Üst ekstremite travmatik intimal yaralanma ve oklüzyon BT bulguları

Özet

Künt gerilme kuvvetleri arter duvarında kontüzyon, yırtılma ve diseksiyon yaratarak intimal flep ve intramural hematom oluşturabilir; penetran travmalar ise genellikle liserasyon veya transeksiyonla sonuçlanır. Üst ekstremite BT anjiyografisi (BTA) yaralanmanın seviyesini, uzunluğunu, lümen etkisini ve distal akımı gösterir; çok düzlemli rekonstrüksiyonlar, maksimum yoğunluk projeksiyonları ve hacimsel renderleme küçük lezyonların doğrulanmasında rutin olarak kullanılmalıdır. Tam olmayan duvar yaralanması görünürde açık bir damar lümeniyle birlikte bulunabilir ve yalnız çevre yumuşak doku bulgularına bakılarak dışlanamaz. İntimal lezyon ilerleyen tromboz veya distal emboliyle el perfüzyonunu bozabileceğinden raporda kesintisiz arter haritası ve eşlik eden travma tarif edilmelidir.

Faz ve pencere

BTA tanısal: Arter duvarındaki ince flep, eksantrik lümen daralması, kısa segment dolum defekti veya kesilme; komşu hematom, kırık ve distal radial-ulnar opasifikasyonla birlikte değerlendirilir.
Gecikmiş tanısal: Arteriyel fazda önkol distalinde opasifikasyon azalması erken tarama zamanlamasına bağlı teknik olarak kuşkulu bir bulgu olabilir; karşı tarafla karşılaştırma ve seçilmiş olgularda gecikmiş faz incelemesi kuşkuyu gidermeye yardımcı olur.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40), Kemik (G 1800 / M 400).

BT bulguları

İntimal flep — kontrastlı lümen içine uzanan ince lineer membran aksiyel ve ortogonal kesitlerde aynı noktada devam eder.
İntimal flep veya duvar içi hematom, yaralanma düzeyinde hilal biçimli lümen deformasyonu ve eksantrik daralma yapabilir; dış damar konturu ayrıca değerlendirilir.
İntralüminal trombüs — flep distalinde veya zedelenmiş intima üzerinde kontrastla çevrelenen dolum kusuru; tam oklüzyona ilerleyip ilerlemediği izlenir.
Kısa segment oklüzyon — brakiyal ya da önkol arterinde ani lümen kaybı, varsa distal kollateral yeniden doluşla birlikte gösterilir.
Damar duvarı düzensizliği — fokal kontur çentiklenmesi veya kısa daralma, küçük intimal yırtığın tek görünür işareti olabilir.
Perivasküler travma — hematom, yumuşak doku gazı, yabancı cisim, kırık veya çıkık yaralanmış arterle anatomik ilişki içinde tarif edilir.
Runoff azalması — radial ve ulnar arterlerden birinin ya da ikisinin el bileğine kadar izlenememesi, yaralanmanın distal etkisini gösterir.

Ölçütler ve sınıflamalar

Periferik arter yaralanması: intimal düzensizlik/yırtık için morfolojik eşik: CTA'da intimal düzensizlik/yırtık kontrastlı lümen içine uzanan lineer flep; diseksiyon veya intramural hematom ise semiliner lümen deformasyonu veya eksantrik darlık olarak tanımlanır.
Periferik arter yaralanması: diseksiyon/intramural hematom için morfolojik eşik: CTA'da intimal düzensizlik/yırtık kontrastlı lümen içine uzanan lineer flep; diseksiyon veya intramural hematom ise semiliner lümen deformasyonu veya eksantrik darlık olarak tanımlanır.
Periferik arter yaralanmalarının CTA morfolojik sınıflaması: Periferik damar yaralanmaları CTA'da vazospazm, kontüzyon, intimal flep veya hematom, dıştan bası, laserasyon, transeksiyon, psödoanevrizma ya da arteriovenöz fistül gibi bulgularla tanımlanabilir. Periferik damar yaralanmaları CTA'da vazospazm, kontüzyon, intimal flep veya hematom, dıştan bası, laserasyon, transeksiyon, psödoanevrizma ya da AV fistül gibi bulgularla tanımlanır; intimal flep lineer lümen içi membran, diseksiyon/hematom ise semiliner deformasyon veya eksantrik darlık şeklinde görünür. Diğer morfolojik örüntüler psödoanevrizmayla kısmi transeksiyon, duvarı korunmuş trombotik oklüzyon ve tam transeksiyondur.

Normalde

Brakiyal arter normalde antekubital fossada radial ve ulnar arterlere ayrılır. Normal lümende duvar boyunca uzanan çizgi, hilal biçimli daralma veya odaksal dolum kusuru yoktur; yaralı tarafı karşı tarafla aynı seviyede kıyaslayın ve kemik penceresinde eşlik eden kırık-çıkığı ilişkilendirin.

Ayırıcı tanı

Vazospazm, düzgün kenarlı konsantrik, fokal ve segmental lümen daralması şeklinde görülebilir.
Eksternal hematom basısı: damar dıştan basık ya da yer değiştirmiştir; damar duvarı içinde flep yerine komşu kitle görülür.
Kalsifikasyon veya psödoanevrizma, aktif kanamadan ayırt edilmelidir; gecikmiş fazda kalsifikasyonun değişmeden kalması ayırıcı tanıya yardımcı olabilir.
Erken tarama zamanlaması artefaktı: distal arterlerde geç doluş taklit edebilir; gecikmiş faz görüntüleme kontrast dağılımını netleştirerek gerçek oklüzyondan ayırır.

Tuzaklar

Metal donanım ve balistik fragmanlar, CTA tanısal doğruluğunu azaltabilen ışın sertleşmesi artefaktlarına yol açabilir.
İntimal flep değerlendirilmesi — çok düzlemli rekonstrüksiyonlar (MPR), maksimum yoğunluk projeksiyonları (MIP) ve hacimsel renderleme küçük fleplerin ve lümen deformasyonlarının doğrulanmasında rutin olarak kullanılmalıdır.
Distal arterlerin geç dolması gerçek oklüzyon izlenimi verebilir; kademeli opasifikasyon kaybında gecikmiş faz ve karşı taraf arterlerini kıyaslayın.
Travma çevresindeki hematom kontrast damar dışı diye yorumlanmamalıdır; arteryel seride yeni oluşan odaksal opasite ve seri görüntülerde lümen dışındaki yayılım ayrımı sağlar.

Kendini dene

Diseksiyonun BT'deki tipik lümen görünümü hangisidir?
Cevabı göster
Semilunar lümen deformasyonu veya eksantrik darlık. Diseksiyon BT'de semilunar lümen deformasyonu veya eksantrik darlık şeklinde görülebilir.
Periferik damar CTA'sında hangi etkenler ışın sertleşmesi artefaktlarına yol açabilir?
Cevabı göster
Metal donanım ve balistik fragmanlar. Metal donanım ve balistik fragmanlarla ilişkili ışın sertleşmesi artefaktları CTA tanısal doğruluğunu olumsuz etkileyebilir.

İlgili konular

Akut üst ekstremite iskemisi

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 17 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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