Lumbar artery injury from which the Adamkiewicz artery originated associated with lumbar spine injury: successfully treated by transcatheter arterial embolization

Delayed lumbar plexus palsy due to giant psoas hematoma associated with vertebral compression fracture and direct oral anticoagulants: a case report

Background

Osteoporotic vertebral compression fractures (VCFs) are commonly observed in elderly people and can be treated by conservatively with minimal risk of complications in most cases. However, utilization of direct oral anticoagulants (DOACs) increases the risks of secondary hematoma even after insignificant trauma. The use of DOACs increased over the past decade because of their approval and recommendation for both stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. It is well known that DOACs are safer anticoagulants than warfarin in terms of major and nonmajor bleeding; however, we noted an increase in the number of bleeding events associated with DOACs that required medical intervention. This report describes the first case of delayed lumbar plexus palsy due to DOAC-associated psoas hematoma after VCF to draw attention to potential risk of severe complication associated with this type of common and stable trauma.

Case presentation

An 83-year-old man presented with his left inguinal pain and inability to ambulate after falling from standing position and was prescribed DOACs for chronic atrial fibrillation. Computed tomography angiography revealed a giant psoas hematoma arising from the ruptured segmental artery running around fractured L4 vertebra. Because of motor weakness of his lower limbs and expansion of psoas hematoma revealed by contrast computed tomography on day 8 of his hospital stay, angiography aimed for transcatheter arterial embolization was tried, but could not demonstrate any major active extravasation; therefore spontaneous hemostasis was expected with heparin replacement. On day 23 of his stay, hematoma turned to decrease, but dysarthria and motor weakness due to left side cerebral infarction occurred. His pain improved and bone healing was achieved about 2 months later from his admission, however the paralysis of the left lower limb and aftereffects of cerebral infarction remained after 1 year.

Conclusion

In patients using DOACs with multiple risk factors, close attention must be taken in vertebral injury even if the fracture itself is a stable-type such as VCF, because segmental artery injury may cause massive psoas hematoma followed by lumbar plexus palsy and other complications.

Thoraco-lumbar fractures with blunt traumatic aortic injury in adult patients: correlations and management

PURPOSE

Traumatic thoraco-lumbar spine fracture spine with a concomitant blunt aortic injury is uncommon but potentially a fatal association. Our aim was to clarify: morphology of spinal fractures related to vascular damages and vice versa, diagnostic procedures and decision-making process for the best treatment options for spine and vessels.

METHODS

We enrolled 42 cases culled from the literature and five personal ones, reviewing in detail by AO Spine Classification, Society of Vascular Surgery classification and Abbreviated Injury Scale for neurological evaluation.

RESULTS

Most fractures were at T11-L2 (29 cases; 62%) and type C (17; 70%). 17 (38%) were neurological. Most common vascular damage was the rupture (20; 43%), followed by intimal tear (13; 28%) and pseudoaneurysm (9; 19%). Vascular injury often required open or endovascular repair before spinal fixation. Distraction developed aortic intimal damage until rupture, while flexion-distraction lumbar artery pseudoaneurysm and rotation-torsion full laceration of collateral branches. CT and angio-CT were investigations of choice, followed by angiography. Neurological condition remained unchanged in 28 cases (90%). Overall mortality was 30%, but it was higher in AIS A.

CONCLUSION

Relationship between thoraco-lumbar fracture and vascular lesion is rare, but potentially fatal. Comprehension of spinal biomechanics and vascular damages could be crucial to avoid poor results or decrease mortality. Frequently, traction of the aorta and its vessels is realized by C-dislocated fractures. CT and angio-CT are recommended. Spine stabilization should always follow the vascular repair. Early severe deficits worse the prognosis related to neurological recovery and survival. These slides can be retrieved under Electronic Supplementary Material.

Massive retroperitoneal hemorrhage secondary to femoral artery puncture: A case report and review of literature

RATIONALE

A rare case of massive bleeding with rupture of the branch artery deriving from uterine artery was reported in the present study.

PATIENT CONCERNS

A 29-year old female patient received embolism of malformed cerebral vessels. Ten hours after the operation, a sudden drop in blood pressure occurred. The patient developed coma and shock, and again underwent interventional angiography, which revealed bleeding at the right femoral artery puncture site of the first interventional procedure. The bleeding sign disappeared by pressure dressing. At 19 hours after stable condition, blood pressure fell again, and it was considered that recurrent bleeding occurred at the femoral artery puncture point. Therefore surgical suture of punctured blood vessel was performed. Then the condition was stabilized again. After another 20 hours, the third times blood pressure dropped. The third interventional angiography displayed a rupture of the branch artery deriving from the right uterine artery. Blood pressure of the patient elevated after embolism of right uterine artery, and the condition gradually stabilized.

DIAGNOSES

The massive bleeding with rupture of the branch artery deriving from uterine artery seconded huge retroperitoneal hematoma after femoral artery puncture.

INTERVENTIONS

The patient underwent three times interventional treatment including an embolism of malformed cerebral vessels, a right femoral artery interventional treatment, an embolism of the branch artery deriving from the right uterine artery and one time of surgical suture of punctured blood vessel.

OUTCOMES

Half a month of comprehensive treatment later, the patient was discharged from the hospital.

LESSONS

Massive bleeding with rupture of branch of artery deriving from the uterine artery following grain retroperitoneal hemorrhage is extremely rare, to the best of our knowledge, it has not been previously reported. The rupture of branch of artery deriving from the uterine artery should be considered as one the differential diagnosis in the retroperitoneal hemorrhage when the bleeding cause was not found. Endovascular trans-arterial embolism was a safe, effective, and minimally invasive therapeutic option.

Transcatheter Arterial Embolization of a Lumbar Artery Injury with Traumatic Aortic Dissection

Whole-body-enhanced computed tomography of a septuagenarian woman hit by a truck revealed a traumatic aortic dissection (Stanford B) and arterial bleeding from the right lumbar artery in the right iliopsoas muscle. Angiography revealed an active arterial extravasation from a false lumen of the left lumbar artery. We performed a transcatheter arterial embolization (TAE) of the right lumbar artery. After fenestration of the intimal flap, the left lumbar artery was successfully selected and embolized; the patient's clinical condition subsequently stabilized. This is the first report of successful treatment of a lumbar artery injury with a traumatic aortic dissection by a TAE.