Spontaneous non-aortic retroperitoneal hemorrhage : etiology, imaging characterization and impact of MDCT on management. A multicentric study

PURPOSE: The purpose of this multicentric study is to assess the usefulness of multiphasic Computed tomography in the identification of spontaneous non-traumatic retroperitoneal hematoma (SRH) and its management, with references to the role of interventional radiology. MATERIALS AND METHODS: From January 2011 to June 2014, 27 patients with SRH were selected. Patients with aortic, traumatic, or iatrogenic source of bleeding were excluded. All the patients were studied with multiphasic MDCT after injection of intravenous contrast. Digital Subtraction angiography and percutaneous embolization treatment were performed. RESULTS: CT identified SRH in all cases (100%), showing the source of bleeding in 11 cases (40%) and pointing out the source of bleeding in 15 cases (55%). In one case (5%), the bleeding origin was recognized only at surgery as adrenal source. CT has identified a contrast medium extravasation in the arterial phase in 17 patients (63%), treated successfully by percutaneous embolization in 13 and by open-surgery in two cases. Two patients died before undergoing intervention and surgery, respectively. Ten patients (37%) were non-operatively treated successfully with clinical, laboratory, and imaging follow-up. CONCLUSIONS: Multiphasic CT is the gold standard for the identification of a SRH. Recognition of CT signs of active bleeding is the crucial feature influencing the timing of therapeutic treatment. Urgent embolization should be performed in cases of arterial bleeding or contained vascular injuries supplying the retroperitoneal hematoma. Surgery is to be addressed in cases of actively bleeding hematomas associated with complication. Finally, an initial more conservative approach can be adopted in patients without signs of contrast extravasation or low-flow active bleeding. Technical skill, expertise, and recognition of CT signs of arterial active bleeding are critical features influencing patients management