Paramjit Singh

Ultrasonography in detection of single and multiple abnormal parathyroid glands in primary hyperparathyroidism: comparison with radionuclide scintigraphy and surgery

Background  Among the parathyroid imaging techniques, ultrasonography (USG) has the advantage of convenience, easy availability and low cost.

Tuberculous osteomyelitis of the cuboid: a report of four cases.

Osteoarticular tuberculosis, although rare, has shown a resurgence in recent times, especially in immunocompromised patients. Involvement of the foot is infrequent, and the differential diagnosis is confusing, leading to diagnostic delays. We reviewed four cases of tuberculosis of the cuboid where the infection was limited to the bone without articular involvement. All four cases were adults and diagnostic delays were observed in all. Three of the cases had an osteolytic lesion on radiographs resembling a space-occupying lesion. Magnetic resonance imaging (MRI) or Computed tomography (CT) scans were helpful in three cases, and post-treatment MRI helped in evaluating outcome in one case. Antitubercular chemotherapy was sufficient to cause resolution of the lesion in three cases, while in one case surgical intervention was necessary. Since isolated osteomyelitis is usually seen only in the early stages of the disease process, early diagnosis and appropriate therapy are imperative to get good long-term results. Concomitant extraskeletal lesions are not always seen, nor is the organism cultured in a majority of the cases. Thus a high index of suspicion is mandatory in high-risk groups (immigrants, immunocompromised cases or those with history of contact); clinical and radiologic features, along with histopathologic evidence of granulomatous pathology should be sufficient to initiate therapy.

Imaging of granulomatous and chronic invasive fungal sinusitis: comparison with allergic fungal sinusitis.

OBJECTIVE: To study the radiological features of chronic/granulomatous invasive fungal sinusitis (IFS) and identify differentiating characteristics, if any, from allergic fungal sinusitis (AFS). STUDY DESIGN: Prospective radiological study. SETTING: Tertiary hospital in northern India. SUBJECTS AND METHODS: Subjects were nonacute fungal sinusitis patients with orbital involvement presenting between January 1999 and December 2003. Seventeen IFS and 12 AFS patients with mean age 27 years (range 7-59 years) underwent computed tomographic scan (CT) and magnetic resonance imaging (MRI) of paranasal sinuses with contrast. These were operated within one month of doing the scans and had histologically confirmed fungal sinusitis. Outcome measures were characteristics of opacity produced by the diseased tissue on CT and MRI, side and number of sinuses involved, expansion of sinuses, areas of bone erosion, and extra-sinus extension. RESULTS: IFS showed homogenous opacity (isodense or hyperdense to muscle tissue) on CT and isointense and hypointense signal on T1- and T2-weighted MR images respectively. IFS showed involvement of one or two sinuses only, homogenous contrast enhancement, lack of expansion of sinuses, and bone erosion localized to the area of extra-sinus extension, and the extra-sinus component of the disease was more than the intra-sinus component. AFS showed heterogenous opacities with hyperattenuation areas on CT, isointense/hypointense to signal void on T1- and T2-weighted MR images. Expansion of sinuses, extensive bone erosion, lack of contrast enhancement, multiple sinus involvement, and major bulk of disease being intra-sinus rather than extra-sinus were other characteristics of AFS. CONCLUSION: Radiological features of IFS are described that are different from AFS.

Shunt surgery effects on cerebrospinal fluid flow across the aqueduct of Sylvius in patients with communicating hydrocephalus

We aimed to visualize and quantify the flow of cerebrospinal fluid (CSF) across the aqueduct of Sylvius in patients with communicating hydrocephalus using phase contrast MRI, and to evaluate the effect of ventriculoperitoneal (VP) shunt surgery on flow. We investigated aqueductal CSF flow using cine cardiac-gated phase contrast MRI in 10 normal volunteers and 10 patients with communicating hydrocephalus (who underwent VP shunt surgery). For qualitative evaluation, we used an in-plane phase contrast sequence in the midsagittal plane. Quantitative through-plane measurements were performed in the axial plane perpendicular to the aqueduct. The aqueduct area ranged from 0.02 cm(2) to 0.27 cm(2) in the shunt group; and from 0.01 cm(2) to 0.04 cm(2) in the control group (p<0.05). Aqueductal stroke volume (mean, standard deviation SD) ranged from 1.9 microL to 33.17 microL (17.41 microL, 10.1132) in the control group; and from 5.63 microL to 256 microL (87.20 microL, 79.0383) in the study group. Post-operatively the aqueductal stroke volume reduced significantly, ranging from 0.60 microL to 48.77 microL (13.19 microL, 18.08) (p<0.05). Peak systolic velocity (PSV) values in the patients before shunt surgery ranged from -1.05 cm/s to -8.10 cm/s (-4.39cm/s, 2.7619) and peak diastolic velocities (PDV) ranged from 0.62 cm/s to 5.16 cm/s (3.33 cm/s, 1.4451). Post- shunt; PSV values ranged from -0.37 cm/s to -3.90 cm/s (1.78 cm/s, 1.5143) and PDV range was 0.32 cm/s to 4.43 cm/s (1.78 cm/s, 1.6782). The post-operative reduction in velocity was significant (p<0.05). Thus, the aqueductal CSF flow after VP shunt was similar to flow in healthy volunteers.

Dynamic magnetic resonance imaging evaluation of craniovertebral junction abnormalities.

Objectives: To evaluate the role of dynamic magnetic resonance imaging (MRI) in craniovertebral junction (CVJ) abnormalities. Materials and Methods: Twenty-five patients with suspected CVJ abnormalities underwent dynamic MRI of the CVJ, and in 20 of these patients, noncontrast computed tomography scan of the CVJ was done. The images were evaluated for atlantoaxial instability (AAI), spinal canal narrowing, cord compression, presence of altered cord signal intensity, and bony abnormalities in neutral, flexion, and extension. Results: Dynamic MRI detected 15 cases of AAI (10 fixed and 5 mobile AAI), 21 patients had varying degrees of spinal canal narrowing. Five patients showed increased narrowing on flexion/extension. Two patients demonstrated direct cord compression in flexion, whereas in neutral position, only dural compression was seen. One patient had cord compression on extension that was not seen in neutral or flexed position. Conclusion: Dynamic MRI was able to detect cases of cord compression that were not seen in neutral position and was diagnostic in all cases of mobile AAI where mobility at this joint affects the treatment options. Dynamic MRI is extremely useful for evaluating craniovertebral junction abnormalities and, in particular, cord compression.

Prenatal diagnosis of thoracopagus fetus: a case report with brief review of literature.

Conjoined twins are uncommon and refer to monozygotic, monoamniotic and monochorionic twins with varying degree and sites of fusion between the twins. In this report, we illustrate a case of thoracopagus twins highlighting the prenatal sonographic and magnetic resonance imaging appearance. Emphasis is laid on the role of appropriate imaging strategy in prognostic assessment and postnatal surgical treatment planning of these cases.

Role of 18 F-fluorodeoxyglucose Positron Emission Tomography scan in differentiating enhancing brain tumors

Aim: To determine whether F-18-fluorodeoxyglucose positron emission tomography (F-18-FDG PET) can be used to differentiate among common enhancing brain tumors such as gliomas, metastatic brain tumors, and lymphoma. Materials and Methods: We evaluated 20 patients with an enhancing brain tumor on magnetic resonance imaging (MRI). FDG PET scan was done in all patients pre operatively. For PET image analysis, regions of interest were placed over the tumor (T), contralateral cortex (C), and white matter (WM). Average and maximum pixel values were determined at each site. On the basis of these measurements, average and maximum standard uptake values (SUV avg and SUV max ) were calculated, and comparisons among lesions were then made. Results: SUVavg and SUVmax are significantly higher for central nervous system (CNS) lymphoma than for other tumors (P < 0.01). High-grade gliomas showed significantly higher SUVavg and SUVmax than the low grade gliomas (P < 0.05) and metastatic tumor showed higher SUVavg and SUVmax than all gliomas, both low and high grade (P < 0.05). When the lowest values of CNS lymphoma parameter were used as cutoff levels to distinguish CNS lymphomas from other tumors (i.e. 100% sensitivity), SUVmax was the most accurate parameter. Using a SUVmax of 15.0 as a cutoff for diagnosing CNS lymphoma, only one case of metastasis (SUV max , 16.3) was found to be false positive in this study. Conclusion: FDG PET appears to provide additional information for differentiating common enhancing malignant brain tumors, namely lymphoma versus high grade glioma and metastatic tumor, particularly when differential diagnoses are difficult to narrow using MRI alone.

A comparison between intensive and conventional cabergoline treatment of newly diagnosed patients with macroprolactinoma

Intensive treatment with cabergoline may lead to earlier reduction in prolactin and tumour volume in comparison to conventional schedule.

Suprasellar hydatid cyst.

Differential diagnosis of suprasellar mass lesions in children include craniopharyngioma, germinomas, Rathke’s cyst, granulomas and rarely pilocytic astrocytoma. We report the case of a 7-year-old girl who presented with a history of headache and vomiting for 15 days duration and three episodes of seizures before admission. She had experienced similar events 4 years previously and underwent ventriculo-peritoneal (VP) shunt, but remained undiagnosed. Her height was 118 cm (−0.5 SDS), weight 30 kg and had bilateral papilloedema, hypertonia and intermittent tonic posturing. A computed tomographic (CT) scan of her head showed …

Images In...: Giant somatotropinoma

A 28-year-old man presented with fatigue and pronounced weakness. He had a history of headache, coarsening of facial features and progressive decline in vision for the previous 4 years. He also complained of cold intolerance, decreased libido, arthralgia in both knees, and proximal muscle weakness for the last 6 months. On examination, he had features suggestive of active acromegaly. On investigation, he was found to be hypothyroid (thyroxine (T4) 50 nmol/l, normal range (NR) 62–163 nmol/l; thyroid stimulating hormone (TSH) 0.2 uU/ml, NR 0.27–4.2 uU/ml), hypocortisolic (serum cortisol 12.8 nmol/l, NR, 171–536 nmol/l), and hypogonadal (serum testosterone 0.88 nmol/l, NR 9–27 nmol/l). His serum basal growth hormone (GH) was 142 ng/ml (normal <0.4 ng/ml), and it was non-suppressible after glucose load (155 ng/ml, normal <1 ng/ml). Serum IGF-1 concentration was 792 ng/ml (NR 117–329 ng/ml), and serum prolactin was 38.4 ng/ml (NR 5–20 ng/ml). Brain magnetic resonance imaging (MRI) showed sellar mass with huge lobulated suprasellar component (70×62×60 mm) with cystic changes and frontal lobe extension (fig 1). The patient underwent transsphenoidal followed by transfrontal subtotal excision of the tumour. Histopathology of the tumour showed pituitary adenoma with positive immunostaining for growth hormone. Currently, the patient is on hydrocortisone, L-thyroxine, and testosterone replacement, and treatment with radiotherapy is planned. Figure 1 Coronal (A) and sagittal (B) post-contrast magnetic resonance image T1 weighted sections showing a large intrasellar tumour with suprasellar component. Suprasellar solid component shows a lobulated margin with peripheral non-enhancing cystic areas (margins ...