Chyluria: clearing the 'muddiness' with lipiodol lymphangiography.

Chyluria is a rare entity characterised by the presence of chyle/lymphatic fluid within the urine. It develops following an abnormal communication between the perirenal lymphatics and pelvicalyceal lymphatics. There are multiple causes of chyluria including infective (filariasis), post-traumatic, post-surgical, pregnancy and malignancy. We present a case of a 15-year-old male who presented with a complaint of the intermittent passage of milky urine for the preceding 1 year. Conventional lipiodol lymphangiography followed by cone beam computed tomography was done to look for abnormal fistulous channels. Subsequently, the patient was successfully treated with cystoscopy-guided renal pelvic instillation sclerotherapy of povidone-iodine.

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.

Study Protocol: IMPETUS: Implementing a Uniform Stroke Care Pathway in Medical Colleges of India: IMPETUS Stroke.

Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India. Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases. Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Multiphase computed tomography angiography (mCTA) derived source images in acute ischemic stroke: Beyond collaterals. Can it obviate the need for computed tomography perfusion (CTP)?

BACKGROUND AND PURPOSE: To compare Multiphase CT Angiography derived source images (mCTA-SI) in acute ischemic stroke (AIS) with CT Perfusion (CTP) derived automated color maps of cerebral blood flow (CBF) and cerebral blood volume (CBV) and to assess the comparability of mCTA-SI with CTP in the prediction of final radiological and clinical outcome. METHODS: This prospective single-centre observational study comprised of patients with AIS of the anterior circulation, presenting within 24 h and undergoing neuroimaging under stroke protocol with follow-up. Non-contrast computed tomography (NCCT), mCTA, and CTP were acquired with follow-up NCCT at 24 h and modified Rankin score (mRS) at 3 months. mCTA-SI and CTP color maps were scored by the ASPECTS (Alberta Stroke program early CT score) method and compared amongst each other and with the outcome. ROC (Receiver operating characteristic) curves were plotted considering mRS 0-2 and FIV≤ 28 ml as favourable clinical and radiological outcomes respectively. RESULTS: The study included 55 patients. The 1st and 2nd phase of mCTA-SI correlated significantly with CBF maps (r = 0.845, p < 0.01, r = 0.842, p < 0.01 respectively). 3rd phase of mCTA-SI correlated significantly with CBV maps (r = 0.904, p < 0.01). A favourable functional and radiological outcome was best predicted by the 1st (AUC 0.8, 95%CI 0.671-0.896) and 2nd ( AUC 0.895, 95% CI 0.783-0.962) phase of mCTA-SI respectively. CONCLUSIONS: The 1st and 2nd phases of mCTA-SI produces results congruent to CBF color maps and the 3rd phase of mCTA-SI simulate CBV color maps. In addition to predicting radiological and functional outcomes, mCTA can predict the salvageable and non-salvageable tissue in AIS and is non-inferior to CTP.

Computed tomography perfusion (CTP) in primary lung cancer: Results from a tertiary care centre.

Context: Lung cancer is the leading cause of cancer-related deaths in the world. Computed tomography perfusion (CTP) parameters can be used to evaluate the vascular flow dynamics of lung tumours. We set out to evaluate the CTP parameters in lung cancer and correlate them with histopathological subtype and other characteristics of patients with Lung Cancer. Settings and Design: This prospective study was conducted at a tertiary care referral hospital in western India. Methods: Between January 2019 and July 2020, CTP was performed in 46 patients of lung cancer with histopathological confirmation. The CTP parameters were evaluated in detail and correlated with histopathological subtypes, staging and immunohistochemistry (IHC) markers. Analysis of variance (ANOVA) test, receiver operator characteristic (ROC) curve, Box and whiskers plot graph and Pearson correlation tests were used for statistical analysis. Results: The most common subtype was adenocarcinoma (AC) in 21 patients, followed by squamous cell carcinoma (SCC) in 15 patients and others in 10 patients. Statistically significant difference in blood flow (BF) (f = 5.563, P = 0.007), blood volume (BV) (f = 3.548, P = 0.038) and permeability/flow extraction (FE) (f = 3.617, P = 0.036) were seen in different histopathological subtypes of lung cancer. BF is the main perfusion parameter for differentiation of AC from SCC. P63 positive lesions showed statistically significant lower BF, BV and FE parameters compared to P63 negative lesions (P = 0.013, 0.016 and 0.014, respectively). Different T stages showed statistically significant differences in BF (f = 3.573, P = 0.037), BV (f = 5.145, P = 0.010) and in FE (f = 4.849, P = 0.013). Conclusion: CTP is a non-invasive imaging method to assess the vascular flow dynamics of the tumours that may predict the histopathological subtypes in lung cancer. It can be used to target large-sized lesions during biopsy and to predict the chemotherapy response.

Diffusion-Weighted Magnetic Resonance Imaging Is an Ideal Imaging Method to Detect Infection in Pancreatic Collections: A Brief Primer for the Gastroenterologists.

BACKGROUND: The development of infection in pancreatitis significantly increases the mortality rate up to 100% in the absence of any intervention. Therefore, it is extremely important to diagnose these cases at an early stage. The objectives of this study were to assess the diagnostic performance of computed tomography (CT) and diffusion-weighted MR imaging (DW-MRI) in the diagnosis of infection in pancreatic collections. MATERIALS AND METHODS: Prospective observational study of abdominal collections due to pancreatitis that underwent both CT and DW-MRI from August 2018 to July 2020 were enrolled in the study. The collections were analysed for infections - air foci in CT and diffusion restriction on DW-MRI. RESULTS: Of the 39 patients recruited in the study, infected collections were present in 17, and 22 cases had sterile collections. On CT, air foci within the collection were present only in seven of the cases in our study (sensitivity 35%, specificity 95.4%, PPV 85.7%, NPV 65.6%). DW-MRI detected infection in all 17 cases (sensitivity 100%, specificity 72.7%, PPV 74%, NPV 100%). DISCUSSION: Thirteen out of 17 collections suspicious for infection on DW-MR showed microbiological growth on culture examination. We believe that this is likely due to the patient's prior antibiotic use, which might have altered the micro-environment or inflammatory cell and bacterial content of the collection. CONCLUSION: DW-MRI is complementary and superior to CT in detecting infection in pancreatic collections. CT may be used to detect disease burden, extent and vascular complication.

Shoulder Injury Related to Vaccine Administration (SIRVA) with COVID-19 vaccination - A case report.

The case report evaluates shoulder injury related to COVID-19 vaccine administration. A 26-year-old female patient presented with shoulder pain, which increased on extension and overhead abduction in routine work. Magnetic resonance imaging (MRI) was done based on which, a diagnosis of shoulder injury related to vaccine administration (SIRVA) was reported. Significant improvement was seen after Non-steroidal anti-inflammatory drugs (NSAIDs), topical diclofenac ointment, and serratiopeptidase tablets. Physical muscle strengthening exercises were advised. Based on Naranjo and World Health Organization (WHO) casualty assessments, the adverse drug reaction (ADR) was categorized under probable. Preventability, Hartwig's scales for severity was assessed, which showed preventability and moderate grade in severity. The total cost (direct and indirect) for management was found to be rupees 7021 and 41,781 in government and private hospital respectively. Thus ADRs not only add to patient suffering but also increase the economic burden. Health care professionals (HCPs) need to be made aware of potentially fatal ADRs associated with the administration of vaccines and should be keen to report such ADRs to drug safety authorities.

Fibro Adipose Vascular Anomaly: A Rare and Often Misdiagnosed Entity.

Fibro adipose vascular anomaly (FAVA) is a rare type of vascular malformation with distinct clinical features. The authors here discussed the clinical, imaging, differential diagnosis, histopathological features, and treatment options of FAVA along with an illustrative case. It is important to know about this uncommon entity as this can be misdiagnosed due to the overlapping clinical features with other common entities. It is a benign condition with no proven malignant potential. There are no guidelines regarding the best treatment option.

Cascade of Complications Following Carotid Body Tumor Excision.

Carotid body tumor excision can lead to various complications including vascular injury and pseudoaneurysm formation. Here we describe a case of carotid body tumor excision followed by series of complications including pseudoaneurysm formation, failure of primary surgical repair, carotid stump syndrome following parent artery occlusion, and persistent hypotension.

BCG vaccination impact on mortality and recovery rates in COVID-19: A meta-analysis.

COVID-19 is a pandemic caused by SARS-CoV-2 virus which is a very worrisome public health emergency. In this study, we compared the mortality rate and recovery rate in countries with and without BCG vaccination policy. The data of mortality of COVID-19 was extracted from worldometer (https://www.worldometers.info/coronavirus/) on 26th July 2020. The data of countries where BCG vaccination is being done for all individuals is taken from BCG world atlas (http://www.bcgatlas.org/index.php), updated in 2017. BCG vaccination policy recommended countries are intervention group versus countries without BCG vaccination policies which are regarded as control group. Pooled analysis of countries with and without BCG vaccination policy revealed mortality rate of 1.31% (95%CI - 1.31% to 1.32%; I2 = 100%, p<0.01) and 3.25% (95%CI - 3.23% to 3.26%; I2 = 100%, p<0.01), respectively. The recovery rates in two country groups were found to be 72.60% (95%CI - 72.57% to 72.63%) and 55.94% (95%CI - 55.90% to 55.98%), respectively. 52 individuals need to be BCG vaccinated to prevent one death (NNT = 52). In BCG vaccination program countries, there is statistically and clinically significant less mortality (p<0.001) as compared to countries without BCG policy. Our findings corroborate the hypothesis that BCG vaccination may provide protection from COVID-19. High quality evidence from randomised controlled trials are required to establish causality between BCG vaccination and protection from severe COVID-19.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision.

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

Chest-X-ray-Based Scoring, Total Leukocyte Count, and Neutrophil-to-Lymphocyte Ratio for Prediction of COVID-19 in Patients with Severe Acute Respiratory Illness.

OBJECTIVE: This study aimed to use chest-X-ray (CXR)-based scores along with total leukocyte count (TLC) and neutrophil-to-lymphocyte ratio (NLR) in the prediction of coronavirus disease 2019 (COVID-19) in patients presenting with clinical features of severe acute respiratory illness (SARI). MATERIAL AND METHODS: This is a retrospective study involving all patients who presented with clinical features of SARI and who had undergone bedside chest X-ray (CXR), hemograms with TLC, NLR, and reverse transcriptase-polymerase chain reaction (RT-PCR) at our institute from May 1 to June 30, 2020. RESULTS: Of 204 patients, 115 tested RT-PCR-positive and 89 tested negative. The patients who presented with SARI, using CXR-based score of 4 or more, TLC of less than 8,700 cells/µL, and NLR of <7 had a statistically significant area under the curve (p<0.001) for diagnosing COVID-19. The sensitivity and specificity of the CXR score was 80.8% and 73.0%, of TLC was 70.1% and 74.7%, and of NLR was 70.1% and 59.0%, respectively, in diagnosing COVID-19 alone. The specificity further increased to 90.4% when we used the CXR score with NLR and to 92.8% when we used the CXR score with TLC. The post-test odds ("rule in" disease) of a positive test for having the disease were 3, 2.77, and 1.71 times with the use of either CXR score, TLC, or NLR criteria, respectively; whereas, combined use of CXR score and NLR increased the post-test odds by 5.53 times, and combination of CXR score with TLC increased the post-test odds by 7.5 times. CONCLUSION: CXR score with TLC and NLR can predict COVID-19 infection among those who presented with features of SARI. This may help in the early isolation of the patient until the RT-PCR report becomes available.

Morphometric Analysis of parameters of Internal Carotid Artery-Potential Clinical Implications.

BACKGROUND: The study in consideration aimed to do morphometry of internal carotid artery (ICA) and substantiate any differences significant in relation to sex and age on digital subtraction angiography (DSA) imaging. OBJECTIVES: Our study aims to ascertain morphometric parameters of ICA through DSA evaluation and to build a normative data which is accurate enough for the neurovascular procedures to be performed. The study will also carry out correlation of morphometry of intracerebral blood vessels with sex, age, and side-related dimorphism. MATERIAL AND METHODS: Our study, cross-sectional in design was done on 70 patients (>20 years). Diameter of different segments of ICA were measured after imaging was done on DSA using a Philips biplane system clarity (Allura FD20/20). Statistical analysis was done. RESULT AND CONCLUSION: In males, mean diameter of petrous, cavernous, supraclinoid, and choroidal segments of ICA were more when compared to females. Statistically significant differences were found in supraclinoid segment of ICA between males and females. The mean diameter of supraclinoid and choroidal segments of ICA showed a decreasing trend from younger to older age groups. The difference in the mean diameter of petrous segment of ICA with increasing age was statistically significant. The results of our study show that differences were statistically significant in supraclinoid segment of ICA in males and females. Neurosurgeons in order to be confident in tackling the various emergencies in this region need to have in-depth knowledge of morphometery of cerebral arterial circle.

Leukoencephalopathy with Calcifications and Cysts in a Child with Progressive Hemiparesis-A Case Report.

With the advent of modern neuroimaging, the imaging features of various leukoencephalopathies have been unraveled in the past two decades. Leukoencephalopathy with calcifications and cysts (LCC) is one such rare autosomal recessive disorder with marked clinical heterogeneity and a striking but characteristic imaging appearance-diffuse white matter changes, intraparenchymal cysts, and calcifications. The calcifications in LCC are characteristically nodular, dense, bulky, and predominantly located in gray nuclei of the central brain (basal ganglia, thalami) and cerebellum (dentate nuclei). We describe a case of a 9-year-old boy with progressive left hemiparesis and seizures, which on imaging showed characteristic features of LCC. We further review the neuroimaging features of LCC and its differential diagnoses.

Right Atrial Extension of a Giant Retroperitoneal Leiomyosarcoma.

Leiyomyosarcoma of vascular origin is rarely seen occurring in the Inferior Vena Cava. We report a rare case of a young male with giant retroperitoneal leiyomyosarcoma which extended into the right atrium.

Combined hyperdense gallbladder wall-lumen sign: new computed tomography sign in acute gangrenous cholecystitis.

PURPOSE: The objective of our study was to evaluate the combined hyperdense gallbladder wall-lumen sign on computed tomography (CT) in diagnosing gangrenous cholecystitis. MATERIAL AND METHODS: We retrospectively reviewed the unenhanced CT scans of surgically proven cases of acute gangrenous (GCh) and non-gangrenous cholecystitis (nonGCh). Eleven cases of pathologically proven acute gangrenous cholecystitis and 12 consecutive cases of surgically proven acute non-gangrenous cholecystitis that underwent CT at our institute were included in the study so as to have 1 : 1 control. The Hounsfield unit (HU) value of the gallbladder wall and intraluminal bile was measured. Interobserver variability for individual CT findings was also assessed. RESULTS: The gangrenous cholecystitis group had significantly higher HU values of wall and bile (median value of 33 HU vs. 21 HU and median value of 21 HU vs. 8.5 HU, respectively, p < 0.05). The area under the receiver operator characteristic curve for HU lumen was 0.80 (95% CI: 0.62-0.98, p = 0.014) with an ideal cut-off at 31.5 HU, where the sensitivity was 54.5% and specificity was 91.7%. HU lumen has an even better assessment for gangrenous cholecystitis with AUC of its ROC as 0.92 (95% CI: 0.80-1.00, p = 0.001) with an ideal cut-off at 12.5 HU, where the sensitivity was 81.8% and specificity was 91.7%. The combined wall-lumen cut-off is 35 HU with sensitivity of 100% and specificity of 75%. CONCLUSION: A cut-off CT density value of the gallbladder wall of more than 31.5 HU, intraluminal bile more than 12.5 HU, and combined wall-lumen HU of more than 35 can predict GCh.

Quantitative diffusion-weighted magnetic resonance imaging for prediction of early infection in pancreatic collections: Results of a pilot study.

BACKGROUND/AIMS: The development of infection in pancreatitis increases the mortality rate up to 32%. Therefore, it is important to identify patients who are at high risk of developing infection, at an early stage. The objectives of the study were (a) to analyze the quantitative parameters of diffusion-weighted magnetic resonance imaging (DW-MRI) and apparent diffusion coefficient (ADC) in infected as well as sterile pancreatic collections (b) to establish "cut-off" values for ADC that can identify infected pancreatic collections. MATERIALS AND METHODS: Prospective observational study of pancreatitis cases who underwent DW-MRI from August 2018 to July 2019 were enrolled in the study. The collections were analyzed for diffusion restriction. The average of the three ADC values from the wall and center of collection was noted. RESULTS: Infected collections were seen in 7 and sterile collections observed in 11 cases. The optimal cut-off ADC value to differentiate sterile and infected collection in our study was 1.651 × 10-3 mm2/s (sensitivity of 81.8%; specificity of 100.0%). ROC curve for mean ADC from the wall showed a significant diagnostic accuracy with AUC: 0.91; 95% CI: 0.77-1.0 (P = 0.004). CONCLUSION: DW-MRI is a reliable noninvasive technique to differentiate sterile and infected pancreatic collections. ADC values from the periphery of the collection can predict infected pancreatic collections at an early stage. DW-MRI should not be considered as a substitute for aspiration cytology in patients with septic symptoms and absent diffusion restriction on MRI.

Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows.

Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.