Percutaneous Y-shape reconstructive biliary stenting in Klatskin cholangiocarcinoma through a single left-sided entry.

Percutaneous Y-shape reconstructive biliary stenting in the Klatskin tumor is typically performed through bilateral biliary access. Single access from a right-side biliary entry is the more commonly used side for biliary access in general. We present a successful Y-shaped biliary stent reconstruction through a single left-side biliary approach. Unilateral single access Y-shaped biliary stenting can be technically challenging; when performed through a left biliary approach, an additional technical challenge may arise due to the unusual combination of Y-shaped biliary stent reconstruction and the single left-side biliary approach. We concluded that percutaneous Y-shaped biliary reconstruction through a left-sided unilateral approach is a technically feasible, less invasive interventional approach in managing Klatskin tumor. SIMILAR CASES PUBLISHED: None.

Coronary artery calcium score above 250 confirms the presence of significant stenosis in coronary CT angiography of symptomatic patients.

OBJECTIVES: Evaluation of coronary artery calcium score (CACS) at multiple low and high cutoff values for the detection of significant coronary stenosis at two different cutoffs (50 and 70%) in a large number of symptomatic patients was not investigated previously in one study. This study aims to investigate if there are a correlation and statistical significance between different CACS cutoffs and the severity of coronary artery stenosis by coronary CT angiography (CCTA) in symptomatic patients. METHODS: This is a retrospective study that included all symptomatic patients who had CCTA in a tertiary care hospital over a period of 7 years. RESULTS: CCTA of 502 patients was evaluated (406 included, mean age 56.2 years); 230 were males (56.7%). The prevalence of stenosis at any percentage was 53.7%, ≥50% was 26.6% and ≥70% was 12.3%. The mean CACS was 84.5 (range 0-1860), for males was 124.5 and for females was 32.1. Patients with CACS of zero (59%) and CACS of ≥1 (41%) had a mean stenosis of 8.9% (range 0-75%) and 52.6% (range 0-100%), respectively. All patients with a CACS of ≥250 were found to have ≥50% stenosis (100% specificity and positive predictive value, 35.2% sensitivity, 81% negative predictive value and 82.6% accuracy). The percentage of stenosis increased as CACS increased with strong statistical significance (P value < 0.0001) and a positive correlation (r = 0.58). CONCLUSIONS: CACS is a valuable diagnostic tool to predict the severity of coronary artery stenosis. A cutoff value of 250 confirmed the presence of at least 50% stenosis in symptomatic patients.

The Role of Cerebral CT Angiogram in Subacute Ischemic Cerebrovascular Events.

BACKGROUND: Stroke is a spectrum of medical emergencies resulting from a direct insult to the cerebral blood flow. Cerebral computed tomography angiogram (CTA) plays an important role in the diagnostic algorithm of acute stroke. However, the role of CTA in the subacute phase is not well-established. This study aimed to assess the diagnostic role of CTA in subacute ischemic stroke and transient ischemic attack (TIA) in identifying underlying etiology. It also aimed to describe the commonly encountered CTA findings in the subacute phase of ischemic events. METHODS: This is a retrospective study in which we evaluated the radiologic records of all patients who had a cerebral CTA for subacute stroke and TIA during the period from January 1, 2010 to May 30, 2018. RESULTS: The study included 104 cases diagnosed with subacute ischemic stroke or TIA. Patients' ages ranged from 8 to 96 years with a mean age of 52.9 (18.1) years. Most of the patients were males (68.3%; 71). CTA findings were abnormal in 86 cases (82.7%). Stenosis was diagnosed in 34 (32.7%) cases, followed by acute arterial thrombosis (25; 24%) and chronic occlusion (17; 16.3%). The internal carotid artery was the most affected (57.6%), followed by the vertebrobasilar arteries. CONCLUSION: The current study revealed that CTA has a high diagnostic yield in the subacute phase of ischemic cerebrovascular events, with an important role in detecting clinically relevant findings in this group of patients.

Coronavirus Disease (COVID-19) Compared with Middle East Respiratory Syndrome (MERS): A Radiological Perspective.

BACKGROUND: This study aims to describe the radiological findings in chest radiographs (CXRs) of patients with coronavirus disease (COVID-19) and the Middle East respiratory syndrome (MERS) and to compare the radiological patterns of the two diseases. METHODS: A retrospective cohort study was conducted in a tertiary care hospital in the Southern region of Saudi Arabia. The CXRs were evaluated for the presence and distribution of ground-glass opacities (GGO), consolidation, pleural effusions, pneumothorax, cavitation, and nodules. RESULTS: A total of 120 CXRs from 15 MERS and six COVID-19 patients were assessed. In the first available CXR, GGO was present in 11 (73%) of the MERS patients (18% located in the middle zones and 67% located peripherally) and in 100% of COVID-19 patients (peripheral and middle zone involvement in all patients). In the first available CXRs, consolidation was present in 10 MERS patients (67%) and in all six COVID-19 patients, while it was present in all patients of both groups when all the available CXRs were considered. Confluent consolidation was present in 47% of the MERS patients and 50% of COVID-19 patients. All the fatal cases had confluent consolidation and radiological signs of acute respiratory distress syndrome (ARDS). Pneumothorax was present in 13% of patients, with 100% mortality, and pleural effusion was present in 47% of patients, with 57% mortality. Lung nodules were present in one patient of each group. CONCLUSION: COVID-19 patients showed earlier development of GGO and consolidation with greater involvement of the middle and peripheral lung zones. Confluent consolidation and ARDSlike radiological findings were associated with high mortality. Pneumothorax and pleural effusions were more frequent in MERS patients, with high associated mortality.

Diagnostic yield of CT pulmonary angiography for pulmonary embolism in clinically suspected patients.

ABSTRACT: Pulmonary embolism (PE) is a common medical problem. Its diagnostic criteria must be reviewed to determine the need for confirmatory testing. Computed tomography pulmonary angiography (CTPA) is the current standard of care, which provides accurate diagnosis with rapid turnaround. This study aimed to estimate the diagnostic yield of CTPA in clinically suspected PE patients in a tertiary care hospital in Saudi Arabia.Radiology records of all patients with clinically suspected PE who underwent CTPA between January 1, 2012 and September 30, 2018 were reviewed retrospectively. A radiologist with 10 years of professional experience interpreted and reported all cases. The Wells score with 2 tiers (likely and unlikely) was used to raise the clinical suspicion of PE.Positive results for PE were reported in 177 out of 534 clinically suspected cases (33%). Among the positive PE cases, 143 were acute (81%) and 34 (19%) were chronic. Bilateral, right-sided, and left-sided PE were found in 115 (65%), 37 (21%), and 25 (14%) cases, respectively. Involvement of the segmental branches, subsegmental branches, and the pulmonary trunk were noted in 152 (86%), 70 (40%), and 9 cases (5%), respectively. Saddle PE was found in (4%) of the cases. The lower lobe branches (right 55%, left 53%) and the upper lobe branches (right 47%, left 41%) were the most common sites of involvement.CTPA had a higher positive detection rate for PE among clinically suspected cases than its published diagnostic yield. Adequate clinical evaluation when selecting patients for CTPA is emphasized to minimize unjustified exposure of the patients to radiation and intravenous contrast administration. It is crucial for radiologists to provide detailed reports commenting on all relevant findings, including pertinent negatives. A template for reporting radiological findings for CTPA can be recommended for this purpose.

The role of computed tomography angiogram in intracranial hemorrhage. Do the benefits justify the known risks in everyday practice?

BACKGROUND: Intracranial hemorrhage is a commonly encountered medical problem frequently evaluated by computed tomography angiography (CTA). In CTA, there is radiation exposure and possible adverse effects of intravenous contrast administration. Therefore, the yield of this diagnostic tool needs to be explored in a heterogeneous group of daily encountered patients to provide insight into the risks and benefits of CTA. OBJECTIVE: To evaluate the role of cerebral CTA in patients with CT-confirmed or clinically suspected intracranial hemorrhage. METHODS: This retrospective study included all patients who underwent cerebral CTA for evaluation of intracranial hemorrhage that was diagnosed by a plain CT scan or suspected clinically from January 1, 2010, to May 30, 2018. All the scans were evaluated for abnormalities of the cerebral arteries in the CTA. RESULTS: One hundred twenty patients were included, 74 % were males, and the mean age was 46 years. Approximately 18 % were trauma patients. Overall, CTA was abnormal in 52 % of cases, aneurysms were found in 27 %, and arteriovenous malformation (AVM) in 8 %. Among 82 patients who had a hemorrhage on the plain CT scans, 54 % had normal CTA, 28 % showed aneurysm, and 11 % showed AVM. In trauma patients, the most common CTA finding was normality (48 %), followed by aneurysms (19 %) and dissection (14 %). In non-trauma patients, the most common CTA finding was normality (49 %), followed by aneurysms (28 %) and AVM (10 %). CONCLUSIONS: CTA is a valuable diagnostic tool for intracranial hemorrhage because it detected abnormalities related to the hemorrhage in 42 % of patients. However, because more than half (58 %) of the patients had normal CTAs or showed CTA findings that were not relevant to the hemorrhage, clinical judgment should be exhausted before exposing them to radiation and intravenous contrast risks.

Western-designed total knee implants mismatch Saudi patient knees. Anatomical bony measurements documented by computed tomography.

OBJECTIVES: To determine the anthropometric features of Saudi knees compared with knees of other ethnicities and reveal mismatches among different knee implant systems. METHODS: All knee computed tomography images obtained between January 2016 and September 2016 for varying medical reasons in a tertiary care hospital in Southwestern Saudi Arabia were retrospectively evaluated. Patients aged less than 18 years, with trauma or soft tissue or bone tumors were excluded.  Eleven parameters were measured for each knee joint. RESULTS: We evaluated 100 knees of 50 Saudi patients (25 men, 25 women) aged 28-85 (mean, 57.3) years. No statistically significant differences were found in age and Sasaki angle measurements between male and female patients. All other parameters were significantly larger in male than female knees. Our measurements were close to those published for Chinese, Thai, and Korean patients; however, published measurements were larger for Caucasian and Indian knees than our measurements. CONCLUSION: The Saudi population has morphological features of knee bone anatomy that do not match with the widely available prostheses designed for Caucasian knees. As several studies of different ethnicities have documented considerable prosthesis mismatch; our study further indicates the need for new implant designs that take these variations into account.

Radiologists' Knowledge and Attitudes towards CT Radiation Dose and Exposure in Saudi Arabia-A Survey Study.

Computed tomography (CT) is a key imaging technique in diagnostic radiology, providing highly sensitive and specific information. While its use has increased dramatically in recent years, the quantity and associated risks of radiation from CT scans present major challenges, particularly in paediatrics. The fundamental principles of radiation protection require that radiation quantities be as low as reasonably achievable and CT use must be justified, particularly for paediatric patients. CT radiation knowledge is a key factor in optimising and minimising radiation risk. The objective of this study was to analyse knowledge level, expertise, and competency regarding CT radiation dose and its hazards in paediatrics among radiologists in Saudi Arabian hospitals. A self-reported, multiple-choice questionnaire assessed the attitudes and opinions of radiologists involved in imaging studies using ionising radiation. Among the total respondents, 65% ± 13.5% had a good comprehension of the dangers of carcinogenicity to the patient resulting from CT scans, with 80% presuming that cancer risks were elevated. However, only 48.5%, 56.5%, and 65% of the respondents were aware of specific radiation risks in head, chest, and abdominal paediatric examinations, respectively. Regular, frequent, and specific training courses are suggested to improve the fundamental knowledge of CT radiation among radiologists and other physicians.

Brain magnetic resonance imaging and proton MR spectroscopic findings after metabolic crisis in 3-methylcrotonylglycinuria.

Magnetic resonance imaging (MRI) and magnetic resonance spectroscopic (MRS) findings in 3-methylcrotonylglycinuria presenting with acute metabolic decompensation in a previously healthy 7-year old female are described. The patient was hospitalized with fever, irritability, gastrointestinal problems, drowsiness, signs of upper motor neuron deficit, and rapidly progressive respiratory distress requiring assisted ventilation. Laboratory workup showed severe metabolic acidosis, and the diagnosis of 3-methylcrotonylglycinuria was established by the mass spectrometry analysis of urine sample. Although initial CT imaging workup was found to be gross normal, subsequent MRI of the brain in the early chronic stage of the disease showed symmetrical ill-defined signal abnormalities within medulla oblongata, pons, inferior cerebellar peduncles, and periventricular white matter in cerebral hemispheres. Diffusion-weighted images were unremarkable. Single-voxel proton MRS showed elevated levels of lactate, branched-chain amino acids, as well as glutamine and glutamate. To the best of our knowledge, this is the first reported case of late onset 3-methylcrotonylglycinuria with complete MRI and MRS workup in the early chronic phase after metabolic crisis.

Awareness of interventional radiology among final-year medical students and medical interns at a university in Southwestern Saudi Arabia.

OBJECTIVE: To assess the awareness of interventional radiology (IR) among final-year medical students and medical interns at a Saudi University. Analysis of such awareness could help to improve the future of IR in Saudi Arabia. METHODS: This cross-sectional study was based on anonymous surveys administered over a one month period (1st-31st December 2012). One hundred and nineteen medical students and interns of King Khalid University, Abha, Saudi Arabia were included. Forty-two (35.3%) replies were received. The survey consisted of 25 questions covering perception, knowledge, and interest of interventional radiology. RESULTS: The majority of the respondents (52%) felt their knowledge in IR is poor. Only 40% of the respondents either completed or plan to complete an elective rotation in radiology. Thirty-eight percent of respondents were willing to consider a career in IR. The most common reason (43%) for not considering a career in IR was lack of knowledge. Only 33% correctly identified the route of training of interventional radiologist. The majority of respondents thought that interventional radiologists performed cardiac angioplasty (81%), and femoral popliteal bypass (74%). CONCLUSION: Exposure to IR among medical students and interns was poor. This can be addressed by dedicated undergraduate teaching of IR by interventional radiologists with emphasis on the clinical practice.

Endovascular embolization of a giant aneurysm in medial posterior choroidal artery with associated arteriovenous malformation.

A 16-year-old male adolescent who presented with vomiting and headache and in the emergency department had a loss of consciousness, was discovered to have a large mass compressing the brainstem. CT scan showed two adjacent mass lesions. Digital subtraction angiography (DSA) revealed a giant aneurysm in the posterior medial choroidal artery, subsequently embolized with Guglielmi detachable coils (GDCs). Ten GDCs were used to embolize the aneurysm and the distal aspect of its parent artery. Postembolization DSA confirmed complete embolization of the aneurysm. Endovasular embolization of giant aneurysms in the medial posterior choroidal artery with GDCs is technically feasible and represents a successful therapeutic option. In unruptured giant intracranial aneurysms, simultaneous packing of the aneurysm with coils and occlusion of the distal parent artery can have a good outcome.

The spectrum of sclerosing cholangitis and the relevance of IgG4 elevations in routine practice.

OBJECTIVES: American Association for the Study of Liver Diseases (AASLD) guidance recommends measurement of IgG4 in patients with sclerosing cholangitis (SC). The objective of this study was to evaluate this by analyzing our SC practice. METHODS: Characteristics were collected on 168 patients with radiological or biopsy proven SC; IgG4 was measured and magnetic resonance cholangiopancreatography studies were reviewed. RESULTS: In all, 49% of patients were females and 55% had inflammatory bowel disease. Large duct disease was present in 63%, small duct disease in 8%, overlap with AIH in 11%, and secondary SC in 18%. Secondary etiologies included autoimmune pancreatitis (AIP) (8%), intra-hepatic cholelithiasis (3%), portal vein thrombosis (2%), and neonatal Kasai (2%). In all, 101 patients had sufficient radiology and serology for re-evaluation. IgG4 was elevated (>104 mg/dl) in 22% of patients. This was associated with male gender (73%; P=0.016), a past history of pancreatitis (27% vs. 5%; P=0.007), a higher alkaline phosphatase (ALP) value, median 338.5 U/l vs. 160 (P=0.005), and a higher primary sclerosing cholangitis (PSC) Mayo risk score, mean 0.6 vs. -0.2 (P=0.0008). Prior biliary intervention was more likely (36 vs. 13%; P=0.023), while abnormal pancreatic imaging was noted in 15%, more frequently if IgG4 was elevated (40 vs. 8%; P=0.0007). After excluding those with pancreatic disease on magnetic resonance imaging, 14 patients had elevated IgG4. This group had higher ALP 379 U/l vs. 155.5 (P=0.0006), aspartate aminotransferase (AST) 72.5 U/l vs. 34 (P=0.0005), alanine aminotransferase (ALT) 90.5 U/l vs. 36 (P=0.004), and PSC Mayo risk score values 0.4 vs. -0.2 (P=0.017). CONCLUSIONS: SC is a heterogeneous liver injury. IgG4 testing may be clinically important in all patients, since it appears to identify a distinct patient population, more so than just those with AIP.

Small (< or = 4 cm) cortical renal tumors: characterization with multidetector CT.

BACKGROUND: To determine if the pathology of small (< or = 4 cm) solid renal tumors can be predicted from findings on multidetector CT. METHODS: This retrospective study included 46 patients (median age, 60 years; range, 32-91 years; 27 males, 19 females) with 47 tumors who underwent triphasic renal CT with pathology correlation. Two radiologists reviewed CT studies blinded to pathology results and recorded the morphologic and enhancement features of the tumors. RESULTS: The 47 tumors (median diameter, 2.5 cm; range, 0.6-4.0 cm) included: 26 (55%) clear cell renal cell carcinomas; 9 (19%) oncocytomas; 7 (15%) papillary renal cell carcinomas; 2 (4%) chromophobe renal cell carcinomas; 2 (4%) inflammatory pseudotumors; and 1 (2%) angiomyolipoma with minimal fat. Amongst the three commonest tumors, heterogeneity was seen in 23/26 (88%) clear cell renal cell carcinomas, 6/9 (67%) oncocytomas, and 2/7 (29%) papillary renal cell cancer. Median (minimum-maximum) absolute nephrographic phase enhancement (nephrographic minus unenhanced phase) was: clear cell renal cell carcinomas 65 HU (34-120), oncocytomas 80 HU (51-111), and papillary renal cell carcinomas 16 HU (7-32). CONCLUSION: Absolute nephrographic phase enhancement of < or = 32 HU distinguished papillary renal cell carcinomas from clear cell renal cell carcinomas and oncocytomas.

Angiographic findings and endovascular embolization in Dieulafoy disease: a case report and literature review.

Dieulafoy disease is an unusual cause of gastrointestinal (GI) hemorrhage that can be fatal. It arises from an abnormally large eroded submucosal artery commonly located in the proximal stomach. Since this disease first described in 1884, it has been rarely discussed in radiology literature. We describe a case of an elderly patient with multiple medical problems presented with upper and lower GI hemorrhage. Repeated upper GI endoscopies revealed a large fundal clot but otherwise were unremarkable. Angiography showed anomalous short gastric artery originating normally from the splenic artery. The latter was embolized with microcoils and Gelfoam. Following embolization, the frequency and amount of bleeding decreased although did not totally stop and the patient underwent elective partial gastrectomy. The diagnosis was made histologically. Therefore, Dieulafoy disease can represent a diagnostic and therapeutic challenge. It should be suspected if a patient with GI hemorrhage is found to have extravasation from a dilated tortuous artery that appears normal otherwise with no associated large draining veins. Transcatheter selective arterial embolization has a reported role in the literature as a less invasive therapeutic option compared to surgery.

Intralobar pulmonary sequestration presenting as a large multicystic mass.

A large multicystic mass lesion is not a common presentation of pulmonary sequestration. This presentation may result in failure to identify the supplying systemic artery due to multiplicity of the large cysts and, therefore, a wrong diagnosis. We discuss a case of intralobar pulmonary sequestration presented similarly. Chest x-ray and CT appearance gave an initial impression of hydatid disease which is endemic in Saudi Arabia. Fortunately, the supplying systemic artery was identified in the final CT review before surgery. Preoperative correct diagnosis of pulmonary sequestration is important to plan the appropriate surgery and to prevent possible intractable intraoperative hemorrhage. Awareness of this uncommon presentation of pulmonary sequestration helps to prevent such a fatal complication.