Fig. 13.1
18-year-old male with history of penetrating cardiac injury from shrapnel. Frontal (a) and lateral (b) radiographs demonstrate a metallic foreign body (arrows) overlying the anterior heart. A single slice from an axial CT scan of the chest (c) confirms shrapnel (arrow) in the interventricular septum near the apex of the heart. The patient was asymptomatic and no surgery was performed to remove the shrapnel at the time of injury
13.2.2 ECG Findings
13.2.3 CT Findings
In patients with blunt cardiac injury , CT findings can show many types of injury:
Hemopericardium
Increase in pericardial thickness, >4 mm
Pericardial fluid that attenuates greater than water
Pneumopericardium
Gas in the pericardial space
Often associated with pericardial fluid or blood
Pericardial tamponade: pericardial effusion or pneumopericardium that results in:
Flattening or inversion of the right atrial or ventricular walls
Inverted interventricular septum
Dilated superior vena cava and inferior vena cava
Reflux of contrast into the inferior vena cava and azygos vein
Cardiac contusion
Hypodense, nonenhancing focal area of the myocardium
Traumatic pericardial rupture from BCI (rare)
“Collar sign,” caused by constriction of the cardiac contour by the pericardial opening
Intrapericardial bowel herniation (rare)
Traumatic septal wall defect or tear
Blunt force can be great enough to cause a ventricular septal wall defect (VSD) or rupture (Fig. 13.2)
Fig. 13.2
Patient with blunt chest injury (BCI) . (a) Radiograph from this 17-year-old patient demonstrates bilateral pulmonary edema, raising suspicion of a cardiac injury. (b) Short-axis MR image from a FIESTA cine sequence demonstrates a defect in the interventricular septum (1) with turbulent flow from left to right (2). (c) A three-dimensional (3D) color-coded reconstruction from a chest CTA shows the intramuscular ventricular septal defect (VSD, arrow) from blunt chest trauma
Traumatic valve injury
Blunt force may be great enough to cause valvular injury or avulsion (Fig. 13.3) of the papillary muscle attachment to the valve
Fig. 13.3
In the same BCI patient as Fig. 13.2, four-chamber MR FIESTA images (a, b) demonstrate turbulent flow from the traumatic VSD (1) as well as papillary muscle avulsion injury to the tricuspid valve, with regurgitation through the septal leaflet (2) of the tricuspid valve
Penetrating cardiac injuries have a very high mortality rate, and patients are often too clinically unstable to undergo CT examination. When the patient is stable, CT is useful for demonstrating hemopericardium. It also can show retained fragments within the heart, as in Fig. 13.1.
13.2.4 MRI Findings
MRI has limited utility in the acute setting of cardiac trauma, but it can be useful in follow-up imaging to further evaluate the extent of initial injury. For example, the MR images in Figs. 13.2 and 13.3 illustrate with greater detail the extent of septal wall and valvular injury.
Delayed enhancement cardiac MR is particularly useful in evaluating patients with BCI that leads to myocardial infarction (Fig. 13.4).
Fig. 13.4
BCI in a 14-year-old girl who was kicked by a horse. An axial CT scan (a) and 3D color-coded image from a cardiac CT (b) demonstrate marked lateral and septal left ventricular wall thinning with aneurysm formation (arrows) from a myocardial injury following blunt trauma to the chest
13.2.5 Ultrasonographic Findings
Echocardiography can demonstrate findings that are suggestive of cardiac contusion, such as increased myocardial echogenicity and focal hypokinesis [1]. Ultrasound is also useful in detecting other injuries associated with cardiac trauma, such as traumatic VSD, hemopericardium, and valvular injuries (Fig. 13.5) [1].
Fig. 13.5
Frontal radiograph from a 3-year-old boy with a pneumopericardium seen along the right heart border (blue arrow) and a left-sided pneumothorax (white arrow). This patient had penetrating trauma to the left chest
13.2.6 Cardiac Catheterization
Catheter-based coronary angiography is the gold standard in assessing the coronary arteries. It is indicated in the setting of suspected coronary injury or in patients who have ECG findings suspicious for myocardial infarction (Fig. 13.6) [5].
Fig. 13.6
Chest CT scan of a 12-year-old boy with blunt trauma to the right chest demonstrates a large right lower lung contusion and a small hemopericardium accumulating along the right heart border (arrow)
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