Doppler study of middle cerebral artery and umbilical artery in biometrically suspected intra uterine growth restricted pregnancies

Background: Intra uterine growth restricted (IUGR) is when the expected foetal weight is less than 10th percentile for gestational age. The hemodynamics of the feotus takes into account both the umbilical-placental and cerebral vascular beds. Underlying etiology that results in the failure of a foetus to attain its expected growth may vary. However the final infliction is via uteroplacental insufficiency. It is highlighted that inadequate uteroplacental perfusion is the main and primary pathology in growth restriction resulting in an increased umbilical artery impedance. Following this step are the changes in the middle cerebral artery (MCA) which categorically set in as a secondary phenomenon.Methods: Duplex Doppler Sonography is a reliable, non- invasive and rapid diagnostic technique in IUGR patients. Grey scale findings together with colour Doppler characteristics help in the qualitative as well as quantitative evaluation of the Uteroplacental and Fetoplacental circulation. Hence ultrasonography (USG) has become the most widely used, standard and simple way of detecting and confirming IUGR. Ultrasound biometry is the gold standard for assessment of foetal size. Various criteria are used to label a feotus growth restricted; foetal weight less than 10th percentile for gestational age is mostly widely accepted criterion. Others like elevated HC/AC ratio, elevated FL/AC ratio, and presence of oligohydramnios without ruptured membranes, presence of advanced placental grade can also be used for improving the accuracy of diagnosis. After establishing the diagnosis of IUGR, Doppler imaging becomes a valuable investigating method for monitoring the pregnancy because it provides information about the hemodynamic status of the feotus. Uteroplacental system evaluation takes into account the flow pattern of uterine artery, reflecting any underlying Uteroplacental vascular ischemia. Umbilical artery Doppler waveforms reflect the status of the fetoplacental circulation and any underlying placental insufficiency.Results: Fourteen cases showed absent umbilical artery end diastolic flow and four patients showed reversal of end diastolic flow.: Twenty two patients showed elevated PI. Adverse perinatal outcome was observed in all patients with absent and reversal of end diastolic flow. Out of the twenty two with elevated PI fifteen showed adverse outcome. Thirty six cases showed low MCA PI and six showed a pseudonormalization. A cerebro -placental ratio of < 1.08 was observed in 16 patients, it was calculated in only those pregnancies that showed forward diastolic flow in umbilical artery (n= 22). Fifteen of them showed adverse perinatal outcome.Conclusions: Doppler imaging is of value for monitoring pregnancies complicated with IUGR because it can provide indirect evidence of foetal compromise and is known to improve outcome of high risk pregnancies. Doppler evaluation is complementary to all other surveillance modalities. Because the changes in umbilical, uterine & MCA strongly correlate with pregnancy outcome in growth restricted foetuses the use of foetal biometry & Doppler examination is recommended in all cases of suspected IUGR cases

Bilateral retrorenal colon-a case report

Ascending and descending colon normally lie in anterior pararenal space anterior to kidneys. Extension of colon behind kidney is rare. It is more frequently found on the left side behind lower pole of the left kidney. Bilateral retrorenal colon is rare. Its detection is important prior to Retrorenal, Percutaneous nephrolithotomy (PCNL) to avoid complications. We report a case of bilateral retrorenal colon detected incidentally in a case of obstructive jaundice

Post craniectomy paradoxical brain herniation: a case report with radiological review

Sinking skin flap (SSF) syndrome and paradoxical brain herniation are rare complications after craniectomy. On CT scan, there is shrunken appearance of the skin flap at craniectomy site. The meningogaleal complex is drawn inwards and is resting on underlying deformed brain with resultant concave surface. It results due to altered CSF hydrodynamics. Paradoxical brain herniation is rare complications which occur in patients who undergo cerebrospinal fluid (CSF) drainage procedures like lumbar puncture (LP), external ventricular drainage, ventriculo-peritoneal shunting and post craniectomy. Its early detection on imaging is essential as it is a neurosurgical emergency. We report a case of 75 year old male previously operated for left chronic subdural hematoma in the left fronto-temporo-parietal region presenting with altered consciousness and inability to walk. Plain CT scan showed craniectomy defect in the left fronto-temporo-parietal region with indrawing of meningogaleal complex suggestive of Shrunken Skin Flap. There was mass effect on the left lateral ventricle and third ventricle with shift of the midline structures towards right (1cm) with evidence of subfalcine herniation suggestive of paradoxical brain herniation

Renal Cell Carcinoma Arising from Isthmus of Horseshoe K

The most common congenital renal fusion anomaly is the horseshoe kidney (HSK) occurring in about 1 in 600–700 individuals in the Indian population. HSKs are associated with problems such as renal stones, obstruction of uretero-pelvic junction causing stasis, and infection due to ectopic location of the kidneys, malrotation of the kidneys, and vascular changes. In general, normally developed kidneys have more incidents of renal cell carcinoma (RCC) as compared to HSKs. The major issue arises during surgery of HSK due to their altered anatomy and aberrant blood supply. We present a case of HSK with RCC located in the isthmus of a 43-year-old woman

Renal Cell Carcinoma Arising from Isthmus of Horseshoe K

The most common congenital renal fusion anomaly is the horseshoe kidney (HSK) occurring in about 1 in 600–700 individuals in the Indian population. HSKs are associated with problems such as renal stones, obstruction of uretero-pelvic junction causing stasis, and infection due to ectopic location of the kidneys, malrotation of the kidneys, and vascular changes. In general, normally developed kidneys have more incidents of renal cell carcinoma (RCC) as compared to HSKs. The major issue arises during surgery of HSK due to their altered anatomy and aberrant blood supply. We present a case of HSK with RCC located in the isthmus of a 43-year-old woman

High diagnostic value of gradient echo sequence in isolated cortical vein thrombosis

Isolated cortical vein thrombosis is quite less common than dural venous sinus thrombosis. Its diagnosis is difficult and needs high index of suspicion clinically and on magnetic resonance imaging (MRI). A 38-year-old man presented with the history of three episodes of generalized seizures and weakness and sensory loss in the both upper limbs with headache. MRI brain with magnetic resonance venography (MRV) was performed. MRI brain showed hemorrhagic infarcts in bilateral frontoparietal region. Gradient echo sequence showed hypo-intense signal within thrombosed cortical veins. MRV showed paucity of cortical veins in involved areas suggestive of cortical vein thrombosis

Thyroid hemiagenesis with isthmic agenesis: A case report with review of the literature

Thyroid hemiagenesis (THG) is a rare congenital anomaly in which one lobe of thyroid gland fails to develop. Agenesis may be unilateral, total or isthmic. Left thyroid lobe is commonly involved than right lobe in hemiagenesis. Clinically patients can be euthyroid, hypothyroid or hyperthyroid. Often it is diagnosed as an incidental finding during ultrasonography (USG) study of neck, which easily diagnose this condition. Actual incidence of THG is unknown, most cases are diagnosed in patients admitted for thyroid scan or thyroid surgery because of suspicion of other thyroid abnormalities. This explains high frequency of association of hemiagenesis with other thyroid abnormalities such as multinodular goiter, adenoma, hyperthyroidism, hypothyroidism, chronic thyroiditis, and carcinoma. We report a case of 58-year-old male patient detected to have hemiagenesis of left thyroid lobe and isthmus when USG neck was performed for carcinoma right buccal mucosa with metastatic cervical lymphadenopathy

Static MR urography in obstructive uropathy and congenital anomalies in adults and paediatric age

Background: Magnetic Resonance Urography (MRU) provides anatomical imaging of the renal system and urinary tract and is useful in both adults and paediatric patients. Functional MR urography enables differential renal function to be determined and allows the measurement of renal excretion into the collecting systems. The utility of MRU in adult patients who had obstructive uropathy was evaluated in this study to determine the extent and cause of obstruction. Paediatric patients were assessed for anatomical imaging and obstruction thresholds for possible congenital abnormalities.Method: This was a prospective, observational study conducted at a tertiary centre for over a period of 2 years. Total of 62 cases, both adult and paediatric patients were examined under Siemens Avanto Magnetic Resonance Imaging (1.5 Tesla). Data was collected on a pretested proforma, entered in excel sheet and quantitative data was summarised with MEAN and SD.Results: Age: Mean age of the subjects was 39.17. The majority were males at 59.67% (37) and females constituted 40.33% (25). The mean duration of symptoms was 16.52 days. Flank pain was most common presenting complaint in 53.23%. 32.26% of the lesions were observed in kidney, 12.90% in renal pelvis, 6.45% each in upper and mid ureter, 16.13% in distal ureter, 19.35% at PUJ, 4.84% in urinary bladder, 9.68% in urethra. 5 patients had bilateral lesions, 38 had right sided involvement and 13 had left sided involvement. Significant number of paediatric patients had congenital lesions and lesser number of acquired lesions when compared to adults with a P value of 0.000249.Conclusion: Static MR-Urography was useful in detecting the exact aetiology of obstructing lesions presenting in varied aged groups including congenital and acquired lesions. Most common reasons for obstructive uropathy was noted to be lesions in kidney followed by those in pelvis and the ureters. Significant number of paediatric patients presented with congenital lesions compared to the adults who had higher number of acquired lesions. We suggest static MR-Urography is one of the ideal diagnostic tests in diagnosis of cases with obstructive uropathy

Utility of structural MRI and DWI in evaluation of uterine and adnexal lesions

Background: In females, uterine and adnexal pathologies have been the common cause of morbidity. Accurate diagnosis is of utmost importance for timely intervention, which can be done with good accuracy by Magnetic Resonance Imaging (MRI).Diffusion weighted imaging (DWI) is a functional imaging sequence which works on the principle of random mobility of water molecules within the tissues. MRI with DW Imaging emerged as an optimistic tool in detection and characterization of various uterine and adnexal lesions, their anatomical extension, understanding the pathophysiology by ADC values which further helps in differentiation of benign from malignant lesions. Methods: This was a prospective, observational study conducted at a tertiary center for over a period of 2 years with 100 patients of all age groups suspected of uterine and adnexal lesions, examined under Siemens Avanto Magnetic Resonance Imaging (1.5 Tesla). The mean differences in ADC between benign and malignant were compared using a student t-test. Accuracy of ADC Cut off value to differentiate benign from malignant lesions were assessed by Kappa statistic. Results: The mean ADC value for benign uterine lesions was 1.33 + 0.18 ×10-3 mm2/s and for malignant lesions was 0.77 + 0.08 ×10-3 mm2/s with an ADC cut off value of 0.92×10-3mm2/s was suggested for differentiating benign from malignant uterine lesions. The mean ADC value for benign adnexal lesions was 1.35 +78 ×10-3 mm2/s and for malignant lesions was 0.91 + 0.03 ×10-3 mm2/s. Few benign lesions showed ADC values lower than malignant lesions. The mean ADC value for endometriomas was 0.69 + 0.03 ×10-3 mm2/s and the mean ADC value for tubo-ovarian abscess was 0.46+ 0.06 x×10-3 mm2/s. Hence statistically, ADC cut off value of 0.96×10-3mm2/s was not significant in differentiating benign from malignant adnexal lesions with a kappa value of 0.3 and p-value of 0.37.From our study, the sensitivity, specificity, positive predictive, negative predictive value and accuracy of MRI in detecting and differentiating benign and malignant uterine and adnexal lesions was 95%, 100%, 100%, 98.72% and 99% respectively with a strong kappa value. Conclusion: From our study we have concluded that diffusion weighted imaging has a notable role in differentiating benign from malignant uterine lesions rather than adnexal lesions. However, irrespective of ADC values, a complete analysis of the lesions utilizing all sequences we had observed that MRI had a sensitivity, specificity and accuracy in detecting uterine and adnexal lesions

Role of high-frequency linear probe in ultrasound diagnosis of biliary atresia

Cause of cholestatic jaundice in early infancy continues to be a diagnostic dilemma, with biliary atresia being the most common cause. Increasing age is a negative prognostic factor for biliary atresia. Hence, early diagnosis of the same has immense prognostic significance. Ultrasound (US) plays a major role in the evaluation of infants with cholestatic jaundice and in the differentiation of biliary atresia from neonatal hepatitis, which are the two major causes of conjugated hyperbilirubinemia in neonates and infants. Our study concerns a 2-month-old male infant with signs and symptoms of jaundice, as correlated with liver biochemistry. US revealed features of biliary atresia that later got confirmed on biopsy. The present study summarizes the manifestations of biliary atresia on US, emphasizing the importance of a high-frequency transducer and the clinical diagnostic value of US for biliary atresia, in order to provide evidence for its early diagnosis