Initial Computed Tomography Imaging Research Articles

Cervical spine clearance in adults following blunt trauma: a national survey across major trauma centres in England

To assess current practice in cervical spine clearance across major trauma centres in England and review current guidelines. An electronic survey was sent to lead trauma clinicians at 22 major trauma centres in England. This assessed the clinical decision tools used, the choice of initial imaging technique, and the methods used to clear the cervical spine in alert and obtunded patients without focal neurology, and where initial imaging was normal. British Orthopaedic Association Standards for Trauma (BOAST) 2 and Eastern Association for Surgery for Trauma (EAST) guidelines were used as standards. Eighteen out of the 22 (82%) centres responded by completing the survey. Most (71%) centres used the Canadian C-Spine Rule for clearing the cervical spine clinically. Seventy-two percent of centres preferred computed tomography (CT) as the first-line imaging technique, the choice based on age of patient and mechanism of injury. If the initial CT imaging was normal, magnetic resonance imaging (MRI) was performed in 52% of centres to clear the cervical spine, with half of these centres stating that they would discuss further imaging with a radiologist first. The practice across centres was highly variable for the obtunded patient, with most centres preferring continuing immobilisation or MRI to clear the cervical spine, with a small minority removing spinal precautions when a high-quality multidetector CT was normal. Multidetector CT is the preferred initial imaging technique across most major trauma centres in England when blunt cervical spine trauma is suspected. There is widespread reliance on MRI to clear the cervical spine in both alert and obtunded patients, if initial CT imaging is normal and there is no focal neurology on clinical assessment. This calls for greater awareness of the reliability of a high-quality normal multidetector CT examination in clearing the cervical spine in the absence of focal neurology.

The Volume of the Third Ventricle as a Prognostic Marker for Shunt Dependency After Aneurysmal Subarachnoid Hemorrhage.

Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (aSAH). However, in daily routine it is difficult to predict a patient's need for ventricular shunt placement in the course of the disease. The purpose of this study was to identify radiologic predictors for development of a shunt-dependent hydrocephalus after aSAH. A cohort of 217 patients with aSAH with adequate pretreatment computed tomography (CT) imaging was retrospectively reviewed. All variables, including demographic data, treatment, and initial CT imaging were gathered and grading was performed using Hunt and Hess, Graeb, LeRoux, and modified Fisher scores. Analysis of the radiographic parameters consisted of straight measurement and three-dimensional volumetry using manual segmentation. Univariate and multivariate statistical analyses were performed to identify predictive parameters. Of 217 patients, 36 (17.5%) required a ventricular shunt (VS). A receiver operating characteristic analysis between the volume of the third ventricle and shunt-dependent hydrocephalus showed a significant cutoff at a volume of 2.3 cm3 with a 4.3-fold higher risk for shunt dependency (P < 0.001). However, the treatment modality and classification according to the mentioned scores were not associated with the need for VS after aSAH. In univariate and multivariate analysis, the volume of the third ventricle on admission remained a significant prognostic marker for the need of a VS. Our data suggest that the volume of the third ventricle in the initial CT is a strong predictor for shunt dependency after aSAH.

Accuracy of 3-Dimensional Virtual Surgical Simulation Combined With Digital Teeth Alignment: A Pilot Study

To evaluate the accuracy of virtual surgical simulation combined with digital teeth alignment and the applicability of this technique to the diagnosis and establishment of a 3-dimensional (3D) visualized treatment objective for orthognathic surgery by comparing virtual simulation images with actual post-treatment images. This retrospective study included patients who underwent computed tomography (CT) before and after treatment. The 3D digital images were constructed from the initial CT images and dental cast scan data, and virtual surgical simulation combined with digital teeth alignment was performed. Accuracy of the virtual simulation was analyzed by comparing the distances of skeletal and dental landmarks in the horizontal, sagittal, and coronal reference planes with those on post-treatment images using the Wilcoxon signed rank test. Intraclass correlation coefficients were calculated to evaluate the degree of concordance between the 2 images. The study sample included 11 patients (mean age, 18.8yr). Most landmarks had differences smaller than 2mm in the 3 reference planes between virtual simulation and post-treatment images; these differences were not statistically significant (P>.05). Most skeletal landmarks, except the A point, B point, and gonion, showed normal to high concordance between the virtual simulation and post-treatment images in the 3 reference planes (P<.05); dental landmarks exhibited a broad range of concordance. The 3D virtual surgical simulation combined with digital teeth alignment using pretreatment CT images yielded results sufficiently accurate to be used for the diagnosis and establishment of visualized treatment objectives for orthognathic surgery.

Consistency mapping of 16 lymph node stations in gastric cancer by CT-based vessel-guided delineation of 255 patients.

In order to refine the location and metastasis-risk density of 16 lymph node stations of gastric cancer for neoadjuvant radiotherapy, we retrospectively reviewed the initial images and pathological reports of 255 gastric cancer patients with lymphatic metastasis. Metastatic lymph nodes identified in the initial computed tomography images were investigated by two radiologists with gastrointestinal specialty. A circle with a diameter of 5 mm was used to identify the central position of each metastatic lymph node, defined as the LNc (the central position of the lymph node). The LNc was drawn at the equivalent location on the reference images of a standard patient based on the relative distances to the same reference vessels and the gastric wall using a Monaco® version 5.0 workstation. The image manipulation software Medi-capture was programmed for image analysis to produce a contour and density atlas of 16 lymph node stations. Based on a total of 2846 LNcs contoured (31–599 per lymph node station), we created a density distribution map of 16 lymph node drainage stations of the stomach on computed tomography images, showing the detailed radiographic delineation of each lymph node station as well as high-risk areas for lymph node metastasis. Our mapping can serve as a template for the delineation of gastric lymph node stations when defining clinical target volume in pre-operative radiotherapy for gastric cancer.

Initial computed tomography imaging details during first-line systemic therapy is of significant prognostic value in patients with naïve, unresectable metastatic renal cell carcinoma.

PurposeWe aimed to determine the prognostic significance of computed tomography imaging parameters of unresectable primary renal tumor lesions, obtained at baseline and at first follow-up, on overall survival in naïve, unresectable metastatic renal cell carcinoma patients during first-line systemic therapy.Materials and methodsClinicopathological parameters of 56 patients treated between 2007 and 2015, including imaging parameters (such as the longest tumor diameter, necrotic area diameter, and attenuation in primary renal tumor lesions on baseline vs. follow-up computed tomography), were retrospectively reviewed to derive predictive factors of overall survival. The best overall response was measured according to the RECIST v1.1.ResultsThe median treatment period was 206.3 days and the median follow-up was 14.6 months. Forty-four (78.6%) patients progressed after a median 4.6 months of progression-free survival, and 6 (10.7%) patients survived with a median overall survival of 12.5 months. Multivariate analysis showed that the baseline tumor diameter (hazard ratio [HR] 0.903) and mean attenuation (HR 0.936), change of tumor diameter (HR 0.714) and necrosis diameter (HR 0.861), change in the percentage of tumor diameter (HR 1.483) and of necrosis diameter (HR 1.028) between baseline and follow-up computed tomography images; treatment duration (HR 0.986) and baseline serum hemoglobin (HR 1.790) and albumin level (HR 0.060) were significant factors for overall survival (p<0.05).ConclusionThe study showed that baseline and first follow-up computed tomography findings of primary renal lesions during first-line systemic therapy are useful and significant predictors of OS in patients with naïve unresectable mRCC.

Prognostic Significance of Intraventricular Hemorrhage in Vascular Structural Abnormality-Related Intracerebral Hemorrhage

The prognostic significance of intraventricular hemorrhage (IVH) in patients with vascular structural abnormality-related intracerebral hemorrhage (VSARICH) is poorly understood. We prospectively included consecutive patients diagnosed with VSARICH. Imaging of initial brain computed tomography (CT) scans within 48 hours of symptom onset was analyzed. The presence and severity of IVH were recorded. Severity of IVH was measured using the modified Graeb (mGraeb) score. Baseline characteristics and 3-month outcomes were compared between the IVH and non-IVH groups. Multivariate logistic regression was used to examine the independent association between IVH and 3-month outcomes. A total of 132 VSARICH patients were included for analysis, and 71 (53.8%) of them had IVH on initial CT imaging. IVH patients had a median mGraeb score of 15 (6-21), and compared to non-IVH patients, they had shorter delay to first CT scan and higher stroke severity on admission (all P ≤ .005). At 3 months, IVH patients had higher death rates (30.3% versus 7.0%; P = .001) and poor outcome rates (48.5% versus 21.1%; P = .002) than non-IVH patients. After multivariate analysis, IVH severity was associated with 3-month death (Model 1 OR 1.112, 95% CI [1.027-1.204], P = .009; Model 2 OR 1.110, 95% CI [1.027-1.200], P = .009) and poor outcome (Model 2 OR 1.053, 95% CI [1.001-1.108], P = .047), although no independent association between IVH presence and outcomes was observed. IVH severity measured by mGraeb score independently predicts death and poor functional outcome in patients with VSARICH.

Nonoperative management of grade III blunt thoracic aortic injuries

Blunt thoracic aortic injuries (BTAIs) have historically been treated with open surgery; thoracic endovascular aortic repair (TEVAR), however, is rapidly becoming the standard of care for all grades of injury. Previous studies have shown successful, conservative management of low-grade (I and II) BTAI, but limited literature exists regarding nonoperative management (NOM) for high-grade BTAI. The purpose of this study was to evaluate NOM for grade III BTAI compared with TEVAR. There were 75 patients diagnosed with BTAI between January 2004 and June 2015. Of these, 40 were excluded for different grades of BTAI (17), death before any treatment (6), and need for urgent open repair (17). The remaining 35 patients were divided into two groups by treatment approach: NOM (n= 18) and TEVAR (n= 17). Primary end points were complications and mortality. The secondary end point was difference in pseudoaneurysm and aortic diameter measurements between groups. The groups of patients were similar in age, gender, Injury Severity Score, length of stay, in-hospital mortality, and hospital-associated complications. There were four TEVAR-related complications: graft involutions (2), type I endoleak (1), and distal embolization (1). All TEVAR-related complications required either an adjunctive procedure at the time of the primary procedure or an additional procedure. No patients from the NOM group required operative intervention. There were seven in-hospital mortalities: two in the TEVAR group (11.8%) and five in the NOM group (27.8%; P= .402). One death in the NOM group was related to aortic disease. Follow-up computed tomography imaging revealed similar aortic-related outcomes between groups, with a high proportion showing resolved or improved aortic injury (NOM, 87.5%; TEVAR, 92.9%; P= .674). Initial computed tomography imaging showed similar aortic diameters between groups. The average diameter of the aorta distal to the subclavian artery was 22.6mm in the NOM group vs 22.8mm in the TEVAR group (P= .85). The average maximum diameter of the pseudoaneurysm was 30.1mm in the TEVAR group and 29.9mm in the NOM group (P= .90). The average ratio of diameter of the pseudoaneurysm to diameter of the aorta distal to the subclavian artery was 1.32 for the TEVAR group and 1.33 for the NOM group (P= .85). The natural history of grade III BTAIs is not well described. This study suggests that observation and NOM of grade III BTAI may be a reasonable therapeutic option in selected patients. It also speaks to the need for further delineation of the natural history of this injury. Serial imaging and long-term follow-up are necessary to monitor the progression of the pseudoaneurysm.

CT Hounsfield Units as a Predictor for the Worsening of Traumatic Vertebral Compression Fractures

With vertebral compression fractures (VCF), height loss has been associated with kyphotic deformity and intractable pain, 2 indications for potential surgical intervention. Consequently, assessment of factors associated with continual height loss can provide insights regarding management. Computed tomography (CT) Hounsfield units (HU), a measure of radiodensity, have been implicated for the assessment of bone quality. No studies have assessed the relationship between CT HU and traumatic VCF. Consequently, the objective of this study was to evaluate this relationship. Patients who sustained a traumatic VCF from a motor vehicle accident from 2006 to 2015 were reviewed retrospectively. Inclusion criteria were single VCF from L1 to L4, appropriate imaging, and appropriate follow-up. Clinical data were extracted (age, gender, history of osteoporosis, body mass index [BMI], and length of follow-up). Initial CT imaging was evaluated for averaged HU at the levels above and below the index level of the VCF. Interval percentage change (Δ%) in anterior compression was evaluated between radiographs obtained during initial presentation and at follow-up. Age, BMI, and CT HU significantly correlated with Δ% (P < 0.01), whereas initial height loss, history of osteoporosis, and length of follow-up did not. A multiple linear regression for Δ% that combined age, BMI, and CT HU values elicited a regression model with R(2) 0.648, and adjusted R(2) 0.606; each variable in the model showed P<0.05. A receiver operating characteristic analysis to predict Δ% < 10% from Δ% ≥10% showed an area under the curve 0.983 (P < 0.01), where CT HU at 171.58 showed a combination of sensitivity at 0.923 and specificity at 0.91. Age, BMI, and CT HU values are independent predictors of worsening VCF. These factors can help determine appropriate clinical follow-up and need for surgical intervention.

SU‐F‐T‐626: Intracranial SRS Re‐Treatment Without Acquisition of New CT Images

Purpose:Linear accelerator based stereotactic radiosurgery (SRS) for multiple intracranial lesions with frequent surveillance is becoming a popular treatment option. This strategy leads to retreatment with SRS as new lesions arise. Currently, each course of treatment uses magnetic resonance (MR) and computed tomography (CT) images for treatment planning. We propose that new MR images, with course 1 CT images, may be used for future treatment plans with negligible loss of dosimetric accuracy.Methods:Ten patients that received multiple courses of SRS were retrospectively reviewed. The treatment plans and contours from non‐initial courses were copied to the initial CTs and recalculated. Doses metrics for the plans calculated on the initial CTs and later CTs were compared. All CT scans were acquired on a Philips CT scanner with a 600 mm field of view and 1 mm slice thickness (Philips Healthcare, Andover, MA). All targets were planned to 20 Gy and calculated in Eclipse V. 13.6 (Varian, Palo Alto, CA) using analytic anisotropic algorithm with 1 mm calculation grid.Results:Sixteen lesions were evaluated. The mean time between courses was 250 +/− 215 days (range 103–979). The mean target volume was 2.0 +/− 2.9 cc (range 0.1–10.1). The average difference in mean target dose between the two calculations was 0.2 +/− 0.3 Gy (range 0.0 – 1.0). The mean conformity index (CI) was 1.28 +/− 0.14 (range 1.07 – 1.82). The average difference in CI was 0.03 +/− 0.16 (range 0.00 – 0.44). Targets volumes &lt; 0.5 cc showed the largest changes in both metrics.Conclusion:Continued treatment based on initial CT images is feasible. Dose calculation on the initial CT for future treatments provides reasonable dosimetric accuracy. Changes in dose metrics are largest for small volumes, and are likely dominated by partial volume effects in target definition.

Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures

Open pelvic disruptions represent high-energy injuries. The prompt identification and management of these injuries decreases their associated morbidity and mortality. Computed tomography (CT) scans are routinely obtained in the initial evaluation of patients with pelvic injuries. The purpose of this study is to identify the incidence and source of air densities noted on computed tomography (CT) scans of the abdominal and pelvic region in patients with pelvic fractures and evaluate the use of initial CT imaging as an adjunctive diagnostic tool to identify open injuries. A retrospective review of a prospectively collected database was performed at a single institution. Seven hundred and twenty-two consecutive patients with a pelvic disruption over a two-year period were included. Review of initial injury CT scans was performed using bone and lung viewing algorithms to identify the presence of extra-luminal air. The primary outcome was the presence, location and source of air identified on pre-operative CT scans. Secondary measurements were identification of air by plain radiograph and correlation between identified air densities on CT and clinically diagnosed open pelvic fractures. Ninety-eight patients were identified as having extra-luminal air densities on CT scans. Eighty-one patients were included in the final analysis following application of inclusion and exclusion criteria. Air was noted by the radiologist in forty-five (55.6%) instances. Six patients (7.4%) were clinically diagnosed with an open pelvic ring disruption; in two patients (2.4%) this diagnosis was delayed. In all patients, the CT was able to track air from its origin. In patients with pelvic disruptions, the injury CT should also be evaluated for the presence and source of extra-luminal air. In some patients, this finding may represent an open pelvic ring disruption. A complete physical exam and CT evaluation should be used to decrease the missed or delayed diagnosis of an open pelvic ring injury.

Initial screening test for blunt cerebrovascular injury: Validity assessment of whole-body computed tomography

Our whole-body computed tomography protocol (WBCT), used to image patients with polytrauma, consists of a noncontrast head computed tomography (CT) followed by a multidetector computed tomography (40- or 64- slice) that includes an intravenous, contrast-enhanced scan from the face through the pelvis. WBCT is used to screen for blunt cerebrovascular injury (BCVI) during initial CT imaging of the patient with polytrauma and allows for early initiation of therapy with the goal of avoiding stroke. WBCT has not been directly compared with CT angiography (CTA) of the neck as a screening tool for BCVI. We hypothesize that WBCT is a valid modality to diagnose BCVI compared with neck CTA, thus screening patients with polytrauma for BCVI and limiting the need for subsequent CTA. A retrospective review of the trauma registry was conducted for all patients diagnosed with BCVI from June 2009 to June 2013 at our institution. All injuries, identified and graded on initial WBCT, were compared with neck CTA imaging performed within the first 72hours. Sensitivity was calculated for WBCT by the use of CTA as the reference standard. Proportions of agreement also were calculated between the grades of injury for both imaging modalities. A total of 319 injured vessels were identified in 227 patients. On initial WBCT 80 (25%) of the injuries were grade I, 75 (24%) grade II, 45 (14%) grade III, 41 (13%) grade IV, and 58 (18%) were classified as indeterminate: 27 vertebral and 31 carotid lesions. Twenty (6%) of the 319 injuries were not detected on WBCT but identified on subsequent CTA (9 grade I, 7 grade II, 4 grade III); 6 vertebral and 14 carotid. For each vessel type and for all vessels combined, WBCT demonstrated sensitivity rates of over 90% to detect BCVI among the population of patients with at least one vessel injured. There was concordant grading of injuries between WBCT and initial diagnostic CTA in 154 (48% of all injuries). Lower grade injures were more discordant than higher grades (55% vs 13%, respectively; P<.001). Grading was upgraded 8% of the time and downgraded 25%. WBCT holds promise as a rapid screening test for BCVI in the patient with polytrauma to identify injuries in the early stage of the trauma evaluation, thus allowing more rapid initiation of treatment. In addition, in those patients with high risk for BCVI but whose WBCT results are negative for BCVI, neck CTA should be considered to more confidently exclude low-grade injuries.

Use of and regional variation in initial CT imaging for kidney stones.

We sought to determine the prevalence of initial computed tomography (CT) utilization and to identify regions in the United States where CT is highly used as the first imaging study for children with nephrolithiasis. We performed a cross-sectional study in 9228 commercially insured children aged 1 to 17 years with nephrolithiasis who underwent diagnostic imaging in the United States between 2003 and 2011. Data were obtained from MarketScan, a commercial insurance claims database of 17,827,229 children in all 50 states. We determined the prevalence of initial CT use, defined as CT alone or CT performed before ultrasound in the emergency department, inpatient unit, or outpatient clinic, and identified regions of high CT utilization by using logistic regression. Sixty-three percent of children underwent initial CT study and 24% had ultrasound performed first. By state, the proportion of children who underwent initial CT ranged from 41% to 79%. Regional variations persisted after adjusting for age, gender, year of presentation, and insurance type. Relative to children living in West South Central states, the highest odds of initial CT utilization were observed for children living in the East South Central US Census division (odds ratio: 1.27; 95% confidence interval: 1.06-1.54). The lowest odds of initial CT were observed for children in the New England states (odds ratio: 0.48; 95% confidence interval: 0.38-0.62). Use of CT as the initial imaging study for children with nephrolithiasis is highly prevalent and shows extensive regional variability in the United States. Current imaging practices deviate substantially from recently published guidelines that recommend ultrasound as the initial imaging study.

Clinical Factors With Respect to Cervical Body Volume Reduction During Definitive External Beam Radiation Therapy for Hypopharyngeal Squamous Cell Carcinoma

Substantial cervical body volume reduction (CBVR) occurs during fractionated external beam radiation therapy (EBRT) for head and neck cancer and could have dosimetric effects. Adaptive radiation therapy (ART) can address this issue, if necessary. However, it remains unclear whether all patients derive a significant benefit from routine ART. Our aim was to evaluate clinical factors affecting CBVR rates (CBVRR) during definitive conventional EBRT for hypopharyngeal squamous cell carcinoma (HSCC). We retrospectively studied 63 HSCC patients treated with definitive conventional EBRT to the primary tumor and metastatic lymph nodes (LN) between July 2006 and December 2012. This study included 60 men (95%) and 3 women (5%) with a median age of 63 years (range, 51-85 years). No patients received prior surgery for HSCC. The daily dose was either 1.8 or 2 Gy, five times weekly in 62 patients. The other patient received twice-daily 1.2-Gy fractions. For EBRT planning, computed tomography (CT) images were acquired before EBRT initiation and 3 to 5 weeks after the start of EBRT for re-planning in each patient. We examined CBVRR between the initial and re-planning CT images using a MATLAB program. Fifty-nine patients (94%) received concurrent chemotherapy (CC) using the following regimens: TPF [docetaxel (DOC), cisplatin (CDDP) and 5-fluorouracil (5-FU)] in 30 (47%); another CDDP-based regimen in 10 (16%); DOC in 17 (27%); DOC and 5-FU in 1 (2%); and TS-1 in 1 (2%). The remaining 4 patients (6%) did not receive CC. Eight patients were staged as T1 tumors (13%), 31 as T2 (49%), 15 as T3 (24%) and 9 as T4 (14%). Nineteen patients were staged as N0 (30%), 11 as N1 (18%), 2 as N2a (3%), 16 as N2b (25%), 6 as N2c (10%) and 9 as N3 (14%). Multiple linear regression was performed to explore clinical factors affecting CBVRR. The following clinical variables were assessed: age, gender, T stage, N stage, use of CC and the regimen. Backward stepwise regression was performed, and a P value greater than 0.20 was used for variable removal. P < 0.05 was defined as statistically significant. The institutional ethical review board approved this study. The median CBVRR was 6.5% (range, 1.2-23.7%). The final linear regression model identified N3 stage (95% confidence interval [CI] 1.333-7.775, P = 0.006) and TPF chemotherapy (95% CI 0.464-4.977, P = 0.019) as significant variables influencing CBVRR. Thus, intensive TPF-based CC and regional metastatic LN > 6 cm in greatest dimension were associated with substantial CBVRR. CBVRR appears to be associated with concurrent TPF chemotherapy and bulky regional LN metastasis in HSCC. HSCC patients with these factors may benefit from ART.

PP085-SUN: Outstanding abstract: Prognosis Value of Psoas Major Muscle Evaluated on CT Scan in Terminal ill Cancer Patients

Rationale: We previously reported that the area of the psoas major muscle (APMM) measured by computed tomography (CT) is a quick and simple tool to estimate muscle depletion in advanced cancer patients, and its performance as a prognostic value. Here we validated the relationship between depletion of APMM and survival in patients with two different types of cancer, which were colon and stomach cancer. Methods: A retrospective analysis was performed in thirtytwo cancer patients with gastrointestinal malignancies who underwent abdominal CT scans at initial diagnosis in noncachectic status and at follow-up in severe cachexia. Axial CT images at the top level of the iliac crest were obtained. APMM was measured by tracing the contour of the muscle using image analysis software. Decrease of APMM was expressed as percentage of initial CT image. Results: Twenty-three colorectal and nine stomach cancer patients were recruited with a median age of 69 and 63 years, respectively. Mean APMM decreased by 70.8±13.3% (from 16.5±5.3 cm2 to 11.9±4.2 cm2) in colon, and by 65.9±11.9% (from 21.7±3.5 cm2 to 14.3±3.8 cm2) in stomach. The respective linear correlations between prognosis and decrease of APMM were r = 0.622 (P= 0.002; slope = 0.648) and r = 0.75 (P= 0.0025; slope = 1.013). Analysis of covariance indicated no significant difference in slope between the cancer groups (P= 0.35). Conclusion: A simple index, APMM obtained from routine axial CT imaging, is valuable as a prognostic indicator in both colon and stomach cancer. Further studies are needed to confirm any statistically significant difference by cancer phenotype.

Letter by Brandler and Sharma Regarding Article, “Does Use of the Recognition of Stroke In the Emergency Room Stroke Assessment Tool Enhance Stroke Recognition by Ambulance Clinicians?”

We read with great interest the article by Fothergill et al1 that address the concern about prehospital identification of stroke. American Heart Association/American Stroke Association guidelines on the early management of adults with ischemic stroke highlight the role of emergency medical services (EMS) and find EMS use to be strongly associated with decreased time to initial physician examination, initial computed tomography imaging, and neurological evaluation.2 Therefore, the stroke chain of survival relies heavily on the accuracy with which EMS providers can identify strokes. The study by Fothergill et al is the first one to validate the use of Recognition of Stroke in the Emergency Room (ROSIER) scale for EMS providers. They compared ROSIER with Face Arm Speech Test (FAST), an another widely used prehospital stroke scale. Even though ROSIER has …

Subarachnoid Hemorrhage in a Patient With a Meningioma and an Unruptured Aneurysm

Subarachnoid hemorrhage (SAH) is usually elicited by cerebrovascular disease and infrequently by brain tumors. A 64-year-old woman presented with SAH with a left petrous meningioma and an unruptured left internal carotid-posterior communicating artery (IC-PcomA) aneurysm. She suffered sudden onset of headache and nausea followed by consciousness disturbance 7 days after onset. Computed tomography (CT) revealed diffuse SAH and a tumor at the petrous portion. Angiography demonstrated a left IC-PcomA aneurysm. Under a diagnosis of a ruptured aneurysm and a coincidental meningioma, we performed neck clipping of the aneurysm. However, intraoperatively we found that the aneurysm was unruptured and we subsequently performed tumor resection. Intraoperatively we could not find the cause of SAH during resection of the meningioma. The histological diagnosis was transitional meningioma with deposition of fibrin on the surface of the tumor. The findings of initial CT and magnetic resonance imaging, and pathological results could not conclude the definitive etiology of SAH in this case.

Ruptured Cerebral Arteriovenous Malformation Presenting as Intraventricular Hemorrhage

A 64-year-old woman with a history of ovarian carcinoma and cerebrovascular accident presented with the acute onset of a severe throbbing headache with associated nausea and vomiting. The patient described intermittent headaches over the preceding month with associated vision changes during these episodes. She was found to have intraventricular hemorrhage on an initial head computed tomography (CT) scan. Follow-up CT angiography and digital subtraction cerebral catheter angiography were performed. The initial unenhanced head CT (Figure ​(Figure11) reveals hyperdense hemorrhage layering in the frontal horns and atria of the lateral ventricles in addition to suspicious punctuate atrial calcifications. Such calcifications often herald the presence of an arteriovenous malformation (AVM). The CT angiogram (Figure ​(Figure22) and catheter angiogram (Figure ​(Figure33) demonstrate an enhancing nidus of blood vessels located in the medial temporal-occipital lobe and atrium of the right lateral ventricle consistent with an AVM. The vascular malformation is fed predominantly through an enlarged posterior communicating and posterior cerebral artery with drainage through both an enlarged basal vein of Rosenthal and enlarged superficial cortical veins. No intranidal aneurysm was detected. Figure 1 (a, b) Initial unenhanced axial CT images with diffuse intraventricular hemorrhage (arrows) and punctuate AVM calcifications (arrowheads). Figure 2 (a) Axial CT angiogram demonstrates the AVM nidus in the atrium of the lateral ventricle (arrows). (b) Axial reconstructed CT angiogram reveals enlargement of the posterior cerebral and posterior communicating arteries (arrowheads) in addition to an enlarged ... Figure 3 (a) Anteroposterior and (b) lateral catheter angiogram images show the AVM nidus (arrowheads) with enlargement of the right posterior cerebral and posterior communicating arteries (arrows). True AVMs contain one or more enlarged feeding arteries, a nidus, and enlarged early draining veins with no intervening capillary bed. They are considered a congenital anomaly but typically do not become symptomatic until beyond the third or fourth decade of life. AVMs are classified using the Spetzler-Martin grading system (grades 1 through 5) on the basis of size, location, and venous drainage patterns; higher numbers indicate less favorable surgical and treatment outcomes. The presented case meets criteria for a grade 2 AVM in this system. Treatment options for AVMs include endovascular embolization, surgical resection, and radiosurgery alone or in combination. In AVMs <3 cm in diameter, particularly those that are deeply situated in the brain, stereotactic radiosurgery is the therapy of choice, achieving cure rates of 80% to 90% at 2 to 3 years after treatment.

Blunt trauma induced splenic blushes are not created equal

BackgroundCurrently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We hypothesized that not all splenic blushes require intervention.MethodsDuring a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan.ResultsDuring the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 vs 83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 vs 1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 vs 3.5 ± 0.3), systolic blood pressure (125 ± 10 vs 115 ± 6), or age (38.5 ± 8.2 vs 30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications.ConclusionsFor blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.

Alcohol Use by Pedestrians Who Are Struck by Motor Vehicles: How Drinking Influences Behaviors, Medical Management, and Outcomes

Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

Agreement in Endovascular Thrombolysis Patient Selection Based on Interpretation of Presenting CT and CT-P Changes in Ischemic Stroke Patients

To evaluate the agreement in patient selection based on computed tomography (CT) and CT-perfusion (CT-P) imaging interpretation between stroke specialists in stroke patients considered for endovascular treatment. All endovascular-treated acute ischemic stroke patients were identified through a prospective database from two comprehensive stroke centers; 25 consecutively treated patients were used for this analysis. Initial CT images and CT-P data were independently interpreted by five board eligible/certified vascular neurologists with additional endovascular training to decide whether or not to select the patient for endovascular treatment. The CT/CT-P images were evaluated separately and used as the sole imaging decision making criteria, 2 weeks apart from each other (memory wash-out period). For each set of imaging data inter-rater and intra-rater agreement scores were obtained using Cohen's kappa statistic to assess the proportion of agreement beyond chance. Kappa values for the treatment decisions based on CT images was 0.43 (range 0.14-0.8) (moderate agreement), and for the decisions based on CTP images was 0.29 (range 0.07-0.67) (fair agreement) among the five subjects. There was substantial variability within the group and between images interpretation. Observed agreement on decision to treat with endovascular therapy was found to be 75% with CT images and 59% with CT-P images (with no adjustment for chance). Kappa values for intra-rater agreement were -0.14 (ranged -0.27-0.27) (poor agreement). There is considerable lack of agreement, even among stroke specialists, in selecting acute ischemic stroke patients for endovascular treatment based on CT-P changes. This mandates a careful evaluation of CT-P for patient selection before widespread adoption.