Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot.

OBJECTIVES: Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury. METHODS: This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years). RESULTS: Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later. CONCLUSIONS: This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient's functional activity and quality of life.

Diffusion tensor imaging of the median nerve in healthy and carpal tunnel syndrome subjects.

PURPOSE: To determine if diffusion tensor imaging (DTI) of the median nerve could allow identification of patients with carpal tunnel syndrome (CTS). MATERIALS AND METHODS: A total of 13 healthy subjects and 9 CTS patients were scanned on a 3T magnetic resonance imaging (MRI) scanner. The MRI protocol included a DTI sequence from which the fractional anisotropy (FA), apparent diffusion coefficient (ADC), and the parallel and radial diffusivities could be extracted. Those parameters were quantified at different locations along the median nerve (proximal to the carpal tunnel, within the carpal tunnel, and distal to the carpal tunnel). RESULTS: At the carpal tunnel, the FA, radial diffusivity, and ADC differed significantly between healthy subjects and CTS patients (P<0.0002). This highly significant difference between the two groups was due to an opposite trend of changes in the DTI indices between the proximal to the carpal tunnel and within the carpal tunnel locations. In healthy subjects the FA increased (+20%, P<0.001) and the radial diffusivity and ADC decreased (by -15% and -8%, respectively, P<0.05) between the proximal to the carpal tunnel and within the carpal tunnel locations. In CTS subjects the FA decreased (by -21%, P<0.05) and the radial diffusivity increased (by +23%, P<0.01) between the proximal to the carpal tunnel and within the carpal tunnel locations. CONCLUSION: DTI enables visualization and characterization of the median nerve in healthy subjects and CTS patients. DTI indices show clear-cut discrimination between the two groups and in fact enables the of use DTI in the diagnosis of CTS.

Computed tomography colonography ("virtual colonoscopy") in Israel: results of the National CT Colonography Survey of the Israeli Association of Abdominal Imaging and the Israeli Radiological Association.

BACKGROUND: Computed tomographio colonography, also known as virtual colonoscopy, is a rapid, non-invasive imaging technique to detect colorectal masses and polyps that is becoming increasingly popular. OBJECTIVES: To evaluate the availability, technique, standards of performance and indications for CT colonography in Israel. METHODS: A questionnaire on CT colonography was sent to all radiology departments and private institutions that perform CTC in Israel. We evaluated multiple technical parameters regarding the performance and interpretation of CTC as well as radiologists' training and experience. RESULTS: Fourteen institutions--7 hospitals and 7 private clinics--participated in the study. Most of the small radiology departments and nearly all of the more peripheral radiology departments do not perform CTC studies. Since 2000 and until March 2007, a total of 15,165 CTC studies were performed but only 14% (2123 examinations) were performed at public hospitals and 86% (13,042 exams) at private clinics. CTC was performed after an incomplete colonoscopy or for various contraindications to endoscopic colonoscopy in up to a third of cases. In the various institutions patients were self-referred in 20-60% of cases, more commonly in private clinics. All CTC examinations were performed on 16-64 slice CT scanners and only a small minority was performed on 4-slice scanners in 2001. All but one center used low radiation protocols. Nearly all facilities used a 2 day bowel-cleansing protocol. All except one facility did not use stool tagging or computer-aided diagnosis. All facilities inflated the colon with room air manually. All institutions used state-of-the-art workstations, 3D and endoluminal navigation, and coronal multi-planar reconstructions routinely. There are 18 radiologists in the country who perform and interpret CTC studies; half of them trained abroad. Ten of the radiologists (56%) have read more than 500 CTC studies. CONCLUSIONS: In Israel, CTC examinations are performed by well-trained and highly experienced radiologists using the latest CT scanners and workstations and adhering to acceptable CTC guidelines.

T1-weighted functional imaging based on a contrast agent in presurgical mapping.

PURPOSE: To assess the applicability of T1-weighted images in the presence of a contrast agent for functional mapping free of susceptibility artifacts, in comparison to the blood oxygenation level-dependent (BOLD) imaging. MATERIALS AND METHODS: Six patients and five control subjects were scanned using BOLD and T1-weighted functional imaging, in the presence of a Gd-DTPA contrast-agent (TOFICA). In the control group, low- and high-resolution BOLD images were performed. Functional stimuli included motor and language activations. RESULTS: Both BOLD and TOFICA methods resulted in activations in the expected anatomical regions. The TOFICA mapping gave less distributed and with higher percent signal changes in comparison with the BOLD images. Gd-DTPA remained almost constant in the blood for at least 15 min post injection. In one patient with surgical clips, no signal was detected in the left cerebral hemisphere using BOLD imaging, but activation could be mapped using the TOFICA method. CONCLUSION: T1-weighted imaging in the presence of a contrast agent can be used for functional mapping. This method is insensitive to susceptibility artifacts, and is therefore advantageous in the evaluation of presurgical cases and in areas of the brain close to cavities in which the BOLD method cannot reliably be applied.

Vascular and biliary abnormalities mimicking cholangiocarcinoma in patients with cavernous transformation of the portal vein: role of color Doppler sonography.

OBJECTIVE: The purpose of this study was to describe and evaluate the sonographic and color Doppler features of tumorlike biliary and venous changes in patients with cavernous transformation of the portal vein (CTPV). METHODS: The sonographic studies of 24 patients with CTPV were reviewed. Sonographic evaluation of the biliary system included measurement of intrahepatic and extrahepatic biliary duct caliber changes and common bile duct (CBD) wall thickening and character. Color Doppler features of the portoportal collateral circulation at various locations (intrahepatic, periportal, gallbladder, pancreatic, and gastric regions) were carefully evaluated. RESULTS: Biliary abnormalities were detected in 13 (54%) of 24 patients with CTPV. All 13 patients (100%) had intrahepatic biliary dilatation; 11 patients (85%) had CBD abnormalities: diffuse CBD wall thickening causing diffuse narrowing of the true lumen in 7 (54%) and CBD dilatation proximal to the focal area of narrowing due to pericholedochal compressing venous collaterals in 4 (30%). A tumorlike solid mass appeared on the gray scale images of 2 patients (8%): 1 at the porta hepatis and the other at the pancreatic head level. Color Doppler imaging evaluation showed venous-type flow, suggesting a bulk of varicosities. CONCLUSIONS: Portoportal collaterals in patients with CTPV may alter the biliary and venous systems, causing biliary wall thickening, stenosis, intrahepatic and extrahepatic dilatation, and pseudotumors. Detailed sonographic and color Doppler imaging assessment can show and facilitate the correct diagnosis of those changes, thus avoiding the need for a more invasive modality such as endoscopic retrograde cholangiopancreatography or a more expensive investigation such as magnetic resonance cholangiopancreatography.

Coronary ostium-straight tube or funnel-shaped? A computerized tomographic coronary angiography study.

BACKGROUND: The 3D configuration of the aortic-coronary junction is decisive in stenting ostial coronary lesions. We hypothesized that it varies between straight to funnel-shaped tubes and studied arterial orifices using computerized tomographic coronary angiography (CTCA). METHODS AND RESULTS: Axial and sagittal 2-D and volumetric 3-D reconstructions of the aorto-coronary junction were performed in 25 patients who underwent CTCA. The following measurements of the left main (LM) and right coronary (RCA) arteries ostia were obtained: the coronary orifice broad base diameter, the diameter of the coronary vessel most proximal segment, the distance between them, and the angles of the aortic-coronary junction. All patients exhibited a funnel-shaped aortic-coronary junction in at least one plane, and none had an entirely straight tube shape. The RCA take-off had symmetric angling in both the axial and sagittal planes in only one patient, while the LM did not have a symmetric origin in either plane in any patient. The mean coronary orificial funnel depth and ostial cross-sectional diameters were measured. CONCLUSION: The frequency of funnel-shaped and asymmetry of the aortic-coronary junction configuration needs to be considered in designing stents for aortic-ostial coronary lesions in order to achieve optimal results and reduce restenosis.

Percutaneous drainage as the treatment of choice for neonatal ovarian cysts.

BACKGROUND: Involution of neonatal ovarian cysts occurs usually by 12 months. Persisting cysts larger than 4 cm are prone to torsion. Two modes of therapy are advocated: surgery and percutaneous US-guided cyst aspiration. OBJECTIVE: To compare ovarian preservation following the use of US-guided aspiration or conventional surgery for the treatment of large asymptomatic neonatal ovarian cysts, and to suggest alternative treatment when intrauterine ovarian torsion occurs. MATERIALS AND METHODS: The study population comprised 25 baby girls with an ovarian cyst, 5 with a simple cyst and 20 with a complex cyst. Of these 25 infants, 8 had surgery and 17 had US-guided cyst aspiration. RESULTS: In the surgical group of 8, 6 underwent oophorectomy, and in 2 the ovary was saved. In the aspirated group of 17, the ovary was saved in 10, and was lost in 5. At the time of this report one patient was still in the follow-up period, and one was lost to follow-up. CONCLUSION: US-guided aspiration of large neonatal cysts preserves ovarian tissue in a higher percentage of patients than surgery. It is safe, effective, and repeatable. We recommend US-guided aspiration of asymptomatic large ovarian cysts for salvage or for decompression if intrauterine ovarian torsion occurs. Surgery should be reserved for patients with acute torsion, intestinal obstruction and intestinal volvulus.

Intratesticular varicocele: gray scale and color Doppler sonographic appearance.

OBJECTIVE: The purpose of this study was to evaluate the gray scale and color Doppler appearances of intratesticular varicocele (ITV) in a relatively large series of men and to compare the findings with those previously reported. METHODS: Fifteen ITVs found in 12 men referred for sonographic examination of a variety of scrotal conditions were retrospectively evaluated. Review of the side, location, shape, and diameter of the dilated veins, the presence of an extratesticular varicocele (ETV), and the color Doppler appearance of the ITV before and during the Valsalva maneuver was performed. RESULTS: Seven (47%) of 15 ITVs were located in the left testis, 2 (13%) in the right, and 3 (20%) bilateral. Eighty-six percent of the ITVs were associated with an ipsilateral ETV. The locations of the ITVs were subcapsular in 60% of the cases and within or near the mediastinum of the testis in 40%. The shapes of the ITVs were tubular in 46%, oval in 27%, and both tubular and oval in the remaining 27%. Color Doppler imaging showed spontaneous flow in 60% of cases, whereas in the remaining 40%, the blood flow could be seen only after the Valsalva maneuver. CONCLUSIONS: Intratesticular varicocele is a rare condition with a variable clinical and sonographic appearance. It is usually associated with ETV. It occurs in the left, right, or both testes and may be subcapsular or mediastinal in location. The prevalence of a subcapsular location of ITVs in this series was by far higher than previously mentioned in the literature. The Valsalva maneuver plays a very important role in the diagnosis of ITV because in almost half of cases, the flow will not show up spontaneously.

Susceptibility-matched envelope for the correction of EPI artifacts.

Fast gradient echo sequences, such as echo planer imaging (EPI) and spiral imaging, are vulnerable to artifacts resulting from B(0) inhomogeneities. A major contribution to these artifacts is the susceptibility variation across the head, which is most severe in regions adjacent to air-tissue interfaces, such as the mouth, nasal sinuses, ears and the cortex. Susceptibility artifacts can cause geometrical distortions in the image as well as loss of signal due to T(2)* dephasing. The extent of these artifacts increases with the main field, thus compromising the signal-to-noise ratio (SNR) benefit gained in higher fields. In the current work, inhomogeneity caused by susceptibility variations at the external boundary of the human body has been corrected by surrounding the organs with a liquid without hydrogen atoms and whose susceptibility is similar to that of the imaged organ. EPI experiments were conducted on head-sized phantom, human brain, hand and legs. This method causes minimal patient inconvenience and no interference with any function of the scanner, thus yielding a simple and efficient solution for the correction of B(0) variation.

White matter changes in multiple sclerosis: correlation of q-space diffusion MRI and 1H MRS.

OBJECTIVE: To explore the diagnostic usefulness of high b-value diffusion magnetic resonance brain imaging ("q-space" imaging) in multiple sclerosis (MS). More specifically, we aimed at evaluating the ability of this methodology to identify tissue damage in the so-called normal-appearing white matter (NAWM). DESIGN: In this study we examined the correlation between q-space diffusion imaging and magnetic resonance spectroscopy (MRS)-based two-dimensional 1H chemical shift imaging. Eight MS patients with different degree of disease severity and seven healthy subjects were scanned in a 1.5-T magnetic resonance imaging (MRI) scanner. The MRI protocol included diffusion tensor imaging (DTI) (with bmax of 1000 s/mm2), high b-value diffusion-weighted imaging (with bmax of 14,000 s/mm2) and 2D chemical shift imaging. The high b-value data set was analyzed using the q-space methodology to produce apparent displacement and probability maps. RESULTS: We found that the q-space diffusion displacement and probability image intensities correlated well with N-acetylaspartate levels (r=.61 and .54, respectively). Furthermore, NAWM that was abnormal on MRS was also found to be abnormal using q-space diffusion imaging. In these areas, the q-space displacement values increased from 3.8+/-0.2 to 4.6+/-0.6 microm (P<.02), the q-space probability values decreased from 7.4+/-0.3 to 6.8+/-0.3 (P<.002), while DTI revealed only a small, but still significant, reduction in fractional anisotropy values from 0.40+/-0.02 to 0.37+/-0.02 (P<.05). CONCLUSION: High b-value diffusion imaging can detect tissue damage in the NAWM of MS patients. Despite the theoretical limitation of this method, in practice it provides additional information which is clinically relevant for detection of tissue damage not seen in conventional imaging techniques.

Clinical value of 16-slice multi-detector CT compared to invasive coronary angiography.

BACKGROUND: Multi-detector row spiral CT (MDCT) can be applied as a noninvasive tool for the assessment of coronary artery stenoses. Few, confounding reports have been published using 16 detector rows. The aim of the present study was to determine the accuracy of 16-detector row MDCT for the detection of significant stenoses in the coronary arteries, in comparison to conventional invasive coronary angiography. METHODS: Twenty-two patients with suspected coronary artery disease, were prospectively evaluated by 16-slice retrospectively ECG-gated CT coronary angiography and quantitative invasive coronary angiography. The findings were compared for the detection of significant coronary artery stenoses (>50%) in all segments with diameter >1.5 mm. RESULTS: MDCT correctly classified all 14 patients (100%) that were found to have significant coronary artery disease on conventional angiography. Overall, 288 segments were included in the analysis, regardless of their image quality. Significant stenoses were detected in 24 segments by CT and in 28 segments by conventional angiography. Out of 260 segments that were negative for significant stenoses on conventional angiography, 255 were correctly identified on CT. The sensitivity, specificity, positive and negative predictive values were 86, 98, 83 and 98%, respectively. MDCT also revealed supplementary findings that invasive angiography was unable to visualize, including anomalous vessel course, the course of vessels filling via collaterals, intramyocardial course of vessels and non-stenotic plaques. CONCLUSIONS: MDCT coronary angiography utilizing 16-detector rows shows promising results for reliable detection of coronary artery stenoses and particularly for ruling out significant disease.

Normal white matter development from infancy to adulthood: comparing diffusion tensor and high b value diffusion weighted MR images.

PURPOSE: To evaluate the sensitivity of high b value diffusion weight magnetic resonance imaging (DWI) in detecting normal white matter maturation, compare it to conventional diffusion tensor imaging (DTI), and to obtain normative quantitative data using this method. MATERIALS AND METHODS: High b value DWI (b(max) = 6000 sec/mm(2)) using q-space analysis and conventional DTI (b = 1000 sec/mm(2)) were performed on 36 healthy subjects aged 4 months to 23 years. Fractional-anisotropy (FA), apparent-displacement, and apparent-probability values were measured in all slices and in six regions of interest (ROIs) of large fiber tracks. Values were correlated with each other and with age using regression analysis. RESULTS: FA, displacement, and probability indices from all slices were highly correlated with each other (r > 0.87, P < 0.0001) and with age (r > 0.82, P < 0.0001). All age-related changes in the six pre-determined ROIs were best fitted by mono-exponential functions. Changes in the splenium extended to a later age when compared with the genu of the corpus-callosum, while the centrum semi-ovale demonstrated the latest changes with age. CONCLUSIONS: High b-value DWI and DTI showed changes in white matter from infancy through adulthood. However, high b-value detects a signal that is likely to originate mainly from the intra-axonal water population, and thus may represent different aspects of development and different sensitivity to pathology.

Modification of surgical planning based on cardiac multidetector computed tomography in reoperative heart surgery.

BACKGROUND: Repeat open heart surgery is associated with an increased risk of injury to old conduits and cardiac structures. To reduce this risk, we evaluated the contribution of multidetector computed tomography angiography in planning repeat cardiac operations. METHODS: Fifteen patients who had previous coronary artery bypass grafting procedures underwent retrospective-gated computed tomographic angiography with a 16-slice multidetector computed tomography. Relation of the grafts to the expected median sternotomy line, graft patency and anatomic course, possible aortic cannulation and cross-clamp sites, distances between the right ventricle to the sternum, and calcification of the ascending aorta were assessed. RESULTS: Multidetector computed tomography demonstrated 45 conduits (mean, 3 +/- 1.1); 18 arterial grafts and 13 saphenous vein grafts that were patent, and 2 internal mammary artery grafts and 12 saphenous vein grafts that were occluded. Significant narrowing was shown in 3 of the patent internal mammary arteries and 4 of the patent saphenous vein grafts. Adherence of the right ventricle, left internal mammary artery, and saphenous vein graft to the sternum (0 to 3 mm in the midline) was demonstrated in 8, 2, and 1 patients, respectively. Two patients had a heavily calcified aorta. During surgery, all multidetector computed tomographic findings were confirmed. Three aspects of the operative plans of 4 patients were modified according to multidetector computed tomographic findings: median sternotomy approach (3 patients), cannulation site (2 patients), and myocardial preservation technique (3 patients). On the basis of multidetector computed tomographic evaluations, surgery was cancelled in 2 patients in whom repeat operation was judged to be associated with increased risk: 1 patient, scheduled for coronary artery bypass grafting, had an extremely calcified aorta, and the other, scheduled for aortic valve replacement, had grafts that were adherent to the sternum. CONCLUSIONS: Multidetector computed tomography is a new noninvasive tool for three-dimensional preoperative assessment of complex cardiac and graft anatomy. Our initial experience suggests that it may provide information to warrant modifying surgical planning, thus contributing to the safety of reoperative heart surgery.

Radiographic manifestations of normal postoperative anatomy and gastrointestinal complications of bariatric surgery, with emphasis on CT imaging findings.

Recently, there has been a tremendous increase in the frequency of utilization of surgery to control morbid obesity that is very common and increasing in incidence in Western industrialized nations. Imaging plays an important role in the evaluation and management of patients before and after bariatric surgery. In this article, we discuss the imaging findings relating to bariatric procedures, focusing on the role of computed tomography (CT) in the evaluation of normal postoperative anatomy and gastrointestinal complications.

Further development of reconstructive and cell tissue-engineering technology for treatment of complete peripheral nerve injury in rats.

UNLABELLED: In this work we evaluated the efficacy of biodegradable composite co-polymer guiding neurotube, based on tissue-engineering technology, for the treatment of complete peripheral nerve injury where the nerve defect is significant. The right sciatic nerve of 12 three-month-old rats was completely transected and peripheral nerve segment was removed. A 2.2-cm biodegradable co-polymer neurotube containing viscous gel (NVR-N-Gel) with survival factors, neuroprotective agents and Schwann cells was placed between the proximal and the distal parts of the transected nerve for reconnection a 2-cm nerve defect. The proximal and distal parts of the nerve were fixed into the neurotube using 10-0 sutures. Ultrasound observation showed growth of the axons into the composite neurotube 2 months after the surgery. Electrophysiological study indicated compound muscle action potentials in nine out of 12 rats, 2-4 months after peripheral nerve reconstructive surgery. The postoperative follow-up (up to 4 months) on the operated rats that underwent peripheral nerve reconstruction using composite co-polymer neurotube, showed beginning of re-establishment of active foot movements. The tube was dissolved and nerve showed complete reconnection. Histological observation of the nerve showed growth of myelinated axons into the site where a 2-cm nerve defect replaced by composite co-polymer neurotube and into the distal part of the nerve. IN CONCLUSION: (1) an innovative composite neurotube for reconstruction of significant loss of peripheral nerve segment is described; (2) a viscous gel, containing survival factors, neuroprotective agents and Schwann cells served as a regenerative environment for repair. Further investigations of this reconstructive procedure are being conducted.

Pitfalls in the diagnosis of acute pulmonary embolism on spiral computer tomography.

Spiral computer tomography (CT) has become a widely accepted clinical tool in the diagnosis of acute pulmonary embolism. The accuracy of computed tomography in diagnosing pulmonary embolism has increased over the past 10 years, parallel to technological improvements. However, as with most imaging techniques, interpretative pitfalls may occur for a variety of reasons. These include technical problems caused by respiratory motion artifact, improper bolus timing, streak artifact, and patient body habitus. In addition, misinterpretation of normal bronchovascular anatomy may lead to an erroneous diagnosis. This article discusses the various diagnostic pitfalls and methods to minimize and overcome them.

Sonographic evaluation of brachial plexus pathology.

Pre-operative US examinations of the brachial plexus were performed with the purpose of exploring the potential of this technique in recognizing lesions in the region and defining their sonographic morphology, site, extent, and relations to adjacent anatomic structures, and comparing them to the surgical findings to obtain maximal confirmation. Twenty-eight patients with clinical, electro-conductive, and imaging findings suggestive of brachial plexus pathology were included in this study. There were four main etiology groups: post-traumatic brachial plexopathies; primary tumors (benign and malignant); secondary tumors; and post irradiation injuries. Twenty-one of the 28 patients underwent surgery. Advanced imaging (mostly MRI) served as an alternative gold standard for confirmation of the findings in the non-surgically treated group of patients. The US examinations were performed with conventional US units operating at 5- to 10-MHz frequencies. The nerves were initially localized at the level of the vertebral foramina and then were followed longitudinally and axially down to the axillary region. Abnormal US findings were detected in 20 of 28 patients. Disruption of nerve continuity and focal scar tissue masses were the principal findings in the post-traumatic cases. Focal masses within a nerve or adjacent to it and diffuse thickening of the nerve were the findings in primary and secondary tumors. Post-irradiation changes presented as nerve thickening. Color Doppler was useful in detecting internal vascularization within masses and relation of a mass to adjacent vessels. The eight sonographically negative cases consisted either of traumatic neuromas smaller than 12 mm in size and located in relatively small branches of posterior location or due to fibrotic changes of diffuse nature. Sonography succeeded in depicting a spectrum of lesions of traumatic, neoplastic, and inflammatory nature in the brachial plexus. It provided useful information regarding the lesion site, extent, and anatomic relationships; thus, the principal aims of the study were therefore met. Once the technique of examination is mastered, sonography should be recommended as part of the pre-operative evaluation process post-ganglionic brachial plexus pathology. Most disadvantages are related to the restricted field of view and inability to overcome bonny obstacles particularly in evaluating pre-ganglionic region. As sonography is frequently employed for investigation of the supraclavicular region, awareness of the radiologist to the findings described may enable the early recognition of pathologies involving or threatening to involve the brachial plexus.

[Left paraduodenal hernia: a report of a case and a review of clinical and diagnostic CT findings].

Internal hernias are an uncommon cause of small bowel obstruction. Paraduodenal hernias have been considered until recently the most common sub-type. Due to non-specific and intermittent signs and symptoms the diagnosis of these hernias is notoriously difficult. We report a case of a paraduodenal hernia diagnosed correctly with abdominal computed tomography that was confirmed at surgery and review the clinical and imaging findings of these hernias.