Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants.

For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.

Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans.

OBJECTIVES: The standard method of ventriculostomy catheter placement is a freehand pass technique using surface anatomical landmarks. This study was undertaken to determine the accuracy of successful ventriculostomy procedures performed at a single institution's intensive care unit (ICU). The authors hypothesized that use of surface anatomical landmarks alone with successful results frequently do not correlate with desirable catheter tip placement. METHODS: Retrospective evaluation was performed on the head computed tomography (CT) scans of 97 patients who underwent 98 freehand pass ventriculostomy catheter placements in an ICU setting. Using the postprocedure CT scans of the patients, 3D measurements were made to calculate the accuracy of ventriculostomy catheter placement. RESULTS: The mean distance (+/- standard deviation [SD]) from the catheter tip to the Monro foramen was 16 +/- 9.6 mm. The mean distance (+/- SD) from the catheter tip to the center of the bur hole was 87.4 +/- 14.0 mm. Regarding accurate catheter tip placement, 56.1% of the catheter tips were in the ipsilateral lateral ventricle, 7.1% were in the contralateral lateral ventricle, 8.2% were in the third ventricle, 6.1% were within the interhemispheric fissure, and 22.4% were within extraventricular spaces. CONCLUSIONS: The accuracy of freehand ventriculostomy catheterization at the authors' institution typically required 2 passes per successful placement, and, when successful, was 1.6 cm from the Monro foramen. More importantly, 22.4% of these catheter tips were in nonventricular spaces. Although many neurosurgeons believe that the current practice of ventriculostomy is good enough, the results of this study show that there is certainly much room for improvement.

Cooperative learning as applied to resident instruction in radiology reporting.

RATIONALE AND OBJECTIVES: The study is designed to evaluate the effectiveness of an active form of resident instruction, cooperative learning, and the residents' response to that form of instruction. MATERIALS AND METHODS: The residents dictated three sets of reports both before and after instruction in radiology reporting using the cooperative learning method. The reports were evaluated for word count, Flesch-Kincaid grade level, advancement on clinical spectrum, clarity, and comparison to prior reports. The reports were evaluated for changes in performance characteristics between the pre- and postinstruction dictations. The residents' response to this form of instruction was evaluated by means of a questionnaire. RESULTS: The instruction was effective in changing the resident dictations. The results became shorter (P<.035), more complex (P<.0126), and demonstrated increased advancement on clinical spectrum (P<.0204). The resident response to this form of instruction was positive. One hundred percent or respondents indicated enjoyment working with their groups. Seventy-five percent stated they would like to participate in more cooperative learning activities. The least positive responses related to the amount of time devoted to the project. Sixty-three percent of respondents stated that the time devoted to the project was appropriate. CONCLUSION: Cooperative learning can be an effective tool in the setting of the radiology residency. Instructional time requirements must be strongly considered in designing a cooperative learning program.

Sturge-Weber syndrome: a review.

Sturge-Weber syndrome is a rare disorder that occurs with a frequency of approximately 1 per 50,000. The disease is characterized by an intracranial vascular anomaly, leptomeningeal angiomatosis, most often involving the occipital and posterior parietal lobes. Facial cutaneous vascular malformations, seizures, and glaucoma are among the most common symptoms and signs. Stasis results in ischemia underlying the leptomeningeal angiomatosis, leading to calcification and laminar cortical necrosis. The clinical course is highly variable and some children experience intractable seizures, mental retardation, and recurrent strokelike episodes. In this review, we describe the syndrome's characteristic features, clinical course, and optimal management.

Pulsatile tinnitus: a harbinger of a greater ill?

BACKGROUND: Pulsatile tinnitus is an uncommon otologic symptom, which may be the presenting complaint of a potentially devastating pathology. Understanding this manifestation as a possible symptom of a significant vascular abnormality is crucial to guide management and treatment. METHODS AND RESULTS: We describe a 38-year-old woman with sudden-onset right-sided pulsatile tinnitus. A right extracranial internal carotid artery (ICA) dissection was diagnosed with MRI/magnetic resonance angiography (MRA) and treated with anticoagulation. Follow-up MRI/MRA demonstrated complete resolution. Two months later, left-sided pulsatile tinnitus evolved. An MRI/MRA of the neck demonstrated left-sided extracranial ICA dissection. She was treated in a similar fashion and a repeat MRI/MRA demonstrated its resolution. CONCLUSION: Spontaneous extracranial ICA dissection may present with pulsatile tinnitus as the only symptom in 4% to 50% of patients. Subsequent evolution of a contralateral dissection is even more uncommon. Generally, treatment of this phenomenon is conservative utilizing anticoagulation or aspirin; however, surgical intervention may be necessary.