Carotid web prevalence in a large hospital-based cohort and its association with ischemic stroke.

Carotid artery webs are shelf-like protrusions of intimal fibrous tissue arising from the posterior wall of the carotid bulb, found to have a 2.3% prevalence in the United States. Previous studies have demonstrated its association with ipsilateral anterior circulation stroke. The aim of this study is to assess the prevalence of carotid webs in the largest US epidemiologic study to date, and to further characterize the clinical features of carotid web patients. We assembled a cohort of 1467 adult patients with CT angiogram neck from January 1, 2011 to January 1, 2017. CT angiograms were reviewed for diagnosis of carotid web. Demographic and clinical details of web patients were obtained. Differences in demographics and CT angiogram indication between patients with and without carotid web were assessed using appropriate statistical tests. Twenty-four (24/1467 = 1.6%) carotid web patients were identified (mean age: 63 years; 62.5% female; 50% African American). Twelve (12/24 = 50%) had ipsilateral anterior circulation stroke. Of them, 8 were deemed cryptogenic. Four (4/24 = 16.7%) web patients had at least one recurrent stroke in the ipsilateral anterior circulation. One case was reported on the radiology report at the time the study was initially performed. This study confirms a prevalence of 1.6% in our urban, North American cohort. Among carotid web patients, there was a high incidence of ipsilateral anterior circulation stroke, the majority of which were classified as cryptogenic. This study affirms the importance of the diagnosis of carotid web, especially in cryptogenic stroke patients, as a potential unrecognized stroke risk factor.

Right-left propensity of cardiogenic cerebral embolism in standard versus bovine aortic arch variant.

Left-hemispheric ischemic strokes are more frequent overall and often have a worse outcome than their right-hemispheric counterparts. We hypothesized that the right-left propensity of CE cerebral infarcts differs between patients with standard and bovine arch variants. We retrospectively identified all patients with acute stroke of the anterior circulation admitted to our primary stroke center between January 2011 and June 2017 who had moderate- to high-risk cardio-embolic sources according to the SSS-TOAST classification. From amongst these patients, only those with available cross-sectional imaging of the aortic arch were included. Lesion side and patterns on diffusion-weighted magnetic resonance imaging were determined blinded to the aortic arch imaging. One hundred and nineteen patients met the TOAST criteria for moderate- or high-risk cardio-embolic source. Of these, 58 (49%) were men and the median age was 71.9 years; 33% of the patients had a bovine arch. The most common etiologies of CE were atrial fibrillation (n = 80 [67%]) and congestive heart failure with ejection fraction <30% (n = 18 [15%]). In patients with bovine arch there was an approximately 50% chance of having a right- or left-sided infarct. Although there was a trend towards right-sided lesions in patients with standard arches, this did not reach statistical significance. No statistically significant difference in embolic stroke laterality was demonstrated in our relatively small sample. Bovine arch could be an independent risk factor for cardio-embolic embolism. Clin. Anat. 31:310-313, 2018. © 2018 Wiley Periodicals, Inc.

Acute upper extremity flaccid paralysis in a 5year old child secondary to enterovirus infection.

The incidence of acute flaccid paralysis has been on a declining trend with the global efforts on eradication of polio virus. A few scattered clusters of acute flaccid paralysis associated with pathogens like enterovirus other than polio virus and flaviviruses have recently come to limelight. This is a case of acute onset flaccid paralysis of left upper extremity in a fully immunized 5 year old child in New York.

Middle turbinectomy after nasotracheal intubation.

Nasotracheal intubation (NTI) is used for maintaining airway access during maxillofacial surgery or in cases of severe oral trauma. We describe a case of middle turbinectomy complication as a result of NTI. The purposes of this paper are to raise awareness of this complication and review associated imaging findings.

Laryngeal fracture after coughing.

Nontraumatic laryngeal fractures are exceedingly rare disease entities. Only 3 prior instances have been described in the medical literature (Br Med J 1950;1:1052; Acta Otorrinolaringol Esp 2007;58:73-4; Otolaryngol Head Neck Surg 2012;147:801-2). We present a case of thyroid cartilage fracture and associated phlegmon formation after a vigorous coughing spell in a 47-year-old man. On presentation, the patient's symptoms included the triad of odynophagia, dysphagia, and dysphonia as well as diffuse swelling and tenderness over the thyroid cartilage. Computed tomography and magnetic resonance imaging revealed a mildly displaced anterior thyroid cartilage fracture as well as a phlegmon in the strap muscle compartment adjacent to the fracture (Figs. 1 and 2). Intravenous dexamethasone and antibiotics were initiated, and the patient was admitted to the medical intensive care unit. On fiberoptic examination with the flexible laryngoscope, the patient was found to have slightto-moderate watery edema of the right aryepiglottic fold and right greater than left arytenoid cartilages. After 48 hours, the patient's neck swelling and pain significantly improved. On hospital day 4, the patient was discharged with a course of oral antibiotics. One week later, the patient reported only mild odynophagia and persistent dysphonia. He otherwise felt well and was tolerating fluids and soft food without difficulty. A preexisting, congenital abnormality resulting in a focal weakness in the thyroid cartilage might predispose patients to nontraumatic fractures (Otolaryngol Head Neck Surg 2012;147:801-2). Patients in prior case reports of nontraumatic laryngeal fractures presented with similar symptoms (Table). The triad of odynophagia, dysphagia, and dysphonia after a severe coughing or sneezing episode should raise the clinician's suspicion of a thyroid cartilage fracture.

Role of a Chest X-ray Severity Score in a Multivariable Predictive Model for Mortality in Patients with COVID-19: A Single-Center, Retrospective Study.

Predicting the mortality risk of patients with Coronavirus Disease 2019 (COVID-19) can be valuable in allocating limited medical resources in the setting of outbreaks. This study assessed the role of a chest X-ray (CXR) scoring system in a multivariable model in predicting the mortality of COVID-19 patients by performing a single-center, retrospective, observational study including consecutive patients admitted with a confirmed diagnosis of COVID-19 and an initial CXR. The CXR severity score was calculated by three radiologists with 12 to 15 years of experience in thoracic imaging, based on the extent of lung involvement and density of lung opacities. Logistic regression analysis was used to identify independent predictive factors for mortality to create a predictive model. A validation dataset was used to calculate its predictive value as the AUROC. A total of 628 patients (58.1% male) were included in this study. Age (p < 0.001), sepsis (p < 0.001), S/F ratio (p < 0.001), need for mechanical ventilation (p < 0.001), and the CXR severity score (p = 0.005) were found to be independent predictive factors for mortality. We used these variables to develop a predictive model with an AUROC of 0.926 (0.891, 0.962), which was significantly higher than that of the WHO COVID severity classification, 0.853 (0.798, 0.909) (one-tailed p-value = 0.028), showing that our model can accurately predict mortality of hospitalized COVID-19 patients.

Bovine Arch and Stroke Laterality.

Background Left-hemispheric strokes are more frequent and often have a worse outcome than their right-hemispheric counterparts. This study aimed to evaluate whether cardioembolic stroke laterality is affected by anatomical characteristics of the aortic arch. We hypothesized that laterality varies between patients with bovine versus standard arch. Methods and Results We retrospectively identified 1598 acute cardioembolic strokes in patients with atrial fibrillation from our institutional stroke database (2009-2017). Inclusion criteria were acute anterior circulation ischemic infarct and availability of both arch and brain imaging (magnetic resonance imaging or computed tomography). Alternative causes of stroke and anomalous arch were excluded. Imaging was reviewed for stroke characterization and laterality and arch branching pattern. Bovine arch denotes a common origin of the brachiocephalic trunk and left common carotid artery. Strokes were classified as bilateral (left or right). Univariate analysis was performed using chi-square tests. The final cohort comprised 615 patients, mean age 77 years (SD 11.8 years) with 376 women (61%) and 33% white, 30% black, and the remainder mixed/Hispanic. Standard arch (n=424) stroke distribution was left 43.6% (185), right 45.1% (191), and bilateral 11.3% (48). Bovine arch (n=191) stroke distribution was left 51.3% (98), right 35.6% (68), and bilateral 13.1% (25). Bovine arches were associated with more left-sided strokes compared with standard arches (P=0.018). There was an association between black race and bovine arch (P=0.0001). Conclusions Bovine aortic arch configuration is associated with left hemispheric laterality of cardioembolic stroke. This study enriches the understanding that arch anatomy influences stroke laterality and highlights the need for further research into the causative hemodynamic factors.

Brain injury due to ventricular shunt placement delineated by diffusion tensor imaging (DTI) tractography.

OBJECTIVE: Infection and hemorrhage are well-known complications from insertion of intracranial shunts. However, permanent injury to the brain caused by catheterization of the cerebral ventricles has rarely been reported. METHODS: We report a patient who presented at age 14 years for evaluation of a severe behavioral disorder. The patient had sustained direct injury to the corticospinal tract and limbic system during revision of a ventriculoperitoneal shunt at the age of 9 years. RESULTS: Despite persistent evidence of severe disruption of the corticospinal tract on diffusion tensor imaging at age 14 years, the patient had regained complete motor function. CONCLUSION: Recovery of motor function after serious injury to motor cortex during childhood is a dramatic example of the plasticity of the child's brain to injury. In addition, we suggest that the behavioral disorder that emerged in this patient may be related to limbic system injury suffered during the shunt revision.

Computed tomography-guided lumbar drain placement.

The authors describe a technique for lumbar drain placement using CT guidance. Midline or paramidline interlaminar approaches to the thecal sac can be used. The major advantage to CT guidance is direct visualization of the needle tip in relation to the thecal sac. This technical approach is a safe and rapid alternative to fluoroscopic guidance for the placement of lumbar drains in patients in whom standard lumbar drain placement techniques have failed.

Bilateral Cerebrovascular Stroke as an Initial Presenting Symptom of Moyamoya Disease.

Moyamoya disease is a rare condition affecting the circle of Willis and its branching arteries. While the pathogenesis is unclear, it causes progressive occlusion of multiple cerebral vessels leading to severe strokes. We report a case of a 47-year-old Hispanic woman with HTN presented with altered mental status and bilateral upper and lower extremity weakness with dystonic-like upper extremity movement. Serial brain CTs and angiography were performed which showed massive frontal and parietal cerebral infarcts with radiological evidence of moyamoya disease.

Imaging prevalence of nasal septal perforation in an urban population.

OBJECTIVE: To determine the prevalence of nasal septal perforation (NSP) on CT imaging in an urban hospital setting. METHODS: Facial bone CT scans from 3708 consecutive patients were reviewed for the presence of NSP. Size of the perforation was measured in two dimensions. Medical records were reviewed for possible risk factors. RESULTS: The prevalence of NSP was 2.05%. The most common risk factor was a history of drug abuse. Cocaine was the most prevalent drug used. CONCLUSION: The prevalence of NSP was more than double of that previously published, likely related to intranasal drug use in our urban population.

Thoracic Imaging Features of Legionnaire's Disease.

Imaging examinations are often performed in patients with Legionnaires' disease. The literature to date has documented that the imaging findings in this disorder are relatively nonspecific, and it is therefore difficult to prospectively differentiate legionella pneumonia from other forms of pneumonia, and from other noninfectious thoracic processes. Through a review of clinical cases and the literature, our objective is for the reader to gain a better understanding of the spectrum of radiographic manifestations of Legionnaires' disease.

Chorea-acanthocytosis: a mimicker of Huntington disease case report and review of the literature.

BACKGROUND: Neuroacanthocytosis consists of a group of rare heterogeneous neurodegenerative disorders associated with acanthocytosis. Chorea-acanthocytosis, a variety of neuroacanthocytosis, is an autosomal recessive condition with clinical and radiologic features similar to Huntington disease. Although difficult, distinguishing between these entities is crucial as the implications for genetic counseling are significant. REVIEW SUMMARY: We report the case of a 33-year-old female who presented to our institution with a 3-year history of chorea. The patient's prominent orofacial symptoms and the presence of acanthocytes on peripheral blood smear led to the correct diagnosis of chorea-acanthocytosis. CONCLUSIONS: The significant similarities between chorea-acanthocytosis and Huntington disease at the clinical and radiologic levels can lead to an initial misdiagnosis. Clinical clues suggestive of chorea-acanthocytosis include prominent orofacial dyskinesias, often causing dysarthria and dysphagia. Acanthocytosis, when present on peripheral blood smear, can confirm the diagnosis.

Partially Thrombosed Internal Maxillary Pseudoaneurysm after Gunshot Wound.

A 29-year-old man arrived in our emergency department after being shot on the face. Computed tomography (CT) revealed multiple facial bone fractures along the bullet trajectory. On day 10 of admission, CT angiogram of the neck revealed a partially thrombosed pseudoaneurysm in the parapharyngeal fat pad. The pseudoaneurysm was successfully treated with coil embolization. This report discusses diagnosis and treatment of a partially thrombosed internal maxillary artery pseudoaneurysm. Although digital subtraction angiography is the gold standard for pseudoaneurysm diagnosis, CT angiography may provide complimentary information, as seen in this case.

Magnetic Resonance Imaging of Spinal Emergencies.

Like the brain, the spinal cord is subject to trauma, infection, ischemia, hemorrhage, and compression. Early diagnosis is the key to preventing significant morbidity in the form of permanent disability. MR imaging is the gold standard for assessing acute injury to the spinal cord, intervertebral discs, ligaments, and surrounding soft tissues. In this article we systematically review the MRI findings in spinal cord trauma, ligamentous injury, epidural hematoma, epidural abscess, and metastatic disease.