Imaging of Renal Trauma: A Comprehensive Review1
Akira Kawashima, MD,
Carl M. Sandler, MD,
Frank M. Corl, MS,
O. Clark West, MD,
Eric P. Tamm, MD,
Elliot K. Fishman, MD and
Stanford M. Goldman, MD
1 From the Departments of Radiology (A.K., C.M.S., O.C.W., E.P.T., S.M.G.) and Urology (C.M.S., S.M.G.), University of Texas-Houston Medical School, Houston, Tex; the Department of Radiology, Memorial Hermann Hospital, Houston, Tex (A.K., C.M.S., O.C.W., E.P.T., S.M.G.); the Department of Radiology, Lyndon B. Johnson General Hospital, Houston, Tex (A.K., C.M.S., E.P.T.); and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Md (F.M.C., E.K.F.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received June 20, 2000; revision requested July 13 and received August 21; accepted August 22. Address correspondence to A.K., Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: kawashima.akira@mayo.edu).
View larger version (147K):
[in a new window]
|
Figure 1a. Urine extravasation from the collecting system in a 9-year-old boy who had sustained blunt abdominal trauma. (a) Contrast-enhanced generalized-nephrographic-phase helical CT scan reveals what appears to be only a large perinephric hematoma (H) secondary to a distinct renal laceration (not shown). Because this is an early-phase image, there is no contrast material in the collecting system. The descending colon (C) is displaced anteriorly by the hematoma. Note the thickening of the renal (arrow) and lateroconal (arrowhead) fascia. (b) Excretory-phase CT scan demonstrates extensive extravasation of contrast-enhanced urine admixed with the hematoma, a finding that demonstrates that the laceration has disrupted the integrity of the collecting system.
|
|
View larger version (129K):
[in a new window]
|
Figure 1b. Urine extravasation from the collecting system in a 9-year-old boy who had sustained blunt abdominal trauma. (a) Contrast-enhanced generalized-nephrographic-phase helical CT scan reveals what appears to be only a large perinephric hematoma (H) secondary to a distinct renal laceration (not shown). Because this is an early-phase image, there is no contrast material in the collecting system. The descending colon (C) is displaced anteriorly by the hematoma. Note the thickening of the renal (arrow) and lateroconal (arrowhead) fascia. (b) Excretory-phase CT scan demonstrates extensive extravasation of contrast-enhanced urine admixed with the hematoma, a finding that demonstrates that the laceration has disrupted the integrity of the collecting system.
|
|
View larger version (79K):
[in a new window]
|
Figure 2. Drawing illustrates a focal intrarenal hematoma.
|
|
View larger version (151K):
[in a new window]
|
Figure 3. Renal contusion (category I) in a 46-year-old man who had sustained blunt abdominal trauma. Contrast-enhanced nephrographic-phase helical CT scan demonstrates a focal area of decreased contrast enhancement in the interpolar region of the left kidney (arrowhead).
|
|
View larger version (78K):
[in a new window]
|
Figure 4. Drawing illustrates a subcapsular hematoma.
|
|
View larger version (149K):
[in a new window]
|
Figure 5. Subcapsular hematoma (category I) in a 40-year-old man who had sustained blunt abdominal trauma. Contrast-enhanced helical CT scan demonstrates a subcapsular fluid collection (straight white arrows) flattening the posterolateral contour of the left kidney. There is minimal cortical laceration (black arrow). Note also the subcutaneous emphysema in the left side of the back (curved arrow). A chest tube had been inserted for a left pneumothorax (not shown).
|
|
View larger version (81K):
[in a new window]
|
Figure 6. Drawing illustrates a small cortical laceration.
|
|
View larger version (113K):
[in a new window]
|
Figure 7. Simple renal laceration (category I) in a 30-year-old woman who had sustained blunt abdominal trauma. Contrast-enhanced multidetector helical CT scan reveals a small, hypoattenuating laceration crossing the interpolar region of the left kidney (white arrow) associated with a limited perinephric hematoma. A hepatic laceration (black arrow) and hemoperitoneum in the Morrison pouch (arrowheads) are also seen.
|
|
View larger version (73K):
[in a new window]
|
Figure 8. Drawings illustrate a segmental infarct.
|
|
View larger version (140K):
[in a new window]
|
Figure 9. Subsegmental renal infarction (category I) in a 47-year-old man who had sustained blunt abdominal trauma. Contrast-enhanced CT scan demonstrates a sharply demarcated, wedge-shaped area of decreased attenuation in the interpolar region of the right kidney (solid arrow). Note also the evidence of subtle hemorrhage in the right renal hilum (open arrow).
|
|
View larger version (81K):
[in a new window]
|
Figure 10. Drawing illustrates a laceration that extends to the medulla but does not involve the collecting system.
|
|
View larger version (139K):
[in a new window]
|
Figure 11. Major renal laceration without involvement of the collecting system (category II) in a 32-year-old woman who had sustained blunt abdominal trauma. Contrast-enhanced helical CT scan reveals a laceration in the posterolateral aspect of the middle portion of the left kidney (arrows) associated with perinephric hematoma. No urine extravasation was seen on excretory-phase scans (not shown).
|
|
View larger version (79K):
[in a new window]
|
Figure 12. Drawing illustrates a deep parenchymal laceration involving the collecting system.
|
|
View larger version (150K):
[in a new window]
|
Figure 13a. Major renal laceration involving the collecting system (category II) in an 8-year-old boy who had sustained blunt abdominal trauma. (a) Contrast-enhanced nephrographic-phase CT scan shows a large, distracted renal fracture through the interpolar portion of the right kidney. (b) Contrast-enhanced excretory-phase CT scan shows extravasation of contrast material from a laceration of the renal pelvis into the medial perinephric space. (c) Delayed CT scan shows extensive extravasation around the lower pole of the right kidney. Note the antegrade filling of the ureter (white arrow). A small laceration is also seen in the lower pole (black arrow). (Fig 13 reprinted, with permission, from reference 19.)
|
|
View larger version (151K):
[in a new window]
|
Figure 13b. Major renal laceration involving the collecting system (category II) in an 8-year-old boy who had sustained blunt abdominal trauma. (a) Contrast-enhanced nephrographic-phase CT scan shows a large, distracted renal fracture through the interpolar portion of the right kidney. (b) Contrast-enhanced excretory-phase CT scan shows extravasation of contrast material from a laceration of the renal pelvis into the medial perinephric space. (c) Delayed CT scan shows extensive extravasation around the lower pole of the right kidney. Note the antegrade filling of the ureter (white arrow). A small laceration is also seen in the lower pole (black arrow). (Fig 13 reprinted, with permission, from reference 19.)
|
|
View larger version (147K):
[in a new window]
|
Figure 13c. Major renal laceration involving the collecting system (category II) in an 8-year-old boy who had sustained blunt abdominal trauma. (a) Contrast-enhanced nephrographic-phase CT scan shows a large, distracted renal fracture through the interpolar portion of the right kidney. (b) Contrast-enhanced excretory-phase CT scan shows extravasation of contrast material from a laceration of the renal pelvis into the medial perinephric space. (c) Delayed CT scan shows extensive extravasation around the lower pole of the right kidney. Note the antegrade filling of the ureter (white arrow). A small laceration is also seen in the lower pole (black arrow). (Fig 13 reprinted, with permission, from reference 19.)
|
|
View larger version (142K):
[in a new window]
|
Figure 14. Segmental renal infarction (category II) in a 34-year-old man. Contrast-enhanced helical CT scan demonstrates a sharply demarcated area of decreased contrast enhancement in the posterior upper pole of the right kidney, a finding that is consistent with occlusion of the dorsal segmental branch of the renal artery. Note also the splenic laceration with perisplenic hematoma (arrows). (Reprinted, with permission, from reference 29.)
|
|
View larger version (75K):
[in a new window]
|
Figure 15. Drawing illustrates multiple renal lacerations.
|
|
View larger version (144K):
[in a new window]
|
Figure 16. Multiple renal lacerations (category III) in a 9-year-old boy who had sustained blunt abdominal trauma and intraabdominal injury. Contrast-enhanced nephrographic-phase helical CT scan shows several deep lacerations of the interpolar region of the right kidney (straight arrows) associated with areas of active arterial extravasation (curved arrows). Note the anterior displacement of the duodenum (D), pancreas (P), and inferior vena cava (V). Hemoperitoneum (H) is seen in the Morrison pouch.
|
|
View larger version (128K):
[in a new window]
|
Figure 17a. Shattered kidney (category III) in a 28-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced helical CT scan demonstrates a devitalized upper pole of the right kidney due to segmental infarction (R). Note the perinephric hyperattenuating blood clot (arrow). Note also the flattened inferior vena cava (V), a finding that indicates hypovolemic shock. (b) CT scan obtained caudad to a demonstrates a large parenchymal laceration extending horizontally across the middle to lower pole of the right kidney (R), which is displaced anteriorly by a large, perinephric hematoma (H).
|
|
View larger version (134K):
[in a new window]
|
Figure 17b. Shattered kidney (category III) in a 28-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced helical CT scan demonstrates a devitalized upper pole of the right kidney due to segmental infarction (R). Note the perinephric hyperattenuating blood clot (arrow). Note also the flattened inferior vena cava (V), a finding that indicates hypovolemic shock. (b) CT scan obtained caudad to a demonstrates a large parenchymal laceration extending horizontally across the middle to lower pole of the right kidney (R), which is displaced anteriorly by a large, perinephric hematoma (H).
|
|
View larger version (127K):
[in a new window]
|
Figure 18. Active arterial extravasation (category III). Selective angiogram of the right main renal artery obtained following exploratory laparotomy demonstrates vascular extravasation from the upper pole of the right kidney (arrow). Intraarterial embolization was successfully performed to control bleeding.
|
|
View larger version (102K):
[in a new window]
|
Figure 19. Drawings illustrate thrombosis of the main renal artery.
|
|
View larger version (118K):
[in a new window]
|
Figure 20a. Traumatic occlusion of the main renal artery (category III) in a 17-year-old boy who had sustained blunt abdominal trauma. (a) Intravenous urogram demonstrates poor visualization of the left kidney. (b) CT scan obtained without additional contrast material following urography demonstrates rim enhancement of the outer cortex of the left kidney (arrows). (c) Digital subtraction aortogram demonstrates the characteristic tapered occlusion of the proximal left main renal artery (arrow).
|
|
View larger version (134K):
[in a new window]
|
Figure 20b. Traumatic occlusion of the main renal artery (category III) in a 17-year-old boy who had sustained blunt abdominal trauma. (a) Intravenous urogram demonstrates poor visualization of the left kidney. (b) CT scan obtained without additional contrast material following urography demonstrates rim enhancement of the outer cortex of the left kidney (arrows). (c) Digital subtraction aortogram demonstrates the characteristic tapered occlusion of the proximal left main renal artery (arrow).
|
|
View larger version (133K):
[in a new window]
|
Figure 20c. Traumatic occlusion of the main renal artery (category III) in a 17-year-old boy who had sustained blunt abdominal trauma. (a) Intravenous urogram demonstrates poor visualization of the left kidney. (b) CT scan obtained without additional contrast material following urography demonstrates rim enhancement of the outer cortex of the left kidney (arrows). (c) Digital subtraction aortogram demonstrates the characteristic tapered occlusion of the proximal left main renal artery (arrow).
|
|
View larger version (149K):
[in a new window]
|
Figure 21. Traumatic occlusion of the main renal artery (category III) in a 38-year-old man who had sustained blunt abdominal trauma. Contrast-enhanced helical CT scan demonstrates a diminished right nephrogram. The proximal right renal artery (straight arrow) is enhanced; however, the distal main renal artery is not visualized. Note also the hepatic laceration (curved arrow) and hemoperitoneum in the Morrison pouch (H).
|
|
View larger version (126K):
[in a new window]
|
Figure 22a. Laceration of the renal vein (category III) in an 18-year-old woman who had sustained blunt abdominal trauma. (a) Contrast-enhanced helical CT scan demonstrates minimal perinephric hematoma without parenchymal laceration (arrows). (b) CT scan obtained 3 days later shows an interval increase in the amount of perinephric hematoma (H), resulting in deformation of the contour of the right kidney and a heterogeneously diminished nephrogram. The origin of the bleeding was not identified at CT. Laceration of the renal vein was found at surgery.
|
|
View larger version (129K):
[in a new window]
|
Figure 22b. Laceration of the renal vein (category III) in an 18-year-old woman who had sustained blunt abdominal trauma. (a) Contrast-enhanced helical CT scan demonstrates minimal perinephric hematoma without parenchymal laceration (arrows). (b) CT scan obtained 3 days later shows an interval increase in the amount of perinephric hematoma (H), resulting in deformation of the contour of the right kidney and a heterogeneously diminished nephrogram. The origin of the bleeding was not identified at CT. Laceration of the renal vein was found at surgery.
|
|
View larger version (83K):
[in a new window]
|
Figure 23. Drawing illustrates complete transection of the ureter.
|
|
View larger version (118K):
[in a new window]
|
Figure 24a. Avulsion of the ureteropelvic junction (category IV) in a 49-year-old man who had sustained blunt trauma. (a, b) Contrast-enhanced nephrographic-phase helical CT scans (a obtained at a higher level than b) through the lower pole of the right kidney demonstrate a perinephric fluid collection with no renal laceration. (c, d) Contrast-enhanced excretory-phase CT scans (c obtained at a higher level than d) demonstrate medial contrast material extravasation (arrow). No ureteral contrast material filling is noted. The patient underwent exploratory laparotomy for a mesenteric laceration. A diagnosis of ureteropelvic junction avulsion was made, and primary surgical repair of the ureter was performed.
|
|
View larger version (124K):
[in a new window]
|
Figure 24b. Avulsion of the ureteropelvic junction (category IV) in a 49-year-old man who had sustained blunt trauma. (a, b) Contrast-enhanced nephrographic-phase helical CT scans (a obtained at a higher level than b) through the lower pole of the right kidney demonstrate a perinephric fluid collection with no renal laceration. (c, d) Contrast-enhanced excretory-phase CT scans (c obtained at a higher level than d) demonstrate medial contrast material extravasation (arrow). No ureteral contrast material filling is noted. The patient underwent exploratory laparotomy for a mesenteric laceration. A diagnosis of ureteropelvic junction avulsion was made, and primary surgical repair of the ureter was performed.
|
|
View larger version (121K):
[in a new window]
|
Figure 24c. Avulsion of the ureteropelvic junction (category IV) in a 49-year-old man who had sustained blunt trauma. (a, b) Contrast-enhanced nephrographic-phase helical CT scans (a obtained at a higher level than b) through the lower pole of the right kidney demonstrate a perinephric fluid collection with no renal laceration. (c, d) Contrast-enhanced excretory-phase CT scans (c obtained at a higher level than d) demonstrate medial contrast material extravasation (arrow). No ureteral contrast material filling is noted. The patient underwent exploratory laparotomy for a mesenteric laceration. A diagnosis of ureteropelvic junction avulsion was made, and primary surgical repair of the ureter was performed.
|
|
View larger version (121K):
[in a new window]
|
Figure 24d. Avulsion of the ureteropelvic junction (category IV) in a 49-year-old man who had sustained blunt trauma. (a, b) Contrast-enhanced nephrographic-phase helical CT scans (a obtained at a higher level than b) through the lower pole of the right kidney demonstrate a perinephric fluid collection with no renal laceration. (c, d) Contrast-enhanced excretory-phase CT scans (c obtained at a higher level than d) demonstrate medial contrast material extravasation (arrow). No ureteral contrast material filling is noted. The patient underwent exploratory laparotomy for a mesenteric laceration. A diagnosis of ureteropelvic junction avulsion was made, and primary surgical repair of the ureter was performed.
|
|
View larger version (129K):
[in a new window]
|
Figure 25a. Ureteropelvic junction laceration with pre-existing obstruction (category IV) in a 27-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced excretory-phase CT scan demonstrates left-sided pelviectasis and right-sided pelvocaliectasis. A large blood clot is present in the left renal pelvis. (b) Axial CT scan obtained inferior to the lower pole of the left kidney shows contrast material extravasation at the point of laceration of the ureteropelvic junction (straight arrow). A periureteral urinoma is also present. The enhanced ureter contains a filling defect (curved arrow), presumably secondary to a blood clot. (c) Intravenous urogram shows medial perinephric contrast material extravasation on the left side with a normal-caliber ureter distally (arrows), findings that indicate that ureteral continuity has been maintained. Pelvocaliectasis is also present, a finding that is consistent with bilateral ureteropelvic junction obstruction. (Reprinted, with permission, from reference 19.)
|
|
View larger version (123K):
[in a new window]
|
Figure 25b. Ureteropelvic junction laceration with pre-existing obstruction (category IV) in a 27-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced excretory-phase CT scan demonstrates left-sided pelviectasis and right-sided pelvocaliectasis. A large blood clot is present in the left renal pelvis. (b) Axial CT scan obtained inferior to the lower pole of the left kidney shows contrast material extravasation at the point of laceration of the ureteropelvic junction (straight arrow). A periureteral urinoma is also present. The enhanced ureter contains a filling defect (curved arrow), presumably secondary to a blood clot. (c) Intravenous urogram shows medial perinephric contrast material extravasation on the left side with a normal-caliber ureter distally (arrows), findings that indicate that ureteral continuity has been maintained. Pelvocaliectasis is also present, a finding that is consistent with bilateral ureteropelvic junction obstruction. (Reprinted, with permission, from reference 19.)
|
|
View larger version (140K):
[in a new window]
|
Figure 25c. Ureteropelvic junction laceration with pre-existing obstruction (category IV) in a 27-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced excretory-phase CT scan demonstrates left-sided pelviectasis and right-sided pelvocaliectasis. A large blood clot is present in the left renal pelvis. (b) Axial CT scan obtained inferior to the lower pole of the left kidney shows contrast material extravasation at the point of laceration of the ureteropelvic junction (straight arrow). A periureteral urinoma is also present. The enhanced ureter contains a filling defect (curved arrow), presumably secondary to a blood clot. (c) Intravenous urogram shows medial perinephric contrast material extravasation on the left side with a normal-caliber ureter distally (arrows), findings that indicate that ureteral continuity has been maintained. Pelvocaliectasis is also present, a finding that is consistent with bilateral ureteropelvic junction obstruction. (Reprinted, with permission, from reference 19.)
|
|
View larger version (118K):
[in a new window]
|
Figure 26. Renal laceration in a 25-year-old man who had sustained a stab wound to the right posterolateral aspect of the abdomen. Contrast-enhanced nephrographic-phase helical CT scan reveals laceration of the anterolateral aspect of the right kidney (curved arrow) with a blood clot in a right extrarenal pelvis (B). Note the small hepatic laceration (straight black arrow) and minimal hemoperitoneum (H). The stab wound is seen in the abdominal wall (white arrow). An extrarenal pelvis is also present on the left side.
|
|
View larger version (167K):
[in a new window]
|
Figure 27a. Renal injury in a 20-year-old man who had sustained a gunshot wound. (a) Conventional radiograph of the right upper quadrant of the abdomen shows multiple pellets. (b) Unenhanced CT scan reveals a pellet in the upper pole of the right kidney. Note the minimal perinephric hematoma (arrow). (c) On a contrast-enhanced excretory-phase helical CT scan, the pellet is seen in proximity to the collecting system. Retained pellets may potentially migrate into the collecting system and result in ureteral obstruction ("buckshot colic").
|
|
View larger version (149K):
[in a new window]
|
Figure 27b. Renal injury in a 20-year-old man who had sustained a gunshot wound. (a) Conventional radiograph of the right upper quadrant of the abdomen shows multiple pellets. (b) Unenhanced CT scan reveals a pellet in the upper pole of the right kidney. Note the minimal perinephric hematoma (arrow). (c) On a contrast-enhanced excretory-phase helical CT scan, the pellet is seen in proximity to the collecting system. Retained pellets may potentially migrate into the collecting system and result in ureteral obstruction ("buckshot colic").
|
|
View larger version (154K):
[in a new window]
|
Figure 27c. Renal injury in a 20-year-old man who had sustained a gunshot wound. (a) Conventional radiograph of the right upper quadrant of the abdomen shows multiple pellets. (b) Unenhanced CT scan reveals a pellet in the upper pole of the right kidney. Note the minimal perinephric hematoma (arrow). (c) On a contrast-enhanced excretory-phase helical CT scan, the pellet is seen in proximity to the collecting system. Retained pellets may potentially migrate into the collecting system and result in ureteral obstruction ("buckshot colic").
|
|
View larger version (194K):
[in a new window]
|
Figure 28a. Renal cyst complicated by intracystic hemorrhage with communication with the collecting system in a 23-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced nephrographic-phase helical CT scan shows a cyst with hyperattenuating fluid in the upper pole of the left kidney (solid arrow), findings that are consistent with intracystic hemorrhage. Note the splenic laceration (open arrow) and perisplenic hematoma (H). (b) Contrast-enhanced excretory-phase CT scan demonstrates contrast material in the cyst (arrow).
|
|
View larger version (191K):
[in a new window]
|
Figure 28b. Renal cyst complicated by intracystic hemorrhage with communication with the collecting system in a 23-year-old man who had sustained blunt abdominal trauma. (a) Contrast-enhanced nephrographic-phase helical CT scan shows a cyst with hyperattenuating fluid in the upper pole of the left kidney (solid arrow), findings that are consistent with intracystic hemorrhage. Note the splenic laceration (open arrow) and perisplenic hematoma (H). (b) Contrast-enhanced excretory-phase CT scan demonstrates contrast material in the cyst (arrow).
|
|
View larger version (184K):
[in a new window]
|
Figure 29. Rupture of a renal cyst in a 71-year-old man who had sustained blunt abdominal trauma. Contrast-enhanced helical CT scan demonstrates a cyst with a fluid-fluid level in the midpolar region of the left kidney (straight solid arrow) with a perinephric fluid collection (curved arrow). Note the thickening of the renal fascia (open arrow).
|
|
View larger version (143K):
[in a new window]
|
Figure 30. Renal injury in a 33-year-old man with a horseshoe kidney. Contrast-enhanced helical CT scan demonstrates a large renal laceration through the isthmus of a horseshoe kidney associated with perinephric hematoma (H). L = left kidney, R = right kidney. (Courtesy of Stephen Karasick, MD, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pa.)
|
|
View larger version (143K):
[in a new window]
|
Figure 31. Pseudoaneurysm in a patient who had sustained a stab wound and had undergone exploratory laparotomy. Selective arterial-phase right renal angiogram demonstrates a false aneurysm in the lower pole of the right kidney (straight arrow). Subsegmental infarction is noted in the upper pole (curved arrow). Bleeding was controlled with intraarterial embolization. Surgical staples from the laparotomy are seen at the midline.
|
|
View larger version (122K):
[in a new window]
|
Figure 32. Subcapsular hematoma (Page kidney) in a 30-year-old woman with a history of a seizure disorder who presented with right flank pain and hypertension. Contrast-enhanced spiral CT scan demonstrates a subcapsular fluid collection (H) flattening the right kidney. The patient underwent successful US-guided percutaneous drainage of the hematoma.
|
|
Copyright © 2001 by the Radiological Society of North America.
