SA Journal of Radiology

Surfing the intelligence with chatbots

Maya Patel — 2024-01-31

No Abstract.

Why SWI? The sensitivity of susceptibility weighted imaging in aneurysmal subarachnoid haemorrhage in the chronic phase

Yeshkhir Naidoo — 2024-01-31

Background: Incidentally detected unruptured intracranial aneurysms have a prevalence of 3% with some predisposed to rupture and others remaining static. Diagnostic knowledge of previous aneurysmal subarachnoid haemorrhage (ASAH) in the chronic phase could identify patients requiring treatment.

Objectives: To assess the sensitivity of susceptibility weighted imaging (SWI) in the detection of ASAH at 3 months post ictus and determine any influencing effects.

Method: A retrospective chart analysis of 46 patients with ASAH who underwent postembolisation SWI imaging at 3 months. The SWI and available initial CT brain scans or CT reports were evaluated and correlated with patient demographics and clinical severity.

Results: Susceptibility weighted imaging indicated a sensitivity of 95.7% in the detection of ASAH at 3 months. Increased number of haemosiderin zones on SWI correlated with older patient age (p = 0.0003). Clinical severity (World Federation Neurosurgical Societies Score) showed a tendency towards a statistically relevant relationship (p = 0.07). No statistically significant relationship was identified between the number of haemosiderin zones and initial CT modified Fisher score (p = 0.34) or the causative aneurysm location (p = 0.37).

Conclusion: Susceptibility weighted imaging is sensitive in the detection of ASAH at 3 months, increasing in sensitivity with patient age and higher initial clinical severity.

Contribution: In patients presenting in the subacute to chronic phase with a clinically suspicious history of previous aneurysm rupture but without convincing CT or spectrophotometry evidence, SWI can detect previous rupture. This can identify patients who could benefit from endovascular treatment and those who can safely undergo follow-up imaging.

Radiology blues: Comparing occupational blue-light exposure to recommended safety standards

Mari Wentzel — 2024-01-31

Background: The blue-light hazard is a well-documented entity addressing the detrimental health effects of high-energy visible light photons in the range of 305nm – 450nm. Radiologists spend long hours in front of multiple light-emitting diode (LED)–based diagnostic monitors emitting blue light, predisposing them to potentially higher blue-light dosages than other health professionals.

Objectives: The authors aimed to quantify the blue light that radiology registrars are exposed to in daily viewing of diagnostic monitors and compared this with international occupational safety standards.

Method: A limited cross-sectional observational study was conducted. Four radiology registrars at two academic hospitals in Bloemfontein from 01 October 2021 to 30 November 2021 participated. Diagnostic monitor viewing times on a standard workday were determined. Different image modalities obtained from 01 June 2019 to 30 November 2019 were assessed, and blue-light radiance was determined using a spectroscope and image analysis software. Blue-light radiance values were compared with international safety standards.

Results: Radiology registrars spent on average 380 min in front of a diagnostic display unit daily. Blue-light radiance from diagnostic monitors was elevated in higher-intensity images such as chest radiographs and lower for darker images like MRI brain studies. The total bluelight radiance from diagnostic display units was more than 10 000 times below the recommended threshold value for blue-light exposure.

Conclusion: Blue-light radiance from diagnostic displays measured well below the recommended values for occupational safety. Hence, blue-light exposure from diagnostic monitors does not significantly add to the occupational health burden of radiologists.

Contribution: Despite spending long hours in front of diagnostic monitors, radiologists’ exposure to effective blue-light radiance from monitors was far below hazardous values. This suggests that blue- light exposure from diagnostic monitors does not increase the occupational health burden of radiologists.

Correlative imaging and histopathology of a complicated sinonasal teratocarcinosarcoma

Tineke van Zyl — 2024-01-31

Sinonasal teratocarcinosarcoma (SNTCS) is a highly malignant and rare tumour characterised by a complex admixture of teratomatous and carcinosarcomatous components. In the head and neck area, it almost exclusively occurs in the sinonasal cavities; however, rare instances of nasopharyngeal and oral cavity involvement have been reported, with fewer than 100 cases reported in the literature.

Contribution: The contributed case involves the correlative CT, MRI and histopathology of a sinonasal teratocarcinosarcoma with intracranial involvement.

A rare case of small-cell neuroendocrine tumour of the lung metastasising to the urinary bladder

Humphrey Mapuranga — 2024-01-31

A 77-year-old woman with suspected lung carcinoma had multiple bladder masses and lymphadenopathy outside the normal urinary bladder drainage area. Fine needle aspiration and immunocytochemistry of the cervical lymph node complex and transurethral biopsy of the bladder masses confirmed metastatic small-cell neuroendocrine carcinoma.

Contribution: Clinical correlation, imaging findings, tumour markers and immunohistochemistry are necessary for metastatic bladder tumour work-up.

An audit of patient radiation doses in interventional radiology at a South African hospital

Oneile Slave — 2024-01-31

Background: Interventional radiology (IR) is becoming more relevant in patient care and is associated with increased patient radiation exposure and radiation-induced adverse effects. Diagnostic reference levels (DRLs) are crucial for radiation control. There is a paucity of published DRLs for IR in South Africa and sub-Saharan Africa.

Objectives: This study aimed to determine local DRLs for fluoroscopically- guided IR procedures and compare the achieved DRLs with published local and international DRLs.

Method: Retrospective, descriptive, single-centre study. Kerma air product (KAP), reference point air kerma (Ka,r) and fluoroscopy time (FT) were collected for patients (12 years and older) who underwent IR procedures at a university hospital from 01 January 2019 to 31 December 2019. The 75th percentile of the distribution of each dose parameter (KAP, Ka,r and FT) per procedure was calculated and taken as the local diagnostic reference levels (LDRL). The established LDRLs were compared to published DRLs.

Results: A total of 564 cases were evaluated. The 13 most frequent procedures (with 15 or more cases) represented 86.1% (487/564). Percutaneous transhepatic biliary drainage was the most common procedure (n = 146, 25.9%). Diagnostic cerebral angiogram DRLs exceeded the published DRL data ranges for all parameters (DRL 209.3), and interventional cerebral angiogram exceeded published ranges (DRL 275). Uterine artery embolisation (UAE) exceeded these ranges for KAP and Ka,r. (KAP-954.9 Gy/cm² , Ka,r-2640.8 mGy).

Conclusion: The LDRLs for diagnostic cerebral angiogram, interventional cerebral angiogram and UAE exceeded published international DRL ranges. These procedures require radiation optimisation as recommended by the International Commission on Radiological Protection (ICRP).

Contribution: In addition to informing radiation protection practices at the level of the institution, the established LDRLs contribute towards Regional and National DRLs.

Terminal quadrifurcation of the aorta: A case report

Siviwe S. Mpateni — 2024-01-31

Congenital anatomical variations of the terminal aorta are rare. Given the increasing number of endovascular and laparoscopic procedures, such variations are likely to assume greater clinical significance. A 15-year-old male sustained a pelvic vascular injury following a stab to the left gluteus. Computed tomographic angiography and digital subtraction angiography demonstrated a left superior gluteal artery pseudoaneurysm and absence of the common iliac arteries consistent with congenital quadrifurcation of the terminal aorta. The patient was subsequently treated with endovascular coil embolisation with a good angiographic and clinical outcome.

Contribution: Terminal aortic variants are rare and given the increasing number of interventional endovascular procedures performed in the aorta, an awareness of the potential anatomical configurations of the distal aortic branches is of increasing relevance. The authors describe the imaging findings of one such anatomical variant.

Imaging in Van Wyk Grumbach syndrome: An uncommon presentation of hypothyroidism

Poonam Sherwani — 2024-01-31

Isosexual precocious puberty with ovarian masses in long-standing juvenile hypothyroidism is well described in the literature as Van Wyk Grumbach syndrome (VWGS). The present case reports this rare entity in a 4-year-old girl who was referred for imaging to evaluate the cause of non-traumatic bleeding per vagina. Antecedent history, clinical features and thyroid function tests were consistent with long- standing juvenile hypothyroidism with documented clinical response to thyroxine replacement therapy.

Contribution: Typical clinical and radiological features of the syndrome are reported, which helps in the early diagnosis and management, henceforth avoiding the associated complications

Clinicians’ perspective of picture archiving and communication systems at Charlotte Maxeke Johannesburg Academic Hospital

Polite Tshalibe — 2024-01-31

Background: Picture archiving and communication systems (PACS) are now an established means of capturing, storing, distribution and viewing of all radiology images. The study was conducted in a quaternary hospital, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), part of the University of the Witwatersrand teaching circuit, in South Africa.

Objectives: To measure the clinicians’ perceived benefits and challenges of PACS. To document perceived views on how the current PACS can be improved.

Method: This was a cross- sectional observational study over a period of 5 months from September 2021 to January 2022 carried out at CMJAH. Questionnaires were distributed to referring clinicians with PACS experience. Descriptive statistics was conducted. Categorical variables were presented as frequency and percentages. The continuous variables were presented as means ± standard deviation.

Results: A survey with a response rate of 54% found the benefits most reported by clinicians were improved patient care, less time needed to review an exam, improved image comparison and consultation efficiency. With respect to perceived challenges, the unavailability of images at the bedside, problems with access and the lack of advanced image manipulating software were noted. The most frequent recommendations on improvements focused on the aforementioned challenges.

Conclusion: Hospital-wide PACS was viewed beneficial by most clinicians. Nonetheless, there are a few aspects that deserve attention to improve the functionality and access of the system.

Contribution: The findings will assist in future hospital or provincial-wide PACS deployment projects

Comparison between ultrasound and chest X-ray to confirm central venous catheter tip position

Leoni de Man — 2024-01-31

Background: Mechanical central venous catheter (CVC) placement complications are mostly malposition or iatrogenic pneumothorax. Verification of catheter position by chest X-ray (CXR) is usually performed postoperatively.

Objectives: This prospective observational study assessed the diagnostic accuracy of perioperative ultrasound and a ‘bubble test’ to detect malposition and pneumothorax.

Method: Sixty-one patients undergoing peri-operative CVC placement were included. An ultrasound protocol was used to directly visualise the CVC, perform the ‘bubble test’ and assess for the presence of pneumothorax. The time from agitated saline injection to visualisation of microbubbles in the right atrium was evaluated to determine the correct position of the CVC. The time required to perform the ultrasound assessment was compared to that of conducting the CXR.

Results: Chest X-ray identified 12 (19.7%) malpositions while ultrasound identified 8 (13.1%). Ultrasound showed a sensitivity of 0.85 (95% confidence interval [CI]: 0.72 to 0.93) and a specificity of 0.5 (95% CI: 0.16 to 0.84). The positive and negative predictive values were 0.92 (95% CI: 0.80 to 0.98) and 0.33 (95% CI: 0.10 to 0.65), respectively. No pneumothorax was identified on ultrasound and CXR. The median time for ultrasound assessment was significantly shorter at 4 min (interquartile range [IQR]: 3–6 min), compared to performing a CXR that required a median time of 29 min (IQR: 18–56 min) (p < 0.0001).

Conclusion: This study showed that ultrasound produced a high sensitivity and moderate specificity in detecting CVC malposition.

Contribution: Ultrasound can improve efficiency when used as a rapid bedside screening test to detect CVC malposition.

Human parechovirus meningoencephalitis

Pokhraj P. Suthar — 2024-01-31

Human parechovirus-3 (HPeV-3) infection is one of the differential diagnoses of neonatal meningoencephalitis. A 13-day-old full-term female neonate presented with a seizure. Brain MRI showed classic imaging findings of the meningoencephalitis which was confirmed on cerebrospinal fluid analysis.

Contribution: The HPeV-3 is an emerging pathogen for neonatal meningoencephalitis. The case in this study is unique with classic imaging findings, which are not routinely encountered in day-to-day practice. This case raises reader awareness.

Keywords: meningoencephalits; human parechovirus; neonate; MRI; CSF.

Outcomes of breast conserving therapy: Recurrence, imaging findings and histological correlation

Marara N. Sondezi — 2024-01-31

Background: Breast conserving therapy (BCT) is the mainstay therapy in patients with early breast cancer and selected patients with locally advanced breast cancer. No formal audit has been performed on BCT at our institution.

Objectives: To determine the incidence and risk factors for ipsilateral breast tumour recurrence (IBTR). Study the imaging features of IBTR. Determine adherence to the proposed annual mammographic surveillance schedule.

Method: Clinical, radiological and histopathological records of patients who underwent BCT from 01 January 2011 to 31 December 2015 were reviewed. Patients were followed up for at least 5 years.

Results: Ninety-two patients were included in the study with a mean age of 54.3 years. Eighty of the 92 (87.0%) patients were imaged within 1-year post-BCT. Ipsilateral breast tumour recurrence was 6/92 (6.5%) with mean time to IBTR of 34.4 months. One of the 92 (1.0%) patients had a contralateral metachronous recurrence with no IBTR and 11/92 (12.0%) had distant metastases only. Pathological tumour size and extent (pT2) (68.5%) and pathological lymph node (pN0) (65.2%) were the most common locoregional staging. Infiltrating ductal carcinoma was the most common histological type (88%). Age < 35 years was associated with breast cancer recurrence (p < 0.01). Imaging findings of recurrence were microcalcification (odds ratio [OR]: 4), asymmetric density (OR: 4) and skin thickening (OR: 2.5).

Conclusion: The occurrence of IBTR following BCT in our unit is acceptable and comparable to local and international units. The accuracy of assessing the post-BCT breast for IBTR is in keeping with international standards.

Contribution: Improved radiological imaging interpretation of the post-BCT breast.

Ultrasound and computed tomography in the evaluation of mesenteric lesions: A pictorial review

Snehal I. Kose — 2024-01-31

The mesentery is a broad fan-shaped fold of peritoneum that suspends the loops of small intestine from the posterior abdominal wall. Although primary neoplasms arising in the mesentery are rare, the mesentery is a major avenue for the dissemination of tumours, which can spread through hematogenous, lymphatic, direct or peritoneal seeding. Imaging helps in the diagnosis of these tumours and aids in directing appropriate treatment by assessing their size, extent and relationship with adjacent structures. The aim of this article is to describe the spectrum of imaging findings of the various mesenteric lesions using ultrasound and CT.

Contribution: Evaluation of the mesentery is often neglected during routine ultrasound (US) because of inadequate training and unfamiliarity with the common US features encountered with mesenteric disease. CT plays an essential role in the diagnosis of mesenteric disease. Knowledge of imaging characteristics of various mesenteric lesions helps in timely diagnosis and management.

Endovascular management of intracranial aneurysms at Chris Hani Baragwanath Academic Hospital

Herchel Clarke — 2024-01-31

Background: Worldwide, intracranial aneurysms are associated with a high mortality rate. While endovascular management has proven to be the choice of treatment in selected patients, patient demographics and aneurysm characteristics differ between study populations.

Objectives: This study aimed to investigate the profile of patients with intracranial aneurysms who underwent endovascular management in the Interventional Neuroradiology Unit at Chris Hani Baragwanath Academic Hospital. Patient demographics, risk factors, indications, aneurysm characteristics and intra-operative complications were studied.

Method: This was a 3-year retrospective study of all adult patients between 01 January 2018 and 31 January 2021. The Chi-square test was used to compare categorical variables.

Results: A total of 77 patients were included in this study. The mean age of the patients was 47 ± 11.6 with a male-to-female ratio of 1:1.8. Hypertension was the most reported risk factor in 27% of patients. There was no statistical correlation between the gender groups according to presentation, multiplicity, aneurysmal size dimensions and locations. According to the presentation, there was statistical significance in ruptured intracranial aneurysms (p = 0.020), neck size dimensions less than 4 mm (p = 0.010), and aneurysms located in the internal cerebral artery (ICA) circulation (p = 0.001).

Conclusion: The study findings support known parameters including females and anterior circulation aneurysm preponderance, and the low complication risk of endovascular management. Interestingly, intracranial aneurysms presented with rupture at smaller size dimensions.

Contribution: This study provides valuable insights into intracranial aneurysm characteristics and endovascular management efficacy in a resource-limited setting.

Accuracy of CT angiography for detecting ruptured intracranial aneurysms

Nomasonto N. Mkhize — 2024-01-31

Background: Digital subtraction angiography (DSA) is invasive, costly and unavailable in many South African hospitals; however, it remains the gold standard for imaging intracranial aneurysms. CT angiography (CTA) is a non-invasive and readily available screening tool prior to DSA.

Objectives: This study aimed to evaluate the diagnostic performance of CTA in detecting ruptured intracranial aneurysms using DSA as the reference standard and to determine the effect of aneurysm size and location on CTA sensitivity.

Method: A retrospective analysis of CTA and DSA data from reports of patients suspected to have aneurysmal subarachnoid haemorrhage (SAH) at Chris Hani Baragwanath Academic Hospital between January 2017 and June 2020.

Results: Conventional DSA detected aneurysms in 94 out of 115 patients; while of these, CTA detected 75 and missed 19. The CTA sensitivity, specificity and accuracy was 80%, 43% and 73%, respectively. The CTA sensitivity for aneurysms < 3 mm and 3 mm – 5 mm in size was 30% and 81.5%, respectively (p = 0.024). Sensitivity of CTA for posterior communicating artery (PComm) aneurysms was 56% and lower than other major anterior circulation locations (83% – 91%) (p = 0.045).

Conclusion: The CTA diagnostic efficiency was lower than previously reported, with even lower sensitivity for aneurysms < 3 mm and for those arising from the PComm. Thus, CTA should remain a screening tool prior to DSA in all local patients suspected to have aneurysmal SAH.

Contribution: Larger, prospective studies are required to accurately define the role of CTA in diagnosing intracranial aneurysms in a developing country with limited resources.

Torsion of a huge subserosal uterine leiomyoma: A challenging case of acute abdomen

Mankirat S. Dhillon — 2024-01-31

Torsion of a uterine leiomyoma is an extremely rare, albeit life-threatening surgical emergency. A 28-year-old woman presented with acute abdominal pain. Imaging revealed a torsed subserosal uterine leiomyoma which was managed surgically and the diagnosis confirmed intraoperatively as well as on histopathology.

Contribution: While intraoperative findings remain the primary means of diagnosis, radiologists should be familiar with the potential imaging findings of leiomyoma torsion as timely intervention can greatly improve patient outcome.

Radiologists’ experiences and perceptions regarding the use of teleradiology in South Africa

Renata Schoeman — 2024-01-31

Background: Teleradiology was implemented in South Africa in 1999, but the subsequent uptake was low and slow. The onset of the coronavirus disease 2019 (COVID-19) pandemic catapulted South African healthcare into the arena of teleradiology. This created the environment for re-examining the factors that enable or inhibit the uptake of teleradiology in both the public and private sectors.

Objectives: This article reports on a study of a select sample of private and public sector radiologists’ experiences with, and perceptions of, the benefits, opportunities, challenges and barriers to the implementation of teleradiology in the South African context.

Method: Qualitative data on the perceived benefits and challenges of teleradiology, as well as on its enablers and the barriers to its implementation, were collected and analysed.

Results: The uptake of teleradiology in the sample increased by 15.9% during the COVID-19 pandemic. The results demonstrated that teleradiology was perceived to have clear benefits on operational, personal and societal levels.

Conclusion: It is important to address structural barriers to the implementation of teleradiology. Clear communication strategies and multistakeholder engagement are also required.

Contribution: By investigating radiologists’ experience with teleradiology, this study provides an understanding of the benefits, opportunities, challenges and barriers to implementation of services. These insights enable informed decision-making and stakeholder engagement and provide a foundation for establishing recommendations for the viable implementation of teleradiology in South Africa and other lower- and middle-income countries to promote access to healthcare.

The radiologic progression of ameloblastomas

Lene Merbold — 2024-01-31

Background: In developing countries, many diagnosed cases of ameloblastoma (AB) have a significant delay in receiving treatment because of patient factors and healthcare facility constraints.

Objectives: The radiologic progression of ABs with delayed treatment was analysed using panoramic radiographs and cone-beam computed tomography imaging.

Method: Histopathologically confirmed cases of AB with follow-up radiographs indicating no treatment were retrospectively reviewed over a study period of 10 years. Fifty-seven cases with 57 initial and 107 follow-up radiographs were included. Each follow-up radiograph was analysed for changes in borders, locularity, effects on surrounding structures and lesion size.

Results: There was a general increase in poorly-demarcated lesions, with seven cases transforming from an initial unilocular to a multilocular appearance. At follow-up, there was an increase in cortical thinning and cortical destruction. Ameloblastomas presented with a three-fold increase in average size from the initial to follow-up visits. Regression analysis showed a statistically significant relationship between lesion duration and length (p = 0.001). A statistically significant relationship existed between duration and overall lesion dimensions when only the first and last observations per patient were used (p = 0.044).

Conclusion: Considering the aggressive nature and unlimited growth potential, ABs with delayed treatment may show extensive growth, complicating their eventual management.

Contribution: This study aimed to raise awareness of the importance of the timeous management of patients with AB by highlighting the detrimental effects of delayed treatment.

Imaging evaluation of the benign and malignant lesions of the floor of the mouth: Pictorial review

Ashim K. Lahiri — 2024-01-31

The floor of the mouth is an important anatomical region of the oral cavity where primary benign and malignant disease processes can originate or secondary pathologies can extend into adjacent spaces. Knowledge of the anatomy is crucial for accurate localisation of pathology and understanding the spread of disease. The sublingual space is the dominant component of the floor of the mouth, bounded inferiorly by the mylohyoid muscle that separates it from the submandibular space. Imaging is immensely important to characterise and map the extent of disease, considering the fact that the bulk of the disease may be submucosal and not visible on clinical inspection. Contribution: The floor of the mouth is a complex anatomical region for radiological evaluation. The purpose of this pictorial review is to present an understanding of the relevant anatomy and to demonstrate the role and appropriate application of different imaging modalities. This article highlights the imaging spectrum of a wide range of various benign conditions including normal variants and a variety of malignant lesions at different tumour stages, with an aim to establish the correct diagnosis, avoid misinterpretation and help in treatment planning.

Pictorial review of the post-operative cranium

Varsha Rangankar — 2024-01-31

Imaging evaluation of the brain and cranium after cranial surgery is a routine and significant part of the workflow of a radiology department. Various normal expected findings and early and late complications are associated with the post-operative cranium. In this pictorial review, the authors describe the typical imaging features of the spectrum of various conditions associated with cranial surgery with illustrative cases.

Contribution: A good knowledge and understanding of the spectrum of imaging appearances in the post-operative cranium is vital for the radiologist to accurately diagnose potential complications and distinguish them from normal post-operative findings, improving patient outcomes and guiding further treatment.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 1: Congenital

Ranjit K. Chaudhary — 2024-01-31

The embryology of the inferior vena cava (IVC) is complex, involving the sequential appearance and regression of multiple segments that ultimately form the IVC. Any alteration in this process during embryogenesis can result in congenital anomalies of the IVC. This study aimed to recognise common as well as rare anomalies of the IVC and associated veins, and their clinical implications. The anomalies tend to have diverse appearances based on the timing and segments involved. The development of the IVC is intertwined with the development of other veins like the renal vein, azygos vein and portal vein, and these veins may also be anomalous. Additionally, IVC anomalies are associated with various other congenital anomalies including cardiac anomalies, the recognition of which may be important for patient care. The IVC tends to have multiple normal variants and anomalies because of a complex process involving multiple segments contributing to the adult IVC. Knowledge of these variants is crucial for preoperative planning of procedures.

Contribution: This study would help in understanding the embryogenesis of the IVC and correlation with the imaging appearances and the clinical implications of each of these common as well as rare types of congenital anomalies.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 2: Acquired

Ranjit K. Chaudhary — 2024-01-31

The inferior vena cava (IVC) is an uncommon site for primary pathologies and secondary involvement is also infrequent, but involvement of the IVC can often drastically change management. It is therefore important to be cognizant of IVC pathologies. This review discussed common and rare neoplastic and non-neoplastic pathologies of the IVC as well as pathology mimics. Primary and secondary neoplasms can lead to tumour extension or bland thrombus formation and it is often important to distinguish between these two entities. It is also important to be aware of pseudo-lesions for accurate diagnosis. Inferior vena cava filter placement and endovascular treatment of the aorta are commonly performed procedures that can be associated with devastating complications, which are luckily infrequent. The calibre of the IVC also has its own clinical significance. Inferior vena cava pathologies, although rare, have a dramatic impact on the patient’s outcome and knowledge of these pathologies is prudent. Contribution: Understand the principles of IVC imaging, the common as well as the rare primary and secondary IVC tumours, differentiate between tumour thrombus and bland thrombus, and recognise IVC lesion mimics and life-threatening pathologies involving the IVC.

Ipsilateral renal dysgenesis or agenesis with tubulocystic anomalies of the mesonephric duct

Anagha R. Joshi — 2024-01-31

Tubulocystic anomalies of the mesonephric duct (MND) are a rare group of related entities with a perplexing clinical presentation. Ultrasound is a useful screening investigation, which can help identify a dysplastic kidney or point to renal agenesis and identify cystic or tubulocystic changes in the structures derived from the ureteric bud or MND. Further evaluation with MRI can help in characterisation and direct management. The presence of a dysplastic kidney or absence of a kidney should prompt further evaluation for associated ureteric abnormalities such as ectopic insertion or ureterocoele, which could lead to a diagnosis of tubulocystic anomaly of the MND.

Contribution: The authors describe two cases, briefly outline the diagnostic approach and summarise the literature on management. Reporting radiologists should be aware of these entities.

Dual-energy index variation when evaluating the potential ferromagnetism of ex vivo bullets

Francois A. van der Merwe — 2024-01-31

Background: An MRI is potentially hazardous for patients with retained ferromagnetic bullets. Recent studies have aimed to develop dual-energy computed tomography (DECT) as a screening tool for recognising highly ferromagnetic bullets. Inconsistent findings have been ascribed to inherent CT technology differences. Previous research demonstrated significant Hounsfield unit (HU) measurement variation among single-source CT machines.

Objectives: This study investigated the theoretical dual-energy index (DEI) variation between DECT machines when evaluating the potential ferromagnetic properties within the same sample of ex vivo bullets and metal phantoms.

Method: An experimental ex vivo study was conducted on eight metal phantoms and 10 unused bullets individually positioned in the same Perspex head phantom and scanned on two DECT machines. Two senior radiology registrars independently recorded the HU readings, and DEI values were calculated. Statistical analysis was performed using non-parametric methods for paired data, namely the Signed Rank Test. The DEI values based on mean HU readings between the DECT machines were compared.

Results: Inter- and intra-reader agreement was not statistically significant. The metal phantoms had poor interscanner agreement, with an overlap of the ferromagnetic and non-ferromagnetic ranges. The bullets had good interscanner agreement, with a similar ferromagnetic to nonferromagnetic relationship.

Conclusion: The use of DEI values negates the previous assumption that significant interscanner variability exists among different DECT technologies while assessing highly attenuative ex vivo bullets.

Contribution: This investigation demonstrated that even though HU readings may be variable, the implementation of the DEI equation translates this into comparable values with good interscanner agreement.

Utility of MR lymphangiography in chylous ascites: A report of two cases

Pratibha Bhatia — 2024-01-31

Dynamic contrast-enhanced (DCE) lymphangiography is a novel imaging technique with a potential role in suspected cases of lymphatic leaks. A 15-year-old male with a post operative chylous leak and an 8-year-old male who developed chylous ascites secondary to disseminated tuberculosis are presented. Both children underwent MR lymphangiography.

Contribution: The role of DCE-MR lymphangiography in cases of chylous ascites to help guide appropriate management.

Superior labrum anterior to posterior lesions: Part 1 – Imaging and anatomy with arthroscopic classification

Peter Mercouris — 2024-01-31

The glenoid labrum deepens the glenoid fossa and allows for the attachment of the long head of the biceps tendon and the glenohumeral ligaments, contributing to the stability of the glenohumeral joint. The superior labrum is a common site of labral injury, especially in athletic activities involving overhead activity. The acronym SLAP (superior labrum anterior to posterior or anteroposterior) lesion was introduced by Snyder and colleagues in 1990 to describe superior labral tears. The article will review the optimal technique to image the glenoid labrum, covering normal labral anatomy with special emphasis on the anatomic variants of the labrum that can be mistaken for SLAP tears by means of colour illustrations, magnetic resonance imaging and correlative arthroscopy images.

Contribution: The illustrated review functions as a crucial radiological guide for both radiologists and orthopaedic surgeons. The combination of illustrations, MR and correlative arthroscopic images enhances the comprehension of normal labral anatomy and its variants. The review underscores the significance of understanding anatomic variations that may be misinterpreted as pathology. This understanding is vital in guiding orthopaedic management for patients, ensuring appropriate treatment strategies.

Superior labrum anterior to posterior lesions: Part 2 – Classification with arthroscopic correlation

Peter Mercouris — 2024-01-31

The glenoid labrum deepens the glenoid fossa and allows for the attachment of the long head of the biceps tendon and glenohumeral ligaments, contributing to the stability of the glenohumeral joint. The superior labrum is a common site of labral injury. The acronym SLAP (superior labrum anterior to posterior or anteroposterior) lesion was introduced by Snyder and colleagues in 1990 to describe superior labral tears based on arthroscopic evaluation. This original classification has since been expanded, and there are currently 10 types of SLAP lesions. The article will describe and illustrate the 10 types of SLAP lesions by means of colour illustrations, MRI images and correlative arthroscopy images. A practical approach to the assessment of SLAP lesions will be recommended.

Contribution: The illustrated review functions as a crucial radiological guide for both radiologists and orthopaedic surgeons. The combination of illustrations, MR and correlative arthroscopic images enhances the comprehensive understanding of labral pathology. The value of the review lies in the presentation of imaging findings and classification, coupled with findings on arthroscopy. This understanding is vital in guiding orthopaedic management for patients, ensuring appropriate treatment strategies.

Cystic lung tuberculosis in children: A series of five cases

Chetna Mishra — 2024-01-31

Frequent imaging manifestations of pulmonary tuberculosis are airspace or interstitial nodules with or without tree-in-bud nodules, consolidation, cavitation, ground glass opacity, miliary nodules, lymphadenopathy and pleural effusion. It is unusual to encounter cystic changes in patients with pulmonary tuberculosis, and these findings should be differentiated from other cystic lung diseases. This case series describes five cases of cystic lung disease in children with tuberculosis (TB) with illustrative chest radiography and CT findings.

Contribution: The manuscript highlights the need to consider tuberculosis as a possible cause of acquired cystic lung disease in appropriate clinical settings, particularly in endemic regions.

Neuroquantification enhances the radiological evaluation of term neonatal hypoxic-ischaemic cerebral injuries

Shalendra K. Misser — 2024-01-31

Background: Injury patterns in hypoxic-ischaemic brain injury (HIBI) are well recognised but there are few studies evaluating cerebral injury using neuroquantification models.

Objectives: Quantification of brain volumes in a group of patients with clinically determined cerebral palsy.

Method: In this retrospective study, 297 children with cerebral palsy were imaged for suspected HIBI with analysis of various cerebral substrates. Of these, 96 children over the age of 3 years with a clinical diagnosis of cerebral palsy and abnormal MRI findings underwent volumetric analyses using the NeuroQuant® software solution. The spectrum of volumetric changes and the differences between the various subtypes (and individual subgroups) of HIBI were compared.

Results: Compared with the available normative NeuroQuant® database, the average intracranial volume was reduced to the 1st percentile in all patient groups (p < 0.001). Statistically significant differences were observed among the types and subgroups of HIBI. Further substrate volume reductions were identified and described involving the thalami, brainstem, hippocampi, putamina and amygdala. The combined volumes of five regions of interest (frontal pole, putamen, hippocampus, brainstem and paracentral lobule) were consistently reduced in the Rolandic basal ganglia-thalamus (RBGT) subtype.

Conclusion: This study determined a quantifiable reduction of intracranial volume in all subtypes of HIBI and predictable selective cerebral substrate volume reduction in subtypes and subgroups. In the RBGT subtype, a key combination of five substrate injuries was consistently noted, and thalamic, occipital lobe and brainstem volume reduction was also significant when compared to the watershed subtype.

Contribution: This study demonstrates the value of integrating an artificial intelligence programme into the radiologists’ armamentarium serving to quantify brain injuries more accurately in HIBI. Going forward this will be an inevitable evolution of daily radiology practice in many fields of medicine, and it would be beneficial for radiologists to embrace these technological innovations.

Revisiting Rosai Dorfman disease: A rare histiocytic disorder with nodal and extranodal involvement

Smily Sharma — 2024-01-31

Rosai Dorfman disease is a rare but benign and self-limiting disorder. A case of Rosai Dorfman disease in a 16-year-old female with classic radiological and pathological findings is presented. T2W hypointense signal of the soft tissue masses was a distinguishing MRI feature.

Contribution: Rosai Dorfman disease is often overlooked in the differentials of lymphadenopathy and soft tissue masses on account of its rarity. This case report comprehensively discusses the imaging approach to this rare disorder

Calcinosis circumscripta of the breasts: The deeper meaning

Tanusha Sewchuran — 2024-01-31

Calcinosis circumscripta involving the breasts usually hints at an underlying systemic cause, most commonly connective tissue disorders such as scleroderma or dermatomyositis. Localised scleroderma, also known as morphoea, is not usually associated with the systemic anomalies affecting the lungs and gastrointestinal system, but does manifest as calcified dermal and subdermal sclerotic plaques. Histological confirmation with skin biopsy is diagnostic.

Contribution: Recognition of the atypical, bizarre, linear dystrophic calcifications on mammography should direct appropriate systemic investigations.

Imaging spectrum of spinal dysraphism: A diagnostic challenge

Mohit K. Shrivastva — 2024-01-31

Spinal dysraphism (SD) is a collective term for congenital malformations of the spine and spinal cord. It includes a wide range of congenital anomalies resulting from aberrations in the stages of gastrulation, primary neurulation and secondary neurulation. Spinal dysraphism may lead to neurological impairment of varying severity including weakness of the extremities, incontinence of bowel and bladder, sexual dysfunction, among others. Diagnosis of SDs is quite challenging because of its wide spectrum and complex cascade of embryologic events. Knowledge of normal embryology and proper understanding of imaging features of SD are important for early accurate diagnosis.

Contribution: This series of five cases describes the imaging spectrum of spinal dysraphism and highlights the embryological basis for their development, which could facilitate early correct diagnosis, surgical planning and reduced morbidity related to these malformations. It also includes an extremely rare case of complex spinal dysraphism (Type II diastematomyelia with right hemimyelomeningocoele and left hemilipomyelomeningocoele) with Chiari II malformation.