Takayasu Arteritis with Severe Renal Artery Stenosis and an Aberrant Renal Artery in a Child: A Case Report and Discussion.

Takayasu arteritis (TA) is a chronic, idiopathic large vessel vasculitis mainly affecting the aorta and its major branches. It is one of the common causes of reno-vascular hypertension in Indian children. We report a ten-year-old boy who presented with hypertensive encephalopathy, proteinuria, and haematuria without any renal dysfunction. He was initially diagnosed to be a case of acute post streptococcal glomerulonephritis, but detailed clinical examination and haemato-radiological investigations revealed Takayasu arteritis, type V (P+). He had unilateral severe renal artery stenosis along with a small kidney and an aberrant renal artery on left side. He is found to have resistant hypertension, unresponsive to multiple anti-hypertensive drugs, and had a fatal outcome. This case illustrates renal involvement in TA and the significance of four-limb blood pressure measurement in any non-obese child with hypertension. Furthermore, the possible role of aberrant renal artery in the pathogenesis of resistant hypertension is discussed.

Role of perigastric arcade removal in serous epithelial ovarian cancers.

Introduction: Omentectomy is an essential part of cytoreductive surgery (CRS). However, removal of perigastric arcade (PGA) of the omentum is a controversial aspect of omentectomy in view of the fear of injury, vascular compromise and gastroparesis. Hence, we conducted a study to evaluate the necessity and effect of removal of PGA during omentectomy. Methods: The nature of the study was a prospective observational study. The study period was for 1 year between 1.3.2019 and 29.2.2020. Patients with stage III to IV serous epithelial ovarian cancers - chemo naive/post neoadjuvant chemotherapy, without macroscopic involvement of the PGA were included in the study. Patients were divided into two groups - those who had PGA removed (group 1) and those whose PGA was preserved (group 2). Pre, intra and postoperative factors between the two groups were compared using standard statistical methods. Results: Micrometastasis to PGA was present in 36.4% of the patients in group 1. The predictors for this involvement included gross involvement and microscopic involvement of the mobile part of the omentum (p < 0.001), pre surgery Meyer's score (p < 0.05) and requirement of peritonectomy (p < 0.05) during the CRS implying that higher the peritoneal carcinomatosis, more are the chances of microscopic involvement of PGA. On comparing postoperative outcomes between the two groups, we noted a statistically significant difference in intra-operative time (p < 0.01), prolonged recovery time with increased intensive care unit and hospital stay (p < 0.001) in group 1, although all with small absolute difference. However, there was no significant difference in major post-operative complications or time taken to tolerate soft diet. Conclusion: Micrometastasis to PGA was noted in significant number of cases. Its removal is also a safe procedure with minimal morbidity and good postoperative outcomes especially in cases with significant peritoneal carcinomatosis. Hence, it should be considered, provided we are achieving a complete cytoreduction otherwise.

Diagnostic Performance of Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Biliary Obstruction.

Background In a suspected case of biliary obstruction with clinical and laboratory data suggesting obstructive jaundice, the major goal is to confirm the presence of obstruction, its nature and cause, location, and extent. Ultrasonography (USG) and magnetic resonance cholangiopancreatography (MRCP) are primarily used to diagnose suspected biliary tract illnesses. The aim of the study is to evaluate and compare the accuracy of MRCP and USG with endoscopic retrograde cholangiopancreatography (ERCP)/surgical/histopathological outcomes for finding the cause and level of obstruction in the case of clinically suspected biliary obstruction. Methods This was a prospective observational study conducted at Kalinga Institute of Medical Sciences and Pradyumna Bal Memorial Hospital, Bhubaneswar, India, from September 2020 to September 2022 on 120 patients. It included patients with clinical suspicion of biliary obstruction who underwent both USG and MRCP. Characteristics of the obstruction were evaluated for both benign and malignant lesions through USG and MRCP. The findings were then correlated with ERCP, histopathology, or surgery to calculate the diagnostic performance of the former two modalities. Results Out of 120 patients, USG was correctly able to predict the cause of obstruction in 40 patients. The sensitivity, specificity, and accuracy of detecting the nature of obstruction by USG were 33.3%, 84%, and 48.9%, respectively. The overall diagnostic accuracy of USG in predicting the site of obstruction was 64.3%. MRCP was correctly able to predict the cause of obstruction in 113 patients. The sensitivity, specificity, and accuracy of detecting the nature of obstruction by MRCP were 94.1%, 91.9%, and 94.8% respectively. The overall diagnostic accuracy of MRCP in predicting the site of obstruction was 98.33%. Out of 120 patients, no cause of biliary obstruction could be found in 71 patients by USG, out of which the correct diagnosis was made in 67 patients through MRCP. Conclusion USG should be used as the initial screening modality of choice for predicting the level and nature of obstruction in patients with a clinical suspicion of obstructive jaundice. MRCP should be the radiological investigation of choice in patients with clinical suspicion of obstructive jaundice. MRCP has the potential to become the new "Gold standard" investigation for diagnosis in patients with biliary obstruction owing to its excellent diagnostic performance, and non-invasiveness.

Application of Machine Learning Techniques for Characterization of Ischemic Stroke with MRI Images: A Review.

Magnetic resonance imaging (MRI) is a standard tool for the diagnosis of stroke, but its manual interpretation by experts is arduous and time-consuming. Thus, there is a need for computer-aided-diagnosis (CAD) models for the automatic segmentation and classification of stroke on brain MRI. The heterogeneity of stroke pathogenesis, morphology, image acquisition modalities, sequences, and intralesional tissue signal intensity, as well as lesion-to-normal tissue contrast, pose significant challenges to the development of such systems. Machine learning (ML) is increasingly being used in predictive neuroimaging diagnosis and prognostication. This paper reviews image processing and machine learning techniques that have been applied to detect ischemic stroke on brain MRI, including details on image acquisition, pre-processing, techniques to segment, extraction of features, and classification into stroke types. The main objective of this work is to find the state-of-art machine learning techniques used to predict the ischemic stroke and their application in clinical set-up. The article selection is performed according to PRISMA guideline. The state-of-the-art on automated MRI stroke diagnosis, with a focus on machine learning, is discussed, along with its advantages and limitations. We found that the various machine learning models discussed in this article are able to detect the infarcts with an acceptable accuracy of 70-90%. However, no one has highlighted the time complexity to predict the stroke in the model developed, which is an important factor. The work concludes with proposals for future recommendations for building efficient and robust deep learning (DL) models for quantitative brain MRI analysis. In recent work, with the application of DL approaches, using large datasets to train the models has improved the detection accuracy and reduced computational complexity. We suggest that the design of a decision support system based on artificial intelligence (AI) and clinical data presenting symptoms is essential to support clinicians to accelerate diagnosis and timeous therapy in the emergency management of stroke.

Prognostic Factors of Granulosa Cell Tumors: A Retrospective Study in a Tertiary Care Cancer Centre of Eastern India.

Bhagyalaxmi NayakBackground and Aims The main objective of this study was to analyze the clinicopathological profile and prognostic factors of granulosa cell tumor (GCT). Method All the cases of ovarian cancer which were seen at our institute between January 2000 and December 2017 were reviewed. Data were analyzed with failure-free survival (FFS) as the primary end point. Results GCTs consisted of 2.66% of all ovarian cancers at our institute. The median age was 43 years. Majority of the patients (62.5%) were unstaged. Six patients (25%) had a fertility-preserving procedure. Forty two percent of the patients received adjuvant chemotherapy. Thirty eight percent of the patients developed recurrence. Considering tumor-related prognostic factors, there was a statistically significant decrease in FFS with the presence of hemorrhage ( p = < 0.001), larger tumors ( p = 0.042), and juvenile variant ( p = 0.002). On the contrary, when treatment-related factors were considered, there was no statistically significant improvement in FFS with the performance of lymphadenectomy ( p = 0.218), omentectomy ( p = 0.453), fertility sparing surgery ( p = 0.152), or administration of adjuvant chemotherapy ( p = 0.45). Conclusion Inherent tumor-related biological factors tend to play a more important role compared with treatment-related factors in GCTs. Hence, the traditional practice of performance of extensive staging procedures and routine adjuvant chemotherapy should be reviewed. Fertility-preserving surgery appears safe to be offered in early stages when desired. Although it is common knowledge that GCTs tend to be hemorrhagic tumors, this factor has not been well recognized as a prognostic indicator till date. Our study sheds some light on this aspect. Since these tumors have a tendency toward late recurrences, a long follow-up is prudent.

Comparison of dosimetric data of bone marrow between standard IMRT and bone marrow sparing IMRT in carcinoma cervix.

BACKGROUND: The aim of the study was to assess the dosimetric comparison of bone marrow between standard IMRT(SD-IMRT) and bone marrow sparing IMRT (BMS-IMRT) among carcinoma cervix patients who underwent radical or adjuvant chemoradiation in a tertiary cancer center. MATERIALS AND METHODS: Forty eligible patients of histo-pathologically proven carcinoma cervix were enrolled in the study that was randomized on a 1:1 basis between SD-IMRT and BMS-IMRT from July 2018 to October 2019. The whole pelvis, bilateral femoral heads, and upper 1/3rd femur were contoured using the whole bone technique as a surrogate marker for the bone marrow. In both arms, V10, V20, and V40, bone marrow was noted along with mean, maximum, minimum dose, and total volume. DVH for the bone marrow in both arms was compared using the unpaired student t-test. RESULTS: We found no significant difference in the mean of various parameters in SD-IMRT arm vs. BMS IMRT arm - for the bone marrow: V10 (89 ± 4.3% vs. 86.7 ± 3.7%), V20 (73.2 ± 5.3% vs. 73.1 ± 4.5%), V40 (23.9 ± 5.4% vs. 26.6 ± 7.4%) and, similarly, for mean dose (28.1 ± 3.5% vs. 28.1 ± 1.8%), maximum dose (53.4 ± 0.58% vs. 53.2 ± 0.58%), minimum dose (0.33 ± 0.18% vs. 0.38 ± 0.38%), total volume (961 ± 110 cc vs. 901 ± 152 cc). CONCLUSION: This study shows no statistically significant difference in dosimetry between the two groups, which suggests that SD-IMRT spares the bone marrow adequately. Therefore, the need for BMS-IMRT using the present contouring technique does not give any added advantage over SD-IMRT. However, large sample size, other novel contouring technique, and multivariate analysis are needed to reach a definite conclusion.

Significance of Vertebral Endplate Failure in Symptomatic Lumbar Disc Herniation.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Endplate lesions though have been implicated in the genesis of lumbar disc herniation (LDH), very little is known regarding their clinical course. Thus, the present study is aimed to investigate the incidence and types of endplate failure (EPF) in LDH and its correlation with the clinical symptoms and prognosis. METHODS: Clinical and magnetic resonance imaging (MRI) features of 66 patients with isolated single level LDH were studied. Three-dimensional fast spoiled gradient (3D FSPGR) MRI and computed tomography scans were used to identify the bony and cartilaginous EPF. Twenty-five patients were operated on and 41 patients were treated conservatively. Changes in the pain score, function and neurology were noted at 3, 6, 12, 24, and 36 weeks. RESULTS: Endplate lesions were observed in 64 patients (96.9%), including bony endplate failure (bony failure) in 47 patients (71.2%) and isolated cartilaginous endplate lesions in 17 patients (25.7%). Bony failure group had similar pain and functional scores but more severe neurological deficit at the initial evaluation. Clinical parameters improved in all groups, but the recovery was lesser in conservatively treated bony failure patients. CONCLUSION: Endplate lesions are commonly associated with symptomatic LDH. Presence of bony failure can increase neurological deficit and reduce the chance of recovery with conservative management. The 3D FSPGR sequence of MRI can be successfully used for detection of the endplate lesions in the herniated disc.

Massive hemoptysis in a case of intralobar pulmonary sequestration associated with pulmonary hypoplasia and meandering right pulmonary vein: diagnosis and management.

Pulmonary sequestration is a congenital malformation characterized by focal area of dysplastic lung tissue that lacks normal communication with tracheobronchial tree and receives blood supply from systemic arteries. Surgical resection has been the conventional method of treatment of pulmonary sequestration. In recent years transarterial embolization of the anomalous systemic arteries has emerged as a suitable alternative to surgery. In this paper, we describe transarterial coil embolization for control of massive life-threatening hemoptysis in a rare case of intralobar sequestration in right lung associated with ipsilateral pulmonary hypoplasia and meandering right inferior pulmonary vein. A 3-year follow-up computed tomographic (CT) angiography revealed complete regression of the sequestration along with altered pulmonary arterial contour. To the best of our knowledge, transarterial coil embolization for control of massive life-threatening hemoptysis in such a complex pulmonary anomaly has not yet been reported.

Imaging findings in agenesis of the dorsal pancreas. Report of three cases.

CONTEXT: Agenesis of the dorsal pancreas is rare. The dorsal pancreatic agenesis is described in two forms, the partial and the complete form. PATIENTS: with this anomaly may be asymptomatic or may present with diabetes mellitus, epigastric pain, acute or chronic pancreatitis. CASE REPORT: We report the computed tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) findings in three cases with dorsal pancreatic agenesis, one with partial and the other two with complete form. Speckled calcification at pancreatic head was observed in one patient. Lateral contour lobulation of pancreatic head which is seen in one third of normal population is believed to be due to variation in fusion between ventral and dorsal pancreas. In contrast, we observed lateral contour lobulation of pancreatic head in a case of complete agenesis of the dorsal pancreas where structures derived from dorsal pancreas are undeveloped. The ventral and dorsal pancreatic duct lengths were measured on MRCP images and we observed that in partial agenesis, the duct of Wirsung was shorter in length, compared to the duct of Santorini. The duct of Wirsung was relatively longer in cases of complete agenesis of the dorsal pancreas. CONCLUSION: The CT, MRI and MRCP findings in dorsal pancreatic agenesis and the relationship between the length of ventral duct with the type of dorsal pancreatic agenesis will provide a new insight into this particular anomaly.

Isolated iliac artery aneurysm rupture causing lumbar plexopathy.

Isolated iliac artery aneurysms (IIAAs) are rare. We present a patient with lumbosacral plexopathy due to common iliac artery aneurysm rupture that presented with left monoplegia.

Group C streptococcal bacteremia: a case report from India.

Group C streptococci are a common cause of infection in animals and a rare cause of bacteremia in human beings. The entity is often seen in elderly people with a severe underlying illness. We report here the only case of Group C streptococcal bacteremia reported in our hospital, caused by Streptococcus equisimilis, a beta-hemolytic Group C streptococcus. The patient was a 10-year old male with a known history of aplastic anemia. In spite of specific therapy with penicillin, the outcome was fatal.