Introduction
Spontaneous Muscle Hematoma (SMH) is an uncommon condition often overlooked or misdiagnosed. For a quick diagnosis and to choose the best treatment, a high degree of suspicion is necessary especially in patients with acute stroke, because they receive antiplatelet or anticoagulant therapy. We report 1 case associated with SMH of the hemiplegic lower limb.
Case
A 61-year-old woman was admitted to gynecology department of our hospital to receive Laparoscopically Assisted Vaginal Hysterectomy (LAVH). A one day after LAVH, she complained right side weakness and dysarthria. Her National Institutes of Health Stroke Scale score was 23 points. Because brain Magnetic Resonance Imaging (MRI) showed cerebral infarction caused by narrowing of the left anterior cerebral artery, aspirin 100mg and clopidogrel 75mg were started. Two weeks after starting antiplatelet therapy, she complained right hip pain. A physical examination revealed the tenderness on her right posterolateral side of hip and restricted straight leg raise and limited passive hip flexion with a bent knee. But there was no trauma history and no visible skin color change like bruise and petechiae. Simple radiography of hip showed swelling of right hip side, and there was no definite bony abnormality (Figure 1A). After day, she was transferred to our department for rehabilitation. We administered painkillers to modulate her pain, but the pain was aggravated over time. After 4 days, we performed contrast enhanced MRI of hip, and it showed deep soft tissue hematoma of right buttock (Figure 1B). To find out damage of large vessel, Computed Tomography (CT) angiogram was performed, and there was no abnormality of large vessels (Figure 1C). Her hemoglobin level at the time was 9.9 g/dL. The aspiration of hematoma was not performed because large needle aspiration could encourage another bleeding. We stopped antiplatelet after consulting with neurology department of our hospital to prevent additional hemorrhage. After one week, pain was improved and hemoglobin level was increased to 10.6 g/dL. One week follow up contrast enhanced CT of low extremities was done, and it revealed that slight reduction of hematoma (Figure 1D). After discussing with neurology department, we resumed aspirin 100mg and clopidogrel 75mg. The patient was followed-up at 1 week after starting antiplatelet drugs again, she showed a normal clinical examination with absence of symptoms and her hemoglobin level was increased to 11.1 g/dL.
Discussion
We have presented a case associated with deep soft tissue hematoma of hip in hemiplegic limb. A notable point is that there was no trauma history on her total admission period. SMH can be developed in acute stroke patients who take drugs to prevent recurrence of stroke. This case highlights the need to consider SMH as a differential diagnosis of unexplained muscular pain after starting antiplatelet or anticoagulant therapy in acute phase of stroke.
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