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The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries. [ABSTRACT FROM AUTHOR]

In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH.

Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Chen, Colasurdo, Malhotra, Gandhi and Bodanapally.)

Objective: We explore the feasibility to estimate the exudation from chronic subdural hematoma (CSDH) membranes, by using dual-energy computed tomography (DECT) quantification of iodine leak and test if the derived quantitative variables and membrane morphology correlates with hematoma volume, internal architecture (homogeneous, laminar, separated, and trabecular types), and fractional hyperdense hematoma at presentation., Methods: In this retrospective study, consecutive CSDH patients with postcontrast DECT head images from January 2020 and June 2021 were analyzed. Predictor variables derived from DECT were correlated with outcome variables followed by mixed-effects regression analysis., Results: The study included 36 patients with 50 observations (mean age, 72.6 years; standard deviation, 11.6 years); 31 were men. Dual-energy CT variables that correlated with hematoma volume were external membrane volume (ρ, 0.37; P = 0.008) and iodine concentration (ρ, -0.29; P = 0.04). Variables that correlated with separated type of hematoma were total iodine leak (median [Q 1 , Q 3 ], 68.3 mg [48.5, 88.9] vs 38.8 mg [15.5, 62.9]; P = 0.001) and iodine leak per unit membrane volume (median [Q 1 , Q 3 ], 16.47 mg/mL [10.19, 20.65] vs 8.68 mg/mL [5.72, 11.41]; P = 0.002). Membrane grade was the only variable that correlated with fractional hyperdense hematoma (ρ, 0.28; P = 0.05). Regression analysis showed total iodine leak as the strongest predictor of separated type hematoma (odds ratio [95% confidence interval], 1.06 per mg [1.01, 1.1])., Conclusions: Dual-energy CT demonstrates iodine leak from CSDH membranes. The variables derived from DECT correlated with hematoma volume, internal architecture, and fractional hyperdense hematoma., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This technical note describes a novel dual-energy CT (DECT) protocol with iodine map reconstruction that will enable visualization of chronic subdural hematoma (CSDH) membranes. We describe the technique and discuss the potential implications for surgical management. The cohort included 36 patients with 50 hematomas. Enhancing external membrane was demonstrated in all the 50 hematomas, incomplete internal membrane in 13, and complete internal membrane in 23 hematomas. A spandrel sign at the transition zone that indicates partial or complete formation of internal membrane was demonstrated in 36 hematomas. KEY POINTS: • Iodine maps from 5-min delayed post-contrast DECT provide spectral contrast difference and facilitate segregation of chronic subdural hematoma membranes. • The ability to image the membranes helps in assessing the degree of organization of the hematoma by providing the information about the membrane thickness, volume, complexity of the membranes, and the proportion of the liquefied component within the hematoma before surgical procedures are undertaken. • Membrane visualization helps in the localization of the transition zone and extension of the membranes over the cerebral lobes helping in the determination of craniotomy location and size, during membranectomy., (© 2022. The Author(s), under exclusive licence to European Society of Radiology.)

Background: precision-medicine quantitative tools for cross-sectional imaging require painstaking labeling of targets that vary considerably in volume, prohibiting scaling of data annotation efforts and supervised training to large datasets for robust and generalizable clinical performance. A straight-forward time-saving strategy involves manual editing of AI-generated labels, which we call AI-collaborative labeling (AICL). Factors affecting the efficacy and utility of such an approach are unknown. Reduction in time effort is not well documented. Further, edited AI labels may be prone to automation bias., Purpose: In this pilot, using a cohort of CTs with intracavitary hemorrhage, we evaluate both time savings and AICL label quality and propose criteria that must be met for using AICL annotations as a high-throughput, high-quality ground truth., Methods: 57 CT scans of patients with traumatic intracavitary hemorrhage were included. No participant recruited for this study had previously interpreted the scans. nnU-net models trained on small existing datasets for each feature (hemothorax/hemoperitoneum/pelvic hematoma; n = 77-253) were used in inference. Two common scenarios served as baseline comparison- de novo expert manual labeling, and expert edits of trained staff labels. Parameters included time effort and image quality graded by a blinded independent expert using a 9-point scale. The observer also attempted to discriminate AICL and expert labels in a random subset ( n = 18). Data were compared with ANOVA and post-hoc paired signed rank tests with Bonferroni correction., Results: AICL reduced time effort 2.8-fold compared to staff label editing, and 8.7-fold compared to expert labeling (corrected p < 0.0006). Mean Likert grades for AICL (8.4, SD:0.6) were significantly higher than for expert labels (7.8, SD:0.9) and edited staff labels (7.7, SD:0.8) (corrected p < 0.0006). The independent observer failed to correctly discriminate AI and human labels., Conclusion: For our use case and annotators, AICL facilitates rapid large-scale curation of high-quality ground truth. The proposed quality control regime can be employed by other investigators prior to embarking on AICL for segmentation tasks in large datasets., Competing Interests: Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors DD declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Background: Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population., Methods: An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed., Results: Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P  = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P  = 0.02)., Conclusions: Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Purpose: To present a method that automatically detects, subtypes, and locates acute or subacute intracranial hemorrhage (ICH) on noncontrast CT (NCCT) head scans; generates detection confidence scores to identify high-confidence data subsets with higher accuracy; and improves radiology worklist prioritization. Such scores may enable clinicians to better use artificial intelligence (AI) tools., Materials and Methods: This retrospective study included 46 057 studies from seven "internal" centers for development (training, architecture selection, hyperparameter tuning, and operating-point calibration; n = 25 946) and evaluation ( n = 2947) and three "external" centers for calibration ( n = 400) and evaluation ( n = 16    764). Internal centers contributed developmental data, whereas external centers did not. Deep neural networks predicted the presence of ICH and subtypes (intraparenchymal, intraventricular, subarachnoid, subdural, and/or epidural hemorrhage) and segmentations per case. Two ICH confidence scores are discussed: a calibrated classifier entropy score and a Dempster-Shafer score. Evaluation was completed by using receiver operating characteristic curve analysis and report turnaround time (RTAT) modeling on the evaluation set and on confidence score-defined subsets using bootstrapping., Results: The areas under the receiver operating characteristic curve for ICH were 0.97 (0.97, 0.98) and 0.95 (0.94, 0.95) on internal and external center data, respectively. On 80% of the data stratified by calibrated classifier and Dempster-Shafer scores, the system improved the Youden indexes, increasing them from 0.84 to 0.93 (calibrated classifier) and from 0.84 to 0.92 (Dempster-Shafer) for internal centers and increasing them from 0.78 to 0.88 (calibrated classifier) and from 0.78 to 0.89 (Dempster-Shafer) for external centers ( P < .001). Models estimated shorter RTAT for AI-prioritized worklists with confidence measures than for AI-prioritized worklists without confidence measures, shortening RTAT by 27% (calibrated classifier) and 27% (Dempster-Shafer) for internal centers and shortening RTAT by 25% (calibrated classifier) and 27% (Dempster-Shafer) for external centers ( P < .001)., Conclusion: AI that provided statistical confidence measures for ICH detection on NCCT scans reliably detected and subtyped hemorrhages, identified high-confidence predictions, and improved worklist prioritization in simulation. Keywords: CT, Head/Neck, Hemorrhage, Convolutional Neural Network (CNN) Supplemental material is available for this article . © RSNA, 2022., Competing Interests: Disclosures of conflicts of interest: E.G. Employed by Siemens Medical Solutions USA; inventor on related patent filing (to be held by Siemens Medical Solutions USA if granted); stock held in Siemens Healthineers. B.G. Employed by Siemens Healthineers. P.C. Employment at Siemens Healthineers, stock or stock options in Siemens Healthineers. P.H.T. Previously employed by Siemens Healthineers. Y.Y. Relevant patent filed December 3, 2021 (filing no. 2020E25048 US). J.D. Employed by Siemens Healthineers. T.J.R. Consultant fees from Siemens Healthineers, via intermediary Randstad North America (consulting payroll intermediary); support from Siemens Healthineers, Princeton, NJ for attending Radiological Society of North America Annual Meeting December 2018; patents planned, issued, or pending as follows: 16/270,918 (filed November 24, 2020), 21168065.7 (pending), 202110399157.6 (pending), 21180032.1 (pending), 16/946,435 (pending), 16/837,979 (pending), 17/249,783 (pending), 201910491911.1 (pending), 202110346295.8 (pending), 21165531.1 (pending), 16/356,086 (pending), 17/211,927 (pending), 19163699.2, (pending), 16/865,266 (pending), 19177891.9 (pending). V.R.S. Employed by Siemens Healthineers. A.B. Employed by Siemens Healthcare, India as Research & Technology Manager (radiologist by profession). E.E. Employed by Siemens Healthcare; patents planned, issued, or pending. A.C. Employed by Siemens Healthcare; patents planned, issued, or pending; stock/stock options. B.B. Previously employed by Siemens Healthineers. U.K.B. Support from Siemens; has grant. S.N. No relevant relationships. P.C.S. Grants from National Institutes of Health National Institute of Neurological Disorders and Stroke, Siemens Healthineers, and Neiman Health Policy Institute to author’s institution; leadership or fiduciary role in American Society of Neuroradiology. T.J.S. No relevant relationships. T.F. Employed by Siemens Healthcare. D.C. Employed by Siemens Healthineers; stock/stock options in Siemens Healthineers. Y.W.L. Support from Siemens Healthineers (institution received reimbursement for costs from institutional review board and IT related to data collection, clinical research support unit, and a finance and administration surcharge relating to this work)., (© 2022 by the Radiological Society of North America, Inc.)

Dual-energy computed tomography (DE CT) is a promising tool with many current and evolving applications. Available DE CT scanners usually consist of one or two tubes, or use layered detectors for spectral separation. Most DE CT scanners can be used in single energy or dual-energy mode, except for the layered detector scanners that always acquire data in dual-energy mode. However, the layered detector scanners can retrospectively integrate the data from two layers to obtain conventional single energy images. DE CT mode enables generation of virtual monochromatic images, blended images, iodine quantification, improving conspicuity of iodinated contrast enhancement, and material decomposition maps or more sophisticated quantitative analysis not possible with conventional SE CT acquisition with an acceptable or even lower dose than the SE CT. This article reviews the basic principles of dual-energy CT and highlights many of its clinical applications in the evaluation of neurological conditions., (Copyright © 2021. Published by Elsevier Inc.)

OBJECTIVE. The objectives of this study were to examine the performance of CT in the diagnosis of ischemic mesenteric laceration after blunt trauma and to assess the predictive value of various CT signs for this injury. MATERIALS AND METHODS. In this retrospective study, consecutive patients with bowel and mesenteric injury diagnosed by CT or surgery from January 2011 through December 2016 were analyzed. Two radiologists evaluated CT images for nine signs of bowel injury. The outcome evaluated was ischemic mesenteric laceration. Univariable analysis followed by logistic regression was performed. RESULTS. The study included 147 patients (96 men and 51 women; median age, 35 years; age range, 23-52 years). Thirty-three patients had surgically confirmed ischemic mesenteric lacerations. CT signs that correlated with ischemic mesenteric laceration were abdominal wall injury, mesenteric contusion, free fluid, segmental bowel hypoenhancement, and bowel hyperenhancement adjacent to a hypoenhancing segment. The regression model developed after inclusion of clinical variables identified two predictors: segmental bowel hypoenhancement (adjusted odds ratio, 22.9 [95% CI, 7.9-66.2; p < .001] for reviewer 1 and 20.7 [95% CI, 7.2-59.0; p < .001] for reviewer 2) and abdominal wall injury (adjusted odds ratio, 5.26 [95% CI, 1.7-15.9; p = .003] for reviewer 1 and 5.3 [95% CI, 1.9-15.0; p = .002] for reviewer 2), which yielded an AUC of 0.87 for predicting injury. For reviewer 1 and reviewer 2, the sensitivities of CT in detecting the injury were 72.3% (95% CI, 54.5-86.7%) and 78.8% (95% CI, 61.0-91.0%), respectively, whereas the specificities were 94.7% (95% CI, 88.9-98.0%), and 92.1% (95% CI, 85.5-96.3%), respectively. CONCLUSION. CT has limited sensitivity but good specificity for detecting ischemic mesenteric laceration, with segmental bowel hypoenhancement considered the most predictive imaging sign.

This prospective longitudinal study compares the ability of conventional and diffusion tensor imaging (DTI) parameters made at the cervical spinal cord injury (CSCI) site to predict long-term neurological and functional outcomes. Twenty patients with CSCI, with follow-up at 6 or 12 months, and 15 control volunteers were included. Conventional magnetic resonance imaging (MRI) and DTI parameters were measured on admission and follow-up studies. Stepwise regression analysis was performed to find relevant parameters (normalized DTI values, conventional MRI measurements, hemorrhagic contusion [HC] or non-HC [NHC]) that correlated with three primary outcome measures: patient International Standards for Neurological Classification of Spinal Cord Injury total motor score (ISNCSCI-TMS), ability to walk, and expected recovery of upper limb motor scores (ER-ULMS) at 6 or 12 months. Univariate analysis showed HC ( p  < 0.0001 to 0.0098), lesion length on follow-up MRI ( p  < 0.0001 to 0.019), mean diffusivity ( p  = 0.01 to 0.045), and axial diffusivity ( p  = 0.004 to 0.023) predicted all three primary outcomes. Conspicuity of HC was significantly better on axial susceptibility-weighted imaging (SWI) compared with T2* images ( p  = 0.0009). A negative correlation existed between HC volumes on sagittal SWI images and follow-up ISNCSCI-TMS ( p  = 0.02). The regression model identified NHC as the best predictor of the ability to walk (sensitivity = 88.9%; specificity = 100%; positive predictive value = 100%; negative predictive value = 91%; p  < 0.0001) and lesion length on follow-up MRI as the best predictor of ER-ULMS (β coefficient = 0.12, standard error [SE] = 0.07; R 2  = 0.64; p  = 0.0002). Finally, NHC (β coefficient = 24.2, SE = 3.7; p  < 0.0001) and lesion length on initial MRI (β coefficient = 0.78, SE = 0.2; p  = 0.002) were the best predictors of ISNCSCI-TMS (R 2  = 0.83; p  < 0.0001). Our study demonstrates HC and follow-up lesion length are potential neuroimaging biomarkers in predicting long-term neurological and functional outcome following blunt CSCI.

Background and Purpose: Hemorrhagic contusions are associated with iodine leakage. We aimed to identify quantitative iodine-based dual-energy CT variables that correlate with the type of intracranial pressure management., Materials and Methods: Consecutive patients with contusions from May 2016 through January 2017 were retrospectively analyzed. Radiologists, blinded to the outcomes, evaluated CT variables from unenhanced admission and short-term follow-up head dual-energy CT scans obtained after contrast-enhanced whole-body CT. Treatment intensity of intracranial pressure was broadly divided into 2 groups: those managed medically and those managed surgically. Univariable analysis followed by logistic regression was used to develop a prediction model., Results: The study included 65 patients (50 men; median age, 48 years; Q 1 to Q 3 , 25-65.5 years). Twenty-one patients were managed surgically (14 by CSF drainage, 7 by craniectomy). Iodine-based variables that correlated with surgical management were higher iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusions. The regression model developed after inclusion of clinical variables identified 3 predictor variables: postresuscitation Glasgow Coma Scale (adjusted OR = 0.55; 95% CI, 0.38-0.79; P = .001), age (adjusted OR = 0.9; 95% CI, 0.85-0.97; P = .003), and pseudohematoma volume (adjusted OR = 2.05; 95% CI, 1.1-3.77; P = .02), which yielded an area under the curve of 0.96 in predicting surgical intracranial pressure management. The 2 predictors for craniectomy were age (adjusted OR = 0.89; 95% CI, 0.81-0.99; P = .03) and pseudohematoma volume (adjusted OR = 1.23; 95% CI, 1.03-1.45; P = .02), which yielded an area under the curve of 0.89., Conclusions: Quantitative iodine-based parameters derived from follow-up dual-energy CT may predict the intensity of intracranial pressure management in patients with hemorrhagic contusions., (© 2019 by American Journal of Neuroradiology.)

BackgroundTraumatic hemorrhagic contusions are associated with iodine leak; however, quantification of leakage and its importance to outcome is unclear.PurposeTo identify iodine-based dual-energy CT variables that correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.Materials and MethodsIn this retrospective study, consecutive patients with contusions from May 2016 through January 2017 were analyzed. Two radiologists evaluated CT variables from unenhanced admission head CT and follow-up head dual-energy CT scans obtained after contrast material-enhanced whole-body CT. The outcomes evaluated were in-hospital mortality, Rancho Los Amigos scale (RLAS) score, and disability rating scale (DRS) score. Logistic regression and linear regression were used to develop prediction models for categorical and continuous outcomes, respectively.ResultsThe study included 65 patients (median age, 48 years; interquartile range, 25-65.5 years); 50 were men. Dual-energy CT variables that correlated with mortality, RLAS score, and DRS score were iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusion. The single-energy CT variable that correlated with mortality, RLAS score, and DRS score was hematoma volume at follow-up CT. Multiple logistic regression analysis after inclusion of clinical variables identified two predictors that enabled determination of mortality: postresuscitation Glasgow coma scale (P-GCS) (adjusted odds ratio, 0.42; 95% confidence interval [CI]: 0.2, 0.86; P = 0.01) and iodine quantity in pseudohematoma (adjusted odds ratio, 1.4 per milligram; 95% CI: 1.02 per milligram, 1.9 per milligram; P = 0.03), with a mean area under the receiver operating characteristic curve of 0.96 ± 0.05 (standard error). For RLAS, the predictors were P-GCS (mean coefficient, 0.32 ± 0.06; P < .001) and iodine quantity in contusion (mean coefficient, -0.04 per milligram ± 0.02; P = 0.01). Predictors for DRS were P-GCS (mean coefficient, -1.15 ± 0.27; P < .001), age (mean coefficient, 0.13 per year ± 0.04; P = .002), and iodine quantity in contusion (mean coefficient, 0.19 per milligram ± 0.07; P = .02).ConclusionIodine-based dual-energy CT variables correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.© RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Talbott and Hess in this issue.

Purpose: To compare the utility of abdominopelvic fluid volume measurements with established computed tomography signs for refractory post-traumatic abdominal compartment syndrome., Methods: This retrospective observational cohort study included 64 consecutive adult trauma patients with preoperative CT and diagnosis of refractory abdominal compartment syndrome requiring decompressive laparotomy at a level I trauma referral center between 2004 and 2014. We hypothesized that abdominal fluid volume measurements would be more predictive of the need for early laparotomy than previously described conventional CT signs of refractory ACS. Abdominopelvic fluid volumes were determined quantitatively using semi-automated segmentation software. The following conventional imaging parameters were recorded: abdominal anteroposterior:transverse ratio (round belly sign); infrahepatic vena cava diameter; distal abdominal aortic diameter; largest single small bowel wall diameter; hydronephrosis, inguinal herniation; and mesenteric and body wall edema. For outcome analysis, patients were stratified into two groups: those who underwent early (< 24 h) and late (≥ 24 h) decompressive laparotomy following CT. Correlation analysis, comparison of means, and multivariate logistic regression were performed., Results: Abdominal fluid volumes (p = 0.001) and anteroposterior:transverse ratio (p = 0.009) were increased and inferior vena cava diameter (p = 0.009) was decreased in the early decompressive laparotomy group. Multivariate analysis including conventional CT variables, fluid volumes, and laboratory values revealed abdominal fluid volumes (p = 0.012; Δ in log odds of 1.002/mL) as the only independent predictor of early decompressive laparotomy., Conclusions: Segmented abdominopelvic free fluid volumes had greater predictive utility for decision to perform early decompressive laparotomy than previously described ACS-related CT signs in trauma patients who developed refractory abdominal compartment syndrome.

High-energy monochromatic (190 keV) images may be more reliable than standard 120 kV Images for detecting intracranial hemorrhages. We aimed to retrospectively compare virtual high monochromatic (190 keV) and standard 120 kV images from dual-energy computed tomography (CT; DECT) for the diagnosis of intracranial hemorrhages in traumatic brain injury (TBI). We analyzed admission CT studies in 100 trauma patients. Three radiologists independently reviewed four image sets: 120 kV and 190 keV (thin [1 mm] and thick [5 mm] section) images for the presence of various types of intracranial hemorrhages. The proportions of positive variables were compared and differences calculated by McNemar test and sensitivities determined by contingency tables. Randomly selected hemorrhagic lesions were analyzed for contrast index (CI). Thin-section 190 keV images were superior in the detection of subdural hematomas (SDH) (p < 0.0001), supratentorial contusions (p < 0.0001), and epidural hematomas (EDH) (p = 0.014), when compared with standard 120 kV images. However, 190 keV images were inferior to standard 120 kV images in diagnosis of subarachnoid hemorrhage (SAH) (thin-sections, p = 0.059; thick-sections, 0.0075). The 190 keV images yielded moderate increase in CI of contusions (Cohen's d > 0.53) and a large increase in CI of extra-axial hematomas (Cohen's d > 0.86). Our results indicate that virtual high monochromatic (190 keV, thin-section) images combined with standard 120 kV images may provide optimal diagnostic performance for evaluation of patients suspected of TBI.

Background and Purpose: In patients with hemorrhagic contusions, hematoma volumes are overestimated on follow-up standard 120-kV images obtained after contrast-enhanced whole-body CT. We aimed to retrospectively determine hemorrhagic progression of contusion rates on 120-kV and 190-keV images derived from dual-energy CT and the magnitude of hematoma volume overestimation., Materials and Methods: We retrospectively analyzed admission and follow-up CT studies in 40 patients with hemorrhagic contusions. After annotating the contusions, we measured volumes from admission and follow-up 120-kV and 190-keV images using semiautomated 3D segmentation. Bland-Altman analysis was used for hematoma volume comparison., Results: On 120-kV images, hemorrhagic progression of contusions was detected in 24 of the 40 patients, while only 17 patients had hemorrhagic progression of contusions on 190-keV images ( P = .008). Hematoma volumes were systematically overestimated on follow-up 120-kV images (9.68 versus 8 mm 3 ; mean difference, 1.68 mm 3 ; standard error, 0.37; P < .001) compared with 190-keV images. There was no significant difference in volumes between admission 120-kV and 190-keV images. Mean and median percentages of overestimation were 29% (95% CI, 18-39) and 22% (quartile 3 - quartile 1 = 36.8), respectively., Conclusions: The 120-kV images, which are comparable with single-energy CT images, significantly overestimated the hematoma volumes, hence the rate of hemorrhagic progression of contusions, after contrast-enhanced whole-body CT. Hence, follow-up of hemorrhagic contusions should be performed on dual-energy CT, and 190-keV images should be used for the assessment of hematoma volumes., (© 2018 by American Journal of Neuroradiology.)

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. © RSNA, 2018.

Background and Purpose: Extravasation of iodinated contrast into subdural space following contrast-enhanced radiographic studies results in hyperdense subdural effusions, which can be mistaken as acute subdural hematomas on follow-up noncontrast head CTs. Our aim was to identify the factors associated with contrast-enhancing subdural effusion, characterize diffusion and washout kinetics of iodine in enhancing subdural effusion, and assess the utility of dual-energy CT in differentiating enhancing subdural effusion from subdural hematoma., Materials and Methods: We retrospectively analyzed follow-up head dual-energy CT studies in 423 patients with polytrauma who had undergone contrast-enhanced whole-body CT. Twenty-four patients with enhancing subdural effusion composed the study group, and 24 randomly selected patients with subdural hematoma were enrolled in the comparison group. Postprocessing with syngo.via was performed to determine the diffusion and washout kinetics of iodine. The sensitivity and specificity of dual-energy CT for the diagnosis of enhancing subdural effusion were determined with 120-kV, virtual monochromatic energy (190-keV) and virtual noncontrast images., Results: Patients with enhancing subdural effusion were significantly older (mean, 69 years; 95% CI, 60-78 years; P < .001) and had a higher incidence of intracranial hemorrhage ( P = .001). Peak iodine concentration in enhancing subdural effusions was reached within the first 8 hours of contrast administration with a mean of 0.98 mg/mL (95% CI, 0.81-1.13 mg/mL), and complete washout was achieved at 38 hours. For the presence of a hyperdense subdural collection on 120-kV images with a loss of hyperattenuation on 190-keV and virtual noncontrast images, when considered as a true-positive for enhancing subdural effusion, the sensitivity was 100% (95% CI, 85.75%-100%) and the specificity was 91.67% (95% CI, 73%-99%)., Conclusions: Dual-energy CT has a high sensitivity and specificity in differentiating enhancing subdural effusion from subdural hematoma. Hence, dual-energy CT has a potential to obviate follow-up studies., (© 2017 by American Journal of Neuroradiology.)

Background and Purpose: The present prognostic models for open globe injuries have a limited ability to predict visual outcome before a comprehensive ophthalmologic examination or operation because they depend on the data derived from the ophthalmologic examination and intraoperative findings. The purpose of our study was to determine the specific CT and preoperative clinical data that can predict the prognosis of open globe injury., Materials and Methods: We analyzed the relationship of 29 variables derived from clinical and CT data from 97 globe injuries with visual acuity at 1 month. A prediction model was derived from 49 globe injuries by regression analysis, followed by receiver operating characteristic curve analysis of the best CT predictor., Results: Four variables with significance on a regression model were the following: posterior segment hemorrhage (β = -0.93, P < .0001), presenting visual acuity (β = 0.28, P = .042), orbital emphysema (β = 0.46, P = .0018), and complex facial fracture (β = -0.43, P = .009). Receiver operating characteristic analysis of the posterior segment hemorrhage predicted profound vision loss (light perception or no light perception) with an area under the curve of 0.97. The receiver operating characteristic table indicated that grade III posterior segment hemorrhage has a strong positive predictive value of 100% for profound vision loss. On the other hand, the absence of posterior segment hemorrhage has a strong positive predictive value of 93% for mild-to-severe vision loss (visual acuity better than light perception)., Conclusions: Radiologists, with the help of CT and preoperative clinical data, can predict visual acuity after open globe injury., (© 2017 by American Journal of Neuroradiology.)

Purpose To determine the diagnostic performance of multidetector computed tomography (CT) with trajectography for penetrating colorectal injuries. Materials and Methods This institutional review board-approved and HIPAA-compliant study was a 6-year blinded retrospective review by two independent readers of 182 consecutive patients who preoperatively underwent 40- or 64-row multidetector CT for penetrating torso trauma below the diaphragm and had surgically confirmed findings. Colorectal perforation was present in 42 patients. Trajectory analysis with postprocessing software was used for all studies. Additional signs evaluated were rectal contrast agent leak, collections of extruded fecal material, mural defect, wall thickening, abnormal enhancement, free fluid or stranding, and free air. The quality of the colorectal contrast agent administration was recorded. Sensitivity, specificity, predictive values, areas under the receiver operating characteristic curves (AUCs), and Cohen κ were determined. Results In patients with rectal contrast agent administration (n = 151), AUCs were 0.90-0.91, which indicated excellent accuracy. Trajectory was sensitive (88%-91%). For single wounds (n = 104), sensitivity of trajectory was 96% for both readers, but was only 80% for multiple wounds (n = 47). Contrast agent leak was highly specific (96%-98%), but insensitive (42%-46%). Improved diagnostic performance was observed in patients with poor colonic distension or opacification. Accuracy remained high (AUC, 0.86-0.99) in the group without rectal contrast agent administration (n = 31). Conclusion Trajectory had excellent sensitivity, while rectal contrast agent leak was specific but insensitive. Sensitivity of trajectory was lower for multiple wounds. Accuracy remained high in patients without rectal contrast agent administration. © RSNA, 2016.

Objective: Pelvic binders may hinder radiologic assessment of pelvic instability after trauma, and avulsive injuries can potentially unmask instability in this setting. We compare the performance of MDCT for the detection of pelvic disruptions in patients with binders to a matched cohort without binders, and we assess the utility of avulsive injuries as signs of pelvic instability., Materials and Methods: MDCT examinations of 56 patients with binders were compared with MDCT examinations of 54 patients without binders. Tile grading by an experienced orthopedic surgeon was used as the reference standard (A, stable; B, rotationally unstable; C, rotationally and vertically unstable). Two radiologists performed blinded reviews of CT studies in two reading sessions (sessions 1 and 2). In session 1, Tile grade was predicted on the basis of established signs of instability, including pubic symphysis and sacroiliac (SI) joint widening. In session 2, readers could change the Tile grade when avulsive injuries were seen. Diagnostic performance for predicting rotational instability and vertical instability was assessed., Results: In the binder group, AUCs under the ROC curves for rotational instability increased from fair (0.73-0.77) to good (0.82-0.89) when avulsive signs were considered. In the control group, AUCs were good in both sessions. AUCs for vertical instability were fair with binders in both sessions. Agreement with the reference standard increased from fair (0.30-0.32) to moderate (0.46-0.54) when avulsive signs were considered in the binder group but were in the moderate range for both sessions in the control group. Combined evaluation for inferolateral sacral fractures, ischial spine fractures, and rectus abdominis avulsions resulted in optimal discrimination of rotational instability., Conclusion: Evaluation for avulsive signs improves MDCT sensitivity for the detection of rotational instability but not vertical instability in patients with binders.

Purpose: Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined., Materials and Methods: This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures., Results: Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury., Conclusion: CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery., Key Points: • The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

Objective: Manually segmented traumatic pelvic hematoma volumes are strongly predictive of active bleeding at conventional angiography, but the method is time intensive, limiting its clinical applicability. We compared volumetric analysis using semi-automated region growing segmentation to manual segmentation and diameter-based size estimates in patients with pelvic hematomas after blunt pelvic trauma., Materials and Methods: A 14-patient cohort was selected in an anonymous randomized fashion from a dataset of patients with pelvic binders at MDCT, collected retrospectively as part of a HIPAA-compliant IRB-approved study from January 2008 to December 2013. To evaluate intermethod differences, one reader (R1) performed three volume measurements using the manual technique and three volume measurements using the semi-automated technique. To evaluate interobserver differences for semi-automated segmentation, a second reader (R2) performed three semi-automated measurements. One-way analysis of variance was used to compare differences in mean volumes. Time effort was also compared. Correlation between the two methods as well as two shorthand appraisals (greatest diameter, and the ABC/2 method for estimating ellipsoid volumes) was assessed with Spearman's rho (r)., Results: Intraobserver variability was lower for semi-automated compared to manual segmentation, with standard deviations ranging between ±5-32 mL and ±17-84 mL, respectively (p = 0.0003). There was no significant difference in mean volumes between the two readers' semi-automated measurements (p = 0.83); however, means were lower for the semi-automated compared with the manual technique (manual: mean and SD 309.6 ± 139 mL; R1 semi-auto: 229.6 ± 88.2 mL, p = 0.004; R2 semi-auto: 243.79 ± 99.7 mL, p = 0.021). Despite differences in means, the correlation between the two methods was very strong and highly significant (r = 0.91, p < 0.001). Correlations with diameter-based methods were only moderate and nonsignificant. Mean semi-automated segmentation time effort was 2 min and 6 s and 2 min and 35 s for R1 and R2, respectively, vs. 22 min and 8 s for manual segmentation., Conclusion: Semi-automated pelvic hematoma volumes correlate strongly with manually segmented volumes. Since semi-automated segmentation can be performed reliably and efficiently, volumetric analysis of traumatic pelvic hematomas is potentially valuable at the point-of-care.

After the nasal bones, the mandible is the second most common site of facial fractures, and mandibular fractures frequently require open reduction. In the trauma injury setting, multidetector computed tomography (CT) has become the cornerstone imaging modality for determining the most appropriate treatment management, fixation method, and surgical approach. Multidetector CT is also used to assess the adequacy of the reduction and evaluate potential complications in the postoperative period. For successful restoration of the mandible's form and function, as well as management of posttraumatic and postoperative complications, reconstructive surgeons are required to have a detailed understanding of mandibular biomechanics, occlusion, and anatomy. To provide added value in the diagnosis, treatment planning, and follow-up of mandibular fractures, radiologists should be aware of these concepts. Knowledge of the techniques commonly used to achieve occlusal and anatomic reduction and of the rationale behind the range of available treatment options for different injury patterns-from isolated and nondisplaced fractures to multisite and comminuted fractures-also is essential. This article focuses on the use of multidetector CT for pre- and postoperative evaluation of mandibular fractures and outlines fundamental concepts of diagnosis and management-beginning with an explanation of common fracture patterns and their biomechanical underpinnings, and followed by a review of the common postoperative appearances of these fractures after semirigid and rigid fixation procedures. Specific considerations regarding fractures in different regions of the tooth-bearing and non-tooth-bearing mandible and the unique issues pertaining to the edentulous atrophic mandible are reviewed, and key features that distinguish major from minor complications are described. (©)RSNA, 2016.

Objectives: To determine the specific CT findings of penetrating neck wound profile predicting aerodigestive injuries, diagnostic performance of CTA and to propose a modified selective management algorithm to reduce nontherapeutic invasive procedures., Methods: We retrospectively evaluated CTAs of 102 patients to determine the presence of various CT signs. "Trajectory"-based signs included trajectory of the wound extending into the aerodigestive tract and trajectory violating the deep neck spaces. "Conventional" signs included transcervical injury; wall defect; air or blood in the deep neck spaces; irregular or thickened aerodigestive tract; and active mucosal bleeding., Results: Trajectory of the wound extending into the aerodigestive tract (sensitivity 76 %, specificity 97 %) and trajectory of the wound violating the suprahyoid deep neck spaces or the infrahyoid visceral space (sensitivity 97 %, specificity 55 %) were the best predictors of injury on regression analysis. The most specific "conventional" CT signs were "wall defect" and "active mucosal bleed", but had very low sensitivity. The sensitivity of CTA for detecting an injury ranged from 89.5 % to 92 %, specificity ranged from 62.5 % to 89 %., Conclusion: CTA can be a useful technique in detecting aerodigestive injury. Our proposed management algorithm can exclude an injury with high degree of confidence (sensitivity 97 %)., Key Points: • Trajectory-based CT signs predict aerodigestive injury after penetrating neck trauma. • Surgery should be considered when trajectory extends into the infra-arytenoid aerodigestive tract. • Endoscopy or exploration should be considered when trajectory violates deep neck spaces. • This modified approach can decrease negative explorations and invasive diagnostic procedures.

Objectives: To determine the frequency, clinical characteristics, and visual outcomes of patients who present with high or normal intraocular pressure (IOP) and open globe injuries., Design: Retrospective chart review., Setting: University of Maryland Medical Center, a level 1 trauma center., Patient or Study Population: All cases of open globe injury presenting to The University of Maryland Medical Center from July 2005 to January 2014., Observation: Demographics, initial physical examination, computed tomography findings, IOP of the affected and unaffected eyes, and follow-up evaluations., Main Outcome Measures: (1) IOP 10 mm Hg or greater and (2) visual acuity., Results: Of 132 eyes presenting with open globe injury, IOP was recorded in 38 (28%). Mean IOP for the affected and unaffected eyes was 14±10.3 mm Hg and 16.6±4.1 mm Hg, respectively. Twenty-three (59.4%) eyes had IOP greater than 10 mm Hg. Six eyes (16.2%) had IOP greater than 21 mm Hg. Using bivariate analysis, IOP greater than 10 mm Hg was associated with posterior open globe injury (P=0.01), posterior hemorrhage (P=0.04), and intraconal retrobulbar hemorrhage (P=0.05). Adjusting for age, sex, and race, IOP greater than 10 mm Hg was associated with the presence of posterior open globe injury on clinical examination (P=0.04). Higher presenting IOP was found to predict light perception or worse vision (P=0.01). Multivariate analysis showed that poor presenting vision was the best predictor of poor final vision (P<0.01)., Conclusions: High IOP does not exclude open globe injury. It is a frequent finding in patients with open globe injuries and may be associated with posterior injury and poor visual prognosis.

Objective: The aim of our blinded retrospective study was to evaluate the diagnostic performance of the Subaxial Cervical Spine Injury Classification (SLIC) System in predicting the need for surgical intervention after subaxial cervical spine injury; SLIC scores were determined using CT alone or both CT and MRI., Materials and Methods: Patients were included if they had injuries that were subaxial (C3-C7), if they had undergone CT and MRI within 48 hours of admission, if they were either treated surgically or had sufficient clinical documentation describing nonsurgical management (halo device or hard collar), and if the SLIC neurologic score could be determined from a documented neurologic examination. Two hundred two consecutive patients (139 surgical patients and 63 nonsurgical control subjects) from January 2010 through December 2013 met all criteria and were included in the study. Additionally, 40 patients were randomly selected from this group for the purpose of determining interrater agreement. Initially, readers gave a SLIC score (< 4 for nonsurgical, 4 = indeterminate, > 4 for surgical) based on neurologic status and CT only. After waiting 4 weeks to minimize recall bias, the readers repeated scoring with the addition of MRI. Diagnostic performance values-that is, sensitivity, specificity, AUC under the ROC curve, and interrater agreement (Cohen kappa)-for both trials were determined., Results: Using a SLIC score of 4 as the cutoff value for surgical intervention, we found that SLIC scoring based on CT and MRI had a sensitivity of 94.6%, specificity of 71.0%, and AUC of 0.87 with a kappa value of 0.28. SLIC scoring based on CT alone had a sensitivity of 86.2%, specificity of 77.3%, and AUC of 0.88 with a kappa value of 0.52., Conclusion: SLIC scoring based on CT alone performs similarly to SLIC scoring based on CT and MRI but with improved interobserver agreement. Although MRI is useful for surgical planning, these results indicate that MRI may have limited added value in the initial triage of patients with subaxial cervical spine injury for conservative versus surgical management.

Objective: The purposes of this study were to assess the diagnostic performance of 40- and 64-MDCT angiography with digital subtraction angiography as the reference standard in the detection of arterial injuries in patients at high risk after penetrating neck trauma and to perform a separate analysis of injuries to the external carotid artery., Materials and Methods: In a retrospective evaluation of 53 sets of angiograms from 51 patients with penetrating neck injury, three reviewers unaware of the digital subtraction angiographic findings reviewed the CT angiographic (CTA) images to discern the presence or absence of arterial injuries. Sensitivity and specificity of CTA were calculated per injury, and a separate analysis of external carotid artery injuries was performed., Results: Sensitivity of CTA for detecting arterial injuries ranged from 75.7% (95% CI, 62.3-86.9%) to 82.2% (95% CI, 69.5-92.1%). Specificity ranged from 96.4% (95% CI, 94.0-98.4%) to 98.4% (95% CI, 96.0-100%). CTA was highly sensitive for detection of the subgroup of injuries involving the large-caliber vessels that contribute to cerebral circulation. These sensitivities ranged from 92.8% (95% CI, 66-98.8%) to 100% (95% CI, 76.6-100%) for internal carotid artery injuries and from 88.9% (95% CI, 65.2-98.3%) to 94.4% (95% CI, 72.6-99.0%) for vertebral artery injuries. In contrast, sensitivity of CTA was limited for external carotid artery injuries, ranging from 63.4% (95% CI, 45.5-79.5%) to 70.0% (95% CI, 52.0-85.0%)., Conclusion: CTA can be used for initial evaluation and may help guide management decisions if an external carotid artery injury is detected. Negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.

Victims of penetrating torso trauma often present with findings that necessitate emergent exploratory laparotomy, precluding scanning with multidetector computed tomography (MDCT) until the postoperative period. This article reviews the wide range of complications as well as expected findings that may be encountered at MDCT performed postoperatively. Little has been written to guide the radiologist in interpreting these often complex and potentially confusing studies.

Objective: This article aims to familiarize radiologists with the terms used to describe clinicoradiologic mismatch in blunt spinal cord injuries, and also assesses MRI findings and their prognostic value for both pediatric and adult patients., Conclusion: Knowledge of the lexicon of spinal cord injury without radiographic abnormality, the spectrum of MRI findings, and imaging predictors of outcome can help render a precise imaging diagnosis and can provide evidence-based prognostic information.

The purpose of this study was to determine the relationship between admission visual acuity (VA) and facial computed tomographic (CT) findings of traumatic optic neuropathy (TON). We retrospectively evaluated CT findings in 44 patients with TON. Mid-facial fractures, extraconal and intraconal hematomas, hematomas along the optic nerve and the posterior globe, optic canal fracture, nerve impingement by optic canal fracture fragment, and extraconal and intraconal emphysema were evaluated. CT variables of patients with and without available VA were compared. VA was converted into logarithm of the minimum angle of resolution (logMAR) to provide a numeric scale for the purpose of statistical analysis. The risk factors related to poor VA on univariate analysis were as follows: intraconal hematoma [median logMAR -4.7 versus -1.15, p = 0.016] and hematoma along the optic nerve [median -4.7 versus -1.3, p = 0.029]. Intraconal hematoma was the best predictor of poor VA (coefficient, 1.01; SE, 0.34; and p = 0.008). Receiver operating characteristic (ROC) curve analysis showed that the presence of intraconal hematoma and hematoma along the optic nerve predicted poor VA (logMAR of -3.7 or lower) with an area under the curve of 0.8 and 0.85, respectively. TON patients at higher risk of severe visual impairment may be identified based on admission facial CT.

Background and Purpose: Abnormal signal intensity of the optic nerve due to diffusion restriction may be seen in traumatic optic neuropathy. In addition to evaluating optic nerve hyperintensity on diffusion-weighted imaging, we compared the group differences of ADC values between the injured and uninjured contralateral nerve and identified the relation between measured ADC values and admission visual acuity., Materials and Methods: We retrospectively evaluated 29 patients with traumatic optic neuropathy who underwent MR imaging with DWI. Uninjured contralateral optic nerves were used as controls. Two attending radiologists, blinded to the side of injury, independently reviewed the DWI for the presence of signal-intensity abnormality and obtained ADC values after manually selecting the ROI., Results: Hyperintensity of the optic nerve was demonstrated in 8 of the 29 patients, with a sensitivity of 27.6% (95% CI, 12.8-47.2) and a specificity of 100% (95% CI, 87.9-100). ADC values were obtained in 25 patients. The mean ADC in the posterior segment of the injured nerve was significantly lower than that in the contralateral uninjured nerve (Welch ANOVA, F = 9.7, P = .003). There was a moderate-to-strong correlation between low ADC values and poor visual acuity in 10 patients in whom visual acuity could be obtained at admission (R = 0.7, P = .02). Patients with optic nerve hyperintensity presented with worse visual acuity., Conclusions: Hyperintensity of the optic nerve due to diffusion restriction can serve as a specific imaging marker of traumatic optic neuropathy. When paired with reduced ADC values, this finding may be an important surrogate for visual acuity., (© 2015 by American Journal of Neuroradiology.)

Imaging plays an important role in the management of patients with traumatic brain injury (TBI). Computed tomography (CT) is the first-line imaging technique allowing rapid detection of primary structural brain lesions that require surgical intervention. CT also detects various deleterious secondary insults allowing early medical and surgical management. Serial imaging is critical to identifying secondary injuries. MR imaging is indicated in patients with acute TBI when CT fails to explain neurologic findings. However, MR imaging is superior in patients with subacute and chronic TBI and also predicts neurocognitive outcome., (Copyright © 2015 Elsevier Inc. All rights reserved.)

This article reviews current and evolving concepts in the diagnosis of penetrating diaphragmatic injury with multidetector CT (MDCT). As criteria for nonoperative management in the setting of penetrating trauma become more inclusive, confident exclusion of penetrating diaphragmatic injury (PDI) has become imperative. Diagnostic performance of MDCT for PDI has improved substantially with the use of thin sections and multiplanar reformats. Evaluation of injury trajectory in nonstandard planes using 3D post-processing software can aid in the diagnosis. Contiguous injury and transdiaphragmatic trajectory are the best predictors of PDI. Careful appraisal of the diaphragm for defects should be undertaken in all patients with thoracoabdominal penetrating trauma.

Object: The object of this study was to determine the specific CT findings of the injury profile in penetrating brain injury (PBI) that are risk factors related to intracranial arterial injuries., Methods: The authors retrospectively evaluated admission head CTs and accompanying digital subtraction angiography (DSA) studies from patients with penetrating trauma to the head in the period between January 2005 and December 2012. Two authors reviewed the CT images to determine the presence or absence of 30 injury profile variables and quantified selected variables. The CT characteristics in patients with and without arterial injuries were compared using univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis to determine the respective risk factors, independent predictors, and optimal threshold values for the continuous variables., Results: Fifty-five patients were eligible for study inclusion. The risk factors for an intracranial arterial injury on univariate analysis were an entry wound over the frontobasal-temporal regions, a bihemispheric wound trajectory, a wound trajectory in proximity to the circle of Willis (COW), a subarachnoid hemorrhage (SAH), a higher SAH score, an intraventricular hemorrhage (IVH), and a higher IVH score. A trajectory in proximity to the COW was the best predictor of injury (OR 6.8 and p = 0.005 for all penetrating brain injuries [PBIs]; OR 13.3 and p = 0.001 for gunshot wounds [GSWs]). Significant quantitative variables were higher SAH and IVH scores. An SAH score of 3 (area under the ROC curve [AUC] for all PBIs 0.72; AUC for GSWs 0.71) and an IVH score of 3 (AUC for all PBIs 0.65; AUC for GSWs 0.65) could be used as threshold values to suggest an arterial injury., Conclusions: The risk factors identified may help radiologists suggest the possibility of arterial injury and prioritize neurointerventional consultation and potential DSA studies.

Object: The authors conducted a study to compare the sensitivity and specificity of helical CT angiography (CTA) and digital subtraction angiography (DSA) in detecting intracranial arterial injuries after penetrating traumatic brain injury (PTBI)., Methods: In a retrospective evaluation of 48 sets of angiograms from 45 consecutive patients with PTBI, 3 readers unaware of the DSA findings reviewed the CTA images to determine the presence or absence of arterial injuries. A fourth reader reviewed all the disagreements and decided among the 3 interpretations. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CTA were calculated on a per-injury basis and in a subpopulation of patients with traumatic intracranial aneurysms (TICAs)., Results: Sensitivity of CTA for detecting arterial injuries was 72.7% (95% CI 49.8%-89.3%); specificity, 93.5% (95% CI 78.6%-99.2%); PPV, 88.9% (95% CI 65.3%-98.6%); and NPV, 82.9% (95% CI 66.4%-93.4%). All 7 TICAs were correctly identified by CTA. Sensitivity, specificity, PPV, and NPV of CTA in detecting TICAs were 100%. To compare agreement with DSA, the standard of reference, confidence scores categorized as low, intermediate, and high probability yielded an overall effectiveness of 77.8% (95% CI 71.8%-82.9%)., Conclusions: Computed tomography angiography had limited overall sensitivity in detecting arterial injuries in patients with PTBI. However, it was accurate in identifying TICAs, a subgroup of injuries usually managed by either surgical or endovascular approaches, and non-TICA injuries involving the first-order branches of intracranial arteries.

Purpose: To determine the specific facial computed tomographic (CT) findings that can be used to predict traumatic optic neuropathy (TON) in patients with blunt craniofacial trauma and propose a scoring system to identify patients at highest risk of TON., Materials and Methods: This study was compliant with HIPAA, and permission was obtained from the institutional review board. Facial CT examination findings in 637 consecutive patients with a history of blunt facial trauma were evaluated retrospectively. The following CT variables were evaluated: midfacial fractures, extraconal hematoma, intraconal hematoma, hematoma along the optic nerve, hematoma along the posterior globe, optic canal fracture, nerve impingement by optic canal fracture fragment, extraconal emphysema, and intraconal emphysema. A prediction model was derived by using regression analysis, followed by receiver operating characteristic analysis to assess the diagnostic performance. To examine the degree of overfitting of the prediction model, a k-fold cross-validation procedure (k = 5) was performed. The ability of the cross-validated model to allow prediction of TON was examined by comparing the mean area under the receiver operating characteristic curve (AUC) from cross-validations with that obtained from the observations used to create the model., Results: The five CT variables with significance as predictors were intraconal hematoma (odds ratio, 12.73; 95% confidence interval [CI]: 5.16, 31.42; P < .001), intraconal emphysema (odds ratio, 5.21; 95% CI: 2.03, 13.36; P = .001), optic canal fracture (odds ratio, 4.45; 95% CI: 1.91, 10.35; P = .001), hematoma along the posterior globe (odds ratio, 0.326; 95% CI: 0.111, 0.958; P = .041), and extraconal hematoma (odds ratio, 2.36; 95% CI: 1.03, 5.41; P = .042). The AUC was 0.818 (95% CI: 0.734, 0.902) for the proposed model based on the observations used to create the model and 0.812 (95% CI: 0.723, 0.9) after cross-validation, excluding substantial overfitting of the model., Conclusion: The risk model developed may help radiologists suggest the possibility of TON and prioritize ophthalmology consults. However, future external validation of this prediction model is necessary.

The objective of this study was to determine the accuracy of individual radiologists in detection of vascular injury in patients after penetrating brain injury (PBI) based on head CT findings at admission. We retrospectively evaluated 54 PBI patients who underwent admission head CT and digital subtraction angiography (DSA), used here as a reference standard. Two readers reviewed the CT images to determine the presence or absence of the 29 CT variables of injury profile and quantified selected variables. Four experienced trauma radiologists and one neuroradiologist assigned their own specific scores for each CT variable, a high score indicative of a high probability of artery injury. A sixth set consisted of the average score obtained from the five sets, generated by five experts. Receiver operating characteristic (ROC) curves were constructed for each set to assess the diagnostic performance of an individual radiologist in predicting an underlying vascular injury. The area under ROC curve (AUC) was higher for CT scores obtained from the sixth set (average of five sets of scores) of variable rank score 0.75 (95% CI 0.62-0.88) and for the rest of the data sets, the value ranged from 0.70 (95% CI 0.56-0.84) to 0.74 (95% CI 0.6-0.88). In conclusion, radiologists may be able to recommend DSA with a fair accuracy rate in selected patients, deemed 'high-risk' for developing intracranial vascular injuries after PBI based on admission CT studies. A better approach needs to be developed to reduce the false positive rate to avoid unnecessary emergency DSA.

Background: Using diffusion tensor imaging, we evaluated the directional diffusivities of the optic nerve in patients with traumatic optic neuropathy (TON)., Methods: Our study consisted of 12 patients with unilateral TON, 6 patients with severe traumatic brain injury (comparison group A), and 6 patients with normal conventional brain magnetic resonance imaging (comparison group B). The contralateral optic nerve in patients with TON also was evaluated (comparison group C). Two trauma radiologists, blinded to the clinical diagnosis, independently obtained the directional diffusivities. The intraorbital optic nerve was divided into anterior and posterior segments to evaluate intersegmental differences in directional diffusivities., Results: The mean axial diffusivity (AD) in both optic nerve segments and the mean diffusivity (ADC) in the posterior segment on the affected side were significantly lower and differentiated subjects with TON from those in comparison groups A and B. Area under the receiver operating characteristic curve was 0.762, 0.746, and 0.737 for posterior AD, anterior AD, and posterior ADC, respectively. The mean AD, mean diffusivity, and radial diffusivity were lower in the affected nerves in comparison to the contralateral nerve (comparison group C), but the values did not reach statistical significance., Conclusion: Decreased AD and mean diffusivity in the posterior segment of the optic nerve may serve as a biomarker of axonal damage in patients with TON and merits further investigation as a predictor of initial visual acuity and potential visual recovery.

Introduction: Cerebral fat embolism syndrome (CFES) mimics diffuse axonal injury (DAI) on MRI with vasogenic edema, cytotoxic edema, and micro-hemorrhages, making specific diagnosis a challenge. The objective of our study is to determine and compare the diagnostic utility of the conventional MRI and DTI in differentiating cerebral fat embolism syndrome from diffuse axonal injury., Methods: This retrospective study was performed after recruiting 11 patients with severe CFES and ten patients with severe DAI. Three trauma radiologists analyzed conventional MR images to determine the presence or absence of CFES and DAI. DTI analysis of the whole-brain white matter was performed to obtain the directional diffusivities. The results were correlated with clinical diagnosis to determine the diagnostic utility of conventional MRI and DTI., Results: The sensitivity, specificity, and accuracy of conventional MRI in diagnosing CFES, obtained from the pooled data were 76, 85, and 80 %, respectively. Mean radial diffusivity (RD) was significantly higher and the mean fractional anisotropy (FA) was lower in CFES and differentiated subjects with CFES from the DAI group. Area under the receiver operating characteristic (ROC) curve for conventional MRI was 0.82, and for the differentiating DTI parameters the values were 0.75 (RD) and 0.86 (FA), respectively., Conclusions: There is no significant difference between diagnostic performance of DTI and conventional MRI in CFES, but a difference in directional diffusivities was clearly identified between CFES and DAI.

Study Objective: To evaluate the impact of 24/7 radiology services on trauma resuscitation unit (TRU) length of stay (LOS) for patients with minor trauma and to analyse the economic benefits of such an impact from trauma centre perspective., Methods: The study was HIPAA compliant and had IRB approval. Data were extracted from hospital and radiology information systems. Inclusion criteria specified patients: (a) with minor trauma (i.e., Injury Severity Score<16 and Maximum Abbreviated Injury Scale<4); (b) cross-sectional imaging performed between 12 and 7AM; and (c) admission during 2006 (before 24/7 coverage; comparison group 1) or 2007 (24/7 coverage). Mean, median, standard deviation, and variance for the groups were determined. The theoretical economic benefit achieved with 24/7 radiology coverage was estimated from decreases in TRU LOS for each patient., Results: Totals of 1087 and 1323 patients for 2006 and 2007, respectively, met our selection criteria. Mean TRU LOS decreased from 11.19 to 8.25 h (26%; P<0.001). The median decreased from 10.8 to 7.2 h (33%; P<0.001). The (Q3-Q1) indicator, used as a proxy for variance and spread, decreased from 7.36 to 5.76 h. Theoretical economic benefits from 24/7 radiology coverage were achieved by the product of TRU bed fixed costs with mean decrease in TRU LOS for the calendar year 2007, which equaled $340,069., Conclusion: The economic benefits of 24/7 radiology services are related to LOS, which can be shortened by limiting patient discharge delays resulting from report unavailability. This can be a cost-saving replacement for conventional radiology practice when the trauma centre makes appropriate use of vacant TRU beds to realise its opportunity cost., (Copyright © 2011 Elsevier Ltd. All rights reserved.)