Multidetector Row Computed Tomography in the Management of Penetrating Neck Injuries
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.
References (46)
- et al.
Imaging of traumatic neurovascular injury
Radiol Clin North Am
(2006) - et al.
A twelve-year survey of cervicothoracic vascular injuries
Am J Surg
(1989) - et al.
Penetrating neck trauma: An overview of management
J Oral Maxillofac Surg
(2002) - et al.
Management of penetrating neck injuriesThe controversy surrounding zone II injuries
Surg Clin North Am
(1991) - et al.
Penetrating neck trauma
Emerg Med Clin North Am
(1998) - et al.
Noninvasive diagnosis of vascular trauma by duplex ultrasonography
J Vasc Surg
(1991) - et al.
Vertebral artery injury in cervical spine trauma
Injury
(2001) - et al.
The nonoperative management of penetrating internal jugular vein injury
J Vasc Surg
(2006) - et al.
Interventional techniques in vascular trauma
Surg Clin North Am
(2001) - et al.
Vascular trauma: Endovascular management and techniques
Surg Clin North Am
(2007)
Management of extra-cranial vertebral artery injuries
Eur J Vasc Endovasc Surg
Clinical practice guideline: Penetrating zone II neck trauma
J Trauma
Five thousand seven hundred sixty cardiovascular injuries in 4459 patientsEpidemiologic evolution 1958-1987
Ann Surg
Carotid vertebral trauma
J Trauma
Prospective evaluation of screening multislice helical computed tomographic angiography in the initial evaluation of penetrating neck injuries
J Trauma
A critical reappraisal of a mandatory exploration policy for penetrating wounds of the neck
Surg Gynecol Obstet
Routine versus selective exploration of penetrating neck injuries: A randomized prospective study
J Trauma
Penetrating injuries of the neck: Use of helical computed tomographic angiography
J Trauma
Penetrating neck injuries: Helical CT angiography for initial evaluation
Radiology
Diagnosis of arterial injuries caused by penetrating trauma to the neck: Comparison of helical CT angiography and conventional angiography
Radiology
Computed tomography in the evaluation of penetrating neck trauma: A preliminary study
Arch Surg
Penetrating zone II neck injury: Does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury?A prospective blinded study
J Trauma
Impact of MDCT angiography on the use of catheter angiography for the assessment of cervical arterial injury after blunt or penetrating trauma
AJR Am J Roentgenol
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Penetrating Head and Neck Trauma: A Narrative Review of Evidence-Based Evaluation and Treatment Protocols
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2019, Seminars in Ultrasound, CT and MRICitation Excerpt :This can be mostly evident in projectile penetrating trauma due to gunshot injury where radiological interpretation may be further hindered by streak artifacts (Figs. 1 and 2). Injury of the pharynx and proximal (cervical) esophagus is uncommon,21 but should be considered when the trajectory of the penetrating injury comes into close proximity with either of these structures.22,23 The abdomino-pelvic region (Figs. 3-5) has been considered as one of the most vulnerable regions of the body, and injuries involving this area of the body are very serious.24-26
ACR Appropriateness Criteria<sup>®</sup> Penetrating Neck Injury
2017, Journal of the American College of RadiologyCitation Excerpt :Early studies comparing US and catheter-based angiography demonstrated a sensitivity of 91%, a specificity of 98% to 100%, a positive predictive value of 100%, and a negative predictive value of 99% for patients with clinical soft signs imaged by US [24,25]. MRI and MR angiography (MRA) are limited in the initial trauma setting given the length of scanning, potentially critical nature of the patient’s condition, and concern for metallic foreign bodies [4,13,15,23]. Concern for metallic foreign bodies may be investigated by either CT or radiographs.
Multi-Detector Row CT Angiography of the Neck in Blunt Trauma
2012, Radiologic Clinics of North AmericaCitation Excerpt :With newer MDCTA units, the ability for volumetric acquisition allows for generation of high quality multiplanar and curved reformatted images, which improves the visualization of previously difficult areas to evaluate, such as the high cervical and intracranial portions of the carotid and vertebral arteries, as well as improving the ability to characterize the types of vessel injury and their relationship to the surrounding tissues. Vascular lesions following blunt and penetrating trauma have similar imaging features.28–33 Minimal intimal irregularity (grade 1) is an injury finding described in the literature as an area of nonstenotic luminal irregularity that may be seen only on multiplanar or volume-rendered reconstructions (see Fig. 4).
PENETRATING NECK INJURY CAUSED BY A GUN SCREW: A CASE REPORT
2023, Gomal Journal of Medical Sciences‘No zone’ approach to the management of stable penetrating neck injuries: a systematic review
2021, ANZ Journal of Surgery