title: "Blush at first sight": significance of computed tomographic and angiographic discrepancy in patients with blunt abdominal trauma.
abstract: BACKGROUND
  "Blush," defined as a focal area of contrast pooling within a hematoma, is frequently encountered in patients with severe blunt torso trauma. Contemporary clinical practice guidelines recommend the use of angiography with embolization in all hemodynamically stable patients with evidence of active extravasation. Patients presenting with blush visualized on computed tomography (CT), but not demonstrated on subsequent angiography, present a challenging clinical dilemma. The purpose of this study was to study the natural course of patients with this blush disparity between CT and angiography.
  
  
  METHODS
  The study was conducted as a retrospective analysis of patients who underwent angiography after initial CT scans revealed blush after blunt abdominal trauma at a level I trauma center (January 2005 to December 2014).
  
  
  RESULTS
  A total of 143 patients with blunt splenic injuries were found to have CT blush and underwent catheter angiography. Of the 143 patients with blush on CT, 24 (17%) showed no evidence of blush on angiography. Patients with CT-angiographic discrepancy were more than twice as likely to rebleed compared with those with angiographic evidence of blush (25% vs 10%, P < .05). This is due to the fact that although all patients with blush on angiography underwent embolization, only 7/22 of those with no evidence of blush were embolized. Sixty-eight patients with blunt liver injuries demonstrated blush on CT and underwent catheter angiography. Of the 68 patients with blush on CT, 22 patients (33%) showed no evidence of blush on angiography. None of these 22 patients underwent angioembolization. The rebleeding rate in this cohort was 32% (7/22). Again, this was more than twice the rate observed in patients who did have angiographic evidence of blush and were embolized (11%, 5/46).
  
  
  CONCLUSIONS
  CT imaging has enhanced our ability to detect contrast extravasation after injury, and evidence of blush on CT suggests the presence of active hemorrhage. This analysis suggests that in clinical situations in which CT blush is noted secondary to blunt trauma to the spleen or liver, a negative angiogram still carries a significant risk of recurrent hemorrhage; consideration for empiric embolization at the time of the initial procedure even in the absence of blush on angiographic evaluation is thus warranted. Prospective studies are needed to validate these findings and to assess the utility of this clinical paradigm.
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Abdul Q
authors.initials: AQ
authors.lastname: Alarhayem
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: John G
authors.initials: JG
authors.lastname: Myers
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Dent
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lamus
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Jorge
authors.initials: J
authors.lastname: Lopera
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Lily
authors.initials: L
authors.lastname: Liao
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Ramon
authors.initials: R
authors.lastname: Cestero
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA.
authors.forename: Ronald
authors.initials: R
authors.lastname: Stewart
authors.affiliation: Departments of Surgery and Radiology, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78260, USA. Electronic address: Eastridge@uthscsa.edu.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Eastridge
mesh_terms: D000007:Abdominal Injuries / Q000000981:diagnostic imaging* / Q000628:therapy*; D000328:Adult; D000792:Angiography; D003287:Contrast Media; D004621:Embolization, Therapeutic; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000000981:diagnostic imaging; D005260:Female; D006470:Hemorrhage / Q000000981:diagnostic imaging* / Q000628:therapy*; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging / Q000293:injuries; D008297:Male; D012189:Retrospective Studies; D013154:Spleen / Q000000981:diagnostic imaging / Q000293:injuries; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging* / Q000628:therapy*
chemical_list: D003287:Contrast Media
keywords: Abdominal CT; Angiography; Embolization; Hemorrhage; Solid organ