Renal angiomyolipoma: Beyond size criteria for predicting rupture.

INTRODUCTION: Renal angiomyolipomas (AMLs) are vascular tumours that while histologically benign, carry a risk of rupture and potentially life-threatening haemorrhage. Selective arterial embolisation (SAE) has been demonstrated as effective treatment; however, given most tumours are asymptomatic, the challenge facing the radiologist is selection of which AML should undergo treatment. This study considers presence and size of intratumoural aneurysm, to advance the readers treatment decision-making beyond historical size criteria. METHODS: Retrospective cohort analysis of all SAE-treated AML at a quaternary-level institution in the last 10 years was completed independently by two radiologists. Computerised tomography (CT) and angiographic imaging were reviewed to evaluate tumour size, presence of intratumoural aneurysm and aneurysm size. Univariant and multivariant statistical analyses were used to identify predictors of spontaneous rupture and haemorrhage. RESULTS: Twenty-seven renal AML underwent SAE. Five tumours had presented with haemorrhage. Twenty-two were asymptomatic or without CT/angiographic detectable haemorrhage. There was no statistically significant size difference between ruptured (mean 7.8 cm, range 6.1-12.0 cm) and unruptured AML (7.5 cm, 3.3-21.7 cm) in the study population. Eighty percent of ruptured AML and 27% of unruptured AML contained at least one intratumoural aneurysm (P-value < 0.05). Mean aneurysm size in ruptured AMLs was 5.4 mm, versus 4.6 mm among unruptured AML (P-value > 0.05). CONCLUSION: The presence of intratumoural aneurysm is a useful predictor for AMLs that are at risk of spontaneous rupture and haemorrhage. Intratumoural aneurysm should therefore be considered when selecting patients to undergo SAE.

Is Size All That Matters? New Predictors of Complications and Bleeding in Renal Angiomyolipoma.

Purpose: Renal angiomyolipoma (AML) is the most common benign renal tumor. Whilst generally asymptomatic, they can cause life-threatening bleeding. Selective angioembolization (SAE) may be used to treat large symptomatic and asymptomatic AMLs. We aimed to evaluate the efficacy of SAE for symptomatic and asymptomatic renal AMLs and determine characteristics that predict spontaneous bleeding. Patients and Methods: Data were retrospectively collected from a prospectively maintained database from July 2011 to April 2022. Patients were included if AML was >4cm and they underwent subsequent SAE. Follow-up imaging was analyzed to calculate mean reduction in AML size. Clinical notes were reviewed to analyze lesion characteristics including vascularity, fat content and presence of aneurysm as well as post-procedural complications. Results: 26 patients with 30 AMLs were identified. Interval of follow-up imaging ranged from 1 to 60 months. 25 AMLs were embolized electively with 5 emergency embolizations performed for bleeding. Mean reduction in AML volume was 41% at 3 months (p=0.013) and 63% at 12 months (p=0.007). All 5 bleeding AMLs had a rich vascularity with 60% also having either aneurysms or a low fat content. Complications included post-embolic syndrome (n=9), segmental renal parenchyma devascularization (n=3), acute bleeding requiring re-embolization (n=2), nephrectomy for ongoing bleeding (n=1) and delayed bleeding managed conservatively (n=1). No deterioration in renal function was observed. Conclusion: SAE is an effective procedure for managing symptomatic and asymptomatic renal AML, with minimal significant complications. AML vascularity, fat content and aneurysms may be useful characteristics to assess future risk of bleeding in patients with renal AML.

Ruptured gastric artery aneurysms: two cases and emergency imaging findings.

A ruptured gastric artery aneurysm is a rare but important possible cause of massive intra-abdominal or gastrointestinal haemorrhage, and carries a high risk of mortality. Although aneurysms of the gastric arteries are uncommon, emergency radiologists and clinicians should be familiar with the clinical presentation, imaging findings and pathophysiology. We present two cases of massive intra-abdominal haemorrhage and haemodynamic shock secondary to acute rupture of previously occult gastric artery aneurysm and review the relevant anatomy, imaging findings and pathophysiology of gastric and other visceral artery aneurysms. By virtue of its location in the lesser omentum, a ruptured gastric artery aneurysm may result in a typical pattern and distribution of adjacent haematoma in the upper abdomen. Our description of imaging findings highlights a characteristic epicentre of intraperitoneal haemorrhage, and its typical mass effect displacement of surrounding viscera, to aid the emergent diagnosis of gastric artery aneurysm rupture.

Transfalciform greater omental herniation.

Internal herniae are rare, those involving the falciform ligament even rarer. To the best of our knowledge, there have been approximately 20 cases of herniae involving the falciform ligament previously reported. Of these cases, only one previously reported case involves herniation of the greater omentum through the falciform ligament. We present a second case of an adult man who presented with a 48-hour history of epigastric pain and was found on contrast multidetector CT to have a strangulated transfalciform greater omental hernia. The hernia was repaired laparoscopically and the patient recovered uneventfully.