070417 IATROGENIC PREVESICAL SPACE HEMATOMA

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070417 IATROGENIC PREVESICAL SPACE HEMATOMA

Contributed by: pedrad CSH, Radiologist, Chung Shan Medical University Hospital, Taiwan.

Patient: 2 month old female

History: 2+ month old female.
She was received ultrasound examination due to hyperbilirubinemia.
Ultrasound showed normal liver and biliary ducts but a cystic lesion in lower abdomen with unknown etiology.

Birth history:
Prematurity (Gestational age: 27 weeks).
Birth weight: 1100g

1. Respiratory distress syndrome since birth.
2. Progressive hyperbilirubinemia
3. Suspicious necrotizing enterocolitis, post contrast lower GI study.
4. Ever received blood transfusion due to blood loss after right femoral central line (Hb: 12.6 --> 6.4 gm/dl).

Images:

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Fig. 1: Photo


Fig. 2: Ultrasound


Fig. 3: Ultrasound


Fig. 4: MRI


Fig. 5: MRI


Fig. 6: MRI


Fig. 7: MRI


Fig. 8: MRI


Fig. 9: MRI


Fig. 10: MRI


Fig. 11: MRI


Fig. 12: MRI


Fig. 13: KUB


Fig. 14: Follow up MRI


Fig. 15: Follow up MRI

Findings: Photo (figure 01):
1. Dark-color skin, due to hyperbilirubinemia.
2. Right femoral central line.
3. Left leg peripherally inserted central catheter.

Ultrasound (figure 02,03):
1. A thickened-wall cystic lesion with internal echoic spots
    in lower abdomen.
2. Suspicious a bladder with debris in more deep region.

MRI (figure 04-12):
1. A "molar tooth" like big lesion, about 3.3cm in greatest
   dimension, with short T1 and long T2 thick (0.7cm) wall,
   iso T1 and T2 central cystic component in lower abdomen,
   in favor of hematoma with methemoglobin containing in
   prevesical space (space of Retzius) of extraperitoneum.
2. Small short T1 and long T2 fluid accumulation in presacral space
   of extraperitoneum, compatible with small blood.
3. Non-distended UB.

KUB (figure 13) (3wks before Ultrasound and MRI):
1. No abnormal finding in "pre-right femoral central line KUB".
2. A ovoid big opacity in pelvis with some degree mass effect
   (I missed this finding at that time) in "post-right femoral
   central line KUB", compatible with hematoma.

Follow up MRI (figure 14,15) (10days after first time MRI):
1. Clearer demonstration the relationship of the lesion, distended
     bladder, and pubic bone.

Diagnosis: Iatrogenic Prevesical Space Hematoma

Discussion: This is a nice case to teaching:
1. The obvious history (Hb from 12.6 gm/dl to 6.4 gm/dl after
    central line) was ignored and not been informed to
    radiologist by clinical staffs (vital sign stable after blood
    transfusion).
2. The big pelvic opacity in KUB was missed by a
    "stupid radiologist" (It's me!).
3. The "molar tooth" like lesion in lower abdomen is a
    typical image to prevesical space lesion and the short T1
    phenomenon (under fat saturation technic) is a typical
    presentation to methemoglobin. But the examination
    seems not necessary and the diagnosis seems a little
    late to the patient.

Comments:

1. Border of prevesical space (also called the retropubic space or space of Retzius):
   1). anterior and lateral: umbilicovesical fascia
   2). deep: transversalis fascia
   3). inferiorly: posterior part of the pubic bone
   4). posterior extensions: surrounding urinary bladder laterally
   5). potential communicates with properitoneal fat and posterior pararenal space.
2. Feature of prevesical space fluid (ex: hematoma or abscess):
"Molar tooth" configuration in an axial plane (because of the orientation of
umbilicovesical fascia) with anterior to bladder between umbilicovesical
fascia and transversalis fascia of anterior abdominal wall.

By Dr. Tsao

--pedrad CSH, 2007-04-19

Additional Details:

Case Number: 8794426Last Updated: 04-30-2007
Anatomy: Genitourinary (GU) Pathology: Trauma
Modality: Conventional Radiograph, Photograph, MR, USAccess Level: Readable by all users
Keywords: iatrogenic, prevesical, hematoma, hemorrhageACR: 875.43

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