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CTCriteriaforManagementofBluntLiverTrauma:CorrelationwithAngiographicandSurgicalFindingsFromtheDepartmentsofDiagnosticRadiologyandInterventionalRadiologyUniversityofMarylandMedicalCenterandShockTraumaCentePierreA.Poletti,MD,StuartE.Mirvis,MD,KathirkamanathanShanmuganathan,MDKarenL.Killeen,MD,DouglasColdwell,MDRadiology2000;216:418–427PrefaceInpreviouslypublishedstudies(1–7),50%–96%hemodynamicallystablepatientswithblunthepatictraumacanbesuccessfullytreatedwithoutsurgeryThequantityofhemoperitoneumbyinitialCTinitiallyconsidered--indicatorofhepatictraumaseverity(8,9).severalsubsequentstudies(6,10–12):thequantityofhemoperitoneumdoesnotcorrelatewithfailednonsurgicalmanagement.ACT-basedgradingsystemhasbeenadaptedfromtheAmericanAssociationfortheSurgeryofTraumaclassificationofblunthepaticinjury.thedirectapplicationofsuchaCTclassification,althoughreflectiveoftheextentofparenchymalliverdamage,cannotreliablypredicttheneedforangiographicassessmentoftheliverortheprobableclinicaloutcomeofattemptednonsurgicalmanagement(6,12).EvenmajorhepaticinjurieswithaseverityofuptoCTgrade4typicallycanbemanagedwithoutsurgeryinthosepatientswhomaintainhemodynamicstability(6,12–18).SomeauthorshavedescribedwidediscrepanciesbetweentheCTinjurygradeandtheinjuryseveritydeterminedatsurgery(19),withCTgenerallyyieldinganunderestimationoftheextentofinjury.theadventofspiralCTandimprovementsinimagequalityhaveledtoanincreasingroleofandrelianceonCTforevaluatingacutetraumatichepaticlesions(6,7,20–25).ThevalueoftheperiportalbloodtrackasaCTsigntohelpguidethemanagementoflivertraumaremainsuncertainandcontroversial(26,27).Thepoolingofcontrastmateriallocallyintheliverparenchymaorfreelyintheperitonealspacehasbeenrecognizedasaspecificsignofactivebleedingthatwarrantsembolizationorceliotomy(28).Earlydetectionofarterialcontrastmaterialextravasationisclearlyimportantforimprovingthesuccessofnonsurgicalmanagement,becauseitallowsarterialembolizationtobeperformedbeforethepatientbecomeshemodynamicallyunstableandthuspotentiallypreventstheneedforurgentsurgery.IntrahepaticvascularinjurieshavebeenreportedmorefrequentlyinassociationwithliverinjuriesofahigherCTgradethaninassociationwiththoseofalowerCTgrade(4).Someauthors(4,29)advocateperformingmandatoryhepaticangiographyinallpatientswithhepaticinjuriesofCTgrade3orhighertoavoidtheriskofmissingarterialbleedingatCT.Inthepresentstudy,ouraimwastofurtherdeterminethevalueofCTforassistingindecisionsregardingthetreatmentofhemodynamicallystablepatientswithblunthepatictrauma.TheaccuracyofCTindepictinghepaticarterialhemorrhagewasdeterminedbycomparingtheCTfindingswiththeresultsofangiographyandsurgery.MATERIALSANDMETHODSFrom1995.6to1999.4,20,537patientstotheUniversityofMarylandShockTraumaCenter.Ofthesepatients,7,188(35%)werewithbluntabdominaltrauma.Duringthisperiod,admissionCToftheabdomenandpelvisdepictedhepaticinjuryin420(6%)ofthepatientsadmittedwithblunt-forceabdominaltrauma.AllpatientswhounderwentbothhepaticCTandangiographyduringtheiracuteimagingassessmentwereincludedinthestudy.Seventy-twopatients(37female,35male;meanage,37.5years;agerange,14–93years;with29.5%ofallCT-depictedhepaticinjuries)metthesecriteriaandformedthestudypopulation.mechanismsofinjury:motorvehiclecollision(n=64),pedestrianstruckbyvehicle(n=4),fall(n=2),impactwithafallingbeam(n=1),andjetskiaccident(n=1).In47(65%)ofthe72patients,morethanoneCTscanwasobtainedatadmission.AllinitialabdominalCTscanswereobtainedwithin24hoursafteradmission—typicallyinlessthan2hours.CTwasperformedfromthelungbasestothepelviswith8-mmcontiguoussections.TheindicationsforhepaticangiographyincludedconfirmationofandpotentialembolizationforCTsignsofcontrastmaterialextravasation(ie,CTblush)inhemodynamicallystablepatients.HepaticangiographywasperformedalsotoexcludehepaticarterialinjuryinpatientswithCTevidenceofliverinjurywithoutdirectCTfindingsofvascularinjurywhohadunexplainedtransienthypotension(ie,peaksystolicpressureequaltoorbelow100mmHg).Hepaticangiographywasperformedwithin12hoursafterCTin59patientsandwithin24hoursafterCTin11patients;itwasdelayedintwopatientsfor4and7daysafterCT.Figure1.Activebleedingintheliverofa77-year-oldmanstruckbyabus.TransverseCTscanshowsagrade3liverinjury(arrows)withareasofhighattenuation(arrowheads)withinthelaceration.Activebleedingina17-year-oldmalepatientadmittedfollowingbluntabdominaltrauma.(a)TransverseCTscanshowsagrade4liverlaceration(arrows)intherightlobeoftheliverwithtwohigh-attenuatingareas(arrowheads),whichrepresentactivebleeding.(b)Selectiverighthepaticarterialangiogramobtainedafterembolizationofonebleedingsite(solidarrow)confirmsthesecondareaofactivebleeding(openarrow),asseenina.Angiographieswereassessedforthepresenceorabsenceofhepaticvascularinjuries,includinglocalizedretentionofcontrastmaterial(ie,parenchymalextravasation),pseudoaneurysm,occlusionorluminalirregularityofhepaticarteries,devascularizedhepaticsegments,arteriovenousorarteriobiliaryfistulas,andmajorportalvenousperfusionabnormalities.Embolizationswereperformedforevidenceofar