Multidetector Row Computed Tomography in the Management of Penetrating Neck Injuries

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Penetrating neck trauma may occur from gun shots, stabbings, and accidental injury. Approximately 50% of gunshot and 10%-20% of stab-wound patients are reported as having severe injuries and the mortality from severe vascular injuries is reported as high as 50%. Penetrating traumatic neck injury is no longer best managed with exploratory surgery or conventional angiography in the stable patient. Computed tomography angiography has proven to be a useful, safe, and reliable means of diagnosis. Experience with interpreting and reconstructing computed tomography images, understanding the clinically important findings, and avoiding pitfalls is critical for successful patient care. Therefore, radiologists and clinicians who treat trauma patients need to familiarize themselves with the computed tomography angiography technique and appearances of vascular injury and know when to recommend further evaluation, such as interventional angiography or open surgery.

Section snippets

Anatomical Considerations

The neck is subdivided into 3 anatomic zones based on access to underlying anatomy. Zone 1 encompasses the region from the clavicles and sternal notch to the cricothyroid membrane and is treated similarly to a thoracic injury. Zone 2 includes the area between the cricothyroid membrane and the angle of the mandible. Zone 3 includes the area from the angle of the mandible to the skull base (Fig. 1).6 Making clinical decisions based on these anatomic zones is problematic because an external wound

Patient Management

It is generally agreed that hemodynamically unstable patients and those with direct evidence of vascular or aerodigestive tract injury, such as heavy bleeding, pulsatile or expanding hematoma, bruit, thrill, hematemesis, hemoptisis, stridor, difficulty breathing, or obvious injury to the trachea with air leak, are immediately taken for surgical exploration (Fig. 2).8, 9 Patients who sustain injuries elsewhere requiring immediate surgical intervention also undergo concurrent neck exploration.

CTA Technique

Evaluating penetrating neck injury by CT requires at least 100 mL nonionic contrast administered at a rate of 4-5 mL/s. We do not obtain noncontrast scans. We recommend using the lowest slice thickness available to obtain true isotropic data set given the high spatial resolution that is required to diagnose injuries of the small vascular structures of the neck. We recommend placement of an 18-gauge catheter within the antecubital vein for adequate power injector bolus. Anatomic coverage

Limitations and Pitfalls

CTA of the neck can be limited by a variety of artifacts and technical limitations. Beam hardening artifact from the shoulders of large patients, vascular calcifications, bullet fragments, metallic foreign bodies, and contrast in the subclavian vein can obscure details at the base of neck (Fig. 5). In addition to the artifact from the shoulders and venous contrast, the course of the subclavian artery in the axial plane makes its evaluation difficult on axial images. 3D reconstructed images can

Findings in Penetrating Injury

Direct signs of arterial injury on CTA include abrupt changes in caliber, contrast extravasation, irregular margins, and filling defects within the vessel lumen. Subtle signs of vascular injury include indistinctness of the perivascular fat planes, perivascular hematoma, or bone or bullet fragments within 5 mm from a major vessel (Fig. 7). Frequently, when metallic fragments lie in such close vicinity to the vessel, streak artifact obscures anatomic details and direct signs of injury. Indirect

Interventional Angiography

Diagnostic angiography, while still the gold standard for assessing vascular injury, has been relegated to a secondary role because of potential complications and logistical demands. However, when CTA is nondiagnostic or a vascular injury amenable to intervention is identified, the interventionalist can spare patients from open surgery. Conventional angiography is also helpful for endovascular treatment planning in patients with positive CTA findings. Angiography can provide better assessment

Conclusions

Penetrating traumatic neck injury is no longer best managed with exploratory surgery or conventional angiography in the stable patient. CTA has proven to be a useful, safe, and reliable means of diagnosis. Therefore, radiologists and clinicians who treat trauma patients need to familiarize themselves with the CTA technique and appearances of vascular injury and to know when to recommend further evaluation, such as interventional angiography or open surgery.

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