Inguinoscrotal Hernia: An Unusual Presentation of Retroperitoneal Liposarcoma.

Liposarcoma presenting within an inguinal hernia is rare. It may manifest as either primary spermatic cord liposarcoma or as an extension of retroperitoneal liposarcoma into the inguinoscrotal region. Tumors originating in the retroperitoneum can extend toward the inguinal region through the gonadal vein pathway. Utilizing imaging modalities is crucial for differentiating between a retroperitoneal component and a fat-containing inguinal mass. Identification of non-lipomatous components within a fat-containing tumor provides diagnostic clues on radiological imaging.

Pictorial review of the post-operative cranium.

Imaging evaluation of the brain and cranium after cranial surgery is a routine and significant part of the workflow of a radiology department. Various normal expected findings and early and late complications are associated with the post-operative cranium. In this pictorial review, the authors describe the typical imaging features of the spectrum of various conditions associated with cranial surgery with illustrative cases. Contribution: A good knowledge and understanding of the spectrum of imaging appearances in the post-operative cranium is vital for the radiologist to accurately diagnose potential complications and distinguish them from normal post-operative findings, improving patient outcomes and guiding further treatment.

An Unusual Case of Ehlers-Danlos Syndrome Presenting as Proptosis.

Ehlers-Danlos syndrome (EDS) is a rare, heterogeneous group of genetic connective tissue disorders that affect collagen proteins. Currently, they are classified into 13 subtypes, many of which share general characteristics such as thin, hyperextensible skin and joint hypermobility. Vascular Ehlers-Danlos syndrome (vEDS) is characterized by tissue fragility, which predisposes individuals to premature arterial, uterine, or intestinal rupture. In this case, a young female presented with proptosis, skin hyperelasticity, and multiple joint dislocations. On computed tomography angiography (CTA), a direct caroticocavernous fistula, along with multiple segments of narrowing and ectasia in the internal carotid arteries and vertebral arteries, were detected, leading to a diagnosis of vEDS. This case report highlights the importance of clinical evaluation and the role of imaging in detecting this rare condition.

Renal Cell Carcinoma Arising from Isthmus of Horseshoe K.

The most common congenital renal fusion anomaly is the horseshoe kidney (HSK) occurring in about 1 in 600-700 individuals in the Indian population. HSKs are associated with problems such as renal stones, obstruction of uretero-pelvic junction causing stasis, and infection due to ectopic location of the kidneys, malrotation of the kidneys, and vascular changes. In general, normally developed kidneys have more incidents of renal cell carcinoma (RCC) as compared to HSKs. The major issue arises during surgery of HSK due to their altered anatomy and aberrant blood supply. We present a case of HSK with RCC located in the isthmus of a 43-year-old woman.

Thyroid Storm in Lupus: A Rare Cause of Unrelenting Pyrexia.

Systemic lupus erythematosus may present with fever, and it is a challenge to attribute fever to a particular cause. Very rarely it can be due to hyperthyroidism. Thyroid storm is a medical emergency causing unrelenting pyrexia. Here we report a case of a young female who first presented as fever of unknown origin (FUO), was subsequently diagnosed as neuropsychiatric lupus, and in whom the cause of unrelenting high fever, which did not respond to adequate immunosuppression to quell disease activity, was documented to be thyroid storm after excluding all other causes such as infection and malignancy. To our knowledge, this is the first case of this kind reported in literature, although cases of thyrotoxicosis preceding or following the diagnosis of lupus is known. Her fever resolved after starting antithyroid drugs and beta blockers.

Validation of a Deep Learning Model for Detecting Chest Pathologies from Digital Chest Radiographs.

Purpose: Manual interpretation of chest radiographs is a challenging task and is prone to errors. An automated system capable of categorizing chest radiographs based on the pathologies identified could aid in the timely and efficient diagnosis of chest pathologies. Method: For this retrospective study, 4476 chest radiographs were collected between January and April 2021 from two tertiary care hospitals. Three expert radiologists established the ground truth, and all radiographs were analyzed using a deep-learning AI model to detect suspicious ROIs in the lungs, pleura, and cardiac regions. Three test readers (different from the radiologists who established the ground truth) independently reviewed all radiographs in two sessions (unaided and AI-aided mode) with a washout period of one month. Results: The model demonstrated an aggregate AUROC of 91.2% and a sensitivity of 88.4% in detecting suspicious ROIs in the lungs, pleura, and cardiac regions. These results outperform unaided human readers, who achieved an aggregate AUROC of 84.2% and sensitivity of 74.5% for the same task. When using AI, the aided readers obtained an aggregate AUROC of 87.9% and a sensitivity of 85.1%. The average time taken by the test readers to read a chest radiograph decreased by 21% (p < 0.01) when using AI. Conclusion: The model outperformed all three human readers and demonstrated high AUROC and sensitivity across two independent datasets. When compared to unaided interpretations, AI-aided interpretations were associated with significant improvements in reader performance and chest radiograph interpretation time.

"Pneumomediastinum: A marker of severity in Covid-19 disease".

Objective: The goal of this study was to look at the incidence, risk factors, clinical characteristics, and radiological aspects of COVID-19 patients who developed pneumomediastinum and compare these features between those who died and those who survived. Materials and methods: This retrospective observational study included COVID-19 patients having pneumomediastinum on CT from May 2020 to May 2021 in a COVID-19 care hospital. 1st wave patients were considered between the period of May 2020 to January 2021 and those in the second wave between February 2021 to May 2021. The clinical details were analyzed by a consultant intensivist and CT scans were read by a team of 6 resident radiologists and 5 experienced radiologists. Demographic data, co-morbidities, clinical parameters, hemodynamic markers, radiological involvement and associated complications were analyzed. Results: During the study period, 10,605 COVID-19 patients were admitted to our hospital of which 5689 underwent CT scan. 66 patients were detected to have pneumomediastinum on CT; 26 of them in the first wave and 40 in the second wave. Out of 66, 28 patients were admitted to ICU, 9 during the first wave and 18 during the second wave. The overall incidence of developing pneumomediastinum was 1.16%. Incidence in the 1st wave was 1.0% and in the 2nd wave was 1.29%. The overall mortality rate in admitted COVID-19 patients was 12.83% while it was 43.9% in COVID-19 patients who developed pneumomediastinum. Incidence of pneumomediastinum and pneumothorax was high in patients with extensive parenchymal involvement. 59/66 (89%) cases of pneumomediastinum had severe CT score on imaging. Conclusion: We conclude that pneumomediastinum is a marker of poor prognosis. Timely diagnosis of interstitial emphysema or pneumomediastinum will aid in planning early protective ventilation strategies and timely intervention of complications.

Radiation-Induced Hemorrhagic Vasculopathy and Seventh and Eighth Nerve Complex Neuropathy.

Radiation-induced (RI) changes such as radiation-induced cavernous malformations (RICMs) and radiation-induced cranial neuropathy (RICN) manifest as late delayed complications and can be seen on post-treatment imaging. Cavernous malformations (CMs) are vascular malformations that are made up of dilated, thin-walled capillary spaces without intervening brain parenchyma. Cranial nerve damage due to radiation exposure is a rare consequence of radiation therapy (RT). We present a case of intracerebral CMs/hemorrhagic vasculopathy and left seventh and eighth nerve complex cranial neuropathy 14 years following RT to the brain for tectal glioma.

A case of leiomyosarcoma of the ovarian vein with obstructive uropathy and hepatic metastasis.

Leiomyosarcoma (LMS) is a smooth muscle-derived malignant mesenchymal tumour. Primary LMS arising from the ovarian vein is uncommon. A 51-year-old female presented with left loin pain and was diagnosed with a LMS arising from the gonadal vein. The patient refused any treatment. Early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients. CT imaging plays an important role in diagnosis. Contribution: Retroperitoneal leiomyosarcoma of vascular origin is a rare entity. CT plays crucial role in diagnosing them by demonstrating the extent of the tumor along the gonadal vein. Early detection and timely diagnosis of retroperitoneal masses will improve the prognosis and survival rate in these patients.

A deep learning approach for automated diagnosis of pulmonary embolism on computed tomographic pulmonary angiography.

BACKGROUND: Computed tomographic pulmonary angiography (CTPA) is the diagnostic standard for confirming pulmonary embolism (PE). Since PE is a life-threatening condition, early diagnosis and treatment are critical to avoid PE-associated morbidity and mortality. However, PE remains subject to misdiagnosis. METHODS: We retrospectively identified 251 CTPAs performed at a tertiary care hospital between January 2018 to January 2021. The scans were classified as positive (n = 55) and negative (n = 196) for PE based on the annotations made by board-certified radiologists. A fully anonymized CT slice served as input for the detection of PE by the 2D segmentation model comprising U-Net architecture with Xception encoder. The diagnostic performance of the model was calculated at both the scan and the slice levels. RESULTS: The model correctly identified 44 out of 55 scans as positive for PE and 146 out of 196 scans as negative for PE with a sensitivity of 0.80 [95% CI 0.68, 0.89], a specificity of 0.74 [95% CI 0.68, 0.80], and an accuracy of 0.76 [95% CI 0.70, 0.81]. On slice level, 4817 out of 5183 slices were marked as positive for the presence of emboli with a specificity of 0.89 [95% CI 0.88, 0.89], a sensitivity of 0.93 [95% CI 0.92, 0.94], and an accuracy of 0.89 [95% CI 0.887, 0.890]. The model also achieved an AUROC of 0.85 [0.78, 0.90] and 0.94 [0.936, 0.941] at scan level and slice level, respectively for the detection of PE. CONCLUSION: The development of an AI model and its use for the identification of pulmonary embolism will support healthcare workers by reducing the rate of missed findings and minimizing the time required to screen the scans.

Susceptibility Weighted Imaging: An Effective Auxiliary Sequence That Enhances Insight Into the Imaging of Stroke.

AIM: To evaluate the utility of susceptibility-weighted imaging (SWI) sequence in stroke imaging and assess supplemental information provided by SWI in an acute stroke scenario. MATERIALS AND METHODS: In this study, the appearance of cerebrovascular stroke on the SWI images were analyzed in 50 patients who presented with acute-onset neurological symptoms. RESULTS: Brain MRI with SWI was performed on 50 patients presenting with acute neurological symptoms. The majority were males, 32/50 (64%) and 18/50 (36%) were females. Most of the patients were in the age group > 60 years (36%), followed by 50-60 years (22%). Most of the patients had bilateral pathology, 20 (40%). The majority of patients had supratentorial lesions 34 (68%). Among 50 patients, the majority of patients had arterial stroke 20 (40%) and cerebral venous sinus thrombosis (CVST) 20 (40%) followed by amyloid angiopathy five (10%), and five (10%) had hypertensive microhemorrhage. Among the 20 patients with arterial stroke, the majority had middle cerebral artery (MCA) thrombosis 10 (50%) and among the 20 patients with venous thrombosis, eight (40%) patients had hemorrhagic infarcts. SWI was better as compared to computed tomography (CT) (P<0.05) in the detection of hemorrhagic transformation of arterial infarct, cerebral hemorrhagic venous sinus thrombosis, hemorrhagic venous infarct, hypertensive microhemorrhage, and cerebral amyloid angiopathy. CONCLUSION: SWI is a useful imaging sequence that provides additional information on stroke patients. SWI requires only an additional three-four minutes to perform and can be easily incorporated into standard stroke protocol. SWI can identify various features such as hemorrhage, intraarterial thrombus, or concomitant microbleeds that are of prognostic value and affect therapeutic decisions.

Utility of 3D-T2 space MRI sequence in diagnosing a rare cause of lower backache: horseshoe cord and meningocoele manqué in a case of composite split cord malformation.

Diastematomyelia is the asymmetric or symmetric lateral duplication of the spinal cord into two hemicords. Pang divided it into three types: type-1, type-2 and composite split cord malformation (SCM). Composite SCMs are uncommon and are defined by the coexistence of multiple types of split cord with normal cord in between. When partially bridged, they are called a horseshoe cord. We report a case of a young woman who presented with backache and was diagnosed with composite SCM with horseshoe cord and type-2 SCM with intervening normal cord. In our case, 3D-SPACE due to its superior topographical evaluation, allowed us to visualise and characterise the thin meningocoele manque bands and detect horseshoe cords, asymmetric cords and demarcate the precise extent of syrinx, which were suboptimally imaged on isolated T2 and T1WI sequences. If left untreated during surgery, bands can be the potential cause for persistent backache.

Evaluating the Association Between Comorbidities and COVID-19 Severity Scoring on Chest CT Examinations Between the Two Waves of COVID-19: An Imaging Study Using Artificial Intelligence.

Background Coronavirus disease 2019 (COVID-19) has accounted for over 352 million cases and five million deaths globally. Although it affects populations across all nations, developing or transitional, of all genders and ages, the extent of the specific involvement is not very well known. This study aimed to analyze and determine how different were the first and second waves of the COVID-19 pandemic by assessing computed tomography severity scores (CT-SS). Methodology This was a retrospective, cross-sectional, observational study performed at a tertiary care Institution. We included 301 patients who underwent CT of the chest between June and October 2020 and 1,001 patients who underwent CT of the chest between February and April 2021. All included patients were symptomatic and were confirmed to be COVID-19 positive. We compared the CT-SS between the two datasets. In addition, we analyzed the distribution of CT-SS concerning age, comorbidities, and gender, as well as their differences between the two waves of COVID-19. Analysis was performed using the SPSS version 22 (IBM Corp., Armonk, NY, USA). The artificial intelligence platform U-net architecture with Xception encoder was used in the analysis. Results The study data revealed that while the mean CT-SS did not differ statistically between the two waves of COVID-19, the age group most affected in the second wave was almost a decade younger. While overall the disease had a predilection toward affecting males, our findings showed that females were more afflicted in the second wave of COVID-19 compared to the first wave. In particular, the disease had an increased severity in cases with comorbidities such as hypertension, diabetes mellitus, bronchial asthma, and tuberculosis. Conclusions This assessment demonstrated no significant difference in radiological severity score between the two waves of COVID-19. The secondary objective revealed that the two waves showed demographical differences. Hence, we iterate that no demographical subset of the population should be considered low risk as the disease manifestation was heterogeneous.

REAL-TIME strain elastography: Applications in musculoskeletal system.

BACKGROUND: Strain or compression sonoelastography (CE) provides a colour-coded elastogram representing tissue elasticity by measuring tissue deformability after repeated probe compression. Elastographic ultrasound (EUS) is a valuable tool for screening diagnosis and follow-up of inflammatory, degenerative, benign and malignant neoplastic pathologies of skin, subcutaneous tissue, muscles, tendons, ligaments, fascia and nerves; help in targeted biopsy; monitor healing tendons after surgery or nerve stiffness changes during physiotherapy. OBJECTIVES: To assess stiffness of normal tendons, muscles and nerve. To diagnose cellulitis, fasciitis, abscess, tendinopathy, myositis, muscle/tendon rupture/contusion and differentiate between benign and malignant soft tissue tumours. To derive elastic score (ES) and strain ratio (SR) in cases and controls. To correlate B-mode findings with CE. MATERIALS AND METHODS: A prospective study on 50 healthy subjects between 25 and 30 years and 50 cases of diffuse and focal musculoskeletal pathologies was done using B-mode and CE over 2 years. Statistical analysis of distribution, mean, associations, sensitivity, specificity, area under Receiver Operating Characteristic curve (AUROC) for B-mode, ES, SR combined B-mode/CE and their comparison was done. RESULTS: Significant association was noted between SR in muscles and tendons with sex. Significant correlation was noted between ES/SR with B-mode. CE and B-mode had 100% and 52.4% sensitivity respectively for diagnosing diffuse pathologies. For differentiating benign and malignant masses sensitivity, specificity, and diagnostic accuracy of B-mode was 71.43%, 86.36% and 82.76%; of SR was 71.43%, 90.91% and 86.21%; of Combined B-mode with CE was 100%, 90.91% and 93.1% respectively. Elastographic pattern had highest diagnostic accuracy and largest AUROC. CONCLUSION: CE as a screening test had higher diagnostic accuracy, supporting need for standardizing it for clinical use in MSK. EUS being a widely available, fast and affordable modality, can aid follow up of chronic MSK pathologies, response to medication, physiotherapy and surgery and mitigate the need for MRI.

A case of carotid web: Cause of stroke in healthy and young patients.

Carotid webs are important, often undiagnosed causes of cryptogenic and recurrent strokes. CT angiography and digital subtraction angiography adequately demonstrate webs as linear filling defects in the carotid bulb. However, findings are overlooked unless viewed in optimal planes and easily misdiagnosed as dissection flaps or atheromatous plaques, altering management and outcome. A case of unilateral carotid web is presented, detected during imaging in a young lady presenting with hemiparesis without other risk factors for stroke.

Arachnoid Cyst in Middle Cranial Fossa With Intraorbital Cyst (Orbital Meningocele).

Intracranial arachnoid cysts are extra-axial non-enhancing cerebrospinal fluid (CSF) density lesions. These are usually incidental findings on radiological investigations. Usually, the patients with arachnoid cysts are asymptomatic until the cyst grows large while symptomatic patients present with headaches, seizures, and focal neurological deficits. The adjacent calvarial bone may show remodeling and scalloping. Magnetic resonance imaging (MRI) stands superior in soft-tissue contrast and multiplanar imaging in excluding other lesions from the arachnoid cyst. Arachnoid cysts follow CSF signals in all pulse sequences with no gadolinium enhancement. Intraorbital extension of the intracranial arachnoid cyst (intraorbital meningocele) is rarely reported in the literature and occurs through the small bony defect. We report a case of a 20-year-old male presenting with proptosis who was detected to have an arachnoid cyst in the middle cranial fossa with intraorbital extension through a small bony defect in the lateral wall of orbit with the resultant orbital cyst.

Utility of Constructive Interference in Steady-State Sequence in Detecting Thin Pituitary Stalk in Pituitary Stalk Interruption Syndrome.

Pituitary stalk interruption syndrome (PSIS) is a rare congenital anomaly, causing hypothalamic-pituitary malfunction. It is characterized by hypoplastic anterior pituitary, absent or thin infundibulum, and absent or ectopic posterior pituitary. Its early recognition is important in disease management. MRI plays a pivotal role in early diagnosis. We report a case of a 13-year-old male child, presenting with stunting of growth and discrepancy between chronological and bone age of four years. A subsequent MRI revealed a small anterior pituitary, hypoplastic pituitary stalk, and an absence of visualization of the bright pituitary gland signal in the sella. The posterior pituitary gland was present ectopically in the midline along the floor of the third ventricle near the median eminence.

Unusual Locations of Pancreatic Pseudocysts in Lumbar Triangle, Psoas Muscle and Intercostal Space, and Obturator Externus.

Pancreatic pseudocyst develops as a complication of both acute and chronic pancreatitis. Although the common location of pseudocyst is lesser sac, extension of pseudocyst can occur into mesentery, retroperitoneum, inguinal region, scrotum, liver, spleen, mediastinum, pleura, and lung. Extension of pseudocyst into psoas muscle and lumbar triangle is extremely rare. The development of pseudocyst in lumbar triangle is radiologically equivalent and further extension of Grey Turner's sign seen clinically in acute pancreatitis. This extension occurs due to the destructive nature of pancreatic enzymes. The lumbar triangle is the site of anatomic weakness in the lateral abdominal wall in the lumbar region. We report the case of a 35-year-old alcoholic male patient who presented with abdominal pain followed by distension and swelling in the right lumbar region for 1 week. On computed tomography scan of the abdomen, acute-on-chronic pancreatitis with multiple pseudocysts in the right posterior pararenal space, extending through the right lumbar triangle in the right lateral abdominal wall, right posterior paraspinal muscles, right iliopsoas, right obturator externus, and medial aspect of the right upper thigh, beneath anterior abdominal wall in the upper abdomen and in the right lateral thoracic wall through the right 11th intercostal space, was detected.

Necrotizing Fasciitis of Thoracic and Abdominal Wall with Emphysematous Pyelonephritis and Retroperitoneal Abscess.

Emphysematous pyelonephritis is a life-threatening severe form of pyelonephritis usually occurring in patients with diabetes mellitus with or without obstructive uropathies in whom there is necrotizing infection leading to the gas production of an unclear mechanism involving the renal parenchyma and the collecting system. Necrotizing fasciitis is characterized by progressive necrosis of fat and fascia due to deep-seated infection of subcutaneous tissue. It has a fulminant course with considerable mortality. Diabetes Mellitus is a common predisposing factor. The combined occurrence of emphysematous pyelonephritis and necrotizing fasciitis is extremely unusual. Early recognition and management is mandatory to avoid mortality. We report a case of a 53-year-old female, a known case of Type II diabetes mellitus, who presented with necrotizing fasciitis of thoracic and abdominal wall with emphysematous pyelonephritis in the left kidney with a retroperitoneal abscess.