rentradВестник рентгенологии и радиологииJournal of radiology and nuclear medicine0042-46762619-0478Limited Liability Company "LUCHEVAYA DIAGNOSTIKA", Russian Association of Radiologists10.20862/0042-4676-2023-104-6-338-347rentrad-843Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL RESEARCHМожно ли планировать ангиографию, опираясь на специфические КТ-признаки продолжающегося кровотечения в мягкие ткани у больных COVID-19, получающих антикоагулянты?Can Angiography Be Planned Based on Specific CT Signs of Ongoing Soft Tissue Bleeding in COVID-19 Patients Receiving Anticoagulants?https://orcid.org/0000-0001-5015-6650ПоляевА. Ю.PolyaevA. Yu.

Поляев Александр Юрьевич, к. м. н., рентгеноэндоваскулярный хирург ; доцент кафедры факультетской хирургии № 1  

ул. Сосенский Стан, 8, Москва, 108814;  ул. Островитянова, 1, Москва, 117997

Аlexander Yu.Polyaev, Cand. Med. Sc., Endovascular Surgeon; Associate Professor, Chair of Faculty Surgery No. 1

ul. Sosenskiy Stan, 8, Moscow, 108814; ul. Ostrovityanova, 1, Moscow, 117997

apolyaev@yandex.ruhttps://orcid.org/0000-0003-0558-4079ТягуновА. Е.TyagunovA. E.

Тягунов Александр Евгеньевич, д. м. н., профессор кафедры факультетской хирургии № 1

ул. Островитянова, 1, Москва, 117997

Аlexander Е. Tyagunov, Dr. Med. Sc., Professor, Chair of Faculty Surgery No. 1

ul. Ostrovityanova, 1, Moscow, 117997

https://orcid.org/0000-0001-9414-7588СтрадымовЕ. А.StradymovE. A.

Страдымов Егор Андреевич, к. м. н., врач-хирург ГБУЗ; ассистент кафедры факультетской хирургии № 1

ул. Сосенский Стан, 8, Москва, 108814;  ул. Островитянова, 1, Москва, 117997

Еgor А. Stradymov, Cand. Med. Sc., Surgeon; Assistant Professor, Chair of Faculty Surgery No. 1

ul. Sosenskiy Stan, 8, Moscow, 108814; ul. Ostrovityanova, 1, Moscow, 117997

ГБУЗ «Московский многопрофильный клинический центр Коммунарка ДЗМ»; ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава РоссииРоссияKommunarka Moscow Multidisciplinary Clinical Center; Pirogov Russian National Research Medical UniversityRussian FederationФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава РоссииРоссияPirogov Russian National Research Medical UniversityRussian Federation2023260520241046338347Copyright © Поляев А.Ю., Тягунов А.Е., Страдымов Е.А., 20242024Поляев А.Ю., Тягунов А.Е., Страдымов Е.А.Polyaev A.Y., Tyagunov A.E., Stradymov E.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.russianradiology.ru/jour/article/view/843Актуальность

Актуальность. Антикоагулянтная терапия рекомендуется в качестве базового медикаментозного лечения больных COVID-19 при наличии факторов риска. В то же время она сопровождается большим количеством геморрагических осложнений. Массивные кровотечения в мягкие ткани брюшной и грудной стенок, а также забрюшинное пространство значительно ухудшают течение основного заболевания.

Цель

Цель: оценить прогностическое значение специфических КТ-признаков и их корреляцию с данными ангиографии для диагностики продолжающегося кровотечения в мягкие ткани у пациентов с COVID-19.

Материал и методы

Материал и методы. Проведено ретроспективное исследование, в котором оценены и сопоставлены данные мультиспиральной компьютерной томографии (МСКТ) и ангиографии у 60 пациентов с COVID-19 и спонтанными кровотечениями в мягкие ткани грудной и брюшной стенок, а также забрюшинного пространства. Ретроспективный анализ МСКТ проведен с целью выявления симптомов, специфичных для коагулопатического кровотечения в мягкие ткани: экстравазация контрастного препарата, эффект гематокрита и феномен сигнальной вспышки.

Результаты

Результаты. Экстравазация контрастного препарата, установленная на МСКТ, при ретроспективном анализе рентгенограмм подтверждена у 57 (95%) пациентов. Чаще экстравазацию выявляли в артериальную фазу МСКТ – 39 случаев (68,4%). В венозную фазу МСКТ она отмечена у 17 (29,8%) больных, в отсроченную – у 1 (1,8%). При нативной МСКТ у 43 (71,7%) пациентов гематома содержала сгустки и уровень жидкости (эффект гематокрита), у 17 (28,3%) – гомогенную структуру. При внутривенном контрастировании в 39 случаях (90,7%) с уровнем жидкости установлен феномен сигнальной вспышки, который чаще наблюдался в артериальную фазу (у 33 (84,6%) больных). Экстравазация на ангиографии отмечена у 27 (45%) пациентов, им проведена лечебная эмболизация. Еще в 15 случаях выполнена профилактическая эмболизация. При экстравазации в гематому без уровня жидкости (13 больных) на МСКТ экстравазация на ангиографии установлена у 4 (30,8%) пациентов. При наличии экстравазации в гематому с уровнем жидкости, но без феномена сигнальной вспышки (4 случая) экстравазация на ангиографии установлена у 1 пациента. При наличии всех трех признаков (экстравазация, эффект гематокрита и феномен сигнальной вспышки – 39 пациентов) частота экстравазации на ангиографии была самой высокой – 56,4% (р = 0,028), а больным чаще требовалась лечебная эмболизация.

Заключение

Заключение. Обнаружение на МСКТ в структуре спонтанной гематомы у пациентов с COVID-19 экстравазации, уровня жидкости и феномена сигнальной вспышки соответствовало продолжающемуся кровотечению и требовало эмболизации чаще, чем при изолированной экстравазации.

Background

Background. Anticoagulant therapy is recommended as basic medical treatment for COVID-19 patients with risk factors. At the same time, it is accompanied by a large number of hemorrhagic complications. Massive bleeding into abdominal and chest walls soft tissues as well as retroperitoneal space significantly worsens the course of underlying disease.

Objective

Objective: to assess the prognostic value of specific CT signs and their correlation with angiography data for the diagnosis of ongoing bleeding into soft tissues in COVID-19 patients.

Material and methods

Material and methods. A retrospective study was conducted, in which multi-slice computed tomography (MSCT) and angiography data were assessed and compared in 60 COVID-19 patients with spontaneous bleeding into chest and abdominal wall soft tissues as well as retroperitoneal space. A retrospective analysis of MSCT was carried out to identify symptoms specific to coagulopathic bleeding into soft tissues: contrast agent extravasation, hematocrit effect, and signal flare phenomenon.

Results

Results. Contrast agent extravasation identified by MSCT was confirmed in 57 (95%) patients. More often (39 (68.4%) patients), extravasation was detected in MSCT arterial phase. In MSCT venous phase it was noted in 17 (29.8%) cases, in delayed phase – in 1 (1.8%) patient. With native MSCT, hematoma contained clots and fluid level (hematocrit effect) in 43 (71.7%) patients, in 17 (28.3%) patients it had a homogeneous structure. With intravenous contrast, in 39 (90.7%) cases with fluid level the signal flare phenomenon was established, which was more often detected in the arterial phase (33 (84.6%) cases). Extravasation was detected on angiography in 27 (45%) patients; they underwent therapeutic embolization. In another 15 patients preventive embolization was performed. When extravasation into hematoma without fluid level on MSCT (13 cases), extravasation on angiography was detected in 4 (30.8%) patients. In the presence of extravasation into hematoma with fluid level, but without signal flare phenomenon (4 patients) it was noted on angiography in 1 case. In the presence of all three signs (extravasation, hematocrit effect, and signal flare phenomenon – 39 patients), the incidence of extravasation on angiography was the highest – 56.4% (p = 0.028), and patients more often required therapeutic embolization.

Conclusion

Conclusion. Detection of extravasation, fluid level and signal flare phenomenon on MSCT in the structure of spontaneous hematoma in COVID-19 patients corresponded to ongoing bleeding and more often required embolization than in isolated extravasation. 

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The authors declare that there are no conflicts of interest present.