Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Variant 5: Suspected inflammatory cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. Inflammatory myocardial disease can present either in acute or subacute fashion. Acute myocarditis is due to infections (viral, bacterial, fungal, or tuberculosis), toxins, drugs, injuries, or idiopathic etiology. It can present with acute chest pain, elevated cardiac enzymes, and ECG changes that may mimic acute coronary syndrome (MINOCA). Other presentations include LV dysfunction, arrhythmias, and sudden cardiac death. Acute myocarditis accounts for up to 75% of patients who present with MINOCA, 12% of those with sudden death, and 9% of DCM [132]. Patients may recover or progress to DCM. Sarcoidosis may occasionally present in an acute fashion similar to acute myocarditis. Myocarditis can also be seen in rheumatological diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis [133].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Chagas diseases are caused by a parasite, Trypanosoma cruzi, which is endemic in Central and South America, with 13% of the population at risk and 11% affected [134]. Chagas disease has an acute, a long indeterminate, and a chronic cardiac phase, with one-third of seropositive individuals developing chronic heart disease [135]. Cardiac Chagas presents as HF, arrhythmia, heart block, sudden death, and thromboembolic events [2]. Human immunodeficiency virus can cause cardiomyopathy in 8% of asymptomatic individuals [2]. There is no single test that can accurately diagnose inflammatory cardiomyopathy are evaluated using history, clinical examination, serology, ECG, and noninvasive imaging tests.


Nonischemic Myocardial Disease

Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Nonischemic Myocardial Disease


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Endomyocardial biopsy with histopathology, immunohistology, and molecular techniques may be necessary for diagnosis.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders when ischemia has already been excluded.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CT Chest There is no relevant literature to support the use of CT chest for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CT Heart Function and Morphology CT has been shown to display focal or multifocal enhancement and absence of coronary stenosis correlating with MRI [136].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CTA Coronary There is no relevant literature to support the use of CTA coronary arteries for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . FDG-PET/CT Heart FDG-PET/CT may be useful in the evaluation of inflammatory cardiomyopathies, particularly in the evaluation of acute presentation of cardiac sarcoidosis [54,60]. FDG-PET/CT is not commonly used in the diagnosis of myocarditis. However, if performed, high uptake may be seen in FDG-PET/CT. In 111-antimyosin antibody can be used to identify myocarditis [14].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . MRI Heart Function and Morphology In acute myocarditis, MRI is performed in patients with symptoms of myocarditis, evidence of myocardial injury, and suspected viral etiology. MRI has been shown to have an impact on making a decision in >50% of patients and provides a new diagnosis in 11% of patients [115]. One study showed that using MRI at a lower threshold in patients with MINOCA (ie, using MRI independent of clinical likelihood of myocarditis) led to a 6.3-fold increase in the incidence of myocarditis with doubling of MRIs positive for myocarditis, indicating that myocarditis is currently an underdiagnosed entity [137]. MRI shows functional abnormalities (global systolic dysfunction or focal wall motion abnormalities), capillary hyperemia (high signal in EGE), edema (high signal in T2-weighted images, high native T1 and T2 values, increased ECV), necrosis/fibrosis (LGE in mid myocardial/subepicardial; high T1 and ECV), and pericardial effusion. The Lake Louise criteria, which were used in the diagnosis of acute myocarditis, required two out of the three criteria (edema, EGE, and/or LGE) to be positive [138]. A combination of all three is required if high positive predictive value is desired (positive likelihood ratio of 7.7, accuracy of 80%, specificity of 90%, sensitivity of 77%, positive predictive value of 96%, and negative predictive value of 53%), whereas T2 or LGE criteria are adequate for high sensitivity (91% sensitivity, 84% accuracy) [138]. Removing EGE as a criterion does not change the accuracy (80% with, 84% without) but reduces sensitivity (90% with, 60% without) [138]. Native T1-mapping is useful in detecting subtle, focal disease with sensitivity of 90%, specificity of 91%, and accuracy of 91%, which is superior to T2-weighted MRI and LGE techniques [115]. The updated Lake Louise criteria requires at least one T2-based criterion (global/regional elevation of myocardial T2 or increased T2 signal of myocardium) with at least one T1-based criterion (elevated myocardial T1, elevated ECV, or LGE) for diagnosing acute myocarditis with high specificity [139]. Having only one criterion will still support a diagnosis of acute myocarditis but has lower specificity than with two criteria [139]. Different LGE patterns have been reported based on the viral etiology, with parvovirus B19 showing subepicardial or mid myocardial distribution LGE in the LV inferolateral wall and recovering


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Nonischemic Myocardial Disease without serious damage, whereas HHV-6 infection involves the LV basilar septum in linear mid myocardial LGE pattern, often rapidly progressing to HF [140]. Myocardial edema without fibrosis indicates good potential for recovery, whereas a high amount of EGE and LGE indicate adverse prognosis, particularly if LGE is persistent at 4 weeks after onset [2]. LGE may not correlate with the clinical and lab markers, indicating it is an independent risk assessment tool [141]. A normal MRI in patients with suspected myocarditis indicates a good long-term prognosis, independent of clinical and other findings [142].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . In Chagas disease, patients are typically not imaged in the acute phase, but the indeterminate phase may show changes including RWMA and diastolic dysfunction without overt systolic dysfunction. The chronic phase shows global systolic dysfunction, apical aneurysm, and thrombus. LGE is seen in up to 72% of patients [135] and in 100% of those with arrhythmias, more common in apical and basal inferolateral segments. LGE has been reported in all the phases, including early indeterminate [135]. LGE is subendocardial in 27%, transmural in 36%, mid myocardial in 14%, and subepicardial in 23% of patients [143]. Hence, the pattern is not specific, with contributions possibly from myocarditis and microvascular dysfunction. The diagnosis is therefore made in the context of appropriate epidemiological history [143]. EGE and myocardial edema similar to that of acute myocarditis can also be seen in all phases [135]. All these parameters correlated directly with disease severity [143].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Echocardiography Transesophageal There is no relevant literature to support the use of echocardiography transesophageal for the evaluation of inflammatory myocardial disorders.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Echocardiography Transthoracic Resting Echocardiography shows global and regional functional abnormalities in acute myocarditis. Pericardial effusion may also be seen. Echocardiography is a first-line imaging modality in the evaluation of Chagas disease. It may present with hypokinetic dilated LV with diminished LVEF or biventricular dilation. Aneurysms, thrombus, and valvular disease (mitral and tricuspid regurgitation) may be seen [144]. Global longitudinal strain correlates with the amount of myocardial fibrosis in MRI [145].


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Introduction/Background Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy. Breast reconstruction options following mastectomy range from saline or silicone implants to autologous breast reconstruction. The latter procedure uses skin, fat, blood vessels, and/or muscle from the upper back, abdomen, buttocks, or hips. Transverse rectus abdominis muscle flap procedure is a traditional method of breast reconstruction that harvests underlying muscle. This can result in increased donor site morbidity. The deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle [1].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Compared with transversus rectus abdominus muscle flaps, DIEP flaps result in less fat necrosis and loss of function at the donor site. The DIEP tissue harvesting procedure involves dissecting the anterior abdominal wall subcutaneous tissues to locate and visually identify the most suitable vessel to serve as the vascular pedicle. Although the DIEA is reliably identified because of its consistent take off from the external iliac artery, the anatomy of the perforators used in DIEP flap is variable. Lack of preoperative imaging can lead to increased operative times given the time-consuming nature of identifying the variable vascular anatomy. The efficiency of the vascular pedicle selection process can be significantly improved with preoperative imaging [2].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Multiple perforators are identified by imaging, which are typically ranked based on size, location, and intramuscular course. The ideal perforator is the largest caliber [1,3] and is medially located within the flap with an extended vascular territory beyond the midline to provide optimal perfusion. Dissection of the selected perforator should preserve muscle innervation and avoid fat necrosis [1,3,4]. A short intramuscular course allows for successful dissection [3,14,15]. Perforators are reported by the location where they pierce the anterior rectus sheath in relation to the umbilicus. This is important because, although the perforator can move within the subcutaneous tissues with applied pressure, its position at the rectus sheath is fixed relative to the umbilicus [5].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Reprint requests to: publications@acr.org


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . OR Discussion of Procedures by Variant Variant 1: Imaging of deep inferior epigastric arteries for surgical planning (breast reconstruction surgery). Initial imaging. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients, and even between the left and right hemiabdomen of the same patient. Improved clinical outcomes with preoperative imaging have been shown to include decreased length of surgery, decreased flap loss rate, decreased hernia rate, decreased intraoperative blood loss, shorter mean inpatient stay, reduced learning curve when compared with hand-held Doppler, and increased surgeon confidence [7-15].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Arteriography Abdomen and Pelvis Although catheter directed arteriography can aid in delineation of variant anatomy of the DIEA to guide surgical planning for breast reconstruction, it is an invasive procedure with risks that outweigh benefits compared to current alternative noninvasive imaging methods. Additionally, given the small caliber of the vessels and potentially tortuous course, this would likely lead to prolonged procedure times and potentially unreliable assessment of vessel caliber given variable source and detector distances. Furthermore, the course of perforator arteries in the abdominal wall musculature and subcutaneous tissues is not easily assessed with catheter directed arteriography. There is no relevant literature supporting the use of arteriography in evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CT Abdomen and Pelvis With IV Contrast To date, there is no relevant literature supporting the use of CT abdomen and pelvis with intravenous (IV) contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without and with IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CT Abdomen and Pelvis Without IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CTA Abdomen and Pelvis With IV Contrast CTA is currently beneficial in evaluating the perforator anatomy for preoperative planning before DIEP flap breast reconstruction. Perforator size, perforator location relative to abdominal landmarks, branching pattern of DIEA, presence of superficial inferior epigastric vessels, subcutaneous course, and intramuscular course all affect operative techniques, operative time, and outcomes. CTA is a fast, efficient, and highly reproducible modality, capable of yielding excellent opacification of the small caliber perforator arteries with optimal contrast bolus timing. CTA evaluation performed with the use of specific postprocessing and display techniques may yield more accurate assessment of the optimal vessel for selection for breast reconstruction when compared to color Doppler ultrasound (CDU) [2,8,16]. Some studies have demonstrated superiority of CTA over CDU utilization [17,18], suggesting a routine use of preoperative CTA. A virtual 3-D plan based on CTA can be preoperatively projected onto the abdomen intraoperatively, which can aid in identifying perforator locations and thus decreasing operative time [19].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CTA is also helpful in predicting which DIEA perforators are the most clinically useful in patients with scarred abdomens [20]. Therefore, preoperative imaging is essential for DIEP flap surgery [17,21-28]. Preoperative CTA evaluation can also reliably estimate the volume of abdominal tissue for DIEP flap breast reconstruction [19,29].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Imaging of Deep Inferior Epigastric Arteries Preoperative mapping allows calculation of a flap viability index, which predicts the amount of tissue which will survive based on perforator diameter as well as flap weights [30]. CTA evaluation also allows for the assessment of factors, which may lead to venous congestion of the flap and, therefore, flap failure [31]. A superficial inferior epigastric vein larger than the deep inferior epigastric vein as well as axial nonarborizing superficial venous system are highly predictive of subsequent venous congestion. Knowledge of these findings can aid in preoperative discussion with patients, which may alter management [32]. Preoperative use of CTA allows estimation of contralateral abdominal perfusion and therefore allows for efficient breast reconstruction and decreased complications [33].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Use of preoperative CTA has been shown to result in the increased use of single perforators, increased use of medial- row perforators, significantly reduced operative time, decreased intraoperative blood loss, decreased inpatient hospital stay, and decreased complications such as hernias [9,11,12,14,34]. CTA evaluation allows for faster selection of laterality of dissection, as well as reduced flap loss rates [15].


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . MRA Abdomen and Pelvis Without and With IV Contrast Donor site preoperative imaging for mapping the perforator artery anatomy results in improvement in perforator selection, reduces operative time, and reduces donor site morbidity. Although CTA is considered most helpful, emerging literature supports MR angiography (MRA) as an alternative imaging tool with accurate assessment of DIEA perforator anatomy [35-44]. A recent meta-analysis demonstrates that CT and MRI appear to have similar accuracy in preoperative DIEP mapping [44]. MRA evaluation is limited by increased scanning times relative to CTA evaluation. Continued research is needed to evaluate the accuracy of the new emerging MRA techniques and their role in preoperative perforator branch imaging.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . MRA Abdomen and Pelvis Without IV Contrast The literature review yields one study that used noncontrast MRA for preoperative planning in 56 women who underwent DIEP flap with preoperative planning using MRA without IV contrast. The perforator chosen intraoperatively corresponded to the dominant perforator selected on the MRA in all the patients, yielding 100% predictive value with no false-positive or false-negative results [41]. MRA evaluation is limited by increased scanning times relative to CTA evaluation. To date, there is no other relevant literature supporting the use of MRA abdomen and pelvis without IV contrast in evaluation of imaging of deep inferior epigastric arteries for surgical planning. Continued research is needed to evaluate the accuracy of the new emerging MRA techniques and their role in preoperative perforator branch imaging.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . MRI Abdomen and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of MRI abdomen and pelvis without and with IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . MRI Abdomen and Pelvis Without IV Contrast There is no relevant literature supporting the use of MRI abdomen and pelvis without IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Imaging of Deep Inferior Epigastric Arteries For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Relative Radiation Level Designations 30-100 mSv


10-30 mSv

Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . 10-30 mSv


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Introduction/Background Clinical assessment and audiometric testing can determine the type of hearing loss as conductive, sensorineural, or mixed [1,2] and guide the appropriateness of subsequent imaging. Conductive hearing loss results from diseases affecting the conduction of mechanical sound wave energy to the hair cells of the organ of Corti within the cochlea. These serve as the auditory receptors, converting the mechanical energy of sound waves into electrical neural impulses that are then transmitted along the auditory pathways to the auditory cortex [1]. Sensorineural hearing loss is caused by diseases that impair the cochlear function or the transmission of electrical signal along the auditory pathway, including the cranial nerve nucleus in the brainstem through the superior olive, inferior colliculus, medial geniculate body of the thalamus, and auditory cortex in the temporal lobe.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Given the proximity of the cranial nerves and their nuclei, disorders that affect hearing may also affect vestibular function and vice versa. The vestibule and semicircular canals are the end organs responsible for balance and equilibrium. Central vestibular pathways involve extensive connections between the vestibular nuclei within the brainstem and the cerebellum, extraocular nuclei, and spinal cord. Vertigo is a sensation that you or the environment around you is moving or spinning. Although vertigo often indicates dysfunction of the vestibule or semicircular canals, patients commonly report dizziness, a less specific term that may imply disequilibrium, light- headedness, or presyncope [3-5]. Accordingly, imaging workup in these patients may require assessment for disease processes that produce symptoms reported as dizziness rather than vertigo. Appropriateness of imaging often depends upon clinical categorization of vertigo into peripheral (vestibular) and central (affecting central vestibular pathways) categories based upon factors such as onset, duration, persistence, aggravating factors, and results of clinical testing [3-7]. In some cases however, this categorization may be difficult on clinical assessment, especially in less subspecialized care [3].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Reprint requests to: publications@acr.org


Hearing Loss and or Vertigo

Hearing Loss and/or Vertigo

Hearing Loss and or Vertigo. Hearing Loss and/or Vertigo


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Given the density of temporal bone and the rather small size of individual structures of interest, such as ossicles, details of temporal bone morphology are only evident on bone windows. Accordingly, intravenous (IV) contrast is not beneficial for evaluation of temporal bone in patients with conductive hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head There is no evidence to support use of CT head in patients with conductive hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head There is no evidence to support use of CT angiography (CTA) in patients with conductive hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal MRI of the temporal bone is insufficient in delineation of the bony details usually needed for evaluation of patients with conductive hearing loss, and there is no evidence to support its use as a first-line imaging modality in these patients.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head There is no evidence to support use of MR angiography (MRA) for initial evaluation of patients with conductive hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support use of MR venography (MRV) for initial evaluation of patients with conductive hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 2: Acquired conductive hearing loss secondary to cholesteatoma or neoplasm with suspected intracranial or inner ear extension. Surgical planning. CT Temporal Bone High-spatial resolution CT of the temporal bone is helpful in defining small inflammatory or neoplastic masses within the middle ear cavity [1,2,13]. In addition, CT can help in surgical planning by demonstrating erosions of ossicles or other inner ear structures (such as perilymphatic fistulae) caused by such masses [14]. Given the surrounding dense bone, IV contrast is usually not beneficial in studying enhancement characteristics of middle ear masses. However, contrast enhancement may help delineate extraosseous soft tissue associated with invasive neoplasms.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head There is no evidence to support use of CT head for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head There is no definite evidence to support use of CTA as a first-line modality for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy. However, in patients with high clinical suspicion of middle ear paraganglioma, CTA is sometimes used initially for diagnostic confirmation and for planning further management.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal Extent of a middle ear cavity mass identified on otoscopy in a patient with conductive hearing loss is much better defined using MRI obtained without and with IV contrast [2,5,13,15]. This assessment is better done using thin sections across the temporal bone as part of a dedicated internal auditory canal (IAC) protocol rather than a routine brain MRI. Excellent soft-tissue contrast afforded by even a noncontrast MRI often complements the bony details seen on temporal bone CT for complete evaluation of such patients prior to surgical intervention.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head MRA is usually not used as a first-line imaging modality in patients presenting with conductive hearing loss. However, it may be helpful in assessing patency of the carotid artery if initial imaging raises suspicion of vascular involvement.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head Although not used as the initial imaging modality, MRV may be helpful in assessing patency of jugular vein for surgical planning in patients with documented middle ear masses.


Hearing Loss and or Vertigo

Hearing Loss and/or Vertigo


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 3: Acquired sensorineural hearing loss. Initial imaging. CT Temporal Bone CT of the temporal bone is insensitive in detection of soft-tissue abnormalities that commonly cause sensorineural hearing loss. Small size and proximity to the dense bone of inner ear structures and IAC also precludes visualization of intralabyrinthine or intracanalicular enhancement following IV contrast administration. It may demonstrate labyrinthine ossification [16] resulting from prior infection or give an indirect clue to presence of a vestibular schwannoma in the form of bony remodeling of the IAC. In post-traumatic sensorineural hearing loss, CT can demonstrate fractures extending across the otic capsule [2,13].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head Contrast-enhanced head CT is a less-sensitive imaging modality to detect tumors, such as vestibular schwannomas [17], or assess the IAC, cerebellopontine angle cisterns, or the brainstem compared to MRI.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with isolated sensorineural hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal Imaging evaluation of patients presenting with sensorineural hearing loss involves detailed assessment of the cochlear contents, vestibulocochlear nerve, and auditory pathways. MRI is the imaging modality of choice for evaluating these soft-tissue structures [2,5,18-20]. MRI can demonstrate signal alterations induced by inflammation or hemorrhage within the cochlear contents, identify neoplasms within the cochlear labyrinth or IAC, assess the size of vestibular aqueducts, and visualize abnormalities affecting the brain parenchyma along the auditory pathways [21-25]. Although differential considerations may vary based upon sudden, fluctuating, or progressive nature of sensorineural hearing loss, MRI remains the imaging modality of choice for all these subcategories. MRI should be done using dedicated IAC protocol using thin sections across the IAC and the inner ear. These protocols include evaluation of the brainstem and thalami. Given the extreme rarity of cortical deafness, there is no strong evidence to recommend routine assessment of the entire brain parenchyma in addition to the MRI IAC protocol in patients presenting with isolated sensorineural hearing loss [26,27]. High-resolution 3-D T2-weighted images providing submillimeter assessment of fluid-filled inner ear structures and the IAC are highly sensitive for detection of diseases presenting with sensorineural hearing loss [27,28]. Visualization of inflammatory changes (eg, labyrinthitis, neuritis) as well as neoplasms, such as vestibular schwannomas, can be facilitated by administration of IV contrast [29,30]. However, there is insufficient evidence to prove incremental benefit of contrast administration beyond an MRI IAC protocol performed without IV contrast [27,28].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with isolated sensorineural hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated sensorineural hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 4: Mixed conductive and sensorineural hearing loss. Initial imaging. CT Temporal Bone CT scan of the temporal bones can delineate changes of otospongiosis, a common cause of mixed conductive and sensorineural hearing loss. In some patients with clinical suspicion of otospongiosis, it may suggest alternate diagnoses to explain hearing loss. [31,32]. Administration of IV contrast is usually not beneficial for assessment of temporal bone.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head Relative to MRI, CT head is much less sensitive in detecting or excluding retrocochlear pathology to account for the sensorineural component of the hearing loss [17].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with mixed hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and/or Vertigo

Hearing Loss and or Vertigo. Hearing Loss and/or Vertigo


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal MRI obtained using IAC protocol can be helpful in looking for any retrocochlear pathology responsible for a sensorineural component of the hearing loss. In case IV contrast is administered, punctate enhancement can be seen within the bony otic capsule in the presence of otospongiosis [2].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with mixed hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with mixed hearing loss.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 5: Congenital hearing loss or total deafness or cochlear implant candidate. Surgical planning. CT Temporal Bone High-spatial resolution provided by CT of the temporal bone is valuable prior to cochlear implantation surgery in patients with profound hearing loss. It can provide preoperative delineation of underlying cochlear malformation in patients with congenital hearing loss, detect changes of otospongiosis, suggest round window occlusion, identify labyrinthitis ossificans, congenital bony fusion of the ossicles, and alert the surgeon regarding underlying otomastoiditis or variant anatomy (such as that of the facial nerve) [33,34]. It can also delineate the size of cochlear and vestibular aqueducts, alerting the surgeon for possibility of intraoperative cerebrospinal fluid gusher [24,35,36].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head High-spatial resolution of CT head is insufficient in providing anatomic details of temporal bone needed for surgical planning prior to cochlear implantation. Accordingly, there is no evidence to support routine use of CT head for this indication.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head There is no evidence to support routine use of CTA for surgical planning prior to cochlear implantation in patients with deafness.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal MRI may provide a complementary role to temporal bone CT in preoperative assessment of patients prior to cochlear implantation. Exquisite details of inner ear structures visible on high-resolution T2-weighted images can help in detecting abnormalities, such as cochlear malformations or cochlear nerve deficiency, that directly impact surgical approach [37,38]. In addition, MRI may reveal unexpected soft-tissue abnormalities, such as vestibular schwannomas that may impact the planned surgery [39].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head There is no evidence to support routine use of MRA for surgical planning prior to cochlear implantation in patients with deafness.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support routine use of MRV for surgical planning prior to cochlear implantation in patients with deafness.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 6: Episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo). Initial imaging. CT Temporal Bone CT of the temporal bone provides excellent delineation of the bony labyrinth and is helpful in detecting a number of pathologies resulting in peripheral vertigo. It is highly sensitive in detecting temporal bone fractures in patients with post-traumatic vertigo, assessing for superior semicircular canal dehiscence in patients with vertigo provoked by loud noises, and diagnosing erosions in the bony labyrinth from inflammatory or iatrogenic causes [5,8,9,14].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head CT head provides insufficient details of the inner ear to be useful in patients with peripheral vertigo. Accordingly, diagnostic yield of CT head in patients presenting with vertigo is low [40].


Hearing Loss and or Vertigo

Hearing Loss and/or Vertigo


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head and Neck There is no evidence to support use of CTA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, CTA can be used to detect underlying vertebrobasilar insufficiency [41].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal Based on clinical assessment, peripheral vertigo in many patients is presumed to be secondary to benign processes such as benign paroxysmal positional vertigo or Meniere disease, and these patients are often managed successfully without images are capable of delineating endolymphatic sac, and delayed 3-D FLAIR images can demonstrate hydrops associated with Meniere disease following IV or intratympanic contrast administration as contrast accumulates in perilymphatic but not endolymphatic space. However, the role of such studies in management of these patients is still not clearly established [42-53]. IV contrast can be helpful in showing enhancement of vestibule or semicircular canals in patients with labyrinthitis. MRI of the brain can be used to detect rare but significant central causes of vertigo in cases where distinction between peripheral and central categories is not clinically evident [54].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head and Neck There is no evidence to support use of MRA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, MRA without and with IV contrast can be used to detect underlying vertebrobasilar insufficiency [55].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with vertigo; however, in patients who may have vertigo as a symptom of pseudotumor cerebri, MRV may show narrowing of the transverse sinuses.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Variant 7: Persistent vertigo with or without neurological symptoms (central vertigo). Initial imaging. CT Temporal Bone CT of the temporal bone is not useful in looking for central causes of vertigo.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CT Head Head CT without or with IV contrast may be used to look for central causes of dizziness, albeit with lesser sensitivity than MRI [40,54]. IV contrast may help in either detection or characterization of various neoplastic or inflammatory disease processes affecting the central nervous system. In patients presenting to the emergency department with acute onset of symptoms, CT may demonstrate intracranial hemorrhage as a rare central cause of dizziness [56].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. CTA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, CTA can be used to detect vascular stenosis or occlusion [41].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRI Head and Internal Auditory Canal MRI is the modality of choice in evaluation of the brain in patients suspected to have central cause for vertigo. It can detect posterior fossa neoplasms, Chiari malformation, posterior fossa infarcts, and demyelinating lesions that may result in dizziness or vertigo [3,54,56-58]. Contrast administration can be helpful in detection or characterization of such lesions [58]. Compared to CT, MRI has a much higher sensitivity of detecting acute infarcts in patients with dizziness [40]. It should be noted that infarcts causing isolated vestibular symptoms are usually small, and normal initial MRI does not entirely exclude brain infarction as a cause for vertigo [59].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MRA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, MRA can be used to detect vascular stenosis or occlusion [55].


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated vertigo.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Summary of Recommendations Variant 1: CT temporal bone without IV contrast is the first-line imaging modality in patients presenting with acquired conductive hearing loss without any mass lesion seen within the middle ear cavity.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Hearing Loss and/or Vertigo Variant 2: For presurgical planning of patients with acquired conductive hearing loss secondary to cholesteatoma or neoplasm with suspected intracranial or inner ear extension, CT temporal bone without IV contrast or MRI head and internal auditory canal without and with IV contrast is recommended. It may be necessary to do both examinations for complete presurgical evaluation. Variant 3: MRI head and internal auditory canal without IV contrast, or without and with IV contrast, is recommended for evaluating patients with acquired sensorineural hearing loss. Variant 4: Mixed conductive and sensorineural hearing loss can be evaluated with either CT temporal bone without IV contrast, or MRI head and internal auditory canal without IV contrast, or without and with IV contrast. Variant 5: Congenital hearing loss, total deafness, or cochlear implant is best assessed with either CT temporal bone without IV contrast, or MRI head and internal auditory canal without IV contrast, or without and with IV contrast. Variant 6: Episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo) can best be assessed with either CT temporal bone without IV contrast, MRI head and internal auditory canal without IV contrast, or without and with IV contrast. Variant 7: Evaluation of persistent vertigo with or without neurological symptoms (central vertigo) can best be assessed initially with MRI head and internal auditory canal without IV contrast, or without and with IV contrast.


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Although there are references that report on studies with design limitations, 13 well-designed or good-quality studies provide good evidence.


Hearing Loss and or Vertigo

Hearing Loss and/or Vertigo

Hearing Loss and or Vertigo. Hearing Loss and/or Vertigo


Hearing Loss and or Vertigo

Hearing Loss and or Vertigo. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Multiple studies have shown significantly decreased length of hospital stay and decreased perioperative morbidity with EVAR [8-11] compared to open repair [12-14]. Despite this, open repair is still performed in patients with unsuitable aneurysm morphology for EVAR and in those with failed EVAR [15]. For patients who present de novo for treatment of AAA without any prior imaging available, the entire aorta (including the thoracic portion) should be assessed to fully characterize the aneurysm and exclude a concomitant thoracic aortic aneurysm. Preoperative imaging for open repair of AAA has one primary focus: to determine the need for surgery based on aneurysm size, extent, and rate of growth. Additional information regarding potential variant anatomy can also be helpful in guiding appropriate treatment and preventing unexpected complications at the time of repair.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Reprint requests to: publications@acr.org


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up In recent years, new devices have become available to mitigate unfavorable aortic neck anatomy. Several designs feature an uncovered proximal portion that allows for placement of the stent directly at the origin of aortic branches, whereas others possess ready-made vessel origins for placement within the renal and mesenteric arteries [18]. FEVAR is an alternative approach for those with aortic necks of inadequate length. In FEVAR, fenestrations within the graft material allow for perfusion of major visceral arteries while securing an adequate proximal seal [7]. A variant of the FEVAR technique describes the placement of bridging stents through these fenestrations [23]. Such devices may be especially favorable in women, as these patients are less likely to have aneurysm neck and iliac diameters sufficient for traditional EVAR [16]. FEVAR obviates the need for open femoral exposure and offers the benefit of shorter procedure times, lower complication rates, and shorter hospital stays [5]. FEVAR requires common femoral artery anatomy that is suitable for percutaneous access and free of significant calcification. Candidates for FEVAR should be carefully selected, as the presence and degree of vessel calcification is a major determinant of technical failure [24].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. The advantages of EVAR come at a cost of lifelong imaging surveillance. This is due to a higher rate of complications that require reintervention when compared to open repair [11,25]. Complications of EVAR include stent graft migration, kinking, infection, thrombosis, and renal dysfunction. The most important complication to detect is continued aneurysm expansion leading to eventual rupture, which can occur even after successful EVAR [26]. The most common complication of EVAR is endoleak formation, which may contribute to aneurysm sac enlargement and rupture [27]. Endoleaks are classified by their etiology, with Types I and III most commonly leading to rupture [15,28]. Appropriate classification is therefore crucial for subsequent management and should be clarified whenever possible. Although EVAR is safe and has a low mortality rate [29], the possibility of complications and need for reintervention remains high [12-14], thereby requiring life-long monitoring.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. The ultimate goal of endovascular therapy is to prevent aneurysm rupture. Follow-up imaging is the most useful tool for evaluating post-therapeutic outcomes and monitoring potential complications. Successful therapy results in an aneurysm that remains stable or decreases in size over serial follow-up imaging examinations, with decreasing size of the aneurysm sac believed to indicate a low risk of future rupture [30,31]. All available imaging modalities have been investigated over time for their efficacy in post-EVAR follow-up. According to Society of Interventional Radiology guidelines, the imaging modality of choice should allow at least (1) measurement of aortic aneurysm diameter, (2) detection and classification of endoleaks, and (3) detection of morphologic details of the stent grafts [32]. Imaging modalities should be assessed by their effectiveness in satisfying these three requirements, as well as their respective safety profiles and use of potentially nephrotoxic contrast material.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Overview of Imaging Modalities CT and CTA Computed tomography (CT) is a cross-sectional imaging modality that offers excellent spatial resolution, fast image acquisition times, and widespread availability. However, without contrast material administration, its ability to assess vascular structures is limited. Evaluation of the vessel lumen is accomplished through CT angiography (CTA), a technique that utilizes the administration of iodinated contrast material. The addition of 3- D volumetric postprocessing techniques allow the abdominal aorta and associated vasculature to be viewed in any obliquity and affords quantification of luminal diameter, cross-sectional area, and sac volume. A disadvantage of CTA includes potential nephrotoxicity from administered contrast material [33-35].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. For the purposes of distinguishing between CT and CTA, the ACR Appropriateness Criteria topics use the definition in the Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [36]:


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. All procedure elements are essential: (1) timing, (2) recons/reformats, and (3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that CMS has applied to the CPT codes.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. CTA imaging may be performed as a single arterial phase, biphasic study (noncontrast and arterial or arterial and delayed phases), or as a triphasic study (noncontrast, arterial, and delayed phases). To reduce the cumulative lifetime radiation dose of patients undergoing CTA surveillance, several authors have proposed eliminating either


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up the arterial phase [37] or delayed phase [38,39], although one author has suggested eliminating noncontrast scans from all surveillance examinations with the exception of an initial 1-month follow-up [40].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Several studies have reported significant dose reduction using dual-energy CT with acquisition of delayed-phase images only [41,42]. Accompanying software allows for the isolation of iodine from a selected region and enables reconstruction of virtual noncontrast images. A colored overlay can be applied to voxels containing iodine, rendering detection of contrast material within the aneurysm sac external to the stent-graft more visible [41]. Dual-phase dual-energy CT can potentially reduce the radiation dose by 19.5% when compared to a standard triphasic CT examination [34]. Additional dose reduction techniques include the use of automatic exposure control and iterative reconstruction algorithms [34].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Determining the optimal dose-efficient CT technique is a work in progress that will continue to evolve with increased experience and technological advancement.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Aortography Aortography is an invasive imaging modality that can accurately assess aortic side branch patency, knowledge of which is crucial for deployment of conventional and fenestrated endografts with or without bridging stents. However, it fails to demonstrate mural thrombus, thereby limiting diameter measurements and landing zone assessment. Though less sensitive than CTA in detecting endoleaks, aortography is able to demonstrate the direction of blood flow in or out of the aneurysm sac, rendering it more accurate than CTA in classifying endoleaks [43]. Although traditional aortography relies on iodinated contrast material, recent studies suggest that carbon dioxide may be an acceptable alternative for evaluating endoleaks in patients at risk for contrast-related nephropathy [44,45].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. MRA The major advantage of MR angiography (MRA) relative to CTA is improved soft tissue characterization. Despite relatively low nephrotoxicity, gadolinium-based contrast media (GBCM) have been linked to nephrogenic systemic fibrosis (NSF) [46]. As such, evaluation of renal function in high-risk patients before administering a GBCM long scanning duration, patient claustrophobia, decreased spatial resolution, and contraindication in patients with certain implantable devices. MRA is also limited in its ability to detect intimal calcification [33]. Additionally, susceptibility artifact from the metal interstices of the stent graft presents a diagnostic challenge for assessing device integrity and may mimic graft stenosis. Although the presence of an implanted cardiac pacemaker was previously an absolute contraindication to MRI, several new models are FDA-approved for conditional use.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Superior soft-tissue characterization inherent to MRA may assist clinicians in differentiating slow-growing aneurysms from fast-growing aneurysms. A recent study demonstrated that AAAs containing intraluminal thrombus that have high T1-weighted signal intensity are associated with higher growth rates [47].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. US Color duplex ultrasound (CDUS) is a noninvasive imaging modality that is portable and safe, sparing patients from nephrotoxic contrast material administration. CDUS is able to assess blood flow dynamics in real-time and allows for quantification of luminal diameter and cross-sectional area. Image quality in CDUS is highly dependent on operator experience, patient cooperation, and patient body habitus [48,49]. Although excellent correlation between AAA diameter measurements made by CT and CDUS is well documented, there is general agreement that conventional ultrasound (US) techniques systematically underestimate aneurysm diameter by ~2 mm [35,50-52].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Contrast-enhanced ultrasound (CEUS) utilizes the infusion of stabilized sodium hexafluoride gas to visualize the vessel lumen. Unlike iodinated contrast materials used in CTA, this gas is not nephrotoxic and is safely eliminated via the respiratory system. The advent of 3-D CEUS utilizes positional information for magnetic field emitters to assemble collected US reflections into a high-resolution 3-D image, which results in improved image quality relative to CDUS [53]. 3-D CEUS is reported to be more accurate than 2-D methods in quantifying maximum vessel diameter, as the former allows measurements to be made orthogonal to vessel centerline [50].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. For patients with absolute contraindications to iodinated contrast material, whether due to severe renal impairment or life-threatening contrast allergy, US is an important adjunct to nonenhanced CT.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up Discussion of Procedures by Variant Variant 1: Planning for pre-endovascular repair (EVAR) or open repair of AAA. Radiography Radiographs are unable to adequately visualize the abdominal aorta, thereby prohibiting proximal landing zone assessment and luminal diameter quantification. As such, there is no role for radiography in the preoperative evaluation of AAA. However, given the high spatial resolution of radiography, this modality affords optimal visualization of stent graft geometry. When utilizing consistent centering protocols, this allows for reliable detection of kinks and stent graft migration to within 2 mm [54].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. CT and CTA Due to its superior spatial resolution and rapid image acquisition, CTA with 3-D volumetric reconstruction and vessel analysis has gained wide acceptance as the gold standard for pre-EVAR evaluation. The utilization of 3-D reconstruction software has become paramount in EVAR planning, as it diminishes the impact of vessel tortuosity on diameter and length measurements, in addition to reducing intraobserver variability [55]. One author found that routine 3-D analysis of pre-EVAR images led to a significant reduction in Type I endoleaks [56]. Reformatted CTA images in the coronal and sagittal planes should be utilized for increased diagnostic accuracy. In most cases, a CTA of the abdomen and pelvis is appropriate to ensure coverage of the entire aneurysm and vascular access. The CTA should include the chest in patients with thoracoabdominal aortic aneurysms (TAAA).


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Aortography As aortography and radiography are unable to accurately provide aneurysm sac diameter measurements and landing zone assessment, these modalities are inadequate for pre-EVAR or open repair evaluation. However, aortography may be of value in assessing branch vessel patency and is usually part of branch vessel occlusion procedures before aneurysm repair.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. MRA For the purpose of pre-EVAR planning, T1-weighted spin-echo images and flow-based methods such as time of flight or phase contrast provide adequate details regarding aneurysm morphology and relevant vascular anatomy. However, these techniques are limited by low spatial resolution and signal-to-noise ratio and are therefore suboptimal for evaluating small-vessel lesions or diminutive side branches [33]. Furthermore, flow-based sequences are susceptible to flow artifacts that may overestimate the degree of stenosis or falsely demonstrate an occlusion [57]. To overcome these limitations, contrast-enhanced MRA (CE-MRA) should be added to conventional T1- and T2-weighted spin-echo sequences. CE-MRA is much less susceptible to flow and susceptibility artifacts and has a high signal-to-noise ratio for evaluating small vessels and fine structural details. The effectiveness of CE-MRA has been found to be comparable to that of CTA in assessing the suitability of aneurysms for EVAR [58]. In most cases, an MRA of the abdomen and pelvis is appropriate to ensure coverage of the entire aneurysm and vascular access. The MRA should include the chest in patients with TAAA.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Acquisition of noncontrast balanced steady state free precession (bSSFP) images may be useful in the preoperative evaluation of patients who poorly tolerate GBCM or are at risk for NSF. One study found that AAA measurements obtained by noncontrast MRA were not significantly different from those measured by CTA [59].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. US Although the United States Preventative Services Task Force currently recommends one-time US screening for AAA in men ages 65 to 75 years who have ever smoked [60], no evidence is present within the medical literature to support the use of either CDUS or CEUS in the formal preoperative evaluation of AAA.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Variant 2: Follow-up for post-endovascular repair (EVAR) or open repair of AAA. CT and CTA The exceptional spatial resolution and fast imaging speeds of CTA has made it the de facto gold standard for post- EVAR and post-open repair imaging surveillance. After EVAR, the most widely used surveillance regimen utilizes multiphasic contrast-enhanced CT at 1 month, 12 months, and yearly thereafter. If an abnormality is detected 1 month post-EVAR, a follow-up scan at 6 months is performed. In the absence of adverse outcomes at the 1-month follow-up imaging, the intensity and frequency of the surveillance program may be modulated accordingly [61-64]. Compared to aortography, CTA has higher sensitivity in detecting endoleaks after EVAR. Compared to US, CTA is better able to visualize kinking and migration of the stent-graft and is equivalent in quantifying aneurysm sac size [34] .


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up Initial post-EVAR surveillance studies monitored the maximum diameter of the aneurysm sac as a marker for response to therapy [65]. This method has been shown to be unreliable due to substantial interobserver variability [66]. Volume analysis of the aneurysm sac has since proven to be the most reliable indicator for aneurysm rupture and/or need for reintervention [67-69]. In an effort to reduce radiation dose and contrast material exposure, several authors have proposed using serial volumetric analysis of AAAs with noncontrast CT as the sole screening test for post-EVAR follow-up [70-73]. Volume discrepancy due to interoperator variability has been demonstrated to be less than 2% when the procedure is performed by experienced personnel [72,74]. In patients in whom contrast materials are contraindicated, serial volume measurements of the nonenhanced aneurysm sac provides valuable information in guiding management [75].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. In most cases, a CTA of the abdomen and pelvis is appropriate to ensure coverage of the treated aneurysm and stent graft. The CTA should include the chest in patients with TAAA.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Aortography Due to the relatively invasive nature of aortography, it is not practical for routine post-EVAR surveillance. However, in the setting of a known endoleak, aortography may be more accurate than CTA in classifying endoleaks. One study revealed only 86% agreement in endoleak classification between aortography and CTA, in which subsequent correct classification by aortography significantly improved patient management [43]. It therefore stands to reason that aortography may be best utilized as a second-line imaging modality in post-EVAR patients, playing a vital role in endoleak classification and reintervention [35].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. MRA When considering using MRA for post-EVAR surveillance, stent material and orientation are important considerations. Typical stent construction employs nitinol, elgiloy, or stainless steel. Nitinol is a nickel-titanium alloy that causes relatively few artifacts on MRA, while allowing adequate visualization of the stent lumen and adjacent structures. Elgiloy is an alloy of cobalt, chromium, and nickel that may obscure the stent lumen but still allows for visualization of adjacent structures. Patients with nitinol stents are the optimal candidates for MRA, while those with elgiloy or stainless steel stents may experience significant artifacts that compromise visualization of the stent lumen and limit morphological resolution of the stent wall [76]. However, artifacts may arise even with nitinol stents secondary to stent geometry [77]. Due to severe susceptibility artifact associated with stainless steel embolization coils, MRA is poor in the follow-up of patients who have undergone coil embolization of the internal iliac artery before EVAR [35].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. MRA of the post-EVAR aorta shares multiple features with CTA. Like CTA, isotropic 3-D MRA images may be reformatted in any plane for volume analysis or orthogonal diameter measurements. In patients with nitinol stents, aortic diameter measurements for MRA have been shown to be as reliable as those obtained with CTA [78]. MRA has been shown to be more sensitive than CTA for the detection of endoleaks [35,79]. Consequently, the higher rate of endoleak detection seen by MRA in cases with a negative CTA may shed light on the phenomenon of endotension [80]. More recently, time-resolved MRA has been used in the characterization of endoleaks and may provide relevant information regarding contrast and flow dynamics within endoleaks [35]. As such, replacing aortography as an effective and noninvasive method for endoleak characterization shows promise [81].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. In most cases, MRA of the abdomen and pelvis is appropriate to ensure coverage of the treated aneurysm and stent graft. The MRA should include the chest in patients with TAAA.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Blood pool contrast materials such as ferumoxytol [82,83] remain intravascular for a prolonged duration, thereby allowing for generation of high-resolution 3-D multiplanar images [82,83]. Use of these contrast materials may improve detection of slow-flow endoleaks [82,83].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Patients intolerant of GBCM or those at risk for NSF may benefit from the acquisition of noncontrast bSSFP images in post-EVAR surveillance. One small retrospective study found that noncontrast bSSFP images can be used to exclude endoleak after EVAR, with postcontrast imaging reserved for verification and further characterization of a suspected endoleak [84].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. US CDUS and CEUS are being increasingly recommended for post-EVAR follow-up. These are convenient, noninvasive, and have a favorable safety profile. In the evaluation of endoleak, CDUS has high specificity but limited sensitivity, reported in two large meta-analyses to be 91% to 93% and 66% to 69%, respectively [85,86]. The major limitations of US are the inability to detect stent-graft kinking, fracture, migration, or component


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up separation [87-89]. For this reason, adjunct four-view radiographs are recommended to be obtained with all post- EVAR US examinations [49,53,84,87,89,90]. For FEVARs that involve the celiac trunk, US is unable to adequately visualize the proximal sealing zone [89].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Not unexpectedly, published results regarding the accuracy of CDUS in post-EVAR follow-up are varied [51,85,91-93]. Nevertheless, US offers the ability to determine endoleak flow direction and therefore assist in guiding management. Spectral waveform analysis of reperfusion to the aneurysm sac has been shown to have prognostic value, in which Type II endoleaks with bidirectional flow [94] and low flow velocities [95] have been associated with spontaneous closure.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Several studies have compared 2-D CEUS to CDUS in the setting of post-EVAR follow-up, with a recent meta- analysis finding no clinically significant differences between the two [96]. In the setting of post-FEVAR follow- up, 2-D CEUS was found to be equivalent to CTA in aneurysm sac measurement and in assessing patency of visceral vessels [84,89]. Additional studies have demonstrated the superiority of 3-D CEUS over standard 2-D methods in both endoleak detection [53] and sac measurement [50]. Three-dimensional CEUS has been found to be equivalent or superior to CTA in endoleak detection [53,88] and sac measurement, in addition to being highly reproducible [50,97].


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Although there are references that report on studies with design limitations, 32 well-designed or good-quality studies provide good evidence.


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. AAA: Interventional Planning & Follow-Up


Abdominal Aortic Aneurysm or Dissection Interventional Planning and Follow up. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Penetrating Torso Trauma

Penetrating Torso Trauma. Introduction/Background Penetrating torso trauma occurs when a foreign body disrupts the skin and enters the patient. The anatomical boundaries of the torso begin cranially at the thoracic inlet and caudally at the inferior margins of the greater trochanters, excluding the appendicular skeletal structures. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. High rates of mortality and morbidity are associated with gunshot wounds, with approximately 42,222 deaths in 2020 or 13.7 deaths per 100,000 people [1]. Stab wounds are much more common, estimated at 434,259 injuries annually; however, these wounds rarely result in death. According to the Centers for Disease Control and Prevention, between 2003 and 2019, a total number of 6,015 deaths were reported in the United States from stab injuries [1].


Penetrating Torso Trauma

Penetrating Torso Trauma. Special Imaging Considerations Imaging, in particular multidetector CT, plays a central role in guiding management in patients with penetrating trauma. Contrast-enhanced CT with multiplanar reformations is the standard imaging tool in the evaluation of patients with penetrating trauma due to its fast acquisition and excellent resolution [2,3]. Single versus multiphasic protocols vary depending upon both institutional protocols and clinical presentation. Multiphasic protocols that include an arterial phase may improve the identification and characterization of vascular injuries, whereas the assessment of solid organs in the abdomen and pelvis is best performed during the portal venous phase [6]. Furthermore, the American Association for the Surgery of Trauma recommends dual-phase CT (arterial and venous phases) for accurate diagnosis of vascular injuries of the solid organs including the spleen, liver, or kidney [7]. Throughout this manuscript, CT angiography (CTA) will presuppose at least 2 postcontrast phases of imaging in addition to the angiography phase. When there is suspicion or knowledge of renal injury, delayed excretory phase imaging should be acquired [8]. In addition to intravenous (IV) administration of contrast, some institutions advocate the administration of oral and rectal contrast when there is concern for bowel injury in the setting of


Penetrating Torso Trauma

Penetrating Torso Trauma. aUniversity of Kentucky, Lexington, Kentucky; Committee on Emergency Radiology-GSER. bResearch Author, University of Kentucky, Lexington, Kentucky. cHackensack University Medical Center, Hackensack, New Jersey; American Association for the Surgery of Trauma. dMayo Clinic Arizona; Committee on Emergency Radiology-GSER. eUniversity of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. fUniversity of California Davis Health, Sacramento, California; Society for Academic Emergency Medicine. gMassachusetts General Hospital, Boston, Massachusetts. hVancouver General Hospital, Vancouver, British Columbia, Canada; Committee on Emergency Radiology-GSER. iPCP - Internal medicine, University of Kentucky, Lexington, Kentucky. jPennsylvania State University College of Medicine, Hershey, Pennsylvania; American College of Emergency Physicians. kR. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland. lUniversity of Washington, Seattle, Washington; Committee on Emergency Radiology-GSER. mRadiology Associates of Hollywood, Pembroke Pines, Florida. nSpecialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio.


Penetrating Torso Trauma

Penetrating Torso Trauma. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Penetrating Torso Trauma

Penetrating Torso Trauma. Reprint requests to: publications@acr.org


Penetrating Torso Trauma

Penetrating Torso Trauma

Penetrating Torso Trauma. Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. penetrating trauma [9,10]. Radiography and focused assessment with ultrasonography for trauma (FAST) play an important role in triage, often directing next step management [11-17].


Penetrating Torso Trauma

Penetrating Torso Trauma. The role of FAST (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [18,19]. Ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, but it is an insufficient test to fully exclude injuries to these areas because it has a relatively lower specificity compared with CT [20].


Penetrating Torso Trauma

Penetrating Torso Trauma. FAST can help triage patients and direct initial bedside and surgical procedures. Hemopericardium, pneumothorax, and free intraperitoneal fluid discovered at FAST have significant implications on next steps in management of the patient. Some trauma systems also use prehospital FAST to expedite management upon arrival to the hospital [14,16].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis With IV Contrast Traditionally and in most practices, patients with penetrating trauma demonstrating signs of hemodynamic instability would be operatively managed without CT imaging [24]. However, recently, some authors recommend whole-body CT while continuing resuscitation regardless of hemodynamic status [25,26]. Proponents of this approach suggest the information gathered during CT helps determine the optimal surgical approach and prevents delay of definitive management. The degree of hemodynamic instability and distance to the CT scanner should be accounted for when deciding upon use of CT in this clinical scenario.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma with hypotension. If CT imaging is performed in this patient population, the imaging time should be minimized as much as possible, and therefore without IV contrast imaging is not routinely recommended.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without IV contrast for initial evaluation of patients with penetrating torso trauma with hypotension. If CT imaging is performed in this patient population, IV contrast should be administered.


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Chest, Abdomen, and Pelvis IV Contrast Most literature supporting the use of multiphase CTA imaging in the torso is derived from the blunt trauma patient population [27]. Literature suggests the detection of vascular injury is similar between routine contrast-enhanced CT of the chest and CTA of the chest; however, the justification for performing routine contrast-enhanced CT of the chest and CTA imaging was to reduce the need for two separate contrast injections [28]. Most modern-day CT


Penetrating Torso Trauma

Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. scanners and protocols enable imaging of the entire body in multiple phases with one IV contrast bolus [29]. If imaging is pursued in this imaging population, single-phase imaging to include the portal venous phase may provide the most relevant information for next step imaging.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of MRI chest, abdomen, and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma with hypotension.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature regarding the use of MRI chest, abdomen, and pelvis without IV contrast for initial evaluation of patients with penetrating torso trauma with hypotension.


Penetrating Torso Trauma

Penetrating Torso Trauma. Radiography Trauma Series Chest radiographs can recognize contusions, pneumothorax, hemothorax, rib fractures, foreign bodies and/or ballistic fragments, and mediastinal injuries, which could be treated immediately. Radiographic evaluation can also help identify retained foreign bodies and suggest trajectory, which may direct initial surgical exploration.


Penetrating Torso Trauma

Penetrating Torso Trauma. Variant 2: Adult. Ballistic penetrating torso trauma, unknown trajectory, normotensive. Initial imaging. FAST can help triage patients and direct initial bedside and surgical procedures. Hemopericardium, pneumothorax, and free intraperitoneal fluid discovered at FAST have significant implications on next steps in management of the patient. Some trauma systems also use prehospital FAST to expedite management upon arrival to the hospital [14,16].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without and with IV contrast for initial evaluation of penetrating torso trauma. The addition of a noncontrast phase may delay definitive diagnosis and typically does not provide additional information pertinent to penetrating trauma [31].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without IV contrast for initial evaluation of penetrating torso trauma. Although noncontrast CT may be helpful in determining trajectory, demonstration of internal injuries, specifically solid organs, is much more apparent with IV contrast. During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [32].


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Chest, Abdomen, and Pelvis IV Contrast In the hemodynamically stable patient population, multiphasic imaging can provide additional useful information regarding the source of active bleeding. Additionally, it is important to remember that imaging can be performed after damage control surgery to identify injuries that may need definitive treatment [29,33]. In their retrospective study, Nummela et al [29] found that arterial and venous phases of the chest, abdomen, and pelvis CT facilitated recognition of active bleeding in patients with penetrating thoracic trauma. Differentiating between arterial and venous hemorrhage may have treatment implications. For example, a hemodynamically stable patient with active arterial bleeding may be treated with an angioembolization procedure, whereas bleeding from a venous structure may result in supportive care [29,33].


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest, Abdomen, and Pelvis Without And With IV Contrast There is no relevant literature regarding the use of MRI chest, abdomen, and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma

Penetrating Torso Trauma. Penetrating Torso Trauma


Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. Radiography Trauma Series Chest radiographs can recognize contusions, pneumothorax, hemothorax, rib fractures, foreign bodies and/or ballistic fragments, and mediastinal injuries, which should be treated immediately. Radiographic evaluation can also help identify retained foreign bodies and suggest trajectory which may direct initial surgical exploration.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis With IV Contrast CT could be performed if there is suspected suspicion for intraperitoneal violation. Overall, liberal use of imaging in ballistic trauma is recommend because the trajectory can be unpredictable. Diaphragmatic excursion may be high at time of injury, making intra-abdominal injuries difficult to exclude.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of adding a noncontrast phase to a contrast-enhanced CT abdomen and pelvis for initial evaluation of penetrating torso trauma limited to the chest.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis Without IV Contrast There is no relevant literature regarding the use of CT abdomen and pelvis without IV contrast for initial evaluation of penetrating torso trauma. During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [36].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest Without And With IV Contrast There is no relevant literature regarding the usefulness of adding a noncontrast phase to a contrast-enhanced CT chest for initial evaluation of penetrating torso trauma limited to the chest


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest Without IV Contrast During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [36]. Noncontrast imaging of the chest is inadequate to definitively evaluate the chest for vascular injuries in the setting of ballistic trauma isolated to the chest.


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Abdomen and Pelvis With IV Contrast Nummela et al [29] concluded that CTA of the whole body is recommended because multiple injuries and active bleeding are common in penetrating thoracic trauma. CTA of the abdomen and pelvis should be used liberally because the terminal ballistics of bullets and other fragments may have an unpredictable trajectory.


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Chest With IV Contrast CTA of the chest is a valuable modality in assessment of penetrating transmediastinal injury in hemodynamically stable patients. It can guide immediate surgical intervention versus expectant management in conjunction with


Penetrating Torso Trauma

Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. transesophageal echocardiogram [38]. CTA may better demonstrate pseudoaneurysm, vascular occlusion, active contrast extravasation, intimal tear, and early venous filling in arteriovenous fistulas.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Abdomen and Pelvis Without And With IV Contrast There is no relevant literature regarding the use of MRI abdomen and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Abdomen and Pelvis Without IV Contrast There is no relevant literature regarding the use of MRI abdomen and pelvis without IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest Without And With IV Contrast There is no relevant literature regarding the use of MRI chest without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest Without IV Contrast There is no relevant literature regarding the use of MRI chest without IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. Radiography Trauma Series Chest radiographs can recognize contusions, pneumothorax, hemothorax, rib fractures, foreign bodies and/or ballistic fragments, and mediastinal injuries, which could be treated immediately. Radiographic evaluation can also help identify retained foreign bodies and suggest trajectory, which may direct initial surgical exploration. Some authors suggest that a chest radiograph may be adequate in this patient population, and CT identifies additional findings that do not require surgical intervention [41]. Other authors, however, point out the limitations of chest radiography [42]. Berg et al [43] found that patients with penetrating thoracic trauma or asymptomatic patients with unremarkable initial chest radiographs can be safely discharged by short-term repeat chest radiographs.


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis Without And With IV Contrast There is no relevant literature regarding the use of CT abdomen and pelvis without and with IV contrast for initial evaluation of penetrating torso trauma. The addition of a noncontrast phase does not provide additional information pertinent to penetrating trauma [31].


Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest With IV Contrast Given the unpredictable trajectory of ballistic trauma, liberal use of CT imaging of the chest is typically performed when there is presumed isolated abdominal and pelvic trauma [2].


Penetrating Torso Trauma

Penetrating Torso Trauma

Penetrating Torso Trauma. Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest Without and With IV Contrast There is no relevant literature regarding the use of CT chest without and with IV contrast for initial evaluation of penetrating torso trauma. The addition of a noncontrast phase does not provide additional information pertinent to penetrating trauma [31].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest Without IV Contrast There is no relevant literature regarding the use of CT chest without IV contrast for initial evaluation of penetrating torso trauma. During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [36].


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Abdomen and Pelvis With IV Contrast In the hemodynamically stable patient population, multiphasic imaging can provide additional useful information regarding the source of active bleeding. Additionally, it is important to remember that imaging can be performed after damage control surgery to identify injuries that may need definitive treatment [29,33]. In their retrospective study, Nummela et al [29] found that arterial and venous phases of the chest, abdomen, and pelvis CT facilitated recognition of active bleeding in patients with penetrating thoracic trauma. Differentiating between arterial and venous hemorrhage may have treatment implications. For example, a hemodynamically stable patient with active arterial bleeding may be treated with an angioembolization procedure, whereas bleeding from a venous structure may result in supportive care [29,33].


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Chest With IV Contrast CTA of the chest is now routinely used for both blunt and penetrating trauma at many level 1 trauma centers. CTA may better demonstrate pseudoaneurysm, vascular occlusion, active contrast extravasation, intimal tear, and early venous filling in arteriovenous fistulas [29,48].


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Abdomen and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of MRI abdomen and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest Without and With IV Contrast There is no relevant literature regarding the use of MRI chest without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. Radiography Trauma Series It is common practice at many trauma centers to mark presumed penetrating wounds with radiodense markers. Radiographic evaluation can help identify retained foreign bodies and suggest trajectory, which may direct additional imaging or mandate surgical exploration.


Penetrating Torso Trauma

Penetrating Torso Trauma. Variant 5: Adult. Nonballistic penetrating torso trauma, unknown trajectory, normotensive. Initial imaging. FAST can help triage patients and direct initial bedside and surgical procedures. Hemopericardium, pneumothorax, and free intraperitoneal fluid discovered at FAST have significant implications on next steps in management of the patient. Some trauma systems also use prehospital FAST to expedite management upon arrival to the hospital [14,16].


Penetrating Torso Trauma

Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. the sites of skin violation, which is much more important with sharp object low energy penetrating trauma. Additional information should be sought regarding blade length or the presence of bruising or a "hilt mark" at the skin entry site when evaluating stab wounds. Single-acquisition whole torso-imaging is preferred over segmental imaging so that the tract of the wound can be followed [2].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without And With IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without and with IV contrast for initial evaluation of penetrating torso trauma. The addition of a noncontrast does not provide additional information pertinent to penetrating trauma [31].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature regarding the use of CT chest, abdomen, and pelvis without IV contrast for initial evaluation of penetrating torso trauma. Although noncontrast CT may be helpful in determining trajectory, demonstration of internal injuries, specifically solid organs, is much more apparent with IV contrast. During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [36].


Penetrating Torso Trauma

Penetrating Torso Trauma. CTA Chest, Abdomen, and Pelvis IV Contrast In the hemodynamically stable patient population, multiphasic imaging can provide additional useful information regarding the source of active bleeding. Additionally, it is important to remember that imaging can be performed after damage control surgery to identify injuries that may need definitive treatment [29,33]. In their retrospective study, Nummela et al [29] found that arterial and venous phases of the chest, abdomen, and pelvis CT facilitated recognition of active bleeding in patients with penetrating thoracic trauma. Differentiating between arterial and venous hemorrhage may have treatment implications. For example, a hemodynamically stable patient with active arterial bleeding may be treated with an angioembolization procedure, whereas bleeding from a venous structure may result in supportive care [29,33].


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of MRI chest, abdomen, and pelvis without and with IV contrast for initial evaluation of patients with penetrating torso trauma.


Penetrating Torso Trauma

Penetrating Torso Trauma. MRI Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature regarding the use of MRI chest, abdomen, and pelvis without IV contrast for initial evaluation of patients with penetrating torso trauma with hypotension.


Penetrating Torso Trauma

Penetrating Torso Trauma. Radiography Trauma Series Chest radiographs can recognize contusions, pneumothorax, hemothorax, rib fractures, retained foreign bodies, and mediastinal injuries, which should be treated immediately. Radiographic evaluation can also help identify retained foreign bodies and suggest trajectory, which may direct initial surgical exploration. The limitations of radiography, particularly chest radiography, should be understood in the setting of nonballistic trauma. Nguyen et al [50] showed that greater than one-third of patients in their study had additional findings on CT after a normal screening chest radiograph.


Penetrating Torso Trauma

Penetrating Torso Trauma. Variant 6: Adult. Nonballistic penetrating torso trauma, limited to chest, normotensive. Initial imaging. Injuries that are considered limited to the chest occur outside of the thoracoabdominal zone. Anatomical landmarks can include above the nipple line in men or above the fourth rib. Wounds occurring below these anatomical landmarks could involve abdominal structures given significant diaphragmatic excursion.


Penetrating Torso Trauma

Penetrating Torso Trauma. FAST can help triage patients and direct initial bedside and surgical procedures. Hemopericardium, pneumothorax, and free intraperitoneal fluid discovered at FAST have significant implications on next steps in management of the patient. Some trauma systems also use prehospital FAST to expedite management upon arrival to the hospital [14,16].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis With IV Contrast It is useful to get CT scans of the abdomen and pelvis if there is suspicion of peritoneal violation or possible diaphragmatic injuries.


Penetrating Torso Trauma

Penetrating Torso Trauma

Penetrating Torso Trauma. Penetrating Torso Trauma


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature regarding the use of CT abdomen and pelvis without and with IV contrast for initial evaluation of penetrating torso trauma isolated to the chest and does not provide additional information pertinent to penetrating trauma [31].


Penetrating Torso Trauma

Penetrating Torso Trauma. CT Abdomen and Pelvis Without IV Contrast There is no relevant literature regarding the use of CT abdomen and pelvis without IV contrast for initial evaluation of penetrating torso trauma isolated to the chest. During the global shortage of contrast in 2022, unenhanced CT scans were used for acute and posttraumatic patients in emergency departments at some institutions [36].