 Current approaches to patients with penetrating neck injuries result from clinical evaluation and the findings of hard versus soft signs. Hard signs of vascular or aerodigestive injury include active hemorrhage, pulsatile or expanding hematoma, bruit or thrill in the region of the wound, hemodynamic instability, unilateral upper- extremity pulse deficit, massive hemoptysis or hematemesis, air bubbling in the wound, and airway compromise. These hard signs of injury are associated with an unstable or a potentially unstable patient and often mandate immediate operative evaluation and treatment without preoperative imaging. Symptoms related to cerebral ischemia are also hard signs of penetrating injury, but these patients may be stable enough to benefit from first performing imaging studies. Imaging of the brain in addition to the head and neck vasculature may be used to determine optimal surgical, endovascular, or medical therapy. Soft signs of vascular and aerodigestive injury include nonpulsatile or nonexpanding hematoma, venous oozing, dysphagia, dysphonia, and subcutaneous emphysema [6,7]. These commonly result in further evaluation, typically with imaging. Overview of Imaging Modalities CTA dominates the imaging landscape when it comes to the initial evaluation of patients with penetrating neck trauma who do not require immediate surgical exploration [2,6,8,11]. In early comparisons with catheter angiography, CTA demonstrated high sensitivity and specificity [5,11-16]. This held true in a prospective study in 2012 [5] for detecting vascular and aerodigestive injury by CTA, where sensitivity was 100% and specificity was 97.5%. Early adoption of CTA in the initial evaluation of patients with penetrating injuries to the neck led to a 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.
Penetrating Neck Injury PCAs.  Current approaches to patients with penetrating neck injuries result from clinical evaluation and the findings of hard versus soft signs. Hard signs of vascular or aerodigestive injury include active hemorrhage, pulsatile or expanding hematoma, bruit or thrill in the region of the wound, hemodynamic instability, unilateral upper- extremity pulse deficit, massive hemoptysis or hematemesis, air bubbling in the wound, and airway compromise. These hard signs of injury are associated with an unstable or a potentially unstable patient and often mandate immediate operative evaluation and treatment without preoperative imaging. Symptoms related to cerebral ischemia are also hard signs of penetrating injury, but these patients may be stable enough to benefit from first performing imaging studies. Imaging of the brain in addition to the head and neck vasculature may be used to determine optimal surgical, endovascular, or medical therapy. Soft signs of vascular and aerodigestive injury include nonpulsatile or nonexpanding hematoma, venous oozing, dysphagia, dysphonia, and subcutaneous emphysema [6,7]. These commonly result in further evaluation, typically with imaging. Overview of Imaging Modalities CTA dominates the imaging landscape when it comes to the initial evaluation of patients with penetrating neck trauma who do not require immediate surgical exploration [2,6,8,11]. In early comparisons with catheter angiography, CTA demonstrated high sensitivity and specificity [5,11-16]. This held true in a prospective study in 2012 [5] for detecting vascular and aerodigestive injury by CTA, where sensitivity was 100% and specificity was 97.5%. Early adoption of CTA in the initial evaluation of patients with penetrating injuries to the neck led to a 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.