Surgical bypass of superior and inferior mesenteric arteries with Dacron graft in a patient with acute on chronic mesenteric ischaemia with atherosclerotic complete occlusion of the infrarenal aorta.

A 67-year-old male presented to us with symptoms of postprandial abdominal pain for the last 3 months and was not able to take meals for the last month. The computed tomography (CT) angiogram showed complete occlusion in the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) with complete occlusion of infrarenal aorta and bilateral iliac arteries. While waiting for elective surgical mesenteric bypass, patient suddenly developed signs of peritonitis for which emergency surgery was done using a Dacron bifurcated graft 12 × 6 mm size. Inflow was taken from the supra coeliac aorta. At 6 months follow-up, the patient was doing well and the CT angiogram showed a patent graft. In our case, the challenge was from where to take inflow, as the patient's aorta was atherosclerotic and infrarenal aorta was completely occluded, and he was also not suitable for endovascular stenting. So, we decided to take inflow from the supra coeliac aorta and a distally mesenteric bypass was done. Although mesenteric ischaemia has very high morbidity and mortality rates, prompt and well-planned mesenteric bypass surgery can save both bowel and patients life as well.

Magnetic resonance imaging patterns and perfusion changes of posterior reversible encephalopathy syndrome in children with clinical outcome correlation.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) in children has a propensity towards atypical features on magnetic resonance (MR) imaging, with limited literature on perfusion changes and clinicoradiological correlation. OBJECTIVE: We aimed to comprehensively study MR imaging patterns of pediatric PRES, including cerebral blood flow variations on arterial spin labeling, and looked for any MR biomarkers of poor clinical outcome. MATERIALS AND METHODS: In this retrospective observational study conducted in a tertiary hospital setting, MR records over a 4-year period (May 2019 to May 2023) were systematically searched along with their clinical details. Patients with an age less than 18 years and a clinicoradiological constellation consistent with PRES were included. MR scans were analyzed by two neuroradiologists with 8 years' and 10 years' experience. Association was sought with poor clinical outcome (defined as modified Rankin Scale score at discharge of > 2). RESULTS: A total of 45 patients (29 boys) were included in the study, with a mean age (± standard deviation) of 11.19 (± 4.53) years. On MR imaging, 95.6% of patients (n = 43) showed atypical features and/or atypical areas of involvement. The superior frontal sulcus (n = 18) was the most predominant MR pattern, and cerebellar involvement was not uncommon (n = 15). Unilateral involvement (n = 3), isolated central pattern (n = 1), and spinal cord involvement (PRES-SCI: n = 1) were also encountered. Brainstem involvement (n = 4) showed a characteristic "V-sign" of anterior medullary hyperintensity. Patchy restricted diffusion (46.6%), punctate hemorrhages (37.7%), and leptomeningeal contrast enhancement (36%) were not uncommon. Arterial spin labeling sequence (available in 24 patients) showed increased cerebral blood flow in the involved areas in 79.2% of patients. Univariate analysis showed a significant association of the presence of hemorrhage (P = 0.003), involvement of brainstem (P = 0.007), deep white matter (P = 0.008), and thalamus (P = 0.026) with poor clinical outcome. Multivariate regression analysis found that hemorrhage on MRI (P = 0.011, odds ratio 8) was an independent factor associated with poor clinical outcome. CONCLUSIONS: The conventionally described atypical features in PRES are common in children and therefore may no longer be considered exceptions. Raised perfusion on arterial spin labeling sequence was seen in the majority of cases. Hemorrhage on MRI was an independent predictor of poor clinical outcome in pediatric PRES.

Outcomes after Embolization in Pediatric Abdominal Solid Organ Injury: A Trauma Center Experience.

Background Trauma is a significant cause of morbidity and mortality worldwide among children. Nonoperative management is the standard of care in hemodynamically stable children with blunt abdominal solid organ injury. Embolization is a potential pathway, which has shown increasing evidence for benefit in adult trauma patients. However, the data in children is limited. Materials and Methods A retrospective analysis of hospital data of all children (<18 years of age), presenting to a tertiary-care trauma center in India, with history of blunt trauma from January 2021 to June 2023, was performed. Preprocedural imaging, angiographic and embolization details, number of blood transfusions, and length of hospital stay were assessed. Results Two hundred and sixteen children (average age: 11.65 years) presented with a history of abdominal trauma during the study period. Eighty four children were FAST positive, out of whom, 67 patients had abdominal solid organ injury on computed tomography. Liver was the most commonly injured solid organ ( n = 45), followed by the spleen and kidney. Ten children had solid abdominal organ arterial injuries for which eight children underwent embolization. The average length of hospital stay in embolization group ( n = 8) was 4 days, as compared to 11 days in children undergoing operative management ( n = 2). At 6 months follow-up, all children were asymptomatic. Conclusion Superselective embolization is a safe and feasible procedure in appropriately selected children with abdominal injury.

Comparison of neuraxial acoustic target window of the spine among rider sitting, cross leg, hamstring stretch, and classical sitting position: An observational study.

Background and Aims: To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions. Material and Methods: This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions. Results: The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001). Conclusions: There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.

Assessing the accuracy of pleural puncture sites in patients with pleural effusion as determined by clinical examination versus ultrasound-A single-centre prospective study.

INTRODUCTION: This study aimed to ascertain the accuracy of clinical examination for the determination of pleural puncture sites as compared to the use of ultrasonography in patients with pleural effusion. MATERIAL AND METHODS: A single-centre, prospective, observational study was carried out amongst 115 patients with pleural effusion in a tertiary care hospital in western India. Patients were subjected to clinical assessment for determination of pleural puncture sites and the same were confirmed with ultrasonography. All physicians were blinded to the marking of the previous physician to prevent any influence on their assessment. RESULTS: The study had 345 physician observations. The overall accuracy of the clinical examination was 94.8%. Multivariate logistic regression of the factors responsible for the accuracy of clinical examination demonstrated a significant role of higher body mass index (BMI) (OR-1.19) and lower zone pleural effusions (OR-4.99) when adjusted for age, gender, side of effusion, and experience of examining doctors. When the effusions were classified according to their location, lower zone pleural effusions and loculated pleural effusions had an error rate of 15.9% and 8.33%, respectively. CONCLUSION: An ultrasound is the standard of care to assess all pleural effusions and guide the best point for aspiration.

Circulating miRNA-21 Levels in Breast Cancer Patients Before and After Chemotherapy and Its Association with Clinical Improvement.

Breast cancer is the most frequent type of cancer in women, many patients experience recurrences and metastasis. miR-21 (microRNA-21) as biomarker is under investigation for breast cancer. At present, there is very limited information available regarding effect of chemotherapy on miR-21 expression in breast cancer and its correlation with the clinical improvement. Hence, this study was planned to evaluate the effect of chemotherapy on miR-21 in metastatic breast cancer and its relationship with the clinical outcome. Females, aged-18-90 years diagnosed with Invasive Ductal Carcinoma of breast and candidate of neoadjuvant chemotherapy including Adriamycin (60 mg/m2), Cyclophosphamide (600 mg/m2) with or without Taxane (75-175 mg/m2) were included in the study. Before and after 42 days of staring of chemotherapy sample was collected for circulatory miR-21 and RECIST 1.1 criteria was applied to assess the clinical status. Blood samples for routine clinical biomarkers including liver function test and renal function tests was also collected. miR-21 expression before and after chemotherapy was assessed using standard method based on real time PCR. Expression of miR-21, RECIST criteria and other liver and kidney related biomarkers were compared before and after chemotherapy. After neoadjuvant chemotherapy expression of miR-21 was significantly increased by 5.65-fold. There was significant improvement in clinical scores based on RECIST criteria (0.046). No significant correlation was observed between miR-21 expression and difference in RECIST score (r = - 0.122, p = 0.570). Neoadjuvant chemotherapy causes clinical improvement in breast cancer patients however it is not correlated with the miR-21 expression which significantly increased after chemotherapy.

Multimodality imaging in cerebral venous thrombosis: a synopsis for emergency radiologist.

Cerebral venous thrombosis (CVT) is an uncommon but potentially fatal condition which presents with a wide range of symptoms. Some of these presenting features are vague thus contributing to the delay in diagnosis. A prompt diagnosis and initiation of appropriate therapy are therefore of paramount importance. In this pictorial, we have tried to illustrate the direct and indirect imaging features of CVT in detail on multiple imaging modalities, along with the potential pitfalls of imaging.

Applicability of the Suchey-Brooks method for age estimation in an Indian population: A computed tomography-based exploration using Bayesian analysis and machine learning.

Age estimation occupies a prominent niche in the identification process. In cases where skeletal remains present for examination, age is often estimated from markers distributed throughout the skeletal framework. Within the pelvis, the pubic symphysis constitutes one of the more commonly utilized skeletal markers for age estimation, with the Suchey-Brooks method comprising one of the more commonly employed methods for pubic symphyseal age estimation. The present study was targeted towards assessing the applicability of the Suchey-Brooks method for pubic symphyseal age estimation, an aspect largely unreported for an Indian population. In order to do so, clinically undertaken pelvic computed tomography scans of individuals were evaluated using the Suchey-Brooks method, and the error associated with the method was established using Bayesian analysis and different machine learning regression models. Amongst different supervised machine learning models, support vector regression and random forest furnished lowest error computations in both sexes. Using both Bayesian analysis and machine learning, lower error computations were observed in females, suggesting that the method demonstrates greater applicability for this sex. Inaccuracy and root mean square error obtained with Bayesian analysis and machine learning illustrates that both statistical modalities furnish comparable error computations for pubic symphyseal age estimation using the Suchey-Brooks method. However, given the numerous advantages associated with machine learning, it is recommended to use the same within medicolegal settings. Error computations obtained with the Suchey-Brooks method, regardless of the statistical modality utilized, indicate that the method should be used in amalgamation with additional markers to garner accurate estimates of age.

Programmed cell death ligand 1 (PD-L1) expression in non-small cell lung cancer: Findings from a tertiary care institute in western part of India.

BACKGROUND: Immune checkpoint inhibitors targeting either programmed cell death protein 1 (PD-1) or programmed cell death ligand 1 (PD-L1) have been established as a novel target for immunotherapy in non-small cell lung cancer (NSCLC). Prevalence of PD-L1 expression in NSCLC varies from 13% to 70%, with sparse data from the Indian subcontinent. In this study, we looked at PD-L1 expression and its association with demographic, clinical, radiologic and pathologic parameters in NSCLC patients. METHODS: This was an observational study carried over a period of 18 months in which 65 patients of NSCLC were included. Immunohistochemistry (IHC) for PD-L1 was done using an automated IHC stainer and testing was performed using PD-L1 IHC CAL10. For statistical analysis, unpaired t test, Chi square test, Fisher's exact test and binomial logistic regression were used. P < 0.05 was taken to be statistically significant. RESULTS: Mean age of the patients was 62.9 ± 9.2 years, and majority (87.3%) of them were males. Seventeen (26.2%) patients expressed PD-L1, among whom 10 had high PD-L1 expression (≥50%) and 7 had low PD-L1 expression (1-49%). PD-L1 expression was seen in 13 out of 43 cases of squamous cell carcinoma (SCC) and 4 out of 15 cases of adenocarcinoma. On applying binomial logistic regression analysis, association between smoking and PD-L1 expression was found to be insignificant. CONCLUSION: Almost a quarter of NSCLC cases were PD-L1 positive without any difference in expression between SCC and adenocarcinoma. PD-L1 status was not associated with any specific demographic, clinical or radiologic parameter including the histologic subtype.

Applicability of the six-phase method for auricular age estimation in an Indian population: A CT-based study.

Age estimation plays a crucial role in human identification. Amongst numerous age markers located throughout the skeletal framework, the auricular surface of the ilium presents as a resilient structure, with different methods for auricular age estimation currently in practice. Amongst these methods, the Osborne method is believed to permit accurate age estimation through its use of robust age categories and discrete phase descriptors. The present study aimed to assess the applicability of the Osborne method in an Indian population through a computed tomographic (CT) examination of the auricular surface, an aspect presently unreported. In order to do so, CT scans of 380 individuals were collected and evaluated using the Osborne method. A CT-based examination indicated that surface texture described by Osborne is difficult to appreciate through 3D CT images. Indistinct definitions associated with certain features, and the mosaic display of features within each phase further prevents applying the method effectively. Overall accuracy percentages of 99.47% and 98.90% were obtained using the method in males and females, respectively, with corresponding inaccuracy values of 10.10 years and 9.04 years. Significantly reduced accuracy percentages were obtained with alternate, more robust age brackets presented within the original study, demonstrating the limited reliability associated with the method. Inaccuracy and bias values computed for each decade indicate the relative utility of the method in aging 40-59-year-old individuals. Low accuracy percentages, high error rates and different methodological hindrances encountered within the present study illustrate the limited applicability of the Osborne method in aging an Indian population.

Computed tomographic age estimation from the iliac crest and ischial tuberosity in an Indian population using supervised machine learning approaches.

Within the pelvis the iliac crest and ischial tuberosity display delayed ossification and fusion, thus, presenting as reliable maturity indicators. Amongst the different iliac crest and ischial tuberosity age estimation methods, the modified Kreitner-Kellinghaus stages constitute one of the more promising methods. The present study was directed towards establishing the applicability of the modified Kreitner-Kellinghaus method using five supervised machine learning approaches. Clinical CT scans of consenting individuals were collected and scored using the modified Kreitner-Kellinghaus method for the iliac crest and ischial tuberosity, independently. Age was subsequently estimated using different machine learning models. Cumulative scores computed from both markers were additionally employed for age estimation using machine learning. For iliac crest age estimation, Random Forest and Gradient Boosting Regression furnished lowest mean absolute error (2.42 years) and root mean square error (3.06 years). For ischial tuberosity age estimation, Gradient Boosting Regression garnered the lowest computations of mean absolute error (2.60 years) and root mean square error (3.09 years). For cumulative score based age estimation, Support Vector Regression and Gradient Boosting Regression yielded lowest mean absolute error (2.48 years) and root mean square error (3.07 years). Obtained error computations indicate that the iliac crest is a more accurate age marker in comparison to the ischial tuberosity. Additionally, cumulative score-based approaches garnered similar/ marginally more precise results in comparison to the iliac crest with all five models. This marginal improvement is not sufficient to justify employing the relatively more complicated cumulative score-based approach for age estimation. Hence, whenever available, the iliac crest should be preferred over the ischial tuberosity/ cumulative score-based approaches for age estimation.

Pediatric Renovascular Hypertension: A Pediatric Interventional Radiologist's Perspective.

Renovascular hypertension (RVH) contributes close to one-fourth of the secondary etiologies of hypertension in children and a delay in diagnosis can result in adverse clinical outcomes. RVH in children is clinically silent with elevations in blood pressure measurements sometimes as its sole manifestation. Only a high index of suspicion by the clinician can prompt its detection. Despite the availability of other imaging modalities like ultrasound, computed tomography, and magnetic resonance imaging, digital subtraction angiography is still considered the gold standard to make a diagnosis of RVH. Angioplasty is considered the treatment of choice in appropriately selected patients. In this article, we shall focus on the various imaging findings, and management of RVH in children, which requires a multidisciplinary approach with a special focus on the role of interventional radiology.

Machine learning and regression analysis for age estimation from the iliac crest based on computed tomographic explorations in an Indian population.

Age estimation constitutes an integral parameter of identification. In children, sub-adults, and young adults, accurate age estimation is vital on various aspects of civil, criminal, and immigration law. The iliac crest presents as a suitable age marker within these age cohorts, and the modified Risser method constitutes a relatively novel and unexplored method for iliac crest age estimation. The present study attempted to ascertain the applicability of this modified method for age estimation in the Indian population, an aspect previously unexplored, through computed tomographic examination of the iliac crest. Computed tomography scans of consenting individuals undergoing routine examinations of the pelvis/ abdomen for various clinically indicated reasons were collected and scored using the modified Risser stages. Computed tomographic examinations of the iliac crest indicate that the recalibrated method accurately depicts the temporal progression of ossification and fusion changes. Different regression and machine learning models were subsequently derived and/or trained to evaluate the accuracy and precision associated with the method. Amongst the ten regression models derived herein, compound regression exhibited the lowest inaccuracy (4.78 years) and root mean squared error values (5.46 years). Machine learning yielded further reduced error rates, with decision tree regression achieving inaccuracy and root mean squared error values of 1.88 years and 2.28 years, respectively. A comparative evaluation of error computations obtained from regression analysis and machine learning illustrates the statistical superiority of machine learning for forensic age estimation. Error computations obtained with machine learning suggest that the modified Risser method is capable of permitting reliable age estimation within criminal and civil proceedings.

Chyluria: clearing the 'muddiness' with lipiodol lymphangiography.

Chyluria is a rare entity characterised by the presence of chyle/lymphatic fluid within the urine. It develops following an abnormal communication between the perirenal lymphatics and pelvicalyceal lymphatics. There are multiple causes of chyluria including infective (filariasis), post-traumatic, post-surgical, pregnancy and malignancy. We present a case of a 15-year-old male who presented with a complaint of the intermittent passage of milky urine for the preceding 1 year. Conventional lipiodol lymphangiography followed by cone beam computed tomography was done to look for abnormal fistulous channels. Subsequently, the patient was successfully treated with cystoscopy-guided renal pelvic instillation sclerotherapy of povidone-iodine.

Clinical Utility of Bronchoalveolar Lavage Neutrophilia and Biomarkers for Evaluating Severity of Chronic Fibrosing Interstitial Lung Diseases.

Introduction It is hypothesized that bronchoalveolar lavage (BAL) neutrophilia, Krebs von den Lungen-6 (KL-6), and C-reactive protein (CRP) predict the severity of chronic fibrosing interstitial lung diseases (CF-ILDs). Methods This cross-sectional study enrolled 30 CF-ILD patients. Using Pearson's correlation analysis, BAL neutrophils, KL-6, and CRP were correlated with forced vital capacity (FVC), diffusing lung capacity for carbon monoxide (DLCO), six-minute walk distance (6MWD), partial pressure of oxygen (PaO2), computed tomography fibrosis score (CTFS), and pulmonary artery systolic pressure (PASP). Using the receiver operator characteristic (ROC) curve, BAL KL-6 and CRP were evaluated against FVC% and DLCO% in isolation and combination with BAL neutrophilia for predicting the severity of CF-ILDs. Results BAL neutrophilia significantly correlated only with FVC% (r = -0.38, P = 0.04) and DLCO% (r = -0.43, P = 0.03). BAL KL-6 showed a good correlation with FVC% (r = -0.44, P < 0.05) and DLCO% (r = -0.50, P = 0.02), while BAL CRP poorly correlated with all parameters (r = 0.0-0.2). Subset analysis of BAL CRP in patients with CTFS ≤ 15 showed a better association with FVC% (r = -0.28, P = 0.05) and DLCO% (r = -0.36, P = 0.04). BAL KL-6 cut-off ≥ 72.32 U/ml and BAL CRP ≥ 14.55 mg/L predicted severe disease with area under the curve (AUC) values of 0.77 and 0.71, respectively. The combination of BAL neutrophilia, KL-6, and CRP predicted severity with an AUC value of 0.89. Conclusion The combination of BAL neutrophilia, KL-6, and CRP facilitates the severity stratification of CF-ILDs complementing existing severity parameters.

MDCT evaluation of Dorsal Pancreatic Artery and Intrapancreatic arcade anatomy.

OBJECTIVE: The purpose of the study was to analyze the anatomy and variations in the origin of the dorsal pancreatic artery, greater pancreatic artery and to study the various types of arterial arcades supplying the pancreas on multidetector CT (MDCT). METHODS: A retrospective analysis of 747 MDCT scans was performed in patients who underwent triple phase or dual phase CT abdomen between December 2020 and October 2022. Variations in origin of Dorsal pancreatic artery (DPA), greater pancreatic artery (GPA), uncinate process branch were studied. Intrapancreatic arcade anatomy was classified according to Roman Ramos et al. into 4 types-small arcades (type I), small and large arcades (type II), large arcades (type III) and straight branches (type IV). RESULTS: The DPA was visualized in 65.3% (n = 488) of cases. The most common origin was from the splenic artery in 58.2% (n = 284) cases. The mean calibre of DPA was 2.05 mm (1.0-4.8 mm). The uncinate branch was seen in 21.7% (n = 106) with an average diameter of 1.3 mm. The greater pancreatic artery was seen in 57.3% (n = 428) predominantly seen arising from the splenic artery. The most common arcade anatomy was of Type II in 52.1% (n = 63) cases. CONCLUSION: Pancreatic arterial variations are not very uncommon in daily practice. Knowledge of these variations before pancreatic surgery and endovascular intervention procedure is important for surgeons and interventional radiologist.