Imaging Pearls ❯ Musculoskeletal ❯ Vascular
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- BACKGROUND: Retroperitoneal and rectus sheath hematomas can occur spontaneously. There is a lack of research about the disease progression, optimal treatment strategies and the need for surgical intervention. Our study investigated their outcomes and management.
RESULTS: 99 patients were included; median age was 73-years (IQR 61-80). 88 patients were on an anticoagulant or antiplatelet agent. Warfarin and intravenous heparin being the most commonly utilized agents (42% and 36.4%, respectively). All 99 patients were diagnosed by CT scan. 79 patients received some sort of blood product (79.8% PRBC, 43.4% FFP, 17% platelets), and 26 patients were in hemorrhagic shock. 17 patients underwent angiography and/or angioembolization. Neither anticoagulation in general nor any specific agent was associated with the need for blood product transfusion or angiography. 13 patients died but none were attributable to the hematoma.
CONCLUSION: Both hematomas are usually self-limiting and rarely require surgical intervention. A subset may require angioembolization.
Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.
Warren MH et al.
Am J Surg. 2019 May 14. pii: S0002-9610(19)30097-2. doi: 10.1016/j.amjsurg.2019.05.002. [Epub ahead of print} - “A rectus sheath hematoma (RSH), or bleeding into the rectus abdominis muscles, is usually secondary to damage to the epigastric arteries or the muscle itself. Like SRH, these hemorrhages can be difficult to diagnose, as patients present with abdominal pain and often an abdominal mass that can imitate many other conditions. While trauma is a common etiology, spontaneous RSH can occur.”
Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.
Warren MH et al.
Am J Surg. 2019 May 14. pii: S0002-9610(19)30097-2. doi: 10.1016/j.amjsurg.2019.05.002. [Epub ahead of print} - “One of the main objectives was to determine how clinicians are currently diagnosing these cases. In this study, all cases were diagnosed by CT scan. This is not surprising since patients often present with vague, non-specific symptoms that make organ specific imaging difficult to use. Also detecting retroperitoneal pathology can be limited by other imaging modalities. CT scan with contrast also provides additional information as evidence of active contrast extravasation may direct the clinician toward angioembolization.”
Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.
Warren MH et al.
Am J Surg. 2019 May 14. pii: S0002-9610(19)30097-2. doi: 10.1016/j.amjsurg.2019.05.002. [Epub ahead of print} - ”Spontaneous retroperitoneal and rectus sheath hematomas are serious complications for patients and require close monitoring. As they closely correlate with age and anticoagulation, clinicians will continue to see more of these cases. These patients rarely require surgical intervention and are primarily managed without an intervention. Larger multicenter studies are needed to establish guidelines.”
Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.
Warren MH et al.
Am J Surg. 2019 May 14. pii: S0002-9610(19)30097-2. doi: 10.1016/j.amjsurg.2019.05.002. [Epub ahead of print} - ” First described almost 70 years ago, retroperitoneal hematomas are relatively rare conditions with a reported incidence in anticoagulated patients as low as 0.1% and as high as 0.6%. While most commonly seen after procedures such as femoral artery catheterizations or blunt abdominal trauma, a subgroup of these bleeds occurs without associated trauma or medical instrumentation thus classified as spontaneous retroperitoneal hematomas (SRH). Patients with SRH often present in the emergency department with vague complaints, such as abdominal and back pain, which increase the likelihood of a delayed or missed diagnosis.”
Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas.
Warren MH et al.
Am J Surg. 2019 May 14. pii: S0002-9610(19)30097-2. doi: 10.1016/j.amjsurg.2019.05.002. [Epub ahead of print}
- CT Angiography of the Upper Extremities: Applications
- Atherocsclerotic disease
- Thromboembolic disease
- Aortic dissection
- Vasculitis
- Small artery vasculitis
- Fibromuscular dysplasia
- Extrinsic compression syndrome
- Connective tissue disorders
- Preprocedural planning and postprocedural evaluation - “ Takayasu arteritis, giant cell arteritis and thromboangitis obliterans are the most common types of vasculitides that affect upper extremity vessels.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763 - “ Thoracic outlet syndrome (TOS) refers to compression of the neurovascular bundle as it crosses through the thoracic inlet.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763 - Thoracic Outlet Syndrome: Facts
- Clinical presentation is pain, tingling, weakness, or other symptoms of the ipsilateral upper extremity
- The syndrome may be caused by neurogenic, arterial, venous or combined causes although the neurogenic cause is most common
- Arterial involvement can be diagnosed by CT with arm in both abduction and the neutral position - “ CTA plays a significant role in the planning of complex arterial surgical reconstructions where upper extremity arterial mapping is needed.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763 - “ Traditionally, vascular mapping is performed with duplex ultrasound, but CTA and MRA may be performed for more anatomic imaging.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763 - “ Complications of dialysis access are typically diagnosed with DSA and ultrasound. However, CTA has also been shown to reveal complications such as arterial steal,aneurysm formation, stenoses, and occlusions.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763 - “ CT angiography has become an important diagnostic imaging modality for the evaluation of upper extremity vascular pathologic abnormalities. The attractiveness of upper extremity is 24 hour availability, rapid acquisition, minimal invassiveness, and the display of both vascular and musculoskeletal structures.”
CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
Bozlar U et al.
AJR 2013; 201:753-763