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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 30 | Issue 3
Page Nos. 251-414

Online since Thursday, October 15, 2020

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EDITORIAL  

COVID-19 pandemic: The value of antibody testing for imaging facilities Highly accessed article p. 251
Anirudh Kohli
DOI:10.4103/ijri.IJRI_819_20  
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MUSCULOSKELETAL IMAGING Top

Evaluation of spinopelvic parameters in lumbar prolapsed intervertebral disc Highly accessed article p. 253
Apoorva Poonia, Sambhav Lodha, NC Sharma
DOI:10.4103/ijri.IJRI_49_20  
Background: Sacro-pelvic morphology and orientation are usually described in terms of pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). Orientation and morphology of pelvis can affect degenerative changes in the lumbar spine. Thus, here we investigated the relationships between various sagittal spinopelvic parameters and the degree of disc degeneration in young adults. Material and Methods: A hospital-based cross-sectional study with a total of 60 cases was done. Patients presenting with back or leg pain having prolapsed disc on magnetic resonance imaging (MRI) were included in the study. A standing X-ray of LS spine from dorso-lumbar junction to mid-thigh was taken. Various spinopelvic parameters were assessed from the scannogram using the software. Results: The mean age was 39.27 years. L5S1 was the most common level. Mean SS, PT, PI, and LL were 37.78°, 13.52°, 51.33°, and 41.01°. Disc pathologies at L1L2, L2L3, and L4L5 level showed a positive correlation with PT, PI, and LL. Disc pathology at the L5S1 level shows a positive correlation with PT and LL. A statistically significant correlation between SS and degenerative spondylolisthesis at L4L5 was found from data with P = 0.023. Discussion: An increase in SS statistically significantly increases the chance of development of degenerative spondylolisthesis at L4L5. An increase in PT, PI, and LL will cause an increase in disc pathology at L1L2. An increase in SS, PT, PI, and LL will cause an increase in disc pathology at L2L3. An increase in SS, PT, PI, and LL will cause an increase in disc pathology at L4L5. An increase in PT and LL will cause an increase in disc pathology at L5S1. Conclusion: Standing lateral view radiograph from dorso-lumbar junction to the mid-thigh is as good as standing whole spine radiograph for measurement of spinopelvic parameters. Degenerative spondylolisthesis at L4L5 has a statistically significant correlation with an increase in SS.
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Exploring the correlation between increased femoral anteversion and pars interarticularis defects in the lumbar spine: A single center experience p. 263
James Kho, Siddharth Thaker, Christine Azzopardi, Steven L James, Rajesh Botchu
DOI:10.4103/ijri.IJRI_364_20  
Introduction: Altered femoral version can result in lumbar hyperlordosis and hip spine syndrome. We conducted a retrosepctive study to evalute if there is correlation between altered femoral version and pars defect. Materal and Methods: A cohort of pateints with CT rotational profile and MR of lumbar spine over a 12 year period were included in the sutdy. The femoral version was calculated and the MR was evaluated for pars defect. Results: 130 patients had CT rotational profile and MR of lumbar spine with a female predomiannce ( 94 female and 36 males) and average age of 24.3 years. There were 6 patients with bilateral pars defects involving L5 ( 3 with increased femoral version, 2 with decreased version and one had normal version). Conclusion: Increased femoral anterversion is not associated with increased prevalence of pars defects.
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CHEST IMAGING Top

Inflammatory myofibroblastic tumours of the thorax: Radiologic and clinicopathological correlation p. 266
Aparna Irodi, Binita R Chacko, Anand Prajapati, Anne J Prabhu, Leena R Vimala, Devasahayam J Christopher, Birla R Gnanamuthu
DOI:10.4103/ijri.IJRI_93_20  
Context and Aims: Inflammatory myofibroblastic tumour (IMT) is a rare mesenchymal neoplasm with intermediate malignant potential. The aim of this study is to describe and compare the clinical presentation, computed tomography (CT) findings and anaplastic lymphoma kinase -1 (ALK-1) expression of IMT of the thorax in children and adults. We also sought to study the tumour behaviour after treatment on the follow-up imaging. Materials and Method: This is a retrospective observational study of 22 histopathologically proven cases of IMT in the thorax. The clinical parameters, CT findings, biopsy results, treatment received and follow-up were recorded. Statistical analysis was performed using Fisher's exact test. Results: IMT of the thorax had diverse imaging appearances, presenting either as large invasive lung masses with or without calcifications or as smaller endobronchial lesions. Children commonly presented with long duration fever (P = 0.02) and large invasive lung masses (P = 0.026), whereas adults presented with long duration haemoptysis (P = 0.001) and endobronchial lesions or smaller lung parenchymal lesions. Calcifications were more common in children (P = 0.007). ALK-1 was positive in 40% of children and 18.2% of adults (P = 0.547). Endobronchial lesions showed a trend for ALK-1 negativity. Patients with bronchoscopic excision had local recurrence and patients with surgical wedge resection had metastatic brain lesions as compared to those with lobectomy and pneumonectomy (P = 0.0152). A patient with unresectable lung mass had malignant transformation to spindle cell sarcoma after 9.5 years. Conclusions: Thoracic IMT presents with some distinct clinical and CT findings in adults and children. The CT findings and management options have implications for prognosis. If resectable, lobectomy is a better option than wedge resection or bronchoscopic excision for preventing local recurrence and metastasis. IMT can undergo malignant transformation.
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Imaging spectrum of pulmonary infections in renal transplant patients p. 273
Zohra Ahmad, Soumita Bagchi, Priyanka Naranje, SK Agarwal, Chandan J Das
DOI:10.4103/ijri.IJRI_357_19  
In the post renal transplant setting, pulmonary infections comprise an important set of complications. Microbiological diagnosis although specific is often delayed and insensitive. Radiography is the most common and first imaging test for which patient is referred, however it is relatively insensitive. HRCT is a very useful imaging tool in the scenario where radiography is negative or inconclusive and high clinical suspicion for infection is present. HRCT features vary among the various pathogens and also depend on the level of immunocompromise. Certain HRCT findings are characteristic for specific pathogens and may help narrow diagnosis. In this review article , we will summarize the imaging findings of various pulmonary infections encountered in post renal transplant patients.
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CARDIAC IMAGING Top

Utility of cine MRI in evaluation of cardiovascular invasion by mediastinal masses p. 280
Sourav Panda, Aparna Irodi, Riya Daniel, Binita R Chacko, Leena R Vimala, Birla R Gnanamuthu
DOI:10.4103/ijri.IJRI_69_20  
Background: Accurate imaging assessment of cardiovascular invasion by mediastinal masses is essential for determining surgical feasibility. This can sometimes be difficult on CT owing to limited space available in the mediastinum, resulting in mediastinal masses abutting and indenting adjacent cardiovascular structures. Cine MRI may aid in such situations by demonstrating differential mobility. Aims and Objectives: To evaluate the role of cine MRI in assessing cardiovascular invasion by mediastinal masses, by evaluating sliding motion and the presence of chemical shift artifact between the mediastinal mass and apposing structures. Material and Methods: Retrospective study of 44 patients with mediastinal masses, with equivocal involvement of 162 cardiovascular structures on CT scan, in whom cine MRI was done. Involvement on CT was considered equivocal when there was a loss of intervening fat plane and broad surface (>3 cm) or angle (>90°) of contact between the mediastinal mass and cardiovascular structure. The presence of either sliding movement or type 2 chemical shift artifact or both between mass and the cardiovascular structure was considered as no adherence or invasion. The absence of both the parameters was considered as the presence of invasion or adhesion. Imaging findings were correlated with intraoperative findings. Results: After excluding 25 cardiovascular structures in 7 patients, 137 cardiovascular structures whose involvement was suspected on CT were evaluated in 37 patients with mediastinal masses. In all, 31 cardiovascular structures showed invasion on MRI out of which 28 structures were invaded or adhered intraoperatively and 106 cardiovascular structures showed no invasion on MRI out of which 97 structures were intraoperatively not invaded/adhered. The sensitivity, specificity and accuracy of our study are 75.7%, 97% and 91.2%, respectively. Conclusion: Cine MRI can be used as an effective tool in patients with equivocal cardiovascular invasion by mediastinal masses on CT scans.
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NEUROIMAGING Top

Pial arteriovenous fistula: A clinical and neuro-interventional experience of outcomes in a rare entity p. 286
Gorky Medhi, Arun K Gupta, Jitender Saini, Arvinda H Ramalingaiah, Hima Pendharkar, Subhendu Parida
DOI:10.4103/ijri.IJRI_26_19  
Purpose: Pial arteriovenous fistulae (PAVF) are rare intracranial vascular malformations, predominantly seen in children and distinct from arteriovenous malformations and dural arteriovenous fistulae. PAVF often leads to high morbidity and mortality. The aim of our study was to describe the clinical features and endovascular management of PAVF at various intracranial locations; to analyze the use of liquid embolic agents and coils alone or in combination in the treatment of PAVF and to analyze the outcome of embolization. Materials and Methods: Retrospective review of diagnostic angiography and neurointerventional database of our institution identified a cohort of 15 patients with non-galenic PAVF from 2008 to 2014 out of 6750 patients. Fourteen patients were treated endovascularly with coils and liquid embolic materials in combination or alone. Patients were followed up for evaluation of prognosis. Results: Age of the patients ranged from 3 to 37 years. Most patients were male and most common presentation was headache followed by seizure. Most common location of fistula was frontal lobe. The most common type was single artery single hole fistula with venous varix. Satisfactory obliteration was seen in all cases. One patient developed intraparenchymal hematoma on the first post procedural day and outcome was poor. Conclusions: PAVF are rare intracranial vascular malformations which can effectively be managed endovascularly with liquid embolic, coils alone, or in combination. Complete occlusion of the fistula can be achieved in most cases in a single sitting with a reasonable morbidity related to the procedure, compared with the natural history of this disease.
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GIT IMAGING Top

Comparative analysis and assessment of diagnostic accuracy of 256 slice CT and endoscopic ultrasound in evaluation of pancreatic masses p. 294
Surabhi Gupta, Sunil K Puri
DOI:10.4103/ijri.IJRI_437_19  
Context: Pancreatic masses are routinely encountered on imaging and often present as a diagnostic dilemma. These masses range from benign inflammatory masses, requiring no intervention to malignant masses, which carry grave prognosis and hence require aggressive management. Aims: Compare the diagnostic accuracy of 256 multislice CT and endoscopic ultrasound (EUS) in characterization and assessment of resectability of pancreatic masses and compare the multidetector computed tomography (MDCT) and EUS findings with histopathological findings. Settings and Design: Prospective study. Subjects and Methods: 36 patients with pancreatic masses were included who underwent dual phase CT using pancreatic protocol and EUS using 5–13 MHz transducer. Fine needle aspiration cytology (FNAC) was done wherever feasible. Parameters regarding tumor size, location, imaging morphology, and vessel involvement were recorded. Findings were compared with histopathological/operative diagnosis/clinical follow-up. Statistical Analysis Used: Descriptive statistics with percentages and proportions and Chi-square test. Results: Multidetector computed tomography (MDCT) and EUS established diagnosis consistent with tissue diagnosis in 30 (83%) and 22 (61%) patients, respectively. However, the best results were obtained with the combined use of MDCT and EUS. The number of patients categorized as inconclusive by MDCT were lower compared to EUS. Assessing resectability for pancreatic adenocarcinoma, MDCT showed specificity and positive predictive value (PPV) of 100% compared to EUS, which had specificity and PPV of 75% and 92.3%, respectively. MDCT is the first-line imaging modality in detection, characterization of pancreatic masses, and assessment of resectability in malignant neoplasms. EUS is beneficial in the detection of masses <2 cm in size causing pancreatic contour deformity on CT, for guiding FNAC. MDCT and EUS with EUS-guided FNA are complementary not competitive tools in preoperative imaging of pancreatic masses.
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GYNECOLOGY IMAGING Top

Prospective revalidation of IOTA “two-step”, “alternative two-step” and “three-step” strategies for characterization of adnexal masses – An Indian study focussing the radiology context p. 304
Shabnam Bhandari Grover, Sayantan Patra, Hemal Grover, Pratima Mittal, Geetika Khanna
DOI:10.4103/ijri.IJRI_279_20  
Objectives: The purpose of this study was to revalidate the diagnostic performance of IOTA “two step” (Simple Descriptors and Simple Rules), “ alternative two step” (Simple Rules Risk Calculation tool / SRrisk score), and three step (two step with subjective assessment) strategies, for characterization of adnexal masses as benign or malignant, using histopathology as gold standard. Materials and Methods: This prospective, study comprised of 100 patients with newly diagnosed adnexal masses, who underwent ultrasound evaluation first by a level I and then by a level III investigator (EFSUMB criteria). Initially, the level I investigator evaluated each adnexal mass, applying IOTA “two-step” strategy and simultaneously assigned a risk category, by applying the simple rules risk score (SRrisk score ) or performing the “alternative two step” strategy. Subsequently the inconclusive masses were evaluated by the level III investigator using “real time subjective assessment”, thereby performing the third step. Following histopathology diagnosis, the performance of each strategy was evaluated using diagnostic tests. Results: The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of “two-step” strategy were 87.5%, 79.2%, 89.4%, 76%, and 84.7%, respectively; those of “alternative two-step” strategy were 91.5%, 75.6%, 84.4%, 86.1% and 88%; and those of “three-step” strategy were 98.2%, 93.3%, 94.7%, 97.7% and 96%, respectively. Conclusion: All IOTA strategies showed good diagnostic performance for characterization of adnexal masses and the “three-step” strategy performed best. We believe this is the first ever prospective re-validation and comparative evaluation of all three IOTA strategies by Indian Radiologists. Since ultrasound is the primary modality for evaluation of adnexal masses, based on the good results of our study, a recommendation for henceforth standard application, of the three-step IOTA strategy in routine Radiology practice appears justified. Although, IOTA strategies been proposed and validated mainly by Gynaecologists and Oncology surgeons, based on the results of our study, this paradigm can now be made to shift back to the arena of Radiology and Radiologists, the imaging experts.
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BREAST IMAGING Top

PET-CT upstaging of unilateral operable breast cancer and its correlation with molecular subtypes p. 319
Srishti Singh, Bagyam Raghavan, Sivaramalingam Geethapriya, VV Sathyasree, Jayaraj Govindaraj, G Padmanabhan, Murali Krishna, Rasheed Arafath
DOI:10.4103/ijri.IJRI_59_20  
Context: Prognosis and survival rates for breast cancer vary greatly depending on the cancer stage of the patient. Instead of a step-by-step approach using multiple investigations, we can get all the information about the metastatic load of the disease in PET-CT imaging by one single investigation. There is also a correlation between prognosis, FDG uptake, and molecular subtype of breast cancer (Luminal A, Luminal B, Human epidermal growth factor receptor 2 (HER2) positive and Triple-negative). Pre-treatment baseline PET-CT scan was done in 156 unilateral early and operable breast cancer patients from November 2017 to April 2019 in our prospective observational study. Aims:
  • To evaluate the utility of PET-CT in staging and upstaging of early and operable breast cancer by detection of unsuspected lymph nodes and distant organ metastases.
  • To determine the prognostic association between SUVmax of the primary breast lesion in the upstaged cases and the molecular subtypes.
Results:
  • Thus, PET-CT can serve as one-stop imaging in unilateral operable early breast cancer patients for upstaging and prognostication based on the correlation of SUVmax with molecular subtypes of breast lesions in patients who will surely benefit from whole-body imaging.
  • Out of 156 patients, approximately 27 patients were upstaged after pre-treatment PET CT.
  • Six patients were upstaged to stage IIIC and 21 patients were upstaged to IV.
  • Regional nodes like internal mammary and supraclavicular nodes were detected in 7 patients and 5 patients, respectively, out of 156 patients.
  • Non-regional distant nodes and organ metastases were detected in 11 and 18 patients out of 156 patients.
  • Most common molecular subtype detected in the upstaged cases in our study was Luminal A (13 patients) followed by Triple negative (6), Luminal B (3) and HER2-neu-positive subtypes (1).
Conclusions:
  • FDG PET-CT is a substantial modality to provide information on regional, non regional lymph nodes and distant metastases in early operable breast cancer.
  • It helps in evaluating the whole body metastatic burden in a single sitting, therefore, reducing the need for multiple investigations.
  • SUVmax association of the index lesion with molecular subtype in the FDG PET scanning can serve as a prognostication factor in operable early breast cancer patients.
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Zuska's breast disease: Breast imaging findings and histopathologic overview p. 327
Luis F Serrano, MarÍa M Rojas-Rojas, Fedel A Machado
DOI:10.4103/ijri.IJRI_207_20  
Zuska's disease describes the clinical condition of recurrent central or periareolar nonpuerperal abscesses associated with lactiferous fistulas. Pathogenesis involves the occlusion of an abnormal duct through an epithelial desquamation process that causes ductal dilatation, stasis of secretions, and periductal inflammation. Patients with Zuska's disease may develop chronic draining sinuses near the areola from lactiferous ducts fistula; therefore, the underlying abnormal duct system must be located and excised for proper treatment. Zuska's disease is often misdiagnosed and mistreated and is associated with significant morbidity, including the recurrence of abscess and cutaneous fistula formation. This case series aimed to help clinicians investigate and manage this disorder. The clinical and imaging findings, histopathologic correlation, and treatment of Zuska's disease are discussed.
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HEAD AND NECK IMAGING Top

Dynamic manoeuvres on MRI in oral cancers – A pictorial essay p. 334
Diva Shah
DOI:10.4103/ijri.IJRI_117_20  
Magnetic resonance imaging has been shown to be a useful tool in the evaluation of oral malignancies because of direct visualization of lesions due to high soft tissue contrast and multiplanar capability. However, small oral cavity tumours pose an imaging challenge due to apposed mucosal surfaces of oral cavity, metallic denture artefacts and submucosal fibrosis. The purpose of this pictorial essay is to show the benefits of pre and post contrast MRI sequences using various dynamic manoeuvres that serve as key sequences in the evaluation of various small oral (buccal mucosa and tongue as well as hard/soft palate) lesions for studying their extent as well as their true anatomic relationship.
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“Radiographic demonstration of association of ubernaculum Dentis(Gubernaculum tract) in odontogenic cysts and tumors”-A CBCT finding p. 340
Nagaraju Kamarthi, Dhruvesh Gupta, Suhasini Palakshappa Gotur
DOI:10.4103/ijri.IJRI_467_19  
Spectrum of lesions that occur in the jaws have a cyst-like radiographic appearance. These lesions may be odontogenic or non-odontogenic and are often difficult to differentiate them on the basis of their clinical, radiographic features alone. Among odontogenic lesions without mineralization, ameloblastomas, odontogenic keratocysts, and dentigerous cysts can all appear as well-defined, unilocular, well-corticated, lucent lesions that can mimic with non-odontogenic cysts and tumors like nasopalatine duct cyst, aneurysmal bone cyst, central giant cell granuloma, hemangioma and so on. So understanding the pathogenesis of these lesions become the most imperative criteria for determining the additional investigations and treatment protocol. We hereby discuss 8 diagnosed cases of odontogenic and non-odontogenic jaw lesions, which were retrospectively visualized in cone beam computed tomography(CBCT), and an association of gubernaculum tract(cord) with odontogenic origin lesions was demonstrated.
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USG AND COLOUR DOPPLER Top

Diagnostic categorization of erectile dysfunction using duplex color doppler ultrasonography and significance of phentolamine redosing in abolishing false diagnosis of venous leak impotence: A single center experience p. 344
Reddy Ravikanth
DOI:10.4103/ijri.IJRI_419_19  
Background and Aims: Erectile dysfunction (ED) is an inability to achieve and maintain erectile rigidity sufficient for satisfactory sexual performance. It is either organic or psychogenic in origin. This study was aimed at establishing vasculogenic causes among patients being evaluated for ED using Penile Doppler Ultrasound. Methods: Fifty-two consecutive patients with the clinical diagnosis of ED were evaluated with color Doppler ultrasound scan using a 7.5 MHz high-frequency linear transducer between July 2016 and June 2019. The examination was commenced 3 min after an intracavernosal injection with 10-20 μg of PGE1 and continued for 30 min. The measurements were obtained alternately from both deep penile arteries. The variables analyzed were the peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistive index (RI), calculated as (PSV-EDV)/PSV. Erection Hardness was evaluated subjectively using the EH Score (EHS), a 5-point response score denoting how the patient would rate his erection. ED was subjectively assessed using the International Index of Erectile Function (IIEF-5) questionnaire. In patients with a diagnosis of vasculogenic ED, intracavernosal PGE1injection was started with a 5 μg dose and then increased in 5 μg increments until the final dose of 20 μg was reached. Results: PSV of cavernosal arteries (CA) varied between 19.2 and 106.2 cm/s (mean: 43.8 ± 18.2) among the entire patients and between 19.7 and 80.2 cm/s (mean: 42.6 ± 11.3) among patients with arteriogenic ED. Arteriogenic ED was found in 8 patients (15.3%), while venogenic ED was observed in 12 patients, which constituted 23% of the entire study population and mixed arteriogenic-venogenic ED was found in 6 patients (11.5%) of the study population. DICC performed on patients diagnosed with venogenic ED on color Doppler ultrasonography revealed venous leakage and no statistically significant differences between results of DICC and color Doppler ultrasonography were found in EDV, RI, and PI measurements (P<0.005). Among patients with venogenic ED and mixed arteriogenic-venogenic ED,2 patients had a normal erectile response and the remaining 16 received 2 mg phentolamine. A significant increase in PSV between baseline and 20 mg PGE1 (P < 0.001) was observed in all cases. Following phentolamine, there was a significant increase in grade of erection (P = 0.0001) and a significant reduction in the EDV (P = 0.0001). A reduction of the EDV to below 0.0 cm/s was observed in 12 patients. In patients with arteriogenic erectile dysfunction, mean (±standard deviation) duration of erection for consecutive doses of PGE1 5 μg, 10 μg, 15 μg, and 20 μg were 42.2±18.4, 55.4±24.1, 66.1 ± 31.1, and 83.3±36.7 minutes, respectively, with significant increase for each dose. In patients with veno-occlusive dysfunction, mean durations of erection significantly increased from 9.1±8.0 minutes at 10 μg to 19.2±9.8 minutes at 20 μg. Conclusion: In the current study, 50% of patients had vasculogenic ED and “false-positive'' diagnosis of venous leakage was unmasked by phentolamine re-dosing. It is therefore imperative that patients with ED benefit from duplex color Doppler ultrasonography which is safe, cheap and non-ionizing diagnostic modality before initiating therapy as ED treatment is cause specific.
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MISCELLANEOUS Top

Holography applications toward medical field: An overview p. 354
Abid Haleem, Mohd Javaid, Ibrahim Haleem Khan
DOI:10.4103/ijri.IJRI_39_20  
Purpose: 3D Holography is a commercially available, disruptive innovation, which can be customised as per the requirements and is supporting Industry 4.0. The purpose of this paper is to study the potential applications of 3D holography in the medical field. This paper explores the concept of holography and its significant benefits in the medical field. Methods: The paper is derived through the study of various research papers on Holography and its applications in the medical field. The study tries to identify the direction of research &development and see how this innovative technology can be used effectively for better treatment of patients. Results: Holography uses digital imaging inputs and provides an extensive visualisation of the data for training doctors, surgeons and students. Holography converts information about the body into a digital format and has the potential to inform, promote and entertain the medical students and doctors. However, it needs a large amount of space for data storage and extensive software support for analysis and skills for customising. This technology seems good to solve a variety of medical issues by storing and using patient data in developing 3D holograms, which are useful to assist successful treatment and surgery. It seems useful in providing flexible solutions in the area of medical research. Finally, the paper identifies 13 significant applications of this technology in the medical field and discusses them appropriately. Conclusion: The paper explores holographic applications in medical research due to its extensive capability of image processing. Holographic images are non-contact 3D images having a large field of depth. A physician can now zoom the holographic image for a better view of the medical part. This innovative technology can create advancements in the diagnosis and treatment process, which can improve medical practice. It helps in quick detection of problems in various organs like brain, heart, liver, kidney etc. By using this technology, medical practitioners can see colourful organs at multiple angles with better accuracy. It opens up an innovative way of planning, testing of procedures and diagnosis. With technological developments, compact hardware and software are now available to help medical research and related applications.
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Technical and patient-related sources of error and artifacts in bone mineral densitometry using dual-energy X-ray absorptiometry: A pictorial review p. 362
Mohsen Qutbi, Mehdi Soltanshahi, Yaser Shiravand, Saba Karami Gorzi, Babak Shafiei, Isa Neshandar Asli
DOI:10.4103/ijri.IJRI_495_19  
Dual-energy X-ray absorptiometry is currently the standard and validated tool for measurement of bone mineral density and for the evaluation of osteoporosis. Current densitometry scanners based on dual-energy X-ray absorptiometry method produce two X-ray beams with different energies to differentiate the overlapped soft tissue and bony structures, by creating two different attenuation profiles. Procedural guidelines are available to technicians and physicians to guarantee the best practice, including consistent positioning during scanning and standard reporting. However, similar to other imaging modalities, dual-energy X-ray absorptiometry may be influenced by technical errors, and thus, imaging artifacts may arise and accuracy and precision of the results may be influenced. This issue may, in turn, affect the final result and interpretation. Hence, the article is arranged with the intention of presenting some less common and rare technical and patient-related sources of error and resultant artifacts, from poor patient preparation to acquisition and data processing. Where appropriate, the corresponding tables of densitometric results (bone mineral density) and statistical parameters (T- and Z-scores) are provided.
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TECHNICAL NOTES Top

Radiological aspects of CO2peripheral DSA: Preliminary analysis on the dedicated protocols p. 372
Pier Luca Rossi, David Bianchini, Alessandro Lombi, Sonia Sapignoli, Manami Zanzi, Ivan Corazza
DOI:10.4103/ijri.IJRI_247_20  
Objectives: Thanks to its lack of allergic reactions and renal toxicity, CO2represents an alternative to iodine as a contrast medium for peripheral subtraction angiography. Since CO2has a lower and negative contrast than iodine, postprocessing DSA and stacking are mandatory. So, it seems that higher doses than traditional iodine angiography are required. We addressed the dosimetric aspects of CO2angiography for two different commercial DSA-apparatus. Materials and Methods: Two different radiological suites were analyzed by recreating the same setup on all the apparatuses: we used a PMMA slabs phantom with a MPD Barracuda dosimeter on its side to collect all radiological parameters. Results: Results show that the irradiation parameters were left completely unchanged between the traditional and CO2angiographic programs. Conclusions: This leads to thinking that these CO2protocols do not operate on the X-ray emission, but only differ on image manipulation. The possibility of improvements by changing radiological parameters are still not explored and really promising.
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Retrieval of retained pigtail in the liver p. 376
Manthreshwar Premkumar, George K Chiramel, Shyamkumar N Keshava
DOI:10.4103/ijri.IJRI_97_20  
The incidence of catheter breakage during percutaneous image-guided treatment of liver hydatid is very rare. A “telescoping” technique was used to retrieve the broken pigtail in this case report. Alternative options for pigtail retrieval are briefly discussed.
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CASE REPORTS Top

“The unpredictable brain tumor” p. 379
Srishti Singh, Bagyam Raghavan, Jayaraj Govindaraj, Sivaramalingam Geethapriya
DOI:10.4103/ijri.IJRI_66_20  
Histiocytosis is a group of rare diseases with vast imaging findings, few of which are distinctive and characteristic that help to differentiate each one of them. Therefore, typical imaging appearances must be recognized to include the possibility in the differential diagnosis, whenever considered pertinent. Hereby, we present one such unique case of histiocytosis in a 26-year-old female, which involved intertwined and overlapping features of radiological findings.
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Unusual case of persistent primitive hypoglossal artery with anterior choroidal artery aneurysm in Chiari type I malformation p. 383
Shinya Haryu, Naoki Shida, Teiji Tominaga
DOI:10.4103/ijri.IJRI_429_19  
Persistent primitive hypoglossal artery (PPHA) is a rare form of persistent embryonic carotid-basilar anastomosis. We present an unusual case of PPHA and an anterior choroidal artery (AChoA) aneurysm associated with Chiari type I malformation. A 45-year-old woman presented with transient dizziness. Magnetic resonance imaging revealed Chiari type I malformation and a left AChoA aneurysm. Digital subtraction angiography incidentally revealed a left PPHA. To the best of our knowledge, this is the first reported case of Chiari malformation in conjunction with PPHA and aneurysms. In this case, the perfusion of the posterior circulation is completely dependent on PPHA. It is very important to identify such variant vessels and complex angioarchitecture before planning neuroendovascular or surgical intervention to prevent possible risks.
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The unforeseen orbital tumor p. 386
Srishti Singh, Bagyam Raghavan, Sivaramalingam Geethapriya, Jayaraj Govindaraj, G Padmanabhan, Murali Krishna, Rasheed Arafath, VV Sathyasree
DOI:10.4103/ijri.IJRI_73_20  
Inflammatory myofibroblastic tumor is a rare group of neoplasms showing a mixture of spindle-shaped myofibroblasts or fibroblasts and a variable amount of inflammatory cells (eosinophils, plasma cells, and lymphocytes). They are not usually included in the differential diagnosis of nodules and masses because of their rarity, therefore, remaining an underdiagnosed entity. We report one such rare case in a 3-year-old female.
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Wandering spleen: A rare entity and a diagnostic dilemma p. 389
Ravinder Kaur, Ashish Dua, Ashwani Dalal
DOI:10.4103/ijri.IJRI_46_20  
Wandering spleen refers to a spleen that is ectopic in its location contrary to a normal spleen which rests in the left hypochondrium. Although it is a rare clinical entity seen in children, it can also be rarely seen in females of reproductive age group. We present one such case of wandering spleen which was misdiagnosed earlier as a sub-hepatic collection.
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Intrapancreatic accessory spleen: An imaging enigma p. 392
Saksham P Yadav, Shivam D Kotak, Sachin Kumar, Vishnu S Pujari, Akhila Chandrasekaran
DOI:10.4103/ijri.IJRI_407_20  
The pancreatic tail is an uncommon location for the accessory spleen. Although it is a benign entity, it can mimic and get misdiagnosed as a pancreatic tumor which can lead to unnecessary biopsy and surgery. Here, we present a case who was detected to have a tail of pancreas mass. On CT and MRI, it showed similar density, signal intensity, and matching enhancement pattern with the orthotopic spleen. The ADC value of the mass was found to be similar to that of the spleen and significantly less than that of normal pancreas. A diagnosis of intrapancreatic accessory spleen was hence made and the patient was followed up after 6 months on MRI. No change in lesion morphology and size was noted. Thus, intrapancreatic accessory spleen should be kept in mind as a differential diagnosis while reviewing a case with pancreatic mass.
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A case of dorsal agenesis of pancreas associated with unilateral renal agenesis, unicornuate uterus, and ovarian ectopia: A brief review and learning points p. 395
Arindam Bhandari, Samrat Mandal
DOI:10.4103/ijri.IJRI_165_19  
Dorsal agenesis of the pancreas is a rare entity, with about 100 cases reported. It can be overlooked on ultrasound due to the non visualization of the body and tail of the pancreas.This is due to overlying gas in the stomach, which offers a poor acoustic window and obscures visualization. Renal agenesis and Mullerian duct anomalies are uncommon associations of dorsal agenesis of the pancreas because of the separate embryological origin of the pancreas and genitourinary organs. Here, we present a case of a 17-year-old patient who had dorsal agenesis of the pancreas, associated with unilateral renal agenesis, unicornuate uterus, and ectopic ovary. We describe the anomalies and discuss the radiological differential diagnosis and potential pitfalls. We provide a brief review of the literature with few radiological teaching points and possible genetic implications of the case.
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111In-Octreoscan SPECT/CT hybrid imaging and 68Ga-DOTANOC PET/CT in neuroendocrine adenoma of the middle ear (NAME) p. 400
Mariano Pontico, Viviana Frantellizzi, Laura Cosma, Giuseppe De Vincentis
DOI:10.4103/ijri.IJRI_125_20  
Neuroendocrine adenoma of the middle ear (NAME) represents a rare tumour consisting of an adenoma with mixed neuroendocrine differentiation. A 40-year-old woman was referred to our attention to further investigate the occurrence of a pathological tissue located in the mastoid process of the left temporal bone depicted by head CT and MRI scans. Histopathological examination revealed an epithelial neoplasm with neuroendocrine differentiation features, consistent with the diagnosis of NAME. In order to obtain an accurate differential diagnosis and confirmation of this rare disease, 111In-Octreoscan single photon emission computed tomography (SPECT)/CT and 68Ga-DOTANOC positron emission tomography (PET)/CT were performed, both showing overexpression of somatostatin receptors and thus corroborating the histopathological findings.
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Percutaneous transluminal angioplasty of complex aortoiliac occlusive disease secondary to Takayasu's aortoarteritis in a young female Highly accessed article p. 405
Pankaj Jariwala, Rajendra V Irlapati, Suresh Giragani, Sikandar Shaikh
DOI:10.4103/ijri.IJRI_225_20  
As the initial treatment of patients with the iliac occlusive disease, percutaneous transluminal angioplasty (PTA) became common. Though not supported by the latest TransAtlantic Inter-Society Consensus (TASC) II guidelines, percutaneous treatment of complex aortoiliac lesions is possible and provides comparable angiographic and clinical outcomes compared to open surgery at both short- and long-term follow-up, also in complex lesion settings. TASC C and D lesions with the latest instruments, procedures, and modalities may also be managed endovascularly. It provides new opportunities for a population of highly comorbid patients. We assume that the outcomes of endovascular therapy for aortoiliac lesions in the setting of Takayasu's arteritis will be further enhanced through continuous technological progress and new advances in materials. In light of the current progression towards minimally invasive procedures, a growing number of skilled centres should be able to treat by endovascular intervention the great majority of all arterial pathologies.
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Contrast-enhanced voiding urosonography (CEVUS) as a novel technique for evaluation in a case of male urethral diverticulum p. 409
Shabnam Bhandari Grover, Sayantan Patra, Hemal Grover, Anup Kumar
DOI:10.4103/ijri.IJRI_50_20  
Male urethral diverticulum is an uncommon entity, the abnormality being more frequently encountered in females. The pathology may be congenital or acquired and the more frequent acquired type usually occurs following trauma. Afflicted patients usually lack specific symptoms, although in a few instances, symptoms of lower urinary tract obstruction, calculi, or infection may prevail. Imaging investigations utilizing a composite Retrograde urethrography (RGU)– Voiding cystourethrography (VCUG) protocol are accepted as standard approach and ultrasound is considered a secondary supplementary investigation. However, recent literature reports the utility of contrast-enhanced ultrasound (CEUS) as a novel technique in the evaluation of urinary bladder and urethra, for vesico-ureteric reflux (VUR) in children and for urethral diverticula in women. We report a case of acquired post-traumatic urethral diverticulum in an adult male patient and document a relatively unexplored novel application of contrast enhanced voiding uro-sonography (CEVUS) for the evaluation of this malady.
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