Radiology Grand Rounds XXVIII

Here is a case of Carotid Artery Dissection 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

Carotid artery dissection is a significant cause of ischemic stroke in all age groups. Dissection of the internal carotid artery can occur intracranially or extracranially, with the latter being more frequent. Internal carotid artery dissection can be caused by major or minor trauma, or it can be spontaneous in which case genetic, familial, and/or heritable disorders are likely etiologies. MRA signs of dissection include irregular vessel margins, filling defects, extravasation of contrast, vascular occlusion, and caliber changes of the vessel. The latter sign is important and appreciated on axial views, but 3-dimensional reconstructed views allow study from any angle. This is 11yr old who presented with hemiplegia after head injury, also noted was beaded appearance of external carotids which suggest pre-existing fibromuscular dysplasia.

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)

Journal Submissions Invited

Radiology related scientific article submissions are invited in the following journals. Both of these are open access journals ensuring wider readership and offer free publication.

Internet Journal of Radiology

(For which I am the editor-in-chief)

This is a peer reviewed journal. Every published article has been reviewed by members of the editorial board and the editor-in-chief. All articles are archived by Internet Scientific Publications LLC and recognized by The Library of Congress Catalog of Publications

Journal of Radiology Case Reports

(In which i am the Section Editor for Neuroradiology)

This journal is dedicated solely to Radiology case reports. Case reports are usually "neglected" by large or traditional journals, mainly due to competition with "higher value" articles (review, original research etc.) for valuable space in the hardcopy version of the journal.

Regards

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology

Section Editor, Journal of Radiology Case Reports
Director, DAMS (Delhi Academy of Medical Sciences)

Bowel Carcinoid-MRI

Carcinoids from 2% of all gastrointestinal tumors and are the second most common small-bowel malignancy . they belong to a category of tumors called apudomas (amine precursor uptake and decarboxylation tumors) because they arise from endocrine amine precursor uptake and decarboxylation cells that can be found throughout the gastrointestinal tract and in other organs such as the pancreas and the lung. The tumor arises in the wall of the bowel as a submucosal mass that may result in scarring and kinking of the surface. Tumours originating from the foregut develop in the stomach, duodenum, and pancreas; those arising in the midgut develop in the small bowel, appendix, and right colon; and those arising from the hindgut develop in the transverse colon, left colon, or rectum. Small-bowel carcinoids are multiple in 29–41% of patients and will be associated with a second primary malignancy, usually in the gastrointestinal tract, in a significant percentage (29–53%) of patients most common in fifth or sixth decade with average of hormonal symptoms dating for 9 yrs arise from the Kulchitsky's cells in the crypts of Lieberkühn. Therefore, they grow as submucosal nodules, Visualization of the enhancing mural mass is improved if water is given as an oral contrast agent and if multiplanar reconstructions or 3D imaging software is used

CT could detect mesenteric infiltratin or liver metastases On early (arterial) phase imaging after the administration of an IV contrast agent, these metastases enhance brightly. On delayed imaging, these lesions may become isodense with the liver parenchyma.

On MRI the primary tumor appears as a discrete mass that enahnces with gadolinium. The appearance of unenhanced T1- and T2-weighted images varies. Most tumors are isointense to muscle on T1-weighted images and either hyperintense or isointense to muscle on T2-weighted images . During the portal venous phase, many lesions become isointense. In some cases, somatostatin receptor scintigraphy or biopsy may be necessary.

Case Submitted by Dr MGK Murthy, MD, Sr Consultant Radiology

Teleradiology Providers

Glioma MRS

This is classical MR spectroscopy findings of thalamic glioma.

Parameniscal cyst

Parameniscal cysts occur relatively infrequently. They are usually associated with horizontal cleavage tears. However, isolated cysts without meniscal pathology have also been reported.

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)

Extraspinal Ependymoma Recurrence

This is a postoperative follow up of Ependymoma and reveals enahncing mass in the right paraspinal region, suspected to be extraspinal recurrence in relation to the operative site.

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)

Cerebral Venous Sinus Thrombosis-MRV

Classical MRV picture of patient with venous sinus thrombosis presented with severe headache. CT done outside revealed high density in the region of the sagittal sinus.

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)

Check before loading your power point on the net!!

"William J. Weadock et al in Radiology 2008;249:285-293 discuss the likelihood of protected health information about patients being accidentally present in the power points loaded on the net. Must read."

Hippocampus-MR Spectroscopy

"According to King et al in Radiology 2008;249:242-250 there is significant metabolic heterogeneity along anteroposterior axis of healthy hippocampus. Mean NAA, creatine, and choline concentrations are higher in posterior hippocampus than anterior hippocampus. Thereby implying that consistent voxel placement are important for correct comparisons of both absolute metabolic levels and metabolite ratios."

Marchiafava Bignami Disease

In 1903 Marchiafava and Bignami, 2 Italian pathologists, described 3 men with alcoholism who died after having seizures and coma. In each patient, the middle two thirds of the corpus callosum were severely necrotic. Most patients are men with alcoholism. In some cases, the damage extends to areas such as the nearby subcortical white matter, the anterior commissure, or both. These are FLAIR, Sagittal and Diffusion weighted images of a 50 year old chronic alcoholic showing corpus callosal necrosis.

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)

Persistent Trigeminal Artery

Embryologic development of the basilar artery occurs along two axis systems: longitudinal fusion and axial fusion. Longitudinal fusion consists of midline fusion of paired ventral arteries and reflects the simplified pattern of arterial anatomy found in the spinal cord. Axial fusion consists of fusion of the distal basilar artery, which arises from the caudal division of the internal carotid artery, to the midbasilar agenesis to the posterior inferior cerebellar artery termination of the vertebral arteries. Persistent longitudinal nonfusion (or complete duplication) of the basilar artery is very rare, and persistent axial nonfusion is even rarer.The trigeminal artery appears embryologically at the 4-mm stage and involutes at the 7–12-mm stage. It arises from the basilar artery, unlike the posterior communicating artery, another of the carotid-basilar anastomosis, which arises from the posterior division of the internal carotid artery . A persistent trigeminal artery is estimated to occur in 0.1–0.2% of the population and, in most cases, is an incidental finding.

Case by Dr MGK Murthy, Sr Consultant Radiologist

Teleradiology Providers

Blogging for Health

For many people with serious illnesses, blogging offers a way to cope and share their stories. Joanna Moorhead in The Hindu discusses the benfits and risks involved with patients especially critically ill patients blogging about their health conditions.

Osteochondral Defect

Berndt and Harty radiographic classification of osteochondral lesions of the talus is as follows:
Stage I - Normal radiograph (subchondral compression fracture of the talus with no ligamentous sprain)

Stage II - Partially detached osteochondral fragment
Stage III - Complete, nondisplaced fracture remaining within the bony crater
Stage IV - Detached, loose osteochondral fragment



Anderson MRI classification of osteochondral lesions of the talus is as follows:
Stage I - Bone marrow edema (subchondral trabecular compression; radiograph results are negative with positive bone-scan findings)
Stage IIa - Subchondral cyst
Stage IIb - Incomplete separation of the osteochondral fragment
Stage III - Fluid around an undetached, undisplaced osteochondral fragment
Stage IV - Displaced osteochondral fragment

Case by Dr MGK Murthy, Sr Consultant Radiologist

Is raised choline on MRS a non-specific finding?

This is a biopsy proven case of tuberculomas which improved dramatically with ATT. However, MRS findings of raised choline and lipid-lactate peak was seen which is traditionally associated with neoplastic etiologies. Review of literature revealed an article in J. Magn. Reson. Imaging 2001;14:8-15. which also questioned specificity of this finding.

Vertebral artery compressing the brainstem

Medullary compression by the vertebral artery is a little known clinical entity in the medical literature. This is a patient with vague neurological complaints on the left side with ventrolateral medullary compression on the brainstem.

Further reading
Vertebral Artery Compression of the Medulla. By Sean I. Savitz, MD; Michael Ronthal, MD; Louis R. Caplan, MD. Arch Neurol. 2006;63:234-241

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)

Carcinoma Esophagus with tracheo-esophageal fistula

Here is a case of carcinoma esophagus with communication with the left mainstem bronchus. Consolidation is noted in the left lower lobe and area of contact with aorta is more than 90 degrees.

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)

Cerebral vascular malformations-MRI

Here are two cases seen in a day one showing cavernous angioma in the midbrain showing characteristic variegated "popcorn" appearance. The lesion shows signal supression on GRE because of blood products. Other case is a venous angioma with enhancing vascular channel, characteristic appearance is called as "medusa head appearance" in the left parietal region.

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)

Radiology Grandrounds-XXVII

Here is a case of unusual branchial cyst for the Radiology Grand Rounds submitted by Dr MGK Murthy and Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds

As per King’s criteria any cyst arising outside the midline of the neck and having lymphoepithelial characteristics should be regarded as a branchial cyst. Such cysts are found more commonly in females and usually occur in the 2nd or 3rd decade of life. They are most commonly found in the anterior triangle of the neck anterior to the upper third of the sternomastoid. A cyst occupying the posterior triangle is extremely rare. However these cysts have been reported to occur in all the regions of the neck, and even in the mediastinum and the abdomen. Hence they should be suspected in all the cystic swellings of the neck except the median ones. Ultrasonography and FNAB definitely help in arriving at the diagnosis and is especially recommended for patients in the older age group to rule out cystic secondaries from head and neck malignancies. On operation a unilocular cyst with clear fluid, deep to the investing fascia and without a connecting stalk more or less makes the diagnosis certain. The histological picture is classical and confirmatory.The ‘Branchial theory’ has now fallen into disfavour and the most appropriate hypothesis explaining the aetiology of these cysts is the "Lymph node inclusion theory" with he palatine tonsils as the most likely source of the enclosed epithelium.Complete surgical removal remains the only acceptable form of treatment. The first branchial cleft develops into the external auditory canal. The second, third, and fourth branchial clefts merge to form the sinus of His, which will normally become involuted. When a branchial cleft is not properly involuted, a branchial cleft cyst forms. Occasionally, both the branchial pouch and branchial cleft fail to become involuted, and a complete fistula forms between the pharynx and skin

First type-1- near tragus and type 2 near submandibular gland

Second Branchial-most common(95%) near outer border of strenocleidomasotid

Third-rare , posterior and enters larynx

Fourth-goes along reccurrent laryngeal nerve and can go anywhere in to mediastinum

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)

Kienbock's Disease

Plain films form the basis for staging and treatment of Kienböck disease. Lichtman's modification of Stahl's classification is most widely used and divides the disease into 5 stages, as follows:
Stage I - Normal radiograph
Stage II - Increased radiodensity of lunate with possible decrease of lunate height on radial side only
Stage IIIa - Lunate collapse, no scaphoid rotation
Stage IIIb - Lunate collapse, fixed scaphoid rotation
Stage IV - Degenerative changes around the lunate

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)

Epidermoid cyst of the pineal region

Epidermoid cysts constitute 0-2-1% of intracranial tumours and are generally found at the base of the brain. They rarely occur in the pineal region,in this case of a 17yr old girl, T1, T2, FLAIR and diffusion weighted images have been provided lesion was very bright on DWI and show no significant post gadolinium enhancement.

Teleradiology Providers