Novel approach clears large, painful bleed in woman with VWD
Fluid drainage with clot-busting medication successfully treats hip hematoma
Doctors successfully treated a large and painful muscle bleed in a 32-year-old woman with von Willebrand disease (VWD) using a minimally invasive approach: a catheter to drain the fluid combined with a powerful “clot-busting” medication.
The combination of fluid drainage and alteplase — a medication typically used to break down blood clots — resolved the large hematoma (a collection of blood) in the woman’s hip muscle. Because of the hematoma, the woman had developed pain in her left thigh as well as neuropathy, which is nerve damage that causes pain, numbness, tingling, or weakness. The symptoms eased as the hematoma decreased with treatment.
This case “illustrates that, in resource-limited settings where specific factor concentrates are unavailable, innovative strategies … may provide a viable therapeutic alternative,” researchers note.
Risks and VWD background
However, “the use of alteplase in patients with inherited bleeding disorders theoretically carries a significant risk of [bleeding] complications,” and more studies are needed to validate the safety of this approach, they wrote.
The case was described in an article, “Intralesional Alteplase as an Adjunct to Percutaneous Drainage for a Large Iliopsoas Muscle Hematoma in a Patient With Von Willebrand Disease: A Case Report,” published in Cureus.
VWD is typically caused by mutations in the VWF gene, resulting in a deficiency of functional von Willebrand factor (VWF), a protein essential for blood clotting. As a result, blood clotting is impaired, leading to symptoms such as easy bruising or unusual bleeding.
In the report, researchers described the case of a woman treated at a hospital in Mexico who had a history of irregular periods and heavy menstrual bleeding, which frequently required blood transfusions.
Following a chiropractic session, she experienced a hematoma where the abdomen meets the thigh, damage in the femoral nerve (a large nerve in the leg), and excruciating pain.
A CT scan revealed a hematoma in the left iliopsoas muscle in the hip. The woman was admitted to the hospital, with an interdisciplinary consultation confirming she had type 3 VWD.
Initial treatment involved intranasal desmopressin and the antifibrinolytic medication tranexamic acid to prevent bleeding. It also included cryoprecipitate, a concentrated blood component rich in clotting factors, and fresh-frozen plasma to stabilize the levels of hemoglobin, the protein that carries oxygen in red blood cells.
After the woman’s condition stabilized, a multidisciplinary team decided to perform a minimally invasive approach because of the high risk of bleeding during surgery and in accordance with the patient’s preference.
In the first week, a thin tube was placed through the skin to drain fluid from the hematoma. In the second week, due to persistent femoral nerve damage, the woman was given alteplase into the lesion.
By week three, the hematoma had significantly reduced by about half, leading to clinical improvement. The patient discontinued cryoprecipitate and fresh-frozen plasma but resumed the treatments after she developed blood in her urine from a urinary infection.
In the fourth week, her hematoma had further decreased, with the patient reporting resolution of pain, improved leg strength, and limited tingling and numbness. She was able to walk and was discharged despite her residual hematoma.
Two weeks later, she was able to walk with slight weakness. At six weeks, imaging revealed near-complete resolution of her hematoma, and she was able to return fully to her daily activities.
“This case demonstrates the success of combining percutaneous drainage with fibrinolytic agents as an effective and safe alternative to conventional surgical management in patients with severe coagulopathies [bleeding disorders],” the researchers wrote.
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