Percutaneous evacuation of anterior abdominal wall hematomas using catheter-based mechanical thrombectomy

Post-operative hematoma is a common surgical complication, often treated conservatively. However, persistent, recurrent or symptomatic hematomas may require percutaneous or surgical drainage. The authors present two cases of persistent post-surgical hematomas which were successfully evacuated in a single-setting using a percutaneous mechanical thrombectomy system.

Infectious consequences of hematoma from cardiac implantable electronic device procedures and the role of the antibiotic envelope: A WRAP-IT trial analysis

BACKGROUND

Hematoma is a complication of cardiac implantable electronic device (CIED) procedures and may lead to device infection. The TYRX antibacterial envelope reduced major CIED infection by 40% in the randomized WRAP-IT (World-wide Randomized Antibiotic Envelope Infection Prevention Trial) study, but its effectiveness in the presence of hematoma is not well understood.

OBJECTIVE

The purpose of this study was to evaluate the incidence and infectious consequences of hematoma and the association between envelope use, hematomas, and major CIED infection among WRAP-IT patients.

METHODS

All 6800 study patients were included in this analysis (control 3429; envelope 3371). Hematomas occurring within 30 days postprocedure (acute) were characterized and grouped by study treatment and evaluated for subsequent infection risk. Data were analyzed using Cox proportional hazard regression modeling.

RESULTS

Acute hematoma incidence was 2.2% at 30 days, with no significant difference between treatment groups (envelope vs control hazard ratio [HR] 1.15; 95% confidence interval [CI] 0.84-1.58; P = .39). Through all follow-up, the risk of major infection was significantly higher among control patients with hematoma vs those without (13.1% vs 1.6%; HR 11.3; 95% CI 5.5-23.2; P <.001). The risk of major infection was significantly lower in the envelope vs control patients with hematoma (2.5% vs 13.1%; HR 0.18; 95% CI 0.04-0.85; P = .03).

CONCLUSION

The risk of hematoma was 2.2% among WRAP-IT patients. Among control patients, hematoma carried a >11-fold risk of developing a major CIED infection. This risk was significantly mitigated with antibacterial envelope use, with an 82% reduction in major CIED infection among envelope patients who developed hematoma compared to control.

[Optical coherence tomography for the differential diagnosis of unclear nail pigmentation]

In daily practice, nail pigmentation can be a diagnostic challenge, especially if the dermoscopic findings are nonspecific. We present examples of cases, in which optical coherence tomography-a rapid, noninvasive imaging method-showed typical changes that were indicative for the diagnosis.

Renal pelvic rupture: A case report of an unexpected cause

INTRODUCTION

Renal pelvic rupture (RPR) is a rare condition, that is most usually caused by obstructive calculi. In another hand, primal ureteral tumors are also uncommon, with only a few cases reporting their involvement in a RPR.

PRESENTATION OF CASE

We report a case with a multimodality discussion of an ureteral tumor, with a spontaneous renal pelvic rupture (RPR) forming a large retrorenal urohematoma.

DISCUSSION

Only few series reported the subject of RPR in the English literature. Only some single cases reported the causality of urinary tract tumors in RPR. RPR is an imaging based diagnosis. Herein, upper urinary tract tumors show a variable appearances at imaging.

CONCLUSION

By reporting this case, we highlight the role of both computed tomography (CT) and magnetic resonance (MR) imaging in the diagnosis of the RPR and their accuracy in the detection of the ureteral tumor. We also consolidate the effectiveness of the conservative attitude in the management of the RPR.

Finding new indicators for operation and angiographic embolization in blunt renal injury patients: a single-center experience over 13 years

Purpose

Traumatic kidney injury can be treated surgically or nonsurgically. Nonsurgical treatment options include angiography, embolization, and conservative treatment. We aimed to identify factors that help in making clinical decisions on treatment plans for patients with traumatic kidney injury caused by blunt trauma.

Methods

The study included 377 patients aged ≥18 years with traumatic kidney injury caused by blunt abdominal trauma admitted to the emergency room of Wonju Severance Christian Hospital between January 2008 and July 2020. Medical records, laboratory test results, and computed tomography results were retrospectively reviewed.

Results

Multivariable logistic analysis showed diastolic blood pressure at admission and disruption of Gerota's fascia were significantly associated with surgical treatment, and that perinephric hematoma rim distance was the only significant indicator favoring embolization. Receiver operating characteristic curve analysis showed that angiography and embolization should be considered when hematoma size exceeds 2.97 cm.

Conclusion

When a patient with traumatic kidney injury due to blunt trauma visits an emergency room, even when vital signs are stable, Gerota's fascia should be checked by computed tomography prior to deciding on surgical treatment, and angiographic embolization should be considered if perinephric hematoma rim distance exceeds 2.97 cm.

"Hepatic rupture in preeclampsia and HELLP syndrome: A catastrophic presentation"

The objective of index study is to review the available literature on hepatic rupture or hematoma in hypertensive disorders of pregnancy to find the incidence, associated risk factors, clinical presentation, mode of management and feto-maternal outcome. Electronic database was searched using hepatic rupture or hematoma in pregnancy, preeclampsia, eclampsia, and HELLP syndrome (Hemolysis, EL: elevated liver enzymes, LP: low platelet count) as key words and literature published since January, 2000 to December, 2018 which met the inclusion criteria was reviewed. A total of 56 articles were reviewed describing 93 cases of hepatic hemorrhage in hypertensive disorders of pregnancy. Treatment varied from conservative management to abdominal packing, hepatic artery embolization, and partial hepatectomy to liver transplantation. Seven out of 93 patients with liver rupture met mortality and in one of them diagnosis was established on autopsy. Unawareness of the hepatic rupture in pregnancy by an obstetrician demands high index of suspicion for diagnosis and requires specialized, focused and exhaustive management for optimal feto-maternal outcome. Laparotomy and perihepatic packing is a viable option in patients with unstable vitals and is feasible even in limited resource settings.Short interval between diagnosis and management may enhance the feto-maternal survival rate and prevent further morbidity or mortality.

Short-term outcomes of endoscopic evacuation of supratentorial spontaneous intracerebral hematoma: Early experience from developing country

Background:

Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage (ICH). However, the technique still needs improvement.

Methods:

We report our early clinical experience of using this technique to evacuate supratentorial spontaneous intracerebral hematomas and evaluate its short-term outcomes.

Results:

The study included 15 patients, basal ganglia hematoma was the most common location 62.5%, mean preoperative hematoma volume was 61.07 cc, mean ICH score was 3, and mean rate of hematoma evacuation was 89.27%. Factors that could be related to mortality were Glasgow Coma Score (GCS) on admission (P = 0.001), ICH score (P = 0.004); postoperative GCS (P < 0.001), postoperative hematoma volume (P = 0.006); intraventricular extension (P = 0.001), and rate of evacuation (P = 0.001).

Conclusion:

Endoscopic technique is a safe surgical option for evacuation of spontaneous supratentorial ICH. This minimally invasive technique could be helpful to provide better short-term outcomes for selected patients. However, in our experience, this minimally invasive technique did not change the outcome for cases presented with poor GCS on admission 4/15. Our results warrant a future prospective, randomized, controlled efficacy trial.

Comparison of Radiomic Models Based on Different Machine Learning Methods for Predicting Intracerebral Hemorrhage Expansion

PURPOSE

The objective of this study was to predict hematoma expansion (HE) by radiomic models based on different machine learning methods and determine the best radiomic model through the comparison.

METHOD

A total of 108 patients with intracerebral hemorrhage were retrospectively evaluated. Images of baseline non-contrast computed tomography (NCCT) and follow-up NCCT scan within 24 h were retrospectively reviewed. An HE was defined as a volume increase of more than 33% or an increase greater than 12.5 mL from the volume of the baseline NCCT. Texture parameters of the baseline NCCT images were selected by the least absolute shrinkage and selection operator (LASSO) regression. We used support vector machine (SVM), decision tree (DT), conditional inference trees (CIT), random forest (RF), k‑nearest neighbors (KNN), back-propagation neural network (BPNet) and Bayes to build models. Receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) was performed and compared among models.

RESULTS

Every model had a relatively high AUC (all > 0.75), SVM and KNN had the highest AUC of 0.91. There were significant differences between SVM and CIT (Z > 2.266, p = 0.02345), KNN and CIT (Z = 2.4834, p = 0.01301), RF and CIT (Z = 2.6956, p = 0.007027), KNN and BPNet (Z = 2.0122, p = 0.0442), RF and BPNet (Z = 1.9793, p = 0.04778). There was no significant difference among SVM, DT, RF, KNN and Bayes (p > 0.05). The SVM obtained the largest net benefit when the threshold probability was less than 0.33, while KNN obtained the largest net benefit when the threshold probability was greater than 0.33. Combined with ROC and DCA, SVM and KNN performed better in all the models for predicting HE.

CONCLUSION

Radiomic models based on different machine learning methods can be used to predict HE and the models generated by SVM and KNN performed best.

The new Hematoma Maturity Score is highly associated with poor clinical outcome in spontaneous intracerebral hemorrhage

OBJECTIVES

The purpose of this study was to analyze the new combined indicators on noncontrast computed tomography (NCCT) to predict functional outcome at discharge, compared to previously individual radiological NCCT signs.

METHODS

Patients with spontaneous intracerebral hemorrhage (ICH) who underwent baseline CT scan were retrospectively analyzed. Black hole (BH) sign, blend sign (BS), island sign (IS), swirl sign (SwS), Barras classification, any hypodensity, any irregularity, and two combined novel indicators-Combined Barras Total Score (CBTS) and Hematoma Maturity Score-were assessed independently by two radiologists blinded to clinical information. Patients were trichotomized depending on the disability or dependency at discharge according to the Modified Rankin Scale (mRS): no symptoms or no significant/mild disability (mRS 0-2); moderate or severe disability (mRS 3-5); and mortality (mRS 6).

RESULTS

One hundred fourteen patients with spontaneous ICH confirmed by NCCT were included in the analysis. Multivariable statistical analysis was adjusted for anticoagulation, hematoma volume, ventricular expansion, hypertension, blood glucose level at admission, age, and history of atrial fibrillation and demonstrated that any hypodensity (OR 4.768, p 0.006), any irregularity (OR 4.768, p 0.006), CBTS ≥ 4 (OR 3.205, p 0.025), and the new Hematoma Maturity Score (Immature) (OR 5.872, p 0.006) are independent predictors of functional outcome at discharge.

CONCLUSIONS

The new concept of the Hematoma Maturity Score was the radiological sign on NCCT with the highest impact on clinical outcome in comparison with the rest of the evaluated radiological signs.

KEY POINTS

• This is the first manuscript where density and shape characteristics of the ICH had been evaluated together and integrated in a new Hematoma Maturity Score. • The new Hematoma Maturity Score is the radiological sign on NCCT with the highest impact on clinical outcome at discharge.

Management of Ear Trauma

Facial trauma remains a common reason for visits to the emergency department or urgent care facility. The ear remains susceptible to trauma given its delicate anatomy and position in the maxillofacial region. Understanding the anatomy and recognizing the circumstances regarding the mechanism of injury help dictate treatment. The goals of treatment should remain to restore the physiologic form and function of the ear. Middle ear injuries should also be addressed during the process. Although primary repair remains feasible in most cases, there are instances when delayed and staged reconstruction is necessary to achieve successful results.

Juvenile myelomonocytic leukemia presenting in an infant with a subdural hematoma

BACKGROUND

Juvenile myelomonocytic leukemia (JMML) is a rare childhood hematopoietic disorder typically presenting with hepatosplenomegaly, lymphadenopathy, pallor, fever, and cutaneous findings. The authors report the first case, to our knowledge, of JMML presenting in a pediatric patient with a subdural hematoma.

CASE DESCRIPTION

A 7-month old male with recurrent respiratory infections and a low-grade fever presented with a full fontanelle and an increasing head circumference and was found to have chronic bilateral subdural collections. Abusive head trauma, infectious, and coagulopathy workups were unremarkable, and the patient underwent bilateral burr holes for evacuation of the subdural collections. The postoperative course was complicated by the development of thrombocytopenia, anemia, and an acute subdural hemorrhage which required evacuation. Cytologic analysis of the subdural fluid demonstrated atypical cells, which prompted flow cytometric analysis, a bone marrow biopsy, and ultimately a diagnosis of JMML. Following chemotherapy, the patient's counts improved, and he subsequently underwent a hematopoietic stem cell transplant.

CONCLUSION

Subdural collections may rarely represent the first presenting sign of hematologic malignancies. In patients with a history of recurrent infections and a negative workup for abusive head trauma, clinicians should include neoplastic etiologies in the differential for chronic subdural collections and have a low threshold for fluid analysis.

Systemic inflammation status at admission affects the outcome of intracerebral hemorrhage by increasing perihematomal edema but not the hematoma growth

Acute stress and inflammation responses are associated with worse outcomes in intracerebral hemorrhage (ICH) but the precise mechanisms involved are unclear. We evaluated the effect of neutrophil-to-lymphocyte ratio (NLR) in ICH outcome, with focus on hematoma expansion and early cerebral edema. In a retrospective study, we included all patients with primary ICH admitted to our center within 24-h from symptom onset from January 2014 to February 2015. We retrieved demographic and medical history data, Glasgow Coma Scale scores, blood cell counts, glucose, and C-reactive protein, and calculated NLR. We obtained hematoma volumes by computerized planimetry. Outcomes included independence at 90 days (modified Rankin scale 0-2), mortality at 30 days, significant hematoma expansion (> 33% or > 6 mL) and early cerebral edema causing significant midline shift (> 2.5 mm) at 24 h. We included 135 patients. NLR independently associated with independence at 90 days (adjusted odds ratio (aOR) 0.79, 95% CI 0.67-0.93, p = 0.006) significant cerebral edema (aOR 1.08, 95%CI 1.01-1.15, p = 0.016) but not hematoma expansion (aOR 0.99, 95%CI 0.94-1.04, p = 0.736). The severity of midline shift was positively correlated with NLR (adjusted beta = 0.08, 95% CI 0.05-0.11, p < 0.001). In ICH, an immediate and intense systemic inflammatory response reduces the likelihood of a better functional outcome at 90 days, which is more likely to be explained by perihematomal edema growth than due to a significant hematoma expansion. These findings could have implications in new treatment strategies and trial designs, which endpoints tend to target exclusively hematoma enlargement.

Life threatening hepatic hemorrhage after shockwave lithotripsy - A case report and review of literature

We report a 31 year old female with urologic history significant for right ureteropelvic junction obstruction managed with open right pyeloplasty in 1996 with recurrent stricture managed with right ureterocalycostomy in 1997 along with right distal ureteroneocystostomy for iatrogenic distal ureteral stricture. She developed symptomatic stone episodes and recurrent urinary tract infections and elected to proceed with shockwave lithotripsy. Postoperatively she developed a large liver hemorrhage requiring supportive care and endovascular embolization.

A Case Series of Life-Threatening Hemorrhagic Events in Patients with COVID-19

Since venous microthrombotic and thromboembolic events in end organs have been pathophysiologically confirmed as a component of thrombo-inflammatory cascade in COVID-19 syndrome, anticoagulant prescription with prophylactic or therapeutic goal is recommended. Different guidelines for the above are introduced; however, there is no general consensus on any neither the type of anticoagulant nor for the dosage and duration of prescription. In our medical center, adopted internal guideline was considered for patients COVID-19. We consulted patients with COVID-19 who suffered from concurrent hematoma. Appropriate surgical approach was considered. Finally autopsy study was performed for patients. In this article, we presented a series of seven SARS-CoV-2 confirmed cases faced with bleeding complication following initiation of anticoagulation protocol. The rectus sheath hematoma with extension to pelvic and/or retroperitoneal space, even involving bowel mesentery was seen most commonly. Despite receiving appropriate surgical care, all seven cases died. Finally, in all cases, autopsy studies revealed no evidence for confirmation of DIC/SIC or organ failure as the reason of death although pulmonary involvement with SARS-CoV-2 and bleeding phenomena were approved. The nature of the COVID-19 syndrome makes patients vulnerable to hemorrhagic events following anticoagulant administration which relatively causes or accelerates patient's expiration.

Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection

Background:

The treatment of spontaneous spinal epidural hematomas (SSEHs), depending on the lesion size and myeloradicular involvement, can be surgical or conservative. Here, we present a 55-year-old patient who sustained a SSEH several months following a systemic SARS-CoV-2 infection.

Case Description:

A 55-year-old immunocompromised female (i.e., history 17 years ago of Hodgkin’s lymphoma, nodular sclerosis variant) recently developed a SARS-CoV-2 infection treated with nonsteroidal anti-inflammatory agents. She then reported the sudden onset of cervicodorsalgia after a slight cervical flexion/extension maneuver. The brain and cervicothoracic spine MRI studies documented a clival anterior spinal epidural hematoma with maximum spinal compression at the T1-T2 level; it also extended inferiorly to the T6 level. Two weeks later, the follow-up MRI showed a remarkable reduction in the anteroposterior diameter of the hematoma that correlated with significant neurological improvement and almost complete pain regression. She was discharged after a total 15-day hospital stay, with complete symptoms relief.

Conclusion:

We present a 55-year-old chronically immunocompromised (i.e., due to the history of Hodgkin’s lymphoma) female who, following a SARS-CoV-2 infection, developed an anterior SSEH extending from the clivus to the T6 spinal level that spontaneously regressed without surgical intervention.

Postoperative neutrophil-to-lymphocyte ratio variation is associated with chronic subdural hematoma recurrence

INTRODUCTION

Chronic subdural haematoma (CSDH) is one of the most common neurosurgical pathologies. The recurrence of chronic subdural haematomas is an important concern, considering that elderly patients are the most affected and reoperations in these patients may represent a risk of neurological and clinical complications. In accordance with the inflammatory theory regarding CSDH and its recurrence, we aimed to evaluate the role of an inflammatory marker, neutrophil-to-lymphocyte ratio (NLR), as a risk factor and prognostic variable for CSDH recurrence.

METHODS

We performed a cohort study of adult patients operated for post-traumatic CSDH traumatic CSDH between January 2015 and December 2019 in our neurotrauma unit, whose data was retrospectively retrieved. We excluded patients with previous inflammatory or infectious diseases as well as use of anticoagulant/antiplatelet medications. Neutrophil and lymphocyte counts were obtained 24 h preoperatively and 48-72 h postoperatively. The primary endpoint was symptomatic recurrence of CSDH up to 1 year after the surgery. An independent sample was used to validate the findings.

RESULTS

The testing sample comprised 160 patients (59.4% male, mean age 69.3 ± 14.3 years, recurrence rate 22.5%). Postoperative neutrophil count and NLR were higher in those who recurred, as well as the neutrophils (median 1.15 vs 0.96, p = 0.022) and NLR (median 1.29 vs 0.79, p = 0.001) postoperative-to-preoperative ratios. Preoperative laboratory parameters or other baseline variables were not associated with recurrence. Postoperative NLR ratio (each additional unit, OR 2.53, 95% CI 1.37-4.67, p = 0.003) was independently associated with recurrence. The best cut-off for the postoperative NLR ratio was 0.995 (AUC-ROC 0.67, sensitivity 63.9%, specificity 76.6%). Postoperative NLR ratio ≥ 1 (i.e. a post-operative NLR that does not decrease compared to the preoperative value) was associated with recurrence (OR 4.59, 95% CI 2.00-10.53, p < 0.001). The validation sample analysis (66 patients) yielded similar results (AUC-ROC 0.728, 95% CI 0.594-0.862, p = 0.002) and similar cut-off (≥ 1.05, sensitivity 77.8%, specificity 66.7%).

CONCLUSION

NLR ratio can be a useful parameter for the prediction of post-traumatic CSDH recurrence. This hypothesis was validated in an independent sample and the accuracy was moderate.

Delayed lumbar plexus palsy due to giant psoas hematoma associated with vertebral compression fracture and direct oral anticoagulants: a case report

Background

Osteoporotic vertebral compression fractures (VCFs) are commonly observed in elderly people and can be treated by conservatively with minimal risk of complications in most cases. However, utilization of direct oral anticoagulants (DOACs) increases the risks of secondary hematoma even after insignificant trauma. The use of DOACs increased over the past decade because of their approval and recommendation for both stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. It is well known that DOACs are safer anticoagulants than warfarin in terms of major and nonmajor bleeding; however, we noted an increase in the number of bleeding events associated with DOACs that required medical intervention. This report describes the first case of delayed lumbar plexus palsy due to DOAC-associated psoas hematoma after VCF to draw attention to potential risk of severe complication associated with this type of common and stable trauma.

Case presentation

An 83-year-old man presented with his left inguinal pain and inability to ambulate after falling from standing position and was prescribed DOACs for chronic atrial fibrillation. Computed tomography angiography revealed a giant psoas hematoma arising from the ruptured segmental artery running around fractured L4 vertebra. Because of motor weakness of his lower limbs and expansion of psoas hematoma revealed by contrast computed tomography on day 8 of his hospital stay, angiography aimed for transcatheter arterial embolization was tried, but could not demonstrate any major active extravasation; therefore spontaneous hemostasis was expected with heparin replacement. On day 23 of his stay, hematoma turned to decrease, but dysarthria and motor weakness due to left side cerebral infarction occurred. His pain improved and bone healing was achieved about 2 months later from his admission, however the paralysis of the left lower limb and aftereffects of cerebral infarction remained after 1 year.

Conclusion

In patients using DOACs with multiple risk factors, close attention must be taken in vertebral injury even if the fracture itself is a stable-type such as VCF, because segmental artery injury may cause massive psoas hematoma followed by lumbar plexus palsy and other complications.

Delayed unilateral hematoma after reconstructive and aesthetic breast surgery with implants in Asian patients: two case reports

Hematomas represent one of the postoperative complications in patients undergoing reconstructive or aesthetic breast surgery with a silicone implant. Although there are few reports of intracapsular hematoma, those presenting late hematoma after reconstructive and aesthetic augmentation surgeries are rarer. This study reported two Asian patients with late hematoma after reconstruction and aesthetic breast surgery. A 54-year-old female patient underwent bilateral nipple-sparing mastectomy with immediate breast reconstruction using anatomically shaped textured implant for intraductal carcinoma in August 2019. Contralateral nipple-sparing mastectomy was performed for the BRCA gene mutation on the left breast, which was immediately reconstructed with an anatomically shaped textured implant. In a 1-year postoperative magnetic resonance imaging evaluation, an extracapsular hematoma was found on the right side, which was removed following the removal of both implants. Another case was a 63-year-old female patient who underwent augmentation of both breasts with smooth round implants and experienced right unilateral swelling and painless firmness about 30 years postoperatively. A preoperative magnetic resonance imaging evaluation showed both intracapsular and extracapsular ruptures on the right breast and a bulging implant herniation on the left breast. During the operation, hematoma, implants, and capsule were all removed. The excised capsule was sent for histological evaluation. Slightly dark colored blood was emptied before removing the semisolid-state intracapsular hematoma. In both cases, the patients responded well postoperatively and were discharged to their homes with no postsurgical complications, including seroma, or additional hematoma on the breasts. The etiology of late hematoma following breast augmentation or reconstruction has been poorly characterized. Further reports are needed to clearly establish the reasons for this increase in late hematoma formation.

Inferior vena cava injury after blunt trauma: Case report

•

Inferior vena cava injury is a rare injury with high rate mortality.

•

Few clinical cases have described the clinical findings and radiologic appearance of this kind of injury.

•

We describe a rare clinical case of inferior vena cava hematoma.

•

The management depends on the hemodynamic stability of the patient and the level of injury, it might be surgical, endoscopic.

Introduction

inferior vena cava IVC injury is rare with lethal outcomes, the clinical signs depends on the location and associated injuries, andt he treatment might be endovascular, surgical.

Clinical case

A 25 years with no medical history was admitted to the emergency department after a car accident. After intubation and hemodynamic stabilization, the computerized tomography CT scan showed hepatic laceration with a rupture of the IVC in the retro-hepatic portion, he was admitted to the operation room for damage control laparotomy; the patient died 12 h after the operation despite appropriate management.

Conclusion

IVC are rare and lethal, the CT scan remains the gold standard and the evolution of endovascular techniques decreased the mortality rate.

Burr-Hole Evacuation of an Acute Epidural Hematoma using the Artemis Neuroevacuation Device With Flexible Endoscopic Visualization: 2-Dimensional Operative Video

Minimally invasive (MIS) endoscopic burr-hole evacuation of both acute and subacute subdural hematomas (SDHs) has been demonstrated as a way to avoid large craniotomies and additional morbidity, particularly for patients who are poor surgical candidates.^1,2 Although generally safe and effective, there are risks of complications including SDH recurrence or new hemorrhage including epidural hematoma (EDH).^3,4 Acute intraparenchymal hemorrhage has also been successfully treated using MIS endoscopic techniques with the assistance of aspiration devices; however, acute EDHs generally still necessitate a craniotomy for evacuation, nullifying many of the advantages of burr-hole craniostomy.^5,6 In this surgical video, we demonstrate-to our knowledge-the first case of endoscopic burr-hole evacuation of an acute EDH using an Artemis Neuro Evacuation device (Penumbra, Alameda, CA). We present the case of a 40 year-old man with a left anterior middle cranial fossa arachnoid cyst who developed a traumatic left subacute SDH and hemorrhage into the cyst. He underwent burr-hole craniostomy for endoscopic evacuation of subacute SDH, evacuation of hemorrhage within the cyst, and fenestration of arachnoid cyst. On postoperative day 2, he developed an acute left EDH with midline shift. An Artemis device was inserted into 1 of the pre-existing burr-holes and used to evacuate the acute EDH with direct visualization from a flexible endoscope inserted into the second burr-hole. The patient did well, was discharged 2 days later, and demonstrated complete resolution of hemorrhage 5 weeks post-procedure. The video also provides a brief background on arachnoid cysts, their association with hemorrhage, and MIS techniques for hemorrhage evacuation.^7-12 There is no identifying information in the video. The patient provided informed consent for both procedures (Video 1).

Retropharyngeal Hematoma under Rivaroxaban: A Rare Entity to Know for Its Risk of Airway Obstruction

Teaching Point: Retropharyngeal hematoma appearing under rivaroxaban is uncommon but should be suspected in cases of dysphagia, dysphonia or breathing difficulties.

Evaluation of Surgical Outcomes of Type A Intramural Hematoma

INTRODUCTION

In this study, we aimed to retrospectively evaluate the results of type A intramural hematoma (TA-IMH) cases that underwent ascending aortic surgery.

METHODS

One hundred ninety-four patients who underwent aortic surgery between 2010 and 2018 were included in this study. TA-IMH was differentiated according to tomography angiographic images. Demographic data, operation type, hypothermic circulatory arrest times, echocardiographic findings, wall thickness of IMH, complications, and prognosis were retrospectively analyzed.

RESULTS

TA-IMH (n=14) or type A aortic dissection (AD) (n=35) data were collected from patients' files and 49 cases were enrolled into the study. Bentall operation was performed in eight patients (type A AD = six [17.1%], TA-IMH = two [14.3%]); 41 patients underwent tubular graft interposition of ascending aorta (AD = 29 [82.9%], TAIMH = 12 [85.7%]). There was no significant difference in terms of age, gender distribution, aortic dimensions, cardiopulmonary bypass times, hypothermic circulatory arrest times, hospital ward stay, and intensive care unit stay between the two groups. The mortality rate of AD group was 34.4% and of TA-IMH group was 14.3%. There was no significant difference in terms of mortality between the groups. In our study, 45.7% of patients had hypertension and that rate was lower than the one found in the literature. In addition, bicuspid aorta was not observed in both groups. Connective tissue disease was not detected in any group.

CONCLUSION

Surgical treatment of aorta is beneficial for TAIMH. Our aortic surgical indications comply with the European aortic surgical guidelines. Hypertension control should be provided aggressively.

Recurrent Nasal Septal Hematoma and Abscess: A Rare Manifestation of Leukemia

Nasal septal abscess and hematoma are rare clinical entities. To the best of our knowledge, there have only been 2 cases of nasal septal abscess associated with haematological malignancy reported in the literature. Herein, we present a unique case of recurrent spontaneous nasal septal hematoma and abscess in a patient prior to and after the diagnosis of acute myelogenous leukemia. Its rarity in immunocompromised population, clinical presentation, treatment and complications are further discussed.

Comparison of the effectiveness of position change for patients with pain and vascular complications after transfemoral coronary angiography: a randomized clinical trial

BACKGROUND

Prolonged immobilization after transfemoral coronary angiography (TFA) may cause pain and vascular complications in patients. This study aimed to evaluate the effectiveness of a change in position to decrease pain and vascular complications for patients after TFA.

METHODS

This randomized clinical trial was conducted in 2020. Purposive sampling of 72 eligible patients undergoing TFA were selected and randomly assigned to either an experimental or control group. Patients in the experimental group (EG) were placed in a supine position for 2 h after angiography, followed by a semi-seated position with the bed angle gradually increased to 45° over 4 h. Patients in the control group (CG) remained in the supine position for 6 h. Vital signs, groin, back and leg pain, hematoma, hemorrhage, and urinary retention were assessed in both groups before, immediately after, and over 6 h after angiography. The Visual Analogue Scale was used to measure pain, the Christensen scale to measure hematoma, counting bloody gases to measure hemorrhage, and patient self-rating to determine urinary retention.

RESULTS

There was no significant difference between EG and CG on score of groin (2.69 ± 1.00 vs. 2.61 ± 1.00, P = 0.74), back (2.19 ± 0.98 vs. 2.47 ± 0.87, P = 0.21), and leg pain (2.14 ± 0.71 vs. 2.50 ± 1.08, P = 0.27) before the TFA. However, from the second hour to the sixth hour after the TFA, the pain in the EG was significantly less than the CG (P < 0.001). So that pain in the groin (1.36 ± 0.48 vs. 3.28 ± 0.81), back (1.25 ± 0.50 vs. 3.81 ± 1.06), and leg (1.44 ± 0.55 vs. 3.28 ± 0.81) for the EG patients was significantly less than the CG in the sixth hour after TFA (P < 0.001). No patients experienced hematoma. No differences were noted between groups in hemorrhage and urinary retention.

CONCLUSIONS

Position change to a semi-seated position in patients after TFA is effective and safe for reduction of pain without increasing vascular complications.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials: IRCT registration number: IRCT20200410047011N1, Registration date: 30/04/2020.

The Effect of Antithrombotics on Hematoma Expansion in Small- to Moderate-Sized Traumatic Intraparenchymal Hemorrhages

BACKGROUND

Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication.

METHODS

The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded.

RESULTS

Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were <5 cm³. The size of tIPH on initial imaging did not statistically significantly differ between the antithrombotic cohort (0.7 ± 0.1 cm³) and the non-antithrombotic cohort (0.5 ± 0.1 cm³) (P = 0.091). Similarly, the volume of tIPH failed to differ on 24-hour repeat imaging (1.0 ± 0.2 cm³ vs. 0.6 ± 0.1 cm³, respectively, P = 0.172). Following a multiple linear regression, only history of stroke, not antithrombotic medications, predicted increased tIPH on 24-hour repeat imaging.

CONCLUSIONS

In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.

A rare cough complication: Internal oblique muscle hematoma

Cough-related hematomas occur most frequently in the rectus sheath and retroperitoneum while lateral abdominal wall hematomas are rarely reported. Intramuscular hematoma might be mistaken for tumors and acute inflammatory diseases of the abdomen. A definite diagnosis is made with computerized tomography. In the case presented in this study, a 78-year-old female patient who had cough and shortness of breath for 1 week applied to the outpatient clinic with complaints of ecchymosis on the left side of the abdomen accompanied by swelling and pain under the left rib. The International Normalized Ratio of the patient, who used Warfarin sodium 5mg / day for mitral valve replacement, was in the effective range (INR: 2.4). Superficial ultrasound revealed a heterogeneous lesion with a well-circumscribed, hypoechoic and locally cystic component in the lateral abdominal wall in the left subcostal area. On computerized tomography, the lesion in the left internal oblique muscle of 27 × 60 mm, heterogeneous density, and with smooth borders was classified as Type 2 hematoma. Hemodynamics of the patient were stable and did not exceed INR 3 in follow-up, and there was no decrease in hemoglobin values. The patient's ecchymosis disappeared on the fifth day, and control ultrasonography showed the hematoma was partially resorbed. The aim of this study is to emphasize that conservative methods should be applied and surgery should be avoided as much as possible in internal oblique muscle hematoma.

Successful management of traumatic giant pulmonary hematoma in poly-trauma patient

Traumatic pulmonary giant hematoma, resulting from blunt trauma, is a relatively rare event. Here, we report the rare case of a patient with a giant traumatic pulmonary hematoma that was associated with blunt trauma. A 50-year-old man was admitted to our medical center after a fall from a height of 5 m. He was diagnosed with pulmonary contusion, and tests showed a huge pulmonary hematoma of approximately 8.2 × 5.3 × 13.2 cm in the left lung field along with other significant injuries. Treatment comprised of aggressive coagulation management, broad-spectrum antibiotics, and pulmonary hygiene. The patient's symptoms gradually improved and magnetic resonance scan revealed that he did not develop an abscess formation. No complications were seen at the 6 months follow-up visit. If the above mentioned measures would have failed to control the bleeding or secondary infection, then emergency surgery would have been warranted. Awareness of this kind of injury and efforts to reduce infection are important to guide the giant traumatic pulmonary hematoma to the benign course.

Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.

Current and emerging methods for treatment of hemoglobin related cutaneous discoloration: A literature review

Background

Currently, there is no available medication for immediate correction of bruise discoloration. Instead, makeup, cosmetic powders, concealers, and various traditional herbal remedies are used to mask discoloration. These approaches have no influence on the pathology behind the discoloration. The purpose of this study was to explore existing methods and current trends in correction of hemoglobin related cutaneous discoloration.

Methods

This paper describes the treatment methodologies available for proposed correction of hemoglobin related cutaneous discoloration. A thorough literature review was conducted to assess current knowledge of available treatments for bruise discoloration.

Results

current cosmetics being marketed under the names "Bleacher bruises," "Bleaching agents" and "Blood bleachers" addressing bruise related discoloration do not offer targeted pathological treatment. Several methods for immediate discoloration of the skin and nail plate in the area of bruising and hematoma were found, yet no method offered sufficient clinical data in support of its efficacy and safety. The intricate mechanisms of discoloration associated with hemoglobin extravascular deterioration are not targeted by any treatment method. Only one paper outlining the clinical application of bleaching agents was found.

Conclusion

The primary blood pigments responsible for the discoloration in bruises include methemoglobin, oxyhemoglobin, carbohymoglobin, verdoglobin, biliverdin, and bilirubin. No existing method targets the degradation of hemoglobin in the area of ecchymosis. The efficacy of existing patented methods remains questionable and unsupported clinically. Future research should focus on developing a drug targeting hemoglobin derivatives, preventing discoloration at an early stage.

A comparison of the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing hematoma and seroma in rhytidectomy: A randomized, double-blind, controlled study

BACKGROUND

One of the most feared complications of rhytidectomy is the formation of hematoma and seroma, which may harm patients' health and compromise the surgical outcome.

OBJECTIVE

To compare the efficacy of autologous fibrin glue/platelet-poor plasma versus suction drainage in preventing surgical complications such as hematoma and seroma following rhytidectomy procedures.

METHODS

A prospective, randomized, double-blind, controlled study was conducted to compare the efficacy of the two interventions. Seventy-two patients were selected and divided into two groups of 36 (autologous fibrin glue versus suction drainage). Forty-eight hours after the procedures, all patients underwent ultrasound examination, always by the same radiologist, to measure the volume of exudate under the facial skin flaps.

RESULTS

The mean total volume of exudate was 3.21 mL in the suction drainage group and 1.02 mL in the fibrin glue group, with effect size of 68.1% and confidence interval of 55.3 to 77.2 (P < 0.001).

CONCLUSIONS

Results significantly favor the use of fibrin glue and show that it was 68.1% more effective than suction drainage in preventing hematoma or seroma in rhytidectomy procedures.

Subperiosteal Orbital Hematoma: An Uncommon Complication of Acute Sinusitis

Non-traumatic subperiosteal orbital hematoma is a rare finding and uncommon cause of proptosis. Reported cases describe an association with increased venous pressure. However, it is important to note that there is also an association with sinusitis, which must be differentiated from subperiosteal abscess. This article describes the unique imaging features of subperiosteal hematoma in the setting of sinusitis, as well as the suspected pathophysiology.

The Effect of Simultaneous Sand-Ice Bag Application on Hemorrhage and Hematoma after Percutaneous Coronary Intervention: A Randomized Clinical Trial

Introduction: Angioplasty is widely used as a selective treatment for acute coronary syndromes. The complications of this procedure often lead to an increase in the length of the patients’ stay and hospital costs. Therefore, this study aimed to determine the effect of using sand and ice bags on hematoma and hemorrhage after percutaneous coronary intervention (PCI).

Methods: In this randomized clinical trial, study was completed with participation of 60 patients with femoral angioplasty candidate, referring to Imam Reza hospital in Mashhad, were randomly divided into control and intervention groups. In the control group, a sand bag was placed on the location for up to 4 hours. In the intervention group, the ice bag and the sand bag were used simultaneously for 15 minutes, and then for 45 minutes, with the pressure of the sand bag only. This cycle was repeated four times. Hemorrhage (volume and weight) and hematoma (area and lump) were checked four times. The data were analyzed using SPSS software version 22.

Results: The rate of hemorrhage after intervention was significantly reduced in the intervention group compared to the control group. Although the incidence of hematoma in the intervention group decreased from control to 20% to 6.7%, but the statistical test was not significant.

Conclusion: According to the results of the present study, the simultaneous sand-ice bag application can reduce post-PCI’ hemorrhage (and hematoma rate, though insignificantly) through compression and vasoconstriction.

Successful management of retropharyngeal hematoma by trans-arterial embolism without intubation

BACKGROUND

Retropharyngeal hematoma can cause suffocation if there is delay in securing the airway by intubation. However, there are also concerns about complications that can arise with intubation; it is still unknown which cases do not require intubation.

CASE PRESENTATION

An 88-year-old woman slipped and was found prone and was transported to the emergency room. She was alert without any stridor. Physical examination revealed a subcutaneous hematoma in the anterior cervical region. Computed tomography revealed a retropharyngeal hematoma. Angiography and computed tomography angiography showed extravasation from the right costocervical trunk. A radiologist performed trans-arterial embolization, and she had an uneventful course without intubation or developing any complication. She became ambulatory on postoperative day 5.

CONCLUSION

Angiography and computed tomography angiography help in early recognition of extravasation in retropharyngeal hematoma, and trans-arterial embolization can help to avoid intubation and its complications.

Post-traumatic adrenal hematoma: A case report and revue of literature

Post-traumatic adrenal hematoma, which has rare but severe complications, is a difficult to diagnose condition. Only computed tomography, which is often performed systematically during lesional assessments of violent thoraco-abdominal trauma, can confirm the diagnosis. Symptoms are often masked by associated visceral or parietal lesions. Standard biological examinations are generally not very helpful. We will describe the case of a 47-year-old man who presented with a right adrenal hemorrhage following a road accident, for only associated lesion, a fracture of the middle arch of the first and 8th ribs, and the transverse process L1.

Hemorrhagic stroke

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.

Mini Craniotomy in the Management of Supratentorial Spontaneous Intracranial Hemorrhage: A Single-Center Outcome of the Minimally Invasive Treatment

Hemorrhagic stroke accounts for a significant proportion of mortality and confers a poor quality of life with high dependency among survivors. Surgical evacuation of hematoma has the advantage of rapidly controlling the increased intracranial pressure, halting the ongoing herniation syndrome, and mitigating the secondary cascades of events mediated by the inflammatory and blood degradation products. The advantage is hindered by the concurrent insult to the healthy brain tissue while passing through the normal brain tissue. Therefore, minimally invasive approaches to evacuate the hematoma are employed, but the need for an expensive surgical armamentarium and the expert multidisciplinary team is the bottleneck for their application, particularly in low-income nations. We herein performed a study upon the role of mini craniotomy open surgical method of evacuating hematoma in selected patients with supratentorial intracerebral hemorrhage. We found a significant reduction in the surgery length, minimized risk of post-surgery complications, shortened intensive care unit stay, and reduced mortality compared to the full-fledged craniotomy and endoscopy-guided surgery. There is a need for a large-scale randomized multicenter prospective study to verify the advantages of minimally invasive approaches in the management of symptomatic supratentorial intracerebral hemorrhages.

Acute, major muscular hematoma associated with antithrombotic agents: A multicenter real-world cohort

BACKGROUND

There is little data on major muscular hematomas and the little there is has mainly focused on patients exposed to oral anticoagulants.

OBJECTIVE

To describe the clinical characteristics, management and outcomes of patients admitted to emergency department (ED) for major muscular hematoma associated with an antithrombotic agent, and to identify predictors of in-hospital mortality.

PATIENTS AND METHODS

Over a three-year period, all consecutive cases of adult patients admitted to the ED of 5 tertiary care hospitals for major muscular hematoma while exposed to an antithrombotic agent were prospectively collected and medically validated. Clinical and biological data, therapeutic management of the bleeding event, and in-hospital mortality were collected from the medical records and compared across five groups of hematoma locations. Potential confounders were taken in account using a multivariate binomial regression model.

RESULTS

Three hundred and seventy-five patients were included (mean age = 81.4 years): 271 were exposed to vitamin K antagonists, 58 to parenteral anticoagulants (heparin, LMWH, fondaparinux), 33 to antiplatelets, and 13 to direct oral anticoagulants. The muscular hematomas were located in the lower limbs (n = 198), the rectus sheath (n = 71), the iliopsoas (n = 45), the upper limbs (n = 33), or elsewhere (n = 28). Reversal therapy was prescribed for 48.5% of patients, red cell transfusions for 63.6%, surgery for 12.3% and embolization for 3.5%. For 84% of patients, hospitalization was required, with a median length of stay of 10 days. Overall, in-hospital mortality was 8.5%. Reversal therapy, the need for intensive care and mortality were significantly more frequent among patients with iliopsoas hematomas. The independent predictors of in-hospital mortality were: decrease in mean arterial pressure (RR = 1.84), decrease in hemoglobin level (RR = 1.37) and the iliopsoas location (RR = 3.06).

CONCLUSION

Frail elderly patients with major muscular hematomas linked to antithrombotic agents risk substantial morbidity and in-hospital mortality. The iliopsoas location was the most life-threatening bleeding site. Close observation of this population is warranted to ensure better outcomes.

Extracorporeal shock wave therapy treatment of painful hematoma in the calf: A case report

BACKGROUND

Extracorporeal shock wave therapy (ESWT) can be applied to various musculoskeletal conditions including calcific tendinitis. Muscle injuries can lead to hematomas, and unabsorbed hematomas sometimes cause pain. We report a case of painful hematoma successfully treated with ESWT. To our knowledge, this is the first reported case of painful intramuscular hematoma treated with ESWT.

CASE SUMMARY

A 65-year-old man visited the outpatient department for left calf pain with swelling that had persisted since he slipped two weeks prior. The calf pain had persisted and was rated visual analog scale 7. On physical examination, there was a localized, stiff, ovoid mass on his left upper posterior calf. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle; its texture was firm with low heterogeneity. We applied ESWT to the hematoma. His pain decreased immediately to a visual analog scale 3, and the mass was softened. The texture of the hematoma became more heterogeneous on ultrasonography. Due to planned overseas travel, he returned three months after the initial visit to report that the pain and swelling were dramatically relieved after ESWT.

CONCLUSION

We propose that painful hematomas could be a new indication for ESWT. Further investigation on the effects of ESWT for hematomas is needed.

The risk factors of intracranial infection in patients with intracerebral hemorrhage undergone hematoma puncture: what should we care

BACKGROUND

Intracranial infection after puncture of cerebral hematoma in patients with intracerebral hemorrhage is very common in the department of neurosurgery, yet the relevant risks remain unknown. We attempted to analyze the risk factors of intracranial infection after puncture of cerebral hematoma, to provide insights into the management of patients with intracerebral hemorrhage after puncture of cerebral hematoma.

METHODS

Patients with intracerebral hemorrhage after puncture of cerebral hematoma treated in our hospital from January 2017 to January 2020 were selected, the related characteristics of intracranial infection and no infection patients were compared. Logistic regression analyses were conducted to analyze the risk factors for intracranial infection after puncture of cerebral hematoma.

RESULTS

A total of 925 patients with puncture of cerebral hematoma were included. The incidence of postoperative intracranial infection was 7.03%. There were significant statistical differences between the infected group and the no infection group in the American Association of Anesthesiologists (ASA) grade, length of hospital stay, consecutive operation, duration of surgery, extra-ventricular drainage (EVD) use (all p < 0.05). There was statistically significant difference in the duration of EVD between the infection and no infection groups (p = 0.002), and there was no significant difference in the frequency of EVD insertion between the two groups (p = 0.094). The length of hospital stay≥10 days (OR1.832, 1.062-3.158), consecutive operation (OR2.158, 1.358-3.430), duration of surgery≥4 h (OR1.581, 1.031-2.425), EVD use (OR1.694, 1.074-2.670), and duration of EVD ≥ 7 days (OR2.699, 1.689-4.311) were the risk factors of intracranial infection in patients with intracerebral hemorrhage after puncture of cerebral hematoma (all p < 0.05).

CONCLUSION

Clinical medical workers should take corresponding preventive measures against the different risk factors for prevention of intracranial infection in patient with puncture of cerebral hematoma.

Detection and estimating the blood accumulation volume of brain hemorrhage in a human anatomical skull using a RF single coil

Objective

An experimental study for testing a simple robust algorithm on data derived from an electromagnetic radiation device that can detect small changes in the tissue/fluid ratio in a realistic head configuration.

Methods

Changes in the scattering parameters (S₂₁) of an inductive coil resulting from injections of chicken blood in the 0-18 ml range into calf brain tissue in a human anatomical skull were measured over a 100-1,000 MHz frequency range.

Results

An algorithm that combines amplitude and phase results was found to detect changes in the tissue/fluid ratio with 90% accuracy. An algorithm that estimated the injected blood volume was found to have a 1-4 ml average error. This demonstrates the possibility of the inductive coil-based device to possess a practical ability to detect a change in the tissue/fluid ratio in the head.

Significance

This study is an important step towards the goal of building an inexpensive and safe device that can detect an early brain hemorrhagic stroke.

Midline spinous process splitting laminoplasty in a newborn with thoracolumbar epidural hematoma: a bone-sparing procedure based on anatomy and embryology

Spinal epidural hematoma (SEH) is a rare condition leading to spinal cord compression after trauma, surgery, or other. In 40% of the cases, the cause is unknown or unidentified. Due to the absence of specific symptoms, the diagnosis is often delayed. The mainstay of treatment is urgent evacuation of the hematoma. The choice of the surgical technique is surgeon-dependent and ranges from simple decompression and hematoma evacuation to variable combinations of decompression and reconstruction of the posterior spinal arch. To our knowledge, we describe the youngest case in the literature of a thoracolumbar SEH in a newborn with hemophilia A which was evacuated by spinous process splitting laminoplasty (SPSL). SPSL was chosen to avoid damaging the primary ossification centers, preserve the paravertebral musculature, and evade the sequelae of multilevel laminectomies. In our opinion, this technique should be propagated in the pediatric population for accessing the posterior and posterolateral spinal canal.

The effects of intravenous and local tranexamic acid on bone healing: An experimental study in the rat tibia fracture model

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent. It has long been used to reduce the need for perioperative blood loss in various surgeries. Few studies have investigated the effects of local and intravenous administration of TXA on fracture healing. Thus, we aimed to evaluate if TXA influences hematoma volume and fracture healing in the rat tibia fracture model.

MATERIALS AND METHODS

A tibia fracture with intramedullary Kirschner wire fixation was created in all animals. Rats were randomly divided into three groups as local TXA, intravenous TXA, and control. A dose of 50 mg/kg local and intravenous TXA was administered to the study groups. Hematoma volume was measured on the first and third days of the study. The animals were sacrificed on the 14th and 21st days for radiological and histopathological examinations.

RESULTS

There was no significant difference between the groups in terms of hematoma volume measured on Day 1 and the mean decrease of hematoma volume from Day 1 to Day 3 (p = 0.158 and p = 0.239, respectively). The total radiological scores of Day 14 and Day 21 were similar in all groups (p > 0.05 for all). There was also no significant difference between the histological staging of the fracture repair on Day 14 and Day 21 for all groups (p > 0.05 for all).

CONCLUSION

Our findings suggest that TXA's local and intravenous application makes no significant difference in fracture healing.

Robot-assisted neurosurgery versus conventional treatment for intracerebral hemorrhage: A systematic review and meta-analysis

The aim of this review is to determine the efficacy and safety of robotic surgery for intracranial hemorrhage (ICH). PICO question was formulated as: whether robot-assisted neurosurgery is more effective and safer than conventional treatment for ICH with respect to drainage time, complications, operation time, extent of evacuation and neurological function improvement. We searched PubMed, Web of Science, Wiley Online, OVID, Embase, Cochrane Library, Clinical Trails, Current Controlled Trials, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), OpenGrey and references of related papers. Key words included robot, robotic, hematoma, hemorrhage and neurosurgery. Then we used Microsoft Excel to collect data. Except from qualitative analysis, we did meta-analysis using Review Manager 5.3. 9 papers were included in qualitative synthesis, 6 in meta-analysis for rebleeding rate and 4 in analysis for operative and drainage time. Qualitative synthesis showed shorter operative time and drainage time, a larger extent of evacuation, better neurological function improvement and less complications in robotic group, while meta-analysis suggested that robot-assisted surgery reduced rebleeding rate compared to other surgical procedures, but whether it is superior to conservative treatment in preventing rebleeding still needs more proof. Meta-analysis for operative and drainage time should be explained cautiously because a significant heterogeneity existed and we supposed that differences in baseline characteristics might influence the results. Finally, we drew a conclusion that robotic neurosurgery is a safe and effective approach which is better than conventional surgery or conservative treatment with respect to rebleeding rate, intracranial infection rate and neurological function improvement.

Current strategies to minimize postoperative hematoma formation in patients undergoing cardiac implantable electronic device implantation: A review

There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices.

How to Avoid Life-Threatening Complications Associated with Implant Surgery

Life-threatening complications of dental implant surgery are rare, but include hematoma/hemorrhage of the floor of the mouth, aspiration, and ingestion. Prevention of lethal hemorrhagic complications stem from knowledge of anatomic structures and precise surgical planning. Prevention of aspiration and ingestion can be improved by simple techniques while understanding clinical settings and factors that put patients at higher risk. In the event of these potential lethal situations, early recognition of signs and symptoms along with immediate action followed by transfer to an emergency department is often necessary.