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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 29 | Issue 3
Page Nos. 233-340

Online since Thursday, October 31, 2019

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EDITORIAL  

CT FFR A paradigm shift in evaluation of coronary artery disease p. 233
Anirudh Kohli
DOI:10.4103/ijri.IJRI_412_19  
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CHEST IMAGING Top

Imaging protocols for CT chest: A recommendation Highly accessed article p. 236
Ashu Seith Bhalla, Abanti Das, Priyanka Naranje, Aparna Irodi, Vimal Raj, Ankur Goyal
DOI:10.4103/ijri.IJRI_34_19  
Computed Tomography (CT) is the mainstay of diagnostic imaging evaluation of thoracic disorders. However, there are a number of CT protocols ranging from a simple non-contrast CT at one end of the spectrum, and CT perfusion as a complex protocol available only on high-end scanners.With the growing diversity, there is a pressing need for radiologists, and clinicians to have a basic understanding of the recommended CT examinations for individual indications. This brief review aims to summarise the currently prevalent CT examination protocols, including their recommended indications, as well as technical specifications for performing them.
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INTERVENTIONAL RADIOLOGY Top

Radiation dose reference card for interventional radiology procedures: Experience in a tertiary referral centre p. 247
Anna Varghese, Shyamkumar N Keshava, Vinu Moses, George Koshy, Suraj Mammen, Munawwar Ahmed, Roshan S Livingstone
DOI:10.4103/ijri.IJRI_35_19  
Background: Fluoroscopy-guided interventions can potentially increase radiation risk to patients, if awareness on angiographic imaging technique and radiation dose is neglected. Aim: To develop patient radiation dose reference card from standardized imaging techniques for various radiology interventions performed using flat detector based angiography system. Materials and Methods: Real-time monitoring of angiographic exposure parameters and radiation dose were performed for 16 types of radiological interventions. Effective dose (ED) was estimated from dose area product (DAP) using PCXMC Monte Carlo simulation software. Radiation risk levels were estimated based on Biological Effects of Ionising radiation (BEIR) report VII predictive models for an Asian population. Results: Pulse rates of 7.5 pps and 0.6 mm Copper filtration during fluoroscopy and 4 frames per second (fps) and 0.1-0.3 mm Cu filtration during image acquisitions were found to reduce radiation dose. Owing to increased number of image acquisitions, DAP was highest during diagnostic spinal angiography 186.7 Gycm2 (44.0–377.5). This resulted in highest ED of 59.4 mSv with moderate risk levels (1 in 1000 to 1 in 500). Most of the radiological interventions had low radiation risk levels (1 in 10,000 to 1 in 1000). Conclusion: The patient radiation dose reference card is valuable to the medical community and can aid in patient counselling on radiation induced risk from radiological interventions.
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Computed tomography guided radio-frequency ablation of osteoid osteomas in atypical locations p. 253
Julie Senne, Ryan Davis, Junaid Yasin, Olubusola Brimmo, Andrea Evenski, Ambarish P Bhat
DOI:10.4103/ijri.IJRI_259_19  
Purpose: Percutaneous radio-frequency ablation is a minimally invasive treatment option for osteoid osteomas. The ablation process is straightforward in the more common locations like the femur/tibia. Surgery has historically been the gold standard, but is currently used in lesions, that may not be effectively and safely ablated, i.e. close to skin/nerve. Radio-frequency ablation can still be used in such cases along with additional techniques/strategies to protect the sensitive structures and hence improve the outcomes. The authors describe their experience with four challenging osteoid osteoma ablation cases. Methods: We retrospectively reviewed radio-frequency ablations of four osteoid osteomas in rather atypical locations, the protective techniques/strategies employed, the adequacy and safety of the radio-frequency ablation with the use of these techniques. Results: All patients had complete resolution of pain with no recurrence in the follow-up period. No complications were reported. Conclusion: RFA has been proven to be an effective and safe option for treatment of OOs in the common locations. It is generally recommended to have a 1 cm safety margin between the RF probe and any critical structures in the vicinity. However, with OOs in atypical locations this may not be always possible and hence additional techniques may be needed to ensure protection of the surrounding sensitive structures and also allow for effective ablation.
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Current review with evolving management strategies in critical limb ischemia p. 258
Arun Sharma
DOI:10.4103/ijri.IJRI_208_19  
Critical limb ischemia represents the end stage of peripheral artery disease, which is associated with impaired quality of life and considerable morbidity and mortality. Economical impact of the disease is huge with a substantial burden on patients, healthcare providers, and resources. Varied therapeutic strategies have been employed in the management of these patients. These patients usually have complex multilevel occlusive arteriopathy with significant comorbidities, rendering surgical interventions undesirable in many cases. Recent therapeutic advances with evolving endovascular techniques and gene or cell-based therapies have the potential to dramatically change the therapeutic outlook in these patients.
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MUSCULOSKELETAL IMAGING Top

MR neurography in Parsonage-Turner syndrome p. 264
Vaishali Upadhyaya, Divya Narain Upadhyaya, Richa Bansal, Tarun Pandey, Ashok Kumar Pandey
DOI:10.4103/ijri.IJRI_269_19  
Background and Aims: Parsonage Turner Syndrome is a well known clinical entity. Several excellent articles have succinctly described Magnetic Resonance Imaging (MRI) findings in PTS. However, these articles have inferred neural involvement in PTS based on the patterns of denervation of muscles in the shoulder region. The aim of this study is to directly visualize the distribution and extent of abnormality in MR Neurography (MRN) of the brachial plexus in known cases of brachial plexus neuritis or Parsonage-Turner Syndrome (PTS). Methods: 15 patients who were diagnosed with PTS based on clinical and electrophysiological findings participated in the study. MRN of the brachial plexus was done in a 1.5T system using a combination of T1W (T1-weighted), T2W (T2-weighted) fat-saturated, STIR (Short Tau Inversion Recovery), 3D STIR SPACE (Sampling Perfection with Application Optimized Contrasts) and 3D T2W SPACE sequences. Findings were recorded and assessed. Results: The age range of our patients was 7-65 years (mean 37.87 years). Most of the patients had unilateral symptoms. All patients had weakness in shoulder abduction. Other common associated complaints included pain in the shoulder/neck/arm and preceding fever. MRN revealed the percentage of involvement of roots, trunks, cords and terminal branches was 53.3%, 46.7%, 40% and 13.3% respectively. Evidence of muscle denervation in the form of edema, fatty infiltration and atrophy was noted in 8 (53.3%) patients. Conclusion: Most of the patients in this study had unilateral involvement on MRN. The roots were the commonest site of involvement followed by the trunks, cords and terminal branches. C5 was the most commonly involved root.
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Solid variant ABC of long tubular bones: A diagnostic conundrum for the radiologist p. 271
Adarsh Ghosh, Anuradha Singh, Richa Yadav, Shah A Khan, Venkatesan S Kumar, Shivanand Gamanagatti
DOI:10.4103/ijri.IJRI_160_19  
Solid variant of aneurysmal bone cyst (sABC) is an extremely rare, reactive and non-neoplastic osseous lesion. On imaging it presents as a diaphyseal aggressive, eccentrically placed lytic and expansile lesion. However, differentiating this entity from the other possible malignant differentials is confounded by the histopathology mimicking several commoner lesions. We describe the distinctive MRI features of sABC of long bones from a series of four cases and briefly review the literature. We hope this review will educate all radiologists about this rare entity increasing their diagnostic confidence while formulating differentials for similar appearing lesions.
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GENITOURINARY IMAGING Top

Role of MRI in staging and surgical planning and its clinicopathological correlation in patients with renal cell carcinoma p. 277
Hira Lal, Paritosh Singh, Manoj Jain, Uday Pratap Singh, Sanjoy Kumar Sureka, Rajanikant R Yadav, Raghunandan Prasad, Pragati Verma, Anuradha Singh, Priyank Yadav
DOI:10.4103/ijri.IJRI_177_19  
Background and Aims: Radiological evaluation of renal cell carcinoma (RCC) is used for non-invasive staging for better surgical planning. However, the correlation of radiological staging using magnetic resonance imaging (MRI) with histopathological findings has not been done so far. The aim of this study is to assess the role of MRI in pre-operative staging of RCC in patients undergoing radical nephrectomy and nephron sparing surgery (NSS) and correlate it with histopathological findings. Settings and Design: This prospective observational study was conducted from February 2015 to October 2016 at a tertiary care hospital in northern India. Methods: MR imaging was done on 3 Tesla MR scanner (Signa Hdxt General Electrics, Milwaukee, USA). Preoperative staging was based on 2010 TNM staging system. The preoperative parameters in MRI were tumor size, detection/breach of pseudocapsule, tumor extension into perirenal fat and detection of tumor venous thrombus. The staging on MRI was compared with surgical and pathological staging. Statistical Analysis Used: The agreement between these three staging methods was determined using the kappa statistics (0.0-0.2, poor; 0.2-0.4, fair; 0.4-0.6, moderate; 0.6-0.8, good; 0.8-1.0, excellent). Results: 30 patients with suspected RCC underwent NSS (n = 10) and radical nephrectomy (n = 20). Mean tumor size was 9.66 ± 2.99 cm in the radical nephrectomy group and 4.06 ± 1.16 cm in the NSS group. There was perfect agreement between MRI, surgical and pathological staging for breach of pseudocapsule (κ =1.0, Percentage of Agreement = 100%,P < 0.05). In none of the patients, MRI missed extension beyond the Gerota's fascia or presence of venous thrombus. Conclusion: MRI staging of RCC is an accurate predictor of the surgical and pathological stage and has the potential to become a useful tool for preoperative identification of patients with RCC who can undergo NSS.
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RECENT ADVANCES Top

MR-guided focused ultrasound surgery: A novel non-invasive technique in the treatment of adenomyosis –18 month's follow-up of 12 cases p. 284
Bhawna Dev, Sameera Gadddam, Mitesh Kumar, Suresh Varadarajan
DOI:10.4103/ijri.IJRI_53_19  
Background: Adenomyosis is a gynecological condition of the uterus, characterized by the presence of ectopic endometrial tissue in the myometrium. Hysterectomy, uterine artery embolization, and endometrial ablation therapy are the various surgical treatment options available for adenomyosis. A novel and globally upcoming technique is MR-guided focused ultrasound surgery “MRgFUS,” which is a promising non-invasive surgical treatment option. This study was carried out to determine the effectiveness of MRgFUS in the symptomatic management of adenomyosis. Subjects and Methods: This study was carried out as a long-term follow-up study among 12 cases of adenomyosis, which were treated by MR-guided focused ultrasound. In all these participant's, three parameters – symptom severity score (SSS), menstrual pain score accessed using visual analogue score (VAS), and number of approximate pads used during menstruation were recorded prior to the treatment and on follow-up at 3, 9, and 18 months, respectively. The Friedman's test was used to test the difference in the values of scores before and after treatment. Results: There was a significant improvement in the SSS, VAS, and the numbers of sanitary napkins used after surgery and sustained during the long-term follow-up. These values were statistically significant (P < 0.05). Conclusion: MRgFUS can be used in successful treatment of adenomyosis/focal adenomyoma by careful selection of the participant, good planning, and proper monitoring of the technique during ablation.
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Applications of dual energy CT in clinical practice: A pictorial essay p. 289
Parang S Sanghavi, Bhavin G Jankharia
DOI:10.4103/ijri.IJRI_241_19  
In dual-energy CT (DECT), two different x-ray spectra are used to acquire two image datasets of the same region, to allow the analysis of energy-dependent changes in the attenuation of different materials. Each type of material demonstrates a relatively specific change in attenuation between images obtained with a high-energy spectrum and those obtained with a low-energy spectrum. Based on the relatively specific change in attenuation with two different energies, material composition information can be obtained to allow tissue characterization. The DECT ability of material differentiation allows bone removal in various CT angiography studies and bone marrow edema depiction, while with material optimization, metal artefacts can be significantly reduced to almost nil. DECT allows material separation to differentiate uric acid crystals from calcium to determine the composition of urinary calculi and to diagnose gout. Using the DECT ability of material decomposition, iodine maps can be generated, which are useful in the evaluation of any enhancing lesion in the body without the need to obtain a plain scan and allow perfusion maps to be created in cases of pulmonary thromboembolism.
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MISCELLANEOUS Top

Artifacts in cranial MRI caused by extracranial foreign bodies and analysis of these foreign bodies p. 299
Selim Kayaci, Ahmet Tabak, Irmak Durur-Subasi, Tugba Eldes, Vaner Koksal, Murat Sirin, Yusuf Kemal Arslan
DOI:10.4103/ijri.IJRI_211_18  
Purpose: The purpose of our study was to conduct a chemical analysis of extracranial foreign bodies (FBs) causing artifacts in cranial magnetic resonance imaging (MRI) and to investigate the association between chemical composition, magnetic susceptibility, and artifact size. Materials and Methods: A total of 12 patients were included in the study. The FBs responsible for the artifacts were visualized using cranial computed tomography (CT). Artifact-causing FBs were removed from the scalps of 10 patients and analyzed using scanning electron microscope with energy dispersive spectroscopy (SEM-EDS), X-ray diffraction spectroscopy (X-RD), and Fourier-transform infrared spectroscopy (FT-IR). The magnetic susceptibility of the samples was determined using the reference standard material MnCl2.6H2O. The volume of the MRI artifacts was measured in cubic centimeters (cm3). Results: EDS results demonstrated that the mean Fe ratio was 5.82% in the stone samples and 0.08% in the glass samples. Although no phase peaks were detected in the X-RD spectra of the glass samples, peaks of Fe2O3, Al2Ca (SiO4) were detected in the X-RD spectra of the stone samples. The FT-IR spectra revealed metal oxide peaks corresponding to Fe, Al, in the stone samples and peaks confirming Al2SiO5and Na2SiO3structures in the glass samples. The mean volumes of the MRI artifacts produced by the stone and glass samples were 5.9 cm3 and 2.5 cm3, respectively. Conclusions: Artifacts caused by extracranial FBs containing metal/metal oxide components are directly associated with their chemical composition and the artifact size are also related to element composition and magnetic susceptibility.
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Postmortem CT scan in intoxication cases: A necessity or just an indulgence p. 305
Lai Poh Soon, Kunasilan Subramaniam, Nor Fadhilah Madon, Mohamad Helmee Mohamad Noor, Mansharan Kaur Chainchel Singh, Mohd Shah Mahmood
DOI:10.4103/ijri.IJRI_2_19  
Introduction: The aim of this study is to correlate urinary bladder distension and pulmonary edema on postmortem computed tomography (CT) scans with toxicology results in postmortem cases. Methods and Results: The study population was the postmortem cases of Asian population ranging from 16 to 75 years old in which blood and/or urine samples sent for alcohol and/or drug of abuse (DoA) analysis in year 2016 at our centre. Out of 434 cases, 54 from each group of positive and negative alcohol and/or DoA. Postmortem findings of lungs and postmortem CT scan urinary bladder volume (UBV) were recorded. Statistical significant correlation was obtained between urinary bladder distension on postmortem CT scan and cases with positive alcohol detection. However, the sensitivity was relatively low at 51.7%, whereas the specificity was 75% at the cut-off point. Low sensitivity and specificity at around 52.7% were obtained for pulmonary edema related to alcohol/DoA. This showed that UBV alone or pulmonary edema alone was not really a good indicator for alcohol or DoA intoxication. However, combination of both indicators provided higher sensitivity (73.3%) although specificity was lowered to 53.8%. Conclusion: The findings of postmortem CT scan bladder distension and pulmonary edema could possibly identify intoxication cases but not conclusive.
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CASE REPORTS Top

Bilio-cutaneous fistula obliteration with NBCA p. 310
Antonio Bottari, Salvatore Silipigni, Alberto Stagno, Simona Caloggero
DOI:10.4103/ijri.IJRI_16_19  
Biliary fistula and bile leakage are complications that can occur during hepato-biliary surgery (both open and laparoscopic) and percutaneous biliary intervention. In some cases, spontaneous resolution is documented but more often re-intervention (surgical or percutaneous) is necessary. We present the case of a male patient who underwent right hepatectomy with bilio-digestive anastomosis for a cholangiocarcinoma which developed a bilo-cutaneous fistula through the path of a previously inserted percutaneous transhepatic drainage. Sealing of bilo-cutaneous fistula was obtained using N-butil-Cyanoacrylate. This technique has already been reported in some papers as a useful tool for biliary tree obliteration; however, to our knowledge, no cases describing the use of glue to seal a sub-cutaneous route are available in literature.
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A rare case of bleeding duodenal varices from superior mesenteric vein obstruction -treated with transhepatic recanalization and stent placement p. 313
Ambarish P Bhat, Ryan M Davis, William D Bryan
DOI:10.4103/ijri.IJRI_21_19  
Ectopic varices are complex and highly variable entities that are not fully understood. Duodenal varices from pancreatitis have rarely been reported. Ectopic varices have much higher bleeding rates than the more common gastro-esophageal varices, and are associated with higher mortality. The ideal management of this difficult problem is not only to ensure prompt hemostasis, but also address the etiology or hemodynamics of the ectopic varices. We discuss the endovascular management of bleeding duodenal varices, which developed from superior mesenteric vein occlusion, following repeated attacks of pancreatitis. This unusual case was managed by a multidisciplinary collaborative approach between the gastrointestinal service and Interventional radiology. The classification system for ectopic varices and management options has been discussed in some detail. Medium term follow-up (8 months), at the time of this writing, showed that the patient is doing well, without interval hematemesis, imaging findings of recurrent/new varices or stent occlusion.
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Left atrial isomerism associated with aneurysmal enlargement of right atrial appendage: A case report with literature review p. 318
Prateek Agarwal, Rajesh Kumar Agarwal
DOI:10.4103/ijri.IJRI_341_19  
We present a prenatally diagnosed case of heterotaxy syndrome (HS) in which left atrial isomerism (LAI) was associated with an aneurysmal enlargement of the right atrial appendage (RAA). Although LAI is usually associated with complex cardiac and extracardiac anomalies, the association of LAI and right atrial appendage aneurysm (RAAA) is exceptional. Congenital RAAA itself is an idiopathic, very rare cardiac anomaly characterized by the enlargement of the appendage in the absence of any other cardiac or extra-cardiac defect. The prognosis of the heterotaxy is poor with associated major cardiac malformations and even cases with minor cardiac anomalies are at risk postnatally for complications like biliary atresia, intestinal rotational abnormalities, and immune disorders. In this case, the prenatal diagnosis of the isomerism was mainly based on the abnormalities of caval veins. Although no typical complex cardiac anomaly was present, the HS was associated with biliary atresia, polysplenia, and malrotation of the gut. Associated RAAA further imposed an additional risk of complications such as tachyarrhythmias, thromboembolic events, and aneurysmal rupture.
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A rare case of epidermoid cyst in urinary bladder p. 324
Sirisha N Puppala, Ajit Mahale, Sonali Ullal
DOI:10.4103/ijri.IJRI_194_19  
Epidermoid cyst in urinary bladder is a rare pathology with only one known case published prior to this study. In this article, we described imaging findings of epidermoid cyst in the urinary bladder and other parts of urogenital system. Plain CT KUB was performed on Multidetector 16 slice computed tomography scanner-GE Bright speed Elite and plain magnetic resonance imaging on 1.5 T Siemens Magnetom Avanto.
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Adenocarcinoma and neuroendocrine tumor arising within presacral teratoma associated with Currarino syndrome: A case report p. 327
Shohei Chatani, Hiroaki Onaya, Seiichi Kato, Yoshitaka Inaba
DOI:10.4103/ijri.IJRI_148_19  
We present a case of a 59-year-old woman with a malignant tumor arising within presacral teratoma associated with Currarino syndrome (CS). A characteristic crescent-shaped sacrum was detected on preoperative image examination and the presacral mass was pathologically diagnosed as a malignant tumor associated with CS. To our knowledge, this is the first case report of presacral teratoma associated with CS coexisting with both adenocarcinoma and a neuroendocrine tumor.
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Cerebrotendinous xanthomatosis - A case report p. 332
Arshed Hussain Parry, Abdul Haseeb Wani, Muiez Bashir, Tariq A Gojwari
DOI:10.4103/ijri.IJRI_444_18  
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder resulting from a defective enzyme in bile acid synthesis pathway leading to neurological, ocular, vascular, and musculoskeletal symptoms from deposition of cholestanol and cholesterol in these tissues. We present clinical and imaging features of a 32-year-old female who presented with mental retardation, gait instability and swelling along posterior aspect of both ankles. Imaging studies were performed which revealed spectrum of CTX findings in brain and tendons. Subsequently the diagnosis was confirmed by biopsy and laboratory tests.
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LETTERS TO THE EDITOR Top

Change the Spot! p. 335
Ravi Ramakantan
DOI:10.4103/ijri.IJRI_294_18  
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Being a “Clinical Radiologist” “Patient-centric approach” and “problem-solving attitude” in radiology p. 336
Nitin P Ghonge
DOI:10.4103/ijri.IJRI_173_19  
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Re: Non-radiation occupational hazards and health issues faced by radiologists – A cross-sectional study of indian radiologists' by Kawthalkar AS et al. p. 337
Venkatraman Indiran Venkatraman, Jagannathan Kokilavani
DOI:10.4103/ijri.IJRI_172_19  
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The other woman - A day in the life of a breast radiologist p. 339
Teena Sleeba
DOI:10.4103/ijri.IJRI_408_19  
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