Spontaneous intra-abdominal hematomas in a hepatocellular carcinoma patient treated with lenvatinib:a case report

A 44-year-old patient was admitted with tumor rupture in the left hepatic lateral lobe,and he underwent emergent exploratory laparotomy and proceeded for hepatic left lateral lobectomy on September 19,2021.The final diagnosis of hepatocellular carcinoma was confirmed by histopathological examination of the surgical specimen.Afterward,the patient received hepatic arterial infusion chemotherapy with FOLFOX(oxaliplatin,fluorouracil,and leucovorin)for 5 cycles.Subsequently,recurrence of the hepatocellular carcinoma was diagnosed in the abdominal cavity.The patient was then treated with lenvatinib.Within less than 1 month of the treatment with lenvatinib,the patient was admitted to the emergency room on June 2,2022,because of acute intra-abdominal bleeding(hematomas).Percutaneous intra-abdominal angiography found that the bleeding vessels were the right gastroepiploic artery and left gastric artery.The patient was stabilized after arterial embolization using gelatin sponges.The diagnosis and management of spontaneous intra-abdominal hematomas are discussed.

Pseudotumoral Chronic Subdural Hematomas on Two Cases

Introduction: Calcified forms with pseudo-tumor symptomatology of chronic subdural hematomas are rare. They are the result of slow bleeding over several years. The main etiology is related to the complications of the ventriculo-peritoneal shunt (VP). The purpose of this study was to recall the peculiarities and physiopathology of its pseudotumoral hematomas through 2 observations. Observation: Case 1: 8-year-old patient with a history of ventriculoperitoneal shunt at 3 months of age for congenital hydrocephalus, was admitted for functional impotence of the left-side of the body of insidious onset spreading over 9 months in a chronic headache, blurred vision and generalized seizure. CT scan showed a heterogeneous subdural hematoma of the right frontoparietal with calcifications. The patient underwent an excision by morcellation of a yellowish, friable partly calcific mass. The postoperative history was marked by a total recovery of the neurological deficit. There was no recurrence at 6 months postoperatively. Case 2: 11-year-old adolescent, treated with VP shunt at 6 months of age for post-meningitic hydrocephalus, was admitted for helmet headache, dizziness, lightheadedness and apathy progressing for 3 years. CT scan showed hypodensity of right peri-hemisphere with calcified linings, exerting a mass effect on the medial structures. The patient was given a block excision of a calcific mass with blood content. The evolution was marked by the complete resolution of seizures and hemiparesis. There was no recurrence at 6 months postoperatively. Conclusion: Calcified subdural hematomas are rare and consecutive to the complications of VPS. The clinical signs are those of a benign brain tumor. Treatment is dominated by the difficulties of cerebral reexpression.

Multiple different remote epidural hematomas after craniotomy:A case report

BACKGROUND Epidural hematoma is one of the common postoperative complications after craniotomy.However,multiple remote epidural hematomas in different sites,including supratentorial and infratentorial regions,are exceedingly rare.CASE SUMMARY We present a rare case in which three remote epidural hematomas occurred after craniotomy.A 21-year-old woman was admitted with a headache for 1 mo,vomiting,and rapid vision loss for 1 wk.Brian magnetic resonance imaging indicated a right thalamic tumor.The intraoperative diagnosis was a cystic tumor,posterior cerebral artery aneurysm,and vascular malformation.The operation was successful.Unfortunately,the patient developed three extradural hematomas within 48 h.Family members consented to the first two hematoma evacuations but refused the third.CONCLUSION More attention should be paid to this kind of rare complication.Adequate preoperative evaluation is important,especially for acute patients.Monitoring neural function and early computed tomography scanning of the brain after surgery should be highlighted.

Effect of Postoperative Administration of Saireito for Bilateral Chronic Subdural Hematomas

The aim of this retrospective study was to investigate the efficacy of saireito for bilateral chronic subdural hematomas (B-CSDH). Between April 2006 and March 2010, a total of 18 patients undergoing unilateral burr hole drainage for B-CSDH took part in a controlled clinical study. Postoperative status of the nonsurgical side was subsequently evaluated, with (n = 10) and without (n = 8) saireito administration. Two in the saireito-treated group patients and four in the control group patients ultimately required contralateral surgical intervention. The remainder, including eight saireito-treated hematomas, resolved without further surgery, generally within eight weeks of the surgical side procedure. However, two of the four resolving control lesions took longer to regress. The hydragogue and anti-inflammatory/steroid-evoking properties ascribed to saireito may facilitate hematoma resolution. After unilateral surgery for B-CSDH, saireito administration may prevent symptomatic deterioration of a contralateral low-density CSDH, preempting subsequent surgery.

Hematomas and Limb Skeletal Malformations in Chicken Embryos Following Exposure to 5-Fluoro-2'-Deoxyuridine

Vascular injury or interruption may play a role in vertebrate limb teratogenesis. Since 5fluoro- 2'- deoxyuridine (FdU) can cause vascular injury in the murine limb and skull prior to the appearance of skeletal malformations in these structures, we studied the effects of this chemical on skeletal development in the chick embryo and noted any vascular injury. The yolk sacs of day three ehick embryos (Hamburger and Hamilton states 17-19) were injected with solutions of vary concentrations of FdU in saline. The embryos developed until the 10th day of incubation when they were fixed for study. Uninjected, saline injected, and sham injected control embryo were similarly fixed. Upon gross inspection, frequent diffuse and saccular hernatomas, as well as fluid-filled blisters, were noted in the limbs of embryos treated with FdU. After the embryos were fixed and cleared, and the skeletons stained, significant skeletal malformations were observed in these limbs. Bony elements of both the upper and lower limbs were affected in at least some of the embryos. The combination of FdU-induced hematomas and blisters with associated skeletal malformations in the same regions of some embryos suggests a relationship between these phenomena.

Contribution of Surgery in the Care of Intracranial Hematomas in Developing Countries: Case Series of 30 Patients in Abidjan

Intracranial hematomas, whatever its causes, represent an important disabling, and dreaded adult’s lesion. This brain’s condition has not well been studied in developing countries. The aim of our study is to overview the management of intracaranial hematomas in Abidjan. It is a retrospective analytical and descriptive study, involving patients who had been admitted and monitored by neurosurgeons for intracranial hematomas, documented in brain CT scan and had been operated on from 1 January 2007 to December 31, 2009 in Abidjan. These 30 patients were 23 men and 7 women. The average age was 58.6 years old. 90% of the patients were admitted with wakefulness issues. Half had a Glasgow score of less than 8. The brain scanner allowed identification of an intraparenchymal hematoma associated or not with a cerebral ventricle contamination in 28 patients. There were 18 external ventricle derivations with or without decompressive craniectomy and 12 independent decompressive craniectomy. The evolution was marked by 20 deaths. 10 patients (33.3%) survived. Among the survivors, the first attack and arterial hypertension were the only illness before the attack. None had blood in the membranes and all had Glasgow scores greater than or equal to 9 at admission. Around 7 out of 10 patients were operated on during the first 48 hours. The operative indications of intracranial hematomas are still the subject of controversy. By basing itself on criteria and rigorous clinical and neuroimaging selection, surgery could eventually contribute to the management of this pathology which has become very frequent in Africa.

Endoscopic appearance of esophageal hematomas

INTRODUCTIONEsophageal hematomas develop from the dissectionof the mucosa from the muscular layers of theesophageal wall and represent an uncommoncondition affecting all ages.Although the mostcommon cause of esophageal hematomas isiatrogenic mechanical injury-induced by prolongednasogastric intubation,difficult or forcefulendoscopic intubation,or the result of

Surgical Treatment of Poor Grade Middle Cerebral Artery Aneurysms Associated with Large Sylvian Hematomas Following Prophylactic Hinged Craniectomy

The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms （MCAAs） associated with large sylvian hematomas （SylH） were ana- lyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight pa- tients were graded into Hunt-Hess grades IV-V and emergency standard micro-neurosurgeries （aneu- rysm clipping, hematoma evacuation and prophylactic hinged craniectomy） were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable out- comes on discharge. The favorable outcome group and the poor outcome group significantly differed in terms of patients＇ anisocoria, Hunt-Hess grade before surgery, extent of the midline shift and time to the surgery after bleeding （P〈0.05）. There were no significant differences in age, sex, volume and location of the hematoma, size of aneurysm between the favorable and poor groups （P〉0.05）. However, ingen- ious designed prophylactic hinged craniectomy efficiently reduced the patients＇ intracranial pressure （ICP） after surgery. It was suggested that preoperative conditions such as Hunt-Hess grading, extent of the midline shift and the occurrence of cerebral hernia affect the prognosis of patients, but time to the surgery after bleeding and prophylactic hinged craniectomy are of significant importance for optimizing the prognosis ofMCAA oatients 19resenting with large SylH.

Multiple Density Subdural Hematomas

The chronic subdural hematoma is a well known entity in old age and the treatment is very challenging. Treatment protocol depends upon the radiological finding. The loculation and multilayering indicates the bleeding at multiple times and respectively found in 13.2% and 13.6%, which was more common in patients more than 75 years. Burr hole evacuation was the treatment of choice except in recurrent cases where craniotomy was performed.

Decompressive Craniotomy and Fast-Track Duraplasty in Acute Subdural Hematomas

Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.

Outcome of Surgically Treated Acute Traumatic Epidural Hematomas Based on the Glasgow Coma Scale

This study was a retrospective analysis of outcome of surgically treated acute traumatic epidural hematomas based on the Glasgow coma scale. The series enrolled forty-six consecutive cases of acute traumatic epidural hematomas. The mean age of patients was 29.56 years and 63.04% of the patients were between 21 and 30 years of age. Forty-tree out of 46 (93.47%) of the patients were males. Road traffic crash was the main mode of injury. The severity of the traumatic brain injury was classified according to the Glasgow coma scale score at admission. The injury was mild or moderate in 35 (76.08%) cases and severe in 11. Eight patients (17.39%) presented with pupillary abnormalities. The computed tomography scanning of the head has objectivized the epidural hematoma in all patients and has shown a mass effect with midline shift in all but one case (45/46). The most frequent surgical procedure done was craniotomy. Six (13.04%) patients died (GOS 1), but 38 (82.60%) recovered fully (GOS 5) and two (04.34%) were disabled but independent (GOS 4). The Glasgow coma score at admission was very predictive for good or poor outcome, since all patients but one who died and all survivors who were disabled were comatose at admission (GCS ≤ 8).

Spontaneous Cervical Epidural Hematomas in Mild Cervical Spondylotic Myelopathy Patients：An Analysis of 8 Cases

Spontaneous cervical epidural hematoms（SCEH） complicated with mild cervical spondylotic myelopathy（CSM） is a rare but emerging condition.Early diagnosis and treatment are important for good outcomes.This study aimed to investigate the clinical characteristics of this condition and to discuss the optimal treatment.The clinical data from 8 patients with SCEH plus CSM who were divided into two groups by treatment methods were retrospectively analyzed.The neurological function of the patients was assessed by Japanese Orthopedic Association（JOA） score before and after the surgical operations.Other factors were reviewed with medical records.Among them,4 out of the 8 patients underwent emergency surgery,and the rest 3 patients experienced an initial conservative treatment and ultimately received a laminectomy.We found that the Frankel Scale scores in most of the surgical patients were increased after surgery（6/7,85.7%）.However,the JOA scores at the 6th month after onset were even lower than those before onset in 3 of the operative cases,and those in the patients who were given conservative treatment showed no significant change.It was concluded that some patients with SCEH and CSM treated with a timely operation may obtain relief from their previous CSM symptoms.However,the final neurological deficits of these patients were closely related to the progressive interval which refers to the hours between the initial onset and the occurrence of new neurological deficits or mild CSM deterioration,no matter whether they accept the operation.We found the crucial progressive interval may be in 9 h.Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits.

Role of N-formyl peptide receptor 2 in germinal matrix hemorrhage:an intrinsic review of a hematoma resolving pathway

Germinal matrix hemorrhage is one of the leading causes of morbidity,mortality,and acquired infantile hydrocephalus in preterm infants in the United States,with little progress made in its clinical management.Blood clots have been shown to elicit secondary brain injury after germinal matrix hemorrhage,by disrupting normal cerebrospinal fluid circulation and absorption after germinal matrix hemorrhage causing post-hemorrhagic hydrocephalus development.Current evidence suggests that rapid hematoma resolution is necessary to improve neurological outcomes after hemorrhagic stroke.Various articles have demonstrated the beneficial effects of stimulating the polarization of microglia cells into the M2 phenotype,as it has been suggested that they play an essential role in the rapid phagocytosis of the blood clot after hemorrhagic models of stroke.N-formyl peptide receptor 2(FPR2),a G-protein-coupled receptor,has been shown to be neuroprotective after stroke.FPR2 activation has been associated with the upregulation of phagocytic macrophage clearance,yet its mechanism has not been fully explored.Recent literature suggests that FPR2 may play a role in the stimulation of scavenger receptor CD36.Scavenger receptor CD36 plays a vital role in microglia phagocytic blood clot clearance after germinal matrix hemorrhage.FPR2 has been shown to phosphorylate extracellular-signal-regulated kinase 1/2(ERK1/2),which then promotes the transcription of the dual-specificity protein phosphatase 1(DUSP1)gene.In this review,we present an intrinsic outline of the main components involved in FPR2 stimulation and hematoma resolution after germinal matrix hemorrhage.

Loculated pericardial hematoma diagnosed with point-of-care ultrasound

Pericardial hematoma is a rare but potentially lifethreatening consequence following cardiac surgery that requires prompt recognition and intervention.Patients can present with symptoms such as chest pain,dyspnea,tachycardia,and hypotension,which may mimic other post-operative issues.Loculated pericardial hematoma compressing the atria might be difficult to diagnose.Bleeding and hematoma are more common in patients receiving early anticoagulant therapy.A focused cardiac ultrasound (Fo CUS) plays a pivotal role in the diagnosis,revealing the presence of pericardial effusion and signs of cardiac compression.The aim of this report was to provide a prompt diagnosis of loculated pericardial hematoma via Fo CUS in the emergency department (ED).

ATAT1 deficiency enhances microglia/macrophage-mediated erythrophagocytosis and hematoma absorption following intracerebral hemorrhage

MIcroglia/macrophage-mediated erythrophagocytosis plays a crucial role in hematoma clearance after intracerebral hemorrhage.Dynamic cytoskeletal changes accompany phagocytosis.However,whether and how these changes are associated with microglia/macrophage-mediated erythrophagocytosis remain unclear.In this study,we investigated the function of acetylatedα-tubulin,a stabilized microtubule form,in microglia/macrophage erythrophagocytosis after intracerebral hemorrhage both in vitro and in vivo.We first assessed the function of acetylatedα-tubulin in erythrophagocytosis using primary DiO GFP-labeled red blood cells co-cultured with the BV2 microglia or RAW264.7 macrophage cell lines.Acetylatedα-tubulin expression was significantly decreased in BV2 and RAW264.7 cells during erythrophagocytosis.Moreover,silencingα-tubulin acetyltransferase 1(ATAT1),a newly discoveredα-tubulin acetyltransferase,decreased Ac-α-tub levels and enhanced the erythrophagocytosis by BV2 and RAW264.7 cells.Consistent with these findings,in ATAT1-/-mice,we observed increased ionized calcium binding adapter molecule 1(Iba1)and Perls-positive microglia/macrophage phagocytes of red blood cells in peri-hematoma and reduced hematoma volume in mice with intracerebral hemorrhage.Additionally,knocking out ATAT1 alleviated neuronal apoptosis and pro-inflammatory cytokines and increased anti-inflammatory cytokines around the hematoma,ultimately improving neurological recovery of mice after intracerebral hemorrhage.These findings suggest that ATAT1 deficiency accelerates erythrophagocytosis by microglia/macrophages and hematoma absorption after intracerebral hemorrhage.These results provide novel insights into the mechanisms of hematoma clearance and suggest ATAT1 as a potential target for the treatment of intracerebral hemorrhage.

Dengue hemorrhagic fever with rectus sheath hematoma:A case report

Rationale:Acute pain is a medical emergency that requires prompt abdominal evaluation and management.Dengue,a mosquito-borne arboviral infection,can lead to complications such as acute abdominal pain.Patient concerns:A 72-year-old hypertensive female presented with high-grade intermittent fever with chills and rigors for four days.She was diagnosed with dengue fever(NS1Ag-reactive)the day before admission.A contrast-enhanced computed tomography of the abdomen showed a hematoma along the rectus sheath which was managed conservatively as per surgical opinion.Diagnosis:Dengue hemorrhagic fever with rectus sheath hematoma.Interventions:Blood transfusion and fluid therapy.Outcomes:Ten days after discharge,the patient reproted no pain in the right iliac fossa and the size of the hematoma was significantly reduced.Lessons:Although it is rarely seen as a cause of acute abdomen,complaints of adnominal pain should never be ignored in critical or convalescent phase of dengue fever.Radiological investigations should be promptly conducted as hematoma is often difficult to be diagnosed clinically.Delay in diagnosis of rectus sheath hematoma can be fatal.

Hematochezia due to rectal invasion by an internal iliac artery aneurysm: A case report

BACKGROUND This case report presents the rare occurrence of hematochezia due to an internal iliac artery aneurysm leading to an arterioenteric fistula,expanding the differential diagnosis for gastrointestinal bleeding.It emphasizes the importance of considering vascular origins in cases of atypical hematochezia,particularly in the absence of common gastrointestinal causes,and highlights the role of imaging and multidisciplinary management in diagnosing and treating such unusual presentations.CASE SUMMARY A 75-year-old man with a history of hypertension presented with 12 d of hematochezia,experiencing bloody stools 7-8 times per day.Initial computed tomography(CT)scans revealed an aneurysmal rupture near the right internal iliac artery with suspected hematoma development.Hemoglobin levels progressively decreased to 7 g/dL.Emergency arterial angiography and iliac arterycovered stent placement were performed,followed by balloon angioplasty.Despite initial stabilization,minor rectal bleeding and abdominal pain persisted,leading to further diagnostic colonoscopy.This identified a neoplasm and potential perforation at the proximal rectum.An exploratory laparotomy confirmed the presence of a hematoma and an aneurysm invading the rectal wall,necessitating partial rectal resection,intestinal anastomosis,and ileostomy.Postoperative recovery was successful,with no further bleeding incidents and normal follow-up CT and colonoscopy results after six months.CONCLUSION In cases of unusual gastrointestinal bleeding,it is necessary to consider vascular causes for effective diagnosis and intervention.

Splenic subcapsular hematoma following endoscopic retrograde cholangiopancreatography:A case report and review of literature

BACKGROUND Splenic injury following endoscopic retrograde cholangiopancreatography(ERCP)is a rare complication.The literature contains around 30 articles reporting various degrees of splenic injuries resulting from ERCP since the first report of splenic rupture after ERCP in 1989.CASE SUMMARY This report describes a case of splenic hematoma and stent displacement in a 69-year-old male patient who developed these conditions 7 days after undergoing ERCP and stenting.The patient had bile duct stenosis caused by a malignant tumor that was obstructing the bile duct.The diagnosis was confirmed by epigastric computed tomography and magnetic resonance cholangiopancreatography.The patient was successfully treated with percutaneous transhepatic cholangial drainage,endoscopic pyloric stent placement,and conservative management.The causes of splenic injury following ERCP are discussed.CONCLUSION ERCP has the potential to cause splenic injury.If a patient experiences symptoms such as abdominal pain,decreased blood pressure,and altered hematology after the procedure,it's important to be thoroughly investigated for postoperative bleeding and splenic injury.

Subarachnoid hemorrhage misdiagnosed as acute coronary syndrome leading to catastrophic neurologic injury: A case report

BACKGROUND Elevated levels of cardiac troponin and abnormal electrocardiogram changes are the primary basis for clinical diagnosis of acute coronary syndrome(ACS).Troponin levels in ACS patients can often be more than 50 times the upper reference limit.Some patients with subarachnoid hemorrhage(SAH)also show electrocardiogram abnormalities,myocardial damage,and elevated cardiac biomarkers.Unlike ACS patients,patients with SAH only have a slight increase in troponin,and the use of anticoagulants or antiplatelet drugs is prohibited.Because of the opposite treatment modalities,it is essential for clinicians to distinguish between SAH and ACS.CASE SUMMARY A 56-year-old female patient was admitted to the emergency department at night with a sudden onset of severe back pain.The final diagnosis was intraspinal hematoma in the thoracic spine.We performed an emergency thoracic spinal canal hematoma evacuation procedure with the assistance of a microscope.Intraoperatively,diffuse hematoma formation was found in the T7-T10 spinal canal,and no obvious spinal vascular malformation changes were observed.Postoperative head and spinal magnetic resonance imaging(MRI)showed a small amount of SAH in the skull,no obvious abnormalities in the cervical and thoracic spinal canals,and no abnormal signals in the lumbar spinal canal.Thoracoab-dominal aorta computed tomography angiography showed no vascular malfor-mation.Postoperative motor system examination showed Medical Research Council Scale grade 1/5 strength in both lower extremities,and the patient experienced decreased sensation below the T12 rib margin and reported a Visual Analog Scale score of 3.CONCLUSION Extremely elevated troponin levels(more than 50 times the normal range)are not unique to coronary artery disease.SAH can also result in extremely high troponin levels,and antiplatelet drugs are contraindicated in such cases.Emergency MRI can help in the early differential diagnosis,as a misdiagnosis of ACS can lead to catastrophic neurological damage in patients with spontaneous spinal SAH.

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation:A case report and review of literature

BACKGROUND While most complications of cervical surgery are reversible,some,such as symptomatic postoperative spinal epidural hematoma(SEH),which generally occurs within 24 h,are associated with increased morbidity and mortality.Delayed neurological dysfunction is diagnosed in cases when symptoms present>3 d postoperatively.Owing to its rarity,the risk factors for delayed neurological dysfunction are unclear.Consequently,this condition can result in irreversible neurological deficits and serious consequences.In this paper,we present a case of postoperative SEH that developed three days after hematoma evacuation.CASE SUMMARY A 68-year-old man with an American Spinal Injury Association(ASIA)grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall.The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day.Postoperatively,the patient showed no changes in muscle strength or ASIA grade.The patient experienced neck pain and subcutaneous swelling on the third day postoperatively,his muscle strength decreased,and his ASIA score was grade A.Magnetic resonance imaging showed hypointense signals on T1 weighted image(T1WI)and T2WI located behind the epidural space,with spinal cord compression.Emergency surgical intervention for the hematoma was performed 12 h after onset.Although hypoproteinemia and pleural effusion did not improve in the perioperative period,the patient recovered to ASIA grade C on day 30 after surgery,and was transferred to a functional rehabilitation exercise unit.CONCLUSION This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery.Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.