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Emergent aortography is commonly used to confirm and define a suspected thoracic aortic rupture detected by CT screening. We evaluated whether helical CT aortography can replace transcatheter aortography for critically injured patients.Over 22 months, 38 thoracic aorta and great vessel injuries were detected in 3229 patients with nontrivial blunt chest trauma who underwent helical CT screening. Planar, oblique, and curved two-dimensional reconstructions and three-dimensional shaded-surface display and maximum intensity projection volume-rendering techniques were used to evaluate the aortic injuries. Transcatheter aortography or surgery was performed in all stable patients.Twenty-eight of the injuries involved the descending thoracic aorta. All such injuries were best identified on axial images before CT angiography. CT angiography adequately showed tears over 15 mm long. Smaller tears required axial images for corroboration.Technically adequate axial helical CT detects and defines all injuries of the thoracic aorta. CT angiography supplements the conventional examination and can replace transcatheter aortography except for small tears or indeterminate studies.

To determine the effectiveness of helical computed tomography (CT) as a screening device to detect traumatic aortic rupture.Helical CT was used to examine 1,518 patients with nontrivial blunt trauma. Of these patients, 127 (8.37%) with abnormal CT scans of the mediastinum or aorta underwent thoracic aortography--89 patients solely for evaluation of mediastinal hematoma depicted at CT. Imaging abnormalities were correlated with surgical or clinical outcome.Twenty-one aortic injuries were identified that ranged from subtle intimal flaps to complete aortic disruption. Helical CT was more sensitive than aortography (100% versus 94.4%, respectively) but less specific (81.7% versus 96.3%, respectively) in detection of aortic injuries in patients who underwent both examinations. The association between CT findings and outcome was phi = 0.62 (chi2 = 49.1, 1 df, P.01) and between aortography and outcome was phi = 0.85 (chi2 = 92.2, 1 df, P.001). The P value of the difference between the phi coefficients was .10.Helical CT of the chest is effective for screening critically injured patients with possible blunt thoracic aortic injuries.

Solitary focal demyelination (SFD) in the brain is an uncommon and poorly understood disorder of uncertain etiology that may represent an intermediate entity between multiple sclerosis and acute disseminated encephalomyelitis. In a few reported cases of SFD, the patient was briefly noted to have a nonneurological malignancy. We studied two patients who had solitary focal lesions in the brain. Utilizing magnetic resonance imaging and tissue biopsy, we found the characteristics of the brain lesions in these two patients to be those of SFD. In our combined experience over the past 10 years, we have encountered no similar brain lesions at our medical center. We found it remarkable that both of these patients also had malignancy outside of the nervous system. One had a seminoma, and the other a lymphoma. We conclude that some cases of SFD in the brain may occur as a paraneoplastic disorder associated with nonneurological malignancies.

Factors that have been shown to affect outcome after acute subdural hematoma (ASDH) include age, Injury Severity Score (ISS), intracranial pressure (ICP), direct admission to a trauma center, presence of subarachnoid hemorrhage, score on the Glasgow Coma Scale (GCS), and timing of operation. However, these data come from selected patient populations (e.g., operated, comatose, or minimally symptomatic patients, etc.). In an effort to evaluate factors that predict outcome for the entire spectrum of ASDH patients, we evaluated 211 patients with ASDH and GCS scores of 3 to 15. One hundred twenty-eight patients (61%) were managed nonoperatively (Nonop), whereas 83 (39%) were managed with craniotomy [operatively (Op)]. Op patients had more severe brain injuries, as evidenced by their lower GCS scores (Op 7.8 vs. Nonop 10.7, p = 0.0001), higher incidence of large ASDH with midline shift (Op 61% large ASDH, 83% midline shift vs. Nonop 16% large ASDH, 30% midline shift, p = 0.001 for each comparison), and higher incidence of basilar cistern effacement (Op 61% vs. Nonop 21%, p = 0.001). Thirty-five percent of the Op patients had their hematoma evacuated within 4 hours (early), whereas 65% did not (delayed). Early Op patients had a significantly lower incidence of functional survival (early = 24% vs. delayed = 51%, p = 0.02). The early patients seem to have had more significant head injuries, as evidenced by their lower GCS scores (early = 7.0 vs. delayed = 8.4), higher incidence of associated intracranial injuries (early = 1.14 vs. delayed = 0.85), and higher incidence of cistern effacement (early = 76% vs. delayed = 53%, p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p.01), open cisterns (90% vs. 28%; p.001), and small (or = 1 cm) ASDHs (92% vs. 62%; p.001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.