Pelvik travmada aktif kanama

Özet

Yüksek enerjili pelvis halkası kırığı veya hemodinamik bozulması olan travma hastasında aktif kanama, hızla tanınması gereken yaşamı tehdit eden bir bulgudur. Kontrastlı çok fazlı BT, ekstravazasyonun yerini ve fazlar arasındaki yoğunluk değişimini göstererek aktif kanamanın hematomdan ayırt edilmesine yardımcı olur. Arteriyel seride komşu arter lümenine benzer yoğunlukta ve damar konturu dışında görülen kontrast odağının sonraki seride büyümesi veya yayılması aktif ekstravazasyonu destekler. Pelvik kanama değerlendirmesinde kontrastsız seriyi arteriyel ve portal venöz fazlar izler; kanama bulguları BT ve gerektiğinde DSA ile klinik bağlam içinde değerlendirilir. Kanama gözden kaçarsa şokun kaynağı ve yaralanan damar dalı belirlenemeyebilir.

Faz ve pencere

Kontrastsız

Kontrastsız seri, çok fazlı protokolde arteriyel ve portal venöz fazlardan önce alınır; hematom dağılımı ile aktif ekstravazasyon veya psödoanevrizma kontrastlı BT’de değerlendirilir.

Arteriyel tanısal

Arter lümeniyle benzer yoğunlukta, damar konturu dışında kalan odak; damar duvarı kesintisi veya fokal kese ile birlikteyse aktif arteriyel kaçak ya da psödoanevrizma lehinedir. Odağın köken olduğu arteri (örn. internal iliak veya harici iliak/korona mortis sistemi) geriye doğru takip edin; kaynak dalı kırık hattı ve anatomik dağılımla ilişkilendirin.

Portal tanısal

Ardışık BT görüntülerinde damar dışındaki kontrastın ilerleyici artışı aktif ekstravazasyonu destekler. Pelvik kanama değerlendirmesinde kontrastsız seriyi arteriyel ve portal venöz fazlar izler; kanama bulguları BT ve gerektiğinde DSA ile klinik bağlam içinde değerlendirilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40), Kemik (G 1800 / M 400).

BT bulguları

• Kontrast ekstravazasyonu — arteriyel seride damar dışı, arterle eş yoğunlukta yeni kontrast odağı.
• Ardışık BT görüntülerinde damar dışındaki kontrastın ilerleyici artışı aktif ekstravazasyonu destekler.
• Pelvik BT’de hematomun dağılımı, aktif ekstravazasyon veya psödoanevrizma bulgularıyla birlikte değerlendirilir.
• Pubik ramus komşuluğu — obturator, internal pudendal veya inferior epigastrik arter dallarını arayın.
• Pelvik kırıkla komşu hematom veya kontrast ekstravazasyonu, BT’de kanama dağılımı ve damar yaralanması açısından değerlendirilir.
• Pelvik travma sonrası BT anjiyografide superior gluteal arter kaynaklı psödoanevrizma görülebilir.
• Eşlik eden damar lezyonu — ekstravazasyondan ayrı olarak fokal psödoanevrizma, damar kesilmesi veya erken ven dolumu aranır.

Normalde

Kontrastlı pelvis BT’sinde aktif ekstravazasyon veya psödoanevrizma bulgularıyla birlikte hematomun dağılımı değerlendirilir. Şüpheli pelvik damar bulguları, kontrastlı BT ve gerektiğinde DSA ile klinik bağlam içinde değerlendirilir.

Ayırıcı tanı

Psödoanevrizma

yuvarlak veya oval kontrast kesesi arterle aynı fazda dolar ve damar dışı yayılım göstermeden sınırlı kalabilir.

Kemik parçası

kemik penceresinde kortikal yoğunluk ve kırıkla süreklilik gösterir; kontrast fazları arasında değişmez.

Tuzaklar

• Tek fazlı portal incelemede arteriyel fazda belirgin olan ekstravazyonun gözden kaçması arteriyel yaralanmayı dışlamaz; travma protokolünün tüm fazlarını birlikte değerlendirmeniz gerekir.
• Damarla üst üste düşen kırık parçası veya flebolit yalancı kontrast odağı izlenimi verebilir; kontrastsız seri ve kemik penceresinde aynı noktayı bulun.
• Aktif ekstravazyonun görünmemesi devam eden kanamayı kesin dışlamaz; klinik kötüleşme veya yaygın hematom varlığında kanama kaynağı seçici anjiyografi ile saptanabilir.
• Arteriyel kaynaklı odağın sonraki fazda artık görülmemesini kanamanın olmadığı şeklinde yorumlamayın; başlangıç fazındaki damar dışı kontrast da pozitiftir.

Kendini dene

1. Pelvik travmada aktif arteriyel kanama ve psödoanevrizma tanı konulan hastalarda, hemostazı sağlamak amacıyla müdahale gerektiren temel radyolojik bulgu hangisidir?

   • Damar dışı kontrast ekstravazasyonu veya psödoanevrizma
   • Yumuşak doku ödem düzeyi
   • Kemik parça displasmanı derecesi
   • Retroperitoneal hava varlığı
   Cevabı göster

   Damar dışı kontrast ekstravazasyonu veya psödoanevrizma. S4 ve S16'da pelvik travmada kontrastlı damar dışı ekstravazyon (aktif kanama) ve psödoanevrizmanın tanımlandığı, S16'da ise bu bulguların hızlı tanı ve müdahale için altın standart olan çok fazlı BT'nin temel amaçları olarak belirtildiği vurgulanmaktadır.

2. Pubik ramus kırığına bağlı pelvik travmada, inferior epigastrik arterin pubik dalları veya korona mortis yoluyla aktifleşen kanamanın kaynağı hangi arter sisteminden beklenir?

   • Dış iliak arter / inferior epigastrik arter sistemi
   • İç iliak arter trunku
   • Renal arter
   • Splenik arter
   Cevabı göster

   Dış iliak arter / inferior epigastrik arter sistemi. S4'te inferior epigastrik arterin (IEA) harici iliak arterden köken aldığını, caudal yönde pubik dallar verdiğini ve bu dalların obturator arterle anastomoz yaparak korona mortisi oluşturduğunu; pubik ramus kırıklarında bu pubik dalların veya korona mortisinin kanama kaynağı olabileceğini belirtmektedir.

İlgili konular

• Pelvik venöz kanama örüntüsü

Kaynaklar

Bu sayfadaki 34 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 17 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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