Imaging traumatic cardiac injury: A mechanism-based diagnostic approach

Traumatic cardiac injury (TCI) is a critical condition with high morbidity and mortality, often presenting with nonspecific clinical signs or being masked by coexisting thoracic trauma. Prompt diagnosis is essential but challenging. Using representative clinical cases as an organizing framework, this narrative review summarizes the imaging manifestations of TCI across blunt, penetrating, and iatrogenic mechanisms, with attention to modality-specific capabilities, limitations, and practical selection based on hemodynamic status and expected injury patterns. Representative pathologies include myocardial rupture, hemopericardium, cardiac herniation, pseudoaneurysm, device-related injuries, and coronary perforation, as well as underrecognized entities such as intramyocardial hematoma and bullet embolism. Electrocardiography and cardiac troponin, rather than imaging, remain the initial screening tests for blunt cardiac injury; imaging is directed at patients with hemodynamic compromise, abnormal screening results, or a mechanism suggesting a specific structural lesion. Within that pathway, contrast-enhanced computed tomography (CT), with selective electrocardiography (ECG) gating, is central to structural assessment in stable patients, echocardiography enables rapid bedside triage when instability precludes transfer, and magnetic resonance imaging (MRI) provides tissue characterization in the subacute setting. By outlining trauma mechanisms, modality strengths, and common clinical contexts, this review offers practical guidance to support radiologists in recognizing TCI, selecting the most informative next imaging test, and coordinating care with trauma surgeons, emergency physicians, and cardiologists. Because much of the available evidence derives from case reports and small series, management statements are presented as reported practice rather than as evidence-graded recommendations.