Active Contrast Extravasation Research Articles

1:54 PM, Abstract No. 111 - Provocative mesenteric angiography for gastrointestinal hemorrhage

Mesenteric angiography with transcatheter embolization can be a highly effective means of controlling gastrointestinal bleeding (GIB) when a source of hemorrhage is identified. However, given the intermittent nature of hemorrhage, a majority of cases of mesenteric angiography performed for GIB fail to demonstrate active bleeding. One approach for increasing the positive diagnostic rate is that of provocative angiography. Here we report our recent experience and outcomes with this protocol. A protocol for provocative angiography at a major academic medical center was developed and standardized as follows. In all cases at least one prior negative mesenteric arteriogram without provocation has been performed, any contraindications to the thrombolytic agent, tissue plasminogen activator (tPA), are excluded and surgical backup is obtained. The superior mesenteric artery is selectively catheterized and injected with 5000 units of heparin and 100 micrograms of nitroglycerin. Subsequent DSA is performed. If no source of hemorrhage is identified, 10 mg of tPA are administered via the catheter and repeat angiography is performed. If negative, the inferior mesenteric artery is catheterized and an additional 10 mg of tPA are administered. The total dose of tPA is limited to 20 mg. 19 cases of provocative mesenteric angiography were performed from June 2008 through September 2013. Of these, 14 (74%) were negative despite the provocative maneuvers. 5/19 (26%) demonstrated active contrast extravasation. Of these positive cases, 3 (60%) were successfully embolized at the time of angiography. In one case, the decision was made in conjunction with the surgical staff to defer embolization in favor of surgery. In the second case, a very small focus of bleeding was identified in distal arterial branches which could not be safely accessed. Provocative angiography can be performed safely, without causing life-threatening hemorrhage. By provoking hemorrhage in a controlled environment, positive rates are increased and the majority of these patients can be treated immediately. This can reduce the number of cases requiring invasive surgery.

Post-Operative Hemorrhage after Myomectomy: Safety and Efficacy of Transcatheter Uterine Artery Embolization

ObjectiveTo evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.Materials and MethodsWe identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.ResultsThe pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.ConclusionUterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Right Ventricular Rupture and Active Contrast Extravasation on MDCT in a Trauma Patient: A Case Report

Cardiac chamber rupture is very rare in traumapatients who reach the emergency department alive. Here, we report a case of cardiac injury after Motor Vehicle Crash (MVC), in which sternal fracture fragment was thought to penetrate the pericardium as well as the right ventricular free wall and result in eventual exsanguinations and death. The diagnosis of this case was confounded by patient’s vague symptoms and prior history of coronary disease. This case highlights the utility of using Multi Detector Computed Tomography (MDCT) in accurately diagnosing these rare but potentially fatal injuries.

Active extravasation of contrast within the hemorrhage (spot sign): a multidetector computed tomography finding that predicts growth and a worse prognosis in non-traumatic intracerebral hemorrhage

Intracerebral hemorrhage (ICH) causes high rates of disability and neurological sequelae Objective To evaluate spot signs as predictors of expansion and worse prognosis in non-traumatic ICH in a Brazilian cohort. Method We used multidetector computed tomography angiography to study 65 consecutive patients (40 men, 61.5%), with ages varying from 33 to 89 years (median age 55 years). Clinical and imaging findings were correlated with the findings based on the initial imaging. Results Of the individuals who presented a spot sign, 73.7% died (in-hospital mortality), whereas in the absence of a spot sign the mortality rate was 43.0%. Although expansion of ICH was detected in 75% of the patients with a spot sign, expansion was observed in only 9.0% of the patients who did not present a spot sign. Conclusions The spot sign strongly predicted expansion in non-traumatic ICH and an increased risk of in-hospital mortality.

Outcomes following “rescue” superselective angioembolization for gastrointestinal hemorrhage in hemodynamically unstable patients

Therapeutic angioembolization is a relatively new "rescue treatment" modality for gastrointestinal hemorrhage (GIH) for unstable patients who fail primary treatment approaches; however, the effectiveness of this treatment and the incidence of ischemic necrosis following embolization for acute GIH are poorly described. The purpose of this study was to evaluate the effectiveness and safety of "rescue" transcatheter superselective angioembolization (SSAE) for the treatment of hemodynamically unstable patients with GIH. A 10-year retrospective review of all hemodynamically unstable patients (systolic blood pressure < 90 mm Hg and ongoing transfusion requirement) who underwent "rescue" SSAE for GIH after failed endoscopic management was performed. All patients with evidence of active contrast extravasation were included. Data were collected on demographics, comorbidities, clinical presentation, and type of intravascular angioembolic agent used. Outcomes included technical success (cessation of extravasation), clinical success (no rebleeding requiring intervention within 30 days), and incidence of ischemic complications. Ninety-eight patients underwent SSAE for GIH during the study period; 47 were excluded owing to lack of active contrast extravasation. Of the remaining 51 patients, 22 (43%) presented with a lower GIH and 29 (57%) with upper GIH. The majority underwent embolization with a permanent agent (71%), while the remaining patients received either a temporary agent (16%) or a combination (14%). The overall technical and clinical success rates were 98% and 71%, respectively. Of the 14 patients with technical success but clinical failure (rebleeding within 30 days) and the 1 patient with technical failure, 4 were managed successfully with reembolization, while 2 underwent successful endoscopic therapy, and 9 had surgical resections. Only one patient had an ischemic complication (small bowel necrosis) requiring resection. SSAE, with reembolization if necessary, is an effective rescue treatment modality for hemodynamically unstable patients with active GIH. Of the patients, 20% will fail SSAE and require additional intervention. Ischemic complications are extremely rare. Therapeutic study, level IV.

Hepatic Hematoma After Islet Cell Transplantation

Hepatic Hematoma After Islet Cell Transplantation

Abstract No. 365 - Angiographic intervention in patients with gastrointestinal bleeding

Purpose To assess the clinical effectiveness of angiography and transcatheter intervention in patients with gastrointestinal (GI) bleeding Materials and Methods Clinical records of 76 patients who underwent angiography and embolization for gastrointestinal bleeding were reviewed after obtaining IRB approval. Patient demographics, history, angiographic findings, treatment and outcomes were recorded. The technical success, 24hr and 30day rebleeding and mortality rates were calculated. Multivariate analyses were performed to assess the factors associated with 24hr and 30day rebleeding. Results There were 53 men and 23 women with a mean age of 66 years. 22 patients (29%) underwent endoscopy prior to angiography. All endoscopies were positive: 15/22 (68%) patients with upper GI bleeding and 7/22 (32%) of patients with lower GI bleeding. Tc 99m labeled RBC scan, available in 7 (10%), was positive for bleeding in 6 (85%). Patients received blood transfusions (n=47, 62%) and vasoconstrictors (n=12, 16%) prior to angiography. Positive angiographic findings were seen in 58 (active contrast extravasation in 43 (56.5%), and pseudoaneurysm in 15 (20%). Angiography was negative for GI bleeding in 18. Embolization was performed in 75 (99%). This included empiric embolization in 17. The agents used were coils (n=35, 46%), gel foam (n=12, 16%), microparticles (n=14, 18%), glue (n=1, 1%) or a combination of these (n=13, 17%). Embolization was technically successful in 74 (98.6%). 24 hr and 30 day rebleeding rates were 11 (14.5%) and 14 (18.5%) respectively. Of the 11 who had 24 hr rebleeding, 7 required surgery and two had successful repeat embolization. Of the 14 who had rebleeding at 30 days, 5 required surgery, 5 underwent successful repeat embolization. 24 hr and 30 day mortality rates were 7 (9%) and 7 (9%) respectively. Ischemic complications following embolization were seen in 3 (4%) of which two required surgery. Prior GI bleeding was an independent variable associated with 30 day rebleeding. Conclusion Angiographic intervention has high technical success and acceptable clinical success with minimal complications for patients presenting with GI bleeding. Repeat intervention may increase overall clinical success.

Letter Reply Re: “Endoscopy-Guided Empiric Arterial Embolization for Angiographically Negative Upper Gastrointestinal Bleeding: Use it Without Fear!”

To the Editor, We thank the author’s constructive comments and appreciate the opportunity to respond to the comments about our article [1]. We agree with the comment that the rate of active bleeding at angiography in our study was low at 32.5 % comparable to some studies [2, 3]. However, our figure is similar to a study by Padia et al. [4] where approximately 33% of patients showed active contrast extravasation during angiography. In our study, a majority of the patients who underwent empiric embolization had prior endoscopy (82 %, 14/17) with either refractory or failed attempted endoscopic treatment. This attempt to achieve hemostasis combined with the known intermittent nature of upper gastrointestinal bleeding (UGIB) may have been contributing factors to the low contrast extravasation rates observed. The use of provocative angiography was first described in 1982 [5]. In our institution, we do not routinely use vasodilator and anticoagulants to induce bleeding. This may have increased the number of positive cases; however, in the few cases for which we have used them, we did not find them particularly useful. There is increasing evidence for using empiric GDA embolization [1–4, 6]. The literature has demonstrated that provocative angiography has been useful and safe in lower gastrointestinal hemorrhage [6], but there is little evidence for its use in UGIB. In patients who are already compromised, there is still a theoretical risk of provocative-related hemorrhage, thereby making them further unstable. We agree that empiric embolization of the suspected culprit artery is important and the role of a multidisciplinary team is fundamental. As we adopt an increasingly aggressive approach to empiric embolization, the need for provocative angiography also will decrease.

Contrast Extravasation on CT Angiography Predicts Hematoma Expansion and Mortality in Acute Traumatic Subdural Hemorrhage

The presence of active contrast extravasation at CTA predicts hematoma expansion and in-hospital mortality in patients with nontraumatic intracerebral hemorrhage. This study aims to determine the frequency and predictive value of the contrast extravasation in patients with aSDH. We retrospectively reviewed 157 consecutive patients who presented to our emergency department over a 9-year period with aSDH and underwent CTA at admission and a follow-up NCCT within 48 hours. Two experienced readers, blinded to clinical data, reviewed the CTAs to assess for the presence of contrast extravasation. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. aSDH maximum width in the axial plane was measured on both baseline and follow-up NCCTs, with hematoma expansion defined as >20% increase from baseline. Active contrast extravasation was identified in 30 of 199 discrete aSDHs (15.1%), with excellent interobserver agreement (κ = 0.80; 95% CI, 0.7-0.9). The presence of contrast extravasation indicated a significantly increased risk of hematoma expansion (odds ratio, 4.5; 95% CI, 2.0-10.1; P = .0001) and in-hospital mortality (odds ratio, 7.6; 95% CI, 2.6-22.3; P = 0.0004). In a multivariate analysis controlled for standard risk factors, the presence of contrast extravasation was an independent predictor of aSDH expansion (P = .001) and in-hospital mortality (P = .0003). Contrast extravasation stratifies patients with aSDH into those at high risk and those at low risk of hematoma expansion and in-hospital mortality. This distinction could affect patient treatment, clinical trial selection, and possible surgical intervention.

Endovascular Management of Extra-cranial Supra-aortic Vascular Injuries

Supra-aortic vessel injuries are uncommon but can be life-threatening and surgically challenging. Trauma to these vessels may be blunt or penetrating, including iatrogenic trauma following the insertion of central venous lines, which may be preventable. Recent advances in technology have resulted in endovascular therapy becoming a common first-line treatment, and interventional radiologists now play a major role in the management of these vascular injuries. We review the literature on the endovascular management of these types of injuries and describe a spectrum of case-based extra-cranial supra-aortic vascular injuries managed at our institution and the range of imaging appearances, including active contrast extravasation, traumatic vessel occlusion, true aneurysms, pseudoaneurysms, and arteriovenous fistulae.

The efficacy of empiric arterial embolization for treating severe hemoptysis

Aim: Purpose of the study was to investigate the efficacy of empiric arterial embolization in order to achieve hemostasis in patients with massive hemoptysis. Materials and Methods: A retrospective review of histories and interventional studies of 56 patients (40 male, 16 female, median age 57 years; range, 16 - 83 years) referred for endovascular treatment of massive hemoptysis over a period of 17 years. Arteries supposed to supply the bleeding bronchoalveolar sections were embolized with particles in all cases. Digital subtraction angiographical (DSA) studies were analyzed with respect to the morphology of the embolized arteries. Arteries were termed pathologic when they were either hypertrophic or supplied hypervascular lung sections as well as actively bleeding branches. Empiric embolization was defined as endovascular occlusion of arteries without visible contrast-material extravasation on DSA studies. Results: Continuing hemoptysis was encountered in one (25%) of 4 patients with active contrast extravasation and in 11 (21%) of 52 empirically embolized patients: Six (19%) of 32 patients with pathologic arteries visible on aortography, 3 (18%) of 17 with pathologic arteries visible by selective arteriography and 2 (67%) of 3 with no visible pathologic arteries. From 6 patients (11%, 5 male, 1 female) who died within 30 days after embolization, 3 suffered from tuberculosis while 3 had malignant tumors. Three had ongoing hemoptysis. One patient died of multiple organ failure caused by post-interventional paraplegia and consecutive pneumonia. Conclusion: In patients with hemoptysis, empirical embolization is effective when pathologic bronchial arteries can be identified by DSA.

Unusual upper gastrointestinal bleeding: Ruptured superior mesenteric artery aneurysm in rheumatoid arthritis

This case report describes an unusual case of upper gastrointestinal (UGI) bleeding caused by a ruptured superior mesenteric artery (SMA) aneurysm in the duodenum in a patient with rheumatoid arthritis. The patient presented with UGI bleeding and hemorrhagic shock. Emergency UGI endoscopy could not identify the source of the bleeding because of excessive blood clots under the second portion of the duodenum. An SMA aneurysm with active contrast extravasation was diagnosed by computed tomography. The aneurysm, together with the fourth portion of the duodenum and the proximal portion of the jejunum, was surgically resected, and the SMA was skeletonized. On postoperative day 15, the patient was discharged from hospital under satisfactory conditions. Rheumatoid arthritis has been known to cause a wide spectrum of manifestations, and an SMA aneurysm is an unusual extra-articular manifestation. An SMA aneurysm rupture presenting as upper gastrointestinal bleeding is a rare complication with a high mortality rate. The clinician must be alert to this potential issue to achieve rapid diagnostic confirmation, and immediate surgical or radiological intervention.

A young woman with systemic lupus erythematosus and extensive mesenteric vasculitis involving small and medium vessels

History of the present illness The patient had 2 recent hospital admissions. Two months prior to her current presentation, she presented to the emergency department with a tooth abscess for which she underwent incision and drainage, and received a 1-week course of penicillin. One week later, she was admitted with a fever of 40.8°C and was noted to have tooth decay on panoramic radiographs without evidence of an abscess. She was treated with intravenous vancomycin and piperacillin tazobactam for 48 hours and then switched to oral clindamycin. Because of her elevated international normalized ratio (INR), she was unable to undergo tooth extraction prior to discharge. Two weeks later, she was readmitted with 4 days of recurrent fevers, malaise, diffuse arthralgias, and increased dyspnea with minimal exertion. Previous lupus exacerbations were characterized by arthralgias, rash, and hemolytic anemia. On this admission, laboratory evaluation revealed leukocytosis, worsening anemia and thrombocytopenia, creatinine of 0.7 mg/dl, alkaline phosphatase of 127 units/liter (normal value 111), spot urine proteinto-creatinine ratio of 1.47 (prior 1.1), low C3 and C4, and an increase in her double-stranded DNA by enzyme immunoassay from 120 to 768 IU/ml (normal value 30). She was empirically treated with vancomycin and piperacillin tazobactam given her recent tooth infection. The elevated alkaline phosphatase level prompted an abdominal ultrasound that showed multiple small hypoechoic areas in the spleen. An extensive infectious evaluation, including blood cultures, fungal serologies, knee arthrocentesis, magnetic resonance imaging of the lumbar spine, transthoracic and transesophageal echocardiograms, and computed tomography of the chest, abdomen, and pelvis, was negative. Her viral serologies were also unremarkable, other than evidence of IgG seropositivity for cytomegalovirus (CMV) with a negative viral load, consistent with prior exposure. Despite broad-spectrum antibiotics, she remained febrile. Her baseline prednisone dose of 12.5 mg was increased to 60 mg daily for possible lupus flare, after which she defervesced within 48 hours. Her thrombocytopenia was thought to be secondary to SLE-related idiopathic thrombocytopenic purpura because it resolved with high-dose steroids and intravenous immunoglobulin. She was discharged home 11 days after admission. The patient remained afebrile for 1 week at home. During this period she developed new-onset progressive upper abdominal pain with meals lasting 20–30 minutes. She denied associated constitutional symptoms, diarrhea, hematochezia, or melena.

Endovascular Repair of a Ruptured Type II Renal Artery Aneurysm Using an Endograft

The purpose of this study was to describe a case of an endovascular exclusion of a ruptured type II renal artery aneurysm in a hemodynamically unstable patient using an endograft. A 73-year-old woman, with an extensive medical history, presented with a sudden onset of abdominal pain and hypovolemic shock. A computed tomography scan showed a massive right-sided retroperitoneal hematoma and a type II aneurysm of the right renal artery just proximal to the bifurcation. Angiography demonstrated active contrast extravasation from the aneurysm. The aneurysm was excluded using a 5-cm long, 6-mm wide endograft. After a 6-month interval, duplex ultrasonography showed a patent endograft and normal perfusion of the renal parenchyma in the lower and middle pole, with a glomerular filtration rate of 75 mL/min. Endovascular exclusion using an endograft may provide a safe and rapid alternative to surgery to treat ruptured renal artery aneurysms in a selected group of patients.

Laparoscopic cholecystectomy for traumatic gallbladder perforation.

In trauma, laparoscopic surgery is commonly utilized as a diagnostic rather than therapeutic measure (1). Its use is often negated because of exigency or limitations in visibility due to haemorrhage. In the present case, a 35-year-old male was involved in a motor vehicle collision and arrived haemodynamically stable with abdominal pain. Abdominal CT revealed liver laceration and active contrast extravasation near the gallbladder fossa. Although angiography with embolization would normally be used, exploratory laparoscopy was performed because of concern for gallbladder injury. The gallbladder was found to be perforated and nearly completely avulsed from the fossa. Laparoscopic cholecystectomy was performed and the patient recovered uneventfully. Gallbladder perforation after trauma is typically an incidental finding during operation for haemorrhagic shock or other indication. Early diagnosis and swift surgical intervention are required, usually via laparotomy. However, when diagnosed preoperatively in the stable trauma victim, gallbladder perforation can be treated successfully with laparoscopy.

Pseudoaneurysms of the Heart

Case 1 : An 85-year-old man with a history of ischemic cardiomyopathy and recent reoperation coronary bypass surgery was noted on a routine follow-up echocardiogram to have a 25×25-mm fluid-filled extracardiac mass adjacent to the basal inferolateral wall of the left ventricle (Figure 1). Cardiac computed tomography (CT) identified the structure to be a pseudoaneurysm of a saphenous vein graft to an obtuse marginal branch of the left circumflex coronary artery. How should this patient be managed? Figure 1. Saphenous vein graft (SVG) pseudoaneurysm in an 85-year-old man after recent reoperation coronary artery bypass surgery. The pseudoaneurysm was visible as a mass (arrow) in the left atrioventricular (AV) groove on the chest x-ray ( A ). Transthoracic echocardiography ( B ) demonstrated a vascular mass (arrow) adjacent to the basal lateral wall. Cardiac computed tomographic angiography ( C ) demonstrated the pseudoaneurysm (arrow) connecting to the SVG by a narrow neck with contrast enhancement (light gray) and some thrombus (dark gray). Four-chamber view ( D ) demonstrating the pseudoaneurysm (arrow) in the left AV groove; a magnified view ( D , inset) demonstrates the pseudoaneurysm connected to the SVG via a narrow neck (arrow) with active contrast extravasation (red outline) contained by thrombus (white outline). Invasive angiography showing contrast extravasation ( E ) into the pseudoaneurysm (arrow) and postintervention angiogram demonstrated successful occlusion of the pseudoaneurysm ( F ). LA indicates left atrium; LV, left ventricle. Case 2 : A 27-year old man with prior homograft aortic valve replacement developed recurrent endocarditis (Figure 2). Echocardiography noted a periaortic valvular fluid collection concerning for abscess or valvular dehiscence. However, Doppler signal to and from the fluid collection connecting to the left ventricular outflow tract also raised concern for pseudoaneurysm. Cardiac CT confirmed the structure to be a 37×32-mm pseudoaneurysm involving the left coronary cusp of a trileaflet homograft prosthetic aortic valve just below the takeoff of …

Deep External Pudendal Artery Injury After Percutaneous Adductor Tenotomy During THA in Ankylosing Spondylitis

Arterial injuries following total hip arthroplasty (THA) are uncommon and are usually related to revision THA. Deep external pudendal artery injury and delayed bleeding due to percutaneous adductor tenotomy during THA has not been reported.A 62-year-old man with bilateral hip osteoarthritis and ankylosing spondylitis was treated with right cementless THA. Persistent severely limited hip abduction after prosthetic implantation required a percutaneous adductor tenotomy, which was performed bilaterally. No clinical signs of bleeding existed postoperatively. On postoperative day 3, the patient had a hypotensive attack, his right anteromedial thigh at the tenotomy site was distended, and the hemoglobin was 5.9 g/dL. Computed tomography angiography of the iliac and femoral vessels showed a right hematoma medial to the common femoral artery, with active contrast extravasation. Volumetric data reconstruction revealed active bleeding from the right external pudendal artery into an inguinal collection. Angiography was performed by the standard Seldinger technique via the contralateral femoral artery. A guiding catheter was placed as near to the lesion as possible. A microcatheter system and microguidewire were used for superselective catheterization, and 2 embolization coils were used to control the bleeding. The patient remained hemodynamically stable and was discharged 12 days later. Two-year follow-up was uneventful.The deep external pudendal artery may be injured during percutaneous adductor tenotomy, especially in patients with fragile arterial walls, and life-threatening complications may occur. Angiography and embolization are the best treatment options.

Hyperacute cerebral aneurysm rerupture during CT angiography

The object of this study was to identify the clinical features and outcomes of a subgroup of patients with aneurysmal subarachnoid hemorrhage (SAH) who had active contrast extravasation from a ruptured aneurysm during initial cerebral CT angiography (CTA). The authors performed a retrospective study of spontaneous SAH cases involving patients treated at their institute. They identified 9 cases in which active contrast extravasation was evident on the initial CT angiogram. Another 12 similar cases were also identified in a literature review and data was gathered from these cases to evaluate the outcomes. Analysis of all 21 cases revealed that the overall outcomes in cases characterized by active aneurysmal bleeding during CTA were poor. Seventy-six percent of patients had unfavorable results. Patients who showed poor neurological status at presentation died no matter what kind of treatment they received. In contrast, patients who presented with good neurological status initially had a chance of favorable outcome. Among the patients with good initial neurological status, most demonstrated rapid deterioration of their condition during the CTA examination; only those who received immediate and effective decompressive surgery and aneurysm obliteration had good results. Active aneurysmal rebleeding during CTA is an uncommon but devastating event. Though the mortality of this distinct group of patients remains high, a clinical subgroup may benefit from immediate surgery. Patients with good initial neurological status who show rapid neurological deterioration may still have a favorable outcome if they undergo timely and successful decompressive surgery and proper aneurysm obliteration. Patients who present with poor neurological status do badly, and there is no effective treatment for such patients.

CT features of blunt abdominal aortic injury

Abdominal aortic injuries are uncommon following blunt trauma, with relatively few reported series in the radiology literature. This study was conducted to identify common locations and imaging features of blunt traumatic abdominal aortic injury, the presence of associated visceral and osseous injuries, and the mechanisms of trauma. A retrospective review of 9,213 trauma registry entries over a 7-year period yielded 103 patients with aortic injuries, 12 of which had direct signs of abdominal segment involvement (dissection flap, focal intimal injury, intramural hematoma, active extravasation of contrast, or pseudoaneurysm formation). The majority (75 %) was isolated to the abdomen-67 % of which was infrarenal, 33 % suprarenal-while the other 25 % was a contiguous extension from a thoracic injury. Abdominal aortic injuries were uncommonly seen in isolation: all but one patient (92 %) demonstrated either retroperitoneal blood or stranding, hemoperitoneum, and/or CT signs of hypoperfusion complex, and only one patient (8 %) had no associated solid organ or skeletal injuries. All patients had a mechanism of injury which involved direct trauma to the abdomen, most commonly a motor vehicle collision. Similar to other recent series, there was an increased rate of abdominal segment injury (11.7 % of all aortic injuries) in this series compared to more remote autopsy series. This difference is likely due to detection of injuries which went undiagnosed before the widespread use of multidetector CT, which has become the standard of care for both acute evaluation following blunt trauma and for follow-up.

Abstract 104: APOE Genotype Is Associated With CT Angiography Spot Sign In Lobar Intracerebral Hemorrhage

Purpose: The presence of active contrast extravasation following CT angiography (CTA), the spot sign, predicts the development of hematoma expansion and poor clinical outcome in patients with primary intracerebral hemorrhage (ICH). The biological underpinnings of the spot sign remain poorly understood, and there are no established risk factors for its presence. We conducted a prospective cohort study to identify determinants of the CTA spot sign. Materials and Methods: We performed a prospective cohort study of consecutive patients presenting to a single center with primary ICH over an 11-year period. Patients were included in this analysis if they underwent CT and CTA at presentation and consented to participation in genetic studies. CTAs were reviewed by two experienced readers, blinded to clinical data, according to previously published validated criteria. Due to its established association with lobar ICH volume, APOE genotype, as well as common clinical covariates, were analyzed for association with spot sign presence. Analyses were stratified by deep, lobar and probable / definite cerebral amyloid angiopathy (CAA) related ICH (by Boston criteria). Results: Of 372 patients, 151 had deep, 198 had lobar and 23 had mixed ICH. We identified at least 1 spot sign in 96 of 372 patients (25.8%). In multivariate analysis, patients on warfarin were more likely to have a spot sign regardless of ICH location: OR 3.85 (95% CI 1.33-11.13, p-value 0.013) in deep ICH, OR 2.86 (95% CI 1.33-6.13, p-value 0.007) in lobar ICH and OR 6.65 (95% CI 1.34-32.99, p-value 0.020) in the subset meeting criteria for CAA-related ICH. APOE ε2, but not ε4, was associated with spot sign in lobar ICH (OR 2.09 [95% CI 1.05-4.19], p = 0.036) and CAA-related ICH (OR 2.07 [95% CI 1.24-3.46], p-value 0.005). There was no effect for ε2 or ε4 in deep ICH. ( Table 1 ) Conclusion: Patients on warfarin at the time of ICH are more likely to have a spot sign at presentation, regardless of the location of the ICH. Among patients with lobar ICH, those who possess the APOE ε2 allele are more likely to have a spot sign. Given the established relationship between APOE ε2 and vasculopathic changes in CAA, our findings suggest that both hemostatic factors and vessel pathology influence spot sign presence and risk of prolonged bleeding in ICH.