Empyema

Empyema is a collection of pus in between the space of the lung and chest wall. It is an infection that spreads from the lungs and leads to a build up of fluid in the pleural space. Symptoms of this condition include chest pain, cough, dyspnea, fever, and sometimes weight loss.
Empyema has several possible causes but is most often is an associated complication of pneumonia.

There are three phases of empyema. The acute phase that fills the lung cavity with thin purulent fluid, second stage in which the fluid thickens, and then a third stage in which the lung is covered with a thick fibrous material. The third phase can only be cured with a thoracotomy to remove that thick fluid and scrape the lining of the lung of the fibrous material. In the earlier phases antibiotics or drainages can help clear the infection.

When this infection complicates pneumonia it raises the risk of death and permanent damage to lung tissue significantly. But, with long term antibiotic therapy and drainages the patient most often recovers.

Kyphoplasty for compression fractures of thoracic spine

When particular patients are assessed after a spinal fracture and meet certain guidelines, their physician may recommend a procedure called kyphoplasty. These patients usually have a pathologic fracture or a fracture due to osteoporosis. Osteoporosis weakens the bone and makes the simplest fall or cough a major problem.

The goal of this procedure is to help relieve pain from the spine due to fracture and to stabilize the spine as well. The other goal is to return loss of height to the vertebral body.

The exam is usually done in a Special Procedures lab or an OR setting. The physician will insert a balloon into the vertebrae and inject a special filler that is a hard cement like material that expands. This assists with the bone height loss due to the compression fracture. After the procedure is over many patients immediately feel relief. To document the placement a CT scan is done post procedure. I've attached some images of a pre kyphoplasty patient with a t12 compression fracture and then the same patient's post exam.

Burst Fractures

Burst fractures most often occur in the thoracolumbar spine, around T-11 through L2. Burst fractures are usually the result of some sort of trauma to the spine such as a motor vehicle accident or fall. These fractures can occur in patients of any age. Treatment does vary for these injuries. Neurosurgeons will evaluate images from CT and MRI. If the patient is not paralyzed and has no significant canal compromise then normally a brace is in order for the patient. The physician will monitor healing by obtaining lateral radiographs of the fracture sight to document healing. If patient has paralysis that is not resolving with canal compromise, then surgery to decompress the stenosis will need to be performed. I have attached some CT images demonstrating this deformity.

Cervical disc bulge

We received a 61 y/o male through the emergency room for a CT cervical spine among everything else ordered. He was alert and orientated and was responding to questions. However, he had tingling sensation to the nipple line, but was unable to feel anything from that point down. He suffered a 4 foot fall from a truck bed.



The exam was performed and it was noted that he had a significant C-3 fracture with significant offset. All other imaging studies were negative. After a short time in the emergency room, the patient's respiratory effort declined significantly and had to be intubated.





The following day a CT cervical myelogram was ordered. An attempt by the Radiologist was made, but due to equipment and patient condition a blind stick by the Neurosurgeon in the ICU was performed. The patient then returned to the CT suite to have post images performed.

I've attached the reformats performed and it shows a moderate to severe disc bulge. This certainly can be causing his paralysis.

Neurosurgeon re-evaluated patient and states he is ineligible for MRI due to pain stimulator implant. He will give the patient another day to recover and see him again to evaluate stability with flexion and extension movements. He also states that he has cord contusion that can resolve with some time.

Due to the numbness/tingling and inability to feel past that point the ED physician felt certain that there was a spine injury. These injuries can resolve on their own or often require surgery to assist healing.

Carotid Stenosis and Strokes

Carotid stenosis is a narrowing of the artery due to a build up of plaque. The carotid arteries are what feeds the brain. When there is a major stenosis or plaque build up it can cause an ischemic stroke, the most common stroke diagnosed.

Stroke symptoms range from weakness in extremities, slurred speech, headache, facial droop, and trouble with gait among others. To evaluate a patient for a stroke, normally a routine CT head is done to rule out a bleed. Once this is negative, a carotid ultrasound may be ordered. Oftentimes now, a CTA head and neck is ordered from the ER. When a CTA is performed it is specifically looking at the vessels. Stenosis can be determined with precision accuracy rather than traditional angiography which is more invasive and carries some additional risks.

Treatment for this condition depends on the results but ranges from medication to surgery. The most important rule for stroke is early intervention.

The picture at the left top shows an ICA with near total occlusion.

The picture at left bottom shows carotid stenosis which is the dark spot by the area.

Malignant Parotid Tumor

Malignant tumors of the parotid gland are actually quite rare. They occur at a rate of 1-2 cases per 100,000. These tumors occur in slightly more women than men and also have a higher rate of incidence in the Eskimo population. Mortality will depend on the characteristic of the tumor and the stage of the tumor. Some tumors are slow growing and just need to be watched and others are very agressive and require surgery. Sometimes these tumors can grow back. Pain is not necessarily an indicator that this tumor is malignant, but it can be an indicator of progression in a patient diagnosed with a malignancy.

Most tumors affect adults aged 30-70, but vary in stages and malignancy. Tumors that do occur in children have a much higher incidence of malignancy, around 35%.

CT and MRI are both imaging modalities of choice for these tumors for different reasons. CT will best demonstrate the inflammatory, recurrent mass and MRI is best for those masses that are not painful. These tests combined with a fine needle aspiration to determine cellular structure will diagnose this condition with near precision accuracy.

CTA versus conventional angiogram or DSA in diagnosing aneurysms

The picture at the left is a right middle cerebral saccular aneurysm demonstrated on an MRA. The above picture is a great comparison of a CTA image of a rt posterior inferior cerebral aneurysm and then the same on a DSA image. The DSA image is the conventional angiographic approach to diagnosis. CTA, computed tomography angiography, has nearly replaced traditional angiography in many cases. CTA is faster and non-invasive, whereas angiography carries more risk. There is a femoral stick and often sedation for the patient. More cost is involved as well. A physician must perform this exam. It is also a slower process with some recovery time involved. Physicians most often are turning to CTA first as a guide to finding the answers they need. This has not removed the need for MRA, however. Most neurosurgeons require both a CTA and a MRA pre-op to ensure all their bases are covered.

There was a study published in the Open Neurology Journal in January 2009 regarding the efficacy of CTA vs traditional approaches. They looked at how effective CTA was in pre-operative planning. They found that 72% of the cases CTA was the best imaging quality to define the aneurysm. There were no cases that DSA demonstrated aneurysms that CTA simply missed. They only significant reason for performing the DSA was simply for blood flow demonstration.

I think this study definitely makes the case for CTA and I think with the advent of more platforms such as Vitrea and Tera Recon and upgrades, our reformats will just get better.

Susan Brumley