Anomalous Left Portal Vein

A rare case,  patient 55 years-old man was examined because he found to have small esophageal varices. He reports that in the childhood  he was operated for atrial septal defect. CT shows some tributaries to form an anomalous left portal vein  which  opens into the right atrium. Case submitted by Nikos Vougioukli.

Os Acromiale with Impingement-MRI

Evidence of bony fragment in relation to the acromion process along with fibrous synchodrosis consistent with os acromiale which shows lateral inferior tilt leading to impingement of the subacromial bursa and myotendinous junction of supraspinatus muscle which shows signal alteration at this level. Acromio-humeral distance is reduced.

Rare Association of Dandy Walker malformation and Occipital Meningocele

We present a 3month old child of Dandy-Walker malformation associated with occipital meningocele.  Small numbers of cases of Dandy-Walker malformation with occipital meningocele have been described in the literature before and this is the first one from our second opinion practise. Communication between the posterior fossa cyst and the occipital meningocele may have compensated for the increased intracranial pressure in fetal life.

Further reading::
1. Pediatr Neurol. 1989 May-Jun;5(3):191-3. Dandy-Walker cyst associated with occipital meningocele.
2. Neurosurgery. 1991 Jun;28(6):844-7.Occipital meningoceles in patients with the Dandy-Walker syndrome.

Temporal Lobe Cerebritis with Midbrain Compression

This is 52 year old diabetic with pan sinusitis and altered signal intensity and inhomogenous enhancement in the temporal lobe which rapidly progressed on day 2 and patient developed ipsilateral III nerve palsy and contralateral weakness, which was explained on the basis of cerebral peduncle compression. 

Learning points: Uncal (transtentorial) herniation is herniation of the medial temporal lobe from the middle into the posterior fossa, across the tentorial opening. The uncus of the temporal lobe is forced into the gap between the midbrain and the edge of the tentorium. This compresses the ipsilateral oculomotor nerve, causing a fixed and dilated pupil, and collapses the ipsilateral posterior cerebral artery, causing an infarct in its distribution. Cortical blindness resulting from this infarct is a false localizing sign because it gives the erroneous impression that the primary lesion is in the occipital lobe. As the herniating uncus displaces the midbrain laterally, the contralateral cerebral peduncle is compressed against the edge of the tentorium, causing paralysis on the same side as the primary lesion, another false localizing sign. 

Mobile Technology for Radiologists

Radiologists rank in the top 5 for mobile technology usage.

According to the reference article: Dr. Shrestha, the Vice President of Medical Information Technology, University of Pittsburgh Medical Center says, “Imagers are often earlier adopters of newer technologies, and radiologists have been quick to adopt mobile devices, for both personal and professional use.”

Reference and Further Reading

Calgary Scientific

Do patients consider us (Radiologists) as Doctors?

There is an interesting article in the British Journal of Radiology (2012) 85, e1184-e1189, in which patients  attending the breast clinic who required  imaging (mammography and/or ultrasound) were asked to complete a questionnaire.  Surprisingly, 76% of patients thought that radiologists were radiographers and only 14% knew that radiologists were medical doctors. Nearly 40% of patients did not consider that radiologists had a role to play in their care. 

Guys we need to work on our public image building sooner than we think!!

Telemedicine in India

Following are the a few points which came from a discussion with a friend regarding telemedicine. Although, there are many proposers for telemedicine today in India as a commercial exercise, it is still to come into mainstream, while Teleradiology has gradually matured into a viable business even for India operations. Our own firm (TeleRad Providers) being a prime example, when we started to say in 2007 that India will generate good amount of teleradiology work, no one believed us and it was and is still an uphill task, but key thing, for me is to be able to create a viable, self sustaining system with this kind of business model. And i have a feeling the tipping point for teleradiology in India is not far away. But you need to think out of the box.  But i somehow don’t share the same enthusiasm for telemedicine. For me Phase for Telemedicine in India-should focus on Tele-imageology-- Radiology, Pathology, Dermatology, ECG,etc. Wherein we are able to deliver the final product. Most of patients never meet the radiologist even if he is in the hospital, so it hardly makes a difference to him when radiologist is located remotely, but somehow i dont get the same feeling with physician and hence the gap between tele-imageology and telemedicine. Will a patient or insurance company be willing to reimburse for a remote consultation?  Further we feel in times to come Government and telecom majors will play a part in major development of Telemedicine in India, but to make a viable option people should realise, each task we do should fill a lacuna and it will work. And Doctors not just planners should be integral to this development.

Post Ictal Edema-DWI

 MR signal changes following seizure or status epilepticus are transient increase of signal intensity and swelling at the cortical gray matter, subcortical white matter, or hippocampus on peri-ictal T2-weighted and diffusion-weighted images. These findings reflect transient cytotoxic and vasogenic edema induced by seizure. This  11 year old patient has a calcified granuloma in the posterior parietal region and this MRI was done immediately following seizure.

Inverted Napoleon's hat sign-Plain Film

Spondylolisthesis :  The inverted Napoleon's hat sign is produced when a severely subluxed L5 vertebral body (the dome of the hat) projects end-on and overlaps the sacrum, with the superimposition of images appearing as an inverted Napoleon hat on AP view.

ACL Tear-Plain Film Signs

The Segond fracture, avulsion fracture of the anterior tibial spine, impacted lateral femoral condyle fracture, and fracture of the posterior lateral tibial plateau are radiographic signs often associated with ACL injury. It is important to recognize the significance of these subtle abnormalities and if found, MRI should be done to identify the presence and the extent of ACL injury. In this Plain film segond fracture and avulsion fracture of tibial spine are evident.

Terry Thomas Sign-Plain Film

The Terry Thomas sign refers to an increase in the scapholunate space on an AP radiograph of the wrist .  The increased distance indicates scapholunate dissociation (rotary subluxation of the scaphoid) due to ligamentous injury.  The sign is named after Terry Thomas who had large gap between his two front teeth, also called as David Letterman sign.

Balls of fat-Dermoid Cyst

This is a case of mature ovarian teratoma with multiple fat balls seen as high signal on T1 weighted MRI images. The fat globules in literature have been described as being 1.5–2 cm in diameter and composed of cheese-like sebum and hairs.   In the reported cases, fat globules have occurred in rather large cysts so the fat balls might require sufficient space for their formation. Whether globule formation occurs in both benign and malignant cysts is not known.

Interesting Case of ICA Aneurysm

Evidence of dilatation of the ICA flow void in relation to cavernous sinus region-consistent with ICA aneurysm-cavernous region. Note is also made of elongated globes. These findings together may be a pointer to underlying connective tissue disorder-like-marfan's syndrome etc.

Face of the Giant Panda Sign-Wilson's Disease

'Face of the giant panda' sign consists of high signal intensity in the tegmentum except for red nucleus, preservation of signal intensity of the lateral portion of the pars reticulata of the substantia nigra and hypointensity of the superior colliculus. The exact pathogenesis of the marked hypointensity of the corpus striatum and superior colliculus in the T2 weighted MRI is possibly because of paramagnetic effects of the deposition of heavy metals.

International Day of Radiology

November 8 is now annual International Day of Radiology. This is a joint initiative by European Society of Radiology (ESR), the Radiological Society of North America (RSNA) and the American College of Radiology (ACR). On November 8, 1895, Wilhelm Conrad Röntgen discovered the existence of x-rays.

More details on this here- International Day of Radiology

Medullary nephrocalcinosis: Ultrasound

Medullary nephrocalcinosis : There are increased triangular shaped echogenicities in both kidneys in the distribution of the renal pyramids. There is no associated acoustic shadowing. The first diagnosis was established by prenatal ultrasound.   This condition varies from a subtle distribution of the calcifications to a florid deposition of calcium throughout the pyramids. With minimal calcifications, there is no shadowing. Ultrasound is more sensitive than x-ray or CT in detecting the faint calcifications. Case submitted by- Dr Nikos Vougioukli

Also note:

Medullary variety is much more common than cortical (95% to 5%).

Nephrocalcinosis is caused by hyperparathyroidism 40%; renal tubular acidosis (distal variety, type l)  20%, medullary sponge kidney  20 % 

Cryptorchid Testis & Germ Cell Tumour-CT

Heterogenously enhancing , partially calcified pelvic mass in the undescended right testis - germ cell tumor. There is increased risk for development of testicular germ cell tumor in cryptorchid testes. Also it has been found that the cryptorchid testis is arrested in its descent, the greater the risk of subsequent germ cell tumor. Case submitted by Dr Ayush Goel.

Carotid Body Tumour-MRI

Carotid body tumour (also known as a chemodectoma or carotid body paraganglioma) is a highly vascular glomus tumour that arises from the paraganglion cells of the carotid body.  It is located at the carotid bifurcation with characteristic splaying of the ICA and ECA. On T1 WI, lesion is iso to hypointense compared to muscle salt and pepper appearance, representing a combination of punctate regions of haemorrhage or slow flow (salt) and flow voids (pepper)  and is hyperintense compared to muscle on T2 WI. Case submitted by Dr Swati Shah, Dr Ajay Garg & Dr Sumer Sethi.

Breast Hamartoma-Mammogram

There is presence of a  large thin walled well defined encapsulated lesion with heterogeneous density in retroareolar region of right breast,extending to both outer and inner periareolar region. It consists of both fat and soft tissue density. Globular homogeneous soft tissue density is noted within the rim on upper inner aspect of the lesion. No  intralesional calcification is noted. No skin thickening or nipple retraction is noted. Possibility of benign hamartomatous lesion (fibroadenolipoma). It results from a benign proliferation of fibrous, glandular, and fatty tissue (hence fibro-adeno-lipoma) surrounded by a thin capsule of connective tissue. All components are found in normal breast tissue (hence the term hamartoma). Also called as BREAST WITHIN BREAST APPEARANCE. Case submitted by Dr Swati Shah, FRCR.

Aneurysmal bone cyst- MRI

20 year old male shows presence of an expansile lesion noted in right sided hemivertebra, right pedicle, lamina and transverse process of D5 vertebra.Significant intraspinal component is noted causing compression of thecal sac. It is hypointense on T1W and hyperintense on T2W sequence. Patchy areas of T1 hyperintensity is noted within the lesion suggesting haemorrhagic areas.CT scan correlation is suggested for bony details evaluation. In view of age of the patient and imaging findings, aneurysmal bone cyst may be considered. Case submitted by Dr Swati Shah, FRCR.

Dandy Walker Malformation-MRI

Hypoplasia of cerebellar vermis and cerebellar hemispheres with large posterior fossa cyst/cisterna magna communicating with fourth ventricle and gross hydrocephalus in both lateral ventricles with thinning of cerebral parenchyma- Dandy walker malformation. Case submitted by Dr Swati Shah, FRCR.