Venous sinus thrombosis in traumatic brain injury: a major trauma centre experience.

BACKGROUND: This study explores the presentation, management and outcomes of traumatic venous sinus thrombosis (VST) and identifies risk factors associated with poor outcomes. METHODS: This study is a retrospective review of all patients with VST secondary to trauma who presented to a major trauma centre, between April 2015 and January 2020. VST was confirmed by CT venogram and a consultant neuroradiologist. RESULTS: Forty-six patients were identified (38 male), mean age of 43 (range 12-78) and median follow-up 10.2 months (range 0.7-39.1). Fifty-two percent presented as a severe traumatic brain injury, and all had an associated skull fractures overlying the sinus. Ninety-six percent had cerebral contusions, 96% had an intracranial haematoma, 91% had traumatic subarachnoid haemorrhage (tSAH) and 22% had acute cerebral infarction. Thirty-seven percent of the VSTs were occlusive. Fifty-eight percent had sustained, unprovoked intracranial pressure (ICP) spikes (> 20 mmHg). Fifty percent underwent surgical intervention-20% external ventricular drain and 46% craniotomy/craniectomy. Nine percent were treated with anticoagulation and 4% with antiplatelets, at a median of 13.5 days and 9.5 days post-injury, with no additional complications. Age > 60 was associated with poor outcome (GOS of 3-5) (p = 0.0098). On follow-up CT, 52% of the VSTs remained unchanged, 29% re-canalised, 14% improved and 5% worsened, independent of treatment. CONCLUSIONS: This study demonstrated a higher incidence of VST in severe TBI and strong associations with skull fractures, cerebral contusions, tSAH, raised ICP and surgical intervention. Management was inconsistent, with no difference in outcome with or without anticoagulation. Larger, prospective cohort studies are needed to better understand this condition and establish evidence-based guidelines.

Reliability of salivary cortisol and testosterone to a high-intensity cycling protocol to highlight overtraining.

Athletes physically overload to improve performance. Unbalanced stress/recovery may induce overtraining, which is difficult to diagnosis as no diagnostic marker exists. Hormonal responses to a 55/80 cycle (30-min of alternating blocks of 1-min at 55% and 4-min at 80% maximum work rate) may highlight early-stage overtraining (overreaching), as blunted cortisol and testosterone responses to 55/80 follows intensified training. However, the reliability of hormonal responses to 55/80 when not overreached is unknown. Therefore, reported blunted hormonal responses could be due to inconsistent cortisol and testosterone responses to 55/80. Participants (n = 23) completed three 55/80 bouts, >7 days apart, with no exercise 24 h pre-trials. Pre-exercise urine osmolality and stress questionnaire responses were measured. Pre, post, and 30-min post-exercise saliva samples were collected for cortisol and testosterone assessment. Salivary cortisol and testosterone responses, osmolality and well-being were not different between trials. Salivary cortisol and testosterone elevated from pre- to post-exercise [by 4.2 nmol.L-1 (cortisol) and 307 pmol.L-1 (testosterone)], and 30 min post-exercise [by 160 pmol.L-1 (testosterone) only]. Intraclass correlation coefficients for pre to peak post-exercise cortisol (0.89; good) and testosterone (0.53; moderate) were calculated. This demonstrates that 55/80 induces reliable elevations of salivary cortisol and testosterone when in a healthy state.

Presentation, Management, and Outcome of Primary Leiomyosarcoma of the Spine: A Systematic Review.

OBJECTIVE: Primary spinal leiomyosarcoma (PSL) is extremely rare. A case is presented, followed by a systematic review establishing the consensus on presentation, diagnosis, management, and outcomes. Comparison is made with metastatic spinal leiomyosarcoma (MSL). METHODS: A systematic review was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligibility criteria were decided before the literature search was conducted. Data were extracted and analyzed. RESULTS: A total of 397 articles were identified, 25 of which conformed to the eligibility criteria. Thirty-four cases were included in the analysis. PSL had a female preponderance (69.2%), with back pain being the most common presenting symptom (60.9%). Neurologic signs were present in most (69.6%), with tumors typically in the thoracic spine (46.9%). Diagnosis was primarily made using magnetic resonance imaging (64.7%) and computed tomography (55.9%), with a histologic sample being obtained in all cases. Most patients underwent operative management (91.2%), with variable use of neoadjuvant and adjuvant therapies. Operative approach differed greatly and outcome after surgical management was stated in 48.4% of patients, all noting an improvement from presentation. Patient follow-up was limited (median, 7 months), with most patients being free of disease (43.8%). CONCLUSIONS: PSL diagnosis is challenging, with positron emission tomography-computed tomography and histopathologic sampling playing an important role. There is a limited evidence base for the treatment strategies used but surgical management is key, with generally good outcomes. Prognosis for PSL seems to be better than for MSL. There is scope for more dedicated research in PSL and MSL.