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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 30 | Issue 2
Page Nos. 105-250

Online since Monday, July 13, 2020

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EDITORIAL  

COVID 19- Tips for getting back to work Highly accessed article p. 105
Anirudh Kohli
DOI:10.4103/ijri.IJRI_569_20  
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NEUROIMAGING Top

Accuracy of radiologists, nonradiologists, and laypeople for identifying children with cerebral cortical atrophy from “Mercator map” curved reconstructions of MRIs of the brain p. 111
Anith Chacko, Schadie Vedajallam, Savvas Andronikou, Ewan Simpson, Ngoc Jade Thai
DOI:10.4103/ijri.IJRI_130_20  
Background: Using text reports to communicate bilateral, symmetric, and zonal cortical brain atrophy in children with term hypoxic ischemic injury (HII) to parents and legal professionals contesting compensation rights can be difficult. Using standard cross-sectional images for explaining bilateral, regional brain imaging to laypeople is also challenging. A single flattened image of the brain surface, much like a map of the earth is derived from a globe, can be generated from curved reconstruction of magnetic resonance imaging (MRI) scans, i.e., a Mercator map. Laypeople's ability to identify abnormal “Mercator brain maps,” without prior training, requires evaluation before use in nonmedical settings. Aim: To determine the sensitivity and specificity of laypeople in detecting abnormal pediatric Mercator flat-earth maps of the brain, without prior training. Methods and Materials: 10 Mercator brain maps were provided to 111 participants individually. The maps comprised 5 HII, 1 cortical dysplasia, and 4 normal cases. Participants were required to identify the abnormal scans. Sensitivity and specificity overall and for participants' subgroups were calculated. Results: Overall sensitivity and specificity were 67% and 80%, respectively. General radiologists (n = 12) had sensitivity and specificity of 91.2% and 94.6%, respectively. Laypeople (n = 54) had a sensitivity of 67% and specificity of 80%. Conclusion: The high specificity and sensitivity of radiologists validated the technique for distinguishing abnormal scans, regarding cortical pathology. High specificity of laypeople for identifying abnormal brains using Mercator maps indicates that this is a viable communication tool for demonstrating cortical MRI abnormalities of HII in children to laypersons.
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Cranial nerve schwannoma – A pictorial essay p. 116
Sivaramalingam Geethapriya, Jayaraj Govindaraj, Bagyam Raghavan, Banupriya Ramakrishnan, Rasheed Arafath, Sathyashree Vishwanathan, Murali Krishna
DOI:10.4103/ijri.IJRI_17_20  
Schwannomas are peripheral nerve sheath tumours arising from cranial, spinal or peripheral nerves. Most of the schwannomas are benign with the rare possibility of malignant transformation. Cranial nerve schwannomas can be seen along the course of any cranial nerve in the intracranial region or head and neck location. Although a majority are solitary sporadic lesions, multiple schwannomas can be seen in syndromes like neurofibromatosis type 2 and rarely in type 1. Since intracranial schwannomas are slow-growing, clinical presentation varies between no symptoms to cranial nerve palsy. Most of the times, the symptoms are due to mass effect over the adjacent structures, foraminal widening, compression of other cranial nerves, denervation injury or hydrocephalus. Familiarity with the course of the cranial nerves, imaging appearances and clinical presentation of schwannomas helps in accurate diagnosis and possible differential diagnosis, especially in uncommon clinical and radiological appearances. In this pictorial review, we illustrate relevant anatomy of cranial nerves, imaging features of schwannomas of most of the cranial nerves, clinical presentation and differential diagnosis.
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HEAD AND NECK IMAGING Top

MR evaluation of tongue carcinoma in the assessment of depth of invasion with histopathological correlation: A single center experience Highly accessed article p. 126
Reddy Ravikanth
DOI:10.4103/ijri.IJRI_286_19  
Introduction: Magnetic resonance imaging (MRI) has become the cornerstone for pretreatment evaluation of carcinoma tongue and provides accurate information regarding the extent of the lesion and depth of invasion that helps the clinician to optimize treatment strategy. Aim of the study is to correlate MRI and histopathological findings, to evaluate the role of MRI in loco-regional tumor node metastasis (TNM) staging, and to assess the depth of invasion of tongue carcinoma. Materials and Methods: This study was undertaken on 30 patients with clinical diagnosis of tongue carcinoma referred for MR imaging at a tertiary care hospital over the 2-year period between July 2017 and June 2019. MRI was performed with GE 1.5 Tesla scanner, neurovascular (NV) array coil. Clinical and MRI staging of tongue carcinoma was done preoperatively and correlated. Post-surgery, histopathological TNM staging was done and correlated with clinical and MRI TNM staging. The cutoff value of histopathological (HP) depth that could determine the existence of nodal metastasis was 5 mm. Results: In 30 patients diagnosed with tongue carcinoma, the incidence was higher in males (92%). Moderate agreement (k = 0.512) was noted for T staging between clinical and MRI staging assessments. Fair agreement (k = 0.218) was noted for N stage between clinical and MRI staging assessments. There was good agreement (k = 0.871) for M stage between the clinical and MRI staging assessments. Good agreement (k = 0.822 and k = 0.767, respectively) was noted for both T staging and Nstaging between MRI and histopathology staging assessments. The agreement for the T stage was poor (k = 0.012) between the clinical and histopathology staging assessments. Agreement for the N stage was also poor (k = 0.091) between the clinical and histopathology staging assessments. Mean depth of invasion by histology and MRI was 14.22 mm and 16.12 mm, respectively. Moderate agreement (k = 0.541) was noted between clinical and pathological tumor depth and good agreement (k = 0.844) was noted between radiological and pathological tumor depth. As for the T1WGd MRI depth with a cutoff value of 5 mm, the nodal metastasis rate in the group with values >5 mm was 52%, and for those <5 mm was 24%, both of which were significantly different (P = 0.040). Pearson's correlation coefficient of HP depth and T1WGd MRI depth was 0.851 (P < 0.001) suggesting that HP depth shows a strong correlation with T1WGd MRI depth. Conclusion: MRI is the imaging modality of choice for evaluation of tongue carcinoma as MRI helps in accurate staging of the tumor using TNM classification which is crucial for optimizing treatment options. The current study shows a high correlation between MRI and histopathological findings regarding thickness of tumor and depth of invasion. MRI and histopathology assessments of tumor spread were equivalent to within 0.5 mm DOI. Estimation of invasion depth using MRI as a preoperative study in oral tongue carcinoma is essential in planning surgical treatment strategies such as the extent of elective neck dissection. Invasion depth, which greatly affects occult node metastases, must be included in the TNM staging of oral tongue carcinoma.
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Imaging in congenital inner ear malformations—An algorithmic approach p. 139
Abhinav C Bhagat, Jyoti Kumar, Anju Garg, Anjali Prakash, Ravi Meher, Shivali Arya
DOI:10.4103/ijri.IJRI_58_19  
Malformations of the inner ear are an important cause of congenital deaf-mutism. Arrest in embryologic development of inner ear during various stages gives rise to the variety of malformations encountered. Current treatment options include hearing aids, cochlear implants, and auditory brainstem implants (ABI). With the advent of cochlear implant surgery and ABI, decent functional outcomes can be obtained provided such cases are diagnosed correctly and timely. To that end, high-resolution computed tomography (HRCT) has a fundamental role in the assessment of these conditions, ably supplemented by magnetic resonance imaging (MRI). The purpose of this pictorial essay is to illustrate the imaging features of inner ear anomalies in children with congenital deaf-mutism as per the latest terminology and classification and provide an algorithmic approach for their diagnosis.
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FETAL IMAGING Top

Fetal ultrasound parameters: Reference values for a local perspective Highly accessed article p. 149
Navita Aggarwal, GL Sharma
DOI:10.4103/ijri.IJRI_287_19  
Background: Fetal biometry, with the help of ultrasonography (USG) provides the most reliable and important information about fetal growth and well-being. Frequently used parameters for fetal measurements by this method are the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). These fetal dimensions depend upon the racial demographic characteristics, nutrition, genetics and many more environmental factors of a particular population. Aims: The purpose of the present investigation was to define and analyze these fetal biometric parameters in our local population and to compare them with the given norms. Methods: This cross-sectional study with convenience sampling was conducted on a total of 425 fetuses with a period of gestation between 18 to 38 weeks. Descriptive statistics was used to calculate the mean with standard deviation and 95% confidence interval (CI) for each fetal parameter in each gestational week. Results: Mean of BPD and FL in our population are similar to the mean values given by Hadlock throughout the pregnancy, except near the end of the third trimester where our population shows a slightly lower range of mean values. HC and AC fall below the lower range of Hadlock as early as 24 weeks of pregnancy. Conclusions: Fetal biometric parameters in the studied population are at the lower range of established nomograms by Hadlock on white fetuses, more so with the progression of pregnancy.
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Analysis of factors influencing accuracy of ultrasound-based fetal weight estimation p. 156
Sujitkumar Hiwale, Celine Firtion
DOI:10.4103/ijri.IJRI_167_19  
Context: The primary objective of this study was to examine the impact of maternal age, parity, gestational age, fetal gender, gestational diabetes mellitus, and pregnancy-induced hypertension on the accuracy of ultrasonography-based fetal weight estimation. The secondary objective was to find the impact of a formula selection on the accuracy of fetal weight estimation. Subjects and Methods: The inclusion criteria were a live-birth singleton pregnancy and the last ultrasound scan to delivery interval ≤7 days. Fetal weight was estimated using the Hadlock-4 formula. To study the concurrent impact of all the factors on the accuracy, cases were divided into two subcategories based on percentage error, with ±10% as a threshold. The accuracy of Hadlock-4 formula was compared with the two Indian population-based formulas, Hiwale-1 and Hiwale-2. Results: In total, 184 cases were included in the study. It was observed that the systematic error in weight estimation was significantly less in the male fetuses (8.45 ± 9.34%) in comparison to the female fetuses (11.71 ± 10.34%). The combined impact of all the factors on the accuracy was found to be nonsignificant by the multivariate analysis. The Hiwale-1 (-0.59 ± 8.75%) and Hiwale-2 (-0.65 ± 8.7%) formulas had statistically significant less errors compared to the Hadlock-4 formula (11.67 ± 7.95%). Conclusion: All the studied clinical factors were found to have a limited impact on the overall accuracy of fetal weight estimation. However, the formula selection was found to have a significant impact on the accuracy, with the native population-based formulas being significantly more accurate.
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THORACIC IMAGING Top

Correlation of asthma severity, IgE level, and spirometry results with HRCT findings in allergic bronchopulmonary aspergillosis p. 163
Zafar Neyaz, Zia Hashim, Sunil Kumar, Alok Nath, Ajmal Khan, Namita Mohindro
DOI:10.4103/ijri.IJRI_443_19  
Context: Few studies have been done for correlating asthma severity, IgE level, and spirometry results with high-resolution computed tomographic (HRCT) findings in allergic bronchopulmonary aspergillosis (ABPA). Aims: This prospective observational study was conducted to correlate asthma severity, IgE level, and spirometry results with HRCT findings in ABPA. Settings and Design: Prospective observational. Subjects and Methods: Fifty consecutive adult patients with asthma and positive specific IgE (>0.35 kUA/L) to Aspergillus fumigatus were recruited from October 2015 to July 2017. Asthma severity, IgE levels, and spirometry results were correlated with HRCT score, bronchiectasis score, air trapping segments, and low-attenuation lung volume on inspiratory CT and expiratory CT. Statistical Analysis Used: One way ANOVA, Spearman's correlation coefficients. Results: Asthma severity showed a significant positive correlation with HRCT score and bronchiectasis score. MEF pre and postbronchodilator values showed a significant negative correlation with HRCT score, bronchiectasis score, and percentage expiratory volumes -851 to -950 HU voxels. FEV1 prebronchodilator value showed a significant negative correlation with percentage expiratory volume -851 to -950 HU voxels and percentage expiratory volume -851 to -1024 HU voxels. Specific IgE antibody level showed a significant positive correlation with bronchiectasis score. Conclusions: Asthma severity, specific IgE level, and MEF values showed a good correlation with HRCT findings. The restrictive pattern is common on spirometry in patients of ABPA. In addition to central bronchiectasis, peripheral bronchial and small airway involvement was an important finding in ABPA. Expiratory HRCT may reveal air trapping in patients having no abnormality on inspiratory CT.
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CARDIOVASCULAR IMAGING Top

Determining the normal effective diameter of thoracic aorta in pediatric population of India p. 170
Sunita V Kale, Shah Alam
DOI:10.4103/ijri.IJRI_2_20  
Background: It is imperative to establish normative ranges of aortic diameter to diagnose various aortic pathologies. There have been very few studies establishing the normal aortic diameter on cross-sectional imaging, and none pertaining to the Indian pediatric population. The objective of this study was, therefore, to establish the normal effective diameter of thoracic aorta at multiple levels using computed tomographic data, calculate z-scores, and plot reference curves. Subjects and Methods: The effective thoracic aorta diameters (average of anteroposterior and lateral diameters) were measured at predefined levels (aortic root, ascending aorta at the level of right pulmonary artery, aortic arch, proximal descending aorta, and aorta at the level of diaphragmatic hiatus) on double-oblique reconstructed computed tomography (CT) images perpendicular to the direction of the vessel. Multiple functional forms relating the effective diameter to subjects' age were evaluated with least square regression methods, and further R2 was used to ascertain the best model. Age-based formulas to derive normal aorta diameters and mean squared errors (MSEs) were established. Results: Two hundred and seven contrast-enhanced CT (CECT) thorax studies of children without known cardiovascular disease were studied. The polynomial regression model relating the effective diameter that included linear, quadratic, and cubic age terms as independent variables were found to the best statistical model. The z scores were calculated, and normative curves were plotted. Conclusions: We have established normative effective diameters of the thoracic aorta at multiple levels in Indian children of different age groups. Measurements outside of the normal ranges are indicators of ectasia, aneurysm, hypoplasia, or stenosis.
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Horizontal sandwiched interventricular septum: Complex cardiac anatomy deciphered with DSCT p. 177
Amit A Deshpande, SH Chandrashekhara, Arun Sharma
DOI:10.4103/ijri.IJRI_362_19  
The superior-inferior ventricle is a rare anomaly with the unknown incidence owing to less number of reported cases. However, one of the studies has reported this incidence to be <0.1% of all congenital heart diseases. This has a characteristic imaging appearance with horizontal interventricular septum. Most of the previous reports of superior-inferior ventricles have been described on echo, catheter angiography and only a few with cross-sectional imaging. We report two cases of superior-inferior ventricles associated with complex congenital cardiac defects on dual-source CT.
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INTERVENTIONAL RADIOLOGY Top

Low incidence of vascular uptake during ganglion impar sympathetic nerve blocks for coccydynia p. 181
Patrick M Foye, Woon T K Jason, Kevin Y Zheng, Kenneth K Leong
DOI:10.4103/ijri.IJRI_302_19  
Context: Focal sympathetic nerve blocks of the ganglion impar are often effective treatments for coccydynia (coccyx pain) and other pelvic pain syndromes. These injections are generally performed under contrast-enhanced fluoroscopic guidance. Vascular uptake may potentially occur during the injection and vascular uptake rates have been reported for other spinal injections, but never for ganglion impar blocks. Aims: The purpose of the study was to determine vascular uptake rates during fluoroscopy-guided ganglion impar blocks. Settings and Design: An academic/University-based Coccyx Pain Center. Methods and Materials: A total of 78 consecutive trans-coccygeal ganglion impar blocks were analyzed for vascular uptake of contrast as determined by intermittent fluoroscopy. Statistical Analysis Used: Direct calculation of incidence. Results: Only one patient (1.3%) demonstrated a vascular uptake pattern, which was readily recognized and corrected by slightly adjusting the position of the needle tip and thereby subsequently obtaining the desired contrast pattern at the ganglion impar. Conclusions: Vascular uptake incidence is low during ganglion impar blocks. This information can be one of the multiple factors considered when a physician is deciding whether or not to use contrast in an individual patient.
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MISCELLANEOUS Top

MRI evaluation of soft tissue vascular malformations p. 184
Peeyush K Dhagat, Megha Jain, Afaq Farooq
DOI:10.4103/ijri.IJRI_439_19  
Background: Soft tissue vascular malformations are not uncommonly encountered in clinical practice and are often mistaken for other pathologies. Vascular anomalies are divided into vascular tumors and malformations. Vascular malformations progressively increase in size with increasing age and are classified into low-flow (venous, lymphatic, veno-lymphatic, capillary and capillary venous) and high-flow malformations (arteriovenous malformations (AVM) and arteriovenous fistula (AVF)) depending on the presence or absence of arterial flow. Aim: Aim of this study is to evaluate the Magnetic resonance imaging (MRI) features of the soft tissue vascular malformations and to classify the lesions depending on flow pattern. Materials and Methods: A total of 52 patients of soft tissue vascular malformations were included in this study over a period of 3 years. All patients underwent detailed clinical examination and dynamic post contrast MRI evaluation. Doppler and ultrasound were done as an adjunct. Results: There were 31 females and 21 male patients with age ranging from 9 to 34 years. In total 33 venous, 11 lymphatic, 8 veno-lymphatic malformations were seen. No case of high-flow malformation was seen. Majority of the lesions involved the head and neck region and the extremities. Fat saturated T2WI, STIR, and 3D dynamic post contrast sequences were found to be the most useful MRI sequences. Conclusion: MRI is the modality of choice for evaluating the soft tissue vascular malformations. It depicts the extent of the lesion, classifies the lesions into low or high flow and helps in treatment planning.
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Life cycle costing of MRI machine at a tertiary care teaching hospital p. 190
Anupam Sahu, H Vikas, Nishant Sharma
DOI:10.4103/ijri.IJRI_54_19  
Background: Life cycle costing (LCC) is an excellent decision-making tool that can assist a hospital administrator in seeking more cost-effective decisions to select the best course of action. LCC can be defined as “an economic assessment of competing design alternatives, considering all significant costs of ownership over the economic life of each alternative, expressed in equivalent rupees. Aim: To determine the LCC of magnetic resonance imaging (MRI) machine at a tertiary care teaching hospital. Settings and Design: A descriptive, observational study in MRI scan center of a tertiary care teaching hospital. Materials and Methods: LCC analysis (LCCA) was performed to ensure total cost visibility for the entire life span of the MRI scan equipment, which was assumed to be 10 years. Statistical Analysis: Data were analyzed using MS Excel. Results and Conclusions: The total cost per MRI scan was calculated to be Rs. 2944. It was estimated that the MRI scan center would reach the break-even point by the end of the third year.
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Phakomatoses: A pictorial review p. 195
M Sarthak Swarup, Swati Gupta, Sapna Singh, Anjali Prakash, Anurag Mehndiratta, Anju Garg
DOI:10.4103/ijri.IJRI_497_19  
Phakomatoses or Neurocutaneous syndromes are a heterogeneous group of disorders and have variable inheritance pattern. Currently, more than 30 entities are included in this group. These disorders primarily affect the central nervous system; however, skin, viscera, and other connective tissues can also be involved with variable clinical presentation. We will describe and illustrate the various radiological findings of the common entities through the iconography of the cases presented to our department.
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TECHNICAL NOTE Top

Microwave ablation: How we do it? p. 206
Kunal B Gala, Nitin S Shetty, Paresh Patel, Suyash S Kulkarni
DOI:10.4103/ijri.IJRI_240_19  
Minimally invasive techniques such as Image guided thermal ablation are now widely used in the treatment of tumors. Microwave ablation (MWA) is one of the newer modality of thermal ablation and has proven its safety and efficacy in the management of the tumors amenable for ablation for primary and metastatic diseases. It is used in the treatment of primary and secondary liver malignancies, primary and secondary lung malignancies, renal and adrenal tumors and bone metastases. We wanted to share our initial experience with this newer modality. In this article we will describe the mechanism and technique of MWA, comparison done with RFA, advantages and disadvantages of MWA along with pre procedure workup, post procedure follow-up and review of literature.
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CASE REPORTS Top

A unique presentation of 5-fluorouracil (5-FU) induced cerebral encephalopathy p. 214
Shailendra S Naik, Ilavarasi Vanidassane, Ekta Dhamija, Atul Sharma
DOI:10.4103/ijri.IJRI_17_19  
5-Fluorouracil (5-FU), a commonly used antimetabolite and antineoplastic agent, has been approved for the treatment of various cancers. It is associated with systemic side-effects such as gastrointestinal problems, neutropenia. 5-FU-related encephalopathy is very rarely reported. Imaging with computed tomography (CT) and magnetic resonance imaging (MRI) plays a key role in diagnosing and monitoring the changes. Since the prognosis of cerebral involvement is usually good if recognized and treated in time, the reporting radiologist and treating physician should be familiar with them. We present a rare case of 5-FU-induced encephalopathy that was diagnosed based on her clinical and MRI findings and managed successfully.
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Isoniazid: A rare drug-induced cause for bilateral dentate nuclei hyperintensity p. 218
S Senthil Raj Kumar, S Shanmuga Jayanthan, G Rupesh
DOI:10.4103/ijri.IJRI_421_19  
Dentate nucleus, the largest deep nucleus of the cerebellum, is affected by numerous conditions, including leukodystrophies, toxins, drugs, infections, and various metabolic and inflammatory conditions. This case report is a drug-induced cerebellitis, caused by isoniazid (INH), characterized in magnetic resonance imaging (MRI) as bilateral dentate nuclei hyperintensity. Isoniazid, an antituberculosis therapy (ATT) drug, is both neurotoxic and hepatotoxic but cerebellitis is a rare complication. INH-induced cerebellitis is characterized in MRI by bilateral and symmetrical T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity in dentate nuclei. Though metronidazole is the most common drug associated with such MRI signal changes in the dentate nucleus, the uncommon association with INH has been described in literature especially in patients with renal function impairment. MRI findings together with clinical signs of cerebellar involvement, in a patient with abnormal renal function tests and in whom the ATT regimen was recently initiated, favors the diagnosis of INH toxicity. INH withdrawal and pyridoxine supplementation can reverse this condition.
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Anti-myelin oligodendrocyte glycoprotein antibody-positive coursing with optic neuritis: Imaging and clinical implications p. 222
Nithisha Thatikonda, Juan Gomez, Eduardo Gonazalez Toledo
DOI:10.4103/ijri.IJRI_486_19  
A 9-year-old boy was admitted to our institution with acute onset of bilateral blurry vision. Physical examination revealed bilateral papilledema. Cerebrospinal fluid analysis and comprehensive metabolic panel were normal. Magnetic resonance imaging (MRI) of the brain showed extensive bilateral optic nerve inflammation with post-contrast gadolinium enhancement on T1-weighted sequence. The involvement was limited to the anterior segments of the optic nerves sparing chiasma and optic tracts. Anti-aquaporin-4 antibody (AQP4) was negative while anti-myelin oligodendrocyte glycoprotein antibody (MOG) was positive. After intravenous methylprednisolone, his vision dramatically improved. The patient was discharged with only mildly impaired visual acuity, 2 weeks after admission. Follow-up brain MRI and MOG assay after 3 months were within normal limits.
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A case report on granular cell ameloblastoma – A rare histological entity p. 225
Anju Mathew
DOI:10.4103/ijri.IJRI_145_19  
Granular cell ameloblastoma is a rare condition, accounting for 3.5% of all ameloblastoma cases that shows marked transformation in the cytoplasm of tumor cells, which are usually stellate reticulum-like cells. The transformed cells possess very coarse, granular eosinophilic cytoplasm. Granular cell ameloblastoma is aggressive in nature with a marked propensity for recurrence and can progress to metastasis. This article discusses a case report of a 35-year-old female patient diagnosed with granular cell ameloblastoma of the right mandible.
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A rare cause of median neuropathy at the carpal tunnel: Thrombosis of the persistent median artery p. 229
Richa D Jain, Lokesh Bathala, HK Anuradha, Sudhir K Kale, Guruprasad S Pujar, Man M Mehndiratta, Leo H Visser
DOI:10.4103/ijri.IJRI_423_19  
Carpal tunnel syndrome is a common peripheral nerve entrapment neuropathy caused due to compression of the median nerve at the level of the wrist joint. Bifid median nerve associated with a persistent median artery is a rare entity and in itself asymptomatic anatomical variant. However, distension of the persistent median artery due to a thrombus can be symptomatic due to compression on the median nerve and can compromise the blood flow to the palm. We report a case of persistent median artery thrombosis in a young female patient who presented with symptoms of carpal tunnel syndrome diagnosed on the ultrasonography and confirmed on the MRI with subsequent improvement post anticoagulation therapy.
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Pseudotumor deltoideus: An underreported and misinterpreted cause of shoulder pain p. 233
Surbhi Singh, Akhil Tanwar
DOI:10.4103/ijri.IJRI_407_19  
Pseudotumor deltoideus refers to focal cortical irregularity and thickening at the deltoid insertion. It is benign in nature with a possible role as a tumor stimulator and possesses various anatomic variations. A well-defined area of cortical irregularity and radiological lucency at the deltoid insertion are uncommon radiological findings that pose a diagnostic dilemma. In this case report, we demonstrate a 45-year-old male with right shoulder pain along with radiological images indicative of the condition to make this previously less discussed entity more understandable. Cases of shoulder pain along with X-ray findings of cortical thickening in the proximal humerus should be investigated further with computed tomography (CT)/magnetic resonance imaging (MRI). Findings of an elongated lucency on CT and T2 hyperintensity in the cortex should help in the correct diagnosis of the condition. It should not be misdiagnosed as infective foci or a malignant entity and biopsy should be avoided.
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An unusual case with a missing parotid gland: A case report p. 237
Vaibhav Gulati, Arif Mirza, Parveen Gulati
DOI:10.4103/ijri.IJRI_416_19  
Unilateral or bilateral agenesis of the parotid gland is an uncommon condition with unclear aetiology. Only 22 cases of unilateral salivary agenesis have been reported excluding the present case. We present a case of a 4-year-old female child who presented with complaints of slight discoloration of her tongue and was referred for MRI to rule out any vascular malformation. Imaging revealed a complete absence of the right parotid gland. Hypertrophy of the sublingual gland and hypoplasia of the parotid gland on the opposite side was also noted, an unusual finding as the contralateral parotid showed compensatory hypertrophy in the other reported cases.
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Fallot type of absent pulmonary valve syndrome - A case report p. 240
Divya B Desai, Neeti P Mathur, Arnab Marik
DOI:10.4103/ijri.IJRI_508_19  
Absent pulmonary valve syndrome (APVS) is a rare congenital cardiac malformation characterized by absent, dysplastic, or rudimentary pulmonary valve leaflets in association with other cardiac anomalies. It has an incidence of 3-6% in cases of tetralogy of Fallot (TOF) and 0.2-0.4% of live-born infants with congenital heart disease (CHD). Absent pulmonary valve leads to dilated main pulmonary artery; presenting as a pulsatile, paracardiac cystic lesion on antenatal ultrasound (USG). We report a case of this rare anomaly in association with ventricular septal defect (VSD), TOF, and left axis deviation of heart detected at 23 weeks of gestation.
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LETTERS TO THE EDITOR Top

Lithopedion: An unusual cause of an abdominal calcified mass p. 244
Alexis Morales, Guillermo Aguilera, Dieter Krause
DOI:10.4103/ijri.IJRI_452_19  
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Hyperglycemia-induced seizures and blindness p. 245
Ayush Jain, Shilpa Sankhe
DOI:10.4103/ijri.IJRI_41_20  
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Rare case of duodenal obstruction due to abdominal aortic aneurysm, “aortoduodenal syndrome”: An Indian case report p. 247
Esther L Pachuau, Isak Lallawmkima
DOI:10.4103/ijri.IJRI_356_19  
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Introduction to research for international young academics, Radiological Society of North America scientific assembly and annual meeting, 2019, Chicago: Our experience p. 249
Ankit Balani, Chinky Chatur
DOI:10.4103/ijri.IJRI_489_19  
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