J Thorac Cardiovasc Surg 2005;129:233-234
© 2005 The American Association for Thoracic Surgery
Rapidly accumulating spontaneous pulmonary hematoma
Ibrahim Sersar Sameh, MBBCH,
Mohammed ElShabrawii, MBBCH,
Ahmed Sabry Elsaeid, MBBCH,
Yasser Ahmed Farag, MD,
Shaban Abulela, MD,
Mohammed Mounir El Salid, MD
Department of Cardiothoracic Surgery, Mansoura University, Elgomhoria, Mansoura 123, Egypt
To the Editor:
We read with the greatest interest the article entitled "Rupture of a Chronic Expanding Hematoma of the Thorax Into Lung Parenchyma."1 We have the following comments. First of all, there is a delay in patient management. Why did the authors not do a diagnostic bronchoscopy, and why did they do a pneumonectomy and not a lobectomy? The chest radiograph A is a case suggestive of aspiration pneumonia. We wonder why they chose median sternotomy and not a thoracotomy. What was the pathology of the removed lung? We think that this was a case of spontaneous pulmonary hematoma caused by an arteriovenous malformation. We had a similar case that we published in Interactive Cardiovascular and Thoracic Surgery.2 The chest x-ray film, computed tomogram, and magnetic resonance angiogram are attached (Figure 1). Pulmonary hematoma consists of hemorrhage into the alveolar and interstitial spaces. It is usually associated with surrounding intraparenchymal hemorrhage.3 However, 24 to 48 hours after the trauma, a hematoma typically develops into a discrete mass with distinct margins. It usually resolves in approximately 2 to 4 weeks. Occasionally, these hematomas might cavitate if they become secondarily infected and present as an abscess requiring drainage.4 Posttraumatic pulmonary hematoma might result from direct blunt trauma, blast injury, or indirect forces from the ballistics of a missile. Pulmonary hematomas might also result from overdose of anticoagulants or, rarely, as a complication of subclavian vein catheterization.
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Figure 1. Radiologic appearance of small spontaneous rapidly accumulating pulmonary hematomas complicating a small pulmonary aneurysm. (Reprinted from Interactive Cardiovascular and Thoracic Surgery, volume 3, Sersar IS, Ismaeil MF, Abdel Mageed NA, Elsaeid MM. Rapidly Accumulating Spontaneous Pulmonary Hematoma Complicating A Small Parenchymal Aneurysm, p 243-4, copyright 2004, with permission from Elsevier.)
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Although Nakayama and coworkers5 have reported that pulmonary hematoma can occur as isolated injuries in children, in adults they are typically associated with other injuries and have an overall mortality rate of 22% to 30%, as recorded by Besson and Saegesser6 and Stellin.3,7,8 The most frequent clinical sign is hemoptysis. Chest pain and compression symptoms might be present. Pulmonary hematoma should be suspected in any patient with major chest wall injury; it can be confirmed by radiologic evaluation. Computed tomographic scanning can be helpful in distinguishing between contusion and hematoma. It is a more sensitive and accurate means of diagnosing pulmonary hematoma. Magnetic resonance imaging allows documentation of pulmonary hematoma and exclusion of more ominous lesions.9 Indications for surgical intervention were as follows: infection, hemoptysis, and suspicion of a malignant lesion. The early and late results are excellent.6
References
- Okubo K, Okamoto T, Isobe J, Ueno Y. Rupture of a chronic expanding hematoma of the thorax into lung parenchyma. J Thorac Cardiovasc Surg 2004;127:1838-1840.[Free Full Text]
- Sersar IS, Ismaeil MF, Abdel Mageed NA, Elsaeid MM. Rapidly accumulating spontaneous pulmonary hematoma complicating a small parenchymal aneurysm. Interactive Cardiovasc Thorac Surg 2004;3:243-244.[Abstract/Free Full Text]
- Trinkle JK, Richardson JD, Franz JL. Management of flail chest without mechanical ventilation. Ann Thorac Surg 1975;19:355-363.[Abstract/Free Full Text]
- Mathai M, Byrd Jr RP, Roy TM. The posttraumatic pulmonary mass. J Tenn Med Assoc 1996;89:41-42.[Medline]
- Nakayama DK, Ramenofsky ML, Rowe MI. Chest injuries in childhood. Ann Surg 1989;210:770-775.[Medline]
- Besson A, Saegesser F. Color atlas of chest trauma and associated injuries. Vol. 1. Oradell (NJ): Medical Economics; 1983..
- Colebunders R, Parizel P, De Backer W, De Schepper A, Vermeire P. Pulmonary haematoma caused by oral anticoagulant therapy. Report of a case. Acta Radiol Diagn (Stockh) 1983;24:445-447.[Medline]
- Stellin G. Survival in trauma victims with pulmonary contusion. Am Surg 1991;57:780-784.[Medline]
- Obretenov E, Petrov D, Alaidzhiev G, Plochev M. Surgical treatment of posttraumatic intrapulmonary haematomas. [in Bulgarian] Khirurgiia (Sofiia) 2002;58:24-27.
