23DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 23.1 (A, B) Ultrasound of the left hypochondrium showing the presence of hemoperitoneum, pleural fluid and a defect in the left hemidiaphragm more posteriorly, consistent with diaphragmatic rupture (arrow).

• Fig. 23.2 Multiple splenic injuries in the same patient. (A) Splenic low attenuation linear defect due to a splenic laceration. (B) More inferiorly a splenic fracture with separation of fragments is present. Hemoperitoneum is localised to the left upper quadrant. (C) In the splenic bed active extravasation of contrast is identified.

• Fig. 23.3 Intrasplenic haematomas are characterised by irregular margins and swelling of the spleen, altering the normal crescentic contour.

• Fig.23.4 Resolving splenic lacerations and haematomas. A peripheral crescentic low-attenuation collection is due to a subcapsular haematoma and, although small, poses a risk Of delayed rupture.

• Fig. 23.5 Normal splenic clefts. These can be distinguished from lacerations by their relatively superior location, lobulated contour and the absence of perisplenic hemoperitoneum. Note the preservation of the fat planes around the spleen.

• Fig. 23.6 (A, B) Flush DSA aortogram showing splenic arterial bleeding with a persistent blush in the spleen on the delayed image.

• Fig. 23.7 (A, B) Contrast-enhanced CT: there is frank arterial bleeding from the splenic artery associated with a fragmented spleen. Extensive haemoperitoneum is also present.

• Fig. 23.8 (A,B) Motorcyclist after a road traffic accident. A fractured rib has caused a direct small peripheral laceration to the right lobe of the liver.

• Fig. 23.9 Multiple right lobe lacerations. This configuration has been described as a 'bear claw' appearance.

• Fig. 23.10 Subacute subcapsular haematoma of the liver. The low-attenuation collection indents the liver margin. Unlike splenic subcapsular collections, these collections are not thought to predispose to delayed rupture.

• Fig. 23.11 (A) Contrast-enhanced CT: a large right hepatic lobe contusion with acute haematoma extending into the right portal vein. (B) The venous phase of the superior mesenteric angiogram demonstrates an acute cut-off to the right portal vein.

• Fig. 23.12 (A) Massive central haematoma (grade 4) with laceration extending through the liver capsule in a patient with a ruptured liver. (B) The right hepatic artery arises from the superior mesenteric artery. The angiogram demonstrates areas of devascularisation and separation by the extrahepatic haematoma seen on CT. No arterial bleed is seen. (C) The venous phase of the angiogram shows complete disruption of the portal vein (arrow) and contrast extravasation (arrowhead).

• Fig. 23.12 (A) Massive central haematoma (grade 4) with laceration extending through the liver capsule in a patient with a ruptured liver. (B) The right hepatic artery arises from the superior mesenteric artery. The angiogram demonstrates areas of devascularisation and separation by the extrahepatic haematoma seen on CT. No arterial bleed is seen. (C) The venous phase of the angiogram shows complete disruption of the portal vein (arrow) and contrast extravasation (arrowhead).

• Fig. 23.13 Periportal low attenuation. Extensive periportal low attenuation is identified in a central and peripheral distribution in an 11 year old. As is frequently the case, no hepatic laceration was identified.

• Fig. 23.14 Embolisation of a traumatic false aneurysm in a patient with liver laceration. (A) Dynamic CT scan showing an area of liver laceration. There is abnormal tubular enhancement in the lacerated area. (B) Hepatic artery angiogram demonstrates a traumatic false aneurysm. (C) Embolisation: hepatic arteriogram, again showing the aneurysm with abnormal vascular blush in the lacerated liver. (D) A supraselective coaxial catheterisation of the right hepatic artery leading to the false aneurysm, which was successfully embolised.

• Fig. 23.14 Embolisation of a traumatic false aneurysm in a patient with liver laceration. (A) Dynamic CT scan showing an area of liver laceration. There is abnormal tubular enhancement in the lacerated area. (B) Hepatic artery angiogram demonstrates a traumatic false aneurysm. (C) Embolisation: hepatic arteriogram, again showing the aneurysm with abnormal vascular blush in the lacerated liver. (D) A supraselective coaxial catheterisation of the right hepatic artery leading to the false aneurysm, which was successfully embolised.

• Fig. 23.15 Large irregularly marginated segmental right lobe contusion. The contusion extends to the IVC and is associated with only minimal haemoperitoneum anterior to the liver. Such injuries may be significantly underestimated by ultrasound, particularly if the haemoperitoneum is not detected.

• Fig. 23.16 Non-specific findings in an adult male following a fall. (A). Pericholecystic free fluid. This finding may be due to gallbladder injury but is more frequently due to other injuries. (B) Anterior pararenal haemorrhage. This is a frequent site of haematoma secondary to renal injuries but also pancreatic tail injuries. The visceral injury is often not visible.

• Fig. 23.17 Layered high-attenuation haematoma is present in the injured gallbladder. Additional active extravasation in the hepatorenal angle is noted within a hepatic haematoma.

• Fig. 23.18 Laceration recovery. (A) Acute phase imaging demonstrates a complex laceration extending to the IVC. Despite this extension the patient was successfully treated conservatively. (B) One month after injury the laceration has almost healed. The splenic size had significantly increased from the initial scan, presumably due to reversal of adrenergic stimulation

• Fig. 23.19 Air within a hepatic laceration. This CT was performed a week after a therapeutic selective embolisation. This finding is well described in resolving lacerations and does not necessarily indicate infection. Associated peritoneal and pleural collections are present.

• Fig. 23.20 After a renal biopsy extensive haemorrhage is present, splitting the renal fascia (interfascial). In addition, haematoma has spread to the psoas and left flank soft tissues.

• Fig. 23.21 Renal cell carcinoma detected incidentally following minimal trauma. A large anterolateral renal cell carcinoma is present. A posterolateral subcapsular haematoma indents the renal contour and displaces the kidney anteriorly.

• Fig. 23.22 Unenhanced CT. Extensive hyper dense perirenal haematoma is present. Unenhanced CT is not essential in the analysis of renal trauma as most significant haematomas are sufficiently conspicuous on postcontrast imaging alone.

• Fig. 23.23 Central irregular low attenuation of the left kidney due to a traumatic contusion. There is associated perirenal haematoma surrounding the renal margin. Further pararenal haemorrhage is separated from this haematoma by perirenal fat bounded by Gerota's fascia. Intraperitoneal haemorrhage is present in both flanks.

• Fig. 23.24 A segmental peripheral low-attenuation wedge is noted in the right kidney consistent with a peripheral infarct. These injuries are seen relatively frequently post-traumatically but may also predate the injury in older patients with concomitant vascular disease.

• Fig. 23.25 Well-demarcated area of hypoperfusion secondary to traumatic infarction. Haemoperitoneum is present in the hepatorenal angle

• Fig. 23.26 Renal lacerations. Two stabbing injuries are identified in the same patient. (A) Superficial laceration limited to the cortex. (B). Deep laceration extending to the medulla. Such injuries are more frequently associated with urinary leakage. Associated perirenal haematoma is present.

• Fig. 23.27 (A-C) Major renal trauma with multiple devascularised segments. Such injuries are traditionally treated surgically, although in haemodynamically stable patients angiography and embolisation may obviate the need for nephrectomy.

• Fig. 23.28 (A) Contrast-enhanced CT following blunt trauma demonstrates a largely absent left nephrogram except for preserved rim cortical perfusion. The left renal artery is dilated. The right kidney is congenitally absent. (B) Selective arteriography demonstrates a dissection of the renal artery with poor distal perfusion. (C) Delayed phase: poor and patchy nephrogram appearances (Images (A) and (B) reproduced with kind permission from McAlinden et al 2001.)

• Fig. 23.28 (A) Contrast-enhanced CT following blunt trauma demonstrates a largely absent left nephrogram except for preserved rim cortical perfusion. The left renal artery is dilated. The right kidney is congenitally absent. (B) Selective arteriography demonstrates a dissection of the renal artery with poor distal perfusion. (C) Delayed phase: poor and patchy nephrogram appearances (Images (A) and (B) reproduced with kind permission from McAlinden et al 2001.)

• Fig. 23.29 (A) CT following blunt trauma demonstrates a right renal contusion with perirenal haemorrhage. The patient was haemodynamicaIly stable and treated conservatively. (B) Angiography performed for persistent haematuria demonstrates a traumatic false aneurysm. (C) Successful embolisation of the supplying branch artery. (Courtesy of Dr C. Blakeney, Royal London Hospital.)

• Fig. 23.29 (A) CT following blunt trauma demonstrates a right renal contusion with perirenal haemorrhage. The patient was haemodynamicaIly stable and treated conservatively. (B) Angiography performed for persistent haematuria demonstrates a traumatic false aneurysm. (C) Successful embolisation of the supplying branch artery. (Courtesy of Dr C. Blakeney, Royal London Hospital.)

• Fig. 23.31 Angiography for persistent haemorrhage demonstrates abnormal vasculature due to a renal angiomyolipoma. (Reproduced with kind permission from McAlinden et al 2001 .)

• Fig. 23.32 Contrast cystography. Following trauma there is an intraperitoneal rupture of the bladder dome. Contrast is starting to line the small bowel in the left iliac fossa. (Courtesy of Dr T. Fotheringham, Royal London Hospital.)

• Fig. 23.33 (A) Extra peritoneal bladder base rupture. Following an ascending urethrogram, contrast surrounds the bladder base within the perineum. (B) Contrast has tracked around the bladder, which still contains urine. There are associated fractures of the right iliac blade and of the left pubic rami.

• Fig. 23.34 Pancreatic laceration following a go-karting car accident. Complete transection of the junction of the body and tail with fragmentation. The pancreatic duct would almost certainly be disrupted in such an injury. Associated extensive peritoneal and retroperitoneal haematoma is present. Note that despite the significant injury the splenic vein is not separated from the pancreas, demonstrating the low sensitivity of this sign.

• Fig. 23.35 Gunshot injury to the abdomen. (A) There is an intrahepatic contusion with haemoperitoneum. Within the haemoperitoneum air bubbles are identified due to an associated large bowel injury. (B) There is a further large devascularising injury of the posterior right kidney but no other bowel injury localising signs were identified.

• Fig. 23.36 Duodenal rupture with leakage into the right anterior pararenal space.

• Fig. 23.37 (A,B) Localised bowel wall thickening due to small bowel haematoma following blunt abdominal trauma.

Fig. 23.38 Bowel trauma. There is extensive intraperitoneal free fluid with no evidence on other images of a solid visceral injury. (A) The ascending colon demonstrates intense staining of the wall and lumen consistent with haemorrhage. (B) More inferiorly a large haematoma compresses the colonic lumen.

Fig. 23.39 Haematoma is present in the perirectal space secondary to a 20 metre fall resulting in blunt injury to the rectum.

• Fig. 23.40 Bowel findings in a 7 year old following a road traffic accident. (A) The diffuse fluid dilatation of the small bowel with brightly enhancing walls suggest 'shock bowel'. This is supported by the collapsed IVC and the small calibre aorta. (B) The focal dilatation and thickening of the terminal ileum with extraluminal air lateral to the colon suggests bowel trauma with perforation. The findings of trauma and 'shock bowel' may coexist and be difficult to differentiate.

• Fig. 23.41 Laceration of the IVC in a child after a 15 metre fall. Contrast has been instilled via a femoral line. Active contrast extravasation into the retroperitoneum is noted. There is almost no contrast in the systemic circulation and hence the kidneys.