PMC8661284_01
Ultrasonography of the liver. Image (a and b) showing multiple clustered hypo and anechoic complex cystic lesions (red arrows) with a mildly hyperechoic rim. Image (c) showing an oedematous gall bladder wall (yellow arrow).
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Emergency ultrasonography of the abdomen revealed multiple discrete and clustered hypo to anechoic lesions with a mildly hyperechoic irregular rim in the right lobe of the liver and mildly prominent central biliary radicles (Figure 1a, b). The gall bladder was mildly distended with an oedematous wall (Figure 1c).
Axial (a, b) and sagittal (c) portal venous phase CT images showing multiple clustered hypodense lesions (red arrows) in the right lobe of the liver with indistinct margins. Few linear hypodense tracks (white arrows a, c) are also seen, consistent with the migration of larvae. There is hyperdense content within the gall bladder (GB) lumen (yellow arrow b) sludge or haemorrhage. A small non-enhancing portal vein (PV) segment is noted on sagittal image c in segment VIII, suggestive of segmental PV thrombosis (thin black arrow c). Associated transient hepatic arterial difference (THAD) is also found (open white arrow c). Coronal minimum intensity projection (MinIP) image (d) showing mildly dilated central biliary radicles (open black arrow).
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Dual-phase computed tomography (CT) of the abdomen revealed multiple discrete and clustered variable-sized hypoechoic lesions with an enhancing rim in the right lobe of the liver, predominantly along the peripheral hepatic parenchyma (Figure 2). A few linear hypodense tracks were also depicted, consistent with the migration of larvae (Figure 2a and 2c). Small segmental portal thrombosis was found in segment VIII along with a few geographical areas of hypoperfusion noted as hypodensity on the portal-venous phase (Figure 2c). Mildly dilated biliary radicles were demonstrated on the minimum intensity projection (MinIP) images (Figure 2d).
Axial arterial phase (a) image showing a well-defined contrast pooling (black arrow) in segment VIII with its attenuation parallel to that of the abdominal aorta without any change in morphology as seen in the axial portal venous phase image (black arrow b). It remains isodense to the aorta in the portal venous phase as well, suggestive of hepatic arterial pseudoaneurysm without any apparent active contrast extravasation. A geographical peripheral hypodense area is noted in segment VIII (open white arrow b), representing a transient hepatic arterial difference (THAD).
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Additionally, there was a well-defined pseudoaneurysm of 1.1 cm size along the anterior branch of the right hepatic artery; however, no apparent active contrast extravasation was seen (Figure 3a, b).
Coronal CT maximum intensity projection image (a) shows a well-defined pseudoaneurysm in close proximity to the segment VIII artery (red arrow a). Angiography via a microcatheter (b) shows a small pseudoaneurysm arising from the segment VIII artery (red arrow b) which was embolised (c) by placing a microcoil across the neck of pseudoaneurysm using the sandwich technique (yellow arrow c).
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The branch of the right hepatic artery from which pseudoaneurysm originated was selectively catheterised with a microcatheter through a right femoral artery approach and the pseudoaneurysm was embolised with microcoils using a sandwich technique (Figure 4).