✓ A 38-year-old man developed secondary adrenal insufficiency as a consequence of intrathecal methylprednisolone administration. Evidence in support of this diagnosis included an absent plasma cortisol response to insulin-induced hypoglycemia, an inadequate adrenal response to exogenous corticotropin stimulation, a typical delayed response to prolonged corticotropin infusion over 3 days, and the finding of an elevated level of prednisolone in the cerebrospinal fluid a full 2 months after its administration. It is therefore recommended that patients receiving intrathecal steroids be carefully observed for the possible development of secondary adrenal insufficiency.
Bart Chernow, Robert Vigersky, John T. O'Brian and Leon P. Georges
Ramesh Grandhi, Gregory M. Weiner, Nitin Agarwal, David M. Panczykowski, William J. Ares, Jesse S. Rodriguez, Jonathan A. Gelfond, John G. Myers, Louis H. Alarcon, David O. Okonkwo and Brian T. Jankowitz
Blunt cerebrovascular injuries (BCVIs) following trauma carry risk for morbidity and mortality. Since patients with BCVI are often asymptomatic at presentation and neurological sequelae often occur within 72 hours, timely diagnosis is essential. Multidetector CT angiography (CTA) has been shown to be a noninvasive, cost-effective, reliable means of screening; however, the false-positive rate of CTA in diagnosing patients with BCVI represents a key drawback. Therefore, the authors assessed the role of DSA in the screening of BCVI when utilizing CTA as the initial screening modality.
The authors performed a retrospective analysis of patients who experienced BCVI between 2013 and 2015 at 2 Level I trauma centers. All patients underwent CTA screening for BCVI according to the updated Denver Screening Criteria. Patients who were diagnosed with BCVI on CTA underwent confirmatory digital subtraction angiography (DSA). Patient demographics, screening indication, BCVI grade on CTA and DSA, and laboratory values were collected. Comparison of false-positive rates stratified by BCVI grade on CTA was performed using the chi-square test.
A total of 140 patients (64% males, mean age 50 years) with 156 cerebrovascular blunt injuries to the carotid and/or vertebral arteries were identified. After comparison with DSA findings, CTA findings were incorrect in 61.5% of vessels studied, and the overall CTA false-positive rates were 47.4% of vessels studied and 47.9% of patients screened. The positive predictive value (PPV) for CTA was higher among worse BCVI subtypes on initial imaging (PPV 76% and 97%, for BCVI Grades II and IV, respectively) compared with Grade I injuries (PPV 30%, p < 0.001).
In the current series, multidetector CTA as a screening test for blunt cerebrovascular injury had a high-false positive rate, especially in patients with Grade I BCVI. Given a false-positive rate of 47.9% with an estimated average of 132 patients per year screening positive for BCVI with CTA, approximately 63 patients per year would potentially be treated unnecessarily with antithrombotic therapy at a busy United States Level I trauma center. The authors’ data support the use of DSA after positive findings on CTA in patients with suspected BCVI. DSA as an adjunctive test in patients with positive CTA findings allows for increased diagnostic accuracy in correctly diagnosing BCVI while minimizing risk from unnecessary antithrombotic therapy in polytrauma patients.