Hematoma Size Research Articles

Clinical and radiological risk factors for poor outcomes in patients with spontaneous muscle hematomas

PurposeSpontaneous muscle hematomas (SMH) are frequently seen in the Emergency Department (ED), particularly as a complication of anticoagulation treatments. To date, there are no standard guidelines for the management of this condition in the ED.This work aims to identify clinical-radiological parameters of SMH at risk of poor outcomes. MethodThis is a retrospective, observational cohort study conducted in an urban teaching hospital from 2016 to 2019. A multivariate logistic regression analysis was performed to identify parameters independently associated with an adverse outcome defined as the need for treatment (blood products, TAE, surgery) or hospitalization. The parameters analyzed were hematoma size, anticoagulation therapy, age, and the Charlson Comorbidity Index (CCI). ROC analysis was performed to identify the best cut-off hematoma size value to predict poor outcomes. ResultsOur study enrolled 231 patients aged between 18 and 96 years, with a mean age of 67 years. In our population, 125 patients (54.1 % %) were on anticoagulant therapy.Multivariate analysis showed that an SMH diameter > 5.5 cm was independently associated with poor outcome ((odds Ratio [95 % CI] 4,009 [1,786–9,001], p 0.001). Among clinical parameters, only advanced age was proved to be an independent predictor of adverse outcomes (odds Ratio [95 % CI] 1,035 [1,003–1,069], p = 0.033) ConclusionsOur data suggest that an SMH diameter greater than 5.5 cm on a CT scan and advanced age are predictors of poor outcomes. Surprisingly, anticoagulant therapy seems to play a minor role in the outcome of SMHs.

Impact of Local Forearm Heating on Pain Intensity and Hemorrhage in Patients Undergoing Radial Artery Cardiac Catheterization: A Pilot Study.

Radial artery cardiac catheterization is a common diagnostic and interventional procedure for cardiovascular conditions. Pain and hemorrhage at the access site can cause patient discomfort and complications. This pilot study investigates the potential of local forearm heating to reduce pain and hemorrhage in patients undergoing radial artery cardiac catheterization. We enrolled 100 patients scheduled for radial artery cardiac catheterization and randomly assigned them to the heating or control group. The heating group received local forearm heating before sheath removal, while the control group did not. Pain intensity was assessed with a visual analog scale, and hemorrhage was measured by assessing ecchymosis or hematoma size at the catheterization site. Hemodynamic parameters were also monitored. Statistical analysis compared outcomes between the groups. Patients who received local forearm heating had significantly lower pain intensity (4.15 ± 2.73) compared to the control group (5.84 ± 3.34) (P =.009). Hemodynamic parameters and the extent of hemorrhage at the catheterization site did not significantly differ between the heating and control groups (P >.05). No adverse effects related to forearm heating were reported. Local forearm heating is a promising intervention to reduce pain intensity without increasing hemorrhage or affecting hemodynamic parameters during radial artery cardiac catheterization. This simple, noninvasive approach has the potential to enhance patient comfort and safety post procedure.

Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study

IntroductionTraumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention.MethodA multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant.ResultThe incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732).Conclusion and recommendationThe incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.

Size of Splenic Subcapsular Hematoma Is Associated With Varying Outcomes of Nonoperative Management.

The presence of a splenic subcapsular hematoma (SCH) has been associated with higher rates of failure of nonoperative management (FNOM) in patients with blunt splenic injury (BSI), with rates up to 80%. We hypothesized that contemporary rates are lower. A retrospective review was conducted of patients admitted with BSI to a level I trauma center (2016-2021). Patients with SCH who had FNOM were compared to those who did not. There were 661 BSI patients, of which 102 (15.4%) had SCH. Among the SCH patients, 8 (7.8%) had FNOM. Failure of nonoperative management was higher in patients who had a SCH measuring 15mm or greater. To the best of our knowledge, this is the largest study to date examining the relationship between SCH and FNOM. The presence of a SCH alone is not associated with a high risk for FNOM contrary to previous literature. However, SCH thickness was larger in those who failed.

GPR39 Agonist TC-G 1008 Promoted Mitochondrial Biogenesis and Improved Antioxidative Capability via CREB/PGC-1α Pathway Following Intracerebral Hemorrhage in Mice.

Mitochondrial dysfunction and excessive reactive oxygen species production due to impaired mitochondrial biogenesis have been proven to exacerbate secondary brain injury after intracerebral hemorrhage (ICH). The G-protein-coupled receptor 39 (GPR39) agonist TC-G 1008 has been shown to exert anti-oxidative stress effect in acute hypoxic brain injury. Herein, our study aimed to investigate the potential effects of TC-G 1008 on neuronal mitochondrial biogenesis and antioxidative stress in a mouse model of ICH and explore the underlying mechanisms. A total of 335 male C57/BL6 mice were used to establish an autologous blood-induced ICH model. Three different dosages of TC-G 1008 were administered via oral gavage at 1h, 25h, and 49h post-ICH. The GPR39 siRNA and cAMP response element-binding protein (CREB) inhibitor 666-15 were administered via intracerebroventricular injection before ICH insult to explore the underlying mechanisms. Neurobehavioral function tests, Western blot, quantitative polymerase chain reaction, immunofluorescence staining, Fluoro-Jade C staining, TUNEL staining, dihydroethidium staining, transmission electron microscopy, and enzyme-linked immunosorbent assay were performed. Expression of endogenous GPR39 gradually increased in a time-dependent manner in the peri-hematoma tissues, peaking between 24 and 72h after ICH. Treatment with TC-G 1008 significantly attenuated brain edema, hematoma size, neuronal degeneration, and neuronal death, as well as improved neurobehavioral deficits at 72h after ICH. Moreover, TC-G 1008 upregulated the expression of mitochondrial biogenesis-related molecules, including PGC-1α, NRF1, TFAM, and mitochondrial DNA copy number, associated with antioxidative stress markers, such as Nrf2, HO-1, NQO1, SOD, CAT, and GSH-Px. Furthermore, treatment with TC-G 1008 preserved neuronal mitochondrial function and structure post-ICH. Mechanistically, the protective effects of TC-G 1008 on neuronal mitochondrial biogenesis and antioxidative stress were partially reversed by GPR39 siRNA or 666 -15. Our findings indicated that GPR39 agonist TC-G 1008 promoted mitochondrial biogenesis and improved antioxidative capability after ICH, partly through the CREB/PGC-1α signaling pathway. TC-G 1008 may be a potential therapeutic agent for patients with ICH.

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas.

Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithmdeveloped using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as second-line treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH. A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes. There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy.Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001).Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement. Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

Perinephric Hematoma Size can be a Strong Prognostic Factor of Need of Surgical Intervention in High Grade Renal Trauma

Background: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. The aim of our study is to assess the characteristics of perinephric hematoma and other prognostic factors of surgical intervention for high grade renal trauma independent of AAST OIS. Materials and Methods: A total of 119 patients with high grade renal trauma from January 2005 to September 2021 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for surgical intervention, including total and partial nephrectomy. Factors examined include patient age, gender, ISS (Injury severity score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation and devitalised segment status. Descriptive statistics and binary logistic regression were performed as appropriate. Results: Mean patient age was 31, 39 and mean ISS was 22, 80. A total of 24 surgical intervention were required (20%) including partial and total nephrectomy. On univariate analysis, hypotension on admission, hematoma diameter, degree of devitalised fragment superior of 25% and AAST OIS grade were associated with the need of surgical intervention. On multivariate analysis, only hypotension on admission (p: 0,029), hematoma diameter greater than 3,5 cm (p:0,021) and AAST-OIS grade (p: 0,010) remained independently associated with surgical intervention. Conclusions: Perinephric hematoma size remains among prognostic factors for surgical intervention that allow better stratification of renal lesions and its study allows a better management of high-grade renal trauma.

Transcatheter arterial embolization outperforms surgery in reducing blood transfusions for postpartum vulvovaginal hematoma

Postpartum vulvovaginal hematoma is a complication of vaginal delivery that may progress to life-threatening conditions. However, the management of hematomas, including conservative therapy, surgery, and arterial embolization, is yet to be standardized. This study aimed to: (1) evaluate hematoma features that can be treated conservatively, and (2) determine whether surgery or transcatheter arterial embolization is superior in reducing blood transfusion. This cross-sectional study included postpartum women transferred to Tohoku University Hospital, Japan, between January 2016 and September 2023 for postpartum vulvovaginal hematomas. Notably, all patients except 1 underwent contrast-enhanced computed tomography. The patients were classified into the following groups: (1) the conservative group who received neither surgery nor transcatheter arterial embolization and (2) the therapeutic intervention group who received surgery or transcatheter arterial embolization. The primary analysis included all patients. Variables for the choice of therapeutic intervention, including the shock index, hemoglobin concentration at arrival, hematoma size, and presence of extravasation, were assessed using a modified Poisson regression model. The secondary analysis included patients who received therapeutic intervention (ie, surgery or transcatheter arterial embolization). Variables for estimating the total amount of blood transfusion, including shock index, hemoglobin concentration at arrival, hematoma size, type of intervention, and presence of extravasation, were analyzed using multiple linear regression. Fifty-seven cases were included in this study. Patients underwent conservative treatment (n=19), surgery (n=11), or transcatheter arterial embolization (n=27). In primary analysis, only the presence of extravasation was significantly associated with the choice of therapeutic intervention (adjusted risk ratio [95% confidence interval], 5.30 [1.53-18.37]). In the secondary analysis, the choice of surgery as a therapeutic option (unstandardized coefficient [95% confidence interval], 4.64 [1.15-8.13]; reference: transcatheter arterial embolization), lower hemoglobin concentration at arrival (-2.84 [-4.71 to-0.97]; 1 g/dL increment), and larger hematoma size (3.38 [1.23-5.53]; 100 cm3 increments) were significantly associated with increased blood transfusion. When a vulvovaginal hematoma does not exhibit extravasation, it can be treated conservatively regardless of size. When a therapeutic intervention is selected, transcatheter arterial embolization reduces the total amount of blood transfusion compared with surgery.

Stereotactic hematoma puncture and drainage for primary pontine hemorrhage: Clinical outcomes and predictive model

Primary pontine hemorrhage (PPH) is a particularly grave form of hemorrhagic stroke, characterized by its significant mortality rate. stereotactic hematoma puncture and drainage is a procedure that has been shown to improve the prognosis of patients with PPH. However, there are currently no established criteria for selecting patients for this procedure. We contrasted the clinical outcomes of PPH patients treated with stereotactic hematoma puncture and drainage with those who received conservative treatment in this study. We conducted logistic regression analysis to identify the risk factors associated with postoperative mortality. A mortality risk nomogram was then constructed using these risk factors. A total of 127 conservatively treated patients and 96 patients who underwent stereotactic hematoma puncture and drainage were included in this study. In the surgical group, the 30-day mortality rate stood at 28.1%, significantly lower than the 43.3% observed in the control group (p = 0.02). Age, along with the Glasgow Coma Scale (GCS) score and hematoma size, were identified as independent risk factors associated with death within 30 days post-surgery. The mortality risk nomogram was well calibrated and discriminatory, with a c-index of 0.878 (95% CI 0.80–0.95) as validated by bootstrapping, and a c-index of 0.849. This study provides a predictive model for selecting patients who are most likely to benefit from stereotactic hematoma puncture and drainage. The results of this study could be helpful to neurosurgeons in their decision-making process. However, further external validation is necessary to confirm these findings.

Predictors of nephrectomy in high-grade renal trauma patients treated primarily with conservative intent

Background: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. The aim of our study is to assess the characteristics of perinephric hematoma and other prognostic factors of surgical intervention for high-grade renal trauma independent of AAST OIS. Materials and methods: A total of 119 patients with high-grade renal trauma from January 2005 to September 2021 were identified for analysis. Hospital records and diagnostic imaging were reviewed to identify the need for surgical intervention, including total and partial nephrectomy. Factors examined include patient age, gender, ISS (Injury severity score), AAST-OIS, laceration location, length and number, perinephric hematoma characteristics, intravascular contrast extravasation, and devitalized segment status. Descriptive statistics and binary logistic regression were performed as appropriate. Results: The mean patient age was 31,39 and the mean ISS was 22,80. A total of 24 surgical interventions were required (20%) including partial and total nephrectomy. On univariate analysis, hypotension on admission, hematoma diameter, degree of devitalized fragment superior of 25%, and AAST OIS grade was associated with the need for surgical intervention. On multivariate analysis, only hypotension on admission (p: 0,029), hematoma diameter greater than 3,5 cm (p: 0,021), and AAST-OIS grade (p: 0,010 ) remained independently associated with surgical intervention. Conclusion: Perinephric hematoma size remains among prognostic factors for surgical intervention that allow better stratification of renal lesions and its study allows a better management of high-grade renal trauma.

Abstract TP168: Association of Factors With Disorders of Consciousness in Hemorrhagic Stroke Patients

Objective: Disorders of consciousness (DoC) are known to correlate with worse functional outcome after hemorrhagic stroke. Here we evaluate factors associated low Glasgow Coma Scale [GCS] score at time of admission in patients with hemorrhagic stroke. Methods: We performed a prospective cohort study of patients enrolled in the Neurological Emergencies Outcomes Study between January 2014 and June 2023 of patients with primary intracranial hemorrhage (intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)). The primary outcome was coma (GCS ≤ 8) at time of admission. Univariable analysis with chi-squared test and Mann Whitney U test followed by adjusted logistic regression were used to assess the relationship between admission factors and DoC. We then confirmed the association with admission GCS and discharge modified Rankin score (mRS). Results: We included 314 patients admitted with intracranial hemorrhage, 51 (16%) of whom had GCS ≤ 8 at time of admission, 51% female and median [interquartile (IQR)] age of 63 [51-73]. The median [IQR] ICH volume was 9.3 ml [2.5-27.2] for ICH patients and the median [IQR] modified Fisher score was 3 [3-4] for SAH patients. Female gender, Asian race, hematoma size, hydrocephalus, peak temperature, lowest hemoglobin, and peak glucose in the first 24 hours were all associated with DoC (p&lt;0.05 for all). Controlling for age, disease process (ICH vs SAH), and all factors with p &lt; 0.05, we found female gender (OR 4.7, 95% CI 1.7-13.4), highest temperature (OR 3.8, 95% CI 1.9-7.3), lowest hemoglobin (OR 0.8, 95% CI 0.6-0.99), and highest glucose OR 1.01, 95% CI 1.00-1.02) remained significantly associated with coma at time of admission. Premorbid dependency as measured by Barthel Index was not a predictor of coma. However, coma at time of admission was associated with a worse discharge mRS (median discharge mRS [IQR] for patients with coma 5 [4-6] vs without 3 [2-4], p &lt; 0.001). Conclusions: We found that female gender, low hemoglobin, high body temperature, and elevated glucose at time of admission were all associated with coma. Low admission GSC (≤ 8) was associated with higher mRS at time of discharge. These modifiable risk factors are an important therapeutic target for improving outcomes for patients with DoC.

Abstract WP174: A Reassessment of Cost Effectiveness and Clinical Effectiveness of Anticoagulation Reversal in Direct Oral Anticoagulant - Related Intracerebral Hemorrhage

Introduction: Anticoagulation use is associated with increased risk of hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH). We sought to assess rates of HE in patients with ICH on direct oral anticoagulants (DOAC) and annual cost associated with anticoagulation reversal and occurrence of HE. Methods: We performed an observational cohort study on consecutive patients with ICH on DOAC admitted to a Comprehensive Stroke Center over 3 years, using data from an institutional ICH registry. We prospectively collected baseline demographic and clinical variables, neuroimaging data on baseline and follow-up hematoma volumes (HV) and HE and outcomes on discharge via modified Rankin scale (mRS). Hemostatic efficacy on hematoma size was adjudicated based on the Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors-4 (ANNEXA-4) trial, with a ≤20% increase in HV compared to baseline considered “excellent” and a ≤ 35% increase in HV compared to baseline considered “good.” Weighted hematoma expansion cost was estimated based on common odds ratio of mRS increase with HE and distributions of mRS with HE. Results: We identified 103 patients who met inclusion criteria: mean age 75.8 (± 11.4) years, 55.3% female. 92 patients (89.3%) received anticoagulation reversal with prothrombin complex concentrate (PCC), of which 19 (20.7%) had HE. A more severe coagulopathy (antiXa &gt; 0.5) was associated with increased risk of HE (p&lt;0.05). 74 patients (80.4%) achieved good or excellent hemostasis. Use of PCC was associated with a 19.6% hematoma expansion rate using the definition above, which translates into a $6700 increase in annual cost per every ICH patient attributed to HE. Conclusion: Cost effective and clinically effective treatments for anticoagulation reversal are needed to reduce the risk and cost associated with HE in anticoagulation-related ICH.

Abstract TP160: Minimum Intracerebral Hemorrhage Volume to Maximize Diagnostic Accuracy of Simplified Edinburgh Criteria

Introduction: Simplified Edinburgh criteria, based on plain CT, facilitates etiology diagnosis of ICH on cerebral amyloid angiopathy (CAA). Excellent performance in autopsy cohort though, the criteria show disparate discrimination ability amongst survivors with smaller hematoma size in external validation. On assumption that diagnostic accuracy may depend on ICH volume, cutoff volume could likely be found to better the application of Edinburgh criteria. Methods: Primary lobar ICH patients with CT and one of the following: pathology OR qualified MRI available for probable CAA diagnosis per Boston 2.0 criteria were retrospectively enrolled. Clinical characteristics, ICH volume, histology and markers of CT and MRI were collected for validation test. Additionally, likelihood-ratio curves for rule-in and rule-out criteria were plotted, taking 3.0 and 0.3 as the threshold of positive likelihood ratio (PLR) and negative likelihood ratio (NLR) respectively. Results: The criteria were tested among 52 lobar ICH patients with histological proof and 120 with MRI data. Patients with pathology by hematoma evacuation were characterized by larger ICH volume (31.45(31.45), 12.61(16.07), P&lt;0.001) and younger age (67±7, 71±9, P=0.002), compared to those tested on MRI. Discrimination of pathology-evidenced CAA was good (AUC 0.74) for both rule-out (NLR 0.26) and rule-in (PLR 2.97) criteria, while less satisfying when validated against probable CAA on MRI (AUC 0.58, NLR 0.61, PLR 1.42), evincing volume-dependent performance of Edinburgh criteria. According to likelihood-ratio curves (Figure 1), cutoff volume of 30ml may maximize positive likelihood ratio for rule-in criteria and optimize rule-out criteria with NLR≤0.3. Conclusion: Simplified Edinburg criteria was initially validated against pathology- or MRI-attested CAA in Asian population. Dependent on ICH volume, the diagnostic accuracy may be considerably augmented when cutoff value of 30ml was applied.

A dispensable role of oligodendrocyte-derived laminin-α5 in brain homeostasis and intracerebral hemorrhage

Laminin, a major component of the basal lamina in the CNS, is also expressed in oligodendrocytes (OLs). However, the function of OL-derived laminin remains largely unknown. Here, we performed loss-of-function studies using two OL-specific laminin-α5 conditional knockout mouse lines. Both mutants were grossly normal and displayed intact blood-brain barrier (BBB) integrity. In a mouse model of intracerebral hemorrhage (ICH), control mice and both mutants exhibited comparable hematoma size and neurological dysfunction. In addition, similar levels of hemoglobin and IgG leakage were detected in the mutant brains compared to the controls, indicating comparable BBB damage. Consistent with this finding, subsequent studies revealed no differences in tight junction protein (TJP) and caveolin-1 expression among control and knockout mice, suggesting that neither paracellular nor transcellular mechanism was affected in the mutants. Furthermore, compared to the controls, both mutant lines showed comparable oligodendrocyte number, oligodendrocyte proliferation rate, MBP/MAG levels, and SMI-32 expression, highlighting a minimal role of OL-derived laminin-α5 in OL biology. Together, these findings highlight a dispensable role of OL-derived laminin-α5 in both brain homeostasis and ICH pathogenesis.

Prognostic Factors and Treatment Efficacy in Spontaneous Spinal Epidural Hematoma: A Single Center Experience and Literature Review.

Spontaneous spinal epidural hematoma (SSEH) is a rare but serious condition, accounting for less than 1% of spinal lesions, with an incidence of 0.1 per 100,000 annually. Discovered by Jackson in 1869, around 40-50% of SSEH cases often lack a definitive cause, though risk factors, such as anticoagulant usage, vascular malformations, and hypertension are recognized. Symptoms vary from mild pain to severe neurological impairments like paraparesis, depending on the spinal cord compression level. Prompt treatment, usually involving spinal decompression and hematoma removal, is crucial, especially in cases of neurological decline. The study aims to provide comprehensive analysis of SSEH through examination of by patient cases, critical prognostic factors, and therapeutic strategies, based on demographics, clinical data, and outcomes observed at the Tri-Service General Hospital. This retrospective study, spanning 2003-2023 at the Tri-Service General Hospital, analyzed 14 patients with SSEH. It examined demographics, risk factors, clinical and radiological profiles, treatments, outcomes, and prognoses, using SPSS software (version 22.0) and adhering to the Modified Rankin Scale (mRS) and the American Spinal Injury Association (ASIA) impairment scale guidelines for data analysis. In this study of 14 patients with SSEH, 93% underwent urgent surgery, including total laminectomy or open-door laminoplasty, while 7% received conservative treatment. Post-surgery, 69.2% showed favorable outcomes (mRS ≤2) in the one-year follow-up, while 30.8% had poorer results (mRS 3-4). A significant negative correlation was noted between initial ASIA scores and one-year mRS outcomes, suggesting less initial impairment predicts better recovery. These findings indicated that a moderate positive correlation between treatment delay and one-year mRS scores. Nevertheless, factors, such as age, antiplatelet use, spinal levels with hematoma localization, and myelopathy signs observed before treatment did not demonstrate any significant effects on neurological outcomes during the one-year follow-up. Patients with minor initial deficits or those receiving early surgery, preferably within 12-36 h of symptom onset, exhibit better neurological recovery. Poor prognosis correlates with high International Normalized Ratio (INR) on anticoagulants, hematoma size, lumbar involvement, or severe motor issues. Rapid surgical hematoma evacuation is advised. Our study supports recovery of neurological function following surgical intervention in all cases, highlighting the potential efficacy of surgical decompression even in severe and prolonged instances of SSEH.

The effects of subchorionic hematomas on the future of pregnancies with threatened miscarriage

Objective: The clinical significance of subchorionic hematoma, which is worrisome to pregnant women in terms of the outcome of the pregnancy, still remains unclear. The objective of this study is to examine the association between subchorionic hematomas in patients with threatened miscarriage and adverse pregnancy outcomes. Materials and Methods: The retrospective cohort study was conducted in a tertiary center from September 2022 to January 2024. 200 patients who were hospitalized with threatened miscarriage during the sixth to fourteenth week of a singleton pregnancy were included. The individuals that satisfy the established criteria for the study were categorized into two groups with threatened miscarriage based on the ultrasound examination: the study group, which included patients with subchorionic hematoma and the control group, which included patients without subchorionic hematoma. Demographic information, maternal and neonatal outcomes were compared for both groups. Results: Maternal age, BMI, parity, gestational age at diagnosis, history of abortus were similar for both groups (p &gt; 0.05). Miscarriage rates were higher in the group with SCH than without SCH (28% vs. 25%, p= 0.631), but no statistical significance was observed. The frequencies of intrauterine death, gestational age at delivery, preterm delivery, mode of delivery, hypertensive disorders of pregnancy, placenta previa-placenta accreta spectrum, gestational diabetes mellitus, intrauterine growth restriction were not statistically significant (p &gt; 0.05) between groups. The hematoma sizes did not show any statistically significant difference between those whose pregnancies led to miscarriage and those whose pregnancies did not (29.6±14.30 mm vs. 27.1±14.58 mm, respectively; p = 0.367). The subchorionic hematoma diameters did not show any correlation with the gestational age at delivery, birth weight, APGAR scores at 1st and 5th minute. Conclusions: Our study suggests that detection of threatened miscarriage with subchorionic hematoma did not result in an elevation in miscarriage rates, maternal and neonatal complications.

Chronic subdural hematoma: Epidemiological analysis and factors associated with hematoma size – A single center experience

ObjectiveThis study aims to analyze the profile of patients with chronic subdural hematoma (cSDH) and to verify the factors associated with hematoma size. MethodsWe conducted a single-center, retrospective and observational case series of consecutive patients who underwent surgical treatment for cSDH at the Hospital de Clínicas de Passo Fundo, between 2018 and 2022. Data were extracted from the patients’ history records and imaging exams available. Patients’ characteristics were grouped and described through their respective prevalence. The relationship between patients’ characteristics and outcome (discharge or death) was analyzed using Fisher's exact test. Hematoma size was described in millimeters using means, and the relationship between hematoma size, patient age and hematoma side was tested using Student's t test. ResultsA total of 95 individuals were included in the study. Of these, 66.3 % were male and 7.4 % died. The mean age was 72 years. The most common symptoms and history findings were history of trauma (69.9 %), motor deficit (68.4 %) and cognitive deficit (26.3 %). The average hematoma size was similar on both sides, and showed an increasing trend with aging. The size of cSDH was also greater in those who presented motor deficits. ConclusionSurgically treated patients with cSDH had high rates of cognitive deficit, motor deficit and history of trauma. In addition, mortality rate was considered low and the size of hematoma was associated with age and motor deficits.

Influence of antithrombotic medication on size and neurological outcome of spinal epidural hematoma after neuraxial anesthesia: a systematic review.

Anticoagulation guidelines were developed to reduce the potential risk of epidural bleeding following neuraxial anesthesia. However, the influence of antithrombotic medication on size of spinal epidural hematoma and neurological outcome is unclear. Therefore, our aim was to analyze whether there is a correlation. The study was registered at Prospero (CRD42021285833). A systematic search in MEDLINE, EMBASE, CENTRAL, Web of Science and Google Scholar was conducted in August 2023 for studies reporting spinal epidural hematoma following neuraxial anesthesia. Primary endpoints were segmental extension and neurological outcome. Secondary endpoints were age, sex, body mass index, predisposition, American Society of Anesthesiologists physical status, complicated puncture, multiple punctures, bloody puncture, successful puncture, catheter usage, needle size and worst neurological deficit before treatment. Prespecified multivariate regression and propensity score matching was performed. Publications reporting on more than one patient were critically appraised. A total of 345 cases reported in 304 publications were included. Size of hematoma was not significantly different (antithrombotic medication: OR 0.11, 95% CI (-0.67 to 0.89), p=0.78, 'non-guideline adherent' for puncture/removal: OR 0.13, 95% CI (-0.92 to 1.18), p=0.81). Patients receiving antithrombotic medication were more likely to have persistent neurological deficit (OR 2.00, 95% CI 1.24 to 3.23), p<0.01). Significance persisted after propensity score matching (p=0.04). Patients with non-guideline adherence had a 3.42 higher chance of persistent neurological deficit (95% CI 1.71 to 6.86, p<0.001). Antithrombotic medication is not significantly associated with hematoma size; however, the use of antithrombotic medication doubled the risk for persistent neurological deficit after spinal epidural hematoma.

Factors affecting and effects of hemodynamic stability of pediatric patients with grades 3–5 renal trauma: a prospective non-randomized comparative study

BackgroundResearches on the effect of hemodynamic stabilization on the implantation of conservative management for pediatric high-grade renal traumas are lacking. We aimed to assess the effect of maintaining the initial hemodynamic stability of pediatric patients with grades 3–5 renal trauma on the implementation of the conservative treatment and identify its defining factors.MethodsA prospective study was performed on pediatric patients with grade 3–5 renal traumas who presented to our hospital during July 2020–June 2022. Hemodynamically stable patients were compared with the unstable patients for clinical characteristics, hemodynamic stabilization, and rates of success of conservative treatment.ResultsForty-three patients were studied, including 26 boys and 17 girls. Of them, 28 (65.1%) patients presented with hemodynamic stability and 15 (34.9%) patients were unstable. Overall, 32 (74.4%) patients achieved and/or maintained hemodynamic stability for conservative management. There was a significant difference in blood pressure level at presentation (p < 0.001). The improvement of the hemodynamic parameters was significant per group and, in comparison (p < 0.001). The size of hematoma was significantly smaller in patients with hemodynamic stability (p = 0.023). Despite the longer (p = 0.033) hospital stay with conservative management, the rates of blood transfusion (p = 0.597) and hospital stay (p = 0.785) were not significantly different between both groups. The rates of nephrectomy and mortality were 14% and 0%, respectively. Blood pressure was independently associated with the achievement of maintained hemodynamic stability for conservative management (p = 0.022).ConclusionsHemodynamic stabilization seems to be effective and safe for implementing successful conservative management for pediatric patients with high-grade renal traumas. Blood pressure was the only independent factor of maintaining hemodynamic stability.

Spontaneous Laryngeal Hematoma: A Rare Presentation of Supratherapeutic INR

Introduction: Warfarin is one of the most routinely used drugs for anticoagulation. However, it poses a significant bleeding risk. Incidence of major bleeding events ranges from 0.4-7.2% per year, and that of minor bleeding events can be as high as 15.4% per year. Here we present a rare case of laryngeal hematoma due to supratherapeutic INR. Case description: A 48-year-old male with past medical history of hypertension, Insulin dependent diabetes mellitus, and multiple episodes of deep venous thromboses on chronic anticoagulation with warfarin presented to the emergency department complaining of left sided neck pain and hoarseness of voice that started and progressively worsened since the past 24 hours. He denies any fever, chills, cough, shortness of breath, or dental pain. He was found to be hemodynamically stable with no oxygen requirement. He spoke with a hoarse voice, but no stridor was noted. Tenderness of the left anterior triangle of the neck below the jawline and mild trismus was noted. Laboratory work-up showed stable hemoglobin of 12.2 and a supratherapeutic INR of 9.9. CT of soft tissue neck showed retropharyngeal fluid collection extending from skull base to C7 with mild to moderate supraglottic airway narrowing. Flexible nasopharyngeal endoscopy showed significant collection of secretions with omega shaped epiglottis and retropharyngeal swelling, raising concerns for a hematoma. INR reversal with 2 units of fresh frozen plasma was initiated and patient was transferred to medical intensive care unit. He underwent daily endoscopies for three days; on day 3 significant improvement of the hematoma size was noted. Daily oral Vitamin K for 3 days ensured INR reversal from 9.9 to 1.7. After transferring to floors, the patient was gradually re-started on his anticoagulation and discharged home safely. Discussion: This case exemplified one of the rare but life-threatening complications of supratherapeutic INR. Bleeding into the larynx is a very rare life-threatening complication of chronic anticoagulation with warfarin. Similar case was reported by Cody A. Koch et al in 2010. In 2017 another case was reported which resulted in death from asphyxia before patient was taken to the hospital. A patient with similar presentation and demographics with the index case was reported also in 2019. As per literature, this case will be one of the very few reported cases of Spontaneous laryngeal hematoma due to supratherapeutic INR. Several factors could potentially affect the INR level of patients on chronic warfarin therapy and can cause acute elevation of INR which can lead to several complications including epiglottal hematoma as seen in this case. The index patient has significant history of chronic diarrhea along with OTC Tylenol ingestion for chronic patient both of which can cause INR increase. Thus, high index of suspicion is important especially for patients with comorbidities due to the fragile interaction of warfarin with several common medications and clinical conditions. Epiglottal hematoma can expand and potentially compromise the airway if immediate reversal of supratherapeutic INR is not commenced. Regardless of presentation, every patient who exhibits warfarin-associated upper airway hemorrhage should receive treatment that includes stopping anticoagulation, correcting the coagulopathy quickly, closely monitoring the patient's airway in an intensive setting, and having a low threshold for tracheostomy. Given the predicted difficulty with direct and fiberoptic laryngoscopy, the delayed time course for hematoma clearance, and the potential trauma resulting in further bleeding in an anticoagulated patient, securing the airway via intubation is frequently not desirable. Such cases of non-traumatic hemorrhage may be managed medically or surgically. Spontaneous hemorrhage is usually managed conservatively. Regarding the ideal course of treatment, there is, however, no agreement. Conclusion: There is need for a high index of suspicion for atypical presentations of supratherapeutic INR (including bleeding into the airway) in patients on prolonged anticoagulation with warfarin. The need for immediate reversal and routine INR monitoring in these patients is also emphasized in this clinical vignette.