Penetrating Neck Injuries

Penetrating neck injuries are usually evaluated in zones. 

• Zone I: 
• extends from the sternal notch to the cricoid cartilage
• contents - branches of the inominate artery and brachiocephalic veins, branches of subclavian arteries and veins, common carotid and vertebral arteries, trachea, esophagus, thyroid
• Zone II:
• extends from the cricoid cartilage to the angle of the mandible
• contents - common, internal, and external carotid arteries, larynx, upper esophagus, pharynx
• most commonly surgically explored
• Zone III: 
• extends from the angle of the mandible to the base of the skull
• contents - internal cartoid, vertebral, and branches of the external carotid arteries, internal jugular vein, pharynx

Due to the various vascular structures in each of the zones, CTA is often used to evaluate neck trauma. 

The above images are from a patient with bilateral penetrating neck injuries (note the subcutaneous and intramuscular emphysema). The second image shows the bifurcation of the left common carotid artery (arrowhead). In more cephlad images, the left internal carotid artery is not opacified (arrowhead, third image). Surgical exploration demonstrated a Zone II injury to the left common carotid artery as well as to the left internal jugular vein.

REFERENCES

Nunez DB, Torres-Leon M, Munera F. Vascular injuries of the neck and thoracic inlet: helical CT-angiographic correlation. Radiographics 2004;24:1087-98.

Steenburg SD, Sliker CW, Shanmuganathan K, et al. Imaging evaluation of penetrating neck injuries. Radiographics 2010;30:869-86.

Lady Windermere Syndrome

An 88 year old Caucasian woman presents to the ER with hemoptysis. CT scan reveals bronchiectasis in the medial segment of the right middle lobe with scattered peripheral nodules. Findings are typical for  Mycobacterium avium intracellulare complex (MAIC). This is an atypical mycobacterial infection seen in elderly females. It is thought that the imaging findings may be due to chronic suppression of a cough leading to retained secretions in the dependent portions of the ventral lung fields.


REFERENCES
Rossi SE, Franquet T, Volpacchio M, et al. Tree-in-bud pattern at thin-section CT of the lungs: radiologic-pathologic overview. Radiographics 2005;25:789-801.

Gastrointestinal Manifestations of Behcet Disease

Behcet disease (BD) is an idiopathic vasculitis affecting multiple organs. Involvement of the GI tract is seen in up to 50% of cases. Specific GI tract manifestations include:

• ulceration: most common finding
• localized - usually in the ileocecal region
• diffuse - usually in the colon
• ulcers are deep, often penetrating to the serosal layer 
• recur at surgical anastamotic sites
• thickened mucosal folds in the small bowel
• increased incidence of fistulas and perforations
• microperforations are common due to deep, penetrating nature of ulcers

REFERENCES

Chae EJ, Do KH, Seo JB, et al. Radiologic and clinical findings of Behcet disease: comprehensive review of multisystemic involvement. Radiographics 2008;28:e31.

Chung SY, Ha HK, Kim JH, et al. Findings of Behcet syndrome involving the gastrointestinal tract. Radiographics 2001;21:911-24.

Lower Extremity Arterial Trauma

A middle aged male presented with a femur fracture sustained after a tree fell on his leg. After closed reduction of the fracture, peripheral pulses were absent. Diagnostic conventional angiogram demonstrated a dissection of the distal superficial femoral artery at the level of the fracture with no distal reconstitution of the popliteal artery.

Imaging recommendations:

• perform CT angiography in patients who are stable and have suspected (but not confirmed) arterial injury
• faster than conventional angiography
• limitations include poor timing of contrast bolus, streak and motion artifact
• conventional angiography in patients with strong indication of arterial injury
• prolongs ischemic time 
• radiologic intervention is possible and preferred over surgical exploration.

REFERENCES
Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics 2005;25:S133-42.
Rieger M, Mallouhi A, Tauscher T, et al. Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography. AJR Am J Roentgenol 2006;186(3):656-64.

Menetrier Disease

• rare, idiopathic hypertrophic gastropathy
• patients usually present with epigastric pain and hypoalbuminemia (from loss of albumin into the gastric lumen)
• bimodal age distribution
• childhood form thought to be linked to cytomegalovirus infection
• diagnosis is made by combination of endoscopic and radiologic findings
• Upper GI series: thickened, lobulated folds in the gastric fundus which trap barium; hypersecretion may dilute barium which may prevent mucosal coating
• CECT: thickening of mucosa and submucosa which projects into the gastric lumen
• differential diagnosis
• Zollinger Ellison Syndrome - rugal fold thickening is not as pronounced, gastric ulcers, pancreatic involvement
• Gastritis - thickened folds usually in the antrum, H. pylori positive
• Lymphoma - thickened folds due to soft tissue masses not due to edema

REFERENCES
Friedman J, Platnick J, Farruggia S, et al. Menetrier Disease. Radiographics 2009;29:297-301.

Kanne JP, 

Gonadal Vein Thrombosis

Gonadal vein thrombosis can be a cause of acute pelvic pain. It is most commonly seen in post partum females but may also present in patients after pelvic surgery, pelvic trauma, and pelvic inflammatory disease. There is a predilection for this finding on the right side as retrograde flow through the left gonadal vein prevents stasis. 

On CECT, an enlarged gonadal vein that parallels the course of the psoas muscles with an enhancing wall and an intraluminal filling defect will be seen. Perivenous inflammatory changes may be seen. The patient above is post cesarean section. A filling defect is seen in the right gonadal vein (adjacent to the IVC) consistent with thombosis.


REFERENCES
Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics 2002;22:785-801.

AV Fistula Planning

In patients with end stage renal disease (ESRD), the ideal venous access for hemodialysis should fulfill three requirements: 1. indefinite life, 2. high flow, 3. no complications such as thrombosis or aneurysm formation. The native arteriovenous (AV) fistula comes closest to fulfilling these requirements and is the best option for venous access. 

In planning for creation of an AV fistula several factors have to be taken into considerations including the patient's vascular history. Patients who have had prior central venous catheters, pacemakers may be poor candidates for AV fistula creation because these procedures are associated with venous stenosis.


REFERENCES
Patel AA, Tuite CM, and Trerotola SO. K/DOQI guidelines: what should an interventionalist know? Semin Intervent Radiol 2004;21(2):119-24.