CEH is related to a history of surgery or trauma. In addition, CEH in the chest occur in patients with a history of treatment for tuberculosis [4, 5]. The durations between these previous episodes and first diagnosis of CEH can vary from one month to decades [6]. CEH can result from stimulation of blood and its degradation products, leading to repeated exudation or bleeding from the capillaries of granulation tissue. The factors that trigger this behavior in some hematomas are unclear[7]. Anticoagulant therapy was shown to be associated with the incidence of CEH. Treatment of CEH is total resection. However, complete resection has been reportedly difficult due to the presence of fibrous adhesions [8].
Of the 133 cases found in the present review (Table 1), 94 (71%) of the cases were in males and 39 (29%) of the cases were in females. The median age of the patients was 65 years (range of 8 - 89 years). The reported clinical latent periods ranged widely from 1 month to 660 months (median period of 252 months). The most common lesion site was the thorax including the chest wall of 59 (44.4%) of the patients. Two patients (1.5%) and 36 patients (27.0%) patients had lesions in the upper and lower extremities, respectively, and 13 patients (9.7%) and 16 patients (12.0%) patients had lesions in the abdomen and pelvis, respectively. Forty patients (30.0%) and 46 patients (36.8%) had antecedent episodes of trauma and surgery, respectively, 7 patients (5.2%) had undergone anticoagulant therapy, and 5 patients (3.8%) were dialysis patients. The most common therapy for CEH was total resection; however, 6 patients (4.5%) patients did not undergo resection. In 6 patients (4.5%) patients, CEH was the cause of death.
Table 1
Review of the 133 cases with chronic expanding hematoma
| N=133 |
Sex | |
Male | 94 (71%) |
Female | 39 (29%) |
Age (years) | |
Median | 65 (48–89) |
Location | |
Upper extremities | 2 (1.5%) |
Lower extremities | 36 (27.1%) |
Thorax | 59 (44.4%) |
Abdomen | 13 (9.7%) |
Pelvis | 16 (12.0%) |
Head and neck | 3 (2.3%) |
Other | 4 (3.0%) |
Antecedent episode | |
Trauma | 40 (30.0%) |
Surgery | 49 (36.8%) |
Tuberculosis | 32 (24.1%) |
Radiation therapy | 3 (2.3%) |
Other | 2 (1.5%) |
Range from antecedent episode (months) | |
Median | 252 (1-660) |
Treatment | |
Surgery | 115 (86.4%) |
Observation | 6 (4.5%) |
Embolization | 15 (11.3%) |
Unknow | 11 (8.27%) |
Our review showed that 3 cases (2.2%) had a history of radiotherapy after surgery. In 2 cases with a history of radiotherapy, the irradiation area and dose were not clear. Sakamoto et al. reported that CEH occurred in the foot after an operation with adjuvant radiotherapy (84Gy) [9]. There have been reports of CEH in the brain after treatment with gamma knife for cerebral arteriovenous malformations [2][3]. However, there has been no report about chronic CEH after SBRT. This is the first report of CEH after SBRT.
Haemodialysis (HD) patients are at an increased risk of bleeding because of uraemic bleeding tendency and systemic anticoagulation caused by intermittent heparinization [10]. Therefore, HD might be associated with the incidence of CEH. CEH occurred in some patients undergoing HD. Our patient had a medical history of HD due to nephrotic syndrome.