Large Hematoma Research Articles

Mesenteric arteries aneurysms rupture secondary to paradoxical hypertension after aortic coarctation stenting.

A 51-year-old female with long-term poorly controlled hypertension was found to have a systolic murmur on physical examination. A transthoracic echocardiogram showed a bicuspid aortic valve with left ventricular hypertrophy and normal ejection fraction. Computed tomography (CT) detected a critical coarctation of the aorta (Panel A). The invasive gradient through the coarctation was 80 mmHg. It was decided to treat with stent implantation (Panels B and C). A covered cheatham-platinum stent of 39 mm mounted on a balloon-in-balloon balloon of 16 × 40 mm was successfully implanted. Immediately after stent deployment, the systolic blood pressure reached 210 mmHg, despite pharmacological treatment. The day after the procedure, the patient started with abdominal pain and an emergency CT scan was performed (Panel D). Computed tomography showed a large mesenteric haematoma (with no active bleeding at that moment), a large aneurysm of the proximal ileocolic artery, and a small aneurysm of the middle colic artery. Angiography confirmed these findings (Panel E) and it was decided to embolize both aneurysms using Micro Vascular Plugs and coils, which resulted in a successful exclusion of the aneurysms but also in a lack of vascularization of the distal ileum and ascending colon (Panel F), that eventually required resection (right hemicolectomy). The possibility of aneurysms and other alterations in the vessels of patients with aortic coarctation should be considered. Whether these anomalies should be treated before stenting is still unknown. Paradoxical hypertension after stent implantation and its severe complications could be prevented by pharmacological treatment days before the intervention.

Mouse Models of Musculocontractural Ehlers-Danlos Syndrome

Musculocontractural Ehlers-Danlos syndrome (mcEDS) is a subtype of EDS caused by mutations in the gene for carbohydrate sulfotransferase 14 (CHST14) (mcEDS-CHST14) or dermatan sulfate epimerase (DSE) (mcEDS-DSE). These mutations induce loss of enzymatic activity in D4ST1 or DSE and disrupt dermatan sulfate (DS) biosynthesis. The depletion of DS causes the symptoms of mcEDS, such as multiple congenital malformations (e.g., adducted thumbs, clubfeet, and craniofacial characteristics) and progressive connective tissue fragility-related manifestations (e.g., recurrent dislocations, progressive talipes or spinal deformities, pneumothorax or pneumohemothorax, large subcutaneous hematomas, and/or diverticular perforation). Careful observations of patients and model animals are important to investigate pathophysiological mechanisms and therapies for the disorder. Some independent groups have investigated Chst14 gene-deleted (Chst14-/-) and Dse-/- mice as models of mcEDS-CHST14 and mcEDS-DSE, respectively. These mouse models exhibit similar phenotypes to patients with mcEDS, such as suppressed growth and skin fragility with deformation of the collagen fibrils. Mouse models of mcEDS-CHST14 also show thoracic kyphosis, hypotonia, and myopathy, which are typical complications of mcEDS. These findings suggest that the mouse models can be useful for research uncovering the pathophysiology of mcEDS and developing etiology-based therapy. In this review, we organize and compare the data of patients and model mice.

Acute necrotizing pancreatitis with hemorrhagic shock in secondary splenic rupture: a case report and literature review

Atraumatic splenic rupture is a rare complication of acute and chronic pancreatitis. It arises due to its anatomical proximity to the pancreas, for instance, due to erosion of large pseudocysts or walled-of-necrosis (WON).Following we describe the case of a 62-year-old woman who presented for further diagnostics and treatment of acute pancreatitis with the development of large walled-of necrosis (WON) in the pancreatic corpus and tail. During the course, the patient developed a hemorrhagic shock. An emergency computer tomography (CT) of the abdomen revealed a ruptured spleen with a large capsular hematoma with no evidence of active bleeding. In contrast to previous published case reports, our treatment was exclusively minimal-invasive: by radiological guided embolization of the splenic artery and by endosonographic guided implantation of a lumen apposing metal stent (LAMS). The splenic hematoma was spontaneously regressive without secondary drainage.

Man With Acute Chest Pain.

A previously healthy 47-year-old man presented to the emergency department with a sudden attack of severe chest pain during a car ride. It was persistent, unrelated to breathing, and accompanied by epigastric and back pain. On physical examination, he was conscious, with a blood pressure of 125/91 mmHg, a pulse rate of 75 beats/min, and afebrile. He presented no tenderness on palpation of his chest, back, and epigastrium. The ECG showed sinus rhythm with early repolarization (Figure 1). The results of the laboratory tests were normal, including serum troponin levels. Point-of-care ultrasound was performed (Figure 2, A and Video E1), and the diagnosis was confirmed by contrast-enhanced computed tomography (Figure 2, B, and Figure 3).Figure 2A, Point-of-care ultrasound of echocardiogram in parasternal long axis view demonstrated well-defined heterogeneous mass in the posterior mediastinum (asterisk), surrounding the descending aorta (arrowhead), and compressed the LA. B, The findings as seen on computed tomography angiography. Ao, aortic root; LA, left atrium; LV, left ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3A reconstructed maximum intensity projection image of computed tomography angiography showed extravasation and pseudoaneurysm of left 10th intercostal artery (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Spontaneous rupture of an intercostal artery. The patient received modified thoracic endovascular aortic repair and was hospitalized in the vascular surgery department. He was asymptomatic at discharge 4 days later and at the 2-week follow-up. Intercostal artery rupture is a rare disease, which can be associated with neurofibromatosis type 1, aorta coarctation, or trauma. The rupture of the intercostal artery could cause hemothorax, retroperitoneal hemorrhage, hemorrhagic shock, or respiratory failure. The diagnosis is based mainly on the computed tomography study. Early diagnosis is critical and challenging. In our case, the point-of-care ultrasound evaluation unveiled posterior mediastinum hematoma and eventually led to the final diagnosis. The management of an intercostal artery rupture in an individual ranges from careful observation to interventions, including transcatheter arterial embolization or surgery.1Izumoto S. Abe T. Koroki T. et al.A 48-year-old man presenting as an emergency with severe back pain, a large anterior paravertebral hematoma, and spontaneous rupture of the right 9th intercostal artery successfully managed by transcatheter arterial embolization: a case report.Am J Case Rep. 2022; 16e934173Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Y2VkNjBjMDgwZTg2NjAwNjc4ODI4OTkxZDk3YzUxYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNDkwfQ.aGsxHuVrG046F2O67mFbDXdJB6uhIDHZjF-VVT7E1fYtLhHfdCLzNltHhT0RT158jaWjvBTv25NgeV81SQjlTrQW-79H4JOf69to6txArmtMBwW2KcFvDfw24ax6S2r6eABepzn1FIyvo4b0aFRpxFkEthGCjuyrn9MZbsjU2tg8FBSfRnHu0VqpnjHRjMZJJiLuukNRQ0ocM3iPypHr8FHzzoKThdbwG5SzMrnWWJ3otinL-F76RTTvuG6Y68GHo2Wn1r7ZmmfjYNetoc0JyR0Ygn8MTis-gHNwDBhNs2wB1vLQKM9e-n3tTxVBHqyTxCBKv-IqT8cf2TBvxcHhDQ Download .mp4 (2.78 MB) Help with .mp4 files Video E1Bedside echocardiogram in parasternal long axis view demonstrated a hematoma (asterisk) in the posterior mediastinum, surrounding the descending aorta (arrowhead), and compressing the left atrium (visible at 00:00 to 00:05). Point-of-care ultrasound of the epigastrium revealing a well-defined hypoechoic lesion (arrow) posterior to the descending aorta, correlated with the pseudoaneurysm seen on computed tomography angiography (visible at 00:06 to 00:12).

COVID 19 vaccine induced thrombotic thrombocytopenia, cerebral venous thrombosis and neurogenic stunned myocardium.

To the Editor, Vaccine-induced thrombotic thrombocytopenia (VITT) manifesting as cerebral venous thrombosis (CVT) is rare but life-threatening complication after COVID-19 vaccination.[1] Neurogenic stunned myocardium (NSM) is a phenomenon of cardiac abnormalities occurring due to sympathetic storm after acute neurological injury.[2] This case reporting is done after obtaining written informed consent. We describe rare manifestation of VITT, CVT, and NSM after COVID-19 vaccination and its successful management. A 19-year-old lady presented with altered sensorium for 2 days. Prior to her current visit, she had low-grade fever for 2 days and holocranial headache with vomiting for one week after COVID-19 vaccination with COVAXIN® (Bharat Biotech). On examination, she was drowsy, obeying simple commands on repeated asking, aphasic, with motor power of 3/5. Her pupils were equal and reactive. Respiratory and cardiovascular system examination was normal. Brain computed tomography showed left temporo-parietal CVT with raised intracranial pressure (ICP), midline shift to right and left transverse sinus thrombosis [Figure 1]. Laboratory tests revealed thrombocytopenia (platelet count 43,000/μL), elevated D-dimer (7457 ng/mL), and prolonged prothrombin time (18.8s). VITT associated CVT was diagnosed. In view of neurological status and imaging findings, she underwent emergency temporo-parieto-occipital decompressive craniectomy. She received four units of random donor platelet transfusion and three units of fresh frozen plasma before and during surgery. She was shifted to neuro-intensive care unit for elective ventilation and further management. VITT was managed with Fondaparinux and therapeutic plasma exchange (TPE). On 2nd postoperative day (POD), she developed persistent hypotension with tachycardia resistant to fluid therapy, with abnormal arterial blood gas (PaO2 = 40.9 mmHg, PaCO2 = 25.7 mmHg, pH = 7.48, SaO2 = 80.9%). Hence, norepinephrine was started, positive end expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2) increased to 8 cm water and 0.7, respectively. Following this, her heart rate was 112/min, blood pressure was 112/80 mmHg, electrocardiogram showed sinus tachycardia and oxygen saturation was 90%. The FiO2 was gradually reduced with improvement in oxygenation. Transthoracic echocardiography (TTE) showed left ventricular global hypokinesia with ejection fraction of 34%. She was diagnosed with acute left ventricular failure from NSM. Dobutamine and furosemide infusion with oral ivabradine resulted in improvement and cardiovascular medications were tapered and stopped on 9th POD and trachea was extubated on 10th POD. After 24h observation, she was shifted to ward and subsequently discharged home with improved neurological status. Follow up TTE at discharge showed normal cardiac contractility.Figure 1: Contrast computed tomography of the brain showing large temporo-parietal hematoma due to cerebral venous thrombosis with midline shift, mass effect, and significant cerebral edema with loss of gray-white differentiationVITT is characterized as vaccine-induced immune syndrome of severe thrombosis, antibodies to platelet factor 4–polyanion complexes and thrombocytopenia.[3] VITT begins 5-10 days after vaccination and is diagnosed between 5 to 30 days.[4] It is associated with CVT, splanchnic vein thrombosis, deep venous and arterial thrombosis with thrombocytopenia, and elevated D-dimer. Treatment includes non-heparin anticoagulants such as indirect Xa inhibitors (fondaparinux, danaparoid), oral anticoagulants or thrombin inhibitors (argatroban, bivalirudin), and intravenous immunoglobulin or TPE. NSM is reported after stroke, traumatic brain injury, and subarachnoid hemorrhage but not after CVT. Catecholamine excess, systemic inflammation, and neuroendocrine derangements contribute to occurrence of NSM.[5] It is likely that the NSM in our patient was due to interplay of acute increase in ICP (neurogenic) from VITT-associated malignant CVT and systemic vaccine-induced complication-associated stress on the myocardium. Treatment is supportive to improve myocardial function and prevents cardiovascular complications including sudden death.[5] Ivabradine reduces heart rate and improves cardiac failure while dobutamine improves hemodynamic instability associated with NSM.[5,6] To conclude, VITT-associated CVT leading to NSC is rare and challenging to identify and manage. Management goals include reduction of acute intracranial hypertension, restoration of platelet function, anti-coagulation, and supporting cardiac function. Patient consent form Yes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Opioid-Related Side Effects and Complications After Intrathecal Morphine Trial or Pump Implantation

Objective: A few cases of post-surgical spine syndrome (PSSS) are resistant to standard treatment. Intrathecal morphine (ITM) therapy can be used to achieve improved pain control with fewer side effects compared to systemic analgesics alone. ITM-associated complications may be associated with the intrathecal catheter, implanted pump, device management, and the drugs themselves.Methods: Twenty-six patients with PSSS were retrospectively evaluated. All patients had visual analog scale (VAS) scores of 7 or higher, which continued for more than 6 months, and all received a single dose of the ITM trial. If the VAS score was reduced by 50%, and there were no side effects from the trial, ITM pump (ITMP) implantation was performed for continuous morphine injection to control pain. Of the 26 patients, 19 underwent only the ITM trial, and 7 in whom the VAS decreased by more than 50% after the trial further underwent ITMP implantation. Patients who underwent only the trial were observed for an average of 5.4 days (range: 3–14 days), and those who underwent ITMP implantation were observed for an average of 55.9 months (range: 15–123 months). The occurrence of side effects following ITM injection and complications related to the ITM trial or ITMP implantation were analyzed. Results: The most common complications were drug side effects (n=11), followed by procedural (n=1) and equipment (n=1) side effects. The most common symptoms were urinary difficulty (n=8) and pruritus (n=3). Serious complications included a large lumbosacral subdural hematoma, intradural fibrotic tissues at the lumbar puncture site, and urinary retention (n=1). A case of mid-catheter occlusion caused by precipitated morphine crystals and skin infection on an implantable pulse generator was also reported (n=1). In another case, skin necrosis was observed in the surgical area (n=1). Conclusion: The most common drug-related side effect is urination difficulty, and patients generally recover within a few days after the ITM trial. Complications, such as procedure-related subdural bleeding or IT catheter blockage, may also occur. A better understanding of IT drugs, equipment, and meticulous procedural techniques, can allow a reduction of complications.

Admission neutrophil-to-lymphocyte ratio to predict 30-day mortality in severe spontaneous basal ganglia hemorrhage.

Spontaneous intracerebral hemorrhage (ICH) usually occurs in the basal ganglia and is highly lethal and disabling. The aim of this study was to evaluate the predictors of 30-day mortality in patients with severe spontaneous basal ganglia hemorrhage. This retrospective study included patients with severe basal ganglia intracerebral hemorrhage treated in the Third Affiliated Hospital of Soochow University from 2012 to 2018. Demographic, clinical, laboratory and neuroradiological data were collected. The short-term prognosis was evaluated and divided into death within 30-days and survival over 30-days. We studied the factors affecting the prognosis of patients with severe intracerebral hemorrhage, analyzed the parameters related to neutrophil-to-lymphocyte (NLR) at admission, and evaluated the predictive effect of NLR on 30-day mortality. A total of 105 patients was included in this retrospective study. The 30-day death group had a larger hematoma, a higher probability of ventricular hemorrhage, a higher ICH score and a lower Glasgow Coma Scale (GCS) score on admission. Meanwhile, the patients in the death group had higher White blood cells (WBC) counts, neutrophil counts, NLRs and C-reactive protein (CRP) levels. The risk factors for 30-day death were related to the ICH volume, GCS score, ICH score, WBC count, neutrophil count, NLR and CRP. The univariate receiver operating characteristic (ROC) curve of the risk factors showed that the NLR had the best prediction performance. Mathematical predictive models for ICH patients showed that the model with NLR had better prediction accuracy. The NLR is expected to be a potential biomarker for predicting the prognosis of patients with severe basal ganglia hemorrhage.

Two recovered cases of large pontine hematoma

AbstractThe comatose patients with pontine hemorrhage of diameter greater than 2 cm have poor prognosis. A 59‐year‐old male was brought with Glasgow coma scale (GCS) score of E2M5V2. He was mechanically ventilated. Magnetic resonance imaging (MRI) showed a pontine hematoma, of size 3 cm. He improved. Glasgow outcome scale (GOS) score was five. A 57‐year‐old male was brought with GCS score E1M3V1. He was ventilated. MRI scan showed a pontine hematoma of size 2.8 cm. His GOS score was three at 6 months. This is a report of two survived cases of large pontine hematoma with poor prognostic factors. This is the first report of good recovery with large pontine hematoma to GOS 5.

Avulsion of the gluteus maximus associated with a Morell Lavellè lesion in a pelvic ring fracture

Morell Lavellè injury is associated with high-energy trauma. By itself, avulsion of the gluteus maximus is an extremely rare injury, and their association is extremely rare.Case report: A 21-year-old was victim of a car accident. On admission, he presented pelvic instability and a large hematoma in the right gluteal region. X-rays and computerized axial tomography (CT) were performed. He was diagnosed with a bilateral sacral wing fracture with dislocation of the left sacroiliac joint and underwent fixation of the sacroiliac joint with cannulated screws on the left. After discharge, he recurred due to fever with inflammatory signs on the posterior surface of the right buttock, with palpation of a gap. Faced with this situation, a CT scan was repeated where an extensive degloving lesion of the soft parts was identified, opting for debridement and surgical cleaning. During the surgery, detachment of the gluteus maximus from its ileal insertion was verified. After adequate mobilization and release, transosseous reinsertion was performed with a multifilament suture. To date, no incidents to report, with good clinical and imaging evolution. Discussion: The gluteus maximus is one of the external rotators and the most important extensor of the hip, playing a preponderant role in gait. In addition, it has functions as a global stabilizer of the pelvic ring. Diagnose is not easy, it might even go unnoticed. Form of repair is not consensual: we performed a transosseous reinsertion with Ethibond® and Vicryl®. With this case we intend to highlight the importance of soft tissue degloving injuries in the context of polytraumatized patients.

Large epidural haematoma in an infant following a minor fall

Large epidural haematoma in an infant following a minor fall

Association of cerebrospinal fluid CD4+/CD8+Ratio with 60-day functional outcome after intracerebral hemorrhage.

Background: The immune inflammatory reaction has vital function in pathologic mechanism of critical intracerebral hemorrhage. It recently has been reported that CD4/CD8 ratio may represent a novel composite immune inflammatory marker to predict prognosis of critical intracerebral hemorrhage (ICH). Nevertheless, as for considering the effects of surgical evacuation upon initiation of immune inflammatory reactions, the association between cerebrospinal fluid (CSF) CD4/CD8 ratio and 60-day functional outcome of patients with critical ICH after surgery has not been investigated. Present study aimed to evaluate the predictive value concerning postoperative complement system and immunoglobulin, paired cerebrospinal fluid and peripheral blood lymphocyte subsets, as well as inflammation index before and after the operations upon the 60-day prognosis of patients with ICH.Methods: In total, 69 patients with acute critical ICH admitted in First Central Hospital of Baoding City from January to July in 2022 were prospectively enrolled. We recorded and analyzed the relevant clinical data. Laboratory parameters included postoperative lymphocyte subsets in paired cerebrospinal fluid and peripheral blood, inflammation index before and after operation. The associations between 60-day outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. Comparisons of predictive value regarding independent predictors was evaluated by receiver operating characteristic (ROC) curves.Results: In total, 51 patients with critical ICH exhibited poor outcomes at 60days, which was associated with fever after surgery, hernia before surgery, SAH and lower Glasgow Coma Scale (GCS) at admission and large hematoma volume, greater CD3T%CSF, greater CD4T%CSF, and greater CD4/CD8 ratioCSF. CD4/CD8ratio CSF showcased significant predictive power by comparing with other laboratorial variables (AUC = 0.6808; cut-off = 1.61; sensitivity = 80.39%; specificity = 61.11%; 95% CI: 0.5232-0.8385; p = .0233), which was found to correlated linearly with postoperative fever, first CSF test time, CD3T% CSF, CD4T% CSF, CD8T% CSF, NKCSF, CD3T%PB, CD8T%PB, CD4/CD8 ratioPB, and glucoseCSF. Poor outcome at 60days linearly correlated with CD4/CD8ratioCSF after adjustments. In 3-5days after surgery tested CSF lymphocyte subsets, CD4/CD8ratioCSF ≥1.61 was associated with a higher risk for 60-day poor outcome comparing with corresponding subgroups.Conclusions: In association of critical ICH patient prognosis, CSF CD4/CD8 ratio, especially in 3-5days after surgery, exhibited potential independent predictive ability for 60-day functional outcomes of patients with critical ICH.

23 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) EXPLOSION AFTER GUNSHOT: WHEN DEVICE PROTECTS TWICE

Abstract A 70 years old man presented to the emergency department with “accidental” gunshot wound at left hemithorax and left shoulder/arm. Initial clinical assessment showed stable vital signs and implantable cardioverter defibrillator(ICD) protruding outside from large wound in the infraclavicular region. The ICD, previously implanted for secondary prevention of ventricular tachycardia, appeared burned and the battery was exploded. Urgent chest computed tomography scan was performed with evidence of left omeral displaced fracture, large hematoma without arterial injury and many shotgun pellets in left shoulder/arm. The ICD generator was disconnected from passive fixation leads and removed. Patient was stabilized and omeral fracture was fixed. Following leads extraction was successfully performed in hybrid operating room with cardiac surgery standby considering the difficulty of the procedure, the type of leads (double coil, passive fixation) and the risk of complications. The patient was discharged home in good clinical conditions after re-implantation of novel ICD in right infraclavicular region. Emerging technologies are promising in making lead extractions safer and more accessible for patients worldwide. This clinicl case report will provide the most up-to-date indications and procedural approaches for lead extractions and insight on the future trends in this field.

Single-center experience of temporary-permanent pacemaker use in COVID-19 patients supported with veno-venous ECMO: A case series.

In the first year of the COVID-19 pandemic, nine out of 129 patients (7%) developed life-threatening bradycardia episodes ultimately requiring a TPPM, whilst being supported with VV-ECMO for severe COVID-19 ARDS in our tertiary cardio-pulmonary failure center. All subjects had asystole due to sinus node dysfunction and experienced at least one episode involving cardiopulmonary resuscitation. Most bradycardic events were seen in the context of vagal hypersensitivity. Mean time from general ICU admission to TPPM insertion was 20.6 ± 8.9days. One patient developed a large chest wall hematoma weeks after TPPM implantation, no other TPPM-related issues were observed. No patient required a long-term pacing system. Six-months survival rate was high (89%). These findings suggested that transient life-threatening sinus node disease is not uncommon in ECMO-dependent COVID-19 ARDS patients. TPPM with an active fixation lead is sometimes needed to facilitate ongoing ICU care, however, long-term permanent pacing was not required.

The conservative management of a large hepatic subcapsular hematoma in a pregnant woman with preeclampsia: A case report

Hepatic subcapsular hematoma is a rare but potentially life-threatening complication that is caused by preeclampsia and hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome, which may be manifest with nonspecific signs and symptoms. The present case was a 36-year-old woman with a secondary subcapsular liver hematoma as a rare complication of HELLP syndrome. The patient complained of nausea, vomiting, pain in the right upper quadrant of the abdomen, epigastric pain, and severe pain in the right shoulder. On the fourth day after delivery, a computed tomography (CT) scan was performed on the patient, showing a large subcapsular hematoma around the liver. Six weeks after delivery, the follow-up ultrasound exhibited no residual hematoma or free peritoneal fluid, and the patient’s blood pressure was controlled without taking medication.

Report of two cases of subconjunctival haemorrhage as first sign of post‐pregnancy acquired haemophilia a (AHA)

AbstractPurpose: To show that subconjunctival haemorrhage may be the first sign of post‐pregnancy acquired A haemophilia (AHA), a potentially fatal bleeding disorder.Methods: Case reports.Results: Two thirty‐year‐old caucasic women at first pregnancy presented slight pain without visual loss 2 weeks after uncomplicated spontaneous full‐term delivery. The only clinical findings were a subconjunctival bleeding for both and a small haematoma in the first case. The clinical history was negative for spontaneous bleeding also in infantile age and at previous surgery and no bleeding tendency was observed in the main relatives. The first patient was lost on follow‐up and admitted to urgent haemathologic evaluation due to large multiple cutaneous hematomas, a massive deep muscle haematoma, asthenia and dyspnea. In the second case quick routine coagulation labs were performed immediately after the subconjunctival bleeding. In both cases PTT ratio was increased. An extensive study of blood coagulation suggested the presence of a circulating inhibitor against factor VIII [1,2], confirming the diagnosis of AHA. First case was treated with a bypassing agent, however the eradication was obtained only with immunosuppressive therapy. Second case was initially placed in close follow‐up, since the post‐pregnancy form is often self‐limiting, however an immunosuppressive therapy was set after clinical progression due to the appearance of spontaneous hematoma.Conclusions: AHA is a relevant acquired bleeding disorder that can be fatal if not quickly recognized and treated even when the initial clinical signs are minor [3], how it can happen in post‐pregancy mainly in the first month [4]. Since it may present as spontaneous subconjunctival haemorrhage, routine hemathological and coagulation labs should be performed to exclude this serious condition or once identified, allow for proper clinical management.

CASE STUDY OF A PARAVAGINAL HAEMATOMA FOLLOWING VAGINAL DELIVERY

We present the case of a primigravida who had an induced delivery for mild IUGR at 38+6weeks. She had a normal vaginal delivery with right mediolateral episiotomy and minimal vaginal bleeding. She complained of increasing rectal pain in the postpartum period. Vaginal examination revealed a large left sided vaginal haematoma with intact episiotomy wound site.The haematoma was evacuated ,wound exploration done and sutured in layers. Vaginal packing was done. Postoperatively she again complained of rectal pain. Urgent CT scan conrmed nding of a large left pararrectal haematoma with possibility of small left broad ligament extension. She was managed conservatively with vaginal and rectal packing, analgesics,intravenous antibiotics and 3units of packed red cell transfusion. Follow up ultrasound showed reduction in the size of the haematoma and eventual resolution. This case supports the conservative management of even large paravaginal haematomas, when surgical evacuation is technically difcult as long as the patient is clinically stable.

Association between preadmission low-density lipoprotein cholesterol concentration and risk of large intracerebral hemorrhage: Results from the Kailuan study.

To examine the association between low-density lipoprotein cholesterol (LDL-C) concentrations and the risk of a large hematoma volume after intracerebral hemorrhage (ICH). Patients from the Kailuan study (Tangshan, China) who were hospitalized with ICH during 2006 and 2020 were included in this study. The concentration of lipid concentrations, hematoma volume and other clinical characteristics were retrospectively collected and analyzed. Hematoma volumes were measured on the first available brain scan using the ABC/2 method. LDL-C concentrations were obtained from the last physical examination before the occurrence of ICH. LDL-C concentration was categorized into four groups in accordance with the quartiles. Logistic regression was used to assess the association between LDL-C concentrations and the risk of a large hematoma volume of ≥30 ml. A generalized linear regression model was used to analyze the dose-response relationship between LDL-C concentration and hematoma volume. A total of 836 patients with ICH were evaluated. In the Multivariate logistic regression, compared to the second quartile of LDL_C, the first quartile of LDL_C had a significantly higher risk of a large hematoma volume (OR 2.49 [95% CI 1.54-4.01]), and the higher quartile of LDL_C is not associated with higher odds of large hematoma volume. In the generalized linear regression model, the adjusted β for the association between LDL-C concentration and hematoma volume was 9.46 (95% confidence interval 2.87-16.04), whereas higher LDL-C concentration was not associated with a large hematoma volume. This study confirmed that low LDL-C concentrations prior to ICH are associated with a higher risk of a large hematoma volume.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities.

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

Real-World Outcomes of Emicizumab in Hemophilia A with or without FVIII Inhibitors from the Canadian Hemophilia Bleeding Disorder Registry

Background: Hemophilia A is a bleeding disorder characterized by deficiency or absence of blood coagulation factor (F)VIII, which leads to lifelong bleeding tendency. The Canadian Bleeding Disorders Registry (CBDR) is a clinical database designed to assist clinicians in Canadian hemophilia treatment centers with the management of people with bleeding disorders and gain a better understanding of their incidence and prevalence, their treatment patterns, outcomes, and safety. Emicizumab is a bispecific monoclonal antibody that bridges activated FIX and FX to substitute for missing activated FVIII in people with hemophilia A (PwHA), thereby restoring hemostasis. Emicizumab was approved by Health Canada for the treatment of PwHA with FVIII inhibitors in 2018, and for PwHA without FVIII inhibitors in 2019. In this non-interventional, secondary data use cohort study, we use data routinely collected by the CBDR to evaluate the effectiveness, safety, and treatment patterns of emicizumab in Canada. The study includes patients treated according to routine clinical practice; therefore, it reflects patterns of care and outcomes in the real world, outside of the experimental setting. Methods: We retrieved de-identified data from the CBDR database of all registered PwHA who had received emicizumab at least once prior to December 31, 2021. Baseline demographic characteristics, including sex, body mass index, FVIII inhibitor status, emicizumab regimen, and immune tolerance induction (ITI) while receiving emicizumab were stratified by disease severity (defined by the level of endogenous FVIII activity) and age. Real-world efficacy outcomes were measured by the proportion of patients with zero traumatic, spontaneous, or joint bleeds as well as annualized bleeding rates (ABR) for any treated bleed. ABRs were calculated as (total number of bleeds/duration of follow-up [days])*365.25. Efficacy outcomes also included patients’ Hemophilia Joint Health Score (HJHS), Patient Reported Outcomes Burdens and Experiences (PROBE), and EQ-5D index and visual analog scale (VAS) scores. We performed a complete data analysis, without imputation. Intra-patient comparisons of bleeding were performed for all patients This study was approved by the research ethics board of McMaster University and other participating centers, and abides by the guiding principles of the Declaration of Helsinki. Results: In total, 146 PwHA received emicizumab at least once up to December 2021 in the CBDR database. The median (Q1, Q3) age at initiation of emicizumab was 13.9 (6.7, 28.7) years; 58.9% (n=86) of PwHA were ≤18 years (Table 1). Overall, 132 PwHA had severe disease, 10 had moderate disease, and 4 had mild disease. In total, 40.4% (n=59) of PwHA had current FVIII inhibitors, 15.1% (n=22) had a history of FVIII inhibitors, and 44.5% (n=65) had no history of inhibitors; 4.1% (n=6, all with severe HA) received ITI while on emicizumab. Three adverse events were reported during 2021, including two allergic reactions and one case of large hematoma at the operative site following removal of a port-a-cath. No thromboembolisms or thrombotic microangiopathies were reported. Over a median follow-up of 389.0 days, 76.7% (n=112) of PwHA had no recorded bleeds (Table 2). For the 34 patients with recorded bleeds on emicizumab, median (Q1, Q3) ABR was 1.0 (0.5, 2.0); 13 of the 34 had joint bleeds, 18 had traumatic bleeds, and 19 had spontaneous bleeds. An intra-patient comparison in all PwHA (n=146) showed a decrease in mean (95% confidence interval [CI]) ABR from 2.38 (1.77-3.22) pre-emicizumab (2018, prior to first dose) to 0.36 (0.24-0.53) post-emicizumab (rate ratio [RR] 0.15, p<0.0001). In PwHA with bleeds before or after initiation of emicizumab (n=97), mean (95% CI) ABR decreased from 5.31 (3.79-7.45) pre-emicizumab to 0.87 (0.58-1.32) post-emicizumab (RR 0.16, p<0.0001). Conclusions: This analysis describes the baseline characteristics, bleed outcomes, and safety of Canadian PwHA treated with emicizumab before December 31, 2021. The majority had severe disease and current or historical FVIII inhibitors. The data show 76.7% had no recorded bleeds and there was a substantial decrease in bleeds post-emicizumab. The CBDR allows for a longitudinal follow-up of the Canadian hemophilia A population, which can inform healthcare practitioners and regulatory authorities of the real-world safety and effectiveness outcomes of treatments. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Papillary Renal Cell Carcinoma with Massive Hemorrhage: An Autopsy Case Report

Abstract Introduction/Objective Spontaneous renal hemorrhage is a rare complication of various kidney pathologies. It can be due to renal artery aneurysms, arteriovenous malformations, cystic renal diseases, renal calculus, coagulation disorders, as well as neoplastic lesions like angiomyolipoma and renal cell carcinoma (RCC). Individuals present with sudden flank or scapular pain, hypovolemic shock, termed as Wunderlich syndrome (WS). 30-35% cases of WS are from spontaneously ruptured RCC, commonly clear cell variant (70%) followed by papillary (10-15%) and chromophobe variant (4-6%). We present an autopsy case of a papillary variant RCC identified as a small kidney mass with a pathogenetic correlation behind the intractable bleeding. Methods/Case Report An 81-year-old Caucasian man with a history of atrial fibrillation, on long-term Xarelto treatment, was found to have a 1.2 cm incidental mass in the right kidney. He started experiencing right-sided scapular pain, then rapidly became hypotensive, drowsy. CT scan revealed a large right-sided perinephric and retroperitoneal hematoma (17.5 x 5.7 x 8.9 cm) extending in the pelvis. Despite receiving blood products, other supportive treatment, and successful angio-embolization, his condition worsened to acute kidney injury, bowel ischemia, and persistent lactic acidosis leading to death. On autopsy, bloody ascites, clots on mesenteric root insertion, and bulging in retroperitoneal spaces were seen. The perinephric spaces had organized clots. The bleeding originated from a 2.0 x 2.0 cm brown mass in the middle pole of the right kidney. There was a slit-like vessel at the interface of the kidney and the mass. Microscopic examination of the mass shows trabecula of abnormal cells with abundant eosinophilic cytoplasm in the hemorrhagic and necrotic background. These cells are positive for PAX8, CK7, CD10, dim positive for CAIX, and negative for CD117, which is consistent with renal cell carcinoma, papillary variant. Results (if a Case Study enter NA) NA. Conclusion Papillary RCC is much less vascular and less aggressive than clear cell RCC. However, necrosis or bleeding into renal vessels may occur. In this case, blood-leaks and accumulation in enclosed space followed by necrosis, fibrosis, and hyalinization cause neovascularization forming a negative spiral for re-bleeding. Anticoagulants can lead to profuse sustained bleeding from even very small size RCC.