Sachit Shah

Imaging in bariatric surgery: service set-up, post-operative anatomy and complications

Obesity is an increasingly prevalent and costly problem faced by the healthcare system. The role of bariatric surgery in managing obesity has also increased with evidence showing a reduction in long-term morbidity and mortality. There are unique challenges faced by the radiology department in providing an imaging service for this population of patients, from technical and staffing requirements through to the interpretation of challenging post-surgical images. We describe these challenges and provide an overview of the most frequently performed procedures, normal post-operative imaging findings and the appearance of common complications.

The common dementias: a pictorial review.

Imaging plays an important role in the diagnosis and management of dementia. This review covers the imaging features of the most common dementing illnesses: Alzheimer’s disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB) and frontotemporal lobar degeneration (FTLD). It describes typical findings on structural neuroimaging and discusses functional and molecular imaging techniques such as FDG PET, amyloid PET, magnetic resonance (MR) perfusion imaging, diffusion tensor imaging (DTI) and functional MR imaging (fMRI).

Adult onset leukodystrophy with neuroaxonal spheroids and demyelinating plaque-like lesions

Adult onset leukodystrophy with neuroaxonal spheroids is an uncommon cause of dementia. Both hereditary (autosomal dominant) and sporadic cases have been described. A 41‐year‐old African woman presented with inappropriate behavior and personality change consistent with frontal lobe dysfunction. MRI demonstrated diffuse frontoparietal white matter signal abnormality and volume loss, as well as focal enhancing white matter lesions, while CT scan showed white matter calcifications. She had been gradually deteriorating over the last 5 years, diagnosed as having progressive demyelinating illness. She died of recurrent chest infections. There was no familial history. The brain showed prominent symmetrical white matter changes with greyish discolorization mainly affecting the frontal and parietal lobes, with less involvement of the temporal lobe and only mildly affecting the occipital white matter. Histology revealed deep white matter atrophy with many neuroaxonal spheroids labelled by neurofilament and β‐amyloid precursor protein. In addition, scattered inactive demyelinating plaque‐like lesions were found in the periventricular areas, brainstem and the cervical spinal cord. This case had typical features of an adult onset leukodystrophy with neuroaxonal spheroids. However, we also demonstrated demyelinating plaque‐like lesions, which has not been previously described. The possibility of a demyelinating origin contributing to the changes may be considered in the pathogenesis of this condition.

Mediastinal involvement in lymphangiomatosis: a previously unreported MRI sign.

BackgroundMultifocal lymphangiomatosis is a rare systemic disorder affecting children. Due to its rarity and wide spectrum of clinical, histological and imaging features, establishing the diagnosis of multifocal lymphangiomatosis can be challenging.ObjectivesThe purpose of this study was to describe a new imaging sign in this disorder: paraspinal soft tissue and signal abnormality at MRI.Materials and methodsWe retrospectively reviewed the imaging, clinical and histopathological findings in a cohort of eight children with thoracic involvement from this condition.ResultsEvidence of paraspinal chest disease was identified at MRI and CT in all eight of these children. The changes comprise heterogeneous intermediate-to-high signal parallel to the thoracic vertebrae on T2-weighted sequences at MRI, with abnormal paraspinal soft tissue at CT and plain radiography.ConclusionMultifocal lymphangiomatosis is a rare disorder with a broad range of clinicopathological and imaging features. MRI allows complete evaluation of disease extent without the use of ionising radiation and has allowed us to describe a previously unreported imaging sign in this disorder, namely, heterogeneous hyperintense signal in abnormal paraspinal tissue on T2-weighted images.

Clinical outcomes in patients with nonfunctioning pituitary adenomas managed conservatively

The natural history and the optimum management of patients with nonfunctioning pituitary adenomas (NFPAs) are unclear.

Cranial nerve, spinal root and plexus hypertrophy in chronic inflammatory demyelinating polyneuropathy

A middle-aged patient with a history of chronic inflammatory demyelinating polyneuropathy of over 20 years presented with new onset of numbness of the penis and impaired erections. Review of the clinical history revealed an initial presentation in his early 20s with an unsteady gait and numbness of the feet, following which he developed progressive asymmetric distal weakness and sensory loss of his lower and upper limbs. Previous electrophysiological studies had demonstrated a demyelinating sensorimotor polyneuropathy with absent sensory nerve action potentials and markedly decreased motor nerve conduction velocities (8 m/s in the right median nerve). Raised protein content (3 g/l) had been established on cerebrospinal fluid analysis and sural nerve biopsy revealed ‘onion bulb’ formation …

A diagnostic conundrum

A 26-year-old man was referred with facial weakness, dysarthria, dysphagia, ophthalmoparesis and severely weak and wasted legs. His symptoms had begun when aged 20 with electric shock pains and paraesthesia in both feet progressing over 6 months to the lower calves. He then developed buttock numbness and occasional faecal incontinence. By age 22, he had diffuse lower limb weakness and wasting, with difficulty standing from a seated position and frequent tripping. He became wheelchair-dependent within 3 years. Over the same time period, he developed progressive facial weakness, bilateral ptosis, slurred speech, difficulty chewing and swallowing and lost 10 kg of weight. He reported hearing difficulty, and an audiogram showed high-frequency hearing loss. Important negatives included absence of upper limb symptoms, autonomic, cardiac, respiratory or cognitive dysfunction. He was from a non-consanguineous, Lithuanian background and the eldest of three siblings. He was born following a normal pregnancy and delivery, and motor development was normal. He had sustained a left corneal abrasion with visual impairment following an accidental chemical injury aged 14. During the initial investigation of his symptoms (age 23), he was found to have a choroid plexus lesion in the fourth ventricle. It was completely resected and histology confirmed benign choroid plexus papilloma WHO grade I. Postoperative neuro-oncology discussion deemed the lesion cured. He had bilateral ptosis, bilateral facial wasting and could not close his mouth against gravity (figure 1A). Visual acuity was reduced to perception of light on the left, 6/9 on the right. There was almost complete, complex ophthalmoplegia (figure 1B) without fatiguability. Trigeminal sensation was reduced. He could not achieve eyelid closure; frontalis, buccinator and orbicularis oris were symmetrically weak. His speech was dysarthric and his tongue was weak. His uvula was central with symmetrical palatal movement, but the gag reflex was reduced. Figure 1 Clinical examination at age 26. …

Wisdom tooth extraction causing lingual nerve and styloglossus muscle damage: a mimic of multiple cranial nerve palsies

The combination of tongue hemianaesthesia, dysgeusia, dysarthria and dysphagia suggests the involvement of multiple cranial nerves. We present a case with sudden onset of these symptoms immediately following wisdom tooth extraction and highlight the clinical features that allowed localisation of the lesion to a focal, iatrogenic injury of the lingual nerve and adjacent styloglossus muscle.