Spontaneous ilio-psoas hematomas complicating intensive care unit hospitalizations

BACKGROUND

Ilio-psoas hematoma is a potentially lethal condition that can arise during hospital stay. However, neither the incidence nor the prognosis of patients whose stay in intensive care units (ICU) is complicated by a iatrogenic ilio-psoas hematoma is known.

METHODS

A bicentric retrospective study was conducted to compile the patients who developed an ilio-psoas hematoma while they were hospitalized in ICU between January 2009 and December 2016. Their biometric characteristics, pre-existing conditions, the circumstances in which the hematoma was diagnosed, the treatments they received and their prognosis were recorded.

RESULTS

Forty patients were diagnosed with an ilio-psoas hematoma during their ICU stay. The incidence of this complication was 3.8 cases for 1000 admissions, taking into account only patients who stayed more than three days in ICU. The median age of patients was 74 years old and the median time between admission and the diagnosis of ilio-psoas hematoma was 12.6 days. A large proportion of them was obese (42.5%) and/or under dialysis (50%) prior to developing their hematoma. Ninety-five percent of the patients had heparin at prophylactic or therapeutic doses. Only 10% of them were above the therapeutic range of anticoagulation. The ICU mortality rate was of 50% following this complication (versus a general mortality rate of 22% for the patients without IPH over the same period of time). Patients with IPH that were complicated by disseminated intravascular coagulopathy had a significantly higher mortality rate than those with IPH and no disseminated intravascular coagulopathy (OR 6.91, 95% CI [1.28; 58.8], p = 0.04).

CONCLUSION

Age, anticoagulation, a high body mass index and dialysis seem to be risk factors of developing an ilio-psoas hematoma in ICU. Iatrogenic ilio-psoas hematomas complicated by disseminated intravascular coagulopathies are more at risk of leading to death. It is noteworthy that activated partial thromboplastin time above the therapeutic range was not a good predictor of developing a hematoma for patients who received unfractioned heparin therapy.

Emergency Department Presentation of Iliopsoas Hematoma in a Severe Hemophiliac

Severe hemophilia A is defined by factor VIII level of <1%. Limited research and case series show that these patients are at the highest risk for bleeding complications, the most common being hemarthrosis and muscle hematoma, respectively.1 While rare, iliopsoas hematoma carries significant morbidity, mortality, and requires prompt intervention in hemophiliac patients. As such, it is essential the emergency providers evaluate for this condition in this unique patient population. We present the case of 21-year-old male with severe hemophilia A who presented with one day of right groin pain after going without his prophylactic factor VIII infusions for one week, with subsequent diagnosis and initial treatment of iliopsoas hematoma made in the ED.

Feasibility of FAIR imaging for evaluating tumor perfusion

PURPOSE

To evaluate the feasibility of flow-sensitive alternating inversion recovery (FAIR) for measuring blood flow in tumor models.

MATERIALS AND METHODS

In eight mice tumor models, FAIR and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was performed. The reliability for measuring blood flow on FAIR was evaluated using the coefficient of variation of blood flow on psoas muscle. Three regions of interest (ROIs) were drawn in the peripheral, intermediate, and central portions within each tumor. The location of ROI was the same on FAIR and DCE-MR images. The correlation between the blood flow on FAIR and perfusion-related parameters on DCE-MRI was evaluated using the Pearson correlation coefficient.

RESULTS

The coefficient of variation for measuring blood flow was 9.8%. Blood flow on FAIR showed a strong correlation with Kep (r = 0.77), percent relative enhancement (r = 0.73), and percent enhancement ratio (r = 0.81). The mean values of blood flow (mL/100 g/min) (358 vs. 207), Kep (sec(-) (1)) (7.46 vs. 1.31), percent relative enhancement (179% vs. 134%), and percent enhancement ratio (42% vs. 26%) were greater in the peripheral portion than in the central portion (P < 0.01).

CONCLUSION

As blood flow measurement on FAIR is reliable and closely related with that on DCE-MR, FAIR is feasible for measuring tumor blood flow.

Transcatheter Arterial Embolization of Concurrent Spontaneous Hematomas of the Rectus Sheath and Psoas Muscle in Patients Undergoing Anticoagulation

We report a case of concurrent rectus sheath and psoas hematomas in a patient undergoing anticoagulant therapy, treated by transcatheter arterial embolization (TAE) of inferior epigastric and lumbar arteries. Computed tomography (CT) demonstrated signs of active bleeding in two hematomas of the anterior and posterior abdominal walls. Transfemoral arteriogram confirmed the extravasation of contrast from the right inferior epigastric artery (RIEA). Indirect signs of bleeding were also found in a right lumbar artery (RLA). We successfully performed TAE of the feeding arteries. There have been few reports in the literature of such spontaneous hemorrhages in patients undergoing anticoagulation, successfully treated by TAE.

Anticoagulant-related iliopsoas muscle bleeding leading to fatal exsanguination: report of two autopsy cases

Two cases of massive iliopsoas muscle bleeding leading to fatal exsanguination are presented. Both patients (two women, 61 and 74 years old, respectively) received oral anticoagulation with phenprocoumon. The intramuscular bleeding occurred spontaneously in women of relatively good physical condition. Intriguingly, phenprocoumon concentrations were within the therapeutic range (1.55 microg/ml and 1.26 microg/ml, respectively) as detected by toxicologic analysis. These cases demonstrate that severe bleeding in the iliopsoas muscle has to be considered in all patients receiving anticoagulant medication, even in those who have coagulation parameters within the therapeutic range. Especially in older patients with a high degree of comorbidity or in patients receiving analgesic drugs, the potential of fatal outcome of iliopsoas muscle bleeding seems to be of clinicopathologic relevance.

CT of unusual iliopsoas compartment lesions

The authors reviewed the anatomy of the iliopsoas compartment and a spectrum of unusual lesions affecting structures in this compartment, with emphasis on the role of computed tomography (CT). Lesions in the iliopsoas compartment are caused by acute infection, tumor, or hemorrhage. The knowledge of detailed clinical data can help improve the diagnostic accuracy, particularly with regard to primary iliopsoas lesions. CT is useful for delineating the source of secondary iliopsoas lesions, guiding biopsy, and performing follow-up of treated lesions. Nonenhanced CT can help detect fresh hemorrhage, fat-containing tumor, and calcification, whereas contrast material enhanced CT optimizes imaging of infection, tumor, and aneurysm.

Rats with moderate renal failure show capillary deficit in heart but not skeletal muscle

In previous studies on experimental renal failure, hypertrophy of cardiomyocytes, diminished capillarization, and increased intercapillary distances had been observed, abnormalities that will expose the heart to reduced ischemia tolerance. It has not been established, however, whether such structural alterations are unique for the heart (eg, as a consequence of left ventricular hypertrophy) or are demonstrable in other tissues as well. Clarification of this point is important to test hypotheses on some potential mechanisms for cardiac undercapillarization. To address this issue further, we compared capillary length density (by stereologic techniques) in perfusion-fixed skeletal muscle (m. psoas) and hearts of subtotally nephrectomized (SNX) rats with moderate renal failure to those in sham-operated pair-fed controls. The duration of renal failure was 8 weeks. SNX rats had significantly higher mean systolic blood pressure (128 mm Hg v 109 mm Hg), serum creatinine, and urea levels. Despite pair feeding, the mean body weight was significantly lower in the SNX rats (409 g v 471 g), but the left ventricular weight to body weight ratio tended to be higher than in the sham-operated controls (2.39 mg/g v 2.13 mg/g). In the heart, myocyte mean cross-sectional area (675 +/- 112 microm2 v 545 +/- 111 microm2) and volume density of nonvascular interstitial tissue (3.47 +/- 1.04 v 1.33 +/- 0.22) were significantly higher in the SNX rats than in the controls. In parallel, myocardial capillary length density was significantly reduced after subtotal nephrectomy (3,036 +/- 535 mm/mm3 v 3,916 +/- 615 mm/mm3). In contrast, in skeletal muscle, myocyte cross-sectional area (3,109 +/- 783 microm2 v 3,042 +/- 639 microm2), capillary length density (718 +/- 248 mm/mm3 v 717 +/- 184 mm/mm3), and three-dimensional capillary fiber ratio (2.10 +/- 0.26 v 2.13 +/- 0.4) were similar in SNX and control rats. These data document a selective defect of capillarization in the heart of animals with moderate renal failure, pointing to tissue-specific abnormalities of cardiac capillarogenesis.

Spontaneous iliopsoas hematoma in patients with unstable coronary syndromes receiving intravenous heparin in therapeutic doses

OBJECTIVE

To identify the relationship between the use of anticoagulants, specifically heparin, and the development of iliacus and psoas muscle hematoma. Three patients with unstable angina who developed groin pain while on heparin anticoagulation are presented. Patients who are anticoagulated with heparin are at increased risk of developing iliacus or psoas hematoma, manifesting a wide range of symptoms from groin pain to massive bleeding and shock. Identification of these patients is crucial in cardiology practice.

DATA SOURCES

MEDLINE searches under "iliacus', "psoas' and "iliopsoas hematoma' were conducted and cross-referenced with patients on anticoagulant therapy. Only English language articles were included.

STUDY SELECTION

The search covered January 1966 to February 1995. Fifty-one articles were studied.

DATA SYNTHESIS

The current literature suggests that anticoagulation can cause iliacus or psoas muscle hematoma and usually presents as femoral neuropathy. However, the presented case reports provide evidence that an earlier manifestation of this entity is the development of groin pain, and that early identification is crucial to improving patient morbidity and mortality.

CONCLUSIONS

Patients who are on heparin anticoagulation should be carefully monitored for development of groin pain or leg weakness. In such cases, early recognition of possible iliacus or psoas hematoma should be by abdominal ultrasound or computed tomography, and heparin anticoagulation should be modified according to its clinical requirement.

Smooth muscle cell types at different aortic levels and in microvasculature of rabbits with renovascular hypertension

BACKGROUND

The monoclonal antimyosin antibodies smooth muscle (SM)-E7, non-muscle (NM)-G2 and NM-F6 recognize smooth muscle myosin heavy chains, and A- and B-like non-muscle myosin heavy chains, respectively. On this basis, aortic smooth muscle cell types have been identified as adult (SM-E7-positive), postnatal (SM-E7- and NM-G2-positive) and fetal (SM-E7-, NM-G2- and NM-F6-positive). We have demonstrated previously that hypertrophy of the smooth muscle cell layer of the upper aorta in two-kidney, one clip hypertensive rabbits is achieved via a selective increase in postnatal-type smooth muscle cells.

OBJECTIVE

To monitor the time-course change of postnatal-type smooth muscle cells along the entire aortic tree and to define the phenotypic characteristics of the microvasculature in the same rabbit model.

MATERIALS AND METHODS

Hypertensive rabbits were killed 0.5, 1, 2.5, 4, 6 and 8 months after clipping. Normotensive age-matched rabbits served as controls. The entire aorta was frozen during perfusion at a constant pressure for morphometric and immunocytochemical studies. Transverse cryosections were taken 1 cm from the aortic valve (level A), immediately after the anonymous trunk (level B), immediately before the diaphragm (level C), and near the bifurcation (level D). Small vessels and arterioles were studied in psoas skeletal muscle and in left ventricular myocardium.

RESULTS

On the whole, aortae from hypertensive rabbits displayed a striking increase in postnatal-type smooth muscle cells at all levels by 4 months of hypertension and a progressive decrease in the number of these cells to near the control value by 8 months of hypertension. A peculiar pattern of myosin heavy chain expression was found in the microvasculature. In control and in hypertensive rabbits, both at 4 and at 8 months, small vessels and arterioles were equally reactive with the three antimyosin heavy chain antibodies. This indicates a basic prevalence of fetal-type smooth muscle cells, which is little influenced by blood pressure.

CONCLUSIONS

The present data elucidate some of the basic changes which the entire aortic segment and microvasculature undergo in the present experimental model.

CT diagnosis of concurrent hematomas of the psoas muscle and rectus sheath: case reports and review of anatomy, pathogenesis, and imaging

Two cases are presented in which psoas muscle and rectus sheath hematomas occurred concurrently. The case presentations are followed by a review of anatomy, pathogenesis, and imaging modalities involved in the cause and diagnosis of such hematomas.