Zafar Neyaz

CT-Guided Percutaneous Biopsy of Intrathoracic Lesions

Percutaneous CT-guided needle biopsy of mediastinal and pulmonary lesions is a minimally invasive approach for obtaining tissue for histopathological examination. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications. In this pictorial review, we reviewed important anatomical approaches, technical aspects of the procedure, and its associated complications.

The Utility of 64 Channel Multidetector CT Angiography for Evaluating the Renal Vascular Anatomy and Possible Variations: a Pictorial Essay

The increased use of laparoscopic nephrectomy and nephron-sparing surgery has prompted the need for a more detailed radiological evaluation of the renal vascular anatomy. Multidetector CT angiography is a fast and accurate modality for assessing the precise anatomy of the renal vessels. In this pictorial review, we present the multidetector CT angiography appearances of the normal renal vascular anatomy and a spectrum of various anomalies that require accurate vascular depiction before undergoing surgical treatment.

Clinical and magnetic resonance imaging characteristics of tubercular ventriculitis: An under-recognized complication of tubercular meningitis☆ , ☆☆

BACKGROUND Ventriculitis also referred as ependymitis or ventricular empyema is a known complication of pyogenic meningitis. Despite high incidence of tubercular meningitis in developing countries, there are hardly any reports of tubercular ventriculitis. METHODS Five patients (four males and one female) of tubercular ventriculitis were retrospectively identified from December 2007 to August 2013. Their clinical features, cranial MRI characteristics, treatment offered, and outcome were reviewed. RESULTS The median age of 5 patients was 29 years (range 15 to 64 years). Two patients had preceding pulmonary/pleural tuberculosis and one had Potts spine. One patient had multi-drug resistant tuberculosis. All five patients had papilledema, four had seizures, two had hemiparesis, and two had vision loss. On cranial MRI all patients showed contrast enhancement of ependymal wall of lateral/fourth ventricle with restricted diffusion and hydrocephalus; three showed intra-ventricular septations with sequestered ventricles, and two had ventricular sludge. Magnetization transfer (MT) images were available in only two patients. Both showed hyperintense epedymal wall on MT images. Four patients required ventriculo-peritoneal shunt and two underwent temporal lobectomy. Two patients with sequestered temporal lobe had acute deterioration in consciousness with signs of impending herniation and required urgent surgical intervention. Four patients recovered on anti-tubercular treatment over 18 months; one receiving secondary line ATT for residual brain abscess. CONCLUSION Tubercular ventriculitis is a rare complication of tubercular meningitis. MRI feature of sequestered ventricles/intraventricular septations and hyperintense ependymal wall on MT images could suggest tubercular etiology. Symptomatic hydrocephalus may require CSF diversion in most patients.

Tracheobronchopathia osteochondroplastica--a rare or an overlooked entity?

Tracheobronchopathia osteochondroplastica is an idiopathic non-malignant disease of large airways featured by submucosal cartilaginous to osseous nodules overlying the cartilaginous rings, which may be focal or diffuse. Clinical presentation varies from asymptomatic to symptoms like breathlessness, recurrent chest infections, cough and hemoptysis. Due to the lack of awareness of this disease, it remains an under recognized entity. We are describing the computed tomography and bronchoscopic findings of two recently diagnosed cases at our institute. The purpose of this report is to familiarize radiologists with imaging appearance of this condition, with the goal of increasing clinical suspicion of this uncommon condition.

Localized cystic disease of the kidney: a rare entity

Localized cystic disease of the kidney is a benign nonsurgical entity and presents with multiple cystic lesions in just one portion of the kidney or involves the entire one kidney. We report a case of localized cystic disease of the kidney in a 16 year-old-male. This patient underwent an ultrasound examination and incidentally found to have multiple cysts in the right kidney whereas the left kidney was normal. Diagnosis was confirmed by typical MRI findings, absence of any family history, normal results of urine analysis and renal function tests.

Role of P-Glycoprotein in Refractoriness of Seizures to Antiepileptic Drugs in Lennox-Gastaut Syndrome

Mechanism of seizure refractoriness to antiepileptic drugs in children with Lennox-Gastaut syndrome is not known. Efflux of antiepileptic drugs due to increased expression/function of P-glycoprotein, a multidrug efflux transporter protein on the cell surface is a proposed mechanism. The authors studied the expression/function of P-glycoprotein on peripheral blood mononuclear cells of 29 children with Lennox-Gastaut syndrome, 23 children with other epilepsies, and 19 healthy children. The authors found a higher P-glycoprotein expression/function in Lennox-Gastaut syndrome, a higher percent positive cells as compared to children with other epilepsy (P < 0.001) and to healthy controls (P = 0.012), higher P-glycoprotein expression as compared to healthy controls (P = 0.003), a higher total P-glycoprotein expression (relative florescence intensity × percent positive cells) as compared to children with other epilepsies (P < 0.001) and healthy controls (P < 0.001), and a higher P-glycoprotein function as compared to children with other epilepsies (P = 0.001) and healthy controls (P = 0.002). These findings may explain seizure refractoriness to anti-epileptic drugs in Lennox-Gastaut syndome.

Bronchial Artery Aneurysm due to Pulmonary Tuberculosis: Detection with Multidetector Computed Tomographic Angiography

A case of bronchial artery aneurysm due to pulmonary tuberculosis is reported. The patient presented with massive hemoptysis and the diagnosis was made using multidetector computed tomographic (MDCT) angiography. Selective bronchial arteriogram confirmed the MDCT findings and bronchial artery embolization was successfully performed with cessation of hemoptysis. Our article emphasizes the value of MDCT angiography in the diagnosis and management of such cases.

Computed tomographic versus catheterization angiography in tetralogy of Fallot

Aim To compare multidetector computed tomographic angiography with the gold standard cardiac catheterization and angiography in tetralogy of Fallot. Methods In 40 consecutive patients over 5 years of age with tetralogy of Fallot, multidetector computed tomographic angiography and catheterization angiography studies were compared for intracardiac anatomy, pulmonary anatomy and indices, coronaries and collaterals. Safety parameters, relative advantages and limitations were also analyzed. Results All catheterization studies required hospitalization whereas all tomographic studies were performed as outpatient procedures. The need for sedation and amount of contrast used were significantly greater in catheterization than in tomographic studies. Complications noted during catheterization were access site complications in 4 patients, cyanotic spells in 2, transient complete heart block requiring temporary pacing in 2, and air embolism in one. No complication was observed during tomographic studies. All tomographic studies were adequate, but 2 catheterization studies were inadequate. Ventricular septal defects, aortic override, level of right ventricular outflow tract obstruction, and pulmonary artery anatomy were equally assessed by both imaging modalities. However, tomographic studies missed additional small muscular ventricular septal defects. There was a linear correlation between tomographic and catheterization studies for pulmonary annulus size, artery sizes, Z-score, and Nakata index. There was complete concordance with respect to side of aortic arch and detection of collaterals. Coronary anatomy was better delineated in tomographic studies. Conclusions For preoperative evaluation of tetralogy of Fallot patients, multidetector computed tomographic angiography can be used as a reliable noninvasive alternative to cardiac catheterization angiography.

Local recurrence and multi-organ metastasis of primary retroperitoneal leiomyosarcoma in unusual locations after surgical resection

We report a case of retroperitoneal leiomyosarcoma in a 52-year-old woman, who developed local recurrence, pulmonary, hepatic, peritoneal, pancreatic, subcutaneous and intramuscular metastases two years after surgical resection of the primary tumor. Metastasis to the pancreas, subcutaneous or muscular tissue is very rare; however, presence of a lesion in these locations in a known case of leiomyosarcoma might indicate a metastatic tumor deposit.

Teaching NeuroImages: Amlodipine-responsive trigeminal neuralgia An alibi for vascular compression theory

A 55-year-old woman developed recurrent short-lasting shock-like pain involving her left lower face. Initiation of amlodipine for concurrently detected hypertension relieved her of pain besides normalizing her blood pressure. Interestingly, occasions of noncompliance with amlodipine brought her pain back. Her cranial MRI revealed tortuous blood vessels compressing the left rostro-antero-lateral medulla and left trigeminal nerve root (figure 1). Vascular compression of medulla is known to produce neurogenic hypertension1 (figure e-1 at Neurology.org). Possibly, a decrease in vessel tortuosity2 mediated by voltage-gated L-type calcium channels (antihypertensive effect) and an action on N-type channels (sympathetic modulation/antinociceptive effect) played a role in amlodipines inadvertent efficacy (figure e-2).