Clinical characteristics of acute aortic syndrome in korean patients: from the korean multi-center registry of acute aortic syndrome

Background and Objectives

Acute aortic syndrome (AAS) is a heterogeneous group of disorders that often present with severe chest or back pain. It includes acute aortic dissection (AD), intramural hematoma (IMH), dissecting aneurysm, and penetrating aortic ulcer (PAU). The clinical picture of AAS and its prognosis have not been studied in a large number of Korean patients. Therefore, we organized a multi-center registry to identify the clinical characteristics and treatment patterns, as well as long-term outcomes in Korean patients with AAS.

Subjects and Methods

Five-hundred twenty-eight patients, who had been diagnosed with AAS, were enrolled into this registry from 10 centers. On a retrospective basis, we collected demographic, laboratory, imaging data, as well as follow-up clinical outcomes by reviewing medical records from individual centers. All the data were collected in core lab and analyzed in detail.

Results

The mean patient age was 60.1±14.5 years; the male-to-female ratio was M : F=297 : 231. The prevalent risk factors for AAS included hypertension (361, 68.4%) and diabetes (52, 11.1%). The components of AAS that are included in this study are acute AD (446, 84.5%), IMH (57, 10.7%), and PAU (11, 2.1%). By type of AAS, patients diagnosed with Stanford A were 45.6% of enrolled patients, whereas those with Stanford B were 54.4% of enrolled patients. Among nearly half of the patients were treated with medicine (55.7%) alone, whereas 40.0% underwent surgery and 4.3% underwent endovascular treatment. Overall, the in-hospital event rate was 21.2% and the in-hospital death rate was 8.1%. The mean follow-up duration was 42.8 months and there showed 22.9% of total event and 10.1% of death during this period.

Conclusion

By organizing a multi-center registry of AAS, we could identify the characteristics of AAS in real-world Korean patients. Further, prospective study is warranted with a larger number of patients.

Antithrombotic or anti-platelet agents in patients undergoing permanent pacemaker implantation

Background and Objectives

The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. We assessed the risk of significant bleeding complications in patients receiving anti-platelet agents or anticoagulants at the time of permanent pacemaker (PPM) implantation.

Subjects and Methods

We reviewed bleeding complications in patients undergoing PPM implantation. The use of aspirin or clopidogrel was defined as having taking drugs within 5 days of the procedure and warfarin was changed to heparin before the procedure. A significant bleeding complication was defined as a bleeding incident requiring pocket exploration or blood transfusion.

Results

Permanent pacemaker implantations were performed in 164 men and 96 women. The mean patient age was 73±11 years old. Among the 260 patients, 14 patients took warfarin (in all of them, warfarin was changed to heparin at least 3 days before procedure), 54 patients took aspirin, 4 patients took clopidogrel, and 25 patients took both. Significant bleeding complications occurred in 8 patients (3.1%), all of them were patients with heparin bridging (p<0.0001). Heparin bridging markedly increased the length of required hospital stay when compare with other groups and the 4 patients (1.5%) that underwent the pocket revision for treatment of hematoma.

Conclusion

This study suggests that hematoma formation after PPM implantation was rare, even among those who had taken the anti-platelet agents. The significant bleeding complications frequently occurred in patients with heparin bridging therapy. Therefore, heparin bridging therapy was deemed as high risk for significant bleeding complication in PPM implantation.

Intramural hematoma of the esophagus

We report the case of a patient with an intramural hematoma of the esophagus. This rare condition is more common in elderly women and can be misdiagnosed as cardiovascular or other digestive emergent disease. The classical clinical triad includes chest pain, sudden dysphagia or odynophagia and minor hematemesis. Known precipitating factors are Valsalva maneuver, blunt, direct or iatrogenic injuries, but spontaneous cases have also been described. Chest imaging including computed tomography or magnetic resonance imaging as well as upper gastrointestinal endoscopy are useful tools for diagnosis. The treatment is conservative and the prognosis usually excellent with complete resolution within a few weeks.

Symptomatic extensive thoracolumbar epidural hematoma following lumbar disc surgery treated by single level laminectomy

Spinal epidural hematomas (SEHs) are rare complications following spine surgery, especially for single level lumbar discectomies. The appropriate surgical management for such cases remains to be investigated. We report a case of an extensive spinal epidural hematoma from T11-L5 following a L3-L4 discectomy. The patient underwent a single level L4. A complete evacuation of the SEH resulted in the patient's full recovery. When presenting symptoms limited to the initial surgical site reveal an extensive postoperative SEH, we propose: to tailor the surgical exposure individually based on preoperative findings of the SEH; and to begin the surgical exposure with a limited laminectomy focused on the symptomatic levels that may allow an efficient evacuation of the SEH instead of a systematic extensive laminectomy based on imaging.

Spontaneous perforation of an intramural rectal hematoma: Report of a case

Spontaneous hematomas are rare and most occur secondary to hematologic disorders or during anticoagulant therapy. Most spontaneous hematomas occur above the sigmoid colon, and rarely in the rectum. Herein we present the case of a patient with a spontaneous perforating hematoma of the rectum who presented with severe abdominal pain after a bloody stool. The hemoglobin level decreased by 33 g/L within 20 h. An abdominal sonogram showed a hydrops in the lower abdomen with a maximum depth of 7.0 cm. A hematoma, 8 cm × 6 cm × 5 cm in size, was noted intra-operatively in the rectosigmoid junction, with a 1.5-cm perforation in the hematoma and active hemorrhage. Thus, a partial rectectomy and sigmoidostomy were performed. Three months later, a second operative procedure to re-establish intestinal continuity was performed. The patient is in good condition 12 mo after the last surgery. In addition to this case, the causes of spontaneous perforating hematomas and the treatment are discussed.

Splenic Injury and ERCP: A Possible Risk for Patients with Advanced Chronic Pancreatitis

Splenic injury is a rare but potentially life-threatening complication of endoscopy, with very few cases of endoscopic retrograde cholangiopancreatography (ERCP)-induced injury reported in the literature. Here we report a patient with chronic alcoholic pancreatitis who was diagnosed with a sub-capsular splenic laceration nearly 6 days after an ERCP. Clinicians should be alerted to the potential post-procedure complications associated with ERCP, particularly as this procedure is being utilized more frequently for the management of patients with complex hepatobiliary and pancreatic conditions.

Traumatic lumbar hernia

BACKGROUND

Trauma has various presentations ranging from common injuries that are easily managed to uncommon presentations such as traumatic hernia that may be missed.

METHODS

Despite being operated for fracture of the femur after a road traffic accident, a 50-year-old female patient remained undiagnosed with a right sided traumatic lumbar hernia for nearly six months after the accident. In this period, the patient underwent incision and drainage thrice for swelling in the right flank which was diagnosed as an infected hematoma by a doctor.

RESULTS

The patient underwent surgery for repair of traumatic lumbar hernia by combined fascia lata graft and mesh hernioplasty. She remains well on follow-up.

CONCLUSION

This case underscores the need for awareness of this entity for correct diagnosis and appropriate management that are the key to avoiding complications.

Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient -A case report-

The addition of thoracic epidural anesthesia to general anesthesia during cardiac surgery may have a beneficial effect on clinical outcome. However, epidural catheter insertion in a patient anticoagulated with heparin may increase the risk of epidural hematoma. We report a case of epidural hematoma in a 55-year-old male patient who had a thoracic epidural placed under general anesthesia preceding uneventful mitral valve replacement and tricuspid valve annular plasty. During the immediate postoperative period and first postoperative day, prothrombin time (PT) and activate partial thromboplastin time (aPTT) were mildly prolonged. On the first postoperative day, he complained of motor weakness of the lower limbs and back pain. An immediate MRI of the spine was performed and it revealed an epidural hematoma at the T5-6 level. Rapid surgical decompression resulted in a recovery of his neurological abnormalities to near normal levels. Management and preventing strategies of epidural hematoma are discussed.

Factors associated with hematoma of the floor of the mouth after placement of dental implants

PURPOSE

The aim of this article is to determine factors associated with hematoma during placement of dental implants in the anterior mandible and to provide the dental practitioner with preventive measures to avoid such a life-threatening complication.

METHODS

All available clinical case studies from (1986 to 2010) published in English or with English abstract were reviewed and analyzed.

RESULTS

Nineteen studies have been identified and written in the literature. Most of the reported studies were case series and they showed that hematoma is a very rare complication, but general dental practitioners do not pay attention to the significance of the mandible anatomy in the anterior area and the possibility of perforation of the lingual cortex during placement of the dental implants in that position.

CONCLUSIONS

The use of dental CT in planning the implant treatment coupled with accurate determination of implant length in order to provide detailed data about the mandible anatomy are highly recommended to avoid the occurrence of hematoma in the floor of the mouth and the airway obstruction that may lead to death during placement of dental implants in the anterior mandible.

Visual hemifield loss in thalamic hematoma

A 45 year old hypertensive patient presented to the emergency medical room (EMR) with sudden onset of severe headache, episode of vomiting, visual loss and confusion. A C.T scan and MRI brain was done revealing a large hematoma in the region of posterior part of left thalamus. The patient was disoriented in time, place and had right visual field hemianopia. The headache and higher functions became normal with control of intracranial pressure and supportive therapy. There were no motor or sensory symptoms or signs. This case is unique as a large thalamic hematoma presented with only visual field deficit and no sensory or motor system affection.

Hemorrhagic facet cyst in the lumbar spine causing contralateral leg symptoms: a case report

Here we present a case of hemorrhagic lumbar facet cyst presenting with progressive radiculopathy only on the contralateral side. If a patient has previous back pain or neuropathy for several months and then suddenly deteriorates, hemorrhagic facet cyst of the lumbar spine should be part of the differential diagnosis. However, as in the present case, we should be aware that there is a possibility of a contralateral lesion.

A huge mediastinal organizing hematoma causing reversal of atrial septal defect shunt flow

We report a case of a 46-year-old woman who presented with subacute exertional dyspnea and severe hypoxia. A large cystic mass compressing the right side of the heart along with right-to-left atrial shunt flow through an alleged atrial septal defect (ASD) were detected on echocardiography. CT scan of the chest and MRI of the heart revealed a loculated cystic mediastinal mass with hemorrhage measuring 5.5×8 cm compressing the right atrium and ventricle. The patient underwent cyst resection and primary closure of the ASD. This report illustrates a case of an unusual symptomatic pericardial mass compressing the right atrium and ventricle in a patient with an secundum ASD.

Posterior reversible encephalopathy syndrome in a case of postoperative spinal extradural haematoma: case report and review of literature

A 14-year-old girl presented with progressive paraparesis and paresthesia of one-year duration. Magnetic resonance imaging revealed a T6 vertebral hemangioma with epidural compression on the spinal cord. Following angiography and embolization, she underwent dorsal laminectomy and excision of the soft tissue component compressing the cord. In the postoperative period she had rapid worsening of lower limb power and imaging demonstrated an epidural haematoma at the operative site. The patient was taken up for urgent re-exploration and evacuation of haematoma. Postoperatively the patient complained of visual failure, headache and had multiple episodes of seizures. An magnetic resonance imaging brain showed characteristic features of posterior reversible encephalopathy syndrome (PRES) and the patient improved gradually after control of hypertension. This is the first documented case of PRES following spinal cord compression in a patient without any known risk factors. We postulate the possible mechanism involved in its pathogenesis.

Ligamentum Flavum Hematoma in the Adjacent Segment after a long Level Fusion

Ligamentum flavum hematoma (LFH) is a very rare condition of dural compression; most are observed in the mobile cervical and lumbar spine regions. A 67-year-old man who had a long level interbody fusion at L3-S1 four years ago presented with symptoms suggestive of dural compression. Magnetic resonance imaging showed a posterior semicircular mass located at the adjacent L2-L3 level. After decompression of the spinal canal and removal of the mass lesion, pathological examination of the surgical specimen revealed a hematoma within the ligamentum. The patient fully recovered to normal status after surgery. Here, we report our experience with a LFH in the adjacent segment after a long level fusion procedure and discuss the possible associated mechanisms.

A case of intra- and extra-mural hematomas during recanalization for chronic total occlusion

An intramural hematoma is an accumulation of blood between the internal and external elastic membranes within the medial space, whereas an extramural hematoma is a dilution and/or dissemination of blood throughout the adventitia. Intra- and extra-hematomas are observed by intravascular ultrasound during percutaneous coronary intervention (PCI). The patient described herein presented with angina pectoris. Her coronary angiogram showed diffuse narrowing of the mid-left anterior descending artery and total occlusion of the distal right coronary artery (RCA). Intra- and extra-mural hematomas developed during PCI of the RCA; however, the lesions were covered successfully using long drug-eluting stents.

Serial MR imaging of intramuscular hematoma: experimental study in a rat model with the pathologic correlation

Objective

We wanted to demonstrate the temporal changes of the magnetic resonance imaging (MRI) findings in experimentally-induced intramuscular hematomas in rats and to correlate these data with the concurrent pathologic observations.

Materials and Methods

Intramuscular hematoma was induced in 30 rats. The MR images were obtained at 1, 4, 7 and 10 days and at 2, 3, 4, 6 and 8 weeks after muscle injury. The characteristic serial MRI findings were evaluated and the relative signal intensities were calculated. Pathologic specimens were obtained at each time point.

Results

On the T1-weighted imaging (T1WI), the intramuscular hematomas exhibited isointensity compared to that of muscle or the development of a high signal intensity (SI) rim on day one after injury. The high SI persisted until eight weeks after injury. On the T2-weighted imaging (T2WI), the hematomas showed high SI or centrally low SI on day one after injury, and mainly high SI after four days. A dark signal rim was apparent after seven days, which was indicative of hemosiderin on the pathology. The gradient echo (GRE) imaging yielded dark signal intensities at all stages.

Conclusion

Unlike brain hematomas, experimentally-induced intramuscular hematomas show increased SI on both the T1WI and T2WI from the acute stage onward, and this is pathologically correlated with a rich blood supply and rapid healing response to injury in the muscle. On the T2WI and GRE imaging, high SI with a peripheral dark signal rim is apparent from seven days to the chronic stage.

Acute spontaneous extraconal hematic cyst of the orbit

A 49 year old man presented with one day history of mild right eye pain and proptosis. There was no definite history of trauma. On examination there was limitation of movement in all directions of gaze and 6 mm proptosis of his right eye. CT scan showed extraconal lesion compressing the optic nerve and inferior rectus muscle. Right inferior conjunctival fornix based approach was performed with lateral canthotomy and inferior cantholysis and exploration revealed a cyst containing blood which was removed.

Cervicothoracic spinal epidural hematoma after anterior cervical spinal surgery

The purpose of this case report is to describe a rare case of a cervicothoracic spinal epidural hematoma (SEH) after anterior cervical spine surgery. A 60-year-old man complained of severe neck and arm pain 4 hours after anterior cervical discectomy and fusion at the C5-6 level. Magnetic resonance imaging revealed a postoperative SEH extending from C1 to T4. Direct hemostasis and drainage of loculated hematoma at the C5-6 level completely improved the patient's condition. When a patient complains of severe neck and/or arm pain after anterior cervical spinal surgery, though rare, the possibility of a postoperative SEH extending to non-decompressed, adjacent levels should be considered as with our case.

Initial experience with hemostatic fibrin glue as adjuvant during drainless parotidectomy

OBJECTIVES

To evaluate the use of Hemostatic Fibrin Glue in parotidectomy without the use of surgical drains.

STUDY DESIGN

Prospective cohort study of 10 patients undergoing parotidectomy. Surgery as a one day admission without the use of surgical drains was planned. The complication and duration of the hospital stay were obtained.

METHODS

Parotidectomy was undertaken by one surgeon. Prior to wound closure, the skin flap and wound bed were approximated using Tisseel tissue sealant. Data regarding the incidence of any complication and the duration of the hospital stay were obtained. Patients were followed to assess surgical outcome and document any complications. The mean follow-up period was 8 months (range 4-12 months).

RESULTS

There were no major surgical complications. Two patients had facial nerve weakness due to adherence of the tumour in the facial nerve, in there was which complete recovery after few months. All patients were discharged the next day. None of the patients felt that the discharge had been premature.

CONCLUSIONS

Parotidectomy can be undertaken safely without the need for surgical drains, therefore, allowing the patients to leave the hospital on the first postoperative day.

Cardiovascular Behçet's Disease Presenting as a Subepicardial Hematoma: An Uneventful 2-Year Clinical Course

Cardiovascular involvement in Behçet's disease is not uncommon and could be life-threatening. We describe here a 28-year-old man, who developed sudden onset chest pain during warfarinization due to deep vein thrombosis. Echocardiography and computed tomography showed a 60×60 mm-sized hematoma in the pericardial space compressing the right heart. Coronary angiography showed totally occluded proximal right coronary artery. The hematoma was located at the subepicardial plane of the right atrium on surgical view and successfully evacuated. Follow-up echocardiography revealed complete resolution of the hematoma. He is doing well for 24 months after surgery.

Delayed intrathyroidal hematoma causing respiratory distress after a seemingly benign fall: a case report

A rare event of a fall causing delayed intrathyroidal hematoma and respiratory distress is reported here. A 75-year-old woman with symptoms of vertigo causing syncope and fall 24 h earlier was seen and discharged from our emergency department after an unremarkable physical exam and 6-h observation period. Within 3 h of discharge, the patient was transported back by Emergency Medical Services with an enlarging neck mass and subjective respiratory distress. CT scan demonstrated a large, expanding hematoma, and the patient underwent an emergency hemithyroidectomy. Hürtle cell adenoma was found on pathologic specimen examination. A review of the literature of similar cases is presented, emphasizing the notion that concurrent thyroid pathology is a risk factor for airway compromise after seemingly benign trauma and that airway compromise can present in a delayed fashion.

Clinical experience and management of cervico-thoracic epidural hematoma

Spinal epidural hematoma (SEH) causing acute myelopathy is rare. The usual clinical presentation of a SEH is sudden severe neck or back pain that progresses toward paraparesis or quadriparesis, depending on the level of the lesion. Recent studies have shown that early decompressive surgery is very important for patient's recovery. We experienced five patients of cervico-thoracic epidural hematomas associated with neurologic deficits that were treated successfully with surgical intervention.

Life-threatening complication after extracorporeal shock wave lithotripsy for a renal stone: a hepatic subcapsular hematoma

Extracorporeal shock wave lithotripsy (ESWL) has revolutionized the management of urolithiasis since it was first introduced in 1980. ESWL is a well-established, safe and effective therapeutic alternative to surgical treatment for urolithiasis. Complications of ESWL do occur in a small number of patients, and when they do, they typically involve the kidney. We present a case of a young female patient who developed a huge hepatic subcapsular hematoma accompanied by hypovolemic shock after ESWL for a 9 mm stone in the right kidney. The hematoma measured 13×6 cm. Conservative care with no surgical intervention was chosen because there was no evidence of active bleeding on the computed tomography. After conservative therapy, the hematoma was gradually absorbed and the patient was discharged.

Acute symptomatic hematoma with defined etiology seven years after breast reconstruction: A case report and literature review

Augmentation mammaplasty with implants can be complicated by hematoma formation. The majority of hematomas occur in the immediate postoperative period. There are, however, some reports of hematomas with a delayed presentation. These hematomas in the late postoperative period are rare, and many of these cases do not have a definitive mechanism of injury or develop symptoms immediately after the triggering event. A case of late capsular hematoma seven years after breast reconstruction with a saline implant following mastectomy is presented. In contrast to the majority of published cases, the patient presented with both a known and traceable cause of her bleed and with symptoms that developed immediately after the initial event. Furthermore, the mechanism of her injury was consistent with a bleeding capsular tear that was observed intraoperatively. The present case emphasizes the importance of thorough evaluation and management of patients with a history of breast reconstruction.

Right ventricular wall hematoma secondary to percutaneous coronary intervention

Intramyocardial hematoma is known to be associated with myocardial infarction, chest trauma, coronary artery bypass operation, and complication of percutaneous coronary intervention (PCI). We describe here a rare case of 50-year-old man with a huge right ventricular (RV) wall hematoma which was newly developed two hours after PCI. The patient was treated conservatively with a successful outcome. We discuss plausible mechanisms for the development of RV wall hematoma and treatment options for the case.