Sequence of actions for visualization of soft tissue hemorrhages/hematomas in elderly patients infected with SARS-CoV-2.

Aim. To determine ultrasound, computed tomography and angiographic image characteristics for soft tissue hemorrhages/hematomas, the sequence of using imaging methods in patients infected with SARS-CoV-2, to study the morphology of changes in soft tissues, to determine the essence of the concept and to develop treatment tactics for this complication of COVID-19. Material and methods. During 4 months of treatment of elderly patients (+60) infected with SARS-CoV-2, 40 patients were identified with soft tissue hemorrhages/hematomas, of which 26 (65%) patients with large hematomas (>10 cm in size and > 1000 ml in volume). The analysis of clinical and laboratory parameters, methods of instrumental diagnostics (ultrasound - 26 patients, CT - 10 patients, angiography - 9 patients, punctures - 6 patients) was carried out;autopsy material was studied in 11 cases. Results. Image characteristics of hemorrhages/hematomas of soft tissue density were obtained using modern instrumental methods, and the sequence of application of visualization methods was determined. A tactic for managing a patient with stopped and ongoing bleeding has been developed. The morphological substrate of hemorrhagic complications in a new viral infection was studied. All patients were treated with conservative and minimally invasive procedures (embolization, puncture with pressure bandage). 15 patients (57.7%) recovered, 11 patients (42.3%) died from the progression of COVID-19 complications. Conclusion. Comprehensive clinical and laboratory sequential instrumental diagnosis of soft tissue hemorrhages in COVID-19. Treatment should be conservative and significantly invasive. The use of the term "soft tissue hematoma" in SARS-CoV-2 infected patients is not a natural quality of the normal pathological process and should not be observed from our point of view.Copyright © 2022 Rostovskii Gosudarstvennyi Meditsinskii Universitet. All rights reserved.

COVID-19-Related Spontaneous Aortic Arch Thrombus With Delayed Embolization.

Presentation of a 62-year-old man with baseline chronic obstructive pulmonary disease admitted to the hospital with dyspnea and newly diagnosed COVID-19 infection. CT scan of the chest was obtained to rule out pulmonary embolism. This revealed a mural thrombus of the inner curvature of the aortic arch with a floating component. Therapeutic full dose anticoagulation was initiated in combination with close clinical observation and treatment for modest hypoxia. He did well for 1 month and then returned with ischemic rest pain of the right foot. Angiography revealed thrombosis of all 3 tibial arteries in the right leg. Percutaneous mechanical thrombectomy with tissue plasminogen activator injection and angioplasty was performed with success in 1 tibial artery to achieve in line flow to the foot. After continued anticoagulation, the remainder of the tibial arteries autolysed and the aortic thrombus was noted to be resolved 4 months later. A brief pathophysiology discussion is included.

Marginal Artery of Drummond Pseudoaneurysm Masquerading as Fistulous Tract Resulting in Recurrent Lower Gastrointestinal Bleeding

Introduction: The mortality rate of patients hospitalized with a lower gastrointestinal bleed has been reported at 1.1% in the United States from 2005 to 2014. Pseudoaneurysms, typically associated with pancreatitis, have been described in case reports as a rare condition with a small subset presenting as gastrointestinal bleeding. Our study describes a rare case of recurrent lower gastrointestinal bleeding diagnosed as a pseudoaneurysm by endoscopy and angiography. Case Description/Methods: A 38-year-old male presented to our facility from a long-term care facility with hematochezia and blood clots per gastrostomy-jejunostomy. He had recently been hospitalized for severe coronavirus disease 2019 with a complicated hospital course in the intensive care unit including necrotizing pancreatitis with an abdominal drain, multiple secondary infections, tracheostomy, and percutaneous endoscopic gastrostomy-jejunostomy. On previous hospitalization, he was found to have a small pseudoaneurysm of the gastroduodenal artery and received embolization of the gastroduodenal and gastroepiploic arteries at that time. During transport to our hospital, he was noted to have tachycardia, hypotension requiring norepinephrine, and was transfused one unit of red blood cells. Hemoglobin at this time was 7.5 g/dl after transfusion. Esophagogastroduodenoscopy was completed and showed a gastrojejunostomy tube in the expected location but was noted to be tight to the mucosa, which was pale in appearance. Flexible sigmoidoscopy revealed localized areas of edematous and erythematous mucosa with some associated oozing throughout the sigmoid colon. Repeat evaluation was completed one week later due to recurrent hematochezia. Colonoscopy was performed with identification of an apparent fistulous tract in the sigmoid colon located at 35 cm. Computed tomography angiography localized a pseudoaneurysm arising from the marginal artery of Drummond just proximal to its anastomosis with the ascending branch of the left colic artery and was successfully embolized. Discussion(s): Pseudoaneurysms, such as the one described in this case, have been shown to be associated with pancreatitis and can result if a pseudocyst involves adjacent vasculature. Gastrointestinal bleeding is a rare presentation of this condition. However, this case highlights the importance of repeat colonoscopy and angiography in the setting of a lower gastrointestinal bleed of unknown etiology.

Pulmonary sarcoidosis

The lung is the most common organ affected by sarcoidosis. Multiple tools are available to assist clinicians in assessing lung disease activity and in excluding alternative causes of respiratory symptoms. Improving outcomes in pulmonary sarcoidosis should focus on preventing disease progression and disability, and preserving quality of life, in addition to timely identification and management of complications like fibrotic pulmonary sarcoidosis. While steroids continue to be first-line therapy, other therapies with fewer long-term side-effects are available and should be considered in certain circumstances. Knowledge of common clinical features of pulmonary sarcoidosis and specific pulmonary sarcoidosis phenotypes is important for identifying patients who are more likely to benefit from treatment.Copyright © ERS 2022.

Bronchial Artery Embolization Treatment During COVID-19 Pandemic: A Single-center Experience

Objective: Bronchial artery embolization (BAE) now serves as the standard treatment for hemoptysis. The aim of this study was to determine the characteristics and outcomes of the patients who undergo BAE during the coronavirus disease-2019 pandemic period. Methods: We retrospectively investigated patients that presented to the hospital with hemoptysis and received bronchial arterial embolization treatment during the pandemic period. Age, gender, history of previous diseases, and related data were collected. Results: The study was conducted with 11 patients whose 18.18% (n=2) were female and 81.81% (n=9) were male. The mean age of the patients is 61.27 +/- 10.94 and they stayed in hospital 21.18 +/- 19.59 days on average. Infection and bronchiectasis were seen as the leading cause of hemorhagee. Also, alveolar hemorrhage seen 81.8% (n=9) of the patients. Dilated bronchial arteries were seen on 72.7% (n=8) of the patients. Although 54.5% (n=6) of the patients admitted to the intensive care unit after the procedure, no complication or mortality seen in any patient during the procedure. Conclusion: Bronchial arterial embolization is an effective minimally invasive technique for treating hemoptysis. This invasive procedure could be applied safely during the pandemic period.

Monitored Anesthesia Care in Uterine Artery Embolization for Leiomyomas and Adenomyosis

Background: Patients undergoing an interventional radiology procedure report some degree of anxiety. Therefore, procedure-related anxiety needs to be managed. The aim of our study was to investigate patient satisfaction with monitored anesthesia care (MAC) for uterine artery embolization (UAE)-related procedural anxiety in symptomatic uterine fibroids or adenomyosis. Method(s): Between May 2021 and June 2022, 36 patients with symptomatic fibroids or adenomyosis underwent UAE with MAC. Follow-up evaluations consisted of clinical symptoms, degree of satisfaction with MAC in UAE, and complications. Result(s): MAC in UAE was successfully performed in all patients. UAE significantly reduced patients' complaints such as bleeding and pain: the scores for bleeding and pain were significantly reduced after 3 months of UAE compared with those before UAE, indicating the effectiveness of UAE. The mean score of satisfaction with MAC in UAE was 4.3 points, meaning that 94.4% of women were satisfied or very satisfied. No major complications were observed. Conclusion(s): MAC in UAE for symptomatic uterine fibroids or adenomyosis can be emotionally effective and safe for patients who are anxious about the procedure.Copyright © 2023 The Author(s).

Adjunctive techniques in endovascular repair of postcarotid endarterectomy pseudoaneurysm: Case report and literature review.

Pseudoaneurysm (PA) following carotid endarterectomy (CEA) is a rare and dangerous complication. In recent years endovascular approach has been preferred to open surgery as it is less invasive and reduces complications in an already operated neck, especially cranial nerve injuries. We report a case of large post-CEA PA causing dysphagia, successfully treated by deployment of two balloon-expandable covered stents and coil embolization of the external carotid artery. A literature review dealing with all cases of post-CEA PAs since 2000 treated by endovascular means is also reported. The research was conducted on Pubmed database using keywords "carotid pseudoaneurysm after carotid endarterectomy," "false aneurysm after carotid endarterectomy," "postcarotid endarterectomy pseudoaneurysm," and "carotid pseudoaneurysm."

Lemierre's Syndrome in COVID Pandemic: Is there an Association?

Background: Lemierre's syndrome is an uncommon life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein (IJV), anaerobic sepsis, and metastatic infections. Case description: A 57-year-old diabetic male presented to the emergency department with progressively increasing left-sided neck swelling. A contrast-enhanced computed tomography of the neck revealed an air-containing abscess showed a long-segment thrombus in the left internal jugular vein with septic embolization to the right upper lung. He was also positive for SARS-CoV-2 infection. He underwent emergency drainage of the abscess along with culture appropriate antibiotics. Two days postprocedure, he developed atrial fibrillation and received anticoagulation treatment for 3 months. Discussion(s): This case report adds to the growing body of literature of co-occurrence of Lemierre's syndrome in SARS-CoV-2 infection and discusses the possible associations between the two. Besides, it also highlights Klebsiella pneumoniae as an uncommon pathogen causing Lemierre's syndrome.Copyright © The Author(s). 2022 Open Access.

Endovascular Treatment of Pulmonary Artery Pseudoaneurysms Post-COVID-19 Pneumonitis

Pulmonary artery pseudoaneurysms (PAPs) are uncommon entities consisting of contained rupture of the pulmonary artery and are a potentially fatal cause of hemoptysis. We describe two index cases of left lower lobe PAPs and arterial ectasia post-COVID-19 pneumonitis and their endovascular treatment with Amplatzer vascular plug, coils, and glue.Copyright © 2022. Indian Society of Vascular and Interventional Radiology. All rights reserved.

Spontaneous embolization of an aortic prosthesis disc

We report the case of spontaneous disc embolization of a mechanical aortic prosthesis 4 years after its implantation. The reason for the implant was due to bacterial endocarditis. The patient was admitted with dyspnea and severe pulmonary edema due to aortic insufficiency that required immediate prosthesis replacement surgery. Cardiac catheterization revealed the absence of the disc, which was confirmed intraoperatively. Postoperative radiographic controls showed that the disc was embedded in the center of the longitudinal axis of the left iliac without causing obstruction to blood flow. The disc was never removed. The patient remained asymptomatic without vascular sym ptoms for 15 years. He died due to Fornier's gangrene complicated by Covid-19.Copyright © 2022 Sociedad Espanola de Cirugia Cardiovascular y Endovascular

Alternative Management of Cushing's Syndrome During Covid-19 Pandemic

Cushing's syndrome results from prolonged exposure to glucocorticoids. Surgery is often the first-line treatment for this condition, regardless of etiology. However, the COVID-19 pandemic caused a decrease in surgical procedures due to the risk of infection transmission. There are still emergency cases of Cushing's syndrome that are admitted to the hospital and require urgent management. The current treatment should be focused on medical management and endovascular embolization in selective cases. Embolization can be performed in facilities where there aretrained personnel with experience in adrenal embolization. Surgery, which traditionally is a first-line therapy, can increase the risk of infection, therefore, it should be avoided. The current review provides a brief description of the possible options for the management of adrenal Cushing's syndrome during the COVID-19 pandemic.Copyright © 2022 Bentham Science Publishers.

Looks Like a Vegetation but It Is Not Endocarditis

Background Myxomas are the second most common primary cardiac tumor (PCT) but overall have a low incidence rate. They usually arise from the interatrial septum whereas infective endocarditis (IE) vegetations frequently develop where there is turbulent blood flow, i.e., on the atrial side of the atrioventricular valves. Case A 75 year old male presented with fatigue, shortness of breath (SOB), myalgias and lower extremity edema for 2 weeks. His vital signs were stable and he was afebrile. Blood cultures were negative, WBC was normal, COVID-19 test was negative, and troponin was mildly elevated. TEE showed an ejection fraction of 20% with a large mitral valve (MV) mass (Figure 1A,B). Decision-making The mass was surgically resected and the MV was replaced (Figure 1C). On pathologic evaluation, the mass was confirmed to be a myxoma. The patient was later discharged without complication. Conclusion Clinical features of myxoma can overlap with IE including fever, malaise, SOB, and other signs of valvular obstruction or embolization. About 5% of myxomas originate from the MV and the differential diagnosis for an intra-atrial mass should include IE, PCT, metastatic tumors, and intracardiac thrombus. On echocardiography, myxomas appear irregularly frond-like or grape-cluster in shape. They are typically nonhomogeneous and can have areas of calcifications (Figure 1A). Both TEE and TTE are the mainstay for diagnosis of intracardiac masses and TEE specifically assists in guiding surgical excision. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Mechanical compression management of the right middle cerebral artery inferior trunk using a stent during coil embolization of middle cerebral artery aneurysms: A case report and literature review

Endovascular coil embolization is a minimally invasive, rapid, and effective method for the treatment of intracranial aneurysms. However, complications associated with coil embolization, such as intraoperative aneurysm rupture or arterial occlusion, should be promptly managed during the procedure to avoid catastrophic consequences. This study presents a case of mechanical compression management of the right middle cerebral artery (MCA) inferior trunk during coil embolization for bilateral MCA aneurysms. The inferior trunk of the right MCA was abruptly occluded due to mechanical compression during coil embolization of the right MCA bifurcation aneurysm. A Solitaire AB stent (4 x 20 mm, Covidien/Medtronic, Dublin, Ireland) was implanted in the inferior trunk of the right MCA after tirofiban was injected via a microcatheter, and the right inferior trunk was recanalized. The patient also underwent coil embolization of the left MCA bifurcation aneurysm, without any complications. It is crucial to recognize compressive occlusion of adjacent aneurysm branches to avoid severe complications during intracranial aneurysm embolization. Stent placement is a rescue treatment option for recanalization of an occluded artery. Copyright © 2022 Shanghai Journal of Interventional Radiology Press

Transarterial Embolization for Spontaneous Soft-Tissue Hematomas: Predictive Factors for Early Death.

INTRODUCTION: The aim of this retrospective monocentric study was to assess the safety and efficacy of spontaneous soft-tissue hematoma transarterial embolization (TAE) and to evaluate predictive factors for early mortality (≤30 days) after TAE for spontaneous soft-tissue hematoma (SSTH). MATERIALS AND METHODS: Between January 2010 and March 2022, all patients referred to our hospital for spontaneous soft-tissue hematoma and treated by emergency TAE were reviewed. Inclusion criteria were patients: ≥18-year-old, with active bleeding shown on preoperative multidetector row computed tomography, with spontaneous soft-tissue hematoma, and treated by TAE. Exclusion criteria were patients with soft-tissue hematomas of traumatic, iatrogenic, or tumoral origin. Clinical, biological, and imaging records were reviewed. Imaging data included delimitation of hematoma volume and presence of fluid level. Univariate and multivariate analyses were performed to check for associations with early mortality. RESULTS: Fifty-six patients were included. Median age was 75.5 [9-83] ([Q1-Q3] years and 23 (41.1%) were males. Fifty-one patients (91.1%) received antiplatelet agent and/or anticoagulant therapy. All 56 patients had active bleeding shown on a preoperative CT scan. Thirty-seven (66.0%) hematomas involved the retroperitoneum. Median hemoglobin level was 7.6 [4.4-8.2] g/dL. Gelatine sponge was used in 32/56 (57.1%) procedures. Clinical success was obtained in 48/56 (85.7%) patients and early mortality occurred in 15/56 (26.8%) patients. In univariate and multivariate analysis, retroperitoneal location and volume of hematoma were associated with early mortality. CONCLUSION: Retroperitoneal location and volume of hematoma seem to be risk factors for early death in the context of TAE for spontaneous soft-tissue hematoma. Larger multicenter studies are necessary to identify others predictive factors for early mortality and to anticipate which patients may benefit from an interventional strategy with TAE.

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.

Left Ventricular Apical Thrombus after Covid-19 Infection Associated with Pediatric Stroke

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

Incidental Diagnosis of Massive Mobile Left Ventricle Thrombi Following Covid-19 Infection in a Heart Failure Patient

A 71-year-old woman, known to have a non-ischemic dilated cardiomyopathy with reduced ejection fraction (EF), and a previous transcatheter edge-to-edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars-Cov-2, experienced a paucisymptomatic COVID-19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months before showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast ecocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses;the largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49x15 mm). mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses' dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2-week a complete resolution of the masses was documented with no clinical or embolic events. Cardiovascular complications of the coronavirus disease have been documented both in the acute phase and in convalescence;one such complication is the formation of LV thrombus;the pro-thrombotic nature of COVID-19 infection is well known: the coagulation activation mechanism is currently uncler, but it might be correlated to excessive inflammation, COVID-induced hypoxia, direct cytopathic effects on the cardiac endothelial cells, immobilization. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non-severe COVID-19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring could yield a benefit in selected patients;current guidelines do not support the use of anticoagulation prophylaxis for non-severe COVID.19, but further studies regarding anticoagulant prophylaxis for COVID-19 patients with chronic heart diseases, including DCM, are warranted. (Figure Presented).

[Computed tomography and endovascular occlusion in diagnosis and treatment of spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space in patients with COVID-19]. / Komp'yuternaya tomografiya i rentgenendovaskulyarnaya okklyuziya v diagnostike i lechenii spontannykh krovotechenii v myagkie tkani bryushnoi, grudnoi stenok i zabryushinnogo prostranstva u bol'nykh COVID-19.

OBJECTIVE: To investigate the results of therapeutic and prophylactic endovascular hemostasis of spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space in patients with COVID-19. MATERIAL AND METHODS: We retrospectively studied 35 patients with COVID-19 complicated by spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space. According to CT data, the volume of hematoma was 1193.4±706.1 ml. In all patients, CT signs of ongoing bleeding were detected. Moreover, contrast agent extravasation in all phases of examination was established in 15 patients. In other ones, extravasation was detected in late phases or study phase was not identified. All patients underwent angiography. Ongoing bleeding was detected in 12 (34.3%) patients (group 1). They underwent embolization of the target vessel. In 23 patients, bleeding was not established during angiography. Of these, 13 ones underwent prophylactic embolization (group 2). No embolization was carried out in 10 patients (group 3). All groups differed in hematoma localization and COVID-19 severity. RESULTS: Fourteen (40%) patients died in postoperative period. Mortality was similar in all groups. The most common cause of death was progressive respiratory failure following pneumonia. The last one was established by autopsy in 10 (71.4%) patients. CONCLUSION: Angiography confirmed MR signs of contrast agent extravasation in 34.3% of patients. In case of extravasation in all CT phases, ongoing bleeding was confirmed in 66.7% of patients. Endovascular embolization is effective for arterial bleeding into soft tissues. However, large-scale studies are needed to assess the effect of this technique on survival.

Hematoma Presenting as Lower Extremity Pain: A Case Series

Case Diagnosis: 67-year-old woman with right adductor pain and 57-year-old woman with right knee pain, both found to have hematomas Case Description or Program Description: Patient A is a 67-year-old female with breast cancer who presented to hospital with vomiting, was diagnosed with COVID, and developed encephalopathy. During inpatient rehabilitation (IPR), she developed right adductor muscle pain. Patient B is a 57-year-old female with history of multiple aneurysms, who presented to hospital with COVID complicated by gastrointestinal bleed. She required intubation due to altered mental status. During IPR, she developed severe right knee pain. Setting(s): Inpatient rehabilitation hospital Assessment/Results: Patient A had increase in right thigh circumference with negative bilateral lower extremity Dopplers. Her hemoglobin was 5.4. CT right lower extremity without contrast revealed a large hematoma in left mid thigh. Surgery recommended wrapping with ACE bandage. Patient B was found unresponsive with pulse and significant hypotension. Her hemoglobin dropped to 6.1. CT abdomen and pelvis revealed large retroperitoneal bleed of right iliopsoas and iliacus. She underwent interventional radiology guided embolization of lumbar artery. Discussion (relevance): Patient A had pancytopenia due to cancer. Her hemoglobin was 8.5 prior to the discovery of the hematoma. Her underlying comorbidities played a role in her rapid presentation of hematoma. Patient B was found to be unresponsive at home prior to acute care hospital admission. Etiology was unclear. Her decreased mental status may have complicated the interpretation of musculoskeletal pain. She reported 10/10 knee pain but had a benign exam. Conclusion(s): Musculoskeletal complaints are common, especially in IPR setting. As physiatrists, we must keep anemia from hematomas, associated with high mortality, on the differential diagnosis for lower extremity musculoskeletal pain. Frequent lab monitoring and physical exams are essential in timely diagnosis and treatment of hematomas.

A Case of Femoral Neuropathy Secondary to Iliacus/iliopsoas Hematoma in the Setting of COVID-19 Pneumonia

Case Diagnosis: Femoral neuropathy secondary to iliacus/iliopsoas hematoma Case Description or Program Description: A 66-year-old Hispanic male presented to PM and R clinic with left leg weakness and left anterior thigh numbness. His symptoms began during a recent hospitalization for COVID-19 pneumonia, during which he developed left thigh pain, swelling, and weakness while on warfarin for a DVT. CT revealed a 6.5 cm by 3.0 cm by 7.4 cm intramuscular hematoma of the left iliacus/iliopsoas. PM and R and physical therapy evaluated him while inpatient. While he was previously independent in ambulation, he was discharged home with a walker. Setting(s): Tertiary-care teaching hospital Assessment/Results: Upon follow up in PM and R clinic, he ambulated with a rolling walker with frequent falls, noting difficulty with activities of daily living. Physical exam demonstrated 1/5 left hip flexion and knee extension strength, without left thigh light touch sensation. EMG demonstrated acute denervation of the left quadriceps muscle with no MUAP recruitment on activation, suggestive of an axonal femoral neuropathy. He began outpatient physical therapy, with improvement in ambulation and ADLs. Five months post hematoma, he continues to ambulate with a rolling walker, however with no further falls. Discussion (relevance): The femoral nerve originates from the posterior division of L2-L4 and runs between the psoas tendon and iliacus muscle under the inguinal ligament. Femoral nerve compression occurs along the iliopsoas gutter, where it is at highest ischemia risk due to poor vascular supply. Iliacus hematoma occurs most commonly in patients with hemophilia and those receiving anticoagulation. Treatment is typically conservative;however, embolization may be indicated with active bleeding. In cases of femoral neuropathy, early iliacus muscle fasciotomy with or without hematoma evacuation may be considered. Conclusion(s): Our patient's femoral neuropathy was managed conservatively with physical therapy, and he experienced improvements in strength, ambulation, and function. Femoral neuropathy should be considered in patients with weakness following thigh intramuscular hematoma.