Multi-trauma with traumatic aortic injury, diaphragmatic rupture and small bowel injury

Case contributed by Heather Pascoe


Motor bike accident.

Patient Data

Age: 40 years
Gender: Male


  • blunt traumatic thoracic aortic transection and pseudoaneurysm with an associated large volume mediastinal hematoma
  • displaced right posterior 12th rib fracture
  • left diaphragmatic rupture with stomach herniation into the chest
  • left hemothorax and pulmonary contusions
  • small right sided pneumothorax and posterior pulmonary contusions


  • hemoperitoneum
  • small bowel mesenteric fat stranding suspicious for a mesenteric tear (high suspicion) +/- terminal ileal injury/perforation
  • fat stranding in the retroperitoneum around the left renal vascular pedicle. No evidence of active bleeding or direct vascular injury. Enhancement of the left kidney is normal.
  • small subcapsular splenic hematoma (AAST Grade II)
  • focal right lower renal pole poorly defined cortical hypodensity, possibly a blunt renal contusion (AAST Grade I)
  • low volume IVC consistent with volume depletion
  • gas with the left abdominal wall and pelvis

Case Discussion

A mediastinal hematoma is an indirect sign of traumatic aortic injury (TAI). Direct signs of TAI include:

  • intimal tear/flap
  • irregularity of the aortic wall
  • pseudoaneurysm
  • abrupt change in aortic caliber (pseudocoarctation)
  • active extravasation of intravenous contrast

The sagittal plane is usually the best plate to evaluate the contour of the aorta.

CT diagnosis of bowel and mesenteric injury can be difficult. Both direct and indirect signs need to be carefully sought for. The main goal in evaluating these signs is to distinguish significant bowel and mesenteric injuries that require surgical intervention from those that can be managed non-surgically.​

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