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To study the use of serial ultrasound gastric residual volume (GRV) measurements in predicting feed intolerance in critically ill patients.This study was conducted in various intensive care units (ICUs) of All India Institute of Medical Sciences, New Delhi. Forty-three critically ill patients aged more than 18 years were studied for a total of 130 enteral feeding days. Gastric residual volume was obtained by calculating the antral cross-sectional area (CSA), which is the product of anteroposterior (AP) and craniocaudal (CC) diameters of gastric antrum obtained using ultrasound in the right lateral decubitus position. A baseline measurement was done before the initiation of the enteral feed and termed GRV0, the ultrasound scanning was repeated every 1 hour for the first 4 hours and termed GRV1, GRV2, GRV3, and GRV4, respectively, and the patients were watched for feed intolerance. The receiver operating characteristic (ROC) curves were constructed to correlate the GRV at each time with feed intolerance.The data from 43 medical and surgical critically ill patients were analyzed. Out of 130 feeding days, 13 were noted to be feed intolerant. Gastric residual volume at the end of the fourth hour of feed, that is, GRV4 was the best predictor of feed intolerance with 99.3% area under the curve (AUROC), sensitivity of 99%, specificity of 99.3%, and 95% CI, 0.89-0.98 followed by GRV3, with AUROC of 96% and sensitivity and specificity of 92.3 and 96%, respectively, with 95% CI, 0.92-0.99.Ankalagi B, Singh PM, Rewari V, Ramachandran R, Aggarwal R, Soni KD

A mass or a tumor may not always be an underlying cause for a clinically apparent swelling. A wide range of myotendinous disorders can present as pseudomasses. These include muscle/myofascial hernia, tendon tears, benign hypertrophy, accessory muscles, tendon xanthomas, diffuse myositis, and exertional compartment syndromes. We have briefly reviewed these lesions highlighting their typical radiological findings and have also highlighted the role of different imaging modalities and the role of dynamic imaging. Although rare, radiologists should be aware of these entities to avoid mislabeling a pseudomass as a mass or malignancy and to detect the abnormality in not-so-apparent masses.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is becoming the most common cause of cirrhosis. Although magnetic resonance spectroscopy (MRS) is considered the gold standard, it has a few limitations. The role of diffusion-weighted imaging (DWI), which is a simpler sequence, in the diagnosis and grading of fatty liver is not well studied. The aim of the study was to investigate the value of DWI in the diagnosis and grading of hepatic steatosis in patients with NAFLD. MATERIALS AND METHODS: Fifty-one adults (mean age: 38 years; 28 men, 23 women) with NAFLD, diagnosed clinically and by ultrasonography (USG), were included in the study after obtaining informed consent and approval from the institute ethics committee. USG was performed for grading of hepatic steatosis in all patients, followed by magnetic resonance imaging with DWI and MRS, on a 1.5T scanner. The mean apparent diffusion coefficient (ADC) values and proton density fat fraction (PDFF) were calculated, and MRS was used as the gold standard. The mean ADC values were compared with the PDFF and USG grades. RESULTS: There was a weak correlation between ADC values and PDFF (r = −0.36; P < 0.05). In addition, there was a weak correlation between the ADC values of the liver and USG grade (r = −0.34; P < 0.05). However, an overall increase in USG grades and PDFF was associated with decrease in the mean ADC value (P < 0.001). CONCLUSION: DWI is not accurate in the diagnosis and grading of hepatic steatosis in patients with NAFLD. However, a significant increase in fat deposition in the liver lowers the ADC values.

PURPOSE: In the present study, we aimed at assessing the effect of femoral and tibial coronal bowing on varus malalignment and Oxford knee score (OKS) at different grades of knee osteoarthritis (OA). MATERIALS AND METHODS: This prospective observational study was conducted at a tertiary referral centre in New Delhi, India. Consecutive patients presenting to the “knee OA” outpatient clinics were invited to take part in the study conducted over a 12-month period. All consented patients underwent long-leg standing alignment radiographs using standardised technique and patient reported knee pain and function were recorded using Oxford knee score. The following radiological parameters were measured from weight-bearing long-leg radiographs of 824 varus aligned limbs via a morphometric software (Matlab R2009a) (1) hip–knee–ankle angle (HKAA), (2) femoral bowing, (3) tibial bowing. The knees were graded according to Kellegren and Lawrence grade (K&L) and OKS was recorded. 3 groups of HKAA were made based on the angle, A (0° to − 3°), B (− 3° to − 10°) and C ( + 2°). RESULTS: The mean (± SD) of HKAA, femoral bow and tibial bow of the whole cohort was − 6.97° ± 5.64°, − 1.54° ± 4.31° and − 1.96° ± 3.5°, respectively. An increase in the lateral bow of both femur and tibia was seen with an increase in the severity of OA. A consequent increase in the varus malalignment was observed with an increase in the lateral bow of both femur as well as the tibia at all grades of OA, with significant correlation observed between HKAA with Femoral bowing and HKAA with tibial bowing. The mean OKS for femoral bow, in-range, varus and valgus was 30.6 ± 11.5, 21.3 ± 11.5 and 35.3 ± 11.4, respectively, and for tibial bow, in-range, varus and valgus was 27.6 ± 11.5, 26. ± 11.5 and 28 ± 11.4, respectively. The difference in the mean OKS was observed to be significant when the varus bow group was compared to in range as well as valgus group (p

Medial pivot (MP) total knee arthroplasty (TKA) aims to restore native knee kinematics due to highly conforming medial tibio-femoral articulation with survival comparable to contemporary knee designs. Posterior stabilized (PS) TKAs use cam-post mechanism to restore native femoral rollback. However, there is conflicting evidence regarding the reported patient satisfaction with MP TKA designs when compared to PS TKAs. The primary aim of this study is to compare the patient satisfaction between MP and PS TKA and the secondary aim is to establish potential reasons behind any differences in the outcomes noted between these two design philosophies. In this IRB-approved single surgeon, single centre prospective RCT, 53 patients (mean age 62 years, 42 women) with comparable bilateral end-stage knee arthritis undergoing simultaneous bilateral TKA were randomized to receive MP TKA in one knee and PS TKA in the contralateral knee. At 4 years post-surgery, all patients were assessed using Knee Society Score (KSS)-Satisfaction and -Expectation scores, and Oxford Knee Score (OKS). In addition, all the patients underwent standardized radiological and in vivo kinematic assessment. Patients were more satisfied with the MP TKA as compared to PS TKA: mean KSS-Satisfaction [34.5 ± 3.05 in MP and 31.7 ± 3.16 in PS TKAs (p

To compare the technical difficulty, safety, radiation exposure and success rates between right-sided and left-sided percutaneous transhepatic biliary drainage (RPTBD and LPTBD) in patients with malignant biliary obstruction (MBO). Fifty patients (28 males, 22 females; mean age 51.78 years) with MBO were randomized to undergo either RPTBD or LPTBD during the study period between June 2016 and May 2018. The procedure time, fluoroscopy time, radiation doses to the operators and patients, technical success, clinical success, complications and effect on quality of life were evaluated and compared between the two groups. Twenty-five patients were included in each group. The technical success was 100% in both groups. There was no significant difference between RPTBD and LPTBD groups in terms of major complications [4% and 12%, respectively; p = 0.297] and minor complications [40% and 32%, respectively; p = 0.597]. Further, the average procedure time (37.80 ± 13.07 min vs 41.04 ± 14.94 min), fluoroscopy time (5.88 ± 4.2 min vs 5.97 ± 3.8 min), radiation doses to the operator (136.84 ± 106.67 μSv vs 130.40 ± 106.46 μSv) and to the patient (8.23 ± 5.80 Gycm2 vs 11.74 ± 11.28 Gycm2) were not significantly different between the groups. Clinical success was achieved in 21 patients (84%) of RPTBD group and 17 patients (68%) of LPTBD group with no significant difference (p = 0.416) between them. There was no significant difference between RPTBD and LPTBD with reference to the technique, safety, radiation dose, success rates and impact on quality of life suggesting no laterality advantage for biliary drainage in cases of MBO.

Purpose:This study aimed to investigate the alignment based on deformity in knees affected by osteoarthritis (OA) at different stages and evaluate its association with OA. Material and methods:The following radiological parameters were measured from weight bearing long leg radiographs of 966 legs in the Indian subjects via a morphometric software (Matlab R2009a) (1)Hip-Knee-Ankle angle (HKAA), (2) Femoral bowing, (3) Tibial Bowing, (4) Condylar Plateau angle (CPA). The knees were classified according to the Kellegren and Lawrence grading and these parameters were evaluated with OA for its association using appropriate statistical tests. Results:The mean HKAA angle was 174.5° ±6.5°, 65.8% of the limbs were in found to be in varus (183°). The mean femoral and tibial bowing was -1.19 ± 4.95° and -1.54 ± 3.58° respectively. 55.8% of femorae and 41.4% of the tibia were observed to have varus bowing while 24.12% of femorae and 12.11% the tibia were observed to have valgus bowing. An increase in odds of disease severity was observed with femoral and tibial bowing >2°. With an increase in the grades of OA a significant increase in the lateral bow of both femur and tibia was observed. The mean condylar plateau angle was observed to be -2.53° ±7.9°. Positive association was seen between the varus CPA, HKA and OA (p

The portal vein is the largest vessel supplying the liver. A number of radiological interventions are performed through the portal vein, namely for primary pathologies of the portal vein, for inducing liver hypertrophy or to treat the sequelae of portal hypertension among others. The routes used include direct transhepatic, transjugular, and, uncommonly, trans-splenic and through subcutaneous varices. Portal vein embolization and transjugular intrahepatic portosystemic shunt are among the most common portal vein interventions that are performed to induce hypertrophy of the future liver remnant and to treat complications of portal hypertension, respectively. Other interventions include transhepatic obliteration of varices and shunts, portal vein thrombolysis, portal vein recanalization, pancreatic islet cell transplantation, and embolization of portal vein injuries. We present a detailed illustrative review of the various radiological portal vein interventions.

Objective: Early detection of peripheral neuropathy is extremely important as leprosy is one of the treatable causes of peripheral neuropathy. The study was undertaken to assess the role of diffusion tensor imaging (DTI) in ulnar neuropathy in leprosy patients. Methods: This was a case–control study including 38 patients (72 nerves) and 5 controls (10 nerves) done between January 2017 and June 2019. Skin biopsy proven cases of leprosy, having symptoms of ulnar neuropathy (proven on nerve conduction study) were included. MRI was performed on a 3 T MR system. Mean cross-sectional area, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of ulnar nerve at cubital tunnel were calculated. Additional ancillary findings and appearance of base sequences were evaluated. Results: Ulnar nerve showed thickening with altered T2W signal in all the affected nerves, having an average cross-sectional area of 0.26 cm2. Low FA with mean of 0.397 ± 0.19 and high ADC with mean of 1.28 ± 0.427 x 10 −3 mm2/s of ulnar nerve in retrocondylar groove was obtained. In the control group, mean cross-sectional area was 0.71cm2 with mean FA and ADC of 0.53 ± 0.088 and 1.03 ± 0.24 x 10 −3 mm2/s respectively. Statistically no significant difference was seen in diseased and control group. Cut-off to detect neuropathy for FA and ADC is 0.4835 and 1.1020 × 10 −3 mm2/s respectively. Conclusion: DTI though is challenging in peripheral nerves, however, is proving to be a powerful complementary tool for assessment of peripheral neuropathy. Our study validates its utility in infective neuropathies. Advances in knowledge: 1. DTI is a potential complementary tool for detection of peripheral neuropathies and can be incorporated in standard MR neurography protocol. 2. In leprosy-related ulnar neuropathy, altered signal intensity with thickening or abscess of the nerve is appreciated along with locoregional nodes and secondary denervation changes along with reduction of FA and rise in ADC value. 3. Best cut-offs obtained in our study for FA and ADC are 0.4835 and 1.1020 × 10 −3 mm2/s respectively.

Melon seed bodies are a non-specific manifestation of chronic synovial inflammation associated with various arthritides such as tubercular, rheumatoid, and seronegative arthritis. Characteristic magnetic resonance imaging (MRI) appearance of these bodies differentiates them from other differential diagnoses (such as synovial chondromatosis and pigmented villonodular synovitis). Ultrasonography and MRI, in combination with clinical and laboratory details, can suggest the possible etiology. Medical management of the underlying cause, along with arthroscopic removal of pathognomonic bodies, is the preferred treatment.

OBJECTIVE. The purpose of this article is to present the pathologic and clinical features of IgG4-related sclerosing cholangitis (ISC), illustrate the associated imaging findings, and discuss treatment of the disorder. CONCLUSION. ISC is an inflammatory disorder involving the biliary system and resulting in strictures. Although often associated with autoimmune pancreatitis, it may be an isolated disease. Differentiation of ISC from other forms of cholangitis and cholangiocarcinoma is difficult but necessary for management. Imaging is important in diagnosing and assessing the extent of disease and planning a management strategy.

Purpose To evaluate and compare the immediate and long-term outcomes of radiological interventions for hemorrhagic complications in patients with acute and chronic pancreatitis. Materials and Methods This retrospective study, conducted between January 2014 and June 2020, included all patients with acute and chronic pancreatitis presenting with hemorrhagic complications who underwent angiography and/or embolization. Their clinical, angiographic, and embolization details were evaluated and correlated with procedure success, complications, recurrence, and mortality. The patients were subgrouped into groups A (acute pancreatitis) and C (chronic pancreatitis), and comparisons were made. Results The study included 141 patients (mean age, 36.3 ± 11.2 years; 124 men), of whom 106 patients had abnormal angiography findings and underwent embolization. Of them, group A had 50 patients (56 lesions) and group C had 56 patients (61 lesions). All the patients in group A had severe acute pancreatitis, with a mean computed tomography severity index of 7.6. The technical and clinical success rates of embolization, complications, recurrence, and long-term outcomes were not significantly different between the groups. Group A had significantly higher mortality due to sepsis and organ failure. Embolic agents did not have any significant association with complications, recurrence, and mortality. After a mean follow-up of 2 years, 72.5% of the patients were asymptomatic, and none had symptoms attributable to embolization. Conclusions Success, complications, and recurrence after embolization for hemorrhagic complications were comparable between acute and chronic pancreatitis. Acute pancreatitis was associated with significantly higher mortality. Embolic agents did not significantly influence the outcomes. None had long-term adverse effects attributable to embolization.

Hemorrhagic complications are uncommon after percutaneous transhepatic biliary drainage. The presenting features include bleeding through or around the drainage catheter, hematemesis or melena. Diagnosis requires cholangiography, CT angiography or conventional angiography. Minor venous hemorrhage is managed by catheter repositioning, clamping or upgrading to a larger bore catheter. Major vascular injuries require percutaneous or endovascular procedures like embolization or stenting. A complete knowledge of these complications will direct the interventional radiologist to take adequate precautions to reduce their incidence and necessary steps in their management. This review presents and discusses various hemorrhagic complications occurring after percutaneous transhepatic biliary drainage along with their treatment options and suggests a detailed algorithm.

Background Normalized iodine concentration (NIC) (ratio of iodine concentration of liver to that of aorta) of liver at delayed dual-energy CT (DECT) may reflect the amount of fibrosis based on the extent of iodine uptake. Purpose To stage liver fibrosis by using 5-minute delayed DECT and compare findings with those of transient elastography (TE), shear-wave elastography (SWE), and histologic examination. Materials and Methods This prospective study included patients with chronic liver disease who were scheduled to undergo multiphase abdominal CT and liver biopsy from January 2017 to September 2018. Fifty individuals being screened as renal donors comprised the control group. Study participants underwent TE, SWE, multiphasic DECT (including 5-minute delayed dual-energy scanning), and liver biopsy. Multiphasic DECT and SWE were performed in the control group. The NIC of the right lobe of the liver (RNIC) was compared with liver stiffness (LS) as measured with TE and SWE and with the METAVIR fibrosis stage (ranging from F0 to F4). Diagnostic performance was assessed by using areas under the receiver operating characteristic curve (AUCs). Results A total of 107 participants (mean age, 35 years ± 12 [standard deviation]; 57 men) and 50 control subjects (mean age, 47 years ± 11; 29 women) were evaluated. The RNIC showed strong correlation with METAVIR stage (Spearman ρ = 0.81, P < .001). The AUC for RNIC with each METAVIR stage ranged between 0.86 (95% CI: 0.76, 0.97) and 0.96 (95% CI: 0.92, 0.99). The cut-off value of RNIC was 0.24 (sensitivity: 85% [86 of 101 participants; 95% CI: 77%, 91%]; specificity: 83% [84 of 101 participants; 95% CI: 42%, 98%]) for stage F1 fibrosis and 0.29 (sensitivity: 84% [67 of 80 participants; 95% CI: 74%, 90%]; specificity: 81% [65 of 80 participants; 95% CI: 63%, 92%]) for stage F2 fibrosis. RNIC correlated well with LS as measured with TE and SWE (Spearman ρ = 0.60 and 0.64, respectively; P < .001). Conclusion Normalized iodine concentration of liver at 5-minute delayed dual-energy CT showed strong correlation with the histologic stages of liver fibrosis and good diagnostic performance in estimating liver fibrosis. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Chandarana and Shanbhogue in this issue.

Corrosive injury is a devastating injury which carries significant morbidity. The upper gastrointestinal tract is predominantly affected with severity ranging from mild inflammation to full thickness necrosis which may result in perforation and death. Among the complications, stricture formation is most common, causing dysphagia and malnutrition. Endoscopy has a pivotal role in the diagnosis and management, with a few shortcomings. Imaging has an important role to play. Besides radiography, there is an increasing role of CT scan in the emergency setting with good accuracy in identifying patients who are likely to benefit from surgery. Further, CT scan has a role in the diagnosis of complications. Oral contrast studies help in assessing the severity and extent of stricture formation and associated fistulous complications in the subacute and chronic phase. The scope of intervention radiology for this condition is increasing. Fluoroscopy-guided balloon dilatation, drainage of collections or mucoceles, endovascular embolization of point bleeders, placement of feeding jejunostomy and image-guided biopsy are among the procedures that are being performed. Through this review we aim to stress the role the radiologist plays in the diagnosis and follow-up of these patients and in performing radiological interventions. Besides this, we have also highlighted few salient points to help understand the pathophysiology and management of such injuries which is paramount to ensure a good long-term outcome.

Liver rupture in pregnancy is an acute condition with significant risk to the mother and fetus. It is known to occur with tumors such as hepatic adenoma, infective causes such as abscess, granulomatous diseases, and parasitic infections, and rarely spontaneously. Most of these conditions have overlapping clinicoradiological findings, almost always requiring histopathological confirmation. We report a case of a ruptured hepatic lesion, with an unusual diagnosis of Bartonella henselae infection causing cat-scratch disease, in a 24-year-old pregnant lady.

Background/Aims To compare splenic stiffness (SS) with intra-operative portal pressures (PPs) in patients of extrahepatic portal vein obstruction (EHPVO). Methods Twenty-one patients (14 males; 7 females) of mean age 20.4 years with clinical and sonographic diagnosis of EHPVO were included in this approved prospective study. Endoscopy for esophageal varices (EV) was done in all patients followed by ultrasonographic 2D shear wave elastography (SWE) of spleen. Three values were taken at different areas of spleen avoiding major vessels and mean was calculated. Intra-operative PP was measured from an omental vein during proximal spleno-renal shunt surgery. The PP was compared and correlated with SS along with other parameters. Results The mean SS was 46.04 ± 8.0 kPa and the mean PP was 33.29 ± 4.1 mmHg. There was no significant correlation between PP and SS (P = 0.61) and between grades of EV and SS (P = 0.38). Significant correlation was seen between grades of EV and PP (0.04). SS also did not show significant correlation with splenic size or duration of disease. Conclusion SS measured by 2D SWE did not correlate with PP and thus may not help in predicting gastrointestinal bleed in patients of EHPVO.

Oxford unicompartmental knee replacement (OUKR) has shown excellent long-term clinical outcomes as well as implant survival when used for correct indications with optimal surgical technique. Anteromedial osteoarthritis is highly prevalent in Indian patients, and OUKR is the ideal treatment option in such cases. Uncertainty prevails about the best method to determine femoral component size in OUKR. Preoperative templating has been shown to be inaccurate, while height- and gender-based guidelines based on European population might not apply to the Indian patients. Microplasty instrumentation introduced in 2012 introduced the sizing spoon, which has the dual function of femoral component sizing and determining the level of tibia cut. We aimed to check the accuracy of sizing spoon and also to determine whether the present guidelines are appropriate for use in the Indian patients. A total of 130 consecutive Oxford mobile bearing medial cemented UKR performed using the Microplasty instrumentation were included. The ideal femoral component size for each knee was recorded by looking for overhang and underhang in post-operative lateral knee radiograph. The accuracy of previous guidelines was determined by applying them to our study population. Previously published guidelines (which were based on Western population) proved to be accurate in only 37% of cases. Hence, based on the demographics of our study population, we formulated modified height- and gender-based guidelines, which would better suit the Indian population. Accuracy of modified guidelines was estimated to be 74%. The overall accuracy of sizing spoon (75%), when used as an intraoperative guide, was similar to that of modified guidelines. Existing guidelines for femoral component sizing do not work in Indian patients. Modified guidelines and use of intraoperative spoon should be used to choose the optimal implant size while performing OUKR in Indian patients.

To evaluate the diagnostic performance of stalk morphology on diffusion-weighted imaging (DWI) in comparison with conventional MRI in predicting muscle invasion in urinary bladder cancer. The study was prospective and approved by the institutional ethics committee. A written informed consent was obtained from all the patients. The study included 56 patients who presented with bladder mass between January 2014 and November 2015. After excluding 16 patients, 40 patients with 92 tumors were assessed. All the 40 patients underwent MRI at 3.0 Tesla (Achieva, Philips) inclusive of DWI (b0, 500, 1000 and 1500). Two radiologists evaluated the images independently, and disparities were resolved through consensus. For predicting muscle invasion on T2-weighted images, tumor morphology (papillary versus non-papillary), distensibility of the underlying bladder wall, and perivesical fat infiltration were evaluated. On DWI, the criterion used in a previous study (Takeuchi et al.) was used along with tumor stalk morphology. Findings were compared with histopathology using Pearson’s χ2 test, and diagnostic performance indices were calculated. All the evaluated features were present with significantly higher frequency in muscle-invasive tumors (p

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

Intraosseous entrapment of the median nerve is an uncommon complication of elbow dislocation and fractures. The condition is seen to occur in adolescent age group with a remote history of trauma. We report two rare cases of type 2 intraosseous median nerve entrapment. Though the diagnosis of median neuropathy is made with clinical tests and neurophysiological studies, however exact site of entrapment and presurgical mapping of nerve is done accurately with MR neurography. Imaging thus plays a pivotal role in management of this condition.

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

Background: The purpose of our study was to compare magnetic resonance arthrography (MRA) as a diagnostic modality against the gold standard of wrist arthroscopy in the evaluation of chronic wrist pain. Materials and Methods: Thirty three patients with chronic wrist pain suspected to have ligament injuries of the wrist were prospectively recruited. They underwent MRA examinations followed by wrist arthroscopy. Arthroscopic findings were compared with radiological findings focusing on three important structures – triangular fibrocartilage complex (TFCC), scapholunate ligament (SLL), and lunotriquetral ligament (LTL). Results: For the 17 patients with TFCC tears/perforations on arthroscopy, MRA gave a sensitivity (SEN) = 88%, specificity (SPE) = 87.5%, positive predictive value (PPV) = 88%, and negative predictive value (NPV) = 87.5%. For the 13 patients with SLL tears on arthroscopy, MRA gave SEN = 77%, SPE = 100%, PPV = 100%, and NPV = 87%. For the 7 patients with LTL tears on arthroscopy, MRA gave SEN = 29%, SPE = 100%, PPV = 100%, and NPV = 84%. A composite correlation between findings on MRA and wrist arthroscopy revealed an overall SEN = 73%, SPE = 96%, PPV = 93%, and NPV = 85% for MRA, with overall accuracy = 88%. Conclusions: The presented diagnostic results of MRA are superior to those of magnetic resonance imaging quoted in literature. MRA is a potent tool for evaluating chronic wrist pain but tends to miss lesions of intrinsic carpal ligaments (SLL and LTL) more than TFCC. Wrist arthroscopy may be recommended when the clinical suspicion is strong.

This review discusses the relevant anatomy, etiopathogenesis, current notions in clinical and imaging features as well as management outline of lower limb entrapment neuropathies.The review is based on critical analysis of the current literature as well as our experience in dealing with entrapment neuropathies of the lower limb.The complex anatomical network of nerves supplying the lower extremities are prone to entrapment by a heterogenous group of etiologies. This leads to diverse clinical manifestations making them difficult to diagnose with traditional methods such as clinical examination and electrodiagnostic studies. Moreover, some of these may mimic other common conditions such as disc pain or fibromyalgia leading to delay in diagnosis and increasing morbidity. Addition of imaging improves the diagnostic accuracy and also help in correct treatment of these entities. Magnetic resonance imaging is very useful for deeply situated nerves in pelvis and thigh while ultrasound is well validated for superficial entrapment neuropathies.The rapidly changing concepts in these conditions accompanied by the advances in imaging has made it essential for a clinical radiologist to be well-informed with the current best practices.

Objectives To evaluate the utility of perfusion CT (PCT) in differentiating pancreatic adenocarcinoma from mass forming chronic pancreatitis (MFCP). Methods In this ethically approved study, PCT was performed in 122 patients with pancreatic masses of which 42 patients had pancreatic adenocarcinoma and 13 had MFCP on histopathology. Perfusion parameters studied included blood flow (BF), blood volume (BV), permeability surface area product (PS), time to peak (TTP), peak enhancement intensity (PEI) and mean transit time (MTT). Twenty five controls with no pancreatic pathology were also studied. Results Amongst the perfusion parameters BF and BV were found to be the most reliable for differentiating between adenocarcinoma and mass forming pancreatitis. Although they were reduced in both pancreatic adenocarcinoma (BF- 16.6 ± 13.1 ml/100 ml/min and BV- 5 ± 3.5 ml/100 ml) and MFCP (BF- 30.4 ± 8.7 ml/100 ml/min and BV- 8.9 ± 3.1 ml/100 ml) as compared to normal controls (BF- 94.1 ± 24 ml/100 ml/min and BV- 36 ± 10.7 ml/100 ml) but the extent of reduction was greater in pancreatic adenocarcinoma than in MFCP. Based on ROC analysis cut off values of 19.1 ml/100 ml/min for BF and 5 ml/100 ml for BV yielded optimal sensitivity and specificity for differentiating pancreatic adenocarcinoma from MFCP. Conclusions PCT may serve as an additional paradigm for differentiating pancreatic adenocarcinoma from mass forming chronic pancreatitis and a useful tool for detecting masses which are isodense on conventional CT.

Purpose This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies. Methods The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies. Results Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies. Conclusion It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.

Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist's armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.

The purpose of this article is to review the status of interventional radiology (IR) in India.After a few initial challenges, the specialty of interventional radiology (IR) is well established in most cities in India, where various quality procedures are now regularly performed. The national IR society, the Indian Society of Vascular and Interventional Radiology, is still new, but its collaboration with other international societies will help its progress. Education and training in IR are fast evolving in India, and as more radiologists choose IR as their career, IR is bound to progress.

Biliary tract shows a large number of anatomic variations and duplication of the bile duct is an extremely rare anomaly. It has been reported to be associated with other congenital conditions like Abnormal Pancreato Biliary Junction (APBJ), biliary atresia and choledochal cyst and may lead to complications like cholangitis, choledocholithiasis and malignancy. The clinical presentation may be with one of the above complications and the condition usually reveals itself only on imaging investigations, as a surprise to the radiologist and the surgeon. Its detection is important prior to any biliary tract surgery to prevent inadvertent bile duct injury. The authors report a case of a rare subtype of extrahepatic bile duct duplication with coexisting choledochal cyst.

Complete surgical resection is the best treatment option for retroperitoneal sarcomas even if it entails a multi-visceral resection. The extent of surgery is determined not only by the aggressiveness of the tumour but also by its location. This report presents a challenging case of retroperitoneal sarcoma and describes the planning and decision-making that resulted in the success of such an extensive surgical procedure.

The portal vein is the main vascular channel of the liver and is affected by many pathologies. Imaging plays an important role in the detection and characterization of these abnormalities, guiding the surgeon and the interventional radiologist in planning further management. We discuss the imaging appearances of various abnormalities affecting the portal vein and the imaging modalities used in their diagnosis. We also briefly discuss the radiological interventions done in some of these cases.

Alveolar echinococcosis is a parasitic disease primarily invading the liver. Due to its aggressive nature, it invades the adjacent structures and can even metastasize to distant organs. The appearance of hepatic involvement on computed tomographic scan is characteristic, but not specific, with areas of calcification seen within a hypoenhancing mass. Although magnetic resonance imaging may better define the extent of the disease, it often misleads the radiologist, especially if the lesion is devoid of cystic component(s) and if it occurs in nonendemic areas. Knowledge of the imaging appearance may prompt serological evaluation and aid in making an early diagnosis and planning appropriate treatment of this uncommon fatal disease, especially in nonendemic areas.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract and may occasionally present with acute gastrointestinal bleed (GIB). Multidetector computed tomography (MDCT) angiography is extremely useful in demonstrating the tumor as well as the presence of active hemorrhage, thereby guiding subsequent interventional or surgical management. We report a case of a 38-year-old man who presented with acute-onset melena and compensated shock, whose source of bleed remained elusive on endoscopy. MDCT angiography performed on a dual-energy scanner showed a jejunal tumor with active intraluminal contrast extravasation. The tumor was subsequently resected and the patient did well on follow-up. This was one of the few instances when MDCT angiography demonstrated active bleeding in a GIST and the first such case demonstrated on a dual-energy scanner.

Purpose: To evaluate the technical and clinical success of radiofrequency ablation of osteoid osteoma and analyze the factors responsible for clinical success. We also tried to investigate the role of follow-up computed tomography (CT) imaging. Materials and Methods: This is a prospective study approved by the institute's ethics committee involving 87 patients with appendicular osteoid osteoma. CT-guided radio frequency ablation was performed using a bipolar ablation system. Patients were followed up over 15.4 (4–24) months for pain, and clinical success/failure was determined using established criteria. Patients with clinical failure were taken for repeat ablation. Follow-up CT was obtained at 6 months and correlated with clinical success. Procedural scans were later reviewed for technical success in a blinded manner and correlated with clinical success along with other imaging and patient characteristics. Results: Mean pre-procedure visual analog scale (VAS) score was 7.0 ± 0.8. Primary success rate after single session was 86.2%(75/87 patients), and overall success rate after one/two sessions was 96.6%(84/87). No major complications were noted. Technical success rate was 89.7%(78/87). All 9 patients who had a suboptimal needle positioning had recurrence where as three patients had recurrence despite technical success. None of the imaging characteristics or history of prior intervention was significantly associated with clinical success. Follow-up CT showed advanced bone healing in 48 lesions, and was confined to the treatment success group. Alternately, minimal/absent bone healing was seen in all (12) patients of primary treatment failure and 27 patients with treatment success. Conclusions: CT-guided percutaneous radio frequency ablation is a safe and highly effective treatment for osteoid osteomas even in recurrent and residual cases. Technical success is the most important parameter affecting the outcome. Post radio frequency ablation CT findings have a good positive but a poor negative predictive value in prognostication.

Summary Background and objective To compare T2W-MRCP and T1W contrast-enhanced MRC (CE-MRC) using Gd-BOPTA for evaluation of biliary-enteric anastomotic (BEA) stricture. Patients and methods Twenty-one patients who were suspected to have BEA stricture underwent T2W-MRCP and CE-MRC on a 1.5 T scanner. Images were evaluated for evidence of anastomotic stricture. Composite gold standard was used including the findings on percutaneous transhepatic cholangiogram or percutaneous transhepatic biliary dilatation, surgery, alkaline phosphatase level and clinical follow-up. Results The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of T2W-MRCP for the diagnosis of anastomotic stricture were 94.4%, 80%, 94.4% and 80% respectively. On CE-MRC, biliary excretion was seen in only 60.87% anastomoses and only these were taken for analysis. The sensitivity, specificity, PPV and NPV of CE-MRC for the diagnosis of anastomotic stricture were 40%, 75%, 80% and 33.3%. The combined evaluation of T2W-MRCP and CE-MRC showed sensitivity, specificity, PPV and NPV of 83.3%, 80%, 93.8% and 57.1%. Conclusion At present, T2W-MRCP is still the diagnostic modality of choice in the evaluation of patients with BEA stricture and the usage of Gd-BOPTA enhanced MRC is inappropriate in this setting.

The glenohumeral joint is the most commonly dislocated joint in the body, and anterior instability is the most common type of shoulder instability. Depending on the etiology and the age of the patient, there may be associated injuries, for example, to the anterior-inferior labro-ligamentous structures (in young individuals with traumatic instability) or to the bony components (commoner in the elderly), which are best visualized using MRI and MR arthrography. Anterior instability is associated with a Bankart lesion and its variants and abnormalities of the anterior band of the inferior glenohumeral ligament (IGHL), whereas posterior instability is associated with reverse Bankart and reverse Hill-Sachs lesions. Cases of multidirectional instability often have no labral pathology on imaging but show specific osseous changes including increased chondrolabral retroversion. This article reviews the relevant anatomy in brief and describes the MRI findings in each type, with the imaging features of the common abnormalities.

Purpose To objectively assess recovery of thumb opposition in patients with carpal tunnel syndrome (CTS) after open carpal tunnel release and to evaluate electrophysiological and magnetic resonance (MR) neurography findings as predictors of thumb opposition recovery. Methods A total of 22 patients with severe CTS and thenar atrophy were included in this study. A detailed clinical, electrophysiological, and MR neurography evaluation was done both before and after surgery at 6 months to assess thumb opposition recovery. Results The median duration of symptoms was 12 months (interquartile range, 12–20 months). The compound muscle action potential of the abductor pollisis brevis (CMAP-APB) also showed statistically significant improvement of 0.5 + 0.2 mV after surgery. Tip-tip pulp pinch strength increased from 1.2 ± 0.4 to 2.0 ± 0.4 kg at 6-month follow-up, lateral pulp pinch strength increased from 1.9 ± 0.6 to 2.8 ± 0.9 kg at 6-month follow-up, and 3-point pulp pinch also improved from 1.9 ± 0.5 to 2.8 ± 0.9 at final follow-up. On MR neurogram, the proportion of patients with abnormal median nerve morphology decreased from 81.8% to 68.2%, abnormal thenar branch morphology decreased from 63.6% to 36.4% and denervation edema deceased from 59.1% to 13.6%. Conclusions Patients suffering from severe CTS with thenar atrophy and detectable CMAP-APB showed promising improvement following open carpal tunnel release. Type of study/level of evidence Prognostic IV.