|Year : 2015 | Volume
| Issue : 4 | Page : 163-165
Oral Anticoagulation-induced Iliacus Hematoma and Femoral Neuropathy!
Sunil Joshi, Mario Newton, Deep Shikha Kerketta
Department of Surgery, Division of Vascular Surgery, St. Johns Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||13-Apr-2016|
Department of Surgery, Division of Vascular Surgery, St. Johns Medical College, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Oral anticoagulation is very effective in the management of thrombotic disorders. However, it can be associated with significant bleeding complication as its side effects. Iliacus hematoma presenting as a femoral neuropathy is a rare clinical scenario. Patients on anticoagulation with iliacus hematoma and neurological dysfunction should be taken up for decompression to avoid permanent disability. We, hereby, we report an interesting case of progressive femoral neuropathy due to iliacus hematoma which was decompressed successfully with prompt recovery of neurological dysfunction.
Keywords: Decompression, femoral neuropathy, iliacus hematoma, oral anticoagulation
|How to cite this article:|
Joshi S, Newton M, Kerketta DS. Oral Anticoagulation-induced Iliacus Hematoma and Femoral Neuropathy!. Indian J Vasc Endovasc Surg 2015;2:163-5
| Introduction|| |
Oral anticoagulation is routinely used in the field of vascular surgery for arterial as well as venous thromboembolism. However; it is not without any complications. Well-known side effects are related to bleeding complications. Spontaneous bleeding in the retroperitoneal region results in major morbidity and mortality. Patients with retroperitoneal bleeding are treated by conservative approach or surgically based on hemodynamic status. However, hematoma of iliacus muscle resulting in femoral nerve compression is a rare condition in these patients. Because of the rareness of this condition, the optimal treatment remains controversial.
Hereby, we present a case of iliacus muscle hematoma that caused progressive neuropathy, in a patient on oral anticoagulation, treated by decompression and prompt recovery.
| Case Report|| |
A 25-year-old male with presented with right lower abdomen pain, radiating to the right thigh from 4 days. He complained of difficulty in walking. The patient had deep vein thrombosis (DVT) involving the right superficial femoral vein in the thigh and was on warfarin daily with irregular coagulation profile monitoring over the last 8 months. He was not a known case of thrombophilia. On admission, his vital signs were stable. Right iliac fossa tenderness was present along with painful spasm and fixed flexion deformity at the right hip joint [Figure 1]. Hb - 13 mg/dl, platelet count - 2 lakhs, prothrombin time - 52.7, International Normalized Ratio - 4.5, and ultrasound abdomen showed probe tenderness in right iliac fossa, mild inter-loop fluid, and sluggish bowel movements. Clinically, he was diagnosed to be appendicitis, but vascular surgery reference was sought for an opinion regarding DVT and anticoagulation. Computerized tomography (CT) scan of the abdomen and pelvis was done which showed bulky right iliacus and quadrates lumborum muscle with the iliacus pushing the psoas anteromedially [Figure 2]. Few hyperdense and hypodense areas with a fluid-fluid level noted in the iliacus with fat stranding around the psoas and iliacus muscle suggestive of hematoma.
The patient was managed conservatively initially; his warfarin was withheld and fresh frozen plasma transfusions were given. There was no daily drop in the hemoglobin levels and the patient was hemodynamically stable. However, over the next 48 h, patient symptoms worsened and he was unable to extend his knee and stand on his feet. Neurology evaluation revealed loss of sensation in the right thigh and motor weakness of Grade 2/5. Electroneuromyography (ENMG) of right lower limb showed severe right femoral motor axonopathy with right lateral cutaneous and saphenous axonal neuropathy.
The patient was diagnosed to have right femoral compressive neuropathy and in view of progressive deterioration, he was subjected for emergency surgery for evacuation of hematoma and nerve decompression.
Under general anesthesia, retroperitoneum explored through the right paramedian incision. Iliacus muscle was tense and bulging [Figure 3]. There was no other collection in retroperitoneum. On incising iliacus fascia and muscle, about 400 ml of hematoma was evacuated [Figure 4]. There was no evidence of infection or active bleeding at exploration. Femoral nerve was seen deep to the fascia, safeguarded, and relieved of compression [Figure 5]. Hemostasis was achieved and thorough saline wash given. Abdomen closed in layers.
The painful spasm at the right hip joint was relieved. The patient was able to extend his right thigh completely [Figure 6]. He started walking by the 2 nd day with improved sensation over the femoral nerve distribution. On follow-up after 3 months, repeat ENMG was done which showed complete recovery of the femoral neuropathy.
| Discussion|| |
The clinical impact of anticoagulant-related major bleeding in patients with venous thromboembolism is considerable.  There is a strong relationship between the intensity of anticoagulant therapy and the risk of bleeding that has been reported in patients with DVT.  Retroperitoneal hematoma incidence in patients undergoing therapeutic anticoagulation varies between 0.6% and 6.6% among studies. 
Iliac hematomas are rare, usually associated with acetabular fracture, muscle tear, hemophilia, and oral anticoagulation. The incidence of warfarin-induced incidence of femoral neuropathy is not known. Anatomical course of the nerve is essential, to see why small hematoma in iliacus can cause femoral compressive neuropathy. The femoral nerve (L2-L4) originates within the body of the psoas muscle, runs between the psoas tendon and iliacus muscle beneath the iliac fascia. It provides motor innervations to the quadriceps, sartorius, pectineus, and iliopsoas muscles, and supplies sensory innervations to the anteromedial thigh and medial leg. The iliacus fascia is so strong that it is usually not stretched by the underlying hematoma, leading to femoral nerve compression in the illiopsoas gutter. Femoral nerve in this region has poor vascular supply and, therefore, is easily susceptible to ischemia.  Iliacus hematoma never dissolves spontaneously; it gets organized causing chronic compression of the femoral nerve. 
The goal of the treatment is to stop bleeding by correcting hematological abnormalities. The anticoagulants must be ceased immediately and patient has to be immobilized. In general, conservative approach with close hemodynamic and neurological monitoring is suggested in stable patients. Retroperitoneal hematomas with progressive neurological dysfunction cannot be managed conservatively. Operative evacuation of hematoma has been suggested.  If managed conservatively or surgical decompression is done more than 48 h later, the risk of permanent femoral neuropathy is much larger. 
| Conclusion|| |
Patients on anticoagulation with complaints of pain in the femoral nerve distribution should be suspected to have iliacus hematoma. High index of suspicion is necessary to diagnose these cases. CT with contrast is usually required in workup. Patients with progressive neurological dysfunction should be taken up for decompression to avoid permanent disability.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]