PAIN IN THE SIDE

Resident(s): Paul Haste, MD

Attending(s): Dan Wertman, MD
Program/Dept(s): Indiana University School of Medicine

CHIEF COMPLAINT & HPI

Chief Complaint
Hypotension

History of Present Illness

55 year old woman presenting with hypotension and anemia. She
reports recent seat belt injury with left flank pain which has persisted
for the past week

RELEVANT HISTORY
Past Medical History
Bilateral renal angiomyolipomas requiring prior transfusions and right sided
embolizations
Glaucoma
Depression

Past Surgical History

Multiple right renal embolizations

Medications
Citalopram

Allergies
NKDA

DIAGNOSTIC WORKUP NON INVASIVE IMAGING

Axial and coronal images
from CT abdomen
demonstrate a large,
hemorrhagic left renal
angiomyolipoma (yellow
arrows).
An angiomyolipoma is also
evident in the right kidney,
with evidence of prior
embolizations (white
arrows).

DIAGNOSIS
Retroperitoneal bleed secondary to left renal
angiomyolipoma hemorrhage.

QUESTION
At what size should resection and/or embolization of an angiomyolipoma be
considered due to the increased risk of hemorrhage? (click on one of the
following answers)
A.
B.
C.
D.
E.

3
4
5
6
7

cm
cm
cm
cm
cm

CORRECT!
At what size should resection and/or embolization of an angiomyolipoma be
considered due to the increasing risk of hemorrhage? (click on one of the
following answers)
A.
B.
C.
D.
E.

3
4
5
6
7

cm
cm
cm
cm
cm

CONTINUE WITH CASE

SORRY, THATS INCORRECT.

At what size should resection and/or embolization of an angiomyolipoma be
considered due to the increasing risk of hemorrhage? (click on one of the
following answers)
A.
B.
C.
D.
E.

3
4
5
6
7

cm
cm
cm
cm
cm

CONTINUE WITH CASE

INTERVENTION - EMBOLIZATION

Left renal arteriogram demonstrates multiple large, hypervascular

tumors (arrows)

INTERVENTION - EMBOLIZATION
A

Figure A: Upper pole arteriogram prior to embolization

Figure B: Following upper pole embolization. The arrow points to an embolization
coil in an upper pole renal artery.

INTERVENTION - EMBOLIZATION
Left lower pole renal
arteriogram, following
embolization of upper pole
renal artery with particles and
coils.
The lower pole renal artery
was not embolized as it
supplied the only functioning
portion of the kidney. More
than 80% of tumor was
devascularized after
embolization.

QUESTION
What syndrome is classically associated with bilateral
angiomyolipomas?
A.
B.
C.
D.
E.

Von-Hippel Lindau
McCune-Albright
Osler-Rendu-Weber
Klippel-Trenaunay
Tuberous sclerosis complex

CORRECT!
What syndrome is classically associated with bilateral
angiomyolipomas?
A.
B.
C.
D.
E.

Von-Hippel Lindau
McCune-Albright
Osler-Rendu-Weber
Klippel-Trenaunay
Tuberous sclerosis complex

CONTINUE WITH CASE

SORRY, THATS INCORRECT.

What syndrome is classically associated with bilateral
angiomyolipomas?
A.
B.
C.
D.
E.

Von-Hippel Lindau
McCune-Albright
Osler-Rendu-Weber
Klippel-Trenaunay
Tuberous sclerosis complex

CONTINUE WITH CASE

SUMMARY & TEACHING POINTS

55 y/o woman presenting with hypotension from a hemorrhaging left
angiomyolipoma who underwent particle/coil embolization.
Post embolization arteriography showed devascularization of >80% of the tumors
with sparing of the functional left lower pole kidney.
Patient was discharged with outpatient follow-up scheduled.
On CT or MR, the characteristic imaging finding of angiomyolipoma (AML) is a mass
that contains macroscopic fat . It is usually well-marginated and is comprised
predominantly of fat density (-30 to -100 HU). A renal mass with fat density is
nearly diagnostic of an AML. Roughly 5% of AMLs will not have fat and therefore
cannot be distinguished by imaging. Calcification is almost never present in an
AML, and if seen, renal cell carcinoma should be considered.
Bilateral angiomyolipomas are associated with tuberous sclerosis complex.
Resection or embolization of angiomyolipomas 4cm or greater should be