Traumatic retroperitoneal hemorrhage from lumbar artery avulsion and abdominal aorta injury

There is a moderate para-aortic and large left posterior pararenal space hematoma. There is extensive contrast extravasation throughout these regions with no clear bleeding source, although lumbar artery or aortic injury are suspected. The aortic contour itself is smooth with no definite luminal defect.

There is left perinephric stranding and cortical defects in the anterosuperior and posteroinferior aspects, with associated small hematoma (probably subcapsular). The right kidney has a normal appearance.

A comminuted, mildly displaced fracture of the right iliac wing is noted with associated right retroperitoneal and right gluteal hematomas.

A 20 mm soft tissue nodule in the left adrenal is likely incidental, measuring 40-50 HU, differential between adrenal mass vs. hemorrhage. There is no intraperitoneal free fluid or free gas.

Transverse process fractures involve the left T11, right L1, bilateral L2-L3, right L4. No vertebral body or other spinal fractures.

Conclusion:

1. Active retroperitoneal bleeding particularly in the paraaortic and left posterior pararenal spaces. Exact source of bleeding is unclear although lumbar artery or aortic is thought most likely. The patient has been referred for urgent angiography.
2. Left renal traumatic injuries with subcapsular and perinephric hematomas.
3. Left adrenal hemorrhage vs. nodule. A follow-up, non-urgent adrenal CT is suggested if clinically appropriate.
4. Right iliac wing fracture.
5. Vertebral transverse process fractures.

Abdominal aortogram did not demonstrate a convincing active bleeding.

Selective lumbar runs demonstrated: Avulsed left L1 to L3: Large cavity with avulsion of the L2 from the root and an aortic hole, and massive extravasation. No stump to coil. L3 stump was coiled using 2 x Figure of Eight Pushable -18 coils until complete exclusion. Vascular team was informed and was involved: Aortic injury was treated with a 22 x 80 mm COOK covered stent. Good final angiographic run.