Introduction Imaging in stroke, allows its classification into ischaemic stroke (IS) or intracranial haemorrhagic stroke (ICH), ensuring time-sensitive treatment to be administered. Imaging can also allow detection of cerebral microbleeds (CMBs), which may further determine pharmacological intervention in acute stroke. True gradient echo (T2∗GRE) or susceptibility weighted imaging (SWI) have high sensitivity for the detection of CMBs. These two sequences are included in the national guidelines; however, the implementation of these guidelines can vary depending on local interpretation and scanner capabilities. Aim To explore the use and application of blood sensitive MRI sequences in a specialist UK stroke unit for the detection of CMBs, to improve local practice. Methods A retrospective data analysis of the native database, spanning a 6-month period, was used. The data of 281 acute stroke patients with an MRI were reviewed and analysed. The MRI sequences applied, and the final diagnosis were noted for each case. Results Of the 281 acute stroke patients with MRI, 259 (92.1%) had an IS, 16 (5.68%) an ICH and 6 (2.14%) had both. Overall, 13 (4.63%) had a CMB diagnosis. All of these 13 patients had a true T2∗GRE sequence. CMBs were not detected in the absence of a T2∗GRE sequence. Conclusion T2∗GRE imaging is essential for detecting CMBs. When omitted, CMB incidence can be considerably lower than that suggested in the literature. Missing CMB diagnoses in stroke patients may result in suboptimal treatment pathways, compromising the patients' standard of care. Implications for practice When SWI is not available, it is imperative to always include a true T2∗GRE sequence to detect microbleeds in suspected acute stroke cases.

STUDY DESIGN:Prospective study.OBJECTIVE:To ascertain the prevalence of posterior circulation stroke in traumatic chronic spinal cord injured (SCI) patients and associated traumatic vertebral artery injuries (VAI).METHODS:All adult patients with cervical SCI and American Spinal Injury Association Impairment Scale (AIS) grade A or B referred for follow-up magnetic resonance imaging of their spinal cord were invited to take part in the study between January 2010 and December 2012 at the National Spinal Injury Centre. Two additional sequences were added to the existing imaging protocol to evaluate the brain and vertebral arteries.RESULTS:Ninety-eight patients were recruited. All imaging were analysed independently by three consultant radiologists. Posterior circulation infarcts were noted in seven (7%) patients. Significant VAI was noted in 13 patients (13%) with 10 occlusions and 3 with high-grade stenosis. However, only one patient had co-existent posterior circulation infarct and significant VAI.CONCLUSION:There is an increased prevalence of posterior circulation infarction in SCI patients. The relationship with associated traumatic VAI requires further investigation.

STUDY DESIGN:Retrospective case series.OBJECTIVES:To evaluate the efficacy of body computed tomography (CT) in spinal cord injury (SCI) patients with sepsis.SETTING:Specialist acute care and rehabilitation SCI centre in United Kingdom.METHODS:Patients with SCI and suspected or known sepsis, who had CT of the chest, abdomen and pelvis, over a 4-year period, were identified. Only patients who fulfilled the definition of sepsis or severe sepsis were included. Their medical notes and CT scans were reviewed and clinical outcomes and radiological findings recorded.RESULTS:Twenty-two patients with sepsis were identified including seven categorised as having severe sepsis. A specific radiological diagnosis was found in three patients (14%) and non-specific findings were found in 15 patients (68%).CONCLUSION:Although in the majority of cases, the findings were non-specific, a small number of patients had significant pathology identified by CT, which influenced their management significantly.

AIM:To examine current out-of-hours magnetic resonance imaging (MRI) provision through a snapshot survey of National Health Service (NHS) trusts and to assay how radiographer staffing cover was provided for out-of-hours services. MATERIALS AND METHODS:A snapshot postal survey was mailed to heads of service of all 234 trusts in England and Wales. A literature search on the models of service delivery and correlation with the authors' internal MRI rota, which has provided a full on-call service for 20 years was undertaken. RESULTS:The response rate was 45.7% (107 of 234); 14% of responders provided full access to MRI 24 h a day; 63% provided extended weekday service, typically to 20.00 h; and 81% provided a weekend daytime service. The radiographers running the service were typically from the core MRI team. Approximately one-third (29.9%) of trusts provided training in basic brain and spine MRI to non-core MRI team members, but they typically did not participate in out-of-hours provision. CONCLUSION:There is currently a paucity of information on the provision of out-of-hours MRI in the NHS. However, there is increasing pressure to provide complex imaging out of hours, and in the future, trauma centres may be required to provide MRI to assess spinal injury. The authors describe a system to provide access to MRI at no additional cost to the organization based on 20 years of experience. A minority of surveyed acute NHS trusts have full out-of-hours access to MRI. Demand for MRI provision out of core hours is likely to increase.

Purpose: To demonstrate the use of dynamic intravenous bolus in targeted CT fluoroscopy guided soft tissue biopsy.

Study design: Case report. Objective: To describe the clinical benefit of a spinal cordectomy with the aim of limiting neurological deterioration related to the development of a subacute posttraumatic ascending myelopathy (SPAM) supporting previously described mechanism for SPAM formation. Setting: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK. Method and results: A 38-year old patient presented 6 months after spinal cord injury substantial neurological deterioration expanding from the initial T4-injury level through C4. Magnetic resonance imaging revealed intra-medullary haemorrhage at the site of injury and subsequent-ascending cord oedema. A cordectomy was performed leading to neurological stabilisation and complete resolution of SPAM. Conclusion: Cordectomy can be an effective intervention in case of rapid progressive neurological deterioration.

Introduction and Objectives CT guided lung biopsy is a proven diagnostic method for lung cancer. However, traditionally complication rates from this procedure have been high. The aim of our study was to assess current complication rates from this procedure and the determine what possible risk factors may account for these. Methods A retrospective cohort of CT guided lung biopsy procedures done between August 2008 and November 2010 were analysed. Patient notes and electronic radiology records (Centricity PACS) were reviewed. Complications of haemorrhage, pneumothorax, and death were recorded and the sample adequacy of biopsy specimens for pathological examination was determined for each procedure. A univariate analysis was performed for determining the risk of post-biopsy pneumothorax and biopsy type (core or FNA), number of co-axial needle passes, needle pleural angle, lesion size, and lesion distance from pleura at point of biopsy, and lesion location (lung or mediastinal). Consequently, a multiple logistic regression analysis was performed on the most significantly correlated risk factors for pneumothorax from the univariate analysis. Results Exactly 200 biopsy procedures done in 184 patients were included of which 64% were core biopsies (n=128). The mean age was 69 years (range 31–90 years) with with 79.5% of patients over 65 years old (n=151) and 59.5% of patients male (n=119). Haemorrhage occurred in 2.5% (n=5) and pneumothorax in 17% (n=34) with 5% (n=10) of procedures requiring intercostals chest drain insertion for pneumothorax. No deaths were recorded. A statistically significant higher risk was observed for core biopsy (OR 3.65, p=0.00, 95% CI 1.38 to 9.65) and lesion distance from pleura >2 cm (OR 4.13, p<0.001, 95% CI 1.88 to 9.08). A multivariate analysis showed that the risk was greatest when core biopsies were taken from lesions more than 2 cm from the pleura at point of biopsy (OR 9.14, p<0.001, 95 % CI 2.72 to 30.69). The sample adequacy rate was 95.5% (n=191). Conclusions In this recent study all complication rates were found to be lower than that reported in the national survey which is the current standard for BTS guidelines on acceptable complication rates. However, a higher rate of intercostal drain insertion was observed. Lesion distance from pleura at point of biopsy >2 cm and core biopsies were the most significant risk factors for post-biopsy pneumothorax and operators should consider these prior to biopsy. Larger studies are needed to reasses current national complication rates and target complication rates may need to be specified by biopsy type.

Study design: Pictorial review. Objectives: To illustrate MRI signs of acute and subacute injury with emphasis on evidence-based links to clinical outcome and implications for treatment. Methods: Description of important aspects of MRI techniques and illustration of critical MRI signs important in the assessment of spinal cord injury following trauma, in the acute and subacute stages. Conclusions: Familiarity with cord MRI appearances has an important impact on planning the management of the acutely spinal cord injured patient and also identifying complications in the subacute phase particularly in the presence of neurological deterioration.

Introduction The explanation for the prognostic value of the ABCD2-score remains uncertain. If it genuinely measures cerebral susceptibility to ischaemia, it should correlate with other markers of susceptibility, such as leukoaraiosis (LA). We studied the association of the ABCD2-score with the severity of LA in a large cohort of patients with TIA or minor stroke. Methods Consecutive patients attending a TIA-clinic were recruited and underwent routine MR-imaging (T2/DWI). Detailed clinical data were obtained and the ABCD2 score calculated. Two independent observers assessed the presence and severity of LA with standard rating scales. Results 671 patients (56% men; mean age=71 (SD=11) years) with TIA (45%) or minor stroke attended the clinic. LA was more prevalent (p=0.015) and more severe (p=0.007) in patients with stroke vs TIA. LA was associated with lesion presence on DWI (p<0.0001) and history of prior stroke (p=0.026). LA and the ABCD2-score were strongly associated (p<0.0001), due mainly to association of LA with age (p<0.0001), with motor symptoms at presentation (p<0.0001) and with hypertension (p=0.001). Associations were similar in analyses stratified by diagnosis and adjusted for age. Conclusion The associations of LA with prior stroke, presenting stroke and with lesion presence on DWI confirm it as a marker of cerebral susceptibility to ischaemia. The strong association of the ABCD2-score with LA may therefore at least partly explain its prognostic value.

Study design: Single-centre, prospective (comparative cohort) clinical study, with ethical approval and patient consent. Objective: Confirmation of vertebral fracture union can pose significant challenges for clinicians in the management of spinal cord injury and in the decisions around patient mobilization. Bony union is usually assessed with computed tomography (CT). This study hypothesizes that magnetic resonance imaging (MRI) can identify vertebral bone union. Setting: A major spinal injuries unit in the United Kingdom. Method: Patients underwent CT and MRI at 12 weeks post-injury, if conservatively managed, or 12 weeks post-fixation. With CT as the gold standard, the MRI scans were reviewed blind to the CT result and indicators for fracture healing were compared. Results: A total of 35 patients with 55 fractures were imaged. Comparison of CT and MRI showed sensitivity of 88%, specificity of 100% and positive predictive value of 100% for fracture union imaged with MRI using CT as the gold standard. Conclusion: MRI correlates well with CT in identifying vertebral fracture union and non-union. We suggest that where imaging is indicated in the assessment of vertebral body fracture healing MRI can be used routinely with CT reserved for problematic or inconclusive cases.

Diffusion-weighted MRI (DWI) has become increasingly widely available over recent years and is recognized as a powerful tool in neuroimaging. It is primarily used to identify acute ischaemia in patients presenting with stroke because of the improved sensitivity it offers early in the course of the disease. DWI also contributes useful diagnostic information in a range of other conditions. In this review we describe the magnetic resonance imaging (MRI) features of a number of conditions characterized by cortical diffusion restriction (CDR).

Study design: Retrospective Case Review.Objectives: To describe the clinical presentation and course of patients with magnetic resonance imaging (MRI) features of subacute progressive ascending myelopathy (SPAM). A rare complication of spinal cord injury.Setting: National Spinal Injuries Centre, Stoke Mandeville Hospital, UK.Materials and methods: A retrospective review of the case notes and MRI studies of 11 cases with typical MRI features of ascending myelopathy presenting to a tertiary Spinal Injuries centre over a 15-year period.Results: Eleven patients were identified with MRI features typical of SPAM, a median of 13 days (mean 24, range 4-86 days) following cord injury. The median number of cord segments involved above the initial insult was 6 (mean 6.2, range 4-11). MRI appearances include extension four or more segments cephalad to the initial cord injured segment, cord expansion and increased intramedullary T2 signal with a rim of cord sparing peripherally. Cord changes and neurological deficits improved over time but did not return to the initial injured level on MRI. One patient died (mortality 9%).Conclusion: SPAM is a rare cause of neurological deterioration following spinal cord injury but may remain subclinical. SPAM most commonly presents as neurological deterioration but may present with shoulder pain, respiratory deterioration or remain subclinical. There are characteristic MRI appearances. It can be fatal.

Background: Early risk of stroke after a transient ischaemic attack (TIA) can be reliably predicted with risk scores based on clinical features of the patient and the event, but it is unclear how these features correlate with findings on brain imaging and few studies have investigated this in the subacute phase. Methods: Two hundred consecutive patients attending a specialist clinic underwent diffusion-weighted brain imaging (DWI) on the day of the clinic (≧3 days after a TIA) and the presence of recent lesions (positive DWI) was related to the presence of clinical features associated with a high stroke risk and to 2 validated risk scores (ABCD and California). Results: Thirty-one patients (16%) had positive DWI. Increasing ABCD and California scores were associated with positive DWI (p = 0.02 for both) independent of the delay from TIA to scan. Conclusion: Presence of recent ischaemic lesions on DWI correlates with validated clinical scores for risk of stroke after TIA in patients scanned subacutely. Future prognostic studies of DWI after TIA should adjust for the risk scores to determine the independent predictive value of DWI and hence the likely role of DWI in refinements of the scores.

AIM:To evaluate the feasibility and impact of diffusion weighted magnetic resonance imaging (DW MRI) as the first line neuroimaging of stroke at a district general hospital.METHODS:Prospective audit of all in-patients admitted with clinically suspected acute stroke and referred for imaging over a consecutive 17 week period. The data collected included scan type, time from cerebral event to imaging request, and time from formal radiological request to neuroimaging. Clinicians' (general physicians, neurologists, and radiologists) perceptions were assessed by a questionnaire.RESULTS:148 patients had neuroimaging for clinically suspected stroke during this period. Eighty one per cent of patients (120 of 148) had DW MRI as first line. Ninety two per cent of these patients had DW MRI within 24 hours of the formal radiological request. Twenty eight patients did not undergo DW MRI because lack of MRI safety, clinical state, unavailability because of maintenance service or lack of trained staff. Clinicians found the introduction of the DW MRI based service a significant improvement on computed tomography, especially for equivocal cases.CONCLUSION:DW based MRI service is both feasible and sustainable in the setting of a district general hospital and most clinicians feel that this is a significant improvement to stroke services.

Study design: Reviewing documents about Lord Admiral Nelson's wound inflicted at the Battle of Trafalgar and studying the collected data in connection with ballistics and human anatomy.Objectives: Attempting to find out the actual cause of death of Lord Nelson as soon as 4 h postinjury by a musket ball.Setting: United Kingdom.Methods: ( 1) Review of the original report of Mr W Beatty, Lord Nelson's surgeon, on his examination of His Lordship's wound. ( 2) Investigating the course of the musket ball in connection with an atlas of human anatomy. ( 3) Investigating the course of the musket ball on a cadaver by RP ( one of the authors). ( 4) Reviewing modern medical literature.Results: The report of Mr Beatty suggested that division of a large branch of the pulmonary artery was the cause of Lord Nelson's early death. Assuming the left pulmonary artery was injured, anatomical studies based on atlases and dissection on a cadaver failed to support a simple straight-line course of the musket ball that could have divided the artery and damage the spinal cord on its pathforward.Conclusion: The question remains open as to how the musket ball following a relatively straight-line trajectory by entering the body at the acromion, could have divided the left pulmonary artery and damaged the spinal cord later in its course. The mechanism needs further investigation.

Background and Purpose— Many patients with transient ischemic attack (TIA) or minor stroke present to medical attention after a delay of several days or weeks, at which time it may be more difficult to obtain a clear history and clinical signs may have resolved. Because ischemic lesions on diffusion-weighted MRI (DWI) often persist for several weeks, we hypothesized that adding DWI to a standard protocol with T2-weighted imaging might be useful in the management of patients presenting late. Methods— We studied consecutive patients with TIA or minor stroke presenting ≥3 days after the event. Two independent observers recorded the presence or absence of recent ischemic lesions on 2 different occasions, first with the T2 scan only, and second with T2 and DWI. Each time, with the aid of a written clinical summary, the observers recorded their diagnosis and proposed management. Results— 300 patients (159 men) were scanned at a median of 17 (interquartile range=10 to 23) days after symptom onset. DWI showed a high signal lesion in 114/164 (70%) minor strokes versus 17/136 (13%) TIAs ( P <0.0001). The presence of high-signal lesions on DWI decreased nonlinearly with time since symptom onset ( P <0.0001) and increased with National Institutes of Health Stroke Score ( P =0.038) and with age ( P =0.01). In 90/206 (43.7%) patients with 1 or multiple lesions on T2, DWI helped to clarify whether these were related to a recent ischemic event (79 [48%] strokes; 11 [31%] TIAs). Compared with T2 alone, DWI provided additional information in 108 (36%) patients (91 [56%] strokes and 17 [13%] TIAs), such as clarification of clinical diagnosis (18 patients, 6%) or vascular territory (28 patients, 9.3%), which was considered likely to influence management in 42 (14%) patients (32 [19%] strokes; 10 [7.4%] TIAs). Conclusions— The clinically useful information available from DWI provides a further justification for an MRI-based imaging protocol in patients with subacute TIA or minor stroke.