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   Table of Contents - Current issue
Coverpage
April-June 2019
Volume 29 | Issue 2
Page Nos. 109-231

Online since Tuesday, July 9, 2019

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EDITORIAL  

Has the time come to shift to paper DICOM printing? p. 109
Anirudh Kohli
DOI:10.4103/ijri.IJRI_278_19  PMID:31367082
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GASTRO-INTESTINAL IMAGING Top

Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement Highly accessed article p. 111
Saurabh Kedia, Raju Sharma, Govind Makharia, Vineet Ahuja, Devendra Desai, Devasenathipathy Kandasamy, Anu Eapen, Karthik Ganesan, Uday C Ghoshal, Naveen Kalra, R Karthikeyan, Kumble Seetharama Madhusudhan, Mathew Philip, Amarender Puri, Sunil Puri, Saroj K Sinha, Rupa Banerjee, Shobna Bhatia, Naresh Bhat, Sunil Dadhich, GK Dhali, BD Goswami, SK Issar, V Jayanthi, SP Misra, Sandeep Nijhawan, Pankaj Puri, Avik Sarkar, SP Singh, Anshu Srivastava, Philip Abraham, BS Ramakrishna
DOI:10.4103/ijri.IJRI_153_18  PMID:31367083
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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Gastrointestinal Stromal Tumor (GIST) from esophagus to anorectum – diagnosis, response evaluation and surveillance on computed tomography (CT) scan Highly accessed article p. 133
Sushil N Panbude, Suman K Ankathi, Anant T Ramaswamy, Avanish P Saklani
DOI:10.4103/ijri.IJRI_354_18  PMID:31367084
Gastrointestinal stromal tumor (GIST) are the most common non epithelial tumor of the gastrointestinal (GI) tract. They arise from interstitial cells of Cajal present in the myenteric plexus. They can also arise outside the GI tract from mesentery, retro peritoneum and omentum. With the advent of new targeted molecular therapy c- tyrosine kinase inhibitor (Imatinib), it has become important to differentiate between response and pseudo-progression of the disease as response evaluation criteria for GIST are different from Response Evaluation Criteria in Solid Tumors (RECIST). Purpose of this pictorial essay is to enumerate the characteristic CT features of GIST, and discuss atypical features and response evaluation criteria.
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Barium esophagogram in various esophageal diseases: A pictorial essay p. 141
Uma Debi, Madhurima Sharma, Lokesh Singh, Anindita Sinha
DOI:10.4103/ijri.IJRI_465_18  PMID:31367085
Recent years have seen a decline in number of barium procedures due to wider availability of cross sectional imaging modalities. Though use of barium esophagography/barium swallow has decreased in day to day clinical practice, it still remains a valuable test for structural and functional evaluation of esophagus. It can be performed as single or double contrast examination or as a multiphasic examination comprising upright double contrast views followed by prone single contrast views. This pictorial essay demonstrates imaging features of various esophageal diseases on barium esophagogram.
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MUSCULOSKELETAL IMAGING Top

Pelvic muscle size and myosteatosis: Relationship with age, gender, and obesity p. 155
Thomas Pacicco, Shayna Ratner, Yin Xi, Takeshi Yokoo, David Fetzer, Orhan K Oz, Craig D Rubin, Avneesh Chhabra
DOI:10.4103/ijri.IJRI_414_18  PMID:31367086
Purpose: To evaluate interreader performance in the measurement of the cross-sectional area and myosteatosis of pelvic skeletal muscles using fat quantification magnetic resonance imaging (MRI) and correlate with patient anthropomorphic characteristics. Materials and Methods: A Health Insurance Portability and Accountability Act–compliant retrospective cross-sectional study was performed. Between January and April 2016, 61 patients (26 males and 35 females) underwent a lumbosacral plexus 3T MRI with a modified three-dimensional spoiled gradient echo sequence dedicated to fat quantification (mDixon Quant; Philips Healthcare). Two independent reviewers outlined muscle cross-sectional area on axial images using a freehand region of interest tool and documented proton-density fat fraction (FF) and muscle area (cm2) of the psoas, gluteus medius, gluteus maximus, and rectus femoris muscles on each side. Interreader agreement was assessed by intraclass correlation coefficient (ICC), and correlation between the measurements and subject's age, gender, and body mass index (BMI) was assessed using multiple linear regression analysis. Results: Excellent interreader agreement was obtained (ICC ≥0.74) for all muscle groups except for the left gluteus medius area and right psoas FF which showed good agreement (0.65 and 0.61, respectively). Statistically significant (P ≤ 0.05) positive correlation was seen between the gluteal muscle FF and area with BMI, and rectus muscle FF with age and BMI. Statistically significant negative correlation between the rectus femoris area and age was also observed. Conclusion: Fat quantification MRI is a highly reproducible imaging technique for the assessment of myosteatosis and muscle size. Intramuscular FF and cross-sectional area were correlated with age and BMI across multiple muscle groups.
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WOMENS IMAGING Top

Conventional and magnetic resonance hysterosalpingography in assessing tubal patency—A comparative study p. 163
Devimeenal Jagannathan, Fouzal Hithaya
DOI:10.4103/ijri.IJRI_109_18  PMID:31367087
Context: Tubal factors, one of the leading causes of female infertility, have been conventionally evaluated by hysterosalpingography (HSG). The role of magnetic resonance imaging (MRI) in assessing female infertility is gaining importance because of its inherent efficiency in detecting structural abnormalities. Magnetic resonance hysterosalpingography (MR HSG) is less invasive and avoids exposure of ovaries to ionizing radiation. Its utility is extrapolated to visualize fallopian tubes. Aims: To assess the diagnostic accuracies of dynamic MR HSG and conventional HSG (cHSG) in identifying tubal patency in women with infertility using diagnostic laparoscopy (DL) as gold standard. Materials and Methods: A prospective study of 40 patients was conducted over a period of 6 months. The patients were subjected to MR HSG followed by cHSG during the preovulatory period. If tubes were blocked, the patients were subjected to DL in the next menstrual cycle. If the tubes were patent and there was failure of conception, they were subjected to DL in the interval of 3 months. Results: Twenty-four patients had bilateral tubal spill which was confirmed using cHSG and DL. One patient had discordant MR HSG and cHSG results and six patients had discordant MR HSG and DL results. No statistical difference was observed between MR HSG and cHSG. Conclusion: Pelvic MRI is an inevitable tool in infertility evaluation. MR HSG can be used in addition as it avoids exposure of the reproductive organs to radiation and has the same efficacy as cHSG.
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NEURORADIOLOGY Top

Functional MRI in epilepsy – Comparison of Lateralization index and language scoring p. 168
Anuj Prabhakar, Niranjan Khandelwal, Sameer Vyas, Vivek Gupta, Parampreet S Kharbanda, Manju Mohanty
DOI:10.4103/ijri.IJRI_281_18  PMID:31367088
Aims: To evaluate the role of functional magnetic resonance imaging (fMRI) in epilepsy management and to ascertain whether laterality index (LI) derived from fMRI data, using routinely utilized paradigms, can serve as an adjunct to/or replace preoperative neuropsychological testing for evaluation of language lateralization and impairment. Materials and Methods: This was a prospective study which included 20 consecutive patients with a clinical diagnosis of temporal lobe epilepsy over a period of 1 year. Neuropsychological assessment included oral word association test and animal names test. The scores of both tests were compared with normographic data provided in the NIMHANS neuropsychology battery. Three fMRI paradigms were used, namely, picture naming, word generation, and sentence completion. Processing and statistical analysis were performed subsequently. Results and Conclusion: Right temporal lobe epilepsy (RTLE) was seen in 12 patients and left temporal lobe epilepsy (LTLE) in 8 patients. All patients were right handed. The activation pattern was predominantly left lateralized. Language lateralization varied with the type of paradigm. The overall percentage of patients showing left lateralization ranged from 44.00% for the picture naming task to 75% for the sentence completion. Reduced left lateralization was noted in both LTLE and RTLE patients. A negative correlation was observed in LTLE patients between performance in the verbal fluency and the lateralization index in the temporal and parietal regions of interest (ROI) in the word generation paradigm, suggesting that increased left lateralization was associated with a poorer score on neuropsychological tests. In RTLE patients, however, there was no significant correlation between performance in neuropsychological tests and LI. In conclusion, language lateralization using LI can serve as an adjunct during preoperative evaluation. However, it cannot replace neuropsychological testing.
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INTERVENTIONAL RADIOLOGY Top

Outcome of conventional transarterial chemoembolization (cTACE) in the management of spontaneously ruptured hepatocellular carcinoma p. 177
Yashwant Patidar, Rohit Khisti, Ankusha Yadav, Amar Mukund, Shiv K Sarin
DOI:10.4103/ijri.IJRI_252_18  PMID:31367089
Background and Objectives: Hepatocellular carcinoma (HCC) is a highly vascular tumor and mortality after spontaneous rupture of HCC remains considerably high. There are no definitive guidelines for the management of ruptured HCC and no fixed protocol has been proposed in the literature. We evaluated the outcome of conventional transarterial chemoembolization (cTACE) in the management of spontaneously ruptured HCC and factors affecting the outcome of cTACE. Materials and Methods: This is a single center retrospective study analyzing the outcome of patients presenting with spontaneous rupture of HCC who received cTACE from January 2014 to June 2017. These patients were followed up periodically for clinical and imaging findings to ascertain the technical effectiveness along with survival. Results: Sixteen patients were identified who received cTACE for ruptured HCC. Majority of the patients (81.3%) had abdominal pain, while 25% had hypovolemic shock at initial presentation. Complete response and partial response were seen in 35.7% and 57.1% of patients, respectively. One patient (7.1%) showed progressive disease in form of peritoneal spread along the liver surface. The overall cumulative survival rates at 30 days, 180 days, and at 1 year were 87.5%, 72.2%, and 54.1%, respectively. Conclusion: cTACE is safe in patients with spontaneous HCC rupture and it leads to immediate hemostasis along with overall survival advantage. Achieving quick hemostasis may be a key to better outcome.
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Basic interventional procedures: Practice essentials p. 182
Amar Mukund, Krishna Bhardwaj, Chander Mohan
DOI:10.4103/ijri.IJRI_96_19  PMID:31367090
There has been an increasing demand in image-guided minimally invasive procedures and these have become an integral part of present-day clinical practice. Basic interventional radiology (IR) procedures have greatly reduced the need for invasive procedures for sampling as well as treating conditions like abscess and fluid collections. Owing to their minimally invasive nature, most of these procedures may be performed on the outpatient patients as daycare procedures. Some of these procedures in critically ill patients may be lifesaving. Basic interventional radiology (IR) procedures consist of image-guided fine-needle aspiration cytology and biopsy, tru-cut (core) biopsy, needle aspiration/drainage and percutaneous catheter drainage. This review aims to provide practice requisites for basic IR procedures.
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HEPATOBILIARY AND PANCREATIC IMAGING Top

Acoustic radiation force impulse elastography of liver as a screening tool for liver fibrosis in alcoholic liver disease p. 190
Iranna M Hittalamani, Bhushita B Lakhkar, Ramesh C Pattanashetti, Bhushan N Lakhkar
DOI:10.4103/ijri.IJRI_399_18  PMID:31367091
Context: Acoustic radiation force impulse (ARFI) elastography is a noninvasive and quantitative technique for diagnosis of liver fibrosis. To the best of our knowledge, there are only two studies reported in literature for evaluation of alcoholic liver disease using ARFI. Aims: The aim of this study was to evaluate the diagnostic performance of ARFI elastography for assessing liver fibrosis in alcoholic liver disease and compare it with biochemical indices aspartate transaminase-to-platelet ratio index (APRI) and fibrosis-4 Index (FIB-4) using histopathology as the reference standard. Settings and Design: Institutional cross-sectional study. Methods and Materials: The patients visiting our hospital over a period of 2 years with a high-risk consumption of alcohol (>40 g/day for men and >20 g/day for women for a cumulative period of more than 5 years) were subjected to ARFI elastography of liver, Liver Function Tests (to calculate APRI and FIB-4 indices), and liver biopsy. Statistical Analysis Used: Area under the receiver operating characteristic (AUROC) curve analysis, Kruskal--Wallis test for ANOVA. Results: A total of 50 patients of chronic alcoholic liver disease were evaluated with ARFI elastography, which performed better than the biochemical indices in distinguishing cirrhosis of the liver (F = 4) from the severe fibrosis (F ≥ 3) with area under the receiver operating characteristic of 0.97, whereas for significant fibrosis (F ≥ 2) and severe fibrosis (F ≥ 3), it was comparable to the biochemical indices with AUROC of 0.65 and 0.70. In our study, the median shear wave velocity cutoff values were 1.37 m/s, 1.51 m/s, and 1.87 m/s for F ≥ 2, F ≥ 3, and F = 4 fibrosis stages, respectively. Conclusions: ARFI elastography is a noninvasive, reliable, and repeatable diagnostic test for grading of liver fibrosis. It performs better than the biochemical indices to differentiate severe fibrosis and cirrhosis of liver.
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Diagnostic accuracy of intermediate b-value diffusion-weighted imaging for detection of residual hepatocellular carcinoma following transarterial chemoembolization with drug-eluting beads p. 195
Ahmed E Hassan, Radwa E Mostafa, Ayman Nada, Mohamed S Elazab, Ahmed Sayed Awad, Ikram M Hamed
DOI:10.4103/ijri.IJRI_383_18  PMID:31367092
Purpose: To evaluate the role of diffusion-weighted magnetic resonance imaging (DW-MRI) in the detection of residual malignant tumor of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) with drug-eluting beads (DEBs). Subjects and Methods: Pre-contrast T1, T2, dynamic contrast–enhanced, and respiratory-triggered DW-MRI (b factor 0, 400, and 800 s/mm2) were obtained in 60 patients with HCC who underwent tran-sarterial hepatic chemoembolization with DEBs. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the DW imaging images. Apparent diffusion coefficients (ADCs) were calculated searching for the optimal cut-off value using the receiver operating characteristic (ROC) curve. Results: DW-MRI had a sensitivity of 77.1%, a specificity of 60.7%, a PPV of 71.05%, and a NPV of 68%. The difference between the malignant and benign groups' ADC variables was statistically significant (P < 0.003). The ROC curve showed that the area under the curve is C = 0.718 with SE = 0.069 and 95% confidence interval from 0.548 to 0.852. Conclusion: In our study, we demonstrated that diffusion MRI has limited diagnostic value in the assessment of viable tumor tissue after TACE with DEBs in cases of HCC.
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Imaging in chronic pancreatitis: State of the art review p. 201
Rohan Kamat, Pankaj Gupta, Surinder Rana
DOI:10.4103/ijri.IJRI_484_18  PMID:31367093
Chronic pancreatitis (CP) is an important gastrointestinal cause of morbidity worldwide. It can severely impair the quality of life besides life-threatening acute and long-term complications. Pain and pancreatic exocrine insufficiency (leading to malnutrition) impact the quality of life. Acute complications include pseudocysts, pancreatic ascites, and vascular complications. Long-term complications are diabetes mellitus and pancreatic cancer. Early diagnosis of CP is crucial to alter the natural course of the disease. However, majority of the cases are diagnosed in the advanced stage. The role of various imaging techniques in the diagnosis of CP is discussed in this review.
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CASE REPORTS Top

Endovascular treatment of refractory iatrogenic femoral artery pseudoaneurysm using Amplatzer vascular plugs following unsuccessful retrograde Angio-Seal deployment p. 211
Eu Jhin Loh, Robert Allen
DOI:10.4103/ijri.IJRI_332_18  PMID:31367094
Iatrogenic common femoral artery pseudoaneurysm is a well-known vascular access complication of angiography and transfemoral intervention. Thrombin injection is a well-accepted technique in treating these pseudoaneurysms but possess a significant risk of distal lower extremity thrombosis leading to severe consequences. Several case reports described the novel approach to closing these pseudoaneurysms via a retrograde deployment of an Angio-Seal vascular closure device. We describe a case of a successful treatment of refractory iatrogenic femoral artery pseudoaneurysm using Amplatzer vascular plugs following unsuccessful retrograde deployment of an Angio-Seal vascular closure device.
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MRI evaluation of Kimura's disease with emphasis on diffusion weighted imaging and enhancement characteristics p. 215
Minhaj Shaikh, Pawan Garg, Parameshwar Sharma, Pushpinder Khera
DOI:10.4103/ijri.IJRI_468_18  PMID:31367095
Kimura's disease is a rare disease of the head and neck region affecting mainly the adult males in eastern countries. The parotid and periparotid subcutaneous regions are the most common sites in head and neck region. Coupled with peripheral eosinophilia and raised serum IgE levels as characteristic features on hemogram, a painless swelling in parotid and periparotid region is diagnostic of Kimura's disease. Magnetic resonance imaging (MRI) has been an important modality in evaluating lesions of the head and neck region. Recently, interest in the diffusion weighted imaging (DWI) and contrast enhanced MRI (CEMRI) imaging of lesions in Kimura's disease has been noted to characterize it and differentiate it from other pathologies. We describe a case a recurrent Kimura's disease of the periparotid region and its MRI features with special emphasis on its characteristics on DWI and contrast enhanced sequences.
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Role of interventional radiology in the diagnosis and management of congenital extrahepatic portosystemic shunts: Two case reports p. 219
Sheetal V Mathai, Victor Kondray, Elias Salloum, Kamlesh Kukreja, Sidhartha Tavri
DOI:10.4103/ijri.IJRI_461_18  PMID:31367096
Congenital extrahepatic portosystemic shunt (CEPS) is a rare splanchnic venous malformation, wherein the portal venous outflow drains into the systemic venous circulation via a pathologic shunt. CEPS exhibits heterogeneous clinical behavior and angiography is the gold standard for evaluation of the portomesenteric communication to systemic vasculature. The potential severity of complications necessitates shunt closure. Here, we present two cases of CEPS. The first patient presented with an asymptomatic hyperammonemia and was found to have a Type 1 CEPS with absence of intrahepatic portal system. The second patient was asymptomatic and was incidentally found to have a Type 2 CEPS on imaging with normal intrahepatic portal system. Both patients were successfully treated with endovascular occlusion of the CEPS.
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Venous reflux into renal and spinal veins on MDCT in a surviving patient p. 223
Sumana Bingi, Sahaja Kanugula, Swarupa Keerthipati, Kalyani Bankupalli, Balakrishna Gowdu Thimmoji, Rajanikanth Rao Vedula
DOI:10.4103/ijri.IJRI_353_18  PMID:31367097
In patients of cardiac arrest or near death, opacification of inferior vena cava and renal veins during the arterial phase of intravenous contrast administration at computed tomography (CT) examination is well known. We present a case of extensive reflux into renal and spinal veins in a patient who survived for 1 week following multidetector computed tomography (MDCT) examination without any life supporting devices.
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Pediatric chylous ascites treatment with combined ultrasound and fluoroscopy-guided intranodal lymphangiography p. 226
Zainab A Vora, Devasenathipathy Kandasamy, Priyanka Naranje, Rohan Malik
DOI:10.4103/ijri.IJRI_424_18  PMID:31367098
Chylous ascites is a form of ascites resulting from the leakage of lymph into the peritoneal cavity, which is particularly rare in children, most common etiology being an iatrogenic injury to lymphatics during surgery. Initial conservative management options include medium-chain triglycerides-based diet, somatostatin analogs, and total parenteral nutrition. If these fail, then interventions such as paracentesis with sclerotherapy, surgical ligation, or peritoneal shunts have been described. This study reports a case of a 7-year-old child with refractory chylous ascites to demonstrate a minimally invasive technique of intranodal lymphangiography with lipiodol as a viable treatment option for chylous ascites in children, particularly in cases of minor and undetectable leaks.
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LETTER TO THE EDITOR Top

Imaging in sump syndrome: A rare complication of choledochoduodenostomy p. 229
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/ijri.IJRI_427_18  PMID:31367099
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