COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

71 The Use of Sternocleidomastoid Rotational and Cervicofacial Advancement Flap for Closure of a Persistent Mastoid Cutaneous Fistula

Introduction

Postauricular mastoid fistula is a rare occurrence, typically following repeated soft tissue injury, commonly caused by chronic suppurative otitis media and repeated surgical treatments. Management is challenging with a limited number of reported, successful surgical techniques, which often have limited applicability.

Case report

We present a case of a 55-year-old male patient with a persistent right post-auricular cutaneous mastoid fistula as a result of two previous mastoidectomies. Although the patient underwent two simple primary closures, the fistula recurred. This was successfully treated with a new technique utilising a Sternocleidomastoid Rotational and Cervicofascial Advancement Flap which was completely healed at the 1-year follow-up without a recurrence of the fistula.

Conclusions

This novel technique provided a definitive obliteration of a persistent cutaneous mastoid fistula. By utilising a double layered flap, via a facelift incision, the flap results in an excellent functional and cosmetic result.

Diagnostic decision-making tool for imaging term neonatal bowel obstruction

Term neonatal bowel obstruction is common, and absence of treatment is potentially catastrophic. There is a relatively narrow differential diagnosis, with causes categorised as either low or high bowel obstruction. The commonest causes of low bowel obstruction include anorectal malformations (ARM), Hirschsprung's disease, ileal atresia, meconium ileus, meconium plug, and colonic atresia. The commonest causes of high bowel obstruction include duodenal atresia, duodenal stenosis/web, jejunal atresia, and malrotation with volvulus (and hypertrophic pyloric stenosis usually presenting in slightly older infants). Diagnosis can be decided using a step-wise binary decision tool that includes the appropriate imaging steps and evaluation of bowel calibre. This paper presents the decision-making tool from the presenting features, through plain radiographic findings and, where necessary, the additional radiological investigations to assist the general radiologist, novice paediatric radiologist and paediatric surgeon. The tool is pictorial, with the radiological findings accompanied by eight schematics, serving as a simplified visual aid for memorizing the imaging patterns of the differential diagnosis. The imaging and decision-making steps allow for a rapid, simplified diagnosis that can benefit patients by recommending when to perform surgery, when to perform further imaging, and when imaging can act in a therapeutic manner.

Use of a sternocleidomastoid rotational and cervical-fascial advancement flap for closure of a persistent mastoid cutaneous fistula

BACKGROUND

Post-auricular mastoid fistula is a rare occurrence. It typically appears following repeated soft tissue injury, and is commonly caused by chronic suppurative otitis media and repeated surgical treatments. Management is challenging, with few reported successful surgical techniques, which often have limited applicability.

CASE REPORT

This paper presents the case of a 58-year-old male with a persistent right-sided post-auricular cutaneous mastoid fistula resulting from two previous mastoidectomies. Although the patient underwent two simple primary closures, the fistula recurred. This was successfully treated with a new technique utilising a sternocleidomastoid rotational and cervical-fascial advancement flap, which was completely healed at the one-year follow up without a recurrence of the fistula.

CONCLUSION

This novel technique provided definitive obliteration of a persistent cutaneous mastoid fistula. Utilising a double-layered flap and a facelift incision results in excellent functional and cosmetic outcomes.