Saturday, April 28, 2012

MRI in Orthopedics-Conference

Right now at Kochi, tomorrow i am the faculty for MRI in orthopedics topic for SICOT-ICL Kochi session. Schedule is attached for tomorrow. Looking forward to meeting the delegates.

iDAMS-Tablet Based PG Medical Entrance Coaching

Another Pioneering Effort By the Number 1 Institution in the country
First Time in India, after having many Firsts to our credit including NEET Mocks, Test & Discussion Series, Bounce Back Series, regular classes, GT series, Foundation and Prefoundation Courses, First Step - DAMS the Pioneers in the PG Medical Entrance Coaching, have added another ACE in their courses-The iDAMS. This product was launched on 25th April in Delhi Head office with more than 1000 eager PG aspirants in the audience by our lead Educationist & Visionary–Dr Sumer Sethi, Radiologist and Director, DAMS. iDAMS Program is a tablet based complete distance learning product that combines the best of classroom learning and self-study. iDAMS program gives access to real time video lectures along with test papers to test your skills. Combining this Tablet with DAMS facebook club and other postal options provides access to famous and learned educationists at DAMS while remaining at your home, which was not possible so far with any of the technologies.

With the launch of iDAMS a large number of aspirants, who otherwise couldn't take the advantage of the DAMS teaching because of various reasons like non-availability of DAMS centre in the vicinity would be greatly benefited.

Friday, April 27, 2012

String of Beads Sign-Small Bowel Obstruction

The string of pearls sign can be seen on abdominal radiographs obtained with the patient in the upright position or on decubitus abdominal radiographs. Also commonly referred to as the “string of beads sign,” the sign consists of a row or line of several small air bubbles obliquely or horizontally oriented in the abdomen.

Acute Pyelonephritis-CT

Clinical data: one month following stone surgery, haematuria.
Right kidney appears enlarged and shows delayed contrast uptake in the parenchyma which shows areas of striated nephrogram which likely indicates acute pyelonephritis. There is evidence of perinephric stranding & fascial thickening. Right psoas is bulky. There is dilatation of pelvicalyceal system with multiple hyperdense filling defects possibly clots in pelvicalyceal system and upper ureter. There are filling defects in the bladder as well which appears thick walled possibly clots. Foleys bulb is noted in the urinary bladder.

Thursday, April 26, 2012

Superior Sagittal Thrombosis-MRI

This is a 55 year old person with loss of flow void in relation to the superior sagittal sinus consistent with thrombosis. MR equivalent of the delta sign.

On Day 2 Follow up MRI & MRV, the findings are confirmed.

Wednesday, April 25, 2012

Constrictive Pericarditis-CT

Evidence of extensive calcification and thickened pericardium, surrounding predominately in the right atrial and right ventricle.   IVC is dilated. There is evidence of right pleural effusion.  There is ascites. GB wall is thickened.  There is evidence of hepatomgaly with hypodense CT appearance. Possibly indicating calcific constrictive pericarditis.

RAPUNZEL SYNDROME – An ultrasound diagnosis

“A large & long intestinal Trichobezoar causing intussusception like bowel mass & obstruction”

Case presented by-
Dr.Subhash Tailor [ MD Radiology ]
Dr.Gaurav Bahety [M Ch pediatric surgery ]
BHILWARA [ Rajasthan]

The Rapunzel syndrome is a trichobezoar with a long tail extending from the stomach to small bowel .  To our knowledge , this is a very rare & uncommon case in a male child [ as most of the reported cases of Rapunzel syndromes in pediatric age were females ] in which the trichobezoar has passed from stomach into jejunam , & caused bowel mass & obstruction involving the entire bowel upto sigmoid colon .  Ultrasound revealed a large , elongated , curved multilayedred bowel mass[appearing like that of intussusception] encasing thick central echogenicity [ the trichobezor & its tail ] .Hence this should be suspected in the appropriate clinical & imaging circumstances.

Key Points  
-Trichobezoars are usually asymptomatic until they reach a large size .
-The Rapunzel syndrome [ a trichobezoar with a long tail extending from the stomach to the small bowel ] is a rare cause of intussusceptions & obstruction.

Case Details-
A   6 yrs old boy having h/o chronic pain abdomen  , presented with acute pain abdomen ,vomiting  &  distension , was asked for  abdominal sonography . His laboratory tests were noncontributory ,  and  abdominal radiograph revealed few air fluid levels.

USG  abdomen  showed  a large elongated  multilayered bowel mass [ like intussusception] occupying most of the left side abdomen and extending in pelvis  with  few dilated small bowel loops & mild ascites . The bowel mass was typically simulating intussusception & showing long curved course , with a long intraluminal/central echodense area[suspected trichobezoar ] within it. The proximal part of the central  echodense area was a bit large [the trichobezoar ] , &  rest appeared thin & long extending in entirety of bowel mass[tail of bezoar ]  . Color Doppler scan revealed mural vascularity within mass , indicating adequate bowel perfusion . In light of USG findings probable diagnosis of intussusception like bowel mass ,may be due to intraluminal  elongated bezoar , with mild obstruction & ascites was made.[ see US images ]  Further evaluation by CT scan was suggested.

Operative details  – Pt. was taken for urgent surgery to avoid impending gut gangrene & perforation. A large & elongated trichobezoar , found within lumen from jejunum to proximal sigmoid colon colon , making clustered redundant looped obstructed bowel mass , was removed successfully with appropriate surgical steps . The proximal  large part of trichobezoar was ,of stomach shape & crossed pyloric canal ,seen lodged in proximal jejunum . The rest thin elongated  bazoar tail was extending in rest of the redundant clustered  bowel loops to reach upto sigmoid colon [ see per ].

Figure 1- Large intraluminal echodensity in left upper abdomen ,representing proximal part of bezoar in jejunum

Figure 2 –Large elongated  multilayered bowel mass [like intussusception] in left side abdomen  extending into pelvis, containing long central echodensity - consistent with trichobezoar tail

Figure 3 – Multilayered bowel mass with mural vasculature present on doppler

Figure 4 – Per op. photograph showing  large proximal part of  bazoar in jejunum

Figure 5 –Per operative trichobezoar removal in progress

Secrets of Diffusion-For Radiology Resident

This is a special documentary prepared for Radiology residents preparing for various exams. Submitted by Dr MGK Murthy. 

1.Molecular Movements

-          3 Types
-          intravascular, intracellular or extracellular .
2.Techniques of DW sequence

-          Normal Spin echo T2 sequence  consists of 90 deg  RF pulse followed by 180 deg pulse and signal is collected thereafter which largely depends on T2 decay related to transversal relaxation
-           In DW sequence ,  a  Diffusion sensitizing Gradient (dephasing gradient) is applied before 180 deg RF pulse and another one symmetrically after 180 deg RF pulse

-          can be performed with SE, FSE, Gradient echo, and EPI(most commonly used)

Two scenarios are possible:

-          In Scenario  “1”,  tissues with limited impedence of water molecules ,first dephasing gradient signal effect , would be canceled by second symmetrically applied rephasing gradient  and hence T2 bright signals  would remain.( possible with increased cellularity ,or intact cell membrane , as in  tumour, abscess,  cytotoxic oedema, fibrosis etc)
-          In Sccenario “2”,tissues with  increased mobility of  water molecules , the molecules move considerable distance between the dephasing and Rephasing Diffusion gradient pulse  and hence can not be completely canceled , and therefore net loss of T2  bright signal occurs (possible in decreased cellular content or broken cell membrane  permitting movement )

3.“b” Value
·         Refers to the strength of gradient  pulse applied
·         Is proportional to amplitude of the gradient, duration of application and time interval between dephasing and rephrasing applications(Parameter adjusted to increase the  “b”value  is amplitude)
·         Atleast two sets of images are needed , one with b=0 and other b=500 or 1000sec/square mm
·         Small b value (50-100sec/sq mm) would affect the fast moving molecules say in bloodvessels , because  they move before the rephasing pulse could take effect and hence lose the T2 bright signal  due to dephasing pulse already applied (also called “black blood” sequence )

·         Represents the slope of  “log of relative tissue signal”on “Y” axis  versus “b” value on “X”axis
·         Atleast two “b” value acquisitions are needed(multiple will enhance  information, but takes time)(amount of “b” value varies with organs for eg Liver is ideal with = 0 and 500-600 sec/sq mm, pelvis goes to 800 and brain with =0 and 1000)

5.T2 Shine Through
·         Some lesions like cysts/fluid in gall bladder etc show  high signal on diffusion , however can be differentiated from lesions by  lack of corresponding ADC  low signal(T2 signal retained)
·         Slow flowing blood is an exception with high signal on b=0 as well as 500 sec/sqmm, and sometimes even with reduced ADC values mimicking tumours – we need to depend on other sequences  in these situations , particularly in   liver haemangioma


·         Low SNR and  Susceptible for artifacts

·         Can help by (a) increasing magnetic strength(b) increase No of acquistions  (c) minimizing echotime(<100msec) (d) coarse acquisition matrix(256 by 256 at 3.0T)(e) increase slice thickness(at least 6-7 mm)

Sunday, April 22, 2012

Post ACL Repair-MRI

This is patient who is post ACL repair with persistent flexion deformity. MRI was done as a part of evaluation. MRI revealed following : Metallic screws are noted in the lower end of femur and tibia limiting the evaluation by resultant suspectibility artifacts.  There is evidence of altered signal intensity around the ACL graft which is not well seen which probably indicates arthrofibrosis of the ACL graft.  There is evidence of altered lesion in the tibial insertion of the graft which may be indicative of cyclops lesion versus cystic lesion as it hyperintense on T2 weighted images and cyclops lesion is usually low-intermediate signal. Tibial tunnel appears mildly anteriorly placed as compared to intercondylar roof line.

Saturday, April 21, 2012

Medial Tibial Condyle Stress Fracture-MRI

This is a case of a marathon runner with obscure pain and MRI shows evidence of altered signal intensity in the medial tibial condyle with hyperintense signal on T2 and STIR images along with linear hypointense area likely consistent with a medial tibial condyle stress fracture with associated bone bruise/marrow edema. Although stress fractures of the tibial diaphysis are common among athletes, the proximal tibial metaphysis is an unusual location for such injuries.  MRI scan has proved very sensitive for diagnosing stress fractures and provided a definite diagnosis in our case.

Friday, April 20, 2012

Mayer-Rokitansky-Kuster-Hauser syndrome-MRI

There is evidence of bilateral pelvic kidneys. Uterus and cervix are not seen. Lower part of vagina is visualized as blind ending pouch. Both ovaries are visualized. These findings likely indicate mullerian agenesis. (Possibly Mayer-Rokitansky-Kuster-Hauser syndrome ). Case submitted by Dr Sumer Sethi & Dr Ajay Garg, Radiologists)

Bilateral Ectopia Lentis in a case of Marfan Syndrome – An ultrasound diagnosis

Introduction –
Marfan syndrome is an inherited disorder that affects connective tissue which supports and anchor body parts and organs structures . It most commonly affects heart , eyes , blood vessels and sketelal system.

There is no any  unique sign and symptom of this disease but constellation of long limbs, dislocation of lenses and aortic root dilation are the key findings to make the diagnosis with confidence . Dr. Subhash Tailor , MD  Bhilwara [ Rajasthan ]  is presenting a case of Marfan syndrome whose ocular ultrasound revealed bilateral dislocation of lens [Ectopic lentis].

Case report –
A 25 years old man attended my clinic for ocular ultrasound , asked for decreased vision.  His medical , clinical and genetic history was notably suggesting a case of Marfan syndrome . Ocular USG was performed with a voluson – 730 [ wipro GE ] system with 6 to 12 MHZ broad band linear probe . Examination of his one eye revealed absence of crystalline lens at its position and it was seen lodged posteriorly near retina as a well defined oval echogenic area [ see figure  ]. The second eye was also attempted and revealed the same findings of dislocated lens , suggesting bilateral ectopia lentis . The dislocation was typically supero-temporal . The other ocular  findings were obliterated anterior chamber, some low level intragel internal echos indicating degenerative changes and slightly increased axial diameter of the eye balls . No retinal detachment was seen .
Discussion –
Marfan syndrome is a disorder of connective tissue that holds the structures in position   in various parts of body . So weakness in the ligaments that holds the lens in place causes subluxation and even complete dislocation of ocular crystalline lens , called ectopia lentis . In this my case bilateral ectopia lentis noted with subtle degenerative echos in the vitreous  gel , and slightly increased axial diameter of the eye balls  . No evidence of retinal detachment was  found in either eye . The dislocation of lens in  Marfan syndrome is classically  superotemporal whereas in similar condition Homocystinuria , the dislocation is infero nasal type . In Marfan syndrome ectopia lentis noted in about 80% of cases.

The other ocular manifestations are glaucoma and retinal detachment . The diagnosis of ectopia lentis in this case was straight forward because of absence of lens at its normal position , and presence of the cataractus  [ small oval echogenic structure ] lens dislocated and lodged posteriorly near retina in both eyes , suggesting bilateral ectopia lentis in the light of  appropriate clinical settings.

Figure – Axial US images of both eye balls showing a well defined oval echogenic structure posteriorly near retina , s/o ectopia lentis  . Some low level intragel internal echoes  also evident. 

Wednesday, April 18, 2012

Diskoid Medial Meniscus-Rare Lesion

Evidence of bulkiness in relation to the medial mensicus which likely indicates diskoid medial mensicus. There is altered intrasubstance signal in the body and posterior horn of the diskoid mensicus possibly grade I signal change not reaching till the articular surface.  Suprapatellar plica is noted.  There is moderate increase in the joint fluid extending into the suprapatellar bursa. 

Possible symptomatic mediopatellar plica-MRI

This is a 35 year male with pain in the knee with no trauma. Evidence of thickened mediopatellar plica noted as thickened cord in the retropatellar & suprapatellar bursa with localized collection/synovial thickening anterior to it, seen as hypointense on T1 and T2 weighted images, hyperintense on STIR images.  Findings may indicate mediopatellar plica syndrome with associated synovitis. Hypointense signal on T2 weighted image within the thickened synvoium may also indicate a differentials showing chronic blood products including Pigmented villonodular synovitis etc. Case submitted by Dr Sumer Sethi & Dr Ajay Garg, Radiologists.

Tuesday, April 17, 2012


Uterine arterio-venous malformation (AVM) is uncommon cause of uterine bleeding.  Reported here is rare case of arteriovenousmalformation in lower section cesarean scar diagnosed with color Doppler. Submitted by: Dr. Subhash Tailor, MD Consultant Radiologist in Bhilwara [ Rajasthan]

A 32  year old female ,with one live issue , presented  with profuse episodic bleeding per vaginum. Her last childbirth (by caesarean section) was 2 years ago. There was no past history of menorrhagia. On examination, there was pallor and she was anaemic.

Pelvic gray scale ultrasound showed small anechoic cystic spaces in anterior myometrium of lower part of body of uterus at the level of previous cesarean section (Figure 1).

Figure 1: TVS scan shows  multiple small anechoic cystic spaces in anterior myometrium of lower part of body of uterus at the level of previous cesarean section [ arrow ].

Colour Doppler US scan showed color signals in these cystic areas with intense mosaic flow with colour aliasing  apparent ..(Figure 2).

Figure 2: TVS Colour Doppler US scan showing intense flow with colour aliasing and
apparent tangle of  flow  channels .

The spectral Doppler reveals the classic features of arteriovenous shunting i.e. high PSV, low pulsatility of arterial waveform, pulsatile high velocity venouswaveforms with little variations in systolic – diastolic velocities.(Figure 3).

Figure 3:Spectral Doppler revealing classic  arterio-venous shunting.

Monday, April 16, 2012

Importing outside studies to PACS

This is one idea which definitely benefits the patient by reducing the repeat studies done and making the patient studies available in the hospital system even if they were done outside and patient is carrying the CD of the outside scan. Everyone who has tried his hand on a CD created outside will agree sometimes it is a pain for the radiologist to see the images on an unfamiliar imaging platform. Importing to them to the PACS obviously helps.

Further reading

Sunday, April 15, 2012

Early Avascular Necrosis-MRI

This is a 48 year old with clinical suspicion of early avascular necrosis right hip. There is evidence of a subtle area of T1/T2 hypointense linear serpignious area in the right femoral head in the subchondral region which possibly indicates subchondral fracture. There is no significant marrow edema in the femoral head and neck. Shape and contour of the femoral head is maintained. There are no secondary degenerative changes in the acetabulum. These findings can be consistent with the clinical diagnosis of early avascular necrosis. Follow up and clinical correlation is suggested.


Following set of representative shoulder ultrasound images have been submitted by Dr Subhash Tailor, MD-Consultant Radiologist at Bhilwara.


 A 45 yrs male with h/o trauma right shoulder  , painful arc syndrome  & inability to abduct  right shoulder .
AT  US – focal inhomogenicity with  hyopoechoic  defect  in articular fibres of right supraspinatus tendon , & adjacent GT cortical iiregularity , s/o partial supraspinatus tear. [ see figure 1 ]

Figure 1-  Focal inhomogenicity supraspinatus with adjacent greater tuberosity cortical irregularity s/o -Partial tear articular fibres  


A  60 years female with h/o trauma with pain & inability to abduct shoulder

AT US -  focal fluid filled defect in supraspinatus tendon involving full thickness with   mild subdeltoid bursal effusion . [ see figure 2]

Figure  2 – shows echolucent full thickness  defect  in supraspinatus tendon with mild subdeltoid bursal effusion


A  75 years old man with h/o fall , & was unable to abduct shoulder

AT US -  There is complete absence or nonvisualsation of supraspinatus tendon at its position , s/o Naked/ Bare tuberosity sign . In this case deltoid muscle is directly resting on humeral head . [see Figure 3]

Figure 3 – Nonvisualisation of supraspinatus tendon ,& deltoid muscle is directly resting on humeral head – Bare /Naked tuberosity sign

Thursday, April 12, 2012

Possible Link Between Dental X-rays and Meningioma Risk

According to a study published online April 10, 2012 in the journal Cancer, researchers examined answers to a health survey from a group of 1433 meningioma patients and compared them to answers from a control group of 1350 people without these tumors. The meningioma group was twice as likely as the control group to report ever having had a bitewing exam, the meningioma group also was more likely to report having had a panorex exam at a young age (under 10 years old) or on a yearly or more frequent basis. The panorex exam is taken outside the mouth and shows all of the teeth in one film. 

Although the study is not conclusive, there is need for further research on this and this study is apparently linking diagnostic xrays to tumour, that too low dose. Further reading: Cancer-dot-org


14 year old young male present with Pain in the knee joint with no history of trauma. X-ray revealed an ill defined lucency in the tibial epiphysis.

MRI shows a relatively, well defined, regular , heterogeneously altered signal intensity, space occupying lesion involving tibial epiphysis including the spines with extension across the physis into the metaphysis with peripheral low signal on all sequences with extensive perilesional oedema  and heterogeneous enhancement – Chondroblastoma is likely.

Teaching points by Dr MGK Murthy, Scan by: Mr Abdul Hamid.

-          A, rare, benign, cartilaginous tumor of the epiphysis of the growing skeleton.
-          Signal intensity reflex the cellularity with lower than normal marrow on T1, low / high signal on T2 fat suppression.
-          Extension into the metadiaphysis is uncommon ( 60%), in which case could mimic chondromyxoid fibroma / GCT.
-          Perilesional oedema is usually extensive mimicking and aggressive lesion particularly clear cell chondrosarcoma or GCT.
-          72% occur in lower limb with 18% in the tibia.
-          T2 low signal is attributed to abundance of immature chondroid matrix / chondroblastic hypercellularity / calcification / haemosiderin.

Monday, April 09, 2012

Young Radiologists in India look for a change in employment terms-Debate

Young Indian  radiologists of today ask for change in Radiology Practise/Job Scenario in India. In India usual trend is for radiologists to work on fixed pay-scale. These are some extracts from the conversations i had on my facebook page with some colleagues. What are your thoughts on these thought provoking discussion?  Comments are welcome. 

Sumer Sethi:  lets have this discussion over here, which was my topic was the last IRIA as well. Entrepreneurship. Well we just cant blame the centre owners for shortchanging us when fault is primarily of the cut governing the market rather than quality reporting. Q1 Who owns the radiology, is it actually radiologists? Q2 who earns maximum from radiology radiologists or referring physicians or investors? Q3 This blind race of Teslas, Digital MRI, PET CT, 256 slice CT has kind of taken it away from the radiologist 1st generation entrepreneur. Does the average patient actually need these, debatable? they are better no doubt but are an high risk investment. So, my idea for the younger rads is start small and do the MRI and CT on a part time job. then gradually build momentum and put your own set up....

Sumer Sethi: Something which i wanted to voice & try in voice in IRIA, everywhere i go in India is : Radiologists should be paid as percentage of gross collection from radiology department not as fixed pay rolls. Once we become strong to accept that if work is less i take less but if it is more i ll take more and these partnership contracts should be durations like 1-3 years depending on ease of relationship like any business with exit policies defined. What i meant in my previous post was that radiologist is as important probably more important than machine while reverse is being projected in the market by lala entrepreneurs. They say we have 3 tesla, we have 256 slice while more important is the eyes who report them.

Colleague A: I totally agree with you and we must get this implemented at any cost by taking stringent initiatives.

Sumer Sethi:  there is just one policy that is required, i am f..g radiologist and i am not available for fixed payroll, u can partner with me i ll take x percentage of the collection from the radiology department and contract has to be executed legally.

Colleague A: agreed

Sumer Sethi if somehow radiologist stop being greedy of apparently fat pay package that u get after residency and learn to work for money if the centre work is low i take less but it is more i take more... also another thing, in India they bundle our reports with the cost of doing the study, while if ur doing an MRI for 6000 odd rupees that is the cost doing the scan and reporting should be charged separately and that should be our domain. It should not be assumed that if u pay 1000 Rs u have bundled doing the study with report from fixed pay radiologist included

Colleague A: There is nothing wrong in demanding a fat pay . are we inferior to any other specialities ?

Colleague A: when people can charge crores of rupees for item numbers in films what wrong are we doing by asking decent pay in this era of extreme inflation to get on with our responsibilities.

Sumer Sethi no what i mean is it is "apparently" fat pay, it is not big as compared to what the owner earns. So it should be a partnership and then u earn variable depending on business with some minimum clauses as u suggest but if ur reporting gets more business you shud the fruit of it as well.

Colleague A: The core problem is business productivity and its economics.

Sumer Sethi entertainment industry pays more than the healthcare as we are catering to sick people and item numbers are catering to majority :)))

Colleague A : I understand that we are in a service industry , that is the reason once again the managements take wrong advantage of . For them it is purely business they make money out of sick people and expect us to be only service oriented and do away with minimum hardearned compensation we deserve.

Sumer Sethi : yes that is why i stress on partnering not payroll and that is the mistake all our community has done.. if my work has made the centre progress i should be earning as a percentage not as fixed payroll... Ahamad Mastan Mukarrab more you think, more you know this is main problem, think of referring physician even they charge fixed percentage as commision not fixed payroll, only the people on fixed payrolls loose the game and radiologists should not be on fixed pay rolls.........

Sumer Sethi: even CEOs of topic companies are paid as some salary and equity, once you get paid as percentage of gross collection things will change unimaginably and u ll drive out of the centre on a beamer.. now please understand i am telling you percentage of "gross" not profit as u ll never be able to get the profit statement from these businessmen they will show you losses always and make you look like a fool... radiology reporting and radiography should be considered as a specialised job which is done as percentage of collection and we give them time as per our idea and we manage work howsoever we want to ...

Colleague A: I agree with you what if we do not get the minimum expected amount if the centre is running in a loss ? percentage share of a gross income is a good idea provided the income of the organisation is healthy

Sumer Sethi:  then u reduced your time spent on that organisation, i dont sit there whole day or for 8hours like we do if we were on payroll and work was not there but u were marking ur attendance on that idiotic finger print machine that corporates us to make us feel equal to rest of the staff, no we are not staff we are consultants and we will be flexible,..
Colleague A:  good feedback.

Sumer Sethi:  u have a long term contract and u can define exit clauses and exit the arrangement whenever, u feel they are not generating enough revenue and i am not marrying them ...

Colleague A:  choosing an organisation with healthy income or good potential will be critical in signing of the contract.

Sumer Sethi yes and that is true for any business.... if u choose a poor organisation and go for fixed payroll, i bet they will still not pay, i have seen cheques bouncing....

Colleague B:  A common consensus should b passed, say through IRIA. Strict watch and some sort of action should b taken against radiologist if he/ she found serving on fixed pay. Imaging centre/ hospital owners also need to work in accord. Only implemented rules can help us to earn what we DESERVE.

Colleague C:  Sir you could not have been more correct is assessing the whole situation i mean the bad deals we radiologists are meted out, it becomes more painful to learn WHEN IT IS DONE BY OUR FELLOW RADIOLOGISTS. Please guide us so that a common platform can be formed from where we can start a concerted effort.

Colleague A:  I need few representatives of each state voluntarily to help me in this campaign to propogate the message very clearly to such centres. please mail me the minimum benchmark for payscales, leaves , other issues , dearness alowance, health insurance and also psychological issues that arise out of such exploitation.

Colleague D: very true . there r surgeons who get cuts per surgery n physicians who get consultation fee , so it is logical and prctical that e1 radiologists should get a cut in usgs / ct / mri they report . to make it work we need to take our voice to the administration

Friday, April 06, 2012

Superdominant Right Coronary Artery

Left coronary artery and LAD is very small in this case. Right Coronary artery supplies most of the left side of heart. Not very common.  Case submitted by : Dr Rakesh Gopal , worked at Apollo hospital chennai (Consultant Interventional Cardiologist)

Monday, April 02, 2012

Silicone Gel Breast Implants: MRI

A lady with silicone gel breast implants(SGBI)   reported for evaluation  with no clinical abnormality.  MR shows normal SGBIs with diaphragm type valves and no complications with rest of the breast unremarkable

Teaching points by Dr MGK Murthy

·         Performed for augmentation or Reconstructions
·         Modern silicone gel breast implants date back to first use in 1963 by Dr Thomas Cronin, after paraffin, plastics, and gels have produced  unacceptable complications
·         MR mammography is considered as gold standard for evaluation including detection of complications .
·         Short  tau Inversion recovery (STIR) to null fat at inversion time of 150 m sec with frequency selective pulse train (to exploit chemical shift difference) with transverse magnetization spoiler to null water, with spin echo will leave only silicone signal to be highlighted
·         14 implant types: 1) single-lumen silicone gel-filled, 2) single-lumen gel-saline adjustable, 3) single-lumen saline-, dextran-, or polyvinyl pyrrolodone-filled, 4) standard double-lumen, 5) reverse double-lumen, 6) reverse-adjustable double-lumen, 7) gel-gel double-lumen, 8) triple-lumen, 9) Cavon “cast gel”, 10) custom, 11) solid pectus, 12) sponge (simple or compound), 13) sponge (adjustable), and 14) other.

Intact  single lumen implant appearance 

    Smooth, low–signal-intensity silicone membrane shell
    Low–signal-intensity radial folds in the shell, (may be complex; always abut the implant at its periphery and span the gel substance only at periphery)
    A few internal water droplet signals (common; not a reliable indication of rupture)
    Reactive fluid around textured implants (common; not indicative of rupture)
    Fibrous capsule (dark, ring like structure around the implant)

Intact Double-lumen implants
·         Gradual deflation of the saline chamber leads to complex fold patterns
·         Most of the implants presently are valve less, however the older ones could be seal-seal type or retention, peripheral folds, internal tube valve, four quadrant fixation patches  or diaphragm types
Intracapsular rupture
·         Collapsed and folded elastomer shell floating in gel,  is the most reliable sign of intracapsular rupture.(Linguine sign)
·         Presence of silicone both inside and outside a radial fold is key hole or teardrop or inverted tear drop sign.
Extra capsular rupture
       Intracapsular rupture + silicone in to surrounding parenchyma/pectorals/Lymphnodes.  Internal rupture of double lumen implants
       Saline droplets  floating within(some tiny ones are normal variation also)
Capsular contracture
·         Asymmetrical, serrated, focal folding of the fibrous capsule that changes the normal ovoid appearance
·         Transverse diameter less than twice the AP depth= clinically felt as contracture
False Positives
·         Radial folds are normal and mimic keyhole sign(false +)(Silicone should not be present however, inside and outsideof radial folds)
·         Excessive gel bleeding looks like intracapsular rupture(however keyhole sign  is positive  and Linguine sign negative)

Haematometra & Hematosalpix-MRI

Evidence of  extensive fluid distension of the uterocervical cavity along with fluid in the upper vagina with areas of signal suppression on GRE images, these findings possibly indicate hematometra. There is an hypointense transverse area which may indicate a transverse vaginal septum.  There is evidence of tubular distension in both adenxal region consistent with associated hematosalpinx.  Vaginal septum was confirmed operatively.
Ultrasound images are also available courtesy Dr Ajay Garg, MD Hospital. Bathinda.


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