Monday, October 29, 2012

Anomalous Right Coronary Artery Origin-MDCT

Anomalous origin of right coronary artery from left coronary sinus on CT coronary angiography . If anomalous vessel passes between aorta and pulmonary artery, it could be compressed , especially during exercise.

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai 
(Consultant Interventional Cardiologist)
Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

Tuesday, October 23, 2012

Osteoblastic Secondaries-CT

This is 60 year old male with history of Ca Prostate. CT of the LS spine shows degenerative changes along with patchy sclerotic secondaries.

Friday, October 19, 2012

Dense Persistent Nephrogram -- Causes

In this case on IVP there is persistent dense nephrogram on left side, even when contrast has washed off from the right side.

  • Most commonly seen in Acute Ureteric Obstruction as in this case. This patient had a left UV junction calculus and presented with acute colic.
  • Renal Artery Stenosis 
  • Renal Vein thrombosis
  • Acute Pyelonephritis

Thursday, October 18, 2012

Space of Parona Infection-MRI

Evidence of hourglass shaped collection involving the lower anterior compartment of forearm anterior to pronator quadratus and deep to flexor tendons (space of parona) with collection extending distal to the flexor retinaculum along the flexor tendons of the hand. Possible infected collection. Clinical correlation suggested.

Diabetic myonecrosis-MRI

A 44-year-old woman with well  controlled  diabetes presented with intense pain in the left femur and local edema. Creatine kinase levels were slightly  elevated. A diabetic myositis diagnosis was established. Diabetic muscle infarction occurs most commonly in insulin-dependent patients (85%) with poorly controlled diabetes and concomitant end-organ complications. Average time of insulin use prior to diagnosis is 14 years. There is equal gender involvement. The pathogenesis of diabetic myonecrosis is unclear. Theories include occlusive peripheral vascular disease in the affected muscles, implicating arteriosclerosis obliterans as a cause of the inadequate perfusion and resultant ischemia. Other theories include endothelial damage from microangiopathy with an activated coagulation cascade, eventually causing a hypercoagulable state leading to ischemia and subsequent muscle necrosis. Case submitted by- Dr Nikos Vougioukli

Wednesday, October 17, 2012

Van der knaap disease, a megalencephalic leukoencephalopathy

Megalencephalic leukoencephalopathy (MLC) with subcortical cysts is a rare disease first described by van der Knaap et al, in 1995.  Megalencephalic leukoencephalopathy with subcortical cysts is a relatively new entity of neurodegenerative disorder characterized by infantile onset macrocephaly, cerebral leucoencephalopathy and mild neurological symptoms and an extremely slow course of functional deterioration  
Case submitted by Dr Mitesh Gupta.

Thursday, October 11, 2012

Amyloidosis-Pathological Fracture

38 yr old male  on long term dialysis  referred for pain and swelling  right thigh after  trivial trauma. MRI shows  well defined, lobulated, irregular, expansile, T1/T2 low signal intensity mounds  in subcapitate (Pararticular) femur with path fractures, with soft tissue involvement, extensive  contusions , with similar such erosive lesion left femur midshaft –In view of history, signal intensity , and location, secondary amyloidosis  is possible 

 Teaching points by Dr MGK Murthy
-          Long tem hemodialysis  causes unique type of amyloidosis, occurs secondary  to deposits of beta-2 microglobulin.
-          duration of CRF, dialysis, Age, bio incompatibility of  dialysis membranes   have role
-          predominately involves osteoarticular system (erosive , destructive osteo-arthropathies, destructive spondyloarthropathy, and carpal tunnel syndrome)
-          common  hips(acetabulum and subcapitate femur), wrists, shoulders, knees, and spine
-          cysts typically  periarticular bones and ligamentous insertions and are frequently bilateral
-          Visceral  amyloidosis  less common(unlike   amyloidosis due to inflammation or myleoma)
-          X-rays  show well defined punched out lesions with endosteal sclerosis
-          USG could show thickened tendons and synovium and is  echogenic
-          MRI   intermediate to low signal on both T1 and T2 with only mild peripheral enhancement
-          MRI helps in intraarticular, periarticular ,soft tissue lesions, atlanto axial lesions
-          Increased serum levels of beta-2 microglobulin not enough for diagnosis with biospy mandatory
-          Path  fractures and compressive myleopathy  are common sequelae
-          Differentials  are metastases , brown tumors(subperiosteal , subchondral  erosions and not para-articular)  and  myeloma(lab data will help)

Wednesday, October 10, 2012

Subcoracoid-Subscapularis Bursa MRI

35 yr old male with pain  and 64 yr old  with degeneration and rotator cuff tear.  MRIs displayed together  for differentiating between the  subcoracoid bursal fluid (64yrs) and superior subscapularis  recess fluid (35 yrs)

Teaching points by Dr MGK Murthy

(A)subcoracoid bursa
-between subscapularis and  coracoid process.
-extends caudally to tendon of coracobrachialis and short head biceps
- does not normally communicate with the glenohumeral joint
- Fluid here is invariably pathological eg: bursal / other causes
-associated with Rotator cuff tears

(B) superior subscapularis recess also known as the subscapularis bursa.
-recess of the  glenohumeral joint capsule projecting anteriorly between SGHL and MGHL
-saddlebag appearance created by hanging over the subscapularis  tendon
- size varies inversely with MGHL(larger the MGHL, smaller is the recess)
- fluid here can mimic subcoracoid bursal fluid , because it extends to ant surface of subscapularis tendon
-fluid here could be simply normal joint fluid

(C) Inferior subscapularis recess exists between MGHL and IGHL(inferiorly)

Tuesday, October 09, 2012

Chronic Tophaceous Gout-MRI

Evidence of degenerative  changes in the tibiotalar and subtalar joints with subchondral erosions and signal alteration.  There is evidence of increase in the fluid in the ankle joint with mixed signal contents along with intermediate signal intensity soft tissue masses surrounding the ankle mortice. These soft tissue masses with signal characteristics as described are suspicious for chronic tophaceous gout. 

Smartphones for Telestroke

Smartphones will soon bring the much needed push in the battle against time in patients with stroke, with possibility of quick response from the radiologists aiding in quick management. This may take Telestroke to new heights particularly in developing country like ours. 

Monday, October 08, 2012

Perirectal Cyst-Differentials

This is 30 year old female with lobulated cystic lesion in right perirectal region abutting right lateral wall of rectum and extending into right ischiorectal fossa, hyperintense on T2 weighted images and moderately hyperintense on T1 weighted images as well. Possible benign cystic lesion with proteinaceous / chronic organised contents appear to be likely. Differentials include enteric duplication cyst / neurenteric cyst or epidermoid cyst. Histological correlation was suggested. Case submitted by Dr Swati Shah, FRCR.

Unsual ganglion cyst in intercondylar notch in childern

There is evidence of fluid signal in the region of the intercondylar notch with anterior and posterior cruciate ligaments normally visualized. This finding particularly with no history of trauma and intact cruciate ligaments indicates ganglion cyst of the intercondylar notch. The incidence of ganglion cysts of the anterior cruciate ligament (ACL) has increased significantly since the advent of MRI, but it remains exceptional in children. This is a case of 9-year-old boy, with an exceptional imaging exam finding of a ganglion cyst.  Ganglion cyst of the ACL in children differs in pathogenesis from common degenerative cyst in adults.

DEXA Pitfall

In the A way the radiographer used orthogonal measurement, he excluded a segment of L4 vertebra which generally has higher bone density (BD), moreover he included the T12 vertebra which also has lower BD  ;    L1-L4 0.903   T -2.4.

In the correct B way he took under consideration the inclination of the L4 vertebra, the new measurement resulted in higher  BD ; L1-L4 0.959  T -1.9.

Submitted by : Dr. Vougiouklis Nikolaos

Do Referring doctors actually follow up on all radiology results?

In a systematic review published in Journal of general internal medicine, Nineteen studies were included in the review and reported wide variation in the extent of tests not followed-up: 6.8% to 62%  for laboratory tests; 1.0% to 35.7%  for radiology. The impact on patient outcomes included missed cancer diagnoses.  Failure to follow-up test results is an important safety concern which requires urgent attention. These are US based studies. Problem in countries like ours probably will be manifold.   I feel probably technology will play increasing role in minimising this in future.

Ramus intermedius-LCA- Cardiac CT

The left main coronary artery arises from above the left portion of the aortic valve and then usually divides into two branches, known as the left anterior descending (LAD) and the circumflex coronary arteries. In some patients (15%), a third branch arises in between the LAD and the Circumflex.  This is known as the ramus  intermediate, or optional diagonal coronary artery.  This intermediate branche behaves as a diagonal branch of the Cx.

Pediatric Baker's Cyst-MRI

Baker cysts, though generally rare in children, show a relatively high prevalence in certain paediatric subpopulations, namely, in patients with arthritis and benign joint hypermobility syndrome. This is MRI of 7 year old boy with swelling in popliteal fossa. There is evidence of T2 hyperintense fluid intensity lesion in the popliteal fossa in semimembranous-gastrocnemius bursa with thin neck apparently  communicating with the knee joint.  Possible baker's cyst. No obvious underlying arthritis.

Wednesday, October 03, 2012

MSK Radiology Conference

Best MSK imaging course in Asia, run by Dr John George, Malayasia, The Penang Course  is now accepting registration for the March event. Limited seats. Check the website for further details.

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