Presentation
Sudden onset left sided chest pain. No history of trauma. No past medical history.
Patient Data
There is a large right hydropneumothorax with collapse of the underlying lung and displacement of the mediastinum towards the left.
Large right hemopneumothorax. Contrast extravasation in the right apex, appearing to originate from the posterior second intercostal space. No underlying mass or vascular malformation identified. Right lung atelectasis. No midline shift. Right ICC with the tip posterior to the left atrium. Associated subcutaneous emphysema.
Right subclavian angiogram demonstrates bleeding from the superior (highest) intercostal arising from the costo-cervical trunk. A series of a small pseudo-aneurysms were present and active bleeding at the time of angiography. The common trunk leading to the site of the bleeding, the highest intercostal was embolized with a series of 2 mm coils without compromise of the costocervical trunk. Post embolization there was cessation of bleeding.
Images courtesy Dr Alex Rhodes, The Royal Melbourne Hospital.
Case Discussion
This patient present with sudden onset of chest pain, with the initial chest x-ray demonstrating a right hydropneumothorax. A right intercostal catheter was inserted with approximately 1 L of fresh blood draining initially with another liter draining over the next 2 hours.
CTA demonstrated active bleeding in the upper intercostal region with this confirmed on DSA with subsequent successful embolization.
No cause was identified with no proceeding trauma or infection, and no past medical history. No mass or vascular malformation identified on imaging.
Spontaneous hemopneumothorax is rare, with a few mechanisms proposed 1,2:
- torn adhesion between the parietal and visceral pleura after a spontaneous pneumothorax
- rupture of a bulla resulting in damage to underlying vascularized lung parenchyma