Hillary R. Kelly

Prospective Validation of the Computed Tomographic Angiography Spot Sign Score for Intracerebral Hemorrhage

Background and Purpose— Intracerebral hemorrhage (ICH) results in high mortality and morbidity for patients. Previous retrospective studies correlated the spot sign score (SSSc) with ICH expansion, mortality, and clinical outcome among ICH survivors. We performed a prospective study to validate the SSSc for the prediction of ICH expansion, mortality, and clinical outcome among survivors. Methods— We prospectively included consecutive patients with primary ICH presenting to a single institution for a 1.5-year period. All patients underwent baseline noncontrast computed tomography (CT) and multidetector CT angiography performed within 24 hours of admission and a follow-up noncontrast CT within 48 hours after the initial CT. The ICH volume was calculated on the noncontrast CT images using semiautomated software. The SSSc was calculated on the multidetector CT angiographic source images. We assessed in-hospital mortality and modified Rankin Scale at discharge and at 3 months among survivors. A multivariate logistic regression analysis was performed to determine independent predictors of hematoma expansion, in-hospital mortality, and poor clinical outcome. Results— A total of 131 patients met the inclusion criteria. Of the 131 patients, a spot sign was detected in 31 patients (24%). In a multivariate analysis, the SSSc predicted significant hematoma expansion (odds ratio, 3.1; 95% confidence interval, 1.77–5.39; P⩽0.0001), in-hospital mortality (odds ratio, 4.1; 95% confidence interval, 2.11–7.94; P⩽0.0001), and poor clinical outcome (odds ratio, 3; 95% confidence interval, 1.4–4.42; P=0.004). In addition, the SSSc was an accurate grading scale for ICH expansion, modified Rankin Scale at discharge, and in-hospital mortality. Conclusions— The SSSc demonstrated a strong stepwise correlation with hematoma expansion and clinical outcome in patients with primary ICH.

Prevalence of Traumatic Dural Venous Sinus Thrombosis in High-Risk Acute Blunt Head Trauma Patients Evaluated with Multidetector CT Venography

PURPOSE To determine the prevalence of trauma-related dural venous sinus thrombosis (DVST) in high-risk patients with blunt head trauma who are examined with multidetector computed tomographic (CT) venography. MATERIALS AND METHODS With institutional review board approval, HIPAA compliance, and waived informed consent, the authors retrospectively studied the findings in 195 consecutive patients who presented to the emergency department with acute blunt head trauma and were examined with multidetector CT venography because they were considered to be at high risk for DVST owing to the presence of a fracture near a dural venous sinus or jugular bulb or a high index of clinical suspicion. Nonenhanced CT images and CT venograms were reviewed for the presence of skull fractures, intracranial hemorrhage, and traumatic DVST. Magnetic resonance and nonenhanced CT images subsequently obtained in patients with traumatic DVST were assessed for hemorrhagic venous infarctions. Statistical analyses were performed by using Student t and Pearson chi(2) tests. RESULTS Multidetector CT venography depicted thrombosis of 98 dural sinuses or jugular bulbs in 57 (40.7%) of the 140 patients with skull fractures extending to a dural sinus or jugular bulb. Fifty-four (55%) of the 98 sinuses or bulbs had occlusive thrombosis. DVST was seen in only those patients with skull fractures extending to a dural sinus or jugular bulb. Among the skull fractures extending to the transverse sinus, sigmoid sinus, or jugular bulb, those of the petrous temporal bone had a higher risk (50%, 36 of 72 fractures) of traumatic DVST than did those of the occipital bone (34% risk [32 of 93 fractures]) (P = .044). However, among the skull fractures extending to the superior sagittal sinus, those of the occipital bone had a higher risk (67% [eight of 12 fractures]) of traumatic DVST than did those of the parietal (39% risk [11 of 28 fractures]) and frontal (24% risk [four of 17 fractures]) bones (P = .065). Four (7%) patients with traumatic DVST had associated hemorrhagic venous infarctions, all secondary to occlusive DVST. CONCLUSION In patients with blunt head trauma, multidetector CT venographic evaluation should be performed only if there is a fracture extending to a dural venous sinus or jugular bulb.

4D-CT for Preoperative Localization of Abnormal Parathyroid Glands in Patients with Hyperparathyroidism: Accuracy and Ability to Stratify Patients by Unilateral versus Bilateral Disease in Surgery-Naive and Re-Exploration Patients

BACKGROUND AND PURPOSE: 4D-CT is an emerging technique that uses high-resolution images, multiplanar reformats, and perfusion characteristics to identify abnormal parathyroid glands in patients with hyperparathyroidism. This study evaluates the accuracy of 4D-CT for localization and lateralization of abnormal parathyroid glands in preoperative planning for minimally invasive parathyroidectomy vs bilateral neck exploration at a tertiary referral center. MATERIALS AND METHODS: Radiology, pathology, and operative reports were retrospectively reviewed for 208 patients with hyperparathyroidism who underwent 4D-CT and parathyroid surgery between May 2008 and January 2012. 4D-CT performance in localizing side and site was determined by use of surgical and pathologic findings as a reference. RESULTS: Of 208 patients, 155 underwent initial surgery and 53 underwent re-exploration parathyroid surgery. No lesions were found in 8 patients (3.8%). A total of 284 lesions were found in 200 patients; 233 were correctly localized by 4D-CT (82.0%). Of the 200 patients with parathyroid lesions, 146 underwent unilateral and 54 bilateral neck exploration. 4D-CT correctly identified unilateral vs bilateral disease in 179 (89.5%) of 200. 4D-CT correctly localized parathyroid lesions in 126 of the unilateral cases (86.3%). In the re-exploration cohort, 4D-CT correctly identified unilateral vs bilateral disease in 46 (95.8%) of 48. There was no statistically significant difference in subgroups stratified by surgery type (primary or subsequent) and number of scan phases (3 or 4) (P > .56). CONCLUSIONS: 4D-CT leverages modern high-resolution CT scanning and dynamic contrast enhancement to localize abnormal parathyroid glands in patients with hyperparathyroidism of any cause and can be used for planning minimally invasive parathyroidectomy vs bilateral neck exploration.

Multidetector CT Angiography in the Evaluation of Acute Blunt Head and Neck Trauma: A Proposed Acute Craniocervical Trauma Scoring System

PURPOSE To determine the diagnostic yield of multidetector computed tomographic (CT) angiography in the evaluation of patients presenting to the emergency department with acute blunt head and neck trauma to assess for arterial injury and to propose a practical scoring system for the identification of patients at highest risk of arterial injury. MATERIALS AND METHODS With institutional review board approval, Health Insurance Portability and Accountability Act compliance, and waived informed consent, a retrospective study was conducted of 830 consecutive patients who presented to the emergency department with acute blunt head and neck trauma over 9 years and were evaluated with multidetector CT angiography. Unenhanced CT scans and CT angiograms were reviewed for the presence of cervical interfacetal subluxations and/or dislocations, fractures, intracranial hemorrhage, and arterial injury. Medical records were reviewed for mechanism of injury (MOI). Multivariate logistic regression analysis was performed to identify independent predictors of an increased risk of arterial injury. RESULTS Multidetector CT angiographic results showed injury to 118 arterial structures in 106 (12.8%) patients. Multivariate logistic regression analysis showed that the presence of cervical interfacetal subluxation/dislocations (44.4%; odds ratio [OR], 6.3; P < .0001), fracture lines reaching an arterial structure (22.1%; OR, 4.4; P < .0001), and high-impact MOIs (16.5%; OR, 3.1; P < .0001) were independent predictors of an increased risk of arterial injury and were used to construct a scoring system. Patients with scores of 2 and 3 (21.9% and 52.2%, respectively) were at highest risk of arterial injury. CONCLUSION The proposed acute craniocervical trauma scoring system could be used as a guide to select blunt trauma patients for multidetector CT angiographic evaluation. Future validation of this scoring system is necessary.

Multiparametric Evaluation of Head and Neck Squamous Cell Carcinoma Using a Single-Source Dual-Energy CT with Fast kVp Switching: State of the Art

There is an increasing body of evidence establishing the advantages of dual-energy CT (DECT) for evaluation of head and neck squamous cell carcinoma (HNSCC). Focusing on a single-source DECT system with fast kVp switching, we will review the principles behind DECT and associated post-processing steps that make this technology especially suitable for HNSCC evaluation and staging. The article will review current applications of DECT for evaluation of HNSCC including use of different reconstructions to improve tumor conspicuity, tumor-normal soft tissue interface, accuracy of invasion of critical structures such as thyroid cartilage, and reduce dental artifact. We will provide a practical approach for DECT implementation into routine clinical use and a multi-parametric approach for scan interpretation based on the experience at our institution. The article will conclude with a brief overview of potential future applications of the technique.

CT angiography spot sign predicts in-hospital mortality in patients with secondary intracerebral hemorrhage

Background and objective The presence of active contrast extravasation during CT angiography, the spot sign, is a potent predictor of in-hospital mortality in patients with primary intracerebral hemorrhage (ICH). However, its predictive value in patients with ICH due to a vascular abnormality, secondary ICH (SICH), is unknown. The aim of this study was to determine the clinical and radiological predictors of a spot sign and in-hospital mortality in patients with SICH. Methods Two experienced readers independently reviewed CT angiograms performed on 215 consecutive patients presenting to the emergency department with SICH over a 10-year period to assess the presence of spot signs according to strict radiological criteria. Differences in reader interpretation were resolved by consensus. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. Univariate and multivariate logistic regression analyses were performed to determine the clinical and radiological predictors of a spot sign and in-hospital mortality in patients with SICH. Results Spot signs were identified in 31 of 215 patients with SICH (14.4%), four of which were delayed spot signs (12.9%). Spot signs were most common in patients with arteriovenous fistulas (42%), Moyamoya (40%), elevated admission blood glucose (23%) and large intraventricular hemorrhage volumes (29%). Spot signs were most predictive of in-hospital mortality in patients with aneurysms of the anterior cerebral artery (100%) and anterior communicating artery (75%). In univariate analysis, the presence of a spot sign significantly increased the risk of in-hospital mortality in patients with SICH (38.7%, OR 2.2, 95% CI 1.0 to 4.9, p=0.0497). However, in multivariate logistic regression analysis the admission Glasgow Coma Scale was the only independent predictor of in-hospital mortality in patients with SICH (OR 2.8, 95% CI 1.6 to 5.1, p=0.0004). Conclusion The spot sign identifies patients with SICH at increased risk of in-hospital mortality. However, the admission Glasgow Coma Scale was the only independent predictor of in-hospital mortality in this cohort of patients with SICH.

Discriminating Parathyroid Adenoma from Local Mimics by Using Inherent Tissue Attenuation and Vascular Information Obtained with Four-Dimensional CT: Formulation of a Multinomial Logistic Regression Model

PURPOSE To identify a set of parameters, which are based on tissue enhancement and native iodine content obtained from a standardized triple-phase four-dimensional (4D) computed tomographic (CT) scan, that define a multinomial logistic regression model that discriminates between parathyroid adenoma (PTA) and thyroid nodules or lymph nodes. MATERIALS AND METHODS Informed consent was waived by the institutional review board for this retrospective HIPAA-compliant study. Electronic medical records were reviewed for 102 patients with hyperparathyroidism who underwent triple-phase 4D CT and parathyroid surgery resulting in pathologically proved removal of adenoma from July 2010 through December 2011. Hounsfield units were measured in PTA, thyroid, lymph nodes, and aorta and were used to determine seven parameters characterizing tissue contrast enhancement. These were used as covariates in 10 multinomial logistic regression models. Three models with one covariate, four models with two covariates, and three models with three covariates were investigated. Receiver operating characteristic (ROC) analysis was performed to determine how well each model discriminated between adenoma and nonadenomatous tissues. Statistical differences between the areas under the ROC curves (AUCs) for each model pair were calculated, as well as sensitivity, specificity, accuracy, negative predictive value, and positive predictive value. RESULTS A total of 120 lesions were found; 112 (93.3%) lesions were weighed, and mean and median weights were 589 and 335 mg, respectively. The three-covariate models were significantly identical (P > .65), with largest AUC of 0.9913 ± 0.0037 (standard error), accuracy of 96.9%, and sensitivity, specificity, negative predictive value, and positive predictive value of 94.3%, 98.3%, 97.1%, and 96.7%, respectively. The one- and two-covariate models were significantly less accurate (P < .043). CONCLUSION A three-covariate multinomial logistic model derived from a triple-phase 4D CT scan can accurately provide the probability that tissue is PTA and performs significantly better than models using one or two covariates.

Radiologic classification of superior canal dehiscence : Implications for surgical repair

Objective Surgical access to repair a superior canal dehiscence (SCD) is influenced by the location of the bony defect and its relationship to surrounding tegmen topography as seen on computed tomography. There are currently no agreed-upon methods of characterizing these radiologic findings. We propose a formal radiologic classification system of SCD based on dehiscence location and adjacent tegmen topography. Study Design Retrospective case review Setting Tertiary, neurotology referral center Patients We identified 298 patients with superior canal dehiscence on CT from February 2001 to October 2013. Of these, 251 had symptomatic superior canal dehiscence syndrome and were included in the study. Intervention Patients underwent high-resolution temporal bone CT scans with creation of axial, coronal, Pöschl, and Stenver reformatted images to examine the superior semicircular canal. Two residents-in-training and a head and neck radiologist independently read the scans. Main Outcome Measures CT scans were assessed for (1) superior canal dehiscence or “near” dehiscence, (2) defect location relative to the skull base, (3) surrounding tegmen defects, (4) geniculate ganglion dehiscence, (5) superior petrosal sinus-associated dehiscence (SPS), (6) low-lying tegmen, and (7) the distance between the outer table of the temporal bone and the arcuate eminence.

Recurrent scalp metastasis from glioblastoma following resection

A 62-year-old right-handed male presented with several onths of mild headaches, word-finding difficulties, and 25 pound eight loss. MRI showed an irregularly enhancing intra-axial ass lesion in the left frontal lobe extending to the ependymal urface and measuring approximately 6 cm in maximum diamter. Left frontal craniotomy for subtotal resection of the mass as performed. Pathologic assessment revealed a WHO Grade IV lioblastoma with oligodendroglial component, MGMT promoter ethylated, EGFR amplified, and 1p deleted/19q intact (Fig. 1). he patient subsequently received 60 Gy of radiation therapy and emozolomide (75 mg/m2 21/28 days). Ten months after the subtoal resection of the intracranial mass, follow-up MRI revealed n avidly enhancing, infiltrative nodular lesion with restricted

Contrast Extravasation on CT Angiography Predicts Hematoma Expansion and Mortality in Acute Traumatic Subdural Hemorrhage

Here the authors used the “spot sign” to evaluate contrast extravasation in subdural hematomas. A cohort of 157 patients underwent emergent CTA and 48-hour follow-up CT. Of these subjects, 15% showed active contrast extravasation initially and interobserver agreement for its detection was excellent. The presence of active extravasation correlated with significant hematoma expansion and predicted higher in-hospital mortality. Thus, this sign identifies high-risk patients. BACKGROUND AND PURPOSE: The presence of active contrast extravasation at CTA predicts hematoma expansion and in-hospital mortality in patients with nontraumatic intracerebral hemorrhage. This study aims to determine the frequency and predictive value of the contrast extravasation in patients with aSDH. MATERIALS AND METHODS: We retrospectively reviewed 157 consecutive patients who presented to our emergency department over a 9-year period with aSDH and underwent CTA at admission and a follow-up NCCT within 48 hours. Two experienced readers, blinded to clinical data, reviewed the CTAs to assess for the presence of contrast extravasation. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. aSDH maximum width in the axial plane was measured on both baseline and follow-up NCCTs, with hematoma expansion defined as >20% increase from baseline. RESULTS: Active contrast extravasation was identified in 30 of 199 discrete aSDHs (15.1%), with excellent interobserver agreement (κ = 0.80; 95% CI, 0.7–0.9). The presence of contrast extravasation indicated a significantly increased risk of hematoma expansion (odds ratio, 4.5; 95% CI, 2.0–10.1; P = .0001) and in-hospital mortality (odds ratio, 7.6; 95% CI, 2.6–22.3; P = 0.0004). In a multivariate analysis controlled for standard risk factors, the presence of contrast extravasation was an independent predictor of aSDH expansion (P = .001) and in-hospital mortality (P = .0003). CONCLUSIONS: Contrast extravasation stratifies patients with aSDH into those at high risk and those at low risk of hematoma expansion and in-hospital mortality. This distinction could affect patient treatment, clinical trial selection, and possible surgical intervention.