Helical computed tomographic scan in the evaluation of mediastinal gunshotwounds

Background: The standard evaluation of mediastinal gunshot wounds usually r equires angiography and either esophagoscopy or esophagography. In the pres ent study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies. Methods: This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiogra phy and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missi le tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued. Results: A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on th e basis of the result of the CT scan. Because of proximity of the bullet tr act, 12 patients required additional evaluation with eight angiograms and n ine esophageal studies. One of these patients had a positive angiogram (bul let resting against the ascending aorta) and underwent sternotomy for missi le removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aort a nor the esophagus, and no additional evaluation was pursued. There were n o missed mediastinal injuries in this group. Overall, 12 of 24 patients (50 %) had a change in management (either received an operation or avoided addi tional radiographic or endoscopic evaluation) on the basis of the CT scan. Conclusion: The helical CT scan provides a rapid, readily available, noninv asive means to evaluate missile trajectories. This permits accurate assessm ent of potential mediastinal injury and reduces the need for routine angiog raphic and esophageal studies.