Claudia T. Sadro

Imaging of Trauma: Part 2, Abdominal Trauma and Pregnancy—A Radiologist's Guide to Doing What Is Best for the Mother and Baby

OBJECTIVE The pregnant trauma patient requires imaging tests to diagnose maternal injuries and diagnostic tests to evaluate the viability of her pregnancy. This article will discuss abdominal trauma in pregnancy and the specific role of diagnostic imaging. Radiation concerns in pregnancy will be addressed. CONCLUSION Trauma is the leading cause of nonobstetric maternal mortality and a significant cause of fetal loss. Both major and minor trauma result in an increased risk of fetal loss. In major trauma, when there is concern for maternal injury, CT is the mainstay of imaging. The risks of radiation to the pregnancy are small compared with the risk of missed or delayed diagnosis of trauma. In minor trauma, when there is no concern for maternal injury but there is concern about the pregnancy, ultrasound is performed but is insensitive in diagnosing placental abruption. External fetal monitoring is used to dictate patient care.

Acute onset flank pain-suspicion of stone disease

* See Last Page for Key 2015 Review Coursey Page 1 Reference Study Type Patients/ Events Study Objective (Purpose of Study) Study Results Study Quality 1. Ha M, MacDonald RD. Impact of CT scan in patients with first episode of suspected nephrolithiasis. J Emerg Med. 2004;27(3):225-231. ObservationalDx 121 patients had CT Prospective observational study to evaluate use of HCT in first episode of suspected nephrolithiasis. Four categories grouped the pre-CT diagnostic certainty: 0-49%, 50-74%, 75-90%, and 90100%. The CT scan found urinary calculi in 28.6%, 45.7%, 74.2%, and 80.5% of patients in each category, respectively. CT scanning revealed alternate diagnoses in 40 cases (33.1%). Of these, 19 (47.5%) included other significant pathology. Before CT scanning, physicians planned to discharge 115 patients and admit six patients. After CT scanning, six of the former group were admitted, and five of the latter group were discharged. Patients presenting with a first episode of clinically suspected nephrolithiasis should undergo CT scanning because it enhances diagnostic certainty by identifying alternate diagnoses not suspected on clinical grounds. 2

Current Concepts in Imaging Evaluation of Penetrating Transmediastinal Injury

Penetrating transmediastinal injuries (TMIs) are injuries that traverse the mediastinum. These injuries are most commonly caused by firearms and knives. The investigation and management algorithms for TMI have undergone changes in recent years due to increasing evidence that computed tomography (CT) in useful in the evaluation of hemodynamically stable TMI patients. Initial investigation of TMI patients depends on the question of hemodynamic stability. In unstable patients, imaging (if any) should be limited to bedside radiography and focused ultrasonography. In hemodynamically stable patients in whom a mediastinal trajectory of injury is suspected, the primary imaging modality after radiography should be multidetector CT. CT is invaluable in the assessment of TMI due to its capacity to depict the injury track as well as demonstrate both direct and indirect signs of organ injury. On the basis of the suspected trajectory and specific findings, radiologists can play an essential role in determining future patient management and investigations for each mediastinal organ, thereby expediting appropriate investigation and treatment and avoiding unnecessary and sometimes invasive tests or surgery. The authors provide an up-to-date and evidence-based approach for the management of hemodynamically unstable and stable patients with suspected TMI, discuss management algorithms and CT protocols, and highlight common and uncommon imaging findings and diagnostic pitfalls associated with vascular, cardiac, esophageal, tracheobronchial, pleural, and pulmonary injuries. Online supplemental material is available for this article.

Lower male genitourinary trauma: a pictorial review

Blunt and penetrating trauma to the male pelvis and external genitalia may result in significant injury to the lower genitourinary system including the bladder, urethra, penis, and scrotum. Emergent imaging plays an important role in identifying these injuries and directing appropriate, timely management. In this article, we review indications for dedicated genitourinary system imaging in trauma and illustrate the imaging features of injuries to the lower male genitourinary system in order to facilitate accurate and rapid diagnosis.

Heterotopic Mesenteric Ossification after Blunt Abdominal Trauma and Multiple Surgical Operations

We present a case of a 26-year-old man with mesenteric heterotopic ossification following blunt abdominal trauma and multiple surgical operations. Computed tomography 10 months after the initial trauma demonstrated linear, branching opacities within the small bowel mesentery that had a cortical and trabecular structure indicative of mature bone. We found only 25 reports in the literature of small bowel mesentery heterotopic ossification. The significance of this non-neoplastic process is three-fold: (1) patients often present with bowel obstruction; (2) the process tends to worsen or reoccur after repeat laparotomy, and (3) rare forms of malignant neoplasms such as extraskeletal osteosarcoma may have a similar appearance.

Torsion of an accessory spleen: Case report and review of the literature

Torsion of an accessory spleen is an uncommon cause of abdominal pain. Only a few cases have been reported in the literature. Most cases occur in children, and in most cases the diagnosis is made at surgery. We report a case of torsion of an accessory spleen in an adult female who presented with acute left-flank pain. The diagnosis was made on contrast-enhanced computed tomography (CT) and was confirmed at surgery. Without treatment, torsion of an accessory spleen can lead to hemorrhagic shock, peritonitis, and bowel obstruction. It is useful for the radiologist to make this diagnosis on imaging so that biopsy can be avoided and surgery performed to avoid complications.

Growth disturbances-risk of intrauterine growth restriction.

Procedure Appropriateness Category SOE RRL Panel Rating Group Median Rating Final Tabulations 1 2 3 4 5 6 7 8 9 US pregnant uterus with Doppler May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0 References Study Quality US pregnant uterus biophysical profile May be appropriate O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0 References Study Quality US pregnant uterus Usually appropriate O 0 mSv O 0 mSv [ped] 9 n/a 0 0 0 0 0 0 0 0 0 References Study Quality

Pictorial Review of Complications of Uterine Anomalies

Uterine anomalies are a potential cause for amenorrhea, infertility, and abnormal obstetrical outcomes in young women [1]. Uterine anomalies occur due to failed formation or fusion of the paired M€ullerian ducts early in embryonic life and are also referred to as M€ullerian duct anomalies. Uterine anomalies may also be associated with symptoms of pain or a mass due to hematometros, hematocolpos, endometriosis, or ectopic pregnancy [2]. The overall incidence of uterine anomalies is often quoted to be 2%-3%. However, the incidence is up to 5%-10% in women with recurrent first trimester miscarriage and up to 25% in women with recurrent second trimester pregnancy loss [1].