M. Reza Taheri

Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography

Spontaneous rectus sheath hematoma is an uncommon condition that can mimic other conditions associated with an acute abdomen. We report the case of a patient with a spontaneous rectus sheath hematoma due to a ruptured inferior epigastric artery pseudoaneurysm who presented with hypotension and severe abdominal pain and was diagnosed using emergency department point-of-care ultrasonography. Point-of-care ultrasonography has been increasingly used in the evaluation of emergency department patients with acute abdomen and hypotension to expedite the diagnosis and management of aortic aneurysm and intraperitoneal bleeding. Resuscitation and urgent surgical and interventional radiology consultations resulted in the successful embolization of a branch of the inferior epigastric artery and a good outcome.

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management

Objective: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. Methods: In this retrospective institutional review board–approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty‐three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial‐caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial‐caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. Results: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial‐caudal discrepancy had a sensitivity of 100% and specificity of 92%. &kgr; Agreement between the 2 readers evaluating the CT images was 0.93. Conclusion: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial‐caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial‐caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

Extra-axial ependymoma presenting as a cerebellopontine angle mass

Ependymomas are glial tumors most commonly located within the posterior fossa (60%Y70% in both adults and children), classically originating from the ependymal cells of the fourth ventricle (1,2). As ependymomas may exist anywhere along the nueroaxis, a minority of ependymomas have been documented in supratentorial and spinal cord sites (1,2). Isolated extra-axial ependymomas at the cerebellopontine angle (CPA) are rare, particularly when no fourth ventricle involvement is identified. It has been suggested that deposition of heterotopic ependymal rests in surrounding tissue during fetal development could give rise to extra-axial ependymomas (1). Ependymomas may be cystic or demonstrate areas of necrosis and hemorrhage (3). On histologic examination, pleomorphic cells with rare mitoses form perivascular pseudorosettes and occasional ependymal canals (3). Vestibular schwannomas and meningiomas combine for 80% to 95% of CPA lesions, with epidermoid cysts being the next most common (4). Only rarely do ependymomas present as primary CPA lesions and, for this reason, these tumors are often initially misdiagnosed. A 48-year-old man presented with a 2-month history of worsening headaches, lightheadedness, progressive ataxia, nausea, and vomiting. The patient was found to have mild ipsilateral sensorineural hearing loss on the audiogram despite subjective perception of normal hearing. A noncontrast head computed tomography showed a subtle mass effect on the right lateral margin of the fourth ventricle by a noncalcified extra-axial mass centered near the CPA (Fig. 1). Axial T2-weighted magnetic resonance imaging at the level of the foramen of Luschka showed a cerebrospinal fluid cleft separating the extra-axial mass from the cerebellum and the brainstem. The lesion did not extend through the foramen of Luschka or the porus acusticus and was homogeneously hypointense to brain on T1 and hyperintense on T2. After the administration of contrast, the mass showed mild to moderate heterogeneous enhancement (Fig. 2). The imaging appearance of this lesion is inconsistent with that of the more common CPA lesions, meningioma and schwannoma, as well with the less frequently encountered choroid plexus papilloma. Schwannomas tend to be isointense to the brain on precontrast T1, have variable intensity on T2 based on cystic degeneration of the tumor, and enhance intensely with contrast (4). They also usually have a concentric growth around the component extending into the internal auditory canal (IAC) (4). Meningiomas tend to be isointense to brain on T1 and T2 sequences, brightly enhance with contrast, are dural based,

Cranial fasciitis of the petrous temporal bone.

Cranial fasciitis (CF) is a rare benign neoplastic lesion affecting the pericranium and deep fascia of the scalp. We report a case confined to the temporal bone, resembling a malignant destructive lesion. The mass was identified during myringotomy for recurrent unilateral otitis media. Biopsy was consistent with CF, which was partially resected. The patient has remained disease free for 12 months. Due to its rarity, no defined treatment algorithm for CF exists. Despite aggressive features on radiology, they may respond very well to partial resection.

Unique presentation of cerebellopontine angle choroid plexus papillomas: case report and review of the literature.

Objectives We present the case of a choroid plexus papilloma (CPP) in the cerebellopontine angle (CPA), describe the different appearances of CPPs with a variety of imaging techniques, and discuss the differential diagnosis of CPA tumors. Participant and Design We report the case of a 52-year-old woman with headache, tinnitus, and unilateral hearing impairment whose preoperative magnetic resonance imaging revealed a heterogeneously enhancing CPA mass that extended into the internal auditory canal. Main Outcome Measures, Results, and Conclusion The preoperative imaging appearance of the lesion was most consistent with that of a schwannoma. Postoperative histopathologic examination found the tumor to be a CPP with cuboidal epithelial cells overlying fibrovascular stroma. CPPs are rare benign central nervous system neoplasms arising from choroid plexus epithelium. The most common site of presentation is in the fourth ventricle in adults and the lateral ventricles in children. CPPs rarely occur in the CPA, and when they do, clinical-radiologic diagnosis is difficult due to both the rarity of this presentation and to nonspecific radiological features.

Small subdural hemorrhages: is routine intensive care unit admission necessary?

With advancing technology, the sensitivity of computed tomography (CT) for the detection of subdural hematoma (SDH) continues to improve. In some cases, the finding is limited to one or 2 images of the CT examination. At our institution, all patients with an SDH require intensive care unit (ICU) admission, regardless of size. In this report, we tested the hypothesis that patients with a small traumatic SDH on their presenting CT examination do not require the intensive monitoring offered in the ICU and can instead be managed on a hospital unit with a lower level of monitoring. This is a retrospective study of patients evaluated and treated at a level I trauma center for acute traumatic intracranial hemorrhage between 2011 and 2014. The clinical and imaging profile of 87 patients with traumatic SDH were studied. Patients with small isolated traumatic subdural hemorrhage (tSDH) (<10 cm(3) blood volume) spent less time in the ICU, demonstrated neurologic and medical stability during hospitalization, and did not require any neurosurgical intervention. It is our recommendation that patients with isolated tSDH (<10 cm(3)) do not require ICU monitoring. Patients with small tSDH and additional intracranial hemorrhages overall show low rates of medical decline (4%) and neurologic decline (4%) but may still benefit from ICU observation. Patients with tSDH greater than 10 cm(3) overall demonstrated poor clinical courses and outcome and would benefit ICU monitoring.

Neoadjuvant chemotherapy and transoral surgery as a definitive treatment for oropharyngeal cancer: A feasible novel approach.

The purpose of this study was to present our evaluation of the outcome of oropharyngeal cancer managed with neoadjuvant chemotherapy and transoral surgery (TOS) with neck dissection as definitive treatment.

Lemierre's syndrome and rapidly deteriorating respiratory failure in the emergency department.

Rapidly progressive acute respiratory distress along with life-threatening gram-negative anaerobic sepsis in a young, immunocompetent individual should always raise concern for Lemierres syndrome. Although still rare, the incidence of Lemierres syndrome has been increasing over the past 20 years. Lemierres syndrome is characterized by postanginal septicemia and secondary internal jugular vein suppurative thrombophlebitis. In the emergency department (ED), patients often present with evidence of sepsis and secondary septic emboli to different organs, primarily the lungs.We report a case of a 24-year-old patient who presented to the ED with acute respiratory distress with an atypical and rapidly deteriorating course. She was later diagnosed with Lemierres syndrome and recovered well after antibiotic treatment, respiratory support, and a lengthy intensive care unit stay. This case report represents an atypical presentation of acute respiratory distress and pharyngitis but is classic for Lemierres syndrome.

Impact of Asynchronous Training on Radiology Learning Curve among Emergency Medicine Residents and Clerkship Students.

CONTEXT Web-based learning (WBL) modules are effectively used to improve medical education curriculum; however, they have not been evaluated to improve head computed tomography (CT) scan interpretation in an emergency medicine (EM) setting. OBJECTIVE To evaluate the effectiveness of a WBL module to aid identification of cranial structures on CT and to improve ability to distinguish between normal and abnormal findings. DESIGN Prospective, before-and-after trial in the Emergency Department of an academic center. Baseline head CT knowledge was assessed via a standardized test containing ten head CT scans, including normal scans and those showing hemorrhagic stroke, trauma, and infection (abscess). All trainees then participated in a WBL intervention. Three weeks later, they were given the same ten CT scans to evaluate in a standardized posttest. MAIN OUTCOME MEASURES Improvement in test scores. RESULTS A total of 131 EM clerkship students and 32 EM residents were enrolled. Pretest scores correlated with stage of training, with students and first-year residents demonstrating the lowest scores. Overall, there was a significant improvement in percentage of correctly classified CT images after the training intervention from a mean pretest score of 32% ± 12% to posttest score of 67% ± 13% (mean improvement = 35% ± 13%, p < 0.001). Among subsets by training level, all subgroups except first-year residents demonstrated a statistically significant increase in scores after the training. CONCLUSION Incorporating asynchronous WBL modules into EM clerkship and residency curriculum provides early radiographic exposure in their clinical training and can enhance diagnostic head CT scan interpretation.

Orbital malignant meningioma: a unique presentation of a rare entity

ABSTRACT An elderly female with progressive proptosis was found to have an aggressive retrobulbar solid orbital mass. The mass was distinct from the optic nerve sheath and intracranial meninges, and produced concave erosion of the sphenoid wing. Operative findings demonstrated an orbital mass adherent to the dura of the superior orbital fissure. The mass did not demonstrate meningeal violation, infiltrate the superior orbital fissure, or display intracranial spread. The dura remained intact after gross total resection. Histopathology revealed a malignant meningioma with papillary and focal rhabdoid morphology and bony invasion (WHO grade III). The patient received 2500cGy of stereotactic radiotherapy in addition to gross total resection. Postoperatively, the signs and symptoms of orbital mass effect resolved (proptosis, relative afferent papillary defect, and periorbital edema) and the vision improved. There was no orbital recurrence or intracranial extension. The follow-up time was limited to eight months secondary to the patient succumbing to metastatic lung adenocarcinoma, which was demonstrated to be a separate process from the orbital meningioma. We propose the etiology of this tumor to be most consistent with an orbital malignant primary extradural meningioma – the first case reported in the literature.