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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 29 | Issue 1
Page Nos. 1-107

Online since Friday, March 29, 2019

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EDITORIALS  

A new beginning p. 1
Anirudh Kohli
DOI:10.4103/ijri.IJRI_147_19  PMID:31000932
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Is next-generation radiologist ready for the challenges? Highly accessed article p. 2
Chander Mohan
DOI:10.4103/ijri.IJRI_124_19  PMID:31000933
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PRESIDENTIAL ADDRESS Top

Presidential address p. 4
Hemant Patel
DOI:10.4103/ijri.IJRI_73_19  PMID:31000934
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GASTRO-INTESTINAL IMAGING Top

Corrosive injuries of the upper gastrointestinal tract: A pictorial review of the imaging features Highly accessed article p. 6
Rohan Kamat, Pankaj Gupta, Yalaka Rami Reddy, Suman Kochhar, Birinder Nagi, Rakesh Kochhar
DOI:10.4103/ijri.IJRI_349_18  PMID:31000935
Corrosive ingestion is a common form of poisoning. Corrosive agents cause severe damage to the gastrointestinal (GI) tract. The most severe forms of injury can lead to mortality; however, the major concern with this type of injury is life-long morbidity. Upper GI endoscopy is the test of choice for assessing severity in the acute phase of the disease. The long-term management is based on the site, length, number, location, and tightness of the stricture. This information is best provided by the barium contrast studies. In this pictorial review, a spectrum of findings in patients with corrosive injuries of the esophagus and stomach is illustrated. The role of various imaging modalities including barium studies, endoscopic ultrasound, computed tomography, and magnetic resonance imaging is discussed.
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”Honeycomb” pattern of gallbladder wall thickening – A forward step in early diagnosis of “Severe Dengue Fever” p. 14
Jitendra Parmar, Maulik Vora, Chander Mohan, Sandip Shah, Harsh Mahajan, Tapan Patel
DOI:10.4103/ijri.IJRI_363_18  PMID:31000936
Aims and Objectives: To study “Honeycomb” pattern of gallbladder wall thickening (GBWT) in dengue fever (DF) and to assess its clinical significance in early diagnosis of severe DF. Materials and Methods: A total 244 patients of DF were studied, 84 patients were classified as severe DF, 61 patients as DF with warning signs, and 99 patients as DF without warning signs. Abdominal ultrasound was performed for assessment of GBWT patterns, hepatomegaly, splenomegaly, pancreatic enlargement, ascites, pleural effusion, and other additional findings were recorded in severe DF cases. Statistical comparison between “Honeycomb” pattern of GBWT and clinically severe DF was done using Pearson correlation test. Results: Out of 244 patients, 145 patients were males and 99 patients were females, belonging to various age groups ranging from 1 to 81 years and 14.34% (35 patients) among them included in pediatric group. In total, 65.57% (160 patients) were non-severe DF cases and 34.42% (84 patients) were severe DF cases. A total of 84 patients of severe DF, 92.85% patients showed GBWT, and out of which, 71.42% patients had “Honeycomb” pattern, whereas a total of 160 patients of non-severe DF patients, 45% patients had GBWT and out of which, only 5.6% patients showed “Honeycomb” pattern.”Honeycomb” pattern of GBWT shows sensitivity of 71.4%, 94.37%, Positive predictive value of 86.95%, and Negative predictive value of 86.28% in severe DF. Conclusion:”Honeycomb” pattern of GBWT is significant finding in severe DF. Its sensitivity and specificity are high in severe DF with significant statistical correlation. It can aid in early diagnosis of severe DF.
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MUSCULOSKELETAL IMAGING Top

Adhesive capsulitis: MRI correlation with clinical stages and proposal of MRI staging p. 19
Amarnath Chellathurai, Komalavalli Subbiah, Atchaya Elangovan, Sivakumar Kannappan
DOI:10.4103/ijri.IJRI_116_18  PMID:31000937
Objective: The purpose of this study was to correlate the magnetic resonance imaging (MRI) findings of adhesive capsulitis with clinical stages and thereby propose a MR staging system. Materials and Methods: This study consisted of 74 patients with clinically diagnosed adhesive capsulitis. The edema of the inferior glenohumeral ligament (IGHL), pericapsular edema, thickness of anterior band of IGHL, axillary pouch, thickness of coracohumeral ligament, and obliteration of fat in the subcoracoid triangle were evaluated by MRI. Results: Thickening of the anterior band of IGHL showed most significant correlation with the clinical stages. The distribution of edema of IGHL and pericapsular edema also showed significant correlation with the clinical stages of adhesive capsulitis. Pericapsular edema and IGHL edema was not observed in stage IV. Conclusion: MR is a useful tool for evaluation and prediction of clinical stage of adhesive capsulitis.
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WOMENS IMAGING Top

Role of apparent diffusion coefficient as a biomarker in the evaluation of cervical cancer p. 25
Sunita Dashottar, T Preeth Pany, Nishant Lohia
DOI:10.4103/ijri.IJRI_441_18  PMID:31000938
Background: Diffusion-weighted magnetic resonance imaging (DW-MRI) has evolved as a major diagnostic and prognostic tool in cervical cancer. The aim of our study was to compare the change in mean apparent diffusion coefficient (ADC) value before and after concurrent chemoradiation therapy (CCRT) in carcinoma cervix thereby establishing its role as a cancer biomarker. Materials and Methods: A hospital-based prospective study was conducted in 35 patients diagnosed with cervical cancer. All 35 patients underwent pelvic MRI before and after 6 months of CCRT. The study was done over a period of 12 months. Conventional axial and sagittal T2 imaging was followed by DW-MRI. In the axial DW/ADC images at “b-value” of 800 s/mm2, a circular region of interest was drawn covering more than 60% of the tumor volume to calculate the ADC values. Statistical Package for the Social Sciences (version 21.0) was used for statistical evaluation. Chi-square test, independent samples t-test, and analysis of variance were used to analyze the data. The results are depicted as frequencies (number), proportion (percentages), and mean ± standard deviation. Results: Pre-CCRT mean ADC value was 0.814 × 10−3 mm2/s. Post-CCRT mean ADC value was 1.294 × 10−3 mm2/s. Mean ADC value of patients having lymph node involvement and parametrial extension was significantly lower when compared with those without lymph node involvement and parametrial extension (P = 0.001). Nonresponders with residual lesion had lower ADC values than responders with no residual lesion. An interesting and unique observation was that pre-CCRT mean ADC value of responders was higher than nonresponders. Conclusion: An increase in mean ADC value of 0.480 × 10−3 mm2/s after CCRT was found to be statistically significant (P < 0.001) thereby proving its role as an imaging biomarker in cancer cervix.
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CARDIAC RADIOLOGY Top

Cardiac T2* magnetic resonance analysis of membranous interventricular septum in assessment of cardiac iron overload in pediatric thalassemia patients: A pilot study p. 33
Ishan Kumar, Priyanka Aggarwal, Vineeta Gupta, Ashish Verma, Suwen Kumar, Ram C Shukla
DOI:10.4103/ijri.IJRI_395_18  PMID:31000939
Background: Cardiac iron deposition in transfusion-dependent thalassemia patients is patchy in distribution. Purpose: The purpose of this study is to assess the correlation between T2* matrices of membranous interventricular septum (MIVS) and T2* values of muscular interventricular septum (IVS) on magnetic resonance imaging (MRI) and to evaluate the relationship of myocardial T2* at these two locations with MRI-estimated liver iron concentrations (LIC) and electrocardiographic (ECG) parameters. Material and Methods: MRI of heart and liver was performed in 16 consecutive pediatric patients of transfusion-dependent thalassemia major to calculate liver iron concentration and T2* time of membranous and muscular IVS. ECG parameters of these patients were charted and correlated with MRI parameters. Results: No significant correlation between T2* values of muscular IVS and MIVS was observed. Mean T2* of MIVS (9.8 ms) was significantly lower than that of muscular IVS (26.9 ms). T2* of MIVS correlated strongly with LIC where as a weak correlation was observed between T2* of IVS and LIC. Significantly higher mean QTc (corrected QT interval) value (439.86 ms) was seen in patients with T2* IVS <20 ms. Conclusion: Addition of T2* analysis of MIVS to the existing MRI protocol, consisting of muscular IVS analysis, may offer a more sensitive estimation of cardiac iron overload.
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INTERVENTIONAL RADIOLOGY Top

Safety and outcomes of pre-operative portal vein embolization using N-butyl cyanoacrylate (Glue) in hepatobiliary malignancies: A single center retrospective analysis p. 40
Amar Mukund, Aniket Mondal, Yashwant Patidar, Senthil Kumar
DOI:10.4103/ijri.IJRI_454_18  PMID:31000940
Aims and Objectives: To evaluate the outcome of preoperative portal vein embolization (PVE) using N-butyl cyanoacrylate (NBCA) for change in future liver remnant (FLR) volume, biochemical changes, and procedure-related complications. The factors affecting FLR hypertrophy and the rate of resection was also evaluated for this cohort. Materials and Methods: From 2012 to 2017, PVE utilizing NBCA mixed with lipiodol (1:4) was performed using percutaneous approach in 28 patients with hepatobiliary malignancies with low FLR. All patients underwent volumetric computed tomography (CT) assessment before and at 3–5 weeks after PVE and total liver volume (TLV), FLR volume, and FLR/TLV ratio, changes in portal vein diameter and factors affecting FLR were evaluated. Complications and the resectability rate were recorded and analyzed. Result: PVE was successful in all 28 patients. The mean FLR increased by 52% ± 32% after PVE (P < 0.0001). The FLR/TLV ratio was increased by 14.2% ± 2.8% (P < 0.001). Two major complications were encountered without any impact on surgery. There was no significant change seen in liver function test and complete blood counts after PVE. Eighteen patients (64.28%) underwent hepatic resection without any liver failure, and only three patients developed major complication after surgery. Remaining ten patients did not undergo surgery because of extrahepatic metastasis detected either on follow-up imaging or staging laparotomy. Patients with diabetes showed a lower rate of hypertrophy (P < 0.05). Conclusion: Preoperative PVE with NBCA is safe and effective for increasing FLR volume in patients of all age group and even in patients with an underlying liver parenchymal disease with hepatobiliary malignancy. Lesser hypertrophy was noted in patients with diabetes. A reasonable resectability was achieved despite having a high rejection in gall bladder cancer subgroup due to rapid disease progression.
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Early experience of combination therapy of transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma measuring 3–7 cm p. 47
Yashwant Patidar, Lalit Garg, Amar Mukund, Shiv Kumar Sarin
DOI:10.4103/ijri.IJRI_352_18  PMID:31000941
Background of the Article: Hepatocellular carcinoma (HCC) is one of the most common human malignancies worldwide. Radiofrequency ablation (RFA) is considered curative option in selected patients; efficacy is severely limited by lesion size and lesions bordering a large vessel. On the other hand, transarterial chemoembolization (TACE) is not limited by lesion size and arterial occlusion of the tumor feeding vessels leads to increase the volume of the ablative zone. Combination treatments using both intraarterial liver-directed therapy and percutaneous ablation seek to overcome the disadvantages of the individual treatments alone, theoretically improving response to therapy and survival. Material and Methods: This is a single-center retrospectively study in which patients who received TACE plus RFA for HCC were evaluated for technical success, local tumor progression rates, distant intra and extrahepatic recurrences and survival. Results: The study included 22 patients, 21 patients had a solitary HCC of size 3–7 cm and one patient had three target lesions. Technical success achieved after first session of combination treatment was 100% (24/24). At 1 and 3 months follow-up 100% patients (24 target lesions) had complete response and at 6 months; 21 (87.5%) had complete response, one (4.2%) had local tumor progression and two patients (8.3%) developed progressive disease. No major difference in complication was noted. The event-free survival as shown by Kaplan–Meier graph analysis at 6 and 12 months were 90.7% and 66.4% with mean time to event-free survival was 11.1 months. Conclusion: The combined use of TACE and RFA is a safe and effective option in the treatment of patients with single large or multinodular HCC when surgical resection is not feasible and this approach provides better results than RFA or TACE alone.
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RADIOPHYSICS Top

The investigation of dose and image quality of chest computed tomography using different combinations of noise index and adaptive statistic iterative reconstruction level p. 53
Supawitoo Sookpeng, Colin J Martin, Chitsanupong Butdee
DOI:10.4103/ijri.IJRI_124_18  PMID:31000942
Background: Computed tomography (CT) automatic tube current modulation (ATCM) systems and iterative reconstruction (IR) play an important role in CT radiation dose optimization. How the two can best be used together is one of the challenges faced by radiology professionals. Aim: To determine optimum settings of ATCM noise index (NI) together with adaptive statistic iterative reconstruction (ASIR) for a general electric (GE) scanner that aims to achieve similar image quality to the standard protocol used in the hospital (Smart mA technique with NI of 11.57 and 30% ASIR reconstruction) with a lower dose. Methods: Different NI and ASIR levels were set for scans of a phantom. Objective image quality assessments in terms of noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), low-contrast detectability (LCD), and modulation transfer function (MTF) were carried out in an anthropomorphic chest and a Catphan 700 phantom. Subjective image quality assessment was also performed with five readers to confirm whether the image quality of the new protocols was adequate. Result and Conclusion: SNR and CNR increased with the strength of ASIR, and decreased with higher NI settings. The MTF improved slightly for higher dose levels and from filtered back projection (FBP) to higher strength of ASIR. LCD improved with ASIR compared to FBP and with higher strengths of ASIR. Qualitative scoring ranged between 3.0 and 4.6. A moderate degree of reliability was found between scoring. Use of NI 15.04 with 70% ASIR can reduce dose by 41% compared to the standard protocol of NI 11.57 with 30% ASIR without degradation of image quality.
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MISCELLANEOUS Top

Non-radiation occupational hazards and health issues faced by radiologists – A cross-sectional study of Indian radiologists p. 61
Ameya S Kawthalkar, Rachel A Sequeira, Supreeta Arya, Akshay D Baheti
DOI:10.4103/ijri.IJRI_403_18  PMID:31000943
Context: Radiologists as a group face unique occupational health hazards among which musculoskeletal injuries, chronic eye strain, and others are yet to receive adequate attention. Constant mental strain due to demanding turnaround times and work pressures may lead to burnout and depression. These combine to decrease overall work satisfaction and productivity. Aims: To study the prevalence of various health issues faced by radiologists in India and to assess whether specific demographic and occupational factors are associated with an increased risk. Settings and Design: Cross-sectional observational study conducted as a voluntary anonymous electronic survey. Methods and Materials: A 36-item survey was sent to radiologists through email and social media. All respondents who completed survey were included in the study. Questions regarding workload, repetitive stress injuries, eye strain, burnout, and so on were asked. Statistical Analysis Used: Chi-square test was used to test significance of correlation (P < 0.05). Results: In all, 383 radiologists completed the survey. A high prevalence of repetitive stress injuries, chronic eye strain, depression, and burnout was found. Significant correlation was found between repetitive stress injuries and burnout. Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT) related issues and work overload were the most common causes of high stress levels. Radiologists whose practices followed ergonomic design showed significantly less prevalence of neck pain. Conclusion: Radiologists in India have a high prevalence of repetitive stress injuries, chronic eye strain, and burnout, along with unique mental stressors such as PCPNDT-related issues.
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CASE REPORTS Top

Upper limb peripheral neuropathy in sickle cell anemia: MR neurography appearances p. 67
Feng Poh, Rocco Hlis, Avneesh Chhabra
DOI:10.4103/ijri.IJRI_364_18  PMID:31000944
Sickle cell anemia is an inherited disorder with many systemic complications. Peripheral neuropathy related to this disorder has been sparsely reported. We report an interesting case of upper limb peripheral neuropathy from sickle cell disease with emphasis on MR neurography appearances and electrophysiology correlation.
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Primary intracranial leiomyoma - A case report and literature review p. 72
Mary Varunya Jehendran, V Monish, Suresh Aswathappa, HV Ramprakash
DOI:10.4103/ijri.IJRI_250_18  PMID:31000945
Primary intracranial leiomyoma is a rare tumour of mesenchymal origin, with less than 30 cases reported in literature including two cases from the Indian subcontinent. In this article, we describe a case of primary intracranial leiomyoma in an immunocompromised patient with a brief review of literature.
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Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack p. 77
Ana Isabel Franco, Sari Arponen, Fátima Hermoso, María-José García
DOI:10.4103/ijri.IJRI_340_18  PMID:31000946
Introduction: Simultaneous subcutaneous emphysema, spontaneous pneumothorax, and pneumomediastinum are complications rarely observed synchronously during an acute exacerbation of bronchial asthma. Although spontaneous pneumothorax has already been reported in asthma patients in the literature, its concurrence with subcutaneous emphysema and pneumomediastinum is extremely rare except for iatrogenic conditions. Case Study: We describe a patient who presented to the emergency room with progressive dyspnea and chest pain. Three days before, she consulted her general physician with a history of violent dry cough and wheezing. An acute asthma exacerbation was diagnosed, and an inhaled short-acting beta 2 agonist and oral prednisone were prescribed. The patient developed simultaneous subcutaneous emphysema, spontaneous pneumothorax, and pneumomediastinum, a rare complication of an asthma attack. Conclusions: Our aim is to emphasize that occult pneumothoraces should be considered in a patient presenting with an acute asthma attack failing to respond to conventional medical therapy.
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Coronary artery air embolism complicating a CT-guided percutaneous lung biopsy p. 81
Ashwin Deshmukh, Nirav Kadavani, Ritu Kakkar, Shrinivas Desai, Ganapathi M Bhat
DOI:10.4103/ijri.IJRI_347_18  PMID:31000947
Coronary arterial air embolism is an extremely rare but readily recognizable condition on computed tomography (CT) that may complicate a lung biopsy. We present an incidence of symptomatic air embolism into the right coronary artery during a percutaneous CT-guided lung biopsy that was successfully recognized during the procedure and managed accordingly. An active search for this complication should be made when the patient deteriorates on table and the usual complications (pneumothorax, vasovagal shock, etc.) are ruled out, as immediate resuscitative measures could be life-saving.
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Multimodality imaging features of primary breast lymphoma – A rare entity p. 85
Vinay Maurya, Giriraj Singh, Birma Ram, Prosenjit Ganguli
DOI:10.4103/ijri.IJRI_344_18  PMID:31000948
Primary lymphoma of breast is very rare which has no tell-tale imaging characteristics. Multimodality imaging helps not only in suggesting the possibility of lymphoma but also in its management. We present here one such case which was extensively worked up with various imaging modalities and was histologically proven as primary breast lymphoma.
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A rare case of neonatal mastauxe: Case report p. 89
Bhumika Suthar, Kanishka Aggarwal
DOI:10.4103/ijri.IJRI_317_18  PMID:31000949
Neonatal breast enlargements have varying number of presentations on imaging and these have been underreported in the literature. Our case report profiles a 2-week-old female who presented with a history of bilateral breast enlargement with redness and clear, non-bloody, milk-like discharge, who was clinically diagnosed and managed for neonatal mastitis, which was actually a neonatal breast enlargement only. Awareness on neonatal breast enlargement that can be just physiological without any associated mastitis or inflammatory/infective changes can prevent unnecessary hospitalization and treatment with parenteral antibiotics.
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Ultrasonography and X-Ray guided drain placement to evacuate a pneumopericardium/pneumomediastinum in a 1-day-old infant p. 94
Ambarish P Bhat, Ashwin Pimpalwar, Peter C Dyke II
DOI:10.4103/ijri.IJRI_447_18  PMID:31000950
Ultrasonographic (US) guided procedures have wide range of application in the abdomen and pelvis, however their role is somewhat limited in the chest due to complete reflection of the ultrasound beam by the air in the lungs, preventing the direct imaging of the tissues deep to the air-sound interface. Most of the chest procedures, other than the exception of thoracentesis, rely on the use of CT (computed tomography) scan. The disadvantages of using CT scan is the cost, lack of portability, and most importantly the radiation involved, particularly in case of infants and children, whose tissues are more radiosensitive than the adults. Identification of air by Ultrasonography can help direct needles and wires, to accomplish procedures which may otherwise need CT. A 1-day-old infant with respiratory distress syndrome (RDS) on a ventilator, developed an expanding symptomatic pneumopericardium/pneumomediastinum. The patient was too unstable to leave the neonatal intensive care unit (NICU), so a pericardial/mediastinal drain was placed under ultrasonographic and radiographic guidance. This case, highlights a method for bedside treatment of pneumopericardium/pneumomediastinum in an unstable neonate. This procedure may be equally effective in older children and adults.
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COMMENTARY Top

Commentary: Noncardiac uses of chest ultrasonography other than pleural effusion p. 98
Sivasubramanian Srinivasan
DOI:10.4103/ijri.IJRI_102_19  PMID:31000951
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CASE REPORT Top

Congenital biotinidase deficiency – MRI findings in two cases p. 99
Rahul S Ranjan, Sunil Taneja, Anil Singh, Vikas Gupta
DOI:10.4103/ijri.IJRI_159_18  PMID:31000952
Congenital biotinidase deficiency is a rare inborn error of metabolism that most commonly presents in infantile age group. Diffusion changes on magnetic resonance imaging (MRI) are sparsely described in the literature. We are presenting diffusion-weighted MRI findings in two confirmed cases of congenital biotinidase deficiency in infantile age group with review of literature.
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LETTERS TO THE EDITOR Top

Explanation of radiological signs and fracture indices in a unicameral bone cyst p. 104
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/ijri.IJRI_443_18  PMID:31000953
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Comment on: Subspecialization in radiology – Is it time to hatch out of the cocoon? p. 106
K Nihaal Reddy, Harpreet S Grewal
DOI:10.4103/ijri.IJRI_511_17  PMID:31000954
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