Nk Prabhu

Clinical applications of diffusion weighted MR imaging: A review

Diffusion MR imaging is now a routine component of the brain MR imaging examination and is critical in the evaluation of stroke patients. However, high signal intensity on diffusion MR and hypo intensity on apparent diffusion co-efficient (ADC) images, which are features of acute cerebral infarction, have been reported in such diverse conditions as hemorrhage, abscess, tumor and even in Wernicke encephalopathy. Differentiating between there conditions is critical for determination of appropriate treatment. We present a systematic review of hyperintense lesions on diffusion MR images and their potential clinical applications.

Para duodenal hernias- a pictorial essay

Intestinal obstruction is a common clinical condition that is usually suspected on the basis of clinical signs and patient history. For many decades, evaluation was based on findings at conventional radiography, with a sensitivity of 69% and a specificity of 57% (1). Several studies have demonstrated the value of CT in confirming the diagnosis and revealing the cause of small bowel obstruction, with a sensitivity of 94%-100% and an accuracy of 90%-95% (1,2). Internal hernias are rare cause for intestinal obstruction. Para duodenal hernias constitute approximately 53% of all internal hernias (3,4). These rare hernias have unique radiological finding which allow definitive diagnosis to be made. In this article we will review relevant anatomy of the peritoneal cavity and characteristic CT appearance of para duodenal hernias.

Utility of C-arm CT in overcoming challenges in patients undergoing Transarterial chemoembolization for hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the well-known treatment for hepatocellular carcinoma. Multiple digital subtraction angiography (DSA) acquisitions in different projections are required to identify difficult arterial feeders. Moreover, the tell-tale tumor blush can be obscured by proximity to lung base, small size of lesion, and breathing artifacts. C-arm CT is a revolutionary advancement in the intervention radiology suite that allows acquisition of data which can be reformatted in multiple planes and volume rendered incorporating both soft tissue and vascular information like multidetector computed tomography (MDCT). These images acquired during the TACE procedure can provide critical inputs for achieving a safe and effective therapy. This case series aims to illustrate the utility of C-arm CT in solving specific problems encountered while performing TACE.

Infrapopliteal angioplasties for limb salvage in diabetic patients: Does the clinical outcome justify its use?

Purpose: To analyze the results of infrapopliteal percutaneous transluminal angioplasty (PTA) as a primary treatment modality in diabetic patients with non- healing ulcers or gangrene. Materials and Methods: We retrospectively studied 35 angioplasties, performed as the first line of treatment to salvage diabetic feet. The patients were followed up for 12 months. Results: Grade 1 and 2 ulcers were seen in only 20% of patients (5.71 and 14.28%, respectively); 37.14% of patients had grade 3 ulcer, and 42.8% were in the gangrene stage (grade 4 - 34.2% and grade 5 - 8.5%). A total of 77 lesions in 46 arteries (including six popliteal and suprapopliteal lesions) were dilated in 35 limbs. Of the 71 infrapopliteal lesions, 86% of lesions were classified as group C or D (group A - 9.3%, group B - 4.65%, group C - 37.2%, and group D - 48.83%). Overall technical success rate was 84.7%. The vascular complication rate was 26% (12 arteries out of 46). Clinical success was achieved in 29.1% of cases at the end of 6 months and 58.6% at the end of one year. Limb salvage rates were 79.4% at the end of 6 months and 75.8% at the end of one year. Conclusions: A high technical success rate can be achieved even in situations traditionally considered unfavorable for angioplasty. Infrapopliteal angioplasty can produce limb salvage rates comparable to bypass surgery in diabetic patients with extensive disease.

Role of multi detector computed tomography (MDCT) in preoperative staging of pancreatic carcinoma

INTRODUCTION Pancreatic carcinoma is one of the leading causes of cancer related death in advanced countries and has shown rising trends in developing countries like India. Increase in the incidence has been linked to risk factors like lifestyle modification associated with increased alcohol consumption and rapid urbanization. Most patients at the time of diagnosis present with an advanced condition. Surgical resection offers the only chance for cure in them and imaging plays a crucial role in the early diagnosis of the condition. AIM To compare the staging of pancreatic carcinoma by MDCT (Multi Detector Computed Tomography) with surgery in a preoperative setting in a tertiary referral centre in Kerala. MATERIALS AND METHODS A cross-sectional observational study was performed between November 2014 and October 2016, 25 patients (12 men, 13 women), with a mean age of 54.2 years, were evaluated. MDCT was performed using 16 slice, 64 slice and 256 slice multi detector CT machines. The gold standard for diagnosis was histopathology and operative data. All statistical analysis was done using IBM SPSS version 20.0. Validity parameters like sensitivity, specificity, accuracy and Positive Predictive Value (PPV) / Negative Predictive Value (NPV) were computed for MDCT with respect to surgery. RESULTS Of the 25 patients who were evaluated for surgery, 15 (60%) cases were classified as resectable tumours, 3 (12%) as borderline resectable and 7 (28%) as unresectable tumours. CT showed a sensitivity of 82.3% with a specificity of 87.5%. However, for assessing vascular invasion, CT showed sensitivity and specificity of 100% and 93.3% respectively. Three (12%) patients in the study who were classified as borderline resectable pancreatic tumours underwent surgery. CONCLUSION Contrast-enhanced multiphase pancreatic imaging using MDCT plays a pivotal role in diagnosing and assessing resectability and vascular invasion of pancreatic tumours. It is very useful for determining borderline resectable tumours pre-operatively, which aids for better treatment planning.

Percutaneous transhepatic techniques for management of biliary anastomotic strictures in living donor liver transplant recipients

Aim: To retrospectively analyze the percutaneous transhepatic techniques and their outcome in the management of biliary strictures in living donor liver transplant (LDLT) recipients. Materials and Methods: We retrieved the hospital records of 400 LDLT recipients between 2007 and 2015 and identified 45 patients with biliary strictures. Among them, 17 patients (37.8%) (Male: female = 13:4; mean age, 36.1 ± 17.5 years) treated by various percutaneous transhepatic biliary techniques alone or in combination with endoscopic retrograde cholangiopancreatography (ERCP) were included in the study. The technical and clinical success of the percutaneous management was analyzed. Results: Anastomotic strictures associated with leak were found in 12/17 patients (70.6%). Ten out of 12 (83.3%) patients associated with leak had more than one duct-duct anastomoses (range, 2–3). The average duration of onset of stricture in patients with biliary leak was 3.97 ± 2.68 months and in patients with only strictures it was 14.03 ± 13.9 months. In 6 patients, endoscopic-guided plastic stents were placed using rendezvous technique, plastic stent was placed from a percutaneous approach in 1 patient, metallic stents were used in 2 patients, cholangioplasty was performed in 1 patient, N-butyl- 2-cyanoacrylate embolization was done in 1 child with biliary-pleural fistula, internal-external drain was placed in 1 patient, and only external drain was placed in 5 patients. Technical success was achieved in 12/17 (70.6%) and clinical success was achieved in 13/17 (76.5%) of the patients. Posttreatment mean time of follow-up was 19.4 ± 13.7 months. Five patients (29.4%) died (two acute rejections, one metabolic acidosis, and two sepsis). Conclusions: Percutaneous biliary techniques are effective treatment options with good outcome in LDLT patients with biliary complications.

Percutaneous transluminal angioplasty and stenting in the management of chronic mesenteric angina: A single center experience

Introduction: The objective of our study was to review the results of percutaneous angioplasty (PTA)/stenting in the treatment of patients who presented with symptoms and angiographic findings of chronic mesenteric ischemia (CMI). Materials and Methods: We performed a retrospective analysis of 13 consecutive patients from a single institution who underwent PTA/stenting for the treatment of symptoms suggestive of CMI. Results: All 13 patients in our study were men, and most common presenting symptoms were weight loss and postprandial pain. Atherosclerosis was the most common cause. PTA and stenting was performed in 9 patients and PTA alone was done in 4 patients. Primary technical success rate was 92% with complete resolution of symptoms within 2 weeks in all patients. No statistical difference was noted in primary clinical success rate based on the number of vessels treated or the method of treatment. However, in patients whom SMA was treated had longer duration of symptom-free survival as compared to other vessels. Conclusion: PTA and stenting are very effective therapeutic options for patients presenting with CMI symptoms. It should be considered as the first-line of management in such patients.

Hereditary hemorrhagic telangiectasia

Hereditary Hemorrhagic Telangiectasia (HHT) or Osler-Weber-Rendu disease is an autosomal dominant genetic disorder. HHT frequently presents with gastrointestinal bleeding with diagnostic and therapeutic challenge. Hepatic involvement in this disease is increasingly recognized and poses another therapeutic challenge. With advances in genetic screening and diagnostic procedures, and the increasing awareness of the condition by physicians and patients, this disease is now diagnosed more often. This case report reviews the available literature on various manifestations of HHT, and the various diagnostic and therapeutic modalities available for its management.