Case #11 Discussion:

Background:

A 27 y/o woman was found lying outside. She was covered with bruises, abrasions, and lacerations that were concentrated on her face, upper arms, and pelvis, and was bleeding from her vagina and rectum. The prior evening she had been assaulted by her boyfriend of three years. After being severely beaten, raped, dragged on the road, and threatened with drowning, she spent the night outside in cold rain. She was treated for hypothermia and received a preliminary imaging work-up at the local hospital.

What imaging studies are important in the initial assessment of this patient?

She has likely acquired multiple injuries secondary to her severe beating and exposure. Top priority is to assess for the presence of life-threatening injuries, such as spinal injury, head trauma, and damage to internal organs, and internal hemorrhage. Life-threatening injuries to the chest and abdomen take priority over facial injuries as long as a patent airway is obtained and bleeding is controlled. However, all patients with facial and neck trauma require cervical spine immobilization until injury to the cervical spine is ruled out.

(1) Chest: Severe trauma to the chest can result in broken Aab, lung contusions, hemo- and/or pneumothorax, ruptured diaphragm and damage to mediastinal structures, as well as thoracic spinal injury. PA and lateral chest X-rays are appropriate to screen for these types of injuries and to assess the need for further work-up. In particular, one should look for signs of tension pneumothorax (air in pleural space with opposite shift of mediastinal structures) and dissecting aorta (widened mediastinum and/or cardiac silhouette, and apical capping) which require immediate treatment. If she were unable to be positioned for PA and lateral films, much of this information could be obtained from an AP view. If abnormalities are found by radiograph, a CT should be done for improved visualization of bony and soft-tissue damage.

(2) Pelvis and abdomen: Blunt trauma results in organ damage such as lacerations, contusions, and shattering of organs that may be viewed by CT. Particularly vulnerable to damage are her liver, spleen, and small bowel, due to shearing forces. Diaphragmatic rupture, bladder rupture in the intraperitoneal or extraperitoneal spaces can be visualized by CT scan with oral and intravenous contrast. Plain films of the abdomen and pelvis may be obtained to assess skeletal integrity; however, a CT of abdomen and pelvis can provide more information about internal damage than X-rays with less manipulation of the patient.

(3) Head and neck: Any possibility of cervical spine injury demands a cervical spine series to assess the integrity of the spine, so as to prevent any additional damage secondary to moving the patient. The lateral view is most useful for viewing significant injuries, including vertebral body fractures, dislocations, and soft tissue injuries. A complete series would also include anteroposterior, open- mouth, flexion and extension radiographs, and possibly a swimmer's view to fully assess vertebrae C1 through T1.

Although trauma to the face is more likely to produce soft tissue damage, in a typical inner-city emergency department, 80% of maxillofacial trauma is caused by assault. A nasal bone or zygomatic fracture may occur with a relatively low-energy impact, while a midline maxillary or frontal bone fracture requires many times more force. Evaluation and treatment of facial fractures in the multiple-trauma patient are usually deferred until more life-threatening injuries have been addressed. Plain films can used to assess most facial injuries: (1) Shallow Water 's view-- AP view with head tilted back provides a good view of the orbital rims, zygomatic bone, and maxillary sinuses; (2) Cross-table lateral view- when taken with the PA view will demonstrate the integrity of the mandible, sinuses, and nasal bones; and (3) Submental vertex view-- an axillary view of the skull that will reveal zygomatic, maxillary, and mandibular integrity.

If CT is available, one should consider its use as a primary imaging modality for detecting craniofacial injuries, as the absence of skull fractures on plain X-ray does not exclude significant intracranial injury. Lack of a rapidly available CT scanner in the face of significant head trauma is a criterion for transfer of the patient to a trauma center. A non-contrast CT scan of the head can be used to rule out intracranial trauma, including skull fractures, subarachnoid hemorrhage, and lesions that require immediate surgical attention, such as intraparenchymal hemorrhage and extracerebral hematomas. Three window settings should be used: A narrow window width is used to evaluate the brain, a slightly wider window width will accentuate contrast between extraaxial fluid collections and the adjacent skull, and the skull is imaged with a very wide window.

Imaging work-up of this patient:

This patient had a cervical spine series and PA lateral chest X-rays that revealed no bony abnormalities or internal damage. Her head CT was also negative. CT scan of the abdomen and pelvis were performed at her local hospital, at which point she was transferred for further work-up and treatment. She underwent CT of her abdomen and pelvis, as well as laboratory diagnosis that revealed AST = 1185 and Amylase = 404.

Outcome: (See follow-up images for this patient Follow-up Findings)

Although this patient recovered from her injuries without surgical intervention, she began to experience RUQ pain and tenderness that increased over the next few months. A hepatic artery to portal vein fistula was visualized by arteriography with the catheter tip in the right hepatic artery just distal to the aorta (#3). Coil embolization was performed to close the fistula with a satisfactory result seen on post-embolization right hepatic arteriogram (#4). (Compare pre- and post-embolization angiograms-- note the high attenuation coil at the site of the fistula on the latter films.)

Although the intervention was initially successful, her fistula recurred shortly thereafter as demonstrated by CT (#5). A series of post-contrast liver windows demonstrates filling of the AV fistula. Note the high attenuation coil at the site of the AV fistula. Reembolization was attempted; however, collaterals had formed from the right and left hepatic artery, as well as from the gastroduodenal artery, therefore the procedure was only partially successful in reducing the hepatic artery to portal vein shunt. Her assailant is in jail for the time-being, but this patient faces a lifetime of medical complications secondary to her abuse.

Discussion:

This case demands appreciation of the medical cost of domestic abuse and the variety of injuries that can result from blunt assault. The liver, surpassed only by small-bower and spleen, is the third most commonly injured intraabdominal organ. Blunt injuries are even more damaging to the liver than penetrating injuries owing to associated shearing forces. The seriousness of hepatic trauma is reflected in a death rate of 15% and a major complication rate of 50% in affected individuals. With large parenchymal injuries, the likelihood of serious sequelae is increased, including sepsis, rupture with recurrent hemorrhage, biliary fistula and stricture, and vascular lesions such as aneurysm, arteriovenous fistula (AVF), and hemobilia.

Although less common than pseudoaneurysm formation, hepatic AVF formation following trauma can result in portal hypertension with bleeding varices, splenomegaly, and occasionally ascites. Hepatic AVFs are also associated with RUQ abdominal pain, diarrhea, and gastrointestinal bleeding from congestive vascular enteritis. Hepatic AVFs that are located peripherally and are small may spontaneously resolve; however, this is less likely with larger and more central lesions. Percutaneous angiographic embolization is now the treatment of choice for early or late complications of vascular hepatic injuries.

Failure of embolization has been reported secondary to rapid development of collaterals and from portal vein thrombosis that can occur years after the procedure. In the case of this patient, surgical embolization with or without resection may be possible; however, the injury may be too large, in which case she may require a liver transplant down the road. Indeed, transplant of liver with or without small intestine has been necessary in other victims of domestic abuse, at great cost to the individual and to society.