Aortic wrapping is life-saving in high-risk acute aortic dissection and intramural haematoma.

Aortic wrapping is a controversial repair in patients presenting with acute type A aortic dissection or intramural haematoma, but this method may be a potential alternative to medical treatment or conventional repair in patients aged >80 years and in those presenting with prohibitive co-morbidities such as stroke, circulatory collapse, full oral anticoagulation with the last generation drugs. We report on 5 high-risk and/or patients over 80 years who received external aortic wrapping with or without cardiopulmonary bypass during the last 18 months. All survived the procedure and could be extubated early postoperatively. No patient remained on the intensive care longer than 2 days and all were discharged without additional complications. Postoperative radiological control was acceptable and no patient had any new aortic event up to 18 months postoperatively.

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.

[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.

Spontaneous rectus sheath hematoma in three patients with COVID-19: Computed tomography findings.

The pulmonary symptoms secondary to severe acute respiratory syndrome in coronavirus (COVID-19) infections are the most common presentation for the disease; however, it is now known that in a small portion of patients, severe hemorrhagic complications can also be seen. In this report, three cases of elderly women with known COVID-19 infection, developing spontaneous rectus sheath hematoma on anticoagulation therapy, are presented. Three cases presented above emphasize the need to perform a computed tomography examination after a sudden hemodynamic deterioration and a decrease in hemoglobin count in COVID-19 patients in intensive care units (ICUs). Since this clinical deterioration can be caused by spontaneous rectus sheath hematomas (RSH), it must be taken into consideration while examination. If these RSHs rupture into the abdominal cavity, the outcome may be fatal in few hours as represented in two of our cases. Major spontaneous hemorrhage in COVID-19 patients is quite uncommon; therefore, it may cause serious complications as it is rarely taken into consideration. Failure to acknowledge such a risk could significantly worsen the prognosis of the patients especially in ERs and ICUs.

[Surgical complications in patients with COVID-19]. / Khirurgicheskie oslozhneniya u bol'nykh COVID-19.

OBJECTIVE: To analyze in-hospital perioperative complications in COVID-19 patients. MATERIAL AND METHODS: We analyzed medical records of 1.250 patients with COVID-19 for the period from April 2020 to December 2021. Mean age of patients was 62.8±2.1 years, length of hospital-stay - 44.3±3.7 days. All patients received therapy in accordance with the national guidelines on prevention, diagnosis and treatment of new coronavirus infection (COVID-19)¼ (versions 1-12). Visualization of hematomas, arterial and venous thrombosis was performed using ultrasound, CT and CT angiography. RESULTS: Mortality rate was 1.5%. Surgical complications included various hematomas, arterial and venous thrombosis of great vessels. Hematomas were detected in 15 (1.2%) patients, 2 of them died. There were hematomas of extremities in 5 cases, retroperitoneal space - 4, soft tissues of the body - 4, internal organs (spleen) -2 patients. The volume of hematoma was up to 100 ml in 6 patients, 100-500 ml in 5 patients, 500-1000 ml in 3 patietns, more than 1000 ml in 1 patient. Hematomas occurred in 23.1±1.1 days after laboratory verification of COVID-19. Four (26.7%) patients underwent emergency surgery. Conservative therapy was followed by lysis of hematoma after 25.1±2.7 days. Venous thrombosis without signs of flotation occurred in 20 (1.6%) patients, arterial thrombosis - in 3 (0.24%) patients (2 ones required surgery). CONCLUSION: Management of COVID-19 patients with various hematomas should be as conservative as possible. Arterial thrombosis and extensive spleen hematomas requiring surgical treatment are features of COVID-19.

Diagnosis and Management of Postpartum Retroperitoneal Hematoma: A Report of 3 Cases.

BACKGROUND The retroperitoneal hematoma is a very rare entity in obstetrics. A type of obstetric hematoma that extends into the retroperitoneal space, this hematoma usually occurs after laceration of the uterine artery, after uterine rupture, or by extension of a vaginal hematoma. Although the hematoma usually manifests as intense abdominal pain, sometimes the clinical signs can go unnoticed. This is the main reason it is important to report the cases in which retroperitoneal hematomas occur. In addition to clinical suspicion, experience in management can also help improve maternal morbidity and mortality from this cause. CASE REPORT We present a series of 3 clinical cases in which retroperitoneal hematomas occurred after instrumental deliveries. The 3 clinical cases described took place before the COVID-19 pandemic. In the first 2 deliveries, a vacuum was used, while in the third delivery, spatulas were used. CONCLUSIONS Our findings showed that suspicion is essential in patients with symptoms of nonspecific pain, as well as in patients with anemia that causes hemodynamic instability in the immediate postpartum period. The use of early computed tomography angiography in hemodynamically stable patients is essential to reach a diagnosis and to determine if the patient can be treated by embolization of the bleeding vessel.

Spontaneous large liver haematoma with extensive intraperitoneal bleeding in a patient with COVID-19 infection.

Thrombotic complications during COVID-19 infections occur frequently, and anticoagulants to prevent and treat deep vein thrombosis appear to have a good safety profile in these patients. In addition, haemorrhagic complications during COVID-19 infections have also been reported. Hepatic inflammation can occur in COVID-19 infections as a direct consequence of cellular infection and cytopathy. Spontaneous subcapsular hepatic haematoma is extremely rare and can be life-threatening.A woman in her 40s presented to the hospital with fever and shortness of breath and was diagnosed with COVID-19 infection with respiratory failure requiring intubation. On day 49 of hospitalisation, she developed melena and acute anaemia; her haemoglobin dropped from 97g/L (9.7g/dL) to 56g/L (5.6g/dL). Abdominal and pelvic CT scans showed a large subcapsular liver haematoma with retroperitoneal extension. The patient received blood transfusions and remained haemodynamically stable. She was eventually extubated and discharged home.

A Rapid Fatal Outcome of Iliopsoas Hematoma: Clinical and Autopsy Findings.

A case of massive muscular bleeding of iliopsoas resulting in lethal exsanguination is presented. The intramuscular bleeding occurred spontaneously in an old man with heart failure, presented to the emergency department after the acute onset of shortness of breath, and treated with therapeutic doses of antiplatelets and heparin to prevent thrombosis. On the sixth day of recovery, pain in the left lumbar region develops while there was a decrease in hemoglobin level. Computed tomography (CT) scan revealed a 10 × 3 cm hematoma of the left iliac muscle. The treatment was immediately stopped, but within 6 hours, the death was confirmed. The autopsy revealed that the hematoma, and its increased size since the latest imaging assessment, was the leading cause of death. Particularly in older patients with comorbidity, even in those with clotting parameters in the therapeutic range, the potential for fatal result of iliopsoas muscle bleeding should be considered. Identifying potential patience with increased risk of this complication could be important, especially in pandemic time of COVID-19, when the use of anticoagulant therapy-both for treatment and for prevention of severe disease-has become massive and addressed also to people without previous and specific pathologies.

Does COVID-19 increase the incidence of spontaneous rectus sheath hematoma?

BACKGROUND: The COVID-19 pandemic started to affect Turkey in March 2020. In this study, we retrospectively investigated spontaneous rectus sheath hematoma (S-RSH) in patients with COVID-19 presenting with acute abdominal pain during the ongoing pandemic. METHODS: The demographic characteristics, laboratory findings, length of hospital stay, and treatment processes of COVID-19 cases with S-RSH detected between March and December 2020 were recorded. The rectus sheath hematoma diagnosis of the patients was made using abdominal computed tomography, and the patients were followed up. Low-molecular-weight heparin treatment, which was initiated upon admission, was continued during the follow-up. RESULTS: S-RSH was detected in 13 out of 220 patients with COVID-19 who were referred to general surgery for consultation due to acute abdominal pain. The mean age of these patients was 78±13 years, and the female-to-male ratio was 1.6. Mechanical ven-tilation support was applied to three patients, all of whom were followed up in the intensive care unit. Two patients died for reasons independent of rectus sheath hematoma during their treatment. Among the laboratory findings, the activated partial thromboplastin time (aPTT) values did not deviate from the normal range. While there was no correlation between the international normalized ratio (INR) and aPTT (p>0.01), a significant correlation was found between INR and interleukin-6 (IL-6) (p<0.002). None of the patients required surgical or endovascular interventional radiology procedures. CONCLUSION: In the literature, the incidence of S-RSH in patients presenting with acute abdominal pain is 1.8%. However, in our series, this rate was approximately 3 times higher. Our patients' normal INR and aPTT values suggest that coagulopathy was mostly secondary to endothelial damage. In addition, the significantly higher IL-6 values (p<0.002) indicate the development of vasculitis along with the acute inflammatory process. S-RSH can be more commonly explained the high severity of vasculitis and endothelial damage due to viral infection.

Multisystem inflammatory syndrome in a neonate with severe hemophilia - a diagnostic challenge in COVID times: a case report.

BACKGROUND: Multisystem Inflammatory Syndrome in Neonates (MIS-N) can occur following antenatal COVID- 19 infection in the mother. Here we report a rare case of a neonate with Hemophilia A and MIS-N. CASE PRESENTATION: A 2-day-old baby presented with an intramuscular hematoma, neonatal seizures, and isolated activated partial thromboplastin time (APTT) prolongation. The neurosonogram showed a subdural hematoma. A diagnosis of Hemophilia A was made and was confirmed by factor 8 assay and genetic analysis. Supportive measures and Factor 8 replacement was initiated. A rising trend of inflammatory markers and an ongoing need for mechanical ventilation were noted. As there was a history of COVID-19 in the mother in the third trimester, MIS-N was diagnosed. The baby was treated with intravenous immunoglobulin (IVIG) and steroids, and there was an improvement in the clinical and laboratory markers. However, the baby developed seizures on day 16. There was an increase in the subdural hemorrhage and a further rise in inflammatory markers. A craniostomy and hematoma evacuation was done and the baby improved. CONCLUSION: The concurrent occurrence of hemophilia A with intracranial bleed, and MIS-N in a neonate is a diagnostic challenge. It is important to have a high index of suspicion to ensure timely diagnosis and treatment of MIS-N in this pandemic era.

Tranexamic acid for intracerebral haemorrhage within 2 hours of onset: protocol of a phase II randomised placebo-controlled double-blind multicentre trial.

RATIONALE: Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. METHODS AND DESIGN: Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. HYPOTHESIS: In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. SAMPLE SIZE ESTIMATES: A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. INTERVENTION: Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. PRIMARY EFFICACY MEASURE: The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. DISCUSSION: We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.

Spontaneous Retroperitoneal Hematoma Treated with Percutaneous Transarterial Embolization in COVID-19 Era: Diagnostic Findings and Procedural Outcome.

(1) Background: Spontaneous retroperitoneal hematomas are a relatively common occurrence in hospitalized patients with COVID-19 related pneumonia, and endovascular treatment of trans-arterial embolization (TAE) may be a life-saving procedure after failure of medical and supportive therapy. The aim of our study was to evaluate spontaneous retroperitoneal hematomas in the COVID-19 era, focusing on their imaging features at CTA and DSA and on the safety, as well as technical and clinical success, of TAE, comparing patients affected by COVID-19 and non-COVID-19 patients. (2) Materials and Methods: We retrospectively enrolled 24 patients with spontaneous retroperitoneal hematoma who underwent TAE; of these, 10 were hospitalized for COVID-19-related pneumonia, while the other 14 were without COVID-19 infection. We evaluated the demographic data, hemoglobin values before and after the procedure, preprocedural aPTT, preprocedural INR, diagnostic and interventional imaging findings, procedural outcome (technical success) and survival periprocedural (clinical success), and major and minor complications. (3) Results: The mean age of the study population was 72.7 ± 11.2 years. CTA revealed signs of active bleeding in 20 patients (83%). DSA showed signs of active bleeding in 20 patients (83%). In four patients (17%), blind embolization was performed. The overall technical success rate was 100%. Clinical success was achieved in 17 patients (71%), while seven patients (29%) rebled within 96 h, and all of them were retreated. No major periprocedural complication was reported. The comparison between the two groups did not show statistically significant differences for gender, mean age, mean pre- and postprocedural hemoglobin, aPTT and INR, mean hematoma volume (cm3), or mean delay between CT and DSA. Active bleeding at CTA was detected in 90% of COVID-19 patients and 79% of non-COVID-19 patients (p = 0.61). At DSA, active bleeding was assessed in eight out of 10 (80%) patients in the COVID-19 group and 12 out of 14 (86%) patients in the non-COVID-19 group (p = 1). Technical success was obtained in 100% of patients in both groups. Clinical success rates were 70% for COVID-19 group and 71% for the non-COVID-19 group. We found no statistical significance between the clinical success rates of retroperitoneal spontaneous hematoma embolization in patients with or without SARS-CoV-2 infection. (4) Conclusions: We suggest that, similar to what has been reported in other studies in non-COVID-19 patients, TAE should be considered an important safe, effective, and potentially life-saving option for the management and the treatment of patients affected by COVID-19 who present with spontaneous retroperitoneal hematoma and who could not benefit from conservative treatment.

Spontaneous Hematomas and Deep Vein Thrombosis during the Recovery from a SARS-CoV-2 Infection: Case Report and Literature Review.

Background: The frequent occurrence of thromboembolic events in patients infected with the severe acute respiratory syndrome CoV2 (SARS-CoV-2) virus is a well-recognized fact in the medical literature, but less data is available about possible hemorrhagic incidents. Methods: We report the case of a 76-year-old patient who suffered from a mild COVID-19 infection in September 2021 and after four weeks, experienced a completely spontaneous popliteal hematoma followed by deep vein thrombosis (DVT). Therapy with low molecular weight heparins (LMWH) was started, but subsequently, the patient developed a massive sub-pectoral and calf hematoma leading to moderate post-hemorrhagic anemia and acute kidney injury. This patient was treated completely conservatively. Conclusions: Considering the continuous spread of the infection with various, continuously evolving strains of this virus and the extended use of LWMH in clinical practice, such cases were seldom described in the medical literature, but should be considered as a potential cause for hemorrhagic events.

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.

Retroperitoneal Haematoma - Still a Medical Challenge for Abdominal Trauma.

Introduction: The study is presenting a personal experience of a Trauma Centre Level I and is try to conclude on optimal medical attitude for patients with retroperitoneal hematoma, still a controversial topic for traumatologists. Material and Method: A retrospective analysis of 22 cases of post-traumatic retroperitoneal hematoma admitted on Bucharest Emergency Hospital between September 2018 August 2021 (including time of Covid-19 pandemic), is presented Results: The patients (males predominance, mean age 43, mean ISS of 23), benefited of nonoperative management on admission for 10 cases (45%) with a failure rate of 4/10 due to recurrent bleeding from spleen injuries and continuous bleeding from mesenteric vessels lesions. CT scan (73% - 16 cases) within 1 hour from the admission and emergency surgery were necessary for 12 cases (55%). 2 patients benefited of angioembolization on admission. Conservative attitude for retroperitoneal hematoma was adopted for 72% cases. Over-all mortality: 18% (4 patients, mean ISS of 36), among 82% polytrauma cases. Conclusions: Algorithm of treatment is adapted to every case of retroperitoneal hematoma but the following sequences are mandatory: rapid transportation to Trauma Centre Level I with medical help, correct resuscitation, immediate relevant imagistic (CT scan), emergency surgery prior to angioembolization (for hemodynamic instable patients) or after it, ICU stabilization of the patient and then definitive repair of the injuries. Despite all, mortality remains high.