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CÁCH ĐỌC CÁCH ĐỌC CHỤP CLVT CHỤP CLVT

BỤNGBỤNGBùi Văn GiangBùi Văn Giang

Saint Paul, 8-2008Saint Paul, 8-2008

Một số khái niệmMột số khái niệm

Cửa sổCửa sổ Đơn vị tỷ trọngĐơn vị tỷ trọng Giải phẫuGiải phẫu Một số dấu hiệu cơ bảnMột số dấu hiệu cơ bản

Một số khái niệmMột số khái niệm Cửa sổCửa sổ


Cửa sổCửa sổ Nhu mô: tổn thương tạng: u, Nhu mô: tổn thương tạng: u,

vỡ, nang, chảy máuvỡ, nang, chảy máu Mỡ: thâm nhiễm mỡ (viêm), khí Mỡ: thâm nhiễm mỡ (viêm), khí

(thủng tạng rỗng).(thủng tạng rỗng).

Một số khái niệmMột số khái niệm Đơn vị tỷ trọngĐơn vị tỷ trọng

Khí: -1000HUKhí: -1000HU HH22O: 0 HUO: 0 HU Mỡ: <0 HUMỡ: <0 HU Dịch 20HUDịch 20HU Nhu mô: 30-40Nhu mô: 30-40 Máu 70-80HUMáu 70-80HU Xương >100 HUXương >100 HU


Cửa sổ Đơn vị tỷ trọng Giải phẫu lớp cắtGiải phẫu lớp cắt Một số dấu hiệu cơ bảnMột số dấu hiệu cơ bản


Cửa sổ Đơn vị tỷ trọng Giải phẫu Một số dấu hiệu cơ bảnMột số dấu hiệu cơ bản

Pancréatite aiguë + thrombose splénique

Viêm tụy cấp + giả phình

Chấn thương thận kínChấn thương thận kínĐộ 1Độ 1


• • Độ 1: 75-85 % chấn thương thận kínĐộ 1: 75-85 % chấn thương thận kín

• • Tổn thương nhỏ:Tổn thương nhỏ:

- Đụng giập nhỏ nhu mô, không lấn tới tủy - Đụng giập nhỏ nhu mô, không lấn tới tủy

thậnthận

- Tụ máu dưới bao- Tụ máu dưới bao

• • Điều trị bảo tồnĐiều trị bảo tồn

[5]:Kawashima RadioGraphics 2001

• • Độ 2: 10%Độ 2: 10%

• • Tổn thương nhu mô nhiều:Tổn thương nhu mô nhiều:

- Rách nhu mô vào tới tủy thận.- Rách nhu mô vào tới tủy thận.

- Thiếu máu thùy thận.- Thiếu máu thùy thận.



• • Độ 3 : Tổn thương nhu mô nặngĐộ 3 : Tổn thương nhu mô nặng- 5% - 5%

- Rách nhu mô thận phức tạp vào tới - Rách nhu mô thận phức tạp vào tới

xoang thận kèm tổn thương mạch ngoại vi xoang thận kèm tổn thương mạch ngoại vi

gây tụ máu, đái máu, thiếu máu nhu môgây tụ máu, đái máu, thiếu máu nhu mô

- Độ 4 : Tổn thương sâu vào tới - Độ 4 : Tổn thương sâu vào tới

đường bài xuất, mạch máuđường bài xuất, mạch máu



DIVERTICULITE COECALEDIVERTICULITE COECALE

Trauma to the Solid VisceraTrauma to the Solid Viscera

Trauma to the Solid VisceraTrauma to the Solid Viscera

• LiverLiver• SpleenSpleen• KidneyKidney• PancreasPancreas• AdrenalAdrenal

Other Traumatic InjuriesOther Traumatic Injuries

• DiaphragmDiaphragm• MesenteryMesentery• SpineSpine• AortaAorta• Abdominal WallAbdominal Wall

Hepatic Injury ClassificationHepatic Injury ClassificationGradeGrade CriteriaCriteria

11 Capsular avulsionCapsular avulsion

Superficial laceration(s) < 1 cm. deepSuperficial laceration(s) < 1 cm. deep

Subcapsular hematoma < 1 cm. thickSubcapsular hematoma < 1 cm. thick

Periportal blood trackingPeriportal blood tracking

22 Lacerations(s) 1-3 cm. deepLacerations(s) 1-3 cm. deep

Central/subcapsular hematoma(s) 1-3 cm. thickCentral/subcapsular hematoma(s) 1-3 cm. thick

33 Laceration(s) > 3 cm. deepLaceration(s) > 3 cm. deep

Central/subcapsular hematoma(s) > 3 cm. thickCentral/subcapsular hematoma(s) > 3 cm. thick

44 Central/subcapsular hematoma(s) > 10 cm. thickCentral/subcapsular hematoma(s) > 10 cm. thick

55 Bilobar maceration or devascularizationBilobar maceration or devascularization

hemangiomahemangioma

Globular peripheral Globular peripheral enhancementenhancement

Lesion fills inLesion fills in

from from peripheryperiphery

Gunshot to liver with active bleedGunshot to liver with active bleed

Liver InjuryLiver Injury

Grade 1 lacerationGrade 1 laceration Liver laceration thought Liver laceration thought to be fissureto be fissure


Grade 2 liver lacerationGrade 2 liver laceration


Grade 3 Grade 3 Subcapsular Subcapsular hematomahematoma

Grade 3 Grade 3 Intraparenchymal Intraparenchymal hematomahematoma

Liver LacerationLiver Laceration

Grade 4 lacerationGrade 4 laceration Delayed biloma Delayed biloma formationformation

Liver LacerationLiver Laceration

Laceration extends to inferior vena cavaLaceration extends to inferior vena cava


Devascularized left Devascularized left lobelobe

Gallbladder hematomaGallbladder hematoma

Splenic Injury ClassificationSplenic Injury Classification

GradeGrade CriteriaCriteria

11 Localized capsular disruptionLocalized capsular disruption

Small subcapsular hematomaSmall subcapsular hematoma

22 Small peripheral lacerationsSmall peripheral lacerations

Parenchymal hematoma < 3 cm.Parenchymal hematoma < 3 cm.

33 Fracture extending to hilumFracture extending to hilum

Parenchymal hematoma > 3 cm.Parenchymal hematoma > 3 cm.

44 Shattered spleenShattered spleen

Vascular disruptionVascular disruption

Splenic InjurySplenic Injury

Congenital cleftCongenital cleft


Grade 1 injuryGrade 1 injury Grade 2 injuryGrade 2 injury


Grade 3 injuryGrade 3 injury Grade 4 injuryGrade 4 injury


Infarcted spleenInfarcted spleen


Sentinel clot Sentinel clot signsign


Active arterial Active arterial bleedbleed

Delayed hematomaDelayed hematoma


Active arterial extravasation from splenic Active arterial extravasation from splenic lacerationlaceration

Subcapsular and perisplenic hematomasSubcapsular and perisplenic hematomas

Splenic injurySplenic injury

Angiographic Angiographic embolizationembolizationActive bleedActive bleed

Pancreas injuryPancreas injury

Pancreatic laceration with pseudocyst Pancreatic laceration with pseudocyst

Pancreas injuryPancreas injury

Pancreas tail Pancreas tail laceration with blood laceration with blood in left anterior in left anterior pararenal spacepararenal space

Pancreatic body Pancreatic body lacerationlaceration

Pancreas InjuryPancreas Injury

Pancreatic neck Pancreatic neck laceration - blood laceration - blood between pancreas between pancreas and splenic veinand splenic vein

Pancreatic head Pancreatic head contusioncontusion

Renal Injury ClassificationRenal Injury Classification

CategoryCategory CriteriaCriteriaMinorMinor Renal contusionRenal contusion(85%)(85%) Small Small corticomedullary corticomedullary lacerationlaceration

Intrarenal hematomaIntrarenal hematomaSegmental infarctionSegmental infarctionSmall subcapsular Small subcapsular

hematomahematoma

Renal Injury ClassificationRenal Injury Classification

CategoryCategory CriteriaCriteriaMajorMajor Parenchymal lacerations that communicate Parenchymal lacerations that communicate

(10%) (10%) with the collecting systemwith the collecting system Large subcapsular hematomaLarge subcapsular hematoma Complete lacerationComplete laceration Renal fractureRenal fracture Renal vein injuriesRenal vein injuries

CategoryCategory CriteriaCriteriaCatastrophicCatastrophic Shattered kidney Shattered kidney(5%)(5%) Renal artery avulsion or occlusion Renal artery avulsion or occlusion

Renal InjuryRenal Injury

Ruptured congenital Ruptured congenital UPJ obstructed UPJ obstructed kidneykidney

Ruptured calyceal Ruptured calyceal diverticulumdiverticulum


Renal contusionRenal contusion Renal laceration with Renal laceration with perirenal hematomaperirenal hematoma


Small lacerationSmall laceration Delayed scan-Delayed scan-extravasation of extravasation of contrastcontrast


Extravasated Extravasated contrast on 10 min contrast on 10 min delay scandelay scan

Ureter intact-surgery Ureter intact-surgery not necessarynot necessary


Bilateral renal extravasation of Bilateral renal extravasation of contrastcontrast


Fractured Fractured kidneykidney

Devascularized Devascularized segment,large segment,large hematomahematoma


UPJ lacerationUPJ laceration Renal artery Renal artery occlusionocclusion


Arterial occlusion Arterial occlusion causing renal infarctioncausing renal infarction

Arterial OcclusionArterial Occlusion

Renal injuryRenal injury

Renal artery Renal artery pseudoaneurysmpseudoaneurysm

Renal injuryRenal injury

Renal artery pseudoaneurysm Renal artery pseudoaneurysm embolizedembolized

Adrenal HematomaAdrenal Hematoma

Adrenal hematoma and grade II liver Adrenal hematoma and grade II liver lacerationlaceration

Patient struck on right sidePatient struck on right side

Bladder TraumaBladder Trauma

CT Cystography in the Evaluation of CT Cystography in the Evaluation of Bladder TraumaBladder Trauma

Lis,L.E., Cohen,A.J.Lis,L.E., Cohen,A.J. J Comput Assist Tomogr J Comput Assist Tomogr

1990;14:386-3891990;14:386-389

Bladder Bladder Rupture(intraperitoneal)Rupture(intraperitoneal)

CT cystogram-350 cc of contrast (4%) CT cystogram-350 cc of contrast (4%) infused through Foley catheter.infused through Foley catheter.

free contrast in peritoneal cavityfree contrast in peritoneal cavity

Bladder Bladder Rupture(intraperitoneal)Rupture(intraperitoneal)

Free contrast around Free contrast around liverliver

Contrast in cul-de-sacContrast in cul-de-sac

Bladder Bladder Rupture(extraperitoneal)Rupture(extraperitoneal)

Extravasated contrast Extravasated contrast prevesicle spaceprevesicle space

Contrast tracks Contrast tracks into scrotuminto scrotum

Mimic of bladder ruptureMimic of bladder rupture

Paravesicle hematoma with active arterial Paravesicle hematoma with active arterial bleedbleed

Chest Chest

Pericardial and pleural effusionPericardial and pleural effusion

Chest TraumaChest Trauma

Severe Lung contusionSevere Lung contusion


Lung contusionLung contusion Pneumothorax, Pneumothorax, lacerationslacerations


Paravertebral Paravertebral hematomahematoma

T6 vertebral T6 vertebral body fracturebody fracture

Chest traumaChest trauma

Traumatic rupture of inferior vena cava into pericardiumTraumatic rupture of inferior vena cava into pericardium

DiaphragmDiaphragm

Huge diaphragmatic hernia-patient fell Huge diaphragmatic hernia-patient fell from ladderfrom ladder

Diaphragmatic HerniaDiaphragmatic Hernia

Subtle traumatic Subtle traumatic diaphragmatic herniadiaphragmatic hernia

Two days later, Two days later, stomach up in stomach up in chestchest

Diaphragmatic HerniaDiaphragmatic Hernia

Stomach in chestStomach in chest Stomach constricted passing through Stomach constricted passing through

diaphragmdiaphragm

Abdominal WallAbdominal Wall

Actively bleeding rectus muscle hematomaActively bleeding rectus muscle hematoma

Soft tissue injurySoft tissue injury

Back hematomaBack hematoma

SpineSpine

COMBINATION COMBINATION INJURIESINJURIES

Spine TraumaSpine Trauma

Originally missed burst fractureOriginally missed burst fracture

Spine TraumaSpine Trauma

Posterior element Posterior element spinous fracturespinous fracture

patient with patient with Ankylosing Ankylosing SpondylitisSpondylitis

Combination InjuriesCombination Injuries

Devascularized left Devascularized left lobe of liverlobe of liver Pancreatic laceration Pancreatic laceration

and left renal infarctand left renal infarct


Wide mediastinumWide mediastinum Periaortic hematoma-Periaortic hematoma-sign of aortic injurysign of aortic injury


Aortic tearAortic tear Jejunal perforationJejunal perforation


Aortic tearAortic tear Pancreatic lacerationPancreatic laceration


Aortic tearAortic tear Bladder hematoma Bladder hematoma and ruptureand rupture


Jejunal perforationJejunal perforation

Intraperitoneal bladder perforationIntraperitoneal bladder perforation


Pattern of Impact determines Pattern of Impact determines combination injuriescombination injuries

Avoid Satisfaction of Search ErrorAvoid Satisfaction of Search Error

Trauma to the Hollow Trauma to the Hollow VisceraViscera

DuodenumDuodenum JejunumJejunum IleumIleum ColonColon StomachStomach

Bowel and Mesenteric Bowel and Mesenteric InjuriesInjuries

- 5% of patients after blunt abdominal trauma who 5% of patients after blunt abdominal trauma who undergo surgical explorationundergo surgical exploration

- Mortality of duodenal perforationMortality of duodenal perforation

= 65% if surgery delayed > 24 hours= 65% if surgery delayed > 24 hours

= 5% if surgery done in 1= 5% if surgery done in 1stst 24 hours 24 hours

CT FindingsCT Findings

Bowel Wall InjuriesBowel Wall Injuries

- thickeningthickening

- - intense wall enhancementintense wall enhancement

CT FindingsCT FindingsPneumoperitoneumPneumoperitoneum-anterior peritoneal surface-anterior peritoneal surface-perihepatic/splenic areas-perihepatic/splenic areas-mesentery/omentum-mesentery/omentum-ligaments (falciform, etc)-ligaments (falciform, etc)

Free FluidFree Fluid-small bowel, low density & no air-small bowel, low density & no air-blood, intermediate density (high density if -blood, intermediate density (high density if

arterial)arterial)-oral contrast, very high density, > 150 HU-oral contrast, very high density, > 150 HU

Duodenal TraumaDuodenal Trauma

Duodenal hematomaDuodenal hematoma


Duodenal InjuriesDuodenal Injuries

-descending/horizontal -descending/horizontal segmentssegments

-Retro/intraperitoneal-Retro/intraperitoneal

Duodenal InjuryDuodenal Injury

Duodenal perforation-Duodenal perforation-missed originallymissed originally

Perforation seen on Perforation seen on UGI examUGI exam

Duodenal PerforationDuodenal Perforation

Periduodenal Periduodenal hematomahematoma

One day later, One day later, duodenal duodenal perforationperforation

Jejunal/Ileal InjuryJejunal/Ileal Injury

CT FindingsCT Findings fixation points fixation points ligament of Treitzligament of Treitz ileocecal valveileocecal valve

Jejunal InjuryJejunal Injury

Triangles imply extraluminal fluidTriangles imply extraluminal fluid Jejunal perforationJejunal perforation


Mesenteric Mesenteric hematomahematoma

Jejunal Jejunal perforationperforation


Jejunal hematoma which perforatedJejunal hematoma which perforated

Jejunal PerforationJejunal Perforation

Wall thickeningWall thickening Seat belt signSeat belt sign


Bowel wall Bowel wall thickeningthickening

Blood in pelvisBlood in pelvis


Extravasated oral Extravasated oral contrastcontrast

Burst fracture of Burst fracture of L2L2

Free Intraperitoneal AirFree Intraperitoneal Air ““Little bubbles, big troubles”Little bubbles, big troubles” DistributionDistribution

- around liver- around liver

- in mesentery- in mesentery

- posterior to the rectus abdominis muscles- posterior to the rectus abdominis muscles

midrectus recessmidrectus recess

pararectus recessespararectus recesses

Delayed Scans May Be HelpfulDelayed Scans May Be Helpful


Occult jejunal Occult jejunal injuryinjury

Subtle bowel wall Subtle bowel wall thickeningthickening

Free fluid in pelvisFree fluid in pelvis


Extraluminal air Extraluminal air at porta at porta hepatis, over hepatis, over liverliver

Same patient one day laterSame patient one day later

Extravasation of oral Extravasation of oral contrastcontrast


Paracolic gutter fluid and mesenteric fluid Paracolic gutter fluid and mesenteric fluid may have different originsmay have different origins


Extraluminal gas bubblesExtraluminal gas bubbles

LITTLE BUBBLESLITTLE BUBBLES BIG TROUBLESBIG TROUBLES

Ileal, Cecal, Gastric TraumaIleal, Cecal, Gastric Trauma

Intense Bowel Wall EnhancementIntense Bowel Wall Enhancement

Low flow stateLow flow state Intravasation of contrastIntravasation of contrast

Jejunal, Ileal InjuriesJejunal, Ileal Injuries

Bowel wall Bowel wall enhancement-enhancement-jejunal and ileal jejunal and ileal perforationsperforations

pneumoperitoneumpneumoperitoneum

Ileal InjuryIleal Injury

Ileal wall Ileal wall enhancementenhancement

At operation, ileal perforationAt operation, ileal perforation

Bubble of Bubble of extraluminal air in extraluminal air in pararectus recesspararectus recess

Ileal InjuryIleal Injury

Ileal injury – wall Ileal injury – wall thickeningthickening

Delayed perforationDelayed perforation

Ileal PerforationIleal Perforation

Subtle Subtle pneumoperitoneumpneumoperitoneum

Ileal perforationIleal perforation

Colonic InjuryColonic Injury

Pneumatosis of cecal wall-degloving injury of Pneumatosis of cecal wall-degloving injury of serosaserosa


Cecal Cecal perforationperforation

Traumatic herniaTraumatic hernia


Colonic infarctColonic infarct Traumatic herniaTraumatic hernia


Stab wound to colonStab wound to colon extravasated extravasated

contrastcontrast

Rectal Contrast used Rectal Contrast used alsoalso

Stomach InjuryStomach Injury

Greater curvature hematoma and Greater curvature hematoma and perforationperforation


Stomach RuptureStomach Rupture

-children > adults-children > adults

-anterior wall > greater -anterior wall > greater curve > lesser curvecurve > lesser curve

-associated with splenic -associated with splenic traumatrauma

Stomach RuptureStomach Rupture

Pneumoperitoneum-falciform ligament Pneumoperitoneum-falciform ligament seenseen

CT-pneumoperitoneumCT-pneumoperitoneum

Stomach PerforationStomach Perforation

Extravasated oral contrast from stomachExtravasated oral contrast from stomach

Mesenteric InjuriesMesenteric Injuries

CT FindingsCT Findings mesenteric fat streakingmesenteric fat streaking mass effect on bowelmass effect on bowel

Mesenteric InjuryMesenteric Injury

Mesenteric hematomasMesenteric hematomas


Superior mesenteric vein bleedSuperior mesenteric vein bleed


Missed mesenteric Missed mesenteric bleed mimicking bleed mimicking bowel loopbowel loop

Delayed Delayed HematomaHematoma

PneumoperitoneumPneumoperitoneum

Plain filmPlain film CT with lung windowsCT with lung windows

PneumoretroperitoneumPneumoretroperitoneum

Plain filmPlain film CTCT

Shock BowelShock Bowel

Small aorta and IVCSmall aorta and IVC Nonexcreting kidneysNonexcreting kidneys Diffuse bowel wall edemaDiffuse bowel wall edema


Diffuse bowel wall edemaDiffuse bowel wall edema

OverhydrationOverhydration

Periportal edemaPeriportal edema

Bowel wall Bowel wall thickeningthickeningDistended IVC and Distended IVC and aortaaortaPeriportal edemaPeriportal edemaRetroperitoneal Retroperitoneal effusionseffusions

OverhydrationOverhydration

Retroperitoneal Retroperitoneal effusioneffusion

Diffuse bowel wall Diffuse bowel wall edemaedema


Jejunal perforationJejunal perforation Shock bowelShock bowel

CT signs suggestive of small CT signs suggestive of small bowel injurybowel injury

NO. (%)NO. (%)Small bowel wall thickeningSmall bowel wall thickening 18/19 18/19 (95)(95)Free Fluid or blood without Free Fluid or blood without associated solid visceral injuryassociated solid visceral injury 9/19 9/19 (47)(47)

Casey L, Vu D, Cohen AJ. Small Bowel Casey L, Vu D, Cohen AJ. Small Bowel Rupture after Blunt Trauma: CT signs and Rupture after Blunt Trauma: CT signs and Their SensitivityTheir Sensitivity

CT signs pathognomic of bowel CT signs pathognomic of bowel rupturerupture

NO. (%)NO. (%)Extraluminal airExtraluminal air 7/19 7/19 (37)(37)Oral contrast extravasationOral contrast extravasation 8/19 8/19 (42)(42)Extraluminal air onlyExtraluminal air only 3/19 3/19 (16)(16)Oral contrast extravasation onlyOral contrast extravasation only 4/19 4/19 (21)(21)Both extraluminal air and Both extraluminal air and oral contrast extravasationoral contrast extravasation 4/19 4/19 (21)(21)

TOTALTOTAL 11/19 (58) 11/19 (58)


Duodenal perforation extravasates into the Duodenal perforation extravasates into the right anterior pararenal spaceright anterior pararenal space

Duodenal wall may be thickened by Duodenal wall may be thickened by edema or bloodedema or blood

Jejunal and Ileal PerforationJejunal and Ileal Perforation

Jejunal and ileal perforation manifests as bowel Jejunal and ileal perforation manifests as bowel wall thickeningwall thickening

Extraluminal air and fluid may be subtleExtraluminal air and fluid may be subtle Lung windows help to disclose extraluminal airLung windows help to disclose extraluminal air

Extraluminal FluidExtraluminal Fluid

Triangles imply extraluminal fluidTriangles imply extraluminal fluid Paracolic gutter fluid and mesenteric fluid Paracolic gutter fluid and mesenteric fluid

may have different originsmay have different origins

Small Bowel InjurySmall Bowel Injury

Do not hesitate to repeat scan if the clinical Do not hesitate to repeat scan if the clinical condition deterioratescondition deteriorates

Shock and overhydration can cause Shock and overhydration can cause abnormal appearing small bowelabnormal appearing small bowel

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