Multiparametric Measurements of the Eustachian tube and Peritubal Region Using Computed Tomography as a Preoperative Workup for Tuboplasty.

Background: Eustachian tube dysfunction (ETD) is considered a causative factor for middle ear disease as well as treatment failure. The pathogenesis may be a result of chronic infection, allergy, laryngopharyngeal reflux, primary mucosal disease, dysfunction of the dilation mechanism and anatomical obstruction. Hence, it becomes essential to know the structure and anatomical variations of the Eustachian tube(ET), particularly with the advent of novel therapeutic options such as tuboplasty to ensure optimal therapeutic outcome. Aims: This cross-sectional study is done to perform multiparametric measurements of the ET and peritubal region using computed tomography and develop a structured protocol for pre-tuboplasty workup. Materials and methods: This study was done for a period of 20 months, in 100 normal subjects aged between 18 and 60 years, who underwent computed tomography (CT) study of the head and face region, for indications other than nasal/ pharyngeal and sinus disease. Results: The mean bony, cartilaginous and overall ET lengths were higher in males. In females, the mean ET angles with Reid's plane were higher. Higher mean craniocaudal diameters of the ET lumen were observed in males. Carotid canal dehiscence was seen in equal prevalence on both sides (5%), with no significant gender differences. Conclusion: Therapeutic interventions such as eustachian tuboplasty will benefit from preoperative imaging based planning. This structured protocol provides standardization of pre-operative workup for tuboplasty.

Spinal Epidural Bleed in Hemophilia: A Rare Site of Bleeding With Complete Resolution With Nonsurgical Management.

Hemophilia A is an inherited bleeding disorder, seen in 1 in 10,000 live births. It is characterized by an increased risk of bleeding, especially involving the musculoskeletal system. Central nervous system bleeding, including brain and spinal cord bleed is rare in the absence of overt trauma, seen in <5% patients. Epidural spinal bleeding in hemophilia is even rarer, and described in <20 patients so far in literature. We describe a young boy who presented with a cervical spine epidural bleed, and was managed conservatively without any sequelae. We also look at the controversies and recent evidence weighing surgical and conservative management of such bleeds.

Prospective Randomized Comparative Study to Evaluate Epidural Fibrosis and Surgical Outcome in Patients Undergoing Lumbar Laminectomy with Epidural Autologous Free Fat Graft or Gelfoam: A Preliminary Study.

INTRODUCTION: Epidural fibrosis (EF) contributes to unsatisfactory relief of symptoms and failed back syndrome after spine surgery. EF around the nerve root can be more refractory to treatment than the original disc herniation itself. Reoperation on the scar can produce more scarring. Few studies have been conducted regarding the type of material to be used for decreasing EF. MATERIALS AND METHODS: The prospective randomized comparative study was conducted in the Department of Neurosurgery and Radiodiagnosis, of a tertiary care hospital. Informed and written consent was obtained. Patients previously unoperated with symptoms and radiological features of lumbar spinal canal stenosis were included in the study. Fifteen patients were assigned to Group A (free fat graft) and 15 patients in Group B (Gelfoam group). Postoperatively, at 3 and 6 months, clinical outcome was evaluated and EF was assessed on CE-MRI. RESULTS: Age and sex were comparable in both groups. The pain relief at 3 and 6 months was more in Group A as compared to Group B. In Group A, on CEMRI at 3 months, 87% of patients had none to mild fibrosis, with none had extensive fibrosis. The CEMRI at 6 months showed no increase in fibrosis. In Group B, 80% of patients had none to mild fibrosis at the end of 3 months. At 6 months, 13.3% patients had extensive fibrosis. The extent of EF was found to be statistically significant at 6 months postsurgery. CONCLUSION: Use of free fat graft at laminectomy site helps in reducing EF.

A new approach for the management of esophageal atresia without tracheo-esophageal fistula.

Long gap esophageal atresia (OA) is a challenging condition. While discussing the various methods of management available to us, we report the use of magnetic resonance imaging in a case of pure OA to judge the gap between two ends of the esophagus.

Radiology-pathology conference: malignant solitary fibrous tumor of the seminal vesicle.

Mesenchymal neoplasms are rarely encountered in the seminal vesicle. Only four cases of the seminal vesicle solitary fibrous tumor have been reported in English literature, all of which were benign in nature. We are describing the clinicoradiological and pathological features of a locally aggressive malignant solitary fibrous tumor arising from the seminal vesicle, which posed the therapeutic challenge for the surgical management in a 52-year-old male patient. To our knowledge, this is the first reported case of the malignant solitary fibrous tumor arising from the seminal vesicle.

Isolated granulomatous hepatitis-A histopathological surprise mimicking cholangiocarcinoma in ulcerative colitis.

A 63-yr-old woman, known case of ulcerative colitis, was diagnosed with sclerosing cholangitis 2 years back. She was admitted for investigation of abdominal discomfort, fatigue with elevated alkaline phosphatase and deranged liver function test. Imaging studies (computerised tomography and magnetic resonance imaging) demonstrated a normal biliary tree with focal hepatic lesion which was showing features of cholangiocarcinoma. Ultrasound guided biopsy of the lesion surprisingly revealed non caseating granulomata. Granulomatous hepatitis occurs in less than 1 percent of cases of inflammatory bowel disease. A clinical diagnosis of isolated granulomatous hepatitis was established as the lesion remained stable on follow up and no other cause for it was identified on further investigation. Although the differential diagnosis of focal hepatic lesion in patients with ulcerative colitis with sclerosing cholangitis is wide, granulomatous hepatitis presenting as focal mass lesion mimicking cholangiocarcinoma has never been described previously.

MRI in evaluation of perianal fistula.

This essay illustrates the usefulness of MRI in evaluating perianal fistulas, a common disease, notorious for recurrence if not assessed and treated adequately. MRI exquisitely depicts the perianal anatomy and shows the fistulous tracks and their associated ramifications and abscesses. It thus provides an excellent preoperative understanding of the disease, enabling selection of the most appropriate surgical treatment and therefore minimising all chances of recurrence.

Current status of stenting in intracranial atherosclerotic disease: the story thus far and the way ahead.

Despite medical management, symptomatic intracranial atherosclerotic disease has a high risk of stroke and death. This unacceptably high rate has provided the impetus for development and continuous advancements in the field of endovascular revascularization. From early attempts at angioplasty alone to state-of-the art stents including self-expanding and drug-eluting stents specially designed for the cerebral vessels, developments in this field has come a long way. As we stand today, however, there are still mixed views on the use of these endovascular techniques vs aggressive medical management. In this article, we review the mechanisms of stroke in patients with intracranial atherosclerotic disease and review the current status of stenting in this condition. A brief discussion of the important clinical and procedural considerations is also provided along with a mention of the ongoing trials likely to provide valuable information on the future of stenting.

Magnetic resonance "flip-flop" in idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH) is a headache syndrome with raised CSF pressure in the absence of an intracranial mass lesion. Though earlier confined to excluding intracranial lesions, magnetic resonance imaging (MRI) in recent years has been shown to identify intracranial changes from prolonged raised CSF pressure, suggestive of IIH. We present the MRI and TOF (time-of-flight) venography findings involving the orbit, sella tursica and cerebral venous structures in a 45-year-old lady with IIH and illustrate their reversibility ("flip-flop") following CSF drainage. Our case highlights the role of imaging in evaluation and follow-up of patients with IIH, without the need for repeated lumbar punctures to monitor pressures.

Unusual coexistence of caudal duplication and caudal regression syndromes.

Caudal duplication syndrome includes anomalies of the genitourinary system, gastrointestinal tract, and the distal neural tube. Caudal regression syndrome presents with lumbosacral hypogenesis, anomalies of the lower gastrointestinal tract, genitourinary system, and limb anomalies. Both happen as a result of insult to the caudal cell mass. We present a child having features consistent with both entities.

A rare antenatally detected mass of the hand: tumour or congenital anomaly?

Tumour and tumour-like lesions of the hand can arise from various tissues and may present at birth. Rarely, anomalies of the hand may have an appearance mimicking a mass. We describe the imaging features of an antenatally detected floating thumb and describe its unusual mass-like appearance. While no hand tumour with similar imaging appearance has been reported, a few congenital lesions mimicking this appearance have been described. Awareness of these anomalies and identification of the typical imaging features of floating thumb allow diagnosis to be made with certainty.

Susceptibility-weighted imaging in the evaluation of brain arteriovenous malformations.

BACKGROUND: Digital subtraction angiography (DSA) remains the gold standard in the evaluation of arteriovenous malformations (AVMs). Susceptibility-weighted imaging (SWI), a relatively new magnetic resonance imaging (MRI) technique, exploits the magnetic susceptibility differences of various tissues, such as blood, iron and calcification. Earlier studies have shown that the magnitude and phase information of SWI offers improved sensitivity, revealing low-flow vascular malformations that are invisible on conventional gradient-echo (GRE) sequences. AIM: To evaluate the imaging appearance of AVMs on SWI. MATERIALS AND METHODS: In this retrospective study, the appearance of the various components (feeding artery, nidus, and draining veins) of AVMs on the phase, magnitude, and minimal intensity projection (minIP) images of SWI were analyzed in 14 patients with AVM and compared with conventional sequences. RESULTS: Detection and delineation of various components of AVMs was best achieved in the magnitude images. Although minIP was most effective in detecting hemorrhage and calcification, it was the magnitude image that could separate the hemorrhagic and calcified component in the nidus from the remaining nidus. The minIP was less effective in detecting the AVM components, especially nidus and draining vein, whereas conspicuity was poor with the phase images. CONCLUSION: The magnitude images of the SWI help in differentiating the different components of AVM and also helps in differentiating nidus from hemorrhage and calcification.

Retrorectal hamartoma: A 'tail' of two cysts!

Retrorectal hamartomas or tail gut cysts are rare congenital anomalies most commonly seen in a retrorectal location; most common in middle aged women. This article describes the radiological appearance in two cases of tail gut cysts in males, one a child with a visible perianal swelling since birth and the other, a 72-year-old man with symptoms for one week. In both, the tailgut cysts were in a right perirectal location. Presentation in such a location in males, at extremes of age, is unusual for tailgut cysts.