Segmental arterial mediolysis leading to spontaneous rupture of splenic artery and fatal hemorrhage in pregnancy.

We report an unexpected death of a 22-year-old primigravida who was admitted to the hospital with sudden abdominal pain two days before a scheduled delivery. During an emergency caesarean section due to intrauterine asphyxia, intraabdominal bleeding was observed with no apparent source of bleeding. Newly formed blood clots in the subdiaphragmatic space and arterial bleeding near the splenic hilum required a surgery on the next day. Hemorrhagic shock led to multiple organ failure on the fourth day of admission. The autopsy revealed ruptured splenic artery at the pancreatic tail and near the splenic hilum. Microscopically, different stages of segmental arterial mediolysis were observed in partially thinned and aneurysmatic artery.

Spontaneous Oropharyngeal Bleeding Caused by Lingual Artery Pseudo-Aneurysm.

Spontaneous oropharyngeal bleeding is an uncommon but serious medical emergency mainly caused by accidental trauma or post-tonsillectomy. In extremely rare cases, it can be attributed to arterial pseudoaneurysm (PA) of head and neck vessels. The authors present the case of a young female patient presenting with recurring spontaneous oropharyngeal bleeding who was found to have a lingual artery PA on angiography. Due to the active nature of the hemorrhage and extensive blood loss, embolization of the tonsillar branch of the lingual artery was successfully performed. When evaluating patients with spontaneous oropharyngeal bleeding, one should suspect the presence of an arterial PA, especially if the bleeding recurs following initial conventional interventions.

Non-traumatic spontaneous abdominal haemorrhage.

Spontaneous abdominal hemorrhage is defined as intra-abdominal hemorrhage from a non-traumatic cause. It is a challenging clinical situation and in most cases the diagnosis is made on the basis of imaging findings. CT is the technique of choice for the detection, localization and extension of bleeding. Objective is to review the main imaging findings expected in spontaneous abdominal hemorrhage as well as its main etiologies.

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.

[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.

Severe Retroperitoneal Hemorrhage in a COVID-19 Patient on a Therapeutic Dose of Low Molecular Weight Heparin: A Case Report.

Extensive drug treatment for coronavirus disease 2019 (COVID-19) includes low molecular weight heparin (LMWH). At therapeutic doses of LMWH, there is an increased risk of bleeding complications. Spontaneous, non-traumatic bleeding into the retroperitoneum is a life-threatening condition that can progress very rapidly. We describe a complication of COVID-19 bronchopneumonia treatment in which a patient developed a shock condition caused by non-traumatic bleeding into the retroperitoneum and abdominal wall due to LMWH overdose. The patient was operated on under difficult conditions - in biosafety level 3 (BSL-3). This case is exceptionally fascinating and informative. Nowadays, it is essential to point out possible complications associated with the treatment of COVID-19. Based on this report, we emphasize the need for careful LMWH dosing and quick and accurate diagnosis. Surgeons should maintain a higher index of suspicion for spontaneous bleeding in non-specific abdominal pain patients with COVID-19 or patients receiving therapeutic doses of LMWH.

Severe Coagulopathy in a Patient With Short Bowel Syndrome.

BACKGROUND: Short bowel syndrome (SBS) refers to a malabsorptive state caused by extensive resection of the intestinal tract that leads to chronic diarrhea, electrolyte disturbances, and malnutrition. Although relatively uncommon, patients with SBS can present to the emergency department with more serious complications that are potentially life-threatening. Among these complications, coagulopathy secondary to SBS is an underrecognized condition. CASE REPORT: We present a case of severe coagulopathy secondary to vitamin K deficiency in SBS. The patient presented with unexplained coagulopathy and spontaneous bleeding in multiple organs. With a review of surgical history and detailed clinical evaluation, SBS complicated with vitamin K deficiency was diagnosed, and the patient was treated successfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When a patient with a history of repeated intestinal surgery presents with diarrhea, malnutrition, or electrolyte abnormalities, emergency physicians should suspect SBS. Among complications of SBS, vitamin K deficiency is a rare but serious cause of unexplained coagulopathy presenting to the emergency department. Understanding the pathophysiology of SBS facilitates early identification of complications and improves patient outcomes.

Spontaneous Retroperitoneal Hematoma: A Deadly Complication for Patients Awaiting Liver Transplant.

BACKGROUND: Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLD at a single center. METHODS: All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival. RESULTS: Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score. CONCLUSION: Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in the literature.

Management of Spontaneous Bleeding in COVID-19 Inpatients: Is Embolization Always Needed?

BACKGROUND: critically ill patients with SARS-CoV-2 infection present a hypercoagulable condition. Anticoagulant therapy is currently recommended to reduce thrombotic risk, leading to potentially severe complications like spontaneous bleeding (SB). Percutaneous transcatheter arterial embolization (PTAE) can be life-saving in critical patients, in addition to medical therapy. We report a major COVID-19 Italian Research Hospital experience during the pandemic, with particular focus on indications and technique of embolization. METHODS: We retrospectively included all subjects with SB and with a microbiologically confirmed SARS-CoV-2 infection, over one year of pandemic, selecting two different groups: (a) patients treated with PTAE and medical therapy; (b) patients treated only with medical therapy. Computed tomography (CT) scan findings, clinical conditions, and biological findings were collected. RESULTS: 21/1075 patients presented soft tissue SB with an incidence of 1.95%. 10/21 patients were treated with PTAE and medical therapy with a 30-days survival of 70%. Arterial blush, contrast late enhancement, and dimensions at CT scan were found discriminating for the embolization (p < 0.05). CONCLUSIONS: PTAE is an important tool in severely ill, bleeding COVID-19 patients. The decision for PTAE of COVID-19 patients must be carefully weighted with particular attention paid to the clinical and biological condition, hematoma location and volume.

[Epidemiology of spontaneous nasal, ear and throat bleedings]. / Epidemiologiya spontannykh krovotechenii iz ukha, gorla, nosa.

Bleeding is a life-threatening condition, requiring an urgent care. The first line of treatment this kind of patients is ambulance doctors (emergency medical team). Spontaneous bleeding (SB), in this case, don't have a traumatic agent (including surgical trauma). STUDY OBJECTIVE: The purpose of this study was to evaluate spontaneous bleeding epidemiological profile of Moscow city emergency service. METHODS: Study included statistical reports of Moscow city emergency services medical teams (EMT) were servicing adults. We analyzed total number of calls and number of EMT calls to pa-tients with SB during the period between 2015 and 2019. The excluding criteria was EMT re-calls to patents with SB. RESULTS: In a study, it was found that over five-year period of observation, EMT made 15 709 862 calls, included 215 840 calls (1.37%) to patients with SB. It was found that the most frequency sources of SB were: the gastrointestinal tract (33.18%), the nasal cavity (28.14%) and the vagina with the uterus (23.91%). There is the proportion of patients suffering of SB from ENT organs is 28.52% in structure of Moscow city Emergency Medical Service. There are the proportion of epistaxis 98.65%, ear bleeding - 0.89%, throat bleeding - 0.46% in structure of SB from ENT organs. We analyzed, that spontaneous epistaxis most frequent between October and April. This period characterized with 70.6% EMT calls from the total EMT calls to patients with SE.

Meningioma-related subacute subdural hematoma: A case report.

BACKGROUND: Meningiomas are the most frequent benign head tumors, although spontaneous hemorrhage is a rare form of presentation of such lesions. Of all possible bleeding locations associated with them, the subdural space is one of the most uncommon, with very few cases reported worldwide. CASE DESCRIPTION: A middle-aged woman presented with progressively worsening left-sided headache, initiated 2 weeks before, with no other complaints, denying any previous head trauma. Head computed tomography revealed a subacute left hemisphere subdural hematoma and left frontal, suggestive of meningioma on magnetic resonance imaging. Surgical treatment was performed with hematoma evacuation and lesion removal. Neuropathology showed a transitional meningioma with signs of hemorrhage. After surgery, no neurological deficits were registered, and headache abated. CONCLUSION: As we could not identify any other cause for the subacute subdural hematoma, hemorrhage from the meningioma was the most probable cause, and thus, we decided to remove it along with clot evacuation. Based on neuropathological findings, we propose an alternative mechanism for this spontaneous hemorrhage from the meningioma, involving the place where the periphery of the lesion insertion, the dura mater as the origin of the hemorrhage. Knowledge of this association could help define the best treatment in such cases.

A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants.

Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.

Spontaneous bleeding in systemic lupus erythematosus: Endovascular treatment of two rare cases.

Among the multiple clinical manifestations of systemic lupus erythematosus, spontaneous bleedings are rare but clinically important events. They could be potentially fatal, if not promptly treated. The appropriate diagnosis, followed by the timely treatment of these rare clinical presentations, is essential to prevent their lethal consequences. The purpose of this paper is to describe the diagnostic features and the endovascular treatment of 2 cases of spontaneous bleeding-respectively occurred in a 42-year-old woman with abdominal pain and melena, and in a 33-year-old woman with an extensive and painful hematoma in the left axillary region. The timely endovascular treatment-performed by a minimally invasive approach of super-selective percutaneous embolization-has allowed an immediate clinical improvement, avoiding major surgery.

Hypofibrinogenaemia: A Case of Spontaneous Bleeding and Central Venous Thrombosis in the Same Lifetime.

The authors present the case of a 27-year-old patient who suffered from spontaneous bleeding during infancy and from a severe and central venous thrombosis in adult years. The patient underwent a thorough laboratory work-up on both occasions and was diagnosed with hypofibrinogenaemia as well as protein S deficiency, 2 diseases that contrast in their intrinsic bleeding/thrombotic risk. The patient's high-risk pregnancy was carried out up to a successful full-term eutocic delivery which required fibrinogen concentrate to reduce life-threatening bleeding. The patient's child was also diagnosed with hypofibrinogenaemia, later on confirmed with the pathogenic mutation Fibrinogen Marseilles II. This case was used to conduct a literature review of congenital fibrinogen disorders, rare entities that require more awareness for early diagnosis and accurate management. LEARNING POINTS: Fibrinogen disorders are uncommon causes of either bleeding or thrombotic events and may be acquired or inherited in a recessive or dominant autosomal manner.Congenital fibrinogen deficiencies are rare but should be investigated when undergoing diagnostic work-up for thrombotic or haemorrhagic events in adult years.Determination of molecular defects is important for confirmation and to elaborate a treatment strategy according to the inherent risk for either thrombotic or haemorrhagic events.

Spontaneous hemorrhage from varicose veins: A single-center experience.

OBJECTIVE: Whereas the commonly described manifestations of venous insufficiency include telangiectasia, varicose veins (VVs), edema, skin changes, and ulcers, we have noted some patients who present with external hemorrhage from lower extremity VVs. Because there are few recent data examining this entity, we herein describe our experience. METHODS: During 29 months, we had 32 patients present with hemorrhage from lower extremity VVs. There were 15 men and 17 women with a mean age of 60.2 years (range, 38-89 years; standard deviation [SD], ±14.9 years). Interestingly, 16 of these patients presented after coming into contact with warm water; 28 patients, 19 patients, and 1 patient presented with reflux >500 milliseconds in the great, small, and accessory saphenous veins, respectively. Eight patients and six patients had reflux >1 second in the femoral and popliteal veins, respectively. RESULTS: All patients were treated with weekly Unna boots. Mean ulcer healing time was 2.12 weeks (range, 1-8 weeks; SD, ± 2.15 weeks). Patients with VV hemorrhage after contact with warm water had a mean healing time of 1.75 weeks, whereas those who bled without such exposure took an average of 3.5 weeks (P = .0426). Twenty patients underwent at least one endovenous thermal ablation procedure, with the average patient in the cohort receiving 2.16 procedures (range, 0-9; SD, ± 2.37). There was no significant difference between laterality, age, or sex between patients who bled after warm water contact and those who bled spontaneously. The ulcers recurred in three of the patients, and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months (range, 26 months; SD, ± 8.9 months), and we noted no recurrent bleeding episodes. CONCLUSIONS: Spontaneous hemorrhage of VVs, although relatively under-reported, is not a rare occurrence. Risk factors are unknown; however, half of our patient cohort reported VV hemorrhage during or directly after coming into contact with warm water. Furthermore, these patients demonstrated a significantly shorter wound healing time compared with the rest of the cohort. Basic first aid, wound care, and hemostasis control education should be provided to all patients with VVs. Further investigation surrounding the risk factors associated with VV hemorrhage is warranted.

Intratumoural renal cell carcinoma haemorrhage following stereotactic radiotherapy: a case report.

BACKGROUND: Stereotactic radiotherapy is an emerging treatment option for patients with inoperable renal cell carcinoma (RCC). Haemorrhage has not previously been reported to occur as a result of Stereotactic Body Radiotherapy (SBRT) to the kidney for primary RCC. We report an acute haemorrhage in a patient who received only one of three planned fractions of SBRT as part of a clinical trial. CASE PRESENTATION: A 74 year old female had a left renal mass under observation for 4 years, during which time she was imaged repeatedly using ultrasound and CT scans. There has been no evidence of metastases, and the lesion has demonstrated a steady pattern of growth over the 4-year period. Fine needle aspiration histologically confirmed RCC. Following a multidisciplinary review, the patient was recommended for SBRT as she was not considered a surgical candidate. Treatment was planned for an ablative 42Gray (Gy) to be delivered in 3 fractions at 14Gy/fraction as part of a clinical trial. Our patient presented to the emergency department (ED) suffering left flank pain, fever and vomiting within 3 h of the first fraction of SBRT. CT showed the mass to have markedly increased in size, measuring 8.7 × 8.1 × 7.0 cm, from 6.5 × 5.4 × 5.6 cm. It was reported as an internal haemorrhage into the malignancy. The patient was admitted for analgesia, anti-pyretics, and transfusion of 2 units of packed red blood cells. The patient recovered without any further intervention but radiotherapy was discontinued. The patient was alive and free from disease progression two years after the aborted treatment. CONCLUSION: Such events, though rare, are potentially serious, and therefore clinicians should be aware of such treatment related complications.

Spontaneous bleeding in thrombocytopenia: Is it really spontaneous?

Spontaneous bleeding is a clinical hallmark of thrombocytopenia and can take multiple forms including petechiae, epistaxis, gum bleeding, or, in worst cases, intracranial hemorrhage. Those bleeding events are called " spontaneous " because they occur in the absence of overt trauma. Spontaneous bleeding manifestations have long been considered to be a direct consequence of low platelet counts. Nevertheless, although low platelet counts may lead to ultrastructural endothelial alterations, those alterations and the associated state of vascular fragility are unlikely sufficient to cause spontaneous rupture of the microvessel wall. Indeed, in addition to endothelial injury, factors capable of damaging the basement membrane are required to allow escape of red blood cells in the extravascular space. Therefore, despite their misleading name, spontaneous bleeding events in thrombocytopenia are most likely provoked and involve subclinical biological processes in which platelets normally intervene to ensure hemostasis. In this review, we discuss past and more recent studies on the possible triggers of spontaneous bleeding events in thrombocytopenia, with a particular focus on the role of inflammatory reactions.

Sangrado espontáneo masivo en adulto conocido sano / (Massive spontaneous bleeding)

ResumenSe reporta el caso de un paciente que presentó de manera espontánea diátesis hemorrágica, sin tener causa alguna aparente que lo justificase. Tal diátesis hemorrágica forja un amplio apartado de posibilidades diagnósticas en cuanto a trastornos de la coagulación del adulto se refiere, en el contexto de un paciente conocido sano que nunca ha presentado episodios de sangrado mayor y debuta con hemorragias de forma masiva. Entre las muchas posibilidades diagnósticas se encuentra una poco conocida: la hemofilia adquirida. La hemofilia adquirida es un trastorno infrecuente de la hemostasia, caracterizado por la presencia de inhibidores adquiridos de los factores de la coagulación, en el plasma del paciente enfermo. Los inhibidores adquiridos son anticuerpos que a su vez podrían ser de tipo aloanticuerpos o autoanticuerpos. Los aloanticuerpos se desarrollan en pacientes deficitarios per se de factores de la coagulación, en respuesta a la terapia de sustitución de factores, lo que complica su tratamiento. Por su parte, los autoanticuerpos se desarrollan en sujetos sin defectos previos; son anticuerpos específicos contra un factor de la coagulación, afectando o no su función, alterando una o varias etapas de las vías de la coagulación. El caso que aquí se presenta es de un paciente masculino de 58 años, quien se presentó con sangrado espontáneo masivo y a quien se diagnosticó hemofilia adquirida por la presencia de autoanticuerpo específico del factor VIII.

AbstractA patient that presented with spontaneous hemorrhagic diathesis, with no apparent cause is presented. Hemorrhagic diathesis presents a wide range of diagnosis possibilities as of coagulation disorders are referred, in the context of a healthy patient with no previous major bleeding episodes and that debuts with massive hemorrhages. Acquired hemophilia, a little known disease, is one that must be considered.Acquired hemophilia is an uncommon hemostasis disorder characterized by the presence of acquired inhibitors of coagulation factors in the plasma of the sick patient. These acquired inhibitors, are antibodies that could be alloantibodies or autoantibodies. Alloantibodies are developed in patients who have coagulation factor deficiency, in response to factor replacement therapy, thus complicating treatment.On the other hand, autoantibodies are developed in people without previous defects and are specific against a factor of coagulation, affecting or not their function, obstructing one or several stages of the coagulation pathways. We report a case of acquired hemophilia due to an autoantibody against factor VIII in a 58 years old male patient with spontaneous massive bleeding.