Radiological prediction of contralateral extradural haematoma following evacuation of traumatic acute subdural haematoma.

OBJECTIVES: To identify radiological predictors of contralateral extradural haematoma (CEDH) in patients undergoing evacuation of acute subdural haematoma (ASDH). DESIGN: Retrospective case-control study. SUBJECTS: Patients requiring evacuation of traumatic ASDH via craniotomy/craniectomy with contralateral skull fracture were analysed in two groups: those who developed CEDH postoperatively and those who did not. MATERIALS AND METHODS: Retrospective analysis of severe traumatic brain injury admissions over 24 months (2017-2019) at a major trauma centre. Pre- and post-operative CT scans were reviewed by a Consultant Neuroradiologist for initial fracture haematoma (FH) and specific contralateral skull fracture features (CLFF) comprising: complex petrous fracture, suture diastasis and fractures involving foramen spinosum or middle meningeal groove (MMG). RESULTS: 35 patients had ASDH evacuation (age: 11-74); 7 with craniotomy, 28 with craniectomy. 9/35 developed CEDH of whom 7 underwent bilateral craniotomy/craniectomy. 8/9 with CEDH had FH, 6/26 of those without CEDH had FH. All patients with CEDH had CLFF. 6/9 had >1 CLFF. CLFF was identified in 9/26 patients without CEDH and only 3/26 non-CEDH had >1 CLFF. Analysis using univariate logistic regression identified statistically significant factors for the development of CEDH which were: younger age, FH on initial CT, increasing number of CLFF and MMG involvement alone. After multivariate analysis, only younger age and FH were significant. CONCLUSIONS: FH and CLFF on CT enable prediction of CEDH in patients undergoing evacuation of traumatic ASDH. These features raise a high index of suspicion for this complication and may expedite investigation and management for CEDH.

Survival following Pulmonary Metastasectomy for Sarcoma.

OBJECTIVES: The aim of this study is to report the overall survival after pulmonary metastasectomy in patients with metastatic sarcoma and prognostic factors for survival. METHODS: This is a retrospective observational study of consecutive patients having pulmonary metastasectomy for sarcoma over a 5-year period. Survival was calculated by Kaplan-Meier method. RESULTS: Between August 2007 and January 2014, a total of 80 pulmonary metastasectomies were performed on 66 patients with metastatic sarcoma. There were no postoperative in-hospital deaths. The median age was 51 years (range, 16-79) and 39 (59%) patients were male. Fourteen patients had bilateral lung operations and surgical access was by video-assisted thoracoscopic surgery in 48 (73%) cases. The median number of metastases resected was 3 (range, 1-9). The median disease-free interval was 25 months (range, 0-156). Median overall survival was 25.5 months (range, 1-60). At follow-up, 19 patients (29%) were dead with a median follow-up of 31 months (range, 1-60). Recurrence of metastases significantly affected survival: median of 25.5 months (95% confidence interval [CI], 17.7-33.4) versus 48.4 months (95% CI, 42.5-54.4) in patients with no recurrent metastases (p = 0.004). There was no significant difference in survival between patients with high-grade versus low-grade tumors (p = 0.13), histological type (osteosarcoma vs. other soft tissue sarcoma types, p = 0.14), unilateral versus bilateral lung metastases (p = 0.48), or lung metastases alone versus lung and other sites of metastases (p = 0.5). CONCLUSION: In selected patients, pulmonary metastasectomy for sarcoma is safe and may confer a good medium-term survival. Recurrent metastasis after resection confers a poor prognosis.

Impaired thrombolysis: a novel cardiovascular risk factor in end-stage renal disease.

AIMS: End-stage renal disease (ESRD) patients have an excess cardiovascular risk, above that predicted by traditional risk factor models. Prothrombotic status may contribute to this increased risk. Global thrombotic status assessment, including measurement of occlusion time (OT) and thrombolytic status, may identify vulnerable patients. Our aim was to assess overall thrombotic status in ESRD and relate this to cardiovascular risk. METHODS AND RESULTS: Thrombotic and thrombolytic status of ESRD patients (n = 216) on haemodialysis was assessed using the Global Thrombosis Test. This novel, near-patient test measures the time required to form (OT) and time required to lyse (lysis time, LT) an occlusive platelet thrombus. Patients were followed-up for 276 ± 166 days for major adverse cardiovascular events (MACE, composite of cardiovascular death, non-fatal MI, or stroke). Peripheral arterial or arterio-venous fistula thrombosis was a secondary endpoint. Occlusion time was reduced (491 ± 177 vs. 378 ± 96 s, P < 0.001) and endogenous thrombolysis was impaired (LT median 1820 vs.1053 s, P < 0.001) in ESRD compared with normal subjects. LT ≥ 3000 s occurred in 42% of ESRD patients, and none of the controls. Impaired endogenous thrombolysis (LT ≥ 3000 s) was strongly associated MACE (HR = 4.25, 95% CI = 1.58-11.46, P = 0.004), non-fatal MI and stroke (HR = 14.28, 95% CI = 1.86-109.90, P = 0.01), and peripheral thrombosis (HR = 9.08, 95% CI = 2.08-39.75, P = 0.003). No association was found between OT and MACE. CONCLUSION: Impaired endogenous thrombolysis is a novel risk factor in ESRD, strongly associated with cardiovascular events.

Misleading 68 GALLIUM-dotatate PET scan in a patient with a history of a phaeochromocytoma: Unsuspected uptake in papillary thyroid carcinoma metastases.

Scanning for somatostatin receptors using 68 Ga-dotatate positron emission tomography with co-registration with computed tomography or magnetic resonance imaging is now in widespread use for the identification of neuroendocrine tumours, phaeochromocytomas, and paragangliomas and their metastases. We present a case where a patient with a phaeochromocytoma showed uptake in her neck considered diagnostic of a head-and-neck paraganglioma, which was subsequently confirmed to be a metastatic papillary thyroid carcinoma. We alert clinicians to such falsely-identified tumours using this extensively used imaging technique.

A clinical approach to parasellar lesions in the transition age.

Many reviews have summarised the pathology and management of the parasellar region in adult patients, although an analysis of these aspects in the transition years, from puberty onset to the age of peak bone mass, has been lacking. A comprehensive search of English-language original articles, published from 2000 to 2020, was conducted in the MEDLINE database (December 2019 to March 2020). We selected all studies regarding epidemiology, diagnosis and management of the following parasellar lesions: germinoma, craniopharyngioma, Langerhans cell histiocytosis, optic glioma, hypothalamic hamartoma, tuber cinereum hamartoma, cranial chordoma, Rathke cleft cyst, hypophysitis and hypothalamitis during the transition age from childhood to adulthood. In the present review, we provide an overview of the principal parasellar lesions occurring in the transition age. Symptoms are usually a result of the mass effect of the lesions on nearby structures, as well as anterior pituitary deficits. Diabetes insipidus occurs frequently in these patients. In this age group, pubertal developmental disorders may be more evident compared to other stages of life. Parasellar lesions in the transition age mostly include neoplastic lesions such as germinomas, hamartomas, optic gliomas, craniopharyngiomas Langerhans cell histiocytosis and chordomas, and rarely inflammatory lesions (hypophysitis, hypothalamitis). There are limited data on the management of parasellar lesions in the transition age. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life of the individual patient in this complex age range. The clinical approach to parasellar lesions involves a multidisciplinary effort.