Saturday, November 28, 2009

Empty Sella and CSF Rhinorrhea-MRI & CT

Spontaneous cerebrospinal rhinorrhea is a rare clinical condition. More commonly it develops due to cerebral tumors or hydrocephalus; it is seldom seen in association with empty sella syndrome. This is a 40 yr old female with spontaneous CSF leak. MRI images reveal a flattened thinned out pituitary gland and defect in the sellar floor on coronal CT scan images. Contrast MRI images are provided.

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Friday, November 27, 2009

Significance of DWI hyperintensity in splenium

This is a case of 38 yr old female who presented to us with a history of convulsions. MR imaging brain was performed and a small focus of splenium hyperintensity is noted on diffusion weighted and slightly hyperintense on FLAIR images.
Focal splenial hyperintensity has been reported in patients with clinically mild encephalitis/encephalopathy, epilepsy, in association with antiepileptic drug, acute cerebellitis, and stroke-like episodes. In a study by Bulakbasi et al, AJNR 27: 1983-86, transient lesion of splenium of corpus callosum (SCC) is a significant but nonspecific finding. It is probably due to inflammatory changes of the splenium and may be only detectable change in patients with good prognosis, indicating a clinically mild form of encephalitis/encephalopathy. Clinically all patients recover on days 4-9.


The incidence of hemorrhage in metastatic neoplasms is highest in melanoma, hypernephroma, bronchogenic carcinoma, and choriocarcinoma. Other metastatic tumours that bleed are breast and thyroid metastasis. Of the primary intracranial neoplasms, hemorrhage occurs most frequently in relation to pituitary neoplasms. Other primary tumors that have been reported to bleed include glioblastoma multiforme, lower-grade gliomas, ependymomas, choroid plexus papillomas, sarcomas, and meningiomas.
Our patient is 55 yr old male and shows large ring enhancing, slightly hyperintense lesions in parietal and frontal region. Lesions are hyperintense on both T1 and T2 weighted images and show ring enhancement on contrast study. This appearance is very suggestive of secondaries from renal cell carcinoma.
Second Opinion by -Teleradiology Providers

Thursday, November 26, 2009


Sacrococcygeal teratoma is the most common tumour of the fetus and neonate, with a reported incidence of 1 in 35,000-40,000. This neoplasm is composed of tissues from all three germ layers. The extent of sacrococcygeal teratoma was classified according to the American Academy of Pediatrics.
Type 1 – Primarily external and has only a mimimal presacral component.
Type 2 – Primarily external but has a significant intrapelvic portion.
Type 3 – Partially external but is predominantly intrapelvic with abdominal extension.
Type 4 – Located entirely within the pelvis and abdomen.
Associated complications :
· Intrapelvic mass effect- bladder displacement, hydronephrosis, large tortuous ureters and urinary ascites.
· Dysplastic changes in kidney.
· Severe oligohydoamnios.
· Congenital hip dislocation.
On MRI the content of teratomas can be well assessed. They may be solid, cystic or mixed with areas of necrosis, haemorrhage, and calcification. Predominantly solid masses have a poorer prognosis than cystic avascular masses.
Case Submitted by Dr Sangeeta Aneja, MD, Associate Professor & Head, Department of Radiodiagnosis, L.L.R.M. Medical College, Meerut.

Monday, November 23, 2009

Cortical Dysplasia-MRI

Focal cortical dysplasia is a common cause of intractable epilepsy in children and is a frequent cause of epilepsy in adults. All forms of focal cortical dysplasia lead to disorganization of the normal structure of the cerebral cortex. This is a 9year old girl presented with refractory complex partial seizures.

Orbital Lymphoma-CT

This is 68 year old man with bilateral propotosis and lymphadenopathy. CT images are characterstic of orbital lymphoma.
Second Opinion- Teleradiology Providers

Tuberous Sclerosis

These are the follow up images done for the case of bilateral Renal angiomyolipoma presented in this blog few days back. CT brain reveals characterstic subependymal nodules and CT chest shows lung cysts. These are classical findings of tuberous sclerosis.

Sunday, November 22, 2009


Original Articles
Radiofrequency denervation of the sacroiliac joint- experiences in a series of 30 patients - J. Gossner & B. Kietzmann
CT Evaluation Of Parapharyngeal Masses: Pictorial Assay - K. Rajagopal, A. Ramesh, S. Sreepathi & C. Shetty
Case Reports
Cranial and Spinal involvement in Neurofibromatosis type 2 - S. Aneja, R. Sangal, M. Murthy & S. Sethi
Periadrenal Bronchogenic Cyst with Intracystic Milk of Calcium - S. Park & S. Hwang
Hypoplastic Vertebral Artery as a predisposing cause for dissection - N. Mahmood, C. Ballal, V. Hegde & H. Suresh
Vein of Galen Malformation - A. Singh, M. D’Alessandro, S. Kao & Y. Sato
Steroid-induced Extensive Bilateral Femoral and Tibial Bone Infarcts in a Patient with Ulcerative Colitis - I. Chernev & K. Yan
Longitudinal stress fracture of tibia – a rare diagnosis - I. Gupta, S. Sethi & J. Shankar
Sunburn appearance on MRI - T. Bartalena, M. Rinaldi, E. Rimondi, G. Rossi & D. Bartalena
Magnetic Resonance Imaging findings in a case of intramedullary teratoma of conus medullaris - G. Chand, V. Chowdhury & S. Singh
Splenic torsion, an unusual cause of acute abdominal pain. - M. Murthy, S. Rajani & K. Bhagheerathi
Pneumatosis intestinalis with superior mesenteric and hepatic portal venous gas in sigmoid colonic cancer: CT findings. - G. Di Salvo, G. Zotto, P. Spillare, G. Schittullo & A. Bruscagnin
Healthcare Blogging-A review - S. Sethi

Sumer's Blog now on Medscape-Radiology

Thanks to Lakhs of visitors and readers who benefited from this site over last 5 years now, i am now also blogging with Medscape at my blog called as "Radiology 2.0". Before giving the diagnosis on any film look at the image from a distance, take a bird's eye view and then concentrate on the findings. This is what will make a radiologist's interpretation of films superior to other clinical counterparts.

Saturday, November 21, 2009

Hydatid Cyst-CT

Two cases of hydatid cysts in lung and exophytic lesion in the left lobe of liver diagnosed in last two days on CT.

Bilateral Massive Renal Angiomyolipomatosis-CT

Renal angiomyolipoma is a rare benign neoplasm composed of varying amounts of mature adipose tissue, smooth muscle, and blood vessels. Angiomyolipomas, particularly when multiple or bilateral, suggest the diagnosis of tuberous sclerosis.
Second Opinion by Teleradiology Providers


Note the linear and rounded cut sections of worm on CT abdomen. Common in our side of the world.


X-linked recessive disorder which occurs due to deficiency of peroxisomal enzyme Acyl Coa Synthetase. It is a white matter demyelination involving occipital lobes and splenium in bilateral and symmetric pattern (demyelination moves from centre to periphery). Males between 3-10 yrs of age are affected. Auditory pathways are involved commonly with sparing of subcortical white matter. On NECT, large symmetric low density lesion are seen in peritrigonal parieti-occipital white matter. Enhancement is noted in advancing rim surrounded with peripheral nonenhancing edematous zone. Calcifications may be seen. On MRI, central necrotic zone appears low on T1, high on T2. Intermediate zone enhances following contrast administration. Peripheral zone appears hypointense on T1 and high on T2. In one study, published in AJNR Vol 18, Issue 1, medullary and pontine corticospinal tract involvement was present in eight out of ten patients with ALD. So, pontomedullary corticospinal tract involvement is a common finding in ALD and is unusual in other leukodystrophy. On diffusion weighted images, advancing rim of demyelination shows restricted diffusion and appears as bright signal which is very well documented in our case.

Thursday, November 19, 2009

Tension Pneumocephalus-CT-Peaking Sign

Pneumocephalus can occur in iatrogenic and noniatrogenic disruption of the skull base or calvaria. It is important to differentiate tension from non tension pneumcephalus. A “peaking sign” of bilateral compression of the frontal lobes by subdural air collections without the characteristic separation of the frontal lobes has been linked to tension pneumocephalus as seen in the current case of post operative subdural hematoma. A more characteristic sign of tension pneumocephalus is Mount fuji sign in which bilateral subdural hypoattenuating collections cause compression and separation of the frontal lobes.

Wednesday, November 18, 2009

Tuesday, November 17, 2009

Rare Posterior Epidural Disk Sequestration-MRI

This is a 40 year old male with sudden onset paraparesis. Posterior and left lateral epidural lesion in the L2-L3 showing hypointense signal on T1 weighted image and hyperintense signal on T2 weighted image along with peripheral rim enhancement on post gadolinium images. This may suggest an extruded disc with left lateral and cranial migration along with posterior epidural sequestration, which is although rare but reported. Other possibility is an infective posterior epidural collection.
Disk sequestration can be defined as a herniated disk with perforation of the fibrous ring (or outermost annulus fibrosus) and posterior longitudinal ligament with migration of the disk fragment to the epidural space. The most common path of disk fragment migration is a posterior and posterolateral direction to the anterior epidural space, which is delimited by the attachment of the posterior longitudinal ligament and its associated “midline septum” and “lateral membranes.” Therefore, disk fragment migration usually occurs cranial, caudal, or lateral but seldom posterior to the anterior epidural space. Migration of a sequestrated disk fragment in this manner has been reported only rarely.
Second opinion by - Teleradiology Providers

Ectopic Thyroid-MRI

This is a 9 year old girl with midline neck swelling with a paramedian neck lesion anterior to the thyroid lamina with no obvious thyroid tissue in the pretracheal region. This may be consistent with n ectopic thyroid tissue. Thyroid scan was suggested.

Sacral Neural Tumour-MRI

This is 26 year old man with pain in the back and leg. There is evidence of minimally enhancing lesion in the sacral canal extending at the level of S1 and S2 levels predominately towards right appearing hypointense on T1 weighted image and inhomogenously hyperintense on T2 and fat sat T2 weighted images. There is evidence of extension of the lesion via the neural canals at S1/S2 levels more towards left with some expansion of the neural canal at this level. There is mild posterior scalloping of the posterior vertebral body at S1 level, however, there is no obvious bony erosion or osseous destruction at this level. Neurgenic origin tumour is likely. Nerve sheath tumours are slow growing tumours characteristically expanding the bony canals without significant bony erosion.On MRI, they are characteristically iso-intense to muscle on T1, heterogeneously hyperintense on T2 and show minimal contrast enhancement.

Saturday, November 14, 2009

New MRI Blog on the Block

Here is the link to another good addition to the Radiology Blogosphere called as MRI BLOG. Throughout this blog, assorted topics, mostly relating to the clinical applications of MRI are covered. You will be directed to other websites for the relevant MRI physics through hyperlinks where appropriate.


Our patient is a post operative status for lumbar disc disease and has pain in the left leg. Plain study was done and revealed likely L4/5 disc protrusion and L5/S1 central/right paracentral bulge, which could not explain the left sided persistent pain. Post gadolinium study was advised by our radiologists. On post gadolinium scans in addition to the residual/recurrent disc pathology, focal enhancing soft tissue was noted in the left lateral recess at L5/S1 level with impingement of the left sided traversing root (S1) and exiting nerve root (L5) at this level. This likely suggests scar tissue. As residual disc doesn’t enhance and epidural scar tissue enhances. Although, recurrent disc prolapse and epidural scar are not mutually exclusive diagnosis, they may be seen together as in our case but they need to be identified independently as the former may improve after re-exploration.


Sialoliths are commonly 1-10 mm in size, but giant sialoliths (greater than 3.5 cm) have been reported occasionally. Large sialoliths like the one seen in this case are relatively rare. The largest reported sialolith was 6-cm in length and had a dry weight of 50 grams. Generally, CT in this setting is best performed without administration of contrast material, since small opacified blood vessels may simulate small sialoliths. However, if an abscess or an inflammatory process is suspected, contrast may be administered after identifying the stone on unenhanced scans
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