AAST liver injury grading

AAST grade	Imaging criteria (CT findings)	Operative criteria	Pathologic criteria
I	Subcapsular hematoma <10% surface area Parenchymal laceration <1 cm in depth	Subcapsular hematoma <10% surface area Parenchymal laceration <1 cm in depth Capsular tear	Subcapsular hematoma <10% surface area Parenchymal laceration <1 cm Capsular tear
II	Subcapsular hematoma 10 to 50% surface area; intraparenchymal hematoma <10 cm in diameter Laceration 1 to 3 cm in depth and ≤10 cm length	Subcapsular hematoma 10 to 50% surface area; intraparenchymal hematoma <10 cm in diameter Laceration 1 to 3 cm in depth and ≤10 cm length	Subcapsular hematoma 10 to 50% surface area; intraparenchymal hematoma <10 cm in diameter Laceration 1 to 3 cm depth and ≤10 cm length
III	Subcapsular hematoma >50% surface area; ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma >10 cm Laceration >3 cm depth Any injury in the presence of a liver vascular injury or active bleeding contained within liver parenchyma	Subcapsular hematoma >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma >10 cm Laceration >3 cm in depth	Subcapsular hematoma >50% surface area; ruptured subcapsular or intraparenchymal hematoma Intraparenchymal hematoma >10 cm Laceration >3 cm in depth
IV	Parenchymal disruption involving 25 to 75% of a hepatic lobe Active bleeding extending beyond the liver parenchyma into the peritoneum	Parenchymal disruption involving 25 to 75% of a hepatic lobe	Parenchymal disruption involving 25 to 75% of a hepatic lobe
V	Parenchymal disruption >75% of hepatic lobe Juxtahepatic venous injury to include retrohepatic vena cava and central major hepatic veins	Parenchymal disruption >75% of hepatic lobe Juxtahepatic venous injury to include retrohepatic vena cava and central major hepatic veins	Parenchymal disruption >75% of hepatic lobe Juxtahepatic venous injury to include retrohepatic vena cava and central major hepatic veins

Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.
Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.
More than one grade of liver injury may be present and should be classified by the higher grade of injury.
Advance one grade for multiple injuries up to a grade III.

AAST: American Association for the Surgery of Trauma; CT: computed tomography.

From: Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg 2018; 85:1119. DOI: 10.1097/TA.0000000000002058. Copyright © 2018 American Association for the Surgery of Trauma. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

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AAST liver injury grading