Prediction of Rupture of Pre-existing Cerebral Aneurysm by CT Findings in Patients with Traumatic Brain Injury

PURPOSE: Rupture of pre-existing cerebral aneurysms has occasionally been reported as a cause of traumatic subarachnoid hemorrhage (TSAH) and intraparenchymal hemorrhage (IPH). SAH due to rupture of pre-existing cerebral aneurysm is an important differential diagnosis in TSAH. The aim of our study was to determine whether a rupture in a pre-existing cerebral aneurysm could be predicted based on the pattern of hemorrhage on the initial computed tomography (CT) scan in patients with traumatic brain injury (TBI). METHODS: A total of 336 patients who had undergone computed tomography angiography (CTA) for detection of rupture of pre-existing cerebral aneurysm in TBI between the years 2004 and 2013 were retrospectively studied. In order to investigate CT findings of ruptured cerebral aneurysm, patients who had a lesion of SAH, IPH, or IVH were compared with the control group (who had intracranial lesions of contusion, epidural hematoma, subdural hematoma, or hemorrhagic contusion). RESULTS: Fifty eight (17.3%) patients with TSAH harbored cerebral aneurysms, and 45 (13.4%) patients had ruptured cerebral aneurysms. The ruptured aneurysms showed significant association with CT findings of a diffuse hemorrhage in the basal cisterns (29.2%, p=0.003, OR=23.130), unilateral sylvian fissure (13.8%, p=0.039, OR=8.842), anterior interhemispheric fissure (20.0%, p=0.028, OR=14.000), and associated IPH (22.6%, p=0.011, OR=16.333). However, the ruptured aneurysms did not show association with CT findings of hemorrhage on convexities, perimesencephalic cisterns, bilateral sylvian fissure, and IVH (p>0.1). CONCLUSION: Patterns of distribution of SAH and associated IPH on initial CT can be predicted of rupture pre-existing cerebral aneurysm in patients with TBI.

Clinical Features of Spontaneous Isolated Superior Mesenteric Artery Dissection

PURPOSE: Spontaneous isolated superior mesenteric artery dissection (SISMAD) is defined as superior mesenteric artery (SMA) dissection without an associated aortic dissection. SISMAD is an uncommon mesenteric ischemia, but can lead to death if not recognized early. Here, we present our experience on features characterizing SISMAD in an early period and review imaging findings. METHODS: Twelve symptomatic SISMAD patients who received conservative treatment between March 2005 and February 2012 were included in this study. Their clinical characteristics, imaging findings, treatment methods and outcomes were retrospectively analyzed. A diagnosis of SISMAD was confirmed by multidetection computed tomography (MDCT) and computed tomographic (CT) angiography. RESULTS: All patients complained of severe (6 patients) or moderate abdominal pain (6 patients), and 4 patients complained of radiating back pain at the same time. Eight patients had an acute onset (< or =3 days) of abdominal pain, and 4 patients had a chronic onset of the abdominal pain. The abdominal pain was located in the upper abdomen in 7 patients and in the periumbilical area in 5 patients. Angiographic types of SISMAD were classified into Sakamoto's type I (3 patients), type II (1), type III (4), and type IV (4). The dissection occurred within 3 cm from the orifice of the SMA in 9 patients (75%). The angiographic type of SISMAD was not associated with clinical symptoms and treatment methods. Ten out of 12 patients were treated with conservative management such as expectation and anticoagulation. Aneurysmal dilation of the SMA was noted in 4 patients, and 2 patients out of these 4 underwent surgical operations due to persistent abdominal pain and a growing aneurysm. No patients had a recurrence of symptoms and lesion progression on follow-up CT angiography. CONCLUSION: Patients with an acute onset of severe abdominal pain or chronic persistent abdominal pain should be suspicious of SISMAD and CT angiography should be performed.

CT Findings of Rupture of Pre-existing Cerebral Aneurysm in Blunt Head Trauma

PURPOSE: Rupture of pre-existing cerebral aneurysms has been reported as a cause of traumatic subarachnoid hemorrhage (TSAH). SAH due to rupture of pre-existing cerebral aneurysm is an important differential diagnosis in TSAH. Our study was aimed to assess whether a rupture in a pre-existing cerebral aneurysm could be predicted on the basis of the quantity and distribution pattern of hemorrhage on the initial computed tomography (CT). METHODS: 197 patients with TSAH were retrospectively studied between the years 2003 and 2008. We examined the age and sex of patients, mechanisms of injury, consciousness level at admission, and CT parameters including the distribution and quantity of SAH, localized blood clot, intraventricular hemorrhage, or hemorrhagic contusion and extra-axial hematoma. We compared the patients with nonaneurysmal TSAH to the patients with aneurysmal TSAH. RESULTS: 22(11.2%) patients with TSAH harbored pre-existing cerebral saccular aneurysms. The aneurysms were found in the patients with diffuse or anteriorly located blood in the basal cisterns(40.6%), unilateral sylvian fissure (16.7%), and anterior interhemispheric fissure(18.2%). But the aneurysm was not found in all patients with perimesencephalic hemorrhage, bilateral sylvian fissures, and convexities. TSAH with localized clot in the anterior interhemispheric or sylvian fissure (OR=5.924, p=0.005), or SAH completely filling any cistern or fissure (OR=3.148, p=0.034) was significantly associated with rupture of pre-existing cerebral aneurysm in logistic regression analysis. CONCLUSION: SAH in the basal cisterns extended into bilateral sylvian fissures and anterior interhemispheric fissure, and SAH in the unilteral sylvian fissure on initial CT could be predicted rupture of pre-existing cerebral aneurysm.

Is Routinely Repeated Brain Computed Tomography Necessary after Traumatic Brain Injury in an Emergency Setting?

PURPOSE: Computed tomography (CT) is the standard diagnostic method employed in cases of blunt head trauma, and repeat CT (RCT) scans are very often obtained in order to monitor for acute progression of intracranial pathology. The purpose of this study was to retrospectively evaluate the utility of the routine RCT scans in patients with traumatic brain injury (TBI), and to suggest the guidelines for RCT scans of the head. METHODS: The trauma registry and medical records of patients who were admitted to the emergency department of our university hospital from January 2004 to December 2006 were retrospectively reviewed. All patients admitted with TBI who received RCT scans of head were enrolled in this study. Results of initial head CT scans, indications for RCT (routine vs. neurologic change), and neurosurgical interventions (craniotomy and extraventricular drainage) were recorded. For patients who received worsened or unchanged subsequent RCT scans, the scans were compared and independent predictors of a worsened RCT were identified by stepwise logistic regression. Patients were categorized according to the Glasgow Coma Scale (GCS) as having mild (GCS 14-15), moderate (GCS 9-13), or severe (GCS< or =8) head injury. RESULTS: All inclusion criteria were met in 338 patients. Most (70.7%, n=239) RCT scans were preformed on a routine basis, whereas 29.3% (n=99) were ordered in response to neurological change. One hundred eleven (32.8%) patients showed signs of worsening on RCT, and 62 (13.8%) required neurosurgical intervention. Risk factors associated with worsening on CT evaluations were coagulopathy; skull fracture; multiple lesions; and an initial diagnosis of acute subdural hematoma, acute epidural hematoma, or hemorrhagic contusion. No patient with a mild or moderate TBI without neurological deterioration underwent an neurosurgical intervention after routine RCT. However, of the 48 patients with severe TBI who underwent routine RCT, the repeat scanning led to neurosurgical intervention in 5 patients (10.4%). CONCLUSION: In patients with mild and moderate TBI without clinical deterioration, routine RCT does not alter management and is unnecessary. Nevertheless, conclusions about patients with moderate TBI should be drawn with caution. Routine RCT is unequivocally indicated for patients with severe TBI, because the results sometimes dictate neurosurgical intervention even in the absence of obvious neurological deterioration.

Bone Mineral Density in Patients with Osteoporotic Compression Fractures

Osteoporosis is the most common generalized skeletal disease, which lays a significant socioeconomic burden to Korea. The early diagnosis and treatment of osteoporosis are of the great interest to minimize the economic co nsequence. We have studied vertebral BMD and bone scan of 30 patients with osteoporotic compression fractures. The purpose of this study was to investigate the effect of osteoporotic compression fracture on bone mineral density(BMD). We have measured the vertebral heights, vertebral bone mineral density, and bone scan counts of vertebral bodies on osteoporotic patients. Vertebral BMD was measured from T12 to L4 using dual photon absorptiometry. Anterior(Ha), middle(Hm), and posterior(Hp) height of vertebrae were measured from T12 to L4, and the spinal deformity indices(Ha/Hp, Hm/Hp, and Hp/Hi ratios) were calculated. The bone scan counts were measured from T12 to L4, and bone scan ratios were calculated. The BMD of fractured vertebrae was significantly higher than that of non-fractured vertebrae The spinal deformity indices were not correlated to the BMD of fractured vertebrae. The bone scan ratio was correlated to the BMD of fractured vertebrae. This study suggests that the increased BMD observed in fractured vertebrae is related to metabolic effect of compression fractures rather than mechanical effect.

Clinical Analysis of Primary Intracerebral Hematoma

We experienced 150 cases of spontaneous intracerebral hematoma which were confirmed by CT scan in Gang Nam Sacred Heart Hospital from November 1980 to October 1982. The analysis is based on 110 patients with primary intracerebral hematoma on whom operation was performed in 44 cases and conservative treatment was done in 66 cases. The CT scan of brain allows the clinical diagnosis of intracerebral hematom, and size, location, extension, ventricular penetration and evolution of hemorrhage are accurately portrayed. The results of the treatment were affected by conscious level, location and volume of hematoma, ventricular penetration and blood pressure. The operative treatment was better than conservative management in followings : 1. semicomatose and drowsy mental state, 2. subcortical hemorrhage, 3. more than 20 cc in volume, 4. progressively deteriorating neurological function and consciousness. We have obtained the best results in operating cases between 4th and 7th day after the stroke.

Clinical Analysis of Primary Intracerebral Hematoma

We experienced 150 cases of spontaneous intracerebral hematoma which were confirmed by CT scan in Gang Nam Sacred Heart Hospital from November 1980 to October 1982. The analysis is based on 110 patients with primary intracerebral hematoma on whom operation was performed in 44 cases and conservative treatment was done in 66 cases. The CT scan of brain allows the clinical diagnosis of intracerebral hematom, and size, location, extension, ventricular penetration and evolution of hemorrhage are accurately portrayed. The results of the treatment were affected by conscious level, location and volume of hematoma, ventricular penetration and blood pressure. The operative treatment was better than conservative management in followings : 1. semicomatose and drowsy mental state, 2. subcortical hemorrhage, 3. more than 20 cc in volume, 4. progressively deteriorating neurological function and consciousness. We have obtained the best results in operating cases between 4th and 7th day after the stroke.

A Case of Traumatic False Aneurysm of the Vertebral Artery

The traumatic false aneurysm of the vertebral artery, as distinct from arteriovenous fistula, is rare condition. The aneurysm of the extracranial vertebral artery is most frequently related to penetrating or perforating injury, such as gunshot or stab injury, and it is not true aneurysm but false aneurysm. We expected a case of false aneurysm in 52 years old man who had taken penetrating neck trauma by sharp steel rod at work. The vertebral angiogram disclosed an aneurysmal shadow and occlusion of the vertebral artery at the level of the axis and successfully treated by clipping of the artery and resection of the aneurysmal mass.