CT Case 085
A 30-year-old female is brought into emergency following a high speed motor vehicle accident (MVA).
She required intubation on scene with her GCS falling rapidly from 13 to 8.
On arrival vital include HR 130, SBP 116/70
A CXR is taken in the resuscitation bay

Urgent CT angiography is requested


Describe and interpret the CT chest
Clinical Pearls
Acute thoracic aortic injuries (ATAI) typically occur due to rapid deceleration, such as from a high speed MVA or a fall from height.
The most common location of injury is at the aortic isthmus in 90% of cases, which is located between the left subclavian artery and the ligamentum arteriosum.
This area is particularly prone to injury due to its tethering and immobility which result in sheer stress at the time of rapid deceleration.
The majority of patients with ATAI will die at the scene, with only around 15% making it to hospital.
CXR features that may suggest an aortic injury include;
- Widened mediastinum > 8cm*
- Obscured aortic knuckle*
- Depressed left main bronchus
- Deviation NG to the right
- Apical cap
- Loss of aortopulmonary window*
- Widened paratracheal stripe*
*seen in this patient
ATAI are classified according to the severity of injury;
- grade 1: intimal tear
- grade 2: intramural haematoma
- grade 3: pseudoaneurysm formation
- grade 4: free rupture
Management of high-grade injuries is with Thoracic Endovascular Aortic Repair (TEVAR). This has the benefit of being minimally invasive, which is important in this patient group who frequently have multiple other associated injuries.
References
- Scaglione M, Pinto A, Pinto F, Romano L, Ragozzino A, Grassi R. Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma. Eur Radiol. 2001;11(12):2444-8.
- Hahn LD, Prabhakar AM, Zucker EJ. Cross-sectional imaging of thoracic traumatic aortic injury. Vasa. 2019 Jan;48(1):6-16
- Cline M, Cooper KJ, Khaja MS, Gandhi R, Bryce YC, Williams DM. Endovascular Management of Acute Traumatic Aortic Injury. Tech Vasc Interv Radiol. 2018 Sep;21(3):131-136.
TOP 100 CT SERIES
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney