Friday, February 25, 2011

Early Cavernous Sinus Thrombosis-Gd MRI

The cavernous sinuses receive venous blood from the facial veins (via the superior and inferior ophthalmic veins) as well as the sphenoid and middle cerebral veins. They, in turn, empty into the inferior petrosal sinuses, then into the internal jugular veins and the sigmoid sinuses via the superior petrosal sinuses. This complex web of veins contains no valves; blood can flow in any direction depending on the prevailing pressure gradients. This is diabetic female with clinical history of multiple cranial nerve palsies. Case submitted by Dr MGK Murthy.

Teaching points

  • Multiple cranial nerve palsies in diabetic lady should always suggest infection base of the skull and venous thrombosis unless other wise proved
  • Superior opthalmic vein is sensitive indicator of things hapening in cavernous sinus 
  • Base of the  skull in this case shows diffuse enhancing oedema -producing literally sheet of gadolinium possibly encasing all the foramina at base including foramen ovale
  •  Widened cavernous sinus with some asymetry is suggestive of stasis and thrombus along with asymmetry of flow void of ICA within
  • No proptosis is no guarantee against venous thrombosis 
  • Sphenoid sinus is is notorious for producing base of the skull and meningeal inflammation
  • All muslces and soft tissues including temporalis are inflammed

Residents are NOT students-NEJM

An interesting article in NEJM- Residents: Workers or Students in the Eyes of the Law? NEJM | January 12, 2011 | Topics: Health Law. sparks off a debate on liability of resident doctor if he errs, does the court take him as student or is he liable in the same way as senior doctors. 

According to recent court verdict cited in the article --" On January 11, 2011, the Supreme Court ruled in an 8-to-0 decision (Justice Elena Kagan was recused) that the Treasury regulation making residents categorically ineligible for the student exemption was a “perfectly sensible” way of distinguishing education from service for the purposes of the tax code."

Wednesday, February 23, 2011

Transient bone marrow oedema of the hip-MRI

Transient bone marrow oedema of the hip also referred as transient osteoporosis of the hip is self-limited conditions that improves spontaneously over several months.  TOH was first described in 1959 in two women in their 3rd trimesters of pregnancy but now is more commonly seen in middle-aged men. This is 34 yr old female, immediate post partum, note the bulky uterus and marrow edema involving the right femoral head and neck, along with increased synovial fluid.

Tuesday, February 22, 2011

Pancreatic Calcification- Radiograph

This is a case of 22 year old male with characteristic pancreatic calcification crossing the midline marked by arrows. Few causes of pancreatic calcification are-
  1. Alcoholic pancreatitis.
  2. Hereditary pancreatitis
  3. Few patients with advanced cystic fibrosis and diabetes mellitus
  4. Protein malnutrition


Monday, February 21, 2011

Can Robots Replace Radiologist in Future?

This came from a recent article on The Atlantic-   “Anything You Can Do, Robots Can Do Better”  which claims “in spite of the radiologist's training requirement of at least thirteen additional years beyond high school, it is conceptually quite easy to envision this job being automated. The primary focus of the job is to analyze and evaluate visual images. Furthermore, the parameters of each image are highly defined since they are often coming directly from a computerized scanning device”.  Although, i don’t agree and think the author has forgotten much of the medical imaging interpretation requires more than just the visual skills there is lots of brains involved, it makes interesting reading.

Do you think Robots will replace radiologists in future?

MDR Tuberculomas Mimicking Brain Tumour.

This is a case of 19 year old male with rapidly increasing lesion(despite ATT)  in the parieto-occipital region and extensive edema which was initially diagnosed as mitotic etiology but later on histopathology and surgical evaluation turned out to be tuberculomas, possibly multidrug resistant tuberculomas.

Thursday, February 17, 2011

Tibial Metastases in Carcinoma Breast-MRI

The primary cancers most commonly associated with bone metastases are:- Lung, Breast, Prostate, Thyroid and Kidney. The spine appears to be the most affected bony site followed by the pelvis, ribs, skull and the upper arm bones. Breast cancer and lung cancer (which is 20% in frequency) form the commonest causes of distal or below elbow and below-knee metastases. This is known case of carcinoma breast and reveals tibial shaft lesion confirmed as metastases.

Further reading - Foot (Edinb). 2010 Mar;20(1):35-8. Epub 2009 Nov 4. Tibial involvement in breast cancer: issues in diagnosis and management. Goyal S, Puri T, Gupta R, Suri V, Julka PK, Rath GK.

NEJM- osteochondromas after body irradiation

An article in this weeks NEJM entitled Osteochondromas after Total-Body Irradiation. N Engl J Med 2011; 364:687-688. By Marisa K. Matthys, B.S., Jane E. Benson, M.D. from Johns Hopkins University, Baltimore, MD  reports-
" The occurrence of osteochondroma after total-body irradiation has been increasingly reported in the literature and is probably the result of a prolonged duration of epiphyseal opening caused by damage to bone and cartilage at the epiphysis. Analyses have shown that the age at the time of transplantation is an independent risk factor for osteochondroma, with most reports involving children under the age of 5 years. "

Wednesday, February 16, 2011

Possible Tolosa Hunt Syndrome

The Tolosa Hunt syndrome (THS) refers to the presence of a painful ophthalmoplegia secondary to surrounding cavernous sinus inflammation Tolosa Hunt syndrome is essentially a clinical diagnosis of exclusion.
MRI findings in THS can include:

  1. Inflammation of the cavernous sinus, superior orbital fissure, or orbital apex.
  2. Narrowing of the intracavernous internal carotid artery.

This case of 52 year old female reveals isointense lesion in the region of left cavernous sinus with enhancement on post gadolinium scans and smaller left ICA flow void, as the lesion was isointense on T2 weighted images and differential diagnosis of meningioma versus THS was suggested. Along with follow up scan after steroid to confirm the diagnosis.  MRI scans should be performed every 1-2 months to monitor improvement and maintenance of improvement on and then off treatment, until findings normalize.

Fiber Tracking-MRI

Diffusion tensor imaging is unique in its ability to non-invasively visualize white matter fiber tracts in the human brain in vivo. Diffusion is the incoherent motion of water molecules on a microscopic scale. This motion is itself dependent on the micro-structural environment that restricts the movement of the water molecules. In white matter fibers there is a pronounced directional dependence on diffusion. With white matter fiber tracking projections among brain regions can be detected in the three dimensional diffusion tensor dataset according to the directionality of the fibers. This is a case of glioma shown with fiber tracking. 

Tuesday, February 15, 2011

Ecchordosis physaliphora- Rare Retroclival Pathology

Ecchordosis physaliphora is a rare congenital, benign, hamartomatous, retroclival mass derived from notochordal tissue that is typically located intradurally in the prepontine cistern. Ecchordosis physaliphora is usually asymptomatic. The differential diagnosis of EP also includes chordoma, dermoid, epidermoid, arachnoid cysts and partially thrombosed vertebrobasilar aneurysm. When a retroclival mass is established on MRI, any associated osseous stalk should be evaluated on thin-section CT as in our case which is classical for the diagnosis of Ecchordosis Physaliphora. This is 29 year old male with prepontine and retroclival lesion on MRI with no significant enhancement and diffusion restriction.

Clival Invasion in Pituitary Macroadenoma-MRI

Despite histological benign nature of the pituitary tumour they can achieve large size and in our case also showed unsual invasion into the region of clivus and pterous bones demonstrated by contrast MRI study in this young 20 year old male. Preoperatively the diagnosis was in doubt because of extensive involvement of clivus and was confirmed histopathologically.

Pulmonary Edema- CXR

"Early signs of pulmonary edema (intersticial edema) are the Kerley B lines, horizontal lines seen laterally in the lower zones, 2 cm long at last reach the lung edge. As the edema progress alveolar edema is observed with its "butterfly-batwing" pattern, characterized by the central predominance of shadows with a clear zone at periphery lobes. Other feature that may be seen is cardiac enlargement, in case of cardiac failure previously present. A helpful feature in distinguishing cardiac pulmonary edema from non cardiac pulmonary edema and from pneumonia, is the speed with which the edema appears and disappears. Substantial improvement in a 24 hour period is virtually diagnosis of cardiac pulmonary edema. These are two CXR done before and after decongestant therapy. "

Teleradiology session in IRIA-2011 gets covered in Express Healthcare

My talk in IRIA 2011 on Teleradiology-Asia Africa Perspective  gets covered in Express Healthcare

"Sumer Sethi, Founder Director, Teleradiology Providers, Delhi on the other hand spoke about opportunities in Asia-Africa. Comparing the past and the present day radiology, he said that the future can be visualised. Being the internet era, radiology and imaging has witness a paradigm shift, believed Dr Sethi. He further went on to say that what we see today is Imaging 2.0 which has five important parameters namely: quality, dependability, flexibility, speed and cost. Today, India's healthcare spending has increased with increased education, growing significance of health insurance and rise in income, informed Dr Sethi. Highlighting the advantages of teleradiology, he mentioned that teleradiology can be of immense use during emergencies, when doctors are on leave, as an option for soliciting second opinions as well as serving a support system for sub-speciality expertise."

Saturday, February 12, 2011

Open Source DICOM workstation-Useful Link

 Information Link- Ginkgo CADx  (  is a new open source DICOM Workstation, designed to be a DICOM Viewer and also provide CADx algorithms included in plugins. Ginkgo CADx is multi platform so runs perfectly in Linux, MacOSx, and Windows. 

Friday, February 11, 2011

Atypical teratoid/rhabdoid tumors-MR

Primary atypical teratoid/rhabdoid tumors (AT/RTs) are rare malignant intracranial neoplasms, usually occurring in young children. They were termed "AT/RT" because they contain nests or sheets of rhabdoid tumor cells as well as varying proportions of primitive neuroectodermal tumor (PNET) cells, mesenchymal spindle-shaped tumor cells, and/or epithelial-type tumor cells. As reported in the literature this patient had MR imaging signal-intensity characteristics  as nonhomogeneous, secondary to the heterogeneous cellular populations in these tumors as well as the frequent presence of necrosis, hemorrhage, and/or calcifications.

Monday, February 07, 2011

Hypoglycemic Encephalopathy-MRI

Hypoglycemic coma can be fatal if prolonged and severe. Lesions are described that involve the temporal, occipital, and insular cortex; the hippocampus; and the basal ganglia with sparing of the thalami  as in our patient who is 57 year old male with significant history of hypoglycemia followed by vegetative state shows striatal hyperintensity with relative sparing of thalami. These findings can be similar to sporadic Creutzfeldt-Jacob disease, although the clinical setting should exclude the neurodegenerative disorder.

Pancreatic Divisum-MRCP

Pancreatic ductal anatomy can be subject to a number of variations. Pancreas divisum is the most common congenital pancreatic ductal anatomic variant, with abnormality results from failure of the dorsal and ventral pancreatic anlage to fuse during the sixth to eighth weeks of gestation. In most cases of pancreatic divisum, no communication exists between the dorsal and ventral pancreatic ducts.Dorsal pancreatic duct is dilated which indicates associated chronic pancreatitis.  This is 29 year old male with chronic pancreatitis.

Landmark Decision- FDA clears Radiology Smartphone App

The U.S. Food and Drug Administration has reversed course on one of the first radiology apps ever pulled from the Apple Store.  Now, U.S. radiologists who can't make it to a workstation but need to review medical images can make a diagnosis off their iPhone or iPad.
Read more- FDA clears first diagnostic radiology smartphone app

Saturday, February 05, 2011

DWI- intracranial tuberculoma & tuberculous abscess versus cysticercus granulomas

Restricted diffusion is noted in a large number of non-stroke conditions including tuberculoma. According to various studies vesicular and degenerating stages of cysticercus cysts from the core showed ADC values significantly higher than tuberculomas and tuberculous abscess.

This is a patient, 25 year old female with headache and no other constitutional symptoms  which on CEMR show ring enhancing lesion and T2 hyperintense core. When reported outside, it was reported as degenerating neurocyticercosis on basis of these findings as there was perilesional edema.  However, these is evidence of diffusion restriction on DWI and that led us to give possibility of tubercular abscess.

Further reading- Role of diffusion weighted imaging in differentiation of intracranial tuberculoma and tuberculous abscess from cysticercus granulomas-a report of more than 100 lesions. European Journal of Radiology - September 2005 (Vol. 55, Issue 3, Pages 384-392, DOI: 10.1016/j.ejrad.2005.02.003)

Friday, February 04, 2011

Cavernous Haemangioma of Cavernous Sinus-MRI

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.  Extraaxial cavernous hemangiomas are rare and very rarely arise in the cavernous sinus . Diagnostically differentiating hemangiomas from tumors such as meningiomas or schwannomas at this site is often difficult.
Further reading at Characteristic MR Imaging Findings of Cavernous Hemangiomas in the Cavernous Sinus. American Journal of Neuroradiology 24:1148-1151, June-July 2003

Thursday, February 03, 2011

Mount Fuji Sign-CT

"The Mount Fuji sign on CT scans of the brain is useful in discriminating tension pneumocephalus from nontension pneumocephalus. Tension pneumocephalus can be a neurosurgical emergency, unlike nontension pneumocephalus. Tension pneumocephalus occurs most commonly after the neurosurgical evacuation of a subdural hematoma."
The collapsed frontal lobes and the widening of the interhemispheric space between the tips of the frontal lobes have the appearance of the silhouette of Mount Fuji —hence, the Mount Fuji sign. 

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