Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma.

PURPOSE: The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients. METHODS: We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared. RESULTS: Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal. CONCLUSION: In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

Influence of comorbidities on treatment of unruptured intracranial aneurysms in the elderly.

Current evidence does not conclusively justify conservative management of unruptured intracranial aneurysms (UIA) in the elderly (age ≥ 65 years). To rationalise intervention, the authors investigated the role of age and comorbidity burden on treatment outcomes. A retrospective chart review for consecutive cases of UIAs treated in the elderly between 2007 and 2018 was performed. Preoperative Charlson Comorbidity Index (CCI) and Neurovascular Comorbidities Index (NCI) were calculated. Standard statistical methods with univariate and multiple logistic regression were used. A total of 123 patients (46 surgery, 77 endovascular) with 131 UIAs were treated. The mean age was 70.6 ±â€¯4.1 years, and 90 patients were female (73.1%). The mean aneurysm size was 8.6 ±â€¯5.0 mm, and the mean follow up period was 22.9 ±â€¯21.3 months. The rates of poor outcome (mRS > 1) at discharge, 6 weeks and 6 months were 9.8%, 5.8% and 3.6%, respectively. There was no difference in outcomes between surgical and endovascular treatment. Correlation and regression analyses revealed that aneurysm size, higher preoperative comorbidity index (CCI > 4), and endovascular treatment with a stent or flow diverter (p = 0.009, 0.02, and 0.005, respectively) were associated with a poor outcome. When adjusted in a multivariate analysis, only high comorbidity burden (CCI > 4) predicted unfavourable outcome (p = 0.01). Elderly patients who undergo treatment for UIAs are at high risk of postoperative deterioration. Careful preoperative case selection based on comorbidity burden, rather than chronological age, would be useful for improved risk stratification.

Neonatal intracranial aneurysms: case report and review of the literature.

Intracranial aneurysms in the neonate, presenting in the first 4 weeks of life, are exceedingly rare. They appear to have characteristics, including presentation and location, that vary from those found in adults. The authors present a case of a 28-day-old neonate with a ruptured distal middle cerebral artery (MCA) aneurysm. Initial noninvasive imaging with transfontanelle ultrasound and CT confirmed intraparenchymal and subarachnoid hemorrhage. Contrast-enhanced MRI revealed a 14-mm ruptured fusiform MCA aneurysm that was not identified on time-of-flight magnetic resonance angiography (MRA). Microsurgical treatment was performed with partial neurological recovery. A comprehensive review of the literature from 1949 to 2017 revealed a total of 40 aneurysms in 37 neonates, including the present case. The most common presenting symptom was seizure. Although subarachnoid hemorrhage was the most common form of hemorrhage, 40% had intraparenchymal hemorrhage. The median aneurysm size was 10 mm (range 2-30 mm) and the most common location was the MCA, with two-thirds of cases involving the distal intracranial vasculature. Over the last 10 years, there has been a trend of increasing noninvasive diagnosis of ruptured cerebral aneurysms in neonates, with CT angiography and contrast-enhanced MRI being the most useful diagnostic modalities. The use of contrast-enhanced MRI may improve sensitivity over time-of-flight MRA. Microsurgical treatment was the most common treatment modality overall, with increased use of endovascular treatment in the last decade. Most patients underwent microsurgical vessel ligation or endovascular parent vessel occlusion. There were high rates of neurological recovery after microsurgical or endovascular treatment, particularly for patients with distal aneurysms.