ADVANCES IN EMERGENCY RADIOLOGY I 0033-8389/99 $8.00 + .

OO

HELICAL CT GRADING OF
TRAUMATIC AORTIC INJURIES
Impact on Clinical Guidelines for Medical and
Surgical Management

Morris L. Gavant, MD

Modern civilian trauma centers and their ad-
vanced ambulance and communication networks
were developed after the success of the US mili-
tary experience with airborne evacuation of
wounded soldiers during the Korean and Vietnam
Wars. These regional acute care systems allow crit-
ically injured patients suffering blunt trauma to
receive early medical attention resulting in greater
likelihood of successful resuscitation and sur-
vival.Z,3,54,58
Upon arrival at the trauma center, patient triage
requires rapid hemodynamic stabilization and si-
multaneous detection and treatment of life-threat-
ening injuries.52Musculoskeletal injuries are usu-
ally apparent.l0, 36 Sensory or motor deficits
indicate a central nervous system injury. Identifi-
cation of the location and severity of internal injur-
ies to the chest, abdomen, or pelvic soft tissues,
however, is challenging.30,35 The medical history
and a description of the forces causing the injury
may be i n ~ o m p l e t ePhysical
.~~ findings may be
masked by intoxication or neurologic insult^.^ Lab-
oratory findings, although crucial in the resuscita-
tion of the patient, are nonspecific. Conventional
radiographs of the torso may be falsely normal,
underestimate injury, or technically inadequate.'O,
39, 61 Other imaging methods that rely on conven-
tional radiography and fluoroscopy, such as urog-
raphy, cystography, and barium studies, are time
consuming and evaluate only one organ system
at risk.
Until the late 1970s, visceral injuries were de-
tected by complicated, invasive, or expensive
procedures, such as aortography, selective angi-
ography, diagnostic peritoneal lavage, or explor-
atory l a p a r ~ t o m y . ~Medical
~, treatment of other
injuries was hampered or delayed while these
time-consuming studies were performed to ex-
clude an injury capable of causing fatal internal
hemorrhage.
The development of rapid abdominal CT and
nonionic water-soluble contrast media were ad-
vancements that improved the ability to exclude
or detect noninvasively, safely, and rapidly internal
injuries to the abdomen and The chest
and especially the thoracic aorta, however, re-
mained difficult areas to evaluate. Cardiovascular
and respiratory motion and insufficient resolution
of small aortic injuries limited the utility of con-
ventional CT. Because the risk of fatal exsanguina-
tion was high, patients underwent thoracic aortog-
raphy regardless of chest CT findings to exclude
even a small aortic injuryz0,31,56
Volumetric helical or spiral CT slip-ring technol-
ogy with continuous data acquisition was intro-
duced in the early 1990s. Improvements in reduc-
ing motion and volume averaging artifacts
allowed reliable demonstration of the aortic wall
and lumen so that helical scanning of the chest
was sufficient for directly excluding or detecting
aortic injuries.23Today, critical internal injuries of
the entire torso including the thoracic aorta can be
detected quickly, even while the patient is being
resuscitated and assessed?, 13, 25* 42, 43, 44,59, *

From the Department of Radiology, University of Tennessee; and Regional Medical Center at Memphis, Elvis Presley
Memorial Trauma Center, Memphis, Tennessee

~~ ~ ~ ~ ~

RADIOLOGIC CLINICS OF NORTH AMERICA

VOLUME 37 NUMBER 3 MAY 1999 553
554 GAVANT
The goals of this article are to (1) describe the
triage and imaging protocols for screening patients
with helical CT of the chest to detect aortic injur-
i e ~ , 2(2)
~ review the range of aortic injuries that
may be identified and to propose a grading system
to judge the severity of aortic injury detected by
helical CT?19 and (3) discuss the clinical manage-
ment decisions that should be considered when
helical CT detects various types of aortic injury.
This review is based on the cIinicaI experience
gained at a level one trauma center serving the
mid-south region of the United States. Since the
autumn of 1993, over 90 vascular injuries of the
aorta and great vessels have been detection in over
10,000 patients who have been screened with heli-
cal CT of the chest.12,13, 24, 25
GUIDELINES FOR HELICAL CT FOR
EVALUATION OF BLUNT TRAUMA
The clinical indication for CT evaluation of pa-
tients with blunt injury is not complex. After as-
sessment and hemodynamic stabilization, regard-
less of chest radiographic findings, mechanism of
injury, or physical findings, patients with nontriv-
ial blunt trauma should undergo helical CT of
the chest in conjunction with screening CT of the
abdomen, pelvis, brain, or spine to detect the loca-
tion and severity of suspected and unsuspected
internal injuries.12,23, 25
Hemodynamic Stabilization
Imaging of the thoracic aorta cannot begin until
the patient is hemodynamically stable enough to
move to the CT or angiographic suite. Portable
transthoracic ultrasonography performed by emer-
gency medical technicians in the field or trans-
esophageal studies by physicians and ultrasonog-
raphers in the trauma resuscitation rooms may
allow early noninvasive detection of pleural and
pericardial hemorrhage and even thoracic aortic
injuries. Ultrasonography, however, requires expe-
rience and good technical skills to maintain exami-
nation quality and reproducibility. In addition, it
is further limited because it cannot evaluate all the
organs susceptible to major injury.5,27, 40 Advances
in portable CT technology may allow imaging of
the chest to begin in the emergency department
even as the resuscitation team makes their initial
approach to the patient.
If the patient survives to undergo a CT examina-
tion, it is unlikely that he will die from a delayed
rupture of an aortic injury.1z*25,47Given the critical
nature of the injuries, the occasional death before
or during CT examination or before surgery is not
unexpected.
Patient Assessment: Mechanism of
Injury, Physical Findings, and Chest
Radiography
The classic triad of mechanism of injury, physi-
cal examination findings, and findings on chest
radiography previously used to screen patients at
risk for thoracic aortic injury should not be relied
on for the triage of patients to helical CT. A di-
rected medical history and physical examination
of hemodynamically labile patients must be brief
and may be incomplete. The easily obtained, inex-
pensive, noninvasive, portable chest radiograph is
important to detect critical lung, pleural, or bony
injuries. It is frequently suboptimal, for evaluating
the mediastinum and aorta.
An aortic injury is unlikely in a hemodynami-
cally stable, nonintubated, nonintoxicated patient
with a normal, properly positioned and exposed,
72-in tube-to-film distance, upright chest radio-
graph.4l The performance of a technically adequate
examination, can be quite challenging. A more ac-
curate helical CT study can be completed during
the time used to repeat a meticulously performed
examination. In addition, the chest radiograph can
only detect the secondary findings of aortic injury
caused by changes in the normal mediastinal mor-
phology by hematoma. Many of these secondary
findings are subtle or inconsistent and may be
unrelated to an aortic abnormality.10,23, 39, 41 Helical
CT directly evaluates the aorta regardless of the
mediastinal findings.12,25, 43 In addition, it detects
minimal aortic injuries that otherwise go unde-
tected because they have little or no associated
mediastinal hematoma (Figs. 1 and 2).17,3, 4, 38
Nontrivial Blunt Trauma
Typically, patients at risk for suffering aortic in-
juries are injured in automobile crashes, especially
if they are unrestrained, survive ejection from the
vehicle, or have other internal injuries. Uncon-
scious or intoxicated patients who cannot provide
a medical or accident history or reliable physical
examination must be assumed to have nontrivial
trauma. Patients injured during uncontrolled falls
or by severe crushing injuries to the chest also
should be considered at risk for thoracic aortic
injury.7,8, 1 3 , X
Patients who have suffered criminal assaults,
falls from a standing position, or are injured in
minor car accidents and have normal physical and
neurologic physical examinations and a normal
chest radiograph have suffered trivial trauma and
are not usually suspected of having an aortic in-
jury. Traumatic aortic ruptures can be missed, if
the severity of injury is underestimated in this
group of patients (Fig. 3).
Associated Injuries
CT of the head and spine should be used to
detect or exclude suspected central nervous system
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 555

Figure 1. Unsuspected minimal aortic injury. A 32-year-old woman injured in an automobile crash.
A, Small aortic pseudoaneurysm (arrowheads) at the level of the main left pulmonary artery (LPA),
with minimal para-aortic posterior mediastinal hematoma. Also note the wall motion artifact that
surrounds the ascending aorta (A). Normal fat-filled anterior mediastinum bulging the lateral
mediastinal borders. S = Superior vena cava. This was an unsuspected injury that was initially
overlooked. 6, Gated-MR imaging study using open, low-field scanner confirmed the injury
(arrows) and convinced the patient to undergo aortography. C, Digital aortography revealed subtle
injury (curved arrow) best seen on nonsubtracted images in lateral position. Overlying ribs make
the injury difficult to see. The patient underwent successful surgical repair the next day.
556 GAVANT

Figure 2. Minimal aortic injury (pseudoaneurysm) and bony pelvic injury. An 18-year-old woman
injured in an automobile crash. A, Surgically proven small (less than 1 cm) pseudoaneurysm (arrow-
head). S = SVC; A = ascending aorta; P = main pulmonary artery. Paucity of mediastinalfat makes
detection of hematoma difficult. B,The only other internal injury was a sagittal pelvic fracture through
the right sacrum (arrows).

Figure 3. Unexpected confined aortic injury. A 46-year-old woman injured in an automobile crash.
Transferred for evaluation of hematuria and low back pain. A, Confined aortic injury with pseudoaneu-
rysm and large intimal flap (arrowheads). Small left hemothorax abuts aorta and small left para-
aortic mediastinal hematoma. 6,Three-dimensional maximal intensity projection (MIP) reconstruction
demonstrates relationship of injury (curved arrow) to great vessels. Surgical repair performed without
conventional aortography.
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 557

injury (Figs. 2, 4 and 5). Brain injuries are present
in nearly 40% of patients with aortic injuries. Spine
injuries, present in up to 15%, may cause the most
severe long-term morbidity.Iz Also, it is important
to know if central nervous system injuries are con-
tributing to any hemodynamic deterioration while
the patient undergoes CT examination.
The same limitations of the medical history and
physical examination affect the detection of ab-
dominal or pelvic injurie~.~ Almost a third of pa-
tients with aortic injuries have an abdominal vis-
ceral injury (Figs. 5 and 6). A third of patients
also have a pelvic fracture (Fig. 7).12,45Thus, CT
examination of the abdomen and pelvis should be
routinely performed immediately after the chest
study.
HELICAL CT PROTOCOL FOR
EVALUATION OF THE THORACIC AORTA
Preliminary Preparations and Technical
Parameters
Head, cervical spine, and face CT examinations
are performed first. The arms are then repositioned

Figure 4. Minimal aortic injury (intimal injury) and fatal head injury, A 40-year-old woman injured in
an automobile crash. A, Small triangular shaped intimal flap or thrombus (arrowhead). No mediasti-
nal hematoma. B, Severe anoxic brain injury with resultant cerebral infarction (arrows) delayed
surgical repair. C,Aortic injury healed by repeat CT 1 week later. Patient died 2 days later from
brain injury.
558 GAVANT

Figure 5. See legend on opposite page

 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 559

Figure 6. Fatal traumatic aortic disruption with associated liver injury. A 48-year-old woman injured
in an automobile crash. A, Complete aortic disruption, with an irregular and large pseudoaneurysm
(curved arrows) that displaces the left mainstem bronchus anteriorly. The para-aortic hematoma
displaces the nasogastric tube to the right. 6,Severe injury to the liver (lac). Despite pharmacologic
management of blood pressure and pulse to control aortic wall stresses, the patient died while being
prepared for emergency surgery. Multiple potentially fatal injuries can be identified in the same
patient, obviously complicating surgical triage decisions.

above the head while the x-ray tube cools. Naso-
gastric tubes are not withdrawn because of the
technical difficulty, inconvenience, and additional
delays when replacing them. The “twinkling”
streak artifacts from these tubes in the esophagus
become easily recognizable and are rarely a diag-
nostic problem (See Fig. 5)?3*25,
Respiration is voluntarily suspended. If the pa-
tient is intubated, the ventilator is paused. Little
time, however, is invested in these maneuvers. The
mediastinum is a fixed structure. The thoracic
aorta is more affected by cardiovascular pulsation
artifacts then those caused by respiratory motion
(see Fig. 1). Except for the juxtadiaphragmatic ar-
eas, respiratory motion does not limit the ability
to detect lung injuries, pleural fluid collections,
pneumothoraces, or chest and endotracheal tube
p0sitions.5~
Nonionic contrast media (300 mg I/mL, 2 mL/
sec IV) is preferred to reduce somatic side effects
and discomfort, especially nausea and vomiting.
This may decrease the risk of aspiration during
the CT study. Nonionic contrast agents also de-
crease the risk of idiosyncratic reactions in patients
who cannot provide a medical history. Finally,
these contrast agents are used to decrease the risk
of renal injury from concomitant use of other
nephrotoxic drugs and antibiotics, renal underper-
fusion due to hypotension, or myoglobin overload
from muscle injuries.
After a delay of 25 seconds, a continuous scan
from the lung apices through the aortic hiatus of
the diaphragm is performed (table speed 7 mm/s,
slice thickness 5 to 7 mm, pitch 1 to 1.4, image
reconstruction every 3.5 mm with a 50% overlap
of images). This results in 50 to 60 images for film
or monitor review. Rapid playback of the images
on a computer workstation assists in the identifi-
cation of small aortic injuries and clarification of
artifacts caused by cardiovascular or respiratory
motion and streak artifacts from nasogastric or
endotracheal tubes. Two-dimensional multiplanar
and three-dimensional volume reconstructions are
esthetically pleasing and help demonstrate ana-

Figure 5. Confined aortic injury with associated head, spine, and body injuries. A 16-year-old boy in
an automobile crash. A, Large, well-defined, confined aortic injury (curved arrows). Artifact from left
mainstem bronchus causes hypodensity across anterior aspect of injury. “Twinkling” artifact from
nasogastric tube does not interfere with detecting injury. Pleural effusions and lung collapse obscure
any para-aortic mediastinal hematoma. B, Repair of aortic injury was delayed 3 days because
left parietal lobe contusion (arrow) increased risk of intracranial hemorrhage from intraoperative
anticoagulation.Additional injuries complicating the thoracic surgery included severe liver hematoma
and laceration (arrows) (C) and lumbar spine fracture (arrowheads and curved arrow) (0)€, . Three-
dimensional shaded surface display (SSD) reconstruction demonstrated the injury (arrowheads) on
the medial side of the proximal descending aorta distal to the great vessel origins obviating conven-
tional aortography.
560 GAVANT

Figure 7. Confined aortic injury with associated chest and pelvic injuries. A 38-year-old woman
injured in an automobile crash. A, Large, confined pseudoaneurysm (curved arrow) delimited by
retracted intimal flaps (arrowheads). 6,Wider window setting demonstrates right mainstem bronchus
intubation (arrowhead) and left lung contusion and collapse and pneumoihorax [arrows). C, Extraperi-
toneal bladder rupture (curved arrow) from pubic symphysis fracture (not shown) detected on screen-
ing CT cystography performed at time of chest CT. B = Bladder.

tomic and surgical landmarks (Figs. 5, 8, and 9).
They rarely provide additional diagnostic informa-
tion, however, from an educated review of the
source transverse images.
The helical CT examination of the chest is com-
pleted during the time delay required to reach the
equilibrium phase of contrast media distribution
for imaging the liver and spleen. Thus, scanning
can continue immediately into the abdomen to
detect other internal injuries. The technique chosen
to examine the abdomen or pelvis depends on the
heat loading and cooling characteristics of the CT
x-ray tube, the speed of image reconstruction by
the technical computer workstation, and the dis-
play capabilities of the physician workstation.
DIAGNOSING TRAUMATIC THORACIC
AORTIC INJURIES ON HELICAL CT
Approximately 1% of patients presenting with
blunt trauma have a thoracic aortic injury detected
by helical CT of the chest.12,13, 25, 43 Helical CT can
demonstrate a variety of anatomic variations and
injuries that affect the aorta.l7,23, 24, 42, 44,
In general, the normal aorta demonstrates ho-
mogeneous enhancement of the aortic lumen with-
out filling defects, wall thickening, or extravasa-
tion. The injured aorta demonstrates intimal flaps
or mural thrombi attached to the inner aortic wall
or pseudo or true aneurysms that involve the outer
aortic wall.
An indeterminate finding confined to a single
image is usually artifactual with the aorta invari-
ably normal on conventional transcatheter aortog-
raphy. False-positive helical CT studies occur
when a questionable finding is present on two or
three images. In these instances, the presence of a
mediastinal hematoma can guide the recommen-
dation for aortography and influence the eventual
decision to submit the patient to exploratory
thoracotomy.lz,25
A CT grading system (Table 1) can be proposed
that estimates the severity of aortic injury. In con-
junction with the treatment necessary for other
injuries, the CT estimation of severity of aortic
injury may be used to guide the early clinical
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 561

Figure 8. Ductus diverticulum remnant mimicking aortic injury. An 83-year-old man injured in an
automobile crash, with sacral and liver injury. A, Well-defined, slightly irregular diverticulum extends
from anterior aortic lumen toward left pulmonary artery (arrow). No intimal irregularity or mediastinal
hematoma. 19,Two-dimensionalplanar sagittal oblique reconstruction demonstrates close relationship
of diverticulum to left pulmonary artery and aorta. D = Diverticulum of the ductus arteriosus remnant
with small degenerative or atherosclerotic mural calcification; Arch = aortic arch; PA = left main
pulmonary artery.

Figure 9. Confined aortic injury with renal embolization. A 30-year-old woman with isolated blunt
injury to chest. A, Moderate-size, confined aortic injury with large intimal flap (arrow). 6, Three-
dimensional SSD reconstruction demonstrates injury (arrowheads) distal to left subclavian artery. C,
Asymptomatic wedge-shaped infarct (arrowhead) from small embolus to right kidney also detected.
Table 1. PRESLEY TRAUMA CENTER CT GRADING SYSTEM OF AORTIC INJURY
Grade CT findings TriagdClinical Management
Grade I Normal aorta
Grade Ia 1. Normal thoracic aorta on CT 1. No aortic injury
2. No mediastinal hematoma 2. Proceed with treatment of other injuries
Grade lb 1. Normal thoracic aorta on CT 1. No aortic injury
2. Mediastinal hematoma (para-aortic) 2. Exclude thoracic spine or sternal injury
present 3. Proceed with treatment of other injuries
Grade I1 Minimal aortic injury
Grade IIa 1. Small (<l cm) pseudoaneurysm 1. Institute ICU medical management
2. Indeterminate CT suggests <I cm isolated 2. IVUS and aortography if no other major
intimal flap or thrombus injuries or serious risk factors
3. No mediastinal hematoma If IVUS and aortography normal
1. No aortic injury
2. Discontinue ICU medical therapy
If NUS or aortography abnormal
1. Continue ICU medical therapy
2. Exploratory thoracotomy if no other
major injuries or serious risk factors
Grade 1% 1. Small (usually <1 cm) pseudoaneurysm 1. Institute ICU medical management
2. Indeterminate CT suggests (1 cm isolated 2. I W S and aortography if no other major
intimal flap or thrombus injuries or serious risk factors
3. Mediastinal hematoma (para-aortic) If I W S and aortography normal
present 1. No aortic injury
2. Discontinue ICU medical therapy
If NUS or aortogram abnormal
1. Continue ICU medical therapy
2. Exploratory thoracotomy if no other
major injuries or serious risk factors
3. Consider aortotomy if no external
injury visible at thoractomy
4. If no surgery:
a. Repeat CT at 3-7 days
No change discontinue ICU
therapy
b. Repeat CT at 30 days:
i. If unchanged, no aortic injury:
d u c t u s remnant
-false-positive CT
ii. Discontinue medical therapy
Grade 111 Confined thoracic aortic injury
Grade IIIa 1. >I cm easily identified regular, well- 1. Institute ICU medical management
defined pseudoaneurysm with intimal flap If no other major injuries or serious risk
or thrombus factors:
2. No ascending aorta, arch, or great vessel 2. Emergent (within 12 hours) CTA or
involvement MRA if surgical repair planned, or,
3. Mediastinal hematoma present 3. Emergent IVUS and DSA if
endovascular repair planned
If major injuries or serious risk factors
preclude early repair:
4. Maintain ICU medical management
5. Repeat CT at 3,7,14, and 30 days
Grade IIlb 1. >1 cm easily identified regular, well- 1. Institute ICU medical management
defined pseudoaneurysm with intimal flap 2. Emergent I W S and DSA prior to
or thrombus surgical repair
2. Ascending aorta, arch, or great vessel
involvement present
3. Mediastinal hematoma present
Grade IV Total aortic disruption
1. Easily identified, irregular, poorly defined 1. Institute ICU medical management
pseudoaneurysm with intimal flap or 2. Disregard other non-life-threatening
thrombus injuries
2. Mediastinal hematoma present 3. Immediate (<2 hours) surgical or
endovascular repair, whichever can be
performed first
4. Consider blind or IVUSdirected intra-
aortic balloon occlusion of aortic lumen
if exsanguinating

TVUS = intravascular ultrasound; CTA = CT aortography; MRA = M R aortography; DSA = distal aortography; ICU = intensive
care unit.
562
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 563

management of the patient, and may help in pre- of low pressure veinsz3Rarely, blunt injury to in-
dicting the clinical outcome of patients treated sur- ternal mammary arteries may be the cause of the
gically or medically?*l9 anterior mediastinal hematoma (See Fig. 11).

GRADING SYSTEM OF AORTIC INJURIES Grade 2: Minimal Aortic Injury Versus

Grade 0: Normal Mediastinum and
Normal Aorta
Most patients have a normal CT examination of
the mediastinurn with no abnormal collections of
blood, fluid, or air. The normal aortic lumen (Figs.
8,9, and 10) brightly enhances, typically 250 to 300
H, without any low-density filling defects (intimal
flaps or adherent thrombus) or any high-density
accumulations beyond the expected aortic wall
(pseudoaneurysm or traumatic aneurysm). Motion
and beam-hardening artifacts that cross the lumen
are present on only a single image (Figs. 3, 5,
and 11).
Grade 1: Abnormal Mediastinum and
Normal Aorta
Five percent to 10% of patients screened for
blunt trauma have an isolated mediastinal hema-
toma and a normal thoracic aorta. In the past,
any mediastinal hematoma was an indication for
a~rtography.'~, 31, 39 This is no longer the case when
the aorta can be directly evaluated by helical CT.lZ,
25,44,60 A normal thoracic aorta on helical CT of the
chest means that no aortic injury is present.
When posterior mediastinal hematoma is pres-
ent around a normal aorta, a thoracic spine injury
should be considered.'", 36 A sternal fracture or an-
terior chondral rib separation should be consid-
ered when anterior mediastinal hematoma is iden-
tified. If no bony injury is identified, mediastinal
blood may be assumed to have arisen from injury
Ductus Arteriosus Remnant or
Atherosclerosis
CT of the minimally injured aorta demonstrates
a small, subtle abnormality that is present on only
two or three contiguous images. Because the heli-
cal data are reconstructed every 3.5 mm, the injury
may be only 1 cm in length (Figs. 1, 2, and 12).
Ductus diverticular remnants (Figs. 8, 13, and
14) and atherosclerotic plaques (Fig. 15) can appear
identical to small aortic injuries. A small injury
must be excluded if para-aortic mediastinal hema-
toma is present. Transesophageal or intravascular
ultrasonography may complement the CT study
(Fig. 16).', 40, 4q Nevertheless, aortography should
be performed to determine if an aortic injury is
present. The absence of mediastinal hematoma
may someday be sufficient to exclude a small aor-
tic injury and obviate the need for aortography.
Angiography must be of consistent high quality.
Otherwise, small aortic injuries are missed and
aortographic and accompanying CT studies are
misinterpreted (see Figs. 1, 12, 14, and 16).15,16,18
Angiography must be properly performed so that
projections of the aortic wall are perpendicular to
the CT abnormality. The aortic lumen must be
completely opacified by an adequate amount of
contrast media. Radiologic technique must pene-
trate the thoracic spine. If digital subtraction angi-
ographic acquisition is used, images must also be
reviewed without subtraction. Otherwise, isolated
intimal injuries and flaps are mistaken for subtrac-
tion and motion Intravascular or trans-
esophageal ultrasound might clarify discrepant CT
and aortographic studies.

Figure 10. Extrathoracic vascular injury. A 61-year-old woman

with blunt injury to chest. Left axillary hematoma (arrows) from
injury to brachial artery. The aortic arch is normal, with the higher
density SVC to its right and the top of the main pulmonary artety
to its left.
564 GAVANT

Figure 11. Traumatic injury to internal mammary artery. A 25-year-old woman with blunt injury to
chest. A, Small, well-defined area of extravasation (straight arrow), with large surrounding hematoma
in the anterior mediastinum. The aortic arch is normal. Streak artifacts from high density SVC and
nasogastric tube do not compromise evaluation of aortic lumen. Note internal mammary artery and
vein (curved arrow). 6, Selective left subclavian artery injection demonstrates a 1-cm pseudoaneu-
rysm (arrow) of the proximal left internal mammary artery (i). This was successfully occluded with
transcatheter coil embolization. S = subclavian artery.

Figure 12. Minimal aortic injury with severe aortic lumen compromise. An 18-year-
old woman injured in an automobile crash. A, Large, filling defect (arrow) caused by
heaped up intima and adjacent thrombus in surgically proven injury fills over half of
the aortic lumen at the level of the ligamentum arteriosum. No pseudoaneurysm.
Anterior and para-aortic mediastinal hematoma is present. B, Lateral subtracted
digital aortogram demonstrates shallow defect in aortic lumen (arrow). Overlying
bones and respiration subtraction artifact obscure fine detail.
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 565

Figure 13. Ductus diverticulum as cause of indeterminate, false-positive CT for minimal

aortic injury. A 41-year-old man injured in a motor vehicle accident. A, Possible small
pseudoaneurysm (curved arrow) typical of minimal aortic injury. No mediastinal hematoma.
B, Injury (curved arrows) appeared to be enlarging on follow-up aortography 1 month later.
Surgical exploration revealed a ductus diverticulum remnant and no aortic injury.

Figure 14. Ductus diverticulum and atherosclerosis as cause of indeterminate,false-positive CT for

minimal aortic injury. A 51-year-old man with blunt injury. A, Possible small pseudoaneurysm
(curved arrow) adjacent to calcified atherosclerotic plaque (straight arrow) in region of ligamentum
arteriosum. Small amount of para-aortic mediastinal hematoma is present. B, Possible small injury
detected on digital subtraction aortogram. Examinationis compromisedby inadequatex-ray penetra-
tion over the spine and respiratory motion causing bone and diaphragm subtraction artifact. Surgical
exploration revealed no aortic injury.
566 GAVANT

Figure 15. Atherosclerosis as cause of indeterminate false-positive CT and aortogram for aortic
injury. A 78-year-old woman with blunt chest injury. A, Irregular filling defect along the posterior-
superior aspect of the aortic arch lumen (arrow) suggests intimal injury. Calcified atherosclerotic
plaque is in the area. Possible small mediastinal hematoma along right paratracheal region. B,
Digital subtraction aortogram reveals marked intimal irregularity (arrowheads) from atherosclerotic
disease.

Grade 3: Confined Aortic Injury
Confined aortic injuries are easily identified (> 1
cm) injuries with regular, well-defined outer walls
formed by restraining adventitia (pseudoaneu-
rysm). Usually, intimal flaps or adherent thrombus
are readily apparent. This is the most common
type of thoracic aortic injury and is typically lo-
cated in the proximal descending aorta just distal
to the left subclavian artery origin (see Figs. 3, 5,
7, and 9). An injury is diagnosed regardless of
the size of the para-aortic mediastinal hema-
toma.24,25.51.60
Aortography is generally not required unless the
relationship to the left subclavian artery origin is
unclear or if the injury involves the ascending
aorta, aortic arch, or great vessels. Two- and three-
dimensional computer models can demonstrate
the injury similar to conventional a0rtography.2~~ 51
With experience, these reconstructions are not nec-
essary because they do not add information be-
yond the source axial images.
The distance from the left Subclavian artery ori-
gin to the injury is readily determined by calculat-
ing the difference in slice position between the last
image with the proximal left subclavian artery and
the first image with any aortic abnormality. Involve-
ment near the subclavian artery requires cross-
clamping of the aorta between the subclavian and
left common carotid arteries during surgical repair.
Variations in aortic arch anatomy, such as the
aberrant right subclavian artery, must be detected
while determining the relationship of the aortic
injury to the great vessels.z9The aneurysmal origin
of an aberrant subclavian artery should not be
confused with an injury. In addition, the occasional
left vertebral artery arising as the next-to-last or
last branch of the aortic arch should not be over-
looked or misidentified as an injury to the origin of
the left subclavian or left common carotid arteries.
Identification of these anatomic variations is im-
portant in the presurgical planning for adequate
intraoperative preservation of cerebral blood flow.
Most injuries detected by helical CT occur at the
ventral aspect of the aorta at the junction of the
arch and proximal descending thoracic The
transverse component of the injury may be local-
ized to the area of the ligamentum arteriosum or
extend medially or laterally. The injury may be
circumferential or involve only a portion of the
wall. The cranial or caudal extent of an injury
might be underestimated if the injured intima re-
tracts or intussuscepts superiorly or inferiorly.
Complicated confined injuries involve the as-
cending aorta, aorta arch, great vessel origins, or
distal aorta near the diaphragmatic hiatus (Figs. 16
and 17). Aortography may be required to demon-
strate the vascular anatomy, although two- and
three-dimensional computer reconstructions may
be acceptable.
Grade 4: Traumatic Aortic Disruption
Total aortic disruption is an easily identified,
irregular, poorly defined traumatic aneurysm with
obvious extravasation of contrast into the medias-
tinum (Figs. 6 and 18). A large mediastinal hema-
toma is always present. There is no time for diag-
nostic aortography.
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 567

Figure 16. Emerging role of intravascular ultrasound in evaluating aortic injury. A 54-year-old man
with severe closed head and blunt chest injury. A, Small aortic wall defect (curved arrow), with
adjacent wall thickening in the left posterior-lateral wall of the distal descending thoracic aorta well
above the aortic hiatus of the diaphragm. Atelectatic medial basal segment of left lung (asterisk)
abuts the aorta. No mediastinal hematoma. B, lntravascular ultrasound demonstrates similar findings.
The probe (curved arrow) is adjacent to a hyperechoic intirnal flap superficial to the pseudoaneurysrn
and thickened media (large arrow). The remaining intirna and aortic wall (arrowheads) opposite the
injury are normal. C,Digital subtraction aortogram demonstrated a more extensive pseudoaneurysrn
(curve arrows). An isolated, penetrating, aortic ulcer might cause similar findings, although no
atherosclerotic disease was present elsewhere.
568 GAVANT

Figure 17. Confined aortic injury with traumatic dissection. A 38-year-old normotensive man injured
in an automobile crash. No history of cardiovascular disease. A, Large intimal irregularity and
thrombus with small pseudoaneurysm involves anterior third of aortic lumen (arrowhead). P = main
pulmonary artery. 6, Two-dimensional sagittal planar reconstruction demonstrates the intimal flap
(curved arrow) as the leading edge of a long dissection (arrowheads)that extends into the abdominal
aorta. C, Unsubtracted digital aortogram demonstrates compression of true lumen by dissection
(arrow).
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 569

Figure 18. Traumatic aortic disruption with immediate paraplegia. A 13-year-old boy
injured in a motor vehicle accident. He was paraplegic on arrival. A, A circumferential
injury (curved arrows) is present at the level of the left pulmonary artery (P). Only a
small mediastinal hematoma is present at this site. A = ascending aorta; S = superior
vena cava. B, Aortography demonstrates identical findings (curved arrows). Paraplegia
presumably was caused by traumatic occlusion of anterior spinal artery.

MANAGEMENT ISSUES WHEN USING Utility of Helical CT in Detecting

HELICAL CT TO DETECT AORTIC
INJURIES
Patients with aortic injuries detected by screen-
ing helical CT of the chest have a wide variety of
clinical presentations.21Some patients with mini-
mal aortic injuries might be best treated nonsurgi-
cally if other critical injuries or medical diseases
are present.16 Other aortic injuries require urgent
repair regardless of other injuries to prevent fatal
exsanguination.8 Pharmacologic control of blood
pressure and systolic blood pressure should be
instituted whenever an aortic injury is s~spected.~,
12, 34, 47, ss The patient must be admitted to an
intensive care unit until an injury is repaired or
excluded.
Grade 0 and 1: Triage Decisions With a
Normal CT of the Thoracic Aorta
Patients with a normal thoracic aorta on helical
CT of the chest do not have a vascular injury even
if a mediastinal hematoma is suspected on chest
radiograph or is detected on CT.I2,24, 25, 43 The need
for conventional aortography falls over 50%,
whereas the percent of positive aortographic stud-
ies doubles or triplesI2,43 if CT is used to exclude
or identify an aortic injury. This decrease in utiliza-
tion of personnel and equipment does not occur if
patients with an abnormal mediastinum on CT
continue to undergo aortography despite a normal
aorta. Helical CT of the chest could still be of
benefit to evaluate nonvascular structures, but lib-
eral screening may be too expensive to use when
compared with conventional chest radi~graphy.~~, s9
Nonvascular Abnormalities
Indeed, helical CT of the chest can be quite
beneficial in detecting unsuspected nonvascular in-
juries and confounding incidental anatomic anom-
alies (see Figs. 5, 7, 11, and 16). In addition, axial
CT scans frequently display injuries of nonmedias-
tinal structures better than chest radiography.
Traumatic and iatrogenic injuries, such as pneumo-
thorax, hemothorax, pneumomediastinum, lung
lacerations, shoulder girdle injuries, displaced rib
fractures, diaphragmatic injuries, and malposi-
tioned or intraparenchymal chest tubes, may only
be demonstrated on helical CT of the chest. These
nonvascular injuries may complicate medical and
surgical treatment if left undiscovered. Thus, the
pneumothorax that goes undetected on a portable
supine admission chest radiograph may compli-
cate positive-pressure artificial respiration. Lung
lacerations might indicate a more complicated or
prolonged intensive care admissi0n.2~, 59
Grade 2: The Minimal Aortic Injury
Versus the False-Positive CT
Examination
The most difficult diagnostic dilemmas occur
when trying to distinguish the minimal aortic in-
jury from ductus diverticulum remnants and ath-
erosclerotic disease.ls,23, 38 It is in this group that
false-positive CT studies occur. In practice, a diag-
nosis of minimal aortic injury or tear should be
made when the CT study is indeterminate. The
presence of periaortic mediastinal hematoma fa-
vors a diagnosis of minimal aortic injury. The pa-
570 GAVANT
tient should be monitored in an intensive care unit
with blood pressure and pulse pharmacologically
controlled.
Other methods have to be used to determine if
the CT is falsely positive. As with CT, aortographic
findings of small injuries overlap with congenital
and degenerative abn~rmalities.~, 15, 17,
237 32 In addi-
tion, an injury can coincide with these other non-
traumatic conditions further confounding CT and
aortographic interpretations. Intravascular ultraso-
nography may become the definitive examination
in confirming the small injury.49
Patients from this group occasionally undergo
exploratory thoracotomy and are found to have
no injury.I5 This may be acceptable in a young,
otherwise healthy patient where the risk of de-
layed exsanguination or chronic thoracic aneurysm
formation from an undetected minimal aortic in-
jury outweighs the risk of surgery and general
anesthesia. The decision to operate on an indeter-
minate or small injury is complicated by the pa-
tient’s age, associated injuries, and other chronic
medical conditions.
The diagnostic studies should be repeated after
a few days if surgical exploration is delayed. If the
lesion is resolving or enlarging, a diagnosis of aor-
tic injury can be made. A nontraumatic cause of
the imaging findings might be assumed if the area
does not change. Mediastinal hemorrhage disap-
pears after a few days. Its absence on follow-up
studies should not be taken as an indication that
no injury is present.
Previously, many of these small injuries might
have gone undetected.l6.l7 The long-term outcome
of these injuries is unclear. Do they heal spontane-
ously? Will they enlarge into chronic traumatic or
atherosclerotic aneurysms that threaten the patient
at an older more clinically fragile time? The short-
term outcome is also unclear. Thrombi developing
from the exposed intimal injury can embolize dis-
tal organs (Figs. 9 and 19). Until further clinical
experience with nonsurgical management is forth-
coming, these injuries should be repaired when
the patient is clinically stable.’**22, 34, 47, 55
Grade 3: Triage Decisions When CT
Reveals a Confined Thoracic Aortic
Injury
The classic aortic injury is the pseudoaneurysm
that is confined by the integrity of the overlying
adventitia and mediastinal tissues. There should
be no clinical doubt about the presence of an injury
when the helical CT study detects this type of
abnormality. Aortography may be used to clarify
the relationship of the injury to the great vessels
and diaphragm. The usefulness and frequency of
aortography decrease, as the referring thoracic sur-
geon becomes familiar with the technology and
cross-sectional anatomy.
Intimal abnormalities can be demonstrated by
two-dimensional multiplanar reconstructions and
to a lesser extent three-dimensionalmaximal inten-
sity projection reconstructions. Two- and three-di-
mensional reconstructions can beautifully display
the injury identical to its demonstration on con-
ventional aortography (see Figs. 3, 5, 8, 9 and 17).
These reconstructions may also become unneces-
sary as referring physicians become familiar with
the cross-sectional anatomy.I2,24
Medical Management of Thoracic Aortic
Injury
Patients with an aortic injury detected or sus-
pected by CT should immediately begin pharma-
cologic intervention to limit aortic wall stress by
controlling blood pressure and heart rate. Physio-
logic monitoring and medical therapy of aortic
injury include:
Physiologic Monitoring
Arterial and central venous pressure
Urinary output
Chest tube output
EKG
Arterial oxygen saturation
Medical Therapy
Vasodilators to decrease systolic pressure be-
low 140 mm Hg
Beta-receptors antagonists to maintain heart rate
below 90 beats per minute after blood volume
is adequate
Limitations of fluids after systolic pressure
reaches 90 mm Hg
The goal is to decrease the upstroke of the left
ventricular ejection curve, thereby decreasing the
aortic wall stress changes, which could cause the
partial aortic tear or confined pseudoaneurysm to
rupture completely.12,47 Nonhypotensive patients
should be placed on intravenous beta-blockers (es-
molol HC1 or labetalol HC1) to maintain systolic
blood pressure between 120 and 140 mm Hg with
a pulse less than 90 bpm. Nitroprusside should be
added if the blood pressure cannot be controlled
with beta-blockade. This pharmacologic protocol is
similar to the medical management used to control
acute dissections of the aorta. By altering the force
of ventricular ejection, the shear pressures experi-
enced by the aortic wall can be reduced. This re-
duces the risk of structural failure of the remaining
intact aortic wall with resultant rupture and fatal
exsanguination into the chest.
Over the past few decades, several medical tech-
nologic and logistic improvements have been
made that decrease early mortality in patients with
life-threatening aortic injuries. For instance, the de-
velopment of advanced air and ground ambulance
transportation systems delivers the patient to the
hospital before rupture occurs. Routine screening
helical CT examination of the chest eliminates a
missed diagnosis because of clinical underestima-
tion of injury. Logistical and time delays while
 HELICAL CT GRADING OF TRAUMATIC AORTIC INJURIES 571

Figure 19. Spontaneous resolution of minimal aortic injury complicated by delayed splenic emboliza-
tion. A 61-year-old man injured in a motor vehicle accident. A, Screening CT demonstrated a 1-cm
intimal flap or thrombus (arrowhead) in the anterior aortic lumen at the level of the left pulmonary
artery. B, Repeat examination 1 week later revealed near complete resolution of injury. S = superior
vena cava; P = left pulmonary artery; A = ascending aorta. C,Screening CT of spleen (S) and left
upper abdomen was normal. 0,Repeat examination revealed clinically silent infarction of the upper
pole of the spleen (arrows) from embolization of thrombus or intimal debris from the site of aortic injury.

aortography is performed are also eliminated.I2,
24,30 Now, the risk of aortic rupture after diagnosis
but before surgical repair can be reduced because
medical management can be started soon after ad-
mission.
Medical management should eliminate the risk
of delayed rupture in patients with a minimal aor-
tic injury. Although experience in a wide variety
of clinical settings is still required, the risk of fatal
rupture may also be nearly eliminated for patients
with confined aortic injuries. It is certainly re-
duced.", 34,47.55
Nevertheless, urgent surgical repair is still indi-
cated in the presence of a confined aortic injury.
Although complacency must be avoided, medical
management converts a critical catastrophic clini-
cal setting into a more controlled, even elective
environment. The decision to proceed to explor-
atory thoracotomy can be individualized and
based on the clinical assessment that considers the
patient's hemodynamic stability, transfusion re-
quirements, age, risk of general anesthesia, con-
comitant diseases, and severity of other injuries.
Percutaneous graft techniques may someday allow
earlier intervention in otherwise surgically inap-
propriate patients.", 33, 48
Initial nonoperative management may be indi-
cated when aortic injuries involve the aortic arch,
great vessel origins, or ascending aorta so that
patient preparations for full cardiopulmonary by-
pass can be completed. In addition, rarer injuries,
such as those occurring in patients with anoma-
lies of the great vessels origin or with distal aortic
dissection, might benefit from medical manage-
ment and elective surgical repair (see Fig.
17).28. 29, 46
Follow-up CT examinations can be used to con-
firm the stability of injuries that are followed non-
surgically.Changes in size or shape should prompt
re-evaluation of the need for surgical repair.
Grade 4: Triage Decisions When CT
Reveals Traumatic Aortic Disruption
Total aortic disruption is a clinical catastrophe.
If possible, medical management should be insti-
572 GAVANT
tuted while the patient is still in the CT suite.
There is no time for diagnostic aortography.
Even with prompt initiation of medical manage-
ment, ventricular ejection fracture and blood pres-
sure must be maintained to perfuse the brain and
vital organs. These may still be too great to prevent
failure of the totally disrupted aortic wall despite
confining mediastinal tissues. Thus, mortality even
in the best of circumstances is high with exsangui-
nation occurring prior to or during surgery.
Unless the patient has suffered an irreversible
severe brain injury or cannot be hemodynamically
stabilized, the aorta must be repaired as soon as
possible. Other nonfatal injuries must be ignored.
An intravascular ultrasound (1VUS)-directed in-
tra-aortic balloon might be inflated to occlude
temporarily the aortic lumen. This may assist in
obtaining vascular control and prevent exsangui-
nation when the chest or mediastinum is first
entered.
Ultimately, endovascular repair of these lesions
may decrease the risk of fatal rupture. This avoids
a mediastinal exploration that might complete the
disruption of the few remaining fragile tissues
maintaining vessel integrity and continuity. Percu-
taneous access to the femoral artery could begin
immediately after diagnosis by CT. Catheter ad-
vancement and positioning might be conducted
under ultrasound guidance while the patient is
transported to the interventional radiology suite
for endovascular graft deployment.
CONCLUSION
The introduction of helical CT technology to the
trauma center and emergency department has pro-
vided an important noninvasive tool for rapidly
screening patients for internal injuries including
the thoracic aorta. CT can be used to direct patients
to aortography, endovascular repair, surgery, or
observation. No other imaging modality can com-
prehensively detect even subtle injuries to the
aorta, brain, spine, or body as rapidly. Aortic rup-
ture is rarely fatal if aggressive pharmacologic
management of blood pressure and pulse is begun
when an injury is detected on the helical CT exam-
ination of the chest.
Further areas of investigation are needed to clar-
ify the clinical importance of detecting and re-
pairing minimal aortic injuries. Additionally, it is
unknown if the use of long-term beta-receptor
blockade can limit delayed complications in tho-
racic aortic injuries that are not immediately re-
paired. Although promising, the usefulness of en-
dovascular ultrasonography and the clinical
outcome of endovascular grafting of minimal, con-
fined, and completely disrupted aortic injuries are
as yet undetermined.
In conclusion, only continued and improved
preventive measures, such as increased availability
of automobile airbags, increased seat belt use, and
decreased rates of drunken driving, might de-
crease the overall number and severity of thoracic
aortic injuries. Patients who survive their initial
trauma long enough to be evacuated and resusci-
tated at a modem trauma center and are stable
enough to undergo a screening CT examination of
the chest should rarely die from their aortic injury.
Early recognition of the injury allows rapid medi-
cal, surgical, or endovascular interventional radio-
logic treatment to be initiated. Repair of such injur-
ies, especially small mural flaps, does not take
priority over other life-threatening injuries. If the
patient does not die from other injuries, helical CT
examination is an easy and reproducible method
for following the thoracic aortic injury.
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Address reprint requests to
Morris L. Gavant, MD
Department of Radiology
University of Tennessee, Memphis
800 Madison Avenue
Memphis, TN 38163
e-mail: mgavantOutmeml.utmem.edu
mgavantl@aol.com