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   Table of Contents - Current issue
January-March 2020
Volume 30 | Issue 1
Page Nos. 1-104

Online since Monday, March 30, 2020

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Can imaging impact the coronavirus pandemic? Highly accessed article p. 1
Anirudh Kohli
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Presidential address 2020 p. 4
Deepak Patkar
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Impact of a standardized reporting format on the quality of MRI reports for rectal cancer staging p. 7
Neeti A Gupta, Shivani Mahajan, A Sumankumar, Avanish Saklani, Reena Engineer, Akshay D Baheti
Background and Aims: Besides providing a surgical roadmap, rectal MRI plays a major role in treatment planning. We recently started using a structured template for reporting rectal cancer via MRI. We study the impact of using this template at our hospital in terms of number of essential imaging parameters described in the reports as compared to the pre-template free-text reports. Methods: A structured rectal MRI reporting template was created in consensus with members of the colorectal tumour board and was introduced in the department, which included 14 essential parameters to be mentioned in the reports. We conducted a retrospective analysis of rectal MRI reports of 100 cases with histologically proven rectal cancer, comprising 50 consecutive free-text reports before the template was introduced and 50 consecutive structured reports after its introduction, checking for the presence or absence of inclusion of the 14 parameters. An anonymous online feedback survey was conducted as well after the introduction of the template for the members of the colorectal tumour board. Results: Overall, the total number of parameters reported increased from a median value of 10 (range 6-13) to 14 (range 12-14). The common unreported parameters prior to template introduction included T staging, presence or absence of restricted diffusion, anterior peritoneal reflection (APR) involvement, and presence or absence of extramural vascular invasion; these were reported in 16%, 22%, 30% and 50% respectively. These improved to 98-100% reporting after template introduction. Maximum improvement was in T staging (16% to 98%) (P < 0.0001), restricted diffusion on DWI (from 22% to 100%) (P < 0.0001) and APR involvement (from 30% to 100%) (P < 0.0001). The most common unreported parameter after template introduction was the “tumoral T2 signal intensity” (unreported in 4% cases). The results of the survey were as follows: 100% felt a decreased need to talk to the radiologist to clarify the report, 81.8% felt an improvement in the quality of reporting as compared to free style reports, and 91% felt that the new template is easier to interpret. Conclusion: The introduction of a structured template for rectal cancer significantly improved the quality of rectal MRI reports, along with the satisfaction of referring providers.
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Diffusion weighted imaging in breast cancer – Can it be a noninvasive predictor of nuclear grade? p. 13
R Rupa, R Thushara, S Swathigha, R Athira, N Meena, Mathew P Cherian
Background: DWI and ADC values are noninvasive MRI techniques, which provide quantitative information about tumor heterogeneity. Aim: To determine the minimum and mean ADC values in breast carcinoma and to correlate ADC values with various prognostic factors. Settings and Design: Prospective observational study. Materials and Methods: Fifty-five patients with biopsy-proven breast carcinoma were included in this study. MRI with DWI was performed with Siemens 3T Skyra scanner. ADC values were measured by placing regions of interest (ROIs) within the targeted lesions on ADC maps manually. The histopathological and immunohistochemical analysis of surgical specimen was done to determine the prognostic factors. Statistical Analysis: Students T test and ANOVA were used to study the difference in ADC between two groups. Pearson correlation coefficient was used to quantify the correlation between ADC values and prognostic factors. Results: Lower grade (grade I) breast carcinoma had a significantly high ADC value as compared to higher grade carcinoma (grade II and III). For differentiating Grade I tumors from grade II and III, a minimum ADC cut-off value was 0.79 × 10-3 mm2/sec (83% sensitivity and 84% specificity) and a mean ADC cut-off value was 0.82 × 10-3 mm2/sec (83% sensitivity and 71% specificity) was derived. There was no significant correlation between ADC and other prognostic factors. Conclusion: ADC values can be used to differentiate lower grade breast carcinoma (grade I) from higher grades (grade II and III). Minimum ADC values are more accurate in predicting the grade of the breast tumor than mean ADC value.
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Chemotherapy-induced pulmonary complications in cancer: Significance of clinicoradiological correlation p. 20
Ekta Dhamija, Pankaj Meena, Vidyasagar Ramalingam, Ranjeet Sahoo, Sameer Rastogi, Sanjay Thulkar
Chemotherapy while revolutionizing cancer management by improving survival and quality of life; is also associated with several adverse effects. Lung is the most common organ affected in chemotherapy-related complications, due to either drug toxicity or more commonly due to infections caused by immunosuppression and less commonly due to immune-mediated injury. Radiology, when used in combination with clinical and lab data, can help reach the specific diagnosis or narrow down the differentials. The common radiological patterns of drug toxicity include pulmonary interstitial and airway infiltrates, diffuse alveolar damage, nonspecific interstitial pneumonia, eosinophilic pneumonia, cryptogenic organizing pneumonia, pulmonary hemorrhage, edema and hypertension. Cancer patients are immunosuppressed due to the underlying malignancy itself or due to therapy and are prone to a gamut of opportunistic infections including viral, bacterial, fungal and mycobacterial pathogens. Immune reconstitution inflammatory syndrome (IRIS), a well-known complication in HIV, is now being increasingly recognized in non-HIV patients with immunosuppression. Engraftment syndrome is specifically seen following hematopoietic stem cell transplant during neutrophil recovery phase. Pulmonary involvement is frequent, causing a radiological picture of noncardiogenic pulmonary edema. Thus, radiology in combination with clinical background and lab parameters helps in detecting and differentiating various causes of pulmonary complications. This approach can help alter potentially toxic treatment and initiate early treatment depending on the diagnosis.
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Discordant dating of pregnancy by LMP and ultrasound and its implications in perinatal statistics p. 27
Lalit K Sharma, Jyoti Bindal, Vishal A Shrivastava, Mansi Sharma, Rijo M Choorakuttil, Praveen K Nirmalan
Context: High perinatal mortality in India may be caused by inaccurate dating of pregnancy resulting from suboptimal uptake of antenatal care and ultrasound services during pregnancy. Aim: To determine the discrepancy in the last menstrual period (LMP) assigned expected date of delivery (EDD) and ultrasound assigned EDD in pregnant women in a rural district of central India. Methods: Data from an ongoing cross-sectional screening program providing fetal radiology imaging in Guna district of Madhya Pradesh from 2012–2019 was analyzed for recall of LMP and discordance between LMP and ultrasound assigned EDD. The discrepancy was present when EDD assigned by ultrasound differed by 3 or more days at gestational ages less than 8+6 weeks, 5–7 days at gestational ages 8+6 weeks till 14 weeks, and 7–10 days at gestational ages 14–20 weeks. Results: The program screened 14,701 pregnant women of which 4,683 (31.86%, 95% CI: 31.11, 32.61) could not recall LMP. EDD assigned by LMP and ultrasound matched in 7,035 (70.22%, 95% CI: 69.32, 71.12) of the remaining 10,018 pregnant women. EDD was overestimated by LMP for 26.06% (95% CI: 25.21, 26.93) women; these foetuses were at risk of being misclassified as a term fetus. In 2018, the project had no maternal deaths, infant mortality rate of 24.7, low birth weight rate of 9.69%, and 100% antenatal coverage. Conclusion: Accurate dating of pregnancy and systematic follow-up integrating radiology imaging and obstetrics care for appropriate risk-based management of pregnant women can significantly improve perinatal statistics of India.
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Niche role of MRI in the evaluation of female infertility p. 32
Shabnam Bhandari Grover, Neha Antil, Amit Katyan, Heena Rajani, Hemal Grover, Pratima Mittal, Sudha Prasad
Infertility is a major social and clinical problem affecting 13–15% of couples worldwide. The pelvic causes of female infertility are categorized as ovarian disorders, tubal, peritubal disorders, and uterine disorders. Appropriate selection of an imaging modality is essential to accurately diagnose the aetiology of infertlity, since the imaging diagnosis directs the appropriate treatment to be instituted. Imaging evaluation begins with hystero- salpingography (HSG), to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at HSG but usually require further characterization with pelvic ultrasound (US), sono-hysterography (syn: hystero-sonography/saline infusion sonography) or pelvic magnetic resonance imaging (MRI), when US remains inconclusive. The major limitation of hysterographic US, is its inability to visualize extraluminal pathologies, which are better evaluated by pelvic US and MRI. Although pelvic US is a valuable modality in diagnosing entities comprising the garden variety, however, extensive pelvic inflammatory disease, complex tubo-ovarian pathologies, deep-seated endometriosis deposits with its related complications, Mulllerian duct anomalies, uterine synechiae and adenomyosis, often remain unresolved by both transabdominal and transvaginal US. Thus, MRI comes to the rescue and has a niche role in resolving complex adnexal masses, endometriosis, and Mullerian duct anomalies with greater ease. This is a review, based on the authors' experience at tertiary care teaching hospitals and aims to provide an imaging approach towards the abnormalities which are not definitively diagnosed by ultrasound alone.
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Correlation between MRI characteristics of medulloblastoma with histopathological subtypes and 2-year survival p. 46
Intan Zariza Hussain, Faizah Mohd Zaki, Shahizon Azura Mukari, Suria Hayati Md Pauzi, C-Khai Loh, Hamidah Alias
Objectives: The objective of this study is to describe the imaging features of medulloblastoma (MB) and correlate the MR characteristics with the different histological subtype of MB with 2-year survival. Materials and Methods: This is a retrospective descriptive study. A total of 29 patients diagnosed with MB from January 2005 to December 2015 were included in this study. The MRI brain and spine studies of these patients were retrieved and reviewed by a pediatric radiologist and a neuroradiologist independently, both blinded from the histological type of the MB. The HPE slides were also retrieved and reviewed by a pathologist. Results: 80% of desmoplastic MB showed the presence of intracranial leptomeningeal seeding and 57.1% of anaplastic MB showed the presence of necrosis. The presence of intracranial leptomeningeal seeding (P = 0.002) and necrosis (P = 0.019) was predictive of the histological subtypes. There is a significant correlation between the enhancement pattern and the 2-year outcome (P = 0.03) with 6 out of 8 patients whose tumors showed minimal enhancement having disease progression within 2 years. A significant correlation was also seen between the presence of necrosis with a poorer outcome (P = 0.03) and between the HPE subtype and 2-year outcome (P = 0.03) with anaplastic MB having the poorest prognosis. Conclusion: MR imaging features of intracranial leptomeningeal seeding and the presence of necrosis were correlated with a specific histologic subtype of MB. The enhancement pattern as well as necrosis correlated with 2-year poorer outcome of the disease.
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Utility of Doppler ultrasound in early-onset neonatal sepsis p. 52
Chetana R Ratnaparkhi, Madhura V Bayaskar, Avinash P Dhok, Vikrant Bhende
Background: Neonatal sepsis is an important cause of morbidity and mortality among newborns. As there is paucity of literature regarding early alteration of the cerebral blood flow (CBF) in neonatal sepsis our study aims to evaluate the changes in the CBF velocities and Doppler indices in neonates with early-onset neonatal sepsis (EONS) and to evaluate the predictive accuracy of cerebral blood flow velocities (CBFV) by using ultrasound Doppler as a diagnostic marker of EONS. Methods: This cross-sectional analytical study was conducted over a period of 2 years with 123 neonates enrolled in the study. The neonates were divided into two groups: Group I (with 54 neonates) - neonates with EONS and group II (with 69 neonates) - age-matched neonates without any signs of sepsis. Ultrasound Doppler examination was performed and the cerebral hemodynamics assessed in neonates during the first seventy two hours of life. Doppler indices and CBFV were measured in the internal carotid artery (ICA), middle cerebral artery (MCA), and vertebral artery (VA) of either side. Data were analyzed using the statistical program SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated at different selected cutoff values for CBFV parameters. Results: Lower resistance and higher peak systolic velocity and end diastolic velocity have been documented in neonates with EONS. Conclusion: Our study shows that the cerebral hemodynamics in neonates with EONS is altered which can be assessed bedside by noninvasive ultrasound Doppler examination.
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Diagnostic accuracy of dual energy CT in the assessment of traumatic bone marrow edema of lower limb and its correlation with MRI p. 59
Harsh Yadav, Sachin Khanduri, Poonam Yadav, Sushma Pandey, Vivek Kumar Yadav, Shahla Khan
Background: Bone marrow edema is assumed to be caused as a result of trabecular microfractures that are detected by MRI. As MRI is not widely available in countries like India, this study aims to encourage the use of DECT in detection of bone edema as evidence with comparable efficiency to MRI. Aim: To assess the diagnostic accuracy of dual-energy CT in detecting bone marrow edema in patients of trauma of lower limb and correlate it with MRI. Setting and Design: It is a cross-sectional study. Materials and Methods: The study included 40 patients of age 15–70 years irrespective of sex. All the patients of lower extremity trauma underwent DECT and MRI evaluation after clinical evaluation. All the images were postprocessed on a work station and were further evaluated by a radiologist. Results: Mean attenuation at fractured site observed by Dual energy CT was found to be significantly higher as compared to that at adjacent site (170.75 ± 33.99 vs. 19.73 ± 22.50 HU). The sensitivity and specificity of dual energy CT as compared to MRI in detecting bone marrow edema were 94.1% and 91.3%, respectively. Of the 40 cases enrolled in the study, agreement of MRI and Dual energy CT was observed in 37 (92.5%). Conclusion: Dual energy CT can be an effective alternative to MRI in the detection of bone marrow edema in patients of lower limb trauma. Dual energy CT can also be used in patients in whom MRI is contraindicated.
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A study to assess the knowledge and practice of medical professionals on radiation protection in interventional radiology p. 64
Mohsen Shafiee, Razieh Rashidfar, Jamil Abdolmohammadi, Sajad Borzoueisileh, Zaker Salehi, Kheibar Dashtian
Objective: Ionizing radiation has been extensively used in medical procedures throughout the world. Such interventional radiological procedures could result in occupational exposure that needs urgent control. Therefore, MPs (medical professionals) should receive education and appropriate training on occupational radiation protection. In this context, the present study is aimed to investigate the MPs' knowledge and practice regarding radiation protection principles during interventional radiological procedures. Material and Methods: A descriptive questionnaire-based study was carried out among 215 MPs involved in interventional fluoroscopy procedures. The practice of 31 MPs was studied using a checklist based on ALARA principles and ICRP guidelines. Results: A total of 43.3% and 45.1% answered correctly for knowledge and practice. However, the difference between radiation protection knowledge and practice between the physicians and nurses was statistically significant. The knowledge and practice survey of MPs demonstrated that nurses rarely adhered to radiation-protection measures. Conclusion: The present study reflects the lack of knowledge and practice concerning radiation protection concepts among the nurses. This deficiency needs to be resolved by periodic practical radiation protection courses in the curriculum of medicine.
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Insights into obtaining FRCR and beyond: Obstacles, opportunities and post-relocation dilemma – An Indian perspective p. 70
Siddharth Thaker, Rajesh Botchu, Harun Gupta
Indian radiology trainees and radiologists are interested to have FRCR (Fellow of the Royal College of Radiologists) qualification for various reasons including academic career progression, subspecialty interest and other socioeconomic factors. The path for acquiring FRCR qualification is adventurous yet onerous and exhausting. Perseverance, meticulous planning and clarity in the vision are essential prerequisites for an Indian graduate aiming to complete FRCR qualification, and one may require to invest an average of 1.5–2 years even if there is no reattempt in this tripartite examination. Indian doctors including radiologists are considered amongst the finest across global medical fraternities. However, the Indian medical education is skewed and variably distributed over the subcontinent due to organisational inability to provide single radiology curriculum-based education to all radiology training programmes. Parallel educational boards and a variety of institutions such as government, trust-funded and private organisations provide radiology training to further complicate the grand picture of radiology education in India. Conversely, UK radiology education is uniform nationally and rigorously enforced by deaneries based upon state-provided guidelines. UK training opportunities are essentially academically rewarding experience but they require herculean efforts to gain access to one. One should constantly focus on building a resume at par with that of a UK trainee by obtaining experience required to fulfil checklist for such opportunities. Alongwith addressing local (UK) competition thoughtfully, hard work, diligence, and high standards of work ethics are absolute musts to build a great resume, to obtain training opportunity and, in turn, to satisfy the ultimate goal of carrier advancement.
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MDCT evaluation of intramyocardial-sinusoids-coronary artery communications in a neonate with pulmonary atresia and intact ventricular septum p. 77
Karuna M Das, Taleb M Almansoori, Tarek Suliman Momenah, Klaus Neidl-Van Gorkom
A patient of tetrology of Fallot with complete atresia of the pulmonary outflow tract with ventriculocoronary connections is presented.MDCT imaging revealed left coronary sinus, with a large fistula draining into the free wall of hypoplastic right ventricular cavity with tortuous channel arising from right ventricular outflow, and communicating with proximal limb of the fistula forming a complete loop suggesting a right ventricle–to – left coronary sinus sinusoid.
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Interrupted aortic arch: A case report p. 81
Andrea Franconeri, Francesco Ballati, Maurizio Pin, Luisa Carone, Gian M Danesino, Adele Valentini
Interrupted aortic arch diagnosed in adult age is a rare entity, with only a few cases published in the literature. Most of them are classified as type A interrupted aortic arch and differential diagnosis is associated with severe chronic coarctation. We present a case of a 52-year-old woman accessed to the emergency department for chest and right upper limb pain that increased in the last days. She underwent a computed tomography angiogram showing interruption of the aortic arch, distal to left subclavian artery origin, large bilateral collateral vessels connecting subclavian arteries to descending aorta with multiple voluminous aneurysms, a bicuspid aortic valve, dilatated tubular segment of ascending thoracic aorta, and a suspected atrial septal defect. A nonsystematic literature review regarding these conditions has been performed.
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SAPHO syndrome: A radiological case report p. 84
Anil Kumar Singh, Rahul S Ranjan
The SAPHO syndrome (synovitis–acne–pustulosis–hyperostosis–osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. Herein, we present a case of incidentally detected SAPHO syndrome in a middle-aged male patient who visited the hospital for pulmonary complaints.
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Myositis ossificans of mobile wad of Henry-Tennis elbow mimic p. 89
Ghassan Almeer, Christine Azzopardi, James Kho, Rajesh Botchu
Lateral epicondylitis also known as “tennis elbow” is the most common cause of lateral elbow pain. Several pathologies can mimic symptoms of tennis elbow. We present a case of myositis ossificans within the mobile wad of Henry (MWH), which presented with symptoms of tennis elbow and believe this to be the first reported case in literature.
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Traumatic intralenticular abscess—What is so different? p. 92
S Balamurugan, Bharat Gurnani, Kirandeep Kaur, Prasanth Gireesh, Shivanand Narayana
Intralenticular abscess is a very rare entity that occurs after trauma, cataract surgeries, or as metastatic infection. It is important to pinpoint this sequestrated infection and to evacuate the abscess surgically to prevent chronic endophthalmitis. In this report, we describe a case of posttraumatic lenticular abscess highlighting the characteristic clinical features and their management. Additionally, here we report the first time use of Anterior Segment Optical Coherence Tomography as a diagnostic tool in delineating lens abscess from traumatic cataract which further guide the management and prognosis of the case. Traumatic intralenticular abscess (TILA)—What is so different?
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Multiple small bowel intussusceptions as a feature of celiac disease p. 95
Bhautik Kapadia, Sunil Karshanbhai Vatukiya
Intussusception is commonly associated with celiac disease in adults. However, it is rarely reported in children in radiology journals. Here, we report a case of a 3-year-old girl with celiac disease presented with complaints of intermittent abdominal pain, distension, and vomiting for 6 months. The patient was underweight (8.6 kg). Her X-ray of the abdomen standing revealed abnormal air-fluid levels and ultrasound of the abdomen revealed single small bowel intussusception. Contrast-enhanced CT abdomen done before planning surgery and it revealed five small bowel intussusceptions with few dilated small bowel loops. Her IgA antibodies to tissue transglutaminase were done to look for the cause of failure to thrive and its titer raised significantly. Gluten-free diet was started for her and symptoms were resolved within 7 days without surgical management.
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Hereditary hemorrhagic telangiectasia of liver: Pathophysiology with role of radiology in diagnosis and treatment p. 98
Maheswaran Viyannan, Devanand Balalakshmoji, Venkatakrishnan Leelakrishnan
Hereditary hemorrhagic telangiectasia (HHT) or Osler–Weber–Rendu syndrome is a rare condition which can result in significant systemic and hepatobiliary abnormalities. Liver involvement in HHT consists primarily of the consequence of various intrahepatic shunts. Even though these vascular shunts are present in the majority of patients with HHT, symptoms occur only in minority with clear predilection to female gender. The symptoms and imaging findings of liver vascular malformations can be easily overlooked or misdiagnosed which can result in delay in treatment or potentially harmful vascular interventions. In this case report, we discuss the pathophysiology of HHT in liver involvement, role of imaging in diagnosis, and the possible role of interventional radiologist in the treatment.
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18F-FDG PET/CT in cyst infection in autosomal dominant polycystic kidney disease p. 102
Meghana Prabhu, Nishikant A Damle, Animesh Ray, Devasenathipathi Kandasamy
Infection of a cyst within an autosomal dominant polycystic kidney disease (ADPKD) is a serious complication. Diagnosis with conventional imaging techniques such as ultrasonography, computed tomography (CT), and magnetic resonance imaging can be sometimes challenging. The definite diagnosis is analysis of the cyst fluid, but cyst punctures can cause bleeding, rupture, and contamination of adjacent cysts. Recently, FDG PET/CT has been reported as a sensitive tool for detection of cyst infection. We describe a case of 63-year-old woman with infected cysts in the left kidney, in whom accurate diagnosis was made on FDG PET/CT. FDG PET/CT is an important investigation in patients with fever of uncertain etiology, where renal cyst infection is a possible cause, but other etiologies also need to be ruled out.
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