Unravelling the Complex Relationship Between Frontal Sinus Pneumatization and Paranasal Sinus Anatomical Variants: Insights from CT Imaging.

The aim of this study was to analyse the relationship between frontal sinus pneumatization and its effect on various variations of paranasal sinuses on paranasal sinus CT scan. A total number of 100 patients (51 males, 49 females) were included in this study. Patients were divided into three groups on the basis of their frontal sinus pneumatization extent on paranasal sinus CT as Type 1 pneumatization (aplasia and hypoplasia), Type 2 pneumatization (medium) and Type 3 pneumatization (hyperplasia). The prevalence of various variations like pneumatization of upper and middle turbinate, presence of agger nasi, Haller and Onodi cell, maxillary sinus hypoplasia, extent of sphenoid sinus pneumatization, pneumatization of anterior clinoid process, pterygoid process and greater wing of sphenoid sinus, dehiscence and protrusion of internal carotid artery and optic nerve types were ascertained and compared within each group. The prevalence of Onodi cell, anterior clinoid process and greater wing of sphenoid pneumatization and optic nerves type 3 and 4 were higher in Type 3 frontal sinus pneumatization group as compared with other groups. Excessive pneumatization of frontal sinus has various effects on paranasal sinus variations. Surgeons dealing with endoscopic sinus surgery, maxillofacial and skull base surgery must be vigilant of association between these variations preoperatively for avoiding complications.

Our experience with liver and spleen elastography in the prediction of oesophageal varices.

Background: Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive. Objectives: This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV. Method: The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups. Results: Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05). Conclusion: Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs. Contribution: This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Heparin Dosing During Percutaneous Coronary Intervention and Obesity.

ABSTRACT: Unfractionated heparin is the most common anticoagulant used during percutaneous coronary intervention. Practice guidelines recommend an initial weight-based heparin bolus dose between 70 and 100 U/kg to achieve target activated clotting time (ACT) of 250-300 seconds. The impact of severe obesity on weight-based heparin dosing is not well studied. We performed a retrospective analysis of 424 patients undergoing percutaneous coronary intervention who received heparin for anticoagulation. We collected detailed data on cumulative heparin administration and measured ACT values in this cohort. We performed separate analyses to identify clinical predictors that may affect dose-response curves. There was significant variability in dosing with mean dose of 103.9 ± 32-U/kg heparin administered to achieve target ACT ≥ 250 seconds. Women received higher initial heparin doses when adjusted for weight than men (97.6 ± 31 vs. 89 ± 28 U/kg, P = 0.004), and only 49% of patients achieved ACT ≥ 250 s with the initial recommended heparin bolus dose (70-100 U/kg). Lower heparin dose (U/kg) was required in obese patients to achieve target ACT. In multivariate linear regression analysis with ACT as dependent variable, after inclusion of weight-based dosing for heparin, body mass index was the only significant covariate. In conclusion, there is significant variability in the therapeutic effect of heparin, with a lower weight-adjusted heparin dose required in obese patients.

Pediatric presacral tumors with intraspinal extension: a rare entity with diagnostic challenges.

The presacral space is a potential space located between the rectum and the lumbosacral spine. It contains various primitive germ cell types that serve as the origin for a range of tumors. Imaging is crucial in characterizing, assessing the extent of and evaluating the treatment response to these tumors. We report a series of six cases of pediatric presacral tumors with intraspinal extension, including an immature sacrococcygeal teratoma (Altman type II), a malignant sacrococcygeal teratoma (Altman type IV), a neuroblastoma, a rhabdomyosarcoma, a clear cell sarcoma and an Ewing's sarcoma of the ilium. These tumors can be broadly categorized as tumors of germ cell, neuroblastic, mesenchymal and osteogenic origin. Despite overlapping imaging features, a review of the existing literature and careful retrospective observation revealed several distinctive features that aid in the optimal characterization of tumors. These include the tumor's epicenter, the pattern and degree of bone involvement, the status of sacral foramina and neural elements, and internal tumor characteristics such as the presence of fat, calcification, hemorrhage and necrosis.

Lung Ultrasound: A Complementary Imaging Tool for Chest X-Ray in the Evaluation of Dyspnea.

The present study was designed to evaluate the spectrum of imaging findings seen on chest ultrasonography in patients presenting with dyspnea and verify the concordance between chest X-ray and chest ultrasound. Methods Fifty-three patients presenting with dyspnea were included in this study. Patients with known/suspected cardiac disease were excluded from the study. All patients underwent chest X-ray and chest ultrasound, reported by two different investigators. The concordance was analyzed using Cohen's kappa value with a ' p -value' less than 0.05 considered statistically significant. Results Among the fifty-three patients with dyspnea, five diagnostic pathologies were evaluated. Concordance between lung ultrasound and chest X-ray for diagnosis of pneumonia, pneumothorax, acute exacerbation of COPD/severe asthma, and diffuse alveolar interstitial syndrome was found to be high with Cohen's kappa value > 0.8 ( p < 0.01). Ultrasound was able to correctly diagnose more cases of pneumothorax and pulmonary edema compared with chest X-ray with sensitivity and negative predictive value of 100%. Chest X-ray was found to be superior in correctly diagnosing COPD. The difference was, however, not statistically significant. Similarly, no statistically significant difference could be inferred between the diagnostic value of ultrasound and Chest X-ray in the diagnosis of pneumonia or pleural effusion. Conclusions A high concordance was noted between ultrasound and chest X-ray for diagnosis of all pathologies studied ( p < 0.01), the highest noted in pneumonia/pleural effusion and diffuse interstitial syndrome (κ = 0.9). Hence, ultrasound may be considered a complimentary imaging modality for Chest-X-ray in the evaluation of dyspnea.

Can Sublingual Nitrate Improve Visualization of Lower Limb Arteries on Computed Tomography Angiography?

OBJECTIVE: The aim of the study is to evaluate the role of sublingual nitrate in improving vessel visualization on peripheral computed tomography angiography (CTA). METHODS: Fifty patients clinically diagnosed with peripheral arterial disease of the lower limb were prospectively included in this study: Twenty-five underwent CTA after sublingual nitrate administration (nitrate group) and 25 without (non-nitrate group). Two blinded observers qualitatively and quantitatively assessed the data thus generated. The mean luminal diameter, intraluminal attenuation, site, and percentage of stenosis were evaluated in all segments. Assessment of collateral visualization at sites of significant stenosis was also done. RESULTS: Patients in the nitrate and non-nitrate groups were similar in age and sex characteristics ( P > 0.05).On subjective evaluation, there was significantly improved visualization of the femoropopliteal and tibioperoneal vasculature of the lower limb in the nitrate group compared with the non-nitrate group ( P < 0.05). Quantitative evaluation showed a statistically significant difference in the measured arterial diameters for all evaluated segments in the nitrate group versus the non-nitrate group ( P < 0.05). Intra-arterial attenuation was significantly greater for all segments in the nitrate group resulting in better contrast opacification in these studies. Collateral visualization around segments with more than 50% stenosis/occlusion was also better in the nitrate group. CONCLUSIONS: Our study suggests that nitrate administration before peripheral vascular CTA can improve visualization, especially in the distal segments by increasing the vessel diameter and intraluminal attenuation along with better delineation of the collateral circulation around stenotic areas. It may also improve the number of evaluable segments of vasculature in these angiographic studies.

Magnetic resonance imaging of rhino-orbito-cerebral mucormycosis: a pictorial review.

Rhino-orbito-cerebral mucormycosis is a potentially fatal disease requiring early magnetic resonance imaging (MRI) for disease evaluation and timely detection of intracranial complications. Angio-invasive nature leading to necrosis and infarction is the hallmark of mucormycosis. The disease follows a fulminant course extending from the paranasal sinuses to involve the orbit, deep neck spaces, skull base, facial bones, and intracranial compartment. Loss of vision either due to direct extension into the orbit or optic nerve infarction adds to disease morbidity. Prompt MRI using dedicated sequences can help in assessing the exact disease extent including early osseous and intracranial changes, which aid in precise disease management.

Tuberculoma - a great mimicker: can diffusion tensor imaging and tractography help?

BACKGROUND: Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas. PURPOSE: To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography. MATERIAL AND METHODS: Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated. RESULTS: Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10-3 mm2/s and 1.157 ± 0.277 ×10-3 mm2/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors. CONCLUSION: Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors.

Lung ultrasound for evaluation of dyspnea: a pictorial review.

Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. In recent years, lung ultrasound has emerged as an important alternative for quick evaluation of the patient at the bedside. Several techniques and protocols for performing lung ultrasound have been described in the literature, with the most popular one being the Bedside Lung Ultrasound in Emergency (BLUE) protocol which can be utilized to diagnose the cause of acute dyspnea at the bedside. We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea.

"Hood Sign" in Nuclear Medicine: An Unusual Presentation of Mantle Cell Lymphoma as Detected on FDG PET/CT.

ABSTRACT: Mantle cell lymphoma is a rare and aggressive non-Hodgkin lymphoma with a high propensity for extranodal involvement, typically seen in the liver, marrow, and gastrointestinal system. Being an FDG-avid disease and a sensitive modality for detecting both nodal and extranodal disease, FDG PET/CT is recommended in the workup of mantle cell lymphoma. We present a rare pattern of cutaneous involvement of the head-neck region in a patient with mantle cell lymphoma, which can be described on FDG PET/CT as a "hood sign."

Cerebrospinal Fluid Flow Analysis in Tuberculous Meningitis Using Phase Contrast Technique on 3 Tesla MRI: A New Paradigm and Our Initial Experience.

Background: Phase-contrast magnetic resonance imaging (PC-MRI) has been used for studying cerebrospinal fluid (CSF) dynamics in various CSF related disorders at aqueduct of Sylvius. Objective: To analyze the CSF flow dynamics qualitatively and quantitatively using PC-MRI across the aqueduct of Sylvius in diagnosed patients of tuberculous meningitis. Methods: Thirty patients, clinically diagnosed with tuberculous meningitis and mean age of 24 years (range: 12-60 years) were taken up to study the changes in CSF flow dynamics using PC-MRI with retrospective cardiac gating. Thirty age and sex matched healthy volunteers were also included for comparison and reference values. Flow quantification was done by through-plane scans acquired in the axial plane perpendicular to the aqueduct. For qualitative examination, in-plane phase contrast scans were acquired in the mid-sagittal plane. Encoding velocity was kept in craniocaudal direction. Calculated parameters were peak velocity (cm/s), average velocity (cm/s), average flow (mL/s), net forward volume (mL), and stroke volume (µL). Results: Qualitatively, loss of normal sinusoidal waveform of CSF flow was noted in two cases of hydrocephalus with exaggerated flows. Quantitatively, CSF flow parameters showed marked numerical difference in tuberculous meningitis patients with hydrocephalus on comparison with healthy volunteers and with cases without hydrocephalus. Conclusion: PC-MRI is a sensitive technique to analyze altered CSF flow dynamics in tuberculous meningitis patients. This is a useful adjunct in imaging these patients to extract both the qualitative and quantitative information about CSF flow for comprehensive evaluation.

Diffusion-weighted magnetic resonance imaging of abdominal tuberculosis: a new take on an old disease.

Abdominal tuberculosis is a major cause of mortality and morbidity in developing countries also re-emerging in western world due to the AIDS epidemic and population migration. Large proportion of the patients are young and hence radiation exposure is of concern. In addition, in some patients, contrast may be contraindicated or repeat studies may be required, where MR especially DWI may be useful. The aim of the study is to describe MRI features in abdominal tuberculosis including DWI in the involved bowel, lymphadenopathy, omental, and peritoneal thickening. Nodes being especially easy to appreciate on DWI, thus DWI in conjunction with routine noncontrast MR sequence can be useful technique to identify abdominal tubercular lesions in patients with contraindication to contrast.

Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia.

Pancreatic pseudocyst is a common complication that can occur following acute or chronic pancreatitis. Commonly, they are peripancreatic in location. Rarely, they can extend to the mediastinum, and further extension to the neck is even rarer. A 55-year-old man who presented with neck stiffness and dysphagia and on imaging, was found to have a cystic lesion in the neck. Aspiration of the lesion revealed raised amylase levels suggestive of a pancreatic pseudocyst.

Massive ovarian edema mimicking an ovarian neoplasm in a patient with IVC web.

Massive ovarian edema is an uncommon benign condition affecting young females predominantly those in the child bearing age group and preadolescent girls. Its clinical and radiologic overlap with ovarian neoplasms and torsion which require surgical intervention makes it imperative for the radiologist to consider this entity preoperatively as preserving fertility is vital in this young age group. We report a case of massive ovarian edema, a rare presentation in a patient with inferior vena cava web and consequent Budd Chiari Syndrome, an association previously unreported in literature.

Predictive Value of Grooming Behavior for Development of Dermatitis in Selectively Bred P Rats as a Model of Trichotillomania Hair Pulling Disorder.

Trichotillomania (TTM) is a body-focused repetitive disorder affecting as much as 0.5 to 2% of the population, with women four times more likely to be affected than men. This disorder causes impairment in daily function and significant distress. A potential animal model for this disorder is the inbred C57BL/6J mouse which displays clinical signs and behavioral characteristics similar to those described for people affected by this disorder. Because alcohol-preferring P rats also display similar clinical signs and behavioral characteristics, it was hypothesized that this selectively bred stock could be an additional animal model. In this study, 112 female P rats were recorded on digital media for 15 min after being sprayed with a mist of water and assessed for grooming patterns-oral, manual, and scratching. Significant elevations in scratching and oral grooming behavior were predictive of the future development of skin lesions. These findings suggest that P rats may be an additional model to study TTM, with the advantage of increased genetic variation (i.e., non-inbred) which mirrors the human population. The use of this model may help to identify preventative and therapeutic interventions for humans and other animals with similar body-focused repetitive disorders.

Multidetector Computed Tomography Angiography Role in Diagnosing Superior Mesenteric Arteriovenous Fistula with Superior Mesenteric Vein Thrombosis: A Case Report.

Introduction: Arteriovenous fistulas (AVF) of the superior mesenteric vasculature are rare vascular abnormalities. It often occurs due to iatrogenic injuries during bowel resection or abdominal traumas. As the patient exhibits a variety of signs and symptoms and can present late, diagnosis may be difficult.Multidetector computed tomography (MDCT) is the most common modality for imaging the small bowel, vessels, and mesentery in patients with mesenteric ischemia. Case presentation: We present the case of a 25-year-old man who presented with features of acute intestinal obstruction and was operated on in an emergency. Resection of gangrenous small bowel and bowel adhesiolysis with double barrel ileostomy was performed. During exploratory laparotomy, gangrenous bowels were found, but no cause of mesenteric ischemia could be delineated. Finally, on computed tomography angiography (CTA) superior mesenteric arteriovenous fistula (SMAVF) with superior mesenteric vein (SMV) thrombosis was diagnosed. The patient was advised of aggressive anticoagulant therapy. Conclusion: Computed tomography angiography has become the most reliable diagnostic modality to confirm the diagnosis and guide the best treatment strategy. How to cite this article: Satyam S, Kose S, Singh S, et al. Multidetector Computed Tomography Angiography Role in Diagnosing Superior Mesenteric Arteriovenous Fistula with Superior Mesenteric Vein Thrombosis: A Case Report. Euroasian J Hepato-Gastroenterol 2022;12(2):98-101.

18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Postsurgical and Postprocedural Setting in Thorax and Abdominopelvic Malignancies: A Pictorial Essay (Part II).

This pictorial essay depicts normal appearances, complications and residual or recurrent disease on fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) studies in the postsurgical and postprocedural setting, other than head and neck malignancy. Reading and reporting FDG PET/CT in this scenario is daunting due to the multiple confounding false positives seen during this period. This article which is the second part in this series will familiarize the readers with the normal appearance and pitfalls seen in FDG PET/CT studies in thoracic and abdominopelvic malignancies during the postoperative and postprocedural period so as to avoid misinterpretations.

18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Postsurgical Setting in Head and Neck Cancers - A Pictorial Essay.

This pictorial essay depicts normal appearances, complications, and findings of residual and/or recurrent disease on fluorodeoxyglucose positron emission tomography/computed tomography (18F- FDG PET/CT) studies in the postsurgical setting. Reading and reporting 18F- FDG PET/CT in the postoperative scenario is demanding due to the multiple false positives seen during this period. This article which contains two parts will familiarize the readers with the normal appearance and pitfalls seen in 18F- FDG PET/CT studies during the postoperative period so as to avoid misinterpretations. This pictorial will discuss 18F- FDG PET/CT in the postoperative scenario in head and neck cancers.

Pelvic Venous Thromboembolism Leading to Pulmonary Embolism in a Case of Chondroblastic Osteosarcoma Detected on FDG PET/CT.

Chondroblastic osteosarcoma is an uncommon subtype of osteosarcoma, constituting about 25% of all osteosarcoma cases. It has shown high propensity for developing tumor thrombi and thromboembolism, with poor overall survival rate. Differentiation between tumor thrombus and bland thrombus is an important factor in making treatment decisions. 18 F fluorodeoxyglucose positron emission tomography/computed tomography plays a very important role in detecting and differentiating bland thrombus from tumor thrombus.