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April-June 2018
Volume 28 | Issue 2
Page Nos. 137-269

Online since Thursday, June 28, 2018

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EDITORIAL  

Artificial intelligence in radiology – Are we treating the image or the patient? Highly accessed article p. 137
Chander Mohan
DOI:10.4103/ijri.IJRI_256_18  PMID:30050233
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NEURORADIOLOGY & HEAD AND NECK IMAGING Top

Preoperative ultrasonography for tumor thickness evaluation in guiding management in patients with early oral tongue squamous cell carcinoma p. 140
Anirudh V Nair, M Meera, Bindhu M Rajamma, Soumya Anirudh, PK Nazer, PV Ramachandran
DOI:10.4103/ijri.IJRI_151_17  PMID:30050234
Objectives: (1) To assess the statistical correlation between the tumor thickness (TT) by ultrasonography (USG) and microscopic measurement in cases of early oral tongue squamous cell carcinoma (OTSCC). (2) To assess the predictive capacity of TT by ultrasound in detecting nodal metastasis. Materials and Methods: Prospective analysis was performed in 24 patients for a period of 2 years from 2012 to 2013. Nodal status and TT measurement was done preoperatively by neck and intraoral USG respectively in cases of early (pT1 & T2, clinically N0) OTSCC. As per the institution protocol after histopathological confirmation of malignancy, all patients underwent resection of primary lesion and ipsilateral elective neck dissection (Level - I to IV). Measurement of TT was obtained intraoperatively from fresh glossectomy specimen and postoperatively from histopathological paraffin section examination. The statistical correlation between TT measured by USG and histopathology was assessed by Pearson's correlation coefficient. Chi-square test was used to find the association of pathological T stage, TT with pathological nodal status. Results: Significant statistical correlation was seen between TT by USG and microscopic measures. Between the two, TT measurements were within 1 mm in 37.5% (9/24) of cases, within 2 mm in 29.16% (7/24), and was greater than 2 mm in 8 cases. The Pearson's correlation r is 0.678 (P < 0.001) and ICC (interclass correlation coefficient) is 0.808. The average difference between microscopic and US thickness (Bias) is -0.14637 and the limits of agreement is (4.717, -4.863) with 95% limits of agreement. The rate of occult nodal metastasis was 16.6% and TT of <4 mm had no incidence of nodal metastasis. Conclusion: Ultrasonographic evaluation is reliable and cost-effective tool to measure the TT preoperatively, which will be of help in deciding the management in early OTSCC. TT of 4 mm and above was predictor of occult cervical nodal metastasis.
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Language lateralization in pre-adolescent children: FMRI study using visual verb generation and word pair paradigms p. 146
Ruma M Sreedharan, Jija S James, Chandrasekharan Kesavadas, Sanjeev V Thomas
DOI:10.4103/ijri.IJRI_211_17  PMID:30050235
Background: FMRI is a noninvasive tool for mapping language networks, especially in children. We conducted FMRI studies in children in the age group 8- 12 years using 2 different paradigms for assessing language networks and lateralization. Aim: To map language networks in pre-adolescent children and to calculate lateralization index using two different visual paradigms. Methods and Materials: The study was conducted in normal right handed children in the age group 8-12 years. Sixteen normal subjects underwent FMRI using 2 paradigms- visual verb generation (VVG), word pairs paradigm (WPP) to stimulate language areas. FMRI data analysis was done using SPM8 (statistical parametric Mapping) software. Total activated voxels were calculated for each hemispheres in the pre-defined ROIs for both paradigms. Results: FMRI showed left language lateralization in 13 out of 16 children with both VVG and WPP and bilateral language lateralization in two subjects. With VVG there was more significant activation in the left inferior triangular gyrus (ITG) (P < 0.001), left inferior opercular gyrus (IOG) (P < 0.01), left middle frontal gyrus (MFG) (P < 0.05), left and right dorsolateral prefrontal cortex (P < 0.05). Left posterior superior temporal gyrus (STG or WA) (P < 0.001), Left AG (P < 0.03), Left SMG (P < 0.05) were significantly activated with WP paradigm. Conclusion: Our FMRI studies showed that VGP predominantly activated frontal language areas and WPP predominantly activated temperoparietal language areas. Several other brain regions were also involved in language processing apart from the classical language areas.
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Imaging of dentate nucleus pathologies; a pictorial essay Highly accessed article p. 152
Kajari Bhattacharya, Hima Pendharkar, Arun K Gupta
DOI:10.4103/ijri.IJRI_290_17  PMID:30050236
Dentate nucleus is affected in a wide variety of conditions. Magnetic resonance imaging of the brain is the diagnostic modality of choice for delineating the signal characteristics, which helps in narrowing down a vast list of differentials for conditions affecting the dentate. Computed tomography plays an important role, especially for pathologies associated with calcification of dentate nucleus.
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First case of neurofibromatosis with posterior reversible encephalopathy syndrome showing spinal cord involvement p. 161
Pui Kwan Joyce Chan, Kin Sun Tse, Wing Shan Elaine Fok, Wai Lun Poon
DOI:10.4103/ijri.IJRI_320_17  PMID:30050237
Posterior reversible encephalopathy syndrome (PRES) is a well-documented pathology of the brain in systemic upsets. Majority of PRES cases present with edema in the cerebrum, most commonly in the territory of posterior circulation. It has been reported to show spinal cord involvement in a rare subgroup known as PRES with spinal cord involvement (PRES-SCI), with very limited existing literature even in adult patients. Our institution recently encountered a pediatric case with neurofibromatosis type I (NF 1) showing PRES with extensive reversible spinal cord changes. This case illustrates the features of this rare entity in the pediatric group of patients, and is the first reported case in NF 1 patients.
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Morning glory syndrome with Moyamoya disease: A rare association with role of imaging p. 165
Janardhana Ponnatapura
DOI:10.4103/ijri.IJRI_219_17  PMID:30050238
Morning glory disc anomaly (MGDA) is a congenital optic nerve anomaly characterized by a funnel-shaped excavation of the posterior globe that incorporates the optic disc. Most cases are isolated and not associated with systemic anomalies. Systemic anomalies include midline cranial facial defects, hypertelorism, agenesis of the corpus callosum, cleft lip and palate, basal encephalocele, congenital forebrain abnormalities, and renal anomalies. We report a case of 4-year-old male child who presented with reduced visual acuity on left eye with poor fixation. The left eye demonstrated 6-diopter esotropia. Examination of fundus revealed features of MGDA. The child was further subjected to magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of brain to rule out other associated anomalies. It demonstrated narrowing at the distal part of internal carotid artery on both sides, left more than right with prominence of lenticulostriate and leptomeningeal vessels. MRI also revealed funnel-shaped excavation of the posterior globe on the left side consistent with MGDA. Ascertaining the accurate diagnosis of MGDA guides appropriate ophthalmic management and should also prompt a search for associated intracranial abnormalities. Although the diagnosis of MGDA is typically made clinically, imaging may feed supplementary value in establishing the diagnosis and reveal the extent and character of associated ocular abnormalities, and cross-sectional imaging permits for evaluation of the globe in the setting of associated opacities of the refractive media, including persistent hyperplastic primary vitreous, which may alleviate the capacity to make this diagnosis on the basis of the fundoscopy examination alone.
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GENITOURINARY RADIOLOGY Top

Comparative accuracy of magnetic resonance morphometry and sonography in assessment of post-cesarean uterine scar p. 169
Gayatri Satpathy, Ishan Kumar, Manjari Matah, Ashish Verma
DOI:10.4103/ijri.IJRI_325_17  PMID:30050239
Objective: To compare the diagnostic accuracy of magnetic resonance imaging (MRI) with that of ultrasonography (USG) for the measurement of lower segment cesarean scar during trial of labor after cesarean (TOLAC). Materials and Methods: This was a prospective case-control observational study conducted with a cohort of 30 participants being considered for TOLAC but eventually proceeding to lower segment cesarean section (LSCS) at a university-based teaching institute over a period of 2 years. Measurement of scar thicknesses were done by MRI and USG preoperatively and validated by surgical findings. Comparison of diagnostic accuracy as well as the cut-off values (to differentiate a normal scar from an abnormal scar) was done between the two modalities. Results: Insignificant systematic error between the measurements obtained by the two modalities was noted by a Bland–Altmann analysis. The diagnostic accuracy of USG for differentiating a normal from an abnormal uterine scar was 96.7% while that of MRI was at a slightly lower level of 90%. A strong level of agreement between the two modalities was observed. Conclusion: MRI offers no advantage in diagnostic accuracy for the measurement of LSCS scar thickness during consideration of TOLAC. Advances in Knowledge: Measurement of uterine scar by MRI has a good correlation with that done on USG in the setting of post-cesarean pregnancy. The results hold good both for normal (grades 1 and 2) and abnormal (grades 3) scars. MRI, however, does not offer any added advantage over sonographic scar thickness measurement for the differentiation of a normal (grades 1 and 2) from an abnormal (grade 3) scar.
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Role of diffusion tensor imaging in renal parenchymal changes p. 175
Shimona Saini, Vikas Kumar, Prakashini Koteshwara
DOI:10.4103/ijri.IJRI_128_17  PMID:30050240
Context: Diffusion Tensor Imaging (DTI) is a reliable noninvasive tool to assess renal function with medullary Fractional Anisotropy (FA) values showing the most consistent results. Aims: Evaluation of FA, Apparent Diffusion Coefficient (ADC) for detecting diabetic nephropathy (DN) using 1.5-Tesla magnetic resonance imaging (MRI). To determine FA and ADC values in chronic kidney disease (CKD) patients and controls, and comparing these with estimated glomerular filtiration rate (eGFR) and categorizing the stage of CKD. Patients and Methods: Thirty nondiabetic volunteers underwent DTI.The study included 83 diabetics, 30 frank urine proteinuric, 30 micro-albuminuric, 23 normo-albuminuric with only raised blood sugar patients.Patients were stratified by eGFR into groups: eGFR <60 and eGFR>60ml/min. ADC and FA values in cortex and medulla were compared between controls and study groups. Statistical Analysis Used: Analysis of variance and Pearson correlation using SPSS 16 were performed. Results: There was significant difference of FA medulla in controls versus albuminuric and micro-albuminuric versus frank proteinuric patients (P < 0.001).Also, there was significant difference between cortical ADC values between normal, microalbuminuric/proteinuric groups (P = 0.010, P =0.000, respectively). Significant difference between medullary FA values of patients with eGFR >60 and eGFR < 60 versus normal controls (P < 0.001) was noted.With declining renal function from normal to CKD category 5, a negative correlation between medullary FA (r= −0.785, P = 0.001) and ADC cortex values (r= −0.436, P = 0.001) was noted. A strong positive correlation between medullary FA and cortex ADC with eGFR (r = 0.598 and 0.344, respectively) was noted. Conclusion: Medullary FA of diabetics with relatively intact kidney function were significantly lower than those of controls. Hence, drop in medullary FA values can be an indicator of early nephropathy/patients at risk where eGFR is in near normal range. Cortical ADC and medullary FA demonstrated a significant correlation with eGFR with the latter showing a stronger positive correlation.
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Hydropic degeneration of leiomyoma in nongravid uterus: The “split fiber” sign on magnetic resonance imaging p. 182
Aruna R Patil, Shrivalli Nandikoor, Ramya Padilu
DOI:10.4103/ijri.IJRI_214_17  PMID:30050241
Extensive hydropic degeneration in uterine leiomyoma is a rare occurrence and is commonly reported in association with pregnancy. It is a close mimicker of malignancy due to rapid growth and atypical imaging appearances. Awareness of the imaging features helps in diagnosis, avoids unnecessary patient anxiety, and hence reassurance especially when encountered in pregnancy. We report two cases of extensive hydropic degeneration of leiomyoma in nonpregnant females with imaging and histopathology correlation. We also propose the “split fiber” sign as a useful magnetic resonance imaging feature for diagnosing this condition.
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GASTROINTESTINAL RADIOLOGY AND HEPATOLOGY Top

Anorectal malformations: Role of MRI in preoperative evaluation p. 187
Madhusmita , Rohini G Ghasi, MK Mittal, Deepak Bagga
DOI:10.4103/ijri.IJRI_113_17  PMID:30050242
Purpose: To evaluate the spectrum of magnetic resonance imaging (MRI) findings in pediatric patients with anorectal malformation (ARM) and compare the accuracy of MRI and distal cologram (DC) findings using surgery as reference standard. Materials and Methods: Thirty pediatric patients of age less than 14 years (19 boys and 11 girls) with ARM underwent preoperative MRI. MRI images were evaluated for the level of rectal pouch in relation to the pelvic floor, fistula, and development of sphincter muscle complex (SMC). Associated spinal and other anomalies in lumbar region and pelvis were also evaluated.DC was done in 26 patients who underwent colostomy. Ultrasound of abdomen and pelvis was also done for associated anomalies. Results: Overall accuracy of MRI and DC to detect the exact level of rectal pouch including cloacal malformation was 93.33% and 76.9% respectively. MRI and DC could correctly identify presence or absence of fistula in 76.6% and 76.9% cases respectively. MRI and DC correctly identified the anatomy of fistula in 76% and 65% cases respectively. On MRI, correlation of development of levator ani and puborectalis with the level of rectal pouch as found on surgery was significant (P = 0.008; 0.024 respectively). Subjective assessment of sphincter muscle development on MRI correlated well with the surgical assessment [P = 0.019 and 0.016 for puborectalis and external anal sphincter (EAS) respectively]. Lumbosacral spine anomalies were present in 33.3% of patients and were most common in high type of ARM. Vesicoureteric reflux and renal agenesis were the most common renal and urinary tract anomalies and were present in 40% of cases. Conclusion: MRI allows reliable preoperative evaluation of ARM and should be considered as a complementary imaging modality for preoperative imaging in ARM.
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Computed tomography imaging of complications of acute cholecystitis p. 195
Giancarlo Schiappacasse, Pablo Soffia, Claudio Silva, Fabian Villacrés
DOI:10.4103/ijri.IJRI_316_17  PMID:30050243
Acute cholecystitis (AC) is a frequent complication of biliary cholelithiasis. Although ultrasound is the first diagnostic imaging procedure, frequently the initial imaging modality is computed tomography (CT). Therefore, familiarization of CT findings in AC and potential related complications are extremely important. This pictorial essay reviews a broad spectrum of complications related to AC and its key findings in CT.
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False-positive 18F fluorodeoxyglucose positron emission tomography-avid benign hepatic tumor: Previously unreported in a male patient p. 200
Binit Sureka, Archana Rastogi, Amar Mukund, Shiv Kumar Sarin
DOI:10.4103/ijri.IJRI_170_17  PMID:30050244
We report a case of 18F fluorodeoxyglucose (FDG) positron emission tomography (PET)–computed tomography-avid histologically confirmed inflammatory hepatic adenoma in a 77-year-old male patient without any history of steroid, alcohol use. This is the first case report of inflammatory hepatic adenoma in a male patient documented in the published literature showing uptake on 18F-FDG PET. Previous single case report of 18F-FDG PET-avid hepatic adenoma in a male patient was of hepatocyte nuclear factor-1-α subtype.
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MUSCULOSKELETAL RADIOLOGY Top

Idiopathic chondrolysis of hip in children: New proposal and implication for radiological staging p. 205
C Amarnath, Priya Muthaiyan, T Helen Mary, Shilpa Mohanan, K Gopinathan
DOI:10.4103/ijri.IJRI_185_17  PMID:30050245
Purpose: Our objective was to evaluate the radiological appearances in different stages of idiopathic chondrolysis of hip (ICH) which will be helpful in the early diagnosis and guiding appropriate treatment for this condition to prevent progression of disease. Materials and Methods: We evaluated 14 patients of ICH in varying stages: Stage 1 (n = 9), Stage 2 (n = 3), Stage 3 (n = 2). Average age at presentation was 10–11 years. Plain radiograph and magnetic resonance imaging (MRI) was done in all these patients. Results: In the current study, we have attempted to stage ICH based on the radiological progression of the disease, where MRI was used as the primary tool. Stage 1 showed a wedge-shaped hyperintensity in T2 weighted (T2W) and hypointensity in T1 weighted (T1W) images involving the middle one-third of the femoral head and it is the earliest and characteristic finding in MRI. Associated findings like joint space narrowing, synovial hypertrophy with joint effusion may also be observed. Stage 2 showed acetabular edema in the affected hip in addition to the above-mentioned findings. Stage 3 showed more extensive involvement of femoral head and acetabulum, with collapse of the femoral head, degenerative changes in hip, early osteoporotic changes, and ultimately loss of joint space. Conclusion: Imaging-based staging system proves very useful in the early diagnosis, staging, and assessing the prognosis of ICH.
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Among the fibers: A multimodality imaging review of intramuscular mass lesions p. 214
Karthik Shyam, Soumya Cicilet, Babu Philip
DOI:10.4103/ijri.IJRI_299_17  PMID:30050246
The common presentations of patient complaints regarding the musculoskeletal system, such as pain, swelling, and restriction of movement, lead to the imaging discovery of various lesions often located in, or arising from, skeletal muscle in the region of interest. Knowledge of the patients' clinical history, laboratory parameters, and various imaging characteristics of the implicated lesions would assist the radiologist in coming to a timely, reasonably accurate conclusion about the etiology of the patient's complaints, the severity of disease, and in directing patient therapy.
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INTERVENTIONAL RADIOLOGY & VASCULAR Top

Percutaneous gastrostomy placement by intervention radiology: Techniques and outcome p. 225
Balasubramanian Karthikumar, Shyamkumar N Keshava, Vinu Moses, George K Chiramel, Munawwar Ahmed, Suraj Mammen
DOI:10.4103/ijri.IJRI_393_17  PMID:30050247
Background: Interventional radiology (IR) has played an important role in the technical evolution of gastrostomy, from the first surgical, endoscopical to percutaneous interventional procedures. Aim: This study is done to assess the technical feasibility and outcome of IR-guided percutaneous gastrostomy for patients requiring nutritional support for neuromuscular disorders or head and neck malignancies, as well as to describe simplified and newer technique for pull-type gastrostomy. Materials and Methods: This is a retrospective study including 29 patients who underwent IR-guided percutaneous gastrostomy over a period of 8 years in a tertiary-level institution. Either pull or push-type gastrostomy was performed in these patients as decided by the interventional radiologist. The procedures were assessed by analyzing the indications, technical aspects, and complications. Statistical Analysis: Descriptive summary statistics and frequencies were used to assess the techniques and related complications. Results: The sample consists of 27 patients (93%) with pull technique and 2 patients (7%) with push technique. The technical success rate was 100%. Most of the complications were minor 24% (7/29), including superficial skin infections around the tube site, self-resolving pneumoperitoneum, tube-related complications such as block, leakage, deformation, and dislodgement. Three patients (10.3%) had major complications. One patient (3.4%) developed massive pneumoperitoneum and mild peritonitis due to technical failure in the first attempt and needed re-puncture for successful placement, and other two patients (6.9%) developed peristromal focal abscess. One patient died on the third postoperative day due to type II respiratory failure. Conclusion: IR-guided percutaneous gastrostomy is a safe and effective procedure in selected patients.
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Endovascular treatment of ruptured pica aneurysms and association with its extradural origin: A single-center experience p. 232
Somit Mittal, Vivek Singh, RV Phadke, Zafar Neyaz
DOI:10.4103/ijri.IJRI_318_17  PMID:30050248
Background: Posterior inferior cerebellar artery (PICA) like other intracranial arteries is prone to aneurysm formation. Aneurysms usually arise from the vertebral artery (VA)—PICA junction and the proximal segment of the PICA. The surgical clipping of PICA aneurysms can be challenging and carries a potentially significant risk of morbidity and mortality. Experience with endovascular therapy has been limited to a few studies; however, the use of endovascular therapy as an alternative treatment to surgery has been increasing. We present our experience of last 5 years in treating the ruptured PICA aneurysms. Materials and Methods: A total of 11 patients with PICA aneurysms, out of them 7 were at proximal PICA, 2 at the vertebral-PICA junction, and 1 each at mid and distal PICA, underwent endovascular treatment at our institution between 2011 and 2016. Results: All the patients presented with an acute intracranial hemorrhage, confirmed on CT head. Most of the aneurysms were at proximal PICA (anterior and lateral medullary segments) with the partial incorporation of PICA origin in the sac. Low origin of PICA was seen in 7 (out of 11) cases, out of these cases, 5 had proximal PICA, aneurysm, and one (n = 1) had VA-PICA, junction aneurysm (1/7) and. one distal PICA aneurysm. There were seven proximal PICA aneurysms, and out of them, parent vessel occlusion was done in six and selective coiling in one (n = 1) case. From seven (n = 7) proximal PICA aneurysms, there were five cases of low origin and rests showed normal course and origin. Two (n = 2) junctional aneurysms were treated with simple coiling. Low origin was seen in right VA-PICA junction aneurysm. Endovascular treatment of all the 11 aneurysms was successful. The treatment consisted of selective aneurysm coiling in four (36.3%) patients and aneurysm with parent vessel trapping in seven patients (63.6%). Out of these seven patients, in one (n = 1) patient where aneurysm was distal PICA, glue embolization was done. There was no intra-procedural rupture/contrast extravasation or any thrombo-embolic complications. Follow-up studies ranged from 6 months to 5 years. Conclusion: Endovascular therapy of ruptured proximal PICA aneurysms is possible and safe with the use of adjuvant devices and should be considered as first-line treatment.
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THORACIC IMAGING Top

Coronary-pulmonary fistula with common sac: An uncommon variant p. 239
Neeraj Jain, Shashidhar Achar, Naveen K Garg, Sunil Kumar
DOI:10.4103/ijri.IJRI_399_17  PMID:30050249
A 68-year-old male patient presented with chief complaints of chest pain and dyspnea on exertion. On physical examination, his pulse was regular at 82 bpm and blood pressure was 140/80 mmHg. Resting electrocardiography (ECG) was within normal limit and chest X-ray also did not reveal any significant abnormality. Routine blood investigations were unremarkable; transthoracic echocardiography also did not show any significant abnormality. Catheter coronary angiography revealed severe triple vessel disease and showed possibility of coronary artery fistula. Computed tomography (CT) coronary angiography showed three aberrant branches arising from right and left coronary arteries forming a sac which subsequently opened into the main pulmonary artery.
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PAEDIATRIC IMAGING Top

Esophageal stents in children: Bridge to surgical repair p. 242
Bethany J Slater, Ashwin Pimpalwar, David Wesson, Oluyinka Olutoye, Sheena Pimpalwar
DOI:10.4103/ijri.IJRI_313_17  PMID:30050250
Management of complex esophageal problems in children is challenging. We report our experience with the use of esophageal stents in three children with esophageal strictures, leaks, or airway-esophageal fistulae refractory to conventional treatment. The stent played a key role in allowing extubation of a child with a large tracheo-esophageal-pleural fistula and in the resolution of pulmonary infection in a child with esophago-bronchial fistula, both followed by surgery. In the third child, with stricture, stents were complicated with migration, esophageal erosion, and esophago-bronchial fistula. In our experience, esophageal stents were useful mainly as a bridge to definitive surgical repair.
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Wilm's tumor presenting with scrotal varicocele in an 11-month-old boy p. 247
Bukunmi M Idowu, Adebayo G Tanimola
DOI:10.4103/ijri.IJRI_279_17  PMID:30050251
This is a case report of Wilms' tumor which presented with varicocele in an 11-month old infant. The age of the patient and the uncommon mode of presentation are the unique features of this case. This case emphasizes the need to exclude a renal tumor in children with scrotal varicoceles.
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MISCELLANEOUS Top

Radiation dose metrics in multidetector computed tomography examinations: A multicentre retrospective study from seven tertiary care hospitals in Kerala, South India p. 250
Binoj Varghese, Indu Kandanga, Paul Puthussery, Dhanesh Vijayan, S P Harish Babu, MK Aneesh, Muhammad Noufal, EV Binu, Arun C Babu, Sheen M James, Siva Kumar
DOI:10.4103/ijri.IJRI_394_17  PMID:30050252
Background: Presently, computed tomography (CT) is the most important source of medical radiation exposure. CT radiation doses vary considerably across institutions depending on the protocol and make of equipment. India does not yet have national or region-specific CT diagnostic reference levels. Aim: To evaluate radiation doses of consecutive multidetector CT (MDCT) examinations based on anatomic region, performed in 1 month, collected simultaneously from seven tertiary care hospitals in Kerala. Settings and Design: Descriptive study. Materials and Methods: We collected the CT radiation dose data of examinations from the seven collaborating tertiary care hospitals in Kerala, performed with MDCT scanners of five different makes. The data included anatomic region, number of phases, CT dose index (CTDIvol), dose-length product (DLP), and effective dose (ED) of each examinations and patient demographic data. Statistical Analysis: We calculated the 25th, 50th, and 75th percentiles of the CTDIvol, DLP, and ED according to anatomic region. We made descriptive comparisons of these results with corresponding data from other countries. Results: Of 3553 patients, head was the most frequently performed examination (60%), followed by abdomen (19%). For single-phase head examinations, 75th percentile of CTDIvolwas 68.1 mGy, DLP 1120 mGy-cm, and ED 2.1 mSv. The 75th percentiles of CTDIvol, DLP, and ED for single-phase abdomen examinations were 10.6, 509.3, and 7.7, and multiphase examinations were 14.6, 2666.9, and 40.8; single-phase chest examinations were 23.4, 916.7, and 13.38, and multiphase examinations were 19.9, 1737.6, and 25.36; single-phase neck were 24.9, 733.6, and 3.814, and multiphase neck were 24.9, 2076, and 10.79, respectively. Conclusion: This summary CT radiation dose data of most frequently performed anatomical regions could provide a starting point for institutional analysis of CT radiation doses, which in turn leads to meaningful optimization of CT.
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A simple quality control tool for assessing integrity of lead equivalent aprons p. 258
Roshan S Livingstone, Anna Varghese
DOI:10.4103/ijri.IJRI_374_17  PMID:30050253
Background: Protective lead or lead-equivalent (Pbeq) aprons play a key role in providing necessary shielding from secondary radiation to occupational workers. Knowledge on the integrity of these shielding apparels during purchase is necessary to maintain adequate radiation safety. Aim: The aim of the study was to evaluate the lead equivalence in aprons based on simple quality assessment tool. Materials and Methods: 0.25 mm and 0.5 mm lead and lead-free aprons from 6 manufacturers were assessed using a calibrated digital X-ray unit. The percentage attenuation values of the aprons were determined at 100 kVp using an ionization chamber and the pixel intensities were analyzed using digital radiographic images of lead apron, copper step wedge tool, and 2 mm thick lead. Results: Mean radiation attenuation of 90% and 97% was achieved in 0.25 mm and 0.5 mm lead or lead-free aprons respectively. The pixel intensities from 0.25 mm Pbeq apron correspond to 0.8–1.2 mm thickness of Cu while 0.5 mm Pbeq aprons correspond to 2.0–2.8 mm of Cu. Conclusion: Pixel intensity increased with increase in the thickness of copper step wedge indicating a corresponding increase in lead equivalence in aprons. It is suggestive that aprons should be screened for its integrity from the time of purchase using computed tomography (CT), fluoroscopy, or radiography. It is recommended that this simple test tool could be used for checking lead equivalence if any variation in contrast is seen in the image during screening.
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Clinical radiology: Going an extra mile for patient care p. 263
Upendra Kumar Joish, Hirdesh Sahni, R Harikiran Reddy, Vivek Sreekanth
DOI:10.4103/ijri.IJRI_145_17  PMID:30050254
Context: Clinical details help radiologists report accurately. However, the clinical aspect has taken a backseat among radiologists, who are overdependent on referral notes. This leads to inaccurate assessment, financial burden, and loss of man hours. Aims: To re-emphasize the benefits of detailed clinical evaluation and real-time monitoring of imaging in interpreting images. Settings and Design: Prospective study. Materials and Methods: A study was done in the Department of Radiodiagnosis for 10 days, including all referred patients above 18 years of age. Detailed history taking and examination was done by radiologists prior to imaging. Any additional significant clinical detail was endorsed on the referral slips. Appropriate imaging modality under given circumstances was carried out. Imaging was studied by the radiologists, near simultaneously with the acquisition. Any additional imaging needed was performed on the same day. Comprehensive reports with specific outputs were provided. Wherever apt, imaging-guided management options were offered to the patients. Results: During the study, 1024 patients with mean age of 46.3 years underwent various types of imaging, including radiography, computed tomography, magnetic resonance imaging, ultrasound scans, and fluoroscopic procedures. Additional clinical details were endorsed in referral slips in 32.4% patients, 53% of which helped in interpreting images appropriately. Primary imaging modality was changed in 3% patients. Additional imaging was done in 10.9% patients. 3.6% of patients underwent imaging-guided procedures. Conclusion: Detailed history taking and examination help radiologists in deciding appropriate imaging and better interpretation of images. This will also reduce the number of visits to the hospital and expenditure on part of patients.
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LETTERS TO THE EDITOR Top

Thoracic sarcoidosis versus tuberculosis: Need for a multi-disciplinary approach p. 267
Agrima Mian, Animesh Ray
DOI:10.4103/ijri.IJRI_61_18  PMID:30050255
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Author's Reply p. 268
Ashu S Bhalla, A Das, P Naranje, A Goyal, R Guleria, Gopi C Khilnani
DOI:10.4103/ijri.IJRI_85_18  PMID:30050256
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