Kusum Hooda

Transarterial Therapies for Hepatocellular Carcinoma: a Comprehensive Review with Current Updates and Future Directions.

Hepatocellular cancer is a very common cause of cancer related deaths worldwide. Only 30-40% of patients present with early-stage disease open to curative treatments, such as resection or transplantation, while others can only undergo local therapies or palliative care. Various trans-arterial approaches have been used for treatment of hepatocellular carcinoma in patients who need a down-staging to liver transplantation, and who are not candidates for transplantation or radiofrequency ablation. Transarterial chemoembolization (TACE), transarterial embolization (TAE), drug-eluting beads, and radioembolization have been used for locoregional control, and have been shown to prolong the overall survival when compared with supportive care. In this review, we discuss patient selection, pre- and post-procedure imaging, techniques, safety, and clinical outcomes related to these therapies. Newer advances with future directions in various fields related to trans-arterial therapies are also discussed.

Neonatal cranial sonography: ultrasound findings in neonatal meningitis—a pictorial review

Neonatal bacterial meningitis is a common manifestation of late onset neonatal sepsis. Cranial sonography (CRS) has a crucial role in assessment of infants with clinical suspicion of bacterial meningitis as well as follows up of its complications. CRS is performed with high frequency transducer through anterior fontanelle in both coronal and sagittal planes. Various sonographic findings range from echogenic and widened sulci, ventriculomegaly, ventriculitis, hydrocephalus, extra-axial fluid collections, cerebritis and brain abscess. Sonography is extremely beneficial in evaluating intraventricular contents, especially debris and intraventricular septations. Linear high frequency probe along with color Doppler interrogation are of utmost importance in evaluating extra-axial fluid collection and helps differentiating it from benign subarachnoid space enlargement. Due to low cost, easy portability, speed of imaging, no need for sedation and above all lack of ionizing radiation make it superior to other cross sectional imaging, like CT and MRI, in evaluation of these sick neonates. Apart from textbooks, there is paucity of recently available literature on cranial sonographic findings in neonatal meningitis. This article is written with an educational intent to review the spectrum of findings in neonatal meningitis, with stress on findings that will be beneficial in the clinical practice.

Toxins in Brain! Magnetic Resonance (MR) Imaging of Toxic Leukoencephalopathy – A Pictorial Essay

Summary Toxic leukoencephalopathy results from damage to the white matter caused by various toxins. It manifests itself as white matter signal abnormalities with or without the presence of restricted diffusion. These changes are often reversible if the insulting agent is removed early, with the exception of posthypoxic leukoencephalopathy that can manifest itself 1–2 weeks after the initial insult. However, many other potential causes of white matter signal abnormalities can mimic the changes of toxic leukoencephalopathy. Thus, familiarity with the causes, clinical presentation and particularly imaging findings of toxic leukoencephalopathy is critical for early treatment and improved prognosis. The purpose of this pictorial essay is to familiarize the reader with the various causes of toxic leukoencephalopathy along with its differential diagnoses and mimics.

Caudal Regression Syndrome: A Case Series of a Rare Congenital Anomaly

Summary Background Caudal regression syndrome is a rare, neural tube defect characterized by an abnormal development of the caudal aspect of the vertebral column and the spinal cord., It results in neurological deficits ranging from bladder and bowel involvement to severe sensory and motor deficits in the lower limbs. Maternal diabetes, genetic factors and some teratogens have been shown to be associated with its pathogenesis. Caudal regression syndrome is usually diagnosed initially by antenatal ultrasound with more definitive diagnosis made by antenatal or postnatal MRI. In this case series, we report four cases of caudal regression syndrome in different age groups including prenatal, infant and adult. Case Report We are presenting multimodal imaging findings of 4 cases of caudal regression syndrome in 4 different age groups including fetus, infant, early childhood and adult. The pathogenesis, associated risk factors, complications, treatment options and prognosis of caudal regression syndrome are discussed as well. Conclusions Caudal regression syndrome is a rare entity, characterized by sacrococcygeal dysgenesis with an abrupt termination of a blunt-ending spinal cord. Ultrasound and fetal MRI can be used to make a prenatal diagnosis, while MRI is the imaging modality of choice in adults. Early detection and prompt treatment is very important to decrease the risk of complications, and thus, to improve the prognosis.

Poland Syndrome with Ipsilateral Hypoplasia of Gluteal Muscles and Contralateral Hidradenitis Suppurativa

Summary Background Poland syndrome (PS) is a rare congenital anomaly associated with absent or hypoplastic pectoralis major muscle and a wide spectrum of ipsilateral thoracic and upper extremity deformities. Hidradenitis suppurativa (HS) is a recurrent inflammatory follicular disease that commonly affects the apocrine-bearing skin and involves follicular occlusion and hyperkeratosis. Case Report We report a case of a 46-year-old male with a history of chronic recurrent hidradenitis suppurativa who was incidentally found to have a simple type of Poland syndrome with incidental hypoplasia of ipsilateral gluteal muscles. Conclusions Not only can PS present with HS, which we describe for the first time, but it is also associated with a wide variability of symptoms such as previously unknown co-existence of gluteal muscles hypoplasia.

Some Mushrooms are Hard to Digest: Gastrostomy Tube Exchange

Summary Background Percutaneous endoscopic gastrostomy (PEG) is an effective and safe mode of enteral nutrition for patients needing chronic enteric nutritional support. Exchanging PEG tubes may result in complications due to inexperience as well as due to lack of protocol. Case Report We encountered a 73 year-old female with unnoticed, accidently detached portion of the internal bumper of a PEG tube in the gastric lumen after a challenging gastrostomy tube exchange. Conclusions This case report discusses the complications associated with gastrostomy tube exchange and proposes a planned protocol for successful gastrostomy tube exchange.

Paraneoplastic limbic encephalitis in a patient with rectal adenocarcinoma: A rare entity

Introduction: Paraneoplastic neurological syndromes are defined as remote effects of cancer, not caused by the tumor and its metastasis, or by metabolic disruptions or ischemia. Paraneoplastic limbic encephalitis (PLE) is one of them, and commonly have been described in patients with lung or breast cancer. Colon and rectal cancers have also been shown to be associated with PLE as in our case. Case Report: We report a case of 56-year-old male who had been diagnosed with adenocarcinoma of the rectum one year ago. He initially responded well to systemic chemotherapy, resulting in symptomatic relief related to the primary disease. However, one year after the initial diagnosis, the patient presented with recurrent seizures and disorientation for few days. Magnetic resonance imaging (MRI) scan of the brain was performed which demonstrated findings of PLE. Serum analysis revealed a high titer of anti-Ri, an antibody shown to be associated with paraneoplastic Kusum Hooda1, Nishant Gupta2, Charu Chanana3, Pranav Sharma1, Salil Sharma1, Joshua Sapire4 Affiliations: 1Resident, Diagnostic Radiology, Yale New Haven Health System at Bridgeport Hospital, Bridgeport, CT, USA; 2Resident, Diagnostic Radiology, St. Vincent Medical Center, Bridgeport, CT, USA, Bridgeport, CT, USA; 3Attending Obstetrician and Gynecologist, Bassett Healthcare Network, Cooperstown, NY USA; 4Clinical Assistant Instructor in Diagnostic Radiology, Yale New Haven Health System at Bridgeport Hospital. Corresponding Author: Kusum Hooda, 267 Grant Street, Deptt of Diagnostic Radiology, Bridgeport, CT, USA 06610; E-mail: kusumhooda78@gmail.com Received: 02 October 2016 Accepted: 24 November 2016 Published: 17 January 2017 PEER REVIEWED | OPEN A CE S neurologic syndromes. The patient’s symptoms improved markedly after treatment with antiepileptic therapy (phenobarbital) and methylprednisolone. After two months followup MRI scan showed complete resolution of the abnormalities. Conclusion: Paraneoplastic limbic encephalitis can complicate the patient’s clinical course, response to treatment and affect the prognosis. In a patient with non-neurological malignancy presenting with new neurologic problems PLE should always be kept in the differential diagnosis. The characteristic MRI findings of these syndromes are very helpful in early diagnosis and excluding other causes.

Think outside the breast: Emergencies can present on screening mammogram!

A 53-year-old-female presented for annual screening mammogram. The technologist saw “something unusual” on the mammograms and asked the patient to wait; however, the patient was feeling uneasy and wanted to leave. Radiologist immediately looked at the screening mammogram, which revealed a few linear and curvilinear lucencies in the left axillary region (Figure 1). On physical examination, crepitus was palpated in bilateral axillary regions, chest wall and neck compatible with subcutaneous emphysema. Promptly frontal and lateral chest radiographs were obtained, which confirmed subcutaneous emphysema and unfolded the underlying mild pneumothorax and pneumomediastinum. The patient was transferred to the emergency department and a CT scan of the chest was performed. CT confirmed findings of bilateral mild pneumothorax, and better delineated pneumomediastinum and subcutaneous emphysema. The patient was admitted to ICU for further evaluation, which demonstrated interstitial lung with extensive lung fibrosis (Figure 2). This case highlights mammographic signs of air in the breast pneumomastia, which was due to extension of pneumothorax in this patient with chronic interstitial lung disease. Pneumomastia is frequently seen in postbreast biopsy mammograms for confirming the clip placement; however, we never think about the mammographic appearance of subcutaneous emphysema in the patient with

Comparison between MR Perfusion and 18F-FDG PET in Differentiating Tumor Recurrence from Nonneoplastic Contrast-enhancing Tissue

Objective: Comparison of the accuracy of MR perfusion and 18-FDG-PET for differentiating tumor progression from nonneoplastic contrast-enhancing tissue. Methods and Materials: Retrospective review of MR perfusion and 18-FDG-PET in 23 cases of primary brain tumors (17 high grade and 6 low grade glial neoplasms) and 5 cases of metastatic lesions with enhancing lesions on post-treatment MRI was performed. The accuracy of MR perfusion versus 18-FDG-PET for distinguishing between nonneoplastic contrast-enhancing tissue and tumor recurrence was assessed. Results: Both CBV (p<0.004) and SUV (p<0.02) are higher in recurrent tumors than necrosis. MR perfusion has an accuracy of 94.5% for differentiating between tumor recurrence and necrosis, while 18-FDG-PET has an accuracy of 85.1% for differentiating between tumor recurrence and nonneoplastic contrast-enhancing tissue. Conclusion: Overall, recurrent tumor demonstrates significantly higher CBV and SUV than nonneoplastic contrast-enhancing tissue. However, MR perfusion appears to be more accurate than FDG PET for distinguishing the two entities.