Smadar Bogardus
University of Tennessee Medical Center
Knoxville, Tennessee
Disclosure information not submitted.
Alex Cavalea, MD
Assistant Professor
University of Tennessee Medical Center, United States
Disclosure information not submitted.
Bradley Pollard, MD, JD
Assistant Professor of Radiology
The University of Tennessee Medical Center at Knoxville, United States
Disclosure information not submitted.
Lou Smith, MD
Associate Professor of Surgery
University of Tennessee Medical Center, United States
Disclosure information not submitted.
Title: Management of Hemorrhage in an Extrapleural Hematoma with Intercostal Artery Embolization
Case Report Body:
Introduction:
An extrapleural hematoma (EPH) is an uncommon, potentially life-threatening condition of accumulated blood in the extrapleural space. EPH usually occurs after blunt thoracic trauma causing fractures which tear the intercostal or internal mammary vessels. Typical radiological findings of EH are a biconvex opacity on the involved hemithorax and the so-called displaced “extrapleural fat sign.”
Case Description:
A 96yo male presented with right-sided rib fractures, small right hemothorax and large right extrapleural hematoma with arterial extravasation with hypotension after a ground-level fall. Interventional radiology (IR) performed emergent thoracic angiography and embolized tertriary order branches of the right 10th intercostal artery. He was admitted to the intensive care unit for resuscitation. A multidisciplinary discussion ensued regarding drainage of the EPH included thoracoscopic vs. IR vs. bedside thoracostomy drainage. Given patient’s advanced age, a right-sided thoracostomy tube was placed at bedside under local anesthesia, creating a connection between the hematoma and pleural cavity. Approximately 1L of blood was evacuated on entry into the thorax using sterile suction and an additional 2.2L drained via the right-angled chest tube over the subsequent 48 hours.
Discussion:
EPH can present with respiratory distress and hypotension and has characteristic radiological findings. Contrast-enhanced CT is not only the best imaging tool for confirming EPH, but also the best technique for detecting the source of the bleeding. IR can be useful in minimally invasive hemorrhage control. Furthermore, the best approach to drainage of EPH is controversial.