Intramuscular Hematoma on the Psoas Muscle

Embolisation of iatrogenic lumbar artery bleed causing psoas haematoma following elective lumbar puncture

The case of a female patient in her 50s presenting as a surgical emergency with abdominal pain and a positive Obraztsova's sign. Seven days prior to the presentation, a lumbar puncture (LP) had been performed to investigate severe headaches and exclude a subarachnoid haemorrhage. The patient was subsequently found to have an acute lumbar arterial bleed causing haemodynamic instability and a psoas haematoma. An emergency lumbar artery embolisation procedure was performed by the interventional radiology department in order to stabilise the bleed. The patient made a full recovery prior to discharge.

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.

Fatal iliopsoas and rectus sheath hemorrhage in a critically ill patient with COVID-19 on therapeutic anticoagulation

Pulmonary embolism and thrombosis are two common postmortem findings in novel coronavirus disease 2019 (COVID-19), the fact which led experts to include anticoagulants in the standard management of COVID-19. However, at least until now, no guidelines stated the exact safe yet optimal dose of anticoagulants. We report a case of a 65-year-old man admitted to our hospital with severe acute respiratory distress syndrome due to COVID-19. He showed remarkable improvement during the first 10 days of treatment at our facility but subsequently developed spontaneous iliopsoas hemorrhage (IPH). We discontinued antithrombotic and anticoagulant agents as soon as we confirmed the IPH from the abdominal computed tomography scan. His condition worsened even after he received adequate blood transfusion sets and eventually developed disseminated intravascular coagulation. Due to the limitation of our hospital, we could not perform stent grafting and angiographic embolization. He finally died 6 days after the occurrence of IPH. To the best of our knowledge, this is the first case of COVID-19 with IPH in Indonesia. As a developing country, many hospitals in Indonesia do not have stent grafting and angiographic embolization. This condition urges the dose recommendation for anticoagulant therapy to provide safe and efficient management for COVID-19.

Anticoagulant-Related Intramuscular Hematomas in an Inpatient Acute Rehabilitation Population: A Case Series

ABSTRACT

Anticoagulant-related intramuscular hematomas are uncommon. However, when they do occur, the clinical consequences can be significant. The authors describe nine patients on anticoagulation undergoing rehabilitation who experienced an intramuscular hematoma. In all cases, activity in therapy before the intramuscular hematoma was considered normal therapeutic activity and consistent with activity commonly performed during rehabilitation. The study found that the anticoagulated rehabilitation population is at risk for intramuscular hematomas and poses a diagnostic challenge because many are insensate and, therefore, present atypically.

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.

Non-penetrating traumatic psoas muscle hematoma presenting with gross hematuria: a case report

Psoas muscle hematoma is defined as a spontaneous or traumatic retroperitoneal collection of blood involving the psoas muscle. Early symptoms of an iliopsoas hematoma include lower abdominal or severe groin pain. Although psoas hematoma is a known complication of coagulopathy, psoas hematoma caused by non-penetrating trauma is the subject of only scattered reports and its significance has not been well described in the literature, so the aim of this study was to report a case of blunt traumatic psoas hematoma with the fracture of vertebral transverse process with the presentation of gross hematuria. A 65-year-old Iranian man slipped backward to the ground, and the patient complaint of gross hematuria and difficulty in walking. There was severe left costo-vertebral angle (CVA) tenderness, and mild groin tenderness, and the lower back area was painful, and he had some pain with the flexion of the vertebral column, and there was tenderness on lumbar spine, but there was no tingling, paresthesia, and weakness in left lower extremity. Hip flexion was 3/5 in the left lower. We used some diagnostic modalities as x-ray radiography, ultrasonography, computed tomography (CT) scan with intravenous (IV) contrast, CT cystography, and intravenous pyelogram (IVP) IVP to differentiate the diagnoses and also find skeletal and other organ injuries associated with this kind of injury. We can conclude that post-traumatic psoas hematoma is a rare condition. The diagnostic modality of choice is CT scan which allows rapid identification and measurement of the hematoma. The lesion usually treated with non-operative conservative management.

Psoas Hematoma and Late Femoral Nerve Palsy After Extreme Lateral Interbody Fusion and Posterior Spinal Fusion with Instrumentation: A Case Report

Introduction

Psoas hematoma is an uncommon complication following spinal surgeries. It has been reported in both extreme lateral interbody fusion (XLIF) and posterior spinal fusion with instrumentation. Minimally invasive techniques are gaining popularity in recent years due to the appealing advantages of reduced operative time, blood loss, hospital stay, and faster recovery.

Case Presentation

We are presenting a case of a 77-year-old male with chronic low back pain, diagnosed to have multilevel degenerative disc disease with central and foraminal disc protrusion at L2-L3, L3-L4, L4-L5 with secondary spinal stenosis, underwent XLIF at L3-L4, L4-L5 and then 2nd stage with posterior L3-L5 fusion with pedicle screws. On the fourth day post-operatively, the patient had flank pain and dropping hemoglobin with femoral nerve palsy symptoms, a CT scan revealed a large psoas hematoma. Conservative management was decided on; a follow-up CT scan and examination showed complete resolution of the hematoma and femoral nerve recovery.

Discussion

The approach to iliopsoas hematoma post spinal surgeries remains controversial. Iliopsoas hematoma should be suspected in any patients post spinal surgeries even with delayed presentations. The decision to proceed with either surgical intervention or conservative management depends on multiple factors, including patient hemodynamic status, progression of collection and femoral nerve palsy.

Conclusion

The exact cause of iliopsoas hematoma post different spinal surgery approaches remains vague. In our opinion, other causes including pre- and post-operative anticoagulants should be investigated. Rushing to drain iliopsoas hematomas in case of femoral nerve palsy might not be the ideal option. Instead, monitoring patient responses to resuscitation and taking a watch and wait approach for femoral nerve palsy might be the proper approach.