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Corona mortis in the setting of pelvic trauma: Case series and review of the literature
How to cite this article: Sealy EB, Schammel CM, Varma R, Devane AM. Corona mortis in the setting of pelvic trauma: Case series and review of the literature. Am J Interv Radiol 2023;7:9.
Corona mortis is a variant vessel located posteriorly against the superior pubic ramus, “crowning” the pelvis; actual prevalence is unknown due to broad definitions: A connection between the obturator artery and an external iliac artery branch or the external iliac artery anastomosis, or any variant vessel behind the superior pubic ramus. Rapid identification and immediate treatment of injury to an arterial corona mortis resulting from pelvic trauma or pelvic surgeries are essential as hemorrhage or death may result. Interventional radiology can selectively target corona mortis and obstruct hemorrhage through catheter-guided embolization. We present four cases of corona mortis and pelvic trauma with successful embolization and include a comprehensive literature review to further educate regarding the morbidity and potential mortality associated with this important anatomic variant.
Arterial corona mortis
Variant pelvic vessel
Corona mortis, or “crown of death,” has been defined as a variant vessel that originates from the external iliac artery system and dives deep into the pelvis, crossing the superior pubic ramus, potentially creating an arterial or venous anastomosis with branches of the internal and external ipsilateral iliac vessels. The connections between the obturator artery, typically an internal iliac artery branch, and an external iliac artery branch or the external iliac artery have prompted a more comprehensive definition of corona mortis that reflects the potential problem for surgeons in the retropubic region, and not simply describing the anatomy. Thus, corona mortis can be defined as any vessel crossing the superior pubic ramus.
Corona mortis is not typically taught during medical training, with most anatomy textbooks labeling corona mortis as “anomalous,” “aberrant,” or “accessory” despite published reports noting an arterial prevalence of 17–25% and a venous prevalence of 41.7–42%.[4,5] In addition, training often fails to emphasize the importance of identifying corona mortis, particularly given the location behind the pubic ramus that predisposes the vessel to injury in pelvic surgeries and trauma, a bleeding control challenge intraoperatively when a lacerated vessel spasms. Injury to the arterial corona mortis is associated with severe adverse outcomes, resulting in rapid hemodynamic instability and death if left unrecognized.
Catheter-guided embolization provides a minimally invasive alternative to rapidly achieve prompt hemostasis in cases of pelvic trauma, as it can selectively embolize a particular vessel without exposing the patient to surgical risk. Following Institutional Review Board approval utilizing universal consent, we outline four reports of pelvic trauma resulting in hemorrhage due to the presence of arterial corona mortis and successful catheter-guided embolization.
Following a motor vehicle collision, an 81-year-old male presented to the emergency department (ED). Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed bilateral fractures of the pubic rami (superior and inferior); active contrast extravasation was present within the left gluteal musculature. A small abnormal branch of the left external iliac artery was noted [Figure 1a]. Emergent angiography was performed due to hypotension. The obturator artery was noted by angiogram to arise directly from the external iliac artery, extending into the deep pelvis, and creating corona mortis [Figure 1b]. Selective angiography of the obturator muscle bed further demonstrated active bleeding [Figure 1c]. Gelfoam (Pfizer, New York, NY) embolization was performed, followed by coil embolization (Concerto coils, Medtronic, Minneapolis, MN). Post-embolization angiogram confirmed hemostasis [Figure 1d]. Following fracture stabilization, the patient was discharged on hospital day 10.
A 47-year-old male was admitted to the ED with injuries sustained in a motorcycle accident. Intravenous contrast-enhanced CT demonstrated an anterior-posterior compression III pelvic injury demonstrating sacroiliac joint widening; the left pelvis demonstrated contrast extravasation [Figure 2a]. Active arterial contrast extravasation was also noted by angiography from the left internal iliac artery near the left pubic symphysis [Figure 2b]. Embolization of the left internal iliac artery anterior division utilizing Gelfoam slurry was performed. Follow-up angiogram demonstrated active arterial extravasation from a corona mortis [Figure 2c], a branch of the left inferior epigastric artery originating from the left inferior epigastric artery in communication with the left internal iliac artery anterior division. Coil embolization (Concerto coils, Medtronic, Minneapolis MN) of the corona mortis was performed; a follow-up angiogram demonstrated no further hemorrhage [Figures 2d-f]. His pelvic fractures were internally fixated and he was discharged 15 days post-embolization.
A 61-year-old male presented to the ED with multiple pelvic fractures following a car accident. The patient presented as hemodynamically stable. Contrast-enhanced CT of the pelvis showed multiple displaced pelvic fractures, bilateral pelvic hematomas, and a right-sided corona mortis vessel [Figures 3a-c]. Angiography demonstrated multifocal blush on the right hemipelvis [Figure 3d]. The right corona mortis arising from the external iliac artery was readily identified, demonstrating active contrast extravasation on selective angiogram [Figure 3e]. The variant artery was successfully embolized with Gelfoam [Figure 3f]. The patient was discharged post-procedure on day 5.
A 64-year-old female presented to the ED after falling at home. She was initially hemodynamically stable. Contrast-enhanced pelvic CT showed a right acetabular fracture with active extravasation and a pseudoaneurysm lateral to an aberrant right obturator artery [Figures 4a and 4b]; angiography was performed in the interventional radiology (IR) suite. Investigation of the right internal iliac artery demonstrated patency of the right internal iliac artery and branching vessels without evidence of active extravasation. An arteriogram of the right external iliac artery was performed, revealing a slight blush of contrast from an aberrant right obturator artery. This artery originated from the mid-right external iliac artery and shared a common trunk with the inferior epigastric artery [Figure 4c]. It then traveled over the superior pubic ramus before entering the obturator foramen, forming a corona mortis [Figure 4d]. Embolization of the corona mortis was then performed using Concerto detachable coils (Medtronic, Minneapolis, MN) with no further evidence of active bleeding or pseudoaneurysm [Figure 4e]. The patient was discharged on post-procedure day 7.
Management of pelvic trauma typically includes placement of a pelvic binder, with CT on the vast majority of patients and FAST for unstable patients. Patients positive for FAST are treated surgically with pre-peritoneal packing; if FAST is negative, IR is typically consulted for angioembolization. Corona mortis is defined as an “anastomosis between the obturator and the external iliac or inferior epigastric artery or vein” and any other vessels, posing a risk of hemorrhage to surgeons operating in the space posterior to the superior pubic ramus.[2,3,8] Corona mortis is classified by the Rusu et al. system into three main categories (I. Arterial, II. Venous, III. combined), with further classification into subcategories based on morphological patterns. In our series, Cases 1 and 4 could be classified as the most common form, Rusu et al. type I.1 variant, while Cases 2 and 4 could be classified as Rusu et al. type I.2.
Various definitions have resulted in discrepancies in the documented prevalence of corona mortis. A comprehensive literature search identified corona mortis cases from cadaveric, intraoperative, radiologic, and individual case studies [Table 1[1-3,8-52] and 2[6,53-75] Figure 5]. Arterial corona mortis in cadaveric and intraoperative studies reported the widest range, with averages of 30.13% and 35.14%, respectively, possibly related to intraoperative spasm of a lacerated corona mortis, making definitive identification of corona mortis challenging. Radiologic studies reported a lower prevalence, with a mean of 26.2%. Interestingly, two separate meta-analyses reported arterial corona mortis prevalence as 17% and 25%, respectively, which is much lower than our evaluation of the literature (8.3– 86%; [Tables 1 and 2]) Venous corona mortis prevalence was reported to be higher than arterial corona mortis, at approximately 50% overall.[4,5] Arterial corona mortis poses the greatest risk for surgeons and interventionalists in the setting of pelvic trauma, suggesting that corona mortis is not uncommon, and thorough mapping of the vasculature is essential.
|Study||Population||Type||Hemipelvises||Average age (range)||Gender||CMOR prevenance (%)||Distance from pubic symphysis (mm), (range)||Distance from lacunar ligament||Diameter (mm), (range)||Laterality|
|Teague, 1996||USA||Cadaveric||79||71 (56–88)||55% M||43 Arterial, 59 Venous|
|Tornetta, 1996||USA||Cadaveric||50||84||62 (30–90)||(2–4)|
|Missankov, 1996||South Africa||Cadaveric||98||45–80||71.4% F||69 Arterial, 46 Venous|
|Gilroy, 1997||USA, China||Cadaveric||105||38 Arterial, 82 Venous (USA)
33 Arterial, 67 Venous (China)
|USA arterial: Bilateral 20%, Unilateral 35%, Absent 45%
China arterial: 17% Bilateral, 33% Unilateral, 50% Absent
USA venous: Bilateral 75%, Unilateral 15%, Absent 10%
China venous: 50% Bilateral, 33% Unilateral 17% Absent
|De Kleuver, 1998||Netherlands||Cadaveric||12||74.5% M||50|
|Bereroglu, 2001||Turkey||Cadaveric||14||86 Arterial, 100 Venous||40.4 (33.2–52.7) Arterial or Venous||0.98 (0.6–1.2) Arterial, 3.3 (2.2–4.9) Venous|
|Sarikcioglu, 2003||Turkey||Cadaveric||54||92.5% M||0 Arterial, 20.37 Venous||39.79 (28.37–51.21) Arterial or Venous||12.18 (8.63–15.73) Arterial or Venous|
|Okcu et al., 2004||Turkey||Cadaveric||150||40 (16–78)||77.3% M||19 Arterial, 52 Venous, 9 Mixed||64 (45–90) Arterial, 56 (37–80) Venous||28% Bilateral|
|Ersoy, 2004||Turkey||Cadaveric||10||61.4 (52–71)||100% F||100 Venous|
|Drewes, 2005||USA||Cadaveric||30||77 (46–95)||100% F||33 Arterial, 60 Venous||54||12% Bil arterial
33% Bil venous
|Pungpapong, 2005||Thailand||Cadaveric||66||54.5% F||13.6 Arterial, 77.3 Venous||52.8|
|Darmanis et al., 2007||UK||Cadaveric||80||67.5% M||36 Arterial, 60 Venous, 27.5 Mixed||71 (42–88) Arterial, 65 (39–82) Venous||14 (11–16)||2.6 (1.6–3.5)|
|Namking, 2007||Thailand||Cadaveric||204||20–95||54.4% M||22.5 Arterial, 70.6 Venous, 17.2 Mixed||Arterial: Right 20.8%, Left 24.3%
Venous: Right 70.3%, Left 70.9%
Mixed: Right 14.9%, Left 19.4%
|Pathi, 2009||USA||Cadaveric||24||79 (65–96)||100% F||25 Arterial, 67 Venous|
|Mahato, 2009||India||Cadaveric||50||40–60||88% M||40 Venous, 22 Mixed||Venous: Right 36%, Left 43%
Mixed: Right 23%, Left 21%
|Rusu et al., 2010||Romania||Cadaveric||40||60% M||25 Arterial, 15 Venous, 40 Mixed|
|Kacra, 2011||Turkey||Cadaveric||10||20 Venous, 20 Mixed|
|Greece||Cadaveric||70||100% F||11.43 Arterial, 14.29 Venous||52.4 (40–75) Arterial, 46.7 (35–55) Venous||3 Arterial, 3.1 Venous||Arterial: 37.5% Right, 12.5% Left, 50% Bilateral
Venous: 20% Left, 80% Bilateral
|Bible, 2014||USA||Cadaveric||10||60 Arterial, 80 Venous|
|Nayak, 2016||S India||Cadaveric||73||50–80||94.5% M||51 Venous|
|Tajra, 2016||Brazil||Cadaveric||24||66.7% M||22.72 Arterial||Arterial: Right 27.27%, Left 18.18%|
|Al Talawah, 2016||Austria||Cadaveric||208||73% M||12 Arterial|
|Pillay, 2017||India||Cadaveric||67||63% M||12.5 Arterial, 60.7 Venous, 26.78 Mixed||54.5 (38–79)||20.8% Bilateral|
|Leite, 2017||Brazil||Cadaveric||60||83.3% M||45 Arterial||49.62||2.66|
|Zhou, 2017||China||Cadaveric||20||38.3 (21–60)||65.8% M||15% Arterial, 55% Venous||65.30|
|Kashyap, 2019||N India||Cadaveric||24||68 (54–82)||91.7% M||8.3 Arterial, 58.3 Venous, 8.3 Mixed||41 (35–70) Venous||83% were<4 mm||20.8% Right, 37.5% Left, 41.7% Bilateral|
|Cardeiro, 2019||Brazil||Cadaveric||80||67.5% M||22.5 Arterial|
|Dias, 2019||India||Cadaveric||50||44.8||88% M||4 Arterial, 40 Venous|
|Du, 2020||China||Cadaveric||16||62.5% M||18.75 Arterial, 43.75 Venous, 12.5 Mixed||59.0 (53.9–65.2)||2.5 (1.6–3.5)|
|Kati, 2021||Turkey||Cadaveric||12||70.8 (59–80)||66.7% M||83 Arterial or Venous||47.7 (43–55)|
|Wada, 2021||Japan||Cadaveric||122||85 (65–106)||52.5% F||28.3 Arterial, 76.1 Venous||Anteroposterior view: 47.7 (45.9–49.6), Inlet view: 59.4 (57.3–61.5)|
|Karakurt, 2002||Turkey||Angiography (prospective)||98||55 (23–73)||60.2% M||28.5 Arterial||33.4 (21.4–41)|
|Smith, 2009||USA||CT (prospective)||100||26 (18–87)||54% F||29 Arterial||56 (41–72)||2.5 mm (1.6–3.5)||Arterial: 28% Left, 30% Right, 22% Bilateral|
|Requarth and Miller, 2011||USA||Angiography (Retrospective)||243||50.6% F||Arterial
38.4% of all hemipelvises, 55.1% in all pts
|Arterial: 37.7% Right, 39.1% Left 21.7% Bilateral|
|Castellani, 2016||Italy||CT (Prospective)||94||100% F||27.7||69% Bilateral|
|Wada, 2017||Japan||CTA (Retrospective)||196||66 (54–78)||63.3% M||14.3 Arterial|
|Han, 2017||China||CTA (Prospective)||660||43 (11–72)||100% F||14.1% Arterial, 51.1% Venous||59.6 (43–82) Arterial, 66.87 (41–119) Venous||2.56 Arterial, 3.63 Venous||Arterial: 6.06% Bilateral, venous: 34.24% Bilateral|
|Steinberg, 2017||Isreal||CTA (Retrospective)||200||67 (19–96)||66% M||33 Arterial||55.2 (45–72) Right, 57.2 (35–71) Left||Right: 2.4 (1.4–3.7), Left: 2.24 (1.6–3.5)||Arterial: 45.5% Left, 54.5% Right, 45.5% Bilateral|
|Duenas-Garcia, 2018||USA||3D-Imaging from CTA||87||66.9||100% F||27.9 Arterial||51.3 (37–59) Right, 52.7 (36–58) Left|
|Perandini, 2018||Italy||CTA (Retrospective)||300||73 (22–95)||74% M||30 Arterial||50 (42–72)||1.7 (0.8–3.2)||Arterial: 45.4% Left, 55.6% Right, 35.6% Unilateral
|Zlotorowicz, 2018||Poland||CTA||100||46.7 (14–80)||72% F||33 Arterial||Arterial: 56% Right, 44% Left, 52% Bilateral|
|Bhoil, 2020||India||CTA (Prospective)||200||40 (22–74)||67% M||14 Arterial||54.55 (Range 42–68) Right, 54.26 (Range 40–66) Left||Right: 2.6 (1.7–3.0), Left: 2.3 (1.6–3.2)||20% Unilateral
|Teague, 1996||USA||Intraoperative (Prospective)||38||31 (13–67)||78.9% M||37|
|Bereroglu, 2001||Turkey||Intraoperative||36||86 Arterial, 94 Venous||Arterial<1 mm|
|Lau, 2003||Hong Kong, China||Intraoperative (Prospective)||141||64 (49–79)||96.7% M||22 Arterial, 27 Venous||Arterial: 41.9% Left, 58.1% Right Venous: 52.6% Left, 47.4% Right|
|Darmanis et al., 2007||UK||Intraoperative (Retrospective)||492||34 (7–80)||71.5% M||0.01 Arterial Or Venous|
|Pellegrino, 2014||Italy||Intraoperative||50||59 (46–68)||100% F||8 Arterial, 48 Venous, 23 Mixed||Right 60%, Left 28%, Bilateral 12%|
|Jensen, 2015||Switzerland||Intraoperative (Retrospective)||130||51 (38–70)||66.2% M||41.5|
|Ates, 2016||Turkey||Intraoperative (Retrospective)||391||46
|83.5% M||28.4 Arterial||22.8% <2 mm, 5.5% >2 mm|
|84% M||31.3 Arterial, 5.8 Venous||25.05% <2 mm, 6.32% >2 mm|
|Guzel, 2020||Turkey||Intraoperative||34||43.5 (21–65)||77.4% M||23 Arterial, 45 Venous, 26 Mixed||35.9 (21.6–48.7)|
|Case||Imaging||Age/Gender||Hemodynamics||Clinical Situation||Transfusion Requirement||Laterality||Type||Rusu classification||Tx||Distance from pubic symphysis (mm)||Diameter (mm)|
|Initially stable, rapid decompensation while in ED (BP 70/40, HR 100s)
BP 109/80, HR 126
|Pubic rami fractures s/p 4-ft fall
Pubic rami fractures s/p 20-ft fall
|7 U blood
10 U blood
|Pubic branch of the inferior epigastric artery||Embolization|
|Daeubler, 2003||CT with contrast/Angiography||46/M||Initial BP was 133/107. Decompensated while in CT with BP of 100/65, pulse of 120 bpm.||Superior and inferior pubic ramus fracture secondary to car versus cyclist in which the pt was the cyclist.||6 U whole blood, 8 U PRBCs, 2 U FFP||Left||Obturator artery originating from inferior epigastric artery||I2||Embolization with microparticles and 0.018 in coils|
|Macdonald, 2006||Angiography||71/F||Initially stable, developed hypotension and tachycardia after admission. Hemoglobin decreased from 13.2 to 6.3 g/dL||Superior ramus fracture s/p fall||10 U PRBCs, 3 U FFP||Left||Pubic branch of left inferior epigastric artery||Embolization with coils|
|Henning, 2007||CT with contrast/Angiography||81/F||Became hemodynamically unstable during overnight stay with hemoglobin decreasing from 13.3 to 8.1 g/dL and BP of 92/54.||Superior and inferior left pubic ramus fracture after fall.||7 U PRBC, 4 U FFP||Left||Distal branch of interior epigastric artery||Embolization with microparticles and 2 mm in coils|
|Smith, 2009||CT with contrast/Angiography||19/M||Stable on arrival but patient became tachycardic in CT scanner and interval hemoglobin showed decrease from 13.1 to 11.3 g/dL. Post procedural hemoglobin was 9 g/dL.||Fractures of left superior pubic ramus, left ischiopubic ramus, and first sacral segment after high speed MVA.||4 U of PRBCs||Left||Obturator artery originating from inferior epigastric artery||I2||Embolized with alcohol particles and and gelgoam slurry|
|Larsson, 2010||Intraoperative||53/F||Stable, however, hemoglobin decreased from 13.0 to 12.2 g/dL postoperatively||Intraabdominal bleeding postop TVT-Secur procedure||Left||Surgical ligation|
|Rehder, 2010||CT||46/F||Stable||Retropubic hematoma following invasive MUS for stress urinary incontinence||Left||Anastomoses between obturator and inferior epigastric artery||I3||Conservative management|
|Dixon, 2011||CTA||70/F||Stable||Type II endoleak found on 10-year follow up s/p open surgical aortobiilac graft placement for isolated internal iliac artery aneurysm||Right||Anastomoses between obturator and inferior epigastric artery||I3||Embolization with three 6 mm Tornado coils, 4mL of thrombin, and Glubran 2|
|Ferrada, 2011||CT with contrast/Angiography||72/M||Initially stable with BP of 172/83 but later decompensated to systolic of 100 s||Fractures to bilateral inferior pelvic rami after MVC||Bilateral||Obturator arteries arising from inferior epigastric arteries bilaterally||I2||Embolization|
et al., 2011
|Angiography||78/F||Initially stable, became unstable within 2 h||Superior pubic ramus fracture s/p fall||8 U blood, 4 U FFP||Right||Embolization with gelfoam|
|Angiography||70/F||Initially stable and discharged home. Returned 72 h later with BP 95/64, HR 140||Iliopubic rami fracture and a nondisplaced right ischiopubic rami fracture s/p fall||6 U||Left||distal portion of a small branch of the obturator artery||Embolization|
|Kong and Tsai, 2012||CT with contrast/Angiography||58/F||Initially stable, became hypotensive (77/48) within 2 h||Simple pubic ramus fracture s/p MVC||4 U PRBCs, 4 U FFP||Right||Pubic branch of right inferior epigastric artery||Embolization|
|Pua, 2012||CT/Angiography||55/M||Right superior and inferior pubic rami fracture and diastasis of the right SI joint s/p MVC||Bilateral||Bilateral obturator arteries arising from CM as a branch distal to the right inferior epigastric||I2||Embolization with gelatin sponge slurry and coil|
|Ten Broek, 2014||Angiography||79/F||Initially stable, became hypotensive (82/43) the following day
Hemoglobin 5.5 mmol/L
|Superior pubic rami fracture s/p fall||2 U PRBCs||Right||Branch of internal iliac artery communicating with inferior epigastric artery||Likely I3||Embolization|
|Ramser, 2014||Intraoperative||97/F||Stable||Incidental finding during laparoscopic obturator hernia repair||Right||None required|
|Kandhari, 2015||CTA||40/F||Stable||Patent CMOR preserved blood flow to lower extremity of a patient with blocked external iliac artery after failed fixation of fractured acetabulum causing avascular necrosis of the hip||Left||Anastomosis between obturator and external iliac artery||None|
|Cerda, 2016||Cadaver||M||Incidental finding during routine dissection||Bilateral||Obturator artery originating from inferior epigastric artery||Likely I2||Left: 47.24, Right: 49.23||Left: 2.77, Right: 2.8|
|Pinochet, 2016||Cadaveric||81/F||Cadaveric study||Bilateral||Left: obturator vein draining into inferior epigastric vein, Right: External iliac vein into the obturator canal||Left: Type II2, Right: unclassified||65 Left, 67 Right||8 Left, 3 Right|
|Xu, 2018||CT with contrast/Angiography||88/M||When transferred from outside hospital, pt became diaphoretic, tachycardic and hypotensive with BP of 81/56.||Superior pubic ramus fracture following a fall.||16 U PRBCs, 3.5 L FFP||Right||Distal branch of right external iliac artery||Embolization with balloon-assisted coiling|
|Babinski, 2018||Cadaveric||M||Incidental finding during dissection||Right||Venous and arterial anastomoses between inferior epigastric and obturator vessels||I3 and II3||3 mm|
|Yasuda, 2018||Intraoperative||66/M||On POD 1, BP 79/54 and hemoglobin decreased from 14.7 to 12.7 g/dL. POD 2, BP was 9.6 g/dL.||Corona mortis vein was injured by the tip of the electric cautery during transabdominal preperitoneal laparoscopic hernioplasty.||Unknown amount||Left||Vein across Cooper’s ligament||Exploratory laparoscopy with evacuation of hematoma and application of surgical clips|
|Herskowitz, 2019||CTA/Angiography||50/M||Initial BP 91/58, hemoglobin decreased fromo 13.2 to 7.3 g/dL on repeat labs.||Pelvic fracture (diastasis of the symphysis pubis, avulsion fracture of the medial aspect of the left superior pubic ramus, separation of the left sacroiliac joint) secondary to MVA.||6 U PRBC, 5 U FFP, 1 pack platelets||Bilateral||Right: branch off of inferior epigastric artery, Left: aberrant pubic branch off external iliac arery||Right: I2, Left: unclassified||Embolization with 0.018 coils and gelfoam slurry|
|Han, 2020||CT with contrast/Angiography||71/M||Stable but was readmitted with episodes of near-syncope, abdominal distension and anemia on POD 6||CMOR pseudoaneurysm in causing delayed intermittent hemoperitoneum after robotic radical prostatectomy||Left||Embolization|
|Pisanno, 2021||CT with contrast||60/M||CMOR pseudoaneurysm 12 weeks after RALP||Left||Branch of external iliac artery which gave origin to inferior epigastric artery, pseudoaneurysm cavity, and obturator artery.||Embolization|
An isolated pubic ramus fracture can often be treated with conservative management; however, in cases involving a corona mortis, patients are at risk of delayed hemorrhage. These vessels are deep within the pelvis and are often challenging to identify during surgery due to spasm. It is not surprising that, of the traumas that documented fracture of the pubic rami (n = 13) and of 12 traumas that mentioned hemodynamic status, all of the patients exhibited delayed hemorrhage [Table 2]. Interestingly, of the four patients in which corona mortis was identified intraoperatively, 50% were hemodynamically stable, and 50% had delayed hemorrhage. The three corona mortis identified post-operatively (n = 3) had only one (33%) with delayed hemorrhage, suggesting more success in corona management during non-trauma operative procedures. Awareness and early recognition of the corona mortis variant by radiologists in cases of trauma are vital.
The sensitivity and specificity of CT angiography (CTA) in identifying corona mortis in non-pelvic fracture patients are 90% and 100%, respectively. This vessel could be missed on initial CT without angiography as the sensitivity and specificity decrease to 63.6% and 92.3% in the setting of pelvic fracture. However, an evaluation of the case reports [Table 2] indicated that all trauma cases utilized CTA successfully to identify corona mortis. More importantly, all of the cases were successfully managed using embolization.
In the setting of pelvic fracture, it is essential to identify corona mortis as an injury may result in a life-threatening hemorrhage due to its position over the superior pubic ramus. Thus, careful radiological evaluation of corona mortis is key to preventing delayed life-threatening hemorrhage, as this entity is more common than previously thought. The interventionist needs to focus on the external iliac artery during catheter angiography in all cases of pelvic trauma, as the data suggest that the obturator artery may arise from that location in greater than 25% of cases.
In the setting of pelvic injury or pelvic surgery, catheter-guided embolization provides quick and successful management of hemorrhage.
Olivia Corso developed the illustration. These data were presented at the 17th Annual SC Upstate Research Symposium (pg 197–200) and at the 2022 ARRS virtual meeting May 1–5, 2022.
Declaration of patient consent
Institutional Review Board (IRB) permission obtained for the study.
Conflicts of interest
There are no conflicts of interest.
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