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Helical CT of Blunt Diaphragmatic Rupture

¹ Department of Medical Imaging, University Hospital Sart Tilman, B-4000 Liège, Belgium.
² Department of Medical Imaging, Centre Hospitalier Chrétien, Les Cliniques St.-Joseph, Rue de Hesbaye, 75, B-4000 Liège, Belgium.

Received February 19, 2004; accepted after revision June 30, 2004.

 
Address correspondence to A. Nchimi (alain.nchimi{at}chc-liege.be).

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. This study evaluated CT findings for signs of blunt diaphragmatic rupture.

MATERIALS AND METHODS. CT examinations of 179 blunt trauma patients, including 11 with left-sided and five with right-sided blunt diaphragmatic rupture, were reviewed by two staff radiologists who first decided by consensus on the presence or absence of 11 published signs of blunt diaphragmatic rupture and then formulated the diagnosis in terms of absence of, presence of, or suggestion of blunt diaphragmatic rupture. The significance of the findings was assessed by multivariate logistic regression. Four other reviewers interpreted the CT findings independently. They were asked first to formulate a diagnosis in terms of absence of, presence of, or suggestion of blunt diaphragmatic rupture and then to enumerate the findings supporting a diagnosis or suggestion of blunt diaphragmatic rupture. These findings were compared with those of the staff radiologists.

RESULTS. Diaphragmatic discontinuity, diaphragmatic thickening, segmental nonrecognition of the diaphragm, intrathoracic herniation of abdominal viscera, elevation of the diaphragm, and both hemothorax and hemoperitoneum were strong predictors of blunt diaphragmatic rupture (p < 0.001). The combination of the first three findings was 100% sensitive (16/16). The staff radiologists' sensitivity for diagnosing blunt diaphragmatic rupture was 100% (16/16). The four reviewers' sensitivities were 56.2% (9/16), 81.2% (13/16), 62.5% (10/16), and 87.5% (14/16).

CONCLUSION. Six of 11 signs were good predictors of blunt diaphragmatic rupture. Despite diaphragmatic thickening, focal defect and segmental nonrecognition had 100% cumulative sensitivity; the reviewers formulating the diagnosis before analyzing CT signs overlooked blunt diaphragmatic rupture on CT in 12.5–43.8% of the patients.

Introduction

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Blunt diaphragmatic rupture is present in 3–8% of patients undergoing emergency celiotomy after trauma [1]. Blunt diaphragmatic rupture rarely accounts for immediate mortality and may go clinically silent until complications occur. Gastrointestinal strangulation and obstruction complicating unrecognized diaphragmatic herniation may have a mortality rate as high as 60% [2]. Although many imaging techniques have proven useful for the diagnosis of blunt diaphragmatic rupture [3–6], diaphragmatic injuries, especially those on the right side, most frequently have remained undiagnosed on CT during the acute evaluation of trauma patients [7–13]. The suspected reasons for poor CT results include the usually associated and potentially distracting thoracic and abdominal injuries, lack of awareness of blunt diaphragmatic rupture, and discreet abnormalities on axial CT slices. Initial reports found CT to have a sensitivity (0–50%) lower than or equal to that of chest radiography [9, 14–17]. As a result, numerous signs indicating blunt diaphragmatic rupture have been described in the literature during the past 10 years, with variable significance [7, 8, 10–13, 18].

The purpose of this study was to objectively assess the reported CT signs of blunt diaphragmatic rupture and their impact on observer performance in diagnosis.

Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Patients
We searched the hospital registry for cases of surgically or autopsy-proven diaphragmatic rupture from January 1995 to January 2002. Among 53 cases, 19 patients with penetrating injury and 18 patients with incomplete imaging were excluded. Finally, CT, clinical, surgical, or autopsy data of 16 patients (13 men and three women; age range, 21–68 years; mean age, 38 years) with a proven diagnosis of blunt diaphragmatic rupture, after a car crash (15 patients) or a fall from a height (one patient), were available for review. Eleven patients had left-sided and five had right-sided blunt diaphragmatic rupture; none had bilateral or pericardiophrenic injury. Two of the five patients with right-sided blunt diaphragmatic rupture and five of those with left-sided blunt diaphragmatic rupture were intubated with positive pressure ventilation on or before arrival at the hospital. Associated thoracic or intraabdominal injuries were found in 15 patients. Diaphragmatic injury was diagnosed through CT in 11 patients: on the admission CT for eight and on repeated CT (6–19 days later) for three (whose CT findings on admission had erroneously been interpreted as negative for blunt diaphragmatic rupture). In five patients, the diagnosis of blunt diaphragmatic rupture was established only during surgery or autopsy.

An additional 163 consecutive patients (131 males and 32 females; age range, 12–78 years; mean age, 35 years) who had sustained blunt abdominal or thoracic trauma during the same period, with either a surgically or an autopsy-proven normal diaphragm (98 patients) or at least 1 year of follow-up without evidence of diaphragmatic injury on chest radiography or CT (65 patients), served as true-negative cases (91.0% of all cases). Thus, a prevalence of 9% for blunt diaphragmatic rupture was assumed. Intraabdominal or thoracic injuries were found in 103 patients of the control group. Patient consent was not required for this retrospective study.

CT Examinations
On admission, all 179 patients underwent helical CT (PQ 2000, upgraded to PQ 5000, Philips) of the chest, the abdomen, or both according to a standardized protocol. None of the patients received oral or rectal contrast material. For all but four patients, scans of 5- to 10-mm collimation and 5- to 8-mm reconstruction interval were obtained 70–120 sec after the start of IV contrast administration, 2 mL/kg (Ultravist 300 [iopromide], Schering; or Optiray 300 [ioversol] or Xenetix 300 [iobitridol], Guerbet), at a rate of 1.8–3 mL/sec. Images of the entire liver and base of the thorax printed with soft window settings (level, 40 H; width, 450 H) were available for review. For four patients of the control group, CT was performed only without contrast enhancement. Images with large window settings (level, -600 H; width, 1,600 H) covering the region of interest were not printed regularly but were also available for 12 patients of the control group.

CT Review
First, two staff radiologists who had at least 5 years' experience in trauma radiology and no prior exposure to the patients together completed a questionnaire on the presence or absence of 11 CT signs of rupture reported in the literature [7, 8, 10–15, 18]: diaphragmatic discontinuity; segmental nonrecognition of the diaphragm; herniation of abdominal organs into the thoracic cavity; a waistlike appearance of herniated organs at the level of the diaphragm, the so-called collar sign; abnormally elevated abdominal organs; thickening of the diaphragm, the so-called curled diaphragm sign; thoracic fluid abutting the intraabdominal viscera; absence of interposition of lungs between the upper part of the abdominal organs and the chest wall, the so-called dependent viscera sign; hemothorax and hemoperitoneum; IV contrast medium extravasation at the level of the diaphragm; and presumed laceration of the diaphragm by a fractured rib. Extending chest radiographic findings to CT, we considered right-sided abdominal organs abnormally elevated when visible 5 cm or more above the dome of the left hemidiaphragm and left-sided abdominal organs abnormally elevated when visible 4 cm or more above the dome of the right hemidiaphragm [4]. Diaphragmatic thickening was assessed by visual comparison with the contralateral hemidiaphragm at the same level, as described by Leung et al. [11]. To avoid considering the variations in normal size of the crus, the staff radiologists were asked to assess diaphragm thickness at least 10 mm from the midline. After reviewing the signs, the staff radiologists were asked to describe, consistently, each hemidiaphragm as normal, injured, or suggestive.

Then the CT findings were retrospectively interpreted by four reviewers with no prior exposure to the patients who were unaware of the surgical and autopsy findings. The reviewers included a third-year radiology resident (reviewer 1), a thoracic radiologist (reviewer 2), and two abdominal radiologists (reviewers 3 and 4). To assess the importance of reviewer experience in the diagnosis of blunt diaphragmatic rupture, reviewers 2 and 4 had at least 5 years' experience in trauma radiology, whereas reviewers 1 and 3 were less experienced. Reviewers were asked to describe each hemidiaphragm as ruptured, normal, or suggestive and thereafter to list explicitly all signs supporting the positive or suggestive diagnoses.

Statistical Analysis
Using the findings of the staff radiologists, we calculated the sensitivity and specificity for each sign of right and left blunt diaphragmatic rupture for the entire patient population. Logistic regression analysis was used to assess the significance of each sign and the contribution of the number of signs to the diagnosis of blunt diaphragmatic rupture. Sensitivity and specificity for the diagnosis of blunt diaphragmatic rupture were calculated for the staff radiologists and the reviewers, suggestive findings being considered positive for rupture. To compare the mean diagnostic performance of the reviewers for each sign (i.e., the sensitivity and specificity with which they depicted each sign) with that of the staff radiologists, the reviewers' reported findings were formulated in terms that matched those of the questionnaire. The Cochran Q test was used to compare the reviewers' sensitivities for the diagnosis of blunt diaphragmatic rupture. Continuous data are expressed as mean ± SD. A p value less than 0.05 was considered to express a statistically significant difference. The software used for statistical analysis was Systat 9.0 (Systat Software).

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
Table 1 shows that for the two staff radiologists, intrathoracic herniation of abdominal organs was the most sensitive sign for left-sided blunt diaphragmatic rupture (90.9% [10/11]) (Fig. 1) and diaphragmatic thickening, for right-sided blunt diaphragmatic rupture (100% [5/5]) (Figs. 2, 3A, and 3B). All left-sided ruptures had either diaphragmatic discontinuity (5/11) or segmental nonrecognition of the diaphragm (6/11). Combination of both signs with diaphragmatic thickening resulted in 100% cumulative sensitivity (16/16) for rupture on both sides. The collar sign and the dependent viscera sign were 100% specific (163/163) for blunt diaphragmatic rupture. Contrast medium extravasation at the level of the diaphragm (Fig. 4) and presumed laceration by fractured ribs had 0% sensitivity (0/16). In addition to the signs listed on the questionnaire, the staff radiologists described, for one patient, a hypoattenuated hemidiaphragm associated with right-sided blunt diaphragmatic rupture (Figs. 5A, 5B, 5C, and 5D). Sensitivity and specificity for isolated signs ranged from 0% (0/16) to 75% (12/16) and from 91.4% (149/163) to 100% (163/163), respectively. Any positive finding significantly increased the likelihood of blunt diaphragmatic rupture (p < 0.001). Multivariate logistic regression found six signs to be isolated good predictors (p < 0.001) of blunt diaphragmatic rupture: diaphragmatic discontinuity, segmental unrecognized diaphragm, intrathoracic herniation of abdominal content, elevated abdominal organs, thickened diaphragm, and the presence of both hemothorax and hemoperitoneum. The other signs were poor predictors of blunt diaphragmatic rupture (p > 0.05). The staff radiologists diagnosed normal diaphragms in 154 patients, blunt diaphragmatic rupture in 14 patients (all true-positive cases), and a suggestion of hemidiaphragm in 11 patients (including two true-positive cases of right-sided blunt diaphragmatic rupture and nine false-positive cases) (Figs. 4, 6A, and 6B), resulting in 100% sensitivity (16/16) and 94.6% specificity (154/163).

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —32-year-old man who sustained blunt trauma to torso. Abdominal CT scan obtained after IV injection of contrast medium shows herniation of upper part of stomach into chest, in contact with posterior thoracic wall (arrow) and adjacent to pleural effusion (asterisk). Left hemidiaphragm is not visible above abdominal fat (arrowheads).

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —43-year-old man who sustained abdominal blunt trauma. Abdominal CT scan obtained after IV injection of contrast medium shows diffuse thickening of right hemidiaphragm (arrows). This sign was only indication of right-sided diaphragmatic rupture, which was confirmed at surgery.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —Abdominal CT scans obtained after IV injection of contrast medium in 32-year-old man admitted after frontal impact during car crash. Right hemidiaphragm is visualized over liver, thanks to fat interposition (asterisk).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —Abdominal CT scans obtained after IV injection of contrast medium in 32-year-old man admitted after frontal impact during car crash. Image at level inferior to A shows lateral discontinuity of right hemidiaphragm (straight arrow), whereas anterior leaf is retracted and thickened (arrowheads). Associated constriction (curved arrow) of contused and partially herniated liver is present.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —36-year-old man after car crash. Abdominal CT scan obtained after IV injection of contrast medium shows representative pitfall of CT for diagnosis of blunt diaphragmatic rupture. Extensive splenic contusion and massive hemoperitoneum are evident. Left subphrenic hematoma (arrows) simulates diaphragmatic thickening. Linear extravasation of contrast material is seen in contact with diaphragm (arrowheads). This patient was diagnosed as having, or was suspected of having, left-sided blunt diaphragmatic rupture by all reviewers. At surgery, no diaphragmatic rupture was found.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —Abdominal CT scans obtained after IV injection of contrast medium via right common femoral vein in 27-year-old man who sustained abdominal trauma during car crash. Image at level of celiac trunk shows crus of right hemidiaphragm in contact with aorta (white arrowheads), whereas posterior part is not visible (black arrowheads). Focal infarct of right kidney (asterisk) is also seen.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —Abdominal CT scans obtained after IV injection of contrast medium via right common femoral vein in 27-year-old man who sustained abdominal trauma during car crash. Image at level of liver hilum shows hypoattenuated right diaphragmatic crus (arrows), hypoperfusion complex of spleen, hemoperitoneum, and focal infarct of right kidney (asterisk).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C. —Abdominal CT scans obtained after IV injection of contrast medium via right common femoral vein in 27-year-old man who sustained abdominal trauma during car crash. Images at levels superior to B show progressively thickened but normally attenuated right hemidiaphragm (arrows).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D. —Abdominal CT scans obtained after IV injection of contrast medium via right common femoral vein in 27-year-old man who sustained abdominal trauma during car crash. Images at levels superior to B show progressively thickened but normally attenuated right hemidiaphragm (arrows).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —Axial CT scans obtained after IV contrast administration in 55-year-old man who sustained thoracoabdominal trauma during car crash. Image of posteromedial part of left hemidiaphragm shows defect (arrows).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —Axial CT scans obtained after IV contrast administration in 55-year-old man who sustained thoracoabdominal trauma during car crash. Image at level superior to A displays fully continuous left hemidiaphragm. This patient illustrated another pitfall of CT for diagnosis of diaphragmatic rupture. Staff radiologists considered findings suggestive of left-sided blunt diaphragmatic rupture, whereas at surgery no diaphragmatic rupture was found.

Table 2 gives the four reviewers' diagnostic scores for blunt diaphragmatic rupture. The Cochran Q statistic was 4.55 (4 df), indicating no significant differences between reviewers for sensitivity in the diagnosis of blunt diaphragmatic rupture (p = 0.34). Table 3 gives the mean sensitivity and specificity with which the reviewers depicted the signs of blunt diaphragmatic rupture.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Because blunt diaphragmatic rupture occurs in fewer than 10% of polytraumatized patients undergoing emergency laparotomy [1], we have assumed a prevalence of 9% in our study. Because of this relatively low percentage, it is likely that any radiologist working in a trauma center may encounter annually only a few cases. Despite systematic CT screening of thoracoabdominal injuries in hemodynamically stable patients and the description of 11 different CT signs, reported diagnostic sensitivities for blunt diaphragmatic rupture have been 42–90% [7–10, 13]. Notwithstanding the fact that blunt diaphragmatic rupture was diagnosed on CT at admission in only eight (50%) of 16 patients in our institution, we noticed the reviewers to have sensitivities (range, 56.2–87.5%) similar to those reported in the literature. Thus, in a fully prospective evaluation, the diagnosis of blunt diaphragmatic rupture remains challenging and subject to observer performance. However, the staff radiologists' retrospective sign-by-sign review showed that all cases of blunt diaphragmatic rupture were identifiable on the first search for the signs. The main purposes of the current study were to determine how frequently each sign of blunt diaphragmatic rupture is visible on CT and to point out the importance of axial CT signs for the diagnosis of blunt diaphragmatic rupture. We found that searching for any single sign is crucial for the diagnosis, because finding any sign is linked to a significantly high probability (p < 0.001) of blunt diaphragmatic rupture.

Despite the notorious difficulty of diagnosing right-sided blunt diaphragmatic rupture, all cases were identified by the presence of diaphragmatic thickening. Diaphragmatic injury correlates strongly with this sign, because it represents either retraction of the leaves of the ruptured diaphragm or muscular hematoma [11]. However, as an isolated finding, diaphragmatic thickening does not distinguish between injury that requires surgical repair and partial-thickness diaphragmatic rupture. This sign was falsely positive in eight patients in our study and associated with retroperitoneal hematoma that involved the diaphragm (three on the left side and five on the right side). Our observation suggests that in the absence of retroperitoneal contusion, diaphragmatic thickening may be considered highly suggestive of blunt diaphragmatic rupture, although because of the study design, the four reviewers, unlike the staff radiologists, were not asked to assess diaphragmatic thickening at least 10 mm from the midline. The result was a high percentage of interpretation errors by the reviewers, confirming the large variations in the normal crus thickness found by Larici et al. [18]. Segmental nonrecognition of the diaphragm associated with diaphragmatic discontinuity resulted in identification of all cases of left-sided blunt diaphragmatic rupture. In six patients, segmental nonrecognition of the diaphragm was not related to blunt diaphragmatic rupture; the diaphragm was obscured by retroperitoneal hematoma in four (67%) of the six, by hemoperitoneum in one (17%) of the six, and by basal chest injuries in one (17%) of the six. Reviewer performance varied, indicating that not all studied signs had equal diagnostic value.

The collar sign, the "dependent viscera" sign, and thoracic fluid abutting the intraabdominal viscera were highly specific for blunt diaphragmatic rupture in our study. However, they were isolated poor predictors of blunt diaphragmatic rupture and were always associated with other obvious signs—such as intrathoracic herniation of abdominal organs and either diaphragmatic discontinuity or segmental nonrecognition of the diaphragm—that were good predictors of blunt diaphragmatic rupture. The dependent viscera sign has a reported sensitivity of 90% [13] but had a sensitivity of 56.2% for patients with blunt diaphragmatic rupture in our study, all of whom also had intrathoracic herniation of abdominal organs. Intrathoracic herniation of abdominal organs was found in 60% of patients in the study of Bergin et al. [13], versus 75% in our study. This sign is a prerequisite for observing the collar sign, which may be more visible with orthogonal reformatting [19]. Among the other poor predictors of blunt diaphragmatic rupture, diaphragmatic laceration by a fractured rib, described by Larici et al. [18], had 0% sensitivity for the diagnosis of blunt diaphragmatic rupture in our series. Also, unlike Larici et al., we found contrast medium extravasation at the level of the diaphragm to be insensitive (0%). This sign may be responsible for a false-positive diagnosis in the presence of a hemorrhaging liver or spleen injuries with spread of contrast medium to the diaphragmatic concavity. On the other hand, a hypoattenuated hemidiaphragm, found in one patient in association with segmental nonrecognition and thickening of the diaphragm, indicated devascularization of the diaphragmatic muscle. To our knowledge, this sign has not previously been described.

Six of the 11 evaluated signs were strong predictors of blunt diaphragmatic rupture. An association between hemothorax and hemoperitoneum is frequently observed in thoracoabdominal contusions and, like blunt diaphragmatic rupture, may reflect the severity of trauma. Reported sensitivity in the series of Murray et al. [8] was 18%, compared with 50% in our series, with a specificity of 95%. Pitfalls have to be avoided in the interpretation of the other strong predictors of blunt diaphragmatic rupture. As an illustration, the only patient with a false-positive sign of abdominal organ elevation had right-sided diaphragmatic relaxation. The other patients with false-positive signs of diaphragmatic discontinuity and intrathoracic herniation of abdominal organs included those with diaphragmatic defects, which are present in up to 11% of the healthy population and are known to increase with aging [20].

We included in our control group 65 patients who did not undergo surgical exploration; all had 1 year of negative follow-up findings by different imaging techniques. A short follow-up may be considered a relative limitation, because herniation can occur after 1 year in a minority of patients [6]. Absence of gastrointestinal opacification and the use of 5- to 10-mm collimating axial slices that have limited orthogonal reformatting capability were other speculative limitations of our study. Orthogonal reformatting with single-detector scanners has been studied elsewhere, with variable significance [10, 11]. The use of scans with 1- to 3-mm collimation and with the fast orthogonal reformatting allowed by MDCT scanners may improve the diagnosis of blunt diaphragmatic rupture, especially for small defects. However, this possibility will require further assessment, because the recognition of abnormalities in the axial plane first lead performance of orthogonal imaging. Most initial interpretations were performed using the CT display, whereas the current study used printed films. Although the diagnostic sensitivity of the reviewers for blunt diaphragmatic rupture could have been altered by the study design, bias was avoided by giving all reviewers the same material.

In summary, the presence of blunt diaphragmatic rupture should be considered in the presence of any of the reported signs, and a high index of suspicion should be maintained until the diagnosis is ruled out or confirmed. Among the analyzed CT signs in this study, six were good predictors of blunt diaphragmatic rupture. Despite diaphragmatic thickening, focal defect and segmental nonrecognition had a 100% cumulative sensitivity in the current study; reviewers formulating the diagnosis before meticulously analyzing the signs overlooked blunt diaphragmatic rupture at a rate similar to that reported in the literature.

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