Glue Embolization in the Management of Rectus Sheath Hematomas

OBJECTIVE

This study aims to describe the results achieved in the management of rectus sheath hematoma (RSH) using glue embolization.

METHOD

Data about all consecutive patients presenting with RSH, between January 2005 and December 2020 were retrospectively reviewed. RSHs were classified according to the Berna CT scan Classification. Clinical and technical outcomes were evaluated during in-hospital period and 1-month follow-up.

RESULTS

Among 74 patients presenting with RSH, CTA revealed an active bleeding in 61 (n = 42, 69% women; median age = 68.8 y range: 47-91). 19 cases of type 1 RSH (25.7%), under anticoagulation therapy and hemodynamically stable, were successfully managed conservatively. Conversely, endovascular embolization with cyanoacrylate glue diluted with ethiodized oil (Lipiodol Ultrafluid, Guerbet, France) was needed in n = 42 (56.8%) patients, in 16 cases after failure of conservative management; a single session of percutaneous glue embolization was adequate to achieve technical and clinical success in all patients with stabilization or progressive improvement of hemoglobin values after procedure (7.1 + 1.8 g/dL pre-procedure vs 11.1 + 1.6 g/dL post-procedure). No major complications occurred. Two minor complications were reported: 1 case (2.4%) of puncture site-related complication (local self-limiting hematoma) and 1 case (2.4%) of post-embolization syndrome (abdominal pain) spontaneously regressive. The median hospital stay was 7 d. At 30-day follow-up, 2 patients (2.7%) died of multiorgan failure.

CONCLUSIONS

In the management of RSH, glue embolization was shown to be safe and efficacious. Glue allowed the immediate occlusion of both the "front and back doors" of bleeding without the need to reach the bleeding point, preventing potentially life-threatening recurrence.

The pituitary in nuclear medicine imaging

The pituitary is an endocrine gland with ability to uptake diverse radiopharmaceuticals and, therefore, susceptible to be investigated by nuclear medicine diagnostic procedures. Although this topic has been scarcely scrutinized, we have data indicating that somatostatin receptor scintigraphy with¹¹¹In-DTPA-D-Phe-octreotide or ^99mTc-EDDA/HYNIC-TOC may be of clinical utility in the diagnosis of some pituitary adenomas (PA). Only a few studies have evaluated the diagnostic performance of ^99mTc-MIBI and ^99mTc (V)-DMSA scintigraphy in pituitary disease. Scintigraphy using ¹²³I-methoxybenzamide (¹²³I-IBZM) might be useful in macroprolactinomas expressing dopamine D2 receptors. Pituitary gland does not usually accumulate 2-deoxy-2-[¹⁸F]fluoro-d-glucose (¹⁸F-FDG) and, therefore, it is not visualized on positron emission tomography (PET) imaging studies with this radiotracer. The pituitary uptake on¹⁸F-FDG PET/CT scans performed in the follow-up of oncological patients are uncommon. However, 60% of these incidental findings are due to PA, mainly non-functioning pituitary macroadenomas, and a small percentage to metastases or other pituitary lesions. Interestingly, ¹⁸F-FDG PET/CT may identify hypophysitis induced by different immunotherapeutic agents used in cancer patients. Positive ¹⁸F-FDG uptake has been reported in a high percentage of patients with PA, mainly macroadenomas and it seems that there is correlation between tumor size and SUVmax. ⁶⁸Ga-DOTA-TATE PET/CT may identify functioning and non-functioning PA, although this technique is more useful in the detection of remaining normal pituitary tissue after transsphenoidal adenomectomy, and in the confirmation of recurrence of functioning PA, such as thyrotroph-secreting PA. Furthermore, ⁶⁸Ga-DOTA-TATE uptake has potential therapeutic implications on molecular-targeted therapy. Lastly, other radiopharmaceuticals that have shown to be taken up in some patients with pituitary disease include ¹⁸F-DOPA (prolactinoma), ¹¹C-methionine (residual or recurrent PA), O-(2-¹⁸F-fluoroethyl)-l-tyrosine (metastasis), ¹⁸F-choline (silent adenoma, ectopic corticotropinoma), and ¹³N-ammonia (hypopituitarism).