David Rubinstein

Concussion in Sports: Guidelines for the Prevention of Catastrophic Outcome

Concussion (defined as a traumatically induced alteration in mental status, not necessarily with loss of consciousness) is a common form of sports-related injury too often dismissed as trivial by physicians, athletic trainers, coaches, sports reporters, and athletes themselves. While head injuries can occur in virtually any form of athletic activity, they occur most frequently in contact sports, such as football, boxing, and martial arts competition, or from high-velocity collisions or falls in basketball, soccer, and ice hockey. The pathophysiology of concussion is less well understood than that of severe head injury, and it has received less attention as a result. We describe a high school football player who died of diffuse brain swelling after repeated concussions without loss of consciousness. Guidelines have been developed to reduce the risk of such serious catastrophic outcomes after concussion in sports.

Subarachnoid neurocysticercosis with occlusion of the major intracranial arteries: case report.

Cysticercosis is the most common parasitic disease affecting the central nervous system. Stroke is a recognized complication of neurocysticercosis, occurring in 2 to 12% of cases, mostly in the form of small lacunar infarcts. We report a case of hemiparesis and aphasia in a 51-year-old Hispanic woman, which was secondary to complete occlusion of the left internal carotid and bilateral anterior cerebral arteries. Magnetic resonance imaging demonstrated the presence of enhancing subarachnoid material surrounding these occluded cerebral arteries, providing antemortem, noninvasive documentation of the inflammatory meningeal cysticercotic reaction that was presumably responsible for the occlusive arteritis causing the cerebral infarction. This represents the third reported case of internal carotid artery occlusion and the first reported case of anterior cerebral artery occlusion secondary to neurocysticercosis.

MR enhancing brain lesions in methanol intoxication

Methanol intoxication can cause necrosis of the putamen and subcortical white matter that is evident on neuroimaging. We report a 47-year-old man with significant methanol intoxication who had enhancing lesions in the caudate nuclei, putamina, hypothalamus, and subcortical white matter by MRI. This case demonstrates that contrast enhancement of brain lesions can be observed after methanol poisoning.

Venous air emboli identified on head and neck CT scans

OBJECTIVE Small venous air emboli probably occur frequently. Our purpose was to describe the locations of small venous air emboli detected on CT scans of the head and neck and their clinical presentations. MATERIALS AND METHODS The head CT scans of 17 patients and neck CT scans of 10 patients with suspected venous air emboli were reviewed and the locations of the gas collections were recorded. The charts of these patients were reviewed to identify possible sources of these gas collections and any symptoms they may have produced. RESULTS The most likely source of these gas collections was venous air emboli. The neck CT scans demonstrated gas in the inferior internal jugular vein, subclavian vein, and small anterior neck veins. The head CT scans demonstrated gas in the cavernous sinus, the frontal and temporal scalp, the infratemporal fossa, the carotid canal, the straight sinus, the superior ophthalmic vein, the superior sagittal sinus, extracranially in the region of the foramen magnum, and in a canal in the skull base for an emissary vein or the inferior petrosal sinus. Most of the intravenous lines were placed within 6 h of the scans demonstrating gas. The gas collections did not produce symptoms. CONCLUSION Asymptomatic venous air emboli can be identified in several locations in the head and neck. The time between manipulation of intravenous lines and the scan, the position of the patient, and the anatomy of the patient probably all affect the likelihood of identifying venous air emboli on CT scans.

Computed tomographic scans of minimally displaced type II odontoid fractures

OBJECTIVE To determine the computed tomography (CT) appearance of minimally displaced type II odontoid fractures and the optimal protocols to evaluate these fractures by CT. MATERIALS AND METHODS The CT scans of five patients with minimally displaced type II odontoid fractures and 71 patients without odontoid pathology were reviewed for signs of fracture. A phantom consisting of a cadaver specimen with a type II odontoid fracture was evaluated with several protocols on four CT scanners. The protocols differed in slice thickness and reconstruction algorithm. Helical scanning was also performed, and parasagittal and coronal reformations were created from each image set. MAIN RESULTS Multiple cortical disruptions longer than 1 mm were demonstrated on the scans of all five patients with type II odontoid fractures. Only three of the 71 patients without odontoid fractures had multiple cortical disruptions, and none were longer than 1 mm. In the phantom study, thinner sections demonstrated cortical disruptions better than thicker sections. Similarly, images reconstructed with a bone reconstruction algorithm demonstrated the cortical disruptions better than images reconstructed with a soft-tissue reconstruction algorithm. Helical scans (1 mm thick) adequately demonstrated the reduced Type II odontoid fracture. Parasagittal and coronal reformations failed to demonstrate a fracture line through the base of the odontoid process on all image sets. CONCLUSIONS Cortical disruptions greater than 1 mm and multiple cortical disruptions may be the only findings of odontoid fractures and should suggest the diagnosis. Evaluation of potential type II odontoid fractures is improved as CT section thickness is reduced (down to 1 mm) and is also improved by use of a bone reconstruction algorithm. The apparent absence of a fracture line through the base of the odontoid process on parasagittal or coronal reformations does not rule out the diagnosis.

Imaging study protocol selection in the electronic medical record.

WHAT WE SET OUT TO DO The Department of Radiology at the University of Colorado Hospital performs approximately 200 CT and MR studies per day. The imaging ordering and protocoling selection process had until recently been entirely paper based. Each order generated a paper request, which was then passed on to the radiologist in the appropriate subspecialty along with a section-specific protocol sheet. The scheduling office in our department distributed a large stack of these protocoling sheets twice daily to each section. Bassignani et al [1] described a “paperless” protocol selection process in 2010 that involved scanning documents into the PACS for review by a radiologist at the time of protocoling. Although this significantly decreased the manual transfer of paper, it was not a truly electronic process. The University of Colorado Hospital implemented an electronic medical record (EMR) in September 2011. With the deployment of the EMR, the order-entry, order-generation, and scheduling processes all became electronic. At the time of implementation, the expectation was that we would immediately be able to shift to electronic protocol selection of higher-level imaging studies (CT and MR), eliminating the voluminous amounts of paper and the related faxing of orders. A mechanism for this was embedded in our EMR. We envisioned the workflow as a simple progression from clinician order entry to radiologist protocol selection to authorization and scheduling of the examination to performance of the examination. WHAT WAS THE PROBLEM? Our actual workflow turned out to be quite complicated (Fig. 1). Although our EMR analysts had designed a very simple electronic protocol selection form triggered at order entry, this did not accommodate most aspects of this workflow. The simplified form that was created assuming a linear workflow failed for 10 reasons:

Technical Innovation: The Automated Residency Match Rank List

The creation of the final rank list for the National Residency Matching Program every year is a laborious task requiring the time and input of numerous faculty members and residents. This article describes the creation of an automated visual rank list to efficiently organize and guide discussion at the yearly rank meeting so that the task may be efficiently and fairly completed. The rank list was created using a PowerPoint (Microsoft) macro that can pull information directly from a spreadsheet to generate a visual rank list that can be modified on-the-fly during the final rank list meeting. An automatically created visual rank list helps facilitate an efficient meeting and creates an open and transparent process leading to the final ranking.

Unusual Appearance of a Neonatal Brain Lesion

Sonography plays an integral role in evaluation of the brain in premature infants. Screening premature infants for intracranial hemorrhage has been proven to be extremely sensitive and specific. Sonography also plays a critical role in the evaluation of intracranial lesions in this population. We present a case of an unusual manifestation of a brain lesion in a premature infant.