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Renal Trauma


KEY FACTS

Imaging

  • Best diagnostic clue: Renal parenchymal defect with perirenal hemorrhage ± extravasation of blood/urine

  • CT findings

    • Laceration: Linear, hypoattenuating defect

    • Segmental renal infarct: Sharply demarcated, wedge-shaped area of decreased enhancement

    • Global infarction (nonenhancement) and no perinephric hematoma: Renal artery thrombosis

    • Global infarction (nonenhancement) and perinephric hematoma: Renal artery avulsion

  • Protocol advice: If renal laceration is evident, obtain 10- to 12-minute delayed scans

Top Differential Diagnoses

  • Hemorrhage from renal tumor

  • Hemorrhage from vasculitis

Pathology

  • Blunt, penetrating, and deceleration injuries

  • Serious renal injuries usually associated with multiorgan involvement

Clinical Issues

  • Flank pain, ecchymosis, hematuria, shock

  • Poor correlation between degree of hematuria and severity of injury

  • AAST classification correlates well between surgical and MDCT findings

Diagnostic Checklist

  • Consider possibility of underlying tumor if bleeding seems disproportionate to degree of trauma

  • Arterial extravasation usually requires catheter embolization

  • Urinary extravasation often requires ureteral stent ± catheter drainage of urinoma

Axial CECT following a motor vehicle crash shows a contour deformity
of the posterior aspect of the left kidney due to fracture (the shattered fragment is not shown on this image). Note the large perinephric hematoma
.

More inferior axial CECT in the same patient reveals multiple sites of active arterial extravasation
& a fragment of the fractured kidney
, consistent with a grade V injury. Due to the extensive parenchymal damage & active bleeding, emergent nephrectomy was performed.

Axial CECT in a 19-year-old man who sustained blunt abdominal trauma in a motorcycle crash reveals a traumatic renal artery occlusion
due to dissection. Nonenhancement of the right kidney
is consistent with global infarction, consistent with grade V injury.

Axial CECT in the same patient reveals an additional small area of active bleeding from the lumbar artery
, which accounted for bleeding into the perirenal and psoas compartments.

IMAGING

General Features

  • Best diagnostic clue

    • Renal parenchymal defect with perirenal hemorrhage ± extravasation of blood/urine

Radiographic Findings

  • IVP

    • Grade I: Normal

    • Grade II-IV: Delayed, absent excretion or extravasation

  • Most commonly used classification system for renal trauma was set forth by American Association for Surgery of Trauma (AAST)

    • AAST classification consists of 5 injury classifications

      • –

        ~ 80-85% of renal injuries are classified as grade I

    • AAST classification strongly correlates with surgical and MDCT findings

    • AAST classification of injury corresponds to clinical outcome

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