Spontaneous rupture of intercostal arter”>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 33 (2015) 131.e1-131.e3

Spontaneous rupture of intercostal artery after severe cough

Abstract

Pleural or abdominal hematomas induced by spontaneous rupture of intercostal artery are very rare but can often cause fatal problems leading to hypovolemic shock. Spontaneous rupture of intercostal artery mostly occurs in association with neurofibromatosis type 1, coarctation of aorta, or trauma. In the absence of these conditions, there are very few cases. We report a 39-year-old man who complained of left flank pain after severe cough for a few days. His final diagnosis was hematoma of the left lateral abdominal wall induced by rupture of the left 11th intercostal artery. He was treated immediately by Transarterial embolization. Without any serious problems during hospitalization, he was discharged. This case indicates that, in generally healthy individuals, even mild physical force such as cough can lead to rupture of the intercostal artery. Although it is very rare, injury to the intercostal artery should be considered when patients complain of unexplained chest pain, abdominal pain, or flank pain after strong cough or sneezing.

A 39-year-old man presented to our emergency department with left flank pain for 1 day. That pain followed a severe cough lasting for a few days. His past medical history included pneumonia 5 years ago. He had no surgical history or current medication. He denied having any specific familial history. His height was 174 cm, and body weight was 100 kg.

On arrival in ED, he had alert mental status and normal vital signs. His physical examination was unremarkable except mild abdominal distension. In the initial laboratory test, his blood hemoglobin level was 14.8 g/dL, and his coagulation test was normal. Chest radiograph was normal. abdominal radiography (Fig. 1) showed a suspicious masslike lesion in the abdominal wall, so we decided to perform contrast-enhanced computed tomography of the abdominopelvis. The test revealed swelling of the left transverse abdominis muscle with internal hematoma and several active bleeding foci. Scanty fluid collection was also found in the Pelvic cavity (Fig. 2). We immediately consulted a general surgeon and radiologist to determine whether the Exploratory laparotomy or angiographic arterial embolization was appropriate. We then decided to carry out transarterial embolization. A left inferior epigastric arteriogram and abdominal aortogram did not reveal a definite bleeding focus. Angiogram of the 9th to 12th intercostal artery revealed focal contrast extravasation from the 11th intercostal artery (Fig. 3A). No aneurysmal change of intercostal artery was observed. After superselection of the bleeding artery by microcatheter, embolization was performed using gelfoam (Fig. 3B). In subsequent complete arteriogram, additional contrast extravasa- tion was no longer detected (Fig. 3C). When the patient was admitted, his vital sign was normal, and his blood hemoglobin level

was 11.1 g/dL.

On the first day of hospitalization, the patient’s blood hemoglobin level dropped to 9.0 g/dL. He received 1 U of Packed red blood cells. After that, he recovered uneventfully and was discharged from the hospital 5 days after admission.

Spontaneous rupture of the intercostal artery has very rarely been reported. Most cases occur via aneurysm rupture. Most patients with the true aneurysms of intercostal artery have neurofibromatosis type 1 [1,2] or coarctation of aorta [3]. The cause of aneurysm is still not clearly known but is considered to be wall fragility in neurofibroma- tosis type 1 [2]. In addition, turbulent blood flow by coarctation may result in aneurysm in coarctation of aorta [3]. Aneurysmal change of intercostal artery is also reported in association with Kawasaki disease

[4] or Ehler-Danlos syndrome [5]. Highly Elevated blood pressure or mild physical force such as cough can lead to aneurysm rupture. There is a report describing hemorrhage of intercostal artery in a patient with systemic lupus erythematous without aneurysm [6]. In addition, pseudoaneurysm of intercostal artery can occur after stab injury [7], blunt trauma [8], or surgical procedure [9]. Spontaneous rupture of the intercostal artery in generally healthy patients with no definite trauma is extremely rare, and we found only 5 cases in the existing

Fig. 1. Abdominal radiography showed a suspicious masslike lesion in the abdominal wall (white arrow).

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English literature [10-14]. In these 5 cases, patients had 1 or more risk factors of rectus sheath hematoma with Abdominal wall hematoma. The risk factors include elderly, female, on anticoagulation medica- tion, or having a cough [9,15]. However, in our case, the patient had no comorbid disease or trauma history. In addition, he had no other risk factors of abdominal wall hematoma except a cough. This indicates that, in a generally healthy individual, mild physical force such as cough can cause injury of the intercostal artery. Although he was relatively young and healthy, he was overweight. His body mass index was 33.03 kg/m². There are changes in the vascularity and the Extracellular matrix in the subcutaneous tissue of persons with obesity. Goldstein et al [16] suggested that the lack of external compression of an abdominal wall hematoma makes bleeding more likely. For this reason, bleeding from intercostal artery may progress to severe hematoma. In all cases except 1, patients were treated by transarterial embolization. That exceptional case was treated by immediate thoracotomy and later transarterial embolization because that patient had aneurysmosis in both thoraxes [13]. All patients including our case recovered without severe event.

Spontaneous rupture of the intercostal artery is extremely rare but often leads to severe hypovolemic shock. Early recognition, diagnosis, and Rapid treatment, therefore, remain central to successful outcome.

Fig. 2. A contrast-enhanced computed tomography of abdominopelvis shows an extravasation of contrast medium in the large hematoma (white arrow). This indicates active bleeding of a vessel near the left transverse abdominis.

Because the patient may complain of only pain unless the hematoma has severely progressed, artery rupture may not be suspected. Emergency physician should remember spontaneous hematoma, although rare in occurrence, when patients complain with unex- plained chest pain, abdominal pain, or flank pain. Computed tomography is a useful diagnostic tool for differential diagnosis in

Fig. 3. A, Angiogram of the 9th to 12th intercostal artery shows focal contrast extravasation from the 11th intercostal artery (black arrow). B, After superselection of the bleeding artery by microcatheter, embolization was performed using gelfoam. C, In subsequent complete arteriogram, additional contrast extravasation was no longer detected.

J.Y. Jang et al. / American Journal of Emergency Medicine 33 (2015) 131.e1–131.e3 131.e3

patients with suspected spontaneous hematoma. Angiography can localize the bleeding point. Transarterial embolization is the treat- ment of choice for spontaneous rupture of intercostal artery unless there is a surgical indication.

Jee Yong Jang, MD Yong Su Lim, MD, PhD? Jae Hyug Woo, MD

Jae Ho Jang, MD

Department of Emergency Medicine Gachon University Gil Medical Center, Incheon, South Korea

?Corresponding author. Department of Emergency Medicine

Gachon University Gil Medical Center 1198, Guwol-dong, Namdong-gu, Incheon, 405-760, South Korea Tel.: +82 32 460 3015; fax: +82 32 460 3019

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.06.033

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