Stardust

Go rent the movie "Stardust"! Fantastic story. That's all.... Back to work....

Rhombencephalosynapsis

Findings

Figure 1: Sagittal T1-weighted image demonstrates enlarged lateral ventricles with upward bowing and thinning of the corpus callosum, compatible with hydrocephalus. Slight rounding of the fastigial recess of the fourth ventricle is also identified, as well as absence of the cerebellar vermis. Included upper cervical spine shows congenital fusion of the C3 and C4 vertebral bodies.
Figure 2 and Figure 3: Coronal T2-weighted images demonstrate fusion of the cerebellar hemispheres, horizontal appearance of the cerebellar folia with gray and white matter crossing the midline. There is no intervening vermis.
Figure 4: Axial gadolinium-enhanced T1-weighted image demonstrates “keyhole” shaped fourth ventricle and absent cerebellar vallecula.
Figure 5: Axial FLAIR image demonstrates fused, horseshoe-shaped cerebellar dentate nuclei.
Figure 6: High resolution T2-weighted sagittal cisternogram is highly suggestive of aqueductal stenosis.
Figure 7: Coronal T2-weighted image shows dilated frontal horns of the lateral ventricles, which are normally separated by the septum pellucidum. Normal massa intermedia without evidence of fused thalami.


Diagnosis: Rhombencephalosynapsis


Rhombencephalosynapsis, originally described by Obersteiner in 1914, is a rare congenital malformation of the posterior fossa featuring fusion of the cerebellar hemispheres (partial or total), agenesis or severe hypogenesis of the cerebellar vermis and apposition or fusion of the dentate nuclei. Failure of dorsal induction/differentiation of the normal midline structures with disturbed cerebellar development is thought to occur following an insult between the 28th and 44th days of gestation, and may be genetic or acquired. The likely genetic defect involves the isthmic organizer, with FGF8 and LMX1A genes being considered; there have been anecdotal reports of interstitial deletion of chromosome 2q and parental consanguinity. Among predisposing maternal factors, hyperpyrexia, diabetes, and phencyclidine and alcohol use have been incriminated.

The most distinctive pathologic feature is midline fusion of the cerebellar hemispheres with folia and fissures transversely oriented (single-lobed cerebellum). There is associated agenesis or poor differentiation of the vermis, the rostral portion being the most severely affected, while the caudal vermis is better formed, usually with a well-developed flocculonodulus. The posterior fossa is smaller than normal. Superior and middle cerebellar peduncles may be fused, as well as the dentate nuclei and the inferior colliculi, sometimes leading to a characteristic diamond or “keyhole” shaped fourth ventricle (narrow, pointing posteriorly). Olivary nuclei may be hypoplastic or absent. Once the diagnosis is established, a prompt search for other supratentorial and infratentorial findings should be performed.

Hydrocephalus is the most frequently associated supratentorial anomaly and may be related to aqueductal stenosis. Other common supratentorial findings include fused thalami, fornices and cerebral peduncles, absence of the septum pellucidum, dysgenesis of the limbic system, cortical malformations and multiple suture synostoses. Associations with septo-optic dysplasia and holoprosencephaly have been suggested. Hypoplasia of the commissural system and the anterior visual pathway and agenesis of the posterior lobe of the pituitary can occasionally be seen.

Rhombencephalosynapsis can be part of the Gomez-Lopez-Hernandez syndrome (cerebellotrigeminal dermal dysplasia), which is also characterized by trigeminal anesthesia, midface hypoplasia and bilateral bands of alopecia.

Segmentation and fusion anomalies of the spine, as well as other musculoskeletal, cardiovascular, urinary tract, and respiratory abnormalities have been described in several patients.

Clinical presentation correlates with the severity of associated supratentorial anomalies, varying from mild truncal ataxia and normal intelligence to cerebral palsy. Patients may manifest hypotonia, motor and cerebellar dysfunction, seizures, strabismus and developmental delays. Compulsive self-injurious behavior is common. Variable growth hormone deficiency depends on midline supratentorial anomalies. Most reported cases are pediatric; patients usually have a short lifespan, although incidental rhombencephalosynapsis in adults has also been described. Management includes treatment of related hydrocephalus and monitoring the hypothalamic-pituitary axis.

Because of multi-planar capabilities, MR is the imaging modality of choice demonstrating transversely oriented cerebellar folia, which cross the midline without an intervening vermis, and associated “keyhole” shaped fourth ventricle, which lacks the normal cerebellar vallecula. On sagittal images, the primary fissure of the vermis is absent and the fastigial recess of the fourth ventricle may appear upwardly rounded. Fusion of the cerebellar dentate nuclei appears as horseshoe-shaped decreased signal along the posterolateral aspect of the fourth ventricle on axial T2-weighted images. On CT, the cerebellar anomaly may be difficult to detect, but may be suggested by the characteristic configuration of the fourth ventricle.

NKOTB!!!!!!!

Just to let you guys know, you can sign up for e-mail and text message alerts for news regarding the upcoming tour from the New Kids On The Block!!!!!! Just go to www.NKOTB.com!!!!! Who's going to come with me to the concert?

Diffusion Tensor Imaging in Obsessive-Compulsive Disorder

Yukiko Saito et al in Radiology 2008;246:536-542 have examined the examine microstructural white matter abnormalities in the corpus callosum (CC) of patients with obsessive-compulsive disorder (OCD). A significant reduction in FA was observed in the rostrum of the CC in patients with OCD compared with the rostral FA in the control subjects. (FA-Fractional anisotropy). Study results support the widely held view that the orbital prefrontal region is involved in the pathophysiology of OCD and indicate that the orbitofrontal circuit influences symptom severity in patients with OCD.

Radiology Grand Rounds XX

Here is a case of Tendoachilles Tear for the Radiology Grand Rounds submitted by Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds.

In Greek mythology, Achilles was a Greek hero of the Trojan War, the central character and greatest warrior of Homer's Iliad which takes for its theme the Wrath of Achilles.Later legends state that Achilles was invulnerable on all of his body except for his heel. These legends state that Achilles was killed in battle by an arrow to the heel, and so an "Achilles' heel" or Achilles' tendon has come to mean a person's principal weakness.

Axial and saggital MRI of the ankle show an abnormal contour and altered signal intensity involving the tendoachilles, On the T2 and fat suppressed image is an area of high signal in the tendon suggesting tear. Clinical signs for complete tear are Thomson's test and inability to tiptoe.

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.

Images Courtesy
Teleradiology Providers

Ivory vertebral body from prostate cancer metastasis

Findings

Figure 1: Lateral Rx of the neck shows dense C5 vertebral body (ivory vertebral body)

Differential diagnosis for ivory vertebral body:
- Metastases
- Lymphoma
- Paget disease
- Less common: Infection (low grade i.e. TB) or Idiopathic segmental sclerosis


Ivory vertebral body from prostate cancer metastasis



Ivory vertebral body refers to an increase in density of a vertebral body that retains its size and contours, with no change in the density and size of adjacent intervertebral disks. The added density may be diffuse and homogeneous and involve most or all of the vertebral body, giving it a white appearance as opposed to the normal or possibly osteoporotic appearance of the rest of the vertebral column

Ivory vertebral body may be caused by numerous etiologies as listed above. Osteoblastic metastases elicit a sclerotic response in which vertebral body spongiosa is replaced with a dense, amorphous bony mass. In similar fashion, lymphomatous spread may cause an osteoblastic response leading to the dense changes. On the other hand, Paget disease usually causes an expansion of the contour of the vertebral body, which sometimes takes it outside of the definition of ivory vertebral body. You may also see reactive bone formation that occurs in response to stress leading to the appearance of an ivory vertebral body. This process is called idiopathic segmental sclerosis.

In children, the finding of ivory vertebra is rare. However, when found it is usually secondary to lymphoma, most frequently Hodgkin disease. Other less frequent causes include osteosarcoma, metastatic neuroblastoma, medulloblastoma or osteoblastoma. There have been rare cases of Ewing sarcoma causing dense vertebral bodies.

In adults, by far the most common cause is osteoblastic metastases from breast or prostate cancer. Other causes include osteosarcoma, carcinoid, Paget disease, and lymphoma. A radiopaque vertebral body is most compatible with a diagnosis of metastatic disease, and in the case of an elderly male would most likely be a result of prostate carcinoma. In a female patient, the most likely diagnosis would be breast carcinoma. Metastatic disease from breast carcinoma will not infrequently present as a solitary vertebral lesion.

Paget disease can present with a uniform appearance, however more often presents with a classic “picture frame” vertebral body where the contour of the vertebra is sclerotic with a relatively lucent center. The trabecular bone is also usually thickened leading to an expansion in the anterior-posterior and lateral dimensions.

Lymphoma can sometimes lead to sclerotic lesions in the vertebra including ivory vertebral body. It usually begins in a patchy fashion and leads to a more generalized pattern and sometimes even to an ivory vertebra pattern. Often you may also see the accompanying, invading soft tissue mass.

Osteomyelitis may also lead to sclerotic changes, however it is rarely found within only a single vertebral body. There are usually erosive changes found at the disk margins.

In general, the three causes that should be considered in the differential for ivory vertebral body are: metastatic cancer, Paget disease and lymphoma.

Subarachnoid hemorrhage secondary to basilar tip aneurysm rupture

Findings

Head CT without contrast shows diffuse subarachnoid hemorrhage, most prominent around the basilar tip but also involving the right Sylvian fissure the anterior interhemispheric fissure. There is also intraventricular blood. CT Head angiography with 3D reconstruction shows a large bilobed aneurysm of the basilar tip. The aneurysm neck extends into the left P1 segment. The left superior cerebellar artery arises from the P1 segment, and therefore the aneurysm incorporates both the left superior cerebellar artery and P1 segment.

Differential diagnosis - Causes of subarachnoid hemorrhage (SAH):
- Aneurysm
- Trauma
- AVM
- Coagulopathy


Diagnosis: Subarachnoid hemorrhage secondary to basilar tip aneurysm rupture


Discussion

Intracranial aneurysms are classified into three categories:
- saccularù
- fusiform
- dissecting aneurysms.

Saccular aneurysms (i.e. berry aneurysms) are true aneurysms that occur at intracranial bifurcation points, most commonly within the circle of Willis. Although previously thought to be congenital in origin, recent studies suggest that most intracranial aneurysms develop as a result of hemodynamic-induced vascular injury.

The incidence of intracranial aneurysms is estimated to be near 1-6% of the population. These percentages increase in patients with congenital anomalies of the intracranial vasculature (fenestrations, persistent trigeminal arteries), vasculopathies (fibromuscular dysplasia), connective tissue disorders (Marfan, Ehlers-Danlos), polycystic kidney disease, coarctation of the aorta, or vascular malformations. Factors associated with increased risk of aneurysm rupture include cigarette smoking, female gender, and younger age at diagnosis.

The risk of aneurysm hemorrhage remains unknown. For many years, a bleeding risk of 1-2% per year was quoted in the literature, and this number remains reported in current investigations. However, a recent study (The International Study of Unruptured Intracranial Aneurysms) found that the risk of aneurysm hemorrhage was quite variable and dependent upon key factors: size, location, and history of prior aneurysm rupture. For example, anterior circulation aneurysms measuring less than 7 mm in a patient without a history of aneurysm hemorrhage had less than 0.05% risk of bleed per year. Unfortunately, basilar tip aneurysms larger than 10 mm and aneurysms in patients with a prior history of an aneurysm bleed were associated with a much higher risk of rupture of 0.5% per year.

Proper management of a ruptured aneurysm is critical since the risk of aneurysm rebleeding after the initial hemorrhage is very high. There is a 20-50% risk of aneurysm rebleeding during the first two weeks after the initial event. Rebleeding carries a high mortality rate of almost 85%. Patients with unruptured aneurysms and clinical symptoms such as new onset 3rd nerve palsy or visual loss should also be treated emergently since the risk of aneurysm hemorrhage in these individuals is significantly higher than incidentally discovered aneurysms in asymptomatic patients.


Radiologic overview of the diagnosis

When non-contrast head CT demonstrates subarachnoid hemorrhage in the suprasellar cistern, Sylvian fissures, and anterior interhemispheric fissure, an aneurysmal etiology should be highly suspected. Three primary modalities are utilized to image intracranial aneurysms - CTA, MRA, and catheter angiography. CTA and MRA are the modalities of choice for imaging of unruptured aneurysms. Traditionally, catheter angiography has been preferred for imaging of patients presenting with non-traumatic subarachnoid hemorrhage. However, CTA alone is gaining in popularity for these cases.

Catheter angiography: Conventional cerebral angiography has always been considered the gold standard for intracranial aneurysm imaging. It remains invaluable for identification of the aneurysm(s), presence and size of the aneurysm neck, clarification of the aneurysm's relationship to the parent vessel, evaluation of the collateral circulation, assessment for vasospasm, and determination of best treatment modality. As conventional angiography is invasive and time-consuming, it does have some disadvantages.

CTA with 3-D reconstruction: Recent studies suggest that CTA is a quick, reliable, and relatively simple diagnostic modality for imaging of intracranial aneurysms. Some reports indicate that the sensitivity of CTA for detection of aneurysms < 5mm is higher than catheter angiography. Advantages include inter-operator reliability and non-invasiveness.

MRA: MRA is typically used in combination with conventional MRI and used to screen patients with risk factors for intracranial aneurysm. MRA currently has a low sensitivity for aneurysms less than 4 mm in size.

Acute calcific tendonitis of the longus colli muscle

Findings

Figure 1: Scout image from CT scan of the head demonstrates prevertebral soft tissue swelling and loss of physiologic cervical lordosis. This finding prompted further evaluation with contrast-enhanced CT scan of the neck.
Figure 2, Figure 3, and Figure 4: Axial (Figure 2 and Figure 3) and reformatted sagittal (Figure 4) contrast-enhanced CT images of the neck demonstrate enlarged right longus colli muscle, focal amorphous calcification within it (Figure 2 and Figure 4), as well as smooth, nonenhancing prevertebral and retropharyngeal effusion (Figure 3 and Figure 4).
Figure 5 and Figure 6: Axial (Figure 5) and reformatted sagittal (Figure 6) contrast-enhanced CT images of the neck with bone settings show focal, off-midline amorphous calcification anterior to C1/C2 level, within the superior tendon of the right longus colli muscle. There is also mild reversal of the physiologic cervical lordosis.

Differential Diagnosis:
- Retropharyngeal space abscess
- Retropharyngeal edema of different etiology (internal jugular vein thrombosis, previous surgery or radiation therapy)
- Accessory ossicle inferior to the anterior arch of C1
- Infectious spondylodiscitis


Diagnosis: Acute calcific tendonitis of the longus colli muscle


Acute calcific tendonitis of the longus colli muscle, also known as acute calcific retropharyngeal (or prevertebral) tendonitis, is a clinical syndrome (originally described by Hartley in 1964) that usually affects adults in the 3rd through 6th decades of life. The presumed mechanism of disease is calcium hydroxyapatite crystal deposition within the superior oblique fibers of the longus colli muscle. Acute symptoms develop when these contained deposits rupture, triggering an acute inflammatory process that usually lasts 2 to 3 weeks. The typical clinical presentation is acute to subacute onset of neck pain, dysphagia, or odynophagia; patients may also have low-grade fever and paraspinal muscle spasm, as well as recent history of upper respiratory infection or minor trauma to the head or neck. Mild leukocytosis, elevation of C-reactive protein and erythrocyte sedimentation rate are occasionally present.

The pathognomonic radiographic findings consist of calcific prevertebral (or retropharyngeal) density on the lateral radiograph of the neck, typically at C1/C2 level (inferior to anterior arch of C1), with associated soft tissue thickening. CT is more sensitive than plain radiography for detection of characteristic amorphous calcification, which is usually off-midline and clearly separate from the vertebral body; its appearance varies from punctate to dense, prominent concretions. Retropharyngeal space edema and specific smooth retropharyngeal effusions usually extend from C1 to the C5 level. MR imaging is not typically necessary for the diagnosis, but may be useful in confirming and further defining the abnormality. T2-weighted images demonstrate hyperintense retropharyngeal space fluid with an acute inferior margin. Diffuse swelling of the longus colli muscle and associated C1/C2 bone marrow edema have also been reported. After administration of intravenous contrast, there may be diffuse prevertebral soft tissue and/or longus colli muscle enhancement. Hypointense calcifications can be detected inferior to the anterior arch of C1 within the superior longus colli tendon, however these are easy to miss on MR.

The most important differential diagnosis is a retropharyngeal space abscess, which would require aggressive antibiotic therapy and possible surgical drainage. Distinction from abscess is easy if four key observations are made: 1) the fluid smoothly expands the retropharyngeal space in all directions; 2) there is absence of an enhancing wall around this fluid, as would be seen in a true retropharyngeal abscess; 3) there is absence of associated suppurative (or presuppurative) retropharyngeal space lymph nodes with low-density centers; 4) there are pathognomonic tendinous calcifications within the longus colli.

Most cases are self-limiting and resolve within several weeks of the onset of symptoms. The calcifications may disappear when the soft tissue swelling recedes. Treatment is usually conservative and consists of analgesics and a short trial of NSAIDs. If symptoms are severe, the patients may require a short course of corticosteroids. Early diagnosis is important to avoid invasive diagnostic and therapeutic procedures. Follow-up imaging is not necessary due to the self-limiting nature of this condition.

Google to get medical imaging information fast

"According to Diagnostic Imaging By Fishman at 2007 RSNA meeting. Radiologists seeking a specific piece of medical information online should consider initiating searches with Google, which provides a list of medical resources likely to contain the information needed. Number of links needed to get to the answer in google was found to be 1.5, yahoo-1.9, and pubmed-4.25."

A Tribute to the Filipina

The Filipina by Fernando Amorsolo

According to Dr. Jose Rizal, one of the greatest treasures of the Philippines is its women. Throughout his life, our national hero paid tribute to the Filipina woman, starting with his deep devotion to his mother, to his respect and love to his seven sisters, and to his loyalty to Leonor Rivera. One of Rizal's greatest writings, A Letter to the Young Women of Malolos, contained some of the most moving tributes to the qualities of Filipina women.

Like Rizal, I would also like to pay tribute to the Filipina. As a blogger, I would like to contribute in my own small way to the wholesome image of the Filipina in the internet. I am quite saddened by the fact that giant Google is very unfair when producing search results about the Filipina woman. When you search "Filipina" in Google images, most of the results contain links to adult, dating, and porno websites. But then again, Google only aggregates results that are very popular with website browsers and bloggers (those hunting for Filipina girls or blogging about sex and the Filipina woman).

Fortunately though, the bad image of the Filipina in the internet is rapidly changing. Two prominent Filipina bloggers, Dine Racoma and Noemi Dado established a website called Filipinaimages.com, with the mission of reshaping the image of the Filipina online. Yesterday, when I searched Google for the word Filipina, Dine and Noemi's website topped the search results, indicating the popularity of their site. The creation of their website alone is a giant step forward into the new image of the Filipina in the web. I salute Dine and Noemi for their great efforts.

To give my own humble contribution to Dine Racoma and Noemi Dado's efforts, I will also contribute in my own humble way to re-shape the image of the Filipina online. As a start, I will feature photos of Filipina women so that Google can also include them in their "Filipina" image database.

Since blogs have tremendous power in the internet, I think that by regularly featuring wholesome photos of Filipinas in blogs, blogs can force Google to relegate the adult-oriented photos into the low-end results (as what Dine and Noemi had done for the "Filipina" name) and give priority to the wholesome images. I challenge all Filipino bloggers to support Dine and Noemi's campaign to reshape the image of the Filipina online.

The few photos below are my first contributions to Google"Filipina" image database. I will tirelessly continue to contribute more in the future- by writing essays, featuring heroic Filipina women, or contributing my own photos of Filipina women. I have a very high regard to the Filipina woman.

The first two photographs below are from our old family album. The next photos I shot myself, with full permission from my models to publish in this blog :)

Radiology Updates

Radiology Blogosphere sees yet another radiology Blog this time by Dr V David, MSK radiologist who has started a MSK MRI blog

Workshop in interventional oncology with in Tata Memorial Hospital, Details here-

6th Conference on Evidence based Management of Cancers in India

Radiology Search a peer reviewed and user tailored radiology search engine specifically for radiology related contents is now available on my blog.

Your faithfully Dr Sumer Sethi is now Radiology Expert on Medhelp. Check out My Medhelp Profile and Diagnostic Radiology Forum for the patients around the world.

Bobby Fischer: In Memoriam (1943-2008)

Robert James Fischer

My personal Chess hero--the man who inspired me to become a Chess player--Bobby Fischer, is dead.

He died January 19, 2008 of Kidney failure in Reykajavik Iceland. He was 64.

I like him a lot. I learned great Chess from reading his books, especially the pocket Bobby Fischer Teaches Chess, and My 60 Memorable Games.

Some years ago, I heard he was living in Baguio City . I decided to search for him in Baguio, to maybe get his autograph, or perhaps an interview. Best would be to have a picture taken with him. But I got nothing.

I discovered he was living near the vacation house of his friend, Filipino grandmaster Eugene Torre. But Bobby would not let anyone visit him on anytime of the day. He was living like a hermit. But I had a chance to see a glimpse of him. Although I did not realized it was him.

His picture always embedded on my mind is the thin debonnair well-dressed young man who dominated the world of Chess in the late 1960s and the early 1970s.

When I finally caught a fleeting glimpse of him in Baguio, I realized how much he had changed. He was balding, bearded, and snob. He was a complete opposite of what had been pictured in my mind.

Yet, I still admire him. After all, he was the one who made Chess hip and sexy (indeed, Fischer revolutionized Chess into a popular sport). And he was the one responsible why I dream of Chess a lot. Why I spend half of my waking life playing chess wether it be under the Cubao overpass, or in one of the online Chess games in the internet.

For me Bobby was the ideal World Champion, an intellectual athlete. He was, indeed, far from the stone-faced Boris Spassky, whom he demolished in the 1972 Reykjavik World Chess Championship.

In 1975, a rising young Chess Soviet superstar named Anatoly Karpov won in the candidates finals to earn a title match against reigning champion Fischer.

But Fisher, hounded by personal demons and petty demands, refused to defend his title. Karpov was declared winner by default.

From then on, Bobby would isolate himself from the world that adored him. Indeed, he began to hate the world that loved him. Friends who still saw him noticed how far removed he had been from the Bobby they knew.


Maybe Bobby's genius is something that we ordinary mortals could not understand. Or maybe an extraordinary genius of his magnitude could never understand his ordinary world.

One thing is sure, though. Bobby Fischer will forever be one of the world's greatest Chess Champions.

So long Bobby, have a nice jouney!

Molar extraction complicated by a masticator space infection and subdural empyema

Findings

Figure 1: Axial CT image with bone algorithm at the level of C2. There is a lucency in the socket of the extracted molar. The irregular hyperdensity within the socket represents surgical packing that was inserted, and left in place post-dental extraction.
Figure 2: Contrast enhanced axial CT image with soft tissue algorithm at the level of the occiput and C1. Irregular hypodense collections with faint rim enhancing walls are seen within the muscle bellies of the lateral pterygoid and the masseter. There is extensive pre-zygomatic subcutaneous soft tissue fat stranding suggesting an overlying cellulitis.
Figure 3: Contrast enhanced axial CT with brain algorithm at the level of the middle cerebral arteries. There is a subtle hypodense collection with leptomeningeal enhancement lateral to the anterior pole of the temporal lobe. We again note subcutaneous fat stranding and edema within the left temporalis muscle, and overlying the left aspect of the frontal and temporal bones.
Figure 4: Axial CT with bone algorithm at the level of the abnormality. This image confirms that the collection crosses the left coronal suture, therefore confirming that it is located within the subdural space.


Diagnosis: Molar extraction complicated by a masticator space infection and subdural empyema


A subdural empyema (SDE) is an intracranial collection containing purulent material located between the dura mater and the arachnoid mater. Intracranial subdural empyemas account for up to 22% of all intracranial pyogenic processes. The majority of subdural empyemas occur as a complication of paranasal sinusitis, otitis media, or mastoiditis, and uncommonly as a result of a masticator space infection. In the largest published series of 699 cases of SDE, dental infection was the fifth most common cause accounting for 0.7% of cases.

Fever, seizures and motor deficits are some of the commonly encountered clinical features of SDE. A subdural empyema is a life threatening illness with a mortality rate ranging from 6-35 %.

Intracranial extension of infection from the head and neck can occur by two primary means. Direct extension by erosion through the skull occurs with sinusitis or mastoiditis. Indirect spread, which is a more common route, occurs by retrograde thrombophlebitis via the valveless veins of the basal venous system which connect the intracranial and extracranial spaces. Masticator space infections resulting from osteomyelitis of the mandible from an uncontrolled dental infection can gain access to the subdural space via the foramen ovale or spinosum. Extension into the middle cranial fossa occurs with peri-neural extension along the mandibular division (V3) of the trigeminal nerve or peri-vascular extension along the middle meningeal artery.

Subdural empyemas (SDE) are characteristically crescentic extra-axial fluid collections extending along the cranial convexities. SDE(s) spread aggressively through the subdural space, crossing the sutures of the skull, until limited by the falx cerebri, tentorium cerebelli, base of the brain, or the foramen magnum. They demonstrate rim enhancement post contrast administration, and can lead to mass effect on the adjacent brain parenchyma. If not evacuated, intraparenchymal extension is a possible complication.

MRI has been shown to be superior to CT in demonstrating the presence, extent, and nature of a subdural fluid collection. However, CT scan remains a widely performed exam in this context due to its rapid availability, and accurate assessment of changes related to osteomyelitis.

Optimal management of a subdural empyema includes prompt surgical drainage of the subdural empyema, simultaneous drainage of the primary source of sepsis, and appropriate high dose intravenous antibiotics.

Diffusion Weighted Imaging in Malignacy- A Review

Seems like diffusion imaging will soon be useful for all body malignancies and follow up post therapy. Newer applications for DWI are on the way.

Diffusion-weighed MR imaging of pancreatic carcinoma.. Abdom Imaging. 2007 Jul-Aug;32(4):481-3. By Matsuki M et al

Diffusion-weighted (DW) images can be helpful in detecting the pancreatic carcinoma and accessing the extent of the tumor. On the DW images, carcinomas were shown as high signal intensity relative to the surrounding tissue. The ADC valuein the carcinoma was significantly lower compared to that of normal pancreas and tumor-associated chronic pancreatitis

Diffusion-weighted MR imaging for urinary bladder carcinoma: initial results. Eur Radiol. 2007 Jan;17(1):201-4. Epub 2006 Jul 25. Matsuki M et al

They concluded, DW images under free breathing enabled the clear detection of theurinary bladder carcinoma, whose ADC values were lower compared with those of the surrounding structure. The DW images may be useful in evaluating tumors invading to the surrounding structures.

Lung carcinoma: diffusion-weighted mr imaging—preliminary evaluation withapparent diffusion coefficient. Radiology. 2007 May;243(2):570-7. Epub 2007 Mar 30.Matoba M et al.

With the Spearman rank test, ADCs of lung carcinomas correlated well with tumor cellularities ADCs of lung carcinomas overlap, but ADCs of well-differentiated adenocarcinoma appear to be higher than those of other histologic lung carcinoma types.

Pituitary macroadenomas: preoperative evaluation of consistency with diffusion-weighted MR imaging—initial experience. Radiology. 2006 Apr;239(1):223-31. Epub 2006 Feb 1. Pierallini A et al

Findings in this study suggest that DW MR images with ADC maps can provide information about the consistency of macroadenomas

Diffusion-weighted MRI in the evaluation of renal lesions: preliminary results. Br J Radiol. 2004 Oct;77(922):851-7. Cova M et al

They concluded diffusion-weighted MR imaging of the kidney seems to be a reliable way to differentiate normal renal parenchyma and different renal diseases. Clinical experience with this method is still preliminary and further studies are required.

Diffusion-weighted MR imaging of metastatic disease of the spine: assessment ofresponse to therapy. AJNR Am J Neuroradiol. 2002 Jun-Jul;23(6):906-12. Byun WM et al.

In cases of metastatic disease of the spine, monitoring the response to medical therapy with plain radiography, bone scanning, and conventional spin-echo sequence MR imaging is unsatisfactory because of the insensitivity or nonspecific findings of these imaging modalities. Diffusion-weighted MR imaging shows that, with successful therapy, there is decreased signal intensity ofmetastatic disease of the vertebral bone marrow.

Hepatic metastases: diffusion-weighted sensitivity-encoding versus SPIO-enhanced MR imaging. Radiology. 2006 Apr;239(1):122-30. Epub 2006 Feb 21. Nasu K et al

They concluded combined reading of DW SENSE images and T2-weighted fast SE and dual-echo T1-weighted FFE MR images showed higher accuracy in the detection of hepatic metastases than did reading of SPIO-enhanced MR images

Teleradiology Providers

It's A Fat World After All!

Mickey Mouse is trying to accommodate for the bigger fatter Americans!

The infamous Small World Attraction at Disneyland has been shut down for ten months because the boats keep bottoming out from the weight of the riders, which in turn, stops the ride for approximately 5 to 10 minutes.

The refurbishments will include making the flume an inch or so deeper and the boats more buoyant, allowing for several hundred more pounds of capacity.

A Bowl Full Of Awesome With Awesome Sauce On Top!

Following the success of the live action Transformer's movie, a new live action movie based on a 1980's cartoon is planned to be released in 2009!

G.I. JOE!!!!!!!!!!!

Very Timely

Did you know that the 2007 World Series of Major League Baseball suffered the second lowest ratings in World Series history!

And the only World Series of Major League Baseball that had lower ratings was the 2006 World Series of Major League Baseball!

I enjoy baseball, but it might be a little more exciting if they didn't have 500 teams play 2,500 games each over the course of a year!!!!!!!

Sumer's Radiology Site gets nominated as one of the finalist in Best Clinical Sciences Blog Category

Dear friends

It gives me great pleasure to share with you that my website- Sumer's Radiology Site has been nominated into the finalists for the best clinical sciences blog on Medgadget Journal. Now to win we need votes

If you like my blog--

Vote here

Ika-401 Taong Pagdiriwang ng Kapistahan ng Quiapo at Mahal na Poong Nazareno

This is now the third year of my "Panata" of going to Quiapo to ask the blessings of the Senyor Nazareno. As before, the crowd was tremendous, but I believe more people flocked to Quiapo yesterday than it did last year. If you want to revisit my last year's account of the 400 Year Feast of the Nazarene, click here

The Senyor Nazareno is believed to be miraculous, a healer who reportedly heals the sick and saved thousands of lives of the terminally ill. Of course, there are also those who have not been healed. Not everyone. Many people take the chance though, because there's really nothing to lose (unless you become a victim of stampede).

Every believer's goal during the procession is to wipe his shirt or handkerchief on the body, face, or dress of the Nazareno. The devotee will then wipe it in the part of his body that is hurting.

*****

I did not bring along my beloved Nikons (D40x and my new D300) because I didn't want to risk damaging them while I elbow my way towards the procession. I just couldn't use them if I was to follow the procession. Besides, I am not just a spectator, but a participant, a devotee if you will. Some photographers perched themselves on top of houses, vehicles, or even make-shift nests. As for me, my main reason for going is not to shoot photographs, but to follow the procession.

In the end, there really is the insistent photographer in me. And so I brought along my tiny digicam Sony DSC-T9. It is a wonderful tiny camera, unobtrusive, easily slips into my polo pocket, and easy to hide from curious people. It always amazes me by producing photos of slr quality (well, sort of).

And so here they are, my photographs of the 401st Quiapo Feast, as seen from the viewfinder of my Sony digicam. They are far from the best photographs you will see on other photographers blog. My idea is not to compose beautiful pictures, but to capture the moment.

If you have a newspaper, magazine, blog, or website, you can use my pictures free to post on your sites and publications, but please kindly credit them to my name. Anyone can use them but I hope nobody abuses them. :)



A sea of people listening to the mass prior to the procession


Handkerchiefs with the image of the Black Nazarene printed on them. 10 pesos each


PARADE OF THE BLACK NAZARENES













SIGHTS AROUND QUIAPO


Suman! Oh, I love Suman!

Eat the suman with kasoy, guaranteed delicious!



I was surprised to find Tupig (the ones wrapped in banana leaves) for sale in Quiapo. I used to eat them in Manaoag whenever I attend the The Feast of the Our Lady of Manaoag. I bought several pieces for pasalubong.



Darna also attended the procession. She (or he) is also a Nazarene devotee.




Crowds everywhere

Herbal medicines. Filipinos still favor herbal medicines against prescription drugs. They say its more effective and definitely cheaper


Pamparegla. I don't know if this will work on men, though.


People qeue to play Lotto after the procession


Miniature Black Nazarenes for sale


Anting-anting (Amulets).

Miniature Sto. Nino for sale


Rosaries of all sizes and lenghts


Nazareno shirts


After the procession