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Extrahepatic duplication of the common bile duct (CBD) is an extremely rare anatomic variation seen in the biliary tract. It represents failure of regression of the primitive duplicated biliary ductal system, resulting in five different subtypes of the duplicated CBD as described by Choi et al. To date, only few such cases have been reported in the literature. Associated variation in branching of intrahepatic bile ducts presenting as combined dual ductal anomaly is even rarer phenomena to be seen. We report a case of a 67-year-old man with chronic kidney disease and obstructive jaundice resulting from choledocholithiasis. Evaluation revealed type IIIa branching of intrahepatic bile ducts with type Va duplication of the CBD.

The COVID-19 pandemic has caused multi-dimensional global crisis in the recent times. There is an increasing necessity of understanding and developing a strategy for optimal utilization of healthcare resources in this time of crisis. Radiology department remains the backbone for diagnosis and for appropriate management of orthopaedic ailments. Amidst COVID-19 pandemic, there is a need to change in imaging algorithm, for various clinical conditions taking care of the exposure risk to patients and healthcare workers and to handle the volume of diagnostic and intervention work. Radiology preparedness is to set the workflow protocols and policies applicable to radiology investigations for different clinical conditions, which will help to attain these objectives. Radiologists are in best position to decide the most appropriate imaging investigation and protocol making it vital to have a frequent Orthopaedic surgeon–Radiologist interaction, which is one of the most important steps in patient management pathway.

Most of the fetal deformities are caused due to genetic abnormalities. Although magnetic resonance imaging (MRI) may be used to accurately diagnose these deformities, it has been reported that gene analysis is a more accurate diagnostic method. Harlequin ichthyosis (HI) or Ichthyosis fetalis (IF) is a rare and extremely severe hereditary skin disorder with autosomal recessive inheritance. The ultrasound features have been described well and the diagnosis can be made with a fair degree of confidence. However, the final diagnosis needs to be established by prenatal invasive tests. In the present study, we describe the diagnosis of HI in the third trimester on fetal MRI referred to our department with suspicion of anterior encephalocele which was later confirmed through postnatal genetic evaluation.

Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on July 7, 2021.

Objectives This prospective study was conducted to evaluate the site-specific incidence of extra-cranial cysticercosis and to study the imaging spectrum of cysticercosis at extra-cranial locations. Material/Methods The study included a total of 57 sites of involvement in 55 patients over a period of two years. All the patients with imaging-based diagnosis of cysticercosis at extra-cranial locations were studied to determine the imaging patterns. Results These extra-cranial locations included orbit (8.7% of all sites), extra-orbital skeletal muscles (19.44%), skin & subcutaneous tissue (5.2%), parotid gland (3.5%), and miscellaneous (1.75%). Visualization of a cyst with an eccentric nodule was present in 37.2%, while cyst without any definite eccentric nodule was seen at 62.8% extra-cranial sites. Rounded cyst morphology was seen at 24.4% sites, while 75.6% sites showed deformed cysts in extra-cranial cysticercosis. Discussion Cysticercosis is commonly seen at extra-cranial locations and often manifest with several common and uncommon patterns. Typical imaging morphology of cysticercosis is less common at extra-cranial locations, as compared to intra-cranial sites and probably account for diagnostic delays.

Cirrhosis of liver is often a silent disease and need early diagnosis for effective treatment strategy. The present article aims to describe new imaging signs for early diagnosis of cirrhosis on routine CT. These are ‘hepato-diaphragmatic fat interposition’ (HDFI) and ‘increased right hemi-diaphragmatic thickness’ (increased r-DT sign). This was a retrospective study based on the presence or absence of cirrhosis of liver (n = 100). ‘HDFI sign’ was labeled as positive if F is more than 50% of D; where F is the medio-lateral extent of the intra-abdominal fat along the postero-medial margin of liver and D is the distance from the lateral vertebral margin to the medial margin of the outer-most rib in the same axial image. Increased ‘r-DT sign’ is labeled when the dimension on right side exceeds left side by at least 0.2 cm. Pearson χ2 was performed to calculate the p value. A p value of

Congenital brain tumors (CBTs) are extremely rare and account for only 0.5%-1.9% of all pediatric brain tumors. Medulloepithelioma is one of the rare tumors with an incidence of about 1% among all CBTs with a very dismal prognosis and typically diagnosed at the median age of 24 months. The objective is reporting medulloepithelioma presenting in the intrauterine period with very few prior cases being reported in the prenatal period, and to add to the limited existing literature on medulloepithelioma. We present a rare case of medulloepithelioma referred to us in the antenatal period at 27 weeks and subsequently causing intrauterine fetal demise. Prenatal MRI of the fetal brain and postnatal histopathological findings on autopsy were suggestive of intracranial medulloepithelioma.

Pancreatic inflammation limited to the area between the wall of the duodenum and common bile duct is referred to as groove pancreatitis. The condition is often associated with cystic dystrophy in the medial wall of the duodenum. These patients can present with features of either pancreatitis or pancreatic malignancy. CA19.9 levels are usually normal and serum amylase and lipase may be slightly elevated. Diagnosis is confirmed with either computerized tomography abdomen or endoscopic ultrasound. Management consists of conservative management and endoscopic shincterotomy. Pancreatico-duodenectomy may be required in some cases. In our case, a pancreatico-duodenectomy was required as the patient was suffering from gastric outlet obstruction and severe episodes of recurrent acute pancreatitis.

Purpose To evaluate whether shear-wave sonoelastography can help differentiate stable renal allograft from acute allograft dysfunction and chronic allograft dysfunction and to correlate shear-wave sonoelastography measurements with resistive index (RI), serum creatinine level, estimated glomerular filtration rate (eGFR) obtained with the Nankivell equation, and biopsy findings. Materials and Methods A prospective study of 60 patients who had undergone renal transplantation was conducted between October 2014 and March 2016. Patients were classified as having stable allograft, acute allograft dysfunction, or chronic allograft dysfunction on the basis of clinical parameters. Mean parenchymal stiffness was compared. The Banff score was used wherever applicable. Receiver operating characteristic curves were drawn to evaluate the feasibility of differentiation. Results Thirty patients had graft dysfunction (acute in 19 patients and chronic in 11). Mean parenchymal stiffness values in stable allograft, acute allograft dysfunction, and chronic allograft dysfunction were 8.51 kPa ± 2.44, 11.06 kPa ± 2.91, and 24.50 kPa ± 4.49, respectively (stable vs acute dysfunction, P = .010; stable vs chronic dysfunction, P.001; acute sysfunction vs chronic dysfunction, P.001). The allograft parenchymal stiffness values for patients with Banff grade I (mild interstitial fibrosis and tubular atrophy) differed significantly from those with Banff grade II (moderate interstitial fibrosis and tubular atrophy) (P = .02). Parenchymal stiffness showed a negative correlation with eGFR (r = -0.725; P.001) and a positive correlation with RI (r = 0.562; P.001) and serum creatinine level (r = 0.714; P.001). The sensitivity was 73.68% and specificity was 80% in the differentiation of stable graft from acute graft dysfunction (threshold value, 10.11 kPa). Conclusion Shear-wave sonoelastographic evaluation of renal parenchymal stiffness may help differentiate stable allograft from acute and chronic allograft dysfunction. The inverse correlation of parenchymal stiffness with eGFR and positive correlation with RI and serum creatinine level show that shear-wave sonoelastography may reflect functional status of the renal allograft.

The illustrated case of 48 years male highlights the challenges in clinical diagnosis of tubercular arthritis. Multi-modality imaging of knee joint and confirmation with synovial fluid aspiration and biopsy allowed prompt and accurate diagnosis.

Pelvic peritoneal adhesions constitute an important cause of concern which affects the life of millions of people worldwide due to complications like abdominal pain, bowel obstruction and infertility along with challenges in surgical exploration. Precise pre-operative diagnosis of the presence and extent of peritoneal adhesions is of great clinical and surgical importance. Diagnostic laparoscopy to detect peritoneal adhesions may itself lead to formation of adhesions. Routine CT and MRI studies are therefore useful non-invasive modalities to achieve this objective. This review article provides a brief background about the causation and patho-physiology of peritoneal adhesions. The article also addresses the range of clinical presentations in these patients, mainly from the gynecologic perspective. This article provides an illustrative review of CT and MRI findings with laparoscopic correlation. A new ′imaging-based grading system′ for pre-operative quantification of the burden of peritoneal adhesions is also proposed. Despite practical challenges in accurate pre-operative diagnosis of peritoneal adhesions on imaging, detection of peritoneal adhesions is certainly feasible on routine CT and MRI scans and should be an integral part of image interpretation.

By definition, antenatal MRI is the MR imaging during state of gestation without causing any significant risk to ongoing pregnancy and the fetus. MRI is in a unique advantageous position during antenatal period where ultrasound often provides limited information and CT is usually avoided due to radiation-related risks. The indications of antenatal MRI can be sub-divided into fetal indications, maternal obstetric indications and maternal non-obstetric indications. Antenatal MRI offers better anticipation of prognosis and facilitates parental counseling by accurate characterization of disease process and detection of concomitant anomalies. Ultrasound will however, remain the primary fetal imaging modality and MRI is not likely to replace its role in fetal imaging because of the proven utility, widespread availability and relatively low cost of ultrasound. But under specific clinical conditions, where Ultrasound does not provide adequate information, MRI is bliss and is a useful adjunct to ultrasound. The specific clinical indications where MRI proved to be more useful include fetal anomaly screening in high risk/precious pregnancy, oligohydramnios / maternal obesity, fetal CNS assessment, characterization of fetal mass, assessment of fetal spine, delineation of fetal alimentary tract and other abdominal viscera, conjoint twin assessment, prior to antenatal intra-uterine fetal surgery or ex-utero intrapartum procedure. MRI indications which are presently at relatively experimental stage include non-invasive MR spectroscopy to detect antenatal fetal hypoxia and lung maturity status. Apart from this, the role of Diffusion-weighted MRI in antenatal imaging of placenta and fetal kidneys/lungs is also likely to emerge in near future. In addition, antenatal MRI also evaluates the maternal pelvis and provides vital information about fetal-pelvic disproportion. By virtue of recent advances in MR technology and the need to practice evidence-based medicine, antenatal MRI is now rapidly moving from the realms of select academic medical centers into community practice in India. The article provides a brief update on antenatal MRI in routine clinical practice.

The present article reports a triad of right renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction (Zinner syndrome) in a 19-year boy who presented with urinary symptoms. A detailed review of the relevant literature is also presented.

To compare the transrectal (TR) spectral Doppler findings between benign prostatic hyperplasia group and prostate cancer group.All the patients were assessed for adequate preparation, and informed consent was obtained prior to the procedure. The control group (n = 33) comprised patients who were negative for malignancy on biopsy. The study group (n = 22) were positive for malignancy and were also divided into three groups on the basis of the Gleason score. Study parameters included mean values for resistive index (RI), pulsatality index (PI), systolic/diastolic ratio (S/D) and peak systolic velocity (PSV). These were separately measured for bilateral capsular and urethral branches and compared between groups. In patients with unilateral tumour, these were compared between the tumour and non-tumour sides. Finally, the parameters were compared with patient's age. Mann-Whitney U test was used to evaluate the statistical significance.The mean values of RI, PI, S/D and PSV were found to be 0.84/1.03, 1.8/1.99, 3.93/4.45 and 15.52/16.15 cm s(-1), respectively, in the control and study groups which were not statistically significant. In patients with unilateral malignancy (n = 16), there was no significant difference from the non-tumour side. Doppler parameters showed statistically significant relationships with age. The mean of minimum RI was found to be 0.60 in patients less than 60 years of age and 0.76 in patients more than or equal to 60 years of age in the benign category (p-value = 0.014). The PI and S/D also showed significant difference in the benign category.TR spectral Doppler parameters did not reveal any significant difference in patients with or without prostatic malignancy, irrespective of the Gleason grade. Doppler parameters, however, showed significant correlation with age and were lower in younger patients.TR spectral Doppler is unlikely to emerge as a diagnostic and prognostic tool for prostate carcinoma.

Renal transplant complications are categorized as those related to the transplant vasculature, collecting system, perinephric space, renal parenchyma, and miscellaneous complications including posttransplant lymphoproliferative disorder. Many of these renal transplant complications are diagnosed with imaging. Medical complications including rejection, acute tubular necrosis, and drug toxicity also can impair renal function. These medical complications are typically indistinguishable at imaging, and biopsy may be performed to establish a diagnosis. Normal transplant anatomy, imaging techniques, and the appearances of renal transplant complications at ultrasound, computed tomography, and MR imaging are reviewed.

Thoracic endometriosis syndrome is a rare disorder characterized by the presence of functioning endometrial tissue in the pleura, the lung parenchyma, or the airways. The diagnosis of thoracic endometriosis syndrome is usually based on the temporal relationship of the patient’s symptoms with menses

Learning Point for Clinicians Cysticercosis is now seen as a global disease affecting the whole world, and clinicians should be aware of the typical clinical presentations and imaging findings of rice-like or starry sky appearance in order to avoid misdiagnosis and thereby instituting appropriate treatment. A 28-year-old man without significant medical history presented to our hospital for premarital health checkup. On clinical examination, several lumps were palpated in the skin of the entire body, with arms and legs predominance. No other clinical abnormalities were found, with normal neurological and opthalmological examinations. Past history revealed occasional eating of several kinds of raw meat during his stay in the rural mountainous region. Blood tests revealed normal hematocrit profile and WBC count. Radiographs were performed which revealed numerous rice-like ovoid calcified lesions resembling starry sky appearance in the abdomen and lower extremities with lower limb predominance (Figure 1, Panel A). Considering high suspicion for parasitic infestation, magnetic resonance imaging (MRI) of the lower extremities was performed for better …

NOTICE: THIS ARTICLE HAS BEEN RETRACTED Salmonella typhi infection presents most commonly as typhoid fever and infrequently as extraintestinal localized infections of bone, joints, soft tissues, spleen, endocarditis, pulmonary, hepatobiliary, genital and urinary systems. Urinary tract infection (UTI) is rare and clinical presentation is indistinguishable from UTIs due to other etiological agents or may even be asymptomatic. We report two cases of patients with chronic kidney disease with UTI due to Salmonella typhi . Renal cyst, nephrolithiasis and urethral strictures were the concomitant findings in one case and renal tubular acidosis with nephrocalcinosis in the other. In patients with relapses and a chronic course with coexisting functional or structural abnormalities of the urinary tract system, the suspicion of salmonella as one of the probable causative agents should be kept in mind so as to ensure appropriate and adequate therapy. Also in the presence of long-standing hypokalemia, one must investigate for renal abnormalities and vice versa. World J Nephrol Urol. 2017;6(3-4):32-34 doi: https://doi.org/10.14740/wjnu310w

The present article reports a case of a 21 years male that was diagnosed to have isolated intramuscular hydatid cyst of the biceps brachii on Ultrasound and MRI. The ‘Scroll appearance’ of the ruptured endocyst in this case is likely to be an intervening transient stage in evolution of the disease and also indicates recent rupture of the endocyst.

Clinical symptoms and signs of ovarian torsion are often nonspecific, and imaging studies have a crucial role in making an accurate timely diagnosis. Ultrasound with color Doppler is often the initial investigation. However, as illustrated in our case, a normal Doppler study cannot exclude the diagnosis of ovarian torsion, and MRI should be performed if a high degree of concern for ovarian torsion persists. We report a case of a case of an 18-year-old female who was diagnosed with ovarian torsion on MRI. To the best of our knowledge, "whirlpool sign on MRI" has not been reported previously. If this sign is present, a specific diagnosis of ovarian torsion can be made.

A 45-year-old male presented with a clinical history of vague upper abdominal pain. There was no significant medical illness or any history of renal disease in the past. Clinical examination and laboratory parameters were unremarkable. A serum creatinine value of 0.83 mg/dL, serum sodium of 139 mEq/L and serum potassium of 4.2 mEq/L were reported. Contrast-enhanced CT study of the abdomen revealed a ‘horseshoe’ configuration of the kidneys with a thick pre-aortic parenchymal isthmus (Figure ​(Figure1).1). The kidneys also showed multiple parenchymal cysts of varying sizes (Panels A and B). These cysts were seen to involve the cortical as well as medullary regions. The renal parenchymal enhancement and contrast excretion were preserved. No definite hydroureteronephrosis, calculus or mass lesion was identified. Multiple small parenchymal cysts were also seen in the liver. No definite cysts were seen in pancreas or seminal vesicles. The diagnosis of polycystic horseshoe kidney was made, which was in fact an incidental detection, as the abdominal pain was ascribed to cholelithiasis and the renal functions were preserved. Fig. 1. Coronal (left panel) and axial (right panel) contrast-enhanced CT images showing a horseshoe configuration of the kidneys, which also shows multiple parenchymal cysts of varying sizes (arrows in both panels). The liver also shows multiple parenchymal ... Polycystic horseshoe kidney is a combination of two distinct renal disorders. Horseshoe kidney is a renal fusion anomaly during embryogenesis while autosomal-dominant polycystic kidney disease (ADPKD) is a hereditary disorder due to gene mutations. Horseshoe kidney is the most common of all renal fusion anomalies and is often asymptomatic. ADPKD is the third most common cause of end-stage renal disease. Polycystic horseshoe kidney is, however, extremely rare with only 20 cases reported in the literature. Concomitant presence of renal polycystic disease and horseshoe anomaly is likely to lower the age of renal failure and therefore warrants closer surveillance of these patients, despite the incidental diagnosis.

Ortner′s syndrome (left recurrent laryngeal nerve palsy caused by cardiovascular pathology) is described in literature as occurring secondary to a variety of conditions. Spontaneous aneurysm of ductus arteriosus is a rare cause of this condition. We present a case where an adult patient with an aneurysm of the ductus arteriosus presented for the first time at the age of 62 years with hoarseness of voice secondary to left recurrent laryngeal nerve palsy.

A 46-year-old man presented with generalized abdominal pain of 6 weeks duration which was more pronounced during the post-prandial period. There was history of intermittent high grade fever with chills since last 34 days. Blood investigations were within normal limits except leukocytosis. Abdominal tenderness and rigidity was also noted on clinical examination. Multi-detector CT (MDCT) of abdomen with angiography revealed multiple segmental foci of small bowel mural thickening and luminal narrowing with proximal dilatation (Fig. 1). The involved segment showed mural stratification with mucosal hyper-enhancement and sub-mucosal edema. There was non-lumen obliterating thrombosis of the proximal part of superior mesenteric artery (SMA). There was near-total occlusion of the SMA in mid segment with nonopacification of the distal branches (Fig. 2). Numerous splanchnic arterial collaterals are also seen with congested venous vasa rectae. Mild generalized peritoneal thickening was also noted without any definite bowel perforation. The patient underwent laparotomy and segmental resection of involved small bowel loops which showed early gangrenous changes. Post-operative investigations however, did not reveal any definite precipitating cause of mesenteric ischemia. Three months later, there was significant improvement in patient’s symptoms. CT scan showed resolution of the thrombus in the proximal SMA and persistent near-total occlusion of the SMA in mid segment. The distal SMA branches showed opacification through extensive splanchnic collaterals.

Dear Sir, With the advent of diagnostic and operative laparoscopy, the role and relevance of hysterosalpingography (HSG) as a routine investigation in infertility is gradually being debated. A recently published article based on a multicenter randomized controlled trial failed to show any statistically significant difference in cumulative pregnancy rates with the routine use of HSG in the workup of infertility.[1] According to us, there are a few technical lapses in the procedure and its interpretation, which result in its relatively poor performance as compared to laparoscopy, hysteroscopy, and salpingoscopy. This issue is now being globally understood and although this procedure has been around for about 100 years, “how-to-do” workshops on HSG were included in the annual conference of the Radiological Society of North America (RSNA) in 2004 and 2005. HSG, if performed and interpreted carefully, can offer a wealth of information.[2] In view of this, the authors undertook a questionnaire-based study to analyze the prevalent clinical practices with respect to HSG, in Delhi and the National Capital Region (NCR) with the aim of predicting the cause of its relatively “poor” performance (See Addendum). The respondents included 50 radiologists and 50 gynecologists, irrespective of their practice settings and years of experience. The predominant number of respondents preferred to use a metal cannula, which is known to cause more pain than a plastic cannula, during the stages of instrumentation, contrast injection and immediately post-procedure.[3] Pre-procedural antibiotics should always be advised.[4] Only 44% of respondents in this study, however, complied with this. As high as 40% of the respondents failed to realize that a slow gradual mode of contrast injection was the best technique to adopt, as this delineates the endometrial cavity in the non-distended state. This provides a unique opportunity to diagnose small subtle intra-endometrial space-occupying lesions or synechiae, which tend to get obscured in the late-distended phase. The patient should always be asked to empty her bladder before the procedure, to avoid discomfort during cannulation. The role of gentle psychological reassurance cannot be neglected.[5] The procedure should be explained to the patient in detail and no attempt should be made to force the catheter against resistance. The use of the Valsalva maneuver may be helpful during a difficult cannulation. After the images are acquired, a “pull-release” maneuver should always be performed. The relative change in position of the non-median uterus and the fallopian tubes gives vital clues about peritubal adhesions.[4] Interestingly, 78% respondents were not aware of these maneuvers. Less than half of the respondents realized that the external uterine contour could also at times be evaluated on HSG, when the extravasated contrast delineates the uterine surface or when there is significant intravasation into the myometrial veins. This information about the external uterine contour helps diagnose underlying uterine anomalies.[6] A little more than one-third of the respondents realized that HSG was useful in predicting the reproductive outcome in patients with an arcuate uterus. The arcuate uterus ratio is the ratio of the depth of indentation and the intercornual distance. If the arcuate uterus ratio is less than 10%, an adverse reproductive outcome is not anticipated.[7] The respondents were particularly concerned about tubal patency rather than mucosal details or peritubal disease, when it came to tubal imaging. Though, the term “tubal patency” is over-emphasized in HSG literature, the ideal terminology should be “tubal normalcy”. It should be ascertained that contrast spill is truly a “free” intraperitoneal spillage and not a “localized” spill. Peritubal venous intravasation is an important sign on HSG that may favor the likelihood of tubal disease. It would be worthwhile to reiterate here that, “free” intraperitoneal spillage is not the only parameter to establish tubal normalcy on HSG. Mucosal evaluation and the likelihood of peritubal adhesions are integral components of tubal assessment.[8] The majority of respondents felt that the therapeutic effect of radiological contrast media was a myth rather than reality.[9] The awareness of selective salpingography (SS) and fallopian tube catheterization (FTC) procedures was also not widespread. About 72% of respondents were not aware that gametes are relatively radio-resistant as compared to zygotes. Radiation-related issues are certainly valid but these should not be over-emphasized and they do not constitute an ethical evidence to eliminate HSG from routine infertility work-up. The ideal practice would be to adopt an accurate technical protocol, which restricts the radiation dose to “as low as reasonably achievable” (ALARA). HSG should never be performed without a fluoroscopy unit. At least 39% of respondents did not realize that digital fluoroscopy decreases mean skin and ovarian dose as compared to analog systems.[10] Apart from these, the ability to save a particular fluoroscopy frame in a digital system with the automatic elimination of “spot film” acquisition helps in further dose reduction. As revealed in this questionnaire-based analysis, there are definite “technical” and “interpretational” lapses in the clinical practice of the HSG. There are certain individual perceptions about HSG and a professional bias towards alternate options, which tend to drive the clinicians away from HSG. Radiation-related misconceptions are particularly significant. These technical lapses can certainly contribute to the “poor” performance of HSG, apart from its inherent limitations. A proper attention to technique will help make HSG a vital component in routine infertility investigations.