Sialadenitis with sialolithiasis

Findings

Uptake image series: Normal thyroid uptake. Symmetric radiotracer visualized in the sublingual glands. Expected radiopharmaceutical by the bilateral parotid glands and right submandibular gland. Increased uptake in the left submandibular gland. Increased radiopharmaceutical visualized in the oral cavity.
L lat washout and R lat washout image: Unchanged symmetric activity in the thyroid gland. Expected washout and decreased radiopharmaceutical in the parotid glands and right submandibular gland. Decreased washout in the left submandibular gland.
15 min post lemon image: Decreased washout of the radiopharmaceutical in the left submandibular gland with normal washout in the remaining salivary glands.

Differential diagnosis:
- Sialadenitis
- Warthin's tumor
- Oncocytoma
- Oxyphilic adenomas


Diagnosis: Sialadenitis with sialolithiasis

Follow-up: Patient subsequently had her left submandibular gland surgically removed. In the operating room they found a calcified stone in the parenchyma of the gland.



Key Points

Nuclear sialography is used to assess the function of the salivary glands. CT and US are used for structural information. CT and US can be used to differentiate masses from inflammation and benign from malignant. US-guided fine needle biopsy has a high degree of accuracy.
The salivary glands consist of three paired exocrine glands. The parotid glands empty into the oral cavity through Stenson's duct. The submandibular glands empty through Wharton's ducts. The sublingual glands are the third type and connect to the oral cavity through multiple small ducts.
Rinsing the mouth with water before Tc99m-pertechnetate increases retention in the salivary gland and delays its secretion into the oral cavity. Patient is placed in the seated position with the head tilted back to prevent superimposition of the thyroid gland. A dynamic blood flow study should be performed, followed by sequential 1 minute images for 60 minutes. This should demonstrate simultaneous, symmetric uptake of the three paired exocrine glands.
The salivary gland is then subjected to gustatory stimulation with a lemon or with a 1:1 lemon juice to water mix (rinse for 5 seconds and spit). Normally see rapid symmetrical and complete resolution of radiopharmaceutical from the salivary glands. It is useful to obtain lateral views of the head and neck to confirm radiotracer in the saliva of the oral cavity after gustatory stimulation.
Warthin's tumor (papillary cystadenoma) appears as a focal region of increased uptake. Oncocytomas and oxyphilic adenomas are other tumors which may have increased radiopharmaceutical uptake. Increased uptake could also be seen with acute inflammation.
Metastatic lesions appear as focal regions of decreased uptake. Also seen with cysts, enlarged lymph nodes, and chronic inflammatory disease. Could also result from congenital aplasia, obstructive sialolithiasis, trauma, or radiotherapy.
Mixed benign tumors are the most common type of tumor of the salivary glands and may present as focal areas of increased or decreased signal.
With Sjögren's syndrome, there may be asymmetric arrival or delayed accumulation of radiotracer. There may be absent or decreased response to gustatory stimulation, especially the submandibular glands. The presence of high Ga-67 concentration in the lacrimal and salivary glands in pathognomonic for Sjögren's syndrome. A poor response to gustatory stimulation can also be seen with systemic connective tissue disease and viral parotitis or mumps, or following radiotherapy. Failure to excrete radiotracer is seen in stenosis or blockage of the salivary duct.

Radiology Grand Rounds XXVIII

Here is a case of Carotid Artery Dissection 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

Carotid artery dissection is a significant cause of ischemic stroke in all age groups. Dissection of the internal carotid artery can occur intracranially or extracranially, with the latter being more frequent. Internal carotid artery dissection can be caused by major or minor trauma, or it can be spontaneous in which case genetic, familial, and/or heritable disorders are likely etiologies. MRA signs of dissection include irregular vessel margins, filling defects, extravasation of contrast, vascular occlusion, and caliber changes of the vessel. The latter sign is important and appreciated on axial views, but 3-dimensional reconstructed views allow study from any angle. This is 11yr old who presented with hemiplegia after head injury, also noted was beaded appearance of external carotids which suggest pre-existing fibromuscular dysplasia.

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Vein of Galen malformation

Findings

Figure 1 and Figure 2: Digital subtraction angiography. Left vertebral artery injection (lateral and frontal projections) demonstrating multiple dilated posterior thalamoperforating arteries filling a large sacular structure and early venous sinus enhancement.
Figure 4 and Figure 5: Fluoroscopic lateral and frontal images demonstrating a coil mass in the venous varix.
Figure 6: 3D TOF MRA demonstrating early filling of a dilated falcine vein and dural sinus via enlarged branches of the anterior and posterior cerebral arteries. The previously noted varix has been coiled and is no longer noted.
Figure 7: T1-weighted sagittal image demonstrating susceptibility artifact from coil material within the varix and a dilated falcine vein and dural sinus.

Differential Diagnosis:
- Vein of Galen malformation
- Childhood dural arteriovenous fistula
- Arteriovenous malformation
- Complex developmental venous anomaly


Diagnosis: Vein of Galen malformation


Vein of Galen malformation (VOGM) can result from
- a pial arteriovenous malformation with deep venous drainage (type 1, choroidal)
- a direct arteriovenous fistula (type 2, mural)
- a combination of both.

VOGM is often a misnomer because the median prosencephalic vein of Markowski is typically involved in the malformation. Arterial supply is usually from the thalamoperforating arteries, anterior cerebral branches, and branches from the posterior cerebral artery, including the posterior choroidal arteries.

The neonatal form of this malformation arises during weeks 6-11 of fetal development when an arteriovenous connection between primitive choroidal vessels and the median prosencephalic vein of Markowski (a temporary drain for the choroids plexus) occurs. The abnormal flow through this connection slows the regression of this embryonic vein, therefore preventing the formation of the vein of Galen. The persistant median vein usually drains into the sagittal sinus via a persistent falcine vein and the straight sinus fails to form.

Children and adults usually present with headaches, seizures, hemorrhage or focal neurologic symptoms. Neonates most commonly present with high output heart failure and seizures, and may have a striking cranial bruit. Mass effect, hydrocephalus, parenchymal loss, intracranial venous stenosis, and steal phenomena leading to ischemia are all sequelae of untreated VOGMs, all increasing morbidity and mortality despite early treatment.

MRA/MRV is as an invaluable imaging tool, helping both to preliminarily map for endovascular procedures and to subsequently monitor for successful therapy. After stabilizing the neonate with medical therapy, endovascular treatment is employed, with embolization options including coils and acrylics. A venous approach is more common due to complications with femoral artery catheterization in neonates; however, an arterial approach appears to be more successful. Multiple endovascular embolizations are often needed. Heart failure responds favorably to embolization. Refractory hydrocephalus may require shunt placement. Endovascular embolization has shown to decrease morbidity and mortality when compared to surgical repair in patients without evidence of cerebral parenchymal damage or multisystem failure.

A Colorful Parade in Calbayog

I have always liked to watch colorful parades and festivals. The Calbayog Sarakiki Festival is a rich array in colors, costumes, wonderful characters, and dances.
It is the grandest part of the annual town fiesta, a literal pride of the Calbayognons' inherent talent for the art of presentation and dancing.
The exciting drum rolls and the well-choreographed movements of the dancers are awe-inspiring, to say the least. I would say without reservation that the Sarakiki Festival is one of the best festivals in the Philippines, no wonder it was always awarded top honors in festival competitions.

These portraits are exclusively for this blog only. If you wish to publish them in any publication, website or blog, please credit them to my name. Many thanks for viewing.

More photos to come!

Journal Submissions Invited

Radiology related scientific article submissions are invited in the following journals. Both of these are open access journals ensuring wider readership and offer free publication.

Internet Journal of Radiology

(For which I am the editor-in-chief)

This is a peer reviewed journal. Every published article has been reviewed by members of the editorial board and the editor-in-chief. All articles are archived by Internet Scientific Publications LLC and recognized by The Library of Congress Catalog of Publications

Journal of Radiology Case Reports

(In which i am the Section Editor for Neuroradiology)

This journal is dedicated solely to Radiology case reports. Case reports are usually "neglected" by large or traditional journals, mainly due to competition with "higher value" articles (review, original research etc.) for valuable space in the hardcopy version of the journal.

Regards

Dr.Sumer K Sethi, MD
Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology

Section Editor, Journal of Radiology Case Reports
Director, DAMS (Delhi Academy of Medical Sciences)

Calbayog Fiesta 2008

I'm back from a wonderful trip to Calbayog City to share the celebration of the annual town Fiesta. It was a such a joy to behold once more the town of my most beautiful memories, and as I walked once more its lovely narrow streets, I felt that I was home away from home.

Some of the locals recognized me while I was covering the town Fiesta. Many of them thought that I was from the Manila press. Yet, they didn't know that I am posting my pictures in my blog just as my way of giving tribute to them and their lovely town.

Old Waray friends invited me to their homes to partake their sumptuous feasts. Indeed, I no longer feel a stranger to this land. I feel proud that I have been accepted not only as a tourist, but also as a naturalized Calbayognon as well. I maybe a Manilenyo by birth by my heart is pure Waray.

Once more, I have taken hundreds of photos in my camera that needs to be posted in this blog, and I'm preparing them now for future blog articles. Yet, I have to rest for a while after a tiring long bus trip back home in Cubao.

For the meantime, I would like to say thank you to the hospitable and beautiful people of Calbayog City, and especially to their dashing town Mayor Mel Senen Sarmiento who gave me a warm hospitable welcome.

Congenital ectopia of the posterior pituitary with anterior pituitary hypoplasia

Findings

Along the tuber cinereum, a 5 mm hyper intensity is noted on precontrast T1 images. The area shows homogenous, hyper intense signal on post contrast sequences. The pituitary infundibulum is threadlike and midline. The anterior pituitary gland is hypoplastic and located in the sella. It shows homogenous enhancement.

Differential diagnosis:
- Ectopia of the posterior pituitary
- Craniopharyngioma
- Rathke cleft cyst
- Sarcoid
- Trauma
- Langerhans cell histiocytosis


Diagnosis: Congenital ectopia of the posterior pituitary with anterior pituitary hypoplasia


Discussion

Ectopia of the posterior pituitary is a rare congenital anomaly. The anterior pituitary is often hypoplastic. Patients often will present with panhypopituitarism and short stature secondary to growth hormone deficiency. Those patients with a visible pituitary stalk typically present with isolated growth hormone deficiency. On the other hand, those with absent pituitary stalks will present with multiple hormonal deficiencies. Hypopituitarism has been associated with breech delivery, genital abnormalities, hypoglycemia, single central incisor and jaundice. Even if not initially present, complete anterior pituitary hormone deficiency can develop during a patient's teens or twenties.


Radiologic Overview

MRI is the imaging modality of choice to study the anatomic relationships that exist in the pituitary-hypothalamic region. Both pre and post contrast T1 weighted images should be obtained. The best imaging planes are sagittal and coronal. Fat suppression imaging can also be useful as the bright signal associated with the posterior pituitary will not typically suppress.

Located in midline at the median eminence, the ectopic posterior pituitary gland will either be T1 hyper intense or isointense on precontrast images. It is posterior and inferior to the optic chiasm. On post contrast images, it will appear hyper intense. The sella will either be hypoplastic or completely absent. Similarly, the anterior pituitary will be hypoplastic or absent. As mentioned above, identifying the presence or absence of the pituitary stalk is important as it correlates with the degree/ type of hormonal abnormality.

Dystrophic intracranial calcifications

Findings

Figure 1 and Figure 2: Axial non-contrast enhanced CT images of the brain reveal bilateral symmetric hyperdense areas consistent with calcification involving the basal ganglia, thalami, and dentate nuclei of the cerebellum.


Diagnosis: Dystrophic intracranial calcifications


Most cerebral calcifications are located in the basal ganglia. Additional sites of intracranial calcification include the thalami, dentate nuclei of the cerebellum as well as the subcortical white matter.

The differential diagnostic considerations for basal ganglia calcification are extensive. The most common cause is idiopathic and of no clinical significance, often seen as an incidental finding as in this case. Physiologic calcification occurs with aging and is commonly noted in patients greater than 40 years of age. Thus, biochemical testing is rarely performed unless indicated by additional features. Endocrine disorders such as hypoparathyroidism and hyperparathyroidism also result in intracranial calcification. Other etiologies include metabolic disorders as in Fahr disease (familial cerebral ferrocalcinosis) which is associated with variable neurological manifestations including progressive deterioration of motor function and psychological impairment. Post inflammatory states also account for calcification and may be seen in the setting of infection with neurocysticercosis, tuberculosis or congenital HIV. Traumatic conditions such as birth anoxia, hypoxia, and cardiovascular events may also result in intracranial calcifications. Finally, cases are also seen with toxic poisoning as in chronic lead exposure.

Radiographically, calcification is readily apparent on non-contrast CT examination as high attenuation in the aforementioned structures. As CT easily depicts calcium, this is the preferred modality for localizing and evaluating the extent of calcifications.

Bowel Carcinoid-MRI

Carcinoids from 2% of all gastrointestinal tumors and are the second most common small-bowel malignancy . they belong to a category of tumors called apudomas (amine precursor uptake and decarboxylation tumors) because they arise from endocrine amine precursor uptake and decarboxylation cells that can be found throughout the gastrointestinal tract and in other organs such as the pancreas and the lung. The tumor arises in the wall of the bowel as a submucosal mass that may result in scarring and kinking of the surface. Tumours originating from the foregut develop in the stomach, duodenum, and pancreas; those arising in the midgut develop in the small bowel, appendix, and right colon; and those arising from the hindgut develop in the transverse colon, left colon, or rectum. Small-bowel carcinoids are multiple in 29–41% of patients and will be associated with a second primary malignancy, usually in the gastrointestinal tract, in a significant percentage (29–53%) of patients most common in fifth or sixth decade with average of hormonal symptoms dating for 9 yrs arise from the Kulchitsky's cells in the crypts of Lieberkühn. Therefore, they grow as submucosal nodules, Visualization of the enhancing mural mass is improved if water is given as an oral contrast agent and if multiplanar reconstructions or 3D imaging software is used

CT could detect mesenteric infiltratin or liver metastases On early (arterial) phase imaging after the administration of an IV contrast agent, these metastases enhance brightly. On delayed imaging, these lesions may become isodense with the liver parenchyma.

On MRI the primary tumor appears as a discrete mass that enahnces with gadolinium. The appearance of unenhanced T1- and T2-weighted images varies. Most tumors are isointense to muscle on T1-weighted images and either hyperintense or isointense to muscle on T2-weighted images . During the portal venous phase, many lesions become isointense. In some cases, somatostatin receptor scintigraphy or biopsy may be necessary.

Case Submitted by Dr MGK Murthy, MD, Sr Consultant Radiology

Teleradiology Providers

Glioma MRS

This is classical MR spectroscopy findings of thalamic glioma.

Parameniscal cyst

Parameniscal cysts occur relatively infrequently. They are usually associated with horizontal cleavage tears. However, isolated cysts without meniscal pathology have also been reported.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

Extraspinal Ependymoma Recurrence

This is a postoperative follow up of Ependymoma and reveals enahncing mass in the right paraspinal region, suspected to be extraspinal recurrence in relation to the operative site.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

Cerebral Venous Sinus Thrombosis-MRV

Classical MRV picture of patient with venous sinus thrombosis presented with severe headache. CT done outside revealed high density in the region of the sagittal sinus.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)

Cochlear otospongiosis

Findings

There are focal lytic plaques in the pericochlear bony labyrinth bilaterally. The internal auditory canals and vestibular systems appear normal in size and configuration. Each cochlea completes 2.5 turns. Incidental (unrelated) fluid was seen within the right middle ear and right Prussak’s space as well as the right mastoid air cells.

Differential diagnosis:
- Cochlear otospongiosis (AKA otosclerosis)
- Osteogenesis imperfecta tarda
- Paget's disease
- Fibrous dysplasia
- Osteoradionecrosis
- Congenital otosyphilis


Diagnosis: Cochlear otospongiosis


Key points

Cochlear otospongiosisis a primary lytic disease of the endochondral layer of bony labyrinth. Best diagnosed by temporal bone CT.
It is characterized by focal ovoid lytic plaques (aka focal demineralization) in the pericochlear bony labyrinth that can become confluent. The bony labyrinth can have a "halo" appearance with more severe, confluent disease.
As the disease progresses, it can spread to other potions of the labyrinth including the lateral walls of the internal auditory canals.
Cochlear otospongiosis is the less common form (15%). Fenestral otospongiosis far more common (85%).
Fenestral form often coexists with cochlear form but the reverse is not true.
Patients typically present with progressively worsening hearing loss (conductive in fenestral form and mixed conductive and sensorineural in the cochlear form). The cochlear form is bilateral and symmetric in 85% of cases.
The etiology of the disease is unknown as is the exact cause of associated hearing loss. It is postulated that sensorineural hearing loss may result from compromise of the spiral ligament or by protease production that is toxic to cochlear nerve cells.
Early treatment for cochlear form is fluoride. If bilateral and severe disease is present, cochlear implants may be considered.

Check before loading your power point on the net!!

"William J. Weadock et al in Radiology 2008;249:285-293 discuss the likelihood of protected health information about patients being accidentally present in the power points loaded on the net. Must read."

Hippocampus-MR Spectroscopy

"According to King et al in Radiology 2008;249:242-250 there is significant metabolic heterogeneity along anteroposterior axis of healthy hippocampus. Mean NAA, creatine, and choline concentrations are higher in posterior hippocampus than anterior hippocampus. Thereby implying that consistent voxel placement are important for correct comparisons of both absolute metabolic levels and metabolite ratios."

In Quiapo, Child Vendors are considered more dangerous than thieves and robbers!

I was walking along in Plaza Miranda, Quiapo yesterday when I spotted this sign board which warns pedestrians against snatchers, thieves, and holduppers. But the sign mentioned that people should be more careful of child vendors selling plastic bags. I find it revolting that the Manila police detachment in the area found that this street child is more dangerous than all the other criminals in the area! Duh?

I bought one plastic bag from this boy and found him to be nice and very accommodating. He is obviously very poor, so I gave him a little extra. I am a frequent Quiapo pedestrian and I have always bought plastic bags from these child vendors, never having any problem with them.

It is a very irresponsible sign. My mind cannot fathom why poor little kids could be more dangerous than the hardened adult criminals in the city. I went to the nearby police detachment for some explanation. I cannot let this pass without doing something. The police told me that they received some complaints that street children selling plastic bags have been stealing change money from their customers. Well, that's possible if the customers are idiots who didn't know how to count their change and to be outwitted by small children.

These little children are poor and no longer go to school. They work hard to help their families. We should pity them rather than suspect them to be criminals. Yet some people are real idiots. And when they lose some money, they even suspect little children of stealing it. Real idiots.

Marchiafava Bignami Disease

In 1903 Marchiafava and Bignami, 2 Italian pathologists, described 3 men with alcoholism who died after having seizures and coma. In each patient, the middle two thirds of the corpus callosum were severely necrotic. Most patients are men with alcoholism. In some cases, the damage extends to areas such as the nearby subcortical white matter, the anterior commissure, or both. These are FLAIR, Sagittal and Diffusion weighted images of a 50 year old chronic alcoholic showing corpus callosal necrosis.

Dr.Sumer K Sethi, MD

Sr Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers

Editor-in-chief, The Internet Journal of Radiology

Director, DAMS (Delhi Academy of Medical Sciences)