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Hello and welcome to Noon Conference, hosted by modality

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Today we are honored to welcome Dr. Benjamin Strong

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for a lecture entitled Thoracic

0:28

and Aortic Trauma CT Dr. Strong completed residencies in

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both internal medicine and radiology

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and completed a fellowship in body M-S-K-M-R.

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He worked as an emergency physician for three years, private

0:43

and practice radiologist for two years,

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and academic radiologist for two years.

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He has worked in various capacities for virtual radiologic

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for the last 21 years

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and holds licenses to practice in all 50 US states.

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At the end of the lecture, please join Dr. Strong in a q

1:00

and a session where he will address questions you

1:02

may have on today's topic.

1:04

Please remember to use the q

1:05

and a feature to submit your questions so we can get to

1:07

as many as we can before our time's up.

1:10

With that said, we are ready to begin today's lecture.

1:12

Dr. Strong, please take it from here.

1:15

Sorry folks. I'm on a laptop today in a hotel room,

1:19

but nothing could stop me from lecturing for modality.

1:23

Uh, it's funny, Ben, uh, read my introduction

1:26

and, uh, when virtual radiologic was acquired many years

1:30

ago, we've been through several of those.

1:32

Uh, we actually got trophies that's a commonplace occurrence

1:38

and it said virtual radiology on it, so they had,

1:41

uh, misspelled our name.

1:43

So it is confusing and he is to be forgiven.

1:47

Alright folks, well, uh, thank you Ben for reading my bio

1:50

and so we can move right on.

1:54

We're doing, uh, thoracic and aortic trauma today.

1:58

This is one of my favorite lectures.

2:01

And so there is something funny about trauma in that,

2:05

uh, the various elements, reporting, accuracy, survival

2:10

of the patient, et cetera,

2:11

they can be definitive if in fact binary.

2:15

And so it lends trauma.

2:17

Lectures lend themselves very nicely to colonization

2:22

of certain of the elements of every case.

2:25

So if you look at the bottom here through every case,

2:28

you will see the following icons.

2:31

The first will be the mechanism of injury.

2:34

Frequently that's going to be a motor vehicle accident

2:38

and that will be denoted by uh, this green triangle.

2:42

So that's the mechanism of injury.

2:44

The second number is the expected mortality for

2:48

that particular injury.

2:51

The third icon will be whether the patient lived or died.

2:55

So there will either be a heart for surviving patients

2:59

and there will be a skull for patients that have

3:02

that did not survive.

3:04

And then lastly, there is either a red X

3:07

or a green check mark for whether

3:10

or not the radiologist reading that study

3:13

accurately reported the findings.

3:15

So watch what those icons.

3:17

If uh, if you question at any point, how did this happen?

3:21

What's the expected mortality, did the patient live or die

3:24

and was it accurately reported?

3:27

So those will be present at the bottom

3:29

for every one of these cases.

3:32

Alright, this first one is one of my favorites.

3:36

Uh, this is an aortic laceration at the classic location

3:39

of the aortic SMUs.

3:42

That's where about 90% of

3:46

aortic lacerations will occur from blunt trauma.

3:49

And of course it's because of the tethering effect

3:52

of the ligament to arterio, uh, right at that spot

3:56

where the posterior aortic arch meets the thoracic

4:00

descending aorta.

4:02

So you can see right here there is an irregularity there.

4:07

VAD has its own teaching file

4:10

where radiologists can submit cases

4:13

and this one happened to be submitted to the teaching file

4:18

and I went into it a kind of out of cycle

4:21

and uh, thought I had an extra hour.

4:24

So I looked at the top case and it was there.

4:27

It was misread as a ductus diverticulum

4:31

with a splenic laceration.

4:33

So here is the aorta.

4:35

You can see that irregularity bothered me right away.

4:38

And there is a faint hint of fluid density

4:42

surrounding that aorta.

4:44

It's not very much. And at the time when I originally read

4:46

this study, I remember going back

4:48

and forth on it, is there any stranding there or not?

4:52

Usually with aortic lacerations,

4:54

there will be a more significant amount of mediastinal

4:57

or peri aortic fluid.

4:59

So this one didn't have much,

5:01

but the irregularity of

5:03

that aortic contour really bothered me.

5:06

So then I went down to the spleen

5:08

and found the definitive finding.

5:12

These are very important.

5:14

These wedge-shaped, uh, subcapsular hypodensities

5:18

that you will see usually either in the spleen

5:22

or the kidneys.

5:23

And that is a sign of an upstream vascular laceration.

5:29

So in this case, they're in the spleen

5:31

and it's an indication to you

5:33

to look very closely at the splenic artery

5:37

or the upstream aorta.

5:39

So that seals the deal.

5:41

That is the effect of a micro embolic shower

5:45

that has come from thrombus forming on that

5:49

laceration of the aorta.

5:51

So these are very important findings

5:54

and I don't want you to blow them off

5:56

or say non-specific hypodensities.

5:58

These are very characteristic wedge-shaped subcapsular

6:03

hypodensities that mean an embolic shower has happened

6:06

and in the setting of trauma,

6:07

that means an upstream vessel laceration.

6:12

All right, so on the sagittal it was quite more apparent.

6:17

You can see an intimal flap right there and anterior to it.

6:22

You can see a small pseudo aneurysm.

6:25

Now that pseudo aneurysm does not look like a

6:28

ductus diverticulum.

6:29

Okay? Pseudo aneurysms resulting from aortic lacerations are

6:33

ever so slightly farther back

6:36

on the aortic arch than a ductus diverticulum would be.

6:40

They have a narrower base

6:43

and they are usually more vertically

6:46

oriented than a ductus diverticulum would be.

6:50

So that's a very important distinction.

6:53

Remember a ductus diverticulum is residual from the

6:57

uh, ductus arteriosis

6:59

and that comes from the underside of the aortic arch

7:02

to the base of the left pulmonary artery right here.

7:06

So a ductus diverticulum will typically be a little more

7:10

anterior and a little more transversely oriented.

7:15

So fortunately this patient did survive.

7:17

I got on the phone and they said, well you, your report said

7:21

that there was a splenic laceration.

7:23

So we kept this patient lying flat all night

7:25

and we were getting ready to get her up and walk her around.

7:29

So fortunately I was able to intervene

7:33

and they kept her flat for yet another week.

7:37

So there is a beautiful example, irregularity of the aorta

7:42

and then those telltale splenic hypodensities.

7:46

And here it is on the sagittal again,

7:49

narrow base vertical orientation,

7:52

slightly farther back on the a aortic arch

7:56

than a ductus diverticulum would be.

7:58

And I've even got a companion case here of A PDA

8:03

and you can see it's just broader based, more transversely

8:07

oriented and ever

8:09

so slightly more anterior on the underside of the aortic arch.

8:13

Look at that little jet that you can see

8:15

of aortic flow entering the base of the left pa.

8:24

Alright? And there again is our aortic

8:26

laceration and sagittal.

8:28

So this patient had a follow up a week later.

8:32

Many times at these small lacerations, uh,

8:35

discretion is the better part of valor

8:38

and they will hesitate to intervene.

8:40

And fortunately for this patient, that was the case here.

8:44

So one week later you can see

8:45

that pseudo aneurysm has really smoothed out.

8:49

And not surprisingly this is very common.

8:53

The splenic hypodensities have resolved completely.

8:57

Usually your thrombolytic system will whip these

9:00

small emboli out.

9:01

And so those subcapsular wedge-shaped hypodensities are

9:05

really just a transient phenomenon.

9:08

So one week later, her spleen looks perfectly normal

9:11

and there is that pseudo aneurysm on the sagittal.

9:17

So this patient survived uneventfully.

9:24

All right, this is an aortic transection

9:27

and these have a slightly different appearance.

9:30

You can see there is a great deal of mediastinal fluid here.

9:33

That pre vascular space is far too dirty.

9:36

That should be perfectly clean, mediastinal fat.

9:40

So tune yourself to spot that

9:42

because it's a clear indication there's been a great vessel

9:44

injury and you are uh, not done looking right

9:48

and there is the irregularity of the aortic arch.

9:52

Now with transects it will often look

9:56

as though you've got two regions of irregularity

9:59

because a transection is a complete laceration

10:03

through the entirety of the aorta.

10:05

And what will typically happen is the two torn ends will

10:08

pull apart and you'll have an intervening segment of

10:13

larger caliber that is bound by the vessel adventitia.

10:17

So this is the proximal torn portion of this aorta.

10:23

Here is that intervening larger segment that's just bound

10:27

by adventitia and is technically a pseudo aneurysm.

10:32

And here is the distal torn portion of the aorta.

10:38

Now there are other things to show you on this case.

10:40

This one's kind of a bogo, a buy one get one.

10:44

Uh, there is marked asymmetry of the nephros.

10:48

In fact, there is an absent right Nephro Graham,

10:52

but there is some contrast opacification centrally.

10:55

And I want you to fix this in your mind.

10:58

That is the appearance of retrograde venous opacification.

11:04

So when you see an absent nephro

11:08

and venous opacification,

11:11

there are two differential possibilities.

11:13

One is you can have a renal artery avulsion

11:17

with backflow venous backflow due to power injection.

11:21

And in that case you'll see a contiguous column of

11:26

of IVC contrast.

11:29

And that's the case here.

11:31

The other differential possibility is you can have a renal

11:35

artery to renal vein arterial venous fistula

11:39

and that will do the same thing.

11:40

It will give you an absent nephro

11:42

with retrograde opacification of the venous system,

11:45

but in that case you will not see the contiguous column

11:49

of IVC contrast.

11:53

All right, so here is that aorta,

11:55

there's the proximal portion, the intervening segment

11:59

of pseudo aneurysm and the distal portion, right?

12:04

One tear, but two pieces, that's supra renal backflow.

12:08

And then there's the renal backflow.

12:10

And that's the lowest cut we got.

12:11

So we didn't actually get to see the uls renal artery,

12:16

but you know it's there because that renal nephro is absent.

12:24

We'll take one more look at that

12:26

and see that contiguous column goes all the way down the IVC

12:30

telling you for sure that that is uh,

12:33

retrograde opacification of the venous system.

12:37

Three Ds are not usually all that helpful

12:39

to the radiologists.

12:40

Sometimes they're helpful to demonstrate things

12:43

to clinicians, but the transection

12:46

of the aorta is definitely an exception to that.

12:48

This really makes it clear exactly what's happening there.

12:52

So you've got one tear through there, two torn ends

12:55

of the aorta and

12:56

that intervening pseudo aneurysm bulging out there.

13:02

This patient also had a T-spine,

13:04

so we've even got it in higher resolution here

13:08

and there again the proximal

13:10

and distal torn aspects of the aorta.

13:14

And here it is on the sagittal again,

13:16

really nice just like the 3D showing you

13:18

that intervening dilated pseudo aneurysm.

13:27

Alright, two other locations for blunt

13:30

traumatic aortic lacerations.

13:33

So those are uh, and about 90% are at the ssus.

13:37

So that's far and away the most common scenario.

13:41

But you can also have tears at the aortic root

13:45

and at the diaphragmatic hiatus, the two other locations

13:48

where the aorta tends to be anatomically pinned

13:52

and thus vulnerable to sheer forces.

13:55

So here is the aortic root laceration.

13:59

You can see that crescentic collection of contrast

14:03

extending out from the right anterior aspect

14:06

of the aortic root.

14:08

And there is a little mediastinal fluid density there

14:11

to call your eye to that finding.

14:14

So this patient is very interesting

14:16

because there are many additional findings markedly deformed

14:21

rib fractures causing total deformity

14:25

of the right anterior chest.

14:27

Look at the right anterior chest wall,

14:29

the flattening of the pectoralis.

14:31

You can see this would actually be visible

14:34

to the ER physician and in this case it was.

14:37

There's also consolidation of the right upper lobe

14:40

that you can even appreciate on soft tissue windows

14:43

and that of course is going

14:44

to be hemorrhage anytime you have a lung contusion

14:48

and see that kind of airspace density, it's going

14:51

to be due to hemorrhage.

14:53

But look at this, that hemorrhage can be a problem.

14:56

It can bubble up into the uh,

14:59

mainstem bronchus on the affected side

15:02

and you can see the fluid density there in the bronchus

15:05

intermedius right there.

15:07

And then lastly there is the tip

15:09

of an endotracheal tube sitting in the left

15:12

mainstem bronchus.

15:14

And I will uh, tell you stories of it.

15:17

We'll look at a blow up there.

15:20

I will tell you stories about my inadequacy as an ER doctor

15:24

and one of the things I did all the time is right

15:27

stem intubate people.

15:30

I'd get so excited seeing the tube get past the cords

15:33

and knowing I'm in that I would just wanna secure it

15:36

and seat that thing as deep as I could.

15:38

Uh, and you know, I figured what's the problem?

15:41

We get a follow up chest x-ray,

15:43

the left lung is already starting to uh, drop

15:47

and become atelectatic due to the jailing

15:49

of the left main stem.

15:51

And then I know exactly

15:53

how far I need to pull the tube back.

15:55

So I figured no one would be hurt.

15:57

Well that was actually stupid

15:59

and I have a case later that will show you exactly

16:01

what you can do to someone should you try

16:04

that approach to intubation.

16:06

So I used to like to call these in

16:08

and tease the emergency physician say, yeah,

16:12

that was my specialty main stem bronchus intubation.

16:15

And as the phone was ringing for me to call this in,

16:19

I realized wait a minute, that's in the left main stem.

16:24

That's very difficult to do. It does not happen by accident.

16:27

If you over intubate someone it goes down the right main

16:31

stem and bronchus intermedius.

16:33

So I realized at the last second

16:34

before the ER doctor picked up the phone

16:37

that this was intentional.

16:39

The ER doctor had seen the deformity

16:42

of the right chest wall.

16:43

He knew the right lung was probably severely injured.

16:46

He probably saw blood bubbling up from

16:50

the bronchus intermedius

16:52

and right mainstem while he intubated.

16:54

And so as a result he pushed the tube into the left maint

16:59

stem bronchus and that is the appropriate maneuver.

17:02

It jails, the right main stem keeps the blood

17:06

that's bubbling up from going over the Corina

17:09

and entering the uninjured left lung

17:11

and it protects that right lung,

17:13

that injured right lung from the barrow trauma

17:16

of positive pressure ventilation.

17:18

So it's a spectacular move.

17:21

And I asked the uh, physician how he managed to get

17:25

that tube into the left mainstem

17:28

and he was uh, very laconic.

17:30

He said, I torked it.

17:33

So pretty impressive, very quick thinking on the part

17:36

of the ER doctor

17:37

and ultimately resulted in this patient surviving a

17:41

very severe injury.

17:43

So look at those deformed rib fractures

17:47

and uh, we'll follow that tube

17:49

and there it goes into the left mainstem bronchus.

17:54

So brilliantly handled by this ER doctor,

17:57

I walked away from this

17:58

and thought to myself, I don't know if uh,

18:02

this patient would've survived if I had been the

18:06

guy on site.

18:08

So I was pretty impressed.

18:10

Alright, let's look at the other location

18:13

where you get blunt trauma aortic lacerations

18:16

and that's here at the diaphragmatic hiatus.

18:19

So this was sad because it was missed by the radiologist who

18:23

otherwise made some pretty impressive calls.

18:27

So you can see there is extra thoracic soft tissue gas

18:32

from a pneumothorax.

18:34

You can see a rib fracture that is displaced

18:38

and has probably injured the right liver lobe.

18:41

So there's an ill-defined hypo density there,

18:44

which could be a, a liver laceration or even contusion

18:49

or possibly a, probably a combination of both.

18:53

But also look at that displaced rib fracture.

18:55

You see how there is a very faint soft tissue density along

18:59

the posterior aspect of the right liver lobe

19:02

and that of course is the diaphragm.

19:04

And this displaced rib fracture is pining

19:08

and probably lacerating that hemi diaphragm.

19:11

So the radiologist reading this was somewhat distracted

19:15

by those findings and called them all uh, liver

19:18

contusion slash slash laceration

19:22

with a probable diaphragmatic laceration.

19:25

But his focus in that region made him miss this.

19:29

So look at that little crescentic collection

19:32

of contrast within the wall of the aorta.

19:35

And note also the retro curl per aortic fat is

19:41

stranded that's far too dirty just like the mediastinal fat,

19:45

that retro choral fat should be perfectly clean

19:49

and not have any of that uh, fluid density there.

19:53

So this patient was admitted for a chest tube

19:56

and observation for the liver and diaphragm laceration

20:01

and then unfortunately died of an aortic rupture

20:05

at 4:00 AM the next morning.

20:08

Note also the thickening of the aortic wall both above

20:12

and below that laceration.

20:16

Right? And that's a very common finding

20:18

with aortic lacerations.

20:20

You can see it again both above

20:21

and below the actual crescentic contrast collection.

20:26

And that usually is intramural hemorrhage extending up

20:30

and down from the point of the tear.

20:33

It can also be peri aortic fluid

20:36

and it's very difficult to tell the two apart.

20:39

So, uh, residents frequently ask me, is

20:42

that intramural hemorrhage or is that per aortic hemorrhage?

20:45

And my answer is usually yes, it's fine

20:50

to report them both ways.

20:51

There is wall thickening

20:53

that may represent intramural hemorrhage

20:55

or peri aortic hemorrhage.

20:59

Alright, this one is a chance fracture.

21:02

It's not a perfect chance fracture.

21:05

A perfect chance fracture is a vertebral compression

21:09

fracture with a transverse fracture line going out

21:12

through both pedicles.

21:14

So oftentimes you won't see it perfectly that way.

21:17

And in this case you've got one pedicle

21:20

that's clearly tilted.

21:21

And look at that. The vertebral compression fracture has

21:25

shot out a cortical fragment there

21:27

that is tickling the aorta.

21:30

And these chance fractures are very frequently associated

21:34

with visceral or vascular injury.

21:36

So when you see one of these,

21:38

you've gotta be particularly vigilant.

21:40

So on the opposite side you can see a classic transverse

21:44

fracture line going right out through the pedicle,

21:46

whereas on the earlier cut the pedicle is essentially

21:51

avulsed and rotated.

21:54

So here is the fracture on the soft tissue windows

21:59

and that's the perfect chance one on that far side.

22:04

And the near side has again sort of an avulsion

22:07

and rotation of the pedicle.

22:12

So here it is on soft tissue windows

22:15

and you can see that that cortical fragment

22:17

that was spit out anteriorly has actually

22:20

transected the aorta.

22:23

So this is another transection

22:25

where you can see the proximal

22:26

and distal aspects of the torn aorta

22:29

and they've pulled apart

22:30

and there is an intervening segment of pseudo aneurysm,

22:34

much like the earlier transection we saw

22:38

and look at that fragment sticking out.

22:43

So the patient, uh,

22:44

things don't always line up perfectly in traumas.

22:48

You never know what position the patient was actually in.

22:52

So I encourage people all the time

22:54

and looking at traumas, look at the vector,

22:56

especially penetrating trauma.

22:58

Look at the vector, track it, make sure

23:00

that you know which organs it would've passed through,

23:03

but don't wear blinders

23:05

and realize that the patient could have been in a different

23:08

position when injured.

23:10

And so you may find injuries that are off the path

23:13

of the vector and this is a nice example

23:16

where those don't quite line up,

23:18

but it's pretty clear what the cause of

23:20

that aortic laceration was.

23:23

So here it is on the axials

23:25

and you can see that little rim of contrast

23:27

outside the confines

23:29

of the abdominal aorta right there.

23:36

And another 3D, these are kind

23:38

of helpful in some fractures as well.

23:40

And this shows the chance fracture very nicely.

23:52

All right, and this patient had a follow-up two days later

23:56

you can see the fracture is of course still there,

23:59

but you can see nice paramagnetic artifact in the lumen

24:04

of the aorta, which shows

24:06

that they have treated this transection with a stent.

24:12

All right, some penetrating traumas.

24:15

And this is another uh, example of the point I made earlier

24:20

about following the vector of penetrating trauma

24:23

but not exclusively focusing on it.

24:27

So this one, I'll give you a spoiler alert, okay,

24:32

there is extra thoracic gas.

24:34

And look at that there is extravasation from the anterior

24:38

aspect of the aortic root.

24:41

So the reason that's a spoiler alert is it took me

24:44

some time to find it.

24:45

Look at this hemo pericardium.

24:47

So when I first looked at this case,

24:50

I said there is a massive hemo pericardium,

24:53

it's obviously causing tamponade

24:56

and compressing the ventricles.

24:58

You can see a lot of backflow down the IVC

25:01

and on the cine you'll note it's going out well into the

25:05

hepatic veins.

25:07

So it's clear there is a great vessel injury here.

25:12

So I went looking for it

25:15

and look at this, this patient was stabbed

25:17

with a screwdriver or an ice pick.

25:19

He did not see which,

25:22

but it clearly gave us this pneumo

25:26

but left this tract right through the left upper lobe

25:30

and it's pointing right at the pulmonary artery.

25:34

So when I saw that tract, I said, well it's going

25:36

to be a main pulmonary artery laceration.

25:39

And so I went to the city and went up

25:42

and down scrolling on this

25:44

and look at all the contrast in that pulmonary circulation.

25:48

It's causing all this spray.

25:50

And I was windowing it like crazy

25:53

and scrolling like crazy trying

25:54

to find the pulmonary artery laceration.

25:57

And then finally I took a breath and sat back

26:00

and said, oh my god,

26:02

there it is coming from the anterior aspect

26:06

of the aortic root completely out

26:10

of line from the vector of the penetrating trauma.

26:13

So again, this patient was probably in a different position,

26:16

it might even be not just anatomic position

26:19

but physiologic position.

26:21

He may have been stabbed in extreme end

26:26

systole where the heart has rocked up a little bit

26:29

and probably exposed the aortic arch to this stabbing wound.

26:36

So there again is the pneumo

26:37

and the tracked left by the screwdriver and or ice pick.

26:44

So this patient survived.

26:46

In fact they got him into surgery so quickly

26:49

that I remember reading his post-op follow-up chest x-ray,

26:54

uh, during the same shift.

26:56

So they got him in and out in the, in a matter

26:58

of just a few hours.

27:03

Alright, this is another penetrating trauma

27:06

and again we have a deceptive soft tissue tract

27:10

suggesting that the injury may be distant from

27:13

where it actually is.

27:15

So there is our soft tissue gas.

27:18

This came in with a, uh, clinical history of pellet gun.

27:24

So there is a little tract there in the pectoral muscle on

27:27

the left and that will,

27:29

on the cine you'll see go down into the patient's left

27:33

literally directing your eye away from the

27:37

actual site of injury.

27:39

I do like to point out on this one,

27:41

I was the QA reviewer on this, so I saw it the morning after

27:46

and as I opened the case

27:48

and started scrolling down, I noted this,

27:53

there's a little rim of fluid density surrounding the base

27:56

of the left common carotid

27:58

and I thought uhoh, something's going on in the mediastinum.

28:02

And sure enough there was look at all

28:04

that stranding in the pre vascular portion

28:06

of the mediastinum, a lot

28:08

of density up along the aortic arch

28:11

and extending out into the fat of the anterior mediastinum.

28:15

So there is no apparent injury to the anterior wall

28:19

of the aortic arch.

28:20

This was a BB gun.

28:23

Uh, and it made a very tiny

28:25

pinhole in the anterior aspect of the arch

28:29

and it is not recognizable,

28:31

but you can see a tiny intimal flap right here

28:36

on the posterior aspect of the arch.

28:39

And that looks for all the world like it might be an

28:42

artifact but it is not.

28:43

It is a tiny intimal flap and we know that

28:47

because ultimately we found the pellet

28:50

here in the patient's calf probably in a branch

28:53

of the posterior tibial artery.

28:56

So this is a bullet or at least BB embolism.

29:00

And actually when I called the facility

29:02

to follow up on this, I said, your tech is brilliant.

29:06

Thank god they got a whole body scout

29:09

that let us localize this bb.

29:12

We otherwise could never have put this all together.

29:16

And the radiologist on site said,

29:19

that's actually our standard protocol.

29:21

If there's any concern for foreign body,

29:23

we do a whole body lateral scout.

29:26

Great idea. Uh, so it apparently wasn't the genius

29:29

of the tech that led to that, but the genius of a protocol.

29:35

Alright, so we saw

29:37

that soft tissue tracted there in the left pectoral,

29:42

there it is apparently very misleading,

29:45

right going down into the left.

29:47

But then there's all that anterior mediastinal stranding,

29:51

that tiny intimal flap posteriorly

29:54

that tell you the real story.

29:56

And it was interesting the all those hilar calcifications

30:00

contributed to this being missed

30:03

because I believe the radiologist reading it thought

30:06

that those might be concealing the actual bb.

30:10

And so I think it bothered him less

30:13

that he couldn't identify a foreign body.

30:16

I also think calling this appellate gun

30:18

and not a BB gun was a little bit

30:20

of a distraction too, right?

30:22

When I first opened it, I wasn't looking for a metallic bb,

30:26

I was conceiving of a pellet maybe

30:29

of some different substance.

30:32

All right, so that is a case of BB embolism.

30:37

This is another bullet embolism.

30:39

This is the most common scenario in which I have seen

30:43

bullet embolism.

30:45

It's a shotgun wound to the axillary region.

30:49

When you get a shotgun wound to the axillary region,

30:53

you have all those small pellets clearly very amenable, uh,

30:58

both by number and size to entering the venous system.

31:03

Uh, and in fact when they're up here,

31:04

they're also aided by gravity.

31:07

So I would say over my career, the most common scenario

31:10

where I've seen bullet or BB

31:13

or shotgun pellet embolization has been this scenario.

31:17

So you can see all the shotgun pellets there.

31:21

And then here are two that have entered the venous system

31:24

and made their way to the right ventricle.

31:27

Now these are small

31:28

and they may be pumped out into the pulmonary arterial

31:31

circulation to be handled by nature's filter,

31:34

the pulmonary capillary bed.

31:36

Uh, or they may just stay there for life.

31:38

They will typically endothelial lies

31:41

and lie quiescent dormant forevermore.

31:45

Uh, unfortunately that was not the case with this patient

31:48

because this patient, as you can see below, did not survive.

31:53

So a couple additional findings in this patient

31:56

that suggest his uh,

31:58

that portend his coming de eyes

32:02

there is a very flat I-V-C-I-V-C

32:06

flattening can be challenging.

32:09

It's certainly dependent on patient positioning,

32:11

volume status, venous return, et cetera.

32:14

But when it's that thin as thin

32:16

or thinner as the renal veins entering it, uh, then it's,

32:21

it's pretty easy.

32:23

And the other finding I like here is the shock bowel.

32:27

This is what's known as fishbone bowel.

32:30

That is the typical appearance of under perfused bowel.

32:34

The hypodensity of the wall gives you a stark contrast

32:38

to the persistent mucosal enhancement

32:42

and it looks like a fishbone.

32:44

So those two findings suggest

32:45

that this patient is severely hypotensive

32:49

and probably at risk for death.

32:53

So here are all the shotgun pellets.

32:55

You can even see a few dropped into the pleural space.

32:58

So low down here in the posterior costophrenic region.

33:01

There you see them, those are pellets

33:04

that just dropped into the plural space.

33:06

So they managed

33:07

to go practically everywhere into the venous system

33:10

and write ventricle and the pleural space as well.

33:16

And we will go through this one more time

33:19

so you can appreciate that flat IVC.

33:22

There it is. And of course the fishbone bowel,

33:34

I don't know why I'm getting that.

33:38

Sorry about that folks.

33:40

Let just put

33:42

it, There we go.

33:47

Alright. Uh, aortic lacerations are

33:51

frequently associated with injuries

33:54

to other important organs.

33:56

They do indicate, uh, a level of severity of trauma

34:01

that should suggest to you that you need

34:02

to do a very thorough evaluation of all structures.

34:06

That said, I do always start with the aorta.

34:10

The aorta is the most important structure in the thorax

34:13

or abdomen, both in traumatic and non-traumatic scans.

34:18

So be very careful

34:20

about assessing the aorta if it's present on any film

34:24

that you're looking at, whether it's contrasted

34:26

or non contrasted protocol for aortic assessment or not.

34:31

Look at the aorta very carefully

34:34

and I seriously do do it first on chest cts.

34:38

So this one is a slightly lower tear,

34:41

it's not at the typical SMUs region.

34:44

It's a few centimeters lower on the descending aorta

34:47

and there is the pseudo aneurysm that has resulted from it.

34:53

But there is also this large collection of gas

34:56

and fluid centrally in the mediastinum.

34:59

And it's incredible to think about the fact that this

35:03

pseudo aneurysm is separated from this collection of gas

35:07

and fluid by just a thin cellophane like adventitia

35:11

that's bounding that the very definition of course

35:14

of a pseudo aneurysm.

35:16

So this is the typical appearance of an a uh,

35:20

esophageal rupture in trauma

35:24

in blunt trauma, the esop, the esophagus ruptures

35:28

and looks very different than in penetrating trauma

35:32

or in the non-traumatic esophageal ruptures say

35:36

with bore hop syndrome in penetrating trauma

35:40

or in boha syndrome,

35:41

you will get a rather extensive pneumo mediastinum.

35:45

It will track along all the mediastinal structures,

35:48

it will go down along the diaphragm,

35:50

it will go up into the base of the neck.

35:53

But in blunt, traumatic esophageal ruptures,

35:57

that is not the case.

35:59

What happens in this setting is the esophagus ruptures

36:03

and expands the mediastinal soft tissue so abruptly

36:08

that they knit together and create an air

36:11

and fluid tight seal.

36:14

And so usually the gas

36:16

and fluid released from a blunt

36:19

traumatic esophageal rupture will be well circumscribed

36:22

and contained and you won't have

36:25

that extensive pneumo mediastinum that you're used

36:27

to seeing from esophageal ruptures.

36:30

So here's a coronal view, there's our pseudo aneurysm

36:34

and here is our gas and fluid collection.

36:40

Now there is the pseudo aneurysm.

36:42

The second time through though, let's track that esophagus.

36:45

You can see the superior esophagus there disappearing into

36:49

that well circumscribed collection of gas and fluid.

36:54

And then there is the inferior distal esophagus exiting

36:58

that collection with the intervening portion

37:01

of the esophagus, essentially macerated

37:04

and almost atomized.

37:08

But that is a finding worth noting

37:11

that it could be kind of confusing.

37:13

Why isn't the pneumo mediastinum everywhere?

37:16

And in all the blunt traumatic esophageal ruptures I've

37:20

seen, this has been the case that the collection of gas

37:23

and fluid is really very well contained.

37:28

So there is that collection again

37:29

and you can see the esophagus coming in and going out.

37:39

All right, another injury that you will see in combination

37:42

with aortic laceration is a diaphragmatic laceration.

37:48

So here we can see the aorta clearly lacerated there.

37:52

This one is similar in

37:54

that it's a little farther down on the descending thoracic

37:58

aorta, but here is the stomach

38:02

and you can see an NG tube there.

38:04

And the stomach is clearly residing in the inferior

38:08

left hemothorax.

38:12

There is a waste to the gastric body.

38:15

Oops, sorry, I got ahead of myself.

38:17

There is another one

38:18

of those wedge-shaped subcapsular

38:20

hypodensities in the spleen.

38:22

So if you happened to have missed that aortic laceration,

38:25

something I don't think likely, uh,

38:28

this would call your attention to the fact

38:30

that there must be an upstream vascular injury.

38:34

But also note there is uh, this waste here

38:40

of the gastric body where it is uh,

38:45

running through a tear in the diaphragm.

38:48

So a little lower down,

38:50

a nice treat here we've got those same findings in the

38:53

kidneys, wedge shaped subcapsular hypodensities.

38:57

And when you see them in both the kidneys

38:58

and the spleen, then you can be pretty sure

39:01

that you're going to find an upstream aortic laceration.

39:06

So there's the aortic laceration

39:12

and we see stomach with ng tube.

39:14

There's the waist in the gastric body where it's passing

39:19

through the torn diaphragm

39:21

and then you can see there's a liver laceration,

39:23

the splenic hypodensities

39:25

and of course the renal hypodensities.

39:31

So it's on the coronals that you really can appreciate, uh,

39:35

diaphragmatic lacerations.

39:37

But let's look first at the sagittal.

39:40

Very nice example of a pseudo aneurysm narrow base vertical

39:43

orientation, slightly farther back on the aortic arch than

39:47

you would expect a ductus diverticulum

39:49

and a very large thickened intimal flap there.

39:54

So just a classic view of an uh,

39:58

its itus laceration.

40:01

But then let's look on the coronals here.

40:04

Uh, I do prefer the coronals for investigating the diaphragm

40:07

and this is a great example of it.

40:09

So you can see the aortic laceration here,

40:12

but then look at this, we've got both stomach

40:14

and some colon up above the level of the diaphragm.

40:18

And how can we tell that we have got the free edge

40:21

of the torn diaphragm visible right there?

40:25

You won't always see it that clearly.

40:27

This one's a real treat.

40:28

Then if we go back a little bit, we see again

40:32

not only the stomach

40:34

and the colon are above the level of the diaphragm

40:37

but also the spleen.

40:39

And I remember first looking at this

40:41

and saying, my God, that spleen is upside down.

40:44

I'm going to publish this

40:46

and name it Strongs upside down spleen.

40:49

It turned out when I looked on the sagittals,

40:51

it was really only rotated about 90 degrees.

40:53

So that was a bit of a disappointment.

40:56

But here again we see that free edge

40:58

of the diaphragm proving that it is both torn

41:01

and that the spleen is above it.

41:04

And look at those wedge-shaped hypodensities.

41:06

We get another view of them there in the kidneys.

41:11

So there is that torn diaphragm

41:13

and look at all the organs passing up through that defect

41:20

and there is that upside down spleen.

41:23

And

41:34

and lastly those renal hypodensities.

41:38

All right, So this is

41:43

the classic triad of bronchial rupture.

41:48

So with bronchial rupture you will typically get

41:52

a pneumothorax, a pneumo mediastinum

41:56

and ectasis of the involved lung lobe or lung.

42:01

And we've got all three here.

42:02

So we've got a pneumothorax, pneumo mediastinum

42:06

and then complete collapse of the left lower lobe.

42:10

And it's right in here

42:12

that the bronchial laceration has occurred.

42:15

And on the cine we'll see that just snuff out.

42:17

We won't be able to follow the bronchus all the way down

42:21

into that left lower lobe.

42:25

And there it is obviously deformed

42:28

and we'll see it is discontinuous.

42:31

So another finding I have attached a great deal

42:34

of significance to over the years is

42:36

what I call bracketing rib fractures.

42:40

When you see a combination of anterolateral

42:44

and posterior rib fractures, that suggests a vector of

42:49

compression that puts the patient at risk

42:52

for three particular injuries.

42:55

So when I see rib fractures in exactly these locations,

42:59

I look at the diaphragm, the esophagus, and the bronchus

43:04

because I have noted over the years

43:06

that these bracketing rib fractures are associated

43:08

with injury to one of those three.

43:11

So when you see them look, look at the diaphragm,

43:14

the esophagus and the bronchus on that side very carefully.

43:18

And this holds true for the left side

43:20

much more than the right.

43:23

So there they are. So you can see extensive

43:28

pneumo mediastinum, uh, quite a bit of soft tissue gas too.

43:33

And there we just saw

43:34

that left lower lobe bronchus snuff out completely.

43:39

There will often be a tiny bit of air broncho graham visible

43:45

even in a completely atelectatic lung with a complete

43:50

transection of the bronchus.

43:52

And that's because of course the bronchi themselves are not

43:55

a gas exchange unit, right?

43:57

That occurs at the respiratory bronchial and distal.

44:01

So there can be a little bit

44:02

of residual gas in the more centrally located bronchi

44:06

and you shouldn't let that deter you from calling this

44:09

complete ectasis of the left lower lobe

44:12

and transection of that left bronchus.

44:16

So I actually read the follow-up on this study.

44:21

The radiologist that read this initial study, uh,

44:25

did not put it all together.

44:26

So they definitely called the pneumothorax

44:28

and the pneumo mediastinum,

44:30

but they didn't call bronchial rupture.

44:32

And so I got a follow-up scan that was about 48 hours later

44:36

and this patient was blown up like the Michelin man,

44:40

it looked like he was going to float away, uh,

44:43

like a weather balloon.

44:45

And that's the unfortunate complication of

44:50

positive pressure ventilation in someone

44:51

with a bronchial rupture.

44:53

So it is a very important finding to make.

44:57

So we'll look at that one more time.

44:59

There is that left lower lobe bronchus

45:02

and now it's gone

45:07

even have a magnified view for you here

45:14

and right there we lose it.

45:23

Alright, this is the one I alluded to earlier.

45:27

Uh, this is what could have happened to me when I, uh,

45:31

was taking my exuberant uh, approach to intubation, right?

45:36

So I always shoved it in too far

45:40

frequently write main stemmed people.

45:41

In fact, I would call the university hospital

45:44

where I transferred patients

45:46

and I would tell them yes, I'm sending the patient

45:48

by helicopter and he's intubated.

45:50

And uh, the doctors on the other end knew me well enough

45:53

to say, did you main stem him?

45:56

And I would always be forced to confess.

45:58

And I always again thought, who is this hurting, right?

46:02

I get the follow up film, I know how far to pull it back.

46:04

Everybody's happy. Well you can

46:07

vols the bronchus intermedius if you over intubate someone

46:10

with too much force.

46:12

And that was actually the situation here.

46:15

So there is no visible bronchus intermedius here.

46:19

And you'll see lower down there is complete ectasis

46:23

of the right middle and lower lobes.

46:25

Very large pneumothorax. In fact hemo pneumothorax here.

46:31

This was a particularly vicious intubation.

46:34

And there you can see we just lost the bronchus intermedius

46:38

and you can see the complete ectasis of the right middle

46:42

and lower lobes.

46:43

So the only aerated lung lobe we're seeing there

46:46

is the right upper lobe.

46:49

And this patient has a beautiful coronal where you can see

46:53

that transection going right

46:56

through the bronchus intermediates just below the takeoff

46:58

of the right upper lobe bronchus.

47:07

So there it is on the coronals. Look at that one more time.

47:11

It's a pretty picture.

47:16

Alright, well that's not the only injury this patient had.

47:18

It actually tore one of the pulmonary arteries.

47:22

And so you can see extravasation there, uh, that's

47:26

bleeding out and piling onto

47:29

some clot formation there in the dependent right hemithorax.

47:33

So that is a particularly concerning finding.

47:36

Whenever you see active extravasation into the pleural

47:39

space, that patient could very easily die.

47:43

Uh, the pleural space has just enormous capacitance

47:47

and can take on a full liter of blood without uh,

47:51

exerting any back pressure to St Stach that bleeding.

47:56

So it's a very concerning finding.

48:00

And here it is right there.

48:01

You can see the active extravasation there

48:04

and all that clot forming in the dependent portion

48:08

of the right hemithorax.

48:14

So not just a bronchial injury

48:16

but also a pulmonary arterial injury.

48:19

So I breathe a sigh of relief every time I see then

48:22

that fortunately it did not happen to me

48:25

and easily could have.

48:28

Alright, this is about the worst lung injury

48:31

I have ever seen, but it shows a few great examples of

48:35

what happens to traumatic, uh, tally injured lung.

48:40

First of all, it gets contused

48:42

and typically will hemorrhage.

48:44

And so all this fluid density

48:45

that you're seeing throughout the airspace, uh, is

48:49

alveolar hemorrhage.

48:51

You can see there is a pneumothorax there as well.

48:54

And also note all these gas collections within the injured

48:58

lung, those are traumatic pneumatic seals

49:01

and they result from the shearing

49:03

of the pulmonary parenchyma.

49:05

So pneumatic seals, uh,

49:07

you'll see them in non-traumatic situations as well.

49:10

They usually result from a necrotic pneumonia.

49:14

Uh, sometimes actually hydrocarbon aspiration is

49:18

on your differential list.

49:20

People that drink hydrocarbons typically vomit it,

49:23

aspirate it, and then it causes pneumatic seals

49:25

within the lungs.

49:27

But in the setting of trauma it's easy enough.

49:30

This was shearing and these are traumatic pneumatics seals.

49:33

So the reason I like this case is actually the rib fracture

49:38

that's associated with it.

49:39

So we'll look at that in a second,

49:41

but, uh, just about the most severely injured lung I've ever

49:44

seen, the entire thing is consolidated from

49:48

contusion into hemorrhage.

49:49

And there are those traumatic pneumatic seals present all

49:53

throughout the lung substance.

49:57

Alright? But my rib fracture, I, this is one

50:00

of the most unusual rib fractures I've ever seen.

50:02

It's completely torn from the costochondral junction

50:06

and is levered up

50:07

and standing straight off the patient's chest.

50:12

And so that whole anterior right lung is exposed to

50:16

outside world essentially.

50:19

And this was a case that I called, this was from Waterloo,

50:23

Indiana, I still remember.

50:26

And I called the trauma coordinator

50:28

and said to her, what did you guys do with that rib?

50:31

And she said, what rib?

50:34

So they never scanned this patient at the site.

50:37

They simply stuck him in a helicopter

50:40

and flew him to the Mayo Clinic.

50:42

And so, uh, they never actually addressed it

50:45

or even noticed it in spite of the marked asymmetry

50:49

of the chest wall.

50:51

So this patient, uh, I actually asked

50:54

that trauma coordinator, I remember saying,

50:56

what exactly was the vector of this injury?

50:59

I'm trying to figure out how

51:01

that crazy rib fracture could have occurred.

51:04

And she said, well this kid, he was 19

51:07

or 20 years old, he went off the road at a hundred miles an

51:11

hour, his car flipped end to end

51:14

and then rolled on its side several more times.

51:17

Uh, so she kind of laughed at me

51:19

and said, I don't think you're going

51:20

to figure out the exact vector.

51:23

It was all vectors, uh, that you can conceive

51:27

of we're involved in this.

51:29

So this patient spent about 10 days on ecmo,

51:33

extra corporeal membrane oxygenation to substitute, uh, for

51:37

that injured lung.

51:39

And he ultimately did survive.

51:41

And that trauma coordinator was very helpful.

51:43

She used to send me daily texts with updates as

51:47

to this patient's status

51:49

and we ultimately sent her a VAD mug for her assistance.

51:54

Alright, a few other mediastinal injuries.

51:56

This is a very unusual injury.

51:59

You can see it's got a very high mortality.

52:01

This is blunt traumatic laceration

52:04

of the superior vena cava.

52:06

These patients typically do not survive

52:09

to get to the hospital.

52:10

So it's a real treat to actually see a scan with this.

52:14

Unfortunately, the patient did not survive.

52:17

So this is the, you can see there's, uh,

52:19

some mediastinal fluid density

52:22

and on the cine you'll appreciate there's a very large

52:25

mediastinal hematoma.

52:27

But right here is the venous pseudo aneurysm.

52:30

It's extending off the posterior aspect of the SVC.

52:35

So this is your brachiocephalic vein coming in.

52:38

This is the native SVC right here.

52:42

And this is all the venous pseudo aneurysm

52:46

that's resulting from this laceration.

52:51

So there, look at all that mediastinal hemorrhage.

52:53

There is a very large contained mediastinal hematoma here

52:58

and there's the, the normal SVC below the level of

53:01

that pseudo aneurysm.

53:03

This was unfortunate

53:04

because it was at a small remote hospital

53:07

that did not have interventional capability.

53:10

So I've presented this in many conferences

53:12

and the inter, there's always an interventionalist

53:15

that raises his hand

53:16

and says, why didn't they put a covered stent on this?

53:20

Well that might not have been as easy as it seems.

53:23

It certainly would've jailed one

53:25

or the other of the brachiocephalic veins.

53:28

But at the, uh, potential cost of life, uh,

53:31

that would result from not treating it, maybe

53:34

that was a reasonable option,

53:36

but the only option that was available

53:38

to this care team was surgery.

53:40

And so they decided they were going to try

53:43

and operate on this.

53:45

And that rarely goes well.

53:46

In fact, most of the IVC

53:48

or SVC lacerations

53:50

that I have seen have generally been treated non inter

53:53

without intervention, uh, without surgery at least.

53:57

And it's surprising given the mortality of these injuries.

54:02

But the IVC

54:04

and SVC are not that amenable to surgical repair.

54:07

They're very thin walled.

54:08

They tend to really macerate once lacerated

54:12

and so they're not something

54:13

that most surgeons wanna run in and do.

54:16

Uh, so this surgeon went in

54:18

and tried to expose this pseudo aneurysm

54:21

and he said when he got into the mediastinum

54:23

that hematoma let loose

54:25

and they just couldn't save the patient.

54:30

So a tragic end and really particularly sad

54:34

because this patient had survived to arrive at the hospital,

54:38

which is pretty unusual with that injury.

54:42

Alright, so in contrast, this one is an Aus laceration

54:46

and this is one that's showing the very concerning finding

54:50

of bleeding active extravasation into the pleural space.

54:54

So if I had to pick between the preceding case

54:58

and this one as to which patient was in more imminent danger

55:02

of death, I would've chosen this one

55:04

because again, bleeding into the pleural space,

55:07

you're very unlikely to build up enough back pressure

55:10

to stench that flow.

55:13

So there is the bleeding right from the azygos vein there

55:16

and you can see a great deal of contrast is extravasated,

55:20

especially for a venous bleed that is really brisk bleeding.

55:27

So this was corrected operatively

55:29

and the patient did survive in the short term.

55:33

Uh, but then as I was doing some follow up, about six months

55:36

after I found, I looked up this patient

55:40

and found that she had died about three months

55:44

after this surgery.

55:45

She had a deep venous thrombosis

55:47

and a massive pulmonary embolism that killed her.

55:51

And so ultimately I would have to say

55:54

that can be blamed on this injury.

55:57

Uh, she had a thoracotomy, which is a very painful surgery.

56:00

She lied around the house for a couple of months such

56:03

that she formed A DVT

56:05

and ultimately that led to her demise.

56:10

Alright, I think we'll stop here so

56:13

that I can answer a few questions.

56:17

So let me stop sharing and I'll get to my chat here

56:22

and we'll see what questions have arisen

56:27

irregularity on the inside

56:29

of the aortic lumen in an asymptomatic patient.

56:33

Uh, well this is a commonly asked question.

56:36

Atherosclerotic plaque

56:39

and calcification can really complicate the, uh,

56:43

interpretation of the aorta.

56:46

It can look like there are little pseudo aneurysms

56:48

or diverticula, uh, extending out

56:51

or crevices that might represent incomplete lacerations.

56:55

And it it can be challenging.

56:58

The things I would say are look very carefully

57:01

for peri aortic stranding.

57:03

Rarely is there an aortic injury without

57:05

that kind of stranding.

57:07

Uh, and of course look

57:09

for the distal micro embolic phenomena, uh,

57:13

that you will typically see with vascular injuries.

57:18

Uh, let's see. Can vasculitis be like an irregular

57:23

inside the lumen without stranding in the

57:26

para aortic region?

57:28

Uh, yes it can.

57:29

Vasculitis usually will look like

57:32

relatively smooth wall thickening, however,

57:35

and I don't usually see that confused with, uh,

57:40

an actual vessel laceration.

57:45

Alright, any other question? Oh, I've got one more here.

57:50

Uh, let's see. Do you have a structure like trauma A TLS

57:53

when reviewing an acute trauma scan?

57:55

Uh, well actually you've pushed my favorite button,

57:58

which is search pattern, search pattern, search pattern.

58:02

I really don't think there's enough emphasis in training

58:05

today on adhering to a search pattern.

58:09

And I can tell you I worked for a solid decade at

58:13

vRad s on vRad D'S QA committee.

58:16

And so I reviewed MRS on a daily basis

58:19

and I came away with the absolute conviction that 90%

58:24

of all radiologic errors are due to failure

58:28

to adhere in a regimented, methodical,

58:31

repeatable search pattern.

58:34

That is the most important thing in all of radiology.

58:37

So if you're in training right now,

58:39

and it may sound crazy,

58:41

you should be compiling your search patterns

58:44

for every body part and every modality.

58:46

Doesn't matter if it's a chest x-ray or a head CT

58:51

or a chest CTA, you should have a search pattern

58:55

with exactly the structures

58:56

and organs you're going to evaluate in order so as

59:00

to never skip a step.

59:03

And we've actually built our entire reporting system on the

59:06

vRad platform around that concept so as to reinforce it

59:10

and enable it, uh, uh, because it's just so important.

59:16

All right. What is the best book for aortic trauma?

59:19

That's an interesting question.

59:21

Uh, I actually don't typically recommend books.

59:25

I would say look at cases.

59:27

Uh, I am a firm believer that what we do is look at cases,

59:32

uh, in our actual work.

59:34

And so when you study, you should emulate that process.

59:39

And so I'm a big fan of looking at teaching files,

59:42

so I won't tell you a book,

59:44

but I will tell you I've got a lot

59:46

of aortic lacerations on my YouTube channel,

59:49

vRad Radiology Education,

59:51

and you can probably see as many

59:53

as 50 aortic lacerations if you, uh, pick

59:56

through my various videos.

60:02

All right, folks, I think that about wraps things up.

60:06

Uh, all right, looks like you got all those questions.

60:08

Good job, Dr. Strong.

60:10

Thanks very much for the opportunity to speak.

60:13

I'll see everyone next time.

60:15

I'll hand things back over to Ben.

60:17

Well, thank you all for participating in our noon

60:20

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60:23

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60:25

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60:29

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60:34

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60:36

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60:41

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60:45

Scrotal Imaging in the ed, a Case-Based Review.

60:48

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60:50

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60:55

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