Luis Jiménez-Roldán

The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.

BACKGROUND Since 1999, the Italian guidelines have been used at our department for the management of patients with mild head injury (MHI). According to these guidelines, a computed tomography (CT) scan should be obtained in all patients with coagulopathy and these should routinely undergo strict observation during the first 24 hours after injury; in addition they should have a control CT scan before discharge. With the increased use of anticoagulant therapy in the elderly population, admitting patients in such treatment with a MHI to the emergency rooms has become very common. The aim of our study was to evaluate the need of performing a control CT scan in patients on anticoagulation treatment who showed neither intracranial pathology on the first CT-scan nor neurologic worsening during the observation period. METHODS We prospectively analyzed the course of all patients on anticoagulation treatment consecutively admitted to our unit between October 2005 and December 2006 who suffered from a MHI and showed a normal initial CT scan. All patients underwent strict observation during the first 24 hours after admission and had a control CT scan performed before discharge. RESULTS One hundred thirty-seven patients were included in this study. Only two patients (1.4%) showed hemorrhagic changes. However, neither of them developed concomitant neurologic worsening nor needed admitting or surgery. CONCLUSION According with our data, patients on anticoagulation treatment suffering from MHI could be managed with strict neurologic observation without routinely performing a control CT scan that can be reserved for the rare patients showing new clinical symptoms.

Acute perfusion changes after spontaneous SAH: a perfusion CT study.

BackgroundPerfusion computed tomography (CT) is a rapid technique that allows the measurement of acute disturbances in local and global cerebral blood flow in patients suffering stroke and spontaneous subarachnoid haemorrhage (SAH). The purpose of this study was to establish the relationship between different measures of brain perfusion made on dynamic-contrast CT reconstructions performed as soon as SAH has been diagnosed and the severity of the bleeding determined by the clinical grade, the extent of the bleeding and the outcome of the patients.MethodsAfter the diagnosis of SAH by conventional CT, a perfusion CT was performed before CT angiography. All imaging studies were performed on a six-slice spiral CT scanner. All images were analysed using perfusion software developed by Philips, which produces perfusion CT quantitative data based on temporal changes in signal intensity during the first pass of a bolus of an iodinated contrast agent. Measurements of mean transient time (MTT), time to peak (TTP), cerebral blood volume (CBV) and cerebral blood flow (CBF) in volumes of interest corresponding to territories perfused by the major cerebral arteries were performed. Different data regarding severity of the bleeding—such as level of consciousness, amount of bleeding in conventional CT—were collected. All poor-grade patients received a ventriculostomy catheter so that ICP recordings were obtained. Also, the occurrence of delayed cerebral ischaemia (DCI) was recorded. Outcome was assessed by the Glasgow Outcome Scale 6 months after the bleeding. For statistical analysis, non-parametric correlations between variables were performed.FindingsThirty-nine patients have been included in the study since January 2007. In SAH patients there are increasing perfusion abnormalities as the severity of the bleeding increases. The most affected perfusion parameters are TTP and MTT, as they significantly increase with the clinical severity of the bleeding and the total volume of bleeding (P < 0.01, Spearman’s Rho). When average MTT time is increased over 5.9 s there is a 20-fold (95% CI = 2.1-182) risk of poor outcome. All patients presenting this MTT time suffered from DCI. This value has a positive predictive value of 100% for DCI and 90% for a poor outcome.ConclusionsSAH causes cerebral blood flow abnormalities even in the acute phase of the illness, consisting mainly of an increase in circulation times (TTP and MTT), which are correlated with the severity of the bleeding.

Validation of a prognostic score for early mortality in severe head injury cases

OBJECT Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs. METHODS The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990-2003, 925 patients). The validation cohort was recruited in 2004-2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model. RESULTS In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R(2)), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0-3 (< 1% predicted mortality); moderate risk, sum score 4-8 (predicted mortality between 1% and 10%); high risk, sum score 9-12 (probability of early death between 10% and 50%); and very high risk, sum score 13-20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early. CONCLUSIONS The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.

Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales

OBJECT There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome. METHODS A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC). RESULTS Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome. CONCLUSIONS The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.

Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study.

BACKGROUND Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a new tool of assessing prognosis. OBJECTIVE To determine the prognostic value of the quantitative estimation of the amount of bleeding after aneurysmal subarachnoid hemorrhage, as well the relative importance of this factor related to other prognostic indicators, and to establish a possible cut-off value of volume of bleeding related to poor outcome. METHODS A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume. RESULTS Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding. CONCLUSION Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk. ABBREVIATION : aSAH, aneurysmal subarachnoid hemorrhage.

Ligaments disruption: a new perspective in the prognosis of spinal cord injury.

The worldwide prevalence of spinal cord injury (SCI) ranges from 233 to 755 per million inhabitants, whereas the reported incidence lies between 10.4 and 83 per million inhabitants annually (Wyndaele and Wyndaele, 2006). Thus, the socioeconomic impact of SCI associated with cervical trauma is high enough that it could become an important concern in the vast majority of developed countries. The ability to predict recovery following SCI is an important part of the physicians role in providing the best care and guidance to patients and families during recovery. The diagnosis of cervical spine injury is an essential aspect of the trauma evaluation. This task is especially difficult in patients whose clinical examinations are not reliable in the midst of distracting painful injuries, intoxication, or concomitant head injury (Levi et al., 2006; Hasler et al., 2011). For this population, the use of radiology is essential. In particular, magnetic resonance imaging (MRI) has become the tool of choice for the diagnosis and management of cervical spine injury after trauma (Levi et al., 2006; Boese and Lechler, 2013). Several studies have been designed to find an association between neurological outcome and a specific radiological finding (Kulkarni et al., 1988; Silberstein and Hennessy, 1993; Flanders et al., 1996; Tewari et al., 2005; Miyanji et al., 2007). Larger lesions and hemorrhage within the spinal cord have been classically described as predictors of bad clinical outcomes in most of these (Kulkarni et al., 1988; Silberstein and Hennessy, 1993; Flanders et al., 1996). Because of its accuracy in detecting soft tissue injuries, MRI is a useful and well-known tool in the management of cervical trauma, particularly in cases of doubtful structural stability (Pizones et al., 2012a). However, there is a lack of knowledge about the prognostic role of ligament injuries (Song et al., 2008). In previous work, disruptions of the ligamentum flavum, anterior longitudinal ligament, and posterior longitudinal ligament were found to be statistically associated with bilateral facet dislocation (Vaccaro et al., 2001). A systematic review that included 1,132 cases of spinal cord injury without radiological abnormalities (SCIWORA) showed that patients with extraneural abnormalities had worse prognoses than patients without abnormalities in their MRIs, but better prognoses than patients with intraneural abnormalities such as edema or hemorrhage (Boese and Lechler, 2013). We recently added substantial information to this topic. In a group of 108 patients with SCI after a cervical trauma (Martinez-Perez et al., 2013), we demonstrated that a specific pattern of ligamentous injury is correlated with the length of spinal cord lesions seen in MRIs. Our results showed that ligamentum flavum injury is independently associated with larger lesions measured at high signal intensity within the spinal cord on T2 sequences. At this point, interpretation of our results should be viewed with caution, because lesion length represents the degree of SCI but is not a measure of neurologic outcome at follow-up. Subjectivity associated with neurological examinations and difficulties with statistical interpretation dictate the use a continuous scale of quantitative variables to analyze the role of soft tissues in SCI. In our opinion, there are two mechanisms that synchronically act to produce greater spinal cord lesions when the ligamentum flavum is damaged. First, the elastic nature of the ligamentum flavum implies that more pressure is required to disrupt it, and these forces are also transmitted to the spinal cord (Figure 1). Secondly, posterior elements are associated with increased instability and therefore with greater SCI. This theory may explain why there are patients without evidence of trauma on radiological imaging, but who manifest neurological deficits secondary to SCIWORA, and why there are patients with different grades of SCI in this subgroup of patients. In fact, we are trying to elucidate a specific pattern of soft tissue injuries in those patients diagnosed with SCIWORA and more severe neurological deficits. Figure 1 Colour scheme showing cervical spine after blunt trauma. Ligamentum flavum is disrupted and associated with intramedullary abnormalities and spinal cord injury. The different mechanisms of injury play unclear roles in the development of SCI (Allen et al., 1982; Alday, 1996; Vaccaro et al., 2007). We may be able to provide a basis of understanding of the association between a specific mechanism of injury and the degree of SCI, which should be corroborated in future studies. Allen and associates (Allen et al., 1982) established a classification based on the mechanism of trauma. In the distractive flexion injuries, failure of the posterior ligamentous complex, including the ligamentum flavum, resulted from a major injury vector directed away from the trunk. The degree of these ligamentous failures was sequentially greater with the grade of Allen classification, and was associated with the progressive severity of SCI (Allen et al., 1982). However, this association is not seen only in flexion injuries. Song and associates (Song et al., 2008) used a group of patients with distractive extension injuries to classify, in grades of progressive severity, the patterns of soft tissue injuries. They found that injuries Grade IV and above, which included damage to the ligamentum flavum, showed increased signal cord changes. Most of the relevant predictors of SCI (edema or intramedullary hemorrhage) are well identified in sagittal T2-weighted images (Silberstein and Hennessy, 1993; Flanders et al., 1996). This sequence should be included in all protocols of cervical trauma for assessing the integrity of soft tissues (Bozzo et al., 2011). However, some authors believe that this may not be enough, and that the standard MRIs have low to moderate specificity in discriminating ligament disruption (Goradia et al., 2007). Fat-suppressed T2 images (Short T1 Inversion Recovery (STIR) sequences) have been used to more accurately rule out ligament disruption (Pizones et al., 2012a, 2012b). Regretfully, STIR is not available in all protocols, and T2 sagittal images are the minimum needed in cervical trauma MRIs. The timing of the MRI is a potential source of critical bias. A literature review by Bozzo and associates (Bozzo et al., 2011) concluded that, for prognostication, MRI should be done in the acute period following SCI. It has been recommended that the first MRI be performed 24–72 hours post injury (Bondurant et al., 1990). There is a lack of evidence supporting a more precise guideline (Goradia et al., 2007; Bozzo et al., 2011). According to previous reports, the extent of lesion is related to the clinical prognosis of SCI when the MRI is performed in the acute phase (Tewari et al., 2005; Miyanji et al., 2007). However, we should take into consideration the findings of other investigators who have found that lesion length changes over time and depends on the length of time between trauma and MRI (Leypold et al., 2008). Most of patients with SCI after cervical trauma are managed in intensive care units under unstable conditions, so performing an MRI, especially within the first days after trauma, can sometimes be challenging, and can worsen the clinical condition of the patient. Ligament disruption is a more stable finding and its detection can be useful in predicting neurological prognosis when the MRI must be delayed. In conclusion, in the past, the role of the ligamentum flavum in the development of SCI has been underestimated. In the future, more effort should be put forth in detecting this injury pattern, particularly in patients whose clinical conditions impede an MRI in the acute phase, and when the classical predictors are not as useful. The MRI is the gold standard to detect and to identify ligament disruption, but most useful sequences, such as STIR, are not included in all cervical trauma protocols.

Embolización de fístula carótido cavernosa indirecta a través de la vena oftálmica superior

Summary Indirect or dural carotid cavernous fistulas are abnormal connections between the cavernous sinus and meningeal branches of the external and/or internal carotid arteries. Most of them are idiopathic and occurs spontaneously. Symptoms vary from a tiny episcleral injection to a severe visual loss. Conservative therapy is recomended in cases with few symptoms and no leptomeningeal drainage, as spontaneous resolution is not infrequent. Whenever symptoms worsen, treatment of the fistula should be prescribed. Nowadays, transvenous endovascular treatment consisting of packing the cavernous sinus is the first choice. In most cases, cavernous sinus can be approached through the inferior petrosal sinus. However, sometimes that is not possible, and an approach directly through the superior ophthalmic vein could be necessary. We report a case of a patient with a dural carotid cavernous fistula treated with embolization of the cavernous sinus through the ophthalmic vein.

Hemorragia subaracnoidea como forma de presentación de aneurisma disecante carotídeo

Resumen Las disecciones carotideas se presentan con muy poca frecuencia en forma de hemorragia subaracnoidea. Sin embargo, la implicacion de la diseccion arterial en la patogenia de algunos aneurismas de la pared dorsal o anterior de la carotida, tronco carotideo y aneurismas “blister-like”, ha hecho que cobre interes la descripcion de los aneurismas disecantes, ya que con frecuencia son lesiones de dificil tratamiento y requieren de tecnicas quirurgicas no habituales. Presentamos el caso de una enferma que debuto con una hemorragia subaracnoidea en mal grado clinico secundaria a un aneurisma disecante de la carotida interna derecha, caracterizado por la presencia en el estudio angiografico de una estenosis carotidea asociada a una dilatacion postestenotica y al hallazgo de una lesion sacular que crecio en el estudio de control. Se realizo un test de oclusion carotidea que mostro una asimetria en la aparicion del drenaje venoso que determino la conveniencia de practicar un by-pass extraintracraneal de alto flujo con injerto de safena para su tratamiento mediante sacrificio de la carotida interna. Ocho meses tras la cirugia la enferma no presenta focalidad neurologica alguna y los estudios de imagen muestran una resolucion de la lesion carotidea con permeabilidad del bypass. Se discuten las dificultades en el diagnostico de estos aneurismas, sus caracteristicas clinicas y radiologicas y los problemas en su tratamiento que casi siempre requieren de sacrificio arterial con o sin revascularizacion cerebral previa.

Symptomatic ptosis cerebelli after suboccipital craniectomy in a patient with severe brain trauma

ABSTRACT Primary objective: To report the first case of symptomatic cerebellar ptosis after a large suboccipital craniectomy in a patient with severe brain trauma and a review of the literature. Patient and methods: A 36-year-old man suffered severe traumatic brain injury after a four-metre fall. He underwent a large suboccipital craniectomy because his computed tomography scan revealed a posterior fossa subdural haematoma and cerebellar swelling. Four weeks after admission, he developed communicating hydrocephalus, and a ventriculoperitoneal shunt was placed. Although he experienced good recovery, seven months after the trauma he complained of cephalea, dizziness, recurrent vomiting and diplopia. Magnetic resonance imaging (MRI) showed descent of the cerebellum through a wide bone defect. Results: We performed a posterior fossa cranioplasty after other causes of delayed worsening were ruled out, such as shunt malfunction, overdrainage and ischaemic lesions. The patient improved, and a post-operative MRI confirmed the upward migration of the cerebellum. Conclusions: Cerebellar ptosis must be considered in cases of delayed symptoms after large suboccipital craniectomy regardless of pathology. Posterior fossa cranioplasty to provide structural support to slumped cerebellum can improve or resolve symptoms.