Asian Cardiovasc Thorac Ann 1999;7:316-318
© 1999 Asia Publishing EXchange Pte Ltd
Intrapulmonary Hematoma and Hemothorax Following Penetrating Chest Injury
Mustafa Çikirikçio
lu, MD,
Ufuk Çairici, MD,1,
Hakan Posaciolu, MD,
Yüksel Atay, MD,
Recep Sava
, MD,2,
Münevver Yüksel, MD,
Önol Bilkay, MD,1
Department of Cardiovascular Surgery
1 Department of Thoracic Surgery
2 Department of Radiology Medical Faculty, Ege University Bornova,  zmir, Turkey
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For reprint information contact: Mustafa Çikirikçiolu, MD Tel: 90 232 388 2866 Fax: 90 232 339 0002 email: mcikirikcioglu{at}hotmail.com Department of Cardiovascular Surgery, Medical Faculty, Ege University, Bornova, zmir 35100, Turkey.
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Abstract
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Hemothorax and intrapulmonary hematoma were successfully treated in a 25-year-old male who suffered a penetrating chest injury. This very rare combination of clinical entities in the same patient is discussed in the light of pertinent literature.
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Introduction
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Chest trauma is one of the leading causes of death around the world. Penetrating injuries caused by either a stab or a small-caliber gunshot, are seen more frequently as a result of increased social violence. The clinical mani-festation varies greatly and is highly dependent on the type of instrument causing the penetrating wound. Pulmonary parenchymal lacerations commonly occur with stabbing weapons. If the visceral pleura remains intact, a pneumothorax, hemothorax, or a combination of these will result. On the other hand, tearing of the visceral pleura may lead to pulmonary hematoma that usually appears as a solitary pulmonary nodule and mimics various posttraumatic lesions.
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Case Report
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A 25-year-old man was taken urgently to the emergency department of Ege University Medical Faculty Hospital after receiving penetrating wounds to the chest and abdomen. Signs of hemorrhagic shock were present on admission and radiography revealed a left-sided hemo-pneumothorax. After placement of a thorax tube in the left hemithorax, he underwent an exploratory laparotomy at which an intestinal injury was diagnosed and repaired. There was no need for prompt thoracotomy for the hemothorax because no further significant bleeding was observed after initial drainage of 600 mL of blood. On the 7th postoperative day, routine posteroanterior and lateral chest radiographs showed an extrapulmonary loculation of fluid in the lateral field of the left hemithorax and a well-defined round homogenous density of 2 cm in diameter in the left hilum (Figures 1 and 2
). The latter was adjacent to the thoracic aorta, suggesting an aortic pseudoaneurysm. A contrast-enhanced computed tomo-graphy (CT) scan of the thorax was performed to clarify the origin of the left hilar density. This revealed a pulmonary parenchymal hematoma and showed a large cavity of very dense fluid, indicating an organized hemothorax (Figure 3). The nonfunctioning chest tube was subsequently replaced but the hemothorax could not be adequately drained. A thoracotomy was carried out on the 10th day after the penetrating injury.
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Figure 1. Posteroanterior chest radiograph showing a round mass superimposed on the left hilum and increased density in the mid and lower zone on the left side.
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Figure 2. Lateral view of the chest showing a large bulge at the dorsal lung zone indicative of hemothorax.
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Figure 3. Computed tomographic section at the mediastinal window setting, showing left pleural effusion (hemothorax) with parenchymal consolidation in the superior segment of the left lower lobe, which has a smooth margin.
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The chest was opened by a left posterolateral thoracotomy incision along the lower border of the 5th rib. A loculated hemothorax measuring 15 x 20 cm was seen between the posterior portion of the chest wall and the lung, compressing the lower lobe. It was surrounded by a thin pleural peel. After evacuation of the hemothorax, decortication was performed and complete reexpansion of the compressed lobe was achieved. Exploring the lung parenchyma, a fluid-filled cavity of 2 cm in diameter was also detected in the superior segment of the lower lobe, adjacent to the aorta. A small incision over the lesion revealed a pulmonary hematoma that was removed by wedge resection. The postoperative period was uneventful and the patient was discharged in good condition. Follow-up chest radiographs were found to be nearly normal (Figure 4).
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Discussion
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Penetrating stab wounds of the chest can be produced by a multiplicity of weapons such as knives or rapiers. The extent of a stab wound depends on the length and width of the inflicting instrument and the trace through which it travels. In this case, there were two stab wounds entering the thoracic and abdominal cavities, which prompted the surgeon to perform an exploratory laparotomy after placing a thorax tube for left-sided hemopneumothorax. Post-laparotomy posteroanterior chest radiographs showed a homogenous mass outlined by a thin pleural layer, suggesting a retained hemothorax. The development of clotted hemothorax was attributed to improper positioning of the patient during the postoperative period. The patient's inability to generate an effective cough also contributed to the maturing process of organized hemothorax. In order to prevent further complications such as empyema or pachypleuritis, early operative removal was undertaken. Although it was suggested that the operation should be delayed for up to 4 to 5 weeks from the time of injury to give the patient additional time to stabilize and recover from the other injuries, in view of the patient's age and the associated pathology, we preferred early thoracotomy.1
Intrapulmonary hematoma, the other coexisting pathology in our patient, is relatively rare.2 It presents clinically as a hemorrhagic collection within a newly-formed cavity in the lung parenchyma and may form following blunt pulmonary injuries.3–5 Penetrating trauma seldom leads to the formation of pulmonary hematoma. Boltro and colleagues,2 emphasized that the typical radiological features, including a round opacity with distinct edges, may be sufficient for diagnosis, whereas Fukuyama and colleagues6 reported a case in which magnetic resonance imaging gave better information. Likewise, Takahashi and colleagues7 favored magnetic resonance findings for the diagnosis of intrapulmonary hematoma. In our patient, the contrast-enhanced CT scan was found to be adequate in establishing the diagnosis and it enabled safe differential diagnosis against a periaortic hematoma and false aneurysm, which were suggested by the routine radio-graphs. Dobrowolski and colleagues8 reported a case of pulmonary hematoma associated with pneumothorax but we were unable to find another case in the literature in which pulmonary hematoma and hemothorax coexisted in the same patient.
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References
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Boyd AD. Pneumothorax and hemothorax. In: Hood RM, Boyd AD, Culliford AT, editors. Thoracic trauma. Philadelphia: Saunders, 1989:133–48.
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Fukuyama S, Aizawa H, Inoue H, Hidaka K, Murayama S, Hara N. Intrapulmonary hematoma diagnosed by magnetic resonance imaging. Nippon Kyobu Shikkan Gakkai Zasshi 1997;35:245–9.
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Takahashi N, Murakami J, Murayama S, Sakai S, Masuda K, Ishida T. MR evaluation of intrapulmonary hematoma. J Comput Assist Tomogr 1995;19:125–7.[Medline]
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Dobrowolski J, Korycki J, Szyszko S. Rare coexistence of pulmonary hematoma and pneumothorax after chest injury. Pol Przegl Radiol 1970;34:323–8.[Medline]
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Abstract
Introduction
