Hematomas present as hard, solid and painful lumps or swellings under the skin. The overlying skin is often bruised and discoloured with ecchymosis as a common presentation. Intracranial hematomas also have symptoms of severe headache, nausea and vomiting, double vision, seizures and unconsciousness. The clinical presentation of intramural hematoma (IMH) and aortic double-lumen dissection (AD) is often similar [7] so a difference needs to be made with the help of imaging studies. Rectus sheath hematomas present with abdominal pain along with a palpable lump.

• Fever

  The chest drainage tube was removed on postoperative day 12 because of persistent air leakage, but fever appeared the same day. Computed tomography revealed a cavity with mixed air and fluid, so antibiotics were started on suspicion of abscess. [ncbi.nlm.nih.gov]

  Large ones may present with lower abdominal pain, dysuria, anemia and fever (if infected). It is an uncommon complication of cesarean section, due to bleeding and uterine dehiscence, usually at transverse lower uterine incision. [radiopaedia.org]

  You have a fever. You have trouble moving the body part that has the hematoma. Contact your healthcare provider if: You have questions or concerns about your condition or care. [drugs.com]

  If infection should develop in the wound, the signs and symptoms might be increasingly severe pain, a fever of 101 degrees or more, swelling with surrounding redness, and pus. [healthcentral.com]

  Hemorrhagic fever, which literally stands for bleeding fever, produces the tell tale bruising all over the body. Other illnesses such as cancer that leave a loved on confined to a bed can be causes for such instances of blood related problems. [healthguidance.org]

• Pseudotumor

  Ozaki et al4 suggest that a hematoma originates from a hemangioma or an inflammatory vascular injury, and they define an organized hematoma without an underlying hemangioma as an inflammatory pseudotumor. [ajnr.org]

  Hemophilic pseudotumor of the stomach. Radiology. 1971; 98 :547–9. [ PubMed ] 20. Durward QJ, Cohen MM, Naiman SC. Intramural hematoma of the gastric cardia. Am J Gastroenterol. 1979; 71 :301–5. [ PubMed ] 21. Leborgne L, Mathiron A, Jarry G. [ncbi.nlm.nih.gov]

  However, some persist for long periods and appear clinically as slowly expanding lesions in soft tissues simulating neoplastic growth; these are called chronic expanding hematomas.[1] These lesions are essentially similar to chronic subdural hematomas, pseudotumors [escholarship.org]

• Localized Pain

  Pathophysiology General Trauma → rupture of micro- and macrovasculature → local hemorrhage and inflammation → accumulation of fluids → localized swelling, pain and heat. [vetstream.com]

  Hematomas may or may not be associated with symptoms, such as localized pain and tenderness. [medicinenet.com]

  If the patient is unable to follow commands, note his or her ability to localize painful stimuli or to exhibit normal flexion on either side in response to the pain. [emedicine.medscape.com]

• Abdominal Mass

  Computed tomography with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 centimeter in the left middle abdominal quadrant. [ncbi.nlm.nih.gov]

  WHAT CAUSES AN ABDOMINAL MASS? Abdominal masses can be the result of a number of factors, including an injury, cyst, tumor, cancer, or disease. [slideshare.net]

  The Fothergill sign (mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles is suggestive of a rectus sheath hematoma) is useful to determine if the abdominal mass is within the abdominal wall [statpearls.com]

  Below the arcuate line, the aponeuroses remain intact anteriorly, but only the weak transversalis fascia and peritoneum separate the muscle mass from the abdominal viscera posteriorly. [reference.medscape.com]

• Hypertension

  However, its role in hypertensive ICH alone has not been determined and is the primary aim of this study. [ncbi.nlm.nih.gov]

  Rupture of AVM Trauma Commonly due to embolisms, thrombi, or microangiopathic changes Arterial hypertension and increasing age are the most important risk factors Clinical features Lucid interval, then loss of consciousness Headache Hemiplegia Increasing [amboss.com]

• Thrombosis

  […] adminadministratitrationlow-dosecurrence of a massive hematomathe rectus sheath is reported in a woman with chronic obstructive pulmonary disease and acute respiratory failure who was receiving low doses of heparin for the prevention of deep venous thrombosis [jamanetwork.com]

  A nurse on the island thought it could be a thrombosis. Since then a smaller "bubble" has appeared beside the larger one. [daneurope.org]

  Deep vein thrombosis of the lower leg was identified and edoxaban, a so-called novel oral anticoagulant, was started on postoperative day 7. [ncbi.nlm.nih.gov]

  Two patients had thrombosis of the basilar artery in the remainder descendent, ascendent, transtentorial herniations and extracranial hemations of the cerebral tissue were involved. [medvik.cz]

  Enforced bed rest in elderly patients may lead to pneumonia, deep venous thrombosis, and aspiration. [americannursetoday.com]

• Cauliflower Ear

  An auricular haematoma requires prompt surgical intervention to avoid cauliflower ear, also known as «wrestler’s ear». A cauliflower ear is a permanent deformity made up of connective tissue and cartilage. [tidsskriftet.no]

  Less serious types include subungual hematoma (under a fingernail or toenail); hematoma auris (in the tissues of the outer ear, better known as cauliflower ear); and perianal hematoma (under the skin around the anus). [healthcentral.com]

  ► CT images of hematomas ‎ (5 C) ► Ultrasound images of hematomas ‎ (3 F) - ► Hematomas in mammals ‎ (2 F) B ► Black eyes ‎ (1 C, 54 F) ► Blood blisters ‎ (13 F) C ► Cauliflower ear ‎ (23 F) E ► Hematoma of ear canal ‎ (1 F) ► Epidural hematoma ‎ (1 [commons.wikimedia.org]

  Often called boxer's ear, wrestler's ear, or cauliflower ear, blood becomes trapped between the thin layer of skin and the cartilage itself. [medicinenet.com]

• Hematuria

  Her urine was clear with no evidence of macroscopic hematuria. Examination of the perineum revealed a 10 × 8 cm swelling of the left vulva with right deviation of the right labia and clotted blood over the left labia minora (Fig. 1). [ncbi.nlm.nih.gov]

  (Please note that bladder infections may be associated with hematuria or blood in the urine and may not need further evaluation once the infection has been treated; clot and hematoma formation is rare.) [emedicinehealth.com]

• Seizure

  Seizures often occur at the time the hematoma forms, or up to months or years after treatment. But medicines can help control the seizures. [ufhealth.org]

  Seizures: Damage to the brain from subdural hematomas can lead to seizures. These can usually be controlled with proper treatment. [baptisthealth.com]

  Burr hole procedure where small holes are made on the skull and rubber tubes are inserted to drain out smaller blood clots in the hematomas Anti-seizure medications to counter seizures due to subdural hematoma Medication to treat brain injury Prescription [apollohospitals.com]

• Difficulty Concentrating

  Possible Complications Complications that may result include: Brain herniation (pressure on the brain severe enough to cause coma and death) Persistent symptoms such as memory loss, dizziness, headache, anxiety, and difficulty concentrating Seizures Short-term [ufhealth.org]

  Complications that may result include: Brain herniation (pressure on the brain severe enough to cause coma and death) Persistent symptoms such as memory loss, dizziness, headache, anxiety, and difficulty concentrating Seizures Short-term or permanent [nlm.nih.gov]

• Convulsions

  Anti-convulsion medications, such as phenytoin, may be used to control or prevent seizures. Surgical Procedures A person with a subdural hematoma may require emergency surgery to reduce pressure in the brain. [baptisthealth.com]

  Take the person to the emergency room or call 911 if the person: Has convulsions (seizures) Is not alert ( loses consciousness ) Avoid head injuries by using seat belts, bicycle and motorcycle helmets, and hard hats when appropriate. [medlineplus.gov]

  Symptoms of subdural hematoma tend to fluctuate and include the following: headache episodes of confusion and drowsiness one-sided weakness or paralysis lethargy enlarged or asymmetric pupils convulsions increased intracranial pressure loss of consciousness [encyclopedia.com]

• Aphasia

  PATIENT CONCERNS: A 74-year-old woman, who was on rivaroxaban 20 mg/d for nonvalvular atrial fibrillation, was admitted to our stroke unit with left-sided hemiparesis and aphasia. [ncbi.nlm.nih.gov]

  Historical note and terminology In 1657 Wepfer described the presence of a "bloody cyst" in the subdural space of an elderly man postmortem who had developed an aphasia and hemiplegia. [medlink.com]

  […] consciousness A dilated or nonreactive pupil ipsilateral to the hematoma (or earlier, a pupil with a more limited range of reaction) Hemiparesis contralateral to the hematoma A host of findings could be associated with these, such as brisk or abnormal reflexes, aphasia [emedicine.medscape.com]

• Radiculopathy

  […] of only 1 per million, 15 the exceedingly high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis of presentations suggesting spinal cord involvement. 2 SSEH can present with features ranging from simple back pain with radiculopathy [nature.com]

Work up includes a thorough physical and neurological examination and patient history, followed by some laboratory tests and imaging studies

Laboratory tests

• Complete blood count
• Prothrombin time and APTT
• Liver function tests
• Serum BUN and electrolytes
• GCS measurement
• Serum alcohol levels

Imaging 

CT scans and MRI are the primary investigative and diagnostic tests for hematomas. Pre-contrast CT scans of an organized hematoma show hyperdense masses with or without calcification [8]. Doppler ultrasounds may also be conducted if needed.

Test results

On the basis of a thorough clinical examination and imaging studies the exact location and the extent of the hematoma can be found out. Tests can also help in assessing the risk of rupture of the hematoma and appropriate treatment can be accordingly planned.

• Occult Blood Positive

  A digital rectal examination revealed occult blood-positive feces. [ncbi.nlm.nih.gov]

Treatment of a hematoma depends on the severity and extent of the hematoma. According to panel consensus statements, if progressive hemorrhage as shown by 2 successive CT or MRI scans along with haemodynamic instability, persistent pain and signs of impending rupture are present, immediate surgical treatment is recommended. If such conditions are absent, medical treatment is recommended [9].

According to the findings of a recent study chances of a good recovery are possible if an aggressive surgical approach is taken in particular cases like those of patients with extradural hematomas [10]. Treatment with medication includes the use of osmotic diuretics, anticonvulsants, analgesics and corticosteroids. In cases of intracranial hematomas, antacids may also be given to reduce the chances of gastric ulcers.

If not treated, intracranial hematomas pose a negative prognosis with very high rates of mortality. The prognosis depends on the size, shape and thickness of the hematoma and how much it is suppressing the underlying and neighbouring structures. Hematomas occurring in the limbs as a result of trauma or in the abdomen usually have a good prognosis. Some hematomas don’t even require treatment and spontaneously resolve.

Causes behind intracranial hematomas include blunt head trauma, clotting disorders, intracranial hypotension like after spinal epidural anaesthesia [1] and lumbar puncture. Some of them are even idiopathic. Underlying arteriovenous (AV) malformations were also identified in one study [2].

Other hematomas can occur due to different causes. Some anticoagulant drugs like heparin or warfarin can also disrupt normal coagulation and cause hematomas. A study reported a case of sublingual hematoma secondary to warfarin therapy [3]. Trauma, AV malformations and clotting disorders are also various other kinds of hematoma formation.

Incidence

Hematomas are common findings in accidents and trauma cases. Around 5% to 25% of people with head trauma develop subdural hematomas and 2% develop epidural hematomas.

Sex

Subdural hematomas are more common in men, with a ratio of 3:1. Epidural hematomas are also more common in men, with a ratio of 4:1.

Age

Hematomas in children are rare unless the child is suffering from inherited coagulation disorders or has suffered trauma. They are much more common in adults in the 5th and 6th decade of life.

Hematomas are localized accumulations of blood outside the blood vessels. Epidural hematomas most commonly involve the middle meningeal artery. They are due to blunt trauma that causes the dura mater to separate from the periosteum and the blood vessels in between to stretch and rupture. This leads to rapid leakage and flooding of blood between the meningeal layers. Subdural hematomas are also typically due to trauma. Some chronic subdural hematomas may enlarge from an osmotic gradient, drawing more fluid into the subdural space. The mechanism of calcification can also be the pathogenesis behind hematoma formation [4]. According to a study performed by Kawakami in 1989, it was found that the coagulation and fibrinolysis systems were both excessively activated due to unknown causes in cases of chronic subdural hematoma [5].

Rectus sheath hematoma (RSH) may develop due to rupture of epigastric arteries in the abdomen or the rectus muscle itself due to severe trauma [6]. Other less common types of hematoma include subungal hematoma which occurs under or around the nailbed, perianal hematoma, subgaleal hematoma which occurs between the periosteum and the galeal aponeurosis and subdermal hematoma which occurs under the skin and typically in muscles.

Hematomas can only be prevented by avoiding injuries and carefully monitoring the use of anticoagulant drugs.

Hematomas are localized collection of extravasated blood that leaks out of ruptured blood vessels and accumulates in the surrounding area. The hematoma may occur inside muscles, in internal organs, between two membranes, in joint cavities and under the skin. According to the area or site of the hematoma, it can be named and divided. By far, intracranial hematomas pose the greatest risk of rupture and damage, even death. Hematomas occurring under the skin of limbs and joints are less dangerous, but no less painful.

Definition

A hematoma is a collection of blood outside the blood vessels which appears as a hard lump or swelling.

Cause

It is most commonly a result of trauma. It may also occur due to clotting disorders, arteriovenous malformations, excessive alcoholism, anticoagulant therapy, etc.

Signs and symptoms

Symptoms include hard, solid swelling under the skin accompanied with pain. Intracranial hematomas also present with headache, double vision, nausea and vomiting, seizures and unconsciousness.

Diagnosis

Diagnosis is made be carefully assessing the physical findings and the results of imaging studies and laboratory tests.

Treatment

Treatment includes medication like painkillers, anticonvulsants, etc and in severe cases, surgical removal of the accumulated blood and repair of the ruptured blood vessels.

1. Mashour GA, Schwamm LH, Leffert L. Intracranial subdural hematomas and cerebral herniation after labor epidural with no evidence of dural puncture. Anesthesiology. Mar 2006;104(3):610-2
2. Sivakumaran R, King A, Bodi I, Chandler CL, Walsh DC. Spontaneous epidural spinal haematoma in children caused by vascular malformations. Eur Spine J. 2014 Oct 10 
3. Pathak R, Supplee S, Aryal MR, Karmacharya P. Warfarin induced sublingual hematoma: a Ludwig angina mimic. Am J Otolaryngol. 2014 Aug 20. pii: S0196-0709(14)00192-6. 
4. Atkinson JL, Lane JI, Aksamit AJ. MRI depiction of chronic intradural (subdural) hematoma in evolution. J Magn Reson Imaging. Apr 2003;17(4):484-6
5. Kawakami Y, Chikama M, Tamiya T, Shimamura Y. Coagulation and fibrinolysis in chronic subdural hematoma. Neurosurgery. Jul 1989;25(1):25-9
6. Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of Risk Factors for Rectus Sheath Hematoma. Clin Appl Thromb Hemost. 2014 Oct 7. 
7. Ibukuro K, Takeguchi T, Fukuda H, Mori M, Abe S, Tobe K. An analysis of initial and follow-up CT findings in intramural hematoma, aortic double-lumen dissection, and mixed type lesions. Acta Radiol. 2014 Sep 26. 
8. Chae HD, Choi SH, Park SH, Jung HW, Yun TJ, Kim JH, Sohn CH. Organized hematoma developed after suboccipital craniectomy. J Neuroimaging. 2014 Nov;24(6):610-2. 
9. Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, Moral S, Fattori R. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2014 Nov 10. 
10. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J. 2014 Nov 10.