Computed Tomography Scan Research Articles

Validating the Brain Injury Guidelines in a Pediatric Population with Mild Traumatic Brain Injury and Intracranial Injury at a Level I Trauma Center.

Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017-2023) using an institutional registry. Patients included (0-17 years) had an initial head computerized tomography scan with ICI and a GCS of 14-15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome.

The Effect of Low-Dose CT Protocols on Shoulder Model-Based Tracking accuracy Using Biplane Videoradiography.

Model-based tracking is being increasingly used to quantify shoulder kinematics and typically employs computed tomography (CT) to create the 3D bone volumes, which adds to the total radiation exposure. Lower-dose CT protocols may be possible given the contrast between bone and the surrounding soft tissues. The purpose of this study was to describe the dose-accuracy tradeoff between low-dose CT scans and the kinematic tracking accuracy of the humerus, scapula, and clavicle when tracked using an intensity-based registration algorithm. Three fresh-frozen cadavers consisting of the torso and bilateral shoulders were tested. The CT protocols investigated included a full-dose protocol and 4 experimental low-dose protocols that modulated x-raytube current and peak voltage. Bead-based tracking (i.e., radiostereometric analysis) served as the reference standard to which model-based tracking results were compared. Accuracy was described in terms of both segmental (humerus, scapula, and clavicle) and joint (glenohumeral, acromioclavicular) kinematics using root-mean-square (RMSE), bias, precision, and worst-case errors. The low-dose CT scans resulted in an average dose reduction of 70.6-92.8%. RMSEs tended to increase as CT dose decreased with average glenohumeral errors increasing from 0.5° and 0.6 mm to 0.6° and 0.6 mm between the highest and lowest-dose protocols, and average acromioclavicular errors increasing from 0.6° and 0.8 mm to 0.7° and 0.9 mm. However, the difference in joint kinematic errors between the highest and lowest-dose CT scanning protocols was generally small (≤0.3°, ≤ 0.1 mm). It is possible to substantially reduce the CT dose associated with shoulder motion analysis using biplane videoradiography without significantly impacting data fidelity.

Outcomes and prognostic factors in pediatric orbital trapdoor fracture: a multi-center study.

To evaluate clinical presentations, computed tomography (CT) findings, and various prognostic factors affecting the surgical outcomes of trapdoor fractures. This retrospective multi-center study reviewed medical records and orbital CT scans of patients under 21 years old, diagnosed with isolated trapdoor fractures. The study was conducted across multiple medical centers, including emergency and clinical departments in Isfahan, Shiraz, and Tehran-Iran. The characteristics and outcomes following surgical intervention were assessed. 45 patients with isolated trapdoor fractures were included in the study, with a mean age of 11.67 ± 4.69 years, predominantly male (84.4%). Vehicle accidents was the major cause of fractures (31.1%). 44 patients (97.8%) had orbital floor fracture, and one patient (2.2%) had medial wall involvement. Nausea/vomiting were reported in 41 patients (91.1%). Surgical intervention within 2 days, resulted in 85.0% of patients experiencing no postoperative diplopia. Delayed surgery beyond 2 days showed increased odds of diplopia, although not statistically significant. CT scan findings suggested a lower risk of diplopia in patients with soft tissue entrapment compared to muscle involvement (OR: 0.336, 95% CI: 0.077-1.462, p = 0.146). Shorter time to surgery (within 2 days) was significantly associated with normal postoperative eye movements (p = 0.002). Nausea/vomiting were more prevalent in patients with muscle entrapment (p < 0.05). Surgical intervention within 48h is crucial for improving ocular motility following trapdoor fractures. Extraocular symptoms, including nausea/vomiting, should raise suspicion for trapdoor fractures in cases of orbital trauma associated with ocular movement impairment. Not applicable.

Trans-Tragal Approach for Mandibular Neck and Head Condylar Fractures.

This retrospective observational study evaluates the trans-tragal approach for the treatment of mandibular head and neck condylar fractures. From January 2009 to May 2024, 34 patients (20 males, 14 females, mean age 34 years) with 36 condylar fractures were treated using this approach. Surgical outcomes were assessed based on occlusal relationship, maximum mouth opening, and facial nerve function (House-Brackmann scale). Postoperative imaging included computed tomography scans, with follow-ups at 1, 3, 6 months, and 1 year. Complications such as wound infection, hematoma, and salivary fistula were also evaluated. Results showed satisfactory postoperative outcomes, with 32 patients maintaining normal occlusion and a mean interincisal opening distance of 40 mm. Three patients experienced complications, including temporary facial nerve numbness in one case, with complete recovery in 2 weeks, and 2 cases requiring reoperation due to condylar segment displacement. No cases of permanent facial nerve damage, salivary fistula, or tragal cartilage necrosis were observed. Aesthetic outcomes were satisfactory, with scars hidden in natural folds. The trans-tragal approach provides adequate surgical exposure to the posterior condylar region while minimizing the risk of facial nerve injury. Although the results of this study indicate favorable outcomes, further randomized controlled studies are required to validate these findings due to the non-randomized design and small sample size.

Thyroglossal cyst with intralaryngeal extension – An unusual case report

Thyroglossal duct cysts are the most prevalent congenital neck masses originating from thyroglossal duct remnants. Here, we present a case of thyroglossal dust cyst with hoarseness and difficulty breathing. A contrast-enhanced computed tomography scan confirmed the intra-laryngeal extension and airway compromise. Sistrunk procedure along with laryngeal reconstruction was done. Histopathology confirmed thyroid follicles in the cyst wall.

Synchronous primary ovarian tumours in postmenopausal women: A rare case report and literature review

The reported incidence of synchronous primary cancers of genital tract is 1-2%, among this synchronous primary ovarian tumour is rarest. Herein, a postmenopausal woman, who had previously undergone abdominal hysterectomy, presented with vague lower abdominal pain persisting for six months. A computed tomography scan confirmed the presence of an 8.1 x 8.2 cm cyst on her right ovary. Despite her CA125 levels being normal, she was scheduled for laparoscopic cystectomy. During the surgery, the left ovary was found to be enlarged, prompting bilateral salpingo-oophorectomy. Histological analysis revealed a serous cystadenoma in the left ovary and a mucinous cystadenoma in the right ovary.Most reported synchronous ovarian tumors are malignant, with only a few cases of benign synchronous ovarian tumors documented in the literature. Early diagnosis and reporting of such cases are crucial for improving our understanding of synchronous ovarian neoplasms, which can impact management strategies and help prevent complications.

Correlation Between Renal Dimensions and Anthropometric Indices Using Computed Tomography in Adults Without Known Renal Disease: A Cross-Sectional Prospective Study

Background: Assessing renal volume as a potential indicator of renal function and related disorders is valuable for clinical decision-making. Computed tomography (CT) can accurately estimate actual kidney size. Objectives: This study aimed to evaluate the relationship between anthropometric parameters and renal dimensions measured by CT. Methods: Renal CT scan evaluations were performed on 634 individuals (308 males and 326 females) who had undergone abdominopelvic CT scans for indications unrelated to renal disease. Renal parameters, including length, width, depth, volume, and cortex length, were measured. Results: The mean age of participants was 53.5 ± 13.7 years (range: 18 - 86 years). Renal dimensions in males were larger than those in females. Additionally, the left kidney showed larger dimensions than the right kidney in both genders. Renal dimensions increased with age initially, but began to decrease after the sixth decade of life. A significant negative correlation was found between age and renal length, cortex, and left renal volume. In contrast, a significant positive correlation was observed between weight and both renal depth, length, volume, and left renal cortex, as well as between height and both renal length and volume on both sides. All dimensions except renal length were greater with increasing Body Mass Index (BMI). Conclusions: The results indicate a significant correlation between kidney dimensions and various anthropometric factors such as age, weight, height, and BMI. These findings provide valuable insights into kidney dimensions measured on CT scans, potentially aiding in the diagnosis and treatment of kidney diseases.

Magnetic resonance imaging in patients with cardiac implantable electronic devices: the RESONANCE Spanish registry.

Despite increasing evidence demonstrating the safety of magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs), this procedure is often neglected in this population. This Spanish registry aimed to determine the proportion of MRI referrals and performance among patients with pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). This prospective, multicenter, open-label registry involved 21 Spanish centers. Data were collected upon implant of PMs or ICDs from BIOTRONIK and one year after, and included the number of MRIs and computed tomography scans prescribed, performed and denied, and reasons for denial. Data from 1105 patients (mean age: 74.2 years) were analyzed and 982 completed the follow-up. Of them, 82.2% had a PM and 17.8% an ICD. A total of 351 imaging tests were prescribed in 220 patients (19.9%), including 52 MRIs in 39 patients (3.5%) and 299 computed tomography scans in 196 patients (17.8%). Among the MRIs, 44 (84.6%) were performed, five (9.6%) were not performed, and three (5.8%) were replaced by an alternative test. Most of the indicated computed tomography scans were performed (97.7%). The proportion of patients with an MRI scan referral was 4.6% during the pre-COVID-19 period and 2.6% during the COVID-19 period. No MRI-related arrhythmic ventricular event was reported. This registry revealed that only 3.5% of patients with CIEDs had an MRI referral over the study, with rates decreasing to 2.6% during the COVID-19 period. These rates contrast with the 85 MRIs conducted per 1000 inhabitants in Spain in 2020.

CT feature of irregular extensive ulceration as a predictor of liver metastasis in gastric gastrointestinal stromal tumours.

This study aimed to investigate whether the computed tomography (CT) finding of irregular extensive ulceration (IEU) can serve as a predictor of liver metastasis (LIM) in patients with gastric gastrointestinal stromal tumours (GISTs). This study retrospectively collected clinical and imaging data from 286 patients diagnosed with low-, intermediate-, or high-risk gastric GISTs, or primary lesions with LIM from three medical institutions. The patients were categorised into non-LIM and LIM groups according to whether they had synchronous or metachronous LIM. Multivariate logistic regression analyses were performed to identify significant predictors of LIM. Additionally, receiver operating characteristic (ROC) curve, subgroup, and pathologic-radiologic correlation analyses were conducted. A total of 124 patients were ultimately enroled. There were significant differences in sex, site, growth pattern, size, shape, ulceration and Ki-67 expression between LIM and non-LIM groups. ROC curve analysis demonstrated that IEU had the highest area under the curve for predicting LIM (AUC = 0.842; 95% CI: 0.760-0.924; p < 0.001). Multivariate analysis indicated that IEU was the most significant independent predictor of high LIM risk (OR = 88.62; 95% CI: 2.80-2803.54; p = 0.011). Subgroup analysis showed that IEU was more frequently associated with male sex, age ≤ 55 years, proximal sites, irregular shapes, mixed growth patterns, and a high Ki-67 expression. The CT feature of IEU serves as an independent predictor of LIM in gastric GISTs and is strongly associated with high Ki-67 expression. Question Accurate assessment of LIM risk in patients with gastric GISTs is crucial, yet current non-invasive predictors remain inadequate. Findings IEU on CT is an independent predictor of LIM, with high diagnostic accuracy and a significant association with elevated Ki-67 expression. Clinical relevance IEU on CT scans enables non-invasive risk stratification for LIM in gastric GISTs. Our study refined the assessment of ulceration types, highlighting significant heterogeneity, which may guide personalised treatment strategies.

Computerized tomography features acting as predictors for invasive therapy in the management of Crohn's disease-related spontaneous intra-abdominal abscess: experience from long-term follow-up.

Decision-making in the management of Crohn's disease (CD)-related spontaneous intra-abdominal abscess (IAA) is challenging. This study aims to reveal predictive factors for percutaneous drainage and/or surgery in the treatment of CD-related spontaneous IAA through long-term follow-up. Data were collected, including clinical manifestations, radiography and treatment strategies, in Chinese patients with CD-related IAA in a tertiary medical center. Univariate and Multivariate Cox analysis were conducted to identify predictors for invasive therapy. Altogether, 48 CD patients were identified as having IAA through enhanced CT scans. The median follow-up time was 45.0 (23.3, 58.0) months. 23 (47.9%) patients underwent conservative medical treatment, and 25 (52.1%) patients underwent percutaneous drainage and/or surgical intervention (invasive treatment group). The 1-, 2-, and 5-year overall survival rates without invasive treatment were 75.0%, 56.1%, and 46.1%, respectively. On univariate Cox analysis, the computerized tomography (CT) features including nonperienteric abscess (HR: 4.22, 95% CI: 1.81-9.86, p = 0.001), max abscess diameter (HR: 1.01, 95% CI: 1.00-1.02, p<0.001) and width of sinus (HR: 1.27, 95% CI: 1.10-1.46, p = 0.001) were significantly associated with invasive treatment. Nonperienteric abscess was significantly associated with invasive treatment on multivariate Cox analysis (HR: 3.11, 95% CI: 1.25-7.71, p = 0.015). A score model was built by width of sinus, location of abscess and max abscess diameter to predict invasive treatment. The AUC of ROC, sensitivity and specificity were 0.892, 80.0% and 90.9% respectively. More than half of CD-related IAA patients needed invasive therapy within 5-year follow-up. The CT features including nonperienteric abscess, larger maximum abscess diameter and width of sinus suggested a more aggressive approach to invasive treatment.

Peri-injury symptomatology as predictors of brain computed tomography (CT) scan abnormalities in mild traumatic brain injury (mTBI)

ObjectiveThis study aimed to identify predictors of brain CT abnormalities in patients who sustained a mild traumatic brain injury (mTBI).MethodsRetrospective observational cohort of adult patients with mTBI (Glasgow Coma Score 13–15) that occurred within the preceding 24 h.Results2548 (91%) of the cohort had a brain CT and 698 (27%) demonstrated abnormal findings. The most frequently observed CT abnormalities were bleeding (638, 25%) and fractures (190, 7.4%). Multivariate logistic regression analysis revealed several significant predictors associated with the presence of brain CT abnormalities including older age [P < 0.0001], male sex [P < 0.0001], loss of consciousness [P = 0.0041], associated vomiting [P = 0.0011], alteration of consciousness (AOC) [P = 0102], and GCS score [P < 0.0001]. This was a robust model with an R² of 14.2%.ConclusionIn this retrospective analysis, older age, male sex, the presence of loss of consciousness or alteration in consciousness, lower GCS score, and associated vomiting were found to be significant predictors of having an abnormal brain CT. These findings highlight the importance of considering these factors when determining the necessity of brain CT scans in patients with mTBI and suggest that existing clinical decision rules may be limited. These findings may also help to inform clinical decision rules. Early identification of individuals at a higher risk of CT abnormalities may assist in appropriate management and allocation of healthcare resources.

Virtual Reality for Preprocedure Planning of Covered Stent Correction of Superior Sinus Venosus Atrial Septal Defects.

Covered stent correction (CSC) of a superior sinus venosus atrial septal defect is an alternative to surgery in selected patients, but anatomic variation means that assessment for CSC requires a 3-dimensional anatomic understanding. Heart VR is a virtual reality (VR) system that rapidly displays and renders multimodality imaging without prior image segmentation. The aim of this study was to evaluate the performance of the Heart VR system to assess patient suitability for CSC. In a blinded fashion, 2 interventionalists reviewed preprocedural computed tomography scans using Heart VR to assess the feasibility of CSC, including the potential need for pulmonary vein protection. The total review time using VR was recorded. Using conventional imaging, 15 patients were deemed suitable for CSC, but at catheterization, 3 cases were unsuitable. Using VR, when both interventionalists agreed that a case was suitable for CSC (n=12), all proved technically feasible. In the 3 cases that were unsuitable for CSC, the interventionalists using VR were either uncertain (n=1) or did not agree on suitability (n=2). The strategy for pulmonary vein protection was correctly identified by interventionalist 1 and 2 in 9/12 and 8/12 cases, respectively. In cases where pulmonary vein protection was required intraprocedurally (n=5), this was correctly identified using Heart VR. Using VR, in 3 cases it was determined that pulmonary vein protection would be required, but this was not the case on balloon interrogation. VR data loading and review times were 82 seconds and 7 minutes, respectively. Verbal feedback indicated that Heart VR assisted in the assessment of case suitability. Heart VR is a rapid and effective tool for predicting suitability for CSC in patients with a superior sinus venosus atrial septal defect and could be a feasible alternative to segmented virtual or physical 3-dimensional models.

The first report of rhinosinusitis by Rhizopus delemar in a patient with severe COVID-19 in Iran: a case report

BackgroundMucormycosis is a severe and fatal fungal infection in patients with coronavirus disease 2019 caused by Mucorales. Here we present a case of a 63-year-old man with coronavirus disease 2019 infection, along with rhinosinusitis mucormycosis caused by Rhizopus delemar.Case presentationA 63-year-old Iranian man suffering from a coronavirus disease 2019 infection with symptoms of cough, shortness of breath, and generalized body pain. On the basis of the clinical manifestations, such as headache, a history of black nasal discharge, nasal hypoesthesia, facial swelling, numbness, nasal obstruction, presence of necrotic lesions on the nasal passages on physical examination, and abnormal computed tomography scans of paranasal sinuses, the patient underwent surgical debridement. Direct microscopy of specimens obtained from the paranasal sinuses, and subsequent isolation and identification, revealed a rhinosinusitis mucormycosis caused by R. delemar. Despite therapeutic measures, such as sinus debridement surgery and antifungal therapy with amphotericin B injection (50 mg/day), the patient died after 35 days of hospitalization.ConclusionIn this report, we present the first documented case of human infection with R. delemar in a patient with coronavirus disease 2019 infection, who also exhibited rhinosinusitis mucormycosis. R. delemar appears to be an emerging agent of rhinosinusitis mucormycosis in this region. Furthermore, prompt diagnosis and the exploration of alternative antifungal treatments, beyond amphotericin B, may be crucial for effectively managing patients with R. delemar infections.

Concomitant Factors Associated With Tillaux-Chaput Fractures in Adults: A Case-Control Study.

Tillaux-Chaput fractures (TCFs) consist of fractures of the anterolateral distal tibia. They rarely occur in isolation in adults. When TCFs are missed, there is a risk of chronic pain, instability, and ankle osteoarthritis. This study aimed to identify which factors are related to the presence of TCFs in ankle injuries. A retrospective review of 1134 ankle fractures evaluated between 2013 and 2023 at a level 1 trauma center was performed. Inclusion criteria were patients aged ≥18 years, ankle radiographs and computed tomographic (CT) scan evaluation, and the presence of a TCF confirmed by CT scan. Exclusion criteria were prior ankle surgery, pilon, or distal tibial fractures. A musculoskeletal radiologist and a foot and ankle-trained orthopaedic surgeon classified the TCFs into type 1, an extraarticular avulsion; type 2, a fracture involving the incisura fibularis; and type 3, a fracture with impaction of the anterolateral tibial plafond. A matching control group of ankle fractures without TCF was created with a 1:2 ratio. The following variables were collected: sex, age (<50 vs >50 years), ankle dislocation or subluxation, Weber classification, Maisonneuve fracture, type of medial and posterior malleolar fracture, Lauge-Hansen classification, malleoli involved, and osteochondral lesion of the talus. Multivariate logistic regression was performed to detect which variables had an association with the TCF and their subtypes. P value <.05 was considered significant. A total of 481 ankle fractures had radiographs and CT scans available for evaluation, of which 83 (17.3%) had a TCF. Of these, 44.6% were type 1, 44.6% type 2, and 9.6% type 3. The mean age was 52.2 years; 66.3% were women. Six patients (7.2%) had an isolated TCF. Fifty-eight (69.9%), 50 (60.2%), and 62 (74.7%) ankles had involvement of the lateral, medial, and posterior malleolus, respectively. Age ≥50 years (OR 2.73, 95% CI 1.45-5.14) and pronation external rotation injuries (OR 2.94, 95% CI 1.43-6.06) had a significant association with TCF. Moreover, ankle dislocation or subluxation (OR 3.16, 95% CI 1.11-8.96) and the absence of posterior malleolar fracture (OR 5.97, 95% CI 1.65-21.6) were significantly associated with TCF type 2 and 3. In this study, age ≥50 years and pronation external rotation injuries were the unique independent risk factors for TCF. Furthermore, ankle dislocation or subluxation and the absence of posterior malleolar fractures increased the odds of having a more severe TCF. This study provides insights into the factors associated with TCF and its subtypes during adulthood.

Effect of abnormal distribution of abdominal adiposity and skeletal muscle on the outcomes of endovascular treatment for emergent large vessel occlusion

BackgroundThe aim of this study was to investigate the relationships between imaging indicators of obesity, as measured by computed tomography (CT), and clinical outcomes at 90 days and 1 year...

Revision of Hip Luxation in a Canine Total Hip Replacement Caused by a Greater Trochanteric Fracture Secondary to an Inflammatory Granuloma.

A hip luxation 3 years following a cementless total hip replacement was diagnosed in a 4.7-year-old neutered male Lagotto Romagnolo that presented with a non-weight-bearing left pelvic limb lameness. Orthogonal radiographs revealed a left hip luxation and an osteolytic fracture of the greater trochanter. A mass consistent with an inflammatory granuloma was identified on preoperative computed tomography scan. Surgical revision consisted of granuloma excision, replacement of the loose acetabular cup, and repair of the femoral fracture with a locking plate. Fracture biology was augmented with the use of recombinant human bone morphogenetic protein 2 (rhBMP2) impregnated collagen sponge applied around the acetabulum and femoral fracture site. Osteointegration of the prosthetics and fracture healing were documented within 3 months of revision. Long-term follow-up at 3 years postrevision showed normal limb usage and no further evidence of total hip replacement complication.

Multiple delayed-onset metachronous ileal stenoses after transcatheter arterial embolisation using N-butyl-2-cyanoacrylate for upper gastrointestinal bleeding: Factors of complication and importance of plain CT evaluations

Abstract A 63-year-old man underwent transcatheter arterial embolisation (TAE) using a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodised oil to treat acute gastrointestinal bleeding. The procedure was initially successful; however, the patient developed ileus &amp;gt;1 month later and subsequently underwent several surgeries to treat the multiple metachronous ileal stenoses. The flux of a small amount of off-target glue was the primary cause of these complications. As the patient had few symptoms in the first month post-TAE, however, affirming the diagnosis took time. A detailed review of plain computed tomography scans was a decisive factor in achieving the final diagnosis. This case demonstrates that TAE using an NBCA–iodised oil mixture effectively treats acute gastrointestinal bleeding. However, a complication such as off-target embolisation is likelier to occur because of a combination of certain factors such as vascular anatomy, complexity of the procedure, and NBCA dilution. Close observation using plain computed tomography should be performed for the identification of off-target embolisation occurrence even in cases of successful TAE.

Brainstem hemorrhage associated with venous hypertensive myelopathy without dural arteriovenous fistula: illustrative case.

Venous hypertensive myelopathy (VHM), formerly known as "Foix-Alajouanine syndrome," is a spinal cord dysfunction caused by impaired perfusion of the spinal cord. Most cases are attributed to spinal dural arteriovenous fistulas (dAVFs), but there are scattered reports of VHM without concomitant dAVF. Furthermore, no cases of VHM associated with intracranial hemorrhage exist. A 68-year-old man with a history of hypertension presented with a sudden headache, proximal paresis of the left upper extremity, impaired pain and temperature sensation in the right upper extremity, dysphagia, and dysarthria. Computed tomography scans showed intraparenchymal hemorrhage in the left medulla oblongata and a linear, continuous high-density area extending from the medulla oblongata to the cervical spinal cord. Magnetic resonance images showed cervical spondylosis at the C5-6 and C6-7 levels, with high signal intensity changes from the medulla oblongata to the lower cervical cord on T2-weighted images. Cerebral angiography showed no abnormal vessels. Conservative treatment gradually improved symptoms and the high signal intensity areas. This case highlights intracranial hemorrhage occurring from extracranial causes and the possibility of VHM due to cervical spondylosis. When hemorrhagic lesions of the craniovertebral junction or spinal parenchymal lesions are encountered, the underlying pathology should be investigated thoroughly and systematically. https://thejns.org/doi/10.3171/CASE24441.

Development of an ultrasound-based clinical decision rule to rule-out diverticulitis

The concern for diverticulitis often leads to the use of computed tomography (CT) scans for diagnosis. We aim to develop an ultrasound-based clinical decision rule (CDR) to confidently rule-out the disease without requiring a CT scan. We analyzed data from a prospective study of adult emergency department (ED) patients with suspected diverticulitis who underwent both bedside ultrasound (US) and CT. Patient history, physical examination, laboratory findings, and US results were used to create a CDR via a recursive partitioning model designed to prioritize sensitivity, with a loss matrix heavily penalizing false negatives. We calculated the test characteristics for this CDR (TICS-Rule) and assessed the potential reduction in CT scans and ED length of stay. Data from 149 patients (84 female; mean age 58 ± 16) were used to develop the TICS-Rule. The final model integrates US diagnosis of simple and complicated diverticulitis, along with variables of heart rate, age, history of diverticulosis, vomiting, and leukocytosis. Negative US results and a heart rate below 100 effectively excluded diverticulitis. The sensitivity increased from 54.5% (32.2–75.6) in the US alone to 100% (84.6–100%) for complicated diverticulitis in the model. The TICS-Rule missed no cases of complicated diverticulitis but one case of simple diverticulitis. The median time from ED greeting to US interpretation was 103 min (IQR 62–169), compared to 285 min (IQR 229–372) for CT. The TICS-Rule uses a combination of negative US and heart rate less thanQ1 100 to exclude diverticulitis without the need for a CT scan. Integration of the TICS-Rule offers a promising enhancement to clinical decision-making while reducing both CT use and ED length of stay.

The most responsive foot position for non-invasive detection of isolated unstable syndesmotic injuries – a 3D analysis

BackgroundThe aim of this study was to identify the most responsive foot position for detection of isolated unstable syndesmotic injury.MethodsFourteen paired human cadaveric lower legs were positioned in a pressure-controlled radiolucent frame and loaded under 700 N. Computed tomography scans were performed in neutral position, 15° internal / external rotation, and 20° dorsal / plantar flexion of the foot before and after cutting all syndesmotic ligaments. For each position, generated 3D models of the intact and injured distal tibiofibular joints were matched and analyzed by calculating three parameters: diastasis, anteroposterior displacement, and shortening of the fibula.ResultsTransection of syndesmotic ligaments resulted in significant posterior translation of the fibula (4.34°, SD 1.63°, p < 0.01) compared to uninjured state for external rotation, significant anterior translation (-2.08°, SD 1.65°, p < 0.01) for internal rotation, and significant posterior translation (1.32°, SD 1.16°, p = 0.01) for dorsiflexion. Furthermore, the syndesmotic injury led to significantly increased clear space (0.46 mm, SD 0.46 mm, p = 0.03) in external rotation of the foot.ConclusionExternal rotation of the foot under loading seems to be the most responsive position for detection of isolated syndesmotic instability. Under external rotational stress, anteroposterior instability and increased clear space resulting from a complete isolated unstable syndesmotic lesion were most evident.