Radiological Quiz-Musculoskeletal

X-ray Dorso-lumbar spine of a middle aged man presented with back ache. Skiagram shows classical changes of a disease.

What is the diagnosis?

ANSWER- Ankylosing Spondylitis, Bamboo Spine Appearance

Winner- ALIREZA, Drop me an email at sumerdoc-AT-yahoo-DOT-com for your prize...

Winner will get a free copy of the book "Review of Radiology" by Dr Sumer K Sethi, a small handbook of Radiology for medical students.

CASE CONTRIBUTED BY- Dr. Suresh Toppo,MD Radiodiagnosis. Senior Resident Lady Hardinge Medical College

"Review of Radiology" by Dr Sumer K Sethi Features in Internet journal of Book Reviews

My book "Review of Radiology" has been put up as the featured Review in-

Anil Aggrawal's Internet Journal of Book Reviews
Volume 4, Number 1, January - June 2005

The Review goes on like-

One of the most important books to hit the literary scene in recent times is Review of Radiology written by Sumer K. Sethi. Dr. Sumer came out with the first edition last year, and just in one year all copies were lapped up by radiology students around the world.

So important has this book been, that it has been recommended by most professors of radiology to their students. Although the book would be useful to all radiologists in practice, it is particularly helpful to students appearing for the MD/MS entrance examinations.

A book with such a mass appeal ought to be examined by more than one reviewer. We at the journal office sent the book to eight reviewers around the world spanning three continents and six countries...

Reviews of the book "Review Of Radiology"

Featured Interview with Dr Sumer Kumar Sethi

Online Radiology Quiz

Triangular Cord Sign in Extrahepatic Biliary Atresia

Objective criteria of triangular cord sign in biliary atresia on US scans.

Thickness of the echogenic anterior wall of the right portal vein (EARPV) is measured. The TC sign was defined as thickness of the EARPV of more than 4 mm on a longitudinal scan. Biliary atresia was diagnosed when the TC sign was present.

Mean thickness of the EARPV was significantly greater in patients with biliary atresia (5.39 mm) than in patients with neonatal hepatitis (2.17 mm) (P <.05). Use of 4-mm thickness as the criterion for TC sign was statistically significant (P <.05), resulting in a sensitivity of 80%, specificity of 98%, and positive and negative predictive values of 94% for the diagnosis of biliary atresia.

An objective criterion of the TC sign is an EARPV thicker than 4 mm on a longitudinal scan.

Read the full Article at-

Radiology.2003 Nov;229(2):395-400

Technical Development-Micro-CT of the Human Lung

Micro-CT of the Human Lung: Imaging of Alveoli and Virtual Endoscopy of an Alveolar Duct in a Normal Lung and in a Lung with Centrilobular Emphysema—Initial Observations

Henrik Watz, MD, Andreas Breithecker, MD, Wigbert Stephan Rau, MD and Andres Kriete, PhD

The appearance of human lung parenchyma at the structural level of alveoli was investigated by the use of micro–computed tomography (CT). Approval for use of autopsy lungs was given by the head of the pathology institute of the university, in accordance with the requirements of the State Ministry of Science and Arts and without the need for institutional review board approval. Two human lungs (one normal lung and one lung with centrilobular emphysema of a mild to moderate degree) were inflated and fixed with hot formalin vapor. Lung specimens excised from the superior segment of the left lower lobe (B6) were stained with silver nitrate in a vacuum and investigated at a volume of interest of 4 mm for each side with a voxel size of 14 µm. Normal-size and enlarged alveoli became visible. A three-dimensional reconstruction of the terminal airspaces made virtual endoscopy of the alveolar ducts possible.

Full Article at-

Radiology 2005;236:1053-1058

Pediatric Urinary Tract Imaging-Current trends

Modern ultrasound technologies and their application in pediatric urinary tract imaging.

Darge K, Heidemeier A

In children ultrasound plays a central role in the diagnostic imaging of the urinary tract. It is used most frequently and as a primary diagnostic option. Consequently, innovations in ultrasound technology and ultrasound contrast media have major impact on pediatric urosonography. Harmonic imaging is a modality that produces artifact-free images with high resolution. It has been shown that harmonic imaging is superior to fundamental mode in many urosonographic indications. Color Doppler is an established imaging modality, but its application for diagnosis of stones in the urinary tract, especially in children, is relatively new. The so-called twinkling sign, a color Doppler artifact at the site where one normally expects the acoustic shadow to be, enhances the conspicuity of the stone. A further development is three-dimensional (3D) ultrasound. It offers better volume measurement of the bladder and kidneys than 2D ultrasound. Contrast-enhanced voiding urosonography has already proven to be a valuable alternative in the diagnosis of vesicoureteral reflux. Thus, a significant decrease of radiation exposure has become possible as it replaces the radiological methods. With the introduction of contrast-specific ultrasound imaging modalities, further improvements in voiding urosonography are emerging.

Full Article-

Radiologe. 2005 Aug 6; [Epub ahead of print]

MDCT in chest pain evaluation-Article in AJR

Chest Pain Evaluation in the Emergency Department: Can MDCT Provide a Comprehensive Evaluation?

Charles S. White, Dick Kuo, Mark Kelemen, Vineet Jain, Amy Musk, Eram Zaidi, Katrina Read, Clint Sliker and Rajnish Prasad

Patients with chest pain who presented to the emergency department without definitive findings of acute myocardial infarction based on history, physical examination, and ECG were recruited immediately after the initial clinical assessment. For each patient, the emergency department physician was asked whether a CT scan would normally have been ordered on clinical grounds (e.g., to exclude pulmonary embolism). Each consenting patient underwent enhanced ECG-gated 16-MDCT. Ten cardiac phases were reconstructed. The images were evaluated for cardiac (coronary calcium and stenosis, ejection fraction, and wall motion and perfusion) and significant noncardiac (pulmonary embolism, dissection, pneumonia, and so forth) causes of chest pain. Correlation was made between the presence of significant cardiac and noncardiac findings on CT and the final clinical diagnosis based on history, examination, and any subsequent cardiac workup at the 1-month follow-up by a consensus of three physicians.

Sensitivity and specificity for the establishment of a cardiac cause of chest pain were 83% and 96%, respectively. Overall sensitivity and specificity for all other cardiac and noncardiac causes were 87% and 96%, respectively.

ECG-gated MDCT appears to be logistically feasible and shows promise as a comprehensive method for evaluating cardiac and noncardiac chest pain in stable emergency department patients. Further hardware and software improvements will be necessary for adoption of this paradigm in clinical practice.

Full Article-

AJR 2005; 185:533-540

A great new link for an Atlas on Diffusion Tensor Imaging

Here is a link to an atlas on normal anatomy on Diffusion Tensor Imaging, its very enlightening.

Check out-

Diffusion Tensor Imaging Atlas

Concept of Diffusion Tensor Imaging

As diffusion is truly a three dimensional process, molecular mobility in tissues may be anisotropic, as in brain white matter. With diffusion tensor imaging (DTI), diffusion anisotropy effects can be fully extracted, characterized, and exploited, providing even more exquisite details on tissue microstructure. The most advanced application is certainly that of fiber tracking in the brain, which, in combination with functional MRI, might open a window on the important issue of connectivity. DTI has also been used to demonstrate subtle abnormalities in a variety of diseases (including stroke, multiple sclerosis,dyslexia, and schizophrenia) and is currently becoming part of many routine clinical protocols.

Vesico-ureteric Reflux

Diagnostic imaging of vesicoureteral reflux.

Darge K, Trusen A, Troeger J

The diagnostic imaging modalities for vesicoureteral reflux in children comprise both radiologic and sonographic methods. The radiologic methods are voiding cystourethrography and radionuclide cystography. Voiding cystourethrography is the commonest imaging modality for reflux. With the introduction of pulsed fluoroscopy the radiation exposure of this examination is significantly curtailed. It is the imaging of first choice of the urethra. Various sonographic methods of reflux examination had been tried in the past. The real breakthrough came with the availability of stabilized US contrast media. The diagnostic accuracy of contrast-enhanced voiding urosonography has been found to be comparable to the radiologic methods. With the emergence of harmonic imaging the potential for significant improvement of the sonographic method has been achieved. Voiding urosonography is primarily performed in follow-up studies and as the first reflux examination in girls.

Full Article at-

Rays. 2002 Apr-Jun;27(2):99-106

RADIOLOGY BOOK STORE

On popular demand a new feature has been added to this site an online radiology book store which directly links to Radiology book on Amazon.com

Check out-

Radiology Book Store

Musculoskeletal sonography-especially useful in infants

Musculoskeletal sonography in the neonate and infant.

Babies are ideal subjects for investigation by sonography. They are small and easily examined with the use of high-frequency transducers. Their unique status in US imaging tends to get lost amid the array of other available modalities, such as MRI and CT imaging. Some of the questions posed in pediatric musculoskeletal imaging that are routinely directed to other imaging modalities can be solved quickly at a lower cost by sonography in neonates and infants without sedation or any known clinical risk. These small children not only have thinner soft tissues but they have long bones and midline spine structures whose ends are largely composed of cartilage, which provides an early opportunity to examine these regions by US. And we cannot overestimate the value of new parents being able to stay next to their baby during imaging in a warm, friendly and non-threatening environment.

Full Article at-

Pediatr Radiol. 2005 Aug 3; [Epub ahead of print]

Image Case-Gynecology Ultrasound

A longitudnal US image of a female who presented with urinary incontinence with a previous history of obstructed labor.

What is the diagnosis?

ANSWER- VESICOVAGINAL FISTULA (almost all got it correct)
WINNER-NADEEM

Dear Nadeem drop me a mail at sumerdoc-AT-yahoo-DOT-com with your postal address to claim your prize.

Winner will get a free copy of the book "Review of Radiology" by Dr Sumer K Sethi, a small handbook of Radiology for medical students
COPYRIGHT (SUMER)

IMAGING REFFERAL-A revolutionary concept for the radiologists in India

CONCEPT OF IMAGING REFFERAL

This is something that I have felt in my days as a diagnostic radiologist. Sometimes the physicians order imaging investigations just like they order an ECG or any other minor investigation. I have always believed that what a clinician should do instead of ordering an investigation he should write an imaging referral to a Radiologist who should then guide the patient accordingly. What investigation should be done should not be decided by the referring physician but by the Radiologist. That way the number of repeat X-rays done would reduce dramatically. Also this would enable the Radiologist to look at the patient as a whole not as a radiograph or a CT scan. That the patient is referred for Imaging to Radiologist, with the possible Differential Diagnoses that thereferring clinician wants to be considered, and the Radiologist decides which all imaging modalities and how should they be done.

In last some time Radiology has gradually but surely got to the peak of the medical branches opted by a medical graduate. In times to come if we the current radiologists promote this beautiful subject as an imaging specialty where patients are referred for imaging and you guide the patient to the diagnosis. Anyhow we radiologists are making the majority of diagnosis!!!!

In times to come we can have a “Diagnostic Referral” instead of “Imaging Referral” where cases would be referred to a Radiologist and a Pathologist for diagnosis by the physician.

Any comments and suggestions are welcome....

What is Pseudo-SAH? An interesting article in Neurology..

Pseudo-subarachnoid hemorrhage: a CT-finding in spontaneous intracranial hypotension.

Schievink WI, Maya MM, Tourje J, Moser FG

Increased attenuation in the basilar cisterns or along the tentorium cerebelli resembling subarachnoid hemorrhage (SAH) may be found on CT in the absence of blood (pseudo-SAH). The authors found pseudo-SAH on CT in four of 40 patients with spontaneous intracranial hypotension. All four patients had brain sagging with obliteration of the cisterns and pachymeningeal enhancement along the tentorium cerebelli. Spontaneous intracranial hypotension should be included in the differential diagnosis of pseudo-SAH.

Full article at-

Neurology. 2005 Jul 12;65(1):135-7.

Usefulness of US in Radiologically negative ankle injuries in children-article in Ped Radiol

Sonographic detection of radiographically occult fractures in paediatric ankle injuries.

Simanovsky N, Hiller N, Leibner E, Simanovsky N

In some paediatric ankle injuries, the clinical picture is suggestive of a fracture despite negative three-view radiographs. Objective: To determine the effectiveness of high-resolution US to differentiate radiographically occult fractures from sprains. A total of 20 children were examined. In 13, US did not reveal a fracture; small fractures were detected in 7. All patients with negative US studies had negative follow-up radiographs. In six patients with positive US the follow-up radiographs demonstrated a periosteal reaction. In one child in whom a fracture line identified by US was in the depth of the lateral malleolus, the follow-up radiograph demonstrated an area of increased bone density.

US is effective for the detection of radiographically silent fractures of the paediatric ankle. It may be used as an adjunct to radiography in clinically suspicious, but radiographically negative ankle injuries.

Full Article at-

Pediatr Radiol. 2005 Jul 27; [Epub ahead of print]

Imaging in peripheral arterial disease-an interesting article in Radiology

Imaging Peripheral Arterial Disease: A Randomized Controlled Trial Comparing Contrast-enhanced MR Angiography and Multi–Detector Row CT Angiography

Rody Ouwendijk, MD, MSc, Marianne de Vries, MD, Peter M. T. Pattynama, MD, PhD, Marc R. H. M. van Sambeek, MD, PhD, Michiel W. de Haan, MD, PhD, Theo Stijnen, PhD, Jos M. A. van Engelshoven, MD, PhD and M. G. Myriam Hunink, MD, PhD

PURPOSE: To prospectively evaluate clinical utility, patient outcomes, and costs of contrast material–enhanced magnetic resonance (MR) angiography compared with multi–detector row computed tomographic (CT) angiography for initial imaging in the diagnostic work-up of patients with peripheral arterial disease.

RESULTS: A total of 157 consecutive patients with peripheral arterial disease were prospectively randomized to undergo MR angiography (51 men, 27 women; mean age, 63 years) or CT angiography (50 men, 29 women; mean age, 64 years). For one of the 78 patients in the MR group, no data were available. Mean confidence for MR angiography (7.7) was slightly lower than that for CT angiography (8.0, P = .8). During 6 months of follow-up, 13 patients in the MR group compared with 10 patients in the CT group underwent additional vascular imaging (P = .5). Although not statistically significant, there was a consistent trend of less improvement in the MR group across all patient outcomes. The average cost for diagnostic imaging was 359 ($438) higher in the MR group than in the CT group (95% confidence interval: 209, 511 [$255, $623]; P < .001). Therapeutic costs were higher in the MR group, but the difference was not significant.

CONCLUSION: The results suggest that CT angiography has some advantages over MR angiography in the initial evaluation of peripheral arterial disease.

Full article in-

(Radiology 2005, 10.1148/radiol.2363041140)