Spontaneous soft tissue hematomas

Out-of-hospital onset versus in-hospital onset for clinical outcomes in spontaneous intramuscular hematoma diagnosed by computed tomography: a retrospective cohort study

The aging global population and the increasing use of antithrombotic agents have made spontaneous intramuscular hematomas (SIH) a growing concern. The association between the settings of SIH onset and clinical outcomes remains unclear. The aim of this study was to determine these associations. A retrospective cohort study was conducted in a tertiary hospital in Hiroshima, Japan between January 2008 and January 2022. We included consecutive patients aged ≥ 15 years with SIH at any site diagnosed by computed tomography. The subjects were divided into two groups according to onset settings: out-of-hospital onset and in-hospital onset. The main outcome was treatment failure (composite of change in initial treatment and in-hospital death), and in-hospital mortality was also assessed. We used inverse probability of treatment weighting (IPTW) to estimate the causal effects of onset settings on outcomes. Of 84 included subjects with SIH, 63 had out-of-hospital onset and 21 had in-hospital onset. One subject (1.6%) with out-of-hospital onset and four subjects (19%) with in-hospital onset experienced treatment failure. In the IPTW cohort, in-hospital onset was associated with treatment failure [odds ratio (OR) 29, 95% confidence interval (CI) 7.2-270]. In addition, one subject (1.6%) with out-of-hospital onset and three subjects (14%) with in-hospital onset died during hospitalization. In-hospital onset was associated with a high rate of in-hospital mortality (OR 25, 95% CI 6.3-240) in the IPTW cohort. SIH with in-hospital onset had a poorer prognosis than that of SIH with out-of-hospital onset, suggesting that onset setting might be a novel predictor of clinical outcomes for SIH.

[Management of anticoagulant-related soft tissue bleeding]

BACKGROUND AND OBJECTIVE

Spontaneous, severe, and life-threatening soft tissue bleeding (STB) in patients taking anticoagulants is associated with high morbidity and mortality due to the substantial blood loss and nonspecific clinical symptoms. The optimal management of these predominantly older patients with multiple comorbidities has not yet been unanimously clarified.

MATERIALS AND METHODS

This work comprises a literature search and analysis of the pertinent retrospective studies and case series.

RESULTS

Structured diagnostic workup with contrast-enhanced computed tomography (CT) is essential for planning transarterial embolization (TAE). Contrast agent extravasation, the signal flare phenomenon, and the hematocrit effect are all indicative of active bleeding or an anticoagulant-related hematoma. For TAE, coils, particles, and liquid embolic agents can be used alone or in combination. A back door/front door embolization should be strived for.

CONCLUSION

Transarterial embolization is the method of choice for managing anticoagulant-related localized or diffuse spontaneous soft tissue bleeding in the context of hemodynamic stabilization of the patient.

Clinical and radiological risk factors for poor outcomes in patients with spontaneous muscle hematomas

PURPOSE

Spontaneous muscle hematomas (SMH) are frequently seen in the Emergency Department (ED), particularly as a complication of anticoagulation treatments. To date, there are no standard guidelines for the management of this condition in the ED. This work aims to identify clinical-radiological parameters of SMH at risk of poor outcomes.

METHOD

This is a retrospective, observational cohort study conducted in an urban teaching hospital from 2016 to 2019. A multivariate logistic regression analysis was performed to identify parameters independently associated with an adverse outcome defined as the need for treatment (blood products, TAE, surgery) or hospitalization. The parameters analyzed were hematoma size, anticoagulation therapy, age, and the Charlson Comorbidity Index (CCI). ROC analysis was performed to identify the best cut-off hematoma size value to predict poor outcomes.

RESULTS

Our study enrolled 231 patients aged between 18 and 96 years, with a mean age of 67 years. In our population, 125 patients (54.1 % %) were on anticoagulant therapy. Multivariate analysis showed that an SMH diameter > 5.5 cm was independently associated with poor outcome ((odds Ratio [95 % CI] 4,009 [1,786-9,001], p 0.001). Among clinical parameters, only advanced age was proved to be an independent predictor of adverse outcomes (odds Ratio [95 % CI] 1,035 [1,003-1,069], p = 0.033) CONCLUSIONS: Our data suggest that an SMH diameter greater than 5.5 cm on a CT scan and advanced age are predictors of poor outcomes. Surprisingly, anticoagulant therapy seems to play a minor role in the outcome of SMHs.

Brachial Plexus Injury Secondary to Spontaneous Upper Limb Haematoma

Spontaneous upper limb muscle haematomas are rare clinical phenomenons, which often go under- or misdiagnosed. They can present management challenges in the context of anticoagulant therapy, especially in the presence of other medical conditions. We present the case of a 52-year-old male with an initially missed presentation of a spontaneous muscle haematoma that progressed and re-presented to the emergency department (ED) with signs of mixed upper limb neuropathy requiring surgical evacuation and an emergency fasciotomy. This case highlights the importance of prompt diagnosis and intervention. While brachial plexus injuries from haematoma compression are uncommon, in our case, we discuss the need for surgical intervention to relieve pressure and optimise patient outcomes when clinically concerned about compartment syndrome or progressive neuropathy.

Case report of unique presentation of spontaneous calf hematoma

INTRODUCTION AND IMPORTANCE

The presentation of spontaneous hematomas remains different between all affected populations, but advanced age and use of anticoagulants are common risk factors in the majority. The progression of the hematoma may require some time to be detected; however, it can prove fatal if it reaches a significant size. A spontaneous calf hematoma can be mistakenly diagnosed as deep vein thrombosis, and the management of both conditions is varying.

CASE PRESENTATION

A 26-year-old man had recently undergone multiple left lower limb surgeries and was using Rivaroxaban for deep vein thrombosis prophylaxis. He presented with a painful contralateral calf swelling for a duration of one month, which was later diagnosed as a spontaneous chronic calf hematoma. Despite the fact that blood tests were within the normal range, imaging confirmed the diagnosis. After extensive discussion among multidisciplinary teams, a surgical exploration was conducted, resulting in the complete evacuation of the hematoma. Subsequently, a meticulous monitoring of the re-administration of anticoagulant was conducted. CLINICAL DISCUSSION: spontaneous calf hematoma is not common pathology and affecting elderly and presentation in young is unique and diagnosis will not be reached easily especially in chronic case.

CONCLUSION

A spontaneous calf hematoma can occur in a young, fit population with coexisting anticoagulant administrations. A thorough history, examination, and imaging must be applied urgently in order to reach a diagnosis.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]

BACKGROUND

 Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy.

METHOD

 Analysis, summary, and discussion of published review articles and expert recommendations.

RESULTS

 The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance.

CONCLUSION

 Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome.

KEY POINTS

  · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates..

CITATION FORMAT

· Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Spontaneous muscle haematoma in a patient with cirrhosis

Decompensated liver disease is associated with alterated haemostasis that can either lead to spontaneous bleeding or development of thrombosis. Alcohol consumption coupled with advanced liver disease favours spontaneous bleeding. There have been only few documented cases of spontaneous muscle haematoma (SMH) in patients with cirrhosis. The pathogenesis of SMH is hypothesised to be multifactorial and it has been seen in patients on anticoagulation or with haemostatic disorders. We report a case of alcohol-related cirrhosis presenting with an expanding, voluminous haematoma in the intermuscular plane between the trapezius and the teres major muscles. This patient also had a retroperitoneal haemorrhage, clinically evidenced by the Grey Turner's and Cullen's signs. Haemorrhage was confirmed radiologically by CT. The patient was managed in an intensive care facility and treated with multiple blood products, including packed red blood cells, fresh frozen plasma and cryoprecipitates. However, as his clinical condition deteriorated, he required surgical intervention by incision and drainage, followed by evacuation. Early identification of coagulopathy and aggressive treatment are essential in these cases of cirrhosis to avoid unfavourable outcomes.

A rare case report: Spontaneous rectus sheath and iliopsoas hematomas: Clinical presentation, management, and implications

INTRODUCTION AND IMPORTANCE

Frequently misdiagnosed, the clinical condition of soft tissue hematoma typically emerges following blunt abdominal trauma and/or anticoagulant medication usage, with spontaneous occurrences being infrequent. In this case report, we present a spontaneous rectus sheath and iliopsoas hematomas without obvious classical risk factors. The purpose of presenting this case is to bring attention to this unusual clinical condition and emphasize the role of thorough history and physical examination in determining the suitable course of treatment.

CASE REPORT

A 50-year-old woman with no medical history presented at the emergency room due to sudden asthenia and abdominal pain. Physical examination revealed a painful 20 cm hypogastric mass and left lumbar swelling causing leg bending. Lab tests indicated anemia and normal coagulation. CT scans showed significant hematomas in the left rectus and psoas muscles. Intensive monitoring and supportive measures stabilized her condition without resorting to surgery.

CLINICAL DISCUSSION

Soft tissue hematomas, notably in the rectus sheath or iliopsoas muscle, are rare but potentially severe conditions. Their pathophysiology is not fully understood, and risk factors include age, anticoagulant use, and comorbidities. Diagnosis involves abdominal examination, anemia, and CT findings. Management varies based on symptom severity and blood loss, ranging from conservative approaches to surgery or embolization.

CONCLUSION

Swift identification and effective handling of soft tissue hematomas hold utmost importance. The thorough history-taking and comprehensive physical examination play pivotal roles within this protocol. While supportive care constitutes the primary mode of management, instances arise where surgical intervention or vascular embolization becomes imperative for hematomas unresponsive to treatment and presenting hemodynamic instability.

A Multicenter Retrospective Cohort Study Evaluating the Clinical Outcomes of Patients with Coagulopathy Undergoing Transcatheter Arterial Embolization (TAE) for Acute Non-Neurovascular Bleeding

Background and Objectives: Transcatheter arterial embolization (TAE) is the mainstay of treatment for acute major hemorrhage, even in patients with coagulopathy and spontaneous bleeding. Coagulopathy is associated with worsening bleeding severity and higher mortality and clinical failure rates. Furthermore, some unanswered questions remain, such as the definition of coagulopathy, the indication for TAE or conservative treatment, and the choice of embolic agent. This study aims to assess the efficacy and safety of TAE for spontaneous non-neurovascular acute bleeding in patients with coagulopathy. Materials and Methods: This study is a multicenter analysis of retrospectively collected data of consecutive patients with coagulopathy who had undergone, from January 2018 to May 2023, transcatheter arterial embolization for the management of spontaneous hemorrhages. Results: During the study interval (January 2018-May 2023), 120 patients with coagulopathy underwent TAE for spontaneous non-neurovascular acute bleeding. The abdominal wall was the most common bleeding site (72.5%). The most commonly used embolic agent was polyvinyl alcohol (PVA) particles or microspheres (25.0%), whereas coils and gelatin sponge together accounted for 32.5% of the embolic agents used. Technical success was achieved in all cases, with a 92.5% clinical success rate related to 9 cases of rebleeding. Complications were recorded in 12 (10%) patients. Clinical success was significantly better in the group of patients who underwent correction of the coagulopathy within 24 h of TAE. Conclusions: Transcatheter arterial embolization (TAE) is effective and safe for the management of acute non-neurovascular bleeding in patients with coagulopathy. Correction of coagulopathy should not delay TAE and vice versa, as better clinical outcomes were noted in the subgroup of patients undergoing correction of coagulopathy within 24 h of TAE.

Spontaneous Abdominal Wall Hematoma Treated with Percutaneous Transarterial Embolization: Diagnostic Findings, Procedural Outcome, and Efficacy-A Multicenter Study

Endovascular management of abdominal wall hematomas (AWHs) is now the primary treatment option in hemodynamically stable patients, and it is often preferred to surgical interventions. The purpose of this multicentric study was to assess the safety, technical, and clinical success of percutaneous transarterial embolization (PTAE) of spontaneous AWHs to evaluate the efficacy of blind or empiric embolization compared to targeted embolization and to compare the outcome of the endovascular treatment approach in patients affected by COVID-19 and non-COVID-19 patients. We retrospectively enrolled 112 patients with spontaneous AWHs who underwent PTAE, focusing on signs of bleeding at pre-procedural CTA and DSA. Patients were separated into two groups depending on whether a blind or targeted embolization approach was used. We also divided patients into COVID-19 and non-COVID-19 groups. The mean age of the study population was 68.6 ± 15.8 years. CTA and DSA revealed signs of active bleeding in 99 and 88 patients, respectively. In 21 patients, blind embolization was performed. The overall technical success rate was 99%. Clinical success was obtained in 96 patients (86%), while 16 (14%) re-bled within 96 h. One patient reported a major peri-procedural complication. The comparison between blind and targeted embolization approaches showed no statistically significant differences in the characteristics of groups and technical and clinical success rates. No significant differences were found in the procedural outcome between COVID-19 and non-COVID-19 groups. Our study confirmed that PTAE is effective for treating spontaneous AWHs, even in COVID-19 patients. It suggests that the efficacy and safety of blind embolization are comparable to targeted embolization.

Transcatheter Arterial Embolization (TAE) in the Management of Bleeding in the COVID-19 Patient

Background and Objectives: Increasing attention is being paid to the coagulation disorders associated with SARS-CoV-2 infection. Bleeding accounts for 3-6% of COVID-19 patient deaths, and is often a forgotten part of the disease. The bleeding risk is enhanced by several factors, including spontaneous heparin-induced thrombocytopenia, thrombocytopenia, the hyperfibrinolytic state, the consumption of coagulation factors, and thromboprophylaxis with anticoagulants. This study aims to assess the efficacy and safety of TAE in the management of bleeding in COVID-19 patients. Materials and Methods: This multicenter retrospective study analyzes data from COVID-19 patients subjected to transcatheter arterial embolization for the management of bleeding from February 2020 to January 2023. Results: Transcatheter arterial embolization was performed in 73 COVID-19 patients for acute non-neurovascular bleeding during the study interval (February 2020-January 2023). Coagulopathy was observed in forty-four (60.3%) patients. The primary cause of bleeding was spontaneous soft tissue hematoma (63%). A 100% technical success rate was recorded; six cases of rebleeding resulted in a 91.8% clinical success rate. No cases of non-target embolization were observed. Complications were recorded in 13 (17.8%) patients. The efficacy and safety endpoints did not differ significantly between the coagulopathy and non-coagulopathy groups. Conclusions: Transcatheter Arterial Embolization (TAE) is an effective, safe and potentially life-saving option for the management of acute non-neurovascular bleeding in COVID-19 patients. This approach is effective and safe even in the subgroup of COVID-19 patients with coagulopathy.

Spontaneous Soft Tissue Hematomas in Patients with Coagulation Impairment: Safety and Efficacy of Transarterial Embolization

The aim of this study is to report the authors' experience of percutaneous transarterial embolization (TAE) in patients with spontaneous soft tissue hematomas (SSTH) and active bleeding with anticoagulation impairment. The study retrospectively identified 78 patients who received a diagnosis of SSTH by CT scan and underwent TAE between 2010 and 2019 in a single trauma center. The patients were stratified using Popov classification into categories: 2A, 2B, 2C, and 3. The patient's 30-day survival after TAE was considered the primary outcome; immediate technical success, the need for additional TAE, and TAE-related complications were considered secondary outcomes. Immediate technical success, complication rate, and risk factors for death were analyzed. Follow-up stopped on day 30 from TAE. 27 patients (35%) fell into category 2A, 8 (10%) into category 2B, 4 (5%) into category 2C, and 39 (50%) into category 3. Immediate technical success was achieved in 77 patients (98.7%). Complications included damage at the arterial puncture site (2 patients, 2.5%) and acute kidney injury (24 patients, 31%). Only 2 patients (2.5%) had been discharged with a new diagnosis of chronic kidney disease. The 30-day overall mortality rate was 19% (15 patients). The mortality rate was higher in hemodynamically unstable patients, in Popov categories 2B, 2C, and 3, and in patients with an initial eGFR < 30 mL/min × 1.73 m². The study demonstrated a higher mortality risk for categories 2B, 2C, and 3 compared to category 2A. Nonetheless, TAE has proven effective and safe in type 2A patients. Even though it is unclear whether type 2A patients could benefit from conservative treatment rather than TAE, in the authors' opinion, a TAE endovascular approach should be promptly considered for all patients in ACT with active bleeding demonstrated on CT scans.

Intramuscular Hematomas in Patients Receiving Prophylaxis or Anticoagulant Treatment after Spinal Cord Injury (SCI)-A Rare Complication: Description of Seven Cases and a Literature Analysis

Spinal cord injuries (SCIs) are associated with a high risk of thromboembolic complications (VTE), despite the use of antithrombotic prophylaxis in the form of low-molecular-weight heparin (LMWH). The occurrence of VTE requires, as in other diseases, full-dose antithrombotic treatment. Herein, we describe seven cases of soft tissue hemorrhagic complications in the form of spontaneous intramuscular hematomas (SMHs) in patients after SCI undergoing rehabilitation. Four patients received anticoagulant therapy due to previously diagnosed deep vein thrombosis (DVT), and three patients received anticoagulant prophylaxis. None of the patients had a significant injury immediately before the hematoma appeared, and the only symptom was a sudden swelling of the limb without accompanying pain. The hematomas in all patients were treated conservatively. In three patients, significant decreases in hemoglobin were observed; in one patient, a blood transfusion was required for this reason. In all patients treated via anticoagulation, the anticoagulation treatment was modified at the time of diagnosis of the hematoma; in three patients, oral anticoagulants were changed to LMWH in a therapeutic dose, while in one patient, anticoagulant treatment was completely discontinued. Conclusions: Intramuscular hematomas are rare complications after SCI. Each sudden swelling of a limb requires ultrasound-based diagnostics. At the time of diagnosis of a hematoma, the level of hemoglobin and the size of the hematoma should be monitored. The treatment or anticoagulation prophylaxis should be modified if necessary.

Increased reliability of CT-imaging signs of bleeding into soft tissue in patients with COVID-19 for planning transarterial embolization

INTRODUCTION

Spontaneous bleeding into the soft tissues of the abdominal and thoracic wall is described as complication of anticoagulant therapy. Computed tomography (CT) allows to detect the presence of extravasation of the contrast agent into a hematoma, which is indicated as a sign of ongoing bleeding. Other specific CT signs of such coagulopathic bleeding have been described earlier.

AIM OF THE STUDY

To evaluate the significance of specific coagulopathic CT signs for predicting the dynamics of spontaneous bleeding into soft tissues in patients with COVID-19.

MATERIALS AND METHODS

A retrospective study included 60 patients with COVID-19 with spontaneous bleeding into soft tissues and extravasation of a contrast agent on CT. In addition to extravasation, a "hematocrit effect" was detected in 43 patients on CT. Of these, 39 had extravasation in the form of a "signal flare." All patients underwent transarterial catheter angiography (TCA). To assess the prognostic value of CT signs, the results of CT and TCA compared. The absence of extravasation on the TCA more often corresponded to stopped bleeding.

RESULTS

Extravasation on TCA found in 27 (45%) patients. The presence of the "hematocrit effect" or the combination of this sign with the phenomenon of a "signal flare" on CT (n = 43) led to more frequent confirmation of extravasation on TCA than in their absence (n = 17): 23.5% vs. 53.4% (p = 0.028).

CONCLUSION

The presence of a fluid level and the phenomenon of a "signal flare" on CT in the structure of spontaneous hematomas of the soft tissues of the abdominal and thoracic wall in COVID-19 patients more often corresponded to ongoing bleeding on the TCA. The absence of coagulopathic CT signs more often corresponded to stopped bleeding.

Exercise-induced traumatic muscle injuries with active bleeding successfully treated by embolization: three case reports

Muscle injuries caused by indirect trauma during exercise are common. Most of these injuries can be managed conservatively; however, further treatment is required in extreme cases. Although transcatheter arterial embolization is a possible treatment modality, its role in traumatic muscle injuries remains unclear. In this case series, we present three cases of exercise-induced muscle hemorrhage treated by transcatheter arterial embolization with successful outcomes. The damaged muscles were the rectus abdominis, adductor longus, and iliopsoas, and the vascular injuries were accessed via the femoral artery during the procedures.

Spontaneous Retroperitoneal Hematoma Treated with Percutaneous Transarterial Embolization in COVID-19 Era: Diagnostic Findings and Procedural Outcome

(1) Background: Spontaneous retroperitoneal hematomas are a relatively common occurrence in hospitalized patients with COVID-19 related pneumonia, and endovascular treatment of trans-arterial embolization (TAE) may be a life-saving procedure after failure of medical and supportive therapy. The aim of our study was to evaluate spontaneous retroperitoneal hematomas in the COVID-19 era, focusing on their imaging features at CTA and DSA and on the safety, as well as technical and clinical success, of TAE, comparing patients affected by COVID-19 and non-COVID-19 patients. (2) Materials and Methods: We retrospectively enrolled 24 patients with spontaneous retroperitoneal hematoma who underwent TAE; of these, 10 were hospitalized for COVID-19-related pneumonia, while the other 14 were without COVID-19 infection. We evaluated the demographic data, hemoglobin values before and after the procedure, preprocedural aPTT, preprocedural INR, diagnostic and interventional imaging findings, procedural outcome (technical success) and survival periprocedural (clinical success), and major and minor complications. (3) Results: The mean age of the study population was 72.7 ± 11.2 years. CTA revealed signs of active bleeding in 20 patients (83%). DSA showed signs of active bleeding in 20 patients (83%). In four patients (17%), blind embolization was performed. The overall technical success rate was 100%. Clinical success was achieved in 17 patients (71%), while seven patients (29%) rebled within 96 h, and all of them were retreated. No major periprocedural complication was reported. The comparison between the two groups did not show statistically significant differences for gender, mean age, mean pre- and postprocedural hemoglobin, aPTT and INR, mean hematoma volume (cm3), or mean delay between CT and DSA. Active bleeding at CTA was detected in 90% of COVID-19 patients and 79% of non-COVID-19 patients (p = 0.61). At DSA, active bleeding was assessed in eight out of 10 (80%) patients in the COVID-19 group and 12 out of 14 (86%) patients in the non-COVID-19 group (p = 1). Technical success was obtained in 100% of patients in both groups. Clinical success rates were 70% for COVID-19 group and 71% for the non-COVID-19 group. We found no statistical significance between the clinical success rates of retroperitoneal spontaneous hematoma embolization in patients with or without SARS-CoV-2 infection. (4) Conclusions: We suggest that, similar to what has been reported in other studies in non-COVID-19 patients, TAE should be considered an important safe, effective, and potentially life-saving option for the management and the treatment of patients affected by COVID-19 who present with spontaneous retroperitoneal hematoma and who could not benefit from conservative treatment.

Spontaneous Iliopsoas Muscle Hemorrhage-Predictors of Associated Mortality

RATIONALE AND OBJECTIVES

Spontaneous iliopsoas muscle hemorrhage (SIPH) is a rare clinical condition associated with high mortality. In this work we aimed to retrospectively investigate the predictors of mortality in a single-institution cohort of consecutive SIPH patients.

MATERIALS AND METHODS

Consecutive patients (n = 61, 30 men, 76 years [range 51-93]) with computed tomography (CT) confirmed diagnosis of SIPH were retrospectively included between January 2010 and April 2020. CT studies were assessed for signs of active bleeding, extramuscular retroperitoneal hematoma, visible sedimentation, and hematoma volume. Medication history, laboratory parameters, comorbidities, and disease management were also recorded. All parameters were subsequently examined with regard to their impact on outcome and survival. Univariate and multivariate Cox regressions were performed to identify variables associated with time to death.

RESULTS

The overall mortality was 22.9%. A total of 77% of patients received anticoagulant therapy prior to the onset of SIPH. Active bleeding in contrast enhanced CT (CECT) was the only independent variable associated with shorter survival (p = 0.01, hazard ratio 7.05 [1.45-34.20]). Hematoma volume or extramuscular retroperitoneal hematoma had no significant influence on short-term mortality.

CONCLUSION

Only active bleeding but not hematoma volume or extra-muscular bleeding is an independent risk factor for short-term mortality in patients with SIPH.

Diagnostic and Imaging Approaches to Chest Wall Lesions

Chest wall lesions are relatively uncommon and may be challenging once they are encountered on images. Radiologists may detect these lesions incidentally at examinations performed for other indications, or they may be asked specifically to evaluate a suspicious lesion. While many chest wall lesions have characteristic imaging findings that can result in an accurate diagnosis with use of imaging alone, other entities are difficult to distinguish at imaging because there is significant overlap among them. The interpreting radiologist should be familiar with the imaging features of both "do not touch" benign entities (which can be confidently diagnosed with imaging only, with no need for biopsy or resection unless the patient is symptomatic) and lesions that cannot be confidently characterized and thus require further workup. CT and MRI are the main imaging modalities used to assess the chest wall, with each having different benefits and drawbacks. Chest wall lesions can be classified according to their predominant composition: fat, calcification and ossification, soft tissue, or fluid. The identification or predominance of signal intensities or attenuation for these findings, along with the patient age, clinical history, and lesion location, can help establish the appropriate differential diagnosis. In addition, imaging findings in other organs, such as the lungs or upper abdomen, can at times provide clues to the underlying diagnosis. The authors review different chest wall lesions classified on the basis of their composition and highlight the imaging findings that can assist the radiologist in narrowing the differential diagnosis and guiding management. ^©RSNA, 2022.

Efficacy of Percutaneous Transarterial Embolization in Patients with Spontaneous Abdominal Wall Hematoma and Comparison between Blind and Targeted Embolization Approaches

Background: Endovascular treatment of abdominal wall hematomas (AWHs) has been increasingly used when conservative treatments were not sufficiently effective, and it is often preferred to surgical interventions. The aim of our study was to evaluate the safety and technical and clinical success of percutaneous transarterial treatment of AWH and to evaluate the efficacy of blind embolization compared to targeted embolization. Materials and Methods: We retrospectively enrolled 43 patients (23 men and 20 females) with spontaneous AWH who underwent digital subtraction angiography (DSA) and embolization, focusing on the presence of signs of bleeding at pre-procedural CT-Angiography (CTA) and at DSA. Furthermore, we divided patients into two groups depending on blind or targeted embolization approaches. Results: The mean age of the study population was 71 ± 12 years. CTA revealed signs of active bleeding in 31 patients (72%). DSA showed signs of active bleeding in 34 patients (79%). In nine patients (21%), blind embolization was performed. The overall technical success rate was 100%. Clinical success was achieved in 33 patients (77%), while 10 patients (23%) rebled within 96 h, and all of them were re-treated. No major peri-procedural complication was reported. The comparison between blind and targeted embolization showed no statistically significant differences for characteristics of groups and for clinical success rates (78% and 77%, respectively, −p = 0.71). The technical success was 100% in both groups. Conclusions: Our study confirms that transarterial embolization is a safe and effective option for the treatment of spontaneous AWHs, and it suggests that the efficacy and safety of blind embolization is comparable to non-blind.

Spontaneous Haematomas in Anticoagulated Covid-19 Patients: Diagnosis and Treatment by Embolization

PURPOSE

To assess the safety and efficacy of embolization for spontaneous bleeding in anticoagulated patients with COVID-19.

MATERIAL AND METHODS

Single center retrospective study in 9 patients with COVID-19 who experienced bleeding complications following anticoagulation. The study included 8 men and 1 woman aged from 48 to 80 years (mean 69.7 years), who had a total of 10 soft tissue haematomas: 1 in the thigh, 1 in the anterior abdominal wall, 6 retroperitoneal and 2 thoracic haematomas. All patients were referenced for vascular embolization, mostly with Onyx-18.

RESULTS

A total of 10 haematomas were embolized in 9 patients. Technical success was achieved in all patients. No complications or adverse events were noted. One patient required percutaneous drainage of an infected haematoma 88 days after embolization. The mean hemoglobin level before embolization was 8,64 mg/dL and increased to 9,08 mg/dL after embolization (p = 0,3). After embolization all patients recovered haemodynamic stability and blood pressure levels improved. Seven patients resumed anticoagulation therapy after embolization. There were no recurrences or new bleedings in all treated patients. No patients required any additional invasive therapies or surgery. Mean intensive unit care and hospital stay was 6.7 and 35.2 days, respectively. All patients were discharged and were well at follow-up clinic visits 2-7 months after embolization. Seven patients performed a control CT scan 1-6 months after embolization, showing complete resolution of the haematoma.

CONCLUSION

Embolization is safe and effective to treat spontaneous haematomas in anticoagulated patients with COVID-19, allowing to resume anticoagulation therapy. Level of evidence IV Level 4, case-series.

Bilateral multifocal muscular hemorrhage in the triceps surae during antiplatelet therapy: a case report

Hemorrhagic complications are often reported following antiplatelet therapy; however, simultaneous multifocal hemorrhages in both legs are uncommon. The patient was a 75-year-old man diagnosed with ST elevation myocardial infarction who underwent percutaneous coronary intervention in the right coronary artery. He was prescribed oral acetylsalicylic acid and ticagrelor. Three days after initial drug treatment, he complained of bilateral leg pain that was aggravated by walking and moving his ankle across a broad range of motion. No deep vein thrombosis was detected on Doppler ultrasonography; however, muscular hemorrhage was suspected according to musculoskeletal ultrasonography. Multifocal muscular hemorrhage was confirmed in the soleus and gastrocnemius muscles on magnetic resonance imaging. To reduce the risk of bleeding, we changed the medication from ticagrelor to clopidogrel. The patient performed leg elevation exercises, compression, and applied an ice pack. He also performed range of motion exercises and gait training in addition to receiving drug treatment. With these therapies, his pain score improved from 5 to 3 on a visual analog scale, without further complications. Multifocal muscular hemorrhage rarely occurs bilaterally; however, when it does occur, an appropriate treatment plan can be developed based on musculoskeletal ultrasonography.

Infected Leg Hematoma: A Rare Cause of Recurrent Leg Cellulitis

Intramuscular hematoma most commonly occurs following trauma; however, spontaneous hematomas may be seen in elderly patients due to anticoagulation. Intramuscular hematomas may not be chronically expanding, and their signs and symptoms vary, ranging from asymptomatic to swelling that may be expanding in size. In some cases, chronic hematoma may become infected as we witnessed in the case we present in this report. Our patient reported recurrent cellulitis and occasional fever with no other history of probable cause of the recurrent cellulitis. Such an atypical presentation poses a risk of delayed or missed diagnosis of a condition that can threaten the limb of a patient, as seen in our case.

Spontaneous Muscle Hematoma in Japanese Patients with Severe COVID-19 Treated with Unfractionated Heparin: Two Case Reports

In hospitalized coronavirus disease 2019 (COVID-19) patients, anticoagulation therapy is administered to prevent thrombosis. However, anticoagulation sometimes causes bleeding complications. We herein report two Japanese cases of severe COVID-19 in which spontaneous muscle hematomas (SMH) developed under therapeutic anticoagulation with unfractionated heparin. Although the activated partial prothrombin time was within the optimal range, contrast-enhanced computed tomography (CECT) revealed SMH in the bilateral iliopsoas muscles in both cases, which required emergent transcatheter embolization. Close monitoring of the coagulation system and the early diagnosis of bleeding complications through CECT are needed in severe COVID-19 patients treated with anticoagulants.

Ultrastructural Analysis of Volumetric Histotripsy Bio-effects in Large Human Hematomas

Large-volume soft tissue hematomas are a serious clinical problem, which, if untreated, can have severe consequences. Current treatments are associated with significant pain and discomfort. It has been reported that in an in vitro bovine hematoma model, pulsed high-intensity focused ultrasound (HIFU) ablation, termed histotripsy, can be used to rapidly and non-invasively liquefy the hematoma through localized bubble activity, enabling fine-needle aspiration. The goals of this study were to evaluate the efficiency and speed of volumetric histotripsy liquefaction using a large in vitro human hematoma model. Large human hematoma phantoms (85 cc) were formed by recalcifying blood anticoagulated with citrate phosphate dextrose/saline-adenine-glucose-mannitol solution. Typical boiling histotripsy pulses (10 or 2 ms) or hybrid histotripsy pulses using higher-amplitude and shorter pulses (0.4 ms) were delivered at 1% duty cycle while continuously translating the HIFU focus location. Histotripsy exposures were performed under ultrasound guidance with a 1.5-MHz transducer (8-cm aperture, F# = 0.75). The volume of liquefied lesions was determined by ultrasound imaging and gross inspection. Untreated hematoma samples and samples of the liquefied lesions aspirated using a fine needle were analyzed cytologically and ultrastructurally with scanning electron microscopy. All exposures resulted in uniform liquid-filled voids with sharp edges; liquefaction speed was higher for exposures with shorter pulses and higher shock amplitudes at the focus (up to 0.32, 0.68 and 2.62 mL/min for 10-, 2- and 0.4-ms pulses, respectively). Cytological and ultrastructural observations revealed completely homogenized blood cells and fibrin fragments in the lysate. Most of the fibrin fragments were less than 20 μm in length, but a number of fragments were up to 150 μm. The lysate with residual debris of that size would potentially be amenable to fine-needle aspiration without risk for needle clogging in clinical implementation.

A case report of a spontaneous sternocleidomastoid hematoma: a challenging diagnosis in infantile neck swellings

Background

Pediatric neck masses are a common complaint in children. The most common etiologies include congenital lesions, lymphadenopathy, vascular malformations, inflammatory, and malignant lesions. Spontaneous sternocleidomastoid hematoma is exceptional in infant.

Case presentation

We describe a case of spontaneous cervical hematoma diagnosed in a 4-month-old child. Past history did not reveal a neck trauma, a history of difficult labor, a bleeding disorder or a pertinent family history. The diagnosis was suspected based on the imaging features and confirmed after surgical removal.

Conclusions

Sternocleidomastoid swelling is commonly encountered in infancy.

Ultrasound still remains the initial modality of choice. The management modalities are controversial.

Spontaneous Muscle Hematoma in Patients with COVID-19: A Systematic Literature Review with Description of an Additional Case Series

Coagulation abnormalities, thrombosis, and endothelial dysfunction have been described in COVID-19 patients. Spontaneous muscle hematoma (SMH) is a rare complication in COVID-19. The aims of this study are to: (1) perform a systematic review of the literature to better define the clinical SMH characteristics, (2) describe the prevalence and the clinical characteristics of SMH in COVID-19 patients referring to a Department of Internal Medicine (IM) (Federico II University of Naples), a Department of Sub-Intensive Care Medicine (SIM) (Ospedale Del Mare), and a Department of Intensive Care Unit (ICU) (Federico II University). The systematic review was performed according to PRISMA criteria. The local prevalence of SMH in COVID-19 was evaluated retrospectively. The medical records of all COVID-19 patients referring to IM and ICU from March 11th, 2020, to February 28th, 2021 were examined for SMH occurrence. In our retrospective analysis, we describe 10 cases of COVID-19 patients with SMH not previously reported in literature, with a prevalence of 2.1%. The literature review, inclusive of our case series, describes a total of 50 SMHs in COVID-19 patients (57.4% males; mean age 68.8 ± 10.0 years). The SMH sites were ileo-psoas, vastus intermedius, gluteus, sternocleidomastoid, and pectoralis major muscles. Males developed SMH earlier than females (9.5 ± 7.8 vs. 17.1 ± 9.7 days). Ileo-psoas hematoma was more frequent in males (69.2 vs. 30.8%), while pectoralis major hematoma occurred only in females. The in-hospital mortality rate of SMH in COVID-19 patients was 32.4%. SMH is a rare but severe complication in COVID-19 hospitalized patients, associated with high mortality. A gender difference seems to be present in the clinical presentation of the disorder.

Iliopsoas Hematomas in a Patient with Progressive Encephalomyelitis with Rigidity and Myoclonus

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare and severe syndrome characterized by rigidity of the limb and truncal muscles, brainstem signs, myoclonus, and hyperekplexia. Iliopsoas hematoma is a serious complication of bleeding disorders that occurs most commonly in patients with hemophilia and also in association with anti-coagulant drug treatment. We herein present a case of PERM complicated with bilateral iliopsoas hematomas. His neurological symptoms improved after immunotherapy, and thereafter the iliopsoas hematomas disappeared. Neurologists should consider iliopsoas hematomas as a serious potential complication of PERM.

Spontaneous psoas haematoma: a life-threatening complication of anticoagulation in COVID-19. A case series of four episodes

BACKGROUND

Anticoagulant prophylaxis is part of the standard management of hospitalized COVID-19 patients. Despite adequate thromboprophylaxis, one-third of COVID-19 patients with pneumonia developed pulmonary embolism. This high rate of thrombotic complications has led to higher doses of anticoagulants according to clinical complexity (e.g. intensive care unit (ICU) patients) and D-dimer levels. On the other side of the coin, haemorrhagic complications are being increasingly reported.

CASES PRESENTATION

We herein report four cases of spontaneous psoas haematomas (SPH) among 548 patients hospitalized for SARS-CoV-2 pneumonia between March 2020 and January 2021 (incidence of 7.3 cases per 1000 patients). All patients had pneumonia, with age ranging between 62 and 83 years. All patients received anticoagulant therapy with low weight molecular heparin (100 U.I. anti-Xa/kg 2 times/d) from admission: in two cases, a diagnosis of pulmonary embolism was made. In another case, a thrombosis of left axillary and basilic veins was found, and only in one case anticoagulant therapy was started because of elevated levels of D-dimer. In all cases, signs of anaemia were detected and patients experienced low back or abdominal pain. The diagnosis of spontaneous psoas haematoma was made by computed tomography (CT) after a median of 12.5 d (9;16) from admission and 19.5 d (14.75; 24.25) from the beginning of COVID-19 symptoms. Half of these patients died from haemorrhagic shock.

CONCLUSIONS

Given the potential life-threatening of SPH and the possible subtle clinical presentation, we believe it is crucial to raise clinicians awareness of this complication among COVID-19 patients undergoing anticoagulants.

Spontaneous massive pectoral hematoma induced by vitamin K antagonist therapy: a case report

Vitamin K antagonists (VKA) based oral anticoagulation, is widely used for the prevention and treatment of thromboembolic disease. The major complication of this therapy is bleeding, and sometimes it can occur in unsuspected areas. Spontaneous pectoral hematoma is one of the rare complications due to over anticoagulation by VKA therapy, with only a few cases reported in the literature. Concomitant use of this therapy with commonly used antibiotic, especially in the elderly with multiple comorbidities, can increase the risk of bleeding. Herein, we report a case of a 72-year-old woman under VKA for the treatment of atrial fibrillation, who presented with a spontaneous massive pectoral hematoma, while using antibiotic to treat a respiratory tract infection, who was successfully managed.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of abdominal wall hemorrhage

PURPOSE

We aimed to evaluate the effectiveness and safety of n-butyl cyanoacrylate (n-BCA) in the context of the transarterial embolization (TAE) of abdominal wall hemorrhage in an urgent scenario.

METHODS

A retrospective study of cases admitted from January 2008 to December 2017 in the emergency unit of our institution revealed 11 patients with abdominal wall hemorrhage who underwent digital subtraction angiography and TAE with n-BCA. We analyzed the sex, age, hemorrhagic risk factors, etiology, embolized vessel, technical success (no rebleeding in the embolized area), clinical success (hemoglobin level control and hemodynamic stability after the procedure), complications inherent to the procedure, and clinical outcome (mortality in 30 days).

RESULTS

The mean age was 63.4 years (52-83 years), with a predominance of the female sex (64%). The majority (91%) of patients presented hemorrhagic risk factors (chronic hepatopathy and anticoagulation drug usage). Spontaneous hemorrhage was present in 18% of patients, and the other 82% had an iatrogenic etiology. Technical success was achieved in 100% of the patients, which required the embolization of inferior epigastric artery in 10 patients (91%), circumflex iliac artery in 2 (18%), and superior epigastric artery in 1 (9%). Five patients were hemodynamically unstable, and despite achieving technical success, 4 (36%) died in less than 30 days due to decompensation of their clinical comorbidities caused by the acute phase. There were no complications inherent to the procedures.

CONCLUSION

The present study concludes that TAE with n-BCA is a safe and effective treatment for abdominal wall hemorrhage in an urgent scenario, with high rates of technical and clinical success.

Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma

AIM

To evaluate the technical and clinical success of embolisation in patients with life-threatening spontaneous retroperitoneal haematoma (SRH) and to assess predictors of clinical outcome.

MATERIALS AND METHODS

Thirty patients (mean age: 71.9±9.8 years) with SRH underwent digital subtraction angiography (DSA). All patients received anticoagulant or antiplatelet medication or a combination of both at the time the SRH occurred.

RESULTS

Pre-interventional computed tomography angiography (CTA) revealed active retroperitoneal bleeding in 28 of 30 (93.3%) patients. DSA identified active haemorrhage in 22 of 30 patients (73.3%). Twenty-nine of 30 (96.7%) patients underwent embolisation. n-Butyl-2-cyanoacrylate (NBCA) was used in 15 patients (51.7%), coils were used in 10 patients (34.5%), and both embolic agents were used in four patients (13.8%). The technical success rate was 100%. Pre-interventional haemoglobin levels increased significantly after embolotherapy from 70.9±16.1 g/l to 87±11.3 g/l (p<0.001), whereas partial thromboplastin time decreased from 58±38 to 30±9 seconds (p<0.001) after embolotherapy. The need for transfusion of concentrated red cells decreased from 3±2.2 to 1±1.1 units (p<0.001) after the intervention. Clinical success was achieved in 19 of 29 (65.5%) patients. No major procedure-related complications occurred. Seven patients (24.1%) died within 30 days after the procedure.

CONCLUSION

Embolotherapy in patients with life-threatening SRH leads to a high technical success rate and is a safe therapeutic option. The clinical success rate was acceptable and influenced by pre-interventional coagulation status and by the amount of transfused concentrated red cells.

Coagulopathy-related soft tissue hematoma: a comparison between computed tomography findings and clinical severity

Background

Despite increases in the incidence of coagulopathy-related soft-tissue hematoma (CRSH), the relationship between computed tomography (CT) features and clinical severity remains unclear.

Purpose

To retrospectively evaluate the correlation between CT findings and clinical outcomes in CRSH.

Material and Methods

We retrospectively reviewed data of patients diagnosed with CRSH between March 2011 and March 2018. CRSH was morphologically classified according to the presence or absence of the fluid level pattern and was also divided into groups with or without extravasation as per CT findings. These CT findings were compared with the patients' vital signs and laboratory investigation results.

Results

A total of 47 patients with CRSH were examined. Fluid level and non-fluid level patterns were observed in 28 (60%) and 19 (40%) patients, respectively. Anticoagulant therapy and extravasation were significantly correlated with the fluid level pattern. However, other clinicolaboratory outcomes, including shock index, hemoglobin, hematocrit, platelet count, and coagulation factors, showed no significant difference between the two patterns. In the comparison of hematomas with and without extravasation, none of the clinicolaboratory outcomes except for anticoagulant therapy showed significant differences.

Conclusion

CRSH with a fluid level pattern is significantly associated with extravasation. However, extravasation, which is generally suggestive of active bleeding, does not seem to be related to clinical severity in CRSH.

Trauma CT evaluation prior to selective angiography in patients with traumatic injuries: negative predictive power and factors affecting its utility

PURPOSE

To evaluate the predictive power of arterial injury detected on contrast-enhanced CT (trauma CT (tCT)) imaging obtained prior to selective angiography for treatment of patients with traumatic abdominal and pelvic injuries.

MATERIALS AND METHODS

A retrospective chart review was performed of all patients who underwent angiography after undergoing contrast-enhanced CT imaging for the evaluation/treatment of traumatic injuries to the abdomen and pelvis between March 2014 and September 2018. Data collection included demographics, pertinent history and physical findings, CT and angiography findings, treatment information, and outcomes.

RESULTS

Eighty-nine (63 males, mean age = 45.8 ± 20.5 years) patients that were found to have 102 traumatic injuries on tCT and subsequently underwent angiography met inclusion criteria for this study. Sixty-four injuries demonstrated evidence of traumatic vascular injury on initial tCT. A negative tCT was able to predict subsequent negative angiography in 83% of cases (negative predictive power = 83%). The ability of tCT to rule out a positive finding on subsequent angiography was also 83% (sensitivity = 83%). The average systolic blood pressure and hemoglobin concentration at the time of tCT were higher in patients who had positive tCT than in patients with negative tCT (p < 0.05 and p < 0.01, respectively). The average time to angiography was greater in patients whom had subsequent negative angiography than the patients who had subsequent positive angiography (p < 0.05).

CONCLUSION

Contrast-enhanced CT imaging may be able to help stratify patients who may have subsequent negative angiograms. Hemodynamic factors may affect sensitivity of tCT. Shorter time to angiography may increase the chance of identifying the injury on subsequent angiography.

Clinics in diagnostic imaging (201). Small bowel intramural haematoma induced by anticoagulation therapy with associated reactive ileus

A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.

Incidence and endovascular treatment of severe spontaneous non-cerebral bleeding: a single-institution experience

OBJECTIVES

To investigate the incidence and endovascular treatment of severe spontaneous non-cerebral hemorrhage (SSNCH) in a high-volume, tertiary university hospital.

METHODS

All patients diagnosed with SSNCH between January 2016 and June 2017 were retrospectively analyzed. Endovascular treatment (group EVT) was offered only in patients demonstrating active bleeding at CT angiography (CTA). In cases without active bleeding at CTA, conservative management was decided (group CM). Outcome measures included the incidence of SSNCH, 6-month rebleeding, and survival rates in the two groups as well as EVT technical success and related complications.

RESULTS

Within the 18-month period, 44 SSNCH cases were identified, resulting in an annual incidence of 29.3 cases. In 37/44 cases (84.1%), bleeding was attributed to the antithrombotic therapy. In total, 19/44 patients underwent EVT (43.2%), and 25/44 patients (56.8%) were managed conservatively. Two patients who were initially treated conservatively finally underwent EVT due to rebleeding (7.4%). The technical success of EVT was 100%, while rebleeding occurred in 1 case (5.2%) following lumbar artery embolization and was successfully re-embolized. According to the Kaplan-Meier analysis, the 1-, 3-, and 6-month survival rates were 68.4%, 63.2%, and 42.1% for group EVT and 87.5%, 75.0%, and 58.3% for group CM, respectively. There were no EVT-related complications.

CONCLUSIONS

The annual incidence of SSNCH in our institution is substantial. EVT resulted in uncomplicated, high bleeding control rates. The mortality rate was similarly high following either EVT or conservative treatment and was mainly attributed to severe comorbidities.

KEY POINTS

• This study demonstrates that the incidence of severe spontaneous non-cerebral hemorrhage (SSNCH) in our institution is substantial. • Endovascular treatment was offered only in patients with clinical signs of ongoing hemorrhage and active bleeding at CT angiography and resulted in effective and uncomplicated, minimal invasive hemostasis, in a population with severe comorbidities. • This is the first study to evaluate the outcomes of both endovascular hemostasis and conservative management. Rebleeding following either conservative or endovascular treatment was minimal.