Sumer's Radiology Site

Doctors should use their own name on Social Media

2013-05-24T23:39:00.000+05:30

According is famous medical blogger Kevin MD - The General Medical Council (UK) published new guidelines that state, “If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.”

Molecular US imaging- is this the future of ultrasound?

2013-05-24T23:24:00.001+05:30

In recent issue of Radiology June 2013 267:3 661-662; Wang and coworkers used the clinical-grade P- and E-selectin-targeted microbubbles to image inflammatroy bowel disease and showed that experimental acute colitis leads to significantly increased local accumulation of the targeted microbubbles and that binding of the contrast agent to the inflammatory tissue correlates well with FDG-PET. With the immense ease and potential of ultrasound addition of molecular imaging to ultrasound holds the potential to revolutionize medial imaging in future.

Retained Broken Injection Needle-MRI

2013-05-22T00:54:00.002+05:30

17 years old girl with history of injection at the site 5 years ago with pain presently. MR shows susceptibility artifacts at the deltoid insertional site with no significant fluid collection or abscess formation or osteomyelitis with X-ray suggesting 3 mm needle tip possibly from the injection needle within the granulomatous response. Differential would include foreign bodies of other varieties. Case Submitted by Dr MGK Murthy & Mr Abdul Hamid.

Ruptured Sinus of Valsalva:CT

2013-05-21T23:33:00.001+05:30

Cardiac CT images reveal Ruptured sinus of valsalva aneurysm into right atrium just above septal tricuspid leaflet with left to right shunt.

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai

(Consultant Interventional Cardiologist)

Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

OBOW Exams in Medical Universities in India

2013-05-20T00:42:00.002+05:30

It may take ages to reach to this point in India, but if i was ever made an examiner in a Radiology exam, i would rather look to pass a candidate with more day to day skills than the one who has mugged up all the data. The kind of exam i would to conduct would be an Open Book, Open Web format, which would be more in line with our actual day to practise. Candidate i believe should have fair search skills and should know where to look for. Of course time limits should be strict so that the radiologists understand the value of turn around times and more marks would on the reporting language and formats rather than mugged up values. You are free to search the internet, read the books and come to conclusion in specified TAT for that case and give justification to your final conclusion. To me this would be an exam which will more reflect the radiology practise in the current decade, in contrast to current theory (mugged up) and practical exams conducted in our country where candidates are asked to keep phones, computers and books outside. While in real world problem solving he would have all these with him for ready reference, surely i feel "open web" exams are more reflective of real world.

Patellar instability-CT

2013-05-20T00:05:00.000+05:30

Patellar Instability (TT - TG measurement) Case Submitted by Dr Ayush Goel

Risk factors for patellar instability :
1. Trochlear dysplasia,
2. High positioning of the patella (aka patella alta)
3. Lateralization of the tibial tuberosity (measured as distance between the tibial tubercle and the trochlear groove or the TT-TG distance )

Normal TT-TG is less than 15mm

Borderline 15 - 20
Abnormal > 20mm

The images show measurement of TT-TG distance.

Method : A tangential is drawn joining the posterior margins of femoral condyles. A line is drawn passing through the deepest point in trochlear groove (femoral sulcus), which is perpendicular to the tangential drawn initially.
Now either we can use superimposition or simple scrolling down to reach the tibial tuberosity. Another line is drawn perpendicular to the tangential drawn initially, this 3rd line should pass through the mid point of tibial tuberosity.

Should I Opt for DNB Radiology?

2013-05-13T01:22:00.000+05:30

Well this is an often asked question and answer to this is YES, if you are interested in the branch and are unable to get MD Radiology , DNB is a fair bet, slight catch being somewhat lesser passing rate in DNB, although this has improved in last few years. DNB today for all practical purposes is equivalent to MD even for academic centres. Pay-package wise there is hardly any difference in the private sector.

Usually, in the first go, people prefer: Delhi, Mumbai and Hyderabad for DNB and also, Bangalore & Pune. Usual places preferred in Delhi are Saftardjung, Gangaram, Stefans, Batra Hospital. INMAS is a fair option as well. In Mumbai people prefer, Jaslok, Hinduja, Lilavati and Breach Candy hospitals. NIMS Hyderabad, Nrayana Hrudalya , Bangalore are also popular choices. Radiology is a good well recognized challenging branch and exciting career option. Happiness quotient for radiologists is usually higher than other counterparts, probably to do with possibility of fixed time lifestyle and fair pay packages.

Also note branches like Radiotherapy and Nuclear medicine, nowadays have much better prospects than past with increasing requirements for both professionals with more cancer hospital and PET centers respectively starting in India.

Causes of Intraocular Calcifications

2013-05-13T00:21:00.004+05:30

REMEMBER, these are the causes of intraocular calcification:

Retinoblastoma (>50% of all cases)
Astrocytic hamartoma
Choroidal osteoma
Optic drusen
Scleral calcifications
in systemic hypercalcemic states
Retrolental fibroplasia
Phthisis bulbi

‘DESCENDING COLONIC POLYP’- An ultrasound diagnosis

2013-05-11T23:19:00.002+05:30

A boy of about 10 yrs age , having h/o bleeding per rectum and occasional pain left lower abdomen, was examined with high resolution color doppler ultrasound, showed-a well defined round to oval iso to hypoechoic solid mass within lumen of descending colon. The mass appeared bulging within lumen with echogenic mucosal stripe over it , & displacing muscularis propria ,suggesting mucosal or submucosal location [ fig 1& 2]. It also showed few tiny cystic areas in it ,which appeared spokewheel like vasculature on color doppler [see fig 3&4]. Vascular signals are seen within lesion on both color & spectral doppler .No any other abnormality was noted in descending colon wall & rest of the abdomen. On the basis of high resolution ultrasound & color doppler findings a diagnosis of benign intraluminal ‘mucosal-submucosal descending colonic polyp’ was made , which subsequently proved on colonoscopy [ see fig 5] , & resected endoscopically. Biopsy turned out to be benign hypertrophic colonic polyp. By- Dr. Subhash Tailor, MD, Bhilwara [ Rajasthan , India]

Fig 1- LS US scan left lower abdomen showing round to oval hypoechoic intraluminal mass in descending colon with tiny cystic areas in it .

Fig 2- TS US scan showing same mass in descending colon lumen

Fig 3- Color doppler image showing spoke wheel like vasculature within mass

Fig 4- Spectral doppler image of the mass showing both arterial & venous vascular signals

Fig 5- Colonoscopic view depicting intraluminal mucosal polyp in descending colon [Image -courtsey Dr. Mukesh Kalla ,gastroenterologist, Jaipur]

Two Cases of Plexitis in a Day-MRI

2013-05-08T23:30:00.002+05:30

Case I : Patient presented with foot drop with abnormal high signal on T2/STIR images involving the right gluteal muscles and piriformis with fluid signal consistent with acute denervation changes. There is evidence of thickening and high signal intensity in the right sciatic nerve with high signal in the sacral plexus. These findings may be indicate LS plexopathy/plexitis.

Case 2 Patient with Hepatitis C presented with left arm numbness shows evidence of abnormal high signal involving the left brachial plexus trunks which may indicate acute brachial plexitis (possibly viral in etiology). No obvious denervation changes noted in the scalene muscles and muscles of the shoulder girdle.

Coronary Aneurysm

2013-05-08T12:25:00.002+05:30

Patient was being treated with antibiotics repeatedly for prolonged fever. Healed vegetation on posterior mitral leaflet noted later on. Retrospectively recognized as endocarditis. Came with slow evolving anterior wall myocardial infarction. Angiogram showed coronary aneurysms of right coronary , left circumflex, and ostio proximal left anterior descending. LAD aneurysm is occluded with thrombus ( upper end of picture )

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai

(Consultant Interventional Cardiologist)

Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

Basics of MRI for Orthopedic Residents

2013-05-07T23:03:00.003+05:30

This is video of my lecture done in SICOT, Kochi chapter, done for a group of orthopedic residents. Hope this helps the readers to understand basics of radiology imaging. This is a 10 minute lecture.

Internet Smart Doctor-Sumer Sethi

2013-05-06T22:46:00.002+05:30

I have been rated number 8 in the top 10 Internet Doctors on Internet Medicine.Com, thank you to all readers and supporters on internet. This is what the page says, " Dr Sethi was one of the first physicians to be on the internet with blogging, in 2005. Since then, he was used his blogs as a means for education for the field of radiology, and is probably the most popular blogging Radiologist in the world. Based in India, Dr. Sethi is very active in the field of Teleradiology, and teleradiology services, and he is active on the lecture circuit as well."

Here is the link to the full article on InternetMedicine.Com

Fractures associated with ACL injury-MRI

2013-05-01T23:56:00.002+05:30

When interpreting knee radiographs, we must be aware of fractures associated with ACL injury

Segond fracture
Lateral femoral condyle osteochondral fracture (corresponding to "deep sulcus" sign seen on MR images),
Pivot-shift fracture of the posterolateral tibia
Tibial spine avulsion fracture.

In this patient there is linear fracture of the posterolateral tibia consistent with segond fracture and fibular fractures. Patient had associated rupture of femoral footprint of ACL. We must be careful of these secondary signs when evaluating MRI as these are sometimes easy to miss on MRI.

Fetal MRI with Neural Tube Defect

2013-05-01T01:19:00.001+05:30

Ventriculomegaly is noted with moderate to gross dilatation of both lateral ventricles. Interventricular septum is noted. Thinning of cerebral mantle is noted with poor sulcation. There is presence of neural tube defect noted in lower dorsal spine level at the level of stomach. Meningomyelocele is noted. Lack of dorsal cutaneous covering is noted. Case Submitted by Dr Swati Shah

Unusual Pre-axial Polydactyly

2013-04-30T20:50:00.000+05:30

The preaxial polydactyly represents a complete or partial duplication of the thumb. It is the most common duplication pattern in white and Asian populations. The longstanding classification of thumb polydactyly was initially described by Wassel in 1969. Wassel's classification is the most common used classification.

However, this plain film is atypical with rudimentary duplicated metacarpal and rudimentary duplicated proximal phalanx on the ulnar side of the thumb. Triphalangeal thumb is noted as well. This can be an example of rare triplicated thumb.

Useful tips: Radiographic Features of White Matter Disorders

2013-04-29T23:37:00.002+05:30

Macrocephaly

Canavan's disease
Alexander's disease

Frontal lobe predilection

Alexander's disease

Occipital lobe predilection

Adrenoleukodystrophy

Contrast enhancement

Adrenoleukodystrophy
Alexander's disease

Hyperdense basal ganglia

Krabbe's disease

Ischemic infarctions

Mitochondrial disorders (MELAS, MERRF)
Homocystinuria

Gall Bladder Wall Cyst [ Possibly Submucous Cyst ]: An Ultrasound Diagnosis

2013-04-29T21:45:00.001+05:30

A 22yrs old female presented with h/o vague upper abdominal pain , was examined with ultrasound showed - a well defined smooth & regular walled oval shaped cystic lesion bulging within gall bladder lumen near neck as hypoechoic filling defect . The lesion appears to be involving anterior wall of gall bladder near neck with bulging mucosa within lumen & showed low level homogeneous internal echos[may be altered mucoid fluid ] , & did not reveal internal vascularity on Doppler [ fig 1 & 2]. The 3-D reconstruction image further confirmed the lesion to be mural & cystic lodged near gb neck [fig 3 & 4]. No any other evidence of cholecystitis or wall abnormality or calculi was seen. No pericholecystic fluid or biliary tree dilatation was present. Case by: Subhash Tailor, MD, Bhilwara [ Rajasthan]

On the basis of classical US findings a diagnosis of ‘ gall bladder wall cyst’ was made , possibly containing altered fluid [may be mucoid or hemorrhagic or infected ]. This appears to be a very uncommon &rare ultrasound finding, related to gall bladder pathologies, observed during routine scan , & may be an incidentally detected clinically insignificant lesion , yet important to depict , & put up in gall bladder image gallery. Opinion & comments are welcome.

Ring Sequestrum- Plain Film

2013-04-25T00:21:00.003+05:30

Late finding which is said to be pathognomonic of pin tract infection is "ring" sequestrum. The appearance of this finding is due to the particular geometry of a pin and pin tract. As a pin tract becomes infected, the bone immediately adjacent to the pin becomes infected first, and a certain amount of it dies. The viable bone adjacent to this infected dead bone then becomes hyperemic and becomes relatively osteopenic. The infected dead bone remains at its original density. Once the pin has been removed, if one looks directly down the pin tract with a radiograph, this cylinder of dead bone looks like a "ring".

Radiology Degree and Business

2013-04-24T00:36:00.001+05:30

Interesting question, recent CNN report suggests MD radiology seat is for approximately 3 crores unofficially in some private medical colleges, our question is why the hell would someone spend this much money and do you think it is possible for a doctor to recover this kind of money in a lifetime?

If you look at it on pure business and financial viability model , it cannot be explained for sure. Probably most valid explanations given are, may be their parents own hospitals or diagnostic centers Another set of people believe it is just our Indian mentality of spending on degrees to gain in status just as some spend on marriages. Whatever, this bubble is bound to get burst in future as these numbers are not indicative of actual potential for any individual doctor to earn in India.

Hamartomatous Polyps - A rare cause of adult intussusception

2013-04-22T10:32:00.002+05:30

Intussusception is defined as telescoping of a segment of the gastrointestinal tract into an adjacent one. It is the leading cause of intestinal obstruction and is one of the commonest causes of abdominal emergency in children [1]. Adult intussusception however is rare with an incidence of 2-3 cases per million per year. An identifiable lead point that often requires definitive treatment is found in 70-90% cases. The preoperative diagnosis can usually be made reliably by non-invasive imaging techniques like barium studies, US and CT. Small bowel intussusceptions in most cases are secondary to benign lesions. We describe a case of jejuno jejunal intussusception in a middle aged female secondary to a multiple polyps in the small & large bowel loops which was detected on CT.

Case Submitted by Dr. Chetan (DMRD, DNB resident), Dr. Karunakaran N. (consultant), Department of imaging & interventional radiology, Meenakshi Mission Hospital & Research Centre, Madurai

Case Details : A 37 year old female presented with complaints of intermittent pain in the epigastric and periumbilical region with significant weight loss for one year with bleeding PR. The physical examination was unremarkable. In Ultrasound abdomen was suggestive of intussusception. Computed tomography of the abdomen showed intussusception with typical target appearance on cross section & sausage shape mass on saggital imaging with a well-defined rounded polypoid hypodense mass with smooth margins at the distal end of intussusceptum. The diagnosis of enteric intussusception due to pedunculated polyp was made. Polyps were also noted in colon on virtual colonoscopy.

Intraoperative findings confirmed radiographic findings. Multiple jejunojejunal intussusceptions were noted with a 2 cm intraluminal pedunculated polyp acting as the lead point. Colonic polyps along the entire colon were also noted. Jejunal resection and anastomoses with subtotal colectomy & ileo rectal anastomosis was done. Histopathological examination of the resected mass suggested a hamartomatous polyps; PEUTZ JEGHER’S SYNDROME. The postoperative period was unremarkable.

Discussion : Childhood intussusception is idiopathic in 90% of cases. In contrast, adult intussusception has a demonstrable cause in 70-90% of cases including neoplasms, postoperative changes and adhesions, inflammation and miscellaneous conditions like Meckel's diverticulum and celiac disease [1],[3].

Benign lesions are responsible for approximately 25% of all adult intussusceptions with Peutz-Jeghers polyps and lipomas being common causes of small bowel intussusception (3). Malignant lesions of the small bowel like adenocarcinoma; malignant stromal tumors and metastases, most commonly from malignant melanoma are less common than benign neoplasms and are responsible for approximately 15% cases of small bowel intussusception [4]. Peutz-Jeghers polyps are a rare cause of enteric intussusception in adults. Peutz–Jegher’s syndrome, also known as hereditary intestinal polyposis syndrome, is an autosomal dominant genetic disease characterized by the development of benign hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa & surfaces of palm & soles as seen in our patient. Patient is having history of bowel resection of elder sister for unknown cause favouring the autosomal condition of disease.

The classical features of intussusception on plain film like air crescent sign and presence of a soft tissue mass with decreased colonic air are neither sensitive nor specific, however plain radiograph may be useful in assessing signs of bowel compromise like pneumatosis and pneumoperitoneum [3].

The characteristic finding of intussusception on barium studies is the "coiled spring" appearance with a thin central barium stream with or without a leading mass.

Colour Doppler may be useful in determining the degree of vascular compromise of the involved bowel segments [3] .The characteristic doughnut appearance was seen in the present case on transverse scan with a multilayered appearance on longitudinal scan. In addition the leading mass was well demonstrated by US.

On CT a complex small bowel mass is seen with fat and mesenteric vessels seen between the opposing walls of intussusceptum and intussuscipiens.[3], [6],[7],[8]. Abdominal CT has been shown to be the most accurate modality for indentification of intussusception [3],[6],[7].

Magnetic resonance imaging can distinguish between liquid or solid components and ischemic or necrotic bowel can be detected.

To conclude, intussusception in adults occurs rarely and differs from its paediatric counterpart in terms of aetiology, clinical presentation, diagnosis and treatment. Symptoms are usually non specific and of long duration and the condition is rarely suspected on clinical examination. A correct and timely diagnosis is necessary to prevent the complications of bowel infarction and perforation and to resect the underlying leading mass. Imaging thus plays a crucial role in the diagnosis and management of these patients.

Axial section CECT abdomen showing hypodense polyp at the leading point

Coronal CECT abdomen showing sausage shaped bowel mass with fat & mesenteric vessels between opposing walls of intussusceptum & intussucipiens

Polyp in the colon at the site other than intussusception on vitual colonoscopy

Axial section CECT abdomen: Target appearance of intussusception on axial section

Surgical specimen - colectomy done showing multiple polyps

Pigmentation in oral mucosa & sole favouring the diagnosis of Peutz Jegher’s syndome

References

1. Agha FP. Intussusception in adults. AJR 1986; 146: 527-531.

2. Tan KY, Tan S, Tan AGS, Chen CYY, Chng H, Hoe MNY. Adult intussusception: experience in Singapore. ANZ J Surg 2003; 73: 1044-1047.

3. Huang BY, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. RCNA 2003; 41: 1137-1151.

4. Choi SH, Han JK, Kim SH etal. Intussusception in adults: from stomach to rectum. AJR 2004; 183: 691-698.

5. Olmsted WW, Ros PR, Hjermstad BM, McCarthy MJ, Dachman AH. Tumors of the small intestine with little or no malignant predisposition: a review of the literature and report of 56 cases. Gastrointest Radiol !987; 12: 231-239.

6. Dawes LC, Hunt R, Wong JK, Begg S. Multiplanar reconstruction in adult intussusception: case report and literature review. Australasian Radiol 2004; 48: 74-76.

7. Steinwald PM, Trachiotis GD, Tannebaum IR. Intussusception in an adult secondary to an inverted Meckel's diverticulum. Anerican Surgeon 1996; 62: 889-894.

8. Azar T, Berger DL. Adult intussusception. Ann Surg 1997; 226: 134-138.

Dr John Haaga receives ARRS Gold Medal for distinguished services to radiology

2013-04-22T09:57:00.003+05:30

Author of my favourite book CT and MRI of the Whole Body, John Hagga, has been awarded Gold medal by American Roentgen Ray Society, first and oldest radiology society for distinguished service to radiology. He has 25 U.S. patents. His publications include 183 reports and a textbook in its 6th edition, CT and MRI of the Whole Body. The book is the largest selling radiology textbook in the world, and has been translated into Spanish, Portuguese, Chinese, and Persian.

Wormian Bones-Causes

2013-04-19T23:00:00.000+05:30

Intrasutural ossicles in lambdoid, posterior sagittal, temporosquamosal sutures; normal up to 6 months of age

Mnemonic: PORK CHOPS

Pyknodysostosis
Osteogenesis imperfecta
Rickets in healing phase
Kinky hair syndrome
Cleidocranial dysostosis
Hypothyroidism / Hypophosphatasia
Oto-palato-digital syndrome
Primary acroosteolysis (Hajdu-Cheney) / Pachydermoperiostosis / Progeria
Syndrome of Down

DAMS recognised as one of the Top 35 Education Ideas in India

2013-04-19T12:45:00.001+05:30

Dear friends I am happy to share that DAMS has been featured on The Franchising World-Education Special as one of the Top 35 education business ideas in India, based on their third party surveys. Thank you all for your kind support and wishes.

Xray's Discovery-"I have seen my death"

2013-04-19T00:27:00.003+05:30

Did you know When Roengten placed his wife Bertha’s hand in the path of the rays, in front of a photographic plate, the ‘light picture’ then created was quite astonishing, for it showed not the flesh of her hand but the bones of the skeleton resulting in her famous quote: ‘I have seen my death’.