Hemorrhage Embolization Imaging

Updated: Jul 26, 2016
  • Author: James H Turner, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Overview

Overview

Embolization is useful in a broad spectrum of clinical situations. Embolization can be particularly effective in hemorrhage, regardless of whether the etiology is trauma, tumor, epistaxis, postoperative hemorrhage, or GI hemorrhage (see the images below). It can be performed anywhere in the body that a catheter can be placed, including the intracranial vasculature, head and neck, thorax, abdomen, pelvis, and extremities. With the availability of coaxial microcatheters, superselective embolizations can be performed. In most patients, embolization for hemorrhage is preferable to surgical alternatives.

Digital-subtraction angiogram of the right externa Digital-subtraction angiogram of the right external carotid artery (EC) in a 73-year-old woman with a 1-day history of epistaxis. This image demonstrates a suspicious blush of contrast off one branch of the internal maxillary artery (IM) within the highlighted area. Hemorrhage continued despite anterior and posterior nasal packing.
Digital-subtraction angiogram of the right interna Digital-subtraction angiogram of the right internal maxillary artery in a 73-year-old woman with a 1-day history of epistaxis (same patient as in the previous image). This image confirms the area of blush and further demonstrates active extravasation from the sphenopalatine branch of the internal maxillary artery. A coaxial microcatheter was placed in the internal maxillary artery.
Postembolization digital-subtraction angiogram in Postembolization digital-subtraction angiogram in a 73-year-old woman with a 1-day history of epistaxis (same patient as in the previous 2 images). This image demonstrates cessation of flow past the mid portion of the internal maxillary artery. The internal maxillary artery was embolized using polyvinyl alcohol. No further evidence of extravasation is seen.
Bronchial artery embolization digital-subtraction Bronchial artery embolization digital-subtraction angiogram of the right bronchial artery in a 46-year-old man with massive hemoptysis. Chest computed tomography scanning showed a consolidation of unknown etiology in the right upper lobe. Bronchoscopy confirmed the right upper lobe as the source of bleeding. The angiogram was performed with a Mikaelsson catheter in the descending thoracic aorta. The tip of the catheter is in the ostia to the right bronchial artery. The angiogram demonstrates an abnormally intense blush in the right upper lobe.
Bronchial artery postembolization digital-subtract Bronchial artery postembolization digital-subtraction arteriogram in a 46-year-old man with massive hemoptysis (same patient as in the previous image). Four 1-cm straight coils were used to embolize the main trunk of the right bronchial artery. The arteriogram demonstrates complete embolization of the artery. The proximal trunk of the main artery is opacified.
Bronchial artery embolization in a 46-year-old man Bronchial artery embolization in a 46-year-old man with massive hemoptysis (same patient as in the previous 2 images). This arteriogram is an unsubtracted image of the previous image. The straight coils are demonstrated more clearly. The patient's hemoptysis resolved postembolization.
Splenic artery angiogram in a 32-year-old man who Splenic artery angiogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient as in the previous image). There are numerous small areas of contrast accumulation in the splenic parenchyma known as the "starry night" appearance, which is consistent with splenic injury. At the junction of the mid and superior poles, an area of active extravasation is highlighted within the circled area.

Patient Education

For patient education resources, see the Ear, Nose, and Throat Center and the Digestive System Center, as well as Nosebleeds and Gastrointestinal Bleeding.

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Technique and Equipment

Identifying hemorrhage

Embolization procedures begin with diagnostic angiography to identify the source of bleeding. For example, in epistaxis, angiography of the external carotid artery with attention to the internal maxillary artery can be helpful (see the images below). [1, 2, 3, 4] In pelvic fractures, the internal iliac arteries are examined angiographically. [5, 6]

Digital-subtraction angiogram of the right externa Digital-subtraction angiogram of the right external carotid artery (EC) in a 73-year-old woman with a 1-day history of epistaxis. This image demonstrates a suspicious blush of contrast off one branch of the internal maxillary artery (IM) within the highlighted area. Hemorrhage continued despite anterior and posterior nasal packing.
Digital-subtraction angiogram of the right interna Digital-subtraction angiogram of the right internal maxillary artery in a 73-year-old woman with a 1-day history of epistaxis (same patient as in the previous image). This image confirms the area of blush and further demonstrates active extravasation from the sphenopalatine branch of the internal maxillary artery. A coaxial microcatheter was placed in the internal maxillary artery.
Postembolization digital-subtraction angiogram in Postembolization digital-subtraction angiogram in a 73-year-old woman with a 1-day history of epistaxis (same patient as in the previous 2 images). This image demonstrates cessation of flow past the mid portion of the internal maxillary artery. The internal maxillary artery was embolized using polyvinyl alcohol. No further evidence of extravasation is seen.

Selective and superselective angiography is more sensitive in finding the source of bleeding than are nonselective studies. [2, 7, 8, 9, 10, 11] Consequently, clinical suspicion and the results of other imaging studies such as contrast-enhanced computed tomography (CT) scanning and radionuclide scans with technetium-99m (99mTc)–labeled red blood cells (RBCs) are important in guiding angiographic examination.

In intra-abdominal bleeding, such as after complex trauma, CT scanning may identify the site of acute bleeding, because acute bleeding often demonstrates higher density (Hounsfield units [HU]) than older blood; this is termed the "sentinel clot sign." [12] For angiograms of abdominal wounds, see the images below.

Hepatic artery embolization digital-subtraction ar Hepatic artery embolization digital-subtraction arteriogram of the common hepatic artery (CHA) in a 21-year-old male who was brought to the emergency department with a gunshot wound to the abdomen. Emergent exploratory laparotomy revealed that the bullet traversed the liver. Surgical measures to control the bleeding were unsuccessful. The abdomen was packed with surgical sponges and the patient brought to the angiography suite. This image shows that at the bifurcation of the proper hepatic artery (PHA), a large amount of extravasation is seen from where the bullet lacerated the artery. GDA = gastroduodenal artery.
Hepatic artery embolization digital-subtraction ar Hepatic artery embolization digital-subtraction arteriogram of the proper hepatic artery in a 21-year-old male with a gunshot wound to the abdomen (same patient as in the previous image). A more selective injection with the tip of the catheter in the proper hepatic artery shows a large amount of extravasation from the lacerated artery. Note the subtraction artifact from the radiopaque markers on the surgical sponges. The artery was injured within the hepatic parenchyma, making surgical control difficult, if not impossible.
Hepatic artery postembolization arteriogram in a 2 Hepatic artery postembolization arteriogram in a 21-year-old male with a gunshot wound to the abdomen (same patient as in the previous 2 images). Three 4-mm coils were placed in the mid portion of the proper hepatic artery. Complete embolization of the artery was accomplished. The patient experienced a transient rise in his liver function enzymes, which eventually normalized. The patient was released after a 1-month hospitalization without further sequelae.
Splenic artery embolization in a 32-year-old man w Splenic artery embolization in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident. This computed tomography scan of the abdomen revealed a splenic laceration. The patient was hemodynamically stable with a falling hematocrit.
Splenic artery angiogram in a 32-year-old man who Splenic artery angiogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient as in the previous image). There are numerous small areas of contrast accumulation in the splenic parenchyma known as the "starry night" appearance, which is consistent with splenic injury. At the junction of the mid and superior poles, an area of active extravasation is highlighted within the circled area.
Splenic artery postembolization arteriogram in a 3 Splenic artery postembolization arteriogram in a 32-year-old man who was an unrestrained passenger in a head-on motor vehicle accident (same patient as in the previous 2 images). A microcatheter was used to select the segmental branch supplying the area of extravasation. Three 1-cm straight coils were placed. Repeat arteriogram showed no further evidence of extravasation. Note the wedge-shaped lack of perfusion to the mid spleen. The patient's bleeding was controlled, and he subsequently recovered well.

Hemorrhage is identified by active extravasation of contrast medium outside of the confines of the vessel lumen. The angiographic appearance depends on the rate and location of bleeding. The extravasating contrast medium may flow toward the dependent part of the viscus; in the bowel, the extravasated contrast may outline the mucosa. When the bleeding site and artery have been identified on the initial angiogram, a catheter, often a 3-French (3F) microcatheter, is placed as selectively as possible into the bleeding artery to confirm the bleeding and to stop it with embolization.

Angiography in the setting of lower gastrointestinal (GI) hemorrhage generally does not demonstrate unique diagnostic findings that explain the cause of bleeding, only the site of active bleeding. Thus, angiographic examinations during the episode of acute, brisk bleeding are required. In cases of recurrent occult GI bleeding, angiography can be performed electively in hopes of identifying a distinct finding such as angiodysplasia, arteriovenous malformations (AVMs), or intestinal varices. [12, 13]

Occasionally, provocative protocols that use angiography and infusions of lytic agents or heparin have been administered, although these techniques have provided mixed results. Carbon dioxide angiography may increase the yield of angiography in the acute GI bleeding scenario.

Pulmonary arteriovenous malformations (AVMs) usually are congenital lesions, although they may occur after surgery or trauma. The congenital form is highly associated with hereditary hemorrhagic telangiectasia, also termed Osler-Weber-Rendu Syndrome. There is a genetic predisposition to this condition. It is also associated with liver AVMs; however, preemptive treatment of the latter is presently unwarranted. Screening head CT scans or magnetic resonance images (MRIs) are important to exclude intracranial AVMs. [14]

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