Minnesota Public Radio

The Norwood procedure is the first part of a three-stage surgical palliation for patients with functionally single ventricle anatomy. Complications after the stage I operation are not uncommon. Transthoracic echocardiography (TTE) is traditionally the mainstay for evaluation. The purpose of our study is to compare gated cardiac computed tomographic angiography (CCTA) with TTE when evaluating for postoperative complications after stage I Norwood procedure and to describe management implications. A retrospective chart review of all patients over a 4-year period who underwent nonelective urgent CCTA for suspected complications related to stage I Norwood procedure was performed. Elective CCTA studies before stage II palliation were excluded. Patient demographics, CCTA and TTE findings, as well as interventions performed, were recorded. Thirty-four patients were included. The mean age at CCTA was 63days (range: 4-210days). All patients had a recent TTE with a mean time interval between TTE and CCTA of 2days. CCTA detected 56 abnormalities in 30 patients, with 23 directly related to postsurgical complications, including shunt-related complications (10/23, 43%), Damus-Kaye-Stansel anastomotic narrowing (2/23, 9%) and neo-aortic arch/branch vessel abnormalities (11/23, 48%). These complications were managed as follows: surgery (9, 39%), catheter-based intervention (7, 30%), medical (4, 17%) and no change in management (3, 13%). TTE did not detect 8/23 (35%) findings found on CCTA, of which 75% were either managed with surgery (4/8, 50%) or catheter-based intervention (2/8, 25%). CCTA plays an important role in detecting surgical complications after stage I Norwood procedure and demonstrates additional findings that have direct management implications.

HISTORY: A 16 year old high school football player sustained a head injury while making a routine tackle during a game. The tackle involved helmet to helmet contact. The injured player complained of dizziness and disorientation immediately following the injury and was removed from the game. Initial neurological assessment was within normal limits. The player developed a headache approximately two hours after his injury, which worsened over the next 5 hours. The patient was then taken to the Emergency Department (ED) for evaluation for worsening headache. PHYSICAL EXAM: Initial sideline neurologic exam was unremarkable. The player was oriented x 3, and had no short term memory loss. Extremity movement was normal, with no weakness noted. No evidence of gait disturbance. Modified Glasgow coma scale score was 15. The player was re-evaluated in the ED, with similar findings noted. DIFFERNTIAL DIAGNOSIS: Concussion. Skull fracture. Intracranial hemorrhage. TESTS AND RESULTS: CT scan of the head without I.V. contrast: Images of the head demonstrated a high density crescent-shaped extra-axial fluid collection. Findings were consistent with a right sided subdural hematoma, measuring 5 mm in maximum thickness. There was mild effacement of the overlying sulci of the adjacent cerebral cortex. 5 mm of right to left shift of the midline was also noted. No associated skull fracture identified. FINAL WORKING DIAGNOSIS: Post-traumatic intracranial hemorrhage - subdural hematoma. TREATMENT AND OUTCOMES: Patient was admitted to the hospital and monitored for possible worsening of his condition. Follow up CT scans showed slow resolution of the hematoma without intervention. The patient did not develop cerebral edema. The patient was released after 4 days, and excluded from contact sports for at least one year. The case highlights the need for aggressive work up of any symptomatic head injury, whether or not the athlete loses consciousness, or exhibits a specific neurologic deficit.