Nisar Ahmad Wani

Post-cholecystectomy Mirizzi's syndrome: magnetic resonance cholangiopancreatography demonstration.

A long cystic duct remnant may be found after laparoscopic cholecystectomy. Stone may form in the remnant cystic duct and can cause postcholecystectomy syndrome. Remnant cystic duct calculus may rarely result in postcholecystectomy Mirizzi’s syndrome. Traditionally, Mirizzi’s syndrome has been diagnosed with endoscopic retrograde cholangiopancreatography (ERCP) and treated with open surgery. We report a case of postcholecystectomy Mirizzi’s syndrome that developed 3 years after laparoscopic cholecystectomy. A non-invasive diagnosis of Mirizzi’s syndrome was made comprehensively by magnetic resonance cholangiopancreatography. Endoscopic stone removal was achieved successfully with ERCP without any complication.

Parry–Romberg syndrome associated with unusual intracranial vascular malformations and Phthisis bulbi

Neurovascular anomalies of Parry-Romberg syndrome have been reported infrequently. We report a case of Parry-Romberg syndrome with hypoplastic left internal carotid, middle cerebral, anterior cerebral, posterior communicating and posterior cerebral artery. The patient presented with partial seizures, hemiparesis and phthisis bulbi.

Giant adrenal myelolipoma: Incidentaloma with a rare incidental association

Adrenal myelolipoma is an unusual, benign and biochemically inactive tumor that is composed of mature adipose and hematopoietic tissue. It is usually diagnosed accidentally and nowadays much more frequently because of widespread use of ultrasonography, computed tomography (CT) and magnetic resonance imaging. Adrenal myelolipoma is usually unilateral and asymptomatic, though known to be associated with obesity, hypertension, endocrinological disorders and some malignancies. We report herein two cases of right-sided giant adrenal myelolipoma diagnosed by multidetector-row CT. One patient was symptomatic because of a large mass in the right upper abdomen, which on imaging with CT was seen to be right adrenal myelolipoma. Another patient had a large left side Bochdalek hernia and right adrenal myelolipoma was incidentally discovered on CT.

MRI of oriental cholangiohepatitis

Oriental cholangiohepatitis (OCH) also called recurrent pyogenic cholangitis is characterized by intrahepatic duct calculi, strictures, and recurrent infections. In turn cholangitis can result in multiple hepatic abscesses, further biliary strictures, and in severe cases, progressive hepatic parenchymal destruction, cirrhosis, and portal hypertension. Magnetic resonance cholangiopancreatography (MRCP) and conventional T1-weighted (T1W) and T2-weighted (T2W) magnetic resonance imaging (MRI) findings have been described in patients with OCH. MRCP findings include duct dilation, strictures, and calculi. MRCP can help to localize the diseased ducts and determine the severity of involvement. T1 and T2W sequences reveal the parenchymal changes of atrophy, abscess formation, and portal hypertension in addition to calculi. Post-treatment changes are also well depicted using MRI. Comprehensive, non-invasive assessment is achieved by using conventional MRI and MRCP in OCH providing a roadmap for endoscopic or surgical management.

Giant cystic Virchow-Robin spaces with adjacent white matter signal alteration.

Perivascular spaces surround the small arteries and veins as they enter into the brain parenchyma from the subarachnoid spaces. Also called as Virchow-Robin spaces, these are prominent in the basal ganglia and high convexity white matter of the elderly. Occasionally VR spaces may get massively enlarged and may mimic a cystic mass lesion. The typical CSF-like signal intensity of the cysts and location on MRI, in the absence of a neurological abnormality help in the diagnosis of the giant VR spaces and thus biopsy is avoided. Typically there is no significant adjacent brain abnormality; however FLAIR images may sometimes reveal perilesional white matter hyperintensity, which may be an indication of gliosis due to the mass effect of the lesion. Such a signal alteration should not deter one from making a diagnosis of giant Virchow-Robin spaces when the rest of the imaging findings are typical. We describe a case of a 50-year-old female with incidental giant Virchow-Robin spaces in the right hemispheric subcortical white matter with adjacent white matter hyperintense signal intensity on T2-weighted and FLAIR images.

Sagittal sinus thrombosis due to L-asparaginase.

Cerebral Sinovenous Thrombosis (CSVT) is a serious complication of L-asparaginase chemotherapy for leukemia in children. Clinical features of headache, altered consciousness, focal neurological deficit, and seizures developing during or immediately after treatment with L-asparaginase should alert the treating physician to the possibility of CSVT. Immediate imaging of the brain should be done using CT and MRI and the veins should be visualized noninvasively by CT and MR venography. We report two children on induction therapy for acute leukemia who presented with seizures, headache, and altered consciousness. Venous infarcts with and without hemorrhage were seen on CT in one patient and the empty delta sign was seen after contrast injection; however, the early changes were missed by CT. MRI detected dural sinus thrombosis relatively earlier in another patient, while the CT findings were equivocal; in this patient, contrast-enhanced MRI showed the empty delta sign and MR venography confirmed absent flow in the superior sagittal sinus, which was diagnostic of sinus thrombosis. Rapid anticoagulation was started with heparin and maintained with warfarin. The child with a unilateral small nonhemorrhagic infarct made a complete recovery while the other, with bilateral hemorrhagic infarcts, did not survive. We stress the importance of early diagnosis of CSVT using CT and MRI in children with leukemia being treated with L-asparaginase; this will permit timely treatment.

Perinephric abscess caused by ruptured retrocecal appendix: MDCT demonstration.

Acute appendicitis may occasionally become extraordinarily complicated and life threatening yet difficult to diagnose. One such presentation is described in a 60-year-old man who was brought to the hospital due to right lumbar pain and fever for the last 15 days. Ultrasonography showed a right perinephric gas and fluid collection. Abdominal computed tomography with multidetector-row CT (MDCT) revealed gas-containing abscess in the right retroperitoneal region involving the perinephric space, extending from the lower pole of the right kidney up to the bare area of the liver. Inflamed retrocecal appendix was seen on thick multiplanar reformat images with its tip at the lower extent of the abscess. Laparotomy and retroperitoneal exploration were performed immediately and a large volume of foul smelling pus was drained. A ruptured retrocecal appendix was confirmed as the cause of the abscess.

Infantile Wernicke's encephalopathy

Three exclusively breastfed male infants (Case 1, 3 months; Case 2, 7 months; and Case 3, 6 months of age) presented to our emergency department with vomiting, bilateral non-fatiguable ptosis and altered sensorium in form of lethargy, excessive crying and moaning (figures 1 and 2). Ophthalmic examination in addition revealed abduction deficits. There was no nystagmus. The rest of CNS examination was unremarkable. Maternal dietary history was notable for a diet consisting of polished rice as a …

Role of electroencephalogram and neuroimaging in first onset afebrile and complex febrile seizures in children from Kashmir.

Objectives: (1) To determine the frequency of abnormal neuroimaging in children with new-onset afebrile and complex febrile seizures; (2) to draw a correlation between Electroencephalogram (EEG) and neuroimaging. Study Design: A hospital-based prospective study. Materials and Methods: A total of 276 children (6 months to 14 years of age), who presented with new-onset afebrile or complex febrile seizures, underwent EEG and neuroimaging [Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI)]. Results: Generalized seizures constituted the major seizure group in our study – 116/276 (42%) – followed by partial seizures 86/276 (31.2%) and complex febrile seizure in 64/276 (23.2%). Generalized as well as partial seizures were more common in children aged 6-14 years, while complex febrile seizures were predominantly seen in children less than 6 years old. Most of the patients with generalized and partial seizures had EEG abnormalities, while EEG abnormalities were uncommon in patients with complex febrile seizures. A total of 27/276 (9.8%) patients with seizure disorder had abnormal CT scans and this abnormality was more common in patients with partial seizures. CT abnormality was seen more commonly in those patients who had an abnormal EEG. EEG and CT correlation showed that patients with abnormal EEG had higher rates of CT abnormality, ie, 16.1% (25/155). Abnormal MRI was seen in 32/157 (20.4%) of patients; accuracy of picking abnormality by MRI, when EEG was abnormal, was 24.8% (P<0.05). Conclusion: Our findings indicate that clinical examination and EEG results are good indicators for neuroimaging, and these can be used as one of the criteria for ordering neuroimaging in new-onset seizures.

Hemobilia in a child due to right hepatic artery pseudoaneurysm: multidetector-row computed tomography demonstration.

We present a case of a 12-year-old boy who developed upper gastrointestinal bleeding in the form of hematemesis and melena 1 month after blunt trauma to liver. Computed tomography (CT) angiography with multidetector-row CT demonstrated pseudoaneurysm of right hepatic artery related to old liver laceration to be the cause of the bleeding. Pseudoaneurysm was resected using the roadmap provided by CT angiography findings.