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Penetrating Neck Injury

Variant: 1   Penetrating neck injury. Clinical soft injury signs.
Procedure Appropriateness Category Relative Radiation Level
Radiography neck Usually Appropriate ☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
US neck May Be Appropriate O
Arteriography neck May Be Appropriate ☢☢☢
Fluoroscopy biphasic esophagram May Be Appropriate ☢☢☢
MRA neck without and with IV contrast May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O

Variant: 2   Penetrating neck injury. Normal or equivocal CTA. Concern for vascular injury.
Procedure Appropriateness Category Relative Radiation Level
Arteriography neck Usually Appropriate ☢☢☢
US neck May Be Appropriate O
MRA neck without and with IV contrast May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O

Variant: 3   Penetrating neck injury. Normal or equivocal CTA. Concern for aerodigestive injury.
Procedure Appropriateness Category Relative Radiation Level
Fluoroscopy single contrast esophagram Usually Appropriate ☢☢☢
MRI neck without and with IV contrast May Be Appropriate O
MRI neck without IV contrast May Be Appropriate O

Panel Members
Summary of Literature Review
Introduction/Background
Overview of Imaging Modalities
Discussion of Procedures by Variant

A. Radiography

B. CTA

C. Arteriography, MRI, MRA, US, and Esophagram

A. Arteriography

B. US

C. MRA

A. Barium Swallow

B. MRI
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information
References
1. O'Brien PJ, Cox MW. A modern approach to cervical vascular trauma. Perspect Vasc Surg Endovasc Ther. 2011;23(2):90-97.
2. Saito N, Hito R, Burke PA, Sakai O. Imaging of penetrating injuries of the head and neck:current practice at a level I trauma center in the United States. [Review]. Keio J Med. 63(2):23-33, 2014.
3. Steenburg SD, Sliker CW, Shanmuganathan K, Siegel EL. Imaging evaluation of penetrating neck injuries. Radiographics. 2010;30(4):869-886.
4. Bagheri SC, Khan HA, Bell RB. Penetrating neck injuries. Oral Maxillofac Surg Clin North Am. 2008;20(3):393-414.
5. Inaba K, Branco BC, Menaker J, et al. Evaluation of multidetector computed tomography for penetrating neck injury: a prospective multicenter study. J Trauma Acute Care Surg. 2012;72(3):576-583; discussion 583-574; quiz 803-574.
6. Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck trauma: a review of management strategies and discussion of the 'No Zone' approach. [Review]. American Surgeon. 79(1):23-9, 2013 Jan.
7. Low GM, Inaba K, Chouliaras K, et al. The use of the anatomic 'zones' of the neck in the assessment of penetrating neck injury. Am Surg. 2014;80(10):970-974.
8. Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association critical decisions in trauma: penetrating neck trauma. J Trauma Acute Care Surg. 2013;75(6):936-940.
9. Brennan J, Lopez M, Gibbons MD, et al. Penetrating neck trauma in Operation Iraqi Freedom. Otolaryngol Head Neck Surg. 2011;144(2):180-185.
10. Stallmeyer MJ, Morales RE, Flanders AE. Imaging of traumatic neurovascular injury. Radiol Clin North Am 2006;44:13-39, vii.
11. Burgess CA, Dale OT, Almeyda R, Corbridge RJ. An evidence based review of the assessment and management of penetrating neck trauma. [Review]. Clin Otolaryngol. 37(1):44-52, 2012 Feb.
12. Brywczynski JJ, Barrett TW, Lyon JA, Cotton BA. Management of penetrating neck injury in the emergency department: a structured literature review. Emerg Med J. 2008;25(11):711-715.
13. Munera F, Cohn S, Rivas LA. Penetrating injuries of the neck: use of helical computed tomographic angiography. J Trauma 2005;58:413-8.
14. Patterson BO, Holt PJ, Cleanthis M, et al. Imaging vascular trauma. [Review]. Br J Surg. 99(4):494-505, 2012 Apr.
15. Munera F, Danton G, Rivas LA, Henry RP, Ferrari MG. Multidetector row computed tomography in the management of penetrating neck injuries. Semin Ultrasound CT MR. 2009;30(3):195-204.
16. Meghoo CA, Dennis JW, Tuman C, Fang R. Diagnosis and management of evacuated casualties with cervical vascular injuries resulting from combat-related explosive blasts. J Vasc Surg. 55(5):1329-36; discussion 1336-7, 2012 May.
17. Woo K, Magner DP, Wilson MT, Margulies DR. CT angiography in penetrating neck trauma reduces the need for operative neck exploration. Am Surg. 2005;71(9):754-758.
18. Schroll R, Fontenot T, Lipcsey M, et al. Role of computed tomography angiography in the management of Zone II penetrating neck trauma in patients with clinical hard signs. J Trauma Acute Care Surg. 79(6):943-50; discussion 950, 2015 Dec.
19. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual.
20. Cox MW, Whittaker DR, Martinez C, Fox CJ, Feuerstein IM, Gillespie DL. Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg. 46(6):1227-33, 2007 Dec.
21. Greer LT, Kuehn RB, Gillespie DL, et al. Contemporary management of combat-related vertebral artery injuries. J Trauma Acute Care Surg. 2013;74(3):818-824.
22. Fox CJ, Gillespie DL, Weber MA, et al. Delayed evaluation of combat-related penetrating neck trauma. J Vasc Surg. 44(1):86-93, 2006 Jul.
23. Schroeder JW, Baskaran V, Aygun N. Imaging of traumatic arterial injuries in the neck with an emphasis on CTA. Emerg Radiol. 2010;17(2):109-122.
24. Demetriades D, Theodorou D, Cornwell E, et al. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. World J Surg. 1997;21(1):41-47; discussion 47-48.
25. Demetriades D, Theodorou D, Cornwell E, 3rd, et al. Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow Doppler imaging. Arch Surg. 1995;130(9):971-975.
26. Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A. Imaging of laryngeal trauma. [Review]. European Journal of Radiology. 83(1):142-54, 2014 Jan.
27. Ahmed N, Massier C, Tassie J, Whalen J, Chung R. Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient. J Trauma. 2009;67(1):152-154.
28. American College of Surgeons. Advanced Trauma Live Support (ATLS) for Doctors Student Course Manual. 9th ed. Chicago, IL: American College of Surgeons; 2012.
29. Bodanapally UK, Shanmuganathan K, Dreizin D, et al. Penetrating aerodigestive injuries in the neck: a proposed CT-aided modified selective management algorithm. Eur Radiol. 2016;26(7):2409-2417
30. Conradie WJ, Gebremariam FA. Can computed tomography esophagography reliably diagnose traumatic penetrating upper digestive tract injuries? Clin Imaging. 2015;39(6):1039-1045
31. Montalvo BM, LeBlang SD, Nunez DB, Jr., et al. Color Doppler sonography in penetrating injuries of the neck. AJNR Am J Neuroradiol. 1996;17(5):943-951.
32. American College of Radiology. ACR–ASNR–SNIS–SPR Practice Parameter for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=73+&releaseId=2
33. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.