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INTERNAL CAROTID ANEURYSM PRESENTING AS HYPOGLOSSAL AND GLOSSOPHARYNGEAL NERVE PALSY
233
CORRESPONDENCE
doi:10.1053/crad.2001.0757, available online at http://www.idealibrary.com on
APPLYING `TECHNOLOGY ASSESSMENT' AND `EVIDENCE-BASED MEDICINE' THEORY TO INTERVENTIONAL RADIOLOGY. PART ONE: SUGGESTIONS FOR THE PHASED EVALUATION OF NEW PROCEDURES SIR ± In a recently published manuscript [1], we suggested that interventional radiology (IR) organizations might develop a system to provide an ` early warning' of technical problems with equipment or harm resulting from IR procedures as they are introduced to the larger denominator of the general hospital population. At the time of writing (early 2000), we were not aware of any mechanism for non-academic radiologists to quickly report non-fatal adverse events/complications during and after interventional procedures. I am writing to draw the attention of your readers to further progress in this area by the British Society of Interventional Radiologists (BSIR). At the BSIR Annual Meeting in November 2000, members were informed that the BSIR website now contains a link to the Medical Devices Agency (MDA). This is an executive agency of the Department of Health in the United Kingdom. At BSIR 2000, Ms H. Randall of the MDA spoke on `Problems with Medical Devices: Why report to MDA?' In summary, the role of the MDA is to `take all reasonable steps to protect public health and safeguard users and patients and to ensure that all non-pharmacological devices and equipment meet appropriate standards of safety, quality and performance as well as complying with EU directives.' The MDA has, as part of this role, provided an infrastructure for adverse event reporting. Events that cause harm or, in the opinion of the operator, have potential for harm are deemed
doi:10.1053/crad.2001.0822, available online at http://www.idealibrary.com on
INTERNAL CAROTID ANEURYSM PRESENTING AS HYPOGLOSSAL AND GLOSSOPHARYNGEAL NERVE PALSY SIR ± We read with interest the article by Ursekar et al. [1] describing a case of hypoglossal nerve palsy due to dissecting aneurysm of the internal carotid artery. We would like to present a further case of unilateral hypoglossal and glossopharyngeal nerve palsy caused by an internal carotid artery aneurysm. A 48-year-old woman was admitted with a tender swelling in the right submandibular region. This was non-pulsatile. Ultrasound demonstrated no abnormality although the right common carotid bifurcation was not clearly visualized as it was retromandibular. A week later she developed a `golf ball' sized, tender, non-pulsatile lump associated with deviation of the tongue to the right and alteration of taste sensation. MRI showed a 4.5 cm lobulated mass in the region of the right carotid bifurcation, displacing and distorting the carotid vessels with the internal carotid artery lying medially. This lesion contained peripheral high signal from the material within the lesion consistent with mural thrombus and a low signal lumen medially (Fig. 1). The appearances were consistent with an aneurysm of the right internal carotid artery. These ®ndings were con®rmed by selective carotid angiography (Fig. 2). At operation a large, true aneurysm was found arising from the internal carotid artery extending from the carotid bifurcation to the
Fig. 1 ± A coronal T1-weighted sequence (TR/TE 560/15 msec) demonstrates a large aneurysm at the right carotid bifurcation. This contains high signal thrombus; (open arrow), a low signal lumen (long arrow), with the internal carotid artery displaced medially (small arrows).
worthy of reporting. These reports are logged onto a monitored database. The person who reports is contacted. The MDA aims to quickly detect trends across the UK, across technologies and between manufacturers, to promote safe use and practice with devices, to decrease the chance of repetitious incidents `in isolation' and to contribute to safer future designs. It determines whether events are a once-o or systematic failure and can issue hazard/safety notices, device alerts/bulletin. If necessary, it has the statutory right to instruct manufacturers to withdraw devices from the market. The MDA can be contacted through the BSIR website http://www.bsir.org or directly at http://www.medical-devices.gov.uk (both sites accessed on 25 January, 2001). Adverse events can be noti®ed on-line, or printed forms convenient for reporting incidents may be downloaded (in pdf format). Had we been aware of this at the time of writing our manuscript, we should certainly have included this information. We hope U.K.-based readers of Clinical Radiology who, like us, were unaware of this information will ®nd it useful. D. E. MALONE P. MacENEANEY
Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
REFERENCE 1 Malone DE, MacEneaney PM. Applying `technology assessment' and `evidence-based medicine' theory to interventional radiology. Part one: suggestions for the phased evaluation of new procedures. Clinical Radiology 2000;55:929±937.
234
CLINICAL RADIOLOGY
Fig. 2 ± A selective right common carotid angiogram showing the catheter in the common carotid artery. It demonstrates splaying of the carotid bifurcation with displacement of the external carotid artery laterally by the aneurysm (arrow). The internal carotid artery lies medially (curved open arrow) and contrast medium opaci®es the aneurysm lumen (arrow head). skull base. The hypoglossal and glossopharyngeal nerves were displaced inferiorly and laterally by the mass. Due to the extent of the aneurysm, it was not amenable to surgical repair, and hence the right internal carotid artery was ligated, having con®rmed the patency of the circle of Willis by measuring the supra-aneurysmal internal carotid pressure. Post-operatively the patient made an excellent recovery. Interestingly, a few weeks before her presentation the patient had undergone several cervical spine manipulations by a chiropractor for chronic neck pain. It is possible, we think, that vigorous neck manipulations might have caused internal carotid artery trauma leading to aneurysm formation. Certainly, internal carotid artery dissection has been previously described following cervical manipulations [2]. P. D. SANGLE D. C. HOWLETT H. J. ANDERSON G. H. EVANS
Eastbourne General Hospital, Eastbourne East Sussex, BN21 2YR U.K.
REFERENCES 1 Ursekar MA, Singhal BS, Konin BL. Hypoglossal nerve palsy due to spontaneous dissection of the internal carotid artery. Clin Radiol 2000;55:978±979. 2 Peters M, Bohl J, Thomke F, et al. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995;45:2284±2286.
doi:10.1053/crad.2001.0829, available online at http://www.idealibrary.com on
CT IN URINARY TRACT TRAUMA SIR ± Wah and Spencer are to be congratulated on an informative review of the role of computed tomography (CT) in the management of adult urinary tract trauma [1]. Although admittedly given only limited mention, I believe the role of intravenous urography (IVU) has been overplayed. There is good evidence that patients who have undergone blunt trauma and have microscopic haematuria do not require imaging providing there has been no evidence of cardiovascular instability since the initial event and no signs of other organ injury [2±4]. Persistent microscopic haematuria can be investigated at leisure. The contention by Wong et al. [5] that all patients with blunt trauma and any degree of haematuria should undergo IVU can hardly be supported today given advances in resuscitation techniques and cross-sectional imaging. Radiological management in this context should focus on whether a patient requires imaging or not, rather than the investigation chosen. Few would argue that the information obtained from CT is vastly superior to IVU notwithstanding the added bene®t of assessment of other organ systems. In addition, the days of a `one shot IVU' to determine contralateral function prior to an emergency nephrectomy seem a distant memory and may become even less common in the light of (dare I be so controversial) Calman training.
As radiologists, one of our most important tasks is to guide our colleagues as to the most expedient and appropriate investigations. In the context of blunt trauma this is particularly important. CT is the investigation of choice. The IVU should be abandoned. D. A. SCULLION
Department of Radiology, Harrogate District Hospital, Lancaster Park Road, Harrogate, HG2 7SX, North Yorks, U.K.
REFERENCES 1 Wah TM, Spencer JA. The role of CT in the management of adult urinary tract trauma. Clin Rad 2001;56:268±277. 2 Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol 1989;141:1095±1098. 3 Eastham JA, Wilson TG, Ahlering TE. Radiographic evaluation of adult patients with blunt renal trauma. J Urol 1992;148:266±267. 4 McAndrew JD, Corriere JN Jr. Radiographic evaluation of renal trauma: evaluation of 1103 consecutive patients. Br J Urol 1994;73: 352±354. 5 Wong L, Waxman K, Smolin M, Rypins E, Murdock M. The role of IVP in blunt trauma. J Trauma ± Inj Inf Crit Care 1988;28:502±504.
CORRESPONDENCE
doi:10.1053/crad.2001.0757, available online at http://www.idealibrary.com on
APPLYING `TECHNOLOGY ASSESSMENT' AND `EVIDENCE-BASED MEDICINE' THEORY TO INTERVENTIONAL RADIOLOGY. PART ONE: SUGGESTIONS FOR THE PHASED EVALUATION OF NEW PROCEDURES SIR ± In a recently published manuscript [1], we suggested that interventional radiology (IR) organizations might develop a system to provide an ` early warning' of technical problems with equipment or harm resulting from IR procedures as they are introduced to the larger denominator of the general hospital population. At the time of writing (early 2000), we were not aware of any mechanism for non-academic radiologists to quickly report non-fatal adverse events/complications during and after interventional procedures. I am writing to draw the attention of your readers to further progress in this area by the British Society of Interventional Radiologists (BSIR). At the BSIR Annual Meeting in November 2000, members were informed that the BSIR website now contains a link to the Medical Devices Agency (MDA). This is an executive agency of the Department of Health in the United Kingdom. At BSIR 2000, Ms H. Randall of the MDA spoke on `Problems with Medical Devices: Why report to MDA?' In summary, the role of the MDA is to `take all reasonable steps to protect public health and safeguard users and patients and to ensure that all non-pharmacological devices and equipment meet appropriate standards of safety, quality and performance as well as complying with EU directives.' The MDA has, as part of this role, provided an infrastructure for adverse event reporting. Events that cause harm or, in the opinion of the operator, have potential for harm are deemed
doi:10.1053/crad.2001.0822, available online at http://www.idealibrary.com on
INTERNAL CAROTID ANEURYSM PRESENTING AS HYPOGLOSSAL AND GLOSSOPHARYNGEAL NERVE PALSY SIR ± We read with interest the article by Ursekar et al. [1] describing a case of hypoglossal nerve palsy due to dissecting aneurysm of the internal carotid artery. We would like to present a further case of unilateral hypoglossal and glossopharyngeal nerve palsy caused by an internal carotid artery aneurysm. A 48-year-old woman was admitted with a tender swelling in the right submandibular region. This was non-pulsatile. Ultrasound demonstrated no abnormality although the right common carotid bifurcation was not clearly visualized as it was retromandibular. A week later she developed a `golf ball' sized, tender, non-pulsatile lump associated with deviation of the tongue to the right and alteration of taste sensation. MRI showed a 4.5 cm lobulated mass in the region of the right carotid bifurcation, displacing and distorting the carotid vessels with the internal carotid artery lying medially. This lesion contained peripheral high signal from the material within the lesion consistent with mural thrombus and a low signal lumen medially (Fig. 1). The appearances were consistent with an aneurysm of the right internal carotid artery. These ®ndings were con®rmed by selective carotid angiography (Fig. 2). At operation a large, true aneurysm was found arising from the internal carotid artery extending from the carotid bifurcation to the
Fig. 1 ± A coronal T1-weighted sequence (TR/TE 560/15 msec) demonstrates a large aneurysm at the right carotid bifurcation. This contains high signal thrombus; (open arrow), a low signal lumen (long arrow), with the internal carotid artery displaced medially (small arrows).
worthy of reporting. These reports are logged onto a monitored database. The person who reports is contacted. The MDA aims to quickly detect trends across the UK, across technologies and between manufacturers, to promote safe use and practice with devices, to decrease the chance of repetitious incidents `in isolation' and to contribute to safer future designs. It determines whether events are a once-o or systematic failure and can issue hazard/safety notices, device alerts/bulletin. If necessary, it has the statutory right to instruct manufacturers to withdraw devices from the market. The MDA can be contacted through the BSIR website http://www.bsir.org or directly at http://www.medical-devices.gov.uk (both sites accessed on 25 January, 2001). Adverse events can be noti®ed on-line, or printed forms convenient for reporting incidents may be downloaded (in pdf format). Had we been aware of this at the time of writing our manuscript, we should certainly have included this information. We hope U.K.-based readers of Clinical Radiology who, like us, were unaware of this information will ®nd it useful. D. E. MALONE P. MacENEANEY
Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
REFERENCE 1 Malone DE, MacEneaney PM. Applying `technology assessment' and `evidence-based medicine' theory to interventional radiology. Part one: suggestions for the phased evaluation of new procedures. Clinical Radiology 2000;55:929±937.
234
CLINICAL RADIOLOGY
Fig. 2 ± A selective right common carotid angiogram showing the catheter in the common carotid artery. It demonstrates splaying of the carotid bifurcation with displacement of the external carotid artery laterally by the aneurysm (arrow). The internal carotid artery lies medially (curved open arrow) and contrast medium opaci®es the aneurysm lumen (arrow head). skull base. The hypoglossal and glossopharyngeal nerves were displaced inferiorly and laterally by the mass. Due to the extent of the aneurysm, it was not amenable to surgical repair, and hence the right internal carotid artery was ligated, having con®rmed the patency of the circle of Willis by measuring the supra-aneurysmal internal carotid pressure. Post-operatively the patient made an excellent recovery. Interestingly, a few weeks before her presentation the patient had undergone several cervical spine manipulations by a chiropractor for chronic neck pain. It is possible, we think, that vigorous neck manipulations might have caused internal carotid artery trauma leading to aneurysm formation. Certainly, internal carotid artery dissection has been previously described following cervical manipulations [2]. P. D. SANGLE D. C. HOWLETT H. J. ANDERSON G. H. EVANS
Eastbourne General Hospital, Eastbourne East Sussex, BN21 2YR U.K.
REFERENCES 1 Ursekar MA, Singhal BS, Konin BL. Hypoglossal nerve palsy due to spontaneous dissection of the internal carotid artery. Clin Radiol 2000;55:978±979. 2 Peters M, Bohl J, Thomke F, et al. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995;45:2284±2286.
doi:10.1053/crad.2001.0829, available online at http://www.idealibrary.com on
CT IN URINARY TRACT TRAUMA SIR ± Wah and Spencer are to be congratulated on an informative review of the role of computed tomography (CT) in the management of adult urinary tract trauma [1]. Although admittedly given only limited mention, I believe the role of intravenous urography (IVU) has been overplayed. There is good evidence that patients who have undergone blunt trauma and have microscopic haematuria do not require imaging providing there has been no evidence of cardiovascular instability since the initial event and no signs of other organ injury [2±4]. Persistent microscopic haematuria can be investigated at leisure. The contention by Wong et al. [5] that all patients with blunt trauma and any degree of haematuria should undergo IVU can hardly be supported today given advances in resuscitation techniques and cross-sectional imaging. Radiological management in this context should focus on whether a patient requires imaging or not, rather than the investigation chosen. Few would argue that the information obtained from CT is vastly superior to IVU notwithstanding the added bene®t of assessment of other organ systems. In addition, the days of a `one shot IVU' to determine contralateral function prior to an emergency nephrectomy seem a distant memory and may become even less common in the light of (dare I be so controversial) Calman training.
As radiologists, one of our most important tasks is to guide our colleagues as to the most expedient and appropriate investigations. In the context of blunt trauma this is particularly important. CT is the investigation of choice. The IVU should be abandoned. D. A. SCULLION
Department of Radiology, Harrogate District Hospital, Lancaster Park Road, Harrogate, HG2 7SX, North Yorks, U.K.
REFERENCES 1 Wah TM, Spencer JA. The role of CT in the management of adult urinary tract trauma. Clin Rad 2001;56:268±277. 2 Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR. Radiographic assessment of renal trauma: a 10-year prospective study of patient selection. J Urol 1989;141:1095±1098. 3 Eastham JA, Wilson TG, Ahlering TE. Radiographic evaluation of adult patients with blunt renal trauma. J Urol 1992;148:266±267. 4 McAndrew JD, Corriere JN Jr. Radiographic evaluation of renal trauma: evaluation of 1103 consecutive patients. Br J Urol 1994;73: 352±354. 5 Wong L, Waxman K, Smolin M, Rypins E, Murdock M. The role of IVP in blunt trauma. J Trauma ± Inj Inf Crit Care 1988;28:502±504.