Prevalence of Pancreato-Biliary Maljunction in Children with Choledochal Cyst - A Prospective Observational Study

Background

Pancreatico-biliary maljunction (PBM) is often found to be associated with choledochal cysts (CCs). According to a European multicenter study, the prevalence of PBM in cases of CC is found to be 72.2%, however, there is no Indian study depicting the prevalence of PBM in Indian children with CCs, which is one of the main postulated factors in the etiopathogenesis of CC. In this study, we have attempted to observe prospectively the prevalence of PBM in children with CC and correlate this to its morphological and biochemical parameters. The association between the presence of PBM and histopathological findings such as epithelial changes of the mucosa of the CC, inflammation, metaplasia or dysplasia, and histopathology of the liver has also been evaluated.

Materials and Methods

We carried out a single center, prospective observational study with a single arm study group. We prospectively selected all patients of CC admitted for surgery from November 2018 to October 2020. Data on biochemical, radiological, and histopathological parameters were collected and analyzed.

Results

We included a total of 20 patients in our study. The mean age of the participants was 6.22 ± 4.32 years. Among them, 11 (55.0%) were male and 9 (45%) were female. Abdominal pain was the most common presenting complaint among our patients (75.0%) and had a significant association with the presence of a PBM (P = 0.001). In symptomatic children, the mean duration of symptoms was 4.50 ± 2.26 months for jaundice, 4.50 ± 1.98 months for abdominal distension, and 5.07 ± 2.02 months for abdominal pain. Among the 3 children with cholangitis, the mean number of episodes was 3.33 ± 2.08, with a median of four episodes. Fourteen (70.0%) of the children had type I a CC, 1 (5.0%) participant each for types I b, I c, II and IV a and 2 (10.0%) of them had type IV b cyst. The mean size of the cyst (cm) was 7.41 ± 3.03 with a median of 6.85 cm. Among the children, 9 (45%) showed the presence of PBM on magnetic resonance cholangiopancreatography (MRCP), with 7 (77.8%) showing Komi's C-P type and 2 (22.2%) showing Komi's PC type. The mean common channel length (mm) on MRCP was 8.11 ± 2.47 with a median length of 8.00 mm. The biochemical analysis of a bile fluid amylase and lipase is the functional indicator of the presence of a PBM. Histopathological examination showed the presence of ulceration in the walls of the CC in 10 (50.0%) of the specimens. There was a significant association of the presence of PBM and ulceration in the mucosa of the CC (P ≤ 0.001), with the median levels being the highest in the PBM present group.

Conclusion

Abdominal pain is the most common complaint in a child with CC, and when present, it is significantly associated with the presence of a PBM. MRCP is the gold standard tool to detect CCs and find out the morphology of PBM. The prevalence of PBM in children with CC of 45% with a mean common channel length of 8.11 mm. The biochemical analysis of a bile amylase and lipase is the functional indicator of the presence of a PBM and there is a significant association of their higher levels and presence of PBM. The presence of chronic inflammation and microscopic ulcers is significant histologic parameters depicting the presence of a PBM.

Large Intraosseous Haemangioma of the Sacral Vertebra: The radiological imaging findings

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Craniospinal MRI Findings in Neuromelioidosis

Background

Melioidosis is a bacterial infection caused by Burkholderia pseudomallei that is endemic in Southeast Asia, northern Australia, and Africa. Neurological involvement is rare and reported in 3-5% of total cases.

Objective

The purpose of this study was to report a series of cases of melioidosis with neurological involvement and a brief review of the literature.

Materials and Methods

We collected the data from six melioidosis patients having neurological involvement. Clinical, biochemical, and imaging findings were analyzed.

Result

All patients in our study were adults (age range 27 to 73 years). The presenting symptoms were fever of varying duration (range 15 days to 2 months). Altered sensorium was noted in five patients. Four cases had brain abscess, one had meningitis, and one had a spinal epidural abscess. All cases of brain abscesses were T2 hyperintense with an irregular wall showing central diffusion restriction and irregular peripheral enhancement. The trigeminal nucleus was involved in one patient, but there was no enhancement of the trigeminal nerve. Extension along the white matter tract was noted in two patients. Magnetic resonance (MR) spectroscopy done in two patients showed increased lipid/lactate and choline peak in both of them.

Conclusion

Melioidosis can present as multiple micro-abscesses in the brain. Involvement of the trigeminal nucleus and extension along the corticospinal tract may raise the possibility of infection by B. pseudomallei. Meningitis and dural sinus thrombosis, although rare, can be presenting features.

Correlation of multiparametric MRI with histopathological grade of peripheral zone prostate carcinoma

BACKGROUND

Prostatic cancer is the second most common malignant tumor in men. Preoperative grading of prostate cancer is important for its management. Our objective is to compare individual and combined detection rates of T2-weighted imaging (T2WI), diffusion weighted imaging (DWI), dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI), and magnetic resonance spectroscopy (MRS) for prostate cancer with histopathological diagnosis as its golden standard.

METHODS

Forty-four patients with positive digital rectal examination (DRE) findings and elevated prostate specific antigen (PSA), underwent multiparametric MRI (Mp-MRI). T2WI, DWI, DCE-MRI and MRS were done in all the patients. Cognitive magnetic resonance-transrectal ultrasound (MR-TRUS) fusion biopsy was done in all the patients. Sensitivity and specificity of T2WI, DWI, DCE-MRI, and Prostate Imaging - Reporting and Data System PIRADS version 2 was obtained. Apparent diffusion coefficient (ADC) value and choline/citrate ratio were obtained for each lesion and correlated with histopathological grade.

RESULTS

The mean age of the patients was 68.7 ± 10.1 years, and the mean serum PSA level was 58.1 ± 22.4 ng/dL. Of the 38 lesions in peripheral zone, 33 (87%) had histopathologically proven prostate cancer. T2WI had a sensitivity and specificity of 75.8% and 80% and DWI had a sensitivity and specificity of 90.9% and 80%, respectively, for detection of malignant prostatic lesion. The mean ADC values for prostate cancer, prostatitis, and normal prostatic parenchyma were 0.702 ± 0.094 × 10-3 mm2/sec, 0.959 ± 0.171 × 10-3 mm2/sec, and 1.31 ± 0.223 × 10-3 mm2/sec, respectively. Type 3 curve has lower sensitivity (45.5%) but high specificity (80%) for diagnosing prostate cancer.

CONCLUSION

DWI can be useful to differentiate benign from malignant prostatic lesions, and low-grade from high-grade prostate carcinoma. ADC value has a positive correlation with histopathological grade of prostate cancer.

Diagnostic Dilemma: Parasitic Ovarian Fibroma With Degeneration

An ovarian fibroma is a rare entity and a diagnostic dilemma due to its solid nature and ultrasound findings being similar to a uterine fibroid. An ovarian fibroma, being parasitic, is extremely rare. We report the case of a 35-year-old, multiparous woman who presented with a 'wandering' abdominal mass of six months duration. Clinical examination revealed a 16-week size, solid, firm, well-defined mass in the right lumbar and iliac regions, separate from the uterus on bimanual examination, suggestive of a pedunculated subserous fibroid uterus. Ultrasound abdomen with color Doppler evaluation was suggestive of the non-uterine origin of the tumor, probably a gastrointestinal stromal tumor. In view of the diagnostic dilemma, MRI was done, which showed that the lesion had features characteristic of ovarian fibroma, however, bilateral ovaries were normally visualized. An exploratory laparotomy was performed. There was a solid parasitic tumor adherent to the bladder peritoneum and attached to the right ovary by a thin band, which was excised. Histopathology confirmed ovarian fibroma. To conclude, a parasitic ovarian fibroma is rare and a careful clinical approach with imaging and surgery helps in solving this diagnostic dilemma.

Assessment of the psoas muscle changes following the oblique lateral interbody fusion (OLIF) approach: A prospective observational study

Background

Traditional open posterior fusion techniques involve stripping of the posterior paraspinal muscles with protracted retraction, which can lead to ischemia and denervation. This may result in poor clinical outcomes despite a well-performed surgery. Oblique lumbar interbody fusion (OLIF) is a minimally invasive modified retroperitoneal anterior approach in the corridor between the psoas major (PM) and great vessels. The purpose of this research was to study changes in psoas properties and clinical outcomes in terms of the loss of hip flexion in patients undergoing OLIF surgery.

Methods

Patients with lumbar pathologies who underwent instrumented OLIF at our center were included. These patients were examined clinically at baseline and 6 months postoperatively. The Oswestry disability index (ODI) and visual analog scale (VAS) scores for back pain and leg pain were noted. Magnetic resonance imaging (MRI) scans were obtained preoperatively and postoperatively (minimum 6 months) to compare the cross-sectional areas (CSAs) of the PM.

Results

In total, 17 patients (male: female = 8:9) with a mean age of 46.06 ± 10.49 years were included. The operation time was 154.94 ± 32.33 min, estimated blood loss was 190 ± 56 mL, and mean CSAs of the right and left psoas were, respectively, 9.94 ± 3.19 and 10.65 ± 3.74 cm2 preoperatively and 10.00 ± 3.06 and 8.53 ± 2.81 cm2 at follow-up. Qualitative measurements revealed that muscle atrophy on the left side (approach side) was 19.12% ± 3.14% and fatty degeneration had occurred in 13 of 17 (76.5%) patients. Postoperatively, all patients had significant improvement in the VAS (back and leg) and ODI scores. Furthermore, 3 of 17 (17.6%) patients had mild hip weakness (4/5) on the left side immediately postoperatively, but it resolved in 6 months. Moreover, 2 of 17 (11.8%) patients complained of paraesthesia.

Conclusion

OLIF does cause injury to the PM but it is clinically insignificant according to MRI scans and clinical evaluations.

Eosinophilic Granuloma as a Solitary Lytic Lesion of the Cervical Spine in a Child

Introduction

Eosinophilic granuloma (EG) is a type of Langerhan cell histiocytosis (LCH) with unknown etiology. This benign tumorous lytic lesion affects mainly children or young adults, causing bone destruction. Although, the flat or the long bones are commonly affected, localized spinal involvement in pediatric age group is rare. A thorough workup is therefore necessary for this condition, which may mimic other severe conditions.

Case Report

A 10-year-old girl presented with neck pain for 4 months without any history of trauma, fever, or neurological weakness. An X-ray revealed radiolucency and sclerosis of the fifth cervical vertebral body, which was hypointense on T1 and heterogeneous on T2-weighted image, with mild peripheral enhancement on fat-suppressed post-contrast T1-weighted image. Biopsy histomorphology revealed a lymphohistiocytic lesion with scatted histiocytes with grooved nuclei, immunopositive for Langerin; thus consistent with LCH (EG). She was managed conservatively with a completely pain free course with full range of movement at 1-year follow-up. Her follow-up X-ray showed complete remodeling and ongoing fusion.

Conclusion

EG should be considered as a differential diagnosis in the evaluation of solitary lytic lesion involving spine in pediatric age group. This, although self-resolving, may occasionally need surgical intervention with or without adjuvant therapy.

Intracranial extraosseous dural-based Ewing's sarcoma with fluid-haematocrit levels: imaging findings of a rare tumour

Extraosseous dural-based primary Ewing's sarcoma of the central nervous system is a rare tumour posing a diagnostic challenge. On cross-sectional radiological imaging, the lesion has an extra-axial location with heterogeneous appearance. These lesions are usually multicystic with internal haemorrhage causing fluid-haematocrit levels. It mimics conditions like an aneurysmal bone cyst, microcystic meningioma, telangiectatic osteosarcoma or cystic metastasis. Exclusion of primary Ewing's sarcoma or malignancy elsewhere in the body is required to rule out a secondary. Surgery along with adjuvant chemotherapy and focal radiotherapy is the preferred mode of treatment. Due to the presence of non-specific small round blue cells on H&E stain, these tumours are also confused with lymphoma, osteosarcoma, rhabdomyosarcoma, Merkel cell carcinoma, ependymoblastoma and neuroendocrine carcinoma. Immunohistochemistry provides a definitive diagnosis. A high degree of suspicion in the preoperative scans is crucial for prognostication and early management of this aggressive tumour leading to improved patient survival.

Vascular Manifestations of Tuberculous Meningitis: MR Angiography and Venography Study

Purpose  The purpose of this study is to evaluate magnetic resonance (MR) angiography (MRA) and venography (MRV) findings in tuberculous meningitis (TBM).

Methods  Thirty consecutive patients of clinically diagnosed TBM were enrolled. Apart from T2-weighted imaging, T1-weighted imaging (T1WI), diffusion-weighted imaging, susceptibility-weighted imaging, fluid-attenuated inversion recovery, and postcontrast T1WI, time-of-flight (TOF) MRA and postcontrast MRV were done in all the patients. MRV was done after intravenous administration of gadolinium-based contrast agent followed by postcontrast T1WI. MRA and MRV findings were analyzed.

Results  Mean age of the patients was 33.13 ± 14.93 years. Duration of symptom was 34.90 ± 33.82 (range: 10–150) days. Out of 30 patients, 11 were categorized as definite TBM and 19 probable TBM. Eighteen (60%) were grade I, 7 (23%) grade II, and 5 (16%) grade III TBM based on severity. MR abnormalities were in varying combinations of leptomeningeal enhancement in 24 (80%), pachymeningeal in 2, both in 3, tuberculomas in 13 (43.3%), ventriculitis in 1, hydrocephalus in 16 (53.3%), and infarcts in 10 (33.3%) patients out of which the tubercular zone infarct in 9 patients. TOF MRA showed arterial abnormality in 13 patients. Anterior cerebral artery and middle cerebral artery have commonly involved vessels. Dural sinus thrombosis was noted in two patients. Both were female. One patient had subacute thrombus in the posterior part of superior sagittal sinus, left transverse sinus, and proximal right transverse sinus. The second patient had a filling defect in the transverse sinus.

Conclusion  In TBM, there is predominant arterial involvement causing infarcts which are usually seen in the tubercular zone. However, occasionally, there may be venous involvement causing cerebral venous sinus thrombosis.

Study protocol: IMPETUS: Implementing a uniform stroke care pathway in medical colleges of India: IMPETUS Stroke

Introduction:

In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India.

Methods and Analysis:

This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases.

Discussion:

Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Gelatin Sponge-induced Early Onset Quadriparesis after the Posterior Decompression for Cervical Myelopathy Due to Ossification of a Posterior Longitudinal Ligament - A Case Report

Introduction: Gelatin foam has been regularly used the complex neuro and spinal surgeries for a long time. Apart from their hemostatic properties, these are inert and provide form an inert membrane that prevents scar adhesions o vital structures such as the brain or spinal cord. Case Presentation: We present a case of cervical myelopathy due to an ossified posterior longitudinal ligament that underwent the instrumented posterior decompression and had neurological worsening 48 h after the index surgery. An magnetic resonance imaging showed a hematoma compressing the spinal cord which on exploration was confirmed to be a gelatin sponge. It represents the rare phenomenon of mass effect due to their osmotic properties, especially in a closed space causing neurologic deterioration. Conclusion: We emphasize the rare cause of early onset quadriparesis after the posterior decompression due to the swollen gelatin sponge over the neural elements. The patient recovered with timely intervention.

Spontaneous Spinal Epidural Hematoma in a Near-term Pregnant Patient

Introduction: Spontaneous development of spinal epidural hematoma (SEH) is rare condition with acute presentation and usually associated with some predisposing factors. Early diagnosis and management of SEH are very important because of the risk of permanent neurological deficit. Case Report: Here, we report a rare case of SEH in young pregnant female at 35 week of gestation who presented with short history of paraplegia that was diagnosed on magnetic resonance imaging (MRI) and treated successfully with delivery of the baby by caesarean section and release of cord compression by laminectomy. Conclusion: Spontaneous SEH can be rarely seen in pregnancy. MRI is the investigation of choice. Clinical suspicion is necessary for early management and better prognosis.

Pure Neuritic Leprosy with Bilateral Foot Drop and Central Nervous Involvement: A Clinical, Electrophysiological, and MR Correlation

Background

Central nervous system (CNS) involvement in leprosy is sparsely documented. Neurophysiological tests and magnetic resonance imaging (MRI) helps in demonstrating CNS involvement in the patient of pure neuritic leprosy.

Objectives

To demonstrate CNS involvement in pure neuritic leprosy.

Methods

Detailed clinical presentation and skin lesions were evaluated. Sural nerve biopsy, MRI diffusion tensor imaging of spinal cord and optic nerve were performed. Visual evoked potential and tibial somatosensory evoked potential were done. Their clinical, electrophysiological, and MRI were done at follow-up visits.

Results

We report three patients of pure neuritic leprosy with bilateral foot drop as the initial presentation. MRI T2W sequence of cervico dorsal cord showed dorsal column hyperintensity in two patients. Diffusion-weighted MR revealed decrease fractional anisotropy and an increase in the apparent diffusion coefficient. Similar findings were also noted in the optic nerves. The patients were managed with multidrug therapy multibacillary regimen and steroid in tapering dose. At follow-up, they showed clinical improvement in vision and power of ankle dorsiflexor.

Conclusions

Patients of pure neuritic leprosy may manifest with bilateral foot drop with the involvement of posterior column and cranial nerves.

Comparison of bone SPECT/CT and MRI in detection of pain generator in ankle and foot pain: a retrospective diagnostic study

OBJECTIVE

To study the sensitivity and specificity of MRI and bone SPECT-CT in detecting the pain generator in ankle and foot pain with diagnostic dilemma.

METHODS

Retrospectively data of patients with ankle or foot pain who underwent both MRI and Bone SPECT-CT were analyzed. The lesions and probable pain generator sites were reported as per MRI and bone SPECT-CT findings. These lesions were correlated clinically, managed accordingly and followed up. The patients who had significant improvement in response to the treatment provided were considered to have been diagnosed accurately. The foot and ankle disability index (FADI) was used to evaluate the patient's pre- and postintervention condition.

RESULTS

The study included 37 patients retrospectively (18 women and 19 men). The lesions were classified into soft tissue lesions (ligaments/tendons), joint lesions (arthritis) and bony lesions (fractures/osteomyelitis/osteochondral lesions). Overall, MRI had sensitivity, specificity, positive predictive value and negative predictive value of 82, 31, 74 and 42%, respectively, and SPECT-CT had sensitivity, specificity, positive predictive value and negative predictive value of 84, 60, 84 and 60%, respectively. The mean FADI score pretreatment for all patients was 61.5 (SD = 13.8) and posttreatment 88.4 (SD = 13.01) showing significant improvement in the score (P < 0.05), suggesting that the final diagnosis of these patients was accurate. Overall, management change due to bone SPECT-CT over MRI was seen in 26% of patients.

CONCLUSION

Bone SPECT-CT has incremental value over MRI in the diagnosis of pain generator in foot and ankle pain. The overall specificity of bone SPECT-CT is higher than MRI in detection of pain generators. Bone SPECT-CT performed better than MRI in detection of culprit pathology in the bone, whereas MRI is better in soft tissue lesions.

ADVANCES IN KNOWLEDGE

There are only a few published literature with direct comparison of bone SPECT-CT scintigraphy and MRI in detection of foot and ankle pain generator. This study directly compares diagnostic utility of bone SPECT-CT scintigraphy and MRI in foot and ankle pain. In the present study, the bone SPECT-CT performed better than MRI in detection of culprit pathology in the bone, whereas MRI is better in soft tissue lesions.

Transmesenteric Internal Abdominal Hernia: Multi-detector row computed tomography findings

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A Study of Diffusion Tensor Imaging in Hirayama Disease

Background

Hirayama disease (HD) is a motor neuron disease and occasionally is associated with lower limb hyper-reflexia. Corticospinal tract dysfunction can be evaluated by diffusion tensor imaging (DTI), but there is paucity of study in HD.

Objective

We report corticospinal tract functions using DTI in the patients with HD and correlate with clinical findings.

Materials and Methods

The patients with HD diagnosed on the basis of clinical and electromyography findings were included. Their age, duration of illness, side of initial involvement, and progression were noted. Presence of lower limb hyper-reflexia, and cervical spine magnetic resonance imaging (MRI) findings were noted. Cranial MRI was done and DTI findings at internal capsule, cerebral peduncle, pons, and pyramid were noted.

Results

In total, 10 patients with HD and 5 matched controls were evaluated. The apparent diffusion coefficient (7.03 ± 0.27 vs 6.83 ± 0.36), fractional anisotropy (0.79 ± 0.04 vs 0.82 ± 0.05), axial diffusivity (5.08 ± 0.08 vs 5.04 ± 0.07), and radial diffusivity (3.79 ± 0.05 vs 3.76 ± 0.05) between HD patients and controls were not different in internal capsule. These values were also not significantly different in cerebral peduncle, pons, and pyramid. These values were also not significantly different between the severe and less severely affected sides. The fractional anisotropy did not correlate with lower limb hyper-reflexia (P = 1.00) and spinal cord atrophy (P = 0.60).

Conclusion

DTI study in HD patients did not reveal corticospinal tract involvement in brain.

Heteropagus Twins: A Tale of Two

Parasitic twin is a rare occurrence, with rachispagus being the rarest. The surgical approach and timing are not standardized. We describe the management of two cases of rachispagus and review the sparse literature on this entity. Both cases were operated early because of the social burden on the family as well as difficulty in nursing care. The first patient had associated major systemic malformations in the autosite (cerebral, spinal and cardiac), and succumbed in the postoperative period. The entity was isolated in the second who is doing well.