Jejunal access loop cholangiogram and intervention using image guided access

Jejunal access loop is fashioned in patients who undergo Roux en Y hepaticojejunostomy and biliary intervention is anticipated on follow up. Post-operative study of the biliary tree through the access loop is usually done under fluoroscopic guidance. We present a series of 20 access loop cholangiograms performed in our institution between August 2004 and November 2008. We aimed to evaluate the safety and efficacy of the procedure and to highlight the role of CT guidance in procuring access. Access loop was accessed using CT (n = 13), ultrasound (n = 3) or fluoroscopic guidance (n = 4). Fluoroscopy was used for performing cholangiograms and interventions. Twelve studies had balloon plasty of the stricture at anastomotic site or high up in the hepatic ducts. Seven studies showed normal cholangiogram. Plasty was unsuccessful in one study. Technical success in accessing the jejunal access loop was 100%; in cannulation of anastomotic site and balloon plasty it was 95%. One case required two attempts. Procedure-related complications were not seen. All patients who underwent balloon plasty of the stricture were doing well for variable lengths of time. Access loop cholangiogram and interventions are safe and effective. CT guidance in locating/procuring the access loop is a good technique.

Development and dysmorphism in Joubert syndrome--short case series from India

Five children with Joubert syndrome (JS), who fulfilled the criteria and had molar tooth sign (MTS) on magnetic resonance imaging were included in the study. Prominent forehead, open mouth and low set ears were consistent facial features. Severe developmental delay was seen in three children (66%). A differential developmental delay was noticed in all children and was independent of the radiological features. The children who had complications in the neonatal period were found to have more developmental delay on follow-up. The optimal control of sleep disturbances and hyperkinesis in one child resulted in a better cognitive performance. A regular neuro-developmental follow-up and interventions can optimize the potential of children with JS. In addition to the regular screening for retinal, renal and hepatic functions in JS, there is a need to monitor cognitive functions, sleep and behavior.

Transjugular intrahepatic portocaval shunt placed through the strut of an inferior vena cava stent in a patient with Budd-Chiari syndrome: a technical modification

Transjugular intrahepatic portocaval shunt (TIPS) is performed in patients with symptomatic Budd-Chiari syndrome (BCS) who do not have repairable hepatic veins. We report the case of a patient who had an inferior vena cava (IVC) stent placed previously as part of the management for BCS, and who subsequently required TIPS. The TIPS tract was created through the strut of the previously placed IVC stent; the TIPS stent was placed after dilatation of the liver parenchyma as well as the strut of the IVC stent. This novel technique of "strutplasty" of a previously placed stent as part of TIPS has not been reported in the literature.

Breast filariasis: real-time sonographic imaging of the filarial dance

A 50-year-old woman presented with a palpable tender nodule in the upper quadrant of the breast that was clinically thought to be a fibroadenoma, with mammographic findings of a well-defined lobulated density. Sonographic examination revealed a "filarial dance sign" within the cystic lesion, which is diagnostic of lymphatic breast filariasis. In endemic areas, sonographic examination is recommended to search for this pathognomonic real-time diagnostic feature and, if present, to initiate treatment without delay.

Large retroperitoneal schwannoma mimicking a cystic ovarian mass in a patient with Hansen's disease

We present a rare case of retroperitoneal cystic schwannoma of the pelvis in a patient with Hansen's disease that mimicked an ovarian cyst. Due to economic constraints and because the lesion was assumed to be of ovarian origin, the patient did not undergo any cross-sectional imaging other than sonography. Sonographically guided fine needle aspiration of the cystic lesion was inconclusive. A cystic schwannoma was diagnosed at laparotomy.

Capillary haemangioma involving the middle and external ear: Radiotherapy as a treatment method

Capillary haemangiomas rarely occur in the auditory canal and have mainly been managed with surgical excision or kept on close follow up for development of symptoms. Radiotherapy, as a treatment method, has not been reported previously in the published work. We describe a study of a capillary haemangioma in the auditory canal of a 26-year-old woman who presented with bleeding. She was treated with radiotherapy, after the lesion was found to be unsuitable for surgery and embolization. The patient remains well 5 years after completion of treatment.

Blind placements of peripherally inserted antecubital central catheters: initial catheter tip position in relation to carina

BACKGROUND

We investigated how often blind placement of peripherally inserted central catheters (PICCs) through the antecubital veins results in a correct tip location in relation to carina and evaluated the inter-observer agreement in locating the tip of PICCs in plain radiography with digital imaging.

METHODS

In this study, 202 suitable chest radiographs with PICCs out of 803 patients were identified. An initial audit on the tip of these catheters in relation to carina was done by a consultant anaesthetist and was recorded as the first observer. The same sets of CXRs were examined by a consultant radiologist and the tips were identified and recorded as the second observer. Inter-observer agreement was assessed.

RESULTS

In 75 of 202 (37%), PICCs had a central tip location in relation to the carina. Fifty-five of 131 (42%) right-sided catheters had a central location compared with 20 of 71 (28%) of the left-sided catheters. The tip position for right-sided catheters was most frequently centrally located whereas the tip for left-sided catheters was most commonly positioned in the ipsilateral innominate vein. There was excellent agreement between the observers in reporting the tip of PICCs at all positions (kappa=0.87) including central locations (kappa=0.83).

CONCLUSIONS

Right antecubital PICCs are more likely to be placed in the central location in relation to the carina. PICCs inserted through the left antecubital veins need to be pushed further down to aim for a central location. Inter-observer variability in identifying the tip of PICCs is least with the introduction of digital imaging.

Solitary fibrous tumor of the lateral ventricle: CT appearances and pathologic correlation with follow-up

Intracranial solitary fibrous tumors are rare, and intraventricular fibrous tumors are even more unusual. We report a case of solitary fibrous tumor in the region of trigone and body of the left lateral ventricle and discuss the clinical presentation, CT characteristics, and histopathologic features with 1-year follow-up. We speculate that the tumor arose from the perivascular connective tissue of the choroid plexus.

Variations in the cerebral venous anatomy and pitfalls in the diagnosis of cerebral venous sinus thrombosis: low field MR experience

BACKGROUND

Knowledge of variations in the cerebral venous anatomy and apparent signal abnormalities seen on Magnetic resonance (MR) angiography are essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST), while interpreting the MR angiograms.

AIMS

To evaluate the variations of cerebral venous anatomy and signal abnormalities by using 3D phase contrast MR angiography performed in a 0.5 Tesla MRI scanner.

MATERIALS AND METHODS

One hundred patients who underwent MR imaging and MR angiography examinations at our institution from March 2004 to February 2005, with normal MR imaging of brain were studied retrospectively. Patients with clinical suspicion of CVST and patients who underwent color doppler evaluation for suspected deep vein thrombosis were excluded.

RESULTS

The superior sagittal, straight sinus and the internal cerebral veins were visualized in all patients. There was hypoplasia of the right transverse sinus in 13 patients, left transverse sinus in 35 patients, right sigmoid sinus in 6 patients and left sigmoid sinus in 19 patients. Absence of transverse sinus on left side was observed in one patient and absence of sigmoid sinus in 2 patients on left side. Flow gaps were observed in non-dominant transverse sinus, sigmoid sinus as well as transverse sigmoid sinus junctions. The occipital sinus was visualized in 17 patients.

CONCLUSIONS

MR angiography done at low field strengths is also a reliable method, for assessing cerebral venous sinuses. Awareness of the normal anatomical variations of venous sinuses and apparent MR angiographic flow gaps prevent misdiagnosis of cerebral venous sinus thrombosis.

Globe calcification in congenital toxoplasmosis

Various patterns of distribution of intracerebral calcification have been described in congenital toxoplasmosis. We report a case of congenital toxoplasmosis with a rare finding of calcification in the globe detected by CT scan that has not been described earlier.

Variations in the cerebral venous anatomy and pitfalls in the diagnosis of cerebral venous sinus thrombosis: low field MR experience

BACKGROUND

Knowledge of variations in the cerebral venous anatomy and apparent signal abnormalities seen on Magnetic resonance (MR) angiography are essential to avoid over-diagnosis of cerebral venous sinus thrombosis (CVST), while interpreting the MR angiograms.

AIMS

To evaluate the variations of cerebral venous anatomy and signal abnormalities by using 3D phase contrast MR angiography performed in a 0.5 Tesla MRI scanner.

MATERIALS AND METHODS

One hundred patients who underwent MR imaging and MR angiography examinations at our institution from March 2004 to February 2005, with normal MR imaging of brain were studied retrospectively. Patients with clinical suspicion of CVST and patients who underwent color doppler evaluation for suspected deep vein thrombosis were excluded.

RESULTS

The superior sagittal, straight sinus and the internal cerebral veins were visualized in all patients. There was hypoplasia of the right transverse sinus in 13 patients, left transverse sinus in 35 patients, right sigmoid sinus in 6 patients and left sigmoid sinus in 19 patients. Absence of transverse sinus on left side was observed in one patient and absence of sigmoid sinus in 2 patients on left side. Flow gaps were observed in non-dominant transverse sinus, sigmoid sinus as well as transverse sigmoid sinus junctions. The occipital sinus was visualized in 17 patients.

CONCLUSIONS

MR angiography done at low field strengths is also a reliable method, for assessing cerebral venous sinuses. Awareness of the normal anatomical variations of venous sinuses and apparent MR angiographic flow gaps prevent misdiagnosis of cerebral venous sinus thrombosis.