rCBV- and ADC-based Grading of Meningiomas With Glimpse Into Emerging Molecular Diagnostics.

INTRODUCTION: This study was conducted to grade meningiomas based on relative Cerebral Blood Volume (rCBV) and Apparent Diffusion Coefficient (ADC) to help surgeons plan the approach and extent of operation as well as decide on the need of any adjuvant radio/chemo therapy. The current and evolving genomic, proteomic, and spectroscopic technologies are also discussed which can supplement the current radiologic methods and procedures in grading meningiomas. METHODS: A total of 35 patients with meningioma prospectively underwent basic MR sequences (T1W, T2W, T2W/FLAIR) in axial, sagittal and coronal planes followed by Diffusion Weighted (DW) imaging having b value of 1000 (minimum ADC values used for analysis). Then, gadobenate dimeglumine/meglumine gadoterate was administered (0.1 mmol/kg at a rate of 4 mL/s) followed by saline flush (20 mL at a rate of 4 mL/s). Next, T2*W/FFE dynamic images were acquired; dynamics showing maximum fall in intensity was used for creating rCBV and relative Cerebral Blood Flow (rCBF) maps and calculating rCBV. RESULTS: Both maximum rCBV and minimum ADC within the tumor were not significant for differentiating benign from malignant meningiomas. A cut-off maximum rCBV of 2.5 mL/100 g in peritumoral edema was 75% sensitive, 84.6% specific, and 83.3% accurate in differentiating benign from malignant meningiomas. CONCLUSION: Benign and malignant meningiomas can be differentiated based on maximum rCBV in peritumoral edema but ADC values within the tumor are insignificant in differentiating benign and malignant tumors. rCBV values within tumor, however, may be helpful in subtyping meningiomas, especially transitional and meningothelial meningiomas.

Sensitivity and specificity of CT scan in revealing skull fracture in medico-legal head injury victims.

BACKGROUND: Emergency departments rely on CT scans to manage trauma victims, especially for head injuries. Although the detection of an undisplaced fracture on a CT scan of the head without significant intracranial findings may be insignificant for a clinician, such cases are of paramount importance for medico-legal purposes because they help ascertain the nature, manner, and cause of the head injury. AIMS: The study was conducted with the objective of knowing the sensitivity and specificity of ante-mortem CT scan findings indicating the presence or absence of skull fractures. METHODS: Findings were confirmed during post-mortem examination of the subjects who had died during management but who had not had any surgical intervention. A comparative study of ante-mortem CT scan and autopsy findings with respect to fracture in traumatic head injuries was undertaken on 60 deceased individuals brought in for medico-legal post-mortem examination over a period of two years. RESULTS: Considering the autopsy findings as the gold standard, we have concluded that 14.6 per cent of the fractures were missed on CT scan findings compared to fractures found during autopsy. The sensitivity of CT scan for skull fractures was found to be 85.4 per cent and specificity was 100 per cent. Kappa was 0.787, which shows good agreement with p<0.001, which was highly significant. CONCLUSION: In developing countries, images are interpreted in the axial plane only on a CT scan of the head, which may be due to a lack of financial and human resources. For better delineation of fractures, the use of techniques like multi-detector CT with sagittal and coronal reformations should be considered in the routine interpretation of a CT scan of the head.

Conjoined twins in a spontaneous trichorionic quadruplet pregnancy: a case report.

BACKGROUND: Multifetal pregnancies are high-risk pregnancies. Coexistence of conjoint twins with multifetal pregnancies further increases the risk factor, which is already considerably high with multiple births. Assisted reproductive techniques lead to an increase in multifetal pregnancies, especially monozygotic pregnancies, which in turn lead to an increase in the rate of conjoined twins. CASE: A spontaneously achieved quadruplet pregnancy with coexisting conjoint twins has not been reported previously. We report one such case of spontaneously achieved quadruplet pregnancy with coexisting conjoined twins. CONCLUSION: Early (preferably first trimester) recognition of multifetal pregnancy, chorionicity, amnionicity and fetal malformation help in proper pregnancy management and optimizing outcome.

CT-guided FNAC of intrathoracic mass lesions--a study among 35 patients.

The present study was performed to evaluate the accuracy of CT-guided FNAC among 35 patients with intrathoracic mass lesions. It was done using 19 gauge coaxial needles. Patients were in the age group 7-77 years (mean 47.3 years, median 50 years). Maximum number of patients (60%) were in 41-70 years age group. There were 29 males (82.86%) and 6 females (17.14%).Total number of biopsies done were 40 in 35 patients; one attempt in 31 patients (88.57%), two attempts in 3 patients (8.57%) and three in 1 patient (2.86%). Only 2 patients (5.7%) had pneumothorax as a complication of FNAC. A correct diagnosis could be made in 31 patients amounting to an accuracy of 88.57%. Accuracy with respect to the number of biopsies was 77.5% (31/40). There were 28/35 patients (80%) with malignancies, and only 3/35 with benign inflammatory lesions. Average depth of the lesion ranged from 20-80 mm (mean 48mm). Average diameter of the lesions in this study ranged from 7 mm-8 cm (mean 4.7cm). Diagnostic accuracy for 7/35 small lesions < 1.5 cm was 85.7%, for 15/35 medium sized lesions (> or =1.5 cm - <3 cm) was 93.33% and for 13/35 large lesions (> or = 3 cm) was 84.6%. CT-guided FNAC is accurate, safe and minimally invasive procedure for diagnosis of intrathoracic mass lesions.

Meniscal ossicle.

Meniscal ossicle, or bone within the substance of meniscus, is a rare entity and commonly confused with a loose body both clinically and radiologically. MRI is the modality that can definitely diagnose meniscal ossicle and avoid unnecessary diagnostic arthroscopy. Here we report one such case diagnosed using MRI; this patient is doing well without surgery one year after diagnosis.

Lipoma of Guyon's canal causing ulnar neuropathy.

Lipoma is a benign soft tissue tumor which rarely causes neuropathy. In closed compartments such as Guyon's canal, even small volume loss can lead to compression of nerve. Hence in such areas, even innocuous tumors such as lipomas can cause neuropathy and warrant surgery. We present one such case of ulnar neuropathy caused by lipoma of Guyon's canal.

Profile of compressive myelopathy as evaluated by magnetic resonance imaging.

To evaluate spectrum of diseases causing compressive myelopathy and accuracy of magnetic resonance imaging in diagnosing these conditions, a total of 69 clinically diagnosed cases of compressive myelopathy were evaluated by magnetic resonance imaging and results were tabulated. Caries spine was the commonest condition (24.6%) followed by metastasis spine (17.4%), ossified posterior longitudinal ligament (7.8%), primary bone tumours, nerve sheath tumours, intramedullary tumours and rare conditions like epidural abscess, spontaneous epidural haematoma, subdural haematoma, epidural lipomatosis, etc. Sensitivity, specificity and accuracy for diagnosing caries by magnetic resonance imaging was found to be 94%, 98% and 97% while that of metastasis spine was 91%, 98% and 97% respectively. Magnetic resonance imaging is the modality of choice for diagnosing compressive myelopathy.

Evaluation of myelography and computed tomography in clinically diagnosed patients of lumbar disc herniation.

Forty patients with dinical diagnosis of lumbar disc herniation were evaluated with myelography and CT scan. Myelography diagnosed lumbar disc hemiation at 59 levels in 40 patients, while CT diagnosed disc hemiation at 64 levels. Lumbar disc hemiation was confirmed peroperatively in 30 out of 40 patients at 48 levels. Myelography correctly diagnosed 43 levels out of 48 levels and thus had a sensitivity of 89.6 per cent. CT diagnosed all the 48 levels correctly with a sensitivity of 100 per cent. Thus CT is super to conventional myelography in the diagnosis of lumbar disc herniation. However, conventional myelography supplements CT examination by limiting the number of scans to the level of interest and thus reduces radiation exposure.

Oesophageal foreign body in four month old infant.

A 4 month old male infant was brought with only strong suspicion of foreign body ingestion without any symptomatology. X-ray examination revealed foreign body at cricopharyngeus, which was managed successfully emphasizing the fact that a strong suspicion and relevant radiography is the key to early and successful management.

A profile of renal/renovascular abnormalities in patients of hypertension.

After a thorough dinical examination and laboratory investigations, ultrasonography (USG) followed by minute sequence urography (MSU) and aortography and/or selective renal angiography were done in 108 patients, clinically suspected of having renal hypertension of which 32 patients (29.6%) were found to be positive for renal/renovascular disease. Out of 82 patients, who were only young hypertensives, a definite diagnosis of renal/renovascular disease could be made in only 15 cases (18.3%), whereas the pick up rate increased to 65.4% in the rest of the 26 patients who had some other clinical criteria besides hypertension and it further increased up to 92.3% (out of these 26 patients) who had 2 or more than 2 clinical criteria of selection of patients besides hypertension. USG was useful in diagnosing renal parenchymal disease/ suggesting renal abnormalities in 30 cases and MSU was able to detect renal changes in 31 patients. Aortography and/or selective renal angiography could make a definite diagnosis of renovascular disease in 17 cases and renal agenesis in one case.

Gallstone expectoration following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the treatment of choice for uncomplicated gallstone disease. Laparoscopic cholecystectomy may result in lost (spilled) gallstones. Such stones may precipitate various infective intra-abdominal complications. An unusual case of spilled gallstones eroding the diaphragm and eventually being expectorated out 12 months after laparoscopic cholecystectomy is reported.