Accuracy of dual‐bolus CT in the diagnosis of active arterial bleeding in adult pelvic trauma

Abstract

Introduction A single‐phase dual‐bolus CT (DB‐CT) simultaneously opacifies both arterial and venous systems and can be utilised in the trauma setting to aid in the diagnosis of active bleeding while also allowing for optimal assessment of the abdominal and pelvic viscera. Active bleeding can be venous or arterial, the latter being amenable to angiography and potentially embolisation. We aimed to establish the accuracy of single‐phase DB‐CT vs commonly performed portal venous CT (PV‐CT) in the diagnosis of active bleeding when compared to formal digital subtraction angiography as the gold standard. Methods All patients diagnosed with active bleeding on PV‐CT or DB‐CT at a level 1 tertiary centre over a 6‐year period and who subsequently proceeded to digital subtraction angiography (DSA) were included for analysis. The initial CT images were retrospectively reviewed by two consultant interventional radiologists who were blinded to the subsequent outcome of the DSA and to each other’s results. The sensitivity, specificity and inter‐observer agreement between the two readers was then able to be assessed. Results A total of 60 patients were included in the analysis. Sensitivity for the diagnosis for any active bleeding was high for both DB‐CT and PV‐CT (range 88.9%–100%) while diagnosis of specifically arterial bleeding was comparatively lower (51.9%–79%). Inter‐observer agreement for the identification of arterial bleeding was better for DB‐CT (fair) compared to PV‐CT (poor). Conclusion Both PV‐CT and DB‐CT demonstrate high sensitivity in the diagnosis of any active bleeding though identification of specifically arterial bleeding is lower for both scanning methods. Nevertheless, inter‐observer reliability for the identification of arterial bleeding is higher for DB‐CT. Multi‐phase arterial and venous CT may yield better results and could be a focus for future studies.

A retrospective observational study assessing mortality after pelvic trauma embolisation

“…Both selective and nonselective embolisation have been shown to be effective in pelvic haemorrhage management, and the use of either is generally at operator discretion. However, non-selective treatment is usually faster to administer thus improving time to haemostasis 1,3,4,21 and non-selective embolisation is recommended in the EAST guidelines. 21 The high use of non-selective in our patients may reflect a decision to perform rapid damage-control measures to arrest bleeding such as gelatin sponge embolisation from the internal iliac artery.…”

“…3 Computed Tomography Angiography (CTA) plays an important role in further assessing patients with pelvic haemorrhage as it is cheap, fast, accessible, and easily reproducible. 4 It is also both sensitive and specific for identifying and planning which patients might need endovascular management. 4 A 2014 study from Tanizaki et al 5 assessed mortality after pelvic trauma embolisation, showing an overall post-embolisation mortality rate of 17%.…”

“…4 It is also both sensitive and specific for identifying and planning which patients might need endovascular management. 4 A 2014 study from Tanizaki et al 5 assessed mortality after pelvic trauma embolisation, showing an overall post-embolisation mortality rate of 17%. Their study showed that mortality was significantly higher in those who were unstable (50%) and that embolisation within 60 min of arrival significantly improved mortality compared to embolisation after 60 min.…”

“…Occasionally, branches of the posterior division can be involved or less commonly, bleeding can be the result of injury to branches arising from the external iliac artery such as the inferior epigastric or circumflex iliac arteries 3 . Computed Tomography Angiography (CTA) plays an important role in further assessing patients with pelvic haemorrhage as it is cheap, fast, accessible, and easily reproducible 4 . It is also both sensitive and specific for identifying and planning which patients might need endovascular management 4 …”

“…Computed Tomography Angiography (CTA) plays an important role in further assessing patients with pelvic haemorrhage as it is cheap, fast, accessible, and easily reproducible 4 . It is also both sensitive and specific for identifying and planning which patients might need endovascular management 4 …”