E1772. Dethroning the Crown of Death: Review and Treatment of Corona Mortis in the Setting of Pelvic Trauma
University of South Carolina School of Medicine Greenville
Pathology Associates; University of South Carolina School of Medicine Greenville
Department of Radiology, Prisma Health Upstate; University of South Carolina School of Medicine Greenville
Department of Radiology, The University of Alabama at Birmingham
The name alone, corona mortis (CM), or “crown of death,” signifies its importance; however, the specific definition of corona mortis is still debated. Most commonly, CM is defined as a vascular connection between the obturator artery and either the inferior epigastric artery or the external iliac artery itself . The existence of CM is not commonly taught during medical school, which may be due to anatomic textbooks historically labeling the vessel “anomalous or “aberrant”. However, with a prevalence of approximately 46%, the presence of CM is common. Located posteriorly over the superior pubic ramus, CM is at risk for injury in pelvic trauma and various pelvic surgeries.
Educational Goals / Teaching Points
This exhibit aims to describe CM variants according to the Rusu classification system; highlight the importance of early recognition of CM in the setting of pelvic trauma; and illustrate the effectiveness of catheter-guided embolization as an effective treatment for CM hemorrhage.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
CM is a venous or arterial connection between the internal and external iliac systems that lies posteriorly over the superior pubic ramus. Given the inconsistent terminology, Rusu et al. 2010 developed a classification system. Their system defines three main types (I. arterial, II. venous, III combined), which are further classified into subcategories based on morphological patterns. For arterial CM (type I), the obturator artery can emerge from the external iliac artery (I.1), or the inferior epigastric artery (I.2). In addition, it can appear as an anastomosis between the obturator and inferior epigastric artery (I.3) or as pubic branches from the obturator artery that do not anastomose but cross over the superior pubic ramus (I.4). For venous CM (type II), the obturator vein can drain into the external iliac vein (II.1) or into the inferior epigastric vein (II.2). Venous anastomosis of the obturator vein and inferior epigastric vein are classified as II.3. One of the most common ways to injure the CM is through pelvic trauma. Spasm of the lacerated CM during displaced fractures makes them challenging to identify intraoperatively. Interventional radiologists are uniquely equipped to locate and stop hemorrhage from deep within the pelvis quickly. Here, we present four cases of CM hemorrhage in the setting of trauma. Two types of arterial corona mortis were identified. The first, and most common, variant was the obturator branch arising from the external iliac artery. The second was a communication between the left inferior epigastric artery and the anterior division of the left internal iliac artery. All patients were successfully treated with embolization with Gelfoam followed by coils.
The CM is created by a ring of abnormal, but not uncommon, pelvic vessels. Interventional radiologists must be aware of these anatomic variants and investigate both the internal and external iliac arteries for potential bleeding. As demonstrated above, catheter-guided embolization is an effective treatment for CM hemorrhage.