Hematomas present as hard, solid and painful lumps or swellings under the skin. The overlying skin is often bruised and discoloured with ecchymosis as a common presentation. Intracranial hematomas also have symptoms of severe headache, nausea and vomiting, double vision, seizures and unconsciousness. The clinical presentation of intramural hematoma (IMH) and aortic double-lumen dissection (AD) is often similar [7] so a difference needs to be made with the help of imaging studies. Rectus sheath hematomas present with abdominal pain along with a palpable lump.

Work up includes a thorough physical and neurological examination and patient history, followed by some laboratory tests and imaging studies

Laboratory tests

• Complete blood count
• Prothrombin time and APTT
• Liver function tests
• Serum BUN and electrolytes
• GCS measurement
• Serum alcohol levels

Imaging 

CT scans and MRI are the primary investigative and diagnostic tests for hematomas. Pre-contrast CT scans of an organized hematoma show hyperdense masses with or without calcification [8]. Doppler ultrasounds may also be conducted if needed.

Test results

On the basis of a thorough clinical examination and imaging studies the exact location and the extent of the hematoma can be found out. Tests can also help in assessing the risk of rupture of the hematoma and appropriate treatment can be accordingly planned.

Treatment of a hematoma depends on the severity and extent of the hematoma. According to panel consensus statements, if progressive hemorrhage as shown by 2 successive CT or MRI scans along with haemodynamic instability, persistent pain and signs of impending rupture are present, immediate surgical treatment is recommended. If such conditions are absent, medical treatment is recommended [9].

According to the findings of a recent study chances of a good recovery are possible if an aggressive surgical approach is taken in particular cases like those of patients with extradural hematomas [10]. Treatment with medication includes the use of osmotic diuretics, anticonvulsants, analgesics and corticosteroids. In cases of intracranial hematomas, antacids may also be given to reduce the chances of gastric ulcers.

If not treated, intracranial hematomas pose a negative prognosis with very high rates of mortality. The prognosis depends on the size, shape and thickness of the hematoma and how much it is suppressing the underlying and neighbouring structures. Hematomas occurring in the limbs as a result of trauma or in the abdomen usually have a good prognosis. Some hematomas don’t even require treatment and spontaneously resolve.

Causes behind intracranial hematomas include blunt head trauma, clotting disorders, intracranial hypotension like after spinal epidural anaesthesia [1] and lumbar puncture. Some of them are even idiopathic. Underlying arteriovenous (AV) malformations were also identified in one study [2].

Other hematomas can occur due to different causes. Some anticoagulant drugs like heparin or warfarin can also disrupt normal coagulation and cause hematomas. A study reported a case of sublingual hematoma secondary to warfarin therapy [3]. Trauma, AV malformations and clotting disorders are also various other kinds of hematoma formation.

Incidence

Hematomas are common findings in accidents and trauma cases. Around 5% to 25% of people with head trauma develop subdural hematomas and 2% develop epidural hematomas.

Sex

Subdural hematomas are more common in men, with a ratio of 3:1. Epidural hematomas are also more common in men, with a ratio of 4:1.

Age

Hematomas in children are rare unless the child is suffering from inherited coagulation disorders or has suffered trauma. They are much more common in adults in the 5th and 6th decade of life.

Hematomas are localized accumulations of blood outside the blood vessels. Epidural hematomas most commonly involve the middle meningeal artery. They are due to blunt trauma that causes the dura mater to separate from the periosteum and the blood vessels in between to stretch and rupture. This leads to rapid leakage and flooding of blood between the meningeal layers. Subdural hematomas are also typically due to trauma. Some chronic subdural hematomas may enlarge from an osmotic gradient, drawing more fluid into the subdural space. The mechanism of calcification can also be the pathogenesis behind hematoma formation [4]. According to a study performed by Kawakami in 1989, it was found that the coagulation and fibrinolysis systems were both excessively activated due to unknown causes in cases of chronic subdural hematoma [5].

Rectus sheath hematoma (RSH) may develop due to rupture of epigastric arteries in the abdomen or the rectus muscle itself due to severe trauma [6]. Other less common types of hematoma include subungal hematoma which occurs under or around the nailbed, perianal hematoma, subgaleal hematoma which occurs between the periosteum and the galeal aponeurosis and subdermal hematoma which occurs under the skin and typically in muscles.

Hematomas can only be prevented by avoiding injuries and carefully monitoring the use of anticoagulant drugs.

Hematomas are localized collection of extravasated blood that leaks out of ruptured blood vessels and accumulates in the surrounding area. The hematoma may occur inside muscles, in internal organs, between two membranes, in joint cavities and under the skin. According to the area or site of the hematoma, it can be named and divided. By far, intracranial hematomas pose the greatest risk of rupture and damage, even death. Hematomas occurring under the skin of limbs and joints are less dangerous, but no less painful.

Definition

A hematoma is a collection of blood outside the blood vessels which appears as a hard lump or swelling.

Cause

It is most commonly a result of trauma. It may also occur due to clotting disorders, arteriovenous malformations, excessive alcoholism, anticoagulant therapy, etc.

Signs and symptoms

Symptoms include hard, solid swelling under the skin accompanied with pain. Intracranial hematomas also present with headache, double vision, nausea and vomiting, seizures and unconsciousness.

Diagnosis

Diagnosis is made be carefully assessing the physical findings and the results of imaging studies and laboratory tests.

Treatment

Treatment includes medication like painkillers, anticonvulsants, etc and in severe cases, surgical removal of the accumulated blood and repair of the ruptured blood vessels.

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10. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J. 2014 Nov 10.