Tracheoinnominate Artery Fistula Formation in a Child with Long-Term Tracheostomy Dependence.

We report a fatal tracheoinnominate artery fistula (TIF) in a 13-year-old female patient with long-term tracheostomy tube dependence due to chronic respiratory failure. Thirteen years after placement of her tracheostomy tube, the patient experienced two separate episodes of sentinel bleeding prior to a fatal hemorrhagic event. Diagnostic evaluation after the sentinel events was mostly nonconclusive. This case highlights the risk of TIF in pediatric age group, even years after initial tracheostomy tube placement, and the need for a high index of suspicion for TIF when children present with unexplained tracheal bleeding.

Yield of head computed tomography in patients with new onset of transient headaches.

BACKGROUND: Headache is a common patient complaint. The threshold for brain imaging in headache is debated, especially when the headache is transient, although even if the headache has resolved at presentation, a sentinel bleed heralding a subarachnoid haemorrhage (SAH) often remains a concern. AIM: To assess the yield of computed tomography (CT) head scan referrals for patients with transient headache symptoms. METHODS: This study looked at 6 months of CT results in order to assess for brain pathology, with a particular focus on subarachnoid haemorrhage. Where any pathology was identified, detailed chart review looked for potential high-risk indicators. RESULTS: Between January and July 2015, 531 undifferentiated headache patients were referred for head CT. Of these, 177 (33.3%) presented with a transient or episodic pattern. None of these cases had SAH on imaging nor re-presented with SAH within 3 months of initial CT. However, 7.3% (13/177) had other significant intracranial pathologies. The only significant risk factor for CT abnormality in this setting was focal neurology on presentation (odds ratio 3.1 (95% confidence interval (CI) 1.2-11.0); P = 0.044). All identified cases of SAH over the 6-month study period occurred in patients with persistent headache, and their clinical presentations showed a similar cluster of symptoms to previous literature (including thunderclap headache, vomiting and loss of consciousness). CONCLUSION: This study suggests that patients with transient headache are at a low risk of SAH; however, further study is needed to quantify this, and other serious pathologies remains a concern, especially in the setting of focal neurology at presentation.