대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Spontaneous hemopneumothorax with active bleeding.

Radiologic Findings

Fig 1. Chest PA shows collapsed right lung, increase opacity of right pleural cavity, and mediastinum shifting to left side.
Figs 2-5. Lung window setting and mediastinum window setting of the chest CT scan shows air fluid level in right pleural cavity, heterogenous high attenuatied fluid, and collapsed right lung.
Figs 6,7. Pre-post contrast chest CT scan shows contrast attenuation, suspicious contrast media leakage.

Brief Review

This patient present with sudden onset of chest pain, with the initial chest x-ray demonstrating a right hydropneumothorax. No cause was identified with no proceeding trauma or infection, and no past medical history. No mass or vascular malformation identified on imaging. VATS was decided, and adhesion band, multiple bullae, and active bleeding were observed in OP finding.
Haemothorax is a clinical entity that in most cases can be caused by trauma, coagulopathy, or iatrogenic causes through procedures such as central line insertion, thoracocentesis, pleural biopsies. Spontaneous haemothorax (SH) is a subcategory of haemothorax that involves the accumulation of blood within the pleural space in the absence of trauma or other causes.
Spontaneous hemopneumothorax, defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax, is a rare entity occurring in young patients and may be life threatening. The clinical presentation is variable and includes a rapid progression of symptoms of chest pain and dyspnea that can be life threatening when hemodynamic instability and hypovolemic shock occurs.
There are said to be three mechanisms of bleeding in hemopneumothorax. First, result from a tom adhesion between the parietal and visceral pleura. Second, result from the rupture of vascularized bullae and underlying lung parenchyma. Third, result from torn congenitally aberrant vessels between the parietal pleura and bullae.
The diagnosis of spontaneous hemopneumothorax is concurrent presence of pneumothorax and hemothorax (over 50 HU fluid, blood-fluid level), absence of trauma or other causes.
Thoracoscopic draining is usually for stable patients. In haemodynamically unstable patients or if the rate of bleeding is more than 500 mL/hr in the first hour with 200-300 mL/hr subsequently, early surgical approach is favoured.

References

1. Etiology and management of spontaneous haemothorax, J Thorac Dis 2015 Mar; 7(3): 520–526.
2. Spontaneous Hemopneumothorax Revisited: Clinical Approach and Systemic Review of the Literature, Nan-Yung Hsu et all, Ann Thorac Surg, 2005;80:1859 – 63

Keywords

Pleura,