Mediastinal hematoma after trans-radial cerebral angiography: a case report.

BACKGROUND: Trans-radial (TRA) access has become increasingly prevalent in neurointervention. Nonetheless, mediastinal hematoma after TRA is an infrequent yet grave complication associated with a notably elevated mortality rate. While our review found no reported mediastinal hematoma cases managed conservatively within neuro-interventional literature, similar complications are documented in cardiac and vascular interventional radiology, indicating its potential occurrence across disciplines. CASE PRESENTATION: Carotid computed tomography angiography (CTA) showed calcified plaques with stenosis (Left: Severe, Right: Moderate) in the bilateral internal carotid arteries (ICAs) of an 81-year-old male presented with paroxysmal weakness in the right upper limb. Dual antiplatelet therapy with aspirin and clopidogrel was administered. On day 7, DSA of the bilateral ICAs was performed via TRA. Post-DSA, the patient experienced transient loss of consciousness, chest tightness, and other symptoms without ECG or MRI abnormalities. Hemoglobin level decreased from 110 g/L to 92 g/L. Iodinated contrast-induced laryngeal edema was suspected, and the patient was treated with intravenous methylprednisolone. Neck CT indicated a possible mediastinal hemorrhage, which chest CTA confirmed. The patient's treatment plan involved discontinuing antiplatelet medication as a precautionary measure against the potential occurrence of an ischemic stroke instead of the utilization of a covered stent graft and surgical intervention. Serial CTs revealed hematoma absorption. Discharge CT showed a reduced hematoma volume of 35 × 45 mm. CONCLUSIONS: This case underscores the need for timely identification and precise manipulation of guidewires and guide-catheters through trans-radial access. The critical components of successful neuro-interventional techniques include timely examination, rapid identification, proper therapy, and diligent monitoring.

Chronic Encapsulated Intracerebral Hematoma after Carbon Ion Therapy for Chordoma Mimicking Malignant Glioma: A Case Report.

Chronic encapsulated intracerebral hematoma is a rare type of intracerebral hemorrhage. Reportedly, it is associated with vascular malformations, including arteriovenous malformations, cavernous hemangiomas, microaneurysms, and venous malformations. Recently, an association between chronic encapsulated intracerebral hematoma and stereotactic radiosurgery for arteriovenous malformations has been reported. In general, as the hematoma enlarges, symptoms progress slowly. In this report, we present a case of a 50-year-old woman who had undergone clivus chordoma resection and carbon ion therapy for the clivus respectively 27 and 20 years before developing chronic encapsulated intracerebral hematoma with rapidly progressing disturbance of consciousness. She was referred to our hospital because of difficulty walking due to left hemiparesis. Head computed tomography and magnetic resonance imaging showed a cystic lesion in the right temporal lobe with perifocal edema. On the second day of hospitalization, the patient's consciousness worsened. We suspected a malignant glioma and performed an emergency craniotomy; however, the pathological diagnosis was chronic encapsulated intracerebral hematoma. After the rehabilitation therapy, the patient became ambulatory and was discharged. To the date of reporting, the patient remained recurrence-free. Chronic encapsulated intracerebral hematoma may be due to invasive craniotomy or carbon ion therapy. It usually progresses slowly; however, in some cases, such as this one, it may cause rapid deterioration of consciousness.

Total intestinal obstruction due to traumatic submucosal jejunal hematoma: A case report.

INTRODUCTION AND IMPORTANCE: Blunt abdominal trauma can result in various injuries, including intestinal hematomas causing obstruction. Traumatic submucosal jejunal hematomas are rare, especially in children, with bicycle handlebar injuries being a potential cause. Prompt recognition and appropriate imaging are crucial for accurate diagnosis and management. CASE PRESENTATION: A 10-year-old boy presented with delayed abdominal pain, vomiting, and absence of bowel movements following blunt abdominal trauma from a bicycle handlebar injury. Abdominal CT scan confirmed a submucosal jejunal hematoma, leading to exploratory laparotomy and duodenojejunostomy. CLINICAL DISCUSSION: Bicycle handlebar injuries, although seemingly minor, can cause significant internal damage, especially in children. Delayed symptoms pose a diagnostic challenge, necessitating a high index of suspicion and imaging modalities like CT scans for timely intervention. CONCLUSION: This case underscores the importance of considering traumatic submucosal jejunal hematomas in children with blunt abdominal trauma, particularly from bicycle handlebar injuries. Surgical intervention may be necessary in cases of complete intestinal obstruction, emphasizing the need for prompt diagnosis and treatment.

Risk Factors for the Recurrence of Chronic Subdural Hematoma.

Objective: Chronic subdural hematoma (CSDH) is commonly encountered in neurosurgery, and often occurs in elderly patients following a head injury. Despite favorable postoperative prognosis, recurrence remains common. Herein, we retrospectively analyzed the clinical and radiological data of patients at our institute to identify the risk factors for CSDH recurrence. Methods: We investigated 370 patients who underwent surgery for CSDH at our institute. The following data were analyzed: sex, age, antiplatelet/anticoagulant use, preexisting diseases, radiological parameters, and surgical techniques. A univariate analysis was subsequently performed to examine the association between these variables and CSDH recurrence. Variables with a p-value of <0.05 in univariate analysis were further subjected to a multivariate logistic regression model to identify independent risk factors of CSDH. Results: Of the 370 patients, 345 (93.2%) had no recurrence and 25 (6.8%) had recurrence. Univariate and multivariate analyses revealed that male sex, advanced age, bilateral hematoma, moderate or severe brain atrophy, separation type, gradation type, and burr hole trephination were independent risk factors for CSDH recurrence. Conclusion: Sex, age, bilateral hematoma, brain atrophy, hematoma density and architecture, and surgical techniques are all associated with CSDH recurrence.

Middle Meningeal Artery Embolization in the Treatment of Acute Subdural Hematoma: A Case Series Featuring Access Through a Carotid Stent.

The first objective of this case series was to describe the case of a patient with severe symptomatic left internal carotid artery stenosis after a recent stroke. Several days after stent placement by transcarotid artery revascularization, the patient developed a left-sided subdural hematoma. The patient then underwent embolization of the left middle meningeal artery (MMA) despite blocked access to the left MMA because of an internal carotid stent. The external carotid artery was accessed by passing a guiding catheter through the stent wall. We describe this method as "intrawall access." This allowed a coaxial system to deliver polyvinyl alcohol particles to the MMA for embolization. Embolization was successfully performed, with the stent integrity and blood flow through it remaining uncompromised. Overall, we demonstrated a new method of access through a previously placed internal carotid stent to gain neurointerventional access to the external carotid artery, which was jailed by a stent, for treating an acute subdural hematoma via MMA embolization. The second objective of this case series was to demonstrate the first MMA embolization in literature carried out in the acute or acute-on-subacute setting, in this case, and in four others.

Pediatric duodenal stenosis caused by posttraumatic mesenteric hematoma managed with a double elementary diet tube.

A 6-year-old male child was admitted to the hospital because of abdominal trauma and acute stomach pain. Computed tomography scan revealed a jejunal mesenteric hematoma and an enhanced intestinal wall compressed by the hematoma. The patient presented with vomiting 10 days after the injury. He underwent upper endoscopy under tracheal intubation and general anesthesia 12 days after the injury. A double elementary diet tube was inserted endoscopically with the tip placed in the jejunum beyond the stenosis and the decompressed portion of the stomach. Stenosis was improving, and the patient was discharged on the 27th day after the injury. In conclusion, a double elementary diet tube can be effective for treating posttraumatic duodenal stenosis in pediatric patients.

Leakage sign is a reliable predictor of hematoma expansion in acute epidural hematoma.

BACKGROUND: Hematoma expansion in small/medium-sized acute epidural hematoma (AEDH) cases upon emergency admission is critical. Predicting hematoma expansion can lead to early surgical interventions, improving outcomes and eliminating the need to check for expansion via computed tomography (CT). This study aimed to identify the most reliable predictors of AEDH expansion. METHODS: We retrospectively collected data from patients with pure AEDH not requiring surgical treatment upon emergency admission from 2012-2022. We assessed clinical and laboratory data, time from injury to the first CT, and time to follow-up CT. Factors predictive of hematoma expansion on the second follow-up CT, including the leakage sign (LS), were analyzed. RESULTS: A total of 23 patients with pure AEDH without surgery at admission were included, and LS was positive in 18. Thirteen patients showed hematoma expansion. The hematoma expansion group showed a significantly higher rate of positive LS and lower mean platelet count than the group without hematoma expansion. LS's predictive value for AEDH expansion showed 100% sensitivity and 50% specificity. All patients with negative LS and normal platelet counts showed no hematoma expansion. Analyzing the time from injury to the first CT suggested that LS (+) within 120 min strongly predicted hematoma expansion. Reconstructed three-dimensional images of the leakage point on the skull revealed multiple mottled bleeding points on the dural surface. CONCLUSION: LS can predict hematoma expansion in patients with pure AEDH for whom emergency surgery is unnecessary at admission. The time from injury and platelet counts must also be considered.

Unraveling the Pathogenesis of Post-Stroke Depression in a Hemorrhagic Mouse Model through Frontal Lobe Circuitry and JAK-STAT Signaling.

Post-stroke depression is a common complication that imposes significant burdens and challenges on patients. The occurrence of depression is often associated with frontal lobe hemorrhage, however, current understanding of the underlying mechanisms remains limited. Here, the pathogenic mechanisms associated with the circuitry connectivity, electrophysiological alterations, and molecular characteristics are investigated related to the frontal lobe in adult male mice following unilateral injection of blood in the medial prefrontal cortex (mPFC). It is demonstrated that depression is a specific neurological complication in the unilateral hematoma model of the mPFC, and the ventral tegmental area (VTA) shows a higher percentage of connectivity disruption compared to the lateral habenula (LHb) and striatum (STR). Additionally, long-range projections originating from the frontal lobe demonstrate higher damage percentages within the connections between each region and the mPFC. mPFC neurons reveal reduced neuronal excitability and altered synaptic communication. Furthermore, transcriptomic analysis identifies the involvement of the Janus Kinase-Signal Transducer and Activator of Transcription (JAK-STAT) signaling pathway, and targeting the JAK-STAT pathway significantly alleviates the severity of depressive symptoms. These findings improve the understanding of post-hemorrhagic depression and may guide the development of efficient treatments.

An unusual case of ventral spontaneous thoracic epidural hematoma.

Spontaneous spinal epidural hematoma (SSEH) rarely occurs. Without early diagnosis, SSEH can lead to the acute onset of neurologic deficits. We report the case of a 65-year-old male with diabetes mellitus who was admitted to our emergency department with a chief complaint of sharp and severe pain in the left scapula and behind the sternum. He was misdiagnosed with cardiovascular disease until the onset of progressive bilateral paraplegia and lower limb numbness. Magnetic resonance imaging revealed a ventral thoracic SSEH. Surgical treatment to remove epidural hematoma and laminectomy for decompression were performed. Except for urine retention, bilateral lower limb paraplegia and numbness were alleviated postoperatively. Due to the high risk of poor neurological outcomes without treatment or with delayed intervention, timely surgical evacuation of the hematoma and hemostasis are recommended to ensure favorable neurological outcomes.

Effective Non-invasive Treatment of Lingual Hematoma in an End-Stage Renal Disease (ESRD) Patient on Rivaroxaban: A Case Report.

Lingual hematoma is a rare, life-threatening condition that can obstruct the airway. We report a 73-year-old male with end-stage renal disease (ESRD) who developed lingual hematoma while on rivaroxaban. He presented with odynophagia and significant tongue swelling. Treatment with vitamin K, dexamethasone, tranexamic acid, and prothrombin complex concentrate led to rapid improvement without the need for intubation. This case highlights the importance of prompt medical management to prevent airway obstruction in similar patients.

Chronic expanding intrapericardial hematoma mimicking ST elevation myocardial infarction: A case report.

INTRODUCTION AND IMPORTANCE: The pericardium shields the heart, with pericarditis and Tetralogy of Fallot (TOF) posing diagnostic challenges. CEIH, a rare post-TOF repair complication, demands recognition for effective management. CASE PRESENTATION: A 57-year-old male, post-TOF repair, presented with chest pain and hypotension. Diagnostic tests revealed CEIH with right ventricular strain. CLINICAL DISCUSSION: CEIH, though rare, warrants consideration in post-TOF repair patients with chest pain. Timely recognition and intervention are vital to prevent serious complications. CONCLUSION: Vigilance for CEIH in post-TOF repair patients experiencing chest pain is crucial for optimal management and improved outcomes.

Good outcome with conservative treatment of delayed spinal epidural hematoma following combined spinal-epidural anesthesia: a rare case report.

BACKGROUND: Delayed spinal epidural hematoma (SEH) following central neuraxial block (CNB) is a rare but serious complication. The underlying causes of SEH associated with neuraxial anesthesia are still unclear. Furthermore, the decision between surgical intervention and conservative management for SEH remains a complex and unresolved issue. CASE PRESENTATION: We report a case of delayed SEH in a 73-year-old woman who underwent vaginal hysterectomy under combined spinal-epidural anesthesia, with the administration of postoperative anticoagulants to prevent deep vein thrombosis on the 1st postoperative day (POD). She experienced symptoms 56 h after CNB. Magnetic resonance imaging (MRI) revealed a dorsal SEH at the L1-L4 level with compression of the thecal sac. On conservative treatment, full recovery was achieved after six months. CONCLUSIONS: This case reminds anesthesiologists should be alert to the possible occurrence of a delayed SEH following CNB, particularly with the administration of anticoagulants. Immediate neurological evaluation of neurological deficit and MRI are advised. Conservative treatment combined with close and dynamic neurological function monitoring may be feasible for patients with mild or nonprogressive symptoms even spontaneous recovery.

Grade III en-plaque meningioma mimicking subacute subdural hematoma: A case report.

INTRODUCTION: En-plaque meningioma (EPM) presents preoperative diagnostic challenges due to its atypical radiologic features. This case report describes the preoperative diagnostic challenges in identifying EPM that affected its operative management. CASE REPORT: A 58-year-old female patient presented to the emergency department with decreased consciousness and a history of a fall on the head two months earlier. For the past year, the patient also complained of worsening headaches. One week before, the patient also complained of nausea, vomiting, and fluctuating fever. Although a CT scan of the head showed a mass in the left temporoparietal region, the patient was initially diagnosed with subacute subdural hematoma (saSDH) and planned for SDH evacuation surgery using the burr hole technique. However, intraoperative findings revealed an extradural intracranial tumor, so the procedure was switched to tumor excision craniotomy, and based on histopathological examination, it was confirmed to be an anaplastic malignant meningioma, WHO grade III. DISCUSSION: EPM is one of the rare subtypes of meningioma with an atypical and radiologically variable appearance that often presents challenges in preoperative diagnosis. In this case, the patient's history of falling on the head and the CT scan of the head that resembles saSDH may obscure the preoperative diagnosis and affect the patient's management. CONCLUSION: EPM can manifest like other intracranial disorders. In this case, the patient's fall history may obscure the clinicians' diagnosis of the meningioma, leading to preoperative misdiagnosis with saSDH. Therefore, meticulous preoperative diagnosis is essential to determining the patient's medical treatment and outcome.

Successful Management of Acute Subdural Hematoma in Deep Brain Stimulation Patient: A Case Report and Literature Review.

Deep brain stimulation (DBS) has emerged as an important therapeutic option for several movement disorders; however, the management of acute complications, such as acute subdural hematoma (ASDH), remains challenging. This is the case of a 71-year-old woman with Parkinson's disease who developed ASDH 12 years after bilateral DBS placement. On admission with altered consciousness, imaging revealed significant displacement of the DBS electrodes because of the hematoma. Emergent craniotomy with endoscopic evacuation was performed with preservation of the DBS system. Postoperatively, complete evacuation of the hematoma was confirmed, and the patient experienced significant clinical improvement. ASDH causes significant electrode displacement in patients undergoing DBS. After hematoma evacuation, the electrodes were observed to return to their proper position, and the patient exhibited a favorable clinical response to stimulation. To preserve the DBS electrodes, endoscopic hematoma evacuation via a small craniotomy may be useful.

Rectus Sheath Hematoma.

The authors report on the case of a 69-year-old female who presented to the emergency department due to exquisite abdominal pain she described as occurring after she coughed. Imaging revealed a rectus sheath hematoma (RSH). A RSH is an uncommon but significant cause of acute abdominal pain that occurs when blood accumulates in the sheath of the rectus abdominis muscle. It can be caused by a muscular tear or a ruptured epigastric artery and can happen spontaneously or after trauma. The etiology, presentation, diagnosis, and management are discussed.

Fetal movement during delivery can lead to damage to the umbilical vessels and endanger the life of the fetus.

INTRODUCTION: Fetal umbilical cord hematoma has a low incidence but high mortality, and its cause during delivery is often unclear. We report an autopsy case in which it was concluded that umbilical cord hematoma resulted from fetal movements during childbirth. CASE PRESENTATION AND AUTOPSY FINDINGS: A 27-year-old primigravida at 39 + 2 weeks gestation with normal antenatal visits suffered a fetal heart rate decrease during active labor. Bedside ultrasound revealed fetal death in utero 22 min later. Forensic pathologists found that the umbilical vessels were torn and bleeding on almost the same plane, and the hematoma compressed both umbilical arteries, which is the cause of fetal stillness in utero. A total of 32 cases were reported, including 6 umbilical cord ruptures and 26 umbilical cord hematomas. The cause of hematoma was unknown in 77 % of cases, while dysplasia was present in 56.25 % of umbilical cords. DISCUSSION: This case indicates that fetal movements may cause umbilical cord vessel injury, particularly when oxytocin is used to induce labor. When fetal heart sounds decrease for no apparent reason, the possibility of cord injury should be considered, and cesarean delivery should be performed as soon as possible. Therefore, rigorous fetal heart tracing during active delivery is necessary.

The efficacy and safety of the internal medication therapy of the triple drugs for chronic subdural hematoma: Retrospective analysis.

The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis.

Neighborhood Deprivation is Associated With Increased Postoperative Complications After Implant-Based Breast Reconstruction.

PURPOSE: The Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction. PATIENTS AND METHODS: Patients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: "High ADI" (6-10) and "Low ADI" (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models. RESULTS: In total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05). CONCLUSION: Patients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction.

Prediction of hematoma expansion in spontaneous intracerebral hemorrhage using a multimodal neural network.

Hematoma expansion occasionally occurs in patients with intracerebral hemorrhage (ICH), associating with poor outcome. Multimodal neural networks incorporating convolutional neural network (CNN) analysis of images and neural network analysis of tabular data are known to show promising results in prediction and classification tasks. We aimed to develop a reliable multimodal neural network model that comprehensively analyzes CT images and clinical variables to predict hematoma expansion. We retrospectively enrolled ICH patients at four hospitals between 2017 and 2021, assigning patients from three hospitals to the training and validation dataset and patients from one hospital to the test dataset. Admission CT images and clinical variables were collected. CT findings were evaluated by experts. Three types of models were developed and trained: (1) a CNN model analyzing CT images, (2) a multimodal CNN model analyzing CT images and clinical variables, and (3) a non-CNN model analyzing CT findings and clinical variables with machine learning. The models were evaluated on the test dataset, focusing first on sensitivity and second on area under the receiver operating curve (AUC). Two hundred seventy-three patients (median age, 71 years [59-79]; 159 men) in the training and validation dataset and 106 patients (median age, 70 years [62-82]; 63 men) in the test dataset were included. Sensitivity and AUC of a CNN model were 1.000 (95% confidence interval [CI] 0.768-1.000) and 0.755 (95% CI 0.704-0.807); those of a multimodal CNN model were 1.000 (95% CI 0.768-1.000) and 0.799 (95% CI 0.749-0.849); and those of a non-CNN model were 0.857 (95% CI 0.572-0.982) and 0.733 (95% CI 0.625-0.840). We developed a multimodal neural network model incorporating CNN analysis of CT images and neural network analysis of clinical variables to predict hematoma expansion in ICH. The model was externally validated and showed the best performance of all the models.

Portable Percussive Massage Device-Related Rectus Sheath Hematoma and Obstructive Uropathy: A Case Report.

Introduction: Rectus sheath hematomas (RSHs) can occur from the rupture of the epigastric arteries, leading to blood accumulation within the rectus abdominis sheath. Herein, we report the unique case of an RSH resulting in acute ureteral obstruction, which was associated with the use of a handheld deep-tissue percussive massage device in attempts to relieve abdominal pain. Case Report: A morbidly obese man in his late 50s was admitted with complications of COVID-19, including acute respiratory syndrome, bilateral peroneal deep vein thromboses, and acute kidney injury. He was treated with anticoagulants (subcutaneous enoxaparin and apixaban), dexamethasone, and remdesivir. He developed severe abdominal pain, and a large (14 × 17 cm) right rectus sheath and an extraperitoneal pelvic hematoma were identified by computed tomography. The hematoma extended across the midline into the left pelvis and the retroperitoneum with associated mild right hydronephrosis. A handheld percussive massage device (Theragun®) was applied repeatedly at the site of enoxaparin injection into the abdominal wall in attempts to alleviate the pain. On day 12, bilateral nephrostomy tubes were inserted. A nephrostogram revealed mild hydroureteronephrosis to the ureterovesicular junction bilaterally and extrinsic compression of the bladder. On day 17, the patient suffered a cardiac arrest and died. Conclusion: This case report offers insights into the pathophysiology of obstructive uropathy and is a reminder of the importance of considering uncommon causes of obstructive uropathy in the diagnosis and management of AKI, particularly in hospitalized patients receiving anticoagulation. We know of no previous reference of obstructive uropathy caused by retroperitoneal hematoma associated with the use of a portable massage device applied to the abdominal wall.