Skip to main content
Log in

Spontaneous Intramuscular Hematomas of the Abdomen and Pelvis: A New Multilevel Algorithm to Direct Transarterial Embolization and Patient Management

  • Clinical Investigation
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript



To report our experience using a multilevel patient management algorithm to direct transarterial embolization (TAE) in managing spontaneous intramuscular hematoma (SIMH).

Materials and Methods

From May 2006 to January 2014, twenty-seven patients with SIMH had been referred for TAE to our Radiology department. Clinical status and coagulation characteristics of the patients are analyzed. An algorithm integrating CT findings is suggested to manage SIMH. Patients were classified into three groups: Type I, SIMH with no active bleeding (AB); Type II, SIMH with AB and no muscular fascia rupture (MFR); and Type III, SIMH with MFR and AB. Type II is furthermore subcategorized as IIa, IIb and IIc. Types IIb, IIc and III were considered for TAE. The method of embolization as well as the material been used are described. Continuous variables are presented as mean ± SD. Categorical variables are reported as percentages. Technical success, clinical success, complications and 30-day mortality (d30 M) were analyzed.


Two patients (7.5%) had Type IIb, four (15%) Type IIc and 21 (77.5%) presented Type III. The detailed CT and CTA findings, embolization procedure and materials used are described. Technical success was 96% with a complication rate of 4%. Clinical success was 88%. The bleeding-related thirty-day mortality was 15% (all with Type III).


TAE is a safe and efficient technique to control bleeding that should be considered in selected SIMH as soon as possible. The proposed algorithm integrating CT features provides a comprehensive chart to select patients for TAE.

Level of Evidence


This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Zidane M, Schram MT, Planken EW, Molendijk WH, Rosendaal FR, van der Meer FJ, Huisman MV. Frequency of major hemorrhage in patients treated with unfractionated intravenous heparin for deep venous thrombosis or pulmonary embolism: a study in routine clinical practice. Arch Intern Med. 2000;160(15):2369–73.

    Article  CAS  PubMed  Google Scholar 

  2. Smithson A, Ruiz J, Perello R, Valverde M, Ramos J, Garzo L. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579–82. doi:10.1016/j.ejim.2013.02.016 PMID: 23535226.

    Article  PubMed  Google Scholar 

  3. Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of risk factors for rectus sheath hematoma. Clin Appl Thromb Hemost. 2016;22(3):292–6. doi:10.1177/1076029614553024 PMID:25294636.

    Article  CAS  PubMed  Google Scholar 

  4. Zissin R, Gayer G, Kots E, Ellis M, Bartal G, Griton I. Transcatheter arterial embolisation in anticoagulant-related haematoma–a current therapeutic option: a report of four patients and review of the literature. Int J Clin Pract. 2007;61(8):1321–7. [Epub 2007 Mar 2].

  5. Zainea GG, Jordan F. Rectus sheath hematomas. their pathogenesis, diagnosis, and management. Am Surg. 1988;54(10):630–3.

    CAS  PubMed  Google Scholar 

  6. Titone C, Lipsius M, Krakauer JS. “Spontaneous” hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment. Surgery. 1972;72(4):568–72.

    CAS  PubMed  Google Scholar 

  7. Zissin R, Ellis M, Gayer G. The CT findings of abdominal anticoagulant-related hematomas. Semin Ultrasound CT MRI. 2006;27(2):117–25.

    Article  CAS  Google Scholar 

  8. Berna JD, Zuazu I, Madrigal M, Garcia-Medina V, Fernandez C, Guirado F. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging. 2000;25(3):230–4.

    Article  CAS  PubMed  Google Scholar 

  9. Katz DS, Lane MJ, Mindelzun RE. Unenhanced CT of abdominal and pelvic hemorrhage. Semin Ultrasound CT MRI. 1999;20(2):94–107.

    Article  CAS  Google Scholar 

  10. Isokangas JM, Perala JM. Endovascular embolization of spontaneous retroperitoneal hemorrhage secondary to anticoagulant treatment. Cardiovasc Interv Radiol. 2004;27(6):607–11. [Epub 2004 Jun 3].

  11. Levy JM, Gordon HW, Pitha NR, Nykamp PW. Gelfoam embolization for control of bleeding from rectus sheath hematoma. AJR Am J Roentgenol. 1980;135(6):1283–4.

    Article  CAS  PubMed  Google Scholar 

  12. Katsumori T, Nakajima K. A case of spontaneous hemorrhage of the abdominal wall caused by rupture of a deep iliac circumflex artery treated by transcatheter arterial embolization. Eur Radiol. 1998;8(4):550–2.

    Article  CAS  PubMed  Google Scholar 

  13. Qanadli SD, El Hajjam M, Mignon F, Bruckert F, Chagnon S, Lacombe P. Life-threatening spontaneous psoas haematoma treated by transcatheter arterial embolization. Eur Radiol. 1999;9(6):1231–4.

    Article  CAS  PubMed  Google Scholar 

  14. Basile A, Medina JG, Mundo E, Medina VG, Leal R. Transcatheter arterial embolization of concurrent spontaneous hematomas of the rectus sheath and psoas muscle in patients undergoing anticoagulation. Cardiovasc Interv Radiol. 2004 ;27(6):659-62. [Epub 2004 Aug 12].

  15. Ozyer U. Transcatheter Arterial Embolization with N-Butyl-2-Cyanoacrylate in the Management of Spontaneous Hematomas. Cardiovasc Interv Radiol. 2016; [Epub ahead of print].

  16. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105–10.

    Article  Google Scholar 

  17. Gonzalez C, Penado S, Llata L, Valero C, Riancho JA. The clinical spectrum of retroperitoneal hematoma in anticoagulated patients. Medicine (Baltimore). 2003;82(4):257–62.

    Google Scholar 

  18. Ivascu FA, Janczyk RJ, Bair HA, Bendick PJ, Howells GA. Spontaneous retroperitoneal hemorrhage. Am J Surg. 2005;189(3):345–7.

    Article  PubMed  Google Scholar 

  19. Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med. 2012;43(2):e157–61. doi:10.1016/j.jemermed.2011.06.006. [Epub 2011 Sep 10].

  20. Finlay IG, Edwards TJ, Lambert AW. Damage control laparotomy. Br J Surg. 2004;91(1):83–5.

    Article  CAS  PubMed  Google Scholar 

  21. Dabney A, Bastani B. Enoxaparin-associated severe retroperitoneal bleeding and abdominal compartment syndrome: a report of two cases. Intensive Care Med. 2001;27(12):1954–7 Epub 2001 Nov 10.

    Article  CAS  PubMed  Google Scholar 

  22. Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma. 1985;25(11):1021–9.

    CAS  PubMed  Google Scholar 

  23. Sharafuddin MJ, Andresen KJ, Sun S, Lang E, Stecker MS, Wibbenmeyer LA. Spontaneous extraperitoneal hemorrhage with hemodynamic collapse in patients undergoing anticoagulation: management with selective arterial embolization. Journal of vascular and interventional radiology. J Vasc Interv Radiol. 2001;12(10):1231–4.

    Article  CAS  PubMed  Google Scholar 

  24. Farrelly C, Fidelman N, Durack JC, Hagiwara E, Kerlan RK Jr. Transcatheter arterial embolization of spontaneous life-threatening extraperitoneal hemorrhage. J Vasc Interv Radiol. 2011;22(10):1396–402. doi:10.1016/j.jvir.2011.06.008 Epub 2011 Jul 21.

    Article  PubMed  Google Scholar 

  25. Pathi R, Voyvodic F, Thompson WR. Spontaneous extraperitoneal haemorrhage: computed tomography diagnosis and treatment by selective arterial embolization. Australas Radiol. 2004;48(2):123–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Salah D. Qanadli.

Ethics declarations

Conflict of interest

All authors declare that they have no conflicts of interest.

Statement of Informed Consent

For this type of study, formal consent is not required.

Statement of Human and Animal Rights

This does not apply to this type of study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Popov, M., Sotiriadis, C., Gay, F. et al. Spontaneous Intramuscular Hematomas of the Abdomen and Pelvis: A New Multilevel Algorithm to Direct Transarterial Embolization and Patient Management. Cardiovasc Intervent Radiol 40, 537–545 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: