A rare case of median nerve intraneural hematoma after stenting of right iliac artery: a case report

Aim: Brachial artery access is an alternative approach to endovascular interventions when access to the femoral, radial, or ulnar arteries is not feasible, but it carries higher risk of periprocedural complications than other approaches, including median nerve injury. Nerve injuries can occur by direct puncture or by compression, with hematoma being the most common cause. Sometimes the compartment syndrome can accompany the direct nerve injury, masking the signs of a nerve dysfunction. Case report: We present a patient with a false aneurysm of brachial artery, surrounding soft tissue hematoma with volar arm and forearm compartment syndrome and a simultaneous median nerve intraneural hematoma caused by a direct punction. The combination of injuries occurred after brachial artery access for endovascular treatment of bilateral iliac artery steno-occlusive disease. The patient was successfully treated by fasciotomy, arterial sutures, and nerve decompression via paraneuriotomy. Conclusions: Intraneural hematoma caused by direct puncture can be masked by concomitant compartment syndrome. Emphasis should be put on prevention, early recognition, and timely surgical treatment of intraneural hematomas, especially those accompanied by fascial compartment syndrome after endovascular interventions. Cilj: Pristup brahijalnoj arteriji alternativni je pristup endovaskularnim intervencijama kada pristup femoralnoj, radijalnoj ili ulnarnoj arteriji nije izvediv, ali nosi veći rizik od periproceduralnih komplikacija nego drugi pristupi, što uključuje i ozljede medijanog živca. Ozljede živca mogu nastati izravnom punkcijom ili kompresijom, pri čemu je najčešći uzrok hematom. Ponekad sindrom mišićnih odjeljaka može pratiti izravnu ozljedu živca, prikrivajući znakove živčane lezije. Prikaz slučaja: Predstavljamo bolesnicu s lažnom aneurizmom brahijalne arterije, okolnim hematomom mekih tkiva, sindromom volarnog mišićnog odjeljka nadlaktice i podlaktice te s istodobnim intraneuralnim hematomom medijalnog živca koji je bio uzrokovan izravnom punkcijom. Ove udružene ozljede nastale su nakon punkcije brahijalne arterije u sklopu endovaskularnog liječenja bilateralne stenookluzivne bolesti ilijačne arterije. Pacijentica je bila uspješno liječena fasciotomijom, izravnim šavom arterije i dekompresijom živca (paraneuriotomijom). Zaključci: Intraneuralni hematom uzrokovan izravnom punkcijom može biti prikriven znakovima pratećeg sindroma mišićnih odjeljaka. Stoga treba staviti naglasak