Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis.

BACKGROUND: Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma. METHODS: A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology. RESULTS: 744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity. CONCLUSIONS: Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma. IMPLICATIONS OF KEY FINDINGS: Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

Vulnerable Carotid Artery Plaque Evaluation: Detection Agreement between Advanced Ultrasound, Computed Tomography, and Magnetic Resonance Imaging: A Phantom Study.

PURPOSE: Imaging plaque morphology, in addition to luminal grading, may improve stroke risk-management by identifying structural atherosclerotic plaques alterations responsible for cerebrovascular events. The purpose of this study was to evaluate the agreement between our enhanced ultrasound (US) imaging method and high-resolution cross-sectional imaging modalities, such as multidetector-row computed tomography (CT) and magnetic resonance imaging (MRI), in the characterization of vulnerable plaques. METHODS: Sixty tissue-like phantoms were created to simulate various types of diseased plaque segments. We prospectively assessed each sample with US, CT, and MRI. Plaque characteristics considered included surface irregularity, ulceration, fissure, and presence of internal fluid core(s). We evaluated the agreement between and among the three modalities, as well as the accuracy of each compared with the true pathology. RESULTS: There was moderate to substantial agreement among the three modalities in the detection of morphologic characteristics. There was no significant difference in accuracy between US and CT in the presence of ulceration(s) (P = .23), lucency (P = .23), or fissures (P = .07); however, US was significantly more accurate than MRI for each of these characteristics (P = .0001, P = .0001, P = .02, respectively). None of the three modalities did display any significant difference in accuracy in the identification of irregular surface. There was substantial agreement among the three radiologists (intraclass correlation coefficient, 0.61; 95% confidence interval, 0.46-0.74) in their assessment of plaque subtype, ranging from 80%-85% accuracy in identifying the plaque subtypes for each classification. CONCLUSIONS: Enhanced plaque imaging can identify potentially significant plaque characteristics and provide insight into early causative conditions of carotid atherosclerosis. Our results suggest that the types of plaque pathologies derived from our US method showed good agreement with CT and surpass information gathered on MRI. This imaging protocol could potentially shift the paradigm in early carotid plaque imaging likely to predict the onset of vulnerable plaques, thus improving preventative management of atherosclerosis.

Advanced Ultrasound Evaluation of Vulnerable Carotid Artery Plaque: Can a Combined Two-dimensional and Three-dimensional Plaque Imaging Analysis Identify Significant Plaque Characteristics Responsible for Strokes? A Case Series Study.

OBJECTIVES: Imaging carotid plaque morphology with the use of ultrasound (US) may improve stroke risk management by identifying alterations in atheroma at increased risk for cerebrovascular events. Limited reports on advanced US plaque imaging have identified the potential for evaluation and risk stratification of vulnerable carotid plaques. The purpose of this series was to evaluate the usefulness of integrating an advanced US plaque imaging method to characterize atheromas and to measure the agreement with multidetector row computed tomography (CT) and radiographic pathology. METHODS: Three patients with known high-grade symptomatic carotid artery disease confirmed on CT and scheduled for endarterectomy were recruited for this study. Before surgery, we prospectively assessed carotid arteries for high-risk morphological characteristics using our advanced US plaque imaging mechanism. The plaque characteristics considered included the presence of ulceration, internal lipid or hemorrhagic core(s), calcification(s), and/or thin/dense fibrous plaque caps. US plaque features were correlated with previous CT imaging and postendartertectomy histologic studies. RESULTS: There was substantial agreement in the detection of morphologic characteristics. Our advanced US method yielded 100% sensitivity, specificity, and accuracy in the identification of ulceration, lipid/hemorrhagic core(s) and calcification(s), leading over CT. In the identification of a thin/dense fibrous plaque cap, CT yielded 0% sensitivity versus 33% on US. CONCLUSIONS: Advanced US plaque imaging to further identify significant plaque abnormalities responsible for strokes can reliably identify vulnerable plaque characteristics on both two-dimensional and three-dimensional US. Our results suggest that the type of abnormality identified with our advanced US imaging method surpassed information gathered on CT. Our advanced imaging protocol shows potential for early noninvasive prediction of plaque vulnerability, thus improving preventive management of atherosclerosis.

Radiologic reporting for paranasal sinus computed tomography: a multi-institutional review of content and consistency.

OBJECTIVES/HYPOTHESIS: To optimize clinical care, radiologic reporting should consistently include clinically pertinent information. The purpose of this study was to: 1) determine the current satisfaction of otolaryngologists with paranasal sinus computed tomography (CT) radiologic reporting and 2) evaluate the comprehensiveness of paranasal sinus CT radiologic reporting. STUDY DESIGN: Two parts: 1) A national survey of all practicing otolaryngologists in Canada and 2) a retrospective review of paranasal sinus CT scan radiologic reporting. METHODS: A national survey of all Canadian otolaryngologists was conducted in September 2011. Questions were focused on eliciting the current satisfaction with sinus CT radiologic reporting. At two major centers (Alberta Health Services-Calgary Zone and the Ottawa Hospital), all sinus CT scans performed over a 2-year period were identified (9,739), and 100 from each center were randomly selected for analysis. The radiology reports were scrutinized to determine if seven critical and 11 noncritical items were mentioned. RESULTS: Many (22%) otolaryngologists are dissatisfied with current sinus CT radiologic reporting, and the majority (67%) would like more clinically useful information. All predefined sinus CT items were inconsistently reported. Anterior ethmoid artery anatomy, ethmoid skull base integrity, and sphenoethmoidal cell were the most infrequently reported critical items. CONCLUSIONS: This study has demonstrated that important information is inconsistently reported for sinus CT, and most otolaryngologists would like to see more clinically relevant content in radiology reports. Optimizing the reporting of sinus CT scans will improve communication between the radiologist and other clinicians managing patients with sinonasal disease. LEVEL OF EVIDENCE: 2b.