The use of magnetic resonance imaging in patients with fiberoptic intracranial pressure monitors.
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Fiber Optic Technology↗
Biomedical subjects
J A Prall
Publications and source records attributed to J A Prall.
Incidence of unsuspected blunt carotid artery injury.
OBJECTIVE: This study attempts to document the incidence of unsuspected blunt carotid artery injury (BCI) in a prospective series of consecutive blunt trauma patients undergoing angiographic evaluation of the aorta. Previous studies have included mainly patients who became symptomatic from BCI, thus documenting a "detected incidence." METHODS: During a 22-month period, all patients undergoing angiographic evaluation of the aorta after blunt trauma who were not felt to be at increased risk for BCI were included in the screening protocol. All patients initially suspected of BCI were studied outside the protocol. Angiographic evaluation of the carotid arteries was performed using nonselective contrast injections after aortic injury had been ruled out. RESULTS: The incidence of BCI among those patients screened under the protocol (n = 119) was 2.5% (3 of 119). Among all patients undergoing aortic evaluation at presentation (n = 171), the detected incidence of BCI was 3.5% (6 of 171). The detected incidence of BCI among all patients during the study period was 0.32% (10 of 3174). No risk factors for BCI were identified beyond the severity of trauma that led to aortic evaluation. CONCLUSION: The incidence of BCI found in those patients screened in this study, nearly 10 times the incidence of BCI in our blunt trauma population overall, suggests that these patients represent a subgroup on which to focus screening efforts, regardless of the diagnostic tools employed. The similarity between the angiographic incidence and the detected incidence of BCI in this study argues that few BCIs remain asymptomatic. All blunt trauma patients injured sufficiently to prompt aortic evaluation at presentation should be screened in some manner for BCI.
Adult↗
Magnetic resonance imaging: utilization in the management of central nervous system trauma.
OBJECTIVE: To determine the availability, use, and perceived value of magnetic resonance imaging (MR) in the management of acute central nervous system (CNS) trauma in United States Level I (or equivalent) trauma centers (TCs). DESIGN, MATERIALS, AND METHODS: One hundred sixty-nine American College of Surgeons, state or locally designated Level I (or equivalent) TCs were identified using compiled lists and telephone contacts. Surveys about MR use in CNS trauma were mailed to each institution. Follow-up telephone calls were made to nonresponding institutions. Data were analyzed using frequency distribution. MEASUREMENTS: Using returned questionnaires from trauma directors and follow-up telephone contacts, data on the physical location, technologist availability, and patient monitoring capabilities were accrued. The questionnaire addressed the perceived value and cost-effectiveness of MR for acute CNS trauma in general, distinguishing between spinal cord and traumatic brain injury, using a Likert-type rating scale. MAIN RESULTS: One hundred nine (65%) of identified TCs responded by mail. Sixty (33%) required contact by telephone. One hundred fifty-two (93%) reported MR scanners "on site." Five of seven TCs without on-site MR had facilities within 5 miles. No TC reported the inability to obtain MR scans. Seventy-four percent of TCs reported MR angiography capabilities. Ninety-seven percent of MR facilities were staffed 24 hours per day, 83% by on-call, out-of-hospital technologists at night and on weekends. TCs reported patient monitoring capabilities including cardiac monitoring (83%) and pulse oximetry (91%). Seventy-one percent reported the ability to scan intubated patients. Forty-five percent of TCs "rarely" use MR, 51% report "occasional" use, and 4% "frequently" use MR for acute trauma. Ninety-four percent of trauma directors agreed or strongly agreed that MR directed management and was cost-effective for spinal cord trauma. Fifty-four percent agreed or strongly agreed that MR directed management and was cost-effective for traumatic brain injury. No correlation existed between perceptions of MR applicability in CNS trauma and the number of trauma admissions or on-site availability. CONCLUSIONS: Most trauma directors consider MR important in the acute evaluation of spinal trauma and, to a lesser extent, for traumatic brain injury. Despite these opinions, the vast majority of these centers reported only "rare" to "occasional" use of MR in the setting of acute CNS trauma. Our results show that most TCs have on-site and continuously available MR facilities capable of cardiac and pulmonary monitoring. Other factors such as the higher relative cost of MR may be responsible for the discrepancy between the perceived value and the actual utilization of MR imaging in the setting of CNS trauma.
Brain Injuries↗
Mild traumatic brain injuries in low-risk trauma patients.
BACKGROUND: Moderate or severe traumatic brain injury (TBI) resulting from cranial trauma is usually easily recognizable. Mild TBI (MTBI), however, may escape detection at presentation because of delayed symptoms and the absence of radiographic abnormalities. Despite its subtle or delayed presentation, the spectrum of symptoms often experienced after MTBI, collectively referred to as "postconcussive syndrome," may cause serious psychosocial dysfunction. METHODS/RESULTS: To assess the sensitivity of emergency department screening for MTBI, a prospective follow-up study was conducted on a group of patients (N = 129) who had been evaluated at a regional trauma center after blunt trauma. None had symptoms or signs of TBI at presentation, nor any history of direct cranial trauma. All were discharged to home from the emergency department without a diagnosis of TBI. At 1 month after injury, 41 of 129 (32%) patients described an increase in symptoms consistent with MTBI. The most common symptoms were insomnia (62%), headaches (58%), irritability (56%) and fatigue (56%). At 2 months, most symptoms had decreased significantly, and none had increased in severity. Despite improvement in their symptoms over that time period, 11% of those with persistent symptoms remained unable to resume their premorbid daily activities. CONCLUSIONS: These data, obtained from a population of patients considered to be at extremely low risk for TBI, indicate that MTBI occurs more often among blunt trauma patients than is commonly appreciated, even in busy trauma centers. Because early recognition of MTBI may expedite referral of these patients for appropriate outpatient follow-up care, thereby avoiding potentially serious social and financial repercussions, emergency department personnel should have a high index of suspicion for MTBI in any patient sustaining blunt systemic trauma. Current measures that screen for MTBI appear to be inadequate; follow-up protocols may prove to be more sensitive screening tools.
Adolescent↗
Severe snowboarding injuries.
Thirty-seven consecutive patients with severe snowboard-related injuries (defined by referral to a Level I trauma centre) were reviewed. The type and mechanism of each injury were examined and found to be similar to those reported for skiers. Mild closed head injuries were common (54 per cent). Head and abdominal injuries were more common among snowboarders than skiers, but chest and skeletal injuries were rare. There were no deaths. Serious snowboarding injury rates were similar to those for serious skiing injuries. The incidence of snowboarding injuries sufficiently severe to require tertiary referral was estimated at 0.03 injuries/1000 snowboarder days. Similar to reports of minor snowboarding injury, these data indicate that injury patterns in more serious snowboarding accidents are quite different from those of serious downhill skiing accidents. Injured snowboarders suffer splenic injuries more often and chest and spinal injuries less often than do skiers, and should be evaluated for blunt injuries with these statistical differences in mind.
Abdominal Injuries↗
Elevated intracranial pressure masks hemorrhagic hypotension in a canine model.
Previous clinical studies of blunt trauma patients with severe brain injuries have demonstrated that emergency department vital signs failed to consistently identify life-threatening abdominal injury. One hypothesis to explain this is that bradycardia and systemic hypertension from brainstem injury (the Cushing response) may mask the tachycardia and hypotension ordinarily manifested by hemorrhagic hypovolemia. This would result in inappropriately normal or near-normal emergency department vital signs for otherwise clinically apparent hypovolemia. To test this hypothesis, splenectomized dogs (n = 9) were phlebotomized to a systolic blood pressure (SBP) of 60 mm Hg. Subsequently, intracranial pressure (ICP) was artificially elevated in a controlled, incremental fashion. From a mean SBP of 58.4 +/- 3.9 mm Hg at a baseline ICP of 8.1 +/- 4.2 mm Hg, increases in ICP of only 20 mm Hg significantly raised SBP (in some animals). When ICP reached 70 mm Hg, mean SBP reached 95.1 +/- 8.7 mm Hg (p < 0.001) in spite of profound hemorrhagic hypovolemia. In all subjects, the tachycardia that accompanied hypovolemia tended towards normal with incremental increases in ICP. However, this did not reach statistical significance. In response to elevations in ICP, this hypovolemic canine model displayed normalization of SBP with variable changes in heart rate. These changes could mask hemorrhagic hypotension in humans sustaining multiple system trauma. These experimental data support clinical studies advocating immediate definitive abdominal evaluation in unconscious blunt trauma patients, regardless of vital signs.
Abdominal Injuries↗
Rhabdomyolysis following spinal cord injury: case report.
Rhabdomyolysis is commonly seen in association with multisystem trauma. We report an unexpected case of rhabdomyolysis and subsequent renal insufficiency after spinal cord injury unassociated with acute muscular injury. Immobilization, in conjunction with mild systemic hypoperfusion, was the suspected cause. Due to the likelihood of muscle catabolism, the difficulties of diagnosing soft tissue injury, and the impact of any decrease in renal reserve in patients with spinal cord injuries, surveillance for laboratory evidence of rhabdomyolysis in patients with neurologically complete spinal cord injuries appears warranted.
Acute Kidney Injury↗
Spine and spinal cord injuries in downhill skiers.
Spine and spinal cord injuries are the most debilitating and costly of serious injuries sustained by downhill skiers. We present a series of 126 skiers with spine and spinal cord injuries drawn from 636 consecutive injured skiers evaluated at one center over an 11-year period. The incidence of spinal injury was very low (0.001/1000 skier-days). Eighteen (17%) patients had spinal cord injuries associated with their fractures; injuries in the cervical region were most likely to involve the spinal cord. The most commonly fractured levels were C6, T12 and L1; the most common fracture pattern was compression (38%). One-third of all patients had multisystem trauma; those with thoracolumbar injuries were much more likely to sustain torso and extremity trauma than those with cervical injuries. Information about injury patterns in skiers with spinal injuries should aid in the triage and initial evaluation of this blunt trauma population.
Adolescent↗
Intracranial malignant germ cell tumor and the Klinefelter syndrome. Case report and review of the literature.
A case of intracranial mixed malignant germ cell tumor (GCT) in a patient with the Klinefelter syndrome (KS) is reported. Extragonadal GCTs, including those of intracranial origin, have previously been noted in KS patients. A review of the English literature suggests that although this phenomenon is rare, there appears to be more than a coincidental relationship between GCTs and a 47,XXY karyotype. This case represents the sixth reported case of intracranial GCT in KS but the first to be histologically confirmed to have mixed malignant germ cell elements. This occurrence of malignant cell types in a KS patient emphasizes the need for a histologic diagnosis prior to initiation of therapy.
Brain Neoplasms↗
Traumatic brain injury associated with an intradiploic epidermoid cyst: case report.
We present a case of an intradiploic epidermoid cyst with an unusual complication. After a minor fall, a patient with a large right parietal epidermoid suffered a traumatic brain injury caused by the transfer of the force of the fall through the cyst contents to the brain and by transdural herniation of the cyst contents into brain parenchyma. Elective resection of intradiploic epidermoids associated with large bony defects is recommended to avoid this apparently rare but potentially dangerous complication of an otherwise benign condition.
Bone Cysts↗
Early definitive abdominal evaluation in the triage of unconscious normotensive blunt trauma patients.
The need for simultaneous diagnosis and treatment of life-threatening intracranial mass lesions and intra-abdominal injury results in controversy over the appropriate triage of unconscious blunt trauma patients with stable vital signs. To aid in early decisions for these patients, a retrospective analysis of 290 patients with Glasgow Coma Scale (GCS) scores < or = 8 and systolic blood pressures (SBP) > 90 mm Hg was undertaken. The hypothesis of this study was that life-threatening abdominal injury frequently occurs in these patients and injuries cannot be consistently identified from vital signs alone. Data were analyzed for injury mechanism, SBP, heart rate (HR), Injury Severity Score (ISS), Revised Trauma Score (RTS), Abbreviated Injury Scale score for the abdomen and brain (A-AIS, CNS-AIS), and the need for emergent laparotomy. Patients with concurrent injuries were more likely to come from motor vehicle crashes than falls (p < 0.001). Although severe abdominal injuries (A-AIS > or = 3) were frequently identified based on SBP and HR, the use of clinical signs alone resulted in more missed injuries than did using the results diagnostic peritoneal lavage (DPL). This study suggests that all unconscious normotensive blunt trauma patients undergo immediate DPL to prevent missing life-threatening injuries.
Abdominal Injuries↗
Treatment of traumatic carotid pseudoaneurysm with endovascular stent placement.
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Accidents, Traffic↗