Narayanam R. S. Surendrababu

Variations in the cerebral venous anatomy and pitfalls in the diagnosis of cerebral venous sinus thrombosis: Low field MR experience

BACKGROUND Knowledge of variations in the cerebral venous anatomy and apparent signal abnormalities seen on Magnetic resonance (MR) angiography are essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST), while interpreting the MR angiograms. AIMS To evaluate the variations of cerebral venous anatomy and signal abnormalities by using 3D phase contrast MR angiography performed in a 0.5 Tesla MRI scanner. MATERIALS AND METHODS One hundred patients who underwent MR imaging and MR angiography examinations at our institution from March 2004 to February 2005, with normal MR imaging of brain were studied retrospectively. Patients with clinical suspicion of CVST and patients who underwent color doppler evaluation for suspected deep vein thrombosis were excluded. RESULTS The superior sagittal, straight sinus and the internal cerebral veins were visualized in all patients. There was hypoplasia of the right transverse sinus in 13 patients, left transverse sinus in 35 patients, right sigmoid sinus in 6 patients and left sigmoid sinus in 19 patients. Absence of transverse sinus on left side was observed in one patient and absence of sigmoid sinus in 2 patients on left side. Flow gaps were observed in non-dominant transverse sinus, sigmoid sinus as well as transverse sigmoid sinus junctions. The occipital sinus was visualized in 17 patients. CONCLUSIONS MR angiography done at low field strengths is also a reliable method, for assessing cerebral venous sinuses. Awareness of the normal anatomical variations of venous sinuses and apparent MR angiographic flow gaps prevent misdiagnosis of cerebral venous sinus thrombosis.

Large retroperitoneal schwannoma mimicking a cystic ovarian mass in a patient with Hansen's disease

We present a rare case of retroperitoneal cystic schwannoma of the pelvis in a patient with Hansens disease that mimicked an ovarian cyst. Due to economic constraints and because the lesion was assumed to be of ovarian origin, the patient did not undergo any cross‐sectional imaging other than sonography. Sonographically guided fine needle aspiration of the cystic lesion was inconclusive. A cystic schwannoma was diagnosed at laparotomy.

Breast filariasis: real-time sonographic imaging of the filarial dance.

A 50‐year‐old woman presented with a palpable tender nodule in the upper quadrant of the breast that was clinically thought to be a fibroadenoma, with mammographic findings of a well‐defined lobulated density. Sonographic examination revealed a “filarial dance sign” within the cystic lesion, which is diagnostic of lymphatic breast filariasis. In endemic areas, sonographic examination is recommended to search for this pathognomonic real‐time diagnostic feature and, if present, to initiate treatment without delay.

Measurement of hepatic venous pressure gradient revisited: Catheter wedge vs balloon wedge techniques

Aims: To evaluate the accuracy of measurement of hepatic venous pressure gradient by catheter wedge as compared to balloon wedge (the gold standard). Materials and Methods: Forty-five patients having a clinical diagnosis of intrahepatic portal hypertension were subjected to the two different types of pressure measurements (catheter wedge and balloon wedge) during transjugular liver biopsy under fluoroscopic guidance. Statistical Analysis: Spearmans rank correlation coefficient, Bland–Altman plot for agreement, and single measure intraclass correlation were used for analysis of data. Results: There was a close correlation between the results obtained by both the techniques, with highly significant concordance (P < 0.0001). Hepatic venous pressure gradients as measured by the catheter wedge technique were either equal to or less than those obtained by the balloon wedge technique. Conclusions: The difference in hepatic venous pressure gradients measured by the two techniques is insignificant.

Cannula-Assisted and Transabdominal Ultrasound-Guided Hepatic Venous Recanalization in Budd Chiari Syndrome: A Novel Technique to Avoid Percutaneous Transabdominal Access

We describe a technique for facilitating recanalization of hepatic veins via the transjugular approach in patients with Budd Chiari syndrome, where a transjugular liver biopsy cannula provides support to the catheter–glidewire combination and transabdominal ultrasound helps in positioning the tip of the cannula at the hepatic venous ostium.

Budd-Chiari Syndrome Complicating Hydatid Cyst of the Liver Managed by Venoplasty and Stenting

Budd-Chiari syndrome (BCS) and portal hypertension is an uncommon complication of hydatid cyst of the liver. Previous reports describe cyst excision or portosystemic shunt surgery for such patients. Here we present a case of hydatid cyst of the liver with BCS that was treated successfully with hepatic venoplasty and transjugular stent placement.

Endovascular management of posttraumatic arteriovenous fistulae.

Surgery is considered to be the treatment of choice for vascular injuries caused by trauma. However, endovascular techniques are emerging as an alternative means of treatment. In this article, we describe three patients with posttraumatic arteriovenous fistulae in different body regions that were managed using endovascular techniques. Each case had its unique set of associated problems requiring innovative methods and a multidisciplinary approach. While the short-term results are encouraging, long-term follow-up of posttraumatic arteriovenous fistulae that have been treated with endovascular techniques is still required.

Primary hepatic leiomyosarcoma in an infant

A 1-year-old boy presented with fever, right upper quadrant pain and vomiting for 15 days. US showed a large cystic lesion in the right lobe of the liver with multiple thick septations and few internal echoes, with no color flow on Doppler (Fig. 1). Abdominal CT revealed a hypodense lesion with enhancing thick septa (Fig. 2). There was no lymphadenopathy or other lesions. Serum alpha fetoprotein and carcinoembryonic antigen were normal. Tests for HIV and [HBsAg] were negative. Excision biopsy confirmed leiomyosarcoma. Leiomyosarcoma is a malignant mesenchymal tumor of myogenic origin. Primary hepatic leiomyosarcoma is rare in children. Isolated case reports have been associated with AIDS and EBV [1]. Most hepatic sarcomas lack specific imaging characteristics. Hepatic leiomyosarcoma tends to metastasize hematogenously to the lung, but lymphatic metastasis and peritoneal seeding have been described. The lesions are homogeneous or heterogeneous low-density masses on CT with no enhancement [2]. Differential diagnoses include hepatoblastoma, hepatocellular carcinoma, infantile hemangioendothelioma, undifferentiated embryonal sarcoma, mesenchymal hamartoma, and infected hydatid cyst. Prognosis is poor.

Ethanol sclerotherapy for treatment of venous malformations of face and neck— a single centre experience

Due to complicated anatomy of the face and neck, complete surgical excision of venous malformation is rarely possible and may lead to bleeding, nerve damage and cosmetic deformity. Sclerotherapy is an alternative method of treatment with few complications. Ethanol shows the lowest rate of malformation recurrence and is the most reliable substance of all of the sclerosing agents. This study aims to evaluate the efficacy of ethanol instillation in venous malformation of the face and neck. Between July 20, 2008, to December 30, 2009, 15 patients with venous malformation of the face and neck were included in the study. After confirmation of diagnosis (combination of history, physical findings and magnetic resonance imaging), percutaneous ethanol (99.5% ethyl alcohol) sclerotherapy was used under DSA road mapping using general anaesthesia. Sclerotherapy provided significant improvement of symptoms for all patients, with no major complications. All patients experienced pain and swelling to a variable degree in the immediate post procedure period that resolved over few days. Ethanol sclerotherapy for venous malformations of the face and neck is a safe and effective treatment option.

Development and Dysmorphism in Joubert Syndrome—Short Case Series from India

Five children with Joubert syndrome (JS), who fulfilled the criteria and had molar tooth sign (MTS) on magnetic resonance imaging were included in the study. Prominent forehead, open mouth and low set ears were consistent facial features. Severe developmental delay was seen in three children (66%). A differential developmental delay was noticed in all children and was independent of the radiological features. The children who had complications in the neonatal period were found to have more developmental delay on follow-up. The optimal control of sleep disturbances and hyperkinesis in one child resulted in a better cognitive performance. A regular neuro-developmental follow-up and interventions can optimize the potential of children with JS. In addition to the regular screening for retinal, renal and hepatic functions in JS, there is a need to monitor cognitive functions, sleep and behavior.