Intraabdominal Active Bleeding: Helical CT, MDCT (64slice), DSA and Homeostatic Embolization Findings

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1 Intraabdominal Active Bleeding: Helical CT, MDCT (64slice), DSA and Homeostatic Embolization Findings Poster No.: C-2495 Congress: ECR 2012 Type: Educational Exhibit Authors: B. ALPARSLAN, N. YILDIRIM, B. Hakyemez, A. Ozer, G Savci ; Bursa/TR, BURSA/TR, Türkiye/Bursa/TR Keywords: Hemorrhage, Embolisation, CT-Angiography, CT, Catheter arteriography, Emergency, Abdomen DOI: /ecr2012/C-2495 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives To illustrate the findings of intraabdominal active bleeding on helical CT, MDCT and DSA. To discuss the imaging manifestations, protocol advices and clinical implications. Background Vascular injuries of abdominal and pelvic organs may cause life-threatening bleeding and it is critical to recognize the imaging findings of active bleeding immediately and direct patients to either therapeutic angiography suit for embolization or urgent laparotomy. CECT and especially MDCT-A correctly demonstrates abdominal vessel map and integrity in a few seconds. Hence, these are substantial modalities in evaluating patients with suspected intraabdominal active bleeding. Imaging findings OR Procedure details CT findings indicative of vascular injury are: 1. End-organ abnormalities -> hypoperfusion, 2. Active contrast material extravasation, 3. Irregular or indistinct contour instead of the expected smooth vascular morphology, 4. Narrowing of the lumen of a vessel (may be due to spasm, perivascular hematoma, dissection, intramural hematoma or intimal injury with focal thrombosis), 5. Traumatic occlusion, evidenced by abrupt termination of the vessel, 6.Pseudoaneurysm, arteriovenous fistulae. Source of bleeding: artery vs. vein? It is important to differentiate the source of contrast extravasation to decide the treatment modality: conservative, coil embolization or laparotomy. At this point 'multiphasic imaging' helps us to distinguish: Page 2 of 16

3 active bleeding from contained vascular injury & arterial bleeding from venous bleeding Table 1 References: B. ALPARSLAN; Radiology, Bursa, TURKEY Multiphasic imaging: Arterial phase * 20-25'' Venous phase 60-70'' Delayed phase * 5-15' * X-ray dose should be modified! Page 3 of 16

4 Table 2 References: B. ALPARSLAN; Radiology, Bursa, TURKEY Images for this section: Page 4 of 16

5 Fig. 1 Fig. 2: Case 1: 23, M, trauma, hepatic artery injury Helical CT, 60'' image (a)at the hilum of the liver, just anterior to the portal vein, high density contrast extravasation with irregular margins(#) and surrounding hematoma(#) can be seen. Helical CT, delayed phase (5-10') (b)contrast media leaks from the injured artery and spreads through the perihepatic space (#). Fig. 3: To get further information about which vessel was effected (artery/venula) and severity of bleeding, MDCT and MDCT-A was performed. Extravasation within hematoma (#) is clearly seen in arterial phase (a) and extravasation becomes more prominent (#) in the portal phase (b). (also seen splenic injury and perisplenic hematoma) Page 5 of 16

6 Fig. 4: DSA was performed 30 min after MDCT and extravasation (#) from hepatic artery (just distal to the gastroduodenal artery bifurcation) was determined (a). With selective catheterization the extravasation became more prominent (#)(b).and the contrast agent spread to the perihepatic area (#, c). Page 6 of 16

7 Fig. 5: The bleeding was stopped by urgent coil embolization (#). The patient was hospitalized for other traumatic injuries and was discharged from the hospital after full recovery. Page 7 of 16

8 Fig. 6: Case 2: 26, M, trauma, hepatic artery injury Helical CT, 60'' image: In two consecutive images, active contrast extravasation spot in the center of the hematoma (#) at the gallbladder fossa and hepatic hilus. DSA demonstrated contrast extravasation from right hepatic artery (not shown) which was embolized with coils. Patient was discharged uneventfully. Fig. 7: Case 3: 43, M, trauma, spleen Helical CT, 60'' image: Active contrast media extravasation(#) and hematoma at the pancreatic tail region; laceration at the inferior pole of spleen(*) were detected. Page 8 of 16

9 Fig. 8: Multiphasic MDCT was performed 2h later: In arterial phase (a) lack of active contrast extravasation was in favour of bleeding from venous origin. Venous phase coronal reformatted images (b,c) showed enlarging hematoma(*) related to the inferior pole of spleen (#). The patient was discharged uneventfully after conservative therapy. Fig. 9: Case 4: 51, M, Hodgkin Lymphoma (+), trauma, spleen Helical CT, unenhanced(a) & 60'' image (b)hyperdense, spheric hematoma is clearly seen in unenhanced image (a, *). In portal venous phase image (b) contrast extravasation area isodense to vascular structures around (+) is depicted. Patient underwent splenectomy and bleeding was controlled but was lost due to other reasons. Page 9 of 16

10 Fig. 10: Case 5: 38, M, trauma, gastric perforation Helical CT (NECT and 60'' images: In NECT images (a and b) gastric wall irregularity is also seen(#) in addition to perihepatic fluid.in venous phase image (c) contrast blush (isodense to aorta) is seen within gastrohepatic ligament (#). Patient underwent surgery, in laparotomy gastric perforation and gastric artery injury were detected and successfully repaired. Fig. 11: Case 6: 47, M, trauma, liver hematoma Helical CT (60'' images): Hyperdense active bleeding spot is seen within the right lobe of liver (a,#) but due to the lack of multiphasic imaging it is hard to differentiate arterial-portal venous or hepatic venous origin. Three days later control CT was performed (b). The patient was treated conservatively and recovered uneventfully. Page 10 of 16

11 Fig. 12: Case 7: 63, M, multiple myeloma MDCT 70'' axial image(a), coronal (b) and sagittal (c) reformatted images: In some patients active bleeding(#) can be present irrelevant with the prediagnosis (in this case intraabdominal mass was suspected). Radiologists should be aware of the findings and immmediately inform the clinician. The patient was hemodynamically stable in CT suit but became unstable in his room and was lost despite vigorous resuscitation. Fig. 13: Case 8: 79, F, trauma Helical CT (60''): Images of pelvic (a), liver (b) and umblicus (c) levels demonstrate high density, intraperitoneal fluid (a,#), mesenteric haziness on the right side (c,#)and also thickening of left anterior renal fascia (c, #). The patient was treated conservatively and recovered uneventfully. Page 11 of 16

12 Fig. 14: Helical CT (15`): Images of pelvic (a), liver (b) and umblicus (c) levels demonstrate intraperitoneal fluid with increased density (a,#). The fluid also fills the perihepatic area (b,#). Mesenteric haziness on the right side became more prominent (c,#). Findings favour active bleeding. The patient was treated conservatively and recovered uneventfully. Fig. 15: Case 9: 82, M, massive rectal bleeding, angiodysplasia DSA images of the patient with massive rectal bleeding. Active extravasation site was detected (#) and was controlled after coil embolization. Page 12 of 16

13 Table 3 Page 13 of 16

14 Conclusion 1. Radiologist should be able to recognize active contrast extravasation immediately and inform the clinician ASAP. 2. Multiphasic imaging protocol is helpful for distinguishing active vs. contained and arterial vs. venous bleeding. The radiological conclusion is included in many clinical scoring systems & changes patient management. 3. Conservative therapy, Embolization and Surgery are the treatment options. Imaging has distinctive influence on the decision. Images for this section: Table 4 Page 14 of 16

15 Personal Information References 1. Vu M, Anderson SW, Shah N, Soto JA, Rhea JT. CT of blunt abdominal and pelvic vascular injury. Emerg Radiol Jan;17(1):21-9. Epub 2009 Apr 21. Review. 2. Uyeda J, Anderson SW, Kertesz J, Soto JA. Pelvic CT angiography: application to blunt trauma using 64MDCT. Emerg Radiol Mar;17(2): Epub 2009 Jul9. 3. Anderson SW, Lucey BC, Rhea JT, Soto JA. 64 MDCT in multiple trauma patients: imaging manifestations and clinical implications of active extravasation. Emerg Radiol Jul;14(3): Epub 2007 May Lane MJ, Katz DS, Shah RA, Rubin GD, Jeffrey RB Jr. Active arterial contrast extravasation on helical CT of the abdomen, pelvis, and chest. AJR Am J Roentgenol Sep;171(3): Sivit CJ. Detection of active intraabdominal hemorrhage after blunt trauma: value of delayed CT scanning. Pediatr Radiol Feb;30(2): Willmann JK, Roos JE, Platz A, Pfammatter T, Hilfiker PR, Marincek B, Weishaupt D. Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma. AJR Am J Roentgenol Aug;179(2): Taourel P, Vernhet H, Suau A, Granier C, Lopez FM, Aufort S. Vascular emergencies in liver trauma. Eur J Radiol Oct;64(1): Epub 2007 Sep Anderson SW, Soto JA, Lucey BC, Burke PA, Hirsch EF, Rhea JT. Blunt trauma: feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT. Radiology Feb;246(2): Murakami AM, Anderson SW, Soto JA, Kertesz JL, Ozonoff A, Rhea JT. Active extravasation of the abdomen and pelvis in trauma using 64MDCT. Emerg Radiol Sep;16(5): Epub 2009 Mar Kertesz JL, Anderson SW, Murakami AM, Pieroni S, Rhea JT, Soto JA. Detection of vascular injuries in patients with blunt pelvic trauma by using 64-channel multidetector CT. Radiographics Jan-Feb;29(1): Salazar GM, Walker TG. Evaluation and management of acute vascular trauma. Tech Vasc Interv Radiol Jun;12(2): Page 15 of 16

16 12. Letoublon C, Morra I, Chen Y, Monnin V, Voirin D, Arvieux C. Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications. J Trauma May;70(5): Page 16 of 16