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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Extraaxial Hematoma, Brain
KEY FACTS
IMAGING
• NECT as initial screen
○ Subdural hematoma (SDH)
– Crescentic hyperdense extraaxial collection spread
diffusely over convexity
– Supratentorial convexity most common
Remote Complications
– May cross sutures, not dural attachments
○ Acute epidural hematoma
– Biconvex extraaxial collection
– May cross dural attachments, limited by sutures
TOP DIFFERENTIAL DIAGNOSES
• Hygroma
○ Clear CSF, no encapsulating membranes
• Effusion
○ Xanthochromic fluid secondary to extravasation of
plasma from membrane; 1-3 days post trauma; near CSF
density/intensity
• Empyema
(Left) Axial graphic shows an
acute subdural hematoma
(SDH) st compressing the left
hemisphere and lateral
ventricle resulting in midline
shift. Note also the
hemorrhagic contusions
and diffuse axonal injuries .
Additional traumatic lesions
are common in patients with
SDHs. (Right) Axial NECT
shows multiple lowattenuation foci st within this
hyperacute SDH ſt, findings
consistent with active
extravasation. Note the
significant associated midline
shift.
○ Peripheral enhancement, hyperintensity on FLAIR and
PATHOLOGY
• Incidental durotomies occur in 1.7% of spine surgeries
• Dural injury → intracranial hypotension → tearing of
bridging veins → SDH
• Predisposing factors
○ Atrophy
○ Shunting (→ increased traction on superior cortical veins)
○ Coagulopathy (e.g., alcohol abuse) and anticoagulation
DIAGNOSTIC CHECKLIST
• Symptoms of persistent postural headache with nausea
and vomiting after spinal intervention
○ Consider intracranial hypotension and SDH
• Wide window settings for CT increases conspicuity of subtle
SDH
• FLAIR, T2* usually most sensitive sequences for SDH
380
(Left) Postoperative film of
intracranial epidural
hematomas following lumbar
surgery shows L2-S1 fusion
with pedicle screws. Surgery
was complicated by a large
dural tear. Patient had history
of remote scoliosis surgery ſt
with multilevel posterior
fusion. (Right) Postoperative
CT in the same patient shows
large bilateral parietal
epidural hematomas .
Epidural hematomas after
lumbar surgery are very rare
with only a few cases in the
literature.
Retroperitoneal Hemorrhage
KEY FACTS
Remote Complications
TERMINOLOGY
• Often misnomer: Most retroperitoneal hemorrhage is
primarily in posterior abdominal wall musculature
IMAGING
• Major causes and CT findings
○ Coagulopathy or anticoagulation; high-density collection
in retroperitoneum or body wall with cellular-fluid level
(hematocrit sign)
○ Ruptured abdominal aortic aneurysm; large eccentric
aneurysm with blood ± active extravasation contiguous
with aorta
○ Renal tumors
○ Trauma
○ Vasculitis
• CT appearance of blood
○ Active bleeding
○ Linear or flame-like appearance isodense to enhanced
vessels
○ Sentinel clot sign
– Heterogeneous, high attenuation (60-80 HU)
– Accumulates 1st near site of bleeding
– Chronic, lower density (20-40 HU) more
homogeneous lysed blood in adjacent spaces
• MR hyperacute phase (due to oxyhemoglobin)
○ T1WI: Slightly hypointense
○ T2WI: Hyperintense
• MR acute phase (due to deoxyhemoglobin)
○ T2WI: Markedly hypointense
TOP DIFFERENTIAL DIAGNOSES
• Retroperitoneal abscess
• Retroperitoneal sarcoma
• Asymmetrical muscles
CLINICAL ISSUES
• Often pain-free interval immediately after lumbar surgery
with development of groin pain
(Left) Sagittal MR prior to
surgery shows disc
degeneration at L5-S1 ſt.
Psoas and retroperitoneal
hematoma following anterior
interbody fusion at the L5-S1
level can also be seen. (Right)
Sagittal T2WI MR after
surgery in the same patient
shows a large, low-signal mass
ventral to the operative site at
L5-S1 ſt from postoperative
hemorrhage. Note low signal
from the screw fixation .
The low signal within the
posterior elements relates to
an interspinous spacing device
st.
(Left) Axial MR in the same
patient shows the large
retroperitoneal hematoma ſt
extending eccentrically to the
left. (Right) Coronal CTA study
in the same patient shows the
large retroperitoneal
hematoma ſt extending
circumferentially around the
left iliac artery . The
anterior approach to the
lumbar spine shows a
complication rate of 20%; 12%
are major complications.
381
Retroperitoneal Lymphocele
KEY FACTS
TERMINOLOGY
• Definition: Pseudocyst formed when lymph leaks from
disrupted lymphatics
IMAGING
• CT: Low-density pelvic or retroperitoneal fluid collection in
postoperative patient
Remote Complications
○ Along iliac vessels, paraaortic retroperitoneum, inguinal
area
○ Unilocular or multilocular; round or oval
○ Calcification of wall is rare
○ Fat (chyle) within cyst
• MR: Homogeneous low intensity on T1WI, high on T2WI
• US: Anechoic or hypoechoic mass with acoustic
enhancement
• May have dependent debris, septations
TOP DIFFERENTIAL DIAGNOSES
• Other pelvic cystic masses
(Left) Well-defined low-density
fluid collection in the
surgical bed following
retroperitoneal lymph node
dissection in a patient with
testicular malignancy is
shown. Note the surgical clips
st. These usually develop
within 2-4 weeks of surgery.
(Right) This is the typical
appearance of a
retroperitoneal lymphocele
caused by prior surgery. CECT
shows a well-circumscribed,
low-attenuation lesion in the
left pelvis, which appeared
postoperatively ſt.
○ Urinoma: Should fill with contrast on delayed contrast-
enhanced CT or MR
• Bladder diverticulum: Fills with contrast on delayed imaging
• Lymphangioma (mesenteric cyst): Multiloculated
• Pseudomyxoma retroperitonei: Multicystic masses with
thick walls
PATHOLOGY
• Occurs in up to 40% of patients undergoing hysterectomy,
prostatectomy, or renal transplantation
• Rare after anterior lumbar spine surgery ~ 0.3%
CLINICAL ISSUES
• Most lymphoceles remain asymptomatic unless they
become infected
• Percutaneous aspiration: Not definitive
• Long-term catheter drainage: Success in 50-87%
• Sclerotherapy: Success in 79-94%
• Surgical fenestration or marsupialization
382
(Left) CECT shows a large
retroperitoneal lymphocele
. The mass is cystic, well
defined, and has an
imperceptible wall. There is
considerable mass effect on
the descending colon ſt and
left common iliac artery st.
(Right) Axial CECT in a patient
with a lymphocele following
renal transplantation shows a
multiseptate mass ſt
compressing the renal
allograft .
Ophthalmic Complications
KEY FACTS
Remote Complications
TERMINOLOGY
• Devastating vision loss related to operative event
• Postoperative visual loss (POVL)
• Ischemic optic neuropathy (ION)
• Anterior ischemic optic neuropathy (AION)
• Posterior ischemic optic neuropathy (PION)
• Central retinal artery occlusion (CRAO)
TOP DIFFERENTIAL DIAGNOSES
• CRAO
○ Unilateral severe vision loss
• Cortical blindness
○ Procedures where there is high risk of emboli
○ Profound hypotension
• Pituitary apoplexy
CLINICAL ISSUES
• Highest incidence of ION after spine surgery 1:1,000
• AION → injury to optic nerve anterior to lamina cribrosa
○ May have immediate POVL or period of normal vision
with progressive loss
○ Blindness may be delayed from 48 hours to > 1 week
after surgery
• PION → injury posterior to lamina cribrosa
○ PION most common cause of POVL where venous
congestion occurs
○ Prone spine surgery
• Risk factors
○ Prolonged surgery in prone position (> 6 hours)
○ Venous congestion of head
○ Large intraoperative blood loss (> 1 liter)
○ Hypotension
• POVL → urgent ophthalmologic exam to exclude treatable
causes
○ Direct globe injury, acute angle glaucoma, retinal
detachment
○ Funduscopic exam also will diagnose untreatable
vascular causes such as CRAO
Sagittal graphic of the optic nerve shows the affected locations for anterior ischemic optic neuropathy (AION) ſt and posterior ischemic
optic neuropathy (PION) . AION occurs at the nerve head, and the funduscopic examination shows swollen optic disc. PION is probably
associated with intraoperative venous congestion and has a normal funduscopic examination.
383
Esophageal Perforation
KEY FACTS
IMAGING
• Diagnosis depends on high degree of suspicion and
recognition of clinical features
○ Majority are due to esophageal instrumentation/anterior
cervical spine surgery; confirmed by contrast
esophagram or CT
• Cervical esophageal perforation (EP): Subcutaneous or
Remote Complications
interstitial emphysema; neck and mediastinum
• Thoracic EP
○ Chest film: Pneumomediastinum, pleural effusion
• EP of intraabdominal segment of distal esophagus
○ Abdominal plain film: Pneumoperitoneum
• EP near GE junction
○ Extravasated contrast from left lateral aspect of distal
esophagus into mediastinum, pleural space, ± abdomen
• CT shows extraesophageal air in almost all cases, fluid and
contrast medium in most
• Intramural EP: Extravasated gas and contrast remain within
esophageal wall
(Left) Axial CECT of a
hardware-induced fistula from
the cervical esophagus into
the retropharyngeal space
shows air, fluid, and debris
filling the retropharyngeal
space as a result of the
fistula. At surgery, a rent in
the back of the esophagus was
caused by the surgical
hardware. (Right) Axial CECT
shows gas, fluid, and debris
within the retropharyngeal
space as a result of a
fistula connecting the
esophagus to this space.
○ Much better prognosis
• Esophagography: Technique
○ Nonionic water-soluble contrast media initially, followed
with barium if no leak or fistula seen
• Barium (or CT) may detect small leak not visible initially
TOP DIFFERENTIAL DIAGNOSES
• Postoperative state, esophagus
• Esophageal ulceration
• Tracheobronchial aspiration
• Esophageal diverticulum
• Boerhaave syndrome
CLINICAL ISSUES
• Surgical treatment
○ Cervical EP: Cervical mediastinotomy, open drainage
○ Thoracic EP: Immediate thoracotomy, primary closure of
EP, mediastinal drainage
384
(Left) Hardware-induced
fistula from the cervical
esophagus into the
retropharyngeal space is
shown. The fistula connection
can be seen on the lateral
esophagram image ſt with
the retropharyngeal contrast
visible below st. (Right) AP
esophagram of a hardwareinduced fistula from the
cervical esophagus with
secondary fistulae to the neck
and lung abscesses best
delineates the inferolateral
2nd fistula ſt extending into
the lung abscess cavity .
Acute Pancreatitis
KEY FACTS
Remote Complications
TERMINOLOGY
• Acute inflammatory process of pancreas with variable
involvement of other regional tissues or remote organ
systems
IMAGING
• Enlarged pancreas, fluid collections, and obliteration of fat
planes
• ERCP: Communication of pseudocyst with main pancreatic
duct (acutely)
• CT
○ Focal or diffuse pancreatic enlargement
○ Heterogeneous enhancement, nonenhancing necrotic
areas
PATHOLOGY
• Etiology: Alcohol, gallstones, metabolic, infection, trauma,
drugs
• Pathogenesis: Reflux of pancreatic enzymes, bile, duodenal
contents, and increased ductal pressure
• Most important criteria: Presence and extent of necrotizing
pancreatitis (nonenhancing parenchyma)
CLINICAL ISSUES
• Pancreatitis is major cause of morbidity after spine
fusion for scoliosis management
○ Prevalence of > 30%
○ Higher risk patients: GERD with feeding difficulties and
reactive airway disease
• Increased serum amylase and lipase
• Leukocytosis, hypocalcemia (poor prognostic sign)
DIAGNOSTIC CHECKLIST
• Bulky, irregularly enlarged pancreas with obliteration of
peripancreatic fat planes, fluid collections, pseudocyst, or
abscess formation
• Rule out other pathologies that can cause "peripancreatic
infiltration"
(Left) Axial CECT in an 82year-old man with nausea,
vomiting, and abdominal pain
shows acute necrotizing
pancreatitis. Note the
heterogeneous and diminished
enhancement of the pancreas
ſt. (Right) Axial CECT 4 weeks
later in the same patient
reveals organized pancreatic
necrosis ſt or a pseudocyst
within the body of the
pancreas; the foci of gas st
likely represent a
superimposed infection.
Infected pancreatic necrosis is
one of the most deadly
complications of pancreatitis.
(Left) Supine radiograph
shows dilation of the
transverse colon with an
abrupt "cutoff" at the splenic
flexure ſt due to spread of
inflammation in this patient
with pancreatitis. (Right) Axial
enhanced CT shows the classic
appearance for uncomplicated
pancreatitis, demonstrating
mild pancreatic enlargement
and peripancreatic stranding
and edema ſt.
385
Pseudomembranous Colitis (Clostridium difficile)
KEY FACTS
TERMINOLOGY
• Synonyms: Antibiotic colitis, Clostridium difficile colitis
• Acute inflammation of colon caused by toxins produced by
C. difficile bacteria
IMAGING
• Best diagnostic clue: Marked submucosal edema over long
Remote Complications
segment of colon
• Location
○ Usually entire colon (pancolitis)
○ Rectum, sigmoid colon (80-90% of cases)
• Thumbprinting
○ Unusual, wide, transverse bands due to haustral fold
thickening
• CECT
○ Accordion sign: Trapped enteric contrast between
thickened colonic haustral folds
○ Target sign
○ Pericolonic stranding
(Left) Graphic demonstrates
pancolitis with marked mural
thickening and multiple,
elevated, yellow-white
plaques (or
pseudomembranes). (Right)
Axial CECT in a 62-year-old
man who presented with
diarrhea and dehydration
demonstrates a classic case of
pseudomembranous colitis.
Note the severe bowel wall
thickening throughout the
entire colon ſt.
Pseudomembranous colitis
typically presents as a
pancolitis, as in this example.
• Best imaging tool: CECT with oral contrast
• Protocol advice: 150 mL IV contrast at 2.5 mL/sec with 5mm collimation, 5-mm reconstruction interval
CLINICAL ISSUES
• Elderly at higher risk for developing pseudomembranous
colitis and recurrent pseudomembranous colitis
• Clinical profile: Patient with history of watery diarrhea after
antibiotic use or hospitalization
• Treatment in mild cases: Discontinue offending antibiotic
therapy
• Severe cases
○ Metronidazole (drug of choice) or oral vancomycin
○ Fulminant and toxic megacolon: Colectomy
DIAGNOSTIC CHECKLIST
• Check history of antibiotic use or debilitating diseases
• Suspect in any hospitalized patient with acute colitis
386
(Left) Axial CECT in a 47-yearold man who had been taking
antibiotics for 2 weeks for
sinusitis now presents with a
2-day history of right lower
quadrant pain, fever, and
concern for appendicitis. Note
the marked submucosal
edema of the right colon ſt
and the intense mucosal
enhancement st (or accordion
sign). (Right) Endoscopic
photograph of the right colon
in the same patient reveals the
classic hyperemic mucosa and
yellow plaques ſt
characteristic of
pseudomembranous colitis.
Rhabdomyolysis
KEY FACTS
Remote Complications
TERMINOLOGY
• Clinical and biochemical syndrome resulting from damage
of integrity of skeletal muscle with release of toxic muscle
cell components into circulation
IMAGING
• Increased T2 signal within affected skeletal muscle group
• May show patchy contrast enhancement
• Severe disease with myonecrosis shows peripheral
enhancement with no central enhancement
PATHOLOGY
• Major etiologies include trauma (38%), including
prolonged immobilization for surgical procedures,
prolonged seizures, direct muscle injury
○ Ischemia (14%), including compression and vascular
occlusion
○ Drug overdose (7%) and wide variety of drugs (including
statins)
• Risk factors for rhabdomyolysis include surface area of
muscle isolated and strained by retraction and surgical
duration
○ Operative mean time in series of 5 affected patients was
420 minutes for minimally invasive spine surgery
• Risk factors for acute renal failure due to rhabdomyolysis
○ Presence of sepsis
○ Age > 70
○ Volume depletion
○ Degree of elevation of CPK, potassium, phosphorus
CLINICAL ISSUES
• Classic triad of muscle pain, weakness, and dark urine
• Treatment
○ Hydration with isotonic crystalloid
○ Treatment of acute renal failure (mannitol, diuretics)
• Life-threatening complications include acute renal failure,
hyperkalemia, and cardiac arrest
(Left) Axial NECT of
rhabdomyolysis following the
right lateral decubitus position
shows enlargement of the
right paraspinal muscles
without abnormal
attenuation. There is irregular
reticulation of subcutaneous
fat due to edema ſt. (Right)
Axial T2WI MR shows diffuse
hyperintensity of dorsal right
paraspinal muscles ſt with a
sharp ventral margin. The
patient was in a prolonged
right decubitus position for
surgery.
(Left) Axial T1 C+ MR shows
diffuse and irregular muscle
enhancement ſt with a
central nonenhancing
component . (Right)
Coronal T1 C+ MR shows
irregular abnormal
enhancement of the right
dorsal paraspinal muscles ſt
in contrast to normal left
muscle signal intensity.
387
Bowel Perforation
KEY FACTS
TERMINOLOGY
• Injury to bowel (duodenum, small bowel, colon)
IMAGING
• Best diagnostic clue: Bowel wall thickening, mesenteric
infiltration ± extravasation of enteric or vascular contrast
medium
Remote Complications
• Best imaging tool: CECT
• CT findings
○ Sentinel clot sign: Localized > 60 HU mesenteric
hematoma at site of bleeding
○ Bowel wall thickening > 3 mm (75% of transmural
injuries)
○ Hemoperitoneum: Common in intraperitoneal bowel or
mesenteric injury
○ Water-density peritoneal or interloop fluid
TOP DIFFERENTIAL DIAGNOSES
• Shock bowel
(Left) Axial CECT in a 24-yearold man presenting after a
motorcycle collision
demonstrates a
hemoperitoneum in the left
lower quadrant with active
bleeding, as evidenced by the
contrast extravasation ſt,
which is a typical finding in
intestinal trauma. (Right) Axial
CECT shows mesenteric
infiltration and active
bleeding represented by
extravasated contrast ſt;
much of the bleeding is
adjacent to descending colon
.
• Coagulopathy
• Vasculitis
• Ischemic enteritis
PATHOLOGY
• Related to anterior lumbosacral surgery < 0.5%
• Rare cases of perforation from migrated cage or graft
CLINICAL ISSUES
• Abdominal pain, distension, tenderness, and guarding
• Diagnostic peritoneal lavage: Severe injury if positive
DIAGNOSTIC CHECKLIST
• Check for motor vehicle accident history or other
abdominal injury
• Image interpretation
○ CT evidence of extraluminal air/contrast, bowel wall
thickening, free fluids, mesenteric stranding
388
(Left) Axial CECT in a 19-yearold man presenting with
abdominal pain after a
motorcycle crash shows free
air ſt, hyperdense bowel st,
and a high-attenuation
mesentery consistent with a
hematoma . Jejunal
perforation was revealed at
surgery. (Right) Axial CECT
shows high-attenuation active
bleeding into the mesentery of
the right colon ſt, a
characteristic finding in the
setting of intestinal trauma.
Ureteral Trauma
KEY FACTS
Remote Complications
TERMINOLOGY
• Injury of ureter from blunt, penetrating, or iatrogenic
trauma
IMAGING
• Best imaging tools: CECT with CT urography for global view
of abdomen and urinary tract
○ Antegrade or retrograde pyelography for detailed
analysis of site and character of injury
• Sites of urine accumulation
○ Perirenal or subcapsular from blunt renal injury
○ Medial to ureteropelvic junction for proximal ureteral
and ureteropelvic junction leaks
○ May enter peritoneal cavity (after penetrating trauma or
laparotomy/laparoscopy)
• Ureteral strictures less accurately diagnosed by CT
○ Difficult to distinguish foci of ureteral spasm from
peristalsis due to stricture
○ Indirect signs of ureteral stricture: Delayed nephrogram,
hydronephrosis
• Image-guided aspiration of fluid collection may identify
fluid as urine and guide drainage
TOP DIFFERENTIAL DIAGNOSES
• Abdominal abscess
• Postoperative hematoma or seroma
• Postoperative edema
PATHOLOGY
• Iatrogenic trauma accounts for 80-90% of ureteral injuries
○ Open abdominal or gynecologic surgery (> 50%)
• Spine surgeries such as total lumbar disc replacement
and total disc replacement removal, revision lumbar
arthrodesis
○ Reported spine surgery complications include ureteral
injury with nephrectomy
(Left) Axial CECT in a patient
with ureteral perforation from
spine surgery shows 1 of
several metallic screws and
the path of 1 that had been
removed st. Note the waterdensity fluid collection in
the retroperitoneum adjacent
to the spine and psoas muscle.
(Right) Antegrade pyelogram
in the same patient shows
transection of the distal left
ureter ſt as well as 1 of the
metallic screws st. A
nephrostomy catheter was
subsequently placed.
(Left) CT urography in the
same patient shows
extravasation of contrastopacified urine ſt from the
transected ureter. Note that
the more distal ureter is not
opacified. The extravasated
urine collected within the
previously identified lentiform
collection. (Right) Oblique CT
urogram in the same patient
clearly shows the
extravasation of urine ſt from
the distal ureter.
389