(Kiosk 2) Nervous Under Pressure: Severe Femoral Neuropathy Post Cardiac Catheterization - a Case Report

Case Diagnosis: A 79-year-old male with left iliopsoas hematoma causing motor and sensory deficits across the femoral nerve territory.

Case Description or Program Description: A 79-year old male was admitted for left lower extremity (LLE) dysfunction following transfemoral cardiac catheterization. Physical exam confirmed 0/5 strength with LLE hip flexion and knee extension and sensory loss across the femoral nerve distribution. Computed Tomography (CT) of the abdomen and pelvis without contrast showed left retroperitoneal intramuscular iliopsoas hematoma measuring 8.3cm x 7.8cm x 15.5cm. Electromyography (EMG) revealed fibrillations, positive sharp waves, increased motor unit amplitude, and severely reduced recruitment in the left vastus lateralis and rectus femoris. The patient was diagnosed with severe left femoral neuropathy. He required minimum assistance with static balance and was unable to ambulate.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: CT abdomen and pelvis without contrast prior to discharge demonstrated less high attenuation, suggesting resolving hematoma. Upon discharge, the patient achieved independent static balance, was able to ambulate 50 feet with contact guard, and negotiate 12 stairs with minimum assistance.

Discussion (relevance): The development of iliopsoas hematoma following cardiac catheterization is rare, at 0.5%, although incidence of femoral nerve compression with an established hematoma can be as high as 70% due to inelastic iliacus fascia. Management includes conservative and surgical approaches, with the average length of time to recover strength to a 4/5 level varying between 2.3 months with surgery and 3.6 months with conservative management. EMG findings of fibrillation potentials, increased motor unit amplitude and decreased recruitment are indicative of a neuropathic process.

Conclusions: Although rare, femoral neuropathy due to retroperitoneal hematoma may occur in patients post cardiac catheterization. Compressive femoral neuropathy due to retroperitoneal hematoma should be considered if muscle weakness is observed. Early diagnosis and appropriate rehabilitation treatment plans are helpful for a functional prognosis, but surgical management should be considered if motor weakness does not improve.