Pre-operative embolisation of vertebral metastases has been known to effectively devascularise hypervascular vertebral tumours and to reduce intra-operative bleeding. However, the complications that occur during the procedure are rarely reported. This case study attempts to highlight one rare complication, which is epidural tumoural haemorrhage intra-procedure. It may occur due to the fragility of the tumour and presence of neovascularisation. A small arterial dissection may also have occurred due to a slightly higher pressure exerted during injection of embolising agent. Haemostasis was secured via injection of Histoacryl into the area of haemorrhage. The patient was able to undergo the decompression surgery and suffered no direct complication from the haemorrhage.
In endoscopic neurosurgery problems with haemostasis due to poor access exist. We have developed a system which allows the delivery of a variety of haemostatic agents in a more efficacious manner. The system has been used successfully in endoscopic skull base surgery and endoscopic surgery within the parenchyma of the brain using tube systems.
The administration of intrapleural streptokinase (IPSK) is widely practiced in the management of loculated empyema thoracis. To our knowledge, there have been only 4 cases of hemorrhagic complications attributed to the administration of IPSK reported in the literature. In this article, we report a case of a 17-year-old girl who received IPSK and developed shock, anemia, coagulopathy and massive hemothorax. Our discussion focuses on the hemorrhagic complication of chest tube insertion and the role of IPSK in blood clot lysis and inhibition of local hemostasis.
Vulvo-vaginal haematomas are not an uncommon obstetric complication. Despite advances in obstetric care, practice and technique, vulvo-vaginal haematomas do occur especially in complicated vaginal deliveries. Various management options are available for vulvo-vaginal haematomas. We describe three cases of vulvo-vaginal haematomas with different severity and presentations which were managed in different manners i.e. local haemostasis control, laparotomy with hysterectomy, and transarterial embolisation. The choice of treatment options would mainly depend on the clinical presentations, availability of expertise as well as facilities. Early identification is crucial.
Various factors may contribute to a hypercoagulable state and acute vascular thrombosis. A prospective study was conducted involving 165 coronary heart disease (CHD) patients from the Cardiology Unit, Hospital Universiti Sains Malaysia. The purpose of this study was to investigate the relationship among factor VIII (FVIII), prothrombin time (PT), activated partial thromboplastin time (APTT), and activated protein C resistance (APC-R) state among CHD patients and to look for potential clinical applications from these laboratory findings. There were 110 cases diagnosed as acute coronary syndrome (ACS), whereas another 55 were stable coronary artery disease (SCAD) patients. PT, APTT, FVIII, and APC-R assays were performed on all subjects. There was a significant difference between the FVIII level and the APTT results (P value < 0.0001). A negative relationship was found between the FVIII level and the APTT from linear regression analysis (R(2) = 10%, P value < 0.0001). For each 1% increase in the FVIII level, the APTT was reduced by 0.013 s (95% confidence interval (CI) between -0.019 and -0.007). Interestingly, none of the SCAD patients had abnormally short APTT. Approximately 68.4% of cases with a positive APC-R assay were found to have a high FVIII level. In conclusion, the APTT test is a potential hemostatic marker for hypercoagulable state including in arterial thrombosis.
Study site: Cardiology unit (outpatient and inpatient), Hospital Universisti Sains Malaysia (HUSM), Kelantan, Malaysia
Gingival overgrowth is frequently observed in patients taking certain drugs such as calcium channel blockers, anticonvulsants and immunosuppressant. This can have a significant effect on the quality of life as well as increasing the oral bacterial load by generating plaque retention sites. Amlodipine, a third generation calcium channel blockers has been shown to promote gingival overgrowth although in very limited cases reported. The management of gingival overgrowth seems to be directed at controlling gingival inflammation through a good oral hygiene regimen. However in severe cases, surgical excision is the most preferred method of treatment, followed by rigorous oral hygiene procedures. This case report describes the management of gingival overgrowth in a hypertensive patient taking amlodipine. Combination of surgical gingivectomy and CO2 laser treatment was used to remove the gingival overgrowth. CO2 laser surgery produced good hemostasis and less pain during the procedure and post operatively. This case report has also shown that periodontal treatment alone without a change in associated drug can yield satisfactory clinical response.
Intramural duodenal haematoma is a rare injury of the duodenum. Most reported cases are secondary to blunt trauma to the abdomen. Such injury following endoscopic intervention is even rarer, and there are no definite guidelines for its management. We report a case where endoscopic haemostasis of a bleeding duodenal ulcer resulted in a massive dissecting intramural duodenal haematoma with gastric outlet obstruction and obstructive jaundice.
Bleeding is a serious complication of peptic ulcer and mortality rate has remained at approximately 10% or more. Traditionally surgeons selected patients who were at significant risk of continued or re-bleeding and advocated early surgery. However, patients with bleeding peptic ulcers are generally elderly with coexisting medical illness and surgery results in significant morbidity and mortality. In the last decade, endoscopic haemostatic therapy has been effective in arresting the bleeding with surgical option considered only after endoscopic treatment has failed. We report the outcome of 196 patients who were endoscopically diagnosed to have bleeding from peptic ulcers. One hundred and thirty patients were to have active bleeding or recent bleed from the ulcer. Endoscopic adrenaline injection therapy was used in 53 patients who had active bleeding ulcers and another 77 patients with endoscopic evidence of recent bleed. The injection therapy was successfully in 127 (97.7%) patients. The treatment failed in three patients and they underwent urgent surgery. Re-bleeding occurred in 26 (20.5%) patients and endoscopic adrenaline therapy was repeated in these cases. Haemostatic was achieved in 19 patients, however 7 patients continued to bleed and required surgery. There were 3 deaths, principally from advanced age and coexisting medical illness. Endoscopic therapy for bleeding peptic ulcers is simply to apply, safe and effective. In cases of re-bleeding after initial endoscopic hemostasis, re-treatment is a preferable alternative to surgery. The role of surgery is limited to bleeding that is refractory or inaccessible to endoscopic control.
The aim of this investigation was to determine the prognostic value of coagulation abnormalities in a defined subset of patients with acute head injury. Prothrombin time, accelerated partial thromboplastin time (APTT), thrombin clotting time, fibrinogen assay, platelet count, fibrin degradation products (FDP) were assayed in 204 patients with acute closed head injury. Their values were graded on a score 0-3 and the sum score for each patient regarded as the disseminated intravascular coagulation (DIC) score. Moderate to severe DIC scores were evident in 38% of the cohort. At least one parameter was abnormal in 71% of patients. The DIC score correlated inversely with the Glasgow coma score (GCS) (p < 0.0001). In the GCS 13-15 subset, FDP scores were significant predictors of poor outcome (p < 0.001). In the GCS 6-12 subset, the APTT score (p < 0.001), and DIC score (p < 0.0001) predicted an adverse outcome. The DIC scores were significantly abnormal in most patients who had a poor outcome, without evidence of adverse predictors on CT. Logistic regression analysis confirmed the independent predictive capacity of APTT, FDP and DIC scores when values for GCS were fixed. Abnormal haemostatic parameters may enhance the predictive ability in subsets of patients with acute head injury defined by clinical or CT predictors.
Nephrotic syndrome is often associated with a hypercoagulable state and thrombotic complications. Thrombosis may be due to a number of abnormalities in blood, including AT III deficiency, increased concentrations of fibrinogen, factors V and VIII, and platelet hyperaggregability. The therapeutic approach to thrombosis in nephrotic syndrome is the use of anticoagulants as a preventive measure or an attempt at thrombolysis with streptokinase, urokinase, or stanozolol.