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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.

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.

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.

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.

Objective: To explore the utility of first-order MRI-texture analysis (TA) parameters in predicting histologic grade and muscle invasion in urinary bladder cancer (UBC). Methods: After ethical clearance, 40 patients with UBC, who were imaged on a 3.0-Tesla scanner, were retrospectively included. Using the TexRADTM platform, two readers placed freehand ROI on the sections demonstrating the largest dimension of the tumor, evaluating only one tumor per patient. Interobserver reproducibility was assessed using the intraclass correlation coefficient (ICC). Mann–Whitney U test and ROC curve analysis were used to identify statistical significance and select parameters with high class separation capacity (AUC >0.8), respectively. Pearson’s test was used to identify redundancy in the results. Results: All texture parameters showed excellent ICC. The best parameters in differentiating high and low-grade tumors were mean/ mean of positive pixels (MPP) at SSF 0 (AUC: 0.897) and kurtosis at SSF 5 (AUC: 0.828) on the ADC images. In differentiating muscle invasive from non-muscle invasive tumors, mean/ MPP at SSF 0 on the ADC images showed AUC >0.8; however, this finding resulted from the confounding effect of high-grade histology on the ADC values of muscle invasive tumors. Conclusion: MRI-TA generated few parameters which were reproducible and useful in predicting histologic grade. No independent parameters predicted muscle invasion. Advances in knowledge: There is lacuna in the literature concerning the role of MRI-TA in the prediction of histologic grade and muscle invasion in UBC. Our study generated a few first-order parameters which were useful in predicting high-grade histology.

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.

Gallbladder cancer is the most common malignancy of the biliary tract. It is also the most aggressive biliary tumor with the shortest median survival duration. Complete surgical resection, the only potentially curative treatment, can be accomplished only in those patients who are diagnosed at an early stage of the disease. Majority (90%) of the patients present at an advanced stage and the management involves a multidisciplinary approach. The role of imaging in gallbladder cancer cannot be overemphasized. Imaging is crucial not only in detecting, staging, and planning management but also in guiding radiological interventions. This article discusses the role of a radiologist in the diagnosis and management of gallbladder cancer.

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.

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

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.

Background: Navigation is associated with improved accuracy in alignment. However, its influence on clinical outcome is inconclusive. The aim of this study was to compare the component alignment and functional outcome in patients undergoing navigation-assisted and conventional total knee replacement (TKR). Materials and method: A prospective randomized study consisting of two groups (group A and group B) was carried out. Group A consisted of patients undergoing TKR using conventional jig-based method, whereas group B consisted of patients undergoing TKR using computer navigation-assisted method. We measured and compared the coronal and sagittal plane alignment in X-ray and rotational alignment in computed tomography scan between both groups. Functional outcome was analysed using Knee Society Score (KSS) and Western Ontario and McMaster University scale (WOMAC) score. Results: A total of 50 patients were randomized into two groups A and B each with 25 patients. Navigation was associated with more accuracy in mechanical axis alignment ( p = 0.011) and femoral component rotation ( p = 0.033). The mean follow-up was 4.6 years (range 48–62 months). There was no statistically significant difference between the groups with respect to KSS and WOMAC score at the minimum follow-up of 4 years. Conclusion: We concluded that even though navigation-assisted system is associated with better accuracy, there was no difference in clinical outcome at an average follow-up of 4.6 years.

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.

OBJECTIVE: To assess the accuracy of splenic stiffness (SS) measured by 2D-shear wave elastography (SWE) for predicting variceal bleeding in the patients with extrahepatic portal vein obstruction (EHPVO). METHODS: 52 patients with EHPVO (mean age: 22.29 years; 26 each males and females) were included in the study after obtaining approval from the institute ethics committee. All patients initially underwent upper gastrointestinal endoscopy followed by ultrasonography, including 2D-SWE on the Aixplorer Supersonic Imagine scanner. The SS was measured through the anterior abdominal wall and an average of three measurements was taken. The SS was then compared with clinical symptoms, variceal grade, and other ultrasonography (USG) parameters. USG parameters were also compared with variceal grade. RESULTS: The mean SS was 44.92 ± 12.35 kPa. There was no significant difference in the mean SS of patients with high grade varices (44.30 kPa; n = 25) from those with low grade varices (46.91 kPa; n = 20). The ROC analysis showed a poor area under the curve of 0.477 for the prediction of high grade varices by the SS. The SS did not show any significant correlation with other ultrasonography parameters except splenic size, with which there was a weak but significant correlation. The measurement of SS by 2D-SWE was reliable and Cronbach’s alpha was 0.905. CONCLUSION: The SS measured by 2D-SWE is not an accurate predictor of variceal grade and thus bleeding in patients of EHPVO. ADVANCES IN KNOWLEDGE: EHPVO is a vascular pathology with most patients showing splenomegaly and preserved liver function. Although, elastography of spleen has been shown to be useful in patients with cirrhosis for predicting portal hypertension, it does not seem to be helpful in patients with EHPVO.

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.

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.

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.

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.

Peripheral neuropathy is defined as any disease or damage to the peripheral nerves. Imaging modalities are emerging as a complementary tool of choice for diagnosis of peripheral neuropathies. This has been made possible by the advent of high-resolution ultrasound, higher field strength magnets, better surface array coils, and superior software. In addition, imaging plays a pivotal role in deciding the management. They help in determining the continuity and course of the nerve, thereby helping in the pre-surgical mapping of nerve. Imaging studies also help in prognosticating the recovery by determining the event to be acute or chronic. This article describes the imaging findings of various neuropathies affecting upper limb peripheral nerves, broadly categorized as traumatic and non-traumatic. The non-traumatic group is further divided as entrapment, infective, inflammatory and tumors.

Objective: In the management of epithelial ovarian cancer (EOC), the identification of peritoneal deposits is the most important prognostic factor. We conducted a prospective study to evaluate the role of multidetector CT (MDCT) in identifying peritoneal deposits pre-operatively. Methods: 38 previously untreated patients (median age 50 years; range 26–70 years) were evaluated with contrast-enhanced MDCT of the abdomen and pelvis. All CT scans were performed on a four-slice MDCT scanner with thin-slice image acquisition. Multiplanar coronal, sagittal or oblique images were constructed and all images were reviewed by at least two radiologists. The extent of disease was determined and mapped for all areas of the abdomen and pelvis. CT scans were reviewed and compared with surgical findings. Peritoneal deposits and thickening were separately noted for each of the nine segments of the abdomen and pelvis (i.e. bilateral hypochondria, bilateral lumbar, bilateral iliac fossa, epigastrium, umbilical region and hypogastrium) and were mainly used to determine the accuracy of MDCT in the depiction of peritoneal carcinomatosis. Results: Sensitivity, specificity, positive and negative predictive values and accuracy of CT in the detection of peritoneal deposits were similar to those reported in the literature. The most common anatomical sites to have peritoneal deposits were the pouch of Douglas (18 cases) and the right subdiaphragmatic region (18 cases). Conclusion: Despite the improved scanning technology, image reconstruction and viewing ability of MDCT, its overall accuracy for the detection of peritoneal deposits is not significantly improved when compared with conventional CT; however, MDCT is useful in the assessment of disease at specific locations in the abdomen and pelvis.

Hemangioma is the most common benign tumor of liver and is often asymptomatic. Spontaneous rupture is rare but has a catastrophic outcome if not promptly managed. Emergent hepatic resection has been the treatment of choice but has high operative mortality. Preoperative transcatheter arterial embolization (TAE) can significantly improve outcome in such patients. We report a case of spontaneous rupture of giant hepatic hemangioma that presented with abdominal pain and shock due to hemoperitoneum. Patient was successfully managed by TAE, followed by tumor resection. TAE is an effective procedure in symptomatic hemangiomas, and should be considered in such high risk patients prior to surgery.

A broad spectrum of congenital anomalies and pathologic conditions can affect the inferior vena cava (IVC). Most congenital anomalies are asymptomatic; consequently, an awareness of their existence and imaging appearances is necessary to avoid misinterpretation. Imaging also plays a central role in the diagnosis of Budd-Chiari syndrome secondary to membranous obstruction of the intrahepatic IVC. Primary malignancy of the IVC is far less common than intracaval extension of malignant tumors arising in adjacent organs, and imaging can accurately help determine the presence and extent of tumor thrombus, information that is crucial for surgical planning. However, the radiologist should be aware that artifactual filling defects at computed tomography and magnetic resonance imaging can mimic true thrombus in the IVC and must be able to differentiate true from pseudo filling defects. Other imaging findings such as flat IVC and early enhancement of the IVC are useful in limiting the differential diagnosis. Familiarity with the imaging features of the various congenital and pathologic entities that can affect the IVC is paramount for early diagnosis and management.

To prospectively evaluate, in a multicenter clinical trial, dosimetry-guided transarterial radionuclide therapy (TART) with rhenium 188 ((188)Re) 4-hexadecyl 1,2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol (HDD)-labeled iodized oil in inoperable hepatocellular carcinoma (HCC).Ninety-three patients were recruited from 2000 to 2005 for this ethics committee-approved study. Informed written consent was obtained. After complete clinical evaluation (including assessment of liver status, serum alpha-fetoprotein [AFP] level, tumor size, portal vein status, Child-Pugh classification, Okuda staging), radiation absorbed dose (RAD) to various organs, including tumor, was calculated after injecting 185 MBq of (188)Re HDD iodized oil via the hepatic artery. From this value, the maximum tolerable activity of (188)Re, defined as the amount of radioactivity delivering no more than 12 Gy of RAD to lungs, 30 Gy to normal liver, or 1.5 Gy to bone marrow, was calculated and injected.Mean patient age was 53 years (80 men and 13 women). Sixty-eight percent of patients had serologic evidence of hepatitis B and/or C; 40% had clinicoradiologic evidence of cirrhosis. Mean tumor diameter was 10.3 cm +/- 4.4, with 40% of patients having more than three lesions; in 50% of patients, tumor was either unilateral, occupying 50% or more of the liver, or bilateral. AFP was elevated in 68% of patients and was elevated to more than 300 ng/mL in 44% of patients. There was portal vein thrombosis in 38% of patients, Child-Pugh status B disease in 37% of patients, and Okuda stage II or III disease in 50% of patients. Mean first administered activity was 5.3 GBq +/- 1.6, which delivered 88 Gy of RAD to the tumor. Treatment was tolerated well. Of 66 patients in whom complete tumor response occurred, five (8%) had complete tumor mass ablation, 17 (26%) had a partial response (50% tumor reduction), and 23 (35%) had stable disease. Only RAD to the tumors was found to be significantly (P = .001) associated with tumor and/or AFP response. Survival rates at 6, 9, 12, 24, and 36 months among patients with objective tumor response were 100%, 95%, 90%, 58%, and 30%, respectively, with a median survival of 980 days.TART appears to be a safe, effective, and promising therapeutic option in patients with inoperable HCC.

Purpose To evaluate the results of radiofrequency ablation in treating hepatic metastases from breast cancer. Materials and methods Fourteen breast cancer patients with 16 hepatic metastases measuring 1.1 to 4.0 cm in the longest axis (mean, 1.9 cm) were prospectively studied. All patients had previously received chemotherapy. Radiofrequency ablation was done using 17-G, internally cooled electrodes under ultrasound guidance. A single index tumor was treated in 12 patients, and two tumors each were treated in two patients. Follow-up was done using serial computed tomography for a duration ranging from 6 to 45 months (mean, 18 months; median, 16 months). Results All patients were treated in a single session. No major complications occurred. Minor complications or side effects (asymptomatic pleural effusion, perihepatic fluid collection) were observed in three patients. Complete necrosis, defined as an absence of detectable disease on computed tomography at 6 months follow-up was achieved in 14 (88%) of 16 index tumors. Treatment failure due to the development of new metastases was observed in seven (50%) of 14 patients. Five (36%) patients died in the first 12 months after radiofrequency ablation due to the development of new hepatic and extrahepatic metastases. At the time of writing, nine (64%) of 14 patients are alive, of whom four patients (29%) are disease-free and three patients (21%) are progression-free. Conclusions A high overall treatment failure rate (50%) was observed due to the development of new metastases on follow-up. Despite this, radiofrequency ablation appears to be a safe and effective adjunct to systemic chemotherapy for the loco-regional treatment of liver metastases from breast cancer.

We tried to evaluate the role of dosimetry-guided transarterial radionuclide therapy (TART) with rhenium-188 (Re-188)-4-hexadecyl 1-2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol (HDD)-lipiodol in a patient with multiple intrahepatic recurrences after radiofrequency ablation of hepatocellular carcinoma (HCC). The dosimetry helped in delivering the maximum possible activity of Re-188, thus the radiation-absorbed dose, safely to the tumour without jeopardizing other organs. There was no procedure-related complication and the patient tolerated therapy well with no adverse effects. The lesions were completely ablated with a single dose of Re-188 and the patient has been disease free for the past 18 months. TART with Re-188-HDD-lipiodol appears to be a promising therapeutic option in patients with HCC who experience recurrence after percutaneous ablative therapy.

Surgical resection with partial hepatectomy is the treatment of choice in patients with hepatocellular carcinoma (HCC). However, after recurrence, which is common, such patients have limited therapeutic options. In the present report, transarterial radionuclide therapy (TART) with rhenium 188 HDD–labeled Lipiodol was used to treat a patient with postsurgical recurrence of HCC. The patient tolerated therapy well and the lesions were completely ablated with a single dose of 188 Re; the patient is free of disease for 14 months. TART with 188 Re-HDD Lipiodol appears to be a promising new therapy in case of HCC recurrence after partial hepatectomy and requires further investigation.

We present the study of colour duplex Doppler ultrasonography on Indian patients with non-vasculogenic erectile dysfunction. Patients with a history suggestive of psychogenic impotence along with a normal clinical response to intracavernosal papaverine were presumed to have non-vasculogenic erectile dysfunction. In our patients, the incidence of psychogenic impotence was much higher and the mean age of patients presenting with erectile dysfunction was lower as compared to patients from developed countries reported in research. The Doppler flowmetry showed much higher mean peak systolic velocities (PSVs) with a negative correlation between age and PSV. End diastolic velocity, resistive index and acceleration time values conformed to the literature.

Primary hepatic lymphoma is an uncommon malignancy affecting the liver, with limited reports and series in the literature. Imaging appearance is not well described, with no definite features suggesting a diagnosis, and it may mimic other focal hepatic lesions. However, biopsy is needed in most of the cases for confirmation. We report a case of 22-year-old pregnant woman who on ultrasonography showed a large heteroechoic solitary liver mass mimicking focal nodular hyperplasia. Further evaluation after parturition with contrast-enhanced magnetic resonance imaging showed a large mass with central scar and peripheral diffusion restriction and contrast enhancement, which was atypical. Biopsy confirmed it as lymphoma. The case illustrates unusual presentation and magnetic resonance imaging features, including diffusion-weighted imaging, of primary hepatic lymphoma in a young female.

Pancreatic necrosis is an important determinant of patient outcome in severe acute pancreatitis (SAP). This prospective study was conducted to evaluate if perfusion CT (PCT) can predict the development of necrosis at an early stage in SAP. PCT was performed within 72 h of abdominal pain in 57 consecutive admitted patients of acute pancreatitis, out of which four patients were excluded. Thirty-two patients were classified as SAP and 21 as mild acute pancreatitis (MAP) on the basis of APACHE II or SIRS criteria or presence of organ failure. All patients underwent a follow-up CECT at 3 weeks to look for pancreatic necrosis. Out of 32 patients of SAP, 14 patients showed perfusion defects. The mean blood flow (BF) in these areas was 11.47 ± 5.56 mL/100 mL/min and median blood volume (BV) was 3.92 mL/100 mL (0.5–8.49 mL/100 mL). All these patients developed necrosis on follow-up scan. Two patients who did not show perfusion defects also developed necrosis. Remaining 37 patients (16 SAP and 21 MAP) did not show perfusion defect and did not develop necrosis on follow-up. All regions showing BF less than ≤23.45 mL/100 mL/min and BV ≤8.49 mL/100 mL developed pancreatic necrosis. The values of perfusion parameters may vary with the scanner, mathematical model and protocol used. The sensitivity and specificity of PCT for predicting pancreatic necrosis were 87.5% and 100%, respectively. The cut off values of BF and BV for predicting the development of pancreatic necrosis were 27.29 mL/100 mL/min and 8.96 mL/100 mL, respectively, based on ROC curve. PCT is a reliable tool for early prediction of pancreatic necrosis, which may open new avenues to prevent this ominous complication.

This prospective study evaluated the clinical and radiologic results of transcatheter arterial embolization (TAE) for the treatment of symptomatic cavernous hemangiomas of the liver. The technique, its complications, and effectiveness also were analyzed.Eight patients (five male, three female; mean age +/- SD = 47.75 +/- 8.59 years) with symptomatic cavernous hemangiomas of the liver were treated by TAE with polyvinyl alcohol particles or gelfoam and steel coils (single session) followed by supportive treatment. Tumor characterization (including the extent and number of lesions) was done on triple-phase helical computed tomography or gadolinium-enhanced dynamic magnetic resonance imaging.The lesions were located in the right lobe in five patients, left lobe in one, and both lobes in two. The largest diameter of the lesions was 6-18 cm (9.28 +/- 5.13 cm). The treatment response was assessed on follow-up ultrasound and color Doppler and/or contrast-enhanced helical computed tomography. There were no treatment-related deaths and morbidity was minimal. Embolization was the only method of treatment in seven patients; however, one patient had surgery after TAE because the symptoms were only partly relieved. Indications for embolization were abdominal pain (eight patients), rapid tumor enlargement (four of eight), and recurrent jaundice (one of eight). Symptomatic improvement was documented in all patients after embolization. Symptoms did not worsen in any patient. The mean size of the tumor did not show any statistically significant change on follow-up radiologic examinations. However, in one patient, the tumor significantly regressed in size after embolization.TAE of hepatic cavernous hemangioma is a useful procedure in the therapy of symptomatic hemangiomas.

Gastrointestinal hemorrhage in patients with hepatocellular carcinoma is common and a major contributor to mortality. These patients tend to have a very poor prognosis. This report describes five such cases in which gastrointestinal bleeding was one of the presenting problems and required urgent management. The causes of massive intermittent gastrointestinal bleeding were variceal (two cases), direct invasion of the duodenum (one case), transverse colon (one case), and stomach (one case). All five patients were inoperable because of locally advanced disease, poor general condition, or comorbid disorders and were managed with angioembolization. After transcatheter embolization, the bleeding stopped completely in two patients and was reduced significantly in the remaining three. We report the role of transhepatic arterioembolization in the management of gastrointestinal bleed in such patients, and we recommend its use more often in similar situations.

An 8-month-old infant presented to our hospital with global developmental delay. MRI brain findings revealed the diagnosis of syntelencephaly ([figure][1], A–C). ![Figure][2] Figure Syntelencephaly: MRI appearance Axial T1-weighted inversion recovery (IR) sequence shows absence of septum

Purpose.To compare magnetic resonance (MR) arthrography and arthroscopy as a means of assessing the severity of labral tear in anterior glenohumeral instability.Methods.52 patients presenting with traumatic recurrent anterior shoulder instability were evaluated using MR arthrography; 30 shoulders with a labroligamentous lesion were treated with arthroscopic Bankart repair. Their MR arthrographic images were interpreted by 3 senior musculoskeletal radiologists, and a radiological diagnosis was reached by consensus. The sensitivity and positive predictive values of MR arthrography for detecting a labral tear were determined. Agreement between MR arthrography and arthroscopy in terms of the width and depth of the labral tear was analysed.Results.On arthroscopy, a labroligamentous lesion (Bankart lesion and its variants) was present in all the 30 shoulders. Agreement between the MR arthrography and arthroscopy in terms of the width and depth of the labral tears was good.Conclusion.MR arthrography is an accurate means of assessing the severity of anterior labroligamentous lesions and yields a good correlation with arthroscopy.

Purpose To evaluate prospectively the role and impact of multidetector row computed tomography (MDCT) before bronchial artery embolization (BAE) in patients with hemoptysis. Methods MDCT of the thorax was performed in 27 patients (21 men, 6 women; age range, 22-70 years; mean, 39 years) with hemoptysis who were referred for BAE. Transverse, multiplanar reconstruction, and 3-dimensional reconstruction (maximum intensity projection and volume rendered) images were analysed to identify the abnormal hypertrophied bronchial and nonbronchial systemic arteries causing hemoptysis, their origin and course were noted. Digital subtraction angiography was performed with the knowledge of findings of MDCT. Selective arteriogram of abnormal bronchial as well as nonbronchial arteries was performed. Embolization was attempted in 25 of these patients (92.6%) by using polyvinyl alcohol particles (350-500 μm), Gelfoam or Embospheres (400-700 μm). Follow-up was done for a mean period of 20.5 months. Results Based on MDCT, 2 of 27 patients were found unsuitable for BAE. On computed tomography, 38 arteries (27 bronchial and 11 nonbronchial systemic arteries) were identified as abnormal hypertrophied vessels. On angiography, 34 of these arteries (25 bronchial and 9 nonbronchial systemic arteries) were found to be responsible for hemoptysis. Three of these arteries could not be evaluated during angiography, and 1 artery that was identified as abnormal on computed tomography was found normal on angiography. All 25 bronchial and 9 nonbronchial systemic arteries that cause hemoptysis were detected at MDCT. Embolization was successful in 23 of 25 patients. Conclusion MDCT enables detection and depiction of all bronchial and nonbronchial systemic arteries causing hemoptysis.

We present a case of multifocal epithelioid hemangioendothelioma occurring in an adolescent boy who presented with massive hemoptysis and showed a pulmonary perihilar mass with multiple lesions in the liver and two lytic lesions in the ribs on imaging. The diagnosis was confirmed by lung and liver biopsy. He was treated with oral steroids.

To prospectively compare the feasibility, safety and diagnostic role of carbon dioxide (CO(2)) digital subtraction angiography (DSA) using a 'home made' delivery system with iodinated contrast medium (ICM) DSA in the evaluation of peripheral arterial occlusive diseases (PAOD) of lower limbs. Twenty-one patients (27 limbs; all men; mean age, 47.6 years) who presented with PAOD of lower limbs underwent DSA using both intra-arterial CO(2) and ICM. Conventional ICM DSA was performed first and used as gold standard. Carbon dioxide was then injected by hand using a locally improvised home made plastic bag delivery system. Patient tolerance was assessed subjectively. Arteries from aortic bifurcation to the ankle were independently evaluated by two radiologists and graded for stenosis using a five-point scale. For each patient, the quality of CO(2) DSA images were compared with the corresponding images of ICM DSA and an overall grade of 'good', 'acceptable' or 'poor' was assigned. Cohen's kappa coefficient was used to determine inter-observer agreement. Carbon dioxide opacified 86.2% (188/195) of major arteries and depicted stenosis adequately in 84.5% (191/226) of arterial segments. A good or acceptable image quality of CO(2) DSA was obtained in over 95% of patients. Infrapopliteal arteries were inadequately visualized. Mild pain was seen in six (28.6%) patients with both contrast agents; one patient developed severe pain during CO(2) DSA. Inter-observer agreement was good (k > 0.75) at 70% of the segments. Administration of CO(2) into lower limb arteries is well tolerated. Carbon dioxide DSA using the locally improvised home made delivery system is a feasible and safe alternative to ICM DSA in the evaluation of PAOD. It provides adequate imaging of arteries of lower extremities except infrapopliteal segments.

MR-guided biopsy may aid to obtain samples in cases which are not feasible with conventional US or CT guidance. To evaluate safety and efficacy of MRI-guided abdominal biopsy at 1.5-T closed MR system. MRI guided abdominal biopsy was performed using Siemens Avanto 1.5-T closed MR system. Eighteen samples were obtained in 10 patients under local anesthesia using a novel technique to define skin entry site. None of the cases included in the study were amenable to biopsy using the conventional ultrasound (US) or computed tomography (CT) guidance. MR compatible 18G needle (US Biopsy) was used to obtain biopsy samples. Intravenous gadolinium was used in two patients for better delineation during biopsy. Patients were followed up for 3–5 h and were discharged on the same day. Technical success was achieved in all patients. Average number of biopsy passes were two (range 1–4). All biopsy samples were adequate for histopathological examination. Average size of the core biopsy specimen was 9 mm. 1.5-T closed MR system allows adequate biopsy sampling from various abdominal organs. This technique may help to sample lesions which are not otherwise amenable for biopsy under conventional CT or US guidance.

Choledochal cyst is a rare congenital anomaly of the biliary system, presenting in infancy. Two cases of choledochal cyst (one infected) with grossly deranged liver function tests and associated biliary atresia, which were successfully managed pre-operatively by sonoguided percutaneous choledochalcystostomy, are reported here. The use of this technique in the treatment of patients such as these is proposed.

article i nfo Objective: To evaluate the efficacy and complications of uterine artery embolization (UAE) versus laparoscopic occlusion of uterine vessels (LOUV) in the management of symptomatic fibroids. Methods: A pilot randomized clinical trial in which 20 patients with symptomatic fibroids were randomly allocated into two groups. Ten women underwent UAE, and 10 women underwent LOUV. Symptomatic improvement in menorrhagia and reduction in the volumes of the uterus and the fibroid were assessed at 3 and 6 months. Results: The patients were comparable with regard to age and parity. At 6 months, there was no significant difference in the mean reduction in menstrual blood loss, uterine volume, and volume of the dominant fibroid between the two groups (P=0.436, P=0.796, P=1.00, respectively). However, higher pain scores were recorded on day 1 in the UAE group compared with the LOUV group (P=0.0002). Conclusions: The effects of UAE and LOUV in the management of symptomatic fibroids are comparable. The main advantage of LOUV is less postoperative pain compared with UAE. © 2009 InternationalFederationofGynecologyandObstetrics.PublishedbyElsevierIrelandLtd.Allrightsreserved.