Ct findings in blunt renal trauma

Conservative management of grade 5 renal injury: Case report

Blunt trauma is a common cause of renal injuries, usually managed conservatively unless there's hemodynamic instability, which warrants surgery. We present a case of a 22-year-old male with isolated Grade 5 renal injury, diagnosed via CT scan after blunt trauma. Despite the severity, he was successfully treated without surgery through conservative management in the ICU, with frequent monitoring and stabilization of his condition. While the best approach for hemodynamically stable Grade 5 renal injuries remains debated, our case suggests that conservative management is a viable option when patients are carefully monitored for any signs of instability.

Imaging of renal emergencies: Review of infectious, hemorrhagic, vascular, and traumatic etiologies

Diagnostic imaging allows for accurate and early recognition of acute renal pathologies, thus allowing for appropriate clinical triage, life-saving treatments, and preservation of renal function. In this review, we discuss the clinical presentation and imaging findings of renal emergencies with infectious, hemorrhagic, vascular, and traumatic etiologies.

Occult Abdominal Trauma

Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.

Complications of renal interventions: a pictorial review of CT findings

A number of potential vascular and non-vascular complications can arise from surgical, extracorporeal shock wave lithotripsy, radiotherapy and radiological renal interventions, including percutaneous image-guided biopsy and drainage. Computed tomography scan is usually one of the first and most important diagnostic imaging examinations requested when a potential complication is suspected. There are a wide range of common and uncommon potential complications from renal interventions. An understanding of underlying risk factors is important to reduce potential complications from renal intervention. Radiologists play a crucial role in recognising and diagnosing post-renal intervention complications on computed tomography scans, which could significantly improve the patient’s prognosis.

Computed tomography imaging of resuscitative endovascular balloon occlusion of the aorta (REBOA): pearls and pitfalls

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is performed in patients with hemorrhagic shock who develop massive subdiaphragmatic bleeding. This procedure enables rapid and less invasive aortic blockade compared to resuscitative thoracotomy and aortic cross-clamp procedures. However, the REBOA procedure is often blindly performed in the emergency department without fluoroscopy, and the appropriateness of the procedure may be evaluated on computed tomography (CT) after REBOA. Therefore, radiologists should be familiar with the imaging features of REBOA. We present a pictorial review of the radiological findings of REBOA along with a description of the procedure, its complications, and pitfalls.

Name That Nephrogram: Asymmetric Renal Enhancement in the Acute Care Setting

Disorders of the kidney and urinary collecting system are common encountered in the acute care setting. Computed tomography has progressively replaced intravenous pyelography for the evaluation of most urinary tract pathology including acute flank pain, suspected malignancy, congenital abnormalities, anatomical variants, and inflammatory/vascular conditions through evaluation of the "nephrogram" produced by intravenous contrast material filtering through the kidneys. In this review, we describe the most common types of abnormal nephrograms seen on renal computed tomography, and highlight the salient features and conditions associated with them, in addition to a pictorial review with specific and interesting related cases. The types of abnormal nephrograms reviewed are absent, unilateral delayed, striated, spotted, and persistent.

CT Imaging of Emergent Renal Conditions

The kidneys are paired intra-abdominal organs which provide essential functions and maintain homeostasis throughout the human body. Numerous disease processes affect the kidneys and cause acute renal dysfunction or other potentially catastrophic complications. These conditions can be broadly categorized into obstructive, infectious, hemorrhagic, traumatic, and vascular diseases. Imaging plays a vital role in the work-up and diagnosis of acute and emergent renal conditions. Evaluation of emergent renal conditions with a focus on CT imaging is discussed.

CT imaging spectrum of infiltrative renal diseases

Most renal lesions replace the renal parenchyma as a focal space-occupying mass with borders distinguishing the mass from normal parenchyma. However, some renal lesions exhibit interstitial infiltration-a process that permeates the renal parenchyma by using the normal renal architecture for growth. These infiltrative lesions frequently show nonspecific patterns that lead to little or no contour deformity and have ill-defined borders on CT, making detection and diagnosis challenging. The purpose of this pictorial essay is to describe the CT imaging findings of various conditions that may manifest as infiltrative renal lesions.

Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system

PURPOSE

An accelerated clinical care pathway for solid organ abdominal injuries was implemented at a level one pediatric trauma center. The impact on resource utilization and demonstration of protocol safety was assessed.

METHODS

Data were collected retrospectively on patients admitted with blunt abdominal solid organ injuries from 2012 to 2015. Patients were subdivided into pre- and post-protocol groups. Length of hospital stay (LOS) and failure of non-operative treatment were the primary outcomes of interest.

RESULTS

138 patients with solid organ injury were studied: 73 pre- (2012-2014) and 65 post-protocol (2014-2015). There were no significant differences in age, gender, injury severity score (ISS), injury grade, or mechanism (p>0.05). LOS was shorter post-protocol (mean 5.6 vs. 3.4days; median 5 .0 vs. 3.0days; p=0.0002), resulting in average savings of $5966 per patient. Patients in the protocol group mobilized faster (p<0.0001) and experienced fewer blood draws (p=0.02). On multivariate analysis, protocol group (p<0.001) and ISS (p<0.001) were independently associated with LOS. There were no differences between groups in the need for operation, embolization, or transfusion.

CONCLUSION

An accelerated care pathway is safe and effective in the management of pediatric solid organ injuries with early mobilization, less blood draws, and decreased LOS without significant morbidity and mortality.

LEVEL OF EVIDENCE

Therapeutic, cost effectiveness, level III.

Renal Artery Injury Secondary to Blunt Abdominal Trauma - Two Case Reports

BACKGROUND

Blunt abdominal trauma is routinely encountered in the Emergency Department. It is one of the main causes of morbidity and mortality amongst the population below the age of 35 years worldwide. Renal artery injury secondary to blunt abdominal trauma however, is a rare occurrence. Here, we present two such cases, encountered in the emergency department sustaining polytrauma following motor vehicle accidents.

CASE REPORT

We hereby report two interesting cases of renal artery injury sustained in polytrauma patients. In these two cases we revealed almost the entire spectrum of findings that one would expect in renal arterial injuries.

CONCLUSIONS

Traumatic renal artery occlusion is a rare occurrence with devastating consequences if missed on imaging. Emergency radiologists need to be aware of the CT findings so as to accurately identify renal artery injury. This case report stresses the need for immediate CT assessment of polytrauma patients with suspected renal injury, leading to timely diagnosis and urgent surgical or endovascular intervention.

Renal trauma: imaging evaluation and implications for clinical management

Severe renal injuries are usually associated with multisystem injuries, may require interventional radiology to control hemorrhage and improve the chances for renal salvage, and are more likely to fail nonoperative management. However, most renal injuries are mild in severity and successfully managed conservatively. The AAST classification is the most widely used system to describe renal injuries and carries management and prognostic implications. CT with intravenous contrast is the imaging test of choice to assess for renal injuries. Contrast extravasation indicating active bleeding should be mentioned as its presence is predictive for failure of nonoperative management. Radiologists play a critical role in identifying renal injuries and should make every effort to describe renal injuries according to the AAST grading scheme to better inform the surgeon's management decisions.

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.

Imaging of Urinary System Trauma

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

MDCT of blunt renal trauma: imaging findings and therapeutic implications

Objectives

To show the wide spectrum of computed tomography (CT) findings in blunt renal trauma and to correlate them with consequent therapeutic implications.

Methods

This article is the result of a literature review and our personal experience in a level II trauma centre. Here we describe, discuss and illustrate the possible CT findings in blunt renal trauma, and we correlate them with the American Association for the Surgery of Trauma (AAST) classification and their therapeutic implications.

Results

CT findings following blunt renal trauma can be grouped into 15 main categories, 12 of them directly correlated with the AAST classification and 3 of them not mentioned in it. Non-operative management, which includes the “watchful waiting” approach, endourological treatments and endovascular treatments, is nowadays widely adopted in blunt renal trauma, and surgery is limited to haemodynamically unstable patients and a minority of haemodynamically stable patients.

Conclusions

The interpretation of CT findings in blunt renal trauma may be improved and made faster by the knowledge of their therapeutic consequences.

Teaching Points

• The majority of blunt renal injuries do not require surgical treatment.

• CT findings in blunt renal injury must be evaluated considering their therapeutic consequences.

• Some CT findings in blunt renal trauma are not included in the AAST classification.

Intra-abdominal Solid Organ Injuries: An Enhanced Management Algorithm

The organ injury scale grading system proposed by the American Association for the Surgery of Trauma provides guidelines for operative versus nonoperative management in solid organ injuries; however, major shortcomings of the American Association for the Surgery of Trauma injury scale may become apparent with low-grade injuries, in which conservative management may fail. Nonoperative management of common intra-abdominal solid organ injuries relies increasingly on computed tomographic findings and other clinical factors, including patient age, presence of concurrent injuries, and serial clinical assessments. Familiarity with characteristic imaging features is essential for the prompt diagnosis and appropriate treatment of blunt abdominal trauma. In this pictorial essay, the spectrum of the American Association for the Surgery of Trauma organ injury scale grading system is illustrated, and a multidisciplinary management algorithm for common intra-abdominal solid organ injuries is proposed.

MDCT of renal trauma: correlation to AAST organ injury scale

Renal injuries affect 8-10% of patients presenting with blunt abdominal trauma. Imaging with multidetector computed tomography (MDCT) is the preferred modality at most trauma centers. Renal injuries have been categorized by several grading schemes in the literature. The classification proposed by the American Association for the Surgery of Trauma (AAST) predicts clinical outcome with reasonable accuracy. Although the AAST classification for renal injury is primarily based on findings during surgery, it has a strong correlation with MDCT findings.

Severe spasm of the renal artery after blunt abdominal trauma simulating end-organ infarction

Traumatic occlusion of the renal artery is a serious injury. Management differs according to the grade of injury. In most circumstances, emergency surgical revascularization or endovascular intervention is required. We describe the case of a child with multiorgan injuries and spasm of the main renal artery after blunt trauma simulating arterial occlusion or end-organ infarction.

Conservative management of a grade V injury to an ectopic pelvic kidney following blunt trauma to the lower abdomen: a case report

Introduction

Ectopic pelvic kidneys represent an anatomic variant that remains clinically asymptomatic in most patients. While there is some literature to suggest that ectopic kidneys may be more predisposed to blunt trauma injuries, there are few examples to guide the management of these injuries. To our knowledge, we present the first case of a grade V renal injury to an ectopic pelvic kidney managed successfully with conservative measures.

Case Presentation

We present a case of grade V renal injury to an ectopic pelvic kidney in a 21 year-old African-American male. The clinical and radiographic findings are presented, along with the patient's conservative hospital course.

Conclusion

We suggest that management of grade V renal injuries to ectopic pelvic kidneys can be treated similarly to that of kidneys in normal anatomic position. Conservative measures may be considered in properly selected patients.

Multidetector computed tomography in the diagnosis and management of renal trauma

Renal injuries fall within the broad and complex subject of retroperitoneal trauma. Although their computed tomography (CT) features have been known for a while, the timing, diagnostic approach and management are still debated. In addition, some areas of uncertainty remain regarding timing, indications and imaging modalities to be used in the follow-up of these patients. The purpose of this paper is to review the impact of CT on the management of renal trauma, stressing the importance of this technique and the role of the radiologist in the timing of decisions. Finally, we discuss the diagnostic approach to the follow-up of renal trauma.

Imaging children with abdominal trauma

OBJECTIVE

Trauma is a leading cause of morbidity and mortality in children. The abdomen is the second most common site of injury. This article discusses abdominal trauma in children.

CONCLUSION

The clinical evaluation of children with potential blunt abdominal injury presents a challenging task. Therefore, imaging plays an essential role in the evaluation of such children.

[Thoracic and abdominal trauma in children]

Knowledge of the characteristics of thoraco-abdominal trauma in children is important to optimize the imaging work up while keeping radiation exposure to a minimum. Because of the plasticity of the pediatric rib cage, rib fractures are infrequent, and severe parenchymal injuries may be present in the absence of rib fracture. Mediastinal injuries are unusual. The increased mobility of solid intraabdominal organs combined with a weaker abdominal wall are specific to pediatric patients. First-line imaging typically includes chest radiograph and abdominal US with Doppler imaging. Contrast-material enhanced CT is used as a second-line technique, with delayed imaging in patients with urinary tract lesions. Dedicated pediatric acquisition protocols are mandatory. Follow-up is obtained mainly with US.

CT imaging of mass-like renal lesions in children

Mass-like renal lesions in children occur in a diverse spectrum of conditions including benign and malignant neoplasm, infection, infarction, lymphatic malformation, and traumatic injury. Although mass-like renal lesions can sometimes be suspected on plain radiographs and evaluated with US in children, subsequent CT is usually performed for the confirmation of diagnosis and further characterization. The purpose of this pictorial essay was to review the CT imaging findings of both common and uncommon mass-like renal lesions in pediatric patients. Understanding the characteristic CT appearance of mass-like renal lesions in children enables an accurate diagnosis and optimizes patient management.

Multidetector computed tomography of the renal arteries in vascular emergencies

Multidetector computed tomography (MDCT) has drastically changed the diagnostic imaging protocol in both traumatic and non-traumatic vascular emergencies, replacing almost completely the traditional primary role of catheter angiography. MDCT is a well-established tool for the elective evaluation of stenoses, malformations, and dysplasias in the settings of renovascular hypertension, but probably less used in the settings of acute traumatic and non-traumatic clinical situations. The aim of this review is to define the role of MDCT in renal arteries emergencies.

Multislice computed tomography in blunt abdominal trauma

Blunt abdominal trauma is a frequent finding in patients with multiple trauma, and is associated with significant morbidity and mortality. Multislice computed tomography (MSCT), allowing for multiplanar reconstructions and three-dimensional images, has become the imaging modality of choice for these patients. MSCT is indicated in all haemodynamically stable patients with suspected blunt abdominal trauma. A `focussed CT' algorithm, as recommended by the Advanced Trauma Life Support (ATLS®) program, may be useful for patients with isolated abdominal trauma who are conscious and cooperative. For unconscious patients with or without multiple trauma `unfocussed' whole-body MSCT algorithms should be used, as these lead to earlier as well as more accurate diagnosis. MSCT allows for rapid diagnosis of abdominal and retroperitoneal injuries and for grading of solid organ injuries. Active haemorrhage may be detected with accuracy similar to angiography. Even bowel, diaphragmatic and bladder injuries, where CT used to miss a significant number of injuries, can be diagnosed with high accuracy by the new generation of MSCT scanners.

Second-generation sonographic contrast agents in the evaluation of renal trauma

PURPOSE

The purpose of this study was to define the indications, diagnostic accuracy and limitations of second-generation sonographic contrast agents in the evaluation of patients with renal trauma.

MATERIALS AND METHODS

Between March 2004 and April 2005, 277 patients with blunt abdominal trauma were evaluated. Twenty-eight out of 277 patients had renal lesions, the severity of which was graded according to the organ injury severity scale of the American Association for the Surgery of Trauma (AAST). All the patients enrolled in the study had minor trauma and were evaluated with baseline ultrasound (US), contrast-enhanced US after injection of a second-generation contrast agent (SonoVue) and, if positive, with multiphasic multidetector computed tomography (MDCT).

RESULTS

Five out of 28 traumatic parenchymal lesions with perirenal fluid collection were identified at baseline US. All 28 renal parenchymal lesions, with or without perirenal or retroperitoneal haematoma, were identified at contrast-enhanced US. Multiphase MDCT confirmed all the cases that were positive at contrast-enhanced US and demonstrated the integrity of the urinary tract in the delayed phase.

CONCLUSIONS

Our experience confirmed the diagnostic accuracy of second-generation sonographic contrast material both for diagnosis and for appropriate patient management. In particular, contrast-enhanced sonography proved to be a reliable technique for the evaluation and follow-up of low-grade renal injuries. Its main advantage is reduced radiation exposure, as fewer MDCT examinations are needed, whereas its limitation is the high cost of the technique if used in unselected patients.

[Traumatic rupture of a horseshoe kidney]

One-third to one-half of all patients with horseshoe kidney are asymptomatic and the condition is found incidentally. This congenital renal anomaly has shown as a predisponent condition for renal injury in blunt abdominal trauma, but often the degree of injury has a nonoperative therapy. Horseshoe kidney rupture is an exceptional pathology that require a complete diagnostic study to make an adequate management when surgical therapy is indicated. We present a fifteen-year-old male with previously unsuspected horseshoe kidney that suffered an atypical right upper-pole and mesorrenal kidney rupture after low-velocity-impact blunt abdominal trauma. A correct presurgical diagnose let a deferred surgical approach with right lower pole and horseshoe renal isthmus preservation. The trauma conditions, an excesive clinic manifestation, a clinical investigation about known congenital simultaneous anomallies and typical radiological signs, can suggest this infrequent patology. Computed tomography provides the best radiological information.

MDCT Findings of Renal Trauma

OBJECTIVE

The purposes of this pictorial essay are to show MDCT findings of renal trauma and describe the indications and protocol for MDCT.

CONCLUSION

CT is indicated when patients have gross hematuria, hypotension, lumbar spinal injury, and fractures of lower ribs or the transverse process. The CT examination must be designed specifically for urinary tract evaluation, and MDCT is especially useful for this purpose. Injury to the kidney is graded I to V according to degree of laceration and amount of hematoma.

Maximizing clinical information obtained by CT

CT scanning is an integral part of the urologist's practice today. It is the most commonly used imaging modality and the one with which urologists are most familiar. CT urography, CT angiography, and 3D reconstruction enable the urologist to perform comprehensive evaluations of patients who have different urologic diseases, using a single imaging modality. It is thus prudent that urologists become familiar with CT applications, to maximize the clinical information available from them.

Multidetector CT of the kidney

The technological development of multidetector CT offers new possibilities for better imaging of organic structures that can be used in diagnosis of the kidney. The thinner slices allow a better spatial resolution, and slice fusion allows improved contrast resolution. The isotropic voxel has been realized in the latest 64-channel scanners. The image quality of arbitrarily reconstructed planes has arrived at the image quality of the scan plane. Faster scanning allows studies in different contrast phases, which is helpful for better discrimination of benign or malignant lesions especially in the highly vascularized kidney. Different phases of contrast uptake can be differentiated (arterial, cortico-medullary, nephrographic, and excretory phase). Multidetector CT brings along the risk of increased dose due to thinner slice collimation and overranging phenomena. Indications for CT investigation of the kidney include urolithiasis, tumor diagnosis and staging, renal trauma, and vascular disease. Even in children, special indications for CT of the kidney remain in polytrauma and tumor staging. Multidetector CT of the kidney has become a very valuable tool in urology, but a careful protocol strategy is mandatory.

[Kidney trauma in children: state of the art medical imaging]

Traumatic renal lesions have some particularities in the pediatric age group, especially for anatomic reasons. Imaging is very important for diagnosis and staging. Ultrasonography with Doppler is the first line examination performed in children and frequently allows initial diagnosis. From the Doppler-ultrasonographic results and the type of trauma, renal Computed Tomography (CT) is complementary performed. The association of these imaging techniques allows comprehensive work-up of traumatic renal lesions, and also of associated or pre-existing lesions. Conservative management is the rule in most cases. Interventional imaging techniques are sometimes used for therapeutic care of renal pedicular vascular lesions or lesions of the collecting system. Far from the traumatic event, imaging allows to follow up the morphologic and functional evolution of major renal lesions, in particular lesions of excretory renal ducts.

Blunt Abdominal Trauma:Does the Use of a Second-Generation Sonographic Contrast Agent Help to Detect Solid Organ Injuries?

OBJECTIVE

The objective of our study was to prospectively evaluate whether a second-generation sonography contrast agent (SonoVue) can improve the conspicuity of solid organ injuries (liver; spleen; or kidney, including adrenal glands) in patients with blunt abdominal trauma.

SUBJECTS AND METHODS

Two hundred ten consecutive hemodynamically stable trauma patients underwent both abdominal sonography and CT at admission. The presence of solid organ injuries and the quality of sonography examinations were recorded. Patients with false-negative sonography findings for solid organ injuries in comparison with CT results underwent control sonography. If a solid organ injury was still undetectable, contrast-enhanced sonography was performed. Findings of admission, control, and contrast-enhanced sonograms were compared with CT results for their ability to depict solid organ injuries. Contrast-enhanced sonography was also performed in patients in whom a vascular injury (pseudoaneurysm) was shown on admission or control CT.

RESULTS

CT findings were positive for 88 solid organ injuries in 71 (34%) of the 210 patients. Admission, control, and contrast-enhanced sonograms had a detection rate for solid organ injury of 40% (35/88), 57% (50/88), and 80% (70/88), respectively. The improvement in the detection rate between control and contrast-enhanced sonography was statistically significant (p = 0.001). After exclusion of low-quality examinations, contrast-enhanced sonography still missed 18% of solid organ injuries. Five vascular liver (n = 1) and spleen (n = 4) injuries (pseudoaneurysms) were detected on CT; all were visible on contrast-enhanced sonography.

CONCLUSION

Contrast-enhanced sonography misses a large percentage of solid organ injuries and cannot be recommended to replace CT in the triage of hemodynamically stable trauma patients. However, contrast-enhanced sonography could play a role in the detection of pseudoaneurysms.

Renal trauma in Australian Rules Football: an institutional experience

BACKGROUND

Australian rules football is the most popular team sport in Australia. Literature on severe abdominal injuries in this sport is limited. The present study aims to review cases of renal trauma in Australian football at our institution.

METHODS

A retrospective study was performed. All men admitted to our institution with renal trauma or haematuria associated with Australian football from July 1995 to July 2001 were analysed.

RESULTS

There were 13 cases of renal trauma; two were grade V injuries requiring nephrectomy.

CONCLUSION

Renal injury will be intermittently encountered owing to the popularity of Australian football. Renal injuries are often difficult to assess and early recognition, management and referral to a district hospital is crucial.