Warfarin Woes: A Rare Case of Hemoperitoneum with Intramural Small Bowel Hematoma.

BACKGROUND Small bowel hematoma is a rare yet clinically significant condition characterized by the accumulation of blood within the mucosa and submucosa layers of the small intestine wall. It can lead to complications such as bowel obstruction, ischemia, perforation, and even hemorrhagic shock. The etiology of intramural small bowel hematoma is diverse, encompassing factors such as anticoagulant therapy, coagulopathies, vascular disorders, trauma, and underlying systemic conditions. CASE REPORT We present the case of a 67-year-old man with a history of aortic valve replacement who presented with intense abdominal pain. Physical examination revealed generalized abdominal tenderness and black stools upon rectal examination. Laboratory tests indicated coagulopathy with a prolonged thrombin time. A computed tomography scan confirmed the presence of an intramural small bowel hematoma and hemoperitoneum. The patient's condition significantly improved within 48 h under conservative management, including nasogastric tube insertion, continuous monitoring of gastric aspirate, nil per os status, intravenous fluids, and analgesics. Warfarin was temporarily stopped, and fresh frozen plasma was administered for anticoagulation reversal. Heparin infusion was initiated once the INR became within the therapeutic level. CONCLUSIONS The occurrence of spontaneous intramural small bowel hematoma, although rare, demands rapid diagnosis and prompt, well-coordinated management. This case underscores the pivotal role of multidisciplinary collaboration in providing a comprehensive assessment and a tailored approach to treatment. While conservative measures, including careful monitoring and supportive care, have demonstrated favorable outcomes, the consideration of surgical intervention remains crucial, particularly in severe cases.

Successful Transcatheter Arterial Embolization of Abdominal Wall Hematoma from the Left Deep Circumflex Iliac Artery after Abdominal Paracentesis in a Patient with Liver Cirrhosis: Case Report and Literature Review.

The occurrence of an abdominal wall hematoma caused by abdominal paracentesis in patients with liver cirrhosis is rare. This paper presents a case of an abdominal wall hematoma caused by abdominal paracentesis in a 67-year-old woman with liver cirrhosis with a review of the relevant literature. Two days prior, the patient underwent abdominal paracentesis for symptom relief for refractory ascites at a local clinic. Upon admission, a physical examination revealed purpuric patches with swelling and mild tenderness in the left lower quadrant of the abdominal wall. Abdominal computed tomography revealed advanced liver cirrhosis with splenomegaly, tortuous dilatation of the para-umbilical vein, a large volume of ascites, and a large acute hematoma at the left lower quadrant of the abdominal wall. An external iliac artery angiogram showed the extravasation of contrast media from the left deep circumflex iliac artery. Embolization of the target arterial branches using N-butyl-2-cyanoacrylate was then performed, and the bleeding was stopped. The final diagnosis was an abdominal wall hematoma from the left deep circumflex iliac artery after abdominal paracentesis in a patient with liver cirrhosis.

Evaluation of intramural hematoma: a novel use of 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging.

BACKGROUND: Aortic intramural hematoma (IMH) is one of the typical entities of acute aortic syndrome and probably accounts for 5-25% of all cases. The ulcer-like projections (ULP), which are described as a focal, blood-filled pouch protruding into the hematoma of the aortic wall, are regarded as one of the high-risk imaging features of IMH and may cause initial medical treatment failure and death. CASE PRESENTATION: We present a case report of an acute type B IMH patient with impaired renal function and newly developed ULP in the acute phase. The 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (18F-FDG PET/MR) was performed to evaluate the condition of aortic hematoma. The 18F-FDG focal uptake along the aortic wall of the hematoma was normal compared to the background (SUVmax 2.17; SUVSVC 1.6; TBR 1.35). We considered the IMH stable in such cases and opted for medical treatment and watchful observation. Six months after discharge, the patient's recovery was satisfactory, and aortic remodeling was ideal. CONCLUSIONS: The 18F-FDG PET/MR is a novel tool to evaluate the risk of IMH patients and thus provides information for therapy selection.

Wunderlich syndrome as a rare complication of polyarteritis nodosa: a case report.

Spontaneous subcapsular and perirenal hemorrhage, known as Wunderlich syndrome (WS), is a rare clinical manifestation of polyarteritis nodosa (PAN). We report a case of a 48-year-old male with a history of recurrent episodes of leg muscle tenderness and dysesthesia, bilateral flank pain, painful nodular skin lesions in the lower limbs, weight loss, and difficult-to-control arterial hypertension. The abdominopelvic computed tomography angiography showed a large left perirenal hematoma, leading to the patient's admission to the intensive care unit. After the exclusion of infectious or neoplastic foci, the patient was diagnosed with PAN and started intravenous methylprednisolone pulses with a good response. Since WS is a rare initial clinical manifestation of PAN, an early diagnosis and aggressive treatment will significantly improve clinical outcomes.

Nephrotic syndrome with rectus sheath hematoma: a case report.

BACKGROUND: Rectus sheath hematoma is a rare presentation often associated with abdominal trauma and anticoagulant therapy. Here, we present a patient with severe rectus sheath hematoma accompanied by nephrotic syndrome who achieved significant clinical improvement without the need for invasive treatment. CASE PRESENTATION: A 72-year-old Japanese woman was referred to our hospital for the treatment of nephrotic syndrome. She was receiving steroid and anticoagulant therapy. Then she had abdominal pain and she was diagnosed with spontaneous rectus sheath hematoma by abdominal computed tomography. She received transfusion and was managed conservatively with bed rest, which led to improvement in abdominal pain. CONCLUSION: Despite the absence of trauma history, rectus sheath hematoma should be considered in patients at risk of vascular failure, including those receiving anticoagulant or steroid therapy, those who are elderly, and those with nephrotic syndrome.

A large post-stenting intramural hematoma in the left anterior descending artery caused by a small intimal calcium spur; should we respect the calcium shape?

Coronary heavy calcification (HC) poses a sturdy challenge to percutaneous coronary intervention (PCI). Scores considering calcification length, thickness, or circumferential extent, are widely accepted to dictate upfront calcium modification to improve PCI outcomes. Although often marginalized, calcification shape (morphology) may require consideration during procedure planning in selected cases. This case demonstrates how a focal but spur-shaped calcification led to a massive proximal left anterior descending (LAD) dissecting intramural hematoma.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]. / Spontane retroperitoneale und Rektusscheidenhämatome und ihre interventionelle Therapie: ein Review.

BACKGROUND: Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy. METHOD: Analysis, summary, and discussion of published review articles and expert recommendations. RESULTS: The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance. CONCLUSION: Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome. KEY POINTS: · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates.. CITATION FORMAT: · Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Novel treatment of intracerebral hemorrhage with mechanical tissue resuscitation.

OBJECTIVE: The previous laboratory and clinical experience of the authors had demonstrated that application of controlled subatmospheric pressure directly to injured soft tissue can result in increased survival of compromised tissues. Mechanical tissue resuscitation (MTR) is a new concept evolving from these discoveries. The authors' recent studies have demonstrated that traumatic brain injury tissue can also be salvaged. The aim of this study was to examine the effects of MTR application to injuries from intracerebral hemorrhages (ICHs) in a swine model. METHODS: The ICHs in swine were simulated by infusion of autologous artery blood into the right frontal lobe. A specially designed silicone manifold device was introduced directly into the hematoma. Continuous negative pressure at -50 mm Hg was applied through this device. T2- and T2*-weighted MRI, histological H&E staining, and immunostaining were examined. RESULTS: After 1 week of treatment, MTR significantly decreased gross hematoma volume by more than 60%, from 472.62 ± 230.19 mm3 in the nontreated group to 171.25 ± 75.38 mm3 in the MTR-treated group (p < 0.05). Total hypointense volumes measured on T2*-weighted MR images decreased from 791.99 ± 360.47 mm3 in the nontreated group to 371.16 ± 105.75 mm3 in the MTR-treated group (p < 0.05). The hyperintense area on the T2-weighted MR image decreased significantly from 2656.23 ± 426.26 mm3 in the nontreated group to 1816.66 ± 525.26 mm3 in the MTR-treated group (p < 0.05). When ICHs were treated with MTR for 2 weeks, the gross hematomas were reduced by 94%, from 112.23 ± 66.21 mm3 in the nontreated group to 6.12 ± 10.99 mm3 in the MTR-treated group (p = 0.003). MTR significantly decreased the total necrotic tissue volume in H&E staining from 120.42 ± 48.35 mm3 in the nontreated group to 60.94 ± 38.99 mm3 in the MTR-treated group (p < 0.05). The total hypointense volumes on T2*-weighted MR images were significantly reduced, from 385.54 ± 93.85 mm3 in the nontreated group to 220.54 ± 104.28 mm3 in the MTR-treated group (p < 0.05), while their mean T2 hyperintense volume decreased significantly from 2192.83 ± 728.27 mm3 in the nontreated group to 1366.97 ± 463.36 mm3 in the MTR-treated group (p < 0.05). Histology revealed that the capillary diameter in the reactive tissue rim adjacent to the hematoma increased in both the 1- and 2-week MTR-treated groups. Both von Willebrand factor and CD31 signals were detectable in endothelial cells within the hematoma cavity of both MTR-treated groups. CONCLUSIONS: This study demonstrates that local continuous application of controlled subatmospheric pressure to an ICH can safely remove more than half of a clot in 1 week and more than 90% in 2 weeks.

Femoral nerve palsy as a complication due to COVID-19 coagulopathy and iliopsoas muscle hematoma - case report.

BACKGROUND: COVID-19 (Coronavirus disease 2019) pandemic is the main medical problem around the world from the end of 2019. We found until now many symptoms of this disease, but one of the most problematic was thrombosis. Wide recommendation on COVID-19 treatment was pharmacological thromboprophylaxis. In some papers we found that clinicians face the problem of bleeding in those patients. Is still unknown that coronavirus could led to the coagulopathy. CASE PRESENTATION: We described case report of patient who with COVID-19 disease present femoral nerve palsy caused by the iliopsoas hematoma. There were no deviations in coaguology parameters, patient got standard thromboprophylaxis, besides above probably COVID-19 was risk factor of hematoma formation. Non-operative treatment was applied, thrombophylaxis was discontinued. In the follow up in the radiological exam we saw reduction of the haematoma and patient report decrease of symptoms. CONCLUSIONS: We should assess individually patient with COVID-19 according to thrombosis risk factors. Probably we should be more careful in ordering thrombophylaxis medications in COVID-19 patients.

Giant thoracic hematoma post-transradial coronary angiography: a case report and review of the literature.

BACKGROUND: Although there are cardiac interventional procedures, certain transradial access complications might be life-threatening. CASE PRESENTATION: A 67-year-old male was admitted for coronary angiography due to chest tightness and shortness of breath on exertion. Hours after the right transradial access angiography, the patients complained the right side of chest pain. Emergent chest X-ray revealed a giant mass in the right chest. The right radial artery was reaccessed and subsequent arteriograms confirmed that the presence of a rupture of the branch of right internal mammary artery. Simultaneously, a microcoil was implanted to seal the perforation. The perforation caused a thoracic hematoma measuring 13.8 cm × 6.7 cm, along with a decrease in hemoglobin concentration from 14.1 g/dL to a minimum of 7.8 g/dL. Additionally, the drainage of the hematoma and red blood cells transfusion were carried out. Further, the patient underwent ascending aortic replacement, aortic valve replacement, mitral valve replacement, and thoracic hematoma removal. Postoperative echocardiography showed that the prosthetic valves were properly positioned and functioning normally. The patient recovered well after the surgery and remained event-free during the latest 14moth follow-up period. CONCLUSIONS: Vascular perforation and subsequent hematoma might occur due to guidewire maneuvering during transradial approach. Awareness of prevention, early recognition and management of access complications may help reduce the occurrence and severity of complications related to the transradial approach.

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.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT.

PURPOSE: This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated. MATERIALS AND METHODS: In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system. RESULTS: One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively. CONCLUSIONS: In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Electro-nape-acupuncture regulates the differentiation of microglia through PD-1/PD-L1 reducing secondary brain injury in acute phase intracerebral hemorrhage rats.

INTRODUCTION: This study aimed to investigate the effect of electro-nape-acupuncture (ENA) on the differentiation of microglia and the secondary brain injury in rats with acute-phase intracerebral hemorrhage (ICH) through the programmed cell death protein-1/ligand-1 (PD-1/PD-L1) pathway. METHODS: A total of 27 male Sprague-Dawley rats were randomly divided into three groups: sham group, ICH group, and ENA group. The autologous blood infusion intracerebral hemorrhage model was used to study the effects of ENA by administering electroacupuncture at GB20 (Fengchi) and Jiaji (EX-B2) acupoints on 24 h after the modeling, once per day for 3 days. The neurological function damage, hematoma lesion, and inflammatory cell infiltration were measured by the beam walking test and hematoxylin-eosin staining. The expression of PD-1, PD-L1, CD86, CD206, and related cytokines around the hematoma was measured by western blot, quantitative reverse transcription polymerase chain reaction, and immunofluorescence. RESULTS: The ICH group had significant neurological deficits (p < .001), hematoma lesions, and inflammatory cell infiltration. The levels of CD86 protein, inflammatory factors tumor necrosis factors (TNF)-α, interleukin (IL)-1ß, and IL-6 were increased (p < .001), while CD206 protein was reduced (p < .01), and the number of CD86+ /CD11b+ cells was also increased (p < .001) compared to the sham group. However, after ENA intervention, there was a significant reduction in neurological function damage (p < .05), infiltration of inflammatory cells, and the expression levels of CD86+ /CD11b+ cells (p < .05), resulting in the increased expression of PD-1 protein and differentiation of M2 phenotype significantly (p < .001). CONCLUSION: The study concludes that ENA could reduce neurological function damage, inhibit the expression of pro-inflammatory cytokines, and improve the infiltration of inflammatory cells to improve secondary brain injury in acute-phase intracerebral hemorrhage rats. These effects could be related to the increased expression of PD-1 around the lesion, promoting the differentiation of microglia from M1 to M2 phenotype.

Association Between Hematoma Expansion Severity and Outcome and Its Interaction With Baseline Intracerebral Hemorrhage Volume.

BACKGROUND AND OBJECTIVES: Hematoma expansion (HE) is a major determinant of neurologic deterioration and poor outcome in intracerebral hemorrhage (ICH) and represents an appealing therapeutic target. We analyzed the prognostic effect of different degrees of HE. METHODS: This was a retrospective analysis of patients with ICH admitted at 8 academic institutions in Italy, Germany, Canada, China, and the United States. All patients underwent baseline and follow-up imaging for HE assessment. Relative HE (rHE) was classified as follows: none (<0%), mild (0%-33%), moderate (33.1%-66%), and severe (>66%). Absolute HE (aHE) was classified as none (<0 mL), mild (0-6.0 mL), moderate (6.1-12.5 mL), and severe (>12.5 mL). Predictors of poor functional outcome (90 days modified Rankin Scale 4-6) were explored with logistic regression. RESULTS: We included 2,163 patients, of whom 1,211 (56.0%) had poor outcome. The occurrence of severe aHE or rHE was more common in patients with unfavorable outcome (13.9% vs 6.5%, p < 0.001 and 18.3% vs 7.2%, p < 0.001 respectively). This association was confirmed in logistic regression (rHE odds ratio [OR] 1.98, 95% CI 1.38-2.82, p < 0.001; aHE OR 1.73, 95% CI 1.23-2.45, p = 0.002) while there was no association between mild or moderate HE and poor outcome. The association between severe HE and poor outcome was significant only in patients with baseline ICH volume below 30 mL. DISCUSSION: The strongest association between HE and outcome was observed in patients with smaller initial volume experiencing severe HE. These findings may inform clinical trial design and guide clinicians in selecting patients for antiexpansion therapies.

Severe Spontaneous Hematomas in Patients Hospitalized with COVID-19.

Objective: To describe the epidemiological, clinical, laboratory, and radiological characteristics, medical treatment, and outcomes of a case series of severe spontaneous hematoma in COVID-19. Material and Methods. This retrospective study included patients hospitalized for COVID-19 who were diagnosed with severe spontaneous bleeding complications by following a standardized treatment protocol that included computed tomography angiography (CTA) from 1 March 2020 to 28 February 2022. The main outcomes were embolization and all-cause mortality. Baseline variables were analyzed for their association with mortality using bivariable logistic regression, and results were expressed as odds ratios (OR) and 95% confidence intervals (CI). Results: In total, 2450 adults were hospitalized for COVID-19 in our center during the study period. 20 patients presented severe and spontaneous intramuscular bleeding (8.1 per 1000 COVID-19 admission vs. 0.47 per 1000 non-COVID-19 admissions, p < 0.001); their median age was 68.5 years (interquartile range (IQR) 63, 80), they had high comorbidity (median Charlson comorbidity index 4.5), and 95% were receiving high doses of heparin. The median interval from COVID-19 symptoms to bleeding was 17 days (IQR 13, 24), and 70% reported cough as a previous symptom. Hypovolemic shock, hypotension, and abdominal pain were the most frequent symptoms of the hematoma. All presented decreased hemoglobin, and 95% required transfusion. Intramuscular hematoma occurred most frequently in the rectus sheath, iliopsoas compartment, and femoral-iliac compartment. All patients underwent embolization; mortality was 45%. We did not identify risk factors associated with an increased risk of death. Conclusion: Although severe bleeding is an uncommon complication of COVID-19, its prevalence is higher than in inpatients without COVID-19, it usually needs embolization, and it is associated with high mortality.