Introduction Chiari malformation is characterized by caudal descent of the cerebellar tonsils through the foramen magnum. Acquired Chiari malformations (ACM) have previously been described after a variety of pathologies including lumbar puncture, cerebrospinal fluid (CSF) drainage, lumboperitoneal shunts, and conditions causing craniocephalic disproportion. Case presentation We present four cases of ACM following spinal cord injury (SCI), which has not previously been described in the literature. Discussion ACM is rare and typically associated with abnormalities in CSF pressure or space-occupying lesions. This case series describes the potential association of SCI with ACM. We discuss the imaging findings and clinical management of these patients. Early recognition and intervention may be important to prevent progressive neurology in this vulnerable patient group.

Introduction Cervical spine (c-spine) injury has a high morbidity and mortality in patients over the age of 65; more than 60% result from falls from standing height (Beedham et al., 2019). The Canadian Cervical Spine Rule (Stiell et al., 2001) deems that there is a high risk of c-spine fracture if any of the following apply: The c-spine cannot be cleared clinically if the patient fits any of the above criteria. Imaging should be considered. As a result of recent clinical experiences Trust Guidelines at Stoke Mandeville Hospital now reflect this evidence (Hadley et al., 2019). Methods Fifty patients over the age of 65 who had a computerised tomography (CT) head scan in the Emergency Department (ED) following a traumatic head injury were randomly selected over a 1 month period. Cases were checked for examination of c-spine and/or CT c-spine. Results of the first cycle of the audit were presented at an ED Education Meeting. Indications for CT c-spine were displayed in poster format around the ED. Following these interventions, a re-audit was carried out using the same methodology. Results In fifty patients aged over 65 attending ED during one month, 16% had a CT c-spine in addition to a CT head. There was documented c-spine examination of 16% of those without CT c-spine on admission. In the re-audit 38% of the fifty patients who had a CT head underwent CT c-spine. In the group that did not have imaging of the c-spine, the proportion with documented cervical spine examination on admission remained the same (16%). Conclusion There was a 137.5% increase in the number of patients aged over 65 who appropriately underwent a CT c-spine as per Trust and National guidelines. Simple interventions (staff education and posters within the ED) were sufficient to significantly alter practice. Current trauma triage is not optimal for older patients who are reviewed by more junior doctors, less likely to be transferred to Major Trauma Centres and more likely to die than younger patients with similar injuries (Major Trauma In Older People 2017 Report). An older person’s trauma team in ED with age-appropriate triage would lead to appropriate imaging in a timely fashion, potentially improving the morbidity and mortality of these vulnerable patients.

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Spontaneous resolution of frontotemporal brain sagging syndrome Editor-Like Dr Kent and colleagues, 1 I have recently seen a patient with apparently spontaneous resolution of neuroradiological features of frontotemporal brain sagging syndrome (FTBSS), but with different clinical outcome. A previously healthy 70-year-old man was referred from primary care with memory symptoms and headaches, the latter worse in the mornings. Family members reported forgetfulness over about 12 months, mixing up people's names and sometimes repeating himself. He had developed low mood, not helped with antidepressant medications. On neurological examination, there was psychomotor retardation, and the head turning and applause signs were evident, 2 but no other features. On the Mini-Addenbrooke's Cognitive Examination he scored 10/30 (attention 2/4, memory 4/7, letter fluency 2/7, clock drawing 0/5, memory recall 2/7), and on Free-Cog 12/30 (cognitive function 8/25, executive function 4/5). Magnetic resonance (MR) brain imaging, performed prior to neurology referral, showed normal brain parenchyma aside from minor small vessel ischaemic changes, but bilateral shallow subdural collections, slight inferior displacement of the brainstem, and uniform meningeal enhancement on contrast imaging, suggestive of low cerebrospinal fluid (CSF) pressure. A presumptive diagnosis of FTBSS was made. Subsequent MR spinal imaging revealed no CSF leak. Blind blood patching was planned, but deferred when at 3-month follow-up both the patient and his family reported improvement in cognitive function. However, at 6-month follow-up the patient's clinical state had deteriorated, with reduced speech output and personality change with uncharacteristic outbursts of anger. Repeat MR imaging, 10 months after the initial study, showed complete resolution of both subdural collections and meningeal enhancement. There was evidence for right temporal lobe atrophy. A presumptive diagnosis of frontotemporal dementia was made. The exact relationship of the neuroradiological signs of low pressure and the clinical features was uncertain in this patient. Resolution of the former with progression of the latter suggests that in this case they were incidental. Clinicians should keep an open mind on the cause of cognitive symptoms in the presence of neuroradiological signs of low CSF pressure. Based on experience of this case, I suggest continued follow-up of patients with spontaneous resolution of FTBSS is indicated. ■ OVERVIEW