Arachnoid cyst with acute subdural hemorrhage

Findings

Large left frontal cystic lesion with thin septations and no enhancement. Unclear whether this lesion is intra-axial or extra-axial. No diffusion restriction (image not shown), no surrounding vasogenic edema. Also present is an acute right subdural hematoma caused by the patient's fall.

Differential diagnosis for the cystic lesion:
- Arachnoid cyst
- Ependymal cyst
- Glial cyst


Diagnosis: Arachnoid cyst. Acute subdural hemorrhage.


Key points

Arachnoid cysts are CSF containing cysts which are intra-arachnoid, and do not communicate with the ventricular system.
50-60% occur within the middle cranial fossa.
May arise as a developmental anomaly, or may be acquired as a complication of adhesions.
Small number are associated with neoplasms.
Walls of cyst are formed by splitting of the arachnoid membrane.
Usually asymptomatic. Can have headache or seizures.
The most effective surgical treatment appears to be excision of the outer cyst membrane and cysto peritoneal shunting.

Radiology Grand Rounds XVII

Here is a case of Pediatric Aneurysm for the Radiology Grand Rounds submitted by Dr MGK Murthy, Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds.

The incidence of congenital aneurysms in the general population is about 1-2%. Clinically, a ruptured aneurysm presents as sudden onset of severe headache. In cases of subarachnoid hemorrhages, the most common aneurysms are posterior communicating, 38%; anterior communicating, 36%; middle cerebral, 21%. These three locations account for 95% of all ruptured aneurysms. The basilar artery accounts for only 2.8% and posterior fossa aneurysms are even less common. Posterior fossa aneurysms are as such uncommon. PICA (Posterior inferior cerebellar artery) aneurysms are extremely rare. In this child we can see that aneurysm producing mass effect and no leak has occurred. The speciality of paediatric aneurysms are increased incidence in posterior fossa and a higher incidence of giant aneurysms (more than 2.5 cm diameter) and there is diversity of type and these are more often located in peripheral location . In this case of a eleven year old boy congenital saccular variety is possible.

Childhood intracranial aneurysms are exceedingly uncommon. Diagnosis of intracranial aneurysms in childhood may be difficult because of their infrequency and confusing clinical presentation. The first report of an aneurysmal SAH in a child was published in 1871 in the German pathology literature, when Eppinger detailed the case of a 15-year-old boy, a gymnast who collapsed while exercising. Postmortem analysis revealed an intracerebral hemorrhage associated with an aneurysm as well as a stenosis of the aorta. The development of contemporary neuroimaging has contributed greatly to the study, understanding, diagnosis, and treatment of pediatric intracerebral aneurysms. The emergence of CT and MR imaging studies obtained with contrast agents has allowed noninvasive, detailed characterization of aneurysms and the structures surrounding them.

Take Home Message-- Aneurysms unequivocally occur in children and cause SAH. Giant aneurysms and lesions in the posterior fossa are relatively more common in children than in adults. The termination of the CA and the ACA are disproportionately common sites of aneurysm formation in the anterior circulation of children. Traumatic and infectious aneurysms occur more frequently in children than in adults, but this may reflect a relative paucity of spontaneous aneurysms in children. Vasospasm occurs in children but appears to be better tolerated. Surgical outcomes in children appear to be moderately better than in adults.

Reference- Medscape ( Registration required). Intracranial Aneurysms

Also, the pioneering experience of Teleradiology Providers for an Indian Village settings has been accepted as a letter to editor in Radiology. Read the full text here-

Teleradiology: A Rural Indian Center's Pioneering Experience

I hope you enjoyed this edition of Radiology Grand Rounds submissions are requested for the next Radiology Grand Rounds posted every month last sunday. If you interested in hosting any of the future issues contact me at sumerdoc-AT-yahoo-DOT-com.

Some Things

There are times that we say things and we don't really mean it. Have you done it? I'm thinking of some things people said which I hope are really true. I mean, some people will tell you bullshit straight away. It may be the truth but they can hurt your feelings by becoming too honest. Well, here are some things which we hope are true, but--on second thought.... are they really true?

1. One Size Fits All (Really?)
2. Can I talk to you for a second? (Who talks with someone for a second?)
3. Oh you look gorgeous!
4. The check is in the mail (Serious?)
5. I'll be back in a minute
6. I promise to keep it a secret between the two of us
7. I love you
8. You're the best thing that's ever happened to me
9. You look younger everyday
10. Oh that's bullshit
11. I'll pay you before the deadline
12. You want? (offering an expensive chocolate)
13. You're great!
14. Wash and wear
15. Good morning
16. I'm sorry
17. I'll take care of you
18. I like your hair
19. You're a real friend!
20. Come on, this will change your life
21. I'm quitting (when?)
22. You're really cute on that dress
23. Come on, this is a chance in a lifetime!
24. Thank you very much, I appreciate it.
25. I can't live without you (I've heard this many times)
26. Let's meet at exact 9 am tomorrow
27. Wow you're a great cook!
28. Nothing matters to me except you...
29. You're mother is a great woman
30. Sure, go ahead and do what you want! (You're in serious trouble if you really did go ahead!)
31. Everything will be just fine
32. I believe you
33. Tomorrow will be better
34. This is outrageous! (looking at porno pictures in the internet)
35. You are the most wonderful person I've ever met (meaning, can you lend me 500 pesos?)
36. Come on, it will go away before you know it (talking about pimples)
37. You are my best friend
38. Very interesting
39. (On a personal ad in the net) Attractive young woman seeking soul mates (how can an attractive young woman be looking for geeks in the internet?)
40. This won't hurt (Dentist tells the patient)
41. I don't like sex

Capillary telangiectasia of the pons

Findings

There is an irregular FLAIR hyperintense focus located along the left anterior aspect of the pons, demonstrating mild lacy contrast enhancement. There is no associated mass effect or restricted diffusion.

Differential diagnosis:
- Developmental venous anomaly
- Cavernous malformation
- Neoplasm
- Inflammation
- Demyelination
- Capillary telangiectasia


Diagnosis: Capillary telangiectasia of the pons


Key points

Capillary telangiectasia
- Represents clusters of dilated capillaries within normal brain
- Usually an incidental finding at imaging
- Represents 15 to 20 percent of brain vascular malformations
- Increased risk for development after brain radiation
- Associated with other vascular malformation, such as cavernous malformation or venous angioma
- Associated with hereditary hemorrhagic telangiectasia

Clinical:
- Usually an incidental finding
- Rarely associated with headache or vertigo
- Found at any age
- No treatment necessary


Imaging

Characteristically found in the pons, but may also be seen in the midbrain, medulla, and elsewhere
Usually small, average 3 cam in diameter
Poorly defined, without mass effect, edema, or restricted diffusion

CT: Usually normal

MRI:
- T1 weighted sequence = usually normal
- T2 weighted sequence = half are normal, half show fine hyperintensity
- Gradient echo = hypointense
- FLAIR = usually normal, but may show foci of hyperintensity
- Diffusion weighted image = usually normal
- Post contrast images = faint lacy or speckled enhancement
- May have associated linear vessels or draining veins if associated with venous angioma

Angiography: Usually occult

Failed back surgery syndrome

Findings

Figure 1: Axial T1 post-contrast weighted image demonstrates a low signal rim-enhancing collection with posterior compression of the thecal sac.
Figure 2: An axial T2 weighted image shows a high-signal epidural collection with posterior compression of the thecal sac.
Figure 3: Sagittal T1 weighted post contrast imaging demonstrates a prior laminectomy with an elongated, peripherally enhancing epidural fluid collection with displacement of the thecal sac anteriorly.
Figure 4: Sagittal T2 weighted image reveals a septated fluid collection with posterior compression of the thecal sac consistent with an epidural abscess.

§









Figure 1: Axial T1 weighted image demonstrates a low signal epidural mass in the right neuroforamen with some mass effect on the thecal sac.
Figure 2: Axial T1 post contrast fat suppressed image demonstrates high signal scar or granulation tissue surrounding a low signal right neuroforaminal mass with mass effect on the thecal sac.
Figure 3: One slice below, an axial T1 post contrast fat suppressed image displays the right nerve root surrounded by high signal scar and/or granulation tissue.
Figure 5 and Figure 7: Pre- and post-contrast sagittal T1 image reveals the low signal right neuroforaminal mass to be continuous with the L5-S1 disk with rim enhancement and compression of the thecal sac consistent with a recurrent disk herniation.
Figure 4 and Figure 6: Axial and sagittal T2 weighted images demonstrate a low-signal herniated disk in the right neuroforamen with compression of the thecal sac.


Diagnosis: Failed back surgery syndrome


Failed back surgery syndrome (FBSS) presents with recurrent or persistent low back pain after lumbar spine surgery. Patients may present with weakness and numbness related to lumbar radiculopathy or generalized low back pain. The etiologies of FBSS are vast and include early or late phenomenon. “Early” phenomena include post-operative hemorrhage; infection leading to diskitis, osteomyelitis, meningitis, or epidural abscess; dural tear with pseudomeningocele; sequestered disk fragment; hardware malposition and surgery at the wrong level. These entities demonstrate typical imaging findings depending upon the cause. “Late” etiologies of FBSS include: foraminal or central stenosis (20-60%), instability (14%), recurrent disk herniation (7-12%), epidural fibrosis (5-25%) and arachnoiditis.

Causes of Failed Back Surgery Syndrome:
- Arachnoiditis
- Central or foraminal stenosis
- Epidural Fibrosis
- Infection
- Hematoma
- Surgical trauma to roots
- Insufficient decompression
- Mechanical instability
- Pseudoarthrosis
- Residual or recurrent disk
- Spondylolisthesis
- Surgery at wrong level


Diagnosis of FBSS is made with contrast enhanced MR imaging of the lumbar spine. Canal stenosis is manifest on MR imaging by a “trefoil” appearance of the spinal canal with a thickened ligamentum flavum. Enhancing nerve roots may be present on contrast enhanced imaging. Vertebral body instability can be diagnosed on flexion and extension views on plain radiographs by demonstrating a “dynamic slip” of greater than 3 millimeters. MR findings of instability include antero- or retrolisthesis or loss of disc height with loss of disc signal on T2 weighted images. Epidural fibrosis appears low in signal on T1 weighted images with slightly higher signal than disc on T2 images with diffuse contrast enhancement. This is in contrast to herniated disc material which demonstrates little or thin peripheral enhancement after contrast administration. Post-operative arachnoiditis appears on MR imaging as peripheral or central clumping of nerve roots with variable enhancement.

Because post-operative scarring does not warrant additional surgery, its differentiation from herniated disk is crucial. This is best demonstrated on contrast-enhanced T1 fat saturated weighted images as disc material will demonstrate no or peripheral enhancement while scar tissue will avidly enhance. Additional differentiating features include traction of the dural tube secondary to fibrosis and compression of nerve roots from disk material. MR is 96-100% accurate in detecting epidural fibrosis versus disc material.

Treatment of FBSS is dependent on the etiology. Therapeutic modalities include physiotherapy, epidural steroids, spinal cord stimulators and when warranted, repeat surgery for treatment of recurrent herniation, foraminal stenosis and instability.

Pilocytic astrocytoma

Findings

Large posterior fossa mass with central cystic portion and peripheral thick rind with enhancement and effacement of the 4th ventricle and cerebellar tonsillar herniation. There is secondary mild ventricular enlargement with transependymal edema.

Differential diagnosis:
- Medulloblastoma
- Pilocytic astrocytoma
- Ependymoma


Diagnosis: Pilocytic astrocytoma, atypical


Key points

Juvenile pilocytic astrocytomas are typically benign tumors that arise in the cerebellum, brainstem, hypothalamic region, or optic tracts. The tumor is classified as a WHO grade 1 benign lesion. Their most common site of origin is the cerebellum. It is the most common tumor to occur in the cerebellum. The medulobllastoma is more common in the posterior fossa but it has 4th ventricle origins rather than the cerebellum itself. The tumor generally is found in patients aged 5-14, but can be seen at any age more rarely. There is no sex predilection. The tumors are associated with neurofibromatosis type 1. Common presentations would include ataxia like in this patient, headache, nausea, vomiting or visual disturbances depending on where it is located. Hydrocephalus secondary to mass effect on the fourth ventricle is responsible for the majority of the presentations.

On imaging the tumors are typically well circumscribed with a large cystic component and a mural nodule. The nodule typically enhances. There can be calcification present but only up to 25% of the time. The tumors have a lot of variability in their appearance; they can be entirely solid with or without cystic degeneration. Vasogenic edema is a very uncommon finding and can be used to differentiate this tumor from others in the differential. They are typically hypo attenuating on CT which is helpful in differentiating from a medulloblastoma which is usually hyper attenuating if not at least iso- to the brain secondary to its closely packed cells.

Prognosis for the lesions is quite good. Surgical resection is the first line therapy if the lesion is accessible. Total resection is often possible in the posterior fossa lesions which can yield a 10-year survival rate is as high as 90%. No adjuvant therapy is utilized in that scenario. Even without total resection the 10-year survival rate is still as high as 45%. Radiation therapy had been employed for incomplete resections, but it remains controversial due to risk of brain radiation. Stereotactic radiation is now more commonly used and has shown some promising results. Chemotherapy is reserved for the rare pilocytic astrocytoma that continues to grow post radiation therapy.

Radiology Outsourcing Discussion Group

Here is a link to newly formed Radiology Outsourcing Discussion forum. Do participate if interested in the topic.

Radiology Outsourcing hosted by sumer.sethi.

Join now

---

Chat about what's on your mind. More about public chats.

Coarctation Of Aorta-Interesting Case Report

Coarctation of the aorta (CoA) is a relatively common defect that accounts for 5-8% of all congenital heart defects. CoA may occur as an isolated defect or in association with various other lesions, most commonly bicuspid aortic valve and ventricular septal defect (VSD). The diagnosis of CoA may be missed unless an index of suspicion is maintained, and diagnosis is often delayed until the patient develops congestive heart failure (CHF), which is common in infants, or hypertension, which is common in older children. Note the narrowed segment on the black blood image and the MIP. In the axial section note the discrepancy between ascending and descending aorta. Also note the scapular & intercostal collaterals. Case by- Dr MGK Murthy & Dr Sumer Sethi of Teleradiology Providers

Spinal Dermoid-MRI

A case of low back acke with right leg pain for 2 months. Radiology- T1 and Fat suppressed T2 weighted images.

Diagnosis-Spinal Dermoid Cyst

There is equal male and female preponderance. The most frequent site of these tumors begin in an extramedullary location; a few may lie in the substance of the cord itself. Complications of the cyst include secondary infection, particularly when associated witha dermal sinus. Rarely these lead to chemical meningitis from the cholesterol-laden keratin released in the subarachnoid space from a ruptured cyst leading to a foreign body type of reaction.

Case By Teleradiology Providers

I Am Now a Multi-Millionaire!

Yes, I am now multi-millionaire!

Well, at least that's what this email told me when I opened my inbox early this morning. Actually I've been receiving several emails of this kind lately--that I won in a Lottery, or that I have been chosen to be the heir to a great fortune of an unclaimed money in banks in Britain, Zaire, and the United States.

I found that if I sum up the amount of money I have won in these lotteries, I am now one of the richest men in the world! I could now rub shoulders with the likes of Sultan Bolkiah, Bill Gates, Oprah, Donald Trump, and even Manny Pacquiao.

What will I do with so much money?..I found that this is one of the big problems being confronted by an instant multi-millionaire.

Well, here's the list of the most important things I will do after collecting my prize money:

First, I'll destroy all the pirated DVDs in my collection, and buy the originals from Astrovision or ACA Video. At last I can now afford the original DVD of Amadeus and Godfather!

Second, I'll buy a cellphone with camera. It's always been my dream to buy a cellphone with camera. I mean, the one with which I can take pictures of myself while holding it in front of my face at arms length....the way I see some students do inside FX taxis. My old reliable Nokia 3210 is still fine, however, so I'd still use it as a back-up. I will also buy 1,000 pesos pasaloads. I'm sick and tired of going to the Sari-sari store and load my cellphone with 30-bucks worth of text messages.

Third, I will upgrade my personal computer. Well, my present Pentium II computer still serves me well, but I can no longer tolerate its 128MB Ram and 10 Gig Hardisk (which slows down my job as Wiki editor). I'll buy a 512 and a 20Gig HD. I will also upgrade to broadband. My dial-up keeps on making funny noises whenever I try to connect.

Fourth, I will throw a party to all the homeless beggars/child vendors in the streets--in Jolibee. It has always been my dream to invite the homeless to a night party, but I guess it would be extremely difficult sending them invitation if they don't have addresses. Anyway, I'll just pick them up from the streets. Each one will have a Value Meal #2 (2-piece Chickenjoy with go-large softdrinks). I will also buy all their for sale stuffs like sampaguita, and trapong bilog.

Fifth, I will buy whole year subscriptions of the following magazines: National Geographic, Discover, Reader's Digest, Wall Street Journal (Hmmm feeling executive!) , Liwayway, Carlo Caparas Komiks, and... (a little shy here)...Playboy and Penthouse...heheh

Sixth, I'll go to Recto and buy my favorite second-hand books--at least I won't make any tawad (bargaining) anymore!

Seventh, I'll stack a good number of Ligo canned-sardines in my kitchen--in case I come home again hungry driving from traffic-congested EDSA.

Eighth, I'll buy a whole cinema--that means having to avoid the long lines of buying movie tickets in Gateway Mall. I will invite all my friends for free viewing each time there is a showing. Each guest will have a free popcorn with butter or cheese of their choice. Additional salt is also free of charge.

Ninth, I'll buy (finally!)--Encyclopedia Britannica. I think this will be the realization of my childhood dream. I have often envied families with complete sets of the Britannica. People say that bookform encyclopedias are no longer necessary due to the arrival of internet encyclopedias. But they just don't know the value of the book form encyclopedias...How can you display in the bookshelf the Wikipedia?

Tenth, I'll travel the Philippines from North to South even as far as Bicutan, or even as remote as Navotas and Novaliches.

Okay, okay, forgive my should buy wish lists, but you have to understand that I didn't have practice being a multi-millionaire....

Quote of the Month--Where do we stand in Medicine now?

2000 B.C. - Here, eat this root.
1000 A.D. - That root is heathen. Here, say this prayer.
1850 A.D. - That prayer is superstition. Here, drink this potion.
1940 A.D. - That potion is snake oil. Here, swallow this pill.
1985 A.D. - That pill is ineffective. Here, take this antibiotic.
2000 A.D. - That antibiotic is unhealthy. Here, eat this root.

Read this somewhere i don't remember but surely makes a lot of sense.

Frontoethmoid encephalocele

Findings

Figure 1: Sagittal MR image demonstrates frontal lobe tissue protruding through a defect in the anterior calvarium. A portion of the umbilical cord is seen wrapping around the fetus’s neck.
Figure 2: Axial MR image demonstrates a soft tissue mass protruding between the orbits, with hypertelorism and bilateral hydrocephalus.


Diagnosis: Frontoethmoid encephalocele


A frontoethmoid encephalocele is herniation of intracranial contents through a defect of the skull in the nasofrontal region (1). These are usually detected first on prenatal screening or diagnostic US performed for further evaluation of prenatal screening lab abnormalities, usually elevated maternal serum alpha-fetoprotein levels (2). Sonographic clues include hypertelorism and a facial mass. The best diagnostic clue is visualizing brain parenchyma herniating through an anterior skull defect. Prenatal MR can be used to better delineate the anatomy in a suspected encephalocele, and can better determine size, location, and communication with intracranial structures (1).

Small encephaloceles can be missed on prenatal ultrasound. Other imaging clues include hypertelorism and other associated anomalies which include dysgenesis or absence of the corpus callosum, heterotopia, microcephaly, hydrocephalus, microophthalmos, beaked tectal plate, flattened basiocciput and an interhemispheric lipoma (2). In the postnatal period, they can present as a skin-covered facial or nasal mass (3).

The pathogenesis of an encephalocele is a late neurulation defect during the fourth gestational week. There is a disturbance of separation of the surface ectoderm and neuroectoderm in the midline just following neural fold closure (3). As a result there is failure of the fonticulus frontalis to close with herniation of intracranial parenchyma through persistent embryologic relationships. For unclear reasons, occipital lesions are most common (80%) in North America and Europe (1:35,000 live births) and frontoethmoidal lesions are more common in Southeast Asia (1:5000 lives births) (3).

Prognosis depends on the presence of other associated congenital or developmental brain anomalies. Prognosis is often better with frontoethmoidal lesions than occipital or parietal lesions. An overall mortality of 7-20% has been seen, with a favorable developmental outcome (3). Treatment to prevent infection and further herniation of intracranial contents involves excision of the dysplastic brain tissue with watertight closure of the dura and reconstruction of the skull defect (3). Most of the time, the glial tissue can be resected without causing additional neurological deficits. The exception is in the case of transphenoidal encephaloceles which can contain pituitary gland, hypothalamus or part of the Circle of Willis (3). Hydrocephalus should be treated first (3).

Chiari 2 malformation

Findings

There is enlargement of the lateral ventricles and third ventricle. The fetal Posterior fossa appears small with downward displacement of the cerebellar tonsils. There is discontinuity of the posterior elements beginning at the thoracolumbar junction with myelomeningocele at this level.


Diagnosis: Chiari 2 malformation


Key points

Complex deformity of the calvarium, dura, and hindbrain
Almost always associated with a myelomeningocele
Lacunar skull
Concave clivus and petrous ridge
Small posterior fossa
Fenestrated falx
Cerebellar peg
Medullary kink
Towering cerebellum
The cerebellopontine cistern and the cisterna magna are obliterated
Beaked tectum
Hydrocephalus
Prominent mass intermedia

News

We go on a vacation for two weeks to the other side of the country, and when we come back, nobody bothers to tell me that one of the most notable news broadcasters in the country had passed away?


By the way, for all of you who happen to read this blog.... This is Hal Fishman, head anchor of the "Channel 5 News at 10" from 1975-2007.

Dedication

Did you guys hear about the recent American Idol auditions? A woman trying out for American Idol, wouldn't leave the line until she got her chance in front of the judges, despite the fact that she was in labor. According to the news reports, she was actually experiencing contractions while performing for the judges. After she found out that she is going to go to Hollywood to further her chance to become the next American Idol, she finally agreed to get in an ambulance and go to the hospital to deliver little Jamil Labarron Idol McCowan. That's going to be good television.

Funny Names

Ok, so there's a gynecologist in Fairfax, Virginia named Harry Beaver.....

Now I come to find out that there's a professor at the University of Albany named Sho-Ya Wang.....

Look it up if you don't believe me!

Also, screw the Red Sox winning the World Series....This play was sports event of the year. With two seconds left in the game, Trinity laterals the ball fifteen times to make it downfield for the winning touchdown.

Carbon monoxide poisoning

Findings

There are fairly symmetric foci of T2 hyper intensity and restricted diffusion in the globus pallidus bilaterally.

Differential Diagnosis:
- Anoxic injury (carbon monoxide)
- Small vessel ischemic disease
- Wilson disease
- Creutzfeldt-Jakob disease
- Leigh's disease


Diagnosis: Anoxic brain injury - Carbon monoxide poisoning


Key points

Changes are typically seen in globus pallidus, but can occur in cerebral white matter (second most common), putamen, caudate, thalamus.

Imaging:
- Hypodense on CT
- T1W can be normal, hypo- or hyperintense (edema or hemorrhage)
- T2W hyperintense
- Diffusion WI restricted diffusion.

Pathologically one sees necrosis in globus pallidus with demyelination of periventricular white matter.
Presents with nonspecific symptoms of variable severity: Nausea / vomiting, headache, confusion, cognitive impairment, seizures, coma, death.
Clinically may have persistent sequelae or resolution of symptoms depending on severity and duration of exposure.
Most common cause of U.S. accidental poisoning
Can confirm diagnosis with carboxyhemoglobin level
Treatment: Hyperbaric O2 for acute cases

Locations of Misidentified Intracranial Hemorrhage

"In an article by W.M. Strub et al in American Journal of Neuroradiology 28:1679-1682 did an interesting review on the patterns of error of radiology residents in the detection of intracranial hemorrhage on head CT examinations while on call. Radiology residents prospectively interpreted 22,590 head CT examinations out of which there were a total of 1037 discrepancies identified, of which 141 were due to intracranial hemorrhage. The most common types of intracranial hemorrhage that were missed were subdural and subarachnoid hemorrhage. The most common location for missed subdural hemorrhage was either parafalcine or frontal. The most common location of missed subarachnoid hemorrhage was in the interpeduncular cistern. "

Tuberculosis of Shoulder-MRI

Here is case of Tubercular involvement of Shoulder by Teleradiology Providers

An Early Morning Walk in Calbayog, Samar

How early do you regularly wake up in the morning? According to studies, if you are the average person, it is most likely that you wake up between 6 and 8 in the morning.

I guess I'm not an average person because I wake up at 4 in the morning, and sometimes as early as 3am. That is not to mention that I sleep at 1 in the morning. I have not been an sleepy person, I may be insomniac, possibly brought about by my passion for coffee.

Even in vacation, I always sleep late and wake up early. Those of you who have read my previous entries know how one time I spent a lonely walk along Cubao at 12 in the midnight, photographing and sightseeing.

Anyway, in Calbayog City, Samar, last week, I woke up at 2 in the morning (having slept at 1 am), put on my sneakers, hung my Nikon D40x in my shoulders, and started on a walking tour of the rural city at 3 am. Rural city? Well, I think Calbayog qualifies to be a rural city.

In Calbayog, the fog is visible in the morning, and mists dampen my camera. It was a dark early morning, the sun had not yet risen, and the soft breeze of cool wind remind me that I'm in the middle of one of the most rural places in the Philippines.

In moments like this, a nostalgic feeling of a time that has not yet come encourages me to take photos for future remembrances. Nostalgia in the future? Yes, because I know I will remember the good old days, and my photographs will help bring back the memories.

And so, here are the pictures of my One Day in the Life of Calbayog. I know I will return to these pictures, in some future nostalgic times.

At 3 am. A lonely street in Calbayog City. It seemed that a lone
Manileno can invade the whole town in one sweep!

An hour later, people started to wake up, and some are ready to get
on their usual business. Like this trike driver, up and working at 4am.

The lovely full moon over a village in Calbayog, 5am.

The clouds above Calbayog are lovely in the early morning.
Shot from the beach in Payahan village.

Calbayog Port before at dawn. The bancas are beginning
to arrive bringing fresh seafoods harvested from the sea.

The sun is rising, and so are many Calbayognons.

Calbayog market at early morning offers plentiful
supply of fresh vegetables, meat, and seafoods.

Traffic is non-existent in Calbayog, even at the beginning of rush hour. Most people do not own an automobile. Some are contented with bikes or motorcycles, or just riding in the local pedicabs. Many prefer to just walk, which is of course the best form of excercise. No wonder there are many centenarians in Calbayog.
(My lolo-for instance- is 90 years old. A viudo, he recently re-married to a 21 year old village girl. He is not guwapo, but he owns a carabao, and that's something in a Calbayog village).


Calbayog trikes are the Kings of the Calbayog streets. The drivers are some of the most honest people I've encountered. Some would be contented with 5 pesos for a drive anywhere in the city. These are people with attitude, unlike the brusque Jeepney and bus drivers in Manila.

The local taxis, called motor. The kindly drivers are
still waiting for their first passengers.

The Cathedral of Sts. Peter and Paul, Calbayog City, Samar

Handumanan, the Calbayog's prison. It has been closed due
to absence of criminals. It is now being converted into a museum.

A village Sari-sari store. A trike driver stops for a while
to sip a 5-peso coffee and eat 3-peso suman.

As the day progresses, more and more people are beginning to crowd the city.

A street scenery at 8am.

A View from Calbayog Inn Hotel.

Early mornings in Calbayog port, people are buying wholesale
seafoods by the banyera or timba for later redistribution in the market.

Sidewalk vendors in the Calbayog market. I think they were selling labong. The old lady in the middle didn't want to get photographed because she feared someone might discover her in the movies. And she didn't have plans to become a movie star.

Here's the place to buy sese (a salty condiment made of talaba and tahong), bagoong (fish paste), and all your condiment needs.

Okay, okay, I think that I will have to eat my breakfast now, see you then :)