Hemorrhage Embolization Imaging

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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.

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

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]}

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.

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]

Tan LK, Calhoun KH. Epistaxis. Med Clin North Am. 1999 Jan. 83(1):43-56. [Medline].

Moreau S, De Rugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope. 1998 Jun. 108(6):887-8. [Medline].

Cullen MM, Tami TA. Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. Otolaryngol Head Neck Surg. 1998 May. 118(5):636-42. [Medline].

Kobata H, Sugie A, Yoritsune E, Miyata T, Toho T. Intracranial extravasation of contrast medium during diagnostic CT angiography in the initial evaluation of subarachnoid hemorrhage: report of 16 cases and review of the literature. Springerplus. 2013 Aug 28. 2:413. [Medline]. [Full Text].

Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol. 1997 Apr. 176(4):938-48. [Medline].

Agnew SG. Hemodynamically unstable pelvic fractures. Orthop Clin North Am. 1994 Oct. 25(4):715-21. [Medline].

Boulleret C, Chahid T, Gallot D, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol. 2004 Jul-Aug. 27(4):344-8. [Medline].

Ledermann HP, Schoch E, Jost R, Decurtins M, Zollikofer CL. Superselective coil embolization in acute gastrointestinal hemorrhage: personal experience in 10 patients and review of the literature. J Vasc Interv Radiol. 1998 Sep-Oct. 9(5):753-60. [Medline].

Gordon RL, Ahl KL, Kerlan RK, et al. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997 Jul. 174(1):24-8. [Medline].

Guy GE, Shetty PC, Sharma RP, Burke MW, Burke TH. Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles. AJR Am J Roentgenol. 1992 Sep. 159(3):521-6. [Medline]. [Full Text].

Maruno M, Kiyosue H, Tanoue S, Hongo N, Matsumoto S, Mori H, et al. Renal Arteriovenous Shunts: Clinical Features, Imaging Appearance, and Transcatheter Embolization Based on Angioarchitecture. Radiographics. 2016 Mar-Apr. 36 (2):580-95. [Medline].

Lefkovitz Z, Cappell MS, Kaplan M, Mitty H, Gerard P. Radiology in the diagnosis and therapy of gastrointestinal bleeding. Gastroenterol Clin North Am. 2000 Jun. 29(2):489-512. [Medline].

Sag AA, Brody LA, Maybody M, Erinjeri JP, Wang X, Wimmer T, et al. Acute and delayed bleeding requiring embolization after image-guided liver biopsy in patients with cancer. Clin Imaging. 2016 May-Jun. 40 (3):535-40. [Medline].

Ku YK, Wong YC, Fu CJ, Tseng HJ, Wang LJ, Wang CJ, et al. Timely Antecedent CT or MRI Can Help Predict Hemorrhage Site of Posttreatment Head and Neck Cancer, With Digital Subtraction Angiography Used as the Reference Standard. AJR Am J Roentgenol. 2016 Apr. 206 (4):829-36. [Medline].

James H Turner, MD President, Qew Imaging Associates, PC; Consulting Radiologist, Virtual Radiological Corporation

James H Turner, MD is a member of the following medical societies: Cardiovascular and Interventional Radiological Society of Europe

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System

Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Anthony Watkinson, MD Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK

Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Charles E Ray, Jr, MD, MS, FSIR, FCIRSE, to the development and writing of this article.

Hemorrhage Embolization Imaging

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