# Unexpected early pulmonary thrombi in war injured patients

## TL;DR

Young war-injured patients show unexpected early pulmonary thrombi, often missed by radiologists, with no right ventricular issues.

## Contribution

Identifies a high prevalence of undiagnosed pulmonary thrombi in young trauma patients using AI detection.

## Key findings

- AI detected 5.6% of war-injured patients with pulmonary thrombi, 60% of which were undiagnosed initially.
- No significant right ventricular dilatation was observed in any patient with pulmonary thrombi.

## Abstract

Pulmonary embolism is commonly associated with deep vein thrombosis and the components of Virchow’s triad: hypercoagulability, stasis, and endothelial injury. High-risk patients are traditionally those with prolonged immobility and hypercoagulability. Recent findings of pulmonary thrombosis (PT) in healthy combat soldiers, found on CT performed for initial trauma assessment, challenge this assumption. The aim of this study was to investigate the prevalence and characteristics of PT detected in acute traumatic war injuries, and evaluate the effectiveness of an artificial intelligence (AI) algorithm in these settings.

This retrospective study analyzed immediate post-trauma CT scans of war-injured patients aged 18–45, from two tertiary hospitals between October 7, 2023, and January 7, 2024. Thrombi were retrospectively detected using AI software and confirmed by two senior radiologists. Findings were compared to the original reports. Clinical and injury-related data were analyzed.

Of 190 patients (median age 24, IQR (21.0–30.0), 183 males), AI identified 10 confirmed PT patients (5.6%), six (60%) of whom were not originally diagnosed. The only statistically significant difference between PT and non-PT patients was increased complexity and severity of injuries (higher Injury Severity Score, median (IQR) 21.0 (20.0–21.0) vs 9.0 (4.0–14.5), p = 0.01, accordingly). Despite the presence of thrombi, significant right ventricular dilatation was absent in all patients.

This report of early PT in war-injured patients provides a unique opportunity to characterize these findings. PT occurs more frequently than anticipated, without clinical suspicion, highlighting the need for improved radiologists’ awareness and the crucial role of AI systems as diagnostic support tools.

Question
What is the prevalence, and what are the radiological characteristics of arterial clotting within the pulmonary arteries in young acute trauma patients?

Findings
A surprisingly high occurrence of PT with a high rate of missed diagnoses by radiologists. All cases did not presented right ventricular dysfunction.

Clinical relevance
PT is a distinct clinical entity separate from traditional venous thromboembolism, which raises the need for further investigation of the appropriate treatment paradigm.