Faculty Bibliography

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

Every year in North America, approximately 3 million patients are evaluated for spinal injury. Of blunt trauma patients presenting to the emergency department, 3% to 4% will have a cervical spine injury, and up to 18% will suffer a thoracolumbar spine injury. Failure to identify an unstable spine injury can lead to devastating outcomes.

Contrast-enhanced multidetector computed tomography (MDCT) has become a critical tool in the evaluation of the trauma patient. MDCT can quickly and accurately assess trauma patients for renal, ureteral, and bladder injuries. Moreover, CT guides clinical management triaging patients to those requiring discharge, observation, angioembolization, and surgery. Recognition of urinary tract trauma on initial scan acquisition should prompt delayed excretory phase imaging to identify urine leaks. Urethral and testicular trauma are imaged with retrograde urethrography and sonography, respectively.

Introduction and Objectives: Prior studies have alluded to gender differences in aortic neck morphology resulting in anatomic exclusion of some women from EVAR. The objective of this study is to correlate gender differences in aortic neck morphology and changes in the neck and aneurysm sac after EVAR. Methods: A retrospective review of consecutive EVARs performed for infrarenal AAA was conducted from 2004 to 2013 at a single institution. Pre- and post-operative imaging studies were utilized to measure aortic neck length and diameter, shape, and angulation, aneurysm sac diameter. Volumetric analysis of neck thrombus burden was performed using TeraRecon. Results: 146 patients met inclusion criteria 21% were women with a mean age of 75.5 (p=0.724) with comparable baseline comorbidities to men. Neck angulation was greater in women 23.9degreevs 13.5degree (P<0.028). The percent thrombus of the aortic neck was greater in female patients at 35.7% vs 30%(P=0.02). Preoperative AAA diameter was 5.8 in female and 5.5 in males (p=0.348). Abdominal aneurysm sacs were smaller in women at 1 year follow up (4.2cm vs. 5.1cm, P<0.002). In addition, although not statistically significant, reintervention rates post-EVAR for type 1 leaks were higher in men (3.5% vs. 0% P=0.27). Neck shape, changes in neck diameter, neck length, percent oversizing of graft where not significantly different between gender (table 1). Conclusions: Although female patients have more hostile aortic neck morphology compared to males, AAAs post-EVAR have acceptable sac regression and reintervention rates. Long term follow up is necessary to further validate findings

Evidence suggests that normal pressure hydrocephalus (NPH) is underdiagnosed in day to day radiologic practice, and differentiating NPH from cerebral atrophy due to other neurodegenerative diseases and normal aging remains a challenge. To better characterize NPH, we test the hypothesis that a prediction model based on automated MRI brain tissue segmentation can help differentiate shunt-responsive NPH patients from cerebral atrophy due to Alzheimer disease (AD) and normal aging. Brain segmentation into gray and white matter (GM, WM), and intracranial cerebrospinal fluid was derived from pre-shunt T1-weighted MRI of 15 shunt-responsive NPH patients (9 men, 72.6 +/- 8.0 years-old), 17 AD patients (10 men, 72.1 +/- 11.0 years-old) chosen as a representative of cerebral atrophy in this age group; and 18 matched healthy elderly controls (HC, 7 men, 69.7 +/- 7.0 years old). A multinomial prediction model was generated based on brain tissue volume distributions. GM decrease of 33 % relative to HC characterized AD (P < 0.005). High preoperative ventricular and near normal GM volumes characterized NPH. A multinomial regression model based on gender, GM and ventricular volume had 96.3 % accuracy differentiating NPH from AD and HC. In conclusion, automated MRI brain tissue segmentation differentiates shunt-responsive NPH with high accuracy from atrophy due to AD and normal aging. This method may improve diagnosis of NPH and improve our ability to distinguish normal from pathologic aging.

Purpose: A pilot study was performed to assess the feasibility of a single pass spiral technique to image the head and face, or head, face, and cervical spine in the emergency setting. Materials and Methods: 23 patients requiring emergency imaging of head, face and cervical spine, and 5 patients for head and face were enrolled. Radiation dose (DLP) was measured and compared with isolated CT head and face and cervical spine acquisitions. Time to perform the single spiral scan was also measured. The quality of spiral CT heads was compared with 21 consecutive trauma axial CT heads on a five point scale in a blinded fashion. Results: Average DLP for single spiral CT head, face, and cervical spine was 2581.24, compared with DLP of 2867.22 for these performed separately. Average DLP for single pass head and face (including mandible) CT was 1749.45, compared with standard 2 scan DLP of 1887.81. Time to scan a single pass CT head, face, and cervical spine ranged from 4.4 to 5.8 s. Quality of spiral head CTcomparedwith axial in trauma patients showed no significant difference. Conclusion: Single pass emergency CT head & face, and head, face, & cervical spine is both time and radiation efficient without reduction in image quality

OBJECTIVE: We proposed to characterize the radiologic spectrum of occipital condyle fractures in a large series of patients and to correlate fracture pathology with neurosurgical treatment and patient outcome. MATERIALS AND METHODS: We conducted a retrospective review of the findings on conventional radiography, CT, and MR imaging in 95 patients with 107 occipital condyle fractures. We described fracture patterns according to two previously published classification systems. Clinical findings, neurosurgical management, and patient outcome were obtained from the medical records. RESULTS: Inferomedial avulsions (Anderson and Montesano type III) were the most common type of occipital condyle fracture, constituting 80 (75%) of 107 overall fractures. Unilateral occipital condyle fractures were found in 73 (77%) of 95 patients, and 58 patients were treated nonoperatively; occipitocervical fusion was required in nine patients for complex C1-C2 injuries, and six patients died. Bilateral occipital condyle fractures or occipitoatlantoaxial joint injuries were seen in 22 (23%) of 95 patients. Occipitocervical fusion or halo traction for the craniocervical junction was required in 12 patients, all of whom had CT evidence of bilateral occipitoatlantoaxial joint disruption and six of whom showed normal craniocervical relationships on conventional radiographs. Six patients with nondisplaced fractures were treated nonoperatively, and four patients died. Thirty (32%) of 95 patients showed continued disability, whereas 55 (57.5%) of 95 patients had good outcomes at 1 month. Associated cervical spine injuries were present in 29 (31%) of 95 patients. CONCLUSION: Given their associated traumatic brain and cervical spine injuries, occipital condyle fractures are markers of high-energy traumas. That conventional radiographs alone may miss up to half of the patients with acute craniocervical instability has not been well established. Avulsion fracture type and fracture displacement are associated with both injury mechanism and the need for surgical stabilization. In this series, most unilateral occipital condyle fractures were treated nonoperatively, whereas bilateral occipitoatlantoaxial joint injuries with findings of instability usually required surgical stabilization