Reducing the gray zone: imaging spectrum of hypoperfusion and hypoxic brain injury in adults.

The purpose of this pictorial essay is to illustrate the computed tomography and magnetic resonance imaging manifestations of hypoperfusion and hypoxic brain injury in adults, a clinical scenario not uncommon in the emergency room setting. The imaging findings can be subtle or marked depending on the type of injury and the time elapsed from injury to imaging. Accurate recognition of the imaging findings in hypoperfusion and hypoxic injury in adults is important for accurate therapy and family-patient counseling.

Translaminar cervical epidural steroid injection: short-term results and factors influencing outcome.

PURPOSE: To assess the efficacy of translaminar cervical epidural steroid injection (ESI) in the management of localized or radicular neck pain and assess categoric factors that can help predict clinical outcome. MATERIALS AND METHODS: In all patients studied, treatment of neck pain with oral pain medications or physical therapy had failed. A total of 280 translaminar cervical ESIs were performed in 161 patients with an average age of 58 years (range, 26-82 y). The average duration of symptoms until the time the procedure was performed was 18.2 months (range, 0.25-240 months). All patients were assessed by telephone approximately 10 days after the procedure to determine efficacy. RESULTS: Of the 280 total injections, 233 (83%) resulted in pain relief. Patients were more likely to experience pain relief if they presented with multilevel degenerative changes (odds ratio [OR] = 4.13, P = .0055), had radicular symptoms in the hand and/or finger (OR = 2.72, P = .0011), or underwent injection at the C7-T1 level (OR = 2.44, P = .0034). Patients who required narcotics for their symptoms before the procedure showed lower odds of pain relief (OR = 0.80, P = .4367). There were no major complications and the overall minor complication rate was 5.18%. CONCLUSION: Translaminar cervical ESI is a safe procedure. Although repeat injections may be necessary in some patients, excellent short-term clinical results can be achieved.

First year radiology residents not taking call: will there be a difference?

Currently, there is a debate in the academic radiology community about whether or not first year residents should take overnight call. The purpose of this study was to track discrepancies on overnight resident preliminary reads on radiographs from the emergency department to see if the experience level of the resident makes a difference. From October 1, 2005 to September 22, 2006, 13,213 radiographs were prospectively interpreted by residents at night at a Level I Trauma Center. Discrepancies were documented after review of the films with the staff radiologist in the morning. The patient's medical record was then examined to determine if there was any adverse clinical outcome as a result of the reading. Of the 13,184 radiographs interpreted, 120 total discrepancies were identified (overall discrepancy rate 0.9%). First year residents showed a discrepancy rate of 1.59%, higher than other residents, which were ranged from 0.39 to 0.56%. Of the 54 patients with follow-up imaging, the abnormality that was felt to be present by staff persisted on follow-up imaging in 22 cases; however, the abnormality was not present on follow up of the other 32 patients (59.2% of discrepancies with follow-up imaging). Although there is higher rate of discrepancy among reports generated by first year residents, the difference compared to the other levels of experience is small, and its overall significance can be debated. Follow-up imaging often showed that staff interpretations were false positives when there was a discrepancy reported.

Overnight resident preliminary interpretations on CT examinations: should the process continue?

We report our experience with resident preliminary interpretations given at night on both abdominal and neurological CT scans to quantify the discrepancy rate when compared to the final report. An attempt was also made to document any adverse clinical outcomes as a result of the preliminary interpretation. From January 1, 2004 to December 31, 2004, adult CT examinations were prospectively interpreted by residents at night at a level I trauma center. Both the neurological and body CT scans were reviewed beginning at 7:00 a.m. the following morning by the respective subspecialty staff and discrepancies were noted. Adult CT examinations (6,858) were prospectively interpreted by residents: 5,206 cranial spinal CT examinations and 1,652 body CT examinations. Among the neurological studies, there were six cases identified as major discrepancies (0.1%) and 185 minor discrepancies (3.5%). Among the body CT cases, there were seven cases identified as major discrepancies (0.4%) and 23 cases of minor discrepancies (1.4%). There is a low discrepancy rate (0.2% major and 3.1% minor) in the preliminary resident interpretations from the final report. The process of overnight preliminary CT interpretations should continue as it is not substandard care.

Biliary duct ablation with N-butyl cyanoacrylate.

PURPOSE: To assess the efficacy of percutaneous insertion of n-butyl cyanoacrylate (NBCA) in the ablation of bile ducts in patients with persistent postsurgical bile leaks in which traditional means of treatment have failed. MATERIALS AND METHODS: Ablation of bile ducts with NBCA was performed in six patients (two men and four women). The average length of follow-up was 27 months (range, 13-46 months). Four patients presented after hepatic lobectomy with a persistent bile leak, one patient presented after cholecystectomy with a chronically obstructed bile duct, and one patient presented after cholecystectomy from intraoperative bile duct injury. After access to the biliary system was obtained, a cholangiogram was obtained. After the desired duct was isolated, it was copiously irrigated with saline solution. A glue solution containing NBCA glue, Ethiodol, and tantalum powder was delivered into the duct through a polyethylene catheter that had been irrigated with dextrose solution. RESULTS: Four patients had problems arising from isolated segmental ductal systems that had no communication with the normal biliary ductal system and were treated successfully on the first attempt. In two patients, there was communication to the main biliary ductal system and a persistent bile leak occurred that required placement of a coil and a second final gluing procedure. The only complication observed was unintentional spillage of glue into the main biliary system in one patient, which was ultimately clinically insignificant. CONCLUSIONS: The use of NBCA glue in obliteration of bile ducts is a safe procedure with excellent results in patients with complications from isolated segmental ducts. Although a repeat procedure may be necessary if the duct communicates with the main biliary tree, the procedure can decrease the morbidity associated with chronic external biliary drainage.

Persistent falcine sinus in an adult: demonstration by MR venography.

The falcine sinus is a normal anatomic structure located in the falx cerebri that closes after birth and is rarely observed in the adult population. We describe a unique case of persistent falcine sinus in an adult who presented with venous sinus obstruction.

CT brain prescriptions in Talairach space: a new clinical standard.

BACKGROUND AND PURPOSE: Head CT prescriptions are currently plagued by intra- and intersubject image variance and do not match standardized MR imaging planes. We developed and tested a simple method to improve CT precision and approximate the Talairach reference standard advocated for MR imaging. METHODS: We retrospectively reviewed midline sagittal T2-weighted brain MR images of 126 consecutive patients to determine the mean angle subtended by the Talairach anterior commissure-posterior commissure (AC-PC) line and the hard palate. On the basis of this data set, a new head CT protocol was instituted with pitch similarly prescribed relative to the hard palate as identified on the lateral CT scout film. We then compared the precision of the new protocol, our former method (nominally parallel to the orbito-meatal line) and fixed-gantry angulation. Two head CT studies from 50 consecutive patients imaged with our old protocol and 50 consecutive patients imaged with our new protocol were reviewed for a total of 200 CT examinations. RESULTS: The Talairach AC-PC line was rotated 12.0 degrees +/- 6.1 degrees from the hard palate line and 15.6 degrees +/- 10.1 degrees from the axial plane of the magnet. The new CT protocol approximated the Talairach-referenced MR images obtained at our institution and improved intrapatient CT scan precision compared with fixed-gantry selection (P <.004) and compared with our previous prescription technique (P <.064; P <.025, controlling for excessive head extension). CONCLUSION: By prescribing CT images angled +12 degrees from the hard palate, a structure readily identified by technologists, interscan precision can be improved and Talairach-referenced MR imaging studies can be approximated. Along with AC-PC-referenced MR imaging studies, we advocate this CT protocol as a new clinical standard.

Subacute Propionibacterium acnes osteomyelitis of the spine in an adolescent.

Moderate to severe facial acne is caused by infection with Propionibacterium acnes, an organism that has also been implicated in subacute osteomyelitis. The symptoms are often indolent in nature, but slowly progressive. We present a case report of subacute P. acnes osteomyelitis at our institution. A high index of suspicion and an extended incubation time are required for diagnosis. Treatment usually requires irrigation and debridement, with or without antibiotics.

Clinical brain MR imaging prescriptions in Talairach space: technologist- and computer-driven methods.

BACKGROUND AND PURPOSE: Variability in patient head positioning may yield substantial interstudy image variance in the clinical setting. We describe and test three-step technologist and computer-automated algorithms designed to image the brain in a standard reference system and reduce variance. METHODS: Triple oblique axial images obtained parallel to the Talairach anterior commissure (AC)-posterior commissure (PC) plane were reviewed in a prospective analysis of 126 consecutive patients. Requisite roll, yaw, and pitch correction, as three authors determined independently and subsequently by consensus, were compared with the technologists' actual graphical prescriptions and those generated by a novel computer automated three-step (CATS) program. Automated pitch determinations generated with Statistical Parametric Mapping '99 (SPM'99) were also compared. RESULTS: Requisite pitch correction (15.2 degrees +/- 10.2 degrees ) far exceeded that for roll (-0.6 degrees +/- 3.7 degrees ) and yaw (-0.9 degrees +/- 4.7 degrees ) in terms of magnitude and variance (P <.001). Technologist and computer-generated prescriptions substantially reduced interpatient image variance with regard to roll (3.4 degrees and 3.9 degrees vs 13.5 degrees ), yaw (0.6 degrees and 2.5 degrees vs 22.3 degrees ), and pitch (28.6 degrees, 18.5 degrees with CATS, and 59.3 degrees with SPM'99 vs 104 degrees ). CATS performed worse than the technologists in yaw prescription, and it was equivalent in roll and pitch prescriptions. Talairach prescriptions better approximated standard CT canthomeatal angulations (9 degrees vs 24 degrees ) and provided more efficient brain coverage than that of routine axial imaging. CONCLUSION: Brain MR prescriptions corrected for direct roll, yaw, and Talairach AC-PC pitch can be readily achieved by trained technologists or automated computer algorithms. This ability will substantially reduce interpatient variance, allow better approximation of standard CT angulation, and yield more efficient brain coverage than that of routine clinical axial imaging.

Neonatal kyphectomy in the patient with myelomeningocele.

STUDY DESIGN: A retrospective cohort study was used to investigate a group of neonates with myelomeningocele who had a kyphectomy performed in conjunction with dural sac closure during the first few days of life. OBJECTIVES: To assess the effectiveness of operative intervention in the neonatal period to correct the kyphotic deformity in the patient with myelomeningocele and to monitor its long-term results. SUMMARY OF BACKGROUND DATA: Orthopedic management originally focused on the immediate treatment of the kyphotic deformity in the infant with myelomeningocele. However, there has been a movement toward postponing surgical treatment of the kyphos until a later age. This study included the longest follow-up of the largest group of neonates that a single surgeon has managed surgically since the treatment of this condition was originally described. METHODS: The radiographic and clinical results for all neonates treated with a kyphectomy at the time of myelomeningocele closure between 1980 and 2000 were analyzed. RESULTS: Neonatal kyphectomy was performed on nine males and two females. The average preoperative kyphotic angle measured 67 degrees. The average initial correction was 77 degrees, and the average loss of correction at follow-up assessment was 55 degrees. There were no serious complications, and wound closure was successful in all patients. One patient required a repeat kyphectomy and posterior spinal fusion at the age of 9 years and 2 months. The average follow-up period was 7 years and 4 months (range 44-174 months). CONCLUSIONS: Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. However, it occurs in the form of a longer, more rounded deformity that is less technically demanding.

Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.

The inherent ability of pediatric metaphyseal radius fractures to heal and remodel made us question the need for immediate anatomic reduction under conscious sedation. We believe that isolated closed distal radius fractures with 15 degrees of angulation and 1 cm of shortening will heal well and remodel completely without clinical or functional sequelae. Time and expense can be decreased by splinting and follow-up without the need for immediate anatomic reduction in the emergency room. In order to answer this question, we retrospectively evaluated 34 pediatric metaphyseal wrist fractures that lost position after attempted reduction and healed in their angulated or shortened position. We looked at the time to healing, time to remodeling and any residual clinical or functional deficits. We then did a comparison cost analysis with time matched patients who had complete but minimally displaced fractures of the distal radius that were treated by immediate splinting with orthopaedic follow-up. Our results showed that skeletally immature patients with open physes, isolated injuries, dorsovolar and radioulnar angulations less than 15 degrees and less than 1 cm of shortening will heal and be out of cast within an average of 6 weeks and completely remodel within an average of 7.5 months. The average time in the emergency room was 2 h less with no reduction. The cost of the emergency room visit with attempted reduction was 50% more than splinting with early referral (US dollars 536 versus US dollars 270). None of our patients had significant clinical deformities or residual functional deficits.

Self-inflicted transorbital and intracranial injury from eyeglasses.

Orbital injuries are commonly seen in the emergency department, and if they are high-energy they can lead to concomitant intracranial injuries. Plain films, CT, MRI, and ultrasound are used in various combinations to evaluate the extent of these injuries. We describe a unique case of self-inflicted transorbital penetrating intracranial injury from the temporal wire rim of a pair of eyeglasses. Imaging well demonstrates the full course of the wire rim in situ, and pathoanatomic correlates are highlighted.