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   Table of Contents - Current issue
Coverpage
July-September 2017
Volume 27 | Issue 3
Page Nos. 261-365

Online since Monday, September 25, 2017

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EDITORIAL  

Subspecialization in radiology – Is it time to hatch out of the cocoon? Highly accessed article p. 261
Chander Mohan
DOI:10.4103/ijri.IJRI_345_17  
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NEURORADIOLOGY & HEAD AND NECK IMAGING Top

Complications exclusive to long strut grafts used following multilevel cervical corpectomy: Utilization of advanced imaging techniques p. 263
Pushpa B Thippeswamy, Sunitha P Kumaran, Vinay Hegde, Sanjaya Viswamitra
DOI:10.4103/ijri.IJRI_211_16  
When surgical decompression of cervical spine is considered, multilevel cervical corpectomy with long strut grafts is the preferred treatment. This procedure is used in a variety of pathologies including degenerative disease, tumors, trauma and infection. Corpectomy with interbody grafting helps in adequate spinal canal and neural decompression compared to multilevel discectomy, which could be difficult as well as inadequate. Fibular/iliac strut grafts are used for reconstruction along with a stabilizing hardware in this procedure. So far, complete imaging spectrum of complications exclusive to strut graft has not been reported in the literature. This pictorial essay presents complications exclusive to the strut graft, utility of advanced imaging in diagnosis and a brief note on the clinical management of complications.
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Role of whole-brain computed tomography perfusion in head injury patients to predict outcome Highly accessed article p. 268
TS Bindu, Sameer Vyas, Niranjan Khandelwal, Vikas Bhatia, Sivashanmugam Dhandapani, Ajay Kumar, Chirag K Ahuja
DOI:10.4103/ijri.IJRI_454_16  
Purpose: To evaluate utility, pattern, and extent of perfusion abnormalities in traumatic brain injury by using whole-brain computed tomography perfusion (CTP) and to assess co-relation of CTP data clinically with Glasgow outcome score (GOS). Materials and Methods: Prospective analytic evaluation of the traumatic head injury patients who were immediately taken up for CTP was done. Patient's demographic, clinical, and radiological findings were tabulated and analyzed. GOS was measured by a neurosurgeon after 3 months of trauma who was blinded to CTP results. Results: Of the 78 patients included in this study, 28 patients were found to have GOS 5, 19 of them had GOS 4, 27 of them had GOS 3, and 4 of them had a GOS 2. Higher mean cerebral blood flow (CBF) and cerebral blood volume (CBV) values were observed in those who had a better GOS, i.e., 4 or 5, whereas those in the GOS range ≤3 had lower mean CBF and CBV values. Conclusion: Statistically significant positive correlation was found between cerebral perfusion parameters with that of GOS. CBF of frontal area shows better correlation with GOS. CBF was the most important predictor among all the perfusion parameters.
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Radiological requirements for surgical planning in cochlear implant candidates Highly accessed article p. 274
Mohamad Hasan Alam-Eldeen, Usama Mohamed Rashad, Al Hussein Awad Ali
DOI:10.4103/ijri.IJRI_55_17  
Objective: This study is concerned with clarification of radiological findings that should be addressed and reported in patients listed for cochlear implant (CI) operation. These findings may force a surgeon to consider modifications of the surgical approach by a CI surgeon. Materials and Methods: The study was performed from January 2015 to January 2016. It included 50 patients with severe-to-profound sensorineural hearing loss who fulfilled the criteria for CI. Patients underwent CI surgery in the Department of Otolaryngology. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI) assessment in the Department of Diagnostic Radiology. Combined examination of the CT and MRI by the radiologist and the surgeon was advocated. Results: Many anatomical variants were observed regarding the pattern of mastoid pneumatization, position of middle cranial fossa dura, sigmoid sinus position jugular bulb position, and the size and position of the mastoid segment of facial nerve canal. Labyrinthitis ossificans was seen in 3 patients (6%), otospongiosis in 1 patient (2%), and dilated vestibular aqueduct and endolymphatic sac in 9 patients (18%). Conclusion: Cochlear implantation is a major treatment modality in patients with severe-to-profound sensorineural hearing loss. Radiological evaluation is integral in surgery planning.
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Unusual presentation of hydatid cyst – ruptured intraventricular hydatid p. 282
Sneha H Thakur, Priscilla C Joshi, AB Kelkar, N Seth
DOI:10.4103/ijri.IJRI_70_16  
Echinococcosis in humans occurs as a result of infection by the larval stages of taenid cestodes of the genus Echinococcus. Most of the intracranial hydatids develop in brain parenchyma. Hydatid cyst within the cerebral ventricle is quite unusual. Literature review showed few case reports of childhood as well as adult intraventricular hydatid cysts. None of these cases presented for the first time with features of ruptured intraventricular cyst. This is a very rare presentation of a common disease. The possibility of infestation with E. granulosus should be included in the differential diagnosis of raised intracranial tension in patients reporting from endemic areas, because the prognosis following surgical intervention is excellent, especially in the pediatric age group.
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Serial brain MRI findings in a rare survivor of rabies encephalitis p. 286
Akhilesh Rao, Yayati Pimpalwar, Arindam Mukherjee, Neha Yadu
DOI:10.4103/ijri.IJRI_440_16  
Rabies is a neurotropic viral illness, almost always fatal, that is equally dreaded by healthcare practitioners and patients due to the dismal prognosis and limited treatment options once symptoms set in. There are hardly any reports on MRI changes in the brain in survivors of rabies encephalitis. We present the clinical course and the imaging findings on serial MRI examinations in a rare patient who survived rabies infection. Initial brain MRI done 8 days after onset of symptoms revealed bilaterally symmetrical non-enhancing areas of T1 and T2 hyperintensity in the basal ganglia, thalami, mid brain, and pons along with T2 hyperintensity and restricted diffusion in fronto-parietal cortical grey matter and left hippocampus. Subsequent MRI scans at 2 months and 5 months revealed progressive brain atrophy, leukoencephalopathy, and gliosis.
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Horizontal gaze palsy with progressive scoliosis – A case report p. 290
P Shalini, Virna M Shah
DOI:10.4103/ijri.IJRI_368_16  
Horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare congenital disorder characterized by absence of conjugate horizontal eye movements and accompanied by progressive scoliosis developing in childhood and adolescence. It occurs due to mutation in ROBO 3 gene/chromosome 11q23-q25. We report a case of a 60-year-old lady who presented with complaints of defective vision in both eyes. On examination, she had scoliosis with restricted abduction and adduction in both eyes with intact elevation and depression. Magnetic resonance imaging of the brain and orbit showed brainstem hypoplasia with absence of facial colliculi, presence of a deep midline pontine cleft (split pons sign), and a butterfly configuration of the medulla, which are the radiological findings seen in this disorder.
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GENITOURINARY RADIOLOGY Top

Endovascular management of iatrogenic renal vascular injuries complicating percutaneous nephrolithotomy: Role of renal angiography and embolization; an analysis of 159 cases p. 293
J Venkateswarlu, M Sravan Kumar, Ravindra P Babu, Anand Abkari
DOI:10.4103/ijri.IJRI_54_17  
Objective: To describe the use of renal angiography in the detection of renal vascular injuries following percutaneous nephrolithotomy and to assess the efficacy of endovascular management of these complications. Materials and Methods: This was a retrospective review of 159 consecutive patients over a period of 12 years from 2005 to 2016 who presented with significant post nephrolithotomy hemorrhage and who were evaluated by renal angiography as a first-line diagnostic study, followed by embolization of identified renal vascular injuries in the same session. The parameters assessed for each patient included type of renal vascular injury identified, type of embolic material and therapeutic outcome. Results: Renal vascular lesions identified in 119 patients were treated with embolization with complete resolution of hemorrhage, no further clinical deterioration and preservation of renal function. Conclusions: Renal vascular injury is a rare complication of percutaneous nephrolithotomy. Early renal angiography and selective embolization can play an integral diagnostic and therapeutic role.
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Unilateral renal agenesis with subseptate uterus and sacrococcygeal teratoma: A unique triad p. 298
Muhammad S Ahmed, Sheeza Imtiaz, Hina Pathan, Rahila Usman
DOI:10.4103/0971-3026.215577  
Unilateral renal agenesis (URA) is a rare condition with a reported incidence of 0.93–1.8 per 1000 autopsies. It is commonly diagnosed as an incidental finding on imaging.URA is frequently associated with other genitourinary anomalies. Different associations have been described in both males and females, however, to our knowledge, it has not been reported with subseptate uterus (SSU) and sacrococcygeal teratoma (SCT) in the same individual. Here, we present a unique case of URA with SSU and SCT.
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An extremely rare case of dermoid cyst of urinary bladder p. 302
Chirag Jain, Mahesh K Mittal, Fouzia Shiraz
DOI:10.4103/ijri.IJRI_287_16  
We report an extremely rare case of a dermoid cyst of the urinary bladder in a 30-year-old female who presented with pain in the left flank and dysuria since 9 months. On imaging (ultrasound and computed tomography), a relatively well-defined mass lesion with areas of fat and calcification was seen arising from the bladder wall. Cystoscopy showed presence of hair on the surface of the lesion. Histopathological findings were consistent with dermoid cyst in the urinary bladder.
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GASTROINTESTINAL RADIOLOGY AND HEPATOLOGY Top

Embryonal rhabdomyosarcoma of the biliary tree: A rare cause of obstructive jaundice in children which can mimic choledochal cysts p. 306
Dhara J Kinariwala, Andrew Y Wang, Patrick D Melmer, William P McCullough
DOI:10.4103/ijri.IJRI_460_16  
Jaundice in children is more often due to hepatic disease than obstruction. Differential considerations for obstructive jaundice in children include choledocholithiasis, choledochal cysts and rare neoplasms. Rhabdomyosarcoma, the most common soft tissue sarcoma in pediatric patients, typically involves the head and neck, genitourinary system and extremities. Embryonal rhabdomyosarcoma of the biliary tree is a rare entity. We present a 3-year-old boy with abrupt onset obstructive jaundice. Although initial imaging suggested a dilated biliary system with fusiform common bile duct, sludge, and possible cholelithiasis, endoscopic retrograde cholangiopancreatogram (ERCP) diagnosed a common bile duct embryonal rhabdomyosarcoma and further imaging showed involvement of the cystic duct. This case illustrates the importance of considering malignant etiologies in cases of obstructive jaundice, particularly when imaging is not classic for common causes.
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Acute post traumatic portal venous thrombosis associated with shattered spleen: A case report p. 310
Ranjana Gupta, Puneet Mittal, Preetparkash S Sekhon, Amit Mittal, Harkirat Kaur, Mohammad Aamir
DOI:10.4103/ijri.IJRI_262_16  
Post-traumatic portal venous thrombosis is a rare event, and is usually seen in association with penetrating injuries. Portal venous thrombosis following blunt abdominal trauma is extremely rare with only few reports in the literature, some associated with underlying coagulation disorders. We report multidetector computed tomography findings in a case of blunt abdominal trauma with otherwise normal coagulation profile, which showed shattered spleen and MDCT evidence of acute thrombosis in the right branch of the portal vein. To the best of our knowledge, this is the first documented report of acute portal venous thrombosis in association with shattered spleen.
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Utility of diffusion weighted imaging in diagnosing subdiaphragmatic endometriosis presenting as shoulder pain p. 314
Anuradha Singh, Chandan J Das, Bimal K Das, AK Gupta
DOI:10.4103/ijri.IJRI_86_16  
Extrapelvic endometriosis (EPE) is a rare entity which may potentially occur at any site. Symptomatic EPE is now increasingly being managed laparoscopically. Imaging is imperative in diagnosis as well as extent delineation prior to surgery. In addition to increasing the success rate of diagnostic laparoscopy, prior knowledge of EPE at certain sites may modify the standard surgical technique. We present here an unusual case of chronic pain in the right shoulder in a 26-year-old female caused by subdiaphragmatic endometriosis (SDE). It was noticed on conventional magnetic resonance imaging (MRI) sequences; however, due to the lack of the characteristic signal intensity, imaging findings were noncontributory. Diffusion-weighted imaging (DWI) facilitated its characterization and precisely mapped the extent of involvement. SDE should be suspected in young females presenting with cyclical shoulder pain. Due to nonspecific clinical features, it may remain undiagnosed. MRI is the imaging modality of choice in evaluation of EPE. Including DWI sequence in the MR protocol increases the diagnostic precision besides delineating the extent of involvement noninvasively.
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MUSCULOSKELETAL RADIOLOGY Top

CT-guided radiofrequency ablation in osteoid osteoma: Result from a tertiary cancer centre in India p. 318
Suyash S Kulkarni, Nitin S Shetty, Ashwin M Polnaya, Amit Janu, Suresh Kumar, Ajay Puri, Ashish Gulia, Venkatesh Rangarajan
DOI:10.4103/ijri.IJRI_30_17  
Aims: The aim of this study is to evaluate the clinical efficacy of computed tomography (CT)-guided radiofrequency (RF) ablation as a minimally invasive therapy for osteoid osteoma. Materials and Methods: This is a retrospective analysis of prospectively maintained data of 43 symptomatic osteoid osteoma patients who were treated by radiofrequency ablation (RFA). Forty out of 43 patients were naive cases and underwent primary treatment for osteoid osteoma with RFA, whereas 3 patients included in the study underwent RFA for local recurrence after having undergone surgical treatment. Diagnosis was based on clinical and characteristic imaging findings, and biopsy was done for cases with atypical presentation. Pre and post procedure Visual Analog Score (VAS) was documented in all cases. Monopolar RFA system was used in all patients, and the electrode was placed within the lesion nidus under CT guidance coaxially through 11G introducer needle. Ablation was performed at 90° C for 5 min. Results: Technical success rate of intranidal placement of electrode was 100%. The primary clinical success in our study was 97.7% (42 of 43), and the secondary clinical success was 100%.Pre and postprocedure VAS score in our study group was 7.8 and 0.4, respectively. Mean follow-up period in our study was 48 months (Range: 4–129 months).One patient had recurrence of pain 4 years after treatment and was treated successfully by a second session. Minor complications were seen in 3 patients with two cases of RF pad burns and one case of skin burn at the treatment site, and these were managed conservatively. No patients developed temporary/permanent neurological deficits, and no procedure-related mortality was seen in our study. Conclusion: CT-guided percutaneous RFA is a simple, safe, minimally invasive, and highly effective treatment option for osteoid osteoma with good long-term pain control and potentially low disease recurrence.
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Ganglion impar block in patients with chronic coccydynia p. 324
Nitesh Gonnade, Neeraj Mehta, Pushpinder Singh Khera, Dewesh Kumar, Rengarajan Rajagopal, Pramod Kumar Sharma
DOI:10.4103/ijri.IJRI_294_16  
Introduction: Coccydynia refers to pain in the terminal segment of the spinecaused by abnormal sitting and standing posture. Coccydynia is usually managed conservatively, however in nonresponsive patients, ganglion impar block is used as a good alternate modality for pain relief. This article studies the effect of ganglion impar block in coccydynia patients who were not relieved by conservative management. Materials and Methods: The study was carried out at the pain clinic in the departments of Physical Medicine and Rehabilitation and Radiology in a tertiary centre in India.It was a prospective hospital-based study, in which 35 patients with coccydynia were considered for fluoroscopy-guided trans-sacro-coccygeal ganglion impar block. The outcome assessment was done using Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) scores for a follow-up period of 6 months. Of the 35 patients, 4 were lost to follow-up. Analysis was done usingthe data from the remaining 31 patients. Results: The mean age of the patients suffering from chronic coccydynia was 42.9 ± 8.39 years, and patients' age range was 28–57 years. The mean score of NRS and ODI before the procedure was 7.90 ± 0.16 and 48.97 ± 1.05, respectively. The interquartile range (IQR) of NRS score remained almost unchanged during pre and postprocedure, however, IQR of ODI varied during the pre and post procedural events. The NRS and ODI scores immediately after the procedure decreased drastically showing significant pain relief in patients, and the difference of scores till the end of study was statistically significant. Conclusion: This study recommends the trans-sacro-coccygeal “needle inside needle” technique for local anesthetic block of the ganglion impar for pain relief in patients with coccydynia. This should be integrated with rehabilitative measures including ergonomical modification for prolonging pain free period.
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Prenatal diagnosis of nail patella syndrome: A case report p. 329
LD Padmanabhan, D Yesodharan, S Nampoothiri
DOI:10.4103/ijri.IJRI_438_16  
The Nail Patella Syndrome (NPS) is an autosomal dominant connective tissue disorder affecting the nails, skeletal system, kidneys and eyes. Here, we report a case of NPS detected at 19 weeks of gestation. The movements of the elbow and knee joints were restricted and there was rotational deformity of the knee joints. To our knowledge, this is the first report of in-utero restriction of limb movements in a fetus with NPS.
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INTERVENTION RADIOLOGY & VASCULAR Top

Use of multidetector computed tomography angiography of upper limb circulation in patients undergoing coronary artery bypass grafting surgery p. 332
Hasan B Altinsoy, Ozkan Alatas, Hidayet Kayancicek, Erhan Hafiz, Omer F Dogan
DOI:10.4103/ijri.IJRI_365_16  
Objective: This study aimed to evaluate the bilateral forehand circulation using a 64-channel multidetector computed tomography (MDCT) as a noninvasive method to define criteria for an upper extremity arterial anatomy and pathology prior to the use of arterial conduits. Materials and Methods: Fifty-five patients with coronary artery disease who underwent total arterial coronary artery bypass grafting (CABG) were randomly selected for this prospective study. MDCT angiography was performed for 110 examinations of forearm and hand arterial anatomy. Prior to MDCT, Allen tests were performed in all patients with a normal result, except four. Thirteen patients had diabetes mellitus (DM), 8 had peripheral artery occlusive disease, and 19 had a history of smoking. Results: All arteries, including axillary, ulnar artery (UA) and radial artery (RA), were clearly visualized in all patients. Upper extremity anatomical and pathological results were examined in 16 patients (29.1%). Severely calcified RA and/or UA were found in 6 patients who had a moderate renal failure. Nearly total occlusion of the RA was detected in another two patients. Focal intimal RA calcification was recorded in 1 female and 3 male patients. Ten patients who had severe calcification or intimal sclerosis of the upper extremity arteries had DM. The remaining patients had normal forehand arterial circulation. A persistent median artery with the absence of radial and ulnar arteries and a high bifurcation of RA from the brachial artery was detected as an anatomic variation in seven patients (12.7%). Conclusions: The major advantages of MDCT angiography are its non-invasiveness and the ability to detect calcific subadventitial plaques, which are difficult to diagnose using conventional angiography. MDCT may be used as a safe and non-invasive method to assess RA and UA prior to harvesting the upper limb artery. Preoperative imaging of forehand arteries is a means to avoid unnecessary forearm exploration or the use of an unsuitable arterial conduit in CABG operations, especially in patients with DM and moderate renal impairment.
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Acute ischemic pancreatitis: A rare complication of empirical gastroduodenal artery embolization p. 338
Wei Ming Chua, Nanda Venkatanarasimha, Karthikeyan Damodharan
DOI:10.4103/0971-3026.215571  
Empirical embolization of the gastroduodenal artery (GDA) is accepted as a safe and effective treatment option for endoscopy-refractory nonvariceal upper gastrointestinal bleeding (UGIB) in patients with high surgical risk. Nontarget embolization is a recognized complication of transarterial embolization, however, symptomatic pancreatic injury is extremely rare. We report a patient who developed acute ischemic pancreatitis immediately after embolization of the GDA, which was confirmed intraoperatively. Interventionists as well as referring clinicians need to be aware of this rare but life threatening complication.
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THORACIC IMAGING Top

Follow-up chest radiographic findings in patients with MERS-CoV after recovery p. 342
Karuna M Das, Edward Y Lee, Rajvir Singh, Mushira A Enani, Khalid Al Dossari, Klaus Van Gorkom, Sven G Larsson, Ruth D Langer
DOI:10.4103/ijri.IJRI_469_16  
Purpose: To evaluate the follow-up chest radiographic findings in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) who were discharged from the hospital following improved clinical symptoms. Materials and Methods: Thirty-six consecutive patients (9 men, 27 women; age range 21–73 years, mean ± SD 42.5 ± 14.5 years) with confirmed MERS-CoV underwent follow-up chest radiographs after recovery from MERS-CoV. The 36 chest radiographs were obtained at 32 to 230 days with a median follow-up of 43 days. The reviewers systemically evaluated the follow-up chest radiographs from 36 patients for lung parenchymal, airway, pleural, hilar and mediastinal abnormalities. Lung parenchyma and airways were assessed for consolidation, ground-glass opacity (GGO), nodular opacity and reticular opacity (i.e., fibrosis). Follow-up chest radiographs were also evaluated for pleural thickening, pleural effusion, pneumothorax and lymphadenopathy. Patients were categorized into two groups: group 1 (no evidence of lung fibrosis) and group 2 (chest radiographic evidence of lung fibrosis) for comparative analysis. Patient demographics, length of ventilations days, number of intensive care unit (ICU) admission days, chest radiographic score, chest radiographic deterioration pattern (Types 1-4) and peak lactate dehydrogenase level were compared between the two groups using the student t-test, Mann-Whitney U test and Fisher's exact test. Results: Follow-up chest radiographs were normal in 23 out of 36 (64%) patients. Among the patients with abnormal chest radiographs (13/36, 36%), the following were found: lung fibrosis in 12 (33%) patients GGO in 2 (5.5%) patients, and pleural thickening in 2 (5.5%) patients. Patients with lung fibrosis had significantly greater number of ICU admission days (19 ± 8.7 days; P value = 0.001), older age (50.6 ± 12.6 years; P value = 0.02), higher chest radiographic scores [10 (0-15.3); P value = 0.04] and higher peak lactate dehydrogenase levels (315-370 U/L; P value = 0.001) when compared to patients without lung fibrosis. Conclusion: Lung fibrosis may develop in a substantial number of patients who have recovered from Middle East respiratory syndrome coronavirus (MERS-CoV). Significantly greater number of ICU admission days, older age, higher chest radiographic scores, chest radiographic deterioration patterns and peak lactate dehydrogenase levels were noted in the patients with lung fibrosis on follow-up chest radiographs after recovery from MERS-CoV.
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Diagnosing thoracic venous aneurysm: A contemporary imaging perspective p. 350
Rohit Aggarwal, Ruchi Gautam, Dhiraj Jhamb, Rajeev Sivasankar
DOI:10.4103/ijri.IJRI_354_16  
Thoracic venous aneurysms are a rare clinical entity and contrast-enhanced computed tomography has been the cornerstone of their diagnosis. We are reporting a rare case of isolated left brachiocephalic vein aneurysm, which was surgically managed, highlighting the role of dynamic contrast-enhanced magnetic resonance imaging as a definitive diagnostic modality in this patient.
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MISCELLANEOUS Top

Imaging of retained surgical items: A pictorial review including new innovations p. 354
GV Santhosh Kumar, Subhash Ramani, Abhishek Mahajan, Nikshita Jain, Rachel Sequeira, Meenakshi Thakur
DOI:10.4103/ijri.IJRI_31_17  
With the advent of newer imaging modalities retained surgical items are now easily diagnosed by their characteristic imaging appearances. A combination of complementary imaging modalities helps to arrive at the diagnosis of this relatively rare complication. Factors contributing to their imaging features include the timing of diagnosis and imaging, presence of secondary infection, communication of the retained item with hollow viscus or external skin wound, and type of imaging modality used. A high index of suspicion is necessary for diagnosis before labeling it as a retained surgical item. In parallel with recent advances in surgery, it is essential that there is increasing awareness among radiologists regarding the newer types of retained surgical items.
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LETTERS TO THE EDITOR Top

Comment on: Dual LAD with anomalous origin of long LAD from right coronary sinus: A variant of type VI LAD p. 362
Abhishek Prasad, Shradha Sinha, Rahat Brar, Shaleen Rana
DOI:10.4103/ijri.IJRI_369_16  
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Comment on: Percutaneous retrograde approach for mesenteric revascularization in chronic mesenteric ischemia p. 363
Suresh Giragani, Ankit Balani, D Prabakar, Viswanath Reddy
DOI:10.4103/ijri.IJRI_73_17  
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