STUART E MIRVIS MD FACR

DEPARTMENT OF RADIOLOGY

UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE

Retroperitoneal Injury in Blunt Trauma ndash

Focus on Renal Injury

Goals

Indications for CT in renal trauma

CT- grading system versus management

Appearances of injuries on CT

Injury of the abnormal kidney

Adrenal injury and other hellip

Retroperitoneal injuries

Introduction

Renal injury in 3 trauma all admissions and 10

with abdominal trauma

Blunt gtgt Penetrating injury

Most blunt trauma is minor (gt90) ndash observed

Miller KS McAninch JW Radiographic assessment of renal trauma our

15-year experience J Urol 1995154352-5

Indications for renal CT

Penetrating flankback trauma

Shock with any hematuria

Gross hematuria - stable (84 have renal injury)

Microscopic hematuria with evidence of impact over

kidneys (lower posterior rib transverse process

fracture contusion)

Known renal injury with dropping hematocrit or

increased flank pain

Microscopic hematuria alone is not an indication

(serious injury lt02)

Complications of renal trauma

ContusionHematomaHematomaLacerationLacerationLacerationVascular LacerationVascular Microscopic or gross hematuria urologic studies normalSubcapsular nonexpanding without parenchymal lacerationNonexpanding perirenal hematoma confirmed to renalretroperitoneumlt10 cm parenchymal depth of renal cortex without urinaryextravagationlt10 cm parenchymal depth of renal cortex without collectingsystem rupture or urinary extravagationParenchymal laceration exteding through renal cortexmedulla and collecting systemMain renal artery or vein injury with contained hemorrhageCompletely shattered kidneyAvulsion of renal hilum which devascularizes kidney86601866118660186611866028661286602866128660386613222234455Advance one grade for bilateral injuries up to grade IIIFrom Moore et al [7] with permission

Grade I contusion or non-enlarging subcapsular hematoma but no

laceration

Grade II superficial laceration lt 1cm depth and does not involve

the collecting system non expanding perirenal hematoma

Grade III laceration gt 1cm without extension into the renal pelvis

or collecting system and with no evidence of urine extravasation

Grade IV laceration extends to renal pelvis or urinary

extravasation

Grade V shattered kidney devascularization of kidney due to hilar

injury

Moore EE Shackford SR Pachter HL et al Organ injury scaling

spleen liver and kidney J Trauma 1989291664-6

Renal Trauma Grading System - 1989

Goals

Indications for CT in renal trauma

CT- grading system versus management

Appearances of injuries on CT

Injury of the abnormal kidney

Adrenal injury and other hellip

Retroperitoneal injuries

Introduction

Renal injury in 3 trauma all admissions and 10

with abdominal trauma

Blunt gtgt Penetrating injury

Most blunt trauma is minor (gt90) ndash observed

Miller KS McAninch JW Radiographic assessment of renal trauma our

15-year experience J Urol 1995154352-5

Indications for renal CT

Penetrating flankback trauma

Shock with any hematuria

Gross hematuria - stable (84 have renal injury)

Microscopic hematuria with evidence of impact over

kidneys (lower posterior rib transverse process

fracture contusion)

Known renal injury with dropping hematocrit or

increased flank pain

Microscopic hematuria alone is not an indication

(serious injury lt02)

Complications of renal trauma

ContusionHematomaHematomaLacerationLacerationLacerationVascular LacerationVascular Microscopic or gross hematuria urologic studies normalSubcapsular nonexpanding without parenchymal lacerationNonexpanding perirenal hematoma confirmed to renalretroperitoneumlt10 cm parenchymal depth of renal cortex without urinaryextravagationlt10 cm parenchymal depth of renal cortex without collectingsystem rupture or urinary extravagationParenchymal laceration exteding through renal cortexmedulla and collecting systemMain renal artery or vein injury with contained hemorrhageCompletely shattered kidneyAvulsion of renal hilum which devascularizes kidney86601866118660186611866028661286602866128660386613222234455Advance one grade for bilateral injuries up to grade IIIFrom Moore et al [7] with permission

Grade I contusion or non-enlarging subcapsular hematoma but no

laceration

Grade II superficial laceration lt 1cm depth and does not involve

the collecting system non expanding perirenal hematoma

Grade III laceration gt 1cm without extension into the renal pelvis

or collecting system and with no evidence of urine extravasation

Grade IV laceration extends to renal pelvis or urinary

extravasation

Grade V shattered kidney devascularization of kidney due to hilar

injury

Moore EE Shackford SR Pachter HL et al Organ injury scaling

spleen liver and kidney J Trauma 1989291664-6

Renal Trauma Grading System - 1989

Introduction

Renal injury in 3 trauma all admissions and 10

with abdominal trauma

Blunt gtgt Penetrating injury

Most blunt trauma is minor (gt90) ndash observed

Miller KS McAninch JW Radiographic assessment of renal trauma our

15-year experience J Urol 1995154352-5

Indications for renal CT

Penetrating flankback trauma

Shock with any hematuria

Gross hematuria - stable (84 have renal injury)

Microscopic hematuria with evidence of impact over

kidneys (lower posterior rib transverse process

fracture contusion)

Known renal injury with dropping hematocrit or

increased flank pain

Microscopic hematuria alone is not an indication

(serious injury lt02)

Complications of renal trauma

ContusionHematomaHematomaLacerationLacerationLacerationVascular LacerationVascular Microscopic or gross hematuria urologic studies normalSubcapsular nonexpanding without parenchymal lacerationNonexpanding perirenal hematoma confirmed to renalretroperitoneumlt10 cm parenchymal depth of renal cortex without urinaryextravagationlt10 cm parenchymal depth of renal cortex without collectingsystem rupture or urinary extravagationParenchymal laceration exteding through renal cortexmedulla and collecting systemMain renal artery or vein injury with contained hemorrhageCompletely shattered kidneyAvulsion of renal hilum which devascularizes kidney86601866118660186611866028661286602866128660386613222234455Advance one grade for bilateral injuries up to grade IIIFrom Moore et al [7] with permission

Grade I contusion or non-enlarging subcapsular hematoma but no

laceration

Grade II superficial laceration lt 1cm depth and does not involve

the collecting system non expanding perirenal hematoma

Grade III laceration gt 1cm without extension into the renal pelvis

or collecting system and with no evidence of urine extravasation

Grade IV laceration extends to renal pelvis or urinary

extravasation

Grade V shattered kidney devascularization of kidney due to hilar

injury

Moore EE Shackford SR Pachter HL et al Organ injury scaling

spleen liver and kidney J Trauma 1989291664-6

Renal Trauma Grading System - 1989

Indications for renal CT

Penetrating flankback trauma

Shock with any hematuria

Gross hematuria - stable (84 have renal injury)

Microscopic hematuria with evidence of impact over

kidneys (lower posterior rib transverse process

fracture contusion)

Known renal injury with dropping hematocrit or

increased flank pain

Microscopic hematuria alone is not an indication

(serious injury lt02)

Complications of renal trauma

ContusionHematomaHematomaLacerationLacerationLacerationVascular LacerationVascular Microscopic or gross hematuria urologic studies normalSubcapsular nonexpanding without parenchymal lacerationNonexpanding perirenal hematoma confirmed to renalretroperitoneumlt10 cm parenchymal depth of renal cortex without urinaryextravagationlt10 cm parenchymal depth of renal cortex without collectingsystem rupture or urinary extravagationParenchymal laceration exteding through renal cortexmedulla and collecting systemMain renal artery or vein injury with contained hemorrhageCompletely shattered kidneyAvulsion of renal hilum which devascularizes kidney86601866118660186611866028661286602866128660386613222234455Advance one grade for bilateral injuries up to grade IIIFrom Moore et al [7] with permission

Grade I contusion or non-enlarging subcapsular hematoma but no

laceration

Grade II superficial laceration lt 1cm depth and does not involve

the collecting system non expanding perirenal hematoma

Grade III laceration gt 1cm without extension into the renal pelvis

or collecting system and with no evidence of urine extravasation

Grade IV laceration extends to renal pelvis or urinary

extravasation

Grade V shattered kidney devascularization of kidney due to hilar

injury

Moore EE Shackford SR Pachter HL et al Organ injury scaling

spleen liver and kidney J Trauma 1989291664-6

Renal Trauma Grading System - 1989

ContusionHematomaHematomaLacerationLacerationLacerationVascular LacerationVascular Microscopic or gross hematuria urologic studies normalSubcapsular nonexpanding without parenchymal lacerationNonexpanding perirenal hematoma confirmed to renalretroperitoneumlt10 cm parenchymal depth of renal cortex without urinaryextravagationlt10 cm parenchymal depth of renal cortex without collectingsystem rupture or urinary extravagationParenchymal laceration exteding through renal cortexmedulla and collecting systemMain renal artery or vein injury with contained hemorrhageCompletely shattered kidneyAvulsion of renal hilum which devascularizes kidney86601866118660186611866028661286602866128660386613222234455Advance one grade for bilateral injuries up to grade IIIFrom Moore et al [7] with permission

Grade I contusion or non-enlarging subcapsular hematoma but no

laceration

Grade II superficial laceration lt 1cm depth and does not involve

the collecting system non expanding perirenal hematoma

Grade III laceration gt 1cm without extension into the renal pelvis

or collecting system and with no evidence of urine extravasation

Grade IV laceration extends to renal pelvis or urinary

extravasation

Grade V shattered kidney devascularization of kidney due to hilar

injury

Moore EE Shackford SR Pachter HL et al Organ injury scaling

spleen liver and kidney J Trauma 1989291664-6

Renal Trauma Grading System - 1989

CT Grading of Blunt Renal Injury ndash MD Shock-Trauma Center

Grade 1 Superficial laceration ndash cortex

Renal contusion (intravasation)

lt 1 cm subcapsular hematoma

Segmental renal infarct

No active bleed

Perinephric hemorrhage not filling

Gerotarsquos fascia

Grade 2 Renal laceration extends to medulla

gt 1 cm subcapsular hematoma not

delaying renal function

Stable perinephric hematoma not

distending Gerotarsquos capsule

No active bleed or urine leak

CT Grading of Blunt Renal Injury

Grade 3 Laceration into collecting system extravasation

contained within retroperitoneum

Perinephric hematoma distending Gerotarsquos space or involving

pararenal spaces no active bleed

Renal split (2-fragments) with gt 50 parenchymal viability

Subcapsular hematoma causing delay in renal

perfusion

Grade 4 Fragmentation of 3 or more segments (usually with major

devitalization and large perinephric hematoma) ldquoshatteredrdquo

Devascularization gt 50 of parenchyma

Renal pseudoaneurysm

Urine leak confined to retroperitoneum

UPJ or pelvic tear

Renal artery dissection (flow-limited)

Grade 5 Renal Injury - Intervention

Active bleeding with expanding hematoma

Urinary leak into peritoneal cavity

Complete pelvic avulsion

Main renal artery injury

Main renal vein injury

Management

Grade 1 and 2 injuries usually non-surgical (74-98)

Grade 4 and 5 often require intervention Surgery vs injury grade 2467 pts

grade 1= 0 grade II=0 grade III=3 grade IV =9 grade V = 86

OR- vascular injuries (active bleeding or pseudoaneurysm) collecting system disruption major hematoma and persistent or enlarging urinoma

Decrease in renal function correlates with injury grade

Santucci R et al Validation of the American Association for the Surgery of Trauma organ

injury severity scale for kidney J Trauma 200150195-200

Thomason R et al Microscopic hematuria after blunt trauma

is pyelography necessary Am Surg 198955145-150

Grade 1 renal injury

Superficial laceration-small

perinephric hematoma

Contusion - segmental infarct

Subcapsular hematoma normal

perfusion

No treatment

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

CT Grading of Blunt Renal Injury

Grade 3 Laceration into collecting system extravasation

contained within retroperitoneum

Perinephric hematoma distending Gerotarsquos space or involving

pararenal spaces no active bleed

Renal split (2-fragments) with gt 50 parenchymal viability

Subcapsular hematoma causing delay in renal

perfusion

Grade 4 Fragmentation of 3 or more segments (usually with major

devitalization and large perinephric hematoma) ldquoshatteredrdquo

Devascularization gt 50 of parenchyma

Renal pseudoaneurysm

Urine leak confined to retroperitoneum

UPJ or pelvic tear

Renal artery dissection (flow-limited)

Grade 5 Renal Injury - Intervention

Active bleeding with expanding hematoma

Urinary leak into peritoneal cavity

Complete pelvic avulsion

Main renal artery injury

Main renal vein injury

Management

Grade 1 and 2 injuries usually non-surgical (74-98)

Grade 4 and 5 often require intervention Surgery vs injury grade 2467 pts

grade 1= 0 grade II=0 grade III=3 grade IV =9 grade V = 86

OR- vascular injuries (active bleeding or pseudoaneurysm) collecting system disruption major hematoma and persistent or enlarging urinoma

Decrease in renal function correlates with injury grade

Santucci R et al Validation of the American Association for the Surgery of Trauma organ

injury severity scale for kidney J Trauma 200150195-200

Thomason R et al Microscopic hematuria after blunt trauma

is pyelography necessary Am Surg 198955145-150

Grade 1 renal injury

Superficial laceration-small

perinephric hematoma

Contusion - segmental infarct

Subcapsular hematoma normal

perfusion

No treatment

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 5 Renal Injury - Intervention

Active bleeding with expanding hematoma

Urinary leak into peritoneal cavity

Complete pelvic avulsion

Main renal artery injury

Main renal vein injury

Management

Grade 1 and 2 injuries usually non-surgical (74-98)

Grade 4 and 5 often require intervention Surgery vs injury grade 2467 pts

grade 1= 0 grade II=0 grade III=3 grade IV =9 grade V = 86

OR- vascular injuries (active bleeding or pseudoaneurysm) collecting system disruption major hematoma and persistent or enlarging urinoma

Decrease in renal function correlates with injury grade

Santucci R et al Validation of the American Association for the Surgery of Trauma organ

injury severity scale for kidney J Trauma 200150195-200

Thomason R et al Microscopic hematuria after blunt trauma

is pyelography necessary Am Surg 198955145-150

Grade 1 renal injury

Superficial laceration-small

perinephric hematoma

Contusion - segmental infarct

Subcapsular hematoma normal

perfusion

No treatment

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Management

Grade 1 and 2 injuries usually non-surgical (74-98)

Grade 4 and 5 often require intervention Surgery vs injury grade 2467 pts

grade 1= 0 grade II=0 grade III=3 grade IV =9 grade V = 86

OR- vascular injuries (active bleeding or pseudoaneurysm) collecting system disruption major hematoma and persistent or enlarging urinoma

Decrease in renal function correlates with injury grade

Santucci R et al Validation of the American Association for the Surgery of Trauma organ

injury severity scale for kidney J Trauma 200150195-200

Thomason R et al Microscopic hematuria after blunt trauma

is pyelography necessary Am Surg 198955145-150

Grade 1 renal injury

Superficial laceration-small

perinephric hematoma

Contusion - segmental infarct

Subcapsular hematoma normal

perfusion

No treatment

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 1 renal injury

Superficial laceration-small

perinephric hematoma

Contusion - segmental infarct

Subcapsular hematoma normal

perfusion

No treatment

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 1 renal injuries

medical management

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

G1 - Renal contusion contrast

leak

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 1 Renal injury

contusion delayed flow

Subcapsular

hematoma

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Segmental renal infarct

Grade 1 injury

No treatment needed

Segmental or capsular artery occlusion

Often isolated injury

No treatment

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Lower pole segmental

occlusion

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Subcapsular Hematoma ndash G2

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

CT Grade 3 Renal

Injury

Typically medical

management with FU CT

imaging

CT Grade 2-3

Renal Injury

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

6 hour delay

Grade 2 injury

Grade 3 injury

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 3 renal injury

Renal split and extension of

hematoma to pararenal space

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Urinoma

Grade 3 renal

injury

Most resolve without treatment if

there is antegrade urine flow

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Urinoma

Usually self-limited

Need to maintain low pressure collecting system

(antegrade flow nephrostomy stent)

Requires delayed images to opacify

Rarely become infection - drainage

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 3 Injury No intervention with

resolution fu at 9 months

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 3 subcapsular

hematoma

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

MAJOR RENAL INJURY ndash

Grade 3

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Fragmentation

Devascularization

CT Grade 4 Renal Injury

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 5 renal injury

Rupture UPJ

Grade 5 (4) renal

Injury (UPJ

obstruction)

Renal vein avulsion

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Blunt trauma Horseshoe with UPJ

leak

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Abnormal kidney = greater injury

Horseshoe ectopic polycystic kidneys and

congenital UPJ obstruction

Chronic hydronephrosis renal infection simple

renal cysts and renal cell cancers

Always follow hematuria to resolution

19 of patients who sustained a renal injury had a

preexisting renal anomaly

Schmidlin F et al The higher injury risk of abnormal kidneys in

blunt renal trauma Scand J Urol Nephrol 199832388-392

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Ruptured Pelvis (G4

or G5)

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Sledding accident ndash

15 yr

CT Grade 4

Renal Angiomyolipomatosis

Tuberous Sclerosis

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Bleeding renal vein

pseudoaneurysm-

bleeding (Gr 5)

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Renal Vein Pseudoaneurysm amp

Bleeding (Gr 5)

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

CT Grade 5 Renal Injury

Active bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Bleeding

versus urine

leak

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Penetrating flankback trauma

Limited to retroperitoneum with no direct involvement of organs

Involves visceral structure(s) but limited to retroperitoneum

Extends into the intraperitoneal compartment

Higher likelihood of vascular injury - pseudoaneurysm

Consider cavitation energy and secondary missiles with bullets

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Renal Angiography Embolization

Active bleed by CT or progression of hematoma

size

High grade (4-5) injury in blunt trauma

Consider in any penetrating renal trauma

Preserves maximal functioning parenchyma

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

BLUNT TRAUMA

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Grade 4 Renal Artery

Dissection

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Blunt trauma Right renal artery

dissection intimal flap emboli

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Renal artery occlusion

Probably secondary to stretching of artery

Variable time from injury to complete thrombosis

( Warm ischemic time)

Abrupt proximal renal artery occlusion ndash can be

long dissection

Very rare to salvage kidney unless multiple renal

arteries well developed collaterals stenting

possible

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

CT Grade 5

Renal artery

occlusion

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

31 y man -

weight lifting

23 y woman blunt

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Renal Vein Thrombosis

Increased renal vein size

Increased kidney size

High attenuation intraluminal mass (non-enhanced)

Delayed nephrogrampyelogram ndash prolonged nephrogram

Renal infarcts (entire kidney on right collaterals on left usually allows

return of function)

Etiologies

Dehydration

Nephrotic syndrome

Trauma (3-4 renal based injuries)

Pro-coagulant factors

Severe illness

Transplant kidney

Renal cancer

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Ureteropelvic injury Diagnosis on delayed CT

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Uretero-pelvic

junction

tear

Need delayed imaging

Common site of tear in ureter

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Complications of Renal Trauma

3-10 - increases with injury Grade

Early urinoma delayed bleeding fistula abscess

hypertension renal artery stenosis pseudoaneurysm

Late hydronephrosis AV fistula calculus formation

pyelonephritis hypertension ureteral stricture

High-grade blunt and penetrating kidney injuries

managed nonoperatively associated with 111 and

200 complication rate identified on follow-up CT

usually in 8-10 days

Burkur M et al J Routine follow-up imaging of kidney injuries may not

be justified J Trauma 2011701229-33

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Zone 1 Centrally located

pancreaticoduodenal or major

vascular injury most common

surgical

Zone 2 Flank or perinephric

regions associated with injuries

to GU system or colon 2nd most

common

Zone 3 Pelvic location

associated with pelvic fractures

or ileal-femoral vascular injury

(most common)

Retroperitoneal

Hematoma

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Retroperitoneal hematoma

Poor sensitivity by exam

Can accumulate 4L

Pain abdomen flank back distension mass

hypotension femoral neuropathy

Sonography insensitive about 60

Central zone more likely than lateral zone to need

surgery

Lateral zone seen with renal injury often Rx non-

op

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Adrenal hematoma

vs adenoma (HU lt 10) or

50 drop density at 10

min post contrast

Hematoma 40-60 HU no

enhancement

Decreases size may

calcify vs tumor

Periadrenal hemorrhage

Direct compression

shear venous pressure

elevation

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Adrenal Hematoma

2 blunt abdominal

trauma

Rarely isolated commonly

assoc wliver contusion

Majority on the right

(77) left 15 bilat 8

Proposed mechanisms-

Direct crush injury

Increased adrenal venous

pressure thrombosis

Shear injury

Daly K P et al Radiographics 2008281571-1590

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

IVC Pseudoaneurysm ndash Massive

Retroperitoneal Hematoma

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Right iliac vein

rupture

Spinal Fractures

Intercostal Bleeding

Spinal Fractures

Intercostal Bleeding