Arthur B. Dublin

Fractures of the scapula.

One hundred thirty-seven fractures of the scapula in 121 patients were reviewed. The average age at the time of injury was 35 years, with fractures predominant in males (64%). The majority of cases (43%) involved fractures of the body of the scapula, with fractures of the scapular neck being second most common (26%). Automobile accidents produced the most injuries (52%), followed by auto-pedestrian (18%), falls (12%), and motorcycle accidents (11%). Associated bony or major soft-tissue trauma was present in all but 15 of the 121 patients, the most common being fractured ribs in 44%. Other associated injuries included fractures of the clavicle (26%), fractured skull (24%), cerebral contusion (20%), neurologic deficit (13%), and pulmonary contusion or hemo-pneumothorax (16%). Patients with injuries involving the acromion process or acromioclavicular joint had a significantly higher incidence of associated peripheral nerve injuries than those with other fractures of the scapula, indicating that special attention should be given to the neurologic examination of patients with these fractures. Careful neurovascular examination is mandatory. Treatment was usually conservative, independent of the location of the fracture, with satisfactory long-term results. We recommend simple immobilization followed by early active range of motion exercise.

Computed tomography in head trauma.

Retrospective analysis of 200 cases of documented head trauma demonstrated an accuracy approaching 100% in the diagnosis of intra- and extracerebral collections of blood. Caution must be exercised in the evaluation of trauma 1 to 5 weeks old, since subdural hematomas have the same density as normal brain tissue, and angiography may be necessary. The clinical diagnosis of brainstem contusion is associated with a remarkably high level (54%) of surgically correctable lesions. The use of computed tomography in the evaluation of other traumatic intracranial lesions is discussed.

The association of brainstem lesions with migraine-like headache: an imaging study of multiple sclerosis.

Objective.—To determine if the prevalence of migraine‐like headache in patients with multiple sclerosis (MS) is associated with plaques in the brainstem or in other locations.

DEVELOPMENT AND VALIDATION OF A STANDARDIZED METHOD FOR CONTOURING THE BRACHIAL PLEXUS: PRELIMINARY DOSIMETRIC ANALYSIS AMONG PATIENTS TREATED WITH IMRT FOR HEAD-AND-NECK CANCER

PURPOSE Although Radiation Therapy Oncology Group protocols have proposed a limiting dose to the brachial plexus for patients undergoing intensity-modulated radiotherapy for head-and-neck cancer, essentially no recommendations exist for the delineation of this structure for treatment planning. METHODS AND MATERIALS Using anatomic texts, radiologic data, and magnetic resonance imaging, a standardized method for delineating the brachial plexus on 3-mm axial computed tomography images was devised. A neuroradiologist assisted with identification of the brachial plexus and adjacent structures. This organ at risk was then contoured on 10 consecutive patients undergoing intensity-modulated radiotherapy for head-and-neck cancer. Dose-volume histogram curves were generated by applying the proposed brachial plexus contour to the initial treatment plan. RESULTS The total dose to the planning target volume ranged from 60 to 70 Gy (median, 70). The mean brachial plexus volume was 33 +/- 4 cm(3) (range, 25.1-39.4). The mean irradiated volumes of the brachial plexus were 50 Gy (17 +/- 3 cm(3)), 60 Gy (6 +/- 3 cm(3)), 66 Gy (2 +/- 1 cm(3)), 70 Gy (0 +/- 1 cm(3)). The maximal dose to the brachial plexus was 69.9 Gy (range, 62.3-76.9) and was >/=60 Gy, >/=66 Gy, and >/=70 Gy in 100%, 70%, and 30% of patients, respectively. CONCLUSIONS This technique provides a precise and accurate method for delineating the brachial plexus organ at risk on treatment planning computed tomography scans. Our dosimetric analysis suggest that for patients undergoing intensity-modulated radiotherapy for head-and-neck cancer, brachial plexus routinely receives doses in excess of historic and Radiation Therapy Oncology Group limits.

Dural and carotid cavernous sinus fistulas: Diagnosis, management, and complications

Carotid cavernous sinus fistulas (CCSFs) are a rare entity occurring as a result of head trauma and also spontaneously. The major threat from these fistulas is loss of vision. The authors reviewed 18 cases of direct and dural CCSFs seen over the last 10 years and compared our results with 553 cases treated in the literature. Seventy-one percent of our patients with direct CCSFs had successful balloon embolization. In the literature, successful closure of direct CCSFs has ranged from 58 to 100%. As experience with embolization techniques broadens, morbidity and mortality is reduced. The clinical features, diagnostic procedures, therapeutic options, and complications of treatment of CCSFs are discussed.

Endovascular Treatment of Traumatic Injuries of the Vertebral Artery

BACKGROUND AND PURPOSE: There are a few reports regarding the treatment of traumatic vertebral arteriovenous fistulas and pseudoaneurysms. Our aim was to describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the vertebral artery. MATERIALS AND METHODS: The clinical and angiographic features of 18 traumatic injuries of the vertebral artery during an 8-year period were reviewed. There were 14 male (78%) and 4 female patients (22%). The average age was 28 years (range, 11–49 years). Of the 18 lesions of the vertebral artery, 17 (95%) were the result of penetrating trauma (gunshot or stab wound injury) and 1 (5%) was iatrogenic (jugular vein catheter). In 16 (89%) instances, the injury resulted in an arteriovenous fistula, and in the other 2 (11%), in a pseudoaneurysm. All patients were treated with an endovascular approach by using different techniques (balloon occlusion, coil embolization, and/or stent deployment). RESULTS: Endovascular therapy resulted in immediate lesion total occlusion in 16 (89%) patients. Delayed total occlusion was demonstrated angiographically during follow-up in the 2 remaining patients. Clinical improvement was documented in all patients, and there were no clinically symptomatic complications. CONCLUSION: In this small series, endovascular techniques were a safe and effective method of treatment and were not associated with significant morbidity or mortality.

The value of cervical magnetic resonance imaging in the evaluation of the obtunded or comatose patient with cervical trauma, no other abnormal neurological findings, and a normal cervical computed tomography.

BACKGROUND: The value of magnetic resonance imaging (MRI) in the evaluation of the obtunded or comatose patient with a potential neck injury is a controversial subject. Some authors have suggested that MRI of the cervical spine adds no value in the evaluation of patients with a normal computed tomography (CT) of the neck. However, others have suggested that MRI is the gold standard for clearing the cervical spine in a clinically suspicious or unevaluatable blunt trauma patient. The purpose of this study is to evaluate our data in regard to these conflicting hypotheses. METHODS: Five consecutive years of data from 17,000 patients seen at our Level I trauma center yielded 512 individuals who underwent both CT and MRI of the cervical spine. Of the latter group, 150 individuals met three strict inclusion criteria for this study: (1) obtundation (Glasgow Coma Scale ⩽13, with 94 of this group comatose [Glasgow Coma Scale ⩽8]); (2) no obvious neurologic deficits; and (3) a normal cervical CT. The effect of MRI on the clinical management of these patients was evaluated. RESULTS: Among the 150 obtunded or comatose patients with a negative CT, the majority (51%) had a normal MRI. Among the patients with a positive MRI, the most common MRI-positive findings were ligamentous and soft tissue injury (81%). However, no MRI findings were deemed unstable, and no surgical intervention or change in the clinical management aside from collar immobilization of these individuals occurred after MRI. CONCLUSIONS: The addition of a cervical MRI to the evaluation protocol of obtunded or comatose patients with an otherwise normal neurologic examination and a normal cervical CT did not provide any additional useful information to change the management of these patients.

Imaging Findings of Rhinocerebral Mucormycosis

BACKGROUND AND OBJECTIVES The purpose of this study was to describe common radiographic patterns that may be useful in predicting the diagnosis of rhinocerebral mucormycosis. METHODS We retrospectively evaluated the imaging and clinical data of four males and one female, 3 to 72 years old, with rhinocerebral mucormycosis. RESULTS All the patients presented with sinusitis and ophthalmological symptoms. Most of the patients (80%) had isointense lesions relative to brain in T1-weighted images. The signal intensity in T2-weighted images was more variable, with only one (20%) patient showing hyperintensity. A pattern of anatomic involvement affecting the nasal cavity, maxillary sinus, orbit, and ethmoid cells was consistently observed in all five patients (100%). Our series demonstrated a mortality rate of 60%. CONCLUSION Progressive and rapid involvement of the cavernous sinus, vascular structures and intracranial contents is the usual evolution of rhinocerebral mucormycosis. In the context of immunosupression, a pattern of nasal cavity, maxillary sinus, ethmoid cells, and orbit inflammatory lesions should prompt the diagnosis of mucormycosis. Multiplanar magnetic resonance imaging shows anatomic involvement, helping in surgery planning. However, the prognosis is grave despite radical surgery and antifungals.

Intranasal schwannoma: Magnetic resonance and computed tomography appearance☆

Most intranasal polyps are benign, wellcircumscribed masses that are probably secondary to allergy, and are usually removed casually in an outpatient settinge However, although intranasal schwannomas are rare and only comprise 4% of head and neck neural tumors, such lesions should be considered for unusual-appearing masses, especially in adults who do not have a long history of polyps or nasal allergy.lmg

Endovascular Treatment of Penetrating Traumatic Injuries of the Extracranial Carotid Artery

PURPOSE To describe the clinical and angiographic results of endovascular therapy for traumatic injuries of the extracranial carotid artery. MATERIALS AND METHODS The clinical and angiographic features of 36 traumatic injuries of the carotid artery during a 12-year period were reviewed. There were 35 male patients (97.2%) and 1 female patient (2.8%) with an average age of 28.8 years (range 13-60 years). Of the 36 lesions of the carotid artery, 29 (80.6%) were the result of gunshot injury, and 7 (19.4%) were secondary to stab wounds. In 24 (66.7%) instances, the injury resulted in a pseudoaneurysm; in 7 (19.4%), in an arteriovenous fistula (AVF); in 4 (11.1%), in a dissection; and in 1 (2.8%), in inactive bleeding. All patients were treated with an endovascular approach using different techniques (balloon occlusion, embolization, or stent deployment). RESULTS Endovascular therapy resulted in documented lesion occlusion in 34 (94.4%) patients. Two patients declined any follow-up postprocedural imaging; however, they have remained asymptomatic. Clinical improvement was documented in 35 (97.2%) patients, and there was one procedure-related complication with fatal consequences. CONCLUSIONS In this series, endovascular techniques were an effective method of treatment. It was possible to use different endovascular reconstructive techniques or parent artery occlusion depending on the degree of vessel damage, with resolution of clinical symptoms and avoidance of surgery in most cases.