education exhibits 869 imaging evaluation of ......diagnosed with these techniques. much of this...

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869EDUCATION EXHIBITS

Scott D. Steenburg, MD • Clint W. Sliker, MD • Kathirkamanathan Shanmuganathan, MD • Eliot L. Siegel, MD

Penetrating neck injuries are a significant source of morbidity and mortality. Diagnostic imaging plays an integral role in the diagnosis and management of these injuries. Although clinical management of penetrating injuries to the neck remains controversial, many institutions have shifted away from mandatory surgical exploration of most penetrating neck injuries toward use of endoscopy, various imaging modalities, and selective surgery to manage specific injuries diagnosed with these techniques. Much of this shift can be attrib-uted to computed tomographic (CT) angiography, a fast, reliable, and noninvasive procedure that provides a global assessment of the neck, thereby reducing the frequency of nontherapeutic surgical neck explorations and limiting the need for diagnostic conventional angiography. Therefore, radiologists interpreting images from CT angiography should be prepared to provide management recom-mendations on the basis of the CT angiographic findings. An appre-ciation of the value, roles, and limitations of multidetector CT an-giography and other imaging modalities can position the radiologist as a vital participant in the care of patients with penetrating trauma to the neck. Supplemental material available at http://radiographics .rsna.org/lookup/suppl/doi:10.1148/rg.304105022/-/DC1.©RSNA, 2010 • radiographics.rsna.org

Imaging Evaluation of Penetrating Neck Injuries1

Abbreviations: CCA = common carotid artery, ICA = internal carotid artery, MIP = maximum intensity projection

RadioGraphics 2010; 30:869–886 • Published online 10.1148/rg.304105022 • Content Codes: 1From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center and R. Adams Cowley Shock Trauma Center, 22 S Greene St, Baltimore, MD 21201. Recipient of a Cum Laude award for an education exhibit at the 2009 RSNA Annual Meeting. Received February 5, 2010; revision requested February 23 and received March 5; accepted March 8. E.L.S. serves on the speakers bureau of TeraRecon; the board of directors of Carestream Health; and the advisory boards of Fovia, McKesson, Medrad, and Mercury Computer Systems; he also receives research grants from Anatomic Travelogue, Anthro, Barco, Evolved Technologies, GE, Herman Miller, Hitachi, Intel, Philips, RedRick Technologies, Siemens, Steelcase, Vital, and XYBIX Systems; all other authors, editors, and reviewers have no relevant relation-ships to disclose. Address correspondence to S.D.S. (e-mail: [email protected]).

See also the editorial by Siegel et al (pp 849–850) in this issue.

©RSNA, 2010

ONlINE-ONly CME

See www.rsna.org /education/rg_cme.html

lEARNING OBJECTIVES

After reading this article and taking the test, the reader will be able to:

Describe the imaging ■

strategies for evaluating patients with penetrating neck injuries.

Identify various penetrat- ■

ing neck injuries at multi-detector CT angiography.

Discuss the role of mul- ■

tidetector CT angiography in the management of pen-etrating neck injuries.

EdITOR’S NOTEContent of the online sup-plemental material linked to this article has been pro-vided by the authors only for educational purposes. It is not copyrighted by the RSNA, and the authors are solely responsible for all materials contained therein. None of the online supplemental material can be downloaded for any purpose.

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870 July-August 2010 radiographics.rsna.org

IntroductionPenetrating neck injuries can be the result of low- or high-energy projectiles. These wounds are associated with a high risk of clinically significant injury because a high concentration of vital struc-tures, all of which are essential for survival, is closely packed within a small anatomic area. The mortality from penetrating neck injuries ranges from 2% to 10% (1–4), and thus these injuries require immediate medical attention by surgeons experienced in managing such injuries.

The classic management of penetrating inju-ries to the neck has been dictated primarily by the location and depth of the injury, in addition to clinical signs of active hemorrhage, airway compromise, and injuries to the pharynx or up-per esophagus, with some patients undergoing surgical exploration to both diagnose and treat injuries and others undergoing various diagnostic tests instead of immediate surgery. As experience with penetrating neck trauma accrued, manage-ment evolved into a more selective approach, with many patients in stable condition evaluated with conventional angiography, endoscopy, and esophagography. Spurred primarily by advances in diagnostic imaging, particularly multi–detector row computed tomography (CT), management of cases of penetrating trauma to the neck further evolved, with management decisions guided by the results of multidetector CT angiography.

Penetrating neck injuries can be quickly evaluated with multidetector CT angiography by noninvasive means, as it provides a global assess-ment of large anatomic regions with high spatial resolution. Multidetector CT angiography can provide information about the integrity of the neck vasculature, skeletal structures, airway, and digestive tract. By delineating the wound track, it can be used to determine the potential for injury to vital structures when a definitive diagnosis cannot be rendered; this can be especially useful when evaluating pharyngoesophageal injuries. As a result, multidetector CT angiography can be used to determine the need for further diagnostic evaluation with endoscopy, esophagography, or conventional angiography, in addition to helping definitively identify injuries that require surgical or endovascular repair.

In this article, we discuss the evolution of the diagnosis and management of acute penetrat-ing neck injuries. The role that imaging plays in diagnosing injuries and directing patient care is presented, and, reflecting current trends, special attention is given to the use of multidetector CT

angiography, with emphasis on the use of three-dimensional volume viewers. A wide variety of vas-cular injuries are illustrated, in addition to injuries to the spine, spinal cord, esophagus, and airway.

AnatomyPenetrating neck injuries are characterized by the anatomic zone of the entry wound as determined by physical examination (Fig 1) (5–7), with the site of injury localized to one of three zones. Al-though its role in directing patient care is no lon-ger as important in many contemporary centers, this anatomic classification system is still widely used by trauma surgeons. Thus, the radiologist involved in the care of patients with penetrating neck injuries should be familiar with this scheme to facilitate and clarify communication with the trauma surgeon.

Zone I is the most inferior of the three zones. It is bounded inferiorly by the sternal notch and clavicles and superiorly by the cricoid cartilage (Fig 1). At the inferior margins, there is consider-able overlap with the thoracic inlet and superior mediastinum. Important structures within zone I include segments of the innominate artery and brachiocephalic veins, segments of the subclavian arteries and veins, the common carotid and verte-bral arteries, esophagus, trachea, and thyroid. In some patients, the aortic arch and lung apices may extend into this region. Given the overlap with the thoracic inlet, patients requiring surgi-cal repair of injuries in zone I may require both transcervical and transthoracic approaches (5).

Figure 1. Three-dimensional volume-rendered image from multidetector CT angiography shows the three anatomic zones of the neck.

RG • Volume 30 Number 4 Steenburg et al 871

Zone II extends from the level of the cricoid cartilage to the angle of the mandible. Impor-tant structures in zone II include the common, internal, and external carotid arteries and jugular veins, larynx, upper esophagus, and pharynx.

Zone III extends from the level of the angle of the mandible to the base of the skull. Important structures in zone III include the internal carotid and vertebral arteries, external carotid artery branches, internal jugular vein, and pharynx. Many of the vital structures in this region are poorly accessible to the surgeon because of their proximity to the skull base and overlying facial structures (5).

During the evaluation of patients with pen-etrating neck trauma, it is important to remember that the zone of injury refers to the site of the entry wound and that the wound track may cross into another zone or zones as well as the face, cranium, or thorax. Consequently, the location of an injury to any given vital structure may be in a zone or compartment remote from the zone of entry. This fact highlights the need for the radi-ologist to clearly localize the site of an injury or potential injury to a specific vital structure.

Evolution of the Manage- ment of Penetrating Neck Injuries

Penetrating neck injuries were described in the medical literature as early as the 1500s, when military surgeons reported ligation of injured ves-sels in attempts to control exsanguinating hem-orrhage (5,8). This technique improved survival but was accompanied by significant morbidities, primarily stroke (8,9). Expectant, nonoperative management of penetrating neck injuries domi-nated from the Civil War era through World War II (5,7,10–13), an interval during which overall mortality rates ranged from 11% to 15% (10,14). Field triage, improvements in hemostasis, and emergent airway management during World Wars I and II resulted in only modest improvements in mortality rates over those seen in preceding decades. Near the end of World War II, the unac-ceptably high rate of undiagnosed neurovascular injuries resulted in a shift away from expectant management to immediate surgical exploration for all patients with penetrating neck injuries violating the platysma (5,15–22). This trend con-tinued through the Korean and Vietnam conflicts and into recent decades.

The post–World War II management approach (or classic management) of penetrating neck inju-ries incorporates surgical exploration and invasive diagnostic tests (19,20,23–27). This aggressive management philosophy was driven primarily

by fear of missed vascular injuries at physical examination and the potential for catastrophic central nervous system complications (17,22). In patients in whom no clinical indications for immediate surgical exploration were found, the location of the entry wound(s) determined the approach taken. Zone II injuries (which tend to be more common because this is the largest zone) better lend themselves to surgical exploration be-cause this zone is easily accessible to the surgeon. Although it facilitated rapid repair of many inju-ries, the philosophy of mandatory surgical explo-ration of all zone II injuries, regardless of clinical presentation, resulted in high rates of negative, nontherapeutic neck explorations, reportedly as high as 50%–60% (1–3,25,28).

In contrast, injuries involving zone I or III presented a dilemma, because surgical exposure of these regions can (a) be technically difficult (or impossible) and (b) may involve the thorax or intracranial cavity, respectively (5). With the clas-sic approach, zone I or III injuries were therefore evaluated with angiography, endoscopy, laryngos-copy, and esophagography (23–27). Regardless of the zone of injury, immediate surgical explora-tion was indicated in clinically unstable patients, including those patients who exhibited massive hemorrhage, an actively expanding hematoma, shock, or airway compromise (2,5,20,24,29–33).

The 1990s saw a re-evaluation of the estab-lished approach to managing cases of penetrating neck injuries, with a shift away from mandatory surgical exploration of many zone II injuries toward more selective use of surgical exploration. On the partial basis of several prospective and outcomes studies that suggested that physical ex-amination alone is highly accurate for detection of internal injuries that require surgical repair, thereby limiting the utility of mandatory neck explorations, a selective approach was shown to decrease the rate of nontherapeutic neck explo-rations (1,4,5,13,17–21,34,35). However, as documented by other authors, the absence of overt clinical signs or symptoms of a clinically significant injury does not mean that one is not present, especially a vascular injury. For example, according to Fogelman and Stewart (14), 43% of patients with clinically significant cervical vas-cular injury have no evidence of hemodynamic instability, and 70% do not exhibit clinical evi-dence of active bleeding at the time of admission. In a study of 393 patients with penetrating neck injuries, Apffelstaedt and Müller (23) reported


Figure 2. Evaluation of wound trajectory in an 18-year-old woman with a right-sided zone III gunshot wound. Coronal oblique multiplanar reformatted im-age from CT angiography shows innumerable small metallic ballistic and bone fragments (straight arrows) oriented along a single path, a finding indicative of the trajectory of the projectile. Although the entrance wound (*) is at the level of zone III, the trajectory ex-tends inferiorly to zone II (curved arrow). The patient was found to have a fracture of C2 and short-segment occlusion of the left vertebral artery at the level of C1-C2 (see also Image Dataset [online]).

that clinical findings of cervical vascular injury were absent in 30% of patients with significant vascular injuries identified at surgery. Bishara et al (25) reported that 23% of patients with penetrating zone II neck injuries identified at surgical exploration were not suspected of having them at clinical examination.

Coupling the need to diagnose clinically signif-icant injuries with the need to limit unnecessary surgical neck explorations, the approach to man-aging cases of penetrating neck injuries evolved into a selective one. This approach limited the influence of zone of injury on the decision to pro-ceed to surgery in favor of physical examination and a variety of diagnostic tests, including radi-ography, conventional angiography, esophagogra-phy, endoscopy, ultrasonography (US), magnetic resonance (MR) angiography, and, later in the 1990s, CT angiography (5,13,17–21,33,36). The further development of CT angiography, facilitated by recent advances in multidetector CT, has contributed to this shift in management philosophy. CT angiography has been shown to be a fast, safe, and reliable noninvasive method for evaluating patients with penetrating neck trauma (13,17,19–21,34,37). Several studies have indicated that the use of CT angiography can virtually eliminate nontherapeutic (ie, negative) surgical neck explorations (1,5,13,18,35). Direct and indirect signs of vascular injuries of the neck can be detected and often excluded on the basis of CT angiography. In addition, simultaneous evaluation of the osseous structures and upper aerodigestive tract can be performed (5,34).

Additional evaluation of the upper trachea and esophagus with laryngoscopy, endoscopy, and esophagography is still advocated by some authors for comprehensive evaluation of the pa-tient with penetrating neck injuries (23–25,27). At our institution, the use of these procedures is most often limited to those patients in whom the wound track approaches the aerodigestive tract or in whom signs or symptoms of an aerodiges-tive injury are noted. The results of neck CT angiography often can be used to determine whether patients with such injuries would be better served with surgical or nonsurgical treat-ment. On the basis of our experience and the reported benefits of CT angiography, selective management has evolved into a CT angiogra-phy–based approach, and most patients with a history of penetrating neck trauma but without indications for emergent surgical exploration

undergo neck multidetector CT angiography as the initial diagnostic examination.

Mechanism of Injury and BallisticsIn general, penetrating injuries can be classified as high- or low-energy injuries. Low-energy injuries typically are the result of low-velocity handgun ammunition and sharp objects, such as knives, glass, or other thin sharp objects. High-energy injuries are the result of high-velocity projectiles, such as those from military-style rifles, and typi-cally have potential for more widespread tissue destruction than do low-energy injuries. The sever-ity of a bullet wound depends on velocity, bullet characteristics, and the tissues through which the bullet travels (38).

The projectile can cause injury to a structure by direct impact, transfer of its kinetic energy through tissues with resulting shock wave forma-tion and cavitation, or a combination of both. As a result, anatomic structures may be dam-aged even in the absence of direct contact with a projectile. Because they are associated with high kinetic energy distributed throughout the surrounding tissues on impact, high-velocity


projectiles tend to cause more cavitation than low-velocity projectiles and, consequently, more secondary damage. Bone fracture fragments and missile fragmentation can form secondary projec-tiles that cause additional injuries (38).

determination of Wound Trajectory with CT Angiography

Determining the trajectory of the wound track aids in the evaluation of patients with penetrating neck trauma, because the organs lying along the track can be considered to have a high likelihood of being injured (16,17,38,39). If there is a single track with defined entrance and exit wounds, estimation of trajectory may be straightforward. However, the trajectory of penetrating injuries is often difficult to determine clinically.

For example, patients with gunshot wounds may exhibit multiple entrance wounds, multiple exit wounds, or entrance wounds without exit wounds. Many high-velocity projectiles are de-signed to fragment on impact and thus generate multiple secondary missiles. Although fragments typically follow the course of the main missile (Fig 2; see also Image Dataset [online]), they may veer off into differing trajectories and cause

damage along a path separate from the main track (38). Missile impact with bone can result in deviation of the projectile from its initial trajectory and can create osseous fragments that can also serve as secondary projectiles, each of which may have a different trajectory, causing additional injury (38).

Determining the trajectory of low-velocity objects can be especially difficult (Fig 3) (33), because entrance wounds often have no cor-responding exit wounds and the diameter of the tracks may be small. Reliable prediction of the orientation of a stab wound is best made when the object is left in situ, a presentation not fre-quently encountered. Consequently, the role of imaging is vital in determining wound trajectory and thereby identifying those structures at risk for injury and limiting the number of diagnos-tic tests or procedures required to evaluate the patient (39).

Initial imaging with radiography can be used to determine the presence and number of foreign bodies and, if orthogonal views are obtained, to triangulate the locations of the foreign bodies. Despite the useful information obtained from radiography, the exact extent of internal injuries may not be precisely determined, and additional imaging evaluation is usually war-ranted (40).

At our urban level I trauma center, multide-tector CT angiography is the primary means by which patients with penetrating neck injuries are imaged. In our experience, multidetector CT angiography regularly shows the trajectory of wound tracks. However, because wound tracks often are not oriented in standard axial, sagittal, and coronal planes, liberal use of an interactive viewer to manipulate the dataset is essential to appreciate the true orientation of the track. Often, the track can be displayed on a single image by this means (Fig 2; see also Image Dataset [online]). Interactive viewing may also help identify tracks caused by secondary projectiles.

At times, penetrating objects may leave behind no residual foreign bodies or bone fragments (Fig 3), thereby rendering identification of the track difficult if not impossible. We typically encounter this situation in patients with stab wounds. In such cases, foci of gas and small areas of hemor-rhage or edema (ie, fat stranding) may be the only clues to the location of the track (Fig 4). Al-ternatively, creating a straight line that connects

Figure 3. Evaluation of wound trajectory in an 18- year-old man with low-velocity gunshot wounds to the face and zone III. Image from multidetector CT angiog-raphy shows a right-sided zone III gunshot wound. Ex-act orientation of the wound track could not be deter-mined because diffuse hemorrhage obscures fat planes (*), soft-tissue gas is confined to the anterior neck, and no foreign bodies are retained. The patient had a pseu-doaneurysm of the common carotid artery (CCA).


definitively identified injuries can give a clue as to the trajectory and help identify other intervening structures that may be injured.

Specific Penetrating Neck Injuries

Arterial InjuriesPenetrating arterial injuries contribute substan-tially to negative clinical outcomes in penetrating neck trauma, primarily as a result of neurologic events such as stroke (4,30). Approximately 15%–25% of penetrating injuries to the neck result in an arterial injury (21,24,33). Among penetrating arterial injuries of the neck, up to

80% involve the carotid arteries and up to 43% involve the vertebral arteries. Carotid artery inju-ries are particularly devastating, leading to stroke in as many as 15% of patients and death in 22% (8,21,22,41).

Signs of arterial injuries at multidetector CT angiography include partial or complete occlu-sion (Figs 5–7; see also Image Dataset [online]),

Figure 4. Evaluation of wound trajectory in a 51-year-old man with a left-sided zone III stab wound. (a) Axial image from initial multidetector CT angiography shows small bubbles of gas in the left parapharyngeal soft tis-sues (straight arrow), a finding suggestive of medial orientation of the wound track. A single small bubble of gas in the posterior neck (arrowhead) (a clue that the wound extends posteriorly) and a left vertebral artery injury (curved arrow) were not detected prospectively. The patient was discharged without a diagnosed arterial injury. He returned to the hospital 10 days later with bleeding from the stab wound. (b) Axial image from repeat multi-detector CT angiography shows a large pseudoaneurysm of the left vertebral artery (arrow) that developed from the intimal injury. The pseudoaneurysm was successfully treated with coil embolization.

Figure 5. Arterial occlusion in an 18-year-old man with a facial gunshot wound that traversed zone III. Sagittal thin-slab maximum intensity projection (MIP) image from CT angiog-raphy shows gradual tapering of the proximal internal carotid artery (ICA) with complete occlusion (arrowhead). The pa-tient later developed a high-flow arteriovenous fistula between the ICA and internal jugular vein; the fistula was treated with endovascular occlusion. The patient recovered without neuro-logic sequelae (see also Image Dataset [online]).


Figure 7. Arterial occlusion in a 25-year-old man with a zone II gunshot wound. (a) Axial CT image shows numerous metallic bullet fragments at the level of the skull base with as-sociated artifact, which completely obscures the regional arterial structures. (b) Axial image from CT angiography, obtained at the level of the petrous apices, shows the enhanced right ICA but no enhancement of the left ICA (arrow) or basilar artery (arrowhead). Unen-hanced brain CT showed severe diffuse cerebral edema resulting from extensive ischemia.

Figure 6. Arterial occlusion in an 18- year-old man with a zone III gunshot wound. (a) Oblique sagittal MIP image from multidetector CT angiography de- picts complete occlu-sion of the right ICA (arrow). (b) Unen-hanced brain CT image obtained at admission demon-strates an infarct (arrowhead) in the right frontal lobe. (c, d) Diffusion-weighted MR image (c) and apparent diffusion coefficient map (d) show the in-farct (arrowhead).


pseudoaneurysm (Figs 4, 8), intimal injuries (Fig 9), arteriovenous fistula (Fig 10), active bleed-ing (Fig 11; see also Image Dataset [online]), and luminal caliber changes (4,19,33,34,37,42). Because venous contamination may mask the hallmark early venous filling of an arteriovenous fistula when multidetector CT angiography is used, conventional angiography may be required when an arteriovenous fistula is suspected.

Accuracy of CT Angiography in Evaluation for Neck Arterial Injuries.—In acute penetrating trauma to the neck, exclusion of arterial injuries is often the most immediate concern given the

risk of stroke or exsanguination. In this regard, CT angiography has several practical advantages over four-vessel conventional angiography, the traditional standard of reference. CT angiogra-phy is available in most contemporary emergency departments and trauma centers; it provides a global perspective of the vasculature, soft tissues, and osseous structures; it is fast; and it does not require mobilizing the additional personnel that constitute an angiography team.

Several groups have compared CT angiogra-phy with conventional angiography for detection of neck arterial injuries in the setting of penetrat-ing neck trauma; all reported sensitivities and specificities for CT angiography in excess of 90% (4,5,13,17–19,37). In one study, Múnera

Figure 8. (a–c) CCA pseudoaneurysm in a 31-year-old man with a zone II gunshot wound. (a) Axial image from CT angiography shows a subtle anterior contour irregularity of the right CCA (arrow). The irregularity is caused by a small, blister-like pseudoaneurysm. (b) Sagittal thin-slab MIP reformatted CT image shows the pseu-doaneurysm more clearly (arrow). (c) Image from digital subtraction angiography shows the pseudoaneurysm (arrow). (d, e) CCA pseudoaneurysm in an 18-year-old man with gunshot wounds to the face and zone III (same patient as in Fig 3). Axial (d) and coronal oblique thick-slab MIP (e) images from CT angiography show a pseu-doaneurysm of the right CCA (arrowhead).


Figure 10. Arteriovenous fistula in a patient with multiple stab wounds to zone I. Axial (a) and coronal oblique thick-slab MIP (b) images from CT angiography show a direct com-munication (arrow) between the CCA (A) and internal jugular vein (V) with a large adjacent pseudoaneurysm (arrowhead). The enhancement of the internal jugular vein is comparable with that of the CCA. The patient was treated successfully with surgery.

Figure 9. Intimal injury in a 25-year-old man with a zone II gunshot wound. (a, b) Axial (a) and sagittal oblique MIP (b) CT images show an eccentric intraluminal filling defect in the ICA (arrow). The filling defect is related to intimal injury and thrombus. (c) Image from digital subtraction angiography performed before endovascular repair shows the injury (arrow), which was successfully treated with a stent.

Figure 11. Active bleeding in a 43- year-old man with a zone II gunshot wound. Axial image from CT angiog-raphy shows active bleeding in the sub-lingual region (arrowhead). The bleed-ing was treated with transcatheter coil embolization (see also Image Dataset [online]).


et al (4) evaluated 60 patients with penetrat-ing neck trauma who underwent both helical single-section CT angiography and conventional angiography. Ten of these patients had cervical arterial injuries, which involved the carotid arte-ries in seven patients and the vertebral arteries in three patients. With conventional angiography used as the reference standard, single-section CT angiography had a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 98%. In the single false-negative case, a small pseudoaneurysm at the origin of the CCA, later seen with conven-tional angiography, was missed at CT angiogra-phy because the origins of the CCAs were not included in the acquisition.

In a follow-up study, Múnera et al (19) de-tailed their experience with an additional 175 patients who underwent single-section helical CT angiography after penetrating neck trauma. Al-though these cases were interpreted prospectively to aid the trauma surgeon in clinical decision making, statistical analyses were performed with data obtained by blinded retrospective consen-sus review performed within 72 hours of image acquisition. CT angiography demonstrated arte-rial injuries in 27 patients. With a combination of conventional angiography, surgical findings, and clinical follow-up used as the reference standards, the sensitivity, specificity, and positive and nega-tive predictive values for CT angiography were 100%, 98.6%, 92.8%, and 100%, respectively.

In what, to our knowledge, is the only study reporting the use of multidetector CT angiog-raphy to diagnose penetrating arterial injuries of the neck, Inaba et al (43) used four-section multidetector CT angiography to prospectively screen 93 patients with penetrating neck injuries. With an aggregate of surgical, angiographic, and clinical follow-up used as the reference standards, the authors found that multidetector CT angiog-raphy had 100% sensitivity and 93.5% specificity for the detection of vascular and aerodigestive injuries. No injuries requiring intervention were missed with multidetector CT angiography, although there were five false-positive cases. Four patients suspected of having aerodigestive injuries had normal findings according to the reference standards (two underwent surgical exploration and two underwent endoscopy and esophagog-raphy), and one patient suspected of having a vertebral artery injury had normal findings at four-vessel angiography (43).

To our knowledge, no data have been pub-lished detailing the accuracy of 16-section multidetector CT (or higher-section-number multidetector CT) in penetrating neck injuries. On the basis of the aggregate single-section CT angiography and multidetector CT angiography data and the associated practical advantages, multidetector CT angiography has essentially replaced conventional angiography at many major trauma centers for the initial evaluation of patients with potential penetrating arterial inju-ries of the neck, with conventional angiography reserved as a problem-solving tool or a stepping stone to endovascular intervention (5).

At our institution, axial, sagittal, and coronal multiplanar reformation and MIP images are routinely generated as part of every neck multi-detector CT angiography examination and can quickly be generated by the technologist without additional radiologist time. Futhermore, nearly every injury detected with these routine refor-mation techniques is further evaluated by using approaches similar to those shown by Velthuis et al (44) and Ferencik et al (45). When these additional postprocessing techniques are used, the source data are reviewed on an independent workstation with liberal dataset manipulation by means of interactive processing techniques, including off-axis and oblique multiplanar refor-mation, MIP, and even volume-rendered images. It is often on these tailored images that the extent of injury and precise injury morphology can be fully understood (Figs 2, 5, 6, 8–10).

Although multidetector CT angiography has advantages over conventional angiography, some limitations characterize this approach. Initial CT angiography may result in an overall large con-trast material load if the patient later undergoes conventional angiography for problem solving or intervention. Open communication with the referring surgeons is important to maximize the information obtained while minimizing contrast material load. Conventional angiography should be considered first if assessment indicates that the patient will ultimately need angiography with or without intervention, especially if the patient is at risk for contrast material–induced nephropathy (although this may be a secondary consideration in young, healthy patients). Immediate therapeutic interventions cannot be performed after diagnostic multidetector CT angiography, a limitation not associated with diagnostic catheter angiography. In our experience, the advantages of CT angiography generally outweigh the disadvantages, which are significant in only a minority of cases.


CT Angiography: Limitations and Pitfalls.—Lim-itations of cervical CT angiography in penetrating trauma are largely related to imaging technique and artifacts. Suboptimal timing may result in poor visualization of the arteries, and venous con-tamination can mask early venous filling, which may signify an arteriovenous fistula. Body habitus can negatively affect image quality, particularly at the shoulders and lower neck, where image noise can significantly compromise visualization of the proximal common carotid and vertebral arteries. Motion artifact may either obscure or mimic an injury. Dental amalgam, spinal hardware, and metallic foreign bodies (eg, bullet fragments) can create significant beam-hardening artifact that can (a) simulate an injury, especially an intimal flap, or (b) partially or completely obscure an adjacent vessel. Occasionally, conventional angiography may be needed to adequately visualize an artery obscured by beam-hardening artifact from an adjacent bullet fragment or metallic shrapnel frag-ment (Figs 7a, 12). These potential limitations are fortunately uncommon, affecting approximately 1% of properly performed multidetector CT an-giography examinations (19).

Despite a normal-appearing artery, indirect signs of vascular injury (eg, periarterial hematoma and fat stranding) or signs that the artery is within the wound track (eg, periarterial gas or a missile fragment within 5 mm of the artery) can create a diagnostic dilemma. Because of the potential for stroke or hemorrhage to occur owing to an injury

overlooked at CT angiography, it has been recom-mended that the vessel in question be studied with conventional angiography or, at least, follow-up CT angiography (33) to more definitively exclude an injury. It is our opinion that outcomes studies will be needed to determine the significance of these findings in the absence of direct signs of vas-cular injury before their significance is dismissed.

MR Angiography.—MR angiography is an established means for evaluating the neck ar-teries. Although MR angiography can be used to diagnose blunt carotid and vertebral artery injuries (20,46,47), its use in penetrating trauma is limited, primarily by the potential presence of retained metallic foreign bodies, which may serve as contraindications to entry into the MR imag-ing suite. In addition, the role of MR imaging in diagnosis of other injuries, especially aerodi-gestive injuries, has not been explored, so that evidence is not yet sufficient to support its value as a comprehensive diagnostic tool. For these rea-sons, we do not believe that MR angiography and MR imaging should currently play a major role in evaluating patients with potential penetrating vascular injuries of the neck.

Conventional Angiography.—Digital subtrac-tion angiography remains the standard of refer-ence for diagnosis of arterial injuries of the neck.

Figure 12. Obscuration of arteries by beam-hardening artifact in a 20-year-old man with a zone III gunshot wound. (a) Axial image from CT angiography shows severe beam-hard-ening artifact caused by multiple metallic bullet fragments (*).The artifact obscures adja-cent arterial structures. (b) Image from conventional angiography shows intimal irregularity of the ICA (arrow) due to an intimal injury or vasospasm. The intimal irregularity could not be visualized at CT angiography.


However, it does not provide the comprehensive diagnostic evaluation afforded by multidetector CT angiography and has a relatively low rate of positive results (10%–30%) (16,33,48,49). Com-plications from conventional angiography are rare (0.16%–2%) but significant and include punc-ture site hematoma, access vessel thrombosis, thromboembolization distal to the access point, arteriospasm, ischemia, and arterial dissection (4). Thus, at our institution and others, conven-tional angiography (except as part of endovascu-lar repair) has taken on the secondary role of a problem-solving modality.

Ultrasonography.—Doppler US is another po-tential test for evaluation of the cervical vascula-ture in the setting of trauma (33,50–53). It can provide information on the patency of a vessel, as well as flow velocity, and can provide high-resolu-tion images of the arterial wall. It is noninvasive, portable, and inexpensive compared with other imaging options, is free of ionizing radiation, and does not require contrast material.

Several studies report that US is a viable screening modality in the setting of penetrating neck trauma (50,51,53). In 1996, Montalvo et al (53) prospectively evaluated the accuracy of color Doppler US in 52 patients, with angiography and surgery used as the reference standard in 48 patients. They concluded that Doppler US is as accurate as angiography in screening for zone II and III vascular injuries in stable patients. Corr et al (50) in 1999 came to a similar conclusion when they prospectively studied 25 patients with penetrating neck injuries with both color Doppler US and angiography. Ten patients had positive findings, which were later confirmed at angiog-raphy or surgery, with no false-positive or false-negative Doppler US examinations.

In another study, Demetriades et al (51) evalu-ated a population of 200 patients with penetrat-ing neck injuries, including 82 patients who underwent both angiography and color flow Dop-pler US. US allowed correct detection of 10 of 11 vascular injuries, with no false-positive cases. A small intimal injury seen at angiography in one patient was not detected with US, but no surgery or other intervention was required in that case. Color flow Doppler US had a sensitivity of 91% and specificity of 98.6% for detection of all vas-cular injuries, with 100% sensitivity and specific-ity for detection of surgical vascular injuries (51).

However, these apparent advantages are overshadowed by the limitations of this modality in the setting of penetrating neck trauma. Color Doppler US is operator dependent and may not be available at all times. In addition, visualization of the vasculature in lower zone I as well as zone III is limited with color Doppler US. Visualiza-tion of the vertebral arteries can also be limited by overlying bone (20,53,54). The presence of subcutaneous gas and limited acoustic windows because of wound bandages can also significantly limit visualization of the underlying vasculature. Moreover, US is of limited to no value in evalu-ation of the upper airway, esophagus, and spine. Because of these significant limitations, color Doppler US is not routinely used in initial evalu-ation of penetrating neck injuries.

Venous InjuriesPenetrating venous injuries are seen in 16%–18% of patients with penetrating neck trauma (23,43, 55). Historically, cervical venous injuries were identified at surgical exploration, but the shift toward selective management has reduced the number of neck explorations. Although the optimal imaging strategy for diagnosis of cervical venous injuries has not yet been determined, CT angiography has been shown to better demon-strate these injuries (Fig 13), which are often missed at physical examination (55). In the series

Figure 13. Venous injury in a 24-year-old man with a zone II gunshot wound. CT image shows a filling defect in the left internal jugular vein (curved arrow), a finding indicative of an intraluminal thrombus, which was presumably due to a mural injury. The adjacent CCA (A), gas (straight arrow), and metallic foreign bodies (arrowheads) are also seen. The vein was ligated at neck exploration.


of Gonzalez et al (55), cervical venous injuries were the most frequently missed neck injury at physical examination, although no complications were noted, suggesting that imaging should be focused on the identification of other, more clini-cally significant injuries.

Spinal InjuriesPenetrating injuries to the cervical spine account for approximately 11%–14% of spine injuries (56–59). The diagnosis of injuries to the osseous spine in the setting of penetrating neck trauma is

generally not a diagnostic dilemma, particularly with multidetector CT angiography (Figs 2, 14, 15). The radiologist should report fractures and the distribution and location of foreign bodies and describe any signs of dural violation, such as gas, bone, or foreign bodies in the spinal canal (60). Low-energy sharp objects do have the ability to cut bone without the fragmentation typically seen with high-energy penetrating injuries (Fig 16).

Figure 15. Spinal injury in a 20-year-old man with a transcervical gunshot wound. (a) Axial image from CT angiography shows bilateral C7 fractures (arrow), a finding indicative of a wound track through the spinal canal. (b) Axial T2-weighted MR image shows the spinal cord injury (arrowhead).

Figure 14. Spinal injury in a 49-year-old man with quadriplegia after facial and transcer-vical gunshot wounds. (a) Axial image from CT angiography shows a comminuted fracture of the C5 spinous process (arrowhead) with bone fragments displaced into the spinal canal (arrow). No metallic ballistic fragments are seen. (b) Sagittal short τ inversion-recovery MR image shows spinal cord enlargement and abnormal increased signal intensity spanning C1-2 through C5 (arrowhead), findings consistent with contusion.


A wound track extending through the spinal canal implies the presence of a spinal cord injury (Fig 15) (59). With high-energy weapons, it is common for bone and metal fragments to align along the track through the spinal canal, but cord injury can occasionally result from secondary

cavitation without the bullet entering the spinal canal (61). However, not all penetrating injuries to the spinal cord are straightforward, especially stab wounds (Fig 17). MR imaging can be used to confirm or better delineate spinal cord injuries, provided no contraindications to entry into the MR environment are present (eg, retained metal-lic missile fragments of unknown or ferromag-netic composition).

Figure 17. Spinal injury in a 21-year-old man with an upper extremity neurologic deficit after a stab wound to the posterior neck. (a) Image from CT angiography shows a small soft-tissue hematoma (white oval) but no active bleeding or fracture. (b) Axial gradient-echo MR image shows a small focal spinal cord contusion (arrowhead) at the C3-C4 level. The soft-tissue hematoma is also seen (white oval).

Figure 16. Spinal injury in a 23-year-old man with upper extremity numbness and paresthesias after stab wounds to the posterior neck and upper arm. (a) Image from CT angiography shows small bubbles of soft-tissue gas (arrow-head) within the wound track, which extends to a fracture of the C4 left lamina (arrow). (b, c) Axial gradient-echo (b) and sagittal T2-weighted (c) MR images show a small hemorrhagic spinal cord contusion (arrowhead) at the C3 level; the hemorrhage is best demonstrated on the gradient-echo image. The C4 fracture and C3 cord contusion indicate a superiorly oriented stab wound. The sagittal image shows a defect in the nuchal ligament (N in c) in the suboccipital region and disruption of the ligamentum flavum at C3-C4 (arrow in c).


Injuries to the EsophagusCervical esophageal injuries are uncommon, seen in only 0.9%–6.6% of patients with penetrating neck trauma (5,36,62–64). Delayed diagnosis is the most important contributor to death from penetrating esophageal injuries, which occurs mainly as a result of mediastinitis and sepsis. Therefore, diagnosis and repair of esophageal in-juries should be given high priority (5). Mortality from penetrating esophageal injuries is high, ap-proaching 20% in some series (5,64–67). Mortal-ity remains high even when the injury is promptly diagnosed. For example, in the series of Symbas et al (64), 12.5% of patients with penetrating cer-vical esophageal injuries who underwent imme-diate repair died. Therefore, esophageal injuries should be suspected when a penetrating injury is near the esophagus or the esophagus is directly in the trajectory of a penetrating injury (Fig 18).

The clinical history, physical examination find-ings, and chest radiographic findings are often nonspecific for both diagnosis and exclusion of penetrating esophageal injuries. In our experi-ence, esophageal injury can be excluded with multidetector CT angiography when the wound track is remote from the esophagus. However, if the esophagus is involved or is close to the track, an esophageal injury should be suspected, even when an esophageal defect is not directly visual-ized (Fig 18) (39). In instances when physical examination or multidetector CT angiographic findings suggest an esophageal injury, further investigation with esophagography or endoscopy

is warranted, with a combination of esophagog-raphy and endoscopy yielding a sensitivity of 90%–100%.

The esophagographic procedure is typically biphasic, with an initial study performed with water-soluble contrast material. If results are normal, the initial study is immediately fol-lowed by one performed with a suspension of barium sulfate. However, it has been suggested that monophasic esophagography with water-soluble contrast material alone is safe, reliable, and cost-effective (36). It can be difficult, if not impossible, to perform esophagography in acutely injured patients.

Injuries to the Trachea and larynxTracheolaryngeal injuries are seen in approxi-mately 1%–7% of patients with penetrating neck injuries (62,68,69). Although they are rare, a high suspicion should be maintained because of the potential for life-threatening airway compromise. Imaging often allows direct identification of a penetrating injury to the trachea or larynx (Figs 19–21) and can help plan definitive therapy. CT is a rapid, noninvasive technique for visualizing the structures of the larynx and can be used as an important adjunct to clinical examination in determining the most optimal therapy (70). Even when an injury is not directly visualized, its presence can often be inferred when a wound track crosses or is close to the trachea or larynx

Figure 18. Esophageal injury in a 24-year-old man with zone I stab wounds. (a) Axial CT image (lung window) shows multiple gas bubbles (arrow) in the posterior mediastinum in the region of the esophagus. (b) Anteroposterior chest radiograph obtained immediately after esophagography shows a contrast material leak (arrowhead), which was due to an esophageal injury at the thoracic inlet.


CT angiography. The need for surgery or further evaluation with endoscopy, esophagography, and conventional angiography is often directed by the results of CT angiography. Therefore, radiologists interpreting images from CT angiography should be prepared to provide management recommenda-tions on the basis of the CT angiographic findings. An appreciation of the value, roles, and limita-tions of multidetector CT angiography and other imaging modalities can position the radiologist as a vital participant in the care of patients with penetrating trauma to the neck.

Acknowledgments.—The authors thank Nancy Knight, PhD, for her editorial work with the manu-script; Robert Taylor, TeraRecon, San Mateo, Califor-nia, for loan of the visualization engine used for the image datasets; and Ryan Moffitt, TeraRecon, Balti-more, Md, for his work in developing and refining the interfaces required to publish them.

References 1. Biffl WL, Moore EE, Rehse DH, Offner PJ, Fran-

ciose RJ, Burch JM. Selective management of pene-trating neck trauma based on cervical level of injury. Am J Surg 1997;174(6):678–682.

Figures 19–21. (19) Tracheal injury in a patient with a zone I stab wound. Axial image from CT angiography (lung window) shows soft-tissue gas and a small focal defect in the trachea (arrow), a finding that definitively indicates a penetrating tracheal injury. (20) Laryngeal injury in a patient who fell onto a wood survey spike. Nonenhanced CT image shows air extending into a focal defect in the left lamina of the laryngeal thyroid cartilage (arrow). (21) Laryngeal injury in a patient with a zone II gunshot wound. CT image shows multiple bullet fragments oriented along the wound track (arrow), which traverses the larynx. Laryngeal in-jury was confirmed at surgery.

(Fig 21). If clinical examination indicates a suspected tracheal or laryngeal injury with in-determinate CT findings, endoscopy and bron-choscopy are generally recommended to directly visualize the upper airway (1,13,16,62).

When tracheolaryngeal injury is suspected, the integrity of all of the cartilaginous structures of the larynx should be assessed, particularly the cricoid, as it is the only circumferential support ring in the larynx. The status of the airway and the degree of cartilaginous displacement should be noted (5,69,71–73), particularly in patients who do not yet have a mechanical airway. The goal of treatment is to restore function and pre-vent complications such as airway compromise, dysphonia, tracheal and laryngeal stenosis, and dysphagia (5). Therapy must be tailored to the individual patient, involves medical or surgical in-terventions, and can depend on the results of im-aging studies, such as the degree of cartilaginous displacement and airway compromise (69,74).

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This article meets the criteria for 1.0 AMA PRA Category 1 CreditTM. See www.rsna.org/education/rg_cme.html.

Teaching Points July-August Issue 2010

Imaging Evaluation of Penetrating Neck InjuriesScott D. Steenburg, MD • Clint W. Sliker, MD • Kathirkamanathan Shanmuganathan, MD • Eliot L. Siegel, MD

RadioGraphics 2010; 30:869–886 • Published online 10.1148/rg.304105022 • Content Codes:

Page 871The 1990s saw a re-evaluation of the established approach to managing cases of penetrating neck injuries, with a shift away from mandatory surgical exploration of many zone II injuries toward more selective use of surgical exploration.

Page 873Determining the trajectory of the wound track aids in the evaluation of patients with penetrating neck trauma, because the organs lying along the track can be considered to have a high likelihood of being injured (16,17,38,39).

Page 873However, because wound tracks often are not oriented in standard axial, sagittal, and coronal planes, liberal use of an interactive viewer to manipulate the dataset is essential to appreciate the true orienta-tion of the track.

Page 874Penetrating arterial injuries contribute substantially to negative clinical outcomes in penetrating neck trauma, primarily as a result of neurologic events such as stroke (4,30). Approximately 15%–25% of penetrating injuries to the neck result in an arterial injury (21,24,33).

Page 876Several groups have compared CT angiography with conventional angiography for detection of neck ar-terial injuries in the setting of penetrating neck trauma; all reported sensitivities and specificities for CT angiography in excess of 90% (4,5,13,17–19,37).

education exhibits 869 imaging evaluation of ......diagnosed with these techniques. much of this...

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