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Endovascular treatment of three hundred consecutive middle cerebral artery aneurysms: clinical and radiological outcomes
Abstracts / Clinical Radiology 68 (2013) S1eS7
complications and if the risk can be minimized by performing common femoral endarterectomy at the at the time of the surgical cut down. Review of general practitioner direct access referrals for lumbar spine MRI Authors: Christopher Watura, Steven James Purpose: GPs are increasingly given access to MRI. This is expected to accelerate following GP commissioning of secondary care. We assessed appropriateness and completeness of GP lumbar spine MRI requests. Methods: Retrospective review of data from an NHS Trust and regional centre for spine surgery. All lumbar spine MRI referrals between MarchJune 2012 were retrieved. Only those from GPs were included. Paediatric and follow-up cases were excluded. One hundred cases were randomly selected and assessed against RCR and NICE guidelines. Results: Patient age range 18-89 (mean 52) years, 61%(61/100) female. Sixty-five percent (65/100) referrals met indications for lumbar spine MRI, of which 25%(16/65) were red flags. MRI not indicated in 35%(35/100). Ninety-seven percent (97/100) request forms provided some symptom information, 33%(33/100) omitted symptom duration. No clinical examination given in 73%(73/100). No diagnostic question asked in 50%(50/100). Forty-two percent (42/100) of reports consistent with referral, 5%(5/100) positive findings unrelated to referral, 41%(41/100) degenerative changes only, 12%(12/100) negative findings. Conclusion: There is need to increase GP awareness of indications for lumbar spine imaging, information required on request forms, and limitations of MRI in investigating back pain. There is a potential role for request form pro forma, and triage systems or an intermediary service to exclude inappropriate referrals. Trauma CT scanning; is there an awareness of the ionising radiation involved? Authors: David Roberts, Emma Rowbotham, Sophie Dennis Purpose: The inclusion of a ‘whole body’ or trauma CT in the pathway of a multiply injured patient has been shown to significantly increase the survival rate. A potential risk however is the radiation involved. Many junior doctors will work in departments encountering such patients, being involved in decisions and requests for trauma CT’s. The Royal College of Radiologists’ undergraduate curriculum states graduates should recognise ionising radiation can be harmful, patients should be involved in decision making and if appropriate, consent should be gained for investigations. Methods: 52 post final examinations medical students/junior doctors completed a questionnaire regarding knowledge of trauma CT scans and associated ionising radiation. Results: Only 19 (37%) participants could identify any unit of radiation. Estimated doses of radiation of a trauma CT scan, ranged from 6 to 10,000 gray. 33 (63%) participants were ‘not confident at all’ to discuss the radiation dose and potential risks of trauma CT imaging, with 5 (10%) participants not aware of any risks associated with radiation. Conclusion: This study demonstrates many current and future junior doctors are not aware of the ionising radiation involved in trauma CT’s and do not feel confident in discussing radiation doses. Although there is a clear undergraduate curriculum, this study suggests the need for strengthening the clinical application of education in this area. Endovascular treatment of three hundred consecutive middle cerebral artery aneurysms: clinical and radiological outcomes Authors: Alex Mortimer, Marcus Bradley, Shelley Renowden Purpose: There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series treated at our centre. Methods: This was a retrospective analysis of a prospectively acquired database, supplemented by case note review. All patients with MCA aneurysms treated between November 1996 and June 2012 were included.
S5
WFNS grade, aneurysm site, size and neck morphology were recorded, along with clinical outcome assessed with Glasgow Outcome Score and radiographic occlusion assessed using the Raymond classification at 6 months and 2 years. Results: 295 patients with 300 MCA aneurysms were treated including 242 (80.7%) ruptured aneurysms. Complete or near complete occlusion was achieved in 91%. The technical failure rate was 3.3%. Complications included rupture (4.3%), thrombo-embolism (5.7%) and early re-bleeding (1%). Overall permanent procedural-related morbidity and mortality was 9%. Of the ruptured aneurysms, 79% had a favourable clinical outcome (GOS 4-5). 32 patients (13%) died. On angiographic follow-up, significant recurrence was seen in 18 aneurysms (8.1%). 13 (4.3%) patients were retreated. Conclusion: Our experience demonstrates that endovascular treatment of MCA aneurysms is safe with low rates of technical failure, complications and re-treatment. Therefore coiling is acceptable as the primary treatment for MCA aneurysms. Whatever happened to the sphenoid sinus level in head trauma? Authors: Jonathan Rodrigues, Matthew Seager, Hyeladzira Thahal, Nick Ridley Purpose: A horizontal beam, brow-up lateral skull radiograph was once commonplace in head trauma. A sphenoid sinus effusion suggested blood or cerebrospinal fluid and increased the suspicion of more severe intracranial injury. This study has been superseded by CT. We aimed to determine the relevance of this sign in the modern CT era. Methods: 100 consecutive emergency department CT(head) for trauma were retrospectively reviewed for sphenoid sinus opacification (SSO) and CT evidence of trauma (intra/extra axial haemorrhage and/or fracture). Where SSO was present, its mean attenuation was measured. Using CT findings as gold standard, sensitivity (SN), specificity (SP), positive (PPV) and negative predictive values (NPV) of SSO as a predictor of intracranial injury were determined. Results: SSO was present in 7/100. 28.6% (2/7) of these had CT evidence of trauma (SN ¼ 25.0%, SP ¼ 94.6%, PPV ¼ 28.6% & NPV ¼ 93.5%). In comparison, 6.5% (6/93) of cases without SSO had evidence of trauma. When SSO with mean attenuation >60 HU (presumed blood) was used, specificity, NPV and PPV increased (SN ¼ 25.0%, SP ¼ 97.8%, PPV ¼ 50% & NPV ¼ 93.8%). Conclusion: If SSO is absent on trauma CT(head), haemorrhage and/or fracture are unlikely. However, the high NPV and specificity may relate to low prevalence of intracranial injury in our cohort. Post-traumatic SSO on CT is a poor positive predictor of intracranial injury. This radiological sign is probably best confined to history. The Radiology Events Register (RaER): incident reporting in radiology Authors: Catherine Schultz
Mandel, Natalie
Hannaford, Jane
Grimm, Tim
Purpose: Incident reporting is a valuable patient safety tool. Radiologyrelated issues may not be apparent in hospital and national databases. RaER was created to investigate the nature and type of incidents in radiology. Methods: The RaER database was analysed to determine: * the number of incidents submitted * source of incidents * principle incident type * year of submission vs initiatives to improve reporting * who reports A literature review looked at barriers and enablers to reporting. Results: Over 4000 incidents have been received, 2602 entered into RaER and 828 subject to detailed analysis. 41% of incidents were entered directly by clinicians and 25% were from a state incident reporting database. 72% related to clinical management and 7% involved documentation. Of directly reported incidents, 70% are reported by registrars and 23% by consultant radiologists. Initiatives to increase reporting had varied success. The most successful was the introduction of mandatory reporting by radiology trainees. Conclusion: Dedicated radiology incident reporting is invaluable. Gaining and maintaining radiologist engagement is an ongoing challenge and the introduction of incentives such as providing continuing professional development points and making incident reporting a mandatory
complications and if the risk can be minimized by performing common femoral endarterectomy at the at the time of the surgical cut down. Review of general practitioner direct access referrals for lumbar spine MRI Authors: Christopher Watura, Steven James Purpose: GPs are increasingly given access to MRI. This is expected to accelerate following GP commissioning of secondary care. We assessed appropriateness and completeness of GP lumbar spine MRI requests. Methods: Retrospective review of data from an NHS Trust and regional centre for spine surgery. All lumbar spine MRI referrals between MarchJune 2012 were retrieved. Only those from GPs were included. Paediatric and follow-up cases were excluded. One hundred cases were randomly selected and assessed against RCR and NICE guidelines. Results: Patient age range 18-89 (mean 52) years, 61%(61/100) female. Sixty-five percent (65/100) referrals met indications for lumbar spine MRI, of which 25%(16/65) were red flags. MRI not indicated in 35%(35/100). Ninety-seven percent (97/100) request forms provided some symptom information, 33%(33/100) omitted symptom duration. No clinical examination given in 73%(73/100). No diagnostic question asked in 50%(50/100). Forty-two percent (42/100) of reports consistent with referral, 5%(5/100) positive findings unrelated to referral, 41%(41/100) degenerative changes only, 12%(12/100) negative findings. Conclusion: There is need to increase GP awareness of indications for lumbar spine imaging, information required on request forms, and limitations of MRI in investigating back pain. There is a potential role for request form pro forma, and triage systems or an intermediary service to exclude inappropriate referrals. Trauma CT scanning; is there an awareness of the ionising radiation involved? Authors: David Roberts, Emma Rowbotham, Sophie Dennis Purpose: The inclusion of a ‘whole body’ or trauma CT in the pathway of a multiply injured patient has been shown to significantly increase the survival rate. A potential risk however is the radiation involved. Many junior doctors will work in departments encountering such patients, being involved in decisions and requests for trauma CT’s. The Royal College of Radiologists’ undergraduate curriculum states graduates should recognise ionising radiation can be harmful, patients should be involved in decision making and if appropriate, consent should be gained for investigations. Methods: 52 post final examinations medical students/junior doctors completed a questionnaire regarding knowledge of trauma CT scans and associated ionising radiation. Results: Only 19 (37%) participants could identify any unit of radiation. Estimated doses of radiation of a trauma CT scan, ranged from 6 to 10,000 gray. 33 (63%) participants were ‘not confident at all’ to discuss the radiation dose and potential risks of trauma CT imaging, with 5 (10%) participants not aware of any risks associated with radiation. Conclusion: This study demonstrates many current and future junior doctors are not aware of the ionising radiation involved in trauma CT’s and do not feel confident in discussing radiation doses. Although there is a clear undergraduate curriculum, this study suggests the need for strengthening the clinical application of education in this area. Endovascular treatment of three hundred consecutive middle cerebral artery aneurysms: clinical and radiological outcomes Authors: Alex Mortimer, Marcus Bradley, Shelley Renowden Purpose: There is controversy as to the best mode of treating MCA aneurysms. We report the results of a large endovascular series treated at our centre. Methods: This was a retrospective analysis of a prospectively acquired database, supplemented by case note review. All patients with MCA aneurysms treated between November 1996 and June 2012 were included.
S5
WFNS grade, aneurysm site, size and neck morphology were recorded, along with clinical outcome assessed with Glasgow Outcome Score and radiographic occlusion assessed using the Raymond classification at 6 months and 2 years. Results: 295 patients with 300 MCA aneurysms were treated including 242 (80.7%) ruptured aneurysms. Complete or near complete occlusion was achieved in 91%. The technical failure rate was 3.3%. Complications included rupture (4.3%), thrombo-embolism (5.7%) and early re-bleeding (1%). Overall permanent procedural-related morbidity and mortality was 9%. Of the ruptured aneurysms, 79% had a favourable clinical outcome (GOS 4-5). 32 patients (13%) died. On angiographic follow-up, significant recurrence was seen in 18 aneurysms (8.1%). 13 (4.3%) patients were retreated. Conclusion: Our experience demonstrates that endovascular treatment of MCA aneurysms is safe with low rates of technical failure, complications and re-treatment. Therefore coiling is acceptable as the primary treatment for MCA aneurysms. Whatever happened to the sphenoid sinus level in head trauma? Authors: Jonathan Rodrigues, Matthew Seager, Hyeladzira Thahal, Nick Ridley Purpose: A horizontal beam, brow-up lateral skull radiograph was once commonplace in head trauma. A sphenoid sinus effusion suggested blood or cerebrospinal fluid and increased the suspicion of more severe intracranial injury. This study has been superseded by CT. We aimed to determine the relevance of this sign in the modern CT era. Methods: 100 consecutive emergency department CT(head) for trauma were retrospectively reviewed for sphenoid sinus opacification (SSO) and CT evidence of trauma (intra/extra axial haemorrhage and/or fracture). Where SSO was present, its mean attenuation was measured. Using CT findings as gold standard, sensitivity (SN), specificity (SP), positive (PPV) and negative predictive values (NPV) of SSO as a predictor of intracranial injury were determined. Results: SSO was present in 7/100. 28.6% (2/7) of these had CT evidence of trauma (SN ¼ 25.0%, SP ¼ 94.6%, PPV ¼ 28.6% & NPV ¼ 93.5%). In comparison, 6.5% (6/93) of cases without SSO had evidence of trauma. When SSO with mean attenuation >60 HU (presumed blood) was used, specificity, NPV and PPV increased (SN ¼ 25.0%, SP ¼ 97.8%, PPV ¼ 50% & NPV ¼ 93.8%). Conclusion: If SSO is absent on trauma CT(head), haemorrhage and/or fracture are unlikely. However, the high NPV and specificity may relate to low prevalence of intracranial injury in our cohort. Post-traumatic SSO on CT is a poor positive predictor of intracranial injury. This radiological sign is probably best confined to history. The Radiology Events Register (RaER): incident reporting in radiology Authors: Catherine Schultz
Mandel, Natalie
Hannaford, Jane
Grimm, Tim
Purpose: Incident reporting is a valuable patient safety tool. Radiologyrelated issues may not be apparent in hospital and national databases. RaER was created to investigate the nature and type of incidents in radiology. Methods: The RaER database was analysed to determine: * the number of incidents submitted * source of incidents * principle incident type * year of submission vs initiatives to improve reporting * who reports A literature review looked at barriers and enablers to reporting. Results: Over 4000 incidents have been received, 2602 entered into RaER and 828 subject to detailed analysis. 41% of incidents were entered directly by clinicians and 25% were from a state incident reporting database. 72% related to clinical management and 7% involved documentation. Of directly reported incidents, 70% are reported by registrars and 23% by consultant radiologists. Initiatives to increase reporting had varied success. The most successful was the introduction of mandatory reporting by radiology trainees. Conclusion: Dedicated radiology incident reporting is invaluable. Gaining and maintaining radiologist engagement is an ongoing challenge and the introduction of incentives such as providing continuing professional development points and making incident reporting a mandatory