HELPING THE TRAUMA SURGEON S201

CT Findings in Blunt
Renal Trauma1
CME FEATURE Alison C. Harris, MB, ChB, MRCP, FRCR ● Charles V. Zwirewich,
See accompanying
MD, FRCPC ● Iain D. Lyburn, MB, ChB, MRCP, FRCR
test at http:// William C. Torreggiani, MB, ChB, MRCPI, FRCR, FFRRCSI
www.rsna.org Lorie O. Marchinkow, RTR
/education
/rg_cme.html

LEARNING Computed tomography (CT) can provide essential anatomic and

OBJECTIVES physiologic information required to determine management of intraab-
FOR TEST 4 dominal and retroperitoneal injuries sustained during blunt abdominal
After reading this trauma. It can help in evaluation of the type and severity of parenchy-
article and taking
the test, the reader mal injury, the extent of perirenal hemorrhage and parenchymal devas-
will be able to:
cularization, and the presence of urinary extravasation. CT can help
䡲 Discuss the CT
imaging findings and confirm the presence of major injuries to the vascular pedicle and de-
severity grading of pict occult renal pathologic conditions. Principal indications for the use
renal injury due to
blunt abdominal of CT in the evaluation of blunt renal trauma include (a) the presence
trauma. of gross hematuria, (b) microscopic hematuria associated with shock
䡲 Identify those pa- (systolic blood pressure ⬍90 mm Hg), and (c) microscopic hematuria
tients in whom renal
imaging is indicated. associated with a positive result of diagnostic peritoneal lavage. The
䡲 Develop manage- majority of renal injuries sustained during blunt abdominal trauma are
ment strategies to contusions and minor parenchymal lacerations amenable to nonopera-
deal with the range of
renal injuries that tive management. Deep parenchymal lacerations, urinary extravasa-
may be presented. tion, and mild to moderate degrees of parenchymal devascularization
may also be treated conservatively. Radiologists should look for coex-
isting renal lesions such as tumors and traumatic false aneurysms that
may alter management.

Index terms: Kidney, CT, 81.12114 ● Kidney, hemorrhage, 81.413 ● Kidney, infarction, 81.77 ● Kidney, injuries, 81.41, 81. 482

RadioGraphics 2001; 21:S201–S214

1From the Department of Radiology, Vancouver General Hospital, 855 W 12th Ave, Vancouver, British Columbia, Canada V5Z 1M9. Presented as

an education exhibit at the 2000 RSNA scientific assembly. Received February 2, 2001; revision requested April 5 and received May 10; accepted May
29. Address correspondence to C.V.Z. (e-mail: zwirecv@unixg.ubc.ca).
©
RSNA, 2001
S202 October 2001 RG f Volume 21 ● Special Issue

Renal Injury Scale of the American Association of Surgeons in Trauma

Grade Injury Description

1 Microscopic or gross hematuria with normal findings of imaging studies; renal contusion; nonexpanding
subcapsular hematoma without parenchymal laceration
2 Nonexpanding perirenal hematoma confined to the retroperitoneum; superficial lacerations (⬍1 cm
depth) in the renal cortex
3 Lacerations ⬎1 cm depth in the renal cortex without extension into the collecting system or urinary
extravasation
4 Lacerations extending through the renal cortex, medulla, and collecting system; injuries to the main
renal artery or vein with contained hemorrhage; thrombosis of a segmental renal artery without
parenchymal laceration
5 Lacerations that completely shatter the kidney; injuries to the renal hilum with devascularization of the
kidney: traumatic renal arterial disruption, traumatic renal arterial occlusion

Introduction genital variants that may affect the choice of man-

Computed tomography (CT) is widely used in
the evaluation of intraabdominal and retroperito-
neal injuries sustained during blunt abdominal
trauma. Abdominal CT in the setting of acute
trauma can provide essential anatomic and physi-
ologic information required in determining treat-
ment.
Renal injuries occur frequently among patients
who sustain blunt abdominal trauma. Ninety-five
percent of injuries are minor and can be managed
without surgery (1). The presence of hematuria
and hypotension are two important clinical signs
associated with an increased risk of significant
renal injury. Unfortunately, there is poor correla-
tion between the severity of hematuria and sever-
ity of renal injury. Computed tomography (CT) is
currently the diagnostic tool of choice for the
evaluation of blunt abdominal trauma in the pa-
tient in hemodynamically stable condition. It can
be used to accurately assess the severity of renal
injury, determine the presence of urinary extrava-
sation and perirenal hemorrhage, and determine
the status of the renal vascular pedicle. It can also
be used to identify clinically occult active renal or
perirenal bleeding, as well as unsuspected struc-
tural abnormalities including tumors and con-
agement.
This article reviews the spectrum of CT find-
ings in patients with blunt renal trauma and cur-
rent treatment guidelines for each class of injury.
Classification of Injuries
Renal injuries are classified into five grades of se-
verity (Fig 1) according to the American Associa-
tion of Surgeons in Trauma organ injury severity
scale (Table) (2). This surgical-pathologic classi-
fication system recognizes the progressive nature
of parenchymal and vascular damage associated
with increasingly severe mechanisms of trauma.
Approximately 82% of injuries may be classified
as grade 1 and include parenchymal contusions
and isolated subcapsular hematomas. Grade 2
injuries include superficial cortical lacerations less
than 1 cm in depth and nonexpanding perirenal
hematomas. Grade 3 injuries include lacerations
greater than 1 cm in depth without extension into
the collecting system or evidence of urinary ex-
travasation. Deep lacerations that involve the col-
lecting system, traumatic thrombosis of a segmen-
tal renal arterial branch, and injuries to the main
renal artery not associated with renal devascular-
ization are all grade 4 injuries. Grade 5 injuries,
the most severe, include shattering of the kidney

Figure 1. Graphical representation of the American Association of Surgeons in Trauma grading system: grades ‹
1–5. (a) Grade 1: subcapsular hematoma (arrow). (b) Grade 2: superficial renal laceration (arrow) with perirenal
hemorrhage (arrowhead). (c) Grade 3: deep laceration (arrows) without extension into the collecting system of the
kidney. (d) Grade 4 parenchymal injury: deep laceration (straight arrows) that involves the renal collecting system
(curved arrow). (e) Grade 4 vascular injury: thrombosis of a segmental renal arterial branch (arrows) with segmental
renal infarction (shaded area). (f) Grade 5 parenchymal injury: multiple deep lacerations that result in a shattered
kidney. (g) Grade 5 vascular injury: traumatic occlusion of the main renal artery due to intimal injury (solid arrow)
with distal arterial thrombosis (open arrows). (h) Grade 5 vascular injury: renal arterial avulsion (arrow).
RG f Volume 21 ● Special Issue Harris et al S203
S204 October 2001
Figure 2. Imaging algorithm. BAT ⫽
blunt abdominal trauma, BP ⫽ blood pres-
sure, DPL ⫽ diagnostic peritoneal lavage,
IVP ⫽ intravenous pyelography, Pos. ⫽
positive result of.
into multiple fragments and devascularizing inju-
ries to the renal pedicle. They also include avul-
sion of the renal artery, as well as in situ thrombo-
sis of an intact renal artery, usually due to a shear-
ing injury to the intima. In one large urologic
series, minor parenchymal lacerations (grade 2)
accounted for 6% and major lacerations (grades 3
and 4) accounted for 7% of injuries. Vascular in-
juries (grades 4 and 5) accounted for only 5.5%
of cases (3).
Imaging Algorithm
in Suspected Blunt Renal Trauma
There is general consensus in the urologic com-
munity that the urinary tract in any patient with
blunt abdominal trauma should be imaged under
the following circumstances (Fig 2): (a) presence
of gross hematuria, (b) presence of microscopic
hematuria associated with shock (defined as sys-
tolic blood pressure less than 90 mm Hg in the
field or during resuscitation), and (c) microscopic
hematuria associated with a positive result of di-
agnostic peritoneal lavage. Renal imaging is gen-
erally unnecessary if the patient is normotensive
and has only microscopic hematuria, because the
risk of serious injury that needs operative manage-
ment is less than 0.2% in this group (1,3– 6). CT
is the preferred method of investigation in the
setting of acute renal trauma. The kidneys are
generally assessed as part of a dedicated abdomi-
RG f Volume 21 ● Special Issue
nal and pelvic trauma CT protocol that involves
utilization of intravenous contrast medium (100 –
150 mL of a solution of 320 mg of iodine per mil-
liliter) administered at rates of 2– 4 mL/sec. A
scanning delay of 60 –70 seconds after injection of
contrast medium ensures good enhancement of
the renal parenchyma (corticomedullary phase) in
most patients. Delayed scanning of the kidneys
during the excretory phase is recommended if the
initial CT images show a deep parenchymal lac-
eration or large perirenal fluid collection. Excre-
tory-phase images may be acquired 3–5 minutes
after injection of contrast medium (7). Section
thickness of 5– 8 mm and a reconstruction inter-
val of 2.5– 4 mm are generally acceptable. CT
cystography may be combined with this protocol
when bladder rupture is a concern. Renal angiog-
raphy and selective embolization are generally
reserved for patients in hemodynamically stable
or marginally unstable condition with (a) active
hemorrhage detected at CT or (b) delayed hem-
orrhage that occurs while the patient is under
nonoperative management.
CT Features of Specific Injuries
Contusions and Hematomas
Renal contusions (grade 1) are characterized by a
focal area of decreased enhancement in the renal
parenchyma relative to normal adjacent regions.
Contusions may have sharply or poorly defined
margins (Fig 3). They are differentiated from ar-
eas of renal infarction by the presence of contrast
RG f Volume 21 ● Special Issue Harris et al S205

Figure 3. Renal contusions. CT scans show poorly defined (arrow in a) and sharply marginated (arrows in b) areas
of decreased parenchymal enhancement in the right kidney of two different patients with renal contusions. Perirenal
hemorrhage is absent in both cases.

Figure 4. (a) CT scan shows a hyperattenuating subcapsular hematoma (h) resulting from trauma to a clinically
unsuspected lower pole renal adenocarcinoma. (b) CT scan obtained after injection of contrast medium shows the
tumor (arrow).

enhancement in the former and its absence in the
latter. Subcapsular hematomas (grade 1) may
vary in attenuation value as a function of the age
of the clot. Acute hematomas are typically hyper-
attenuating (40 – 60 HU) relative to renal paren-
chyma on unenhanced CT images. When small,
subcapsular hematomas appear crescentic and
may exert minimal mass effect on the adjacent
renal parenchyma (Fig 4). As they enlarge, they
S206 October 2001 RG f Volume 21 ● Special Issue

Figure 5. Perirenal hemorrhage after minimal trauma in two patients with preexisting renal lesions. (a) CT scan
reveals hemorrhage in a traumatized right renal cyst (solid arrow) and associated perirenal hematoma (open arrows).
(b) CT scan of a different patient shows perirenal hemorrhage (h) that occurred after trauma to an occult small renal
carcinoma (arrow).

tend to assume a biconvex appearance at CT.

When the renal capsule is lacerated, hematoma
can enter the perinephric space (Fig 5).

Lacerations
Renal lacerations appear as linear, low-attenua-
tion areas in the parenchyma and may be superfi-
cial (⬍1 cm depth; Fig 6) or deep (⬎1 cm depth;
Fig 7). Deep lacerations may spare the collecting
system (grade 3) or may involve it (grade 4),
which results in urinary extravasation (8,9). Lac-
erations generally contain clotted blood and
therefore do not enhance on scans obtained after
intravenous administration of contrast medium.
Perirenal hematomas with attenuation values in
the 45–90 HU range are common and may be
large.

Figure 6. Superficial lacerations. CT scan reveals a

moderate perirenal hematoma that surrounds the pos-
terior aspect of the left kidney (H) adjacent to two su-
perficial lacerations (arrows).
RG f Volume 21 ● Special Issue
Figure 7. Deep renal lacerations. (a) CT scan of one patient shows a deep laceration (open arrow) that has re-
sulted in a large perirenal hematoma (solid arrows). (b) CT scan of another patient shows a deep, full-thickness pa-
renchymal fracture (arrow) with only minimal perirenal bleeding. The depth of the fracture does not reliably correlate
with the size of the perirenal hematoma.
Figure 8. Active arterial hemorrhage in a patient in
marginally unstable condition. CT scan reveals a ser-
pentine collection of vascular contrast material (arrow)
within a large tissue-attenuation hematoma posterior to
the right kidney. The diagnosis of arterial bleeding
rather than caliceal rupture with urine leakage was
predicated on the patient’s clinical status and the com-
plete absence of fluid-attenuation, unopacified urine in
the perirenal space. The patient became hypotensive
during CT and underwent partial nephrectomy.
Harris et al S207
Active Hemorrhage
and Urinary Extravasation
When intense contrast enhancement occurs
within a laceration or an adjacent hematoma dur-
ing the early phase of the CT examination, the
diagnosis of traumatic false aneurysm or active
hemorrhage should be considered (Fig 8). Active
hemorrhage tends to track into surrounding tis-
sues and has a linear or flamelike appearance,
whereas false aneurysms tend to be more focal
and rounded. Extravasation of vascular contrast
medium appears with attenuation values of 80 –
370 HU, is typically within 10 –15 HU of the
aorta or adjacent major artery, and is generally
surrounded by lower-attenuation clotted blood
(10 –12). This finding is an important indicator
that a patient may be about to pass from hemody-
namic stability to decompensation. In one series,
38% of patients with this finding became hypo-
tensive during or immediately after the CT ex-
amination (11). Patients in stable condition with
S208 October 2001 RG f Volume 21 ● Special Issue

Figure 9. Spontaneous resolution of urinary extravasation. (a) Initial CT scan shows extravasation of urinary con-
trast medium around the medial hilar lip of the right kidney (arrow). (b) CT scan obtained 3 days later while the pa-
tient was managed conservatively shows that the leak has closed. No urinoma was present.

Figure 10. Value of excretory-phase CT in the detection of urine leaks in a patient kicked by a horse. (a) CT scan
shows a fractured left kidney surrounded by a large mixed-attenuation collection (arrows). It is not clear whether this
collection represents hematoma or a combination of blood and urine. (b) Excretory-phase CT scan shows a large
volume of urine extravasated into the perinephric space (arrow). Partial nephrectomy was required because of ongo-
ing bleeding.
RG f Volume 21 ● Special Issue
Figure 11. Multiple segmental renal infarcts. Late-nephrographic- (a) and excretory-phase (b) CT scans show
multiple wedge-shaped infarcts in the right kidney (straight arrows). Perirenal hematoma (curved arrow in a) and
urinary extravasation (curved arrow in b) are also present.
Figure 12. Grade 5 renal parenchymal injury. CT
scan demonstrates a shattered and partially devascular-
ized right kidney (arrows), surrounded by a large hema-
toma.
active vascular extravasation should be referred
for angiographic embolization.
Contrast enhancement within a laceration or
around the kidney during the pyelographic phase
Harris et al S209
of the CT examination indicates the presence of a
urine leak (Fig 9). Delayed scanning 10 –15 min-
utes after intravenous administration of contrast
medium may be useful in selected patients to
show the extent of urinary extravasation (Fig 10).
Renal Infarction
Thrombosis or laceration of a segmental renal
arterial branch produces a focal area of renal in-
farction. Infarcts typically appear as peripherally
based, wedge-shaped areas of parenchyma that
fail to enhance during both the corticomedullary
and pyelographic phases of a CT study. Segmen-
tal infarcts may be solitary or multiple and are
frequently associated with other renal injuries
(Fig 11). The term shattered kidney refers to gross
renal parenchymal disruption by multiple lacera-
tions; these injuries are frequently associated with
multiple areas of renal infarction (Fig 12). Devas-
cularization of the entire kidney due to laceration
or to in situ thrombosis of the main renal artery
constitutes the most severe form of renal injury
(grade 5). Such injury may occur with or without
S210 October 2001 RG f Volume 21 ● Special Issue

Figures 13, 14. (13) Grade 5 renal vascular injury: avulsion of the renal artery. CT scan shows that the right kidney
(arrows) is devascularized and surrounded by a hyperattenuating clot that extends into multiple deep lacerations in
the renal parenchyma. Traumatic avulsion of the renal artery was found at nephrectomy. (14) Grade 5 renal vascular
injury: infarcted right kidney secondary to traumatic renal arterial thrombosis. (a) CT scan shows virtually no en-
hancement of the right kidney, and retrograde opacification of the right renal vein is present (arrow). (b) Aortic digi-
tal subtraction angiogram shows occlusion of the renal artery (arrow). (c) Selective renal digital subtraction angio-
gram shows thrombus within the artery (arrow). Retroperitoneal hematoma is completely absent from this vascular
injury. This finding is typical of shearing injuries to the renal artery that result in intimal disruption and in situ vascu-
lar thrombosis rather than full-thickness arterial disruption.

parenchymal lacerations (Figs 13, 14). If the kid-
ney is devascularized as a consequence of an iso-
lated intimal injury to the renal artery that results
in thrombosis, extensive retroperitoneal hemor-
rhage and hematuria may be absent. The classic
findings of traumatic renal infarction at CT in-
clude absent nephrogram on the affected side,
retrograde opacification of the renal vein from the
inferior vena cava, and abrupt truncation of the
renal arterial lumen at the point of occlusion (Fig
14) (13). The cortical rim nephrogram sign of a
devascularized kidney (Fig 15) may be absent in
the acute setting. Traumatic renal venous throm-
bosis is suggested by a persistent nephrogram and
reduced or no opacification of the ipsilateral renal
vein.
RG f Volume 21 ● Special Issue Harris et al S211

Figure 16. Conservative management of a grade 4

injury with complete healing in a patient involved in a
motor vehicle accident. (a) CT scan shows a deep lac-
eration to the posterior renal parenchyma (arrow).
(b) Excretory-phase CT scan shows a large volume of
urinary extravasation (arrows). The injury was treated
by means of observation only. (c) CT scan obtained 9
months later shows a normal kidney with virtually no
evidence of previous trauma.

Management Options
Urologists have adopted a conservative manage-
ment strategy for all but the most severe renal
injuries. This conservatism is due to historical
evidence that the nephrectomy rate is higher
among patients who undergo operative explora-
tion (35%) than among those who simply un-
dergo observation (12.6%) (8). Radiologists must
recognize that before a renal injury can be se-
lected for nonoperative management it must be
accurately imaged and staged. The only absolute
indication for surgical exploration is life-threaten-
ing renal bleeding (9). Relative indications for
operative management include the presence of
(a) extensively devitalized tissue (⬎50% of the
renal parenchyma), (b) urinary extravasation that
cannot be controlled with conservative means
such as ureteral stent placement or nephrostomy,
and (c) arterial thrombosis (8,9).
Grades 1 and 2 injuries are managed nonop-
eratively with excellent results; patients have nor-
mally functioning kidneys at follow-up imaging
(8). Most patients with injuries of intermediate
severity (grades 3 and 4) also undergo nonopera-
tive management. Urinary extravasation alone
(grade 4) is not an indication for surgery, as the
urine leak will spontaneously resolve in up to 87%
of patients (Fig 16) (9). Careful follow-up with
Figure 15. CT scan shows capsular rim nephrogram
in the left kidney (arrows) after a renal infarction.
S212 October 2001 RG f Volume 21 ● Special Issue

Figure 17. Delayed hemorrhage from a grade 3

injury treated with subselective embolization in a
patient injured in a motor vehicle accident 2 weeks
prior to the CT examination. Her injuries were be-
ing treated with observation when massive gross he-
maturia developed and she became hypotensive.
(a– c) CT scans show a deep laceration in the left
kidney (arrows in a) and clots within the renal pelvis
(arrow in b) and bladder (arrow in c). (d) Selective
left renal angiogram shows a false aneurysm arising
from an interpolar arterial branch (arrow). (e) Se-
lective left renal angiogram obtained after emboliza-
tion shows that the aneurysm was successfully em-
bolized with coils. Renal function was preserved and
partial nephrectomy avoided.
RG f Volume 21 ● Special Issue Harris et al S213

Figure 18. Embolization of active hemorrhage in a patient with a solitary kidney who was hypotensive with
gross hematuria after blunt abdominal trauma due to a vehicular accident. (a) Selective right renal arteriogram
shows a small false aneurysm in the lower pole of a hypertrophied right kidney (arrow). (b) Angiogram ob-
tained after subselective injection shows the false aneurysm (arrow). (c) Angiogram obtained after embolization
with gelatin sponge particles was used to obliterate the aneurysm and stop the bleeding. (d) Postembolization
CT scan obtained without additional intravenous contrast medium shows a residual focal collection of extrava-
sated angiographic contrast medium within a deep renal laceration (arrow). The patient remained in stable
condition and recovered uneventfully.

serial CT examinations is warranted in these pa-
tients to monitor the severity of the urine leak and
to direct percutaneous drainage of any collections
in patients with symptoms or sepsis. Grade 4 in-
juries associated with infarction of ⬍50% of the
renal parenchyma are treated conservatively un-
less they are accompanied by a large hematoma or
urine leak, in which case surgical débridement is
strongly considered. Aggressive monitoring of
patients with grade 3 and 4 injuries and use of
percutaneous drainage or angiographic emboliza-
tion as required has reduced the laparotomy rate
in this group to approximately 10% (Figs 17, 18)
(9).
Actively bleeding renovascular pedicle injuries
(grade 5) may need prompt surgical exploration
S214 October 2001
to prevent exsanguination (9). Traumatic throm-
bosis or avulsion of the renal artery must be diag-
nosed and treated rapidly, as permanent, progres-
sive loss of renal function begins after 2 hours of
warm-ischemia time (14). Although some authors
have reported technical success in repair of arte-
rial injuries after several hours of warm ischemia
(15), most concur that repair must occur within 4
hours of injury if meaningful renal function is to
be realistically expected (16). Even with recon-
structive surgery, only 14%–29% of kidneys re-
turn to normal function (9,15). If renal ischemia
has exceeded 4 hours and the contralateral kidney
is normal, most urologists will avoid surgery and
allow the devascularized kidney to atrophy. If
devascularizing injuries are bilateral or involve a
solitary kidney, reconstructive surgery is generally
attempted even if the ischemia time has exceeded
4 hours (14,16).
Summary
Radiologic investigation of the kidneys in patients
who have sustained blunt trauma can generally be
restricted to those with systolic blood pressure
less than 90 mm Hg, gross or microscopic hema-
turia, and a positive result of peritoneal lavage.
CT is the preferred imaging method and is accu-
rate in staging the severity of renal injuries. The
majority of renal injuries are minor and need no
urologic intervention. Conservative management
is also possible among most patients with deep
parenchymal lacerations, urinary extravasation,
and mild to moderate degrees of parenchymal
devascularization. Renal arterial injuries associ-
ated with devascularization of the entire kidney
should be treated with prompt surgical revascu-
larization within 4 hours of injury to minimize the
risk of irreversible loss in renal function. When
the diagnosis is delayed beyond this point, pa-
tients in hemodynamically stable condition with a
normal contralateral kidney undergo nonopera-
tive management.
Immediate laparotomy is indicated in hemody-
namically unstable patients with grade 5 injuries.
Angiography and selective embolization are useful
adjuncts in stable patients with active bleeding at
the time of initial CT or those with delayed hem-
orrhage while undergoing conservative manage-
ment. Radiologists should carefully search for
coexisting renal lesions such as tumors and trau-
matic false aneurysms that will affect case man-
This article meets the criteria for 1.0 credit hour in category 1 of the AMA Physician’s Recognition Award. To obtain
credit, see accompanying test at http://www.rsna.org/education/rg_cme.html.
RG f Volume 21 ● Special Issue
agement. Close cooperation between the radiolo-
gist and urologist is essential in optimizing the
management of blunt renal injuries and ensuring
a favorable outcome.
Acknowledgment: We gratefully acknowledge the
secretarial support of Betty Fowler in the preparation of
the manuscript.
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