Successful thoracoscopic evacuation of an extrapleural hematoma with delayed symptomatic pleural effusion: a case report
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Traumatic extrapleural hematoma is a rare condition and is usually managed conservatively until spontaneous resolution unless active bleeding or expansion is found.
An 80-year-old man taking an anticoagulant medication was referred to our hospital after accidentally falling in a street ditch while riding a bike. Chest X-ray and computed tomography (CT) scan showed multiple fractures on ribs 7–9, hemothorax, and extrapleural hematoma in the posterior chest wall. Though the patient’s hemothorax was improved by chest tube drainage, the extrapleural hematoma still remained. He was transferred to another hospital for rehabilitation, but he was readmitted to our hospital because of dyspnea with accumulation of left pleural effusion, including a subpopulation of neutrophils, but without bacterial infection. We performed thoracoscopic evacuation of the hematoma on day 57 after the initial blunt chest trauma. The patient has had no recurrence of pleuritis for 6 months after surgery.
Since posttraumatic extrapleural hematoma may result in delayed secondary intractable pleural effusion causing dyspnea, careful observation is necessary when considering indications of surgical intervention.
KeywordsChest wall Pleura Trauma Blunt
An extrapleural hematoma is a rare and occasionally life-threatening condition defined as hemorrhage between the parietal pleura and endothoracic fascia. This condition may occur as a complication after blunt chest trauma associated with rib or sternal fractures, which cause injury to the intercostal or parasternal vessels. In the acute phase, patients with extrapleural hematomas should be treated surgically if their vital signs are unstable or if they are in hypovolemic shock. Otherwise, the patient’s status can be observed for active bleeding or expansion of the hematoma until spontaneous resolution. We herein present the case of a patient with multiple rib fractures and an extrapleural hematoma requiring surgical treatment due to a delayed intractable pleural effusion during the chronic phase.
Extrapleural hematomas occur in approximately 7% of patients with blunt chest injuries . These patients almost always have complications of rib fractures and hemothorax [1, 2]. Hemothorax after thoracic trauma can result in serious conditions, such as hemorrhagic shock. Conversely, the extrapleural space is a rare site of blood pooling because of the limited space between the parietal pleura and thoracic muscle fascia. Usually, a watch-and-wait approach can be taken if the vital signs of the patient are stable, there is no progression of anemia, and the hematoma does not expand in size. Several cases of conservative treatment for extrapleural hematomas including observation or image-guided drainage have been reported [3, 4]. Regarding the indications for surgical treatment, Chung et al. reported that a biconvex extrapleural hematoma on CT tended to be larger than other types (nonconvex), and surgical intervention might be necessary . Rashid et al. also reported a single case of a patient who underwent surgical treatment with thoracotomy following insufficient needle aspiration drainage, while conservative treatment with observation and chest X-ray monitoring was performed in the remaining 33 patients with extrapleural hematomas . However, patients with extrapleural hematomas who are administered antithrombotic or anticoagulant agents should be strictly followed up because they have a high risk of rapid expansion of the hematomas [5, 6]. Posttraumatic pleural effusions might be caused by the infiltration of eosinophils into the pleural space  or bacterial empyema . In the present case, a large amount of pleural effusion was found in the left thoracic cavity with a residual extrapleural hematoma 2 months after the patient sustained a chest injury. With neither infection nor eosinophilic infiltration in the pleural effusion and the thickened parietal pleura as intraoperative findings, we speculated that a relatively large chronic hematoma outside the parietal pleura contributed to secondary pleural inflammation and resulted in delayed pleuritis.
Residual extrapleural hematoma occupying a portion of the thoracic cavity should be carefully observed in patients undergoing conservative treatment, and surgical resection might be an option for nonregressive lesions.
All authors equally participated in the care of the patient. All authors participated in the acquisition, analysis, or interpretation of the data; drafting and revising of the manuscript; and the final approval of the paper. Furthermore, all authors agreed to be accountable for the integrity of the case report and have read and approved the final manuscript.
We have no disclosures of financial support relating to this study.
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The authors declare that they have no competing interests.
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