Monday, February 28, 2011

Anterior Arch of Atlas Fissure-CT



This 8 yr old child had minor injury and then was unable to rotate his neck. Anterior arch of the atlas appears congenitally split and shows 5mm gap in the anterior arch possibly indicating fissure in the anterior arch. Although, altantodental distance is maitained, there is some altered articulation in the atltanto-axial articulation.  Torticollis has been reported after minor trauma in patients with split atlas.  Reference- Torticollis of a Specific C1 Dislocation With Split Atlas. Spine: 15 June 2010 - Volume 35 - Issue 14 - pp E672-E675.




Hot Cross Bun Appearance-MRI


The hot cross bun sign is seen on transverse T2-weighted magnetic resonance images of the brain as a cruciform hyperintensity in the pons This appearance is seen in patients with MSA-c. The sign is due to a selective loss of myelinated transverse pontocerebellar fibers and neurons in the pontine raphe with preservation of the pontine tegmentum and corticospinal tracts.  Note in our case of 47 year old female, cruciform hyperintensity in pons, cerebellar atrophy and high signal in the middle cerebellar peduncles, possibly MSA-c.





Chikungunya fever & Carpal Tunnel Syndrome-MRI

"Chikungunya fever is a re-emerging viral disease, especially in South India, characterised by abrupt onset of fever with severe arthralgia followed by generalized fatigue, fever, chills, nausea, vomiting, lower back pain and rash lasting for 1-7 days.  Neurologically, encephalopathy is the most common sequela, with alterred sensorium and ataxia.  On MRI, multiple high-intensity areas are seen. There are no spinal cord changes. Other common neurologic manifestations are myelopathy, polyradiculopathy, neuropathy (early > late), and carpal tunnel syndrome (2/2 excess synovial fluid and swelling) as seen in our lady patient who had chikungunya followed by carpal tunnel syndrome. "




Friday, February 25, 2011

Early Cavernous Sinus Thrombosis-Gd MRI

The cavernous sinuses receive venous blood from the facial veins (via the superior and inferior ophthalmic veins) as well as the sphenoid and middle cerebral veins. They, in turn, empty into the inferior petrosal sinuses, then into the internal jugular veins and the sigmoid sinuses via the superior petrosal sinuses. This complex web of veins contains no valves; blood can flow in any direction depending on the prevailing pressure gradients. This is diabetic female with clinical history of multiple cranial nerve palsies. Case submitted by Dr MGK Murthy.

Teaching points

  • Multiple cranial nerve palsies in diabetic lady should always suggest infection base of the skull and venous thrombosis unless other wise proved
  • Superior opthalmic vein is sensitive indicator of things hapening in cavernous sinus 
  • Base of the  skull in this case shows diffuse enhancing oedema -producing literally sheet of gadolinium possibly encasing all the foramina at base including foramen ovale
  •  Widened cavernous sinus with some asymetry is suggestive of stasis and thrombus along with asymmetry of flow void of ICA within
  • No proptosis is no guarantee against venous thrombosis 
  • Sphenoid sinus is is notorious for producing base of the skull and meningeal inflammation
  • All muslces and soft tissues including temporalis are inflammed


Thursday, February 24, 2011

Residents are NOT students-NEJM

An interesting article in NEJM- Residents: Workers or Students in the Eyes of the Law? NEJM | January 12, 2011 | Topics: Health Law. sparks off a debate on liability of resident doctor if he errs, does the court take him as student or is he liable in the same way as senior doctors. 

According to recent court verdict cited in the article --" On January 11, 2011, the Supreme Court ruled in an 8-to-0 decision (Justice Elena Kagan was recused) that the Treasury regulation making residents categorically ineligible for the student exemption was a “perfectly sensible” way of distinguishing education from service for the purposes of the tax code."

Wednesday, February 23, 2011

Lateral medullary syndrome (Wallenberg syndrome)












Findings

Axial FLAIR (Figure 1 and Figure 2) and T2-weighted (Figure 3 and Figure 4) images demonstrate mild signal hyperintensity in region of the left lateral and posterior medulla PICA territory.
Axial DWI (Figure 5 and Figure 6) and matching ADC maps (Figure 7 and Figure 8) demonstrate true restricted diffusion in the left lateral and posterior medulla PICA suggestive of cytotoxic edema fort an acute infarction.
3D TOF posterior circulation MIP projection (Figure 9) demonstrates absence of a normal left PICA. It's possibile to see the right PICA for comparison, arising from the distal right intracranial vertebral artery. There is also a mild narrowing of the basilar artery. It's possibile also to appreciate bith the superior cerebellar arteries.


Diagnosis: Lateral medullary syndrome (Wallenberg syndrome)


Adolf Wallenberg (November 10, 1862-1949) was a German internist and neurologist who first described the clinical manifestations (1895) and the autopsy findings (1901) in occlusions of the arteria cerebelli posterior inferior (Wallenberg syndrome).

Lateral medullary syndrome is characterized by sensory deficits affecting the trunk and extremities on the opposite side of the infarct and sensory, and motor deficits affecting the face and cranial nerves on the same side with the infarct. Other clinical symptoms and findings include ataxia, facial pain, vertigo, nystagmus, diplopia, Horner syndrome, and dysphagia. The cause of this syndrome is secondary to occlusion of the PICA near its origin. Similar symptoms may be produced by vertebral artery occlusion near the origin of the PICA.

Afflicted persons can have dysphagia resulting from involvement of the nucleus ambiguus and slurred speech (dysphonia and dysarthria). Damage to the spinal trigeminal nucleus causes absence of pain on the ipsilateral side of the face as well as an absent corneal reflex. The spinothalamic tract can be damaged, resulting in loss of pain and temperature sensation to the opposite side of the body. Damage to the cerebellum can cause ataxia. Damage to the hypothalamospinal fibers disrupts sympathetic nervous system relay and gives symptoms analogous to Horner syndrome (ptosis, anhidrosis, and miosis).

In older patients, the most common cause of posterior circulation ischemia is thromboembolic disease resulting from accelerated atheromatous disease or embolic disease from a cardiac source. In young patients with posterior fossa ischemia, in addition to embolic disease, the diagnosis of arterial dissection should also be considered.
Wallenberg syndrome synonyms: dorsolateral medullary syndrome, lateral bulbar syndrome, lateral medullary infarction syndrome, and PICA syndrome.

Transient bone marrow oedema of the hip-MRI


Transient bone marrow oedema of the hip also referred as transient osteoporosis of the hip is self-limited conditions that improves spontaneously over several months.  TOH was first described in 1959 in two women in their 3rd trimesters of pregnancy but now is more commonly seen in middle-aged men. This is 34 yr old female, immediate post partum, note the bulky uterus and marrow edema involving the right femoral head and neck, along with increased synovial fluid.





Tuesday, February 22, 2011

Pancreatic Calcification- Radiograph

This is a case of 22 year old male with characteristic pancreatic calcification crossing the midline marked by arrows. Few causes of pancreatic calcification are-
  1. Alcoholic pancreatitis.
  2. Hereditary pancreatitis
  3. Few patients with advanced cystic fibrosis and diabetes mellitus
  4. Protein malnutrition

 
 

Monday, February 21, 2011

Can Robots Replace Radiologist in Future?


This came from a recent article on The Atlantic-   “Anything You Can Do, Robots Can Do Better”  which claims “in spite of the radiologist's training requirement of at least thirteen additional years beyond high school, it is conceptually quite easy to envision this job being automated. The primary focus of the job is to analyze and evaluate visual images. Furthermore, the parameters of each image are highly defined since they are often coming directly from a computerized scanning device”.  Although, i don’t agree and think the author has forgotten much of the medical imaging interpretation requires more than just the visual skills there is lots of brains involved, it makes interesting reading.

Do you think Robots will replace radiologists in future?

MDR Tuberculomas Mimicking Brain Tumour.

This is a case of 19 year old male with rapidly increasing lesion(despite ATT)  in the parieto-occipital region and extensive edema which was initially diagnosed as mitotic etiology but later on histopathology and surgical evaluation turned out to be tuberculomas, possibly multidrug resistant tuberculomas.




Wednesday, February 16, 2011

Tibial Metastases in Carcinoma Breast-MRI

The primary cancers most commonly associated with bone metastases are:- Lung, Breast, Prostate, Thyroid and Kidney. The spine appears to be the most affected bony site followed by the pelvis, ribs, skull and the upper arm bones. Breast cancer and lung cancer (which is 20% in frequency) form the commonest causes of distal or below elbow and below-knee metastases. This is known case of carcinoma breast and reveals tibial shaft lesion confirmed as metastases.





Further reading - Foot (Edinb). 2010 Mar;20(1):35-8. Epub 2009 Nov 4. Tibial involvement in breast cancer: issues in diagnosis and management. Goyal S, Puri T, Gupta R, Suri V, Julka PK, Rath GK.


NEJM- osteochondromas after body irradiation

An article in this weeks NEJM entitled Osteochondromas after Total-Body Irradiation. N Engl J Med 2011; 364:687-688. By Marisa K. Matthys, B.S., Jane E. Benson, M.D. from Johns Hopkins University, Baltimore, MD  reports-
" The occurrence of osteochondroma after total-body irradiation has been increasingly reported in the literature and is probably the result of a prolonged duration of epiphyseal opening caused by damage to bone and cartilage at the epiphysis. Analyses have shown that the age at the time of transplantation is an independent risk factor for osteochondroma, with most reports involving children under the age of 5 years. "

Possible Tolosa Hunt Syndrome


The Tolosa Hunt syndrome (THS) refers to the presence of a painful ophthalmoplegia secondary to surrounding cavernous sinus inflammation Tolosa Hunt syndrome is essentially a clinical diagnosis of exclusion.
MRI findings in THS can include:

  1. Inflammation of the cavernous sinus, superior orbital fissure, or orbital apex.
  2. Narrowing of the intracavernous internal carotid artery.


This case of 52 year old female reveals isointense lesion in the region of left cavernous sinus with enhancement on post gadolinium scans and smaller left ICA flow void, as the lesion was isointense on T2 weighted images and differential diagnosis of meningioma versus THS was suggested. Along with follow up scan after steroid to confirm the diagnosis.  MRI scans should be performed every 1-2 months to monitor improvement and maintenance of improvement on and then off treatment, until findings normalize.






Tuesday, February 15, 2011

Fiber Tracking-MRI


Diffusion tensor imaging is unique in its ability to non-invasively visualize white matter fiber tracts in the human brain in vivo. Diffusion is the incoherent motion of water molecules on a microscopic scale. This motion is itself dependent on the micro-structural environment that restricts the movement of the water molecules. In white matter fibers there is a pronounced directional dependence on diffusion. With white matter fiber tracking projections among brain regions can be detected in the three dimensional diffusion tensor dataset according to the directionality of the fibers. This is a case of glioma shown with fiber tracking. 



Ecchordosis physaliphora- Rare Retroclival Pathology

Ecchordosis physaliphora is a rare congenital, benign, hamartomatous, retroclival mass derived from notochordal tissue that is typically located intradurally in the prepontine cistern. Ecchordosis physaliphora is usually asymptomatic. The differential diagnosis of EP also includes chordoma, dermoid, epidermoid, arachnoid cysts and partially thrombosed vertebrobasilar aneurysm. When a retroclival mass is established on MRI, any associated osseous stalk should be evaluated on thin-section CT as in our case which is classical for the diagnosis of Ecchordosis Physaliphora. This is 29 year old male with prepontine and retroclival lesion on MRI with no significant enhancement and diffusion restriction.





Monday, February 14, 2011

Clival Invasion in Pituitary Macroadenoma-MRI



Despite histological benign nature of the pituitary tumour they can achieve large size and in our case also showed unsual invasion into the region of clivus and pterous bones demonstrated by contrast MRI study in this young 20 year old male. Preoperatively the diagnosis was in doubt because of extensive involvement of clivus and was confirmed histopathologically.




Pulmonary Edema- CXR

"Early signs of pulmonary edema (intersticial edema) are the Kerley B lines, horizontal lines seen laterally in the lower zones, 2 cm long at last reach the lung edge. As the edema progress alveolar edema is observed with its "butterfly-batwing" pattern, characterized by the central predominance of shadows with a clear zone at periphery lobes. Other feature that may be seen is cardiac enlargement, in case of cardiac failure previously present. A helpful feature in distinguishing cardiac pulmonary edema from non cardiac pulmonary edema and from pneumonia, is the speed with which the edema appears and disappears. Substantial improvement in a 24 hour period is virtually diagnosis of cardiac pulmonary edema. These are two CXR done before and after decongestant therapy. "

Teleradiology session in IRIA-2011 gets covered in Express Healthcare


My talk in IRIA 2011 on Teleradiology-Asia Africa Perspective  gets covered in Express Healthcare


"Sumer Sethi, Founder Director, Teleradiology Providers, Delhi on the other hand spoke about opportunities in Asia-Africa. Comparing the past and the present day radiology, he said that the future can be visualised. Being the internet era, radiology and imaging has witness a paradigm shift, believed Dr Sethi. He further went on to say that what we see today is Imaging 2.0 which has five important parameters namely: quality, dependability, flexibility, speed and cost. Today, India's healthcare spending has increased with increased education, growing significance of health insurance and rise in income, informed Dr Sethi. Highlighting the advantages of teleradiology, he mentioned that teleradiology can be of immense use during emergencies, when doctors are on leave, as an option for soliciting second opinions as well as serving a support system for sub-speciality expertise."

Sunday, February 13, 2011

Philippine Love Motels

Cheap motels abound in Metro Manila, and they are thriving in popularity. I remember once entering one of those cheap motels in downtown Manila on the night of the Quiapo Fiesta in 2009. Virtually exhausted after following the procession of the Senyor Nazareno from morning through evening, I decided to try my luck and "check-in" for the night in one of the small-time motels in downtown.

This motel was located in the second floor of a decrepit old building along Quezon Boulevard. From the sidewalk, a double swinging doors opened to a flight of stairs, on top of which was a small receiving area. A thin middle-aged Chinese man in a white sando was in the counter, and behind him was a collection of keys with room numbers printed on them. In a smattering of Tagalog, he asked me if I was going to stay “short time or overnight.” For the uninitiated, “short time” means one to three hours of stay. I answered "overnight". He told me the cost would be P200. I paid in cash and was ushered into my room by a teenage boy who also gave me a towel and a small piece of soap.

Entering this motel was a decision I would later regret with much shame. The room was grimy, and the bathroom stank. Scribbled on the walls were phone numbers of people offering sex. "Just call this number," one said, "and I’ll be knocking on your door in a few minutes." Here and there were scribbled lewd drawings of sex organs and sexual positions. During the night, I had difficulty getting to sleep. I could hear passionate moans from the adjoining rooms, and even some banging on the walls. I hurriedly dressed and took a taxi back home. I never entered a cheap motel since then.

Some of you may think that entering the motel all alone is very unusual, since a motel, in the Philippine context, is a place where people usually spend very private moments with the opposite sex. To say it bluntly, it meant satisfying one's earthly urges. Indeed, by checking in, I risked censure of my friends and colleagues if they found out. Yet I have always maintained that there are no sinful places, only sinful people. Motels cannot be sinners, in the same way that a prison cannot become a criminal.

Postwar travelers' lodgings

The very first Philippine motels(short for "motor hotel"), however, were not originally designed as places to have illicit sexual affairs. The first motels in the Philippines sprang up to meet the postwar shortage of lodgings for travelers. Immediately after the Second World War, ruined Manila had no hotels but a lot of lodgers, especially the American soldiers who traveled regularly from their camps to different destinations.

To cope with the demand for lodgings, the first rooming houses were established in downtown Manila in 1945. Then, in 1946, the first authentic motel was established in Apelo St., in Pasay. This motel was a six-garage bungalow with air-conditioned units that came complete with toilets and bathrooms and hot and cold showers. The motel also served food for the G.I.s weary after a long journey from their camps. At P30 a day, the motel's rooms were cheap and always filled to capacity. Of course no G.I.s short of cash would have thought of staying in expensive Manila Hotel with only a few bucks in their pockets!

Then in the 1950s regular hotels began to be built in Manila. Offering better conveniences and services, these hotels were considered classier than motels. By this time, most of the G.I.s had already returned to the United States, and thus in the 1950s and 1960s, motels became superfluous. No longer were they as popular as before and their usefulness in the city had dwindled. The changing culture in Manila, however, saved the motels from oblivion. In the early 1950s, night clubs and bars began to be built in Manila, and many motels began offering cheap "short-time" rates, which were for one- to three-hour stays--to male clients who found instant sexual partners from the red light establishments.

Back then, it was considered highly improper if a man was seen entering a motel with a female companion. Thus, many couples entered motels a few minutes apart. Patrons also didn't want their identities known -- men pretended to read newspapers while entering motels and women wore dark shades and used abanicos to hide their faces from public view.

'Tira-han ng mag-syota'

The transformation of motels from simple lodging houses to private venues to conduct illicit sexual affairs became complete in the 1960s. A popular joke back then was a question of the difference between a hotel and a motel. The answer was "Ang hotel ay tirahan ng mag-asawa, samantalang ang motel ay tira-han ng mag-syota (Hotels are where married couples live, while motels are where boyfriends and girlfriends stay)."

The so-called "love hotels" were considered anathema by women civic groups in the 1960s. In particular, the Catholic Women’s League of Manila (CWL) filed a petition to then- Manila Mayor Antonio Villegas to close the motels because, they argued, the motels were increasingly becoming venues for illicit sexual affairs (Mayor Antonio Villegas was the author's late grandfather). The motel owners, primarily thought to be rich Chinese businessmen, fought back. They argued that closing the motels fringe on their right to operate legal business. There were no laws banning motels and especially banning people from entering motels!

Pressured from both sides (CWL and motel owners), Mayor Villegas reached a compromise. Although he did not order the closure of the motels, he nevertheless levied heavy taxes on the motel operators. In short, while he gave the motels a new lease for life, he made their existence difficult. Then at about this time came one of the most serious blows to the image of the motel: the rape in a motel of Antonieta Cabahug by Cesar Guy, a Chinese lumber magnate. It was perhaps one of the most sensational crimes of the decade, and Cabahug died as a result of the rape. Eventually Guy was sentenced to life imprisonment (he has since been released and is now a Christian preacher). From this time on, however, motels became associated not only with illicit affairs but with crimes, too.

Removing the tarnish

It was only in the late 1970s and the 1980s when motels began a serious effort to rebuild their tarnished image. Some of the high-end motels even began changing their names into vogue-sounding names like "Ritz and Waldorf," "Bermuda," "Victoria Court," "Town and Country" and "Capri". They also remodeled their interiors to provide a hotel-like ambiance -- spacious and wholesome lobbies, and themed rooms, offering patrons choices of Disneyland-painted rooms or, for the more adventurous lovers, jungle-themed suites . Some of the high-end rooms also offered private jacuzzi, water beds, and sound-proof walls, all of which, of course, cater to the more affluent clients.

At present, love motels in Metro Manila are as ubiquitous as the shopping malls -- you can find them everywhere. In the university belt alone, one could count more love hotels than there are universities, so the area could also have been termed the "Motel Belt" with none the wiser. In Quiapo’s Quezon Boulevard stretch for instance, I recently counted a dozen motels, not including the numerous cheaper, more dubious, no-signage motels that operate like boarding houses, located in the smaller inside streets.

The cheapest of motels sometimes masquerade as lodgings for travelers, although very few transients actually go there to slumber. Unlike motels in the past that were located in high-walled compounds for the utmost privacy, love motels nowadays operate more openly in large modern buildings that have been designed to have entrances and exits that lead to shopping malls, MRT train stations, and even call centers.

A 'romantic' atmosphere

The inside of motel rooms tells something conspicuous about their very nature. One notices the absence of windows and the presence of dim lights. Some motel rooms even provide a swing hanging from the ceiling, in the middle of the bed. Some rooms are provided with cable television. What can be shocking to the uninitiated, though, is that these cable subscriptions include channels showing pornographic movies. Also, inside bedside bureau drawers one can find condoms in different fruit flavors.

Motel managers are very strict in following the concept of “short time”. Fifteen minutes before the “short time” lapses, occupants will be reminded that they need to get ready to vacate the room as the next customers are already waiting to occupy it. Such is the popularity of motels that there are not enough rooms for their numerous clients, and as such numerous love seats are provided in the lobbies for the lovers waiting for their turns.

These conditions suggest the nature of the relationships of people lodging in motels -- many times, they are after sex without the benefit of marriage. Since married couples usually have sexual intercourse at home, couples staying “short-time” in motels are generally thought to be engaging in: (1) Pre-marital sex (sex before matrimony) (2) Adultery/concubinage (i.e., a married woman having sex with a man not her husband, vice versa), and (3) Prostitution (sex trade).

Of the three, the last is the most flagrant and the most obvious. Prostitution, as the saying goes, is the world’s oldest profession. But in Metro Manila and in other big cities for that matter, prostitution has also become a thriving industry. One could count Manila, Cubao, Monumento, Pasay, Pasig, Quezon Avenue, as the places with the highest concentration of motels in the metro because of the thriving sex trade in these places. In all these places, prostitution is a 24-hour business. One only needs to walk at anytime of the day in certain streets and furtive offers will be made in exchange for money.

We are thus drawn to answer a very crucial question. Could the proliferation of motels in our midst be an indication of the moral degeneration of Filipinos? Or are Filipinos just beginning to experience a modern sexual revolution already experienced in Japan, the United States, Sweden, and many other countries?

Indeed, one cannot escape the conclusion that although many people consider motels as sinful places of fornication, illicit sex, and prostitution, their popularity reflects the general attitude of the Filipinos towards motels in particular and sex in general. Manilans in general are loathed to be seen entering motels. Nonetheless, the very popularity of these establishments only indicate that motels are a product of our culture-- and not the other way around.