Large Gastric Perforation Sealed by Splenic Lysis: Emphasis on Indirect Signs - A Rare Case Report.

BACKGROUND: Gastric perforation is a life-threatening condition, requiring early and reliable discovery. The delay before surgical treatment is a strong determinant of poor outcome, associated complications and hospitalization costs. By using ultrasound and multi-detector computed tomography (MDCT) we can further evaluate undiagnosed cases of silent gastric perforations presenting with non-specific acute abdomen. Here we bring forth the role of a radiologist in cases of perforation which present with indirect signs involving the organs forming the stomach bed, like the spleen, pancreas and kidney. CASE REPORT: A 25-year-old male patient presented with an acute onset of severe upper abdominal pain radiating to the back and vomiting. MDCT of the abdomen was done which revealed atrophic pancreas with organized collection in the sub-capsular location indenting the superior pole of the left kidney. Spleen was not visualized. The most striking imaging finding in that case was destruction of the splenic parenchyma with protrusion of the remaining tissue into the stomach lumen. The hypothesis behind this was a cascade of events which started with gastric perforation, spillage of highly destructive gastric juice over the stomach bed and finally becoming silent with rapid sealing of the defect by the omentum and the spleen. CONCLUSIONS: Acute abdomen is a diagnostic challenge to a clinician and radiologist with gastric perforation being a great mimicker of other urgent abdominal pathologies. To avoid a delayed diagnosis or a misdiagnosis, familiarity with typical and atypical imaging features is essential as in our case of splenic lysis. It acted as the 2(nd) policeman and provided a great clue to solve the diagnostic dilemma.

Hydranencephaly associated with cerebellar involvement and bilateral microphthalmia and colobomas.

Hydranencephaly is an encephaloclastic central nervous system disorder characterised by severe destruction of the cerebral hemispheres with preservation of posterior fossa structures. We present MRI and neurosonography features of a unique case of hydranencephaly involving cerebellum (in the form of complete liquefaction of cerebellar hemispheres) and cerebral hemispheres with associated bilateral microphthalmia and ocular colobomas. This is an exceptional case as to the best to our knowledge. In humans, such a severe involvement of cerebellum has not been reported in cases of hydranencephaly. It is essential to distinguish hydranencephaly from gross hydrocephalus, as treatment and prognosis of the two are totally different. During differentiation, it is important to remember that severe cerebellar involvement can be seen in hydranencephaly.

Prolapsed simple ureterocele: evaluation by transvaginal voiding sono-urethrography.

Prolapsed ureterocele is a rare complication that may present with acute bladder outlet obstruction, generally in female infants. We present a case of prolapsed simple ureterocele in an adult woman, evaluated by transvaginal micturating sono-urethrography. High-frequency transvaginal sonography of the urethra performed during micturation revealed the relationship of the ureterocele with the urethral wall.

Outcomes using a 1470-nm laser for symptomatic varicose veins.

PURPOSE: The aim of this study was to evaluate safety and effectiveness of the laser fiber with wavelength of 1470 nm for ablation of symptomatic varicose veins. MATERIALS AND METHODS: This was a prospective study carried out from November 2007 to October 2009. Seventy-six limbs in 72 consecutive patients were treated by endovenous laser ablation (EVLA). Baseline preprocedural clinical and ultrasonic grading of varicose veins was done. Endovenous laser ablation was done under ultrasonic guidance, and prior superficial venogram was taken if required. After the procedure all the patients were followed up with for 1 year with duplex ultrasound scan, and improvement in grading of venous disease was assessed. RESULTS: One hundred eight treated veins of 76 limbs were followed up on day 2, 1 month, 6 month, and 12 months postprocedurally. At the end of 1-year follow-up, venous occlusion rate and ulcer healing rate were 98.61% and 85%, respectively. The average preoprocedure clinical grade and venous disability score improved significantly at 12 months. Most of the postprocedure complications were transient and self limiting; the most common complication was paresthesia (10.53%). No major complications, such as deep vein thrombosis, occurred. When the authors compared legs treated with linear endovenous energy density below or above 100 J/cm, the paresthesia rate and postoperative pain was significantly higher in the second group, with energy density more than 100 J/cm. CONCLUSIONS: EVLA, using 1470-nm laser, is a minimally invasive, safe, outpatient department (OPD) procedure that causes less postprocedural pain with linear endovenous energy density (LEED) less than 100J/cm.

Partial hydatidiform mole in septate uterus.

Partial mole is a form of gestational trophoblastic disease that may be associated with serious medical complications and occasionally progresses to the second trimester of pregnancy. We present a case report of a partial mole diagnosed at 18 weeks of gestation in a septate uterus with molar placenta in one horn and a dead fetus in the other.

Diagnosis of short rib polydactyly syndrome type IV (Beemer-Langer syndrome) with cystic hygroma: A case report.

Short rib polydactyly syndrome (SRPS) is a very rare congenital autosomal recessive inherited disease, classified into four subtypes. It has distinct imaging findings on prenatal sonography (US) and ancillary findings on both pre- and postnatal examinations may help classify individual cases into one of four subtypes. We report the US findings in a case of SRPS type IV (Beemer-Langer dysplasia) in a male fetus with multiple congenital anomalies, including cystic hygroma. The postnatal ultrasound, radiographic, and postmortem examinations helped to classify the SRPS as type IV. We believe this is the first documented case associating cystic hygroma and polydactyly.

Renal Doppler indices in sickle cell disease: early radiologic predictors of renovascular changes.

OBJECTIVE: The purpose of our study was to detect changes in renovascular resistance through renal Doppler indexes in young sickle cell disease patients with normal routine urine laboratory tests. CONCLUSION: Renal Doppler sonography resistive index and pulsatility index values can serve as early radiologic predictors of renovascular changes in sickle cell disease. Thereby, these findings can guide clinicians in the use of more intensive monitoring of laboratory values and initiating adequate treatment at an early stage.

Intrapericardial teratoma diagnosed on CT.

Intrapericardial teratomas are rare tumors which usually present in infancy. These tumors may be life-threatening because of the associated large pericardial effusion and cardiac compression. Here we present a case of intrapericardial teratoma which presented with cardiac tamponade in a neonate and was diagnosed using multidetector spiral computed tomography. The imaging features, clinical presentation, and differential diagnosis of this seldom-encountered entity are discussed.

Accuracy of Common Femoral Artery Doppler Waveform Analysis in Predicting Haemodynamically Significant Aortoiliac Lesions.

INTRODUCTION: Doppler ultrasound is cost-effective and accurate noninvasive method for evaluation of peripheral arterial disease. However, there is difficulty in detection of aortoiliac lesions due to inadequate visualization of aortoiliac arteries in many patients. The Doppler waveform changes occurring distal to significant stenosis or occlusion are well documented. Accordingly, common femoral artery (CFA) Doppler waveform analysis may be used to predict haemodynamically significant proximal aortoiliac lesions. AIM: To evaluate the accuracy of Doppler waveform analysis at the CFA for diagnosing haemodynamically significant aortoiliac stenosis or occlusion in patients of peripheral arterial disease. MATERIALS AND METHODS: A total of 67 patients (114 aortoiliac segments) with suspected peripheral arterial disease were retrospectively evaluated and labeled as normal or abnormal by analysing the Doppler waveform of CFA. The triphasic waveform with normal reversal pattern was categorized as normal, while low velocity biphasic or monophasic waveform were labeled as abnormal and indirect diagnosis of normal or diseased (>50% stenosis or occlusion) aortoiliac segment was made. The results were compared to intra-arterial angiography, considered as the gold standard. RESULTS: The Doppler waveform analysis of CFA was abnormal in 41 out of 114 common femoral arteries, while intra-arterial angiography showed significant stenosis (21 arteries) or occlusion (26 arteries) in 47 (41%) of 114 aortoiliac segments in 67 patients. Out of 67 normal aortoiliac segments seen on angiography, the CFA waveform analysis was interpreted as normal in 62 segments. An abnormal CFA waveform could diagnose significant aortoiliac lesion with 87% sensitivity, 92% specificity, 89% Positive Predictive Value (PPV), 91% Negative Predictive Value (NPV) and 90% accuracy using angiography as the gold standard. The low velocity monophasic waveform which was seen in 38 (33%) of 114 segments was reliable predictor of significant aortoiliac disease with 93% positive predictive value. CONCLUSION: CFA Doppler waveform pattern analysis is a sensitive and accurate technique for the prediction of haemodynamically significant aortoiliac stenosis or occlusion.

Computed tomographic analysis of the position of the mandibular canal in unilateral temporomandibular joint ankylosis patients.

The aim of this study was to investigate the position of the mandibular canal through the region of the mandibular angle and body using computed tomographic (CT) imaging, and to relate the findings to those in the molar region on the ankylosed temporomandibular joint (TMJ) and the normal side. The mandibles of 25 patients with unilateral ankylosis of the TMJ (14 women and 11 men) were recorded on coronal CT slices 2mm thick. All patients included in the study had had ankylosis diagnosed before they were 16 years old. The position of the mandibular canal was studied from the region of the third molar to that of the first molar on ankylosed and normal mandibles. The following variables were measured: the distance between the external surface of the buccal cortical plate and the outer surface of the mandibular canal (B); the distance between the external surface of the lingual cortical plate and the outer surface of the mandibular canal (L), and the distance between the external surface of the inferior border of the mandible and the outer surface of the mandibular canal (I). Our results suggest that changes are more pronounced in the regions of the second and third molars. The mandibular canal is closest to the inferior border of the mandible in the region of the second molar and farthest in that of the third molar. The greatest distance between the outer surface of the mandibular canal to the external surface of the buccal cortex on the ankylosed and normal sides was found in the first and second molars, and it was greater on the normal side. To minimise the risk of injury to the inferior alveolar nerve, the measurements of B, L, and I should be considered separately on the ankylosed and normal sides when planning mandibular osteotomies for distraction osteogenesis and orthognathic surgery, and when using monocortical screws.

Fibrochondrogenesis, an antenatal and postnatal correlation.

Fibrochondrogenesis is a rare, neonatally lethal osteochondrodysplasia, with autosomal recessive inheritance. It differs from other lethal dwarfisms in that it leads to broad, long-bone metaphyses (dumb-bell shaped) and pear-shaped vertebral bodies. We report a case of fibrochondrogenesis with severe pear-shaped platyspondyly, suspected antenatally, and give a comprehensive pictorial review of the antenatal ultrasound and postnatal radiographic findings. Only few cases of fibrochondrogenesis are diagnosed before the termination of pregnancy.

Ellis van creveld syndrome with synpolydactyly, an antenatal diagnosis with postnatal correlation.

Ellis Van Creveld syndrome (EVC), also known as chondroectodermal dysplasia, presents at birth with short limbs accompanied by postaxial polydactyly, nail dysplasia, and dental anomalies. Other manifestations of EVC include atrial septum defects and other congenital heart diseases. We report a case of the EVC syndrome with postaxial polydactyly (Synpolydactyly with seven fingers on the right side and hexadactyly on the left side) and a partial atrioventricular canal defect diagnosed antenatally. This variation of EVS has not been reported in English literature till date.

Endovascular stent graft for post-traumatic superficial femoral artery pseudoaneurysms with arteriovenous fistula: 6 months follow-up of 2 cases.

Pseudoaneurysms are common vascular abnormalities due to disruption of the vessel wall. Pseudoaneurysm with arteriovenous fistula is a rare presentation. Complications associated with them develop unpredictably and carry a high mortality rate. Traditionally pseudoaneurysms have been treated surgically. However, with the advent of new interventional techniques, management using endovascular approach have gained popularity in treating pseudoaneurysms. Here, we present two cases of large pseudoaneurysms with arteriovenous fistula treated by percutaneous stent graft. Present studies on pseudoaneurysms are all either iatrogenic or secondary to nephrologic dialysis treatment and only few present studies exist describing such large post-traumatic femoral pseudoaneurysms with arteriovenous fistulas were treated successfully by stent grafting through femoral approach, with good patency at 6 months follow up.

Communicating tubular duplication of upper esophagus-a rare occurrence.

Duplications of esophagus are commonly classified into two types, tubular and cystic. Tubular duplication of esophagus is a rare occurrence and is much less common than cystic duplication of foregut. Most esophageal duplications are located in the lower third of the esophagus. A cervical esophageal duplication is extremely rare. Esophageal duplications have been reported twice as commonly on the right as on the left. We report a case of incidental finding identified on computed tomography of communicating tubular esophageal duplication involving the left side of the upper esophagus in a tuberculosis patient that was subsequently confirmed on barium swallow test.

Imaging features of extra cranial parapharyngeal space meningioma: case report.

Parapharyngeal tumors are less common in clinical practice and are often difficult to diagnose upon clinical examination due to the anatomic complexity of the region. We report a rare case of extracranial parapharyngeal space meningioma presenting as a cervical mass with encasement of cranial nerves giving tram track appearance and features on various imaging modalities [Radiographs, Ultrasound, Computed tomography (CT) scan and Magnetic resonance imaging (MRI)].

A rare case of male primary breast lymphoma.

Primary lymphoma of the breast is a rare occurrence because of the paucity of lymphoid tissue in the breast and is an even rarer entity in the male breast. Imaging, along with tissue diagnosis goes a long way in diagnosing breast lymphoma which has a significantly different management scheme than other breast neoplasms with respect to radio-chemotherapy rather than surgical resection. We present a case of primary male breast lymphoma which was evaluated with magnetic resonance imaging as well as other conventional imaging modalities and was treated by chemotherapy with a 7-month follow-up.

Chorioangioma of placenta: sonographic features.

Chorioangioma is a benign vascular tumor of the placenta arising from primitive chorionic mesenchyme. Large (>4 cm) chorioangiomas are much rarer and are often associated with maternal and/or fetal complications. We describe the sonographic features of a large placental chorioangioma with normal outcome.

Sonographic diagnosis of uncomplicated first-trimester pregnancy in the rudimentary horn of a unicornuate uterus.

Although pregnancy in a rudimentary uterine horn is rare, the correct diagnosis of this condition on routine sonographic examination is critical, because its natural history usually involves the rupture of the pregnant horn during the second or third trimester, resulting in life-threatening bleeding. We report a case in which the diagnosis of right unicornuate uterus with a left noncommunicating rudimentary horn was made in the first trimester on routine sonographic examination.

Pyloric wall thickening in carcinoma stomach: a pseudokidney sign on computed tomography.

Bowel wall thickening on ultrasound simulates appearance of kidney. The appearance of kidney on contrast enhanced computed tomography is entirely different. However, surprisingly bowel wall thickening or mass can mimic this appearance even on contrast enhanced computed tomography. A case of pyloric malignancy with pseudokidney appearance on contrast enhanced computed tomography is being reported.