Hepatocellular Carcinoma with Inferior vena cava invasion

HCC is a malignant tumor of hepatocellular origin that develops in patients with risk factors such as alcohol abuse, viral hepatitis, and metabolic liver disease. It can also occur, rarely, in patients with normal liver parenchyma. Grossly, HCC can undergo hemorrhage and necrosis because of a lack of fibrous stroma. Vascular invasion, particularly of the portal system, is common. This is a known case of HCC with raised alphfetoprotein with MRI showing inferior vena cava and right atrial thrombus.

Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

Aneurysmal Bone Cyst of Talus

"Usually it occurs in abnormal bone due to local haemodynamic factors of venous obstruction or AV fistulae. it can arise from chondroblastoma, a chondromyxoid fibroma, an osteoblastoma, a giant cell tumor, or fibrous dysplasia. Less frequently, it results from some malignant tumor. It can be itraosseous or from surface and invade the soft tissues. Peak age is 16 yr old girl. Only 3% ocur in foot like in our case. MRI-Fluid- fluid levels are depicted only when the patient is lying motionless for about 10 minutes and when the scans are obtained in the plane perpendicular to that of the fluid levels. Fluid-fluid levels also are seen in many other bone lesions, such as giant cell tumors, and in telangiectatic osteosarcomas. MRI shows low to intemediate signal intensity both on t1 and t2 alon with thin low signal rim on t2 with septa and expansion. Gadolinium shows enhancement. "

Case by Dr MGK Murthy, Sr Consultant Radiologist

&

Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

CT scan findings in Otzi the Iceman-Radiology providing insight into archaeology

Ötzi the Iceman is modern nicknames of a well-preserved natural mumm of a man from about 3300 BC found in 1991 in the Schnalstal glacier in the Ötztal Alps, near Hauslabjoch on the border between Austria and Italy. Why he died was a mystery for a long time, till the time we radiologists intervened. Initially it had been believed that Ötzi died from exposure during a winter storm. Later it was speculated that Ötzi had been a victim of a ritual sacrifice. In 2001 X-rays and a CT scan revealed that Ötzi had an arrowhead lodged in one shoulder when he died and a matching small tear on his coat.

In the article originally published in the Journal of Archaeological Science,
“lesion of a close-to-the-shoulder artery has been found… lesion of the dorsal wall of the left subclavian artery, the artery underneath the clavicle, caused by an earlier, already-detected arrowhead that remains in the back. In addition, a large haematoma could be visualized in the surrounding tissue. By incorporating historic as well as modern data on the survival ship of such a severe lesion, the scientists concluded that the Iceman died within a short time due to this lesion.”

Images and details here-
Anthropology.net

Avascular Necrosis of the Hip

MRI appearance
T1-weighted images: A peripheral band of low signal is present in the superior portion of the femoral head outlining a central area of bone marrow.
T2-weighted images: The inner border of the peripheral band demonstrates high signal. This is termed the double-line sign and is pathognomonic for AVN.

Classification of the AVN lesion
Class A: Central osteonecrotic focus signal analogous to that of fat.
Class B: Central osteonecrotic focus signal analogous to that of blood.
Class C: Central osteonecrotic focus signal analogous to that of fluid.
Class D: Central osteonecrotic focus signal analogous to that of fibrous tissue

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

Pneumothorax after Central Line Placement

Pneumothorax (for central lines placed in the chest) is a known complication of Central line placement and doctors routinely order a chest X-ray (CXR) after insertion of a subclavian or internal jugular line. The incidence is thought to be higher with subclavian vein catheterization. For experienced clinicians, the incidence of pneumothorax is about 1%. Note the abnormally placed central line extending upwards from subclavian vein into internal jugular vein along with pneumothorax.

Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences

Basilar Artery Dissection-MRA

"Vertebral artery dissection occurs in younger people around 40 yrs(females more in vertebrals where as males more often affected in basilar dissections). Cervicocerebral artery dissection accounts for 2% of ischaemic strokes but in younger than 45 yrs it accounts for 10%, extracranial dissection is 80 to 90% cases , supraclinoid ICA and MCA stem have predilection for dissection.

An expanding hematoma in the vessel wall is the root lesion in arterial dissection in vertebral artery. Evolution: it can heal spontaneously or it can be subintimal and produce partial or complete block and also low flow state which can produce thrombus leading to shower of emboli as seen in this 45 yr old male with no history of trauma or it can be subadventitial which leads to pseudo-aneurysm formation

Crescent shaped thrombus and double lumen sign with intimal flap identification on MR are highly specific to dissection. Because of flow abnormalities, it is easier to appreciate intracranial dissections on T2 w images"

Reference- Z Han et al China. In Hongkong med journal Vol 13 No 2, Apr 2007

Case by Dr MGK Murthy, Sr Consultant Radiologist
&
Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences

Radiologists Having All The Fun

This one is good and a unique application of Apple iPhone called as iFluoroscope on Not totally Rad here-Radiology party Tricks. Really funny one loved the way everybody gets tricked by this.

PACS for medical students

In May 2008 AIIMS examination this question was asked so read on-
In medical imaging, picture archiving and communication systems (PACS) are computers or networks dedicated to the storage, retrieval, distribution and presentation of images. The medical images are stored in an independent format. The most common format for image storage is DICOM (Digital Imaging and Communications in Medicine).Types of imagesMost PACSs handle images from various medical imaging instruments, including ultrasound, magnetic resonance, PET, computed tomography, endoscopy, mammograms, etcUsesPACS replaces hard-copy based means of managing medical images, such as film archives. It expands on the possibilities of such conventional systems by providing capabilities of off-site viewing and reporting (distance education, telediagnosis). Additionally, it enables practitioners at various physical locations to access the same information simultaneously, (teleradiology). With the decreasing price of digital storage, PACSs provide a growing cost and space advantage over film archives. A PACS allows to store volumic exams and to reconstruct 3D images.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

Pancreatic Hypoplasia-CT

Pancreatic Agenesis and HypoplasiaTotal agenesis of the pancreas is extremely rare and is incompatible with life. It is associated with other malformations such as gallbladder aplasia, polysplenia, and fetal growth retardation. Hypoplasia (partial agenesis) results from the absence of the ventral or dorsal anlage. Absence of the dorsal anlage is visualized as a short or truncated pancreas and can be partial or complete. It may be seen as a solitary finding or in association with heterotaxia syndromes. Partial agenesis of the dorsal pancreas is relatively more common than agenesis of the ventral portion, but complete agenesis of the dorsal pancreas is extremely rare. This patient had partial agenesis or hypoplasia of dorsal pancreas and presented with symptoms of diabetes mellitus.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences

Is the Term "Outsourcing" appropiate?

Came acroos this excellent article followed by discussions from various people in the Fersht's Outsourcing Blog. Fersht's says in his blog-"Having worked on a large number of "O" initiatives with enterprises over the last few years, the term outsourcing has given me nothing but problems. The minute the "O" word is uttered, staff get defensive, passions get stirred, resistance occurs..." Do read the complete article.

Teleradiology Providers

Adobe Photoshop for Medical Imaging

Latest version of its popular Photoshop image-manipulation software is released—Photoshop CS3 Extended. Photoshop CS3 E contains a variety of new capabilities, including tools designed to meet the needs of medical imaging professionals.

Details and Hat Tip-PACS Digest

Multicystic Dysplastic Kidney

The metanephric blastema forms the proximal components of the nephron from the glomerulus to the distal convoluted tubule. The ureteric bud arises from the Wolffian (mesonephric) duct and forms the distal components of the nephron, including the collecting ducts, calyces, and pelvis. The metanephric blastema is generally believed to differentiate into the renal parenchyma under the influence of the ampulla of the ureter. The ureteral bud begins its ampullary branching in the first 8-10 weeks of fetal life. MCDK results when the terminal portions of the first few ampullary divisions enlargeeteric bud. MCDK results from an abnormal induction of the metanephric blastema by the ureteral bud. Most cases of unilateral MCDK undergo spontaneous involution. whether involutin of cysts leads to renal parenchymal involutin is not clear. Large kidney with MCDK is not associated with contralateral urinary abnormalities, whereas small kidney with MCDK is associated with contralateral urinary abnormalities and with other congenital anomalies.

Case by Dr MGK Murthy,Sr Consultant Radiologist

&

Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

Submandibular Space Lipoma

Lipomas in the submandibular region are relatively rare. We describe a case of a lipoma in the submandibular region. The CT value of the tumor was -103HU suggesting lipomatous lesions. The tumor was extra-orally resected. The histopathological diagnosis was lipoma.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences

Aneurysmal Bone Cyst of Neural Arch

Primary tumors of the vertebrae are rare in infancy and childhood. An aneurysmal bone cyst is a rare, expanding benign lesion that appears most commonly in children and young adults, but can occur later in life. When the cyst appears in the spine, the neural arch is the most frequently involved portion of the vertebrae, although other parts of the body can occasionally be affected. On radiographic examination, the lesion usually appears as an expanding, lytic process, surrounded by a thin cortical shell. In our case, findings from both CT and MRI were suggestive of aneurysmal bone cyst.

Case by Dr MGK Murthy,Sr Consultant Radiologist
&
Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences

Gray Matter Heterotopia

This is a 21 year old female presenting with history of seizure. MRI shows subependymal heterotopic band like gray matter heterotopia lining the lateral ventricles seen isointense to the gray matter on all sequences. She was apparently normal before this episode of seizure.

Gray matter heterotopia are common malformations of cortical development. From a clinical perspective, affected patients are best divided into three groups: subependymal, subcortical, and band heterotopia (also called double cortex). Symptomatic women with subependymal heterotopia typically present with partial epilepsy during the second decade of life; development and neurologic examinations up to that point are typically normal. Symptoms in men with subependymal heterotopia vary, depending on whether they have the X-linked or autosomal form. Nearly all affected patients that come to medical attention have epilepsy, with partial complex and atypical absence epilepsy being the most common syndromes.

Reference and detailed review in Neurology 2000;55:1603-1608 by Barkovich and Kuzniecky.

Case by-Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Fibrous Dysplasia-MRI

Fibrous dysplasia - Fibrous dysplasia (FD) is a benign condition associated with normal bone marrow replacement by proliferative fibro-osseous tissue with varied quantities of stroma and bone. FD may affect only one (monostotic form) or multiple bones (polyostotic form). It is a relatively common disease and is most frequent in teenagers and young adults.
Affected bones will be expanded and strongly enhance after intravenous contrast medium injection. A noncontrasted CT scan with bone algorithm will show the classic "ground glass" appearance of fibrous dysplasia. MRI shows homogeneous low signal on T1WI, unless there is pathological fracture. On T2WI, the lesion is heterogeneous depending on the amount of fibro-osseous tissue, cellularity, cystic alterations, hemorrhage and cartilaginous tissue. The lesions usually have well defined borders. All the sequences show a hypointense halo that corresponds to sclerotic margins. MRI is the modality of choice to demonstrate the internal structures of the lesion and evaluate disease extension, especially in cases due for surgical treatment.

Case by-Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

Lacunar skull (Luckenschaedel)

Lacunar skull (Luckenschaedel) a/k/a: craniolacunia
Mesenchymal dysplasia
may appear normal after several yrs

Associated with:
Chiari malformation (almost always)
myelomeningocele
encephalocele

This is case of lacunar skull with associated craniosynostosis.

Case by-Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)
And
Dr Jaya Shankar , MD
Consultant Radiologist ,VIMHANS

Carotid Body Tumour-MRI & MRA

"The carotid body is derived from both mesodermal elements of the third branchial arch and neural elements originating from the neural crest ectoderm. It is a small ovoid or irregular mass bilaterally situated on the bifurcation of the common carotid artery, and functions as a chemoreceptor sensitive to changes in arterial pO2, pCO2 and pH, which induces reflex changes in vasomotor activity and respiration. Carotid body tumour (paraganglioma) is both unusual and highly vascular, arising from the paraganglion cells of the carotid body.The presence of a lyre-like image (an enhancing high vascular oval mass widening the angle of the bifurcation with displacement of the internal and external carotid arteries) is essentially pathognomonic of a carotid body tumour . The blood supply is primarily from the bifurcation and external carotid artery, but contribution from the internal carotid artery, vertebral artery, and thyrocervical trunk can occur. Knowledge of the sources of blood supply aids in exposure and hemostasis."

Further reading and reference-
World Journal of Surgical Oncology 2005, 3:10
doi:10.1186/1477-7819-3-10

Case by-Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

And

Dr Jaya Shankar , MD

Consultant Radiologist ,VIMHANS

Legal issues of Telemedicine

"Doctors have been practicing some form of telemedicine since before the invention of the telephone. And while the communication technology has evolved—doctors can now conduct a video consultation with colleagues in the next county or on the next continent—laws governing these events have not kept up. There is no universal law of telemedicine, and different states take significantly different approaches to regulating it. Consequently, jumping into telemedicine without first analyzing a few critical legal issues could have serious consequences. "

Full detialed article appeared on April 30, 2008 in HHN Magazine online site by David D. Storey

Quote of the Day

Interesting quote-

Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.

By-Thomas Szasz

This is a picture from "Leptus Magna", Roman remains which i visited during my visit to Tripoli and Misurata as a visiting Professor.

Radiology Grand Rounds XXIII

Here is a case of Cannavan's Disease for the Radiology Grand Rounds submitted by Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds.

Canavan’s disease
Deficiency of N- acetylaspartate cyclase enzyme – Increase in NAA.

"Canavan disease demonstrates bilateral symmetric T2 white matter hyperintensity, including involvement of the subcortical arcuate fibers. This disease appears diffusely throughout the cerebral white matter, does not enhance at computed tomography (CT) or MR imaging, and demonstrates variable involvement of the basal ganglia and cerebellar white matter. For example, both Canavan disease and Alexander disease demonstrate macrocephaly with bilaterally symmetric increased T2 signal intensity of cerebral white matter and involvement of subcortical arcuate fibers. MR spectroscopy, however, has been shown to be a useful diagnostic tool in making this distinction. There is an accumulation of NAA in patients with Canavan disease because of a deficiency in the myelin synthesis pathway; thus, MR spectroscopy reveals a markedly elevated NAA peak. "

In other white matter diseases there is Axonolysis hence NAA decreases, Defective myelination leads to increased Choline and lactate is seen in the activer disease.

Further reading (Radiology 2006;241:310-324.)

Hope you enjoyed this edition of Radiology Grand Rounds submissions are requested for the next Radiology Grand Rounds posted every month last sunday. If you interested in hosting any of the future issues contact me at sumerdoc-AT-yahoo-DOT-com.

Case by-Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

MR Spectroscopy in Meningioma

MR spectroscopy may provide additional information in cases in which the differential diagnosis
of tumors by neuroimaging is difficult. Cho reflects membrane turnover, correlates with malignancy in astrocytic tumors, and forms high peaks in meningioma. The most common proton spectrum found in meningiomas is a high Cho peak with low or absent NAA and Cr and variable amounts of lactate. Most important, an unusually high ratio of Ala to Cr has been found in meningiomas because of the high Ala and low Cr content, and this is a relatively specific finding for meningioma. Alanine is seen as doublet centered at 1.47 ppm and inverts on the long-TE sequence.

Reference- AJNR Am J Neuroradiol 20:882–885, May 1999

Mesenchymal Hamartoma Shoulder-MRI

MR shows well defined heterogenous SOL in subacromial and superior aspect shoulder with no marrow oedema or joint involvemnt or rotator cuff involvement Smooth muscle hamartoma is an uncommon, usually congenital, cutaneous hyperplasia of the arrectores pilorum muscles. We report a case of this rare tumor in a 19-year-old man. The disease started several years ago as multiple small skin-colored papules that subsequently coalesced to form a large soft plaque on the back of the left shoulder. The diagnosis of acquired smooth muscle hamartoma was confirmed on histopathology. The patient was reassured about the benign nature of the lesion and was not advised any treatment.

Case by Dr MGK Murthy,Sr Consultant Radiologist

&

Dr.Sumer K Sethi, MD

Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)