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(Circulation. 1996;94:2865-2870.)
© 1996 American Heart Association, Inc.

Articles

Delayed Surgery of Traumatic Aortic Rupture

Role of Magnetic Resonance Imaging

Rossella Fattori, MD; Francesca Celletti, MD; Paola Bertaccini, MD; Roberto Galli, MD; Davide Pacini, MD; Angelo Pierangeli, MD; Giampaolo Gavelli, MD

the Institute of Radiology and Cardiac Surgery, University Hospital, Bologna, Italy.

Correspondence to Rossella Fattori, MD, Istituto di Radiologia, II Cattedra (Radiologia 3^o), Policlinico S Orsola, Via Massarenti 9, 40138 Bologna, Italy.

	Abstract

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Background Traumatic aortic rupture (TAR) is a pathological entity with a high mortality, both spontaneous and perioperative. Delayed surgical repair has been proposed when associated lesions are stabilized. The aim of this study was to validate MRI for detecting both the presence and type of TAR and to monitor posttraumatic aneurysm and associated lesions.

Methods and Results Twenty-four consecutive patients with acute chest trauma and suspected aortic rupture, as suggested by emergency CT or chest radiographs, were subjected to MRI and/or angiography in random order. Such parameters as the presence and type of lesion; presence of periaortic, pericardial, mediastinal, or pleural effusion; and presence of associated lesions were considered in every patient. Follow-up imaging was performed exclusively by MRI every 1 to 2 months. TAR was present in 20 patients. No patient underwent surgery in the acute phase; 14 patients underwent surgery at 6.8±2.7 months; 5 are waiting for surgery; and 1 healed spontaneously. There was no overall mortality. For detection of TAR, the accuracy of MRI was 100%; angiography, 84%; and CT, 69%. In detecting the type of lesion, the diagnostic accuracy of MRI was 92%. During follow-up, a significant increase in the posttraumatic aneurysm was observed in 2 patients, and surgical repair was initiated.

Conclusions In chest trauma patients, MRI provides complete anatomic data to assess the severity of aortic and thoracic lesions. Moreover, along with the concept of delayed surgical repair of TAR, MRI is the ideal modality to monitor and follow TAR before surgical repair.

Key Words: aorta • magnetic resonance imaging • surgery

	Introduction

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Blunt aortic trauma is an infrequent but not rare pathological entity. World Health Organization case reports indicate that thoracic trauma is responsible for 25% of deaths caused by traumatic injury, second only to head trauma.^{1 2} In the past, the diagnosis of traumatic aortic rupture (TAR) has increased greatly because of the rise in car accidents and the wider use of imaging techniques that allow early diagnosis.

In TAR, both traction and torsion forces lead to shearing stress, and the sudden increase in intraluminal pressure caused by an impact³ is acting on the sites of anatomic fixation. The extent of involvement of the aortic wall ranges from subintimal hemorrhage to complete laceration of the aorta. In 80% to 90% of cases, all three layers of the aortic wall are involved in the rupture, causing immediate death from a massive periaortic hemorrhage. Survival is due to the integrity of the adventitia and the surrounding mediastinal structures. The lesion, an intimal/medial tear, may partially involve the aortic surface with possible subsequent formation of a diverticular aneurysm; the intimal tear may also be circumferential, causing a fusiform aneurysm with possible invagination of the aortic lumen.^{4 5 6 7}

This kind of trauma usually is also associated with multiple injuries, potentially constituting a life-threatening emergency.^{8 9} Standard chest radiographs and total body CT are routinely performed on these patients on arrival at the emergency room. Even though CT^{10 11 12 13} and transesophageal echocardiography (TEE)^{14 15} have demonstrated good accuracy in the diagnosis of TAR, angiography is still considered the gold standard in clinical practice. Regardless of its invasive approach and documented low accuracy, angiography is often routinely performed in suspected TAR. MRI has been widely used in the diagnosis of acute aortic pathology, demonstrating the best accuracy among various imaging procedures^{16 17} ; its use in acute trauma of the aorta, however, has been limited to just case reports.^{18 19}

The aim of this study was to identify the diagnostic value of MRI in the detection of TAR. With respect to the different anatomic characteristics of TAR and associated lesions accurately described by MRI, we also investigated the risk of delaying surgical aortic repair.

	Methods

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From January 1992 through December 1995, 24 consecutive patients with acute chest trauma and highly suspected aortic rupture were admitted to the Cardiac Surgery Department of the University Hospital of Bologna (Italy), which is a referral center for a wide area (Table 1). Because of the involvement of many different referring centers, it was not possible to derive the actual number of evaluable patients from which the 24-patient cohort was selected. In all patients, the suspicion of aortic rupture was based on a positive chest radiograph (5 patients)²⁰ or on CT (19 patients) performed at the emergency room or the referring community hospitals. On arrival at the Cardiac Surgery Department, angiography and/or MRI were performed in random order.

View this table: [in this window] [in a new window]   Table 1. Demographics, Diagnostic Procedures, Validation Findings, and Outcome of the 24 TAR Patients

In the acute phase,²¹ MRI (0.5-T MR MAX PLUS, General Electric Medical System) was used in 24 patients (5 hours, 12 days after the trauma), CT was used in 19 patients (3 hours, 3 days after the trauma), and angiography was used in 13 patients (8 hours, 2 days after the trauma). The three major diagnostic delays (3, 3, and 12 days, respectively, after the trauma) were due to emergency interventions for severe orthopedic lesions treated in the referring hospitals. In the subacute phase,²¹ only MRI was used to monitor the fate or evolution of the traumatic lesion. Parameters to confirm the diagnosis of the aortic trauma and to obtain the information requested for surgical planning—such as presence and type (partial or circumferential) of lesion; type of aneurysm (diverticular or fusiform); size of the aneurysmatic dilation; distance from the left subclavian artery (for aortic clamping during surgery); presence of periaortic effusion or hematoma; presence of pericardial, mediastinal, or pleural effusion; and presence of associated lesions—were obtained in each patient. A lesion was defined as partial when it involved only the anterior or posterior wall of the aorta (Fig 1) and as circumferential when it involved the whole surface of the vessel in axial projection and was visible both on anterior and posterior walls in the sagittal plane (Fig 2).

View larger version (301K): [in this window] [in a new window]   Figure 1. Top, Axial spin-echo MRI of partial aortic rupture. An intimal flap is visible on the anterior wall of the descending aorta. Left pleural effusion also is present. Bottom, Sagittal spin-echo MRI of partial aortic rupture. A diverticular aneurysm is visible on the anterior wall of descending aorta but the posterior wall is intact. A wide area of periaortic and pleural effusion also is visible.

View larger version (319K): [in this window] [in a new window]   Figure 2. Top, Axial spin-echo MRI of circumferential aortic rupture. Bottom, Sagittal spin-echo MRI of circumferential aortic rupture. The involvement of both the anterior and posterior walls creates a fusiform aneurysm with an invagination of the anterior and posterior flaps.

Follow-up was performed in 17 patients with MRI. MRI was repeated once every 1 to 2 months, and such parameters as possible invagination of the intimal flap in the circumferential lesion, possible increase of posttraumatic aneurysm, augmentation or decrease of periaortic effusion, and modification of associated lesions were assessed.

	Results

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There were 14 male and 10 female patients, 16 to 67 years of age (mean, 35.1±16.4). The trauma was caused by car accidents in 20 patients and by falls from height in 4 patients. At the time of admission, 6 patients required endotracheal intubation and ventilation. The mean injury severity score⁹ was 31.2±14 (range, 13 to 75), and the systolic blood pressure was 124±12 mm Hg (range, 80 to 160 mm Hg).

Multiple injuries as a result of impact were made up of head injury (4 patients), lung focal contusions (5 patients), liver focal contusions (2 patients), rib fractures (5 patients), fractured limbs (8 patients), and facial fractures (3 patients). During transportation to the MRI Unit, physician support was available for all critically ill patients. No patient died during or after transportation.

MRI examination time ranged from 10 to 40 minutes (range, 19.2±9.7 minutes). Six patients were scanned on ventilation; an anesthetist was present to monitor clinical and hemodynamic parameters and blood saturation. Of the 8 patients with fractured limbs, 6 had metal traction devices that were removed before MRI examination.

The diagnostic accuracy of MRI in the diagnosis of TAR was 100% as validated by intraoperative findings in 14 patients and based on repetitive negative validation with two independent modalities (CT and angiography) with identical results and/or repeated MRI follow-up. Conversely, the diagnostic accuracy was 84% for angiography (10 true positives, 1 true negative, and 2 false negatives) and 69% for CT (8 true positives, 1 true negative, 1 false positive, and 3 false negatives; Table 2).

View this table: [in this window] [in a new window]   Table 2. Identification of TAR According to Imaging Procedure*

All lesions were localized at the isthmic aorta. One patient had evidence of an intimal hemorrhage with no sign of laceration (Fig 3), 5 patients presented circumferential lesions, and 14 patients had partial lesions. Two patients truly negative for aortic trauma showed a periaortic hematoma as a result of ruptured mediastinal veins. In the 14 surgically treated patients, the diagnostic accuracy of MRI in detecting the type of lesion was 92% (1 false negative indicating a circumferential partial lesion); for angiography, it was 38%. CT was not helpful in defining the type of lesion in any case.

View larger version (100K): [in this window] [in a new window]   Figure 3. Axial spin-echo MRI of intimal hemorrhage (high signal intensity) without any sign of aortic wall laceration. The lesion healed spontaneously.

Measurement of the aneurysm diameter varied from 23 to 60 mm with MRI, from 18 to 64 mm with angiography, and from 28 to 70 mm with CT. The distance from the left subclavian artery ranged from 4 to 23.5 mm with MRI and from 2 to 20 mm with angiography. When present, periaortic, pleural mediastinal, and pericardial effusions all were visible on MRI, whereas the diagnostic accuracy of CT was suboptimal in diagnosing periaortic and pericardial effusions. Because of the lack of an intraluminal component, angiography cannot provide this information.

Other lesions seen with MRI were focal lung contusions in 5 patients (Fig 4), diffuse bilateral lung opacity in a respiratory distress syndrome in 1 patient, rib fractures associated with pleural effusions in 5 patients, and liver focal contusions in 2 patients. In the preoperative period, all patients with TAR were treated with ß-blockers, as recommended in patients subjected to delayed surgery.^{22 23}

View larger version (157K): [in this window] [in a new window]   Figure 4. Axial spin-echo MRI of thoracic trauma in a patient with aortic rupture. Right rib fractures, right pleural effusion, and right lung focal contusions are visible.

During follow-up, 2 patients had significant increases in posttraumatic fusiform aneurysm subsequent to a circumferential type of lesion (from 30 to 37 mm in patient 11 after 1 month and from 33 to 45 mm in patient 17 after 2 months). Therefore, surgical repair was initiated. One of the five cases of periaortic hematoma enlarged during follow-up. Focal lung contusions and pleural and pericardial effusions progressively decreased, resulting in good respiratory condition at the time of surgery.

Fourteen patients underwent surgical repair at a median time of 6.8±2.7 months after the trauma (range, 1 to 11 months); 5 are still awaiting surgery. In the patient with intimal hemorrhage, surgery was not performed because of spontaneous healing of the lesion documented by subsequent MRI examinations in 2-month intervals.

All patients survived the period from trauma to surgery without hemodynamic instability. During and after surgery, there were no deaths and only one minimal complication (chylothorax). To date, all conservatively treated patients have survived and remained stable during a follow-up of 6.8±2.7 months.

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
TAR secondary to blunt trauma is an injury associated with an extremely high mortality. The considerable variability of progression is probably explained by the extent of involvement of the aortic wall. Parmely et al⁴ classified the aortic traumatic lesions on the basis of 296 autopsy cases as intimal hemorrhage, intimal hemorrhage with partial laceration, medial laceration with false aneurysm formation (diverticular or fusiform) and/or periaortic hemorrhage, and complete laceration. In their group of isolated TAR (171 patients), 34 patients (19.8%) survived the initial injury. Ten patients survived >15 days, with an average mortality time of 200 days. The authors suggested that survival may depend on the formation of a hematoma surrounded by the mediastinal structure and adjacent tissues. A posttraumatic aneurysm may develop, and the survival rate may be prolonged for months or years. In most patients, the aneurysm grew progressively larger over time; only a few remained unchanged. Many authors^{24 25 26} have reported that the natural history of these aneurysms is dominated by rupture but the timing is unpredictable (ranging from months to several years) as reported by Bennet and Cherry,²⁴ who reviewed 105 patients with posttraumatic chronic aneurysm.

Until now, TAR has always been considered a surgical emergency, and it is common practice to operate as soon as possible despite a high mortality rate in both the perioperative and postoperative periods.^{25 26 27 28 29} In the acute phase, the timing of thoracotomy may constitute a major problem. When other organs are injured and operated on first, aortic hematoma may progress to rupture; conversely, when the aorta receives attention first, the patient may bleed to death from intra-abdominal lesions or intracranial hemorrhage^{8 25 29 30} aggravated by heparin used for cardiopulmonary bypass. Lung contusions may create severe respiratory instability during thoracotomy, and complicated bone fractures may cause septicemia in the postoperative period. Moreover, hypotension and unstable hemodynamic conditions are the most important causes of paraplegia, which varies from 10% to 25%, according to surgical records, with emergency aorta surgery.^{8 27 29 30 31 32 33}

Surgical mortality ranges between 13% and 42%, but hemodynamic instability and associated lesions are responsible for death in 2% to 18% of patients.^{25 26 27 28 29 30 31 32 33}

Some authors suggested a different strategy for the treatment of TAR. Kipfer et al,²³ Akins et al,²⁵ and Warembourg et al³³ have reported cases of delayed surgery; the operations were performed once the severe associated lesions stabilized to avoid perioperative and postoperative complications. Furthermore, Kipfer et al²³ recommended the use of ß-blockers during the period between the trauma and surgical repair. They reported 10 patients operated on at 49 weeks from the trauma with no overall mortality.

Aortic trauma needs to be diagnosed rapidly, and the anatomic characteristics of the injuries, along with associated lesions, must be described precisely for optimal timing of surgical repair.

The diagnostic workup starts with a chest radiograph.^{20 34} Mirvis et al,²⁰ studying 205 patients with TAR, found that chest radiographs had a low specificity but high positive predictive value of 96% in patients in the supine position and 98% in patients in the standing position. The role of angiography has been established over the years and is still considered the gold standard in the detection of aortic rupture.^{21 25 26 35 36} Angiography can identify the site of rupture by visualizing intimal irregularity, the presence of an intimal flap, or the appearance of extraluminal contrast material (very rare). It is also possible to evaluate the size of posttraumatic aneurysm. However, such normal anatomic variants as a prominent ductus diverticulum, aortic aneurysm, syphilitic aortitis, aortic dissection, streaming, or mixing defects can mimic aortic tears, constituting 14% of false-positive findings. A false-negative diagnosis of rupture with angiography can result from poor opacification by contrast agents, inadequate projections, thrombosis of the pouch, or a tear that is too small to be visualized.^{37 38 39 40 41 42} Under these circumstances, even angiography in multiple projections may miss the diagnosis. In our study, 2 of 13 patients had false-negative readings by angiography. By design, angiography cannot visualize subtle vascular lesions, intimal hemorrhage, or extraluminal information such as periaortic, pericardial, and mediastinal effusions. Moreover, in polytraumatized patients, this invasive technique has a 10% risk of complication resulting from the use of catheters and contrast media, causing systemic vasodilation³⁰ ; in addition, angiography is costly and relatively time consuming. Furthermore, considering the concept of delaying surgical repair, angiography is not the ideal technique for follow-up evaluation.

Numerous reports have suggested the use of noninvasive diagnostic techniques like TEE and CT in aortic injuries^{10 11 12 13 14 15} . In daily clinical practice, however, such modalities are underused; angiography is still prevalent.

TEE provides accurate information and can be performed at the patient's bedside. Nevertheless, TEE has a limited field of view and may not visualize all portions of the aorta with the same accuracy. Moreover, it is a semiinvasive technique that cannot be used in patients with facial and mandibular fractures.¹⁴ In our population, it was performed only in selected patients and not systematically, as with other methods.

CT is widely available and provides essential information about the general condition of trauma patients. In most cases, TAR is suspected after CT; however, the diagnostic accuracy of CT is low. Madayag et al¹¹ reported 19% of false-positive findings in suspected TAR with no false negatives, whereas a study by Miller et al¹⁰ reported 4.8% false-negative findings. False positives have been reported as a result of artifact and the presence of effusions in the upper pericardial recess that can mimic a double lumen. False negatives have been reported as a result of poor anatomic detail.^{10 11} In our population, CT gave two false negatives and three false positives in a series of 19 patients. This low accuracy may be related to the critical conditions of the patients, which resulted in suboptimal quality of images, and little experience with TAR at the community hospitals at which most examinations were performed. Nevertheless, failure to provide imaging in longitudinal planes may be the reason that a lesion was missed because lesions mostly extend longitudinally. The capacity of CT, however, to analyze the anatomic detail such as the type of laceration or its relationship with the brachiocephalic vessels is limited. Ultrafast CT and spiral CT might solve these problems and improve diagnostic accuracy,^{12 13} with the advantage of requiring a shorter examination time.

In the past, MRI demonstrated the best accuracy among noninvasive techniques in diagnosing aortic lesions, especially for aortic dissection,^{16 17} in both the chronic and acute phase. Furthermore, the development of fast MRI techniques enabled the examination to be shortened to a few minutes, which is an important advantage in critically ill patients. Nevertheless, in the diagnosis of TAR, the routine use of MRI has not yet been reported.^{18 19}

The aim of this study was first to evaluate MRI in the diagnosis of TAR and second to provide data such as the type and severity of aortic lesions that are important for surgeons deciding on both the risk and timing of surgery.

All lesions were clearly detected by MRI but with the limitation of a selection of patients with a high suspicion of aortic trauma.

The diagnostic accuracy of MRI (for the 14 surgically treated patients) in detecting the type of lesion was 92%. The presence of a circumferential lesion is very important for the evolution of this pathological entity because of the potential development of a fusiform posttraumatic aneurysm, which has a higher risk of sudden expansion than the diverticular aneurysm (as documented in 2 of 4 patients), and because of the potential invagination of the intimal circumferential flap into the aortic lumen. This type of lesion needs strict monitoring during follow-up.

In all cases, MRI detected the lesion and gave very accurate measurements of both the aneurysm dimensions and the distance from the left subclavian artery. MRI detected mediastinal or pleural effusion and the presence and quantity of periaortic effusion, which can result in a more difficult surgical exposure of the aortic wall. Moreover, MRI provided information on the traumatic impact to the entire chest because of its wide field of view.

In our population, the mean follow-up time was 6.8±2.7 months because surgical treatment was performed after the resolution of associated lesions to ensure a stable condition.

Before surgery, MRI was performed once every 1 to 2 months. The most important parameters to monitor were the dimension of the posttraumatic aneurysm and the eventual increase of periaortic effusion as an indirect sign of instability. In 14 patients, only minimal (1 to 2 mm) or no increases in aneurysm dimension were observed. Increments of 7 and 12 mm, as observed in 2 patients with circumferential lesions, were considered a sign of instability and thus an indication for early surgical repair.

So far, all patients have survived during follow-up. Surgery was performed at a median time of 6.8±2.7 months after the trauma; there was no operative mortality, and the postoperative course was uneventful.

In conclusion, MRI represents the optimal diagnostic technique in the detection of aortic rupture. MRI can replace angiography in the setting of suspected TAR. It is simple and noninvasive, allows a comprehensive diagnosis in <30 minutes, and provides the complete and accurate anatomic detail necessary to assess lesion severity. Furthermore, MRI provides an excellent overview of the mediastinum and the periaortic region and detects pleural, pericardial, or periaortic effusion. Combined with the concept of delayed surgical repair, MRI is the ideal modality both acutely and during follow-up because of its accuracy, repeatability, and safety.

	Acknowledgments

 
We wish to express our thanks to Christoph A. Nienaber, MD, FACC, FESC, University Hospital Eppendorf, Hamburg, for his helpful review of the manuscript and for thoughtful discussions. We also gratefully acknowledge the support and assistance of the technicians in the MRI unit. Particular thanks go to Carla Acrobini for her cooperation.

Received March 7, 1996; revision received May 31, 1996; accepted June 13, 1996.

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				R. Galli, D. Pacini, R. Di Bartolomeo, R. Fattori, B. Turinetto, G. Grillone, and A. Pierangeli Surgical Indications and Timing of Repair of Traumatic Ruptures of the Thoracic Aorta Ann. Thorac. Surg., February 1, 1998; 65(2): 461 - 464. [Abstract] [Full Text] [PDF]

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