Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint

BACKGROUND

Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget).

PURPOSE

In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury.

STUDY DESIGN

This was a prospective cohort study.

METHODS

Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five.

RESULTS

Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Assessing Diagnostic Accuracy of Four-dimensional CT for Instable Scapholunate Dissociation: The Prospective ACTION Trial

Background Timely treatment of scapholunate instability depends on early identification, but current imaging methods are either intricate or fail to demonstrate the dynamic stages. Purpose To calculate the diagnostic accuracy of four-dimensional (4D) CT for diagnosing instable scapholunate ligament (SLL) tears. Materials and Methods This prospective study enrolled consecutive participants with clinically suspected SLL tears who underwent 4D CT from July 2020 to May 2022. A historical study sample diagnosed at cineradiography served as a comparison, and wrist arthroscopy was the reference standard. Scapholunate joints greater than 3 mm were interpreted as instable at index 4D CT and cineradiography. Diagnostic accuracy was expressed as sensitivity and specificity. Areas under the receiver operating characteristic curve and cutoff values for both index tests were calculated. Intraclass correlation coefficients (ICCs) were computed to compare interrater reliability. Effective radiation doses at 4D CT were measured with thermoluminescent dosimeters. Results The study included 40 participants (mean age, 43 years ± 14 [SD]; 24 male) evaluated at 4D CT and 78 patients (mean age, 45 years ± 11; 50 male) historically evaluated at cineradiography. Four-dimensional CT helped detect instable tears in 26 of 35 participants (sensitivity, 74.3% [95% CI: 56.7, 87.5]. Cineradiography revealed instable tears in 52 of 63 patients (sensitivity, 82.5% [95% CI: 70.9, 91]). Four of five participants with stable scapholunate joints were identified at 4D CT (specificity, 80.0% [95% CI: 28.4, 99.5]), and 12 of 15 patients with stable SLLs were identified at cineradiography (specificity, 80.0% [95% CI: 51.9, 95.7]). Interrater agreement of radiologic measurements on 4D CT scans was good to excellent (ICC range, 0.89-0.96). The effective radiation dose ranged from 67 to 72 mSv at the wrist and was less than 1 mSv at the head. Conclusion Four-dimensional CT results are highly reproducible. Instable scapholunate joints greater than 3 mm were detected with a sensitivity of 74.3% and a specificity of 80% in an exploratory trial. Further evidence from larger randomized trials is warranted. German Register for Clinical Trials no. DRKS00021110 (Universal Trial Number U1111-1249-7884) Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Demehri and Ibad in this issue.

Cervical spine fracture detection in computed tomography using convolutional neural networks

OBJECTIVE

&#xD;In the context of primary in-hospital trauma management timely reading of computed tomography (CT) images is critical. However, assessment of the spine is time consuming, fractures can be very subtle, and the potential for under-diagnosis or delayed diagnosis is relevant. &#xD;Artificial intelligence is increasingly employed to assist radiologists with the detection of spinal fractures and prioritization of cases.&#xD;Currently, algorithms focusing on the cervical spine are commercially available.&#xD;A common approach is the vertebra-wise classification.&#xD;Instead of a classification task, we formulate fracture detection as a segmentation task aiming to find and display all individual fracture locations presented in the image.\\ &#xD;Approach:&#xD;Based on 195 CT examinations, 454 cervical spine fractures were identified and annotated by radiologists at a tertiary trauma centre. &#xD;We trained for the detection a U-Net via 4-fold-cross validation to segment spine fractures and the spine via a multi-task loss. &#xD;We further compared advantages of two image reformation approaches - straightened curved planar reformatted (CPR) around the spine and spinal canal aligned volumes of interest (VOI) - to achieve a unified vertebral alignment in comparison to processing the Cartesian data directly.&#xD;Main results:&#xD;Of the three data versions (Cartesian, reformatted, VOI) the VOI approach showed the best detection rate and a reduced computation time. The proposed algorithm was able to detect 87.2\% of cervical spine fractures at an average number of false positives of 3.5 per case. Evaluation of the method on a public spine dataset resulted in 0.9 false positive detections per cervical spine case. &#xD;Significance:&#xD;The display of individual fracture locations as provided with high sensitivity by the proposed voxel classification based fracture detection has the potential to support the trauma CT reading workflow by reducing missed findings. &#xD.

Whole-Body Magnetic Resonance Tomography and Whole-Body Computed Tomography in Pediatric Polytrauma Diagnostics-A Retrospective Long-Term Two-Center Study

Although serious accidents remain the leading cause of pediatric mortality, protocols to orient diagnostic procedures towards a certain type of initial imaging are widely needed. Since 2007, we have performed whole-body magnetic resonance imaging (WBMR) and whole-body computed tomography (WBCT) for diagnoses of severely injured children. We retrospectively reviewed 134 WBMR and 158 WBCT in patients younger than 16 years that were performed at two trauma centers between 2007 and 2018. A higher Injury Severity Score (ISS) was found in WBCT vs. WBMR (10.6 vs. 5.8; p = 0.001), but without any significant difference in mortality. The WBMR was significantly preferred at younger ages (9.6 vs. 12.8 years; p < 0.001). The time between patient's arrival until diagnosis was 2.5 times longer for WBCT (92.1 vs. 37.1 min; p < 0.001). More patients in the CT group received analgesic sedation and/or intubation at 37.3% vs. 21.6% in the MRI group. Of these patients, 86.4% (CT) and 27.6% (MRI) were already preclinically sedated (p < 0.001). Correspondingly, 72.4% of the patients were first sedated in-hospital for MRIs. In conclusion, WBMR is an alternative and radiation-free imaging method for high-energy-traumatized children. Although the selected diagnostics seemed appropriate, limitations regarding longer duration or additional analgesic sedation are present, and further studies are needed.

Superselective Catheter Angiographies of the Wrist (SCAW): Approaches for Vascularized Bone Grafts

Background: This study assesses the variability of the palmar radiocarpal artery (PRCA), dorsal carpal branch of the ulnar artery (DCBUA), and anterior interosseous artery (AIA) in superselective catheter angiographies of the wrist (SCAW). Methods: Secondary analysis of consecutive SCAW (2009-2011). Measurements of the distances of the PRCA to the midface of the radiocarpal joint, the DCBUA to the styloid process of the ulnar, and maximum diameters of PRCA, DCBUA, and AIA. Results: Seven female and ten male patients (mean 35 years) received SCAW. All patients suffered from Kienbock's disease. The mean distance from the PRCA to the radiocarpal joint was 7.9 ± 2.3 mm and the distance from the DCBUA to the styloid process of the ulna was 29.6 ± 13.6 mm. The mean maximum diameter of the PRCA was 0.6 ± 0.2 mm, that of the DCBUA was 1.1 ± 0.4 mm, and that of the AIA 1.2 ± 0.3 mm. In six cases (35%), all three arteries contributed to the PRCA; in eight cases (47%), the radial and AIA; in two cases (12%), the radial and ulnar artery; and in one case (6%), only the radial artery contributed. Conclusions: SCAW are feasible to assist in preoperative planning. Os pisiforme transfer with DCBUA might be the best choice for a vascular bone graft in Kienbock's disease.

Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial

Background

Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial.

Methods

MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway.

Discussion

The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH.

Trial registration

German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.

Quality Assurance of a Cross-Border and Sub-Specialized Teleradiology Service

Background: The current literature discusses aspects of quality assurance (QA) and sub-specialization. However, the challenges of these topics in a teleradiology network have been less explored. In a project report, we aimed to review the development and enforcement of sub-specialized radiology at Telemedicine Clinic (TMC), one of the largest teleradiology providers in Europe, and to describe each step of its QA. Evaluation: The company-specific background was provided by the co-authors—current and former staff members of TMC. Detailed descriptions of the structures of sub-specialization and QA at TMC are provided. Exemplary quantitative evaluation of caseloads and disagreement rates of secondary reviews are illustrated. Description of Sub-specialization and Quality Assurance at TMC: Sub-specialization at TMC is divided into musculoskeletal radiology, neuroradiology, head and neck, a body, and an emergency section operating at local daytime in Europe and Australia. Quality assurance is based on a strict selection process of radiologists, specific reporting guidelines, feedback through the secondary reading of 100% of all radiology reports for new starters, and a minimum of 5% of radiology reports on a continuous basis for all other radiologists, knowledge sharing activities and ongoing training. The level of sub-specialization of each radiologist is monitored continuously on an individual basis in detail. After prospective secondary readings, the mean disagreement rate at TMC indicating at least possibly clinically relevant findings was 4% in 2021. Conclusion: With continuing and current developments in radiology in mind, the essential features of sub-specialization and innovative QA are relevant for further expansion of teleradiology services and for most radiology departments worldwide to respond to the increasing demand for value-based radiology.

Obstacles and Solutions Driving the Development of a National Teleradiology Network

Background: Teleradiology has the potential to link medical experts and specialties despite geographical separation. In a project report about hospital-based teleradiology, the significance of technical and human factors during the implementation and growth of a teleradiology network are explored. Evaluation: The article identifies major obstacles during the implementation and growth of the teleradiology network of the Berlin Trauma Hospital (BG Unfallkrankenhaus Berlin) between 2004 and 2020 in semi-structured interviews with senior staff members. Quantitative analysis of examination numbers, patient numbers, and profits relates the efforts of the staff members to the monetary benefits and success of the network. Identification of qualitative and quantitative factors for success: Soft and hard facilitators and solutions driving the development of the national teleradiology network are identified. Obstacles were often solved by technical innovations, but the time span between required personal efforts, endurance, and flexibility of local and external team members. The article describes innovations driven by teleradiology and hints at the impact of teleradiology on modern medical care by relating the expansion of the teleradiology network to patient transfers and profits. Conclusion: In addition to technical improvements, interpersonal collaborations were key to the success of the teleradiology network of the Berlin Trauma Hospital and remained a unique feature and selling point of this teleradiology network.

Deep learning algorithm in detecting intracranial hemorrhages on emergency computed tomographies

BACKGROUND

Highly accurate detection of intracranial hemorrhages (ICH) on head computed tomography (HCT) scans can prove challenging at high-volume centers. This study aimed to determine the number of additional ICHs detected by an artificial intelligence (AI) algorithm and to evaluate reasons for erroneous results at a level I trauma center with teleradiology services.

METHODS

In a retrospective multi-center cohort study, consecutive emergency non-contrast HCT scans were analyzed by a commercially available ICH detection software (AIDOC, Tel Aviv, Israel). Discrepancies between AI analysis and initial radiology report (RR) were reviewed by a blinded neuroradiologist to determine the number of additional ICHs detected and evaluate reasons leading to errors.

RESULTS

4946 HCT (05/2020-09/2020) from 18 hospitals were included in the analysis. 205 reports (4.1%) were classified as hemorrhages by both radiology report and AI. Out of a total of 162 (3.3%) discrepant reports, 62 were confirmed as hemorrhages by the reference neuroradiologist. 33 ICHs were identified exclusively via RRs. The AI algorithm detected an additional 29 instances of ICH, missed 12.4% of ICH and overcalled 1.9%; RRs missed 10.9% of ICHs and overcalled 0.2%. Many of the ICHs missed by the AI algorithm were located in the subarachnoid space (42.4%) and under the calvaria (48.5%). 85% of ICHs missed by RRs occurred outside of regular working-hours. Calcifications (39.3%), beam-hardening artifacts (18%), tumors (15.7%), and blood vessels (7.9%) were the most common reasons for AI overcalls. ICH size, image quality, and primary examiner experience were not found to be significantly associated with likelihood of incorrect AI results.

CONCLUSION

Complementing human expertise with AI resulted in a 12.2% increase in ICH detection. The AI algorithm overcalled 1.9% HCT.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00023593).

Comparison of Calculated Skin Doses in Cineradiography and Four Dimensional Kinematic Computed Tomography of the Wrist

Background: Previous studies have discussed the diagnostic value of four dimensional kinematic CT in cases of carpal instabilities. This analysis compares calculated skin doses of 4D CT and conventional cineradiography of the wrist in cases of suspected SLL rupture. Methods: Retrospective calculation and interpolation of skin doses and effective doses for ten consecutive 4D CT examinations and 41 cineradiographies for suspected lesions of the scapholunate ligament. Standardised anterior-posterior and lateral cine sequences using a flat-panel digital subtraction imager and of 4D kinematic CT using a dual-source scanner were acquired and acquisition parameters recorded. We tested if the skin dose of 4D CT is different from cineradiography. Results: Median dose area product (DAP) of cineradiography was 135.34 cGycm² resulting in a calculated median skin dose of 32.6 mSv (confidence interval 26.86-42.90 mSv) and an estimated effective skin dose of 3.26 µSv. CT dose index (CTDI) for 4D examinations was recorded to be 26.79 mGy and the dose-length product (DLP) was 150 mGy × cm. This resulted in an estimated skin dose of 34 mSv, which is covered by the confidence interval of cineradiography, and an effective skin dose of 3.4 µSv. Conclusions: Skin dose calculations are comparable for 2D cineradiography in two plains and 4D kinematic CT of the wrist. Calculated effective doses are < 0.01 mSv.

[Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?]

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

BACKGROUND

To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries.

METHODS

Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1-2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate.

RESULTS

Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence.

CONCLUSION

Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably.

TRIAL REGISTRATION

The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment

BACKGROUND

We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma.

METHODS

Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses.

RESULTS

We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later.

CONCLUSIONS

The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious.

LEVEL OF EVIDENCE

III.

Increase of weight-bearing capacity of patients with lesions of the TFCC using a wrist brace

STUDY DESIGN

Retrospective cross-sectional case series.

BACKGROUND

Lesions of the triangular fibrocartilage complex (TFCC) can result in pain during axial load and unstable distal radioulnar joint (DRUJ). Conventional wrist orthoses decrease initial pain sufficiently but also prevent any movement during recovery and do not contribute to the stabilization of the DRUJ.

PURPOSE

In this retrospective analysis, we tested if the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex was increased by wearing a brace that stabilizes the distal radioulnar joint.

METHODS

Twenty-three patients had an arthroscopically confirmed TFCC lesion. We compared preoperative dynamic weight-bearing capacity of both hands with and without a commercially available wrist brace (WristWidget). Subgroup analysis was performed for stability of the distal radioulnar joint and etiology of the TFCC lesion. The dynamic ulnar variance was measured in a modified weight bearing test. We used parametric tests for normally distributed values.

RESULTS

The weight-bearing capacity of the hand with TFCC lesion was significantly lower than of the control hand (16 verus 36 kg; p <0.001). The relative load of the affected hand compared to the unaffected hand increased from 48 % (CI 37-60, SD 27) to 59 % (CI 47-72, SD 29 with a brace. The device had no effect on the control hand. Twelve patients with unstable DRUJ had a lower weight-bearing capacity compared to the eleven with stable joint. The percentage improvement with bracing was higher for those with unstable joints (versus stable) and traumatic lesions (versus degenrative).

CONCLUSION

The use of a wrist brace significantly increases the weight-bearing capacity and therefore the maximum tolerated axial load of patients with a lesion of the TFCC. Patients with traumatic lesion or unstable DRUJ tend to show lower values than with degenerative lesions or stable joints.

ACTION trial: a prospective study on diagnostic Accuracy of 4D CT for diagnosing Instable ScaphOlunate DissociatioN

Background

Early detection of scapholunate ligament (SLL) tears is essential after minor and major trauma to the wrist. The differentiation between stable and instable injuries determines therapeutic measures which aim to prevent osteoarthritis. Arthroscopy has since been the diagnostic gold standard in suspected SLL tears because non-invasive methods have failed to exclude instable injuries reliably. This prospective study aims to determine the diagnostic accuracy of dynamic, 4D computed tomography (CT) of the wrist for diagnosing instable SLL tears.

Methods

Single center, prospective trial including 40 patients with suspected SLL tears scheduled for arthroscopy. Diagnostic accuracy of 4D CT will be tested against the reference standard arthroscopy. Radiologists will be blinded to the results of arthroscopy and hand surgeons to radiological reports. A historical cohort of 80 patients which was diagnosed using cineradiography before implementation of 4D CT at the study site will serve as a comparative group.

Discussion

Static imaging lacks the ability to detect instable SLL tears after wrist trauma. Dynamic methods such as cineradiography and dynamic magnetic resonance imaging (MRI) are complex and require specific technical infrastructure in specialized centers. Modern super-fast dual source CT scanners are gaining popularity and are being installed gradually in hospitals and ambulances. These scanners enable dynamic imaging in a quick and simple manner. Establishment of dynamic 4D CT of the wrist in patients with suspected SLL tears in in- and outpatient settings could improve early detection rates. Reliable identification of instable injuries through 4D CT scans might reduce the number of unnecessary diagnostic arthroscopies in the future.

Trial registration

This study was registered prospectively at the German Clinical Trials Register (DRKS) DRKS00021110. Universal Trial Number (WHO-UTN): U1111–1249-7884.

What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears?

BACKGROUND

Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported.

QUESTIONS/PURPOSES

(1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method?

METHODS

This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices.

RESULTS

The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol.

CONCLUSION

Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study

OBJECTIVES

Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods.

MATERIALS AND METHODS

Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed.

RESULTS

Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg.

CONCLUSION

ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.

Unique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers

OBJECTIVE

 To describe unique indications for covered stent grafts in trauma-associated cerebrovascular injuries.

PATIENTS

 Between 2006 and 2018, five patients with cerebrovascular injuries were treated with a covered stent graft. We present a retrospective analysis of technique and outcomes.

RESULTS

 In all cases stent deployment was successful. Endoleaks occurred in two cases requiring additional transvenous embolization of a carotid cavernous fistula (CCF) in one patient. Two cases of in-stent thrombosis were observed during intervention and 2 days postintervention in a patient with a long-segment dissection of the internal carotid artery (ICA) and another patient with a contained ICA rupture, both of which could not be prepared with dual antiplatelet therapy. Intravenous heparin and intra-arterial tirofiban dissolved in-stent thrombosis efficiently. One CCF and an iatrogenic vertebral artery injury were covered adequately with GraftMaster stent grafts.

CONCLUSION

 Patient selection with regard to individual anatomy and the site of vascular lesions is essential for an uncomplicated deployment of covered stent grafts and the success of therapy. Management of dual antiplatelet therapy, anticoagulation, and an escalation of medication in cases of in-stent thrombosis require expertise, a strict therapeutic regime, and an evaluation of individual risks in polytraumatized patients.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).

Pre-conditioning with synthetic CpG-oligonucleotides attenuates myocardial ischemia/reperfusion injury via IL-10 up-regulation

The aim of the study was to investigate whether pre-conditioning with CpG-oligodeoxynucleotides (CpG-ODN) may change cardiac ischemia/reperfusion (I/R)-dependent inflammation and modulates infarct size and cardiac performance. WT and TLR9-deficient mice were pre-treated with 1668-, 1612- and H154-thioate or D-Gal as control. Priming with 1668-thioate significantly induced inflammatory mediators in the serum and a concomitant increase of immune cells in the blood and spleen of WT mice. Furthermore, it induced myocardial pattern recognition receptors and pro-inflammatory cytokines peaking 2 h after priming and a continuous increase of IL-10. 16 h after pre-conditioning, myocardial ischemia was induced for 1 h. Infarct size determined after 24 h of I/R was reduced by 75 % due to pre-conditioning with 1668-thioate but not in the other groups. During reperfusion, cytokine expression in 1668-thioate primed mice increased further with IL-10 exceeding the other mediators by far. These changes were observed neither in animals pre-treated with 1612- or H154-thioate nor in TLR9-deficient mice. The 1668-thioate-dependent increase of IL-10 was further supported by results of a micro-array analysis 3 h after begin of reperfusion. Block of IL-10 signaling increased I/R size and prevented influence of priming. In the group pre-treated with 1668-thioate, cardiac function was preserved 24 h, 14 days and 28 days after I/R, whereas animals without pre-conditioning exhibited impaired heart function 24 h and 14 days after I/R. The excessive 1668-thioate-dependent IL-10 up-regulation during pre-conditioning and after I/R seems to be the key factor for reducing infarct size and improving cardiac function. This is in agreement with the finding that IL-10 block prevents cardioprotection by pre-conditioning.

Endoscopic Treatment of Isolated Fourth Ventricle

BACKGROUND:

Treatment of an isolated fourth ventricle should be considered when clinical symptoms or a significant mass effect occur.

OBJECTIVE:

To report clinical and radiographic outcomes after endoscopic transaqueductal or transcisternal stent placement into the fourth ventricle.

METHODS:

In 19 patients (age, 34th week of gestation-20 years; median age, 17.5 months), 22 endoscopic procedures were performed. Either an aqueductoplasty or, in cases with a supratentorially extended fourth ventricular component, an interventricular fenestration was performed. In all patients, a stent connected to the cerebrospinal fluid--diverting shunt was placed through the fenestration. Surgical complications and radiological and clinical outcomes are reported.

RESULTS:

All 19 patients had a mean follow-up of 26.9 ± 18.2 months. No persisting neurological complications were observed; 27.3% of patients experienced complete resolution of presenting symptoms, whereas 68.3% demonstrated partial resolution. Symptoms with short duration (&lt; 4 weeks) resolved completely, whereas long-standing symptoms partially improved. Short-term shunt complications (n = 2; insufficient catheter placement and subdural hygroma) and a need for long-term stent revisions (n = 3; stent retraction and shunt revision for other causes) were observed. The mean fourth ventricular volume was reduced after surgery (44.2 ± 25.8 to 23.1 ± 21.9 mL; P &lt; .01). Pontine diameter increased from 0.9 ± 0.3 to 1.2 ± 0.3 cm (P &lt; .01) after surgery. Both effects were still demonstrated on later radiological follow-up of 24.4 ± 14.2 months (fourth ventricular size, 24.7 ± 28.1 mL; P &lt; .01; pontine diameter, 1.3 ± 0.3 cm; P &lt; .01).

CONCLUSION:

The clinical and radiological outcomes after endoscopic aqueductoplasty and interventriculostomy in children with an isolated fourth ventricle indicate that this procedure is feasible, effective, and safe.