James E. Wilberger

The impact of magnetic resonance on the diagnostic evaluation of acute cervicothoracic spinal trauma

From 1984 to 1987 magnetic resonance (MR) imaging was performed on 100 patients suffering acute spinal trauma. MR demonstrated one or more injuries to the cervicothoracic region in 31 patients. It displayed a spectrum of spinal cord injury ranging from mild compression and swelling to complete transection. MR was also useful in evaluating alignment at the cervicothoracic junction, in depicting ligamentous injury, in establishing the presence of disc herniation, and in identifying unsuspected levels of injury. We present a diagnostic algorithm that incorporates the role of MR in evaluating acute cervicothoracic spinal trauma and emphasizes the replacement of myelography by MR in the initial assessment of neurologic deficit.

Traumatic atlanto-occipital dislocation with survival: case report and review.

Traumatic atlanto-occipital (A-O) dislocation is a rare injury that is associated with a high mortality rate. We are presenting the case of a 5-year-old child with this entity to illustrate the mechanism of injury, the often-confusing clinical picture, and the use of diaphragmatic fluoroscopy to localize the neurological lesion. We suggest using plain lateral roentgenograms, anteroposterior tomograms, and a cervical computed tomographic scan to confirm the diagnosis of A-O dislocation. We strongly favor using the halo apparatus for immediate immobilization and posterior occipitoatlantoaxial fusion for long term stability. The various diagnostic radiographic criteria for A-O dislocation are compared and discussed.

Primary intrasellar schwannoma: case report.

A case is presented of a primary intrasellar and suprasellar schwannoma mimicking a pituitary tumor clinically, endocrinologically, and radiographically.

Acute tissue tear hemorrhages of the brain: computed tomography and clinicopathological correlations.

Tissue tear hemorrhages (TTHs) are often seen on high-resolution computed tomographic scans after closed head injury. Generally, TTHs have been thought to be visible manifestations of more severe forms of diffuse axonal injury and thus portend a poor prognosis. Computed tomographic scans from 600 patients with head injuries were reviewed; 48 (8%) were found to have TTHs. The clinical spectrum of TTHs was characterized. No direct relationship could be established between either the presence or the number of TTHs and the severity and/or outcome from the head injury in this group, except that patients with TTHs in both the brain stem and the corpus callosum uniformly had a poor outcome. Magnetic resonance imaging provided more sensitive information than computed tomography in evaluating TTHs.

Magnetic Resonance Imaging and Intraoperative Neurosonography in Syringomyelia

Treatment of syringomyelia remains a difficult and controversial problem. However, the recent advent of magnetic resonance imaging (MRI) and intraoperative ultrasound allows a more precise approach to the diagnosis and management of this disorder. Experience with 27 cases of syringomyelia has shown that MRI is superior to all other forms of diagnostic imaging for the exact anatomical delineation of syrinxes and other spinal cavities. One-third of the syrinxes demonstrated by MRI were either not adequately visualized or missed by myelography and/or computed tomographic scanning. Intraoperative ultrasound has been used to allow more precise operative approaches to the syrinx as well as to guide the exact placement of shunt tubes into syrinx cavities. A method has also been developed to allow intraoperative ultrasound of the spinal cord with patients in the sitting position.

Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article.

OBJECT Clearance of the cervical spine in patients who have sustained trauma remains a contentious issue. Clinical examination alone is sufficient in neurologically intact patients without neck pain. Patients with neck pain or those with altered mental status or a depressed level of consciousness require further radiographic evaluation. However, no consensus exists as to the appropriate imaging modality. Some advocate multidetector CT (MDCT) scanning alone, but this has been criticized because MDCT is not sensitive in detecting ligamentous injuries that can often only be identified on MRI. METHODS Patients were identified retrospectively from a prospectively maintained database at a Level I trauma center. All patients admitted between January 2004 and June 2011 who had a cervical MDCT scan interpreted by a board-certified radiologist as being without evidence of acute traumatic injury and who also had a cervical MRI study obtained during the same hospital admission were included. Data collected included patient demographics, mechanism of injury, Glasgow Coma Scale score at the time of MRI, the indication for and findings on MRI, and the number, type, and indication for cervical spine procedures. RESULTS A total of 1004 patients were reviewed, of whom 614 were male, with an overall mean age of 47 years. The indication for MRI was neck pain in 662 patients, altered mental status in 467, and neurological signs or symptoms in 157. The MRI studies were interpreted as normal in 645 patients, evidencing ligamentous injury alone in 125, and showing nonspecific degenerative changes in the remaining patients. Of the 125 patients with ligamentous injuries, 66 (52.8%) had documentation of clearance (29 clinical, 37 with flexion-extension radiographs). Another 32 patients were presumed to be self-cleared, bringing the follow-up rate to 82% (98 of 119). Five patients died prior to clearance, and 1 patient was transferred to another facility prior to clearance. Based on these data, the 95% confidence interval for the assertion that clinically irrelevant ligamentous injury in the face of normal MDCT is 97%-100%. No patient with ligamentous injury on MRI was documented to require a surgical procedure or halo orthosis for instability. Thirty-nine patients ultimately underwent cervical surgical procedures (29 anterior and 10 posterior; 5 delayed) for central cord syndrome (21), quadriparesis (9), or discogenic radicular pain (9). None had an unstable spine. CONCLUSIONS In this study population, MRI did not add any additional information beyond MDCT in identifying unstable cervical spine injuries. Magnetic resonance imaging frequently detected ligamentous injuries, none of which were found to be unstable at the time of detection, during the course of admission, or on follow-up. Magnetic resonance imaging provided beneficial clinical information and guided surgical procedures in patients with neurological deficits or radicular pain. An MDCT study with sagittal and coronal reconstructions negative for acute injury in patients without an abnormal motor examination may be sufficient alone for clearance.

Burning Hands Syndrome Revisited

The burning hands syndrome of spinal cord injury was first described in 1977. The syndrome is characterized by burning dysesthesias and paresthesias in the hands and may be associated with either cervical fracture/dislocation or no detectable cervical spine abnormalities. A case of burning hands syndrome without cervical spine injury is presented in which somatosensory evoked potentials and magnetic resonance imaging were used to delineate the pathophysiology of this syndrome.

Craniocerebral injuries from dog bite in an infant

Animal bite is a common cause of craniofacial injuries in children. Whereas scalp lacerations from animal bites are often extensive and severe, only four instances of compound depressed skull fractures from animal bites have been reported. A case of a dog bite to the head of an infant is presented to point out the potential for such an insult to produce cranial perforation and underlying brain damage. The associated roentgenographic and computed tomographic features are shown.

Intrasellar mucocele simulating pituitary adenoma: case report.

Mucoceles occupying the sella turcica with suprasellar extension are quite rare. A case of intrasellar mucocele is reported. The preoperative clinical and computed tomographic appearance could not be differentiated from that of pituitary adenoma.

The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI

OBJECT Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries. METHODS The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patients injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline. RESULTS Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R(2) = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score. CONCLUSIONS Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.