Magnetic resonance imaging evaluation of the cervical spine in the comatose or obtunded trauma patient.

OBJECT: Confirmation of cervical spine stability is difficult to obtain in the comatose or obtunded trauma patient. Concurrent therapies such as endotracheal intubation and the application of rigid cervical collars diminish the utility of plain radiographs. Bony as well as supportive soft-tissue structures must be evaluated before the cervical spine can be determined to be uninjured. Although major injuries to extradural soft-tissue structures in the awake trauma patient are frequently excluded by physical examination, when the patient is obtunded the physical examination may be unreliable. Therefore, an enhanced diagnostic method for the evaluation of soft-tissue injury is desirable. The authors conducted a study in which magnetic resonance (MR) imaging was used as such a method to assess posttraumatic spinal stability in the comatose or obtunded patient. METHODS: Early, limited (sagittal T1- and T2-weighted) MR imaging was performed posttruama in 121 patients to assess soft-tissue injury. In all patients the mechanism of injury potentially could be associated with cervical spine instability, and each patient was endotracheally intubated because of head injury or severe multisystem injuries. All patients underwent imaging studies within 48 hours of injury and were either treated or cleared and spinal precautions were discontinued. Patients were excluded from this study if they had an obvious cervical spine injury identified on the initial radiographic studies or if they were determined to be too medically unstable to undergo MR imaging within the acute period (<48 hours postinjury). Thirty-one (25.6%) of the 121 patients were found to have sustained significant injury to the paravertebral ligamentous structures, the disc interspace, or the bony cervical spine. These injuries were undetected by plain radiography. The other 90 patients (74.4%) were determined within 48 hours not to have sustained a soft-tissue injury. Eight patients (6.6%) ultimately underwent surgery to treat the cervical spine injury, and MR imaging was the first test that identified the injury in each of these patients. There were no complications related to imaging procedures. CONCLUSIONS: Sagittal T1- and T2-weighted MR imaging appears to be a safe, reliable method for evaluating the cervical spine for nonapparent injury in comatose or obtunded trauma patients. In the early postinjury period, nursing and medical care are thereby facilitated for patients in whom occult injury to the spine is ruled out and for whom those attendant precautions are unnecessary.

Primary epithelioid hemangioendothelioma of the clivus.

We describe the clinical, radiologic, and pathologic features of a primary intracranial hemangioendothelioma arising in the clivus in a 38-year-old female, emphasizing the importance of including this rare entity in the differential diagnosis of tumors arising at the base of the skull. To our knowledge, this is the first reported case of a clival hemangioendothelioma. Aside from its unusual location, this case is also notable for its apparent rapid growth and mixed epithelioid-spindle cell morphology. Appropriate neuroimaging studies may offer crucial information, ensuring that this uncommon entity is included in the differential diagnosis of a clival mass.

Sagittal sinus thrombosis following minor head injury treated with continuous urokinase infusion.

BACKGROUND: Cerebral dural sinus thrombosis is a rare clinical entity. Symptoms may be vague, and left untreated thrombus progression may be fatal because of venous congestion and infarction. METHODS: We report a case of post-traumatic dural sinus thrombosis treated with selective transfemoral, transvenous catheterization and infusion of urokinase. RESULTS: Urokinase infusion into the dural venous sinuses using a microcatheter introduced from the femoral vein was successfully carried out, and patency of the venous sinuses was reestablished. CONCLUSION: Venous sinus thrombosis can be an overlooked sequel to head injury. If the diagnosis is entertained, prompt performance of appropriate imaging studies should be instituted so that therapy can be initiated. The use of selective sinus catheterization using microcatheter techniques with instillation of urokinase is an excellent mode of therapy that should be considered in any patient with symptomatic occlusion.

External carotid-to-middle cerebral bypass in the treatment of complex internal carotid injury.

Patients with penetrating carotid injuries above C2 present special challenges to the cerebrovascular surgeon. A subgroup of patients may lack the vascular collaterals necessary to tolerate carotid sacrifice or prolonged ischemia during direct carotid repair. We present a technique of extracranial-intracranial (EC-IC) saphenous vein bypass in two patients with high cervical and skull base carotid injuries and poor vascular collaterals. This technique allows preservation of internal carotid flow during the proximal anastomosis. Interruption of cerebral blood flow is limited to the duration required for a distal intracranial anastomosis and is confined to the territory supplied by a single middle cerebral branch. The procedure eliminates systemic anticoagulation, includes trapping of the injured segment of the internal carotid artery, and restores a volume of flow similar to that of the internal carotid artery. It is a valuable adjunct in this specific population of patients with high carotid injuries who cannot tolerate even brief periods of temporary occlusion or in whom clinical urgency precludes an endovascular trial occlusion.

Focal dermal hypoplasia (Goltz syndrome) with vertebral solid aneurysmal bone cyst variant. A case report.

Focal dermal hypoplasia or Goltz syndrome is a rare clinical entity, usually presenting in early childhood as a mix of ectodermal and mesodermal anomalies. Previously reported cases have included skeletal lesions of the long bones, metacarpals, metatarsals and pelvis. We present a case with a vertebral lesion causing neurologic deficit. A discussion of the history of the syndrome is included as well as detailed histologic description.

Evaluation of pulmonary infections in patients with extremity fractures and blunt chest trauma.

The use of preventive antibiotics has become the standard of care in the management of patients with multiple trauma who have injuries at risk for infection. In many areas of surgical practice, preventive antibiotic utilization has been restricted to the perioperative period only. In this study we reviewed a series of trauma patients with combined blunt chest injuries and extremity fractures to determine whether the duration of postoperative antibiotic administration would have adverse effects upon nosocomial pneumonia rates and severity.