Spontaneous Atraumatic Mediastinal Hemorrhage: Challenging Management of a Life-Threatening Condition and Literature Review

Mediastinal hematoma following thrombolysis for acute pulmonary thromboembolism

Massive pulmonary thromboembolism (PE) is a cardiorespiratory emergency and can be fatal if left untreated. The recommended treatment for PE in the presence of right ventricular dysfunction and hemodynamic instability is thrombolysis. However, the latter is a double-edged sword as life-threatening bleeding manifestations can occur post-thrombolysis. Timely identification and management of these complications can prevent a catastrophic outcome. We report a case of mediastinal hematoma with new onset hemodynamic compromise following thrombolysis for acute massive pulmonary embolism. Clinico-radiological features and Point of Care Ultrasound (POCUS) findings helped in the identification of the bleeding site in our case. Despite early diagnosis and timely intervention, the patient succumbed to secondary complications.

Successful interventional management of mediastinal hematoma caused by thyroid ima artery injury

Background

The thyroid ima artery (ThIA) is a rare anatomical anomaly, commonly branching from the brachiocephalic artery. Thyroid ima artery injury can cause severe mediastinal hematoma because its descending branch extends into the mediastinum.

Case presentation

A 91‐year‐old man presented with syncope after a motor vehicle accident. A bruise on the chest was evident. Contrast‐enhanced computed tomography revealed a massive mediastinal hematoma with signs of active hemorrhage. Injury to a descending branch of the ThIA was indicated. Transcatheter arterial embolization (TAE) was successful in stopping the bleeding.

Conclusions

Although a ThIA injury is rare, it can cause serious mediastinal hematoma. Thyroid ima artery injury should be considered as a cause of traumatic mediastinal hematoma. Transcatheter arterial embolization for traumatic ThIA injury is considered a safe and effective treatment.

Posterior mediastinal hematoma after a simple fall in a patient with normal coagulation

Case

A 77-year-old woman presented with neck swelling and odynophagia following a fall from standing height. She had no history of antiplatelet or anticoagulant use. Computed tomography of the chest showed an isodense to hypodense soft tissue mass in the bilateral carotid space, retropharyngeal space, and posterior mediastinum. With no airway obstruction symptoms, the patient was placed on bed rest under close observation.

Outcome

The mass decreased in size spontaneously over the 10 days following symptom onset, accompanied by overall clinical improvement. The patient was diagnosed with a posterior mediastinal hematoma.

Conclusion

This is the first reported case of posterior mediastinal hematoma caused by a neck hyperextension injury secondary to a simple fall in a patient with normal coagulation. The outcome was good; however, emergency physicians should be aware that hematomas necessitating airway management may occur after a fall.