shows a lack of perfusion (arrows) to the left lateral section of the liver. B. The follow-up contrast-enhanced CT image acquired 7 days later shows total necrosis (asterisk) of the left lateral section of the liver.

Fig. 7.

Periportal low attenuation in an 18-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows low-attenuation areas around the portal vein and its branch (arrows). Note the laceration that extends to the portal vein branch (arrowheads).

Fig. 8.

Periportal low attenuation in a 31-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows low-attenuation areas around the portal vein and its branches (arrowheads). A finding of marked distention of the inferior vena cava (arrow) may indicate vigorous fluid replacement.

Fig. 9.

Hepatic hemangioma initially diagnosed as hematoma in a 68-year-old man after a motor vehicle accident. A. The initial contrast-enhanced CT image demonstrates a low-attenuation lesion (arrow) in the left hemiliver, simulating a liver hematoma. B. The contrast-enhanced CT image acquired 3 days later shows peripheral-enhancing portions (arrowheads) within the low-attenuation lesion (arrow), which are most consistent with a hemangioma. Note the hepatic hematoma in the right hemiliver (black arrow).

Fig. 10.

Post-traumatic pseudoaneurysm in a 56-year-old man after a 2-meter fall. A. The initial contrast-enhanced CT image shows a large hematoma (arrows) in the right hemiliver. B. The contrast-enhanced CT image acquired 18 days later shows a newly developed, well-defined pseudoaneurysm (arrow) within the hepatic hematoma.

Fig. 11.

Bile duct injury in a 63-year-old man after a motor vehicle accident. A. The initial contrast-enhanced CT image shows multiple lacerations and hematoma (arrows) in the medial section of the left liver and anterior section of the right liver. B. The follow-up contrast-enhanced CT image acquired 83 days later shows the development of a biloma (arrows) and left intrahepatic duct dilatation (arrowheads).

Fig. 12.

Splenic laceration in a 31-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows an irregular and linear low-attenuation area (arrows) in the spleen. Hematoma in the left adrenal gland is also seen (arrowheads).

Fig. 13.

Congenital cleft in a 42-year-old man after a motor vehicle accident. The contrast-enhanced CT image demonstrates a smooth low-attenuation line (arrows) in the spleen without perisplenic fluid collection. Note the lacerations of the liver (arrowheads).

Fig. 14.

Splenic pseudoaneurysm in a 54-year-old man after a motor vehicle accident. A. The contrast-enhanced CT image acquired in an early phase of enhancement during chest CT shows a high-attenuation area (arrowheads) in the spleen. B. The contrast-enhanced CT image acquired in the portal venous phase of enhancement shows that the

Fig. 15.

Transection of the pancreas with active bleeding in a 47-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows a linear low-attenuation area (arrow) across the pancreatic tail. Note the high-attenuation contrast material extravasation (arrowheads) within the intrapancreatic hematoma.

Fig. 16.

Pancreatic laceration with the disruption of the pancreatic duct in a 43-year-old man after a motor vehicle accident. A. The contrast-enhanced CT image shows a deep laceration with hematoma (arrows) in the pancreatic tail. B. The endoscopic retrograde pancreatogram shows extravasation (arrows) of contrast material from a pancreatic duct, indicating duct disruption.

Fig. 17.

Sigmoid colon perforation in a 57-year-old man after a motor vehicle accident. A large mural defect is seen at the sigmoid colon (arrows) with feces (F) spilling from the lumen (L) and multifocal intraperitoneal extraluminal air (arrowheads).

Fig. 18.

Large bowel transection in a 49-year-old man after a motor vehicle accident. The contrast-enhanced CT image shows abnormal dual bowel wall enhancement (both increased and decreased), as well as the Janus sign (arrowheads). The surrounding hematoma (arrows) makes it difficult to recognize the transected bowel end.

Fig. 19.

Monnettsrreaanssttt–eeernnichh haaennmcceeaddt o CCmTT aiimm inaa ggaeen sa8hc7oq-ywueisra erfod-oc 2lad0l mhdaaazynisn aleafsttese rr(aasrh mroowowtsso)tr ih nvee t hrheiecs lomel uaetcsiceoinndt eeonrf ytm. esenteric haziness.

Fig. 20.

Delayed bowel perforation in a 62-year-old man after a motor vehicle accident. A. The initial contrast-enhanced CT image shows minimal amount of mesenteric fluid (arrow) without abnormality of the bowel. B. The contrast-enhanced CT image acquired 5 days later shows a newly developed mural defect of the small bowel (arrows) with extraluminal air (asterisk).

Fig. 21.

Hypoperfusion complex in a 61-year-old man after a motor vehicle accident. The contrast-enhanced CT image demonstrates hyperen-hancement of the small bowel mucosa, consistent with a shock bowel. Flattening of the inferior vena cava (arrow) is also seen.

Table 1.

Liver Injury Grading System by American Association for the Surgery of Trauma

Grade	Injury Type	Description
Grade I	Injury Type Hematoma	Description Subcapsular, < 10% surface
	Laceration	Capsular tear, < 1 cm in parenchymal depth
II	Hematoma	Subcapsular, 10–50% surface area; intraparenchymal, < 10 cm in diameter
	Laceration	1–3 cm in parenchymal depth, < 10 cm in length
III	Hematoma	Subcapsular, > 50% surface area or expanding or ruptured subcapsular hematoma with active bleeding; intraparenchymal, > 10 cm or expanding or ruptured
	Laceration	> 3 cm in parenchymal depth
IV	Hematoma	Ruptured intraparenchymal hematoma with active bleeding
	Laceration	Parenchymal disruption involving 25–75% of a hepatic lobe or one to three Couinaud segments within a single lobe
V	Laceration	Parenchymal disruption involving > 75% of a hepatic lobe or more than three Couinaud segments within a single lobe
	Vascular	Juxtahepatic venous injuries (ie, retrohepatic vena cava or central major hepatic veins)
VI	Vascular	Hepatic avulsion

Adapted from Moore et al. J Trauma 1995;38:323–324 (31).

Table 2.

Spleen Injury Grading System by American Association for the Surgery of Trauma

Grade	Injury Type	Description
I	Hematoma	Subcapsular, < 10% surface
I	Laceration	Capsular tear, < 1 cm in parenchymal depth
II	Hematoma	Subcapsular, 10–50% surface area; intraparenchymal, < 5 cm in diameter
II	Laceration	1–3 cm in parenchymal depth; dose not involve a trabecular vessel
III	Hematoma	Subcapsular, > 50% surface area or expanding; ruptured subcapsular or parenchymal hematoma
III	Laceration	> 3 cm in parenchymal depth or involved trabecular vessels
IV	Laceration	Laceration involving segmental or hilar vessels and producing major devascularization (> 25% of spleen)
^V	Laceration	Completely shattered spleen
^V	Vascular	Hilar vascular injury that devascularizes spleen

Adapted from Moore et al. J Trauma 1995;38:323–324 (31).

Table 3.

Multidetector CT-based Spleen Injury Grading System

Grade	Criteria
1	Subcapsular hematoma < 1 cm thick
	Laceration < 1 cm parenchymal depth
	Parenchymal hematoma < 1 cm diameter
2	Subcapsular hematoma 1- to 3-cm thick
	Laceration 1–3 cm in parenchymal depth
	Parenchymal hematoma 1–3 cm in diameter
3	Splenic capsular disruption
	Subcapsular hematoma > 3 cm thick
	Laceration > 3 cm in parenchymal depth
	Parenchymal hematoma > 3 cm in diameter
4a	Active intraparenchymal and subcapsular splenic bleeding
	Splenic vascular injury (pseudoaneurysm or arteriovenous fistula)
	Shattered spleen
4b	Active intraperitoneal bleeding

Adapted from Marmery et al. AJR Am J Roentgenol 2007;189:1421–1427 (38).

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