Facial fractures: The "bottom-up" approach.

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

Imaging of Spine Trauma.

Every year in North America, approximately 3 million patients are evaluated for spinal injury. Of blunt trauma patients presenting to the emergency department, 3% to 4% will have a cervical spine injury, and up to 18% will suffer a thoracolumbar spine injury. Failure to identify an unstable spine injury can lead to devastating outcomes.

Imaging Genitourinary Trauma.

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

Differentiating shunt-responsive normal pressure hydrocephalus from Alzheimer disease and normal aging: pilot study using automated MRI brain tissue segmentation.

Evidence suggests that normal pressure hydrocephalus (NPH) is underdiagnosed in day to day radiologic practice, and differentiating NPH from cerebral atrophy due to other neurodegenerative diseases and normal aging remains a challenge. To better characterize NPH, we test the hypothesis that a prediction model based on automated MRI brain tissue segmentation can help differentiate shunt-responsive NPH patients from cerebral atrophy due to Alzheimer disease (AD) and normal aging. Brain segmentation into gray and white matter (GM, WM), and intracranial cerebrospinal fluid was derived from pre-shunt T1-weighted MRI of 15 shunt-responsive NPH patients (9 men, 72.6 ± 8.0 years-old), 17 AD patients (10 men, 72.1 ± 11.0 years-old) chosen as a representative of cerebral atrophy in this age group; and 18 matched healthy elderly controls (HC, 7 men, 69.7 ± 7.0 years old). A multinomial prediction model was generated based on brain tissue volume distributions. GM decrease of 33% relative to HC characterized AD (P < 0.005). High preoperative ventricular and near normal GM volumes characterized NPH. A multinomial regression model based on gender, GM and ventricular volume had 96.3% accuracy differentiating NPH from AD and HC. In conclusion, automated MRI brain tissue segmentation differentiates shunt-responsive NPH with high accuracy from atrophy due to AD and normal aging. This method may improve diagnosis of NPH and improve our ability to distinguish normal from pathologic aging.

Radiologic and clinical spectrum of occipital condyle fractures: retrospective review of 107 consecutive fractures in 95 patients.

OBJECTIVE: We proposed to characterize the radiologic spectrum of occipital condyle fractures in a large series of patients and to correlate fracture pathology with neurosurgical treatment and patient outcome. MATERIALS AND METHODS: We conducted a retrospective review of the findings on conventional radiography, CT, and MR imaging in 95 patients with 107 occipital condyle fractures. We described fracture patterns according to two previously published classification systems. Clinical findings, neurosurgical management, and patient outcome were obtained from the medical records. RESULTS: Inferomedial avulsions (Anderson and Montesano type III) were the most common type of occipital condyle fracture, constituting 80 (75%) of 107 overall fractures. Unilateral occipital condyle fractures were found in 73 (77%) of 95 patients, and 58 patients were treated nonoperatively; occipitocervical fusion was required in nine patients for complex C1-C2 injuries, and six patients died. Bilateral occipital condyle fractures or occipitoatlantoaxial joint injuries were seen in 22 (23%) of 95 patients. Occipitocervical fusion or halo traction for the craniocervical junction was required in 12 patients, all of whom had CT evidence of bilateral occipitoatlantoaxial joint disruption and six of whom showed normal craniocervical relationships on conventional radiographs. Six patients with nondisplaced fractures were treated nonoperatively, and four patients died. Thirty (32%) of 95 patients showed continued disability, whereas 55 (57.5%) of 95 patients had good outcomes at 1 month. Associated cervical spine injuries were present in 29 (31%) of 95 patients. CONCLUSION: Given their associated traumatic brain and cervical spine injuries, occipital condyle fractures are markers of high-energy traumas. That conventional radiographs alone may miss up to half of the patients with acute craniocervical instability has not been well established. Avulsion fracture type and fracture displacement are associated with both injury mechanism and the need for surgical stabilization. In this series, most unilateral occipital condyle fractures were treated nonoperatively, whereas bilateral occipitoatlantoaxial joint injuries with findings of instability usually required surgical stabilization.