Sex: male
Age: 24 years
History
Train accident. Blunt abdominal trauma. Initial emergency ultrasonography showed a large amount of fluid in the peritoneum and a laceration of the liver. At operation a 15 cm long and 3 cm deep lesion laterodorsal in the right liver lobe and 1.5 litres of hemoperitoneum were seen. The liver was packed, and at a second operation 2 days later no bleeding was seen to persist.
Laboratory data
Hbg 6.2, alkaline phosphatase 314, alanine-aminotransphase 74, lactate-dehydrogenase 441,
leucocytosis, temperature 39°C.
Physical findings
Pale, BP 120/70.
Case text
Two weeks after the accident blood showed up in the drainage tube.
Image 1-5
Ultrasonography and CT of the liver.
Ultrasonography. Axial view of the liver (image 1).
Axial post-contrast CT, 10 mm slice-thickness, at a level of the upper part of the liver (image 2).
Axial post-contrast CT, 10 mm slice-thickness, at a level near the gastro-oesophageal junction (image 3).
Axial pre- and post-contrast CT, 10 mm slice-thickness, at a level 2 cm caudal to image 3 (images 4,5).
Image 6-7
Hepatic arteriography.
Transfemoral hepatic arteriography. DSA technique. Arterial phase (image 6), parenchymal phase (image 7).
Image 8-10
Arterial transcatheter embolization, post-embolization arteriography.
0.4 ml Histoacryl/lipiodol embolization in the subsegmental artery supplying the aneurysm. Selective arteriogram with injection in the subsegmental artery (image 8). Embolization with histoacryl/lipiodol (image 9). Post-embolization arteriogram (image 10).
Image 11-14
CT 8 days following the embolization (image 11).
CT 20 days following the embolization (image 12).
CT 25 days following the embolization (image 13).
Ultrasonography 4 days following the embolization (image 14).
Image 1-5
1. What are the abnormalities present on the ultrasonogram?
Laceration of the liver. Subcapsular hematoma. Hypoechogenic structure within the hematoma with increased turbulent flow.
2. What are the abnormalities present on the CT scan?
Laceration of the liver. Subcapsular areas with low attenuation values pre-contrast, and no attenuation after injection of i.v. contrast media represent a subcapsular hematoma.
On the post-contrast scan in the arterial phase a well-defined round structure with attenuation values comparable to the aorta can be detected in the hematoma.
3. What is your diagnosis?
Posttraumatic aneurysm.
4. What is your next diagnostic step?
Selective arteriography.
Image 6-7
5. What are the abnormalities present on the arteriogram?
An avascular mass, around which arteries are stretched and bowed, representing the subcapsular hematoma. Filling of contrast into the aneurysm. No out-flow into hepatic or portal veins.
6. What is your diagnosis?
Traumatic aneurysm.
7. What is your next step?
Arterial transcatheter embolization of the subsegmental artery supplying the aneurysm.
Image 8-10
8. What is seen on the post-embolization arteriogram?
The embolization material contains lipiodol in the subsegmental artery.
No filling of contrast media into the pseudoaneurysm.
9. What is your next diagnostic step?
Follow-up examination after continuation of antibiotic therapy.
Image 11-14
10. What are the abnormalities present on the CT scans and the ultrasonogram?
The hypoechogenic pseudoaneurysm cannot be seen anymore. Mixed echogenity in the hematoma is present.
On the post-embolization CT no post-contrast attenuation of the aneurysm can be seen. Small air bubbles are present in the hematoma. The hematoma gradually decreases with time.
Lipiodol is seen in the embolized artery.
Final diagnosis
Traumatic hepatic artery aneurysm.
Differential diagnosis
None.
Discussion
The liver and spleen are the organs most frequently involved in the blunt abdominal trauma.
Most intrahepatic hematomas and contusions resolve spontaneously within weeks to several months. However, pseudoaneurysms may develop in some cases.
Selective arteriography may demonstrate an arterial bleeding site, AV-fistula, or pseudoaneurysm.
Transcatheter arterial embolization is an effective therapeutic procedure to control posttraumatic hepatic artery pseudoaneurysms.
Embolization of intrahepatic branch vessels is generally quite safe and effective.
Patency of the portal system will ensure hepatic viability, but even when the portal vein is partially or completely occluded, subsegmental embolization is usually well tolerated.
Gas may be present within a traumatic lesion, even though there is no infection or communication with bowel, possibly caused by the products of acute tissue necrosis.