Surgical treatment of left atrial dissection caused by percutaneous coronary intervention.

Left atrial dissection (LatD), also known as left atrial intramural haematoma, is a rare condition that requires rapid diagnosis and frequently calls for timely surgical intervention. Diagnosis can be challenging because of a lack of definitive clinical criteria, and a patient's situation can be complicated by co-morbidities, including unstable haemodynamics. We surgically repaired a case of LatD related to percutaneous coronary intervention (PCI). The operation went smoothly, and the patient was discharged one week after the operation. For LatD patients with co-morbidities, especially haemodynamic disorders, active surgical intervention is recommended.

Spontaneous bleeding in COVID-19: A retrospective experience of an Italian COVID-19 hospital

AJOL : Background: Haemorrhages in coronavirus disease 2019 (COVID-19) patients require proper knowledge and management.Objectives: To highlight the characteristics of haemorrhages in patients with COVID-19 infection.Method: A retrospective study examined CT scans performed over a 13-month period in patients hospitalised with COVID-19 infection to determine those who developed spontaneous bleeding. The authors also investigated correlations between the bleeding events and the patients' characteristics.Results: Haemorrhages occurred in 2.22% (31/1396) of patients hospitalised with COVID-19 infection (7.88%, 19/241 in the intensive care unit). Bleeding, major in most cases, occurred in anticoagulated patients, especially males with multiple comorbidities, aged between 60 and 79 years and mainly appeared in a single anatomical region (especially retroperitoneal), with the most voluminous in the chest wall. The complication was diagnosed on average 16.7 days after admission and occurred predominantly in critically ill patients undergoing invasive ventilation and pronation-supination cycles. In just under half of the cases, the haematomas were active, and in these cases, mainly with a single contrast blush and with earlier onset after the start of anticoagulation than in non-active bleeding. Major bleeding was also earlier in the presence of multiple morbidity. The vast majority of patients were treated conservatively and survived.Conclusion: At COVID-19 hospital centres, it is advisable that there is knowledge of such a complication for which CT imaging is essential for diagnosis and proper management. Although some authors have expressed doubts about anticoagulant treatment in patients with COVID-19, the bleeding complication in this study did not significantly affect the outcome.Contribution: Spontaneous haemorrhage did not significantly affect the outcome in this series

Spontaneous Surgical Intracranial Haemorrhages Associated with SARS-Cov-2 Infection: Case Report.

Spontaneous surgical acute and chronic intracranial haemorrhage in patients with SARS-Cov-2 infection is a theoretical possibility. We report two cases of SARS-CoV-2 infection that was associated with spontaneous surgical acute and chronic intracranial haemorrhage. The two patients had successful surgical intervention. Surgical haemorrhages should be considered in patients with SARS-COV-2 infection especially if there is an associated altered sensorium.

Cutaneous Complications Secondary to Haemostasis Abnormalities in COVID-19 Infection.

We describe the case of a patient hospitalized for acute decompensated heart failure in a standard medical ward. During hospitalization, he was diagnosed with COVID-19 and transferred to a special unit. The clinical course was marked by worsening of the respiratory disease, the development of right parotiditis and thrombosis of the left internal jugular vein. Therapeutic anticoagulation was initiated and 2 days later, the minimal dermatoporosis lesions previously present in the upper extremities evolved to haemorrhagic bullae with intra-bullae blood clots and dissecting haematomas. Surgical management of the dissecting haematomas was difficult in the context of haemostasis abnormalities. The patient died 29 days after hospital admission. LEARNING POINTS: Single room accommodation should be preferred to double room accommodation in standard wards during the COVID-19 pandemic.Anticoagulation therapy and the presence of lupus anticoagulant may induce cutaneous complications during COVID-19 infection.The discontinuation of anticoagulation therapy did not help improve the management of cutaneous lesions.

Iliopsoas haematoma during extracorporeal membrane oxygenation: A registry report from the COVID-19 critical care consortium across 30 countries.

INTRODUCTION: Iliopsoas haematoma (IPH) during extracorporeal membrane oxygenation (ECMO) is a rare bleeding complication that can be fatal due to its progression to abdominal compartment syndrome, but its incidence and risk factors are not well known. We have previously reported an IPH incidence rate of 16% in Japan. Among possible reasons for this high incidence, ethnicity has been hypothesised to play a role. Therefore, we used an international multi-centre cohort registry to test this hypothesis by determining the incidence rate of IPH. METHODS: This study was performed using the COVID-19 Critical Care Consortium database, conducted in 30 countries across five continents between 3 January 2020, and 20 June 2022. RESULTS: Overall, 1102 patients received ECMO for COVID-19-related acute respiratory distress syndrome. Of them, only seven were reported to have IPH, indicating an incidence rate of 0.64%, with comparable rates between the countries. The IPH group tended to have a higher mortality rate (71.4%) than the non-IPH group (51%). CONCLUSIONS: Overall incidence of IPH in the studied COVID-19 ECMO cohort was 0.64%. Most cases were reported from Japan, Belgium, and Italy. In our study, this rare complication did not appear to be confined to Asian patients. Due to the high fatality rate, awareness about the occurrence of IPH should be recognised.

Massive iliopsoas haematoma during the course of COVID-19 pneumonia.

This report presents a case of life-threatening iliopsoas haematoma in an immunosuppressed 86-year-old man with a history of prostate cancer during the clinical course of coronavirus disease 2019 (COVID-19). The patient was hospitalized for COVID-19-associated pneumonia. One week after admission, he complained of pain in his right thigh when he changed his position. Laboratory findings revealed markedly progressive anaemia and elevated creatine phosphokinase levels. Chest computed tomography revealed a massive haematoma in the right iliopsoas muscle spreading to the retroperitoneal space. Considering the advanced age and status of the patient, he was treated with red blood cell transfusions and bed rest. Fortunately, the anaemia was improved, and the haematoma gradually reduced in size. It should be noted that even during isolation, careful physical examination is important. In addition, physicians who administer heparin to patients with COVID-19, even if prophylactic, should be aware of bleeding complications.

Spontaneous Retropharyngeal Haematoma Causing Upper Airway Obstruction in a Child: Case Report.

Bleeding into the retropharyngeal region in children is an unusual cause of acute upper airway obstruction. Even in the absence of known risk factors or aetiology, this rare entity should be considered as one of the differential diagnoses of retropharyngeal swellings in children. Prompt surgical intervention is required whenever rapid progression to airway obstruction is observed. In this case report, we present an 18-month-old girl previously managed as upper respiratory tract infection, who presented with progressive dysphagia, drooling and eventually airway obstruction with stridor and respiratory distress. Conservative prolonged airway protection by intubation or tracheostomy was averted by an emergency incision and drainage of the haematoma. There was complete resolution by the second week and no recurrence reported at follow-up 18 months later.

Spontaneous bleeding in COVID-19: A retrospective experience of an Italian COVID-19 hospital.

Background: Haemorrhages in coronavirus disease 2019 (COVID-19) patients require proper knowledge and management. Objectives: To highlight the characteristics of haemorrhages in patients with COVID-19 infection. Method: A retrospective study examined CT scans performed over a 13-month period in patients hospitalised with COVID-19 infection to determine those who developed spontaneous bleeding. The authors also investigated correlations between the bleeding events and the patients' characteristics. Results: Haemorrhages occurred in 2.22% (31/1396) of patients hospitalised with COVID-19 infection (7.88%, 19/241 in the intensive care unit). Bleeding, major in most cases, occurred in anticoagulated patients, especially males with multiple comorbidities, aged between 60 and 79 years and mainly appeared in a single anatomical region (especially retroperitoneal), with the most voluminous in the chest wall. The complication was diagnosed on average 16.7 days after admission and occurred predominantly in critically ill patients undergoing invasive ventilation and pronation-supination cycles. In just under half of the cases, the haematomas were active, and in these cases, mainly with a single contrast blush and with earlier onset after the start of anticoagulation than in non-active bleeding. Major bleeding was also earlier in the presence of multiple morbidity. The vast majority of patients were treated conservatively and survived. Conclusion: At COVID-19 hospital centres, it is advisable that there is knowledge of such a complication for which CT imaging is essential for diagnosis and proper management. Although some authors have expressed doubts about anticoagulant treatment in patients with COVID-19, the bleeding complication in this study did not significantly affect the outcome. Contribution: Spontaneous haemorrhage did not significantly affect the outcome in this series.

Spontaneous atypical muscle bleeding of the anterior abdominal wall in patient with COVID-19 - case report

COVID-19 is an unpredictable disease that can lead to multiorgan dysfunctions. There is a high frequency of venous and arterial thrombosis, among other symptoms. Spontaneous bleeding in COVID-19 patients has also been described, but rarely, whether or not they are on anticoagulant therapy. We report a case of a 65-year-old female COVID-19 patient treated in our hospital. During the hospitalisation, she experienced sudden, severe pain in the lower part of the abdomen and had signs of hemorrhagic shock. CT of the abdomen and pelvis revealed a spontaneous giant haematoma of the anterior abdominal wall. A surgical procedure was done. We identified spontaneous bleeding in the muscles of the anterior abdominal wall. The patient recovered well. Rapid diagnosis and timely intervention are crucial to ensure a good patient outcome.

An unexpected cause of a swollen pacemaker pocket: a case report.

Background: A complication originating from the pacemaker pocket after device implantation can most often be explained by a post-operative pocket haematoma, or, less frequently, by a pocket infection. Both conditions need immediate assessment, dedicated treatment, and specialized follow-up. In rare cases, however, a swollen pacemaker pocket has an alternative diagnosis, which is exemplified by the following case. Case summary: A 70-year-old male patient had a-specific symptoms of fatigue, dyspnoea, and coughing for some weeks. He also noted an evident, new swelling of his pacemaker pocket several months after pacemaker implantation, a procedure that was performed in a high-volume center and without any complication. Ultrasound imaging of the pocket suggested the presence of a soft tissue mass with increased vascularity, rather than a fluid collection or a late organized haematoma. Ultrasound-guided biopsy of the mass was obtained for histopathology analysis and revealed a well-differentiated invasive squamous cell carcinoma. Additional PET-CT imaging demonstrated multiple fluorodeoxyglucose-avid hotspots: a voluminous lesion in the left lung hilum, smaller lesions in the liver, some mediastinal lymph nodes, several bone lesions, and a large mass surrounding the pacemaker. The multidisciplinary oncologic specialty team concluded that the patient had an aggressive metastatic lung carcinoma. The patient refused to undergo further treatment and died 1.5 months after diagnosis. Discussion: To the best of our knowledge, we did not find any earlier reports of a squamous cell carcinoma of the lung spreading to a pacemaker pocket. Presentation of a primary tumour or a metastasis in a pacemaker pocket is extremely rare. Ultrasound imaging with ultrasound-guided biopsy is a fast and reliable method to sample the tissue and to obtain a reliable diagnosis.

Heparin-induced rectus sheath hematoma in a COVID-19 patient with pulmonary emboli: a case report and literature review

Introduction: Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain that is often misinterpreted. Only about 2% of patients who present with acute abdominal pain display this condition. Damage to the superior or inferior epigastric arteries or their branches, as well as direct rupture of the rectus abdominis muscle, causes bleeding into the rectus sheath. In hospitalized COVID-19 patients, anticoagulant prophylaxis with heparin has become a standard part of medical care. This method may raise the risk of bleeding in older people with comorbidities. Case presentation: The patient was a 60-year-old woman with a history of asthma and diabetes mellitus who was referred to the emergency department with shortness of breath and cough. Chest X-Ray demonstrated Covid-19 pneumonia. On the second day of hospitalization, after the exacerbation of tachypnea, computed tomography (CT) angiography was performed, and the results confirmed pulmonary embolism;therefore, the therapeutic dose of heparin was initiated. On the 21st day of hospitalization, the patient experienced abdominal pain and was visited by a general surgeon. A large ecchymosis was observed in the periumbilical;nonetheless, there was no significant tenderness in the abdominal exam. The patient's hemoglobin dropped to 7.9 mg/dl at this time. An abdominal and pelvic CT scan showed a 45 mm hematoma in the left rectus muscle.

Atraumatic splenic rupture as a rare complication of acute myeloid leukemia: a case report and literature review

Introduction: Atraumatic Splenic Rupture (ASR) is a rare but life-threatening clinicopathological phenomenon with limited information on patient features, occurrence, or etiology. ASR is an uncommon and lethal complication that is observed in infectious (mainly mononucleosis) and hematological diseases (mainly malignant homeopathies) in more than half of cases. Mortality is approximately around 20%, and some deaths occur before the diagnosis is confirmed, while others occur after surgery due to delayed management and poor patient status. Case Presentation: A 48-year-old man with no history of the underlying disease presented to the Emergency Department with abdominal pain. He was admitted with leukocytosis 145..103/l, hemoglobin 6.4 g/dl, platelets 15..103/l, erythrocyte sedimentation rate 89 mm/h, and D-Dimer 1043 ng/FEU ml. Sputum test through PCR ruled out severe acute respiratory syndrome coronavirus 2 infections. Due to peripheral blood smear and bone marrow aspiration/biopsy, acute myeloid leukemia was diagnosed for the patient. On the third day of hospitalization, the patient's abdominal pain intensifies. Ultrasound revealed medium free fluid inside the abdomen and pelvis. The patient was transferred to the operating room to undergo an emergency laparotomy. There was a large hematoma in the spleen with a rupture in its posterior surface. Splenectomy was performed, and the histopathological study of the spleen showed leukemic involvement, capsular ruptures, and subcapsular hematomas.

Spontaneous Haematomas in Anticoagulated Covid-19 Patients: Diagnosis and Treatment by Embolization.

PURPOSE: To assess the safety and efficacy of embolization for spontaneous bleeding in anticoagulated patients with COVID-19. MATERIAL AND METHODS: Single center retrospective study in 9 patients with COVID-19 who experienced bleeding complications following anticoagulation. The study included 8 men and 1 woman aged from 48 to 80 years (mean 69.7 years), who had a total of 10 soft tissue haematomas: 1 in the thigh, 1 in the anterior abdominal wall, 6 retroperitoneal and 2 thoracic haematomas. All patients were referenced for vascular embolization, mostly with Onyx-18. RESULTS: A total of 10 haematomas were embolized in 9 patients. Technical success was achieved in all patients. No complications or adverse events were noted. One patient required percutaneous drainage of an infected haematoma 88 days after embolization. The mean hemoglobin level before embolization was 8,64 mg/dL and increased to 9,08 mg/dL after embolization (p = 0,3). After embolization all patients recovered haemodynamic stability and blood pressure levels improved. Seven patients resumed anticoagulation therapy after embolization. There were no recurrences or new bleedings in all treated patients. No patients required any additional invasive therapies or surgery. Mean intensive unit care and hospital stay was 6.7 and 35.2 days, respectively. All patients were discharged and were well at follow-up clinic visits 2-7 months after embolization. Seven patients performed a control CT scan 1-6 months after embolization, showing complete resolution of the haematoma. CONCLUSION: Embolization is safe and effective to treat spontaneous haematomas in anticoagulated patients with COVID-19, allowing to resume anticoagulation therapy. Level of evidence IV Level 4, case-series.

Spontaneous Multiple Haematomas in a Patient with Severe COVID-19 Fully Recovered with a Conservative Approach.

A significant number of hospitalized patients with COVID-19 are prone to thromboembolic events including deep vein thrombosis, pulmonary embolism, cerebrovascular accident, and myocardial infarction. However, some COVID-19 patients have a higher risk of bleeding that is associated with an increased risk of mortality. We report a 71-year-old woman who was a confirmed case of COVID-19 admitted for pulmonary involvement and complicated acute renal failure. During hospitalization, she suffered from a sudden onset of severe pain in the lower left abdomen as well as a sudden drop in blood pressure and hemoglobin. Haematomas in the left rectus and obturator internus muscle were observed in abdominal and pelvic computed tomography scan. Signs of haemorrhage were also seen in the anterolateral aspect of the bladder with extension to the paracolic, subdiaphragmatic, perihepatic and, perisplenic spaces. The patient was totally recovered by a conservative approach. Bleeding tendency could be a serious complication, especially, in COVID-19 patients with complicated renal failure that receive heparin prophylaxis.

Spontaneous ilio-psoas haematomas (IPHs): a warning for COVID-19 inpatients.

INTRODUCTION: Critically ill patients with COVID-19 are at increased risk of developing a hypercoagulable state due to haemostatic changes directly related to the SARS-CoV-2 infection or to the consequence of the cytokine storm. Anticoagulation is now recommended to reduce the thrombotic risk. Ilio-psoas haematoma (IPH) is a potentially lethal condition that can arise during the hospitalization, especially in intensive care units (ICUs) and frequently reported as a complication of anticoagulation treatment. MATERIALS AND METHODS: We report a case series of seven subjects with SARS-CoV-2 pneumonia complicated by Ilio-psoas haematomas (IPHs) at our COVID-Hospital in Rome, Italy. RESULTS: Over the observation period, 925 subjects with confirmed SARS-CoV-2 infection were admitted to our COVID-hospital. Among them, we found seven spontaneous IPHs with an incidence of 7.6 cases per 1000 hospitalization. All the reported cases had a severe manifestation of COVID-19 pneumonia, with at least one comorbidity and 5/7 were on treatment with low weight molecular heparin for micro or macro pulmonary thrombosis. CONCLUSIONS: Given the indications to prescribe anticoagulant therapy in COVID-19 and the lack of solid evidences on the optimal dose and duration, it is important to be aware of the iliopsoas haematoma as a potentially serious complication in COVID-19 inpatients. KEY MESSAGE Critically ill patients with COVID-19 are at increased risk of hypercoagulability state and anticoagulation therapy is recommended. Ilio-psoas haematoma (IPH) is found to be a complication of anticoagulation regimen especially in severe COVID-19 cases. An incidence of 7.6 cases per 1000 admission of IPHs was reported. Hypoesthesia of the lower limbs, pain triggered by femoral rotation, hypovolaemia and anaemia are the most common symptoms and signs of IPHs that should alert physician.

Spontaneous psoas haematoma: a life-threatening complication of anticoagulation in COVID-19. A case series of four episodes.

BACKGROUND: Anticoagulant prophylaxis is part of the standard management of hospitalized COVID-19 patients. Despite adequate thromboprophylaxis, one-third of COVID-19 patients with pneumonia developed pulmonary embolism. This high rate of thrombotic complications has led to higher doses of anticoagulants according to clinical complexity (e.g. intensive care unit (ICU) patients) and D-dimer levels. On the other side of the coin, haemorrhagic complications are being increasingly reported. CASES PRESENTATION: We herein report four cases of spontaneous psoas haematomas (SPH) among 548 patients hospitalized for SARS-CoV-2 pneumonia between March 2020 and January 2021 (incidence of 7.3 cases per 1000 patients). All patients had pneumonia, with age ranging between 62 and 83 years. All patients received anticoagulant therapy with low weight molecular heparin (100 U.I. anti-Xa/kg 2 times/d) from admission: in two cases, a diagnosis of pulmonary embolism was made. In another case, a thrombosis of left axillary and basilic veins was found, and only in one case anticoagulant therapy was started because of elevated levels of D-dimer. In all cases, signs of anaemia were detected and patients experienced low back or abdominal pain. The diagnosis of spontaneous psoas haematoma was made by computed tomography (CT) after a median of 12.5 d (9;16) from admission and 19.5 d (14.75; 24.25) from the beginning of COVID-19 symptoms. Half of these patients died from haemorrhagic shock. CONCLUSIONS: Given the potential life-threatening of SPH and the possible subtle clinical presentation, we believe it is crucial to raise clinicians awareness of this complication among COVID-19 patients undergoing anticoagulants.

COVID-19-associated spontaneous subacute subdural haematoma: report of two cases.

Since March 2020, the pandemic of coronavirus disease 2019 (COVID-19) has become a threat to global health. Several kinds of coronavirus-associated disorders, including vascular involvements with neurological symptoms, have been reported worldwide. Here, we describe two individuals with COVID-19 with no history of traumatic brain injury nor of vascular injuries, who developed spontaneous subdural haematoma in a subacute process. Both individuals became lethargic and unresponsive during admission in the intensive care unit. Both have undergone emergent craniotomy with acceptable outcome. The first patient improved significantly and was discharged a week after surgery. However, the second individual had no improvement on her consciousness and died 3 days after surgery. Haemorrhagic events, including subdural haematoma, can happen during COVID-19 infection with several possible mechanisms. Brain imaging and further neurological evaluation must be performed in any individuals with COVID-19 who show signs of alteration in their state of consciousness.

Chronic subdural haematoma during the COVID-19 lockdown period: late presentation with a longer interval from the initial head injury to the final presentation and diagnosis.

BACKGROUND: The COVID-19 novel coronavirus is contagious, and the mortality is higher in the elderly population. Lockdown in different parts of the world has been imposed since January 2020. Chronic subdural haematoma (cSDH) has a unique natural history in which symptoms can be non-specific, and the onset is insidious. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation of cSDH. METHODS: Consecutive adult cSDH patients admitted from 1 March 2020 to 30 April 2020 were reviewed. Exclusion criteria including those who had no definite history of head injury or the diagnosis of cSDH were made from a scheduled follow-up scan. Corresponding data during the same period in 2019 were reviewed for comparison. The primary outcome was the interval between the initial head injury and the final radiological diagnosis of cSDH. Secondary outcomes include Markwalder chronic subdural haematoma grade upon admission, length of stay in the acute hospital, and the modified Rankin scale (mRS) upon discharge. RESULTS: For the primary outcome, the average interval between head injury and the diagnosis of cSDH was significantly longer at 56.6 days (49 to 74 days, SD 9.83 days) during the period from March to April 2020, versus 29.4 days (17 to 42 days, SD 8.59 days) in 2019 for the corresponding period (p = 0.00703). There was no significant difference in the functional outcome upon discharge. CONCLUSIONS: cSDH patients can present late during the COVID-19 lockdown period. The functional outcome was comparable when operations for drainage were timely performed.

Spontaneous muscle hematoma in older patients with COVID-19: two case reports and literature review.

BACKGROUND: In late December 2019, a cluster of pneumonia cases due to a novel betacoronavirus, SARS-CoV-2 was reported in China. The so-called COVID 19 is responsible not only for respiratory symptoms, from mild up to pneumonia and even acute respiratory distress syndrome, but also for extrapulmonary involvement. CASES PRESENTATION: Here we present two cases of spontaneous muscle hematoma in patients with SARS-CoV-2 infection, both on therapeutic LMWH for atrial fibrillation: the first one was an 86-year-old Caucasian female with a history of hypertensive cardiomyopathy and the second one was an 81-year-old Caucasian male with a history of hypertension, diabetes and ischemic heart disease. Blood tests revealed a considerable drop of hemoglobin and alterations of coagulation system. In both cases, embolization of femoral artery was performed. A few other cases of bleeding manifestations are reported in literature, while a lot has been published about the hypercoagulability related to COVID-19. CONCLUSIONS: Our reports and literature review highlight the need of active surveillance for possible hemorrhagic complications in patients with SARS-CoV-2 infection.