Complications:

The case to show weird complication of the most common invasive diagnostic test - Coronary angiography
Right hip pain after femoral artery puncture is commonly due to development of pseudoaneurysym which is very easy to deal with,But this patient is not so lucky.

Angiography with femoral puncture and stenting are performed elsewhere . Not in our facility but she came to us with right hip pain

Radiograph showing Right hip Joint and pubic symphysis space narrowing and which progressed rapidly with osteolysis
MRI  showing same findings more elegantly. Extensive paraarticular edema and synovial effusion
Synovial fluid aspiration and culture came positive for staphylococci.

Final diagnosis - septic arthritis after femoral artery puncture
Review of literature showed only one more similar case in pub Med index

http://journals.sagepub.com/doi/abs/10.1177/0267659109359961?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

Atrocities of two German neuropathologists Julius Hallervorden and Hugo Spatz during Second World War are notorious. The eponymous term Hallervorden –Spatz syndrome is disfavoured and neurodegeneration with brain iron accumulation (NBIA) is encouraged.

Ante mortem diagnosis of this rare condition is made possible with the use of MRI examination. Two distinct clinical presentations are described one is classical form and another is atypical variant based on the age of onset. Both the forms are progressive with poor prognosis.

Patients present in early age with progressive gait impairment, rigidity of all limbs, dysarthria and mental retardation. 

MRI findings are striking and reflect the pathology. Preferential deposition of the iron in globus pallidus will result in its destruction. The MRI appearance is described as eye of the tiger appearance. This sign is seen in both T2W and FLAIR imaging. Foci of T2 Hyper intensity noted with in the area of T2 Hypo intensity. Hypo intensity reflecting the iron deposition and the hyper intensity reflecting the gliosis changes.

Ref:

1.       http://www.ajnr.org/content/27/6/1230.full

2.       http://www.jpma.org.pk/full_article_text.php?article_id=2442

3.       http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2005;volume=53;issue=1;spage=102;epage=104;aulast=Sharma

4.       http://www.nejm.org/doi/full/10.1056/NEJMoa020817

All the cases of omental infarcts have been described in the last fifteen years only. These are increasingly recognised as an important cause of the right lower quadrant abdominal pain. Two factors contribute to the increased recognition of this entity. One is the availability of CT scanning technology and the other is epidemic of obesity.

Commonly the severity of the pain is disproportionate to the clinical signs. It is almost always located in the right iliac fossa in close association to the ascending colon and hepatic flexure. CT imaging is highly specific for omental infarcts. A cake like high attenuation fat density mass centered in the omentum is typically observed. If the adjacent bowel wall is thickened it is very minimal and pathology is primarily located in the omentum.

Omental infarcts are classified as primary and secondary types. If an aetiology is identified it is called as secondary and if no cause could be found it is called as primary.

Omental infarcts and epiploic appendagitis may have similar appearance, but omental infarct is a right sided pathology where as epiploic appendagitis is a left sided pathology. When it is not possible to differentiate an umbrella term intrabdominal focal fat inflammation can be used with no harm.

The importance in recognising these entities is to prevent unnecessary surgery. Most of the cases of omental infarcts get well with conservative management but when there is detoriation in the patient condition surgery and necrosectomy can be performed with out hesitation. In this patient there is nonrotation of the small bowel with midgut volvulus and this can be precipitating factor for omental infarct 

Ref:

1.       http://radiologycme.stanford.edu/2008mdct/handouts/wed/1105-Federle-Omental_Infarction_.pdf

2.       http://www.m-hikari.com/cems/cems2013/cems5-8-2013/concannonCEMS5-8-2013.pdf

3.       http://www.ajronline.org/doi/full/10.2214/ajr.178.6.1781537

4.       http://radiographics.highwire.org/content/24/3/703.full

Osteopetrosis is a developmental bone abnormality radiologically characterised by generalised increase in bone density. Bone appears chalky white and is brittle. Paradox it may seem but they are more prone for fractures like osteoporotic bones.

Heinrich Ernst Albers-Schonberg of Hamburg (Germany) first described this condition. He was one of the pioneer radiologist and many radiographic techniques used in day to day practice were developed by him. He is well known for is early reports of radiation induced damage of the rabbit ovaries in 1903.

Excessive resorption of the bone causes osteoporosis, similarly defective bone resorption leads to osteopetrosis. At least eight subtypes of osteopetrosis are described. Tarda variant of osteopetrosis is encountered in adults and have reasonably good prognosis. Mode of inheritance is autosomal dominant. More malignant varieties are encountered is early age group and show autosomal recessive inheritance.

Long bones show generalised increased density and undertubulation of the bones resulting in the Erlenmeyer flask deformity. Joint is spared. Sclerosis of the vertebral endplates results in sandwich vertebra. Failure of the osteoclasts to remodel the bone result in endobone formation or bone with in bone appearance. 

Ref:

1.http://jama.jamanetwork.com/article.aspx?articleid=381625-The 'Bone Within a Bone'David H. Frager, MD; Kakarla Subbarao, MD

2. http://hmg.oxfordjournals.org/content/10/25/2861.full- perspective from genetics

3. http://www.ijri.org/article.asp?issn=0971-3026;year=2003;volume=13;issue=4;spage=387;epage=388;aulast=Phatak- case report and review

4. http://www.ajnr.org/content/21/6/1110.long-  cranial manifestations

5. http://dentistry.tbzmed.ac.ir/joddd/index.php/joddd/article/viewFile/398/261 - case reports and review

6. http://bjr.birjournals.org/content/79/940/359.full- case report from BJR

 

 

Optic neuritis is a condition often quoted as a problem in which clinician sees nothing and patient see nothing. Diagnosis is clinical and treatment empirical. Clinically another entity that closely mimics optic neuritis is optic nerve sheath meningioma(ONSM). Unless one  specifically look for it, it is easy to miss this tumour.

Prof.Alan Jackson article in AJNR  discussed about 6 cases of intracanlicular meningioma in whom diagnosed is missed for more than a year. Inappropriate imaging protocols will delay the diagnosis. Radiologists should have high index of suspicion and should adhere to standard imaging protocols. Prof.Alan Jackson in a seminal study way back in 1998 stressed the importance both water and fat suppression for evaluation of the optic nerve pathology (Radiology Jan 1998 20657-63).Recently in May 2013 Acta Radiological issue Alexander M.McKinney discussed role of contrast enhanced T1W imaging, fat suppressed FLAIR & DWI sequence in evaluation of acute optic neuritis.

Meningioma is a common brain tumor but ONSM is a rarity and is said to constitute 1 to 2% of meningiomas.  When a tumor arise near planum sphenoidale and extends to involve optic nerve it is called as secondary tumor but when it arises from arachnoid cap cell with in the dural sheath of optic nerve it is called as primary optic nerve sheath meningioma. Canalicular variety is often (40%) bilateral.                                           

Management :

You can’t excise tumor while keeping nerve intact.  Surgery is attempted with the concern of developing intracranial extension but often leaves patient blind.  Medical management is unsuccessful.  Meningiomas are considered as radiotherapy resistant tumors. But ONSM is a type of meningioma where radiotherapy is considered as primary treatment option.

Ref :

1.     http://www.ajnr.org/content/17/5/901.full.pdf

2.     http://www.ajnr.org/content/24/6/1167.full

3.     http://radiology.rsna.org/content/227/3/718.full

4.     http://www.annals.edu.sg/pdf/35volno3200604/v35n3p168.pdf

Abdominal imaging  GUT 

Abdominal radiograph of a fifty year diabetic old lady suffering with fever showing abnormal air lucency in the left illiac fossa concerning for emphysematous pyelonephritis- a CT scan confirmed diagnosis patient managed conservatively with  percutaneous drainage catheter and antibiotics 

renal emphysema is fulminant suppurative infection characterised by formation of gas . invariably affects diabetic patient and is fatal if not recognised. 75% of times the offending microbe is Escherichia coli.

Huang and Tseng classified CT findings into following 4 classes for prognostic implication 

class 1. gas in collecting system only

class 2: gas in renal parenchyma with out extension to extrarenal space 

class 3A : extension of gas or abscess to the perinephric space 

class 3B : extension of gas or abscess to the paranephric space 

class 4 : bilateral EPN or solitary kidney EPN 

Wan et al.  classified EPN into two  types 

 Type 1 EPN is acutely more fulminant, and shows  a streaky or mottled  gas pattern and no adjacent fluid collections. Type 2 EPN has a lower mortality rate shows a bubbly gas pattern in the renoureteral unit  and fluid either in the kidney or surrounding the kidney mortality rate is high for type I 68% when compared to type II 18% 
more information from radiographics article in 2008 pyelonephritis - radiologic and pathologic review and also form AJR article in 2010 194 S70-72