CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption.

Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. © RSNA, 2018 Online supplemental material is available for this article.

[1]  J. Soto,et al.  64 MDCT in multiple trauma patients: imaging manifestations and clinical implications of active extravasation , 2007, Emergency Radiology.

[2]  Byoung Wook Choi,et al.  How to Develop, Validate, and Compare Clinical Prediction Models Involving Radiological Parameters: Study Design and Statistical Methods , 2016, Korean journal of radiology.

[3]  L. Lönn,et al.  Update on the roles of angiography and embolisation in pelvic fracture. , 2008, Injury.

[4]  Edward Herskovits,et al.  Volumetric analysis of pelvic hematomas after blunt trauma using semi-automated seeded region growing segmentation: a method validation study , 2016, Abdominal Radiology.

[5]  Peter Cummings,et al.  Predicting major hemorrhage in patients with pelvic fracture. , 2006, The Journal of trauma.

[6]  Borut Marincek,et al.  Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. , 2002, AJR. American journal of roentgenology.

[7]  G. Velmahos,et al.  Angiographic embolization for pelvic fractures in older patients. , 2004, Archives of surgery.

[8]  N. Schep,et al.  Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature. , 2009, Injury.

[9]  Stephan W Anderson,et al.  Multidetector CT of blunt abdominal trauma. , 2012, Radiology.

[10]  J. Soto,et al.  CT of Major Vascular Injury in Blunt Abdominopelvic Trauma. , 2016, Radiographics : a review publication of the Radiological Society of North America, Inc.

[11]  Heoung Keun Kang,et al.  Pelvic arterial hemorrhage in patients with pelvic fractures: detection with contrast-enhanced CT. , 2004, Radiographics : a review publication of the Radiological Society of North America, Inc.

[12]  D. Dreizin,et al.  Blunt polytrauma: evaluation with 64-section whole-body CT angiography. , 2012, Radiographics : a review publication of the Radiological Society of North America, Inc.

[13]  K. Linnau,et al.  Can CT predict the source of arterial hemorrhage in patients with pelvic fractures? , 2002, Emergency Radiology.

[14]  Stanley Lemeshow,et al.  Applied Logistic Regression, Second Edition , 1989 .

[15]  W. Mali,et al.  Atherosclerotic renal artery stenosis: ostial or truncal? , 1996, Radiology.

[16]  A. Cohen,et al.  Multidetector CT evaluation of active extravasation in blunt abdominal and pelvic trauma patients. , 2008, Radiographics : a review publication of the Radiological Society of North America, Inc.

[17]  H. Kreder,et al.  Early detection of arterial bleeding in acute pelvic trauma. , 1999, The Journal of trauma.

[18]  Marvin Tile,et al.  Acute Pelvic Fractures: I. Causation and Classification , 1996, The Journal of the American Academy of Orthopaedic Surgeons.

[19]  D. Cicchetti.  Guidelines, Criteria, and Rules of Thumb for Evaluating Normed and Standardized Assessment Instruments in Psychology. , 1994 .

[20]  Y. Ben-menachem,et al.  Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. , 1991, AJR. American journal of roentgenology.

[21]  J. Hanley,et al.  A method of comparing the areas under receiver operating characteristic curves derived from the same cases. , 1983, Radiology.

[22]  J. Soto,et al.  Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT. , 2008, Radiology.

[23]  Heinz Holling,et al.  A limitation of the diagnostic-odds ratio in determining an optimal cut-off value for a continuous diagnostic test , 2011, Statistical methods in medical research.

[24]  K. Linnau,et al.  Assessment of volume of hemorrhage and outcome from pelvic fracture. , 2003, Archives of surgery.

[25]  P. Rhee,et al.  Does Pelvic Hematoma on Admission Computed Tomography Predict Active Bleeding at Angiography for Pelvic Fracture? , 2005, The American surgeon.