Extrapleural Hematoma Research Articles

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BackgroundIntercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.Case presentationA 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.ConclusionWe report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Continuous erector spinae plane block: a simple, safe and effective technique for pain control in patients with rib fractures

Ribs are frequently affected after a blunt or penetrating thoracic trauma. Acute key complications associated with rib fractures include pain, hemo-pneumothorax, extrapleural hematoma, pulmonary contusion and laceration, and vascular injury. In high energy traumas, injuries to abdominal solid organs may also coexist. A later complication that can limit the weaning of patients from sedation and ventilation is neuropathic pain, which is frequently associated with rib fractures and that is often poorly responsive to oral and topical medications. The benefit of interventional nerve block procedures is still controversial. Ultrasound-guided erector spinae plane (ESP) block is a relatively new technique for thoracic analgesia that can be both a simpler and safer alternative to more complex and invasive neural blocking techniques, especially in intensive care unit patients whereas major contraindications (i.e. coagulation alteration, infection etc.) might limit the feasibility of more invasive methods, such as central blocks.

Successful Conservative Management of a Rare Surgical Complication of Vascular Ehlers-Danlos Syndrome: A Case Report

Vascular Ehlers-Danlos syndrome is a hereditary disorder of the connective tissue characterized by a reduction in the production of type III collagen. Clinical evolution of the disease is unpredictable because vascular lesions can occur everywhere in the body. Bruising, arterial and bowel fragility, and uterine fragility during pregnancy are the most common symptoms. Thoracic surgeons should take with these patients because, in rare cases, thoracic complications may occur, such as recurrent pneumothorax or spontaneous hemothorax. We report an extra-pleural hematoma in a patient with vascular Ehlers-Danlos syndrome, an unusual complication treated successfully with conservative management.

Hemothorax or not: Use of extrapleural fat sign

Extrapleural hematoma is a collection located between the chest wall and the parietal pleura and is usually associated with rib fractures. Computed tomography is an excellent modality to diagnose extrapleural hematoma and rib fractures as well as differentiate it from a pleural collection. Extrapleural hematoma needs to be differentiated from a hemothorax for appropriate management. We hereby report a case of a large extrapleural hematoma and associated pleural effusion following trauma being managed as a hemothorax based only on chest radiograph appearance.

Atraumatic bleeding of the subclavian artery 20 years after surgical treatment of pneumothorax

BackgroundBleeding of the subclavian artery is a fatal condition. Adhesion between the pleura and staple line may develop after surgical treatment of pneumothorax, and collateral arteries often develop from the subclavian artery toward the adhesion at the lung apex; however, atraumatic tearing and bleeding of these collateral arteries into the extrapleural and intrathoracic cavities is rare.Case presentationA 70-year-old man visited the hospital for evaluation of left chest pain. Contrast-enhanced chest computed tomography showed a huge tumor in the left apex of the lung. It was suspected to be an extrapleural huge hematoma, and it ruptured into the thoracic cavity. Bleeding from the left subclavian artery was suspected; therefore, emergency angiography was performed. Angiography showed some collateral circulation from the left subclavian artery to the apex of the left lung. Distal and proximal bleeding points were identified. The distal bleeding point was embolized using coils. The proximal bleeding point was blown out, and stents were placed in the left subclavian artery. He had undergone pneumothorax surgery 20 years previously, and the present bleeding episode was strongly suspected to be associated with that surgery. The collateral circulation from the subclavian artery could have developed because of post-pneumothorax inflammation, eventually rupturing and bleeding into the extrapleural space.ConclusionsThis report described an important case of atraumatic subclavian artery bleeding considered to have been caused by surgical treatment of pneumothorax 20 years previously. Emergency angiography and percutaneous stent placement or coil embolization should be considered first in such cases.

Two extremely rare cases of extrapleural hematoma

BackgroundExtrapleural hematoma is uncommon. However, according to the size of hematoma and/or the progression of anemia, surgical treatment to control bleeding might be necessary because a huge hematoma can cause ventilator and circulatory disturbances to press heart and lung. We present two unusual cases of huge extrapleural hematoma in an anticoagulated patient with no apparent history of trauma or otherwise traumatic episodes.Case presentationCase 1: A 78-year-old man presented to our emergency department with pain in his right shoulder and disturbance of consciousness. He had no apparent history of trauma. Computed tomography (CT) of the chest revealed the presence of a huge lens-like encapsulated lesion measuring 220 × 90 mm in the right thoracic cavity. These findings all supported a diagnosis of extrapleural hematoma with hemothorax. Case 2: A 73-year-old man was brought to our hospital by ambulance after bruising his back in his house. CT of the chest revealed the presence of a huge lens-like encapsulated lesion measuring 230 × 70 mm in the left thoracic cavity. Hemorrhagic effusion was obtained by thoracocentesis, and the lesion was suspected of being a hematoma. In both two cases, we performed video-assisted thoracic surgery (VATS), which was minimally invasive and effective. These two patients were cured and discharged smoothly after surgery.ConclusionsWe reported two rare cases of extrapleural hematoma. This disease requires close attention when it manifests in patients undergoing anticoagulation therapy. Regarding treatment, VATS was particularly effective in these cases.

The extrapleural fat sign on postmortem computed tomography may differentiate acute from chronic extrapleural hematomas

Extrapleural fat sign is currently regarded as a CT finding that is useful in detecting Extrapleural hematoma (EH). The EH is caused by bleeding between parietal pleura and fascia endothoracica. The incidence of EH is low and thus the opportunity to study EH with both postmortem computed tomography (PMCT) and autopsy remains rare. Here we report two autopsy cases of EH that were also studied with PMCT. Case 1, acute EH case, was 90-year-old male, knocked down by a car. Two days after, he died. On PMCT, clear extrapleural fat sign was found in EH. On autopsy, his EH was shown to be mainly made by fresh clot. Fracture of the ribs was found under the EH. Hematoxylin-eosin (HE)-stained section revealed vacuoles, implying the existence of fatty tissue, between EH and pleura. Case 2, chronic EH case, was 76-year-old male, found dead in bathtub. On PMCT, EH without extrapleural fat sign was demonstrated. On autopsy, EH made by organized clot, was found. HE stained sections revealed heavy proliferation of fibroblasts lacking vacuoles in this clot. Thus it seems likely that extrapleural fat sign on PMCT reflects the time elapse after EH formation: Fat layer is present in acute EH, causing fat sign on image. Then, the fat layer is replaced by fibroblasts along with the development of inflammation reaction, causing disappearance of fat sign. Thus, evaluation of fat sign may be used to know if the HE is acute or chronic in forensic medicine as well as in clinical medicine.

Successful thoracoscopic evacuation of an extrapleural hematoma with delayed symptomatic pleural effusion: a case report

BackgroundTraumatic extrapleural hematoma is a rare condition and is usually managed conservatively until spontaneous resolution unless active bleeding or expansion is found.Case presentationAn 80-year-old man taking an anticoagulant medication was referred to our hospital after accidentally falling in a street ditch while riding a bike. Chest X-ray and computed tomography (CT) scan showed multiple fractures on ribs 7–9, hemothorax, and extrapleural hematoma in the posterior chest wall. Though the patient’s hemothorax was improved by chest tube drainage, the extrapleural hematoma still remained. He was transferred to another hospital for rehabilitation, but he was readmitted to our hospital because of dyspnea with accumulation of left pleural effusion, including a subpopulation of neutrophils, but without bacterial infection. We performed thoracoscopic evacuation of the hematoma on day 57 after the initial blunt chest trauma. The patient has had no recurrence of pleuritis for 6 months after surgery.ConclusionSince posttraumatic extrapleural hematoma may result in delayed secondary intractable pleural effusion causing dyspnea, careful observation is necessary when considering indications of surgical intervention.

Rapidly growing pleural liposarcoma masquerading as extrapleural hematoma

Intrathoracic liposarcoma can occur in the lung, mediastinum, pleura, and chest wall, and tends to remain clinically silent until becoming large enough to displace adjacent structures. Treatment usually includes sufficient surgical resection followed when necessary by adjuvant chemoradiotherapy. We report a case of an uncommon presentation of a rapidly growing pleural liposarcoma, the diagnosis of which may have been obscured by coexisting thoracic trauma with suspected extrapleural hematoma.

A Delayed Presentation of an Extrapleural Hematoma After a Blunt Chest Trauma in an Anticoagulated Patient

A Delayed Presentation of an Extrapleural Hematoma After a Blunt Chest Trauma in an Anticoagulated Patient

Extrapleural Hematoma: A Complication of Jugular Vein Cannulation

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: For centuries, central venous catheters (CVC) have been used as a means of assessing a patients cardiovascular hemodynamics and administering noxious medications. While the role of CVC in managing critically ill patients is indispensable, we must be cognizant of its complications. In this case report, hemodynamic instability complicates a surgical procedure, and the need for central venous access inadvertently leads to the development of an extrapleural hematoma (EPH). CASE PRESENTATION: We present a case of a 78 year old female, whose medical history of atrial fibrillation and transient ischemic attacks placed her at high risk of an ischemic cerebral event (CHA2DS2-VASc scoring). Her recurrent episodes of severe epistaxis precluded her from receiving anticoagulation therapy, and a left atrial appendage closure device (Watchman) was pursued as an alternative for stroke prevention. Sustained intraoperative hypotension necessitated the placement of a right-sided internal jugular CVC for the delivery of norepinephrine to regain hemodynamic stability. Without the availability of ultrasound guidance, anatomic landmarks led to successful cannulation after a failed first attempt. Post procedural chest x-ray (CXR) revealed a near complete opacification of the right hemithorax and CT scan of the chest confirmed a large apical hematoma (Image 1). Thoracoscopic surgery was performed for clot evacuation due to persistence of the EPH despite the placement of chest tubes and conservative medical management. Subsequent CXR revealed a complete resolution of the EPH (Image 2), and she was liberated from mechanical ventilation and vasopressor support. DISCUSSION: The lung parenchyma is surrounded by a physiologic visceral and parietal pleura which lies deep to the endothoracic fascia (ETF). The ETF is the outermost layer of the thoracic cavity and extends from the most inferior portions of the lung to the superior thoracic aperture to encase the lung apices. When diagnosed, the inciting event that precipitates an EPH is typically a penetrating injury to the chest or blunt trauma with injury to the ribs. Damage to the intercostal vasculature leads to the extravasation of blood into the physiologic space that lies between the ETF and the innermost intercostal musculature. This space occupying lesion displaces the ETF centrally, leading to a characteristic “fat stripe” seen on CT scans. CONCLUSIONS: EPH are a pleural space disease and a potential complication of CVC placement. Although a rare occurrence, the disruption in cardiopulmonary physiology can lead to life-threatening complications unless detected early. Reference #1: Chung, JH, Carr RB, Stern EJ. Extrapleural hematomas: imaging appearance, classification, and clinical significance. Journal of Thoracic Imaging. 2011:26:218-223 Reference #2: Aquino, S., Chiles, C., Oaks, T. Displaced extrapleural fat as revealed by CT scanning: evidence of extrapleural hematoma. American Journal of Radiology, 1997. DISCLOSURE: The following authors have nothing to disclose: Christopher Lee, Reenal Patel, Christian Castaneda, Olumayowa Abe, Samarth Beri No Product/Research Disclosure Information

Multidetector CT for Evaluation of the Extrapleural Space.

The extrapleural space (EPS) is an anatomic space at the periphery of the chest that can be involved in a number of disease processes. This space lies between the inner surface of the ribs and the parietal pleura and contains adipose tissue, loose connective tissue, lymph nodes, vessels, endothoracic fascia, and the innermost intercostal muscle. It is often overlooked on cross-sectional imaging studies and almost invariably overlooked on conventional radiographic studies. At conventional radiography, the EPS occasionally can be seen when there is extrapleural fat proliferation, which might be confused with pleural thickening or pleural effusion. Knowledge of the normal anatomy of the EPS depicted at computed tomography (CT) and of the relationship of the EPS with parenchymal, pleural, and chest wall processes is key to the detection of extrapleural abnormalities. Disease entities that most commonly affect the EPS include chronic inflammatory disorders, infection, trauma, and neoplasms. Chronic inflammatory conditions and infectious processes of the lungs and pleurae induce adipocyte proliferation adjacent to the inflamed tissue, resulting in increased extrapleural fat. Chest wall trauma with extrapleural hematoma formation causes characteristic CT findings that enable differentiation of the extrapleural hematoma from hemothorax and warrant a different treatment approach. Extrapleural air is commonly seen in patients with pneumomediastinum and should be distinguished from pneumothorax because it requires a different treatment approach. Intrathoracic neoplasms can cause an increase in the attenuation of normal extrapleural fat owing to pleural inflammation, lymphatic obstruction, lymphangitic spread, or direct invasion by tumor. The normal and pathologic appearances of the EPS, as depicted at thoracic CT, and the differential diagnosis of findings in the EPS are reviewed. ©RSNA, 2017.

Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment.

The ribs are frequently affected by blunt or penetrating injury to the thorax. In the emergency department setting, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury, specific traumatic patterns, and acute rib trauma complications that require emergent attention. Rib injuries can be separated into specific morphologic fracture patterns that include stress, buckle, nondisplaced, displaced, segmental, and pathologic fractures. Specific attention is also required for flail chest and for fractures due to pediatric nonaccidental trauma. Rib fractures are associated with significant morbidity and mortality, both of which increase as the number of fractured ribs increases. Key complications associated with rib fracture include pain, hemothorax, pneumothorax, extrapleural hematoma, pulmonary contusion, pulmonary laceration, acute vascular injury, and abdominal solid-organ injury. Congenital anomalies, including supernumerary or accessory ribs, vestigial anterior ribs, bifid ribs, and synostoses, are common and should not be confused with traumatic pathologic conditions. Nontraumatic mimics of traumatic rib injury, with or without fracture, include metastatic disease, primary osseous neoplasms (osteosarcoma, chondrosarcoma, Ewing sarcoma, Langerhans cell histiocytosis, and osteochondroma), fibrous dysplasia, and Paget disease. Principles of management include supportive and procedural methods of alleviating pain, treating complications, and stabilizing posttraumatic deformity. By recognizing and accurately reporting the imaging findings, the radiologist will add value to the care of patients with thoracic trauma. Online supplemental material is available for this article. ©RSNA, 2017.

Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment-Erratum.

The ribs are frequently affected by blunt or penetrating injury to the thorax. In the emergency department setting, it is vital for the interpreting radiologist to not only identify the presence of rib injuries but also alert the clinician about organ-specific injury, specific traumatic patterns, and acute rib trauma complications that require emergent attention. Rib injuries can be separated into specific morphologic fracture patterns that include stress, buckle, nondisplaced, displaced, segmental, and pathologic fractures. Specific attention is also required for flail chest and for fractures due to pediatric nonaccidental trauma. Rib fractures are associated with significant morbidity and mortality, both of which increase as the number of fractured ribs increases. Key complications associated with rib fracture include pain, hemothorax, pneumothorax, extrapleural hematoma, pulmonary contusion, pulmonary laceration, acute vascular injury, and abdominal solid-organ injury. Congenital anomalies, including supernumerary or accessory ribs, vestigial anterior ribs, bifid ribs, and synostoses, are common and should not be confused with traumatic pathologic conditions. Nontraumatic mimics of traumatic rib injury, with or without fracture, include metastatic disease, primary osseous neoplasms (osteosarcoma, chondrosarcoma, Ewing sarcoma, Langerhans cell histiocytosis, and osteochondroma), fibrous dysplasia, and Paget disease. Principles of management include supportive and procedural methods of alleviating pain, treating complications, and stabilizing posttraumatic deformity. By recognizing and accurately reporting the imaging findings, the radiologist will add value to the care of patients with thoracic trauma. Online supplemental material is available for this article. ©RSNA, 2017.

Nonoperative Management of a Large Extrapleural Hematoma after Blunt Chest Trauma

BackgroundAn extrapleural hematoma (EH) is an uncommon and potentially life-threatening condition defined as the accumulation of blood in the extrapleural space between the parietal pleura and the endothoracic fascia. EH usually occurs after blunt thoracic trauma causing fractures of the sternum and ribs, which can 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 ReportWe present a case of a 36-year-old man with an isolated scapular fracture after a high-energy blunt chest trauma complicated with a large contralateral EH that was successfully managed nonoperatively with transcatheter arterial embolization (TAE) and image-guided drainage with a pig-tail catheter. To the best of our knowledge there is only one previous report describing a large EH after blunt thoracic trauma without rib fractures. Only two previous cases of large EHs have been treated initially with TAE, but both patients ultimately required open surgery. Why Should an Emergency Physician Be Aware of This?Patients with EH can present with respiratory distress and hypotension, so early identification is important to facilitate proper treatment. EH has characteristic radiological findings, and contrast-enhanced computed tomography is not only the best imaging tool for confirming an EH, but also the best technique for detecting the source of the bleeding and other serious thoracic complications that may not be evident on chest x-ray studies.

Extrapleural hematoma developing from a transection of the internal thoracic artery

L’hematome extrapleural post-traumatique correspond a la presence d’une collection sanguine au niveau de l’espace compris entre la plevre parietale et le fascia endothoracique. Son origine suite a une section traumatique de l’artere thoracique interne est une situation clinique jamais decrite. Le diagnostic est suspecte devant une image radiographique caracteristique. L’etat clinique du patient ainsi que l’importance du saignement peuvent conduire a une thoracotomie d’hemostase. A travers cette observation, nous rapportons un cas d’hematome extrapleural revelateur d’une section traumatique de l’artere thoracique interne.

A case of extra-pleural hematoma after the ultrasound-guided thoracic paravertebral block

A case of extra-pleural hematoma after the ultrasound-guided thoracic paravertebral block

Assessment of internal mammary artery injury after blunt chest trauma: a literature review.

The occurrence, bleeding, and treatment of internal mammary artery (IMA) injury after blunt chest trauma have not been well described in the literature. We reviewed articles published from July 1977 to February 2014 describing IMA injury after blunt chest trauma in 49 patients. There was a predominant incidence in males and on the left side. Blunt trauma to the IMA can cause anterior mediastinal hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and extra-pleural hematoma. Of the 49 patients studied, 20 underwent embolization, 22 underwent surgical operation, 4 were managed by clinical observation, and 3 had undescribed treatment. Different parts and extents of IMA injury, adjacent vein injury, as well as the integrity of the pleura determined differences in bleeding modality. Prompt diagnosis, complete hemostasis, aggressive resuscitation, and multidisciplinary teams are recommended for patients with IMA injury.

Large Extra-pleural Hematoma: A Rare Delayed Presentation after Blunt Thoracic Trauma

Blunt thoracic trauma is among the major causes of mortality in setting of acute trauma. Early mortality in chest trauma is often preventable; however, chest trauma can lead to delayed complications. Extra pleural hematoma is among one of them. Owing to the scarcity of literature present on the extra pleural hematoma and its management after blunt thoracic trauma, we, hereby, report a case of 50 year old man who sustained bilateral multiple rib fractures with no hemothorax after blunt thoracic trauma. Patient developed large radio-opaque shadow in right hemithorax four days after injury which later was diagnosed as extra pleural hematoma and was successfully managed with limited thoracotomy.

Expanding extrapleural hematoma from rib fractures after cardiac surgery

A 79-year-old man underwent coronary artery bypass grafting and ascending aorta prosthetic replacement for aneurysm at our Institution. His postoperative course was characterized by rapid onset of hypotension and anemia. Re-exploration found no surgical source of bleeding. A chest computed tomography showed a huge extrapleural hematoma caused by rib fractures. Percutaneous chest drainage was effective, and the patient recovered quickly. Follow-up computed tomography confirmed a good result.