Retrospective audit of the investigation of patients with suspected acute subarachnoid haemorrhage.

INTRODUCTION: Recommended investigational care (RIC) of emergency department (ED) patients with suspected subarachnoid haemorrhage comprises lumbar puncture (LP) to detect xanthochromia if the preceding CT scan is negative. METHODS: Retrospective audit of the investigational care of 100 consecutive ED patients presenting with possible subarachnoid haemorrhage. RESULTS: Of the 100 patients, 91 had negative CT, and 36 (39.6%) of these patients had an LP performed to detect xanthochromia (i.e. RIC). Fifty-five of 91 (60.4%) patients did not receive RIC. Of the 55 patients who did not receive RIC, 25 (45.5%) had a documented senior clinical decision not to perform an LP; 15 (27.3%) had no documented reason; five (9.1%) refused consent; two (3.6%) had an LP but no xanthochromia requested, one patient did not have an LP because of technical issues, six patients underwent CT angiography (CTA), and one patient underwent magnetic resonance angiography (MRA), in the absence of a LP, following a negative CT. Two patients underwent CTA following a negative xanthochromia result. Patients admitted to the emergency extended care unit had 6.85 times the odds of receiving RIC (95% CI 2.20-21.4). CONCLUSIONS: Fifty-five (55) of 91 (60%) ED patients did not receive RIC. Fifteen of the 55 did not have any documented justification for not performing an LP with xanthochromia testing. Admission to an emergency extended care unit was a predictor of receiving RIC. Inappropriate use of CTA and MRA was identified. These findings have important implications for patient safety. Multifaceted strategies are required to close this evidence-practice gap.

Customization of a generic 3D model of the distal femur using diagnostic radiographs.

A method for the customization of a generic 3D model of the distal femur is presented. The customization method involves two steps: acquisition of calibrated orthogonal planar radiographs; and linear scaling of the generic model based on the width of a subject's femoral condyles as measured on the planar radiographs. Planar radiographs of seven intact lower cadaver limbs were obtained. The customized generic models were validated by comparing their surface geometry with that of CT-reconstructed reference models. The overall mean error was 1.2 mm. The results demonstrate that uniform scaling as a first step in the customization process produced a base model of accuracy comparable to other models reported in the literature.

Associates of change in liver fat content in the morbidly obese after laparoscopic gastric banding surgery.

AIM: Hepatic steatosis affects up to 30% of the population. After weight loss, monitoring of the change in hepatic steatosis is not routinely performed. This study aimed to define the closest associates of change in liver fat content in a population of obese females following laparoscopic gastric banding surgery. METHODS: Before and 3 months after surgery, proton magnetic resonance spectroscopy and magnetic resonance imaging were used to estimate the amount of lipid contained within the liver and abdominal subcutaneous and visceral compartments of 29 obese [mean body mass index (BMI) 39 +/- 5 kg/m(2)], non-diabetic women aged between 20 and 62 years. Liver enzymes, fasting plasma glucose and insulin were also measured as well as body weight, BMI and waist circumference. Insulin sensitivity was estimated using homeostasis model assessment insulin resistance index. RESULTS: Significant reductions occurred in body weight (p < 0.001), abdominal fat volumes (p < 0.001) and liver fat (p = 0.037) 3 months after surgery. Change in liver fat content more closely associated with change in serum gamma-glutamyl transferase (GGT; r = 0.71, p < 0.001) than with changes in weight (r = 0.10, p = 0.612) and waist circumference (r = 0.15, p = 0.468). CONCLUSIONS: Our findings suggest that obese non-diabetic female patients who have undergone significant weight loss over 3 months can be better assessed for the regression of excess liver fat content by monitoring changes in serum GGT levels rather than changes in simple anthropometry.

Intra-articular fibrous band of the ankle: an uncommon cause of post-traumatic ankle pain.

A case of an intra-articular fibrous band of the ankle is presented with emphasis on the MR imaging appearances. This entity is an important but uncommon cause of post-traumatic ankle pain and is well recognized within the arthroscopy literature, but there is little if any documentation of this condition in the imaging literature.

Assessment of player performance following return to sport after hamstring muscle strain injury.

OBJECTIVE: To determine if there is any decrease in playing performance of athletes following return to sport after recovery from hamstring muscle strain injury. DESIGN: Prospective cohort study. PARTICIPANTS: One professional Australian football team over two playing seasons. METHODS: For every game, the team coach rated player performance proportional to time spent on the ground playing (an integer score out of a maximum of 10). Player performance ratings were compared pre- and post-hamstring muscle strain injury to assess player performance upon return to sport. RESULTS: Thirteen athletes had hamstring injuries and the required player ratings were available. The mean player performance rating for the entire playing season in which the player was injured was 6.9. The mean player performance rating for the two games prior to injury was 6.8 as opposed to 5.4 for the two games after return to sport. Athletes had a significantly lower player performance rating immediately upon return to sport when compared to ratings for the entire season (p<0.001) and when compared to ratings from the two games prior to injury (p<0.001). CONCLUSIONS: Following return to sport from hamstring injury, player performance as assessed by the team coach is reduced. This suggests that some athletes may return to sport prior to complete resolution of the injury.

Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury.

Traumatic osteitis pubis is a non-specific entity that relates to chronic groin injury and has recently been described as being akin to a pubic bone stress injury. It is uncertain whether or not reduction of hip joint range of motion occurs in traumatic osteitis pubis. The purpose of this study was to establish whether there is a reduction of hip range of motion in athletes who have chronic groin injury diagnosed as pubic bone stress injury. A case-control study was performed whereby 89 Australian Rules footballers underwent, with clinical history unknown, clinical and MRI examination of the groin region. Clinical criteria (pain with tenderness) and MR-criteria (pubic bone marrow oedema) were used for diagnosis of pubic bone stress injury. End-range internal and external rotation hip motion was measured using a goniometer. Athletes with and without symptoms were compared, as were athletes with current symptoms with athletes who had recovered from their groin pain episode. Chronic groin injury was diagnosed in 47 athletes with 37 having pubic bone stress injury. Thirteen athletes had previous groin injury. A reduction of internal and external hip range of motion was demonstrated in athletes with pubic bone stress injury (p < 0.05) and in athletes who had current symptoms compared to those who had recovered from their groin pain episode (p < 0.05). A reduction in hip range of motion was evident in athletes with chronic groin injury diagnosed as pubic bone stress injury. There may be a role for increasing hip range of motion in rehabilitation.

The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players.

OBJECTIVES: To assess in a single team of Australian Rules football players the effect of a specific intervention program on the incidence and consequence of hamstring muscle strain injuries. METHOD: A prospective study was performed with a single team being followed for four playing seasons for hamstring injury. Magnetic resonance imaging was used to confirm the diagnosis of hamstring muscle injury. After two playing seasons an intervention program was implemented with the number of athletes with hamstring injury, competition days missed, and incidence of hamstring match injuries per 1000 h of playing time being compared pre- and post-intervention. The intervention program involved stretching whilst fatigued, sport specific training drills, and an emphasis on increasing the amount of high intensity anaerobic interval training. RESULTS: In the seasons prior to the intervention, nine and 11 athletes sustained hamstring injury compared to two and four following intervention. Competition days missed reduced from 31 and 38 to 5 and 16 following intervention and match incidence decreased from 4.7 to 1.3 per 1000 h of playing time. A beneficial effect was demonstrated with a smaller number of players having hamstring injuries (p = 0.05), a lower number of competition games missed being recorded (p < 0.001), and a decrease in hamstring strain incidence per 1000 h of playing time (p = 0.01) following the intervention program. CONCLUSIONS: Increasing the amount of anaerobic interval training, stretching whilst the muscle is fatigued, and implementing sport specific training drills resulted in a significant reduction in the number and consequences of hamstring muscle strain injuries.

Abdominal manifestations of cystic fibrosis in adults: a review.

Gastrointestinal manifestations of disease are present in most adults with cystic fibrosis. Radiologists are familiar with the classical imaging characteristics of end-stage pulmonary disease and the radiological findings of meconium ileus in neonates. As most patients now live into adulthood, recognition of the imaging appearances of abdominal disease is important to enable prompt diagnosis and treatment. Accordingly, this article presents typical imaging appearances of the adult gastrointestinal manifestations of cystic fibrosis.

Cement penetration and stiffness of the cement-bone composite in the proximal tibia in a porcine model.

PURPOSE: To assess the stiffness of the cement bone composite and the depth and uniformity of cement penetration into the surface of the tibial component during total knee reconstruction in a porcine model. METHODS: The effectiveness of 3 protocols were compared: 2 commonly used cementing techniques-finger-packing of cement on the cut surface followed by impaction, and coating of the undersurface of the prosthesis with cement followed by impaction-and a new method using a tibial cement-pressurising device. Cement penetration was measured by computed tomography; stiffness was determined by hydraulic penetration testing. RESULTS: Cement penetration at a depth of 1 mm was significantly greater following coating the undersurface of the prosthesis than following finger-packing (p=0.008). There was no significant difference at deeper levels or between the tibial-pressurising device group and either of the 2 other groups at any level (p>0.3 in all cases). Differences in surface stiffness by tibial plateau region were found in tibiae that had been cemented using finger-packing and in those that had had their undersurface coated, but not in tibiae that had been cemented using the tibial-pressurising device. CONCLUSION: The tibial cement-pressurising device eliminated regional differences in stiffness seen with other cementing methods. Elimination of these differences by using this device should reduce micromotion and the incidence of aseptic loosening of tibial base plates in total knee arthroplasty.

Pulmonary nocardiosis re-visited: experience of 35 patients at diagnosis.

Pulmonary infection by Nocardia is an uncommon opportunistic infection in humans. Thirty-five patients with pulmonary nocardiosis were identified in two tertiary referral hospitals. A retrospective review of the patient characteristics, clinical and laboratory features including antimicrobial susceptibility at diagnosis was carried out. Radiological features derived from chest radiographs and CT scans were also documented. In our population, the predominant risk factors were immuno-compromised state, corticosteroid therapy, and underlying pulmonary pathology. The presenting features were similar to those previously described but disseminated infection was not common. The radiological changes were diverse and non-specific. Nocardia asteroides was the commonest species. Most Nocardia isolates were susceptible to imipenem, ceftriaxone, amikacin, and cotrimoxazole. Co-existing microbial agents are common and reflect the underlying complex disorders.

Local osteopenia associated with management of intra-articular distal radial fractures by insertion of external fixation pins in the distal fragment: prospective study.

PURPOSE: To assess the restoration of the bone mass of the distal radius following the use of implants in the distal radial fragment. Highly comminuted Frykman type 7 and 8 fractures were studied to determine whether the use of fixation pins in the comminuted distal radial fragment leads to osteopenia in the distal radial fragment after healing of the fracture. METHODS: As part of a clinical trial, 30 patients with comminuted intra-articular fractures of the distal radius were treated with closed reduction, external non-bridging fixation, and early postoperative mobilisation. To detect local osteopenia, bone density measurements were taken at the distal metaphysis and mid-diaphysis following healing of the fractured radius and the contralateral unaffected radius in 12 patients. RESULT: The mean age of the 12 patients for whom bone density measurements were recorded was 52.5 years (range, 39-87 years). There were 9 females and 3 males included in the study. Seven patients had a Frykman type 8 fracture and 5 patients had a Frykman type 7 fracture. Significant osteopenia was absent despite the use of four 2.5-mm fixation pins in the distal fragments of the healed distal radial fracture. The median value of the maximal step was 2.8 mm (range, 0-9.1 mm). The median value of the intra-articular interfragmentary gap was 1.8 mm (range, 0-13.4mm). CONCLUSION: The findings of this study do not suggest long-term osteopenia following the use of four 2.5-mm pins in the distal fragments. The non-bridging fixator, by allowing early physical activity, possibly led to satisfactory functional and structural results.

Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging.

OBJECTIVE: To prospectively establish risk factors for hamstring muscle strain injury using magnetic resonance imaging (MRI) to define the diagnosis of posterior thigh injury. METHOD: In a prospective cohort study using two elite Australian Rules football clubs, the anthropometric characteristics and past clinical history of 114 athletes were recorded. Players were followed throughout the subsequent season, with posterior thigh injuries being documented. Hamstring intramuscular hyperintensity on T2 weighted MRI was required to meet our criteria for a definite hamstring injury. Statistical associations were sought between anthropometric and previous clinical characteristics and hamstring muscle injury. RESULTS: MRI in 32 players showed either hamstring injury (n = 26) or normal scans (n = 6). An association existed between a hamstring injury and each of the following: increasing age, being aboriginal, past history of an injury to the posterior thigh or knee or osteitis pubis (all p<0.05). These factors were still significant when players with a past history of posterior thigh injury (n = 26) were excluded. Previous back injury was associated with a posterior thigh injury that looked normal on MRI scan, but not with an MRI detected hamstring injury. CONCLUSIONS: Hamstring injuries are common in Australian football, and previous posterior thigh injury is a significant risk factor. Other factors, such as increasing age, being of aboriginal descent, or having a past history of knee injury or osteitis pubis, increase the risk of hamstring strain independently of previous posterior thigh injury. However, as the numbers in this study are small, further research is needed before definitive statements can be made.

Pulmonary hypertension secondary to left-sided heart disease: a cause for ventilation-perfusion mismatch mimicking pulmonary embolism.

Ventilation-perfusion (V/Q) scans are commonly performed in patients with suspected pulmonary thromboembolism (PE). V/Q mismatch is typically attributed to PE. We describe a case in which a V/Q scan performed on a patient with advanced hypertrophic obstructive cardiomyopathy showed large areas of V/Q mismatch not due to PE. The mismatch was due to pulmonary hypertension secondary to left-sided heart disease. The pathophysiology is briefly reviewed.

Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain.

OBJECTIVES: To examine the relation between the clinical features of groin pain and groin magnetic resonance imaging (MRI) appearances in a group largely comprising elite Australian Rules football players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The relation between a past history of groin pain and these other MRI findings was also examined. METHOD: In a prospective study, 116 male subjects (89 footballers, 17 umpires, 10 sedentary men) were examined before history taking and groin MRI. The clinical history was not known to the examiner (GMV) and radiologists (JPS, GTF). Clinical evidence of groin pain and examination findings were correlated with the presence of increased signal intensity within the pubic bone marrow. A past history of groin pain was correlated with the presence of other MRI findings such as cyst formation, fluid signal within the pubic symphysis disc, and irregularity of the pubic symphysis. RESULTS: Fifty two athletes (47 footballers, five umpires) had clinical features of groin pain with pubic symphysis and/or superior pubic ramus tenderness. A high incidence of increased signal intensity (77%) within the pubic bone marrow was identified in this group. There was an association between this group of athletes and the MRI finding of increased signal intensity (p<0.01). There was also an association between a past history of groin pain and the presence of other MRI findings (p<0.01). CONCLUSIONS: Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow oedema. An association exists between the clinical features of osteitis pubis and the MRI finding of pubic bone marrow oedema. A high incidence of pubic bone marrow oedema was also noted. Degenerative features visualised by MRI, such as subchondral cyst formation, were associated with a past history of groin pain. A stress injury to the pubic bone is the most likely explanation for these MRI findings and may be the cause of the clinical entity osteitis pubis.

Inflammatory pseudotumour of the pancreas in a child.

We describe a 4-year-old girl with an inflammatory pseudotumour of the pancreas, which was preceded by varicella-zoster infection. Inflammatory pseudotumour may involve a variety of tissues, the lungs and liver being typical sites of predilection. Imaging and laboratory tests are nonspecific, and for this reason the diagnosis of inflammatory pseudotumour is rarely made prior to surgery. These benign but locally aggressive masses simulate malignancy in the majority of cases. Inflammatory pseudotumour should, therefore, be considered when a mass arises in an unusual location in the paediatric age group.

Shoulder appearances at MR imaging in long-term dialysis recipients.

PURPOSE: To examine shoulder appearances at magnetic resonance (MR) imaging in long-term dialysis recipients. MATERIALS AND METHODS: Twenty-two chronic dialysis recipients underwent 1.0-T MR imaging with a combination of T1-, T2-, and T2*-weighted sequences. Rotator cuff tendon thickening was graded as present or absent by a musculoskeletal radiologist, who also measured the supraspinatus and subscapularis tendon thicknesses with electronic calipers. The long-axis dimension and location of focal osseous lesions, in addition to their T1, T2, and T2* signal intensities, were noted. RESULTS: Supraspinatus (n = 9) and subscapularis (n = 10) tendon thickening was frequently observed. Six (27%) of the 22 patients had combined thickening of the supraspinatus and subscapularis tendons without substantial involvement of the infraspinatus or teres minor tendons. These patients had undergone dialysis longer (median, 19.2 years; range, 16.3-22.8 years) than had the other patients (median, 11.7 years; range, 5.8-19.3 years; P: =.004). The 29 intraosseous lesions had high, intermediate, and low T2 signal intensity in six (21%), nine (31%), and 14 (48%) instances, respectively. CONCLUSION: Supraspinatus and/or subscapularis tendon thickening is common in chronic dialysis recipients. Bone lesions in such patients are of variable T2 signal intensity and usually subchondral or adjacent to the greater tuberosity.

Cerebral white matter lesions in primary Sjögren's syndrome: a controlled study.

OBJECTIVE: To determine the prevalence of neurological and magnetic resonance imaging (MRI) abnormalities in a well defined population of unselected patients with primary Sjögren's syndrome (SS) and age and sex matched healthy patients. METHODS: Thirty patients with SS and 29 age and sex matched controls were examined by a neurologist and subsequently underwent MRI scanning with a 1.0 Tesla Siemens Impact MR scanner. Scans were graded by a neuroradiologist blinded to the clinical status of each subject. The number and location of white matter lesions > 3 mm in long axis (to exclude non-specific perivascular changes) were recorded for each subject. RESULTS: There was a significant increase in lesions detected by MRI in SS patients versus controls (p = 0.02) including deep white matter lesions (p = 0.03) and subcortical white matter lesions (p = 0.02). The presence of white matter lesions did not correlate with serum IgG or rheumatoid factor levels, or with presence of anticardiolipin antibodies. No subjects had symptoms or signs of serious neurological disease including multiple sclerosis, and corpus callosal lesions commonly seen in multiple sclerosis were notably absent in this study. CONCLUSION: Cerebral white matter lesions detected by MRI are more frequent in patients with primary SS than control subjects, yet do not appear to be associated with significant clinical manifestations. Although the pathological nature of these lesions is yet to be defined, their presence should not be over-interpreted.

Extradural cavernous haemangioma simulating a disc protrusion.

Cavernous haemangiomas confined to the epidural space are rare and are therefore infrequently considered in the differential diagnosis of spinal epidural masses. In order to draw attention to this diagnosis, a case in which an epidural cavernous haemangioma simulates a lateral/foraminal disc protrusion is presented.

MRI of car occupants with whiplash injury.

Our purpose was to document and investigate the prognostic significance of features seen on MRI of patients with whiplash injury following relatively minor road traffic crashes. MRI was obtained shortly and at 6 months after the crash using a 0.5 T imager. The images were assessed independently by two radiologists for evidence of fracture or other injury; loss of lordosis and spondylosis were also recorded. Clinical examinations were used to assess the status of patients initially and at 6 months. The results of the independent MRI and clinical investigations were then examined for association using statistical tests. Initial MRI was performed on 29 patients, of whom 19 had repeat studies at 6 months; 48 examinations were thus examined. Apart from spondylosis and loss of lordosis, only one abnormality was detected: an intramedullary lesion consistent with a small cyst or syrinx. There were no statistically significant associations between the outcome of injury and spondylosis or loss of lordosis. No significant changes were found when comparing the initial and follow-up MRI. It appears that MRI of patients with relatively less severe whiplash symptoms reveals a low frequency of abnormalities, apart from spondylosis and loss of lordosis, which have little short-term prognostic value. Routine investigation of such patients with MRI is not justified in view of the infrequency of abnormalities detected, the lack of prognostic value and the high cost of the procedure.

An unusual spinal intradural arachnoid cyst.

Spinal intradural arachnoid cysts are seen most frequently in the thoracic region, particularly near the midline posteriorly. A thoracic intradural arachnoid cyst in this typical location is reported, with the additional unusual finding of herniation of the spinal cord through an anterior defect in the dura matter. The MRI findings are described.