 Hello everyone. This is Dr. Srivratthi from Isomedical College and Research Institute. Firstly, I would like to thank my co-authors for their support and CTBus for providing such a wonderful platform. The title of my study is Multiphasic CTI Evaluation of Blunt Renal Trauma – The Current Breast Practice. In this video, I will brief on how the study was conducted, the results obtained and their clinical implications. In the fast-moving world, we know that the occurrence of road traffic accidents and blunt trauma to abdomen is way more increasing. Though there have been many papers previously that have dealt with CT evaluation of solid organ injury, especially abdominal organ injury, in this study was done to throw more focus on neurotrauma and in particular renal trauma because the kidneys are the most vulnerable genital urinary organ involved in trauma. They constitute up to 5% of all trauma cases and account for about 24% of abdominal solid organ injuries. Though the kidneys are well protected in the retroparitonium, they are fixed only by the renal pelvis in the pelvic urinary junction and by the vascular pedicle. This makes them particularly more vulnerable. Fast scanning, i.e. focus assessment with sonography for trauma, is a rapid mean to detect intraabdominal free flow. However, this technique has got low sensitivity and specificity for renal trauma. Hence the need for CT scanning and contrast enhanced CT scan in particularly a multi-phasic study is a gold standard in hemodynamically stable patients for assessing renal organ injuries. With CT, high quality images can be obtained and multi-planar reconstructions can be done which can show the anatomy in exceptional detail as well as pick up the various injuries and help them grade for surgical management. Coming to the objectives, this study was done to study the pattern of injuries in blunt renal trauma using multi-phasic contrast enhanced CT and to classify these injuries based on the AAST grading system. AAST stands for American Association for Surgery of Trauma. This study was conducted in the department of radio diagnosis, Mysore Medical College and the sample size of 35 patients were included. This was a descriptive study. Those patients who had a positive fast scan for intraperitonal or perinephric fluid collection and those who had clinical suspicion of renal injury and hemodynamically stable patients were included in the study, while all hemodynamically unstable patients who were taken up for surgery were excluded from the study. CT scanning was performed in a somatom, semen CT scanner and it was done under four phases. A pre-contrast study, a post-contrast study which was taken in the arterial that is cortico medullary phase, 20 to 30 seconds post injection, an ephrogenic phase, 70 to 90 seconds and a delayed phase of 5 to 10 minutes. Patients received about 1.5 to 2 ml per kg for IV contrast media. The pre-contrast phase was done to identify active bleeding and intra parenchymal hematoma. Post-contrast phases was done to identify parenchymal and vascular damage including active contrast extravasation and to look for other swallowed organ injuries. The delayed phase in particular can help us visualize the collecting system and help rule out possible uretric injury. Coming to the results of the study, you can see from this pie chart that the majority of the affected populations were males. Around 80% of those affected were males. This is in keeping with the fact that road traffic accidents or blunt trauma to them is much more common in the male population. And when we look at the age distribution, most of the patients were under the age group of 15 years. This is because younger adults and children are particularly at higher risk due to several anatomical factors like decreased perirhenal fat, weaker abdominal musculature and a less ossified thoracic cage. All of these offering to less protection to the kidneys. When looking at the mode of injury, road traffic accident comprises a majority of the cases. Nearly around 49 that is around half the cases were due to road traffic accidents followed by fall and assault. And coming to the grading of injury, we can see that nearly half the cases are grade 4 injuries while this is followed by grade 3 and grade 2 injury. Grade 1 and 5 injuries were minimally observed. So the most common injury that was seen in our study was a grade 4 injury. And these patients, you can see that nearly 89% that is 90% of the cases have been managed conservatively and only a small proportion of the patients have been taken up for surgery. This is the AAST renal injury scoring scale that was followed. There are five grades each grade representing a higher form of injury and one grade was advanced for bilateral injuries up to grade 3. These are the few reference cases. The first image is a coronal CCT image. You can see that a grade 1 injury includes either a subcapsular hematoma or a renal contusion. In this image, you can see there is subcapsular fluid collection that is flattening the post-olateral contour of the left kidney. This is again a grade 1 injury wherein you can see that there is a hypoenhancing area in the in the pole of the left kidney. This was a renal contusion. This case was a grade 2 injury. Grade 2 injuries include renal lacerations that are small that is less than 1 centimeter and which does not extend into the collecting system. You can see that in the interpole region there is a small laceration and an associated subcapsular hematoma. We can very well see that this laceration is not extending into the callusial system. Grade 3 injuries include deeper lacerations that is more than 1 centimeter and which does not involve the collecting system. You can see that there are multiple lacerations in the inter and lower pole region of the left kidney and none of these extended into the collecting system. Hence this patient was graded to have a grade 3 AISD renal injury. Coming to grade 4 injuries, these include much deeper lacerations that is extending into the collecting system. So that will be active contrastabilization or any subsegmental infact is also graded as a grade 4 injury. You can see that in this patient the right kidney in the lower pole region we can see that there is a wedge shaped non-enhancing areas in keeping with the subsegmental renal infact. This was a grade 4 injury. Again one more case of grade 4 injury where you can see that there is thrombotic occlusion of the right renal artery and there is global infarction of the right kidney. This is also graded as a grade 4 injury. Coming to grade 4 injury, this includes either a shattered kidney or a vascular pedicle avulsion at the renal hyalum. So here you can see that in the right kidney there is a through and through laceration in the lower pole region and this extended into the collecting system. This can be very well demonstrated in the delayed scan where in the excretory phase you can see that there is active contrastabilization. Such contrastabilization and collecting system injury will comprise only a grade 4 or a grade 5 injury. So concluding we can very well see that from the study nearly 89% that is 90% of the patients were managed conservatively. So this shows that there is a paradigm shift in the management of renal trauma cases with a clear transition towards a non-operative approach. And this transition is mainly because of improvements in imaging modalities in particularly CT scanning and because of the addition of novel minimally invasive treatment techniques. Thus as a radiologist we need to provide an accurate and a prom diagnosis of the grade of injury so that the neurosurgeon will be benefited and can formulate the appropriate management protocol that is deemed necessary. Hence this study again reiterates the fact that renal multi-phase contrastabilization CT scanning is the current best practice for picking up renal injuries as well as grading them so that the treatment protocol can be formulated easily. These are my references. Thank you.