Hide & Seek

Artthaporn Ajalasereewong, 2nd year fellowship

 History

A 32-YEAR-OLD MYANMAR NO KNOWN ADMIT WITH

FEMALE UNDERLYING NEUROLOGICAL
DISEASE PROBLEM
Additional information

• History of headache 2 week without neurological deficit

• Generalized tonic clonic seizure 1 day
• CT: Intracerebral hemorrhage
• Refer to Siriraj hospital
 • Diagnostic angiogram
• Fusiform aneurysm at V4 segment of left
Rupture vertebral artery
• Small dissecting aneurysm at V3 segment of left
dissecting vertebral artery
vertebral • Two dissecting aneurysm at V2 segment of right
vertebral artery
artery • Management
aneurysm • 18/05/2020 Clipping aneurysm
• 01/06/2020 Translabyrinthine clipping
aneurysm
 Tachycardia 150-160 BPM

Hypotension: BP 70/50 mmHg

Event Neurological sign deterioration:

E1VtM5-6  E1VtM1

Abdominal sign
• Distension
• Cannot evaluated tender point due to
neurological condition
 Laboratory result

CBC: Hb 10 g/dl, Hct

32 %(during blood
Hct 31%  23% transfusion), WBC PT 19.6, APTT 26.1
30,000, Platelet
320,000
CT whole abdomen
Arterial phase, axial
Arterial phase, coronal
Hemoperitoneum of unknown source
Where’s your target?
What’s your plan?
Our management
• Angiogram +/- embolization
• Target LUQ hematoma
• Splenic artery
• Gastroepiploic artery
• Middle colic artery
• Consult vascular surgery for backup plan
 We found…

Pancreatic branch from

splenic artery pseudoaneurysm

Treatment?
Abdominal
apoplexy
Abdominal apoplexy

• Idiopathic hemoperitoneum
• Idiopathic spontaneous
intraperitoneal haemorrhage (ISIH)

• Spontaneous hemorrhage due to

rupture of an intra-abdominal
visceral vessel in the absence of
trauma or underlying pathology

• Find out cause of Hemoperitoneum

 Hemoperitoneum

RadioGraphics2007;27:109–125
Management

Abdom Imaging (2015) 40:343–351

Can’t find the target…
look for “Sentinel clot”

• Bleeding vessel is most likely to be

found at the site of maximum
hematoma

• There are certain arteries which are

known to rupture spontaneously ,
should be examined carefully
 Reported spontaneous ruptured vessels

Second or third order branch of the abdominal aorta

• Right gastric artery

• Left gastric artery

• Middle colic artery

• Left colic artery

• Pancreaticoduodenal artery
Br. J. Surg. Vol. 65 (1978) 321-322
Surgery case report

Br. J. Surg. Vol. 65 (1978) 321-322

Radiology case report

Abdom Imaging (2015) 40:343–351

Visceral

artery

aneurysm
Mesenteric aneurysm
Abrams’ angiography. 2nd ed. 2006
Eur J Med Res(2019) 24:17
 • False aneurysm: All

Indication to • True aneurysm

treat splenic • Women of child bearing age : > 2 cm
artery aneurysm • Patient undergoing liver transplant: > 2 cm

• Symptomatic: Ischemia, bleeding

• Increased in size

Abrams’ angiography. 2nd ed. 2006

Additional Indication
to treat splenic artery aneurysm

• Portal hypertension

• Etiology: non-atherosclerotic/

non-degenerative cause

• Growth rate > 0.5 cm/year

J Vasc Surg 2020;72:3S-39S

Emergency
• Rupture Timing of treatment
Elective
• True aneurysm:
Woman of child bearing age + any
size
Size > 3 cm
Associated symptom
Interval growth
• False aneurysm: all

Conservative
• Stable in size of true aneurysm less than
3 cm In asymptomatic patient
• Significant medical co-morbidity
• Short life expectancy
J Vasc Surg 2020;72:3S-39S
 J Vasc Surg 2020;72:3S-39S
Treatment option
Open: Standard
Surgery Technique
Laparoscopic: optional

Rupture
Selected case Pregnancy
Mycotic aneurysm

Endovas Favorable option due to higher quality of life

First treatment option

Post embolization syndrome
Drawback Non target embolization
Higher failure rate compare to surgery
 J Vasc Surg 2020;72:3S-39S
Treatment option
Open: Standard
Surgery -Technique
Rupture SAA: Splenectomy without
Laparoscopic: optional
vascular reconstruction
-Selected
Electivecase
case: Splenic artery ligation +/-
Rupture
Pregnancy
aneurysmectomy Mycotic aneurysm
Endovas Favorable option due to higher quality of life
- Embolization: standard treatment
First treatment option
- Endovascular ablation: need more
Post embolization syndrome
Drawback Non target embolization
information Higher failure rate compare to surgery
Embolization

Korean J Radiol 2016;17(3):351-363

Our choice

NBCA glue
 Result
• Post embolization: hemodynamic stable but not gained conscious

• Follow up CT brain: marked cerebral edema with brain herniation

• Patient pass away due to brain death

 Vasculitis
• ANA: positive(titer 1:10)

• Negative for ANCA, AntiPR3, Anti-

lactoferrin, Anti-MPO, Antielastase,
Anti-cathepsin, Anti-BPI

• Work up not finished yet

Referrence