Seizures and Vaping-A Report of Two Cases.

The purpose of this qualitative study is to describe the clinical course of two patients who presented with new-onset seizures within hours of vaping and to survey neurologists' screening for vaping in such patients. A 30-subject single-institution survey found that 19 out of 30 neurology providers have not been subjectively qualifying vaping as a potential seizure-provoking factor since the 2019 emergence of literature on this topic. Inquiring about vaping during a new-onset seizure assessment could lead to earlier recognition of a seizure-provoking factor. Further investigations into the epileptogenicity of vaping are needed and the utility of AntiEpileptic Drug (AED) initiation for these patients is currently unknown.

Embolic MCA Stroke Treated With tPA and TICI-3 Mechanical Thrombectomy Complicated by Hemiballismus: A Case Study and Literature Review.

This report examines the etiology of hemiballistic movements that began 24 hours after a 63-year-old male with vascular risk factors received tissue plasminogen activator (tPa) and thrombolysis in cerebral ischemia 3 (TICI3) thrombectomy for a left middle cerebral artery (MCA) ischemic stroke. The clinical course was reviewed from an admission at a large academic institution where assessments included physical exams, head and neck computed tomography angiography (CTA), and head magnetic resonance imaging (MRI) without contrast. The patient's initial physical exam was consistent with a left MCA syndrome and included a National Institute of Health Stroke Scale (NIHSS) of 20. CTA showed an embolic M2 occlusion. After tPA and TICI 3 thrombectomy, NIHSS improved to 3 for dysarthria, facial weakness, and language deficits. MRI showed left insular diffusion restriction. New right-sided hemiballistic movements began 24 hours after treatment. At his six-week follow-up outpatient appointment, the movements were no longer present, and his neurologic exam was unremarkable, including an NIHSS of zero. No prior cases of hemiballism have been reported as a likely complication of treatment with tPa and thrombectomy. The globus pallidus is the suspected origin of the ballistic movements either from a decreased insular signal or embolic event during treatment. As stroke interventions improve, the susceptibility of certain tissues to brief ischemic events during treatment must be assessed.

Rapid Cognitive Decline Secondary to CSF Venous Fistula With Postoperative Rebound Intracranial Hypertension and a Hyperintense Paraspinal Vein Sign Seen Retrospectively.

A 56-year-old female with 2 prior Chiari decompressions presented with rapidly progressive cognitive decline. Brain magnetic resonance imaging, computed tomography myelogram, and prone digital subtraction myelography revealed signs of brain sag and left T9 perineural cysts but no cerebrospinal fluid leaks. Symptoms improved after multilevel blood patches but recurred. Lateral decubitus digital subtraction myelography revealed a spinal cerebrospinal fluid venous fistula (SCVF), which resolved after neurosurgeons ligated the nerve root. Rebound headaches with papilledema occurred on postoperative day 9 and then resolved 2 months after acetazolamide was started. A hyperintense paraspinal vein was seen retrospectively on T2-weighted magnetic resonance imaging with Dixon fat suppression sequencing. This case is unique in the acuity of cognitive decline secondary to SCVF. Acetazolamide at the time of treatment may potentially be used as prophylaxis for rebound intracranial hypertension. The hyperintense paraspinal vein may have utility in future diagnosis of SCVF.

Using 3D Printing (Additive Manufacturing) to Produce Low-Cost Simulation Models for Medical Training.

Objectives: This work describes customized, task-specific simulation models derived from 3D printing in clinical settings and medical professional training programs. Methods: Simulation models/task trainers have an array of purposes and desired achievements for the trainee, defining that these are the first step in the production process. After this purpose is defined, computer-aided design and 3D printing (additive manufacturing) are used to create a customized anatomical model. Simulation models then undergo initial in-house testing by medical specialists followed by a larger scale beta testing. Feedback is acquired, via surveys, to validate effectiveness and to guide or determine if any future modifications and/or improvements are necessary. Results: Numerous custom simulation models have been successfully completed with resulting task trainers designed for procedures, including removal of ocular foreign bodies, ultrasound-guided joint injections, nerve block injections, and various suturing and reconstruction procedures. These task trainers have been frequently utilized in the delivery of simulation-based training with increasing demand. Conclusions: 3D printing has been integral to the production of limited-quantity, low-cost simulation models across a variety of medical specialties. In general, production cost is a small fraction of a commercial, generic simulation model, if available. These simulation and training models are customized to the educational need and serve an integral role in the education of our military health professionals.

Imaging of Combat-Related Thoracic Trauma - Review of Penetrating Trauma.

Introduction: Combat-related thoracic trauma is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries were the most common mechanisms of trauma. Imaging plays a key role in the management of combat-related thoracic trauma casualties. This review discusses the imaging manifestations of thoracic injuries from penetrating trauma, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. Materials and Methods: The assessment of radiologic findings in patients who suffer from combat-related thoracic trauma is the basis of this review article. The imaging modalities for this study include multi-detector computed tomography and chest radiography. Results: High-velocity penetrating projectile injuries appear as hemorrhage and re-expansion pulmonary edema from the temporary cavity and a linear, blood-filled track from the permanent cavity. In cases where the projectile passes totally through the body, entrance wounds at the skin surface and tracks through the subcutaneous tissues may be the only indications of penetrating trauma. When assessing vascular injury, special attention should be paid to the right hilum in contrast-enhanced multi-detector computed tomography, as contrast is concentrated in the superior vena cava and superior cavoatrial junction may obscure small fragments. Additionally, CT angiography may show vessel disruption or extravasation of contrast distal to normal vessel location in addition to intraluminal filling defects and pseudo-aneurysms. Tension pneumopericardium may rarely complicate penetrating or blunt chest trauma. On imaging, distension of the pericardial sack by pneumopericardium and compression of the heart support the diagnosis of tension. On multi-detector computed tomography in the acute trauma setting, fluid in the pleural space should be considered hemothorax, particularly when Hounsfield units are above 35. Acutely, extravasated blood will have similar attenuation to the thoracic vasculature, whereas clotted blood will have higher values of 50-90 Hounsfield units. Conclusion: Combat-related thoracic trauma continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. This review of the imaging manifestations of penetrating thoracic injury during OEF and OIF focuses on key diagnostic findings for clinicians caring for combat casualties. The distinct injury pattern and atypical imaging manifestations of penetrating trauma are important to recognize early due to the acuity of this patient population and the influence of accurate diagnosis on clinical management.

Imaging of Combat-Related Thoracic Trauma - Blunt Trauma and Blast Lung Injury.

Introduction: Combat-related thoracic trauma (CRTT) is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries are the most common mechanisms of trauma to the chest. Imaging plays a key role in the battlefield management of CRTT casualties. This work discusses the imaging manifestations of thoracic injuries from blunt trauma and blast injury, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. Materials and Methods: The assessment of radiologic findings in patients who suffer from combat-related blunt thoracic trauma and blast injury is the basis of this work. The imaging modalities for this work include multi-detector computed tomography (MDCT) and chest radiography. Results: Multiple imaging modalities are available to imagers on or near the battlefront, including radiography, fluoroscopy, and MDCT. MDCT with multi-planar reconstructions is the most sensitive imaging modality available in combat hospitals for the evaluation of CRTT. In modern combat, blunt and blast injuries account for a significant portion of CRTT. Individual body armor converts penetrating trauma to blunt trauma, leading to pulmonary contusion that accounted for 50.2% of thoracic injuries during OIF and OEF. Flail chest, a subset of blunt chest injury, is caused by significant blunt force to the chest and occurs four times as frequently in combat casualties when compared with the civilian population. Imaging features of CRTT have significant diagnostic and prognostic value. Pulmonary contusions on chest radiography appear as patchy consolidations in the acute setting with ill-defined and non-segmental borders. MDCT of the chest is a superior imaging modality in diagnosing and evaluating pulmonary contusion. Contusions on MDCT appear as crescentic ground-glass opacities (opacities through which lung interstitium and vasculature are still visible) and areas of consolidation that often do not respect the anatomic boundaries of the affected lobes. Additionally, small pulmonary contusions may exhibit sub-pleural sparing and may distinguish contusion from pneumonia or other lung pathology. Although pulmonary laceration is typically the result of penetrating trauma, laceration may also be caused by displaced rib fractures or significant shearing forces on the lung without penetrating injury. Because of elastic recoil of the normal pulmonary parenchyma surrounding the injury, pulmonary lacerations may present as late as 48-72 h after injury. Pulmonary lacerations may appear similar to pulmonary contusions on chest radiography initially and will require MDCT for definitive diagnosis. Blast injury is a defining injury of modern combat. Blast lung injury is initially diagnosed with chest radiography, where the pattern of lung opacities has previously been described by clinicians as "batwing" or "butterfly" because of its central appearance in the lung. "Peribronchovascular" may be a more accurate description of primary blast lung based on its appearance on MDCT. This pattern may differentiate primary blast lung injury from other causes of thoracic trauma. Conclusion: CRTT continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. The distinct injury patterns and atypical imaging manifestations of blunt trauma and blast lung injury are important to recognize early because of the acuity of this patient population and the influence of accurate diagnosis on clinical management.