Monday, March 26, 2012

Interventional Radiology for MS and venous insufficiency

 Researchers report that performing angioplasty on veins in the neck and chest is safe—and may be an effective way to treat the venous abnormalities found in those with multiple sclerosis and provide symptom relief. The findings were presented at the Society of Interventional Radiology's 37th Annual Scientific Meeting in San Francisco, California.

Read more here:

iPad 3 for the Radiologist

This version for iPad has more pluses for the radiologists and probably wil become the device for the Radiologist on the go.
- Higher resolution: retina display” of 2047 by 1536 pixels — double that of the iPad2.
- Higher memory
- Improved in-plane switching

With these improvements, can they become the primary read device in the future for Radiologists? 

Indian Radiologists move HC against restrictions under PNDT Act

Radiologists have moved the Nagpur bench of Bombay high court against the government's recent restrictions on them, including a ban on consulting at more than two places and hike in registration charges of ultrasound machines.

Friday, March 23, 2012

Pelvic Osteosarcoma-CT

This is a 16 year old girl with left pelvic mass. CT shows evidence of areas of osseous destruction along with areas of spiculated new bone formation, sclerosis in the left iliac blade, ischium and left acetabulum with associated extensive soft tissue component extending intrapelvic and extrapelvic region. There is displacement of the bladder and pelvic viscera to opposite side. There are areas of ossification in the associated soft tissue. Nodular lymphnodes with ossification/calcification are seen in the left inguinal and femoral region. There findings are likely consistent with mitotic etiology, differentials include osteosarcoma.  Biopsy was consistent with osteosarcoma.

Thursday, March 22, 2012

Myeloperoxidase as an Imaging Biomarker

Latest article in Radiology 111593; Published online March 21, 2012, talks of use of myeloperoxidase as an Imaging Biomarker and Therapeutic Target in Demyelinating Diseases. According to them, MPO could represent a promising therapeutic target, as well as an imaging biomarker, for demyelinating diseases and potentially for other diseases in which MPO is implicated. 

Intra-articular Osteoid Osteoma

  1. Osteoid osteomas have been categorized by location as subperiosteal, cortical, and cancellous. 
  2. The classic radiographic appearance of the more common cortical osteoid osteoma is that of a radiolucent nidus, with or without internal calcification and surrounding sclerosis or cortical thickening. 
  3.  This is in contrast to intraarticular osteoid osteomas, which are are characterized by little or no reactive sclerosis; for this reason, the radiolucent nidus is often overlooked on radiographs.  Although endosteal sclerosis may occur with intraarticular osteoid osteomas, periosteal new bone is absent, because the periosteum is not present within the joint capsule. In this patient there is reactive calcification in the periarticular region possibly secondary to synovitis.

Tuesday, March 20, 2012

Torus Fracture-Radius

  • Torus is derived from Latin (tori) meaning a swelling or protuberance
  • Break in cortical continuity on the compression side, 2-3 cm proximal to physis, torus (buckle) fractures of distal metaphysis of radius & ulna is most common fracture in lower forearm in young children
  • Deformity should not occur in torus fracture because the periosteum and cortex are intact on the side of the bone opposite to fracture

Adrenal Masses in Testicular Lymphoma

The most common primary testicular tumor in men older than 50 years is testicular lymphoma.  This is 84 year old man post operative status for testicular lymphoma showing bilateral adrenal masses and retroperitoneal lymphnodes suggesting possible relapse. Follicular lymphoma is the most frequently reported type of primary testicular lymphoma in the pediatric age group, whereas diffuse large B-cell lymphoma accounts for 80% to 90% of cases in adults.  Computerized tomography of the head, chest, abdomen and pelvis are required for staging and knowing extranodal involvement.  Testicular NHL has shown tendencies to relapse in central nervous system (CNS), contra lateral testis and, less commonly, lung, skin, bone, adrenal glands, liver, gastrointestinal tract and nodal sites. 

Saturday, March 17, 2012

AC Joint Disruption MRI

Evidence of altered signal intensity in relation to the AC joint with disruption of acromioclavicular ligaments and displacement of distal end of clavicle with respect to acromion process. There is increased signal intensity in relation to the coracoclavicular ligament as well. There is capsular distension and edema in relation to the AC joint. These findings suggest AC joint disruption as described.

Round Pneumonia-CXR

Round pneumonia refers to a rounded region of consolidative parenchymal pulmonary infection, usually identified in children.  The most commonly proposed theory is due to absence of collateral air communicating pathways in children (i.e. pores of Kohn, canals of Lambert) which limit spread of infection. On a CXR,the region appears as a rounded lung opacity with well formed borders. It is most commonly seen in the superior segments of lower lobes. Air-bronchograms may be seen, but are often absent.

Thursday, March 15, 2012

Tribute to Roengten's Gesture of not Patenting Xrays

Sometimes you feel things could have been better if everybody thought in the same way as this great man whose discovery is the basis for our science. Read this with the background of today's world, when we read about IT bigs fighting out in courts for patents, and people justifying paybacks for sending studies, this is extra-ordinary. 

"1901 Röntgen was awarded the very first Nobel Prize in Physics. The award was officially "in recognition of the extraordinary services he has rendered by the discovery of the remarkable rays subsequently named after him". Röntgen donated the monetary reward from his Nobel Prize to his university. Like Pierre Curie, Röntgen refused to take out patents related to his discovery, as he wanted mankind as a whole to benefit from practical applications of the same (personal statement). He did not even want the rays to be named after him."

Shared on twitter by Mariano Anto Bruno Mascarenhas


Recently, CT has become the imaging test of choice for the diagnosis of appendicitis. Sensitivity and specificity range from 94% to 98% based on findings of a thickened appendix with some degree of adjacent inflammation.  The main CT criteria for acute appendicitis are periappendiceal inflammatory changes, an appendix with a diameter of more than 6 mm, or a wall thickness of more than 3 mm.

Wednesday, March 14, 2012

Brief Radiology Resident Notes on Iodinated contrast media

 Introduction:   An attempt is made to discuss  the overview with existing  practice recommendations including by ACR and should not be construed as either complete  or perfect.  Submitted by Dr MGK Murthy
Definition : medium that increases contrast of  various anatomical structures  to differentiate between them
 Mechanism:  Increased absorption of X rays by them
Types: Positive(iodinated) and Negative (air or Co2)
Iodinated could be Oily/ water insoluble(not used) or Water soluble (WS)
WS could be monomeric , and dimeric(both having Ionic and non ionic  varieties)
Ionic ( high osmolar for practical purposes)
·        Monomeric salts of triiodinated  benzoic acid
·        Dissociates  while becoming  soluble
·        For every 3 iodine molecules present, 2 charged particles  (one  cation and one anion)produced (also called 3:2  compounds) which can interfere with brain and heart electrical activity to produce neuro and cardiotoxicity, apart from  increasing the osmolality(1400 to 1800 mosm/kg of water)
·        Anion is responsible for radio-opacity
·        If we make  them iso-osmolar to plasma/CSF (300),iodine  will be only 6% and not useful
·        Examples include, diatrizoate,iothalamate,and metrizoate

NON IONIC (Low osmolar)
·        Hypertonicity decreased(400 to 750 mosm/kg of water) as triodinated substitutes in the ring compound do not dissociate while becoming  soluble (side chains altered to make this possible )
·        For every 3 iodine molecules present, 1 neutral molecule(non charged) produced,  making them as 3:1 compounds
·        Osmotic dilution by body fluids is much less  leads to sharpness of image lasting longer  apart from increased opacity due to accumulation
·        Examples include  Metrizamide,iopamidol/iohexol

·        Most spoken about (hence not being discussed), exact cause not known
·        Usually due to physiochemotoxic(due to altered dynamics) or idiosyncrasies (higher iodine concentration may lead to higher risk), they are anaphylactoid in nature.
·        ACR  advises in some given high risk situations, steroids with prednisolone 50 mg orally 13,7,and 1 hour before procedure  along with 50mg of Diphenhydramine (benadryl) iv/im/oral with the last dose of prednisolne

·        ACR recommends testing  of serum creatinine  only  if there is clinical possibility of  renal dysfunction, or in high risk groups   (hx of renal disease including in the family, nephrotoxic drugs, diabetes , collagen diseases ,paraproteinaemias and all inpatients etc )

·         Between the pathologists serum creatinine level and nephrologists  GFR levels of  renal dysfunction(normal adult level is 120 to 130 ml/mt/1.73 sqm), lies the  Radiologists  domain and no consensus  exists

Various surveys have put levels of acceptance of (radiological) normal as 1.5 to 2.0 mg%, corresponding to appx 133 mmol/L, or Expected GFR of> 60 ml/mt/1.73 sqm, excluding  diabetics where   <1.68 mg% is  preferred.

·        Definition of nephrotoxicity is controversial as std European teaching of creatinine raising >25%(within72 hrs of contrast) is dented by studies claiming  normal variations of creatinine  could range from  0 to 40%
·        Pts on Metformin do not have  increased risk of contrast induced nephropathy(CIN). However if pt develops CIN, Metformin could produce  lactic acidosis
·        Preventive medication   like n- acetyl cysteine (600mg twice day  before and on day of test)(favoured by cardiogists) has not been accepted as radiological standard  of practice, however  may be used.
·        The most important thing seems to be adequate hydration{100ml oral or iv(0.9%N saline)per hour  starting 6 to 12 hours before , continuing  4 to 12 hours after the procedure}
·         Renal  insuffiency is defined(American  kidney society ) as GFR<60 ml/mt/1.73  sq m or  creatinine above 1.5 mg% (133 mmol/l),with loss of half or more of adult level of normal kidney function
·        Renal failure  is  GFR of <15 ml/mt/1.73 sq m ,which is when dialysis  etc is initiated

Monday, March 12, 2012

Diverticulitis- CT

Diverticula are identified on CT scans as outpouchings of the colonic wall. These outpouchings may contain air, barium, or fecal material. The diagnosis of diverticulitis with CT scanning is based on the detection of colonic and paracolic inflammation in the presence of underlying diverticula.

Out of Hour Radiology-Reads in Medical colleges

Recently came across this article in Acta Radiologica which  questioned registrars doing emergency reads in South Africa and this made me think about our training times. What about India , where in many medical colleges have post graduate students doing the emergency cover? What is their error rate? Do the government hospitals take patient care seriously in India by having PG students independently sign off reports? Do you think as a doctor we need to create a more accountable system in India tertiary medical schools for patient care?
Opinions and comments are welcome

Saturday, March 10, 2012

Idiopathic intracranial hypertension-MRI

Evidence of mild tortousity of optic nerves with distension of the perioptic subarachnoid space. Posterior sclera appears flattened.  There is evidence of partially empty sella with flattened pituitary gland. There is no obvious enhacing ICSOL. Venous sinuses are unremarkable. These findings indicate idiopathic intracranial hypertension.

Orbital Apex Meningioma showing hyperosteosis & Optic Nerve compression

Evidence of homogenously enhacing mass in the left anterior temporal region likely consistent with meningioma with involvement of the left orbital apex and intraorbital extraconal extension. There is extensive hyperosteosis of the sphenoid bone. There is mass effect on the optic nerve with displacement and distortion of the nerve consistent with compressive optic neuropathy. There is also resultant axial left sided proptosis. 

Thursday, March 08, 2012

Quiz for Medical Student & 1st Year Residents only

This patient is post hip replacement and had presented with hip pain. Diagnosis please.  Some history is being withheld in this 67 year old female and will be posted later. Think NEET and post your answers in the comments.

Correct Answer- Secondaries from Breast cancer. There are multifocal sclerotic lesions. 
Winner : EmiSpett

Spinal Cord Stimulators-Plain Film

An adult with post by pass surgery X ray chest for evaluation  shows  spinal cord stimulator located possibly at  D-10  for effective sciatica management.

 Teaching points by Dr MGK Murthy.

·         Spinal cord stimulation for analgesia is used to exert pulsed electrode stimuli to   cord  to control chronic pain
·         Consists of    epidural  electrodes(number could vary from 4 to 12) (Wire or paddle variety)at one or multiple levels usually in epidural space and  connected via wires  to the generator  in lower abdomen, or gluteal space (for patient to manipulate)
·         Alters local neuro chemistry at dorsal horns  by decreasing the hyperexcitability  of neurons(possibly by increasing GABA and serotonin)(decreasing glutamate and  aspartate)
·         Radiology has role to identify the gadget ,  assist in correct positioning and  look for complications like leads mal positioned, detachment, breakage, and migration etc
·         Complications are  extremely unusual , however could range from local discomfort to transient paraplegia
·         Indications are usually Chronic  pain , like  Failed back syndrome, sciatica, malignancy etc

Comparison of MR contrast Media

Results of the MERIT Study, the latest in a series of intraindividual studies compared MRI contrast agents within the same test subjects, published  in American Journal of Neuroradiology (AJNR Am J Neuroradiol. 2012 Mar 1. [Epub ahead of print]) . According to the study Significantly greater morphologic information and lesion enhancement are achieved on brain MR imaging with 0.1-mmol/kg gadobenate dimeglumine compared with gadobutrol at an equivalent dose. 

Reference: AJNR Article

Femoro-Acetabular Impingement-MRI

There is evidence of altered signal intensity in the left femoral head in its superolateral aspect along with altered signal and cystic changes in the acetabulum. Also noted is bump in the femoral head just at the level of physeal scar. These findings are indicative of cam type femoro-acetabular impingement with associated degenerative changes in labrum/subchondral bone.

Cam impingement
Cam impingement results from an abnormality of the femoral head. On MRI or radiography, a prominent lateral extension of the femoral head at the expected step-off to the adjacent femoral neck can be seen  as in this case. This femoral “bump” is typically located lateral to the physeal scar. 

Pincer impingement
In pincer FAI, the acetabulum, rather than the proximal femur, has a morphologic abnormality that results in abnormal contact between the femur and acetabulum. Radiographic findings of acetabular retroversion include the crossover or “figure-8” sign and the posterior wall sign. The crossover sign is caused by the anterior wall of the superior aspect of the acetabulum projecting lateral to the posterior wall of the superior aspect of the acetabulum. The line that demarcates the posterior wall passes medial to the center point of the femoral head, rather than following the normal passage at or lateral to the center of the femoral head. 

Vastus medialis obliquus (VMO) tendinous tear-MRI

Rupture of the quadriceps tendon was first reported in the English literature by Samuel in 1838. The quadriceps tendon usually ruptures transversely at the osteotendinous junction. The rupture often extends through the vastus intermedius, slightly proximal to the rupture of the rectus femoris tendon. Isolated vastus medialis obliquus (VMO) tendinous rupture is a very rare injury. In this case there is evidence  of discontinuity, fluid signal and localized swelling in relation to the vastus medialis obliquus (VMO), indicating disruption of VMO (quadriceps). Overlying medial patellofemoral ligament is intact, which is an important findings to be noted by MRI. 

Tethered Cord-Thickened Fatty Filum Terminale

There is a growing focus on the role which a tight filum terminale plays in tethered cord syndrome. Thick filum is currently defined as greater than 2mm in width or with fatty deposits. This is 8 year old child with lower limb weakness and segmentation anomalies on radiograph. MRI shows thickened lipomatous filum along with low lying conus.

Tuesday, March 06, 2012

Reporting Templates- RSNA Initiative

The RSNA radiology reporting initiative is intended to improve reporting practices by creating a library of clear and consistent report templates. Supported in part by the National Institute of Biomedical Imaging and Bioengineering (NIBIB). So you are struggling to get standard reporting template for your practise here is an extremely useful link for you.

Monday, March 05, 2012

Radiation Concern in MDCT Coronary Angiography

Review article in Journal of Medical Imaging and Radiation Oncology Volume 56, Issue 1, pages 5–17, February 2012 entitled  A systematic review of radiation dose associated with different generations of multidetector CT coronary angiography, discusses radiation conerns in coronary CT.

Key points indicated by the review are:

  • Radiation dose has risen from early-generation scanners of four-slice to 16- and 64-slice CT and will continue to do so if no dose-saving strategies are applied. This includes the highly effective strategy of ECG-controlled tube current modulation and very effective strategy of prospective ECG gating, which result in a significant reduction of radiation dose.
  • Despite promising results of coronary CT angiography, coronary CTA suffers from the disadvantage of high radiation dose, and associated high radiation risks.Brenner and Hall1 estimated that approximately between 1.5 and 2% of all cancers in the United States may be caused by radiation exposure from CT examinations. Thus, protecting young and female patients from high radiation doses is very important. 
  • Also review showed, effective radiation dose was estimated in female significantly higher than in male patients due to the different size thickness on the chest region. However, the breast tissue is radiosensitive, and keeping the radiation dose to the breast at the minimum level is paramount. 

Friday, March 02, 2012

Term of the day: "faceless kidney"

The term faceless kidney- CT sign of duplicated collecting system. Faceless refers to the appearance of the kidney on a CT section obtained at a level between duplicated collecting system elements; at this level, the kidney is entirely filled by normal renal parenchymal tissue, thus lacking the typical familiar signature of central renal sinus structures and sinus fat.

Thursday, March 01, 2012

Shearwave Elastography-Medical Device Update

Proven Benefits of ShearWave(TM) Elastography: Radiology and European Radiology Journals Report High Reproducibility and Significant Improvement of Breast Ultrasound Specificity.  Unlike conventional elastography methods, which rely on manual compression and measure tissue displacement, ShearWave Elastography requires no manual compression and computes true tissue elasticity by measuring the velocity of shear waves as they propagate in tissue. Further reading Press release by  SuperSonic Imagine. We have no financial interest involved. This is posted only for information by Sumer's Radiology Site.

1.    ShearWave Elastography for breast masses is highly reproducible. Cosgrove DO et al. European Radiology 2011 Dec 31

2.    Shear-wave Elastography Improves the Specificity of Breast US: The BE1 Multinational Study of 939 Masses Radiology (2012 Feb;262(2):435-449) by Wendie A. Berg, MD, PhD, et al. (C) RSNA, 2012 -

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