MR Venous Flow in Sigmoid Sinus Diverticulum.

BACKGROUND AND PURPOSE: Case reports demonstrate that coiling of a sigmoid sinus diverticulum can treat pulsatile tinnitus. We hypothesized that MR imaging 4D flow and computational fluid dynamics would reveal distinct blood flow patterns in the venous outflow tract in these patients. MATERIALS AND METHODS: Patients with pulsatile tinnitus of suspected venous etiology underwent MR imaging at 3T, using venous phase contrast-enhanced MR angiography, 4D flow, and 2D phase contrast. The contrast-enhanced MRA contours were evaluated to determine the presence and extent of a sigmoid sinus diverticulum. Computational fluid dynamics analysis was performed using the 4D flow inlet flow and the luminal contours from contrast-enhanced MRA as boundary conditions. In addition, computational fluid dynamics was performed for the expected post treatment conditions by smoothing the venous geometry to exclude the sigmoid sinus diverticulum from the anatomic boundary conditions. Streamlines were generated from the 4D flow and computational fluid dynamics velocity maps, and flow patterns were examined for the presence of rotational components. RESULTS: Twenty-five patients with pulsatile tinnitus of suspected venous etiology and 10 control subjects were enrolled. Five (20%) of the symptomatic subjects had sigmoid sinus diverticula, all associated with an upstream stenosis. In each of these patients, but none of the controls, a stenosis-related flow jet was directed toward the opening of the sigmoid sinus diverticulum with rotational flow patterns in the sigmoid sinus diverticulum and parent sigmoid sinus on both 4D flow and computational fluid dynamics. CONCLUSIONS: Consistent patterns of blood flow can be visualized in a sigmoid sinus diverticulum and the parent sinus using 4D flow and computational fluid dynamics. Strong components of rotational blood flow were seen in subjects with sigmoid sinus diverticula that were absent in controls.

Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash.

BACKGROUND: Pain from rib fracture pain may affect pulmonary function, morbidity, and length of intensive care unit stay. Previous trials have varied epidural technique within the study and have used several outcome variables. METHODS: The charts of patients who sustained rib fractures after a motor vehicle crash between January 1, 1994, and June 30, 1997, were reviewed. Data were collected from 64 patients who had three or more rib fractures and initiation of intravenous patient-controlled analgesia with morphine or thoracic epidural analgesia with bupivacaine and fentanyl within 24 hours of admission. RESULTS: Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores were not significantly different between groups. Patients in the epidural group had significantly more rib fractures and were significantly older. Patients who received epidural analgesia had significantly lower pain scores at all times. There were no differences in the lengths of intensive care unit or hospital stays, or the incidence of pulmonary complications or organ failure between groups. CONCLUSION: Thoracic epidural analgesia with bupivacaine and fentanyl provided superior analgesia than intravenous patient-controlled analgesia morphine.