Spontaneous non-traumatic mediastinal hematoma associated with oral anticoagulant therapy: A case report and literature review

Abstract

Introduction: Mediastinal hematoma is usually caused by thoracic trauma or a ruptured aortic aneurysm. Spontaneous non-traumatic mediastinal hematomas are rare but potentially life-threatening conditions that can occur in patients taking anticoagulants.

Presentation of case: We report a case of 72-year-old man with a massive mediastinal hematoma associated with anticoagulant therapy. He had complained of acute chest discomfort and subsequent tarry diarrhea. Because he had been taking warfarin for paroxysmal atrial fibrillation, an upper gastrointestinal hemorrhage was initially suspected, but no bleeding was detected by upper endoscopy. A computed tomography scan revealed a massive posterior mediastinal hematoma and markedly compressed surrounding structures. The compression of the left atrium caused a congested lung and exacerbated respiratory and hemodynamic status despite conservative therapy. Therefore, we surgically removed the hematoma. Immediately after removal, the respiratory and hemodynamic conditions improved, and the postoperative course was uneventful.

Discussion: Spontaneous mediastinal hematoma is rare but can occur in patients who are administered anticoagulants regardless of the therapeutic level of anticoagulation. Although conservative therapy is commonly effective, active surgical intervention should be considered for cases in which the hematoma is symptomatic or conservative therapy is ineffective.

Conclusion: To facilitate prompt and proper management, clinicians should be aware of this condition as a potential complication of anticoagulant therapy.

Keywords: Anticoagulant therapy; Case report; Spontaneous mediastinal hematoma; Surgery.

Fig. 1

Preoperative computed tomography scan findings. A massive mediastinal hematoma extended from the superior to the posterior mediastinum (arrows). The trachea, main bronchi, and left atrium were extremely anteriorly displaced by the hematoma (A–C), and a congested lung was detected (D). LA, left atrium.

Fig. 2

Preoperative echocardiogram findings. The left atrium was compressed and narrowed because of the hematoma. LA, left atrium; LV, left ventricle; Ao, aorta.