Continuous Suction Drainage of Postoperative Hematoma and Seroma Using Cystofix Device

In this study, an easy and useful method used for the drainage of seroma and hematoma formations occurring after operations requiring extensive tissue undermining is presented. The method utilizes the trocar of the conventional suprapubic urinary catheterization system in combination with the catheter of the negative pressure vacuum drainage system. It provides quick, safe, and painless seroma and hematoma evacuation and can easily be performed in office setting.

NO LEVEL ASSIGNED

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The etiologic subtype of intracerebral hemorrhage may influence the risk of significant hematoma expansion

BACKGROUND

Intracerebral hemorrhage (ICH) growth is an important independent predictor of clinical deterioration and outcome. Little is known about the association between etiology of ICH and occurrence of hematoma expansion (HE). The aim of the present study was to assess whether ICH etiologic subtype may influence the risk of significant HE.

METHODS

We conducted an analysis on retrospectively collected data of 424 consecutive patients with ICH, who were admitted to the Verona General Hospital, from March 2011 to December 2014. Using the SMASH-U (Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined) classification, we identified the ICH etiologic subtypes. Outcome measure was significant HE (an absolute increase in ICH volume>12.5 mL or >50%) within 48 h.

RESULTS

Significant HE occurred in 11/57 (19.3%) Amyloid, 7/14 (50%) Structural, 31/57 (54.4%) Medication, 25/44 (56.8%) in Systemic, 62/139 (44.6%) Hypertensive, and 21/68 (30.9%) Undetermined ICH. Baseline ICH volume (OR 1.011 per mL, 95% CI 1.006-1.017, p<0.001) and onset-to-baseline CT time (OR 0.919 per hour, 95% CI 0.852-0.990, p=0.027) were predictors of significant HE. Compared with Amyloid ICH, ORs for significant HE were higher in patients with Structural ICH (OR 1.430, 95% CI 1.060-1.948, p=0.023), Medication ICH (OR 4.344, 95% CI 1.382-13.653, p=0.012), Systemic ICH (OR 1.796, 95% CI 1.070-3.015, p=0.027), and Hypertensive ICH (OR 3.081, 95% CI 1.426-6.655, p=0.004).

CONCLUSION

Our study shows that Structural, Medication, Systemic, and Hypertensive ICH were the etiologic subtypes associated with a higher risk of significant HE, compared with Amyloid ICH patients.

Huge Intramural Hematoma in a Thrombosed Middle Cerebral Artery Aneurysm: A Case Report

We describe a case of a huge intramural hematoma in a thrombosed middle cerebral artery aneurysm. A 47-year-old female patient with liver cirrhosis and thrombocytopenia presented to the neurosurgical unit with a 5-day history of headache and cognitive dysfunction. Magnetic resonance imaging and computed tomography of the brain showed a thrombosed aneurysm located in the right middle cerebral artery with a posteriorly located huge intramural hematoma mimicking an intracerebral hematoma. Imaging studies and cerebrospinal fluid analysis showed no evidence of subarachnoid hemorrhage. Angiography showed a partially thrombosed aneurysm at the origin of the right anterior temporal artery and an incidental aneurysm at the bifurcation of the right middle cerebral artery. Both aneurysms were embolized by coiling. After embolization, the thrombosed aneurysmal sac and intramural hematoma had decreased in size 4 days later and almost completely disappeared 8 months later. This is the first reported case of a nondissecting, nonfusiform aneurysm with a huge intramural hematoma, unlike that of a dissecting aneurysm.

Outpatient Thyroidectomy: Is it Safe?

Outpatient thyroid surgery is controversial because of concerns over life-threatening cervical hematoma. Despite this concern, outpatient thyroidectomy is becoming increasingly common, especially among high-volume endocrine surgeons. Multiple studies have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. This article reviews the data on safety and outcomes for outpatient thyroidectomy and discusses several techniques used to minimize risk to patients.

[Clinical spectrum of patients with spontaneous retroperitoneal hematomas]

INTRODUCTION AND OBJECTIVE

Spontaneous retroperitoneal hematoma (SRH) is a potentially fatal clinical entity requiring immediate recognition and intervention.

MATERIAL AND METHODS

The clinical records of 18-year-old and older patients admitted to the University Hospital Marqués de Valdecilla from 2003 to 2013 were reviewed. "Spontaneous" was defined as unrelated to trauma, invasive procedures or bleeding due to aortic aneurysm rupture.

RESULTS

Thirty-four patients with SRH (44% were on anticoagulant drugs). One-third of cases had chronic renal insufficiency. Abdominal pain was the most common symptom both in anticoagulated and non-anticoagulated patients (80% in anticoagulated and 89% in non-anticoagulated patients). About one half of the patients developed shock. A CT scan was the most commonly performed diagnostic test, followed by abdominal ultrasound. Most cases were managed conservatively (80%). More than half of the patients (66%) restarted anticoagulation therapy after the acute event with a mean delay of 19 days (range 2-90 days). None of them suffered a new bleeding episode.

CONCLUSION

Restarting the anticoagulation treatment after hematoma resolution seems to be a safe practice. There is an increasing frequency of SRH in non-anticoagulated patients.

The Optimal Surgical Approach for Treatment of Chronic Subdural Hematoma: Questionnaire Assessment of Practice in Iran and Review of Literature

Chronic subdural hematoma (CSDH) is a curable entity frequently encountered by neurosurgeons. The present study was conducted to explore expert opinion and common practice in Iran. Besides, a Review of randomized clinical trials in literature was performed. A questionnaire including six questions discussing major aspects of practice on CSDH, with multiple choices was designed. A pilot study was performed for reliability analysis of the questionnaire. A total of 100 neurosurgeons were selected randomly from the members of Iranian Association of Neurological Surgeons. Frequency of answers to each item, differences in response rates and correlation of various categories were analyzed using Chi-square statistics. The mean duration of experience was 15.4 ± 5 years, with a range of 10 to 37 years. The most common initial procedure of choice was burr-hole drainage (64%). At recurrent cases, surgical approach was changed to craniotomy at one-third of those treated initially with burr-hole drainage. The participants believed that surgical technique was predictive of outcome and recurrence. Burr-hole without drainage was used by less expert neurosurgeons (mean 12.5 ± 6), however, burr-hole drainage was the dominant technique at more than 15 years of experience and craniectomy was used only by participants with more than 30 years of experience (10%). Irrigation was used by most of the neurosurgeons (87.5%) in combination with drainage and burr-hole. The majority of participants used flat position at the postoperative period. At the current study, the pattern of management for CSDH was similar to other reports at literature suggesting the burr-hole drainage and irrigation as optimal treatment. Individualized decision-making could be made at challenging cases.

Spontaneous Pulmonary Hematoma with No Underlying Causes: A Case Report

A 57-year-old male patient was admitted to our center because of a cystic mass on the lower portion of the right major fissure that was found incidentally by chest X-ray. He did not have a history of trauma or anticoagulant use. The lesion was removed by video-assisted thoracoscopic surgery. Pathological examination revealed an organizing pulmonary hematoma without any complications, and a follow-up chest X-ray after 1 year showed no recurrence.

Surgical Treatment of a Life-Threatening Large Retropharyngeal Hematoma after Minor Trauma : Two Case Reports and a Literature Review

Only a few cases of anterior longitudinal ligament (ALL) injury related with retropharyngeal hematoma without fracture have previously been reported. The treatment of choice for retropharyngeal hematoma is generally considered to be conservative care, but we believe that early surgery of this pathology would be better in certain situations. Here, we describe two cases with life-threatening large retropharyngeal hematomas related with ALL injuries and operated on at an early stage. Two previously healthy patients visited the emergency room with neck pain and dyspnea after falling. Serious neck swelling was observed and lateral neck X-ray showed severe widening of the prevertebral space. Due to dyspnea progression, emergency endotracheal intubation was performed. Although there was no primary cause of the retropharyngeal hematoma on preoperative examination, ALL tearing was intraoperatively confirmed during early surgery. The in-hospital evolutions of the patients were favorable after surgery. We should bear in mind the possibility of ALL injury and perform early surgery where possible given the earlier convalescence and good prognosis.

Does preoperative heparin increase the postoperative bleeding risk in women undergoing prosthetic breast implant surgery? A review of the data from a single institution

BACKGROUND

In 2008, the authors' institution adopted a policy requiring that all patients, regardless of preoperative risk, receive both sequential compression devices and a single preoperative subcutaneous 5000 unit injection of heparin. A previously published 12-year review at this same institution before this policy demonstrated a 1.5% 30-day postoperative incidence of hematoma in primary augmentation or delayed tissue expander based breast reconstructions.

OBJECTIVE

To determine the incidence of postoperative bleeding complications associated with preoperative administration of 5000 units of subcutaneous heparin and compare that incidence with previously published data.

METHODS

Patient data were collected prospectively and maintained in a secure database at a single institution with institutional review board approval. Current procedural terminology and International Classification of Diseases, Ninth Revision, coding was then used to identify all patients who received either primary breast augmentation or delayed tissue expander based breast reconstruction during a five-year period. The primary outcome was the incidence of postoperative bleeding complication. A bleeding complication was defined as any hemorrhagic event that required a return to the operating room.

RESULTS

The overall incidence of significant postoperative bleeding was 1.47% (five of 340 [1.16% augmentation, 2.50% expander]). Comparing the current results with the previously published data, demonstrated an OR of 0.98 (95% CI 0.38 to 2.55).

CONCLUSION

In women undergoing primary breast augmentation or delayed tissue expander breast reconstruction, heparin prophylaxis did not increase the risk for significant postoperative bleeding compared with historical controls.

Dual antiplatelet therapy increases pocket hematoma complications in Chinese patients with pacemaker implantation

Objective

To assess the prevalence of the bleeding complications in pacemaker implanted patients receiving different antiplatelet regimens, and the influence of each regimen on hospital stays after device implantation.

Methods

We prospectively enrolled 364 patients receiving the cardiac rhythm device implantations in Fuwai Hospital from July 2012 to December 2013. Bleeding complications including pocket hematoma, hemothorax, cardiac tamponade and blood transfusion requirement were measured as endpoints. Post operation hospital stay was also included in the endpoints.

Results

Bleeding complications were detected in 15 patients (14 with hematoma, one with hemothorax) out of all 364 patients (4.12%). Dual antiplatelet therapy (DAT) significantly increased hematoma (19.3%) compared with aspirin treatment (ASA) (3.2%, P = 0.001) and no antiplatelet therapy (1.9%, P < 0.001). There was no significant difference in incidence of pocket hematoma between the ASA group and the control group (P = 0.45). The post procedure hospital stay was longer in DAT group (5.45 ± 2.01 days) compared to those in the ASA group (3.65 ± 1.37 days, P < 0.05) or control group (3.99 ± 2.27 days, P < 0.05). Pocket hematoma was considered an independent predictor of hospital stay prolongation (OR: 5.26; 95% CI: 1.56−16.64; P = 0.007).

Conclusions

Among the Chinese patients undergoing device implantation in this study, the use of dual antiplatelet agents significantly increased the risk of pocket hematoma complications and led to a longer hospital stay. Use of aspirin alone did not increase the risk.

Intraneural Hematoma: A Proposed Anatomic Classification with Potential Treatment Implications

Intraneural hematoma is a rare entity with fewer than 20 cases reported in the literature. There is no consensus on surgical treatment due to its rarity. We present a novel classification for intraneural hematomas based on a review of the literature and illustrated by 4 cases that were treated in our 3 centers. This classification system localizes the hematoma to the different connective tissue layers that compose the nerve: the paraneurium, epineurium, and perineurium. We believe that this classification has consequences for surgical treatment and can form the foundation for future research into the natural history of these types of lesions.

Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery

The authors describe a case of a rare complication occurring after cardiac surgery. Three weeks after aortic valve replacement a young male became hemodynamically unstable. The echocardiogram showed a large loculated hematoma compressing the right atrium. The patient was reoperated and the mass was removed. Recovery was complete.

Imaging characteristics of sinonasal organized hematoma

BACKGROUND

Sinonasal organized hematoma is a rare benign disease that may be mistaken for malignancy.

PURPOSE

To define the imaging characteristics of sinonasal organized hematoma.

MATERIAL AND METHODS

We retrospectively reviewed computed tomography (CT) images of eight patients (4 male patients, 4 female patients; mean age, 40 years; range, 9-83 years) with pathologically proven sinonasal organized hematomas; magnetic resonance imaging (MRI) was performed in one patient among them. The following lesions characteristics were analyzed: size, shape, location, expansile nature, density, signal intensity, internal structure, enhancement pattern, and surrounding bony wall change.

RESULTS

The lesion sizes were in the range of 2-5.2 cm (mean, 3.55 cm), and the shapes were lobular, lumpy, or nodular. They were located in the nasal cavity (n = 1), maxillary sinuses (n = 2), or both nasal cavities and maxillary sinuses (n = 5). Expansile lesions with locally aggressive margins were observed in two cases. All lesions were hyperdense on precontrast CT scans; the smaller lesions showed even hyperdensity, whereas the larger lesions showed uneven density. The signal intensity was mixed on MRI, consisting of hemorrhage, fibrosis, and neovascularization. Papillary or frond-like enhancement was noted after contrast injection. All cases showed smooth erosion of the medial walls of the maxillary sinuses, and the epicenters were the secondary maxillary ostia. Two lesions showed erosion of the lateral walls of the maxillary sinuses and were expansile in nature. Non-hemorrhagic polyps accompanied the organized hematomas in three cases.

CONCLUSION

Although sinonasal organized hematoma can be mistaken for a malignant tumor, the following characteristic imaging findings facilitate the diagnosis of an organized hematoma: erosion of the bony sinus walls, markedly heterogeneous signal intensity, and papillary or frond-like enhancement.

Simultaneous bilateral cochlear implantation in a five-month-old child with Usher syndrome

OBJECTIVE

To report a rare case of simultaneous bilateral cochlear implantation in a five-month-old child with Usher syndrome.

METHOD

Case report.

RESULTS

A five-month-old boy with Usher syndrome and congenital profound bilateral deafness underwent simultaneous bilateral cochlear implantation. The decision to perform implantation in such a young child was based on his having a supportive family and the desire to foster his audiological development before his vision deteriorated. The subject experienced easily resolvable intra- and post-operative adverse events, and was first fitted with an externally worn audio processor four weeks after implantation. At 14 months of age, his audiological development was age-appropriate.

CONCLUSION

Simultaneous bilateral cochlear implantation is possible, and even advisable, in children as young as five months old when performed by an experienced implantation team.

[Breast hematoma masking a sarcoma]

Sarcomas account for less than 1% of malignant breast tumors. We present the case of a sarcoma (malignant fibrous histiocytoma) of the breast that debuted as a lump. The patient associated the lump with trauma, and the clinical, sonographic, and cytological findings were suggestive of a hematoma. The lump grew rapidly, and the follow-up sonogram one month later clearly revealed hypervascular solid poles. This atypical presentation is useful for reviewing the management of lesions suggestive of hematomas, which are often associated with nonspecific findings and occasionally with signs that raise suspicion of malignancy. The emergence of what appears to be a hematoma in the breast, even when accompanied by a history of trauma or a tendency toward bleeding, calls for prudence: very short-term follow-up and biopsy, even excisional biopsy, are recommended if the lesion does not evolve like a hematoma.

Chronic intradiploic hematomas of the skull without coagulopathy: Report of two cases

BACKGROUND

Chronic intradiploic hematoma was first described by Chorbski and Davis in 1934. To date, only twelve cases have been reported in the literature. Chronic intradiploic hematomas have also been described as non-neoplastic cysts of the diploe, traumatic cysts, and giant cell repetitive granulomas. The term chronic intradiploic hematoma was coined by Sato et al. in 1994.

CASE DESCRIPTION

Case 1: a 16-year-old male presented with a non-tender scalp swelling on the right fronto-orbital region. Computed tomography (CT) scans showed an intraosseous isodense lesion with surrounding sclerosis. Magnetic resonance imaging (MRI) results revealed an intradiploic mass with homogeneous cystic and abnormal signal intensities. Case 2: a 64-year-old male presented with a 6-month history of headaches and visual disturbances. CT scans showed an isodense lesion with surrounding sclerosis in the posterolateral left orbit. MRI results revealed a hypointense lesion on both the T1weighted and T2-weighted images of the posterolateral left orbit.

CONCLUSION

Although rarely seen, the presence of a benign chronic hematoma should be considered as part of the differential diagnosis for each intradiploic mass lesion. When taking the medical history, all patients with such mass lesions should be asked about previous minor or major head traumas. Due to the possibility of progressive growth, surgical excision of an intradiploic hematoma is recommended after radiological diagnosis of the condition.

Post-traumatic Jejunojejunal Intussusception

Intussusception is a well-known cause of acute abdomen in the pediatric population. Traumatic intussusception is exceedingly rare, with only 22 cases reported in the English language literature. We report a case of jejunojejunal intussusception that happened after blunt trauma to the abdomen in a 10-year-old boy. The patient presented with clinical presentation of small-bowel obstruction. Through this case and brief review of the literature, we try to focus on the etiology of this rare condition, the clinical particularities, and treatment modalities.

Hemophilia A in a Senior Patient: A Case Report of Spinal Epidural Hematoma as First Presentation

Hemophilia A is a hereditary coagulation disorder. Most cases are diagnosed at birth or at least during childhood. A spontaneous spinal epidural hematoma was developed in a 74-year-old male patient who hadn't had a family or past medical history of bleeding disorders. On magnetic resonance imaging, epidural hematoma at L1-2 was accompanied by spinal stenosis at L4-5 and spondylolytic spondylolisthesis at L5. Hematoma evacuation and surgery for distal lumbar lesions were performed at once. After transient improvement, complete paraplegia was developed due to redevelopment of large epidural hematomas at L1-2 and L4-S1 which blocked epidural canal completely. Emergency evacuation was performed and we got to know that he had a hemophilia A. Factor VIII was 28% of normal value. Mild type hemophilia A could have not been diagnosed until adulthood. Factor VIII should have been replaced before the surgical decompression.

Simple suturing of the nasal septum using the Maniceps septum stitch device

OBJECTIVE

To present the utility of the recently introduced Maniceps septum stitch device for suturing of the nasal septum.

METHODS

This paper describes nasal septum suturing techniques using the Maniceps septum stitch device following septoplasty to prevent post-operative complications such as haematoma and nasal septum perforation.

CONCLUSION

Nasal septum suturing using the Maniceps septum stitch device appears to be a safe and easy surgical procedure to help prevent post-operative complications and may reduce the incidence of nasal septum perforation following septoplasty.

Large intraluminal ileal hematoma presenting as small bowel obstruction in a child

Intraluminal small bowel hematoma has been rarely reported in children, as a rare cause of small bowel obstruction. We present a case of an intraluminal ileal hematoma presenting as small bowel obstruction in a child. Computed Tomography (CT) indicated a large intraluminal hyperdense lesion in the distal ileum as the cause of small bowel obstruction. Abdominal ultrasonography (US) showed an echogenic mass-like lesion with multiple septa in the distal ileum. Small bowel obstruction due to a complicated cystic mass was provisionally diagnosed. Histopathologic examination of the resected mass suggested a submucosal ileal hematoma. Although intraluminal small bowel hematoma is rare in children, it can present as an intraluminal cystic mass and should be considered as a rare cause of small bowel obstruction. The US and CT findings of submucosal ileal hematoma could be useful for the diagnosis of such cases in the future.

Acute compartment syndrome occurring in forearm with relatively small amount of hematoma following transradial coronary intervention

A 59-year-old female with angina pectoris successfully underwent percutaneous coronary intervention via the right radial artery. She complained of right forearm pain and numbness 4.5 h after the procedure. Though the swelling in her right arm seemed relatively mild, pressure measurement showed significant increase of internal forearm pressure. She developed acute compartment syndrome in the right forearm, and fasciotomy was performed immediately. The weight of subcutaneous hematoma in her right arm was approximately 100 g. Symptoms of paralysis and the impairment of perception remained for some time, but had completely recovered 4 months post-surgery.

Delayed Orbital Hemorrhage around Alloplastic Implants after Blowout Fracture Reduction

Alloplastic implants have been used to repair orbital wall fractures in most cases. Orbital hemorrhage is a rare complication of these implants and has been reported rarely in Korea. The purpose of this article is to report a late complication case focusing on their etiology and management. A 20-year-old male patient underwent open reduction with Medpor (porous polyethylene) insertion for bilateral orbital floor fractures. The initial symptom occurred with proptosis in the right side as well as vertical dystopia, which had started 4 days earlier, 8 months after surgery. Any trauma history after the surgery was not present. We performed an exploration and removal of hematoma with Medpor titanium meshed alloplastic implant. A case of delayed orbital hematoma following alloplastic implant insertion was identified. It occurred within the pseudocapsule of the implant. One week after surgery, overall symptoms improved successfully, and no complications were reported during the 11-month follow-up period. Although rare, orbital hemorrhage is a potential complication of alloplastic orbital floor implants, which may present many years after surgery. As in the case presented, delayed hematoma should be included in the differential diagnosis of late proptosis or orbital dystopia.

Spontaneous Rectus Sheath Hematoma: an Overview of 4-Year Single Center Experience

Rectus sheath hematoma is a clinical entity characterized by the presence of blood within rectus abdominis muscle sheath. The aim of this study was to analyze clinical characteristics, diagnostic approach, treatment strategy, and outcomes of patients with rectus sheath hematoma. Patients diagnosed and treated for spontaneous rectus sheath hematoma between March 2010 and March 2014 were included in the study. A total of 10 patients were diagnosed as spontaneous rectus sheath hematoma. The mean age was 66.5 ± 16.9 years, and the mean hospital stay was 4.4 ± 1.8 days. There was no mortality. Six patients were using anticoagulant or antiplatelet agents. Eight patients recovered after conservative treatment. Two patients underwent surgery. Spontaneous rectus sheath hematoma is associated with anticoagulant therapy. Cases with abdominal pain and a non-pulsatile abdominal mass particularly in elderly women should be kept in mind. Treatment is mostly based on supportive care to preserve hemodynamic stability.

Lower extremity hemorrhage in patients with spinal cord injury receiving enoxaparin therapy

Low-molecular-weight heparin is commonly favored over unfractionated heparin because of its predictable pharmacokinetic and pharmacodynamic properties. However, full-dose enoxaparin can cause major soft tissue bleeding that may lead to compartment syndrome and even limb amputation. In patients with spinal cord injury, range of motion exercises should be carefully performed if on full-dose enoxaparin. This vulnerable patient population is particularly susceptible to aggressive stretching, which could lead to bleeding, and compartment syndrome. Providers should also monitor weight fluctuations in patients receiving full-dose enoxaparin. Changes in weight without proper dose adjustment can cause over or under treatment. Attention to both these issues can improve patient care.