case_images: PMC7201948_01
case_images: PMC7201948_02
case_images: Chest X-Ray and Ultrasound. On the left picture (a), the supinous chest-X ray in expirium shows a right pneumothorax, suggested by the radiolucency of the apex and the collapsed the lung parenchyma (arrowheads pointing the visceral pleural line), while the radiopacity at right lung base shows the presence of pleural effusion. As a consequence, a slight controlateral mediastinal shift is present. The right lung effusion was confirmed with the ultrasound examination, revealing a dishomogenous hyperechoic material settled in the posterior pleural cavity compatible with a huge blood clot (asterisk) as illustrated in the figure on the right (b)
case_images: 13037_2020_244_Fig1_HTML.jpg
case_images: PMC7201948_02_13037_2020_244_Fig1_HTML.jpg
case_images: Fig1
case_images: They showed signs of pneumo-haemothorax and lung collapse of the right hemithorax (Fig. 1).
case_images: CT scan with contrast medium and Volume rendering of the active bleeding. The Axial CT scan (a) shows the blushing of contrast media in the right lung apex (star) that crosses into a blood clot. The volume rendering reconstruction (b) with a back view of the subclavian artery highlights its passage between the clavicle and the first rib. The three-dimensional reconstruction shows also, two vessels arising from the superior side of the artery, the thick white arrow points the thyrocervical trunk while the star indicates the outflow of contrast media. In the CT slice (c) are detectable: the right lung collapse (arrowheads), the presence of an air-fluid level (dashed line) with a dishomogeneous avascular irregular-shaped mass in the posterior pleural cavity as hallmark of a haemo-pneumothorax with huge coagulated blood (asterisk) and, lastly, the consequent mediastinal left-shifting
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case_images: PMC7201948_02_13037_2020_244_Fig2_HTML.jpg
case_images: Fig2
case_images: A blood transfusion was performed in order to stabilise the patient before the Computed Tomography (CT) scanning with contrast media, which confirmed the diagnosis of bleeding revealing a haemorrhagic focus at the right lung apex with the suspicion of subclavian origin (Fig. 2).
case_images: PMC7201948_03
case_images: Digital Subtractive Angiography and operative planning. The picture taken with digital subtractive angiography shows the extravasation of blood from the thyrocervical trunk (asterisk) and the branch feeding the anterior mid-line artery of the spinal cord (white circle) that led to slide the catheter tip forward in order to reach a selective embolisation of the bleeding branches. The two vessels supplying the haematoma are highlighted with the white arrows
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case_images: PMC7201948_03_13037_2020_244_Fig3_HTML.jpg
case_images: Fig3
case_images: The subclavian artery and its branches were evaluated, showing a consistent and faint contrast media leaking in the vascular field of the thyrocervical trunk (Fig. 3).
case_images: Embolisation with spirals. The first Fig. (a) shows an angiogram of the tortuous course of the bleeding vessels. The micro-catheter was inserted over the branch supplying the spinal cord in order to obtain a selective embolisation of the blood leaking branches with two micro-coils. The second angiographic image (b) demonstrated the closure of the haemorrhagic vessels and the patency of the radiculo-medullary spinal branch. The typical longitudinal course of the anterior spinal artery is shown in the right frame, where it runs in parallel to the spinal processes of the vertebrae
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case_images: PMC7201948_03_13037_2020_244_Fig4_HTML.jpg
case_images: Fig4
case_images: At the angiographic control any bleeding or collateral supply to the haematoma emerged (Fig. 4).
case_images: PMC7201948_04