Current update on the role of endoanal ultrasound: a primer for radiologists

Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 2: Acquired

The inferior vena cava (IVC) is an uncommon site for primary pathologies and secondary involvement is also infrequent, but involvement of the IVC can often drastically change management. It is therefore important to be cognizant of IVC pathologies. This review discussed common and rare neoplastic and non-neoplastic pathologies of the IVC as well as pathology mimics. Primary and secondary neoplasms can lead to tumour extension or bland thrombus formation and it is often important to distinguish between these two entities. It is also important to be aware of pseudo-lesions for accurate diagnosis. Inferior vena cava filter placement and endovascular treatment of the aorta are commonly performed procedures that can be associated with devastating complications, which are luckily infrequent. The calibre of the IVC also has its own clinical significance. Inferior vena cava pathologies, although rare, have a dramatic impact on the patient's outcome and knowledge of these pathologies is prudent.

Contribution

Understand the principles of IVC imaging, the common as well as the rare primary and secondary IVC tumours, differentiate between tumour thrombus and bland thrombus, and recognise IVC lesion mimics and life-threatening pathologies involving the IVC.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 1: Congenital

The embryology of the inferior vena cava (IVC) is complex, involving the sequential appearance and regression of multiple segments that ultimately form the IVC. Any alteration in this process during embryogenesis can result in congenital anomalies of the IVC. This study aimed to recognise common as well as rare anomalies of the IVC and associated veins, and their clinical implications. The anomalies tend to have diverse appearances based on the timing and segments involved. The development of the IVC is intertwined with the development of other veins like the renal vein, azygos vein and portal vein, and these veins may also be anomalous. Additionally, IVC anomalies are associated with various other congenital anomalies including cardiac anomalies, the recognition of which may be important for patient care. The IVC tends to have multiple normal variants and anomalies because of a complex process involving multiple segments contributing to the adult IVC. Knowledge of these variants is crucial for preoperative planning of procedures.

Contribution

This study would help in understanding the embryogenesis of the IVC and correlation with the imaging appearances and the clinical implications of each of these common as well as rare types of congenital anomalies.

Papillary Urothelial Carcinoma of Urinary Bladder Identified on 18F-Fluciclovine PET/CT

ABSTRACT

18F-fluciclovine is a radiolabeled synthetic amino acid recently approved by the Food and Drug Administration for evaluating recurrent prostate cancer. Upregulated amino acid transporters in prostate cancer cells result in elevated radiotracer uptake in sites of tumor recurrence. However, 18F-fluciclovine is not specific for prostate cancer. Nonprostatic malignancies and benign conditions can also demonstrate uptake. This information combined with the knowledge about common patterns of prostate cancer recurrence helps guide appropriate management. We present an 87-year-old man with biochemical recurrence for prostate cancer but found to have a urinary bladder wall mass on 18F-fluciclovine PET/CT with moderate avidity. Biopsy revealed papillary urothelial carcinoma.

Multimodality imaging of adult gastric emergencies: A pictorial review

Acute gastric emergencies require urgent surgical or nonsurgical intervention because they are associated with high morbidity and mortality. Imaging plays an important role in diagnosis since the clinical symptoms are often nonspecific and radiologist may be the first one to suggest a diagnosis as the imaging findings are often characteristic. The purpose of this article is to provide a comprehensive review of multimodality imaging (plain radiograph, fluoroscopy, and computed tomography) of various life threatening gastric emergencies.

Multimodality imaging spectrum of complications of horseshoe kidney

Horseshoe kidney is the most common congenital renal fusion anomaly with an incidence of 1 in 400–600 individuals. The most common type is fusion at the lower poles seen in greater than 90% of the cases, with the rest depicting fusion at the upper poles, resulting in an inverted horseshoe kidney. Embryologically, there are two theories hypothesizing the genesis of horseshoe kidney – mechanical fusion theory and teratogenic event theory. As an entity, horseshoe kidney is an association of two anatomic anomalies, namely, ectopia and malrotation. It is also associated with other anomalies including vascular, calyceal, and ureteral anomalies. Horseshoe kidney is prone to a number of complications due to its abnormal position as well as due to associated vascular and ureteral anomalies. Complications associated with horseshoe kidney include pelviureteric junction obstruction, renal stones, infection, tumors, and trauma. It can also be associated with abnormalities of cardiovascular, central nervous, musculoskeletal and genitourinary systems, as well as chromosomal abnormalities. Conventional imaging modalities (plain films, intravenous urogram) as well as advanced cross-sectional imaging modalities (ultrasound, computed tomography, and magnetic resonance imaging) play an important role in the evaluation of horseshoe kidney. This article briefly describes the embryology and anatomy of the horseshoe kidney, enumerates appropriate imaging modalities used for its evaluation, and reviews cross-sectional imaging features of associated complications.

Problem-solving with MRI in acute abdominopelvic conditions, part 1: gastrointestinal, hepatobiliary, and pancreatic diseases

The purpose of this article is to review the benefit and added value and advantages of magnetic resonance imaging (MRI) compared with other cross-sectional imaging in patients presenting with abdominopelvic emergencies. During the past decade, there has been increased utilization of MRI in the emergency department with widespread availability of MR scanners, improvement in rapid imaging techniques, and methods to overcome motion-related artifacts. This has benefited patients at higher risk of radiation, particularly children and pregnant women, and patients with contraindications to iodinated contrast including allergy and renal dysfunction. Still the challenges are: on site MR scanner in the emergency department, after-hour services, as well as availability of time slot to rapidly scan emergency patient. MRI has additional advantages over other imaging modalities due to its high contrast resolution, which allows it to better characterize tissue and fluid collections, and may avoid the need for intravenous contrast. Radiologists must be familiar with the role and added value of MRI, spectrum of imaging findings, and problem-oriented modified MR protocols in abdominal and pelvic emergencies. In part 1, we will discuss the utility of MRI in gastrointestinal, hepatobiliary, and pancreatic diseases. In part 2, the authors will focus on the key MR imaging features of female pelvic gynecological diseases, pregnancy related complications, abdominal vascular complications, and renal diseases.

Imaging spectrum of common and rare infections affecting the lower genitourinary tract

In this review, we will discuss the imaging findings of common as well as uncommon lower genitourinary tract infections. For both clinicians and radiologists, it is imperative to understand etiopathogenesis, epidemiological information, clinical presentation, imaging findings and management options of such conditions. Knowledge of salient imaging features of these infections is of utmost importance because prompt recognition enables appropriate management.

Imaging of ureter: a primer for the emergency radiologist

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Rare presentation of chronic recurrent multifocal osteomyelitis of the Iliac wing mimicking Ewing's sarcoma

This report describes a case of chronic recurrent multifocal osteomyelitis (CRMO) in an 11-year-old girl, involving the iliac bone as an initial, solitary site. Atypical imaging features were suspicious of a bone tumour, such as Ewing's sarcoma. Chronic recurrent multifocal osteomyelitis is a great masquerader and can present atypically. Radiologists should be familiar with both typical and atypical presentations, to determine an accurate diagnosis and guide appropriate management. Timely diagnosis may avoid invasive bone biopsy and inappropriate long-term antibiotic prescription for children.

"Perifollicular rim sign" in an enlarged ovary-an additional non-contrast CT finding in ovarian torsion

PURPOSE

To look for the presence of "perifollicular rim sign" on non-contrast CT in surgically proven cases of ovarian or adnexal torsion.

METHODS

A retrospective analysis of abdominopelvic non-contrast CT examinations in surgically proven cases of ovarian or adnexal torsion was conducted seeking the presence of "perifollicular rim sign" in torsed ovaries. "Perifollicular rim sign" was defined as a complete ring of perifollicular hyperdensity around ovarian follicles with an attenuation value of > 50 HU and thickness > 1-2 mm. A positive sign was equated to the presence of perifollicular hemorrhage. Pre-operative non-contrast CT was available in 7 out of the 39 ovarian or adnexal torsions included in our study.

RESULTS

"Perifollicular rim sign" was present in 5 out of the 7 ovarian torsions on pre-operative non-contrast CT. MRI correlation was available in one patient. Ovarian enlargement (>4 cm) was present in all 7 cases.

CONCLUSION

In an appropriate clinical setting, presence of "perifollicular rim sign" in an enlarged ovary on non-contrast CT examination can be considered a useful additional sign for ovarian torsion.

Extraprostatic extension in prostate cancer: primer for radiologists

The presence of extraprostatic extension (EPE) on multiparametric MRI (mpMRI) is an important factor in determining the management of prostate cancer. EPE is an established risk factor for biochemical recurrence of prostate cancer after radical prostatectomy (RP) and patients with EPE may be considered for wider resection margins, non-nerve-sparing surgery, adjuvant radiation therapy (RT), or androgen deprivation therapy (ADT). Several statistical nomograms and scoring systems have been developed to predict pathological stage at time of RP but with varying accuracies. Using the current PI-RADS v2 mpMRI staging guidelines results in high specificity but lacks in sensitivity. These findings reveal the need for more standardization and further refinement of existing MRI protocols and prostate cancer prediction tools. Current studies have looked into indirect additional imaging criteria such as index tumor volume, length of capsular contact, and apparent diffusion coefficient. Measuring for these features can improve the robustness of mpMRI in staging prostate cancer, as they have been shown to be independent predictors of EPE. MRI/ultrasound fusion-guided targeted biopsy can detect EPE not found on standard biopsy. Collectively, these measurements and imaging techniques can augment the detection of EPE and subsequent risk stratification.

Imaging of non-epithelial neoplasms of the prostate

The purpose of this article is to review the spectrum of rare non-epithelial tumors of the prostate. This focused article will help the readers to understand the imaging findings of such rare entities attributed to their clinicopathological features. Radiologists must be familiar with the spectrum of non-epithelial tumors of the prostate, which helps to suggest alternate diagnosis other than adenocarcinoma, when imaging features are atypical. This is important because these tumors have different management approaches and prognoses when compared to adenocarcinoma of the prostate.

Agenesis of the piriformis muscle: A case report with review of literature

Agenesis of the piriformis muscle is an extremely rare occurrence. Knowledge about this anatomic variant is important because of its close proximity with the sciatic nerve and sacral plexus. The piriformis muscle also serves as an important anatomic landmark for image-guided intervention and hip surgery. We report a case of piriformis muscle agenesis in a 28-year-old woman, incidentally detected on magnetic resonance imaging of the lumbosacral spine and pelvis, performed for low back pain.

A pictorial review of non-traumatic adrenergic crisis

Non-traumatic adrenal crisis is a rare but critical diagnosis to make in emergency settings due to grave consequences. Various pathologies can present as acute crisis, such as spectrum of endocrine imbalance, ranging from catecholamine excess in pheochromocytomas to acute adrenal insufficiency related to glandular dysfunction. Critical manifestations may be due to structural causes related to adrenal hemorrhage, especially when they are bilateral. Oncological complications such as vascular invasion, tumoral bleed, rupture, and hormonal dysfunction can occur. Due to non-specific clinical presentation, these conditions may come as a surprise on imaging performed for other reasons. Recognition of these imaging findings is critical for appropriate patient management. Although there are few articles discussing non-traumatic emergencies in literature, this review is inclusive of all possible etiologies, thus provides a holistic approach and insight into each situation. Specific imaging approach is needed to tailor the diagnosis. This article will also discuss about the advanced imaging techniques that will complement diagnosis.

Desmoplastic Infantile Ganglioglioma Masquerading as an Arachnoid Cyst

Desmoplastic infantile ganglioglioma (DIG) is a rare supratentorial brain tumor, which is usually diagnosed before the age of two and has a favorable prognosis. To date, only a few cases have been reported in the literature. We report a case of DIG in a three-month-old boy who presented to our pediatric emergency department with decreased activity and excessive crying. This case report highlights the computed tomography (CT) and magnetic resonance imaging (MRI) findings of this rare tumor. Non-contrast CT scan findings in our case initially masqueraded as an extra-axial arachnoid cyst; however, the MRI findings after contrast agent administration were typical for the diagnosis of DIG.

Imaging of non-traumatic urinary bladder emergencies

Non-traumatic urinary bladder emergencies are rare but critical diagnoses to make in an emergency setting. Acute urinary bladder pathologies require an accurate and timely diagnosis to ensure a favorable clinical outcome. Multidetector computed tomography (CT) is the imaging modality of choice for acute and emergent conditions affecting the urinary bladder. MRI is helpful as a problem-solving modality due to better soft tissue characterization and higher in-plane resolution. The purpose of this article is to illustrate the spectrum of urinary bladder emergencies, review the imaging findings, and briefly describe the role of imaging in the evaluation of such patients. Although there are a few cases of bladder emergencies been reported separately, the literature summarizing the spectrum is lacking. The objective of this article is to review the imaging of acute emergencies involving urinary bladder that will help us to think beyond non-specific conclusion in an emergency setting. For the sake of focused discussion, traumatic bladder emergencies will be excluded in this review. In the era of highly image reliant clinical practice, radiologists must be familiar with the diagnostic strategy to approach these entities.

Utility of MRI in Management of a Rare Case of Unilateral Dichorionic-Diamniotic Twin Tubal Ectopic Pregnancy

Twin tubal ectopic pregnancies are rare events but critical diagnoses to make in emergency settings. They are common in patients who received in vitro- fertilization and in those with history of PID. Unless 2 embryos are live with detectable heart beats, ultrasound cannot definitely diagnose twin tubal EP. In clinically stable patients, MRI may provide other concrete findings to establish the diagnosis and lead to better management. In literature, to best of our knowledge, there has been no reported case of twin tubal EP evaluated with MRI. In this article, we have briefly reviewed the role of MRI in different types of EP and its limitations. We report an interesting case of ruptured tubal twin EP diagnosed with MRI which was sub optimally evaluated with ultrasound.

"The Great Masquerader": Sonographic Pictorial Review of Testicular Tuberculosis and its Mimics

Testicular tuberculosis (TB) is an uncommon presentation of extrapulmonary TB. Although rare in incidence, it is a great masquerader and should be kept in consideration while assessing focal abnormalities involving the testis. Ultrasound findings alone may be non-specific and mimic other diagnoses including infection, inflammation, tumor, infarct, and trauma. The main objective of this sonographic pictorial review is to discuss the imaging findings, specific differentiating features against each differential and use of ancillary imaging findings whenever available. Concurrent involvement of epididymis, septated hydrocele, scrotal wall edema, and calcification of tunica vaginalis provides strong evidence in an appropriate setting. Available extratesticular ancillary imaging findings must be correlated for correct diagnosis due to non-specific imaging and clinical presentation. Misdiagnosis of scrotal TB may lead to otherwise avoidable epididymo-orchiectomy.

Common Soft Tissue Tumors Involving the Hand with Histopathological Correlation

Soft tissue tumors involving the hand are common and most often benign. It is important to know the spectrum of soft tissue tumors of the hand and understand the typical as well as atypical imaging features are seen on different imaging modalities. The imaging features are largely determined by the tumor histopathology; thus, the basic idea about the tumor histopathology will always be useful. This article intends to focus on a comprehensive approach including demographics, clinical presentation, and imaging findings required to diagnose the tumor definitely or narrow the differentials. This article discusses common soft tissue tumor mimics of the hand as well, however, excludes the bone tumors for the sake of brevity.

Abnormal descent of the testis and its complications: A multimodality imaging review

Cryptorchidism refers to an absence of the testis in the scrotal sac. Testicular descent occurs in two stages: transabdominal and gubernacular. The descent of the testis can be arrested in its usual path of descent (true undescended testis) or can migrate from the usual path of descent (ectopic testis). Localising the missing testis is important for surgical planning, as well as for identification of complications that are more common with cryptorchidism. Ultrasound is the initial imaging modality to visualise, as well as localise the testis in cryptorchidism. However, ultrasound imaging is limited in visualising testes that are not superficial in location. This article highlights various examples of abnormal descent of the testis in usual as well as unusual locations and complications of undescended testes. Further evaluation with computed tomography scan or magnetic resonance imaging is needed in indeterminate cases and for identification of complications. We have highlighted the role of specific modalities with imaging findings in this pictorial review for the appropriate selection of each modality in clinical practice.

Chart-stimulated Recall as a Learning Tool for Improving Radiology Residents' Reports

RATIONALE AND OBJECTIVES

Workplace-based assessments gauge the highest tier of clinical competence. Chart-stimulated recall (CSR) is a workplace-based assessment method that complements chart audit with an interview based on the residents' notes. It allows evaluation of the residents' knowledge and heuristics while providing opportunities for feedback and self-reflection. We evaluated the utility of CSR for improving the radiology residents' reporting skills.

MATERIALS AND METHODS

Residents in each year of training were randomly assigned to an intervention group (n = 12) or a control group (n = 13). Five pre-intervention and five post-intervention reports of each resident were independently evaluated by three blinded reviewers using a modified Bristol Radiology Report Assessment Tool. The study intervention comprised a CSR interview tailored to each individual resident's learning needs based on the pre-intervention assessment. The CSR process focused on the clinical relevance of the radiology reports. Student's t test (P < .05) was used to compare pre- and post-intervention scores of each group.

RESULTS

A total of 125 pre-intervention and 125 post-intervention reports were evaluated (total 750 assessments). The Cronbach's alpha for the study tool was 0.865. A significant improvement was seen in the cumulative 19-item score (66% versus 73%, P < .001) and the global rating score (59% versus 72%, P < .001) of the intervention group after the CSR. The reports of the control group did not demonstrate any significant improvement.

CONCLUSION

CSR is a feasible workplace-based assessment method for improving reporting skills of the radiology residents.

Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes

Although large bowel obstruction (LBO) is less common than small bowel obstruction, it is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. Plain radiographs are sufficient to diagnose LBO in a majority of patients. However, further evaluation with multidetector computed tomography (MDCT) has become the standard of care to identify the site, severity, and etiology of obstruction. In this comprehensive review, we illustrate the various causes of LBO emphasizing the role of MDCT in the initial diagnosis and detection of complications along with the tips to differentiate from disease which can mimic LBO.

Upper gastrointestinal endoscopy: expected post-procedural findings and adverse events

Complications related to endoscopy are commonly encountered in the emergency department (ED) due to an increased use of outpatient diagnostic and therapeutic upper gastrointestinal endoscopic procedures. A majority of these procedures are performed on an outpatient basis, and patients with post-procedural symptoms may return to the ED. Since these patients often undergo computed tomography (CT) for diagnosis of post-procedure complications, the emergency radiologist should be familiar with the spectrum of expected post-procedural findings, as well as common and rare complications. We present a pictorial review of post-endoscopy complications and review imaging protocols in different clinical scenarios.

Prostate MRI: access to and current practice of prostate MRI in the United States

PURPOSE

MRI of the prostate has increasingly become more important in clinical medicine because of the risk of over-detection of low-grade, low-volume prostate cancer, as well as because of the poor sampling of transrectal ultrasound-guided prostate biopsy in high-risk patients. We sought to determine the access, imaging protocols, and indications for MRI imaging of the prostate in the United States.

METHODS

A brief survey was sent through mailing lists to members of the Society of Abdominal Radiology and Texas Radiological Society.

RESULTS

Thirty-six academic centers responded to the survey, 88.9% of which routinely perform prostate MRI. Nine centers routinely performed imaging at 1.5T with an endorectal coil (25%), 11 performed at 3.0T without an endorectal coil (31%), and 10 performed at 3.0T with an endorectal coil (28%). All institutions used T1-weighted axial and orthogonal T2-weighted sequences. Most groups used diffusion-weighted imaging (94.7%) and dynamic contrast enhancement (81.6%). Only 21.1% of groups performing prostate MRI routinely performed MR spectroscopy as part of their protocol.

CONCLUSIONS

Prostate MRI is becoming a commonly performed examination at academic institutions, with most locations performing prostate MRI at minimum standards. There is a need to educate nonacademic practices regarding the addition of functional MRI techniques to anatomic techniques, increase the number of institutions that regularly perform prostate MRI, and increase access to direct MRI-guided biopsy in institutions that perform prostate MRI on a regular basis.

Adrenal collision tumors and their mimics: multimodality imaging findings

Adrenal collision tumors (ACTs) refer to coexistence of two adjacent, but histologically distinct neoplasms involving the adrenal gland without histologic admixture at interface. ACTs include adenoma with myelolipoma, adenoma with metastases, hemangioma with adenoma, and adrenocortical carcinoma with myelolipoma. In addition, hemorrhage into a pre-existing adrenal mass can mimic an ACT, and it is important to differentiate these two pathologies. Accurate characterization of ACTs is difficult, but critical, for correct staging of patients with malignancies and to guide percutaneous biopsy. Magnetic resonance imaging (MRI) and multidetector computed tomography imaging techniques may depict different tumor components separately; however, biopsy may be required in selected patients for confirmation. [¹⁸F]Fluorodeoxyglucose-positron emission tomography (PET) shows increased uptake in the malignant component of ACTs, and guides percutaneous biopsy. Even in patients requiring percutaneous biopsy for a definite diagnosis, imaging findings can help in guiding the appropriate component to be biopsied. Knowledge of imaging findings of different ACTs and their mimics on MRI, computed tomography, and PET help in optimal patient management.

Current concepts in the imaging of uterine sarcoma

Recent advances in genetics and pathology have improved our understanding of diagnosis and staging of uterine sarcomas. The major types of uterine sarcomas include leiomyosarcoma, low-grade endometrial stromal sarcoma, undifferentiated endometrial sarcoma, adenosarcoma and carcinosarcoma. The distinctive biological behavior and poor overall survival of uterine sarcoma create challenges in the management of these tumors. We herein present a comprehensive review of taxonomy, epidemiology, pathology, imaging findings and natural history of a wide spectrum of uterine sarcomas.

MDCT of abdominopelvic oncologic emergencies

Acute complications arising in abdominopelvic malignancies represent a unique subset of patients presenting to the emergency room. The acute presentation can be due to complications occurring in the tumor itself or visceral or vascular structures harboring the tumor. Multidetector computed tomography (MDCT) is the investigation of choice in the workup of these patients and enables appropriate and timely management. Management of the complication depends primarily on the extent of the underlying malignancy and the involvement of other viscera. The purpose of this article is to depict the imaging features of these complications on MDCT.

Imaging of tuberculosis of the abdominal viscera: beyond the intestines

There is an increasing incidence of both intra- and extra-thoracic manifestations of tuberculosis, in part due to the AIDS epidemic. Isolated tubercular involvement of the solid abdominal viscera is relatively unusual. Cross-sectional imaging with ultrasound, multidetector computed tomography (CT), and magnetic resonance imaging (MRI) plays an important role in the diagnosis and post treatment follow-up of tuberculosis. Specific imaging features of tuberculosis are frequently related to caseous necrosis, which is the hallmark of this disease. However, depending on the type of solid organ involvement, tubercular lesions can mimic a variety of neoplastic and nonneoplastic conditions. Often, cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis, and image-guided tissue sampling is needed. In this article, we review the pathology and cross-sectional imaging features of tubercular involvement of solid abdominopelvic organs with a special emphasis on appropriate differential diagnoses.

Abdominal Hemangiomas: A Pictorial Review of Unusual, Atypical, and Rare Types

Hemangiomas are a radiologist's dream lesions because they allow a confident diagnosis most of the time. However, within the abdomen, hemangiomas may occur in such atypical locations and can have such unusual features that they cause significant diagnostic dilemma and may end up being excised surgically. The literature is replete with isolated case reports of atypical hemangiomas in the abdominal cavity, and, to our knowledge, so far, there is no comprehensive review. We present, in this article, a pictorial review of a gamut of uncommon hemangiomas and hemangiomatosis syndromes. Knowledge of these rare types can help in limiting diagnostic errors and increase the confidence of radiologists, thus avoiding unnecessary surgeries.

Non-Invasive Diagnosis of Abdomino-Pelvic Masses: Role of Multimodality Imaging

Recent advances in radiology have greatly increased the ability to make highly accurate diagnosis. Biopsy of many commonly seen lesions is no longer performed as the radiological findings are pathognomonic. This gives rise to the concept of ‘virtual biopsy’, a term coined on the lines of other imaging techniques such as virtual colonoscopy. Virtual biopsy is not a new imaging technique but a new concept which refers to the use of existing imaging modalities to evaluate the morphological features of tumors and arriving at a non-invasive diagnosis with a high degree of confidence obviating the need for true biopsy. Elements of virtual biopsy have already been incorporated into some evidence-based guidelines, and it is expected that with further technological advancements, an increasing number of tumors may be diagnosed and managed accordingly. A wider acceptance of virtual biopsy could further reduce the need for invasive biopsies and its attendant costs and risks. In this review article, we use index cases to further emphasize this concept.

Real time spatial compound ultrasound in the evaluation of meniscal injuries: a comparison study with conventional ultrasound and MRI

The aim of this study was to compare real time spatial compound ultrasound (RTCS) and conventional ultrasound with MRI in the evaluation of meniscal injuries. Thirty five patients with clinical suspicion of meniscal injury underwent ultrasound of knee alternating between conventional and compound sonography followed by MRI of the knee on a 1.5 T MR system. The images were compared for their quality and ability to detect meniscal tear. Compound ultrasound significantly improved definition of soft tissue planes, reduced speckle and other noise, improved contrast resolution (p value<0.05) with improved confidence in detection of tears in doubtful cases. Interobserver variability was seen only for conventional ultrasound and the sensitivity, specificity, accuracy were 83.3%, 87.5% and 85.7% for the first observer and 80%, 87.5% and 84.3% for second observer. For compound ultrasound it was same for both the observers with sensitivity, specificity and accuracy being 90% each. Although compound ultrasound improves image quality in the evaluation of meniscal injuries the benefit with respect to detection of tears is only marginal. It is a valuable tool for screening the patients before MRI and we recommend that instead of conventional ultrasound, compound ultrasound should be routinely used for sonographic evaluation of meniscal injuries.

Basilar artery aneurysm treated with coil embolization via persistent primitive hypoglossal artery

A saccular aneurysm at the basilar artery bifurcation associated with a persistent primitive hypoglossal artery (PPHA) was successfully treated by endovascular occlusion with Guglielmi detachable coils. As both vertebral arteries were aplasitc, a microcatheter was advanced via PPHA. To the best of our knowledge, this is the first case report describing the treatment of a basilar top aneurysm through the PPHA.

Multidetector CT angiography in pulmonary sequestration

PURPOSE

To evaluate the role of multidetector CT angiography in the diagnosis and preoperative assessment of pulmonary sequestration with angiographic or surgical correlation.

METHODS

Eight patients (5 males, 3 females) in the age range of 2 days to 35 years suspected of having pulmonary sequestration on the basis of clinical history and chest radiographs were included in the study. All patients underwent CT angiography (4 or 16 slice) and MPVR, MIP and 3D volume rendered images were generated. The axial images were also reviewed at soft tissue and lung window settings to evaluate the parenchymal changes.

RESULTS

CT angiography showed five pulmonary sequestrations on the left and three on the right, located in the basal segments (n = 7) or paravertebral region (n = 1). Aberrant systemic arterial supply was demonstrated in all cases: from the descending thoracic aorta (n = 2); abdominal aorta (n = 3) and celiac axis (n = 3). Venous drainage into inferior pulmonary veins was demonstrated in 4 patients. The angioarchitecture depicted on CT angiography was confirmed on surgery in five patients and by DSA in two patients who subsequently underwent embolization using PVA particles and/or coils.

CONCLUSION

The ability of CT angiography to simultaneously image the arterial supply, venous drainage and parenchymal changes in a single examination makes it the imaging modality of choice for the diagnosis and preoperative assessment of pulmonary sequestration.

Primary Ewing′s sarcoma of occipital bone

Ewing′s sarcoma commonly involves the long bones. Primary Ewing′s sarcoma of the cranium is rare and is difficult to distinguish from other tumors involving the cranium. Radiological features and immuno-histochemistry are helpful in diagnosing this tumor. In this report we present a rare case of primary Ewing′s sarcoma of the occipital bone and discuss the differential diagnostic options.

Tuberculous abscess of the thyroid gland: a report of two cases

Tuberculosis of the thyroid gland is very rare, with an acute abscess formation being the least common form of presentation. We report the sono-graphic features of two cases of tuberculous thyroid abscess that were confirmed via ultrasound-guided fine needle aspiration biopsy.

Preoperative embolization of a large vaginal leiomyoma: Report of a case and review of the literature

Leiomyoma of the vagina is a very rare tumour of the lower urogenital tract. These slow-growing masses may be asymptomatic or present with pain, dyspareunia or urinary symptoms. Rarely, these tumours may present with life-threatening haemorrhage. These hypervascular tumours are treated by surgical excision. Preoperative embolization therefore may aid in devascularization of these tumours before surgical excision. We present the MRI features of a case of vaginal leiomyoma, which was managed by preoperative embolization and was then excised in toto. To the best of our knowledge, this is the first report where preoperative embolization was performed before excision of a vaginal leiomyoma with minimal peroperative blood loss.