Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants.

BACKGROUND: Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs). OBJECTIVE: We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs. METHODS: We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations. RESULTS: Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS). CONCLUSIONS: We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.

Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury.

BACKGROUND: Incidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH. OBJECTIVES: Utilizing INR to risk stratify head trauma patients who may be managed without repeat imaging. METHODS: This was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count. RESULTS: There were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6-3.0), three of which might have been present on initial HCT; incidence rate of 0.51-1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8-100), specificity 21% (95% CI 16.6-28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281). CONCLUSION: No patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.

Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections.

BACKGROUND: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone. METHODS: Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports. RESULTS: Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection. CONCLUSIONS: We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.

Magnetic resonance imaging screening to identify spinal and paraspinal infections associated with injections of contaminated methylprednisolone acetate.

IMPORTANCE: Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection. OBJECTIVE: To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening. DESIGN, SETTING, AND PARTICIPANTS: There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013. MAIN OUTCOMES AND MEASURES: Number of persons identified with previously undiagnosed spinal or paraspinal infection. RESULTS: Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection. CONCLUSIONS AND RELEVANCE: Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.

Percutaneous vertebroplasty.

Vertebroplasty, the augmentation of vertebral compression fractures by image-controlled intracorporeal injection of polymethylmethacrylate cement, has shown a steady increase in use. Its chief indication is to palliate pain after a failure of noninvasive therapies. Other benefits include preventing further compression of the treated vertebra and fusing unstable fractures. Controversies include questions regarding its long-term benefit compared with natural history, claims of height restoration, biomechanical compromise of adjacent vertebrae, and its performance compared with kyphoplasty. Complications are uncommon but can be devastating with reported cases of procedural death and paralysis. New operators should be adequately trained and respect the dangers of this procedure.

Extradural spinal meningioma as a source of plasmacytoid cells. A case report.

BACKGROUND: Meningiomas, tumors that often affect middle-aged and elderly people, occasionally arise in the spine, typically at the thoracic level. The cytologic findings in meningiomas include whorls and syncytial clusters of bland-looking cells with scattered, psammomatous calcifications and intranudclear cytoplasmic inclusions. However, in many cases, not all these findings are seen, and in rare cases, unusual cytomorphologic features are observed. CASE: A case of spinal meningioma was located in the extradural compartment and composed predominantly of singly scattered cells with a plasmacytoid appearance, demonstrated on fine needle aspiration biopsy smear preparations. The cell block showed more typical features of meningioma, and the diagnosis was supported by the results of immunohistochemical staining. CONCLUSION: The diagnosis of spinal meningioma is readily made by employing magnetic resonance imaging. The diagnosis can be difficult to confirm pathologically when atypical histologic findings are present, as in this case, with prominent plasmacytoid features. Sections from the cell block and immunohistochemical stains as well as clinical and radiologic findings were extremely helpful in arriving at the final diagnosis.

Basilar artery herniation into the sphenoid sinus resulting in pontine and cerebellar infarction: demonstration by three-dimensional time-of-flight MR angiography.

We report a unique case of basilar artery herniation into the sphenoid sinus caused by a traumatic skull base fracture, with persistent patency of the basilar artery. Clinical and imaging features, as well as the relevant literature, are described.