Spontaneous rupture of an intercostal artery in a patient with neurofibromatosis type 1

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BACKGROUND

Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.

CASE PRESENTATION

A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.

CONCLUSION

We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Spontaneous Intercostal Artery Bleeding in a Patient With Buerger's Disease: A Case Report

Intercostal artery (ICA) injury and bleeding are well-known complications of thoracic procedures and trauma; however, spontaneous ICA bleeding is a rare condition usually associated with specific underlying disorders that typically lead to the weakening of vasculature. Herein, we present a 42-year-old male with a history of Buerger's disease who developed spontaneous bleeding of the second left ICA after undergoing lower limb angioplasty. The bleeding was complicated by a large hemothorax and retropleural hematoma, resulting in hemorrhagic shock that necessitated massive transfusion, embolization, and eventual thoracotomy with evacuation.

Successful endovascular management for spontaneous hemothorax in a patient with neurofibromatosis Type1: A case report and review

INTRODUCTION AND IMPORTANCE

Neurofibromatosis Type 1 (NF1) is a rare autosomal dominant genetic disorder that affects multiple organs and systems, including the nervous system, integumentary system, and connective tissues. Spontaneous hemothorax occurs infrequently in patients with NF1 and is associated with high fatality rates. However, it is commonly overlooked or misdiagnosed.

CASE PRESENTATION

We present the case of a 29-year-old woman with NF1 who complained of chest pain and was detected with hemothorax on radiographic examination. No bleeding sites were identified following thrombectomy. The patient's condition deteriorated with conservative treatment over nine days, posing a potentially life-threatening risk. After a diagnostic evaluation using computerized tomography angiography (CTA) and digital subtraction angiography (DSA) of the neck vasculature, the patient was diagnosed with spontaneous rupture of the vertebral artery (VA) and subclavian artery (SuA) aneurysm. Following a multidisciplinary discussion and extensive investigations, the patient underwent successful endovascular treatment. A VIABAHN covered stent was implanted in the left SuA to overlay the emergent orifice. The endovascular treatment challenge due to the inaccessible of the proximal of left VA. To prevent retrograde flow into the VA aneurysm, the coils were used to embolize the left VA via the right vertebral artery-basilar artery (VA-BA) passage. The patient was alive at the 5-year follow-up without further complications.

CLINICAL DISCUSSION

The CTA examination led to the diagnosis of vascular rupture due to NF1, and endovascular treatment was performed to occlude the vascular lumen. There have been no recurrences during the five-year follow-up period.

CONCLUSION

Vasculopathy is the second leading cause of death in patients with NF1 after malignancy. Early diagnosis of spontaneous hemothorax in patients with NF1 is crucial, as misdiagnosis can result in missed treatment opportunities. CTA plays a vital role in preliminarily diagnosing the cause of spontaneous hemothorax, while endovascular treatment offers a new therapeutic option for such patients.

Successful endovascular therapy involving direct puncture for spontaneous internal iliac artery aneurysm rupture

Neurofibromatosis type 1 (NF-1) is associated with fatal vascular complications. A 40-year-old woman with NF-1 who had previously undergone left iliac artery ligation and femorofemoral bypass grafting for internal iliac artery (IIA) aneurysm rupture was transported to our hospital for the treatment of a newly developed IIA aneurysm. Although endovascular therapy was difficult owing to the previous surgery, we successfully performed embolization of the aneurysm and its feeding vessels via direct percutaneous puncture under ultrasound guidance. Aneurysm enhancement had completely disappeared at 2 months postoperatively. We have reported a novel approach of direct percutaneous puncture for IIA aneurysm embolization in a patient with NF-1.

Massive hemorrhage from the posterior intercostal artery following lower partial sternotomy

Background

Median sternotomy remains the most common approach in cardiovascular surgery. Recently, minimally invasive procedures, such as minimally invasive cardiac surgery, robot surgery, and catheter therapy have been developed in cardiovascular surgery. However, all these surgeries cannot be performed by minimally invasive approaches. Several complications associated with median sternotomy have been reported, although post-sternotomy hemorrhage from the posterior intercostal artery is extremely rare.

Case presentation

We present a case of posterior intercostal artery bleeding following lower partial sternotomy. A 79-year-old man underwent aortic valve replacement using lower partial median inverted L-shaped sternotomy that cut into the right second intercostal space. A postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Hence, we inserted a drainage tube immediately. Approximately 2 hours after the surgery, his blood pressure gradually decreased. Blood drainage was observed from the tube, and the amount of blood drainage was not large. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed emergency surgery. The lower partial sternotomy was repeated. We detected the origin of the bleeding that was identified in the right fourth posterior intercostal artery, and the bleeding was stopped. The postoperative course was uneventful.

Conclusions

This case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of clearly rib fracture. In our case, we did not identify the cause of bleeding, although we suggest the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.

First case of cough-induced combined intercostal artery rupture with partial diaphragm tear

We describe a case of vigorous cough-induced left intercostal artery rupture with partial diaphragmatic tear in a 60-year-old obese male with chronic obstructive pulmonary disease. He presented with left hemothorax, a rapidly spreading chest and abdominal wall hematoma, and progression of anemia. Computed tomography (CT) scan revealed a bleeding focus from the left 8th intercostal artery. CT-guided surface marking of the bleeding point was done over the chest wall. The patient underwent open thoracotomy with drainage of clotted hemothorax and ligation of bleeding intercostal artery. Incidentally, a partial diaphragm tear was detected during the surgery which was repaired. The combined presentation of cough-induced intercostal artery rupture with partial diaphragm tear is not reported earlier. Awareness of these co-existing pathologies can facilitate timely diagnosis and appropriate life-saving management.

Spontaneous rupture of the pancreatic arcade artery caused by neurofibromatosis type 1 successfully treated using emergency transcatheter arterial embolization, partial intra-aortic balloon occlusion, and stent graft placement: a case report and review of the literature

Background

Vascular abnormalities in neurofibromatosis type 1 (NF1) are rare, but are the second leading cause of death in persons with NF1. In NF1 vasculopathy (NF-V), fatal bleeding due to a spontaneous arterial rupture sometimes occurs. Ruptured extracranial arteries in patients with NF1 often involve thoracic vessels, such as the intercostal and subclavian arteries; very few reports exist regarding the abdominal region. Herein, we present the first case of intraperitoneal bleeding due to spontaneous pancreatic arcade artery (PAA) rupture associated with NF1, successfully treated by transcatheter arterial embolization (TAE) combined with stent-graft placement and partial intra-aortic balloon occlusion (IABO).

Case presentation

A 40-year-old woman complained of back and abdominal pain. Upon admission, her blood pressure was 85/41 mmHg and heart rate was 129 beats/min. Computed tomography (CT) showed large intraperitoneal bleeding due to PAA rupture. After CT scanning, her systolic blood pressure decreased to 50 mmHg. Therefore, we performed emergency TAE with partial IABO. She was treated by TAE of the anterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, and inferior pancreaticoduodenal artery. However, even after TAE, minor extravasation around the superior mesenteric artery continued, and her vital signs remained unstable. Stent-graft placement was selected to stop the haemorrhage, preserving normal blood flow of the superior mesenteric artery trunk. Excellent patency of the stent graft was confirmed on follow-up CT, and she was discharged on postoperative day 56.

Conclusion

PAA rupture associated with NF1 can be successfully treated by TAE combined with partial intra-aortic balloon occlusion, and stent-graft placement.

Spontaneous Hemothorax Complicating von Recklinghausen Disease: Case Report and Treatment Algorithm

BACKGROUND

Neurofibromatosis type 1 (NF1) is generally a benign disease but has the potential for rare and fatal complications. Vascular signs and symptoms associated with NF1 are reported in only 1-3% of patients. Pulmonary complications have been rarely described in the literature and spontaneous rupture of a major thoracic artery is, however, extremely uncommon.

CASE REPORT

We report the case of a patient with NF1 admitted to the emergency department for the management of a spontaneous life-threatening left hemothorax. The patient became hemodynamically unstable after thoracic drainage. Computed tomography angiography revealed extravasation at the level of the eighth intercostal artery. Digital angiography showed an intercostal aneurysm. Catheterization of the eighth intercostal artery was unsuccessful and an open surgery was finally performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We highlight the importance of recognizing that patients with a benign disease like NF1 may present to the emergency department with a spontaneous life-threatening hemothorax. Immediate transfer for embolization is not always the best treatment management but thoracotomy is preferred in unstable patients.

Spontaneous Hemothorax in a Patient with von Recklinghausen's Disease: A Case Report and Review of the Literature

BACKGROUND Von Recklinghausen's disease, also known as Type 1 neurofibromatosis (NF1), is a genetic disorder characterized by skin tumors, neurofibromas of multiple organs and vascular abnormalities. Spontaneous thoracic hemorrhage is a rare but potentially fatal consequence of this disorder. After a review of the literature over the last 10 years and on the basis of a case study, the aim of this study was to report the challenges of management of this pathology. CASE REPORT We report a rare case of a 45-years-old male with a medical history of neurofibromatosis who complained of a 3-day history of progressive dyspnea. At his admission to the Emergency Department, the patient was hemodynamically stable. A chest computed tomography (CT) scan showed a large left hemothorax with mediastinal shift to the right without active bleeding. A chest tube was introduced, and conservative treatment was followed. Another CT scan performed 2 days later revealed a middle lobar pulmonary embolism on the opposite side. A full treatment of anticoagulation was administered, and the patient was released after 8 days of hospitalization. Three weeks later, a new chest CT scan indicated the absence of vascular aneurysm or source for hemothorax. CONCLUSIONS Our systematic literature review found 15 articles which were described as early as 2005. To our knowledge, endovascular treatment produces the best immediate successful result (100%) and may be used in adjunction with video-assisted thorax surgery (VATS) or thoracic drainage to optimize outcomes. In the present case, conservative treatment showed a good result despite anticoagulation for pulmonary embolism. The endovascular approach seems to be the most promising, but treatment needs to be tailored to each individual patient.

Endovascular management of unruptured intercostal artery aneurysms

Background

Intercostal artery aneurysms are rare vascular abnormalities that are typically diagnosed following rupture in patients with predisposing conditions. Our report is the first to document a patient with unruptured intercostal artery aneurysms in the absence of any associated disease.

Case presentation

A 70-year-old male with prostatic adenocarcinoma was incidentally discovered to have multiple unruptured aneurysms of his intercostal arteries. Three of the aneurysms were embolized utilizing microcoils and glue. At six-month follow-up the patient remained asymptomatic.

Conclusion

We demonstrate successful endovascular management of a unique case of multiple idiopathic unruptured intercostal artery aneurysms. Appropriate diagnosis and prompt treatment of these rare vascular lesions is essential in preventing the potentially catastrophic consequences of rupture.

Endovascular Treatment for a Ruptured Lumbar Artery Aneurysm in a Patient with von Recklinghausen Disease

Introduction

Vasculopathy, such as an aneurysm, stenosis, rupture, or arteriovenous fistula, in patients with neurofibromatosis type I (NF-1; von Recklinghausen disease) is well recognised. However, there has been no report regarding treatment for a ruptured lumbar artery aneurysm associated with NF-1. We present the first report of successful endovascular treatment by coil embolisation for a ruptured lumbar artery aneurysm in a patient with NF-I.

Report

A 52 year old man with a history of NF-1 was referred with back pain and anaemia. The computed tomography scan showed rupture of a solitary lumbar artery aneurysm. The rupture was successfully treated by endovascular embolisation with a coil and N-butyl-2-cyanoacrylate.

Discussion

Endovascular treatment with coil embolisation was performed safely in this patient.

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Vasculopathy in neurofibromatosis type 1 (NF-1) is rarely encountered clinically.

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Surgical treatment of a ruptured lumbar artery aneurysm associated with NF-1 is undocumented.

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Endovascular treatment with coil embolisation was performed safely.

Developing Cervical Hematoma Following Jaw Thrust Maneuver Triggered Diagnosis of Neurofibromatosis: A Case Report and Brief Literature Review

A 25-year-old man underwent an excision of a thigh mass under general anesthesia without any complication. After the operation, he developed oxygen desaturation requiring a jaw thrust maneuver. A rapidly expanding hematoma on the right side of the neck was formed shortly after the application of the maneuver. The patient was returned to the operation room for a neck exploration. Damage to the facial artery and vein was noted. Further evaluations confirmed the diagnosis of Neurofibromatosis type 1 (NF-1). It is recommended that considering the probable risk of arising hematoma in NF-1 patients, application of jaw thrust maneuver should be performed meticulously.

Spontaneous intercostal artery bleeding in a hemodialysis patient

Spontaneous rupture of an intercostal artery (ICA) is a rare but could be a life-threatening emergency requiring prompt diagnosis and intervention for optimal outcome. We report a patient presented with swelling in his right-side back which started immediately after scheduled hemodialysis and continued to increase in size. Contrast computed tomography scan revealed soft tissue attenuated lesion with internal enhancing dots which suggested expanding hematoma with active bleeding. Arteriography detected focal contrast extravasation from seventh ICA, and transcatheter arterial embolization was successfully done. To the best of our knowledge, this is the first report describing spontaneous bleeding of ICA in a hemodialysis patient.

Management of Giant Facial Neurofibroma With Intratumoral Hematoma in Neurofibromatosis Type 1 Patient

Type-1 neurofibromatosis, a common autosomal dominant disease, is also known as von Recklinghausen disease. Surgical procedures to treat this condition are challenging because of the brittleness of the surrounding blood vessels and soft tissues that bring the risk of causing fatal bleeding. With improvements in neurovascular embolization procedures, some literatures have been published about the application of preoperative embolization for neurofibromatosis. This case report describes a 60-year-old female with Type-1 neurofibromatosis, who presented giant facial neurofibromas with intratumoral hemorrhage on both cheeks. This patient demonstrates that these huge and challenging lesions can be successfully treated with preoperative embolization and surgical treatment. We also discuss the timing of surgical treatment with such lesions.

Spontaneous intercostal arterial rupture restrained by conservative management

A spontaneous intercostal arterial rupture in patients without associated illness or trauma is extremely rare. We present a 58-year-old man with an idiopathic and spontaneous arterial rupture restrained by conservative management. He was admitted to our institute with an intermittent back pain lasting for 3 days. His past history included no notable diseases and chest trauma. An enhanced computed tomography revealed an effusion of blood around the descending aorta and hematoma from right 10th intercostal artery. Management of blood pressure and administration of tranexamic acid were performed and he was uneventfully discharged at 11 days after onset.

Spontaneous Hemothorax in a Patient With von Recklinghausen's Disease

Type I neurofibromatosis (NF-1) is a rare autosomal dominant disease. It can affect any organ system including vascular tissues. A 53 years old man, with a past medical history of NF-1, retinitis pigmentosa and hypertension attended to the emergency department for chest pain and palpitations and was discharged 2 days after acute coronary syndrome was ruled out. During this admission an echocardiogram was performed which showed a left ventricular hypertrophy with normal ejection fraction and a chest X-ray which revealed no pathologic images. No invasive procedures were preformed. Three days after discharge, he returned to our hospital for sudden onset of oppressive chest pain in the right arm, irradiated to the ipsilateral shoulder, chest and back. After several tests, a diagnosis of hemothorax was made. Hemoglobin levels declined during the first 2 days of admission from 12.1 to 9.6 g/dL, although the patient remained hemodynamic stable. An arteriography was performed, which showed the presence of bleeding from a branch of the right subclavian artery, which was selectively catheterized and embolized with coils. Afterwards, a video-assisted thoracoscopy was made, in order to drain the hemothorax and to carry out a visual review of the pleural cavity. The patient had a good clinical and radiologic progression and was discharged after few days. After a year of follow-up, the patient has remained clinically asymptomatic with no further episodes of active bleeding.

Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: a systematic literature survey

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.

Intercostal aneurysm causing spinal cord compression in an NF1 patient

PURPOSE

The authors illustrate a case where an intercostal aneurysm was observed in a patient with type 1 neurofibromatosis.

METHODS

A 32-year-old man with NF1 presented with thoracic back pain. The patient's symptoms progressed to include myelopathic symptoms, including difficulty urinating, numbness in the lower extremities, and increased weakness. Imaging revealed what appeared to be a neurofibroma at the T4-T5 level and a plan to resect the mass was formulated. Upon initial limited hemilaminotomy, significant arterial blood was encountered. The patient was then taken to the interventional suite and angiography was performed, revealing a left T4 intercostal aneurysm. The aneurysm was coil-embolized with no residual filling.

RESULTS

By 6 months post-surgery, the patient had regained full strength and sensation in his lower extremities and no longer had difficulty urinating. There has been no recurrence of symptoms 3 years postoperatively.

CONCLUSIONS

Intercostal artery lesions must be considered as a possible diagnosis in NF1.

Spontaneous massive hemothorax in a patient with neurofibromatosis type 1 with successful transarterial embolization

Vascular involvement in neurofibromatosis type 1 is rare but has the potential to be fatal. We report a case of a patient with spontaneous rupture of a left intercostal artery aneurysm, which presented as a massive left hemothorax and was successfully treated by transarterial coil embolization.

Giant intercostal aneurysm complicated by Stanford type B acute aortic dissection in patients with type 1 neurofibromatosis

Vascular involvement is rare in neurofibromatosis type 1 (NF1). It is often missed because it is usually asymptomatic. We report a case of a 42 years old male with neurofibromatosis type 1 who presented with left back discomfort. CT angiography revealed a massive 42 mm aneurysm of left 11th intercostal artery. After a discussion between radiologists and cardiothoracic surgeons, endovascular coil embolization was chosen to treat this patient. Percutaneous aneurysm embolization was successfully performed. However, the procedure was complicated by Stanford type B acute aortic dissection. Stanford type B acute aortic dissection was medically managed and patient remained well after discharge. Fragile vascular nature was thought to be one of the causes of this unreported complication.