Emergency Computed Tomography Scan Research Articles

Pneumoperitoneum, pneumoretroperitoneum and pneumomediastinum: rare complications of perforation peritonitis: a case report

BackgroundGas extravasation complications arising from perforated diverticulitis are common but manifestations such as pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum happening at the same time are exceedingly rare. This case report explores the unique presentation of these 3 complications occurring simultaneously, their diagnosis and their management, emphasizing the importance of interdisciplinary collaboration for accurate diagnosis and effective management.Case presentationA 74-year-old North African female, with a medical history including hypertension, dyslipidemia, type 2 diabetes, goiter, prior cholecystectomy, and bilateral total knee replacement, presented with sudden-onset pelvic pain, chronic constipation, and rectal bleeding. Clinical examination revealed hemodynamic instability, hypoxemia, and diffuse tenderness. After appropriate fluid resuscitation with norepinephrine and saline serum, the patient was stable enough to undergo computed tomography scan. Emergency computed tomography scan confirmed perforated diverticulitis at the rectosigmoid junction, accompanied by the unprecedented presence of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum. The patient underwent prompt surgical intervention with colo-rectal resection and a Hartmann colostomy. The postoperative course was favorable, leading to discharge one week after admission.ConclusionsThis case report highlights the clinical novelty of gas extravasation complications in perforated diverticulitis. The unique triad of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum in a 74-year-old female underscores the diagnostic challenges and the importance of advanced imaging techniques. The successful collaboration between radiologists and surgeons facilitated a timely and accurate diagnosis, enabling a minimally invasive surgical approach. This case contributes to the understanding of atypical presentations of diverticulitis and emphasizes the significance of interdisciplinary teamwork in managing such rare manifestations.

The Impact of Computed Tomography Scans on the Management and Wait Times in Perianal Abscess Diagnoses.

Background Diagnosis and management of perianal abscesses (PAA) are based on history and clinical examination. Imaging is not indicated except in complicated cases, as determined by the surgical team. The monetary, ionizing radiation, and resource utilization costs of a computed tomography (CT) scan in the emergency room must be considered when used for diagnostic purposes of PAAs. Methods A retrospective analysis of 129 patients diagnosed with a diagnosis of PAA between 2015-2020 was performed. The primary endpoints included length of stay, CT performed, time from patient presentation to CT, and CT scan completion prior to surgical consultation. Data is reported as n (%) or median (IQR). Results Of the 129 patients diagnosed with PAA, 81 underwent CT, and 48 did not. General surgery was consulted in 88% of cases. There were no statistically significant differences in age (p=0.562), sex (p=0.531), or ethnicity (p=0.356). The median hospitalization time was two days when CT was performed (p=0.001). The median time elapsed from presentation to the emergency department and CT scan performed was 16 hours (p=0.001). CT scans were ordered before the surgical consultation in 65% of cases (p=0.001) and 17% after a surgical consultation was placed (p=0.009). Conclusion Performing CT scans prior to surgical evaluation for the diagnosis of PAA is not a responsible practice. The cost, resources, and radiation exposure must be considered. This study demonstrated that more CT scans are ordered prior to surgical consultation for PAA, resulting in a prolonged wait time in the emergency department.

Mesenteric arteries aneurysms rupture secondary to paradoxical hypertension after aortic coarctation stenting.

A 51-year-old female with long-term poorly controlled hypertension was found to have a systolic murmur on physical examination. A transthoracic echocardiogram showed a bicuspid aortic valve with left ventricular hypertrophy and normal ejection fraction. Computed tomography (CT) detected a critical coarctation of the aorta (Panel A). The invasive gradient through the coarctation was 80 mmHg. It was decided to treat with stent implantation (Panels B and C). A covered cheatham-platinum stent of 39 mm mounted on a balloon-in-balloon balloon of 16 × 40 mm was successfully implanted. Immediately after stent deployment, the systolic blood pressure reached 210 mmHg, despite pharmacological treatment. The day after the procedure, the patient started with abdominal pain and an emergency CT scan was performed (Panel D). Computed tomography showed a large mesenteric haematoma (with no active bleeding at that moment), a large aneurysm of the proximal ileocolic artery, and a small aneurysm of the middle colic artery. Angiography confirmed these findings (Panel E) and it was decided to embolize both aneurysms using Micro Vascular Plugs and coils, which resulted in a successful exclusion of the aneurysms but also in a lack of vascularization of the distal ileum and ascending colon (Panel F), that eventually required resection (right hemicolectomy). The possibility of aneurysms and other alterations in the vessels of patients with aortic coarctation should be considered. Whether these anomalies should be treated before stenting is still unknown. Paradoxical hypertension after stent implantation and its severe complications could be prevented by pharmacological treatment days before the intervention.

Interpretation of Emergency CT Scans of the Head in Trauma: Neurosurgeon vs Radiologist.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity across all ages in all countries. Management of the patient with TBI is time critical. Emergency computed tomography (CT) scans of the head are often assessed by neurosurgeons and patient management plans are implemented before the final radiological report is released in hospitals, particularly where there is a shortage of radiologists in LMIC. The aims of this study were to identify discrepancies in the interpretation of CT scans of the head in patients with isolated head injury between the neurosurgeon and radiologist and to assess if these differences impacted patient management. This 6-month long prospective observational study was performed at a tertiary hospital in South Africa. The study population comprised 347 patients with isolated head injury who had a CT scan of the head performed on admission. The neurosurgeons' initial CT scan interpretation and the final radiological report were compared. Out of 347 CT head scans, the neurosurgeons correctly interpreted 318 cases. Of the 29 incorrectly interpreted cases, there were 17 false negatives and 12 cases with mismatching abnormalities. The concordance rate was 91.64% (95% CI 88.73-94.55) with a kappa of 0.78. An accuracy rate of 95.33% (95% CI 92.63-97.26) was achieved by the neurosurgeon. No patient was negatively impacted by any neurosurgical error in misinterpretation. In the interpretation of CT head scans in trauma, there is good neurosurgical and radiological interobserver agreement without negative patient impact. The neurosurgeons' interpretation of CT scans of the head in TBI is safe especially when radiology reports are not timeously available.

Emergency computed tomography scans in trauma: Where radiology is lacking the clinician fills the gap!

Emergency computed tomography scans in trauma: Where radiology is lacking the clinician fills the gap!

Impact of the COVID-19 pandemic on osteoporotic vertebral fracture incidence and follow-up at the emergency department. A retrospective study of a tertiary hospital in southern Spain

The COVID-19 pandemic has affected trauma practices all over the world. Despite the increasing number of studies focused on the epidemiology of vertebral fractures (VFs) in COVID-19 patients, the impact of the pandemic on the incidence of trauma pathologies at the emergency department (ED) remains unclear. In Spain, very few studies have explored how the pandemic has affected the care of patients with osteoporotic vertebral fracture (OVF) in the ED and on their follow-up. The aim of this work is to evaluate the impact on the demand for care and diagnosis of VF during the COVID-19 pandemic, as well as the repercussions on patient follow-up. A longitudinal retrospective observational study was designed comparing two cohorts (pre-COVID and COVID) of patients for whom an emergency computed tomography scan was requested due to suspected vertebral fracture. Information was gathered on patient demographics, number and type of OVFs, time of day at which the diagnosis was made, follow-up, and treatment received. Comparative analyses were performed between both patient groups, with stratification by time intervals according to the pandemic waves in the COVID cohort. A total of 581 eligible patients were included in the study. The analyzed cohorts included 288 patients (145 and 143 in the pre-COVID and COVID cohorts, respectively), with a mean age of 73.4 ± 13.8 years and 205 (71.4%) women. No significant differences were observed on most measured variables. In the COVID cohort, the group of patients who received follow up care had a significantly lower mean age than the group that did not receive follow up care (70.2 ± 12.7 vs 76.2 ± 14.1 years, respectively, p = 0.008). In conclusion, the COVID-19 pandemic has had little impact on the diagnosis and management of patients with OVF in our hospital. This could be explained by the specific characteristics of OVFs and the type of patients it affects. Our study has some limitations, mainly derived from its retrospective and single-center nature with a short follow-up interval.

Evaluating delays for emergent CT scans from a rural British Columbia hospital.

Computed Tomography (CT) scans help diagnose and triage life-threatening and time-sensitive emergency conditions, but most rural hospitals in British Columbia do not have access to a local CT scanner. We investigate how many transfers from a rural British Columbia hospital were for CT scans and describe the time delays to emergent CT imaging. This was a prospective cohort study, over a 1-year period, on all patients requiring a transfer from the Golden and District Hospital, located 247km from the closest CT scanner. Data collection forms were completed prospectively and the main measurements included age, transport triage level, reason for transfer, referral hospital, transfer request time, and CT scan time. The time interval between the CT request and CT imaging was calculated and represents the 'delay to CT scan' interval. The study hospital received 8672 emergency department (ED) visits and 220 were transferred to referral centres (2.5%). 61% of all transfers received a CT scan. Transfers for time-sensitive emergencies took an average of 6h 52min. Patients with acute stroke experienced a 4h 44min time interval. Less urgent and non-urgent conditions entailed an even greater time delay. This study highlights that the lack of a rural CT scanner is associated with increased transfers and significant time delays. Improving access to CT scanners for rural communities may be one of the many steps in addressing healthcare disparities between rural and urban communities.

A silver bullet? The role of radiology information system data mining in defining gunshot injury trends at a South African tertiary-level hospital.

BackgroundSouth Africa (SA) has no national injury surveillance system, and hence, non-fatal gunshot injuries are not routinely recorded. Most firearm-related injuries require multi-detector computer tomography (MDCT) assessment at a tertiary-level facility. MDCT scanning for victims with gunshot injuries thus provide an indication of the societal burden of firearm trauma. The potential of the modern radiology information system (RIS) to serve as a robust research tool in such settings is not fully appreciated.ObjectiveThe aim of this study was to evaluate the use of institutional RIS data in defining MDCT scanning trends for gunshot victims presenting to a tertiary-level SA hospital.MethodA single-institution, retrospective, comparative study was conducted at the Tygerberg Hospital (TBH) Trauma Unit for the years 2013 and 2018. Using data-mining software, customised RIS searches for information on all gunshot-related emergency computed tomography scans in the respective years were performed. Demographic, temporal, anatomical and scan-protocol trends were analysed by cross tabulation, Chi-squared and Fisher’s exact tests.ResultsGunshot-related emergency MDCT scans increased by 62% (546 vs. 887) from 2013 to 2018. Lower-limb CT angiography was the commonest investigation in both periods. A higher proportion of victims in 2018 sustained thoracic injuries (12.5% vs. 19.8%; p < 0.01) and required imaging of more than two body parts (13.1% vs. 19.2%; p < 0.01).ConclusionBy using RIS data to demonstrate the increasing gunshot-related MDCT workload in the review period, as well as a pattern of more complex and potentially life-threatening injury, this study highlights the burden of firearm trauma in the society and the potential role of the modern RIS as a robust research tool.

Rare Clinical Onset of Nontraumatic Intracavernous Aneurysm of the Internal Carotid Artery: A Diagnostic and Therapeutic Challenge

AbstractWhile the so-called pseudoaneurysms can result from arterial injury during trans-sphenoidal surgery or after a trauma, spontaneous aneurysms of cavernous–internal carotid artery (CICA) are rare. Symptoms vary and the differential diagnosis with other, more frequent, sellar lesions is difficult. We describe three cases of misdiagnosed CICA spontaneous aneurysm. In two cases the onset was with neuro-ophthalmological manifestations, classifiable as “cavernous sinus syndrome.” The emergency computed tomography scan did not show CICA aneurysm and the diagnosis was made by surgical exploration. The third patient came to our attention with a sudden severe unilateral epistaxis; endonasal surgery revealed also in this case a CICA aneurysm, eroding the wall and protruding into the sphenoidal sinus. When the onset was with a cavernous sinus syndrome, misdiagnosis exposed two patients to potential serious risk of bleeding, while the patient with epistaxis was treated with embolization, using coils and two balloons. Intracavernous nontraumatic aneurysms are both a diagnostic and therapeutic challenge, because of their heterogeneous onset and risk of rupture, potentially lethal. Intracavernous aneurysms can be managed with radiological follow-up, if asymptomatic or clinically stable, or can be surgically treated with endovascular or microsurgical techniques.

A RARE COMPLICATION OF TUMOR NECROSIS FACTOR INHIBITORS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tumor necrosis factor (TNF)-inhibitors are one of the first line agents prescribed for management of rheumatoid arthritis (RA). Hemorrhagic pericardial effusion is a rare side effect of TNF inhibitors1,2, and if left untreated, may cause life threatening complications such as pericardial tamponade or cardiac arrest. CASE PRESENTATION: A thirty-four-year-old morbidly obese female with past medical history of Diabetes and RA presented to the emergency department after a syncopal episode with complains of shortness of breath and anxiety. An emergent Computed tomography scan was done which showed a large pericardial effusion. (Figure 1). As the patient was being transported to intensive care, she developed hypotension and hypoxia leading to cardiac arrest. Cardiopulmonary resuscitation was started. A bedside echocardiogram showed a large circumferential pericardial effusion with tamponade physiology (Figure 2). Return of spontaneous circulation was achieved after six rounds of compressions but the patient remained in obstructive shock requiring multiple vasopressors. An emergent bedside pericardiocentesis was performed and 60cc fluid was drained. She was then taken to the catheterization lab with further drainage of 550cc of hemorrhagic fluid. Post drainage her hypotension resolved and she was weaned off of all vasopressors. Pericardial studies showed an elevated red blood cell with a normal white blood cell count, negative culture and cytology. Autoimmune workup showed elevated histone antibodies. Of note, the patient had a history of seropositive, non-erosive RA which was managed with prednisone and adalimumab. Due to decreased response to adalimumab, patient was switched to etanercept and received her first dose one month prior to presentation which was discontinued after patient developed skin peeling. DISCUSSION: The exact mechanism of TNF-inhibitors causing pericardial tamponade is currently unknown. However, some have proposed a paradoxical flare up of the underlying autoimmune condition, immune-mediated or drug induced reactions as the cause. Even though RA can occasionally cause pericardial effusions, they are not typically hemorrhagic in nature. The significant medication history in our patient along with anti-histone antibodies made drug induced pericardial effusion the likely cause. More research needs to be done to ascertain the pathophysiology of effusions due to TNF-Inhibitors, as with increasing utility of TNF-inhibitors, they may be more common than currently documented. CONCLUSIONS: With increased use of TNF-inhibitors in autoimmune conditions, clinicians should be well aware of their side effect profile as a delayed diagnosis may lead to life threatening complications as was evident in our case. Reference #1: Lather HD, Kahlenberg JM. Hemorrhagic Pericardial Effusion with Tamponade: A Rare Adverse Effect of Infliximab-Case Report and Literature Review. Case reports in rheumatology. 2016;2016:2576496 Reference #2: Soh MC, Hart HH, Corkill M. Pericardial effusions with tamponade and visceral constriction in patients with rheumatoid arthritis on tumour necrosis factor (TNF)-inhibitor therapy. International journal of rheumatic diseases. 2009;12(1):74-77. DISCLOSURES: No relevant relationships by Kourtney Erickson, source=Admin input No relevant relationships by Sara Godil, source=Web Response No relevant relationships by Kareem Godil, source=Web Response No relevant relationships by Emilee Kurtz, source=Web Response

Cerebral Aspergilloma in Patient with Diabetes – A Case Report with Short Literature Review

BACKGROUND: In the recent years, the incidence of fungal brain abscess has been rising as a result of the increased use of corticosteroid therapy, broad-spectrum antimicrobial therapy, and immunosuppressive agents. Aspergillosis of the central nervous system (CNS) is reported in 10%–20% of the patients having invasive fungal disease. Commonly, the disease is observed in immunocompromised or immunosuppressed patients; also, patients who suffered traumatic head injury are reported as well to develop the infection due to due cranial defect accompanied by dural tearing. Symptoms are non-specific neurologic manifestations.&#x0D; CASE PRESENTATION: We presented a case of a 68-year-old man who had diabetes mellitus type II. He was admitted to in neurosurgery clinic due reported head trauma. Initially, he complained of a headache, dizziness, slurred speech, nausea, and pain in the right ear with tinnitus and pain in his right upper teeth – continuous for a month. The patient was conscious, adequate, Glasgow Coma Scale – 15 points, with left-sided hemiparesis, general symptomatic syndrome. An emergent computed tomography scan was performed, which showed tumorous formation in patient’s right temporal lobe that had mass effect and compression of the right lateral ventricle. The patient was discussed on a emergent clinical counsel and it was decided that he was shown for surgical treatment. An informed consent was signed by the patient and his relatives. After the surgery intervention – the histological result of the biopsy was aspergilloma of the brain and the microbiological result was Aspergillus fumigatus.&#x0D; CONCLUSION: The prognosis for CNS aspergillosis is poor, but the early diagnosis and effective medical and surgical treatments may reduce morbidity and mortality.&#x0D;

Interpretation of emergency CT scans in polytrauma: trauma surgeon vs radiologist.

IntroductionTime is critical in the trauma setting. Emergency computed tomography (CT) scans are usually interpreted by the attending doctor and plans to manage the patient are implemented before the formal radiological report is available. This study aims to investigate the discrepancy in interpretation of emergency whole body CT scans in trauma patients by the trauma surgeon and radiologist and to determine if the difference in trauma surgeon and radiologist interpretation of emergency trauma CT scans has an impact on patient management.MethodThis prospective observational comparative study was conducted over a 6 month period (01 April–30 September 2016) at the Inkosi Albert Luthuli Central Hospital which has a level 1 trauma department. The study population comprised 62 polytrauma patients who underwent a multiphase whole body CT scans as per the trauma imaging protocol. The trauma surgeons' initial interpretation of the CT scan and radiological report were compared. All CT scans reported by the radiology registrar were reviewed by a consultant radiologist. The time from completion of the CT scan and completion of the radiological report was analysed.ResultsSince the trauma surgeon accompanied the patient to radiology and reviewed the images as soon as the scan was complete, the initial interpretation of the CT was performed within 15–30 min. The median time between the CT scan completion and reporting turnaround time was 75 (16–218) min. Critical findings were missed by the trauma surgeon in 4.8% of patients (bronchial transection, abdominal aortic intimal tear and cervical spine fracture) and non-critical/incidental findings in 41.94%. The trauma surgeon correctly detected and graded visceral injury in all cases.ConclusionThere was no significant discrepancy in the critical findings on interpretation of whole body CT scans in polytrauma patients by the trauma surgeon and radiologist and therefore no negative impact on patient management from missed injury or misdiagnosis.The turnaround time for the radiology report does not allow for timeous management of the trauma patient.

Yield of Emergent CT in Patients With Epilepsy Presenting With a Seizure

Studies of emergent neuroimaging in the management of patients presenting with a breakthrough seizure are lacking. We sought to determine how often emergent computed tomography (CT) scans are obtained in patients with known epilepsy presenting with a seizure and how often acute abnormalities are found. This multicenter retrospective cohort study was performed in the emergency department at 2 academic medical centers. The primary outcomes were percentage of visits where a CT scan was obtained, whether CT findings represented acute abnormalities, and whether these findings changed acute management. Of the 396 visits included, CT scans were obtained in 39%, and 8% of these scans demonstrated acute abnormalities. Patients who were older, had status epilepticus, a brain tumor, head trauma, or an abnormal examination were all significantly more likely to undergo acute neuroimaging (P < .05). In the multivariable model, only history of brain tumor (odds ratio [OR] 5.88, 95% confidence interval [CI], 1.33-26.1) and head trauma as a result of seizure (OR 3.92, 95% CI, 1.01-15.2) reached statistical significance in predicting an acutely abnormal scan. The likelihood of an acute imaging abnormality in visits for patients without a history of brain tumor or head trauma as a result of the seizure was 2.7% (2 visits). Both of these patients had abnormal neurological examinations. Obtaining an emergent CT scan for patients with epilepsy presenting with a seizure may be avoidable in most cases, but might be indicated for patients with a history of brain tumor or head trauma as a result of seizure.

Discrepancies in interpretation of night-time emergency computed tomography scans by radiology residents.

BackgroundIn many emergency radiology units, most of the night-time work is performed by radiology residents. Residents’ preliminary reports are typically reviewed by an attending radiologist. Accordingly, it is known that discrepancies in these preliminary reports exist.PurposeTo evaluate the quality of night-time computed tomography (CT) interpretations made by radiology residents in the emergency department.Material and MethodsRetrospectively, 1463 initial night-time CT interpretations given by a radiology resident were compared to the subspecialist’s re-interpretation given the following weekday. All discrepancies were recorded and classified into different groups regarding their possible adverse effect for the emergency treatment. The rate of discrepancies was compared between more and less experienced residents and between different anatomical regions.ResultsThe overall rate of misinterpretations was low. In 2.3% (33/1463) of all night-time CT interpretations, an important and clinically relevant diagnosis was missed. No fatalities occurred due to CT misinterpretations during the study. The total rate of discrepancies including clinically irrelevant findings such as anatomical variations was 12.2% (179/1463). Less experienced residents were more likely to miss the correct diagnosis than more experienced residents (18.3% vs. 10.9%, odds ratio [OR] = 1.82, P = 0.001). Discrepancies were more common in body CT interpretations than in neurological CTs (18.1% vs. 9.1%, OR = 2.30, P < 0.0001).ConclusionThe rate of clinically important misinterpretations in CT examinations by radiology residents was found to be low. Experience helps in lowering the rate of misinterpretations.

Pembrolizumab combined with stereotactic body radiotherapy in a patient with human immunodeficiency virus and advanced non-small cell lung cancer: a case report

BackgroundPembrolizumab has significantly improved outcomes in patients with advanced non-small cell lung cancer. Combining programmed death-1 inhibitor with stereotactic body radiotherapy showed a slight toxicity and good benefits in recent clinical trials. However, patients infected with human immunodeficiency virus were excluded from most trials because it was assumed that their anti-tumor immunity was compromised compared with immunocompetent patients.Case presentationIn June 2016, a 52-year-old Chinese man presented with human immunodeficiency virus and lung adenocarcinoma (T1bN3M1b). From November 2016 to December 2016, systemic chemotherapy and palliative radiotherapy for bone metastasis of femoral neck were carried out, but the tumor progressed. In January 2017, after immunochemistry detection of programmed death-1 and programmed death-ligand 1 expression (both > 50%), pembrolizumab was started. Three weeks after pembrolizumab, we combined stereotactic body radiotherapy for the primary lung tumor. He received no comfort and his CD4 lymphocyte count was stable. Human immunodeficiency virus-ribonucleic acid remained below the limits of detection. In March 2017, after three cycles of pembrolizumab and 5 weeks of stereotactic body radiotherapy therapy, he suddenly presented with palpitations. Emergency computed tomography scanning showed massive pericardial effusion and interstitial pneumonia. So we interrupted the pembrolizumab use and initiated treatment with prednisolone 1 mg/kg; however, the tumor progressed. Then, his CD4 lymphocyte count declined. Finally he died in June 2017 due to dyscrasia.ConclusionsPembrolizumab combined with SBRT therapy for patients with human immunodeficiency virus infection and non-small cell lung cancer may lead to serious immune-related adverse events and more clinical trials are needed.

First installation of a dual-room IVR-CT system in the emergency room

Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phase of trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures, CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table. Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER can potentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features (dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we can perform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement of both the survival of severely injured or ill patients and patient throughput.

Improper Use of Thrombolytic Agents in Acute Hemiparesis Following Misdiagnosis of Acute Ischemic Stroke.

Objective Acute hemiparesis is often an early presentation of acute ischemic stroke, though it can occur in various disorders. This study aimed to investigate the improper use of thrombolytic agents for patients with acute hemiparesis, following the misdiagnosis of acute ischemic stroke.MethodsWe analyzed the clinical and radiological data of nine patients initially misdiagnosed with cerebral stroke in the emergency room from May 2013 to January 2017. All the patients were treated with tissue plasminogen activator (TPA) owing to the presence of acute hemiparesis. Subsequently, emergent computed tomography scan showed no intracranial hemorrhage. Clinical findings including neurological deficits, clinical course, and related complications were detected and analyzed.ResultsAcute hemiparesis was observed in the following conditions: spontaneous spinal epidural hematoma, Brown-Séquard syndrome caused by cervical disc herniation, cervical epidural abscess, hypoglycemia in the presence of an old stroke, and seizure or convulsion disorder. Although acute hemiparesis was regarded as a contraindication, inappropriate TPA administration did not aggravate the neurological condition in any of the patients who required surgery.ConclusionUpon presentation of acute hemiparesis, various conditions mimicking cerebral stroke should be considered to avoid misdiagnosis. We suggest that physicians should exercise caution when prescribing thrombolytic agents.

A case of attempted bilateral self-enucleation in a patient with bipolar disorder

Attempted and completed self-enucleation, or removal of one's own eyes, is a rare but devastating form of self-mutilation behavior. It is often associated with psychiatric disorders, particularly schizophrenia, substance induced psychosis, and bipolar disorder. We report a case of a patient with a history of bipolar disorder who gouged his eyes bilaterally as an attempt to self-enucleate himself. On presentation, the patient was manic with both psychotic features of hyperreligous delusions and command auditory hallucinations of God telling him to take his eyes out. On presentation, the patient had no light perception vision in both eyes and his exam displayed severe proptosis, extensive conjunctival lacerations, and visibly avulsed extraocular muscles on the right side. An emergency computed tomography scan of the orbits revealed small and irregular globes, air within the orbits, and intraocular hemorrhage. He was taken to the operating room for surgical repair of his injuries. Attempted and completed self-enucleation is most commonly associated with schizophrenia and substance induced psychosis, but can also present in patients with bipolar disorder. Other less commonly associated disorders include obsessive-compulsive disorder, depression, mental retardation, neurosyphilis, Lesch-Nyhan syndrome, and structural brain lesions.

Rotterdam Computed Tomography Score to Predict Outcome in Traumatic Brain Injury Patients

Introduction In this article, we describe our experience of using Rotterdam computed tomography (CT) score at index admission to predict the outcome in traumatic brain injury (TBI) patients. Materials and Methods A total of 370 TBI patients admitted to the Neurosurgery Intensive Care Unit, Narayana Medical College and Hospital, Andhra Pradesh, between January 2014 and December 2014 were evaluated. Based on availability of emergency CT scan, these patients' charts were reviewed prospectively. CT scan findings were quantified using Rotterdam CT classification (basal cistern, midline shift, and intraventricular blood/subarachnoid blood). Patient characteristic, Glasgow Coma Scale (GCS) score, Rotterdam CT classification, and outcome were analyzed. Correlation between Rotterdam CT classification at index admission and outcome at discharge from the hospital, alive or dead, was assessed. Results The mean age of patients was 39.19 ± 15.18 years. Rotterdam CT score was significant ( p p = 0.618). The outcome and individual components of Rotterdam CT classification were statistically significant. Conclusion Increase in Rotterdam CT score was significantly associated with mortality at discharge. We suggest that it is possible to predict the outcome based on CT scan findings. However, the findings can have shortcomings, due to obvious reasons.

Ultrasound findings of incidental adnexal and ovarian lesions on emergency CT scans

A search through 6076 nontraumatic emergency computed tomography (CT) scans of female patients yielded 266 (4.4%) CT scans with an incidentally detected adnexal lesion and ultrasound follow-up within 7days. The population was 87% premenopausal and 13% postmenopausal. Follow-up ultrasound yielded an ultrasound diagnosis 32% of the time. Potentially serious diagnoses included pelvic infection (3%) and suspected malignancy (2%). Benign diagnoses included normal ovaries (16%), hemorrhagic cyst (6%), and benign cyst (5%). The remaining 68% of cases were equivocal, requiring further evaluation.