Liberalized screening for blunt carotid and vertebral artery injuries is justified.

BACKGROUND: Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. METHODS: From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. RESULTS: Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. CONCLUSION: The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

Gouty tophus presenting as a soft-tissue mass diagnosed by fine-needle aspiration: a case report.

We present a case in which a primary diagnosis of gout was made by fine-needle aspiration. The patient had a right distal ulnar mass, and the initial clinical and radiological diagnoses were that of giant cell tumor of tendon sheath. While tophi are the hallmark of gout, they rarely undergo aspiration because of the known clinical history. This case demonstrates that a tophus may mimic a soft-tissue neoplasm. Whenever an aspiration yields amorphous or granular material, the cytopathologist should be aware of and consider gouty tophus as a diagnostic possibility and perform compensated polarized microscopy on the specimen smears.

Fine-needle aspiration of primary gallbladder carcinoma.

Primary carcinoma of the gallbladder is a rare neoplasm that is frequently difficult to diagnose preoperatively. The obstacles to diagnosis include vague symptoms and the relative inaccessibility of the gallbladder and cystic duct to biopsy. Cytological descriptions of gallbladder carcinoma are sparse and are largely confined to malignant cells identified in aspirated bile. Examination of bile is a fairly insensitive technique for diagnosing carcinoma, partially due to the degradative effect of biliary salts on cellular morphology. In the following, we report the findings of three cases of primary carcinoma of the gallbladder examined by fine-needle aspiration cytology.

Prospective evaluation of pulmonary artery pressures during pulmonary angiography performed with low-osmolar nonionic contrast media.

PURPOSE: To determine the effects of pulmonary angiography performed with low-osmolar, nonionic contrast media on pulmonary artery pressures. PATIENTS AND METHODS: In a prospective, uncontrolled clinical trial, pulmonary artery pressures (systolic, diastolic, mean) of 116 patients referred for pulmonary angiography were recorded before and 1 and 5 minutes after injection of contrast material. RESULTS: There was a statistically significant rise in systolic, diastolic, and mean pulmonary artery pressure at 1 minute (4.6, 3.4, 4.1 mm Hg, respectively) and 5 minutes (3.8, 2.7, 3.4 mm Hg, respectively) after the initial contrast material injection (P < .05). Increases were smaller with additional injections. Systolic pressure changes at 1 and 5 minutes after the first injection were linearly dependent on the volume of contrast material injected (P < .05). There was no statistically significant difference in the increase in pulmonary artery pressure between patients with pulmonary embolus or pulmonary arterial hypertension and those without. CONCLUSION: There is a small but statistically significant rise in pulmonary artery pressure after injection of low-osmolar, nonionic contrast material for pulmonary angiography; it is unlikely to be of clinical significance.

Pulmonary angiography performed with iopamidol: complications in 1,434 patients.

PURPOSE: To evaluate the safety of pulmonary angiography performed with iopamidol compared with pulmonary angiography performed with ionic contrast media. MATERIALS AND METHODS: The data in 1,434 patients who underwent pulmonary angiography with iopamidol 76% were retrospectively reviewed. Complications that occurred within 48 hours were identified with review of hospital charts and/or computer records. RESULTS: Pulmonary arterial hypertension was present in 402 patients and was severe in 99. Pulmonary embolus was diagnosed in 357 patients (24.9%). Major complications occurred in four patients (0.3%). Respiratory insufficiency occurred in two of these patients. Catheterization was not completed in two patients due to catheter-induced cardiac arrhythmia that was refractory to treatment. No procedure-related deaths occurred. During the periprocedural period, eight patients required intubation and 10 patients died; all patients previously were critically ill. CONCLUSION: Pulmonary angiography is a safe procedure, and the margin of safety is enhanced by the use of iopamidol.