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   Table of Contents - Current issue
Coverpage
October-December 2020
Volume 30 | Issue 4
Page Nos. 415-539

Online since Wednesday, January 13, 2021

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EDITORIAL  

COVID-19 pneumonia-residual changes on CT scan are they all fibrosis Highly accessed article p. 415
Anirudh Kohli
DOI:10.4103/ijri.IJRI_4_21  
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MUSCULOSKELETAL IMAGING Top

Tumours of the odontoid peg revisited Highly accessed article p. 420
Ahmed Saad, Christine Azzopardi, Shahnawaz Haleem, Marcin Czyz, Steven L James, Rajesh Botchu
DOI:10.4103/ijri.IJRI_363_20  
Introduction: Tumours of the odontoid peg are rare but can potentially cause significant morbidity and mortality. Methods: A retrospective review of oncology and radiology database of tertiary orthopaedic oncology centre for all lesions affecting the odontoid peg over the last 12 years was performed. Results: We identified a total of 15 tumours involving the odontoid peg, majority being malignant. Myeloma was the most common tumour. Conclusion: Tumours of the odontoid peg are rare. Spinal surgeons and Radiologists need to be aware of them.
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Is thoracic facet joint arthritis over-reported? It's time to review CT grading parameters - An analytical cross-sectional study p. 427
Punit Tiwari, Harmeet Kaur, Vivek Jha
DOI:10.4103/ijri.IJRI_390_20  
Background: In the absence of any exclusive classification for dorsal FJA, there is a lot of confusion while labelling grade 1 FJA in thoracic spine based on decreased FJ space. Purpose: The purpose of this study was to know the facet joint space measurements in thoracic spine of asymptomatic and symptomatic participants and to comment whether the lower cut-off of 2 mm used in lumbar FJA classification can be safely applied in thoracic spine too. Materials and Methods: This cross-sectional study was done from December 1, 2018 to November 30, 2019. Patients above 18 years of age in this study who underwent CT thorax for causes unrelated to dorsal spinal pain were included. IBM SPSS Statistics v 26 was used for statistical analysis. Results: We measured and analysed 1512 thoracic facet joints in 63 patients (30 females and 33 males) in both axial and sagittal plane on CT scan. Mean age of the entire sample was 59.19 ± 15.19 years, ranging from 33 to 97 years and a standard error of mean 1.365 years. Overall mean thoracic facet joint space was measured to be 1.270 mm ± 0.3416 mm, ranging from 0 to 3.1 mm and a standard error of mean 0.0088 mm and a variance of 0.117 mm. The median was 1.300 mm while mode was 1.1 mm. Conclusion: The popular lumbar FJA classification by Weishupt et al. cannot be applied in its present form in thoracic spine, without the modification in parameters of grade 1 FJA. The lower cut-off of normal thoracic facet joint space probably lies around 1 mm. MeSH Terms: Zygapophyseal joints, dorsal, thoracic, facet joint, arthritis, classification
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Spine radiograph in dysplasias: A pictorial essay p. 436
Pavan Gabra, Manisha Jana, Priyanka Naranje, Neerja Gupta, Madhulika Kabra, Arun K Gupta, Richa Yadav
DOI:10.4103/ijri.IJRI_395_20  
Spine radiograph is an essential component of a skeletal survey. It provides important diagnostic clues to various types of skeletal dysplasia. In some conditions, a spine radiograph alone may be diagnostic and characteristic; but mostly, it yields more value as a part of the complete skeletal survey. In this article we will discuss about a few common lethal and non-lethal skeletal dysplasias and their characteristic imaging findings; primarily focusing on the spine radiograph.
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INTERVENTIONAL RADIOLOGY Top

Recovering from nonspecific low back pain despair: Ultrasound-guided intervention in iliolumbar syndrome p. 448
Bibhu K Nayak, Dharmendra K Singh, Nishith Kumar, Binita Jaiswal
DOI:10.4103/ijri.IJRI_382_19  
Background: Iliolumbar syndrome is a frequent cause of chronic nonspecific low back pain. The cornerstone of its treatment lies upon the specific diagnosis of the iliolumbar syndrome. The ultrasound guided interventions have the potential for the specific diagnosis and treatment of the iliolumbar syndrome. Objective: To assess the role of ultrasound-guided intervention for the diagnosis and treatment of the iliolumbar syndrome. Materials and Methods: The study comprised of fifty-seven patients of nonspecific low back pain with the clinically suspected iliolumbar syndrome. Two-staged ultrasound-guided interventions were performed: Primary diagnostic and secondary therapeutic interventions. Favorable response after the injection of local anesthetic agent in iliolumbar ligament (defined as VAS score to ≥3) was classified as confirmed Ilio-lumbar syndrome. Clinico radiological efficacy after platelet-rich plasma (PRP) injection in confirmed iliolumbar syndrome patients was done. Results: Out of 57 patients, 45 (78.95') were diagnosed with confirmed Iliolumbar syndrome after primary diagnostic intervention. The mean value of VAS at presentation was 8.02 ± 0.72 which was decreased to 3.16 ± 1.63; P < 0.0001. All 45 patients underwent PRP injection in iliolumbar ligament and 42 patients (93.33') showed reduction in mean VAS score from 8 ± 0.67 (at presentation) to 0.89 ± 1.23 after 6 weeks follow up; P < 0.0001. Iliolumbar ligament thickness was decreased from the day of presentation (2.66 ± 0.22) to 6 weeks after therapeutic intervention (0.91 ± 0.42); P < 0.0001. Conclusion: The ultrasound guided diagnostic and therapeutic intervention were found to result in a specific diagnosis and remarkable recovery in the iliolumbar syndrome group of nonspecific low back pain patients.
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Microwire navigation and microcatheter positioning by balloon manipulation for the treatment of intracranial aneurysms: A pilot study p. 453
Ali Burak Binboga, Mehmet Onay, Cetin Murat Altay
DOI:10.4103/ijri.IJRI_482_19  
Background and Objective: An intracranial aneurysm (IA) is a life-threatening condition and endovascular treatment (EVT) is a demanding procedure, especially in IAs with an unfavorable anatomy. The aim of this study was to investigate the safety and efficacy of balloon-assisted microwire navigation and microcatheter positioning in the EVT of IAs with challenging anatomies. Materials and Methods: This retrospective study included patients that underwent balloon-assisted microwire navigation and microcatheter positioning in the EVT of IAs between September 2016 and January 2019. All EVT procedures and data collection were performed by the same two neurointerventional radiologists. Technical success and complication rates, safety, and efficiency of the balloon manipulation method were evaluated. Statistical software was used to analyze the basic descriptive data of the patients and aneurysms. Results: This study included 14 patients. The microwire navigation of the target artery with balloon manipulation was used in 4 aneurysms of 4 patients. Microcatheter positioning with balloon manipulation was used in 10 aneurysms of 10 patients. There was no complication caused by the balloon manipulation technique. The technical success rate was 100'. Conclusion: In the EVT of IAs with challenging anatomies, the presented technique is a safe and effective option without additional complications, especially in the target artery with an acute angle and in small aneurysms.
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CARDIAC IMAGING Top

Safety profile of adenosine stress cardiac MRI in a tertiary hospital in India p. 459
Vimal Raj, A Pudhiavan, VJ Hrishikesh, Asik Ali, Richa Kothari
DOI:10.4103/ijri.IJRI_283_20  
Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality in India. Stress Cardiac Magnetic Resonance (CMR) using vasodilator agent is well established in assessing the functional significance of CAD. Adenosine is the preferred agent, but can have severe side effects including dyspnoea, chest pain, atrioventricular block or bronchospasm. The stress CMR examination is not routinely performed in many of the clinical imaging departments in India. Objective: The aim of this study was to establish safety of adenosine as a pharmacological stressor agent for CMR in a tertiary care radiology department in India. Methods: A review of all patients undergoing stress CMR in our institution from May 2018 to May 2019 was made. Records were reviewed to collect response parameters and documented adverse reactions. Results: A total of 1057 patients underwent stress CMR during this period. No death, myocardial infarction or atrio-ventricular block related complications were seen. Transient hypotension was seen in 20 patients (1.8') with spontaneous recovery after stopping infusion. Chest pain and breathlessness severe enough to discontinue the scan were seen in 6 (0.5') and 10 (0.9') patients, respectively. All patients with breathlessness recovered on low flow oxygen therapy with three requiring bronchodilator. Out of six patients with chest pain, three had immediate relief with sublingual nitroglycerin, and three required hospital admission for unstable angina. Of the latter three, 1 underwent revascularization on the same day and other two later in the week. Conclusion: Stress CMR using adenosine in appropriately selected patients is a highly safe procedure with significant side effects seen in less than 1’ of patients. Therefore, it is safe to perform stress CMR studies in a fully equipped and well-trained radiology department in India.
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Native T1 mapping in diffuse myocardial diseases using 3-Tesla MRI: An institutional experience p. 465
Vimal Chacko Mondy, S Babu Peter, R Ravi
DOI:10.4103/ijri.IJRI_326_20  
Aims: Newer cardiac magnetic resonance techniques like native T1 mapping are being used increasingly as an adjunct to diagnose myocardial diseases with fibrosis. However, its full clinical utility has not been tested extensively, especially in the Indian population. The purpose of this study was to find native T1 values in healthy individuals without cardiac disease in our 3-Tesla MRI system and examine whether native myocardial T1 values can be used to differentiate between normal and diffuse myocardial disease groups. Subjects and Methods: After approval from the institutional ethics committee, native T1 mapping was performed in 12 healthy individuals without cardiac disease who served as controls and in 26 patients with diffuse myocardial diseases (acute myocarditis (n = 5), hypertrophic cardiomyopathy (HCM) (n = 8), nonischemic dilated cardiomyopathy (DCM) (n = 7), restrictive cardiomyopathy (RCM) due to amyloidosis (n = 6)) in a 3-Tesla MRI system in short axis slices and four-chamber view using a modified Look-Locker inversion recovery sequence. The mean native T1 values and standard deviations were calculated for control and disease groups and compared. The ability of native myocardial T1 mapping to differentiate between normal and diffuse myocardial disease groups was assessed. One-way ANOVA with Tukey's Post-Hoc test was used to find significant difference in the multivariate analysis and Chi-Square test was used to find the significance in categorical data. Results: The native T1 values for the healthy group in our 3-Tesla MRI system was 1186.47 ± 45.67 ms. The mean T1 values of the groups acute myocarditis (1418.68 ± 8.62 ms), HCM (1355.86 ± 44.67 ms), nonischemic DCM (1341.31 ± 41.48 ms), and RCM due to amyloidosis (1370.37 ± 90.14 ms) were significantly higher (P = 0.0005) than that of the healthy control group. Conclusion: Native myocardial T1 mapping is a promising tool for differentiating between healthy and diffuse myocardial disease groups.
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PEDIATRIC IMAGING Top

Characterization of pediatric head and neck masses with quantitative analysis of diffusion-weighted imaging and measurement of apparent diffusion coefficients p. 473
Ali Baiomy, Ayman Nada, Ahmed Gabr, Ayda Youssef, Esmat Mahmoud, Iman Zaky
DOI:10.4103/ijri.IJRI_129_19  
Purpose: Our objective was to investigate the accuracy of quantitative diffusion-weighted imaging (DWI) to determine the histopathologic diagnosis of pediatric head and neck lesions. Materials and Methods: This retrospective study included 100 pediatric patients recently diagnosed with head and neck tumors. All patients underwent preoperative conventional magnetic resonance imaging (MRI) and DWI. Each lesion was evaluated according to signal characteristics, enhancement pattern, and diffusivity. The average apparent diffusion coefficient (ADC) obtained from each tumor was compared to the histological diagnosis of benign, locally malignant, or malignant categories. Results: Our retrospective study showed a significant negative correlation between average ADC and tumor histopathologic diagnosis (P < 0.001, r = -0.54). The mean ADC values of benign, locally malignant lesions, and malignant tumors were 1.65 ± 0.58 × 10–3, 1.43 ± 0.17 × 10–3, and 0.83 ± 0.23 × 10–3 mm2 s-1, respectively. The ADC values of benign and locally malignant lesions were overlapped. We found a cut-off value of ≥1.19 × 10–3 mm2s-1 to differentiate benign from malignant pediatric head and neck masses with a sensitivity of 97.3', specificity of 80.0', positive predictive value of 94.7', and negative predictive value of 88.9'. Conclusion: Diffusion-weighted MRI study is an accurate, fast, noninvasive, and nonenhanced technique that can be used to characterize head and neck lesions. DWI helps to differentiate malignant from benign lesions based on calculated ADC values. Additionally, DWI is helpful to guide biopsy target sites and decrease the rate of unnecessary invasive procedures.
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Decoding the neonatal chest radiograph: An insight into neonatal respiratory distress Highly accessed article p. 482
Sanjay N Jain, Tanvi Modi, Ravi U Varma
DOI:10.4103/ijri.IJRI_281_20  
Respiratory distress is one of the leading causes of neonatal morbidity and mortality. Factors such as gestational age at birth, pulmonary maturity, and congenital factors are peculiar to this demographic. Clinical evaluation accompanied by chest radiography is the standard protocol for evaluating the underlying causative factors. Knowledge of the radiographic appearances of various pathologies and associations with certain congenital factors is quintessential for radiologists and primary neonatal care providers to steer the management in the right direction.
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BREAST IMAGING Top

Can strain elastography be used in reclassification of indeterminate breast lesions in BIRADS lexicon?: A prospective study p. 493
Dimpi Sinha, Nischal G Kundaragi, Sukrity Sharma, Sudhir K Kale
DOI:10.4103/ijri.IJRI_425_19  
Purpose: To evaluate the role of strain elastography (SE) in reclassification of indeterminate breast lesions placed under BIRADS 3 and 4 categories by conventional ultrasound (US) parameters so as to recourse biopsy only for suspicious stiffer lesions. Methods: 113 breast lesions in 100 women assigned as BIRADS category 3 and 4 on US parameters were prospectively evaluated by SE followed by histo-pathological examination. Strain ratio (SR) and Elastography Score (ES) were determined for each lesion. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each modality and diagnostic performance were compared. The best cut-off point was calculated for each of the elastography parameter using the receiver operator curve analysis (ROC). Results: Out of the 113 lesions, 40 were malignant (35.4') and 73 were benign (64.6'). A statistically significant difference was observed in the AUC for ES and conventional US: 0.98 vs 0.90 (Difference = 0.08, P = 0.02). Elastography parameters were more specific as compared to US (ES-94.5 & SR-93.2’ vs 63', P < 0.05) with high NPV. SE performed better in BIRADS 4 category lesions. On the basis of elastography parameters, 85’ of BIRADS 4 category lesions were correctly predicted as benign with overall sensitivity, specificity and diagnostic accuracy of elastography being 97', 84.6’ and 91.9'. Among BIRADS 3 category lesions, 97’ were correctly predicted as benign and 50’ lesions were correctly predicted as malignant with a sensitivity of 50', specificity of 97.8’ and diagnostic accuracy of 94'. Conclusion: Strain elastography is a useful adjunct to conventional ultrasonography for the assessment of indeterminate breast lesions and may help in avoiding unnecessary follow ups and biopsies. Elastography score is a better parameter as compared to strain ratio.
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CASE REPORTS Top

COL4A1 mutation in an Indian child presenting as ‘Cerebral Palsy’ mimic p. 500
Siddharth M Shah, Drushi D Patel
DOI:10.4103/ijri.IJRI_274_20  
The COL4A1 gene (COL4A1) plays an important role in vascular basement membrane function and pathogenic mutations have been reported in mice and humans. The gene is expressed mainly in the human brain, eyes and kidneys. Pathogenic mutations result in a vast array of manifestations that can present throughout life including the foetal period. We present a case of an 11-year-old girl with right hemiparesis, congenital cataracts, epilepsy and magnetic resonance imaging (MRI) brain findings with a pathogenic COL4A1 mutation. Many of her clinical features are similar to those of a non-genetic cause of cerebral palsy highlighting the difficulties and delays in making this genetic diagnosis.
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A rare case of melorheostosis with intra-articular extension causing medial patellar impingement p. 504
Nilesh N Haran, Ameya S Kawthalkar
DOI:10.4103/ijri.IJRI_189_20  
Melorheostosis is an uncommon mesenchymal dysplasia manifesting as regions of sclerosing bone with a characteristic flowing candle wax appearance. We describe here a rare presentation of melhoreostosis with the intra-articular extension of the disease in the knee joint and causing medial patellar impingement.
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Isolated distal adductor magnus tendon avulsion as a rare cause of medial knee pain. A case report Highly accessed article p. 507
Aamer Iqbal, Shekhar Kalia, David Beale, Steven L James, Rajesh Botchu
DOI:10.4103/ijri.IJRI_523_19  
Avulsion injuries of adductor frequently involve the proximal origin. We report the first case of avulsion fracture of adductor magnus at its insertion and discuss the relevant anatomy.
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Carpal tunnel syndrome or C8/T1 radiculoneuropathy due to perinural cyst: A diagnostic conundrum p. 510
Vikas Bhatia, Neeraj Balaini, Paramjeet Singh
DOI:10.4103/ijri.IJRI_414_20  
Perineural cysts are usually described in Lumbosacral region and are uncommonly seen in cervical spine.These are mostly asymptomatic, with only a few cases of symptomatic cervical perineural cysts.No previous case report of perineural cyst causing C8/T1 radiculoneuropathy mimicking clinically as Carpal tunn?el syndrome is reported in the literature. We report a case of elderly female who was operated for presumed Carpal tunnel syndrome. However, her symptoms did not improve. The MRI of the patient revealed presence of perineural cysts at the level of C8/T1 exiting nerve root, compressing it and causing the symptoms. We present the clinical, nerve conduction study and radiological presentation of cervical perineural cyst mimicking Carpal tunnel syndrome in this patient.
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Upper cervical spinal bronchogenic cyst: A rare lesion at an exceptional location p. 513
Viral Patel, Shreya Desai, Vishal Thakkar, Sanjayx Chaudhari
DOI:10.4103/ijri.IJRI_262_19  
An intraspinal bronchogenic cyst is a rare but important cause of compressive cord myelopathy, commonly seen in the cervicothoracic spine. We report a case of a 30-year-old female, presented with complaints of neck pain and progressive weakness of the extremities. The magnetic resonance imaging of the cervical spine revealed an intradural extramedullary, well-defined, multiloculated, cystic lesion in the upper cervical canal extending from the C2 to C5 vertebral levels. To our knowledge, only 11 cases of spinal bronchogenic cysts have been reported in the literature so far. We discuss the rare location of this unusual lesion, possible embryological reasons, and the overall surgical outcome.
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Temporal encephalocele into transverse sinus in an adult with partial seizures: MRI evaluation of a rare site of brain herniation p. 517
Taruna Yadav, Minhaj Shaikh, Samhita Panda, Pushpinder Khera
DOI:10.4103/ijri.IJRI_503_19  
Herniation of brain parenchyma outside its normal enclosure (also known as encephalocele) has long been known to occur at certain classic sites and is classified accordingly. With widespread use of modern neuroimaging, the previously unknown atypical and rare sites of encephalocele have now been identified. Brain herniation into a dural venous sinus is one such recently described entity with case reports extending only upto the earlier part of this decade. With no definite clinical symptomatology, imaging is crucial to diagnose this lesion accurately and differentiate it from the more familiar entity in this region of the brain, the arachnoid granulations. Also known as occult encephalocele, focal brain herniation into dural venous sinus has few specific imaging features and characteristic sites. We report a case of a 21-year-old man with partial seizures in whom MRI of the brain revealed focal herniation of the normal temporal lobe parenchyma into the left transverse sinus and discuss the key imaging features and pathophysiology of this entity.
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Remote cerebellar haemorrhage: A case report p. 521
Sachin Kumar, Hrishikesh A Kale
DOI:10.4103/ijri.IJRI_123_20  
Intracranial haemorrhage after supra-tentorial craniotomies can occur in a typical pattern and location which may suggest the diagnosis of remote cerebellar haemorrhage (RCH) which is quite a rare occurrence. The 'Zebra Sign’ refers to a pattern of hyperdensity indicative of blood and hypodensity indicative of normal cerebellar parenchyma in a curvilinear, stripe-like fashion along the cerebellar folia and is a characteristic imaging finding in RCH. RCH in general doesn't require surgical treatment, however in cases of significant hydrocephalus or progressive deterioration of consciousness surgical treatment may be warranted. The knowledge of this condition is important as it can pre-empt unnecessary further investigations and biopsy. Although imaging appearance may be striking, close imaging follow-up and clinical monitoring are often enough for the management of this entity.
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Parathyroid cyst eclipsed by parathyroid adenoma: Value of adjunct imaging p. 524
Khyati Bhatia, Deepak Sarin, Gopal Kumar Singh, Alka Ashmita Singhal
DOI:10.4103/ijri.IJRI_458_19  
Parathyroid cyst is a rare clinical entity and often presents as a diagnostic challenge, especially when presents in conjunction with a coexistent parathyroid adenoma. Patient with primary hyperparathyroidism had presented with a localised left inferior parathyroid adenoma with a coexistent right inferior parathyroid cyst which was initially missed on routine ultrasound and sestamibi scan. Suspicion of right inferior thyroid cyst was raised on ultrasound done by a dedicated parathyroid ultrasonologist. Right inferior thyroid cyst was confirmed to be parathyroid cyst on histopathological examination. Parathyroid cysts are seldom picked on sestamibi due to compressed parathyroid tissue present only at the periphery of the cyst. Hence, use of adjunct anatomical imaging like ultrasound, CT scan or MRI is worthwhile to reduce chances of missing hyperfunctional parathyroid tissue, which can eventually lead to revision surgery for persistent primary hyperparathyroidism.
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Where there is pancreatic juice, there is a way: Spontaneous fistulization of severe acute pancreatitis-associated collection into urinary bladder p. 529
Yashant Aswani, Shehbaz M S Ansari, Ulhaas S Chakraborty, Priya Hira, Sudeshna Ghosh
DOI:10.4103/ijri.IJRI_349_20  
Pancreatic fluid collections (PFC) are notorious for their extension beyond the normal confines of the pancreatic bed. This distribution is explained by dissection along the fascial planes in retroperitoneum due to the digestive enzymes within the PFC. In genitourinary track, PFCs have been described to involve the kidneys and the ureters. We report a case of severe acute necrotizing pancreatitis in a 28-year-old male, chronic alcoholic, who on readmission developed features of cystitis. The urine was turbid but did not show significant bacteriuria. Close location of the PFC near the urinary bladder (UB) prompted evaluation of urinary lipase and amylase. Elevated urinary enzyme levels suggested a Pancreatico-vesical fistula, conclusive demonstration of which was established by CT cystography. Percutaneous drainage of the necrosum and stenting of pancreatic duct led to spontaneous healing of the pancreatico-vesical fistula. Our case reiterates the remarkable property of pancreatic enzymes to dissect the fascial planes which is demonstrated by decompression of PFC via UB causing spontaneous Pancreatico-vesical fistula. Further, presence of main pancreatic duct fistulization should prompt endoscopic-guided stenting to obliterate the communication with the fistula and accelerate healing.
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LETTERS TO THE EDITOR Top

Chronic Regional Multifocal Osteomyelitis RE: SAPHO syndrome: A Radiological Case Report p. 533
Abhijeet Taori, Divya Malpani
DOI:10.4103/ijri.IJRI_340_20  
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Extrapleural air versus pneumothorax: A close call p. 535
Animesh Ray, Surabhi Vyas, Aishwarya Ramprasad, Naval Vikram
DOI:10.4103/ijri.IJRI_492_20  
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ASL perfusion in atypical Japanese encephalitis p. 536
Babu Peter Sathyanathan, Aishwarya Ravichandran, Ravi Ranganathan
DOI:10.4103/ijri.IJRI_268_20  
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