Conservative Management of Postpartum HELLP Syndrome and Intraparenchymal Liver Hematoma; A Case Report

The HELLP syndrome is an important variant of pre-eclampsia which is known by triad of hemolysis (H), elevated liver enzymes (EL) and low platelet count (LP). Intraparenchymal liver hematoma is a rare and important complication of HELLP syndrome which is a life threatening condition. The incidence of intraparenchymal hematoma of the liver has been reported to vary from 1 in each 40,000 to 250,000 deliveries worldwide. Herein we report a case of intraparenchymal liver hematoma following HELLP syndrome. An 18 year- old woman with moderate to severe preeclampsia after delivery, presented with Right upper quadrant (RUQ) pain and tachycardia and significant drop in hemoglobin level. Ultrasonography revealed intraparenchymal liver hematoma. This finding was also confirmed by computerized tomography (CT)-scan. Conservative treatment was applied and the patient improved without need of any surgical intervention. Spontaneous hepatic hematoma should always be considered as a life threatening and important complication of HELLP syndrome during pregnancy and it can be managed conservatively in a hemodynamically stable patient.

[Shock wave treatment in a case of complicated plantaris muscle rupture]

Muscle injuries are frequent in the workplace. They are produced by sudden direct or indirect trauma that involves a rupture of the fibres, causing bruising. Currently, there is no single protocol-based model of treatment. We present the case of a patient diagnosed with complete muscular rupture of the plantaris muscle by an indirect traumatic mechanism (abrupt muscular elongation), with an associated large-volume hematoma. Clinical study consisted of ultrasound, magnetic resonance (MR), pain assessment (VAS) at the beginning and at the end of the treatment (3 weeks), as well as duration of occupational disability. The patient underwent extracorporeal shockwave therapy (ESWT) according to the protocol. At the end of treatment, the hematoma was resolved and there were no complications. ESWT could be a complementary therapeutic alternative to conventional treatment in this entity. However, there is a need for further, randomised controlled studies including a larger number of patients.

Effectiveness of a Non-Taped Compression Dress in Patients Receiving Cardiac Implantable Electronic Devices

Background

Hematoma and skin damage are not uncommon after cardiac implantable electronic device (CIED) placement. The use of conventional hemostatic gauze and tape seems to be suboptimal in controlling these complications. This study aimed to evaluate the impact of a novel compression dress with a special pad and elastic bands for postoperative care.

Methods

A total of 175 CIED recipients were randomly divided into two groups: an experimental group with 85 patients who used a non-taped compression dress and a control group with 90 patients who used conventional gauze ball and elastic tapes. Skin integrity, hematoma, and oozing were compared between these two groups within 7 days after surgery.

Results

The mean age of the patients was 71.2 ± 13.3 years, and 83 (47.4%) were male. The results of the experimental vs. control group were as follows: skin integrity - 96.5% vs. 86.7% (p < 0.05); hematoma - 0% vs. 7.8% (p < 0.05); and oozing - 1.2% vs. 7.8% (p < 0.05). All observed endpoints were better in the experimental group.

Conclusions

The use of a non-taped compression dress was associated with less unfavorable outcomes in terms of skin integrity and hemostasis.

Giant rectus sheath hematoma

Background

Rectus sheath hematoma (RSH) is an uncommon entity associated with predisposing factors such as anticoagulation. It may mimic more frequent abdominal conditions and its accurate diagnosis is important to focus on the correct treatments and improve morbidity and mortality.

Case presentation

An elderly patient with shock, abdominal pain, palpable abdominal mass, and anemia was suspected of having a large RSH by point-of-care ultrasound (POCUS), which was then confirmed by computed tomography. Surgery was performed, markedly improving his clinical status.

Conclusions

POCUS has a good sensitivity for the diagnosis of RSH and it is also an excellent tool for patient follow-up.

Electronic supplementary material

The online version of this article (10.1186/s13089-019-0129-4) contains supplementary material, which is available to authorized users.

Incidence of major hemorrhage after aggressive image-guided liver mass biopsy in the era of individualized medicine

PURPOSE

To analyze a large volume of image-guided liver mass biopsies to assess for an increased incidence of major hemorrhage after aggressive liver mass sampling, and to determine if coaxial technique reduces major hemorrhage rate.

METHODS

Patients who underwent image-guided liver mass biopsy over a 15-year period (December 7, 2001-September 22, 2016) were retrospectively identified. An aggressive biopsy was defined as a biopsy event in which ≥ 4 core needle passes were performed. Association of major hemorrhage after aggressive liver mass biopsy and other potential risk factors of interest were assessed using logistic regression analysis. For the subset of aggressive biopsies, Fisher's exact test was used to compare the incidence of major hemorrhage using coaxial versus noncoaxial techniques.

RESULTS

Aggressive biopsies constituted 11.6% of biopsy events (N =579/5011). The incidence of major hemorrhage with <4 passes was 0.4% (N =18/4432) and with ≥4 passes 1.2% (N =6/579). In univariable models, aggressive biopsy was significantly associated with major hemorrhage (OR 3.0, 95% CI 1.16-6.92, p =0.025). After adjusting for gender and platelet count, the association was not significant at the p =0.05 level (OR 2.58, 95% CI 0.927-6.24, p =0.067). The rate of major hemorrhage in the coaxial biopsy technique group was 1.4% (N =3/209) compared to 1.1% (N =4/370) in the noncoaxial biopsy technique group, which was not a significant difference (p =0.707).

CONCLUSIONS

Although aggressive image-guided liver mass biopsies had an increased incidence of major hemorrhage, the overall risk of bleeding remained low. The benefit of such biopsies will almost certainly outweigh the risk in most patients.

Acute type B aortic intramural hematoma: the added prognostic value of a follow-up CT

OBJECTIVES

To investigate prognostic significance of follow-up CT findings for initially medically treated type B aortic intramural hematoma (IMH).

METHODS

We performed a retrospective pooled analysis of individual patient data, including baseline and follow-up CT characteristics. All enrolled patients were followed up for adverse aorta-related events, defined as a composite of aortic disease-related death and surgical or endovascular aortic repair.

RESULTS

A total of 238 patients (73.9% men) were included, with a mean age of 58.1 ± 9.8 years. During follow-up, 83 patients (34.9%) experienced adverse aorta-related events, most of the events (83.1%) occurred within 1 month after follow-up CT imaging (n = 69). In the Cox regression model for predicting adverse aorta-related events, baseline maximal aortic diameter (MAD) (HR = 1.05, p = 0.008), ulcer-like projection (ULP) (HR = 2.47, p < 0.001), changes of maximal hematoma thickness (MHT) (HR = 1.22, p < 0.001), newly developed ULP (HR = 4.44, p < 0.001), and newly developed pleural effusion (HR = 2.46, p = 0.002) were powerful independent predictors. In combined predictive model for 1-month aortic events, baseline MHT ≥ 11.8 mm (OR = 4.39, p = 0.001), ULP (OR = 3.98, p < 0.001), changes of MHT (OR = 1.46, p < 0.001), newly developed ULP (OR = 9.27, p = 0.002), and newly developed pleural effusion (OR = 3.45, p = 0.015) were independent predictors. Besides, in patients with pleural effusion at baseline, resorption of pleural effusion was associated with adverse aorta-related events (HR = 0.36, p = 0.027) and 1-month aortic events (OR = 0.23, p = 0.026).

CONCLUSIONS

Follow-up CT findings provide strong and incremental prognostic information for initially medically treated type B IMH, which are helpful for risk estimates and decisions-making.

KEY POINTS

• Follow-up CT provides strong and incremental prognostic information for initially medically treated type B aortic intramural hematoma. • Follow-up CT is highly recommended for type B intramural hematoma in patients who did not receive urgent invasive therapy. • Follow-up CT is helpful for risk estimates and decisions-making.

Pulmonary sclerosing pneumocytoma demonstrating intratumoral hematoma

Pulmonary sclerosing pneumocytoma (PSP) is a rare benign neoplasm of the lung that shows a slow growing pattern. Corresponding contrast-enhancements on chest computed tomography (CT) vary widely in both patterns and degrees. However, gross intratumoral radiolucencies, attributable to cyst formation, necrosis, or intratumoral hematoma, were rarely reported in PSP cases. We herein report on a case involving a 61-year-old Japanese women with PSP demonstrating CT-defined intratumoral radiolucency. A chest CT scan revealed a solitary and well-circumscribed nodule that showed a substantial growth over a 7-year period. The tumor was composed of a solid portion visualized with contrast-enhancement and a central radiolucency on a chest CT scan. A positron emission tomography scan revealed high uptake of fluorodeoxyglucose on the solid portion of the tumor, but the radiolucent portion showed negative uptake. The examination of a tumor specimen obtained by a percutaneous core needle biopsy aided in determining a pathological diagnosis of PSP, and the patient subsequently received a right lower lobectomy of the lung. The portion of central radiolucency on the CT scan corresponding to the surgical specimen was pathologically proven to be gross hematoma.

Spontaneous Spinal Subdural and Subarachnoid Hemorrhage with Concomitant Intracerebral Hemorrhage: A Case Report

Most cases of spinal subdural hematoma are very rare and result from iatrogenic causes, such as coagulopathy or a spinal puncture. Cases of non-traumatic spinal subdural hematoma accompanied by intracranial hemorrhage are even more rare. There are a few reports of spontaneous spinal subdural hematoma with concomitant intracranial subdural or subarachnoid hemorrhage, but not with intracerebral hemorrhage. Especially in our case, the evaluation and diagnosis were delayed because the spontaneous intracerebral hemorrhage accompanying the unilateral spinal subdural and subarachnoid hemorrhages caused hemiplegia. We report a case of spinal subdural and subarachnoid hemorrhage with concomitant intracerebral hemorrhage, for the first time, with a relevant literature review.

Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review

BACKGROUND

Spontaneous spinal epidural hematomas (SSEH) are rare yet severe conditions. In pregnancy, this condition is challenging to diagnose and treat because of the risks to the mother and fetus. This study reviews the literature on SSEHs in pregnancy.

METHODS

We performed a systematic review of the English literature on SSEHs from 1990 until 2018. Outcome measures were mode of presentation, risk factors, initial neurologic findings, diagnostic investigations, site and size of the SSEH, treatment, neurologic recovery, and survival.

RESULTS

Fourteen publications (16 patients) were included. Two patients presented in the second trimester, with the remainder in the third trimester. All patients presented with back pain, and 15 subsequently developed spinal cord dysfunction. Magnetic resonance imaging (MRI) was performed in all cases. The cervicothoracic region was the most commonly affected, and the average hematoma size extended across 3.9 vertebral levels. All patients with neurologic dysfunction underwent surgical decompression. In women under 32 weeks' gestation, caesarean section was not routinely performed. In contrast, women of gestational age of 32 weeks or more underwent a caesarean section prior to spinal decompression. Women without neurologic dysfunction underwent a caesarean section and neurologic monitoring without decompression. All patients with abnormal neurology improved after surgery, except 1 patient. No patients died.

CONCLUSIONS

In pregnancy, SSEHs typically present in the second or third trimesters with back pain, predominantly in the cervicothoracic region, followed by progressive neurologic dysfunction. MRI is diagnostic, and the treatment depends on the patient's neurologic dysfunction and gestational age.

Prediction of hematoma expansion in spontaneous intracerebral hemorrhage using support vector machine

Background

Spontaneous intracerebral hemorrhage (ICH) is a devastating disease with high mortality rate. This study aimed to predict hematoma expansion in spontaneous ICH from routinely available variables by using support vector machine (SVM) method.

Methods

We retrospectively reviewed 1157 patients with spontaneous ICH who underwent initial computed tomography (CT) scan within 6 h and follow-up CT scan within 72 h from symptom onset in our hospital between September 2013 and August 2018. Hematoma region was manually segmented at each slice to guarantee the measurement accuracy of hematoma volume. Hematoma expansion was defined as a proportional increase of hematoma volume > 33% or an absolute growth of hematoma volume > 6 mL from initial CT scan to follow-up CT scan. Univariate and multivariate analyses were performed to assess the association between clinical variables and hematoma expansion. SVM machine learning model was developed to predict hematoma expansion.

Findings

246 of 1157 (21.3%) patients experienced hematoma expansion. Multivariate analyses revealed the following 6 independent factors associated with hematoma expansion: male patient (odds ratio [OR] = 1.82), time to initial CT scan (OR = 0.73), Glasgow Coma Scale (OR = 0.86), fibrinogen level (OR = 0.72), black hole sign (OR = 2.52), and blend sign (OR = 4.03). The SVM model achieved a mean sensitivity of 81.3%, specificity of 84.8%, overall accuracy of 83.3%, and area under receiver operating characteristic curve (AUC) of 0.89 in prediction of hematoma expansion.

Interpretation

The designed SVM model presented good performance in predicting hematoma expansion from routinely available variables.

Fund

This work was supported by Health Foundation for Creative Talents in Zhejiang Province, China, Natural Science Foundation of Zhejiang Province, China (LQ15H180002), the Science and Technology Planning Projects of Wenzhou, China (Y20180112), Scientific Research Staring Foundation for the Returned Overseas Chinese Scholars of Ministry of Education of China, and Project Foundation for the College Young and Middle-aged Academic Leader of Zhejiang Province, China. The funders had no role in study design, data collection, data analysis, interpretation, writing of the report.

Management of blunt adrenal gland injury in a community-based hospital

INTRODUCTION

Injury of the adrenal gland in blunt trauma is rare. The routine usage of the whole body computed tomography (CT) scan helps in early diagnosis. We aimed to study the incidence, mechanism of injury, management, and outcome of adrenal injury in blunt trauma patients treated in a community-based hospital.

METHODS

CT scan of the abdomen of all blunt trauma patients who were admitted to our institution between October 2010 and March 2018 were retrospectively reviewed. The files of all the patients with CT scan-detected adrenal injuries were retrieved. Studied variables included demography, mechanism of injury, associated injuries, GCS, ISS, Intensive Care Unit admission, hospital stay, and outcome.

RESULTS

4991 blunt trauma patients were admitted to the hospital. CT scan of the abdomen was performed for 2359 (47%) patients. Blunt adrenal injuries were diagnosed in eleven male patients (0.22%). The main mechanism of injury was motor vehicle collisions in eight (72.7%) patients. Nine (81.8%) patients had right adrenal gland injury. The mean (range) ISS was 22 (6-50). All patients had intra-adrenal hematoma and periadrenal fat stranding. None of our patients had acute adrenal insufficiency. One patient died (overall mortality 9.1%).

CONCLUSIONS

The incidence of blunt adrenal injury, although rare, is similar in a community-based hospital to those reported from trauma I centers. It is associated with severe and multiple organ injuries. Blunt adrenal injuries are usually self-limiting.

Renal Parenchymal Thickness as a Predictor of Post Percutaneous Kidney Biopsy Complication

OBJECTIVE

To investigate the relationship of renal parenchymal thickness and the risk of developing post-procedure hematoma.

METHODS

Ultrasound-guided percutaneous renal biopsy was performed in 122 patients who underwent percutaneous kidney biopsy between January 2013 and -December 2013 at Tai-he hospital. Post-biopsy renal ultrasound was performed within 12 h after the biopsy to assess the presence of hematoma in biopsied kidney. Logistic regression analysis was used to determine the effect of parenchymal thickness on formation of hematoma adjusted for other nonstructural patient-related factors such as age, sex, systolic and diastolic blood pressure, serum creatinine, and urea.

RESULTS

The incidence of complication was 19.4%, all of which were hematoma less than 5 cm. None of the patients went on to have severe complications that required clinical, surgical, or radiological intervention. Out of the collected clinical and anatomical parameters, renal parenchymal thickness of the biopsied kidney was found to be the only factor with strong association with complication risks.

CONCLUSION

This is the first study investigating the impact of structural perimeters on complication risks of percutaneous renal biopsy. Renal parenchymal thickness is a significant predictor of presence of hematoma evident on post-biopsy ultrasound evaluation, which would be used in the early prevent the complications of percutaneous renal biopsy.

Meningioma Presenting with Spontaneous Subdural Hematoma: A Report of Two Cases and Literature Review

BACKGROUND

Although meningiomas are considered benign, encapsulated brain tumors, their distinct intracranial location can lead to devastating complications. Although a highly vascularized tumor, a rarely reported complication of meningioma is hemorrhage. To the best of our knowledge, only 19 cases of meningioma presenting with a subdural hematoma have been reported.

CASE DESCRIPTION

We have outlined the clinical presentation, radiological findings, and outcomes of 2 female patients with a diagnosis of a spontaneous subdural hematoma associated with meningioma. The coagulation profile was within normal limits for both patients. The postoperative histopathologic examination results showed an angiomatous/microcystic subtype of meningioma (patient 1) and meningothelial meningioma (patient 2). Both patients underwent right frontal craniotomy, resection of the dural-based tumor, and evacuation of the subdural hematoma.

CONCLUSIONS

We comprehensively reviewed the pertinent data for meningiomas presenting as subdural hematomas. The mechanism of hemorrhage in meningiomas remains unclear. Therefore, further studies are required to investigate the possible mechanisms of bleeding in such tumors.

Complications and Risks of Percutaneous Renal Biopsy

BACKGROUND

Renal biopsy performed in native and transplant kidneys is generally considered a safe procedure.

AIM

In this study, we evaluated renal biopsy complications and risk factors in one nephrology facility.

MATERIAL AND METHODS

We conducted a three-year retrospective study on patients who underwent renal biopsy between January 2014 and December 2016. Strict written biopsy protocol was followed. Clinical and laboratory data were obtained from medical charts. Complications were categorised as minor and major, according to the need for intervention. Minor complications included macrohematuria and/or hematoma that did not require intervention. Major complications included hematuria or hematoma with fall of hematocrit that required a blood transfusion, surgery or caused death. A binary logistic regression model was used to analyse the possible factors associated with complications after the biopsy.

RESULTS

We analysed 345 biopsies; samples were taken from patients aged from 15-81 years, of whom 61% were men. A total of 21 (6%) patients developed a complication, 4.4% minor and 1.7% major complications. There were no nephrectomy or death due to biopsy intervention. Overweight patients, as well as those with higher creatinine, lower hemoglobin, higher blood pressure and biopsy due to AKI had higher chances to develop complications (p = 0.037, p = 0.023, p = 0.032, p = 0.002, p = 0.002, respectively). The patients' age, gender, kidney dimension, number of passes and uninterrupted aspirin therapy were not found as significant predictors of complications. In the multivariate logistic model, body weight (OR = 1.031, 95%CI = 1.002-1.062), lower hemoglobin (OR = 0.973, 95%CI = 0.951-0.996) and hypertension (OR = 1.025, 95%CI = 1.007-1.044) increased the risk of complications in biopsied patients.

CONCLUSION

Renal biopsy is a safe procedure with a low risk of complications when strict biopsy protocol is observed. Correction of anaemia and blood pressure is to be considered before the biopsy.

Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature

OBJECTIVE

Epidural haematoma (EDH) most commonly occurs in the supratentorial area, particularly in the temporal region, of the brain. Posterior fossa epidural haematoma (PFEDH) is less frequently observed, accounting for only 1.2% to 12.9% of all EDH cases. Because of the non-specific symptoms and the potential for rapid and fatal deterioration in children, an early computed tomography (CT) scanning is necessary for all suspicious cases. The aim of the present study was to share the experience of 48 cases and review the literature concerning PFEDH.

METHODS

A retrospective analysis was conducted for 48 paediatric cases diagnosed with PFEDH and admitted to Yuying Children's Hospital of Wenzhou Medical University from January 2010 to August 2015. The clinical features and outcomes were analyzed and compared with previous literature.

RESULTS

Seventeen patients were surgically treated in this series and 31 patients received non-operative treatment. The outcomes were good in 46 patients, evaluated using the Glasgow outcome score (GOS), while mild disability was observed in one patient, and only one case showed severe disability. There were no cases of mortality in this series.

CONCLUSION

Posterior fossa epidural haematoma is relatively rare compared with supratentorial epidural haematoma. Early and serial CT scans should be performed for all suspicious cases. The criteria for the surgical treatment of paediatric patients with PFEDH were concluded. The overall prognosis was excellent in paediatric patients.

Spinal Hematoma Following Coronary Angioplasty: An Uncommon Complication

We report an unusual case of post-procedural spontaneous spinal epidural hematoma in a 65 year old man who presented with an acute coronary syndrome and underwent complex coronary intervention with adjunct use of a GPIIb/IIIa inhibitor. Although spontaneous spinal epidural hematoma (SSEH) following coronary intervention is extremely rare, clinicians should be aware of this unusual diagnosis. Prompt investigation with MRI and early referral for neurosurgical input are recommended to prevent potentially significant sequelae.

Inflammatory, regulatory, and autophagy co-expression modules and hub genes underlie the peripheral immune response to human intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) has a high morbidity and mortality. The peripheral immune system and cross-talk between peripheral blood and brain have been implicated in the ICH immune response. Thus, we delineated the gene networks associated with human ICH in the peripheral blood transcriptome. We also compared the differentially expressed genes in blood following ICH to a prior human study of perihematomal brain tissue.

METHODS

We performed peripheral blood whole-transcriptome analysis of ICH and matched vascular risk factor control subjects (n = 66). Gene co-expression network analysis identified groups of co-expressed genes (modules) associated with ICH and their most interconnected genes (hubs). Mixed-effects regression identified differentially expressed genes in ICH compared to controls.

RESULTS

Of seven ICH-associated modules, six were enriched with cell-specific genes: one neutrophil module, one neutrophil plus monocyte module, one T cell module, one Natural Killer cell module, and two erythroblast modules. The neutrophil/monocyte modules were enriched in inflammatory/immune pathways; the T cell module in T cell receptor signaling genes; and the Natural Killer cell module in genes regulating alternative splicing, epigenetic, and post-translational modifications. One erythroblast module was enriched in autophagy pathways implicated in experimental ICH, and NRF2 signaling implicated in hematoma clearance. Many hub genes or module members, such as IARS, mTOR, S1PR1, LCK, FYN, SKAP1, ITK, AMBRA1, NLRC4, IL6R, IL17RA, GAB2, MXD1, PIK3CD, NUMB, MAPK14, DDX24, EVL, TDP1, ATG3, WDFY3, GSK3B, STAT3, STX3, CSF3R, PIP4K2A, ANXA3, DGAT2, LRP10, FLOT2, ANK1, CR1, SLC4A1, and DYSF, have been implicated in neuroinflammation, cell death, transcriptional regulation, and some as experimental ICH therapeutic targets. Gene-level analysis revealed 1225 genes (FDR p < 0.05, fold-change > |1.2|) have altered expression in ICH in peripheral blood. There was significant overlap of the 1225 genes with dysregulated genes in human perihematomal brain tissue (p = 7 × 10-3). Overlapping genes were enriched for neutrophil-specific genes (p = 6.4 × 10-08) involved in interleukin, neuroinflammation, apoptosis, and PPAR signaling.

CONCLUSIONS

This study delineates key processes underlying ICH pathophysiology, complements experimental ICH findings, and the hub genes significantly expand the list of novel ICH therapeutic targets. The overlap between blood and brain gene responses underscores the importance of examining blood-brain interactions in human ICH.

Rounded intraplacental hematoma - A high risk placental lesion as illustrated by a prospective study of 26 consecutive cases

BACKGROUND

A rounded intraplacental hematoma (RIH) is a recently delineated placental lesion. Following the observation of two cases of RIH in placentas associated with stillbirth in 2012, we postulated that RIHs were associated with a higher risk obstetric phenotype when compared to other lesions characteristic of maternal vascular malperfusion (MVM). We aimed to investigate this further by reviewing the associated maternal and fetal characteristics in a series of prospectively identified cases.

METHODS

Pregnancies where a RIH was identified on placental examination were prospectively collected from February 2014-July 2016. Comparison was made with pregnancies with placental evidence of MVM but without RIH.

RESULTS

26 placentas with a RIH were identified and 26 placentas with MVM were selected for comparison. There was a statistically significantly increased incidence of stillbirth in the RIH group as compared with the MVM-only group (p = 0.022). Also, pregnancies with RIHs had a lower maternal age (p = 0.041), decreased incidence of antenatally diagnosed growth restriction (p = 0.023), a trend to increased incidence of clinical abruption (p = 0.051) and heavier mean infant birthweight (p = 0.034). Both groups had a high incidence of pre-eclampsia, Caesarean section and preterm delivery when compared with the general population.

DISCUSSION

This is the first study to prospectively identify and collect RIHs using standardised pathological criteria and more than doubles the number of reported cases to date. We present 2 comparable, high-risk cohorts but with a significantly increased incidence of stillbirth in those in which RIHs were seen. Further study of these lesions is justified with an emphasis on the potential for antenatal detection using ultrasound evaluation of placental texture.

Pericardial injury with cardiac tamponade and bleeding from the pericardium confirmed using contrast-enhanced computed tomography: a case report

BACKGROUND

Simple pericardial injuries are asymptomatic in many cases and usually do not cause bleeding that leads to cardiac tamponade. In this study, however, we report a case involving a patient with pericardial injury, in whom extravasation in the pericardium was identified using contrast-enhanced computed tomography (CT).

CASE PRESENTATION

A 67-year-old man fell from a 3-m-high ladder and was injured and transported to our hospital. No pericardial effusion was observed on focused assessment with sonography for trauma (FAST) or plain CT on arrival, but pericardial effusion was detected on follow-up observation. Thereafter, his circulatory dynamics began to deteriorate. We then performed FAST to identify the bleeding source, but it was difficult to visualize on echocardiography. Thus, contrast-enhanced CT (CECT) was performed and extravasation was confirmed in the pericardium. We believed that the accumulation of pericardial effusion caused cardiac tamponade; hence, we performed emergent thoracotomy. When we released the cardiac tamponade, his circulatory dynamics improved, and we could stabilize the patient's condition by ligating the bleeding vessel from the pericardium.

CONCLUSION

If visualization is difficult on FAST, like in this case, CECT is useful for identifying the cause of pericardial effusion if circulatory dynamics can be determined. We were able to confirm that extravasation occurred from the pericardium using CECT; hence, we could confirm that pericardial injury caused bleeding and may cause cardiac tamponade. Thus, if cardiac tamponade is suspected, not only damage to the heart itself, but also damage caused by pericardial vascular injury should be considered. Further, if circulatory dynamics are stable, CECT should be performed.

Acute Compartment Syndrome of the Forearm Secondary to Hematoma after Playing Golf

Acute compartment syndrome of the forearm secondary to hematoma without direct trauma has been reported rarely. We report a case of acute compartment syndrome of the forearm following a hematoma after playing golf. A 55-year-old man felt pain in his left forearm while playing golf that gradually worsened. He could not continue to play and visited the emergency department of our hospital. The radial side of his left forearm was markedly swollen on presentation, and he suffered severe pain that worsened with ulnar flexion of the wrist; no paralysis or hypesthesia was observed. A hematoma in the brachioradialis was seen on magnetic resonance imaging, and radial compartment pressure was 120 mmHg. A diagnosis of acute compartment syndrome was made, and urgent fasciotomy was performed. The patient recovered with no dysfunction of the arm.

Ultrasound of Soft Tissue Masses and Fluid Collections

Soft tissue masses and fluid collections are frequently encountered in sonographic practice, either as principal indication for diagnostic examination or as an incidental finding during an examination performed for other indications. Sonography is a good first-line imaging modality for evaluation of superficial masses and fluid collections, but requires meticulous attention to technique to avoid diagnostic pitfalls. Although many superficial masses are diagnosed with ultrasound, there are several potential diagnostic challenges, including differentiating hematomas from sarcomas. This article provides an image-rich review of the sonographic features of common soft tissue masses, with emphasis on practical tips to accurately recognize important pathology.

Simulation of Urgent Airway Management in a Postthyroidectomy Hematoma

INTRODUCTION

An expanding neck hematoma following thyroidectomy is a rare complication requiring urgent airway management and potential bedside evacuation before definitive surgical intervention. Due to its rare occurrence and life-threatening consequences, appropriate crisis resource management and a systematic approach are critical for patient safety.

METHODS

In this simulation scenario using a high-fidelity mannequin, a 68-year-old male presented with an expanding cervical hematoma 2 hours after a total thyroidectomy. The target audience was junior residents (PGY 1, PGY 2) in otolaryngology-head and neck surgery. Residents were given a case stem to encourage active information gathering through history and physical examination. Setup and flow of the scenario were designed for residents to prioritize establishing an airway through bedside decompression of the hematoma prior to making operating room arrangements for definitive management. Standardized patients playing a ward nurse and patient family member added complexity to the case.

RESULTS

Since 2012, the simulation has been used with a total of 96 residents as part of an annual boot camp. Surveys conducted after the boot camp verified the effectiveness of simulations in learning and, specifically, the usefulness of this scenario.

DISCUSSION

Simulation-based training is an effective learning modality for critical cases in health care disciplines involving emergency airway management. A well-developed simulation that closely resembles a real-life scenario is essential in creating a rich learning environment for trainees. Our scenario can be a valuable resource for other institutions implementing simulation-based training as part of their medical education.

Bladder hematoma: a complication from an oocyte retrieval procedure

INTRODUCTION

More than one million fertilization cycles are performed every year. The incidence of serious complications associated with transvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are inherent to procedures in which thin needles and sharp instruments are introduced into the vaginal wall and ovarian capsule to access the ovaries.

CASE DESCRIPTION

A 45-year-old patient reported urinary discomfort and difficulty urinating after her second cycle, 12 hours after oocyte pick-up. She had visible hematuria with small blood clots. Transvaginal ultrasound examination performed 24 hours after pick-up showed a heterogeneous intravesical image suggestive of a clot; her bladder measured 23x19mm. She was afebrile and in good condition. The patient was managed conservatively and offered fluids. The clot was expelled within a matter of hours. This case of a bladder hematoma was the first in the 21 years of a clinic where all procedures are guided by ultrasonography with clear visualization of the tip of the needle throughout the 15-20 minutes of the procedure. Patients submitted to ultrasound-guided transvaginal oocyte pick-up procedures in IVF protocols must be informed of this rare potential complication.

Progressive Osteolysis with Hematoma Following Revision Total Hip Arthroplasty using Hydroxyapatite Mesh: A Case Report

Introduction:

Osteolysis around the prosthesis following total hip arthroplasty (THA) is usually expanded slowly in the mid to long term, not progressive in the short term. Hematoma around the prosthesis is a rare phenomenon after a period of 1 year or more after surgery other than metal on metal THA. In addition, there are no studies reporting that hydroxyapatite (HA) itself has a possibility to cause osteolysis or hematoma after THA. This case has a particular disease phenomenon with three unusual factors, such as progressive osteolysis, hematoma, and HA debris in granulation tissue, following revision THA.

Case Report:

A 79-year-old woman with pain in the left hip joint underwent a revision THA, using HA mesh and ultra high molecular weight polyethylene fiber cable for impaction bone grafting to fill a bone defect in the proximal femur in 2011. There were no abnormal findings clinically or on radiograph until 2014. Moderate osteolysis was observed at the lesser trochanter and the area distal to the greater trochanter on the radiograph in 2015. The synovial fluid culture was negative. On magnetic resonance imaging examination, the margin showed a low-density shell in both the T1- and T2-weighted images, and the inside was a mosaic mass, with mixed low- and high-density are as extending in a multidirectional manner. During surgery, cystic mass covered with a thick membrane was found around the artificial hip joint, and the inside of the capsule was full of solid and fluid hematoma and dark blood. There was no apparent wear and tear debris of the implant. On pathological examination, evidence of chronic hematoma, granulation tissue, and HA debris, interspersed inside the granulation tissue were observed.

Conclusion:

We experienced an extremely rare case with osteolysis and hematoma that progressively expanded in a short period of time after revision THA using HA mesh, which seemed to be caused by, crushed HA and resulted in osteolysis accompanied by hematoma. This case revealed that HA it has a possibility to cause osteolysis or hematoma after THA.