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Case Series: Vaginal Ewing Sarcoma: An Uncommon Clinical Entity in Pediatric Patients
Nathan M Cross, A Luana Stanescu, Erin R Rudzinski, Douglas S Hawkins, Marguerite T Parisi
J Clin Imaging Sci 2017, 7:17 (25 April 2017)
Ewing sarcoma, including classical Ewing sarcoma of the bone and primitive neuroectodermal tumors arising in bone or extraosseous primary sites, is a highly aggressive childhood neoplasm. We present two cases of Ewing sarcoma arising from the vagina in young girls. Previously reported cases in literature focused on their pathologic rather than radiographic features. We describe the spectrum of multimodality imaging appearances of Ewing sarcoma at this unusual primary site. Awareness of vaginal Ewing tumors may facilitate prompt diagnosis and lead to a different surgical approach than the more commonly encountered vaginal rhabdomyosarcoma.
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Original Article: Lingual Foramina and Canals of the Mandible: Anatomic Variations in a Lebanese Population
Georges Aoun, Ibrahim Nasseh, Sayde Sokhn, Mohamad Rifai
J Clin Imaging Sci 2017, 7:16 (25 April 2017)
Objective: The aim of this study was to evaluate the mandibular lingual foramina (LF) and canals and their anatomic variations using cone-beam computed tomography (CBCT) technology in a Lebanese population. Materials and Methods: In this study, we analyzed CBCT images of 90 adult Lebanese patients (41 males and 49 females). We assessed the number and location of the LF. In additional, we measured: (a) The distance from both the alveolar crest and the inferior border of the mandible to the LF and (b) the length of the lingual canals (LCs). The data obtained was analyzed statistically using Shapiro–Wilk normality test, t-test, Chi-square, and Fisher's exact tests. Statistical significance was set at 0.05. Results: In our sample, the LF and canals were present in 93.33% of the CBCT analyzed, and the majority (76.64%) was located above the genial tubercles. The distance from the foramen of the superior and the inferior LCs to the alveolar crest was 16.24 ± 2.82 mm and 25.49 ± 2.43 mm, respectively. The distance from the foramen of the superior canal to the inferior border of the mandible was 14 ± 2.32 mm. The mean length of the superior canal was 5.81 ± 1.6 mm and 4.25 ± 1.2 mm for the inferior one. There were no gender-related differences in the anatomic characteristics of the LF and canals except for the distance measured from the superior canal foramina to the alveolar crest where the measurement was significantly greater in males compared to females. Neither the number of canals nor the positions of the foramina were different between males and females. Conclusion: Within the limits of this study, we concluded that in our sample of Lebanese adults, there was substantial variability in the LF and canals anatomy and location.
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Review Article: Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes
Subramaniyan Ramanathan, Vijayanadh Ojili, Ravi Vassa, Arpit Nagar
J Clin Imaging Sci 2017, 7:15 (5 April 2017)
Although large bowel obstruction (LBO) is less common than small bowel obstruction, it is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. Plain radiographs are sufficient to diagnose LBO in a majority of patients. However, further evaluation with multidetector computed tomography (MDCT) has become the standard of care to identify the site, severity, and etiology of obstruction. In this comprehensive review, we illustrate the various causes of LBO emphasizing the role of MDCT in the initial diagnosis and detection of complications along with the tips to differentiate from disease which can mimic LBO.
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Pictorial Essay: Anatomic Variations of the Right Portal Vein: Prevalence, Imaging Features, and Implications for Successful Transjugular Intrahepatic Portosystemic Shunt Creation
Senthil S Gunasekaran, Ron C Gaba
J Clin Imaging Sci 2017, 7:14 (28 March 2017)
Given the widespread use of transjugular intrahepatic portosystemic shunt (TIPS) creation for the treatment of portal hypertensive complications, a working knowledge of portal venous anatomy is critical for interventional radiologists. The right portal vein – which is most commonly accessed during TIPS – is subject to various anatomic variants that may potentially impact procedure success. This pictorial essay characterizes the anatomic patterns of the right portal vein branching in terms of type and frequency based on case series review. The work also explains the potential procedural implications of the right portal vein anatomic variations as they pertain to TIPS technical success.
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Radiologic-Pathologic Correlation: Radiologic-Pathologic Correlation: Acellular Dermal Matrix (Alloderm®) Used in Breast Reconstructive Surgery
Christine U Lee, Aleh Bobr, Jorge Torres-Mora
J Clin Imaging Sci 2017, 7:13 (28 March 2017)
Acellular dermal matrix (ADM) such as Alloderm® is sometimes used in tissue reconstruction in primary and reconstructive breast surgeries. As ADM is incorporated into the native tissues, the evolving imaging findings that would correlate with varying degrees of host migration and neoangiogenesis into the matrix can be challenging to recognize. In the setting of a palpable or clinical area of concern after breast reconstructive surgery following breast cancer, confident diagnosis of a mass representing ADM rather than recurring or developing disease can be challenging. Such diagnostic imaging uncertainties generally result in short-term imaging and clinical follow-up, but occasionally, biopsy is performed for histopathological confirmation of benignity. A case of biopsy-proven Alloderm® is described. To the best of our knowledge, this is the first radiologic-pathologic correlation of ADM in the literature.
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Original Article: Apparent Diffusion Coefficient Measurement in Mediastinal Lymphadenopathies: Differentiation between Benign and Malignant Lesions
Fethi Emre Ustabasioglu, Cesur Samanci, Deniz Alis, Nilay Sengul Samanci, Osman Kula, Deniz Cebi Olgun
J Clin Imaging Sci 2017, 7:12 (6 March 2017)
Objectives: We aimed to prospectively assess the diagnostic value of apparent diffusion coefficient (ADC) measurement in the differentiation of benign and malignant mediastinal lymphadenopathies. Materials and Methods: The study included 63 consecutive patients (28 women, 35 men; mean age 59.3 years) with 125 mediastinal lymphadenopathies. Echoplanar diffusion-weighted magnetic resonance imaging of the mediastinum was performed with b-factors of 0 and 600 mm2/s before mediastinoscopy and mediastinotomy, and ADC values were measured. The ADC values were compared with the histological results, and statistical analysis was done. P < 0.05 was considered statistically significant. Results: The mean ADC value of malignant mediastinal lymphadenopathy (1.030 ± 0.245 × 10−3 mm2/s) was significantly lower (P < 0.05) when compared to benign lymphadenopathies (1.571 ± 0.559 × 10−3 mm2/s). For differentiating malignant from benign mediastinal lymphadenopathy, the best result was obtained when an ADC value of 1.334 × 10−3 mm2/s was used as a threshold value; area under the curve 0.848, accuracy 78.4%, sensitivity 66%, specificity of 86%, positive predictive value 76.7%, and negative predictive value of 79.2%. Interobserver agreement was excellent for ADC measurements. Conclusions: ADC measurements could be considered an important supportive method in differentiating benign from malignant mediastinal lymphadenopathies.
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Case Report: Congenital Uterine Arteriovenous Malformation Presenting as Postcoital bleeding: A Rare Presentation of a Rare Clinical Condition
Neha Agarwal, Seema Chopra, Neelam Aggarwal, Ujjwal Gorsi
J Clin Imaging Sci 2017, 7:11 (27 February 2017)
Congenital uterine arteriovenous malformation (AVM) is an extremely rare condition with <100 cases documented in literature. We report multiparous women presenting to us with a history of postcoital bleed. Initial Doppler ultrasonography was consistent with features suggestive of AVM. Subsequently, computed tomography (CT) angiography confirmed the diagnosis. Embolization was chosen as the treatment because of the large extension of AVM and the risk of hemorrhage during hysterectomy. The patient was discharged in a stable condition with a plan of repeat embolization in the next setting. At 6 and 12 weeks of follow-up, she did not experience any further episodes of bleed. The purpose of this case report is to highlight the salient clinical features, diagnosis, and the management options available for this rare clinical condition.
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Erratum: Erratum: SYNTAX Score in Patients with High Computed Tomography Coronary Calcium Score

J Clin Imaging Sci 2017, 7:10 (20 February 2017)
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Case Report: Asymptomatic Urolithiasis Complicated by Nephrocutaneous Fistula
Marion Hamard, Gaël Amzalag, Christoph D Becker, Pierre-Alexandre Poletti
J Clin Imaging Sci 2017, 7:9 (20 February 2017)
Asymptomatic spontaneous nephrocutaneous fistula is a rare and severe complication of chronic urolithiasis. We report a case of 56-year-old woman with a nephrocutaneous fistula (NFC) which developed from a superinfected urinoma following calyceal rupture due to an obstructing calculus in the left ureter. The patient was clinically asymptomatic and came to the emergency department for a painless left flank fluctuating mass. This urinoma was superinfected, with a delayed development of renal abscesses and perirenal phlegmon found on contrast-enhanced uro-computed tomography (CT), responsible for left renal vein thrombophlebitis and left psoas abscess.. Thereafter, a 99 mTc dimercaptosuccinic acid (DMSA) scintigraphy revealed a nonfunctional left kidney, leading to the decision of left nephrectomy. Chronic urolithiasis complications are rare and only few cases are reported in medical literature. A systematic medical approach helped selecting the best imaging modality to help diagnosis and treatment. Indeed, uro-CT scan and renal scintigraphy with 99 mTc-DMSA are the most sensitive imaging modalities to investigate morphological and functional urinary tract consequences of NFC, secondary to chronic urolithiasis.
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Original Article: Computer-aided Detection Fidelity of Pulmonary Nodules in Chest Radiograph
Nikolaos Dellios, Ulf Teichgraeber, Robert Chelaru, Ansgar Malich, Ismini E Papageorgiou
J Clin Imaging Sci 2017, 7:8 (20 February 2017)
Aim: The most ubiquitous chest diagnostic method is the chest radiograph. A common radiographic finding, quite often incidental, is the nodular pulmonary lesion. The detection of small lesions out of complex parenchymal structure is a daily clinical challenge. In this study, we investigate the efficacy of the computer-aided detection (CAD) software package SoftView™ 2.4A for bone suppression and OnGuard™ 5.2 (Riverain Technologies, Miamisburg, OH, USA) for automated detection of pulmonary nodules in chest radiographs. Subjects and Methods: We retrospectively evaluated a dataset of 100 posteroanterior chest radiographs with pulmonary nodular lesions ranging from 5 to 85 mm. All nodules were confirmed with a consecutive computed tomography scan and histologically classified as 75% malignant. The number of detected lesions by observation in unprocessed images was compared to the number and dignity of CAD-detected lesions in bone-suppressed images (BSIs). Results: SoftView™ BSI does not affect the objective lesion-to-background contrast. OnGuard™ has a stand-alone sensitivity of 62% and specificity of 58% for nodular lesion detection in chest radiographs. The false positive rate is 0.88/image and the false negative (FN) rate is 0.35/image. From the true positive lesions, 20% were proven benign and 80% were malignant. FN lesions were 47% benign and 53% malignant. Conclusion: We conclude that CAD does not qualify for a stand-alone standard of diagnosis. The use of CAD accompanied with a critical radiological assessment of the software suggested pattern appears more realistic. Accordingly, it is essential to focus on studies assessing the quality-time-cost profile of real-time (as opposed to retrospective) CAD implementation in clinical diagnostics.
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Case Report: Gastropleural Fistula with Aortic Intramural Involvement
Akshya Gupta, Abhishek Chaturvedi, Patrick Fultz, Susan Hobbs
J Clin Imaging Sci 2017, 7:7 (20 February 2017)
Gastropleural fistula is a relatively rare complication that can be seen as a result of traumatic, nontraumatic, benign, and neoplastic etiologies. Most commonly, these are found in patients with diaphragmatic herniation or prior thoracic surgery. Aortoenteric fistulas are rare communications typically between the abdominal aorta and bowel. We present a rare case of an 88-year-old male who developed a gastropleural fistula with erosions into the wall of the descending thoracic aorta. Computed tomography (CT) is a leading modality in evaluation of suspected gastropleural or aortoenteric fistulas given the quick scan time and widespread availability. Prompt diagnosis is essential and requires an understanding of appropriate CT protocols and CT imaging appearance.
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Pictorial Essay: Different Sonographic Faces of Ectopic Pregnancy
Charu Chanana, Nishant Gupta, Itisha Bansal, Kusum Hooda, Pranav Sharma, Mohit Gupta, Darshan Gandhi, Yogesh Kumar
J Clin Imaging Sci 2017, 7:6 (20 February 2017)
Vaginal bleeding in the first trimester has wide differential diagnoses, the most common being a normal early intrauterine pregnancy, with other potential causes including spontaneous abortion and ectopic pregnancy. The incidence of ectopic pregnancy is approximately 2% of all reported pregnancies and is one of the leading causes of maternal mortality worldwide. Clinical signs and symptoms of ectopic pregnancy are often nonspecific. History of pelvic pain with bleeding and positive β-human chorionic gonadotropin should raise the possibility of ectopic pregnancy. Knowledge of the different locations of ectopic pregnancy is of utmost importance, in which ultrasound imaging plays a crucial role. This pictorial essay depicts sonographic findings and essential pitfalls in diagnosing ectopic pregnancy.
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Case Report: Infantile Hemangioendothelioma of the Parotid Gland
Rajas Chaubal, Om Tavri, Atul Sawant, Chitrangada Singh
J Clin Imaging Sci 2017, 7:5 (27 January 2017)
A 4-month-old infant presented with a painless swelling overlying the left angle of mandible. Ultrasound and magnetic resonance imaging (MRI) revealed a large lesion replacing the entire left parotid gland, with multiple enlarged vessels. Homogeneous enhancement of the lesion was seen on the postcontrast MRI scans. Based on the imaging features, a diagnosis of infantile hemangioendothelioma of the parotid gland was offered. This helped in avoiding any further invasive testing.
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Original Article: Elastography-targeted Thyroid Nodule Aspiration: A Novel Approach
Elliot Landau, Danielle Del Re, Bina Kviatkovsky, Aryeh Rothstein, Jonathan Scheiner, Cheryl Lin
J Clin Imaging Sci 2017, 7:4 (27 January 2017)
Objectives: Since 2009, the rate of nondiagnostic (ND) thyroid nodule fine-needle aspiration (FNA) has ranged from 2% to 20%. A ND result can cause further patient morbidity secondary to repeated procedures and delay in diagnosis. The use of real-time strain elastography (RTE) in determining nodule malignant risk has gained considerable focus recently. A less studied area where RTE may prove beneficial is its role in targeting areas for FNA. Our hypothesis is that FNA performed in concurrence with RTE will show a decreased rate of ND results leading to fewer repeated FNA. Materials and Methods: The Institutional Review Board approval was obtained. A retrospective review of all thyroid nodule FNA from January 1, 2011, to January 1, 2014, was performed with review of nodule size, presence of microcalcifications, vascularity, solid components, patient age, and gender. Cases were separated based if RTE was done before FNA or not. Pathology reports were reviewed to assess for specimen adequacy. Statistical comparison was performed using SAS analysis software. Results: A total of 221 specimens were reviewed, with RTE performed on 140 cases (63.4%). Both groups were similar in demographics and previously described nodule characteristics. The ND rate when RTE was not performed was 16% (13/68) compared to 10% when RTE was performed (14/126). The difference was not found to be statistically significant, P = 0.205. Conclusions: The presence of an elastogram failed to demonstrate a significant decrease in ND FNA rates although these results may be secondary to study design. Further evaluation with prospective trials using larger sample size may ultimately detect increased accuracy of RTE-targeted FNA.
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Case Report: Gastropericardial Fistula as a Late Complication of Laparoscopic Gastric Banding
Adam A Rudd, Chandana Lall, Ajita Deodhar, Kenneth J Chang, Brian R Smith
J Clin Imaging Sci 2017, 7:3 (27 January 2017)
Laparoscopic adjustable gastric banding (LAGB) is a bariatric procedure that is being performed with increasing frequency as an alternative management option for morbid obesity. Several common complications have been reported including gastric band slippage and associated pouch dilatation, intragastric erosion of the band, gastric wall perforation, and abscess formation. We present a case of gastropericardial fistula occurring nine years after an LAGB. There have been no previous documented cases of the complication after this procedure.
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Case Report: Bronchial Artery Aneurysm with Associated Bronchial Artery to Pulmonary Artery Fistula: Treatment by Embolization
Caleb G Hsieh, Thomas Le, Keren Fogelfeld, Nader Kamangar
J Clin Imaging Sci 2017, 7:2 (27 January 2017)
Bronchial artery aneurysm (BAA) is a rare vascular phenomenon. This review highlights a case of a BAA that was complicated by the presence of a bronchial artery to pulmonary artery (BA-PA) fistula, consequently presenting a unique challenge to management. BAAs have a strongly reported risk of rupture resulting in life-threatening hemoptysis. Embolization has thus become routine for the management such severe cases. The management of incidentally found anomalies is less obvious, but prophylactic embolization is a generally accepted practice. In this report, we review some of the risks and benefits associated with BAA embolization with specific consideration of the challenges in cases of co-existing BA-PA fistula.
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Original Article: Initial Experience with a Cone-beam Breast Computed Tomography-guided Biopsy System
Posy J Seifert, Renee C Morgan, David L Conover, Andrea L Arieno
J Clin Imaging Sci 2017, 7:1 (27 January 2017)
Objective: To evaluate our initial experience with a cone-beam breast computed tomography (BCT)-guided breast biopsy system for lesion retrieval in phantom studies for use with a cone-beam BCT imaging system. Materials and Methods: Under the Institutional Review Board approval, a phantom biopsy study was performed using a dedicated BCT-guided biopsy system. Fifteen biopsies were performed on each of the small, medium, and large anthropomorphic breast phantoms with both BCT and stereotactic guidance for comparison. Each set of the 45 phantoms contained masses and calcification clusters of varying sizes. Data included mass/calcium retrieval rate and dose and length of procedure time for phantom studies. Results: Phantom mass and calcium retrieval rate were 100% for BCT and stereotactic biopsy. BCT dose for small and medium breast phantoms was found to be equivalent to or less than the corresponding stereotactic approach. Stereotactic-guided biopsy dose was 34.2 and 62.5 mGy for small and medium breast phantoms, respectively. BCT-guided biopsy dose was 15.4 and 30.0 mGy for small and medium breast phantoms, respectively. Both computed tomography biopsy and stereotactic biopsy study time ranged from 10 to 20 min. Conclusion: Initial experience with a BCT-guided biopsy system has shown to be comparable to stereotactic biopsy in phantom studies with equivalent or decreased dose.
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Original Article: Horizontal Long Axis Imaging Plane for Evaluation of Right Ventricular Function on Cardiac Magnetic Resonance Imaging
Abhishek Chaturvedi, Joseph Whitnah, Jeffrey H Maki, Timothy Baran, Lee M Mitsumori
J Clin Imaging Sci 2016, 6:52 (29 December 2016)
Purpose: The purpose of this study was to evaluate a horizontal long axis (HLA) magnetic resonance imaging (MRI) plane aligned to the long axis of the right ventricular (RV) cavity for functional analysis by comparing the measurement variability and time required for the analysis with that using a short-axis (SAX) image orientation. Materials and Methods: Thirty-four cardiac MRI exams with cine balanced steady-state free precession image stacks in both the SAX and the HLA of the RV (RHLA) were evaluated. Two reviewers independently traced RV endocardial borders on each image of the cine stacks. The time required to complete each set of traces was recorded, and the RV end-diastolic volume, end-systolic volume, and ejection fraction were calculated. Analysis times and RV measurements were compared between the two orientations. Results: Analysis time for each reviewer was significantly shorter for the RHLA stack (reviewer 1 = 6.4 ± 1.8 min, reviewer 2 = 6.0 ± 3.3 min) than for the SAX stack (7.5 ± 2.1 and 6.9 ± 3.6 min, respectively; P < 0.002). Bland-Altman analysis revealed lower mean differences, limits of agreement, and coefficients of variation for RV measurements obtained with the RHLA stack. Conclusions: RV functional analysis using a RHLA stack resulted in shorter analysis times and lower measurement variability than for a SAX stack orientation.
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Original Article: Elastography in Distinguishing Benign from Malignant Thyroid Nodules
Bulent Colakoglu, Duzgun Yildirim, Deniz Alis, Gokhan Ucar, Cesur Samanci, Fethi Emre Ustabasioglu, Alev Bakir, Onur Levent Ulusoy
J Clin Imaging Sci 2016, 6:51 (29 December 2016)
Aim: The aim of this study is to test the diagnostic success of strain elastography in distinguishing benign from malignant thyroid nodules. Materials and Methods: The size, echogenicity, and halo integrity of 293 thyroid nodules and the presence of microcalcification in these nodules were evaluated on gray-scale examination. Doppler characteristics and elastography patterns were also evaluated and recorded. Nodules were classified in four categories (patterns 1-4) based on elastographic examination. Results: According to the cytopathological findings, 222 nodules were benign, and 71 nodules were malignant. The risk of a nodule to be malignant was 3.8 times increased by hypoechogenicity, 7.7 times increased by the presence of microcalcification, and 11.5 times increased by the absence of halo. On Doppler patterns, the presence of central vascularity increased the malignancy risk of a nodule by 5.8 times. According to the receiver operating characteristic analysis, patterns 3 and 4 were malignant, and patterns 1 and 2 were benign. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of elastography were 100%, 80.2%, 61.7%, 100%, and 85%, respectively. Conclusion: Strain elastography can be used as a noninvasive method in distinguishing benign from malignant thyroid nodules and in identifying the patients who would undergo surgery.
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Original Article: Multimodality Imaging Characteristics of the Common Renal Cell Carcinoma Subtypes: An Analysis of 544 Pathologically Proven Tumors
Winnie Fu, Guan Huang, Zaahir Moloo, Safwat Girgis, Vimal H Patel, Gavin Low
J Clin Imaging Sci 2016, 6:50 (29 December 2016)
Objectives: The objective of this study was to define the characteristic imaging appearances of the common renal cell carcinoma (RCC) subtypes. Materials and Methods: The Institutional Review Board approval was obtained for this HIPAA-compliant retrospective study, and informed consent was waived. 520 patients (336 men, 184 women; age range, 22-88 years) underwent preoperative cross-sectional imaging of 544 RCCs from 2008 to 2013. The imaging appearances of the RCCs and clinical information were reviewed. Data analysis was performed using parametric and nonparametric statistics, descriptive statistics, and receiver operating characteristic analysis. Results: The RCC subtypes showed significant differences (P < 0.001) in several imaging parameters such as tumor margins, tumor consistency, tumor homogeneity, the presence of a central stellate scar, T2 signal intensity, and the degree of tumor enhancement. Low T2 signal intensity on magnetic resonance imaging (MRI) allowed differentiation of papillary RCC from clear cell and chromophobe RCCs with 90.9% sensitivity and 93.1% specificity. A tumor-to-cortex ratio ≥1 on the corticomedullary phase had 98% specificity for clear cell RCC. Conclusion: The T2 signal intensity of the tumor on MRI and its degree of enhancement are useful imaging parameters for discriminating between the RCC subtypes while gross morphological findings offer additional value in RCC profiling.
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Radiologic-Pathologic Correlation: Ectopic Anterior Mediastinal Pathology in the Chest: Radiologic-pathologic Correlation of Unexpected Encounters with the "Terrible Ts"
Mahsan Rashidfarokhi, Jessica Gupta, Anatoly Leytin, Oleg Epelbaum
J Clin Imaging Sci 2016, 6:49 (29 December 2016)
The complex embryology of the anterior mediastinum makes it home to an array of primary neoplasms tied to the presence of the thyroid and thymus glands in that compartment. While the occurrence of ectopic thyroid deposits in the extramediastinal thorax has not been convincingly established, the other three "Ts" of the classic "4T" mnemonic for the differential diagnosis of an anterior mediastinal mass have occurred in the lung parenchyma, pleural space, and endobronchially as primary tumors. Finding any of the three lesions - thymoma, teratoma, or B-cell lymphoma - in the chest outside the mediastinum is very unusual, but that possibility exists. Herein, we illustrate examples of this rare phenomenon.
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Original Article: Percutaneous Direct Needle Puncture and Transcatheter N-butyl Cyanoacrylate Injection Techniques for the Embolization of Pseudoaneurysms and Aneurysms of Arteries Supplying the Hepato-pancreato-biliary System and Gastrointestinal Tract
Rajanikant R Yadav, Deb K Boruah, Vishwaroop Bhattacharyya, Raghunandan Prasad, Sheo Kumar, VA Saraswat, VK Kapoor, Rajan Saxena
J Clin Imaging Sci 2016, 6:48 (20 December 2016)
Aims: The aim of this study was to evaluate the safety and clinical efficacy of percutaneous direct needle puncture and transcatheter N-butyl cyanoacrylate (NBCA) injection techniques for the embolization of pseudoaneurysms and aneurysms of arteries supplying the hepato-pancreato-biliary (HPB) system and gastrointestinal (GI) tract. Subjects and Methods: A hospital-based cross-sectional retrospective study was conducted, where the study group comprised 11 patients with pseudoaneurysms/aneurysms of arteries supplying the HPB system and GI tract presenting to a tertiary care center from January 2015 to June 2016. Four patients (36.4%) underwent percutaneous direct needle puncture of pseudoaneurysms with NBCA injection, 3 patients (27.3%) underwent transcatheter embolization with NBCA as sole embolic agent, and in 4 patients (36.4%), transcatheter NBCA injection was done along with coil embolization. Results: This retrospective study comprised 11 patients (8 males and 3 females) with mean age of 35.8 years ± 1.6 (standard deviation [SD]). The mean volume of NBCA: ethiodized oil (lipiodol) mixture injected by percutaneous direct needle puncture was 0.62 ml ± 0.25 (SD) (range = 0.5-1 ml), and by transcatheter injection, it was 0.62 ml ± 0.37 (SD) (range = 0.3-1.4 ml). Embolization with NBCA was technically and clinically successful in all patients (100%). No recurrence of bleeding or recurrence of pseudoaneurysm/aneurysm was noted in our study. Conclusions: Percutaneous direct needle puncture of visceral artery pseudoaneurysms and NBCA glue injection and transcatheter NBCA injection for embolization of visceral artery pseudoaneurysms and aneurysms are cost-effective techniques that can be used when coil embolization is not feasible or has failed.
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Original Article: Diagnostic and Clinical Management of Skull Fractures in Children
Christoph Arneitz, Maria Sinzig, Günter Fasching
J Clin Imaging Sci 2016, 6:47 (16 November 2016)
DOI:10.4103/2156-7514.194261  PMID:28028451
Objective: The indications of routine skull X-rays after mild head trauma are still in discussion, and the clinical management of a child with a skull fracture remains controversial. The aim of our retrospective study was to evaluate our diagnostic and clinical management of children with skull fractures following minor head trauma. Methods: We worked up the medical history of all consecutive patients with a skull fracture treated in our hospital from January 2009 to October 2014 and investigated all skull X-rays in our hospital during this period. Results: In 5217 skull radiographies, 66 skull fractures (1.3%) were detected. The mean age of all our patients was 5.9 years (median age: 4.0 years); the mean age of patients with a diagnosed skull fracture was 2.3 years (median age: 0.8 years). A total of 1658 children (32%) were <2 years old. A typical boggy swelling was present in 61% of all skull fractures. The majority of injuries were caused by falls (77%). Nine patients (14%) required a computed tomography (CT) scan during their hospital stay due to neurological symptoms, and four patients had a brain magnetic resonance imaging. Nine patients (14%) showed an intracranial hemorrhage (ICH; mean age: 7.3 years); one patient had a neurosurgery because of a depressed skull fracture. Nine patients (14%) were observed at our pediatric intensive care unit for a mean time of 2.9 days. The mean hospital stay was 4.2 days. Conclusions: Our findings support previous evidence against the routine use of skull X-rays for evaluation of children with minor head injury. The rate of diagnosed skull fractures in radiographs following minor head trauma is low, and additional CT scans are not indicated in asymptomatic patient with a linear skull fracture. All detected ICHs could be treated conservatively. Children under the age of 2 years have the highest risk of skull fractures after minor head trauma, but do not have a higher incidence of intracranial bleeding. Neuroobservation without initial CT scans is safe in infants and children following minor head trauma and CT scans should be reserved for patients with neurological symptoms.
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Original Article: SYNTAX Score in Patients with High Computed Tomography Coronary Calcium Score
Madhav Hegde, Ravindran Rajendran
J Clin Imaging Sci 2016, 6:46 (4 November 2016)
DOI:10.4103/2156-7514.193423  PMID:28028450
Objectives: To study the conventional coronary angiogram ( CA) findings in patients with high coronary calcium on multidetector computed tomogram. Materials and Methods: Fifty patients with coronary calcium high enough in its extent and location to interfere with the interpretation of a contrast-filled coronary artery for a significant lesion were studied with conventional CA. Framingham risk score (FRS), computed tomography (CT) coronary calcium score (CCS), and SYNTAX score (SS) from the CA were calculated by separate investigators who were blinded to other scores. Effectively, 250 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery and posterior descending artery in each subject) with calcium scores were studied for lesions on CA. Results: Thirty-five subjects had high FRS, 10 had intermediate FRS, and 5 had low FRS. Eight subjects of 25 (32%) with CCS between 350 and 1000 had no significant coronary artery disease (CAD). Overall, the CCS and the SS had a strong agreement with each other (r = 0.68, P < 0.01) that persisted in those with very high scores >1000 (r = 0.55, P < 0.01, n = 30), but only a nonsignificant weak correlation with scores between 350 and 1000 (r = 0.1, P = 0.62, n = 20). Individual vessel calcium scores correlated strongly for the presence of any lesion (r = 0.52, P < 0.01) in the same artery but only weakly for a significant lesion (r = 0.29, P = 0.05). Conclusion: High CT CCS in this cohort of intermediate to high (Framingham score) risk patients correlated strongly with the subject's global burden of the CAD as derived by the SS, more so for subjects with very high scores. Similarly, CCS correlated strongly with the presence of any lesion but only weakly for a significant stenosis; also, about one-third of patients with CCS between 350 and 1000 may not have significant disease on conventional CA.
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Case Report: Pulmonary Artery Sarcoma - Multimodality Imaging
Nari Jeong, Sang-Hoon Seol, Il Hwan Kim, Ji Yeon Kim
J Clin Imaging Sci 2016, 6:45 (21 October 2016)
DOI:10.4103/2156-7514.192841  PMID:27833785
Pulmonary artery sarcoma (PAS) is a rare and fatal disease. PAS can often be misdiagnosed as pulmonary thromboembolism. Moreover, the correct diagnosis is frequently delayed due to nonspecific signs and symptoms. The prognosis of patients with PAS is poor. We report a case of a woman with a primary PAS who was initially diagnosed with pulmonary thromboembolism.
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Original Article: Computed Tomography Angiography with a 192-slice Dual-source Computed Tomography System: Improvements in Image Quality and Radiation Dose
Philip V M Linsen, Adriaan Coenen, Marisa M Lubbers, Marcel L Dijkshoorn, Mohamed Ouhlous, Koen Nieman
J Clin Imaging Sci 2016, 6:44 (21 October 2016)
DOI:10.4103/2156-7514.192840  PMID:27833784
Purpose: This study aims to compare image quality, radiation dose, and the influence of the heart rate on image quality of high-pitch spiral coronary computed tomography angiography (CCTA) using 128-slice (second generation) dual-source CT (DSCT) and a 192-slice DSCT (third generation) scanner. Materials and Methods: Two consecutive cohorts of fifty patients underwent CCTA by high-pitch spiral scan mode using 128 or 192-slice DSCT. The 192-slice DSCT system has a more powerful roentgen tube (2 × 120 kW) that allows CCTA acquisition at lower tube voltages, wider longitudinal coverage for faster table speed (732 m/s), and the use of iterative reconstruction. Objective image quality was measured as the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Subjective image quality was evaluated using a Likert scale. Results: While the effective dose was lower with 192-slice DSCT (1.2 ± 0.5 vs. 0.6 ± 0.3 mSv; P < 0.001), the SNR (18.9 ± 4.3 vs. 11.0 ± 2.9; P < 0.001) and CNR (23.5 ± 4.8 vs. 14.3 ± 4.1; P < 0.001) were superior to 128-slice DSCT. Although patients scanned with 192-slice DSCT had a faster heart rate (59 ± 7 vs. 56 ± 6; P = 0.045), subjective image quality was scored higher (4.2 ± 0.8 vs. 3.0 ± 0.7; P < 0.001) compared to 128-slice DSCT. Conclusions: High-pitch spiral CCTA by 192-slice DSCT provides better image quality, despite a higher average heart rate, at lower radiation doses compared to 128-slice DSCT.
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Original Article: The Role of Computed Tomography in Predicting Left Ventricular Assist Device Infectious Complications
Carrie K Gomez, Scott R Schiffman, Susan K Hobbs
J Clin Imaging Sci 2016, 6:43 (21 October 2016)
DOI:10.4103/2156-7514.192835  PMID:27833783
Objective: The purpose of this study is to identify early computed tomography findings around the driveline which would predict mediastinal or left ventricular assist device (LVAD) pocket abscess formation. Materials and Methods: A retrospective analysis was performed on 128 LVAD recipients between January 2007 and December 2011. Infectious complications were subdivided into those affecting the driveline and those resulting in abscess formation either around the LVAD pump or mediastinum. The size and location of infiltrative changes surrounding the driveline were used to predict infection propagation resulting in abscess. Results: Of the 128 patients, 49 (38.3%) patients developed driveline infections and 24 (18.8%) patients developed abscess. 87.5% patients who developed abscess had a preceding driveline infection. The mean time from driveline infection to the development of pump pocket abscess was approximately 7 months. In addition, patients with abscess in the pump pocket or mediastinum had preceding infiltrative changes surrounding the driveline ≥14 mm (P = 0.0001). A preperitoneal location and size of infiltrative changes ≥14 mm were correlated with a higher likelihood of abscess formation (P = 0.0002). Conclusion: Our study demonstrates the predictive value of infection/infiltrative changes around the driveline, which increases the risk for abscess formation in the LVAD pump pocket and/or in the mediastinum.
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Case Report: Telescoping Technique to Engage Left Main Coronary Artery in a Case of Giant Aortic Aneurysm in a Geriatric Patient
Priyank Shah, Rahul Vasudev, Mahesh Bikkina, Hartaj Virk
J Clin Imaging Sci 2016, 6:42 (21 October 2016)
DOI:10.4103/2156-7514.192829  PMID:27833782
We present a case of a geriatric male with giant ascending aortic aneurysm (AAA) who underwent successful coronary angiography using telescoping technique for evaluation his coronary arteries before surgery for AAA. Since the ascending aorta and root were extremely dilated, we knew it would not have been possible to engage the coronaries using regular catheters and standard technique. Hence, telescopic technique was used. Amplatz left 3 (AL3) 7F (French) guide catheter (90 cm) was initially used, and nonselective injection of contrast was done to see the coronary ostium. After that, a 5F multipurpose catheter (110 cm) was telescoped through 7F AL3 guide catheter to engage the ostium of the left main coronary artery. Using this technique, images of coronaries were obtained, and it showed minimal luminal irregularities in major epicardial coronary arteries. The patient underwent successful surgery with aortic valve replacement and excision of aneurysm with graft placement. Although this technique has been described previously in enlarged aortas, this is the first to our knowledge use of telescoping technique in giant aortic aneurysm in a geriatric patient.
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Case Report: Occult Primary Neuroendocrine Tumor Metastasis to the Breast Detected on Screening Mammogram
Fabiana Policeni, Brittany Pakalniskis, Limin Yang
J Clin Imaging Sci 2016, 6:41 (29 September 2016)
DOI:10.4103/2156-7514.191439  PMID:27761301
Metastatic tumors are rare in the breast. Well-differentiated neuroendocrine tumors (WDNETs) are slow-growing neoplasms that arise from neuroendocrine cells, particularly in the gastrointestinal tract and bronchial tree. Metastatic WDNET to the breast is a rare entity. We present a case report of ileal WDNET metastatic to the breast which was initially identified as a small mass in the patient's left breast on screening mammography. Targeted ultrasound identified a suspicious mass, and ultrasound-guided percutaneous core biopsy was performed. Pathology revealed metastatic WDNET. Breast magnetic resonance imaging (MRI) was then performed and demonstrated left axillary Level 2 lymphadenopathy, and liver lesions were suspicious for metastasis. The patient underwent abdominal computed tomography (CT) to evaluate for distant metastatic disease. A spiculated mass was found near the ileocecal valve, suggestive of primary ileal WDNET. In addition, CT identified multiple liver lesions, most compatible with metastasis. Indium 111 OctreoScan confirmed radiotracer uptake in the ileum consistent with primary neuroendocrine tumor. In this report, we review the imaging characteristics of metastatic WDNET to the breast by different imaging modalities including mammogram, ultrasound, and breast MRI.
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Case Report: Extramedullary Plasmacytoma of the Gallbladder Detected on Fluorine 18-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography
Asif Ali Fakhri, Paul David Rodrigue, Amena Fatima Fakhri
J Clin Imaging Sci 2016, 6:40 (26 September 2016)
DOI:10.4103/2156-7514.191127  PMID:27761300
Extramedullary plasmacytoma is rare in patients with diagnosed multiple myeloma. Soft tissue plasmacytoma of the gallbladder is particularly uncommon and has been described in only a handful of cases. Diagnosis of gallbladder plasmacytoma with fluorine 18-fluorodeoxyglucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) has not previously been reported. We present a 65-year-old female with a history of multiple myeloma who underwent a restaging F18-FDG-PET/CT which showed a focal area of hypermetabolic activity, corresponding to a nodular lesion within the posterior gallbladder wall. The patient underwent successful cholecystectomy, with surgical pathology revealing gallbladder plasmacytoma. A follow-up scan was negative for active malignancy. This is a novel case of gallbladder plasmacytoma diagnosed on whole-body F18-FDG PET/CT - thus demonstrating the clinical value of this imaging modality in staging, restaging, and surveillance for patients with multiple myeloma.
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Original Article: Effects of Neoadjuvant Chemotherapy on Benign Breast Lesions Compared to Cancers: Should an Additional Lesion on Magnetic Resonance Imaging Responding Similar to Cancer after Neoadjuvant Chemotherapy be Viewed with Suspicion?
Rebecca Leddy, Abid Irshad, Lara Hewett, Heather Collins, Frank Vento, Susan Ackerman, Madelene Lewis
J Clin Imaging Sci 2016, 6:39 (20 September 2016)
DOI:10.4103/2156-7514.190899  PMID:27833781
Purpose: Determining the effects of neoadjuvant chemotherapy (NAC) on benign breast lesions and to evaluate their response in comparison to breast cancers. Methods: A retrospective analysis performed on breast cancer patients between 2008 and 2014 to identify patients who had a pre- and post-NAC magnetic resonance imaging (MRI) and biopsy-proven benign lesions. Pre- and post-NAC size and intensity of enhancement of benign lesions and cancers were measured. Breast glandularity and background enhancement were graded. A 2 × 2 repeated measures ANOVAs and Sidak post hoc tests were conducted for multiple comparisons. Paired t-tests were conducted to examine changes over time, and two-tailed P values were reported. Results: The effects of NAC in 38 cancers were compared to the effects of NAC in 47 benign lesions in these patients. From pre- to post-NAC, the mean size (cm) of malignant lesions on MRI decreased from 4.09 (±standard deviation [SD] 2.51) to 1.54 (±SD 2.32), (P < 0.001); the mean size (cm) of benign lesions decreased from 0.83 (±SD 0.54 cm) to 0.28 (±SD 0.51), (P < 0.001). Both benign and malignant lesions decreased in size after NAC, the size reduction in malignant lesions was significantly greater than benign lesions. From pre- to post-NAC, the mean lesion enhancement of the malignant lesions (scale 1-4) decreased from 3.43 (±SD 0.80) to 1.02 (±SD 1.34); the mean lesion enhancement of benign lesions decreased from 2.96 (±SD 1.04) to 0.98 (±SD 1.51). For both benign and malignant lesions, there was a significant overall reduction in enhancement after NAC from moderate at pre-NAC to minimal at post-NAC, P < 0.001. There was no overall difference in the enhancement of cancers (mean = 2.22, SD = 0.79) versus benign lesions (mean = 1.97, SD = 1.08), (P = 0.23). There was no significant change in glandularity from pretherapy (mean = 3.11, SD = 0.84) to posttherapy (mean = 3.13, SD = 0.82), P < 0.001. Conclusion: Similar to cancers, benign breast lesions also show a significant decrease in size and enhancement after NAC; however, the decrease in size is less compared to cancers.
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Original Article: Integrating Ultrasound Teaching into Preclinical Problem-based Learning
Eli Tumba Tshibwabwa, Jenifer Cannon, James Rice, Michael G Kawooya, Reza Sanii, Robert Mallin
J Clin Imaging Sci 2016, 6:38 (20 September 2016)
DOI:10.4103/2156-7514.190897  PMID:27833780
Objectives: The aim is to provide students in the preclinical with ultrasound image interpretation skills. Research question: Are students in smaller groups with access to a combination of lectures and hands-on patient contact most likely to have better ultrasound image interpretation skills, than students in larger groups with only interactive didactic lectures? Methodology: First-year students at the preclinical Program of the College of Medicine, participated in two 2-h introductory interactive ultrasound sessions. The study comprised two cohorts: 2012/2013 students, who were offered large group teaching (LGT) sessions (control group), and 2013/2014 students, who received the intervention in small group learning problem-based learning (PBL) sessions (experimental group). The overall learning objectives were identical for both groups. The success of the module was evaluated using pre- and post-tests as well as students' feedback. Results: The students in the experimental group showed significantly higher scores in interpretations of images than those in the control group. The experimental group showed achievement of learning outcomes along with higher levels of satisfaction with the module compared to the latter. Conclusion: Posttest knowledge of the basics of ultrasound improved significantly over the pretest in the experimental group. In addition, students' overall satisfaction of the ultrasound module was shown to be higher for the PBL compared to the LGT groups. Small groups in an interactive and PBL setting along with opportunities for hands-on practice and simultaneous visualization of findings on a high definition screen should enhance preclinical student learning of the basics of ultrasound. Despite the potential of ultrasound as a clinical, teaching and learning tool for students in the preclinical years, standardized recommendations have yet to be created regarding its integration into the curricula within academic institutions and clinical medicine. The interactive and PBL is here to stay at the college of medicine. Further research would be carried out to see if this trend persists in the upcoming vertical system-based curriculum of the college of medicine.
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Case Report: Pylephlebitis with Liver Abscess Secondary to Chronic Appendicitis: A Radiological Conundrum
Divya Santosh, Gavin Low
J Clin Imaging Sci 2016, 6:37 (20 September 2016)
DOI:10.4103/2156-7514.190894  PMID:27833779
Septic thrombophlebitis of the portal vein and/or its intra-hepatic branches (pylephlebitis) with associated liver abscess formation is a rare and potentially fatal complication of intra-abdominal infection. We present such a case that was caused by missed chronic appendicitis. Imaging findings can be complex and mimic other diseases leading to a diagnostic conundrum. Radiologists need to be knowledgeable of this challenging condition to prevent misdiagnosis and because prompt treatment is often life-saving.
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Original Article: Magnetic Resonance Imaging Analysis of Caudal Regression Syndrome and Concomitant Anomalies in Pediatric Patients
Deb K Boruah, Dhaval D Dhingani, Sashidhar Achar, Arjun Prakash, Antony Augustine, Shantiranjan Sanyal, Manoj Gogoi, Kangkana Mahanta
J Clin Imaging Sci 2016, 6:36 (20 September 2016)
DOI:10.4103/2156-7514.190892  PMID:27833778
Objective: The aim of this study was to evaluate the magnetic resonance imaging (MRI) findings of caudal regression syndrome (CRS) and concomitant anomalies in pediatric patients. Materials and Methods: A hospital-based cross-sectional retrospective study was conducted. The study group comprised 21 pediatric patients presenting to the Departments of Radiodiagnosis and Pediatric Surgery in a tertiary care hospital from May 2011 to April 2016. All patients were initially evaluated clinically followed by MRI. Results: In our study, 21 pediatric patients were diagnosed with sacral agenesis/dysgenesis related to CRS. According to the Pang's classification, 2 (9.5%) patients were Type I, 5 (23.8%) patients were Type III, 7 (33.3%) patients were Type IV, and 7 (33.3%) patients were of Type V CRS. Clinically, 17 (81%) patients presented with urinary incontinence, 6 (28.6%) with fecal incontinence, 9 patients (42.9%) had poor gluteal musculatures and shallow intergluteal cleft, 7 (33.3%) patients had associated subcutaneous mass over spine, and 6 (28.6%) patients presented with distal leg muscle atrophy. MRI showed wedge-shaped conus termination in 5 (23.8%) patients and bulbous conus termination in 3 (14.3%) patients above the L1 vertebral level falling into Group 1 CRS while 7 (33.3%) patients had tethered cord and 6 (28.6%) patients had stretched conus falling into Group 2 CRS. Conclusion: MRI is the ideal modality for detailed evaluation of the status of the vertebra, spinal cord, intra- and extra-dural lesions and helps in early diagnosis, detailed preoperative MRI evaluation and assessing concomitant anomalies and guiding further management with early institution of treatment to maximize recovery.
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Original Article: Radio-anatomical Study of the Greater Palatine Canal and the Pterygopalatine Fossa in a Lebanese Population: A Consideration for Maxillary Nerve Block
Georges Aoun, Ibrahim Nasseh, Sayde Sokhn
J Clin Imaging Sci 2016, 6:35 (19 September 2016)
DOI:10.4103/2156-7514.190862  PMID:27833777
Aim: The aim of this study was to describe the morphology of the component, greater palatine canal-pterygopalatine fossa (GPC-PPF), in a Lebanese population using cone-beam computed tomography (CBCT) technology. Materials and Methods: CBCT images of 79 Lebanese adult patients (38 females and 41 males) were included in this study, and a total of 158 cases were evaluated bilaterally. The length and path of the GPCs-PPFs were determined, and the data obtained analyzed statistically. Results: In the sagittal plane, of all the GPCs-PPFs assessed, the average length was 35.02 mm on the right and 35.01 mm on the left. The most common anatomic path consisted in the presence of a curvature resulting in an internal narrowing whose average diameter was 2.4 mm on the right and 2.45 mm on the left. The mean diameter of the upper opening was 5.85 mm on the right and 5.82 mm on the left. As for the lower opening corresponding to the greater palatine foramen, the right and left average diameters were 6.39 mm and 6.42 mm, respectively. Conclusion: Within the limits of this study, we concluded that throughout the Lebanese population, the GPC-PPF path is variable with a predominance of curved one (77.21% [122/158] in both the right and left sides); however, the GPC-PPF length does not significantly vary according to gender and side.
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Case Report: Post biopsy Liver Hemorrhage Successfully Controlled by Ultrasound-guided Percutaneous Microwave Ablation
Ophelia Ka Heng Wai, Lawrence Fung Him Ng, Peter San Ming Yu, James Chi Sang Chan
J Clin Imaging Sci 2016, 6:34 (19 September 2016)
DOI:10.4103/2156-7514.190859  PMID:27833776
Percutaneous microwave coagulation therapy has been one of the major new developments in tumor ablation. Microwave ablation has also been used intraoperatively to achieve hemostasis at surgical margins in laparotomy. However, the use of microwave ablation for coagulation and hemostasis through percutaneous approach has not been described in the literature. Here, we report a case of hepatic amyloidosis with massive post biopsy liver hemorrhage, which could not be by transarterial embolization, and subsequently controlled by ultrasound-guided percutaneous microwave ablation. To the best of our knowledge, this is the first reported case of this technology application in human.
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Pictorial Essay: Unexpected Angiography Findings and Effects on Management
Matthew Neill, Hearns W Charles, Jonathan S Gross, Sean Farquharson, Amy R Deipolyi
J Clin Imaging Sci 2016, 6:33 (1 September 2016)
DOI:10.4103/2156-7514.189727  PMID:27688932
Despite progress in noninvasive imaging with computed tomography and magnetic resonance imaging, conventional angiography still contributes to the diagnostic workup of oncologic and other diseases. Arteriography can reveal tumors not evident on cross-sectional imaging, in addition to defining aberrant or unexpected arterial supply to targeted lesions. This additional and potentially unanticipated information can alter management decisions during interventional procedures.
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Case Report: Tuberculosis-associated Fibrosing Mediastinitis: Case Report and Literature Review
Ronald Tan, Joanne Martires, Nader Kamangar
J Clin Imaging Sci 2016, 6:32 (23 August 2016)
DOI:10.4103/2156-7514.188958  PMID:27625898
Fibrosing mediastinitis is a rare condition defined by the presence of fibrotic mediastinal infiltrates that obliterate normal fat planes. It is a late complication of a previous granulomatous infection, such as histoplasmosis or tuberculosis (TB). Due to its rarity, fibrosing mediastinitis is often under-recognized, and the clinical presentation is variable and dependent on the extent of infiltration or encasement of structures within the mediastinum. We present a case of fibrosing mediastinitis in a man with a prior history of TB, who presented with progressive dyspnea and was found to have chronic mediastinal soft tissue opacities and pulmonary hypertension. His diagnosis was delayed due to the lack of recognition of this clinical/radiographic entity. Fibrosing mediastinitis is a rare entity usually caused by granulomatous disease. Most cases develop as a late complication of histoplasmosis or TB. The presence of calcified mediastinal soft tissue infiltrates on advanced chest imaging can be diagnostic of fibrosing mediastinitis in patients with a prior history of a granulomatous infection once active processes such as malignancy are excluded.
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Case Report: Acute Calculous Cholecystitis Missed on Computed Tomography and Ultrasound but Diagnosed with Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography
Carina Mari Aparici, Aung Zaw Win
J Clin Imaging Sci 2016, 6:31 (16 August 2016)
DOI:10.4103/2156-7514.188474  PMID:27625897
We present a case of a 69-year-old patient who underwent ascending aortic aneurysm repair with aortic valve replacement. On postsurgical day 12, he developed leukocytosis and low-grade fevers. The chest computed tomography (CT) showed a periaortic hematoma which represents a postsurgical change from aortic aneurysm repair, and a small pericardial effusion. The abdominal ultrasound showed cholelithiasis without any sign of cholecystitis. Finally, a fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT examination was ordered to find the cause of fever of unknown origin, and it showed increased FDG uptake in the gallbladder wall, with no uptake in the lumen. FDG-PET/CT can diagnose acute cholecystitis in patients with nonspecific clinical symptoms and laboratory results.
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Case Series: Focal Hepatic Fluorodeoxyglucose Uptake Mimics Liver Metastasis Following External Beam Radiation for Gastroesophageal Cancers: A Case and Review of the Literature
Randy Wei, Avinash Chaurasia, Suhong Yu, Chandana Lall, Samuel J Klempner
J Clin Imaging Sci 2016, 6:30 (9 August 2016)
DOI:10.4103/2156-7514.188089  PMID:27625896
Patients with locally advanced gastroesophageal cancers frequently undergo concurrent chemotherapy and radiation (CRT). 18-fluorodeoxyglucose-positron emission tomography ( 18 FDG-PET) in combination with computed tomography is used for disease staging and assessing response to therapy. 18 FDG-PET interpretation is subject to confounding influences including infectious/inflammatory conditions, serum glucose, and concurrent medications. Radiotherapy induces tissue damage, which may be associated with FDG-avidity; however, few reports have described the focal areas of hepatic uptake following concurrent chemoradiation (CRT). Distinguishing hepatic FDG uptake from disease progression represents an important clinical scenario. Here, we present two cases of unexpected FDG uptake in the liver after CRT and review the literature describing incidental liver uptake on FDG-PET.
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Original Article: Transjugular Intrahepatic Portosystemic Shunt Dysfunction: Concordance of Clinical Findings, Doppler Ultrasound Examination, and Shunt Venography
Joshua M Owen, Ron Charles Gaba
J Clin Imaging Sci 2016, 6:29 (18 July 2016)
DOI:10.4103/2156-7514.186510  PMID:27563495
Objectives: The objective of this study was to evaluate the concordance between clinical symptoms, Doppler ultrasound (US), and shunt venography for the detection of stent-graft transjugular intrahepatic portosystemic shunt (TIPS) dysfunction. Materials and Methods: Forty-one patients (M:F 30:11, median age 55 years) who underwent contemporaneous clinical exam, Doppler US, and TIPS venography between 2003 and 2014 were retrospectively studied. Clinical symptoms (recurrent ascites or variceal bleeding) were dichotomously classified as present/absent, and US and TIPS venograms were categorized in a binary fashion as normal/abnormal. US abnormalities included high/low (>190 or <90 cm/s) TIPS velocity, significant velocity rise/fall (>50 cm/s), absent flow, and return of antegrade intra-hepatic portal flow. Venographic abnormalities included shunt stenosis/occlusion and/or pressure gradient elevation. Clinical and imaging concordance rates were calculated. Results: Fifty-two corresponding US examinations and venograms were assessed. The median time between studies was 3 days. Forty of 52 (77%) patients were symptomatic, 33/52 (64%) US examinations were abnormal, and 20/52 (38%) TIPS venograms were abnormal. Concordance between clinical symptoms and TIPS venography was 48% (25/52), while the agreement between US and shunt venography was 65% (34/52). Clinical symptoms and the US concurred in 60% (31/52) of the patients. The sensitivity of clinical symptoms and US for the detection of venographically abnormal shunts was 80% (16/20) and 85% (17/20), respectively. Both clinical symptoms and the US had low specificity (25%, 8/32 and 50%, 16/32) for venographically abnormal shunts. Conclusion: Clinical findings and the US had low concordance rates with TIPS venography, with acceptable sensitivity but poor specificity. These findings suggest the need for improved noninvasive imaging methods for stent-graft TIPS surveillance.
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Erratum: Erratum: Percutaneous CT Guided Ablation in the Hepatic Dome: Artificially Induced Pneumothorax for Safe Transpleural Access

J Clin Imaging Sci 2016, 6:28 (4 July 2016)
DOI:10.4103/2156-7514.185244  PMID:27512616
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Review Article: Principles and Clinical Application of Dual-energy Computed Tomography in the Evaluation of Cerebrovascular Disease Highly accessed article
Charlie Chia-Tsong Hsu, Gigi Nga Chi Kwan, Dalveer Singh, Jit Pratap, Trevor William Watkins
J Clin Imaging Sci 2016, 6:27 (29 June 2016)
DOI:10.4103/2156-7514.185003  PMID:27512615
Dual-energy computed tomography (DECT) simultaneously acquires images at two X-ray energy levels, at both high- and low-peak voltages (kVp). The material attenuation difference obtained from the two X-ray energies can be processed by software to analyze material decomposition and to create additional image datasets, namely, virtual noncontrast, virtual contrast also known as iodine overlay, and bone/calcium subtraction images. DECT has a vast array of clinical applications in imaging cerebrovascular diseases, which includes: (1) Identification of active extravasation of iodinated contrast in various types of intracranial hemorrhage; (2) differentiation between hemorrhagic transformation and iodine staining in acute ischemic stroke following diagnostic and/or therapeutic catheter angiography; (3) identification of culprit lesions in intra-axial hemorrhage; (4) calcium subtraction from atheromatous plaque for the assessment of plaque morphology and improved quantification of luminal stenosis; (5) bone subtraction to improve the depiction of vascular anatomy with more clarity, especially at the skull base; (6) metal artifact reduction utilizing virtual monoenergetic reconstructions for improved luminal assessment postaneurysm coiling or clipping. We discuss the physical principles of DECT and review the clinical applications of DECT for the evaluation of cerebrovascular diseases.
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Case Report: Viable Intrauterine Pregnancy and Coexisting Molar Pregnancy in a Bicornuate Uterus: A Rare Presentation
Kavitha Krishnamoorthy, Sabrina Gerkowicz, Usha Verma
J Clin Imaging Sci 2016, 6:26 (23 June 2016)
DOI:10.4103/2156-7514.184541  PMID:27403404
A complete hydatidiform mole with a viable coexisting fetus (CMCF) is a rare occurrence. Similarly, Mullerian anomalies such as a bicornuate uterus are uncommon variants of normal anatomy. We report a case of a 40-year-old female with a known bicornuate uterus presenting at 13 weeks gestation with vaginal bleeding. Ultrasound findings showed a healthy viable pregnancy in the right horn with complete molar pregnancy in the left horn. After extensive counseling, the patient desired conservative management, however, was unable to continue due to profuse vaginal bleeding. The patient underwent suction dilation and curettage under general anesthesia and evacuation of the uterine horns. Postoperatively, the patient was followed until serum beta-human chorionic gonadotropin (β-hCG) level dropped to <5 mU. This is the first case of a CMCF reported in a bicornuate uterus, diagnosed with the use of ultrasound imaging.
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Pictorial Essay: Thoracic Presentations of Small Round Blue Cell Tumors
Annalice Chang, Kyle Pfeifer, Peter Chen, Vivek Kalra, Myung Soo Shin
J Clin Imaging Sci 2016, 6:25 (23 June 2016)
DOI:10.4103/2156-7514.184539  PMID:27403403
The term "small round blue cell" is frequently used as a cursory radiologic pathological correlation of aggressive tumors throughout the body. We present a pictorial essay of common and uncommon subtypes of small round blue cell tumors in the chest illustrating the characteristic radiologic findings of each lesion. In addition, we review the pathologic findings of each tumor subtype with characteristic hematoxylin- and eosin-stained photomicrographs and immunohistochemical and molecular studies. Represented tumors include small cell carcinoma, Ewing sarcoma, extranodal marginal zone B-cell lymphoma, embryonal rhabdomyosarcoma, desmoplastic small round cell tumor, and posttransplant lymphoproliferative disorder. Understanding and ability to recognize these lesions are essential to broaden the radiologist's differential diagnosis and help guide patient care.
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Pictorial Review: Fungal Infections of the Central Nervous System: A Pictorial Review
Jose Gavito-Higuera, Carola Birgit Mullins, Luis Ramos-Duran, Cristina Ivette Olivas Chacon, Nawar Hakim, Enrique Palacios
J Clin Imaging Sci 2016, 6:24 (17 June 2016)
DOI:10.4103/2156-7514.184244  PMID:27403402
Fungal infections of the central nervous system (CNS) pose a threat to especially immunocompromised patients and their development is primarily determined by the immune status of the host. With an increasing number of organ transplants, chemotherapy, and human immunodeficiency virus infections, the number of immunocompromised patients as susceptible hosts is growing and fungal infections of the CNS are more frequently encountered. They may result in meningitis, cerebritis, abscess formation, cryptococcoma, and meningeal vasculitis with rapid disease progression and often overlapping symptoms. Although radiological characteristics are often nonspecific, unique imaging patterns can be identified through computer tomography as a first imaging modality and further refined by magnetic resonance imaging. A rapid diagnosis and the institution of the appropriate therapy are crucial in helping prevent an often fatal outcome.
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Pictorial Essay: Sinonasal Fungal Infections and Complications: A Pictorial Review
Jose Gavito-Higuera, Carola Birgit Mullins, Luis Ramos-Duran, Hugo Sandoval, Nassim Akle, Ramon Figueroa
J Clin Imaging Sci 2016, 6:23 (14 June 2016)
DOI:10.4103/2156-7514.184010  PMID:27403401
Fungal infections of the nose and paranasal sinuses can be categorized into invasive and non-invasive forms. The clinical presentation and course of the disease is primarily determined by the immune status of the host and can range from harmless or subtle presentations to life threatening complications. Invasive fungal infections are categorized into acute, chronic or chronic granulomatous entities. Immunocompromised patients with poorly controlled diabetes mellitus, HIV and patients receiving chemotherapy or chronic oral corticosteroids are mostly affected. Mycetoma and Allergic Fungal Rhinosinusitis are considered non-invasive forms. Computer tomography is the gold-standard in sinonasal imaging and is complimented by Magnetic resonance imaging (MRI) as it is superior in the evaluation of intraorbital and intracranial extensions. The knowledge and identification of the characteristic imaging patterns in invasive - and non- invasive fungal rhinosinusitis is crucial and the radiologist plays an important role in refining the diagnosis to prevent a possible fatal outcome.
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Original Article: High Prevalence of Liver Fibrosis in Patients with Human Immunodeficiency Virus Monoinfection and Human Immunodeficiency Virus Hepatitis-B Co-infection as Assessed by Shear Wave Elastography: Study at a Teaching Hospital in Kenya
Samuel Nguku Gitau, Sudhir Vinayak, Micah Silaba, Rodney Adam, Reena Shah
J Clin Imaging Sci 2016, 6:22 (7 June 2016)
DOI:10.4103/2156-7514.183582  PMID:27403400
Objectives: The aim of this study was to determine the prevalence of liver fibrosis in patients with human immunodeficiency virus (HIV) monoinfection versus those with HIV hepatitis-B virus (HBV) co-infection as assessed with shear wave elastography (SWE) in a tertiary sub-Saharan Africa hospital. Materials and Methods: A total of 105 consecutive patients, 70 with HIV monoinfection and 35 with HIV-HBV co-infection, had liver elastography obtained using SWE to assess for the presence of liver fibrosis the cutoff of which was 5.6 kPa. Assessment of aspartate aminotransferase-to-platelet ratio index (APRI) score (a noninvasive serum biomarker of liver fibrosis) in these patients was also done. Results: The prevalence of liver fibrosis was significantly higher (P < 0.0001) in patients with HIV-HBV co-infection, 25.7%, compared to those with HIV monoinfection, 7.1%. APRI score was greater in patients with HIV-HBV co-infection than those with HIV monoinfection. HIV co-infection with HBV accelerates progression to liver fibrosis. Association of a low cluster of differentiation 4 (CD-4) count with advanced fibrosis supports earlier starting of antiretroviral therapy to prevent rapid progression of liver disease in HIV-positive patients. Conclusion: In view of the high prevalence of liver fibrosis in patients with HIV-HBV co-infection, regular monitoring of the disease progression is recommended.
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Original Article: The Influence of Fasting in Summer on Amniotic Fluid During Pregnancy
Aysegül Altunkeser, Muslu Kazim Körez
J Clin Imaging Sci 2016, 6:21 (26 May 2016)
DOI:10.4103/2156-7514.183041  PMID:27313975
Objectives: Ramadan is a holy month in which eating and drinking are forbidden from dawn to sunset. In this study, we investigated using ultrasonography (USG) whether fasting in summer (as occurred in Ramadan 2014) had an influence on the volume of amniotic fluid during pregnancy. Materials and Methods: The study included 119 pregnant women in total who were admitted to our department with a request of obstetric USG between June 28, 2014, and July 27, 2014. The fasting group included 61 pregnant women and the control group of 58 pregnant women. In our study, all the fasting pregnant women had Sahur (predawn meal eaten before starting fasting) and Iftar (the evening meal for fast-breaking) every day, regularly. The women in the control group did not fast. In addition to amniotic fluid index and fetal biometric measurements during Ramadan, amniotic fluid volume was measured ultrasonographically throughout pregnancy. All ultrasound examinations were performed at least 8 h after Sahur during Ramadan. Chi-square test was utilized to compare the measurements of amniotic fluid volume, and Mann-Whitney U-test was utilized to analyze the differences in fetal growth data. Moreover, difference was considered statistically significant when the P value was <0.05. Results: The mean age was 25.7 years in the fasting group and 25.8 years in the control group. Other characteristics and mean gestational weeks of the two groups were similar. Ultrasonographically, there was no significant difference between two groups in respect to amniotic fluid amount during pregnancy (P = 0.7). There was no significant difference with regard to fetal growth parameters either (P > 0.05). Conclusion: In pregnant women who had regular predawn and fast-breaking meals, fasting in summer did not elicit alteration in the amount of amniotic fluid throughout pregnancy.
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Original Article: Sincipital Encephaloceles: A Study of Associated Brain Malformations
Shashidhar Vedavyas Achar, Hemonta Kumar Dutta
J Clin Imaging Sci 2016, 6:20 (26 May 2016)
DOI:10.4103/2156-7514.183040  PMID:27313974
Objective: The aim of this study was to evaluate the associated intracranial malformations in patients with sincipital encephaloceles. Materials and Methods: A hospital-based cross-sectional study was conducted over 8 years from June 2007 to May 2015 on 28 patients. The patients were evaluated by either computed tomography or magnetic resonance imaging whichever was feasible. Encephaloceles were described with respect to their types, contents, and extensions. A note was made on the associated malformations with sincipital encephaloceles. Results: Fifty percent of the patients presented before the age of 3 years and both the sexes were affected equally. Nasofrontal encephalocele was the most common type seen in 13 patients (46.4%), and corpus callosal agenesis (12 patients) was the most common associated malformation. Other malformations noted were arachnoid cyst (10 patients), hydrocephalus (7 patients), and agyria-pachygyria complex (2 patients). Conclusion: Capital Brain malformations are frequently encountered in children with sincipital encephaloceles. Detail radiological evaluation is necessary to plan treatment and also to prognosticate such rare malformations.
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Original Article: Effect of picture archiving and communication system image manipulation on the agreement of chest radiograph interpretation in the neonatal intensive care unit
Denise A Castro, Asad Ahmed Naqvi, Elizabeth Vandenkerkhof, Michael P Flavin, David Manson, Donald Soboleski
J Clin Imaging Sci 2016, 6:19 (19 May 2016)
DOI:10.4103/2156-7514.182730  PMID:27274414
Objective: Variability in image interpretation has been attributed to differences in the interpreters' knowledge base, experience level, and access to the clinical scenario. Picture archiving and communication system (PACS) has allowed the user to manipulate the images while developing their impression of the radiograph. The aim of this study was to determine the agreement of chest radiograph (CXR) impressions among radiologists and neonatologists and help determine the effect of image manipulation with PACS on report impression. Materials and Methods: Prospective cohort study included 60 patients from the Neonatal Intensive Care Unit undergoing CXRs. Three radiologists and three neonatologists reviewed two consecutive frontal CXRs of each patient. Each physician was allowed manipulation of images as needed to provide a decision of "improved," "unchanged," or "disease progression" lung disease for each patient. Each physician repeated the process once more; this time, they were not allowed to individually manipulate the images, but an independent radiologist presets the image brightness and contrast to best optimize the CXR appearance. Percent agreement and opposing reporting views were calculated between all six physicians for each of the two methods (allowing and not allowing image manipulation). Results: One hundred percent agreement in image impression between all six observers was only seen in 5% of cases when allowing image manipulation; 100% agreement was seen in 13% of the cases when there was no manipulation of the images. Conclusion: Agreement in CXR interpretation is poor; the ability to manipulate the images on PACS results in a decrease in agreement in the interpretation of these studies. New methods to standardize image appearance and allow improved comparison with previous studies should be sought to improve clinician agreement in interpretation consistency and advance patient care.
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Review Article: Multiparametric Magnetic Resonance Imaging of Recurrent Prostate Cancer Highly accessed article
Daniel Corey Oppenheimer, Eric P Weinberg, Gary M Hollenberg, Steven P Meyers
J Clin Imaging Sci 2016, 6:18 (29 April 2016)
DOI:10.4103/2156-7514.181494  PMID:27195184
Multiparametric magnetic resonance (MR) imaging of the prostate combines both morphological and functional MR techniques by utilizing small field of view T1-weighted, T2-weighted, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and MR spectroscopy to accurately detect, localize, and stage primary and recurrent prostate cancer. Localizing the site of recurrence in patients with rising prostate-specific antigen following treatment affects decision making regarding treatment and can be accomplished with multiparametric prostate MR. Several different treatment options are available for prostate cancer including radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, or a number of focal therapy techniques. The findings of recurrent prostate cancer can be different depending on the treatment the patient has received, and the radiologist must be able to recognize the variety of imaging findings seen with this common disease. This review article will detail the findings of recurrent prostate cancer on multiparametric MR and describe common posttreatment changes which may create challenges to accurate interpretation.
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Review Article: Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making Highly accessed article
Derik L Davis, James J Morrison
J Clin Imaging Sci 2016, 6:17 (29 April 2016)
DOI:10.4103/2156-7514.181493  PMID:27195183
Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip.
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Review Article: Dermatofibrosarcoma Protuberans: Insights into a Rare Soft Tissue Tumor
Aliya Sarhan Al Barwani, Sawsan Taif, Reem Ahmed Al Mazrouai, Khamis Salim Al Muzahmi, Asif Alrawi
J Clin Imaging Sci 2016, 6:16 (29 April 2016)
DOI:10.4103/2156-7514.181492  PMID:27195182
Dermatofibrosarcoma protuberans (DFSP) is a rare soft tumor which originally represents a cutaneous sarcoma. It grows slowly and presents usually as nodular superficial lesion on the trunk or the extremities. Although these tumors are locally aggressive with high rate of recurrence following surgery; the prognosis is considered excellent when it is effectively treated. The radiological appearance of this tumor has rarely been studied and findings infrequently discussed in the literature probably because many lesions underwent resection before imaging. Although imaging is infrequently performed for this lesion; it can show characteristic features and demonstrate the full extent. Imaging may also play a role in the differentiation of this tumor from more serious soft tissue lesions such as more aggressive sarcomas and hemangioma. In this article, we discuss the imaging findings of DFSP that can aid in its diagnosis and its variable appearances. In addition; the clinical presentation and treatment options are also described with review of the previous literature.
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Case Report: "Reverse Tigroid" Pattern in Pachygyria: A Novel Finding
Ujjawal Roy, Alak Pandit, Urmila Das, Ajay Panwar
J Clin Imaging Sci 2016, 6:15 (29 April 2016)
DOI:10.4103/2156-7514.181491  PMID:27195181
Pachygyria is considered a subtype of lissencephaly which, in turn, is a spectrum of disorders caused by abnormal neuronal migration. Clinical presentation in this disorder may be varied including microcephaly, developmental delay, facial dysmorphism, seizures, and mental retardation. Magnetic resonance imaging (MRI) of brain identifies the exact nature and extent of the disease and helps in delineating further plan of management. A Tigroid pattern on axial MRI scan and leopard pattern on a sagittal plane has been classically reported in disorders of myelin formation such as metachromatic leukodystrophy and Pelizaeus-Merzbacher disease. We present here a case of pachygyria who presented to us with some atypical features including "tigroid-like stripes" and "leopard-like pattern" on MRI brain which has not been reported in the medical literature previously.
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