Neurological complications in carotid body tumors: a 6-year single-center experience.

OBJECTIVE: Carotid body tumors are considered rare. However, there has been an increase in the number of these tumors managed at our center in recent years. Delayed presentation with large tumors is common. We studied the clinical profile, interventions, and outcomes of these tumors and assessed the factors influencing operative neurological morbidity and recurrence. METHODS: This retrospective study was conducted at the Christian Medical College in Vellore, a tertiary care center in south India. We analyzed the inpatient and outpatient records of patients diagnosed to have carotid body tumors undergoing excision from January 1, 2005 to December 31, 2011. Patients diagnosed to have vagal paragangliomas were excluded. RESULTS: Thirty-four of 48 tumors were excised from 32 patients (11 female, 21 male). Average age at presentation was 38.2 years, and three patients had familial bilateral tumors. All patients presented with a painless neck mass. There were 27 Shamblin group III, six Shamblin group II, and one Shamblin group I tumor. Eleven Shamblin group II/III tumors were associated with transient cranial nerve palsy or paresis (32.3%). Two Shamblin group III tumors were associated with perioperative stroke (5.8%). Preoperative embolization was done in 17 tumors, 12 of which were associated with neurological complications (two stroke, nine nerve palsy, one hemianopia). One patient underwent thrombolysis for a middle cerebral artery thrombus and recovered completely on follow-up, and another with a capsuloganglionic infarct managed conservatively had minimal persistent disability. Three patients had persistent nerve palsy (8.8%). Although complications were more common in patients with higher Shamblin group tumors, the difference was not statistically significant. CONCLUSIONS: The overall rate of neurological complications is higher with tumors of higher Shamblin groups. Preoperative embolization was not effective in reducing neurological complications. The rates of postoperative stroke and permanent cranial nerve palsy after resection of large tumors are acceptable.

Ultrasound-guided Fine-needle Aspiration Cytology along with Clinical and Radiological Features in Predicting Thyroid Malignancy in Nodules ≥1 cm.

AIMS AND OBJECTIVES: The aim of the study is to examine the adequacy and accuracy of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in thyroid nodules ≥1 cm and to analyze the clinical, sonological, and cytological features in predicting thyroid malignancy. MATERIALS AND METHODS: US-FNAC was done on 290 patients from December 2013 to December 2014 by the radiologist. The Thyroid Imaging Reporting and Data System (TIRADS) was used to record the sonological features. FNAC samples were reported by a dedicated cytopathologist. Accuracy was calculated by comparing US-FNAC, clinical features and ultrasound (US) features for those who had final histopathology till April 2017. RESULTS: The adequacy of US-FNAC in this study was 80.2%. Thyroidectomy was performed in 128/290 (44.1%). The sensitivity and specificity of US-FNAC in this study is 83.9 and 76.3%, respectively, with a positive predictive value of 85.2%, negative predictive value of 74.4%, and an accuracy of 81% in predicting malignancy in thyroid nodules ≥1 cm. The malignancy rate in benign FNAC sample was 25% (10/40), and was 69% (8/13) in those with a follicular lesion of undetermined significance (FLUS). Around 80% of benign and 89% of FLUS had follicular variant of papillary carcinoma of thyroid (FVPTC). US-FNAC, a high TIRADS score, and US features such as marked hypoechogenicity, taller than wide, irregular margins, microcalcification, and clinical features, such as hard in consistency and significant cervical lymph nodes, were important in predicting malignancy (P < 0.001). CONCLUSIONS: The accuracy of US-FNAC in this study is 81%. The US-FNAC, a high TIRADS score, a hard thyroid nodule, and significant cervical lymph nodes are important in predicting malignancy. The accuracy rate in benign and atypia undetermined significance categories needs to improve in this study. Further research to help in decreasing false negative rates of FVPTC will help in increasing the accuracy of US-FNAC in the present study.

Changing profile of Budd Chiari syndrome in India.

There is increasing evidence that Budd Chiari syndrome occurs when acquired predisposing factor(s) affect a susceptible individual with one or more underlying thrombophilic conditions. Geographical variations in disease pattern of Budd Chiari syndrome exist, which may reflect differing predisposing factors. We review a change in disease profile of Budd Chiari syndrome in India over the past three decades. While earlier studies from India reported isolated inferior vena cava (IVC) obstruction as the commonest disease type, this is a minority in more recent reports where a combination of IVC and hepatic vein obstruction is the commonest type. Longer duration of illness has been shown to be associated with IVC obstruction and the recent change in disease profile in India may reflect earlier diagnosis of Budd Chiari syndrome. Poverty, malnutrition, recurrent bacterial infections and filariasis have been previously suggested as predisposing factors for IVC obstruction. Improvement in hygiene and sanitation may partly explain the recent change in disease profile of Budd Chiari syndrome in India.

Spectrum of Visual Impairment in Cerebral Venous Thrombosis: Importance of Tailoring Therapies Based on Pathophysiology.

Visual impairment can complicate cerebral venous thrombosis (CVT). Here, we describe the various pathophysiological mechanisms and treatments available. A retrospective chart review of all patients treated for CVT in a large quaternary teaching hospital was done, and cases with visual impairment due to CVT were identified. The various mechanisms causing visual impairment in CVT were (1) raised intracranial pressure (ICP) caused by venous thrombosis without venous infarcts resulting in a benign intracranial hypertension-like presentation of CVT, (2) venous infarcts involving the occipital cortex, (3) raised ICP following the development of a secondary dural arteriovenous (AV) fistula, and (4) arterial occipital infarcts due to posterior cerebral artery compression secondary to herniation in large venous infarcts. Apart from using systemic anticoagulants to attempt recanalization and drugs with carbonic anhydrase inhibitor activity to reduce the ICPs, treatment modalities employed to save vision were (1) recanalization by local thrombolysis, stenting, or mechanical devices; (2) cerebrospinal fluid diversion procedures such as theco-periotoneal shunting; (3) optic nerve sheath fenestration; and (4) specific treatment for conditions such as dural AV fistula occurring as a late complication. CVT can cause visual impairment through different pathophysiological mechanisms. Depending on the mechanism, treatment strategies need to be tailored. Furthermore, very close monitoring is needed both in the acute and in the follow-up period, as new pathophysiological mechanisms can arise, compromising the vision. This may require a different treatment approach. Literature on this aspect of CVT is lacking.

Mechanical thrombectomy for acute ischemic stroke in pregnancy using the penumbra system.

Even though intravenous thrombolysis with tissue plasminogen activator (IV tPA) is the standard of care in acute ischemic stroke, its use in pregnancy is not clearly defined. Mechanical thrombectomy devices can be an option; however, literature on the use of such mechanical devices in stroke in pregnancy is lacking. Here we describe two cases that developed acute embolic stroke during pregnancy who were successfully treated by mechanical clot retrieval using the Penumbra system 28 (Penumbra Inc., Alameda, California, USA). To the best of our knowledge, these are the only case reports on the use of the Penumbra device in pregnant patients with acute ischemic stroke.

Giant splenic artery mycotic aneurysm presenting with massive hematemesis.

We report a 40-year-old man with rheumatic heart disease who presented with abdominal pain for three weeks and hematemesis for 24 hours. CT scan showed a large splenic artery aneurysm without evidence of pancreatitis. Mycotic aneurysm due to infective endocarditis was considered and confirmed by echocardiogram, which showed aortic and mitral valve regurgitation and vegetations. He was managed successfully with coil embolization of the aneurysm and antibiotics.

Vesical varix in cirrhosis of liver.

Vesical varices in portal hypertension are rare. We report a patient with portal hypertension who developed recurrent painless hematuria. Cystoscopy was normal. Doppler ultrasound and MR angiography showed a dilated paraumbilical vein within the falciform ligament coursing down to the urinary bladder wall and draining into the right internal iliac vein. He underwent liver transplantation for decompensated chronic liver disease. He is in good health and has not had further episodes of hematuria.

Isolated fourth ventricular cysticercus cyst: MR imaging in 4 cases with short literature review.

We describe the magnetic resonance imaging (MRI) signal characteristics of isolated (solitary lesion) intra fourth ventricular cysticercus cyst in 4 patients who clinically presented with obstructive hydrocephalus. All patients had routine MRI sequences (T1, T2, & proton density-weighted imaging), Fluid Attenuation Inversion Recovery (FLAIR), and post-gadolinium imaging followed by cerebrospinal fluid (CSF) flow study. It revealed a CSF signal intensity (on all pulse sequences), intra fourth ventricular cyst with a nidus (scolex), and wall enhancement. On T1-weighted and FLAIR images, the cyst wall and nidus (scolex) were seen in 3 cases, which were not seen in other routine sequences. The CSF flow study showed the intraluminal nature of the cyst. The MRI features suspected a cysticercus cyst, and per-operative findings and histopathological examination confirmed the diagnosis. The review of literature of the intra fourth ventricular cyst is briefly discussed.

Tuberculosis--the great mimicker.

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Evidence-based practice in radiology: knowledge, attitude and perceived barriers to practice among residents in radiology.

AIM: We examinted the attitude, knowledge and perceived barriers to evidence-based practice of radiology (EBPR) among residents in radiology. STUDY DESIGN AND SETTING: We used the McColl questionnaire (1) and the BARRIERS scale (2) to assess the issues among radiology trainees attending an annual refresher course. Ninety six residents from 32 medical colleges from Southern India attended the course. RESULTS: Eighty (83.3%) residents, 55 male and 25 female of age range 24-34 years, consented and returned the questionnaire. The majority of the participants had a positive attitude towards EBPR. However, 45% were unaware of sources for evidence based literature although many had access to Medline (45%) and the internet (80%). The majority (70%) were aware of the common technical terms (e.g. odds ratio, absolute and relative risk) but other complex details (e.g. meta-analysis, clinical effectiveness, confidence interval, publication bias and number needed to treat) were poorly understood. Though majority of residents (59%) were currently following guidelines and protocols laid by colleagues within their departments, 70% of residents were interested in learning the skills of EBPR and were willing to appraise primary literature or systematic reviews by themselves. Insufficient time on the job to implement new ideas (70.1%); relevant literature is not being complied in one place (68.9%); not being able to understand statistical methods (68.5%) were considered to be the major barriers to EBPR. Training in critical appraisal significantly influence usage of bibliographic databases (p<0.0001). Attitude of collegues (p=0.006) influenced attitude of the trainees towards EBPR. Those with higher knowledge scores (p=0.02) and a greater awareness of sources for seeking evidence based literature (p=0.05) held stronger beliefs that EBPR significantly improved patient care. CONCLUSIONS: The large knowledge gap related to EBPR suggests the need to incorporate structured training into the core-curriculum of training programmes in radiology.

Outcomes of bronchial artery embolization for life-threatening hemoptysis due to tuberculosis and post-tuberculosis sequelae.

PURPOSE: To determine the long-term outcomes of bronchial artery embolization in patients with massive hemoptysis due to pulmonary tuberculosis and post-tuberculosis sequelae and to study the factors influencing success. MATERIALS AND METHODS: In this study, 58 patients underwent 64 bronchial artery embolizations for massive hemoptysis due to tuberculosis or its sequelae between 1998 and 2008. Their images and procedure details were reviewed. Medical records and direct contact were used to obtain information on outcome. The cumulative hemoptysis control rate per follow-up interval was calculated. RESULTS: The data showed that 25 patients presented with acute massive hemoptysis and 33 presented with chronic recurrent hemoptysis. The median quantity of blood was 400 mL (range, 70-2000 mL). The median follow-up period was 432 days (range, 11-1789 days). Twenty-seven patients had recurrence after a median period of 110 days after the procedure (range, 1-959 days). The hemoptysis control rate was 93% at 2 weeks, 86% at one month, 79.5% at 3 months, 63% at 6 months, 51% at one year and 39% at 2 years. Six patients underwent repeat procedures. Chest pain was the most common procedure-related complication (n=20, 34.5%); there was no spinal cord complication or mortality. There were seven deaths, five of which were related to hemoptysis. Nine patients were lost to follow-up. Lung cavities (P = 0.08), nonbronchial systemic artery collaterals (P = 0.081) and systemicto- pulmonary venous shunts (P = 0.053) were more common in those who experienced recurrence. CONCLUSION: Bronchial artery embolization is a relatively safe procedure that is lifesaving in patients who are not suitable for surgery. However, the associated long-term outcome is less satisfactory.

Glove perforations during interventional radiological procedures.

Intact surgical gloves are essential to avoid contact with blood and other body fluids. The objective of this study was to estimate the incidence of glove perforations during interventional radiological procedures. In this study, a total of 758 gloves used in 94 interventional radiological procedures were examined for perforations. Eleven perforations were encountered, only one of which was of occult type. No significant difference in the frequency of glove perforation was found between the categories with varying time duration.

Bladder varices--rare cause of painless hematuria in idiopathic retroperitoneal fibrosis.

A patient presented to the urology outpatient department with complaints of recurrent episodes of painless hematuria. A contrast-enhanced computed tomography scan of the abdomen revealed vesical varices that had developed secondary to obstruction of the inferior vena cava. Additional investigation revealed idiopathic retroperitoneal fibrosis. Steroid therapy was started and tapered during a 6-week period. No recurrence of the hematuria was noted on follow-up. We have described a unique presentation of hematuria due to vesical varices in a patient with idiopathic retroperitoneal fibrosis.

Idiopathic non-cirrhotic intrahepatic portal hypertension: common cause of cryptogenic intrahepatic portal hypertension in a Southern Indian tertiary hospital.

BACKGROUND AND AIM: Patients with intrahepatic portal hypertension and negative etiological work-up for liver disease are often labeled as having cryptogenic cirrhosis. The aim of this study was to evaluate causes of liver disease in patients with unexplained intrahepatic portal hypertension. METHODS: We retrospectively analyzed cause of liver disease in all patients with cryptogenic intrahepatic portal hypertension who underwent liver biopsies between June 2005 to June 2007 in our center. RESULTS: Five hundred and seventeen patients underwent liver biopsies of whom 227 had portal hypertension. Of these, the cause of liver disease could not be detected prior to liver biopsy in 62 patients. Causes of liver disease identified after liver biopsy in these 62 patients were: idiopathic non-cirrhotic intrahepatic portal hypertension (NCIPH) (30 patients, 48%), cirrhosis (14), fatty liver disease (7) and other causes (11). Initial presentations in idiopathic NCIPH patients were splenomegaly and anemia (18 patients), variceal bleed (9) and ascites (3). Median age (range) of patients at first presentation was 32 (15-57) years, and 19 were male. Majority (90%) were in Child's class A. Hepatic vein pressure gradient was <5 mmHg in 2 of 7 NCIPH patients tested. CONCLUSIONS: We identified 30 patients with idiopathic NCIPH at our center over the 2 year study period. The clinical presentation and investigations of NCIPH closely mimic cryptogenic cirrhosis. Idiopathic NCIPH should be considered as a differential diagnosis of cryptogenic cirrhosis in India.

Double superior vena cava with a persistent left superior vena cava: an incidental finding during peripherally inserted central catheter placement.

We describe a case of double superior vena cava with a persistent left-sided superior vena cava discovered at the time of peripherally inserted central catheter (PICC) placement. The diagnosis was suggested by fluoroscopy and confirmed by venography. The relevance of the diagnosis with respect to PICC placement is discussed.

Anterior skull base: High risk areas in endoscopic sinus surgery in chronic rhinosinusitis: A computed tomographic analysis.

Computed Tomography (CT) scan of nose and paranasal sinuses play a key role in preoperative evaluation of patients undergoing endoscopic sinus surgeries (ESS) for chronic rhinosinusitis. The asymmetry of ethmoid fovea olfactory fossa, anatomical variations of lateral lamella and course of anterior ethmoid artery are critical in ESS as it may predispose to dangerous consequences like hemorrhage. CSF leak and intracranial complications. A prospective study was done on 75 patients of clinically and diagnostically proven chronic rhinosimusits. The coronal CT scan was evaluated with special attention to anatomical variations of anterior skull base including ethmoid fovea, olfactory fossa, lateral lamella and course of anterior ethmoid artery. The endoscopic surgeon's awareness of these variations and its role in preventing complications are highlighted.

Collateral artery aneurysm: a unique presentation of thoracic outlet syndrome.

Aneurysms of collateral arteries are unusual. A case of transverse cervical artery aneurysm as the sole presentation of vascular thoracic outlet syndrome is presented and the relevant literature reviewed.