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DOI: 10.1148/radiol.2311021776
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(Radiology 2004;231:185-189.)
© RSNA, 2004

Emergency Radiology

Periaortic Hematoma at Diaphragmatic Crura at Helical CT: Sign of Blunt Aortic Injury in Patients with Mediastinal Hematoma1

Humberto Wong, MD, Michael B. Gotway, MD, A. Daniel Sasson, MD and R. Brooke Jeffrey, MD

1 From the Department of Radiology, Stanford University Medical Center, Stanford, Calif (H.W., A.D.S., R.B.J.); and Department of Radiology, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Ave, 1x55A Box 1325, San Francisco, CA 94110 (M.B.G.). From the 2002 RSNA scientific assembly. Received December 31, 2002; revision requested March 10, 2003; final revision received June 29; accepted August 18. Address correspondence to M.B.G. (e-mail: michael.gotway@radiology.ucsf.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate periaortic hematoma (PH) near the level of the diaphragm at abdominal computed tomography (CT) as an indirect sign of acute traumatic aortic injury after blunt trauma in patients with mediastinal hematoma.

MATERIALS AND METHODS: From 1998 to 2001, 97 patients with CT evidence of mediastinal hematoma after blunt thoracic trauma were retrospectively identified at two level 1 trauma centers. The presence or absence of PH near the level of the diaphragmatic crura was retrospectively established by a blinded reviewer at each institution. Aortic injury status was determined by reviewing angiographic, surgical, and clinical records. Sensitivity, specificity, positive and negative productive values, and positive and negative likelihood ratios were calculated.

RESULTS: Among the 97 patients with mediastinal hematoma, 14 had both PH near the level of the diaphragm and aortic injury; six had aortic injuries without PH, five had PH near the level of the diaphragm without aortic injury, and 72 had no evidence of PH near the diaphragm and no aortic injury. Sensitivity for PH near the level of the diaphragm as a sign of aortic injury was 70%; specificity, 94%; positive predictive value, 74%; and negative predictive value, 92%. The positive likelihood ratio for the presence of aortic injury was 10.8, and the negative likelihood ratio was 0.3.

CONCLUSION: PH near the level of the diaphragmatic crura is an insensitive but relatively specific sign for aortic injury after blunt trauma. The presence of this sign at abdominal CT should prompt imaging of the thoracic aorta to evaluate potential thoracic aortic injury.

© RSNA, 2004

Index terms: Abdomen, CT, 70.12115 • Aorta, CT, 562.12115 • Aorta, injuries, 562.41, 942.41 • Emergency radiology • Mediastinum, hemorrhage, 67.43 • Thorax, injuries, 60.412, 60.4128 • Trauma


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
In the United States and Europe, blunt chest trauma accounts for 90% of cases of chest trauma and leads to 20% of trauma-related deaths (1). Motor vehicle accidents account for 63%–78% of cases of blunt chest trauma, and falls are responsible for 10%–17% (1). Acute traumatic aortic injury (ATAI) is among the most dangerous and life-threatening conditions seen in an emergency department, with only 10%–20% of patients surviving the initial injury (2–8). Among patients with ATAI who survive transport from the initial trauma scene, the mortality of untreated ATAI has been calculated as approximately 1% per hour for the first 48 hours (5,7–9).

Conventional angiography has, until recently, been considered the reference standard for the diagnosis of aortic injury. More recently, however, findings in multiple studies (1,8,10–25) have validated the use of helical computed tomographic (CT) angiography for the screening of patients with hemodynamically stable chest trauma for possible ATAI, with sensitivities ranging from 96%–99%. Many factors have led to the increased use of chest helical CT angiography for the evaluation of suspected ATAI, including its increased availability and speed compared with those of the reference standard aortography (22) and its ability to screen for other extrathoracic injuries, especially head, spine, and abdominal injuries (22).

At many institutions, thoracic and abdominal CT studies for trauma are requested as separate examinations. In such centers, in the absence of either clinical or chest radiographic evidence of clinically important thoracic trauma, thoracic CT angiography may not be performed routinely. We recently encountered two patients with no clinical or chest radiographic evidence of thoracic injury but with periaortic hematoma (PH) near the level of the diaphragm at abdominal CT. Both patients had ATAI and mediastinal hematoma at CT.

PH near the level of the aortic isthmus is an indirect sign of aortic injury, and multiple authors (21,26,27) have identified it as a common and suggestive finding of aortic rupture. The importance of PH near the level of the diaphragm as a sign of ATAI has not been well defined. The purpose of this study was to evaluate PH near the level of the diaphragm at abdominal CT as an indirect sign of ATAI after blunt trauma in patients with mediastinal hematoma.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients and Imaging
Institutional review board approval and waiver of informed consent was obtained at both institutions before initiation of this study.

Thoracoabdominal CT for blunt torso injury is ordered at the discretion of the trauma surgeons at both institutions; therefore, some patients with blunt injury do not undergo CT. However, the majority of seriously injured patients after blunt trauma, those who are at greatest risk for vascular injury, routinely undergo thoracoabdominal CT at both institutions.

The trauma registries at the two level 1 trauma centers were examined to identify all patients who underwent contrast material–enhanced thoracic and abdominal CT between February 1998 through September 2001 for examination after blunt thoracoabdominal injury. From these patient lists, one of the authors (H.W.), who was not involved in the image review portion of the study, obtained the radiology reports for thoracic CT angiography and used them to identify patients with evidence of mediastinal hematoma at helical CT.

The 97 patients in the study population (33 female and 64 male patients; mean age, 40.2 years; age range, 9 months to 88 years) had undergone contrast-enhanced thoracoabdominal helical CT at the two institutions during the time of the study, and had mediastinal hematoma diagnosed at helical CT.

The mean age for the male patients in the study population was 39.9 years, and that for the female patients was 41.0 years. Mediastinal hematoma was considered present if abnormal infiltrative-appearing soft-tissue attenuation was reported to have replaced normal mediastinal fat and to have partially or completely surrounded the descending thoracic aorta. The presence of mediastinal hematoma was first identified by the interpreting radiologist at the time of the CT examination and was subsequently confirmed by the reviewing radiologists involved in this study.

Abdominal CT was performed with helical CT scanners (HiSpeed Advantage and LightSpeed QXi; GE Medical Systems, Milwaukee, Wis). Intravenous contrast material (300 mg/mL iohexol, Omnipaque; Nycomed, Princeton, NJ) (150 mL) was injected at a rate of 2.5–3.5 mL/sec. Pitch of 1.5 and collimation of 5–7 mm with 3–5-mm reconstruction interval were used. A 70-second delay after contrast material injection was used at abdominal CT.

Imaging Examinations, Interpretation, and Aortic Injury Status
Two independent reviewers (M.B.G. and R.B.J., with 9 and 23 years experience, respectively), one at each institution, who were blinded with regard to the final aortic injury status, evaluated the CT images of the distal descending aorta near the level of the diaphragmatic crura for evidence of PH. The reviewers evaluated only those images obtained at their institution. CT images of the thoracic aorta were initially excluded from the reviewer analyses. After the presence or absence of PH was determined by the reviewer at each institution, the thoracic CT images were examined by that reviewer to confirm the original radiologic diagnosis of mediastinal hematoma.

PH was defined as a region of abnormal infiltrative-appearing soft-tissue attenuation that replaced the normal fat surrounding the descending thoracic aorta. PH was initially sought near the level of the cranial aspect of the diaphragm, beginning with the first image in the abdominal imaging volume, usually at approximately T11 or T12. Then, the search was extended inferiorly to the level of the inferior endplate of L1. Because the cranial aspect of the abdominal CT volume is usually prescribed with reference to the cranial aspect of the diaphragm, it was used as a convenient reference structure for the reviewers. Final aortic injury status was determined by reviewing conventional and thoracic CT angiography reports and surgical and medical records (H.W. at San Francisco General Hospital; H.W. and A.D.S. at Stanford University Medical Center). Aortic injury was considered to be present if one or more of the following findings were noted on either thoracic or conventional angiography reports: pseudoaneurysm, abnormal aortic contour, aortic dissection, active extravasation from the aorta, or aortic occlusion. The site of aortic injury was noted independently by the study coordinator at each institution. No attempt to correlate the site of aortic injury and the presence or absence of PH was made. Aortic injury was excluded in patients with negative conventional angiographic images. Patients who did not undergo conventional angiography were followed up clinically to exclude aortic injury, in a fashion similar to that described by Downing et al (25). Injuries to organs near the level of the diaphragm, where PH was sought, were also noted by the reviewers.

Information regarding the aortic injury status of the patients who did not undergo conventional angiography and in whom thoracic CT angiographic images were negative for acute traumatic aortic injury was collected by two of the authors (H.W. and A.D.S. at Stanford University Medical Center and San Francisco General Hospital and M.B.G. at San Francisco General Hospital) at the completion of this study. Specifically, the trauma registry notes and discharge notes for these patients were reviewed to establish if these patients were alive or dead at a minimum of 30 days (range, 30–185 days) after the initial traumatic event and to establish the clinical status of these patients at discharge.

Data Analysis
The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios for PH at the diaphragm as a sign of aortic injury were calculated. True-positive results were those in patients with PH who were subsequently shown to have ATAI, and true-negative results were those in patients without PH but with mediastinal hematoma elsewhere that was subsequently shown not to be ATAI at CT, conventional angiography, or clinical follow-up. False-positive results were those in patients with PH who were subsequently shown not to have ATAI, and false-negative results were those in patients without PH who were shown to have ATAI.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Among the 97 patients with mediastinal hematoma identified at thoracic CT angiography, 50 underwent conventional angiography, with findings that confirmed aortic injury in 10 patients. Findings at thoracic CT angiography in patients who did not undergo conventional angiography confirmed aortic injury in another 10 patients, yielding a total of 20 patients with acute traumatic aortic injury included in the study population. All 20 of these patients underwent surgical repair of the aortic injury; 14 of these patients had both PH near the level of the diaphragm and proved aortic injury (Figs 1, 2). Six patients had no PH near the level of the diaphragm and aortic injury, five had PH and no aortic injury, and 72 had no PH and no aortic injury (Table 1).



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  		Figure 1. Transverse contrast-enhanced CT scan (window width, 440 HU; level, 40 HU) obtained in 43-year-old man with ATAI after pedestrian versus motor vehicle collision. Image shows PH (arrow) at level of diaphragmatic crura as area of increased attenuation surrounding the aorta.

 


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  		Figure 2a. (a) Transverse contrast-enhanced CT scan (window width, 440 HU; level, 40 HU) obtained in 50-year-old woman with ATAI after motor vehicle collision. Image shows PH (arrow) near level of diaphragmatic crura as area of increased attenuation surrounding circumference of the aorta. (b) Left anterior oblique conventional angiographic image confirms the presence of traumatic aortic pseudoaneurysm (arrow) at aortic isthmus.

 


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  		Figure 2b. (a) Transverse contrast-enhanced CT scan (window width, 440 HU; level, 40 HU) obtained in 50-year-old woman with ATAI after motor vehicle collision. Image shows PH (arrow) near level of diaphragmatic crura as area of increased attenuation surrounding circumference of the aorta. (b) Left anterior oblique conventional angiographic image confirms the presence of traumatic aortic pseudoaneurysm (arrow) at aortic isthmus.

 

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  		TABLE 1. PH at Level of Diaphragmatic Crura: Correlation with Presence of ATAI

 
Sensitivity for PH as a sign of aortic injury was 70% (14/20) in patients with mediastinal hematoma identified at CT after blunt thoracoabdominal trauma, specificity was 94% (72/77), the positive predictive value was 74% (14/19), and the negative predictive value was 92% (72/78) (Table 2). The positive likelihood ratio for the presence of aortic injury was 10.8, and the negative likelihood ratio was 0.3 (Table 2).


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  		TABLE 2. Performance of PH at Level of Diaphragmatic Crura as Sign of ATAI

 
The site of aortic injury as determined at angiography and surgical evaluation was at the aortic isthmus (eight patients), in the proximal descending aorta (eight patients), and at the origin of the great vessels in the ascending aorta (four patients) (Table 3).


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  		TABLE 3. Location of ATAI

 
False-positive findings of PH at the level of the diaphragm were associated with other injuries, including diaphragmatic injury (one patient) and vertebral fractures (four patients).

Among the 37 patients without ATAI who did not undergo conventional angiography but had mediastinal hematoma identified at CT angiography, 29 were alive beyond 30 days after the traumatic event. None of the patients who died were thought to have died of ATAI; rather, intracranial injury and complicated hospital courses were thought to account for these fatalities.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
In hemodynamically stable patients after blunt chest trauma, screening thoracic helical CT angiography for ATAI has become standard of care at many institutions, with sensitivity ranging from 96% to 99%. Nevertheless, chest radiography is often performed prior to thoracic CT angiography, and CT may not be requested unless chest radiographs are abnormal, clinical signs suggest thoracic injury, or the mechanism of injury is considered sufficient to warrant thoracic CT angiography even if the chest radiograph does not suggest the presence of mediastinal vascular injury. Screening chest radiography for ATAI has clear limitations. Several reports have documented ATAI in the presence of normal or equivocally normal chest radiographs (1,13,16,17). This has led some observers to advocate routine use of thoracic CT angiography for the evaluation of patients after blunt trauma. Many centers, however, do not perform thoracoabdominal CT routinely in every case of trauma; rather, selected imaging examinations are performed under the direction of trauma surgeons or emergency physicians (22). Patients after blunt trauma may undergo only abdominal CT if ATAI is not suspected clinically and if the chest radiograph in the emergency room is negative for mediastinal hematoma.

Findings in the current study indicate that PH near the level of the diaphragm (approximately T11 through L1) has a relatively low sensitivity but high specificity for the diagnosis of ATAI in patients after blunt trauma with mediastinal hematoma identified at CT. The sensitivity and specificity of PH near the level of the diaphragm as an indirect sign of ATAI in our series were not as high as those reported by other investigators (10). This discrepancy may reflect the level at which the PH was identified. Curry et al (10) evaluated PH at the level of T9 and recorded sensitivity of 88% and specificity 100%. In our study, we examined the presence of PH at a lower level, approximately T11 through L1, which is approximately the level of the diaphragm, and found sensitivity of 70% and specificity of 94% for aortic injury.

Because our study was focused on the more distal aorta farther from the site of injury, it is reasonable to expect lower sensitivity because less blood dissects more distally. Nevertheless, the association between the presence of PH near the level of the diaphragm and thoracic aortic injury in our study indicates that PH near the level of the diaphragm should indicate the possibility of mediastinal vascular injury. Therefore, the presence of PH near the level of the diaphragm should prompt further imaging assessment of the entire thoracic aorta. It should be noted that there are other clinically important injuries that may result in PH near the level of the diaphragm, such as rupture of the diaphragm and vertebral fractures. These injuries may result in bleeding near the distal thoracic aorta and could explain the false-positive images for ATAI in our study. However, these injuries and traumatic aortic injury may coexist, so thoracic imaging would still be indicated when PH is found, even if coexisting injuries are present.

Limitations of this study include the relatively few patients in whom ATAI was evaluated. Obviously, larger studies including more trauma centers would add more power to our results. A second limitation was use of the evidence for mediastinal hematoma at thoracic CT angiography as the main selection criterion for inclusion in this study. The specificity of PH near the level of the diaphragm as a sign of aortic injury would probably decrease if we had evaluated the utility of this sign in all patients with blunt thoracoabdominal injury instead of limiting the analysis to only those patients with hematoma demonstrated at thoracoabdominal CT. If this sign were more widely applied, it is likely that more false-positive images would result, perhaps as a result of mediastinal venous bleeding or adjacent nonvascular injuries. Furthermore, a meta-analysis demonstrated a weighted mean sensitivity for mediastinal hematoma of 99.3% for ATAI (14), whereas other authors have reported a 9% occurrence of ATAI without mediastinal hematoma present (28). Therefore, the absence of PH or other forms of mediastinal hematoma does not necessarily exclude ATAI.

In conclusion, PH near the level of the diaphragmatic crura at abdominal CT should prompt consideration of ATAI, even in the presence of coexisting injuries near this level that could account for the presence of PH. We believe that additional imaging to assess the presence of ATAI is warranted when PH is present near the level of the diaphragm on CT scans obtained for the evaluation of patients after blunt trauma.


   FOOTNOTES
 
Abbreviations: ATAI = acute traumatic aortic injury, PH = periaortic hematoma

Author contributions: Guarantors of integrity of entire study, H.W., R.B.J., M.B.G.; study concepts and design, H.W., M.B.G., R.B.J.; literature research, H.W.; clinical studies, H.W., M.B.G., A.D.S.; data acquisition and analysis/interpretation, all authors; statistical analysis, H.W., R.B.J., M.B.G.; manuscript revision/review, all authors; manuscript preparation, definition of intellectual content, editing, and final version approval, H.W., R.B.J., M.B.G.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 

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