Friday, December 30, 2011

Carpal Fusion-Plain Film

Young adult with pain after trivial fall shows carpal fusion possible isolated without any syndrome of proximal row, presumably involving lunatotriquetral (most common amongst the anomalies). Comparative xray of other hand and CT would help delineate it further

Teaching points by Dr MGK Murthy, Dr Sumer Sethi.
·         Fusion of carpal bones is misnomer as it is not true fusion and is absence of  joint cavitation and chondrification of joint inter zone
·         Leads to synostosis and seen only when  all carpal bones ossify
·         Incidence is 0.1% of population with  increase amongst the females(twice),  and Africans with family history
·         Usually bilateral with left more involved if unilateral
·         Usually asymptomatic but some like pisohammate could lead to pain
·         Reduced movement leads to compensated movements at other  inter carpal joints and premature stress related  degeneration
·         Congenital fusion are two types –isolated ones show usually two bones of the same row
·         Syndrome associated  ones like Ellis van Creveld syndrome, Osteochondritis dissecans, foetal alcohol syndrome, symphalangia, diastrophic dwarfism, gonadal dysgenesis, and Poland syndrome, are quite often multiple

Thursday, December 29, 2011

" Cheating" Radiology Colleague

How many of us have sometimes felt to be on wrong side of a cheating colleague. In my last job there were say 3 odd radiologists all on a fixed payroll in a hospital and hospital management would keep a track on our work based on number of CT and MRIs that we reported. One of the colleagues had this odd habit of picking up the straight forward normal cases where all you had to write or dictate was “normal” and get his number for the day to 10 and push just one case of complicated case to me which would require some brain storming, googling, dictation and explaining to the referring physician but as per the hospital management i had done only 2 cases that day.  Later on we started to randomly report alternate cases to eliminate such filtering of cases.
In our own consult service where we offer teleradiology services, some of the centres for which we report, there is a radiologist on site. Invariably, i see one of them just pushing one of the odd cases to us and managing most of the simpler cases and at the end we get paid for one case and they appear useful/efficient to the management. 
Is this different in your settings? Does your management think only in terms of numbers not the kind of cases / opinion you are offering? What do you think? Does this happen where radiologists are reimbursed per case ? Is this a fixed pay package phenomenon?

Conference Alert- ARRS Annual Meeting

American Roentgen Ray Society's 2012 Annual Meeting in Vancouver, CA this spring. This is the link to the microsite for the meeting.

Key features-

  • 56 CME, category 1 AMA credits will be offered
  • The categorical course is on Clinical Pitfalls
  • There are 11 subspecialty tracks including one designed especially for residents and in-training radiologists.

Wednesday, December 28, 2011

BPOP versus differentials

This is a case of 17 year old female with pain and swelling over 5th metacarpal head dorsally.  Case submitted by: Dr. Wael Nemattalla, MD, Radiodiagnosis from  Egypt. 

Differential diagnosis:
1. Periosteal chondrosarcoma (juxta-cortical chondrosarcoma).
2. Parosteal osteosarcoma.
3. BPOP (bizarre parosteal osteochondromatous proliferation).
4. Reactive florid periostitis.
5. Rarely is cartilage cap chondrosarcoma with totally destroyed most of the osteochondroma but the presence of such large bony component in X-ray is mitigating against such assumption. 

The mass over dorsum of 5th metatarsal head shows malignant features in MR like cortical interruption, bone marrow involvement and avid heterogeneous soft tissue enhancement. Concerning internal bony structure in X-ray film; periosteal chondrosarcoma (juxta-cortical chondrosarcoma) is preferred over other diagnoses. STIR hyperintensity is in favor of chondromatous tumor. 

Parosteal osteosarcoma may also included in DD due to younger patient's age but is rare in hands. 
BPOP (bizarre parosteal osteochondromatous proliferation) is a benign lesion and is common in small bones of hands and feet in younger age groups but usually associated with T2 hyperintense cartilage cap and peripheral and/or partial enhancement of the bony mass; cortex is intact in BPOP; in our case cortex and bone marrow are involved. 

Reactive florid periostitis is also in DD but usually associated with intact cortex and laminated periosteal reaction. Sometimes florid reactive periostitis may have aggressive appearance similar to malignancy; it may have cortical and bone marrow involvement as well as marked soft tissue enhancements.

New-york times reports "Distracted Doctoring"

According to a news item in New York times, technology is usually projected to be of great help to the medical profession but now question is being asked if it is a distraction as well? What about radiologists, i think we guys should be an exception, we enjoy being connected to all our social networks while working don't we?  What are your views? Is technology now a double-edged sword in healthcare?

Read on what the news papers says-Meant to give medical staff instant access to patient data, drug information and case studies, the technology is drawing criticism that doctors and nurses can be focused more on the screen than on the patient, The New York Times reported Thursday. And it's not always used as intended, critics say, citing examples of a surgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll finding half of technicians running bypass machines admitting to texting during a procedure, the newspaper said.”

Tuesday, December 27, 2011

Filarial Dance Sign-USG

Ultrasonography is able to detect adult Wuchereria bancrofti worms in scrotal lymphatic vessels of infected men on account of the characteristic pattern of adult worm movements, known as the filarial dance sign. Furthermore, the technique is able to delineate associated pathology, such as hydrocoele and lymphoedema, which can be diagnosed in early stages. 

Monday, December 26, 2011

Post Radiology Diploma (DMRD) CET or Secondary DNB CET

Post Diploma CET /Secondary DNB CET

This is some basic information for people pursuing DMRD or any Diploma be it DCH, DGO, DORTH, DOMS, DMRT, DA, DVD, DPM, DNM, regarding the now proposed Post Diploma CET.

Pattern of examination
MCQ based examination comprising of 180 MCQs of 1mark each with following scheme:
a) Applied Basic sciences
i) Anatomy, Biochemistry, Physiology 30 MCQs
ii) Pathology, microbiology, pharmacology 30 MCQs
b) Medicine and allied sciences 30MCQs
c) Surgery and allied sciences 30MCQs
d) Obstretic & Gynecology 30MCQs
e) Community Medicine, basic statistics, research methods.

Duration 3 hours
Level of FINAL MBBS, No negative marking. Merit list will be published speciality wise

so we at DAMS have been the pioneers for post graduate medical entrance examination including NEET exam which has been purposed recently. We offer our various courses including regular class room, test & discussion, distant learning programmes to aspirants of PG CET as well. It is clearly mentioned in National Board  Website that this exam will be at level of FINAL MBBS so joining us makes SENSE and we can guarantee success and help you secure HIGHER in the MERIT LIST.  Join DAMS at this crucial stage of our career and get the famous DAMS EDGE.

Detailed Brochure Post Diploma CET

Hypoplastic Uterus-MRI

14 year old girl presented with primary amenorrhoea, with normal secondary sexual charectaristics and karyotyping. USG suggested Mullerian ductal developmental anomaly. MR suggest class I, American Fertility Society (AFS) classification anomaly with apparently normal but hypoplastic structures.

Teaching points by Dr MGK Murthy, Dr Sumer Sethi, Mr Hari Om, Mr Sahadev:

Two paired Mullerian ducts form predominant female reproductive system components including fallopian tubes, uterus, cervix and upper 2/3rds of the vagina. Ovaries are formed from Germ cells that migrate from primitive yolk sac to mesenchyme of the peritoneum to subsequently form Ova and supporting cells. Lower 1/3rds of the vagina is formed from sinovaginal bulb.

3 phases of Mullerian ductal developmental anomalies are possible.

a) Phase of Organogenesis in which, one or both ducts may not develop completely leading to complete agenesis / hypoplasia / unicornuate anomalies.

b)  Phase of lateral fusion where the lower segments of the Mullerian ducts fuse to form uterus, cervix and upper 2/3rds vagina. Failure of this could lead to bicornuate or Didelphys anomalies. Vertical fusion is referred to ascending sinovaginal bulb fusion to descending Mullerian system. Complete fusion leads to normal vagina, incomplete would produce imperforate hymen.

i) Septal resorption – After lower Mullerian system fuses, septum which is present gets resorbed naturally. Failure leads to septate uterus anomaly.

AFS classification suggests 7 varieties of Mullerian Ductal anomalies :

Class I – Hypoplasia / Agenesis (Mayor / Rokitansky / Hauser Syndrome refers to complete absence)

Class II – Unicornuate,      III – Didelphys,       IV – Bicornuate,       V – Septate,       VI – Arcuate
  & VII – Diethyl stilbestrol related 'T' shape uterus.

Obstructive Sleep Apnea-MRI

A young adult with clinical sleep apnoea (lasting more than 10 seconds and atleast 5 per hour), with polysomnography suggesting moderate OSA (Obstructive sleep apnoea) on Dynamic MR shows significant reduction of oropharyngeal air column under induced sleep and mullers manoevuer, with absence of air column in atleast one image in the cinemode.

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

Sleep apnoea is common snoring medicle problem ocuring predominantly in males between 30 to 60 years, leading to day time sleeping and loss of man hours.

Three types are described :

          a) Central where, neural drive is reduced.
          b) Obstructive where, oropharyngeal (Velopharynx), air way narrowing / occlusion – Most common.
          c)  Mixed – Central variety superadded with obstructive component..

Radiology (Primarly MR in mid sagittal and mid axial slices) plays signifiant role in anatomic delineation of the abnormalities including presence of retrognathia, macroglosia, bulky soft palate, high arched palate, posteriorly located palate, reduced mandibulohyoid distance etc.

It also plays a role in demonstration of functional abnormality in induced sleep - Reduced measurements of oropharyngeal air column in wakeful and sleeping state.

Mullers Manoevure (Reversal of Valsalva) can practically replace need for Induction of the sleep in the gantry, demonstrating similar accuracy.

Upto 50 % of reduction of the airway in wakeful to sleeping is considered normal.

More than 70 % is significant.

More than 90 % with atleast one image in the cine-acquisition showing absence of the aircolumn is pathognomic.

Lateral pharyngeal wall collapse leads to 'T' shaping of the sleeping state air column in these patients.

Saturday, December 24, 2011

Pigmented Villonodular Synovitis Ankle

Here is a case of PVNS. 32 years old female with gradual onset ankle swelling. No local manifestation suggestive of arthritis. She is not known to be rheumatoid arthritis patient.  Case submitted by: Dr. Wael Nemattalla, MD, Radiodiagnosis from  Egypt. 

Pigmented villonodular synovitis (PVNS) is relatively uncommon. The disorder results in increased proliferation of synovium causing villous or nodular changes of synovial-lined joints, bursae and tendon sheaths. PVNS should be considered in athletically active patients with persistent lateral ankle pain and swelling, particularly if bone erosions are visible on plain radiographs.

Thursday, December 22, 2011

Be Featured on Our Blog

Send in your interesting case, thought or any random rambling related to radiology and we'll post it here for your peers to see. Just provide images and a short write-up.  It's the easiest way to get published on the web on our very popular blog with dedicated readers from around the world. 

You can send your cases to -sumerdoc-AT-yahoo-DOT-com

Wednesday, December 21, 2011

Lumbar Interspinous Bursitis (Baastrup Disease)

This is also known as kissing spine, is contact between spinous process of the lower lumbar spine. According to various reports, Lumbar interspinous bursitis (Baastrup disease) is uncommon but not infrequent in symptomatic patients undergoing lumbar spine MRI. Patients with MRI evident Baastrup disease tend to be older, have central canal stenosis, bulging discs, and anterolisthesis.

Monday, December 19, 2011

Retroperitoneal Fibrosis limited to Perinephric spaces-Rare Disease

78 year old treated case of collagen disorder in the past with immunosuppression on routine USG Abdomen is detected to have perinephric heterogeneous echogenic regions compressing and paging the kidneys (right > left). MDCT study delineates extensive, symmetrical, perinephric spaces, heterogeneous enhancing nodular mass lesions with fat stranding, compression and displacement of the kidneys, with dilated pelvicollecting system on the right along with ureter with rest of the study including great vessels, origins of the main vessels and retroperitoneum in general unremarkable.Retroperitoneal fibrosis limited to the perinephric spaces is likely.

Teaching Points by Dr MGK Murthy, Dr Sumer Sethi, Mr Hariom Sharma :
·RPF is characterized by proliferation of fibrous tissue around the aorta, through a plaque like infiltrative soft tissue process and commonly involves infrarenal aorta and iliac vessels.
·2/3rds are idiopathic with a male preponderance. RPF as an isolated disease or as a part of other autoimmune disorders is known.
·Perirenal involvement could be secondary or may occur as in this case without associated RPF. 3 stages are described ranging from chronic active inflammation to fibrous scaring.
·Imaging could show soft tissue mass that envelops the kidneys with or without displacement. MR is good for demonstrating high T2 signal and early contrast enhancement in active inflammation stage, and low T2 signal with delayed enhancement in fibrosis stage. Isolated perirenal fibrosis is difficult to diagnose and in cases of doubt biopsy would help.

Sunday, December 18, 2011

Latest CT reports on Otzi -the iceman


New CT scans revealed a deep incision on the right eye of Ötzi the Iceman. Experts disagree about whether an arrow wound killed the Iceman, or if a fall or blow to the head did him in. 

Detailed report here.

Thursday, December 15, 2011

Entrepreneurship in Radiology-IRIA 65

Entrepreneurship in Radiology. This is the title of the talk for which i am invited faculty in IRIA 65th in Hyderabad. Something which is very close to my heart. I have always felt our radiology education system has somehow neglected this very important aspect and we have lost turf to other people because of relative lack of long term vision and zeal to create our own business in young radiologists. Fat pay package is a poison for an entrepreneur. I am sure my talk will inspire more young radiologists into creating their own brands. Please post or email any ideas or thoughts you have regarding this topic.

Tuesday, December 13, 2011

Subacute osteomyelitis-Epiphyseal Involvement

This is a case of 15 year old male with pain, swelling and on aspiration pus was noted. There are areas of altered marrow signal alteration involving the diapmetaphyseal region and extending across the physeal cartilage to involve the epiphysis with patchy areas of T1 hypointensity and T2 /STIR hyperintensity. There are areas of cortical tunneling and minimal fluid collection in the knee joint and suprapatellar bursa.  Findings likely indicate an infective etiology possibly subacute osteomyelitis, which may involve the epiphysis as well. Interconnecting subacute osteomyelitis of the epiphysis and metaphysis is readily explainable in infants younger than 18 months, when one considers that vascular communication between the epiphysis and metaphysis is present until age 18 months.  Epiphyseal lesions may also occur in older adolescents when the growth plate becomes attenuated and fails to provide a barrier to epiphyseal infection.  

Friday, December 09, 2011

DoseWise Initiative

Radiographer of the Year Award 2011

In recognition of the essential role radiographers and radiography technologists play in in the safe delivery of best clinical care to patients, we initiated the Radiography of the Year Award. The award recognizes excellence in maximizing patient and clinical safety by managing medical radiation in the X-ray environment.  Are you DoseWise?
Nomination Deadline: 31 December 2011

Left Ventricular Hypertrophy- Cardiac MRI

Adult male, Known case of concentric LVH on MRI shows : Significant concentric left ventricular wall thickening with septal involvement and hypokinesia of the apical region on cine loops with suggestion of mitral regurgitation. There is mild pericardial effusion all around. Rest of the chambers are normal. Case submitted by Dr MGK Murthy, Dr Krishna Murthy.

Delayed Enhancement-Cardiac MRI

A young male with symptoms of coronary artery disease, shows occlusion of LAD and RCA on cath. CEMRI shows delayed enhancement of transmural nature in the myocardial segments 1, 4, 5, 8, 10 to 12 and 15 to 16 suggesting possible scar formation. There is hypokinesia on the cine loops in the regions affected. Presence of Delayed  contrast enhancement of the myocardium on  inversion recovery gradient echo picture would suggest it to be scar. Case Submitted by Dr MGK Murthy, Dr Krishna Murthy.

Myocardial  segments are named and localized with regards to wall motion abnormalities and delayed enhancement pattern according to American Heart Association classification and are assigned to three major coronary territories.

Basal =

1. Anterior
2. Anteroseptal
3. Inferoseptal
4. Inferior
5. Inferolateral
6. Anterolateral

Mid =

7. Anterior
8. Anteroseptal
9. Inferoseptal
10. Inferior
11. Inferolateral
12. Anterolateral

Apical =

13. Anterior
14. Septal
15. Inferior
16. Lateral

Apex = No. 17.

Basics of Cardiac MRI

Uses:      Congenital Heart Disease, masses, pericardium, Right  ventricular dysplasia, Hibernating myocardium (presently).MR gives more  temporal  and  contrast resolution  vs CT giving more spatial resolution Myocardial perfusion and Ventricular as well as valvular functions are very accurate on MR, but presently clinical science  uses Echo and SPECT studies for them.

Imaging Planes:     Main planes are oblique  to one another , and as they are at arbitrary angles  to the scanner , referred to as ” Double Obliques”
3 Most important  (a) short axis -take 4 chamber  gradient echo axial -----plan perpendicular to ventricular septum----- gives short axis
(b)Horizontal  long Axis   (Long axis- from center of mitral valve to  LV apex) (4 chamber view)
(c) Vertical Long Axis (2 chamber view)
Others include  LV Out flow tract view(Ascending aorta best ) and 3 chamber view (aortic and mitral valves adjacent to each other )

ECG Gating  acquisition is usually the norm (firing usually in  Trigger window of diastolic  phase =typically 10 to 15% R -R interval)(Acquisition window  is  85 to 90 % of R R interval) . Problems with this gating include poor or inaccurate R  wave  and arrhythmias (handled  by medication or very fast sequences )

 Sequences can be summed up depending on main uses
Cardiac  Function: Cine Gradient echo sequences (Bright Blood ) include True FISP(Siemens),FIESTA(GE), and b-FFE(Philips)
Morphology  Function: Half Fourier  single shot fast spin echo sequences(Black blood)  used  include HASTE(Siemens) and SS-FSE( GE and Philips)
Perfusion Function: Magnetization-prepared gradient echo sequences are used to assess myocardial perfusion     .Turbo  FLASH (siemens),Fast SPGR (GE) , and TFE(Philips)
Viability/ infarction: Contrast enhanced  Inversion recovery gradient echo   sequence is used with inversion  time set to  null  viable  myocardium .
Angiography: not popular and uses 2D or 3D Gradient echo sequences

Black Blood  !
Protons must experience the 90° excitation pulse and the 180° refocusing pulse to generate a spin echo. If protons in flowing blood are not present in the slice long enough to experience both pulses, no spin echo is generated

What should I Use?

Fastest- half fourier  Single shot fast Spin Echo (SSFSE) with double inversion recovery time – done in 1 heart beat
Breath hold  SSFSE with inversion recovery time   - done as 1 slice per breath   to give better resolution
Multislice  FSE with free breathing 

Wednesday, December 07, 2011

Term of the day : "Pig Bronchus"

A true tracheal bronchus is any bronchus originating from the trachea, usually within 2 cm of the carina and up to 6 cm from the carina (27–28). When the entire right upper lobe bronchus is displaced on the trachea, it is also called a “pig bronchus” and has a reported frequency of 0.2%. 

Read more bronchial anomalies here :

My blog now available as iPhone & Android App

Exostosis-not always easy to identify!

Young Skeleton with pain after fall  shows exophytic opacity outwards from the metaphyseal location of humerus with undisplaced fractures in the vicinity  with almost 2 Humeral heads appearance   suggesting exostosis with suspicion for   secondary chondrosarcoma  of cartilage cap. MRI is needed for further evaluation.

Teaching points by Dr MGK Murthy, Dr Sumer Sethi.
·         Defined as developmental dysplasia of peripheral growth plate which forms cartilage cap  projection of bone near metaphysis of long bones. Peripheral chondroblast grows  outwards acting as ectopic growth  plate , stopping at maturity
·         Most common benign bone tumor. Any bone forming in cartilage can get involved
·         X ray hallmark is blending of tumor in to  the underlying metaphysis  along with calcification of cap elements 
·         Only 1% solitary  ones can turn secondary chondrosarcoma  at the cap , with  10%  in multiple variety
·         Cartilage cap measuring >1cm in adults and 2-3 cms in children on MRI along with  sudden increase in bone scan uptake in adults  is of concern
·         Other complications include bursal formation

Sunday, December 04, 2011

Recurrent Extra-axial Aspergilloma Mimicking Meningioma

40 year old male comes with history of headache and diplopia of 2 months duration in January 2010. CEMRI Brain was representative of a atypical meningioma with brain edema with only posterior ethmoidal mucosal thickening. At surgery and HPE, it turned out to be extra-axial aspergilloma. After Amphotericin B administration, following surgery, repeat scan 3 months later was near normal. However the present MR suggest gross recurrence. T2 low signals, extensive and disproportionate brain edema, apparent hyperdensity on CT could suggest this possibility.

Teaching points by Dr MGK Murthy, Dr Sumer Sethi, Mr Hari Om :

•Aspergilloma is one of the commonest fungi present in the soil, dust, vegetable matter and timber.

•Infection gets into the body by inhalation of spores into the lungs (preferably damaged tissue), and hematogeneously reaches central nerve system. Alternatively it can reach via nose and para-nasal sinuses.

•Contrary to the popular notion, aspergilloma could occur with no known predisposing immunocompromised factors including diabetes, as in this case. Carpenters by profession are more susceptible for this.

•Prognosis is general poor, though cure is possible with amphotericin B, and less toxic Econazole. Other fungi like Paecilomyces and cephalosporins could mimic aspergilous under the microscope.

Friday, December 02, 2011

Tibialis Anterior Rupture-MRI

Evidence of thickening and altered signal intensity in relation to tibialis anterior tendon with intrasubstance as well peritendinous hyperintensity and fluid signal. There is surrounding myofascial edema. These findings likely indicate laceration or rupture of the tibialis anterior tendon. This is young patient with history of dropping heavy object on foot.  Tears of TA can generally be divided into two categories: first, acute rupture secondary to laceration, a sudden violent force, and fractures; and, second, acute-on-chronic or spontaneous rupture. Spontaneous ruptures are less frequent, and most occur through its mid substance, which is the central portion of the tendon along its short axis.

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