CT Coronary Angiogram With FFR CT - A Revolution In The Diagnostic Flow Of Coronary Artery Disease.

Within the last few years, advances in CT coronary imaging has revolutionised the diagnostic flow of suspected coronary artery disease. CT coronary angiogram has a high diagnostic accuracy and negative predictive value for diagnosis of coronary disease. Its non-invasive nature makes it a lower risk and lower cost procedure compared to conventional invasive coronary angiogram. However, there is restricted value in anatomical evaluation without input regarding the functional significance of each lesion identified with cross-sectional imaging. The gold standard to assess whether a lesion is haemodynamically significant has been the assessment of FFR (fractional flow reserve). Fractional flow reserve is the ratio between maximum coronary flow in the presence of stenosis and in the hypothetical absence of stenosis. This is measured invasively by introducing a pressure wire across the lesion involving intracoronary nitro-glycerine as well as intravenous infusion of adenosine. However, the introduction of FFR CT provides information on functional significance of a lesion only using the CT data set of CT CA. Through complex non-linear equations and supercomputing, it produces a three-dimensional model of the coronary artery giving FFR values at multiple point along every major coronary vessel. It is non-invasive, involves no extra dose or contrast and does not require adenosine stress. A lesion that may appear moderate to severe on CT CA with FFR values above 0.80 can be managed by optimal medical management alone. Together FFR Ct and CTCA provide a comprehensive assessment for CAD leading to a reduction in downstream testing and unnecessary revascularisation procedures.

Anton's syndrome: a rare and unusual form of blindness.

Anton syndrome is characterised by visual anosognosia. It results from damage to both occipital lobes, while the anterior visual pathways remain intact. We describe four cases of Anton's syndrome. First case is that of a 73-year-old woman, who presented with two separate events of intraparenchymal brain haemorrhage, 4 years apart. Her first stroke affected the left and second affected the right occipital lobe. Bilateral occipital lobe damage resulted in cortical blindness. Second case is an 88-year-old man, who suffered from two ischaemic strokes, 2 days apart. Each stroke involved one posterior cerebral artery. This resulted in bilateral occipital and temporal lobe infarcts. Third case is a 64-year-old woman with chronic renal failure, who suffered bilateral occipital lobe infarction after haemodialysis, due to posterior reversible encephalopathy syndrome. Last case is that of an 80-year-old woman who suffered a basilar artery stroke, resulting in bilateral thalamic, temporal and occipital lobe infarction.

Delayed diagnosis of odontoid peg osteomyelitis with bilateral X and XII cranial nerve palsies.

Upper cervical osteomyelitis is rare. Its presenting features are fever and neck pain, but rarely it can involve lower nerves. MRI is the main imaging modality, but it is difficult to interpret due to the unique anatomy of C1 and C2 vertebra and complex intervertebral joint. We describe a case of a 67-year-old woman, who presented with the complaint of loss of voice, neck pain and fever for 5 days. Despite repeated imaging of neck, the diagnosis was not reached. As the patient's condition continued to deteriorate, clinical signs of bilateral 10th and 12th cranial nerve paralysis appeared and lead to a focused workup for base of skull pathology. Discussion with the radiologist helped guide the imaging protocol, which leads to the correct diagnosis being made. Treatment was tailored by blood cultures and available images. Temporary immobilisation with a cervical collar and a total of 12 weeks of antibiotics lead to complete remission.