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Which Predicts the 30-Day Mortality Better for Intracerebral Hematoma?

PLoS One. 2014; 9(7): e102326.

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Chih-Wei Wang

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Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Yi-Jui Liu

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Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan, Republic of China,

Yi-Hsiung Lee

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Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan, Republic of China,

Dueng-Yuan Hueng

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Department of Neurological Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Hueng-Chuen Fan

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Department of Pediatrics, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Fu-Chi Yang

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Department of Neurology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Chun-Jen Hsueh

1
Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Hung-Wen Kao

1
Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Chun-Jung Juan

1
Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Hsian-He Hsu

1
Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

Jon Sherman, Editor

1
Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

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Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan, Republic of China,

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Department of Neurological Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

4
Department of Pediatrics, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

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Department of Neurology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China,

The George Washington University, United States of America,

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: CWW CJJ. Performed the experiments: YJL YHL CWW CJH. Analyzed the data: CJJ DYH. Contributed reagents/materials/analysis tools: YJL HCF FCY HWK HHH. Contributed to the writing of the manuscript: CWW CJJ. Designed the software used in analysis: YJL.

Received 2014 Apr 27; Accepted 2014 Jun 16.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.

This article has been cited by other articles in PMC.

Supplementary Materials
Table S1:
Original data and ICH score of patients with intracerebral hematomas.

(DOCX)

GUID: 7AD195C0-5B8E-46AE-B07D-595F53B8B53D

Data Availability Statement

The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.

Abstract

Purpose

To investigate the performance of hematoma shape, hematoma size, Glasgow coma scale (GCS) score, and intracerebral hematoma (ICH) score in predicting the 30-day mortality for ICH patients. To examine the influence of the estimation error of hematoma size on the prediction of 30-day mortality.

Materials and Methods

This retrospective study, approved by a local institutional review board with written informed consent waived, recruited 106 patients diagnosed as ICH by non-enhanced computed tomography study. The hemorrhagic shape, hematoma size measured by computer-assisted volumetric analysis (CAVA) and estimated by ABC/2 formula, ICH score and GCS score was examined. The predicting performance of 30-day mortality of the aforementioned variables was evaluated. Statistical analysis was performed using Kolmogorov-Smirnov tests, paired t test, nonparametric test, linear regression analysis, and binary logistic regression. The receiver operating characteristics curves were plotted and areas under curve (AUC) were calculated for 30-day mortality. A P value less than 0.05 was considered as statistically significant.

Results

The overall 30-day mortality rate was 15.1% of ICH patients. The hematoma shape, hematoma size, ICH score, and GCS score all significantly predict the 30-day mortality for ICH patients, with an AUC of 0.692 (P = 0.0018), 0.715 (P = 0.0008) (by ABC/2) to 0.738 (P = 0.0002) (by CAVA), 0.877 (P<0.0001) (by ABC/2) to 0.882 (P<0.0001) (by CAVA), and 0.912 (P<0.0001), respectively.

Conclusion

Our study shows that hematoma shape, hematoma size, ICH scores and GCS score all significantly predict the 30-day mortality in an increasing order of AUC. The effect of overestimation of hematoma size by ABC/2 formula in predicting the 30-day mortality could be remedied by using ICH score.

Introduction

Hematoma shape has been recently reported to be related to hematoma size and hematoma growth of intracerebral hematomas (ICH). An irregular shape of hematoma has been linked to a larger hematoma size [1] and a higher risk of hematoma growth [2], which in turns is related to a poorer outcome [3]. Whether the hematoma shape predicts the 30-day mortality for ICH patients is of clinical interest and importance. It has not been reported in this regard, however.

Hematoma size is an important prognostic factor predicting the mortality of ICH patients [4]–[5]. The hematoma size could be either estimated simply by the ABC/2 formula or measured by computed assisted volumetric analysis (CAVA). Although the ABC/2 formula has been used to estimate the hematoma size for predicting clinical outcomes, it tends to overestimate the hematoma size as compared to the CAVA by 2% to 32% [6]–[7]. It remains unanswered whether the estimation error of hematoma size leads to imprecision in predicting the 30-day mortality of ICH patients.

By weighting Glasgow coma scale (GCS) score, age, hematoma size, origin of ICH, and ventricular involvement, the ICH score has been raised as a simple method in predicting 30-day mortality [8]. However, the performance of the ICH score in predicting the 30-day mortality varies in different studies, with the areas under the curve (AUC) in the receiver operating characteristics (ROC) curves ranging from 0.72 to 0.92 [8]–[11]. Whether the ICH score predicts the 30-day mortality better than the hematoma shape, hematoma size, and GCS score has not been assessed in a single study yet.

In this study, we aimed to investigate the performance of hematoma shape, hematoma size, GCS score, and ICH score in predicting the 30-day mortality for ICH patients. In the meanwhile, we also examined the influence of the estimation error of hematoma size on the prediction of 30-day mortality.

Materials and Methods

This retrospective study was approved by the institutional review board of Tri-Service General Hospital (1-103-05-014). The institutional review board waived the need of written informed consent from the patients in this study. All data underlying the findings described in this manuscript are in Table S1.

Subjects

Brain computed tomography (CT) images of 137 patients, who were admitted to our hospital under the diagnosis of acute intracerebral hemorrhage during a period of 10 months, were initially reviewed. All patients received non-enhanced CT with an interval between the time of CT study and the onset of symptoms within 24 hours. Twenty-three patients were excluded based on the following exclusion criteria including concurrent subarachnoid hemorrhage (N = 4), subdural hematoma (N = 1), brain tumor (N = 2), acute ischemic infarction with hemorrhagic transformation (N = 3), old ischemic infarction (N = 5), old hemorrhage (N = 2), severe motion artifact (N = 2), beam hardening artifact (N = 1), and recent intracranial operations (N = 3). Eight patients who had a ventricular shunting catheter seen on CT images were also excluded. Finally, 106 patients (62.8±15.3 years, M: F = 1.9: 1) with intracerebral hematomas were recruited in this study. The clinical data (gender, age, GCS score, blood pressure, pulse rate, respiratory rate, and body temperature), clinical history (hypertension, diabetes mellitus, ischemic heart disease, and congestive heart failure), and laboratory data (blood sugar, white blood cell count, hemoglobin, platelet count, and international normalized ratio) obtained on admission were recorded. To assess the 30-day mortality, the survival statuses of patients were confirmed based on the medical records not only on admission but also in outpatient follow up.

Imaging data acquisition

Non-enhanced CT images were acquired using single or multi-row spiral CT scanners (Somatom Plus 4, Simens, Erlangen, Germany; PQ6000, Picker International Inc., Highland Heights, Ohio, U.S.A.; Brilliance, Philips Medical System, Cleveland, Ohio, U.S.A), which were compatible with the regulation of digital imaging and communications in medicine (DICOM). Imaging parameters included 140 kV, 170 mA, slice thickness of 5 mm, slice gap of 0 mm, field of view of 210 mm, matrix size of 512×512 and gantry angulation being parallel to the supraorbitomeatal line.

Qualitative analysis of hematoma shape

The hematoma shape was independently evaluated by two neuroradiologists (observer 1, C.W.W.; observer 2, C.J.J.) using a binary scoring system, which was first introduced here in this study. A score of 0 represented a regular hematoma shape, including a roundish or ellipsoid hematoma with smooth margin (). A score of 1 represented an irregular hematoma shape, including a pleomorphic contour of hematoma (), several adjacent but separated hematomas () and multicentric hematomas ().

Axial brain CT images demonstrating regular hematoma shapes (A–C) and irregular hematoma shapes (D–I).

Regular hematoma shape implies roundish (A) or ovoid (B & C) shape with smooth margin, while irregular hematoma shape refers to pleomorphic contour (D–F), separated adjacent hematomas (G & H) and multicentric hematomas (I).

Data analysis and volumetric analysis of ICH

The DICOM data were firstly stored in the picture archiving and communication system (PACS) immediately after acquisition. Maximal diameters of the hemorrhage in three orthogonal directions were measured on a PACS viewer (EBM Technologies Inc., Taipei, Taiwan) by a 10-year experienced neuroradiologist (C.J.J.) for calculating the hemorrhagic size using the ABC/2 method as described by Kothari et al. [6].CT image data were also digitally transferred to a personal computer for hemorrhagic volumetric analysis processed with the software programs developed (by Y.J.L.) using Matlab (MathWorks, Natick, MA, U.S.A.). All image processing, region-of-interest drawing, and data analyses were performed by a single author (C.J.J.). The data processing included histogram analysis of a large region of interest (ROI), threshold setting for the hemorrhage, manually polygonal ROI drawing, voxel counting and size calculation slice-by-slice, and finally summing hemorrhagic size of each slice. Thresholds with a lower level of 40∼45 HU and an upper level of 100∼150 HU were adjusted as a mask for the hemorrhage as described by Strik et al. [12]. Small polygonal ROIs encompassing the hyperdense hemorrhage were drawn to avoid the contamination of noises from the adjacent gray matter. The hematoma size was calculated by the equation:

ICH Score and 30-day mortality

The ICH score was calculated based on the clinical information (age and GCS score) and the CT features (hematoma size, infratentorial origin of hemorrhage, and intraventricular hemorrhage) as developed by Hemphill et al [8]. The 30-day mortalities were calculated with respect to the hematoma shape, hematoma size, ICH Score, and other parameters used in calculating ICH Score.

Statistical analysis

Statistical analyses were performed using SPSS Version 16.0 software (SPSS Inc, Chicago, III) and MedCalc Version 13.0 (MedCalc Software Inc, Ostend Belgium). The interobserver reliability was examined by linearly weighted kappa statistics. The normality of parameters was examined by using Kolmogorov-Smirnov tests. Cross-tabulations were analyzed using Fisher exact test. Paired student t test was used for 2-group comparisons regarding parameters with normal distribution, while nonparametric tests (Wilcoxon signed rank tests and McNemar tests) were used for 2-group comparisons regarding parameters without normal distribution. Linear regression analysis was used to assess the relationship between the hematoma size estimated by ABC/2 formula and the hematoma size measured by CAVA. Binary logistic regression was applied to examine the relationships between the independent variables (shape, size, GCS score, age, presence of IVH, presence of infratentorial location) and dependent variable (30-day mortality). The nonparametric receiver operating characteristics (ROC) curves were plotted and areas under curve (AUC) were calculated for 30-day mortality. A P value less than 0.05 was considered as statistically significant.

Results

Of 106 patients, 77 (73%) had a history of hypertension, 21 (20%) had type II diabetes mellitus, four (3.8%) had impaired coagulation function with international normalized ratio (INR) ≧ 1.5, and 47 (44.3%) had simultaneous IVH. The hematomas were located supratentorially in 93 (87.7%) patients, located infratentorially in 13 (12.2%) patients. The overall 30-day mortality was 15.1% (16 of 103). The demographic and clinical characteristics of our study were summarized in . Factors that were significantly associated with outcomes in 30 days included platelet count (P = 0.003), hematoma shape (P = 0.003), hematoma size (P = 0.009), presence of IVH (P<0.032), GCS score (P<0.001), and ICH score (P<0.001).

Table 1

Demographic and clinical characteristics of ICH patients.

Variable Death* (n = 16) Survival* (n = 90) Total (n = 106) P value Missing data
Males 11 (68.8%) 58 (64.4%) 69 (65.1%) 0.74 0
Age (years) 62.1±16.1 63.0±15.2 62.8±15.3 0.83 0
Age ≧ 80 years 3 (18.8%) 16 (17.8%) 19 (17.9%) 0.92 0
Vital signs Systolic BP (mmHg) 185.3±2.3 171.6±34.3 173.7±35.7 0.23 0
Diastolic BP (mmHg) 96.6±14.3 91.3±18.7 9.1±18.1 0.21 0
Pulse pressure (mmHg) 88.7±30.7 80.3±25.3 81.6±26.2 0.31 0
Pulse rate (per minute) 91.8±14.8 89.7±12.3 90.0±12.7 0.60 0
Respiratory rate (per minute) 20.1±1.7 19.7±1.9 19.7±1.8 0.44 0
Body temperature (°C) 36.7±0.3 36.8±0.4 36.8±0.4 0.12 0
Laboratory data Glucose (mg/dL) 185.6±89.5 145.4±51.3 149.5±57 0.22 18 (17.0%)
WBC count (×103/µL) 11.9±5.3 10.5±3.9 10.7±4.1 0.34 3(2.8%)
Hemoglobin (mg/dL) 12.2±2.8 13.3±2.4 13.1±2.5 0.16 1 (0.9%)
Platelet count (×105/µL) 1.76±0.83 2.53±0.99 2.43±1.0 0.003 1 (0.9%)
INR 1.4±0.5 1.2±1.0 1.2±1.0 0.43 19 (18.0%)
CT findings Irregular shape 12 (75%) 33 (36.7%) 45 (42.5%) 0.004 0
Hematoma size (mL) (CAVA) 62.7±57.2 21.6±26.2 27.8±35.6 < 0.001 0
Hematoma size (mL) (ABC/2) 90.3±20.1 29.5±4.0 38.7±51.0 0.009 0
Hematoma size >30 mL (CAVA) 11 (68.8%) 19 (21.1%) 30 (28.3%) 0.001 0
Hematoma size >30 mL (ABC/2) 11 (68.8%) 24 (26.7%) 35 (33.0) 0.001 0
Intraventricular hemorrhage 11 (68.8%) 36 (40%) 47 (44.3%) 0.032 0
Infratentorial origin 3 (18.8%) 10 (11%) 13 (12.3%) 0.48 0
GCS score 4.4±2.1 10.8±3.9 9.8±4.3 <0.001 0
ICH score 3.6±1.0 1.5±1.3 1.8±1.5 <0.001 0

Location of hematomas

The 30-day mortality was 23.1% (3 of 13) for infratentorial hematomas and was 14.0% (13 of 93) for supratentorial hematomas. The difference between the aforementioned locations, however, was not statistically significant (P = 0.391). Patients with pontine hematomas had a 30-day mortality as high as 33.3% (2 of 6), while patients with cerebellar hematomas had a 30-day mortality of 14.3% (1 of 7). Again, the difference was not statistically significant (P = 0.279).

Shape of hematomas: regular hematomas versus irregular hematomas

Hematomas were judged as regular in 62 (58.5%) patients and irregular in 44 (41.5%) patients by observer 1, while regular in 61 (57.5%) patients and irregular in 45 (42.5%) patients by observer 2. Ten patients whose hematomas were judged as regular by observer 1 were considered as irregular by observer 2. On the other hand, 8 patients whose hematomas were judged as irregular by observer 1 were considered as regular by observer 2. Linear weighted Kappa statistics showed a weighted kappa value of 0.632 with a confidence level from 0.483 to 0.782, suggestive of substantial agreement.

The differences between regular hematomas and irregular hematomas were listed in . The irregular group did not differ from regular group in gender (P = 1) and age (P = 0.92). Regarding the vital signs, the irregular group had a significantly higher diastolic pressure (P = 0.021) and higher pulse rate (P = 0.022) than the regular group. The laboratory data showed that the irregular group had a significantly higher WBC count (P = 0.003) than the regular group. With respect to the consciousness, the irregular group had a significantly lower GCS score than regular group (P<0.001). Taking the CT imaging features into consideration, the irregular group had a significantly larger hematoma size (P<0.001), significantly higher percentage of hematomas larger than 30 mL (P<0.001), and significantly higher ratio with intraventricular hemorrhage (P<0.001). The ICH score was significantly higher on irregular group than the regular group (P<0.001). The 30-day mortality was also significantly higher on irregular group than the regular group (P<0.006).

Table 2

Comparisons between regular and irregular intracerebral hematomas.

Hematoma shape Regular (n = 61) Irregular (n = 45) P value
Males 21 (34.4%) 16 (35.6%) 1
Age (years) 62.7±15.0 63.0±15.9 0.92
Age ≧ 80 years (%) 10 (16%) 9 (20%) 0.798
Vital signs Systolic blood pressure (mmHg) 168.4±31.0 180.9±40.5 0.088
Diastolic blood pressure (mmHg) 88.5±15.6 97.0±20.3 0.021
Pulse pressure (mmHg) 79.9±22.8 83.9±30.4 0.46
Pulse rate (beat per minute) 87.4±9.7 93.5±15.2 0.022
Respiratory rate (per minute) 19.7±1.3 19.8±2.4 0.81
Body temperature (°C) 36.8±0.4 36.8±0.2 0.70
Laboratory data Blood sugar (mg/dL) 143.3±51.4 158.1±63.5 0.25
WBC count (×103/µL) 9.6±3.7 12.2±4.3 0.003
Hemoglobin (mg/dL) 13.4±2.2 12.8±2.7 0.23
Platelet count (×105/µL) 2.46±0.94 2.37±1.09 0.67
INR 1.26±1.27 1.17±1.27 0.66
CT findings Hematoma size* (mL) 9.7±10.5 52.3±42.5 <0.001
Hematoma size*>30 mL 3 (4.9%) 27 (60%) <0.001
Intraventricular hemorrhage 26 69 <0.001
Infratentorial origin 9 (14.8%) 4 (8.9%) 0.551
GCS score 11.7±3.7 7.2±3.7 <0.001
ICH score 1.1±1.2 2.8±1.2 <0.001
30-day mortality rate (%) 4 (6.6%) 12 (26.7%) <0.006

Size of hematoma: ABC/2 formula versus CAVA

The overall hematoma size estimated by the ABC/2 formula (38.7±51.0 ml) was significantly higher than that measured by the CAVA (27.8±35.6 ml) (P<0.001). Linear regression analysis showed that the hematoma size (y) estimated by ABC/2 formula was positively correlated to the hematoma size (x) measured by CAVA characterized by the equation, y = 1.409x–0.431, with a R2 of 0.965 significantly (P<0.001). The size difference (y) between two methods was also positively correlated to the hematoma size (x) measured by CAVA characterized by the equation, y = 0.409x–0.434, with a R2 of 0.702 significantly (P<0.001) ().

Scatter plots of size estimated by ABC/2 formula and size difference versus size measured by CAVA of intracerebral hematomas.

GCS score

The overall GCS score was 9.8±4.3. Nineteen patients (17.9%) had a GCS score of 3 or 4, 45 patients (42.4%) had a GCS score ranging 5 to 12, while 42 patients (39.6%) had a GCS score ranging from 13 to 15. Patients with a GCS score of 3 to 4 had a significantly higher 30-day mortality (68.4%) than those with a GCS score of 5 to 12 (6.7%) and a GCS score of 13 to 15 (0%).

ICH Score

The relationship of 30-day mortality versus ICH score was shown on . There was a positive association between the 30-day mortality and ICH score, i.e., with a higher ICH score, the 30-day mortality was also higher, no matter the hematoma size was estimated by ABC/2 formula or measured by CAVA. In each ICH score, the 30-day mortality was of no significant difference between the ABC/2 group and CAVA group.

Bar chart of 30-day mortality versus ICH Score.

There is no apparent difference between the ABC/2 and CAVA methods regarding the 30-day mortality no matter in trend or in each ICH score.

Receiver operating characteristic (ROC) curves

Comparison of ROC curves in predicting the 30-day mortality by GCS, ICH scores, ICH size, and ICH shape was graphically demonstrated (). The predicting performances of the variables were summarized in . The variables of hematoma shape, hematoma size, ICH score, and GCS score all significantly predicted the 30-day mortality with the AUC of 0.692 (P = 0.0018), 0.715∼0.786 (P≤0.0008), 0.877∼0.882 (P<0.0001), and 0.912∼0.922 (P<0.0001), respectively. Pairwise comparisons of ROC curves, summarized in , showed significant differences between AUCs predicted by hematoma size measured by CAVA and hematoma size estimated by ABC/2 formula (P = 0.022), predicted by GCS score and hematoma size (P = 0.0145∼0.0048), predicted by ICH score and hematoma size (P = 0.0336∼0.0076), predicted by GCS score and hematoma shape (P = 0.0009), and predicted by ICH score and hematoma shape (P = 0.0012∼0.0076). The difference between AUCs predicted by ICH score in which the hematoma size was estimated by ABC/2 formula and AUCs predicted by ICH score in which the hematoma size was measured by CAVA was not statistically significant (P = 0.11). Likewise, the difference between AUCs predicted by ICH score and predicted by GCS score was also not statistically significant (P = 0.14∼0.24).

Comparison of ROC curves in predicting the 30-day mortality by GCS, ICH scores, ICH size, and ICH shape.

Table 3

Predictive performance of the variables.

Criterion AUC Sn (%) Sp (%) LR+ LR- Youden index P value
GCS score* >1 0.912 81.25 92.22 10.5 0.2 0.7347 <0.0001
ICH score (CAVA) >2 0.882 87.5 76.67 3.75 0.2 0.6417 <0.0001
ICH score (ABC/2) >2 0.877 87.5 74.44 3.42 0.2 0.6194 <0.0001
ICH size (CAVA)* >0 0.738 68.75 78.89 3.26 0.4 0.4764 0.0002
Platelet (/µL) ≤167000 0.722 53.33 89.77 5.21 0.5 0.4311 0.0023
ICH size (ABC/2)* >0 0.715 68.75 74.16 2.66 0.4 0.4291 0.0008
ICH shape >0 0.692 75 63.33 2.05 0.39 0.3833 0.0018
IVH* >0 0.644 68.75 60 1.72 0.5 0.2875 0.0275
WBC (/µL) >11900 0.568 53.33 69.32 1.74 0.67 0.2265 0.444
Infratentorial origin* >0 0.538 18.75 88.89 1.69 0.9 0.07639 0.4717

Table 4

Pairwise comparisons of ROC curves.

Pairwise comparison Difference between AUCs Standard error 95% CI Z statistic P-value
ICH size (ABC/2) versus ICH shape 0.0193 0.0598 −0.0979 to 0.136 0.323 0.7467
ICH size (CAVA) versus ICH shape 0.0474 0.0597 −0.0696 to 0.164 0.794 0.4272
GCS score versus ICH score (CAVA) 0.0277 0.0238 −0.0189 to 0.0744 1.166 0.2438
GCS score versus ICH score (ABC/2) 0.0362 0.025 −0.0128 to 0.0851 1.447 0.1478
ICH score (ABC/2) versus ICH score (CAVA) 0.00843 0.00528 −0.00192 to 0.0188 1.596 0.1104
ICH score (ABC/2) versus ICH size (CAVA) 0.133 0.0628 0.0103 to 0.257 2.124 0.0336
ICH score (CAVA) versus ICH size (CAVA) 0.142 0.0626 0.0192 to 0.265 2.266 0.0234
ICH size (CAVA) versus ICH size (ABC/2) 0.0281 0.0123 0.0040 to 0.052 2.289 0.0221
GCS score versus ICH size (CAVA) 0.17 0.0694 0.0336 to 0.306 2.444 0.0145
ICH score (ABC/2) versus ICH size (ABC/2) 0.162 0.0632 0.0377 to 0.285 2.557 0.0106
ICH score (CAVA) versus ICH size (ABC/2) 0.17 0.0637 0.0452 to 0.295 2.669 0.0076
GCS score versus ICH size (ABC/2) 0.198 0.0702 0.0602 to 0.335 2.818 0.0048
ICH score (ABC/2) versus ICH shape 0.181 0.0556 0.0718 to 0.290 3.251 0.0012
GCS score versus ICH shape 0.217 0.0651 0.0894 to 0.345 3.333 0.0009
ICH score (CAVA) versus ICH shape 0.189 0.0561 0.0792 to 0.299 3.372 0.0007

Discussion

ICH shape is getting increasing attention recently. Compared to the regular hematoma, the irregular hematoma has been related to a higher risk of hematoma growth [2], which in turns serves a predictor of poor outcome [3] and a determinant of mortality [13]. Nevertheless, whether the hematoma shape independently predicts the 30-mortality has not been verified yet. Our results show that the irregular hematoma has significantly larger hematoma size (52.3 mL versus 9.7 mL) (P<0.001) and higher ratio of hematoma size which is more than 30 mL (60% versus 4.9%) (P<0.001). In addition to hematoma size, the irregular hematoma is also associated with significantly higher ratio of IVH (69% versus 26%) (P<0.001), lower GCS score (7.2 versus 11.7) (P<0.001), and higher ICH score (2.8 versus 1.1) (P<0.001). The irregular hematoma has significantly higher 30-day mortality rate (26.7% versus 6.6%) than the regular hematoma (P<0.006). ROC analysis discloses that the hematoma shape significantly predicts the 30-day mortality with an AUC of 0.692 (P = 0.0018). These associations between hematoma shape and the hematoma size, IVH, GCS score, and ICH score may explain why the hematoma shape serves as an independent predictor of the 30-day mortality.

Although the hematoma size has been proposed as an independent predictor of mortality and used in ICH score for ICH in some researches [4], [8], [14]–[15], it is not considered as an independent predictor for risk stratification and is discarded from ICH score calculation by other studies due to the concern of potential imprecision of hematoma size estimated by the ABC/2 formula [11], [16]–[17]. The ABC/2 formula has been found to overestimate the hematoma size in some studies [7], [18] but to underestimate the hematoma size in other studies [19]. Our study showed that the ABC/2 formula significantly overestimates the hematoma size up to 39.2%, which is higher than those reported by Huttner et al. (8.5%) and by Wang et al (28.7%) [18]. Our results further disclose that the hematoma size overestimated by the ABC/2 formula is positively and linearly related to the hematoma size measured by CAVA significantly (). Using 30 mL as a criterion, the hematoma size estimated by the ABC/2 formula less accurately predicts the 30-day mortality (AUC  = 0.715) than the hematoma size measured by the CAVA (AUC  = 0.738) significantly (P = 0.02).

In predicting the 30-day mortality, the mean AUC of ICH scores in our study (0.882 using CAVA; 0.877 using ABC/2) are higher than Pengs’ study (0.72) [9], Steins’ study (0.736) [10], and Chuangs’ study (0.74) [11], consistent with Clarkes’ study (0.88) [20], and lower than Hemphrills’ study (0.92%) [8]. Our study further reveals that the ICH score predicts the 30-day mortality superior to the hematoma shape (AUC  = 0.692) and the hematoma size (AUC  = 0.715 by ABC/2 and  = 0.738 by CAVA) with significant differences of AUC (P = 0.034 to 0.008). The AUC of ICH score with the hematoma size estimated by ABC/2 is not different to the AUC of ICH score with the hematoma size measured by CAVA.

Our study has three limitations. First, we did not evaluate the functional outcome or quality of life in this study. Nevertheless, 30-day mortality remains an important outcome in ICH patients and easy to be examined by neuroradiologists. Second, we didn’t take surgical intervention into account in this study. According to a random trial performed by Auer et al, the mortality rate of patients who receive endoscopic aspiration of lobar intracerebral hemorrhage was significantly lower than those received medical treatment only [21]. Due to limited number of random trial, it is hard to get conclusion whether surgical intervention benefit ICH patients than medical treatment or not. Nevertheless, this important issue is beyond the scope of this study, in which only the initial conditions are taken into account. Third, our study recruited patients only from a single medical center in one country. The overall 30-day mortality rate (15.1%) of ICH in our study is consistent with those of other oriental population (15%∼20%) [8], [22] but is lower than in those of western countries (31.9%∼45%) [4], [6], [8], [14], [20], [22]–[24]. The difference of 30-day mortality rate between our study and the aforementioned western studies might come from racial difference, age difference, socioeconomic difference, et al. To eliminate the potential bias, a multi-national and multi-center study is suggested.

Conclusions

Our study shows that hematoma shape, hematoma size, ICH scores and GCS score all significantly predict the 30-day mortality in an increasing order of AUC. Although the ABC/2 formula significantly overestimates the hemorrhagic size than the CAVA method, the effect of overestimation of hematoma size by ABC/2 formula in predicting the 30-day mortality could be remedied by using ICH score and GCS score.

Supporting Information

Table S1

Original data and ICH score of patients with intracerebral hematomas.

(DOCX)

Funding Statement

The corresponding author (Chun-Jung Juan) is receiving financial support from National Science Council (NSC 101-2314-B-016-031-MY2), Taiwan, R.O.C. for participating WFNRS 2014, XXth Symposium Neuroradiologicum and presenting this work in part. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.

References

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Abdominal Hematoma – StatPearls – NCBI Bookshelf

Continuing Education Activity

A hematoma is a blood collection in an extravascular space and is named according to the location of the blood collection. Rectus sheath hematomas result from bleeding inside the vascular rectus muscle layer of the abdominal wall. This activity reviews the evaluation and management of rectus sheath hematomas and emphasizes the role of the interprofessional care team in recognizing and managing this condition.

Objectives:

  • Identify the location of the majority of rectus sheath hematomas.

  • Outline the pathophysiology of rectus sheath hematomas.

  • Describe some symptoms and signs that may be present in a patient with a rectus sheath hematoma.

  • Delineate the role of interprofessional team members in recognizing and managing rectus sheath hematomas to improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

A hematoma is a blood collection in an extravascular space. It results from bleeding from a vascular structure. Depending on the location of the blood collection, hematomas are named accordingly, e.g., intracranial hematoma[1], hemothorax[2], pelvic hematoma[3], and abdominal hematoma. Hematomas can collect in extravascular areas near bleeding vessels with space to accommodate this blood collection. An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma. This activity will be focused on rectus sheath hematoma or rectus hematoma. 

Rectus sheath hematoma is bleeding in the rectus sheath. It is a confined space where the blood collects, commonly in the form of localized hematoma. Inferior or superior epigastric arteries and veins or their branches and tributaries form the basis of the bleeding source. A rectus hematoma can occur spontaneously in certain categories of people. But, it usually follows an injury to the inferior or superior epigastric vessels or their perforating branches. While this condition does resolve on its own, sometimes the hematoma can be extensive and lead to hypovolemic shock [4][5][6].

Etiology

Rectus sheath hematomas result from bleeding of the epigastric vessels or their perforator branches in the rectus abdominis muscle sheath[3]. Although rarely life-threatening, they can be severe and lead to hemodynamic instability. However, in most cases, rectus hematoma is self-limiting and usually spontaneously resolves.

Like in other types of bleeding, the cause can be due to the bleeding tendency, anticoagulation, or injury to the vessels. Vascular injury may occur due to external abdominal trauma, trauma during surgery (iatrogenic), or intense contraction of the rectus muscles during activities associated with Valsalva maneuver, as in severe retching, vomiting, or straining [7][8]. In most cases, the hematoma is localized. But in people with excessive loose connective tissue, the hematoma can spread to above the umbilicus, the contralateral side, or become intraabdominal. Risk factors include the use of anticoagulant medications, advanced age, female gender, and intense physical activity. With the increased use of anticoagulation, the rates of rectus sheath hematoma appear to be on the rise.

Epidemiology

Rectus sheath hematomas are uncommon [9][10]. The exact incidence of rectus sheath hematoma is not known as the condition is often misdiagnosed or undiagnosed. Some studies report an incidence of 1.5% to 2% in hospitalized patients.

Overall, rectus sheath hematoma is more common in females than males. A higher female incidence has been linked to decreased muscle mass. While pregnancy is a risk factor in women, trauma and exercise seem to be the most common causes in men. Rectus sheath hematomas are more common on the right side, and the majority are located in the lower quadrant of the abdomen below the arcuate line. 

Pathophysiology

Rectus sheath hematoma is caused by rupture of an epigastric artery or one of its perforating branches. The vessel injury may be due to blunt or penetrating trauma, surgery, or strong contractions of the rectus muscle. Since the epigastric arteries run deep along the posterior rectus sheath, making a diagnosis during a physical exam is difficult, especially in patients who have obesity. The hematoma is usually posterior to the rectus muscle fibers, subcutaneous fat, and skin. Palpating a tender firm bulge is the most common physic exam finding. The fluctuation sign of a fluid collection is not usually possible to detect due to the deep location of the hematoma. The lower quadrants of the abdomen are usually involved because of the long epigastric branches and the lack of a tamponade effect from the loose connective tissues of the rectus sheath.

History and Physical

The typical presentation of a rectus sheath hematoma is abdominal pain and its associated symptoms like nausea and vomiting. The pain is often sudden in onset, sharp, and does not radiate. In extremely rare cases, the hematoma may be large and present with hypovolemia, tachycardia, and tachypnea. Physical exam usually reveals a palpable localized mass that is non-pulsatile. The Fothergill sign is a mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles. This suggests a rectus sheath hematoma and is useful to determine if the abdominal mass is within the abdominal wall or intraabdominal cavity. It is not a highly sensitive sign and is often inconclusive in individuals who are obese.

The clinician should obtain a thorough medical history to determine the presence of any risk factors like surgery, coughing, constipation, asthma, bronchitis, anticoagulation therapy, and use of oral anticoagulants and corticosteroids.

Evaluation

Ultrasound is the first test of choice to confirm a rectus sheath hematoma diagnosis after basic blood work, and coagulation profile are obtained. The hematoma appears as hypoechoic space in the posterior rectus sheath. Further information like the size and exact location of the hematoma can be obtained from the ultrasound study. If the ultrasound study is inconclusive, a CT scan is the next test. It can show more details about the location, size, and extension of the hematoma. When intravenous contrast is administered with the CT scan, active bleeding can be detected by the presence of the contrast in the form of blush in the hematoma if the bleeding is active.

Unless a contrast is visualized in the hematoma, the differential diagnosis of a fluid collection in the rectus sheath should not be ignored. If the diagnosis of hematoma is still in doubt after imaging, needle aspiration can be performed to differentiate a hematoma from an abscess. However, with needle aspiration, there is a risk of puncture the bladder, bowel, or a hernia.[11]

Evaluation of the hematoma should be part of the comprehensive evaluation of the patient’s condition. General assessment addressing the related factors and conditions causing the hematoma or as a complication of the hematoma is necessary for a proper evaluation[12]. Simultaneous treatment of the underlying condition and the possible or pending complications is mandatory for successful management. 

Treatment / Management

Treatment of rectus hematomas depends on the severity of symptoms, size, the stability of the hematoma, and the underlying pathology. The goal of the treatment is to relieve or minimize symptoms, prevent complications, and address the underlying condition. Proper patient’s condition assessment, volume replacement, and correction of any coagulation abnormalities are important initial measures that should be performed before considering more aggressive steps.

If the hematoma is enlarging and or causing significant blood loss, intervention should be taken to stop the bleeding. Interventional radiology localizing and embolizing the bleeding vessel is the appropriate first modality of treatment to use. In most cases, this is successful and sufficient to stop the bleeding, especially with the confined space and the pressure created that counteracts the flow of bleeding.

In a few cases of ongoing bleeding that is not amenable to radiologic intervention or if the service is not available, surgical control of the bleeding and evacuation of the hematoma is necessary. Controlling the bleeding is achieved by ligating the bleeding vessel (epigastric vessel) surgically.

In most cases, bleeding stops after enough pressure build-up inside the rectus sheath. The size of the developed hematoma varies according to the size and pressure of the bleeding vessel, expandability of the rectus space, and the presence and severity of coagulation abnormalities. Once the bleeding stops and the hematoma size stabilizes, treatment is usually directed on the relief of the symptoms. There is no urgency in evacuating the hematoma. In fact, maintaining the pressure inside the hematoma at the initial phase is important to prevent rebleeding. Large hematomas can be drained percutaneously after stabilization and recovery from the acute phase. Small hematomas can be left to be reabsorbed spontaneously to avoid unnecessary intervention.  

Patients with rectus sheath hematoma can be treated as outpatients as long as the hemodynamic status is stable and there is no change in the hematocrit. Patients on anticoagulation therapy should be admitted to ensure that the hematoma is not expanding.[7][13]

Differential Diagnosis

Conditions presenting with a mass:

Conditions presenting pain or acute abdomen:

  • Peptic ulcer disease

  • Bowel perforation

  • Tubo-ovarian abscess

  • Appendicitis

  • Cholecystitis

  • Urinary tract infection

  • Pancreatitis.

A comprehensive history, physical exam, and a low index of suspicion will usually identify the pathology, confirm the diagnosis and assist in the management planning.

Prognosis

Most cases of rectus hematomas are self-limited, non-life-threatening, and can be identified and treated successfully with minimal interventions. Even though fatalities have been reported, most of the fatalities have come to light during an autopsy. Rectus sheath hematoma mortality is higher in elderly individuals who are on oral anticoagulants. Pregnant women are at a higher risk for mortality. Anecdotal old reports reveal a mortality rate of 15% in the mother and nearly 50% in the fetus. However, it is important to know that these data were collected before the wide use of ultrasound and CT scans. Today, these imaging modalities can rapidly diagnose the condition.

Complications

The main consequence of undiagnosed or untreated rectus hematomas is pain. In addition to pain, severe bleeding is serious and can be life-threatening. Therefore severe bleeding should be promptly identified and aggressively treated. Another potential complication is abscess formation. As in any blood collection that is not drained, there is always a chance of superseding infection and the development of an abscess. Draining of abscess becomes mandatory when it develops.

Postoperative and Rehabilitation Care

Follow up and reassessment, including physical activities adjustment to prevent recurrent and further tissue damage. Patients should be advised to avoid indulging in heavy exercises. The decision to restart oral anticoagulation requires clinical judgment and balance between the indication of anticoagulation treatment and possible rebleeding in the rectus sheath.

Consultations

Rectus hematoma is a surgical condition. Once a patient has been diagnosed with a rectus sheath hematoma, surgical consultation should be made. Interventional radiology and hematology specialties may be needed depending on the severity and or the underlying condition.

Pearls and Other Issues

  • Rectus sheath hematoma is an uncommon disorder.

  • It can be confused with other abdominal wall pathologies like tumors or hernias.

  • Ultrasound or CT scan can assist in confirming the diagnosis.

  • Many patients are on oral anticoagulation therapy. They should be held if possible.

  • The condition is usually treated conservatively with pain control and supportive treatment.

  • In a few cases, arterial embolization or surgical intervention are required to stop the bleeding.

Enhancing Healthcare Team Outcomes

Abdominal wall hematoma can occur from a variety of causes. The patient often presents with abdominal pain, which can be mistaken for a number of abdominal pathologies; hence an interprofessional approach to management is necessary. Nurses should be aware of and familiar with abdominal hematomas as they can occur from repeated heparin or insulin injections; they can consult with the pharmacy team to ensure proper dosing and no drug interactions that contribute to the condition. The diagnosis can be difficult to confirm clinically. Imaging studies are usually necessary. Most abdominal hematomas resolve spontaneously over 4 to 6 weeks. Nowadays, mortality rates from abdominal wall hematomas are negligible because of the availability of imaging studies. Patients who recover usually have no residual sequelae. These outcomes are made possible, as described above, by interprofessional teamwork and collaboration/communication, contributing to positive patient outcomes. [Level 5]

References

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Takahashi M, Hotta K, Tamai K, Niwa Y, Egawa A, Takeuchi M. [Abdominal Oblique Muscle Hematoma after Ultrasound-guided Transverse Abdominis Plane Block]. Masui. 2016 Dec;65(12):1276-1278. [PubMed: 30379470]
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Queiroz RM, Filho FB. Spontaneous hematoma of the rectus sheath following percutaneous transluminal coronary angioplasty and stent placement. Pan Afr Med J. 2018;30:88. [PMC free article: PMC6191267] [PubMed: 30344872]
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Ueno T, Nakamura T, Hikichi H, Arai A, Suzuki C, Tomiyama M. Rectus Sheath Hematoma Following Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator for Cerebral Infarction: A Case Report. J Stroke Cerebrovasc Dis. 2018 Dec;27(12):e237-e238. [PubMed: 30122629]
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Mohammady M, Janani L, Akbari Sari A. Slow versus fast subcutaneous heparin injections for prevention of bruising and site pain intensity. Cochrane Database Syst Rev. 2017 Nov 01;11:CD008077. [PMC free article: PMC6486131] [PubMed: 29090459]
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Povar M, Lasala M, Ruiz A, Povar BJ. [Rectus sheath haematoma: experience in our centre]. An Sist Sanit Navar. 2017 Dec 29;40(3):361-369. [PubMed: 28937152]
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Wu JD, Huang WH, Qiu SQ, He LF, Guo CP, Zhang YQ, Zhang F, Zhang GJ. Breast reconstruction with single-pedicle TRAM flap in breast cancer patients with low midline abdominal scar. Sci Rep. 2016 Jul 13;6:29580. [PMC free article: PMC4942775] [PubMed: 27406872]
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Jareño-Collado R, Sánchez-Sánchez MM, Fraile-Gamo MP, García-Crespo N, Barba-Aragón S, Bermejo-García H, Sánchez-Izquierdo R, Sánchez-Muñoz EI, López-López A, Arias-Rivera S. Ecchymosis and/or haematoma formation after prophylactic administration of subcutaneous enoxaparin in the abdomen or arm of the critically ill patient. Enferm Intensiva (Engl Ed). 2018 Jan – Mar;29(1):4-13. [PubMed: 29326015]
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Shaydakov ME, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Operative Risk. [PubMed: 30335273]
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Pierro A, Cilla S, Modugno P, Centritto EM, De Filippo CM, Sallustio G. Spontaneous rectus sheath hematoma: The utility of CT angiography. Radiol Case Rep. 2018 Apr;13(2):328-332. [PMC free article: PMC6000050] [PubMed: 29904466]
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Hope WW, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 26, 2021. Incisional Hernia. [PubMed: 28613766]
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Shaydakov ME, Pastorino A, Tuma F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 4, 2021. Enterovesical Fistula. [PubMed: 30422531]

Intracranial hematoma – Diagnosis and treatment

Diagnosis

Diagnosing an intracranial hematoma can be difficult because people with a head injury can seem fine. However, doctors generally assume that bleeding inside the skull is the cause of progressive loss of consciousness after a head injury until proved otherwise.

Imaging techniques are the best ways to determine the position and size of a hematoma. These include:

  • CT scan. This uses a sophisticated X-ray machine linked to a computer to produce detailed images of your brain. You lie still on a movable table that’s guided into what looks like a large doughnut where the images are taken. CT is the most commonly used imaging scan to diagnose intracranial hematomas.
  • MRI scan. This is done using magnetic field and radio waves to make computerized images. During an MRI scan, you lie on a movable table that’s guided into a tube.
  • Angiogram. If there is concern about a possible aneurysm in the brain or other blood vessel problem, an angiogram might be necessary to provide more information. This test uses X-rays and a special dye to produce pictures of the blood flow in the blood vessels in the brain.

Treatment

Hematomas that are small and produce no signs or symptoms don’t need to be removed. However, signs and symptoms can appear or worsen days or weeks after the injury. As a result, you might have to be watched for neurological changes, have your intracranial pressure monitored and undergo repeated head CT scans.

If you take blood-thinning medication, such as warfarin (Coumadin, Jantoven), you may need therapy to reverse the effects of the medication. This will reduce the risk of further bleeding. Options for reversing blood thinners include administering vitamin K and fresh frozen plasma.

Surgery

Hematoma treatment often involves surgery. The type of surgery depends on the type of hematoma you have. Options include:

  • Surgical drainage. If the blood is localized and has transitioned from a solid clot to a liquid consistency, your doctor might create a small hole in your skull and use suction to remove the liquid.
  • Craniotomy. Large hematomas might require that a section of your skull be opened (craniotomy) to remove the blood.

Recovery

Recovery after an intracranial hematoma can take a long time, and you might not recover completely. The greatest period of recovery is up to three months after the injury, usually with lesser improvement after that. If you continue to have neurological problems after treatment, you might need occupational and physical therapy.

Clinical trials


Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Patience is important for coping with brain injuries. Adults will have the majority of their recovery during the first six months. Then you might have smaller, more-gradual improvements for up to two years after the hematoma.

To aid your recovery:

  • Get enough sleep at night, and rest in the daytime when you feel tired.
  • Ease back into your normal activities when you feel stronger.
  • Don’t participate in contact and recreational sports until you get your doctor’s OK.
  • Check with your doctor before you begin driving, playing sports, riding a bicycle or operating heavy machinery. Your reaction times likely will have slowed as a result of your brain injury.
  • Check with your doctor before taking medication.
  • Don’t drink alcohol until you’ve recovered fully. Alcohol may hinder recovery, and drinking too much can increase your risk of a second injury.
  • Write down things you have trouble recalling.
  • Talk with someone you trust before making important decisions.


June 13, 2020

Show references

  1. Traumatic brain injury: Hope through research. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-Through. Accessed March 23, 2017.
  2. Traumatic brain injury. Merck Manual Professional Version. http://www.merckmanuals.com/professional/injuries-poisoning/traumatic-brain-injury-tbi/traumatic-brain-injury. Accessed March 26, 2017.
  3. McBride W. Subdural hematoma in adults: Etiology, clinical features and diagnosis. https://www.uptodate.com/home. Accessed March 23, 2017.
  4. McBride W. Subdural hematoma in adults: Prognosis and management. https://www.uptodate.com/home. Accessed March 23, 2017.
  5. Karibe H, et al. Surgical management of traumatic acute subdural hematoma in adults: A review. Neurologia Medico-Chirurgica. 2014;54:887.
  6. McBride W. Intracranial epidural hematoma in adults. https://www.uptodate.com/home. Accessed March 23, 2017.
  7. Naidech A. Intracranial hemorrhage. American Journal of Respiratory and Critical Care Medicine. 2011;184:998.
  8. Intracranial hematomas. Merck Manual Professional Version. https://www.merckmanuals.com/home/injuries-and-poisoning/head-injuries/intracranial-hematomas. Accessed April 14, 2020.
  9. Bydon M (expert opinion). Mayo Clinic. May 26, 2020.

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Intracranial hematoma – Symptoms and causes

Overview

An intracranial hematoma is a collection of blood within the skull. It’s most commonly caused by the rupture of a blood vessel within the brain or from trauma such as a car accident or fall. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain.

Some head injuries, such as one that causes only a brief lapse of consciousness, can be minor. However, an intracranial hematoma is potentially life-threatening. It usually requires immediate treatment, which might include surgery to remove the blood.

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Symptoms

You might develop signs and symptoms of an intracranial hematoma right after an injury to your head, or they may take weeks or longer to appear. You might seem fine after a head injury, a period called the lucid interval.

However, with time, pressure on your brain increases, producing some or all of the following signs and symptoms:

  • Increasing headache
  • Vomiting
  • Drowsiness and progressive loss of consciousness
  • Dizziness
  • Confusion
  • Unequal pupil size
  • Slurred speech
  • Loss of movement (paralysis) on the opposite side of the body from the head injury

As more blood fills your brain or the narrow space between your brain and skull, other signs and symptoms may become apparent, such as:

  • Lethargy
  • Seizures
  • Unconsciousness

When to see a doctor

An intracranial hematoma can be life-threatening, requiring emergency treatment.

Seek immediate medical attention after a blow to the head if you:

  • Lose consciousness
  • Have a persistent headache
  • Experience vomiting, weakness, blurred vision, unsteadiness

If signs and symptoms aren’t immediately evident after a blow to the head, watch for physical, mental and emotional changes. For example, if someone seems fine after a blow to the head and can talk but later becomes unconscious, seek immediate medical care.

Also, even if you feel fine, ask someone to keep an eye on you. Memory loss after a blow to your head can make you forget about the blow. Someone you tell might be more likely to recognize the warning signs and get you medical attention.

Causes

A head injury is the most common cause of bleeding within the skull. A head injury may result from motor vehicle or bicycle accidents, falls, assaults, and sports injuries.

If you’re an older adult, even mild head trauma can cause a hematoma. This is especially true if you’re taking a blood-thinning medication or an anti-platelet drug, such as aspirin.

You can have a serious injury even if there’s no open wound, bruise or other obvious damage.

There are three categories of hematoma — subdural hematoma, epidural hematoma and intracerebral (intraparenchymal) hematoma.

Subdural hematoma

This occurs when blood vessels — usually veins — rupture between your brain and the outermost of three membrane layers that cover your brain (dura mater). The leaking blood forms a hematoma that presses on the brain tissue. An enlarging hematoma can cause gradual loss of consciousness and possibly death.

The three types of subdural hematomas are:

  • Acute. This most dangerous type is generally caused by a severe head injury, and signs and symptoms usually appear immediately.
  • Subacute. Signs and symptoms take time to develop, sometimes days or weeks after your injury.
  • Chronic. The result of less severe head injuries, this type of hematoma can cause slow bleeding, and symptoms can take weeks and even months to appear. You might not recall injuring your head. For example, bumping your head while getting into the car can cause bleeding, especially if you’re on blood-thinning medication.

All three types require medical attention as soon as signs and symptoms appear so that permanent brain damage can be prevented.

The risk of subdural hematoma increases as you age. The risk is also greater for people who:

  • Take aspirin or other blood-thinning medication daily
  • Misuse alcohol

Epidural hematoma

Also called an extradural hematoma, this type occurs when a blood vessel — usually an artery — ruptures between the outer surface of the dura mater and the skull. Blood then leaks between the dura mater and the skull to form a mass that presses on brain tissue. The most common cause of an epidural hematoma is trauma.

Some people with this type of injury remain conscious, but most become drowsy or go into a coma from the moment of trauma. An epidural hematoma that affects an artery in your brain can be deadly without prompt treatment.

Intracerebral (intraparenchymal) hematoma

This type of hematoma, also known as intraparenchymal hematoma, occurs when blood pools in the tissues of the brain. There are many causes, including trauma, rupture of a bulging blood vessel (aneurysm), poorly connected arteries and veins from birth, high blood pressure, and tumors. Diseases can cause spontaneous leakage of blood into the brain. A head trauma can result in multiple severe intracerebral hematomas.

Prevention

To prevent or minimize head injury:

  • Wear a helmet and make sure your kids wear helmets. Wear an appropriate and properly fitted helmet when playing contact sports, bicycling, motorcycling, skiing, horseback riding, skating, skateboarding, snowboarding or doing any activity that could result in head injury.
  • Buckle your seat belt and make sure your kids are buckled in. Do so every time you drive or ride in a motor vehicle.
  • Protect young children. Always use properly fitted car seats, pad countertops and edges of tables, block stairways, tether heavy furniture or appliances to the wall to prevent tipping, and keep children from climbing on unsafe or unsteady objects.

Subdural Hematoma: Types, Symptoms Treatments, Prevention

Overview

A subdural hematoma is a type of brain bleed. Blood leaks out of a blood vessel into the space below the outermost membrane of the brain — the dura mater.

What is subdural hematoma?

A subdural hematoma is a type of bleed inside your head. More precisely, it is a type of bleed that occurs within the skull of head but outside the actual brain tissue. The brain has three membranes layers or coverings (called meninges) that lay between the bony skull and the actual brain tissue. The purpose of the meninges is to cover and protect the brain.

If you have a subdural hematoma, you have experienced a tear in a blood vessel, most commonly a vein, and blood is leaking out of the torn vessel into the space below the dura mater membrane layer. This space is called the subdural space because it is below the dura. Bleeding into this space is called a subdural hemorrhage.

Other names for subdural hematoma are subdural hemorrhage or intracranial hematoma. More broadly, it is also a type of traumatic brain injury (TBI).

How common are subdural hematomas?

Subdural hematomas occur in up to 25% of people with head injuries.

Are subdural hematomas serious?

Yes, a subdural hematoma can be a serious event. Occasionally, the bleed is slow and the body is able to absorb the pooled blood. However, if the hematoma is severe, the buildup of blood can cause pressure on the brain. This pressure can lead to breathing problems, paralysis and death if not treated.

Because you don’t immediately know how severe a brain bleed is until further testing, all blows to the head should be considered a serious event. If you hit your head, get checked out at a hospital.

Are there different types of subdural hematomas?

Yes. Doctors sort subdural hematomas by how fast they develop, how much bleeding occurs, and how much damage the bleeding causes. The types of subdural hematoma are:

  • Acute: This is the most dangerous type of subdural hematoma. Symptoms are severe and appear right after a head injury, often within minutes to hours. Pressure on the brain increases quickly as the blood pools. If not diagnosed and treated quickly, you could lose consciousness, become paralyzed or even die.
  • Subacute: Symptoms usually appear hours to days or even weeks after the head injury. A subacute subdural hematoma can occur with a concussion.
  • Chronic: This type of hematoma is more common in older people. Bleeding occurs slowly and symptoms may not appear for weeks or months. Even minor head injuries can cause chronic subdural hematomas. Due to the delay in developing symptoms, an older person may not even recall how their head injury happened. Also, the changes can be so subtle and occur so slowly that symptoms may not be noticed by the older person or their friends or family.

Are some people more likely to get a subdural hematoma?

Although anyone can get a subdural hematoma from an accidental head injury, certain groups of people are at higher risk. Subdural hematomas are more common in:

  • Older adults: As we age, our brains shrinks within our skull and the space between the skull and brain widens. This causes the tiny veins in the membranes between the skull and the brain to stretch. These thinned, stretched veins are more likely to tear in the event of even a minor head injury, such as a fall out of a chair.
  • Athletes who play contact sports: Football players and others who play high-impact sports and who might take a blow to the head have an increased risk of a hematoma.
  • People who take blood thinners: Blood thinners slow down the clotting process or prevent blood from clotting at all. If blood doesn’t clot, bleeding can be severe and long-lasting, even after a relatively minor injury.
  • Hemophiliacs: Hemophilia is an inherited bleeding disorder that prevents blood from clotting. People with hemophilia have a higher risk of uncontrolled bleeding after an injury.
  • Alcoholics and people who abuse alcohol: Drinking too much alcohol causes liver damage over time. Damaged livers can’t produce enough of the proteins that help the blood to clot, which increases the risk of uncontrolled bleeding.
  • Babies: Babies don’t have strong neck muscles to protect themselves from trauma to the head. When someone abuses a baby by shaking him or her, the baby can develop a subdural hematoma. This type of injury is called shaken baby syndrome.

Symptoms and Causes

How do subdural hematomas happen?

Head injuries cause most subdural hematomas. If you fall and hit your head or take a blow to the head in a car or bike accident, a sporting activity or have another type of head trauma, you are at risk for developing a subdural hematoma.

What are the symptoms of subdural hematoma?

Because a subdural hematoma is a type of traumatic brain injury (TBI), they share many symptoms. Symptoms of a subdural hematoma may appear immediately following trauma to the head, or they may develop over time – even weeks to months.

Signs and symptoms of a subdural hematoma include:

  • Headache that doesn’t go away. (Headache is usually severe in the case of acute subdural hematoma.)
  • Confusion and drowsiness.
  • Nausea and vomiting.
  • Slurred speech and changes in vision.
  • Dizziness, loss of balance, difficulty walking.
  • Weakness on one side of the body.
  • Memory loss, disorientation, and personality changes, especially in older adults with chronic subdural hematoma.
  • Enlarged head in babies, whose soft skulls can enlarge as blood collects.

As bleeding continues and the pressure in the brain increases, symptoms can get worse. Symptoms, at this point, include:

  • Paralysis.
  • Seizures.
  • Breathing problems.
  • Loss of consciousness and coma.

Sometimes people have no symptoms immediately following a head injury. This is called a lucid interval. They develop symptoms days later. Also, it’s important to know that subdural hematomas that develop more slowly (the chronic type) might be mistaken for other conditions, such as a brain tumor or stroke.

Special note about head injury and symptoms in seniors: Some of the symptoms of subdural hematoma in older people, like memory loss, confusion, and personality changes, could be mistaken for dementia. The older person may not remember hitting their head. Sometimes, people forget because they are disoriented. Other times, the injury was minor and may have occurred weeks before symptoms appeared. They should still see their healthcare provider for evaluation.

Diagnosis and Tests

How are subdural hematomas diagnosed?

First, your healthcare provider will do a thorough physical and neurological exam. Your healthcare provider will ask you about your head injury (when and how it occurred, review your symptoms and other medical problems, review medications you are taking and ask about other lifestyle habits). The neurology exam will include blood pressure checks, vision testing, balance and strength testing, as well as reflex tests and a memory check.

If your healthcare provider thinks you may have a subdural hematoma, they will order a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of your head. These imaging tests allow healthcare providers to see clear pictures of the brain and determine the location and amount of bleeding or other head and neck injuries.

Management and Treatment

What are the treatments for subdural hematoma?

Healthcare providers treat larger hematomas with decompression surgery. A surgeon drills one or more holes in the skull to drain the blood. Draining the blood relieves the pressure the blood buildup causes on the brain. Additional surgery may be needed to remove large or thick blood clots if present. Usually, healthcare providers leave a drain in place for several days following surgery to allow the blood to continue draining.

Sometimes hematomas cause few or no symptoms and are small enough that they don’t require surgical treatment. Bed rest, medications and observation may be all that is needed. The body can absorb the small amount of blood over time, usually a few months. Your healthcare providers may order regular imaging tests (such as an MRI) to monitor the hematoma and make sure it is healing.

What are the side effects of subdural hematoma treatment?

Side effects from decompression surgery include an increased risk of bleeding, infection and blood clots. Your healthcare providers will monitor you closely after surgery.

What are the complications of having a subdural hematoma?

Without treatment, large hematomas can lead to coma and death. Other complications include:

  • Brain herniation: Increased pressure can squeeze and push brain tissue so it moves from its normal position. A brain herniation often leads to death.
  • Repeated bleeding: Older adults who are recovering from a hematoma have a higher risk of another hemorrhage. Older brains don’t recover as quickly as younger brains. Also, as we age, our brains shrink and the space between the skull and brain widens. This further stretches the tiny thin veins between the outer membrane layers of the brain and skull and makes the older brain more vulnerable to future bleeding if another head injuries occur.
  • Seizures: Seizures may develop even after a hematoma has been treated.

Prevention

How can you prevent a subdural hematoma?

Although it may not be possible to prevent a hematoma as a result of an accident, you can reduce your risk by:

  • Protecting your head: Use your seatbelt and always wear a helmet when riding a bike or a motorcycle. If you play high-impact or contact sports, always wear a helmet. Use safety gear if you work off the ground or at a job with a high risk of head injury.
  • Resting after a head injury: If you’ve had a concussion, rest and allow your brain time to recover. Your healthcare provier will tell you how long to rest before returning to work or previous activities. Remember, a chronic subdural hematoma may not show symptoms for days, weeks and even months.
  • Removing tripping hazards from your home – especially if you are elderly. Get rid of throw rugs; make sure electrical cords are tucked out of the way; add handrails to all stairs; add lights to stairways, hallways and dark areas; and position furniture so you always have something to hold on to as you walk through your home. Use a cane or walker if you walking is unstable.
  • Having your vision checked regularly to prevent falls and accidents.
  • Having your healthcare provider or pharmacist do a medication review. These professionals can check the side effects of your medications to make sure they don’t cause dizziness or loss of balance. If they do, doses can be changed or a different drug may be able to be prescribed.
  • Drinking responsibly: Excessive alcohol consumption makes your brain more likely to bleed when injured. Avoid drinking more than two alcoholic beverages per day.
  • Being careful when taking blood thinners: Even minor head injuries can cause a subdural hematoma in people who take blood thinners. Talk to your healthcare provider about needed precautions if you are on these medications. Examples include aspirin, warfarin, heparin and newer blood thinners like dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixiban (Eliquis®) and edoxaban (Savaysa®).

Outlook / Prognosis

What can I expect if I have a subdural hematoma?

If you have a subdural hematoma, your prognosis depends on your age, the severity of your head injury and how quickly you received treatment. About 50% of people with large acute hematomas survive, though permanent brain damage often occurs as a result of the injury. Younger people have a higher chance of survival than older adults.

People with chronic subdural hematomas usually have the best prognosis, especially if they have few or no symptoms and remained awake and alert after the head injury.

Older adults have an increased risk of developing another bleed (hemorrhage) after recovering from a chronic subdural hematoma. This is because older brains cannot re-expand and fill the space where the blood was, leaving them more vulnerable to future brain bleeds with even minor head injuries.

When should I get emergency medical assistance if I’ve had a head injury?

A subdural hematoma is always a risk after a head injury. If you or someone you know has any of the following symptoms after a head injury, call 911 or seek medical attention immediately.

  • Loss of consciousness (friend or witness needs to call 911).
  • Slurred speech.
  • Confusion.
  • Nausea or vomiting.
  • Change in alertness/drowsiness.
  • Balance/walking problems.
  • Double vision.
  • Weakness or numbness in any part of the body.
  • Seizures.
  • Severe headache.

People at increased risk of a subdural hematoma – even though the head injury appears minor – should also get immediate medical attention. These people include:

  • The elderly.
  • People who take blood-thinning drugs or have diseases that make clotting difficult (like hemophilia, von Willebrand disease).
  • Heavy drinkers of alcohol.

Subdural hematomas can be life-threatening. If you have a head injury, get immediate medical attention. Don’t wait to “see if symptoms develop.” It’s better to be safe, than sorry.

Subdural haematoma – Treatment – NHS

Surgery is recommended for most subdural haematomas. Very small subdural haematomas may be carefully monitored first to see if they heal without having an operation.

If surgery is recommended, it’ll be carried out by a neurosurgeon (an expert in surgery of the brain and nervous system).

There are 2 widely used surgical techniques to treat subdural haematomas:

  • craniotomy – a section of the skull is temporarily removed so the surgeon can access and remove the haematoma
  • burr holes – a small hole is drilled into the skull and a tube is inserted through the hole to help drain the haematoma

Craniotomy

A craniotomy is the main treatment for subdural haematomas that develop soon after a severe head injury (acute subdural haematomas).

During the procedure, the surgeon creates a temporary flap in the skull. The haematoma is gently removed using suction and irrigation, where it’s washed away with fluid.

After the procedure, the section of skull is put back in place and secured using metal plates or screws.

This is usually performed under a general anaesthetic, which means you’ll be asleep while it’s carried out.

Burr holes

Burr hole surgery is the main treatment for subdural haematomas that develop a few days or weeks after a minor head injury (chronic subdural haematomas).

During the procedure, one or more small holes are drilled in the skull and a flexible rubber tube is inserted to drain the haematoma.

Sometimes the tube may be left in place for a few days afterwards to drain away any blood and reduce the chances of the haematoma coming back.

Burr hole surgery is often carried out under general anaesthetic, but is sometimes done under local anaesthetic.

This means you remain awake during the procedure, but the scalp is numbed so you do not feel any pain.

Risks of surgery

Like all operations, surgery for a subdural haematoma carries a risk of complications. Most of these complications are uncommon, but they can be serious.

Problems that can occur after subdural haematoma surgery include:

There’s also a chance that not all of the haematoma can be removed and that some of the symptoms you had before surgery continue. These may get better over time or they may be permanent.

In some cases, the haematoma can come back during the days or weeks after surgery. If this happens, further surgery may be needed to drain it again.

Recovering from surgery

If surgery goes well and you do not have any complications, you may be well enough to leave hospital after a few days.

If you do develop complications, it may be several weeks before you’re able to go home.

If you have persistent problems after surgery, such as memory problems or weakness in your limbs, you may need further treatment to help you gradually return to your normal activities.

The length of time it takes to recover from a subdural haematoma will vary from person to person.

Some people will feel a lot better after a few weeks, while others may never make a full recovery.

Read more about recovering from a subdural haematoma.

Page last reviewed: 19 August 2021
Next review due: 19 August 2024

Subdural Hematoma: Symptoms, Causes, and Treatments

What Is a Subdural Hematoma?

A subdural hematoma is a collection of blood outside the brain. They’re usually caused by serious head injuries. Bleeding and added pressure on the brain from a subdural hematoma can be life-threatening. Some stop and go away suddenly; others need surgical drainage.

In a subdural hematoma, blood collects between the layers of tissue that surround the brain. The outermost layer is called the dura. In a subdural hematoma, bleeding occurs between the dura and the next layer, the arachnoid.

The bleeding is under the skull and outside the brain, not in the brain itself. As blood pools, however, it puts more pressure on the brain. The pressure on the brain causes symptoms. If pressure inside the skull rises to a very high level, a subdural hematoma can lead to unconsciousness and death.

Subdural Hematoma Symptoms

Symptoms of subdural hematoma depend mostly on the rate of bleeding:

  • In head injuries with sudden, serious bleeding causing a subdural hematoma, a person may pass out right away or even go into a coma.
  • A person may appear normal for days after a head injury, but slowly become confused and then pass out several days later. This results from a slower rate of bleeding, causing a slowly enlarging subdural hematoma.
  • In very slow-growing subdural hematomas, there may be no noticeable symptoms for more than 2 weeks after the bleeding starts. 

Symptoms of subdural hematoma include:

The symptoms you have depends on a few things. Besides the size of the subdural hematoma, your age and other medical conditions can affect how your body responds to. Slow-growing subdural hematomas are more common in older people. They can bring on subtle personality changes and apathy.

Subdural Hematoma Causes

Subdural hematoma is usually caused by a head injury, such as from a fall, motor vehicle collision, or an assault. The sudden blow to the head tears blood vessels that run along the surface of the brain. This is referred to as an acute subdural hematoma.

People with a bleeding disorder and people who take blood thinners are more likely to develop a subdural hematoma. A relatively minor head injury can cause a subdural hematoma in people with a bleeding tendency.

In a chronic subdural hematoma, small veins on the outer surface of the brain may tear, causing bleeding in the subdural space. Symptoms may not be apparent for several days or weeks. 

Elderly people are at higher risk for chronic subdural hematoma because brain shrinkage causes these tiny veins to be more stretched and more vulnerable to tearing.

Subdural Hematoma Diagnosis

People who get medical attention after a head injury often undergo head imaging, usually with computed tomography (CT scan) or magnetic resonance imaging (MRI scan). These tests create images of the interior of the skull, usually detecting any subdural hematoma present. MRI is slightly superior to CT in detecting subdural hematoma, but CT is faster and more readily available.

Rarely, angiography may be used to diagnose subdural hematoma. During angiography (angiogram), a catheter is inserted through an artery in the groin and threaded into the arteries of the neck and brain. Special dye is then injected, and an X-ray screen shows blood flow through the arteries and veins.

Subdural Hematoma Treatment

Treatment of subdural hematomas depends on their severity. Treatment can range from watchful waiting to brain surgery.

In small subdural hematomas with mild symptoms, doctors may recommend no specific treatment other than observation. Repeated head imaging tests are often performed to monitor whether the subdural hematoma is improving.

More severe or dangerous subdural hematomas require surgery to reduce the pressure on the brain. Surgeons can use various techniques to treat subdural hematomas:

  • Burr hole trephination. A hole is drilled in the skull over the area of the subdural hematoma, and the blood is suctioned out through the hole.
  • Craniotomy. A larger section of the skull is removed, to allow better access to the subdural hematoma and reduce pressure. The removed skull is replaced shortly after the procedure.
  • Craniectomy. A section of the skull is removed for an extended period of time, to allow the injured brain to expand and swell without permanent damage. Craniectomy is not often used to treat subdural hematoma.

People with severe subdural hematomas are often seriously ill, requiring machine-supported breathing and other forms of life support.

If a person has a bleeding problem or is taking blood thinners, measures should be taken to improve blood clotting. This may include giving medicines or blood products, and reversal of any blood thinners, when possible. Other medications to help reduce swelling or pressure in the brain or control seizures may also be used.

Subdural Hematoma Complications

Some subdural hematomas can bring on serious complications, including coma or even death. This can happen if the hematoma is not treated, or even sometimes after treatment. Possible complications include:

  • Brain herniation. Pressure in your brain can move tissue away from where it’s supposed to be. This can lead to death.
  • More bleeding events. If you’re older, you’re at a high risk of another hemorrhage as you recover from the first one, especially if you have a head injury.
  • Seizures. You may have seizures, even if you’ve treated your hematoma.

Subdural Hematoma Outlook

Your health outlook after your subdural hematoma depends on how old you are, how severe your head injury was, and how quickly you got treatment. The younger you are, the higher your chance of survival. 

Your prognosis is best if your subdural hematomas are chronic, you deal with few symptoms, and you didn’t lose consciousness after your head injury. 

Older adults are at the highest risk of another brain bleed after a subdural hematoma. Older brains don’t expand and fill the space left after a hematoma. With more space between the brain and skull, your chance of bleeding goes up, even with a minor injury to the head.  

Hematoma lancing: price, reviews | Clinic Family Doctor

A hematoma is an accumulation of blood in tissues as a result of bleeding. Usually, hematomas occur as a result of trauma, with a violation of the integrity of the vessels. By location, they are subcutaneous, intermuscular, subfascial, etc. Depending on the size, limited and diffuse hematomas are distinguished.

Usually, opening the hematoma is not required for minor damage and limited hemorrhage.However, in some cases, this is the only effective method of treatment and relief of the condition.

Symptoms and manifestations

Superficial and intramuscular hematomas are accompanied by pain. At the site of injury, the tissue swells, the color of the skin can be from dark red to blue and yellowish green. Sometimes a hematoma becomes the cause of a malfunction of muscles or organs, a local increase in temperature.

Intracranial hematomas require immediate medical attention.They are accompanied by a sharp increasing pain, nausea, fainting.

Peculiarities of treatment

Small hematomas can be treated conservatively. The first step is to apply a cold compress and a pressure bandage. For severe pain, your doctor will prescribe pain relievers. As you recover, physical therapy can be used to speed up the resolution of the bleeding.

If a hematoma occurs against the background of a crack or fracture, the doctor will take measures to prevent complications when applying a plaster cast / splint.

Extensive, deep or complicated hematomas require intervention. Opening of the hematoma is carried out by the doctor after palpation, assessment of the size and condition of the tissues.

Puncture is performed if the blood is in a liquid state. The puncture site is treated with an antiseptic, then the doctor pumps out the contents with a needle. The doctor gently presses the surrounding tissue to facilitate the removal of blood. Drugs can be injected into the cavity to accelerate healing and prevent complications.The procedure is completed by applying a pressure bandage. For large, deep hematomas, a series of punctures may be necessary.

An autopsy is carried out for chronic injuries – 4-5 days after hemorrhage. The incision is made at the bottom or in the center of the hematoma. The blood clots are removed carefully so as not to provoke re-bleeding. The cavity is washed with antiseptics. Sometimes drainage of the hematoma is required – the hole is left open or only partially sutured. Such a measure is necessary to ensure the outflow of blood and in cases where infection and accumulation of purulent contents have occurred.If drainage is not required and the incision is large, sutures are applied.

Surgeons of the Family Doctor clinic are successfully engaged in conservative and surgical treatment of hematomas. We offer high quality medical care. We use only certified drugs, high-quality materials, reliable equipment and tools in our work.

To make an appointment with a surgeon, call the unified contact center in Moscow +7 (495) 775 75 66, use the online appointment service or contact the clinic’s registry.

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90,000 “Hematoma the size of a mouth”: a girl was bitten by dogs in Saratov | In Russia | 10/07/2021

The footage from the scene shows how a five-year-old girl approaches the playground and immediately runs away screaming. A flock of stray dogs is in pursuit of her. The dogs are driven away by the adults. The girl bursts into tears, the dogs managed to bite her hard.

“We had blood, now there is a small hematoma the size of a dog’s mouth, things have been bitten,” – said the mother of the victim, Evgenia Tsareva.

Evgeniya took her daughter to the hospital, then called the local administration. The woman wanted to tell what happened, and at the same time find out who is responsible for capturing stray animals. However, she was told that the administration did not deal with these issues, and hung up.

Later, representatives of the administration nevertheless went to the place, and then reported that they had not found any flock. The locals know why. Soon after the dogs attacked the child, someone poisoned all the yard dogs.

Residents saw that some edible pieces were scattered, animals could pick them up or they could be force-fed.

According to the volunteers, the dogs were fed, sterilized, vaccinated and had veterinary passports. They never complained about these dogs, they did not show aggression and guarded the yard from strangers.

“Children set fire to a burning stick and poked at the dogs, the dogs did not show any aggression. They just ran away from them, time passed, they also played together.There was no such thing that dogs rushed “, – says a local resident.

Residents are determined to punish the poisoners at all costs. Evgenia Tsareva, the mother of the bitten girl, just shrugs her shoulders and assures that she has nothing to do with it.

“I was informed that there were people there, that someone was harassing them, but we are always at home after this incident,” says the girl’s mother.

Angelina’s wounds have already healed. But she still prefers to play at home, and not on the playground.Now the girl is very afraid of dogs. And the girl’s mother fears that the attack could be repeated. After all, the townspeople constantly complain about packs of stray dogs.

“If a homeless animal has bitten someone, then the responsibility lies with the local authorities, the administration is obliged to compensate for the fine, moral damage, compensation for treatment costs at the expense of the treasury” , – explained the lawyer Igor Kimm.

Investigators opened a criminal case on the fact of negligence of the city administration.But the volunteers say that no one is looking for animal poisoners, except for them.

prices for breast areola correction at the MEDSI clinic in St. Petersburg.

When should breast and nipple areola surgery be performed?

Various defects of the mammary glands can be both congenital and acquired (after breastfeeding or exposure to traumatic factors).

Areola of the breast and nipples change when:

  • Wearing the wrong bra size
  • The appearance of scars
  • Abscesses and mastitis
  • Cancer
  • Breast prolapse with age
  • Insufficient functioning of the endocrine glands

Special interventions allow women and men to eliminate existing defects as soon as possible.

As a rule, operations are performed when:

  • Asymmetrical or irregular nipples
  • Stretched areoles
  • Excessively protruding or inverted nipples
  • Damage to the nipple-areola complex after plastic surgery or trauma

An indication for intervention can be not only the elimination of an aesthetic defect, but also difficulties in breastfeeding.

Nipple correction options

There are several types of interventions today. One of the main factors in choosing the appropriate option for women is the planned breastfeeding. The wishes of the patient and his individual characteristics are also taken into account.

Correction of the shape of the nipple and its size can be carried out:

  • With preservation of patency of the milk ducts . Such an intervention is carried out using special modern microscopes.They allow precise tissue removal without damaging the ducts. During the operation, the doctor makes a small incision and removes the excess connective tissue
  • With violation of the integrity of the milk ducts . With this intervention, the nipple is dissected to the very base in the middle. In this case, not only the connective tissue is cut off, but also the lactiferous ducts. Additionally, the nipple is fixed with sutures. This allows him to maintain his position. When the inverted nipple correction is completed, its halves are sutured together

Other operations are also in progress.A popular type of work is to reduce long or thick nipples.

Important! After such an intervention, the ability to breastfeed is almost always lost.

Two methods are used to correct the length of the nipples:

  • Removal of the upper part with suturing of the remaining
  • Removal of the entire nipple, keeping only the apex

Correction of the shape of the areola and its size is a procedure that can also be performed in various ways.Often, this operation is combined with breast augmentation, mastopexy (breast removal), and a lift.

If reduction of the areola is required, a quick procedure is done (usually under sedation or local anesthesia). The operation usually takes only 40-60 minutes. The surgeon makes circular incisions (along the areola and along the smaller diameter). The skin between them is excised. A small scar is located along the edge and is almost invisible. The intervention does not affect the lactiferous ducts.Thanks to this, the patient will be able to breastfeed in the near future.

With an increase in diameter, an even simpler procedure is carried out. It is commonly referred to as “micropigmentation”. In terms of technique, the procedure resembles permanent make-up.

Micropigmentation is carried out with the aim of making the areoles more expressive, matching them in color with the scars on the surface, compensating for the size, creating the appearance of the nipple if the mammary gland was reconstituted from the surrounding tissues after its removal.The procedure is performed under local anesthesia for 30-40 minutes. The final result can be assessed in 4-6 weeks.

General contraindications

Surgeries to correct inverted nipples and other interventions are not performed:

  • During lactation and within 6 months after its completion
  • With decompensated diabetes mellitus
  • For oncological diseases
  • In case of blood clotting disorders
  • For cysts and other seals in the affected area
  • With a tendency to develop keloid and hypertrophic scars
  • For mental illness

The operation should be postponed for acute pathologies (including infectious ones) and exacerbation of chronic diseases.

Diagnostics before intervention

Correction of the nipples and areolas can be performed after the patient has undergone a complete examination. This allows you to identify all contraindications and postpone the procedure or refuse it.

Diagnostics before correction includes:

  • Blood tests (general and biochemical, for hepatitis B and C, HIV, Wasserman reaction)
  • Delivery of urine tests
  • ECG
  • Ultrasound of the mammary glands or mammography

Also, the patient should obtain an opinion on admission to the intervention from a therapist, surgeon and anesthesiologist.

How is the intervention going?

If only an operation to correct the areola and nipple is performed (without breast augmentation), local anesthesia (in some cases with sedation) is sufficient. In some situations, intravenous anesthesia is used. In the first case, the patient can go home immediately after the intervention. If general anesthesia was used, hospitalization is required. The patient spends 1-3 days in the hospital. The duration of the operation usually does not exceed 60-90 minutes.

The peculiarities of the intervention depend on the technique chosen by the surgeon. Typically, surgery includes:

  • Putting the patient into anesthesia or drug sleep
  • Execution of cuts
  • Tissue excision
  • Stitching
  • Removing a patient from anesthesia or sedation

The operating surgeon will tell you about all the features of the intervention in advance.He will also answer your questions.

Recovery after nipple correction surgery

Rehabilitation after interventions usually does not exceed 10-14 days. As a rule, its main period lasts until the sutures are removed. At this time, it is recommended to reduce the risk of bruising and reduce swelling.

Patients are prescribed:

  • Wearing special support garments (non-squeezing)
  • Special medical treatment of wounds after surgery with antiseptic solutions
  • Sleep only on the back or on the side
  • Refusal to take baths and showers, baths, saunas and solariums, various thermal procedures

It is forbidden to touch the site of intervention and expose it to moisture, sun and various cosmetics.

Important! If additional treatment of the wound surface is required, it will be performed by a specialist or by the patient himself using only recommended drugs!

Possible complications after the intervention

The main complications after surgery include:

  • Occurrence of hematomas . They usually form around incisions and on the skin of the breast. Hematomas are not dangerous, they should not become a cause for concern if the shape of the mammary glands does not change and the patient does not suffer from severe bursting pains.You should consult a doctor if the hematomas increase in size. Also, the reason for consulting a specialist is severe pain and increasing tension in the chest
  • Suppuration . This complication becomes a consequence of infection in the wound. Often, the skin around the nipple turns red, its temperature rises, purulent discharge appears in the incision area, and crusts form. As a rule, for suppuration, local antiseptic drugs and antibiotics in the form of tablets are prescribed
  • Disorder of nipple sensitivity (increase or decrease).Usually, such changes go away on their own 2-3 months after the intervention and do not bother patients too much

Advantages of contacting MEDSI

  • Experienced Doctors . Our specialists have a high level of qualifications, regularly undergo training and master new techniques for performing interventions that allow you to achieve the ideal aesthetic effect
  • Modern equipment and techniques . Thanks to this, all interventions are carried out quickly and with minimal discomfort for patients.The terms of rehabilitation are also reduced, as well as the risks of complications
  • Comfortable conditions of hospital stay . The wards in MEDSI are equipped with everything you need. Patients are provided with quality 24/7 care

If you want to sign up for the correction of areolas and nipples, to clarify the cost of the intervention in St. Petersburg, the specifics of its implementation and the conditions of stay in the clinic, call the number: + 7 (812) 336-33-33.

90,000 retrochorial hematoma sizes – 25 recommendations on Babyblog.ru

As a decent girl, I was honestly going to register with the LCD until the 12th week of pregnancy. Time was already running out, until I moved, until I collected all the papers for attachment, until then, while I was in office, I made an appointment with the doctor for the next available date (the period should have been 11 weeks).

But, alas, before I went to my doctor, I went to the ambulance at the hospital (1 GKB). And it was very unexpected …

That day I felt wonderful: I slept well, nothing hurt.I had to go to work on the second shift and I had time to walk in new boots before work. And at work that day everything was like clockwork, that there is nothing to complain about. The shift was over, I went to take some medical records for signature (I work in a medical institution) and then … And then I notice that I am somehow unusually wet. I look at my white trousers – and they are no longer white at all. There was no pain at all. I returned to the office, told my doctor that I had problems – the bleeding was developing quickly and the trousers were scarlet already knee-deep.She started calling an ambulance, and I was escorted to our gynecology department. There I was diagnosed with an abortion in progress, and they gave me a haemostatic injection.

It should be noted that I did not panic at all. It was a little unpleasant from such a bustle around my person, and even at work – but nothing more. My husband called about some of his business, and I was lying, waiting for an ambulance and saying: “Do not worry, they will take me to the hospital now. When I find out which one, I will call and bring things.”

The ambulance arrived quickly.In the admission department there was an old gynecologist who, looking at me, said: “Everything will be fine with you.” Ultrasound diagnosed: “Retrochorial hematoma, 5 cm.”

I spent a week in the hospital, several times they put on a dropper, but mostly – lethal doses of Utrozhestan and Wobenzym. My head was spinning from the drugs and I was constantly sleepy. After being discharged, I did not go to work for another two weeks – it was some kind of somnambulistic time: I slept both at night and during the day. The hematoma decreased in size.

But from blood loss and such a long lying there was anemia and hypotension (with already existing hypotension). And my first exit to work after sick leave on the first shift (at 6:50 am) ended in loss of consciousness in the subway. But that’s a different story.

Now it is the 36th week of pregnancy. I took Utrozhestan until the 20th week, but, to be honest, the dosage is half the prescribed dose. The hematoma has already completely resolved. Low placenta – rose.

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