Leech therapy in the treatment of median nerve compression due to forearm haematoma

A 67 year old patient underwent interventional cardiac catheterisation for cardiac angina. An 80% stenosis of the left anterior descending artery and a 90% stenosis of the posterior descending artery were stented. A distal stenosis of the left anterior descending artery was dilated. Catheterisation was performed via the right radial artery. The patient received a combination of clopidogrel, acetylsalicylic acid, and intravenous heparin. One hour after treatment, the patient noticed diffuse pain in the right forearm as well as numbness in the thumb and index and middle fingers, with subsequent weakness of the thenar muscles and difficulty in flexion of the distal phalanges of the thumb and index finger. In addition, the patient noticed increasing swelling and subsequent hardening of the right forearm together with a bluered discoloration. Neurological examination at this time revealed a sensory deficit of the right median nerve with decreased pinprick and light touch sensation as well as impaired two point discrimination. The motor function of the small thenar muscles and flexor pollicis longus, and flexor digitorum profundus of the index and middle fingers was slightly impaired. The pronator teres function was unremarkable. On examination, there was massive swelling of the forearm and blue-red discoloration. The circumference of the right forearm was increased by 5 cm compared with the left. However, the right radial artery pulse could be palpated without difficulty. Clinically, the patient was diagnosed as having compartment syndrome of the right forearm with affection of the median nerve due to a postpunction haematoma following cardiac interventional therapy. Because of the close relation of the syndrome with the local punction for cardiac catheterisation, and in order not to delay treatment, we did not perform neurophysiological studies or imaging studies such as sonography. A hand surgeon was consulted and surgical incision and removal of the haematoma were considered. However, as the functional impairment of the nerves and muscles was only moderate at this time we initiated therapy with medicinal leeches. A total of 13 leeches were applied to the volar surface of the right forearm. All leeches bit into the skin and sucked about 145 ml of blood. The patient’s symptoms markedly improved within 24 hours. On the next day, only slight sensory disturbances persisted on the skin of the right thumb. No further therapy was needed. At follow up three months later, the patient was noted to have undergone cardiac bypass surgery. Neurologically, the median nerve function was normal. At this time, motor and sensory nerve conduction velocities and amplitudes, as well as distal motor latency of the median nerve, were normal. Discussion The transradial approach is increasingly being used for cardiac catheterisation and also for cerebral angiography. In general, this approach is considered to be associated with fewer major complications, requires a shorter observation period, and there is no need for bed rest. Despite a generally low complication rate, a variety of adverse events, although rare, can occur such as transient radial artery spasm, failure to access the brachial artery, radial artery occlusion, radial artery perforation, pseudoaneurysm, skin desquamation, severe pain and forearm haematoma. The haematoma can lead to compartment syndrome, which can compromise the viability and function of the nerves and muscles. 3 The treatment depends on the severity of the symptoms, current neurological status, and the integrity of the radial artery. In our patient, we initiated treatment with medicinal leeches shortly after onset of the symptoms and establishment of the diagnosis. In the past years, the use of medicinal leeches (Hirudo medicinalis, fig 1) has been rediscovered as an effective method to relieve venous congestion. The treatment aims to counteract tissue ischaemia, hypoxia, acidosis, necrosis, and gangrene. The possible mechanism of action of leech therapy is based on the anticoagulant properties of hirudin (contained in leech saliva) and the capacity of the leech to suck the blood thereby relieving the pressure in the affected compartment. In particular, medicinal leeches have been very effective in regions with diffusely spreading haematomas such as in the tongue or scrotum. 7 Medicinal leeches are commercially available in pharmacies. Before use, the skin has to be cleaned with warm water. In case of a haematoma as in our patient, up to 15 leeches per session are positioned over the skin using a wooden stick or by hand. During 30–60 minutes, each leech sucks 8–10 ml of blood. After one to two hours, the leeches fall off spontaneously. If needed, the leeches can be animated by pricking and scraping the surface of the patient’s skin or by brushing a small amount of butter on the skin. After removal of the leeches the local bleeding should not be suppressed. The bleeding can persist up to 12 hours. When carried out correctly, the risk of bacterial infection is negligible. Leech therapy in treatment of median nerve dysfunction due to forearm compartment syndrome following transradial catheterisation has not hitherto been reported in the literature. Recently, Avci et al reported successful leech therapy in the treatment of digital neurovascular compression due to a forgotten digital tourniquet. We suggest leech therapy as a treatment option in similar conditions, although a hand surgeon should be available in case a surgical procedure becomes necessary.