Nephro-radiology Rounds

Our case of massive renal angiomyolipomas is featured on Pediatric Nephrology Site.

Nephrorad Case Files. Check out the site for many more updates in Pediatric Nephrology.

Small Airway Disease on Dynamic HRCT

Small airway disease is manifested by mosaic appearance on inspiratory film with areas of low attenuation and patchy ground glass haze. These low attenuation areas become more prominent on expiration indicating air trapping because of underlying small airway disease. This is a 40 year old female with tuberculosis.

Os styloideum (carpe bosse disease)

The os styloideum is an ununited bony protuberance, located on the dorsum of the wrist at the base of the second and third metacarpals. The association between dorsal wrist pain or fatigability and an os styloideum is known as carpal bossing (carpe bossu disease). There is an accessory ossicle between capitate and trapezoid with marrow edema in the ossicle and trapezoid. This may indicate a symptomatic os styloideum.

Second opinion by- Teleradiology Providers

Posterior reversible encephalopathy syndrome (PRES)

Characteristic imaging pattern in PRES is the presence of edema involving the white matter of the posterior portions of both cerebral hemispheres, especially the parieto-occipital regions, in a relatively symmetric pattern that spares the calcarine and paramedian parts of the occipital lobes. Recently, studies with diffusion-weighted sequenceshave shown increased apparent diffusion coefficients (ADCs) in the involved regions which suggests reversible vasogenic edema as an underlying pathophysiology. This is a 7 year old girl with classical MRI findings

Reported by Teleradiology Providers

DAMS Best for MD/MS/MCI Screening preparation

DAMS Best PG Entrance Coaching Institute
Contact : 25853434, 42433051, 9811217431, 9873314110
Visit- http://damsdelhi.com

Dear Doctor
At the outset we will introduce ourselves as the leaders in post graduate entrance business country wide. We understand that the students in the state have two main concerns one is the AIPG and other, probably the more important one is State Entrance. We have seen over the years there is some difference between the preparations for the two and there is some variance in the performance of candidates in these examinations. Some students despite not doing so well in the All India PG entrance exams excel in the state exam and vice versa.What is the difference between the two and how as a student should I approach these. In other words can any institute give me a step by step approach for my state pg exam? Let me introduce myself, I have been a Top ranker in AIPG, AIIMS, PGI examinations before and I have authored more than 10 books for PG entrance including the best selling Review of Radiology, which is a country wide best seller. I am the Director of DAMS, Delhi Academy of Medical Sciences which is by far the most consistent result giver in the last 10 yrs or so.Lets come back to the main issue once we have formed some trust that this not just another advertisement, it will change your idea of PG entrance examination and definitely make a change in the end result. Number one thing of importance to understand is the value of positive thinking. That sounds so basic, but we insist the first thing for any student of DAMS is think positive. I don’t want you to say anytime that you can’t do it. That’s the step number-1. Then for the last AIPG, the make or break idea was to read AIIMS Nov 2009 solutions. Anyone who didn’t do the November AIIMS thoroughly is bound to loose out on the AIPG. In that aspect DAMS lead by me and with question recall by this years topper DAMS Student has released an extensive review of the November AIIMS. We bet anyone who doesn’t read our review before AIPG is at a loss. Well you may say we are marketing but the book has gone out of print three times in last two weeks!!This AIPG 2009 was a peculiar paper with say 50 almost unsolvable questions but it would not be preposterous to say that DAMS students had an edge because we not only do repeat questions our teachers predict the pattern also. Some of the questions we must admit were tough like IDEAS, STEPS and amifostine etc that makes us enjoy the challenge of predicting even more and our teachers are spurred to make more predictions in the coming years.Other important thing to do for AIPG is repeat questions and almost all institutes ask you to do this but do they actually make you remember? we at DAMS in addition to our All India Grand test run an exclusive Bounce Back Series popularly called as BB series with repeat questions from various exams and we make you do them again and again. Our Grand Tests have an exclusive feature of new questions we don’t copy and paste from USMLE questions banks, we make new questions. The joke in the PG entrance business is that only DAMS and AIIMS make new questions? We provide authentic references to Grand test which is not so in any other coaching and we give Harrison based supplement with every GT. We understand what you need and we give it. In our classroom series we have the best faculty drawn from AIIMS, MAMC, LHMC and other major colleges. Most of them are popular authors and extremely high yielding teachers. With us being the pioneers in the Regular course and Test and discussion concept, we are a natural choice for students preparing for PG entrance.For state entrance again we recommend doing of repeat questions, and factual questions. On the other hand AIPG and AIIMS we have more number of newer questions and lots of conceptual questions. So the idea is Conceptual questions in AIPG versus Factual in state PG examinations. Once again emphasizing the importance of Bounce Back Series, Exclusive DAMS product. Our notes are based on standard books. For example my students sometimes ask me what books do we need to read these Mudit Khanna and AA quote all the high end books then what? We say supplement your standard books with our notes our notes are based on or are condensed version of the highest order books. Like our medicine is based on Harrison, Surgery is combination from Schwartz, Sabsiton and Bellie, Obs from Williams and Pediatrics from Nelson. Hence our students have the extra edge of the ready made food or The Fast Food.Our classroom centres are running in Delhi, Mumbai, Pune, Nagpur, Chandigarh, Jaipur, Jodhpur, Indore, Bhopal, Baroda, Ahmedabad, Lucknow, Hyderabad with more than 40 GT centres across the countries. We are also now lauching Subject wise Test and Explanation Series country wide, with detailed questions and answers to all subjects. If you cant join our famous class room series join us for “The Ultimate Test Series Combo”.

Dr Sumer Sethi, MD Radiology
• Director DAMS and topper in AIPG, AIIMS and PGI previously.
• Author of review of radiology and many more books for PG entrance.
• Faculty of national and international fame
About the Director DAMS
Sumer Sethi, MD, is Director of Delhi Academy of Medical Sciences Pvt Ltd, and is a very popular teacher, author and motivator. He himself was a topper in previous AIIMS, AIPG and PGI examinations. He also leads Teleradiology ProvidersTM (Prime Telerad Providers Pvt Ltd, http://teleradproviders.com), a company that provides teleradiology services to India and abroad. Dr. Sethi is a senior consulting radiologist at VIMHANS, Delhi. He is a visiting international faculty member of Tripoli Universities, Libya. He has also been an invited faculty member at various conferences, including Teleradiology in IRIA, Hospital Build Middle East, and Congress of the Brain Tumor Radiology in Neuro-oncology Society. Dr. Sethi is Editor-in-Chief of Internet Journal of Radiology. He has a keen interest in Web 2.0 technologies and in maintaining his radiology blog, Sumer's Radiology Site (http://sumerdoc.blogspot.com), which has been featured in multiple international journals. To date, Dr. Sethi is the author of approximately 50 publications, and the fourth edition of his book Review of Radiology is a best-seller among medical students.

Possible Trigeminal Neuritis-MRI

This patient presents with relatively recent onset of right sided hemifacial pain. There is altered signal intensity along with enhancement in the root entry zone of the right Vth nerve and the nerve root. Possibilities are Trigeminal neuritis. Less likely is the possiblity of nerve root origin mitotic etiology. Follow was suggested.

B12 Deficiency- Cord & Brain Involvement

There is associated white matter involvement along with posterior column involvement which is relatively less commonly reported in B12 deficiency. This is 51 year old male who is non alcoholic, with possibly dietary deficiency. Reported by- Teleradiology Providers

CT image contest-Facebook Site

Sumer's Radiology Site gets featured in the Facebook page of the

International CT Image Contest

website -http://www.siemens.com/image-contest

Musculoskeletal Radiology Hands On Workshop in Malaysia

The Secretariat
International Intensive Hands-on Musculoskeletal MRI and Ultrasound Course
c/o UNITED MEDICA SDN BHD 5/F, Tower 2, Wisma MCIS Zurich, Jalan Barat, 46200 Petaling Jaya, Selangor Darul
Ehsan, Malaysia.

For further information, please contact Mr Vinod / Ms Sara at
email: enquiry.my@asia.cmpmedica.com
Tel: +603 7954 2910 fax: +603 7958 7853.

Low Dose CT Image Contest-Siemens

Reducing the radiation dose while maintaining excellent image quality is central in CT these days. As such, Siemens has initiated the first International CT Image Contest where you are invited to sendin your images. Compete with colleagues from all over the world to see who has achieved the best image quality at the lowest possible radiation dose! A highly prominent international jury will be evaluating the submitted entries.

Visit the International CT Image Contest website -
http://www.siemens.com/image-contest

Sturge Weber Syndrome With Arachnoid Cyst-CT

Sturge-Weber syndrome is one of the neurocutaneous syndromes. It is a rare, nonfamiliar disease that is characterized by facial port-wine stain, leptomeningeal angiomatosis, choroidal angioma, buphthalmos, intracranial calcification, cerebral atrophy, mental retardation, glaucoma, seizures and hemiparesis.

This is 3-year-old boy who had seizures with CT findings consistent with Sturge-Weber syndrome who had in addition temporal arachnoid cyst which is an uncommonly reported association.

ADENOMYOMATOSIS GALL BLADDER-MRCP

Adenomyomatosis is characterized by hyperplastic muscular wall thickening, mucosal overgrowth, and intramural diverticula, crypts or sinus tracts - so called Rokitansky Aschoff sinusus. There are 3 pathologic types – Diffuse, segmental and localized.
Our case seems to be of Localized and segmental variety as it is specifically involving the fundal region and also dividing the lumen into separate interconnected compartments.
T2 weighted coronal, axial and MR cholangiography demonstrate these intramural cystic spaces which appears as bright, high signal intensity areas in the thickened gall bladder wall – the “pearl necklace” sign. Also septated compartments due to focal stricture are well visualized.

Rheumatoid Arthritis- Craniovertebral Involvement

The spondylitis of RA is distinctive in that it has predilection for the cervical region. Osteoporosis, disc narrowing and end-plate irregularity are seen with only minimal reactive new bone formation in the upper cervical vertebrae in contrast to the osteoarthritis which involves lower cervical vertebrae.
Facet joint erosions may lead to subluxations at multiple levels in cervical spine giving STEP-LADDER appearance. Atlantoaxial joint subluxation is seen in 30% of cases especially in chronic disease due to involvement of transverse ligament with or without erosion of odontoid. (Separation between anterior border of odontoid and posterior surface of the anterior arch of atlas in flexion of more than 2.5 mm in adults or 4mm in children is considered diagnostic of AAD). The eroded odontoid at times may fracture.
In our case. T1 and T2 weighted images reveal pannus which is hypointense on T1 and T2 with erosion of odontoid peg. Altered signal intensity is also seen in cord at this level due to ischemia/oedema. Mild compression of thecal sac is also noted.

Reported by- Teleradiology Providers

ANEURYSMAL BONE CYST

This is a case of 13 yr old boy who came to us with the complaints of pain and swelling just above the shoulder. Plain skiagram was taken and showed large, well –defined expansile lytic lesion with thinned out peripheral cortex at lateral end of clavicle. Few thin septae were also noted within it. The aspirate contained blood. Ultrasound showed a cystic lesion with few echogenic areas within the cystic lesion. On CT, well-defined rounded,epiphysio-metaphyseal expansile, lytic lesion was seen with thinned out cortex was noted at lateral end of clavicle. Sone fluid – fluid levels were also noted. No periosteal reaction was evident.
MRI revealed an isointense, heterogenous lesion on T1WI and hyperintense on T2. Margin of tumour as line of decreased signal intensity is better delineated on T2. Multiple fluid levels are noted. On GRE sequences, few susceptibility artefacts were noted suggestive of blood.
Provisional diagnosis : Aneurysmal bone cyst.

Intramuscular hematomas -Rare Case

This is 25 year old male who joined gymnasium and developed swelling/pain overlying the shoulder girdle. On further investigation bleeding diathesis was discovered. Intramuscular hematomas/contusions were suspected. Later on he developed fever and pus was aspirated suggesting infected hematomas.

Case reported by-Teleradiology Providers

CME Programme in Rewari District

CME PROGRAMME
Dear Doctor
It is with great pleasure that we cordially invite you to CME programme on 20th December 2009 at our newly opened state of the art diagnostic centre in Mirpur Institute of Medical Sciences. The aim of the CME is to create awareness about current advances and application of CT scan. CT scan has revolutionised the diagnostic field in last century and advances in the technology have enabled radiologists world wide to make more and more accurate diagnosis. We have installed a state of art 3D subsecond high resolution CT scanner in the institute and have the services of Radiologists who have been trained in leading college of Delhi.
Programme for the Academic Session
6.00pm WELCOME OF THE GUESTS BY PADAMSHRI PROF SS YADAV

6.15pm INAUGRATION OF MIRPUR DIAGNSOTICS BY HONOURABLE PROF SM TULI (VIMHANS)

6.30 pm ADDRESS BY IMA PRESIDENT, REWARI, DR PAWAN GOEL

6.45pm CT SCAN-WHAT SHOULD A GENERAL PRACTITIONER KNOW?
Dr Sumer Sethi, MD (Gold Medalist)
Sr Consultant Radiologist
Editor In Chief, Internet Journal of Radiology

7.00pm SOME INTERESTING CT CASES
Dr Jaya Shankar, MD
Sr Consultant Radiologist
Head of Department

7.30pm DINNER

Looking forward to seeing you,
Sincerely,
Dr Sumer Sethi
Programme Convenor

Prostate-MRI

Prostatic carcinoma is the most common malignancy affecting males older than 50 yrs. The combination of serum PSA levels, clinical TNM staging and histopathologic Gleason scoring dictates the course of treatment. Nodal disease is classified as local lymph node involvement within the true pelvis, whereas metastatic lymph node disease is involvement outside the true pelvis. Usually internal iliac and obturator lymph nodes are involved first.
International Staging System for Prostate Cance
I (T1, N0, M0)
Organ confined, clinically and radiologically inapparent.
II (T2, N0, M0)
Organ confined, clinically or radiologically apparent
T2A : ≤ 50 % of single lobe involved.
T2B : ≥ 50% of single lobe involved.
T2C : both lobes involved.
III (T3, N0, M0)
Extracapsular extension or seminal vesicle invasion.
T3A : extracapsular extension.
T3B : seminal vesicle invasion.
IV (N1-2)
Local or regional adenopathy.
N1: microscopic nodal metastases.
N2 : macroscopic nodal metastases.
V (T4 or N3 or M1-2)
Distant metastases.
T4 : bladder, external sphincter or rectal invasion.
N3 : extraregional nodal metastases
M1 : elevated alkaline phosphatase elevation.
M2 : distant visceral or bony metastases

CT is not very reliable in determining tumour extension through the prostate capsule but in determining abdominal and pelvic lymph nodes involvement. On MRI, T1WI, the homogeneity of prostate can make tumour detection difficult. The normal peripheral zone T2 hyperintensity is replaced with low signal from the tumour. Seminal vesical involvement is also discernible on MRI with replacement of normally T2 hyperintense tumour with hypointense tumour.

Japanese Encephalitis

This is case of 5 yr old male who came to us with a history of high grade fever, headache, impaired consciousness and fever.
Initial brain CT revealed :
Bilateral basal ganglia hypodensities and asymmetric bilateral (L>R) thalamic hypodensity.
Patient was suggested MRI brain at our centre. The MR imaging demonstrated bilateral caudate nucleus hyperintensities on Axial T2WI, Fluid Attenuation Inversion Recovery Sequence (FLAIR). Aymmetric hyperintensities were also noted in bilateral thalamic region (L>R). Small hyperintense foci in posterior pons , midbrain and middle cerebellar peduncle were also seen on FLAIR sequences. Diffusion-weighted images showed diffusion restriction in bilateral gangliocapsular regions and thalamic region bilaterally (L>R).
Provisional Diagnosis – Japanese Encephalitis.
• Special predilection to affect subcortical gray matter such as thalamus, basal ganglia and substantia nigra.
• Less frequently cerebellum, pons, cerebral white matter and cortex are involved.
• Bilateral thalamic involvement – most frequent and characteristic finding.
• On MRI, hyperintense lesions on T2WI, FLAIR and hypointense on T1WI are classical.
• Haemorrhagic transformation not uncommon and presents as hyperintense lesions on T1.
• No or minimal enhancement on contrast study.
• Diffusion reveal more and early lesions
• Acute – cytotoxic edema – restricted diffusion
• Subacute – proportion of restricted diffusion decreases.
• Chronic – necrosis & demyelination – hypointensity on diffusion.