Proximal femoral medullary canal diameters in Indians: correlation between anatomic, radiographic, and computed tomographic measurements.

PURPOSE: To compare anatomic, radiographic, and computed tomographic (CT) measurements of the proximal femur in an Indian population. METHODS: 26 left and 24 right dried cadaveric femurs were obtained. Each femur was divided into segments at 10 cross-sectional levels from proximal to distal. At each level, anteroposterior (AP), lateral, 45-degree internal oblique, and 45-degree external oblique diameters of the medullary canal were measured using radiography and CT. To minimise magnification, the femur was placed over the film/board. The neck shaft angle, femoral head offset, neck length, and femoral head diameter were also measured. For anatomic measurements, the cross-sections of the medullary canal at levels 3 to 10 were measured using a calliper. Anatomic measurements were compared with radiographic and CT measurements, and the distortion calculated. Correlation between the 3 modalities was calculated using the Pearson correlation coefficient. Accuracy index of the 2 diagnostic modalities was measured, based on the differences between anatomic and radiographic/CT measurements. Lower accuracy indices indicated higher accuracy. RESULTS: On AP radiographs of all femurs, the mean femoral head diameter was 45 mm, the mean neck shaft angle was 132 degrees, the mean femoral head offset was 42 mm, and the mean neck length was 63 mm. With regard to medullary canal diameters, the radiographic and CT measurements were smaller than anatomic measurements at proximal levels, but similar at distal levels. Variations between femurs and between the 4 diameters at the same level were greater at proximal levels. CONCLUSIONS: Combined use of radiography and CT is recommended for preoperative assessment of implant size, particularly in uncemented arthroplasty where an optimal fit is essential for biological fixation.

Computed tomographic pulmonary angiography: utility in acute pulmonary embolism in providing additional information and making alternative clinical diagnosis.

OBJECTIVE: To evaluate the role of computed tomographic (CT) pulmonary angiography (CT-PA) in detecting additional information that may help in making an alternative clinical diagnosis in patients referred to CT for a suspected acute pulmonary embolism (PE). MATERIALS AND METHODS: 50 patients (34 males, 16 females) in the age group of 18-72 years (mean 42.3 years), having high clinical suspicion of PE, underwent CTPA over a 2 year period. Chest x-ray, arterial blood gas (ABG) analysis, echocardiography were done in all patients. All patients underwent at least one other imaging examination besides CTPA: ventilation perfusion scan, Doppler ultrasound or compression ultrasound (for DVT). All patients were followed for 3 months after completion of the diagnostic work up at baseline. The final diagnosis was achieved by a combination of clinical, imaging, and laboratory analysis, after adequate imaging, laboratory tests, and follow up. RESULT: CTPA helped correctly identify 29 of 30 patients with PE. In the remaining 20 patients (with no evidence of PE), CT-PA provided additional information (that suggested or confirmed alternate clinical diagnosis) in 15 patients (75%): pleural effusion (n=8), mediastinal or hilar lymphadenopathy (6), pneumonia/airspace consolidation (5), atelectasis/collapse (2), aspergilloma (1), malignancy (1), and others (2). CONCLUSION: CT-PA is highly specific and sensitive for diagnosis of PE. In addition, in a majority of patients who do not have PE, it also provides important ancillary additional information and helps in making an alternative clinical diagnosis.

MDCT venography in the evaluation of inferior vena cava in Budd-Chiari syndrome.

OBJECTIVE: To assess the role of multidetector computed tomography (MDCT) venography in the evaluation of the inferior vena cava (IVC) in Budd-Chiari syndrome (BCS), its accuracy as compared to digital subtraction venography (DSV) and the potential of this technique to replace venography for the definitive diagnosis of BCS. METHODS: Twenty-five suspected cases of BCS were prospectively enrolled in this study and underwent both MDCT venography and DSV. Two observers independently evaluated and graded both the axial and reformatted MDCT images for the presence, site, degree and length of IVC narrowing. The collateral pathways and the hepatic veins were also assessed in all cases. The degree of correlation between MDCT venography and DSV was expressed using Spearman's rank correlation coefficient (Rs). RESULTS: There was excellent correlation between MDCT venography and DSV in predicting the presence of stenosis and in grading the degree and length of IVC stenosis (Rs=0.58, p<0.05). Four patients had presence of a web within the IVC and the reconstructed MDCT venography images detected the flap of the membrane in all of them. In three cases of complete obstruction the cranial extent of the obstruction could be determined on the reconstructed MDCT venography images, while double catheter access through the femoral and jugular routes was needed to determine the same on DSV. MDCT venography was significantly more informative in depicting the presence and site of both intrahepatic and extrahepatic collaterals as compared to DSV. CONCLUSION: MDCT venography, in the present study, accurately provided information of both conventional CT and IVCgraphy, in the evaluation of the IVC in a non-invasive way. It helped overcome the shortcomings of CT in the evaluation of IVC and was better than DSV for the evaluation of collaterals, calcification and complete IVC obstruction. We suggest that CT venography can be used as a frontline investigation for the diagnosis of IVC obstruction and for planning surgery or percutaneous endovascular intervention.

Image guided percutaneous splenic interventions.

AIM: The objective of this study is to evaluate the efficacy and safety of image-guided percutaneous splenic interventions as diagnostic or therapeutic procedures. MATERIALS AND METHODS: We performed a retrospective review of our interventional records from July 2001 to June 2006. Ninety-five image-guided percutaneous splenic interventions were performed after informed consent in 89 patients: 64 men and 25 women who ranged in age from 5 months to 71 years (mean, 38.4 years) under ultrasound (n=93) or CT (n=2) guidance. The procedures performed were fine needle aspiration biopsy of focal splenic lesions (n=78) and aspiration (n=10) or percutaneous catheter drainage of a splenic abscess (n=7). RESULTS: Splenic fine needle aspiration biopsy was successful in 62 (83.78%) of 74 patients with benign lesions diagnosed in 43 (58.1%) and malignancy in 19 (25.67%) patients. The most common pathologies included tuberculosis (26 patients, 35.13%) and lymphoma (14 patients, 18.91%). Therapeutic aspiration or pigtail catheter drainage was successful in all (100%) patients. There were no major complications. CONCLUSIONS: Image-guided splenic fine needle aspiration biopsy is a safe and accurate technique that can provide a definitive diagnosis in most patients with focal lesions in the spleen. This study also suggests that image-guided percutaneous aspiration or catheter drainage of splenic abscesses is a safe and effective alternative to surgery.

A clinico-aetiological and ultrasonographic study of Peyronie's disease.

BACKGROUND: Peyronie's disease is a localised connective tissue disorder that involves the tunica albuginea of the penis. Although long recognised as an important clinical entity of the male genitalia, the aetiology of this disease has remained poorly understood. METHODS: The epidemiology and clinical presentation of Peyronie's disease during a 10-year period was evaluated. RESULTS: Forty-two men with Peyronie's disease from Chandigarh, India were reviewed retrospectively. The prevalence of Peyronie's patients was 1.97/1000 patients. Their ages ranged from 23 to 70 years. Most of them presented during the early phase of the disease. The most common presenting complaint was penile curvature in 34 (80.95%) followed by pain on erection in 28 (66.66%). History of penile trauma was revealed by four (9.52%) patients. Among the risk factors, hypercholesterolemia (60%), hypertension (33.3%) and asymptomatic hyperuricemia (28.34%) were the most common. Twenty-two patients with Peyronie's disease were studied by ultrasonography. Ultrasonogram was more accurate than clinical assessment in delineating the extent of lesions. In one-third of the patients, sonography demonstrated the plaques to be more extensive than had been detected by clinical examination. CONCLUSIONS: The clinical symptoms and signs in our study were, in general, similar to those found in the previous studies. Higher incidence of hypertension and diabetes in patients with Peyronie's disease may also be to an extent due to patients being in an older age group.

Role of tissue harmonic imaging in focal hepatic lesions: comparison with conventional sonography.

BACKGROUND: The purpose of the present study was to compare iissue harmonic imaging (THI) and conventional sonography in focal hepatic lesions. METHODS: Fifty patients with focal hepatic lesions were enrolled for study. Conventional grayscale and THI was performed in all the patients and two sets of images of the lesions were recorded (one each for THI and conventional) and assessed for fluid-solid differentiation, detail and overall image quality. These images were compared with conventional sonographic images and graded better, same or worse as per the case. Lesions were confirmed by fine-needle aspiration cytology (FNAC)/surgery/other modalities such as computed tomography (CT) or magnetic resonance imaging (MRI). RESULTS: Out of 50 patients with focal hepatic lesions, 21 patients had metastatic lesions (two single; 19 multiple) five patients had hepatocellular carcinoma (HCC), five patients had hydatid cysts, nine had simple hepatic cyst whereas five patients had liver abscess, three had focal fatty infiltration; and lymphoma and hemangioma were seen in one patient each. The first observer ranked THI better than standard sonography in 40 patients (80%) for fluid-solid differentiation, in 38 (76%) for detail and in 39 (78%) for overall image quality. The second observer ranked THI better than standard sonography in 39 patients (78%) for fluid-solid differentiation, in 40 (80%) for detail and in 42 (84%) for overall image quality. Tissue harmonic imaging provided additional information in eight patients (16%) and resulted in treatment alteration in three patients (6%). CONCLUSION: Tissue harmonic imaging was significantly better than conventional sonography for fluid-solid differentiation, detail and total image quality in focal hepatic lesions, especially in obese patients and patients with poor acoustic window.

Inflammatory pseudotumor of gall bladder fossa of liver.

Inflammatory pseudotumor has been described in the lung, liver and other sites, but pseudotumors of the gall bladder fossa have not been reported earlier. We report a 39-year-old woman with inflammatory pseudotumor of the liver in the gall bladder fossa that resembled carcinoma gall bladder.

Ultrasound-guided percutaneous catheter drainage of splenic abscess.

Splenic abscess is an uncommon clinical condition which is usually treated with splenectomy with its attendant risks. Image-guided percutaneous drainage of splenic abscesses has been described in adults. The case of a 12-year-old boy with a splenic abscess who was successfully treated with ultrasound-guided percutaneous catheter drainage is presented. Image-guided percutaneous drainage in children can be a safe and effective alternative to surgery.

Pulmonary and hematological alterations in idiopathic ulcerative colitis.

BACKGROUND: Patients with idiopathic ulcerative colitis (IUC) may suffer from one or more extraintestinal manifestations. We decided to prospectively study the prevalence of extraintestinal manifestations among patients with IUC, with special reference to pulmonary and hematological alterations. METHODS: Fifty-one consecutive patients with IUC attending the gastroenterology services of our tertiary-care referral center were evaluated prospectively. A detailed clinical evaluation of the musculoskeletal system, eye and skin, X-ray examination of the sacroiliac joints and chest, liver function tests, coagulation profile, hemogram, pulmonary function tests (PFT) and diffusion capacity for carbon monoxide (DLCO) were done in all patients. ERCP, liver biopsy and high-resolution computerized tomography (HRCT) of the chest were performed whenever indicated. RESULTS: Nearly half (24/51; 47%) the patients had one or more extraintestinal manifestations; these included pulmonary function abnormalities (14 patients; 27%), sacroiliitis (8; 16%), arthritis (5; 10%), ocular complications (4; 8%), and pyoderma gangrenosum and Budd-Chiari syndrome (one patient each). Of the 14 (27%) patients who had abnormal pulmonary function, isolated PFT abnormalities were seen in 8 (restrictive pattern in 7, obstructive pattern in 1), decreased DLCO in four, and both of the above in two. All patients with decreased DLCO (n=6) were asymptomatic and had normal chest X-ray and HRCT chest. Thirteen (25%) patients had thrombocytosis, 19 (37%) had increased fibrinogen level, and one patient had decreased antithrombin level. Disease activity had significant association with decreased DLCO (p=0.008), increased platelet count (p<0.0001), increased fibrinogen level (p=0.016), low antithrombin levels (p=0.046) and arthritis (p=0.002). CONCLUSION: Extraintestinal manifestations of IUC were seen in 47% of patients. Asymptomatic pulmonary interstitial involvement was seen in 12%, more often among patients with active disease.

Role of sonography in the diagnosis of gallbladder perforation.

PURPOSE: Gallbladder perforation is a dreaded complication of acute cholecystitis that is associated with a high mortality rate. Early detection of gallbladder perforation reduces the associated mortality and morbidity rates. The purpose of this study was to highlight the role of sonography in the diagnosis of gallbladder perforation and to compare the diagnostic accuracy of sonography with that of CT. METHODS: We retrospectively evaluated the sonographic and CT findings in surgically proven cases of gallbladder perforation. RESULTS: In 18 of 23 cases, both sonography and CT had been performed; in the other 5 cases, only sonography had been performed. Sonography helped to diagnose the defect in the gallbladder wall and gallbladder perforation in 16 (70%) of 23 patients. In the 18 cases in which both sonography and CT had been performed, sonography showed the wall defect in 11 cases (61%), whereas CT was diagnostic in 14 cases (78%). The difference between sonography and CT in the ability to visualize a defect in the gallbladder wall was not statistically significant. CONCLUSIONS: Sonography is useful for diagnosing gallbladder perforation and detecting the defect in the gallbladder wall. We believe that sonography should be the first-line imaging modality for evaluating the patients in these cases.

Emphysema in heavy smokers with normal chest radiography. Detection and quantification by HCRT.

PURPOSE: To determine the severity and extent of emphysema in heavy smokers by high-resolution CT (HRCT) and to correlate the findings with spirometric tests (STs) and symptomatology. MATERIAL AND METHODS: Fifty adult smokers with a mean age of 53 years with a smoking history of more than 30 pack years and normal chest radiographs underwent HRCT of the chest and ST (FEV1, FEV1/FVC, PEFR). Among these, 22 had symptoms of pulmonary disease and 28 were asymptomatic. Quantification of emphysema was done using a density mask program and the visual scoring method. The results were correlated with ST and symptomatology. RESULTS: 58% (29 out of 50) of the subjects had significant emphysema on HRCT. Eleven out of 15 with normal ST showed emphysema on HRCT while 2 with airflow obstruction on ST showed normal CT scores. 14% (4 out of 28) asymptomatic subjects had severe emphysema compared to 64% of symptomatic subjects. Emphysematous changes were predominantly seen in upper lung zones in 48% of the patients while in 52% it was distributed equally in both upper and lower zones. The number of pack years of smoking showed a positive correlation with CT scores. The correlation between HRCT scores and ST was statistically significant. CONCLUSION: A significant number of asymptomatic and clinically undiagnosed smokers tend to have significant emphysema. HRCT helps in early detection of disease and thus helps implementation of preventive measures.