Contrast media-induced compartment syndrome

Intravascular (IV) contrast media are essential in many cases to enhance the diagnostic capabilities of medical imaging procedures. Much is known about the indications, contraindications, and adverse events associated with their use. This Directed Reading focuses on extravasation and IV contrast media-induced compartment syndrome, a less frequent, although serious, adverse event. In addition to describing the compartments within the forearm, wrist, and hand, the article explains how compartment syndrome develops, techniques used to treat the condition, and prevention strategies.     

CT对比剂血管外渗发生机制的讨论及防治措施

对比剂外渗是进行CT增强扫描的重要不良反应之一.由于CT增强扫描越来越广泛的应用于临床,外渗的发生率也有上升趋势.对比剂外渗常常导致组织坏死而影响肢体的形态及功能,大量的对比剂外渗甚至会引发骨筋膜室综合症,造成肢体的不可逆损伤.本文将通过分析对比剂外渗的发生机制及发生影响因素来探讨其防治措施,进一步引起临床对于对比剂外渗的重视及降低其发生率.     

碘对比剂外渗皮肤反应不同治疗方案的对照研究

目的:比较不同治疗方案对碘对比剂皮肤外渗反应的治疗效果。方法:自2010年1月至2012年1月,对84例碘对比剂皮肤外渗反应病例随机使用硫酸镁敷剂+冷敷、磺胺嘧啶银敷剂+冷敷和单纯冷敷治疗。分别在反应后第1、2、3、7天评估皮肤颜色、肢体肿胀程度、局部循环以及患肢功能状况。比较不同治疗方案的治疗效果。结果:45例外渗反应在1天后、18例在2天后、11例在3天后基本痊愈,仅1例出现骨筋膜室综合征,经切开治疗后痊愈,病程超过7天。其中磺胺嘧啶银+冷敷组痊愈最快(χ2a-b=32.56,Pa-b=0.001,χ2b-c=41.02,Pb-c<0.001)。出现反应后1～3天内磺胺嘧啶银组皮肤颜色恢复显著快于其他两组(χ2皮肤a-b=23.10,P皮肤a-b=0.006;χ2皮肤b-c=24.87,P皮肤b-c=0.003);反应后7天,三组在各项评分方面无显著差异(P>0.05)。结论:绝大部分碘对比剂皮肤外渗反应在1天内均有显著好转,7天内基本可痊愈;外渗反应可引起骨筋膜室综合征,宜早诊断并手术治疗;磺胺嘧啶银+冷敷治疗效果更佳。     

Extravasación de medios de contraste intravenosos en el sitio de la punción: Protocolo de actuación

The incidence of contrast medium extravasation at the venipuncture site has increased with the generalized use of automatic injectors. Most extravasations only cause slight edema and erythema. Nevertheless, in some cases extravasation can result in severe skin lesions or even in compartment syndrome. Lesions caused by extravasation usually resolve spontaneously with conservative treatment. Although the complications of extravasation are well known, institutional protocols are normally lacking and the criteria for taking action and the type of treatment, whether based on the literature or personal preferences, tend to vary. In this article, we review the incidence, risk factors, clinical manifestations, and options for preventing and treating contrast medium extravasation in soft tissues. Finally, we present the protocol we use to manage extravasation at our hospital.     

Akutes Kompartmentsyndrom des Unterarms nach Paravasation von Röntgenkontrastmittel

The paravasation of radiographic contrast medium has a wide spectrum of clinical presentations, ranging from local erythema and swelling to extensive damage to the extremity affected. We report the case of a patient who developed an acute compartment syndrome of the forearm after paravenous mechanical injection of 100 ml radiographic contrast medium. After emergency fasciotomy for muscle and nerve decompression the full range of motion and sensitivity could be restored.     

Evaluation of spontaneous renal extravasation of contrast media in the excretory urogram

Spontaneous renal extravasation is the term used to refer to the radiological demonstration of contrast medium outside the collecting system without previous trauma, ureter catheterization, operation on the kidney or its vicinity, and without external compression during urography. In a review of 1300 intravenous urograms, 13 cases of extravasation of contrast medium were found to satisfy the above criteria. Differences in the radiological appearance may cause problems with regard to evaluation and classification. From a therapeutic point of view it is important to distinguish between two forms: transient sinus extravasation due to minute tears in the calyceal fornix after an increase in intrapelvic pressure and persisting rupture of the previously impaired renal pelvis, which may require surgical intervention.     

Results of compartment decompression in chronic forearm compartment syndrome: six case presentations

Methods: Six patients with a flexor compartment chronic compartment syndrome, documented by pressure studies, had forearm compartment decompression. Results: All patients had good relief of their exercise associated forearm pain following the decompression. Widening of the incisional scar was frequently reported. Conclusion: Forearm compartment decompression is effective in relieving the symptoms related to chronic forearm compartment syndrome.     

Chronic exertional compartment syndrome after minor injury to the lower extremity

Since the 1950s, chronic exertional compartment syndrome of the lower leg has been thoroughly reported in the literature. The predisposing factors and pathophysiology of this condition, however, still are not fully understood. We present a case of a well-conditioned individual who developed a chronic exertional compartment syndrome of the left lower leg anterior compartment after a direct blow injury during a softball game. Trauma is not routinely implicated as a risk factor for chronic compartment syndrome, and the literature on this topic is scarce. We suggest that trauma, even low-velocity trauma, may precipitate a chronic exertional compartment syndrome. We review the literature regarding chronic exertional compartment syndromes preceded by trauma and offer explanations regarding the mechanisms by which a traumatic event may induce a chronic compartment syndrome.     

Administración de contrastes intravenosos: las extravasaciones

Local extravasation of intravenous contrast material is a relatively common complication that radiologists need to know about. The risk of extravasation is greater in children, the elderly, and unconscious patients. Although most extravasations are mild and do not lead to further complications, some can result in severe lesions that require surgery, especially in cases that are associated with compartment syndrome. We describe the main characteristics of extravasations, comment on different treatments, and propose a protocol for dealing with them.     

Contrast-enhanced ultrasound imaging of active bleeding associated with hepatic and splenic trauma

Purpose

The aim of this study was to evaluate contrast-enhanced ultrasound (CEUS) imaging of active bleeding from hepatic and splenic trauma.

Materials and methods

Three hundred and ninety-two patients with liver or/and spleen trauma (179 liver and 217 spleen injuries), who underwent CEUS examinations following contrast-enhanced computed tomography (CT), were enrolled in this retrospective study over a period of >4 years. CEUS detected contrast medium extravasation or pooling in 16% (63/396) of liver or spleen lesions in 61 patients, which was confirmed by contrast-enhanced CT. Special attention was paid to observing the presence, location, and characteristics of the extravasated or pooled contrast medium.

Results

The CEUS detection rate for active bleeding was not different from that of contrast-enhanced CT (p=0.333). Information from surgery, minimally invasive treatment and conservative treatment was used as reference standard, and the sensitivities of the two techniques were not different (p=0.122). Of 63 lesions in 61 patients, CEUS showed that 74.6% (47/63) (21 liver lesions and 26 spleen lesions) presented contrast medium extravasation or pooling, both in the organ and out the capsule, in 14.3% (9/63) and only outside the capsule in 11.1% (7/63). CEUS imaging of active bleeding from hepatic and splenic trauma presented various characteristics, and the sizes and shapes of the active bleeding due to contrast medium extravasation or pooling were variable.

Conclusions

CEUS can show the active bleeding associated with hepatic and splenic trauma with various imaging characteristics, thus making it possible to diagnose active bleeding using CEUS.     

Intracerebral extravasation of contrast medium after head injury

Summary A case of intracerebral extravasation of contrast medium is reported. In cases of head injury this occurrence is rare and is manifested by persistent images on both frontal and lateral views of the angiogram. This indicates severe cerebral trauma with active hemorrhage and the prognosis is generally bad. A possible mechanism seems to be contrecoup.     

Chronic compartment syndrome of the forearm in competitive motor cyclists: a report of two cases

Exertional compartment syndrome of the forearm is rare. However, it should be considered in cases of a painful forearm during motorcycle racing. Pressure measurements of all compartments during exercises that simulate the actions of racing confirm the diagnosis. An exertional electromyography may be useful to reveal a nerve compression associated with the compartment syndrome. Fasciotomy of the affected compartments allows relief of symptoms and return to previous activities in all cases.     

Acute exertional medial compartment syndrome of the foot after playing basketball

Compartment syndrome of the foot is an uncommon event. The most common cause of compartment syndrome of the foot is a crush injury. Exceedingly rare is acute compartment syndrome of the foot occurring in the absence of trauma. We describe the clinical scenario involving a 23-year-old healthy male who developed acute exertional compartment syndrome isolated to the medial compartment of the foot after playing basketball. The patient had no evidence of injury nor trauma, and the diagnosis was made based on physical exam, magnetic resonance imaging (MRI), and compartment pressure measurements. The patient did undergo successful fasciotomy on the day of presentation to the emergency department and has since completely recovered. We found four cases reported in the literature of acute exertional medial compartment syndrome of the foot in the absence of trauma or injury. This is the second case reported after playing basketball, while the others occurred after aerobics, a long distance run, and football. The most recent case was reported by Miozzari et al. [Am J Sports Med. 36(5):983–6, 2008] and involved a marathon runner who developed an isolated medial compartment syndrome of the foot. We would like to increase awareness of this uncommon clinical presentation in the absence of trauma and present the dramatic radiographic findings.     

Computed tomography of ureteral disruption

Computed tomography in four cases of urine extravasation due to ureteropelvic disruption secondary to blunt trauma were compared with CT in 15 cases of renal parenchymal injury. In three cases of isolated ureteropelvic disruption the renal parenchyma was intact; contrast medium excretion was normal; no perirenal hematoma was present. Contrast medium extravasation was confined predominantly to the medial perirenal space. The ipsilateral ureter was not opacified in three of the four cases of ureteropelvic disruption. These CT findings of ureteral injury are distinct from those of renal parenchymal injury. When these findings are present on CT done for trauma, confident diagnosis of ureteral disruption can be made. In one case, combined renal parenchymal injury and ureteropelvic disruption occurred.     

Helical computed tomography of liver injuries: A trial of dual phase imaging

This study was performed to evaluate whether consecutive arterial phase and portal venous phase scans of the upper abdomen are contributory in the evaluation of the liver in patients with blunt abdominal trauma. The purpose of the study was to determine whether such dual acquisition using helical computed tomography (HCT) provides improved definition of injuries and significant information about the dynamics of posttraumatic hemorrhage.During a 10-month period, all patients referred for evaluation of blunt abdominal trauma were scanned using a dual phase imaging technique. Two consecutive and comparable scan clusters were programmed to study the upper abdomen, with a slice collimation of 10 mm and a 11 pitch. Intravenous contrast medium was delivered at a rate of 2 ml/sec for a total of 125 ml, with scan delays of 30 and 70 seconds (arterial and venous phases of hepatic enhancement).Thirty-two patients with hepatic lacerations were encountered, and the images from both acquisitions were compared and graded according to lesion conspicuity. The presence of contrast medium extravasation associated with parenchymal injuries was also recorded.In 23 (72%) of the 32 patients, the liver injuries were better defined in the portal venous phase, and in eight (25%) patients, the lesions were equally shown in both phases. In only one case, the lesion was better demonstrated in the arterial phase. Contrast medium extravasation was noted in two patients at the site of liver laceration. In three additional cases, contrast medium extravasation was also noted in associated splenic injuries. In all of these patients, the extravasation (bleeding laceration) was seen only in the images corresponding to the portal venous phase.Dual phase HCT of the upper abdomen does not provide significant additional information in the evaluation of patients with liver injuries resulting from blunt abdominal trauma. With a single scan cluster through the upper abdomen after a 70-second injection-scan delay, lesion definition is optimal, and vascular opacification remains adequate.     

MRI features of intersection syndrome of the forearm

OBJECTIVE: The purpose of this original report is to describe the MRI findings in patients with intersection syndrome of the forearm. CONCLUSION: Intersection syndrome is an overuse disorder of the dorsal distal forearm, presenting with particular symptoms and signs that may be clinically misdiagnosed. MRI can perform an important role in establishing the diagnosis. Peritendinous edema (peritendinitis) around the first and second extensor compartment tendons, extending proximally from the crossover point, is the most characteristic finding that should suggest a diagnosis of intersection syndrome. Chronic cases may be subtle and not show substantial MRI findings likely reflecting the development of a stenosing tenosynovitis.     

A Case of Traumatic Mesenteric Bleeding Controlled by only Transcatheter Arterial Embolization

We report a case of mesenteric hematoma following blunt abdominal trauma that was successfully treated with transcatheter arterial embolization (TAE) and did not require surgical repair. A 43-year-old man with blunt abdominal trauma caused in a factory accident was admitted with a stable general condition and laboratory data. On CT examination, a large mesenteric hematoma with extravasation of contrast media was observed. TAE was first attempted to control the bleeding. A superior mesenteric angiogram showed extravasation of contrast medium from a branch of the ileocolic artery and obstruction of the cecal branch. After successful TAE using microcoils, the distal portion of the cecal branch was still preserved via collateral circulation. No abdominal symptoms have occurred during the 7 months following TAE. In mesenteric injury cases with limited intestinal damage, TAE may therefore be a reasonable alternative to emergent laparotomy.     

Brain magnetic resonance with magnetization transfer in multiple sclerosis. Lesion hyperintensity before and after intravenous gadolinium administration

PURPOSE: The possibility of detecting contrast agent extravasation (i.e., active hemorrhage) with dynamic conventional Computed Tomography (CT) in patients with abdominal trauma has already been reported in small series. We report our experience in the demonstration of contrast material extravasation using helical CT; we also investigate the diagnostic and clinical value of this finding. MATERIAL AND METHODS: January 1997 to July 1998, we examined 41 consecutive patients with upper abdominal trauma. Twelve patients (29%) had contrast material extravasation. The examinations were performed with a helical unit and volumetric acquisitions (thickness 8-10 mm, pitch 1, reconstruction interval 5-8 mm). The intravenous contrast medium (350 mgI/mL, 130-140 mL) was administered with rapid infusion (2-2.5 mL/s, 40-50 s acquisition delay from bolus starting) and using a power injector. We reviewed the CT studies and clinical records of these 12 patients. Contrast agent extravasation was considered present when this finding, not recognizable on plain scans, showed equal attenuation to or higher attenuation than the vessels within the same level. Moreover we assessed leak site, CT appearance, the direct visualization of the involved vessel, the evidence of other abdominal or extra-abdominal injuries, the CT signs of hypovolemic shock, clinical and surgical data. For comparison, we finally evaluated 50 examinations performed with a conventional CT scanner in subjects with abdominal trauma. RESULTS: Active hemorrhage involved the abdominal wall in 1 case (intercostal artery), the solid organs in 4 (splenic in 2, hepatic in 1, of the middle hepatic vein in 1), the peritoneal cavity in 3 (splenic, midcolic, and gastroduodenal artery in 1 each), the retroperitoneum in 4 (renal pedicle in 2, renal parenchyma in 1, lumbar artery in 1). In all cases the site of contrast extravasation corresponded at surgery to the site of active bleeding. The pattern was localized in 10 cases and diffuse in 2. The involved vessel could be identified in 5 cases while in the other ones the origin could be inferred from the leakage site. Associated injuries of upper abdominal organs were seen in 11 of 12 patients and extra-abdominal trauma in 6. In 4 cases there were CT features of hypovolemia. One patient died during transport to the operating room and another after surgery, while all the others survived. Contrast extravasation was identified in 9 (18%) of the patients examined with a conventional CT unit. CONCLUSIONS: Active contrast material extravasation can be recognized with conventional CT scanners, though it has been considered a rare finding. Helical CT seems to increase the detection rate and especially to boost the radiologist's confidence in this diagnosis. Though active bleeding is identified in severely-injured subjects requiring urgent intervention and may be associated with findings of hypovolemic shock, it should not be considered itself as a negative prognostic factor. Contrast extravasation is due to ongoing hemorrhage and its detection is critical for urgent treatment. Accurate anatomical location permits to choose surgical management or transcatheter embolization and thus decreases time consumption for precise bleeding site identification.     

肾损伤伴严重尿外渗的临床处理及随访

目的总结我科5年来收治的肾损伤合并严重尿外渗的处理及转归。方法对21例肾外伤伴严重尿外渗患者,通过静脉尿路造影、CT、彩超等检查确诊后,18例入院后安放伤侧输尿管支架管引流尿液并进行随访行保守治疗,3例由于血流动力学不稳定行急诊手术探查。结果21例肾外伤伴尿外渗患者17例（Ⅳ级损伤）保守治疗成功,随访5～46个月,肾功能均正常,无血尿、结石、肾性高血压等并发症的发生;3例急诊开放行肾切除术,1例Ⅱ期行部分肾切除术,所有需外科处理的患者均为高级别肾损伤Ⅳ或Ⅴ级。结论肾损伤伴严重尿外渗患者（Ⅳ级损伤）早期安放输尿管内支架经保守治疗多数可获良好疗效。     

Contrast medium extravasation injury: guidelines for prevention and management

Extravasation of contrast material is a well-recognized complication of contrast-enhanced imaging studies. The management of this complication is contentious; therefore, the Contrast Media Safety Committee of The European Society of Urogenital Radiology decided to review the literature and issue guidelines. A comprehensive literature search was carried out. The resulting report was discussed at the 8th European Symposium on Urogenital Radiology in Genoa, Italy. Automated power injection may result in extravasation of large volumes and may or can lead to severe tissue damage. Infants, young children and unconscious and debilitated patients are particularly at risk of extravasation during contrast media injection. Fortunately, most extravasations result in minimal swelling or erythema, with no long-term sequelae; however, severe skin necrosis and ulceration may occur. Large volumes of high osmolar contrast media are known to induce significant tissue damage. Compartment syndrome may be seen associated with extravasation of large volumes. Conservative management is often adequate, but in serious cases the advice of a plastic surgeon is recommended. Based on the review simple guidelines for prophylaxis and management of contrast medium extravasation injuries are proposed. Electronic Publication