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Coverpage
October-December 2018
Volume 28 | Issue 4
Page Nos. 379-483

Online since Tuesday, December 18, 2018

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EDITORIAL  

Adiós Amigo - Passing the baton p. 379
Chander Mohan
DOI:10.4103/ijri.IJRI_455_18  PMID:30662195
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NEURORADIOLOGY & HEAD AND NECK IMAGING Top

Precontrast T1 signal measurements of normal pituitary and microadenoma: A retrospective analysis through DCE MRI signal time curves p. 380
Ishan Kumar, Tanya Yadav, Ashish Verma, Ram C Shukla, Surya K Singh
DOI:10.4103/ijri.IJRI_104_18  PMID:30662196
Background: The dynamic contrast enhanced magnetic resonance imaging (DCE MRI) has currently become the most utilized technique for the detection of pituitary microadenoma. However, owing to differential enhancement of normal pituitary, high rate of false positivity remains a concern in its interpretation. Purpose: Our aim was to assess the utility of precontrast T1 signal intensity ratio (SIR) of the lesions suspected on DCE MRI, in prediction of presence of microadenoma. Materials and Methods: We retrospectively reviewed MRI of 23 patients referred for DCE MRI of pituitary (group 1, 15 patients with diagnosis of pituitary microadenoma; and group 2, patients not clinically labeled as microadenoma). STC were plotted and T1-SIR at t = 0 s was obtained at the suspicious zone of differential enhancement (SIR T) and normal pituitary (SIR P). SIR difference (SIR P − SIR T) and relative SIR difference (SIR P − SIR T/SIR P) were calculated for each patient and was compared between the two groups. Results: Mean T1 SIR is lower in patients with microadenoma than those without (P = 0.065). SIR difference and relative SIR difference was higher in patients with microadenoma (P = 0.003 and 0.005, respectively). Receiver-operated characteristic curve analysis demonstrated that a cut-off of 26 and 0.107 for SIR difference and relative SIR difference, respectively, could diagnose microadenoma with 100% specificity and reasonable sensitivities. Conclusion: The baseline precontrast T1 SIR evaluation of the lesion suspected to be microadenoma on DCE MRI, derived through STC curve, can increase diagnostic confidence in diagnosis of microadenoma.
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Role of 3D SPACE sequence and susceptibility weighted imaging in the evaluation of hydrocephalus and treatment-oriented refined classification of hydrocephalus Highly accessed article p. 385
Amarnath Chellathurai, Komalavalli Subbiah, Barakath Nisha Abdul Ajis, Suhasini Balasubramaniam, Sathyan Gnanasigamani
DOI:10.4103/ijri.IJRI_161_18  PMID:30662197
Objective: The aim of our study was to evaluate the diagnostic utility of three-dimensional sampling perfection with application optimized contrast using different flip angle evolution (3D SPACE) sequence and Susceptibility Weighted Imaging (SWI) in hydrocephalus and to propose a refined definition and classification of hydrocephalus with relevance to the selection of treatment option. Materials and Methods: A prospective study of 109 patients with hydrocephalus was performed with magnetic resonance imaging (MRI) brain using standardized institutional sequences along with additional sequences 3D SPACE and SWI. The images were independently read by two senior neuroradiologists and the etiopathogenesis of hydrocephalus was arrived by consensus. Results: With conventional sequences, 46 out of 109 patients of hydrocephalus were diagnosed as obstructive of which 21 patients showed direct signs of obstruction and 25 showed indirect signs. In the remaining 63 patients of communicating hydrocephalus, cause could not be found out in 41 patients. Whereas with 3D SPACE sequence, 88 patients were diagnosed as obstructive hydrocephalus in which all of them showed direct signs of obstruction and 21 patients were diagnosed as communicating hydrocephalus. By including SWI, we found out hemorrhage causing intraventricular obstruction in three patients and hemorrhage at various sites in 24 other patients. With these findings, we have classified the hydrocephalus into communicating and noncommunicating, with latter divided into intraventricular and extraventricular obstruction, which is very well pertaining to the selection of surgical option. Conclusion: We strongly suggest to include 3D SPACE and SWI sequences in the set of routine MRI sequences, as they are powerful diagnostic tools and offer complementary information regarding the precise evaluation of the etiopathogenesis of hydrocephalus and have an effective impact in selecting the mode of management.
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Olfactory fossa depth: CT analysis of 1200 patients Highly accessed article p. 395
Ashok Chirathalattu Babu, Mattavana Ramakrishna Pillai Balachandran Nair, Aneesh Mangalasseril Kuriakose
DOI:10.4103/ijri.IJRI_119_18  PMID:30662198
Background: Olfactory fossa (OF) is a depression in anterior cranial cavity whose floor is formed by cribriform plate of ethmoid. Lateral lamella, which forms its lateral boundary, is a thin plate of bone and is at risk of injury during functional endoscopic sinus surgery, especially when fossa is deep/asymmetric. Aims: To measure the variations in the depth of OF and categorize Kerala population as per Keros classification using computed tomography (CT). Settings and Design: This study was conducted in our institution from January 2016 to August 2017. Patients >16 years of age undergoing CT scan of paranasal sinuses (PNS) were included. Materials and Methods: Coronal PNS CT scan studies of 1200 patients were reviewed. The depth of OF was measured from vertical height of lateral lamella. Statistical Methods: Results were analyzed according to gender and laterality using independent sample t-test and Chi-square test. Results: The mean depth of OF was 5.26 ± 1.69 mm. Statistically significant difference was seen in the mean depth of OF between males and females but not between right and left sides. Keros type I was found on 420 sides (17.5%), type II in 1790 (74.6%), and type III on 190 sides (7.9%). Type III Keros was more on the right (9%) than left (6.8%) side, more in males (9.5%) than females (5.9%), and more among males on the right side (11.4%). Asymmetry in OF depth between two sides was seen in 75% of subjects. Conclusion: Prevalence of the dangerous type III OF, even though low, is significant especially among males and on the right side. Therefore, preoperative assessment of OF depth must be done to reduce iatrogenic complications.
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Neuroimaging features of fatal high-altitude cerebral edema p. 401
Gorky Medhi, Tsella Lachungpa, Jitender Saini
DOI:10.4103/ijri.IJRI_296_18  PMID:30662199
Acute high-altitude cerebral edema can occur in an unacclimatised individual on exposure to high altitudes and sometimes it can be fatal. Here we have described the neuroimaging features of a patient who suffered from fatal high altitude cerebral edema. Available literature is reviewed. Probable pathogenesis is discussed. The risk of acute mountain sickness is reported up to 25% in individuals who ascend to an altitude of 3500 meter and in more than 50% subjects at an altitude of 6000 meter. The lack of availability of advanced imaging facilities at such a higher altitude makes imaging of such condition a less described entity.
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Isolated spontaneous cerebrospinal fluid rhinorrhoea as a rare presentation of idiopathic intracranial hypertension: Case reports with comprehensive review of literature p. 406
Priti Soin, Umer M Afzaal, Pranav Sharma, Puneet S Kochar
DOI:10.4103/ijri.IJRI_228_18  PMID:30662200
Isolated cerebrospinal fluid (CSF) rhinorrhoea as a sole presenting symptom of idiopathic intracranial hypertension (IIH) is extremely rare. IIH typically presents with headache, pulsatile tinnitus, dizziness, nausea, vomiting, and visual disturbance. We report two cases which presented with acute onset spontaneous CSF rhinorrhoea without any other symptom. In addition, we discuss in detail imaging features of IIH with review of its literature.
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MUSCULOSKELETAL Top

Ultrasound elastography findings in piriformis muscle syndrome p. 412
Adnan Demirel, Murat Baykara, Tuba Tülay Koca, Ejder Berk
DOI:10.4103/ijri.IJRI_133_18  PMID:30662201
Background: Piriformis muscle syndrome (PMS) is relatively less known and underestimated because it is confused with other clinical pathological conditions. Delays in its diagnosis may lead to chronic somatic dysfunction and muscle weakness. Objective: Here, we aimed to evaluate the diagnostic performance of the ultrasound elastography (UE) as an easy, less-invasive, and cost-effective method for early diagnosis of PMS. Materials and Methods: Twenty-eight cases clinically diagnosed as PMS at the outpatient clinic were evaluated by UE. The elastographic strain ratio was calculated by dividing the strain value of the subcutaneous fat tissue by the mean stress value of the muscle beneath. The diagnostic performances of the strain rate measures were compared using the receiver operating characteristic curve analysis. Results: Twenty-one (N = 21) cases were female, and seven (N = 7) of the cases were male. The mean age was 45 years (ranged 24–62 years). The strain rates of piriformis muscle (PM) and gluteus maximus (GM) muscles were significantly higher on the PMS-diagnosed side (P < 0.001). The cutoff value of UE strain ratio for the PM and GM were 0.878 [95% confidence interval (CI) 0.774–0.981] and 0.768 (95% CI 0.622–0.913), respectively, and the sensitivity and specificity values were, respectively, 80.95% and 85.71% for the PM, and they were, respectively, 85.71% and 66.67% for the GM. Conclusion: We showed that the muscle elasticity and tissue hardening increased on the problematic side both on PM and GM. UE may provide early diagnosis of PMS, thereby increasing the possibility of treatment with less invasive methods.
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Magnetic resonance imaging of ankle ligaments: A pictorial essay Highly accessed article p. 419
Yogini Nilkantha Sawant, Darshana Sanghvi
DOI:10.4103/ijri.IJRI_77_16  PMID:30662202
Ankle trauma is commonly encountered and is most often a sprain injury affecting the ligaments. Accurate diagnosis and appropriate treatment rest on knowledge of complex ligamentous anatomy of ankle and the entire spectrum of pathologies. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosing ligament pathologies because of its multiplanar capability and high soft tissue contrast. With MRI, it is possible to triage and attribute the cause of post traumatic ankle pain to bone, ligament, or tendon pathologies, which otherwise overlap clinically. In this pictorial essay, emphasis is given to the intricate and unique anatomy and orientation of ankle ligaments. Pathologies of ankle ligaments have been elaborated.
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CARDIAC Top

Myocardial nulling pattern in cardiac amyloidosis on time of inversion scout magnetic resonance imaging sequence – A new observation of temporal variability p. 427
Harshavardhan Mahalingam, Binita Riya Chacko, Aparna Irodi, Elizabeth Joseph, Leena R Vimala, Viji Samuel Thomson
DOI:10.4103/ijri.IJRI_84_18  PMID:30662203
Context: The pattern of myocardial nulling in the inversion scout sequence [time of inversion scout (TIS)] of cardiac magnetic resonance imaging (MRI) is an accurate tool to detect cardiac amyloidosis. The pattern of nulling of myocardium and blood at varying times post gadolinium injection and its relationship with left ventricular mass (LVM) in amyloidosis have not been described previously. Aims: The aim is to study the nulling pattern of myocardium and blood at varying times in TIS and assess its relationship with LVM and late gadolinium enhancement (LGE) in amyloidosis. Materials and Methods: This was a retrospective study of 109 patients with clinical suspicion of cardiac amyloidosis who underwent MRI. Of these, 30 had MRI features of amyloidosis. The nulling pattern was assessed at 5 (TIS5min) and 10 (TIS10min) minutes (min) post contrast injection. Nulling pattern was also assessed at 3min (TIS3min) in four patients and 7min (TIS7min) in five patients. Myocardial mass index was calculated. Mann-Whitney U test was done to assess statistical difference in the myocardial mass index between patients with and without reversed nulling pattern (RNP) at TIS5min. Results: RNP was observed in 58% at TIS5minand 89.6% at TIS10min. Myocardial mass index was significantly higher in patients with RNP at TIS5min[mean = 94.87 g/m2; standard deviation (SD) =17.63) when compared with patients with normal pattern (mean = 77.61 g/m2; SD = 17.21) (U = 18; P = 0.0351). Conclusion: In cardiac amyloidosis, TIS sequence shows temporal variability in nulling pattern. Earlier onset of reverse nulling pattern shows a trend toward more LVM and possibly more severe amyloid load.
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Collateral or fistula? Coronary artery as the primary source of pulmonary blood flow in a patient with pulmonary atresia and ventricular septal defect p. 433
Anurag Yadav, Salil Bhargava, T B S Buxi, Krishna Sirvi
DOI:10.4103/ijri.IJRI_489_17  PMID:30662204
In patients with pulmonary atresia and ventricular septal defect (PA/VSD), a coronary artery being the primary source of pulmonary blood flow is a rare entity. We describe two cases of PA/VSD with coronary-to-pulmonary artery fistula with emphasis on the role of Computed Tomographic Angiography (CTA) in depicting all the sources of pulmonary blood supply, to predict surgical management and need for unifocalization of Major Aortopulmonary Collateral Arteries (MAPCA's).
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CHEST Top

Evaluation of lung transplant perfusion using iodine maps from novel spectral detector computed tomography p. 436
Nils Große Hokamp, Amit Gupta
DOI:10.4103/ijri.IJRI_35_18  PMID:30662205
We report the case of a 51-year-old patient who underwent bilateral lung transplantation and presented with an unstable condition and sepsis 6 days after transplantation. The performed contrast enhanced spectral detector computed tomography (CT) using a dual-layer detector showed absence of perfusion in the left lung on iodine maps, although branches of the pulmonary artery were patent. This prompted retrospective evaluation of CT images and total venous occlusion of the left pulmonary veins was found. Here, iodine maps helped in raising conspicuity of loss of lung perfusion.
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Atypical alveolar proteinosis p. 439
Lova Hasina Rajaonarison Ny Ony Narindra, Emmylou Gabrielle Andrianah, Volahasina Francine Ranaivomanana, Christian Tomboravo, Hasina Dina Ranoharison, Jean Noel Bruneton, Ahmad Ahmad
DOI:10.4103/ijri.IJRI_170_18  PMID:30662206
Alveolar proteinosis is a rare pulmonary disease characterized by intra-alveolar accumulation of surfactant composed of lipoproteinaceous material, related to a lack of surfactant resorption by alveolar macrophages. Crazy paving pattern is characteristic, but not specific. The multinodular forms of this affection remain exceptional.
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PEDIATRIC Top

Percentile reference curves for normal pancreatic dimensions in Indian children p. 442
Dhanraj S Raut, Dhananjay V Raje, Vithalrao P Dandge, Dinesh Singh
DOI:10.4103/ijri.IJRI_189_18  PMID:30662207
Objectives: This study aims at determining the normal pancreatic dimensions in pediatric age groups considering demographic parameters and thus developing percentile reference curves for normal pancreatic dimensions in Indian children. Setting and Design: It is a cross-sectional study. Materials and Methods: A hospital-based cross-sectional study was planned at a children hospital during July 2016–December 2017, in which the pancreatic dimensions of 1078 normal children in the age range of 1 month to 19 years were obtained through abdominal ultrasonography (USG). The demographic details like age and gender were obtained for each child. Statistical Analysis Used: Percentile reference curves were obtained with reference to age for each gender type independently. Generalized additive models for location, scale, and shape were used to obtain percentile plots for each pancreatic part. Results: The mean age of children was 6.65 ± 4.43 years and the male-to-female ratio was 1.63:1. The head, body, and tail dimensions increased with the age. For head, up to 25th percentile, the curves were similar for both genders, while subsequent curves were higher in males as compared to females. Similar was the observation for body of pancreas. For tail, up to 75th percentile, the curves were similar for both genders. Conclusion: The normal ranges can be supportive in diagnosis of illness related to pancreas. The dimensions within 5–95th percentile along with iso-echogenicity can be regarded as normal, while the dimensions beyond these limits along with change of echogenicity can be suspected for pancreatic disorders.
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Clinicoradiologicial aspects of secretory carcinoma breast: A rare pediatric breast malignancy p. 448
Aanchal Bhayana, Ritu N Misra, Sunil K Bajaj, Himani Bankhar
DOI:10.4103/ijri.IJRI_46_18  PMID:30662208
Secretory carcinoma (juvenile carcinoma) is one of the very rare breast malignancy reported to be prevalent in pediatric age group. We report imaging and clinicopathological features of secretory carcinoma breast with distant and axillary metastasis, in an 11-year-old girl, who presented with a painful lump in right breast. Ultrasound revealed a well-defined, partially microlobulated hypoechoic mass with skin and pectoralis muscle involvement and a suspicious morphology right axillary lymph node. Color Doppler revealed increased vascularity in both the breast mass and suspicious axillary node. Magnetic resonance imaging helped in better evaluation of pectoralis muscle involvement. Computed tomography (CT) neck, chest, and abdomen revealed multiple fibronodular opacities in bilateral lung fields. 18 Flouro-Deoxy-Glucose Positron Emission Tomography (FDG PET-CT) showed a hypermetabolic retroareolar breast mass with multiple hypermetabolic bilateral lung nodules suggesting lung metastasis. The histopathology confirmed the diagnosis of secretory carcinoma. The patient was offered chemotherapy for 2 years and put on follow-up since then.
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VACTERL association – Ultrasound findings and autopsy correlation p. 452
Naman Kumar Gaur, Sudheer Gokhale
DOI:10.4103/ijri.IJRI_115_18  PMID:30662209
VACTERL (vertebral, anal, cardiac, tracheoesophagus, renal, and limbs) is an abbreviation for the congenital group of abnormalities, including vertebral or vascular anomalies, anal atresia, cardiac defects, tracheoesophageal – fistula/esophageal atresia, renal defects, and limbs defects. It is a rare association and not accidental event where several organs are affected by developmental defects during blastogenesis. The exact cause is unknown; however, several environmental and genetic factors are included in literature. Three components out of seven are used to label as VACTERL. The combination is necessary, but the patient may have other congenital malformations as well. We present here an antenatal scan with autopsy correlation of one of the forms of VACTERL association spectrum.
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Campomelic dysplasia with 10 pairs of ribs in a preterm neonate: A case report p. 456
Laxman Basani, Roja Aepala, Naresh Macha
DOI:10.4103/ijri.IJRI_173_18  PMID:30662210
Campomelic dysplasia (CD) is a rare form of skeletal dysplasia (incidence 1:200,000 births) which is associated with characteristic phenotypes including bowing of the limbs, a narrow thoracic cage, 11 pairs of ribs, hypoplastic scapulae, macrocephaly, flattened supraorbital ridges and nasal bridge, cleft palate, and micrognathia. In addition to the skeletal abnormalities, hydrocephalus, hydronephrosis, and congenital heart disease have been reported. We describe a preterm neonate who presented with respiratory failure and clinical features of CD. Our case had only 10 pairs of ribs, and to the best of our knowledge this is the first case report of CD with 10 pairs of ribs.
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ENDOCRINE (THYROID, ADRENAL, BREAST) Top

Differentiation between benign and malignant thyroid nodules using diffusion-weighted imaging, a 3-T MRI study p. 460
Leila Aghaghazvini, Hashem Sharifian, Nasrin Yazdani, Melina Hosseiny, Saina Kooraki, Pirouz Pirouzi, Afsoon Ghadiri, Madjid Shakiba, Soheil Kooraki
DOI:10.4103/ijri.IJRI_488_17  PMID:30662211
Background: Preoperative differentiation of benign from malignant thyroid nodules remains a challenge. Aims: This study assessed the accuracy of diffusion-weighted imaging (DWI) for differentiation between benign and malignant thyroid nodules. Materials and Methods: Preoperative DWI was performed in patients with thyroid nodule by means of a 3-T scanner magnetic resonance imaging (MRI). Images were obtained at b value of 50, 500, and 1000 mm2/s to draw an ADC (apparent diffusion coefficient) map. Findings were compared with postoperative histopathologic results. Receiver operating characteristic curve was used to assess the accuracy of different cutoff points. Results: Forty-one thyroid nodules (26 benign and 15 malignant) were included in this study. None of static MRI parameters such as signal intensity, heterogeneity, and nodule border was useful to discriminate between benign and malignant lesions. Mean ADC value was (1.94 ± 0.54) × 10-3 mm2/s and (0.89 ± 0.29) × 10-3 mm2/s in benign and malignant nodules, respectively (P-value < 0.005). ADC value cutoff of 1 × 10-3 mm2/s yielded an accuracy, sensitivity, and specificity of 93%, 87%, and 96% to discriminate benign and malignant nodules. Conclusion: DWI is highly accurate for discrimination between benign and malignant thyroid nodules.
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Normal adrenal gland thickness on computerized tomography in an Asian Indian adult population p. 465
Reetu John, Tharani Putta, Betty Simon, Anu Eapen, Felix Jebasingh, Nihal Thomas, Simon Rajaratnam
DOI:10.4103/ijri.IJRI_129_18  PMID:30662212
Context: The size and morphology of the adrenal glands are affected by several physiological and pathological conditions. Radiologists need to be aware of the normal thickness of adrenal gland to accurately assess patients with suspected adrenal pathology. However, there is limited data on the normal size of the adrenal glands. Moreover, this has not been studied in our population. Aims: To study the normal thickness of adrenal gland on computerized tomography (CT) in Indian adult population. Settings and Design: Retrospective study in a tertiary care hospital in Southern India. Subjects and Methods: Our study included 586 adults who underwent a CT abdominal angiogram over 15 months, and excluding patients with clinical or imaging evidence of adrenal disease. The measurements made included: the maximum thickness of the body, medial and lateral limbs, measured perpendicular to the long axis. Results: The median age was 51 (range: 18–85) years. The mean maximum thickness of the adrenal body, medial, and lateral limbs were 7.2 ± 1.8, 4.1 ± 1.1, and 4.3 ± 1.1 mm on the right side and 8.8 ± 1.9, 4.7 ± 1.1, and 4.9 ± 1.3 mm on the left. The cumulative thickness of the body and the limbs were 15.6 ± 3.7 mm and 18.4 ± 3.8 mm on the right and left sides, respectively. There was a statistically significant difference in all the measurements between the right and left adrenal glands (all P values = 0.000) and between men and women, being larger in men (P value <0.05). Among our patients 27% had at least one adrenal gland body measuring ≥10 mm in thickness. Conclusions: Our study has defined the normal range of adrenal gland thickness in an Asian Indian adult population, which may be used as a baseline reference for future research and as a reference for radiological reporting.
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A case series of metastases to the breast from extramammary malignancies p. 470
Tanvi Vaidya, Subhash Ramani, Ashita Rastogi
DOI:10.4103/ijri.IJRI_218_18  PMID:30662213
Metastases to the breast from extra-mammary malignancies are extremely uncommon. The discovery of a breast mass in a patient with a known primary tumor elsewhere poses a diagnostic challenge to the clinician. An awareness of the various malignancies that can metastasize to the breast and accurate diagnosis of the same is essential to avoid an unnecessary mastectomy and to guide further therapy. In this case series, we describe such clinical scenarios with an emphasis on the imaging features of metastases to the breast, which will enable radiologists to recognize this entity with greater ease.
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INTERVENTIONAL RADIOLOGY Top

Dealing with technical challenges in embolization of a rare aberrant left inferior bronchial artery arising from the left gastric artery in a patient with massive hemoptysis p. 476
Gaurav Gangwani, Ajit Yadav, Amit Dhamija, Arun Gupta
DOI:10.4103/ijri.IJRI_162_18  PMID:30662214
Bronchial artery embolization is an established intervention for management of recurrent massive hemoptysis in a majority of patients. The source of bleeding in a majority of cases is systemic arteries – orthotopic bronchial arteries, anomalous bronchial arteries, or nonbronchial systemic collaterals. We report a case of an aberrant left inferior bronchial artery arising from the left gastric artery (LGA) in a patient with massive hemoptysis. Such origin from infradiaphragmatic vessels and specially left gastric arteries is very rare and needs to be considered by interventional radiologists and pulmonologists in case with hemoptysis disproportionate to supply by orthotopic arteries. Technical challenges were present in the present case in the form of an aneurysm in the aberrant artery and nontarget hepatic and gastric branches arising from LGA. Appropriate selection of hardware and embolic agents was done to deal with the clinical situation.
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LETTERS TO THE EDITOR Top

Drug-induced changes in dentate nuclei of cerebellum p. 480
Yashant Aswani, Nishant Aswani, Rohit Sharma
DOI:10.4103/ijri.IJRI_499_17  PMID:30662215
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Role of proton MR spectroscopy in spinal cord lesions: A guarded espousal p. 481
Arjit Agarwal
DOI:10.4103/ijri.IJRI_401_18  PMID:30662216
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Author's Reply p. 482
Babu Peter Sathyanathan, Ravi Ranganathan, Bharathi Priya Raju, Kailasanathan Natarajan
DOI:10.4103/ijri.IJRI_417_18  PMID:30662218
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Ganglion impar injection approaches and outcomes for coccydynia p. 482
Patrick M Foye, Nourma Sajid, Gerard John D'Onofrio
DOI:10.4103/ijri.IJRI_64_18  PMID:30662217
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