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Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1043-1044

Sciatic Nerve Hematoma - Case Report


Department of Radiology and Imaging Sciences, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Submission01-Jan-2020
Date of Decision16-Mar-2020
Date of Acceptance30-Oct-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Vemireddy P K Reddy
Fellow, Department of Radiology and Imaging Sciences, Sri Ramachandra Medical College and Research Institute, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325299

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 » Abstract 


Hemorrhagic neuropathy is an extremely rare condition. This condition refers to bleed into or around a peripheral nerve, causing either an extra neural or an intraneural hematoma. When they do occur, it is usually due to iatrogenic/inherited coagulopathies or as a consequence of injections targeting nerves. We present a case of sciatic nerve palsy developed secondary to anticoagulant therapy (Warfarin). MRI imaging showed features of sciatic nerve hematoma following which warfarin was withdrawn. The patient showed symptomatic improvement and a follow up ultrasound of left thigh showed resolution of hematoma with normal sciatic nerve diameter. To the best of our knowledge there is limited available literature regarding nerve hematomas secondary to anticoagulation therapy. This complication should be promptly recognized and immediate steps should take place because of the favorable results of the early treatment.


Keywords: Hemorrhagic neuropathy, magnetic resonance imaging, sciatic nerve, warfarin
Key Message: Sciatic nerve hematoma is an extremely rare entity. MRI is a non-invasive modality of choice with high sensitivity for detection of nerve hematomas and acute soft tissue changes without a need for biopsy.


How to cite this article:
K Reddy VP, Rangasami R, Vignesh G. Sciatic Nerve Hematoma - Case Report. Neurol India 2021;69:1043-4

How to cite this URL:
K Reddy VP, Rangasami R, Vignesh G. Sciatic Nerve Hematoma - Case Report. Neurol India [serial online] 2021 [cited 2021 Oct 22];69:1043-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1043/325299




Neuropathy produced by hemorrhage is an infrequently diagnosed and poorly understood condition which has a distinct clinical constellation of signs and symptoms permitting early recognition and treatment before paralysis occurs. The most common presenting feature is mild-to-severe pain of acute or subacute onset in the distribution of the involved nerve followed by signs of motor weakness and variable loss of sensation and of the appropriate reflexes. There are very few available isolated reports of sciatic nerve palsy due to hematoma formation following anticoagulant therapy. Here in we describe a case of sciatic nerve palsy due to hematoma formation.


 » Case Report Top


A 46-year-old male patient presented with complaints of pain in the left leg of 3 days duration. The pain was moderate to severe in intensity and was predominantly in the thigh region. There was no history of trauma and neither were any aggravating nor relieving factors. He was on treatment for hypertension and type II diabetes mellitus for the last 4 years. This patient had a past history of diagnosed left lower limb deep venous thrombosis (DVT) and was administered anticoagulant therapy (Acitrom) as a treatment protocol. The baseline investigations were within the normal limits. Though his general examination was unremarkable, Local examination revealed calf tenderness with normal peripheral pulses. As he was a known case of DVT, he was empirically started on warfarin initially till the INR report and coagulation profile were obtained. After a few days of warfarin administration with assumed diagnosis of recurrent deep venous thrombosis, patient's condition worsened and he started complaining of left lower limb numbness, excruciating pain in the posterior compartment of the thigh with difficulty in dorsiflexion of foot on examination. Suspecting a recurrence of DVT, he was advised a Doppler scan to check for venous flow. However, as it showed good recanalization of the deep veins, the patient was advised MRI. On MRI examination, edema was noted in the muscles of the posterior compartment of the left thigh with streaks of hemorrhage [Figure 1]. Hemorrhage was also seen within the sciatic nerve. The sciatic nerve appeared thickened measuring 8 × 12 mm from the level of sciatic foramen till the popliteal region. On contrast enhanced MR, patchy enhancement was seen. In the routine MRI, Blooming was identified in the GRE sequence within the nerve, indicating a hematoma. Hence patient was subjected to Ultrasound screening which showed a hyperechogenicity within the nerve causing expansion of the nerve with no significant internal vascularity. However, no such hyperechogenicity was noted in the adjacent surrounding structures, indicating that hematoma was confined to the nerve. As the patient's INR (International normalized ratio) turned out to be high (4.1), the anticoagulants were withheld and he was started on parenteral injection of Vitamin K. There was a symptomatic improvement of the patient's condition following withdrawal of warfarin therapy. Patient was later discharged as his condition improved and was advised clinical follow up. His follow up ultrasound done at 6 months showed good resolution of the sciatic nerve hematoma [Figure 2].
Figure 1: A 46-year-old male patient presented with complaints of pain in the left leg. (a) Axial T2 weighted MRI image shows thickened left sciatic nerve. Right leg appears normal. (b) Axial fat suppressed T2 weighted image shows thickened left sciatic nerve (arrows) with surrounding inflammatory changes. (c and d) Coronal T2 and fat suppressed T2 weighted images show thickened left sciatic nerve (arrows) and oedema in the muscles of posterior compartment of thigh (arrow heads). (e and f) Coronal GRE images show blooming along the length of thickened sciatic nerve suggesting haemorrhage along the nerve (arrows)

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Figure 2: A 46-year-old male patient presented with complaints of pain in the left leg shows the following, (a) Ultrasound longitudinal section shows thickened left sciatic nerve (arrows). (b) Follow up ultrasound after 6 months show a normal sciatic nerve diameter (arrow heads) measuring 0.32 cm with resolution of nerve hematoma

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 » Discussion Top


Hemorrhagic neuropathy is a very unusual condition. This condition refers to bleed into or around a peripheral nerve, causing either an extra neural or an intra-neural hematoma. When they do occur, it is usually due to iatrogenic/inherited coagulopathies or as a consequence of injections targeting nerves. It can occur spontaneously or be produced by a multitude of causally related disorders, including bleeding diathesis (natural or iatrogenic), trauma and neoplasms.[1] Usual presentation is mild to severe pain in the distribution of the nerves is followed by flaccid, paralysis with variable atrophy and variable sensory change.[2] Recovery occurs after bleeding gets arrested but the disability may last for many months. Pathogenesis involved in peripheral nerve damage due to hematoma can be divided into extra-neural and intra neural mechanisms.[3] Extra neural mechanism can be explained taking into consideration the extra neural hematoma due to trauma or hemorrhagic diathesis causing direct compression on the nerve. Intra-neural mechanism can be explained by the fact that hematoma formed fails to disperse or dissipate along subepineurial space. The actual formation of subepineural or perineural hematoma initially causes a compressive or anoxic ischemia followed by infarction of the neural elements by occlusion of the vascular supply to the sciatic nerve.[4] Evacuation of the hematoma or decompression of the nerve can reduce the pressure effects and reverse the ischemic effects.[5] In the study done by Gboyega Adeboyeje et al., showed that the rate of major bleeding with warfarin was 6.0 per person-years versus 2.8 with dabigatran, 3.3 apixaban and 5.0 with rivaroxaban.[6] Careful and continuous monitoring of coagulation parameters in high risk patients can help to reduce the chance of sciatic nerve palsy and potential life-threatening complications.


 » Conclusion Top


MRI plays an important role in nerve injuries due to high sensitivity for detection of nerve hematomas and acute soft tissue changes. Prompt diagnosis and timely intervention play a key role in reducing the overall complication rate and the serious morbidity associated with it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Brun A, Caviness V, Rudnick P, Tyler H, Klatzo I. Hemorrhages into peripheral nerves in association with leukemia. J Neuropathol Exp Neurol 1964;23:719-25.  Back to cited text no. 1
    
2.
Abou-Al-Shaar H, Mahan MA. Sciatic nerve intraneural hematoma. World Neurosurg 2019;129:170-1.  Back to cited text no. 2
    
3.
Mitchell SW. Injuries of Nerves and Their Consequences. JB Lippincott; Philadelphia. 1872.  Back to cited text no. 3
    
4.
Richardson RR, Hahn YS, Siqueira EB. Intraneural hematoma of the sciatic nerve: Case report. J Neurosurg 1978;49:298-300.  Back to cited text no. 4
    
5.
Polis L, Brzezinski J. Posttraumatic hematoma beneath the epineurium of a branch of the median nerve: Case report. J Neurosurg 1977;46:542-3.  Back to cited text no. 5
    
6.
Adeboyeje G, Sylwestrzak G, Barron JJ, White J, Rosenberg A, Abarca J, et al. Major bleeding risk during anticoagulation with warfarin, dabigatran, apixaban, or rivaroxaban in patients with nonvalvular atrial fibrillation. J Manag Care Spec Pharm 2017;23:968-78.  Back to cited text no. 6
    


    Figures

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