A multicenter study to improve emergency medicine residents' recognition of intracranial emergencies on computed tomography.

STUDY OBJECTIVE: Cranial computed tomography (CT) has assumed a critical role in the practice of emergency medicine for the evaluation of intracranial emergencies. Several recent studies have documented a deficiency in the emergency physician's ability to interpret these studies. The purpose of this study was to quantify the baseline ability of emergency medicine residents to interpret cranial CTs, and to test a novel method of cranial CT interpretation designed for the emergency physician in training. METHODS: A standardized pretest was administered to assess baseline ability to interpret CT scans. A standardized posttest was given 3 months after the course. Each test consisted of 12 CT scans with a short accompanying history. All scans were validated by 3 expert reviewers for difficulty and diagnosis. A 2-hour course based on the mnemonic "Blood Can Be Very Bad" was then administered. "Blood" reminds the examiner to search for blood, "Can" prompts the examiner to identify 4 key cisterns, "Be" denotes the need to examine the brain, "Very" prompts a review of the 4 ventricles, and finally "Bad" reminds the examiner to evaluate the bones of the cranium. RESULTS: Eighty-three residents at 5 institutions were initially examined. The mean percentage correct before the course was 60% (95% confidence interval [CI] 58%-64%) on the standardized pretest. At retesting 3 months after the course, the accuracy rate increased to 78% (n=61, 95% CI 75%-81%, P<.001 paired t test). CONCLUSION: Emergency medicine residents are deficient in their ability to interpret cranial CT scans. A novel educational course was demonstrated to significantly improve this ability.

Cerebral endometriosis. Case report.

A 20-year-old woman presented with a 3-year history of intermittent focal headaches and a generalized seizure. Computerized tomography demonstrated a hypodense ring-enhancing cystic right parietal lobe lesion. At operation, a chocolate-colored cyst was excised which on histological examination proved to be endometriosis.

Meningioma associated with aneurysm and subarachnoid hemorrhage: case report and review of the literature.

A patient presented with spontaneous subarachnoid hemorrhage after a prolonged episode of coughing. A preoperative computed tomographic (CT) scan confirmed subarachnoid hemorrhage, but demonstrated no other lesion. Arteriography revealed an ophthalmic artery aneurysm. Operation revealed the aneurysm to be intracavernous without sign of prior rupture; however, a small hemorrhagic meningioma was removed from the ipsilateral anterior clinoid process. In this case, coincidental meningioma and aneurysm presented as a subarachnoid hemorrhage secondary to tumor hemorrhage. The follow-up of cases of subarachnoid hemorrhage with negative arteriography with sequential CT scans is discussed.

Intraventricular hemorrhage in a term neonate secondary to a third ventricular AVM. Case report.

An initially healthy infant born of an uncomplicated full-term gestation was brought for evaluation of the acute onset of vomiting, irritability, lethargy, and opisthotonus at 14 days of age. Computerized tomography demonstrated an intraventricular hemorrhage. Arteriography defined an angioma on the roof of the third ventricle which was successfully removed via the transcallosal interfornicial approach on the 34th day of life. Other than an easily controlled seizure disorder, the postoperative course was uneventful. At 8 months of age the child is developing normally. Arteriovenous malformations should be considered in the differential diagnosis of intraventricular hemorrhage in full-term neonates without predisposing trauma or bleeding diathesis. High-speed digital subtraction arteriography may be used to screen for this diagnosis. The transcallosal interfornicial exposure offers a satisfactory approach for excising third ventricular angiomas in young infants.

Discrepancy between computed tomography and magnetic resonance imaging in a case of medulloblastoma.

In a 2-year-old girl with signs and symptoms of a posterior fossa tumor, the computed tomographic scan showed what appeared to be a brain stem glioma. However, magnetic resonance imaging (MRI) demonstrated the lesion to be extrinsic to the brain stem. Posterior fossa exploration disclosed a medulloblastoma filling the 4th ventricle. This discrepancy in imaging techniques points out the usefulness of MRI in the evaluation and treatment of posterior fossa lesions.