A Detailed Assessment of Variations of Ethmoid Roof, Olfactory Fossa, and Anterior Ethmoidal Artery on CT Scan of Paranasal Sinuses of 200 Patients.

To study and analyse the variations in ethmoid roof anatomy and estimate the anatomical location and variations of AEA on CT scans. The study is conducted on 200 patients for detailed analysis of the olfactory fossa (OF) depth, supraorbital pneumatisation, and AEA location and distance from the skull base. In our study, Keros type II was predominant type seen followed by type I. Asymmetry was noted in 32/200 subjects (16%). The anterior ethmoidal artery (AEA) canal was seen in 341/400 sides (85.2%). We found Keros type II was the most common type in our study. We also found grade I anterior ethmoidal artery as the most common variant and the dangerous grade III anterior ethmoidal artery was least common type found in this study, and there was a significant association of Keros type II with increasing anterior ethmoidal artery grading.

Interobserver reproducibility of RENAL nephrometry score in comparison to simplified PADUA Renal nephrometry score.

Introduction: Nephron-sparing surgery (NSS) is the standard of care for renal tumors, especially in the early stages. RENAL Nephrometry scores provide a comprehensive presurgical predictive module for the choice of NSS or Radical Nephrectomy. The validity and reliability of Nephrometry scores is being tested continuously with advancement in the surgical techniques. The Simplified PADUA Nephrometry score (SPARE NS) is a newer proposed score which aims to better the reproducibility of the previously established nephrometry scores. Materials and Methods: The retrospective observational study studied the comparative inter-observer reliability of RENAL (RENAL NS) and SPARE nephrometry scoring systems amongst two radiologists while assessing solid renal tumors in contrast-enhanced computed tomography scans of 42 patients. Interobserver reliability for all components of both scores, final scores and risk grading was done by Kendall's Concordance Coefficient (Tau). Results: Both RENAL NS and SPARE NS showed strong to excellent agreement (RENAL NS = 78.57% and SPARE NS = 88.09%) among observers with comparable correlation co-efficient (RENAL NS = 0.944 and SPARE NS = 0.935). Lesion radius and exophytic/endophytic properties were the most reproducible components of RENAL NS with 97.61% and 92.85% agreement, respectively. Location across polar lines was the least reproducible component with 85.71% agreement among observers. Exophytic rate (97.61%) and Rim location were the most reproducible components of SPARE NS. The final lesion risk stratification by both observers for both was concordant in 92.85% of cases. Conclusion: The SPARE system of scoring matches up to the RENAL NS in total score and risk stratification reproducibility. However, the individual components of the SPARE score are more reproducible than those of RENAL NS, bringing about better compliance among radiology consultants. Comparable reproducibility with the RENAL NS, lesser number of variables, and ease of doing make SPARE NS a plausible option for the customary preoperative assessment of renal tumors.

Role of Endovascular Treatment in Dysfunctional Hemodialysis Fistulae: A Single Center Experience.

Introduction: Arteriovenous fistulas (AVFs) are the preferred route of hemodialysis in end-stage renal disease. However, recurrent patency loss is an obstacle in long-term maintenance. Endovascular treatments may provide a durable option for prolongation of patency in AVFs. Methods: Retrospective observational study was done on 46 patients with AVF for hemodialysis in the Department of Diagnostic and Interventional Radiology for a period of 1 year from September 2020 to August 2021. The characters of dysfunctional fistulas and results of various interventional procedures were assessed for technical and clinical success rates. Short-term follow-up records of patients were assessed for post-intervention primary patency (PIPP) and post-intervention assisted primary patency (PIAPP) of various procedures. Results: The most successful outcomes post intervention were seen in radio-cephalic fistulas formed more than 1 year ago with juxta-anastomotic narrowing. The overall technical success rate was 89.13% with a PIPP of 78.26% and a PIAPP of 82.60% at 3 months. PTA had better technical success rates (88.23%) as compared to dysfunctional segments with thrombosis that underwent angioplasty and thromboaspiration (84.2%). Central venous stenosis undergoing PTA and stenting had a 100% success rate. At 3 months follow-up, PIPP was better among the angioplasty plus thromboaspiration group (73.7%), while PIAPP rate was better in the angioplasty subgroup at 82.35%. Conclusion: Endovascular intervention is the first-line treatment in dysfunctional AVFs attributable to the multitude of options available, all of which have comparable outcomes, high success rates, and notable short-term patency.

Impact of COVID-19 on postgraduate medical education: Cross sectional survey from an Indian Medical College.

BACKGROUND: The corona virus disease (COVID-19) pandemic has caused widespread effect on the lives of health care professionals. The postgraduate medical students, who are the major pillars of medical institutions had to bear multitude of setbacks due to the pandemic involving academic, research and well-being issues. MATERIALS AND METHODS: This was a cross sectional feedback based online survey done in the month of October 2021 to study the effect of COVID-19 pandemic induced changes in the postgraduate medical education; amongst 78 students pursuing MD/MS degree in all departments of a tertiary medical institute in Himalayan foothills of North India. The questionnaire consisted of ten questions; each of which needed to be answered on a five point Likert scale ranging from strongly disagree to strongly agree. Results were assessed for the most common answers of each question (represented by mode) and association between various components of the questionnaire analyzed by Spearman's rho correlation coefficient. RESULTS: The internal consistency of the questionnaire as tested by Cronbach's Alpha (0.82) was good. Most number or respondents were from surgical branches (n = 31, 39.74%). There was a generalized agreement towards preference of resumption of onsite education (75.64%), the lack of variety of cases causing hampering of thesis work (88.46%) and increased mental stress during the pandemic (58.9%). While more time for self-study was seen as the only consensual positive aspect of online teaching (64%), most students opined that technical glitches are a major roadblock in online education (80.76%). Significant positive correlation was seen between disciplinary ease and punctuality in online teaching (R = 0.543, P < 0.001), lack of interaction and its effect on learning and mental health (R = 0.471; P < 0.001) and the lack of diversity in cases and difficulties in dissertation work (R = 0.351; P < 0.05). Negative correlation was observed between the satisfaction from overall learning through online teaching and the desire of resumption of offline classes (R = -0.491; P < 0.001). CONCLUSION: COVID-19 pandemic and its effects on medical education are long lasting. A comprehensive approach is required to rebuild the medical education curriculum, inculcating both traditional and newer virtual methods of education. A consistent support in academics and overall growth needs to be provided to medical postgraduate residents who have been the first line fighters in face of the massive disaster compromising their basic needs and education.

Effect of vaccination on the HRCT profile of COVID-19 patients - A single-center experience.

Introduction: Vaccination against the global pandemic coronavirus disease 2019 (COVID-19) is a promising way out of the havoc caused by the disease. The clinico-radiological profile of COVID-19 patients in relation to the vaccination status is depicted in the present study. Materials and Methods: This is a retrospective observational imaging and hospital data-based study performed on 214 confirmed and clinically suspicious patients of COVID-19 who underwent high-resolution computed tomography (HRCT) scan of the thorax at the Department of Radio-Diagnosis of a tertiary medical center in the Himalayan foothills. The present study aims to evaluate the effect of vaccination on HRCT findings of COVID-19 populations. Results: Forty-three percent of the non-vaccinated population presented with severe HRCT scores (19-25) in comparison to only 11.5% of the study population who had taken both doses of vaccine (P = 0.018). Two doses of vaccination had a negative Pearson correlation coefficient with severe HRCT scores (-0.146). Co-morbidities had a significant correlation with HRCT severity score, with 61.5% diabetics and 63.33% of hypertensive patients showing scores >19 on HRCT. Conclusion: Vaccination proves to be a game changer in the pandemic with two doses of vaccination having a significant negative correlation with COVID-19-induced severe pneumonitis on HRCT of the thorax.

Pneumomediastinum: Radiological profile and associations of uncommon complication of COVID-19.

Introduction: Spontaneous pneumomediastinum is an uncommon complication of Corona Virus Disease (COVID)-19 presenting mostly in moderate to severe cases. Materials and Methods: This is a retrospective observational imaging and hospital data-based study done on 15 confirmed patients of COVID-19 who underwent high resolution computed tomography (HRCT) thorax at the Department of Radio-Diagnosis of a tertiary medical center in the Himalayan foothills. The clinico-radiological profile of the study group was assessed and it was aimed at finding the association of pneumomediastinum with the severity of lung changes. Results: A strong association of pneumomediastinum was observed with severe lung changes on HRCT thorax (n = 13, 87%, P < 0.00001). Dyspnea was the most common presenting factor. The mortality rate is high in mechanically intubated patients of pneumomediastinum with COVID-19 (75%). Conclusion: Pneumomediastinum is a complication of a severe COVID-19 disease spectrum. Along with severe lung parenchymal disease, systemic inflammation, systemic steroid therapy, comorbid state, and mechanical intubation, it is a part of the pool of poor prognostic factors. HRCT is essential for making a quick and comprehensive diagnosis, thereby, guiding the clinician for further management.

Assessment of Cerebrospinal Fluid Hydrodynamics Using Magnetic Resonance Imaging in Postcraniospinal Surgery Patients.

Objective Aim of this study is to evaluate the effect of craniospinal interventions on cerebrospinal fluid (CSF) flow hydrodynamics and study the correlation of postoperative changes in flow alteration with clinical outcome. Materials and Methods Fifty patients who underwent various craniospinal procedures were studied using conventional and phase-contrast magnetic resonance imaging (PCMRI) protocol. CSF flow quantification was performed at cerebral aqueduct, foramen magnum, C2-3, and D12-L1 vertebral levels with site showing maximal alteration of CSF flow dynamics considered as the region of interest. Velocity encoding was kept at 20 cm/s. Patients with pathology atcraniovertebral junction were considered separately (group I) from others (group II) due to different flow dynamics. Follow-up scans were performed after an interval of 1 month for temporal evaluation of changes in CSF flow dynamics. Results Patients in both groups showed a significant change in peak CSF velocity postoperatively (mean change of 1.34 cm/s in group I and 0.28 cm/s in group II) with bidirectional improvement in flow on cine-phase-contrast qualitative images. Regional pain (82%) and headache (46%) were seen in most of the patients preoperatively. Postoperatively clinical symptoms improved in 59.5%, static in 26.2%, and worsened in 14.3%. In both the groups, an improvement in clinical symptomatology had significant correlation with mean changes in peak CSF velocity postoperatively ( p = 0.04 in both groups). Conclusion PCMRI can effectively evaluate changes in CSF flow noninvasively both pre- and postoperatively. This may have potential role in determining clinical outcome and prognosis of patients undergoing procedures in craniospinal axis.

Magnetic Resonance Imaging Cerebrospinal Fluid Hydrodynamics in Patients with Meningitis.

OBJECTIVE: The objective of the study was to evaluate the cerebrospinal fluid (CSF) flow alterations in meningitis using phase-contrast magnetic resonance imaging (PCMRI). MATERIALS AND METHODS: Fifty patients with clinically confirmed or strongly suspected infectious meningitis and 20 controls were evaluated with MRI. Quantitative CSF analysis was performed at the level of cerebral aqueduct using cardiac-gated PCMRI. Velocity encoding (Venc) was kept at 20 cm/s. Patients were subdivided into Group I (patients with hydrocephalus [n = 21]) and Group II (patients without hydrocephalus [n = 29]). RESULTS: The mean peak velocity and stroke volume in controls were 2.49 ± 0.86 cm/s and 13.23 ± 6.84 µl and in patients were 2.85 ± 2.90 cm/s and 16.30 ± 20.02 µl, respectively. A wide variation of flow parameters was noted in meningitis irrespective of the degree of ventricular dilatation. A significant difference in peak velocity and stroke volume was noted in Group II as compared to controls. Viral meningitis showed milder alteration of CSF flow dynamics as compared to bacterial and tuberculous etiologies. At a cutoff value of 3.57 cm/s in peak CSF velocity, the specificity was 100% and sensitivity was 22.7% to differentiate between viral and non-viral meningitis. CONCLUSION: Alteration of CSF flow dynamics on PCMRI can improve segregation of patients into viral and non- viral etiologies, especially in those in whom contrast is contraindicated or not recommended. This may aid in institution of appropriate clinical treatment.

Qualitative and Quantitative Comparison of Contrast-Enhanced Fluid-Attenuated Inversion Recovery, Magnetization Transfer Spin Echo, and Fat-Saturation T1-Weighted Sequences in Infectious Meningitis.

OBJECTIVE: To compare the contrast-enhanced fluid-attenuated inversion recovery (CE-FLAIR), the CE T1-weighted (CE-T1W) sequence with fat suppression (FS) and magnetization transfer (MT) for early detection and characterization of infectious meningitis. MATERIALS AND METHODS: Fifty patients and 10 control subjects were evaluated with the CE-FLAIR and the CE-T1W sequences with FS and MT. Qualitative assessment was done by two observers for presence and grading of abnormal leptomeningeal enhancement. Quantitative assessment included computation of net meningeal enhancement, using single pixel signal intensity software. A newly devised FLAIR based scoring system, based on certain imaging features including ventricular dilatation, ependymal enhancement, infarcts and subdural effusions was used to indicate the etiology. Data were analysed using the Student's t test, Cohen's Kappa coefficient, Pearson's correlation coefficient, the intraclass correlation coefficient, one way analysis of variance, and Fisher's exact test with Bonferroni correction as the post hoc test. RESULTS: The CE-FLAIR sequence demonstrated a better sensitivity (100%), diagnostic accuracy (95%), and a stronger correlation with the cerebrospinal fluid, total leukocyte count (r = 0.75), protein (r = 0.77), adenosine deaminase (r = 0.81) and blood glucose (r = -0.6) values compared to the CE-T1W sequences. Qualitative grades and quantitative meningeal enhancement on the CE-FLAIR sequence were also significantly greater than those on the other sequences. The FLAIR based scoring system yielded a diagnostic accuracy of 91.6% and a sensitivity of 96%. A strong inverse Pearson's correlation (r = -0.95) was found between the assigned score and patient's Glasgow Coma Scale at the time of admission. CONCLUSION: The CE-FLAIR sequence is better suited for evaluating infectious meningitis and could be included as a part of the routine MR imaging protocol.

Detection and Differentiation of Focal Intracranial Calcifications and Chronic Microbleeds Using MRI.

INTRODUCTION: Differentiating calcification from chronic micro-bleeds on imaging may have important clinical implications. AIM: The present study aimed to evaluate the role and relative advantages of Magnetic Resonance Imaging (MRI) in the detection and differentiation of intracranial calcifications and chronic microbleeds. MATERIALS AND METHODS: The retrospective study comprised of 100 patients having either intracranial calcifications or microhaemorrhages selected on the basis of Computerized Tomography (CT) and MRI using predefined criteria. Two independent blinded observers evaluated the images qualitatively and quantitatively. Single pixel values were taken in the circular Region of Interest (ROI) on magnitude SWI, phase Susceptibility Weighted Imaging (SWI) and Diffusion Weighted Imaging (DWI) for quantitative analysis. RESULTS: Fifty patients with 76 focal calcifications and another 50 patients with 245 chronic microbleeds formed part of the study. Overall sensitivity of SWI in detection of calcification was 93.9% with good inter observer agreeability (k= 0.7) on phase SWI. All the chronic microbleeds were seen on SWI but there was only moderate inter observer agreeability in evaluation of signal on phase component (k= 0.5). Average pixel values of calcifications and chronic microbleeds were -312.5±187 SD and 541.9±301.7 SD respectively on phase SWI, (p=0.0001, <0.05). CONCLUSION: SWI can play a pivotal role in the detection of intracranial calcifications and chronic microbleeds and resolving the ambiguity in their diagnosis.

Differentiation of Leptomeningeal and Vascular Enhancement on Post-contrast FLAIR MRI Sequence: Role in Early Detection of Infectious Meningitis.

OBJECTIVE: To qualitatively and quantitatively differentiate leptomeningeal and vascular enhancement on Post-contrast Fluid Attenuated Inversion Recovery (PCFLAIR) sequence compared to post-contrast T1-weighted (PCT1W) sequence with fat suppression (FS) and evaluate its role in early detection of infectious meningitis. MATERIALS AND METHODS: Thirty-one patients with diagnosis of meningitis were evaluated with pre and post-contrast FLAIR and T1-weighted sequences with fat suppression (FS). Qualitative assessment was done by two observers for presence, absence or equivocal status of leptomeningeal enhancement. Further, quantitative estimation of single pixel signal intensities (SPSI) for meningeal and vascular enhancement was undertaken. A statistical comparison was performed using Kappa coefficient and t-test. RESULTS: The overall qualitative accuracy was 90.3% for PCFLAIR compared to 54.8% for PCT1W with FS sequence. PCFLAIR was found to be 100% accurate in the detection of tubercular and pyogenic meningitis and 70% accurate in the detection of viral meningitis while PCT1W with FS sequence showed the corresponding accuracy to be 76.2% and 0% respectively. Both observers rated PCFLAIR images better than PCT1W with FS at detecting meningitis (p<0.05). The quantitative assessment revealed that the SPSI difference between the average meningeal and vascular enhancement on PCFLAIR was significantly greater than that on PCT1W with FS sequence (t= 6.31, p<0.01). CONCLUSION: PCFLAIR sequence has insignificant component of vascular enhancement compared to meningeal enhancement. This makes meningeal inflammation easily discernable and aids in early detection of infectious meningitis.

Role of screening of whole spine with sagittal MRI with MR myelography in early detection and management of occult intrasacral meningocele.

OBJECTIVE: We evaluated the role of screening of the whole spine by sagittal magnetic resonance imaging (MRI) along with MR myelography in early detection and management of occult intrasacral meningocele. MATERIALS AND METHODS: A prospective and retrospective analysis of MRI and MR myelography studies of the whole spine over a period of one year was performed. RESULTS: Thirty cases with sacral meningeal cysts were seen. On MRI, six patients (three males, three females) fulfilled the criterion of occult intrasacral meningocele. These patients showed a cyst of cerebrospinal fluid (CSF) signal intensity in the sacral canal below the dural sac. This cyst communicated with the thecal sac through a narrow pedicle. Fat signal intensity in the filum terminale and occult sacral dysraphism in the form of an absent or hypoplastic neural arch was observed in all the patients. Low-lying conus medullaris with thick filum terminale was seen in five of these six patients. Excision of the cyst with the release of filum was performed in two patients with a favorable outcome. CONCLUSION: Screening MRI with MR myelography of the whole spine may play a role in the early detection and management of occult intrasacral meningocele. The commonly associated thick filum terminale and low-lying conus medullaris may be missed otherwise that may lead to a progression of symptoms.

Additional Merits of Two-dimensional Single Thick-slice Magnetic Resonance Myelography in Spinal Imaging.

OBJECTIVE: To validate the additional merits of two-dimensional (2D) single thick-slice Magnetic Resonance Myelography (MRM) in spinal imaging. MATERIALS AND METHODS: 2D single thick-slice MRM was performed using T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence in addition to routine Magnetic resonance (MR) sequences for spine in 220 patients. The images were evaluated for additional diagnostic information in spinal and extra-spinal regions. A three-point grading system was adopted depending upon the utility of MRM in contributing to the detection of spinal or extra-spinal findings. Grade 1 represented no contribution of MRM while grade 3 would indicate that it was essential to detection of findings. RESULTS: Utility of MRM in spine was categorized as grade 3 in 10.9% cases (24/220), grade 2 in 21.8% (48/220) cases and grade 1 in 67.3% cases (148/220). Thus, the overall additional merit of MRM in spine was seen in 32.7% (72/220) of cases. Besides in 14.1% cases (31/220) extra-spinal pathologies were identified. CONCLUSION: 2D single thick-slice MRM could have additional merits in spinal imaging when used as an adjunct to routine MR sequences.

Pilomyxoid astrocytoma.

Pilomyxoid astrocytoma (PMA) is a recently described brain tumor. PMA shares similar features with pilocytic astrocytoma (PA), the most common central nervous system (CNS) tumor in the pediatric population, yet displays subtle histologic differences. We describe a case of PMA in a six-year-old male involving sellar and suprasellar region presenting with failure to thrive and delayed developmental milestones. The histological findings revealed a tumor composed of a monotonous population of loosely arranged cells with delicate piloid like processes, within a prominent myxoid background. The tumor lacked biphasic appearance, Rosenthal fibers, eosinophilic granular bodies and calcification that are commonly observed in classical PA. Previous studies have shown PMA to behave more aggressively than PA, with shorter progression-free survival as well as a higher rate of recurrence and CNS dissemination. Thus, recognition of PMA and its distinction from classical PA is very important.