Which Morphological Features of Facet Diastasis Predict Thoracolumbar Posterior Ligamentous Complex Injury as Defined by Magnetic Resonance Imaging?

BACKGROUND: The association of various morphological features of facet diastasis with posterior ligamentous complex (PLC) injury has not been previously described. This study aims to determine the diagnostic value of facet diastasis subtypes for diagnosing thoracolumbar PLC injury. METHODS: We retrospectively reviewed 337 consecutive patients with acute thoracolumbar fractures who had computed tomography (CT) and magnetic resonance imaging (MRI) within 10 days of injury. Three and 5 reviewers evaluated MRI and CT images, respectively. Facet diastasis was subclassified as follows: Dislocated, no articular surface apposition; subluxed, incomplete articular surface apposition; and facet fracture articular process fractures which may be displaced ≥2 mm or otherwise undisplaced, facet joint widening (FJW) ≥ 3 mm. We examined the diagnostic accuracy and the multivariate associations of facet diastasis subtypes with PLC injury in MRI. RESULTS: Facet dislocation, subluxation, and displaced facet fracture yielded a high positive predictive value (PPV) for PLC injury (96%, 88%, and 94%, respectively). In contrast, undisplaced facet fracture and FJW yielded a moderate PPV for PLC injury (78%, and 45%, respectively). Facet dislocation, subluxation, and displaced facet fracture showed independent associations with PLC injury (adjusted odds ratio [AOR] = 38.4, 17.1, 13.4, respectively; P < 0.05). Undisplaced facet fracture and FJW were not associated with PLC injury (AOR = 3.9 [95% confidence interval, 0.49-38.4], P = 0.20) and (AOR = 1.94 [95% confidence interval, 0.48-7.13]; P = 0.20; P = 0.33), respectively. CONCLUSIONS: Facet dislocation, subluxation, and displaced facet fracture, but not undisplaced facet fracture or FJW, were independently associated with PLC injury. Therefore, we propose to define facet diastasis as a surrogate marker of PLC injury in MRI based on these morphologies.

Traumatic low lumbar fractures: How often MRI changes the fracture classification or clinical decision-making compared to CT alone?

PURPOSE: To determine the impact of magnetic resonance imaging (MRI) on fracture classification for low lumbar fractures (LLFs) compared to CT alone. METHODS: This study was a retrospective review of 41 consecutive patients with LLFs who underwent CT and MRI within 10 days of injury. Three reviewers classified all fractures according to AOSpine Classification and the Thoracolumbar Injury Classification (TLISS). Posterior ligamentous complex (PLC) injury in MRI was defined by black stripe discontinuity and in CT by the presence of: vertebral body translation, facet joint malalignment, horizontal laminar or spinous process fracture, and interspinous widening. The proportion of patients with AO type A/B/C and with TLISS < 5 and ≥ 5 was compared between CT and MRI. We examined the overall accuracy and individual CT findings for PLC injury. RESULTS: AO classification using CT was: AO type A in 26 patients (61%), type B in 7 patients (17%), and type C in 8 patients (22%). Seventeen patients (41%) had a TLISS ≥ 5 while 24 (59%) had TLISS < 5. The addition of MRI after CT changed the AO classification in only 2 patients (4.9%, 95% CI (0.6-16.5%) due to upgrade of type A to type B or vice versa, but did not change TLISS from < 5 to ≥ 5 [p< 0.0001; 95% CI (0.59, 0.77)]. CONCLUSIONS: CT was highly accurate (95%) for diagnosis of PLC injury in LLFs. Addition of MRI after CT did not change the AO classification or TLISS, compared to CT alone, thus suggesting limited additional value of MRI for PLC assessment or fracture classification.

Functional Outcome After Primary Decompressive Craniectomy for Acute Subdural Hematoma in Severe Traumatic Brain Injury.

AIM: To evaluate the impact of primary decompressive craniectomy (DC) on the functional outcome in patients with post traumatic acute subdural hematoma (SDH). MATERIAL AND METHODS: A retrospective cohort analysis of 92 patients with post traumatic acute SDH who underwent primary DC and evacuation of SDH. The primary outcome variable is Glasgow outcome scale at 6 months follow up, while exposure variables are demographic data (age and gender), initial Glasgow coma scale, Marshall Classification Score of traumatic brain injury, midline shift, side of the lesion, surgery related complications and time of cranioplasty. RESULTS: Out of the 92 patients in this study, 89.1% were males and the mean age was 30.2 ± 14.4 years. At admission, the mean Glasgow Coma Scale (GCS) was 5.8 ± 2 and mean Marshall score was 4.7 ± 0.7, while the average midline shift was 8.8 ± 3.5 mm. Right decompressive craniectomy was performed in 46 (50%) patients, while in 2 (2.1%) cases, bi-frontal craniectomy was performed and left decompressive craniectomy was performed in 44 (47.8%) patients. Mortality was reported in 38 patients (41.3%) and poor outcome was reported in 24 patients (26.1%), while 30 patients (32.6%) showed good outcome. During the follow up period, cranioplasty for restoration of the bone defect was completed in 52 patients. CONCLUSION: Primary decompressive craniectomy after STBI for post-traumatic acute subdural hematoma improved the favorable outcome whenever the initial GCS > 4 among adult patients.

Can Vertical Laminar Fracture Further Discriminate Fracture Severity Between Thoracolumbar AO Type A3 and A4 Fractures?

OBJECTIVE: To determine whether vertical laminar fracture (VLF) can distinguish between AO type A3 and A4 fractures. METHODS: In a retrospective review of 111 consecutive acute thoracolumbar burst fractures, 5 reviewers independently analyzed computed tomography scans to classify fractures into A3 or A4 and to identify VLF. The following computed tomography parameters were measured: spinal canal stenosis >50%, anterior vertebral height ratio <50%, load sharing score >6, and local kyphosis >20°. We calculated the diagnostic performance of VLF in detecting A4 fracture. We compared the proportion of fractures with positive bony parameters, neurological deficit, dural tears, and surgical treatment between A3, A4 with VLF, and A4 without VLF. RESULTS: VLF was present in 62/75 (83%) A4 fractures and 2/36 (5.5%) A3 fractures (P < 0.0001). VLF yielded a high specificity of 94% (95% confidence interval 81%-99%) and moderately high sensitivity of 83% (95% CI 72%-91%) in detecting A4 fractures. A significantly higher proportion of A4 fractures with VLF had neurological deficit (24% vs. 0, P = 0.05), spinal canal stenosis >50% (25% vs. 0, P = 0.04), and anterior vertebral height ratio <50% (24% vs. 0, P = 0.05) than A4 fractures with no VLF. Interrater and intrarater κ values for VLF and AO standard criterion were excellent (>0.85). CONCLUSIONS: We found VLF to be highly specific, sensitive, and reliable in detecting A4 fractures. A higher proportion of A4 fractures with VLF had radiographic parameters and neurological deficit than A4 fractures with no VLF. VLF could be used as a severity modifier to further discriminate A3 and A4 fractures regarding severity and potentially guide treatment decision making.

Cerebral venous sinus thrombosis in patients with COVID-19 infection.

BACKGROUND: Despite the COVID-19 infection is more frequently related to acute respiratory distress but there is an increasing evidence of a heterogeneous spectrum of multi-system involvement including the central nervous system. Thromboembolic events after COVID-19 infection have been reported mainly in the pulmonary vasculature however; thromboembolic complications of the nervous system with subsequent cerebrovascular stroke have been increasingly reported. The most common cerebrovascular complication after COVID-19 infection is ischemic stroke however there is also reported cases of cerebral venous sinus thrombosis in such patients as well. In the current report we present two cases with extensive cerebral venous sinus thrombosis as a potential complication for COVID-19 infection. OBJECTIVE: Increase the awareness of neurological complications in patient with COVID-19 virus disease. METHODS: Reporting two cases with confirmed cerebral venous sinus obstruction in patient with confirmed COVID-19 infection. RESULTS: Two young adult males less than 30 years old have no other risk factors of hypercoagulable state apart from being COVID-19 infection victims complicated by CVST. Both of them had progressive course of deterioration in conscious level, right hemiplegia and only one seizures attack has been reported in (Case-1). Both patients in the current report died within one week of their initial symptoms in spite the aggressive medical and surgical treatment. CONCLUSION: CVST is a devastating complication when associated with COVID-19 infection and early investigations for cerebrovascular integrity by using MRA, MRV whenever there are unexplained neurological manifestations in patient with COVID-19 disease.

An Epidemiological Overview of Spinal Trauma in the Kingdom of Saudi Arabia.

INTRODUCTION: The World Report on Road Traffic Injury Prevention indicates that by 2020, road traffic injuries will be a major killer, accounting for half a million deaths and 15 million disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) has one of the highest rates of spinal cord injuries in the world, with 62 people injured per 1 million, and the injuries are mostly due to traffic accidents. METHODS: All polytrauma patients associated with spinal injuries admitted to Prince Mohammed bin Abdul Aziz Hospital (PMAH), Riyadh, from January 2017 to June 2018, were included in this study. Patients with old spinal injuries, any previous spinal surgery, spine infection, or concomitant diagnosed malignancies or osteoporotic collapse with or without falls were excluded. All patients underwent whole-spine computed tomography scan and, in selective cases, magnetic resonance imaging of the spine. RESULTS: Of the 230 patients, 90.0% were male, and 60% were in the second and third decades. Motor vehicle accidents were responsible for 83% of the cases, of which 50% of the victims were the drivers, and 80% were passengers with no seatbelt on. Nearly 50% of the spinal injuries were associated with injuries in the other body parts. Cervical spine injury accounted for 44% of the cases, followed by the lumbar spine injury. Twenty five percent of the patients presented with fixed neurologic deficit in the form of quadriplegia or paraplegia (ASIA-A). The mortality rate was 1.3%. CONCLUSIONS: This study revealed that motor vehicle accidents are a major cause of spinal injuries in the KSA. One-fourth of the spinal Injuries are associated with complete spinal cord injuries. Therefore, in order to prevent lifelong disability in the young population, a nationwide program should be initiated to prevent road traffic accidents.

Fractures of C2 (Axis) Vertebra: Clinical Presentation and Management.

BACKGROUND: Injuries of the upper cervical spine are a major cause of morbidity and mortality due to associated spinal cord and head injuries. The injury patterns of the upper cervical spine are numerous, and the neurologic sequelae are diverse. The axis (C2) is the most commonly fractured vertebra in the upper cervical spine; its unique anatomy and architecture pose difficulties in the diagnosis and the management of its fractures. METHODS: All cases of acute spinal injuries at Prince Mohammed Bin Abdulaziz Hospital in Riyadh, Saudi Arabia, were screened for fractures of C2 vertebrae. These patients underwent computerized tomography (CT) imaging of the cervical spine with special attention paid to the cranio-cervical junction. Magnetic resonance imaging (MRI) and angiography of the neck were performed to exclude ligamentous tears and vascular injuries. Unstable fractures were fixed surgically. In the remaining cases, a conservative trial was given. All patients were followed up once every 3 months for a period of 1 year. During follow-up, some patients underwent additional CT imaging of the cervical spine to monitor the healing of fractures. RESULTS: Out of 230 spinal trauma patients, 43.5% suffered from cervical spine injury. C2 fractures were recorded in 26% cases, and fractures of the C2 vertebral body, including pedicles, laminae, lateral masses, and articular processes, were found in many cases, followed by odontoid fractures (50%). No case of atlanto-axial or atlanto-occipital dislocation was recorded. Road traffic accidents were found to be responsible for 92% of cases. The majority of patients were young males, and 96% of patients had no neurological deficit. Only 15% of the patients required surgery for their unstable fractures. Half of the patients attended outpatient follow -up appointments, all of whom underwent CT scanning of the cervical spine 9 months after the accident or operation. CONCLUSIONS: The axis (C2) is the most commonly affected vertebra in cervical spine trauma, and odontoid fractures make up 50% of all C2 fractures. C2 fractures rarely cause any neurological deficit or vascular injury, and the majority of affected patients can be managed conservatively; only a small proportion requires surgical intervention. Surgical intervention leads to early and complete healing.

Can brain natriuretic peptide, S100b, and interleukin-6 prognosticate the neurological consequences in Egyptian patients presented with supratentorial intracerebral hemorrhage?

BACKGROUND: Biomarkers in supratentorial intracerebral hemorrhage (SICH) enhance the prognosis of the disease. This study aimed to assess the prognosticative grade of S100 calcium-binding protein B (S100B), interleukin-6 (IL-6), and the pro-brain natriuretic peptide (pro-BNP) in SICH outcome prediction. METHODS: Blood samples of 50 SICH patients were analyzed for the biomarkers. The patients were classified into two groups with and without intraventricular hemorrhage (IVH). The following scales including Glasgow Coma Score (GCS), the Barthel index (BI), intracerebral hemorrhage (ICH) score, ICH volume, National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Score (mRS), and length of stay were used to evaluate the severity. RESULTS: The severity scores (NIHSS, GCS, BI, mRI) were significantly higher in SICH patients with IVH versus SICH patients without IVH (P = 0.002, 0.008, 0.001, and 0.03, respectively). Serum levels for a pro-BNP and S100b are significantly higher in SICH patients with IVH versus SICH patients without IVH (P = 0.02 and 0.027, respectively). Multivariate correlations between demographic (age), biomarkers panel (IL-6, S100b, and proBNP), and clinical and severity scores (ICH score, ICH volume, length of hospital stay [LOS], BI, mRS, GCS, and NIHSSS) in all studied patients showed a highly significant correlation between ICH score and pro-BNP (P = 0.04). There was a highly significant correlation between LOS and IL-6 (P = 0.003). CONCLUSION: Pro-BNP, IL-6, and S100b are greatly associated with the presence of IVH that, in turn, correlated well with poor clinical outcome measures.

Interobserver Agreement of White Matter Tract Involvement in Gliomas with Diffusion Tensor Tractography.

AIM: To assess with diffusion tensor tractography (DTT) the interobserver agreement of white matter tract involvement in patients with gliomas. PATIENT AND METHODS: A prospective study was conducted on 35 patients (21 male, 14 female; age: 2-71 years) with gliomas that underwent DTT. Two independent readers assessed the patterns of involvement of the corticospinal tract, corpus callosum, optic radiation, and fasciculi as normal, edematous, displaced, infiltrated, or disrupted. RESULTS: Overall interobserver agreement of involvement of the white matter tracts was excellent (κ = 0.93; 95% confidence interval [CI], 0.91-0.95; p = 0.001). Interobserver agreement was excellent for involvement of corticospinal tracts (κ = 0.81; 95% CI, 0.57-1.00; p = 0.001), corpus callosum (κ = 0.91; 95% CI, 0.75-1.00; p = 0.001), optic radiation (κ = 0.77; 95% CI, 0.53-0.98; p = 0.001), and fasciculi (κ = 0.912; 95% CI, 0.81-0.99; p = 0.001. The interobserver agreement was excellent for tract edema (κ = 0.81; 95% CI, 0.57-1.00; p = 0.001), tract displacement (κ = 0.91; 95% CI, 0.75-1.00; p = 0.001), tract disruption (κ = 0.81; 95% CI, 0.57-1.00; p = 0.001), and good for tract infiltration (κ = 0.77; 95% CI, 0.53-0.98; p = 0.001). The interobserver agreement was excellent for white matter tract involvement in patients with low-grade gliomas (κ = 0.81; 95% CI, 0.57-1.00; p = 0.001) and high-grade gliomas (κ = 0.91; 95% CI, 0.75-1.00; p = 0.001). CONCLUSION: DTT is a reliable and reproducible method for assessment of white matter tract involvement in patients with low- and high-grade gliomas.

Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center.

OBJECTIVE: To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had >1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability. RESULTS: Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations (P < .05) for prognosis. CONCLUSION: The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

Assessment of diffusion tensor imaging metrics in differentiating low-grade from high-grade gliomas.

AIM: The aim of this article is to assess diffusion tensor imaging (DTI) metrics in differentiating low-grade from high-grade gliomas. PATIENTS AND METHODS: A prospective study was conducted on 35 patients with gliomas who underwent DTI. Gliomas were classified into low-grade and high-grade gliomas. The fractional anisotropy (FA), mean diffusivity (MD), linear coefficient (CL), planar coefficient (CP) and spherical coefficient (CS) of the solid tumoral part and peri-tumoral regions were calculated. RESULTS: There was significant difference (p = 0.001) in MD of the solid tumoral part of low-grade (1.78 ± 0.33 × 10(-3 )mm(2)/s) and high-grade (1.16 ± 0.22 × 10(-3 )mm(2)/s) gliomas. The selection of 1.42 × 10(-3 )mm(2)/s as a cutoff value of MD of the tumoral part was used to differentiate low-grade and high-grade gliomas; the best results were obtained with area under the curve (AUC) of 0.957 and accuracy of 91.4%. There was a significant difference in FA, MD, CP and CS of peri-tumoral regions of both groups with p values of 0.006, 0.042, 0.030 and 0.037, respectively. The cutoff values of MD, FA, CS and CP of the peri-tumoral region used to differentiate low-grade from high-grade gliomas were 1.24, 0.315, 0.726 and 0.321 with AUC of 0.694, 0.773, 0.734 and 0.724 and accuracy of 68.6%, 80.0%, 74.3% and 74.3%, respectively. The combined MD of the solid tumoral part and FA of the peri-tumoral region used to differentiate low-grade from high-grade gliomas revealed AUC of 0.974 and accuracy of 88.6%. CONCLUSION: We conclude that the combination of MD of the solid tumoral part and FA of the peri-tumoral region is a noninvasive method to differentiate low-grade from high-grade gliomas.

Effect of olmesartan and pravastatin on experimental cerebral aneurysms in rats.

The major initiation process of intracranial aneurysms is thought to involve endothelial dysfunction due to hemodynamic stress. Angiotensin II type 1 receptor blockers and statins improve vascular endothelium function. The effects of olmesartan and pravastatin were investigated on the development of experimental aneurysms in rats. Eighty-three rats underwent aneurysm induction. Seven groups of 10-14 rats were treated with low or high dose olmesartan, low or high dose pravastatin, low doses of olmesartan and pravastatin, hydralazine, or no drug (control) for 12weeks, when rats were sacrificed for vascular corrosion casting and scanning electron microscopy. Aneurysmal changes at the anterior cerebral-olfactory artery bifurcation were divided into stages 0 (no abnormality) to III (saccular aneurysm). Systolic arterial blood pressure was elevated over 170mmHg in the control, low dose pravastatin, and high dose pravastatin groups, but not in the other groups. The control group demonstrated aneurysmal changes in 100% and stage III in 50% of rats. Aneurysmal changes were observed in most rats in the other groups, but the incidence of stage III was 10% or less. The staging pattern showed significant differences between the groups (P=0.028). Pravastatin reduced both stages III and II+III and olmesartan ameliorated stage III, implying that these may prevent aneurysmal formation through acting on different steps. (209 words).

Fasudil, a Rho-kinase inhibitor, attenuates induction and progression of cerebral aneurysms: experimental study in rats using vascular corrosion casts.

Fasudil (a Rho-kinase inhibitor) has been shown to attenuate abdominal aortic aneurysm development, but any preventive effect against development of cerebral aneurysms is unclear. The effect of fasudil on the development of cerebral aneurysms was investigated in 55 female Sprague-Dawley rats divided into 4 groups: Group 1 (n=10) was the control group without treatment. Groups 2-4 (n=15 each) were subjected to cerebral aneurysm induction procedures plus 1% NaCl in the drinking water. Groups 3 and 4 were also treated with 0.5 or 1.0mg/mL of fasudil in the drinking water, respectively. Vascular corrosion casts of the cerebral arteries were prepared and examined using a scanning electron microscope after 2 months. No significant differences were observed in the degree of induced hypertension between Groups 2, 3 and 4. No aneurysms were found in Group 1. Examination of the left anterior cerebral-olfactory artery junction, which is the most susceptible site for aneurysm development, found significantly fewer aneurysmal lesions in Groups 3 (60%) and 4 (53%) compared to Group 2 (100%) (P<0.02). This study suggests that fasudil attenuated induction of cerebral aneurysms in the rat model.

Simplified experimental cerebral aneurysm model in rats: comprehensive evaluation of induced aneurysms and arterial changes in the circle of Willis.

Establishing a simple and comprehensive experimental model is one of the most important issues in the study of cerebral aneurysms. Previous models in the rat required two stage surgeries and observations were limited to a few branching sites. The present study aimed to introduce a simplified model in rats and to provide a comprehensive evaluation of induced arterial changes in the circle of Willis. Sprague-Dawley rats underwent ligation of the right common carotid artery, and posterior and inferior (group 2, n=9) or only posterior (group 3, n=12) branches of the bilateral renal arteries, and bilateral oophorectomy. Dahl salt-sensitive rats underwent only carotid ligation and bilateral oophorectomy (group 5, n=11). All surgical procedures were completed in one procedure instead of two in the original method. Salt loading was started after the surgery. Five rats of each strain without treatment served as controls (groups 1 and 4, respectively). Three months later, vascular corrosion casts of the cerebral arteries were examined by scanning electron microscopy. Experimental rats in groups 2, 3, and 5 developed 43 aneurysmal lesions at branching sites. Forty-eight arterial changes including dilatation, tortuosity, and fusiform or lateral wall aneurysms were observed at non-branching sites. Group 3 appeared to be superior to the other groups for experimental studies. The frequency and degree of the induced lesions were comparable with previous studies even after the surgical simplification. The present model may be more practical for the study of experimental cerebral aneurysms.