The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology

Abdominal trauma

Traumatic injuries are the leading cause of death in people aged<45 years, and abdominal trauma is a source of significant morbidity and mortality and high economic costs. Imaging has a fundamental role in abdominal trauma, where CT is a fundamental tool for rapid, accurate diagnosis that will be key for patients' clinical outcomes.

Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review

Major trauma is an event causing injuries that may determine an immediate or potential risk to the patient survival. A correct management of major trauma is decisive in reducing disability, which has relevance both from the point of view of the quality of life of the single individual and from the point of view of health expenditure. The primary clinical approach to the polytraumatized patients is managed, in most cases, as outlined in the guidelines of Advanced Trauma Life Support, proposing conventional radiological investigations, such as chest and pelvis x-ray, and of FAST (focused abdominal sonography in trauma)/E-FAST (extended FAST) examinations, followed by selective targeted computed tomography (CT). This approach is questionable and is increasingly common in clinical practice the adoption of the immediate total-body CT in the diagnostic approach to the hemodynamically stable polytraumatized patient. However, the potential advantages of such conduct both in terms of clinical benefits and in terms of cost-effectiveness still need to be discussed. The objective of this review article consists of a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Role of MRI in early follow-up of patients with solid organ injuries: How and why we do it?

Trauma represents one of the most common causes of death or permanent disability in the population below 50 years. At present, non-operative treatment is the commonly adopted strategy in hemodynamically stable patients with solid organ injuries, when there are not concomitant bowel and mesenteric injuries requiring a prompt surgical approach, but it may require multiple imaging follow-up examinations, especially in the case of major injuries. No data are available about magnetic resonance imaging utilization in the early follow-up of trauma patients with solid organ injuries, particularly in liver and spleen trauma. We report our preliminary experience in this field.

Local ablation of pancreatic tumors: State of the art and future perspectives

BACKGROUND

Currently, the technologies most commonly used to treat locally advanced pancreatic cancer are radiofrequency ablation (RFA), microwave ablation, and irreversible (IRE) or reversible electroporation combined with low doses of chemotherapeutic drugs.

AIM

To report an overview and updates on ablative techniques in pancreatic cancer.

METHODS

Several electronic databases were searched. The search covered the years from January 2000 to January 2021. Moreover, the reference lists of the found papers were analysed for papers not indexed in the electronic databases. All titles and abstracts were analysed.

RESULTS

We found 30 studies (14 studies for RFA, 3 for microwave therapy, 10 for IRE, and 3 for electrochemotherapy), comprising 1047 patients, which were analysed further. Two randomized trials were found for IRE. Percutaneous and laparotomy approaches were performed. In the assessed patients, the median maximal diameter of the lesions was in the range of 2.8 to 4.5 cm. All series included patients unfit for surgical treatment, but Martin et al assessed a subgroup of patients with borderline resectable tumours who underwent resection with margin attenuation with IRE. Most studies administered chemotherapy prior to ablative therapies. However, several studies suggest that the key determinant of improved survival is attributable to ablative treatment alone. Nevertheless, the authors suggested chemotherapy before local therapies for several reasons. This strategy may not only downstage a subgroup of patients to curative-intent surgery but also support to recognize patients with biologically unfavourable tumours who would likely not benefit from ablation treatments. Ablation therapies seem safe based on the 1047 patients assessed in this review. The mortality rate ranged from 1.8% to 2%. However, despite the low mortality, the reported rates of severe post procedural complications ranged from 0%-42%. Most reported complications have been self-limiting and manageable. Median overall survival varied between 6.0 and 33 mo. Regarding the technical success rate, assessed papers reported an estimated rate in the range of 85% to 100%. However, the authors reported early recurrence after treatment. A distinct consideration should be made on whether local treatments induce an immune response in the ablated area. Preclinical and clinical studies have shown that RFA is a promising mechanism for inducing antigen-presenting cell infiltration and enhancing the systemic antitumour T-cell immune response and tumour regression.

CONCLUSION

In the management of patients with pancreatic cancer, the possibility of a multimodal approach should be considered, and conceptually, the combination of RFA with immunotherapy represents a novel angle of attack against this tumour.

Evaluation of Radiation Protection Methods for Assistant Staff during CT Imaging in High-energy Trauma: Lens Dosimetry with a Phantom Study

Staff are exposed to radiation in the scanning room when assisting with CT scans of patients requiring ventilatory support during procedures. We measured lens doses using a phantom during a high-energy trauma protocol. Dosimetry showed that the unprotected lens received 2.02 mGy on the right and 1.91 mGy on the left, which are not negligible doses. Respective exposures to the right and left lens were 53.6% and 55.1% when wearing 0.07 mm Pb protective glasses with side covers; 53.7% and 64.2% when wearing 0.7 mm Pb glasses without side covers when facing away from the patient couch; and 92.1% and 91.2% using protective shielding in the gantry. Since the face direction may change during assistance with CT imaging, it is desirable that the protective glasses have a shape with a side cover. The protective shielding had a major radiation reduction effect, although it is expensive to acquire, install, and maintain.

Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review

Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis.

The additional value of the arterial phase in the CT assessment of liver vascular injuries after high-energy blunt trauma

PURPOSE

In the literature, no consensus exists about which CT protocol is to be adopted in patients who underwent high-energy blunt trauma. The aim of the study is to evaluate the additional value of the arterial phase in the CT assessment of vascular injuries of the liver.

METHODS

Admission CT examinations for patients with traumatic injury of the liver due to high-energy blunt trauma, performed between 2011 and 2017 in two major trauma centres, were retrospectively reviewed. Images were analysed for presence or absence of liver parenchymal injury, intrahepatic contained vascular injuries and active bleeding in the arterial and portal venous phase of the CT study.

RESULTS

Two hundred twelve patients have been identified. Parenchymal injuries were detected as isolated in 90.6% of cases, whereas they were associated with vascular injuries in 9.4% of cases: contained vascular injuries in 3.3% and active bleeding in 6.1%. Out of all parenchymal injuries detected on the CT portal venous phase, 90.5% were also detectable in the arterial phases (p < 0.0001). All of the contained vascular injuries were visible in the CT arterial phase, whereas they were detectable in 28.5% of cases also during the venous phase (p = 0.02). All 13 cases of active bleeding were detected on the CT venous phase, and 76.9% of these cases were also revealed in the arterial phase, thus confirming their arterial origin (p = 0.22).

CONCLUSION

The addiction of the arterial phase to the venous phase in the CT assessment of patients who underwent high-energy blunt trauma allows an accurate identification and characterization of traumatic vascular injuries, so distinguishing between patients suitable for conservative management and those requiring interventional or surgical treatment.

Intraosseous contrast administration for emergency computed tomography: A case-control study

OBJECTIVE

The aim of the study was to evaluate the feasibility of intraosseous (i.o.) contrast media injection (CMI) for emergency computed tomography (CT) of severe trauma and the associated image quality compared to intravenous (i.v.) CMI.

MATERIALS AND METHODS

The authors retrospectively analysed objective (contrast-to-noise ratio (CNR)) and subjective (4-point Likert scale) image quality of CTs after i.o. (n = 4, mean age (y) 57.0±11.0) versus i.v. (n = 20, mean age (y) 58.8±4.4) CMI. All patients underwent a native head CT scan, a cerebral CT angiography (CTA) and CTA of the supra-aortic vasculature as well as a chest and abdominal CT scan in the venous phase; one patient with an i.o. access additionally received a CTA of the lower limbs. Electronic patient records have been reviewed to determine i.o. access related complications.

RESULTS

Both groups were consistent in age, heart rate, scan parameters including the flow rate of the contrast agent, resulting in comparable radiation dose levels. The image noise and CNR had no significant difference between the two groups. Scoring the delineation of the main vessels after i.o. CMI showed no significant difference to the i.v. group. There were no CT or i.o. access related complications observed.

CONCLUSION

The i.o. access is a safe and suitable alternative for emergency CMI in CT. Using established protocols good to very good image quality can be achieved, comparable to i.v. CMI. We show for the first time, that i.o. CMI is also feasible for CTA imaging of the head and neck region as well as of pelvic and leg vessels.

Management of Thoracic and Lumbar Spine Fractures: Is MRI Necessary in Patients without Neurological Deficits?

MRI after a CT scan for thoracolumbar spine (TLS) trauma has become commonplace because of the concerns for detection of posterior ligamentous complex injuries in the absence of substantial scientific evidence to support its use. We hypothesized that MRI scans were not necessary in the clinical management of TLS fractures. A prospective study was conducted at our Level I trauma center. A total of 39 neurologically intact patients with TLS fracture on CT were enrolled. The patients' CT scan and neurological examination were reviewed by a senior neurosurgeon, who determined clinical management based on these data. Assessment was repeated after an MRI of the spine was performed, and a second clinical plan was devised. The two treatment schemes were then compared. MRI resulted in a change in clinical management in 15 per cent of patients. Ten per cent of patients changed from requiring a brace to no brace and merely observation alone. In no patient planned for nonoperative care was surgery deemed necessary after completion of MRI. Among five patients with initial plans for operative intervention, two avoided surgery after the MRI. MRI has little impact on the management of patients with CT-proven thoracic and lumbar spine fractures. Only when surgery is planned based on CT studies does an MRI seem to assist with determining optimal care.

Role of multidetector computed tomography in the assessment of pancreatic injuries after blunt trauma: a multicenter experience

Pancreatic injuries can occur from either penetrating or blunt abdominal trauma. While there are rare, especially in the setting of blunt abdominal trauma, they are associated with a mortality of up to 30%, and a morbidity of 60%. Multidetector computed tomography (MDCT) is the preferred imaging modality in patients with acute blunt abdominal trauma and for the detection of acute pancreatic injury. Magnetic resonance (MR) and magnetic resonance cholangiopancreatography (MRCP) plays an important role in the follow-up of pancreatic injury. In this brief review, we discuss the main MDCT acute imaging findings as well as the complications. Finally, we discuss the role of MR and MRCP in follow up of patients with pancreatic injuries.

Non-Operative Management of Blunt Liver Trauma: Safety, Efficacy and Complications of a Standardized Treatment Protocol

Objective:

To evaluate the safety and effectiveness of NOM (non-operative management) in the treatment of blunt liver trauma, following a standardized treatment protocol.

Methods:

All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS.

Results:

181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results.

Conclusion:

Non-operative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Overuse of computed tomography for minor head injury in young patients: an analysis of promoting factors

AIM

To assess the amount of computed tomography (CT) scans for minor head injury (MHI) performed in young patients in our emergency department (ED), not indicated by National Institute for Health and Clinical Excellence (NICE) and Canadian Computed Tomography Head Rules (CCHR), and to analyze factors contributing to unnecessary examinations. Secondary objectives were to calculate the effective dose, to establish the number of positive CT and to analyze which of the risk factors are correlated with positivity at CT; finally, to calculate sensitivity and specificity of NICE and CCHR in our population.

MATERIALS AND METHODS

We retrospectively evaluated 493 CT scans of patients aged 18-45 years, collecting the following parameters from ED medical records: patient demographics, risk factors indicating the need of brain imaging, trauma mechanism, specialty and seniority of the referring physician. For each CT, the effective dose and the negativity/positivity were assessed.

RESULTS

357/493 (72%) and 347/493 (70%) examinations were not in line with the CCHR and NICE guidelines, respectively. No statistically significant difference between physician specialty (p = 0.29 for CCHR; p = 0.24 for NICE), nor between physician seniority and the amount of inappropriate examinations (p = 0.93 for CCHR, p = 0.97 for NICE) was found but CT scans requested by ED physicians were less inappropriate [p = 0.28, odds ratio (OR) 0.562, CI (95%) 0.336-0.939]. There was no statistically significant correlation between patient age and over-referral (p = 0.74 for NICE, p = 0.93 for CCHR). According to NICE, low speed motor vehicle accident (p = 0.009), motor vehicle accident with high energy impact (p < 0.01) and domestic injuries (p = 0.002) were associated with a higher rate of unwarranted CT; according to CCHR only motor vehicle accident with high energy impact showed a significant correlation with unwarranted CT scan (p < 0.001, OR 44.650, CI 33.123-1469.854). 2% of CT was positive. Multivariate analysis demonstrated that factors significantly associated with CT scan positivity included signs of suspected skull fracture (p < 0.001, OR 20.430, CI 2.727-153.052) and motor vehicle accident with high energy impact (p < 0.001, OR 220.650, CI 33.123-1469.854). In our series, CCHR showed sensitivity of 100%, specificity of 74%; NICE showed sensitivity of 100%, specificity of 72%.

CONCLUSION

We observed an important overuse of head CT scans in MHI; the main promoting factor for inappropriate was injury mechanism. 2% of head CT were positive, correlating with signs of suspected skull fracture and motor vehicle accident with high energy impact.

Imaging Patterns of Injuries After the 2015 Amtrak Philadelphia Train Derailment

OBJECTIVE

The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment.

CONCLUSION

Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures. (www.actabiomedica.it)

A new low-dose multi-phase trauma CT protocol and its impact on diagnostic assessment and radiation dose in multi-trauma patients

Purpose

Computed tomography (CT) examinations, often using high-radiation dosages, are increasingly used in the acute management of polytrauma patients. This study compares a low-dose polytrauma multi-phase whole-body CT (WBCT) protocol on a latest generation of 16-cm detector 258-slice multi-detector CT (MDCT) scanner with advanced dose reduction techniques to a single-phase polytrauma WBCT protocol on a 64-slice MDCT scanner.

Methods

Between March and September 2015, 109 polytrauma patients (group A) underwent acute WBCT with a low-dose multi-phase WBCT protocol on a 258-slice MDCT whereas 110 polytrauma patients (group B) underwent single-phase trauma CT on a 64-slice MDCT. The diagnostic accuracy to trauma-related injuries, radiation dose, quantitative and semiquantitative image quality parameters, subjective image quality scorings, and workflow time parameters were compared.

Results

In group A, statistically significantly more arterial injuries (p = 0.04) and arterial dissections (p = 0.002) were detected. In group A, the mean (±SD) dose length product value was 1681 ± 183 mGy*cm and markedly lower when compared to group B (p < 0.001). The SDs of the mean Houndsfield unit values of the brain, liver, and abdominal aorta were lower in group A (p < 0.001). Mean signal-to-noise ratios (SNRs) for the brain, liver, and abdominal aorta were significantly higher in group A (p < 0.001). Group A had significantly higher image quality scores for all analyzed anatomical locations (p < 0.02). However, the mean time from patient registration until completion of examination was significantly longer for group A (p < 0.001).

Conclusions

The low-dose multi-phase CT protocol improves diagnostic accuracy and image quality at markedly reduced radiation. However, due to technical complexities and surplus electronic data provided by the newer low-dose technique, examination time increases, which reduces workflow in acute emergency situations.

Trauma whole-body MDCT: an assessment of image quality in conventional dual-phase and modified biphasic injection

OBJECTIVE

To compare the image quality of conventional arterial and portal venous (PV) phase multidetector CT (MDCT) with two biphasic injection protocols in polytrauma patients.

METHODS

60 consecutive patients with polytrauma underwent body 256-slice MDCT with a conventional protocol or 1 of 2 single-pass biphasic protocols: Group A, arterial (30 s) and PV (60 s) phase acquisitions; Group B, "biphasic" contrast injection with a single acquisition at 60 s; and Group C, "modified biphasic" injection with a single acquisition at a 70-s delay. Images were analyzed for arterial, venous and parenchymal attenuation profiles with regions of interest in the major arteries, veins and solid abdominal organs. A 5-point scoring system was used to assess the image quality, with 5 representing excellent arterial, venous and parenchymal opacification and <3 representing non-diagnostic opacification. In addition, the effective dose (millisieverts) was compared between the groups.

RESULTS

In 93% of patients, image quality was scored as good or excellent (≥4). All studies were of satisfactory diagnostic quality. Overall, venous and arterial attenuation profiles were comparable. Attenuation profiles in the solid abdominal viscera were significantly higher (p < 0.01) using both biphasic protocols than with arterial or PV phase of conventional protocols. Effective doses were higher in Group A.

CONCLUSION

Comparable image quality can be achieved using a biphasic i.v. contrast injection protocol with single MDCT acquisition with less radiation and reduction in acquisition time.

ADVANCES IN KNOWLEDGE

For these particular biphasic injection protocols, we have shown that image quality is comparable with a conventional protocol. This has been achieved by comparing enhanced densities of specific structures, as well as gestalt scoring by assessors, on a 256-slice MDCT.

Dual-phase CT for the assessment of acute vascular injuries in high-energy blunt trauma: the imaging findings and management implications

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

Errors in imaging patients in the emergency setting

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

Small Bowel Perforations: What the Radiologist Needs to Know

The incidence of small bowel perforation is low but can develop from a variety of causes including Crohn disease, ischemic or bacterial enteritis, diverticulitis, bowel obstruction, volvulus, intussusception, trauma, and ingested foreign bodies. In contrast to gastroduodenal perforation, the amount of extraluminal air in small bowel perforation is small or absent in most cases. This article will illustrate the main aspects of small bowel perforation, focusing on anatomical reasons of radiological findings and in the evaluation of the site of perforation using plain film, ultrasound, and multidetector computed tomography equipments. In particular, the authors highlight the anatomic key notes and the different direct and indirect imaging signs of small bowel perforation.