Tuesday, November 30, 2010

Bucket Handle Meniscal Tear-MRI

"The double PCL sign is associated with bucket-handle tears of the medial meniscus that occur in the presence of an intact anterior cruciate ligament (ACL). A bucket-handle tear is a longitudinal tear of a meniscus that results in a displaced but attached meniscal fragment. . The fragment may become displaced into the notch between the PCL and the medial tibial eminence in the midline, with the fragment orientated parallel to the PCL." Reference- November 2004 Radiology, 233, 503-504.

In our case of running injury this sign is well seen on the sagittal images and confirmed on coronal images.

Monday, November 29, 2010

Post Spinal Anesthesia Syrinx-MRI

This is 25 year old who was operated for appendicitis in the peripheral centre followed by right sided monoparesis. MRI revealed focal syrinx-myelomalacia at D11-L1 levels towards right side. Attempting to use higher lumbar intervertebral spaces for access to the subarachnoid space or epidural space may lead to inadvertent puncture of the lower dorsal spaces; this makes the procedure of spinal anesthesia at this level prone for spinal cord injury, with subsequent risk of development of myelomalacic syrinx in the conus and epiconus region of the spinal cord.

Pigmented Villonodular synovitis (PVNS)

30 yr old young lady with non specific pain knee joint.  MR shows well defined regular, intensely enhancing heterogenously altered signal intensity  lesion anterior to hoffas pad with presence of haemosiderin and  no bone involvement -  focal variety of PVNS is likely. Case submitted by Dr MGK Murthy and Dr Akshay Sahoo.

 Pigmented Villonodular synovitis (PVNS)

 Teaching points
Definition: benign proliferative disease of the synovium  affecting joints, bursae, and tendon sheaths(called giant cell tumour of tendons sheath)

Clinical: pain/ restricted  movements

Types: diffuse-common(Shag carpet type or fern like proliferation of synovium) ,  and rarer focal nodular form(sessile or pedunculated with no true capsule), usually monoarticular, knee (80%) , focal -small joints of hands and feet (commonest  soft tisue tumour of hand)

Xray---soft tissue swelling, no calcification, subchondral  saucerised erosions
CT- hyperdense (haemosiderin), enhancement
MRI- Modality of choice--- soft tissue enhancing swelling , crossing joints with no involvement of articular margins, haemosiderin on gradient sequences, subtle bright on T1 due to lipid laden macrophages and fat, secondary degeneraive changes

Saturday, November 27, 2010

Paget's Disease of Bone

This patient aged 70 years male with history of CABG and bone pains exhibits cotton wool appearance, widened diploae, coarse trabecular pattern of the left femur, not so classical picture frame of L2 vertebral body, nonhomogenous presentation of left sacral ala. Diagnosis- Pagets disease of the bone

Case Submitted by-Dr UV Krishna Murthy and Dr MGK Murthy.

About Pagets disease- 3 to 4 % of the general population above the age of 40 years is expected to harbour the disease. Highest incidence is in the 7 and the 8 decades with male preponderance.  There is genetic predisposition to the disease with other theories of etiology being viral ( paramyxoma virus ) / Autoimmune / Vascular / Connective tissue disease / Metabolic ( parathormone abnormality ) / truly neoplastic. The basic defect is excessive and abnormal remodeling of the bone. Clinically varies from being asymptomatic to bone pains, fractures, anemia, expansion of the bones particularly with reference to craniofacial ( in India, manifesting as frequent changing of the spectacles frames ).

Radiological Findings
Skeletal survey continues to be the number one diagnostic parameter.  Skull 25-65%, spine 30-75%, pelvis 30-75%, proximal long bones 25-30% involvement.

  Depends on the stage of presentation
a)      Lytic ( Incipient – Active ) – Gross Destructive, Expansile, radio lucency of the region with advanced wedging of osteolysis demonstrating chronic sharp margin without sclerosis ( Blade of grass sign )
b)      Mixed ( Active ) - Coarse thickening of the trabecular and the cortical pattern with enlarging of the bone, with areas of new bone formation, with possible incremental fractures and cotton wool appearance of the skull.
c)      Blastic ( late inactive ) – Predominantly new bone formation.

    Nuclear Scintigraphy – Shows hyperactivity in all the phases. CT is more demonstrative of the plain radiographic findings.   MR is good for differentiating and excluding sarcomatous transformation ( 1% of the cases ) – Is reflected as focal bone destruction through the cortex, with the breach and invading the neighboring the soft tissues

Friday, November 26, 2010

Osteitis Condensans ilii-MRI

32 years multiparous lady with complaints of pain SI joints location ( left > right ) with pain involving the hip joint as well with clinically positive compression test for SI joints. MR shows diffuse pyriform areas of low signal intensity  juxta articular lesions involving both iliac bones symmetrically in the lower 2/3rd with focal fatty marrow changes of the juxta articular sacral alae, with no widening, asymmetry, destruction, marrow edema, soft tissue collection. The features are highly suggestive of Osteitis Condensans ilii

Case by Dr MGK Murthy, MD, DNB

Teaching points:

  1. It is predominantly found in women usually after child births.
  2. It is often seen in young people, bilaterally and symmetrically with  general prevalence of 1.6 to 3 percent.
  3. Sacral involvement is not noted.
  4. Unilateral types are uncommon but noted.
  5. The etiology is possibly due to laxity of the ligaments in pregnancy, leading to subtle malalignments and fibrous tissue proliferation with stress response with increase osteoblastic activity with some authers suggesting increase density of trabeculations.
  6. Clinically the compression test for  sacro-iliac tenderness is likely to be positive amongst few people. However not associated chronic back pain or disability.
  7. Marrow edema / Radiological malalignment / destruction / soft tissue collection is most uncommon.
  8. All the other varieties of sacro-ilitis particularly the ankylosing spondylitis would show some marrow edema, ill definition and subchondral erosions.
  9. Chest X-ray, serological evaluation particularly with reference to HLAB27, X-ray / CT sacro-iliac joints along with contrast MRI and if needed bone scan would play useful role.

Wednesday, November 24, 2010

PGI Nov 2010-Radiology Recalled Questions

Few Radiology  recall questions from PGI Nov 2010 examination.

Metastases to bones is infrequent in
1. Spine
2. Proximal long bones
3. Hands and feet
4. Not recalled
5. Pubic bones

Answer- Hand and Feet.  Secondaries distal to the knee and elbow are uncommon. Only three tumours BBC, Bronchus, Bladder and Colon may show secondaries to small bones of hand and feet. Spine, proximal long bones and flat bones are marrow containing areas in adult skeleton, so metastatis is common in this bones.

Bare orbit is seen in
1. Neurofibromatosis
2. osteomyelitis
3. Metastasis
4. Meningioma
5. Hemangioma

Answer 1, 3, 4.
Bare orbit appearance is seen in the NF due to sphenoid dysplasia, Mets due to destruction and meningioma due to sclerosis. Reference -Chapman's Differential diagnosis book.

Heterotopic ossification is seen in 
1. Gout
2.  Revision surgery
3. Reiters
4. prolonged surgery 
5. Forresteir disease

Answer- All

Isotope in external beam therapy
1. cs 137
2. co 60
3. radium 226
4. I-131
5. iridium

1, 2, 5.

Screenin of prostate ca.
1. transrectal usg
2. digital exam
3. PSA
4. Not recalled
5. ct scan

Answer 2, 3. CT scan has not role in diagnosis of prostatic malignancy.

Tuesday, November 23, 2010

Choanal Atresia-CT

There is evidence of retained secretions in the bilateral nasal cavities with fluid level in both nasal cavities more on the right side. Also noted is thickening of vomer which measures 0.4cm, posterior nasal apertures measure 0.13cm on the right side and 0.15cm on the left side.  There is bowing and thickening of the posterior medial maxilla. Findings are consistent with choanal atresia.

Reference- CT criteria for choanal atresia include  narrowing of the posterior choanae (LWNC-V < 0.34 cm in newborn), medial bowing and thickening of the posterior medial maxilla (which may be fused with the lateral margin of vomer), thickening of vomer (>0.34 cm) and retained fluid in the nasal cavity.

Post Traumatic Rupture of Arachnoid Cyst-CT

Arachnoid cysts are a well-recognized benign intracranial lesion occuring most commonly in the middle cranial fossa. Spontaneous and post-traumatic intracystic and subdural haemorrhage has also been reported. This is case of young girl with minor trauma resulting in subdural rupture of the arachnoid cyst.  Arachnoid cysts derive from the meninx primitive, embryologically, which is the primitive membrane ensheathing the developing central nervous system (CNS). As subarachnoid CSF accumulates, this meninx cavitates and resorbs under normal circumstances leaving only the subarachnoid space and the arachnoid membrane. During this process, the arachnoid membrane may split with secretion of fluid by the arachnoid cells into the resulting cleft ultimately yielding a cyst – the so called arachnoid cyst – which is truly intra-arachnoid anatomically. 

Saturday, November 20, 2010

Possible Rassmussen's Encephalitis-MRI

Rassmussen's Encephalitis is also known as Hemiconvulsion-Hemiplegia Epilepsy. This is 9month oldinfant with fever, convulsion and one sided weakness. On MRI left sided hemisphere is swollen and shows white matter hyperintensity confined to one hemisphere well seen on DWI possibly indicating cytotoxic edema. This appearance may indicate early stage of rassmussen's encephalitis and may progress to hemiatrophy. Further follow up was advised.

Gynecological MRI- Two Cases

These are two cases that were referred to Teleradiology Providers ,  one is 55 year old lady with ca endometrium with myometrial invasion more anteriorly and involvement of cervix. Other case is lady with pedunculated lower uterine segment fibroid seen arising from the anterior myometrium with is seen hanging in endocervical and endovaginal cavity.

Friday, November 19, 2010

Posterior Limbus Vertebrae-MRI

Limbus vertebra develops in the immature skeleton due to focal herniation of the disc through the vertebral endplate, isolating fragment of the peripheral secondary ossification center (ring apophysis). The majority involves the anterior margin of the endplate, although posterior limbus veretbrae are not exceedingly rare. Posterior involvement may have neurological implications due to compression and/or inflammation of nerve roots.

Wednesday, November 17, 2010

Pulmonary Embolism-Spiral CT

Pulmonary embolism (PE) was clinically described in the early 1800s, and von Virchow first described the connection between venous thrombosis and PE. This image shows an intraluminal filling defect that occludes the left pulmonary artery. Also present is an infarction of the corresponding lung, which is indicated by a triangular consolidation and pleural effusion.

Sternoclavicular Joint Tuberculosis-MRI

The occurrence of tuberculosis in the flat bones of chest and skull is very rare. With the resurgence of tuberculosis all over the world, there have been reports of unusual sites being affected by the disease. However, cases of clavicular or sternoclavicular tuberculosis are few. The rarity of occurrence of tubercular arthritis of the sternoclavicular joint can be attributed to the peculiar blood supply of this joint. The common conditions, which have to be differentiated from sternoclavicular tuberculosis are low grade pyogenic infections, rheumatoid disease, myeloma or secondary deposits. This is confirmed case of tuberculosis in a 46year old Indian male.

Dural Ectasia-MRI Criteria

This is a 26yr old female with dural ectasia. Dural Ectasia is found in Marfan syndrome, Ehlers-Danlos syndrome, neurofibromatosis, ankylosing spondylitis, and osteogenesis imperfecta tarda .  It may occur as a very unusual complication of spinal surgery or trauma.

Case submitted by Dr MGK Murthy.

Diagnostic Criteria

A. Scalloping of vertebral bodies (Minor Criterion)

The superior and inferior diameters were added and then divided by two, and the midsagittal diameter was subtracted from this value . For this purpose, sagittal plane bony measurements were obtained from each outer black cortical vertebral margin. Ahn et al defined scalloping greater than 3.5 mm at the level of S1 as a minor criterion for dural ectasia. The presence or absence of an anterior sacral meningocele as the maximum manifestation of scalloping is usually followed
B. Dura sac Ratio(Minor Criterion)

A dural sac ratio is calculated for each level from L1 through S1 by dividing the dural sac diameter(perpendicular) by the vertebral body diameter. According to Oosterhof et al , normal cut-off values for levels L1 through S1 in adult patients were 0.64, 0.55, 0.47, 0.48, 0.48, and 0.57.

C. The maximum diameter of the nerve root sleeves on Transverse T1 was measured for each foramen at each level from L1 through S1. According to Ahn et al , a diameter exceeding 6.5 mm at the level of L5 represents a minor criterion

D. Major criterion for dural ectasia is met when the dural sac diameter at S1 is greater than that at L4, which demonstrates that the dural sac is not tapering off

Two standard accepted criterion

(i).Ahn et al described two major criteria for the presence of dural ectasia: width of the dural sac at a level below L5 greater than that above L4 and presence of an anterior sacral meningocele.

Minor criteria were defined as scalloping greater than 3.5 mm at the level of S1 and nerve root sleeve diameter greater than 6.5 mm at the level of L5.

They concluded that dural ectasia is present if one major or two minor criteria are present.

(ii). According to Fattori et al , the degree of dural abnormalities can be classified as follows:

grade 1, mild dural ectasia defined by bulging of the dural sac and lack of epidural fat at the level of the posterior wall of one vertebral body, by the presence of small radicular cysts, or by both features;

grade 2, moderate dural ectasia defined by bulging of the dural sac and lack of epidural fat at the level of the posterior wall of two or more vertebral bodies and presence of large radicular cysts; and

grade 3, severe dural ectasia defined by presence of an anterior sacral meningocele.

Tuesday, November 16, 2010

Video Conferencing Technology Brings New Dimensions to PG Medical Entrance Coaching

Traditionally medical students preparing for PG medical entrance exams for their MD/MS entrance examinations in small town & tier II cities are at a disadvantage as classroom centres are mainly in metropolitan cities.  Now with technology leading academy for PG medical entrance  DAMS (Delhi Academy of Medical Sciences P Ltd) have launched in country which can have exclusive Video Conferencing for PG Medical Entrance Exam in 242 centres across the country in partnership with Reliance World with unique features of two way interaction, interactive classes by best exclusive DAMS faculty and relatively smaller batches.   This programme has been correctly labelled as DAMS Virtual Classroom

Radiology MCQs from AIIMS November-2010

 These MCQs were sent to us by our students from DAMS and are based on memory recall.  We will be releasing fully solved version of all subjects with detailed explanation with Elsevier within 10 days. 
DAMS (Delhi Academy of Medical Sciences [p] Ltd) is the leader in the PG medical entrance preparation currently in the country. 

AIIMS November 2010 Radiology

Radiation exposure is the least in the following procedure:
a. micturating cystourethrogram
b. IVP
c. bilateral nephrostomogram
d. Spiral CT for stones

Answer-A) MCU
 IVP radiation exposure is 2.5mSv (125CXR), Spiral CT abdomen for abdomen-10mSv( 500CXR), MCU-1.7mSv.  Bilateral nephrostomogram is a procedure will require fluoroscopy twice, once for each kidney and possibly will have higher radiation.

A 35 yr old lady with chronic backache. On X ray she had a D12 collapse. But Intervertebral disc space is maintained. All are possible except 
a.) multiple myeloma 
b.) osteoporosis 
c.) metastasis
d) tuberculosis

Answer-d) Tuberculosis
As a rule neoplastic and traumatic/osteoporotic collapse show sparing of the intervertebral disc, while tuberculosis classically is paradiscal, involvement of disc is usual. Common neoplasms in adult causing disc collapse are metastasis and multiple myeloma, while in children vertebral collapse may indicate histiocytosis (vertebra plana). This question has been asked previously in AIIMS but with different framing of the question.

 Bone marrow transplant receipient patient developed chest infection. ON chest Xray Tree on Bud appearance . The cause of this is
a.) klebsiella
b.) pneumocystis 
c.) TB 

Reference- March 2002 Radiology, 222, 771-772.
Answer-b) Pneumocystis carnii
The tree-in-bud sign is a finding seen on thin-section computed tomographic (CT) images of the lung.  Peripheral (within approximately 3–5 mm of the pleural surface), small (2–4 mm in diameter), centrilobular, and well-defined nodules of soft-tissue attenuation are connected to linear, branching opacities that have more than one contiguous branching site, thus resembling a tree in bud. Pulmonary infectious disorders involving the small airways are the most common causes of the tree-in-bud sign.  Any infectious organism, including bacterial, mycobacterial, viral, parasitic, and fungal agents, can involve the small airways and cause a tree-in-bud pattern. In pulmonary infectious disorders, the tree-in-bud sign has most commonly been described in patients with endobronchial spread of M tuberculosis. However,  bronchogenic dissemination of atypical mycobacterial organisms or pyogenic bacteria can result in tree-in-bud opacities. Less frequently, the tree-in-bud sign is seen with viral and fungal infections (eg, invasive aspergillosis of the airways) and Pneumocystis carinii pneumonia.

Frontal Sinus can be best visualised by :
a. Caldwell's view
b. Water's view
c. Towne's view
d. Schuller's view

Answer-A) Caldwell’s view
The Waters view or occipitomental projection is taken at an angle 37° caudal to the canthomeatal line. This view optimally visualizes the superior and inferior orbital rims, nasal bones, zygoma, and maxilla. The Caldwell view, angled 15° caudal to the canthomeatal line, allows additional views of the frontal sinus and superior orbital rim. The 6-ft Caldwell view is helpful intraoperatively for frontal sinus obliteration surgeries.

Most sensitive test to detect ductal carcinoma in situ is-
a.       Mammography
b.      MRI

Answer-b) MRI
Researchers from Germany have reported that MRI (magnetic resonance imaging) detects almost twice as many DCIS as mammography and is especially effective for detecting high-grade DCIS. The details of this study appeared in the August, 2007 issue of Lancet Oncology.This data was also presented at the 2007 meeting of the American Society of Clinical Oncology.
The goal of cancer screening is to detect cancer at an early stage, when treatment will be most successful. For the early detection of breast cancer, the American Cancer Society recommends an annual mammogram and clinical breast exam starting at the age of 40. In addition to mammography, women at high-risk of breast cancer are advised to receive annual screening with breast MRI. Although MRI has been reported to detect more breast cancers than mammography, it is also much more expensive and more likely to produce false-positive test results. Although it has been demonstrated that MRI is more sensitive than mammography in detecting invasive breast cancers, MRI's ability to detect DCIS has been doubted since this technique does not detect calcium.

However, this study suggests that MRI may be better than mammography at detecting DCIS—particularly high-grade DCIS. These findings can only lead to the conclusion that MRI outperforms mammography in tumour detection and diagnosis. MRI should thus no longer be regarded as an adjunct to mammography but as a distinct method to detect breast cancer in its earliest stage.

Reference: [1]  Kuhl CK, Schrading S, Wardelmann E, Braun M, Kuhn W, Schild HH. Magnetic resonance imaging versus mammography for diagnosing ductal carcinoma in situ. Proceedings of the American Society of Clinical Oncology. Chicago/ IL.  2007. Abstract # 1504.
[2] Boetes C, Mann RM. Ductal carcinoma in situ and breast MRI. Lancet Oncology. 2007; 370:459-460.

Patient with 6th cranial nerve palsy on T2 weighted MRI Hyperintense shadow which shows homogenous contrast enhancement. most probable diagnosis is?
 a)schwannoma b)meningioma c)cavernous sinus hemangioma 

Answer is c )cavernous sinus hemangioma.
Schwannoma are heterogenously enhancing, while meningiomas usually are isointense on both T1 and T2 weighted images. Although both meningiomas and hemangiomas will have homogenous enhacement better answer is haemangioma.Cavernous hemangiomas occur very rarely in the cavernous sinus and are difficult to diagnose preoperatively.  MR images showed hypointensity on T1-weighted images and well-defined hyperintensity on T2-weighted images with marked homogeneous enhancement after contrast material administration. AJNR Am J Neuroradiol 2003 Jun-Jul;24(6):1148-51.

Which one of the following is not a CT feature of Adrenal adenoma?

a. Low attenuation
b. Homogeneous density and well defined borders
c. Enhances rapidly, contrast stays in it for relatively longer time and washes out late
d. Calcification is rare.
Adenoma have early washout of contrast not delayed also low attenuation is because of fat content. Well defined border is obvious as it is benign, and calcification is rare.
Reference-December 2000 Radiology, 217, 629-632.
Rapid early CT enhancement washout is a highly sensitive and specific feature of adrenal adenomas; with nonenhanced CT densitometry in the depiction of lipid-rich adenomas, it makes CT the most useful and accurate imaging method in the characterization of adrenal masses. In our department, we first evaluate known adrenal masses by using nonenhanced CT. If the attenuation of the mass is 10 HU or less, we make a diagnosis of lipid-rich adrenal adenoma (a small fraction of these will be cysts rather than adenomas), and no further evaluation is advised

Pt goin for coronary angiography and now to prevent contrast nephropathy what is not needed to be done

a. fenlodopam
b. N acetylcystine
c. hemofilteration
d. NS
Answer-a ) fenoldopam

Several investigators have suggested that ICM nephrotoxicity can be reduced with the use of oral or intravenous theophylline, acetylcysteine, fenoldopam, or bosentan (an endothelin antagonist). Some prospective studies have suggested that prophylactic administration of 600 mg acetylcysteine twice daily in combination with hydration reduces the incidence of ICM nephrotoxicity. Hemodialysis is required only in treatment of extreme cases. In this case more or less prophylaxis is required not treatment. NS means normal saline

Saturday, November 13, 2010

Ranula-CT images

CT shows relatively sharply demarcated, unilocular , homogenous , low attenuation (fluid filled), peripherally enhancing ,cyst in the floor of the mouth pushing the mylohyoid down and shows enlarged ipsilateral submandibular salivary gland with prominent whartons duct most probably represents  oral ranula  

Case by - Dr Sudheer and Dr MGK Murthy,  Consultant Radiologist

 Definition : Term Rana(for Ranula) from latin means  Frog

Collectively, the mucocele, the oral ranula, and the cervical, or plunging, ranula are clinical terms for a pseudocyst that is associated with mucus extravasation into the surrounding soft tissues. These lesions occur as the result of trauma or obstruction to the salivary gland excretory duct and spillage of mucin into the surrounding soft tissues. Mucoceles, which are of minor salivary gland origin, are also referred to as mucus retention phenomenon and mucus escape reaction usually occur in the floor of the mouth and  involve the major salivary glands.

Specifically, the ranula originates in the body of the sublingual gland, in the ducts of Rivini of the sublingual gland, in the Wharton duct of the submandibular gland, and, infrequently from the minor salivary glands at this location. Oral ranulas are secondary to mucus extravasation that pools superior to the mylohyoid muscle, whereas cervical ranulas are associated with mucus extravasation along the fascial planes of the neck.

Interstitial Lung Disease Series-Part 3- Cryptogenic organizing pneumonia

ILD is one of the most difficult topics for the residents to understand. We have put together simple series with points to remember for each type. We agree, it is highly controversial and our points are comprehensive and may need revision periodically.  All we are offering are some typical things to remember and pictures and this in no way is exhaustive and conclusive. This is the third  case in the series.

Main Contributor- Dr MGK Murthy.
Edited and Series Concept by Sumer Sethi

Case Number-3

There are 6 types of Idiopathic Interstitial Pneumonias, also called interstitial lung disease. We will present six posts in this series called as Interstitial Lung Disease Series.

Cryptogenic organizing pneumonia 
Cryptogenic organizing pneumonia  shows  airspace consolidation overlying some other disease at times like SLE with loss of volume.

Short Note on
Cryptogenic organizing pneumonia 
Male=female (40 to 50y)
Relatively short like Flu
Granulation tissue obliterating alveolar ducts/spaces
CXR- Bilateral diffuse peripheral alveolar opacities
HRCT- patchy airspace ground glass(90%), some nodules, Bronchial wall thickening & patchy peripheral prepoderance
Treatment- steroids
Mortality Rare but recurrence is high


Wednesday, November 10, 2010

Radiology Pin Up Calender-Humour

EIZO medical imaging produce high precision displays for the examination and diagnosis of radiographs. They recently produced Pin-Up calendar leaving little to the imagination. Images that you will see in the link attached is  awesome to say the least.

Eizo Pin Up Calender

Monday, November 08, 2010

Tribute to 115th Anniversary of Roentgen Discovery












Sunday, November 07, 2010

Interstitial Lung Disease Series-Part 2- Non specific Interstitial Pneumonia

ILD is one of the most difficult topics for the residents to understand. We have put together simple series with points to remember for each type. We agree, it is highly controversial and our points are comprehensive and may need revision periodically.  All we are offering are some typical things to remeber and pictures and this in no way is exhaustive and conclusive. This is the second case in the series.
Main Contributor- Dr MGK Murthy.
Edited and Series Concept by Sumer Sethi

There are 6 types of Idiopathic Interstitial Pneumonias, also called interstitial lung disease. We will present six posts in this series called as Interstitial Lung Disease Series.

Case Number-2

Non specific Interstitial Pneumonia- second commonest amongst pulmonary fibrosis, just after Usual Interstitial Pneumonia

Note:  symmetric lower lobe involvement(typical), Relative subpleural sparing,  groundglass opacities, peribronchovascular fibrosis, mild reticular abnormalities, and traction bronchiectasis prominent

Golden Point 
Ground-glass abnormality is a common finding in many diffuse lung diseases, including all of the IIPs except UIP . Therefore, although its presence cannot help one make the diagnosis of NSIP, the absence of ground-glass abnormality can steer one toward a diagnosis of UIP, even if no honeycombing is present.

Short Note on Non specific Interstitial Pneumonia

Non smoking Women(40 to50yr)
Relatively  short  history
CXR- BLZ reticular and patchy opacities  rarely unilateral   D/D eosinophilic pneumonia    
HRCT- Bilateral patchy groundglass, irregular lines, bronchial dilatation                                                                                                                                            
Treatment- Steroids                                                      
Mortality- <10% in 5 yrs  

Interstitial Lung Disease Series-Part 1- Usual Interstitial pneumonia

ILD is one of the most difficult topics for the residents to understand. We have put together simple series with points to remember for each type. We agree, it is highly controversial and our points are comprehensive and may need revision periodically.  All we are offering are some typical things to remeber and pictures and this in no way is exhaustive and conclusive .

Main Contributor- Dr MGK Murthy.
Edited and Series Concept by Sumer Sethi

There are 6 types of Idiopathic Interstitial Pneumonias, also called interstitial lung disease. We will present six posts in this series called as Interstitial Lung Disease Series.

Case Number-1

Usual Interstitial pneumonia
Points to be noted

-lower lobes symmetrical  involvement
-extensive honey combing
-absence of ground glass opacities
-lack of subpleural sparing

Short Notes on Usual Interstitial pneumonia 

Mostly male smokers      
Takes years to develop
Exertional dyspnoea and cough
HPE       Alveolar epithelialcell injury              
CXR       Diffuse Reticular shadows both lower zones  & peripheral cystic honeycombing  
HRCT     Traction Bronchiectasis, diffuse patchy subpleural  reticulations  
Treatment     Lung transplant  
Morality    50-70%in 5 yrs      

Friday, November 05, 2010

Nasal Bone Fracture- Grey Zone

Young adult presented with lateral force injury and right nasal bone tenderness
pictures show possible  high fracture of right  side better appreciated as compared to the left, though  airzones and soft tissues are not  grossly abnormal. High freq USG(100% accurate )/CT scan (90%helpful)/ clinical exam  would help.

Case submitted by DR MGK Murthy.

Approximately 80% of fractures occur at the lower one third to one half of the nasal bones. This area represents a transition zone between the thicker proximal and thinner distal segments. Fractures of the nasal bones are frequently transverse. The lateral view obtained by using a soft-tissue technique is probably best for depicting old and new fractures of the nasal bones. Lateral view is not useful in this

The use of plain images and computed tomography (CT) scans for the diagnosis and management of nasal fractures has been controversial. Several small studies have shown that use of these modalities is neither cost-effective nor beneficial to the patient or physician. Nasal fractures are usually evident and can be elicited by means of careful history taking and physical examination. Rarely is the radiologic confirmation of these injuries needed

The misreads were found to be the result of the midline nasal suture, the nasomaxillary suture (low defect), and thinning of the nasal wall (high defect).  Short lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as nasal fractures. Other lines, such as normal sutures or longitudinally oriented nasociliary grooves, can be mistaken for longitudinal fractures. However, a nasociliary groove should never cross the plane of the nasal bridge; if this is demonstrated, the line is a fracture. Fortunately, fractures usually demonstrate a sharpened delineation, with greater lucency than normal sutures and grooves.

The radiologist must look closely for marked deviation, displacement with sharp angulation, and soft-tissue swelling. It is important to remember that only approximately 15% of old fractures heal by ossification; as a result, old fractures are easily mistaken for new fractures, and this increases the rate of false-positive readings.

 Evaluation of air zones by profilogram can provide important information, because the air zones commonly are lost after trauma. Alterations of air-zone shapes may indicate cartilage volume increases or septal hematoma. Other injuries that are commonly associated with nasal fractures include midface injuries involving the frontal, ethmoid, and lacrimal bones; nasoorbital ethmoid fractures; orbital wall fractures; cribriform plate fractures; frontal sinus fractures; and maxillary Le Fort I, II, and III fractures

 Carry home msgs

How to do lat view(Profilogram)

The lateral view (profilogram) is obtained with the infraorbitomeatal line parallel to the transverse axis of the film and the intrapupillary line perpendicular to the plate.  Many prefer to include the full profile from the forehead to the chin

1. physical exam preferably under anaesthsia is good
2.High Resolution USG 100% accurate
3.Medicolegal  req may need Xray/CT- being questioned today
4. Lateral (profilogram) is preferred  along with waters view
5. lower fractures are  more common
6. soft  tissue swelling and Air zones abnormality very helpful for Radiologist
7. sutures  and grooves are our bugbear
8. old fractures do not  heal by ossification  and hence can be read as fresh fxs
9. non bony septal injuries very imp
10. we must look for associated fractures  like maxillary , orbital and  frontal bones

Thursday, November 04, 2010

Ectopic Origin Left Circumflex-MDCT

Our patient for routine diagnostic angiography   shows origin of circumflex from proximal RCA. Vessel  though is thinner in caliber relatively   shows no significant atheromatous changes.

Case submitted by- Dr Krishna Mohan Dr Sudheer  and Dr MGK Murthy

The RCA courses in the right atrioventricular groove and provides nutrient branches to the right ventricular free wall, extending to the acute margin of the heart.  In 90% of patients, the RCA supplies the posterior descending coronary artery branch at the crux of the heart, which supplies the atrioventricular (AV) node and the posterior aspect of the interventricular septum.

The first branch arising from the RCA is the conal or infundibular branch, to supply the muscular right ventricular outflow tract or infundibulum. The RCA supplies blood to the atria with a highly variable pattern of small branches. The sinus node artery arises from the proximal RCA in approximately 50% of patients.
 The left coronary artery (LCA) arises from the mid position of the left (left anterior) sinus of Valsalva The left coronary ostium is usually single, giving rise to a short, common LCA trunk that branches into the left anterior descending (LAD) and circumflex (Cx) coronary arteries.  The LAD courses in the anterior interventricular groove, giving rise to the anterior septal perforating branches as it extends toward the cardiac apex. Small branches may arise from the LAD and supply the anterior wall of the right ventricle. Diagonal branches arise from the LAD and course at downward angles to supply the anterolateral free wall of the left ventricle.
 The Cx coronary artery courses along the left AV groove, around the obtuse margin, and posteriorly toward the crux of the heart. Should the Cx coronary reach the crux of the heart and supply the posterior descending coronary artery, the left coronary system would be termed dominant. This occurs in approximately 10% of patients.

 Atrial branches may arise from the Cx coronary artery and supply the sinus node in 40% of patients. Obtuse marginal branches arise from the Cx system to supply the posterolateral aspect of the left ventricle. In an estimated 70% of patients, a coronary branch (termed ramus medianus, intermedius, or intermediate branch) arises early off the left coronary system to supply an area between diagonal branches from the LAD and obtuse branches from the Cx systems.

 Because of considerable heterogeneity of coronary vasculature, what is considered atypical, abnormal, aberrant, anomalous, accessory, ectopic, incidental, variant, or significant is often unclear. The terms anomalous or abnormal are used to define any variant form observed in less than 1% of the general population.

Coronary artery anomalies are found in 0.6% to 1.55% of patients who undergo coronary angiography. MDCT diagnostic  angiograms are unravelling many anomalies not appreciated before specific anomaly to our case. The ectopic origin of the LCx is a well-recognized variant, which is considered the most common coronary anomaly and can be found in approximately 0.37% to 0.7% of all patients.  The anomalous LCx most commonly arises from a separate ostium within the right sinus, or as a proximal branch of the RCA .  Although this anomaly is classified as benign and asymptomatic, and a few cases of sudden death, myocardial infarction, and angina pectoris in the absence of atherosclerotic lesions have been reported

if needed, angioplasty of these anomalous  vessels is very challenging to the physician

Wednesday, November 03, 2010

Osteoid Osteoma-Ischium

Osteoid osteoma is a benign skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. Radiography is the initial examination of choice and may be the only examination required. CT is used for precise localization of the nidus and may be used for guiding percutaneous ablation. This is young boy with severe pain especially in night and was relieved by aspirin. Note the lytic lesion with extensive sclerosis surrounding.

Tuesday, November 02, 2010

Os Trigonum

Between 8 and 13 years of age, an ossification center forms posterior to the talus. Normally, this ossification center fuses with the talus within 1 year. In approximately 7% of the population, it remains separate and is referred to as the os trigonum. The os trigonum is corticated and articulates with the lateral talar tubercle through a synchondrosis.

Os trigonum syndrome results from repetitive microtrauma or acute forced plantar flexion of the foot. The chondro-osseous border of the synchondrosis may be injured either as a chronic stress fracture or, less frequently, as an acute fracture.

An os trigonum is usually round or oval with well-defined corticated margins, whereas a fracture of the lateral tubercle typically has irregular serrated margins between the fragment and the posterior talus.

Lateral radiographs obtained with the foot in plantar flexion may show the os trigonum impinged between the posterior tibia malleolus and the calcaneal tuberosity. Our case shows  stippled opacity with post talar margin clear with no serrated edges, it is possibly developing os Trigonum with well maintained fat planes. Case by Dr MGK Murthy, Sr Consultant Radiologist

Monday, November 01, 2010

Journal Review-Radiology October 2010

Two papers from Radiology October 2010 are featured here to update the readers of the exciting updates in the field of medical imaging.

Few days back we had post coiling patient who post the procedure deteriorated. Plain CT scan showed increased sulcal density in the area, which could have been persisitent post angiographic contrast versus rebleed. Going through the article "Evaluation of Dual-Energy CT for Differentiating Intracerebral Hemorrhage from Iodinated Contrast Material Staining- October 2010 Radiology, 257,205-211." , possibly dual energy CT is the answer

Right Coronary MR Angiography at 7 T: A Direct Quantitative and Qualitative Comparison with 3 T in Young Healthy Volunteers- October 2010 Radiology, 257,254-259 has found improvement in evaluation of right coronary artery using 7Tesla MRI versus 3T.

Acute cerebellitis-MRI

Acute cerebellitis is one of the main causes of cerebellar dysfunction in children, and may be infectious, post-infectious or post-vaccination. Its aetiology is usually viral and a large number of viruses have been implicated (varicella-zoster, measles, mumps, coxsackie, Epstein-Barr, rubeola, pertussis and diphtheria, among others), although in most cases a definite aetiology remains undetermined . The cerebrospinal fluid examination may be normal or reveal pleocytosis, and the diagnosis is based mainly on clinical criteria . The disease is usually benign and self-limiting, its prognosis is habitually good, and recovery with a few or no sequelae is the usual outcome

IMAGING- It is usually bilateral,symetrical and MRI is the investigation of choice It displays predominantly graymatter and cortical signal abnormality with white matter involvement, which when it occurs is patchy and variable ,compressing the 4 th ventricle leading to obstructive proximal hydrocehalus. It is usually is low on T1 and bright on T2 and FLAIR with NO restricted diffusion(diff from acute infarction). Restricted diffusion is more common in bacterial and anerobic cerebellitis , though it can be seen in viral eiology Contrast enhancement is typically pial and along the sulcal spaces. MRS shows necrosis ,as lactate/ lipid in occassional cases

Differential diagnosis-- include acute intoxication by drugs, alcohol, tumours and demyelination (predominantly white matter involved). Lead poisoning could simulate this and so does Lhermitte-duclos (LDD)which could be differentiated by the presence of contrast enhancement and full recovery in cases of viral cerebellitis . If any surgical intervention is planned, in any caae resembling this disease ,it is worth repeating MRI after few weeks to see progress as viral cerebellitis will invariably improve.

Case by Dr MGK Murthy, Sr Consultant Radiologist.

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