MRI for Cushing Disease: A Systematic Review.

BACKGROUND: MR imaging is key in the diagnostic work-up of Cushing disease. The sensitivity of MR imaging in Cushing disease is not known nor is the prognostic significance of "MR imaging-negative" disease. PURPOSE: Our aim was to determine the overall sensitivity and prognostic significance of MR imaging localization of Cushing disease. DATA SOURCES: We performed a systematic review of the MEDLINE and PubMed databases for cohort studies reporting the sensitivity of MR imaging for the detection of adenomas in Cushing disease. STUDY SELECTION: This study included 57 studies, comprising 5651 patients. DATA ANALYSIS: Risk of bias was assessed using the methodological index for non-randomized studies criteria. Meta-analysis of proportions and pooled subgroup analysis were performed. DATA SYNTHESIS: Overall sensitivity was 73.4% (95% CI, 68.8%-77.7%), and the sensitivity for microadenomas was 70.6% (66.2%-74.6%). There was a trend toward greater sensitivity in more recent studies and with the use of higher-field-strength scanners. Thinner-section acquisitions and gadolinium-enhanced imaging, particularly dynamic sequences, also increased the sensitivity. The use of FLAIR and newer 3D spoiled gradient-echo and FSE sequences, such as spoiled gradient-echo sequences and sampling perfection with application-optimized contrasts by using different flip angle evolutions, may further increase the sensitivity but appear complementary to standard 2D spin-echo sequences. MR imaging detection conferred a 2.63-fold (95% CI, 2.06-3.35-fold) increase in remission for microadenomas compared with MR imaging-negative Cushing disease. LIMITATIONS: Pooled analysis is limited by heterogeneity among studies. We could not account for variation in image interpretation and tumor characteristics. CONCLUSIONS: Detection on MR imaging improves the chances of curative resection of adenomas in Cushing disease. The evolution of MR imaging technology has improved the sensitivity for adenoma detection. Given the prognostic importance of MR imaging localization, further effort should be made to improve MR imaging protocols for Cushing disease.

Can a "novice" do aneurysm surgery? Surgical outcomes in a low-volume, non-subspecialised neurosurgical unit.

The objective of this paper is to review the results of a junior general neurosurgeon performing aneurysm surgery and compare these to the remainder of his low-volume unit. Prospectively collected data was analysed for 114 aneurysms clipped in 99 patients between July 2001 and May 2005. Overall there was a 0.9% mortality rate and 10.8% complication rate. The favourable outcome rate for the unit was 100% for unruptured aneurysms, 90.4% for grades 1-3 patients and 30% for poor grade patients (grades 4 and 5). The novice neurosurgeon had no mortality and a favourable outcome rate of 94.7% for grades 1-3 patients and 50% for poor grade patients. Acceptable results can be obtained with cerebral aneurysm surgery in a low-volume centre by Australian-trained, non-subspecialty neurosurgeons.

Penetrating craniocerebral injuries from nail-gun use.

Three patients with penetrating craniocerebral nail-gun injuries are described. In the first patient the nail was impinging on the internal carotid artery (ICA) in the carotid canal. On removal of the nail, the patient developed a false aneurysm at the site. To our knowledge, this is the first reported case of nail-gun injury affecting the ICA and also the first case of penetrating head injury affecting the ICA in the carotid canal. The second patient had seven intracranial nails in the frontal area. Three nails penetrated the left orbit, one of which perforated the globe. One nail damaged the optic nerve resulting in optic neuropathy. In the third patient the nail extended through the squamous temporal bone into the temporal lobe. All three were managed successfully via closed gentle traction without craniotomy and/or endovascular intervention. The literature is reviewed and management options for penetrating head injuries are discussed.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema.

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.