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Using Contrast-Enhanced Helical CT to Visualize Arterial Extravasation After Blunt Abdominal Trauma

Incidence and Organ Distribution

¹ Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr., H-1307, Stanford, CA 94305-5105.
² Department of Diagnostic Radiology, University of Maryland Medical Center, University of Maryland Hospital, 22 S. Greene St., Baltimore, MD 21201.
³ Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213.
⁴ Department of Radiology, Brooke Army Medical Center, 3851 Roger Brooke Dr., Fort Sam Houston, TX 78234-6200.
⁵ Department of Radiology, Albert Einstein College of Medicine, Jack and Pearl Resnick Campus, 1300 Morris Park Ave., Bronx, NY 10461.
⁶ Department of Radiology, Los Angeles County/University of Southern California Medical Center, Box 631, 1200 N. State St., Los Angeles, CA 90033.

Received April 19, 2001; accepted after revision July 26, 2001.

 
Address correspondence to R. B. Jeffrey, Jr.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. We evaluated the incidence and organ distribution of arterial extravasation identified using contrast-enhanced helical CT in patients who had sustained abdominal visceral injuries and pelvic fractures after blunt trauma.

SUBJECTS AND METHODS. Five hundred sixty-five consecutive patients from four level I trauma centers who had CT scans showing abdominal visceral injuries or pelvic fractures were included in this series. The presence or absence of arterial extravasation, as well as the anatomic sites of arterial extravasation, was noted. We obtained clinical follow-up data, including surgical or angiographic findings.

RESULTS. In our series, 104 (18.4%) of 565 patients had arterial extravasation. Of the 104 patients, 81 (77.9%) underwent surgery, embolization, or both. The combined rate of surgery or embolization in patients with arterial extravasation was statistically higher than expected at all four institutions (p <0.001). The spleen was the most common organ injured, occurring in 277 (49.0%) of 565 patients, and arterial extravasation occurred in 49 (17.7%) of 277 patients with splenic injury. Several other visceral injuries were associated with arterial extravasation, including hepatic, renal, adrenal, and mesenteric injuries.

CONCLUSION. Based on the limited reports of arterial extravasation in the nonhelical CT literature, the percentage (18%) of clinically stable patients in our study with CT scans showing arterial extravasation was higher than anticipated. This finding likely reflects the improved diagnostic capability of helical CT. Although the spleen and liver were the organs most commonly associated with arterial extravasation, radiologists should be aware that arterial extravasation may be associated with several other visceral injuries.

Introduction

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Using contrast-enhanced CT to diagnose arterial extravasation has important implications for the treatment of patients who have experienced blunt abdominal trauma [1, 2]. The extravasation can be used to localize anatomic sites of hemorrhage and to guide angiographic or surgical intervention [2, 3]. In addition, the presence of arterial extravasation has been correlated with failure of nonsurgical management of splenic injuries in both adults [4,5,6] and children [7]. To our knowledge, however, only one small single institutional series has been performed that focused primarily on splenic injuries, and nonhelical CT was the modality used. This report represents a multi-institution prospective study to evaluate comprehensively the frequency and organ distribution of abdominal arterial extravasation in patients studied with helical CT.

Subjects and Methods

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We prospectively studied 565 consecutive patients ranging from 16 to 91 years old (mean age, 38 years) from four level I trauma centers who had positive CT scans for blunt abdominal trauma. All the patients had sustained blunt abdominal trauma from one of three mechanisms: motor vehicle crashes, falls, or assault with a blunt object. No patients with penetrating trauma were included. All patients were considered clinically stable enough to undergo CT. Only patients with CT evidence of visceral injuries (parenchymal laceration, hematoma, subcapsular hematoma, or fracture) or pelvic fractures were included for analysis. Patients with CT scans showing normal findings were excluded from our analysis, as were patients with other types of isolated musculoskeletal injuries (such as rib or vertebral fractures). Data on the CT findings of arterial extravasation were collected prospectively from August 1998 to January 2000 at all four institutions using a common data sheet. The official radiologic interpretation at the time of the CT was used for analysis. Subsequent clinical follow-up findings were recorded at a later date.

All patients underwent contrast-enhanced CT performed with commercially available single-slice helical CT scanners (HiSpeed CT, General Electric Medical Systems, Milwaukee, WI; PQ 6000, Marconi Medical System, Cleveland, OH; or Somatom Plus4, Siemens, Erlangen, Germany). A total of 120-150 mL of nonionic iohexol (Omnipaque 300; Nycomed, Princeton, NJ), ioversol (Optiray 350; Mallinckrodt, St. Louis, MO), or iopamidol (Isovue 300; Bracco Diagnostic, Princeton, NJ) was administered as a contrast agent IV with a power injector at 2.0-3.0 mL/sec, with a delayed scan time of 60-70 sec. A slice collimation of 7 or 8 mm was used. Oral contrast administration was variable and not routinely used at all institutions. Delayed scans of the kidneys were obtained routinely, but delayed scans through the area of active bleeding were not. Relying on previously published criteria, we diagnosed arterial extravasation in patients whose CT scans showed a focal or diffuse area of high attenuation that was isodense compared with major adjacent arteries [2, 3]. A distinction was not made between a contained arterial extravasation (a pseudoaneurysm) and an uncontained arterial extravasation.

The anatomic sites of injuries, the presence or absence of arterial extravasation, and the site of arterial bleeding were recorded prospectively. The clinical outcome was determined by review of medical records and of other radiologic examinations. Further intervention, including surgery or angiographic embolization, was determined for the overall patient population, as well as for specific types of injuries (spleen, liver, pancreas, kidney, bowel, adrenal gland, mesentery, and pelvic fractures).

Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
We included in this study 565 patients with blunt abdominal trauma and positive CT findings for abdominal injury (Table 1). Of these 565 patients, 104 (18.4%) had arterial extravasation and 461 (81.6%) did not. Of the 104 patients with arterial extravasation, 81 (77.9%) underwent either surgery, angiographic embolization, or both. The combined rate of surgery and embolization was significantly higher (p < 0.001) compared with the rate of these procedures in those patients without arterial extravasation; only 129 (28.0%) of these patients required surgical or angiographic intervention.

A breakdown of specific organ injuries is listed in Table 2. The spleen and liver were the most commonly injured organs in our series. Of the 277 patients with splenic injuries, 49 (17.7%) had arterial extravasation, and 228 did not. Of the 49 patients with arterial extravasation, 41 (83.7%) underwent either surgery, angiographic embolization, or both. Sixty-nine (30.3%) of 228 patients without arterial extravasation required surgery, embolization, or both.

Of the 230 patients with hepatic injuries, 21 (9.1%) had arterial extravasation, and 209 did not. Seventeen (81.0%) of the 21 patients with arterial extravasation required surgery, embolization, or both. Thirty-three (15.8%) of the 209 patients without arterial extravasation required surgery.

A total of 38 patients had mesenteric injuries. Nine (23.7%) had evidence of arterial extravasation, and all nine patients underwent laparotomy. Fifteen (51.7%) of the 29 patients without arterial extravasation required surgery.

Sixty-two patients had renal injuries; of these patients, 13 (21.0%) had arterial extravasation. Nine (69.2%) required further intervention (surgery, embolization, or both), whereas 13 (26.5%) of 49 patients without arterial extravasation required surgery. Of the 36 patients with adrenal gland injuries, only two had arterial extravasation; both patients required surgery. No arterial extravasation was identified in the patients who sustained pancreatic, duodenal, and small-bowel injuries.

Statistical analysis was performed using the chi-square and Fisher's exact test. There were significant differences (p <0.001) between patients with arterial extravasation requiring intervention (surgery, embolization, or both) and those without arterial extravasation. This significance was found for the overall patient population, as well as in all subcategories of specific injuries involving the spleen, liver, mesentery, kidney, and adrenal gland (Table 2).

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In 1989, Sivit et al. [1] were the first researchers to describe the CT appearance of active intraabdominal arterial extravasation in a patient with splenic rupture caused by blunt trauma. In 1991, Jeffrey et al. [2] described 18 patients with active intraabdominal arterial hemorrhage diagnosed using dynamic contrast-enhanced CT. Arterial extravasation was diagnosed in patients whose CT scans showed an area of focal or diffuse high attenuation isodense compared with major adjacent arterial structures that was surrounded by high-attenuation fluid representing hematoma (Figs. 1 and 2). Since that time, several small clinical series at single institutions have looked at the impact of nonhelical CT on the diagnosis of arterial extravasation in patients with splenic injuries [4,5,6,7]. To our knowledge, no large prospective multiinstitutional study that broadly evaluated the use of helical CT in the diagnosis of arterial extravasation has been reported.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —56-year-old woman with blunt trauma from motor vehicle crash. Contrast-enhanced CT scan shows splenic laceration with arterial extravasation (arrow) that is isodense to abdominal aorta. Note large perisplenic hematoma.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —29-year-old man who was involved in motor vehicle crash. Contrast-enhanced CT scan reveals mesenteric arterial injury with arterial extravasation (arrow). Note extravasated contrast material is isodense compared with aorta.

The major finding of our study was that of 565 patients in the series, 104 (18.4%) had CT evidence of arterial extravasation on helical CT. This percentage of clinically stable patients with arterial extravasation was significantly higher than the percentage that we had anticipated on the basis of the relatively few reports of arterial extravasation using nonhelical CT. The higher percentage reflects, in our opinion, better contrast enhancement achievable with helical CT and the ability to scan rapidly at the peak of contrast enhancement.

The spleen was the most common organ injured in this series. Of the 277 patients with splenic injuries, 49 (17.7%) had arterial extravasation detected by helical CT. Of the 49 patients with arterial extravasation and splenic injuries, 41 (83.7%) required either surgery, angiographic embolization, or both. This percentage of patients was highly significant statistically (p < 0.001) compared with the 228 patients who did not have arterial extravasation revealed on helical CT. In those patients without arterial extravasation, surgery of the spleen was required in only 69 (30.3%) of 228 patients.

In the past, splenic injury severity scores based on the degree of parenchymal injury were used to predict the success of nonoperative management. However, several studies have shown a poor correlation between the morphologic grade of splenic injury and the need for surgical intervention [8,9,10,11]. This finding has led some authors to propose the use of angiography to specifically search for arterial extravasation in patients who have CT evidence of splenic injury [12, 13]. More recent studies have noted that presence of a "contrast blush" on a patient's CT scan strongly correlates with failure of nonoperative management [6, 14]. The term "contrast blush" refers to arterial extravasation, either a contained pseudoaneurysm or active extravasation. On the basis of our experience gained with this study, we believe there is a need to re-evaluate existing morphologic severity scores to reflect the detection of arterial extravasation. A comparison of arterial extravasation versus other grading schemes appears warranted.

The liver was the second most frequently injured visceral organ in our series. However, arterial extravasation was noted much less commonly than with splenic injuries, occurring in only 21 (9.1%) of 230 patients. The presence of arterial extravasation in patients with hepatic injuries strongly correlated with the need for either surgery or angiographic embolization; 17 (81.0%) of 21 patients (p < 0.001) required either surgery or angiographic embolization.

Although the liver and spleen were the most common sites of arterial extravasation, radiologists interpreting CT scans of trauma patients should be aware that arterial extravasation may be identified in a wide variety of other injuries, including renal, adrenal, and mesenteric lacerations as well as pelvic fractures. We found a statistically significant correlation between arterial extravasation and the need for surgery or embolization in patients with renal (n = 13), mesenteric (n = 9), and adrenal (n = 2) injuries.

Limitations to our study of the use of helical CT in the diagnosis of arterial extravasation include the fact that the CT examination is a single morphologic snapshot in time and does not necessarily predict ongoing bleeding. Bleeding can stop at any point in the clinical course, and therefore, a CT scan at one point in time is not a perfect predictor of subsequent hemorrhage. Another limitation is the inability to quantitate the degree or rate of bleeding. We are investigating the potential use of delayed scanning to evaluate the evolution of arterial extravasation, but this is an imperfect solution because it requires additional radiation. Animal models of arterial extravasation potentially may be the best way to study this problem in the future. The CT appearance or pattern of arterial extravasation may also be important. A pseudoaneurysm that is contained may have different implications for treatment than extravasation that is free and uncontained. This point will require further analysis and was not specifically addressed in our study.

Another limitation was that we are not able to precisely correlate the need for surgery or angiographic intervention with the diagnosis of arterial extravasation. Criteria for surgery in blunt trauma are variable from institution to institution, and no attempt was made to follow a uniform trauma management algorithm. It is probable that, in some instances, the diagnosis of arterial extravasation may have influenced surgeons to operate and, therefore, introduced a selection bias. Although we freely admit that selection bias may have influenced management in some patients, arterial extravasation was associated with a statistically significant need for intervention at all four institutions and thus did not just reflect an individual institutional practice or biases at one or two trauma centers.

In summary, although clinically unstable patients with blunt abdominal trauma are usually excluded from CT, 18% of the patients with positive CT findings had arterial extravasation that was detected with helical CT. This percentage of patients was larger than we expected from the relatively few articles concerning arterial extravasation in the nonhelical CT literature. Although the spleen is the most common site of arterial extravasation after blunt trauma, arterial extravasation may be noted in a broad spectrum of other visceral injuries as well as pelvic fractures. Radiologists should carefully search for this important finding because it may directly affect patient treatment. In the future, we hope to investigate the use of arterial extravasation using current CT severity scores for splenic injuries in the hope that these scores may be a useful adjunct in predicting patient outcome with nonoperative management.

Acknowledgments
 
We thank Bradley Betts, Department of Radiology, Stanford University Medical Center, for assistance with statistical analysis.

References

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