Can the Third Part of Duodenum Behind SMA Be Detected With Confidence on CT as a Proposed Mechanism for Imaging Suspected Malrotation in Children? A Preliminary Proof of Concept Study.

AIM: The aims of this study were to determine frequency and reliability of computed tomography (CT) detection of anatomic landmarks for imaging suspected midgut malrotation in infants and children, and to calculate an estimated effective dose of an upper abdominal CT scan in our patient population. MATERIALS AND METHODS: Fifty consecutive pediatric patients who underwent a CT scan that included their upper abdomen between August 2016 and February 2018 were included. Four pediatric radiology consultants independently reviewed CT scans for detection of the third part of the duodenum and defined their confidence level of this through identification of continuity with the pyloric antrum, D1, D2, and D4 components of the duodenum, as well as the duodenojejunal flexure.Interobserver variability was assessed using Fleiss κ for agreement. A dose estimate, per scan, was calculated using the scanner dose-length product and published conversion factors by Deak. RESULTS: Thirty patients were boys. The average age was 7.5 ± 5.4 years (6 days to 16 years). The D3 segment was definitely identified in 70% of scans, with 68% to 73%, moderate agreement between the readers and a Fleiss κ of 0.47 to 0.52. The DJ flexure was definitely identified in only 30.5% cases, with 35%, poor agreement between readers (Fleiss κ of 0.03). The average estimated dose for a targeted CT scan of the abdomen was 0.9 mSv (0.04-2.4 mSv). CONCLUSIONS: The third part of the duodenum, which is integral in excluding malrotation on cross-sectional studies, was "definitely" identified in 70% of CT scans of children in our study, with 68% to 73% agreement between the readers and a Fleiss κ of 0.47 to 0.52.These preliminary proof of concept results demonstrating a combination of a comparable CT dose in relation to upper gastrointestinal contrast studies and an acceptable number of cases delineating the third part of the duodenum with moderate agreement are a first step in suggesting low-dose CT for an imaging diagnosis of malrotation. Malrotation can be excluded in cases where D3 is well demonstrated in the normal position, which negates the need to automatically refer children with bilious emesis to specialist centers for upper gastrointestinal contrast studies.

Missed cervical spine injuries: aim for the top.

PURPOSE: To determine the incidence of missed cervical spine injuries by radiology registrars in a major trauma centre and to identify any common blind spots. MATERIALS AND METHODS: All patients with an acute traumatic injury who underwent a CT scan of the cervical spine in our unit, which serves a population of approximately 900,000, between September 2016 and December 2017 and whom had a separate radiology trainee report and final neuroradiology consultant report available were included in the study. We recorded the date and time of the scan, the registrar error and the registrar grade. An error was defined as follows: (1) a missed fracture; (2) a missed ligamentous injury; (3) overcall of a fracture (e.g. degenerative calcification or nutrient vessel). Groups were compared with the chi-square test. RESULTS: Five hundred seventy-three CT scans of the cervical spine fitted the inclusion criteria and were analysed. There were a total of 149 injuries over eight levels in 96 patients. There were 12 registrar errors (2.1% discrepancy rate), of which 11 were missed acute injuries (9 fractures and 2 disco-ligamentous injuries). The grade of the registrar was not significant (p = 0.603). Seventy-three percent (8/11) missed injuries were disproportionately at the cranio-cervical junction, where only 11.6% of traumatic cervical spine injuries occur p < 0.0001. Forty-five percent of the missed injuries included occipital condyle fractures, which occurred in only 12/149 injuries (8%). CONCLUSIONS: Radiology registrars safely report emergency CT scans of the cervical spine performed following trauma with a low discrepancy rate. Missed cervical spine injuries commonly occur at the cranio-cervical junction, which should become a standard review area.

Repaired coarctation of the aorta, persistent arterial hypertension and the selfish brain.

BACKGROUND: It has been estimated that 20-30% of repaired aortic coarctation (CoA) patients develop hypertension, with significant cardiovascular morbidity and mortality. Vertebral artery hypoplasia (VAH) with an incomplete posterior circle of Willis (ipCoW; VAH + ipCoW) is associated with increased cerebrovascular resistance before the onset of increased sympathetic nerve activity in borderline hypertensive humans, suggesting brainstem hypoperfusion may evoke hypertension to maintain cerebral blood flow: the "selfish brain" hypothesis. We now assess the "selfish brain" in hypertension post-CoA repair. METHODS: Time-of-flight cardiovascular magnetic resonance angiography from 127 repaired CoA patients (34 ± 14 years, 61% male, systolic blood pressure (SBP) 138 ± 19 mmHg, diastolic blood pressure (DBP) 76 ± 11 mmHg) was compared with 33 normotensive controls (42 ± 14 years, 48% male, SBP 124 ± 10 mmHg, DBP 76 ± 8 mmHg). VAH was defined as < 2 mm and ipCoW as hypoplasia of one or both posterior communicating arteries. RESULTS: VAH + ipCoW was more prevalent in repaired CoA than controls (odds ratio: 5.8 [1.6-20.8], p = 0.007), after controlling for age, sex and body mass index (BMI). VAH + ipCoW was an independent predictor of hypertension (odds ratio: 2.5 [1.2-5.2], p = 0.017), after controlling for age, gender and BMI. Repaired CoA subjects with VAH + ipCoW were more likely to have difficult to treat hypertension (odds ratio: 3.3 [1.01-10.7], p = 0.049). Neither age at time of CoA repair nor any specific repair type were significant predictors of VAH + ipCoW in univariate regression analysis. CONCLUSIONS: VAH + ipCoW predicts arterial hypertension and difficult to treat hypertension in repaired CoA. It is unrelated to age at time of repair or repair type. CoA appears to be a marker of wider congenital cerebrovascular problems. Understanding the "selfish brain" in post-CoA repair may help guide management. JOURNAL SUBJECT CODES: High Blood Pressure; Hypertension; Magnetic Resonance Imaging (MRI); Cardiovascular Surgery; Cerebrovascular Malformations.

Spinal tophaceous gout encasing the thoracic spinal cord.

Gout rarely compresses the thoracic spinal cord. A 43-year-old man presented with lower limb paraparesis. MRI showed a soft tissue swelling at the level of T10/T11. He was managed with a laminectomy and evacuation of a presumed abscess and started on intravenous antibiotics. However, histology confirmed tophaceous gout.

Measurement of Intraspinal Pressure After Spinal Cord Injury: Technical Note from the Injured Spinal Cord Pressure Evaluation Study.

Intracranial pressure (ICP) is routinely measured in patients with severe traumatic brain injury (TBI). We describe a novel technique that allowed us to monitor intraspinal pressure (ISP) at the injury site in 14 patients who had severe acute traumatic spinal cord injury (TSCI), analogous to monitoring ICP after brain injury. A Codman probe was inserted subdurally to measure the pressure of the injured spinal cord compressed against the surrounding dura. Our key finding is that it is feasible and safe to monitor ISP for up to a week in patients after TSCI, starting within 72 h of the injury. With practice, probe insertion and calibration take less than 10 min. The ISP signal characteristics after TSCI were similar to the ICP signal characteristics recorded after TBI. Importantly, there were no associated complications. Future studies are required to determine whether reducing ISP improves neurological outcome after severe TSCI.

Waveform Analysis of Intraspinal Pressure After Traumatic Spinal Cord Injury: An Observational Study (O-64).

Following a traumatic brain injury (TBI), intracranial pressure (ICP) increases, often resulting in secondary brain insults. After a spinal cord injury, here the cord may be swollen, leading to a local increase in intraspinal pressure (ISP). We hypothesised that waveform analysis methodology similar to that used for ICP after TBI may be applicable for the monitoring of patients with spinal cord injury.An initial cohort of 10 patients with spinal cord injury, as presented by the first author at a meeting in Cambridge in May 2012, were included in this observational study. The whole group (18 patients) was recently presented in the context of clinically oriented findings (Werndle et al., Crit Care Med, 42(3):646-655, 2014, PMID: 24231762). Mean pressure, pulse and respiratory waveform were analysed along slow vasogenic waves.Slow, respiratory and pulse components of ISP were characterised in the time and frequency domains. Mean ISP was 22.5 ± 5.1, mean pulse amplitude 1.57 ± 0.97, mean respiratory amplitude 0.65 ± 0.45 and mean magnitude of slow waves (a 20-s to 3-min period) was 3.97 ± 3.1 (all in millimetres of mercury). With increasing mean ISP, the pulse amplitude increased in all cases. This suggests that the ISP signal is of a similar character to ICP recorded after TBI. Therefore, the methods of ICP analysis can be helpful in ISP analysis.

The dura causes spinal cord compression after spinal cord injury.

MR scans from 65 patients with traumatic spinal cord injury were analysed; on admission 95% had evidence of cord compression - in 26% due to the dura, and in the remaining 74% due to extradural factors. Compression due to dural factors resolved with a half-life of 8.7 days. These findings suggest that bony decompression alone may not relieve spinal cord compression in the quarter of patients in whom dural factors are significant.

Intraspinal pressure and spinal cord perfusion pressure after spinal cord injury: an observational study.

OBJECT: In contrast to intracranial pressure (ICP) in traumatic brain injury (TBI), intraspinal pressure (ISP) after traumatic spinal cord injury (TSCI) has not received the same attention in terms of waveform analysis. Based on a recently introduced technique for continuous monitoring of ISP, here the morphological characteristics of ISP are observationally described. It was hypothesized that the waveform analysis method used to assess ICP could be similarly applied to ISP. METHODS: Data included continuous recordings of ISP and arterial blood pressure (ABP) in 18 patients with severe TSCI. RESULTS: The morphology of the ISP pulse waveform resembled the ICP waveform shape and was composed of 3 peaks representing percussion, tidal, and dicrotic waves. Spectral analysis demonstrated the presence of slow, respiratory, and pulse waves at different frequencies. The pulse amplitude of ISP was proportional to the mean ISP, suggesting a similar exponential pressure-volume relationship as in the intracerebral space. The interaction between the slow waves of ISP and ABP is capable of characterizing the spinal autoregulatory capacity. CONCLUSIONS: This preliminary observational study confirms morphological and spectral similarities between ISP in TSCI and ICP. Therefore, the known methods used for ICP waveform analysis could be transferred to ISP analysis and, upon verification, potentially used for monitoring TSCI patients.

Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study.

We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.

Patient-controlled intracranial pressure for managing idiopathic intracranial hypertension.

Idiopathic intracranial hypertension is a difficult condition to manage. We present a novel treatment that substantially improved the headaches and reduced admissions and shunt revision surgery in a patient. We inserted a ventriculoperitoneal shunt, performed subtemporal craniectomies, and instructed our patient to apply different sized headbands to allow her to anticipate and control her own intracranial pressure: a tight headband for low-pressure headaches; no band for high-pressure headaches. Magnetic resonance imaging and intracranial pressure monitoring revealed this was not a placebo effect.

Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*.

OBJECTIVES: To develop a technique for continuously monitoring intraspinal pressure at the injury site (intraspinal pressure) after traumatic spinal cord injury. DESIGN: A pressure probe was placed subdurally at the injury site in 18 patients who had isolated severe traumatic spinal cord injury (American Spinal Injuries Association grades A-C). Intraspinal pressure monitoring started within 72 hours of the injury and continued for up to a week. In four patients, additional probes were inserted to simultaneously monitor subdural pressure below the injury and extradural pressure. Blood pressure was recorded from a radial artery catheter kept at the same horizontal level as the injured segment of the spinal cord. We determined the effect of various maneuvers on spinal cord perfusion pressure and spinal cord function and assessed using a limb motor score and motor-evoked potentials. SETTING: Neurosurgery and neuro-ICU covering a 3 million population in London. SUBJECTS: Patients with severe traumatic spinal cord injury. Control subjects without spinal cord injury (to monitor spinal cerebrospinal fluid signal and motor evoked potentials). INTERVENTIONS: Insertion of subdural spinal pressure probe. MEASUREMENTS AND MAIN RESULTS: There were no procedure-related complications. Intraspinal pressure at the injury site was higher than subdural pressure below the injury or extradural pressure. Average intraspinal pressure from the 18 patients with traumatic spinal cord injury was significantly higher than average intraspinal pressure from 12 subjects without traumatic spinal cord injury. Change in arterial PCO2, change in sevoflurane dose, and mannitol administration had no significant effect on intraspinal pressure or spinal cord perfusion pressure. Increase in inotrope dose significantly increased spinal cord perfusion pressure. Bony realignment and laminectomy did not effectively lower intraspinal pressure. Laminectomy was potentially detrimental by exposing the swollen spinal cord to compression forces applied to the skin. By intervening to increase spinal cord perfusion pressure, we could increase the amplitude of motor-evoked potentials recorded from below or just above the injury level in nine of nine patients with traumatic spinal cord injury. In two of two patients with American Spinal Injuries Association grade C traumatic spinal cord injury, higher spinal cord perfusion pressure correlated with increased limb motor score. CONCLUSIONS: Our findings provide proof-of-principle that subdural intraspinal pressure at the injury site can be measured safely after traumatic spinal cord injury.

Modified acrylic cranioplasty for large cranial defects.

OBJECTIVE: To describe a novel technique for constructing polymethylmethacrylate (acrylic) cranioplasty to repair large cranial defects. METHODS: A rim of bone is cut from the edge of the skull defect using a craniotome. This bony rim provides a scaffold to fashion the acrylic cement away from the patient thus avoiding thermal injury to the brain. The inner edge of the bony rim is drilled circumferencially to form a groove. Acrylic is then used to fill the defect in the bony rim with continuous manipulation of the paste from both sides to form a dome in the shape of the skull. The groove allows the edge of the acrylic dome to fit snugly with the bony rim thus avoiding sinking. The final cranioplasty, comprised of the hardened acrylic dome with the surrounding bone rim, is firmly attached to the skull with bioplates. RESULTS: We used the modified acrylic cranioplasty technique in three patients. Modified acrylic cranioplasty is cheaper and immediately available, compared with ten cases of titanium cranioplasty, with similar cosmetic outcome, intraoperative blood loss and operating theatre time. CONCLUSION: Our technique is quick and easy to perform, avoids thermal injury to the brain and produces a strong implant with excellent cosmesis even with large bony defects.

Variability in the treatment of acute spinal cord injury in the United Kingdom: results of a national survey.

The aim of this study was to examine how traumatic spinal cord injury is managed in the United Kingdom via a questionnaire survey of all neurosurgical units. We contacted consultant neurosurgeons and neuroanesthetists in all neurosurgical centers that manage patients with acute spinal cord injury. Two clinical scenarios-of complete and incomplete cervical spinal cord injuries-were given to determine local treatment policies. There were 175 responders from the 33 centers (36% response rate). We ascertained neurosurgical views on urgency of transfer, timing of surgery, nature and aim of surgery, as well as neuroanesthetic views on type of anesthetic, essential intraoperative monitoring, drug treatment, and intensive care management. Approximately 70% of neurosurgeons will admit patients with incomplete spinal cord injury immediately, but only 40% will admit patients with complete spinal cord injury immediately. There is no consensus on the timing or even the role of surgery for incomplete or complete injuries. Most (96%) neuroanesthetists avoid anesthetics known to elevate intracranial pressure. What was deemed essential intraoperative monitoring, however, varied widely. Many (22%) neuroanesthetists do not routinely measure arterial blood pressure invasively, central venous pressure (85%), or cardiac output (94%) during surgery. There is no consensus among neuroanesthetists on the optimal levels of arterial blood pressure, or oxygen and carbon dioxide partial arterial pressure. We report wide variability among U.K. neurosurgeons and neuroanesthetists in their treatment of acute traumatic spinal cord injury. Our findings reflect the lack of Class 1 evidence that early surgical decompression and intensive medical management of patients with spinal cord injury improves neurological outcome.

Acute disc herniation in the elderly.

BACKGROUND: Acute disc prolapse in young adults has been studied extensively. However, little is known about acute disc prolapse in the elderly. OBJECTIVE: We aimed to define the features of acute disc prolapse in the elderly. DESIGN, SETTING AND PATIENTS: Elderly (≥ 65 years) patients who had lumbar or thoracic discectomy for acute (< 3 months) disc prolapse in our unit between July 2004 and March 2010 were identified. For comparison, we used a 'young' (25-45 years) patient cohort with acute thoracic or lumbar disc prolapse. Data collected included age, symptom onset, preoperative signs and spinal level. RESULTS: During the study period, 390 patients had discectomy, of which 59.7% were 'young' and 7.4% 'elderly'. The young and elderly patients had significantly different distributions of prolapsed disc levels. In the young, 97% of all disc protrusions were at L4/5 or L5/S1, but < 50% were at these levels in the elderly. In the elderly, about 10% of disc protrusions were thoracic. CONCLUSIONS: Acute disc prolapse is rare in the elderly and primarily affects the upper lumbar and lower thoracic spine.