Vascular Injury in Mediastinal Trauma - Amazon Web …h24-files.s3.amazonaws.com/110213/295881-iPSIy.pdf · CT-A in Trauma Stuart E. Mirvis, MD, FACR MDCT of Mediastinal Injury Stuart

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Stuart E. Mirvis, MD, FACR

MDCT of Mediastinal InjuryMDCT of Mediastinal InjuryMDCT of Mediastinal Injury

Stuart E. Mirvis, MD, FACR

Department of Radiology & Maryland Shock-Trauma Center

University of Maryland School of Medicine

55thth Nordic Trauma Nordic Trauma Radiology CourseRadiology Course

Vascular Injury in Vascular Injury in MediastinalMediastinalTraumaTrauma

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Stuart E. Mirvis, MD, FACR

Major Aortic BranchesMajor Aortic Branches

Dissection / thrombus: Dissection / thrombus: left common carotidleft common carotid

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Stuart E. Mirvis, MD, FACR

Branch vessel injuriesBranch vessel injuries

Right Right subclaviansubclavian artery avulsionartery avulsion

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Stuart E. Mirvis, MD, FACR

Innominate Artery PsAn

Aortic InjuryAortic Injury

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What has been established #1

Essentially all aortic injuries are accompanied by mediastinal hematoma (abnormal chest radiograph) but this may be very minimal.

Helical CT, and particularly MDCT, are adequate to diagnose or exclude the vast majority of aortic injuries.

What has been established #2

Negative CT no angiography or CT follow-up.A positive CT no aortogram to confirm.Use of MDCT screening for blunt chest trauma reliably establishes or excludes aortic injuryA rare equivocal CT requires catheter angiography and TEE may be helpful.

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Stuart E. Mirvis, MD, FACR

Aortic stents: favorable anatomy, not good operative risk

Temporary non-operative management: severe concurrent injury

Long-term non-operative management (blood pressure control) : poor operative risk, minimal injury

Surgical repair: Good surgical candidate, favorable anatomy, poor anatomy for stenting

Anticoagulation for intimal injury

Precise characterization of injury has major influence on treatment

CT Signs of Aortic InjuryCT Signs of Aortic Injury

Pseudoaneurysm

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Stuart E. Mirvis, MD, FACR

CT Signs of Aortic InjuryCT Signs of Aortic Injury

Coarctation: small aorta sign

Traumatic coarctation

Small abdominal aorta

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Stuart E. Mirvis, MD, FACR

CT Signs of Aortic InjuryCT Signs of Aortic Injury

Contour Abnormality

CT Signs of Aortic InjuryCT Signs of Aortic Injury

Intimal Flaps

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Stuart E. Mirvis, MD, FACR

IntimalFlaps

CT Signs of Aortic InjuryCT Signs of Aortic Injury

Retrocrural hemorrhage(15-20%)

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Stuart E. Mirvis, MD, FACR

Atypical Aortic Injuries

Thrombus – embolization

Dissection

Active bleeding

Thrombus

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Stuart E. Mirvis, MD, FACR

Emboli from aortic injury

Renal embolic Renal embolic infarcts from infarcts from

aortic aortic thrombusthrombus

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Stuart E. Mirvis, MD, FACR

Traumatic aortic dissection

Traumatic aortic dissectionTraumatic aortic dissection

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Stuart E. Mirvis, MD, FACR

Active bleeding

BE CAREFUL: Atypical LocationsBE CAREFUL: Atypical Locations

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Stuart E. Mirvis, MD, FACR

Atypical location

Bleeding Ascending Aortic 

PsAn

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Stuart E. Mirvis, MD, FACR

Ascending Aorta Pseudoaneurysms

Atypical Location: Arch and LCC

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Stuart E. Mirvis, MD, FACR

Atypical Location:

ARCH

Aortic Arch

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Stuart E. Mirvis, MD, FACR

Proximal branches

Multifocal intimal flaps

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Stuart E. Mirvis, MD, FACR

BE CAREFUL: BE CAREFUL: CongentialCongential AnomaliesAnomalies

Ductus diverticulum

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Stuart E. Mirvis, MD, FACR

Ductus diverticulum

Smooth wallObtuse margins with aortaNo intimal flapsNo mediastinal hemorrhageNo retained contrast on “wash out”

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Stuart E. Mirvis, MD, FACR

Aberrant Rt. SCA and intimal tear

Left SVC

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Stuart E. Mirvis, MD, FACR

Right aortic arch; aberrant and atrophic left

subclavian artery

Diverticulum of Kommeral (D): Aortic arch pseudoaneurysm

D

D

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Stuart E. Mirvis, MD, FACR

CHALLENGING CASES

USE THE TECHNOLOGY !!

Atypical pseudoaneurysm:

calcified ductus remnant

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Stuart E. Mirvis, MD, FACR

Aortic InjuryAortic Injury

Subtle aortic injury (minimal mediastinal blood)

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Stuart E. Mirvis, MD, FACR

Ductus remnant:

Aortic spindle

Aortic Injury with minimal mediastinal hemorrhage

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Stuart E. Mirvis, MD, FACR

Subtle injury & minimal

periaortic blood

Intimal tear, but no mediastinal blood

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Stuart E. Mirvis, MD, FACR

Aortic Injury ?

YES, BUT NO MEDIASTINAL BLOOD

Aortic Injury or Ductus?

DUCTUS

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Stuart E. Mirvis, MD, FACR

Intimal tear: No mediastinal blood: Resolved 2 days later

2 days later

Distraction T-spineIntimal flap

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Stuart E. Mirvis, MD, FACR

Aortic injury?

Probably not, old injury?, aortic

spindle

3-floor fall: Aortic Injury ???

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Stuart E. Mirvis, MD, FACR

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Stuart E. Mirvis, MD, FACR

Outcome

Patient had positive transesophageal sonographyAorta opened at surgery – NO injury1-month hospitalization from complications of thoracotomy

0.4 - 1.5% after blunt traumaVery high pre-hospital mortality (70-80%)Thoracic trachea > cervical tracheaRight mainstem > Left mainstemTypically within 2.5 cm of carinaDiagnosis not established acutely in 70%

TracheobronchialTracheobronchial TraumaTrauma

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Stuart E. Mirvis, MD, FACR

Tracheobronchial TraumaTracheobronchial Trauma• Mechanisms

– Compression of closed glottis– Crush (spine & sternum)– Traction across carina with compression– Shearing during deceleration– Tranverse force*: cables, tree limb,

clothes-line, rope

–* produces tear with 3 kg force versus 11 kg force for

longitudinal force

Radiologic FindingsRadiologic FindingsProgressive, extensive air leak despite chest tubePneumothorax despite chest tubeEndotracheal balloon overdistensionEctopic endotracheal tube or balloonFallen lung signDeformity of mainstem bronchusAir outline of mainstem bronchi

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Stuart E. Mirvis, MD, FACR

Diffuse air leak as Diffuse air leak as an indirect sign of an indirect sign of

airway injuryairway injury

Fallen Lung with Tension

Pneumothorax

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Stuart E. Mirvis, MD, FACR

TracheoTracheo--bronchial Injurybronchial Injury

Tracheobronchial InjuryTracheobronchial Injury

Trans-tracheal GSW

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Stuart E. Mirvis, MD, FACR

Tracheobronchial Tracheobronchial InjuryInjury

Progressive, persistent air leak

Fallen lung

Ectopic ET tube

Abnormally shaped balloon

Direct air leak – CT

Deformed mainstem bronchi

Peritracheal Air Sign:

Double Wall Mainstem

Bronchi

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Stuart E. Mirvis, MD, FACR

Direct Air LeakDirect Air Leak

Tracheal Rupture: ETT Balloon Sign

Tracheal Rupture: ETT Balloon Sign

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Stuart E. Mirvis, MD, FACR

Right mainstem bronchus rupture

GSW Trachea

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Stuart E. Mirvis, MD, FACR

More proximal tracheal injury less common to have pneumothoraxInflation of endotracheal balloon does NOT rupture airway (75 ml)Accuracy of spiral CT alone 71%*

*Chen JD, Shanmuganathan K, Mirvis SE, et al. AJR 2001

Tracheobronchial Injury

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Stuart E. Mirvis, MD, FACR

Esophageal TraumaEsophageal Trauma

Trauma accounts for Trauma accounts for < 10% injuries< 10% injuriesIatrogenic most Iatrogenic most commoncommonBlunt 96 cases Blunt 96 cases reported 1900 reported 1900 -- 19881988Variable Variable mechanisms:mechanisms:

CrushingCrushingDirect penetrationDirect penetrationTraction (hiatus)Traction (hiatus)

Esophageal TraumaEsophageal Trauma Lacks specific symptoms, often lateRadiography: Non-specific (widened mediastinum, mediastinal air near tear, left pleural fluid)CT: same findings, but may perform after esophagram to increase sensitivityEsophagram -endoscopy

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Stuart E. Mirvis, MD, FACR

EsophagealEsophagealDisruptionDisruption

Consider with any potential penetrating mediastinal traumaCT helps define missile tract to assess likelihood of injuryGas from esophagus (not under pressure) stays near esophagusCan spiral CT with contrast swallow establish diagnosis directly? Consider tracheal and vascular injury

Esophageal TraumaEsophageal Trauma

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Stuart E. Mirvis, MD, FACR

Esophageal Esophageal TraumaTrauma

Thoracic esophagusentrapped in T-spine

dislocation

CardiacCardiac--Pericardial InjuryPericardial InjuryTamponade: blood, air, anterior mediastinal hematoma, gastric herniationPericardial herniationPerforation -ruptureContusion

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Stuart E. Mirvis, MD, FACR

CardiacCardiac--Pericardial TraumaPericardial Trauma

Pericardial hemorrhage with Pericardial hemorrhage with tamponadetamponade

CardiacCardiac--Pericardial TraumaPericardial Trauma

Biatrial rupture

Pericardial tamponade with elevated CVP

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Stuart E. Mirvis, MD, FACR

Cardiac Air Cardiac Air TamponadeTamponade

Tension Pneumopericardium

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Stuart E. Mirvis, MD, FACR

BronchoBroncho--pericardial pericardial fistula, S/P dilation:fistula, S/P dilation:

Intrapericardial gastric Intrapericardial gastric herniationherniation

Cardiac herniationCardiac herniation

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Stuart E. Mirvis, MD, FACR

Pericardial rupture and

cardiac subluxation

Cardiac Tamponade Cardiac Tamponade fromfrom

IMA bleedIMA bleed

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Stuart E. Mirvis, MD, FACR

Thank You !