Intramuscular Hematomas in Patients Receiving Prophylaxis or Anticoagulant Treatment after Spinal Cord Injury (SCI)—A Rare Complication: Description of Seven Cases and a Literature Analysis

Abstract

Spinal cord injuries (SCIs) are associated with a high risk of thromboembolic complications (VTE), despite the use of antithrombotic prophylaxis in the form of low-molecular-weight heparin (LMWH). The occurrence of VTE requires, as in other diseases, full-dose antithrombotic treatment. Herein, we describe seven cases of soft tissue hemorrhagic complications in the form of spontaneous intramuscular hematomas (SMHs) in patients after SCI undergoing rehabilitation. Four patients received anticoagulant therapy due to previously diagnosed deep vein thrombosis (DVT), and three patients received anticoagulant prophylaxis. None of the patients had a significant injury immediately before the hematoma appeared, and the only symptom was a sudden swelling of the limb without accompanying pain. The hematomas in all patients were treated conservatively. In three patients, significant decreases in hemoglobin were observed; in one patient, a blood transfusion was required for this reason. In all patients treated via anticoagulation, the anticoagulation treatment was modified at the time of diagnosis of the hematoma; in three patients, oral anticoagulants were changed to LMWH in a therapeutic dose, while in one patient, anticoagulant treatment was completely discontinued. Conclusions: Intramuscular hematomas are rare complications after SCI. Each sudden swelling of a limb requires ultrasound-based diagnostics. At the time of diagnosis of a hematoma, the level of hemoglobin and the size of the hematoma should be monitored. The treatment or anticoagulation prophylaxis should be modified if necessary.

Spontaneous Adductor Hematoma in a 75-Year-Old Male With Acute Thigh Bruises

“…Intramuscular hematomas are not an uncommon complication in the setting of anticoagulation (AC) therapy [ 12 ]. Risk factors for IH in anticoagulated patients include microtrauma, coagulation disorders, chronic renal insufficiency requiring dialysis, hypertension, heart failure, liver failure, and congenital collagen disorders [ 13 ]. Our patient, his history of chronic kidney disease, hypertension, and heart failure increases the risk for IH.…”

“…Secondly, a thorough physical exam checking for paresthesia, swelling, weakness, and vital signs indicative of hemodynamic instability or compartment syndrome are vital to making an accurate diagnosis, which our patient fortunately had no signs of. Hemoglobin and prothrombin time (PT)/partial thromboplastin time (PTT)/INR levels must also be checked as evidence of active bleeding in the initial evaluation to search for a potential etiology [ 13 ].…”

“…Management of a large intramuscular hematoma involves a clinical risk-benefit decision based on discontinuation of anticoagulation with the risk of thrombus formation [ 13 ]. A multidisciplinary decision is encouraged on anticoagulation therapy dosage and management.…”