Presentation
Fall.
Patient Data
Small to moderate right pneumothorax, right rib fractures, no pleural effusion, lungs clear.
pCXR 1 day after presentation
Right pleural pigtail catheter, no pneumothorax. Lungs clear, no pleural effusion.
pCXR 3 days after presentation
No change right pleural pigtail catheter, no pneumothorax. New hazy opacity right hemithorax suspicious for pleural effusion.
CT 3 days after presentation
Multiple right rib fractures with large dense collection indicating blood products in the right hemithorax. The collection displaces extrapleural fat medially indicating that the blood is extrapleural. Contrast extravasation indicates active arterial bleeding, likely from an intercostal artery. Right lower lobe atelectasis due to mass effect. Right apical intrapleural pigtail, no pneumothorax.
DSA 4 days after presentation
Active extravasation and pooling of contrast midsegment right T9 intercostal artery. The artery was embolized, post embolization injection showed arterial occlusion.
Case Discussion
In this case, the right ninth intercostal artery was disrupted with extravasation of blood/contrast because of the adjacent rib injuries. The resulting hematoma was extrapleural, as shown by medial displacement of the extrapleural fat, well demonstrated on the CT but impossible to see on the plain film.
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