Imaging of Nontraumatic Hemorrhagic Hepatic Lesions1
V. Javier Casillas, MD ,
Marco A. Amendola, MD,
Ana Gascue, MD ,
Nat Pinnar, MD ,
Joe U. Levi, MD and
Juan Manuel Perez, MD
1 From the Departments of Radiology (V.J.C., M.A.A., J.M.P.), Pathology (N.P.), and Surgery (J.U.L.), University of Miami School of Medicine, Miami, Fla; and Centro Médico de Caracas, Caracas, Venezuela (A.G.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 22, 1999; revision requested April 21 and received June 15; accepted June 21. Address reprint requests to V.J.C., Department of Radiology, Jackson Memorial Medical Center, 1611 NW 12th Ave, Miami, FL 33136 (e-mail: jcasilla@mednet.med.miami.edu).
View larger version (122K):
[in a new window]
|
Figure 1a. Hemorrhagic HCC in a 79-year-old woman with acute onset of right upper quadrant (RUQ) pain and a history of HCC. (a) Nonenhanced CT scan shows a 4 x 5-cm, well-circumscribed mass of low attenuation (1) in segment 8 of the liver. (b) Contrast material-enhanced CT scan obtained 8 months later shows marked interval growth of the mass, which now has heterogeneous attenuation with central areas of high attenuation suggestive of fresh hemorrhage (arrows). At right hepatectomy, the presence of a hemorrhagic HCC was confirmed.
|
|
View larger version (144K):
[in a new window]
|
Figure 1b. Hemorrhagic HCC in a 79-year-old woman with acute onset of right upper quadrant (RUQ) pain and a history of HCC. (a) Nonenhanced CT scan shows a 4 x 5-cm, well-circumscribed mass of low attenuation (1) in segment 8 of the liver. (b) Contrast material-enhanced CT scan obtained 8 months later shows marked interval growth of the mass, which now has heterogeneous attenuation with central areas of high attenuation suggestive of fresh hemorrhage (arrows). At right hepatectomy, the presence of a hemorrhagic HCC was confirmed.
|
|
View larger version (143K):
[in a new window]
|
Figure 2a. Hemorrhagic HCC in a 53-year-old man with no history of HCC who presented with acute RUQ pain and hypotension. (a) Contrast-enhanced CT scan shows an exophytic mass in the right lobe of the liver (arrows). Note the high-attenuation fluid around the liver and spleen. (b) CT scan obtained at a lower level shows extension of the process inferiorly in the form of a large hemoperitoneum (arrow). Right hepatectomy showed a bleeding HCC associated with a significant hemoperitoneum.
|
|
View larger version (149K):
[in a new window]
|
Figure 2b. Hemorrhagic HCC in a 53-year-old man with no history of HCC who presented with acute RUQ pain and hypotension. (a) Contrast-enhanced CT scan shows an exophytic mass in the right lobe of the liver (arrows). Note the high-attenuation fluid around the liver and spleen. (b) CT scan obtained at a lower level shows extension of the process inferiorly in the form of a large hemoperitoneum (arrow). Right hepatectomy showed a bleeding HCC associated with a significant hemoperitoneum.
|
|
View larger version (130K):
[in a new window]
|
Figure 3a. Hemorrhagic and nonhemorrhagic hepatocellular adenomas in a 34-year-old woman with RUQ pain. (a) Transverse US scan shows a well-circumscribed, complex mass with cystic and solid elements in the periphery of the right hepatic lobe (arrow). (b) Nonenhanced CT scan shows that the mass has central areas of high attenuation, which are suggestive of acute bleeding. There is also a well-defined, low-attenuation mass in the left hepatic lobe (arrows). (c) Contrast-enhanced CT scan shows peripheral enhancement of the mass in the right lobe and heterogeneous enhancement of the mass in the left lobe. (d) T1-weighted MR image shows that the mass in the right lobe has a central, concentric rim of high signal intensity surrounding an area of low signal intensity (blood). Note some areas of low signal intensity in the left lobe, which correspond to the mass seen at contrast-enhanced CT (c). (Courtesy of Didier Mathieu, MD, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.)
|
|
View larger version (138K):
[in a new window]
|
Figure 3b. Hemorrhagic and nonhemorrhagic hepatocellular adenomas in a 34-year-old woman with RUQ pain. (a) Transverse US scan shows a well-circumscribed, complex mass with cystic and solid elements in the periphery of the right hepatic lobe (arrow). (b) Nonenhanced CT scan shows that the mass has central areas of high attenuation, which are suggestive of acute bleeding. There is also a well-defined, low-attenuation mass in the left hepatic lobe (arrows). (c) Contrast-enhanced CT scan shows peripheral enhancement of the mass in the right lobe and heterogeneous enhancement of the mass in the left lobe. (d) T1-weighted MR image shows that the mass in the right lobe has a central, concentric rim of high signal intensity surrounding an area of low signal intensity (blood). Note some areas of low signal intensity in the left lobe, which correspond to the mass seen at contrast-enhanced CT (c). (Courtesy of Didier Mathieu, MD, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.)
|
|
View larger version (146K):
[in a new window]
|
Figure 3c. Hemorrhagic and nonhemorrhagic hepatocellular adenomas in a 34-year-old woman with RUQ pain. (a) Transverse US scan shows a well-circumscribed, complex mass with cystic and solid elements in the periphery of the right hepatic lobe (arrow). (b) Nonenhanced CT scan shows that the mass has central areas of high attenuation, which are suggestive of acute bleeding. There is also a well-defined, low-attenuation mass in the left hepatic lobe (arrows). (c) Contrast-enhanced CT scan shows peripheral enhancement of the mass in the right lobe and heterogeneous enhancement of the mass in the left lobe. (d) T1-weighted MR image shows that the mass in the right lobe has a central, concentric rim of high signal intensity surrounding an area of low signal intensity (blood). Note some areas of low signal intensity in the left lobe, which correspond to the mass seen at contrast-enhanced CT (c). (Courtesy of Didier Mathieu, MD, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.)
|
|
View larger version (139K):
[in a new window]
|
Figure 3d. Hemorrhagic and nonhemorrhagic hepatocellular adenomas in a 34-year-old woman with RUQ pain. (a) Transverse US scan shows a well-circumscribed, complex mass with cystic and solid elements in the periphery of the right hepatic lobe (arrow). (b) Nonenhanced CT scan shows that the mass has central areas of high attenuation, which are suggestive of acute bleeding. There is also a well-defined, low-attenuation mass in the left hepatic lobe (arrows). (c) Contrast-enhanced CT scan shows peripheral enhancement of the mass in the right lobe and heterogeneous enhancement of the mass in the left lobe. (d) T1-weighted MR image shows that the mass in the right lobe has a central, concentric rim of high signal intensity surrounding an area of low signal intensity (blood). Note some areas of low signal intensity in the left lobe, which correspond to the mass seen at contrast-enhanced CT (c). (Courtesy of Didier Mathieu, MD, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.)
|
|
View larger version (112K):
[in a new window]
|
Figure 4a. Bleeding hepatocellular adenoma in a 42-year-old woman with intense RUQ pain and a 15-year history of oral contraceptive use. (a) Transverse US scan shows a subcapsular fluid collection with internal echoes in the right hepatic lobe (arrows). (b) Nonenhanced CT scan shows a large subcapsular liver hematoma (arrow). At surgery, the presence of a subcapsular hematoma was confirmed, and a small bleeding adenoma not evident at imaging was resected from the periphery of the right hepatic lobe.
|
|
View larger version (169K):
[in a new window]
|
Figure 4b. Bleeding hepatocellular adenoma in a 42-year-old woman with intense RUQ pain and a 15-year history of oral contraceptive use. (a) Transverse US scan shows a subcapsular fluid collection with internal echoes in the right hepatic lobe (arrows). (b) Nonenhanced CT scan shows a large subcapsular liver hematoma (arrow). At surgery, the presence of a subcapsular hematoma was confirmed, and a small bleeding adenoma not evident at imaging was resected from the periphery of the right hepatic lobe.
|
|
View larger version (121K):
[in a new window]
|
Figure 5a. Hemorrhagic FNH in a 43-year-old woman who had been taking oral contraceptives for 15 years and presented with a 3-hour history of dull, nonradiating RUQ pain. Laboratory studies showed a hemoglobin level of 9.5 g/dL (95 g/L) and a hematocrit of 27% (0.27). (a) Transverse US scan of the liver shows a large subcapsular fluid collection (arrow). (b) Contrast-enhanced CT scan shows a heterogeneous subcapsular fluid collection with hyperattenuating components (arrow), findings consistent with fresh bleeding around the right hepatic lobe. The patient was taken to surgery with the tentative diagnosis of ruptured hepatic adenoma, and a trisegmentectomy was performed. (c) Photomicrograph shows an organized blood clot (arrow) and a mass that has undergone hemorrhagic necrosis in the center, thus obscuring the histomorphology of the lesion and probably explaining the absence of a central scar. The expansile lesion lacks a capsule and compresses the adjacent hepatic parenchyma, which exhibits a pattern of sinusoidal congestion. Sections stained with reticulin to highlight tissue architecture (not shown) showed that the infarcted lesion contained portal vein tract structures including proliferating bile ducts, features not seen in hepatic adenoma or HCC but typical of FNH. The diagnosis of hemorrhagic, infarcted FNH was established.
|
|
View larger version (142K):
[in a new window]
|
Figure 5b. Hemorrhagic FNH in a 43-year-old woman who had been taking oral contraceptives for 15 years and presented with a 3-hour history of dull, nonradiating RUQ pain. Laboratory studies showed a hemoglobin level of 9.5 g/dL (95 g/L) and a hematocrit of 27% (0.27). (a) Transverse US scan of the liver shows a large subcapsular fluid collection (arrow). (b) Contrast-enhanced CT scan shows a heterogeneous subcapsular fluid collection with hyperattenuating components (arrow), findings consistent with fresh bleeding around the right hepatic lobe. The patient was taken to surgery with the tentative diagnosis of ruptured hepatic adenoma, and a trisegmentectomy was performed. (c) Photomicrograph shows an organized blood clot (arrow) and a mass that has undergone hemorrhagic necrosis in the center, thus obscuring the histomorphology of the lesion and probably explaining the absence of a central scar. The expansile lesion lacks a capsule and compresses the adjacent hepatic parenchyma, which exhibits a pattern of sinusoidal congestion. Sections stained with reticulin to highlight tissue architecture (not shown) showed that the infarcted lesion contained portal vein tract structures including proliferating bile ducts, features not seen in hepatic adenoma or HCC but typical of FNH. The diagnosis of hemorrhagic, infarcted FNH was established.
|
|
View larger version (188K):
[in a new window]
|
Figure 5c. Hemorrhagic FNH in a 43-year-old woman who had been taking oral contraceptives for 15 years and presented with a 3-hour history of dull, nonradiating RUQ pain. Laboratory studies showed a hemoglobin level of 9.5 g/dL (95 g/L) and a hematocrit of 27% (0.27). (a) Transverse US scan of the liver shows a large subcapsular fluid collection (arrow). (b) Contrast-enhanced CT scan shows a heterogeneous subcapsular fluid collection with hyperattenuating components (arrow), findings consistent with fresh bleeding around the right hepatic lobe. The patient was taken to surgery with the tentative diagnosis of ruptured hepatic adenoma, and a trisegmentectomy was performed. (c) Photomicrograph shows an organized blood clot (arrow) and a mass that has undergone hemorrhagic necrosis in the center, thus obscuring the histomorphology of the lesion and probably explaining the absence of a central scar. The expansile lesion lacks a capsule and compresses the adjacent hepatic parenchyma, which exhibits a pattern of sinusoidal congestion. Sections stained with reticulin to highlight tissue architecture (not shown) showed that the infarcted lesion contained portal vein tract structures including proliferating bile ducts, features not seen in hepatic adenoma or HCC but typical of FNH. The diagnosis of hemorrhagic, infarcted FNH was established.
|
|
View larger version (140K):
[in a new window]
|
Figure 6a. Hemorrhagic hemangioma in a 31-year-old man with a cavernous hemangioma of the liver diagnosed 1 year earlier. The patient presented with acute RUQ pain. (a) Nonenhanced CT scan obtained 1 year earlier shows a large mass in the central portion of the liver (arrow). The diagnosis of cavernous hemangioma was made with dynamic contrast-enhanced CT (not shown). (b) Nonenhanced CT scan obtained at the present admission shows no change in the size or configuration of the tumor; however, a large area of increased attenuation is seen within the lesion (arrow), a finding suggestive of intratumoral bleeding. The patient was treated nonsurgically.
|
|
View larger version (138K):
[in a new window]
|
Figure 6b. Hemorrhagic hemangioma in a 31-year-old man with a cavernous hemangioma of the liver diagnosed 1 year earlier. The patient presented with acute RUQ pain. (a) Nonenhanced CT scan obtained 1 year earlier shows a large mass in the central portion of the liver (arrow). The diagnosis of cavernous hemangioma was made with dynamic contrast-enhanced CT (not shown). (b) Nonenhanced CT scan obtained at the present admission shows no change in the size or configuration of the tumor; however, a large area of increased attenuation is seen within the lesion (arrow), a finding suggestive of intratumoral bleeding. The patient was treated nonsurgically.
|
|
View larger version (137K):
[in a new window]
|
Figure 7a. Hemorrhagic metastases from malignant melanoma in a 25-year-old woman with a palpable mass and RUQ pain. (a) Nonenhanced CT scan shows a large mass with areas of high attenuation involving the right and left hepatic lobes. An additional smaller lesion of high attenuation compresses the inferior vena cava (arrow). (b) T1-weighted MR image (repetition time msec/echo time msec = 728/16) shows a well-circumscribed mass with areas of high and low signal intensity. An ill-defined lesion is present in the posterior aspect of the right hepatic lobe (arrow). (c) T2-weighted MR image (6,783/160) shows a persistent area of high signal intensity in the posterior aspect of the mass. In addition, a mass of intermediate signal intensity is identified in the left hepatic lobe (arrow). At surgery, multiple lesions were found in the liver. The dominant lesion in the right lobe had multiple areas of hemorrhage. However, melanin could also produce high signal intensity on T1-weighted images due to its paramagnetic characteristics. The histopathologic diagnosis was hemorrhagic metastatic melanoma. On further evaluation, a cutaneous malignant melanoma was discovered in the patient's back.
|
|
View larger version (132K):
[in a new window]
|
Figure 7b. Hemorrhagic metastases from malignant melanoma in a 25-year-old woman with a palpable mass and RUQ pain. (a) Nonenhanced CT scan shows a large mass with areas of high attenuation involving the right and left hepatic lobes. An additional smaller lesion of high attenuation compresses the inferior vena cava (arrow). (b) T1-weighted MR image (repetition time msec/echo time msec = 728/16) shows a well-circumscribed mass with areas of high and low signal intensity. An ill-defined lesion is present in the posterior aspect of the right hepatic lobe (arrow). (c) T2-weighted MR image (6,783/160) shows a persistent area of high signal intensity in the posterior aspect of the mass. In addition, a mass of intermediate signal intensity is identified in the left hepatic lobe (arrow). At surgery, multiple lesions were found in the liver. The dominant lesion in the right lobe had multiple areas of hemorrhage. However, melanin could also produce high signal intensity on T1-weighted images due to its paramagnetic characteristics. The histopathologic diagnosis was hemorrhagic metastatic melanoma. On further evaluation, a cutaneous malignant melanoma was discovered in the patient's back.
|
|
View larger version (127K):
[in a new window]
|
Figure 7c. Hemorrhagic metastases from malignant melanoma in a 25-year-old woman with a palpable mass and RUQ pain. (a) Nonenhanced CT scan shows a large mass with areas of high attenuation involving the right and left hepatic lobes. An additional smaller lesion of high attenuation compresses the inferior vena cava (arrow). (b) T1-weighted MR image (repetition time msec/echo time msec = 728/16) shows a well-circumscribed mass with areas of high and low signal intensity. An ill-defined lesion is present in the posterior aspect of the right hepatic lobe (arrow). (c) T2-weighted MR image (6,783/160) shows a persistent area of high signal intensity in the posterior aspect of the mass. In addition, a mass of intermediate signal intensity is identified in the left hepatic lobe (arrow). At surgery, multiple lesions were found in the liver. The dominant lesion in the right lobe had multiple areas of hemorrhage. However, melanin could also produce high signal intensity on T1-weighted images due to its paramagnetic characteristics. The histopathologic diagnosis was hemorrhagic metastatic melanoma. On further evaluation, a cutaneous malignant melanoma was discovered in the patient's back.
|
|
View larger version (157K):
[in a new window]
|
Figure 8. Acute subcapsular hematoma associated with HELLP syndrome in a 38-year-old woman who was 38 weeks pregnant and presented with RUQ pain, hypertension, 4+ proteinuria, and low platelet count. Nonenhanced CT scan shows a large, mostly hyperattenuating, acute subcapsular hematoma (arrow). A diagnosis of HELLP syndrome was established, and a cesarean section was performed. The patient and the neonate did well after this procedure.
|
|
View larger version (154K):
[in a new window]
|
Figure 9. Hepatic infarction associated with HELLP syndrome in a 28-year-old woman with a history of eclampsia and associated HELLP syndrome. Nonenhanced CT scan shows a large, wedge-shaped area of low attenuation in the right hepatic lobe (arrow), a finding suggestive of a hepatic infarction. Note the presence of ascites around the liver.
|
|
View larger version (145K):
[in a new window]
|
Figure 10. Intrahepatic hemorrhage due to primary amyloidosis in a 56-year-old woman with acute abdominal pain and a falling hematocrit. Exploratory laparoscopy revealed a massive hemoperitoneum. The upper right lobe of the liver was found to be the source of the bleeding, and partial right hepatectomy was performed; however, the hospital course was complicated by multiorgan failure. Contrast-enhanced postoperative CT scan shows areas of low attenuation in the left hepatic lobe (arrows). At autopsy, these areas represented old hemorrhage within a liver diffusely infiltrated by amyloid.
|
|
Copyright © 2000 by the Radiological Society of North America.
