An 18-year-old male presented to emergency department with an alleged history of road traffic accident in an unconscious and hemodynamically unstable state with a Glasgow coma score of 3. Primary survey revealed traumatic brain injury, blunt trauma to the abdomen with soft tissue and bone injuries.
Radiographic imaging revealed compound fracture of right distal femur (Fig 1), Shaft of the left tibia (Fig 2), pubic diastasis (Fig 3)
Ultrasound abdomen showed liver contusion (Fig 4) with minimal hemoperitoneum.
CECT [Contrast Enhanced Computed Tomography] abdomen showed Grade-2 liver injury with contusion (Fig 5), hypo enhancing spleen (Fig 5), mild hemoperitoneum (Fig 6), flattened IVC [Inferior vena cava] (Fig 5&7), hyper enhancing small bowel walls with mucosal thickening (Fig 8), hyper enhancing adrenals (Fig 9), heterogenous pancreas with peri pancreatic fluid (Fig 5&10).
CT Pelvis revealed un displaced fracture of right superior and inferior pubic rami and left ala of sacrum, pelvic hematoma, inflammation of the anterior abdominal muscles at the level of pelvis.
CT Brain showed left tentorial SAH, haemorrhage in occipital horns of bilateral lateral ventricles, along the interventricular septum and posterior interhemispheric falx.
This is a case of hypoperfusion complex secondary to polytrauma in a young male patient. Symptomatic management to maintain hemodynamic stability and surgical management for the fractures was done and the patient`s clinical status significantly improved over the time. CT hypoperfusion complex occurs at a higher rate in post-traumatic patients. However, shock can occur due to multiple causes like hypovolemia, trauma, sepsis, cardiac arrest, severe head injury. There are three stages of shock: compensatory, decompensatory, and irreversible. Understanding the signs of CT hypoperfusion complex prevents confusion with other pathologies like ileus, gallbladder perforation, mesenteric ischemia, portal venous thrombosis. The signs of CT hypoperfusion complex can be divided under two: vascular and non-vascular . It is said that vascular signs represent the true hypovolemic state and nonvascular /visceral signs represent hypoperfusion state. Low-calibrated abdominal aorta, IVC, and mesenteric arteries come under vascular signs. Dilated and edematous bowel loops, hyperdense adrenal glands, shock kidney, shock pancreas, free fluid in the abdomen, splenic and hepatic perfusion deficits, and pericholecystic fluid come under non-vascular signs. Presence of two or more vascular, visceral, or parenchymal signs is necessary to establish the presence of CT hypoperfusion complex .
The following can be considered as the diagnostic criteria:
Hypovolemia leads to decreased arterial inflow and venous outflow resulting in the ischemic change. Acute disruption of the autoregulatory mechanisms of circulation results in adrenergic responses maintaining cardiac output and sufficient blood pressure. When compensatory measures are overcome by ongoing haemorrhage, the uncompensated state results in early ischemic changes, which can rapidly become irreversible without resuscitation.. The appropriate treatment is supportive therapy rather than the surgical intervention.
The CT hypoperfusion complex can be seen in blunt trauma patients with hypovolemic shock. It offers a quick guidance in the acute trauma setting, allowing the radiologist to alert the treating physicians to a possible impending hypovolemic shock.
 Di Serafino M, Viscardi D, Iacobellis F, Giugliano L, Barbuto L, Oliva G, Ronza R, Borzelli A, Raucci A, Pezzullo F, De Cristofaro MG, Romano L. Computed tomography imaging of septic shock. Beyond the cause: the "CT hypoperfusion complex". A pictorial essay. Insights Imaging. 2021 Jun 5;12(1):70. doi: 10.1186/s13244-021-01006-5. PMID: 34089401; PMCID: PMC8178660.
 Sugi MD, Menias CO, Lubner MG, Bhalla S, Mellnick VM, Kwon MH, Katz DS. CT Findings of Acute Small-Bowel Entities. Radiographics. 2018 Sep-Oct;38(5):1352-1369. doi: 10.1148/rg.2018170148. PMID: 30207931.
 Ames JT, Federle MP. CT hypotension complex (shock bowel) is not always due to traumatic hypovolemic shock. AJR Am J Roentgenol. 2009 May;192(5):W230-5. doi: 10.2214/AJR.08.1474. PMID: 19380528.
 Anand T, vanSonnenberg E, Gadani K, Skinner R. A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis. Injury. 2016 Jan;47(1):50-2. doi: 10.1016/j.injury.2015.09.013. Epub 2015 Sep 28. PMID: 26434575.
 Elst J, Ghijselings IE, Zuidema WP, Berger FH. Signs of post-traumatic hypovolemia on abdominal CT and their clinical importance: A systematic review. Eur J Radiol. 2020 Mar;124:108800. doi: 10.1016/j.ejrad.2019.108800. Epub 2019 Dec 24. PMID: 31935595.
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