A case of gastrointestinal perforation following transarterial embolization for an intramural hematoma after cold snare polypectomy of an adenoma in the transverse colon.

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

Left Ventricular Intramyocardial Dissecting Hematoma With Late Ventricular Tachycardia Storm.

This case describes an uncommon discovery of a left ventricular intramyocardial dissecting hematoma in a patient experiencing a ventricular tachycardia storm. Imaging modalities, including 2-dimensional and 3-dimensional echocardiography and cardiac magnetic resonance, assisted in diagnosing the intramyocardial dissecting hematoma. The patient underwent conservative treatment and received a single-chamber implantable cardioverter defibrillator.

Spontaneous neck hematoma in a hemodialysis patient: A case report.

We present a 60-year-old maintenance hemodialysis patient who initially presented with neck swelling, which was diagnosed as a thyroid issue. Following a hemodialysis session, the swelling in the neck progressively enlarged, leading to respiratory distress and eventual cardiac arrest. During a life-saving tracheotomy, dark red blood was observed, and endotracheal intubation was urgently performed. Subsequent computed tomography examination identified multiple areas of slight high-density images in the nasopharyngeal cavity, oropharyngeal cavity, and esophagus. As time passed, the patient's hematoma underwent spontaneous absorption, but signs of recovery were absent. We discuss the rarity, etiology, diagnosis, and management of spontaneous neck hematoma in maintenance hemodialysis patients.

Idiopathic Spinal Epidural Hematoma: A Near Miss of a Rare Entity.

Spinal epidural hematomas (SEH) are rare, and cases with a spontaneous etiology are even more infrequent. Management of spontaneous SEH varies, with surgical or conservative approaches determined by the severity of deficits and symptom resolution. Adverse prognostic factors may include thoracic segment location, anticoagulation use, severe neurologic deficits at admission, sphincter dysfunction, and rapid progression. We report a patient with a sudden onset of bilateral lower limb weakness and reduced urinary output. Magnetic resonance imaging was conducted and indicated an epidural hematoma extending from T11 to L4. Surgical decompression and hematoma extraction were performed successfully resulting in the complete resolution of symptoms. This case underscores the importance of considering spontaneous SEH in patients lacking conventional risk factors, such as a history of trauma, when presenting with symptoms of bilateral lower limb weakness and decreased urine output. Depending on the severity of symptoms and the occurrence of spontaneous and rapid improvement, the patient may benefit from surgical intervention, which ameliorated the patient's symptoms in this case.

Unmasking Nasal Septal Hematoma/Abscess: A Systematic Review and Meta-analysis.

Objective: We aim to discuss the demographics, symptoms, bacteriology, treatment, and sequelae associated with nasal septal hematoma/nasal septal abscess (NSH/NSA). Data Sources: CINAHL, PubMed, and Scopus were searched from inception until October 15, 2023. Review Methods: Preferred Reporting Items for Systematic Reviews and Meta-analysis 2020 guidelines were followed. Inclusion criteria included patients who were diagnosed with a traumatic NSH/NSA. NSH/NSA due to surgical procedures was excluded. Demographics included N of patients, patient age, and gender. Symptoms, antibiotics given, bacteriology, and sequelae were analyzed. Meta-analysis of continuous measures (mean, median), and proportions (%) with a 95% confidence interval (CI) was conducted. Results: Thirty studies (N = 598) were included. In total, 72.1% were males (95% CI: 67-78). The total mean age was 21.6 years (range: 0.2-85, 95% CI: 17.2-26.1). The mean time from trauma to diagnosis was 8.2 days. Common symptoms at presentation included nasal obstruction/congestion at 60.3% (95% CI: 37.1-81.4), nasal pain at 30.0% (17.2-44.6), swelling at 20.4% (8.7-35.5), headache at 15.5% (7.3-26.0), and fever at 13.9% (7.3-22.2). The most common pathogens isolated included Staphylococcus aureus at 56.5% (49.0-63.8), Streptococcus species at 8.9% (5.2-14.0), and Klebsiella pneumoniae at 6.3% (3.2-10.8). Antibiotics given included amoxicillin-clavulanate at 10.3% (4.5-18.2), metronidazole at 9.5% (1.1-24.9), ampicillin-sulbactam at 8.9% (0.4-26.5), and unspecified antibiotics at 39.7% (13.8-69.2). The most common sequelae were nasal septal deformity/cartilage destruction at 14.3% (7.7-22.6). Conclusion: NSA/NSH has an 8-day delay in diagnosis from the time of trauma. First-line practitioners should be made aware of the signs and symptoms of this condition to minimize the risk of morbidity.

Distribution of the middle meningeal artery variants in patients undergoing embolization for chronic subdural hematoma.

INTRODUCTION: The middle meningeal artery (MMA) is a major dural vessel that plays a significant role in developing chronic subdural hematomas (cSDH). Understanding its variable anatomy is essential for the effective management of cSDH and the prevention of complications. METHODS: Middle meningeal artery anatomy was retrospectively assessed in a population of 92 patients who underwent digital subtraction angiography of cerebral vessels before middle meningeal artery embolization for chronic subdural hematoma. RESULTS: We assessed 121 middle meningeal arteries in 92 patients who underwent digital subtraction angiography for chronic subdural hematoma treatment from October 2020 to July 2023. The most common type in the extended Adachi classification was IC (19.82%) and the rarest was IB (6.31%). The anterior branch of the MMA was the most frequently dominant, while the most common origin of the posterior branch was observed in the distal segment. We reported 4 cases (3.31%) of the MMA arising from the ophthalmic artery. CONCLUSIONS: The most common configuration of MMA was Adachi-type IC. The MMA most often originated from the maxillary artery. The anterior branch of the MMA was typically dominant, and the posterior branch most frequently originated from the distal segment. There was no significant impact of Adachi type on treatment results or fluoroscopy time.

Comparison of Postoperative Epidural Hematoma Formation Between Biportal Endoscopic Spine Surgery and Conventional Microscopic Surgery: A Randomized Controlled Trial.

BACKGROUND: Biportal endoscopic spine surgery (BESS) has become widely recognized as a minimally invasive method for spinal decompression and discectomy. However, postoperative epidural hematoma (POEH) presents a significant risk in spinal surgery due to its potential to compress neural elements and lead to neurological deficits. This study compares the clinical and radiological outcomes of BESS with those of conventional microscopic surgery. METHODS: In this single-center, single-blinded, actively controlled randomized clinical trial, 46 patients undergoing single-level posterior decompression or discectomy for spinal stenosis or herniated intervertebral discs were enrolled. Participants were randomly allocated to either the conventional microscopic surgery group or the BESS group. Experienced spine surgeons performed all procedures. Postoperative magnetic resonance imaging assessments were conducted following the removal of the drain system. Outcome measures included the cross-sectional area (CSA) of the dura sac and POEH, as well as the incidence of neurological deficits. RESULTS: The demographic and baseline characteristics of the patients were similar across the 2 groups, with 24 in the conventional group and 22 in the BESS group. There were no significant differences in the preoperative and postoperative CSA of the dura sac between the groups. However, the BESS group exhibited a significantly larger CSA of POEH (0.36 ± 0.34 cm²) compared with the conventional group (0.17 ± 0.15 cm², P = 0.033). Despite this higher incidence of POEH, there was no corresponding increase in neurological deficits or revision surgeries. CONCLUSION: The findings indicate that while BESS achieves decompression comparable to that of conventional microscopic surgery, it is associated with a higher incidence of epidural hematomas. Importantly, these hematomas did not result in an increased rate of neurological deterioration or the need for surgical interventions. Further studies with larger sample sizes and extended follow-up are required to confirm these results and further refine the BESS technique. CLINICAL RELEVANCE: Despite a higher incidence of epidural hematomas, BESS offers comparable decompression to microscopic surgery without increased neurological risks, making it a viable, less invasive option for patient care.

Practice variations, trends, and outcomes of drain use in thyroidectomy: A NSQIP study.

BACKGROUND: The benefit of drains remains unclear and variable among thyroid surgeons. This study examines the utility and trend in drain use after thyroidectomy. METHOD: This is a retrospective cross-sectional study utilizing a pooled sample of thyroidectomy patients from the 2016-2019 NSQIP. The impact of drain use on outcomes of interest (rate of postoperative neck hematoma (PNH)-primary outcome, and length-of-stay (LOS)-secondary outcome), as well as year-over-year and practice variations were evaluated using inverse-probability-weighted-regression adjustment and multivariable logistic regression analyses. RESULTS: Of 24,370 patients, 6673(27.4 â€‹%) received drains. The average LOS and PNH rates were 27.3 â€‹h and 1.87 %, respectively. Drain use increased year-over-year for concomitant neck dissections (OR â€‹= â€‹1.08,p â€‹= â€‹0.002). Year-over-year odds of drain use trended down across specialties (OR â€‹= â€‹0.96,p â€‹= â€‹0.005); however, ENT used drains more frequently than General Surgeons (RR â€‹= â€‹3.06, 95%CI â€‹= â€‹2.91-3.22). Drains were associated with longer LOS (mean-difference â€‹= â€‹9.6hrs, 95%CI 8.51-10.62) with no effect on PNH rates (RR â€‹= â€‹0.96,p â€‹< â€‹0.05). CONCLUSION: Drain use is decreasing, but practice variations across specialties persist. Post-thyroidectomy drain use was associated with longer LOS with no effect on PNHR.

Acquired factor XIII deficiency presenting with multiple intracranial hemorrhages and right hip hematoma: A case report.

BACKGROUND: Factor XIII (FXIII) deficiency is a rare yet profound coagulopathy. FXIII plays a pivotal role in hemostasis, and deficiencies in this factor can precipitate unchecked or spontaneous hemorrhaging. Immunological assays for detecting FXIII inhibitors are indispensable for diagnosing acquired FXIII deficiency; however, the availability of suitable testing facilities is limited, resulting in prolonged turnaround times for these assays. CASE SUMMARY: In this case study, a 53-year-old male devoid of significant medical history presented with recurrent intracranial hemorrhages and a hematoma in the right hip. Subsequent genetic analysis revealed a homozygous mutation in the ACE gene, confirming the diagnosis of acquired FXIII deficiency. CONCLUSION: This case underscores the significance of considering acquired deficiencies in clotting factors when evaluating patients with unexplained bleeding episodes.

Post myocardial infarction left ventricular intramyocardial dissecting hematoma penetrated right ventricular outflow tract: a rare complication report.

BACKGROUND: Intramyocardial dissecting hematoma (IDH) is a rare mechanical complication following myocardial infarction (MI), and only a few isolated cases have been reported to date. IDH presents with diverse clinical manifestations, often resulting in missed or misdiagnosed cases due to limited physician understanding. The diagnosis and treatment of IDH is a major challenge. CASE PRESENTATIONS: We report a case of acute extensive anterior MI in a 73-year-old woman, who underwent percutaneous coronary intervention (PCI); the left ventricular intramyocardial dissecting hematoma (LVIDH) penetrated the right ventricular outflow tract (RVOT), resulting in thrombus formation and subsequent RVOT obstruction. Clinically insignificant IDH was detected by transthoracic echocardiography (TTE) at 3 days, 43 days, and 75 days post-PCI, with characteristic changes in the left ventricular wall ultrasound images. This unusual case highlights the important role of continuous transthoracic echocardiography in identifying this rare complication of LVIDH. After a detailed discussion with the patient, the choice between conservative or surgical management of IDH depends on factors such as the size of the hematomae, left ventricular systolic function, and the patient's clinical and haemodynamic status. In this particular case, conservative management was chosen by the patient who declined surgery but unfortunately succumbed to cardiogenic shock. CONCLUSIONS: This case describes a rare complication of acute myocardial infarction (AMI) and also focuses on the utility of TTE in the diagnosis of this rare complication. Whether LVIDH is treated conservatively or surgically requires careful evaluation to achieve the best prognosis for the patient.

Efficacy of neuroendoscopy-assisted surgery in the treatment of chronic subdural hematoma: a meta-analysis.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common diseases in neurosurgery. It is the result of chronic intracranial hemorrhage that converges between the dura mater and arachnoid three weeks after externally injuring the head. Chronic subdural hematomas are a common complication in neurosurgery. With the gradual increase in the amount of hematoma, the surrounding brain tissue is pushed and compressed, resulting in corresponding clinical symptoms and signs. It is reported that the overall incidence rate of CSDH is 1.72 to 20.6 per 100,000 people every year, and the incidence rate of the elderly is particularly high. METHODS: The computer retrieves eight databases to obtain controlled trials at home and abroad on the effects of neuroendoscopy-assisted surgery in patients with chronic subdural hematoma. After a rigorous literature quality evaluation, data analysis was performed using RevMan 5.3 software. RESULTS: Twenty studies were ultimately included in this meta-analysis. Seventeen studies reported the Recurrence rate of the test group and the control group, which was significantly lower (OR 0.27; 95% Cl 0.18, 0.38; P < 0.01) than the control group, Recovery rate (OR 1.18; 95% Cl 1.01, 1.38; P = 0.03), Total effective rate (OR 1.11; 95% Cl 1.04, 1.17; P < 0.01), Operative time (SMD 15.78; 95% Cl 9.69, 21.86; P < 0.01), Hospital stay (SMD - 1.66; 95% Cl - 2.17, - 1.14; P < 0.01) and Complications (OR 0.48; 95% Cl 0.30, 0.78; P < 0.01). CONCLUSION: The results of this study suggest that neuroendoscopy-assisted surgery may be effective in patients with chronic subdural hematoma, as evidenced by recurrence rate, recovery rate, total effective rate, operative time, hospital stay, complications, and the above conclusions need to be verified by more high-quality studies.

Middle meningeal artery embolization for organized chronic subdural hematoma combined with minimal evacuation surgery: Two case reports.

Organized chronic subdural hematoma (OCSDH) is a rare condition lacking standardized treatment protocols. Middle meningeal artery (MMA) embolization has recently demonstrated promising outcomes in managing chronic subdural hematoma (CSDH). We present 2 cases of OCSDH treated with endovascular embolization and minimal evacuation surgery. The first case involved an 83-year-old male with a history of left CSDH drainage, admitted urgently due to right hemiplegia and dysarthria. CT scans confirmed recurrent CSDH. A small craniotomy was performed to decompress the thick hematoma, followed by drain placement. Postoperative magnetic resonance imaging (MRI) indicated OCSDH. Seven days later, MMA embolization with 25% n-butyl-2-cyanoacrylate (NBCA) was performed under local anesthesia. The patient's symptoms improved, and the hematoma resolved within 6 months without recurrence. The second case involved a 76-year-old male with right CSDH and thrombocytopenia (platelet count of 19,000/µL), diagnosed with immune thrombocytopenia. MRI indicated OCSDH. Due to the risk associated with craniotomy, a burr hole perforation and MMA embolization were planned, accompanied by a platelet transfusion. Left MMA embolization with 20% NBCA was performed, followed by burr hole enlargement for decompression and drain placement. The patient's symptoms improved postoperatively, and his platelet count stabilized with steroid therapy and thrombopoietin. The hematoma resolved within 3 months without recurrence. These cases indicate that MMA embolization combined with small craniotomy or perforation may be an effective treatment strategy for OCSDH.

Optimizing shunt integrity during acute subdural hematoma evacuation.

Background: Even mild head trauma can cause severe intracranial hemorrhage in patients with cerebrospinal fluid (CSF) shunts for hydrocephalus. CSF shunts are considered a risk factor for subdural hematoma (SDH). The management of acute SDH (ASDH) in shunted patients with normal pressure hydrocephalus can be challenging. Addressing the hematoma and the draining function of the shunt is important. To preserve the shunt, we set the shunt valve pressure to the highest and perform hematoma evacuation for ASDH. In this study, we report the surgical cases of ASDH in patients with shunts. Methods: Between 2013 and 2019, five patients with ASDH and CSF shunts underwent hematoma evacuation at our hospital. We retrospectively analyzed data regarding their clinical and radiological presentation, hospitalization course, the use of antithrombotic medications, and response to different treatment regimens. Results: The patients presented with scores of 5-14 in the Glasgow coma scale and severe neurological signs, consciousness disturbance, and hemiparesis. Most patients were elderly, taking antithrombotic medications (four of five cases), and had experienced falls (4 of 5 cases). All patients underwent hematoma evacuation following resetting their programmable shunt valves to their maximal pressure setting and shunt preservation. ASDH enlargement was observed in only one patient who underwent burr-hole drainage. Glasgow outcome scale scores at discharge were 1 and 3, respectively. Conclusion: In hematoma evacuation, increasing the valve pressure may reduce the bleeding recurrence. To preserve the shunt, setting the shunt valve pressure to the highest level and performing endoscopic hematoma evacuation with a small craniotomy could be useful.

Spontaneous spinal epidural hematoma in infants: A case report and review of the literature.

Background: Spontaneous spinal epidural hematomas (SSEHs) are exceedingly uncommon, especially in infants, with only two reported cases. Diagnosis can be delayed due to the nonspecificity of presenting symptoms. Case Report: We present a case of SSEH in a 10-month-old boy admitted to the pediatric emergency department with a 5-day history of progressive lower extremity motor weakness. There was no history of prior trauma. Magnetic resonance imaging of the spine revealed a posterior epidural hematoma extending from C7 to L4. After hematoma evacuation, the patient's neurological status gradually improved, and no sensorimotor deficit was present 3 weeks postoperatively. Conclusion: Our case suggests that surgical intervention can lead to an excellent prognosis for SSEH in infants, even if the diagnosis is delayed.

Subdural drain with Nelaton catheter and latex glove, a low-cost alternative and how to make it.

Background: One of the most commonly encountered surgical pathologies in neurosurgical practice worldwide is subdural hematoma. The use of prefabricated drains following surgical procedures is widely recommended. However, their availability can be inconsistent due to various issues. Methods: An intensive search was conducted regarding the availability and cost of subdural drains. The Medtronic subdural evacuating port system costs between 100 and 150 USD, the Blake drain costs between 35 and 40 USD, and the Jackson-Pratt drain costs between 25 and 35 USD. We present a low-cost alternative and describe how it can be implemented using materials available in almost every hospital. Results: A simple step-by-step guide for crafting handmade subdural drains has been created, aiming to make this affordable alternative accessible to every surgeon who may need one due to the unavailability of prefabricated drains in developing countries. Conclusion: The benefits associated with using a subdural drain during the evacuation of subdural hematomas are well-documented. In cases where prefabricated drains are not available, a handmade alternative can always be utilized. Materials are often readily available in every hospital, and the cost may not exceed 100 MXN (5 USD), making it at least 5 times cheaper than the cheapest prefabricated alternative. This solution is particularly beneficial for developing countries without access to prefabricated drains.

Intracranial epidural hematoma after spinal anesthesia for cesarean section: a case report.

BACKGROUND: Although subdural hematoma is a rare complication after spinal anesthesia, there have been no reports of an intracranial epidural hematoma after cesarean section with spinal anesthesia. CASE PRESENTATION: A 32-year-old nulliparous woman at the 35th week of a twin pregnancy underwent an emergency cesarean section due to her first contraction. She had no preoperative complications and the spinal anesthesia was uneventful, with 0.5% bupivacaine 12 mg and fentanyl 15 µg from the L3/4 intervertebral space. She complained of headache and nausea 15 min after spinal anesthesia, demonstrating a consciousness disturbance after surgery. Computed tomography 2 h after the cesarean section revealed an intracranial epidural hematoma. She underwent decompressive craniotomy 1 h later. CONCLUSION: This case highlights the possible development of an intracranial epidural hematoma in low-risk obstetric patients.

Mediastinal and thoracic hematoma following transradial cerebral angiography: a case report.

BACKGROUND: Cerebral angiography through the transradial approach (TRA) is associated with a low risk of complications, but in rare cases, these complications can be life-threatening. CASE PRESENTATION: A 56-year-old female patient was admitted for transradial cerebral angiography due to the complaint of right limb weakness and the diagnosis of cerebral infarction and cerebral artery stenosis. During the procedure, the patient coughed with expectoration and complained of throat discomfort, palpitations, and pains in the right shoulder and back. Emergency CT scan indicated hematoma in the middle mediastinum and the right thoracic cavity, and perforation of a branch of the subclavian artery was highly suspected. Subclavian artery angiography was conducted immediately, which revealed a patchy contrast medium overflow in a branch of the right costocervical trunk. Selective endovascular occlusion therapy was performed successfully with gelfoam particles and placement of 2 microcoils. At 12 days after cerebral angiography, the patient recovered well and was discharged from the hospital. CONCLUSION: Mediastinal and thoracic hematoma may occur due to vessel perforation during TRA cerebral angiography, in which guidewire advancement must be cautious. Early detection and appropriate countermeasures can reduce the severity of vascular perforation and subsequent hematoma.

Spontaneous Auricular Hematoma - An Unusual Complication of Dengue fever.

Dengue is humans' most prevalent and crucial arthropod-borne viral illness. The majority of dengue fever patients have no symptoms, but certain individuals may progress to dengue shock syndrome or dengue hemorrhagic fever. Spontaneous auricular hematoma is a rare complication of dengue fever. We report a unique case of spontaneous pinna hematoma in a young, healthy patient who presented with an unprovoked pinna swelling while being treated for dengue fever. The patient underwent aspiration, drainage, and compression dressing over the auricular hematoma with antibiotic coverage and was discharged well. Early identification of this potential warning symptom may avoid permanent ear deformity. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-024-04867-6.

Predicting Intracerebral Hemorrhage Expansion with Inflammation Indices, Non-Contrast Computed Tomography Signs and Computed Tomography Angiography Spot Sign.

Aim: We aimed to investigate whether a combination of inflammatory and radiological biomarkers can improve intracerebral hemorrhage (ICH) hematoma expansion (HE) prediction. Methods: A retrospective analysis was conducted on patients with primary supratentorial ICH within 6 h of symptom onset between September 2021 and April 2022. Predictors were explored using univariate and logistic regression analysis. We compared the discrimination of inflammatory indice-based model 1 with models 2 and 3, which included image biomarkers, using the receiver operating characteristic curve and De Long test for area under the curve comparison. Results: A total of 205 eligible participants were included, 56 (27.3%) of whom experienced HE. The neutrophil-to-lymphocyte ratio (NLR), black hole sign, BAT score, and computed tomography angiography (CTA) spot sign were independently associated with HE in the logistic regression (P<0.05). The addition of non-contrast computed tomography (NCCT) signs did not provide significant discrimination improvement (AUC, Model 2 0.875 [95% CI, 0.822-0.929] versus Model 1. 0.811 [95% CI, 0.747-0.875], p=0.089), whereas the added value of the CTA spot sign remained statistically significant (AUC, Model 3 0.922 [95% CI, 0.878-0.966] versus Model 2; p=0.030; Model 3 versus Model 1, p=0.005). Conclusion: The combination of inflammatory and radiological biomarkers can predict HE with a satisfactory performance.