Correlation of CT perfusion with MRI brain in symptomatic carotid artery stenosis.

Background: Cerebral white matter disease and large vessel cerebral steno-occlusive are both associated with high incidence of strokes and mortality. There is a lack of literature correlating the cerebral perfusion downstream of a stenotic lesion with white matter changes in the cerebral hemispheres. The aim of this study was to correlate the white matter changes in magnetic resonance imaging (MRI) with computed tomography (CT) perfusion parameters in patients with symptomatic carotid stenosis. Methods: A total of 50 patients with symptomatic carotid stenosis underwent MRI brain and CT Perfusion. Percentage differences in cerebral blood flow (CBF) and mean transit time (MTT) were correlated with symmetric and asymmetric small vessel ischemic disease (SVID) on MRI. Receiver operating characteristic (ROC) curve analysis was performed to determine sensitivity and specificity for different values of percentage CBF and MTT difference. Results: A total of 17 patients with symmetrical SVID had a mean CBF difference of 6.58 (SD of 3.17) and mean MTT difference of 11.61 (SD of 4.32). 33 patients with asymmetrical SVID had a mean CBF difference of 34.73 (SD of 6.87) and mean MTT difference of 44.63 (SD of 9.12). ROC curve analysis showed percentage CBF and MTT differences of 12.5% and 26.5% respectively to be associated with 100% specificity and sensitivity. Conclusion: In patients with symptomatic carotid stenosis, CT perfusion parameters correlate with MRI features of SVID.

Bannwarth's syndrome and a surgical dilemma: An uncommon zoonosis with a rare presentation.

Lyme's disease also known as Erythema chronicum Migrans, is a multisystem infectious disease caused by the spirochete "Borrelia burgdorferi" which is transmitted by "Ixodes" tick, with both specific and nonspecific manifestations. Nervous system involvement occurs in 10%-15% of untreated patients and typically involves lymphocytic meningitis, cranial neuritis, and/or polyradiculitis. Here, we are reporting an interesting and challenging case of Neuro-Borreliosis in a young officer cadet, meeting the description for Bannwarth's syndrome and presenting initially as a surgical emergency followed by paraparesis. The diagnosis was finally clinched based on clinical profile of Chronic Myeloradiculopathy with focal myositis in the setting of recent outdoor camping, and confirmed by demonstrating high IgG antibody titres in serum and Cerebro spinal fluid (CSF). The officer cadet was treated successfully with a 6 week course of Ceftriaxone and Doxycycline, and went back to full training.

A Study of the Clinical Profile, Radiologic Features, and Therapeutic Outcomes in Neurosarcoidosis from Two Tertiary Care Centers in Southern India.

BACKGROUND: Sarcoidosis is an inflammatory granulomatous disease affecting multiple organ systems. Neurological manifestations are rare and seen in approximately 5% cases of sarcoidosis. They may commonly precede the diagnosis of sarcoidosis. Since there is paucity of Indian literature on this subject, we decided to review the clinical and radiological profile, laboratory abnormalities, treatment and long-term outcomes in our patients with neurosarcoidosis (NS). METHODS: The study was done by retrospective review of medical records for all cases diagnosed as NS during the period Jan 2014-Jan 2018. These cases were classified as definite, probable, and possible NS, on the basis of established diagnostic parameters (Zajicek criteria). The follow-up record in these cases ranged from 6 months to 3 years, with special emphasis on monitoring the response to treatment and long-term disability. RESULTS: The cases showed varied clinical abnormalities and imaging findings. Cranial neuropathies and myelopathy were the most common clinical presentations. Optic neuritis was most common cranial neuropathy, followed by facial nerve palsy and lower cranial nerve palsies. Most common magnetic resonance imaging findings were T2 hyperintense parenchymal lesions and meningeal enhancement. There was strong correlation between baseline clinico radiological parameters and long-term outcomes, as evidenced by relatively poor prognosis seen in cases with bilateral optic neuritis, myelopathy and imaging evidence of hydrocephalus, or leptomeningitis. CONCLUSION: The diagnosis of NS requires a high degree of suspicion, coupled with exclusion of alternate diagnosis. It commonly precedes the onset of systemic sarcoidosis. Central nervous system involvement in sarcoidosis is associated with poor clinical outcomes.

Dosimetric and isocentric variations due to patient setup errors in CT-based treatment planning for breast cancer by electronic portal imaging.

BACKGROUND: Inaccuracies in treatment setup during radiation therapy for breast cancers may increase risks to surrounding normal tissue toxicities, i.e. organs at risks (OARs), and compromise disease control. This study was planned to evaluate the dosimetric and isocentric variations and determine setup reproducibility and errors using an online electronic portal imaging (EPI) protocol. METHODS: A total of 360 EPIs in 60 patients receiving breast/chest wall irradiation were evaluated. Cumulative dose-volume histograms (DVHs) were analyzed for mean doses to lung (V20) and heart (V30), setup source to surface distance (SSD) and central lung distance (CLD), and shifts in anterior-posterior (AP), superior-inferior (SI), and medial lateral (ML) directions. RESULTS: Random errors ranged from 2 to 3 mm for the breast/chest wall (medial and lateral) tangential treatments and 2-2.5 mm for the anterior supraclavicular nodal field. Systematic errors ranged from 3 to 5 mm in the AP direction for the tangential fields and from 2.5 to 5 mm in the SI and ML direction for the anterior supraclavicular nodal field. For right-sided patients, V20 was 0.69-3.96 Gy, maximum lung dose was 40.5 Gy, V30 was 1.4-3 Gy, and maximum heart dose was 50.5 Gy. Similarly, for left-sided patients, the CLD (treatment planning system) was 25 mm-30 mm, CLD (EPIs) was 30-40 mm, V20 was 0.9-5.9 Gy, maximum lung dose was 45 Gy, V30 was 2.4-4.1 Gy, and maximum heart dose was 55 Gy. CONCLUSION: Online assessment of patient position with matching of EPIs with digitally reconstructed radiographs (DRRs) is a useful method in evaluation of interfraction reproducibility in breast irradiation.

A study of clinical, radiological and etiological profile of cerebral venous sinus thrombosis at a tertiary care center.

BACKGROUND: A prospective, observational study was done at a tertiary care hospital in Western Maharashtra to describe the etiologies, clinical features, diagnosis and prognosis of cerebral venous sinus thrombosis in an Indian population. METHODS: 54 patients with clinical and MRI features suggestive of cerebral venous sinus thrombosis (CVST), were studied with detailed clinical evaluation and pro-thrombotic work up. All were followed up monthly for 6 months, to assess the response to therapy and clinical outcomes. RESULTS: The mean age of presentation was 35 years. Headache was the most common presenting symptom (94%) and hemi paresis (22%) was the most common neurological sign. The most common sinus involved was transverse sinus in 77% of cases. In the unprovoked CVST subset (n = 29), elevated factor VIII (72%) and protein C deficiency (24%) were the common prothrombotic states identified. In the provoked CVST subset (n = 18), puerperium (44%) and para-infectious (22%) accounted for majority cases. Idiopathic CVST accounted for 13% (7/54) in this study. A Modified Rankin Scale (MRS) of 0-1 was achieved in 96% of patients at the end of 6 months follow up with no mortality in this study. CONCLUSION: CVST is an important yet under recognized cause of intracranial hypertension and stroke in young. Clinical presentation is extremely varied and a high index of suspicion is needed. Magnetic Resonance Imaging (MRI) brain with Magnetic Resonance Venography (MRV) is the current diagnostic modality of choice. Elevated factor VIII and puerperium are the common etiologies in an Indian population. Management with anticoagulants is safe and has excellent clinical outcomes.

Primary Tubercular Abscess of the Axilla-a Rare Case.

Tuberculosis can be broadly classified as pulmonary and extrapulmonary. Though pulmonary tuberculosis is the most common presentation, extrapulmonary tuberculosis is also an important entity. A tubercular cold abscess secondary to involvement of an adjacent bone or suppuration of lymph nodes is a well-known entity; however, a primary cold abscess is rare. We report a case of a young girl who presented with an axillary swelling which turned out to be a primary tubercular abscess of the axilla. To the best of our knowledge, this is the first reported case of a primary tubercular abscess presenting in the axilla. A primary tubercular abscess, though rare, should be considered as a possible diagnosis in appropriate clinical settings backed by evidence of Mycobacterium tuberculosis in form of AFB microscopy, L-J culture, BACTEC culture, or PCR test.

Primary cervical thoracic duct cyst: a case report and review of the literature.

Thoracic duct cysts are uncommon entities that are usually found in the thoracic segments of the thoracic duct. The presence of a thoracic duct cyst in the cervical area has been rarely reported. Etiologically, these cysts can arise either as a primary growth or secondary to trauma, obstruction, or inflammation. This entity was first described in 1964, and only 33 cases have been previously reported in literature. Of these, 16 cases involved a primary cyst. We report a new case of a primary thoracic duct cyst, and we discuss its presentation, diagnosis, and management, with an emphasis on meticulous surgical technique. We also review the relevant literature.

Dry imaging cameras.

Dry imaging cameras are important hard copy devices in radiology. Using dry imaging camera, multiformat images of digital modalities in radiology are created from a sealed unit of unexposed films. The functioning of a modern dry camera, involves a blend of concurrent processes, in areas of diverse sciences like computers, mechanics, thermal, optics, electricity and radiography. Broadly, hard copy devices are classified as laser and non laser based technology. When compared with the working knowledge and technical awareness of different modalities in radiology, the understanding of a dry imaging camera is often superficial and neglected. To fill this void, this article outlines the key features of a modern dry camera and its important issues that impact radiology workflow.

Idiopathic sclerosing encapsulating peritonitis--is a preoperative diagnosis possible? Report of three cases.

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is usually diagnosed during a laparotomy; however, a preoperative diagnosis is possible. Sclerosing encapsulating peritonitis can be classified as primary or idiopathic and secondary types and only about 70 cases of idiopathic type have been reported since it was first described. It is characterized by a total or partial encasement of the small bowel by a thick fibrotic membrane. This report presents a series of three cases in which a diagnosis of idiopathic SEP was made preoperatively based on the clinical features and radiological findings, which were confirmed by a laparotomy and histopathology. All of the cases were successfully managed by the excision of the membrane. This report demonstrates that based on the clinical features and radiological investigations, in the absence of other plausible etiologies for intestinal obstruction, it is possible to suspect a preoperative diagnosis of SEP, thereby preventing a "surprise" finding during a laparotomy and allowing for better management.

Caecal perforation with faecal peritonitis - unusual presentation of Bochdalek hernia in an adult: a case report and review of literature.

The improper fusion of the postero-lateral foramen of the diaphragm was first described by Bochdalek in 1848. The incidence of congenital diaphragmatic hernia varies from1:2000 to 1:5000 live births and Bochdalek hernias (BH) account for 75 to 85% of these. Although it is a well-known entity in neonates, it is occasionally discovered incidentally in adult patients. Until now, a total of around 100 cases of occult asymptomatic Bochdalek hernia have been reported. The symptomatic cases are encountered more rarely. Colon necrosis among the symptomatic cases was reported in some reports. We discuss the present case since we believe it to be, to the best of our knowledge, the first case of a Bochdalek hernia in an adult presenting with caecal perforation and faecal peritonitis and review the published literature about this rare condition.