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Pelvic Arterial Hemorrhage in Patients with Pelvic Fractures: Detection with Contrast-enhanced CT¹

¹ From the Department of Diagnostic Radiology, Chonnam National University Hospital, Chonnam National University Medical School, 8 Hak-dong, Dong-Ku, Gwangju 501–757, South Korea. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received March 4, 2004; revision requested April 7; received and accepted April 26. All authors have no financial relationships to disclose. Address correspondence to W.Y. (e-mail: radyoon@chonnam.ac.kr).

View larger version (158K): [in a new window]   Figure 1.  Angiogram shows the internal iliac artery and its branches: the iliolumbar artery (1), lateral sacral arteries (2), superior gluteal artery (3), obturator artery (4), internal pudendal artery (5), inferior gluteal artery (6), and vesical arteries (7).

View larger version (79K): [in a new window]   Figure 2.  Drawing of the left hemipelvis shows the major branches of the internal iliac artery. IS = ischial spine, IT = ischial tuberosity.

View larger version (56K): [in a new window]   Figure 3.  Drawing of the right hemipelvis shows the anatomy of the greater (G) and lesser (L) sciatic foramina.

View larger version (56K): [in a new window]   Figure 4.  Drawing of the posterior right hemipelvis shows the gluteal arteries exiting the pelvis. GT = greater trochanter of the femur, IS = ischial spine, IT = ischial tuberosity.

View larger version (160K): [in a new window]   Figure 5.  Iliolumbar artery. CT scan shows the right iliolumbar artery (arrow) arising from the posterolateral aspect of the internal iliac artery (arrowhead). I = iliacus muscle, Pm = psoas major muscle.

View larger version (154K): [in a new window]   Figure 6.  Iliolumbar artery. CT scan shows the iliolumbar artery (arrows) running anterior to the sacroiliac joint. Pm = psoas major muscle.

View larger version (167K): [in a new window]   Figure 7.  Iliolumbar artery. CT scan shows the iliolumbar artery, which divides into an iliac branch (arrows) running anterior to the iliacus muscle (I) and a lumbar branch (arrowhead) ascending ventral to the sacrum.

View larger version (169K): [in a new window]   Figure 8.  Lateral sacral arteries. CT scan shows the superior lateral sacral artery (arrow) arising from the posterior trunk of the internal iliac artery (arrowhead) and extending into a sacral foramen.

View larger version (167K): [in a new window]   Figure 9.  Lateral sacral arteries. CT scan obtained inferior to 8 shows the inferior lateral sacral artery (arrow).

View larger version (173K): [in a new window]   Figure 10.  Lateral sacral arteries. CT scan shows bilateral sacral arteries (arrows) running downward anterior to the sacrum.

View larger version (141K): [in a new window]   Figure 11.  Superior and inferior gluteal arteries. CT scan shows the superior gluteal artery arising from the posterior division of the internal iliac artery (arrow).

View larger version (132K): [in a new window]   Figure 12.  Superior and inferior gluteal arteries. CT scan obtained inferior to 11 shows the superior gluteal artery (arrow) exiting the pelvis through the greater sciatic foramen, posterior to the ilium (I) and above the piriformis muscle (P).

View larger version (142K): [in a new window]   Figure 13.  Superior and inferior gluteal arteries. CT scan shows the superficial (arrows) and deep (arrowheads) branches of the superior gluteal artery. The superficial branch runs between the gluteus maximus (1) and gluteus medius (2) muscles. The deep branch runs between the gluteus medius (2) and gluteus minimus (3) muscles.

View larger version (135K): [in a new window]   Figure 14.  Superior and inferior gluteal arteries. CT scan shows the inferior gluteal artery (arrow) approaching the greater sciatic foramen, anterior to the piriformis muscle.

View larger version (126K): [in a new window]   Figure 15.  Superior and inferior gluteal arteries. CT scan obtained inferior to 14 shows the inferior gluteal artery (solid arrow) leaving the pelvis through the lower part of the greater sciatic foramen, above the sacrospinous ligament (arrowheads) and posterior to the ischial spine (S). Note the accompanying internal pudendal artery (open arrow).

View larger version (134K): [in a new window]   Figure 16.  Superior and inferior gluteal arteries. CT scan shows the inferior gluteal artery (arrow), which travels down the posterior buttock and is covered by the gluteus maximus muscle (M).

View larger version (139K): [in a new window]   Figure 17.  Internal pudendal artery. CT scan shows the left internal pudendal artery (arrow) exiting the pelvis together with the inferior gluteal artery (arrowhead).

View larger version (150K): [in a new window]   Figure 18.  Internal pudendal artery. CT scan shows the internal pudendal artery (arrow) posterior to the ischial spine and sacrospinous ligament (arrowheads).

View larger version (149K): [in a new window]   Figure 19.  Internal pudendal artery. CT scan shows the internal pudendal artery (arrow) reentering the pelvis through the lesser sciatic foramen.

View larger version (106K): [in a new window]   Figure 20.  Internal pudendal artery. CT scan shows the internal pudendal artery (arrow) in the lateral wall of the ischiorectal fossa (F), medial to the obturator internus muscle (OI).

View larger version (104K): [in a new window]   Figure 21.  Internal pudendal artery. CT scan shows the internal pudendal artery (arrowheads) running parallel to the ischiopubic rami and ischiocavernous muscle (solid arrow). The cavernosal arteries (open arrows) are terminal branches of the internal pudendal artery.

View larger version (127K): [in a new window]   Figure 22.  Obturator artery. CT scan shows the obturator artery (arrow) running along the pelvic sidewall, close to the acetabulum. B = urinary bladder, GM = gluteus maximus, R = rectum.

View larger version (141K): [in a new window]   Figure 23.  Obturator artery. CT scan shows the obturator artery (arrow) within the obturator canal before leaving the pelvis. GM = gluteus maximus, SPR = superior pubic ramus.

View larger version (132K): [in a new window]   Figure 24.  Obturator artery. CT scan shows the obturator artery dividing into anterior and posterior branches (arrows) in the obturator canal.

View larger version (120K): [in a new window]   Figure 25.  CT scan shows the inferior vesical artery (arrow) posterior to the unenhanced venous structure in the paravesical fat.

View larger version (135K): [in a new window]   Figure 26.  CT scan shows branches of the tortuous uterine arteries (arrows) extending to the uterus (U) via the broad ligament.

View larger version (130K): [in a new window]   Figure 27a.  CT-angiographic correlation for detection of bleeding from the iliolumbar artery. (a) CT scan shows extravasation of contrast material (open arrow) within a hematoma of the left iliacus muscle (solid arrows). (b) Angiogram shows multifocal extravasation (solid arrows) from the left iliolumbar artery (open arrows). Bleeding from the lateral sacral artery is also seen.

View larger version (148K): [in a new window]   Figure 27b.  CT-angiographic correlation for detection of bleeding from the iliolumbar artery. (a) CT scan shows extravasation of contrast material (open arrow) within a hematoma of the left iliacus muscle (solid arrows). (b) Angiogram shows multifocal extravasation (solid arrows) from the left iliolumbar artery (open arrows). Bleeding from the lateral sacral artery is also seen.

View larger version (152K): [in a new window]   Figure 28a.  CT-angiographic correlation for detection of bleeding from the lateral sacral artery. (a) CT scan shows a comminuted fracture of the sacrum with extravasation of contrast material (arrows) anterior to the sacrum. (b) Left common iliac angiogram shows bleeding from the superior lateral sacral artery (arrow).

View larger version (181K): [in a new window]   Figure 28b.  CT-angiographic correlation for detection of bleeding from the lateral sacral artery. (a) CT scan shows a comminuted fracture of the sacrum with extravasation of contrast material (arrows) anterior to the sacrum. (b) Left common iliac angiogram shows bleeding from the superior lateral sacral artery (arrow).

View larger version (157K): [in a new window]   Figure 29a.  CT-angiographic correlation for detection of bleeding from the superior gluteal artery. (a) CT scan shows a comminuted fracture of the right ischium and extravasation of contrast material (arrow) at the level of the suprapiriformis compartment of the greater sciatic foramen. (b) Angiogram shows cutoff of the superior gluteal artery at the origin site with active bleeding (arrow).

View larger version (175K): [in a new window]   Figure 29b.  CT-angiographic correlation for detection of bleeding from the superior gluteal artery. (a) CT scan shows a comminuted fracture of the right ischium and extravasation of contrast material (arrow) at the level of the suprapiriformis compartment of the greater sciatic foramen. (b) Angiogram shows cutoff of the superior gluteal artery at the origin site with active bleeding (arrow).

View larger version (129K): [in a new window]   Figure 30a.  CT-angiographic correlation for detection of bleeding from the internal pudendal artery. (a) CT scan shows a fracture of the right inferior pubic ramus with extravasation of contrast material (arrow) within a hematoma in the ischiorectal fossa. (b) Superselective angiogram obtained with a microcatheter shows active bleeding (solid arrow) from the internal pudendal artery. Note the normal angiographic blush in the perineum (open arrow).

View larger version (176K): [in a new window]   Figure 30b.  CT-angiographic correlation for detection of bleeding from the internal pudendal artery. (a) CT scan shows a fracture of the right inferior pubic ramus with extravasation of contrast material (arrow) within a hematoma in the ischiorectal fossa. (b) Superselective angiogram obtained with a microcatheter shows active bleeding (solid arrow) from the internal pudendal artery. Note the normal angiographic blush in the perineum (open arrow).

View larger version (135K): [in a new window]   Figure 31a.  CT-angiographic correlation for detection of bleeding from the obturator artery. (a) CT scan shows a fracture of the anterior right acetabulum (arrow) and extravasation of contrast material (arrowheads) within a hematoma of the pelvic sidewall. These CT findings are suggestive of bleeding from the obturator artery. (b) Superselective angiogram obtained with a microcatheter (arrowheads) shows active bleeding (arrow) from a branch of the right obturator artery and vertical fractures of the superior and inferior pubic rami. (c) Right internal iliac arteriogram obtained after embolization of the bleeding branch with gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) and a microcoil (arrowhead) shows no further extravasation. (d) Selective left internal iliac arteriogram shows active hemorrhage at the same site (arrow) supplied from the left obturator artery. The left obturator artery was embolized with gelatin sponge and coils. (e) Left internal iliac arteriogram obtained after embolization shows occlusion of the left obturator artery (arrow) and no hemorrhage.

View larger version (154K): [in a new window]   Figure 31b.  CT-angiographic correlation for detection of bleeding from the obturator artery. (a) CT scan shows a fracture of the anterior right acetabulum (arrow) and extravasation of contrast material (arrowheads) within a hematoma of the pelvic sidewall. These CT findings are suggestive of bleeding from the obturator artery. (b) Superselective angiogram obtained with a microcatheter (arrowheads) shows active bleeding (arrow) from a branch of the right obturator artery and vertical fractures of the superior and inferior pubic rami. (c) Right internal iliac arteriogram obtained after embolization of the bleeding branch with gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) and a microcoil (arrowhead) shows no further extravasation. (d) Selective left internal iliac arteriogram shows active hemorrhage at the same site (arrow) supplied from the left obturator artery. The left obturator artery was embolized with gelatin sponge and coils. (e) Left internal iliac arteriogram obtained after embolization shows occlusion of the left obturator artery (arrow) and no hemorrhage.

View larger version (165K): [in a new window]   Figure 31c.  CT-angiographic correlation for detection of bleeding from the obturator artery. (a) CT scan shows a fracture of the anterior right acetabulum (arrow) and extravasation of contrast material (arrowheads) within a hematoma of the pelvic sidewall. These CT findings are suggestive of bleeding from the obturator artery. (b) Superselective angiogram obtained with a microcatheter (arrowheads) shows active bleeding (arrow) from a branch of the right obturator artery and vertical fractures of the superior and inferior pubic rami. (c) Right internal iliac arteriogram obtained after embolization of the bleeding branch with gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) and a microcoil (arrowhead) shows no further extravasation. (d) Selective left internal iliac arteriogram shows active hemorrhage at the same site (arrow) supplied from the left obturator artery. The left obturator artery was embolized with gelatin sponge and coils. (e) Left internal iliac arteriogram obtained after embolization shows occlusion of the left obturator artery (arrow) and no hemorrhage.

View larger version (162K): [in a new window]   Figure 31d.  CT-angiographic correlation for detection of bleeding from the obturator artery. (a) CT scan shows a fracture of the anterior right acetabulum (arrow) and extravasation of contrast material (arrowheads) within a hematoma of the pelvic sidewall. These CT findings are suggestive of bleeding from the obturator artery. (b) Superselective angiogram obtained with a microcatheter (arrowheads) shows active bleeding (arrow) from a branch of the right obturator artery and vertical fractures of the superior and inferior pubic rami. (c) Right internal iliac arteriogram obtained after embolization of the bleeding branch with gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) and a microcoil (arrowhead) shows no further extravasation. (d) Selective left internal iliac arteriogram shows active hemorrhage at the same site (arrow) supplied from the left obturator artery. The left obturator artery was embolized with gelatin sponge and coils. (e) Left internal iliac arteriogram obtained after embolization shows occlusion of the left obturator artery (arrow) and no hemorrhage.

View larger version (146K): [in a new window]   Figure 31e.  CT-angiographic correlation for detection of bleeding from the obturator artery. (a) CT scan shows a fracture of the anterior right acetabulum (arrow) and extravasation of contrast material (arrowheads) within a hematoma of the pelvic sidewall. These CT findings are suggestive of bleeding from the obturator artery. (b) Superselective angiogram obtained with a microcatheter (arrowheads) shows active bleeding (arrow) from a branch of the right obturator artery and vertical fractures of the superior and inferior pubic rami. (c) Right internal iliac arteriogram obtained after embolization of the bleeding branch with gelatin sponge (Gelfoam; Pharmacia & Upjohn, Kalamazoo, Mich) and a microcoil (arrowhead) shows no further extravasation. (d) Selective left internal iliac arteriogram shows active hemorrhage at the same site (arrow) supplied from the left obturator artery. The left obturator artery was embolized with gelatin sponge and coils. (e) Left internal iliac arteriogram obtained after embolization shows occlusion of the left obturator artery (arrow) and no hemorrhage.

View larger version (123K): [in a new window]   Figure 32a.  CT-angiographic correlation for detection of bleeding from the vesical artery. (a) CT scan shows a small focus of extravasated contrast material (arrow) in the wall of the urinary bladder. (b) Aortogram shows active bleeding (arrow) from the left vesical artery.

View larger version (140K): [in a new window]   Figure 32b.  CT-angiographic correlation for detection of bleeding from the vesical artery. (a) CT scan shows a small focus of extravasated contrast material (arrow) in the wall of the urinary bladder. (b) Aortogram shows active bleeding (arrow) from the left vesical artery.

View larger version (157K): [in a new window]   Figure 33a.  Bleeding from the iliolumbar artery detected with selective injection of the internal iliac artery. (a) Contrast-enhanced CT scan shows a fracture and displacement of the left ala of the sacrum with extravasation of contrast material (arrows) between the L5 body and fractured sacrum. (b) Pelvic arteriogram shows no definite site of hemorrhage. (c) Selective left internal iliac arteriogram shows active extravasation (solid arrow) from the iliolumbar artery (open arrow). (d) Left internal iliac arteriogram obtained after embolization of the iliolumbar artery with microcoils (arrows) shows no further hemorrhage.

View larger version (152K): [in a new window]   Figure 33b.  Bleeding from the iliolumbar artery detected with selective injection of the internal iliac artery. (a) Contrast-enhanced CT scan shows a fracture and displacement of the left ala of the sacrum with extravasation of contrast material (arrows) between the L5 body and fractured sacrum. (b) Pelvic arteriogram shows no definite site of hemorrhage. (c) Selective left internal iliac arteriogram shows active extravasation (solid arrow) from the iliolumbar artery (open arrow). (d) Left internal iliac arteriogram obtained after embolization of the iliolumbar artery with microcoils (arrows) shows no further hemorrhage.

View larger version (97K): [in a new window]   Figure 33c.  Bleeding from the iliolumbar artery detected with selective injection of the internal iliac artery. (a) Contrast-enhanced CT scan shows a fracture and displacement of the left ala of the sacrum with extravasation of contrast material (arrows) between the L5 body and fractured sacrum. (b) Pelvic arteriogram shows no definite site of hemorrhage. (c) Selective left internal iliac arteriogram shows active extravasation (solid arrow) from the iliolumbar artery (open arrow). (d) Left internal iliac arteriogram obtained after embolization of the iliolumbar artery with microcoils (arrows) shows no further hemorrhage.

View larger version (111K): [in a new window]   Figure 33d.  Bleeding from the iliolumbar artery detected with selective injection of the internal iliac artery. (a) Contrast-enhanced CT scan shows a fracture and displacement of the left ala of the sacrum with extravasation of contrast material (arrows) between the L5 body and fractured sacrum. (b) Pelvic arteriogram shows no definite site of hemorrhage. (c) Selective left internal iliac arteriogram shows active extravasation (solid arrow) from the iliolumbar artery (open arrow). (d) Left internal iliac arteriogram obtained after embolization of the iliolumbar artery with microcoils (arrows) shows no further hemorrhage.