MEDICO-LEGAL APPLICATIONS OF FRACTURE HEMATOMA: REVIEW.

This review aimed to elucidate the critical role of fracture hematoma in forensic medicine, with a specific focus on its utility in differentiating antemortem from postmortem fractures. The study seeks to provide a comprehensive synthesis of current knowledge on the subject, highlighting the biological and medico-legal implications of fracture hematoma analysis in forensic investigations. A systematic review of literature was conducted, encompassing various scientific databases including PubMed, Scopus, and Web of Science, focusing on studies published from 2000 to 2024. The search employed keywords such as "fracture hematoma," "antemortem fractures," "perimortem fractures" and "postmortem fractures," among others, to explore relevant data. Selected studies were scrutinized based on their relevance, the presence of substantial data on fracture hematoma, and their contribution to forensic analysis. The review underscores the significance of fracture hematoma as an indicator of antemortem injuries, revealing that active blood circulation at the time of injury facilitates hematoma formation. Detailed analyses within the selected studies illustrate the interplay of cellular and molecular dynamics within fracture hematomas, emphasizing the roles of cytokines, particularly IL-6, and cellular constituents in the healing process. Fracture hematoma analysis emerges as a vital forensic tool in establishing the vitality of bone fractures, enhancing the accuracy of forensic assessments. However, the review also acknowledges the challenges posed by individual healing variability and postmortem changes, suggesting a need for further research to refine the interpretative frameworks used in forensic hematoma analysis.

[Spontaneous retroperitoneal hematoma]. / Spontaan retroperitoneaal hematoom.

Spontaneous retroperitoneal hematoma refers to bleeding of the retroperitoneal space without prior trauma or iatrogenic injury. Its diagnosis is often delayed due to a nonspecific clinical presentation. This case-series presents three patients with spontaneous retroperitoneal bleeding. Patient A presented with a spontaneous bleeding around the right iliopsoas muscle due to antiplatelet medication and was managed conservatively. Patient B had a spontaneous arterial bleeding near the right kidney, subsequently determined to be associated with a pheochromocytoma. Endovascular treatment successfully stopped the bleeding. The pheochromocytoma was resected during follow-up. Patient C had a spontaneous rupture of the left iliac vein with a concomitant deep vein thrombosis. She underwent emergent laparotomy, but unfortunately did not survive. This case-series emphasize the diverse presentation, varied causes, and different treatment strategies for spontaneous retroperitoneal hematoma. Timely diagnosis is hard, but crucial to enable an individualized treatment.

Unusual case of retroperitoneal hematoma and duodenal ulcerative bleeding after nephrectomy: Case report.

RATIONALE: Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy. PATIENT CONCERNS: A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection. DIAGNOSES: The patient was diagnosed and confirmed as high-grade urothelial carcinoma. INTERVENTIONS: After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum. OUTCOMES: The patient died on day 15 after surgery. LESSONS: Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.

[A man with fluctuating swelling while coughing]. / Een man die de longen uit z'n lijf hoest.

A 66-year-old man presented to the general practitioner several times with persistent coughing, haematoma formation and swelling fluctuating in size during coughing. An CT scan showed a widened seventh intercostal space based on a rupture of the intercostal muscles with a herniation of part of the left lower lobe.

Extraplaque blood withdrawal stenting: A miraculous cure for subintimal hematoma.

We report the Extraplaque Blood Withdrawal stenting technique to treat chronic total occlusion percutaneous coronary intervention (CTO PCI)-induced extraplaque hematoma.

A Rare Case of Page Kidney in a Young Man with Flank Pain.

BACKGROUND: Page kidney is a rare condition in which an external compression of the kidney as a result of a hematoma or mass causes renal ischemia and hypertension. In a patient with flank pain, elevated blood pressure, and recent trauma, this condition should be considered. Since this condition was first described in 1939, more than 100 case reports have surfaced. CASE REPORT: We describe the case of a 26-year-old man who presented to the Emergency Department with flank pain, vomiting, and elevated blood pressure. A computed tomography scan of the abdomen and pelvis confirmed the presence of a perinephric hematoma, and the interventional radiology team was consulted to resolve the Page kidney. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptoms seen in Page kidney may be similar to other more common diagnoses encountered in the emergency department. It is important to maintain a high suspicion and order imaging studies as needed, especially in the setting of trauma, or a recent procedure in the vicinity of the renal parenchyma.

[Comparison of planimetric CT­based volumetry with simplified models for determining the size of intrapelvic hematomas due to pelvic fractures in emergency room diagnostics]. / Vergleich von planimetrisch CT­gestützter Volumetrie mit vereinfachten Modellen zur Größenbestimmung intrapelviner Hämatome bei Beckenfrakturen im Rahmen der Schockraumdiagnostik.

BACKGROUND: Bleeding in the pelvis can lead to a circulatory problem. The widely used whole-body computed tomography (WBCT) scan in the context of treatment in the trauma resuscitation unit (TRU) can give an idea of the source of bleeding (arterial vs. venous/osseous); however, the volume determination of an intrapelvic hematoma by volumetric planimetry cannot be used for a quick estimation of the blood loss. Simplified measurement techniques using geometric models should be used to estimate the extent of bleeding complications. OBJECTIVE: To determine whether simplified geometric models can be used to quickly and reliably determine intrapelvic hematoma volume in fractures type Tile B/C during emergency room diagnostics or whether the time-consuming planimetric method must always be used. MATERIAL AND METHODS: Retrospectively, 42 intrapelvic hemorrhages after pelvic fractures Tile B + C (n = 8:B, 34:C) at two trauma centers in Germany were selected (66% men, 33% women; mean age 42 ± 20 years) and the CT scans obtained during the initial trauma scan were analyzed in more detail. The CT datasets of the included patients with 1-5 mm slice thickness were available for analysis. By area labelling (ROIs) of the hemorrhage areas in the individual slice images, the volume was calculated by CT volumetrically. Comparatively, volumes were calculated using simplified geometric figures (cuboid, ellipsoid, Kothari). A correction factor was determined by calculating the deviation of the volumes of the geometric models from the planimetrically determined hematoma size. RESULTS AND DISCUSSION: The median planimetric bleeding volume in the total collective was 1710 ml (10-7152 ml). Relevant pelvic bleeding with a total volume > 100 ml existed in 25 patients. In 42.86% the volume was overestimated in the cuboid model and in 13 cases (30.95%) there was a significant underestimation to the planimetrically measured volume. Thus, we excluded this volume model. In the models ellipsoid and measuring method according to Kothari, an approximation to the planimetrically determined volume could be achieved with a correction factor calculated via a multiple linear regression analysis. The time-saving and approximate quantification of the hematoma volume using a modified ellipsoidal calculation according to Kothari makes it possible to assess the extent of bleeding in the pelvis after trauma if there are signs of a C-problem. This measurement method, as a simple reproducible metric, could be embedded in trauma resuscitation units (TRU) in the future.

Diagnostic potential of soluble ST2 and D-dimer for Stanford Type B aortic dissection and intramural aortic hematoma.

OBJECTIVE: Type B aortic dissection (TBAD) and intramural aortic hematoma (IMH) are common manifestations of Acute Aortic Syndrome (AAS), exhibiting overlapping clinical features. The timely and accurate diagnosis and differentiation between TBAD and IMH are critical for appropriate management. Tumorigenicity 2 (sST2) and D-dimer have been shown to elevate levels in both TBAD and IMH, making them valuable as "rule-out" markers. Hence, we aimed to assess the diagnostic utility of sST2 and D-dimer in distinguishing TBAD from IMH. METHODS: In this retrospective study, we analyzed serum levels of sST2 and D-dimer in 182 AAS patients, comprising 90 TBAD cases, 92 IMH cases, and 90 non-AAS cases. Serial measurements were taken at 1 h, 6 h, 12 h, 24 h, and 72 h post-admission. Comparative analyses were conducted between TBAD and non-AAS cases, IMH and non-AAS cases, and TBAD and IMH cases. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic accuracy of sST2 and D-dimer in identifying TBAD or IMH cases. RESULTS: Both TBAD and IMH patients displayed elevated levels of sST2 and D-dimer compared to non-AAS cases. Notably, sST2 levels were significantly higher in TBAD patients than in IMH patients, whereas D-dimer levels exhibited moderate differences. TBAD patients tended to exhibit elevated levels of either sST2 or D-dimer, with a modest correlation between the two (Pearson correlation coefficient = 0.3614). In contrast, IMH patients showed elevations in both markers, with a positive correlation between them (Pearson correlation coefficient = 0.6814). The ROC analysis revealed that both sST2 (AUC, 0.657; 95 % CI, 0.552-0.753; cutoff value, 27.54 ng/ml) and D-dimer (AUC, 0.695; 95 % CI, 0.591-0.787, cutoff value, 1.215 ng/ml) demonstrated favorable diagnostic performance for TBAD. sST2 exhibited a sensitivity of 80.92 % and a specificity of 75.00 %, while D-dimer showed a sensitivity of 80.92 % and a specificity of 75.00 %. For the diagnosis of IMH, the combined assessment of sST2 and D-dimer (AUC, 0.674; 95 % CI, 0.599-0.768; sensitivity, 69.20 %; specificity, 80.00 %) proved effective. CONCLUSIONS: Our results indicate that both sST2 and D-dimer show diagnostic potential for TBAD. Elevated levels of either serve as an indicator of TBAD onset. However, concurrent elevation of both markers seems to be indicative of IMH. The combination of increased sST2 and D-dimer levels demonstrates strong diagnostic performance in identifying IMH cases.

The impact of time to evacuation on outcomes in endoscopic surgery for supratentorial spontaneous intracerebral hemorrhage: a single-center retrospective study.

Supratentorial spontaneous intracerebral hemorrhage (SICH) can be treated with endoscopic surgery, but the optimal timing remains uncertain. We retrospectively analyzed data from 46 patients who underwent endoscopic surgery for supratentorial SICH. We examined the relationship between time to evacuation and functional outcome at 3 months, adjusting for prognostic factors. Surgical outcomes and complications were compared between patients with early (≤ 12 h) or late (> 12 h) evacuation. Median time to evacuation was 12 h, and the rate of unfavorable outcome (modified Rankin Scale > 3 at 3 months) was 32.6%. Longer time to evacuation was independently associated with unfavorable outcome (odds ratio per hour delay: 1.26). Late evacuation carried a 7.25-fold higher risk of unfavorable outcome compared to early evacuation. This association held across subgroups based on hematoma volume, location, and intraventricular extension (P for interaction > 0.05). Patients with late evacuation had fewer spot signs (24% vs. 4.8%, P = 0.035) and markers of hemorrhagic expansion (36% vs. 9.5%, P = 0.018), longer neurosurgical intensive care unit (NSICU) stay (3.2 vs. 1.9 days, P = 0.011) and hospital stay (15.7 vs. 11.9 days, P = 0.014), and higher 30-day mortality (28.6 vs. 4%, P = 0.036) and complication rates (57.1% vs. 28.0%, P = 0.023). This study suggests a potential association between early endoscopic evacuation of supratentorial SICH and improved functional outcomes, lower 30-day mortality and reduced complications. The need for timely intervention in managing supratentorial SICH is highlighted, yet further validation through multi-center prospective studies is essential to substantiate these findings and provide a higher level of evidence.

Large supralevator haematoma: a dilemma in diagnosis and management.

This is a case of postpartum haemorrhage following vaginal delivery of a primigravida in her late 20s resulting from a supralevator haematoma. She delivered in a low-resource hospital setting, with a late diagnosis of severe pre-eclampsia and haemolysis, elevated liver enzymes and low platelet count (HELLP), subsequently developed traumatic postpartum haemorrhage and vaginal haematoma, and was referred to our hospital for further management. She was constantly monitored, and serial ultrasonography revealed an expanding paravaginal haematoma. CT, 4 hours after admission, showed a large ill-defined collection with hyperdense areas of blood attenuation measuring ~8.0×6.2×12.2 cm in toto in the vaginal canal and right paravaginal region with supralevator extension, abutting the rectum posteriorly. The expanding haematoma caused gradual hypovolaemic shock, and hence, she was taken up for vaginal evacuation of supralevator haematoma with drainage tube insertion under ultrasound guidance. She received multiple blood product transfusion. Drain tube was removed on postoperative day 3. Follow-up scan was done and resolving haematoma noted. The patient was discharged on postoperative day 5 in a stable condition. She was followed up in outpatient department, and there was complete resolution of haematoma by 4 weeks.

How to predict the outcome of primary brainstem hemorrhage: Six-year results of a single-center retrospective analysis.

Primary brainstem hemorrhage (PBH) is one of the most fatal intracranial hemorrhages, evaluating the prognosis in the early stage is vital for appropriate therapeutic planning. Our study aimed to identify risk factors for 30-day mortality and 90-day functional recovery of PBH. Data from 63 patients with PBH admitted to Beijing Chaoyang Hospital between 2016 and 2022 were retrieved for this study. We grouped the patients according to 30-day survival or 90-day functional recovery. Independent risk factors of 30-day mortality and 90-day functional recovery were identified by univariate and multivariate logistic regression analyses. 31 patients (49.2%) died within 30 days and 22 patients (34.9%) achieved better functional recovery. By multivariate analysis, Glasgow coma scale <9 on admission and tachycardia were significantly associated with 30-day mortality, while the hematoma volume >5 mL was an independent risk factor for 90-day functional recovery. Initial level of consciousness, tachycardia, massive hematoma were risk factors for prognosis, which must be seriously evaluated for therapeutic planning.

The HELLP syndrome: clinical issues and surgical management. A Case Experience.

AIM: This study aims to challenge the current know-how in patients with spontaneous rupture of a liver hematoma, to differentiate amongst patients requiring such specific surgical therapy and avoiding mistakes during surgical operations, in order to terminate pregnancy with beneficial effects on the mother and fetus. MATERIALS AND METHODS: In a emergency scenario we admitted a 37-year-old woman at 35+4 weeks of gestation for emergency cesarean section after the onset of right hypochondrium pain. A diagnosis of hemoperitoneum and severe preeclampsia with liver and splenic bleeding was done and managed with packing of hepatic and splenic hematomas and according to her haemo-dynamic clinical conditions, done in different time. RESULTS: A diagnosis of hemoperitoneum and severe pre-eclampsia with liver and splenic bleeding was done and managed it with 3 xypho-pubic-laparatomy in different time with haemostatic packing. DISCUSSION: In this case report, the patient underwent an emergency caesarean section and was managed with packing of hepatic and splenic hematomas and according to her haemodynamic clinical conditions was operated in different time. The choice of laparotomy and hepatic packing has proved to be a viable option in patients with unstable vital signs and is feasible even in limited resource settings. CONCLUSION: Short interval between diagnosis and management may enhance the feto-maternal survival rate and prevent further morbidity or mortality. The choice of laparotomy and hepatic packing has proved to be a viable option in patients with unstable vital signs and is feasible even in limited resource settings. KEY WORDS: HELLP syndrome, Liver hematoma rupture, Packing.

[Acute coronary syndrome provoked by a coronary intramural hematoma]. / Hematoma intramural coronario como causa de síndrome coronario agudo.

Background: Intramural coronary hematoma (ICH) is an unusual cause of acute coronary syndrome, and it represents a diagnostic challenge, especially in young patients in which it is not considered among the differential causes of acute myocardial ischemia. Clinical case: 40-year-old female, with type 2 diabetes and no other cardiovascular risk factors, who assisted to the Emergency Room with chest pain. In her first evaluation, electrocardiographic abnormalities, and troponin I elevation were found. A cardiac catheterization was performed, in which a proximal obstruction of the left anterior descending artery was observed, and then an optical coherence tomography (OCT) confirmed the presence of an ICH without a dissection flap. A stent was implanted in the obstruction area, with adequate angiographic outcome. The patient had a satisfactory evolution and was discharged to home without evidence of systolic dysfunction and is free of cardiovascular symptoms at 6-month follow-up. Conclusions: ICH must be considered within the differential diagnosis of acute myocardial ischemia in young patients, especially females. Intravascular image diagnosis is essential for the adequate diagnosis and treatment. Treatment must be individualized considering the extent of ischemia.

Introducción: el hematoma intramural coronario (HIC) es una causa poco frecuente de síndrome isquémico coronario agudo y representa un reto diagnóstico, en especial en pacientes jóvenes en los que puede llegar a no ser contemplado dentro de las causas de isquemia cardiaca no ateroesclerótica. Caso clínico: mujer de 40 años, con diabetes tipo 2 y sin otro factor de riesgo cardiovascular, quien acudió al Servicio de Urgencias manifestando dolor torácico. En su evaluación inicial se encontraron alteraciones en el electrocardiograma y elevación de troponina I. Se decidió la realización de coronariografía donde se observó lesión severa de la arteria descendente anterior. El estudio fue complementado con una tomografía de coherencia óptica intracoronaria, la cual confirmó la presencia de HIC sin disección, por lo que se decidió implantar un stent en el segmento arterial afectado con resultado angiográfico exitoso. La convalecencia posterior evolucionó sin complicaciones, lo que posibilitó su egreso a domicilio sin disfunción sistólica en el ecocardiograma y con seguimiento sin eventualidades a los 6 meses. Conclusiones: el HIC es una entidad que debe ser considerada como una causa posible de isquemia miocárdica aguda en pacientes jóvenes y que requiere de la complementación diagnóstica con estudios de imagen intravascular. Su tratamiento debe ser individualizado en el contexto de la extensión de la isquemia.

Massive Pelvic Hematoma After Atrial Septal Defect Closure Via Femoral Vein Cannulation.

We report a rare case of pelvic hematoma caused by iatrogenic external iliac artery hemorrhage following transfemoral venipuncture for atrial septal defect closure. By means of urgent femoral arteriography, bleeding in the branches of the external iliac artery was confirmed and occlusion of the bleeding branches was performed, thus avoiding the need for surgical laparotomy. The patient recovered well, and the hematoma significantly was reduced 2 months after surgery.

Inflammatory score predicts early hematoma expansion and poor outcomes in patients with intracerebral hemorrhage.

BACKGROUND: This study aimed to develop a prediction score named inflammatory score based on proper integration of several inflammatory markers and investigate whether it was associated with hematoma expansion and poor outcomes in patients with intracerebral hemorrhage (ICH). METHODS: This study involved a consecutive series of spontaneous ICH patients of two cohorts admitted within 24 hours after symptom onset. Inflammatory score (0-9) was developed with the combination of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, systemic immune-inflammation index, lactate dehydrogenase, and C-reactive protein. The authors investigated the association between inflammatory score and hematoma expansion and poor outcomes by using univariate and multivariate logistic regression analyses. The optimal cutoff point of inflammatory score was determined by receiver operating characteristic analysis in the development cohort and then validated. RESULTS: A total of 301 and 154 ICH patients were enrolled in the development and validation cohorts. Inflammatory score was significantly higher in patients with hematoma expansion and poor outcomes. The multivariate logistic regression analysis revealed inflammatory score was independently associated with hematoma expansion, secondary neurological deterioration within 48 hours, 30-day mortality, and 3-month poor modified Rankin scale (4-6). The diagnostic accuracy of inflammatory score exhibited by area under the curve showed numerically or statistically higher than most of the individual indicators. Moreover, inflammatory score greater than or equal to 5 was selected as the optimal cutoff point, which was further prospectively validated with high diagnostic accuracy. CONCLUSIONS: The inflammatory score is a reliable predictor for early hematoma expansion and short-term and long-term poor outcomes with good diagnostic accuracies in ICH patients.

Achenbach Syndrome in Primary Care: A Case Report.

Paroxysmal hematoma of the fingers, or Achenbach syndrome, is a rare vascular disorder of benign course and unknown etiology. The clinical manifestations are sudden onset, paroxysmal spontaneous subcutaneous hematomas, and edema and pain in the fingers and hands. The clinical course is self-limited and does not leave permanent sequela. The diagnosis is clinical, and complementary studies are often unnecessary. We present the clinical case of a 69-year-old woman diagnosed with Achenbach syndrome in a primary care center in Colombia.

Difference of mean Hounsfield units (dHU) between follow-up and initial noncontrast CT scan predicts 90-day poor outcome in spontaneous supratentorial acute intracerebral hemorrhage with deep convolutional neural networks.

OBJECTIVES: This study aimed to investigate the usefulness of a new non-contrast CT scan (NCCT) sign called the dHU, which represented the difference in mean Hounsfield unit values between follow-up and the initial NCCT for predicting 90-day poor functional outcomes in acute supratentorial spontaneous intracerebral hemorrhage(sICH) using deep convolutional neural networks. METHODS: A total of 377 consecutive patients with sICH from center 1 and 91 patients from center 2 (external validation set) were included. A receiver operating characteristic (ROC) analysis was performed to determine the critical value of dHU for predicting poor outcome at 90 days. Modified Rankin score (mRS) >3 or >2 was defined as the primary and secondary poor outcome, respectively. Two multivariate models were developed to test whether dHU was an independent predictor of the two unfavorable functional outcomes. RESULTS: The ROC analysis showed that a dHU >2.5 was a critical value to predict the poor outcomes (mRS >3) in sICH. The sensitivity, specificity, and accuracy of dHU >2.5 for poor outcome prediction were 37.5%, 86.0%, and 70.6%, respectively. In multivariate models developed after adjusting for all elements of the ICH score and hematoma expansion, dHU >2.5 was an independent predictor of both primary and secondary poor outcomes (OR = 2.61, 95% CI [1.32,5.13], P = 0.006; OR = 2.63, 95% CI [1.36,5.10], P = 0.004, respectively). After adjustment for all possible significant predictors (p < 0.05) by univariate analysis, dHU >2.5 had a positive association with primary and secondary poor outcomes (OR = 3.25, 95% CI [1.52,6.98], P = 0.002; OR = 3.42, 95% CI [1.64,7.15], P = 0.001). CONCLUSIONS: The dHU of hematoma based on serial CT scans is independently associated with poor outcomes after acute sICH, which may help predict clinical evolution and guide therapy for sICH patients.