Non-traditional tools for predicting coronary artery disease.

Background The traditional coronary calcium score (CCS) is a time-tested tool for the evaluation of coronary atherosclerosis and predictor of future cardiovascular events. Non-traditional tools can also have a value in predicting and detecting subclinical coronary artery disease (CAD). Methods We studied the role of CCS, the traditional CAD risk predictor, and the less-recognized, non-traditional risk factors, i.e. epicardial fat volume (EFV) and thoracic extracoronary calcium (ECC), to assess the degree of subclinical CAD. In this cross-sectional observational study, we included 950 Indian patients (suspected to have CAD). Coronary computed tomography angiography was performed. Estimation of CCS, EFV and thoracic ECC was done. Results A CCS of 0 was seen in 583 patients (61.4%). Of these, 492 patients had normal coronary angiogram but 91 patients had CAD. The median values of EFV were statistically significantly higher in the 'CAD present and CCS 0' group compared to the 'CAD absent and CCS 0' group (p<0.001). The presence of thoracic ECC involving at least a single site was seen in only 6 of these 91 patients. When both EFV and CCS were considered together for the detection of CAD, the sensitivity and negative predictive value (NPV) were improved compared to either of these in isolation. When ECC was taken together with CCS and EFV, no further improvement in sensitivity or NPV was observed. Conclusion The combined use of traditional CCS along with non-traditional EFV may guide us in better profiling cardiovascular risk and supplement the various traditional cardiovascular risk factors/scores.

CT appearance of gastrointestinal tract mucormycosis.

Mucormycosis is a fungal infection caused by fungi of order mucorales. It is most commonly seen in patients with an impaired immune system due to any cause. Gastrointestinal mucormycosis is the least frequent type and may be a primary disease or a feature of generalized mucormycosis. Angioinvasion is the hallmark feature of mucormycosis, leading to bowel infarction which is the responsible for the most common clinical complaint of pain, and is also responsible for most of the imaging findings in this disease. The stomach is most commonly involved organ in the gastrointestinal tract and pneumatosis and lack of gastric wall enhancement are the most common imaging findings. Areas of bowel wall thickening and/ or lack of enhancement are seen in small bowel mucor and perforation can occur due to ischemia. Colonic mucor can present with mural thickening, or complete lack of definition or 'disappearance' of bowel wall with associated air containing collections. Mucormycosis affecting the bowel has a high mortality rate and early recognition and intervention may improve patient outcomes significantly. It should be suspected in immunosuppressed patients with imaging findings of unexplained bowel ischemia, infarction and/or pneumatosis without any obvious visible vascular thrombus.

Idiopathic Granulomatous Mastitis and its Mimics on Magnetic Resonance Imaging: A Pictorial Review of Cases from India.

OBJECTIVES: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast, which is benign but potentially morbid. Mammographic and sonographic findings have been well characterized, but magnetic resonance imaging (MRI) findings have been less thoroughly documented. The objective of this study was to demonstrate characteristic findings for IGM and its mimics via a retrospective review. MATERIAL AND METHODS: Breast MRI examinations performed at Sir Ganga Ram Hospital in New Delhi, India between 2014 and 2019 were retrospectively reviewed to identify cases in which a pattern suggestive of granulomatous mastitis was seen. Cases of known malignancy were excluded. Any available breast pathology results were then obtained, and cases with presumptive or definitive diagnoses were compiled for analysis. RESULTS: Overall, cases identified with characteristic imaging findings and confirmed diagnosis included seven cases of IGM, four cases of invasive ductal carcinoma, two cases of tuberculous mastitis, one case of non- tuberculous infectious mastitis, one case of foreign body mastitis, and one case of eosinophilc mastitis. One case of IGM with masses rather than of non-mass enhancement was also identified. CONCLUSION: In our review, cases with clustered ring enhancement were found to have inflammatory, idiopathic, infectious and malignant etiologies. While, these etiologies can only be reliably differentiated on pathology, familiarity with the pattern and an awareness of the differential may lead to decreased morbidity due to delays in diagnosis.

Liver hemangioma mimicking cholangiocarcinoma--a diagnostic dilemma.

A 55-year-old man presented with a liver mass that had been diagnosed on ultrasonography, carried out in response to the patient's complaint of non-specific abdominal pain. Triphasic computed tomography (CT) revealed a lesion involving segments 1, 4, 5 and 8 of the liver. It was centrally hypodense with peripheral enhancement in the arterial phase suggesting a cholangiocarcinoma. The middle hepatic vein was encased and the tumour was present near the junction of the left hepatic and middle hepatic veins. We planned a right hepatic trisegmentectomy including resection of the caudate lobe but since the estimated volume of the liver remnant was only 17% of the total, we first embolised the right portal vein. CT scan repeated 5 weeks later revealed that the lesion was still resectable and that the left lateral segment had hypertrophied to 27% of the liver volume. We performed a right trisegmentectomy including caudate lobe resection using intra-operative ultrasonography to establish that the left hepatic vein was not involved. The removed lesion was hard with ill-defined margins. Histopathological examination revealed a hemangioma.

Collateral or fistula? Coronary artery as the primary source of pulmonary blood flow in a patient with pulmonary atresia and ventricular septal defect.

In patients with pulmonary atresia and ventricular septal defect (PA/VSD), a coronary artery being the primary source of pulmonary blood flow is a rare entity. We describe two cases of PA/VSD with coronary-to-pulmonary artery fistula with emphasis on the role of Computed Tomographic Angiography (CTA) in depicting all the sources of pulmonary blood supply, to predict surgical management and need for unifocalization of Major Aortopulmonary Collateral Arteries (MAPCA's).

Correlation of epicardial fat quantification with severity of coronary artery disease: A study in Indian population.

OBJECTIVE: We studied the correlation of quantified epicardial fat with severity of coronary artery disease in patients [suspected cases of coronary artery disease (CAD)] referred for computed tomography (CT) coronary angiography and established cutoffs for epicardial fat volume (EFV) for the presence of CAD and obstructive CAD. METHODS: A prospective cum retrospective cross-sectional observational study was carried out on 950 Indian subjects (suspected cases of CAD) who were referred for coronary CT in the year 2013-2016. EFV was quantified using semiautomatic technique on multidetector coronary CT angiography. The presence of atherosclerotic plaques and degree of stenosis was assessed on coronary CT angiography scans. The correlation between quantified EFV and degree of stenosis was assessed. Multivariate analysis was also performed. RESULTS: A higher quantity of epicardial fat is found in patients with increasing severity of coronary artery stenosis. The EFV cutoff for the presence of CAD and obstructive CAD are 49.75 and 67.69 mL with area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 0.68, 81%, 45.9%,58.24%, 72.2%, and 62.84% and 0.709, 64.9%, 66.4%, 35.84%, 86.55%, and 66%, respectively. EFV correlates with age, weight, and body mass index (BMI). Multivariate analysis revealed EFV to be an independent risk factor for the presence of CAD. CONCLUSIONS: Higher quantities of EFV are found in patients with greater degree of coronary artery stenosis. EFV correlates with age, weight, and BMI. EFV is an independent risk factor for CAD.

The Abernethy malformation-myriad imaging manifestations of a single entity.

Abernethy malformation, also known as congenital extrahepatic portosystemic shunts (CEPS) is a rare clinical entity and manifests with different clinical symptoms. CEPS are abnormalities of vascular development where there is shunting of portal blood into the systemic venous system. Multidetector computed tomography (MDCT) is a fast and effective modality for evaluation of CEPS. CT displays all the information desired by the surgeon as well as the clinician including the anatomy of the splenic and superior mesenteric veins, size and site of the shunt, presence or absence of the portal vein radicles, and helps to plan the therapy and even the follow-up of these patients. Contrast-enhanced magnetic resonance imaging (MRI) has also emerged as a promising tool for the evaluation of liver lesions associated with the malformation. The Radiologist should be aware of the various imaging appearances of this entity including its complications. In this article, we describe the imaging appearances of CEPS, their complications, and their imaging appearances on CT and MRI. We have also described various associated anomalies.

Ectopic Pancreas in the Duodenojejunal Flexure-Computed Tomographic and Endoscopic Ultrasonographic Images.

Ectopic pancreas is a rare entity where the pancreatic tissue has no anatomic and vascular contact with the main body of the pancreas and has its own duct system and vascular supply. A detailed clinical report with contrast-enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) imaging findings of a 40-year-old male came with vague symptoms. CT showed a well-defined homogeneously enhancing mass lesion in the duodenojejunal (DJ) flexure. EUS revealed a well-defined hypoechoic mass lesion in the submucosal layer of the DJ flexure. Surgical resection of the mass was performed, and histopathological examination of specimen confirmed the pancreatic tissues. Here, we have described the CT and EUS imaging features which can help to differentiate the ectopic pancreas from the gastrointestinal submucosal tumours.

CT and MRI in the diagnosis of tuberculosis.

The advent of CT and MRI imaging in the last two decades has redefined the approach and analysis of various diseases including tuberculosis. Tuberculosis afflicts hollow and solid viscera. Genitourinary, hepatobiliary and adrenal tuberculosis is uncommon in children. CT and MRI have however shown several advantages over conventional radiology and other imaging modalities in early diagnosis and follow-up of tuberculosis in different parts of the body.

Coronary cameral fistula treated by the Amplatzer vascular plug.

Coronary artery anomalies occur in less than 1 % of the general population. With the advent of multidetector rows and 3D reconstruction, multidetector computed tomography has emerged as the modality of choice in the delineation of the complex coronary anatomy and diagnosis of coronary artery anomalies, helping in the institution of appropriate therapy. We report a case of coronary cameral fistula of the left anterior descending artery to the right ventricle, which was closed by an Amplatzer vascular plug. Coronary CT angiography was used to evaluate the patient prior to the procedure to locate the placement site for the vascular plug.

Anomalous single coronary artery on low dose MDCT.

Coronary artery anomalies may involve the origin, course, and structure of epicardial coronary arteries and occur in less than 1% of the general population. Clinical presentation ranges from being completely asymptomatic to sudden death. Multi-detector computed tomography has come a long way in the diagnosis of coronary artery anomalies since the introduction of 4 rows of detectors in scanners, considering its non invasive nature and the benefits of 3D reconstruction. Defining the coronary anatomy helps in clinical decision making and timely intervention. Since repeated angiographies may be required, low dose CT is an excellent investigation for diagnosis and post interventional follow up rather than repeated invasive catheter angiographies or high dose CT examination. We report two cases of clinically significant single coronary artery anomalies; a case of single Right coronary artery and another case of single Left coronary artery (Anomaly of origin & course).

Posterior atlantoaxial dislocation without associated fracture.

We report on a 38-year-old man with post-traumatic posterior displacement of the atlas with respect to the axis without any associated fracture or neurological deficit caused by the displacement. Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) revealed posterior displacement of the atlas with the odontoid peg lying anterior and to the right of the anterior arch of the atlas.