Mukul Sinha

Variations of celiac axis, common hepatic artery and its branches in 600 patients

Purpose: To evaluate the spectrum of celiac axis, common hepatic artery (CHA), right, left, middle hepatic artery and gastroduodenal artery variations by using spiral computed tomography (CT). Materials and Methods: A retrospective review of Multidetector CT (MDCT) abdominal angiography scans was performed in patients sent for various liver and other abdominal pathologies between January 2012 and February 2013. A total of 600 patients were evaluated. Definitions of CHA, ambiguous celiac axis, course and division patterns of CHA, replaced hepatic artery, accessory hepatic artery and middle hepatic artery were used as proposed by Song et al., Covey et al., and Wang et al. The pattern of the aortic origin of branches of celiac axis, common hepatic artery and its branches was analyzed. Results: Six types of celiac axis anatomic variations were identified in our study. A total of 546 of the 600 patients had a normal celiac axis anatomy. Anatomic variations were seen in 5.5% of patients. Ambiguous anatomy was seen in 3.5% of the patients. CHA originated from celiac axis in 95.83% of the patients. Variations in anatomic origin of CHA were seen in 8 patients. Ambiguous dual pathway was seen in 4 patients. Normal Sp-preportal course of CHA was identified in 97.78% of cases, Sp-retroportal course in 7 patients, Tp-preportal course in 2, Tp-retroportal in 1, Ip-preportal in 1 and through Ligamentum venosum in 2 patients. Normal origin of RHA from HAP was seen in 79.6% patients. Replaced origin of RHA was seen in 15.16% cases and Accessory origin of RHA was seen in 5.16% cases. LHA originated from HAP in 81.5% patients. Replaced LHA origin was seen in 10.8% cases and Accessory LHA origin seen in 7.6% cases. MHA originated from RHA in 41.3% patients, LHA in 27.83% and from CHA in 4.5% cases. Origin of MHA could not be defined in 26.3% of patients. GDA originated from CHA in 97.6% of patients, from celiac axis in 1.6%, from RHA in 0.33% in patients. Trifurcation of CHA was seen in 7.16% and quadrifurcation of CHA in 2.16%. Conclusion: CT Angiography is a safe and highly sensitive and accurate modality for evaluation of arterial anatomy and its variants.

Radiological review of pleural tumors

Tumors of the pleura are not uncommon and diagnosis is clinched by combined imaging and clinical correlation. Malignant tumors are more common than benign tumors. Initial imaging modalities are chest radiography and Computed Tomography (CT). Further characterization may be required using Ultrasoundgraphy (USG), Magnetic resonance Imaging (MRI) and PET-CT. Biopsy remains gold standard. This article highlights various common and uncommon tumors of pleura and characteristic imaging findings.

Supernumerary kidneys- a rare anatomic variant

Supernumerary kidneys are a rare congenital anomaly with fewer than 100 cases reported over the years. A fused supernumerary kidney is a still rarer entity. We present imaging findings in two cases of supernumerary kidneys—the first case is a spectacular image of four kidneys in one patient seen in an excretory phase of intravenous urogram with only four cases described in the literature. The second case is that of three kidneys (fused supernumerary) seen in another patient.

Imaging spectrum of gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) were first described by Clark and Mazur in 1983 for smooth muscle neoplasms of the gastrointestinal tract differentiating them from leiomyoma, leiomyosarcomas and neurogenic tumors. GISTs can arise from the bowel, peritoneum, omentum or retroperitoneum. This article reviews the computed tomography imaging features of primary GISTs, response to treatment and highlights data on predicting the outcome to chemotherapeutic drugs on imaging.

Melorheostosis: Two atypical cases.

Melorheostosis is an uncommon mesenchymal dysplasia that rarely affects the axial skeleton. We describe two atypical cases of melorheostosis with classical imaging findings – the first one involving the cervico-dorsal spine with encroachment of left vertebral artery canal causing attenuation of the left vertebral artery and the second one of mixed sclerosing bony dysplasia (monomelic involvement coexisting with osteopoikilosis).

What clinician's need to know about imaging features in lung cancer?

Bronchogenic carcinoma is one of the most common cancers both in males and females worldwide. Lung malignancies can present with manifestations involving any organ system and also mimic like benign nodules or infective consolidation. Present review highlights spectrum of typical presentations and imaging features of lung malignancies.

Morphometric analysis of cervical spinal canal diameter, transverse foramen, and pedicle width using computed tomography in Indian population

Background: Accurate and detailed measurements of spinal canal diameter (SCD) and transverse foraminal morphometry are essential for understanding spinal column-related diseases and for surgical planning, especially for transpedicular screw fixation. This is especially because lateral cervical radiographs do not provide accurate measurements. Aim: This study was conducted to measure the dimensions of the transverse foramen sagittal and transverse diameters (SFD, TFD), SCD, and the distance of spinal canal from the transverse foramina (dSC-TF) at C1–C7 level in the Indian population. Materials and Methods: The study population comprised 84 male and 42 female subjects. The mean age of the study group was 44.63 years (range, 19–81 years). A retrospective study was conducted, and data were collected and analyzed for patients who underwent cervical spine computed tomography (CT) imaging for various reasons. Results: One hundred and twenty-six patients were included in the study. Detailed readings were taken at all levels from C1–C7 for SCD, SFD, TFD, and dSc-TF. Values for male and female subjects were separately calculated and compared. For both the groups, the widest SCD were measured at the C1 level and the narrowest SCD at the C4 level. The narrowest SFD was measured at C7 for both male and female subjects on the right and left sides. The widest SFD was measured at C1 both for male and female subjects on the right and left side. The narrowest TFD on the left side was measured at C7 for male and at C1 for female subjects. The narrowest mean distance of dSC-TF was found to be at C4 for both male and female subjects on both left and right side. Conclusion: The computed tomographic (CT) imaging is better than conventional radiographs for the preoperative evaluation of cervical spine and for better understanding cervical spine morphometry. Care must be taken during transpedicular screw fixation, especially in female subjects, more so at the C2, C4, and C6 levels due to a decrease in the distance of dSC-TF.

Unusual imaging presentation of infantile atypical Kawasaki disease

Kawasaki disease is a systemic medium vessel vasculitis of unknown etiology affecting children under 5 years of age. There are no specific diagnostic tests, and thus, the diagnosis of the disease is primarily made on the basis of clinical criteria. Unusual presentations of Kawasaki disease have been variably reported from different parts of the world. However, presentation of the disease in the form of peripheral thromboembolism and florid non-coronary aneurysms has rarely been described This report describes the imaging findings in infantile atypical Kawasaki disease with aneurysms of multiple medium-sized arteries, including coronary arteries, emphasizing the detection of clinically silent aneurysms in the disease.

Imaging spectrum of neurofibromatosis

Neurofibromatosis (NF) belongs to the group of phakomatoses characterized by benign tumors of peripheral nerves seen either due to spontaneous new mutations or due to genetic inheritance. It affects 1:2500-3000 individuals. These tumors are known as neurofibromas and can be localized, the diffuse or plexiform type. There are at least eight subtypes of NF (NF-1-NF-8). Among these, von Recklinghausen′s disease (NF-1), NF with bilateral acoustic schwannomas (NF-2) and segmental NF important both clinically and radiologically.

Celiacomesenteric trunk: a short report.

We read with great interest the article on celiacomesenteric trunk by Bhatnagar et al. [1] published online in the April 2013 issue of the Surgical and Radiologic Anatomy. We wish to supplement our experience with this anatomic variation involving the celiac trunk. Recently, we have conducted a study on variation of celiac axis and hepatic arteries in 600 patients. Approval for the study was obtained from the ethical board of the Institution. Multidetector CT (MDCT) scans were obtained after injecting a maximum of 120 mL of nonionic iodinated contrast material (iodine concentration, 370 mg/mL) through an 18to 20-gauge antecubital intravenous cannula at a rate of 5–7 mL/s and the images acquired in Philips Brilliance 40-slice MDCT scan machine using angiography protocol in patients sent for various liver and other abdominal pathologies in which biphasic contrast-enhanced CT was indicated. The time period of the study was from January 2012 to February 2013. A total of 600 patients were evaluated in this retrospective study. The study population comprised 413 men and 187 women (mean age 39.8 years). We excluded patients with a history of major upper abdominal surgery. The images were analyzed independently by three radiologists Radiologist 1 (B.S.—M.D., DNB) with 5 years, Radiologist 2 (M.S.—M.D.) with 20 years and Radiologist 3 (M.K.M.—M.D., FICR) with 24 years of experience in interpreting CT scans in the concerned field. We encountered normal celiac axis in 546 patients, variant celiac axis anatomy in 33 patients and ambiguous celiac axis in 21 patients. Out of the 33 cases of variant celiac axis anatomy, we encountered celiacomesenteric trunk (CM trunk) in four of patients. Other variants which we came across are common hepatosplenic trunk and left gastric artery arising separately from the aorta in 17, gastrosplenic trunk and common hepatic artery arising separately from aorta in five, gastrosplenic and hepatomesenteric trunk from aorta in four, hepatomesenteric trunk, left gastric and splenic artery arising separately from aorta in two and hepatosplenomesenteric and left gastric artery from aorta in one case, respectively (Figs. 1, 2). Song et al. [3] defined ambiguous celiac axis as congenital absence of common hepatic artery (CHA) with separate origin of hepatic arteries and gastroduodenal artery or presence of a persistent anastomotic channel. Persistent anastomotic channel is smooth, straight vessel connecting celiac axis and SMA or anastomotic channel connecting CHA to the celiac axis and the SMA. Song et al. encountered CM trunk in 53 cases (1.06 %) in their study in 5,002 patients. Anatomic variation of celiac axis and SMA is of critical importance in pancreatic and hepatobiliary surgeries. It is not uncommon to find variations of hepatic arteries in patients with variations in celiac trunk. Preoperative knowledge of such variations would help surgeons to avoid extensive dissection. A small-caliber common hepatic artery often coexists with variant hepatic artery anatomy. Ishigami et al. [2] found that the diameter of the CHA was smaller in patients (mean 5.8 mm) with variant hepatic artery anatomy compared to those with classic hepatic artery anatomy (mean 6.3 mm). CHA diameter in the case discussed by Bhatnagar et al. [1] was found to be 4.8 mm which is supposed to be of reduced caliber according to B. Sureka (&) M. K. Mittal M. Sinha B. B. Thukral Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India e-mail: binitsureka@hotmail.com