Aberrant Collaterals in Cirrhosis and Challenges in its Management.

Portosystemic collateral formation in cirrhotic patients plays an essential role in the natural history of patients. A thorough understanding of collateral anatomy and hemodynamics in cirrhosis, it is important to envisage diagnosis and outcomes of portal hypertension. The understanding of the patterns of aberrant portosystemic collateral channels has important implications both for the clinician and the interventionist. In this case report, our patient presented to us with the formation of aberrant collaterals at the site of subcostal hernia for which he underwent a mesh repair eight years back. The technical challenges in the management of shunt closure of these aberrant collaterals were discussed.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians.

BACKGROUND: Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy. PURPOSE: To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS. MATERIAL AND METHODS: This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019). RESULTS: Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed. CONCLUSION: Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Recanalized Paraumbilical Vein Leading to Hepatic Myelopathy Causing Spastic Paraparesis in a Patient with Chronic Liver Disease.

A 34-year-old male visited our hospital with complaints of recurrent episodes of altered behavior since past 6 months along with difficulty in walking since past 3 months. He was diagnosed of chronic liver disease in the past. Examination revealed spasticity and brisk deep tendon reflexes in both the lower limbs. His blood investigations and spinal cord imaging was normal. Based on his clinical features, a possibility of portosystemic shunting leading to portosystemic encephalopathy (PSE) and shunt myelopathy was suspected. A computed tomography portography showed a recanalized paraumblical vein draining portal blood into external iliac veins. Patient underwent shunt occlusion (Figure- 2). One month after the procedure, while there was no recurrence of symptoms of PSE, those of myelopathy remained unchanged. Shunt myelopathy is a rare complication of spontaneous or iatrogenic portosystemic shunts. Unlike PSE, the management of shunt myelopathy is uncertain due to limited evidence. Limited evidence suggests reversal of myelopathy after early shunt occlusion, highlighting the irreversible changes that may set in spinal cord due to delayed diagnosis. Our case highlights an important but a rare complication of portosystemic shunting in chronic liver disease which should be kept in mind if these patients develop symptoms attributable to spinal cord disease.

Myotendinous pseudomasses: an imaging review.

A mass or a tumor may not always be an underlying cause for a clinically apparent swelling. A wide range of myotendinous disorders can present as pseudomasses. These include muscle/myofascial hernia, tendon tears, benign hypertrophy, accessory muscles, tendon xanthomas, diffuse myositis, and exertional compartment syndromes. We have briefly reviewed these lesions highlighting their typical radiological findings and have also highlighted the role of different imaging modalities and the role of dynamic imaging. Although rare, radiologists should be aware of these entities to avoid mislabeling a pseudomass as a mass or malignancy and to detect the abnormality in not-so-apparent masses.

Dura-to-Spinal Cord Distance at Different Vertebral Levels in Indian Children: A Retrospective Computerized Tomography Scan-Based Study.

Background: Neuraxial techniques provide good postoperative analgesia for painful procedures in the pediatric population. However, any injury to the spinal cord can lead to irreversible long-term effects. Aims: We aimed to evaluate dura-to-cord (DTC) distance from computerized tomography (CT) images of thoracolumbar spine in pediatric age group (1-16 years) at T8-9, T9-10, and L1-2 interspaces to identify the safe space for epidural insertion in Asian children. Settings and Design: It was a retrospective study including 141 children aged 1-16 years who underwent routine CT scan of the thoracolumbar region for unrelated diagnostic indications. Materials and Methods: Patients with spinal abnormalities were excluded. Sagittal CT images of the thoracolumbar spine were obtained to calculate the DTC at T8-9, T9-10, and L1-2 interspaces. The measurements at all levels were obtained perpendicular to the long axis of the vertebral body. Statistical Analysis Used: Continuous data were depicted as mean with standard deviations. The categorical data were presented as counts with percentages. Results: The mean DTC distance at T8-9, T9-10, and L1-2 interspaces was 3.51 ± 0.98 mm (95% confidence interval [CI]: 3.35-3.67), 2.73 ± 0.94 mm (95% CI: 2.57-2.89), and 2.83 ± 1.08 mm (95% CI: 2.66-3.02), respectively. A significant difference was found between the genders at T9-10 (P = 0.02) and L1-2 levels (P = 0.04). No difference in DTC was found in toddlers, preschool children, school-going children, and adolescents. DTC at T8-9 showed a significant correlation with age (R 2 = 0.0479; P = 0.04), weight (R 2 = 0.038; P = 0.02), and height (R 2 = 0.037; P = 0.03). Conclusion: Thoracic epidural space can be used in children and adolescents for epidural catheter placement. T8-9 level showed maximum DTC distance and significant correlation with age, height, and weight in CT imaging in the present study.

Uterine artery Embolization: Interventional Radiologist's Perspective in Management of Uncontrolled Obstetric Hemorrhage.

Purpose: To study the efficacy and safety of uterine artery embolization in treatment of obstetric hemorrhage. Methods: This ethically approved prospective study was conducted between November 2017 and October 2019, and written informed consent was obtained from all patients. Consecutive patients presenting with uncontrolled obstetric hemorrhage were evaluated. Fifty-three patients with uncontrolled bleeding underwent uterine artery embolization (UAE) and were followed up. Results: Spectrum of patients encountered in this study was arteriovenous malformations (AVMs) (n = 25), retained products of conception (RPOC) (n = 16), RPOC with secondary AVMs (n = 5), ectopic pregnancy (n = 5) and iatrogenic trauma to cervix or vagina (n = 2). A total of 57 UAE procedures were performed in these 53 patients as repeat sessions were required in four patients. Most common embolic agent used was polyvinyl alcohol (PVA) particles with gelfoam followed by cyanoacrylate glue as second most common agent. Technical success was achieved in 57 (100%) of 57 UAE procedures. Primary clinical success was achieved in 49 (92%) of 53 patients and secondary clinical success in 52 (98%) patients. Clinical failure was observed in one patient who underwent hysterectomy. Conclusion: Uterine artery embolization is a safe and effective procedure in the management of uncontrolled obstetric hemorrhage.

Neuro-ophthalmic manifestations of tuberculosis.

Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.

Unidentified bright objects of spleen on arterial phase CT: mimicker of splenic vascular injury in blunt abdominal trauma.

PURPOSE: We have described unidentified bright objects of spleen (UBOS), a hitherto undescribed entity, as hyperdense areas on arterial phase (AP) computed tomography (CT) seen in relation to splenic lacerations and are isodense to the normal parenchyma on portal venous phase with no correlate on digital subtraction angiography (DSA). UBOS mimic splenic vascular injuries like active contrast extravasation and pseudoaneurysm and need to be differentiated from them as it would have implications on patient management. We undertook this study to identify CT features of UBOS that can differentiate them from splenic vascular injuries and to calculate their diagnostic accuracy. METHODS: This retrospective study was approved by the institutional ethical committee and the need for informed consent was waived. Patients with splenic injury who had undergone dual-phase CT and DSA were included. All the lesions that were hyperdense on AP were evaluated for their outline, their relation to the adjacent/parallel margins of a laceration (margin sign), string of beads appearance, and the presence of adjacent normal parenchyma (adjacent parenchyma sign). The Hounsfield unit (HU) of the lesion and the aorta on the AP were also noted. The diagnostic accuracy of various signs for distinguishing UBOS from splenic vascular injuries was calculated using DSA as the reference standard. RESULTS: Of 48 patients, 5 were excluded due to suboptimal quality of the examination or a time difference of more than 6 hours between the CT and DSA. A total of 54 hyperdense lesions were detected on AP in 43 patients. These were classified as vascular injuries (pseudoaneurysm, n=11; active contrast extravasation, n=11) and UBOS (n=32) based on DSA. The margin sign, string of beads appearance, and ill-defined outline had high specificity (95%, 86%, and 82%, respectively) but low sensitivity (50%, 65%, and 63%, respectively). The adjacent parenchyma sign had a moderate sensitivity and specificity of 84% and 77%, respectively. ROC analysis showed that a difference of 50 HU between the aorta and the lesion had a high sensitivity and specificity of 88.9% and 90.6%, respectively, with an area under the curve of 0.90. CONCLUSION: An attenuation difference of over 50 HU between the aorta and the lesion and the presence of normal adjacent parenchyma had the highest diagnostic accuracy, while an ill-defined outline, string of beads appearance, and margin sign had high specificity but low sensitivity for differentiating UBOS from splenic vascular injuries.

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature.

BACKGROUND: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. CASE DESCRIPTION: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. CONCLUSION: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Utility of admission perfusion CT for the prediction of suboptimal outcome following uncomplicated minor traumatic brain injury.

PURPOSE: To compare the perfusion parameters of patients with uncomplicated mild traumatic brain injury (mTBI) with healthy controls and to assess whether admission perfusion CT parameters can be used to predict outcome at 6 months post-injury in patients with uncomplicated mTBI. METHODS: Institute ethical committee approval was obtained for this prospective cohort study and informed written consent obtained from all subjects. Patients who sustained mTBI and had no abnormalities on non-contrast CT from June 2010 to January 2012 (20 months) and 10 healthy controls were included and underwent perfusion CT at admission. Outcome was determined at 6 months follow-up using the extended Glasgow Coma Outcome Scale score. RESULTS: Forty-nine patients were included, of which 16 (32.7%) had symptoms at 6 months post-injury (suboptimal outcome). The mean cerebral blood flow and volume were lower in both the gray and white matter of all three arterial territories in the study group than in the control group (p value < 0.05). In the study group, these values were lower in those with suboptimal outcome than in those with optimal outcome (no symptoms). Cerebral blood flow showed higher area under the curve for predicting the outcome. CONCLUSION: Perfusion parameters are altered even in patients with uncomplicated mTBI. A single ROI (region of interest) evaluation of the gray matter in the posterior cerebral artery territory on admission perfusion CT could provide a quick and efficient way to predict patients who would have a suboptimal outcome at 6 months post-injury.

Sinonasal Diseases Affecting the Orbit - A Radiological Pattern-Based Approach.

The orbit is surrounded on three sides by paranasal sinuses with only a thin rim of bone separating the 2 at each site, predisposing it to the risk of being affected by the diseases of primary sinonasal compartment. A wide range of sinonasal pathologies can show orbital involvement and may present mainly with orbital symptoms. While most of these are due to contiguous involvement, a few others may be caused by systemic diseases that often involve both, the orbit and the sinuses in a noncontiguous manner. In this article, we have classified these diseases based on their radiological appearances into 5 patterns: Pattern 1 - Fat stranding predominant, Pattern 2 - Soft tissue without bone destruction, Pattern 3 - Soft tissue with bone destruction, Pattern 4 - Bony pathologies, Pattern 5 - Sinus volume changes. Various pathologies have been classified into these patterns considering the most typical changes in each of the disease processes. We briefly review these patterns, their hallmark radiological signs, typical examples of each pattern as well as review the various diseases process highlighting their radiological appearances. Imaging plays a crucial role in identifying the epicentre of the disease process, narrowing down the differential diagnoses, identifying management modifying complications, planning the surgical management as well as in the follow up of several such lesions. This unique radiological approach, although not absolute, aims to provide a new insight and working algorithm to help narrowing down the differential diagnoses.

Imaging of Lacrimal Gland Pathologies: A Radiological Pattern-Based Approach.

Despite their unassuming size, lacrimal glands can have a variety of pathologies affecting them which often poses a diagnostic challenge clinically in view of their nonspecific presentation as palpable lump in the superolateral aspect of the orbit. There are a myriad of pathological entities ranging from inflammatory to neoplastic lesions that can affect the lacrimal glands. Cross-sectional imaging is must for the detection, characterization, and mapping of these lesions. In this pictorial review, we propose a radiological pattern-based approach for various lacrimal gland lesions that provides a working algorithm for radiologists in the evaluation of lacrimal gland pathologies.

Revised AAST scale for splenic injury (2018): does addition of arterial phase on CT have an impact on the grade?

PURPOSE: To determine whether an additional arterial phase (AP) leads to a change in the grade of splenic injury according to the 2018 revision of the AAST Organ Injury Scale, which has incorporated vascular injuries into the grading system and also to study its impact on management. METHODS: In this retrospective study, 527 patients who sustained blunt abdominal trauma and had underwent dual-phase CT (AP and portal venous phase (PVP)) from December 2014 to October 2016 (23 months) were included. Two experienced radiologists independently graded the splenic injury according to the revised system in 2 blinded ways (AP + PVP and PVP alone). Receiver operator characteristic (ROC) curves were generated for grade of injury on both the phases for all splenic interventions. RESULTS: Splenic injuries were detected in 154 patients, and splenic vascular injuries were detected in 52 of them. Of these, 22 vascular injuries were detected only on the AP, leading to a change in the grade of injury according to the new system in 18 patients. The AUC for ROC curves was generated for the grade of injury on AP + PVP vs. PVP alone for angioembolization (0.80 vs. 0.71, p value 0.002), and all splenic interventions (0.89 vs. 0.83, p value 0.003) showed higher AUC for AP + PVP. CONCLUSION: Addition of AP leads to a significant change in the grading of splenic injuries according to the revised grading system due to increased detection of vascular injuries. Accurate classification of splenic injuries using additional AP would lead to better triage of patients for splenic interventions or conservative management.

Long-Term Outcomes of Endovascular Interventions in More than 500 patients with Budd-Chiari Syndrome.

PURPOSE: To assess and compare the long-term outcomes of various endovascular interventions in patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: In this single-center retrospective study, 510 consecutive patients with BCS who had undergone a total of 618 endovascular procedures from January 2001 to December 2019 were included. Details of the type of endovascular intervention, technical success, clinical success, patency rate, complications, and survival outcomes were analyzed. RESULTS: The overall technical success rate was 96% (593 of 618 procedures; 500 in treatment-naïve patients and 93 repeat interventions for recurrent disease). Endovascular procedures included recanalization procedures (angioplasty and stent placement) in 355 patients (71%) and transjugular intrahepatic portosystemic shunt (TIPS) creation in 145 (29%). Major postprocedure complications occurred in 14 patients (2.8%). Vascular/stent restenosis occurred in 95 patients (19%), and successful repeat intervention was performed in 82 of those 95 (86.3%). An additional 11 of these 82 (13.4%) underwent a third intervention for restenosis. In the recanalization and TIPS groups, the 1- and 5-y cumulative patency rates were 87% and 74% and 95% and 68%, respectively. The 1- and 5-y survival rates were 96% and 89% and 90% and 76%, respectively. CONCLUSIONS: Endovascular interventions for BCS are feasible and safe in the majority of patients, with excellent short- and long-term patency and survival rates.

Evaluation of the Graft Kidney in the Early Postoperative Period: Performance of Contrast-Enhanced Ultrasound and Additional Ultrasound Parameters.

OBJECTIVES: To evaluate the various quantitative parameters of Doppler ultrasound, contrast-enhanced ultrasound (CEUS), and shear wave elastography (SWE) of graft kidneys in the early postoperative period and to explore their utility in the diagnosis of parenchymal causes of graft dysfunction. METHODS: In this ethically approved study, consecutive patients who underwent renal transplantation from March 2017 to August 2018 were recruited, and those with urologic or vascular complications and those who denied consent were excluded. All patients underwent ultrasound with Doppler, SWE, CEUS (using sulfur hexafluoride), and renal scintigraphic examinations 3 to 10 days after transplantation. A composite reference standard was used, including the clinical course, renal function test results, urine output, and histopathologic results for graft dysfunction. Cortical SWE values, quantitative CEUS parameters (generated from a time-intensity curve), and their ratios were analyzed to identify graft dysfunction and differentiate acute tubular necrosis (ATN) from acute rejection (AR). RESULTS: Of the 105 patients included, 19 developed graft dysfunction (18.1%; 12 ATN, 5 AR, and 2 drug toxicity) in the early postoperative period. The peak systolic velocity in the interpolar artery showed a significant difference between control and graft dysfunction groups (P < .001) as well as between ATN and AR (P = .019). Resistive indices and SWE did not show significant differences. Ratios of the time to peak showed a significant difference between control and graft dysfunction groups (P < .05). The rise time and fall time of the large subcapsular region of interest and the rise time ratio were significantly different between ATN and AR (P = .03). CONCLUSIONS: Contrast-enhanced ultrasound can be used to diagnose parenchymal causes of early graft dysfunction with reasonable diagnostic accuracy.