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   2013| July-September  | Volume 23 | Issue 3  
    Online since October 23, 2013

 
 
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GENITOURINARY AND OBSTETRIC RADIOLOGY
Transrectal ultrasound-guided aspiration in the management of prostatic abscess: A single-center experience
Jigish B Vyas, Sanika A Ganpule, Arvind P Ganpule, Ravindra B Sabnis, Mahesh R Desai
July-September 2013, 23(3):253-257
DOI:10.4103/0971-3026.120262  PMID:24347857
Objectives: The safety and efficacy of transrectal ultrasound (TRUS) guided aspiration of prostatic abscess (PA) is known. The objective of this study is to describe a treatment algorithm for management of PA with TRUS-guided aspiration, emphasizing on indications and factors predicting the treatment outcome. Materials and Methods: After the institutional review board approval was obtained, a retrospective study was done of all patients suspected with PA on digital rectal examination (DRE) and confirmed on TRUS. An 18-gauge two-part needle was used for aspiration. The real-time TRUS-guided aspiration of PA was done in the longitudinal axis. The aspiration of pus and the sequential collapse of cavity was seen "real time." A suprapubic catheter was placed, if the patient had urinary retention, persistent dysuria, and/or severe lower urinary tract symptoms (LUTS). Success was defined as complete resolution of the abscess and/or symptoms. Results: Forty-eight patients were studied with PA, with a mean age of 54.6 ± 14.6 (range 26-79) years. The DRE diagnosed PA in 22 (45.83%) patients, while abdominal sonography diagnosed PA in 13 (27.08%) patients. TRUS revealed a hypoechoic area with internal echoes in all 48 (100%) patients. The diagnosis was confirmed in all 48 cases with aspiration. The mean size of the lesion was 3.2 ± 1.2 (range 1.5-8) cm. Mean volume aspirated was 10.2 ml (range 2.5-30 ml). Complete resolution after first aspiration was observed in 20 (41.66%) patients. An average of 4.1 (range 1-7) aspirations was required for complete resolution which was seen in 41 patients (85.42%). Seven (14.58%) patients required transurethral resection (deroofing) of the abscess cavity. We formulated a treatment algorithm based on the above findings. Conclusion: The proposed algorithm based on our experience suggests that patients with PA larger than 2 cm with severe LUTS and/or leukocytosis benefit from TRUS-guided aspiration. In addition, these patients are benefitted from urinary drainage (either perurethral or suprapubic). The algorithm also suggests that if two attempts of TRUS aspiration fail, these patients benefit from transurethral drainage.
  3 4,502 216
ULTRASONOGRAPHY/MUSCULOSKELETAL RADIOLOGY
High-resolution ultrasound imaging of cutaneous lesions
Anitha Mandava, Prabhakar Rao Ravuri, Rajyalaxmi Konathan
July-September 2013, 23(3):269-277
DOI:10.4103/0971-3026.120272  PMID:24347861
High-resolution variable frequency ultrasound imaging is increasingly being used in the noninvasive evaluation of various cutaneous diseases. It plays a complimentary role to physical examination in the assessment of cutaneous lesions. It is the only imaging modality useful in the evaluation of superficial cutaneous lesions that are too small to be evaluated on computed tomography (CT) or magnetic resonance imaging (MRI) and is helpful in reducing invasive procedures like biopsies and fine needle aspirations. In this article, we seek to describe the relevance and basic principles of cutaneous ultrasound, imaging findings of normal skin, current applications of high-resolution ultrasound in the diagnosis and management of various dermatological conditions, along with the features of some commonly encountered lesions.
  2 20,103 1,286
ABDOMINAL RADIOLOGY
Extrahepatic biliary atresia with choledochal cyst: Prenatal MRI predicted and post natally confirmed: A case report
Madhavi Nori, J Venkateshwarlu, Vijaysekhar , G Raghavendra Prasad
July-September 2013, 23(3):238-242
DOI:10.4103/0971-3026.120278  PMID:24347854
Extrahepatic biliary atresia (EHBA) is an uncommon cause of neonatal jaundice. Antenatal Magnetic Resonance Imaging (MRI) diagnosis of EHBA has not been published to the best of our knowledge till date. EHBA with cystic component is likely to be mistaken for choledochal cyst. A case that was antenatally predicted and postnatally confirmed by surgery and histopathology is being reported. All imaging signs are analyzed herewith. Imaging helps in the prediction of EHBA and also helps in early postnatal surgical referral which in turn improves the results of Kasai's portoenterostomy.
  1 6,258 335
BREAST RADIOLOGY
Role of dual-energy contrast-enhanced digital mammography as a problem-solving tool in dense breasts: A case report
Teena Sleeba, Anand Subapradha, Madan Ramachandran, Murali Krishnaswami
July-September 2013, 23(3):219-222
DOI:10.4103/0971-3026.120269  PMID:24347851
Breast density is strongly and independently related to the risk of breast cancer. Women with very dense breasts may have up to five times higher chances of developing malignancy as compared to those with less breast density. Detecting lesions in extremely dense or heterogeneous breasts on screening mammogram can be difficult. We report a case of incidental bilateral breast malignancy in an asymptomatic patient in whom mammogram and screening ultrasound were equivocal.
  1 3,302 268
GENITOURINARY AND OBSTETRIC RADIOLOGY
Rare complications of cesarean scar
Divyesh Mahajan, Mandeep Kang, Manavjit Singh Sandhu, Vanita Jain, Naveen Kalra, Niranjan Khandelwal
July-September 2013, 23(3):258-261
DOI:10.4103/0971-3026.120265  PMID:24347858
Cesarean scar pregnancy (CSP) and cesarean scar dehiscence (CSD) are the most dreaded complications of cesarean scar (CS). As the incidence of CS is increasing worldwide, so is the incidence of CSP, especially in cases with assisted reproduction techniques. It is of utmost importance to diagnose CSP in the early first trimester, as it can lead to myometrial rupture with fatal outcome. On the other hand, CSD may be encountered during pregnancy or in the postpartum period. CSD in the postpartum period is very rare and can cause secondary postpartum hemorrhage (PPH) leading to increased maternal morbidity or even death if not diagnosed and managed promptly. Both complications can be diagnosed on ultrasonography (USG) and confirmed on magnetic resonance imaging (MRI). These two conditions carry high morbidity and mortality. In this article, we highlight the role of imaging in the early diagnosis and management of these conditions.
  1 9,271 593
HEAD & NECK RADIOLOGY
Pseudoaneurysm of internal carotid artery after carotid body tumor excision
Ananathakrishnan Ramesh, Rajakannu Muthukumarassamy, Vilvapathy Senguttuvan Karthikeyan, Govindasamy Rajaraman, Sandeep Mishra
July-September 2013, 23(3):208-211
DOI:10.4103/0971-3026.120264  PMID:24347849
The common causes of pseudoaneurysms of internal carotid artery (ICA) in the neck are penetrating trauma, head and neck surgeries, carotid endarterectomies, infiltrating metastatic lymph nodes and neoplasms. We report a young male patient who presented with a swelling in left upper neck diagnosed as carotid body tumor with ultrasonography and magnetic resonance imaging. Subadventitial excision of the tumor was done. The patient developed dense right hemiplegia in the immediate postoperative period. Doppler study of neck revealed left ICA dissection with partial thrombosis of the lumen. Computed tomography of the brain revealed nonhemorrhagic left capsuloganglionic infarct and he was managed conservatively with heparin. Follow-up Doppler study done 2 weeks later revealed pseudoaneurysm of the ICA. Attempts to obliterate the pseudoaneurysm by interventional procedures failed due to the narrow neck of the pseudoaneurysm. Heparin was stopped and patient was maintained only on oral aspirin. Doppler study repeated 1 week later showed spontaneous thrombosis of the pseudoaneurysm with good flow in the distal ICA. To the best of our knowledge, only one case of pseudo-pseudoaneurysm complicating surgical resection of carotid body tumor has been reported so far The etiology, imaging features, and treatment options of pseudoaneurysms are discussed.
  1 4,344 151
ABDOMINAL RADIOLOGY
Variations of celiac axis, common hepatic artery and its branches in 600 patients
Binit Sureka, Mahesh Kumar Mittal, Aliza Mittal, Mukul Sinha, Narendra Kumar Bhambri, Brij Bhushan Thukral
July-September 2013, 23(3):223-233
DOI:10.4103/0971-3026.120273  PMID:24347852
Purpose: To evaluate the spectrum of celiac axis, common hepatic artery (CHA), right, left, middle hepatic artery and gastroduodenal artery variations by using spiral computed tomography (CT). Materials and Methods: A retrospective review of Multidetector CT (MDCT) abdominal angiography scans was performed in patients sent for various liver and other abdominal pathologies between January 2012 and February 2013. A total of 600 patients were evaluated. Definitions of CHA, ambiguous celiac axis, course and division patterns of CHA, replaced hepatic artery, accessory hepatic artery and middle hepatic artery were used as proposed by Song et al., Covey et al., and Wang et al. The pattern of the aortic origin of branches of celiac axis, common hepatic artery and its branches was analyzed. Results: Six types of celiac axis anatomic variations were identified in our study. A total of 546 of the 600 patients had a normal celiac axis anatomy. Anatomic variations were seen in 5.5% of patients. Ambiguous anatomy was seen in 3.5% of the patients. CHA originated from celiac axis in 95.83% of the patients. Variations in anatomic origin of CHA were seen in 8 patients. Ambiguous dual pathway was seen in 4 patients. Normal Sp-preportal course of CHA was identified in 97.78% of cases, Sp-retroportal course in 7 patients, Tp-preportal course in 2, Tp-retroportal in 1, Ip-preportal in 1 and through Ligamentum venosum in 2 patients. Normal origin of RHA from HAP was seen in 79.6% patients. Replaced origin of RHA was seen in 15.16% cases and Accessory origin of RHA was seen in 5.16% cases. LHA originated from HAP in 81.5% patients. Replaced LHA origin was seen in 10.8% cases and Accessory LHA origin seen in 7.6% cases. MHA originated from RHA in 41.3% patients, LHA in 27.83% and from CHA in 4.5% cases. Origin of MHA could not be defined in 26.3% of patients. GDA originated from CHA in 97.6% of patients, from celiac axis in 1.6%, from RHA in 0.33% in patients. Trifurcation of CHA was seen in 7.16% and quadrifurcation of CHA in 2.16%. Conclusion: CT Angiography is a safe and highly sensitive and accurate modality for evaluation of arterial anatomy and its variants.
  - 8,868 975
CT imaging findings and endovascular management of isolated spontaneous dissecting aneurysm of celiac artery
RS Rama Krishnan, K Murali, R Madan, G Francis
July-September 2013, 23(3):234-237
DOI:10.4103/0971-3026.120275  PMID:24347853
Isolated spontaneous dissecting aneurysm of celiac artery without concomitant involvement of aorta is a rare entity and only a few cases are reported in the literature. More cases are being detected recently with greater advancements in CT technology. Clinicians and emergency physicians should be aware of this condition and should include it in the differential diagnosis of patients who present with refractory postprandial epigastric pain, particularly in middle-aged men. We present a case of a 45-year-old male with isolated spontaneous dissecting celiac artery aneurysm, with special emphasis on CT findings and the role of endovascular management.
  - 4,721 217
Herlyn-Werner-Wunderlich syndrome presenting with infertility: Role of MRI in diagnosis
Zohra Ahmad, Ankur Goyal, Chandan J Das, Dipika Deka, Raju Sharma
July-September 2013, 23(3):243-246
DOI:10.4103/0971-3026.120283  PMID:24347855
Herlyn-Werner-Wunderlich syndrome (HWWS), characterized by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis, is an uncommon combined Mullerian and mesonephric duct anomaly, and its presentation in adulthood is even rarer. We report here a 22-year-old female presenting with primary infertility where magnetic resonance imaging (MRI) suggested the diagnosis of HWWS with endometriosis. In a patient of infertility with endometriosis and unilateral renal agenesis, diagnosis of HWWS should be suspected and MRI is the investigation of choice for such anomalies.
  - 6,234 432
COMPUTERS & RELATED TECHNOLOGIES
Voice recognition is here comma like it or not period
Matthew A Fox, Carl J Aschkenasi, Arjun Kalyanpur
July-September 2013, 23(3):191-194
DOI:10.4103/0971-3026.120252  PMID:24347844
Voice recognition (VR) technology needs improvement, but is as integral to the current practice of radiology as Radiology Information Systems and Picture Archival and Communication Systems. In the 1990s, the radiology community gave VR technology a rather lukewarm reception, but since then it has emerged as the predominant method of radiology reporting in the United States. In this article, we examine how VR technology works, outline the positive and negative aspects of VR technology on work flow, identify common VR transcription errors and review the discussion on VR adoption in the recent literature. We add to the discussion our personal experiences in an international teleradiology group.
  - 5,796 225
EDITORIAL
Voicing the natural way
Sanjay N Jain
July-September 2013, 23(3):189-190
DOI:10.4103/0971-3026.120251  PMID:24347843
  - 4,498 281
GENITOURINARY AND OBSTETRIC RADIOLOGY
MR imaging of carcinoma cervix
Mangal Mahajan, Rajesh Kuber, KR Chaudhari, Prashant Chaudhari, Pravin Ghadage, Rushikesh Naik
July-September 2013, 23(3):247-252
DOI:10.4103/0971-3026.120257  PMID:24347856
Cervical cancer is a common gynecological malignancy and a frequent cause of death. Patient outcome depends on tumor stage, size, nodal status, and histological grade. Correct tumor staging is important to decide the the treatment strategy. Magnetic Resonance Imaging is accepted as a preferred imaging modality to assess the prognostic factors.
  - 24,797 3,571
Increased fetal endocardial echogenicity mimicking endocardial fibroelastosis following maternal organophosphorus poisoning and its complete regression in utero
Karippaliyil Balakumar, Kannan Misha, Karippaliyil Milind
July-September 2013, 23(3):262-265
DOI:10.4103/0971-3026.120266  PMID:24347859
Fetal endocardial fibroelastosis (EFE) has been diagnosed by antenatal ultrasonography in the past few years. A typical case of isolated endocardial fibroelastosis is illustrated here, in a fetus of 22 weeks of gestational age exposed to maternal organophosphorus poisoning at 20 weeks. No other structural cardiac or other systemic anomalies were detected in this fetus. The abnormal fetal echocardiographic features mimicking endocardial fibroelastosis completely regressed after 14 weeks and a normal full-term baby was delivered. Postnatal echocardiogram showed normal cardiac parameters. The diagnostic features mimicking EFE following maternal organophosphorus poisoning at 20 weeks of gestational age and the subsequent complete reversal of these changes after 14 weeks of diagnosis are reported for the first time in the literature.
  - 2,777 119
Validation of the global reference for fetal weight and birth weight percentiles
Anirudh B Badade, Amar Bhide, Purnima Satoskar, Darshan Wadekar
July-September 2013, 23(3):266-268
DOI:10.4103/0971-3026.120270  PMID:24347860
The objective of this study was to evaluate whether the global reference curves adapted on the basis of WHO data for India and the Hadlock reference curves fit the population in India and to validate the reference curves. The data were retrieved retrospectively from the records of women registration for antenatal care at a charitable maternity hospital in Mumbai, India. All pregnancies were dated on CRL obtained before 14 weeks. Births before 34 th week were excluded. The expected frequencies of birth weights below the 1 st , 5 th , 10 th , 50 th , 90 th , 95 th and 99 th centiles from three reference ranges were compared with observed frequencies. It was found that the WHO generic reference adapted to India significantly underpredicted the birth weights and that the Hadlock reference ranges significantly overpredicted the birth weights. The use of generic reference adapted to Sri Lanka showed a better fit to the observed data. We concluded that global reference curves adapted on the basis of WHO data for India and the Hadlock reference ranges do not fit all the population in India and the charts need validation. Reference charts modified on the basis of data for Sri Lankan population show a better fit to the observed data, and therefore are more appropriate for use in clinical practice in South India.
  - 3,477 194
HEAD & NECK RADIOLOGY
Imaging features of rhinosporidiosis on contrast CT
Shailesh M Prabhu, Aparna Irodi, Hannah L Khiangte, V Rupa, P Naina
July-September 2013, 23(3):212-218
DOI:10.4103/0971-3026.120267  PMID:24347850
Context: Rhinosporidiosis is a chronic granulomatous disease endemic in certain regions of India. Computed tomography (CT) imaging appearances of rhinosporidiosis have not been previously described in the literature. Aims: To study imaging features in rhinosporidiosis with contrast-enhanced CT and elucidate its role in the evaluation of this disease. Materials and Methods: Sixteen patients with pathologically proven rhinosporidiosis were included in the study. Contrast-enhanced CT images were analyzed retrospectively and imaging findings were correlated with surgical and histopathologic findings. Results: A total of 29 lesions were found and evaluated. On contrast-enhanced CT, rhinosporidiosis was seen as moderately enhancing lobulated or irregular soft tissue mass lesions in the nasal cavity (n = 13), lesions arising in nasal cavity and extending through choana into nasopharynx (n = 5), pedunculated polypoidal lesions arising from the nasopharyngeal wall (n = 5), oropharyngeal wall (n = 2), larynx (n = 1), bronchus (n = 1), skin and subcutaneous tissue (n = 2). The inferior nasal cavity comprising nasal floor, inferior turbinate, and inferior meatus was the most common site of involvement (n = 13). Surrounding bone involvement was seen in the form of rarefaction (n = 6), partial (n = 3) or complete erosion (n = 3) of inferior turbinate, thinning of medial maxillary wall (n = 2), and septal erosion (n = 2). Nasolacrimal duct involvement was seen in four cases. Conclusions: Contrast-enhanced CT has an important role in delineating the site and extent of the disease, as well as the involvement of surrounding bone, nasolacrimal duct and tracheobronchial tree. This provides a useful roadmap prior to surgery.
  - 7,933 653
MISCELLANEOUS
Thermography in ocular inflammation
Ankush A Kawali
July-September 2013, 23(3):281-283
PMID:24347863
Background and Objectives: The purpose of this study was to evaluate ocular inflammatory and non-inflammatory conditions using commercially available thermal camera. Materials and Methods: A non-contact thermographic camera (FLIR P 620) was used to take thermal pictures of seven cases of ocular inflammation, two cases of non-inflammatory ocular pathology, and one healthy subject with mild refractive error only. Ocular inflammatory cases included five cases of scleritis, one case of postoperative anterior uveitis, and a case of meibomian gland dysfunction with keratitis (MGD-keratitis). Non-inflammatory conditions included a case of conjunctival benign reactive lymphoid hyperplasia (BRLH) and a case of central serous chorio-retinopathy. Thermal and non-thermal photographs were taken, and using analyzing software, the ocular surface temperature was calculated. Results: Patient with fresh episode of scleritis revealed high temperature. Eyes with MGD-keratitis depicted lower temperature in clinically more affected eye. Conjunctival BRLH showed a cold lesion on thermography at the site of involvement, in contrast to cases of scleritis with similar clinical presentation. Conclusion: Ocular thermal imaging is an underutilized diagnostic tool which can be used to distinguish inflammatory ocular conditions from non-inflammatory conditions. It can also be utilized in the evaluation of tear film in dry eye syndrome. Its applications should be further explored in uveitis and other ocular disorders. Dedicated "ocular thermographic" camera is today's need of the hour.
  - 3,199 248
NEURORADIOLOGY
MRI brain in monohalomethane toxic encephalopathy: A case report
Yogeshwari S Deshmukh, Ashish Atre, Darshan Shah, Sudhir Kothari
July-September 2013, 23(3):195-197
DOI:10.4103/0971-3026.120253  PMID:24347845
Monohalomethanes are alkylating agents that have been used as methylating agents, laboratory reagents, refrigerants, aerosol propellants, pesticides, fumigants, fire-extinguishing agents, anesthetics, degreasers, blowing agents for plastic foams, and chemical intermediates. Compounds in this group are methyl chloride, methyl bromide, methyl iodide (MI), and methyl fluoride. MI is a colorless volatile liquid used as a methylating agent to manufacture a few pharmaceuticals and is also used as a fumigative insecticide. It is a rare intoxicant. Neurotoxicity is known with both acute and chronic exposure to MI. We present the characteristic magnetic resonance imaging (MRI) brain findings in a patient who developed neuropsychiatric symptoms weeks after occupational exposure to excessive doses of MI.
  - 5,219 315
Call-Fleming syndrome
Avni Kalangott Padmanabhan Skandhan, Kollengode Gopalakrishnan Ramakrishnan, Rajeev Anand
July-September 2013, 23(3):198-201
DOI:10.4103/0971-3026.120258  PMID:24347846
Call-Fleming syndrome is a part of reversible cerebral vasoconstriction syndrome (RCVS) group and is thought to be of idiopathic origin. It is classically described to be having multisegmental, focal vasospasms in the cerebral arteries. It is characterized clinically by the sudden onset of severe headache, classically described as thunderclap headache, with or without associated neurological deficits. The importance of it lies in that it is a potentially reversible cause of this clinical presentation, unlike its other counterparts, aneurysmal subarachnoid hemorrhage (SAH) or vasculitis.
  - 4,258 479
Cavernous hemangioma located at the foramen of Monro: Radiopathological correlation
Sonia Bhatia, Abhay K Kapoor, Rajiv Gupta, Tushar Sahni
July-September 2013, 23(3):202-204
DOI:10.4103/0971-3026.120259  PMID:24347847
Intraventricular cavernous hemangiomas are rare. Amongst them, cavernomas located at the foramen of Monro are of greater interest because of their rare location, varied symptoms, and often association with hydrocephalus. We present a rare case of cavernous hemangioma located at foramen of Monro, with its radiopathological confirmation.
  - 3,635 225
Herniation of spinal cord into nerve root avulsion pseudomeningocele: A rare cause of delayed progressive neurological deficit
Justin Edmund Moses, Sanjay Kumar Bansal, Deepak Goyal
July-September 2013, 23(3):205-207
DOI:10.4103/0971-3026.120260  PMID:24347848
We present a patient with old traumatic right brachial plexus injury, who developed progressive neurological deterioration 4 years after the initial injury. On magnetic resonance imaging (MRI), herniation of the upper dorsal cord was noted into a post-traumatic pseudomeningocele. Though the herniation of cord into a post-traumatic pseudomeningocele is very rare, it should be suspected in cases of delayed progressive myelopathy. A three dimensional (3-D) T2-weighted sequence such as Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) or constructive interference in steady state (CISS) provides optimal visualization of the herniated cord and helps in surgical planning.
  - 5,155 234
ULTRASONOGRAPHY/MUSCULOSKELETAL RADIOLOGY
Unilateral sternocostoclavicular hyperostosis in a patient with ankylosing spondylitis: A case report with color Doppler ultrasonogram findings
Sumantro Mondal, Debanjali Sinha, Arijit Nag, Alakendu Ghosh
July-September 2013, 23(3):278-280
DOI:10.4103/0971-3026.120280  PMID:24347862
Sternocostoclavicular hyperostosis is a chronic inflammatory disorder affecting the sternoclavicular joint and upper ribs. There is a strong association with seronegative spondyloarthropathy in which bilateral involvement is common. Ultrasonography and Color Doppler findings of this entity have not been described previously, to the best of our knowledge. We describe the findings in a patient of ankylosing spondylitis who was referred for unilateral sternoclavicular joint swelling.
  - 4,769 174
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