Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study.

Background: Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated. Materials and Methods: We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed. Results: We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group. Conclusion: Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.

Multidetector computed tomography evaluation of normal thymus and variations with age.

Background: Thymus is a T-cell-producing lymphoid organ that appears prominent in the paediatric population and involutes in size with ageing. The gland shows a wide variety of appearances across different age groups. The purpose of the study is to evaluate the computed tomography (CT) appearance of thymus gland in the normal population with a focus on size, CT attenuation and fatty infiltration in different age groups. Patients and Methods: This is a retrospective study done after taking approval from the Institutional Ethics Committee. Patients undergone CT scans of the thorax were identified from our database. All evaluations were done in non-contrast CT scans. Patients having underlying diseases that may have associated thymic abnormality were excluded. The appearance of thymus and the presence of fatty replacement were assessed. The size of thymus (length and thickness of right limb and left limb) and non-contrast CT Hounsfield unit (HU) value of thymic tissue were measured and compared in various age groups. Results: Four hundred and fifty patients were included, 262 (58.2%) were male. Mean age was 33.6 ± 17.1 years, range (3 months-80 years). The size of thymus was observed to decrease with increasing age. The mean age of complete fatty replacement in our study was 45 years. Complete fatty replacement was noted in all cases with an age of more than 60 years. The most common shape was arrowhead, and the most common location was pre-aortic and para-aortic location. Non-contrast CT HU value was maximum in infants and gradually decreased with advancing age. Conclusion: Even normal thymus can show varied appearance on CT which changes with the age of the patient being imaged. A comparison with normative data could help differentiate normal from abnormal glands to avoid unnecessary intervention.

Tuberculous splenic abscess in the immunocompetent host: a report and review of literature.

Tubercular splenic abscess is rare, particularly in immunocompetent patients. Diagnostic difficulties usually arise in patients with tubercular splenic abscess because of its non-specific presentation. We report an elderly male who presented with cough and fever and had pulmonary infiltrates suspicious of tuberculosis. Bronchoalveolar lavage microbiology including XpertMTB/Rif assay was non-contributory. Contrast enhanced computed tomography scan of abdomen revealed multiple non-enhancing lesions in the spleen. Ultrasound guided splenic aspirate revealed pus that was positive for Mycobacterium tuberculosis in XpertMTB/Rif assay confirming the diagnosis of tuberculosis.

Role of MR spectroscopy in diagnosis of intracranial neuroenteric cyst.

INTRODUCTION: Neuroenteric cysts are rare benign endodermal lesions of the central nervous system that result from incomplete resorption of neuroenteric canal and mostly found in cervical and upper thoracic spinal canal. Intracranial neuroenteric cysts are extra axial and commonly located anteriorly in the posterior cranial fossa. MRI demonstrates variable intensity within the lesion on T1, T2W, and DWI sequences. METHODS: Three cases of posterior fossa non-enhancing cystic lesions of variable signal intensity underwent MRI with MR spectroscopy, where MR spectroscopy demonstrated dominant peak at 2 ppm, mimicking normal Nacetyl aspartate (NAA). CONCLUSION: MR spectroscopy in addition to conventional MRI may help in differentiating intracranial neuroenteric cyst from its close differentials.

Pellets in the Eye: Cerebral Aneurysm and Encephalomyeloneuropathy as Presenting Syndromes.

Lead poisoning following retained gunshot pellets resulting in recurrent episodes of encephalomyeloneuropathy is rare and association of intracranial aneurysm with lead poisoning is interesting. The case report describes about a 58-year ayurvedic doctor who was hospitalized for recurrent abdominal pain and limb weakness appearing spontaneously and improving in a few days to weeks. He had 20 such attacks in last 30 years starting at 25 years after the gunshot wound that resulted in retention of 2 lead pellets in his skull. Cranial imaging demonstrated left posterior communicating aneurysm. His initial blood lead level was 206.10 µg/dl, and following chelation with oral d-penicillamine, the lead level declined and was asymptomatic. After 4-year follow-up, he developed subarachnoid hemorrhage, which was managed with intravascular coiling of the ruptured aneurysm. The gunshot pellets are generally not removed, especially, if they are in inaccessible location. Our patient highlights that such cases should be closely monitored.

Periureteral inferior vena caval venous ring presenting as urinary obstruction.

The embryological development of the inferior vena cava (IVC) is complex, and thus the vena cava may undergo a large number of congenital anomalies. Periureteric venous ring is a rare developmental anomaly of IVC where the right ureter passes through a slit-like opening in a partially duplicated infrarenal IVC, resulting in dilatation of upper urinary tract. Split-bolus multidetector computed tomography technique is useful in detecting such vascular anomaly causing ureteric obstruction as it can clearly show the vascular and ureteric phase in a single acquisition.

Intradiploic leptomeningeal cyst in an adult: role of percutaneous contrast injection in dural defect demonstration.

Leptomeningeal cysts are commonly seen in children usually following trauma and associated with bulging leptomeninges at the site of fracture. Intradiploic leptomeningeal cyst is an important differential for an expansile lytic lesion in the bony calvarium especially in a patient with a previous history of trauma. Here we present a case of intradiploic leptomeningeal cyst and describe the usefulness of retrograde cisternogram by CT-guided direct percutaneous cyst puncture where a CT cisternogram after intrathecal contrast injection could not demonstrate the dural defect and communication of the subarachnoid space with the intradiploic leptomeningeal cyst.

Leptomeningeal Angiomatosis in a Case of Neurofibromatosis Type 2: An Unusual Finding.

Neurofibromatosis type 2 (NF2) is an autosomal dominant disorder characterised by multiple neoplasms of the central and peripheral nervous system associated with ocular abnormalities. Leptomeningeal angiomatosis has not been described with this tumour predisposition syndrome. This report documents an unusual association of leptomeningeal angiomatosis in a case of NF2.

Correlation between Vertebral Marrow Fat Fraction in MRI Using DIXON Technique and BMD in DXA in Patients of Suspected Osteoporosis.

Aim Osteoporosis is a common metabolic bone disease accounting for low back pain (LBP). It is diagnosed by dual-energy X-ray absorptiometry (DXA). Magnetic resonance imaging (MRI), a routine investigation for LBP, is also sensitive to detect fat fraction (FF) of the vertebral body that increases with increasing age. This study aimed to correlate vertebral marrow FF using MRI and bone mineral density (BMD). Material and Methods Patients presenting with low backache and suspected osteoporosis were included. All patients underwent an MRI of lumbosacral spine and DXA. Patients were categorized into an osteoporotic and a nonosteoporotic group based on the T-score obtained from DXA. "T-scores" of < -2.5 on BMD were considered as osteoporotic spine. T-score of > -2.5 was considered as nonosteoporotic. The FF obtained from the DIXON sequence of MRI was correlated between the two groups. Result Thirty-one patients were included with a mean age of 54.26 ± 11.6 years. Sixteen patients were osteoporotic based on the defined criteria in the methods. The mean vertebral marrow FF was significantly higher in the osteoporotic patients (64.98 ± 8.8%) compared with the nonosteoporotic (45.18 ± 13.2%) ( p = 0.001). The mean FF of the vertebra having fracture (69.19 ± 7.73%) was significantly higher than that of patients without fracture (57.96 ± 5.75%) ( p = 0.03). Taking a cutoff value of vertebral marrow FF of 54.85, the sensitivity and specificity of diagnosing osteoporosis were 93 and 80%, respectively, with a confidence interval of 95%. The area under the curve was 0.925. Conclusion Increased vertebral marrow FF is noted in the osteoporotic spine. FF has an inverse correlation with the T-score obtained from BMD. MRI with FF measurement can provide indirect evidence of osteoporosis, which can be done under one roof, especially in young patients where we need to avoid ionizing radiation.

Beyond the Eyes: Clinico-Radiological Correlation of Bilateral Complete Horizontal Gaze Palsy in Moebius Syndrome.

Moebius syndrome is a rare disease characterized by unilateral or bilateral facial nerve palsies with/without other cranial nerve palsy. It manifests clinically with facial muscle weakness and/or ophthalmoplegia and can be associated with other physical anomalies such as various limb deformities and orofacial malformation. Herein, we have described the clinical and radiological features of Moebius syndrome in a 9-year-old female child who presented with left-side facial palsy and bilateral complete horizontal gaze palsy.

Wunderlich Syndrome Managed with Angiomyolipoma Embolization - Renal Artery Anatomic Variant Augmenting Safe and Nephron-Sparing Intervention.

Background: Wunderlich syndrome is an uncommon entity characterized by spontaneous, nontraumatic renal bleeding into the subcapsular and perirenal regions. The most frequent benign tumor, angiomyolipoma, is the most common cause of Wunderlich syndrome. Case presentation: We report a case of Wunderlich syndrome in angiomyolipoma. Intratumoral pseudoaneurysm arising from feeders of an accessory renal artery supplying the lower pole of the kidney was selectively embolized. Rarely does a sporadic renal angiomyolipoma develop a giant pseudoaneurysm. Conclusion: Transarterial embolization is imperative to control the bleeding or as a preventative measure to reduce the risk of intralesional pseudoaneurysm rupture. When vascular interventional facilities are unavailable, surgery may be necessary.

A Prospective Observational Study of Diagnostic Reliability of Semiquantitative and Quantitative High b-Value Diffusion-Weighted MRI in Distinguishing between Benign and Malignant Lung Lesions at 3 Tesla.

Aim The aim of this study was to evaluate the usefulness of high b-value diffusion-weighted imaging (DWI) to differentiate benign and malignant lung lesions in 3 Tesla magnetic resonance imaging (MRI). Materials and Methods Thirty-one patients with lung lesions underwent a high b-value (b= 1000 s/mm 2 ) DW MRI in 3 Tesla. Thirty lesions were biopsied, followed by histopathological analysis, and one was serially followed up for 2 years. Statistical analysis was done to calculate the sensitivity, specificity, and accuracy of different DWI parameters in distinguishing benign and malignant lesions. Receiver operating characteristic (ROC) curves were used to determine the cutoff values of different parameters. Results The qualitative assessment of signal intensity on DWI based on a 5-point rank scale had a mean score of 2.71 ± 0.75 for benign and 3. 75 ± 0.60 for malignant lesions. With a cutoff of 3.5, the sensitivity, specificity, and accuracy were 75, 86, and 77.6%, respectively. The mean ADC min (minimum apparent diffusion coefficient) value of benign and malignant lesions was 1. 49 ± 0.38 × 10-3 mm 2 /s and 1.11 ± 0.20 ×10-3 mm 2 /s, respectively. ROC curve analysis showed a cutoff value of 1.03 × 10-3 mm 2 /s; the sensitivity, specificity, and accuracy were 87.5, 71.4, and 83.3%, respectively. For lesion to spinal cord ratio and lesion to spinal cord ADC ratio with a cutoff value of 1.08 and 1.38, the sensitivity, specificity, and accuracy were 83.3 and 87.5%, 71.4 and 71.4%, and 80.6 and 83.8%, respectively. The exponential ADC showed a low accuracy rate. Conclusion The semiquantitative and quantitative parameters of high b-value DW 3 Tesla MRI can differentiate benign from malignant lesions with high accuracy and make it a reliable nonionizing modality for characterizing lung lesions.

Reverse Y stenting in the management of vertebrobasilar junction fenestrated aneurysm: A novel technique.

Fenestrated aneurysm at vertebrobasilar junction (VBJ) is very rare and can occur due to non-fusion of longitudinal neural axis forming basilar artery in the early stage of embryonic life. Due to defects in tunica media and weakness in its wall, these fenestrations are more likely to develop an aneurysm. Various treatment strategies are required for the management of these types of aneurysms including simple coiling, stent-assisted coiling, balloon remodeling technique, and more recently kissing flow diverters. Herein, we report the case of ruptured fenestrated VBJ aneurysm which was managed successfully with novel reverse Y stenting with coiling.

Bloody Bile and Rescue Intervention-A Case Series of Post-PTBD Hemorrhagic Complications With a Review of the Literature.

Percutaneous transhepatic biliary drainage (PTBD) is a routinely performed interventional radiological procedure. A myriad of complications can occur after PTBD, the most important being hemorrhagic complications that require immediate attention. Hemorrhage following PTBD may result from arterial, portal, or hepatic venous injury. A catheter or pull-back cholangiogram often demonstrates the venous injury. A computed tomogram angiogram aids in identifying bleeding sources and procedural planning. Catheter repositioning, upsizing, or clamping often suffice for minor venous bleeding. However, major venous injury necessitates tract embolization, portal vein embolization, or stent grafting. Arterial injury may lead to significant blood loss unless treated expeditiously. Transarterial embolization is the treatment of choice in such cases. Adequate knowledge about the hemorrhagic complications of PTBD will allow an interventional radiologist to take necessary precautionary measures to reduce their incidence and take appropriate steps in their management. This article entails four different hemorrhagic complications of PTBD and their interventional management. It also discusses the various treatment options to manage different kinds of post-PTBD hemorrhagic complications.