Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn's disease: A cohort study from northern India.

BACKGROUND: Fistulizing perianal Crohn's disease (CD) is a debilitating condition associated with significant morbidity and reduction in the quality of life. Magnetic resonance imaging (MRI) of the pelvis is the preferred imaging modality for the comprehensive assessment of the perianal fistula. There is a paucity of data from India on the MRI spectrum of complex perianal fistula in CD. METHODS: A single-centre cross-sectional analysis of patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed. The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula (defined according to the American Gastroenterological Association classification) were recorded. RESULTS: Of total 175 patients with CD who attended the gastroenterology clinic during the study period, 27 (15.42%) (mean age 42±15.5 years, 62.96% females and median disease duration four years) had complex perianal fistula and were included in the analysis. The mean PDAI was 5.48±2.53. The median Van Assche Index was 17 (interquartile range [IQR] 13-19). A majority (96.29%) of the fistulae were trans-sphincteric and four (14.81%) fistulae extended into the supralevator space. All fistulae were active on MRI. Concomitant perianal abscess and proctitis were seen in 59.26% (n=16) and 62.96% (n=17) of patients, respectively. Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy. Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment. CONCLUSION: The cumulative risk of the development of fistulizing perianal CD in a northern Indian cohort was similar to the western populations. Complex perianal fistulae were predominantly trans-sphincteric and commoner in females. MRI evaluation is pivotal for the delineation of fistula anatomy, assessment of disease extent and activity and the evaluation of concomitant perianal abscess and other complications.

Correlation between magnetic resonance enterography and ileo-colonoscopy for assessment of disease activity in terminal ileal Crohn's disease.

BACKGROUND: Magnetic resonance enterography (MRE) has emerged as a novel tool for the assessment of disease activity in Crohn's disease (CD). Real world data from Indian subcontinent on performance of MRE in terminal ileal CD are lacking. METHODS: Retrospective analysis of patients with terminal ileal CD who underwent both ileo-colonoscopy and MRE was performed. Ileo-colonoscopy was considered the gold standard for assessment of disease activity. On ileo-colonoscopy, a simple endoscopic score for Crohn's disease (SES-CD) ≥2 was considered active disease; presence of ulcers indicated severe disease. MRE scoring of the disease activity was performed using magnetic resonance index of activity (MARIA) and simplified MARIA (MARIAs). The measure of agreement between ileo-colonoscopy and MRE and comparison of MARIA and MARIAs for assessment of disease activity and sensitivity of MRE to detect mucosal ulcerations were calculated. RESULTS: Seventy patients with terminal ileal CD (mean age 40.74±15.56 years; 71.4% males [n=50]) were evaluated. The sensitivities of MARIA and MARIAs scores to detect active disease were 0.76 and 0.84, respectively. The area under the receiver operating characteristic curve (AUROC) for detecting severe disease was 0.836 (p<0.0001) for MARIA and 0.861 (p<0.0001) for MARIAs. For mild active disease, there was no agreement between SES-CD and MARIA or MARIAs; however, for severe disease, the agreement was fair and moderate for MARIA and MARIAs, respectively. MARIA and MARIAs were comparable for identification of active and severe disease (κ 0.759, p<0.0001 and κ 0.840, p<0.0001, respectively). MRE was 68.18% sensitive to detect mucosal ulcers. CONCLUSION: MRE is a reliable and sensitive tool for detection of endoscopically severe, but not mild, terminal ileal CD.

Case 300: Ruptured Mucinous Cystadenoma of the Pancreas.

History Part one of this case appeared 4 months previously and may contain larger images. A 40-year-old woman presented to the outpatient department of our hospital with a 2-year history of abdominal pain, which had worsened in the past few days. There were no other constitutional symptoms; in particular, there was no weight loss or loss of appetite. The serum amylase and serum lipase levels were always within normal limits, even during the current episode. There was no history of pancreatitis, alcohol abuse, drug use, or trauma. The patient was evaluated at an outside clinic 2 years ago and underwent imaging, including US and dedicated pancreatic CT, which revealed a complex multiseptated noncalcified pancreatic cystic lesion. After CT, the patient underwent endoscopic US, which showed the lesion was suspected to be an infected parasitic cyst; fine-needle aspiration and cytology were not attempted due to the risk of iatrogenic rupture. The patient was advised to undergo surgical resection but declined the procedure and was lost to follow-up for 2 years before her current visit to our facility. On clinical examination, there were no clinically important findings, aside from mild to moderate pain on deep palpation and some shifting dullness that was suggestive of ascites. The patient always remained hemodynamically stable. US-guided ascitic fluid analysis was performed, which revealed amylase levels of 869 IU/L (normal range, 4-234 IU/L). Considering prior CT and endoscopic US reports, the patient was further evaluated with a pancreatic MRI protocol for lesion characterization and to explain the new-onset abdominal pain.

Diagnostic Accuracy of Calculated Tumor Volumes and Apparent Diffusion Coefficient Values in Predicting Endometrial Cancer Grade.

Background: Magnetic resonance imaging (MRI) has been shown to be an accurate imaging technique for the preoperative assessment of local staging of endometrial cancer and for evaluating the depth of myometrial invasion. Materials and Methods: This was a single-center retrospective study performed on patients with histopathologically proven endometrial carcinoma who underwent an MRI examination of the pelvis between October 2017 and May 2020. Results: In the present analysis, mean apparent diffusion coefficient (ADC) values for each histologic grade were 0.72 ± 0.13 × 10-3 mm2/s (G1), 0.76 ± 0.17 × 10-3 mm2/s (G2), and 0.74 ± 0.12 × 10-3 mm2/s (G3), respectively, showing no significant correlation between ADC values and tumor grade (P = 0.73). Overall, ADC minimum was significant in differentiating grades of endometrial carcinoma (P = 0.02) with the ability to differentiate Grade I and II lesions (P = 0.01). A mean tumor volume of 25.2 cc could differentiate low-grade tumors (Grade I and Grade II) from high-grade tumors (Grade III) with a sensitivity and specificity of 88% and specificity of 89%. The tumor volume/uterine volume ratio (TV/UV) differentiates high-grade tumors from low-grade tumors (P < 0.001), however, no significant difference in the ratio was observed among Grade I and II lesions (P = 0.48). The area under the curve of tumor volume was 0.875 (95% confidence interval 0.0-1.00) (P = 0.001), indicating that tumor volume was an effective tool for distinguishing high-grade and low-grade endometrioid adenocarcinomas. The corresponding sensitivity and specificity were 88.0% and 89.0%, respectively. Conclusion: Preoperative noninvasive radiological assessment for tumor volume, TV/ UV or tumor volume/uterine volume is important surrogate markers for preoperative prognostication of endometrial carcinoma.

Muscle strength and physical performance, rather than muscle mass, correlate with mortality in end-stage liver disease.

OBJECTIVES: Sarcopenia is characterized by the loss of skeletal muscle mass, strength and performance. The study aimed to provide cut off values of various Sarcopenia parameters [computerized tomography skeletal muscle index (SMI), handgrip strength (HGS), gait velocity and chair stand] to predict mortality in end-stage liver disease (ESLD). METHODS: The inclusion criteria were age 18-75 years, model for end-stage liver disease > 15. All patients with advanced heart, lung, kidney diseases, active malignancy were excluded from the study. Sarcopenia indices were compared between survivors and non-survivors to find cut off value for prediction of mortality in ESLD patients. RESULTS: One hundred sixty-one subjects suffering from ESLD were enrolled. The cutoff value of the SMI to identify high risk of mortality in sarcopenia patients is ≤21.2 cm2/m2, area under the curve (AUC) 0.537 [95% confidence interval (CI) 0.456-0.616]. The cutoff value of the hand grip strength to identify high-risk mortality is ≤25.3 kilogram-force, AUC 0.682 (95% CI 0.604-0.753). The cutoff value of the gait velocity for the same is as ≤0.84 m/s, AUC 0.551 (95% CI 0.459-0.641). The cutoff value of the chair stand is ≥20.9 seconds, AUC 0.956 (95% CI 0.910-0.983). In the multivariate analysis, HGS, gait velocity and chair stand correlated with mortality. CONCLUSION: The current study is a comprehensive Asian study that gives the cut off values of Sarcopenia: muscle mass, strength and performance which identify high risk of mortality in ESLD patients. Muscle strength and performance correlated with mortality.

Evaluation of Clinical and Magnetic Resonance Imaging Profile of Pituitary Macroadenoma: A Prospective Study.

BACKGROUND: Pituitary macroadenoma is a common tumor of middle-aged people. Magnetic resonance imaging (MRI) is the investigation of choice for its evaluation. Various parameters regarding the extent, consistency, and contrast uptake can be studied and a noninvasive diagnosis is possible. AIMS AND OBJECTIVES: To study the MRI features and extent of pituitary macroadenomas. MATERIALS AND METHODS: We studied clinical and MRI features of 33 patients of all age groups and both sexes with pituitary macroadenomas who presented to Dayanand Medical College and Hospital, Ludhiana from January 2014 to June 2015. MRI was carried out on MAGNETOM Avanto 18 Channel 1.5 Tesla Machine by Seimens India Ltd. The dedicated sellar protocol consisted of sagittal and coronal T1-weighted image (TI-WI) and T2-WI without intravenous contrast using thin slices (3 mm) and a field of view of <200 mm. RESULTS: On analysis of the 33 cases, we observed that patients of pituitary macroadenoma showed an almost equal sex incidence and average age group of 50-60 years. The common presenting complaints were headache and decreased vision. Superior and inferior extent of the lesion was beyond the defined boundaries of sella in most cases, but the lateral extent was limited, resulting in characteristic "snowman-like" appearance. The imaging characteristics showed solid to predominantly solid consistency, appearing mostly heterogeneously hyperintense on T2-WI, and hypo to isointense on T1-WI with intense postcontrast enhancement. Hemorrhage is less common. Pituitary apoplexy is rare and can result in spontaneous resolution. CONCLUSIONS: We conclude that the knowledge of clinical and imaging profile of pituitary macroadenoma can help the radiologists to diagnose these sellar lesions, and hence their therapeutic approach can be defined timely.

Stroke After Minor Head Trauma in Infants and Young Children With Basal Ganglia Calcification: A Lenticulostriate Vasculopathy?

The authors retrospectively reviewed charts of the children with basal ganglia stroke who either had preceding minor head injury or showed basal ganglia calcification on computed tomography (CT) scan. Twenty children, 14 boys and 6 girls were identified. Eighteen were aged between 7 months to 17 months. Presentation was with hemiparesis in 17 and seizures in 3. Preceding minor head trauma was noted in 18. Family history was positive in 1 case. Bilateral basal ganglia calcification on CT scan was noted in 18. Brain magnetic resonance imaging done in 18 infants showed acute or chronic infarcts in basal ganglia. Results of other laboratory and radiological investigations were normal. Four infants were lost to follow-up, 9 achieved complete or nearly completely recovery, and 7 had persistent neurological deficits. Basal ganglia calcification likely represents mineralized lenticulostriate arteries, a marker of lenticulostriate vasculopathy. Abnormal lenticulostriate vessels are vulnerable to injury and thrombosis after minor head trauma resulting in stroke.

Diagnostic tools in maxillofacial fractures: Is there really a need of three-dimensional computed tomography?

INTRODUCTION: Because of its functional and cosmetic importance, facial injuries, especially bony fractures are clinically very significant. Missed and maltreated fractures might result in malocclusion and disfigurement of the face, thus making accurate diagnosis of the fracture very essential. In earlier times, conventional radiography along with clinical examination played a major role in diagnosis of maxillofacial fractures. However, it was noted that the overlapping nature of bones and the inability to visualise soft tissue swelling and fracture displacement, especially in face, makes radiography less reliable and useful. Computed tomography (CT), also called as X-ray computed radiography, has helped in solving this problem. This clinical study is to compare three-dimensional (3D) CT reconstruction with conventional radiography in evaluating the maxillofacial fractures preoperatively and effecting the surgical management, accordingly. MATERIALS AND METHODS: Fifty patients, with suspected maxillofacial fractures on clinical examination, were subjected to conventional radiography and CT face with 3D reconstruction. The number and site of fractures in zygoma, maxilla, mandible and nose, detected by both the methods, were enumerated and compared. The final bearing of these additional fractures, on the management protocol, was analysed. RESULTS: CT proved superior to conventional radiography in diagnosing additional number of fractures in zygoma, maxilla, mandible (subcondylar) and nasal bone. Coronal and axial images were found to be significantly more diagnostic in fracture sites such as zygomaticomaxillary complex, orbital floor, arch, lateral maxillary wall and anterior maxillary wall. CONCLUSION: 3D images gave an inside out picture of the actual sites of fractures. It acted as mind's eye for pre-operative planning and intra-operative execution of surgery. Better surgical treatment could be given to 33% of the cases because of better diagnostic ability of CT.

A prospective study of magnetic resonance imaging patterns of central nervous system infections in pediatric age group and young adults and their clinico-biochemical correlation.

BACKGROUND: Infections of the central nervous system (CNS) are common and routinely encountered. Our aim was to evaluate the neuroimaging features of the various infections of the CNS so as to differentiate them from tumoral, vascular, and other entities that warrant a different line of therapy. AIMS: Our aim was to analyze the biochemical and magnetic resonance imaging (MRI) features in CNS infections. SETTINGS AND DESIGN: This was a longitudinal, prospective study over a period of 1½ years. SUBJECTS AND METHODS: We studied cerebrospinal fluid (CSF) findings and MRI patterns in 27 patients of 0-20 years age group with clinical features of CNS infections. MRI was performed on MAGNETOM Avanto 18 Channel 1.5 Tesla MR machine by Siemens India Ltd. The MRI protocol consisted of diffusion-weighted and apparent diffusion coefficient imaging, turbo spin echo T2-weighted, spin echo T1-weighted, fluid-attenuated inversion recovery (FLAIR), and gradient-echo in axial, FLAIR in coronal, and T2-weighted in sagittal plane. Contrast-enhanced T1-weighted sequence and MR spectroscopy were done whenever indicated. RESULTS AND CONCLUSIONS: We found that most of the children belong to 1-10 years age group. Fungal infections were uncommon, mean CSF adenosine deaminase values specific for tuberculosis and mean CSF glucose-lowered in pyogenic. Hemorrhagic involvement of thalamus with/without basal ganglia and brainstem involvement may indicate Japanese encephalitis or dengue encephalitis. Diffusion restriction or hemorrhage in not expected in the brainstem afflicted lesions of rabies. Congenital cytomegalovirus can cause cortical malformations. T1 hyperintensities with diffusion restriction may represent viral encephalitis. Lesions of acute disseminated encephalomyelitis (ADEM) may mimic viral encephalitis. Leptomeningeal enhancement is predominant in pyogenic meningitis. Basilar meningitis in the presence of tuberculomas is highly sensitive and specific for tuberculosis.

Paediatric brainstem: A comprehensive review of pathologies on MR imaging.

The brainstem is a midline structure formed by the midbrain, pons and medulla and is a home for various vital neurological centres of the human body. A diverse spectrum of disease entities can involve the brainstem, which includes infections, metabolic disorders, demyelination, vascular conditions, neurodegenerative disorders and tumours. Brainstem involvement can be primary or secondary, i.e., as part of systemic disorders. Due to the overlapping clinical presentation and symptomatology, imaging plays a decisive role in the detection, localisation and characterisation of brainstem pathologies. Magnetic resonance imaging (MRI) is the modality of choice and the use of advanced MR techniques such as diffusion-weighted imaging and spectroscopy can be especially helpful in providing a tenable diagnoses. This article is a compilation of the MR imaging manifestations of a spectrum of common and uncommon brainstem pathologies that can be encountered in the paediatric age group. Teaching Points • The paediatric brainstem can be afflicted by many pathologies that may overlap clinico-radiologically. • MRI is the best modality for the localisation and diagnosis of brainstem pathologies. • Diffusion-weighted imaging is useful in the diagnosis of vascular and metabolic disorders. • Occasionally, demyelination and neoplasms can be indistinguishable on imaging.

Tuberous sclerosis complex presenting as pulmonary lymphangioleiomyomatosis--a clinicoradiological diagnosis.

Tuberous sclerosis complex (TSC) manifests predominantly as a neurocutaneous disorder. Lymphangioleiomyomatosis (LAM) is a rare pulmonary manifestation of TSC. Imaging evaluation plays an important role in the assessment of patients with tuberous sclerosis complex. In newly diagnosed patients, it helps not only to confirm the diagnosis of TSC, but also helps in identifying clinically significant complications. We describe the radiological findings in lungs and other organs in a middle aged female with TSC.

Abdominal splenosis mimicking peritoneal deposits - A case report.

Splenosis is a benign condition among patients with a history of splenic trauma or surgery. Most cases of splenosis are intra abdominal due to direct seeding of surrounding structures, although these heterotopic rests may occur almost anywhere in the body, and its diffuse nature may raise the suspicion of metastatic cancer. The increased prevalence of abdominal trauma due to road accidents and the growing armamentarium of available imaging modalities suggest that abdominal splenosis may be expected more often than ever. We, in this article emphasize the crucial role of taking a thorough patient's medical history concerning splenic trauma in the past and the use of novel non invasive diagnostics modalities that allow accurate diagnosis.

Analysis of computed tomography features of fungal sinusitis and their correlation with nasal endoscopy and histopathology findings.

OBJECTIVE: The purpose of this study was to analyze the computed tomography (CT) features of fungal sinusitis and to correlate them with nasal endoscopy and histopathological findings. MATERIALS AND METHODS: Our study included 16 patients of either sex and any age group who presented in the otorhinolaryngology clinic at our hospital and had evidence of definite sinonasal disease on clinical evaluation. Multidetector CT was carried out on Somatom definition AS + 128 slice CT Machine by Siemens Germany Ltd. Axial sections were performed with the plane of data acquisition parallel to the hard palate and slice thickness of 3 mm, reconstructions at 0.75 mm in coronal and sagittal planes. Scanning parameters included 190 mA S, 120 KV and tube rotation time of 0.5 s. Provisional CT diagnosis was made in all cases and correlated with nasal endoscopy and histopathological findings. RESULTS: Out of total 16 patients, 12 showed immunocompromised status and had infection with mucormycosis. Out of 12, 9 patients (75%) showed extension of disease beyond the sinonasal cavities and 4 (33.3%) showed evidence of bone destruction. All patients with candidiasis showed soft-tissue attenuation with hyperdense areas on CT scan. Nearly, 66.6% patients with aspergillosis showed soft-tissue attenuation with hyperdense areas and expansion of sinonasal cavities. Fifteen patients (93%) were proved to be of fungal sinusitis on histopathology. One patient of non-specific granulomatous infection showed bone destruction and mimicked fungal sinusitis on CT. CONCLUSIONS: In the present study, fungal sinusitis could be correctly diagnosed on CT with high accuracy. Thus, understanding the different CT findings of fungal sinusitis allows the radiologist to play a crucial role in the diagnosis and prompt treatment.

Association between epilepsy and cysticercosis and toxocariasis: a population-based case-control study in a slum in India.

PURPOSE: To assess the association between epilepsy and exposure to the parasites, Toxocara canis and Taenia solium in a slum-community in India. METHODS: A door-to-door survey to determine the prevalence of epilepsy was carried out by trained field workers. For every case, one age- and gender-matched control was selected from the same community. Serologic evaluation was carried out to detect antibodies against T. canis and T. solium. KEY FINDINGS: The crude prevalence of active epilepsy was 7.2 per 1,000. We enrolled 114 people with active epilepsy and 114 controls. The prevalence of antibodies to T. canis was similar in people with active epilepsy (4.7%; 5 of 106 people) and in controls (5.7%; 6 of 106 people). The prevalence of antibodies to T. solium was 25.5% (27 of 106) in people with active epilepsy, significantly higher than in controls (12.3%; 13 of 106 cases; p = 0.02). Adjusted conditional (fixed-effects) logistic regression estimated an odds ratio of 2.8 (95% confidence interval 1.2-6.8) for detection of T. solium antibodies. Nineteen people with active epilepsy demonstrated evidence of neurocysticercosis (NCC) on magnetic resonance imaging (MRI), including 7 (36.5%) with solitary cysticercus granuloma. SIGNIFICANCE: Our findings do not support an association between epilepsy and exposure to T. canis in the community studied. A significant association between T. solium exposure and epilepsy was observed. Of those with active epilepsy and evidence of NCC on MRI, a large proportion demonstrated solitary cysticercus granuloma.

Aicardi syndrome.

Aicardi syndrome is a rare neurodevelopmental disease characterised by congenital chorioretinal lacunae, corpus callosum dysgenesis, seizures, polymicrogyria, cerebral callosum, chorioretinopathy and electroencephalogram abnormality. We present a case of Aicardi syndrome with callosal hypogenesis in a 4.5-month-old baby who presented with infantile spasms. Ophthalmoscopy revealed chorioretinal lacunae. The clinical and magnetic resonance imaging features were diagnostic of Aicardi syndrome.

Pseudotumoral hemicerebellitis with hemorrhage.

Acute cerebellitis is an inflammatory syndrome occurring most commonly in young children. It is caused by a variety of insults and is usually bilateral. Pseudotumoral hemicerebellitis is an exceptionally rare unilateral presentation of acute cerebellitis mimicking a tumor. Magnetic resonance imaging (MRI) reveals a diffusely swollen cerebellar hemisphere, but with the lack of a well-defined mass, which is hyperintense in T2-weighted images and with pial enhancement in post-contrast images. It typically has a benign course with regression in follow-up scans, thus distinguishing it from a tumor. Recognizing this entity is important because erroneous diagnosis may lead to needless surgical intervention. We present a case of pseudotumoral hemicerebellitis in a 12-year-old boy with coagulopathy, with follow-up MRI depicting hemorrhage, and discuss the pathogenesis.

Magnetic resonance findings in sellar and suprasellar tuberculoma with hemorrhage.

BACKGROUND: Tuberculosis is endemic in many counteries like India. It can infect any site in the central nervous system. However, islolated involvement of the sellar and suprasellar region is rare. Sellar tuberculoma with hemorrhage is even more rare. We present magnetic resonance (MR) findings in case of sellar and suprasellar tuberculoma with hemorrhage. CASE DESCRIPTION: A 40-year-old female patient presented with a 1-month history of persistent headache and blurred vision on the left side. A contrast-enhanced MR study revealed peripherally enhancing sellar and suprasellar mass with hemorrhage with compression of the left half of the optic chiasma. There was also evidence of infundibular thickening and enhancement of the adjacent dura. The mass was approached through a transphenoidal approach and was partially resected. Subsequent histopathology was suggestive of tuberculosis. The patient was put on anti-tubercular therapy. Patient reported significant improvement in symptoms. Follow-up MR done 8 months later confirmed complete regression of the mass. CONCLUSION: Because of its rarity, sellar tuberculoma is seldom considered in the differential diagnosis and is often mistaken for pituitary macroadenoma, which is the most common tumor in this region. Although rare, presence of infundibular thickening and enhancement of the adjacent dura should suggest the presence of a granulomatous lesion like tuberculoma.