What features of a hematoma should be concerning?

Concerning Features of a Hematoma

The most concerning features of a hematoma are rapid expansion, heterogeneous densities within the hematoma, irregularities at the margins, and signs of mass effect or neurological deterioration, which warrant immediate medical attention as they indicate high risk for poor outcomes. 1

Location-Specific Concerns

Intracranial Hematomas

• Size and expansion: Hematoma expansion is associated with a nearly 5-fold increase in clinical deterioration, poor outcome, and death 1
• Imaging markers of high risk:
  • Heterogeneous densities within the hematoma 1
  • Irregular margins of the hematoma 1
  • "Spot sign" on CT angiography (contrast extravasation) 1, 2
  • Blend sign, black hole sign, and hypodensities on non-contrast CT 2
  • Island sign (multiple small hematomas adjacent to main hematoma) 2
• Clinical signs of deterioration:
  • Decreasing Glasgow Coma Scale score 1
  • New or worsening neurological deficits 1
  • Development of hydrocephalus 1
  • Signs of brain swelling or herniation 1
  • Intraventricular extension of hemorrhage 1

Aortic Intramural Hematomas

• Type A (involving ascending aorta): Requires urgent surgical intervention due to high risk of rupture (33-75%) 1
• Type B (distal to left subclavian artery): Concerning features include:
  • Recurrent pain despite medical management 1
  • Expansion of the hematoma on serial imaging 1
  • Periaortic hematoma formation 1
  • Intimal disruption 1

Extremity and Subcutaneous Hematomas

• Signs of neurovascular compromise:
  • Pain that suddenly worsens 3
  • Numbness or tingling in the affected limb 3
  • Pale, cool, or discolored skin over the hematoma 3
  • Limited range of motion 3
  • Signs of compartment syndrome 4
• Expansion despite conservative management 3
• Chronic expansion: Hematomas that continue to grow over weeks to months may mimic malignancy and require surgical intervention 5, 6

Concerning Patient Factors

• Anticoagulation therapy: Significantly increases risk of hematoma expansion (OR 6.2) and prolongs the expansion period 1
• Elevated temperature (≥37.5°C): Associated with early neurological deterioration 1
• Elevated neutrophil count and serum fibrinogen: Markers of potential deterioration 1
• Elevated serum markers: Matrix metalloproteinase-9, matrix metalloproteinase-3, c-fibronectin ≥6 μg/mL, and interleukin-6 ≥24 pg/mL correlate with hematoma expansion and poor outcomes 1

Monitoring and Assessment

• Serial imaging: Crucial for detecting hematoma expansion, particularly within the first 24 hours 1

  • Most expansion occurs within the first few hours, with 38% of ICH showing ≥33% volume increase when initially scanned within 3 hours of onset 1
  • Two-thirds of expansion cases occur within the first hour 1

• Neurological assessment:

  • For intracranial hemorrhage, perform baseline severity score and monitor for deterioration 1
  • Regular assessment of vital signs, particularly blood pressure 1
  • Evaluation of pain, which may indicate expansion in aortic intramural hematomas 1

Pitfalls to Avoid

• Delayed imaging: Failing to obtain prompt imaging in patients with suspected hematoma can miss critical expansion periods 1
• Inadequate follow-up: Not performing serial imaging in high-risk patients may miss expansion 1
• Overlooking anticoagulation status: Patients on anticoagulants require more aggressive monitoring and management 1
• Misdiagnosing chronic expanding hematomas: These can mimic malignancy and require different management approaches 5, 6
• Underestimating small hematomas: Even small hematomas can cause significant morbidity if located in critical areas or if they expand 3

By recognizing these concerning features early, clinicians can intervene promptly to prevent complications and improve patient outcomes.