Saturday, June 30, 2012

Hyperosteosis frontalis Interna-MRI

Hyperostosis frontalis interna is characterised by benign overgrowth of the inner table of the frontal bone. It is seen most commonly seen in older females. The aetiology is unknown. The condition is generally of no clinical significance and an incidental finding. It is typically bilateral and symmetrical, and may extend to involve the parietal bones.  Image courtesy- Davinder Mann, Radiology Technologist.

Thursday, June 28, 2012

Wernicke's encephalopathy-MRI

This is neglected, alcoholic with complaints of ataxia with MRI features consistent with wernicke's and cerebellar atrophy. Wernicke's encephalopathy is characterized by a quite distinct pattern of MR alterations, which include symmetrical alterations in the thalami, mamillary bodies, tectal plate, and periaqueductal area. Wernicke's encephalopathy is characterized by a quite distinct pattern of MR alterations, which include symmetrical alterations in the thalami, mamillary bodies, tectal plate, and periaqueductal area. In WE, the blood–brain barrier is defective in the periventricular regions, in which there is a high rate of thiamine-related glucose and oxidative metabolism . Contributed by Dr Swati Shah & Dr Sumer Sethi, MD

Posterior Reversible Encephalopathy Syndrome (PRES)

This is 27 year old female, post partum with PIH with visual blurrring as the presentation.  MRI brain shows multiple T2/FLAIR hyperintensities in the bilateral parietal  & temporo-occipital regions. Diagnosis- PRES. Contributors: Dr Sumer Sethi, Dr Swati Shah, Dr Ajay Garg, Dr Gaurav Singla ( Neurologist)

Also called Reversible Posterior LeukoencephalopathySyndrome.

  • Presents with headache, altered consciousness, visual disturbances and/or seizures typically in the setting of new-onset hypertension.
  • Associated with acute hypertensive encephalopathy, eclampsia and cytotoxic/ immunosuppressive drugs..
  • Etiology unclear, thought to be secondary to endothelial damage in the setting of hypertension and failure of cerebrovascularautoregulationwith subsequent vasogenicedema. The posterior circulation is more sensitive to the effects of hypertension.


��Multifocal T2-hyperintensities
�� Favors parietal and occipital cortex (nearly 100% of cases), butcan involve other cortex, thalamus, basal gaglia, cerebellum and brainstem.
�� Variable presentation on diffusion weighting imaging. Ischemic changes on DWI/ADC are associated with worse prognosis.

Wednesday, June 27, 2012

Talar Beak Sign-Plain film

The talar beak sign is seen in cases of tarsal coalition, and refers to a superior projection of the distal aspect of the talus.   It is thought to result from abnormal bio-mechanic stresses at the talonavicular joint. 

Tuesday, June 26, 2012

Cerebellopontine Angle Epidermoid-MRI

This patient presented with left hemifacial spasm. Epidermoid cysts are congenital lesion caused by inclusion of ectodermal elements during neural tube closure, as opposed to dermoid cysts which have both epidermal and skin appendages such as hair and sebaceous cysts. Epidermoids are the 3rd most common cerebellopontine angle mass, after acoustic schwannomas and menigiomas. On imaging they are similar to arachnoid cysts but can usually be distinguished from them due to restriction on DWI and usually slight deviation from CSF on FLAIR.

Pneumocystis Carnii-CT

Clinical Profile : HIV positive status. There is presence of ground glass haziness with interstitial interlobular  and intralobular septal thickening noted in both lungs with symmetrical and perihilar distribution, sparing the lung peripheries. No evidence any cystic lucencies are noted. Possibility of Pneumocystis Carnii. Case  Submitted by Dr Swati Shah, MD, FRCR & Dr Sumer Sethi.

Features  of P. Carnii on CT include:

  • ground-glass pattern
  • predominantly involving perihilar or mid zones
  • there may be a mid, upper or lower zone predilection depending on whether the patient is on prophylactic aerosolised medication , if they are, then the poorly ventilated upper zones are prone to infection , whereas in those who are not the lower zones are more frequently involved
  • reticular opacities or septal thickening may also be present
  • a crazy paving pattern may therefore be seen when both ground-glass opacies and septal thickening are superimposed on one another
  • pneumatocoeles 
  • pleural effusions are rare 

Saturday, June 23, 2012

Nasolabial Cyst-CT

A 35 year old lady with the swelling in right nasoalar location, shows on CT a well defined regular, predominantly fluid density lesion in the nasoalar location,  with partial scalloping and resorption of the alveolar portion of the maxilla  ipsilaterally with no intraosseous extension or calcium within – Possibly  represents nasolabial cyst.

Teaching points by Dr MGK Murthy, Mr Vicky Sharma

Also called nasoalveolar cyst or Klestadt cyst.

Located in the anterior nasal vestibular region.

May show Milk of Calcium appearance in the inferior region.

A variety of epithileal cyst possibly from nasolacrimal ductal epithileum and 
not a retention cyst.

May contain respiratory epitheleum in the wall, statified squamous epitheleum
in apocrine change within it.

May have accessory salivary glandular tissue or even cartilage occasionally.

Secretions are mucoid or serous.

Is unilateral usually with expansile nature and resorption of the alveolar process 
of the maxilla with no enhancement on contrast administration.

CT is better than MRI for demonstrating calcium if present.

Diffentials include nasopalatine ductal cyst  odontogenic variety of cysts (Intraosseous), schwannoma or hemangioma.


A 30 years old male with liver abscess [ on medical treatment] , developed  right side chest pain with cough ,& was asked for  ultrasound examination.
Dr.Subhash Tailor, MD
Bhilwara [Rajasthan]

Ultrasound showed right lobe liver abscess [ See figure - 1 ] measuring about 55 x 47
x 59 mm = 81 c.c. size & volume  with thick internal echos . Mild right pleural effusion & thickening was also noted . The outline of dome was subtle irregular & obliterated .

Pt. was then asked to perform a cough maneuver during scan , & there was a rapid gush of air echos noted from pleural cavity to liver abscess through dome defect , suggestive of Hepato - pleuro fistula . It was because of rupture of liver abscess into pleural cavity . See video clip .

There was some bright echos noted persistent in liver abscess in  the subsequent scans
[ See figure – 2 A & B]  .

Figure 1 – Shows well defined right lobe liver abscess .

Figure 2[A , B ] – Shows right lobe liver abscess with gush of  air echos from pleural cavity to liver abscess ( seen  during & subsequently after cough reflux ) .


Video – Shows rapid gush of air from pleural cavity to right lobe liver abscess on cough .

-In case of right lobe liver abscess near dome ,with pleural effusion & thickening ,one must see for hepato-pleural fistula  by performing cough reflex ,& to observe  for any air gush through dome defect in real time .
Response to this article:

Dear Editor
Dear All,

Re: Liver abscess with Hepato-pleural fistula

Allow me to make few comments regarding this case.

A fistula between the liver and pleura means there must be a communication between the liver and pleural cavity;
The air was shown on video recording to be gushing from the pleural side into the abscess cavity.
This should mean a fistula which is actually pleuro-hepatic according to the direction of air-shift.
But the presenting radiologist is talking about a hepato-pleural fistula in which the air flow is pleuro-hepatic.
A hepato-pleural fistula (with air-leakage) could mean:
- Air is formed under the diaphragm (one cause may be gas-forming organisms)
- Air is expected to flow from the liver toward the pleural cavity.
- We do not even know whether there is air in the pleural spaces.
If the air flows from the pleural cavity to the liver lesion in a pleuro-hepatic fistula WE NEED A SOURCE OF AIR. What is it??
Whether it is hepato-pleural and pleuro-hepatic fistula there is breakdown of the diaphragm/pleura barrier.
(of course the peritoneal cavity may also be involved if the lesion breaks through the zones outside the bare area not covered by peritoneal reflection)
The presence of pleural fluid and adhesions should indicate involvement of the pleura but not necessarily a breakdown or actual tissue defect.
So if we rule out gas-forming infection where would the air come from?
Maybe the air-gush is initiated by a vacuum phenomenon induced by cough…or rapid movement and change of pressure-gradients.
That leads me to wonder why one would have asked the patient to cough as we, under normal working conditions, do not do this maneuver. Do we?
So I guess that the radiologist either saw the air-drifting echoes during forceful breathing or abrupt motion of diaphragm ( ? phrenic irritation ) or simply cough.
The “air “ ( or nitrogen ) is being sucked into the liver lesion just like in any other situation where a vacuum is created.
( E.g.: Caisson disease in divers, or gas seen within abducted child shoulders- on a chest x-ray or in the knees on frog-leg or von-Rosen views) ..etc.

Admittedly it is an interesting finding in this case but it sounds more like a chance observation rather than a deliberate or purposeful US technique…
but still technically smart enough for an applause.
I wish I was there with the radiologist and could have seen the patient’s records and images including chest films, abdominal films, if any etc

With best compliments

Dr. A. M. Al Tamimi
Consultant Radiologist,
Canadian Specialist Hospital

Tuesday, June 19, 2012

Nasal Septal Abscess-CT

Evidence of heterodense collection in relation to nasal spetum and in relation to the nasal cavities  consistent with sepatal abscess with collection anterior  to nasal spine and columnellar cartilages. There is resultant obstruction to the nasal cavities.   Cartilagenous anterior part of the septum is eroded.

Friday, June 15, 2012

Aneurysmal Bone Cyst-Medial Cueniform-MRI

Evidence of an expansile lesion involving the medial cueinifom bone with areas of marrow signal alteration showing isointense signal on T1 WI and hyperintense on T2 and STIR images along with areas of blood fluid levels. There is associated surrounding myofascial edema. Neurovascular bundles are preserved. These finings likely indicate an aneurysmal bone cyst (possible sequale to previous injury)

Learning Points

 The etiology is unknown, although it is now commonly accepted that benign bone cysts are caused by trauma.

 These tumors are benign and are characterized by expansile compartmentalization within cancellous bone.

 The lesions consist of blood filled spaces filled with connective tissue septa containing bone or osteoid and osteoclastic giant cells.

 The cyst is increasingly painful as it begins to expand, and diagnosis will usually be confirmed by ‘fluid-fluid’ levels and compartmentalization seen on CT and MRI.


[ An ultrasound diagnosis with X-ray work up ]

Case & Imaging Details In Brief

Bhilwara, Rajasthan [ INDIA]

A 45yrs old female with H/O recurrent abdominal pain & vomiting , subjected to sonography abdomen, revealed an area of focal short segmental small bowel mural thickening with luminal narrowing[stricture] in suprapubic area,likely involving ileal segment. The proximal bowel loop & few other loops were also seen dilated . Interestingly two well defined echodense shadows were also detected , one being entrapped at the site of stricture [fig 1] , & another one slightly proximal to the former , present in distended bowel loop [ fig 2 ].These are suggested to be enteroliths , likely formed due to concentric calcific condensation over fecolith facing chronic stasis [see fig 3 ] . At the same time radiograph abdomen was performed which showed two adjacent classical oval shaped enterolith opacities [see fig 3 ]. This diagnosis can be suggested in appropriate clinical & imaging situation. More views are welcome !

Fig 1 – Suprapubic US scan shows focal small bowel stricture with entrapped enterolith,both in TS & LS views.

Fig 2 – US scan shows separate another well defined enterolith with distal shadowing in proximal dilated small bowel loop

Fig 3 - US scan shows both enteroliths , one in the region of stricture , & another lodged adjacently in distended proximal small bowel loop

Fig 4 X –ray abdomen shows two adjacently lodged classical oval shaped enterolith opacities in lower abdomen

Thursday, June 14, 2012

Cervicouterine Junction Mass

Findings suggest possibility of circumferential wall thickening at juction of lower body uterus and cervix with an exophytic mass from its left lateral wall extending into left parametrium with no significant local invasion or pelvic lymphadenopathy. Case submitted by Dr Swati Shah MD, FRCR and Dr Ajay Garg, MD Hospital, Bathinda. Technologist: David Mann.

Possible Tubercular Salpingitis-HSG

Fallopian tubes are beaded and show irregular outline. Possibility of tubercular salpingitis was suggested. Differential of salpingitis isthmica nodosa was kept. Images submitted by Dr Swati Shah, FRCR.

Monday, June 11, 2012

Occipital Cortical Dysplasia

Young man with chronic epilepsy and visual symptoms: Area of altered signal intensity in the right occipital  region showing cortical thickening with FLAIR hyperintensity in the periventricular region,this finding particularly in view of chronic epilepsy/visual complaints  may indicate cortical dysplasia. (neuronal migration disorder)

Sunday, June 10, 2012

Choroid Plexus Xantogranulomata-MRI

63 year old lady with giddiness shows : A restriced diffusion focus in the body of left lateral ventricle  with reduced ADC and no blooming on SWI or displacement - Not specific  to etiology. However in view of unilaterality, age acute infarction of the  choroid plexus is possible.

Teaching Points by Dr MGK Murthy

Acute infarctions of the choroid plexus is uncommon.

Restricted diffusion foci within the lateral ventricular systems suggest D/D of Choroid plexus cyst / Parasitic cyst / Uncommon tumours like Papiloma / Hemorrhage / Xanthogranulomata.

Depanding on the lipid / fluid / blood contents, appearance of the focal lesions could very from frank CSF signal on all sequences to only restricted diffusion with or without T2 shine through.

Xanthogranulomata are completely asymptomatic and incidental & are usually found in elderly age.

Acute infarction could be differentiated by unilaterality, reduced ADC value & change of appearance after 3 weeks apart from possible MRA abnormalities.

CT suggest most of these lesions as isodense. The size is usually less than 1 cm.

Thursday, June 07, 2012

Possible Sheehan's Syndrome

Optic chaisma appears pulled down and infundibiular stalk is deviated to right. There is no history of surgery available or drug therapy. Partially empty sella is noted. These findings may indicate optic chiasma herniation into a partially empty sella. Clinical and hormonal correlation suggested along with visual assessment to r/o possible sheehans syndrome sequale.  Comments and inputs are welcome.

Childhood CT and Cancer- NIH Reports

In a study published in Lancet online on June 7th, researchers report that hildren and young adults scanned multiple times by computed tomography (CT), a commonly used diagnostic tool, have a small increased risk of leukemia and brain tumors in the decade following their first scan. These findings are from a study of more than 175,000 children and young adults that was led by researchers at the National Cancer Institute (NCI), part of the National Institutes of Health, and at the Institute of Health and Society, Newcastle University, England. However, they emphasize that when a child suffers a major head injury or develops a life-threatening illness, the benefits of clinically appropriate CT scans should outweigh future cancer risks. 

Further Reading: NIH Study Website

Wednesday, June 06, 2012

iPAD for Emergency Radiology

iPads are just as effective as traditional workstations for radiologists reading MRI and CT scans in emergency situations, according to new research published in the Journal of Digital Imaging. The iPad could provide radiologists with advantages over laptops (bulky with low-battery life) and smartphones (small screen size).


This is a 42 year old lady with complaints of discharge, On MRI uterus is bulky and anterverted; with uniformly thickened junctional zone which is likely indicative of diffuse adenomyosis. Endometrial cavity appears normal. Cervical region appears bulky with heterointense and large nabothian cyst in the region of the posterior lip of cervix.  Possible cervicitis.   On T2-weighted MR images, diffuse adenomyosis usually manifested as diffuse thickening of the endometrial-myometrial junctional zone with homogeneous low signal intensity.

Tuesday, June 05, 2012

Encrusted IUCD-Plain Film

This is a 40 year old female who was not sure of IUCD removal and plain film was done which reveals encrusted IUCD, with calcium deposited around limbs of IUCD. Further ultrasound was suggested to look for location this calcified IUCD.
Follow up USG was done for this case and turned out to be migrated IUCD in urinary bladder and this was a triangular vesical calculus formed over displaced IUCD.

Membranous Labyrinth MRI

These are some high resolution MRI images of membranous labyrinth submitted by Mr SM Arshad, Sr MRI technologist in Punjab.

Monday, June 04, 2012

Superscan Phenomenon

This bone scan of a patient with metastatic disease demonstrates the “superscan” phenomenon. Tracer uptake is so avid in bone that there is almost no renal excretion – the kidneys are barely visualised. Submitted by Dr Rishu Sangal, Consultant Radiologist.

  • Causes of superscan are as follows: renal osteodystrophy; osteomalacia; hyperparathyroidism; hyperthyroidism; diffuse skeletal metastases; myelofibrosis; haematological malignancy; extensive Paget’s disease.

Sunday, June 03, 2012

Endometrial Hyperplasia Versus Endometrial Cancer

 29 yr old married nulliparous who has had D& C done 3 times that showed atypical hyperplasia of the endometrium. Ultrasound was done by the gynecologist and she queried a myoma. MRI was requested to rule out carcinoma endometrium with myometrial extension. 

In this patient entire endometrial cavity appears replaced by mixed signal intensity area which shows imhomogenous post gadolinium enhancement and non-enhancing areas, which are likely indicating endometrial hyerplasia with doubtful loss of interface with the myometrium in the posterolateral part. Uterus per se is enlarged. This thickened endometrium shows areas of high signal on DWI image provided but there is no corresponding signal suppression on ADC map, which may indicate T2 shine through. Low signal on ADC map in endometrium is usually the sign for differentiating hyperplasia from malignancy, which is not seen in this case. So, finally this case likely indicates extensive endometrial hyperplasia with no low signal on ADC map, and doubtful loss of interface in the posterolateral endo-myometrial junction. Clinical and histological correlation will help.

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