Anand Imaging and Neurosurgical Hospital Pvt. Limited

14/10/2017

14/10/2017

A case of Rheumatic heart disease with Severe MS + AS . Mild to moderate degree of AR and MR were also present . Patient was referred to cardiac center for Surgical valve replacement

25/11/2016

A 11-year-old female patient presented with enlarging , painful left thigh mass . Routine X-ray and MRI imaging were performed upon clinical suspicion of Mitotic lesion .

An anteroposterior X-ray projection was taken . MR imaging sequences included a standard (spin-echo) T1-weighted sequence (750/20), a T2-weighted sequence (6200/230) without fat suppression and high TR , a short inversion time inversion-recovery sequence. Imaging planes included the axial / transverse plane and two orthogonal planes.

MR imaging revealed evidence of a fairly large , relatively well-defined , multi-lobulated , altered signal intensity ( T1 iso to hypointense T2/STIR mixed signal intensity lesion ) measuring ~ 14 x 9 x 10 cm ( CC x AP x Tr ) seen involving the antero-medial aspect of deep muscular plane of left Upper thigh .

The lesion is seen as a broad-based surface soft-tissue mass causing extrinsic erosion and scalloping of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into the soft-tissue component .

The lesion has predominantly chondroid matrix with predominantly hyperintense signal on T2 weighted sequence . The lesion is seen “wrapping around” the circumference of the bone in the mid-diaphyseal region of the left femur .

On X-ray correlation there is sunburst pattern of periosteal reaction seen radiating from bone surface with underlying thickening of the diaphyseal cortex .

The lesion is involving the proximal muscle bellies of Left Vastus lateralis , intermedius and medialis . Anteriorly the lesion is closely abutting the posterior aspect of proximal left re**us femoris muscle and lying deep to the muscle .The lesion is displacing the neurovascular bundles antero-medially .

There is also altered T2/STIR hyperintense marrow signal seen involving the proximal and mid-femoral shaft ? Reactive marrow changes ? Marrow infiltration .

A presumptive diagnosis of Periosteal variant of Juxtacortical osteosarcoma was made on imaging findings , which was later confirmed on histopathology last week .

The radiologic appearance of periosteal osteosarcoma is a broad-based surface soft-tissue mass causing extrinsic erosion of thickened underlying diaphyseal cortex and perpendicular periosteal reaction extending into the soft tissue component. Reactive marrow changes are commonly seen at MR imaging,but true marrow invasion is rare.

Surface or juxtacortical lesions constitute 4%–10% of all osteosarcomas . However, these lesions have classically been subdivided into three types: parosteal, periosteal, and high-grade surface lesions. Forming the basis of these categorizations are differences in clinical, radiologic, and pathologic findings .

Parosteal osteosarcomas have an excellent prognosis (80%–95% long-term survival), and low-grade lesions are usually treated with surgical resection and no neoadjuvant chemotherapy or radiation. Because of their frequent metaphyseal location, large parosteal osteosarcomas or those with deep medullary invasion may require limb salvage, including joint replacement.

In contradistinction, periosteal and high-grade surface osteosarcomas are often treated with neoadjuvant chemotherapy and/or radiation therapy, reflecting their higher degree of anaplasia.

The diaphyseal location of the majority of these lesions enables limb salvage with segmental resection that spares the joint surface. High grade surface osteosarcomas have a worse prognosis (22% long-term survival) than periosteal lesions

Pathologically, Periosteal osteosarcomas are intermediate-to high-grade tumors that are thought to arise from the inner layer of the periosteum. Histologic assessment reveals largely chondroblastic tissue with smaller areas of osteoid formation

Periosteal osteosarcoma accounts for approximately 25% of all juxtacortical osteosarcomas. Like high-grade intramedullary (conventional) osteosarcomas, these lesions affect young patients (in the 2nd and 3rd decades of life) and most frequently (85%–95%) involve the femur and tibia, followed by the ulna and humerus (5%–10%). However, unlike conventional osteosarcomas, these lesions show a strong predilection to arise in the diaphysis.

The classic radiographic findings associated with periosteal osteosarcoma have included thickening of the diaphyseal cortex with scalloping and a perpendicular periosteal reaction extending into a broad-based soft-tissue mass. In contradistinction to parosteal osteosarcoma, these lesions only rarely invade the medullary canal . But in our case marrow invasion was confirmed on histopathology .

09/10/2016

A 46-year old male patient presented with a slowly enlarging, painless right thigh mass. Routine MRI study with contrast revealed evidence of a well-defined , fairly large , altered signal intensity lesion measuring ~ 17 x 6 x 10 cm ( CC x AP x Tr ) seen occupying posterior compartment of right thigh in between the intermuscular fascial plane of adductor brevis and adductor magnus muscles . A small nodular non-lipomatous focus of intermediate signal intensity was also seen on the infero-lateral aspect of the lesion which exhibited contrast enhancement? Region of dedifferentiation.

The lesion has multiple internal T1/T2 hyperintense lobules suppressed on STIR and T2 FS sequences. There are multiple thin, enhancing T2/STIR hyperintense fibrovascular septas seen within the lesion.

The lesion is splaying the right adductor magnus and brevis muscles . Based on the imaging findings a presumptive diagnosis of Low grade well-differentiated Liposarcoma was made which was confirmed on Biopsy report today .

Well-differentiated liposarcoma represents the most common type of soft-tissue liposarcoma, accounting for approximately 50% of all liposarcomas . Overall, there is an equal s*x distribution, although inguinal lesions are more frequent in men. This lesion occurs almost exclusively in adults, with the peak prevalence in the 6th to 7th decades of life. Well-differentiated liposarcoma most frequently affects the deep soft tissues of the extremities . Approximately 51% of all these lesions occur in the lower extremity, particularly the thigh. The retroperitoneum is the second most common location, followed by the upper extremity .

Lesions are most commonly intramuscular, but they also may arise in an intermuscular or subcutaneous location . The clinical characteristics of well-differentiated liposarcoma are typically a painless, slow growing (months to years) soft-tissue mass. Pain and tenderness have been reported in 10%–15% of cases .

Retroperitoneal lesions often manifest with intraabdominal symptoms 5–10 years later than extremity lesions, owing to the difficulty in their detection. Lesions may be quite large at presentation, particularly retroperitoneal lesions, which may be greater than 20 cm in size. The gross pathologic appearance of well differentiated liposarcoma is that of a large, multilobulated, well-circumscribed mass ranging from yellow to white .

Well-differentiated liposarcoma is a low-grade neoplasm with five histologic variants: lipoma-like, sclerosing, inflammatory, spindle cell, and liposarcoma with meningothelial whorls (which may indicate early dedifferentiation). Only the first two types—lipoma-like and sclerosing—are common and many pathologists do not routinely subclassify these lesions.

Low grade lesions (atypical lipomas) are almost entirely fat signal with however thick septa, enhancement or evidence of local invasion. These features are used to distinguish these from simple lipomas .

The higher grade lesions are often devoid of macroscopic fat and have appearances similar to other sarcomas.

Both treatment and prognosis vary with location and grade.

Extremity liposarcomas, especially when well differentiated (atypical lipoma or atypical intramuscular lipoma) are indolent but nonetheless have a tendency to locally recur . The rate of recurrence is higher for deep lesions compared to superficial ones.

High grade lesions, especially those of the retroperitoneum have poor prognosis .

Surgical treatment is with wide local excision, which accounts at least in part for the more favorable outcome of extremity lesions.

27/09/2016

A 35 year old female presented with history of multiple episodes of well-controlled upper GI bleed . There was no history of alcohol consumption or use of hepatotoxic drugs . An extensive laboratory workup for metabolic , hematological and immunological diseases , infections and hepatic disorders was negative . Screening tests for known etiologies of Chronic liver disease ( including hepatitis viral serology , autoantibodies such as antinuclear and anti-smooth muscle antibodies , serum ferritin and ceruloplasmin levels ) were negative . Liver function tests were near normal . However , endoscopy revealed Grade-III gastric varices , while the hepatic venous pressure gradient ( HVPG ) was normal .

Outside USG Whole abdomen was wrongly reported as Cirrhosis with decompensated portal hypertension .

Routine CECT Whole abdomen study was performed at our center.
The study revealed relatively smooth marginated liver with moderate splenomegaly , in keeping with Noncirrhotic portal hypertension ( NCPH ) . The splenoportal axis , although patent , is moderately dilated . Axial images revealed attenuation and pruning of the intrahepatic branches of the left and right portal veins . In addition there are multiple anterior and anterolateral abdominal wall collaterals .

In light of the clinical details , presumptive diagnosis of Non-cirrhotic portal fibrosis ( NCPF ) was made , which was confirmed on subsequent Liver Biopsy . Liver biopsy revealed Obliterative portal venopathy and portal tract fibrosis with absent regenerative nodules in spite of exhibiting features of possible cirrhosis .

NCPH is defined as portal hypertension in the absence of cirrhosis , which is secondary to intrahepatic or prehepatic vascular lesions . The 2 most common causes of NCPH in the developing countries include NCPF ( Non-cirrhotic portal fibrosis ) and EHPVO ( Extrahepatic portal vein obstruction ) .

NCPF or idiopathic portal hypertension ( IPH ) is a disease of uncertain etiology characterized by periportal fibrosis , predominantly involving the small and medium intrahepatic portal vein branches with resultant portal hypertension even as the hepatic function and structure tends to remain normal . The liver , which is initially normal in size and contour , may show atrophy and surface nodularity secondary to reduced blood supply to the peripheral parenchyma in the late stages .

The other causes of NCPH are : Budd-chiari syndrome , veno-occlusive disease , schistosomiasis and congenital hepatic fibrosis .

19/08/2016

A 32 year old female patient presented with complains of chronic, worsening ulnar sided wrist pain and distal forearm pain . She is a busy housewife with three kids . She had no obvious history of any significant trauma .

Routine MRI Wrist study was performed yesterday which revealed these findings :

Axial images at level of distal ulna ( lister's tubercle level of radius) showed hyperintense fluid signal surrounding the ECU tendon with well defined intrasubstance tendinous splitting suggesting longitudinal tear in concert with mild tenosynovitis at the ulnar styloid fibro-osseous canal. The ECU subsheath appeared diffusely edematous , mildy fragmented, showing similar but milder involvement of the extensor retinaculum with interposed free fluid.
The tendon appeared undisplaced in the ulnar bony groove under the overlying extensor retinaculum. The tendon sheath and subsheath appear fragmented and edematous with fluid surrounding the tendon . There was also evidence of soft tissue edema at ulnar side of wrist with minimal edema at outer fibres of ulnomeniscal homologue ( UMH ) . No obvious subluxation of tendon within its sheath or in relation to the ulnar bony groove was evident .

These constellation of findings are consistent with Intrasubstance longitudinal tear of ECU with chronic tendinosis in concert with tenosynovitis of ECU and mild tenosynovitis of EDM and ED tendons .

Ulnar sided wrist pain is a common clinical complaint and indication for MR imaging. MR is able to detect and diagnose numerous ulnar sided abnormalities that may account for patient symptoms. A not uncommon site of injury is the sixth extensor compartment, home of the extensor carpi ulnaris (ECU).

The extensor carpi ulnaris tendon (ECU) originates as two heads which attach to the lateral epicondyle and the middle third of the posterior ulna. It has a single distal insertion upon the posterior aspect of the base of the fifth metacarpal. The ECU functions to extend and adduct the hand, and is important in the ability to ulnar deviate the hand.

A unique anatomical characteristic of the ECU is the fibro-osseous tunnel which stabilizes the tendon at the level of the distal ulna. This fibro-osseous tunnel is formed by the distal ulna and is ~ 1.5 to 2 cm in length band of connective tissue referred to as the ECU subsheath. The subsheath lies deep to the extensor retinaculum, which itself does not attach to or stabilize the ECU tendon. The ECU, its subsheath, and the extensor retinaculum are readily seen using MRI .

Tenosynovitis and tendinosis of the ECU are not uncommon, with these abnormalities being a frequent early finding in patients with rheumatoid arthritis. In athletes, the ECU is the second most common site of wrist tendinopathy, typically associated with rowing, racquet sports, and golf. In such patients, chronic stress upon the tendon results in inflammation of its synovial lining, causing tenosynovitis. Over time, stress may also lead to tendon degeneration and altered collagen content, resulting in tendinosis with or without partial tears.

ECU tendinosis and tenosynovitis can often be managed conservatively. Splinting, rest, and non-steroidal anti-inflammatory medications are employed. Local steroid injection may also be of benefit, though it should be used with caution due to the increased risk of tendon degeneration and tearing. In patients who remain symptomatic despite conservative therapy, surgical release of the 6th extensor compartment yields excellent results. Release is accomplished via sectioning of the radial side of the ECU subsheath, followed by fixation of the extensor retinaculum over the region of release to prevent residual or recurrent ECU subluxation.

In patients with ECU subsheath tears and tendon instability, conservative therapy has also proven effective.5 The wrist is immobilized via casting in extension and radial deviation, which seats the tendon tightly within its ulnar groove. Activities that require movement of the elbow are limited. Depending on the severity of injury, immobilization is necessary for six weeks to three months.

Knowledge of the unique anatomy of the ECU and its subsheath must be gained in order to correctly diagnose patients with ECU tendon instability. The astute interpreter of MRI is able to accurately identify and characterize ECU tendon and subsheath abnormalities. Certain patterns of injury require operative repair, and thus MRI is a critical component of the treatment planning process.

17/08/2016

A 40 year old male patient presented with fever , nausea , vomiting and gradually increasing abdominal pain for the past 7 days . The patient had distended abdomen and marked epigastric tenderness .

Lab parameters : TLC ~ 15000 cells / cu mm ; ESR ~ 38 mm in first hour ; Serum amylase ~ 1400 U/L and Serum Lipase ~ 1550 U/L .
Ultrasound couldn't be performed satisfactorily due to extensive gas shadowing in the upper abdominal region .
So , the patient underwent urgent CECT Whole abdomen in our imaging center .

CT imaging revealed extensive mottled gas / emphysematous changes in the pancreatic bed predominantly involving the pancreatic head , neck and proximal body regions .There was associated extensive peripancreatic fat stranding and inflammatory changes . Features are consistent with Acute Necrotizing emphysematous pancreatitis .

Emphysematous pancreatitis is an uncommon , highly agressive variant of acute necrotizing pancreatitis , characterized by gas formation within and around the pancreas . Majority of the cases are secondary to superinfection by Gram-negative bacteria e.g E.coli , Klebsiella and Pseudomonas . The proposed routes of spread of infection include Hematogenous , Lymphatic , transmural extension of the organisms from the colon via an enteropancreatic fistula or reflux of enteric organisms into the pancreatic ductal system through the ampulla of Vater .

The prognosis of emphysematous pancreatitis is extremely poor with mortality and morbidity rates as high as 40 % and 100 % respectively . CT scan is the imaging modality of choice for diagnosing emphysematous pancreatitis .

26/07/2016

A 45 year-old male patient presented with complaints to long standing right ankle pain localized to the anterolateral compartment . The patient had no obvious history of any trauma or sprain .
Routine MRI right ankle study was performed .

MRI revealed mildly thickened distal separate ligament / fascicle of the AITFL ( Anterior inferior Tibiofibular ligament ) located just distal to the AITFL s/o accessory anterior inferior tibiofibular (Bassett's) ligament .

There was mild abnormal thickening upto ~ 3.3 mm ( normal thickness ~ 1-2 mm ) of the fibular attachment site of accessory anterior inferior tibiofibular (Bassett's) ligament surrounded by prominent fluid with associated synovitis within the anterolateral right ankle gutter.

There is oblique orientation of Bassett's ligament , paralleling the AITFL , separated by a thin band of increased signal on T2/STIR sequence .

No obvious evidence of any associated subchondral cystic changes were seen involving the talar dome in the present scan .

There was also mild thickening with mild sprain of the right anterior talo-fibular ligament with surrounding moderate fluid collection .

The calcaneo-fibular ligament appeared unremarkable with normal fan shaped fibro-fatty appearance .

There was also mild thickening of the anterior and posterior , inferior tibio-fibular ligaments.

No significant bony marrow edema was evident .

There was associated bursitis involving the Subcutaneous lateral Malleolar bursa with mild STIR hyperintensity over the lateral malleolus in the subcutaneous plane .

There was mild hyperintense signal surrounding peroneal tendons , Flexor digitorum longus and Flexor Hallucis Longus s/o Tenosynovitis with moderate fluid in the ankle joint and posterior recess of subtalar joint.

Features were suggestive of Anterolateral impingement syndrome with thickened accessory anterior inferior tibiofibular (Bassett’s) ligament with associated sprain and surrounding synovitis within the anterolateral right ankle gutter .
These findings were confirmed on surgery as the patient underwent arthroscopic debridement and he is now symptom free .

22/06/2016

A 25 year old male patient presented with progressive left sided hearing loss since the age of 21 years . On audiometry the patient was diagnosed a case of Moderate–severe SNHL with severe high tone SNHL localized to the left side .

Dedicated High-resolution T2-weighted fast spin-echo MR imaging of the cisternal and intracanalicular segments of the facial nerve and the three divisions of the vestibulocochlear nerve: the superior vestibular, inferior vestibular, and cochlear nerve showed reduction in caliber / deficiency of left cochlear nerve .

The word deficiency is primarily used to indicate a smaller than expected cochlear nerve size, as compared with the other nerves of the IAC. The deficiency may have been due to either congenital hypoplasia of the nerve or acquired degeneration or atrophy. An extremely small nerve below the limits of spatial resolution of MR imaging would appear absent. Thus, in its
broadest sense, the term deficient nerve can encompass all three situations: a small nerve, an imperceptible nerve, and one that is truly absent .

In our case the left Cochlear nerve was relatively thinner in caliber than the right . The inner ear structures (cochlea, modiolus, vestibule, semicircular canals, and endolymphatic duct and sac) were evaluated for abnormalities in contour, size, and signal intensity. The clinical history was reviewed, with particular note being taken of the history and duration of SNHL, congenital anomalies or syndromes, family history of SNHL,other cranial nerve abnormalities, and audiometry findings .

21/06/2016

7 years old female patient with history of delayed developmental milestones , hypotonia and few isolated episodes of seizure like activity . It was very difficult for the MRI to be performed due to restless motion of the child even during deep sleep .

MRI brain study revealed pontine hypoplasia with evidence of marked B/L cerebellar hemispheric atrophy with relative vermian sparing giving a ‘dragonfly’ appearances of the cerebellum ; few small T1 hypointense , T2/FLAIR hyperintense cerebellar hemispheric cysts involving the hypoplastic vermis and left cerebellar hemisphere and mild generalized cerebral cortical atrophy .

Suspected case of Pontocerebellar hypoplasia ? PCH Type II .
Other imaging differentials are Congenital disorders of glycosylation type IA and neuronal ceroid lipofuscinosis (NCL) .

The patient has been referred for further genetic counselling to rule out TSEN54 and RARS2 mutations .

18/06/2016

https://youtu.be/m7Ksx08OjHI

Viewer discretion is advised. View through the high power magnification of surgical microscope while a brain tumor (meningioma) is being removed by Dr. Limon...