Ultrasound and magnetic resonance imaging for the detection of blood: An ex-vivo study.

OBJECTIVES: Early detection of bleeding into a joint is crucial in patients with haemophilia. This study was designed to evaluate the sensitivity of ultrasonography (USG) and magnetic resonance imaging (MRI) to detect the presence of blood in small concentrations in a simulated model to mimic joint bleeding. MATERIALS AND METHODS: Different concentrations of blood in plasma, varying from 0.1% to 45%, were collected in 10-ml plastic syringes and imaged using 12 and 18 MHz USG transducers and with 1.5T and 3T MRI scanners, at different intervals of time following dilution. The images were scored for the presence of blood by four experienced radiologists who were blinded to the concentration of blood. RESULTS: Within the first 2 h, the 18 MHz transducer was able to detect blood consistently up to 0.5%, whereas the 12 MHz transducer could consistently identify blood up to 1.4%. After the first 12 h, both transducers were able to detect blood up to 0.5% concentration. However, at concentrations below 0.5%, there was discordance in the ability to detect blood, with both transducers. There was no correlation between the signal intensities of MRI images and concentration of blood, at different time intervals, irrespective of the magnetic field strength. CONCLUSIONS: Detection of blood using the USG is dependent on variables such as the concentration of blood, frequency of the transducer used and timing of the imaging. As the concentration of blood decreases below 0.5%, the discordance between the observers increases, implying that the detection limit of USG affects its reliability at lower concentrations of blood. Caution is urged while interpreting USG imaging studies for the detection of blood in symptomatic joints.

Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas.

PURPOSE: The purpose of this study is to evaluate the role of spinal angiography and arterial embolization in avoiding spinal cord ischemia in patients undergoing CT-guided alcohol injection of aggressive vertebral hemangiomas. METHODS: In this retrospective study, patients with vertebral hemangioma who underwent CT-guided direct alcohol injection between January 2007 and October 2018 were identified. Of 28 such patients, 26 had neurological deficits, and 2 had only back pain or radiculopathy. Direct alcohol injection without prior arterial embolization was done in 17 patients. Direct alcohol injection with prior arterial embolization was done in 11 patients. Clinical outcome was assessed immediately after the intervention and at follow-up. RESULTS: Three patients, who underwent alcohol injection without trans-arterial embolization, had worsening of neurological deficits in the post procedure period due to spinal cord ischemia. No complications related to spinal cord ischemia were noted in the embolization group. There was no significant difference in the outcomes between the two groups if the three patients with complications are excluded (p = 0.34). CONCLUSION: While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure.

Endografts with mini-cuff-augmented fenestrations for endovascular repair of thoracoabdominal aortic and common iliac artery aneurysms.

OBJECTIVE: To report a technique of creating mini-cuff-augmented fenestrations in endografts for use in endovascular aneurysm repair. METHODS: Circular fenestrations are made in Dacron thoracic (Valiant Captivia, Medtronic) or tapered iliac limb (Endurant, Medtronic) endografts using thermal cautery and the edges are strengthened with radio-opaque wire sutured on with 6-0 polypropylene. Straight thin-wall expanded polytetrafluoroethylene vascular graft of the same diameter as the fenestration is affixed to its edge with nonlocking 5-0 polypropylene suture, everted, trimmed, balloon-dilated to its nominal diameter and prevented from invaginating by relaxed external stay sutures. Mini-cuff-augmented fenestrations are often pre-cannulated with looped or externalized nitinol guidewires to facilitate catheter crossing. Successful use of mini-cuff-augmented fenestrations is illustrated in a symptomatic patient with Crawford extent-3 thoracoabdominal aortic and bilateral common iliac artery aneurysm undergoing endovascular repair. Seven mini-cuff-augmented fenestrations were created to preserve flow into five visceral arteries (celiac, superior mesenteric, left and dual right renal; all arising from the aneurysm) and both internal iliac arteries (arising at the aneurysm edge). RESULTS: Effective sealing was achieved immediately at all mini-cuff-augmented fenestrations. At 6-month follow-up there were no endoleaks, all fenestration stents were patent and undistorted, and the aneurysm sac size had decreased. CONCLUSION: Mini-cuff-augmented fenestrations accomplish effective fenestration sealing, despite being in aneurysmal zones, while preserving the advantages of fenestrations over cuffed branches.

Use of ultrasound for assessment of musculoskeletal disease in persons with haemophilia: Results of an International Prophylaxis Study Group global survey.

AIM: The objective of this survey was to understand the global trends of imaging assessments in persons with haemophilia, focusing on point-of-care ultrasound (POCUS). Insights into the barriers impeding its widespread proliferation as a frontline imaging modality were obtained. METHODS: The survey opened in September of 2017 and closed in May of 2018. Haemophilia Treatment Centres (HTCs) treating both paediatric/adult patients were the population of interest. A REDCap survey of 25 questions was disseminated to 232 clinical staff in 26 countries. RESULTS: The majority of respondents (88.3%, 91/103) reported that POCUS is most useful to confirm or rule out a presumed acute joint bleed. European HTCs reported the highest routine use of POCUS at 59.5% (22/37) followed by HTCs in the "Other" countries of the world at 46.7% (7/15) and North American HTCs at 43.9% (25/57). At the time of the survey, physiotherapists were identified as the clinical staff who perform POCUS 52.8% (28/53) of the time, in contrast with nurses/nurse practitioners who represent only 5.7% (3/53) of users. The greatest perceived barriers to the implementation of POCUS are the lack of trained healthcare professionals who can perform POCUS at 69.2% (74/107) and the overall time commitment required at 68.2% (73/107). CONCLUSION: Despite POCUS being used in 49.5% (54/109) of sampled HTCs, it is still utilized almost 30% less globally than full diagnostic ultrasound. A list of barriers has been identified to inform HTCs which challenges they will likely need to overcome should they choose to incorporate this imaging modality into their practice.

Critical appraisal of the International Prophylaxis Study Group magnetic resonance image scale for evaluating haemophilic arthropathy.

A goal of the International Prophylaxis Study Group (IPSG) is to provide an accurate instrument to measure MRI-based disease severity of haemophilic arthropathy at various time points, so that longitudinal changes in disease severity can be identified to support decisions on treatment management. We review and discuss in this paper the evaluative purpose of the IPSG MRI scale in relation to its development and validation processes so far. We also critically appraise the validity, reliability and responsiveness of using the IPSG MRI scale in different clinical and research settings, and whenever applicable, compare these clinimetric properties of the IPSG MRI scale with those of its precursors, the compatible additive and progressive MRI scales.

What makes non-cirrhotic portal hypertension a common disease in India? Analysis for environmental factors.

In India, an unexplained enteropathy is present in a majority of non-cirrhotic intrahepatic portal hypertension (NCIPH) patients. Small intestinal bacterial contamination and tropical enteropathy could trigger inflammatory stimuli and activate the endothelium in the portal venous system. Groundwater contaminated with arsenic is an environmental factor of epidemic proportions in large areas of India which has similar consequences. Von Willebrand factor (a sticky protein) expressed by activated endothelium may promote formation of platelet microthrombi and occlusion of intrahepatic portal vein branches leading to NCIPH. Environmental factors linked to suboptimal hygiene and sanitation, which enter through the gastrointestinal (GI) tract, predispose to platelet plugging onto activated endothelium in portal microcirculation. Thus, NCIPH, an example of poverty linked thrombophilia, is a disease mainly affecting the lower socio-economic strata of Indian population. Public health measures to improve sanitation, provide clean drinking water and eliminate arsenic contamination of drinking water are urgently needed. Till such time as these environmental factors are addressed, NCIPH is likely to remain 'an Indian disease'.

Imaging evaluation of hemophilia: musculoskeletal approach.

Imaging assessment is an important tool to evaluate clinical joint outcomes of hemophilia. Arthropathic changes have traditionally been evaluated by plain radiography and more recently by ultrasound and magnetic resonance imaging (MRI). Early arthropathic changes can be identified by modern imaging techniques such as T2 mapping MRI of cartilage even before clinical symptoms become apparent. Cross-sectional imaging modalities such as CT, ultrasonography, and MRI are useful in assessing bleeding-related musculoskeletal complications such as pseudotumors that still exist in some parts of the world. This article provides an overview of imaging of hemophilic arthropathy, and discusses the role and scope of individual imaging modalities currently in use in clinical practice, as well as of promising techniques that require further investigation in the immediate future.

Diagnostic accuracy of ultrasound for assessment of hemophilic arthropathy: MRI correlation.

OBJECTIVE. The purpose of this article is to assess the reliability of interpretation of ultrasound findings according to data blinding in maturing hemophilic joints and to determine the diagnostic accuracy of ultrasound compared with MRI for assessing joint components. SUBJECTS AND METHODS. Ankles (n = 34) or knees (n = 25) of boys with hemophilia or von Willebrand disease (median age, 13 years; range, 5-17 years) were imaged by ultrasound, MRI, and radiography in two centers (Toronto, Canada, and Vellore, India). Ultrasound scans were performed by two operators (one blinded and one unblinded to MRI data) and were reviewed by four reviewers who were unblinded to corresponding MRI findings according to a proposed 0- to 14-item scale that matches 14 of 17 items of the corresponding MRI scale. MRI examinations were independently reviewed by two readers. RESULTS. When data were acquired by radiologists, ultrasound was highly reliable for assessing soft-tissue changes (intraclass correlation coefficient [ICC], 0.98 for ankles and 0.97 for knees) and substantially to highly reliable for assessing osteochondral changes (ICC, 0.61 for ankles and 0.89 for knees). Ultrasound was highly sensitive (> 92%) for assessing synovial hypertrophy and hemosiderin in both ankles and knees but had borderline sensitivity for detecting small amounts of fluid in ankles (70%) in contrast to knees (93%) and variable sensitivity for evaluating osteochondral abnormalities (sensitivity range, 86-100% for ankles and 12-100% for knees). CONCLUSION. If it is performed by experienced radiologists using a standardized protocol, ultrasound is highly reliable for assessing soft-tissue abnormalities of ankles and knees and substantially to highly reliable for assessing osteochondral changes in these joints.

Improving pediatric radiology in India.

BACKGROUND: India had a population of 1,259,271,000 in 2012, with 31% of its population composed of children younger than 15 years. In comparison, children younger than 15 compose 20% of the population in the United States and 16% in Canada. Despite the differences in this demographic, little emphasis is placed on pediatric radiology in India. OBJECTIVE: To conduct a needs assessment evaluating the adequacy of pediatric radiology in India and to establish a pediatric radiology education program in India. MATERIALS AND METHODS: We developed a questionnaire to assess radiologists' perspective on the quality of training in pediatric radiology. Responses were obtained from attendees at a pediatric radiology education program in Mumbai. These data were used to obtain funding and implement a program to increase awareness and stimulate pediatric radiology training at select institutions across India. RESULTS: Out of 86 respondents, 82% indicated that their academic institutions did not place emphasis on dedicated pediatric radiology training, and 63% indicated they received less than 2 weeks of dedicated training. Of the respondents, 77% said their institutions practiced pediatric radiology with inadequate standard of care and 75% of respondents said pediatric radiology would gain increasing importance in the future. Outcomes of the implemented program included increased awareness of pediatric radiology and establishment of a pediatric radiology fellowship program in India. CONCLUSION: Education and training in pediatric radiology in India is inadequate. Focused initiatives have the potential to improve the standards set for pediatric radiology in India. Similar initiatives could help develop pediatric radiology in other developing countries.

Use of serum vitamin B12 level as a marker to differentiate idiopathic noncirrhotic intrahepatic portal hypertension from cryptogenic cirrhosis.

BACKGROUND AND AIMS: Idiopathic non-cirrhotic intrahepatic portal hypertension (NCIPH) is often mis-diagnosed as cryptogenic cirrhosis. Serum vitamin B12 levels can be raised in cirrhosis, probably because of excess release or reduced clearance. Because NCIPH is characterised by long periods of preserved liver function, we examined whether serum B12 level could be used as a marker to differentiate NCIPH from cryptogenic cirrhosis. METHODS: We analysed serum B12 levels in 45 NCIPH and 43 cryptogenic cirrhosis patients from January 2009 to September 2011. RESULTS: Serum B12 levels were significantly lower in NCIPH patients than in cryptogenic cirrhosis patients (p < 0.001) and were useful in differentiating the two disorders (area under ROC: 0.84; 95% C.I: 0.76-0.93). Low serum B12 level (≤250 pg/ml) was noted in 25/72 (35%) healthy controls, 14/42 (33%) NCIPH patients, and 1/38 (3 %) cryptogenic cirrhosis patients. In patients with intrahepatic portal hypertension of unknown cause, serum B12 level ≤ 250 pg/ml was useful for diagnosing NCIPH (positive predictive value: 93 %, positive likelihood ratio 12.7), and serum B12 level >1,000 pg/ml was useful in ruling out NCIPH (negative predictive value: 86 %, negative likelihood ratio: 6.67). Low serum B12 levels (≤250 pg/ml) correlated with diagnosis of NCIPH after adjusting for possible confounders (O.R: 13.6; 95% C.I:1.5-126.2). Among patients in Child's class A, serum B12 level was ≤250 pg/ml in 14/35 NCIPH patients compared with 1/21 cryptogenic cirrhosis patients (O.R: 13.3; 95% C.I: 1.6-111). CONCLUSION: Serum vitamin B12 level seems to be a useful non-invasive marker for differentiation of NCIPH from cryptogenic cirrhosis.

Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis.

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

Efficacy of Shadow-Based Needle Positioning System in Performing CT Image-Guided Percutaneous Biopsy of Lung Lesions: Our Initial Experience.

Context Computerized tomography (CT) is widely used for various interventions and there is a need for an effective navigation tool, for best outcomes. Aim The study was performed to evaluate the efficacy of light- and shadow-based needle positioning assistance device, an innovative navigation tool over the conventional freehand technique, in performing CT image-guided percutaneous interventions. Settings and Design This randomized control trial was performed among patients undergoing CT-guided percutaneous intervention for lung pathologies. Methodology A total of 60 participants were randomized into an intervention group and a control group. The accuracy of needle insertion and other efficacy parameters were assessed for both groups. Post needle placement, CT images were used to evaluate the study endpoints. Statistical Analysis Statistical analysis was performed using SPSS ver. 20 software. Results The mean needle positioning accuracy was 2.1 mm in the experimental group compared with 7.2 mm in the control group freehand procedures. The average time to position the needle at the desired target location was 2.5 minutes in the assisted procedure as compared with 5.3 minutes in the freehand procedure ( p < 0.05). The total number of check scans required to position the needle was 1.3 for assisted procedures and 1.9 for freehand procedures. Conclusion The use of shadow-based assistance device for CT-guided interventions is proven to be efficient and safer with high needle positioning accuracy.

De novo arteriovenous malformations in post-thrombotic limbs.

A 50-year-old woman presented with progressive, painful and disabling swelling of the left lower limb following a left ovarian cyst excision 2 years ago. She had gross oedema of the left lower limb with multiple pubic varices. Contrast-enhanced CT and digital subtraction imaging revealed diffuse arteriovenous malformation (AVM) with feeders from the left internal iliac artery and a short segment significant stenosis of the proximal left common iliac vein. She underwent angioplasty and stenting of the left iliac vein. Her symptoms dramatically improved following the procedure and her limb swelling regressed within 6 months. The occurrence of post-thrombotic AVMs has been long established in the dural and portal systems. This report deals with an analogous phenomenon following iatrogenic deep venous thrombosis of the left lower limb, its pathogenesis, natural history and a review of treatment options.

The "Inside-outside" Sign.

We describe a radiological sign, "inside-outside sign," observed during the cannulation of an expandable contrast-filled tubular structure in the human body. In this optical illusion, a catheter or guidewire appears to be outside the lumen when it is inside the lumen in reality. Knowing this rare optical illusion is essential to avoid mistaking it for a catheter or guidewire outside the lumen.

Biopsy with Side-Cutting Coaxial Needle-Knowing the "Cutting Length" and "Throw Length".

Image-guided Trucut biopsy is a well-established procedure. The length of the side notch in the stylet is the "cutting length," which entraps the tissue sample and contributes to the yield. The total distance by which the inner stylet protrudes from the outer cannula with the cutting notch open is the "throw length." It is inevitably longer than the cutting length does not add to the yield of the sample, but potentially to the complication of the procedure. The authors highlight the importance of knowing this distinction to minimize complications during the procedure.

Clinical Radiology Case Presentation: Do's and Don'ts.

Clinical case presentation is part of daily routine for doctors to communicate with each other to facilitate learning, and ultimately patient management. Hence, the art of good clinical case presentation is a skill that needs to be mastered. Case presentations are a part of most undergraduate and postgraduate training programs aimed at nurturing oratory and presentation design skills. This article is an attempt at providing a trainee in radiology a guideline to good case presentation skills.

The Status of Interventional Radiology as a Specialty among Medical Students in India-Knowledge, Interest, and Exposure.

Purpose Interventional radiology (IR) is a young medical specialty where image guidance is utilized in minimally invasive procedures as a treatment option and/or as a diagnostic tool. There is an exponential increase in awareness and interest in IR amongst medical students. This trend is continuing despite lack of proportionate representation of IR in the current medical curriculum. This study aims to understand the exposure to IR as a specialty amongst medical students in India. Materials and Methods Anonymous, voluntary, online questionnaire was sent to medical students from different parts of the country. The survey comprised 15 questions regarding exposure and awareness on IR. Results The responses were obtained from 1,024 medical students from 98 medical colleges across the country, majority (57.0%) in the clinical years of their training. Thirty-six percent of them were interested in an IR career. Lack of awareness was the most (61.6%) cited reason for not choosing an IR career. Majority (57.9%) would consider IR as a clinical management option and believe that IR holds an important place in medical practice (68.4%). Conclusion There is an evident under-representation of IR in the medical curriculum. However, an increasing awareness and interest among medical students toward IR as a specialty is demonstrated. Incorporation of IR into current medical curriculum in a systematic way is the need of the hour. This would ultimately benefit a wide cohort of patients across multiple specialties.

Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention.

The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.