A novel concept on volumetric assessment and quantification of gastrointestinal bleed on computed tomography angiography: Observations based on a case series.

Department of Radiology, Mazumdar Shaw Medical Centre - Narayana Multispecialty Hospital, Narayana Health, Estimation of quantity and rate of bleeding is of great value in the management of patients with acute GI bleed. Endoscopy and multiphase contrast enhanced computed tomography (MCECT) are the presently employed two important methods for this purpose. Still there is a lacuna in the methods of precise estimation of amount of bleed, which at the moment are somewhat unreliable and subjectively evaluated. We present the value of dynamic contrast-enhanced CT examination in quantitatively estimating the amount of extravasated blood with the help of three illustrative clinical examples. Technique CT examination, the methodology for assessment of quantity of bleed is presented and the discussion of existing literature regarding the estimation methods is presented.Bommasandra, Bengaluru, India.

Endosalpingiosis of urinary bladder: report on a rare entity.

A case of endosalpingiosis of the urinary bladder is presented with imaging features on sonography and CT. Patient presented with right flank pain, dysuria and haematuria. She had h/o right renal calculus and abdominal hysterectomy 15 years ago. On sonography a polypoidal filling defect was noted and possibility of a bladder neoplasia was suggested. On cystoscopy and removal of the lesion and subsequent histo-pathological analysis revealed the diagnosis of endosalphingiosis. This report emphasizes the need for evaluation of all clinical inputs while considering the differential diagnosis of an intraluminal bladder lesion. Imaging appearance and aetio-pathology of the rare intra vesical lesion is highlighted.

The Spectrum of Cardiac Anomalies Associated with Heterotaxy: A Single-Center Study of a Large Series Based on Computed Tomography.

The aim of the study was to identify and correlate the anatomical variants of cardiac structures among patients with heterotaxy. In this retrospective cross-sectional analysis of 13 years duration, 302 patients of congenital heart diseases associated with heterotaxy were studied. All these patients had undergone a meticulous clinical evaluation, echocardiography, and cardiac computed tomography. The mean age of the cohort was 38.4 months, with 180 males and 122 females. The cohort had 184 patients of right isomerism and 118 of left isomerism. More than half of the cohort had abnormal pulmonary veins. Over 75% of the cohort had low pulmonary blood flow. Abnormal relationship of great arteries was seen in nearly 69% of the cohort. Atrio-venticular canal defect was the commonest anatomical variant. Overall, 43% of the cohort had single ventricle physiology, predominantly associated with right isomerism. Heterotaxy forms a difficult anatomical subset to comprehend due to the plethora of possible abnormalities. However, unless the cardiac and visceral anatomy is delineated well, the surgical plan becomes suboptimal and often elusive, leaving tough choices for cardiac surgeon. It is essential to obtain all the possible anatomical information using additional imaging modalities to devise a basis for a comprehensive plan for medical and surgical management. A better understanding of the genetic and molecular factors in the etiology, coupled with the application of state-of-the-art imaging techniques, is likely to add to our knowledge of heterotaxy to bring about improved surgical outcomes and a better quality of life for patients suffering from this complex entity.

Subpleural Lung Changes Adjacent to Enlarged Internal Mammary Artery in Patients with Coarctation of Aorta and Pulmonary Hypoplasia: Some Thoughts on an Interesting Observation.

Irregular pleural interface, minimally reduced lung density and/or focal subpleural cystic lung changes were noted in two patients with coarctation of aorta and in a patient with the right pulmonary hypoplasia. Lesions were distributed in the anterior segments of upper lobes, adjacent to internal mammary arteries (IMA). In view of unusual location of lung changes with unique distribution pattern prompted us to look for 'cause and effect' relation of events specific to long standing vascular pulsations, thus explaining the lung changes. While there are multiple factors for cystic lung disease, special distribution the lung changes seen in our patients leads us to explore mechanical process such as water hammer effect by dilated tortuous pulsatile IMA on the lungs as an additional etiology. A brief note on clinical and imaging appearance of our patients and discussion regarding water hammer theory are presented.

Magnetic Resonance Imaging Assessment of Pre- and Post-Surgery Myocardial Changes in Hypertrophic Cardiomyopathy: Correlation with Echocardiography.

Hypertrophic cardiomyopathy (HCM) is a common form of cardiomyopathy and a leading cause of sudden death in the young. Magnetic resonance imaging (MRI) is an established pre-operative tool for the evaluating of patients suspected with HCM for morphological assessment and identifying patients at risk of sudden death. Echocardiography and MRI are equally used in the post-treatment assessment of cardiac function and morphology. In this report, we present the comparative role of these two modalities in pre- and post-operative imaging assessment in our patients, treated surgically with the left ventricular myomectomy. Relative merits of MRI and echocardiography are presented and discussed.

Thoracic Origin of Single Right Renal Artery: Some Interesting Facets.

Two cases of thoracic origin of the right renal artery, arising from the level of D11 vertebrae detected on an incidental computed tomography examination are reported. A brief review of embryology is presented. Simultaneous variation of the origin of the right inferior phrenic artery is highlighted as a unique feature of our cases. The importance of this relatively uncommon anomaly in the clinical context is discussed.

Mitral valve enhancement in a patient with active Rheumatic Fever: An uncommon phenomenon on the MRI examination with possible clinical significance.

Intense enhancement of the mitral valve is documented in a MRI examination performed on a patient with rheumatic multi-valvular disease. Patient had the elevated inflammatory markers indicating active inflammatory process. Such hitherto undocumented phenomenon may have important clinical significance in disease evaluation, thus provide a feasible option to document and follow up, active valvular involvement in patients with active rheumatic fever.

Illustrated Imaging Essay on Congenital Heart Diseases: Multimodality Approach Part III: Cyanotic Heart Diseases and Complex Congenital Anomalies.

From the stand point of radiographic analysis most of the complex cyanotic congenital heart diseases (CHD), can be divided into those associated with decreased or increased pulmonary vascularity. Combination of a specific cardiac configuration and status of lung vasculature in a clinical context allows plain film diagnosis to be predicted in some CHD. Correlation of the position of the cardiac apex in relation to the visceral situs is an important information that can be obtained from the plain film. This information helps in gathering information about the atrio-ventricular, ventricular arterial concordance or discordance. Categorization of the cyanotic heart disease based on vascularity is presented below. Thorough understanding of cardiac anatomy by different imaging methods is essential in understanding and interpreting complex cardiac disease. Basic anatomical details and background for interpretation are provided in the previous parts of this presentation.

Illustrated Imaging Essay on Congenital Heart Diseases: Multimodality Approach Part II: Acyanotic Congenital Heart Disease and Extracardiac Abnormalities.

Acyanotic heart disease constitutes a significant majority of patient who may present with non-cardiac symptoms. Either they are detected incidentally or present with respiratory complaints. Equipped with knowledge of anatomy by echocardiography and radiographic methods described in previous part of this presentation, diagnosis may be confidently attempted. On plain radiography acyanotic congenital heart diseases have variable appearance depending upon severity of disease. Cardiac size, chamber enlargement and pulmonary vascular pattern are key elements. Typically left to right shunts with large volume flow are associated with pulmonary plethora. Plain radiography has an important role in detecting manifestation of pulmonary arterial hypertension. Severe stenosis of pulmonary valve is associated with pulmonary oligemia. Small intra-cardiac shunts and anomalies of coronary arteries generally present with normal cardiac size and pulmonary arterial pattern. Disease spectrum presented in this illustration demands thorough scrutiny of pulmonary, osseous and abdominal abnormalities. This section illustrates some commonly encountered spectrum of acyanotic cardiac disease.

Illustrated Imaging Essay on Congenital Heart Diseases: Multimodality Approach Part I: Clinical Perspective, Anatomy and Imaging Techniques.

Rapid evolution in technology in the recent years has lead to availability of multiple options for cardiac imaging. Availability of multiple options of varying capability, poses a challenge for optimal imaging choice. While new imaging choices are added, some of the established methods find their role re-defined. State of the art imaging practices are limited to few specialist cardiac centres, depriving many radiologists and radiologist in-training of optimal exposure to the field. This presentation is aimed at providing a broad idea about complexity of clinical problem, imaging options and a large library of images of congenital heart disease. Some emphasis is made as to the need of proper balance between performing examination with technical excellence in an ideal situation against the need of the majority of patients who are investigated with less optimal resources. Cases of congenital cardiac disease are presented in an illustrative way, showing imaging appearances in multiple modalities, highlighting specific observations in given instance.

Spectrum of Abdominal Aortic Disease in a Tertiary Health Care Setup: MDCT Based Observational Study.

INTRODUCTION: Abdominal aortic disease is an important cause of clinical disability that requires early detection by imaging methods for prompt and effective management. Understanding regional disease pattern and prevalence has a bearing on healthcare management and resource planning. Non-invasive, conclusive imaging strategy plays an important role in the detection of disease. Multi-Detector Computed Tomography (MDCT) with its technological developments provides affordable, accurate and comprehensive imaging solution. AIM: To evaluate regional demography of abdominal aortic disease spectrum detected using MDCT imaging data in a tertiary hospital. MATERIALS AND METHODS: A descriptive study was conducted based on MDCT imaging data of patients who were investigated with clinical diagnosis of abdominal aortic disease, from March 2008-2010, over a period of 24 months. Patients were examined with the contrast-enhanced MDCT examination. Morphological diagnosis of the aortic disease was based on changes in relative aortic caliber, luminal irregularity, presence of wall calcification, dissection or thrombus and evidence of major branch occlusion. Patients were categorized into four groups based on imaging findings. MDCT information and associated clinical parameters were examined and correlated to management of patient. Descriptive statistical data, namely mean, standard deviation and frequency of disease were evaluated. RESULTS: A total of 90 out of 210 patients (43%) were detected with the abdominal aortic abnormality defined by imaging criteria. Group I, comprising of patients with atherosclerosis -including those with complications, constituted 65.5% of the patients. Group II represented patients with aneurysms (45.5%). Group III, consisting of 32.2% of the patients, contained those with dissections. The rest of the patients, including patients with aorto-arteritis, were classified as group IV. Eight patients with aneurysm and one patient with aorto-arteritis were considered for surgical treatment. Ten patients with dissection underwent endovascular procedure. Rest of the patients was managed conservatively. CONCLUSION: Aortic disease was observed in 43% of investigated patients. Atherosclerosis with and without aortic aneurysm constituted the largest group. MDCT provided comprehensive information about the lesion and associated complications. In view of the wider availability and desired imaging qualities, MDCT provided optimal information for diagnosis and management of aortic pathology. Majority of our patients (90%) were treated conservatively.

Unique branching pattern of aortic arch in a patient with aortopulmonary window.

Aortic arch (AA) anomalies are usually associated with congenital heart disease. Variations such as aberrant subclavian artery have significance if shunt surgery is planned. Other variations may be clinically insignificant or present with respiratory or oesophageal symptoms. Demonstration and understanding of arch anomalies are crucial for managing as well as improving our understanding of their embryological basis. This presentation illustrates an unusual branching pattern of AA in a patient with an aortopulmonary window in which five arteries independently arose from the AA. CT imaging appearance of the anomaly is illustrated. A brief description of the embryological basis and significance of the anomaly is presented.

Spontaneous Chest Wall Interstitial Emphysema Secondary to Chronic Empyema Thoracis.

Spontaneous extension of air from the pleural space to the chest wall, also referred to as pneumothorax necessitans (PN), is a rare occurrence. Few of such cases have been reported in the literature, some appear to have a pattern of extension from pleural cavity to chest wall. Clinical conditions known to predispose to this complication are pneumothorax, empyema thoracis and tuberculosis of the pleural space or rib. We report a case of PN arising as complication of postpneumonectomy empyema (PPE) secondary to broncho-pleural fistula. Imaging features are highlighted emphasizing the likely pattern of spread.

Tracheal quadrifurcation associated with congenital heart disease.

Tracheal anomalies are known in association with congenital cardiac defects. Some of the well-described anomalies include accessory (displaced) tracheal bronchus with variants, tracheal trifurcation and accessory cardiac bronchus. Here we describe a case of tracheal quadrifurcation associated with complex congenital heart disease. Illustration of complex airway anatomy was simplified by the use of multidetector CT using a variety of image display options. Awareness of this complex anomaly will expand our knowledge of tracheal anomalies and equip the anesthesia and surgical team for better airway management.