On Call Radiology

MEDICINE
ON CALL
RADIOLOGY ON CALL
RADIOLOGY
On Call Radiology presents case discussions on the most common and important clinical
emergencies and their corresponding imaging findings encountered on-call. Cases are
divided into thoracic, gastrointestinal and genitourinary, neurological and non-traumatic
spinal, paediatric, trauma, interventional and vascular imaging. Iatrogenic complications are
also discussed.
Each case is presented as a realistic clinical scenario and includes a clinical history
and request for imaging. Multi-modality imaging examples and a case discussion on the
diagnosis and basic management, with emphasis on important radiological findings, are
also presented.
This book combines a case-based discussion format with practical advice on imaging
decision making in the acute setting. It also offers guidance on radiology report writing and
techniques, with a focus on relevant positive and negative findings to pass on to referring
clinicians. On Call Radiology offers invaluable knowledge and practical tips for any
on-call radiologist.
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internet browser
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• link through from references to PubMed
Gareth Lewis • Hiten Patel

K22247
ISBN: 978-1-4822-2167-1
90000
Sachin Modi • Shahid Hussain
9 781482 221671
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ON CALL
RADIOLOGY
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ON CALL
ON CALL
RADIOLOGY
RADIOLOGY
Gareth Lewis, MBChB, FRCR, Radiology Registrar, University Hospitals
Birmingham NHS Foundation Trust, Birmingham, UK
GarethPatel,
Hiten Lewis, MBChB,
MBChB, FRCR,
FRCR Radiology
Radiology Registrar,
Registrar, University
University Hospitals
Hospitals
Birmingham NHS Foundation Trust, Birmingham,
Coventry and Warwickshire NHS Trust, Coventry, UKUK
Hiten Patel,
Sachin Modi, MBChB,
BSc(Hons), Radiology
FRCRMBBS, Registrar,
FRCR, University
Radiology Hospitals
Registrar, University
Coventry and Warwickshire NHS Trust, Coventry, UK
Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Sachin Modi,
Shahid BSc(Hons),
Hussain, MA, MB,MBBS, Radiology
FRCR,, FRCR,
BChir, MRCP Registrar,
Consultant University
Cardiothoracic
Hospitals Birmingham
Radiologist, NHS Foundation
Heart of England Trust, Birmingham,
NHS Foundation UK
Trust, Birmingham, UK
Shahid Hussain, MA, MB, BChir, MRCP, FRCR, Consultant Cardiothoracic
Radiologist, Heart of England NHS Foundation Trust, Birmingham, UK
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CONTENTS iii
Prefacexiv
Acknowledgementsxv
Abbreviationsxvi
INTRODUCTION
ADVERSE REACTIONS TO CONTRAST MEDIA 1
Systemic reactions1
Renal impairment1
Anaphylactic reaction2
Contrast extravasation2
References and further reading2
CHAPTER 1: THORACIC IMAGING 3
ACUTE AORTIC SYNDROME 3
Radiological investigations3
Radiological findings4
Computed tomography4
Key points6
Report checklist7
Reference7
THORACIC AORTIC INJURY 7
Plain films8
Key points9
Report checklist9
References9
PULMONARY EMBOLISM 10
Computed tomography pulmonary angiogram13
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iv Contents
Key points16
Report checklist16
References16
ACUTE PULMONARY OEDEMA 17
Computed tomography and plain films17
Key points18
Report checklist19
Reference19
SUPERIOR VENA CAVA OBSTRUCTION 20
Key points22
Report checklist22
References22
CHAPTER 2: GASTROINTESTINAL AND GENITOURINARY IMAGING 25
ABDOMINAL AORTIC ANEURYSM RUPTURE 25
Computed tomography 25
Key points28
Report checklist28
References28
ACUTE GASTROINTESTINAL BLEEDING 29
Key points32
Report checklist32
References32
BOWEL PERFORATION 32
Plain films33
Gastroduodenal perforation34
Small bowel perforation34
Large bowel perforation34
Key points35
Report checklist35
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Contents v
BOWEL ISCHAEMIA AND ENTEROCOLITIS 36

Plain films40
Key points41
Report checklist41
Reference41
LARGE BOWEL OBSTRUCTION 41
Plain films42
Key points45
Report checklist45
References45
GALLSTONE ILEUS 46
Plain films 46
Key points48
Report checklist48
References48
SMALL BOWEL OBSTRUCTION 49
Plain films49
Adhesions51
Hernias51
Crohn’s disease51
Neoplasia51
Radiation enteritis52
Gallstone ileus52
Key points52
Report checklist52
References52
GASTRIC VOLVULUS 52
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vi Contents
Plain films56
Key points56
Report checklist56
References56
OESOPHAGEAL PERFORATION 57
Radiological findings 58
Fluoroscopy58
Plain films 59
Key points 59
Report checklist 59
Reference59
ACUTE APPENDICITIS 60
Radiological investigations 60
Ultrasound62
Key points 62
Report checklist 62
References62
ACUTE PANCREATITIS 64
Key points 67
Report checklist 67
References67
ACUTE DIVERTICULITIS 68
Key points 70
Report checklist 70
References70
ACUTE CHOLECYSTITIS 71
Ultrasound71
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Contents vii
Key points 73
Report checklist 73
Reference73
EMPHYSEMATOUS PYELONEPHRITIS 74
Ultrasound76
Abdominal plain film imaging 76
Key points 76
Report checklist 77
References77
HYDRONEPHROSIS78
Ultrasound78
Key points 80
Report checklist 80
RENAL TRANSPLANT DYSFUNCTION 80
Ultrasound81
Key points 84
Report checklist 84
Reference84
LIVER TRANSPLANT DYSFUNCTION 85
Ultrasound85
Key points 87
Report checklist 87
References87
TUBO-OVARIAN ABSCESS 88
Ultrasound88
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viii Contents
Key points 90
Report checklist 90
Reference90
OVARIAN TORSION 90
Ultrasound91
Key points 92
Report checklist 92
References92
TESTICULAR TORSION 93
Ultrasound93
Key point 95
Report checklist 95
Reference95
CHAPTER 3: NEUROLOGY AND NON-TRAUMATIC SPINAL IMAGING 97
STROKE97
Magnetic resonance imaging 100
Key points 102
Report checklist 102
References102
CAROTID ARTERY DISSECTION 102
Key points 104
Reference104
SUBARACHNOID HAEMORRHAGE 105
Key points 110
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Contents ix
SUBDURAL HAEMATOMA 110

Key points 112
EXTRADURAL HAEMATOMA 113
Key points 114
CEREBRAL VENOUS SINUS THROMBOSIS 115
Key points 118
Reference118
HYDROCEPHALUS120
Plain films 122
Key points 123
Reference123
VENTRICULOPERITONEAL SHUNT MALFUNCTION 123
Plain films 124
Key points 126
INTRACRANIAL ABSCESS AND SUBDURAL EMPYEMA 126
Key points 130
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x Contents
HERPES SIMPLEX ENCEPHALITIS 131

Key points 133
Reference133
SPINAL CORD COMPRESSION AND CAUDA EQUINE SYNDROME 134
Key points 136
SPONDYLODISCITIS137
Plain films 139
Key points 140
References140
CHAPTER 4: PAEDIATRIC IMAGING 141
INTUSSUSCEPTION141
Ultrasound141
Fluoroscopic air enema 142
Plain films 143
Key points 143
Reference143
BOWEL MALROTATION 143
Upper gastrointestinal contrast study 144
Ultrasound144
Plain films 145
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Contents xi
Key points 145

MECONIUM ILEUS 145
Lower gastrointestinal contrast study 146
Plain films 146
Key points 147
DUODENAL ATRESIA 147
Plain films 148
Upper gastrointestinal contrast study 149
Key points 149
HYPERTROPHIC PYLORIC STENOSIS 149
Ultrasound150
Key points 151
ORBITAL AND PERIORBITAL CELLULITIS 151
Key points 153
ACUTE OTITIS MEDIA 154
Key points 155
Reference155
PARAPHARYNGEAL AND RETROPHARYNGEAL ABSCESS 156
Key points 159
Reference159
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xii Contents
CHAPTER 5: TRAUMA IMAGING 161

INTRODUCTION TO IMAGING IN MAJOR TRAUMA 161
Penetrating injury 163
Active haemorrhage 163
Blunt injury 166
Key points 166
Reference166
MAJOR TRAUMA: THORAX 167
Mediastinal injury 168
Cardiac injury 168
Pneumothorax169
Haemothorax170
Rib fracture and flail chest 171
Lung contusion and lung laceration 172
Diaphragmatic injury 172
Key points 172
References172
MAJOR TRAUMA: ABDOMEN AND PELVIS 173
Solid organ injury 176
Mesenteric and bowel injury 178
Pelvic injury 180
Bladder and urethral injury 180
Key points 182
References182
MAJOR TRAUMA: SPINE 182
Plain films 184
Examples of spinal fractures 185
Jefferson fracture 185
Odontoid peg fractures 186
Flexion teardrop fracture 186
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Contents xiii
Facet joint dislocation 187

Burst fracture 188
Key points 189
Reference189
CHAPTER 6: INTERVENTIONAL AND VASCULAR IMAGING
AND IATROGENIC COMPLICATIONS 191
ACUTE ARTERIAL ISCHAEMIA 191
Key points 193
IATROGENIC COMPLICATIONS 193
NASOGASTRIC TUBE MISPLACEMENT 193
Plain films 194
Key points 194
ENDOTRACHEAL TUBE MISPLACEMENT 195
Plain films 196
Key points 196
ENDOVASCULAR STENT ENDOLEAK 197
Key points 198
Reference198
COMPLICATIONS OF COMMON FEMORAL ARTERY PUNCTURE 199
Ultrasound200
Key points 201
Appendix 1: NICE head injury guidelines 203

Appendix 2: Standards of practice and guidance for trauma radiology in severely injured patients 205
Appendix 3: Trauma computed tomography primary assessment 213
Index215
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xiv PREFACE
Clinical radiology is at the centre of modern medicine The purpose of this book is to try to assist junior
and a high-quality service has repeatedly been shown radiology trainees who are starting their on calls.
to significantly improve patient outcomes. Over the We have presented here the commonest cases that
last 10 years there has been a significant increase in trainees are likely to encounter in an on-call situation.
demand for radiology services, resulting in a 26.5% An almost limitless number of cases could have been
increase in radiology examinations in England, from included, since virtually anything can present in an
just over 30 million in 2004/5 to almost 39 million on-call situation. We have, however, tried to present
in 2010/11. Since 2004/5 the number of computed some of the most common cases as well as a host of tips
tomographic (CT) examinations has increased by on how to approach emergency imaging situations.
86% (Department of Health, 2011). On-call work, Multiple images, as well as tips about reporting, have
unsurprisingly, has followed this same trend with an been included with each case. The majority of on-call
increase in both the number and the complexity of work is CT work, and for this reason we have included
scans now being performed out of hours as emergency CT scan protocols where appropriate. Although
imaging. Understandably, starting on calls in radiology Radiology Departments have standard protocols for
can be a very daunting prospect. It marks a turning imaging of non-emergency work, the out of hours types
point from having very few responsibilities within a of pathology sometimes require fine tuning of these
department to being integral to the work of both the protocols to ensure that appropriate sequences have
Radiology Department and to the Hospital as a whole. been obtained.
On-call work presents a myriad of complex issues We hope that this text will assist junior radiology
including: identifying pathology that may never have trainees in gaining some confidence as they start their
been seen before; coordinating scans and deciding scan on calls and will help assuage some of their fears.
protocols; and communicating with clinicians at all
levels of seniority. Perhaps most importantly, on-call Gareth Lewis
work carries a significant amount of responsibility since Hiten Patel
frequently, a decision on whether a patient needs to Sachin Modi
go to theatre or whether he/she requires immediate Shahid Hussain
intervention will be dependent upon the findings of the
radiology examination.
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ACKNOWLEDGEMENTS xv
The authors acknowledge the following colleagues who kindly contributed images for use in this book:
Dr Ben Miller, Dr John Henderson, Dr Sarah Cooper, Dr Michelle Christie-Large, Dr Helen Williams,
Dr Adam Oates, Dr Martin Duddy, Dr Peter Riley, Dr Peter Guest and Dr Osama Abulaban. Special thanks
to Eloise Lewis, who provided the medical illustrations.
Gareth Lewis: To my wife Eli, thanks for all your help and support.
Hiten Patel: Special thanks to my parents for their continued support.
Sachin Modi: For my Mum, Dad and my wife Kaveeta.
Shahid Hussain: To my family and friends.
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xvi ABBREVIATIONS
AAA abdominal aortic aneurysm HSV herpes simplex virus

AOM acute otitis media Hu Hounsfield unit
AP anterior-posterior
ARDS acute respiratory distress syndrome IMA inferior mesenteric artery
AXR abdominal radiograph IR interventional radiologist
ISS Injury Severity Score
BTS British Thoracic Society IV intravenous/intravenously
IVC inferior vena cava
CAD carotid artery dissection
CFA common femoral artery JVP jugular venous pressure
CIN contrast-induced nephropathy
CMD corticomedullary differentiation LBO large bowel obstruction
CNS central nervous system LP lumbar puncture
CSF cerebrospinal fluid LV left ventricle
CT computed tomography
CTA computed tomography angiography/ MIP maximum intensity projection
angiogram MRA magnetic resonance angiography
CTPA
computed tomography pulmonary MRI magnetic resonance imaging
angiography/angiogram MTC major trauma centre
CTSI computed tomography Severity Index
CXR chest radiograph NG nasogastric (tube)
NICE National Institute for Health and Clinical
DJ duodenojejunal (junction) Excellence
NPSA National Patient Safety Agency
EDH extradural haematoma
ET endotracheal (tube) PA posterior-anterior
EVAR endovascular aneurysm repair PACS picture archiving and communication
EVD external ventricular drain system
PCWP pulmonary capillary wedge pressure
GCS Glasgow Coma Score PI pyloric index
GFR glomerular filtration rate
GI gastrointestinal RI Resistive Index
HIV human immunodeficiency virus SAH subarachnoid haemorrhage

HPS hypertrophic pyloric stenosis SBO small bowel obstruction
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Abbreviations xvii
SDH subdural haematoma TCC transitional cell carcinoma

SMA superior mesenteric artery TIA transient ischaemic attack
SMV superior mesenteric vein TIPS transjugular intrahepatic portosystemic
SVC superior vena cava shunt
SVS slit ventricle syndrome
VP ventriculoperitoneal (shunt)
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INTRODUCTION
1
ADVERSE REACTIONS TO that radiographers and radiologists involved in the

CONTRAST MEDIA administration of IV contrast have up to date life
support training; however, this should not deter them
While reactions to IV contrast can be delayed, it is from involving the on-call medical emergency team in
the immediate, acute reaction that is more relevant to appropriate situations.
the on-call radiologist. Reactions to contrast media
vary depending on the type of agent used, with higher Systemic reactions
incidences of reactions occurring in ionic as opposed The commonest side-effects of acute contrast reactions
to non-ionic agents. Although the use of IV contrast include nausea, vomiting and urticaria. Following
media has become routine, it is always important to injection of contrast media, patients may also develop
remember that severe reactions, while rare, can occur a warm flushing sensation. These are usually self-
(1 in 170,000 people have a fatal reaction, Vamasivayam limiting and generally do not pose any danger for the
et al., 2006). The use of IV contrast is often extremely patient, although it is worthwhile documenting such
beneficial, if not necessary, in the interpretation of reactions in the medical records for future reference.
computed tomography (CT) imaging; however, its use In some patients, symptomatic relief may be achieved
should always be balanced with the potential risks of through the use of antihistamines.
contrast reaction.
Essential information that should be sought from Renal impairment
the patient before contrast administration includes Contrast-induced nephropathy (CIN) is a deterioration
history of: in renal function following the administration of
• Previous contrast reaction. contrast media (American College of Radiology, 2013).
• Asthma. Patients at increased risk of developing CIN include
• Renal impairment. those with pre-existing renal dysfunction, dehydration,
• Diabetes mellitus. nephrotoxic medication and multiple doses of contrast
• Metformin therapy. media in a short space of time. In order to reduce the
incidence of complications, patients at risk of CIN
Clinical features of a contrast medium reaction are should be discussed with the referring team. This
varied, ranging from vomiting and mild urticaria to may include pre-hydration or the decision not to use
acute anaphylaxis and cardiopulmonary collapse. contrast. A guide level of an estimated glomerular
There are numerous risk factors that may predispose filtration rate (GFR) below 60 ml/min has been used
an individual to contrast reactions, such as previous to suggest renal impairment; however, local guidelines
reactions to contrast media, pre-existing renal failure, should be used. Certainly the risks versus the benefits
nephrotoxic medication and advancing age amongst of giving contrast should always be considered.
others (Maddox, 2002). In such instances, radiologists, Following imaging, patients at risk of developing CIN
in conjunction with the referring team, should should have regular observation of renal function
follow the departmental guidelines when making the for at least 72 hours to ensure no acute deterioration
decision to use an IV contrast medium. It is important in function.
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2 Introduction
Anaphylactic reaction Patients with progressively worsening symptoms,

An anaphylatic reaction is the most serious and life- reduced tissue perfusion, signs of skin ulceration/
threatening side-effect of contrast administration blistering or altered sensation should be reviewed by
and requires immediate recognition and treatment. the local surgical/plastics team.
Symptoms include bronchospasm and hypotension,
which may lead to cardiopulmonary arrest. Management References and further reading
of anaphylaxis should follow the advanced life support American College of Radiology (2013) ACR Manual
algorithm and involve the medical emergency team on Contrast Media. Version 9. ACR Committee on
when appropriate (Resuscitaion Council, 2010). Drugs and Contrast Media, pp. 33–41.
If the anaphylactic reaction is mild (e.g. scattered, Department of Health (2011) Imaging and Diagnostics.
protracted urticaria), an antihistamine orally, http://webarchive.nationalarchives.gov.uk/
intramuscularly or IV should be considered. Mild 20130107105354/http://www.dh.gov.uk/en/
bronchospasm can be treated with oxygen by mask Publicationsandstatistics/Statistics/Performance
(6–10 litres/min) and a beta-2 agonist inhaler (2–3 puffs). dataandstatistics/HospitalActivityStatistics/
If moderate (e.g. profound urticaria, laryngeal oedema DH_077487.
or bronchospasm not responsive to inhalers), adrenaline Maddox TG (2002) Adverse reactions to contrast
1:1000 (0.1–0.3 ml intramuscularly) may be required. material: recognition, prevention and treatment.
If severe, the resuscitation team should be called while Am Fam Physician 66: 1229–1234.
all the above measures are undertaken. Resuscitation Council (UK) (2010) Advanced life
support algorithm. In: Adult Advanced Life Support.
Contrast extravasation www.resus.org.uk/pages/alsalgo.pdf. Accessed on
Extravasation of contrast medium can occur with 23rd May 2014.
both hand and pump injections and usually occurs Royal College of Radiologists (2010) Standards for
into the subcutaneous tissues. Patients may be Intravascular Contrast Agent Administration to
asymptomatic or develop erythema, swelling and Adult Patients, Second Edition. Royal College of
pain at the site of extravasation. Most cases are self- Radiologists, London.
limiting and do not require further intervention; Vamasivayam S, Kalra MK, Torres WE et al. (2006)
however, compartment syndrome or skin necrosis Adverse reactions to intravenous iodinated
may occur on rare occasions. Elevation of the limb contrast media: a primer for radiologists. Emerg
and the use of ice packs may help to ease symptoms. Radiol 12: 210–215.
K22247_Introduction.indd 2 16/05/15 3:15 AM

Chapter 1
THORACIC IMAGING
3
ACUTE AORTIC SYNDROME the diagnosis. The mortality rate depends on both
the underlying pathology and the extent of aortic
Acute aortic syndrome encompasses three closely involvement. However, the potential complications
related pathologies: aortic dissection, intramural are severe; as such, the on-call radiologist should have a
haematoma and penetrating atherosclerotic ulcer. The high index of suspicion for this pathology.
wall of the aorta consists of three layers: the innermost
intima, the middle media and the outermost adventitia. Radiological investigations
Dissections can be caused both by an intimal tear CT angiography (CTA), with corresponding
leading to propagation of blood within the media or by unenhanced imaging to identify intramural
primary intramural haematoma with resultant intimal haematoma, has a high sensitivity and specificity for
perforation (Macura et al., 2003). As this progresses, acute aortic syndrome and is the modality of choice.
an intimal flap is lifted away from the media, resulting The scanning area should extend from just above the
in two channels within the aortic lumen, referred to as aortic arch to the femoral heads to prevent missing the
the true and false lumens. Propagation of the flap and true extent of a dissection. Chest plain film imaging
false lumen thrombosis can ultimately result in end- may show signs such as an abnormal aortic contour or
organ ischaemia. Intramural haematoma is thought widened mediastinum; however, plain film imaging is
to be the result of spontaneous bleeding of the vasa neither sensitive nor specific for aortic dissection. (See
vasorum into the media. A penetrating atherosclerotic Table 1.1.)
ulcer is defined as ulceration within atherosclerosis
that herniates into the media. This can also result in
intramural haematoma. Penetrating aortic ulcers and
intramural haematoma can both progress to aortic
dissection (Macura et al., 2003).
Spontaneous aortic dissection is usually seen in the
middle aged to elderly population, with spontaneous
cases commonly associated with hypertension and Table 1.1 Acute aortic syndrome.
atherosclerosis. Secondary causes include trauma Imaging protocol.
(usually preceded by intramural haematoma) and
collagen vascular diseases such as Marfan and MODALITY PROTOCOL
Ehlers–Danlos syndromes; these conditions should CT Unenhanced. No oral contrast. Scan from
be considered in younger patients presenting with just above aortic arch to diaphragm level.
dissection. Aortic angiogram: 100 ml IV contrast via
Typical symptoms and signs of aortic dissection 18G cannula, 4 ml/sec. Bolus track centred
on the descending thoracic aorta. Scan from
include upper limb blood pressure asymmetry and just above aortic arch to femoral head level.
‘tearing’ chest pain that radiates through to the back,
although an absence of these findings does not exclude
K22247_C001.indd 3 16/05/15 3:06 AM

4 Chapter 1
Radiological findings true lumen is smaller, demonstrates denser contrast

Computed tomography opacification and is surrounded by intimal calcification,
The unenhanced phase should be scrutinised for whereas the false lumen is larger, less dense and in time
intramural haematoma, which appears as crescenteric can become thrombosed. Distinguishing a thrombosed
high attenuation material within the aortic wall. This false lumen (which can be seen in aortic dissection) from
is best appreciated on a narrow image window setting atherosclerotic intraluminal thrombus can be difficult;
(Figure 1.1a) and can be difficult to appreciate on the the former may displace intimal calcifications away
enhanced phase (Figure 1.1b). On contrast enhanced from the aortic wall, a useful distinguishing feature.
CT aortography, intramural haematoma presents as a The most cranial and caudal aspect of a dissection
low attenuation crescent or circumferential opacity (in flap/intramural haematoma should be identified;
relation to the IV contrast) and can be confused with this may involve re-scanning the patient if the extent
non-calcified atherosclerotic disease. of dissection is not fully imaged initially. The major
When interpreting contrast enhanced CT branches of the aorta arch should be scrutinised;
aortography, it is vital that the aorta is scrutinised in axial, propagation into the aortic arch can result in thrombosis
sagittal and coronal planes with appropriate windowing and cerebral ischaemia (Figure 1.3). Involvement of
(width 400, level 100), which aids visualisation of the aortic root may threaten the coronary arteries
the dissection flap (Figure 1.2a). This appears as a and can rupture into the pericardium, resulting in
serpiginous, linear filling defect extending across the haemopericardium and cardiac tamponade; the former
lumen of the opacified aorta, dividing the aorta into two is suggested by intermediate to high density (>25 Hu)
channels, the true and false lumen. Inspecting the aorta fluid in the pericardial space (Figure 1.4). Cardiac
on soft tissue window settings alone can result in a false- tamponade can occur with even a small volume of fluid
negative result, since the dissection flap can be obscured and is more dependent on the rate of accumulation.
by adjacent high attenuation IV contrast (Figure 1.2b). Secondary signs (e.g. flattening/bowing of the LV
Delineation of the true and false lumens can be helpful septum, reflux of contrast into the IVC/azygous vein and
as a guide to potential surgical or interventional distension of the SVC/IVC) can be unreliable. Clinical
management. The true lumen is defined as the lumen review looking for a raised JVP and pulsus paradoxus
that is supplied by the aortic root. Generally, the and further investigation with echocardiography is
(a) (b)
Figures 1.1a, b Axial images: unenhanced and IV contrast enhanced scans of the aortic arch in the arterial
phase. The unenhanced image demonstrates a hyperdense crescenteric rim outlining the aortic arch, representing
intramural haematoma (arrow). On the contrast enhanced image, this is difficult to appreciate.
K22247_C001.indd 4 16/05/15 3:06 AM

Thoracic imaging 5
(a) (b)
Figures 1.2a, b Axial images: IV contrast enhanced CT scans of the thorax in the arterial phase. There is a
serpiginous, linear structure within the aortic arch containing flecks of calcification consistent with an aortic
dissection flap (arrow). Figure 1.2b demonstrates the importance of appropriate window width and level, as the
dissection flap is barely visible without image manipulation.
Figure 1.3 Coronal image: IV contrast enhanced Figure 1.4 Axial image: IV contrast enhanced CT scan
CT scan of the thorax in the arterial phase. A dissection of the thorax in the arterial phase. A dissection flap is
flap can be seen extending from the aortic root and shown within the aortic root. In addition, hyperdense
involving the brachiocephalic trunk, which may material is seen in the pericardium consistent with
compromise distal blood flow into the right common haemopericardium (arrow). This may occur in coronary
carotid artery and right subclavian artery. artery rupture as a result of dissection.
K22247_C001.indd 5 16/05/15 3:06 AM

6 Chapter 1
required. Cardiac motion artefact, which commonly A penetrating atherosclerotic ulcer is usually
occurs in the region of the aortic root, can be associated with marked atherosclerotic disease and
misinterpreted as a dissection flap. Familiarity with this appears as a focal bulging or out-pouching of the aortic
artefact can prevent a false-positive result (Figure 1.5). wall, usually separating atherosclerotic calcification
The dissection can also extend caudally into the (Figure 1.6). Although sometimes subtle, this is an
descending thoracic and abdominal aorta; the coeliac important finding and can ultimately progress to
axis, SMA and IMA should be closely inspected for intramural haematoma, aneurysm and aortic rupture.
involvement. Furthermore, it is useful to identify which Comparison with previous imaging is useful to help
of the main abdominal aortic branch vessels arise from identify this important pathology.
the false lumen, as these are at risk of ischaemia. Coeliac
axis involvement can result in liver or splenic ischaemia, Key points
which typically presents as reduced enhancement. SMA • Acute aortic syndrome is a spectrum of
or IMA involvement can result in bowel ischaemia (see abnormality comprising aortic ulceration,
Chapter 2: Gastrointestinal and genitourinary imaging, intramural haematoma and dissection.
Bowel ischaemia and enterocolitis). • Contrast enhanced CT is the imaging
Both intramural haematoma and aortic dissection modality of choice to characterise aortic
should be classified according to the Stanford or dissection. Unenhanced CT imaging should be
DeBakey model; this has important prognostic and performed to aid identification of intramural
management implications (Table 1.2). haematoma.
Table 1.2 Stanford and DeBakey systems.
LOCATION MANAGEMENT
Stanford A Involving thoracic aorta Surgical.
proximal to origin of
left subclavian artery.
Stanford B Involving the aorta Conservative.
distal to the left
subclavian artery.
DeBakey I Involving ascending Surgical.
aorta, aortic arch and
descending aorta.
DeBakey II Involving ascending Surgical.
aorta.
DeBakey III Involving descending Conservative.
aorta only.
Figure 1.5 Axial image: IV contrast enhanced CT scan
of the thorax in the arterial phase. Normal appearance
of the heart. An apparent, linear defect structure can be
seen in the ascending aorta. This is a normal appearance
in non-ECG-gated studies resulting from cardiac
motion during the scan.
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Thoracic imaging 7
• Careful windowing is required to identify THORACIC AORTIC INJURY

dissection flaps. Intramural haematoma appears as
crescenteric high attenuation material within the Aortic injury is a major concern in the setting of primarily
aortic wall on the unenhanced phase. blunt, but also penetrating, thoracic trauma. Traumatic
injury of the thoracic aorta is a spectrum of injury,
Report checklist including aortic intramural haematoma and dissection,
• Presence or absence of intramural haematoma. laceration, pseudoaneurysm (in which a rupture is
• Cranial and caudal extent of the dissection flap. contained by periaortic soft tissues) and complete aortic
• Patency of great vessels/coeliac axis/SMA/IMA/ transection and rupture (see Acute aortic syndrome
renal arteries. for discussion on aortic intramural haematoma and
• Presence of pericardial blood and any signs of dissection). Injury occurs most commonly at regions
cardiac tamponade. of aortic tethering, such as the aortic isthmus. Classic
• Classification. symptoms and signs include chest pain, dyspnoea
and upper limb hypertension with associated lower
Reference limb hypotension. Ultimately, aortic transection and
Macura JK, Corl FM, Fishman EK et al. (2003) rupture result in profound haemodynamic instability.
Pathogenesis in acute aortic syndromes: aortic Mortality rates are high, estimated at 80–90% in
dissection, intramural hematoma, and penetrating untreated aortic injury (Parmley et al., 1958). As such,
atherosclerotic aortic ulcer. Am J Roentgenol the on-call radiologist should have a high index of
181:309–316. suspicion for aortic injury in this scenario. Accurate and
swift diagnosis is vital, facilitating urgent surgical or
interventional repair.
Radiological investigations
CT is the most sensitive and specific modality for
aortic trauma. Both enhanced and unenhanced phases
should be performed, the latter aiding in identification
of intramural haematoma, although often the precise
protocol is determined by departmental polytrauma
guidelines. Depending on the clinical presentation
of the patient, chest plain film imaging can be used as
an initial screening test, although this modality is not
reliable enough to exclude more subtle injury and can
appear normal in up to 7% of significant aortic injuries
(Fabian et al., 1997). (See Table 1.3.)
Table 1.3 Thoracic aortic injury.

Imaging protocol.
MODALITY PROTOCOL
CT Unenhanced. Scan from aortic arch to
diaphragm level.
Figure 1.6 Axial image: IV contrast enhanced Aortic angiogram: 100 ml IV contrast via
CT scan of the thorax in the arterial phase. A small 18G cannula, 4 ml/sec. Bolus track centred
on the aortic arch. Scan from aortic arch to
outpouching of contrast can be seen through a defect
diaphragm level.
in the distal aspect of the aortic arch, representing an
atherosclerotic ulcer (arrow).
K22247_C001.indd 7 16/05/15 3:06 AM

8 Chapter 1
Radiological findings as haematoma. Any loss of definition of the aortic wall

Computed tomography should also be treated with suspicion, as should focal
As with all polytrauma cases, a ‘primary survey’ of periaortic fat stranding. Focal filling defects within the
CT imaging should be performed in an attempt to aortic lumen can indicate intraluminal clot and occult
identify immediately life-threatening aortic injury. injury, although comparison with previous imaging is
The thoracic aorta should be scrutinised using helpful to assess for pre-existing atheroma (Figure 1.9).
multiplanar reformatting and appropriate window Aortic dissection and intramural haematoma can also
settings (window 400, level 100). Focal aortic be seen in traumatic aortic injury (see Acute aortic
contour deformities (including focal aneurysms) syndrome for these findings). Any suspicion of aortic
and mural discontinuity are direct signs of aortic injury should be urgently communicated to the
injury (Figures 1.7a, b). Familiarity with the normal referring team.
appearance of the aortic isthmus is essential, since this
can be mistaken for aortic injury. Active extravasation of Plain films
IV contrast, commonly into the mediastinum or pleural While chest plain film imaging cannot exclude aortic
spaces, is indicative of active bleeding. injury, it can yield helpful signs. Mediastinal widening
There are more subtle signs of aortic injury. The of >8 cm can be an indicator of mediastinal haematoma.
presence of mediastinal haematoma should always It should be noted that the sensitivity and specificity
make the on-call radiologist suspicious, although of mediastinal widening for aortic injury varies from
other causes include venous injury (including the 53–100% and 1–60%, respectively (Groskin, 1992).
azygous vein) and vertebral body fractures. Mediastinal The most common cause of mediastinal haematoma
haematoma presents on CT as increased attenuation in trauma is the tearing of small mediastinal veins, as
material within the mediastinum (>30 Hu). Periaortic opposed to aortic injury. Other signs of aortic injury
haematoma is extremely worrisome for an occult include an indistinct aortic contour, left apical pleural
aortic injury (Figures 1.8a, b). Both residual thymic cap, tracheal deviation and depression of the left main
tissue and pericardial recesses can be misinterpreted bronchus.
(a) (b)
Figures 1.7a, b Axial and coronal images: IV contrast enhanced CT scans of the thorax in the arterial phase. Both
cases demonstrate contour abnormality of the thoracic aorta, in keeping with aortic injury (arrows).
K22247_C001.indd 8 16/05/15 3:06 AM

Thoracic imaging 9
Key points References

• Aortic injury is a life-threatening complication of Fabian TC, Richardson JD, Croce MA et al. (1997)
both blunt and penetrating trauma. Prospective study of blunt aortic injury: multicenter
• CT is the modality of choice to investigate aortic trial of the American Association for the Surgery of
injury but radiological signs may also be seen on Trauma. J Trauma Acute Care Surg 42:374–380;
plain film radiographs. discussion 380–383.
Groskin SA (1992) Selected topics in chest trauma.
Report checklist Radiology 183:605–617.
• Document the relevant negatives of thoracic Parmley LF, Mattingly TW, Manion WC et al. (1958)
aortic injury, including aortic contour abnormality, Nonpenetrating traumatic injury of the aorta.
mediastinal haematoma and active extravasation. Circulation 17:1086–1101.
• Recommend urgent surgical and interventional
radiology opinion.
(a) (b)
Figures 1.8a, 8b Axial images: IV contrast enhanced CT scans of the thorax in the arterial phase. There is
increased density material in the para-aortic regions consistent with haematoma (arrows). This can be seen tracking
inferiorly in the posterior mediastinum along the descending thoracic aorta. An aortic dissection flap can be seen
within the aortic lumen (1.8a).
Figure 1.9 Axial image: IV contrast enhanced CT scan

of the thorax in the arterial phase. There is a filling
defect within the aortic lumen, in keeping with a clot
(arrow). Periaortic haematoma is also present.
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10 Chapter 1
PULMONARY EMBOLISM Table 1.4 Risk factors for venous

thromboembolism (Campbell
et al., 2003).
Pulmonary embolism is a medical emergency, although
clinical presentation varies according to the degree of
MAJOR RISK FACTORS (RELATIVE RISK 5–20)
arterial occlusion. Pulmonary emboli most commonly
Surgery (where appropriate Major abdominal/pelvic
arise from the deep venous system of the lower
prophylaxis is used, relative surgery.
extremities, but emboli can also occur from the upper risk is much lower) Hip/knee replacement.
limbs, right-sided cardiac chambers and jugular venous
Postoperative intensive care.
system. There are many risk factors for pulmonary
Obstetrics Late pregnancy.
embolism, namely those that produce a hypercoagulable
Caesarean section.
state (Table 1.4). Occlusion of the pulmonary arteries
causes both respiratory and cardiovascular effects. Puerperium.
Respiratory effects include increased alveolar dead Lower limb problems Fracture.
space, hypoxaemia, hyperventilation and pulmonary Varicose veins.
infarction. Cardiovascular effects include an increase Malignancy Abdominal/pelvic.
in pulmonary vascular resistance, which also results Advanced/metastatic.
in an increase in right ventricular afterload and right Reduced mobility Hospitalisation.
ventricular failure (compounded by reflex pulmonary Institutional care.
arterial constriction). Symptoms and signs include Miscellaneous Previous proven venous
chest pain, dyspnoea, haemoptysis and collapse. Chest thromboembolus.
pain is typically pleuritic in nature, although this classic MINOR RISK FACTORS (RELATIVE RISK 2–4)
type of pain is only usually present in small peripheral
Cardiovascular Congenital heart disease.
emboli that cause pleural inflammation and irritation.
Congestive cardiac failure.
Hypoxaemia is frequently, but not universally, present
Hypertension.
on arterial blood gas analysis. Large emboli causing
Superficial venous
proximal occlusion of the pulmonary arterial system thrombosis.
can result in profound haemodynamic instability, Indwelling central vein
leading to cardiac arrest. Because of this variable clinical catheter.
presentation, it can be useful to clinically separate cases Oestrogens Oral contraceptive.
into suspected massive and non-massive pulmonary Hormone replacement
embolism, which in turn dictates further investigation therapy.
and urgency of diagnosis. Miscellaneous Chronic obstructive
It is important to appreciate that radiology only pulmonary disease.
plays one part in the investigation pathway of suspected Neurological disability.
non-massive pulmonary embolism, which also includes Occult malignancy.
clinical pre-test probability scoring and laboratory Thrombotic disorders.
D-dimer analysis. The National Institute for Health Long-distance sedentary
and Clinical Excellence (NICE) in the UK has travel.
published revised guidelines for the investigation and Obesity.
management of pulmonary embolism based on a 2-level Other (inflammatory
Wells Score rather than a 3-level Wells Score (Table 1.5; bowel disease, nephrotic
syndrome, chronic dialysis,
Figure 1.10, NICE, 2012). D-dimer analysis should be
myeloproliferative disorders,
performed only on patients with a low or intermediate paroxysmal nocturnal
pre-test probability of pulmonary embolism; a normal haemoglobinuria, Behçet’s
D-dimer test in this scenario has almost a 100% negative disease).
predictive value and excludes the diagnosis. A positive
K22247_C001.indd 10 16/05/15 3:06 AM

Thoracic imaging 11
Table 1.5 Two-level Wells score.
CLINICAL FEATURES POINTS

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate >100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Clinical probability simplified score
PE likely More than 4 points
PE unlikely 4 points or less
Adapted from Wells PS, Anderson DR, Rodger M et al. (2000) Derivation of a simple clinical model to categorize patients probability of
pulmonary embolism: increasing the model’s utility with the SimpliRED D-dimer. Thromb Haemost 83:416–420, with permission.
DVT = deep pain thrombosis; PE = pulmonary embolism.
result necessitates further radiological investigation to performed within 24 hours (Campbell et al., 2003).
exclude pulmonary embolism; however, false-positive CTPA is now considered the initial imaging modality
results can be seen secondary to infection, malignancy, of choice in suspected cases of non-massive pulmonary
pregnancy and recent surgery. D-dimer analysis should embolism. The advantages of CTPA include its
generally not be performed in patients with a high relatively high sensitivity and specificity, availability out
pre-test probability, since a false-negative result can of hours and ability to identify alternative intrathoracic
occur in over 15% of cases (Stein PD et al., 2007). In pathologies. A negative CTPA study of diagnostic
stable patients with suspected non-massive pulmonary quality effectively excludes the diagnosis of pulmonary
embolism, treatment in the form of anticoagulation embolism. Limitations of CT include indeterminate
can be started prophylactically prior to radiological results owing to suboptimal contrast opacification
confirmation or exclusion. The investigation pathway within the pulmonary arterial system, and a breathing
is different for suspected cases of massive pulmonary artefact, which can both limit interpretation of the
embolism, since urgent diagnosis is vital in order to more distal arterial system. Isotope lung scanning
facilitate urgent thrombolytic therapy. can be used as an alternative or adjunct to CT in the
absence of a co-existing structural lung abnormality,
Radiological investigations although this modality is not readily available out of
Due to the often non-specific presentation of hours in most centres. While a low probability result
pulmonary embolism, all stable patients with suspected from an isotope scan effectively excludes the diagnosis,
pulmonary embolism should have chest plain film a high probability study can still yield a significant false-
imaging prior to further imaging. While this modality positive rate.
cannot confirm the diagnosis, it may diagnose Both CTPA and echocardiography are considered
alternative pathologies that can account for the patient’s diagnostic for suspected cases of massive pulmonary
symptoms. British Thoracic Society (BTS) guidelines embolism. The exact modality often depends on local
recommend that diagnostic imaging should ideally be protocol; however, it must be emphasised that imaging
K22247_C001.indd 11 16/05/15 3:06 AM

12 Chapter 1
Patient with signs or symptoms of PE
Other causes excluded by assessment of general medical history, physical examination and chest X-ray
PE suspected
Two-level PE Wells score
PE likely (>4 points) PE unlikely (≤4 points)
D-dimer test
Is CTPA* suitable** and available immediately?
Was the D-dimer test positive?
Yes No
Yes No
Offer CTPA Immediate interim parenteral
(or V/Q anticoagulant therapy
SPECT or
planar Is CTPA* suitable** and available immediately?
scan) CTPA (or V/Q SPECT or
planar scan)
No
Yes
Was the CTPA (or V/Q SPECT or planar scan) positive?
Immediate interim
parenteral anticoagulant
No Offer CTPA
therapy
(or V/Q
Yes SPECT or
Is deep vein thrombosis suspected?
planar
scan) CTPA (or V/Q SPECT or
No
Yes planar scan)
Advise the patient

Consider a it is not likely that
proximal leg he/she has PE. Was the CTPA (or V/Q SPECT or
vein ultrasound Discuss the signs planar scan) positive?
scan. and symptoms of
PE, and when and
where to seek further Yes No
medical help. Take
into consideration
alternative Advise the patient it is not likely that he/
diagnoses. she has PE. Discuss the signs and symptoms
of PE, and when and where to seek further
medical help. Take into consideration
Diagnose PE and treat alternative diagnoses.
*Computed tomography pulmonary angiogram

**For patients who have an allergy to contrast media, or who have renal impairment, or whose risk from irradiation is
high, assess the suitability of V/Q SPECT† or, if not available, V/Q planar scan, as an alternative to CTPA.
†Ventilation/perfusion single photon emission computed tomography
Figure 1.10 Suggested algorithm for the diagnosis of acute pulmonary embolism (PE).
K22247_C001.indd 12 16/05/15 3:06 AM

Thoracic imaging 13
should never delay urgent thrombolysis if massive opacified blood to be introduced into the pulmonary
pulmonary embolism is suspected clinically. (See arterial system, resulting in the mixing and dilution of
Table 1.6.) contrast. The precise sensitivity of CTPA studies varies
according to both the quality of contrast opacification
Radiological findings and the degree of artefact (e.g. breathing). It may be the
Computed tomography pulmonary angiogram case that contrast opacification centrally is adequate;
Interpretation of CTPA studies should begin with however, emboli more distal in the pulmonary arterial
an assessment of the quality of the study, namely the system cannot be excluded. It is good practice to
degree of pulmonary artery contrast opacification quantify to what arterial level emboli can be excluded:
and any potential breathing artefact. An average lobar, segmental or subsegmental.
attenuation of at least 250 Hu is required in the main The pulmonary arterial system should be scrutinised
pulmonary trunk to accurately diagnose more distal systematically using multiplanar reformatting. A
emboli. Opacification depends on the size and site of rounded intraluminal filling defect within a pulmonary
IV access, rate of injection and exact scan protocol; artery, which may also cause slight vessel expansion, is
inspiration just prior to scanning can cause poorly consistent with an acute embolus (Figure 1.11). It can be
difficult to appreciate emboli if the pulmonary arteries
are inspected on standard soft tissue window settings,
Table 1.6 Pulmonary embolus. since they can be obscured by the dense IV contrast.
Imaging protocol. Inspection on a relatively wide window setting (width
700, level 100) can alleviate this. A gradual decrease
MODALITY PROTOCOL in opacification of the distal segmental and sub-
CT Pulmonary angiogram: 100 ml IV contrast segmental pulmonary arteries on a suboptimal study
via 18G cannula, 4 ml/sec. Bolus track should not be confused with multiple emboli. Poorly
centred on main pulmonary artery. Scan
opacified pulmonary veins can also be misinterpreted
from thoracic inlet to diaphragm level.
as emboli within the arterial system. Findings seen
in association with pulmonary embolism include
Figure 1.11 Axial image: IV contrast enhanced

CT pulmonary angiogram. A filling defect is outlined by
intravenous contrast in the right main pulmonary artery
consistent with acute embolus (arrow).
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14 Chapter 1
pleural effusions, atelectasis and pulmonary infarcts. narrowing due to recanalisation (Figures 1.14). A focal
The latter present as peripheral wedge-shaped areas of linear intraluminal filling defect within a pulmonary
consolidation, which in the subacute phase may cavitate artery is suggestive of an arterial web, which can be seen
(Figures 1.12a–c, 1.13). as a result of chronic emboli. Secondary pulmonary
Chronic pulmonary embolism can provide a artery hypertension can result from multiple chronic
diagnostic challenge for the radiologist, although several emboli. The main sign of pulmonary hypertension
findings can be observed that imply this diagnosis. on CT is enlargement of the main pulmonary artery
Calcification of a filling defect suggests chronicity. (greater than 34 mm or larger than the corresponding
Other radiological signs include filling defects that cause ascending aorta; Figure 1.15). Mosaic attenuation of the
narrowing (as opposed to expansion), eccentric filling lung parenchyma can also be seen in cases of chronic
defects that form an obtuse (as opposed to acute) angle pulmonary emboli, although this appearance has a wide
with the pulmonary artery wall and an abrupt artery differential diagnosis (Figure 1.16).
(a) (b)
Figures 1.12a–c Axial images: IV contrast enhanced

(c)
CT scans of the thorax in the arterial phase. Peripheral,
wedge-shaped area of consolidation shown. Over time,
the area of consolidation develops an irregular, thick
rind with areas of cavitation centrally due to infarction.
Note the associated pulmonary arterial filling defects in
1.12b and 1.12c consistent with pulmonary emboli.
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Thoracic imaging 15

CT scan of the pulmonary trunk in the arterial phase.
There are features of chronic pulmonary emboli with
recannalised embolic material seen along the walls of the
right main pulmonary artery (arrow).
Figure 1.13 PA chest radiograph. Area of peripheral
consolidation at the left mid zone representing an area
of peripheral lung infarction.
Figure 1.15 Axial image: IV contrast enhanced Figure 1.16 Axial image: IV contrast enhanced
CT pulmonary angiogram. The diameter of the main CT scan of the thorax in the arterial phase. Mosaic
pulmonary trunk is greater than the diameter of the attenuation of the right upper lobe is shown as a result
ascending aorta at that same level, suggesting pulmonary of abnormal pulmonary perfusion in chronic embolic
hypertension. The cause is chronic pulmonary emboli disease.
completely occluding the right main pulmonary artery.
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16 Chapter 1
CT studies can also yield information regarding • Pulmonary emboli appear as intraluminal filling
the severity of cardiovascular compromise secondary defects on CTPA.
to pulmonary emboli. Right ventricular dysfunction • The severity of cardiovascular compromise
and adverse outcome is indicated by a short-axis right secondary to a large pulmonary embolus is best
ventricle:left ventricle ratio of greater than 1.5 or assessed by the short-axis right ventricle:left
convex bowing of the interventricular septum towards ventricle ratio.
the left (Figure 1.17). This is an important finding and
if present may necessitate thrombolysis, although this Report checklist
ultimately depends on the clinical condition of the • The presence or absence of any evidence of right
patient. heart strain.
Whenever the scan is negative it is important to look
for another cause for chest pain or shortness of breath to References
explain the patient’s symptoms. The aorta and the heart Campbell IA, Fennerty A, Miller AC (2003) British
should be assessed for aortic pathology or myocardial Thoracic Society guidelines for the management
infarction. A septal infarct on a CTPA scan is shown of suspected acute pulmonary embolism. Thorax
(Figure 1.18). 58:47–484.
National Institute of Health and Care Excellence
Key points (NICE) Clinical Guideline 144 (2012) Venous
• Radiology is only a part of the investigation thromboembolic diseases: the management of
pathway for pulmonary embolism, which includes venous thromboembolic diseases and the role of
pre-test probability scoring and D-dimer analysis thrombophilia testing.
where appropriate. Stein P, Woodard P, Weg J et al. (2007) Diagnostic
• CTPA is the out of hours imaging modality of pathways in acute pulmonary embolism:
choice in the investigation of pulmonary emboli. recommendations of the PIOPED II Investigators.
• A Hu of greater than 250 in the main pulmonary Radiology 242:15–21.
artery is required for an optimal study.
CT scan of the thorax in the arterial phase. The right CT scan of the thorax in the arterial phase. There is
ventricle:left ventricle ratio is increased with bowing of focal hypoenhancement in the LV septum suggestive of
the interventricular septum to the left. an acute septal infarct (arrow).
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Thoracic imaging 17
ACUTE PULMONARY OEDEMA auscultation. Co-existing signs, such as peripheral

pitting oedema and elevated JVP, imply congestive
Pulmonary oedema is a medical emergency and can be cardiac failure.
defined as an excess of fluid in the extravascular spaces
of the lung, occurring when there is imbalance of fluid Radiological investigations
deposition and absorption. This complex balance is Plain films are the first-line modality in the
affected by the hydrostatic and oncotic pressures of investigation of pulmonary oedema; additional cross-
the intravascular and extravascular compartments and sectional imaging is not required to make the diagnosis.
capillary membrane permeability (Gluecker et al., However, because of the non-specific symptoms and
1999). Thus, any increases in capillary hydrostatic signs of pulmonary oedema, it can often be seen on CT
pressure or membrane permeability can result in imaging performed for other indications, and therefore
pulmonary oedema. the common CT findings are discussed subsequently.
The many causes of pulmonary oedema can Further investigation of the underlying aetiology often
be broadly divided into cardiac and non-cardiac involves cardiology input.
(Table 1.7). Common causes include pulmonary venous
hypertension secondary to left ventricular failure and Radiological findings
fluid overload. Damage to the capillary bed may also Computed tomography and plain films
result in pulmonary oedema. When associated with An understanding of the anatomy of the lung is
respiratory failure and reduced lung compliance, this necessary to appreciate the spectrum of abnormality
is termed acute respiratory distress syndrome (ARDS) seen in pulmonary oedema on both plain films and
(Table 1.8) and is characterised by a normal pulmonary CT. The secondary pulmonary lobule is the most
capillary wedge pressure (PCWP). basic unit of pulmonary structure and is bordered
Symptoms and signs of pulmonary oedema include by a surrounding septum of connective tissue. It
rapid onset dyspnoea, hypoxia and crepitations on lung is comprised of multiple acini (responsible for gas
exchange) with a central terminal bronchiole and
Table 1.7 Causes of pulmonary oedema. centrilobular artery. The peripheral septum contains
both the pulmonary veins and lymphatics, although
CARDIOGENIC NON-CARDIOGENIC there is another central lymphatic network that courses
Left heart failure. Fluid overload. centrally through the secondary pulmonary lobule with
Mitral valve disease. Post-obstructive pulmonary oedema. the bronchovascular bundle. Excess fluid can fill both
Pulmonary veno-occlusive disease. the alveolar air spaces (resulting in ground glass opacity,
Near drowning pulmonary oedema/
which can progress to consolidation) and the pulmonary
asphyxiation pulmonary oedema.
ARDS–pulmonary oedema with Table 1.8 Causes of ARDS.
diffuse alveolar damage.
Heroin-induced pulmonary oedema. • Septicaemia.
Transfusion-related acute lung injury. • Shock.
High-altitude pulmonary oedema. • Burns.
Neurogenic pulmonary oedema. • Acute pancreatitis.
Pulmonary oedema following lung • Disseminated intravascular coagulation.
transplantation. • Drugs.
Re-expansion pulmonary oedema. • Inhalation of noxious fumes.
Post lung volume reduction • Aspiration of fluid.
pulmonary oedema.
• Fat embolism.
Pulmonary oedema due to air
embolism. • Amniotic fluid embolism.
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18 Chapter 1
interstitium (resulting in smooth interlobular septal interlobular septal thickening and visualisation of the
thickening). secondary pulmonary lobule (Figures 1.20a, b). This,
Interpretation of chest plain films should begin in combination with ground glass opacity, may form a
with an assessment of the quality and radiographic ‘crazy paving’ appearance. This has a wide differential
technique. Anterior-posterior studies can overestimate diagnosis, which includes:
the size of the cardiac silhouette due to X-ray beam • Alveolar proteinosis.
divergence. Supine images, as opposed to erect images, • Oedema (heart failure/ARDS).
can cause redistribution of blood to the upper zones and • Pulmonary haemorrhage.
widening of the vascular pedicle, important signs of left • Infection (e.g. mycoplasma, Legionella,
ventricular failure and pulmonary venous hypertension, Pneumocystis carinii/jiroveci pneumonia).
respectively. Poorly inspired images (<6 anterior ribs) • Organising pneumonia.
can cause crowding of the pulmonary vasculature • Acute interstitial pneumonitis/non-specific
and apparent lung congestion. Therefore, a PA chest interstitial pneumonitis.
radiograph is the best for identifying the appropriate
features. As PCWP continues to increase, alveolar oedema will
The spectrum of findings seen on both plain films occur, appearing as multifocal areas of ground glass and
and CT in pulmonary venous hypertension can be airspace opacity in perihilar and dependent regions of
correlated with a progressive increase in PCWP. A the lungs (Figure 1.21).
mild increase in PCWP results in upper lobe blood Distinguishing the underlying cause of pulmonary
diversion. As PCWP increases, additional findings oedema is helpful clinically, although often difficult.
such as peribronchial cuffing, loss of vascular definition Upper lobe blood diversion and Kerley lines are
and Kerley lines can be seen, all of which indicate most suggestive of pulmonary venous hypertension
excess fluid in the interstitium (Gluecker et al., 1999) secondary to cardiac failure. Associated findings such
(Figure 1.19). On CT, the normal interstitium should as cardiomegaly and bilateral pleural effusions are also
be imperceptible. Excess fluid can result in smooth suggestive of underlying left ventricular failure. In the
absence of cardiomegaly, other causes of pulmonary
oedema should be considered, such as fluid overload
or ARDS, although it should be noted that acute
myocardial infarction can cause pulmonary oedema
with a normal heart size in the absence of pre-existing
left ventricular failure. It is always useful to look at the
myocardial enhancement and attenuation of the left
ventricle on CT. This should be uniform; however,
in myocardial infarction the myocardium may
demonstrate decreased attenuation. This represents
decreased enhancement in acute infarction and fatty
deposition in chronic infarction (Figure 1.22).
Key points
• Pulmonary oedema is a medical emergency and
can cause rapid-onset respiratory failure.
• The commonest cause of pulmonary oedema is
Figure 1.19 AP portable chest radiograph. Fluid pulmonary venous hypertension secondary to left
can be seen in the horizontal fissure, as well as within ventricular failure, although other causes include
the interstitium along the periphery of the thorax. fluid overload and ARDS. In the absence of
There is also loss of vascular definition due to venous associated cardiomegaly, non-cardiogenic causes
hypertension. should be considered.
K22247_C001.indd 18 16/05/15 3:06 AM

Thoracic imaging 19
(a) (b)
Figures 1.20a, b Axial images: IV contrast enhanced CT scans of the thorax. There is a combination of
interlobular septal thickening and patchy ground glass opacity, resulting in a crazy paving appearance.
Figure 1.21 AP chest radiograph. There are bilateral, Figure 1.22 Axial image: IV contrast enhanced
perihilar airspace opacities consistent with alveolar CT scan of the thorax in the arterial phase. There is
oedema. The costophrenic angles are not visible due to subendocardial fat deposition at the LV apex in keeping
bilateral pleural effusions. with previous myocardial infarction.
• Plain films are the first-line modality to investigate Report checklist

pulmonary oedema. CT is NOT indicated in the • Presence or absence of associated cardiomegaly.
investigation of pulmonary oedema, although this
is frequently seen in acute CT chest examinations. Reference
• Loss of vascular definition and Kerley lines imply Gluecker T, Capasso P, Schnyder P et al. (1999) Clinical
interstitial oedema. Alveolar oedema appears as and radiologic features of pulmonary oedema.
multifocal airspace opacities in the perihilar and Radiographics 19:1507–1531.
dependent regions of the lungs.
K22247_C001.indd 19 16/05/15 3:06 AM

20 Chapter 1
SUPERIOR VENA CAVA OBSTRUCTION familiarity with the wide variation of appearances of the
‘normal’ SVC is important. Any large extrinsic mass
Superior vena cava (SVC) syndrome refers to a spectrum significantly compressing the SVC is easily evident on
of clinical findings that occur secondary to obstruction CT (Figures 1.23a–c). Difficulty comes in identifying
of the SVC. The most common causes of SVC intrinsic SVC thrombus or tumour infiltration, since
obstruction are pulmonary and mediastinal malignancy. flow in the SVC can often be turbulent. This is made
Other causes include thrombosis of the SVC secondary even more challenging by the dilution of IV contrast
to central line placement, benign mediastinal tumours, material in the SVC by unenhanced blood from the
vascular aneurysms, mediastinal fibrosis and radiation IVC, which can simulate intraluminal thrombus.
fibrosis. Symptoms and signs include neck and upper Thrombus should be suspected in the presence of a
limb swelling, distended superficial veins in the SVC focal filling defect in the SVC lumen, which may also
territory, dyspnoea and headache (secondary to cerebral cause expansion of the lumen with localised stranding
oedema from impaired venous drainage). The severity of the adjacent fat. Thrombus may extend into the
of symptoms has been shown to depend on the level of brachiocephalic and subclavian veins, which should
obstruction (above or below the azygous arch) and the also be inspected. Regardless of the cause, the length
presence of a collateral network (Plekker et al., 2008). and severity of obstruction should be considered; total
Although the severity of the presentation often depends occlusion of the SVC lumen may require more urgent
on the duration of obstruction, urgent diagnosis is treatment than partial occlusion. Complete obstruction
necessary to facilitate treatment such as radiotherapy of the SVC results in a significant hold up of contrast in
and interventional stenting. the venous system proximal to the level of obstruction.
Knowledge of the potential collateral pathways in
Radiological investigations SVC obstruction is necessary in order to assess the
Contrast enhanced CT allows visualisation of the SVC, severity and duration of the obstruction. The main
venous collateralisation and the potential cause of the collateral systems include the azygous-hemiazygous
obstruction, and is considered the modality of choice for (most important), internal mammary, long thoracic
initial assessment. Catheter venography is reserved for and vertebral venous pathways (Sheth et al., 2009). In
therapeutic stent placement in confirmed cases. While normal conditions, antegrade blood flow should be seen
chest plain films have value in identifying potential
mediastinal and lung masses that may be a cause of
SVC obstruction, this modality cannot confirm venous
obstruction. Ultrasound with Doppler analysis of the
upper limb, subclavian brachiocephalic and internal
jugular veins can also be helpful. Dampening of the
normal venous waveform and loss of normal respiratory
variation are indirect signs of SVC obstruction. Because Table 1.9 Superior vena cava obstruction.
of the limited acoustic window, the SVC itself cannot be Imaging protocol.
imaged in its entirety with ultrasound. (See Table 1.9.)
MODALITY PROTOCOL
Radiological findings CT Post IV contrast: 100 ml IV contrast via
Computed tomography 18G cannula, 3 ml/sec. Scan at 30 seconds
after initiation of injection. Scan from lung
Analysis of CT imaging should begin with the SVC
apices to diaphragm level.
itself. The cross-sectional morphology of the SVC
varies according to circulating volume; as such,
K22247_C001.indd 20 16/05/15 3:06 AM

Thoracic imaging 21
in the azygous and hemiazygous veins, which provide Table 1.10 Causes of azygous distension.
an accessory pathway of blood to the SVC and right
atrium. Collateral flow in the azygous system should be • Congestive heart failure.
suspected with abnormal venous distension, although • SVC obstruction.
this can also be seen with other conditions (Table 1.10). • Azygous continuation of the IVC.
Venous collateral vessels appear as enlarged serpiginous • Portal hypertension.
vessels containing dense IV contrast; these can be • Constrictive pericarditis.
seen in the chest wall, mediastinum, intercostal and
(a) (b)
Figures 1.23a–c Axial and

(c)
coronal images: IV contrast
enhanced CT scans of the thorax
in the arterial phase. There is a
spiculated mediastinally invasive
lung tumour, which is compressing
the SVC to a narrow slit.
K22247_C001.indd 21 16/05/15 3:06 AM

22 Chapter 1
paravertebral regions (Figure 1.24). Obstruction of the Report checklist

SVC above the level of the azygous arch results in flow • Document the degree of SVC obstruction.
through chest wall collaterals into the azygous venous • Consider the underlying cause, such as an
system. Obstruction distal to the level of the azygous obstructing mass or intraluminal thrombus.
arch results in retrograde flow in the azygous vein, • Document the degree of collateralisation.
presenting as dense contrast material within the azygous
venous system on CT, which is normally unenhanced References
in physiological antegrade flow (Gosselin et al., 1997) Gosselin M, Rubin G (1997) Altered intravascular
(Figures 1.25a, b). The presence of collateral vessels contrast material flow dynamics: clues for
implies a significant long-standing venous obstruction. refining thoracic CT diagnosis. Am J Roentgenol
169:1597–1603.
Key points Plekker D, Ellis T, Irusen EM et al. (2008) Clinical
• SVC obstruction is a medical emergency. The and radiological grading of superior vena cava
most common causes include malignancy and obstruction. Respiration 76:69–75.
iatrogenic related thrombosis. Sheth S, Ebert M, Fishman E (2009) Superior vena
• Although catheter venography is more sensitive cava obstruction evaluation with MDCT. Am J
in subtle cases, CT is non-invasive and provides Roentgenol 194:336–346.
useful information of both the degree of
obstruction and the underlying cause.

CT scan of the thorax in the arterial phase. There are
multiple, serpiginous enhancing vessels adjacent to the
diaphragm consistent with venous collaterals, some
of which drain into the IVC (arrow). Incidental note is
made of a chronic left-sided pleural effusion.
K22247_C001.indd 22 16/05/15 3:06 AM

Thoracic imaging 23
(a) (b)
Figures 1.25a, b Axial images: IV contrast enhanced CT scans of the thorax in the arterial phase. Both cases
demonstrate reflux of IV contrast from the SVC into the azygous vein. A hypoattenuating mass can be seen in the
anterior mediastinum causing obstruction of the SVC proximally (1.25a).
K22247_C001.indd 23 16/05/15 3:06 AM

K22247_C001.indd 24 16/05/15 3:06 AM
Chapter 2
GASTROINTESTINAL AND
GENITOURINARY IMAGING 25
ABDOMINAL AORTIC setting. Ultrasound can be performed initially in

ANEURYSM RUPTURE suitable patients who are stable and who do not have
a known history of aortic aneurysm; a normal calibre
Abdominal aortic aneurysms (AAAs) are a vascular aorta is unlikely to rupture spontaneously. The
surgical emergency. A true aneurysm is defined as gross signs of aortic rupture, such as retroperitoneal
focal dilatation of the artery (an increase of at least haematoma, would be expected to be present,
50% of the normal vessel diameter) that involves although the more subtle signs of impending rupture
the intima, media and adventitia. In comparison, a are difficult to assess with ultrasound.
pseudoaneurysm is a focal collection of blood that CT is the imaging modality of choice in assessing
connects with the vessel lumen, but is bound only by potential aortic aneurysm rupture and should be
adventitia or local soft tissues. AAA rupture occurs performed in unstable patients with a strong clinical
more commonly with advancing age, and is estimated suspicion without delay. CT not only has a high
to occur in 2–4% of the population over 50 years of sensitivity and specificity for AAA rupture, but it
age (Bengtsson et al., 1992). is also useful in identifying alternative abdominal
The most common cause of AAA rupture is pathologies to account for the presentation. Both
degeneration of the vessel wall, traditionally attributed unenhanced and arterial phases should be obtained.
to atherosclerosis, although inflammatory, mycotic (See Table 2.1.)
and traumatic pseudoaneurysms can also occur.
Aneurysms are also associated with connective tissue Radiological findings
disease, particularly in younger patients. The classic Computed tomography
sign of a pulsatile abdominal mass may not always In cases where AAA rupture is strongly suspected
be present. Symptoms and signs may be more non- clinically, it can be helpful to review the initial images
specific, including abdominal pain, collapse and locally when the patient is still in the radiology
haemodynamic instability. In practice, the on-call department. This allows prompt communication of
radiologist should have a high index of suspicion for a rupture to the referring team. Comparison with
this condition in any elderly patient presenting with previous imaging is extremely helpful in cases of
abdominal pain. The mortality rate is high; at least known AAA.
65% of patients with aortic aneurysm rupture and
die before reaching hospital. Urgent diagnosis is Table 2.1 Abdominal aortic aneurysm r upture.
vital in order to facilitate life saving open surgical or Imaging protocol.
endovascular aneurysm repair.
MODALITY PROTOCOL
Radiological investigations CT Aortic angiogram: 100 ml IV via
Ultrasound and CT can both accurately assess the 18G cannula, 4 ml/sec. Bolus track centred
on mid-abdominal aorta. No oral contrast.
size of the abdominal aorta. Ultrasound has a well- Scan from just above diaphragm to femoral
established role in the long-term follow up of known head level.
cases of AAA; however, it also has a role in the acute
K22247_C002.indd 25 16/05/15 3:07 AM

26 Chapter 2
An AAA is confirmed when the maximum diameter Degenerative aneurysms are usually fusiform in
of the abdominal aorta exceeds 3 cm (Figure 2.1). shape. Small, focal dissections within degenerative
The size, morphology and location of the aneurysm is AAAs are not uncommon (Figure 2.2). A saccular
best characterised on the arterial phase. Aneurysms can aneurysm or lobulated contour should prompt a
be infrarenal (originating below the level of the renal suspicion of infection (mycotic aneurysm). Additional
arteries) or suprarenal/renal; the location determines findings suggestive of infection include significant
potential treatment. In infrarenal cases, the distance periaortic inflammation, local fluid collections,
between the renal arteries and the most cranial aspect vertebral body destruction and fistulation with adjacent
of the aneurysm should be measured; this information structures (Figure 2.3).
can dictate if a case is suitable for endovascular repair. The presence of retroperitoneal or periaortic
For aortic ruptures where the aneurysm involves the haematoma is indicative of aneurysmal rupture and
renal arteries, endovascular repair is less suitable than should be urgently communicated to the referring team
an open approach, since an adequate ‘landing zone’ (Figure 2.4). It is sometimes possible to identify the
is required for stent placement. Further relevant exact site of rupture; this appears as a focal discontinuity
contraindications of an endovascular approach include in the aortic wall. Active contrast extravasation can
angulated, tortuous or narrowed (<8 mm) iliac arteries also sometimes be identified in the presence of IV
or tapering of the aneurysmal neck. contrast.
Figure 2.1 Axial image: IV contrast enhanced CT scan Figure 2.2 Axial image: IV contrast enhanced CT scan
of the abdomen in the arterial phase. The abdominal of the abdomen in the arterial phase. The abdominal
aorta is aneurysmal, with contrast seen within the lumen aorta is aneurysmal, and a linear dissection flap can be
of the vessel. Hypodense thrombus can also be seen seen traversing the lumen.
along the left aortic wall, in addition to a thin rim of
calcification around the vessel.
K22247_C002.indd 26 16/05/15 3:07 AM

Gastrointestinal and genitourinary imaging 27
There is a spectrum of more subtle CT findings

that are important to appreciate. Contained rupture
should be suspected if the posterior wall of the aorta
is ill-defined or cannot be clearly delineated from
the vertebral bodies, termed the ‘draped aorta’ sign
(Halliday et al., 1996). High attenuation material
in a crescenteric distribution within thrombus in
the aneurysm sac, best appreciated on wide window
settings, can represent infiltration of blood into the
thrombus wall and is suggestive of impending rupture
(Gonsalves, 1999) (Figure 2.5). Further signs that can
indicate impending rupture include aneurysms larger
than 7 cm with increasing abdominal pain, a rapid
increase in the size of an AAA (>10 mm per year) and
fissuring of thrombus or mural calcification (Rakita
et al., 2007).
An additional complication of AAA is aortoenteric
fistulation, in which a communication is formed Figure 2.3 Coronal image: IV contrast enhanced
between the aorta and bowel, usually in the region CT scan of the abdomen in the arterial phase. A saccular
of the second or third part of the duodenum. This is aneurysm is seen arising from the abdominal aorta,
suggested by gas within the aortic lumen, although which is fistulating with the left common iliac vein.
Figure 2.4 Axial image: IV contrast enhanced CT scan Figure 2.5 Axial image: IV contrast enhanced CT
of the abdomen in the arterial phase. There is large scan of the abdomen in the arterial phase. The aorta
volume retroperitoneal haematoma, which can be seen is aneurysmal and contains thrombus. Ill-defined,
outlining the right Gerota’s fascia, extending into the crescenteric high attenuation material can be seen
paracolic spaces. within the thrombus consistent with contained contrast
extravasation/fissuring into the thrombus (arrow).
K22247_C002.indd 27 16/05/15 3:07 AM

28 Chapter 2
this can also be seen with mycotic aneurysms. Active • Anatomical location of the aortic aneurysm:
extravasation of aortic contrast into the bowel, or a infrarenal or juxtarenal.
history of melaena, can be useful distinguishing factors • Renal vessel involvement or renal hypoperfusion.
(Figures 2.6a, b). • Signs of significant intravascular volume depletion
e.g. IVC flattening.
Key points • Patency of coeliac axis/SMA/IMA/renal arteries.
• CT is the optimum imaging modality in the
assessment of potential AAA rupture. References
• An aneurysm is confirmed when the maximum Bengtsson H, Bergqvist D, Sternby NH (1992)
diameter of the aorta exceeds 3 cm. Rupture is Increasing prevalence of abdominal aortic
confirmed in the presence of retroperitoneal or aneurysms: a necropsy study. Eur J Surg 158:19–23.
periaortic haematoma. Gonsalves CF (1999) The hyperattenuating crescent
• More subtle signs of impending aneurysm rupture sign. Radiology 211:37–38.
include increasing pain, an increase in size greater Halliday KE, Al-Kutoubi A (1996) Draped aorta: CT
than 10 mm per year and crescenteric high sign of contained leak of aortic aneurysms. Radiology
attenuation within aortic thrombus. 199:41–43.
Rakita D, Newatia A, Hines J et al. (2007) Spectrum
Report checklist of CT findings in rupture and impending rupture
• Presence or absence of haemorrhage and active of abdominal aortic aneurysms. Radiographics
contrast extravasation. 27:497–507.
• Presence or absence of dissection flap.
(a) ( b)
Figures 2.6a, b Axial images: IV contrast enhanced CT scans of the abdomen in the arterial phase. Ill-defined
contrast can be seen extending from the aorta into a loop of bowel anteriorly, consistent with an aortoenteric fistula
(arrow). The aorta is seen to be aneurysmal more cranially.
K22247_C002.indd 28 16/05/15 3:07 AM

ACUTE GASTROINTESTINAL BLEEDING is more helpful in cases of occult or intermittent GI

bleeding). CTA is increasingly being used as the first-
Acute gastrointestinal (GI) bleeding is a medical and line imaging modality of choice and is a useful adjunct
surgical emergency, with an associated mortality of in cases where endoscopy has failed to identify a source
up to 40% (Walsh et al., 1993). GI bleeding has many of bleeding. The sensitivity of CT decreases if bleeding
causes (Table 2.2) and can be divided into upper and is intermittent and timing the scan with the clinical
lower tract bleeding, according to its location in signs of active bleeding is essential. Utilising triple-
relation to the ligament of Treitz. Upper tract bleeding phase CTA (unenhanced, arterial and delayed phases)
is more common than lower tract bleeding, comprising increases sensitivity and specificity when compared
approximately 75% of cases (Ernst et al., 1999). with using a single phase only. Oral contrast may mask
Symptoms such as haematemesis and melaena usually the potential site of bleeding and should therefore be
indicate an upper tract source, whereas fresh per rectum omitted. It is also important to consider whether the
bleeding usually signifies bleeding from the lower GI patient has had any recent oral contrast examinations,
tract. Profound bleeding can result in haemodynamic since this can also lead to a false-positive result. Barium
instability and therefore urgent localisation of the enemas are of particular importance, since the oral
source is vital. Endoscopy has traditionally been contrast can remain in diverticulae for months or even
considered the first-line investigation for suspected GI years. Catheter angiography is invasive and is nowadays
bleeding, especially in cases of suspected upper tract less sensitive than CTA; as such it is generally performed
bleeding. Limitations of endoscopy include an inability once CTA has identified a bleeding point, with an aim
to visualise the upper tract distal to the fourth part of to embolisation and treatment. (See Table 2.3.)
the duodenum and difficulty in visualising bleeding foci
because of profound intraluminal haemorrhage. With Radiological findings
the increasing sensitivity of CT and ease of access, Computed tomography
radiological investigations are increasingly being The GI tract should be scrutinised systematically, with
considered as the first-line investigation. careful attention being paid to the locations that are
common sources of bleeding (stomach, duodenum
Radiological investigations and colon). The focus of acute GI bleeding is located
Radiological investigations that play a part in the by identifying high attenuation material (>90 Hu)
management of GI bleeding include CTA, catheter within the bowel lumen on the arterial phased scan,
angiography and radionucleotide imaging (the latter which represents active extravasation of IV contrast.
Table 2.2 Causes of gastrointestinal bleeding. Table 2.3 Acute gastrointestinal bleeding.

Imaging protocol.
UPPER LOWER
MODALITY PROTOCOL
Mallory–Weiss tear Angiodysplasia
CT Unenhanced. No oral contrast. Scan from
Oesophageal varices Diverticulitis above diaphragm to femoral head level.
Gastric/duodenal ulcer Colitis Aortic angiogram: 100 ml IV contrast via
Gastritis Malignancy 18G cannula, 4 ml/sec. Bolus track centred on
mid-abdominal aorta. No oral contrast. Scan
Malignancy
from above diaphragm to femoral head level.
Delayed phase. IV contrast as above, scan at
120 seconds after start of contrast injection.
No oral contrast. Scan from above diaphragm
to femoral head level.
K22247_C002.indd 29 16/05/15 3:07 AM

30 Chapter 2
This is usually more apparent and accumulates on serpiginous enhancing vessels in the region of the distal
the delayed phase (Figures 2.7, 2.8). It is vital to oesophagus. Findings suggestive of liver cirrhosis
scrutinise the unenhanced phase to assess for pre- and portal hypertension, such as an irregular liver
existing foci of high attenuation within the bowel outline and splenic enlargement, should prompt
lumen that may lead to false positives; these can the search for oesophageal varices ( Table 2.4;
include ingested tablets, foreign bodies and suture Figures 2.9, 2.10).
material. Previous imaging should also be reviewed in If GI bleeding is identified, it is important to consider
this regard. Cone beam artefact is another common an underlying cause. Mural thickening can be malignant,
false positive, occurring at interfaces between fluid and inflammatory, ischaemic or infective in nature, all of
air within the bowel. which can be complicated by bleeding. It is also important
Bleeding in the distal oesophagus may be secondary to appreciate that GI bleeding is often intermittent and
to oesophageal varices, a complication of portal it is not uncommon for CTA to be normal, even in
hypertension. These may be visualised as dilated, haemodynamically compromised patients.
Figure 2.7 Axial image: contrast enhanced CT scan of Figure 2.8 Axial image: contrast enhanced CT scan of
the abdomen in the arterial phase. Hyperdense material the abdomen in the delayed phase. On delayed imaging,
can be seen in a dependent position within the lumen of further contrast has accumulated within the lumen
the ascending colon (arrow), consistent with an acute, of the ascending colon as a result of continued, active
arterial haemorrhage. haemorrhage at this site.
Table 2.4 Computed tomographic signs of

portal hypertension.
• Splenomegaly.
• Ascites.
• Varices: splenic/oesophageal.
• Underlying cause (i.e. liver cirrhosis with atrophy and
nodular/irregular contour).
• Contrast enhancement of para-umbilical vein.
K22247_C002.indd 30 16/05/15 3:07 AM

(a) ( b)
Figure 2.9a, b Axial and coronal images: unenhanced

CT scans of the abdomen. A transjugular intrahepatic
(a)
portosystemic shunt (arrow) and coiled oesophageal
varices are shown.
Figures 2.10a–c Axial images: unenhanced, arterial

and delayed phase CT scans of the abdomen. This
sequence of images demonstrates a contrast blush
on the arterial phase within the stomach (arrow). No
corresponding density is seen on the unenhanced scan.
Findings are in keeping with acute gastric bleeding.
The spleen is enlarged, s uggestive of underlying portal
hypertension.
( b)
(c)
K22247_C002.indd 31 16/05/15 3:07 AM

32 Chapter 2
Key points BOWEL PERFORATION

• CTA and catheter angiography are useful in
conjunction with oesophagogastroduodenoscopy GI perforation is an emergency condition requiring
and colonoscopy in the investigation of acute GI urgent surgical intervention. Clinical diagnosis of the
bleeding, although the sensitivity is reduced when site of bowel perforation is difficult as the symptoms
bleeding is intermittent. may be non-specific. Diagnosis depends mostly on
• Triple-phase CTA increases the sensitivity imaging investigations, and a correct diagnosis of the
of detection of acute bleeding and should be presence of, site and cause is crucial for appropriate
performed without oral contrast. management and for planning surgery.
• Active bleeding appears as a high attenuation focus Breach of the GI tract wall can be due to peptic
within the bowel lumen on the arterial phase, ulcer disease, inflammatory disease, blunt or
which becomes more pronounced on the portal penetrating trauma, iatrogenic factors, a foreign body
venous phase. Scrutiny of the unenhanced images or a neoplasm. Clinical presentation is usually that of
reduces false positives. abdominal pain and nausea and vomiting, with signs of
peritonitis including rebound tenderness and guarding
Report checklist on palpation. Patients can be extremely unwell with
• Identify the bleeding vessel where possible, and signs and symptoms of shock. Inflammatory markers
the large artery of which it is a branch. (C-reactive protein) and raised white cells may be
• Consider underlying causes. present on laboratory blood analysis.
• Look for signs of significant intravascular volume
loss (e.g. flattening of the IVC). Radiological investigations
• Emphasise that bleeding can be intermittent and The first-line imaging investigations for suspected
therefore a ‘normal’ scan does not exclude GI bowel perforation are plain films, including an erect
bleeding. CXR and a plain abdominal film, but these are only
• Recommend urgent interventional radiology sensitive in 50–70% of cases. Contrast studies are
referral. no longer indicated in the acute setting. As well as
having a suboptimal sensitivity, plain films will not
References demonstrate the site of perforation, which is useful
Ernst AA, Haynes ML, Nick TG et al. (1999) to know prior to surgery. CT is the imaging modality
Usefulness of the blood urea nitrogen/creatinine of choice, as it provides the most information
ratio in gastrointestinal bleeding. Am J Emerg for planning surgery, with a sensitivity of 86% in
Med 17:70–72. identifying the site of perforation. The goal of imaging
Walsh RM, Anain P, Geisinger M et al. (1993) Role is to identify extraluminal leakage and the subsequent
of angiography and embolization of massive inflammatory reaction around the perforation site.
gastroduodenal haemorrhage. J Gastrointest (See Table 2.5.)
Surg 3:61–65.
Table 2.5 Bowel perforation. Imaging protocol.
MODALITY PROTOCOL
Plain film imaging AP supine abdominal radiograph to include the liver. A left lateral decubitus film can be performed with
the patient lying on their left and the right side up.
Erect chest radiograph to include the diaphragms. Patient should be upright for at least 10 minutes
prior to image acquisition.
CT Post IV contrast, portal venous phase: 100 ml IV contrast, 4 ml/sec via 18G cannula. Scan at 70 seconds.
Scan from above diaphragm to femoral head level.
K22247_C002.indd 32 16/05/15 3:07 AM

Radiological findings
Plain films
The presence of free air under the diaphragm
on an erect chest plain film is diagnostic of free
intraperitoneal air (Figure 2.11). As little as 1 ml of air
can be identified under the diaphragm. Care should be
taken not to confuse the stomach bubble under the left
hemidiaphragm with free air.
A plain abdominal film can reveal a bowel perforation,
with the presence of Rigler’s sign (gas outlining both
sides of the bowel wall) (Figure 2.12). Other abdominal
plain film signs of free air include football sign (oval-
shaped peritoneal gas), which is more common in
children (Figure 2.13), increased lucency over the right
upper quadrant (gas accumulating anterior to the liver)
or the triangle sign (gas accumulating between three
loops of bowel). Free gas can also be seen outlining
ligaments in the abdomen, such as the falciform
ligament (Figure 2.14). A left lateral decubitus film can Figure 2.11 AP semi-erect chest radiograph. Large
also be used in the detection of small amounts of free volumes of gas can be seen underneath the diaphragm
air that may be interposed between the free edge of the consistent with pneumoperitoneum.
liver and the lateral wall of the peritoneal cavity.
Figure 2.12 AP supine abdominal radiograph. Gas Figure 2.13 AP supine abdominal radiograph.
can be seen within the peritoneum on both sides of the A large, rounded lucency is seen projected in the
bowel wall (Riggler’s sign), highlighting multiple loops mid-abdomen representing free intra-abdominal gas in a
of dilated small bowel. non-dependent location. The falciform ligament is also
seen outlined clearly by free gas (arrow).
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34 Chapter 2
Computed tomography
The first aim of the radiologist when interpreting an
abdominal CT should be to identify the extraluminal
air. Free air can be seen as small locules around the liver
edge or within the peritoneum or as large collections of
air that are difficult to identify as separate from bowel.
Often, using a wide window (such as lung window
settings) can help identify free air and distinguish
between intra- and extraluminal gas.
The next consideration is the location and
distribution of air. The peritoneal cavity is divided
into supra- and inframesocolic compartments by the
transverse colon, and this distinction can be useful
in radiological differentiation of upper and lower GI
perforations. Subsequently, upper GI tract perforation
(stomach or duodenal bulb) results in supramesocolic
compartment gas and distal small and large bowel
perforation in the inframesocolic compartments.
Sections of the GI tract, such as stomach, first part of Figure 2.14 Axial image: IV contrast enhanced
duodenum (5 cm), jejunum, ileum, caecum, appendix, CT scan of the abdomen in the portal venous phase.
transverse colon, sigmoid colon and upper third rectum, Free intra-abdominal gas is seen anteriorly. A large
are found within the peritoneal cavity; perforation of defect is seen along the anterior wall of the stomach
these sections results in intraperitoneal free air. The as a result of peptic ulcer disease, causing perforation
second and third parts of the duodenum, ascending (arrow).
and descending colon and middle third of rectum are
retroperitoneal and fixed; they may therefore present
with gas within the retroperitoneal compartment. Small bowel perforation
Small bowel perforation is rare; small amounts of free
Gastroduodenal perforation air along the anterior peritoneal surfaces of the liver
Peptic ulcer disease is a major cause of gastroduodenal and mid-abdomen and among the peritoneal folds
perforation, followed by necrotic or ulcerated are usually indicative. Non-specific CT findings,
malignancies and iatrogenic and traumatic causes. such as mural thickening and abnormal enhancement
Gastroduodenal perforation secondary to peptic ulcers of the small bowel, mesenteric fluid and mesenteric
is usually found in the gastric antrum and duodenal stranding, should be considered suspicious in patients
bulb. The descending and horizontal segments of the with suspected small bowel perforation.
duodenum are common sites of perforation caused by
blunt trauma because of their fixed attachment and/or Large bowel perforation
compression against the vertebral column. Perforation sites in colonic loops can frequently be
Perforation sites can be demonstrated by the correlated with their causes. Malignant neoplasm,
CT findings of ulceration or focal defect in the diverticulitis (Figure 2.15), blunt trauma and ischaemia
gastroduodenal wall (Figure 2.14), free air bubbles in are common causes of perforation on the left-sided
contact with the stomach or duodenum, abrupt wall colon. Inflammatory bowel disease and penetrating
thickening associated with adjacent inflammatory trauma tend to be seen in the right-sided colon. The
fat stranding and localised free fluid between the caecum is especially prone to perforate in patients with
duodenum and the pancreatic head. mechanical colonic obstruction.
K22247_C002.indd 34 16/05/15 3:07 AM

oesophageal/tracheal bronchial injury, intra-abdominal

drains and hysteroscopy can explain free intraperitoneal
or retroperitoneal air in the absence of a GI tract
perforation. The amount of air in the postoperative
period is variable, but should be less than 10 ml in the
majority of cases and negligible after day 10. Large
volumes of free air in the postoperative period should
be considered suspicious for anastomotic leaks.
When detected, bowel perforation on any imaging
modality should be immediately communicated to the
surgical team for consideration of surgery, and a record
of this should be made at the end of the report.
Key points
• Plain films (erect CXR and AXR) are useful for
suspected bowel perforation and they can detect
free intra-abdominal air.
• The main aim of CT imaging is to identify free air
Figure 2.15 Axial image: IV contrast enhanced and associated inflammatory stranding in order to
CT scan of the pelvis in the portal venous phase. locate the site of perforation. The distribution of
Locules of extraluminal gas are seen adjacent to the air can help to achieve this.
sigmoid colon at the site of diverticular perforation, in • Be aware that free air within the peritoneal
addition to a contained abscess at this site. cavity may be from sources other than bowel
(e.g. iatrogenic). A review of the clinical history is
imperative.
When perforation occurs owing to diverticulitis or • Bowel perforation is an urgent finding that may
colorectal malignancy without bowel obstruction, the necessitate surgical intervention. Findings should
quantity of free air is usually small and locules of air tend be communicated promptly and directly to the
to be concentrated in close proximity to the involved clinical team.
colonic loops. The presence of free air, phlegmon
and/or an abscess, an extraluminal collection and the Report checklist
underlying colonic abnormality (neoplasm) should be • In the presence of free gas, identify the potential
carefully evaluated on CT scans. perforated site.
A review of the clinical history is important when • Presence or absence of underlying causes such
reviewing CT for suspected bowel perforation. as diverticulitis, bowel malignancy and bowel
A history of recent surgery (laparoscopic or open), ischaemia.
K22247_C002.indd 35 16/05/15 3:07 AM

36 Chapter 2
BOWEL ISCHAEMIA AND Inflammatory bowel disease is subdivided into

ENTEROCOLITIS Crohn’s disease, ulcerative colitis and indeterminate
inflammatory colitis (which demonstrates features of
Acute, occlusive bowel ischaemia carries a high both Crohn’s disease and ulcerative colitis). Crohn’s
morbidity and mortality rate and is a surgical disease and ulcerative colitis classically differ in the
emergency. This condition must be separated from distribution and extent of inflammation. Ulcerative
chronic, non-occlusive ischaemia, which carries a colitis causes inflammation limited to the mucosa,
much lower mortality rate and occurs secondary to initially involves the rectum and can extend proximally
incomplete vessel occlusion. Ischaemia can be both to involve the entire colon. Inflammation is continuous
arterial and venous in nature. Arterial causes include and small bowel involvement is not typical, although
atherosclerosis, emboli, vasculitis and low-flow states involvement of the ileum can be seen with associated
(i.e. the causes of hypotension). Typically, the location backwash ileitis. In contradistinction, Crohn’s disease
of arterial ischaemia is dictated by the vascular anatomy causes transmural inflammation, can involve any
of the bowel. The SMA supplies the small bowel, the aspect of the GI tract and commonly demonstrates
ascending colon and the proximal transverse colon. skip lesions. Whilst a more common cause of colitis
The IMA supplies the distal transverse colon, the in younger demographics than ischaemic colitis,
descending colon and the sigmoid and proximal rectum inflammatory bowel disease has a bimodal distribution
(splenic flexure to rectum). The splenic flexure and of onset and, as such, increasing age should not dissuade
rectosigmoid junction are termed ‘watershed areas’ and from the diagnosis.
are particularly susceptible to ischaemia caused by low- Infective colitis can arise secondary to many different
flow states. causative organisms and can occur in any demographic.
Bowel ischaemia typically affects the middle aged to Of particular importance in the hospital environment
elderly population because of increasing atherosclerotic is pseudomembranous colitis, which is caused by an
burden. Acute bowel ischaemia classically presents with overgrowth of Clostridium difficile, which usually
abdominal pain that is disproportionate to the clinical develops secondary to antibiotic administration.
findings, although this is not a reliable enough sign to Neutropaenic colitis (typhilitis) can be
differentiate it from other intra-abdominal pathologies. another iatrogenic form of colitis, occurring in
Lactate elevation is a sensitive but non-specific marker immunosuppressed patients, commonly secondary to
for ongoing acute bowel ischaemia and can also be chemotherapy.
helpful. A history of abdominal angina, atrial fibrillation
and atherosclerotic disease should always prompt Radiological investigations
suspicion of acute bowel ischaemia and urgent diagnosis CT is the imaging modality of choice in the
is vital to facilitate surgical resection/revascularisation. investigation of bowel ischaemia, although there are
Depending on the degree of clinical suspicion, patients conflicting reports of its sensitivity and specificity.
may proceed to diagnostic laparotomy without The addition of an arterial phase to the standard portal
radiological input, although increasingly imaging is venous phase of the abdomen and pelvis has been
being utilised prior to definitive treatment. shown to increase specificity. Oral contrast should
The diagnosis of acute bowel ischaemia is a not be administered since it can make appreciation of
challenging one for the on-call radiologist. There is a bowel wall enhancement more difficult. It is important
significant overlap in the findings seen in both acute to note that a ‘normal’ CT study cannot definitively
bowel ischaemia and other inflammatory and infective exclude bowel ischaemia, and it can often be difficult to
aetiologies of enterocolitis. While urgent imaging is reliably differentiate bowel ischaemia from other forms
often not required in the emergency setting to diagnose of colitis.
inflammatory and infective causes (the diagnosis of Abdominal plain film imaging is often performed
these is made with endoscopy and microbiological initially and can be helpful; however, this has a
analysis, respectively), they are discussed subsequently low sensitivity and specificity, cannot differentiate
due to the imaging overlap. between the causes of colitis and rarely negates the
K22247_C002.indd 36 16/05/15 3:07 AM

need for further imaging. Chest plain films can also absent or diminished bowel wall enhancement on
be performed in order to identify free gas, evidence of arterial and portal venous phased imaging (Figure 2.16).
associated perforation. (See Table 2.6.) Although this is not seen in other causes of colitis, it
is not always present in cases of ischaemia. Bowel wall
Radiological findings hyperenhancement can also be seen (in hyperacute
Computed tomography iscahemia), although it is non-specific and can be seen
Bowel wall abnormality is the hallmark of enterocolitis in any cause of enterocolitis (Sung et al., 2000). Normal
on CT. The most specific sign of bowel ischaemia is bowel wall should be 3–6 mm in thickness. Bowel wall
thickening and thinning can occur, although the former
is non-specific and can also be seen in both ischaemic
Table 2.6 Bowel ischaemia and enterocolitis. and non-ischaemic causes (Figure 2.17). It should
Imaging protocol.
be noted that bowel wall thickening can also occur
secondary to primary bowel malignancy, although this
MODALITY PROTOCOL
is typically less diffuse and involves only a short segment
CT Aortic angiogram: 100 ml IV contrast via 18G
cannula, 4 ml/sec. Bolus track centred on mid
of bowel. When assessing for bowel wall thickening, the
abdominal aorta. No oral contrast. Scan from degree of luminal distension must always be taken into
just above diaphragm to femoral head level. account. Bowel collapse can often be misinterpreted as
Portal venous phase: IV contrast as above, scan wall thickening and is a common false positive.
at 70 seconds. No oral contrast. Scan from just The superior and inferior mesenteric arteries and
above diaphragm to femoral head level. corresponding veins should be inspected on the arterial
and portal venous phase in order to identify filling

CT scan of the abdomen in the portal venous phase.
Figure 2.16 Axial image: IV contrast enhanced CT There is subtle bowel wall thickening in the transverse
scan of the abdomen and pelvis in the portal venous colon (arrow).
phase. Non-enhancing loops of bowel are seen in the
pelvis adjacent to loops of normally enhancing bowel,
representing loops of ischaemic bowel.
K22247_C002.indd 37 16/05/15 3:07 AM

38 Chapter 2
defects, which may represent thrombus (Figures 2.18, venous engorgement (Figure 2.23), mesenteric fat
2.19). Multiplanar reformatting on wider window stranding, bowel dilatation and ascites, can also be
settings and maximum intensity projections (MIPs) seen, regardless of the cause of the colitis.
can be helpful in this regard. In the context of embolic There is significant overlap between the imaging
disease, splenic or hepatic infarcts may also be seen, findings seen in ischaemia and other causes of colitis,
typically appearing as a peripheral, wedge-shaped although there can be some discriminating factors. The
focus of low attenuation (Figure 2.20). Utilisation of distribution of bowel affected is one of the most useful
lung and bone window settings (window 600, level factors to distinguish between different causes. If bowel
1,600 and window 300, level 2,000, respectively) can wall abnormality corresponds to a segmental arterial
aid in the identification of pneumatosis and portal territory (most commonly the descending colon), then
venous gas, both more specific signs of ischaemia ischaemia must always be considered. Conversely,
when seen in the presence of bowel wall abnormality bowel abnormality involving multiple arterial
(Figures 2.21, 2.22). It should be noted that portal territories is more likely to be due to an inflammatory
venous gas and pneumobilia both present as linear, low or infective cause. Involvement of the terminal ileum
attenuation branching structures within the liver. Gas is highly typical of Crohn’s disease, although this can
within the portal venous system often extends to the also be seen in infective causes. Bowel involvement in
liver periphery, whereas gas within the biliary system ulcerative colitis typically starts at the rectum, extends
does not. Additional findings, such as mesenteric proximally and spares the small bowel (allowing for
Figure 2.18 Axial image: IV contrast enhanced Figure 2.19 Axial image: IV contrast enhanced CT
CT scan of the abdomen in the portal venous phase. scan of the abdomen in the portal venous phase. There
There is a filling defect identified within the SMA is a large filling defect within the aorta extending into
(arrow), with colitic changes affecting the caecum. the SMA (arrow). Free gas is seen anterior to the liver.
Ischaemic, perforated small bowel is seen more caudally
on the scan.
K22247_C002.indd 38 16/05/15 3:07 AM

CT scan of the abdomen in the portal venous phase. CT scan of the abdomen in the portal venous phase.
There is a wedge-shaped low attenuation within the Multiple locules of gas can be seen within the wall of the
spleen in keeping with an infarct. bowel, secondary to bowel ischaemia.
Figure 2.22 Axial images: IV contrast enhanced Figure 2.23 Axial image: IV contrast enhanced
Large volumes of portal venous gas are seen within the The mesenteric vessels are engorged and the mesenteric
liver extending to the periphery. fat has a hazy appearance.
K22247_C002.indd 39 16/05/15 3:07 AM

40 Chapter 2
backwash ileitis). Infective enterocolitis can affect any

part of the bowel (Table 2.7). Pseudomembranous
colitis commonly affects the descending and transverse
colon and typically causes much more pronounced wall
thickening (10–15 mm) than other causes (Figure 2.24).
Neutropaenic enterocolitis typically involves the
terminal ileum, caecum and ascending colon, although
a history of chemotherapy and neutropaenia is the most
helpful tool to make this diagnosis.
Utilisation of lung and bone window settings is also
useful to identify free intra-abdominal gas, suggestive
of associated bowel perforation. Toxic megacolon
is a complication of most colitides and is a risk factor
for imminent perforation. This is diagnosed when
there is colonic dilatation (transverse colon >6 cm) Figure 2.24 Axial image: IV contrast enhanced CT
in the presence of associated colonic inflammation. scan of the abdomen in the portal venous phase.
Any suspicion of toxic megacolon should be urgently There is marked bowel wall thickening involving
discussed with the referring team. the d
escending colon (arrow), typically seen in
pseudomembranous colitis.
Plain films
The hallmark of enterocolitis on plain radiographs is
bowel wall thickening, although again this is a difficult
diagnosis to make due to variable bowel collapse
( Figure 2.25 ). A ‘thumbprinting’ pattern can be
observed in the colon, representing thickened haustral
folds, although this has a wide differential.
Table 2.7 Typical distribution of infective

colitides.
CAUSATIVE ORGANISM DISTRIBUTION

Clostridium difficile Descending and transverse
(pseudomembranous colitis) colon.
Salmonella spp. Colonic inflammation only.
Campylobacter spp. Typically in distal colon.
Yersinia spp. Typically terminal ileum and
caecum.
Mycobacterium spp. Typically terminal ileum and
caecum.
Entamoeba histolytica Diffuse colonic involvement, Figure 2.25 Supine abdominal radiograph. There is
typically ascending colon. thickening of the bowel wall involving the descending
Shigella spp. Typically rectosigmoid colon. colon (arrow), consistent with colitis. No intraperitoneal
free gas is seen.
K22247_C002.indd 40 16/05/15 3:07 AM

Key points LARGE BOWEL OBSTRUCTION

• Enterocolitis may be ischaemic, inflammatory or
infective in nature. Large bowel obstruction (LBO) is a common surgical
• Acute bowel ischaemia is a surgical emergency emergency that can occur as a result of many varying
and has a high mortality rate. Prompt diagnosis pathologies.
is essential in order to facilitate urgent surgical One of the commonest causes of LBO in western
treatment. countries is malignancy, usually as a result of primary
• CT is the modality of choice to investigate cases large bowel carcinoma (Khurana et al., 2002). Invasive
of bowel ischaemia; however, imaging should not malignancies may infiltrate the mucosa, eventually
delay emergency laparotomy in strongly suspected occluding the lumen and resulting in obstruction.
cases. Chronic diverticulitis and radiotherapy to the pelvis
• There is significant overlap in the radiological may lead to fibrosis and stricturing of the bowel.
findings of enterocolitis; however, absent Large bowel volvulus is another common cause of
or diminished bowel wall enhancement obstruction; this occurs when there is twisting of the
corresponding to an arterial territory is highly mesentery resulting in a closed loop obstruction. This
suggestive of ischaemia. leads to bowel obstruction; however, the closed loop of
bowel is also at risk of ischaemia.
Report checklist Causes of LBO include:
• Presence or absence of free gas, indicative of • Colonic malignancy.
perforation. • Inflammatory strictures: Crohn’s, ischaemia,
• Presence or absence of gas within the bowel wall diverticulitis.
or the portal venous system. • Volvulus.
• Presence or absence of filling defects in the • Infective processes: TB, amoebiasis.
coeliac axis/SMA/IMA/SMV or any of their • Extrinsic lesions: abscess, bladder/prostate/uterine
branches. tumour, endometriosis.
• Consider embolic disease in cases of visceral
infarcts. The presence or absence of potential Clinically, patients may present with abdominal pain,
embolic sources (e.g. thrombus in the left atrial distension and vomiting. They may also report an
appendage/left ventricular aneurysm/infarct/aortic inability to pass stool or flatus. If complicated by
dissection/aortic aneurysm). perforation, patients may demonstrate peritonism and
• Consider a differential diagnosis of additional haemodynamic instability (see Bowel perforation).
causes of enterocolitis. Urgent imaging is often necessary to help plan
surgery. The management of LBO varies depending on
Reference the underlying aetiology. Most cases typically require
Sung ER, Hyun KH, Soo-Hyun L et al. (2000) surgical resection for relief of symptoms, although
CT and MR imaging findings of bowel ischemia lesions that cannot be completely resected may instead
from various primary causes. RadioGraphics undergo bowel defunctioning and creation of a stoma.
20:29–42. In palliative cases, colonic stents may be inserted in
K22247_C002.indd 41 16/05/15 3:07 AM

42 Chapter 2
order to relieve symptoms. Sigmoid volvulus is initially Radiological findings

managed conservatively with a rectal flatus tube Plain films
insertion, but persisting volvuli may require surgical On an abdominal plain film, the diagnosis of LBO is
decompression. made by identifying dilated large bowel loops. In a
normal patient, the caecum should not measure more
Radiological investigations than 8–9 cm and the remainder of the large bowel
An abdominal and erect chest plain film is indicated should not measure more than 5 cm, therefore a
in patients who present with signs of LBO. An bowel diameter greater than these values may suggest
abdominal plain film may confirm the presence of underlying LBO (Figure 2.26). The distribution of
obstruction; however, the underlying cause is unlikely bowel dilatation is key; in LBO, large bowel collapse
to be apparent. Definitive diagnosis is routinely made distal to the point of obstruction would be expected.
with contrast enhanced CT imaging. It is not usually Dilated loops of small bowel may also be present,
necessary to administer oral contrast, as the level of indicating ileocaecal valve incompetence. In cases
obstruction is usually identifiable as an abrupt calibre where a nasogastric (NG) tube has been placed, the tip
change or mass. Furthermore, patients who are acutely should be located under the left hemidiaphragm.
obstructed are unlikely to be able to ingest the volume
of oral contrast required to adequately opacify the
bowel. It is important to note that large bowel volvulae
normally have a typical appearance on plain films and,
as a result, CT imaging is not routinely required to
make this diagnosis.
The use of water soluble single contrast enema has
largely been replaced with CT, though some centres
may still practise this. Contrast administered rectally
flows proximally through the large bowel and does not
pass beyond the point of obstruction. If the procedure
is performed, water soluble contrast should be used due
to the risk of bowel perforation and hence leakage into
the peritoneum. (See Table 2.8.)
Table 2.8 Large bowel obstruction. Imaging

protocol.
MODALITY PROTOCOL
CT IV contrast, portal venous phase: 100 ml
IV contrast, 4 ml/sec via 18G cannula. Scan
at 70 seconds. Scan from just above the
diaphragm to just below the pubic symphysis. Figure 2.26 AP radiograph of the abdomen. Dilated
Plain film Erect CXR to include the diaphragm. loops of large bowel are seen in the right abdomen,
imaging Abdominal plain film imaging to include the indicated by the lack of valvulae conniventes. The
liver to the pubic symphysis. ileocaecal valve is patent, resulting in reflux of gas into
small bowel loops seen centrally and in the left abdomen.
K22247_C002.indd 42 16/05/15 3:07 AM

LBO secondary to malignancy or stricture Computed tomography

formation may have similar radiological findings; IV contrast enhanced CT is used not only to diagnose
however, volvulae tend to have a slightly different the presence of LBO, but also the underlying cause,
appearance, which can often allow them to be allowing evaluation of luminal and extraluminal bowel
diagnosed on plain film images. Sigmoid volvulus is structures. Initial review of the CT should begin by
the commonest type of volvulus, and occurs when the confirming the presence of LBO, indicated by large
colon twists about its mesentery. It tends to occur in bowel dilatation proximal to an abrupt transition
slightly older patients compared with those who have point. The same numerical values should be used as
a caecal volvulus. The classic findings include the for plain film imaging (see above). Dilated large bowel
presence of a ‘coffee bean’ appearance to the dilated loops should be traced distally in order to identify a
loop, an inverted ‘U’ shape and the loop extending into mechanical cause of the obstruction. This can usually
the upper abdomen from the pelvis (Figure 2.27). The be seen as a transition in the calibre of the bowel from
sigmoid colon is also usually ahaustral in comparison dilated to normal, or often collapsed beyond the point
with caecal volvulus, which normally retains its normal of obstruction. A quick review on lung window settings
haustral pattern. The other main feature of caecal (width 1,500, level 500) is helpful to reveal any evidence
volvulus is extension of the dilated loop of bowel from of free intra-abdominal gas, suggestive of bowel
the right lower quadrant to the left upper quadrant. perforation. If this is seen, the surgical team should
The differences between sigmoid and caecal volvulae be informed as a matter of urgency as the patient may
are summarised in Table 2.9. require emergency surgery.
Table 2.9 Sigmoid vs. caecal volvulus.
SIGMOID CAECAL
Typical Coffee bean sign. Dilated caecum may be
plain film Large bowel dilatation seen in the mid abdo-
findings proximally. men or LUQ.
Ahaustral closed loop. Haustrations usually
present.
Inferior convergence in
the LIF. Associated small
bowel dilatation.
Left flank overlap sign.
LIF = left iliac fossa; LUQ = left upper quadrant.
Figure 2.27 AP radiograph of the abdomen. There are

dilated loops of large bowel, which arise from the pelvis
with an inverted ‘U’ appearance suggestive of sigmoid
volvulus.
K22247_C002.indd 43 16/05/15 3:07 AM

44 Chapter 2
In cases of malignant obstruction, a soft tissue mass Large bowel volvulus has a distinctive appearance
can often be seen occluding the lumen (Figure 2.28). on CT imaging. Proximal loops of dilated large bowel
Subtle tumours can be easy to miss, manifesting as are visible, as seen with other causes of obstruction;
concentric or eccentric mural thickening. Advanced however, the transition point is seen as a tapering of the
tumours may also demonstrate extension through bowel lumen to a point of completely collapsed bowel.
the serosa, adjacent lymphadenopathy or distant It is vitally important to scrutinise the extraluminal
metastases (usually to the liver, appearing as ill-defined appearance in these cases. The underlying cause of
flow attenuation lesions). Obstruction secondary to volvulus (both caecal and sigmoid) is a twisting of the
stricture formation may be seen as a narrowed segment mesentery. On CT, this can be seen as a ‘swirling’ of
of bowel at the point of calibre transition (Figure 2.29). vessels that appear to rotate about the axis of torsion
This can be a difficult diagnosis to make on a single (Figure 2.30) at the site of the involved loop of bowel.
study since physiologically collapsed bowel can have a The axis of twisting may not be easily seen on axial
similar appearance; correlation with previous imaging imaging, and coronal and sagittal reformats should
is useful in this regard. In general, malignancies tend to therefore be used to confirm the diagnosis.
be shorter segment areas of mural thickening, whereas In cases where there is large bowel dilatation without
strictures tend to be longer segments of collapsed a mechanical cause of obstruction, colonic pseudo-
bowel; however, it can often be difficult to exclude the obstruction may be present. Pseudo-obstruction
presence of a small malignant obstructing lesion within is diagnosed when there are symptoms of bowel
a stricture (particularly in the absence of adequate obstruction and there is large bowel dilatation on
bowel preparation). Colonoscopy is therefore often imaging, but no identifiable mechanical obstruction.
needed and should be recommended in order to assess Often there is a gradual tapering of the bowel rather
the abnormal segments of bowel in further detail. than an immediate point of transition. Alternatively,
Figure 2.28 Axial image: IV contrast enhanced CT Figure 2.29 Axial image: IV contrast enhanced CT
scan of the abdomen and pelvis in the portal venous scan of the abdomen in the portal venous phase. There
phase. A solid mass lesion is seen within the mid- is a long stricture of the mid-sigmoid colon with a
sigmoid colon (arrow), occluding the lumen and massively dilated loop of proximal sigmoid colon shown.
resulting in upstream dilatation of the bowel. A single diverticulum is shown in this image. The
stricture was due to chronic diverticulitis.
K22247_C002.indd 44 16/05/15 3:07 AM

Figure 2.30 Coronal image: IV contrast enhanced CT scan of the abdomen and pelvis in the portal venous phase.
A loop of sigmoid colon can be seen in the midline, which comes to an abrupt stop (arrow). The adjacent vessels
demonstrate a swirling appearance, s uggestive of twisting of the mesentery.
multiple segments of colonic dilatation and collapse Report checklist

are seen, the distribution of which is not suggestive • Degree and level of bowel obstruction.
of mechanical obstruction. Patients with pseudo- • Presence or absence of complications such as
obstruction tend to suffer with constipation, with a perforation or bowel ischaemia.
suggested underlying cause thought to be related to the • Consider underlying causes such as malignancy or
intrinsic nerve supply of the bowel (Choi et al., 2008). post-inflammatory strictures.
• Document the degree of local or distant disease
Key points in cases of malignancy; this determines whether
• Large bowel obstruction is a surgical emergency the patient has palliative as opposed to curative
which, if left untreated, may result in bowel surgical treatment.
perforation or ischaemia.
• CT imaging can confirm the diagnosis and References
identify the underlying cause, although the Choi JS, Lim JS, Kim H et al. (2008) Colonic
presence of LBO may be confirmed on plain film pseudoobstruction: CT findings. Am J Roentgenol
images. 190:1521–1526.
• LBO is suggested on CT imaging by Khurana B, Ledbetter S, McTavish J et al. (2002) Bowel
large bowel dilatation (caecum >8–9 cm, obstruction revealed by multidetector CT. Am J
remainder of large bowel >5 cm) proximal to Roentgenol 178:1139–1144.
a focal transition point, usually with large bowel
collapse distally.
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46 Chapter 2
GALLSTONE ILEUS Table 2.10 Galltone ileus. Imaging protocol.
Gallstone ileus is an uncommon cause of mechanical MODALITY PROTOCOL

small bowel obstruction (SBO). It is a complication of CT IV contrast, portal venous phase:
chronic cholecystitis and occurs when a gallstone passes 100 ml IV contrast, 4 ml/sec via 18G
through a cholecystenteric fistula located between the cannula. Scan at 70 seconds. Scan
gallbladder and the duodenum. The gallstone impacts from just above the diaphragm to just
below the pubic symphysis.
within the small bowel, resulting in SBO.
Plain film imaging Abdominal plain film imaging
Overall, gallstone ileus is an uncommon cause
to include the liver to the pubic
of SBO (4%), but in the elderly population it is symphysis.
more common, accounting for up to 25% of non-
Ultrasound 1–5MHz curvilinear probe.
strangulated bowel obstructions and resulting in
significant morbidity in this group (Lassandro et al.,
2005).
Pathologically, gallstone ileus results from repeated
bouts of cholecystitis resulting in adhesions between the
gallbladder and the small bowel (usually duodenum),
eventually leading to fistula formation and passage of
gallstones into the lumen of the bowel.
Patients usually present with a long history of
recurrent right upper quadrant pain, in keeping with
chronic cholecystitis. The acute presentation of
gallstone ileus is that of a small bowel obstruction, with
colicky abdominal pain and abdominal distension.
A plain abdominal radiograph is useful as a first-line
investigation in patients with suspected SBO. Suspicion
of gallstone ileus on plain film imaging necessitates
CT imaging of the abdomen, which has a sensitivity,
specificity and accuracy of diagnosing gallstone ileus
of 93%, 100% and 99%, respectively (Yu et al., 2005).
Ultrasound is useful in assessment of patients with
right upper quadrant pain to identify the presence of
gallstones or cholecystitis. (See Table 2.10.)
Plain films
The classic findings on an abdominal radiograph are of
SBO (dilated loops of small bowel >2.5 cm), gas within Figure 2.31 AP abdominal radiograph. Multiple loops
the biliary tree (linear branching lucencies projected of dilated small bowel can be seen, consistent with
over the right upper quadrant) and a gallstone (usually SBO. Linear, branching lucencies can be seen at the
in the right iliac fossa) (Figure 2.31). This is known as right upper quadrant consistent with biliary gas (arrow).
Rigler’s triad. The findings are consistent with gallstone ileus. No
radiopaque gallstone can be seen on the radiograph.
K22247_C002.indd 46 16/05/15 3:07 AM

Computed tomography Table 2.11 Causes of p

neumobilia.
Appearances on CT are similar to those seen on plain
film images. SBO is present with dilated fluid-filled • Recent endoscopic retrograde cholangiopancreatography
small bowel loops measuring >3.5 cm. As with any or percutaneous transhepatic cholangiography.
case of obstruction, the entire length of bowel must • Gallstone ileus.
be traced. A transition point (abrupt calibre change • Biliary enteric anastomosis (e.g. Whipple’s).
between dilated and non-dilated bowel) may be • Peptic ulcer disease.
identified and is the likely site of the impacted gallstone • Traumatic.
(Figure 2.32). Care should be taken, as not all gallstones • Emphysematous cholecystitis.
are calcified (12%) and they may be of similar density • Incompetent sphincter of Oddi (sphicterotomy, chronic
to the bowel contents (Lassandro et al., 2005). Multiple pancreatitis and passage of stone).
stones may also be present. • Congenital.
Pneumobilia on CT is identified as branching air-
filled structures in the liver (Figure 2.33). These can
be differentiated from similar appearances of portal
venous gas, as air in the biliary tree does not extend
to the periphery of the liver, unlike portal venous gas.
Causes of pneumobilia are listed in Table 2.11.
scan of the abdomen and pelvis in the portal venous scan of the abdomen in the portal venous phase. Gas
phase. A rounded, hyperdense gallstone is seen within is seen within the biliary tree (arrow). There is a small
the lumen of a small bowel loop in the right iliac fossa. volume of fluid around the liver.
Loops of fluid-filled, dilated small bowel can also
be seen.
K22247_C002.indd 47 16/05/15 3:07 AM

48 Chapter 2
Inflammatory changes may be seen around the • A fistulous tract may be seen between the
gallbladder and second part of the duodenum, with gallbladder and the duodenum and this may be
thickening of the gallbladder wall, pericholecystic fluid associated with surrounding inflammation and
and surrounding inflammatory fat stranding. There locules of free gas.
may also be locules of free gas and evidence of the fistula • It is important to distinguish between portal
between the gallbladder and duodenum. Occasionally, venous gas and biliary air, which appear similar on
the inflamed gallbladder can adhere to ascending CT, the latter not extending to the periphery of
colon and the gallstone can pass into the large bowel. the liver.
This may then lead to passage of the stone or it can
become obstructed, depending on the size of the stone Report checklist
(Figures 2.34, 2.35). • Degree of bowel obstruction/dilatation associated
If gallstone ileus is present, the surgical team with gallstone ileus.
should be informed; treatment options are usually • Presence or absence of associated collections in
surgically based, although some patients are managed the gallbladder bed.
conservatively. • Presence or absence of overt free
intraperitoneal gas.
Key points
• An AXR showing Rigler’s triad is diagnostic for References
gallstone ileus. Lassandro F, Romano S, Ragozzino A et al. (2005)
• CT features are similar to those seen on plain Role of helical CT in diagnosis of gallstone ileus and
film images. The entire bowel should be carefully related conditions. Am J Roentgenol 185:1159–1165.
inspected to identify the transition point or Yu CY, Lin CC, Shyu RY et al. (2005) Value of CT in
gallstone(s). the diagnosis and management of gallstone ileus.
World J Gastroenterol 11:2142–2147.
Figure 2.34 Axial image: unenhanced CT scan of the Figure 2.35 Axial image: unenhanced CT scan of the
abdomen. There is thickening of the gallbladder wall, abdomen. There is an impacted gallstone in the sigmoid
consistent with acute cholecystitis. colon.
K22247_C002.indd 48 16/05/15 3:07 AM

SMALL BOWEL OBSTRUCTION Radiological investigations

An abdominal and erect CXR is indicated in patients
SBO is a common clinical problem, which occurs as a who present with signs of SBO. An abdominal plain
result of mechanical or functional delay in the transit film may confirm the presence of obstruction and/
of small bowel contents. It is a frequent reason for or free intraperitoneal gas. Contrast enhanced CT is
hospitalisation and represents approximately 20% of significantly more effective in the evaluation of SBO and
all surgical admissions (Foster et al., 2006). is considered the most accurate modality for diagnosis.
SBO is caused by a number of pathological entities. (See Table 2.12.) Oral contrast may not be tolerated by
By far the most common is adhesions (60%), followed the patient and is not needed to identify SBO.
by hernias. Other rarer causes include gallstone
ileus and intussusception, which are discussed above Radiological findings
(see Gallstone ileus) and in Chapter 4 (Paediatrics, Plain films
Intussusception). The commonest cause of functional Abdominal plain film imaging can be used to diagnose
SBO is in the postoperative period, termed pseudo- the presence of SBO. The key finding is that of bowel
obstruction or paralytic ileus. dilatation (>3 cm), often containing air fluid levels
Causes of SBO include: (Figure 2.36). Small bowel can be differentiated from
• Adhesions.
• Hernia. Table 2.12 Small bowel obstruction. Imaging
• Gallstone ileus. protocol.
• Crohn’s disease.
• Small bowel or caecal malignancy. MODALITY PROTOCOL
• Intussusception. CT IV contrast, portal venous phase: 100 ml IV
• Malrotation and volvulus. contrast, 4 ml/sec via 18G cannula. Scan
at 70 seconds. Scan from just above the
diaphragm to just below the pubic symphysis.
Clinical symptoms commonly associated with
Plain film Erect CXR to include the diaphragm.
SBO include abdominal pain, nausea, vomiting, imaging Abdominal plain film imaging to include the
fever, tachycardia and constipation or diarrhoea. liver to the pubic symphysis.
Changes in the character of the pain associated with
peritonism or haemodynamic instability may indicate
the development of more serious complications (e.g.
perforated, strangulated or ischaemic bowel).
Imaging may be required at an early stage to confirm
the diagnosis, ascertain the cause and plan for surgery,
especially if there are suspected complications. Some
patients can be managed conservatively, especially in
cases of paralytic ileus. In cases where there is SBO
but no clear cause or transition point is identified, the
cause is likely to be pseudo-obstruction, especially if the
patient is postoperative. Management of this entity is
usually conservative.
Complications of SBO should be assessed for and
communicated to the referring clinician, as these
necessitate urgent surgical management. The main Figure 2.36 AP abdominal radiograph. Multiple loops
complications are perforation (see Bowel perforation) of dilated small bowel are seen in the central and left
and bowel ischaemia (see Bowel ischaemia and abdomen consistent with SBO. The hernia orifices have
enterocolitis). not been included on this image. There is no evidence of
gallstones or biliary gas.
K22247_C002.indd 49 16/05/15 3:07 AM

50 Chapter 2
large bowel on plain film studies because of the presence loops (diameter >3 cm from outer wall to outer wall)
of valvulae conniventes and its central location. (Figure 2.37). Only a portion of the small bowel may be
Signs of perforation of the bowel can be assessed dilated, with collapsed bowel often seen distal to the site
for by looking for free air, either under the diaphragm of obstruction.
on an erect CXR or within the abdomen. The various In cases of proximal SBO, the stomach may also be
signs of perforation were discussed in detail earlier (see distended. If this is the case, a recommendation can be
Bowel perforation). made for the placement of an NG tube, which serves
Other areas to assess on a plain film are the hernial to decompress the stomach and provide symptomatic
orifices. The presence of bowel loops below the relief.
inguinal ligament on a plain film is always abnormal and The next aim should be to trace the entire length of
indicates a hernia. If this is associated with features of small bowel to identify the cause of the obstruction; this
SBO, then the most likely cause is a strangulated hernia. can often be very tricky, especially if there are multiple
The presence of pneumobilia, SBO and a calcified collapsed loops in the pelvis. The use of multiplanar
intraluminal lesion is likely to indicate gallstone ileus as reformats in this situation can be of use. A transition
a cause (see Gallstone ileus). point is determined by identifying a calibre change
between the dilated proximal and the collapsed distal
Computed tomography small bowel loops (Figure 2.38).
CT criteria for SBO are the same as for plain film
imaging, with the presence of dilated small bowel
CT scan of the pelvis in the portal venous phase. There CT scan of the abdomen and pelvis in the portal venous
are multiple loops of dilated, fluid-filled small bowel phase. There are multiple loops of dilated, fluid-filled
consistent with SBO. No cause of obstruction is visible small bowel consistent with SBO. A clear transition
on the selected image. point is seen between the dilated proximal and collapsed
distal bowel loops (arrow). The cause in this case was a
small bowel volvulus.
K22247_C002.indd 50 16/05/15 3:07 AM

Adhesions Crohn’s disease

Adhesions are the commonest cause of SBO in western SBO can result from Crohn’s disease. This is
populations, with most cases occurring as a result of characterised by bowel wall thickening/oedema and
previous abdominal surgery. The diagnosis of SBO surrounding inflammatory fat stranding. Additionally,
due to adhesions is usually one of exclusion, as adhesive it can be a manifestation of chronic disease, which
bands are not seen on conventional CT. An abrupt usually results in stricturing of affected segments.
change in the calibre of the bowel is seen without any Lastly, it may be related to adhesions, incisional
associated mass lesion, significant inflammation or hernias or postoperative strictures in patients who have
bowel wall thickening at the transition point. There undergone previous abdominal surgery.
may often be angulation of the affected loops of bowel
at the site of obstruction. Neoplasia
Primary neoplastic causes of SBO are rare. When small
Hernias bowel adenocarcinoma manifests as SBO, it is usually at
Hernias are considered the second commonest cause of an advanced state and shows pronounced, asymmetric
SBO, responsible for 10% of cases (Silva et al., 2009). and irregular mural thickening at the transition
Hernias are classified according to the anatomical point. Small bowel involvement by metastatic cancer
location of the orifice through which the bowel is more common in the form of peritoneal/serosal
protrudes (Figure 2.39). Distinction should be made deposits. Intraluminal lesions such as neoplasms or
regarding the hernia location, sac size and contents polyps can also form lead points for intussuscepting
and whether there are any complications. Features segments of bowel (see Chapter 4: Paediatric imaging,
such as poor enhancement and bowel wall thickening Intussusception). Colonic malignancies can result
can be suggestive of strangulation or ischaemia in small bowel dilatation if there is an incompetent
(Figure 2.40). ileocaecal valve.
Figure 2.39 Coronal image: IV contrast enhanced Figure 2.40 Axial image: IV contrast enhanced
CT scan of the abdomen and pelvis in the portal venous CT scan of the pelvis in the portal venous phase.
phase. An obstructed right inguinal femoral hernia can There is a loop of incarcerated small bowel within
be seen causing SBO (arrow). a right inguinal hernia (arrow). The bowel wall is
poorly enhancing and there is adjacent fat stranding
and free fluid.
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52 Chapter 2
Radiation enteritis GASTRIC VOLVULUS

Radiation enteritis causes obstruction in the late phase
1 year after radiation therapy, usually to the pelvis. Gastric volvulus is defined as an abnormal rotation of
Radiation enteritis causes SBO primarily by producing the stomach along its mesentery, which can result in a
smooth strictures of the bowel, as well as adhesive and closed loop obstruction. Cases can be divided broadly
fibrotic changes in the mesentery. There may also be into three types: organoaxial, mesenteroaxial and mixed.
abnormal enhancement of the thickened bowel wall Organoaxial is more common, comprising over two
caught in the field of the radiation therapy, in addition thirds of cases (Peterson et al., 2009), and occurs when
to bowel wall thickening. the stomach rotates along its long axis (Figures 2.41a, b).
The greater curvature is displaced superiorly while
Gallstone ileus the lesser curvature moves caudally. This subtype of
See Gallstone ileus. volvulae can be associated with traumatic diaphragmatic
and para-oesophageal hernia. Mesenteroaxial is less
Key points common and occurs when the stomach rotates around
• Abdominal plain film imaging is very useful in its short axis, resulting in displacement of the gastric
detecting the presence of SBO; however, CT antrum to a level above the gastro-oesophageal junction
is required to ascertain the cause and look for (Figures 2.42a, b). All subtypes can be asymptomatic
complications. and chronic, or present acutely with symptoms of
• The criterion for SBO is bowel dilated to >3 cm. pain and obstruction. Symptoms and signs of acutely
The entire small bowel should be traced in order symptomatic cases are described by Borchardt’s triad:
to identify a transition point, which is a clear epigastric pain, intractable retching and inability to
calibre change from dilated to non-dilated bowel. pass an NG tube. The greatest concern in cases of acute
• In cases where a transition point is identified, but obstruction is strangulation of the twisted segment,
no other significant findings are present, the cause which should be especially suspected in the presence of
is likely to be adhesional, especially if there is an elevated serum lactate level. Urgent diagnosis is vital
supporting clinical history of previous surgery. in order to facilitate potential surgical intervention. It is
• Complications of SBO must be communicated important to note that chronic cases are often diagnosed
to the referring clinician urgently as this impacts incidentally on CT and fluoroscopy studies performed
patient management. for other indications, and the diagnosis must always be
correlated with patient symptoms.
Report checklist
• Degree of small bowel dilatation. Radiological investigations
• Presence or absence of a focal transition point. Abdominal plain film imaging can be helpful in
• Presence or absence of underlying causes, such as the initial assessment of gastric volvulus in order to
hernias or malignancy. assess for more distal bowel obstruction. Erect chest
• Presence or absence of complications, such as plain film imaging also has a role in identifying sub-
evidence of perforation or bowel ischaemia. diaphragmatic free gas, indicative of perforation (which
can both complicate gastric volvulus and also be another
References cause of abdominal pain). Fluoroscopy can accurately
Foster NM, McGory ML, Zingmond DS et al. (2006) demonstrate the morphology of the stomach, but this
Small bowel obstruction: a population-based modality may not be available out of hours and is not
appraisal. J Am Coll Surg 203:170–176. always suitable in unstable patients. Fluoroscopy also
Silva CA, Pimenta M, Guimaraes LS (2009) Small requires oral contrast administration, which may not be
bowel obstruction: what to look for? Radiographics tolerated in cases of total obstruction. CT can accurately
29:423–439. demonstrate the morphology of the stomach and has
K22247_C002.indd 52 16/05/15 3:07 AM

(a) ( b)
Figures 2.41a, b The axis of gastric rotation in organoaxial volvulus.
(a) ( b)
Figures 2.42a, b The axis of gastric rotation in mesenteroaxial volvulus.
K22247_C002.indd 53 16/05/15 3:07 AM

54 Chapter 2
several advantages over fluoroscopy: identification of Radiological findings

complicating factors such as perforation and gastric Computed tomography
ischaemia, associated conditions such as diaphragmatic Gastric volvulus should be suspected on CT with an
hernia and alternative causes of abdominal pain. CT abnormal orientation of the stomach. The greater
can be performed with or without water soluble oral curvature should always lie inferior to the lesser
contrast. Oral contrast administration can aid the curvature and the gastro-oesophageal junction should
assessment of the degree of obstruction; however, it can be positioned to the left and more cranial than the
limit interpretation of gastric wall enhancement and gastroduodenal junction. Multiplanar reformats
may not be tolerated by the patient. (See Table 2.13.) should be utilised in order to more easily appreciate
the anatomical orientation of the stomach, particularly
the coronal view, which mirrors the standard supine
Table 2.13 Gastric volvulus. Imaging protocol. view obtained by fluoroscopy and plain film imaging.
An organoaxial orientation of the stomach is diagnosed
MODALITY PROTOCOL when the greater curvature is positioned more cranially
CT Portal venous phase: 100 ml IV contrast via than the lesser curvature, while a mesenteroaxial
18G cannula, 4 ml/sec. Scan at 70 seconds orientation occurs when the antrum is more cranial
after initiation of injection. Oral contrast: than the gastro-oesophageal junction (Figure 2.43).
50 ml water soluble oral contrast diluted Mixed subtype gastric volvulae are diagnosed when
in 500 ml water. Administer just prior to
scanning. Scan from mid thorax to femoral the stomach orientation fulfils the criteria for both
head level. the organoaxial and mesenteroaxial orientation. The
Fluoroscopy Water soluble contrast (iodine concentration stomach may lie in an intrathoracic position when
300 mg/l) administered orally. Barium can associated with a hiatus hernia (Figure 2.44). Note:
cause mediastinitis and in general should not Both subtypes can be chronic and asymptomatic; in
be used (although advocates argue barium incidental cases the term ‘orientation’ should be used as
increases the sensitivity of detecting small
leaks when water soluble contrast has failed opposed to ‘volvulus’ to highlight this point.
to do so). Obstruction is indicated by significant dilatation
of the closed gastric loop, proximal dilatation of the
Figure 2.43 Coronal image: IV contrast enhanced

CT scan of the thorax and abdomen in the arterial
phase. The stomach has an ‘upside down’ configuration
consistent with an organoaxial gastric volvulus.

CT scan of the thorax in the arterial phase. The majority
of the stomach lies within the thorax due to a large
hiatus hernia.
K22247_C002.indd 54 16/05/15 3:07 AM

oesophagus and distal bowel collapse (Figures 2.45, window settings) and poor gastric enhancement should
2.46). In studies where oral contrast is administered, all raise the suspicion of gastric ischaemia, an important
complete hold of contrast signifies complete complication that should be urgently communicated
obstruction, although it should be emphasised that to the referring team. Free gas is indicative of
some contrast passage can still occur in cases of severe perforation and can be seen in both the peritoneum and
obstruction. Gastric wall thickening, pneumatosis mediastinum, depending on the site of the perforated
(gas within the gastric wall, best appreciated on lung portion of the stomach.
Figure 2.45 Oblique coronal image: IV contrast Figure 2.46 Axial image: IV contrast enhanced
enhanced CT scan of the abdomen and pelvis in the CT scan of the thorax in the arterial phase. The
portal venous phase. The stomach is significantly dilated proximal stomach is dilated and fluid filled as a result of
and demonstrates an abnormal configuration, suggestive obstruction. The distal stomach beyond the obstruction
of obstruction secondary to gastric volvulus. is collapsed.
K22247_C002.indd 55 16/05/15 3:07 AM

56 Chapter 2
Plain films single air fluid level, whereas mesenteroaxial volvulae

Plain films may demonstrate a grossly distended gas- demonstrate two discrete fluid levels.
filled viscus in the upper abdomen and a paucity of bowel
gas distally. In cases associated with diaphragmatic Key points
hernia, the stomach may be seen in an intrathoracic • Gastric volvulus can be a long-standing and
position (Figure 2.47). Typically, organoaxial volvulae asymptomatic finding or present with symptoms
present as a horizontally orientated stomach with a of acute obstruction.
• Volvulae can be organoaxial (rotation around
the gastric long axis, greater curvature displaced
cranial to the lesser curvature), mesenteroaxial
(rotation around the gastric short axis, gastro-
oesophageal junction displaced cranial to the
antrum) or mixed.
• CT accurately demonstrates the morphology and
orientation of the stomach, as well as complicating
factors such as perforation and ischaemia.
Report checklist
• Characterise the type of gastric volvulus.
• Degree of associated obstruction.
• Presence or absence of complications, such as
gastric ischaemia and aspiration pneumonia.
• Emphasise that some gastric volvulae may be
long-standing; clinical correlation is required in
these instances.
References
Feldman M, Friedman LS, Brandt LJ (2010) Sleisenger
and Fordtran’s Gastrointestinal and Liver Disease:
Pathophysiology/Diagnosis/Management, 9th edn.
Figure 2.47 PA chest radiograph. There is a large Saunders/Elsevier, St. Louis.
hiatus hernia with the stomach extending into the Peterson C, Anderson J, Hara A et al. (2009)
thoracic cavity. A large gas fluid level is seen within the Volvulus of the gastrointestinal tract: appearances
stomach representing fluid within the volvulus contained at multimodality imaging. Radiographics
in a hiatus hernia. 29:1281–1293.
K22247_C002.indd 56 16/05/15 3:07 AM

OESOPHAGEAL PERFORATION for patients who are unable to swallow oral contrast
media. Some studies have estimated that fluoroscopy
Oesophageal perforation is most commonly iatrogenic can be associated with a significant 10–20% false-
in nature and can be seen secondary to endoscopy, negative rate (Tonolini & Bianco, 2013), although this
oesophageal dilation, myotomy and stent placement, depends on fluoroscopic technique and the experience
foreign body extraction, gastric fundoplication and of the interpreter. CT imaging with oral contrast is
anterior cervical discectomy. Perforation can also occur increasingly being utilised as the initial modality of
secondary to tumours and severe ulceration resulting choice in suspected cases of oesophageal rupture. CT is
from gastro-oesophageal reflux disease. Spontaneous often more appropriate in unstable patients because of
oesophageal rupture, termed Boerhaave syndrome, its speed and the ease with which it can be performed.
is usually associated with vomiting. It is believed that It gives accurate anatomical information regarding
incomplete cricopharyngeal muscle relaxation during the structures adjacent to the oesophagus and can,
vomiting results in a sudden increase in oesophageal in addition, assess for other underlying pathologies.
intraluminal pressure, which can result in perforation. CT can also be performed without oral contrast, unlike
This should be distinguished from a Mallory–Weiss fluoroscopy, although sensitivity will be decreased.
tear, which is also associated with protracted vomiting (See Table 2.14.)
but is not transmural and therefore does not result in
oesophageal perforation. The most common site of
spontaneous perforation is the thoracic oesophagus,
particularly the distal left posterior wall. Symptoms and
signs include sudden onset chest pain, haematemesis Table 2.14 Oesophageal perforation.
and fever. Blood tests may show raised inflammatory Imaging protocol.
markers or, alternatively, may be normal. Oesophageal
perforation has a high mortality rate and early diagnosis MODALITY PROTOCOL
and surgical intervention is vital. CT Post IV contrast, portal venous phase: 100 ml
IV contrast via 18G cannula, 4 ml/sec. Scan
at 30 seconds after initiation of injection.
Oral contrast: 50 ml water soluble oral
Chest plain film imaging is a useful initial tool in the contrast diluted in 500 ml water. Administer
assessment of suspected oesophageal rupture to exclude just prior to scanning. Scan from level of
alternative pathologies, although it is rarely diagnostic thoracic inlet to below diaphragm.
of oesophageal rupture. Definitive diagnosis often Fluoroscopy Water soluble contrast swallow: water
requires either a contrast swallow fluoroscopic study soluble oral contrast (iodine concentration
or CT imaging. While fluoroscopy has traditionally 300mg/l) administered orally.
been thought of as the modality of choice to investigate Barium can cause mediastinitis and in
general should not be used (although
oesophageal perforation, it has inherent limitations. advocates argue barium increases sensitivity
Fluoroscopy is not always suitable in acutely unwell of detecting small leaks when water-soluble
patients, is time-consuming to perform and may not be contrast has failed to do so).
available out of hours. Fluoroscopy is also not suitable
K22247_C002.indd 57 16/05/15 3:07 AM

58 Chapter 2
Radiological findings and left anterior oblique, right and left lateral and prone
Computed tomography positions, although this depends on patient tolerance.
The presence of extraluminal oral contrast in the Ideally, the patient should swallow the oral contrast
posterior mediastinum (which can also track into the medium from a cup on demand. Boluses of oral contrast
left-sided pleural cavity) is indicative of oesophageal
perforation (Figures 2.48, 2.49). An additional helpful
sign is pneumomediastinum; utilisation of lung window
settings aids visualisation of this (Figure 2.50). It should
be noted that this is a non-specific sign and if seen
in isolation, additional causes should be considered
(Table 2.15). Concentric or eccentric oesophageal
mural thickening can also be seen in cases of oesophageal
perforation, although it is also non-specific and can be
seen with oesophagitis or malignancy; the presence of
associated para-oesophageal lymphadenopathy is more
suggestive of the latter. Para-oesophageal enhancing
fluid collections may also be seen. Note: Small
oesophageal leaks may be missed on CT, especially in
the absence of oral contrast; this should be emphasised
in the report.
Figure 2.48 Axial image: oral and IV contrast
Fluoroscopy enhanced CT scan of the thorax in the arterial phase.
Contrast swallow fluoroscopy should be performed Oral contrast is seen collecting in the right pleural space
with the patient in a semi-supine (20°) position, right with locules of gas. Left pleural effusion is also noted.
Figure 2.49 Axial image: oral contrast CT scan of Figure 2.50 Axial image: IV contrast enhanced
the thorax. Contrast can be seen within the stomach. CT scan of the thorax in the arterial phase. Viewed on
Contrast has collected around the oesophagus within lung window settings, gas can be seen surrounding the
the posterior mediastinum (arrow). A left-sided pleural superior mediastinal structures.
effusion is also present, containing locules of gas.
K22247_C002.indd 58 16/05/15 3:07 AM

should be followed down the entire oesophagus. Reference

Rupture is confirmed in the presence of extravasation Tonolini M, Bianco R (2013) Spontaneous esophageal
of oral contrast or an irregular collection of contrast perforation (Boerhaave syndrome): diagnosis
external to the oesophageal lumen. Additional findings with CT-esophagography. J Emerg Trauma Shock
include oesophageal wall irregularity and distortion, 6:58–60.
which may suggest para-oesophageal collections.
Adequate oesophageal luminal distension is vital
to identify oesophageal perforation; this requires a
good oral contrast load. The study should always be
terminated if oral contrast material is aspirated.
Plain films
Chest plain film findings are all non-specific but can
suggest the diagnosis of oesophageal perforation.
The most common sign of oesophageal perforation
seen on chest plain film imaging is a left-sided pleural
effusion and atelectasis/consolidation, reflecting
the fact that the most common site of oesophageal
perforation is the distal left-sided posterior wall.
Pneumomediastinum should always raise suspicion of
oesophageal perforation, especially in the presence of
associated symptoms. Pneumomediastinum has many
appearances on chest plain film imaging, although
all rely on the presence of abnormal gas outlining Figure 2.51 PA chest radiograph. Streaky linear
the normal mediastinal structures ( Figure 2.51 ). lucencies are seen within the superior mediastinum
Note: Pneumomediastinum on plain film imaging and outlining the left heart border. Subcutaneous
has a low sensitivity and specificity for oesophageal emphysema is also seen in the supraclavicular fossa
rupture and can be seen in many other conditions bilaterally.
(Table 2.15).
Key points Table 2.15 Causes of pneumostinum.

• Oesophageal perforation has a high mortality rate
and urgent diagnosis is essential. • Blunt chest trauma.
• Imaging modalities include CT with water soluble • Secondary to chest, neck or retroperitoneal surgery.
oral contrast and fluoroscopy. Small leaks can be • Oesophageal perforation.
missed on both modalities if the oral contrast load • Tracheobronchial perforation.
is inadequate. • Vigorous exercise.
• Asthma.
Report checklist • Barotrauma.
• Presence or absence of extra-oesophageal • Subcutaneous emphysema, pulmonary interstitial
oral contrast. emphysema.
• Attempt to localise any potential oesophageal • Stab wound.
breach. • Infection.
• Document any associated complications • Idiopathic.
(e.g. mediastinal collections and mediastinitis).
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60 Chapter 2
ACUTE APPENDICITIS Table 2.16 Acute appendicitis. Imaging

protocol.
Acute appendicitis is the most common cause of
acute abdominal pain and is a surgical emergency. MODALITY PROTOCOL
Appendicitis occurs in all age groups; it is rare in infants CT Post IV contrast, portal venous phase: 100 ml
but becomes increasingly common in childhood, IV contrast, 4 ml/sec via 18G cannula. Scan at
70 seconds. Scan from above diaphragm to
reaching peak incidence in the late teenage years femoral head level.
and early twenties. Abdominal pain is the primary
Ultrasound 6–9MHz linear probe.
symptom of appendicitis and is initially located in the
lower epigastrium or periumbilical area. The pain
subsequently localises to the right lower quadrant,
where it becomes progressively more severe. Anorexia
nervosa nearly always accompanies appendicitis.
Nausea, vomiting and low-grade fever are common and non-compression) is most diagnostic in the
symptoms. Less commonly, diarrhoea or constipation hands of experienced sonographers and radiologists.
may be seen. The physical examination findings in In the on-call setting, the use of ultrasound and
acute appendicitis are localised abdominal tenderness, experience in scanning for appendicitis may be limited.
rigidity, muscle guarding, pain on percussion (See Table 2.16.)
and rebound tenderness. Pain in the right lower
quadrant with palpation of the left lower quadrant Radiological findings
(Rovsing sign) is helpful in supporting a clinical Computed tomography
diagnosis. High C-reactive protein (>0.8 mg/dl) with The appendix should be identified – the use of
leucocytosis and neutrophilia is the most significant multiplanar reformatting is sometimes necessary
laboratory finding. to achieve this. The normal appendix appears as
The diagnosis of acute appendicitis is primarily a a tubular or ring-like pericaecal structure that
clinical one; however, many conditions have similar is either totally collapsed or partially filled with
clinical presentations to appendicitis and a definitive fluid, contrast material or air. It has a thickness less
diagnosis may be difficult to make. In these cases of than 3 mm. Acute appendicitis causes thickening
clinical uncertainty, the on-call radiologist may be of the appendix with a two-wall diameter greater than
required to aid the diagnosis. 6–7 mm. Periappendicular inflammatory stranding
and free fluid may also be seen ( Figure 2.52 ), as
Radiological investigations may a calcified appendicolith (seen in 30% of cases,
Both CT and ultrasound can be useful in the diagnosis Figure 2.53). Other conditions, such as active Crohn’s
of acute appendicitis and its complications. Radiology, disease in the terminal ileum, can cause a similar
primarily CT, can reduce the number of misdiagnoses appearance of a thickened tubular structure in the
and negative laparotomies, with high positive and right iliac fossa. It is important to differentiate the
negative predictive values of between 95 and 98% two structures anatomically, since the management
and 95 and 100%, respectively (Curtin et al., 1995). In of the two conditions differs. Caecal thickening
addition, it can be of use in the detection of appendicular and inflammatory changes may be present, and if
abscesses, postoperative complications and other oral contrast has been given, it may give rise to an
conditions mimicking appendicitis. Ultrasound also has ‘arrowhead’ appearance, as contrast funnels at the
a diagnostic role in patients where CT is less favourable caecal apex to the point of the obstructed appendicular
(e.g. children, young women and pregnant women). orifice.
The reported positive and negative predictive values Perforated appendicitis is usually accompanied
are 91 to 94% and 89 to 97%, respectively (Curtin by pericaecal abscess formation, which presents as an
et al., 1995). The use of ultrasound (compression enhancing fluid collection (Figure 2.54). These may
K22247_C002.indd 60 16/05/15 3:07 AM

Figure 2.52 Coronal image: oral and IV contrast

enhanced CT scan of the abdomen and pelvis in the
portal venous phase. A thick-walled appendix can be
seen in the right iliac fossa (arrow). There is adjacent
inflammatory fat stranding.
Figure 2.53 Axial image: oral and IV contrast Figure 2.54 Axial image: oral and IV contrast enhanced
enhanced CT scan of the abdomen and pelvis in the CT scan of the abdomen and pelvis in the portal venous
portal venous phase. A thick-walled appendix can be phase. A relatively well-defined mass is seen in the
seen in the right iliac fossa containing a round calcified right iliac fossa just anterior to the right psoas muscle
appendicolith (arrow). (arrow). An abscess has formed around the appendix,
with inflammatory changes visible around the mass.
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62 Chapter 2
involve adjacent structures (Figures 2.55a–c). Free may also be increased echogenicity of the mesenteric
intraperitoneal gas is suggestive of appendicular fat that surrounds the appendix. Adjacent hypoechoic
perforation without abscess formation, and is best free fluid may also be seen, in addition to focal abscess
appreciated on lung or bone window settings. formation.
As with any cause of intra-abdominal inflammation,
acute appendicitis can cause localised small bowel Key points
ileus, suggested by small bowel dilatation without • Appendicitis is primarily a clinical diagnosis.
an associated transition point. Sagittal and coronal Radiology should only be used in situations where
reformats can help to identify the appendix when it the clinical diagnosis is uncertain.
is difficult to find. They can also be used to identify • Ultrasound can be used in cases where CT is less
where abscesses are tracking, and the nature of their favourable (i.e. children and pregnant women), but
relationship to the appendix. it is is user dependent.
• Key CT features include a thickened appendix
Ultrasound (>6 mm), surrounding inflammatory mesenteric
Appendicitis is diagnosed on ultrasound when the total changes and the presence of an appendicolith.
appendix diameter is greater than 6 mm or individual
wall thickness is greater than 3 mm (Brown, 2008). Report checklist
The diagnosis is also suggested by a n on-compressible • Document the diameter of the appendix and the
appendix during scanning ( Figures 2.56a, b ). A degree of appendicular thickening.
technique of graded compression should be adopted. • Presence or absence of complications, such as
This requires the operator to gradually increase appendicular abscesses and perforation.
pressure on the patient during the scan over the site
of tenderness, in order to displace loops of bowel and References
demonstrate the appendix. In normal patients, it can be Brown M (2008) Imaging acute appendicitis. Semin
difficult to visualise the appendix. Ultrasound CT 29:293–307.
An appendicolith appears as a focal hypoechoic Curtin K, Fitzgerald S, Nemcek A et al. (1995) CT
structure within the tubular appendix, which usually diagnosis of acute appendicitis: imaging findings.
demonstrates posterior acoustic shadowing. These are Am J Roentgenol 164:905–909.
often present in patients with acute appendicitis. There
K22247_C002.indd 62 16/05/15 3:07 AM

(a) ( b)
Figures 2.55a–c Axial, coronal and sagittal images:

(c)
IV contrast enhanced CT scans of the abdomen and
pelvis in the portal venous phase. These demonstrate
a thickened, inflamed appendix with a right iliopsoas
abscess.
(a) ( b)
Figures 2.56a, b Transverse and longitudinal ultrasonograms of the appendix. The appendix has a diameter of
8 mm and is non compressible consistent with acute appendicitis. No appendicolith or surrounding fluid collections
are seen. The mesenteric fat surrounding the appendix is echogenic, which is a non-specific feature often seen in
acute appendicitis.
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64 Chapter 2
ACUTE PANCREATITIS arterial pseudoaneurysm formation and venous

thrombosis (e.g. the portal and splenic veins).
Acute pancreatitis is an acute inflammatory process The severity of acute pancreatitis is highly variable;
of the pancreas, which may also involve adjacent or it can range from mild and self-limiting to fulminant.
remote tissues and organs. The incidence rate ranges If severe, the mortality rate is estimated to be as high
from 150 to 420 per 1 million (Johnson et al., 2005). as 50%. Note: The diagnosis of acute pancreatitis is a
The commonest causes of acute pancreatitis are clinical one, usually made on the basis of elevated serum
cholelithiasis and elevated alcohol consumption; the pancreatic enzyme levels and an appropriate clinical
latter, if sustained, can also cause chronic pancreatitis. history. Radiological investigations are not required
Acute pancreatitis can also be iatrogenic, secondary to establish the diagnosis; however, they do play a role
to endoscopic retrograde cholangiopancreatography. in identifying the complications that can arise in more
Additional, rarer causes include abdominal severe cases.
surgery, trauma, congenital pancreatic divisum,
hyperlipidaemia, hypercalcaemia and infection. Radiological investigations
Symptoms and signs of acute pancreatitis include CT is the imaging modality of choice for identifying
abdominal pain, nausea and vomiting and pyrexia. If the complications that can arise secondary to
severe, a profound systemic inflammatory response severe cases of acute pancreatitis. It is quick, readily
can lead to haemodynamic instability and, ultimately, available and also aids in identifying alternative intra-
multiorgan failure. The diagnosis is often suggested abdominal pathologies. An arterial phase, in addition
by a significant elevation in serum pancreatic enzyme to the portal venous phase, aids in the identification
levels (e.g. amylase and lipase), although a low level of vascular complications; however, it is usually only
elevation of amylase is non-specific and can also be seen used when there is concern about necrotic pancreatitis
in other causes of an acute abdomen. Many clinical and therefore an arterial phase may not routinely
scoring systems, such as the Glasgow (Table 2.17) be required. Ultrasound can be used to identify the
and APACHE II (Acute Physiology and Chronic underlying cause (e.g. gallstones); however, it is less
Health Evaluation) Scores are used to provide an sensitive than CT at identifying pancreatic necrosis.
objective assessment of the severity of pancreatitis. Ultrasound can also be technically challenging in
Complications of acute pancreatitis include pancreatic acutely unwell patients; difficulties include a limited
pseudocysts, focal abscess formation and peripancreatic acoustic window, which can result in suboptimal views
fluid collections, pancreatic necrosis, haemorrhage, of the pancreas. (See Table 2.18.)
Table 2.17 Glasgow Score: a score of 3 or more Table 2.18 Acute pancreatitis. Imaging

indicates severe pancreatitis. protocol.
PaO2 <8 kPa 1 MODALITY PROTOCOL

Age >55 years old 1 CT Arterial phase: 100 ml IV contrast via 18G
cannula, 4 ml/sec. Bolus track centred on
Neutrophilia: WCC >15 × 109/l 1
mid-abdominal aorta. No oral contrast.
Calcium <2 mmol/l 1 Image the pancreas only.
Renal function: urea >16 mmol/l 1 Portal venous phase: IV contrast as
Enzymes: LDH >600 U/l; AST >200 U/lL 1 above, scan at 70 seconds after contrast
administration. Scan from just above
Albumin <32 g/l (serum) 1 diaphragm to femoral head level.
Sugar: blood glucose >10 mmol/l 1
K22247_C002.indd 64 16/05/15 3:07 AM

Radiological findings radiologically from a primary pancreatic malignancy

Computed tomography and can prove a diagnostic challenge; clinical history
In mild cases of acute pancreatitis, the pancreas can can be useful in these situations. The pancreas should
appear normal on CT imaging. Findings can include enhance uniformly on the arterial and portal venous
an enlarged oedematous pancreas with associated phases. Loss of pancreatic enhancement, as evidenced
peripancreatic inflammatory fat stranding (Figure 2.57). by decreased parenchymal attenuation (which can be
Localised free fluid is common and may extend along uniform or focal), is suggestive of pancreatic necrosis
the mesentery, mesocolon and hepatoduodenal and indicates severe pancreatitis ( Figure 2.58 ).
ligament and into peritoneal spaces. Acute pancreatitis Locules of gas within the non-enhancing pancreatic
can be diffuse or focal, the latter affecting a single parenchyma are highly suggestive of infective necrosis,
part of the gland such as the head or tail. Cases of again indicating severe pancreatitis. The severity of
focal acute pancreatitis can be difficult to differentiate acute pancreatitis can be graded on CT imaging using
CT scan of the abdomen in the portal venous phase. CT scan of the abdomen in the portal venous
The pancreatic tail is ill-defined and oedematous with phase. The pancreas is ill defined with surrounding
surrounding inflammatory changes consistent with inflammatory changes consistent with acute pancreatitis.
focal p
ancreatitis. A filling defect can be seen within In addition, there are focal areas of non-enhancing
the portal vein near the pancreatic head, representing tissue within the body of the pancreas, consistent with
non-occlusive thrombosis (arrow). pancreatic necrosis.
K22247_C002.indd 65 16/05/15 3:07 AM

66 Chapter 2
the CT Severity Index (CTSI) constructed by Balthazar collection with a uniformly thick wall (Figure 2.59),
et al., 1990 (Table 2.19). the degree of enhancement of which can vary.
Peripancreatic fluid collections can consist of All peripancreatic collections can be complicated by
exudative fluid, necrotic tissue or haemorrhage, infection. The presence of locules of gas within any
all of which can be complicated by infection. The collection should raise the suspicion of infection;
appearance of enhancing fluid collections on however, CT imaging cannot readily differentiate
CT imaging can vary, ranging from uniform low infected from non-infected collections and ultimately
attenuation collections to heterogeneous mixed aspiration and microbiological analysis may be
density collections. It is important to differentiate required. Peripancreatic collections can be drained
these acute collections from pancreatic pseudocysts. percutaneously by ultrasound or CT; discussion with
The latter are common sequelae of acute pancreatitis an interventional radiologist is advised in these cases.
and represent organisation of leaked pancreatic fluid. The portal, splenic and superior mesenteric
Pancreatic pseudocysts develop at least 4 weeks after veins should be inspected for thrombosis, appearing
the onset of acute pancreatic inflammation and the as focal filling defects within the veins on portal
term ‘pseudocyst’ should be avoided in the early venous phased imaging (see Figure 2.57). Arterial
period. Pancreatic pseudocysts generally appear pseudoaneurysms can also occur, most commonly
as a uniform low attenuation peripancreatic fluid involving the splenic artery. Pseudoaneurysms manifest
Table 2.19 Acute pancreatitis. CT Severity

Index.
GRADING OF PANCREATITIS
Normal pancreas 0
Enlargement of pancreas 1
Inflammatory changes in pancreas and 2
peripancreatic fat
Ill-defined single fluid collection 4
Two or more poorly defined fluid collections 5
DEGREE OF PANCREATIC NECROSIS
None 0
Less than or equal to 30% 2
Between 30% and 50% 4
Greater than 50% 6
OVERALL SCORE AND SEVERITY OF ACUTE Figure 2.59 Axial image: IV contrast enhanced CT
PANCREATITIS scan of the abdomen in the portal venous phase. There
0–3 points Mild is a round, thick-walled pseudocyst that lies between the
4–6 points Moderate pancreatic neck and the stomach.
7–10 points Severe
K22247_C002.indd 66 16/05/15 3:07 AM

as well-defined rounded high attenuation foci on the Key points

arterial phase, which demonstrates the same degree • Imaging is not required to establish the diagnosis
of attenuation as the remainder of the arterial system. of acute pancreatitis, but it does play a role in
Pseudoaneurysms may or may not be traced to a parent identifying the complications that can arise. In
vessel. Pseudoaneurysms can be complicated by acute these cases, CT is the imaging modality of choice.
bleeding, which may also appear as a hyperattenuating • CT findings of acute pancreatitis include
contrast blush on arterial phased imaging. On a pancreatic swelling and oedema, peripancreatic
single arterial phase, active bleeding can be difficult inflammatory fat stranding and fluid.
to distinguish from pseudoaneurysms; however, the • Acute pancreatitis can be complicated by
latter wash out on delayed imaging, thus allowing pancreatic necrosis, focal abscess formation
differentiation. and peripancreatic fluid collections, arterial
The gallbladder should be inspected for gallstones, pseudoaneurysms, active bleeding and venous
the presence of which may indicate the likely underlying thrombosis.
cause. Gallstones have a highly variable appearance
on CT imaging; they can be purely calcified or Report checklist
demonstrate laminated calcification. Alternatively, they • Presence or absence of complications of
can be soft tissue density or even isoattenuating to the pancreatitis, including necrosis, abscess formation,
adjacent bile; the latter may be missed on CT imaging. portal vein/splenic vein/superior mesenteric vein
The biliary system should be inspected for dilatation, thrombosis, pseudocyst and abscess formation,
which may indicate an impacted gallstone distally. The pseudoaneurysm formation and bleeding, colitis,
common bile duct should measure less than 6 mm in pneumonia and pleural effusions.
people less than 60 years of age, with an additional 1 • Consider the causes of pancreatitis, for example
mm permitted for every extra decade over 60 years. In the presence or absence of gallstones.
the presence of biliary dilatation, the common bile duct • Presence or absence of biliary dilatation or
should be traced distally in order to attempt to identify obstruction.
an impacted stone or obstructing soft tissue mass; these
can be challenging to differentiate on CT. References
It is important to distinguish acute from chronic Balthazar EJ, Robinson DL, Megibow AJ et al. (1990)
pancreatitis, the latter commonly occurring secondary Acute pancreatitis: value of CT in establishing
to chronic alcohol excess. Chronic pancreatitis prognosis. Radiology 174:331–336.
manifests on CT as atrophy of the pancreas, with Johnson CD, Charnley R, Rowlands B et al. (2005) UK
scattered foci of pancreatic calcification and irregular guidelines for the management of acute pancreatitis.
pancreatic duct dilatation. Gut 54:1–9.
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68 Chapter 2
ACUTE DIVERTICULITIS Table 2.20 Acute diverticulitis. Imaging

protocol.
Diverticulae are mucosal herniations through the
muscularis layer of the bowel wall. They can occur MODALITY PROTOCOL
anywhere in the bowel but are most common in CT Post IV contrast, portal venous phase: 100 ml
the colon due to raised intraluminal pressures. The IV contrast, 4 ml/sec via 18G cannula. Scan at
70 seconds. Scan from above diaphragm to
incidence of colonic diverticulitis is high in the general
femoral head level.
population; however, diverticulitis most commonly
occurs in the elderly (Baker et al., 2008). Clinical
symptoms and signs are varied but typically include
pain mainly localising to the left lower quadrant, low- This is usually seen in conjunction with multiple
grade fever and constipation/diarrhoea. Leucocytosis diverticulae, although these can sometimes be difficult
and a raised C-reactive protein may also be present. to appreciate. Associated free fluid can be seen, as
Complications of acute diverticulitis include with any inflammatory intra-abdominal pathology.
perforation, collection/abscess, fistula formation and Multiplanar reformatting, particularly the coronal
post-inflammatory strictures, which can cause bowel view, may be helpful to show mild pericolonic fat
obstruction. Fistula formation, involving either the stranding associated with horizontally oriented
bladder or vagina, can result in pneumaturia or foul segments of colon. Note: Short segments of colonic
smelling vaginal discharge, respectively. Although wall thickening (<5 cm) can also be seen in cases of
symptoms and signs can vary, perforated diverticulitis primary colorectal malignancy and it can sometimes
is a surgical emergency and often requires urgent be difficult to differentiate radiologically between the
laparotomy. While the diagnosis can be made clinically, two entities. Localised lymphadenopathy can be seen in
imaging is increasingly being utilised to guide potential both. Other findings of disseminated malignancy, such
surgical management and should be performed without as metastatic disease, may help reveal the underlying
delay if there is clinical suspicion of perforation. cause of bowel wall thickening; however, in equivocal
cases the possibility of malignancy should be raised.
IV contrast enhanced CT is the imaging modality
of choice and can diagnose both diverticulitis and its
important complications. Positive oral contrast can be
administered as per local protocol; however, this should
not delay imaging if the patient is acutely unwell.
Abdominal plain film imaging has a role in assessing
for other causes of abdominal pain, such as bowel
obstruction, although it cannot definitively diagnose
diverticulitis. Free gas may be seen on both abdominal
and chest plain film imaging and is consistent with
perforation. (See Table 2.20.)
Computed tomography
Diverticulae appear as multiple small sacular out-
pouchings arising from the bowel wall. They are Figure 2.60 Axial image: IV contrast enhanced
more common on the mesenteric side of the colon, CT scan of the abdomen and pelvis in the portal venous
where nutrient arteries enter. Acute diverticulitis is phase. The sigmoid colon is abnormally thickened in
suggested by a segment of colonic wall thickening the presence of multiple diverticula. The surrounding
(>3 mm) and pericolonic fat stranding (Figure 2.60). mesentery is hazy due to local inflammation.
K22247_C002.indd 68 16/05/15 3:07 AM

Indeterminate cases may ultimately require further is important since this can guide potential treatment.
evaluation with endoscopy. For accessible abscesses, percutaneous radiologically-
An important complication of diverticulitis is guided drainage can be suggested. Fistulation can occur
perforation, confirmed on CT by the presence of free (suggesting a subacute to chronic course), commonly
gas (Figure 2.61). This is better appreciated on both between the bladder and cervix, and should be
lung and bone window settings. Other complications suspected in the absence of a clear fat plain between the
include abscess formation, presenting as a pericolonic two structures. Gas within the vaginal vault and bladder
fluid-containing focus with or without air and an (without prior instrumentation) should also raise the
enhancing wall (Figure 2.62). Interloop abscesses suspicion of fistulation. A thin track of oral contrast
may also occur (Figure 2.63). The size of the abscess can occasionally be seen between the two fistulating
Figure 2.61 Sagittal image:

IV contrast enhanced CT scan
of the abdomen and pelvis in
the portal venous phase. The
image demonstrates locules
of free gas within the bowel
mesentery secondary to perforated
diverticulitis.

Figure 2.62 Axial image: oral and IV contrast CT scan of the pelvis in the portal venous phase.
enhanced CT scan of the pelvis in the portal venous The image demonstrates diverticulitis with an
phase. A focal abscess can be seen in the mid pelvis as a interloop abscess (arrow).
result of localised diverticular perforation. Surrounding
inflammatory changes can be seen as a hazy appearance
within the adjacent mesentery.
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70 Chapter 2
structures, confirming the diagnosis (Figure 2.64). • The main findings of diverticulitis include the
Diverticulitis can also be complicated by hepatic presence of diverticulae, bowel wall thickening
abscess formation, appearing as a ring enhancing and pericolonic fat stranding.
hypoattenuating focus within the liver (DeStigter & • Short segment bowel wall thickening can also be
Keating, 2009). seen in primary colorectal malignancy and should
There is a classification that is intermittently used always be considered as an alternative diagnosis.
for staging diverticulitis according to its severity: The
Hinchey Classification of Diverticulitis (Table 2.21). Report checklist
This classification is useful in guiding management • Presence or absence of complications (e.g. abscess
since localised disease (i.e. stages 1 and 2) is managed formation, perforation, fistulation and post-
conservatively with IV fluid rehydration, IV antibiotics inflammatory strictures).
and, if the abscess collections are large, with image- • Consider the differential diagnosis of underlying
guided percutaneous drainage. Surgical management is colonic malignancy.
recommended for stages 3 and 4, and for patients that • Emphasise that in indeterminate cases, direct
do not improve under medical management or have visualisation via colonoscopy is advised at a
fistula formation. It is also recommended where there clinically appropriate time
is uncertainty as to whether there may be underlying
malignancy. References
Baker M (2008) Imaging and interventional techniques
Key points in acute left-sided diverticulitis. J Gastrointest Surg
• CT is the imaging modality of choice to assess 12:1314–1317.
for the presence of, severity and complications of DeStigter K, Keating D (2009) Imaging update:
acute diverticulitis. acute colonic diverticulitis. Clin Colon Rectal Surg
22:147–155.
Table 2.21 The Hinchey Classification of

Diverticulitis.
Stage 1a Phlegmon.
Stage 1b Diverticulitis with pericolic or mesenteric abscess.
Stage 2 Diverticulitis with walled off pelvic abscess.
Stage 3 Diverticulitis with generalised purulent peritonitis
Stage 4 Diverticulitis with generalised faecal peritonitis.
Figure 2.64 Sagittal image: IV and oral contrast

enhanced CT scan of the pelvis in the portal venous
phase. The image demonstrates the presence of oral
contrast in the vaginal vault (arrow). The adjacent loops
of sigmoid colon are thickened secondary to acute
diverticulitis, which has resulted in a colovaginal fistula.
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ACUTE CHOLECYSTITIS cases may warrant urgent surgical intervention. For

repeated episodes secondary to gallstones, elective
Acute cholecystitis is the most common acute cholecystectomy is often recommended.
inflammatory condition of the gallbladder. The vast Emphysematous cholecystitis must be distinguished
majority of cases occur secondary to gallstones, usually from simple acute cholecystitis secondary to gallstones.
due to gallstone impaction in the gallbladder neck or Emphysematous cholecystitis occurs secondary to
cystic duct. A smaller proportion of cases are due to gas producing organisms such as Clostridium spp.
inflammation in the absence of gallstones and these are and Escherichia coli and can be rapidly fatal. Urgent
termed acalculous cholecystitis. diagnosis is vital to facilitate early surgical intervention.
Cholecystitis due to gallstones classically occurs
in middle-aged women, with obesity being a well- Radiological investigations
recognised predisposing factor. Acute cholecystitis Ultrasound is the imaging modality of choice when
secondary to gallstones should be differentiated from acute cholecystitis is clinically suspected. The sensitivity
acalculous cholecystitis, the latter occurring more of ultrasound ranges from 80% to 100% and specificity
commonly in critically unwell and paediatric patients ranges from 60% to 100% (Smith et al., 2009). CT
without underlying gallstone disease. Symptoms and can also be used to diagnose cholecystitis and may be
signs, regardless of the underlying cause, can include a more appropriate first-line investigation in suspected
right upper quadrant abdominal pain and tenderness, cases of complicated acute cholecystitis; however, CT
fever and nausea and vomiting. The patient may have is less sensitive than ultrasound for subtle gallbladder
a positive Murphy sign, defined as pain on inspiration wall changes. Plain film imaging can yield signs such
while palpating the right upper quadrant. Elevated as radiopaque gallstones or pneumobilia, but it is not
inflammatory markers are a common, but non-specific, diagnostic. (See Table 2.22.)
associated finding.
Complications of acute cholecystitis include Radiological findings
abscess formation, pericholecystic fluid collections, Ultrasound
gallbladder perforation and enteric fistulation. It is Findings on ultrasound include gallbladder wall
important to identify these complications, since they thickening (>3 mm), pericholecystic hypoechoic fluid
carry a significantly increased mortality rate. Treatment and the presence of a positive sonographic Murphy sign
of non-complicated cases is often conservative via (Figure 2.65). Gallbladder wall thickening in isolation is
appropriate antibiotic therapy; however, complicated
Table 2.22 Acute cholecystitis. Imaging

protocol.
MODALITY PROTOCOL
Ultrasound 1–5MHz curvilinear probe.
CT Post IV contrast, portal venous phase: 100
ml IV contrast, 4 ml/sec via 18G cannula.
Scan at 70 seconds. Scan from just above
diaphragm to femoral head level.
Figure 2.65 Transverse ultrasonogram of the

gallbladder. The gallbladder is thick walled with
surrounding pericholecystic fluid in keeping with acute
cholecystitis.
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72 Chapter 2
a non-specific finding (Table 2.23) and must always be Computed tomography

interpreted with additional sonographic findings and CT features include gallbladder wall thickening
an appropriate clinical history. Gallbladder collapse (>3–5 mm), mural or mucosal hyperenhancement,
is a common finding in the post-prandial state. Care pericholecystic fluid and adjacent soft tissue
must be taken since this can give a false impression of inflammatory stranding ( Figure 2.66). Gallstones
wall thickening. Less specific imaging findings of acute on CT, if visualised, may appear as hyperattenuating
cholecystitis include abnormally increased gallbladder (calcified) or hypoattenuating (cholesterol containing)
distension and echogenic bile (sludge) within the filling defects within the gallbladder lumen. Liver
gallbladder. The presence of sludge, in addition to parenchyma adjacent to the gallbladder fossa may also
gallbladder wall thickening in the absence of gallstones, hyperenhance because of reactive hyperaemia.
is suggestive of acalculous cholecystitis. Gallstones may CT is particularly useful in detecting the
or may not be visualised within the gallbladder neck or complications of acute cholecystitis. Specific findings
cystic duct, and they typically appear as echogenic foci that suggest emphysematous cholecystitis include
with posterior acoustic shadowing. Note: Gallstones foci of gas within the gallbladder wall or lumen
are a common incidental finding in asymptomatic (Figure 2.67), which can be quickly identified on lung
patients and their presence does not imply acute window settings. Features of gallbladder perforation
cholecystitis. include a focal discontinuity in the gallbladder wall
Emphysematous cholecystitis is characterised by and pericholecystic fluid collections, although the
gas within the gallbladder wall or lumen, appearing latter can also be seen without gallbladder perforation
as increased echogenic foci with low-level posterior (Figure 2.68). Other complications include abscess
acoustic shadowing and reverberation artefact. formation around the gallbladder. This may extend into
Gallbladder perforation can be challenging to the liver, resulting in a liver abscess that may require
diagnose on ultrasound; however, it should be suspected percutaneous drainage (Figure 2.69).
in the presence of pericholecystic fluid collections or a
focal discontinuity in the gallbladder wall.
Table 2.23 Causes of gallbladder wall

thickening.
• Cholecystitis.
• Hepatitis.
• Cirrhosis.
• Congestive heart failure.
• Hypoalbuminaemia.
• Renal failure.
• Sepsis.

The gallbladder wall is thickened and there is
adjacent inflammatory fat stranding and free fluid.
The appearance is consistent with acute cholecystitis.
K22247_C002.indd 72 16/05/15 3:07 AM

Key points Report checklist

• Ultrasound is the initial imaging modality of • Presence or absence of gallstones.
choice in the diagnosis of acute cholecystitis. • Presence or absence of intrahepatic or extrahepatic
• CT is useful for identifying the complications biliary dilatation, which may imply an impacted
of acute cholecystitis such as emphysematous gallstone more distally within the biliary system.
cholecystitis and gallbladder perforation.
• The hallmark of acute cholecystitis is Reference
gallbladder wall thickening, although in isolation Smith EA, Dillman JR, Elsayes KM et al. (2009)
this is a n
on-specific finding. Cross-sectional imaging of acute and chronic
gallbladder inflammatory disease. Am J Roentgenol
192:188–196.
The gallbladder contains air, as does the gallbladder The gallbladder wall is thickened with large volumes of
wall, in keeping with emphysematous cholecystitis pericholecystic fluid consistent with acute cholecystitis.
A defect is seen in the anterior gallbladder wall (arrow),
consistent with a gallbladder perforation.

The medial wall of the gallbladder is indistinct due
to local perforation. Low attenuation material is seen
within the right lobe of liver, which communicates with
the gallbladder. This appearance is therefore consistent
with gallbladder perforation leading to liver abscess
formation.
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74 Chapter 2
EMPHYSEMATOUS PYELONEPHRITIS Table 2.24 Emphysematous pyelonephritis.

Imaging protocol.
Emphysematous pyelonephritis is a severe, life-
threatening infection of the renal parenchyma by gas MODALITY PROTOCOL
forming organisms. Approximately 70% of cases are CT Post IV contrast, portal venous phase: 100 ml
secondary to Escherichia coli, although other causative IV contrast, 4 ml/sec via 18G cannula. Scan at
70 seconds after initiation of injection. Scan
organisms such as Klesbiella pneumonia and Proteus
from just above diaphragm to femoral head
mirabilis are also seen. There is a strong association with level.
diabetes mellitus, which is seen in up to 90% of cases
(Joseph et al., 1996). Symptoms and signs include flank
pain and fever with a rapid progression to sepsis and
profound haemodynamic instability. Palpable crepitus imaged with CT to fully characterise the severity. (See
over the affected flank is more specific, although the Table 2.24.)
sensitivity of this sign is low. The mortality rate can be
as high as 50% and urgent diagnosis is vital (Grayson et Radiological findings
al., 2002). The on-call radiologist should have a high Comuted tomography
index of suspicion for this condition in any diabetic CT readily identifies gas both within the renal
patient with sepsis of unknown origin. Treatment parenchyma and the collecting system. Gas can appear
can be conservative in mild cases, involving prompt macroscopically similar to fat on CT; direct evaluation
antibiotic therapy, fluid resuscitation and drainage of of Hounsfield units (gas = approximately 1,000;
complicating collections. In severe cases that fail to fat = 50 to –160) and evaluation with lung window
respond to conservative management, nephrectomy settings helps to differentiate the two. Streaky or
may be required. It is important to differentiate true mottled gas in the interstitium of renal parenchyma,
emphysematous pyelonephritis from emphysematous radiating from medulla to cortex, is highly suggestive
pyelitis, in which gas is limited to the renal collecting of emphysematous pyelonephritis (Figures 2.70a, b).
system. The latter is also associated with diabetes Gas can also be seen in the perinephric soft tissues
mellitus infection, but carries a much better prognosis; and retroperitoneum; the latter signifies a breach of
as such, these cases are often managed conservatively. Gerota’s fascia (Figure 2.71). Focal rim enhancement
within the affected renal parenchyma can indicate
Radiological investigations focal abscess formation. Further non-specific signs
CT is the initial imaging modality of choice in cases can also be seen, such as enhancing perinephric fluid
where emphysematous pyelonephritis is strongly collections, unilateral renal enlargement and decreased
suspected. CT is both sensitive and specific and in parenchymal enhancement (the latter should always
addition can identify alternative causes of abdominal prompt scrutiny of the corresponding renal artery and
pain. Although abdominal plain films are usually one vein to assess for thrombus). Hydronephrosis can be
of the first radiological investigations performed in any seen in association with emphysematous pyelonephritis
patient presenting with abdominal pain, the sensitivity and should prompt the search for an obstruction in the
of this modality for the changes of emphysematous ureter.
pyelonephritis is low. Renal ultrasound can be an Gas that is limited to the collecting system is
appropriate initial investigation to perform in patients suggestive of emphysematous pyelitis (Figure 2.72),
presenting with flank pain in order to look for alternative although this can also be seen in ureteric fistulation
pathologies; however, it is user dependent, technically with bowel (secondary to inflammatory bowel disease
challenging in larger patients and not as sensitive as or malignancy) or pre-existing ileal conduit formation.
CT for emphysematous pyelonephritis. Ultrasound The ureters should be traced distally to ensure that this
can also underestimate the extent of renal parenchymal is not the case.
involvement, therefore suspected cases should also be
K22247_C002.indd 74 16/05/15 3:07 AM

(a) (b)
Figures 2.70a, b Axial and coronal images: IV contrast enhanced CT scans of the abdomen in the portal venous
phase. Gas is seen within the left renal parenchyma and there is heterogeneous parenchymal enhancement.
Figure 2.71 Axial image: IV contrast enhanced Figure 2.72 Axial image: unenhanced CT scan of the
CT scan of the abdomen in the portal venous phase. abdomen. Locules of gas are seen within the left renal
Abnormal left renal parenchymal gas and enhancement collecting system and upper ureter.
is once again shown. There is further retroperitoneal
free gas and fluid.
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76 Chapter 2
Various systems have been proposed to stage should be actively excluded. In the presence of diffuse
the spectrum of findings seen in emphysematous retroperitoneal gas, the kidney can be difficult to
pyelonephritis and pyelitis; these have prognostic visualise (Figures 2.74a. b).
importance (Tables 2.25 and 2.26: Huang & Tseng,
2000; Wan et al., 1996). Abdominal plain film imaging
Emphysematous cystitis is a rare separate entity Abdominal plain films can demonstrate abnormal lucent
where a gas forming infection occurs in the bladder gas collections. The diagnosis is suggested by mottled
wall. It may be caused by bacterial or fungal infections lucencies overlying the renal outlines, which may
with E. coli being the most common causative agent also correspond to the outline of the renal pyramids.
(Figure 2.73) Curvilinear lucencies may indicate subcapsular or
perinephric gas. Retroperitoneal gas is indicated by
Ultrasound increased definition of the psoas shadows, representing
Gas within the renal parenchyma has the appearance a gas–muscle interface. Note: Retroperitoneal gas is
of high-amplitude echogenic foci, commonly with not specific for emphysematous pyelonephritis and can
associated reverberation artefact and comet tail ‘dirty’ also be seen in perforation of retroperitoneal bowel
shadowing. Calculi can also give a similar appearance, (duodenum, ascending colon, descending colon and
although they characteristically produce more uniform rectum).
posterior acoustic shadowing. Hydronephrosis
Key points
• Emphysematous pyelonephritis is a life-
threatening infection of the kidney and should be
Table 2.25 Emphysematous pyelonephritis. suspected in any diabetic patient presenting with
Huang–Tseng CT classification flank pain or sepsis of unknown origin.
system.
• CT is the most sensitive and specific radiological
investigation. Emphysematous pyelonephritis
Class 1 Gas limited to collecting system.
is confirmed when gas is identified in the renal
Class 2 Gas limited to renal parenchyma (without
parenchyma, whereas in emphysematous pyelitis,
extrarenal extension).
the gas is limited to the collecting system only.
Class 3a Extension of gas or abscess to perinephric space.
Class 3b Extension of gas or abscess to pararenal space.
Class 4 Bilateral emphysematous pyelonephritis or solitary
kidney with emphysematous pyelonephritis.
Table 2.26 Emphysematous pyelonephritis.

Wan et al. classification system.
Type 1 Renal parenchymal destruction with streaky or

mottled appearance of gas.
Intra- or extrarenal fluid collections are
characteristically absent.
Type 2 Renal or extrarenal collections associated Figure 2.73 Axial image: IV contrast enhanced CT
with bubbly or loculated gas, or gas within the scan of the abdomen and pelvis in the portal venous
collecting system or ureter. phase. There are multiple locules of gas within the
bladder wall, consistent with emphysematous cystitis.
K22247_C002.indd 76 16/05/15 3:07 AM

(a) (b)
Figure 2.74a, b Ultrasonograms of the kidney. Cortical echogenicity is seen in the interpolar region of the kidney,
representing parenchymal gas, resulting in an irregular acoustic shadow, which obscures the normal renal contour.
Report checklist Huang JJ, Tseng CC (2000) Emphysematous

• Distinguish between emphysematous pyelitis and pyelonephritis: clinicoradiological classification,
emphysematous pyelonephritis. management, prognosis, and pathogenesis. Arch
• Presence or absence of adverse prognostic Intern Med 160:797–805.
features, such as breach of Gerotas fascia and Joseph RC, Amendola MA, Artze ME et al. (1996)
pararenal collections. Genitourinary tract gas: imaging evaluation.
• Emphasise urgent surgical review. Radiographics 16:295–308.
Wan YL, Lee TY, Bullard MJ et al. (1996) Acute gas-
References producing bacterial renal infection: correlation
Grayson DE, Abbott RM, Levy AD et al. (2002) between imaging findings and clinical outcome.
Emphysematous infections of the abdomen and Radiology 198:433–438.
pelvis: a pictoral review. Radiographics 22:543–561.
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78 Chapter 2
HYDRONEPHROSIS Radiological investigations

The first-line investigation for suspected
Hydronephrosis is defined as dilatation of the hydronephrosis is ultrasound. Once the presence of
drainage system of the kidney (calices, infundibula hydronephrosis has been confirmed, CT is the modality
and renal pelvis). The term ureterohydronephrosis, or of choice for establishing the cause. (See Table 2.27.)
hydroureter, is used when the dilatation also involves
the ureters. Hydronephrosis can be acute or chronic, Radiological findings
unilateral or bilateral, physiological or pathological. Ultrasound
Hydronephrosis can be due to obstructive or non- Ultrasound of both flanks should be performed
obstructive causes. Obstructive uropathy refers to the to identify both kidneys. Size, corticomedullary
functional or anatomical obstruction of urinary flow at differentiation (CMD) and cortical thickness of the
any level of the urinary tract. Obstructive nephropathy kidneys should be assessed. The pelvicalyceal system
is present when the obstruction causes functional or should be examined in transverse and longitudinal
anatomical renal damage, usually manifesting as a planes; a dilated system indicates hydronephrosis
decrease in GFR. (Figure 2.75). Quantification of hydronephrosis is
Hydronephrosis in young adults is most commonly subjective, but some categorisation into mild, moderate
due to renal tract calculi, while in older adults, prostatic or severe should be made. Cortical thickness can be
hypertrophy/carcinoma, gynaecological malignancies, an indicator of the chronicity of renal disease. In the
retroperitoneal or pelvic neoplasms and calculi are the context of hydronephrosis, a thinned renal cortex
main causes. suggests that the hydronephrosis is long-standing (in
Clinical features may include back/flank pain, the absence of pre-existing renal disease). Parapelvic
haematuria, retention, fever and deranged renal cysts should not be confused for hydronephrosis.
biochemistry (creatinine and GFR specifically). In cases The proximal ureter should be assessed for
of acute hydronephrosis, correction of the obstruction hydroureter. The bladder should ideally be full and
usually returns the renal function to normal levels. examined for the presence of transitional cell carcinoma
Complications or non-treatment can lead to infection (TCC) as a cause for obstruction. The distal ureters can
or pyonephrosis, chronic obstruction or, less commonly, also be assessed here. Bladder outflow obstruction can
perforation of the urinary tract leading to peritoneal often cause prominence of the pelvicalyceal system
urine leak (urinoma). bilaterally. This can be assessed by asking patients
to empty their bladder and rescanning both kidneys to
assess for any changes in the degree of dilatation.
Table 2.27 Hydronephrosis. Imaging protocol.
MODALITY PROTOCOL
Ultrasound Curvilinear probe 1–5MHz.
CT Non-contrast, nephrographic phase and
delayed phase CT post IV contrast: initial
scan unenhanced. 100 ml IV contrast via
18G cannula, 4 ml/sec. Scan at 120 seconds
(nephrographic phase) and 12 minutes
(delayed phase). Scan from above
Figure 2.75 Ultrasonogram of the right kidney in
the longitudinal plane. The renal pelvis and intrarenal
calyces are dilated and contain anechoic fluid.
K22247_C002.indd 78 16/05/15 3:07 AM

Ultrasound should be the only modality used for This easily identifies calcified renal tract calculi and
suspected hydronephrosis in pregnancy, which can hydronephrosis (Figure 2.77). It is sometimes difficult
be physiological if present. CT should otherwise be to differentiate between phleboliths and distal ureteric
performed if acute hydronephrosis is detected on calculi in the pelvis; the use of multiplanar reformatting
ultrasound. in sagittal and coronal planes can help. Thickening or
mesenteric fat stranding around the ureters can indicate
Computed tomography recent passage of stones.
Hydronephrosis is readily visible on unenhanced and Contrast enhanced CT can be performed in the
contrast enhanced CT, shown as a dilated pelvicalyceal portal venous phase. This can be useful for assessing for
system (Figure 2.76). In younger patients presenting pelvic/retroperitoneal/gynaecological malignancies,
with pain/haematuria and hydronephrosis, the most inflammatory aortic aneurysms, and retroperitoneal
likely cause is calculi. In these cases, a plain low- fibrosis (Figure 2.78) as well as large bladder tumours
dose kidney–ureter–bladder CT can be performed. as a cause for hydronephrosis. Retroperitoneal fibrosis
Figure 2.76 Axial image: CT scan of the abdomen Figure 2.77 Axial image: CT scan of the abdomen
without IV contrast. The right pelvicalyceal system without IV contrast. A rounded, hyperdense calculus is
is dilated compared with the left side. Right renal seen occluding the lumen of the right ureter.
parenchymal volume is preserved. There are mild right
perinephric inflammatory changes.
Figure 2.78 Coronal image: IV contrast enhanced

Bilateral ureteric stents are noted. Both ureters are
thickened with abnormal soft tissue seen at the left
renal hlium, suggestive of retroperitoneal fibrosis.
Subcapsular haematoma is noted adjacent to the left
kidney.
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80 Chapter 2
and inflammatory abdominal aneurysms cause medial RENAL TRANSPLANT DYSFUNCTION

deviation of the ureters.
Delayed phase contrast enhanced CT imaging Renal transplantation is an increasingly important
opacifies the pelvicalyceal system, ureters and surgical treatment for end stage chronic kidney
bladder. This technique is useful in detecting ureteric disease, negating the need for lifelong dialysis and its
strictures or carcinomas, bladder carcinoma (TCC) complications. A basic understanding of the common
and non-calcified calculi. This protocol can be used surgical techniques and resulting anatomy is essential
to differentiate between parapelvic cysts and true to allow accurate interpretation of renal transplant
hydronephrosis. pathology. The transplanted kidney is usually situated
Discussion with interventional radiology regarding in the extraperitoneal space in the right iliac fossa.
placement of a nephrostomy in an recommended The exact type of arterial anastomosis depends on the
hydronephrotic kidney should be recommended at the nature of the transplanted kidney. Kidneys from living
end of the report. donors are normally grafted via either an end-to-end
anastomosis of the donor renal artery and the recipient
Key points internal iliac artery or an end-to-side anastomosis of the
• First-line investigation should always be donor renal artery to the recipient external iliac artery.
ultrasound, on which a dilated pelvicalyceal system Cadaveric kidneys are typically harvested with a segment
is diagnostic. Cortical thickness is important in of aorta, which is attached to the external iliac artery
deciding whether the obstruction is chronic or via an end-to-side anastomosis. The venous anatomy
acute. is more consistent; the donor renal vein is attached via
• CT is very useful in identifying the cause for the an end-to-side anastomosis with the external iliac vein.
hydronephrosis. Protocols should be tailored to The donor ureter is usually implanted directly into the
the age of the patient and clinical suspicion. dome of the bladder.
It is important that any potential complications of
Report checklist renal transplantation are identified as quickly as possible
• Characterise the degree of hydronephrosis as mild, in the early postoperative period, since they can result in
moderate or severe. loss of the graft. Potential complications include renal
• Identify the level of obstruction and presence or artery/vein thrombosis, renal artery stenosis, acute
absence of an impacted ureteric calculus. A focal tubular necrosis, infection, perigraft fluid collections,
ureteric calibre change can suggest a pathology hydronephrosis and rejection (hyperacute, acute and
even if an abnormality cannot be seen. chronic).
• Presence or absence of signs of an infected Renal transplant dysfunction should be suspected in
system – this warrants emergency intervention the presence of deranged renal function or absence of
with a nephrostomy. normalising renal function in the early postoperative
• In cases of hydronephrosis emphasise the need for period. Other more non-specific symptoms and signs,
an urgent urological review. such as pain, pyrexia, hypertension and anuria, can also
be seen. Acute vascular complications, such as renal
artery and vein thrombosis, are less commonly seen
outside of the perioperative period. While there are
some non-specific imaging findings of graft rejection,
ultimate diagnosis requires renal biopsy.
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Radiological investigations The overall length of the renal graft should be

Ultrasound is the initial imaging modality of choice, documented during any ultrasound scan. Graft
allowing assessment of the renal graft, surrounding enlargement may indicate acute infection or rejection
soft tissues and Doppler assessment of the major renal and renal vein thrombosis, whereas graft atrophy may
vessels. CT can be used to troubleshoot scenarios where be seen in chronic rejection. CMD in a transplanted
ultrasound is indeterminate (i.e. where the main renal kidney is often not as pronounced as in a normal
artery/vein cannot be identified), although IV contrast kidney; however, it should still be present. The
should be used with caution in patients with impaired cortical echogenicity should be similar to that of the
renal function. Both an arterial and a portal venous liver. Loss of CMD, prominence of the medullary
phase are required for full assessment of vascular and pyramids and cortical thinning are all non-specific
parenchymal complications. Radionucleotide imaging signs of graft dysfunction. Focal areas of increased/
also plays an important role and can help differentiate decreased echogenicity may indicate focal oedema or
between different pathologies where ultrasound infarction.
findings are non-specific. (See Table 2.28.) The Doppler flow of the graft should be assessed
globally. Doppler flow should be uniform throughout
Radiological findings the graft (Figure 2.79); a focal area of decreased flow
Ultrasound is suspicious for an infarct. The main, upper, mid and
As with any postoperative imaging, it is important lower pole interlobar renal arteries and veins should
to obtain a precise description of the operation and be assessed with Doppler ultrasound. Absent flow in
expected anatomy before undertaking ultrasound any of these may indicate arterial/venous thrombosis,
assessment of a renal graft. Before starting the scan, be an important early post-surgical complication, which
sure to identify the transplant site, usually in the right should be urgently communicated to the referring
iliac fossa, and remove any potential wound dressing team. Waveforms from these vessels should be sampled
that can cause an artefact. and analysed. Familiarity with the ‘normal’ arterial
Table 2.28 Renal transplant dysfunction.

Imaging protocol.
MODALITY PROTOCOL
Ultrasound Curvilinear, 4 MHz probe. Doppler and wave-
form sampling of renal vessels.
CT Aortic angiogram: 100 ml IV contrast via 18G
mid-abdominal aorta. Scan from just above
Portal venous phase: IV contrast as above,
scan at 70 seconds. No oral contrast. Scan
from just above diaphragm to femoral head
Figure 2.79 Longitudinal image: colour Doppler
level.
ultrasonogram of the transplant kidney. Colour flow is
seen at the renal hilum, which extends through the renal
sinus and into the medulla uniformly.
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82 Chapter 2
waveform is essential (Figures 2.80, 2.83) – this should collecting system can remain mildly dilated post renal
demonstrate a rapid systolic upstroke and positive transplantation, therefore it is essential to compare with
diastolic flow. A ‘parvus tardus’ waveform (a broadening previous imaging for evidence of progressive dilatation.
of the waveform, with an increase in the acceleration Echogenic material within the collecting system can
time of the systolic upstroke) is commonly seen in renal indicate pyelonephrosis.
artery stenosis (Figures 2.81, 2.84). Elevation of flow
in the main renal artery (>200cm/sec) may also be seen
in this condition. Reversal of arterial flow in diastole
is often an indicator of renal vein thrombosis or acute
tubular necrosis, both common early postoperative
complications (Figure 2.82). The Resistive Index (RI;
Figure 2.85) should be calculated for the main and
interlobar renal arteries and should be less than 0.8;
any elevation of the RI is again an indication of graft
dysfunction (Brown et al., 2000). Pseudoaneurysms can
complicate renal biopsy, appearing as focal hypoechoic
lesions, distinguished from cysts by a turbulent internal
flow on Doppler analysis. Ultimately, if there is doubt as
to whether any vascular abnormality is due to technical
factors, further assessment with CT is advisable.
Ureteric obstruction and hydronephrosis can be
caused by postoperative ureteric fibrosis, usually at
the site of ureteric and bladder anastomosis, although
other causes include infection or compressing fluid Figure 2.80 Diagram of a normal renal artery
collections. Note: Because of denervation, the waveform.
Figure 2.81 Diagram of abnormal ‘parvus-tardus’ renal Figure 2.82 Diagram of abnormal renal artery
artery waveform. waveform demonstrating reversed diastolic flow.
K22247_C002.indd 82 16/05/15 3:07 AM

Perinephric fluid collections are commonly

seen in the early postoperative period and include
haematomas, lymphoceles and urinomas. The size
of any fluid collection should be documented, along
with any evidence of mass effect or adjacent structure
compression. The presence of heterogeneously
echogenic material suggests haematoma, a small
amount of which is not uncommon in the early
postoperative period. Both urinomas and lymphoceles
appear as well-defined hypoechoic fluid collections
and are indistinguishable on ultrasound imaging;
however, urinomas are often associated with pain and
are usually seen earlier in the postoperative period than Figure 2.83 Pulsed wave Doppler ultrasonogram of
lymphoceles, which are typically seen later (5–6 weeks). the renal artery. The normal waveform demonstrates
Ultimate diagnosis often requires percutaneous a rapid systolic upstroke of short duration, followed by
aspiration or drainage. decreased flow. Continuous diastolic flow should always
be observed.
Computed tomography
The principles of CT interpretation mirror that of
ultrasound. The renal graft, commonly identified
in the right iliac fossa, should demonstrate uniform
enhancement on the portal venous phase (Figure 2.86).
Figure 2.84 Pulsed wave Doppler ultrasonogram of

Peak systolic flow − Peak diastolic flow
RI = the renal artery. There is reduced amplitude of the
Peak systolic flow waveform with prolonged systolic upstoke, which is
typically described as a ‘parvus-tardus’ waveform.
Figure 2.85 The Resistive Index.
Figure 2.86 Axial image: IV contrast enhanced CT

scan of the pelvis in the portal venous phase. The renal
transplant located in the right iliac fossa demonstrates
uniform parenchymal and vascular enhancement. A left
iliac fossa colostomy is also present.
K22247_C002.indd 83 16/05/15 3:07 AM

84 Chapter 2
Infarcts appear as focal wedge-shaped areas of Key points

hypoattenuation. The renal artery should be traced • Complications of renal transplantation include
from its site of anastomosis to the renal hilum on the infection, renal artery/vein thrombosis,
arterial phase. Failure to identify the renal artery, or perinephric fluid collections, acute tubular
a filling defect within, is suggestive of thrombosis. necrosis, renal artery stenosis, hydronephrosis and
Any focal narrowing of the renal artery should raise rejection (hyperacute, acute and chronic).
suspicion of stenosis, although this may require • Ultrasound imaging allows accurate assessment
catheter angiography to diagnose definitively. The of the renal parenchyma, collecting system, major
renal vein should also be inspected for filling defects, vessels and surrounding structures. Failure to
which may represent thrombosis. The ureter should be identify the renal artery on Doppler ultrasound is
followed through to its anastomosis with the bladder; a surgical emergency. Further assessment with CT
this can be difficult in the absence of any ureteric can be helpful in these situations.
dilatation. The collecting system should be inspected • Elevation of the RI (>0.8) is suggestive of graft
for hydronephrosis and hyperattenuating material dysfunction.
within; the latter can represent clot or infection.
The precise appearance of perinephric haematoma Report checklist
depends on the age of blood products within, although • Document the RI and acceleration times of the
it generally appears heterogeneous with areas of major renal vessels and flow in the renal vein.
increased attenuation. Although a small amount • Presence or absence of hydronephrosis.
of perinephric haematoma is common in the early • Presence or absence of complications, such as
postoperative period, the presence of this should always renal infarcts and perinephric collections.
prompt the search for active bleeding, appearing as a
hyperattenuating contrast blush on the arterial phase. Reference
As with ultrasound, it is difficult to distinguish between Brown E, Chen M, Wolfman N et al. (2000)
urinomas, lymphoceles and infected fluid collections, Complications of renal transplantation: evaluation
which can all appear as low-density (<20 Hu) enhancing with US and radionuclide imaging. RadioGraphics
fluid collections (Figure 2.87). 20:607–622.

scan of the pelvis in the portal venous phase. There is
a uniform low attenuation fluid collection adjacent to
the renal transplant in the right iliac fossa. Subsequent
percutaneous aspiration confirmed a urinoma. A stent is
seen within the renal pelvis.
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LIVER TRANSPLANT DYSFUNCTION and inferior margins of the IVC are usually end-to-end
anastomoses (Crossin et al., 2003).
Liver transplantation has long been an accepted
treatment for end-stage liver failure, with innovative Radiological investigations
techniques such as living donor and split liver Ultrasound is the initial modality of choice. Patients
transplantation now commonplace. A wide variety in the immediate postoperative period may be unwell
of complications can occur after transplantation, and immobile and in such cases a portable scan may
some more common in the early postoperative be necessary. Colour Doppler imaging is essential in
period. Symptoms and signs vary according to the the assessment of liver transplants and allows dynamic
precise pathology; however, one of the most common evaluation of flow through the hepatic vasculature, with
presentations is delayed or deteriorating liver function. individual assessment of the hepatic artery, IVC and
Assessment of a transplanted liver can often be portal vein required for a complete assessment.
a difficult task, especially in the emergency setting. Further evaluation may be performed with contrast
Urgent diagnosis, particularly of vascular complications enhanced CT in situations where ultrasound has
in the early postoperative period, is vital since some yielded an indeterminate result. Dual phase imaging
complications can result in loss of the graft. There (arterial and portal venous phase) is often performed
are numerous non-vascular complications, including through the upper abdomen in order to fully evaluate
biliary stenosis, biliary leakage and acute and chronic the vascular supply to the liver in addition to the hepatic
graft rejection. The urgency of diagnosis should be parenchyma. (See Table 2.29.)
dictated by the urgency of management, and as such
not all complications require out of hours imaging. Radiological findings
A thorough understanding of the surgical anatomy is Ultrasound
crucial in order to aid image interpretation and identify The parenchymal echogenicity of the hepatic graft
abnormalities. Variations in vascular supply and local should be scrutinised on grey scale imaging. Diffuse
preferences for particular surgical techniques should abnormalities have a wide differential, which include
be taken into consideration, as they may determine the rejection and ischaemia. The appearances can be
type of surgery performed. There are also anatomical
differences between adult and paediatric liver Table 2.29 Liver trasplant assessment. Imaging
transplants (e.g. split versus whole liver transplant), protocol.
which are important when identifying structures on
imaging. It is therefore advisable to become familiar MODALITY PROTOCOL
with the surgical history of individual patients prior to Ultrasound Low frequency curvilinear probe (e.g.
imaging, to better interpret the anatomical findings. 1–5MHz) for assessment of the liver vascula-
ture, subphrenic space and upper abdomen.
In general, the donor common bile duct is
A high frequency linear probe (e.g. 6–9MHz)
anastomosed to the recipient common hepatic duct. may be useful for higher resolution parenchy-
However, if this is not possible, the common bile mal images.
duct may be anastomosed directly into a loop of CT Arterial phase: 100 ml IV contrast via 18G
jejunum (Bhargava et al., 2011). Donor transplants will cannula, 4 ml/sec. Bolus track centred on mid-
routinely undergo cholecystectomy. There can be some abdominal aorta. No oral contrast. Diaphragm
to iliac crests. Helical acquisition, 1 mm slice
variability in the type of hepatic artery anastomosis,
thickness. Scan on inspiration.
but it is usually formed by the union of the donor
Portal venous phase: IV contrast as above,
coeliac axis and the recipient hepatic artery. The site scan at 70 seconds post contrast. No oral
of anastomosis is important to identify in order to contrast. Diaphragm to pubic symphysis.
accurately perform and interpret Doppler studies. The Helical acquisition, 1 mm slice thickness. Scan
on inspiration.
portal vein anastomosis is an end-to-end anastomosis
provided the vessels are patent. Finally, the superior
K22247_C002.indd 85 16/05/15 3:07 AM

86 Chapter 2
non-specific, but may be seen as a heterogeneous narrowing. Similarly, an increase in the peak systolic
echotexture. In cases of rejection, there are often no velocity may also be observed. Severely stenotic arteries
correlating features with Doppler studies. Liver infarcts may eventually thrombose and show no flow. Pulse-wave
occur most commonly in the early postoperative period, Doppler classically shows a ‘parvus-tardus’ waveform in
and present as focal, wedge-shaped areas of decreased stenosed vessels (i.e. increased peak systolic acceleration
echogenicity. Abnormal Doppler waveforms may be time [>0.08 sec] with a slow deceleration) (Figure 2.89).
recorded in cases of infarction. The RI is a measure of the resistance to blood flow
Hepatic artery complications account for the largest and can also be a useful tool in the assessment of the
proportion of vascular complications, which include post-transplant liver (see Figure 2.85, p. 83). Normal RI
thrombosis and stenosis. Hepatic artery thrombosis is values range between 0.5 and 0.8. In the postoperative
a surgical emergency due to the high risk of ischaemia period, RI values may be elevated for several days, but
and infarction to the transplant. In addition to this, they should generally reduce to normal limits. Elevated
the bile ducts receive their blood supply solely from RI values may be a sign of organ rejection or venous
the hepatic artery, and so thrombosis of the vessel may outflow obstruction.
lead to biliary duct ischaemia and stricture formation. Portal vein abnormalities are relatively rare. The
An appreciation of the normal hepatic artery flow and commonest complications include portal vein stenosis
waveform is useful in order to identify abnormalities. and thrombosis. The normal portal vein is anechoic
The normal hepatic artery demonstrates a pulsatile with thin, regular walls and uniform calibre. Acute
waveform with a rapid systolic upstroke and continuous thrombus within the portal vein may present as
diastolic blood flow (Figure 2.88). echogenic material within the lumen of the vessel with
Absent flow within the hepatic artery with colour reduced or no flow on colour Doppler.
and pulse-wave Doppler imaging allows for correct Complications involving the IVC are uncommon
diagnosis of hepatic artery thrombosis in the majority of but include thrombosis and IVC stenosis at the
cases. Assessment should be made of the extrahepatic, anastomotic site. Clinical features are those of Budd–
intrahepatic and right and left branches of the artery. Chiari syndrome and include hepatomegaly, ascites and
Hepatic artery stenosis tends to occur at the site of pleural effusions, which may be seen on ultrasound.
the anastomosis. Colour flow may demonstrate post- Biliary complications are relatively common
stenotic turbulent flow depending on the degree of following transplant and include leaks and stricture
Figure 2.88 Doppler ultrasonogram of the hepatic Figure 2.89 Doppler ultrasonogram of a stenotic
artery. The waveform demonstrates a sharp systolic hepatic artery. The deceleration time of the waveform is
upstroke and short deceleration time with c ontinuous prolonged resulting in a ‘parvus-tardus’ waveform.
diastolic flow. Measurements have been made
documenting the peak systolic and end diastolic values
with the calculated Resistive Index of 0.63.
K22247_C002.indd 86 16/05/15 3:07 AM

formation. Bile leaks may be seen in the immediate Report checklist

postoperative period, and may be seen as anechoic • Presence and quality of colour and Doppler flow
fluid collections lying in close proximity to the liver. within the hepatic artery, portal vein, hepatic veins
Strictures may form at the anastomotic site or as a result and IVC.
of hepatic artery dysfunction. In general, however, these • Comment on the parenchyma and the presence
do not tend to occur in the immediate postoperative of any focal abnormalities that may represent liver
setting. On ultrasound, strictures may be seen as a infarcts in the acutely unwell patient.
narrowing of the luminal diameter of the common bile • Signs of portal hypertension.
duct at the anastomotic site. Significant strictures may
result in biliary obstruction and intrahepatic biliary References
duct dilatation. Bhargava P, Vaidya S, Dick AA et al. (2011) Imaging
of orthotopic liver transplantation: review. Am
Computed tomography J Roentgenol 196:WS15–25.
Multidetector CT imaging provides detailed resolution Caiado A, Blasbalg R, Marcelino A et al. (2007)
of the hepatic vascular anatomy. Arterial phase imaging Complications of liver transplantation:
allows for detailed assessment of the hepatic artery, multimodality imaging approach. Radiographics
while portal phase imaging provides optimal assessment 27:1401–1417.
of the portal vein, hepatic veins and IVC. Each phase Crossin JD, Muradali D, Wilson SR (2003) US of liver
allows for assessment of the vascular patency and transplants: normal and abnormal. Radiographics
calibre of the appropriate structures, as well as allowing 23:1093–1114.
for appraisal of the integrity of the anastomoses. The
main limitation of CT is the inability to assess flow
patterns within vessels, and it should therefore be used
as an adjunct to ultrasound.
Imaging of the hepatic vasculature follows the same
principles regardless of the vessel being assessed on
contrast enhanced CT. Opacification of the vessel
lumen, anatomical course and anastomotic site should
all be assessed for each vessel individually (Figure 2.90).
The liver parenchyma is best assessed on portal
phase images. Liver infarctions are seen as wedge-
shaped areas of low attenuation/non-enhancing tissue.
Perihepatic complications such as haematoma or
biloma can be easily seen as hypodense fluid collections
adjacent to the liver (Caiado et al., 2007).
Key points
• Assessment of the transplanted liver should
be performed with reference to the surgical
procedure and correlated appropriately. Figure 2.90 Axial image: IV contrast enhanced CT
• Ultrasound with use of colour and pulse-wave scan of the abdomen in the portal venous phase. The
Doppler is vital to assess the hepatic vascular hepatic artery is thready and poorly opacified at the
supply and drainage. porta hepatis due to thrombosis. A wedge-shaped area of
• CT may help to clarify anatomical details, but non-enhancing liver is shown on the right, representing
should be used in addition to ultrasound to assess infracted parenchyma as a result of the thrombosed
flow dynamics. hepatic artery (arrow).
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88 Chapter 2
TUBO-OVARIAN ABSCESS Table 2.30 Tubo-ovarian abscess. Imaging

protocol.
Pelvic inflammatory disease is a broad term used to
describe infection of the female genital tract. Tubo- MODALITY PROTOCOL
ovarian abscess is a well-recognised complication of Ultrasound 1–5MHz curvilinear probe to perform a
pelvic inflammatory disease, and occurs as a result of transabdominal scan.
ascending vaginal infection, which may spread to the CT Post IV contrast, portal venous phase: 100 ml
endometrium, fallopian tubes or ovaries and is then IV contrast, 4 ml/sec via 18G cannula. Scan
at 70 seconds. Scan from above diaphragm
complicated by abscess formation. If left untreated, it to femoral head level.
has the potential to cause severe sepsis.
Patients may present with fever, pelvic pain and
vaginal discharge, although these features are non- reporting such studies; it is therefore not discussed in
specific. Typically, patients are young females who may detail. (See Table 2.30.)
or may not have a history of pelvic inflammatory disease.
Patients presenting acutely may have a wide differential Radiological findings
diagnosis, which includes appendicitis, diverticulitis or Ultrasound
endometriosis. As a result, it is an important condition The normal pelvis does not contain fluid-filled
to be aware of when scanning an acutely unwell female, structures, although small traces of physiological fluid
as it may masquerade as other entities. may be present in the pouch of Douglas. Typically,
patients with tubo-ovarian abscess develop adnexal
Radiological investigations abscesses, which may be seen as complex, multilocular
Given the often non-specific nature of the clinical cystic masses. These often extend behind the uterus
presentation, tubo-ovarian abscess may not necessarily and into the pouch of Douglas. The cystic components
be diagnosed easily. However, imaging can be very within the masses may be simple or they may have
useful in aiding diagnosis in conjunction with clinical complex features with thick irregular walls/septations
and biochemical findings. with debris within them. Free fluid may also be seen
Ultrasound is the imaging modality of choice in within the pelvis.
patients with suspected tubo-ovarian abscess, as it In cases of pyosalpinx, adhesions may form within
allows a thorough assessment of the adnexa while the fallopian tubes, causing blockages. This allows pus
avoiding ionising radiation. Unfortunately, if the to collect within the tube and may appear as a tubular,
diagnosis is not considered, patients may proceed cystic structure within the adnexa.
initially to CT; although this often confirms the
diagnosis, the added radiation dose makes this less Computed tomography
favourable. Transabdominal scanning of the pelvis is The findings on CT correspond to the appearance
usually adequate to assess the pelvic structures, with the demonstrated on ultrasound; however, the overall
patient scanned with a full urinary bladder. However, if extent of the disease may be better delineated on cross-
the adnexa are not clearly imaged, a transvaginal scan sectional imaging. Tubo-ovarian abscesses are shown
may be warranted if the experience of the operator as thick-walled cystic masses on contrast enhanced
allows this. CT with internal septations (Wilbur et al., 1992,
CT is often performed to identify the cause of pelvic Figures 2.91–2.94). Other less specific features of tubo-
pain of uncertain origin. MRI is a preferred option to ovarian abscess include inflammation and thickening of
CT, as this can clearly delineate the adnexal structures the uterosacral ligaments and rectosigmoid colon when
without the use of ionising radiation. This is not there is posterior extension of the inflammatory mass.
routinely available out of hours, nor is the expertise in Para-aortic lymphadenopathy may also be present.
K22247_C002.indd 88 16/05/15 3:07 AM

scan of the pelvis in the portal venous phase. There are scan of the pelvis in the portal venous phase. There is
enhancing, tubular structures within both adnexa, which a significant amount of stranding of the fat around the
contain low density material consistent with bilateral uterus due to local inflammation.
pyosalpinx (arrow). There is stranding of the adjacent fat
due to local inflammation.
Figure 2.93 Coronal image: IV contrast enhanced CT Figure 2.94 Sagittal image: IV contrast enhanced CT
scan of the pelvis in the portal venous phase. There are scan of the pelvis in the portal venous phase. There is
enhancing, tubular structures within both adnexa, which a rounded structure seen posterior to the mid uterus
contain low density material consistent with bilateral in keeping with pyosalpinx, with a second collection
pyosalpinx. There is stranding of the adjacent fat due to seen more superiorly, which would be consistent with a
local inflammation. tubo-ovarian abscess (arrow).
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90 Chapter 2
Key points OVARIAN TORSION

• Tubo-ovarian abscess can be a difficult diagnosis
to make given the non-specific symptoms that may Gynaecological causes of pelvic and abdominal pain
be present and the myriad of other mimicking are common in women across a range of ages. The
pathologies. most critical of these is acute ovarian torsion. Although
• Diagnosis can be made effectively on ultrasound a relatively rare condition, misdiagnosis can have
but may be encountered on CT when imaging the significant implications for the patient, resulting in
acutely unwell patient. ovarian necrosis and peritonitis. Similar to testicular
torsion, ovarian torsion occurs when the vascular
Report checklist pedicle supplying the ovary twists about the broad
• Document whether the abnormality is unilateral ligament. This initially results in venous outflow
or bilateral. obstruction causing marked congestion, eventually
• Presence or absence of a drainable collection. leading to arterial compromise and infarction of the
• Consider the differential diagnosis of affected ovary. Suggested predisposing factors include
gynaecological malignancy. large ovarian cysts and cystic neoplasms (Chang et al.,
2008). Previous episodes of pelvic inflammatory disease
Reference and endometriosis may reduce the likelihood of torsion
Wilbur AC, Aizenstein RI, Napp TE (1992) CT owing to the increased incidence of adhesions, which
findings in tuboovarian abscess. Am J Roentgenol act to immobilise the ovary.
158:575–579. Acute iliac fossa and pelvic pain is a common clinical
presentation in women and can prove difficult to
manage. The various pathologies that may mimic the
presenting symptoms can be difficult to distinguish
and include appendicitis, diverticulitis and renal colic
(Duigenan et al., 2012). The role of imaging is often to
help differentiate between these entities, in conjunction
with clinical and biochemical findings.
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Radiological investigations seen. The presence of arterial flow does not exclude
The often non-specific presentation of ovarian torsion torsion, as sporadic flow may be seen in an intermittent
can make diagnosis difficult, and as a result the most torsion.
appropriate form of imaging may not always be clear.
However, in cases where ovarian torsion is suspected, Computed tomography
ultrasound is the initial imaging modality of choice. CT of the pelvis may be performed for the assessment
A transabdominal scan should be adequate to establish of abdominal pain. The principal finding, as seen on
the diagnosis with a well distended urinary bladder, ultrasound, is a unilateral enlarged heterogeneous
but in more difficult cases a transvaginal scan may be
necessary. CT imaging may be performed, although
the findings are more non-specific and it is not
recommended in the first instance. (See Table 2.31.) Table 2.31 Ovarian torsion. Imaging protocol.
Radiological findings MODALITY PROTOCOL

Ultrasound Ultrasound Low frequency curvilinear probe
The principal sonographic finding of ovarian torsion (e.g. 1–5 MHz). Images should be acquired
is unilateral enlargement of the affected ovary of both adnexa to demonstrate the size and
(>4 cm), which occurs due to venous congestion vascularity of both ovaries.
(Figure 2.95). Affected ovaries may also demonstrate
abnormal echogenicity within the parenchyma. It is
therefore important to assess the contralateral ovary
for comparison of ovarian size and volume as well as
for abnormal unilateral parenchymal changes. The
ovaries should be closely scrutinised for an underlying
mass lesion, as these are often present and predispose
to torsion. Another feature that should be assessed is
the distribution of follicles within the ovary. In normal
patients, follicles of varying sizes can be seen randomly
distributed throughout the ovaries. However, in cases of
torsion, the follicles tend to be peripherally distributed.
Free fluid within the pelvis may be seen, which is a non-
specific sign.
Colour Doppler is an important tool for assessing
blood flow within the ovary. Completely absent
arterial flow within the ovary is the classic feature Figure 2.95 Ultrasonogram of the left ovary in the
that may be observed. However, more subtle findings longitudinal plane. The ovary is enlarged with increased
such as reversed or absent diastolic flow may be heterogeneous echogenicity.
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92 Chapter 2
ovary, which may be abnormally positioned in the Report checklist

midline (Figures 2.96, 2.97). Inflammatory fat stranding • Presence or absence of colour Doppler flow
may be seen in the adjacent tissues of the pelvis as well as within the ovary.
small volumes of free fluid. Contrast enhanced CT may • Presence or absence of an adnexal mass as a
reveal abnormal ovarian enhancement and engorged predisposing factor.
vessels on the affected side. • Consider differential diagnoses such as ovarian
malignancy.
Key points
• Ovarian torsion is a relatively rare, but clinically References
significant condition that requires urgent surgical Chang HC, Bhatt S, Dogra VS (2008) Pearls and
intervention. pitfalls in diagnosis of ovarian torsion. Radiographics
• The condition may present with non-specific 28:1355–1368.
signs and symptoms, which may make diagnosis Duigenan S, Oliva E, Lee SI (2012) Ovarian torsion:
difficult. diagnostic features on CT and MRI with pathologic
correlation. Am J Roentgenol 198:W122–W131.
Figure 2.96 Axial image: IV contrast enhanced Figure 2.97 Axial image: IV contrast enhanced CT
CT scan of the pelvis in the portal venous phase. scan of the pelvis in the portal phase. There is a large,
A heterogeneous fat-containing adnexal mass is non-enhancing left adnexal mass with adjacent fluid
shown in the midline, representing a torted dermoid and inflammatory changes within the adjacent tissues
cyst (arrow). consistent with a left ovarian torsion.
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TESTICULAR TORSION Radiological findings

Ultrasound
Testicular torsion is a urological emergency occurring Within the first 6 hours, the affected testicle may
most frequently in adolescent boys and with an be slightly enlarged, with normal or decreased
incidence of 1 in 160 (Chen & John, 2006). Torsion echogenicity (Figures 2.98, 2.99). With increasing
occurs when an abnormally mobile testis twists on the
spermatic cord, obstructing its blood supply. Typical
symptoms and signs include acute onset of severe
testicular pain, nausea and vomiting, and a high riding/
transverse lying testicle. The ischaemia can lead to
testicular necrosis if not corrected within 5–6 hours
of the onset of pain. Torsion can be intermittent and
can undergo spontaneous de-torsion. There are many
other conditions mimicking testicular torsion, such as
epididymitis and torsion of the testes appendage, which
can make clinical diagnosis difficult.
Prompt diagnosis and early treatment is essential as
time is critical for testicular salvage. If clinical suspicion
is high, imaging is not indicated and the patient should
be taken to theatre for an exploration. For indeterminate
cases, imaging may be requested, more often than not
to investigate or exclude alternative pathologies. It is
important to emphasise that imaging cannot exclude
testicular torsion, since the torsion may be intermittent Figure 2.98 Ultrasonogram of both testes in the
in nature. The patient should always undergo surgical transverse plane. The right testicle is enlarged
exploration if clinical suspicion is high. compared with the left, with a heterogeneous, coarsened
echotexture.
Imaging of the testes is by ultrasound. Sonographic
signs may be very subtle in the early period. Always
commence with examination of the clinically normal
testes. The settings for colour Doppler should be
adjusted such that background noise is just visible. (See
Table 2.32.)
Table 2.32 Testicular torsion. Imaging

protocol.
Figure 2.99 Ultrasonogram of both testes in the

MODALITY PROTOCOL
transverse plane. There is a central area of abnormally
Ultrasound 6–9 MHz linear probe. low echogenicity within the left testicle, with a rim of
apparently normal testicular tissue.
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94 Chapter 2
time from symptom onset, the affected testicle shows When blood flow is absent in the affected testicle, the
decreased echogenicity and appears heterogeneous diagnosis of testicular torsion is clear (Figures 2.100a, b,
compared with the other side, which is a sign of poor 2.101a, b). Occasionally, decreased blood flow seen in
viability. A transverse view showing both testicles is early torsion can be erroneously diagnosed as normal.
useful for comparison. Comparison with the contralateral side is therefore
crucial.
(a) (b)
Figures 2.100a, b Ultrasonogram of the left testicle in the transverse plane. The testicle demonstrates abnormal,
coarsened heterogeneous echotexture. There is absent flow within the testicle on colour Doppler imaging.
(a) (b)
Figures 2.101a, b Ultrasonograms of the left testicle in the transverse and longitudinal planes. There is an
abnormal area of central low echogenicity within the testicle. On colour Doppler imaging, peripheral flow can be
seen within the epididymis and surrounding structures, but is absent within the testicle itself.
K22247_C002.indd 94 16/05/15 3:07 AM

Other features of torsion may include enlargement Report checklist

of the epididymal head due to involvement of the • Presence of asymmetry in the testicular
differential artery and a reactive hydrocele. appearances, commenting on Doppler flow,
Testicular appendage torsion appears as a lesion of echogenicity and size.
low echogenicity with a central low echogenic area • Emphasise that even in the case of a ‘normal’
adjacent to the epididymis. Epididymitis appears as ultrasound, testicular torsion cannot be excluded.
a swollen, heterogeneous epididymis with scrotal
thickening, hydrocele and increased vascularity of the Reference
epididymis on colour Doppler. Chen P, John S (2006) Ultrasound of the acute scrotum.
As already highlighted, a normal study cannot Appl Radiol 35:8–17.
exclude the diagnosis; this should be emphasised to the
referring team.
Key point
• Testicular torsion is primarily a clinical diagnosis.
Ultrasound should only be used in situations
where the clinical diagnosis is uncertain.
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K22247_C002.indd 96 16/05/15 3:07 AM
Chapter 3
NEUROLOGY AND NON-TRAUMATIC

SPINAL IMAGING 97
STROKE corresponding imaging findings. Cell hypoxia

causes an ‘ischaemic cascade’, initially resulting in
Stroke can be defined as a rapid onset ischaemic or cytotoxic oedema. Vasogenic oedema occurs within
haemorrhagic insult to the brain, which can result in 4–6 hours. Due to collateralisation, the result is a core
permanent loss of brain parenchyma and permanent of necrosis surrounded by cells that are potentially
neurological deficit. The commonest clinical sign viable if perfusion is restored; the latter region is
of stroke is a focal neurological deficit. While other referred to as the penumbra. As infarction matures,
signs such as headache, reduced Glasgow Coma Score cell death results in encephalomalacia with secondary
(GCS) and vomiting are more typical of haemorrhagic volume loss.
stroke, clinical symptoms and signs cannot differentiate Urgent imaging is vital to identify ischaemic cases,
between either aetiology. The diagnosis of transient since these may be amenable to conventional antiplatelet
ischaemic attack (TIA) is a retrospective one, defined therapy and thrombolysis if the symptomatic period is
as a reversible neurological deficit that resolves within less than 3 hours. More novel treatments also include
24 hours. thrombectomy, although this is currently only available
Ischaemia is the commonest cause of stroke, seen in specialist centres.
in up to 80% of cases (Srinivasan et al., 2006). Most
ischaemic events are secondary to atherosclerotic plaque Radiological investigations
rupture resulting in in-situ thrombosis, and as such they Unenhanced CT imaging and MRI are the main
are heavily associated with atherosclerotic risk factors. imaging modalities used in acute stroke management.
Although rarer, cardiac emboli (or systemic emboli via CT imaging is readily available and is considered
a cardiac septal defect) are nonetheless potential causes, the initial modality of choice. Whilst CT imaging
and should be considered in the absence of appropriate is effective at identifying haemorrhage, it is not
risk factors and in younger patients. uncommon for CT to fail to identify the subtle
Stroke due to haemorrhage should not be confused signs of acute infarction and it is vital to appreciate
with haemorrhagic transformation of an ischaemic that ischaemic stroke cannot be excluded on CT in
event, which can occur in up to 40% of cases (Shiber the early symptomatic period. Depending of the
et al., 2010). Primary intracerebral haemorrhage is a centre, contrast enhanced CTA can also be used to
result of chronic vessel damage due to hypertension. identify an acute thrombus that may be amenable
Secondary causes of haemorrhage include trauma, to thrombectomy. MRI with diffusion weighted
vasculitis and an underlying lesion such as a Circle of sequences is more sensitive than CT at identifying
Willis aneurysm, an arteriovenous malformation or a ischaemic stroke in the hyperacute to acute period and
parenchymal mass lesion. can be used in cases of a normal CT study, although
An understanding of the pathophysiology of this should not delay potential thrombolytic therapy.
ischaemic stoke is necessary to appreciate the Both CT imaging and MRI are discussed subsequently,
K22247_C003.indd 97 16/05/15 3:08 AM

98 Chapter 3
although their exact use depends upon local protocol haemorrhage’ often has a predisposition for the basal
and availability. (See Table 3.1.) ganglia region, brainstem and cerebellum (Figure 3.1).
If haemorrhage is identified in a less typical location, it is
Radiological findings always important to consider alternative causes such as
Computed tomography underlying mass lesions, arteriovenous malformations
Unenhanced CT imaging is primarily used to exclude or venous sinus thrombosis (Figures 3.2, 3.3). In this
intracranial haemorrhage, which contraindicates scenario, contrast enhanced CT imaging should
potential therapies for ischaemic stroke. The be obtained to further characterise any possible
attenuation of blood products varies according to age. underlying cause. The size of any haemorrhagic focus
Acute haemorrhage appears as high attenuation material should be documented, as well as any evidence of mass
within the brain parenchyma. Typical ‘hypertensive effect; the latter is indicated on CT by surrounding low
attenuation representing vasogenic oedema, midline
Table 3.1 Stroke. Imaging protocol. shift and descent of the cerebellar tonsils below the
level of the foramen magnum (Figure 3.4).
MODALITY PROTOCOL Subtle CT signs of an acute ischaemic stroke include
CT Unenhanced. Scan from skull base level focal hyperdensity in a cerebral artery representing
to vertex. acute thrombus (hyperdense cerebral artery sign,
MRI Sagittal T1 weighted, axial T2 and proton Figure 3.5 ) and subtle loss of grey–white matter
density weighted, axial gradient echo and differentiation, which represents early cytotoxic
diffusion weighted imaging and coronal oedema (insular ribbon sign, Figure 3.6). Careful image
FLAIR sequences of the brain.
windowing (width 8 Hu, centre 32 Hu) has been shown
to increase detection of the latter subtle sign.
brain. Ill-defined hyperdense material centred on the brain. There is a small focal haemorrhage in the right
right frontal deep white matter, consistent with an acute frontal lobe with mild adjacent vasogenic oedema. This
hypertensive haemorrhage. is in an unusual position for a ‘hypertensive bleed’.
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Neurology and non-traumatic spinal imaging 99
Figure 3.3 Axial image: IV contrast enhanced CT scan Figure 3.4 Axial image: unenhanced CT scan of the
of the brain. After IV contrast administration, a small brain. There is a focal area of low attenuation centred
abnormal vessel is seen underlying the haemorrhage, in on the right basal ganglia. This causes effacement of
keeping with a vascular malformation (arrow). This is the right lateral ventricle and midline shift to the left.
the same patient as in Figure 3.2. Dependent intraventricular haemorrhage is also noted.
brain. There is a large area of low attenuation involving brain. There is subtle loss of the grey-white matter
the right parieto-occipital lobes with loss of grey-white differentiation of the right-sided insular ribbon (arrow),
matter differentiation consistent with acute stroke. consistent with acute right middle cerebral artery
The right middle cerebral artery is hyperdense due to infarction.
thrombus (arrow).
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100 Chapter 3
As an ischaemic stroke evolves, there is an increase vessel ischaemia (Figure 3.9). However, this should
in the degree of cytotoxic and vasogenic oedema, which not be confused with acute transependymal oedema,
has a typical CT appearance of wedge-shaped low which produces a similar appearance. Lacunar infarcts
attenuation that extends to involve the cerebral cortex present as small focal areas of low attenuation and
(Figure 3.7). It can be useful to classify the infarction in are another common finding in chronic small vessel
relation to its arterial territory. If the oedema does not ischaemia.
correspond to a particular arterial territory, alternative
causes should be considered (e.g. an underlying mass Magnetic resonance imaging
lesion). Haemorrhagic transformation of a formerly The principles of MRI interpretation mirror those
ischaemic stroke can also occur, which typically has the of CT. The signal characteristics of haemorrhage
appearance of petechial haemorrhage on a background on MRI characteristically alter with age (Table 3.2).
of cytotoxic oedema corresponding to a typical arterial Blood products characteristically cause a pronounced
territory. susceptibility artefact on gradient echo sequences,
Chronic infarcts can be identified by their typical CT which can increase sensitivity. Hyperacute to acute
appearance; wedge-shaped regions of cerebrospinal infarction is best identified on diffusion weighted
fluid (CSF) density (encephalomalacia), with secondary sequences as increased signal on diffusion imaging
signs of parenchymal volume loss such as ex-vacuo with corresponding decreased signal on ADC
ventricular dilatation (Figure 3.8). Periventricular mapping (Figures 3.10a, b); however, typical imaging
low attenuation often represents coexisting small characteristics of infarcts vary with time on these
Figure 3.7 Axial image: unenhanced CT scan of the

brain. Wedge-shaped area of low attenuation in the right Figure 3.8 Axial image: unenhanced CT scan of
middle cerebral artery territory, which extends to the the brain. Large area of low attenuation in the right
cortex, consistent with acute infarction. occipital lobe. This is of similar density to CSF, with
evidence of right cerebal volume loss and expansion of
the extra-axial CSF spaces.
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Table 3.2 Signal characteristics of

haemorrhage on MRI.
EVOLUTION MRI SIGNAL BIOCHEMISTRY

CHARACTERISTICS
Hours T1 isointensity Intracellular
T2 isointensity oxyhaemaglobin
Hours–2 days T1 isointensity Intracellular

T2 hypointensity deoxyhaemaglobin
2–7 days T1 hyperintensity Intracellular

T2 hypointensity methaemaglobin
1–4 weeks T1 hyperintensity Extracellular

T2 hyperintensity methaemaglobin
>4 weeks Peripheral T1 Extracellular

hypointensity haemosiderin
Central T2
hyperintensity with a
Figure 3.9 Axial image: unenhanced CT scan of the hypointense rim
brain. Low attenuation periventricular changes around
the frontal horns are consistent with small vessel
disease.
(a) (b)
Figures 3.10a, b Axial images: diffusion and ADC map of the brain. (3.10a) High signal is seen in the left frontal
lobe on diffusion images. (3.10b) The corresponding area on the ADC map is low signal, signifying restricted
diffusion as seen in acute stroke.
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102 Chapter 3
sequences. Care must be taken not to incorrectly CAROTID ARTERY DISSECTION

diagnose T2 ‘shine through’ phenomenon as restricted
diffusion, the former appearing as increased signal on Carotid artery dissection (CAD) is estimated to be an
diffusion weighted sequences without corresponding underlying cause in up to 25% of strokes in young and
decreased signal on ADC mapping. Vasogenic and middle-aged patients and should always be considered
cytotoxic oedema present as increased signal intensity in young patients presenting with acute onset
on T2 weighted and FLAIR sequences. A chronic neurological signs (Rodallec et al., 2008). Dissection
infarct appears as CSF density (increased signal on T2 can be both spontaneous and traumatic in aetiology,
weighted sequences, decreased signal on T1 weighted with traumatic cases associated with high-impact blunt
sequences and FLAIR suppression) with secondary head and neck trauma. Spontaneous dissections are
signs of volume loss. reported following trivial activities such as coughing,
sneezing and normal physiological neck movements.
Key points Where this is the case, underlying arteriopathies such
• Acute stroke can be both ischaemic and as connective tissue disorders should be suspected,
haemorrhagic in nature. including fibromuscular dysplasia, Ehlers–Danlos
• CT is the initial imaging modality of choice and syndrome, Marfan syndrome and polycystic kidney
should be performed immediately to exclude a disease.
haemorrhagic cause, although it can fail to identify Knowledge of the pathophysiology of dissection is
hyperacute to acute infarction. necessary to understand the relevant imaging findings.
• Important early CT signs of stroke include subtle Dissections can be caused by both an intimal tear
loss of the grey–white matter differentiation, leading to propagation of blood within the media, or by
hyperdense cerebral artery sign and insular ribbon primary intramural haematoma with resultant intimal
sign. Careful CT windowing (width 8 Hu, centre perforation. In classic dissections, an intimal flap is
32 Hu) has been shown to increase the sensitivity lifted away from the media; this results in the creation of
for subtle loss of grey–white matter differentiation. two channels within the aortic lumen (referred to as the
• MRI with diffusion weighted sequences is more true and false lumens). The severity of symptoms and
sensitive than CT at identifying infarction in the signs depends on the degree of vascular compromise,
hyperacute to acute period. but can include headache, neck pain, ipsilateral
Horner’s syndrome, pulsatile tinnitus, amaurosis fugax
Report checklist and focal neurology. Although there is currently a
• Presence or absence of haemorrhage. limited evidence base regarding appropriate treatment,
• Presence or absence of thrombus in the cerebral this may involve anticoagulation and therefore urgent
artery which, depending on the institution, may be diagnosis is vital.
amenable to immediate thrombectomy.
References Both CTA and magnetic resonance angiography
Shiber JR, Fontane E, Adewale A 2010 Stroke registry: (MRA) are sensitive and specific for CAD. The carotid
hemorrhagic vs ischemic strokes. Am J Emerg Med artery should be imaged from the aortic arch to the
28:331–333. Circle of Willis; both modalities can also be extended
Srinivasan A, Goyal M, Azri F et al. (2006) State-of- to image the brain to assess for the associated signs of
the-art imaging of acute stroke. RadioGraphics stroke. MRI can be more sensitive than CT for carotid
26:S75–S95. artery intramural haematoma (although this depends
K22247_C003.indd 102 16/05/15 3:08 AM

on the age of blood products) and the intracranial haematoma include eccentric/concentric mural
hyperacute signs of stroke. MRI is, however, more thickening causing narrowing of the lumen and an
time-consuming and may not be available out of hours. increase in the external calibre of the vessel (Rodallec
CTA is quick, can be incorporated into polytrauma CT et al., 2008). As cases progress, complete occlusion of
protocols in the context of a traumatic aetiology and the lumen can occur.
in most centres is considered the initial modality of
choice. The addition of unenhanced imaging increases
the CT sensitivity for intramural haematoma. Catheter
Table 3.3 Carotid artery dissection. Imaging
angiography has traditionally been used in the initial protocol.
assessment for CAD, but this is invasive, carries a
small risk of complications and should be reserved for MODALITY PROTOCOL
indeterminate CT and MRI cases where there is still a CT Unenhanced phase. Scan from aortic arch to
strong clinical suspicion of dissection. (See Table 3.3.) Circle of Willis.
Carotid angiogram: 100 ml IV contrast via
Radiological findings 18G cannula, 4 ml/sec. Bolus track centred
Computed tomography on aortic arch. Scan from aortic arch to
Unenhanced imaging should first be scrutinised for acute Circle of Willis.
intramural haematoma, which appears as eccentric/

concentric high attenuation within the carotid artery
wall; this may only be appreciated as wall thickening in
the presence of IV contrast (Figure 3.11). This should
not be confused with atheroma, which is generally low
to intermediate attenuation on unenhanced imaging,
often demonstrating calcification. The most common
site of CAD is just cranial to the carotid bifurcation.
Artefact from dental amalgam and beam hardening
artefact at the skull base can both create the impression
of high attenuation in the region of the carotid arteries,
which can be misinterpreted as intramural haematoma.
The brain parenchyma should be inspected for the
early subtle signs of stroke.
A classic dissection flap presents on CTA as a linear
low attenuation filling defect coursing across the
opacified carotid artery lumen, although this can be
difficult to appreciate because of the small calibre of
the vessel. The carotid arteries should be scrutinised Figure 3.11 Axial image: IV contrast enhanced
in axial, coronal and sagittal planes using multiplanar CT scan of the upper thorax in the arterial phase.
reformatting and wide window settings. Additional There is thickening of the right common carotid antery,
findings suggestive of dissection and intramural secondary to intramural haematoma (arrow).
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104 Chapter 3
Magnetic resonance imaging patients presenting with acute-onset neurological

Intramural haematoma may be appreciated on axial T1 signs.
fat saturated sequences, characteristically appearing as • Both CT and MRI are sensitive and specific and
crescenteric high signal surrounding a central flow void, play a role in investigating CAD, although CT is
which corresponds to the carotid artery (Figure 3.12). quicker and more readily available out of hours at
The age of the haematoma is important; in the first most centres.
few days, the haematoma consists predominantly of • Eccentric/concentric high attenuation and high
deoxyhaemaglobin and may be isointense (Rodallec signal is suggestive of intramural haematoma
et al., 2008). Intramural haematoma usually causes focal on unenhanced CT imaging and axial T1 fat
dilation of the vessel with corresponding narrowing/ saturated MRI sequences, respectively. Signs of
signal loss in the lumen, which is best appreciated on dissection on CTA and MRA include a dissection
MRA imaging (Figure 3.13). On time of flight MRA flap and focal luminal narrowing.
sequences, intramural haematoma can manifest as a rim
around the carotid artery, which displays signal intensity Report checklist
between that of the arterial flow and periarterial tissues. • In cases positive for intramural haematoma or
As with CT imaging, the brain parenchyma should dissection, document whether flow is seen in the
be scrutinised on MRI, particularly using diffusion carotid artery distal to the abnormality.
weighted sequences, looking for the signs of stroke. • Recommend further imaging of the brain to look
for ischaemia if not already performed.
Key points
• CAD can be spontaneous or traumatic in nature. Reference
Spontaneous cases are commonly associated with Rodallec MH, Marteau V, Gerber S et al. (2008)
connective tissue disorders. Craniocervical arterial dissection: spectrum
• The commonest symptoms are headache and neck of imaging findings and differential diagnosis.
pain. CAD should always be suspected in younger Radiographics 28:1711–1728.
Figure 3.12 Axial image: T1 fat saturated weighted

MR image of the neck. A rim of crescenteric high signal Figure 3.13 Axial image: MRA sequence of the neck.
is seen along the anteromedial wall of the left internal There is absent flow within the left internal carotid
carotid artery, representing intramural haematoma artery due to dissection. Normal flow patterns can be
(arrow). seen in the left external carotid, right internal/external
carotid and vertebral arteries.
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SUBARACHNOID HAEMORRHAGE symptoms, and a LP should always be performed

in ‘normal’ CT studies to prevent a false-negative
Subarachnoid haemorrhage (SAH) is defined as blood result. CT is the imaging modality of choice in the
within the space between the pial and arachnoid initial assessment of acute symptoms, with a reported
membranes and is a neurosurgical emergency. There sensitivity of 95% at 12 hours, although this falls to 75%
are many causes of SAH (Table 3.4); common causes at 72 hours. If the duration of symptoms is longer than
include trauma or the spontaneous rupture of ‘Berry’ this, it may be more appropriate to progress directly to
aneurysms of the Circle of Willis. Complications after LP as CT can yield a false-negative result. For more
initial subarachnoid bleeding include intracerebral subacute presentations, MRI should be considered
haemorrhage, hydrocephalus, cerebral oedema since it is more sensitive than CT. Both CTA and MRA
and raised intracranial pressure, vasospasm and can also be utilised (usually in the absence of a traumatic
re-bleeding. Classic symptoms and signs include an history) to determine the cause of SAH; however,
occipital ‘thunderclap’ headache and meningism,
although focal neurological signs and reduced GCS
can also be seen. Commonly used clinical grading tools
include the Hunt and Hess and the World Federation
of Neurosurgical Societies scales (Tables 3.5 and 3.6). Table 3.5 The Hunt and Hess scale.
Urgent diagnosis is vital to facilitate neurosurgical or
interventional radiological treatment such as coiling Grade 1 Asymptomatic or minimal headache and slight
neck stiffness. 70% survival.
or embolisation; however, the mortality rate in the first
month after bleeding is still estimated to be as high Grade 2 Moderate to severe headache; neck stiffness;
no neurological deficit except cranial nerve palsy.
as 40%. It is important to appreciate that radiology is
60% survival.
only part of the diagnostic pathway, which also involves
Grade 3 Drowsy; minimal neurological deficit. 50% survival.
CSF analysis for xanthochromia obtained from lumbar
puncture (LP). Grade 4 Stuporous; moderate to severe hemiparesis;
possibly early decerebrate rigidity and vegetative
disturbances. 20% survival.
Grade 5 Deep coma; decerebrate rigidity; moribund.
The decision to image with CT or MRI depends on the 10% survival.
symptomatic duration, since this affects the sensitivity
of both modalities. It should be emphasised that CT
cannot exclude SAH, regardless of the duration of
Table 3.6 The World Federation of

Neurosurgical Societies scale for
Table 3.4 Causes of subarachnoid grading subarachnoid haemorrhage.
haemorrhage.
Grade 1 GCS 15.
• Trauma.
Grade 2 GCS 13–14 without deficit.
• Ruptured Berry aneurysm.
Grade 3 GCS 13–14 with focal neurological deficit.
• Non-aneurysmal (perimesencaphalic) haemorrhage.
Grade 4 GCS 7–12.
• Arteriovenous malformation.
• Dural arteriovenous fistula. Grade 5 GCS <7.
• Spinal arteriovenous malformation.
GCS = Glasgow Coma Scale
• Venous infarction.
• Intradural arterial dissection.
• Cocaine use.
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106 Chapter 3
catheter angiography remains the gold standard in Radiological findings

this regard. Catheter angiography has the advantages Computed tomography
(compared with CT and MRI) of increased spatial SAH is confirmed on unenhanced CT imaging by
resolution and temporal information regarding vessel identifying high attenuation blood products in the
flow. (See Table 3.7.) subarachnoid spaces (Figures 3.14a, b), accentuated
by using blood window settings (width 175, level 50).
Common areas to miss subtle haematoma include the
Table 3.7 Subarachnoid haemorrhage. pre-pontine cistern, sylvian fissures, sulcal spaces near
Imaging protocol. the vertex and dependent parts of the ventricular system
(Figures 3.15a–c). The severity of SAH can be graded
MODALITY PROTOCOL with the Fischer scale (Table 3.8). In any CT scan that
CT Unenhanced. Scan from level of foramen does not identify SAH, it is important to emphasise in
magnum to vertex. the report that a ‘normal’ scan does not exclude SAH,
Intracranial angiogram: 100 ml IV contrast and further assessment with LP should be considered.
via 18G cannula, 4 ml/sec. Bolus track
centred on aortic arch. Scan from level of
aortic arch to vertex.
(a) (b)
Figures 3.14a, b Axial images: unenhanced CT scans of the brain. Hyperdense material is seen within the
suprasellar, pre-pontine and interpedicular cisterns consistent with acute SAH.
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(a) (b)
Figures 3.15a–c Axial images: unenhanced CT scans

(c)
of the brain. Serpiginous hyperdense h aemorrhage
can be seen within the sulcal spaces towards the
vertex (3.15a) and in the sylvian fissures (3.15b, c).
Intraventricular haemorrhage is also shown in a
dependent position in the occipital horns (3.15c).
It is important to inspect for the complications

of SAH. SAH can lead to diffuse intracerebral
oedema, which results in raised intracranial pressure.
This presents as generalised sulcal and basal
cistern effacement and reduced grey–white matter
differentiation. If severe, this can lead to tonsillar
descent, indicated by reduced CSF space at the
foramen magnum. Complicating ischaemia, which can
be venous in nature, appears as wedge-shaped areas of
Table 3.8 The Fischer scale. low attenuation involving the cortex. Hydrocephalus
can also occur, which if gross is readily apparent;
Group 1 No blood detected. however, more subtle signs include mild temporal horn
Group 2 Diffuse thin (<1 mm) SAH with no clots. prominence and third ventricle convexity.
All patients without a history of trauma should
Group 3 Localised clots and /or layers of blood >1 mm in
thickness. have further assessment with CT intracranial
angiogrography to assess for underlying causes such as
Group 4 Intracerebral or intraventricular blood (+/− SAH).
intracranial aneurysms or arteriovenous malformations.
Familiarity with the normal Circle of Willis anatomy
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108 Chapter 3
1 (a)
7 (b)
9 8
10
11 Figure 3.17a, b Axial images: IV contrast enhanced

CT angiogram scans of the brain. There are round,
well-defined aneurysms arising from the left middle
cerebral artery bifurcation (3.17a) and the distal
Figure 3.16 The normal Circle of Willis anatomy right middle cerebral artery towards the right sylvian
and common aneurysm locations. 1 = anterior fissure (3.17b, arrow).
communicating artery; 2 = anterior cerebral artery;
3 = middle cerebral artery; 4 = internal carotid artery; is essential (Figure 3.16). The Circle of Willis should
5 = posterior communicating artery; 6 = posterior be systematically scrutinised with appropriate
cerebral artery; 7 = superior cerebellar artery; image window settings, multiplanar reformats
8 = anterior inferior cerebellar artery; 9 = basilar and maximum intensity projection (MIP), looking
artery; 10 = vertebral artery; 11 = anterior spinal artery; for any focal vascular dilatation that is consistent
• = Common aneurysm locations. with aneurysm ( Figures 3.17a, b, 3.18a, b ).
Arteriovenous malformations usually manifest as a
focal cluster of dilated, serpiginous enhancing vessels
(Figures 3.19a, b).
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Sup/Ant
(a) (b)
Ant/Lft Post/Rt
s
A R
L P
I
Inf/Post
Figures 3.18a, b 3-D reconstructed MIP images showing a right internal carotid artery aneurysm (arrow).
(a) (b)
Figures 3.19a, b Axial T2 weighted MR image (3.19a) and MRA MIP image (3.19b) showing a right occipital
arteriovenous malformation. On the axial T2 image this is shown as multiple, serpiginous flow voids in the right
occipital lobe.
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110 Chapter 3
Key points SUBDURAL HAEMATOMA

• SAH is a neurosurgical emergency.
• Radiology plays a part in the diagnostic pathway, Subdural haematoma (SDH) is defined as an
which also includes LP. CT imaging cannot accumulation of blood between the dura and the
exclude SAH, and the sensitivity drops as the time arachnoid mater. Bleeding is venous in nature, due
from symptom onset increases. to the tearing of bridging cortical veins as they cross
• Careful image windowing is essential to identify the subdural space to drain into the adjacent dural
subtle haemorrhage. Review areas should include sinus. SDH can occur in any demographic following
the pre-pontine cistern cistern, sylvian fissures, significant trauma; however, it is more commonly seen
sulcal spaces near the vertex and dependent parts in the elderly, the anticoagulated and patients with
of the ventricular system. chronic alcohol dependence after a more innocuous
• Common complications include secondary injury. In the paediatric demographic with suspicious
venous ischaemia, cerebral oedema and history, SDH should prompt the possibility of non-
hydrocephalus. accidental injury. Symptoms and signs vary significantly,
• All patients with a non-traumatic history of but include headache, confusion, focal neurological
SAH should have further assessment with deficit and depressed GCS. Like symptom severity,
CT intracranial angiography to assess for an the mortality rate varies according to the severity of
underlying cause. haematoma and degree of mass effect. Urgent diagnosis
is important since significant SDHs may require
Report checklist neurosurgical drainage, although smaller haematomas
• The degree of mass effect (i.e. midline shift/ may be treated conservatively. As a result, the on-call
cerebellar tonsillar descent). radiologist should have a high index of suspicion for this
• Presence or absence of hydrocephalus. condition, especially in at-risk demographics following
• In cases of non-traumatic SAH, consider an head injury (see Appendix 1).
underlying aneurysm – advise for the patient to be
recalled for CTA if not already performed. Radiological investigations
• Emphasise that even in cases of a ‘normal’ CT is the imaging modality of choice in the acute
CT scan, SAH cannot be excluded and a LP setting because of its high sensitivity and specificity.
should be performed. (See Table 3.9.)
Table 3.9 Subdural haematoma. Imaging

protocol.
MODALITY PROTOCOL
CT Unenhanced. Scan from level of foramen
magnum to vertex.
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Computed tomography
Subdural collections appear on CT as crescenteric
extra-axial collections adjacent to the surface of
the brain. The attenuation of the collection varies
with the age of the blood products within. Acute
haematomas present as high attenuation in relation
to brain parenchyma (Figure 3.20). The sensitivity
for identifying subtle SDH can be increased by
using blood window settings (width 175, level 50).
In comparison, chronic haematomas demonstrate
decreased attenuation in relation to brain parenchyma
and may contain calcification, another useful clue
to assess age (Figures 3.21a, b). Acute on chronic
haematomas display mixed attenuation and can often
demonstrate dependent layering of acute blood
products within, referred to as a haematocrit level. Figure 3.20 Axial image: unenhanced CT scan of the
brain. There is a crescenteric rim of hyperdense material
overlying the left cerebral hemisphere consistent with
acute SDH. This causes effacement of the left cerebral
hemisphere with midline shift to the right. Further areas
of parenchymal haemorrhage can also be seen in the
frontal lobes.
(a) (b)
Figures 3.21a, b Axial images: unenhanced CT scans of the brain. Hypodense crescenteric collections are seen
overlying the right cerebral hemispheres representing chronic subdural collections. There is mass effect with
effacement of the underlying cerebral sulci, but no midline shift.
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112 Chapter 3
(a) (b)
Figures 3.22a, b (3.22a) Axial image: unenhanced CT scan of the brain. Hyperdense material is seen tracking
along the falx, which should normally be pencil thin, as a result of an acute parafalcine SDH. (3.22b) Coronal image:
unenhanced CT scan of the brain. There is an SDH overlying the right cerebral hemisphere. In addition, there is a
more subtle parafalcine SDH.
Subtle subdural bleeds can often be missed, especially difficult. Subdural hygroma presents as a CSF density
those that track along the falx cerebri and tentorium subdural collection through which vessels may be seen
cerebelli (Figures 3.22a, b). The use of multiplanar traversing; however, it does not extend into the sulcal
reformats, especially coronal images, is useful in this spaces.
regard.
The extent and size of the SDH should be assessed. Key points
This can be described in terms of the maximum depth • SDH can occur following head trauma and can
and the extent of cerebral convexity that the haematoma occur in the elderly following more minor injury.
abuts. Of more importance, although related, is the In paediatric patients, always consider non-
degree of mass effect, which is indicated by local sulcal, accidental injury.
ventricular and basal cistern effacement, midline shift, • CT is the imaging modality of choice. SDHs
and tonsillar descent (Figure 3.23). MRI can sometimes demonstrate a crescenteric morphology and can
be useful to age the bleeds or to differentiate chronic cross suture lines.
bleeds from cerebral atrophy resulting in a large CSF • Visualisation of subtle SDHs can be aided by
space (Figure 3.24). utilising blood window settings (width 175,
The main differential diagnoses include extradural level 50) and multiplanar reformats.
haematoma (EDH) and subdural hygroma. SDHs
are crescenteric in morphology and can cross sutures; Report checklist
conversely, extradural haematomas are lenticular • Comment on the age of the haematoma; acute,
and are bound by sutures (however they can cross acute on chronic, or chronic.
the midline and venous sinus reflections). Extradural • The degree of mass effect (i.e. midline shift/
haematomas are also more commonly associated cerebellar tonsillar descent).
with skull vault fractures, although this finding does • Presence or absence of a skull fracture.
not preclude a subdural collection. Differentiation • Recommend urgent neurosurgical opinion.
between chronic SDH and subdural hygroma can be
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EXTRADURAL HAEMATOMA
EDH is a collection of blood within the extradural

space (i.e. the potential space between the inner table
of the skull vault and the dura mater). It typically
occurs following traumatic head injuries and is often
associated with an underlying skull fracture. EDH is
usually caused by arterial bleeds (typically branches of
the meningeal arteries), in contrast to SDH, which is
usually the result of a venous bleed. As such, it can result
in a rapid accumulation of blood within a relatively
short space of time. Clinically, patients typically present
with a history of significant head trauma, followed by a
lucent interval. Following this, patients may deteriorate
Figure 3.23 Axial image: unenhanced CT scans of the rapidly due to the expanding size of the haematoma.
brain. Crescenteric collection overlying the left cerebral The condition can be life threatening and may require
hemisphere is mixed density with both high and low urgent neurosurgical decompression, therefore urgent
attenuation material, consistent with an acute on chronic diagnosis is vital.
SDH. There is effacement of the underlying sulci with
midline shift to the right. Radiological investigations
Unenhanced axial CT imaging through the brain is the
modality of choice. Bony algorithm reconstructions of
images may be useful to identify underlying fractures.
Small, peripheral haematomas may be subtle and
difficult to identify, so image interpretation on blood
window settings (window 150, level 75) is also advised.
(See Table 3.10.)
Table 3.10 Extradural haematoma. Imaging

protocol.
MODALITY PROTOCOL
magnum to vertex.
Figure 3.24 Coronal image: FLAIR MRI sequence

showing hyperintense bilateral subdural collections
overlying the cerebral hemispheres (arrows). Note the
prominent low signal CSF spaces, suppressed on this
FLAIR sequence.
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114 Chapter 3
Radiological findings Findings should always be urgently communicated

Computed tomography to the neurosurgical team to avoid a delay in potential
Imaging with CT is often all that is required to confirm surgical management.
the diagnosis. Acute EDH is hyperdense on non-
enhanced CT. It is an extra-axial collection and so Key points
appears at the periphery of the brain (Figure 3.25a). • EDH is a neurosurgical emergency and urgent
Typically, an EDH conforms to a lenticular or lens imaging is vital.
type shape, with a convexity that indents into the • The typical appearance is that of a lenticular,
brain. EDHs are bound by the dural attachments and hyperdense extra-axial collection.
therefore cannot extend beyond cranial sutures. This • Findings should be communicated urgently to the
distinguishing feature can help to differentiate between neurosurgical team for consideration of evacuation
subdural and extradural collections. EDHs may also of the haematoma.
show a swirling appearance within the collection; this
has been suggested as indicating active bleeding and Report checklist
therefore continued expansion. As with a SDH, it is • The degree of mass effect (e.g. midline shift/
useful to measure the maximum depth of the EDH cerebellar tonsillar descent associated with
and assess the degree of mass effect and midline shift any EDH).
(Figure 3.25b). Whenever an extra-axial collection • Presence or absence of a skull fracture.
with a morphology suggestive of an EDH is identified, • Recommend urgent neurosurgical opinion.
the skull vault should be scrutinised on bone window
settings to identify associated skull vault fractures
(Figure 3.26).
(a) (b)
Figure 3.25a Axial image: unenhanced CT scan of the Figure 3.25b Axial image: unenhanced CT scan of the
brain. A hyperdense, lenticular extra-axial collection is brain. The extradural haematoma seen in Figure 3.25a
seen overlying the left frontal lobe, consistent with an is indenting the underlying parenchyma, causing sulcal
acute extradural haematoma. effacement and mild midline shift to the right of up
to 4 mm.
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brain. Comminuted linear fractures can be seen through
the greater wing of the left sphenoid bone, extending
into the left sphenoid sinus, which is opacified with
haemorrhage.
CEREBRAL VENOUS SINUS THROMBOSIS often less appropriate in the out of hours setting. While
far less sensitive, venous sinus thrombosis can also be
Although rare, cerebral venous sinus thrombosis is a identified on unenhanced CT, therefore systematic
potentially life-threatening neurological emergency. scrutiny of the venous sinus system should be a review
While up to 25% of cases are idiopathic (Stam, 2003), area on any CT head study. (See Table 3.11.)
any cause of a pro-thrombotic state can predispose
a patient to venous sinus thrombosis. Such causes Radiological findings
include malignancy, sepsis, dehydration, pregnancy, The principles of interpreting venogram imaging are
oral contraceptive pill use and clotting abnormalities. the same regardless of the modality used, although
Localised infection, such as sinusitis, is also a common there are common pitfalls specific to both CT and MRI,
potential cause. Symptoms and signs depend on which are discussed subsequently. Knowledge of the
the site and extent of the thrombosis and include
headache, seizures, focal neurology and reduced GCS.
Complications of venous sinus thrombosis include Table 3.11 Cerebral venous sinus thrombosis.
venous haemorrhage and infarction. Prompt diagnosis Imaging protocol.
is essential to facilitate urgent treatment with IV
heparin. MODALITY PROTOCOL
CT Intracranial venogram: 100 ml IV contrast via
18G cannula, 2 ml/sec. Scan at 45 seconds
after initiation of injection. Scan from skull
Contrast enhanced CT venography is the modality of base to vertex level.
choice in the acute setting. MRI is also utilised in the
investigation of venous sinus thrombosis; however, it is
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116 Chapter 3
normal anatomy of the venous sinus system is essential, is arachnoid granulations, which are physiological
and both the superficial veins and deep sinus system structures that protrude into the normal dural sinus
should be scrutinised in their entirety. The appearance lumen. These are characteristically found laterally in
of thrombus varies with age, although for the purposes the transverse sinus and in the superior sagittal sinus
of this chapter acute and subacute thrombosis are and appear as rounded, very well-defined filling defects.
considered. If there is diagnostic uncertainty on contrast enhanced
modalities, correlation with unenhanced imaging
Computed tomography can be helpful, since arachnoid granulations often
Venous sinus thrombosis presents on contrast display a similar attenuation to CSF. Acute to subacute
enhanced CT as a filling defect within the venous sinus venous sinus thrombosis should be suspected on an
(Figures 3.27a–c). The venous sinus system should be unenhanced study where there is high attenuation
scrutinised in axial, sagittal and coronal planes with corresponding to a segment of the venous sinus system
wide window settings to avoid missing subtle thrombus. (Figures 3.28, 3.29a). Common false positives on
A common false positive on contrast enhanced CT unenhanced CT include transverse sinus physiological
(a) (b)
Figures 3.27a–c Axial and sagittal images: IV contrast

(c)
enhanced CT scans of the brain in the venous phase.
Filling defects are seen within the sagittal sinus,
consistent with venous sinus thrombosis (arrow).
K22247_C003.indd 116 16/05/15 3:08 AM

dominance and dehydration, although the latter usually

causes global venous sinus hyperattenuation as opposed
to a focal abnormality.
The potential complications of venous sinus
thrombosis must be considered. Parenchymal oedema
can occur secondary to venous sinus thrombosis and
presents as focal low attenuation, generally within
the white matter. It should be noted that this is often
reversible and may not necessarily progress to venous
infarction. Indirect signs include atypical haemorrhage
and oedema that does not correspond to an arterial
territory. Bilateral thalamic oedema is highly suggestive
of thrombosis of the deep venous system (internal
cerebral veins, vein of Galen and straight sinus); if
this is seen on unenhanced imaging, further contrast
Figure 3.28 Axial image: unenhanced CT scan of the enhanced imaging should be performed to assess for
brain. The anterior portion of the superior sagittal sinus venous sinus thrombosis (Figure 3.29b). Secondary
is hyperdense (arrow) compared with the corresponding haemorrhage can also be seen, which differs in its
posterior segment, which is suspicious of a venous sinus morphology from a typical ‘hypertensive’ haemorrhage.
thrombus in the anterior portion.
(a) (b)
Figure 3.29a Axial image: unenhanced CT scan of the

brain. High attenuation thrombus is seen within the Figure 3.29b Axial image: unenhanced CT scan of
internal cerebral veins (arrow). the brain. In addition to the thrombosis of the internal
cerebral veins seen in Figure 3.29a, there is low
attenuation change affecting both thalami, consistent
with infarction.
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118 Chapter 3
Typical characteristics include irregular, flame- (Table 3.12). When seen in association with venous
shaped haemorrhage involving both the cortex and sinus thrombosis, increased parenchymal signal on
subcortical regions. The identification of this type of T2 weighted and FLAIR sequences is suggestive of
‘atypical’ haemorrhage on a unenhanced study should associated oedema. Corresponding restricted diffusion
always prompt suspicion of venous sinus thrombosis. on diffusion weighted sequences is indicative of
A common cause of venous sinus thrombosis is complicating infarction (Figures 3.31–3.33a, b).
sinusitis. The paranasal air spaces and mastoid air cells
should be well aerated – any opacification of these Key points
spaces is suggestive of sinusitis. • CT venography is the imaging modality of choice
for diagnosing venous sinus thrombosis in the out
Magnetic resonance imaging of hours setting.
As with CT, venous sinus thrombosis is suggested on • The hallmark of venous sinus thrombosis on
contrast enhanced and time of flight MRI sequences as contrast enhanced CT is a filling defect in the
a filling defect within the venous sinus (Figure 3.30). venous sinus system.
Interpretation of time of flight MRI can be
more challenging than contrast enhanced imaging. Report checklist
A common false positive is flow gap phenomenon, • Document the venous sinuses involved.
which occurs when the plane of acquisition is not • Presence or absence of any complications of
perpendicular to the sinus (for example axial image venous sinus thrombosis (e.g. oedema, infarction
acquisition of the superior sagittal sinus). Knowledge or haemorrhage).
of this limitation, along with correlation with additional
sequences, can help prevent this pitfall. The venous Reference
sinus system should also be scrutinised on T1 and Stam J (2003) Cerebral venous and sinus thrombosis:
T2 weighted sequences, although the precise signal incidence and causes in ischemic stroke. Adv Neurol
characteristic of the thrombus is dictated by its age 92:225–232.
Table 3.12 MRI signal characteristics of an

ageing thrombus.
AGE OF THROMBUS T1 SIGNAL T2 SIGNAL

Acute (0–5 days) Isointense Hypointense
Subacute (6–15 days) Hyperintense Hyperintense
Chronic (>15 days) Isointense Isointense/hypointense
Figure 3.30 3-D reconstruction of a MR venogram

sequence. No flow is seen within the straight sinus
owing to occlusion as a result of venous sinus
thrombosis.
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Figure 3.31 Axial T2 weighted MR image showing Figure 3.32 Axial FLAIR MR image demonstrating
high signal within both thalamic nuclei as well as within high signal within both thalamic nuclei as well as within
the heads of both caudate lobes and the right basal the heads of both caudate lobes and the right basal
ganglia. ganglia.
(a) (b)
Figure 3.33a, b These axial true diffusion and ADC map images show high signal within the affected areas and this
would therefore be in keeping with a subacute infarct within these regions.
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120 Chapter 3
HYDROCEPHALUS Radiological investigations

CT is the imaging modality of choice to diagnose
Hydrocephalus is a commonly encountered, treatable hydrocephalus in the acute setting. This allows
neurosurgical emergency. It occurs when there is accurate assessment of the parenchyma as well as the
excessive CSF within the cerebral ventricles, which ventricular system. If an underlying mass lesion is seen
results in dilatation of the ventricular system causing on unenhanced imaging, post-contrast images may be
increased intracranial pressure. Patients who present acquired to help characterise this further. In patients
acutely may have varied clinical symptoms ranging presenting with a suspicion of hydrocephalus who have
from headache, nausea and vomiting to reduced a VP shunt in situ, shunt fracture should first be excluded
consciousness. Ultimately, increased intraventricular via a plain film series. Ultimately, however, exclusion of
pressure may result in brain damage and death if left hydrocephalus requires evaluation with CT.
untreated. Urgent imaging is indicated and facilitates In the on-call setting, further imaging is not routinely
neurosurgical treatment, usually via external ventricular required to establish the diagnosis. If no underlying
drain (EVD) placement. cause is seen on CT, patients may require an MRI brain
The underlying aetiology of hydrocephalus can study to evaluate CSF and aqueductal flow. Similarly,
be broadly split into two groups: communicating and hydrocephalus in neonates may be assessed with
non-communicating. Communicating hydrocephalus cranial ultrasound in order to avoid ionising radiation;
refers to abnormalities relating to extraventricular CSF however, this is not a standard sonographic skill and
production and absorption, often at the level of the would not routinely be performed out of hours other
arachnoid granulations. Common causes of obstruction than in dedicated paediatric neurosurgical centres.
at this level include meningitis, SAH and venous sinus (See Table 3.13.)
thrombosis. Non-communicating hydrocephalus
tends to occur as a result of obstruction at the level Radiological findings
of the ventricles, which may be due to tumour or Computed tomography
intraventricular haemorrhage, in addition to congenital An unenhanced CT scan of the brain is the imaging
abnormalities such as aqueductal stenosis at the level modality of choice to identify the presence of
of the fourth ventricle. Another, less common cause
of hydrocephalus are CSF producing tumours such as
choroid plexus papillomas.
Patients that have undergone treatment
for hydrocephalus in the past may have a Table 3.13 Hydrocephalus. Imaging protocol.
ventriculoperitoneal (VP) shunt in situ. This is an
internal drain in which the cranial tip lies within MODALITY PROTOCOL
the ventricular system. The line is then positioned CT Unenhanced. Scan from level of foramen
subcutaneously through the neck, along the chest wall magnum to vertex.
and into the abdomen. The caudal line tip lies within the Post contrast images in patients with
peritoneum where the CSF drains and is subsequently suspected or confirmed mass lesion; 50 ml
reabsorbed. Occasionally, these shunts may fracture IV contrast via hand injection, scanned
approximately 2–3 minutes post injection.
and their ability to function may be compromised (see
Ventricularperitoneal shunt complications).
K22247_C003.indd 120 16/05/15 3:08 AM

hydrocephalus. The earliest radiological sign of ventricular system should prompt the suspicion
hydrocephalus is dilatation of the temporal horns of the of communicating hydrocephalus. In contrast,
lateral ventricles. In normal individuals, these should be non-communicating hydrocephalus can manifest
slit-like or conform to a ‘tear drop’ shape (Figure 3.34). as dilatation of a proximal part of the ventricular system.
However, in patients with hydrocephalus the horns For example, dilatation of the lateral and third ventricles
dilate and may become enlarged with added convexity in isolation infers obstruction at the level of the cerebral
(Figure 3.35). If the hydrocephalus continues, dilatation aqueduct, commonly seen in aqueduct stenosis. Space-
of the remainder of the ventricles ensues, with increased occupying lesions can cause pressure and obstruction
ventricular size demonstrated on CT imaging. of the ventricular system. These are best visualised with
It is important to consider which parts of the IV contrast, which should be administered if there is a
ventricular system are dilated. Dilation of the entire suspicion of an underlying mass lesion.
Figure 3.34 Axial image: unenhanced contrast Figure 3.35 Axial image: unenhanced CT scan
CT scan of the brain. Normal appearances of the of the brain. The temporal horns are dilated with
temporal horns of the lateral ventricles with a slit-like loss of the normal tear drop morphology indicating
morphology. hydrocephalus.
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122 Chapter 3
As a result of the increasing ventricular volume, there useful way to assess for any acute changes is to compare
may be considerable mass effect on the brain tissues, with any previous imaging.
which may be seen as effaced sulci and obliterated extra- As with VP shunts, the tips of EVDs should traverse
axial CSF spaces (Figure 3.36). The pressure within the ventricular system. EVDs may be misplaced at
the ventricles may also damage the ependymal lining the time of insertion or subsequently; this results
of the ventricles. If this occurs, the pressure within the in ineffective drainage of the ventricular system. It
ventricles may force CSF into the periventricular tissues. is useful to document the position of the VP shunt,
This is known as transependymal oedema (Figure 3.37). since any movement in the position of the tip can be
This can have a similar appearance to small vessel relevant in the future. It is not uncommon to identify
ischaemia; however, associated ventricular dilatation is mild parenchymal haemorrhage around the tract of the
the key to distinguishing the two entities. EVD in the acute period, although this should not be
Parenchymal atrophy is a normal consequence of excessive.
ageing; compensatory ventricular dilatation often
occurs as a result of this. It is therefore important to Plain films
take the degree of cerebral atrophy into account when VP shunts are used to treat hydrocephalus, and are
assessing the calibre of the ventricular system. In young particularly common in children. The lines used
patients with completely preserved parenchyma, are radiopaque and their position and integrity can
any dilatation of the temporal horns should rouse therefore be assessed fairly well on plain film imaging.
suspicion, but in elderly patients with large amounts The cranial portion of a VP shunt is usually attached
of parenchymal atrophy, the ‘normal’ appearance may to an extracranial port, which lies within the scalp
be prominence of the ventricles. Therefore, the most tissues. At the attachment distal to this port, there is
Figure 3.36 Axial image: unenhanced CT scan of the Figure 3.37 Axial image: unenhanced CT scan
brain. There is effacement of the normal sulcal pattern of the brain. The lateral ventricles are dilated, and
and extra-axial CSF spaces due to raised intracranial periventricular low attenuation changes can be
pressure. seen representing transependymal oedema in acute
hydrocephalus.
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often a short segment of radiolucency representing

the shunt valve, which is normal, but this should not
be longer than a few centimetres (Figure 3.38, Goeser
et al., 1998). This may be difficult to appreciate and
comparison with previous images is therefore crucial to
identify subtle abnormalities.
The distal portion of the line should be traced on
the chest and abdominal plain films to ensure a correct
tip position within the abdomen. Lines should also be
scrutinised for evidence of fracture; normal lines should
be continuous with no breaks evident below the head.
Skull plain films are not indicated for the assessment
of hydrocephalus, other than to assess for VP shunt
abnormalities.
Figure 3.38 Lateral skull radiograph. The radiopaque
Key points shunt can be seen with a short radiolucent gap
• Unenhanced CT imaging is the modality of within the extracranial soft tissues, which is a normal
choice in the acute investigation of hydrocephalus. appearance for a VP shunt (arrow).
• The earliest sign of hydrocephalus is dilatation of
the temporal horns of the lateral ventricles.
• A shunt series should be performed in addition to
CT imaging in patients with VP shunts presenting
with signs of hydrocephalus. VENTRICULOPERITONEAL SHUNT
MALFUNCTIONS
Report checklist
• Document the type of hydrocephalus VP shunting is a common treatment for hydrocephalus,
(communicating or non-communicating) and the particularly in children. CSF is drained via a
level of obstruction. subcutaneous drain and absorbed by the peritoneum,
• Consider underlying causes of non- thus relieving excess intraventricular pressure. Shunt
communicating hydrocephalus (e.g. an obstruction is a common complication and can result
obstructing mass). in progressive hydrocephalus, which is a neurosurgical
• Consider causes of communicating hydrocephalus emergency. Symptoms and signs of shunt failure
(e.g. meningitis or SAH). include headache, nausea and vomiting, reduced GCS
• Recommend urgent neurosurgical opinion. and prolonged refill of the shunt reservoir. In the
paediatric population, clinical signs can also include
Reference increasing head circumference and fontanelle bulging.
Goeser CD, McLeary MS, Young LW (1998) Additional complications of shunt insertion, such as
Diagnostic imaging of ventriculoperitoneal shunt infection, CSF pseudocysts and slit ventricle syndrome
malfunctions and complications. Radiographics (SVS), can also be encountered.
18:635–651v.
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124 Chapter 3
Radiological investigations Radiological findings

Assessment of shunt malfunction should begin with a Plain films
plain film series of the subcutaneous shunt tubing to Plain films should be assessed to identify discontinuity
assess for mechanical breakage of the tubing. If there in the shunt tubing. Breakage commonly occurs at
is clinical suspicion of shunt malfunction, further sites of increased mobility, such as the neck, although
assessment with CT imaging should be performed it can occur in any location (Figure 3.39). There is
without delay. Post IV contrast CT head imaging commonly a radiolucent portion of the shunt tubing
should be obtained if there is a clinical concern of shunt just external to the entry point into the skull (Figure
infection. (See Table 3.14.) 3.40). This can be incorrectly interpreted as a fracture
in the shunt tubing, a common pitfall. The distal end
Table 3.14 Ventriculoperitoneal shunt of the shunt should be coiled in the peritoneal cavity,
malfunctions. Imaging protocol. projected over the middle to lower abdomen (Figure
3.41). Shunt migration can also occur, resulting in an
MODALITY PROTOCOL abnormal course of the shunt tubing. Note: Plain film
Plain film Lateral and AP skull. PA chest radiograph. imaging alone cannot exclude internal blockage of the
series AP abdominal radiograph. The neck should be shunt tubing and hydrocephalus, and therefore CT
imaged in either the chest or skull radiographs.
imaging is required.
magnum to vertex.
Figure 3.39 AP chest and upper abdomen radiograph. Figure 3.40 Lateral skull radiograph. The normal
The shunt can be seen descending from the neck lucency can be seen representing the valve of the
projected through the thorax, where a clear break can be shunt. However, inferior to this, there is a break in
seen just lateral to the left heart, with separation of the the continuity of the shunt consistent with shunt
proximal and distal fragments. fracture.
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Computed tomography
When interpreting CT imaging for shunt
complications, it is important to compare with previous
CT studies. CT imaging allows assessment of the shunt
position – the tube should ideally traverse the ventricular
system (Figure 3.42). Migration of the proximal shunt
tip when compared with previous imaging can occur.
With careful image windowing, the proximal aspect of
the extracranial component of the shunt tubing can be
inspected for discontinuity.
The hallmark of VP shunt obstruction
on CT is progressive ventricular dilatation
(Figure 3.43). The ventricles may remain dilated
despite effective shunting, again highlighting
the importance of comparison with previous CT
head imaging. Ancillary signs of hydrocephalus
include basal cistern effacement, peripheral sulcal
effacement and transependymal oedema; the latter Figure 3.42 Axial image: unenhanced CT scan of the
appears as periventricular low attenuation change. brain. The shunt can be seen entering the right parietal
lobe into the right lateral ventricle, with the tip lying in
the midline in the third ventricle near the foramen of
Munro.
Figure 3.43 Axial image: unenhanced CT scan of

Figure 3.41 AP abdominal radiograph. The shunt can the brain. There is dilatation of the lateral ventricles
be seen projected over the right abdomen, eventually consistent with hydrocephalus. There are periventricular
coiling within the mid abdomen. Shunt continuity is low attenuation changes representing transependymal
maintained with no evidence of shunt fracture. oedema.
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126 Chapter 3
In cases of chronic hydrocephalus, periventricular INTRACRANIAL ABSCESS AND

fibrosis can occur, which reduces the plasticity of the SUBDURAL EMPYEMA
ventricles. It should therefore be noted that increased
intraventricular pressure may occur even in the absence The term ‘intracranial abscess’ may refer to both
of an increase in intraventricular size. SVS is a rare cerebral abscess and subdural empyema. Cerebral
but important complication of VP shunting. Patients abscess results from a focal infection of the brain
present with clinical symptoms of hydrocephalus, but parenchyma. Four stages are recognised in the
conversely have slit-like, disproportionately collapsed progressive evolution of this entity: early cerebritis, late
ventricles in relation to the degree of sulcal/basilar cerebritis, evolving abscess and established abscess.
cistern effacement on cross-sectional imaging. This is Subdural empyema refers to a focal infection located
a difficult diagnosis to make in the absence of previous within the dura and arachnoid mater. Both cerebral
imaging. abscess and subdural empyema share similar aetiologies
In cases where there is clinical suspicion of and can complicate each other. Causes include direct
infection, post IV contrast CT imaging should be spread from adjacent structures (such as sinusitis,
performed. Ependymal or sulcal enhancement can mastoiditis and dental infection), haematogenous
be seen in meningitis, which can occur secondary to spread, complications of neurosurgery and meningitis,
shunt infection. The local soft tissues adjacent to the although haematogenous spread is less commonly seen
extracranial shunt tubing should also be scrutinised for in subdural empyema as opposed to cerebral abscess.
enhancing fluid collections. Symptoms and signs most commonly include headache,
fever, focal neurology and seizures, with the nature of
Key points focal neurological signs depending on lesion location
• VP shunting is a common treatment for and degree of mass effect. An associated elevation
hydrocephalus. Complications include of inflammatory markers can inform the diagnosis;
shunt failure (obstruction and breakage) and however, its absence should not dissuade from this. Risk
infection, which can result in progressive factors for haematological spread include IV drug use,
hydrocephalus. bacterial endocarditis, systemic sepsis, chronic lung
• Shunt plain film and CT head imaging should infection and bronchiectasis, and left to right shunts.
be performed without delay if there is clinical Early diagnosis via imaging is vital; this has helped to
suspicion of shunt failure. decrease the once high mortality rate, although this
• Shunt obstruction can be inferred from the is still estimated at approximately 5–15%. In cases of
presence of increasing ventricular size or established abscess or empyema, treatment involves
transependymal oedema. surgical excision and drainage in addition to antibiotic
therapy.
Report checklist Always consider whether or not the patient is
• Presence or absence of any shunt discontinuity on or could be immunocompromised. Aspergillosis
the plain film series. can present as an invasive paranasal sinusitis with
• Precise location of the tip of the VP shunt and extension into the orbit and brain. It can also present
whether it traverses the ventricular system. as an intracerebral abscess or infarct. Candidiasis
• Presence or absence of hydrocephalus and can present as microabscesses. Toxoplasmosis can
transependymal oedema. present with multiple intracerebral abscesses, which
• Recommend urgent neurosurgical opinion in cases are more commonly seen in the basal ganglia, thalami
of progressive hydrocephalus. and corticomedullary junction. Tuberculosis can
have a variable presentation with leptomeningeal
enhancement, cerebritis and abscesses.
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Lymphoma in immunocompetent patients intra-axial malignant lesions. In this scenario,

usually presents as solid mass lesions with uniform correlation with clinical history is helpful, although
enhancement. In the immunocompromised patient, ultimately confirmation often requires MRI. Both
however, lymphoma can be characterised by ring unenhanced and IV contrast enhanced CT can yield a
enhancing lesions. false-negative result in cases of cerebritis. Unenhanced
CT imaging can readily identify subdural collections,
Radiological investigations but it cannot confirm infection; the addition of IV
MRI with IV contrast and diffusion weighted sequences contrast increases sensitivity. (See Table 3.15.)
is the most sensitive imaging modality in the diagnosis
of cerebral abscess and subdural empyema. However, Radiological findings
MRI is not always available out of hours and may not Computed tomography
be suitable in acutely unstable patients owing to its On the unenhanced phase, a cerebral abscess typically
long acquisition time. CT is often performed prior to has the appearance of a cystic focus of low attenuation
MRI and can be useful to exclude alternative causes (the precise Hu of which varies according to the
of focal neurology, such as stroke or intracranial purulence of the abscess) with an isoattenuating or
haemorrhage. Whilst contrast enhanced CT imaging hyperattenuating rim. There is typically thin rim
can identify the characteristic ring enhancement enhancement after administration of IV contrast, in
that is typical of an established cerebral abscess, its contradistinction to the thick, irregular enhancement
major limitation lies in the low specificity of this sign, seen in malignant lesions, although this is variable
which can also be seen in both primary and secondary (Figure 3.44). Note: It may be difficult on CT to
Table 3.15 Intracranial abscess and subdural

empyema. Imaging protocol.
MODALITY PROTOCOL
magnum to vertex.
Post IV contrast: 100 ml IV contrast via 18G
cannula, 4 ml/sec. Scan at 40 seconds after
start of injection. Scan from level of foramen
magnum to vertex.
MRI Sagittal T1 weighted, axial PD, T2 and
diffusion weighted, coronal FLAIR and pre-
and post-IV contrast T1 weighted sequences.

scan of the brain. A thick-walled lesion is seen in the
right parietal lobe, which demonstrates peripheral wall
enhancement, more so anteriorly than posteriorly.
Centrally the lesion is low attenuation with no
enhancement, representing a necrotic centre. Low
attenuation changes are seen surrounding the lesion,
representing vasogenic oedema.
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128 Chapter 3
distinguish between an abscess and a malignant lesion. Subdural empyemas appear similar to SDHs in
Perilesional low attenuation change often represents their shape and their relationship to sutures and dural
associated vasogenic oedema, which is also seen in reflections. They demonstrate a crescenteric shape (in
association with malignant lesions. The degree of mass contradistinction to extradural collections, which are
effect is important, indicated by sulcal or ventricular convex) and can also be seen tracking along the tentorium
effacement and midline shift. Cerebritis may appear as and falx. Loculation of any subdural collection should
an ill-defined focus of low attenuation and can be difficult always prompt the suspicion of infection. Subdural
to differentiate from areas of ischaemia. The enhanced empyemas are usually hypoattenuating and similar
phase may show absent or patchy enhancement as in density to chronic SDHs; however, they generally
opposed to the typical rim enhancement of cerebral display dural enhancement on the contrast enhanced
abscess. Subependymal enhancement can indicate phase (Figure 3.46). As with any subdural collection,
associated ventriculitis, although this can also be seen the depth and degree of associated mass effect are
with malignant infiltration (Figure 3.45). useful findings and often dictate the urgency of surgical
intervention.
scan of the brain. There is subependymal enhancement scan of the brain. A subdural collection is demonstrated
(arrow), secondary to ventriculitis and meningitis. overlying the right frontal lobe and tracking along the
anterior falx with peripherally enhancing meninges,
consistent with an empyema (arrow). A further subdural
empyema is seen posteriorly tracking along the
tentorium cerebelli.
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Magnetic resonance imaging usually signifies vasogenic oedema, although this can
The principles of MRI interpretation mirror that of sometimes represent tumour infiltration if secondary
CT. Cerebral abscesses usually demonstrate central to malignant lesions. Cerebritis may appear as a non-
hyperintensity on T2 weighted and FLAIR sequences specific focus of increased signal on T2 weighted and
(typically less intense than CSF signal – Figure 3.47). FLAIR sequences. Subdural empyemas generally show
This corresponds to central hypointensity on T1 similar signal characteristics to the central component
weighted sequences (typically of higher signal than of a cerebral abscess and, as with CT, may show
CSF). A thin, regular hypointense to isointense associated dural enhancement on post-contrast T1
capsule can usually be seen on T2 weighted sequences, weighted sequences.
with corresponding enhancement on post-contrast Diffusion weighted sequences allow differentiation
T1 weighted sequences (Figure 3.48). Perilesional of infective and malignant aetiologies; the latter
increased signal on T2 weighted and FLAIR sequences typically does not demonstrate restricted diffusion,
Figure 3.48 Axial image: T1 weighted MR image of

the brain post contrast. There is enhancement of the
peripheral capsule surrounding the abscess. The central
Figure 3.47 Axial image: T2 weighted MR image of contents of the lesion do not enhance.
the brain. The abscess centred on the right thalamus
demonstrates intermediate to high signal centrally with
a low signal capsule. Surrounding high signal changes
around the lesion represent vasogenic oedema.
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130 Chapter 3
although there are exceptions to this rule. Restricted malignancy. Parenchymal abscess can be
diffusion is confirmed by an increased signal on the differentiated due to the associated presence of
diffusion weighted sequence and corresponding restricted diffusion on MRI.
decreased signal on ADC mapping (Figures 3.49a, b). • Intracranial empyema appears as a crescenteric
subdural collection. Associated dural
Key points enhancement and restricted diffusion is
• Intracranial infection in the form of parenchymal characteristic.
abscess or subdural empyema is a neurosurgical
emergency. Report checklist
• MRI with IV contrast and diffusion weighted • Document the degree of surrounding oedema and
sequences is the most sensitive and specific mass effect/midline shift.
modality, although may not be readily available. • Consider other differential diagnoses for multiple
Pre- and post-contrast enhanced CT is a useful ring enhancing lesions including metastases,
alternative out of hours. demyelination, multicentric glioma, lymphoma,
• Parenchymal abscess presents as a ring enhancing embolic infarcts.
lesion on both modalities; however, similar • Consider whether the patient could be
appearances can be seen with intracranial immunocompromised.
(a) (b)
Figure 3.49a, b Axial images: diffusion imaging (3.49a) and ADC map (3.49b) of the brain. The contents of the
abscess are high signal on diffusion imaging and low signal on the ADC map (i.e. the abscess restricts diffusion).
Note how the capsule of the abscess does not restrict diffusion.
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HERPES SIMPLEX ENCEPHALITIS quickly treatment is initiated. Although the ultimate

diagnosis is made from polymerase chain reaction
Herpes simplex encephalitis is an acute or subacute analysis of CSF obtained from LP, typical imaging
infection of the brain parenchyma by the herpes simplex findings can suggest the diagnosis. Treatment with IV
virus (HSV). There are two main subtypes of infection, antiviral agents can be started prophylactically prior to
which differ in their demographics, causative organism diagnosis, therefore imaging does not necessarily have
and pathophysiology. Adult infection (the focus of this to be performed out of hours. HSV encephalitis should
chapter) is caused by HSV-1 in 90% of cases (Bulakbasi be distinguished from HSV meningitis; the latter
& Kocaoglu, 2008). It results in a more focal encephalitis is usually caused by HSV-2 infection and generally
in the frontal or temporal lobes and is considered follows a benign cause.
secondary to reactivation of the dormant virus. As with cerebral abscesses, it is important to consider
Neonatal cases are usually caused by HSV-2, which whether the patient is immunocompromised. Human
produces a more generalised encephalitis and is acquired immunodeficiency virus (HIV) can itself directly
by the neonate via maternal transmission at delivery involve the CNS. It causes a subacute encephalitis
(Bulakbasi & Kocaoglu, 2008). Limbic encephalitis, a characterised by diffuse bilateral signal change in the
paraneoplastic phenomenon that occurs secondary to white matter/basal ganglia in the absence of mass
many non-central nervous system (CNS) malignancies, effect/contrast enhancement. HIV also produces a
can produce similar neurological findings. vasculitis, which can coexist with the infection, causing
Symptoms and signs of adult viral encephalitis include multiple small infarcts. Cerebral atrophy is common.
headache, fever, seizures, focal neurological deficits Progressive multifocal leucoencephalopathy is caused
and altered or decreased level of consciousness. Because by papovavirus (JC virus) in patients with HIV. It is
of the non-specific nature of these symptoms and signs, characterised by extensive asymmetrical involvement
cases cannot reliably be differentiated clinically from of the cerebral white matter with sparing of the
other intracranial pathologies. The mortality rate is cerebral cortex. There is usually little in the way of
high, although the exact prognosis depends on how mass effect or contrast enhancement (Figures 3.50a, b).
(a) (b)
Figure 3.50a, b Axial T2 and FLAIR MR images from a patient with progressive multifocal leucoencephalopathy.
These demonstrate asymmetrical but diffuse white matter signal change with sparing of the cerebral cortex and no
mass effect.
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132 Chapter 3
Cerebral atrophy is not a feature. Cytomegalovirus signal on T2 and FLAIR sequences and corresponding
infection is usually only seen in immunocompromised decreased signal on T1 weighted sequences.
patients and presents with patchy periventricular signal Abnormality can be unilateral or bilateral. In cases
change. causing unilateral abnormality of the insular cortex,
the differential of a middle cerebral artery territory
Radiological investigations infarct should be considered. This usually involves the
MRI is the most sensitive and specific imaging modality basal ganglia structures, which are characteristically
for the changes of herpes simplex encephalitis, although spared in HSV encephalitis, although in practice
this modality can be normal early on in the course of differentiation between the two entities can be difficult.
infection; as such, a normal scan should not exclude the These characteristic findings are normally seen in
diagnosis. Utilisation of diffusion weighted sequences immunocompetent patients. In immunocompromised
increases sensitivity. The main limitation with MRI patients, a more diffuse pattern of involvement is
lies in its limited out of hours availability. CT is less seen. Similar imaging findings can also be seen in
sensitive than MRI. CT imaging is often normal; as limbic encephalitis. Restricted diffusion may precede
with MRI, a normal study cannot exclude the diagnosis. T2 and FLAIR abnormalities. Viral encephalitis can
However, CT is often performed prior to MRI because be complicated by haemorrhagic transformation,
of the non-specific presentation of HSV encephalitis which typically demonstrates increased signal on
and is still useful in excluding alternative pathologies, T1 sequences in the subacute phase. Gyriform (or,
such as stroke. The exact order of imaging depends on less commonly, localised leptomeningeal or ring)
the clinical index of suspicion and local availability of enhancement on post-contrast T1 weighted sequences
MRI. (See Table 3.16.) in affected areas can also be seen subacutely; however,
its absence should not dissuade from the diagnosis.
Radiological findings Generalised leptomeningeal and subependymal
Magnetic resonance imaging enhancement can be seen in cases of meningitis, which
HSV encephalitis typically causes oedema in the medial can present with similar symptoms, although it should
aspect of the temporal lobes, inferolateral frontal lobes be noted that imaging does not routinely form part of
and insular cortex. Oedema presents as increased the investigation pathway for meningitis.
Computed tomography
The temporal and inferior aspect of the frontal lobes
Table 3.16 Herpes simplex encephalitis. should be scrutinised for low attenuation abnormality,
Imaging protocol. suggestive of oedema (Figures 3.51a, b). It should be
noted that assessment of these areas, particularly the
MODALITY PROTOCOL temporal lobes, is hampered on CT by beam hardening
MRI Axial T1 and T2 weighted, sagittal T1 weighted, artefact. This typically causes streaky low attenuation,
coronal FLAIR, diffusion weighted and pre-/ which can be mistakenly interpreted as oedema.
post-contrast T1 weighted sequences.
Familiarity with the ‘normal’ spectrum of appearances
CT Unenhanced. Scan from skull base to vertex.
of these regions on CT is vital to avoid false positives.
Post IV contrast: 100 ml IV contrast via 18G Haemorrhage in involved areas is readily identified
cannula, 4 ml/sec. Scan at 40 seconds after
on CT. As with MRI, gyriform enhancement can be
start of injection. Scan from skull base to
vertex. seen on post-contrast images and suggests subacute
infection. Note: CT cannot exclude viral encephalitis;
this should be emphasised in the report.
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(a) (b)
Figure 3.51a, b Axial images: unenhanced CT scans of the brain. Low attenuation changes can be seen in the left
temporal lobe consistent with oedema. The sulci in the affected region are effaced compared with the unaffected
right side.
Cerebral oedema can also be seen in the presence • MRI is more sensitive than CT; however, neither
of underlying parenchymal lesions, such as cerebral can exclude the diagnosis. Typical findings include
abscess and malignancy. These underlying diagnoses oedema in the temporal and inferior frontal lobes.
should always be considered whenever oedema is Haemorrhagic transformation and subacute
identified on CT. Distinguishing features include gyriform enhancement can be seen.
the acute history and typical fever of encephalitis
and the more convincing ring enhancement seen in Report checklist
parenchymal mass lesions. • Consider differential diagnoses (e.g. infarct).
• Consider whether the patient may be
Key points immunocompromised.
• HSV encephalitis should be suspected in patients • Presence or absence of signs of raised intracranial
presenting with fever, headache, seizures, pressure (e.g. cerebellar tonsillar descent and basal
focal neurological deficits and altered level of cistern/sulcal effacement).
consciousness.
• Diagnosis is made with polymerase chain reaction Reference
analysis of CSF obtained via LP. Antiviral agent Bulakbasi N, Kocaoglu M (2008) Central nervous
treatment can be started prophylactically prior to system infections of herpes virus family.
imaging. Neuroimaging Clin North Am 18:53–84.
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134 Chapter 3
SPINAL CORD COMPRESSION AND level of abnormality within the spine. Cauda equina
CAUDA EQUINA SYNDROME syndrome is a clinical triad of symptoms occurring
secondary to compression of the cauda equina nerve
Spinal cord compression and cauda equina syndrome roots within the spinal canal. This clinical syndrome
are acute neurological emergencies that require urgent is comprised of lower limb motor dysfunction, saddle/
diagnosis and treatment. They occur as a result of perineal anaesthesia and urinary or bowel dysfunction.
compression of either the spinal cord or cauda equina Patients may also have reduced anal tone on rectal
nerve roots; this causes an acute neurological deficit examination.
which, if left untreated, may be irreversible. Prompt
diagnosis requires imaging and is necessary to facilitate Radiological investigations
urgent intervention. MRI is the imaging modality of choice for suspected
Common causes of spinal cord or cauda equina nerve cases of cord or cauda equina nerve root compression.
root compression include malignancy, intervertebral MRI provides accurate assessment of the neurological
disc prolapse and trauma. Malignant cord compression structures, spinal anatomy, bone marrow, intervertebral
most commonly occurs as a result of metastatic discs and soft tissues. Note: Not all centres offer an
infiltration of the vertebral body bone marrow, with MRI service out of hours, therefore some patients may
resulting expansion and encroachment of the spinal require transfer to other centres. (See Table 3.17.)
canal. Less commonly, it can be the result of metastatic
disease to the spinal cord or meninges. Depending on Radiological findings
the severity of symptoms, malignant cord compression Magnetic resonance imaging
may be treated with urgent radiotherapy. In normal patients, the spinal cord runs through
Disc dehydration is a normal part of ageing; the spinal canal and is surrounded by CSF. The cord
however, it can be complicated by herniation of disc terminates at the conus medullaris, above the L1/2 level
contents into the spinal canal. This can compress the in adults. Beyond the conus, cauda equina nerve roots
spinal cord and cauda equina nerve roots, resulting in descend through the spinal canal, exiting through the
neurological compromise. This most commonly occurs intervertebral foramina.
in the lumbar spine.
In the context of trauma, spinal cord or cauda equina
nerve root compression may be due to a combination of
spinal malalignment, fracture with bony retropulsion
or compressing haematoma. In contradistinction to Table 3.17 Spinal cord compression and
malignant cord compression, compression secondary to cauda equina syndrome. Imaging
protocol.
disc prolapse or traumatic injury is usually more acute,
and treatment involves urgent surgical decompression.
MODALITY PROTOCOL
Compression may also occur as a complication of spinal
MRI Sagittal T1, sagittal T2 and axial T2 weighted
surgery; such complications include epidural abscess
sequences. In patients with suspected meta-
and haematoma. static disease and postoperative patients,
Typically, patients with spinal cord compression additional sagittal STIR and post IV contrast
present with a loss of motor function below the level axial and sagittal T1 images should also be
acquired.
of compression and a distinct sensory, dermatomal
deficit, which clinically can be used to anticipate the
K22247_C003.indd 134 16/05/15 3:08 AM

Regardless of the cause of the cord compression, within the spinal canal (Figure 3.53). It is important to
imaging findings include loss of the normal CSF space distinguish this from unilateral compression of a nerve
around the cord and compression, usually indicated root, either in the lateral recess or the intervertebral
by a contour abnormality of the cord. In acute cases, foramina. The latter is a common result of degenerative
compression of the cord may lead to oedema within disc disease and typically presents with radicular
the spinal cord; this appears as increased signal within symptoms.
the cord on T2 weighted sequences (Figure 3.52). An underlying disc prolapse causing cord or cauda
In cases of cauda equina nerve root compression, there equina nerve root compression is readily evident
is obliteration of the CSF space, which may result in on MRI. Normal intervertebral discs demonstrate
significant crowding or displacement of the nerve roots increased signal centrally on T2 weighted sequences;
Figure 3.53 Axial image: T2 weighted MR image of

Figure 3.52 Sagittal image: T2 weighted MR image the lumbar spine. There is a central disc protrusion,
of the cervical spine. There is a fracture/dislocation at which indents into the spinal canal, resulting in cauda
C5/6 resulting in cord compression at this level. No equina nerve root compression.
CSF can be seen surrounding the cord at the level of
the compression. A focus of high signal change can be
seen within the spinal cord at this level, representing a
traumatic cord contusion.
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136 Chapter 3
however, this signal decreases with advancing In patients who have undergone recent spinal
dehydration and degeneration ( Figures 3.54a, b). surgery, post IV contrast T1 imaging is useful in
Malignant cord compression may be caused by a soft identifying enhancing collections within the spinal
tissue or expansile mass arising from the vertebral canal that may be causing cord compression.
body, causing anterior compression of the spinal cord
or cauda equina nerve roots. In adults, the vertebral Key points
bodies typically demonstrate increased signal (relative • Spinal cord compression and cauda equina
to the intervertebral discs) on T1 weighted sequences, syndrome are neurological emergencies
representing normal fatty marrow. Malignant requiring prompt diagnosis and neurosurgical
infiltration typically appears as decreased signal on intervention.
T1 and T2 weighted sequences (Figure 3.55). In • Potential causes include malignancy, intervertebral
cases of metastatic disease, multiple lesions may be disc disease, trauma and epidural abscess/
seen throughout the spine. Diffuse metastatic spinal haematoma.
infiltration may be difficult to appreciate on first
inspection; however, it should be suspected if the Report checklist
vertebral bodies demonstrate diffusely decreased signal • Document the degree of cord compression.
on T1 weighted sequences. Subtle lesions that may be • Presence or absence of myelopathy.
difficult to appreciate on T1 images may be seen more • Consider the underlying cause; for example,
easily on fat suppressed/STIR sequences. disseminated malignancy or degenerative disc
Epidural haematomas can occur as a complication disease.
of spinal surgery or secondary to trauma. They • In cases of cord compression, recommend urgent
demonstrate a variable signal according to their age; neurosurgical opinion.
however, if acute, they typically appear as a lenticular-
shaped collection of increased signal on T1 weighted
sequences.
(a) (b)
Figure 3.54a, b Sagittal and axial images: T2 weighted MR images of the thoracic spine. A large central posterior
disc prolapse is shown, which is obliterating the spinal canal. Cord signal abnormality is also seen.
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adults usually originates from the endplates directly.

Risk factors include immunodeficiency, diabetes
mellitus, remote infection and IV drug use. The
commonest causative organism is Staphylococcus aureus;
others include Streptococcus viridans (particularly in
immunocompromised patients) and Mycobacterium
tuberculosis, although the latter characteristically
spares the vertebral disc. Symptoms include back pain
and pyrexia and the on-call radiologist should always
consider the potential of discitis in a patient with
pyrexia of unknown origin. Swift diagnosis is vital to
ensure appropriate antibiotic and immobilisation
therapy, which can prevent the long-term neurological
morbidity of this condition. Imaging may not
necessarily have to be conducted out of hours unless
there are symptoms or signs of cord compromise, since
this may necessitate urgent surgical intervention.
Plain film imaging of the spine is useful as a first-
line assessment for discitis; however, it is relatively
insensitive in the initial phases and as such cannot
exclude the diagnosis. Plain film imaging can, however,
be helpful in excluding alternative pathologies that
may cause back pain; for example, osteoporotic wedge
Figure 3.55 Sagittal image: T1 weighted MR image of fractures. MRI with IV contrast is sensitive and specific
the lumbar spine. There are multiple low attenuation and is the modality of choice, although both CT
lesions within the lumbar spine consistent with multiple imaging and nuclear imaging can be helpful in cases
metastases. Compression fractures are also noted. where MRI is contraindicated. Even in the presence of
characteristic plain film findings, further imaging with
MRI is usually necessary in order to assess the extent
of bony involvement and the degree of neurological
SPONDYLODISCITIS compromise. (See Table 3.18.)
Spondylodiscitis, or infection of the vertebral

discs and adjacent bodies, can result in aggressive
vertebral destruction and neurological compromise. Table 3.18 Spondylodiscitis. Imaging protocol.
Spondylodiscitis has a bimodal distribution, occurring
both in the paediatric and middle-aged/elderly MODALITY PROTOCOL
populations, although the pathophysiology is different MRI Sagittal and axial T1 and T2 weighted, sagit-
in the two groups. In children, infection usually begins tal STIR and pre/post IV contrast T1 weighted
in the disc itself (due to its good vascular supply), sequences of the whole spine.
spreading to the adjacent endplates. Infection in
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138 Chapter 3
Radiological findings the extent of adjacent vertebral body involvement

Magnetic resonance imaging increases; this is best appreciated as marrow oedema on
Discitis is diagnosed on MRI by identifying characteristic STIR sequences. In advanced disease, bony destruction
inflammation and oedema of the disc and adjacent can occur. While tuberculosis discitis can appear
vertebral body endplates. This is best appreciated on identical to discitis secondary to another organism, it
sagittal T2 and STIR sequences as increased signal usually spares the disc space until late in the disease.
within affected discs and endplates, which corresponds Other findings characteristic of tuberculosis include
to decreased signal on T1 sequences (Figures 3.56a. b). skip lesions and marked kyphosis secondary to bone
Knowledge of the characteristic degenerative changes destruction (gibbus deformity).
that can affect the vertebral body endplates is necessary
since these can be falsely interpreted as infection
(Table 3.19). In contradistinction to infective endplate
changes, degenerative endplate changes are not Table 3.19 Modic degenerative endplate
associated with increased signal within the disc on T2 changes.
weighted or STIR sequences. As infection progresses
the disc space is typically lost. (Note: This is also seen MODIC T1 SIGNAL T2 SIGNAL PATHOPHYSIOLOGY
TYPE
in degeneration; however, this does not demonstrate
increased T2 signal within the disc.) As the endplate I Decreased Increased Bone marrow oedema.
cortices become eroded, the characteristic low signal II Increased Increased Normal haemopoetic
of the cortex is lost. Disc enhancement can also be marrow conversion into
fatty marrow.
seen on post-contrast sequences (best appreciated on
III Decreased Decreased Sclerosis.
sagittal views), although the absence of enhancement
does not exclude the diagnosis. As infection progresses,
(a) (b)
Figures 3.56a, b Sagittal images: T2 weighted and STIR MR images of the lumbar spine. There is high signal
within the L2/3 intervertebral disc shown on both sequences. In addition, abnormal marrow signal can be seen
extending into the L2 and L3 vertebral bodies on the STIR sequence (3.56b).
K22247_C003.indd 138 16/05/15 3:08 AM

Discitis can be complicated by paravertebral and can also involve the paravertebral and psoas major
collections and epidural abscess formation; the latter muscles. Paraspinal collections have similar signal
typically appears as a focus of increased signal on T2 characteristics as epidural abscesses (Figure 3.57).
weighted and STIR sequences in the epidural space,
demonstrating ring enhancement on post-contrast Plain films
sequences. As with any spinal pathology, it is important Typical plain film findings of discitis include loss of
to assess whether any abscess compresses the spinal disc space initially, progressing to irregular, ill-defined
cord or nerve roots (see Spinal cord compression and endplate erosions and eventually bony destruction
cauda equina syndrome). Acute cord compression (Figure 3.58; Jallo & Keenan, 2011; Varma et al.,
requires urgent neurosurgical decompression and 2001). In cases of extensive bony involvement, it can be
should be promptly communicated to the referring difficult to distinguish discitis from other processes that
team. Collections typically spread both superiorly and cause aggressive bony destruction, such as malignancy.
inferiorly under the anterior longitudinal ligament
Figure 3.57 Axial image: T2 weighted MR image of Figure 3.58 AP lumbar spine radiograph. The L2/3
the thoracic spine. There is a paravertebral collection endplates are eroded and ill defined, with loss of disc
(see arrow) as a result of discitis. and vertebral body height at these levels.
K22247_C003.indd 139 16/05/15 3:09 AM

140 Chapter 3
In cases of discitis with an associated paravertebral and nerve roots can occur and should be
abscess, widening or convexity of the normal paraspinal communicated urgently to the referring team.
lines can be seen on AP views of the thoracic spine
(Figure 3.59). Any suspicion of discitis on plain film Report checklist
imaging should prompt further assessment with MRI. • Presence or absence of complications, such as
epidural abscess or paravertebral collection.
Key points • Document whether there is any evidence of spinal
• Spondylodiscitis should always be suspected in cord or cauda equina nerve root compression.
cases of pyrexia of unknown origin. • In cases of neurological compromise, recommend
• MRI with IV contrast is sensitive and specific urgent neurosurgical opinion.
for the changes of discitis and is considered the
modality of choice. Typical findings include disc References
and endplate oedema and enhancement. Jallo GI, Keenan MA (2011) Diskitis. Medline Feb.
• Complications of spondylodiscitis include bony Varma R, Lander P, Assaf A (2001) Imaging of pyogenic
destruction, epidural abscess and paravertebral infectious spondylodiskitis. Radiologic Clin North
collections. Compression of the spinal cord Am 39:203–213.
Figure 3.59 AP chest radiograph. A retrocardiac

paraspinal bulge is seen, which represents a paraspinal
collection (arrow).
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Chapter 4
PAEDIATRIC IMAGING
141
INTUSSUSCEPTION Radiological findings

Ultrasound
Intussusception is defined as forward peristalsis of The entire abdomen and pelvis should be scrutinised
proximal bowel into the lumen of the more distal systematically. Classically, intussusceptions appears
bowel. The proximal part of the bowel is termed the as a solid mass with alternating rings of hyper- and
intussusceptum and the distal bowel is termed the hypoechogenicity. The appearance represents
intussuscipiens. The condition is most common in alternating layers of hypoechoic bowel wall and
children under 3 years and is usually idiopathic in hyperechoic mesenteric fat that have telescoped into
this age group. In children older than 3 years, there is one another, with a typical ‘target sign’ (Figure 4.1).
often a lead point for the cause of the intussusception
(e.g. Meckel’s diverticulum). Intussusception can also Table 4.1 Intussusception. Imaging protocol.
be seen as a rare cause of bowel obstruction in adults.
Clinical features include abdominal pain, bloody MODALITY PROTOCOL
diarrhoea and a palpable mass. A small number of Ultrasound 6–9 MHz linear probe should be used to
cases will reduce spontaneously, but the majority examine the entire abdomen.
require intervention in order to resolve completely. Fluoroscopic Air insufflation of the large bowel to a
The condition is considered an emergency due to the air enema maximum pressure of 120 mmHg via a rectal
high risk of bowel ischaemia and bowel perforation, catheter.
and therefore requires prompt diagnosis to prevent
complications.
The diagnosis of intussusception utilises several
imaging modalities; however, it differs slightly for
paediatric and adult cases. A plain AXR is inevitably
performed, followed by ultrasound +/− fluoroscopic air
enema (in paediatric cases). An ultrasound scan should
be performed in an attempt to localise and identify
the intussusception. An air enema using fluoroscopy
is both diagnostic and therapeutic. This requires
insufflation of the bowel with air via a rectal catheter
with a good seal, up to a pressure of 120 mmHg.
Contrast enhanced CT is reserved for the investigation
of intussusceptions in adults; this modality should not Figure 4.1 Ultrasonogram of the bowel in the
form the routine investigatory pathway in paediatric transverse plane. Typical ‘target’ sign appearance with
cases. (See Table 4.1.) alternating hyper- and hypoechoic rings representing the
hypoechoic bowel wall and the hyperechoic mesenteric
fat telescoping into the intussuscipiens (arrow).
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142 Chapter 4
The ultrasound appearance has also been likened abdominal symptoms should be made (Donnelly
to a ‘pseudokidney’, with the combination of et al., 2005). Contraindications to air enema reduction
hypoechogenic bowel wall and hyperechogenic include bowel perforation, haemodynamic instability
mesenteric fat (Figure 4.2). In patients where no or signs of peritonism/bowel ischaemia.
evidence of intussusception is seen, other pathology
that may mimic the presenting features should be
considered (e.g. appendicitis).
(a)
Fluoroscopic air enema

The aim of an air enema is to identify the site of the
abnormality and to force the intussusceptum into its
normal position. This appears as a round, intraluminal
mass that moves retrograde with increasing air pressure.
Successful reduction is demonstrated by reflux of gas
into the small bowel and the resolution of the soft
tissue mass (Figures 4.3a, b). Insufflation air pressures
of up to 120 mmHg should be used up to a maximum
of three attempts. If repeated insufflation of the bowel
with air is unsuccessful, surgical intervention should
be considered. Success rates of over 80% have been
suggested following air reduction. However, 5–10%
of intussusceptions may reoccur, usually within the
first 72 hours, therefore close attention to worsening
(b)
Figures 4.3a, b AP images of the abdomen

during fluoroscopic air enema reduction. (4.3a) The
Figure 4.2 Ultrasonogram of the bowel in the intussusceptum can be seen at the hepatic flexure
longitudinal plane. ‘Pseudokidney’ appearance is shown outlined by gas instilled within the colon (arrow). (4.3b)
as the hypoechoic bowel wall with central echogenicity The intussusception is no longer visible within the
due to the mesenteric fat herniating into the distal colon, with reflux of gas into the small bowl indicating
bowel lumen. reduction of the intussusception.
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Paediatric imaging 143
Plain films BOWEL MALROTATION

An AXR is rarely normal. Classically, there is a paucity
of gas in the right lower quadrant with non-visualisation Bowel malrotation is considered a surgical emergency
of the caecum. A meniscus of soft tissue outlined owing to the high risk of bowel ischaemia. The vast
by gas within the colon may also be demonstrated. majority of patients present in the first few months
Depending on the site of the intussusception, small of life (many in the first week of life); however, the
bowel obstruction may be apparent. A normal variant condition may be first diagnosed in older children
of the position of the sigmoid colon in the right lower and even in adults, often with a history of chronic
quadrant, and the associated presence of gas in this symptomatology. Presenting features include bilious
position, may provide false reassurance for those vomiting, abdominal distension, weight loss and
presenting with ileocolic intussusceptions, a potential irritability.
pitfall. In normal individuals, during development, the small
bowel rotates about the mesentery in an anticlockwise
Computed tomography direction of 270 degrees. The duodenojejunal (DJ)
CT is not advised in patients presenting acutely; junction is positioned in the left upper quadrant and
however, an intussusception may be seen incidentally the caecum in the right lower quadrant, with a long
in patients presenting with non-specific symptoms, mesenteric base, which secures the bowel leaving it
particularly adult patients. The appearances on CT are unlikely to twist. Malrotation is an embryological
similar to those seen on ultrasound, with telescoping of abnormality whereby the rotation and position of the
bowel with alternating layers of bowel and mesenteric bowel is altered and results in an abnormal mesenteric
fat. The bowel must be assessed in detail, in particular attachment, which is often short with an increased
looking for an underlying lesion that may be acting as a likelihood of midgut volvulus. As a result of this
lead point. Bowel obstruction may also be seen. developmental abnormality, the normal positions of the
DJ junction and caecum are altered and it is this feature
Key points that is utilised in diagnostic imaging.
• Intussusception is a life-threatening condition due
to the risk of bowel ischaemia and perforation, and Radiological investigations
so prompt diagnosis is necessary. An upper GI contrast study should be performed to
• Multiple forms of imaging are usually used to assess the position of the DJ flexure. A dense contrast
confirm the presence of intussusception, with medium should be used (e.g. barium) with the patient
an air enema reserved for both diagnosis and positioned in both supine and lateral positions. A small
treatment. bowel follow through/contrast enema can be performed
• If an air enema fails to reduce an intussusception to demonstrate the position of the caecum in equivocal
after three attempts, the patient should be cases. (See Table 4.2.)
considered for surgical treatment.
Report checklist Table 4.2 Bowel malrotation. Imaging

• Recommend urgent air enema reduction in cases protocol.
of intussusception – the patient will often require
prior fluid resuscitation and stabilisation. MODALITY PROTOCOL
Fluoroscopic Standard formulation barium (e.g. Baritop)
Reference upper should be instilled into the stomach either
gastrointestinal orally or via a nasogastric tube. Contrast
Donnelly LF, Jones BV, O’Hara SM et al. (2005) (eds) contrast study should be followed and observed to pass
Diagnostic Imaging: Pediatrics, 1st edn. Friesens, into the duodenum and to the DJ flexure,
Altona, pp. 74–77. and the position should be documented.
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144 Chapter 4
Radiological findings volvulus present at the time of examination may be

Upper gastrointestinal contrast study shown by a ‘corkscrew’ appearance of the bowel – this
An upper GI contrast study is the procedure of choice occurs due to twisting of the small bowel about the
to diagnose malrotation. On an AP view, the normal mesentery and mesenteric vessels.
position of the DJ flexure is to the left of the spine at If the position of the DJ flexure is not documented on
the same level or above the duodenal bulb (Figure 4.4). the first pass of the contrast, opacification of overlying
Both criteria must be met in order for a diagnosis of distal bowel loops may obscure the duodenum and
malrotation to be excluded. make interpretation difficult, which can result in the
An abnormally positioned DJ flexure is diagnostic procedure having to be repeated. In such cases, the
of malrotation (Figure 4.5). As well as an abnormal patient may have to wait several hours for the contrast
bowel position, the SMA/SMV axis may be abnormal, to pass through the proximal small bowel loops before
although this feature is not specific for malrotation. a repeat examination can be performed. Administering
Gross abnormalities are easy to identify where the too much contrast may also have a similar effect, and
duodenum does not cross the midline at all and is timing is therefore crucial when performing such
located on the right side of the abdomen. However, studies. The normal DJ flexure is mobile in children,
subtle abnormalities in the DJ junction position may and the normal position may be displaced by adjacent
be more difficult to appreciate. In equivocal cases, a masses or feeding tubes.
small bowel follow through or large bowel enema can
be performed to document the position of the caecum. Ultrasound
This should normally be in the right lower quadrant; Ultrasound is usually performed for other pathology
however, in malrotation it is often positioned in such as suspected hypertrophic pyloric stenosis (HPS).
the right upper or left upper quadrants. A mid-gut However, if this is not demonstrated, other upper
Figure 4.4 AP image from an

upper GI contrast study. The
normal position of the duodenal-
jejunal flexure is shown to the left
of the spine at the same level of the
duodenal bulb (arrow).
Figure 4.5 AP image from an upper

GI contrast study in a patient with
malrotation. The duodenal-jejunal
flexure is positioned to the left of
the spine (arrow); however, it is
below the level of the duodenal bulb
(arrowhead).
K22247_C004.indd 144 16/05/15 3:10 AM

abdominal pathology should be sought and malrotation MECONIUM ILEUS

may be the cause. Ultrasound findings are not specific
for malrotation, and may represent normal variation Meconium ileus is one of the commonest causes of distal
without underlying abnormality. Features include bowel obstruction in the neonate. In normal neonates,
a reversed SMA/SMV relationship (i.e. the SMV is meconium is passed within the first 48 hours of birth
to the left of the SMA rather than to the right) or a and when this does not occur, meconium ileus is often
swirled appearance of the mesentery/mesenteric vessels suspected clinically. Other signs and symptoms include
indicating a volvulus. abdominal distension and bilious vomiting. Meconium
ileus occurs because of abnormally thick meconium,
Computed tomography which lodges itself in the distal ileum and cannot pass
Findings are similar to ultrasound, with a reversed into the large bowel, resulting in bowel obstruction. It
SMA/SMV relationship. Mid-gut volvulus may be is a common presenting feature in cystic fibrosis and,
demonstrated by a swirled appearance of the mesentery as such, all patients who present with meconium ileus
and mesenteric vessels. Evidence of bowel ischaemia should be considered to have cystic fibrosis unless
secondary to volvulus may be seen in advanced cases, proven otherwise. In a high proportion of cases the
features of which include pneumatosis coli, abnormal condition may be complicated by bowel perforation
bowel enhancement following IV contrast and free or volvulus; these usually require surgical intervention
intraperitoneal gas due to bowel perforation. to remove the meconium. In uncomplicated patients,
water soluble contrast enemas are performed for
Plain films diagnosis and treatment. The other conditions to
A distended, gas-filled stomach and proximal consider for causes of distal bowel obstruction include
duodenum may be demonstrated by a paucity of gas Hirschsprung’s disease and small bowel atresia.
distally. Patients with volvulus and bowel ischaemia
are very unwell, and signs on plain film include free Radiological investigations
intraperitoneal gas, pneumatosis coli and portal venous In all patients, a water soluble contrast enema is the
gas within the liver. It is important to emphasise, procedure of choice for diagnosis. A reasonably high
however, that abdominal plain films can be normal and osmolar agent should be used to encourage fluid to
do not exclude the diagnosis. move into the bowel lumen and allow easier passage of
the meconium. A catheter should be inserted rectally,
Key points but inflation of the balloon is not recommended
• Malrotation is a surgical emergency and a delay in because of the increased risk of perforation in these
diagnosis can have life-threatening consequences patients. (See Table 4.3.)
for the patient.
• An abnormally positioned DJ flexure on an upper
GI contrast study is diagnostic for malrotation.
• Adjuncts to upper GI contrast studies include Table 4.3 Meconium ileus. Imaging protocol.
small bowel follow through or contrast enemas,
with less emphasis on the use of ultrasound MODALITY PROTOCOL
and CT. Fluoroscopic lower A catheter should be inserted rectally.
gastrointestinal A high osmolar water soluble contrast
Report checklist water soluble agent (e.g. Omnipaque 300) is then
• Document the position of the DJ flexure. contrast study instilled via the catheter to opacify
the large bowel and distal ileum.
• Presence or absence of signs of bowel ischaemia or
perforation.
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146 Chapter 4
Radiological findings The study can simultaneously be used to exclude

Lower gastrointestinal contrast study other causes of distal bowel obstruction. Hirschsprung’s
Water soluble contrast is required to reflux into the disease occurs when a segment of aganglionic bowel
distal ileum in order to demonstrate the meconium, results in bowel obstruction. On a contrast enema, this
which will be shown as filling defects within the lumen is shown as a calibre change between the ganglionic and
of the bowel (Figure 4.6). These are typically multiple aganglionic segments. In small bowel atresia, contrast
and often resemble pellets. Care should be taken not to may reflux into the small bowel but may not progress
introduce too much gas into the bowel, as gas bubbles beyond a certain level due to incomplete formation of
may also have a similar appearance. Other findings the bowel.
include the presence of microcolon, which is thought
to occur as a result of non-use of the large bowel. Plain films
In patients where contrast cannot be seen to enter A plain abdominal film is usually performed by the
the distal ileum or where meconium does not pass admitting team; this may show dilated loops of bowel
despite multiple enemas, surgical intervention is indicating a distal bowel obstruction (Figure 4.7).
recommended. In the absence of any abnormality on Typically, there is a ‘bubbly’ appearance to the bowel
water soluble contrast enema, other causes of bilious in the affected loops (usually the right lower quadrant),
vomiting should be considered, such as small bowel which represents a mixture of gas and inspissated
malrotation. meconium. Complicated cases involving perforation
Figure 4.6 AP image from a single contrast Figure 4.7 AP abdominal radiograph. There are
water soluble enema. The colon is small in calibre multiple dilated loops of bowel consistent with a distal
(microcolon) as a result of non-use. Multiple filling bowel obstruction. There is no free intraperitoneal
defects can be seen in the left colon, hepatic flexure, free gas or peritoneal calcifications to suggest bowel
right colon and distal ileum as a result of inspissated perforation or meconium peritonitis.
meconium within the bowel (arrows).
K22247_C004.indd 146 16/05/15 3:10 AM

may demonstrate free intraperitoneal gas or curvi- DUODENAL ATRESIA

linear peritoneal calcifications as a result of meconium
peritonitis. Soft tissue masses may also form following Abnormalities of the duodenum are among the
perforation, which may be due to pseudocyst formation; commonest causes for proximal small bowel obstruction
if this is suspected, further evaluation can be undertaken in neonates. There is a spectrum of abnormalities
with ultrasound. ranging from complete duodenal atresia to duodenal
stenosis/webs, as well as extraduodenal abnormalities
Key points resulting in obstructions such as haematoma, annular
• Meconium ileus is a common cause of bowel pancreas and SMA syndrome. Each of these has its own
obstruction in the neonate; its presence usually underlying pathology and so the investigations required
indicates an underlying diagnosis of cystic fibrosis. to make each diagnosis can vary. Mid-gut volvulus
• A water soluble contrast enema should be is an important cause for duodenal obstruction (see
performed in all patients, taking care not to Bowel malrotation). Duodenal atresia is an important
inflate a balloon tipped catheter due to the risk or diagnosis that should not be missed, as it requires
perforation. curative surgical repair.
• Typical findings on water soluble contrast enema The exact cause of duodenal atresia is not fully
include microcolon and meconium filling defects understood, but it is thought to be due to a failure of
in the distal ileum. canalisation of the duodenal lumen in utero. It is on a
• Surgical intervention is indicated in cases of spectrum of conditions ranging from complete atresia
complicated meconium ileus or when meconium with a blind ending lumen to duodenal stenosis with
cannot be demonstrated on a water soluble a patent lumen resulting in partial obstruction. The
contrast enema. clinical presentation varies depending on the degree
of atresia/stenosis, but typical features include feeding
Report checklist intolerance, vomiting and dehydration. The vomiting
• Presence or absence of any abnormal filling tends to be bilious, as most atresias are distal to the
defects within the terminal ileum and large bowel. ampulla of Vater; however, non-bilious vomiting may
• Document relevant negatives to exclude the occur in patients with a proximal atresia. Duodenal
presence of Hirschsprung’s disease and small atresia is known to be associated with Down’s syndrome
bowel atresia. and some VACTERL anomalies.
A plain AXR can usually diagnose duodenal atresia. For
duodenal webs/stenosis, an upper GI contrast study
using barium is usually performed to demonstrate
passage of contrast through the abnormal segment
of bowel into the normal distal loops. This can be
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148 Chapter 4
easily performed either by instilling barium into the segment ( Figure 4.8 ). Because of the complete
stomach via an NG tube or administering it orally. obstruction, there is also an absence of bowel gas in the
(See Table 4.4.) distal bowel loops. These two features are diagnostic
of duodenal atresia and no further imaging is necessary
Radiological findings to confirm the diagnosis. If the plain abdominal film
Plain films demonstrates only minimal distension of the stomach
A plain abdominal film is often all that is required to and duodenum in addition to distal bowel gas, this
make the diagnosis of duodenal atresia. The typical appearance may be due to duodenal stenosis/web or
finding of a ‘double bubble’ represents the gas-filled small bowel malrotation. In these cases, an upper GI
stomach and duodenal bulb proximal to the obstructed contrast study is indicated.
Table 4.4 Duodenal atresia. Imaging protocol.
MODALITY PROTOCOL
Abdominal plain AP supine abdominal radiograph to include
film imaging the diaphragms and iliac crests.
Fluoroscopic Standard formulation barium (e.g. Baritop)
upper should be instilled into the stomach either
gastrointestinal orally or via a nasogastric tube. Contrast
contrast study should be followed and observed to pass
into the duodenum and proximal small
bowel.
Figure 4.8 AP radiograph of the abdomen. There is

marked gaseous distension of the stomach and proximal
duodenum producing a characteristic ‘double bubble’
sign. No gas is seen distally within the bowel.
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Upper gastrointestinal contrast study HYPERTROPHIC PYLORIC STENOSIS

If distal bowel gas is seen on the plain film, a contrast
study is indicated. In patients with partial duodenal Hypertrophic pyloric stenosis (HPS) is a relatively
obstruction (e.g. duodenal stenosis or web), contrast common condition of uncertain aetiology resulting
outlines a narrowed duodenal lumen in the affected in gastric outlet obstruction. The condition is
segment, but eventually passes beyond this point into characterised by hypertrophy of the circular muscle of
the distal bowel loops. Bowel malrotation/volvulus may the pylorus, and predominantly affects children up to
also produce symptoms of duodenal obstruction. 12 weeks of age. It typically presents with projectile,
non-bilious vomiting after feeds and secondary
Key points hypochloraemic alkalosis. It has a tendency to affect
• Duodenal atresia is an important and common the first-born males within families. Clinically, patients
cause of duodenal obstruction and requires have a palpable olive-sized mass within the epigastrium,
corrective surgery. which represents the hypertrophied pylorus. Although
• The condition can be confidently diagnosed on the condition may not warrant immediate imaging out
plain film if the relevant radiological features are of hours, patients with long-standing symptoms may
observed (i.e. ‘double bubble’ appearance and an present with considerable weight loss and, as such, a
absence of distal bowel gas). prompt diagnosis is important in order to consider the
• In cases of partial duodenal obstruction an upper most appropriate management. Immediate treatment
GI contrast study is indicated. is often aimed at optimising rehydration and correction
of electrolyte imbalances prior to definitive surgical
Report checklist treatment.
• Presence or absence of signs of perforation.
• Recommend a water soluble upper GI contrast Radiological investigations
study if bowel gas is seen distally to look for Ultrasound is the modality of choice to assess the
incomplete obstruction/other causes. pylorus, with the stomach empty initially. If the
stomach is not distended, giving small amounts of
fluid to distend the stomach may allow observation
of peristaltic waves in the supine or right anterior
oblique positions. The pylorus is typically located
in the right upper quadrant or epigastrium, but the
position is variable depending on the degree of gastric
distension. Barium studies may also be of some use in
demonstrating a narrowed pyloric channel, but they are
not routinely performed. (See Table 4.5.)
Table 4.5 Hypertrophic pyloric stenosis.

Imaging protocol.
MODALITY PROTOCOL
Ultrasound Medium to high frequency linear probe (e.g.
6–9 MHz). Images should be acquired in both
the long and short axis of the pylorus.
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150 Chapter 4
Radiological findings thickness (Figures 4.9, 4.10; Table 4.6). In borderline

Ultrasound patients (e.g. pyloric thickness 3 mm, channel length
Patients should be scanned supine and should initially 11 mm), the pyloric index (PI) may be a useful tool:
have an empty stomach to avoid overdistension and
displacement of the pylorus, which makes imaging T × L × (D − T) × π
PI =
more difficult. Small amounts of fluid can be given Patient’s weight (kg)
to allow dynamic scanning of the pylorus to assess
gastric emptying and peristalsis. HPS is diagnosed T = pyloric wall thickness (cm); L = pyloric channel
on ultrasound by measuring the length of the pyloric length (cm); D = pyloric wall diameter (cm); π = 3.14.
channel, the pyloric diameter and the pyloric wall
Figure 4.9 Ultrasonogram of the

pylorus in the transverse plane.
The thickened pyloric wall is shown
as the hypoechoic circular outer
wall (arrow), while the mucosal
lining is seen as the hyperechoic
central structure containing
gas casting a posterior shadow.
The diameter of the pyloric canal
is greater than 8 mm.
Figure 4.10 Ultrasonogram of

the pylorus in the longitudinal
plane. The pyloric wall thickness is
greater than 4 mm and the pyloric
canal length is greater than 12 mm,
signifying hypertrophic pyloric
stenosis.
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Table 4.6 Typical ultrasound measurements ORBITAL AND PERIORBITAL CELLULITIS

in hypertrophic pyloric stenosis
(accepted values vary between
centres).
Orbital and periorbital cellulitis require prompt and
accurate diagnosis and treatment. Differentiating
NORMAL PYLORIC STENOSIS between these two conditions is vital, as they often
Pyloric wall thickness <2 mm >4 mm require different management strategies.
The distinction between orbital and periorbital
Pyloric diameter <6 mm >8 mm
cellulitis relates to the anatomical compartments of
Pyloric channel length <10 mm >12 mm
the orbit. The orbital septum is a thin layer of fibrous
tissue that acts as the anterior boundary of the orbit.
Infections that lie anterior to this are considered to
This calculation is based on the parameters listed be periorbital (or pre-septal), while infections deep to
and can be particularly useful in premature babies. The this layer are labelled as orbital (or post-septal). It is
PI should be less than 0.46; a value greater than this also useful to make the distinction as to whether the
implies underlying pyloric stenosis. abnormality is intraconal (i.e. within the boundaries of
Additional features that would suggest underlying the ocular muscles) or extraconal, since this can narrow
HPS include hyperperistalsis of the stomach and down the potential differential diagnosis.
reduced or absent gastric emptying on dynamic Clinically, patients may present with proptosis
scanning. Pylorospasm can be incorrectly diagnosed as and ophthalmoplegia in addition to localised or
HPS. In both conditions the pyloric mucosa is often systemic signs of infection. Periorbital infections are
hypertrophied. However, in pylorospasm, the muscle usually managed more conservatively with antibiotics,
thickness is usually normal and abnormal measurements whereas orbital infections may require more intensive
are transient, therefore repeat ultrasound can help to treatment or intervention in order to prevent
exclude HPS. complications such as venous thrombosis or abscess
If no abnormality is seen on initial scanning, other formation. In extreme circumstances, loss of vision may
causes of vomiting should be considered (e.g. bowel result if left untreated.
malrotation with evidence of reversed SMA/SMV axis Note: Not all patients who present with signs of
or duodenal atresia). periorbital infection require imaging. Assessment by
an ophthalmologist can help determine whether the
Key points patient’s symptoms and clinical condition merit further
• HPS is a relatively common condition which, investigation.
depending on the clinical condition of the patient,
may not necessarily require out of hours imaging. Radiological investigations
• The imaging modality of choice is ultrasound CT is the imaging modality of choice, as it provides
to assess the pyloric wall thickness and pyloric excellent soft tissue and bony resolution to assess
channel length. for signs of osteomyelitis and subperiosteal abscess
• The PI is a useful tool in equivocal cases or in formation. Orbital infections may commonly occur
premature babies. as a result of sinus disease, so it is prudent to image
• If no abnormality is demonstrated on ultrasound, both the orbits and sinuses to try and identify a
consider other causes of vomiting such as bowel source of infection. Multiplanar reformats are vital in
malrotation or duodenal atresia/stenosis. order to aid identification of subperiosteal infection.
(See Table 4.7.)
Report checklist
• Document the length of the pyloric channel, the
pyloric diameter and the pyloric wall thickness.
• Document the PI in equivocal cases.
• Consider additional causes if the above
measurements are normal.
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152 Chapter 4
Radiological findings extraconal soft tissue mass (which may or may not
Computed tomography demonstrate post-IV contrast enhancement), stranding
The findings of periorbital cellulitis on CT imaging of the intraconal fat and thickening of the intraorbital
include periorbital soft tissue swelling and inflammatory musculature ( Figures 4.12a, b ). The intraorbital
fat stranding, which are both limited to the pre- structures and intraconal fat are best visualised on
septal soft tissues (Figure 4.11). Orbital cellulitis may appropriate image window settings (width 400, level
demonstrate similar findings to periorbital cellulitis, 40). Post-contrast images should be reviewed in order
but with post-septal involvement. Post-septal to identify any enhancing subperiosteal collections
involvement may be indicated by an intraconal or that may require surgical drainage (Figures 4.13a, b).
Table 4.7 Orbital and periorbital cellulitis.

(a)
Imaging protocol.
MODALITY PROTOCOL
CT Helical acquisition from the supraorbital ridge
to the base of the maxillary sinuses. 0.625–
1.25 mm slick thickness with sagittal, coronal
and bony algorithm reformatted images. Post
contrast images (e.g. 50 ml Omnipaque 300)
should also be acquired at 90–120 seconds.
(b)
Figure 4.11 Axial image: unenhanced CT scan of the Figures 4.12a, b Coronal images: IV contrast
orbits. There is a pre-septal fluid collection involving enhanced CT scans of the orbits in the delayed phase.
the right eye with marked inflammatory changes in the A right subperiosteal collection is seen overlying
surrounding tissues, but not extending into the orbit. the right zygoma, with extension into the lateral
Locules of gas can be seen adjacent to the lateral orbital orbit abutting the lateral rectus muscle. Ill-defined
wall as a result of gas forming infection (arrow). inflammatory changes can be seen in the intraconal
fat (arrow).
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The orbit should be inspected in all three planes using

(a)
multiplanar reformats; subperiosteal collections are
often best visualised in the coronal plane.
Review of images on bone window settings (width
3,000, level 650) is paramount, as sinus disease can
be a common underlying cause. Sinusitis manifests as
opacification of the paranasal air spaces with mucosal
thickening. There may be associated bony destruction
causing a communication between the sinus and
the orbit.
Key points
• It is important to distinguish simple periorbital
cellulitis from orbital cellulitis, as true orbital
involvement may necessitate surgical intervention.
(b)
• CT scans should be reviewed in axial, coronal and
sagittal planes to scrutinise for any post-septal
involvement.
• Review of images on bone window settings is vital
to look for signs of underlying sinus disease.
Report checklist
• Presence or absence of intraorbital involvement or
subperiosteal abscess.
• In cases of subperiosteal abscess, assess the degree
of proptosis.
• Consider an underlying cause, such as sinus
disease. Inspect for bony destruction.
• In cases of orbital involvement, recommend
urgent ophthalmology review.
Figures 4.13a, b Axial and coronal images: IV contrast

enhanced CT scans of the orbits in the delayed phase.
There is an enhancing subperiosteal collection within
the right orbit, causing significant proptosis (arrow).
Note the associated sinus disease in the right maxillary
antrum and ethmoid air cells (arrowhead).
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154 Chapter 4
ACUTE OTITIS MEDIA In patients where there is suspicion of intracranial

abnormality, post-contrast imaging of the brain is
Middle ear infection is a common condition, often indicated to look for signs of abscess or venous sinus
encountered in the paediatric population. Most thrombosis. (See Table 4.8.)
children have at least one episode of acute otitis media
(AOM), usually before the age of 12 months (Lissauer Radiological findings
et al., 2012). Patients typically present with otalgia Computed tomography
and fever, and clinical examination of the tympanic In normal individuals, the middle ear cleft should
membrane is sufficient to make the diagnosis. In the be aerated with no fluid visible around the ossicles
majority of cases, this is a self-limiting condition that (Figure 4.14). In cases of AOM, fluid may accumulate
can be managed conservatively with pain relief and within the middle ear and mastoid air cells. This is
antibiotics when symptoms persist. In chronic cases, shown as fluid density material surrounding the ossicles
AOM can lead to fluid accumulation within the middle (Figure 4.15). This appearance may be seen in patients
ear (glue ear). This may lead to hearing loss and speech with uncomplicated AOM with no further radiological
and language developmental delay. abnormalities.
In the acute setting, the major complications of In cases where there is involvement of the mastoid
AOM include meningitis or mastoiditis, which may air cells, these are opacified rather than being air
lead to epidural abscess and venous sinus thrombosis. filled. In new born patients, the mastoid air cells are
These entities can result in significant morbidity not pneumatised; this process usually occurs over the
and mortality if not diagnosed and treated. Epidural first 1–2 years of life. Therefore, in these patients it is
abscess and venous sinus thrombosis are discussed important to look for asymmetry in the appearance of
separately elsewhere (see Chapter 3: Neurology and the mastoids, which might indicate signs of unilateral
non-traumatic spinal imaging, Intracranial abscess infection. Coalescent mastoiditis may be seen as
and subdural empyema and Cerebral venous sinus destruction of the bony septations within the mastoid
thrombosis). Meningitis is a neurological emergency resulting in coalescence of the air cells into large fluid-
requiring rapid diagnosis and treatment. In general, filled pockets. In chronic cases, the bone may also
diagnosis is made on history and clinical examination in become sclerotic. Inflammatory changes may be seen
conjunction with CSF cultures. There is an occasional in the soft tissues overlying the mastoid. In complicated
role for imaging in cases where there is a suspicion of cases, there may be extension of the infection resulting
intracranial abscess. Mastoiditis occurs when infection in subperiosteal abscess (Figure 4.16). This can be
in the middle ear spreads into the adjacent mastoid
air cells. This often presents as erythema, swelling
and pain over the mastoid/post-auricular region. In
cases of complicated AOM, involvement of the ENT/
neurosurgical teams is advised. Table 4.8 Acute otitis media. Imaging
protocol.
Radiological investigations MODALITY PROTOCOL
Uncomplicated AOM does not require imaging;
CT Unenhanced. Scan from level of orbital floor to
however, patients suspected of developing intracranial foramen magnum. Thin slice (e.g. 0.625 mm)
complications associated with AOM do warrant high-resolution bony algorithm reconstructions
imaging for further assessment in order to characterise required in the axial and coronal planes.
the extent of disease. CT is the imaging modality Post IV contrast: 2 ml/kg via 20G cannula,
of choice as it allows clear delineation of the bony 3 ml/sec. Scan at 120 seconds after start of
architecture of the middle ear and skull to help injection. Scan from level of foramen magnum
to vertex.
identify areas of disease. A limited unenhanced CT
of the temporal bones should be performed initially.
K22247_C004.indd 154 16/05/15 3:10 AM

brain. The middle ear clefts and mastoid air cells are brain. The right middle ear cleft and mastoid air cells
pneumatised with no fluid opacification evident. are opacified with fluid due to infection. There is also
coalescence of the right mastoid air cells (arrow).
seen as a thick-walled, enhancing collection adjacent

to the mastoid, and is important to identify as surgical
drainage may be required.
Key points
• AOM is a common childhood infection that can
usually be managed conservatively for the majority
of patients.
• Patients whose symptoms persist despite treatment
or who develop signs of complications may require
cross-sectional imaging.
Report checklist
• Evidence or otherwise of bony erosion.
• Presence or absence of mastoid air cell
opacification and coalescence.
• Presence or absence of intracerebral infection/
abscess and venous sinus thrombosis.
Figure 4.16 Axial image: post IV contrast CT scan of
the brain. There is a thick-walled, enhancing collection Reference
overlying the right temporal bone consistent with an Lissauer T, Clayden G (2012) Illustrated Textbook of
abscess as a result of underlying mastoiditis. Paediatrics, 4th edn. Mosby Elsevier, London, p. 278.
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156 Chapter 4
PARAPHARYNGEAL AND Radiological investigations

RETROPHARYNGEAL ABSCESS In the emergency setting, IV contrast enhanced CT is
the imaging modality of choice. CT readily delineates
Focal infections of the deep neck are a medical and the deep neck anatomy, allowing identification of
surgical emergency, requiring prompt diagnosis and potential abscesses and their relation to adjacent
treatment. Parapharyngeal and retropharyngeal structures. CT can also differentiate focal abscesses
abscesses usually arise secondary to oropharyngeal from cellulitis and lymphadenopathy, which are
or dental infections such as acute tonsillitis (or post potential differential diagnoses. CT also plays a role
tonsillectomy), dental infection, petrositis and in identifying the cause of a potential abscess, such as
Bezold’s abscess. Whilst both parapharyngeal and tonsillitis or dental infections. Note, however, that CT
retropharyngeal abscesses can occur at any age, they has a not insignificant false-negative and false-positive
are more common in the paediatric population (Craig rate and therefore, even in cases of a normal CT,
& Schunk, 2003). surgical exploration may be required if there is a strong
The presentation of parapharyngeal and clinical suspicion (Craig & Schunk, 2003). Note also
retropharyngeal abscesses varies significantly. that emergency imaging should not be delayed until the
Initially, symptoms and signs can mimic an upper patient develops more significant signs such as airway
respiratory tract infection (which may precede a focal compromise, as by this time it may be too late.
abscess); they include sore throat, fever and cervical Traditionally, lateral cervical X-rays have been
lymphadenopathy. In younger children, symptoms and utilised in the investigation of retropharyngeal abscess.
signs may be more non-specific, such as irritability and These may show soft tissue swelling posterior to the
poor feeding. Inflammatory markers are often elevated, pharynx (i.e. widening of the pre-vertebral soft tissues).
but may also be normal. A key indicator is a rapid This is non-specific and can also be seen in discitis,
progression of symptoms and signs suggesting upper paravertebral collections and trauma. A normal X-ray
airway obstruction, including dysphagia, neck stiffness, does not exclude the diagnosis and, even if abnormal,
stridor, dyspnoea and drooling. further imaging with CT is often indicated to delineate
If untreated, parapharyngeal and retropharyngeal the precise anatomy. (See Table 4.9.)
abscesses can be rapidly fatal. Complications
include laryngeal oedema, which can lead to airway
obstruction, mediastinitis, jugular venous thrombosis Table 4.9 Parapharyngeal and retropharyngeal
and osteomyelitis. Urgent imaging is often necessary abscess. Imaging protocol.
to delineate the location of the abscess and additional
MODALITY PROTOCOL
complications. Small abscesses are sometimes treated
CT 100 ml IV contrast via 18G cannula, 2 ml/
with IV antibiotics in isolation; however, surgical sec. Scan at 50 seconds after initiation of
drainage may often be required in addition to this. injection. Scan from thoracic inlet to skull
base level.
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Radiological findings location, since it connects the deep cervical spaces to

Computed tomography the mediastinum. The prevertebral space is located
Knowledge of the normal anatomy of the neck is vital posterior to the danger space and anterior to the longus
when interpreting CT imaging. The neck can be colli muscles.
broadly divided into seven deep spaces: parapharyngeal, An abscess typically appears as a focal area of
pharyngeal mucosal, retropharyngeal, parotid, carotid, fluid attenuation (0–20 Hu) with associated uniform
masticator and perivertebral ( Table 4.10 ). The rim enhancement post IV contrast. It is important
parapharyngeal space is a pyramidal fatty-filled space to localise any potential abscess to its anatomical
with its base at the skull base and apex at the hyoid bone. compartment. Abscesses in the retropharyngeal space
On cross-sectional imaging, it has a triangular shape. usually displace the triangular parapharyngeal fat
The retropharyngeal space is a potentially mostly fatty- anterolaterally and the pharynx anteriorly. In addition,
filled space in the midline of the neck. It extends from retropharyngeal abscesses displace the longus
the skull base to approximately the level of tracheal colli muscles posteriorly (in contradistinction to
bifurcation, posterior to the pharynx and oesophagus. pathology in the perivertebral space, which displaces
On cross-sectional imaging, it demonstrates a broadly these muscles anteriorly). In normal individuals, the
rectangular shape. It is separated from the more ‘danger’ space cannot be reliably distinguished from
posteriorly situated ‘virtual’ danger space by the alar the retropharyngeal space. Conversely, an abscess
fascia. The danger space is an important anatomical in the parapharyngeal space usually displaces the
Table 4.10 Anatomy of the parapharyngeal and retropharyngeal spaces.
NECK SPACE BOUNDARIES RELATIONS CONTENTS

Parapharyngeal Superior: skull base. Anterior: medial pterygoid. Fat; trigeminal nerve; internal
Inferior: hyoid bone. Posterior: pre-vertebral space. maxillary artery; ascending
pharyngeal artery; pterygoid
Medial: middle layer of deep cervical Lateral: masticator space.
venous plexus.
facia. Medial: pharyngeal mucosal
Lateral: fascia associated with space.
the deep lobe of parotid gland.
Anterior: fascia covering the medial
pterygoid.
Posterior aspect: pre-vertical fascia.
Retropharyngeal Superior: clivus. Anterior: pharyngeal mucosal Fat; lateral and medial
Inferior: point of alar and middle layer space. retropharyngeal lymph nodes.
of deep cervical fascia fusion (usually Posterior: danger space.
T4 level). Posterolateral: carotid space.
Lateral: deep layer of deep cervical Anterolateral: parapharyngeal
fascia. space.
Anterior: middle layer of deep cervical
fascia.
Posterior: alar fascia.
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158 Chapter 4
carotid space and sheath laterally. Abscesses may significantly compress the pharynx, leading to
cause significant compression and displacement respiratory compromise. It is important to appreciate
of adjacent structures; this should be commented that infection may spread to different compartments
upon. For example, a retropharyngeal abscess may within the neck (Figures 4.17a–d).
(a) (b)
(c) (d)
Figure 4.17a–d Axial images: IV contrast enhanced CT scans of the neck in the arterial phase. Multiple images
demonstrating ring enhancing collections/abscesses in the parapharyngeal region in the neck (arrows). Note the
varying degrees of airway compromise secondary to mass effect.
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Distinguishing tumours from abscesses in the demonstrate linear enhancing densities within. If
deep compartments of the neck can be difficult. imaged, the mandible may demonstrate periodontal
Higher attenuation and more solid components lucencies or bone destruction, suggestive of periodontal
of the abnormality are more suggestive of tumour; abscess formation.
however, tumours may become significantly necrotic
with a more cystic appearance, mimicking abscesses. Key points
While pharyngeal tumours may also invade the • Parapharyngeal or retropharyngeal abscesses are
parapharyngeal or retropharyngeal spaces, they are common in the paediatric population, usually
expected to centre on the pharyngeal mucosal space occurring secondary to oral pharyngeal or
(as opposed to the parapharyngeal or retropharyngeal periodontal infection.
spaces). Parapharyngeal or retropharyngeal cellulitis • In the emergency setting, CT is the imaging
typically appears as low attenuation soft tissue swelling; modality of choice.
however, it lacks the focal cystic collection and rim • Knowledge of the deep neck anatomy is vital in
enhancement of an abscess. aiding interpretation of CT imaging.
In the presence of infection within the neck, the
jugular veins should be scrutinised for filling defects, Report checklist
which suggest thrombosis. Cervical lymphadenopathy • Anatomical location and size of any abscess.
is often seen secondary to abscesses. In the case of a • Document the relationship with adjacent
retropharyngeal abscess involving the danger space, structures.
mediastinitis can also occur, manifesting as fat stranding • Degree of mass effect and airway compromise.
or focal collections within the mediastinum; this carries
a significant mortality. Reference
The cause of any potential abscess should be Craig FW, Schunk JE (2003) Retropharyngeal abscess
considered. Tonsillitis may appear as unilateral or in children: clinical presentation, utility of imaging,
bilateral enlargement of the tonsils, which can also and current management. Pediatrics 111:1394–1398.
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K22247_C004.indd 160 16/05/15 3:10 AM
Chapter 5
TRAUMA IMAGING
161
INTRODUCTION TO IMAGING IN by mechanism of injury and at-site assessment) will be

MAJOR TRAUMA taken directly to an MTC if travel time allows or else
to the nearest trauma unit for stabilisation and then
Imaging of severely injured patients within the subsequent transfer to an MTC. Incorrectly triaged or
context of major trauma can present many challenges. self-presenting patients may present to any trauma unit.
The spectrum of injury may be incredibly varied, MTCs have all the services required to receive and
involving multiple body systems and sometimes with manage seriously injured patients. Elements of the
limited clinical information. Injuries may result from requirement of an MTC include:
innumerable circumstances ranging from gunshot • Emergency care:
wounds and work place injuries, to blunt injuries • Consultant on site to lead the trauma team
from road traffic collisions and falls from height. As 24 hours a day.
a result, the imaging findings may be complex and • Appropriately trained trauma team.
a clear understanding of the mechanism of injury • Ability to perform a resuscitative thoracotomy
can be invaluable in predicting patterns of injury and in the emergency department.
identifying which areas to scrutinise in detail. • Massive haemorrhage protocol in place for
In the UK, major trauma patients are cared for patients with acute blood loss.
in dedicated major trauma centres (MTCs). These • Immediate availability of fully staffed operating
are designated hospitals that are equipped with the theatre 24 hours a day.
relevant clinical expertise and resources to deal with • All emergency operative procedures should
these often complex patients. The initial imaging of have evidence of consultant involvement.
trauma patients usually occurs within these specialised • Consultants in all emergency specialities (e.g.
centres; however, a small number may present to other surgery, interventional radiology, anaesthesia)
hospitals; it is vital that in these cases patients are should be available on site within 30 minutes.
managed quickly and safely. • Radiology:
Several different trauma scoring systems are • Immediate access to CT (within 60 minutes)
available, but the most frequently used is the Injury with reporting within 60 minutes of
Severity Score (ISS) (Baker et al., 1974). This scores performing the scan.
injuries from 1 to 75, the latter being the most serious. • Availability of interventional radiologist within
Patients who have an ISS >15 are defined as having 60 minutes of referral.
suffered from a major trauma. Patients with an ISS of • Ongoing care:
9–15 are defined as having suffered a moderately severe • Immediate access to critical care or high-
trauma. Patients with an ISS >15 should be managed dependency unit.
in an MTC. However, it is not possible to determine
the ISS at the time of injury because this requires a The decision to perform imaging should be made in
full diagnostic assessment. For this reason, patients conjunction with the lead trauma physician. Local
with potential major trauma injuries (decision made protocols are usually in place to help determine which
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162 Chapter 5
patients warrant imaging; these protocols should method of imaging. In paediatric patients, there is a
be used as guidelines, with each case assessed on an greater need to consider the effect of ionising radiation
individual basis. The clinical history/mechanism of and its long-term effects. In these patients, a bedside
injury and clinical findings on the primary survey ultrasound may be helpful as an initial triage tool before
of the patient should be considered. In severely proceeding to CT. The Royal College of Radiologists
haemodynamically unstable patients, it may be in the UK has published guidelines advocating the use
appropriate to proceed to surgery without imaging. of CT rather than ultrasound in major trauma patients
Imaging should be performed in a timely fashion (Royal College of Radiologists, 2014).
to provide an accurate assessment of the patient, Many major trauma patients are unable to provide
facilitating the most appropriate management. In an accurate medical history and a clinical decision
general, the primary aim of imaging is to evaluate may need to be made in the best interest of the patient
known injuries that are apparent clinically, as well as given the potential for significant internal injury.
identify those injuries that are not apparent on clinical Departmental guidelines should be consulted where
examination and which may have a bearing on the appropriate. Where there is a significant mechanism
clinical course of the patient. of injury, IV contrast is used to accurately assess the
The Royal College of Radiologists in the UK solid organ parenchyma and vasculature and to identify
provides several standards for Trauma Radiology in sources of active haemorrhage. A compromise may be
Severely Injured Patients (see Appendix 2). made by administering contrast agents with a lower
A whole body polytrauma CT is indicated when: incidence of contrast-induced nephropathy. The
• There is haemodynamic instability. exact CT protocol often depends on local guidelines;
• FAST (if used) has demonstrated intra-abdominal however, most centres advocate both an arterial and
fluid. portal venous phase. The arterial phase facilitates
• If plain films suggest significant injury, such as identification of active arterial haemorrhage, which
pneumothorax/pelvic injuries. may require immediate surgical treatment. The portal
• Obvious severe injury on clinical assessment. venous phase is essential to allow accurate assessment of
• The mechanism of injury or presentation suggests the solid abdominal organs. Acquisition of these images
that there may be occult severe injuries that may be either as separate phases or as a combined
cannot be excluded by clinical assessment or plain dual phase single acquisition, depending on local
films. For example: departmental guidelines.
• Ejection from vehicle. Patient positioning on the CT table should be
• Entrapment in vehicle for >30 minutes. optimised to produce diagnostic quality images.
• Fatality at scene. Monitoring leads should be moved to the periphery
• Injury to more than one body region. where possible. Scanning the head and neck with
• Fall from >10 feet (>3 metres). the arms down helps to acquire images with reduced
• Gunshot wound. artefact. Similarly, scanning the body with the arms
• High speed rollover. up reduces beam hardening artefacts through the
• Pedestrian versus car travelling at >30 mph. abdomen and pelvis that may mimic injuries.
• Fall downstairs (>5 steps) and age >65 years. In all types of injury, the CT scout images should
be reviewed routinely. These often image areas outside
Once the decision has been made to perform imaging, of the imaged region of the main CT scan, and can
the correct modality must then be selected. In adult provide valuable information regarding peripheral
patients with a high suspicion of injury, CT is the initial injuries such as long bone fractures, which may not
imaging modality of choice. Other modalities such as otherwise be included on the CT. It may also allow early
ultrasound, MRI and plain film imaging may be used identification of pathology, which can be relayed to the
as an adjunct; however, the ease of access and relatively referring team (e.g. presence of haemo/pneumothorax,
short scan times for CT make it a practical first-line free intra-abdominal gas).
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Trauma imaging 163
It is useful to do an initial immediate assessment of Active haemorrhage

the images as the scan is being performed. This allows Administering IV contrast and timing the scans
for a ‘primary assessment’ to identify any immediate appropriately can help identify sources of active
life-threatening conditions (e.g. tension pneumothorax, haemorrhage, which may require urgent intervention.
incorrectly sited ET tube, active haemorrhage/splenic Active bleeding often manifests as a ‘contrast blush’
rupture). Most departments will have a proforma for on the arterial phase. Demonstrating contrast
a rapid initial radiological assessment. An example is extravasation during the arterial phase of imaging
included in Appendix 3. suggests active, arterial haemorrhage. Imaging the
same region during the delayed phase can be useful,
Penetrating injury as it can also demonstrate pooling of contrast within
Penetrating injuries include stabbings and gunshot the affected region, which may provide a subjective
wounds, but they may also be sustained in conjunction measure of the rate of blood loss (Figures 5.1a, b).
with blunt injuries depending on the mechanism of It is very important with penetrating injuries
injury. In general, penetrating injuries tend to be more to know:
localised with regards to the body parts involved; • What is the instrument of injury – knife/bullet/
however, depending on the instrument, severe internal other?
injuries can be sustained. It is normally prudent to • How many penetrating injuries have occurred?
image segments of the body above and below the region
where the penetration occurred, since the internal One should always be able to identify the entry wound
tract of the injury may be difficult to predict from the and it is necessary to have an understanding of the
external injury (e.g. imaging a stab injury to the thorax trajectory of the wound and how deep the injury is
may include the neck and abdomen). likely to extend. This is particularly important since
(a) (b)
Figures 5.1a, b Axial images: IV contrast enhanced CT scans of the pelvis in the arterial and delayed phases.
There is active arterial contrast extravasation into subcutaneous haematoma overlying the right anterior pelvis (5.1a,
arrow). On the delayed image (5.1b), the extravasated contrast has dispersed into the haematoma (arrow).
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164 Chapter 5
patients may be unconscious and therefore unable to

give the information themselves. This information
therefore should be made available by the emergency
clinician who has completed a thorough primary and
secondary survey. A stabbing case is shown (Figures 5.2,
5.3a, b). This patient was stabbed with a kitchen knife
a single time. The posterior chest wound can be seen
on the left, but as well as this there is a high attenuation
right-sided pleural effusion (Figure 5.2). On close
examination there are tiny avulsed fragments of bone
from the lateral aspect of the right vertebral body
and rib head at this level, and on the arterial phase
scans (Figures 5.3a, b) there is visible active contrast
extravasation from an intercostal artery, which explains
the right haemothorax. The trajectory of the knife Figure 5.2 Axial image: unenhanced CT chest scan.
can therefore be identified and it would suggest that There is a large laceration to the left posterior chest
the knife would have had to traverse the spinal canal. wall (arrow) with bilateral pleural effusions.
(a) (b)
Figures 5.3a, b Axial images: IV contrast enhanced CT chest scans in the arterial phase. This is on soft tissue
windows. Two tiny fragments of bone are seen at the level of the right rib head. There is high attenuation material
layered in the right pleural effusion consistent with active contrast extravasation (arrows). When re-windowed (5.3b)
it is possible to see the extravasation of contrast from a right intercostal vessel. The trajectory of the knife can be
calculated from the injuries – the path crosses through the spinal canal.
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Trauma imaging 165
The patient was unconscious and unable to give any trajectory of the wound. A left rectus sheath haematoma
clinical information. On MRI, the appearance of the from a stab wound is shown (Figures 5.5a, b). The
thoracic spine with focal high signal within the cord is direction of the stab wound is easily visible on the
consistent with a cord injury (Figures 5.4a, b). sagittal reformat.
Sagittal and coronal reformat assessment is essential
in cases of penetrating trauma to correctly identify the
(a) (b)
Figure 5.4a, b Sagittal and axial T2 weighted MR images of the thoracic spine. There is high signal seen within
the centre of the thoracic spinal cord consistent with cord transection (5.4a, arrow).
(a) (b)
Figure 5.5a, b Axial and sagittal images: unenhanced CT scans of the abdomen and pelvis. There is a left rectus
sheath haematoma with the trajectory of the knife easily identifiable on the reformatted image.
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166 Chapter 5
Blunt injury scanned individually and adjusted to the needs of the

Blunt injury may occur through a variety of situations, patient and the suspected injuries sustained. Referral
which include, but are not limited to: to departmental guidelines, when available, should be
• Road traffic collisions – pedestrians and drivers, the first form of reference for the on-call radiologist.
restrained and unrestrained. In general, it is advised that paediatric traumas should
• Fall from height/stairs. be discussed with the consultant radiologist on call for
• Blast injuries. advice regarding scan protocols.
In general, these types of injuries have the potential to Key points

involve multiple body regions; as such, there should • All trauma scans need to be assessed with sagittal
be a low threshold to image several regions to identify and coronal reformatted images.
occult injuries. • Knowledge about the mechanism of injury as well
Sagittal and coronal reformat assessment is also as the site and number of penetrating injuries is
essential in all cases of blunt trauma in order to correctly required.
identify bony injuries. Fractures are much easier to see
on sagittal and coronal reformatted images than on Reference
the axial images, particularly in the spine. A depressed Baker SP, O’Neill B, Haddon W Jr et al. (1974) The
skull fracture at the skull vault, which could be missed Injury Severity Score: a method for describing
without reformats, is shown (Figures 5.6, 5.7). 3-D patients with multiple injuries and evaluating
reformats can be useful here (Figures 5.8a, b). emergency care. J Trauma 14:187–196.
Individual protocols and techniques are discussed Royal College of Radiologists (2014) Paediatric Trauma
in the following sections. However, it is important Protocols. Royal College of Radiologists, London.
to reiterate that each case should be protocolled and
Figure 5.6 Axial image: unenhanced CT brain scan on Figure 5.7 Coronal image: unenhanced CT brain scan
bone windows. There is a depressed left parietal vault on bone windows. There is a depressed left parietal vault
fracture. fracture, which is more clearly visible than in Figure 5.6.
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Trauma imaging 167
(a) (b)
Figures 5.8a, b Reformatted 3-D

images of the vault fracture (arrows)
shown in Figures 5.6 and 5.7.
MAJOR TRAUMA: THORAX threatening. It can also highlight any acute arterial
haemorrhage, which may necessitate urgent surgical
Thoracic trauma can result in severe, life-threatening or interventional input.
injuries that need rapid diagnosis and treatment. Chest plain film imaging may be performed in
The myriad of pathology can be variable, resulting some centres where CT is not readily available or
in problems with both respiratory and cardiovascular prior to transferring a patient to a dedicated trauma
function and leading to a rapid deterioration in the unit. Although gross pathology may be seen on chest
patient’s condition. Mortality rates have been reported plain film imaging, significant pathologies may be
in the region of 10–15% as a result of thoracic trauma, missed. Images are inevitably acquired in an AP supine
which is second only to head injuries in the context of position, which may obscure important pathologies
major trauma patients (Shorr et al., 1987; Kaewlai et al., such as pneumothorax and haemothorax in addition to
2008). The mechanism of injury, clinical parameters great vessel injuries. (See Table 5.1.)
and examination findings all provide important
information to the radiologist and can often be used to
predict patterns of injury and the underlying pathology.
Table 5.1 Major trauma: thorax. Imaging
Radiological investigations protocol.
In most dedicated trauma centres, patients with MODALITY PROTOCOL
significant chest trauma should ideally be assessed with
CT Arterial phase: 100 ml IV contrast via 18G
contrast enhanced CT. Not only does this allow a rapid cannula, 4 ml/sec. Bolus track centred on the
diagnosis of any acute pathology that may be present, aortic arch. Scan from the thoracic inlet to
it also assists in ascertaining the adequacy of placement the inferior border of liver. Slice thickness of
of support lines and tubes. Contrast enhanced CT 0.625–1.25 mm to allow accurate multiplanar
reformats of the images.
gives an accurate depiction of the aorta to assess for
any acute aortic injury, which may potentially be life
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168 Chapter 5
Radiological findings Haematoma within the mediastinum is most often

Specific pathologies are discussed separately. In the result of venous bleeding; however, when present
general, as with any polytrauma imaging, an initial this should always prompt the suspicion of aortic injury.
survey of CT imaging should be performed in order Deceleration injuries can also result in blunt injury of the
to quickly identify life-threatening injuries. In the mediastinum against the posterior sternum, resulting in
thorax, this includes traumatic aortic injury, tension stranding or haziness of the mediastinal fat (Figure 5.9)
pneumothoraces and haemopericardium with cardiac or focal haematoma. On CT, mediastinal haematoma
tamponade. Once these injuries have been excluded, appears as dense soft tissue material. Knowledge of
a more detailed imaging survey can be carried out. In the normal morphology of the thymus gland, which
all cases, chest CT imaging should always be inspected is present in children (and some young adults), is vital
on lung window (width 1,600, level 550), soft tissue/ since this can be falsely interpreted as haematoma.
mediastinal window (width 450, level 70) and bone Pneumomediastinum is not uncommon and is best
window (width 2,000, level 250) settings in order to appreciated on lung window settings. Causes include
appreciate the full spectrum of injury. alveolar rupture, extension from pneumothoraces
or surgical emphysema, tracheobronchial injury and
Mediastinal injury penetrating trauma. Oesophageal rupture is another
Injury to the mediastinal contents can have catastrophic important cause, and can be the result of penetrating
consequences, particularly when the aorta and great trauma.
vessels are involved. It is advisable to assess for major
mediastinal vascular injury initially, since injuries to Cardiac injury
the thoracic aorta can be immediately life threatening. Cardiac injuries can be fatal and should be identified
The spectrum of traumatic aortic injury also includes and acted upon as a matter of urgency. CT may
aortic dissection, which should be inspected for (see demonstrate haemopericardium, although this can also
Chapter 1: Acute aortic syndrome and Thoracic be seen in cases of dissection and myocardial infarction
aortic injury). (Figure 5.10). As with a pleural effusion, increased
scan of the thorax in the arterial phase. Ill-defined, hazy scan of the thorax in the arterial phase. There is large
linear densities can be seen in the medastinal fat anterior volume, homogenous fluid within the pericardium
to the aortic arch as a result of mediastinal contusional surrounding the heart, which in the context of trauma is
injury (arrow). No active haemorrhage is seen. likely to represent haemopericardium.
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Trauma imaging 169
density of pericardial fluid suggests haemorrhage, during respiration. In a pneumothorax, gas within the
and the Hu of any pericardial fluid should always be pleural space causes the lung to separate from the chest
sampled. The normal pericardium should be pencil thin wall and collapse. This in itself may reduce respiratory
and not contain any significant volume of fluid, with a capacity and compromise function. Gas may collect
normal fat plane seen between the cardiac chambers within the pleural space by several means. The most
and the pericardium. Simple pericardial effusions are common cause is air leakage from traumatic alveolar
not uncommon, and can be seen in pre-existing heart rupture. Other causes include blunt and penetrating
disease. Large pericardial effusions can result in cardiac chest wall injury.
tamponade, whereby the excess fluid around the heart On CT, a pneumothorax is seen as a collection of
impairs cardiac function, resulting in impaired venous gas surrounding the lung within the pleural space
return to the heart. (Figure 5.11). Other features include an absence of
vascular lung markings that reach the chest wall and
Pneumothorax a well-defined lung edge seen within the thorax away
A pneumothorax is the result of gas collecting within from the chest wall. Findings on chest plain film
the pleural space. In normal individuals, the pleural imaging are similar, with a lung edge visible and an
space is a potential space between the visceral and absence of vascular markings at the lung periphery in
parietal pleura. It normally contains a small volume an erect/semi-erect patient (Figure 5.12). In supine
of fluid to lubricate the pleura and allow movement patients, however, findings may be more subtle. In this
Figure 5.11 Axial image: IV contrast enhanced CT Figure 5.12 AP portable chest radiograph. A large
scan of the thorax in the arterial phase. Viewed on right pneumothorax is demonstrated, with no vascular
lung window settings, gas is illustrated as areas of low markings visible. The collapsed right lung is seen as a
attenuation. There are bilateral pneumothoraces. In soft tissue mass adjacent to the right heart. There is no
addition, there is marked pneumomediastinum and mediastinal shift to suggest tension.
surgical emphysema, which can be seen tracking within
and around the muscles of the chest wall.
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170 Chapter 5
position, gas collects in the most dependent position defect in the pleura (e.g. broken rib) and through the
(anteroinferiorly against the diaphragm), appearing as fascial planes into the subcutaneous tissues. It may also
a deep sulcus sign (Figure 5.13). occur as a result of direct penetrating injury to the chest,
The main complication of a pneumothorax is the resulting in a tract between the subcutaneous tissues and
development of a tension pneumothorax. This occurs the outside. On imaging, this is seen as gas overlying
when gas is able to collect within the pleural space but the chest within the subcutaneous tissues. This is often
is not able to escape. This results in a large volume of a fairly self-limiting condition with treatment aimed
gas within the pleural space, which exerts considerable at the underlying pneumothorax. However, it may
mass effect, resulting in shifting of mediastinal contents occasionally progress and become extensive resulting
to the contralateral side. The mass effect of this raises in airway compromise.
the pressure within the thorax and compromises
venous return to the heart, leading to cardiac failure. Haemothorax
A tension pneumothorax ideally should not be seen on Haemothorax is defined as the presence of blood
imaging as it is a clinical diagnosis requiring immediate within the pleural space. The underlying cause may
intervention. However, if it is seen on imaging, it should be any cause of haemorrhage within the thorax, such
be immediately decompressed. as pleural injury, rib fracture or lung injury. On CT
Pneumothoraces in the context of chest trauma may imaging, haemothoraces appear as fluid within the
also result in subcutaneous emphysema. This occurs pleural spaces, which is usually denser than simple
when gas within the pleural space tracks through a pleural effusions (Figure 5.14). It should be noted
Figure 5.13 AP chest radiograph. There is a left Figure 5.14 Axial image: IV contrast enhanced CT
pneumothorax. In the supine position, gas within the scan of the thorax in the arterial phase. Dependent
pleural space collects within the most superior part of fluid can be seen in the right pleural space. A right
the thorax, which is the costophrenic recess antero- pneumothorax is also seen, and this is therefore a
inferiorly (arrow). pneumohaemothorax.
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Trauma imaging 171
that a small amount of blood within simple pleural painful for the patient, and so can result in splinted
fluid can be difficult to appreciate visually, and the Hu breathing and inadequate ventilation, which can lead to
of pleural fluid should be sampled in the context of atelectasis and infection. They are therefore important
trauma (a value >40 Hu is suggestive of haemorrhage). to identify in order to prevent complications.
The chest wall and mediastinum should be scrutinised A flail segment is defined as two or more contiguous
for causes of haemorrhage and for any signs of active ribs that are fractured in at least two places. The result
contrast extravasation. is a separated segment of the chest wall, which moves
independently and paradoxically to the rest of the
Rib fracture and flail chest thoracic cage (Figures 5.15, 5.16) during inspiration and
Rib fractures are very common in patients with chest expiration. Flail segments may be difficult to manage
trauma. Isolated, non-displaced fractures may result due to inadequate respiration and pain, and patients
in a small amount of local lung contusion or small may require sedation. Furthermore, patients with
haemothoraces, but otherwise they do not cause a large flail chest may often have underlying lung contusions,
amount of direct damage. However, they can be very which can further impair respiratory function.
Figure 5.15 Coronal image: IV contrast enhanced CT Figure 5.16 3-D rendered image of the left
scan of the thorax and abdomen in the arterial phase. posterolateral thoracic cage. There are multiple
Viewed on bone window settings, a left-sided flail fractures visible along contiguous ribs consistent with a
segment is seen with multiple posterior rib fractures flail segment.
(arrow). Right lung contusions are also shown.
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172 Chapter 5
Lung contusion and lung laceration tearing. The left dome is more commonly injured than
Lung contusions represent small areas of haemorrhage the right side. Defects within the diaphragm may result
within the alveoli. They may occur as a result of direct, in herniation of abdominal contents into the thorax,
blunt or penetrating injury, but are also often seen in with the potential for strangulation (Figure 5.18). On
deceleration type injuries (Figure 5.17). On CT, they imaging, diaphragmatic defects can be subtle. Images
are usually only visible on lung window levels and should be reviewed in the sagittal and coronal planes,
have a non-specific appearance of patchy, ill-defined and the diaphragmatic contour should be traced
areas of ground glass or air space opacities in a non- carefully, paying particular attention to any defects.
segmental distribution. Lung lacerations represent Other subtle signs include the presence of free fluid
shearing injuries of the lung parenchyma. These have on either side of the diaphragm, which should raise
a very characteristic appearance and manifest on CT suspicions. Diaphragmatic hernias are usually fairly
imaging as linear opacities extending through the obvious to see on CT; however, patients may not
lung parenchyma. As these evolve, cavities form, often develop these until a long time after the initial injury.
containing gas-fluid levels within. Lacerations usually
heal without complication but may take many weeks to Key points
months to fully resolve. • Trauma to the thorax can result in a wide
range of pathologies, many of which can be life
Diaphragmatic injury threatening.
Injuries to the diaphragm can be difficult to identify and • Compromise of the airway, respiratory or
if left untreated, may result in significant complications. cardiovascular functions are all potential problems
Injury may occur from either blunt or penetrating injury with thoracic injuries, and require prompt
to the abdomen. In blunt injuries, a sudden increase diagnosis and treatment.
in intra-abdominal pressure results in the diaphragm
Report checklist
• Think ABCDE when considering chest trauma.
• A = airway. Is the endotracheal (ET) tube in the
right place? Is there a foreign body obstructing
the airway (e.g. blood)? Is there trauma to the
trachea?
• B = breathing. Is there a tension
pneumothorax?
• C = circulation. Is there an aortic injury? Is
there cardiac tamponade or haemopericardium?
Is there a large haemothorax?
• D = diaphragm. Is there diaphragmatic injury?
• And once all of these are excluded, then one
can look at E = everything else.
References
Figure 5.17 Axial image: contrast enhanced CT scan Kaewlai R, Avery L, Asrani A et al. (2008) Multidetector
of the thorax in the arterial phase. Ill-defined, ground CT of blunt thoracic trauma. Radiographics 28:1555–
glass changes in the left lung anteriorly represent lung 1570.
contusions. In addition, a rounded lesion is seen within Shorr RM, Crittenden M, Indeck M et al. (1987) Blunt
the left lung, which contains a gas-fluid level consistent thoracic trauma: analysis of 515 patients. Ann Surg
with a pulmonary laceration. 206:200–205.
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Trauma imaging 173
Figure 5.18 Sagittal image: contrast enhanced CT scan

of the thorax, abdomen and pelvis in the arterial phase.
The left hemidiaphragm is discontinuous and contains
a large defect through which the stomach has herniated
into the thorax (arrow).
MAJOR TRAUMA: ABDOMEN Radiological investigations

AND PELVIS In haemodynamically stable patients, CT is the imaging
modality of choice. It can be undertaken relatively
As with major thoracic trauma, significant intra- quickly and provides definitive imaging of the solid
abdominal injury can carry a high morbidity and organs and bowel, enabling identification of apparent
mortality rate. Because of the number of organ systems and occult injuries. In unstable patients, CT may not
in the abdomen and pelvis, injuries may be varied and be appropriate given the time taken to transfer and
complex; the input of multiple clinical specialties may scan the patient. Under these circumstances, it may
therefore be required. As with all trauma cases, the be more prudent to proceed directly to exploratory
mechanism of injury is key and can help the on-call laparotomy; this should be discussed with the referring
radiologist anticipate potential patterns of injury. trauma team. Ultrasound can also play a role in trauma
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174 Chapter 5
imaging of the abdomen and pelvis, and has been shown acquisition of the abdomen and pelvis, may be used to
to be a useful tool in identifying free fluid in unstable reduce the radiation dose to the patient.
patients (Smith & Wood, 2013; Figure 5.19). It can be Bladder injuries may occur when adjacent pelvic
performed at the patient’s bedside, which may be more injuries are present. Imaging of bladder ruptures can
appropriate for critically unstable patients who cannot be performed as either direct or indirect cystography.
be transferred safely to the CT scanner. Ultrasound A direct cystogram is obtained by instilling contrast
may also be more suitable for paediatric patients with media into the urinary bladder via a urethral catheter
a low clinical suspicion of significant injury. While a and then imaging the patient. This method allows
useful adjunct, it should be emphasised that ultrasound a larger volume of contrast to be instilled under
is not as sensitive or specific as CT for traumatic intra- greater pressure, allowing smaller defects to become
abdominal and pelvic injury. apparent. An indirect cystogram is obtained by carrying
Full assessment with CT imaging should include out delayed imaging of the patient following the
both an arterial and portal phase of the abdomen administration of IV contrast, which is subsequently
and pelvis. The arterial phase is useful for all trauma excreted into the renal collecting systems and bladder.
patients, as it helps to identify active, arterial contrast The volume of contrast within the bladder is often
extravasation (i.e. active bleeding), which may require less than that seen in direct cystography and is under
immediate intervention. The portal venous phase less pressure. As a result, smaller injuries may be
allows accurate assessment of the abdominal viscera. overlooked. In practice, a repeat CT scan at a delayed
On an arterial phase, some of the viscera (in particular interval is often easier to perform acutely. Alternatively,
the spleen) typically demonstrate heterogeneous fluoroscopic assessment via a cystogram study may be
enhancement. It can therefore be difficult to fully performed. (See Table 5.2.)
exclude underlying visceral injuries, such as contusions
or lacerations, when assessing the arterial phase in Radiological findings
isolation. Split bolus techniques, in which a combined As with all trauma imaging, it can be useful to perform an
arterial and portal venous phase is obtained on a single initial survey of CT imaging of the abdomen and pelvis,
with an aim of identifying serious life-threatening
injuries, which may require urgent intervention and
immediate communication to the referring team. Such
injuries include traumatic aortic rupture and active
arterial contrast extravasation leading to significant
haemorrhage. The attenuation of any intra-abdominal
pelvic free fluid should be precisely measured, as
intermediate or high-density fluid is suggestive of
haemoperitoneum. This can be a useful localising sign
on an initial survey; for example, haemoperitoneum
localised around the spleen is suggestive of a splenic
injury. Once significant life-threatening injury has
been excluded, a systematic approach to inspection
of the remaining structures should take place. It is
also useful to look initially for signs that the patient
is compromised/in distress. A significantly flattened
Figure 5.19 Ultrasonogram of the liver and right IVC (Figure 5.20) would suggest a significant loss of
kidney in the longitudinal plane. Anechoic free fluid intravascular volume. Hyperattenuatting adrenal
is seen in the right hepatorenal space. In the context glands (Figure 5.21) suggest that they are overactive,
of abdominal trauma, this most likely represents which is a significant stress response. These features
haemoperitoneum. can reflect the severity of the injuries.
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Trauma imaging 175
Table 5.2 Major trauma: abdomen and pelvis. Imaging protocol.
MODALITY PROTOCOL
CT Arterial and portal phase acquisition: 100 ml IV contrast via 18G cannula, 4 ml/sec. Scan at 25–30 seconds
(arterial phase) and 65 seconds (portal phase) after initiation of injection. Image acquisition from just above
the diaphragm to just below the pubic symphysis, to include the femoral necks. Helical acquisition, slice
thickness of 0.625–1.25 mm to allow accurate multiplanar reformats of images. Bony algorithm reformatted
images should also be produced through the imaged region.
Ultrasound 1–5 MHz curvilinear probe on general abdominal settings should be used to assess the abdomen and pelvis.
CT/fluoroscopy Indirect cystography: delayed imaging of the pelvis when assessing for the presence of bladder wall
rupture. Indirect imaging should be performed between 15 and 30 minutes following the IV contrast
injection.
Direct cystography: the urinary bladder should be distended with water soluble contrast via a urethral
catheter until the patient feels full. Suggested concentration: 50 ml water soluble contrast in 1,000 ml of
water, although this depends on the concentration of contrast. The catheter should be clamped in order
to prevent bladder emptying, and the patient’s pelvis should be imaged.
Figure 5.20 Axial image: IV contrast enhanced CT Figure 5.21 Axial image: IV contrast enhanced
scan of the abdomen in the portal venous phase. There CT scan of the abdomen in the portal venous phase.
is marked flattening of the IVC, suggesting a significant Hyperattanuating adrenals suggest a significant stress
reduction in the intravascular volume. Intra-abdominal response.
free fluid can be seen around the liver and loops of
bowel.
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176 Chapter 5
Solid organ injury which outlines individual scales to categorise injuries

Injuries to the solid abdominal organs are commonplace sustained in trauma (Tables 5.3, 5.4 and 5.5).
in both blunt and penetrating injuries. The liver is the Solid organ injuries, which include the liver, spleen,
most frequently injured organ in blunt injury (Yoon pancreas, kidneys and adrenal glands, can all be assessed
et al., 2005), followed by the spleen. Many solid organ using contrast enhanced CT. The kidneys and pancreas
injuries may be managed conservatively; however, active demonstrate adequate enhancement during the arterial
haemorrhage may require interventional radiological phase, but the remainder show uniform parenchymal
input and it is therefore important to appreciate the enhancement during the portal venous phase.
spectrum of injury. In general, three main visceral injuries are likely
A grading system has been developed by the to occur as a result of significant trauma: laceration,
American Association for the Surgery of Trauma, contusion/haematoma or vascular insult. Parenchymal
Table 5.3 Liver injury scale (1994 revision).
GRADE TYPE OF INJURY DESCRIPTION OF INJURY

I Haematoma Subcapsular <10% surface area.
Laceration Capsular tear <1 cm depth.
II Haematoma Subcapsular 10–50% surface area.
Laceration Capsular tear 1–3 cm depth, <10 cm length.
III Haematoma Subcapsular >50% surface area or intraparenchymal haematoma >10 cm.
Laceration >3 cm parenchymal depth.
IV Laceration Parenchymal disruption involving 25–75% of hepatic lobe or 1–3 Couinaud’s segments.
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s segments
Vascular Juxtahepatic venous injuries (i.e. retrohepatic vena cava/central major hepatic veins).
VI Vascular Hepatic avulsion.
Table 5.4 Spleen injury scale (1994 revision).

I Haematoma Subcapsular <10% surface area.
Laceration Capsular tear <1 cm parenchymal depth.
II Haematoma Subcapsular 10–50% surface area or intraparenchymal <5 cm depth.
Laceration Capsular tear 1–3 cm parenchymal depth that does not involve a trabecular vessel.
III Haematoma Subcapsular >50% surface area or expanding, ruptured subcapsular or parenchymal haematoma,
intraparenchymal haematoma >5 cm or expanding.
Laceration >3 cm parenchymal depth or involving trabecular vessels.
IV Laceration Laceration involving segmental or hilar vessels producing major devascularisation (>25% of
spleen).
V Laceration Completely shattered spleen.
Vascular Hilar vascular injury with devascularised spleen.
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Trauma imaging 177
Table 5.5 Kidney injury scale.

I Contusion Microscopic or gross haematuria, urological studies normal.
Haematoma Subcapsular, non-expanding without parenchymal laceration.
II Haematoma Non-expanding perirenal haematoma confirmed to renal retroperitoneum.
Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravasation.
III Laceration <1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extrava-
sation.
IV Laceration Parenchymal laceration extending through renal cortex, medulla and collecting system.
Vascular Main renal artery or vein injury with contained haemorrhage.
V Laceration Completely shattered kidney.
Vascular Avulsion of renal hilum, which devascularises the kidney.
lacerations typically appear as irregular, linear low

attenuation lesions coursing through the viscera and
represent a shearing type injury (Figure 5.22). It is
important to appreciate the relationship of lacerations
with underlying major vessels, since these are at risk of
injury. Lacerations can also occur in the kidney; if these
extend to also involve the medulla and renal hilum,
injury to the renal pelvis can occur. This should be
suspected in the presence of low attenuation free fluid
around the renal pelvis and kidney. If an underlying
injury to the renal collecting system is suspected,
delayed imaging can be performed. In this scenario,
excreted contrast that lies outside of the renal pelvis and
ureter is indicative of an underlying collecting system/ Figure 5.22 Axial image: IV contrast enhanced CT
ureteric injury. scan of the abdomen in the portal venous phase. The
Parenchymal contusions are often more rounded, body of the pancreas has an ill-defined, fragmented
ill-defined low attenuation lesions within the visceral contour and demonstrates abnormal enhancement due
parenchyma. These typically occur after blunt injury to a laceration (arrow). Free fluid is noted within the
but may also be seen following penetrating injuries. abdomen.
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178 Chapter 5
Both laceration and contusions can be complicated by haematomas can also be seen around the liver and
active bleeding, appearing as a high attenuation contrast spleen, appearing as a hypoattenuating crescenteric or
blush (present on both an arterial phase and a dual phase, lenticular rim in comparison with the enhancing visceral
split bolus study) (Figures 5.23, 5.24a–c). Subcapsular parenchyma (Figures 5.25–5.27). In contradistinction to
free intra-abdominal fluid or haematoma, subcapsular
haematoma typically causes contour abnormality of the
visceral parenchyma. Major vascular injury, including
transection, dissection and avulsions, can result in end
organ ischaemia and infarction (Figure 5.28). Low
attenuation defects in a wedge shape or corresponding
to a vascular territory should raise suspicion of vascular
injury. Pseudoaneurysms can also occur following
traumatic injury. These appear as rounded, well-
defined hyperattenuating lesions (corresponding to the
density of contrast in the arterial vessels), apparent on
both an arterial and dual phase study. These typically
demonstrate washout of enhancement on the portal
venous phase.
Mesenteric and bowel injury

Injuries to the mesentery and bowel can be very difficult
to identify on CT imaging and the on-call radiologist
Figure 5.23 Axial image: IV contrast enhanced must be vigilant when evaluating imaging in trauma
CT scan of the abdomen in the portal venous phase. patients. The consequences of missed injuries include
Contrast blush can be seen in the spleen, indicating bowel ischaemia and intra-abdominal sepsis, which
active contrast extravasation (arrow). may be life threatening.
(a) (b) (c)
Figures 5.24a–c Axial images: unenhanced (5.24a) and IV contrast enhanced CT scans of the abdomen in the
arterial (5.24b) and portal venous (5.24c) phases. On the non-contrast image it is possible to appreciate the slightly
hyperdense rim of material related to the spleen consistent with a subcapsular haematoma. On the arterial phase
images it is possible to make out a splenic artery traumatic pseudoaneurysm (5.24b, arrow), which shows further
contrast filling in the portal venous phase (5.24c, arrowhead). Pseudoaneurysms and active extravasations should be
immediately referred to the interventional radiologist on call for embolisation/coiling of the bleeding vessel.
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Trauma imaging 179

scan of the abdomen in the arterial phase. There is
ill-defined low attenuation in the right posterior liver Figure 5.26 Coronal image:
consistent with a liver laceration (arrow). Active contrast IV contrast enhanced CT scan of
extravasation is seen as high attenuation material within the abdomen in the portal venous
the abnormal region. Subcapsular haematoma is also phase. The spleen is lacerated
noted. and demonstrates abnormal
parenchymal enhancement (arrow).
Contained subcapsular splenic
haematoma is also seen.
scan of the abdomen in the portal venous phase. The scan of the abdomen in the arterial phase. The left renal
right adrenal gland is thickened and does not enhance artery has been avulsed from its pedicle at the aorta and
normally when compared with the left adrenal gland. can be seen as an irregular contrast blush at its origin
The appearance is consistent with a right adrenal gland (arrow). There is end organ ischaemia, seen as a non-
contusion (arrow). enhancing left kidney (arrowhead).
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180 Chapter 5
The normal mesentery should be of fatty tissue Pelvic injury

density and contain regular, linear vessels that course Pelvic fractures may occur as a result of blunt traumatic
through the abdomen towards the bowel. Specific injuries and, depending on the mechanism of injury,
signs of mesenteric injury include active contrast certain patterns of injury may occur, producing
extravasation from mesenteric vessels, mesenteric characteristic fracture patterns. These particular
vascular beading and termination of mesenteric vessels fractures may result in significant vascular and nerve
(Brofman et al., 2006). Less specific signs include damage to local structures and have the potential to
mesenteric infiltration (seen as areas of haziness and cause significant morbidity. In the presence of pelvic
stranding of mesenteric tissue) or focal mesenteric fractures, it is important to identify and follow the
haematomas. Secondary signs of mesenteric injury major pelvic vessels, as these are at risk of injury.
include evidence of bowel ischaemia, such as bowel
wall thickening, abnormal bowel wall enhancement or Bladder and urethral injury
pneumatosis. Bladder injuries can be broadly divided into two
Direct bowel injuries may be difficult to identify on categories: intraperitoneal or extraperitoneal rupture.
CT. Bowel rupture may result in pneumoperitoneum; Both types of bladder injury may be seen as a defect
as such, all abdominal images should be reviewed on within the bladder wall, in addition to an unusual
lung window settings (width 1,600, level 550) in order or irregular contour of the bladder (Figures 5.30,
to identify locules of free intra-abdominal gas. Other 5.31a, b). Typically, the bladder may be pear shaped
specific signs of bowel injury include discontinuity of as a result of external compression of the bladder from
bowel loops and extraluminal oral contrast (Figure 5.29). pelvic haematoma. Extraperitoneal bladder rupture
These signs are not commonly seen, particularly the is far more common, and usually occurs as a result of
latter, as the requirement to administer oral contrast local bony pelvic injury or direct penetrating injury.
prior to CT scanning can cause unacceptable delays in
imaging and therefore diagnosis.
Figure 5.29 Axial image: IV contrast enhanced CT Figure 5.30 Coronal image: IV contrast enhanced
scan of the abdomen in the portal venous phase. There CT scan of the pelvis in the portal venous phase. The
are multiple loops of thickened, hyperenhancing bowel urinary bladder is thickened with an irregular contour
as a result of mesenteric injury, producing a shocked due to blunt abdominal injury. A defect in the wall of the
bowel appearance. bladder can be seen at its superior border (arrow). Pelvic
fractures can also be appreciated.
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Trauma imaging 181
Imaging demonstrates contrast extravasation outside

(a) of the peritoneum, usually around the bladder base
and pelvic floor, and remains confined to the pelvis.
Intraperitoneal bladder rupture is less common, usually
occurring as a result of blunt abdominal injury to a
distended bladder. Imaging demonstrates extravasation
of contrast into the peritoneum (Figure 5.32).
Urethral injuries typically occur in straddle injuries
or as a result of pelvic fractures. Clinically, patients
who have blood at the urethral meatus or perineal
bruising may have an underlying urethral injury.
In these cases, retrograde urethrography is advocated
prior to catheterisation (Ramchandani & Buckler,
2009). Urethral injury is seen as irregular contrast
(b) extravasation and pooling outside of the normal
contour of the urethra.
Figures 5.31a, b Axial and coronal images: IV contrast Figure 5.32 Sagittal image: direct CT cystography scan
enhanced CT scans of the abdomen in the portal venous following intravesical contrast injection. The superior
phase. Intraperitoneal bladder rupture as shown by a bladder wall has an abnormal contour with evidence
left lateral bladder wall defect with fluid density material of contrast leakage seen within the posterior abdomen
leaking into the abdomen (arrows). (arrow).
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182 Chapter 5
Key points MAJOR TRAUMA: SPINE

• Abdominal and pelvic trauma findings can be
complex, but a systematic approach to each area Injuries to the spine may result in significant
can help to identify injuries. morbidity and mortality and therefore require
• Utilise both arterial and portal phase images in careful interpretation when assessing. Unstable
order to assess the vascular tree and solid organs, fractures resulting in severe neurological emergencies
respectively. require rapid diagnosis and discussion with spinal
• Consider performing cystography in patients with surgeons in order to establish the most appropriate
suspected bladder injury. management plan.
Fractures of the spine are relatively commonplace
Report checklist in the context of trauma. It is important to be able to
• Signs that the patient is in distress. describe whether injuries are radiologically stable or
• Presence or absence of active bleeding/contrast unstable, as this has immediate consequences for patient
extravasation. and staff alike. A practical way of determining the
• Document the attenuation of any free fluid stability of a fracture is to assess injuries with the three
– increased density fluid may represent column approach (Denis, 1983). This method divides
haemorrhage. the vertebral body into three columns: anterior, middle
• Comment on each organ to assess for injury. and posterior (Figure 5.33). The anterior column
References
Brofman N, Atri M, Epid D et al. (2006) Evaluation
of bowel and mesenteric blunt trauma with multi-
detector CT. Radiographics 26:1119–1131.
Moore EE, Cogbill TH, Malangoni M et al. Scaling
system for organ specific injuries. American
Association for the Surgery of Trauma. www.aast.
org/Library/TraumaTools/InjuryScoringScales.
aspx Accessed on 22nd February 2014.
Ramchandani P, Buckler PM (2009) Imaging of
genitourinary trauma. Am J Roentgenol 192:1514–
1523.
Smith ZA, Wood D (2014) Emergency focused
assessment with sonography in trauma (FAST) and
haemodynamic stability. Emerg Med J 31:273–277.
Online First 10.1136/emermed-2012-202268.
Yoon W, Jeong YY, Kim JK et al. (2005) CT in blunt
trauma. Radiographics 25:87–104.
cervical spine. Each vertebra can be divided into three
columns. The anterior column encompasses the anterior
two-thirds of the vertebral body including the anterior
longitudinal ligament. The middle column encompasses
the posterior one-third of the vertebral body including
the posterior longitudinal ligament. The posterior
column encompasses the remaining structures including
the pedicles, lamina and spinous processes.
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Trauma imaging 183
comprises the anterior two-thirds of the vertebral body evidence of bony injury on CT imaging may still have
(to include the anterior longitudinal ligament), the significant ligamentous injury, and in these cases MRI
middle column comprises the posterior one-third of the may be indicated.
vertebral body (to include to the posterior longitudinal The majority of the vertebrae within the spine have
ligament) and the posterior column comprises the a similar anatomical configuration, with the vertebral
posterior elements (pedicles, lamina, spinous process, body connected to the spinous processes via the lamina.
ligamentum flavum and interspinous ligaments). With The exceptions to this are C1 and C2, which are
this approach, injury to a single column is deemed to discussed later.
be stable (Figure 5.34), while injuries to two or more
columns should be considered as unstable. Radiological investigations
Evaluation of the soft tissues is paramount when The choice of imaging modality varies across centres,
assessing the spine for bony injury. Significant soft tissue depending on local specialties and access to imaging.
injury, including damage to the major ligamentous In general, patients may have plain film imaging as a
complexes, can be present in the absence of bony injury. first line of investigation, but those who have sustained
CT imaging is both sensitive and specific for acute bony significant trauma or who cannot be accurately
injuries involving the spine; however, soft tissue injuries assessed clinically may proceed immediately to CT.
may not be seen. The limits of CT imaging should This is the modality of choice to assess the bony detail
therefore be appreciated by both the radiologist and the of the spine; however, soft tissue and ligamentous
referring clinician to ensure that radiological findings, structures are poorly assessed. MRI is usually reserved
or the lack there of, are interpreted in conjunction with for patients who may have a suspicion of ligamentous
the clinical examination findings. Patients with no or spinal cord injuries. (See Table 5.6.)
Table 5.6 Major trauma: spine. Imaging

protocol.
MODALITY PROTOCOL
CT Helical acquisition with images acquired at
least one vertebral level above and below the
area of interest. Images should be acquired
as thin slices (i.e. 0.625–1.25 mm) with bony
algorithm reconstructions. Images should
be reformatted to include the sagittal and
coronal planes.
MRI Sagittal T1 weighted, T2 weighted, STIR and
axial T2 weighted images through the region
of interest.
abdomen. There is a minimally displaced fracture of
the right transverse process of the L1 vertebra (arrow).
No other fractures are seen, therefore this is a single
column injury.
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184 Chapter 5
Radiological findings A similar approach to the thoracic and lumbar spines

Plain films may be adopted. Careful evaluation of the vertebral
For patients who have sustained minor trauma, or in body height and cortices can help to identify fractures,
those centres without readily available access to CT in addition to changes in alignment and displacement
imaging, plain film imaging may be performed as the of bony structures.
initial investigation. Plain film images of any part of the In elderly patients, pre-existing degenerative
spine should be acquired in at least two perpendicular changes can make it impossible to confidently exclude
planes. In the cervical spine, a standard trauma series an underlying fracture. In these situations, it is always
comprises a lateral view, an AP view and an open advisable to assess further with CT imaging.
mouth peg view. The thoracic and lumbar spine are
conventionally imaged in the lateral and AP positions. Computed tomography
A systematic approach to assessing the cervical In major trauma patients, CT is often the first-line
spine plain film series is paramount to ensure that imaging modality of choice for the spine. The sensitivity
subtle pathologies are not missed. The adequacy of the of identifying bony injury is far greater than with plain
image should always be assessed initially, as this may film imaging. However, the large number of images
limit the amount of information that can confidently can make it easy to miss pathology. The cervical spine
be given to clinicians. Lateral cervical spine plain film should be visualised in axial, sagittal and coronal planes;
images should include the C7/T1 vertebral junction. fractures in a single plane may be easy to overlook. Many
A swimmer’s view can aid visualisation of the cervical picture archiving and communication systems (PACSs)
spine more distally. An open-mouth peg view of the allow the on-call radiologist to perform multiplanar
C1/C2 vertebrae should not have overlying artefact reformats of images at the reporting workstation.
obscuring the image, as this may result in a poor-quality, The same principles apply to the evaluation of
non-diagnostic study. CT imaging as are used in the assessment of plain
Once the image has been deemed adequate, it should film imaging. They should be carefully examined
be scrutinised for signs of injury. Every cortex of each for evidence of cortical disruption, loss of height and
vertebra should be traced to look for signs of fracture. alignment in order to identify underlying injury. It
Following this, the lateral view should be evaluated is important to clearly state whether injuries appear
for signs of subluxation or dislocation. An assessment stable or unstable depending on the number of columns
should also be made of the pre-vertebral soft tissues, involved in the injury. In addition to this, any significant
which lie anterior to the vertebra. These should have misalignment or retropulsion of bony fragments
a thickness of no more than 5 mm above C4 and into the spinal canal should be communicated to the
20 mm below C4. The contour of the soft tissues is also referring team, as this may require urgent surgical
important and should be smooth. Localised bulging of intervention.
the soft tissues may suggest underlying pathology. While most fractures are readily identifiable
The vertebral body height should be assessed on both on CT imaging, there is a spectrum of more
the lateral and AP view. Loss of vertebral body height subtle abnormalities that can indicate a significant
may be due to fracture. The spinous processes should underlying injury. Such findings include widening
be aligned and centrally positioned on the AP view. The of a single disc space, widening of facet joints and
absence of, or an unusually positioned, spinous process widening of a single interspinous distance. These
should raise suspicion of a subluxation or dislocation. findings may indicate underlying ligamentous or soft
The peg view is usually straightforward to review, tissue injury.
providing there is no artefact. The lateral masses An apparently normal CT study does not exclude
of C1 should be aligned within the C2 facets with underlying ligamentous injury; this should always be
no overhanging; loss of alignment may indicate a emphasised to the referring team. The radiological
fracture of C1. findings should always be correlated with the clinical
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Trauma imaging 185
examination findings; if there is a discrepancy between STIR imaging. It is therefore important to scrutinise
the two, an MRI scan should be considered to assess for T1 images for any evidence of traumatic haematoma
an underlying soft tissue injury. Radiological clearance both within and outside the spine, as this may result in
of the spine may be reassuring to clinicians, but it should spinal cord compression.
not replace the clinical examination findings. As with
plain film imaging, significant degenerative changes Examples of spinal fractures
may make it difficult to fully exclude underlying bony Jefferson fracture
injury, even on CT imaging. Depending on the index This describes an unstable burst fracture of the C1
of suspicion of injury, in these cases further assessment vertebra. It occurs as a result of a significant axial load
with MRI may by prudent. type injury (e.g. diving injury). Radiologically, the
fracture can be seen on an open-mouth peg view as
Magnetic resonance imaging lateral displacement of the lateral masses away from the
Definitive assessment of the spinal cord and odontoid peg. On CT imaging, the fracture appears as
ligamentous structures is performed with MRI. Patients a disrupted ring in comparison with the normally intact
with suspected spinal injuries with neurological deficits vertebra (Figure 5.35). This is considered an unstable
benefit from early scanning and spinal surgical input, injury.
which can prevent lasting damage. In all patients, an
assessment of the spinal cord and canal should be made
to identify any evidence of spinal cord compression
(see Chapter 3: Neurology and non-traumatic spinal
imaging, Spinal cord compression and cauda equina
syndrome). This is best performed on T2 weighted
axial and sagittal imaging.
In trauma patients, it is prudent to perform STIR
imaging to assess for bone marrow and soft tissue
oedema. In the context of trauma, underlying bone
marrow oedema is suggestive of fracture, although the
precise morphology of the fracture is better assessed
with CT imaging. The presence of oedema within the
ligaments is important in assessing the stability of an
injury. Typically, injury to the interspinous ligaments
is inferred by the presence of oedema within these
tissues on STIR imaging. Assessment of the anterior
and posterior longitudinal ligaments is best appreciated
on T2 and STIR imaging; ligaments should appear as
a continuous low signal structure. Any focal defect or
signal change in the ligament is suggestive of injury. Figure 5.35 Axial image: unenhanced CT scan of the
T1 weighted images also have a role in assessing cervical spine. There is a comminuted, burst fracture
injured patients. Acute haematoma appear as high of the C1 vertebra, with fractures seen through the
signal on T1 images and do not suppress signal on anterior arch and left posterior arch.
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186 Chapter 5
Odontoid peg fractures on CT imaging fractures are seen as cortical breaks

Peg fractures can be classified depending on the site through the peg resulting in separation from the
of fracture (Figure 5.36). Fractures are usually visible vertebral body (Figure 5.37).
on lateral cervical spine plain film images as a lucent
line extending through the odontoid process. Similarly, Flexion teardrop fracture
This is a severe, unstable injury that can result in
significant morbidity. The injury occurs as a result of
Type 1
a flexion and compression injury, causing shearing of
the anteroinferior corner of the vertebral body. The
injury also results in subluxation of the facet joints and
displacement of the vertebral body with three column
ligamentous disruption. This may result in spinal cord
compression. The injury should not be confused with
an extension teardrop fracture, which can be seen as an
avulsion injury from the anterioinferior corner of the
vertebral body; however, no other features of vertebral
fracture or compression are present.
Type 2
Type 3
Figure 5.36 The differing well-recognised

configurations of odontoid peg fractures. Type 1
fractures involve the tip of the odontoid process only.
Type 2 fractures involve the base of the odontoid Figure 5.37 Sagittal image: unenhanced CT scan
process but do not extend into the vertebral body. Type of the cervical spine. There is a type 1 odontoid peg
3 fractures involve the base of the odontoid process and fracture with minimal displacement of the fracture
extend into the vertebral body. fragment. There is no retropulsion into the spinal canal.
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Trauma imaging 187
Facet joint dislocation (Figure 5.38a) and CT imaging (Figure 5.38b) typically
Rotational flexion injuries of the cervical spine may shows anterolisthesis at the level of dislocation on the
result in unilateral or bilateral facet joint subluxation lateral view, less than 25% of the width of the vertebral
or dislocation. Unilateral injuries are stable but body. In bilateral facet dislocations, the affected level
bilateral injuries should be treated as unstable. In is shown as ‘perched’ facets, with anterolisthesis of
unilateral facet dislocation, cervical spine plain film >25% at the affected level. Bilateral injuries may result
(a)
(b)
Figures 5.38a, b Lateral cervical spine radiograph (5.38a) and parasagittal CT image (5.38b) of the cervical spine.
The lateral cervical spine radiograph demonstrates an abnormal step between C5 and C6 along the anterior margin
of the vertebral bodies. The CT scan of the same patient demonstrates a C5/6 facet joint dislocation with loss of the
normal articulation and a typical ‘perched’ facet appearance (arrow).
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188 Chapter 5
in ligamentous injury affecting all three columns injuries. These are unstable, three column injuries. On
(Figure 5.39). plain film imaging, the injuries are seen as irregular,
comminuted fractures involving the vertebral body
Burst fracture (Figure 5.40). Typically, there is retropulsion of fracture
Burst fractures typically occur in the thoracolumbar fragments into the spinal canal, which may cause cord
spine as a result of significant axial loading type compression (Figure 5.41).
Figure 5.39 Sagittal image: STIR sequence MR image Figure 5.40 Lateral lumbar spine radiograph. The
of the cervical spine. The normal low signal anterior L2 vertebral body is abnormal, with loss of height
longitudinal ligament is not visible anterior to the and irregular margins as a result of a burst fracture.
C5/C6 intervertebral disc. The posterior longitudinal Sclerotic areas within the vertebral body are due to
ligament is also disrupted and can be seen as an areas of impaction. There is mild retropulsion of the
irregular structure within the spinal canal (arrow). High fragments into the spinal canal. A further fracture can
signal changes can be seen in the C5/C6 interspinous be seen involving the anterosuperior corner of the
ligaments posteriorly, also consistent with ligamentous L5 vertebral body.
disruption (arrowhead). The appearance therefore
suggests three-column ligamentous disruption.
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Trauma imaging 189
Figure 5.41 Sagittal image: unenhanced CT scan

of the lumbar spine. Multiple fractures can be seen
involving the L1–L3 vertebrae. The L1 vertebra has
multiple fractures involving the anterior and middle
columns, with retropulsion of fragments into the
spinal canal. Further fractures can be seen involving
the anterosuperior corners of the L2 and L3 vertebral
bodies.
Key points Report checklist

• Assessment of spinal injuries may involve plain • Document the number of columns involved and
film, CT and MRI. therefore the radiological stability of injuries.
• Apparently normal plain film or CT imaging does • Presence or absence of any evidence of spinal cord
not exclude spinal injuries and clinical examination compromise (e.g. bony retropulsion, epidural
findings play a crucial role in identifying soft haematoma, cord injury).
tissue injuries. In cases of suspected soft tissue or
ligamentous injury, further assessment with MRI Reference
is indicated. Denis F (1983) The three column spine and
its significance in the classification of acute
thoracolumbar spinal injuries. Spine 8:817–831.
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K22247_C005.indd 190 16/05/15 3:11 AM
Chapter 6
INTERVENTIONAL AND V ASCULAR

IMAGING AND IATROGENIC 191
C OMPLICATIONS
ACUTE ARTERIAL ISCHAEMIA symptoms because of the dangerous metabolites

released.
Acute arterial occlusion in an extremity must be treated
as a medical/surgical emergency as there is not only Radiological investigations
danger to the limb, but also to the life of the patient. Ultrasound can be used for the assessment of peripheral
Generally this condition occurs in elderly patients with arterial flow, especially in the arms and legs. Doppler
multiple comorbidities. or duplex scanning can assess arterial flow patterns to
Acute arterial occlusion can be the result of a assess for thrombosis. In the acute setting, however,
proximal embolus lodging in a more distal vessel, the availability of expertise in duplex scanning is
acute thrombosis of a previously patent artery, acute relatively rare.
thrombosis of a stent or graft, dissection of an artery or
direct trauma to an artery.
The most common source of embolism is the heart;
for example, from thrombus within an LV aneurysm
(Figure 6.1) or secondary to arrhythmias. Arterio-
arterial emboli can arise from aneurysms or from
non-occlusive, ulcerated atheromatous plaques. Acute
in-situ thrombosis occurs mostly at sites of stenotic
arteriosclerotic lesions. Other causes of arterial
thrombosis include pro-thrombotic states such as
recent trauma/surgery, pregnancy, cancer, reversal of
anticoagulation, nephrotic syndrome and inflammatory
bowel disease.
Presentation with acute arterial ischaemia is most
commonly seen in the lower limbs and characterised
by ‘the 6 P’s: pain, pallor, pulselessness, paraesthesia,
paralysis and poikilothermia (i.e. coldness). Paraesthesia
and paralysis imply irreversible ischaemia, and muscle
rigidity is a sign of a non-salvageable limb. Figure 6.1 Axial image: IV contrast enhanced CT scan
With acute occlusion of central blood vessels such of the chest in the arterial phase. The non-enhancing
as the aorta, iliac or femoral arteries, there is complete filling defect (arrow) in the left ventricle is consistent
ischaemia with onset of rhabdomyolysis after four to with LV thrombus. There is thinning of the LV
six hours; this can lead to severe local and generalised myocardium at the apex due to a previous infarct.
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192 Chapter 6
CTA is the imaging modality of choice in the acute

setting to assess the vasculature for acute arterial
thrombosis or embolus. The protocol varies depending
on whether the lower or upper limbs are affected.
(See Table 6.1.)
Computed tomography
A good CTA enables the radiologist to fully assess the
arterial tree; however, windowing may be useful to
reduce the glare from the bright contrast within the
vessel and therefore allow more accurate assessment.
The blood vessels must be carefully scrutinised from a
proximal to distal direction.
It is important to first assess the heart for valve
abnormalities, such as vegetation or thrombus within
any of the cardiac chambers. The whole aorta should
then be assessed for the presence of any aneurysms. Figure 6.2 Axial image: IV contrast enhanced CT scan
If an aneurysm is present, comment should be made as of the lower limbs in the arterial phase. The lumen of
to the amount of intramural thrombus and also as to the right superficial femoral artery does not opacify
whether there is any leak. with contrast, while the corresponding artery on the
All the major vessels should be assessed carefully left does. No collateral vessels are seen around the right
in a systematic fashion, one side at a time. Features superficial femoral artery, suggesting acute arterial
suggestive of acute arterial occlusion are an abrupt thrombosis.
cut-off of the arterial opacification, with a lack of
surrounding collaterals ( Figure 6.2). In the acute
thrombosis, the presence of clot leads to a smooth but
abrupt cut-off. The affected arteries may be expanded
with clot and may show subtle peripheral enhancement
(Figure 6.3).
Table 6.1 Acute arterial ischaemia.

Imaging protocol.
MODALITY PROTOCOL
CT Angiogram: 100 ml IV contrast via 18G
the descending thoracic aorta (if assessing
lower limbs)/centre on ascending aorta (for Figure 6.3 Axial image: IV contrast enhanced CT scan
upper limbs). Scan from just above aortic of the pelvis in the arterial phase. An intraluminal filling
arch to ankles for lower limbs or C2 to hands defect can be seen in the right common iliac artery
depending on side. (arrow). A small amount of peripheral enhancement is
seen around the periphery of the occluded vessel.
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Interventional and vascular imaging and iatrogenic complications 193
It is useful to assess the vessels using multiplanar IATROGENIC COMPLICATIONS

reformats. The length, extent and number of vessels
involved should be reported. Distal filling and Iatrogenic complications of medical interventions are
quality of blood vessels beyond the occlusion should relatively commonplace and occur across many facets
be commented on as these have implications for of medical practice. These may be related to routine
management. Treatment is either by vascular surgery procedures that may have minimal clinical significance
or interventional radiology. to the patient (e.g. bruising following venepuncture),
It is often difficult to distinguish between acute but can also have significant and potentially life-
and chronic occlusions; however, the clinical history threatening consequences for patients. Some of these
should be noted, as this is a key factor in deciding are particularly pertinent to radiologists either because
between the two. The presence of collateral vessels can of the frequency of errors that may be avoided by
imply chronicity. thorough radiological interpretation or because they
Arterial thrombus may be present in central vessels may be may be related to common interventional
in patients with pro-thrombotic states. Careful radiology procedures. The following section highlights
assessment of the aorta and its branches is important some of the commonest complications that may be
as well as assessment of visceral enhancement of bowel, encountered.
kidneys, etc.
NASOGASTRIC TUBE MISPLACEMENT
Key points
• Where patients present with the 6 P’s, there is Reducing the harm caused by misplaced NG tubes was a
limited time to salvage the leg. There should be Patient Safety Alert published by The National Patient
no delays in organising a CTA for these patients in Safety Agency (NPSA) in 2005. In the report the NPSA
order to assess the arterial tree. provided guidance for checking and confirming that an
• A systematic approach is always best when NG tube had been inserted into the correct place (i.e.
assessing vasculature; this can be proximal to distal the stomach). After placement, an NG tube is aspirated
and one side then the other. Coronal reformats and the aspirate tested on litmus paper to confirm that
can be very useful. it is acidic (i.e. gastric aspirate).
• Acute thrombus results in a smooth, abrupt In patients who are sedated, have a poor cough reflex,
cut-off of the arterial opacification with a are intubated or agitated there is increased risk of tube
lack of collaterals. The affected vessel may misplacement. This can lead to severe complications
be expanded and show some peripheral such as pneumonia, pneumothorax, empyema and
enhancement. pulmonary haemorrhage.
Report checklist
• The quality of vessels proximal and distal to
any occlusion; whether they are patent and/or
how good they are. This has implications for
management options such as bypass/thrombolysis.
• Degree of collateralisation.
• Recommend urgent vascular surgical opinion.
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194 Chapter 6
Radiological investigations the left hemidiaphragm (Figure 6.4). NG tubes that

Plain film imaging of the chest is usually adequate where do not follow this path may be within a bronchus or
aspiration is not possible or there is concern regarding coiled in the oesophagus (Figures 6.5–6.7). Particular
the position of the NG tube tip. (See Table 6.2.) attention should be paid to whether the path of the
NG tube projects over the right or left main bronchi.
Radiological findings Suspicion of an NG tube within the lungs should be
Plain films urgently discussed with the referring team. If the NG
NG tubes vary in type and opacity. Some tubes are tube is projected in the midline below the carina but
opaque throughout their length, whereas some only not in the stomach (i.e. distal oesophagus), it can be
have a radiopaque tip. A normal NG tube should course suggested that the tube is advanced a further 5–10 cm
centrally through the thorax and lie with the tip below prior to use.
If the NG tube tip cannot be seen clearly, a small
volume of water soluble contrast (e.g. Gastromiro) can
Table 6.2 Nasogastric tube misplacement.
Imaging protocol. be injected through the tube and then re-imaged to
confirm the tip position.
MODALITY PROTOCOL
Plain film PA CXR to include the diaphragm. Water Key points
imaging soluble contrast may be injected through • NG tubes should normally descend centrally
the nasogastric tube if the line tip is not though the thorax, with the tip seen below the left
radiopaque. hemidiaphragm.
• Misplaced NG tubes should be communicated
to the clinical team in order to prevent
inappropriate use.
Figure 6.4 PA chest radiograph. A nasogastric tube is Figure 6.5 PA chest radiograph. A nasogastric tube
seen passing centrally and coursing to the left under the is seen passing into the right lower lobe bronchus and
left hemidiaphragm. A tunnelled left-sided central line is coiled in the right lower zone. An endotrached tube is
also noted. also sited.
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Figure 6.6 PA chest radiograph. A nasogastric tube is Figure 6.7 Axial image: IV contrast enhanced CT
seen passing into the left lower lobe bronchus. There is scan of the thorax, which shows a significant left
evidence of a left lower lobe pneumonia. lower lobe pneumonia with a left lower lobe abscess,
secondary to feeding via an incorrectly sited nasogastric
tube (removed prior to imaging).
ENDOTRACHEAL TUBE MISPLACEMENT Radiological investigations

Plain film imaging of the chest should be performed in
A misplaced ET tube is a relatively common all patients who have undergone ET tube placement.
complication that is detected on post-intubation (See Table 6.3.)
radiographs. If undetected, it can lead to respiratory
complications and unnecessary morbidity and Table 6.3 Endotracheal tube misplacement.
mortality. If the ET tube is too high, it can rub against Imaging protocol.
the vocal cords and cause damage; if too low, it can
selectively intubate the right or left bronchus, causing MODALITY PROTOCOL
collapse of the contralateral lung. Plain film imaging PA chest X-ray to include the
diaphragm.
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196 Chapter 6
Radiological findings This is seen as dense opacification of the collapsed lung

Plain films with volume loss, and mediastinal shift towards the
A correctly placed ET tube tube should be seen in the collapsed lung.
midline with the tip lying 3–5 cm above the carina. Even If the oesophagus has been intubated in error,
when the carina is not visible, it can be assumed that gaseous distension of the stomach will be noted, with
a tip position overlying T3/ T4 is safe. There can be reduced lung volumes.
considerable movement of the ET tube tip depending
on the position of the neck, so accurate positioning can Key points
be difficult to determine. • A normal ET tube tip should lie 3–5 cm above the
Misplacement of the ET tube, either too low or high, carina.
should be communicated immediately to the clinical • Intubation of a main bronchus can cause
team. If too low, there may be selective intubation of significant morbidity and the clinical team should
the right or left main bronchus, with corresponding be informed as a matter of urgency.
collapse of the contralateral lung (Figures 6.8, 6.9).
Figure 6.9 PA chest radiograph. The endotracheal tube

Figure 6.8 PA chest radiograph. An endotracheal tube in the same patient as in Figure 6.8 has been w ithdrawn
is seen in the right main bronchus with almost complete to lie within the trachea and the left lung can be seen to
collapse of the left lung. have re-expanded.
K22247_C006.indd 196 16/05/15 3:12 AM

ENDOVASCULAR STENT ENDOLEAK Radiological investigations

Ultrasound is usually used as a follow-up imaging
An endoleak is characterised by persistent blood modality to assess sac size and to check for the presence
flow within an aneurysm sac following endovascular of an endoleak. It can also be used in the acute setting,
aneurysm repair (EVAR). Normally, the aortic stent- but views may be limited as the quality of the images is
graft used for EVAR excludes the aneurysm from user dependent.
the circulation by providing a conduit for blood to In the acute setting, the most accurate modality is
bypass the sac. Endoleaks are a common complication CT. This enables the radiologist to accurately assess the
of EVAR and are found in 30–40% of patients sac size, confirm and characterise the endoleak as well
intraoperatively (seen on the on-table angiogram after as check for a leaking aneurysm. (See Table 6.5.)
stent deployment) and in 20–40% during follow-up
CTA imaging (Stavropoulos & Charagundla, 2007). Radiological findings
Endoleaks are often asymptomatic; however, they Computed tomography
are significant as flow within the aneurysm sac is at Baseline non-contrast CT imaging of the aorta is
high pressure and if untreated, the aneurysm sac necessary to establish a baseline density within the
may expand, leading to eventual rupture. As such, aneurysm sac. Sometimes, the presence of calcification
aneurysm expansion following EVAR always warrants can mimic contrast and therefore alter the image
investigation for endoleak. The causes of endoleak can interpretation.
be classified into five types (Table 6.4).
Table 6.4 Classification of endoleaks.

Table 6.5 Endovascular stent endoleak.
Imaging protocol.
Type I: Leak at graft attachment site:
• Ia: proximal. MODALITY PROTOCOL
• Ib: distal. CT Unenhanced. No oral contrast. Scan from
Type II: Aneurysm sac filling via branch vessel: just above diaphragm to the femoral heads.
• IIa: single vessel. If a thoracic aortic endovascular stent
endoleak is suspected, coverage of the
• IIb: two vessels or more. thorax may suffice.
Type III: Leak through defect in graft: Aortic angiogram: 100 ml IV contrast
• IIIa: junctional separation of the modular components. via 18G cannula, 4 ml/sec. Bolus track
• IIIb: fractures or holes involving the endograft. centred on mid-abdominal aorta. Scan from
just above diaphragm to femoral heads.
Type IV: Leak through graft fabric as a result of graft porosity.
If a thoracic aortic endovascular stent
Type V: Continued expansion of aneurysm sac without endoleak is s uspected, coverage of the
demonstrable leak on imaging (endotension). thorax may suffice.
K22247_C006.indd 197 16/05/15 3:12 AM

198 Chapter 6
scan of the abdomen in the arterial phase. Contrast is scan of the thorax in the arterial phase. Contrast is seen
seen in the aneurysm sac at the proximal aspect of the in the aneurysm sac at the mid aspect of the covered
graft (arrow). This was not present on the plain scan and stent (arrow). This was not present on the plain scan and
the features are in keeping with a Type 1 endoleak. the features are in keeping with a Type 3 endoleak.
CTA in an endoleak classically demonstrates high Key points

attenuation (representing leaking contrast) external to • Unenhanced CT is very important in order to
the stent in the aneurysm sac, which is not present compare areas of high attenuation within the
in the unenhanced phase. This may be seen adjacent aneurysm sac on follow-up contrast enhanced
to the proximal end of the graft (Type 1) (Figure 6.10) imaging.
or at the junctional zones of the graft (Type 3) (Figures • Type 2 endoleaks can usually be traced back to
6.11, 6.12). a collateral vessel, usually a branch of a lumbar
The most common type of endoleak (Type 2) is artery or inferior mesenteric branch.
seen as focal areas of high density within the aneurysm
sac (Figure 6.13). Often the origin can be traced to a Reference
vessel entering the sac. The vessels are usually lumbar Stavropoulos SW, Charagundla SR (2007) Imaging
or inferior mesenteric collaterals in the case of EVAR. techniques for detection and management of endoleaks
On detecting an endoleak, findings should be after endovascular aortic aneurysm repair. Radiology
communicated to the vascular surgical team. A variety 243:641–55.
of treatment options are available depending on the
type and size of the endoleak.
K22247_C006.indd 198 16/05/15 3:12 AM

scan of the abdomen in the arterial phase. Contrast is scan of the abdomen in the arterial phase. Contrast
seen in the aneurysm sac at the mid aspect of the graft is seen in the aneurysm sac at the periphery on the
(arrow). This is in keeping with a Type 3 endoleak. right. A vessel can be seen superiorly adjacent to the
sac, which is a branch of the inferior mesenteric artery.
The features are in keeping with a Type 2 endoleak.
COMPLICATIONS OF COMMON abdominal swelling/bruising as well as signs and

FEMORAL ARTERY PUNCTURE symptoms of shock. Punctures that are too low can lead
to haematomas extending into the thigh.
Common femoral artery (CFA) puncture is frequently The second most common complication
performed by interventional radiologists (IRs), of CFA puncture is pseudoaneurysm formation.
cardiologists and neurointerventional radiologists. A pseudoaneurysm is defined as an arterial
Arterial puncture site complications include wall disruption in which an extravascular cavity
haematoma, dissection, thrombosis, arteriovenous communicates with the vessel lumen but is contained
fistula and pseudoaneurysm. Although rare, puncture by surrounding haematoma or adjacent tissues. CFA
site injuries may cause serious sequelae and can lead to pseudoaneurysms are more common in punctures
death. that are below the femoral head. Patients often
The most common complication following CFA present days after CFA puncture with a large or
puncture is haematoma. This is usually caused by a expanding pulsatile groin swelling. They may also
puncture that is too high (above the inguinal ligament) present with signs and symptoms of shock as well as
or too low (below the femoral head). Haematomas a reduced haemoglobin level.
may also result from a failure of adequate compression
after sheath removal or failure of endovascular closure Radiological investigations
devices. Haematomas can be of varying sizes; punctures Ultrasound and Doppler ultrasound of the groin is a
above the inguinal ligament are difficult to compress very useful first-line imaging method to assess for CFA
after removal of sheaths and often lead to large puncture complications. The groin and femoral vessels
retroperitoneal haematomas. These can continue to are usually very easy to see on ultrasound. If ultrasound
bleed and patients often present with flank or lower fails to detect any abnormality and there is ongoing
K22247_C006.indd 199 16/05/15 3:12 AM

200 Chapter 6
clinical concern, further evaluation with CTA may be as both these factors play a role in deciding treatment
helpful. This can help to delineate vascular anatomy options.
as well as identify focal areas of active haemorrhage. Following this, the soft tissues surrounding the
(See Table 6.6.) blood vessels should be assessed for haematoma. The
ultrasound features for haematoma are non-specific,
Radiological findings and usually appear as hypo- or mixed echoic areas,
Ultrasound which have variable definition (Figure 6.14). These
Ultrasound of the affected groin should be performed should be assessed for colour Doppler flow, to look for
with a linear transducer. First, the CFA should be active bleeding.
identified and assessed for patency. Colour Doppler
flow and signal should be assessed for normal arterial Computed tomography
waveforms. The same should then be carried out CT assessment for CFA puncture complications is
for the superficial femoral artery, profunda femoris reserved for cases where patients are unstable and/or
artery and the visible external iliac vessel. The arteries ultrasound fails to provide a diagnosis. Unenhanced
should be assessed in longitudinal and transverse CT should be performed in the first instance. This
planes. Any focal outpouchings containing flow and/ not only provides a baseline image for comparison,
or discontinuity of the vessel wall must be considered but it can detect haematomas in the soft tissues and
a pseudoaneurysm. The size of the pseudoaneurysm retroperitoneum. Retroperitoneal haematomas on CT
must be measured as well as the neck of the aneurysm, appear either as linear streaky opacities in the fat or
Table 6.6 Complications of common femoral

artery puncture. Imaging protocol.
MODALITY PROTOCOL
CT Unenhanced. No oral contrast. Scan from just
above the diaphragm to below the femoral
heads.
Aortic angiogram: 100 ml IV contrast via 18G
mid-abdominal aorta. No oral contrast. Scan
from the diaphragm to below the femoral
heads.
Delayed phase: IV contrast as above, scan at
120 seconds after start of contrast injection.
Scan from the diaphragm to the femoral
heads.
Ultrasound High frequency linear probe (e.g. 6–9 MHz)
Figure 6.14 Ultrasonogram showing a mixed
with use of colour Doppler imaging. echogenicity mass in the upper thigh consistent with an
evolving haematoma.
K22247_C006.indd 200 16/05/15 3:12 AM

as well-defined high attenuating soft tissue masses or are seen as a focal contrast-filled outpouching of the
collections. artery in the arterial phase. In the portal venous phase,
It is important to perform an arterial phase study if these outpouchings show a washout of contrast, which
the plain scan confirms a retroperitoneal haematoma. is diagnostic of pseudoaneurysms. There is often
This allows for assessment of active arterial bleeding, surrounding haematoma and or/inflammatory change
which is seen as an ill-defined high attenuation blush (Figure 6.15).
of contrast adjacent to the blood vessel or within the
collections. Delayed phase imaging often shows an Key points
increase in the high attenuation area, in keeping with • A combination of ultrasound and CT imaging
haemorrhage. If active bleeding is detected, urgent should be utilised to identify common
discussion with the clinical team is necessary. complications of CFA puncture.
Pseudoaneurysms can also be seen on CT, although • In unstable patients, triple-phase CT is a useful
most can be detected on ultrasound. Pseudoaneurysms method to characterise the puncture site.

scan of the pelvis in the arterial phase. Contrast is seen
in the right common femoral artery with a thin track of
contrast extending superiorly into a focal collection of
contrast. This area was not present on plain imaging and
showed wash out on subsequent delayed imaging. The
features are in keeping with a right common femoral
artery pseudoaneurysm.
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K22247_C006.indd 202 16/05/15 3:12 AM
Appendix 1
CRITERIA FOR PERFORMING A CT

HEAD SCAN 203
[1] For adults who have sustained a head injury and have any of the following risk factors, perform a
CT head scan within 1 hour of the risk factor being identified:
• GCS less than 13 on initial assessment in the emergency department.
• GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
• Suspected open or depressed skull fracture.
• Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the
ear or nose, Battle’s sign).
• Post-traumatic seizure.
• Focal neurological deficit.
• More than 1 episode of vomiting.
• A provisional written radiology report should be made available within 1 hour of the scan being
performed.
[2] For children who have sustained a head injury and have any of the following risk factors, perform
a CT head scan within 1 hour of the risk factor being identified:
• Suspicion of non-accidental injury.
• Post-traumatic seizure but no history of epilepsy.
• On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS
(paediatric) less than 15.
• At 2 hours after the injury, GCS less than 15.
• Suspected open or depressed skull fracture or tense fontanelle.
• Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from
the ear or nose, Battle’s sign).
• Focal neurological deficit.
• For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head.
performed.
[3] For children who have sustained a head injury and have more than one of the following risk factors
(and none of those listed under [2] above), perform a CT head scan within 1 hour of the risk factors
being identified:
• Loss of consciousness lasting more than 5 minutes (witnessed).
• Abnormal drowsiness.
• Three or more discrete episodes of vomiting.
• Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle
occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other
object).
K22247_Appendix I.indd 203 16/05/15 3:15 AM

204 Appendix 1
• Amnesia (antegrade or retrograde) lasting more than 5 minutes.

performed.
[4] Children who have sustained a head injury and have only 1 of the risk factors listed under [3]
above (and none of those listed under [2] above) should be observed for a minimum of 4 hours after
the head injury. If during observation any of the risk factors below are identified, perform a CT head
scan within 1 hour:
• GCS less than 15.
• Further vomiting.
• A further episode of abnormal drowsiness.
performed. If none of these risk factors occur during observation, use clinical judgement to determine
whether a longer period of observation is needed.
GCS = Glasgow Coma Score

From National Institute for Health and Care Excellence (2014) CG 176 Head injury. Triage, assessment,
investigation and early management of head injury in children, young people and adults. Manchester: NICE.
Available from www.nice.org.uk/CG176. With permission.
K22247_Appendix I.indd 204 16/05/15 3:15 AM

Appendix 2
STANDARDS OF PRACTICE AND

GUIDANCE FOR TRAUMA RADIOLOGY 205
IN SEVERELY INJURED PATIENTS
Standards of practice and guidance for trauma radiology • What quality indicators can be used in the
in severely injured patients. (Taken from The Royal provision of diagnostic imaging and interventional
College of Radiologists (2011) Standards of Practice radiology for trauma
and Guidance for Trauma Radiology in Severely Injured • The provision of protocols for imaging and
Patients. Royal College of Radiologists, London, with reporting that can be adapted according to
permission.) loco-regional service requirements and equipment.
INTRODUCTION The standards reflect consensus opinion based on

available evidence and best existing practice. As stated,
This standards of practice guideline is intended to they are intended for local and regional consideration
complement the recently published NHS report, for adoption and adaptation according to current and
Regional Networks for Major Trauma, 2 to which future resources.
Fellows of The Royal College of Radiologists (RCR) They are based on the principle that the care
contributed through the NHS Clinical Advisory provided to the trauma patient in the first few hours
Group’s (CAG) Report on Regional Trauma Networks. can be absolutely critical in terms of predicting
These standards of practice are written with the longer-term recovery and that good trauma care
support of the National Clinical Director for Trauma involves getting the patient to the right place at the
Care under whose leadership the NHS CAG report right time for the right treatment. The standards
was developed. These standards and guidelines should also recognise that in the overall management
be read in conjunction with the NHS CAG publication of the severely injured patient, from roadside to
which states the definitions and principles on which rehabilitation, diagnostic and therapeutic radiology
these are based. plays a pivotal role but is but a small part of the whole
Although the report is to be actioned by the NHS management process.
in England, a similar standard of care is appropriate The standards will deal largely but not exclusively
in managing severely injured patients in other parts of with the severely injured patient (SIP) following
the UK. major trauma. NHS Choices defines major trauma as
The purpose of this publication is, therefore, to ‘multiple, serious injuries that could result in death or
set standards related to diagnostic and interventional serious disability’.3 These might include serious head
radiology for use by major trauma centres (MTCs) and injuries, severe gunshot wounds, falls, crush injuries
trauma units (TUs) relating to: or road traffic accidents. Major trauma is defined in
• How diagnostic imaging and interventional the scientific literature using the Injury Severity Score
radiology services should be provided and used in (ISS).4 The ISS is an anatomical scoring system derived
the management of the severely injured patient from imaging and clinical examination which assigns
• When diagnostic imaging and interventional a value to injuries in different parts of the body using
radiology are appropriate and when they are the Abbreviated Injury Scale (AIS).5 The highest
contraindicated scores from three different body regions are used to
K22247_Appendix II.indd 205 16/05/15 3:16 AM

206 Appendix 2
calculate a figure representing the severity of injury. • Imaging in SIPs more accurately delineates the
An ISS greater than 15 is defined as major trauma. extent of injury than clinical examination.
This would include serious injuries such as bleeding in • The imaging technique of choice is the one
the brain or a fracture of the pelvis and cases of multiple which is definitive in the trauma setting. In SIPs
injuries, especially where the risk of haemodynamic this will most often be head-to-thigh contrast-
instability is a consideration. enhanced multidetector computed tomography
The acute trauma setting is not the place for (MDCT).
disagreements about the patient pathway. Immediate • Definitive imaging should not be delayed by other,
management decisions must be made by the designated less accurate, investigations.
trauma team leader. • The imaging environment requires all the life
support facilities available in the emergency room.
Standard 1. The trauma team leader is in This will include monitoring and gases. The
overall charge in acute care. room design should allow visual and technical
monitoring of the patient by anaesthetic staff.
Quality indicator
MTCs and TUs will have multidisciplinary Standard 3. MDCT should be adjacent to,
debriefings about SIPs on a regular basis to assess or in, the emergency room. Where this is
the process and adjust pathways if necessary. not the case:
A radiologist involved in trauma management • Transfers must be rehearsed and performed
should attend such meetings. In addition, individual according to protocol
cases should be considered in the radiology • Radiology departments in MTCs and TUs should
department on a regular basis. plan to make this available in the near future.
Digital radiography
Imaging and intervention Digital radiography (DR) must be present in the
Radiologists emergency room. A chest X-ray (CXR) might precede a
Just as the trauma team leader must be an experienced MDCT scan if there is doubt about the side or presence
consultant, there must also be consultant-delivered of a pneumothorax in a patient with respiratory
input for imaging and intervention. compromise. Once the decision is taken to request
an emergency MDCT, plain films of the abdomen
Standard 2. Protocol-driven imaging or pelvis are usually irrelevant and extremity imaging
and intervention must be available and should be delayed until life-threatening injuries have
delivered by experienced staff. Acute care been diagnosed and treated. The British Orthopaedic
for SIPs must be consultant delivered. Association and British Society of Spine Surgeons do
Location and facilities not recommend plain films of the C-spine in a SIP
The location of imaging facilities, their design and and their standard of practice for C-spine clearance
the equipment they contain should be based on the is CT.6
following principles. Cervical spinal injury precautions and pelvic binders
• Speed is of the essence – time is tissue, time is should remain in place until the MDCT has been fully
organs, time is life; delay is deterioration, disability assessed.
and death. Where severe injury is to the spine only, MDCT or
• Moving a severely injured patient introduces MRI scan might be required but a plain film series of
delays and can exacerbate blood loss. The less the the cervical spine might also be indicated.
patient is moved and the shorter the distance, the
greater will be the chance of survival.

STANDARDS OF PRACTICE AND GUIDANCE FOR TRAUMA RADIOLOGY 207
Standard 4. Digital radiography must be Standard 6. MRI must be available with

available in the emergency room. safe access for the SIP.
FAST
Focused abdominal sonography in trauma (FAST) does Quality indicator
not offer any additional information to that obtained Availability of clear protocols for the transfer of
with a CT scan and should not be performed if it would SIPs to MRI facilities within 12 hours.
delay transfer to CT. FAST is a poor discriminator of
the requirement or otherwise for laparotomy in trauma.
Studies have shown negative predictive values of only Indications for imaging in the SIP
50–63% for FAST in unstable patients.7,8 FAST does As stated above, there may be indications for plain DR
have value in the diagnosis of pericardial effusion and in but these should never delay an MDCT if a decision
experienced hands might detect free intra-abdominal has been taken early that this is the imaging modality of
fluid in an otherwise non-compromised patient. It has choice. There may be circumstances where imaging is
an important role in triage when managing multiple inappropriate; for example, where a SIP is admitted with
SIPs simultaneously or in a major incident scenario. profound shock, is not responding to intravenous fluids
As with all imaging, a report on a FAST scan should and the site of bleeding is clear from the mechanism
be documented and the designation of the operator of injury and rapid assessment. Such patients may be
recorded. best taken straight to theatre. The more accessible the
MDCT scanner is to the emergency room and the more
Standard 5. If there is an early decision efficient CT transfer organisation is, the less frequently
to request MDCT, FAST and DR should not this should happen.
cause any delay. A polytrauma protocol MDCT is indicated when:
• There is haemodynamic instability.
Quality indicator • The mechanism of injury or presentation suggests
Where FAST or plain films have been used in a SIP, that there may be occult severe injuries that
their use and value in that case should be evaluated cannot be excluded by clinical examination or
in a multidisciplinary debriefing. plain films.
• FAST (if used) has demonstrated intra-abdominal
fluid.
Magnetic resonance imaging (MRI) • If plain films suggest significant injury, such as
MRI is not indicated in the setting of acute trauma pneumothorax, pelvic fractures.
care. However, in the MTC, it must be available • Obvious severe injury on clinical assessment.
24 hours a day, seven days a week. It should be in the
same building as the emergency department or, if it Standard 7. A CT request in the trauma
is in a different building, protocols should be in place setting should comply with the Ionising
for the transfer of critically injured patients if further Radiation (Medical Exposure) Regulations
management is dependent on MRI in the first 12 hours. 20009 (IR(ME)R) justification regulations
In a TU without access to 24-hour MRI, formal written like any other request for imaging
protocols should be in place for the transfer of patients involving ionising radiation.
to a facility that has 24-hour MRI.
Quality indicator
An annual audit of justification in trauma imaging
should be carried out by the radiology department.

208 Appendix 2
Appendix 1 demonstrates a sample request card which Limb fractures

trusts can modify according to local needs. Rapid immobilisation such as air splints. Only
NOTE: Some MTCs in other European and North immediately limb conserving manipulations/splinting
American countries have adopted a ‘CT first’ protocol. should be performed prior to CT.
The UK awaits the results of the Randomized study of
Early Assessment by CT scanning in Trauma patients Urinary catheter
(REACT) trial currently recruiting patients to a CT-first All significantly injured patients without obvious
or resuscitation-first protocol in the Netherlands. The contraindications should be catheterised unless this
result of that study might supersede the indications would delay transfer to CT. The catheter should be
above and major trauma itself may justify immediate clamped prior to MDCT.
MDCT 10 delaying only in the resuscitation area for
time-critical interventions such as securing an airway Pregnancy
or profound hypotension. There must be awareness of pregnancy status in
female SIPs of childbearing age. The health of the
Preparation and transfer to MDCT mother takes precedence over the health of the fetus
There should be agreed local protocols with clear and, if appropriate, modification of pathways should
attribution of responsibility for every stage. be decided by the trauma team leader and consultant
radiologist.
Request for MDCT
Clear protocols must exist for notifying the CT Standard 8. There should be clear written
department of the need for urgent imaging and how protocols for MDCT preparation and
the department will respond to ensure that the scanner transfer to the scan room.
is clear to receive the incoming injured patient. It must
be clear who is responsible for this at both ends. There Quality indicator
should be a detailed polytrauma request form (see Such protocols should be written and available
Appendix 1). and the process should be a statutory evaluation at
debriefing.
Transfer route to CT
This must be established in advance. Transfer staff
should be notified well in advance. MDCT imaging protocols
Whole-body MDCT has been shown to be a predictor
IV access of survival in SIPs when compared to no CT or
Right antecubital access is preferred for contrast targeted CT.11
administration (left-sided injections compromise Clearly there are many abnormalities that might
interpretation of mediastinal vasculature). However, if be detected on whole-body MDCT in the SIP and
arm vein access is not possible and a central line is in protocols should be designed to image these as clearly as
situ, it should be of a type that can accept 4 ml contrast/ possible. Protocols should be the same across networks
second via a power injector. This might require local so that repeat scanning is not required where transfer
negotiation with emergency department doctors is necessary.
beforehand. Where active contrast extravasation is seen,
the on-call interventional radiologist should be
Pelvic fracture informed immediately along with the trauma team
If a pelvic fracture is suspected, a temporary pelvic leader. Where findings are equivocal, the on-call
stabilisation (wrap, binder and so on) should be applied consultant radiologist should be asked for an immediate
before MDCT. opinion.

Examples of polytrauma CT protocols are listed should involve on-call consultant radiologists as soon
in Appendix 2. An MDCT protocol should be agreed as possible.
across a trauma network to ensure consistency and Reporting follows the Advanced Trauma Life
obviate the need for repeat scanning if transfer is Support (ATLS)12 system in that there should be an
necessary. initial primary survey followed by a secondary survey.
The NHS CAG document2 refers to the patient
who is ‘stable enough to undergo MDCT’. The phrase Initial primary survey review
used reflects the difficulty in being too prescriptive The aim of this is to give an immediate indication
in giving guidance about the stability of a SIP and of the major life-threatening injuries while active
fitness for investigation. It can be argued that the management continues. The initial images should be
greater the haemodynamic instability, the greater the reviewed looking for thoracic injuries that might impair
requirement for accurate diagnosis to allow targeted breathing, vascular injuries that might cause bleeding
surgery/intervention. In the perfect emergency and neurological injuries that might cause disability if
room environment where all imaging is immediately not treated rapidly. A suggested CT primary survey pro
co-located, there should only be a very small minority forma is provided in Appendix 3. Such a form should
of patients who are too unstable for MDCT. Such be filled in at the time, signed and dated. A copy should
patients would probably require open procedures in be handed to the trauma team leader and a duplicate
the emergency room environment. However, local scanned into the radiology information system (RIS).
circumstances will vary and undoubtedly such decisions The clinical team should fill in their contact details so
have to be made at the time by the trauma team leader that when the full trauma pro forma report is completed,
after consultation. all the necessary points of contact are available.
Protocols for unstable patient transfer should take
account of unit geography and be rehearsed to maximise Standard 11. The primary survey report
the proportion of patients who can access CT. should be issued immediately to the
trauma team leader. It should be signed
Standard 9. Whole-body contrast- and designated and a copy should be
enhanced MDCT is the default imaging retained in the CT department (or RIS).
procedure of choice in the SIP. Imaging Secondary/definitive survey
protocols should be clearly defined Once the initial scan results and pro forma have been
and uniform across a regional trauma communicated to the trauma team, the scan should be
network. carefully reviewed against a written set of criteria and
the secondary trauma report completed (Appendix 4).
Standard 10. Future planning and design This should be performed by a consultant radiologist or
of emergency rooms should concentrate in consultation with a consultant radiologist who may
on increasing the number of SIPs stable provide this report via a teleradiology link of suitable
enough for MDCT and intervention. quality.13
NOTE: Radiologists working remotely for
Quality indicator teleradiology companies have imaging equipment
Imaging and reporting protocols should be agreed that allows diagnostic reports in real time and the UK
across referral regions and written protocols must military have reporting facilities in the UK that allows
be available. accurate reporting of trauma scans from field hospitals
anywhere in the world, although they do deploy
radiologists on site to cope with rapid fluctuations in
Reporting patient care.
The initial MDCT should be attended by an All the areas listed in Appendix 4 should be reported
appropriately trained on-call radiologist. Trainees on. This report should be completed within one hour
to ensure there is no unnecessary delay to clinical

210 Appendix 2
management. Any significant findings, particularly A checklist of quality indicators for IR is provided in
where there is a variance to the initial primary survey Appendix 6.
report, should be telephoned through to relevant
clinicians. Again, the list of contact details will be Endovascular theatres
invaluable where there is a change in findings.14 When IR is indicated in SIP management, rapid access
to endovascular intervention is essential. Therefore,
Standard 12. On-call consultant angiography facilities should be located as close as
radiologists should provide the final possible to the emergency department and should
report on the SIP within one hour of MDCT certainly be in the same building and on the same floor.
image acquisition. In future, angiography suites should be co-located
within an acute theatre complex/emergency room that
Standard 13. On-call consultant provides surgical and anaesthetic support to acutely
radiologists must have teleradiology ill patients. Such facilities are not yet available in
facilities at home that allow accurate the UK.
reports to be issued within one hour of
MDCT image acquisition. Standard 14. IR facilities should be
co-located to the emergency department.
Quality indicator Facilities
All imaging should be discussed at debriefing Angiography suites must have modern (installed within
meetings and errors of protocol or fact discussed at the last ten years) fixed C-arm imaging equipment.
discrepancy meetings.15 Rooms need to be large enough to handle the numerous
individuals who accompany the very unstable trauma
patient.
Interventional radiology (IR) They should have the same facilities as an operating
The role of IR in the SIP is to stop haemorrhage as theatre and ideally should have positive pressure air
quickly as possible with minimal interference to the change.
patient’s already damaged physiology. It is as much Portable C-arm equipment should only be used in
a form of damage control as pressing on a bleeding the context of immediate stabilisation by occlusion
artery or surgical packing. Information supplied by balloon inflation. Portable units do not offer the same
MDCT is key to informing the decision-making imaging quality as fixed units and there is evidence
process and guiding a catheter to the haemorrhage of patient harm occurring with the use of such units,
site. It is likely that there will never be Level 1 evidence principally due to poor image quality.16
for endovascular techniques in trauma but, with this In addition, portable units can only operate for a
caveat, there are no significant contraindications to limited time before overheating.
the use of IR to arrest haemorrhage in major trauma.
There is a growing body of Level 2/3 evidence for its Standard 15. Angiographic facilities and
safety, efficacy, speed and cost-effectiveness. endovascular theatres in MTCs should be
The decision on whether a patient with traumatic safe environments for SIPs and should be
haemorrhage undergoes endovascular treatment, open of theatre standard.
surgery, a combination of the two or non-operative Protocols
management (NOM) is typically a decision made by Local services should take particular care to develop
both the trauma team leader and the interventional transfer protocols for both internal and external
radiologist after consultation with other consultants anaesthetic supported transfer. A frequent source
involved (Appendix 5). Decisions must be made of delay in many centres is the internal transfer of
quickly and should be driven by agreed algorithms. haemodynamically compromised patients for CT
Establishing routes of communication between the imaging or embolisation. Agreed pathways and
services is paramount. improvements to local environment should be

prioritised to minimise delay while maintaining patient References

safety. 1. Department of Health. The Operating Framework
for the NHS in England 2011/12. http://www.dh.gov.
Standard 16. Agreed written transfer uk/en/Publicationsandstatistics/Publications/
protocols between the emergency PublicationsPolicyAndGuidance/DH_122738
department and imaging/interventional (last accessed 26/4/11)
facilities internally or externally must be 2. NHS Clinical Advisory Group. Regional Networks
available. for Major Trauma. http://www.excellence.
Workforce eastmidlands.nhs.uk/welcome/improving-care/
Adequate staffing levels (radiologist, radiographer and emergency-urgent-care/major-trauma/nhs-
nursing staff) must be available. Much trauma occurs clinical-advisory-group/ (last accessed 26/4/11)
outside normal working hours and the best clinical 3. N H S C h o i c e s . h t t p : / / w w w . n h s . u k /
outcomes are achieved by rapid access to a consultant- NHSEngland/AboutNHSservices/
led and delivered IR service. Emergencyandurgentcareservices/Pages/
If resident on-call IR staff are not considered Majortraumaservices.aspx (last accessed 26/4/11)
necessary, early warning systems for on-call IR teams 4. Baker SP, O’Neill B, Haddon W Jr, Long WB.
should be in place. The priority must be at all times to The injury severity score: a method for describing
develop systems that reduce the key clinical criterion of patients with multiple injuries and evaluating
the total time to arrest haemorrhage. emergency care. J Trauma 1974; 14: 187–196.
5. Copes WS, Sacco WJ, Champion HR, Bain LW.
Standard 17. IR trauma teams should Progress in Characterising Anatomic Injury. In:
be in place within 60 minutes of the Proceedings of the 33rd Annual Meeting of the
patient’s admission or 30 minutes of Association for the Advancement of Automotive
referral. Medicine, Baltimore, MA, USA: 205–218.
Consumable equipment 6. British Orthopaedic Association and British
There should be a full range of occlusion balloons, Association of Spinal Surgeons. Standards for
catheters, embolic materials and stent grafts available Trauma (BOAST). Spinal clearance in the trauma
and there should be a robust system in place for patient. London: BOA, 2008.
replacement of used items. The use of embolisation 7. Friese RS, Malekzadeh S, Shafi S, Gentilello LM,
packs are particularly recommended, especially on Starr A. Abdominal ultrasound is an unreliable
rare occasions when procedures are being undertaken modality for the detection of hemoperitoneum in
outside the routine angiographic environment. patients with pelvic fracture. J Trauma 2007; 63:
97–102.
Standard 18. Any deficiency in consumable 8. Tayal VS, Nielsen A, Jones AE, Thomason
equipment should be reported at the MH, Kellam J, Norton HJ. Accuracy of trauma
debriefing and be the subject of an ultrasound in major pelvic injury. J Trauma-Injury
incident report. Infection & Critical Care 2006; 61: 1453–1457.
Audit and morbidity and mortality meetings 9. Department of Health. The Ionising Radiation
Multidisciplinary team audit including all involved (Medical Exposure) Regulations 2000 (together
specialties is essential to improve and maintain with notes on good practice) http://www.dh.gov.
high-quality clinical services. Radiologists should uk/en/Publicationsandstatistics/Publications/
ensure they participate in ongoing audit of trauma PublicationsPolicyAndGuidance/DH_4007957
services and contribute to local and national audit (last accessed 19/5/11)
mechanisms. 10. Saltzherr TP, Fung Kon Jin PH, Bakker FC
Approved by the Board of the Faculty of Clinical et al. An evaluation of a Shockroom located CT
Radiology: 25 February 2011. scanner: a randomized study of early assessment by

212 Appendix 2
CT scanning in trauma patients in the bi-located 14. The Royal College of Radiologists. Standards for
trauma center North-West Netherlands (REACT the communication of critical, urgent and unexpected
trial). BMC Emerg Med 2008; 8: 10. significant radiological findings. London: The Royal
11. Huber-Wagner S, Lefering R, Qvick LM College of Radiologists, 2008.
et al. Effect of whole-body CT during trauma 15. The Royal College of Radiologists. Standards for
resuscitation on survival: a retrospective, Radiology Discrepancy Meetings. London: The Royal
multicentre study. Lancet 2009; 373: 1455–1461. College of Radiologists, 2007.
12. http://www.facs.org/trauma/atls/about.html (last 16. MHRA. Joint Working Group to produce guidance
accessed 26/4/11) on delivering an Endovascular Aneurysm Repair
13. The Royal College of Radiologists. Standards for the (EVAR) Service. London: MHRA, 2010. http://
provision of teleradiology within the United Kingdom. www.mhra.gov.uk/Publications/Safetyguidance/
London: The Royal College of Radiologists, 2010. Otherdevicesafetyguidance/CON105763 (last
accessed 26/4/11)
GUIDANCE ON THE INDICATIONS FOR NON-OPERATIVE M

ANAGEMENT (NOM),
INTERVENTIONAL RADIOLOGY (IR) AND DAMAGE CONTROL SURGERY (DCS)
IN THE SIP
Decisions regarding IR or DCS will be modified according to the facilities and staff available and the
patient’s stability at presentation. (After Dr D Kessel)
SITE NOM IR DCS

Thoracic No role except in small Stent graft for suitable lesions. Ascending aortic injury or arch injury involv-
aorta partial thickness tears. ing great vessels.
Abdominal No role. Occlusion balloon, stent graft for suitable Injury requiring visceral revascularisation or
aorta lesions. untreatable by EVAR.
Peripheral or No role. Occlusion balloon, stent graft or Any lesion which cannot rapidly be controlled
branch artery embolisation. or which will require other revascularisation.
Kidney Subcapsular or retroperito- Active arterial bleeding, embolisation or Renal injury in association with multiple
neal haematoma without stent graft. other bleeding sites or other injuries requir-
active arterial bleeding. ing urgent surgical repair.
Spleen Lacerations, haematoma Active arterial bleeding or false aneurysm. Packing or splenectomy for active bleeding
without active bleeding or Focal embolisation for focal lesion in association with multiple other bleeding
evidence of false aneurysm. Proximal embolisation for diffuse injury. sites.
Liver Subcapsular or intraperito- Active arterial bleeding. Packing if emergency laparotomy needed
neal haematoma or lacera- Focal embolisation if possible. with subsequent repeat CT and embolisation
tions without active arterial if required.
Non-selective embolisation if multiple
bleeding.
bleeding sites as long as portal vein is
patent.
Pelvis Minor injury with no active Focal embolisation for arterial injury External compression and subsequent fixa-
bleeding. (bleeding, false aneurysm or cut-off). tion if bleeding from veins or bones.
Intestine Focal contusion with no Focal bleeding with no evidence of Ischaemia or perforation requiring lapa-
evidence of ischaemia, per- ischaemia or perforation. Or, to stabilise rotomy +/- bowel resection.
foration or haemorrhage. patient, allowing interval laparotomy
pending treatment of other injuries.

Appendix 3
TRAUMA COMPUTED TOMOGRAPHY

PRIMARY ASSESSMENT 213
Patient name
Hospital ID
Date
Reporting radiologist
CT HEAD: Vault #/base of skull #/orbital#/facial bones#

Subdural bleed/extradural bleed
Other:
CT C-SPINE: Odontoid peg#/C1#

Other:
Lines Present Satisfactory position

ETT
Central line
Chest drain
NG tube
CT CHEST: Pneumothorax/haemothorax/pneumomediastinum/thoracic aorta injury

Rib #........................................................................... Thoracic spine #..................................................................................
Other:
CT ABDOMEN: Free fluid/pneumoperitoneum/liver laceration/splenic laceration/abdominal aorta injury

Lumbar spine #.......................................................................................................................................................................
Other:
CT PELVIS – Free fluid/bladder injury

Pelvic #...................................................................................................................................................................................
Other:
Adapted from a preliminary report by The Heart of England NHS Foundation Trust Radiology Department, June 2014, with
permission. A full report will be available on CRIS® (Computerised Radiology Information System).
K22247_Appendix III.indd 213 16/05/15 3:17 AM

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MEDICINE
ON CALL
RADIOLOGY ON CALL
RADIOLOGY
On Call Radiology presents case discussions on the most common and important clinical
emergencies and their corresponding imaging findings encountered on-call. Cases are
divided into thoracic, gastrointestinal and genitourinary, neurological and non-traumatic
spinal, paediatric, trauma, interventional and vascular imaging. Iatrogenic complications are
also discussed.
Each case is presented as a realistic clinical scenario and includes a clinical history
and request for imaging. Multi-modality imaging examples and a case discussion on the
diagnosis and basic management, with emphasis on important radiological findings, are
also presented.
This book combines a case-based discussion format with practical advice on imaging
decision making in the acute setting. It also offers guidance on radiology report writing and
techniques, with a focus on relevant positive and negative findings to pass on to referring
clinicians. On Call Radiology offers invaluable knowledge and practical tips for any
on-call radiologist.
• download the ebook to your computer or access it anywhere with an

internet browser
• search the full text and add your own notes and highlights
• link through from references to PubMed
Gareth Lewis • Hiten Patel

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ISBN: 978-1-4822-2167-1
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Sachin Modi • Shahid Hussain
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MEDICINE

• download the ebook to your computer or access it anywhere with an

Gareth Lewis • Hiten Patel

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K22247_FM.indd 1 16/05/15 3:05 AM

No claim to original U.S. Government works

International Standard Book Number-13: 978-1-4822-2168-8 (eBook - PDF)

K22247_FM.indd 3 16/05/15 3:05 AM

K22247_FM.indd 4 16/05/15 3:05 AM

BOWEL ISCHAEMIA AND ENTEROCOLITIS 36

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K22247_FM.indd 6 16/05/15 3:05 AM

K22247_FM.indd 7 16/05/15 3:05 AM

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SUBDURAL HAEMATOMA 110

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HERPES SIMPLEX ENCEPHALITIS 131

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Key points 145

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CHAPTER 5: TRAUMA IMAGING 161

K22247_FM.indd 12 16/05/15 3:05 AM

Facet joint dislocation 187

Appendix 1: NICE head injury guidelines 203

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K22247_FM.indd 14 16/05/15 3:05 AM

K22247_FM.indd 15 16/05/15 3:05 AM

AAA abdominal aortic aneurysm HSV herpes simplex virus

HIV human immunodeficiency virus SAH subarachnoid haemorrhage

K22247_FM.indd 16 16/05/15 3:05 AM

SDH subdural haematoma TCC transitional cell carcinoma

K22247_FM.indd 17 16/05/15 3:05 AM

ADVERSE REACTIONS TO that radiographers and radiologists involved in the

K22247_Introduction.indd 1 16/05/15 3:15 AM

Anaphylactic reaction Patients with progressively worsening symptoms,

K22247_Introduction.indd 2 16/05/15 3:15 AM

K22247_C001.indd 3 16/05/15 3:06 AM

Radiological findings true lumen is smaller, demonstrates denser contrast

K22247_C001.indd 4 16/05/15 3:06 AM

K22247_C001.indd 5 16/05/15 3:06 AM

Table 1.2 Stanford and DeBakey systems.

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• Careful windowing is required to identify THORACIC AORTIC INJURY

Table 1.3 Thoracic aortic injury.

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Radiological findings as haematoma. Any loss of definition of the aortic wall

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Key points References

Figure 1.9 Axial image: IV contrast enhanced CT scan

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PULMONARY EMBOLISM Table 1.4 Risk factors for venous

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Table 1.5 Two-level Wells score.

CLINICAL FEATURES POINTS

K22247_C001.indd 11 16/05/15 3:06 AM

Patient with signs or symptoms of PE

Two-level PE Wells score

PE likely (>4 points) PE unlikely (≤4 points)

Advise the patient

*Computed tomography pulmonary angiogram

BOWEL ISCHAEMIA AND ENTEROCOLITIS 36

SUBDURAL HAEMATOMA 110

HERPES SIMPLEX ENCEPHALITIS 131

Key points 145

CHAPTER 5: TRAUMA IMAGING 161

Facet joint dislocation 187

Appendix 1: NICE head injury guidelines 203

Table 1.3 Thoracic aortic injury.

PULMONARY EMBOLISM Table 1.4 Risk factors for venous

Table 2.2 Causes of gastrointestinal bleeding. Table 2.3 Acute gastrointestinal bleeding.

Table 2.4 Computed tomographic signs of

Figures 2.10a–c Axial images: unenhanced, arterial

Table 2.5 Bowel perforation. Imaging protocol.

Table 2.7 Typical distribution of infective

Table 2.8 Large bowel obstruction. Imaging