Wednesday, November 30, 2011

Rapunzel Syndrome-CT

Bezoar is a tightly packed collection of undigested material that is unable to exit the stomach, Most bezoars are of indigestible organic matter such as hair-trichobezoars; or vegetable and fruit the – phytobezoars; or a combination of both but other rare substances has been also been described in literature. Trichobezoars, commonly occur in patients with psychiatric disturbances who chew and swallow their own hair. Only 50% will have history of trichophagia. Trichobezoars have been described in literature and they comprise 55% of all bezoars. In very rare cases the Rapunzel Syndrome hair extends through the pylorus into the small bowel causing symptom and sign of partial or complete gastric outlet obstruction. Rapunzel Syndrome is a rare form of trichobezoar. It is named after a tale written in 1812 by the Brothers Grimm about a young maiden, Rapunzel, with long hair who lowered her hair to the ground from a castle, which was a prison tower to permit her young prince to climb up to her window and rescue her.

Case submitted by Dr Rammohan Vadapalli, Senior Consultant Radiologist from Hyderabad.

Human Touch in MRI Scanning

"  GE Healthcare has introduced the innovative Magnetic Resonance (MR) Patient Experience Suite, part of its healthymagination strategy to improve the quality of patient care. The suite aims to 'humanize' radiology by softening the clinical look, feel and sound of a traditional MR exam. The MR Patient Experience Suite was conceived by GE Global Design and was created by PDC Facilities, Inc., to reflect the award-winning themes of GE's w-series (wide bore) MR. The suite incorporates the 'caring hands' design philosophy of the Discovery* MR750w system, with lighting, interior decor, scenery and music or sounds that can be customized by the patient using his or her own portable media player. Light, form, color, materials and texture transform the exam environment from one that is cold and clinical to, for example, a home library and fireside"

Reference and further reading at :

GE Healthcare 'Humanizes' Radiology Exams with MR Patient Experience Suite

Carcinoma Sigmoid Colon-CT

There is extensive thickening of the bowel wall in relation to the sigmoid colon with overhanging edges.

Monday, November 28, 2011

Azygos Anterior Cerebral Artery

An azygos anterior cerebral artery is an uncommon to rare variant seen in approximately 0.4 -1% of the population 1 in which the two A1 segments of the ACA join to form a single trunk. As a result no anterior communicating artery is present.

Saturday, November 26, 2011

Invasive sacrococcygeal Teratoma-CT

6 year old child with evidence of large  (appx 10 x 8.7cm in transverse sections) infiltrating and poorly marginated mass in the left gluteal region with solid component and patchya areas of fat density infiltraing the gluteal muscles, extending into left ischiorectal fossa with loss of planes and displacement of rectum. There is intrapelvic extensionthrough the sciatic notch and displaces the rectosigmoid. There is widening of spinal canal and intraspinal extension of the mass. There is evidence of left inguinal lymphadenopathy.

Findings indicate fat containing mitotic infiltrative etiology, with extrapelvic, perineal, intrapelvic and intraspinal extension-possible lymphnodal spread- possibilities include sacrococygeal teratoma versus differentials. Histopathological correlation suggested.

Pleomorphic Adenoma-MRI

This 22 year old male shows a relatively defined lesion in the superficial lobe of parotid measuring 2.0 x 1.7cm appearing hypointense on T1 weighted images and hyperintense on T2 and STIR images. There is inhomogenous post contrast enhacement. Deep lobe of parotid is not involved. Neurovascular planes are preserved. Planes with underlying masseteric muscles are maintained. On MRI, pleomorphic adenomas are usually well-circumscribed, homogeneous masses with low intensity on T1-weighted images and high intensity on T2-weighted images. They commonly have a rim of decreased signal intensity on T2-weighted images. After gadolinium enhancement, the tumors are homogeneously enhancing unless they are large.

Pulmonary Artery Dilatation-CT

Various authors have found that individuals with intrinsic lung disease can be identified as having pulmonary hypertension if the main pulmonary artery is greater than 29 mm. The upper limit of normal for the diameter of the pulmonary artery is 28.6 mm. A value greater than 28.6 mm suggests increased pressures in the pulmonary system. 

Wednesday, November 23, 2011

Informal Second Opinion in Hospital Practise-"To do or not to do"

There is a query that is often faced by radiologists in hospital practise, where clinicians often send films or CDs done outside the facility for second opinion and sometimes say please send a written note of my observations Often these are not accompanied by report of the previous films. 

What should be done in such a scenario?
If i dont read them- I risk spoiling the relations and often the referal to the centre?
If i do- is there a risk of malpractise? 
Should we charge for these studies? 

Even if these opinions are given verbally, i have often seen clinicians add a line in their files "as discussed with Dr X" and make me legally liable for my opinion even if we did not charge for the read. Are their any guidelines for such practise? What is the correct thing to be done according to Indian Radiology Association?

All comments and opinions are welcome.

Term of the day: Mosaic Attenuation

"Mosaic attenuation is a CT pattern defined by the Fleischner Society glossary as a “patchwork of regions of differing attenuation seen on CT of the lungs.” It is characterized by heterogeneous lung attenuation with well-defined borders corresponding to the secondary pulmonary lobules. The name derives from mosaic artwork, which consists of variously colored glass or stone tiles inlaid in a contrasting pattern. The three major pathologic causes of this pattern are pulmonary vascular, small airways, and primary parenchymal disease. "

Further reading and reference-AJR December 2011 vol. 197 no. 6 W970-W977

Tuesday, November 22, 2011

Pitching Injury-MRI Shoulder

This is young pitcher with shoulder pain. MRI shows cystic changes at the insertion site of infraspinatus.If the history is acute may indicate  bone injury or microtrabecular fracture and if the history is chronic may suggest erosion. Symptomatic cystic changes are known to occur at this site in pitchers and this should not be confused with hill sach's lesion.

Saturday, November 19, 2011


6 year old boy with seizures and developmental delay shows on MRI, smooth cortical surface of the supratentorial brain parenchyma with suggestion of subtle sulcation in inferior frontal and temporal lobes. There is no cyst formation of the basal ganglia / hypoplasia of cerebellum / agenesis / hypoplasia of corpus callosum / ocular or collicular abnormalities / posterior parieto-occipital hyperintensity band sign (Attributed to accumulated CSF signal in the absence of neuronal cells. There is extensive white matter T2 / FLAIR abnormalities. The features are suggestive of lissencephaly variety of neuronal migration  with possible leukodystrophy.

Walker – Warburg Syndrome or Fukayama Disease are less likely in the absence  of cephaloceles, callosal / occular including retinal / collicular and brainstem / cerebellar abnormalities / Polymicrogyria / muscular dystrophy.

Teaching Points  by Dr MGK Murthy, Dr Sumer Sethi,  Mr Hari Om, Mr Hamid.

Cortical formation classification have undergone many changes and is presently restricted to the variety based on major stages of formation.

1. Abnormal neuronal cellular proliferation.
- Extends from ventricles to piamater.
- Could be due to too few neurons (Microlissencephaly) / too many
neurons (Hemimegalencephaly) / abnormal cells (Focal cortical dysplasia).

2. Abnormal neuronal migration.
- Located usually in the white matter and / or cortex.
- Arrest of migration (classic lissencephaly) / over migration
(Cobblestone lissencephaly) / ectopic migration (Heterotopia).

3. Abnormal neuronal organization.
- Located only in the cortex.
- Usually due to prenatal ischemia / infection.
- Injury to the superficial parts of the brain (Polymicrogyria) / injury to  the whole thickness of the brain (Schizencephaly).

Classical lissencephaly could be with smooth brain surface (complete form) or with some sulcation in the inferior frontal and the temporal lobes (incomplete form). Complete form presence with seizures or developmental delay, where as incomplete comes with hypotonia / microcephaly / facial dysmorphism.

Friday, November 18, 2011

Blow Out Fracture-MDCT

A young adult with history of injury to the left face with diplopia and restricted gaze, shows on the multidetector CT (128 slices), an orbital floor fracture with inferior rectus intrapment with a chip of the communited component lying as a satellite piece.

Teaching points by Dr MGK Murthy, Dr Sumer Sethi, Mr Hari Om & Mr Shekhar:
Smith and Regan described blowout fracture  in 1957, as orbital floor fracture (maxillary / zygomatic / palatine bones constitute the floor measuring 35 to 40 mm and shortest of all the walls, not reaching upto the orbital apex). Second most common mid facial fracture after nasal bones.
Mechanism usually involves impact injury, large enough not to perforate the globe and small enough not to fracture orbital rim.
Leads to increase in intraorbital hydrolic pressure.
Most occur in posteromedial region which is the thinnest and medial to the infraorbital groove.
Orbital emphysema, intraorbital bleed, inferior rectus entrapment, globe injuries including Hyphaema, retinal injury are possible accompaniments.
CT delineates the fracture including any associated fractures like zygomatic / lefort type II / III, and fracture orbital rims.
Early repair with plating and steel wiring has been practiced for long along with recent biocompatible implants and microplatings.

Thursday, November 17, 2011

Term of the day: HIMAL-Hippocampal Malrotation

Temporal lobe epilepsy is the most common form of partial epilepsy, and hippocampal sclerosis is a common radiologic finding. It is also possible that developmental abnormalities of the hippocampus may predispose or otherwise contribute to epileptogenesis. In normal fetal development, the hippocampus inverts within the medial temporal lobe. In cases of hippocampal malrotation (HIMAL), hippocampal inversion fails to occur.  Further reading : AJNR 2009 30: 1571-1573 . If anyone has a characteristic image and wants to share here, please email me the images and we will acknowledge the contributor on this blog.

Described by Barsi et al, the criteria for HIMAL include :
Ø  Unilateral involvement and incomplete rotation of a hippocampus that is normal in size and signal intensity, but abnormally rounded in shape so that the dimensions in either direction are equal, with blurred inner structure.
Ø  In addition, ipsilateral findings of an atypical collateral sulcus angle and atypical position and size of the fornix were noted.
Ø  The normal collateral sulcus angle is flat at the level of the body and tail of the hippocampus. In cases of HIMAL, the collateral sulcus angle is more vertical.
Ø  The normal position of the fornix is symmetrical. In cases of HIMAL, the fornix can be unilaterally downwardly displaced.
Ø  The corpus callosum is normal, and the temporal lobe remains normal in size, though the temporal horn may appear enlarged.

Hypertrophic Olivary Degeneration-DTI

Hypertrophic olivary degeneration (HOD) is usually caused by a lesion in the triangle of Guillain and Mollaret and presents clinically as palatal tremor. This case is a young lady with known lesion and palatal myoclonus. Palatal tremor, also known as palatal myoclonus, is a rare movement disorder that has intrigued investigators since the 19th century. Symptomatic palatal tremor is usually the result of a lesion in the triangle of Guillain and Mollaret and is associated with hypertrophic olivary degeneration (HOD) that can be seen on MR images as enlargement of the inferior olivary nucleus (ION), with increased signal on T2- and proton density–weighted images. The triangle of Guillain and Mollaret is defined by three anatomic structures: the dentate nucleus, the red nucleus (although not functionally part of the circuit), and the ION. Fiber tractography showed decreased volume of the right central tegmental tract, supporting a diagnosis of HOD.
WINKING FROG SIGN: Look at the antero lateral medulla showing reduced CST color code and anisotropy. Seen in HOD and other CST degenerations (Both primary and secondary).Described first by Prof Sunaret et al in 2005.

Case submitted by Dr Rammohan Vadapalli, Senior Consultant Radiologist from Hyderabad.

Polycystic Kidney Disease-CT

ADPKD is the most common of all the hereditary cystic kidney diseases.  ADPKD is characterized by progressive cyst development and bilaterally enlarged kidneys with multiple cysts. Cyst formation begins in utero from any point along the nephron, although fewer than 5% of nephrons are thought to be involved. As the cysts accumulate fluid, they enlarge, separate entirely from the nephron, compress the neighboring renal parenchyma, and progressively compromise renal function. The major extrarenal complications of ADPKD include cerebral aneurysms, hepatic cysts, pancreatic cysts, cardiac valve disease, colonic diverticula, and aortic root dilatation. These are CT images of 46 year old male showing enlarged kidneys with multiple cysts and renal calculus along with associated hepatic cysts.

Wednesday, November 16, 2011

EMI Original CT scanner

Ever wondered how the original CT scanner looked like? 

The first commercially viable CT scanner was invented by Sir Godfrey Hounsfield in Hayes, United Kingdom, at EMI Central Research Laboratories using X-rays. Hounsfield conceived his idea in 1967.The first EMI-Scanner was installed in Atkinson Morley Hospital in Wimbledon, England, and the first patient brain-scan was done on 1 October 1971. It was publicly announced in 1972.

This is the original photograph by philip cosson showing the first comercial CT head scanner Image uploaded from the English Wikipedia.
English Wikipedia: en:File:Emi1010.jpg.

Radiation Dose Management

We all have faced this query sometime with our patients and referring physicians regarding radiation doses and now it is possible to give an objective answer.  "DoseWatch dose management solution from GE Healthcare uses data acquired from imaging systems, retrieves, tracks, reports, and monitors the radiation dose delivered to patients during an examination and presents this data in an organized manner. Multi-modality and multi-manufacturer, it can be adopted in any imaging program."

For more information visit

Sesamoid Fracture-Plain Film

An adult with history of  injury with pain and swelling near the great  toe. X rays AP/oblique  show three sesamoids instead of usual two, with jarred, and sharp margins of horizontally cleavaged medial sesamoid with soft tissue shadow in the vicinity . In view of local tenderness possibly represents fracture.

Teaching points by Dr MGK Murthy & Dr Sumer Sethi
·         Sesamoid bones occur in the tendon of flexor hallucis brevis(FHB)  in the plantar surface of great toe and are 2 in numbers called tibial and fibular sesamoids
·         Play an important role in giving mechanical advantage to FHB in assisting weight bearing  behind  great toe , in addition to keeping the  head of MT off the ground , with medial sesamoid playing more role  in this
·         Can  be bipartite in about 10% of people (amongst them 25% are bilateral), in which case it  looks 3 in numbers(medial is more bipartite than lateral), with occasional  one multipartite
·         Fracture shows  sharp edges, corners/jarred margins/invariably transverse or horizontal/more involving medial/Soft tissue swelling/pain/local tenderness /other side absent (bipartite is well defined and medial more along with corticated margins)
·         Bone scintigraphy positive only in fractures or MR shows marrow edema
·         Other diseases include sesamoiditis/avascular necrosis/displacement/stress fracture 

Tuesday, November 15, 2011

Non-ossifying Fibroma-Plain Film

Adolescent with pain after trauma  shows intramedullary lesion  consistent with Non ossifying fibroma

Teaching points by Dr MGK Murthy & Dr Sumer Sethi

Ø  30 to 40% of children above 2 yrs show in one (75%)or more (25%) bones
Ø  Usually lower extremities 90%
Ø  Etiology is not known, but could be developmental aberration at epiphysis or muscle pull with periosteal injury as it occurs only after 2 yrs

Ø  Geographic/well marginated/lytic/multilobulated, foamy, mildly expansile/metaphyseal/usually purely intramedullary/eccentric /sclerotic rim/with endosteal sclerosis lesion  on all modalities
Ø  Heal with replacement by normal bone
Ø  Pathological fracture is possible if involves more than 50% of bone diameter or more than 33mm in size
Ø  Associated with  Neurofibromatosis/Osggod-schlatter disease/osteochondritis patella and femur/perthes disease
Ø  Together with Fibrous cortical defect called Fibroxanthamata

Thursday, November 10, 2011

Subungal Glomus Tumour-MRI

Small oval altered signal intensity soft tissue lesion on volar aspect of tip of left index finger displaying isointense signals to muscle on T1 weighted imaging and hyperintense on T2 weighted and STIR sequences. No evidence of MR demonstrable calcification present. No connection with the DIP joint or synovial cavity noted. Scalloping of distal phalanx seen on volar aspect with no e/o any destructive lesion. On MRI glomus mass is usually isointense to dermis of the nail bed on T1 weighted images and homogenously hyperintense on T2 and Fat sat T2 weighted images. Axial and coronal T2 weighted images are usually enough to make the diagnosis. Case submitted by Dr Rishu Sangal, MD.

Wednesday, November 09, 2011

Balance between Radiology Career and Family

In recent article in AJR November 2011 vol. 197 no. 5 W814-W816  author Priscilla J. Slanetz discusses how she managed to balance family priorities with family. She starts off with Few would debate that our medical educational system produces competent knowledgeable physicians. However, most would agree that it does not prepare graduates for the challenge that lies ahead with regard to balancing career and family demands. Well, I feel things are similar across the globe when it comes to balancing professional and family life.  She then offer 10 easy steps to balance the two and out of the points mentioned line  Add “NO” to your vocabulary.” Looks so appropriate.

Well you can not have it all, so have your priorties RIGHT and say no to what you cannot bite.  Worth the complete read.

Monday, November 07, 2011

3D Ultrasound images

Hoping that our readers are enjoying welcome predominance of ultrasound images in last week or so with many submissions from different prominent radiologists. This week we have some excellent visually delightful 3dimensional ultrasound images submitted by Dr Shashank Khanna, Sr Radiologist from Jodhpur. These are selected images from his collection with images showing-fetus yawning, cord around the neck and ureterocele. 

Sunday, November 06, 2011

Nutcracker Syndrome-Ultrasound

 Young male with painless hematuria: USG shows compression of the left renal vein between the aorta and the superior mesenteric artery s/o Nutcracker syndrome. Patient had left sided varicocele also.

Case contributed by-
 Dr Ravi Kadasne, Radiologist
Emirates International Hospital Al Ain, UAE

Wednesday, November 02, 2011

Peripheral Bronchopleural Fistula-CT

On chest radiographs, a bronchopleural fistula usually appears as an intrapleural air-pleural fluid collection-a hydropneumothorax. The fistula itself is almost never visualized directly but is implied in the proper clinical scenario. CT scans show focal areas of low-attenuation lung consolidation that appear to communicate directly with an empyema and an obvious disruption of the visceral pleura with associated air as in this case of a 7month old child.

Tuesday, November 01, 2011

Microdose Mammography-New Development

"Royal Philips Electronics has now introduced MicroDose Mammography, a full-field digital mammography (FFDM) solution that offers a lower radiation dose, as compared to other FFDM systems, without compromising image quality. MicroDose is the only FDA-cleared mammography system that uses X-ray photon-counting technology. Similar to light-emitting diode (LED) lighting which uses less wattage than traditional incandescent bulbs while providing high light output, the Philips MicroDose patented photon-counting detector utilizes less radiation while delivering excellent image quality."

SOURCE Royal Philips Electronics

Blog Archive