Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury

Abstract

This article reviews current and evolving concepts in the diagnosis of penetrating diaphragmatic injury with multidetector CT (MDCT). As criteria for nonoperative management in the setting of penetrating trauma become more inclusive, confident exclusion of penetrating diaphragmatic injury (PDI) has become imperative. Diagnostic performance of MDCT for PDI has improved substantially with the use of thin sections and multiplanar reformats. Evaluation of injury trajectory in nonstandard planes using 3D post-processing software can aid in the diagnosis. Contiguous injury and transdiaphragmatic trajectory are the best predictors of PDI. Careful appraisal of the diaphragm for defects should be undertaken in all patients with thoracoabdominal penetrating trauma.

Multidetector CT for Penetrating Torso Trauma: State of the Art

“…spinal column. They are also necessary for diagnostically acceptable trajectory evaluation in nonstandard planes (48,54,(56)(57)(58).…”

“…Accuracy has improved with the use of thin sections and multiplanar reconstructions (MPRs) (38,56). Additional benefit can be gained by evaluating trajectory in nonstandard planes by manipulating near-isotropic datasets using postprocessing software (48,57,(76)(77)(78)(79). The technique, which has been referred to as trajectory analysis or CT trajectography (or "CTT") (48,57), involves placing a cross-cursor on the point of entry, and swiveling the cut planes obliquely in orthogonal planes to obtain a "double oblique" orientation in which the wound track is visualized in profile.…”

“…Additional benefit can be gained by evaluating trajectory in nonstandard planes by manipulating near-isotropic datasets using postprocessing software (48,57,(76)(77)(78)(79). The technique, which has been referred to as trajectory analysis or CT trajectography (or "CTT") (48,57), involves placing a cross-cursor on the point of entry, and swiveling the cut planes obliquely in orthogonal planes to obtain a "double oblique" orientation in which the wound track is visualized in profile. Independent groups have described its use in both civilian and wartime penetrating torso trauma, and using a Cartesian coordinate system, it has been shown to have excellent interobserver agreement (56,(76)(77)(78)(79).…”

Penetrating Colorectal Injuries: Diagnostic Performance of Multidetector CT with Trajectography

“…Under-opacification and wound tracks and the potential for diffuse intraperitoneal fluid to obscure wound tracks when multiple wounds are present. Trajectories must also be extrapolated in some instances when a continuous track is not visible along its entire course and may not follow a straight path as a result of bullet yaw or ricochet off bone, which limits interobserver agreement (16,32,36). Therefore, trajectory also lacks specificity (50%-78%).…”

MDCT of complications and common postoperative findings following penetrating torso trauma

“…The majority of torso gunshot wound and some stab wound victims are hemodynamically unstable or have overt peritoneal signs and undergo exploration without pre-operative CT [1][2][3][4]. Multiple injuries are seen in most torso gunshot wounds, and patients in shock will often require initial damage control surgery, during which hematomas are explored, bleeding vessels are ligated, and splenectomies and single nephrectomies are performed in unsalvageable cases.…”