J Emerg Med. 2025 Nov 4;80:181-186. doi: 10.1016/j.jemermed.2025.11.001. Online ahead of print.
BACKGROUND: Intercostal artery hemorrhage (ICAH) is an extremely rare, potentially life-threatening condition. The etiology of ICAH includes trauma, anticoagulation therapy, bleeding disorders, infections, and underlying diseases such as neurofibromatosis type 1, systemic lupus erythematosus, and hypertension. Due to the rarity of this condition, standardized treatment strategies remain undefined. We report a rare case of spontaneous ICAH successfully managed with conservative therapy and review relevant literature.
CASE REPORT: A 49-year-old male presented with sudden and progressively worsening abdominal and back pain. He had no history of trauma or underlying diseases, except for previously undiagnosed and uncontrolled hypertension. Imaging revealed a hemorrhage from the intercostal artery in the posterior mediastinum, which was considered to be the likely source of bleeding. Given the patient’s hemodynamic stability and location of the hematoma, conservative management was selected. Blood pressure was initially controlled with intravenous nicardipine, followed by oral sacubitril/valsartan and nifedipine administration. The hematoma did not increase in size, and the patient was discharged on day 15, without complications. Follow-up imaging confirmed complete resolution of the hematoma, and the patient’s blood pressure remained stable without further antihypertensive medication use. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although ICAH is extremely rare, it can cause life-threatening bleeding. Prompt recognition is essential, especially when imaging reveals a posterior mediastinal hematoma without trauma or anticoagulation therapy. Conservative management may be feasible in hemodynamically stable patients with natural tamponade; however, careful patient selection and close monitoring are crucial. Awareness of this condition can help avoid unnecessary invasive procedures.
PubMed:41289784 | DOI:10.1016/j.jemermed.2025.11.001